Symptomatic Lumbar Spondylolisthesis Research Articles

Factors associated with an increased risk of developing postoperative symptomatic lumbar spondylolisthesis after decompression surgery: an explorative two-centre international cohort study

PurposeSymptomatic lumbar spinal stenosis can be treated with decompression surgery. A recent review reported that, after decompression surgery, 1.6–32.0% of patients develop postoperative symptomatic spondylolisthesis and may therefore be indicated for lumbar fusion surgery. The latter can be more challenging due to the altered anatomy and scar tissue. It remains unclear why some patients get recurrent neurological complaints due to postoperative symptomatic spondylolisthesis, though some associations have been suggested. This study explores the association between key demographic, biological and radiological factors and postoperative symptomatic spondylolisthesis after lumbar decompression.MethodsThis retrospective cohort study included patients who had undergone lumbar spinal decompression surgery between January 2014 and December 2016 at one of two Spine Centres in the Netherlands or Switzerland and had a follow-up of two years. Patient characteristics, details of the surgical procedure and recurrent neurological complaints were retrieved from patient files. Preoperative MRI scans and conventional radiograms (CRs) of the lumbar spine were evaluated for multiple morphological characteristics. Postoperative spondylolisthesis was evaluated on postoperative MRI scans. For variables assessed on a whole patient basis, patients with and without postoperative symptomatic spondylolisthesis were compared. For variables assessed on the basis of the operated segment(s), surgical levels that did or did not develop postoperative spondylolisthesis were compared. Univariable and multivariable logistic regression analyses were used to identify associations with postoperative symptomatic spondylolisthesis.ResultsSeven hundred and sixteen patients with 1094 surgical levels were included in the analyses. (In total, 300 patients had undergone multilevel surgery.) ICCs for intraobserver and interobserver reliability of CR and MRI variables ranged between 0.81 and 0.99 and 0.67 and 0.97, respectively. In total, 66 of 716 included patients suffered from postoperative symptomatic spondylolisthesis (9.2%). Multivariable regression analyses of patient-basis variables showed that being female [odds ratio (OR) 1.2, 95%CI 1.07–3.09] was associated with postoperative symptomatic spondylolisthesis. Higher BMI (OR 0.93, 95%CI 0.88–0.99) was associated with a lower probability of having postoperative symptomatic spondylolisthesis.Multivariable regression analyses of surgical level-basis variables showed that levels with preoperative spondylolisthesis (OR 17.30, 95%CI 10.27–29.07) and the level of surgery, most importantly level L4L5 compared with levels L1L3 (OR 2.80, 95%CI 0.78–10.08), were associated with postoperative symptomatic spondylolisthesis; greater facet joint angles (i.e. less sagittal-oriented facets) were associated with a lower probability of postoperative symptomatic spondylolisthesis (OR 0.97, 95%CI 0.95–0.99).ConclusionBeing female was associated with a higher probability of having postoperative symptomatic spondylolisthesis, while having a higher BMI was associated with a lower probability. When looking at factors related to postoperative symptomatic spondylolisthesis at the surgical level, preoperative spondylolisthesis, more sagittal orientated facet angles and surgical level (most significantly level L4L5 compared to levels L1L3) showed significant associations. These associations could be used as a basis for devising patient selection criteria, stratifying patients or performing subgroup analyses in future studies regarding decompression surgery with or without fusion.

Study on Outcome Analysis of Transforaminal Interbody Fusion with Transpedicular Screws and Rods in Lumbar Spondylolisthesis and Spondylolysis

Abstract Introduction The management of spondylolisthesis and spondylolysis is primarily conservative or surgical. There are various surgical procedures available for spondylolisthesis. Objective To evaluate the functional outcome and efficacy in patients undergoing transforaminal lumbar interbody fusion with transpedicular screws and rods in symptomatic lumbar spondylolisthesis and spondylolysis. Methods From 2017 to 2018, a prospective observational study was performed in a tertiary care hospital. The preoperative evaluation was performed both clinically and radiologically. Based on indications, transforaminal interbody fusion was performed. A total sample of 20 patients was included. The primary outcome variables were the visual analogue scale (VAS), the Oswestry Disability Index (ODI), slip percentage, and disc height at follow-up. For the statistical analysis, coGuide (BDSS CORP, Bangalore, Karnataka, India) was used. Results In 20 participants studied, the mean age was 48.25 ± 5.35 years old. Degenerative spondylolisthesis was seen in 60% of the participants. The majority (70%) of the patients had grade 2 slips. The mean difference of the VAS, the ODI, slip percentage, and disc height between the preoperative and postoperative periods was statistically significant (p < 0.001). The majority (70%) of the patients had no complications after the procedure. Conclusions Transforaminal interbody fusion with pedicle screws and rods is a safe, simple procedure and has less morbidity. This procedure also provides better functional outcomes and reduction in symptoms by maintaining the disc height and providing sagittal balance.

