VAS Leg Research Articles

Association between muscle health and patient-reported outcomes after lumbar microdiscectomy: early results

BACKGROUND CONTEXTPoor muscle health has been implicated as a source of back pain among patients with lumbar spine pathology. Recently, a novel magnetic resonance imaging (MRI)-based lumbar muscle health grade was shown to correlate with health-related quality of life scores. However, the impact of muscle health on postoperative functional outcomes following spine surgery remains to be investigated. PURPOSETo determine whether muscle health grade measured by preoperative psoas and paralumbar muscle cross-sectional areas impact the achievement of minimal clinically important difference (MCID) following lumbar microdiscectomy. STUDY DESIGN/SETTINGRetrospective cohort study. PATIENT SAMPLEConsecutive patients who underwent 1-level lumbar microdiscectomy in a single institution between 2017 and 2021. OUTCOME MEASURESRate of MCID achievement, time to MCID achievement, PROMs including Oswestry Disability Index (ODI), visual analog scale for back pain (VAS back), VAS leg, Short Form 12 Physical Component Summary (SF-12 PCS), SF-12 Mental Component Summary (SF-12 MCS), and Patient Reported Outcomes Measurement Information System Physical Function (PROMIS PF). METHODSTwo previously validated methods for muscle health grading were applied. Axial T2 MRI were analyzed for muscle measurements. The psoas-based method utilized the normalized total psoas area (NTPA), which is the psoas cross-sectional area divided by the square of patient height (mm2/m2). Patients were divided into low and high NTPA groups based on sex-specific lowest quartile NTPA thresholds. The paralumbar-based method incorporated the paralumbar cross-sectional area normalized by body mass index (PL-CSA/BMI) and Goutallier classification. Score of 1 was added for either PL-CSA/BMI >130 or Goutallier class of ≤2. “Good” muscle health was defined as score of 2, and “poor” muscle health was defined as score of 0 to 1. Prospectively collected PROMs were analyzed at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year postoperative timepoints. The rate of and time to MCID achievement were compared among the cohorts. Bivariate analyses were performed to assess for correlations between psoas/paralumbar cross-sectional areas and change in PROM scores from baseline. RESULTSThe total cohort included 163 patients with minimum follow-up of 6 months and mean follow-up of 16.5 months. 40 patients (24.5%) were categorized into the low NTPA group, and 55 patients (33.7%) were categorized into the poor paralumbar muscle group. Low NTPA was associated with older age, lower BMI, and greater frequencies of Charlson Comorbidity Index (CCI) ≥1. Poor paralumbar muscle health was associated with older age, female sex, higher BMI, and CCI ≥1. There were no differences in rates of MCID achievement for any PROMs between low versus high NTPA groups or between poor versus good paralumbar groups. Low NTPA was associated with longer time to MCID achievement for ODI, VAS back, VAS leg, and SF-12 MCS. Poor paralumbar muscle health was associated with longer time to MCID achievement for VAS back, VAS leg, and SF-12 PCS. NTPA negatively correlated with change in VAS back (6-week, 12-week) and VAS leg (6-month). PL-CSA/BMI positively correlated with change in PROMIS-PF at 3 months follow-up. CONCLUSIONSAmong patients undergoing lumbar microdiscectomy, patients with worse muscle health grades achieved MCID at similar rates but required longer time to achieve MCID. Lower NTPA was weakly correlated with larger improvements in pain scores. PL-CSA/BMI positively correlated with change in PROMIS-PF. Our findings suggest that with regards to functional outcomes, patients with worse muscle health may take longer to recuperate postoperatively compared to those with better muscle health.

Prospective multicenter study of minimally invasive surgery for the treatment of adult spinal deformity

OBJECTIVE Traditional surgery for adult spinal deformity (ASD) is effective but may result in exposure-related morbidity. Minimally invasive surgery (MIS) can potentially minimize this morbidity; however, high-level evidence is lacking. This study presents the first prospective multicenter investigation of MIS approaches for ASD. METHODS A prospective multicenter study was conducted. Inclusion criteria were age ≥ 18 years, with at least one of the following radiographic criteria: coronal Cobb (CC) angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, and thoracic kyphosis > 60°. Additional inclusion criteria were circumferential MIS, including interbody fusion (transforaminal lumbar interbody fusion [TLIF], lateral lumbar interbody fusion [LLIF], or anterior lumbar interbody fusion [ALIF]) with percutaneous posterior fixation on a minimum of 4 intervertebral levels. Radiographic and clinical outcomes (visual analog scale [VAS], Oswestry Disability Index [ODI], and Scoliosis Research Society–22 [SRS-22]) were collected preoperatively and at 12 months postoperatively; preoperative and postoperative values were compared using paired Student t-tests. RESULTS Seventy-five patients with a minimum 1-year follow-up were identified (75 of 111; 67.6%). The mean ± SD age was 68.8 ± 9.0 years, and 48 patients (64%) were female. Patients underwent a mean of 6.7 ± 2.9 levels of fusion with LLIF (85%), ALIF (55%), and TLIF (9%); the mean estimated blood loss was 547.6 ± 567.2 mL, and the mean length of stay was 7.0 ± 3.7 days. Significant improvements were observed in ODI (−19 ± 12.9, p < 0.001), SRS-22 (0.8 ± 0.66, p < 0.001), VAS back (−4.3 ± 2.8, p < 0.001), and VAS leg (−3.0 ± 3.2, p < 0.001) scores. Significant decreases in SVA (−26.4 ± 53.6 mm; p < 0.001), pelvic incidence–lumbar lordosis (−11.3° ± 14.9°, p < 0.001), and CC angle (−12.1° ± 11.8°, p < 0.001) were also observed. Complications occurred in 39 patients (52%); 11 patients (15%) experienced major complications, and 16 patients (21%) required reoperation. CONCLUSIONS MIS approaches for ASD resulted in meaningful symptomatic improvement. The complication rates were similar to historic norms, with a fairly high reoperation rate at 1 year. Longer follow-up will be necessary to evaluate the durability of this approach in the treatment of ASD.

