Improvement In Oswestry Disability Index Research Articles

Percutaneous Endoscopic Decompression in Lumbar Canal and Lateral Recess Stenosis - The Surgical Learning Curve.

ObjectiveThe purpose of this study is to characterize the learning curve of endoscopic lumbar decompression based on peri- and postoperative parameters and to suggest the potential of full endoscopic decompression as a primary treatment option for lumbar canal and lateral recess stenosis. MethodsThe records of 223 consecutive patients who underwent percutaneous endoscopic decompression by a single surgeon for their lumbar canal and lateral recess stenosis were reviewed. Patients were stratified into group 1 (n=100) and group 2 (n=123), depending on their case number. After the 100th case, the procedural time reached a plateau and subsequent patients were assigned to the second group. Demographics and surgical outcomes, including operative times, change in dural sac dimensions, length of hospital stay, and intraoperative complication rates were compared between the 2 groups. Postoperative clinical outcomes, including the visual analogue scale (VAS), the Oswestry Disability Index (ODI) and reoperation rates were compared between the 2 groups (group 1, n=90; group 2, n=110) by follow-up evaluation. ResultsProcedural times were greater in group 1 than group 2 (group 1, 105.26 minutes; group 2, 67.65 minutes; p<0.05) and they had higher complication rates (group 1, 16% [16 of 100]; group 2, 8.3% [8 of 123]; p<0.05). The length of hospitalization, postoperative improvement in VAS and ODI, and reoperation rates were not different between the groups. In both groups, stenotic spinal canals were effectively decompressed. ConclusionContinued surgical experience was associated with a reduction in operative times and less intraoperative complications. Although the learning curve was steep and additional surgical experience may be needed to overcome the learning curve, percutaneous full endoscopic lumbar decompression is a safe, clinically-feasible, and effective surgical technique and can be adopted as the primary treatment for lumbar canal and lateral recess stenosis.

Percutaneous Ozone Treatment for Herniated Lumbar Discs: 1-Year Follow-up of a Multicenter Pilot Study of a Handheld Disposable Ozone-Generating Device

PurposeTo evaluate the safety and efficacy of oxygen-ozone treatment delivered via a novel, handheld ozone-generating device for improving pain and function in herniated disc patients. Materials and MethodsA total of 39 patients with contained herniated lumbar discs received oxygen-ozone treatment at 1 of 3 centers. Treatment consisted of injection of 2% ozone (10 mL): 3 mL delivered into the nucleus pulposus and 7 mL delivered into the adjacent paravertebral tissues. The first 8 patients received only ozone injections, whereas subsequent patients also received periganglionic methylprednisolone (40 mg) and 0.5% bupivacaine (1 mL) injections. Patients were evaluated at baseline and at 1 month, 6 months, and 12 months after treatment using the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for leg pain and for back pain. Analgesic medication use was also assessed at each timepoint. ResultsOverall, 91% (32/35) of the per-protocol patients (those who completed follow-up and did not have significant protocol deviations) showed detectable improvement in ODI at 1-month follow-up; this increased to 93% (26/28) of patients at 12-months follow-up. At 1 month after treatment, 60% (21/35) of patients showed significant improvement in ODI scores (P = .01); 54% (19/35) showed significant improvement in VAS scores for leg pain (P = .05); and 49% (17/35) showed significant improvement in VAS scores for back pain (P = .12). At 6 months after treatment, 67% (22/33) of patients showed significant improvement in ODI scores (P = .02); 64% (21/33) showed significant improvement in VAS scores for leg pain (P = .01); and 52% (17/33) showed significant improvement in VAS scores for back pain (P = .12). At 12 months after treatment, 68% (19/28) of patients showed significant improvement in ODI scores (P < .01); 64% (18/28) showed significant improvement in VAS scores for leg pain (P < .01); and 61% (17/28) showed significant improvement in VAS scores for back pain (P = .09). Leg pain typically subsided more quickly than back pain. Use of analgesic medications also significantly decreased at all follow-up timepoints compared to baseline (P < .01). There were no adverse events or device-related issues. ConclusionsAt 1, 6, and 12 months after treatment, patients experienced significant improvements in pain and function as well as significantly decreased use of analgesic medication. Taken together with the absence of adverse events at 1-year follow-up, these data suggest that oxygen-ozone treatment is a safe and effective therapy for contained herniated discs.

PROMIS Physical Function Score Strongly Correlates With Legacy Outcome Measures in Minimally Invasive Lumbar Microdiscectomy.