Factors associated with an increased risk of developing postoperative symptomatic lumbar spondylolisthesis after decompression surgery: an explorative two-centre international cohort study

Factors associated with an increased risk of developing postoperative symptomatic lumbar spondylolisthesis after decompression surgery: an explorative two-centre international cohort study

Factors associated with an increased risk of developing postoperative symptomatic lumbar spondylolisthesis after decompression surgery: An explorative two-centre international cohort study

Factors associated with an increased risk of developing postoperative symptomatic lumbar spondylolisthesis after decompression surgery: An explorative two-centre international cohort study

Flexion-extension standing radiographs underestimate instability in patients with single-level lumbar spondylolisthesis: comparing flexion-supine imaging may be more appropriate.

Generally, most spine surgeons agree that increased segmental motion viewed on flexion-extension radiographs is a reliable predictor of instability; however, these views can be limited in several ways and may underestimate the instability at a given lumbar segment. Consecutively collected adult (≥18 years old) patients with symptomatic single-level lumbar spondylolisthesis were reviewed from a two-surgeon database from 2015 to 2019. Routine standing lumbar X-rays (neutral, flexion, extension) and supine lumbar MRI (sagittal T2-weighted imaging sequence) were performed. Patients were excluded if they had prior lumbar surgery, missing radiographic data, or if the time between X-rays and MRI was >6 months. All 39 patients with symptomatic, single-level lumbar spondylolisthesis were identified. The mean age was 57.3±16.7 years and 66% were female. There was good intra- and inter-rater reliability agreement between measured values on the presence of instability. The slip percentage (SP) difference was significantly highest in the flexion-supine (FS) (5.7 mm, 12.3%) and neutral standing-supine (NS) (4.3 mm, 8.7%) groups, both of which were significantly higher compared with the flexion-extension (FE) group (1.8 mm, 4.5%, P<0.001). Ventral instability based on SP >8% was observed more frequently in FS (79.5%) and NS (52.6%) groups compared with FE group (16.7%, P<0.001). No statistically significant correlation was found between SP and disc angle for all radiographic views. Comparing standing lateral and flexion X-rays with supine MRIs provides higher sensitivity to assess instability than standard flexion-extension radiographs. The FS and NS comparisons also show greater slip percentage differences at higher slip grades, but not at different lumbar levels. These changes are not dependent on age or gender.

Retrospective Comparison of Minimally Invasive and Open Monosegmental Lumbar Fusion, and Impact of Virtual Reality on Surgical Planning and Strategy.

Spinal fusion for symptomatic lumbar spondylolisthesis can be accomplished using an open or minimally invasive surgical (MIS) technique. Evaluation of segmental spondylolisthesis and instabilities and review of their therapies are inseparably connected with lumbar tomographic imaging. We analyzed a cohort of patients who underwent MIS or open monosegmental dorsal fusion and compared surgical outcomes along with complication rates. We furthermore evaluated the influence of virtual reality (VR) visualization on surgical planning in lumbar fusion. Patient files were retrospectively analyzed regarding patient- and disease-related data, operative performance, surgical outcomes, and perioperative surgical complications. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans were retrospectively visualized via VR software. A questionnaire evaluated the influence of three-dimensional (3D) VR images versus two-dimensional CT and MRI scans on therapy planning, fusion method, and surgical technique and procedure. Overall, 171 patients were included (MIS/open: 90/81). MIS was associated with less blood loss, shorter surgery time and hospital stay, lower complication rates, equivalent long-term patient-reported outcomes, but lower fusion rates and higher late reoperation rates than open surgery. Image presentation using VR significantly influenced the recommended surgical therapies (decompression only/decompression and fusion; p = 0.02), had no significant influence on the recommended fusion method (rigid/dynamic/stand-alone; p = 0.77), and, in cases of rigid fusion, a significant influence on the recommended technique (MIS/open; p = 0.03) and fusion procedure (p = 0.02). In patients with monosegmental degenerative or isthmic spondylolisthesis, MIS fusion was advantageous concerning perioperative complication rates and perioperative surgical outcomes, but disadvantageous regarding fusion and reoperation rates compared to open fusion. 3D-VR-based analysis of sectional images significantly influenced the recommended surgical planning.

