Two-level Lumbar Research Articles

111. Risk factors for ambulatory surgery conversion to extended stay among patients undergoing one- or two-level posterior lumbar decompression

<h3>BACKGROUND CONTEXT</h3> Ambulatory surgery (AMS), or outpatient surgery, is increasingly common for patients with lumbar spine disease. Previous reports suggest AMS is associated with lower cost and similar quality of care compared to conventional inpatient spine surgery. Under the current Center for Medicare and Medicaid services (CMS) two-midnight rule, a prolonged stay beyond 48 hours is considered an inpatient admission. AMS patients may unintentionally be subjected to extended hospital stays, which can lead to higher medical costs. An unanticipated extension of hospitalization can be a great burden not only to patients, but to medical providers and insurance companies. However, little is known about the risk factors for AMS conversion to extended stay. <h3>PURPOSE</h3> To investigate the factors associated with the conversion of patient status from ambulatory surgery (outpatient) to observation stay (OS) (less than 48 hours) or inpatient (greater than 48 hours). <h3>STUDY DESIGN/SETTING</h3> Retrospective study. <h3>PATIENT SAMPLE</h3> This study included 1,096 adult patients undergoing one- or two-level lumbar decompression surgery at a single academic institution from January 1, 2019 to March 16, 2020. <h3>OUTCOME MEASURES</h3> Conversion rate and risk factors from AMS to OS or inpatient. <h3>METHODS</h3> Ethical board approval was obtained for this study. The records of patients who underwent one- or two-level lumbar decompression surgery planned for AMS were retropectively reviewed. Patients were categorized in three groups based on length of stay that consisted of AMS, OS (less than 48-hour stay), and inpatient (staying greater than 48 hours). Data on patient demographics, medical co-morbidities, surgical information including intraoperative complications and postsurgical pain scores, and administrative information such as operation start time were collected. Simple and multivariable logistic regression analyses were conducted comparing AMS patients and OS/inpatient. Statistical signicance was defined as p <0.05. <h3>RESULTS</h3> Of the 1,096 patients, 641 (58%) patients were converted to either OS (486, 44%) or inpatinet (155, 14%) status. The multivariable analysis demonstrated that age (>80 years old), high ASA grade, history of sleep apnea, drain use, high estimated blood loss, long operation, laminectomy for spinal stenosis, late operation start time, and a high pain score in the acute care unit were considered independent risk factors for AMS conversion to OS/inpatient status. <h3>CONCLUSIONS</h3> Our results indicated that several surgical factors along with patient factors are significantly associated with AMS conversion. Addressing modifiable surgical factors, such as blood loss and operation start time and postoperative pain management might reduce the AMS conversion rate and be beneficial to patients and facilities. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The Effect of Preoperative Marijuana Use on Surgical Outcomes, Patient-Reported Outcomes, and Opioid Consumption Following Lumbar Fusion.

Retrospective Cohort Study. To (1) investigate the effect of marijuana use on surgical outcomes following lumbar fusion, (2) determine how marijuana use affects patient-reported outcomes measures (PROMs), and (3) determine if marijuana use impacts the quantity of opioids prescribed. Patients > 18years of age who underwent primary one- or two-level lumbar fusion with preoperative marijuana use at our institution were identified. A 3:1 propensity match incorporating patient demographics and procedure type was conducted to compare preoperative marijuana users to non-marijuana users. Patient demographics, surgical characteristics, surgical outcomes (90-day all-cause and 90-day surgical readmissions, reoperations, and revision surgeries), pre- and postoperative narcotic usage, and PROMs were compared between groups. Multivariate regression models were created to determine the effect of marijuana on surgical reoperations patient-reported outcomes (PROMs) 1-year postoperatively. Of the 259 included patients, 65 used marijuana preoperatively. Multivariate logistic regression analysis demonstrated that marijuana use (OR = 2.28, P = .041) significantly increased the likelihood of having a spine reoperation. No other surgical outcome was found to be significantly different between groups. Multivariate linear regression analysis showed that marijuana use was not significantly associated with changes in 1-year postoperative PROMs (all, P > .05). The quantity of pre- and postoperative opioids prescriptions was not significantly different between groups (all, P > .05). Preoperative marijuana use increased the likelihood of a spine reoperation for any indication following lumbar fusion, but it was not associated with 90-day all cause readmission, surgical readmission, the magnitude of improvement in PROMs, or differences in opioid consumption. III.

