Patients Undergoing Lumbar Surgery Research Articles

Evaluation of the modified MRI vertebral bone quality score for bone quality in lumbar degenerative disorders.

The traditional VBQ scoring method may lead to overestimation due to the concentration of intravertebral fat and vascular structures in the posterior half of vertebral bodies, potentially resulting in false-positive outcomes. This study aims to modify the measurement method of VBQ score (Modified-VBQ) and evaluate its effectiveness in evaluating bone quality of lumbar degenerative diseases. Retrospective analysis was conducted on clinical data from patients undergoing lumbar surgery for degenerative diseases between September 2022 and September 2023. Preoperative lumbar t1-weighted Magnetic resonance imaging was used for both modified and traditional VBQ scoring. Computed tomography (CT) images and dual-energy X-ray absorptiometry (DEXA) data were collected through the picture archiving and communication system. The effectiveness of the modified VBQ score was evaluated, considering P < 0.05 as statistically significant. The study included 212 patients, revealing a significant difference between the modified VBQ and VBQ scores (P < 0.0001). Notably, patients with a history of hyperlipidemia exhibited a significant difference between the two scores (P = 0.0037). The area under the ROC curve (AUC) for the modified VBQ was 0.86, surpassing the VBQ score (AUC = 0.74). Linear regression analysis demonstrated a moderate to strong correlation between the modified VBQ and DEXA T-score (r = - 0.49, P < 0.0001) and a high correlation with CT Hounsfield units (HU) values (r = - 0.60, P < 0.0001). The modified VBQ score provides a simple, effective, and relatively accurate means of assessing bone quality in lumbar degenerative diseases. Preoperative implementation of the modified VBQ score facilitates rapid screening for patients with abnormal bone quality.

Evaluating the Efficacy of IL-6 as Predictors of Lateral Lumbar Interbody Fusion Success: Insights From Pain Scores and JOABPEQ Assessments.

A prospective study. This study aims to explore the correlation between interleukin (IL)- 6 levels in intervertebral disc (IVD) tissue and clinical outcomes in patients undergoing lumbar surgery for lumbar degenerative disease (LDD). This prospective study analyzed 32 patients (22 men and 10 women, average age 69.6 years) who underwent lateral lumbar interbody fusion (LLIF). IL-6 gene expression in IVD tissues collected during surgery was measured and correlated with pre- and postoperative clinical outcomes, including pain intensity assessed via Numeric Rating Scales (NRS) and quality of life (QOL) evaluated through the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). IL-6 levels showed statistical correlations with postoperative intensity of low back pain (LBP) and several JOABPEQ domains. Patients with higher expression of IL-6 levels experienced more severe postoperative LBP and lower scores in lumbar function, walking ability, social life function, and mental health. The effectiveness rate of JOABPEQ scores was exceptionally high for low back pain (.548), walking ability (.677), and social functioning (.563), demonstrating the effectiveness of LLIF. The average operation time was 105.6 minutes, and the estimated blood loss was 85.6mL. The study underscores IL-6 as a potential biomarker for predicting surgical outcomes in LDD. High IL-6 levels correlate with worse postoperative LBP and lower QOL scores. Integrating molecular markers like IL-6 with patient-reported outcomes could provide a more comprehensive approach to postoperative care in spinal disorders, aiming to improve the overall QOL for LDD patients undergoing LLIF surgery.

Erector Spinae Plane Block Placement Utilizing Fluoroscopic Guidance Improves Efficiency in Lumbar Surgery

The erector spinae plane block (ESPB) is a novel regional analgesic technique which improves postoperative outcomes in lumbar surgery patients including length of hospitalization, days to ambulation, and postoperative opioid use. Traditionally, the block is administered by anesthesiologists trained in the ultrasound guidance technique. The use of fluoroscopic guidance may improve the efficiency and accessibility of the ESPB for spine surgeons. We aim to measure the time to administer an ESPB using fluoroscopic guidance and localize the anesthetic using intraoperative three-dimensional (3D) imaging. Two neurosurgeons administered an ESPB to patients undergoing lumbar surgery. Time from insertion of the spinal needle to localize the erector spinae plane using C-arm guidance to time of complete injection and removal of the needle from the skin was recorded. One patient underwent O-arm imaging following injection of an Isovue-Exparel solution at the L3 level to visualize spread of the anesthetic. A total of 21 patients were enrolled in this study. The average duration to perform an ESPB under fluoroscopic guidance was 1.2minutes. The Isovue-Exparel solution was injected at the L3 level and was well distributed along the ESP on intraoperative O-arm imaging. The anesthetic dissected the erector spinae muscle from the transverse process at L2, L3, and L4. Fluoroscopic guidance allows efficient and appropriate delivery of the anesthetic to the erector spinae plane. Performing an ESPB with fluoroscopic guidance improves efficiency and accessibility of the analgesic technique for spine surgeons, reducing dependence on anesthesiology personnel trained in administering the block.