Retrospective cohort. This study aims to determine the validity of the patient-reported outcomes measurement information system (PROMIS) physical function (PF) in minimally invasive lumbar discectomy (MIS LD) patients. PROMIS was designed to allow for assessment of clinical outcomes in fewer questions than previous outcome measures with the goal of reducing noncompliance associated with longer, time-consuming surveys. However, there exists a paucity of evidence regarding the efficacy of the PROMIS PF domain in patients undergoing MIS LD. A surgical database of patients undergoing 1-3 level MIS LD was retrospectively reviewed. Postoperative changes in PROMIS PF scores were analyzed at 6-weeks, 12-weeks, and 6-months using paired Student t tests. PROMIS scores were compared to Oswestry disability index (ODI), visual analog scale (VAS) back, and VAS leg scores. Correlations were tested using Pearson correlation coefficient. Forty-one MIS LD patients were identified, reporting an average preoperative PROMIS PF score of 35.36 ± 7. Patients demonstrated significant improvement in ODI, VAS back, and VAS leg scores. Additionally, strong associations with PROMIS scores were observed for preoperative and postoperative ODI (r range: 0.5735-0.8543) and postoperative VAS back (r range: 0.5332-0.6522) and VAS leg pain (r range: 0.5257-0.6412). Patients undergoing MIS LD demonstrated significant improvements in PROMIS PF, ODI, VAS back, and VAS leg pain postoperatively. Additionally, improvements in PROMIS physical function scores at each postoperative time point were determined to be significantly correlated with ODI, VAS back, and VAS leg pain. The results of the current study demonstrate PROMIS PF has strong utility as a postoperative outcome assessment tool. 4.

Full Endoscopic Discectomy, Debridement, and Drainage for High-Risk Patients with Spondylodiscitis

To evaluate the efficacy and clinical results of full endoscopic debridement and drainage (FEDD) for high-risk patients with spondylodiscitis. Fourteen patients who underwent FEDD at our institution between November 2015 and September 2017 were retrospectively reviewed. All patients had single-level infectious spondylodiscitis and were high-risk candidates for surgery. Their general condition was evaluated according to the American Society of Anesthesiologists grading system. The Charlson Comorbidity Index was used for comprehensive assessment of comorbidity status. Outcomes were evaluated by numeric rating scale (NRS) pain score, Oswestry Disability Index, modified Macnab criteria, and radiographic images at follow-up. All 14 patients experienced immediate relief of back pain after FEDD, with no procedure-related complications. The causative bacteria were identified in 10 of the 14 patients (71.5%). Half of the 14 patients had an American Society of Anesthesiologists score of ≥3. The average Charlson Comorbidity Index was 5.1 ± 1.6 points. Compared with the preoperative NRS score of 8.2 ± 0.9, the NRS scores at 1 week and 12 months after surgery were 3.4 ± 1.1 and 1.4± 1.2, respectively. A significant improvement in Oswestry Disability Index was observed after surgery (preoperative, 30.1 ± 3.9; 12 months postoperatively, 17.6 ± 6.2; P< 0.05). Satisfaction rate was 85.7% based on the Macnab criteria (excellent or good outcome). None of the patients developed any significant kyphotic deformity after FEDD. FEDD may be an effective alternative to extensive open surgery in patients with infectious spondylodiscitis, especially those who are high-risk candidates for surgery (elderly patients with multiple comorbidities and patients in poor general condition).

Effects of Physical Therapy on Pain, Functional Status, Sagittal Spinal Alignment, and Spinal Mobility in Chronic Non-specific Low Back Pain.

To investigate the effects of physical therapy (PT) on pain, functional status, sagittal spinal alignment, and spinal mobility in chronic non-specific low back pain (NSLBP). The study population consisted of 100 patients with chronic NSLBP. The study group comprised 60 patients to whom a PT program including superficial heat, transcutaneous electrical nerve stimulation, and ultrasound for 10 sessions was assigned. The control group was composed of 40 patients who received no PT. Home exercise programs were applied to both groups. Pain severity was determined using a Visual Analog Scale (VAS), and functional status was evaluated using the Oswestry Disability Index (ODI). Spinal sagittal alignment in regard to lumbosacral, lumbar lordosis, and thoracic kyphosis angles and spinal mobility regarding lumbar and thoracic flexion and extension degrees were assessed using a digital inclinometer. Lumbar flexion was also assessed using the modified lumbar Schober test (mLST). Evaluations were performed at baseline and after completing the therapy sessions. There were significant decreases in VAS scores in each group upon therapy completion. However, significant improvements in ODI, mLST, and all inclinometric evaluations in terms of sagittal spinal alignment and spinal mobility were noted only in the study group compared with baseline values (p<0.05). Despite the short course of treatment, PT was found to have significant positive effects on pain severity, functional status, sagittal spinal alignment, and spinal mobility. PT was determined to be an effective treatment option for chronic NSLBP.