Clinical and Radiographic Outcomes After Minimally Invasive Transforaminal Lumbar Interbody Fusion-Early Experience Using a Biplanar Expandable Cage for Lumbar Spondylolisthesis.

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is a surgical technique frequently used to treat symptomatic lumbar spondylolisthesis. We aim to investigate the safety and efficacy of using a biplanar expandable cage in the treatment of symptomatic lumbar spondylolisthesis using a MIS TLIF approach. A retrospective review of patient records was performed on patients who underwent MIS TLIF for symptomatic lumbar spondylolisthesis using the FlareHawk cage over a 12-month period. Patient demographics, as well as preoperative and postoperative clinical and radiographic outcome measures were recorded and analyzed. A total of 13 consecutive patients underwent MIS TLIF for symptomatic spondylolisthesis during the study period. The mean age was 60.2 ± 13.9 years, and 61.5% were female. The mean preoperative and postoperative slippage was 7.0 ± 3.0 mm and 1.0 ± 1.9 mm, respectively. The preoperative mean segmental lordosis was 5.1° ± 6.0°, mean anterior, posterior disc, and foraminal height were 9.1 ± 3.9 mm, 5.7 ± 1.5 mm, and 11.0 ± 2.0 mm, respectively. The postoperative mean segmental lordosis was 6.8° ± 4.7°, and mean anterior, posterior disc, and foraminal height were 11.4 ± 2.2 mm, 7.8 ± 1.0 mm, and 12.3 ± 1.3 mm. There was improvement in all radiographic parameters postoperatively. The mean Visual Analog Scale (VAS) back pain, VAS leg pain improved from 7.0 ± 2.9 and 5.1 ± 3.0 preoperatively to 3.1 ± 2.9 and 1.1 ± 1.7 at the latest clinic follow-up visit, respectively (P = .0081). The mean EuroQol-Five Dimensions (EQ5D) score improved from 0.37 ± 1.7 to 0.66 ± 0.23 after surgery. There was no subsidence, endplate violation, cage migration, or other implant-related complications. No patient required reoperation. The biplanar expandable cage is both safe and efficacious in treating symptomatic lumbar spondylolisthesis using the MIS TLIF approach. Spine surgeons should be familiar with the biplanar expandable cage technology and keep it in their armamentarium in surgical treatment of lumbar spondylolisthesis. 4.

Inclusion of L5–S1 in oblique lumbar interbody fusion–techniques and early complications–a single center experience