Does Medicare Insurance Mitigate Racial/Ethnic Disparities in Access to Lumbar Spinal Surgery When Compared to Commercial Insurance?

Retrospective cohort study. Compare disparities in lumbar surgical care utilization in Commercially insured versus Medicare patients. While disparities in spinal surgery have been previously described, less evidence exists on effective strategies to mitigate them. Theoretically, universal health care coverage under Medicare should improve health care access. Utilizing National Inpatient Sample data (2003-2018), we included inpatient lumbar discectomy or laminectomy/fusion cases in black, white, or Hispanic patients aged 18-74 years, with Commercial or Medicare insurance. A multivariable Poisson distribution model determined race/ethnicity subgroup-specific rate ratios (RRs) of patients undergoing lumbar surgery compared to their respective population distribution (using US Census data) based on race/ethnicity, region, gender, primary payor, and age (Commercially insured age subgroups: 18-39, 40-54, and 55-64y; Medicare age subgroup: 65-74y). Of the 2,310,956 lumbar spine procedures included, 88.9%, 6.1%, and 5.0% represented white, black, and Hispanic patients, respectively. Among Commercially insured patients, black and Hispanic (compared to white) patients had lower rates of surgical care utilization; however, these disparities decreased with increasing age: black (RR=0.37, 95% CI: 0.37-0.38) and Hispanic patients (RR=0.53, 95% CI: 0.52-0.54) aged 18-39 years versus black (RR=0.72, 95% CI: 0.71-0.73) and Hispanic patients (RR=0.64, 95% CI: 0.63-0.65) aged 55-64 years. Racial/ethnic disparities persisted in Medicare patients, especially when compared to the neighboring age subgroup that was Commercially insured: black (RR=0.61, 95% CI: 0.60-0.62) and Hispanic patients (RR=0.61, 95% CI: 0.60-0.61) under Medicare. Disparities in surgical care utilization among black and Hispanic patients persist regardless of health care coverage, and an expansion of Medicare eligibility alone may not comprehensively address health care disparities. Level III.

Meta-analysis of improved thoracolumbar interfascial plane block on postoperative analgesia and adverse reactions in patients undergoing lumbar surgery

Meta-analysis of improved thoracolumbar interfascial plane block on postoperative analgesia and adverse reactions in patients undergoing lumbar surgery

Correlation of Lumbar Spine Fat Thickness and Surgical Site Infection in Degenerative Lumbar Spine Surgery

Introduction: Surgical site infection (SSI) is a serious and common complication following any surgery. Patientsundergoing lumbar surgery have a higher risk for SSI. Therefore, it is essential to accurately identifythe risk factors of SSIs to prevent them. There is an insufficient number of studies internationally andonly one to our knowledge nationally that studied the correlation between lumbar fat thickness andSSI in patients undergoing lumbar spine surgery. Our aim was to identify the correlation betweenlumbar fat thickness and SSI and determine its predictive value compared to other risk factors inpredicting the incidence of SSI.&#x0D; Methods: This retrospective cohort study involved all patients aged 18 and above who underwent primary elective degenerative lumbar spine surgery in National Guard Health Affairs (NGHA) from 2016 to 2020 at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. All trauma and oncology cases, patients with previous spine surgery, non-instrumented cases, and emergency cases without preoperative radiological images were excluded. The pre-operative and post-operative measurements were assessed using the sagittal MRI images on the T1 view to measure the fat length of the lumbar spine from L2 to S1. Two observers evaluated the films, and the average measurement was documented for each level.&#x0D; Results: 151 patients were included in our study, four of whom developed SSI. When comparing the demographics of both groups, BMI was found to be a significant variable between both groups, with a P-value of 0.013. However, there was no significance regarding age, gender, DM, HTN, steroid use, and level of stay for each group. Furthermore, there was no significance in all vertebrae levels except for L4 fat thickness, which was significantly higher in the SSI group with a P value of 0.0264.&#x0D; Conclusion: Surgical site infection (SSI) is a serious and common complication following any surgical operation. Patients undergoing lumbar surgery have a higher risk for SSI. In this study, we concluded that an increased L4 fat thickness was a significant predictor of SSI.