Percutaneous endoscopic stenosis surgery under local anaesthesia

A retrospective study including 50 cases of lumbar canal stenosis patients who underwent percutaneous endoscopic stenosis decompression surgery through unilateral/bilateral transforaminal approach under local anaesthesia. Clinical outcomes such as back and leg VAS, the Macnab criteria were evaluated. Surgical results including operative time, postoperative hospital stay, recurrence, and surgical complications were also studied.Results: All 50 patients were followed up. The average operation time was 73 +/- 22.8min. The mean VAS of leg and back pain improved from 7.06 +/-1 to 2.2 +/-1. According to the Macnab criteria, 97.7% of patients achieved excellent and good results. There was 1 case of dural tear and 3 cases of transient postoperative dysthesia.Conclusions: Except for the main pathogenic factors on the dorsal side of the dural sac namely bony canal stenosis, percutaneous endoscopic decompression through a unilateral/bilateral transforaminal approach is sufficient for Lumbar canal stenosis and affords better foraminal decompression than an open approach. It is a feasible, safe, and clinically effective minimally invasive procedure.

Impact of Complications on the Quality of Life of Patients Who Underwent Surgery for Adult Spinal Deformity

Study Design: A multicenter, retrospective review of surgical patients with adult spine deformity. Objective: Analyze the impact on the quality of life of patients who suffer complications in adult spine deformity surgery. Summary of Background Data: Adult spine deformity surgery is classically associated with a high rate of complications, in particular it is estimate around 40%. The knowledge of the impact these complications could be a useful to improve the outcome in quality of life of patients. Methods: Retrospective analysis of a prospective database of a cohort of patients who underwent spinal deformity surgery. Patients with 4 or more instrumented vertebras and 2 years follow-up of were included. We created two groups based on the development or not of complications. VAS, ODI and SRS22, as a quality of life questionnaires, were used. Statistical analysis was performed using: T Student and U Mann-Whitney tests depending if variables were adjusted or not to normality; independent and related samples were analyzed with W Wilcoxon test. Results: 65 patients from primary surgery completed all the protocols (75.4% female) , mean age of the cohort was 68 ± 6.21 years, the average number of levels fused was 7 ± 3.37, with an operative time of 305.47 ± 116.90 minutes with 406.50 ± 92.7 mL of estimated blood loss. 24 patients suffered complications including PJK, instrumentation rupture, malposition material and infection. The results of the quality of life of patients with complications showing a significant statistical improvement in all parameters except the function subdomain (Pre- Complication: 2.55 ± 0.66; Post-Complication 2.93 ± 0.85, p = 0.082) and satisfaction subdomain (Pre-Complication 3.25 ± 1.25; Post-Complication 3.84 ± 0.91, p = 0.095) of the SRS-22 regarding the preoperative. The disability, that the ODI shows, is better and statistically significant than the preoperative one although it remains at high levels (Pre-Complication 57.58 ± 16.01; Post-Complication 43.47 ± 17.1, p < 0.05). Considering the pain in the VAS back [(Pre-Complication 8 (5.50-9); Post-Complication 4 (1.50-7.50), p < 0.05] and VAS leg [(Pre-Complication: 8 (5-8); Post 2 (0.50-5), p < 0.05] this significant improvement after complication. Quality of life parameters in patients with complications were affected, although with no statistically significant differences in comparison to the group of patients without re- surgery for some complication. Conclusions: The impact on quality of life of subjects who suffer complications in comparison to those that do not is reflected in greater functional limitations and worse results in subdomains of the SRS-22 questionnaire, despite improving after the surgery and without significant differences in comparison to the group of patients free from complications.

Discharge Disposition and Clinical Outcomes After Spine Surgery.

Spinal decompression with or without fusion is one of the most commonly performed procedures in spine surgery. However, there is limited evidence on the effect of discharge environment on outcomes after surgery. The purpose of this study is to identify the effects of discharge disposition setting on clinical outcomes after spine surgery. Patients who underwent lumbar decompression, lumbar decompression and fusion, or posterior cervical decompression and fusion surgery were retrospectively identified. All clinical and demographic data were obtained from electronic health records. Surgical outcomes included wound complications, revision surgery, "30-day" readmission (0-30 d), and "90-day" readmission (31-90 d). Discharge disposition was stratified into home/self-care, acute inpatient rehabilitation, and subacute rehabilitation. Patient-reported outcome measures including VAS Back, VAS Leg, VAS Neck, VAS Arm, PCS-12 and MCS-12, ODI, and NDI were compared between patient discharge disposition settings using the Mann-Whitney U test. Pearson's chi-square analysis was used to assess for differences in wound complications, revision surgery, 30-day readmission, or 90-day readmission rates. Multivariate logistic regression incorporating age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge disposition was used to determine independent predictors of wound complications. A total of 637 patients were included in the study. A significant difference (P = 0.03) was found in wound complication based on discharge disposition, with subacute disposition having the highest proportion of wound complications (6.1%) and home disposition having the lowest (1.5%). There were no significant differences in the rates of revision surgery, 30-day readmission, or 90-day readmission between groups. Subacute rehabilitation (odds ratio: 3.67, P = 0.047) and CCI (odds ratio 1.49, P = 0.01) were independent predictors of wound complications. Significant improvement in PROMs was seen across all postacute discharge dispositions. Baseline (P = 0.02) and postoperative (P = 0.02) ODI were significantly higher among patients discharged to an acute facility (49.4 and 32.0, respectively) compared to home (42.2 and 20.0) or subacute (47.4 and 28.4) environments. Subacute rehabilitation disposition and CCI are independent predictors of wound complications after spinal decompression surgery. Patients undergoing spine surgery have similar readmission and revision rates and experience similar clinical improvement across all postacute discharge dispositions.

