Surgery For Degenerative Lumbar Spondylolisthesis Research Articles

Fusion with and without lever reduction in degenerative lumbar spondylolisthesis: a retrospective study.

The reduction of slipped vertebra is often performed during surgery for degenerative lumbar spondylolisthesis (DLS). This approach, while potentially improving clinical and radiological outcomes, also carries a risk of increased complications due to the reduction process. To address this, we introduced an innovative lever reduction technique for DLS treatment. This study aims to investigate the clinical efficacy, radiological outcomes, and complications of fusion with or without lever reduction. We conducted a retrospective review of prospectively collected data from a registry of patients who underwent lumbar fusion surgery for DLS, with a follow-up of at least 24months. Self-reported measures included visual analog scale (VAS) for back or leg pain, Oswestry Disability Index (ODI), and the achievement of minimal clinically important difference (MCID). Radiological assessments encompassed spondylolisthesis percentage (SP), focal lordosis (FL), and lumbar lordosis (LL). Complications were categorized using the modified Clavien-Dindo classification (MCDC) scheme. Patients were assigned to the reduction group (RG) and non-reduction group (NRG) based on the application of the lever reduction technique. Clinical and radiological outcomes at baseline, immediately after surgery, and at the last follow-up were compared. A total of 281 patients were analyzed (123 NRG, 158 RG). Baseline patient demographics, comorbidities, and surgical characteristics were similarly distributed between groups except for operating time (NRG 129.25min, RG 138.04min, P = .009). Both groups exhibited significant clinical improvement after surgery (all, P = .000), with no substantial difference between groups (VAS, ODI, or the ability to reach MCID). Patients in RG showed statistically lower SP and higher FL during follow-up (all, P = .000). LL was comparable at different time points within each group or at the same time point between the two groups (all, P > .050). The overall complication rate (NRG 38.2%, RG 27.2%, P = .050) or specific complication rates per MCDC were similar between groups (all, P > .050). Patients in RG were predisposed to a lower risk of adjacent segment degeneration (ASDeg) (NRG 9.8%, RG 6.3%, P = .035). There were no significant differences in postoperative measures such as VAS scores for back and leg pain, ODI, the ability to reach MCID, overall complication rate, or specific complication rates per MCDC between surgical approaches. However, fusion with lever reduction demonstrated a notable advantage in restoring segmental spinal sagittal alignment and reducing the occurrence of ASDeg compared to in situ fusion.

Examining the Role of Paraspinal Musculature in Postoperative Disability After Lumbar Fusion Surgery for Degenerative Spondylolisthesis.

Retrospective analysis of prospectively enrolled patients. To evaluate the relationship between paraspinal muscle (PM) atrophy and Oswestry Disability Index (ODI) improvement after spinal fusion surgery for degenerative lumbar spondylolisthesis. Atrophy of the PM is linked to multiple spinal conditions, sagittal malalignment, and increased postoperative complications. However, only limited evidence for the effect on patient-reported outcomes exists. Patients with degenerative lumbar spondylolisthesis undergoing decompression and fusion surgery were analyzed. Patients with missing follow-up, no imaging, or inadequate image quality were excluded. The ODI was assessed preoperatively and two years postoperatively. A cross-sectional area of the PM was measured on a T2-weighted magnetic resonance imaging sequence at the upper endplate of L4. On the basis of the literature, a 10-point improvement cutoff was defined as the minimum clinically important difference. Patients with a baseline ODI below the minimum clinically important difference were excluded. Logistic regression was used to calculate the association between fatty infiltration (FI) of the PM and improvement in ODI, adjusted for age, sex, and body mass index. A total of 133 patients were included in the final analysis, with only two lost to follow-up. The median age was 68 years (IQR 62-73). The median preoperative ODI was 23 (IQR 17-28), and 76.7% of patients showed improvement in their ODI score by at least 10 points. In the multivariable regression, FI of the erector spinae and multifidus increased the risk of not achieving clinically relevant ODI improvement ( P =0.01 and <0.001, respectively). No significant association was found for the psoas muscle ( P =0.158). This study demonstrates that FI of the erector spinae and multifidus is significantly associated with less likelihood of clinically relevant ODI improvement after decompression and fusion. Further research is needed to assess the effect of interventions.