Preoperative lymphocyte percentage and neutrophil-lymphocyte ratio are useful predictors of 30-day postoperative complications after lumbar fusion.

Background: Lymphocyte percentage/count, platelet-lymphocyte ratio (PLR), and neutrophil-lymphocyte ratio (NLR) have shown prognostic significance in patients with cancer, stroke, and following cardiac surgery. However, the utility of these blood parameters for assessing the 30-day postoperative risk for lumbar fusion complications has not been established.Methods: In this single-center-single-surgeon retrospective series, 77 consecutive patients underwent one- or two-level lumbar fusion. Lymphocyte percentage/count, PLR, and NLR were investigated as predictors of 30-day postoperative complications.Results: Ten of 77 patients had postoperative complications. A unit increase in NLR and lymphocyte percentage was significantly associated with a 23% increase and 7% decrease, respectively, in the odds of a complication occurring. Preoperative NLR ≥ 2.32 and lymphocyte percentage ≤ 29.5% significantly discriminated between the “complication” and “no-complication” groups.Conclusion: Patients with a preoperative lymphocyte percentage of ≤29.5% and/or NLR ≥2.32 should be closely monitored as high-risk groups susceptible to 30-day postoperative complications after lumbar fusion.

Effect of Preoperative Opiate Use on Outcomes After Posterior Lumbar Surgery

IntroductionThe prescription opioid epidemic and widespread use of narcotic medications have introduced new challenges when treating patients undergoing spine surgery. Given the ubiquity of preoperative opioid consumption amongst patients undergoing spine surgery, further research is needed to characterize perioperative risks. Our goal is to compare outcomes following primary lumbar decompression, instrumentation, and fusion based on preoperative opioid prescriptions.MethodsPatients older than 18 years of age who underwent a primary one- to two-level lumbar decompression, instrumentation, and fusion were included in the study. Patients with known malignancy, surgery involving three or more lumbar levels, current or previous use of neuromodulation, revision surgery, anterior or far lateral interbody fusions, acute fractures, or other concurrent procedures were excluded. Patients were divided into chronic opioid therapy (COT; over six months), acute opioid therapy (AOT; up to six months), and opiate-naïve groups. Opioid prescriptions, demographics, smoking status, readmission rates within one year, and reoperation rates within two years were recorded based on electronic medical record documentation.ResultsOut of 416 patients identified, 114 patients met the inclusion criteria. Thirty-eight patients (33.3%) were on COT, 38 patients (33.3%) were on AOT, and 38 patients (33.3%) were opioid naïve preoperatively. Readmission rates within one year for COT, AOT, and opioid naïve patients were 34.2%, 26.3%, and 10.5%, respectively (p=0.047). Reoperation rates within two years for COT, AOT, and opioid naïve patients were 34.2%, 15.8%, and 13.2%, respectively (p=0.049). We also found current or former smokers were more likely to be on AOT or COT than never smokers (78.4% vs. 57.1%; p=0.017). ConclusionLong-term opiate use is associated with an increased risk for readmission within one year and revision within two years. Physicians should discuss the increased risks of readmission and revision surgery associated with lumbar decompression and fusion seen in patients on preoperative opioid therapy.

Clinical and Radiological Outcome following MIS-TLIF and Open-TLIF between Asian and African Population- A Comparative Retrospective Analysis in 104 Patients