Comparison of Clinical and Perioperative Outcomes in Patients Undergoing MIS-TLIF in Outpatient vs Inpatient Setting: Matched Cohort Analysis

Background The most common technique utilized for lumbar arthrodesis in an outpatient setting is minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). While prior studies have assessed this technique’s feasibility in an outpatient setting, there is a paucity of literature comparing long term clinical outcomes of MIS-TLIF in an outpatient versus inpatient setting. This study investigates the differences in clinical outcomes between these two settings through comparison of patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID) achievement. Methods Primary, elective, single-level MIS-TLIF procedures performed between 2005 and 2021 for degenerative spinal pathology were identified in a surgical database. Patient demographics, perioperative characteristics, and PROM scores were collected. PROMs measuring physical function, back pain, leg pain, and disability were administered at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative time-points. Patients were grouped into two cohorts, depending on whether a patient underwent surgery in an inpatient setting or in an outpatient setting at an ambulatory surgery center (ASC) where the patient was discharged within 23 hours. Coarsened exact match was carried out to control for significant demographic differences between cohorts. Demographic and perioperative characteristics were compared among groups using chi-square and Student’s t-test for categorical and continuous variables, respectively. Mean PROM scores were compared between cohorts at each time point utilizing a two-sample t-test. Postoperative PROM improvement from preoperative baseline within each cohort was calculated with use of paired t-test. Achievement of Minimum Clinical Important Difference [MCID] was determined by comparing ΔPROM scores to previously established threshold values. Rates of MCID achievement were compared among groups using simple logistic regression. Results After coarsened exact matching, 227 patients were excluded and final patient cohort consisted of 391 patients – 339 patients in the Inpatient MIS-TLIF cohort and 52 patients in the Outpatient MIS-TLIF cohort (Table 2). Mean estimated blood loss (EBL), postoperative length of stay (LOS), and postoperative narcotic consumption on days 0 and 1 were observed to be significantly lower in Outpatient MIS-TLIF cohort (p<0.041, all) (Table 3). Preoperative and postoperative mean PROM scores were not significantly different for all PROMs collected (Table 5). Both cohorts demonstrated significant improvement for PROMIS-PF, SF-12 PCS, VAS back, and VAS leg at 2-year time-point from preoperative baseline (Table 4). Patients in the Inpatient MIS-TLIF cohort demonstrated greater proportion achieving MCID for overall SF-12 PCS and overall VAS back (p<0.022, all) (Table 6). No significant differences for MCID achievement rates were noted between cohorts at specific postoperative time points (Table 6). Inpatient cohort demonstrated significantly higher rates of postoperative nausea and vomiting (p=0.001) (Table 4). Conclusion After careful patient selection, patients undergoing MIS-TLIF in an outpatient setting demonstrated similar long term clinical outcomes for back pain, leg pain, physical function, and disability as defined by PROMs and MCID achievement. Additionally, patients in outpatient cohort demonstrated reduced postoperative narcotic consumption. Results from our study would suggest patient safety and outcome quality is not compromised from undertaking MIS-TLIF in an outpatient setting.

Clinical Outcomes of Robotic Versus Freehand Pedicle Screw Placement After One-to Three-Level Lumbar Fusion.

Retrospective cohort study. The purpose of this study is to compare patient-reported outcome measures (PROMs) for patients undergoing one-to three-level lumbar fusion using robotically assisted vs freehand pedicle screw placement. Patients who underwent either robotically assisted or freehand pedicle screw placement for one-to three-level lumbar fusion surgery from January 1, 2014 to August 31, 2020 at a single academic institution were identified. Propensity score matching was performed based on demographic variables. Clinical and surgical outcomes were compared between groups. Recovery Ratios (RR) and the proportion of patients achieving the minimally clinically important difference (%MCID) were calculated for Oswestry Disability Index, PCS-12, MCS-12, VAS Back, and VAS Leg at 1 year. Surgical outcomes included complication and revision rates. A total of 262 patients were included in the study (85 robotic and 177 freehand). No significant differences were found in ΔPROM scores, RR, or MCID between patients who underwent robotically assisted vs freehand screw placement. The rates of revision (1.70% freehand vs 1.18% robotic, P = 1.000) and complications (.57% freehand vs 1.18% robotic, P = .546) were not found to be statically different between the 2 groups. Controlling for demographic factors, procedure type (robotic vs freehand) did not emerge as a significant predictor of ΔPROM scores on multivariate linear regression analysis. Robotically assisted pedicle screw placement did not result in significantly improved clinical or surgical outcomes compared to conventional freehand screw placement for patients undergoing one-to three-level lumbar fusion.

Better Functional Outcome and Pain Relief in the Far-Lateral-Outside-in Percutaneous Endoscopic Transforaminal Discectomy.