Background contextThe oblique prepsoas retroperitoneal approach to the lumbar spine for interbody fusion or oblique lumbar interbody fusion (OLIF) provides safe access to nearly all lumbar levels. A wide interval between the psoas and aorta allows for a safe and straightforward left-sided oblique approach to the discs above L5. Inclusion of L5–S1 in this approach, however, requires modifications in the technique to navigate the complex and variable vascular anatomy distal to the bifurcation of the great vessels. While different oblique approaches to L5–S1 have been described in the literature, to our knowledge, no previous study has provided guidance for the choice of technique. PurposeOur objectives were to evaluate our early experience with the safety of including L5–S1 in OLIF using 3 different approach techniques, as well as to compare early complications between OLIF with and without L5–S1 inclusion. Study designRetrospective cohort study. Patient sampleOf the 87 patients who underwent lumbar interbody fusion at 167 spinal levels via an OLIF approach, 19 included L5–S1 (group A) and 68 did not (group B). Outcome measuresDemographics, levels fused, indications, operative time (ORT), estimated blood loss (EBL), vascular ligation, intraoperative blood transfusion, length of stay (LOS), discharge to rehabilitation facility, and complications (intraoperative, early ≤90 days, and delayed >90 days) were retrospectively assessed and compared between the groups. MethodsA retrospective chart and imaging review of all consecutive patients who underwent OLIF at a single institution was performed. Indications for OLIF included symptomatic lumbar degenerative stenosis, deformity, and spondylolisthesis. The L5–S1 level, when included, was approached via one of the following 3 techniques: (1) a left-sided intrabifurcation approach; (2) left-sided prepsoas approach; and (3) right-sided prepsoas approach. Vascular anatomic variations at the lumbosacral junction were evaluated using the preoperative magnetic resonance imaging (MRI), and a “facet line” was proposed to assess this relationship. A minimum of 6 months of follow-up data were assessed for approach-related morbidities. ResultsDemographics and operative indications were similar between the groups. The mean follow-up was 10.8 (6–36) months. ORT was significantly longer in group A than in group B (322 vs. 256.3 min, respectively; p=.001); however, no difference in ORT between the two groups was found in the subanalyses for 2- and 3-level surgeries. Differences in EBL (260 vs. 207.91 cc, p=.251) and LOS (2.76 vs. 2.48 days, p=.491) did not reach statistical significance. Ligation of the iliolumbar vein, segmental veins, median sacral vessels, or any vascular structure, as needed for adequate exposure, was required in 13 (68.4%) patients from group A and 4 (5.9%) from group B (p<.00001). Two patients suffered minor vascular injuries (1 in each group); however, no major vascular injuries were seen. Complications were not significantly different between groups A and B, or between the three approaches to L5–S1, and trended lower in the latter part of the series as the learning curve progressed. ConclusionsInclusion of L5–S1 in OLIF is safe and feasible through three different approaches but likely involves greater operative complexity. In our early experience, inclusion of L5–S1 showed no increase in early complications. This is the first series that reports the use of 3 different oblique approaches to L5–S1. The proposed “facet line” in the preoperative MRI may guide the choice of approach.

Minimally invasive surgery for low-grade spondylolisthesis: percutaneous endoscopic or oblique lumbar interbody fusion.

Aim: To compare the clinical and radiographic outcomes of percutaneous endoscopic-assisted lumbar interbody fusion (PELIF) versus oblique lumbar interbody fusion (OLIF) for the treatment of symptomatic low-grade lumbar spondylolisthesis. Material & methods: The clinical and radiographic records of 48 patients underwent single-level minimally invasive lumbar fusion with a PELIF (n=16) or OLIF (n=32) were reviewed. Results: The clinical and radiographic outcomes were similar in both groups. PELIF procedure exhibited superior capability of the enlargement of foraminal width, but inferior capability of the restoration of foraminal height than OLIF procedure. Conclusion: PELIF minimizes the iatrogenic damages and perioperative risks to a great extent, and seems to be a promising option for the treatment of symptomatic low-grade lumbar spondylolisthesis.

Does the awareness of having a lumbar spondylolisthesis influence self-efficacy and kinesiophobia? A retrospective analysis

BackgroundHigh pain self-efficacy and low kinesiophobia seem related to a better prognosis in patients complaining of low back pain (LBP). The literature stresses the potential negative effects of anatomical defect diagnosis (e.g. lumbar spondylolisthesis) on the psychological profile. The aim of this study is to investigate the relationships between awareness of having a spondylolisthesis, pain self-efficacy and kinesiophobia.MethodsA secondary retrospective analysis was done. Ninety-eight subjects with subacute and chronic LBP were included: 49 subjects with diagnosed symptomatic lumbar spondylolisthesis and 49 subjects with diagnosed non-specific LBP. The pain self-efficacy measured with the Pain Self-Efficacy Questionnaire and the fear of movement measured with the Tampa Scale of Kinesiophobia were considered variables to investigate, whereas diagnosis and demographic/clinical variables were considered predictors or potential confounders.ResultsBy comparing the two groups, the awareness of having a spondylolisthesis did not significantly influence neither pain self-efficacy (p = 0.82), nor kinesiophobia (p = 0.75). Higher perceived pain reduces pain self-efficacy and increases kinesiophobia in both groups (p = 0.002 and p = 0,031 respectively).ConclusionsIt seems that the awareness of an anatomical defect as spondylolisthesis does not significantly affect the beliefs of carry out activities and movements despite the pain. Other studies with wider samples are required, to confirm these preliminary results.