Unilateral laminectomy for bilateral decompression improves low back pain while standing equally on both sides in patients with lumbar canal stenosis: analysis using a detailed visual analogue scale

BackgroundUnilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms.MethodsWe included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement.ResultsDetailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01).ConclusionsULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

Does Gender Influence Postoperative Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion?

Retrospective cohort. The objective of this study was to determine if an association exists between gender and postoperative improvements in patient-reported outcomes (PRO) measures following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Current spine literature presents conflicting findings regarding the influence of gender on clinical outcomes. Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed. PRO measures including Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) back and leg pain scores were collected preoperatively and 6-week, 12-week, and 6-month postoperatively. Rates of minimum clinically important difference (MCID) achievement were determined at 6-months postoperative. Statistical analysis was performed using Pearson χ analysis or Student t test. In total, 169 patients, 40.83% females and 59.17% males, were included. Females experienced greater inpatient pain scores than males (POD 0: 5.30 vs. 4.69, P=0.041; POD 1: 4.80 vs. 4.13, P=0.019). Females demonstrated significantly greater ODI (43.77 vs. 36.22; P=0.002) and VAS leg (6.20 vs. 5.27; P=0.039) scores than males. No differences in postoperative improvements in ODI, VAS back or VAS leg pain scores were identified between genders, with exception to females demonstrating greater improvement in VAS leg pain at 6 months postoperatively (female: -4.40 vs. male: -3.32; P=0.033). Furthermore, no differences in MCID achievement for PROs were identified between cohorts. Females demonstrated greater preoperative pain and disability as well as inpatient VAS pain scores compared to males. Furthermore, gender was not associated with differences in length of stay, perioperative complication rates, or narcotics consumption. Improvements in pain and disability, as well as rates of MCID achievement were similar between genders. These findings suggest that gender is not associated with surgical or clinical outcomes and should not be used as a predictor of outcomes following MIS TLIF. Level III.

Use of a Psychological Evaluation Tool as a Predictor of Spinal Cord Stimulation Outcomes

Preoperative work-up for spinal cord stimulation (SCS) includes a psychological assessment; however, no one psychological factor has correlated with poor outcomes across studies. We developed a Psychological Evaluation Tool for Spinal Cord Stimulation Candidacy (PETSCSC), which includes all factors in the literature found to correlate with outcomes. In this study, we examine whether PETSCSC correlates with postoperative outcomes. Patients undergoing SCS were prospectively enrolled in this study. PETSCSC scores were obtained preoperatively. Numeric rating scale (NRS), global impression of change (GIC), pain catastrophizing scale (PCS), McGill pain questionnaire (MPQ), Oswestry disability index (ODI), and Beck Depression Inventory were assessed preoperatively and postoperatively. Outcomes were correlated with PETSCSC scores. Thirty-four SCS patients had a mean follow-up of 9.88 ± 2.91 months. At latest follow-up, we observed significant improvement in NRS, PCS, MPQ, and ODI. Total PETSCSC score exhibited significant correlation with GIC (p = 0.026, r = 0.380) and improvement in PCS total (p = 0.041, r = 0.351), and MPQ affective (p = 0.002, r = 0.517) scores. The PETSCSC emotive subset significantly correlated with GIC (p = 0.020, r = 0.395). The PETSCSC depression subset significantly correlated with improvement in PCS rumination (p = 0.009, r = 0.439), PCS helplessness (p = 0.021, r = 0.393), PCS total (p = 0.021, r = 0.394), and MPQ affective (p = 0.002, r = 0.501). The PETSCSC therapy subset significantly correlated with improvement in MPQ sensory (p = 0.026, r = -0.381) and MPQ affective (p < 0.001, r = 0.583). PETSCSC scores and subscores demonstrate significant correlation with pain outcomes used in assessment of SCS efficacy. Higher PETSCSC scores correlate with greater improvement in GIC, MPQ affective, and PCS scores. Stratification of these patients based on PETSCSC total and subset scores could help with prognostication.

PROMIS Physical Function for prediction of postoperative pain, narcotics consumption, and patient-reported outcomes following minimally invasive transforaminal lumbar interbody fusion.