Prehabilitation for Patients Undergoing Orthopedic Surgery

Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results. To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery. Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022. Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included. Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Pain, function, muscle strength, and health-related quality of life (HRQOL). Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], -0.70 [95% CI, -1.08 to -0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, -8.20 [95% CI, -8.85 to -7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, -0.51 [95% CI, -0.85 to -0.17]) and at 6 months in those undergoing lumbar surgery (SMD, -2.35 [95% CI, -3.92 to -0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence. In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.

Efficacy of erector spinae plane block for postoperative analgesia lumbar surgery: a systematic review and meta-analysis

ObjectivesThe erector spinae plane (ESP) block is a newly defined regional anesthesia technique first described in 2016. The aim of this meta-analysis is to assess the efficacy of ESP block in improving analgesia following lumbar surgery.MethodsPubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials (RCTs) that compared the analgesic efficacy of the ESP block with non-block care for lumbar surgery from inception 3 August 2021. The primary outcomes were postoperative opioid consumption and pain scores during the first 24 h. Postoperative pain was measured as pain at rest and on movement at postoperative 0, 4, 8, 12, and 24 h expressed on a visual analog scale (VAS), where 0 = no pain and 10 = the most severe pain.Results11 studies involving 775 patients were included in our analysis. The use of ESP block significantly decreased 24-h opioid consumption (WMD, -8.70; 95% CI, -10.48 to -6.93; I2 = 97.5%; P < 0.001) compared with the non-block. Moreover, ESP block reduced pain scores at postoperative time-points up to 24 h. ESP block also prolonged the time to first analgesic request (WMD = 6.93; 95% CI: 3.44 to 10.43, I2 = 99.8%; P < 0.001). There was less PONV with ESP block versus non-block group (RR, 0.354; 95% CI, 0.23 to 0.56; I2 = 25.2%; P < 0.001), but no difference in pruritus.ConclusionsESP block provides less opioid consumption and PONV, lower pain scores, and longer time to first analgesic request in patients undergoing lumbar surgery compared to general anesthesia alone.

Comparison of the feasibility and validity of a one-level and a two-level erector spinae plane block combined with general anesthesia for patients undergoing lumbar surgery.

Spinal surgery causes severe postoperative pain. An erector spinae plane (ESP) block can relieve postoperative pain, but the optimal blocking method has not been defined. The aim of this study is to compare the feasibility of a one-level and a two-level lumbar ESP block and their effect on intraoperative and postoperative analgesia in lumbar spinal surgery. A total of 83 adult patients who were scheduled for posterior lumbar interbody fusion were randomly divided into two groups. Patients in Group I (n = 42) received an ultrasound-guided bilateral one-level ESP block with 0.3% ropivacaine, while patients in Group II (n = 41) received a bilateral two-level ESP block. Blocking effectiveness was evaluated, including whether a sensory block covered the surgical incision, sensory decrease in anterior thigh, and quadriceps strength decrease. Intraoperative anesthetic dosage, postoperative visual analogue scale scores of pain, opioid consumption, rescue analgesia, and opioid-related side effects were analyzed. Of the total number, 80 patients completed the clinical trial and were included in the analysis, with 40 in each group. The time to complete the ESP block was significantly longer in Group II than in Group I (16.0 [14.3, 17.0] min vs. 9.0 [8.3, 9.0] min, P = 0.000). The rate of the sensory block covering the surgical incision at 30 min was significantly higher in Group II than in Group I (100% [40/40] vs. 85.0% [34/40], P = 0.026). The rate of the sensory block in the anterior thigh was higher in Group II (43.8% [35/80] vs. 27.5% [22/80], P = 0.032), but the rate of quadriceps strength decrease did not differ significantly between the groups. The mean effect-site remifentanil concentration during intervertebral decompression was lower in Group II than in Group I (2.9 ± 0.3 ng/ml vs. 3.3 ± 0.5 ng/ml, P = 0.007).There were no significant differences between the groups in terms of intraoperative analgesic consumption, postoperative analgesic consumption, and postoperative VAS pain scores at rest and with movement within 24 h. There were no block failures, block-related complications, and postoperative infection. Among patients undergoing posterior lumbar interbody fusion, the two-level ESP block provided a higher rate of coverage of the surgical incision by the sensory block when compared with the one-level method, without increasing the incidence of procedure-related complications. www.chictr.org.cn, identifier: ChiCTR2100043596.

