Posterior Spinal Decompression Research Articles

F.6 Opportunities for improvement: understanding drivers of emergency department visits within 90 days of posterior spinal decompression surgery

Background: Canadian Emergency Departments (EDs) are overburdened. Understanding the drivers for postoperative patients to attend the ED allows for targeted interventions thereby reducing demand. We sought to identify “bounce back” patterns for subsequent QI initiatives. Methods: From April 1, 2016 to March 31, 2022, all provincial ED datasets (EDIS, STAR, Meditech) identified patients presenting within 90 days post-spine surgery. Using Canadian Classification of Health Interventions codes, laminectomies (1SC80) and discectomies (1SE87) demonstrated the highest ED visit rates. Comprehensive chart reviews were conducted identifying surgical and medical reasons for presentation within this timeframe. Results: Reviewing a cohort of 2165 post-decompression patients, 42.1% presented to the ED (n=912) with 62.8% of these directly related to surgery. Primary reasons included wound care (31.6%), pain management (31.6%), and bladder issues (retention or UTI, 11.0%). Simple wound evaluation constituted 49.7% of wound-related visits, with surgical site infection 37.6% and dehiscence 6.6% accounting for the remainder. Pain-related presentations resulted in 72.3% discharge with additional medications, and 27.7% necessitating hospital admission. New or worsening neurologic deficits were reported in 8.9% of ED visits. Conclusions: These findings illuminate crucial aspects of postoperative care and ED utilization patterns. Prioritizing patient education, pain management, and wound care could help alleviate the national ED crisis.

Cauda Equina Syndrome: Cost Burden After Spinal Decompression.

Observational cohort study. Cauda equina syndrome (CES) is a rare neurologic condition with potentially devastating consequences. The objective of this study was to compare the 2-year postoperative cost-associated treatments after posterior spinal decompression between patients with and without CES. By analyzing a commercial insurance claims database, patients who underwent posterior spinal decompression with a concurrent diagnosis of lumbar spinal stenosis, radiculopathy, or disk herniation in 2017 were identified and included in the study. The primary outcome was the cost of payments for identified treatments in the 2-year period after surgery. Treatments included were (1) physical therapy (PT), (2) pain medication, (3) injections, (4) bladder management, (5) bowel management, (6) sexual dysfunction treatment, and (7) psychological treatment. In total, 3,140 patients (age, 55.3 ± 12.0 years; male, 62.2%) were included in the study. The average total cost of treatments identified was $2,996 ± 6,368 per patient. The overall cost of identified procedures was $2,969 ± 6,356 in non-CES patients, compared with $4,535 ± 6,898 in patients with CES ( P = 0.079). Among identified treatments, only PT and bladder management costs were significantly higher for patients with CES (PT: +115%, P < 0.001; bladder management: +697%, P < 0.001). The difference in overall cost was significant between patients (non-CES: $1,824 ± 3,667; CES: $3,022 ± 4,679; P = 0.020) in the first year. No difference was found in the second year. A short-term difference was observed in costs occurring in the first postoperative year. Cost of treatments was similar between patients apart from PT and bladder management.

Improvement of Postoperative Quality of Life in Patients Over 80 Years Old With Thoracic Spinal Stenosis.

A retrospective comparative study was conducted to analyze the outcome of surgical and conservative treatment for patients over 80 years old with thoracic spinal stenosis (TSS). To evaluate the safety and efficiency of posterior spinal cord decompression surgery for over 80-year-old patients with TSS. Concerned about the risk of surgery, over 80-year-old patients with TSS are usually treated conservatively, which often leads to a decline in quality of life. So far as we know, no study demonstrates the risk and benefit of spine surgery for these patients. Over 80 years of age who underwent dorsal decompression surgery or conservative treatment due to TSS between January 2010 and November 2020 were analyzed. Sixty-four patients who completed follow-up PROM (patient-reported outcome measure) data were collected, including the mJOA (modified Japanese Orthopedic Association score) scoring system, VAS (visual analogue scale), questionnaire-based assessment of the ODI (Oswestry disability index), BI (Barthel index), and SF-36v2 (Short Form-36v2) Health Survey. The clinical characteristics, preoperative and postoperative imaging findings, operative records, complications, and individual outcomes were analyzed. Of the 64 patients, 38 underwent posterior decompression, pedicle screw fixation, and posterolateral fusion; another 26 chose conservative treatment. The baseline characteristics of the TSS patients in 2 groups show no significant differences. The clinical symptoms and imaging outcomes showed a significant improvement in the surgical group compared with the nonsurgical group, according to mJOA, VAS, ODI, BI, and SF-36v2. Cerebrospinal fluid leakage occurred in 6 patients, and transient neurological impairment occurred in 2 patients. Posterior decompression surgery for over 80-year-old patients with TSS is a safe and effective treatment, it has a good clinical outcome as well as an acceptable complication rate. However, there were no obvious improvements in quality of life or pain with conservative treatment.