This study aimed to determine if the preoperative Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF) score is predictive of immediate postoperative patient pain and narcotics consumption or long-term patient-reported outcomes (PROs) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). A prospectively maintained database was retrospectively reviewed. Patients who underwent primary, single-level MIS TLIF for degenerative pathology were identified and grouped by their preoperative PROMIS PF scores: mild disability (score 40-50), moderate disability (score 30-39.9), and severe disability (score 20-29.9). Postoperative pain was quantified using the visual analog scale (VAS), and narcotics consumption was quantified using Oral Morphine Equivalents. PROMIS PF, Oswestry Disability Index (ODI), 12-Item Short-Form Health Survey, Physical Component Summary (SF-12 PCS), and VAS back and leg pain were collected preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. Preoperative PROMIS PF subgroups were tested for an association with demographic and perioperative characteristics using 1-way ANOVA or chi-square analysis. Preoperative PROMIS PF subgroups were tested for an association with immediate postoperative pain and narcotics consumption in addition to improvements in PROMIS PF, ODI, SF-12 PCS, and VAS back and leg pain by using linear regression controlling for statistically different demographic characteristics. A total of 130 patients were included in this analysis. Patients were grouped by their preoperative PROMIS PF scores: 15.4% had mild disability, 63.8% had moderate disability, and 20.8% had severe disability. There were no significant differences among the subgroups in terms of age, sex, smoking status, and comorbidity burden. Patients with greater disability were more likely to be obese and to have workers' compensation insurance. There were no differences among subgroups in regard to operative levels, operative time, estimated blood loss, and hospital length of stay. Patients with greater disability reported higher VAS pain scores and narcotics consumption for postoperative day 0 and postoperative day 1. Patients with greater preoperative disability demonstrated lower PROMIS PF, ODI, SF-12 PCS, and worse VAS pain scores at each postoperative time point. Patients with worse preoperative disability, as assessed by PROMIS PF, experienced increased pain and narcotics consumption, along with less improvement in long-term PROs. The authors conclude that PROMIS PF is an efficient and accurate instrument that can quickly assess patient disability in the preoperative period and predict both short-term and long-term surgical outcomes.

The Effectiveness of Aerobic Exercise Program for Improving Functional Performance and Quality of Life in Chronic Low Back Pain

Background: The presence of persistent low back pain causes patients to avoid daily activities, which may lead to physical deconditioning, both generally and specifically. Such signs of physical deconditioning may result in even more pain and disability and so contribute to the chronicity.. From the patient’s perspective, chronic LBP has a daily impact on functional ability and quality of life(QoL). Endurance exercise reverses the cycle of deconditioning, weakness, and functional loss associated with many chronic disorders. Purpose: The purpose of this randomised controlled trial was to investigate the effectiveness of aerobic exercise program for improving functional performance and quality of life in chronic low back pain. Method: 30 patients of chronic low back pain with mean age (48.6 ± 5.32)having chronic low back pain greater than 3 months completed the trial. Subjects were randomly placed into two groups receiving the Aerobic exercises and conventional treatment (n = 15) or the conventional treatment alone ( n = 15). Conventional treatment consist of mobilization, stretching and exercises for low back patients. Each group receives their respective therapy 5 days a week for 8 weeks. Oswestry disability index, heart rate and RAND -36 were the outcome measures assessed at baseline and again after the 8 week intervention. Results: The aerobic exercises group shows significant improvement in Oswestry disability index (5.73 ± 2.64, p= 0.001) the RAND -36 Physical functioning ( Z score = -4.706, p= 0.00) and Energy and fatigue scores ( Z score = -4.715, p= 0.00) than controls. Conclusion: The study demonstrates that conventional low back pain treatment combined with aerobic exercise program is superior to conventional low back pain treatment alone in improving functional performance and quality of life in patients with chronic low back pain.

Comparison of Cortical Bone Trajectory Screw Placement Using the Midline Lumbar Fusion Technique to Traditional Pedicle Screws: A Case-Control Study.