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

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

Factors influencing the long-term outcomes of instrumentation surgery for degenerative lumbar spondylolisthesis: a post-hoc analysis of a prospective randomized study

BACKGROUND CONTEXTLumbar spinal canal stenosis caused by degenerative lumbar spondylolisthesis is one of the most common indications for spinal surgery. However, the factors that influence its long-term (>10 years) outcomes remain unknown. DESIGNThis is a post-hoc analysis of a prospective randomized study. PURPOSEThis study aimed to determine factors that influence the long-term outcomes of instrumentation surgery for lumbar spinal canal stenosis due to degenerative lumbar spondylolisthesis. PATIENT SAMPLEPatients aged ≤75 years with single L4/5 level lumbar canal stenosis caused by degenerative lumbar spondylolisthesis prospectively underwent instrumentation surgery at two hospitals between May 1, 2003, and April 30, 2012; the final follow-up examination was on May 20, 2021. OUTCOME MEASURESThe following data were collected: modified Japanese Orthopedic Association (JOA) score, JOA score recovery rate, visual analog scale (VAS) score for lower back and leg pain, and scores from eight short-form 36 (SF-36) subscales preoperatively and at the final follow-up examination. METHODSSpearman's correlation analysis and univariate and multivariate regression analyses were used to examine preoperative factors that affect the JOA score recovery rate in patients who underwent instrumentation surgery for lumbar spinal canal stenosis at the L4/5 level due to degenerative lumbar spondylolisthesis. RESULTSA total of 42 patients who underwent instrumentation surgery for degenerative lumbar spondylolisthesis and had a long-term follow-up period were included. Of these, 25 and 17 underwent posterolateral fusion and Graf stabilization, respectively. The mean postoperative follow-up duration was 12.5 years. Spearman's correlation analysis revealed that the long-term recovery rate was correlated with the preoperative VAS score for low back pain. In the univariate regression analysis, sex, preoperative VAS score for low back pain, and the SF-36 general health score were significantly associated with the long-term recovery rate. Meanwhile, the multiple stepwise regression analysis identified the preoperative VAS score for low back pain as an independent predictor of the long-term recovery rate. CONCLUSIONSThis study identified the preoperative VAS score for low back pain as an independent predictor of the long-term recovery rate following instrumentation surgery for degenerative lumbar spondylolisthesis. Therefore, when performing posterolateral fusion or Graf stabilization for degenerative lumbar spondylolisthesis, attention should be paid to the intensity of preoperative low back pain and considerations should be given to whether these procedures can improve the patient's symptoms in the long term.

Patient's expectations of surgery for lumbar degenerative spondylolisthesis: analysis by type of surgery and patient factors from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUND CONTEXTPreoperative expectations influence postoperative outcomes. Patients with lumbar degenerative spondylolisthesis have especially high expectations of pain relief and overall functional well-being compared to patients with lumbar stenosis. PURPOSEThe primary objective was to analyze preoperative expectations of lumbar DS patients with respect to the type of surgery proposed (decompression vs decompression and fusion). Secondarily, we aimed to assess the associations between preoperative expectations and patient and clinical factors as well as postoperative expectations fulfillment. STUDY DESIGN/SETTINGPatients were prospectively enrolled in a multicenter, prospective cohort study evaluating the assessment and management of degenerative spondylolisthesis utilizing the infrastructure of the Canadian Spine Outcomes and Research Network (CSORN) surgical registry. PATIENT SAMPLEPatients with a diagnosis of degenerative spondylolisthesis with symptoms of neurogenic claudication or radiculopathy with or without back pain, unresponsive to nonoperative management over at least 3 months were included. Patients who underwent decompression, decompression and posterolateral fusion or decompression and interbody fusion at Canadian spine centers between January 2015 and September 2021 were included. OUTCOME MEASURESThe North American Spine Society Lumbar Spine Questionnaire was utilized for expectations measurement. The expectation questionnaire was completed following consent and before surgery and at 1 year. METHODSExpectations for pain relief and improvements in overall functional well-being were rated on a scale of 0 to 100. Preoperative expectation in terms of pain relief and functional well-being score were calculated. Multivariate linear regression was used to evaluate the association between expected preoperative patient factors and pain relief and functional well-being. The factors associated with the most important expectation were evaluated using multivariable multinomial logistic regression. RESULTSThree hundred fifty-two patients were included with 100 patients undergoing decompression and 252 patients also undergoing fusion. The seven items of preoperative expectations did not differ between the procedure groups nor did expected change. The mean pain relief and overall functional well-being expectation scores did not significantly differ between procedures.Higher expectations were associated with having more comorbidities [β=-2.0 (SE 0.8), p=.020], being physically active [β=8.4 (SE 3.2), p=.010] and having more leg pain [β=1.6 (SE 0.7), p=.015]. Better perceived physical health measured by SF12 PCS was associated with lower expectation of pain relief [β= -0.4 (SE 0.2), p=.039] and functional well-being [β=-0.84 (SE 0.2), p=.001]. Better perceived mental health measured by SF12 MCS was associated with lower expectation of functional well-being [β=-0.8 (SE 0.2), p=.001].Postoperative expectations fulfillment did not differ between procedures. CONCLUSIONPreoperative expectations in terms of pain relief and functional well-being were similar between the two most common procedures performed, decompression ± fusion. Secondarily, higher preoperative expectations were associated with greater pain, disability and being physically active. Expectations fulfillment did not differ between procedures.