Purpose: This study aimed to evaluate pre-operative and post-operative sagittal parameters using pelvic incidence (PI), lumbar lordosis (LL), and segmental lordosis (SL) between Asian and African population who underwent minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) and open-TLIF surgeries. Study compares blood loss, operative time, and hospital stay; and evaluates disability and pain by Oswestry disability index (ODI) and visual analog scale (VAS) score, respectively, in both groups. Methods: This retrospective study included 104 patients with an average age of 52.1 ± 12.9 years. All were operated for open-TLIF and MIS-TLIF for one- or two-level lumbar canal stenosis or spondylolisthesis. Patients were divided into two groups according to race: Asian and African. Clinical improvements were evaluated using VAS and ODI scores. Modified MacNab’s criteria were used to evaluate outcome. Estimated blood loss, hospital stay, operative time, perioperative morbidity, and complications were reviewed. On radiological parameters, patients’ LL, PI, and SL were compared between two groups. Results: Average follow-up was 40.6 ± 13.9 months. Both groups showed significant post-operative improvement in their VAS and ODI scores in both open- and MIS-TLIF (P &lt; 0.0001); however, comparing clinical improvement between Asian and African groups, it did not show significant difference in VAS (P = 0.103) and ODI (P = 0.077). Both groups showed significant improvement in LL and SL in both open- and MIS-TLIF (P &lt; 0.0001); however, there was no change in PI. It did not show any significant difference in improvement in LL (P = 0.156), PI (P = 0.798), and SL (P = 0.179) between Asian and African groups. Regarding post-operative complications, there were 4 (6.9%) and 3 (6.5%) complications occurred in Asian and African population, respectively. There were no difference in complication rates in both groups (P = 0.939). Discussion: TLIF (MIS and open) gives similar clinical outcome between Asian and African population. Sagittal parameters were higher in African population than the Asian population. Attention should be paid to predetermine the value of LL to achieve during surgery. Keywords: Transforaminal lumbar interbody fusion, Asian versus African, Sagittal parameters, Clinical outcome.

Mobility parameters in two-level lumbar TDR vs hybrid construct: Clinical results in 235 patients

Mobility parameters in two-level lumbar TDR vs hybrid construct: Clinical results in 235 patients

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

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

106. Seven- to 21-year clinical outcomes of 1,187 patients treated with one- and two-level lumbar total disc arthroplasty

<h3>BACKGROUND CONTEXT</h3> Multiple studies have shown that lumbar total disc arthroplasty (TDA) is not only safe and effective in treating chronic lumbar degenerative disc disease (DDD), but also provides a better surgical alternative to fusion with respect to patient-reported results, restoring motion, and reducing reoperation rates and severity of adjacent level degeneration. Published evidence is limited for follow-up past 5-7 years after TDA. In this study, we expand the evidence favoring TDA with results up to 21 years, of a large patient cohort treated with semi-constrained ball-and-socket lumbar TDA. <h3>PURPOSE</h3> To compare the results for one-level vs two-level patients, and evaluate whether prior surgery at these levels has an effect on clinical outcomes. <h3>STUDY DESIGN/SETTING</h3> Retrospective clinical study. <h3>PATIENT SAMPLE</h3> A total of 1,187 chronic lumbar DDD patients (622 male, 565 female, mean age 43±9.81years, range 17-86 years), underwent lumbar TDA from 1999 to 2013. Of the total, 772 patients had one-level and 415 patients had two-level procedures; 373 out of 1,187 patients (31.5%) had prior index-level surgery (recurrent disc herniation or postdiscectomy syndrome). <h3>OUTCOME MEASURES</h3> Data collected included radiographic, neurological/physical assessment, self-evaluation using the Oswestry Disability Index (ODI) and visual analog back and leg pain Scores (VAS). Complication, reoperation/revision rates, and perioperative data points were also assessed. <h3>Methods</h3> Patients were evaluated preoperatively, then followed postoperatively at 3, 6, 12, and 18 months, then yearly thereafter. Patient follow-up ranged between 7 and 21 years (mean 11 years, 8 months). Patients were stratified into one- (1L) and two-level (2L) procedure groups, then divided into prior (PS) or no-prior surgery (NPS) at the index level for data comparison. Patient demographics (age and gender) were comparable for all groups. <h3>Results</h3> All groups showed dramatic and statistically significant ODI reduction by 3 months postsurgery (p<0.001) and then maintained scores over time. ODI improvement was mean 26 points for groups 1, 2 and 3, while group 4 (2L/PS) had mean 24 points ODI improvement. Although patients with prior surgery took longer to reach final VAS pain levels (6 vs 3 months), there was no statistical difference between groups in pain reduction at 24 months. Although not statistically significant, the group with highest average preoperative VAS pain (group 2) had the greatest reduction in pain. Improvement of ODI and VAS pain is documented in all study groups. Of the 1,187 patients, 49 (4.12%) required new or revision surgery. Revisions were classified into four groups: posterior release/laminectomy at same level; TDA revision; scar/hematoma; and adjacent level surgery (ALS). Rates were too low in all groups to compare them statistically. Total TDA revision and ALS rates over 7-21 years were very low: 0.67% and 1.85%, respectively. <h3>Conclusions</h3> In one of the largest groups of TDA patients evaluated, this study demonstrates the robust long-term clinical success of one- and two-level lumbar TDA, as assessed at 7-21 years postoperatively. Patients had significant and maintained reduction in disability and pain scores over time, and low rates of index revision/reoperation or ALS, when compared to long-term published fusion data. Also, both 1- and 2-level lumbar TDA patients improved and patients with prior surgery at the index level had outcomes equivalent to patients with no prior surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Biomechanics of adjacent segment after three-level lumbar fusion, hybrid single-level semi-rigid fixation with two-level lumbar fusion

Multi-level spinal fusion has been reported in some cases to lead to adjacent segment disease (ASD) and proximal junctional kyphosis (PJK). The purpose of this study was to demonstrate a polyether-ether-ketone (PEEK) rod fixation system implanted adjacent to a two-level lumbar fusion would have a lower risk of PJK than three-level lumbar fusion, which was investigated by comparing the biomechanical effects on the adjacent level after surgical procedures. Four finite element (FE) models of the lumbar-sacral spine (intact model (INT), L4-S1 fusion model (L4-S1 FUS), L3-S1 fusion model (L3-S1 FUS), and single-level PEEK rod semi-rigid fixation adjacent to L4-S1 fusion model (FUSPRF)) were established. Displacement-controlled finite element (FE) analysis was used during the simulation. Compared with the two-level fusion model (L4-S1 FUS), both three-level implanted models (L3-S1 FUS and FUSPRF) showed an increase intersegmental rotation angle, and maximum von-Mises stress on the disc annulus. The results also showed that the intersegmental rotation, stress on the disc annulus and maximum stress on the rod were lower in the FUSPRF model than the L3-S1 FUS model. Though the maximum screw stress was higher in the FUSPRF model than the L3-S1 FUS model under all moments except for torsion, the maximum screw stress in the two models were far below the yield strength of titanium alloy. As the parameters above have been indicated as risk factors for PJK, it can be concluded that hybrid single-level PEEK rod semi-rigid fixation and two-level lumbar fusion have a lower risk of PJK than three-level lumbar fusion.

Minimally invasive transforaminal lumbar interbody fusion using the biportal endoscopic techniques versus microscopic tubular technique

BACKGROUND CONTEXTMinimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with microscopic tubular technique is an established surgical procedure with several potential advantages, including decreased surgical-related morbidity, reduced length of hospital stay, and accelerated early rehabilitation. A recently introduced biportal endoscopic technique for spine surgery presents familiar surgical anatomy and can be conducted using a conventional approach with a minimal footprint; it is also applicable to TLIF. PURPOSETo compare the clinical and radiological outcomes of biportal endoscopic technique transforaminal lumbar interbody fusion (BE-TLIF) and microscopic tubular technique transforaminal lumbar interbody (MT-TLIF) in patients with single- or two-segment lumbar spinal stenosis with or without spondylolisthesis. STUDY DESIGNA retrospective cohort study. PATIENT SAMPLEOne hundred two participants with neurogenic intermittent claudication or lumbar radiculopathy with single- or two-level lumbar spinal stenosis with or without spondylolisthesis. OUTCOME MEASURESClinical outcomes were assessed using the visual analog scale (VAS) score for the back and leg pain, Oswestry Disability Index (ODI), and the Short Form-36 health survey Questionnaire (SF-36). Demographic data, operative data (total operation time, estimated blood loss, amount of surgical drain, postoperative transfusion, and length of hospital stay), and laboratory results (plasma hemoglobin, serum creatine phosphokinase, and C-reactive protein) were also evaluated. The fusion rate was assessed using the Bridwell interbody fusion grading system. Postoperative complications were also noted. METHODSPatients were divided into two groups: group A (BE-TLIF) and group B (MT-TLIF). The clinical outcomes, including VAS-Back and VAS-Leg, ODI, and SF-36 scores, were evaluated at 1 month, 6 months, and 1 year after surgery. Differences in demographics, operative data, and the laboratory and radiological results were assessed between the two groups. The fusion rate was assessed using standard standing lumbar radiographs and computed tomography scans conducted 1 year after surgery. RESULTSSeventy-nine patients were analyzed in this study, 47 from group A and 32 from group B. Demographic and operative data were comparable for both the groups. The VAS-Back and SF-36 scores were more significantly improved in group A than in group B at 1 month after surgery. However, there were no significant differences between groups for the mean VAS-Back, VAS-Leg, ODI, and SF-36 scores at 1year after the surgery. Although the total operation time was significantly longer in group A, the estimated blood loss and the amount of surgical drainage was significantly higher in group B (p < .001). There were no between-group differences for the fusion rate and postoperative complications. CONCLUSIONBoth BE-TLIF and MT-TLIF provided equivalent and favorable clinical outcomes and fusion rates. Further large-scale, randomized, controlled trials with long-term follow-ups are warranted.

Reducing Postoperative Opioid-prescribing Following Posterior Lumbar Fusion Does Not Significantly Change Patient Satisfaction.

Retrospective comparative; LOE-3. The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following one- or two-level lumbar fusion has on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results. Previous research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction. A retrospective review of prospectively collected data was conducted on patients who underwent one- or two-level lumbar fusions L3-S1 between October 2014 and October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions more than two levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram morphine equivalents (MME). A total of 330 patients met inclusion criteria: 259 pre-protocol, 71 post-protocol. There were 256 one-level fusions and 74 two-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (P > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7% (95) pre-protocol to 59.2% (42) post-protocol; P < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL (P = 0.003). Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3% (P < 0.001). Average opioids prescribed on discharge in the pre-protocol period was 534 ± 425 MME, compared to after initiation of the protocol, that is 320 ± 174 MME (P < 0.001). There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol versus 4.51 ± 0.82 post-protocol (P = 0.986). A reduction in opioids prescribed at discharge after one- or two-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

Single-Stage Versus Multistage Surgical Management of Single- and Two-Level Lumbar Degenerative Disease

To determine postoperative complications and quality outcomes of single-stage and multistage surgical management for lumbar degenerative disease (LDD). This retrospective cohort study using a national administrative database identified patients who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether their surgeon chose to perform single-stage or multistage LDD surgery, and these cohorts were mutually exclusive. Propensity score matching was used to mitigate intergroup differences between single-stage and multistage patients. Patients who underwent ≥3 levels of surgical correction, who were <18 years old, or who had any prior history of trauma or tumor were excluded from the study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined. Primary surgery for LDD was performed in 47,190 patients; 9438 (20%) of these patients underwent multistage surgery. After propensity score matching, baseline covariates of the 2 cohorts were similar. The complication rate was 6.1% in the single-stage cohort and 11.0% in the multistage cohort. Rates of posthemorrhagic anemia, infection, wound complication, deep vein thrombosis, and hematoma all were higher in the multistage cohort. Length of stay, revisions, and readmissions were also significantly higher in the multistage cohort. Through 2 years of follow-up, multistage surgery was associated with higher payments throughout the 2-year follow-up period ($57,036 vs. $39,318, P < 0.05). Single-stage surgery for LDD demonstrated improved outcomes and lower health care utilization. Spine surgeons should carefully consider single-stage surgery when treating patients with LDD requiring <3 levels of correction.

Patient Outcomes After Single-level Coflex Interspinous Implants Versus Single-level Laminectomy.

Retrospective cohort analysis. The aim of this study was to compare postoperative outcomes of Coflex interspinous device versus laminectomy. Coflex Interlaminar Stabilization device (CID) is indicated for one- or two-level lumbar stenosis with grade 1 stable spondylolisthesis in adult patients, as an alternative to laminectomy, or laminectomy and fusion. CID provides stability against progressive spondylolisthesis, retains motion, and prevents further disc space collapse. Patients ≥18 years' old with lumbar stenosis and grade 1 stable spondylolisthesis who underwent either primary single-level decompression and implantation of CID, or single-level laminectomy alone were included with a minimum 90-day follow-up at a single academic institution. Clinical characteristics, perioperative outcomes, and postoperative complications were reviewed until the latest follow-up. χ2 and independent samples t tests were used for analysis. Eighty-three patients (2007-2019) were included: 37 cases of single-level laminectomy (48.6% female) were compared to 46 single-level CID (50% female). CID cohort was older (CID 69.0 ± 9.4 vs. laminectomy 64.2 ± 11.0, P = 0.042) and had higher American Society of Anesthesiologists (ASA) grade (CID 2.59 ± 0.73 vs. laminectomy 2.17 ± 0.48, P = 0.020). CID patients had higher estimated blood loss (EBL) (97.50 ± 77.76 vs. 52.84 ± 50.63 mL, P = 0.004), longer operative time (141.91 ± 47.88 vs. 106.81 ± 41.30 minutes, P = 0.001), and longer length of stay (2.0 ± 1.5 vs. 1.1 ± 1.0 days, P = 0.001). Total perioperative complications (21.7% vs. 5.4%, P = 0.035) and instrumentation-related complication was higher in CID (10.9% vs. 0% laminectomy group, P = 0.039). There were no other significant differences between the groups in demographics or outcomes. Single-level CID devices had higher perioperative 90-day complications, longer operative time, length of stay, higher EBL compared to laminectomies alone. Similar overall revision and neurologic complication rates were noted compared to laminectomy at last follow-up.Level of Evidence: 3.

Многоуровневый спондилолиз поясничных позвонков: описание клинического наблюдения и обзор литературы

Introduction Diagnosis and treatment of vertebrogenic pain syndrome caused by multilevel lumbar spondylolysis is crucial for patients of different age groups. Objective To report a clinical case of diagnosis and treatment of a two-level lumbar spondylolysis in a 16-year-old male patient, and review the relevant literature. Material and methods We had an experience of treatment and follow-up of a 16-year-old athlete who presented with low back pain and was diagnosed with spondylolysis of the pars interarticularis at the L3 and L5 levels. Diagnostic workup included patient history, physical examination, diagnostic imaging (plain radiograph, computed tomography). Scientific publications from modern medical databases were used for literature review. A total of 32 relevant articles brought out between 1975 and 2019 were reviewed. Results The 16-year-old athlete was diagnosed with multilevel spondylolysis of lumbar spine based on patient history, physical examination data and diagnostic imaging of lumbar spine. No pathognomonic clinical findings were revealed. The diagnosis was confirmed with computed tomography. Conservative treatment was initiated for the patient and a long-termfollow- up was available. Literature review included epidemiologic data characterizing multilevel lumbar spondylolysis: the indicence, patients' gender and age. Major etiological factors, common localization of the pathology, the incidence of spondylolysis and spondylolisthesis, treatment strategy including surgical procedures are described. Discussion There is a small number of scientific publications describing different aspects of multilevel spondylolysis of the lumbar spine in the current medical literature. The diagnosis is often delayed for the reason. The natural history of pain in adolescent athletes sustaining the load placed on them in both training and competition can be helpful for timely diagnosis. Conclusion The implications of this clinical case report can be practical for accentuation of multilevel spondylolysis of the lumbar spine among Russian specialists, contribute to medical knowledge and extend to both early diagnosis and efficient management.

218. Preoperative opioid use is associated with increased readmission and reoperation rates following lumbar decompression, instrumentation and fusion

BACKGROUND CONTEXT The prescription opioid epidemic and widespread use of narcotic medications has introduced new challenges when treating patients undergoing spine surgery. Recent studies in general surgery, spine and total joint arthroplasty literature demonstrate associations between preoperative opioid use and increased emergency department visits, readmission rates, revision rates and risk of developing chronic opioid dependence. Researchers estimate that 33-70% of patients undergoing spinal surgery use opioids preoperatively. Given the prevalence of preoperative opioid consumption among patients undergoing spine surgery, further research is needed to quantify and stratify perioperative risks in this patient population. PURPOSE The purpose of this study is to compare outcomes of primary one- or two-level lumbar decompression, instrumentation and fusion based on preoperative opioid consumption habits. STUDY DESIGN/SETTING A retrospective chart review was performed on patients who underwent one- to two-level posterior lumbar decompression, instrumentation and fusion from two spine surgeons at a single, tertiary referral center from 2013-2017. PATIENT SAMPLE Inclusion criteria included all patients who underwent a primary one- to two-level decompression (laminectomy or laminotomy) with posterior instrumentation, one- or two-level intertransverse arthrodesis (PLF), one- or two-level transforaminal lumbar interbody fusion (TLIF) or one- or two-level posterior lumbar interbody fusion (PLIF). Exclusion criteria included patients undergoing revision surgery, patients with concomitant malignancy or surgery for neoplastic disease, three- or more-level surgery, anterior or lateral (direct or oblique) interbody fusions, traumatic injuries (acute fractures or ligamentous instability) or other concurrent procedures. Patient opioid use was obtained from electronic medical records (Epic Systems Corporation, Verona, WI) including medication history and preoperative clinical documentation. Patients were divided into chronic opioid therapy (COT; >6 months), acute users (0-6 months) and opiate-naive based on their preoperative opioid usage. OUTCOME MEASURES Primary endpoints included readmission rates within 1 year and reoperation rates within 2 years. METHODS A retrospective chart review was conducted from 2013-2017 and patients who met the inclusion criteria were studied. Patients were divided into three groups based on their aforementioned preoperative opioid consumption status. Demographic information (age, BMI, sex and ethnicity), smoking status and primary outcome measures were identified and recorded based on documentation in the electronic medical record. RESULTS A total of 93 patients met the inclusion and exclusion criteria (57 PLF, 31 TLIF and 5 PLIF). Demographics characteristics were similar between all three groups. Thirty-three patients (35.5%) required COT, 31 patients (33.3%) utilized acute opioid therapy and 29 patients (31.2%) remained opioid naive. Current or former smokers were more likely to utilize acute or COT than never smokers (86% vs 59%; p=0.005). Readmission rates within 1 year for patients in the COT, acute and opioid naive groups were 50%, 41.7% and 8.3%, respectively (p=0.0115). Reoperation rates within 2 years for patients in the COT, acute and opioid naive groups were 54.2%, 33.3% and 12.5%, respectively (p = 0.033). CONCLUSIONS Long-term opiate use is associated with an increased risk for readmission within 1 year and revision within 2 years following a primary posterior decompression, instrumentation and fusion. Numerous data base studies have demonstrated similar, suboptimal outcomes for patients on preoperative opioid therapy compared to nonusers. This retrospective chart review corroborates the findings of these previous studies. Given the prevalence of narcotic usage in the US population, physicians should continue to educate acute or chronic opioid users about increased risk of readmission and revision associated with lumbar decompression and fusion. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Tactics of surgical treatment of patients with lumbar spondylolysis

The bilateral defect of the pars interarticularis (spondylolysis) is often the cause of low back pain syndrome and can lead to development of spondylolistesis. In some cases inefficiency of conservative treatment of this condition forces orthopedists to use surgical technologies. At the same time, in young patients with intact intervertebral discs, the rigid segmental fixation of the spine should be avoided. Where no neural decompression is needed, selective osteosynthesis of the pars defect is an optimal technique. The authors present the results of surgical treatment of 15 patients with single and two-level lumbar spondylolysis, 4 of which revealed minimal I degree lytic spondylolystesis of the L5 vertebrae. Localization of the pathological process in all patients was noted on both sides. In two patients spondylolysis defects of two vertebrae were detected (in one- adjacent L4 and L5, in the other - L2 and L4 vertebrae with sacralization of L5). The average period from the onset of symptoms ranged from 6 months to 2 years (an average of 14 months). All patients undergone bone autoplasty with iliac crest bone graft, and osteosynthesis of vertebral arches by a combined laminar-transpedicular system of the screw - rod - hook type. All patients had excellent and good anatomic and functional results. The used method of surgical treatment of patients of this category should be considered pathogenetically justified, as it is aimed at repair of spondylolytic defects as the main cause of segmental instability and forward displacement of vertebrae. The possibility to avoid fixation of intact segments of spine allows to categorize this operation as organ-preserving.

Anterior oblique retroperitoneal approach vs posterior transpedicular approach for the treatment of one- or two-level lumbar vertebral osteomyelitis: a retrospective cohort study.

To evaluate the outcomes of debridement fusion surgery between two surgical approaches for one- or two-level lumbar vertebral osteomyelitis (LVO): oblique retroperitoneal approach (ORA) and posterior transpedicular approach (PTA). We performed a retrospective study for adult patients with one- or two-level lumbar vertebral pyogenic spondylitis. The primary clinical outcomes included the following: surgery-related information (intra-operative blood loss, operation time, and hospital length of stay), infection control (primary failure and recurrence), and bony fusion. The secondary objective was to determine the differences between groups in mean reduction of pain characters and physical functioning. The data of 80 patients were collected retrospectively. The duration of follow-up was 27.8 ± 4.7months (range, 24-42). Intra-operative blood loss, operation time, and hospital length of stay in ORA debridement were significantly lower. Primary failure (2.3% vs 2.7%) was similar between the groups, but recurrence (13.9% vs 5.4%) had difference. Bony fusion (94.6.3% vs 86.1.%) in ORA debridement was higher than those in PTA debridement at the final follow-up. Fusion occurred at six to14months (mean 9.8months). Patients in ORA group had better results in functional and pain scores in the first three months, with similar results at the final follow-up. In summary, ORA debridement provides a quicker recovery compared with PTA debridement for one- or two-level LVO. As for the infection control and fusion rate, both debridement approaches had similar results.

Enhanced Recovery after Lumbar Spine Fusion: A Randomized Controlled Trial to Assess the Quality of Patient Recovery.

Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion. A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein). The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (-3 h; 95% CI, -6, -0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (-11 h; 95% CI, -19, -6; P < 0.001) were shorter; opioid consumption was lower at day 1 (-57 mg; 95% CI, -130, -5; P = 0.030) without adversely affecting pain scores (-2; 95% CI, -3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037). Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.

Global Treatment Outcome after Surgical Site Infection in Elective Degenerative Lumbar Spinal Operations.

Background: Surgical site infection (SSI) is a serious complication after routine lumbar spinal operations, and its effect on global treatment outcome (GTO) is less reported. The aim of the current study was to measure the impact of SSI on outcome, which was evaluated with patient reported outcome measures (PROMs) and patients' subjective judgment (GTO). Methods: A total of 910 patients underwent primary a single- or two-level lumbar decompression or instrumented fusion surgical procedure. Patients completed Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measurement Index (COMI) at baseline and at two-year follow-up. The rate of improvement in PROMs was measured for the total cohort and the group of patients with SSI. Patients evaluated GTO on a five-point Likert scale. This study was approved by the Scientific and Research Ethics Committee of the Medical Research Council (number: 29970-3/2015/EKU) and the Institutional Review Board. Results: Regardless of the presence of SSI, significant improvement was measured in all PROMs without any difference in the rate of change between the clinical subgroups (non-SSI vs. SSI, dODI: p = 0.370, dCOMI: p = 0.383, dVAS: p = 0.793). In the total cohort, 87.3% of patients reported good outcome (N% = 87.3%). After an SSI, however, more patients (25.7%) reported poor outcome compared with those without the complication (chi-square test: value = 5.66; df = 1; p = 0.017; odds ratio = 2.49). Conclusions: Patients with successfully treated SSI can expect as good objective clinical result as patients without SSI while the subjective treatment outcome can be worse. The GTO could also be improved in complicated cases, however, with more extensive peri-operative patient education and information considering the patients' expectations, too.

Future endeavors in ambulatory spine surgery.

Due to the high societal and financial burden of spinal disorders, spine surgery is thought to be one of the most impactful targets for healthcare cost reduction. One avenue for cost-reduction that is increasingly being explored not just in spine surgery but across specialties is the performance of surgeries in ambulatory surgery centers (ASCs). Despite potential cost-savings, the utilization of ASCs for spine surgery remains largely limited to high-volume centers in the US, and predominantly for single- or two-level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) procedures. Factors most commonly cited for the lack of wider adoption include the risk of life-threatening complications, paucity of guidelines, and limited accessibility of these procedures to various patient populations. Thus, the future growth and adoption of ambulatory spine surgery depends on addressing these concerns by developing evidence-based guidelines for patient- and procedure selection, creating risk-stratification tools, devising appropriate discharge recommendations, and optimizing care protocols to ensure that safety, efficacy and outcomes are maintained. Other avenues that may allow for more widespread use of ASCs include the use of electronic health tools for post-operative monitoring after discharge from the ASC, increasing accessibility of ambulatory procedures to eligible populations, and identifying systemic inefficiencies and implementing process-improvement measures to optimize patient-selection, scheduling and peri-operative management. The success of ambulatory surgery ultimately depends not only on the surgical procedure, but also on its organization upstream and downstream. It provides an exciting and burgeoning avenue for innovation, cost-reduction and value-creation.