BackgroundEven though percutaneous endoscopic transforaminal discectomy (PETD) has been widely used for the surgical treatment of lumbar herniated disc, there are only a few studies directly comparing the clinical outcomes between microdiscectomy (MD) and PETD. Therefore, further studies are needed in order to compare the clinical outcomes between PETD and MD on a single level more thoroughly.MethodsWe proposed a far-lateral-outside-in technique for PETD to get an entry point without complex planning and facet violation. From September 2017 to September 2019, a total of 155 patients (69 with PETD and 86 with MD) were enrolled for this retrospective study, with the inclusion criteria: single level between L2 and S1, clinical sciatica for at least 6 weeks, and failed attempts with non-surgical treatments. Patients were excluded due to cauda equina syndrome, progressive neurologic deficits, history of lumbar spinal surgery, endplate modic changes, severe disc degeneration and less than 24 months of follow-up.ResultsPETD showed significantly shorter surgery time and less intraoperative blood loss compared to MD. The difference between PETD and MD in VAS back pain (but not VAS leg pain) at follow-up time was significant. The ODI improvement in the follow-up time of 6 months between the 2 groups showed a significant difference (PETD: 31.23±6.59, MD: 39.85±7.81, p < 0.001). MD had a significantly higher chance of postoperative wound infection and poor healing, while PETD was more likely to have recurrence of the herniated disc.ConclusionMD has been the gold standard procedure for LDH. However, with the advanced endoscopic technology and surgical technique, PETD has emerged as an alternative method due to higher functional outcome and less wound problems.

Do preoperative clinical and radiographic characteristics impact patient outcomes following one-level minimally invasive transforaminal lumbar interbody fusion based upon presenting symptoms?

BACKGROUND CONTEXTPatients undergoing minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) frequently present with lower extremity neurologic symptoms with or without associated lower back pain. While symptomatic improvement of leg and back pain has been reported, the resolution of back pain when it is a predominant presenting symptom remains underreported following MI-TLIF. PURPOSEThe purpose of this study was to compare clinical outcomes at 1 year of patients undergoing MI-TLIF with lower extremity neurologic symptoms with and without a significant component of back pain. STUDY DESIGNA retrospective review of prospectively collected data from a single surgeon surgical database from 2017 to 2019 was performed. PATIENT SAMPLEFifty one patients undergoing MI-TLIF. OUTCOME MEASURESSelf-reported measures included the Oswestry Disability Index (ODI), Visual analog scale back pain (VAS-back), and VAS leg pain (VAS-leg). METHODSPatients were divided into two groups: Leg Pain Predominant (patients reported greater than 50% leg pain upon presentation) and Back Pain Predominant (patients reported 50% or greater back pain). Multivariate analysis was performed to determine differences between groups based upon any significantly baseline characteristics. RESULTSPreoperative demographic and radiographic outcomes were similar between the two groups. Both groups demonstrated significant improvement in ODI, VAS-Back and VAS-leg at 1-year postoperatively. On multivariate analysis, there were differences in ODI at 1-year, 1-year back pain, and 1-year leg pain between groups with those who initially presented with leg pain having a lower ODI, VAS Back, and VAS leg. Patients who presented with predominantly leg pain were more likely to meet minimal clinically important difference (MCID) criteria for ODI and VAS-back compared to those with predominantly back pain. CONCLUSIONFollowing MI-TLIF, patients with lower extremity neurologic symptoms with and without a significant component of back pain have improvements in back pain, leg pain, and ODI regardless of their primary presenting pain complaint; however, patients who presented with predominantly leg pain were more likely to meet MCID criteria for improvement in their back pain and ODI score.

Effectivity of Acupressure in Low Back Pain

Low back pain is defined as located pain and discomfort below the costal margin and above the superior gluteal line, with related pain in the lower limb, and repeated incorrect posture of work activities that demand effort with excess of flexion, rotation, vibration on the chest and carrying weight, being chronic if its persists for three months or more. This research aimed to find out the efficacy of accupressure on Dachangshu, Shenshu, and Yaoyangquan points using pretest-posttest group design by comparing the mean decrease in pain threshold, RMDQ and Test Straight Leg between control using Dingchuan and Waihuaijian points and therapy group using Shenshu, Dachangshu, and Yaoyangquan acupoints twice a day with paired T test formula. The mean decreased in pain threshold VAS, RMDQ and Test Straight Leg obtained form therapy group toward 16 elderly above 45 years for 4 weeks showed that there is a significant result (p=0,000). In conclusion, accupressure therapy using Dachangshu, Shenshu and Yaoyangquan can be used to treat low back pain.

Evaluation of Lumbar Fusion in Recurrent Disc Prolapse

Abstract Background Recurrent disc herniation is the most common cause of reoperation after the primary disc surgery, The management of recurrent disc herniation remains somewhat controversial. Surgical treatment for recurrent disk herniation can be broadly categorized as revision discectomy alone or revision discectomy and fusion or percutaneous endoscopic interlaminar discectomy. Aim of the work to evaluate and compare the therapeutic effect between different modalities of treatment of the recurrent lumbar disc protrusion (RLDP) through 3 groups: (1) First group treated by conventional discectomy. (2) Second group treated by discectomy and lumbar fusion either by PLF, PLIF or TLIF. (3) Third group treated by percutaneous endoscopic interlaminar discectomy. Patients and methods It is a prospective cohort study performed between January 2012 and April 2017 on 150 patients complained of recurrent lumbar disc herniation. They were surgically treated at the Department of Neurosurgery, Ain Shams University Hospitals. All patients are evaluated clinically by VAS, JOA and Oswestry disability index (ODI) through follow up period of 2 years (one month, 6 months, 1 yr, 2 yrs). They were divided into 3 groups (I&amp;II and III) each group was a fifty patients Results the mean overall recovery rate is 89%, comparison between the three groups showed significant improvement of the endoscopic group and fixation group than simple discectomy group in term of VAS LBP, leg pain , JOA and ODI. Intraoperative blood loss, length of operation and hospital stay were significant less in endoscopic group than fixation and simple discectomy group CONCLUSION Recurrent lumbar disc prolapse management is a controversial issue, there are different surgical modalities (either by open discectomy, discectomy and fixation or Percutaneous interlaminar lumbar discectomy PEILD) although those surgical modalities are successful the PEILD is the optional choice that offers less tissue trauma, rapid recovery, less cost effect and early return to work

Comparison of Mid- to Long-term Follow-up of Patient-reported Outcomes Measures After Single-level Lumbar Total Disc Arthroplasty, Multi-level Lumbar Total Disc Arthroplasty, and the Lumbar Hybrid Procedure for the Treatment of Degenerative Disc Disease.