Efficacy of Liposomal Bupivacaine in Reducing Opioid Use After Posterior Lumbar Spinal Decompression and Fusion.

Despite improvements in drug therapy and treatment of lumbar spinal disorders, dependence on opioid medication for postoperative pain control remains a concern nationwide. This study assessed the ability to diminish the reliance on opioid medication postoperatively with the Food and Drug Administration-approved local anesthetic liposomal bupivacaine in open posterior lumbar decompression and fusion procedures. In addition, the possible effects of this modality on other parameters were studied regarding patients and their recovery. A retrospective chart review of 198 patients who underwent an open posterior lumbar laminectomy and fusion surgery with instrumentation treated by a single surgeon in a single institution was conducted. Ninety-nine patients who received liposomal bupivacaine administered intraoperatively were then matched by age, sex, and procedure with the same number of patients treated prior to the availability of liposomal bupivacaine. We evaluated how the use of liposomal bupivacaine affected the requirement for postoperative opioid medication, as well as related changes in length of stay, the use of antiemetics, and urinary retention postoperatively. The patients who received liposomal bupivacaine required less than half of the morphine milligram equivalents of narcotic medications during their hospital stay compared with patients who did not receive liposomal bupivacaine (approximately 57% reduction). The findings of this study suggest that the addition of liposomal bupivacaine to traditional pain management modalities can augment pain management for patients undergoing posterior lumbar surgery, as evidenced by the significant decrease in postoperative morphine milligram equivalents required. [Orthopedics. 2024;47(4):244-248.].

Educating residents in spine surgery: A study of Entrustable professional activities in neurosurgery and orthopedic surgery.

Surgery for spinal disorders represents some of the commonest surgical procedures performed in many countries worldwide, carried out by neurosurgeons and orthopedic surgeons. Residency training is shifting to competency-based medical education, which requires setting standards for graduating residents and their assessments. However, gaps exist in the literature regarding the parameters used for assessment and the mastery levels expected of graduating residents in the performance of common spinal procedures as defined in Entrustable Professional Activities (EPAs). The objectives of the study were to describe the assessment parameters used for residents, identify the standard of performance expected of graduating residents of EPAs of spinal procedures, and identify factors predicting the expected standard of competent performance of graduating residents. The survey was sent to neurosurgery and orthopedic surgery Faculty requesting their recommendations on parameters of assessment and the expected standard competence performance for EPAs related to spinal procedures using our entrustment scale (A-E). Based on total responses, the recommended number of assessments and assessors for each EPA was 5 and 2, respectively. Regarding each specialty, there was no significant difference in the recommended number of assessments for each EPA. However, neurosurgery Faculty recommended higher number of assessors(n = 3) than orthopedic surgery Faculty(n = 2) for both posterior spinal decompression EPA(PSD) (p = 0.01) and spinal instrumentation EPA(SI) (p = 0.04). Based on total responses, 83% felt PSD was appropriate to the general practice, 86.8% considered it not too broad, and 62.3% expected entrustment level E as a graduation target. The proportions of these ratings were slightly lower for SI at 58.5%, 71.7% and 56.6%, respectively. Both specialties indicated that the EPAs were not too broad. In contrast, neurosurgery Faculty were more likely to consider these EPAs appropriate for general practice than orthopedic surgery Faculty for both PSD (94.7% vs 53.3%, p = 0.0003) and SI (68.4% vs 33.3%, p = 0.02). Moreover, neurosurgery Faculty had a higher expected standard of performance as a graduation target for both PSD (Level E 76.3% vs 26.7%, p = 0.001) and SI (Level E 65.8% vs 33.3%, p = 0.03) than orthopedic surgery Faculty. Expectations of entrustment level E for PSD was associated with the belief that the current EPA was appropriate for the general practice of their specialty with an odds ratio of 8.35 (p = 0.01, 95%CI 1.53-45.67). A difference exists in parameters of assessment and expected standard competence performance of spine procedures among spinal surgery specialties. In our opinion, there should be efforts to develop consensus between specialties for the sake of uniform delivery of high-quality care for patients regardless of the specialty of their surgeon. Our results will be particularly valuable to certification bodies in the assessment of spinal milestones. This study has important implications for the design of residency and fellowship education in spinal surgery internationally.