The effects of perioperative low-dose magnesium sulfate infusion on postoperative pain in lumbar surgery

This paper aimed at evaluating the effect of low-dose perioperative magnesium sulfate (MgSO4) on postoperative pain in lumbar surgery. Sixty adult patients were included in this randomized controlled double-blind study. After intubation, an infusion of MgSO4 (10 mg/kg/h) and isotonic saline 0.9% (10 mg/kg/h) were administered in groups M and C, respectively. Heart rate and mean arterial pressure were recorded before and during surgery. Serum magnesium levels were recorded before and after the surgery. Perioperative remifentanil consumption and extubation time were recorded. In the post-anesthesia care room (PACU), Agitation-sedation with Richmond Agitation-Sedation Scale (RASS), the pain was evaluated with Visual Analogue Scale (VAS) and recorded at the baseline, at 5th, 10th, 15th and 30th minutes. Patients were transferred to surgical ward with intravenous patient-controlled analgesia (PCA) for postoperative analgesia and received diclofenac sodium for rescue analgesia if VAS &gt;4. Postoperative VAS scores at 2nd, 4th, 6th and 24th hours, opioid consumption after 4 and 24 hours and rescue analgesic consumption for postoperative 24 h were recorded. In the PACU, RASS scores were statistically lower in group M than in group C (p = 0.001), and VAS scores were statistically lower at all measurement times in group M than in group C. In the surgical ward, VAS Scores were statistically lower in Group M at the 6th and 24th hours than in group C (p = 0.015, p = 0.009, respectively). The need for post-operative rescue analgesic was statistically lower in Group M (p &lt; 0.001). The side effect incidence of both groups was similar. Our findings suggest that perioperative low-dose (10 mg/kg/h) MgSO4 infusion reduces early post-op agitation, VAS scores and the need for analgesics up to 24 hours postoperatively. Low dose MgSO4 infusion can be effectively applied for pain management in patients undergoing lumbar surgery.

Association Between Neighborhood-Level Socioeconomic Disadvantage and Patient-Reported Outcomes in Lumbar Spine Surgery.

Despite an increased understanding of the impact of socioeconomic status on neurosurgical outcomes, the impact of neighborhood-level social determinants on lumbar spine surgery patient-reported outcomes remains unknown. To evaluate the impact of geographic social deprivation on physical and mental health of lumbar surgery patients. A single-center retrospective cohort study analyzing patients undergoing lumbar surgery for degenerative disease from 2015 to 2018 was performed. Surgeries were categorized as decompression only or decompression with fusion. The area deprivation index was used to define social deprivation. Study outcomes included preoperative and change in Patient-Reported Outcomes Measurement (PROMIS) physical function (PF), pain interference (PI), depression, and anxiety (mean follow-up: 43.3 weeks). Multivariable imputation was performed for missing data. One-way analysis of variance and multivariable linear regression were used to evaluate the association between area deprivation index and PROMIS scores. In our cohort of 2010 patients, those with the greatest social deprivation had significantly worse mean preoperative PROMIS scores compared with the least-deprived cohort (mean difference [95% CI]-PF: -2.5 [-3.7 to -1.4]; PI: 3.0 [2.0-4.1]; depression: 5.5 [3.4-7.5]; anxiety: 6.0 [3.8-8.2], all P < .001), without significant differences in change in these domains at latest follow-up (PF: +0.5 [-1.2 to 2.2]; PI: -0.2 [-1.7 to 2.1]; depression: -2 [-4.0 to 0.1]; anxiety: -2.6 [-4.9 to 0.4], all P > .05). Lumbar spine surgery patients with greater social deprivation present with worse preoperative physical and mental health but experience comparable benefit from surgery than patients with less deprivation, emphasizing the need to further understand social and health factors that may affect both disease severity and access to care.