Cortical bone trajectory (CBT) screws are an alternative to traditional pedicle screws (PS) for lumbar fixation. The proposed benefits of CBT screws include decreased approach-related morbidity and greater cortical bone contact to prevent screw pullout. Relatively little data is published on this technique. Here, we compare the midline lumbar fusion (MIDLF) approach for CBT screw placement to transforaminal lumbar interbody fusion (TLIF) for traditional PS placement. A prospectively maintained institutional database was retrospectively reviewed for all patients undergoing lumbar spinal fusion using CBT screws over the past 5 years. Controls were identified from the same database as patients undergoing lumbar spinal fusion with traditional PS placement and matched based on age, sex, and number of levels fused. Exclusion criteria included prior lumbar instrumentation. The electronic health record was retrospectively reviewed for demographic, perioperative, and postoperative data. A total of 23 patients who underwent CBT screw placement and 35 controls who received traditional PS were included in the study. The median follow-up time was 52.5 months. The CBT screw group had significantly less mean estimated blood loss than the PS group (186 mL versus 414 mL respectively; P = .008). Both groups experienced significant improvements in preoperative Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for back and leg pain. However, there was no significant difference between the groups in regard to operative time and amount of improvement in VAS pain score or ODI. The CBT group was associated with a significantly shorter mean length of stay (LOS). There were 2 instances of screw pullout in each group. The MIDLF approach with CBT screw placement is associated with less intraoperative blood loss and shorter LOS than traditional PS placement. There is no difference between the 2 techniques in regard to improvement in pain or disability.

Effectiveness of physiotherapy and minimal invasive technics on functional status and quality of life in geriatric patients with low back pain.

The aim of the study was to determine the effect of physiotherapy and minimal invasive technics (MIT) on pain, quality of life and functional disability in geriatric patients with chronic low back pain. According to previous files, 61 geriatric patients who received MIT and physiotherapy allocated to group 1, the patient who received physiotherapy alone allocated to group 2. All patients received soft tissue mobilizations, muscle-energy technics and spinal stabilization exercises. Pain severity, functional disability, life quality, and fear avoidance were assessed with visual analogue scale, Oswestry Disability Index (ODI), Nottingham Health Profile (NHP) and Fear Avoidance Beliefs Questionnaire, respectively. Improvements in ODI and NHP were seen in favor of group 2 after treatment as to baseline (P<0.05). Although both treatments showed pain relief, functional restoration, and improvement in quality of life; there was no additional improvement in patients received MIT different from the patients received physiotherapy alone.

Triangular titanium implants for sacroiliac joint fusion

BackgroundSacroiliac joint (SIJ) dysfunction is an underdiagnosed condition. Several published cohorts have reported favorable midterm outcomes after SIJ fusion using titanium implants placed across the SIJ. Herein, we report 12-month follow-up from SIJ fusion in a standard clinic setting.MethodsA carefully selected group of 160 consecutive patients with painful SIJ dysfunction were diagnosed at a single center and underwent unilateral or staged bilateral SIJ fusion using triangular titanium implants. Patients were routinely seen in clinic for follow-up every 3 months where they completed visual analog scale (0–10 range) pain ratings and Oswestry Disability Index (ODI). Follow-up CT scan was performed at 1 year.ResultsMean patient age was 58 years, and 68% were women. 30% underwent staged bilateral SIJ fusion. By month 12, SIJ pain decreased from 8.0 to 2.5 (p < 0.0001) and disability (ODI) decreased from 45.3 to 16.4 (p < 0.0001). The proportion with clinically significant improvements in SIJ pain and ODI was high (> 95%). Perioperative adverse events were mild and decreased with increasing surgical experience with the procedure. Subgroup analysis showed slightly smaller improvements in those undergoing bilateral surgery and those with a spinal cord stimulator in place. CT scan at 1 year showed reabsorption along one or more implants in 16% of cases, but there were no breakages or implant removals.ConclusionsIn standard clinical practice, SIJ fusion with triangular titanium implants produces significant improvement in pain and disability related to SIJ dysfunction.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Electromyographic study to predict functional outcome of transforaminal epidural steroid injection in lumbosacral radiculopathy

ContextEpidural steriod injections (ESIs) are commonly used for managment of lumbosacral radiculopathy (LSR). Predicting outcomes after ESIs could be another valuable application of needle electromyography (EMG) in these patients.AimThe aim was to determine if EMG study can predict the functional outcome of transforaminal ESIs in patients with LSR.Materials and methodsThe study included 20 patients with clinical diagnosis of LSR. Peripheral nerve conduction study, late responses, somatomsensory evoked potentials, and needle EMG were performed in both lower limbs followed by transforaminal ESI under fluoroscopic guidance. The functional outcome was evaluated using visual analog scale for pain and Oswestry disability index (ODI) that were performed before and after injections.ResultsThere were statistically significant decrease in pain severity (visual analog scale; P=0.022) and in ODI (improvement in functional score; P=0.029) after injection in patients with symptom duration less than 3 months compared with patients with longer duration of symptoms. In patients with negative EMG findings, there was a significantly greater reduction in pain severity (P<0.01) and ODI score (P<0.01) after injection compared with patients with positive findings. Regression analysis showed that negative needle EMG findings were significant predictors of pain reduction (P=0.001) and functional improvement (P=0.002) in patients with LSR after ESI.ConclusionThis study supports the notion that EMG studies can be used for prediction of functional outcome in patients with LSR performing transforaminal ESI.