P104. A 2-year cost analysis of maximum nonoperative treatments in patients with symptomatic lumbar stenosis or spondylolisthesis that ultimately required surgery

BACKGROUND CONTEXT A variety of nonoperative therapies are attempted for pain management in patients with symptomatic lumbar stenosis or spondylolisthesis prior to surgery. The costs and utilization of maximal nonoperative therapy (MNT) remains unknown. PURPOSE The purpose of this study is to characterize the utilization and costs of MNTs within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1, 2, or 3-level lumbar decompression and fusion procedures between 2007 and 2016 within a large insurance database were included. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. OUTCOME MEASURES The primary outcome was the utilization of MNTs within 2 years prior to index surgery. METHODS Research records were searchable by International Classification of Diseases (ICD) diagnosis and procedure codes, Current Procedural Terminology (CPT) codes, and generic drug codes specific to Humana. “Utilization” of MNTs was characterized by cost billed to the patient, prescriptions written and number of units billed. RESULTS A total of 27,877 out of 3,423,114 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion; 17.6% of patients were smokers, 35.1% of patients had type II DM, and 24.8% were obese (BMI > 30 kg/m2). Patient maximal nonoperative therapy (MNT) utilization was as follows: 11,383 (40.8%) used NSAIDs, 19,770 (70.9%) used opioids, 12,414(44.5%) used muscle relaxants, 14,422 (51.7%) received LESI, 11,156 (40.0%) attended PT/OT, 4,005 (14.4%) presented to the ED, and 4,042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28,241,320. LESI comprised the largest portion of the total cost of MNT ($15,296,941, 54.2%), followed by opioids ($3,702,463, 13.1%) and NSAIDs ($3,058,335, 10.8%). At the patient level, on average $1,013.07 was spent on nonoperative treatments prior to index lumbar surgery. CONCLUSIONS Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio (ICER) for MNT could be highly unfavorable. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. A variety of nonoperative therapies are attempted for pain management in patients with symptomatic lumbar stenosis or spondylolisthesis prior to surgery. The costs and utilization of maximal nonoperative therapy (MNT) remains unknown. The purpose of this study is to characterize the utilization and costs of MNTs within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. Retrospective cohort study. Patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1, 2, or 3-level lumbar decompression and fusion procedures between 2007 and 2016 within a large insurance database were included. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. The primary outcome was the utilization of MNTs within 2 years prior to index surgery. Research records were searchable by International Classification of Diseases (ICD) diagnosis and procedure codes, Current Procedural Terminology (CPT) codes, and generic drug codes specific to Humana. “Utilization” of MNTs was characterized by cost billed to the patient, prescriptions written and number of units billed. A total of 27,877 out of 3,423,114 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion; 17.6% of patients were smokers, 35.1% of patients had type II DM, and 24.8% were obese (BMI > 30 kg/m2). Patient maximal nonoperative therapy (MNT) utilization was as follows: 11,383 (40.8%) used NSAIDs, 19,770 (70.9%) used opioids, 12,414(44.5%) used muscle relaxants, 14,422 (51.7%) received LESI, 11,156 (40.0%) attended PT/OT, 4,005 (14.4%) presented to the ED, and 4,042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28,241,320. LESI comprised the largest portion of the total cost of MNT ($15,296,941, 54.2%), followed by opioids ($3,702,463, 13.1%) and NSAIDs ($3,058,335, 10.8%). At the patient level, on average $1,013.07 was spent on nonoperative treatments prior to index lumbar surgery. Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio (ICER) for MNT could be highly unfavorable.

Racial Differences in Perioperative Opioid Utilization in Lumbar Decompression and Fusion Surgery for Symptomatic Lumbar Stenosis or Spondylolisthesis.