Opioid Use Patterns in a Statewide Adult Medicaid Population Undergoing Elective Lumbar Spine Surgery.

Retrospective administrative database review. Analyze patterns of opioid use in patients undergoing lumbar surgery and determine associated risk factors in a Medicaid population. Opioid use in patients undergoing surgery for degenerative lumbar spine conditions is prevalent and impacts outcomes. There is limited information defining the scope of this problem in Medicaid patients. Longitudinal cohort study of adult South Carolina (SC) Medicaid patients undergoing lumbar surgery from 2014 to 2017. All patients had continuous SC Medicaid coverage for 15 consecutive months, including six months before and nine months following surgery. The primary outcome was a longitudinal assessment of postoperative opioid use to determine trajectories and group-based membership using latent modeling. Univariate and multivariable modeling was conducted to assess risk factors for group-based trajectory modeling and chronic opioid use (COU). A total of 1455 surgeries met inclusion criteria. Group-based trajectory model demonstrated patients fit into five groups; very low use (23.4%), rapid wean following surgery (18.8%), increasing use following surgery (12.9%), slow wean following surgery (12.6%) and sustained high use (32.2%). Variables predicting membership in high opioid use included preoperative opioid use, younger age, longer length of stay, concomitant medications, and readmissions. More than three quarter of patients were deemed COUs (76.4%). On bivariate analysis, patients with degenerative disk disease were more likely to be COUs (24.8% vs. 18.6%; P =0.0168), more likely to take opioids before surgery (88.5% vs. 61.9%; P <0.001) and received higher amounts of opioids during the 30 days following surgery (mean morphine milligram equivalents 59.6 vs. 25.1; P <0.001). Most SC Medicaid patients undergoing lumbar elective lumbar spine surgery were using opioids preoperatively and continued long-term use postoperatively at a higher rate than previously reported databases. Preoperative and perioperative intake, degenerative disk disease, multiple prescribers, depression, and concomitant medications were significant risk factors.

P41. Reoperation, complications and patient reported outcomes in patients with Parkinson's disease undergoing elective spine surgery: a propensity matched analysis

<h3>BACKGROUND CONTEXT</h3> Parkinson's Disease (PD) is a common neurodegenerative condition that has become increasingly prevalent in an aging population. While surgical treatment for degenerative spine pathology is often required in this population, previous literature has suggested that patients with PD have higher complication rates and inferior outcomes compared to the general population. <h3>PURPOSE</h3> To determine if patients with PD have worse PROs and higher reoperation, complication and readmission rates after elective spine surgery compared to the general population when adjusting for baseline covariates through propensity matching. <h3>STUDY DESIGN/SETTING</h3> A retrospective review of prospectively collected data from the Quality Outcomes Database (QOD), a national, longitudinal, multicenter spine outcomes registry was performed. <h3>PATIENT SAMPLE</h3> For the lumbar cohort, 343 patients with PD and 46,738 patients without PD were included. The cervical myelopathy cohort included 49 patients with PD and 6,426 patients without PD. The cervical radiculopathy cohort consisted of 37 patients with PD and 13,751 patients without PD. <h3>OUTCOME MEASURES</h3> Outcomes included: 1) reoperation, 2) complications, 3) readmission, and 4) PROs of NDI/ODI, NRS back/arm/leg pain, mJOA scores, patient satisfaction ratings at 3 and 12 months. In addition, Qaly scores were assessed at 12 months. <h3>METHODS</h3> Data from the QOD was queried between 04/2013-01/2019. Three surgical groups were identified: 1) Elective lumbar surgery, 2) Elective cervical surgery for myelopathy, 3) Elective cervical surgery for radiculopathy. Patients with any other neurodegenerative condition other than PD were excluded. Patients without PD were propensity matched against patients with PD in a 5 to 1 ratio without replacement based on ASA grade, arthrodesis, surgical approach, number of operated levels, age, and baseline ODI, NRS extremity pain, NRS back pain and EQ5D. Regressions with cluster-robust standard errors were used to estimate average effect of how the outcome would change if the PD patient didn't have the disease. The mean difference was used for continuous outcomes (ODI, NRS leg pain, NRS back pain, and EQ-5D at 3 and 12 months after surgery) and the risk difference was used for binary outcomes (patient satisfaction, complications, readmission, revision surgery and mortality). <h3>RESULTS</h3> For the lumbar analysis, PD patients had a higher rate of revision surgery at 12 months (risk difference=0.057, p=0.015) and lower mean Qaly score at 12 months (mean difference=-0.053, p=0.005) when compared to the control group. For the cervical myelopathy cohort, PD patients had lower NRS neck pain scores at 3 months (mean difference=-0.829, p=0.005) but also lower patient satisfaction at 3 months (risk difference=-0.262, p=0.041) compared to the control group. For the cervical radiculopathy cohort, PD patients demonstrated a lower readmission rate at 3 months (risk difference=-0.045, p=0.014) compared to the control group. <h3>CONCLUSIONS</h3> Patients with PD had similar PROs at 12 months following elective spine surgery when adjusting for baseline covariates through propensity matching. PD patients undergoing lumbar surgery had a higher reoperation rate than those without PD. These results demonstrate that a diagnosis of PD should not be a major contraindication to elective spine surgery, as PD patients had similar 12-month PROs compared to those without PD, though decreased PROs at 3-months and higher reoperation rates in lumbar surgery may be seen. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Analgesic Efficacy and Safety of Local Infiltration Following Lumbar Decompression Surgery: A Systematic Review of Randomized Controlled Trials.