Prospective cohort study. The aim of this article is to compare the mid- to long-term patient-reported outcome measures (PROMs) between single-level total disc arthroplasty (TDA), multi-level TDA, and hybrid constructs (combination of TDA and anterior lumbar interbody fusion [ALIF] across multiple levels) for symptomatic degenerative disc disease (DDD). The treatment of single-level DDD is well documented using TDA. However, there is still a paucity of published evidence regarding long-term outcomes on multi-level TDA and hybrid constructs for the treatment of multi-level DDD, as well as lack of long-term comparisons regarding treatment of single-level DDD and multi-level DDD. A total of 950 patients underwent surgery for single-level or multi-level DDD between July 1998 and February 2012 with single-level TDA (n = 211), multi-level TDA (n = 122), or hybrid construct (n = 617). Visual Analog Score for the back (VAS-B) and leg (VAS-L) were recorded, along with the Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ). All PROMs in all groups showed statistically and clinically significant improvements (P < 0.005) in pain and function that is well above the corresponding minimum clinically important difference (MCID) and exceeds literature thresholds for substantial clinical benefit (SCB). Unadjusted analyses show that there were no statistically significant differences in the change scores between the surgery groups for VAS back and leg pain, and RMDQ up to 8 years' follow-up. Adjusted analyses showed the ODI improvement score for the single group was 2.2 points better (95% confidence interval [CI]: 0.6-3.9, P = 0.009) than in the hybrid group. The RMDQ change score was better in the hybrid group than in the multi-level group by 1.1 points (95% CI: 0.4-1.9, P = 0.003) at 6 months and a further 0.4 point at 2 years (95% CI: 0.1-0.8, P = 0.011). In the setting of meticulous preoperative evaluation in establishing a precision diagnosis, clinically and statistically equivalent results can be achieved when treating symptomatic DDD through single-level TDA, multi-level TDA, and hybrid constructs. These results are sustained at mid- to long-term follow-up.Level of Evidence: 3.

Circumferential fusion with open versus percutaneous posterior fusion for lumbar isthmic spondylolisthesis

Study designRetrospective cohort study. ObjectiveTo investigate the clinical and radiographic differences between patients who underwent anterior lumber interbody fusion (ALIF) with either open or percutaneous posterior fusion for lumbar isthmic spondylolisthesis. Summary of background dataCircumferential fusion for isthmic spondylolisthesis is commonly performed with superior clinical outcomes, fusion rates, and restoration of sagittal balance when compared to posterior fusion alone. The outcomes comparing traditional open versus percutaneous posterior fusion in this setting have not been fully evaluated. MethodsA retrospective review of patients who underwent ALIF with either traditional open or percutaneous posterior fusion for isthmic spondylolisthesis between 2014 and 2019 was conducted. Patient demographics, surgical characteristics, and radiographic and clinical outcomes were compared between groups. ResultsA total of 79 patients were included in the final analysis, with 49 in the Open group and 30 in the Percutaneous group. No differences were found with regard to demographic factors between groups including sex, body mass index (BMI), diabetic status, and smoking status. The percutaneous group had less estimated blood loss (EBL, 69.2 mL) and shorter length of stay (3.06 days) compared to the open group (446 mL, p = 0.017; 3.98 days, p = 0.003). Both groups demonstrated significant improvement in all clinical outcome measures after surgery (PCS-12, MCS-12, ODI, VAS Back, and VAS Leg scores). The percutaneous group achieved greater ∆VAS Back (Open = 3.55, Perc = 5.17; p = 0.045) and also had a significantly greater improvements in recovery ratio for VAS Back (Open: 0.43, Perc: 0.73; p = 0.037) and ODI (Open: 0.40, Perc = 0.67; p = 0.031). Regression analysis demonstrated percutaneous surgery to be significant predictor of superior improvement in VAS Back scores (β = 1.957, p = 0.027). ConclusionALIF with percutaneous posterior fusion affords greater improvement in back pain and disability when compared to ALIF with open posterior fusion for isthmic spondylolisthesis. Level of evidenceIII.

220. Do favorable short-term patient reported outcomes after spine surgery predict loss to one- and two-year follow-up?

<h3>BACKGROUND CONTEXT</h3> Because many spine surgery patients are lost to long-term postoperative follow-up, retrospective patient outcome studies are subjected to attritional bias. Controversy ensues in the literature on whether long-term follow-up is associated with adverse clinical outcomes. Furthermore, the factors associated with loss to follow-up after spine surgery are incompletely elucidated. <h3>PURPOSE</h3> To determine if spine surgery patients with greater improvement in patient reported outcomes measures (PROM) at early postoperative follow-up are more likely to be lost to follow-up at the one- year and two- year postoperative visits. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort analysis. <h3>PATIENT SAMPLE</h3> All patients over age 18 who underwent any primary or revision decompression or fusion surgery for degenerative spinal pathologies at a single academic institution were retrospectively identified. All included patients attended a short-term (3 month) postoperative follow-up visit. Patients with a traumatic injury, infection, malignancy, or incomplete medical records or outcome measures were excluded. <h3>OUTCOME MEASURES</h3> Postoperative short- and long- term PROMs: Neck Disability Index (NDI), Oswestry Disability Index (ODI), Short Form-12 (SF-12), VAS Neck, VAS Arm, VAS Back, VAS Leg, and PROMIS pain scores. Delta outcome score. Recovery ratio. <h3>METHODS</h3> Patient surgeries were stratified by anatomic region, revision status, and number of levels fused. Distance from patient residence to postoperative clinic site was determined. Patients lost to one- and two-year postoperative follow-up visits were identified. Univariate analysis compared patient demographics, surgical factors, distances traveled, and PROMs across groups with and without one- and two- year follow-up, respectively. Logistic regression isolated predictors of loss to follow-up. Multivariate regression compared PROMs based on long-term follow-up status. <h3>RESULTS</h3> A total of 1,412 patients met the inclusion criteria. In the total cohort, 25% of patients were lost to one- year follow-up and 66% were lost to two-year follow-up. Change in patient outcome measures and recovery ratios did not meaningfully differ between patient groups with and without one- and two-year follow-up on univariate nor multivariate analyses. Multiple patient factors were found to be associated with failure to follow up at one year after spine surgery including: decreased medical comorbidities, primary and single level surgeries, private insurance status, and longer distance from residence to clinic. Additionally, younger age and female sex were associated with failure to follow up two years after index surgery. <h3>CONCLUSIONS</h3> Patient outcomes were not found to impact loss to long-term follow-up after spine surgery. While a multitude of factors may predict patient propensity to follow-up, the lack of association between postoperative follow-up status and clinical outcome may limit bias introduced in retrospective PROM studies. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

67. The value of overall assessment in adult degenerative scoliosis patients: short- and long-term effect of surgical intervention on static and dynamic balance, gait and pain level

<h3>BACKGROUND CONTEXT</h3> In the diagnosis and treatment of adult spinal deformities, static radiographic measurements in the sagittal and coronal anatomical planes and patient-reported outcome measures (PROMs) serve as the gold standard for assessment of spinal alignment and deformity. However, there is a lack of published literature on their relation to objective functional outcome measures (FOMs) among patients afflicted with adult spinal deformity. Adult spinal deformity (ASD) is due to degeneration, functional decline is partly due to loss of postural stability and neuromuscular capacity and coordination. Objective functional measures (eg, static standing and walking alignment) cover more information than just radiographic alignment in the ASD population. Gait and dynamic balance analysis can reveal functional compensatory alignment changes where static imaging is limited. Previous studies have shown improvement in postoperative gait, approximating non-ASD control cohorts but still symptomatic. Many studies have shown surgical reconstruction in ASD patients has improved patient outcomes, but not overall assessment of objective function along with psychological factors. Therefore, a more comprehensive standard outcome measurement is needed. <h3>PURPOSE</h3> To determine the one-year effects of spinal alignment on function in ASD patients following surgical treatment using radiographic parameters, 3D gait and balance analysis, PROMs, and psychological tests and compared to healthy control. <h3>STUDY DESIGN/SETTING</h3> Nonrandomized, prospective study. <h3>PATIENT SAMPLE</h3> Forty-three symptomatic ASD patients, 24 age-matched control. <h3>OUTCOME MEASURES</h3> Gait spatiotemporal parameters, dynamic balance as measurement by balance effort and Cone of Economy (CoE) dimensions, radiograph alignment measurements, PROMs, and psychological factors. <h3>METHODS</h3> Patients performed dynamic balance and gait evaluations prior to surgery (Pre), 3 months (Post3), and 12 months (Post12) postoperatively. Patients also completed full-length, head-to-toe, micro-dose X-rays along with PROMs, and psychological questionnaires. Balance effort and CoE dimensions were measured by total sway and range of sway, respectively. Repeated measurement analysis of variance (ANOVA) and one-way ANOVA were used to determine differences in radiographic, dynamic balance, gait, and PROMs parameters at Post3 and Post12 and to the match control group. <h3>RESULTS</h3> Significant improvements in radiographic alignment were found in Cobb angle (<0.001), sagittal (<0.009) and coronal (<0.003) vertical axes and pelvic incidence-lumbar lordosis mismatch (<0.001) at Post3 and Post12. There were significant improvements in all PROMs after surgery (VAS mid-back, low back, and leg, ODI and SRS). Surgical intervention resulted in a significant decrease in balance effort (head: p<0.017 and center of mass: p<0.042) and reduced in the CoE dimensions (sagittal: p<0.004; and coronal: p=0.029). Gait was also enhanced after surgery as seen with a faster walking speed (p<0.024) and longer stride length (p<0.024). Psychological factors showed significant improvements in Tampa Scale for Kinesiophobia and Fear Avoidance Belief Questionnaire scores (p<0.050). <h3>CONCLUSIONS</h3> This is the first study to provide insight into a comprehensive global assessment of ASD surgery patients' function which includes complete objective functional and psychological outcomes in addition to standard PROMs and radiographic alignment. Balance effort and CoE limits improved at all time points post-operatively and ultimately matched the controls at 12 months. Similar to the significant improvement in static and dynamic balance in these patient groups, gait parameters also improved Post3 and Post12 to closely resemble the control group and continued to improve over time. Our findings present a more comprehensive set of outcome metrics, which, once combined, provide a more detailed and sensitive assessment of overall treatment outcomes. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

19. Anterior lumbar interbody fusion with porous titanium interbody cages is associated with equivalent fusion rates and patient reported outcomes as bone morphogenetic protein-2

<h3>BACKGROUND CONTEXT</h3> Although frequently used for anterior lumbar interbody fusion (ALIF), concerns regarding the use of recombinant human bone morphogenetic protein 2 (BMP-2) include off-label use, elevated cost and adverse outcomes such as osteolysis. The growing evolution of porous implant technology in promoting osseous integration via ingrowth provides an opportunity for a paradigm shift by relying less on biologic-assisted through-growth and leveraging implant on-growth and in-growth in similar fashion to porous metallic implants used in other orthopedic settings such as hip arthroplasty. <h3>PURPOSE</h3> This study compared perioperative clinical and radiographic outcomes between patients undergoing ALIF with the assistance of BMP-2 in a nonporous, traditional window interbody cage vs those with no biologic using a minimal-window porous titanium interbody cage. <h3>STUDY DESIGN/SETTING</h3> Retrospective clinical. <h3>PATIENT SAMPLE</h3> This study retrospectively examined 75 consecutive patients who underwent 1- or 2-level ALIF between 2014 and 2020 with the use of BMP-2 in a nonporous PEEK cage vs a porous titanium interbody cage and no biologic. All patients had surgery with the senior surgeon and were followed for a minimum follow-up of 6-months postoperatively. <h3>OUTCOME MEASURES</h3> Patient demographics, comorbidities, postoperative complications, and preoperative, immediate and final postoperative patient-reported outcomes (PROs) were assessed. Rates of reoperation were recorded, and arthrodesis was evaluated using Bridwell radiographic criteria and CT when available. Pre- and postoperative radiographic parameters were evaluated for differences in spinopelvic alignment and correction. <h3>METHODS</h3> Statistical methods included student's t-test and chi-square for continuous and categorical variables, respectively. Continuous variables were reported as means and standard deviations, and categorical variables as proportions. The threshold for statistical significance was set to p < .05. <h3>RESULTS</h3> Forty-three (13 female, 30 male) and 32 (19 female, 13 male) patients were assessed in the BMP-2 and titanium cage cohorts, respectively. On PRO assessment, baseline VAS leg among BMP-2 patients (6.87, SD: 1.96 vs 5.16, SD: 2.41; p = .023) while the titanium cage group reported worse VAS back scores (6.23, SD: 2.39 vs 7.82, SD: 1.40; p = .023). However, there were no significant differences recorded in postoperative PRO surveys between groups. Correction of spinopelvic alignment was equally maintained between groups at final follow-up when compared to immediate postoperative radiographs. Similarly, disc spaces were equivalently upheld across cohorts, with the exception of greater degeneration among BMP-2 patients at the L4-L5 anterior (-1.78, SD: 3.00 vs -0.07, SD: 2.63; p = .039) and foraminal (-2.34, SD: 3.11 vs -0.07, SD: 2.06; p = .006) disc spaces. Interbody subsidence was similar at the superior (1.13, SD: 0.84 vs 1.28, SD: 0.88; p = .458) and inferior endplates (0.55, SD: 0.79 vs 0.91, SD: 1.27; p = .154), and radiographic evidence of fusion was observed at equivalent rates (90% vs 90.9%, p = .776). There were no differences in the rates of secondary surgeries for adjacent segment disease (ASD) (4.6% vs 0%, p = .222) or index-level revisions (9.1% vs 18.8%, p = .219). <h3>CONCLUSIONS</h3> Porous titanium interbody cages for ALIF may be equivalent to BMP-2 in nonporous PEEK in achieving arthrodesis, alignment durability and reoperation rates. Although long-term follow-up is necessary, the use of porous titanium implants without external biologics is an intriguing paradigm change which may produce similar outcomes at lower costs. <h3>FDA DEVICE/DRUG STATUS</h3> Alphatec Identiti Cage (Approved for this indication), Recombinant Human Bone Morphogenetic Protein-2 (Approved for this indication)

Clinical outcomes for patients with lateral lumbar radiculopathy treated by percutaneous endoscopic transforaminal discectomy versus tubular microdiscectomy: A retrospective review

BackgroundSurgical management of lateral lumbar radiculopathy is evolving. TMD (Tubular microdiscectomy) and TELD (Transforaminal endoscopic lumbar discectomy) have emerged as viable MIS treatments. We aim to compare clinical outcomes of both techniques for the treatment of lateral lumbar radiculopathy in relation to pre-operative lumbar foraminal stenosis grade (LFS). MethodsRetrospective observational cohort study of patients with back and leg pain from single level foraminal nerve root compression that underwent TMD or TELD. Data analyzed included pre- and post-operative VAS leg and back pain, MacNab clinical outcome scores, hospital length of stay, complication rates, and operative time. Outcomes were correlated with a pre-operative MRI grading system for LFS. Results109 patients were enrolled (71 TELD and 38 TMD). Back and leg VAS pain scores improved in TELD and TMD (p < 0.0001). Patients with grade III stenosis showed significantly higher VAS scores (p < 0.01), and worse functional outcomes at latest follow-up compared with grade I/II LFS. Overall, there was no difference in outcome between procedure groups except that TMD VAS back pain scores were lower than TELD at last follow up (p < 0.05). Clinical outcome comparisons between procedures relating to LFS grade showed higher correlation of LFS to TELD (Spearman’s rho (ρ)= 0.342 for TMD and 0.606 TELD). Regression analyses demonstrated correlation between higher-grade foraminal stenosis and poorer outcomes in TELD and TMD. ConclusionsBoth TELD and TMD are viable for treating lateral lumbar radiculopathy. Higher-grade foraminal stenosis can be indicative of poorer outcomes regardless of procedure type, however, the severity of pre-operative LFS correlates with clinical outcomes in TELD more significantly than TMD.

Do Patients with Back Pain-Dominant Symptoms Improve After Lumbar Surgery for Radiculopathy or Claudication?

Currently, few studies have examined whether patients with back or leg pain-predominant symptoms fare better clinically after lumbar spine surgery; therefore, the purpose of this study was to determine whether patients with back pain-dominant symptoms improved to a similar degree as patients with mixed or leg pain-dominant symptoms after lumbar surgery. A retrospective cohort study was conducted at a single academic center, in which patients were stratified into three groups: (1) back pain-dominant group (B) (visual analog score [VAS] back - VAS leg ≥ 1.0 point), (2) neutral group (N) (VAS back - VAS leg < 1.0 point), or (3) leg pain-dominant group (L) (VAS leg - VAS back ≥ 1.0 point), using a VAS threshold difference of 1.0 point. As a secondary analysis, the VAS leg-to-back pain (LBR) ratio was used to further stratify patients: (1) nonleg pain-dominant (NLPD) group (LBR ≤ 1.0) or (2) leg pain-dominant (LPD) group (LBR > 1.0). Patient outcomes, including physical component score of the short form-12 survey (PCS-12), mental component score of the short form-12 survey (MCS-12), and Oswestry Disability Index (ODI), were identified and compared between groups using univariate and multivariate analysis. There were no significant differences in preoperative, postoperative, or delta scores for PCS-12 or ODI scores between groups. In patients undergoing decompression surgery, those with back pain-dominant or mixed symptoms (B, N, or NLPD groups) did not improve with respect to MCS-12 scores after surgery (P > .05), and those with leg pain-dominant symptoms (LPD group) had greater delta MCS-12 scores (P = .046) and greater recovery rates (P = .035). Multiple linear regression did not find LPD to be an independent predictor of PCS-12 or ODI scores. Patients undergoing lumbar decompression surgery and leg pain-dominant symptoms noted a greater improvement in MCS-12 scores; however, there were no differences in PCS-12 or ODI scores. 3. Patients undergoing lumbar decompression surgery demonstrate no major clinically significant differences when split up by pain-dominance groups.

Spondylolisthesis in young patients: postoperative functional outcomes at 22-year mean follow-up.

Previous short- and intermediate-term clinical and radiographic studies demonstrated good results in patients who underwent spine surgery for spondylolisthesis, long-term outcomes are lacking instead. Young patients are often involved in high-demanding and sport activities, therefore good/excellent functional outcomes are very important for their future quality of life. The aim of this study is to assess the long-term functional results in young patients surgically treated for developmental spondylolisthesis. Retrospective evaluation of consecutive patients who underwent lumbar surgery for spondylolisthesis. Inclusion criteria were: spondylolisthesis from grade 1 to spondyloptosis, age at surgery < 25years, follow-up > 15years. The following outcomes were assessed: VAS back, VAS leg, Oswestry disability index (ODI) score, Short Form 12 (SF-12), rate of revision surgery, postoperative recovery and sport activity. 113 patients were enrolled. Mean age at surgery was 19.8years and mean follow-up was 22.1years (16-32). 16 patients (14.2%) needed revision surgery. Functional outcomes at last follow-up were: VAS back = 1.6, VAS leg = 1.4, ODI = 9.2%, SF-12 physical component summary = 50, SF-12 mental component summary = 48.7. Significant differences were assessed in terms of ODI (p = 0.047) and SF-12 PCS (p = 0.015) between group treated with instrumented and non-instrumented techniques. Among the patients who practiced a sport, 87% returned to sport postoperatively (55% at medium-high-intensity level). This study shows good long-term functional outcomes in patients surgically treated for developmental spondylolisthesis. After surgery, there is a low incidence of back pain, the residual disability is mild and almost half of patients recover the same level of sport activity. Instrumented surgical techniques developed over the years seem to be related to high revision rate, but this does not affect long-term functional results.

Single- and multistage surgical treatment of patients with degenerative sagittal imbalance

Objective. To analyze the nearest clinical and radiological results of simultaneous and staged surgical treatment of patients with degenerative sagittal imbalance.Material and Methods. Retrospective monocentric cohort study included analysis of data from 54 patients who underwent simultaneous combination of surgical methods with obligatory corrective anterior fusion at the L4–L5 or at L4–L5 and L5–S1 levels (Group I, n = 27) or similar surgical intervention though divided into stages with an interval of 5 days or more (Group II, n = 27). A comparison of clinical, radiological, and operational data during inpatient treatment was carried out.Results. The duration of surgery was 410.93 ± 76.34 minutes in Group I and 594.63 ± 102.61 minutes in Group II (p = 0.000001); the blood loss was 926.67 ± 378.63 ml versus 1345.19 ± 522.97 ml, respectively (p = 0.001575). Postoperative clinical and radiological parameters did not differ between groups: VAS back (p = 0.248647), VAS leg (p = 0.196140), PT (p = 0.115965), SVA (p = 0.208449), LL (p = 0.023654), LDI (p = 0.931646), PI-LL (p = 0.693045), GAP (p = 0.823504), and restoration of the ideal Russoly type (p = 0.111476). The incidence of perioperative complications in groups was comparable: 17 (62.96 %) in Group I and 15 (55.56 %) in Group II (p = 0.583171). Patients with a high Charlson comorbidity index had a significantly higher incidence of complications (p = 0.023471). The index of surgical invasiveness in Group I had a significant correlation with the total number of complications (r = 0.421332).Conclusion. Clinical and radiological results and the incidence of complications are comparable between single- and multistage approaches to correct sagittal balance disorders. In staged treatment, the total duration of surgery and the volume of blood loss are significantly higher. With a high Charlson comorbidity index and Mirza surgical invasiveness index, a multistage approach to the treatment of patients with sagittal imbalance is preferred.