UNEXPLAINED UNILATERAL LOWER LIMB NEUROLOGICAL DEFICITS AFTER POSTERIOR SPINAL DECOMPRESSION AND FUSION FOR DEGENERATIVE LUMBAR SPONDYLOLISTHESIS

The observational data from the Spine Patient Outcomes Research Trial (SPORT) confirm the superiority of surgical over conservative management of symptomatic degenerative spondylolisthesis. The most common reported neurologic complications after lumbar posterior decompression and fusion are implant malposition, contralateral foraminal stenosis, hematoma/seroma, arachnoiditis, and nerve root oedema or vascular underlying causes. The current study reported that the patient developed unexpected left side neurological deficit after conventional lumbar posterior spinal decompression surgery for degenerative spondylolisthesis. No intraoperative dural insult. The computer topography (CT) scan and magnetic resonance imaging (MRI) of the spine after index surgery show adequate canal and foraminal decompression. No hardware-related complications or compressive hematoma could explain the patient’s symptoms. The patient recovered completely after removing the redundant posterolateral bone graft. The theory behind that is aggressive posterolateral dissection over the transverse process and abundant application of the bone graft might compress or injure the lumbar plexus. So, we suggested a delicate dissection posterolaterally and only a reasonable amount of bone graft could be applied to prevent such a devastating neurological complication.

Efficacy of cement-augmented pedicle screw fixation for osteoporotic mid-thoracic vertebral fractures.

Osteoporotic mid-thoracic vertebral fractures (OmTVF), often result in severe pain, and neurological deficits secondary to cord compression. Cement-augmented pedicle screw (CaPS) fixation with posterior spinal decompression (PSD) offers simultaneous decompression with stabilization of these osteoporotic vertebral fractures. The study involved 32 patients (2022-2023) with T8-T10 osteoporotic vertebral compression fractures resulting in cord compression. All patients underwent CaPS surgery with PSD. Pain reduction was measured using the visual analog scale (VAS), and outcomes with the Oswestry Disability Index, and the American Spinal Injury Association Grades. The local kyphotic angle was also tracked with computed tomography studies performed 1, 3, and 6 months post-operatively. The average pre-operative VAS score was 8.56 mm; this decreased at 1, 3, and 6 months post-operatively to 2.72 mm, 2.03 mm, and 1.44 mm, respectively. In addition, 31 of 32 patients fully recovered within 6 postoperative months. For 31 of 32 patients with T8-T10 osteoporotic vertebral fractures, CaPS fixation with PSD successfully alleviated pain and resulted in significant post-operative neurological recovery.

Dichotomous Profile of Thoraco-Lumbar Dislocation Fractures. Case Report and Review of the Literature

Dislocated thoracolumbar fractures are uncommon injuries following a major trauma. We report a case of thoraco-lumbar dislocated fracture of which radiological finding was in discrepancy with clinical aspect and postoperative neurological recovery. A 32-year-old female admitted in Neurosurgery Department of the University Hospital of Kinshasa for low back pain, functional impotence of lower limbs and urinary retention following a road traffic accident three weeks prior. She presented a painful swelling at level of T12-L2 spinous processes and Wagner's grade IV gluteal pressure sores. Neurologically, on both limbs, the sensation was preserved and motor strength was graded 3/5 globally. CT-Scan showed a fracture of the vertebral body and pedicles of L2 with retrolisthesis of L1/L2 grade IV (Magerl B.3.3). She underwent posterior spinal decompression followed by spinal stabilisation with pedicle screws. The gluteal ulcers were debrided and sutured during the same surgery. Postoperatively, the pressure ulcers healed and the patient recovered full motor and urinary sphincter functions after twelve months of physiotherapy. This case report demonstrates the possibility of discordance between radiological images of dislocated thoracolumbar fractures and spinal cord injury clinical.

Walking status and spinopelvic parameters in young children with achondroplasia: 10-year follow-up.

Thoracolumbar kyphosis (TLK) is common in children with achondroplasia and resolves in 90% by 10years of age. Our purpose was to describe the natural progression of TLK in a cohort of pre-walking children with achondroplasia. A single-center, retrospective review identified 62 children (32 male, 30 female) with achondroplasia. Clinical information and sagittal spinopelvic parameters were collected. The children were divided into positive pelvic tilt (PT) and negative PT. All parents were routinely counseled about unsupported sitting. Spontaneous resolution rate was 64.5% at 1-year post-walking, 74.2% at 5years of age, and 88.7% at 10years of age. None of the children required posterior spinal decompression and fusion for progressive deformity or symptomatic spinal stenosis. At 1-year post-walking, the negative PT group had a higher sacral slope (p = 0.006), higher lumbar lordosis (p < 0.001), and lower pelvic incidence (p < 0.001). This relationship remained constant up to 10years of age, and there was no association with TLK. In this largest series to date, spontaneous resolution of TLK in children with achondroplasia was 64.5% at 1-year post-walking, 74.2% at 5years of age, and 88.7% in children followed to 10years of age. With early identification and regular follow-up with patient education, no patient in this series required treatment or developed symptomatic spinal stenosis. While not predictive of resolution of TLK, the dichotomous presentation of PT in young children with achondroplasia persists at 5 and 10years of age and reliably predicts the spinopelvic parameters. III-retrospective comparative study.

Uniportal Thoracic Endoscopic Unilateral Laminotomy with Bilateral Decompression of Thoracic Ossification of Ligamentum Flavum: A Systematic Review of Current Literature

Thoracic ossification of ligamentum flavum (TOLF) is a rare disease that often results in worsening neurologic sequelae if left untreated. Although the gold standard treatment for TOLF is open posterior laminectomy, it is often accompanied by high rates of complications and perioperative morbidity. There have been studies looking into feasibility of endoscopic posterior decompression for TOLF, citing potential for lower perioperative morbidity and achieving similar functional outcomes to its open laminectomy counterparts. We provide an up-to-date systematic review of clinical outcomes after endoscopic posterior decompression for TOLF from the latest assemblage of evidence. A systematic review of the technique was conducted from May 2000 to May 2023. Articles were selected based on PRISMA guidelines. Eligibility of studies was independently by 2 reviewers, with disagreements resolved by a third author. Nineteen primary references comprising 337 patients with TOLF who underwent endoscopic posterior decompression were included in the systematic review. Mean follow-up time across all studies ranged from 8.9 to 65.3 months. Mean age ranged from 51.2 to 63 years, with mean intraoperative blood loss ranging from 15 to 62 mL. There is significant improvement in visual analog scale (VAS) score, VAS back, VAS leg, modified Japanese Orthopaedic Association score, and Oswestry Disability Index compared with preoperative recorded values across all studies, with low rates of complications reported. Endoscopic posterior spinal decompression is a safe and effective technique for treatment of TOLF, with a low rate of complications and improvement in pain and function.

Larsen Syndrome and Associated Spinal Deformities.

Larsen syndrome is a rare genetic disorder that affects the connective tissue within the body. The present narrative review aims to examine the genetic basis of Larsen syndrome, clarify its symptoms, and define all the existing therapeutic approaches. A comprehensive search was performed in the PubMed database. Inclusion criteria considered molecular and clinical studies, management and surgical treatment of related deformities, case reports of patients with the syndrome, reviews of the associated anomalies, articles whose full text is available in PubMed, and articles published in the English language. Larsen syndrome is caused by mutations in the FLNB gene, which encodes the cytoskeletal protein filamin B, crucial in the development of the skeleton. Symptoms include joint dislocations, characteristic facial features and anomalies of the spine. Larsen syndrome may be conservatively treated initially, although surgical intervention is usually required. Various surgical techniques, including posterior spinal fusion, anterior decompression, circumferential arthrodesis, and single-stage 360° fixation, have been proposed along with growth-sparing procedures. Preoperative and postoperative care and education ensure optimal results. Further research is needed to identify novel therapeutic modalities for this condition.

DEVELOPMENT OF A MATHEMATICAL MODEL OF SELECTING THE EXTENT OF A SURGICAL INTERVENTION IN SPINAL TUMOR.

The aim: To develop a mathematical model of selecting the extent of surgical intervention in the spinal tumors. Materials and methods: The retrospective study included 237 patients with spinal tumors who underwent the following surgeries: vertebroplasty (V); vertebroplasty and spinal fixation (F+V); posterior spinal decompression and spinal fixation (F+F); vertebrectomy and replacement of vertebra by a cage with posterior spinal fixation (F+F+K). The mathematical model is based on the modified Spine Instability Neoplastic Score (SINS). The patients were divided into two clusters. Cluster analysis was used to build a diagnostic decision tree model. Results: The difference between two clusters is determined by the extent of surgical intervention, the grade of the vertebral lesion, epidural compression, and local kyphosis, and neurological signs as well. The cluster 1 included 115 patients with higher values of SINS compared to the cluster 2. All cases of vertebroplasty belonged to the cluster 2. In the cluster 1 cases of surgery of large extent: F+F; F+V; F+F+K. Analysis of the decision tree model for cluster 1 showed that a type of surgery was determined for 97 patients from 115 that relates to 84.3% of overall accuracy. The decision tree model have a high predictive accuracy for the surgery F+V and better indicators of coverage and predictive accuracy for the surgery F+F+K. Conclusions: Our study developed a decision tree model to optimize spinal neoplasm surgery, achieving 84.3% accuracy based on significant prognosis criteria. The model considers surgical type, neurological signs, vertebra lesion grade, and stage of epidural compression, potentially improving clinical outcomes.

Posterior spinal decompression in adults with spinal cord injury without traumatic compromise of the spinal canal: what is the data?

Spinal cord injury (SCI) can be caused by a variety of factors and its severity can range from a mild concussion to a complete severing of the spinal cord. Τreatment depends on the type and severity of injury, the patient's age and overall health. Reduction of dislocated or fractured vertebrae via closed manipulation or surgical procedures, fixation and removal of bony fragments and debris that compromise the spinal canal are indicated for decompression of the spinal cord and stabilization of the spine. However, when there is no obvious traumatic obstruction of spinal canal, the question arises as to whether laminectomy is needed to be performed to improve neurological outcome. A literature review covering all indexed studies published between 2013 and 2023 was performed using keywords to identify the patient group of interest (spinal cord injury, SCI, spinal cord trauma, cervical, thoracic, lumbar, thoracolumbar),central cord syndrome (CCS) and the interventions (laminectomy, laminoplasty, decompression, duroplasty). This review includes6 observational studies investigating the outcome of posterior spinal decompression in patients suffering from spinal cord injury without traumatic spinal cord stenosis. Most patients already had degenerative stenosis. From a total of 202, 151 patients (74.7%) improved neurologically by at least one grade at ASIA scale, after being treated with either laminectomy, laminoplasty, duroplasty or a combination of these techniques. Early decompression in SCI patients remains a reasonable practice option and can be performed safely, but no specific evidence supports the use of laminectomy alone. There is emerging evidence that intended durotomy followed by extended meningoplasty may improve the neurological outcome in patients suffering from SCI when meta-traumatic edema is apparent. However, the lack of high-quality evidence and results support the need for further research.

Wound drain in lumbar arthrodesis for degenerative disease: an experimental, multicenter, randomized controlled trial

INTRODUCTIONDrains for surgical wound management are frequently used in spine surgery. They are often used to decrease the incidence of postoperative hematoma and decrease wound tension. No conclusive evidence in the literature supports using drains to avoid complications in degenerative lumbar spine surgery. PURPOSEWe aimed to evaluate wound drains in patients with lumbar arthrodesis for degenerative disorders based on clinical outcomes, complications, hematocrit, and length of stay. STUDY DESIGNA multicenter randomized prospective controlled clinical trial. PATIENT SAMPLEWe enrolled surgical candidates for posterior lumbar decompression and fusion surgery for degenerative disorders from October 2019 to August 2021. Patients were randomized into the drain or nondrain group at nine hospitals. The inclusion criteria were as follows: patients aged 40 to 80 years with lumbar and radicular pain, lumbar degenerative disorder, and primary surgery up to three levels. The exclusion criteria were bleeding abnormalities, bleeding >2,500 mL and dural tears. OUTCOME MEASURESPreoperative data including Oswestry disability index (ODI), SF-36, lumbar and lower extremity visual analog scale (VAS), body mass index (BMI), hematocrit, and temperature were recorded. Surgical parameters, including surgical time, complications, estimated blood loss (EBL), postoperative temperature and hematocrit (days 1 and 4), dressing saturation, and length of hospital stay (LOS), were registered. METHODSThe two groups were assessed preoperatively, perioperatively and at the 1-month follow-up. A REDCap database was used for registration. Data analysis was performed using classical statistics. RESULTSOne hundred one patients were enrolled using the Redcap database, and 93 patients were evaluated at the final follow-up. Forty-five patients were randomized to the drain group, and 48 were randomized to the nondrain group. The preoperative characteristics were equivalent in both groups: demographic aspects, pain, ODI, SF-36, BMI, hematocrit, and spine pathology. Surgical time, EBL and complications were similar, with no difference between the groups. No difference was found between BMI and complications. No difference was observed in dressing saturation or postoperative temperature between the groups. The postoperative day 4 hematocrit was higher in the nondrain group [36.4% (32–39)] than in the drain group [34% (29.7–37.6)] without statistically differences (p=.054). The LOS was higher in the drain group [4 (3–5) days] than in the nondrain group [3 (2–4) days] (p=.007). The quality-of-life score, SF-36, was higher in the nondrain group [67.9 (53.6–79.2)] than in the drain group [56.7 (49.1–66)] (p=.043). CONCLUSIONSNondrain patients presented shorter LOS and better outcomes, with similar complication rates. No difference was found between BMI and complications. Based on this study, in patients undergoing primary posterior spinal decompression and fusion up to three levels for degenerative lumbar disorders, we do not recommend the use of postoperative drains.

Intradermal and Intramuscular Bupivacaine Reduces Opioid Use Following Noninstrumented Spine Surgery

To evaluate the efficacy of intraoperative bupivacaine hydrochloride wound infiltration as an adjunct means of pain relief following noninstrumented posterior spine surgery. A retrospective cohort analysis was performed of all patients who underwent posterior spinal decompression surgery at the University of California, San Diego, and at the San Diego VA Medical Center between June 2020 and July 2021, following a change in practice to including bupivacaine infiltration at the end of the surgery. Patients were stratified into groups based on whether they received intrawound bupivacaine during surgery. Demographic and clinical data were extracted from the electronic health record. Postoperative opioid use, visual analog pain scores, heart rate, and blood pressure were compared. The analysis included 43 patients; 21 received bupivacaine infiltration, and 22 did not. No complications were encountered in the perioperative period. Patients who received bupivacaine consumed significantly less opioids over the 72 hours following surgery, had slightly lower pain scores, and experienced slightly lower heart rates. No significant difference was found between groups with respect to systolic blood pressure, operative time, or length of hospital stay. Intraoperative infiltration of the exposed paraspinous musculature and peri-incisional subdermal layer with bupivacaine significantly reduced postoperative opioid consumption for 72 hours after surgery and slightly reduced pain ratings and conferred superior heart rate control. This low-cost intervention produced significant patient benefit with minimal risk and no significant increase in surgical time or hospital stay.

Long-Term Outcomes after Selective Microendoscopic Laminotomy for Multilevel Lumbar Spinal Stenosis with and without Remaining Radiographic Stenosis: A 10-Year Follow-Up Study.

Long-term clinical outcomes of microendoscopic laminotomy (MEL) for patients with multilevel radiographic lumbar spinal canal stenosis (LSS) have not been widely explored. The clinical significance and natural progression of additional untreated levels (e.g., remaining radiographic (RR)-LSS not addressed by selective MEL) remain unknown. This retrospective study aimed to investigate the long-term clinical outcomes of selective MEL in LSS patients and compare outcomes between patients with and without remaining RR-LSS to determine the efficacy of this procedure. Forty-nine patients at a single center underwent posterior spinal microendoscopic decompression surgery for neurogenic claudication or radicular leg pain in moderate-to-severe spinal stenosis. The patients were categorized into the RR-LSS-positive and RR-LSS-negative cohorts based on unaddressed levels of stenosis. Pre-operative and 10-year follow-up evaluations, including the Japanese Orthopedic Association (JOA) score, visual analog scale (VAS) score for low back pain and leg pain, Oswestry Disability Index (ODI), and satisfaction, were compared between the groups. Additionally, the need for reoperation was determined. MEL significantly improved JOA scores, lumbar VAS, and ODI over the 10-year postoperative period. Pre-operative characteristics and postoperative outcomes were not significantly different between the cohorts. Overall, 18.4% (9/49) of patients required reoperation during the follow-up period. The reoperation rate in the RR-LSS-positive (13.8%; 4/29) group was similar to that in the RR-LL-negative (15.0%; 3/20) group. MEL is effective for lumbar stenosis, with improved clinical outcomes up to 10 years following surgery. Selective MEL, addressing only symptomatic levels in multilevel stenosis, with residual remaining lumbar stenosis, is similarly effective without increased reoperation rates. Surgeons may consider more limited selective decompression in patients with multilevel stenosis, avoiding the risk and invasiveness of extensive procedures. Level III.

Unilateral Approaches for Posterior Spinal Canal Decompression in Cervical Spondylotic Myelopathy—An Evaluation of Conceptual Feasibility

Patients with cervical spondylotic myelopathy (CSM) can be treated with posterior approaches for spinal canal decompression. We compared the patients' outcome after 2 different unilateral and a bilateral posterior approach for decompression to elucidate feasibility and potential procedure-related differences. Medical records of 98 patients with CSM undergoing posterior decompression between 2012 and 2018 were assessed. Patients were divided into 3 groups: (1) unilateral interlaminar fenestration with over-the-top "undercutting" (laminotomy) for compression limited to a ligamentum flavum hypertrophy, (2) unilateral hemilaminectomy for lateralized compression with a combination of ligamentous hypertrophy and osseus stenosis, and (3) laminectomy/laminoplasty for circular osseous-ligamentous spinal canal narrowing. The mean age was 73 years (m:f = 1.4:1), and most frequent symptoms (mean duration: 15 months) were ataxia (69%) and sensory changes (57%). Main location of stenoses (median Naganawa Score = 3; mean anteroposterior spinal canal diameter = 7.7 ± 2.2 mm) was C3 to C6. Thirty-one percent of the patients were assigned for a laminotomy procedure, 20% for a hemilaminectomy, and 49% for a laminectomy/laminoplasty. There were no significant differences of patients' characteristics, blood loss, and operation time between the 3 groups. Independent from the mode of surgery, the spinal canal was significantly widened (median Naganawa Score = 0; mean anteroposterior diameter = 11.4 ± 3.6 mm) and myelopathy (mJOA Score) improved ( P &lt; .001); a higher body mass index was significantly correlated with a worse mJOA improvement (r = 0.293/ P = .003). Quality of life (Short-Form 36v2 Health Survey/Neck Disability Index) and reduction of the neck pain level were similar in the 3 groups at last follow-up (mean: 28 months). To minimize patients' periprocedural burden in CSM with dorsal compression, individual tailoring of the posterior approach according to the underlying compressive pathology achieves sufficient decompression and comparable long-term results.

The effects of combined microwave ablation and open surgery for the treatment of lung cancer-derived thoracolumbar metastases.

ObjectiveTo investigate the clinical effects of microwave ablation (MWA) in addition to open surgery for the treatment of lung cancer‐derived thoracolumbar metastases.MethodsThis was a single‐institution, retrospective, cohort study. From January 2019 to December 2020, a total of 47 patients with lung cancer‐derived thoracolumbar metastases underwent posterior spinal canal decompression and fixation surgery in our hospital. Two independent surgical teams treated these patients. One group underwent open surgery combined with MWA therapy, while the other had open surgery only (control). The pre‐ and post‐operative visual analog scale (VAS) scores and the overall survival (OS) were compared between the MWA and control groups. The Frankel Grade classification was applied for the evaluation of the post‐surgical spinal cord function. Improvement was defined as an increase of at least one rank from the pre‐operative scores. Each patient was evaluated pre‐ and post‐operatively at 48 h, 1 month, and 3‐month intervals. Data on surgical‐related complications were recorded.ResultsThirty men and 17 women were included, with an average age of 57.9 ± 11.4 years (range, 26–81 years). Twenty‐eight patients underwent MWA and were in the MWA group, and 19 patients were included in the control group. Post‐operatively all patients were followed up regularly; the median follow‐up time was 12 months (range, 3–24 months), and their median OS was 14 months. Patients in the MWA group had a lower VAS score than those in the control group at the 48‐h (1.75 ± 1.01 vs 2.47 ± 0.96, P = 0.01) and 1‐month (1.79 ± 0.92 vs 2.53 ± 1.35, P = 0.048) check‐ups. At the 3‐month evaluation, the VAS score differences between the two groups were not significant (P = 0.133). After surgery, spinal cord function improvement was not significantly different between the MWA and control groups (P = 0.515). MWA therapy combined with open surgery was not associated with increased OS compared with the control group (P = 0.492).ConclusionMWA can be an effective and safe pain‐relief method but may not extend the OS of patients with lung cancer.

Posterior spinal instrumentation and decompression with or without cross-link?

BackgroundPosterior lumbar instrumentation requires sufficient primary stiffness to ensure bony fusion and to avoid pseudarthrosis, screw loosening, or implant failure. To enhance primary construct stiffness, transverse cross-link (CL) connectors attached to the vertical rods can be used. Their effect on the stability of a spinal instrumentation with simultaneous decompression is yet not clear. This study aimed to evaluate the impact of CL augmentation on single-level lumbar instrumentation stiffness after gradual decompression procedures. MethodsSeventeen vertebral segments (6 L1/2, 6 L3/4, 5 L5/S1) of 12 fresh-frozen human cadavers were instrumented with a transpedicular screw–rod construct following the traditional pedicle screw trajectory. Range of motion (ROM) of the segments was sequentially recorded before and after four procedures: (A) instrumented before decompression, (B) instrumented after unilateral laminotomy, (C) instrumented after midline bilateral laminotomy, and (D) instrumented after unilateral facetectomy (with transforaminal lumbar interbody fusion [TLIF]). Each test was performed with and without CL augmentation. The motion between the cranial and caudal vertebrae was evaluated in all six major loading directions: flexion/extension (FE), lateral bending (LB), lateral shear (LS), anterior shear (AS), axial rotation (AR), and axial compression/distraction (AC). ResultsROM was significantly reduced with CL augmentation in AR by Δ0.03–0.18° (7–12%) with a significantly higher ROM reduction after more extensive decompression. Furthermore, slight reductions in FE and LB were observed; these reached statistical significance for FE after facetectomy and TLIF insertion only (Δ0.15; 3%). The instrumentation levels did not reveal any subgroup differences. ConclusionCL augmentation reduces AR-ROM by 7–12% in single-level instrumentation of the lumbar spine, with the effect increasing along with the extensiveness of the decompression technique. In light of the discrete absolute changes, CL augmentation may be warranted for highly unstable vertebral segments rather than for standard single-level posterior spinal fusion and decompression.

A Polyostotic Paget’s Disease Involving Lumbar Spine Presenting with Cauda Equina Syndrome: An Unusual Entity

Introduction:Paget’s disease of bone (PDB) is a metabolic bone disease presenting as polyostotic or monostotic lesions of the spine. Although common in the Anglo-Saxon population, it is rare on the Indian subcontinent. Neurological complications though infrequent can be severe in pagetic spine.Case Report:We report a case of a polyostotic variant of PDB involving lumbar spine (L2 vertebrae), iliac bones, and femur presenting as chronic low back pain and neurological deficit, i.e., cauda equina syndrome. On initial workup, a diagnosis of PDB was made and given cauda equina compression with neurological deficit, posterior spinal decompression, and biopsy was performed. The histopathological evaluation confirmed the diagnosis and the patient was treated with bisphosphonates for 6 months, along with serial monitoring of alkaline phosphatase levels.Conclusion:Through this case report, we hope to emphasize that PDB should be considered as a possible cause of neurological symptoms at presentation, especially in elderly patients. Also furthermore, early surgical intervention followed by bisphosphonates therapy can lead to favorable outcomes in such patients.