This systematic review aims to appraise available clinical evidence on the efficacy and safety of wound infiltration with adjuvants to local anesthetics (LAs) for pain control after lumbar spine surgery. A database search was conducted to identify randomized controlled trials (RCTs) pertinent to wound infiltration with analgesics or miscellaneous drugs adjunctive to LAs compared with sole LAs or placebo. The outcomes of interest were postoperative rescue analgesic consumption, pain intensity, time to first analgesic request, and the occurrence of adverse events. Twelve double-blind RCTs enrolling 925 patients were selected for qualitative analysis. Most studies were of moderate-to-good methodological quality. Dexmedetomidine reduced analgesic requirements and pain intensity within 24 h postoperatively, while prolonged pain relief was reported by one RCT involving adjunctive clonidine. Data on local magnesium seem promising yet difficult to interpret. No clear analgesic superiority could be attributed to steroids. Τramadol co-infiltration was equally effective as sole tramadol but superior to LAs. No serious adverse events were reported. Due to methodological inconsistencies and lack of robust data, no definite conclusions could be drawn on the analgesic effect of local infiltrates in patients undergoing lumbar surgery. The probable positive analgesic efficacy of adjunctive dexmedetomidine and magnesium needs further evaluation.

Type of anesthesia and quality of recovery in male patients undergoing lumbar surgery: a randomized trial comparing propofol-remifentanil total i.v. anesthesia with sevoflurane anesthesia

BackgroundPrevious studies have shown that women achieve a better quality of postoperative recovery from total intravenous anesthesia (TIVA) than from inhalation anesthesia, but the effect of anesthesia type on recovery in male patients is unclear. This study therefore compared patient recovery between males undergoing lumbar surgery who received TIVA and those who received sevoflurane anesthesia.MethodsEighty male patients undergoing elective one- or two-level primary transforaminal lumbar interbody fusion (TLIF) were randomly divided into two groups: the TIVA group (maintenance was achieved with propofol and remifentanil) or sevoflurane group (SEVO group: maintenance was achieved with sevoflurane and remifentanil). The quality of recovery-40 questionnaire (QoR-40) was administered before surgery and on postoperative days 1 and 2 (POD1 and POD2). Pain scores, postoperative nausea and vomiting, postoperative hospital stay, anesthesia consumption, and adverse effects were recorded.ResultsThe QoR-40 scores were similar on the three points (Preoperative, POD1 and POD2). Pain scores were significantly lower in the SEVO group than in the TIVA group on POD1 (30.6 vs 31.4; P = 0.01) and POD2 (32 vs 33; P = 0.002). There was no significant difference in the postoperative hospital stay or complications in the postanesthesia care unit between the TIVA group and the SEVO group.ConclusionsThis study demonstrates that the quality of recovery is not significantly different between male TLIF surgery patients who receive TIVA and those who receive sevoflurane anesthesia. Patients in the TIVA group had better postoperative analgesic effect on POD2.Trial registrationThis was registered at http://www.chictr.org.cn (registration number ChiCTR-IOR-16007987, registration date: 24/02/2016).

Costs associated with potentially unnecessary postoperative healthcare encounters after lumbar spine surgery

BACKGROUND CONTEXTExcessive use of postoperative imaging after lumbar surgery has been documented, becoming a target for cutting costs. This must be balanced with the patient's need for information and allay their postoperative concerns. PURPOSETo determine the incidence and associated costs of patient interactions with the healthcare system, outside the standard follow up routine, in the first postoperative year. STUDY DESIGNRetrospective longitudinal cohort. PATIENT SAMPLEConsecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 from a multi-surgeon single tertiary spine center. OUTCOME MEASURESAll healthcare encounters: phone calls, office and emergency department visits, and additional testing METHODSA consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 were identified. All non-routine healthcare encounters: phone calls, office and emergency department visits, and additional testing were collected. Direct costs for all healthcare services were determined using the Medicare Allowable rates. Indirect costs were determined using local, median income, length of office visits, and distance from the clinic to the patient's home. RESULTSOf 200 patients, 14 with thoracic fusion were excluded. The mean age of the 186 included patients was 58.26 years and 85 (46%) were male. Forty-seven percent (87/186) had only routine postoperative visits and 24 had revision surgery. Seventy-five patients made a total of 102 phone calls, 55 office visits, leading to 38 diagnostic studies none of which led to an additional intervention. Using Medicare Allowable rates, the mean direct cost was $776 per patient and the using a median income of $16/h the mean indirect cost was $124 per patient. There were no differences in the baseline characteristics among the patients who only had routine post-op encounters, had non-routine encounters or had a repeat surgery. CONCLUSIONSForty percent of the patients undergoing lumbar surgery had a healthcare encounter outside their routine follow up that did not result in additional intervention after their index operation. These potentially unnecessary encounters create additional cost and inconvenience to both the patient and healthcare system. Providing patient reassurance is important and providers should identify ways to reduce associated costs through patient education, virtual visits, or new technologies to monitor patient's postoperative progress.

Preoperative pain neurophysiology education for lumbar radiculopathy: A randomized-controlled trial.

Objectives This study aims to investigate the postoperative short-term effectiveness of preoperative pain neurophysiology education on pain severity, kinesiophobia, and disability in patients undergoing lumbar surgery for radiculopathy. Patients and methods Between April 2019 and August 2019, a total of 41 patients (22 males, 19 females; mean age 52.1±9.5 years; range, 37 to 64 years) scheduled for lumbar radiculopathy surgery were randomized to receive either preoperative routine education only (control group, n=20) or a 70-min pain neurophysiology education in addition to preoperative routine education (intervention group, n=21). The patients were evaluated for the following outcomes prior to surgery (baseline) and at 12 weeks after surgery: low back pain and leg pain using Numeric Pain Rating Scale, disability using Oswestry Disability Index), and kinesiophobia using Tampa Scale for Kinesiophobia. Results There were no statistically significant differences in low back pain (p=0.121), leg pain (p=0.142), and the length of stay hospital (p=0.110) between the groups. However, the interaction effects of intervention group were superior to control group regarding disability (p=0.042) and kinesiophobia (p<0.001). Conclusion The addition of pain neurophysiology education to routine education following lumbar radiculopathy surgery yields significant improvements for disability and kinesiophobia, although no additional benefits is seen regarding the pain severity and length of stay in hospital in the short-term.

Wound infiltration of dexmedetomidine as an adjunct to local anesthesia in postoperative analgesia for lumbar surgery.

Most patients undergoing lumbar surgery experience varying degrees of incision pain, leading to prolonged postoperative recovery and poor satisfaction with treatment. The objective of this meta-analysis was to evaluate the efficacy and safety of dexmedetomidine as an adjunct to local anesthesia for postoperative pain control after lumbar surgery. Two authors independently searched eligible random controlled trials in electronic databases, including PubMed, Embase, Cochrane Library, Web of Science, CNKI (China National Knowledge Infrastructure), CBM (The Chinese BioMedical database) using the search terms "dexmedetomidine," "infiltration," and "lumbar." The random-effect model was used to perform the meta-analysis based on deviance information criteria. Six trials evaluating a total of 330 patients were included in this review. Wound infiltration with dexmedetomidine significantly reduced the postoperative VAS scores (4th hour static VAS scores (MD=-1.03; 95% CI: -1.58 to -0.47; P=0.0003); 24th hour static VAS scores (MD=-0.66; 95% CI: -0.91 to -0.40; P<0.00001); 6th hour dynamic VAS scores (MD=-1.84; 95% CI: -2.23 to -1.45; P<0.00001) and total supplemental analgesic consumption (SMD=-2.01; 95% CI: -3.04 to -0.98; P<0.00001), prolonged the median time to first rescue analgesia (SMD=3.53; 95% CI:2.31 to 4.76; P<0.00001), and reduced the incidence of nausea or vomiting (RR=0.40; 95% CI: 0.17 to 0.93; P<0.05). Dexmedetomidine infiltration appears to be a promising and safe adjunct for postoperative pain control after lumbar surgery. However, more studies are needed to assess the prevalence of other side effects.

Modic Change and Clinical Assessment Scores in Patients Undergoing Lumbar Surgery for Disk Herniation.

Retrospective cohort study. To examine the relationship between preoperative Modic change (MC) and postoperative clinical assessment scores for patients receiving lumbar discectomy or transforaminal lumbar interbody fusion for lumbar disk herniation. Lumbar disk herniation is a risk factor for MC development. MC on spinal magnetic resonance imaging (MRI) has been associated with worse preoperative and postoperative clinical assessment scores. We reviewed data for 285 primary single-level surgeries. Preoperative and 12-month postoperative assessment scores were recorded using the visual analog scale leg pain, Oswestry Disability Index, and Short Form-36 Physical Component Summary. MC subgroup on preoperative MRI was recorded by a single neuroradiologist. One hundred seventy-nine patients (female, 56%; age-53±13 y) with preoperative MRI were included. Age and sex were similar across MC subgroups. The sample prevalence of MC on preoperative MRI was 62%, and MC2 was the most common subgroup (35%). No differences in preoperative assessment scores were identified, regardless of presence or absence of MC. For the overall cohort, improvement in assessment scores were observed: Short Form-36 improved an average of 8.2 points [95% CI (95% CI), 5.8-10.7], Oswestry Disability Index by 11.3 points (95% CI, 8.7-14.0), and visual analog scale by 2.8 points (95% CI, 2.1-3.5). In nearly all cases, MCID values were met, even when stratifying by MC subgroup. Few differences in postoperative assessment scores were identified when comparing across MC1, MC2, or no MC groups. Statistically and clinically significant improvement in postoperative clinical assessment scores was observed for both lumbar discectomy and transforaminal lumbar interbody fusion groups. MC on preoperative MRI was not associated with worse preoperative or postoperative clinical assessment scores. Level III.

Is Length of Stay Influenced by the Weekday On Which Lumbar Surgery is Performed?

Reducing length of stay (LOS) in a safe manner has the potential to save significant costs for the care of patients undergoing elective lumbar spine surgery. Due to the relative absence on weekends of staff required for discharging patients to rehabilitation or nursing facilities, we hypothesize that patients undergoing lumbar surgery later in the week have a longer LOS than their counterparts. To analyze the effect of day of the week for lumbar surgery on LOS. Patients undergoing surgery for lumbar degenerative disease were prospectively enrolled in the multicenter quality and outcomes database registry. A multivariable proportional odds regression model was built with LOS as the outcome of interest and patient and surgical variables as covariates. A total of 11 897 patients were analyzed. Among those discharged home, the regression analysis demonstrated significantly higher odds of longer LOS for patients undergoing surgery on Friday as compared to Monday (P<.001). Among those discharged to a facility, there were significantly higher odds of longer LOS for patients undergoing surgery on Wednesday (P<.001), Thursday (P<.001), and Friday (P=.002) as compared to Monday. The findings of this study suggest that lumbar patients undergoing fusions and those discharged to a facility have longer LOS when surgery is later in the week. Scheduling these patients for surgery earlier in the week and ensuring adequate resources for patient disposition on weekends may lead to LOS reduction and cost savings for hospitals, payers, and patients alike.