Study Design:Retrospective cohort study.Objectives:To assess for racial differences in opioid utilization prior to and after lumbar fusion surgery for patients with lumbar stenosis or spondylolisthesis.Methods:Clinical records from patients with lumbar stenosis or spondylolisthesis undergoing primary <3-level lumbar fusion from 2007 to 2016 were gathered from a comprehensive insurance database. Records were queried by International Classification of Diseases diagnosis/procedure codes and insurance-specific generic drug codes. Opioid use 6 months prior, through 2 years after surgery was assessed. Multivariate regression analysis was employed to investigate independent predictors of opioid use following lumbar fusion.Results:A total of 13 257 patients underwent <3-level posterior lumbar fusion. The cohort racial distribution was as follows: 80.9% white, 7.0% black, 1.0% Hispanic, 0.2% Asian, 0.2% North American Native, 0.8% “Other,” and 9.8% “Unknown.” Overall, 57.8% patients utilized opioid medications prior to index surgery. When normalized by the number opiate users, all racial cohort saw a reduction in pills disbursed and dollars billed following surgery. Preoperatively, Hispanics had the largest average pills dispensed (222.8 pills/patient) and highest average amount billed ($74.67/patient) for opioid medications. The black cohort had the greatest proportion of patients utilizing preoperative opioids (61.8%), postoperative opioids (87.1%), and long-term opioid utilization (72.7%), defined as use >1 year after index operation. Multivariate logistic regression analysis indicated Asian patients (OR 0.422, 95% CI 0.191-0.991) were less likely to use opioids following lumbar fusion.Conclusions:Racial differences exist in perioperative opioid utilization for patients undergoing lumbar fusion surgery for spinal stenosis or spondylolisthesis. Future studies are needed corroborate our findings.

Regional Variation in Nonoperative Therapy Utilization for Symptomatic Lumbar Stenosis and Spondylolisthesis: A 2-Year Costs Analysis.

Study Design:Retrospective cohort study.Objectives:To characterize regional variations in maximal nonoperative therapy (MNT) costs in patients suffering from lumbar stenosis or spondylolisthesis.Methods:Medical records from patients with symptomatic lumbar stenosis or spondylolisthesis undergoing primary ≤3-level lumbar decompression and fusion procedures from 2007 to 2016 were gathered from a large insurance database. Geographic regions (Midwest, Northeast, South, and West) reflected the US Census Bureau definitions. Records were searchable by International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and insurance-specific generic drug codes. Utilization of MNT, defined as cost billed, prescriptions written, and number of units disbursed, within 2-years prior to index surgery was assessed.Results:A total of 27 877 patients underwent 1-, 2-, or 3-level lumbar decompression and fusion surgery. Regional breakdown of the study cohort was as follows: South 62.3%, Midwest 25.2%, West 10.4%, Northeast 2.1%. Regional variations in the number of patients using nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .0001), opioids (P < .0001), muscle relaxants (P < .0001), and lumbar steroid injections (P < .0001) were detected. A significant difference was identified in the regional MNT failure rates (P < .0001). The total cost associated with MNT prior to index surgery was $48 411 125 ($1736.60/patient), with the Midwest ($1943.83/patient) responsible for the greatest average spending. Despite comprising 62.3% of the cohort, the South was accountable for 67.5% of NSAID prescriptions, 64.6% of opioid prescriptions, and 71.2% of muscle relaxant prescriptions.Conclusions:Regional differences exist in the costs of MNT in patients with lumbar stenosis and spondylolisthesis prior to surgery. Future studies should focus on identifying patients likely to fail prolonged nonoperative management.

Long-Term Costs of Maximum Nonoperative Treatments in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis that Ultimately Required Surgery: A 5-Year Cost Analysis.

Retrospective cohort study. The purpose of this study is to characterize the utilization and costs of MNTs prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. The costs and utilization of long-term maximal nonoperative therapy (MNT) can be substantial, and in the current era of bundled payments, the duration of conservative therapy trials should be reassessed. A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Only patients with lumbar stenosis or spondylolisthesis and those continuously active within the insurance system for at least 5 years prior to the index operation were eligible. A total of 4133 out of 497,822 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion. 20.8% of patients were smokers, 44.5% had type II DM, and 38.2% were obese (body mass index [BMI] >30 kg/m). Patient MNT utilization was as follows: 66.7% used nonsteroidal anti-inflammatory drugs (NSAIDs), 84.4% used opioids, 58.6% used muscle relaxants, 65.5% received lumbar epidural steroid injections (LESI), 66.6% attended 21.1% presented to the emergency department (ED), and 24.9% received chiropractor treatments. The total direct cost associated with all MNT prior to index spinal fusion was $9,000,968; LESI comprised the largest portion of the total cost of MNT ($4,094,646, 45.5%), followed by NSAIDS ($1,624,217, 18.0%) and opioid costs ($1,279,219, 14.2%). At the patient level, when normalized per patient utilizing therapy, an average $4010 was spent on nonoperative treatments prior to index lumbar surgery. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost-effectiveness ratio (ICER) for MNTs could be highly unfavorable. 3.