Baseline mental status predicts happy patients after operative or non-operative treatment of adult spinal deformity

The study is a retrospective review of a multi-institutional database, aiming to determine predictors of non-depressed, satisfied adult spinal deformity (ASD) patients with good self-image at 2-year follow-up (2Y). ASD significantly impacts a patients' psychological status. Following treatment, little is known about predictors of satisfied patients with high self-image and mental status. Inclusion: primary ASD pts >18 y/o with complete 2Y follow-up. Non-depressed [Short Form 36-mental component score (SF36-MCS) >42], satisfied patients (SRS22-satisfaction >3) with good self-image (SR22-self-image >3) at 2Y were isolated (happy). Happy and control patients were propensity-matched by baseline and 2Y leg pain, Charlson, frailty, and radiographic measures for the operative (OP) and non-operative cohorts (NOP). Health related quality of life (HRQL), surgical and radiographic metrics were compared. Regression models identified predictors of happy patients. Thresholds were calculated using area under the curve (AUC) and 95%CI. Of 480 patients, 94 OP (happy: 47 vs. control: 47) and 92 NOP (46 each) reached inclusion. At baseline, groups had similar age, gender, Oswestry disability index (ODI) (OP: 39.13 vs. 37.49, NOP: 17.70 vs. 19.74) and SF36-physical component score (PCS) (OP: 33.51 vs. 35.04, NOP: 47.93 vs. 44.72). Despite similar (P>0.05) surgeries, length of stay (LOS), and radiographic outcomes between OP happy and control groups, happy had less peri-operative complications (31.9% vs. 57.4%, P=0.13), better 2Y ODI (17.77 vs. 29.98), SRS22 component, total, and SF36 scores (P<0.05). NOP happy patients also exhibited better 2Y ODI (13.24 vs. 22.09), SRS22 component, total, and SF36 scores (P<0.05). Baseline SRS-mental (OR: 2.199, AUC: 0.617, cutoff: 2.5) and ODI improvement (OR: 1.055, AUC: 0.717, cutoff: >12) predicted happy OP patients, while baseline SRS-self-image (OR: 5.195, AUC: 0.740, cutoff: 3.5) and ODI improvement (OR: 1.087, AUC: 0.683, cutoff: >9) predicted happy NOP patients. Baseline mental-status, self-image and ODI improvement significantly impact long-term happiness in ASD patients. Despite equivalent management and alignment outcomes, operative and non-operative happy patients had better 2Y disability scores. Management strategies aimed at improving baseline mental-status, perception-of-deformity, and maximizing ODI may optimize treatment outcomes.

Treatment outcome of quality of life and clinical symptoms in patients with symptomatic lumbar degenerative disc diseases: which treatment modality is superior?

This was to assess the quality of life and clinical symptoms before and after treatment of patients with symptomatic lumbar degenerative disc disease (LDDD). It was also to determine the superior treatment for well-selected patients: conservative versus surgical treatment. Prospective interventional analytical study. We studied 160 adult symptomatic patients aged 31-60years with diagnosis of LDDD who were enrolled between May 2016 and November 2017. Their pre- and post-treatment clinical symptoms and signs and quality of life were studied using the Oswestry disability index (ODI). The data was analysed using SPSS version 24. One hundred fifty-three adult patients aged 31 to 60years completed the study. The male-to-female ratio was 1:1.5 while the symptom duration ranged between one and 14years. The treatment modalities were medical (46%), epidural steroid injection (26%) and operative treatment (28%). The responses to the treatment were worsened symptoms (10.5%), no improvement (13.1%), moderate/slight improvement (27.5%) and significant improvement (49%). There were statistically significant improvements (p value < 0.05) in clinical symptoms, sign and ODI at six months after treatment. Surgical treatment was superior to all other form of care. This study showed significant improvement in outcome among the participants in different treatment modalities with surgical treatment being the superior. We recommend surgical treatment for well-selected adult patients with symptomatic LDDD and assessment of quality of life and clinical symptoms before and after treatment.

Therapeutic Feasibility of Full Endoscopic Decompression in One- to Three-Level Lumbar Canal Stenosis via a Single Skin Port Using a New Endoscopic System, Percutaneous Stenoscopic Lumbar Decompression.

Study DesignThis retrospective study involved 450 consecutive cases of degenerative lumbar stenosis treated with percutaneous stenoscopic lumbar decompression (PSLD).PurposeWe determined the feasibility of PSLD for lumbar stenosis at single and multiple levels (minimum 1-year follow-up) by image analysis to observe postoperative widening of the vertebral canal in the area.Overview of LiteratureThe decision not to perform an endoscopic decompression might be due to the surgeon being uncomfortable with conventional microscopic decompression or unfamiliar with endoscopic techniques or the unavailability of relevant surgical tools to completely decompress the spinal stenosis.MethodsThe decompressed canal was compared between preoperative controls and postoperative treated cases. Data on operative results, including length of stay, operative time, and surgical complications, were analyzed. Patients were assessed clinically on the basis of the Visual Analog Scale (VAS) score for the back and legs and using the Oswestry Disability Index (ODI).ResultsPostoperative magnetic resonance imaging revealed that PSLD increased the canal cross-sectional area by 52.0% compared with the preoperative area at the index segment (p<0.001) and demonstrated minimal damage to the normal soft tissues including muscles and the extent of removed normal bony tissues. Mean improvements in VAS score and ODI were 4.0 (p<0.001) and 40% (p<0.001), respectively.ConclusionsPSLD could be an alternative to microscopic or microendoscopic decompression with various advantages in the surgical management of lumbar stenosis.

Effect of long spinal fusion including the pelvis on activities of daily living related to lumbar spinal function in adults with spinal deformity

BackgroundSpinal sagittal malalignment is managed by long spinal fusion including the pelvis, which reduces lumbar spine range of motion and impairs the activities of daily living. This study aimed to evaluate the changes in activities of daily living after long spinal fusion in adults with spinal deformity, and clarify the improvement or deterioration in the specific activities of daily living postoperatively. MethodsWe retrospectively reviewed 40 adults who underwent long spinal fusion in a single institution between 2014 and 2016 (female/male, 39/1; mean age, 68.5 years; range, 52–79 years). Each patient undertook three self-assessed health-related quality of life measures preoperatively and again at 2-years postoperatively: Oswestry Disability Index (ODI), Scoliosis Research Society (SRS)-22 questionnaire, and Japanese Orthopaedic Association back pain evaluation questionnaire (JOABPEQ). Radiographic outcomes were measured preoperatively and at 2 years postoperatively. ResultsTotal ODI and all SRS-22 domains were improved at 2 years postoperatively. The JOABPEQ scores were also improved in all domains, except lumbar function. The change in pelvic incidence minus lumbar lordosis correlated with improvements in total ODI, SRS-22 function, and self-image scores. At 2 years postoperatively, satisfaction was correlated with total ODI, all SRS-22 domains, and the JOABPEQ pain domain. Subclass analysis of the JOABPEQ lumbar function domain at 2 years postoperatively revealed that 65% of patients had difficulty ‘putting on socks or stockings’, 42% had great difficulty ‘bending forward, kneeling, or stooping’, 32% reported improvement in ‘sit to stand’, and 32% reported deterioration in ‘putting on socks or stockings’ after surgery compared with before surgery. The JOABPEQ lumbar function domain was not correlated with the SRS-22 satisfaction domain. ConclusionsDespite restricting lumbar function, spinopelvic fusion improves health-related quality of life. Surgeons and patients should discuss potential changes and limitations in the activities of daily living after long spinal fusion including the pelvis.

Validation of Patient Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Tests (CATs) in the Surgical Treatment of Lumbar Spinal Stenosis.

Prospective, cohort study. Demonstrate validity of Patient reported outcomes measurement information system (PROMIS) physical function, pain interference, and pain behavior computer adaptive tests (CATs) in surgically treated lumbar stenosis patients. There has been increasing attention given to patient reported outcomes associated with spinal interventions. Historical patient outcome measures have inadequate validation, demonstrate floor/ceiling effects, and infrequently used due to time constraints. PROMIS is an adaptive, responsive National Institutes of Health (NIH) assessment tool that measures patient-reported health status. Ninety-eight consecutive patients were surgically treated for lumbar spinal stenosis and were assessed using PROMIS CATs, Oswestry disability index (ODI), Zurich Claudication Questionnaire (ZCQ), and Short-Form 12 (SF-12). Prior lumbar surgery, history of scoliosis, cancer, trauma, or infection were excluded. Completion time, preoperative assessment, 6 weeks and 3 months postoperative scores were collected. At baseline, 49%, 79%, and 81% of patients had PROMIS pain behavior (PB), pain interference (PI), and physical function (PF) scores greater than 1 standard deviation (SD) worse than the general population. 50.6% were categorized as severely disabled, crippled, or bed bound by ODI. PROMIS CATs demonstrated convergent validity through moderate to high correlations with legacy measures (r = 0.35-0.73). PROMIS CATs demonstrated known groups validity when stratified by ODI levels of disability. ODI improvements of at least 10 points on average had changes in PROMIS scores in the expected direction (PI = -12.98, PB = -9.74, PF = 7.53). PROMIS CATs demonstrated comparable responsiveness to change when evaluated against legacy measures. PROMIS PB and PI decreased 6.66 and 9.62 and PROMIS PF increased 6.8 points between baseline and 3-months post-op (P < 0.001). Completion time for the PROMIS CATs (2.6 min) compares favorably to ODI, ZCQ, and SF-12 scores (3.1, 3.6, and 3.0 min). PROMIS CATs demonstrate convergent validity, known groups validity, and responsiveness for surgically treated patients with lumbar stenosis to detect change over time and are more efficient than legacy instruments. 2.

A prospective randomized study to analyze the efficacy of balanced pre-emptive analgesia in spine surgery

Background ContextSurgical procedures involving the spine are known to cause moderate to severe postoperative pain. Inadequate management of acute pain in the postoperative period results in higher morbidity, and consequently may lead to chronic pain caused by central sensitization. The role of pre-emptive analgesia (PA) and intraoperative analgesia in management of postoperative pain has gained precedence over recent years. Pathophysiology of postoperative pain in spine surgery is unique, as it is a combination of nociceptive, inflammatory, and neuronal stimuli. Blockage of all three stimuli in the perioperative period by pre-emptively administrating a combination of paracetamol (P), ketorolac (K), and pregabalin (PR) might help in adequate management and alleviation of acute postoperative pain. PurposeTo evaluate the analgesic effect of a combination of P, K, and PR as pre-emptive multimodal analgesia, aimed to block or reduce acute postoperative pain after spine surgery. Study DesignA prospective, randomized, controlled, and double-blinded clinical trial. Patient SampleAfter Institutional Review Board approval, 100 consecutive patients requiring single- or double level spinal fusion procedures were randomized into two groups—PA and control (C). MethodsThe PA group received P, K, and PR 4 hours before surgery, as PA. Both groups underwent identical anesthetic and postoperative pain management protocol. Outcome MeasuresDemographic and surgical data, 4 hourly postoperative pain levels—Numeric Pain Rating scale (NRS), Ambulatory NRS scores; level of consciousness—Ramsay sedation scale, total amount of opioids consumed (TOC) through patient-controlled analgesia; functional levels—Oswestry Disability Index (ODI), surgical satisfaction index-North American Spine Society (NASS) satisfaction scale, duration of hospital stay, and all complications were recorded and analyzed. A research grant of 6,032 USD was obtained from AO Spine toward this work. There is no conflict to disclose. ResultsBoth the groups had identical demographic backgrounds and surgical profiles. The average NRS score within the first 48-hour period in the PA group (2.7±0.79) was significantly less than the C group (3.4±0.98) and the differences were more in the first 12 hours following surgery. Similarly, Ambulatory NRS scores were significantly low in the PA group during the first and second postoperative days. The PA group individuals were found to be more physically motivated, as 95.7% were able to ambulate 50 m on the first postoperative day compared with 30% in the C group. The PA group had significantly low TOC (3.02±2.29 mg) in comparison to the C group (4.94±3.08 mg). The duration of hospital stay was 4.17±1.02 and 4.84±1.62 days in the PA and C groups (p=.017), respectively. No major complications occurred in either groups and were found to be similar in percentage between both the groups, except for nausea and vomiting which were more in C group. Dry mouth was the most common side effect noted irrespective of the groups. All patients had significant improvement in ODI with better results in PA group at first month follow up. The PA group (97.90%) was extremely satisfied compared with C group (72%, p=.002) according to NASS scale. ConclusionsPostoperative pain management in spine surgery is maximized if perioperative painful stimuli can be inhibited, which requires adequate blood levels of analgesic, anti-inflammatory, and neuropathic drugs intraoperatively. The employed strategy of preoperative administration of balanced analgesia with a combination of P, K, and PR, each having different mechanisms of action, resulted in lesser pain intensity, allowed better ambulation tolerance, improved functional outcomes and has also reduced the requirement of opioids and duration of hospital stay with no additional complications. Thus, this balanced analgesia administered preoperatively would address the complicated postsurgical pain.