P.173 Evaluating instability in Degenerative Lumbar Spondylolisthesis: objective variables versus surgeon impressions

Background: The qualitative Degenerative Spondylolisthesis Instability Classification (DSIC) system defines pre-operative instability associated with degenerative lumbar spondylolisthesis (DLS) and facilitates surgical technique selection. Objectives: (1) propose a quantitative DSIC system; (2) compare objective measures to surgeon impressions of DLS-related instability. Methods: We conducted a multi-center prospective study of 408 adult patients undergoing surgery for DLS. Variables included in the quantitative classification were assigned point-values based on evidence quality. Scores were converted to DSIC Types: 0-2 points (“Stable”; Type I), 3 points (“Potentially Unstable”; Type II), 4-5 points (“Unstable”; Type III). Surgeons documented impressions of instability using the qualitative DSIC system. Results: Five variables were included in the quantitative DSIC: presence of facet effusion, preservation of disc height (&lt;6.5mm), translation (&gt;4mm), kyphotic or neutral disc angle in flexion, and presence of low back pain (LBP) (&gt;5/10 intensity). Surgeons categorized higher degrees of instability than the preliminary quantitative DSIC system, in 130 patients (42%) (P &lt; 0.001). Compared to procedures suggested by the quantitative DSIC system, more extensive surgical procedures were performed in 150 patients (57%) (P &lt; 0.001). Conclusions: A quantitative DSIC system allowed DLS-related stability to be scored and categorized. Patients potentially received more extensive surgery than warranted based on quantitative assessments of stability.

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

It remains unclear how type of insurance coverage affects long-term, spine-specific patient-reported outcomes (PROs). This study sought to elucidate the impact of insurance on clinical outcomes after lumbar spondylolisthesis surgery. The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. Twenty-four-month PROs were compared and included Oswestry Disability Index, Numeric Rating Scale (NRS) back pain, NRS leg pain, EuroQol-5D, and North American Spine Society Satisfaction. A total of 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age, 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n= 319; 52.5%), Medicare (n= 235; 38.7%), Medicaid (n= 36; 5.9%), and Veterans Affairs (VA)/government (n= 17; 2.8%). One patient (0.2%) was uninsured and was removed from the analyses. Regardless of insurance status, comparedtobaseline, all 4 cohorts improved significantly regarding ODI, NRS-BP, NRS-LP, and EQ-5D scores (P< 0.001). In adjusted multivariable analyses, compared with patients with private insurance, Medicaid was associated with worse 24-month postoperative Oswestry Disability Index (β= 10.2; 95% confidence interval [CI], 3.9-16.5; P = 0.002) and NRS leg pain (β=1.3; 95% CI, 0.3-2.4; P = 0.02). Medicaid was associated with worse EuroQol-5D scores compared with private insurance (β=-0.07; 95% CI-0.01 to-0.14; P = 0.03), but not compared with Medicare and VA/government insurance (P> 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (odds ratio, 0.2; 95% CI, 0.03-0.7; P = 0.02) compared with VA/government insurance. NRS back pain and North American Spine Society satisfaction did not differ by insurance coverage (P> 0.05). Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs after lumbar spondylolisthesis surgery compared with other payer types. Although all improved postoperatively, those with Medicaid coverage had relatively inferior improvements.

腰椎変性すべり症術後に急性呼吸不全を来したGuillain–Barré症候群の1例(Guillain–Barré syndrome with acute respiratory failure after surgery for lumbar degenerative spondylolisthesis: a case report)

要旨Guillain–Barré 症候群（以下GBS）の先行イベントとして，感染やワクチン接種，外傷，手術などが報告されているが，本邦において，術後発症の報告はわずかしかない。今回，腰椎変性すべり症術後にGBSを発症した1例を経験したので報告する。症例は70歳代の女性で，腰椎変性すべり症に対して椎体間固定術を施行した。術後10日目より四肢脱力が出現し，術後15日目より急性呼吸不全による意識障害を来したため，人工呼吸管理を行った。意識障害改善後の神経学的評価では呼吸筋の低下，対称性四肢麻痺，下肢腱反射の低下を認めた。臨床経過，脳脊髄液検査の蛋白細胞解離所見，神経伝導検査での末梢神経障害所見，抗ガングリオシド抗体陽性所見よりGBSの診断に至った。ICU入室後2日目より隔日で血漿交換療法を計5回施行し，呼吸筋および四肢筋力は緩徐な回復を示した。ICU入室後37日目に人工呼吸器を離脱した。リハビリテーションを継続し，独歩可能な状態まで回復した。術後患者で進行性四肢麻痺や呼吸不全を呈する患者では，本疾患を念頭におき，早期治療介入を検討する必要がある。

Frailty is an important predictor of 30-day morbidity in patients treated for lumbar spondylolisthesis using a posterior surgical approach

BACKGROUND CONTEXTTraditionally, a nonoperative approach has been favored for elderly patients with lumbar spondylolisthesis due to a perceived higher risk of morbidity with surgery. However, most studies have used an arbitrary age cut-off to define “elderly” and this research has yielded conflicting results. PURPOSEThe purpose of this study was to investigate the impact of frailty on morbidity after surgery for degenerative lumbar spondylolisthesis treated with a posterior approach. STUDY DESIGNA retrospective cohort study was performed. PATIENT SAMPLEThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, with years 2010 to 2018 included in this study. Patients who received posterior lumbar spine decompression with or without single level posterior instrumented fusion for degenerative lumbar spondylolisthesis were included. Patients who received anterior and/or lateral approaches were excluded. OUTCOME MEASURESThe primary outcome was Clavien-Dindo grade IV complication. Secondary outcomes were readmission, reoperation, and discharge to location other than home. METHODSPatient demographics and comorbidities were extracted. Logistic regression analysis was performed to investigate the association between outcomes and the Modified Frailty Index-5, adjusting for age, gender, body mass index, smoking status, and surgical procedure performed. A sub-analysis was done to assess the effect of frailty in three different age groups (18–45 years, 46–65 years, and >65 years) for the two surgical cohorts. RESULTSThere were 15,658 patients in this study. The mean age was 62.5 years. Approximately 70% of the patients received decompression with fusion. Frailty was significantly associated with an increased risk of major complication, unplanned readmission, reoperation, and non-home discharge. The risk increased with increasing frailty. For patients who received decompression, frailty was associated with a higher risk of readmission and non-home discharge in patients >65 years. For patients who received decompression and fusion, frailty was associated with a higher risk of complications, readmission, and non-home discharge in patients >65 years. CONCLUSIONSFrailty is independently associated with a higher risk of morbidity after posterior surgery in patients with lumbar spondylolisthesis, especially in patients older than 65. These data are of significance to clinicians in planning treatment for these patients.

Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis

BackgroundIn patients with lumbar spinal stenosis and degenerative spondylolisthesis, it is uncertain whether decompression surgery alone is noninferior to decompression with instrumented fusion.MethodsWe conducted an open-label, multicenter, noninferiority trial involving patients with symptomatic lumbar stenosis that had not responded to conservative management and who had single-level spondylolisthesis of 3 mm or more. Patients were randomly assigned in a 1:1 ratio to undergo decompression surgery (decompression-alone group) or decompression surgery with instrumented fusion (fusion group). The primary outcome was a reduction of at least 30% in the score on the Oswestry Disability Index (ODI; range, 0 to 100, with higher scores indicating more impairment) during the 2 years after surgery, with a noninferiority margin of −15 percentage points. Secondary outcomes included the mean change in the ODI score as well as scores on the Zurich Claudication Questionnaire, leg and back pain, the duration of surgery and length of hospital stay, and reoperation within 2 years.ResultsThe mean age of patients was approximately 66 years. Approximately 75% of the patients had leg pain for more than a year, and more than 80% had back pain for more than a year. The mean change from baseline to 2 years in the ODI score was −20.6 in the decompression-alone group and −21.3 in the fusion group (mean difference, 0.7; 95% confidence interval [CI], −2.8 to 4.3). In the modified intention-to-treat analysis, 95 of 133 patients (71.4%) in the decompression-alone group and 94 of 129 patients (72.9%) in the fusion group had a reduction of at least 30% in the ODI score (difference, −1.4 percentage points; 95% CI, −12.2 to 9.4), showing the noninferiority of decompression alone. In the per-protocol analysis, 80 of 106 patients (75.5%) and 83 of 110 patients (75.5%), respectively, had a reduction of at least 30% in the ODI score (difference, 0.0 percentage points; 95% CI, −11.4 to 11.4), showing noninferiority. The results for the secondary outcomes were generally in the same direction as those for the primary outcome. Successful fusion was achieved with certainty in 86 of 100 patients (86.0%) who had imaging available at 2 years. Reoperation was performed in 15 of 120 patients (12.5%) in the decompression-alone group and in 11 of 121 patients (9.1%) in the fusion group.ConclusionsIn this trial involving patients who underwent surgery for degenerative lumbar spondylolisthesis, most of whom had symptoms for more than a year, decompression alone was noninferior to decompression with instrumented fusion over a period of 2 years. Reoperation occurred somewhat more often in the decompression-alone group than in the fusion group. (NORDSTEN-DS ClinicalTrials.gov number, NCT02051374.)

Association between the appropriateness of surgery, according to appropriate use criteria, and patient-rated outcomes after surgery for lumbar degenerative spondylolisthesis.

Treatment failures in spine surgery are often attributable to poor patient selection and the application of inappropriate treatment. We used published appropriate use criteria (AUC) to evaluate the appropriateness of surgery in a large group of patients operated for lumbar degenerative spondylolisthesis (LDS) and to evaluate its association with outcome. This was a retrospective analysis of prospectively collected outcome data from patients operated in our Spine Centre, 2005-2012. Appropriateness of surgery was judged based on the AUC. Patients had completed the multidimensional Core Outcome Measures Index (COMI) before surgery and at 3 months' and 1, 2 and 5years' follow-up (FU). In total, 448 patients (69.8 ± 9.6years; 323 (72%) women) were eligible for inclusion and the AUC could be applied in 393 (88%) of these. Surgery was considered appropriate (A) in 234 (59%) of the patients, uncertain/equivocal (U) in 90 (23%) and inappropriate (I) in 69 (18%). A/U patients had significantly (p < 0.05) greater improvements in COMI than I patients at each FU time point. The minimal clinically important change (MCIC) score for COMI was reached by 82% A, 76% U and 54% I patients at 1-year FU (p < 0.001, I vs A and U); the odds of achieving MCIC were 3-4 times greater in A/U patients than in I patients. The results suggest a relationship between appropriateness of surgery for LDS and the improvements in COMI score after surgery. The findings require confirmation in prospective studies that also include a control group of non-operated patients.

Predictive Factors Affecting Surgical Outcomes in Patients with Degenerative Lumbar Spondylolisthesis.

Post-hoc analysis of 5-year follow-up data from a prospective randomized multicenter trial. The purpose of this study was to identify preoperative factors that predict poor postoperative outcomes and define clinically important abnormal instabilities in degenerative lumbar spondylolisthesis. Current evidence regarding prognostic factors affecting clinical outcomes after surgery for degenerative lumbar spondylolisthesis is still limited. Moreover, there is no consensus regarding parameters that define clinically important abnormal instability in patients with degenerative lumbar spondylolisthesis. This post-hoc analysis from a prospective randomized trial that compared the effectiveness of decompression, decompression with fusion, and decompression with stabilization for degenerative lumbar spondylolisthesis at the L4/5 level included 70 patients with a 5-year follow-up period. We investigated the correlation between the postoperative recovery rate and preoperative radiographic parameters. We then investigated differences between the good recovery and poor recovery groups. Japanese Orthopaedic Association and visual analogue scale scores improved postoperatively. Of the 70 patients analyzed, 13 were judged to be in the poor recovery group based on their recovery rate. The recovery rate significantly correlated with the intervertebral angle at L4/5. Univariate analysis showed that while the degree of vertebral slippage and the presence of angulation were not associated with poor recovery, the intervertebral angle at L4/5 and the presence of translation were associated with poor recovery. Lastly, multiple stepwise logistic regression analysis revealed the intervertebral angle at L4/5 and the presence of translation as independent predictors of poor recovery after surgery for lumbar degenerative spondylolisthesis. While the degree of vertebral slippage and the presence of angulation were not associated with poor recovery after surgery for lumbar degenerative spondylolisthesis, postoperative outcomes were associated with the intervertebral angle and the presence of translation. Careful preoperative measurement of these factors may help to predict poor postoperative outcomes.Level of Evidence: 3.

Sexual Dysfunction: Prevalence and Prognosis in Patients Operated for Degenerative Lumbar Spondylolisthesis.

There is a paucity of investigation on the impact of spondylolisthesis surgery on back pain-related sexual inactivity. To investigate predictors of improved sex life postoperatively by utilizing the prospective Quality Outcomes Database (QOD) registry. A total of 218 patients who underwent surgery for grade 1 degenerative lumbar spondylolisthesis were included who were sexually active. Sex life was assessed by Oswestry Disability Index item 8 at baseline and 24-mo follow-up. Mean age was 58.0±11.0 yr, and 108 (49.5%) patients were women. At baseline, 178 patients (81.7%) had sex life impairment. At 24 mo, 130 patients (73.0% of the 178 impaired) had an improved sex life. Those with improved sex lives noted higher satisfaction with surgery (84.5% vs 64.6% would undergo surgery again, P=.002). In multivariate analyses, lower body mass index (BMI) was associated with improved sex life (OR=1.14; 95% CI [1.05-1.20]; P<.001). In the younger patients (age < 57 yr), lower BMI remained the sole significant predictor of improvement (OR=1.12; 95% CI [1.03-1.23]; P=.01). In the older patients (age ≥ 57 yr)-in addition to lower BMI (OR=1.12; 95% CI [1.02-1.27]; P=.02)-lower American Society of Anesthesiologists (ASA) grades (1 or 2) (OR=3.7; 95% CI [1.2-12.0]; P=.02) and ≥4 yr of college education (OR=3.9; 95% CI [1.2-15.1]; P=.03) were predictive of improvement. Over 80% of patients who present for surgery for degenerative lumbar spondylolisthesis report a negative effect of the disease on sex life. However, most patients (73%) report improvement postoperatively. Sex life improvement was associated with greater satisfaction with surgery. Lower BMI was predictive of improved sex life. In older patients-in addition to lower BMI-lower ASA grade and higher education were predictive of improvement.

Correlation of return to work with patient satisfaction after surgery for lumbar spondylolisthesis: an analysis of the Quality Outcomes Database.

Return to work (RTW) and satisfaction are important outcome measures after surgery for degenerative spine disease. The authors queried the prospective Quality Outcomes Database (QOD) to determine if RTW correlated with patient satisfaction. The QOD was queried for patients undergoing surgery for degenerative lumbar spondylolisthesis. The primary outcome of interest was correlation between RTW and patient satisfaction, as measured by the North American Spine Society patient satisfaction index (NASS). Secondarily, data on satisfied patients were analyzed to see what patient factors correlated with RTW. Of 608 total patients in the QOD spondylolisthesis data set, there were 292 patients for whom data were available on both satisfaction and RTW status. Of these, 249 (85.3%) were satisfied with surgery (NASS score 1-2), and 224 (76.7%) did RTW after surgery. Of the 68 patients who did not RTW after surgery, 49 (72.1%) were still satisfied with surgery. Of the 224 patients who did RTW, 24 (10.7%) were unsatisfied with surgery (NASS score 3-4). There were significantly more people who had an NASS score of 1 in the RTW group than in the non-RTW group (71.4% vs 42.6%, p < 0.05). Failure to RTW was associated with lower level of education, worse baseline back pain (measured with a numeric rating scale), and worse baseline disability (measured with the Oswestry Disability Index [ODI]). There are a substantial number of patients who are satisfied with surgery even though they did not RTW. Patients who were satisfied with surgery and did not RTW typically had worse preoperative back pain and ODI and typically did not have a college education. While RTW remains an important measure after surgery, physicians should be mindful that patients who do not RTW may still be satisfied with their outcome.

Development and Validation of Machine Learning Algorithms for Predicting Adverse Events After Surgery for Lumbar Degenerative Spondylolisthesis

Preoperative prognostication of adverse events (AEs) for patients undergoing surgery for lumbar degenerative spondylolisthesis (LDS) can improve risk stratification and help guide the surgical decision-making process. The aim of this study was to develop and validate a set of predictive variables for 30-day AEs after surgery for LDS. The American College of Surgeons National Surgical Quality Improvement Program was used for this study (2005-2016). Logistic regression (enter, stepwise, and forward) and LASSO (least absolute shrinkage and selection operator) methods were performed to identify and select variables for analyses, which resulted in 26 potential models. The final model was selected based on clinical criteria and numeric results. The overall 30-day rate of AEs for 80,610 patients who underwent surgery for LDS in this database was 4.9% (n= 3965). The median age of the cohort was 58.0 years (range, 18-89 years). The model with the following 10-predictive factors (age, gender, American Society of Anesthesiologists grade, autogenous iliac bone graft, instrumented fusion, levels of surgery, surgical approach, functional status, preoperative serum albumin [g/dL] and serum alkaline phosphatase [IU/L]) performed well on the discrimination, calibration, Brier score, and decision analyses to develop machine learning algorithms. Logistic regression showed higher areas under the curve than did LASSO methods across the different models. The predictive probability derived from the best model is uploaded on an open-access Web application, which can be found at: https://spine.massgeneral.org/drupal/Lumbar-Degenerative-AdverseEvents. It is feasible to develop machine learning algorithms from large datasets to provide useful tools for patient counseling and surgical risk assessment.

53. Comparison of generic vs spine-specific pain surveys administered before surgery and fulfillment of expectations measured after surgery for lumbar degenerative spondylolisthesis

BACKGROUND CONTEXT Generic and spine-specific surveys are used before surgery for lumbar degenerative spondylolisthesis (LDS) to measure pain. While both types of surveys can discern various aspects of pain, such as pain intensity and pain-associated disability, their ability to capture how pain impacts other outcomes, such as fulfillment of expectations, is not known. PURPOSE To determine which pain surveys are most closely associated with fulfillment of expectations after surgery for LDS. STUDY DESIGN/SETTING Prospective 2-year longitudinal study, tertiary spine center. PATIENT SAMPLE A total of 146 patients undergoing surgery for LDS. OUTCOME MEASURES HSS Lumbar Spine Surgery Expectations Survey. METHODS Patients were interviewed several days before surgery with the valid 20-item Expectations Survey addressing symptoms, physical function, and psychological well-being. Patients rated how much improvement they expected for each item with response options of complete to no improvement. To measure pain, patients completed back-specific measures of global pain with a numeric rating scale (0-10) and the modified Oswestry Disability index (ODI) (0-100), and generic PROMIS measures of Pain Intensity and Pain Interference with computer adapted tests (T scores 50). Medical records were reviewed for surgeon-reported pain on flexion/extension and surgical complexity according to the Invasiveness Index (max 10 points/vertebral level). Two-year postop patients again completed the Expectations Survey rating how much improvement they actually received. A proportion of expectations fulfilled was calculated as total improvement received divided by total improvement expected (range 0 (no improvement), 1 (improved as expected), >1 (improved more than expected). In multivariable linear regression analyses controlling for complexity, the proportion was the dependent variable and various pain measures were independent variables, expressed as estimates with desired 95% confidence intervals (CI) not to cross 0. RESULTS Mean age was 68, 61% were women, 82% had LDS at only one level (69% L45), mean pelvic incidence was 61° (30-84), mean pelvic incidence minus lumbar lordosis was 10° ((-16)-50), and the median surgical complexity was 7 (1-22). With respect to pain, 60% of patients had pain with extension, 25% with flexion. The median global back pain was 6 (0-10), and mean values were: ODI 50 (6-88), PROMIS Intensity 55 (31-72), and PROMIS Interference 63 (3-100). The mean time to follow-up was 2.1 years. The mean Expectations Survey proportion of expectations fulfilled was .99 (0-3.53); 42% of patients had low, 21% had equivalent, and 36% had high proportions (ie, greater expectations fulfilled). Controlling for surgical complexity, higher proportions were associated with less ODI pain (1.1, CI 0.5-1.6, p=.0001), less global back pain (4.5, CI 1.6-7.3, p=002) and, to lesser extents, less generic PROMIS Pain Intensity (1.5, 0.3-2.6, p=.01) and Pain Interference (0.8, -0.1-1.6, p=.08). There were no associations between surgeon-reported pain on extension/flexion and proportions of expectations fulfilled (p>.10). CONCLUSIONS Compared to generic pain surveys, preop pain measured by spine-specific pain surveys were more closely associated with the outcome of fulfillment of expectations. Whether generic pain surveys, such as PROMIS, are sufficiently sensitive to explain other outcomes of LDS needs to be assessed further. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Sexual Dysfunction: Prevalence and Prognosis in Patients Operated for Degenerative Lumbar Spondylolisthesis

Abstract INTRODUCTION There is a paucity of investigation on the impact of spondylolisthesis surgery on back-pain related sexual inactivity. To this end, we utilized the prospective Quality Outcomes Database (QOD) registry to investigate factors predictive of improved sex life following surgery. METHODS This was an analysis of a prospective registry of 608 patients who underwent surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Of these, 218 patients were included who were sexually active and had both baseline and 24-mo sexual function follow-up. Baseline variables were collected. Outcomes were collected at 24 mo. Sexual function was assessed by the associated question in the Oswestry Disability Index, “With regards to pain, how would you say your sex life is?” Outcomes were dichotomized into patients who had improved sexual function and those who had same or worse sexual function. RESULTS Mean age was 58.0 ± 11.0 yr and 108 (49.5%) patients were women. At baseline, 178 patients (81.7%) had an impaired sex life. At final follow-up, 130 patients (73.0% of the 178 impaired) had an improved sex life. In univariate comparisons, those with improved sexual life had lower body mass index (BMI) (29.6 ± 5.5 vs 34.4 ± 6.0; P &lt; .001) and a lower proportion of American Society of Anesthesiologists' grades 3 or 4 (33.1%% vs 54.2%; P = .01). Following surgery, those with improved sex lives noted higher satisfaction following surgery (84.5% vs 64.6% would undergo surgery again, P = .002). In adjusted analyses, lower BMI was associated with an improved sex life at 24 mo (OR = 1.14; 95% CI [1.05-1.20]; P &lt; .001). CONCLUSION Over 80% of patients who present for surgery for degenerative lumbar spondylolisthesis report a negative effect of the disease on sex life. However, most patients (73%) report an improvement in sex life postoperatively. Improvement in sex life was associated with significantly greater satisfaction with surgery. Lower BMI was predictive of improved sex life postoperatively.

Increased Proportion of Fusion Surgery for Degenerative Lumbar Spondylolisthesis and Changes in Reoperation Rate: A Nationwide Cohort Study With a Minimum 5-Year Follow-up.

A retrospective cohort study. The objectives of the present study were to examine the changes in the number of surgeries, surgical methods selected, and reoperation rates between the years 2003 and 2008. The selection of the appropriate surgical method between decompression-only (D) and decompression plus fusion (DF) represents a challenging clinical dilemma in patients with degenerative lumbar spinal spondylolisthesis. DF is selected in greater than 90% of patients, mostly due to the associated low reoperation rate. However, the outcomes of D have been improved with minimally invasive decompression surgery techniques. The Health Insurance Review and Assessment Service database was used to create cohorts of all Korean patients who underwent surgery for degenerative lumbar spinal spondylolisthesis in 2003 (2003 cohort, n = 5624) and 2008 (2008 cohort, n = 11,706). All patients were followed up for at least 5 years. Reoperation was defined as the occurrence of any type of second lumbar surgery during the follow-up period. The probabilities of reoperation were calculated using the Kaplan-Meier method. The number of surgeries increased 2.08-fold in 2008. Patients older than 60 years comprised 38.6% of the 2003 cohort and 52.4% of the 2008 cohort. The proportion of DF surgery was 31.13% in the 2003 cohort but 91.54% in the 2008 cohort. However, the high proportion of fusion surgery failed to reduce the reoperation probability in the 2008 cohort (8.1%) compared with that in the 2003 cohort (6.2%). The cost of DF was US$5264 and that of D was $2719 in 2008. DF decreased the reoperation probability by 1% at the cost of $421/patient in the 2008 cohort. The increased proportion of fusion surgery without improvement in reoperation probability in an aging society may be cautiously addressed in deciding future health policies. 4.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 11. Does back pain improve in surgically treated degenerative lumbar spondylolisthesis: what can we tell our patients?

BACKGROUND CONTEXT Surgery for degenerative lumbar spondylolisthesis (DLS) has traditionally been indicated for patients with neurogenic claudication and radicular pain. Surgery improves patients’ disability and lower extremity symptoms, but little is known about the impact on back pain. PURPOSE This study aims to evaluate changes in back pain after surgery and identify prognostic factors influencing these changes in surgically treated DLS. METHODS Consecutive patients with DLS surgically treated were prospectively enrolled in the Canadian Spine Outcomes Research Network (CSORN) registry. Patients had demographic data, clinical information, disability (ODI), and back pain (NRS Back Pain) scores collected prospectively at baseline, 3-, 12-, and 24-month follow-up. Results were compared to baseline using simple summary statistics and factors associated with improved back pain were assessed with multivariate regression (significance was p RESULTS A total of 557 patients were identified; all had reached 3-month follow-up; 376 (67.5%) had reached 12-month follow-up; and 141 (25.3%) had reached 24-month follow-up. Mean age at baseline was 66.2 (+/−9.5), and 58.5% were female. Back pain improved significantly at 3 months, and was maintained at 12, and 24-month follow-up compared to baseline (p CONCLUSIONS Back pain improved significantly during follow up for patients treated surgically for DLS. This research demonstrates that for patients undergoing surgery for DLS, the majority will have improved back pain at 1-year follow-up. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Which Domains of the ODI Best Predict Change in Physical Function in Patients After Surgery for Degenerative Lumbar Spondylolisthesis?

A retrospective review. The purpose of this study is to determine the differential improvement of the various individual items of the Oswestry Disability Index (ODI) and to determine their relationship to other measures of Health Related Quality of Life (HRQOL). The ODI is an easily scored, common, 10-item questionnaire about symptoms relevant to lumbar spine pathology. It is not clear if all of the items can be reliably applied to spine surgery. The purpose of this study is to determine the differential improvement of the various individual items of the ODI and to determine their relationship to other measures of HRQOL. Analysis of a prospective registry of patients treated at an academic medical center was undertaken. At baseline, standardized outcome measures including ODI and SF12 PCS were collected on all patients undergoing elective fusion surgery for degenerative spondylolisthesis. Multiple linear regressions were performed using change in SF12 PCS as the dependent variable and change in ODI components as the independent variables. Baseline and 1-year follow-up data were collected on 196 patients (mean age 60.4 years). There were statistically significant differences in improvement among ODI items. Surprisingly, the most improvement after surgery was noted in the standing, sex life, and social life domains. The least improvement was noted in the personal care, sleeping, and sitting domains. Linear regression for change in ODI components versus change in SF-12 PCS revealed a significant correlation (R = 0.353, P ≤ 0.001). The only retained domains in the final model were change in lifting, standing, and traveling as predictors for ΔPCS. All domains of the ODI do not improve equally after surgery for degenerative spondylolisthesis. Some of the domains that improve most (e.g., sex life) have no discernible relationship to the known pathophysiology of degenerative spondylolisthesis. Based upon these results, we conclude that the item bank and composite scoring of the ODI are inappropriate for evaluating quality of life in studies of surgically treated degenerative spondylolisthesis patients. 3.