Minimally Invasive Transforaminal Interbody Fusion With Robotically Assisted Bilateral Pedicle Screw Fixation: 2-Dimensional Operative Video.

Minimally invasive surgery (MIS) techniques may enable faster patient recovery and reduce the incidence of postoperative infections. Image-guided approaches to spinal instrumentation and interbody fusion have gained popularity in MIS, reducing radiation exposure and improving screw placement accuracy. Use of a novel computed tomography (CT) navigation-based robotic arm provides for live image-guided surgery, with the potential for augmenting existing MIS approaches and improving the accuracy of instrumentation placement. We report on the surgical technique of MIS transforaminal lumbar interbody fusion (TLIF) performed with the assistance of a new robotic device (ExcelsiusGPS, Globus Medical Inc, Audubon, Pennsylvania) and intraoperative CT guidance in a patient with single-level lumbar spondylolisthesis. The patient gave written informed consent before treatment. Institutional review board approval was deemed unnecessary. The patient was positioned prone on the operating room table, and an intraoperative CT was obtained with stereotactic arrays placed bilaterally in the posterior superior iliac spine. Screw trajectories were planned using the ExcelsiusGPS software and placed percutaneously with the robotic arm without using a Kirschner wire. Interbody placement was performed via an expandable retractor after muscle dilation. Screw placement accuracy was determined with postoperative CT, which demonstrated good screw positioning without breach. The patient recovered well and was discharged home without complications. The combined use of the new robotic device and intraoperative CT enables accurate and safe fixation for the treatment of symptomatic lumbar spondylolisthesis. The operative video demonstrates the technical nuances of positioning, stereotactic marker placement, work flow, and screw placement. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

A 2-Year Cost Analysis of Maximum Nonoperative Treatments in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis That Ultimately Required Surgery.

Study Design:Retrospective cohort study.Objectives:The purpose of this study is to characterize the utilization and costs of maximal nonoperative therapies (MNTs) within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis.Methods:A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1-, 2-, or 3-level lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. The utilization of MNTs within 2 years prior to index surgery was assessed by cost billed to the patient, prescriptions written, and number of units billed.Results:A total of 27 877 out of 3 423 114 (0.8%) eligible patients underwent posterior lumbar instrumented fusion. Patient MNT utilization was as follows: 11 383 (40.8%) used nonsteroidal anti-inflammatory drugs (NSAIDs), 19 770 (70.9%) used opioids, 12 414 (44.5%) used muscle relaxants, 14 422 (51.7%) received lumbar epidural steroid injection (LESI), 11 156 (40.0%) attended physical therapy/occupational therapy, 4005 (14.4%) presented to the emergency department, and 4042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28 241 320 ($1013.07 per/patient). LESI comprised the largest portion of the total cost of MNT ($15 296 941, 54.2%), followed by opioids ($3 702 463, 13.1%) and NSAIDs ($3 058 335, 10.8%).Conclusions:Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio for MNT could be highly unfavorable.

Sex Differences in Opioid Use in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis Undergoing Lumbar Decompression and Fusion.

Retrospective analysis. To investigate sex differences in opioid use after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. Recent studies have demonstrated higher prevalence of chronic pain states and greater pain sensitivity among women compared with men. Furthermore, differences in responsivity to pharmacological and non-pharmacological treatments have been observed. Whether sex differences in perioperative opioid use exists in patients undergoing lumbar fusion for symptomatic stenosis or spondylolisthesis remains unknown. An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1,2, or 3-level index lumbar decompression and fusion procedures between 2007 and 2016. Records were searchable by International Classification of diseases diagnosis and procedure codes, and generic drug codes specific to Humana. Opioid use 6-months prior to through 2-years after index surgery was assessed. The primary outcome was sex differences in opioid use after index lumbar surgery. The secondary outcome was independent predictors of prolonged opioid use after lumbar fusion. Of the 13,257 participants (females: 7871, 59.8%), 58.4% of women used opioids compared with 56.9% of men prior to index surgery. At 1-year after surgery, continuous opioid use was observed in 67.1% of women compared with 64.2% of men (P < 0.001). Within 2-years postoperatively, opioid use was observed in 83.1% of women versus 82.5% men. In a multivariate logistic regression analysis, female sex (odds ration [OR] 1.14, 95% confidence interval [CI]: 1.058-1.237), obesity (OR 1.10, 95% CI: 1.004-1.212), and preoperative narcotic use (OR 3.43, 95% CI: 3.179-3.708) was independently associated with prolonged (>1 yr) opioid use after index surgery. We observed a higher prevalence of chronic opioid use among women following lumbar fusion surgery. Female sex was independently associated with prolonged opioid use after index surgery. 3.

"One and a half" minimally invasive transforaminal lumbar interbody fusion: single level transforaminal lumbar interbody fusion with adjacent segment unilateral laminotomy for bilateral decompression for spondylolisthesis with bisegmental stenosis.

Symptomatic lumbar spondylolisthesis is commonly accompanied by spinal stenosis in multiple segments. These pathologies are routinely treated by multilevel decompression and instrumented fusion. However, it was hypothesized that a minimally invasive surgery (MIS) fusion in the unstable segment combined with a unilateral laminotomy for bilateral decompression (ULBD) in the adjacent stenotic segment is a biomechanically feasible alternative to a two-level fusion and superior to open laminectomy adjacent to a fused segment. This concept has demonstrated success in a recently published biomechanical cadaver study performed by our group. The present article offers a detailed step by step technical description for an MIS-TLIF (transforaminal lumbar interbody fusion) with adjacent ULBD.

Reduction in Narcotic Use After Lumbar Decompression and Fusion in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis.

Study Design:Retrospective cohort study.Objectives:The purpose of this study is to assess change in opioid use before and after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis.Methods:A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Opioid use 6 months preoperatively through 2 years postoperatively was assessed.Results:The study included 13 257 patients that underwent 1-, 2-, or 3-level posterior lumbar instrumented fusion. Overall, 57.8% of patients used opioids preoperatively. Throughout the 6-month preoperative period, 2 368 008 opioid pills were billed for (51.6 opioid pills/opioid user/month). When compared with preoperative opioid use, patients billed fewer opioid medications in the 2-year period postoperatively: 33.6 pills/patient/month (8 851 616 total pills). In a multivariate logistic regression analysis, obesity (odds ratio [OR] 1.10, 95% CI 1.004-1.212), preoperative narcotic use (OR 3.43, 95% CI 3.179-3.708), length of hospital stay (OR 1.02, 95% CI 1.010-1.021), and receiving treatment in the South (OR 1.18, 95% CI 1.074-1.287) or West (OR 1.26, 95% CI 1.095-1.452) were independently associated with prolonged postoperative (>1 year) opioid use. Additionally, males (OR 0.87, 95% CI 0.808-0.945) were less likely to use long-term opioid therapy.Conclusions:This study demonstrates that reduction in opioid use was observed postoperatively in comparison with preoperative values in patients with symptomatic lumbar stenosis or spondylolisthesis that underwent lumbar decompression with fusion. Further prospective studies that are more methodologically stringent are needed to corroborate our findings.

Regional Variation in Opioid Use After Lumbar Spine Surgery

The aim of this study was to investigate regional variations in use of opioids after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients undergoing 1-level, 2-level, or 3-level index lumbar decompression and fusion procedures between 2007 and 2016. Research records were searchable by International Classification of Diseases diagnosis and procedure codes, and generic drug codes specific to Humana. Opioid use 6 months before index surgery to 2 years after surgery was assessed. Of the 13,257 patients included in the study, 63.1% were from the South, 24.3% from the Midwest, 10.5% from the West, and 2.1% from the Northeast. Of patients, 57.8% had a history of opioid use before index surgery, of whom 64.4% were from the South and 23.0% from the Midwest. Over the 6-month preoperative period, 51.6 opioid pills were billed by opioid users monthly (Midwest, 52.7 pills/patient/month; Northeast, 64.9 pills/patient/month; South, 50.6 pills/patient/month; West, 52.2 pills/patient/month). During the 2-year period after surgery, an average of 33.6 opioid pills were billed by opioid users monthly (Midwest, 32.9 pills/patient/month; Northeast, 35.4 pills/patient/month; South, 33.9 pills/patient/month; West, 32.9 pills/patient/month). In a multivariate logistic regression analysis, receiving treatment in the South (odds ratio, 1.18; 95% confidence interval, 1.07-1.29) or West (odds ratio, 1.26; 95% confidence interval, 1.10-1.45) was independently associated with prolonged (>1 year) opioid use after index surgery. Our study suggests that regional variations may exist in the use of opioids after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis.