RESUMO
BACKGROUND: Follow-ups more than 20 years after neck surgery are extremely rare. No previous randomized studies have investigated differences in pain and disability more than 20 years after ACDF surgery using different techniques. The purpose of this study was to describe pain and functioning more than 20 years after anterior cervical decompression and fusion surgery, and to compare outcomes between the Cloward Procedure and the carbon fiber fusion cage (CIFC). METHODS: This study is a 20 to 24-year follow-up of a randomized controlled trial. Questionnaires were sent to 64 individuals, at least 20 years after ACDF due to cervical radiculopathy. Fifty individuals (mean age 69, 60% women, 55% CIFC) completed questionnaires. Mean time since surgery was 22.4 years (range 20,5-24). Primary outcomes were neck pain and neck disability index (NDI). Secondary outcomes were frequency and intensity of neck and arm pain, headache, dizziness, self-efficacy, health related quality of life or global outcome. Clinically relevant improvements were defined as 30 mm decrease in pain and a decrease in disability of 20 percentage units. Between-group differences over time were analyzed with mixed design ANOVA and relationships between main outcomes and psychosocial factors were analyzed by Spearman´s rho. RESULTS: Neck pain and NDI score significantly improved over time (p < .001), with no group differences in primary or secondary outcomes. Eighty-eight per cent of participants experienced improvements or full recovery, 71% (pain) and 41% (NDI) had clinically relevant improvements. Pain and NDI were correlated with lower self-efficacy and quality of life. CONCLUSION: The results from this study do not support the idea that fusion technique affects long-term outcome of ACDF. Pain and disability improved substantially over time, irrespective of surgical technique. However, the majority of participants reported residual disability not to a negligible extent. Pain and disability were correlated to lower self-efficacy and quality of life.
Assuntos
Degeneração do Disco Intervertebral , Fusão Vertebral , Humanos , Feminino , Idoso , Masculino , Resultado do Tratamento , Seguimentos , Cervicalgia/etiologia , Cervicalgia/cirurgia , Degeneração do Disco Intervertebral/cirurgia , Qualidade de Vida , Vértebras Cervicais/cirurgia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Descompressão , Discotomia/métodosRESUMO
PURPOSE: Lumbar spinal stenosis (LSS) can be surgically treated, with variable outcome. Studies have linked socioeconomic factors to outcome, but no nation-wide studies have been performed. This register-based study, including all patients surgically treated for LSS during 2008-2012 in Sweden, aimed to determine predictive factors for the outcome of surgery. METHODS: Clinical and socioeconomic factors with impact on outcome in LSS surgery were identified in several high-coverage registers, e.g., the national quality registry for spine surgery (Swespine, FU-rate 70-90%). Multivariate regression analyses were conducted to assess their effect on outcome. Two patient-reported outcome measures, Global Assessment of leg pain (GA) and the Oswestry Disability Index (ODI), as well as length of sick leave after surgery were analyzed. RESULTS: Clinical and socioeconomic factors significantly affected health outcome (both GA and ODI). Some predictors of a good outcome (ODI) were: being born in the EU, reporting no back pain at baseline, a high disposable income and a high educational level. Some factors predicting a worse outcome were previous surgery, having had back pain more than 2 years, having comorbidities, being a smoker, being on social welfare and being unemployed. CONCLUSIONS: The study highlights the relevance of adding socioeconomic factors to clinical factors for analysis of patient-reported outcomes, although the causal pathway of most predictors' impact is unknown. These findings should be further investigated in the perspective of treatment selection for individual LSS patients. The study also presents a foundation of case mix algorithms for predicting outcome of surgery for LSS. These slides can be retrieved under Electronic Supplementary Material.
Assuntos
Vértebras Lombares/cirurgia , Licença Médica/estatística & dados numéricos , Estenose Espinal/cirurgia , Adulto , Idoso , Dor nas Costas/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Medidas de Resultados Relatados pelo Paciente , Prognóstico , Sistema de Registros , Fatores Socioeconômicos , Estenose Espinal/complicações , Estenose Espinal/reabilitação , Suécia , Resultado do TratamentoRESUMO
The surgical treatment of spinal metastases is evolving. The major problem is the selection of patients who may benefit from surgical treatment. One of the criteria is an expected survival of at least 3 months. A prediction model has been previously developed. The present study has been performed in order to validate externally the model and to demonstrate that this model can be generalized to other institutions and other countries than the Netherlands. Data of 356 patients from five centers in Germany, Spain, Sweden, and the Netherlands who were treated for metastatic epidural spinal cord compression were collected. Hazard ratios in the test population corresponded with those of the developmental population. However, the observed and the expected survival were different. Analysis revealed that the baseline hazard function was significantly different. This tempted us to combine the data and develop a new prediction model. Estimating iteratively, a baseline hazard was composed. An adapted prediction model is presented. External validation of a prediction model revealed a difference in expected survival, although the relative contribution of the specific hazard ratios was the same as in the developmental population. This study emphasized the need to check the baseline hazard function in external validation. A new model has been developed using an estimated baseline hazard.
Assuntos
Neoplasias da Mama/patologia , Neoplasias Renais/patologia , Modelos de Riscos Proporcionais , Neoplasias da Próstata/patologia , Neoplasias da Medula Espinal/secundário , Neoplasias Epidurais/secundário , Feminino , Alemanha , Humanos , Masculino , Países Baixos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Prognóstico , Reprodutibilidade dos Testes , Espanha , Suécia , Fatores de TempoRESUMO
Prediction studies testing a thorough range of psychological variables in addition to demographic, work-related and clinical variables are lacking in lumbar fusion surgery research. This prospective cohort study aimed at examining predictions of functional disability, back pain and health-related quality of life (HRQOL) 2-3 years after lumbar fusion by regressing nonlinear relations in a multivariate predictive model of pre-surgical variables. Before and 2-3 years after lumbar fusion surgery, patients completed measures investigating demographics, work-related variables, clinical variables, functional self-efficacy, outcome expectancy, fear of movement/(re)injury, mental health and pain coping. Categorical regression with optimal scaling transformation, elastic net regularization and bootstrapping were used to investigate predictor variables and address predictive model validity. The most parsimonious and stable subset of pre-surgical predictor variables explained 41.6, 36.0 and 25.6% of the variance in functional disability, back pain intensity and HRQOL 2-3 years after lumbar fusion. Pre-surgical control over pain significantly predicted functional disability and HRQOL. Pre-surgical catastrophizing and leg pain intensity significantly predicted functional disability and back pain while the pre-surgical straight leg raise significantly predicted back pain. Post-operative psychomotor therapy also significantly predicted functional disability while pre-surgical outcome expectations significantly predicted HRQOL. For the median dichotomised classification of functional disability, back pain intensity and HRQOL levels 2-3 years post-surgery, the discriminative ability of the prediction models was of good quality. The results demonstrate the importance of pre-surgical psychological factors, leg pain intensity, straight leg raise and post-operative psychomotor therapy in the predictions of functional disability, back pain and HRQOL-related outcomes.
Assuntos
Dor Lombar/cirurgia , Vértebras Lombares/cirurgia , Dor Pós-Operatória/psicologia , Complicações Pós-Operatórias/psicologia , Fusão Vertebral/efeitos adversos , Adolescente , Idoso , Estudos de Coortes , Feminino , Seguimentos , Humanos , Perna (Membro)/inervação , Dor Lombar/psicologia , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Valor Preditivo dos Testes , Estudos Prospectivos , Fusão Vertebral/psicologia , Resultado do Tratamento , Adulto JovemRESUMO
In a local and national quality control study based on Swespine the rate of satisfied patients and the rate of patients with reduced leg pain after surgery for spinal stenosis at Nacka Hospital was 70,5 % and 62,3 %, respectively, compared to 67,8 % and 60,5 % nationally. The rate was unchanged locally as well as nationally 2009-2019. Controlling for mix of patients by multiple regression analysis greatly reduced all differences between Swedish clinics with no statistically significant differences between them. Private clinics, assessed as a group, had a slight but significant improved outcome compared to public hospitals, 68,8 % compared to 64,8 % satisfied patients. PROMs are to a substantial degree affected by factors other than the surgical procedure per se, and should be interpreted with great caution in outcome assessments of degenerative spine surgery. The study underlines the need of objective outcome measures.
Assuntos
Estenose Espinal , Hospitais , Humanos , Vértebras Lombares , Sistema de Registros , Estenose Espinal/cirurgia , Suécia/epidemiologia , Resultado do TratamentoRESUMO
PURPOSE: The current literature on clinical appearance after surgery for high-grade spondylolisthesis is inconclusive. The few long-term comparative studies on surgical reduction versus in situ fusion report contradictory findings concerning appearance-related issues. The purpose of the current study was to evaluate and quantify clinical appearance three decades after in situ fusion for high-grade isthmic spondylolisthesis. METHODS: The Scoliosis Research Society (SRS)-22r questionnaire, digital photographs and standing lateral radiographs were used to evaluate clinical appearance for 22 patients three decades after in situ fusion for high-grade spondylolisthesis. The appearance was assessed by two spine surgeons, by the patient themselves, and by quantification of cosmesis relevant radiographic variables including pelvic parameters and sagittal balance. RESULTS: The surgeon inter- and intraobserver reliability of the photographic evaluation of the trunk deformity was at most moderate (Cohen's kappa 0.5). Correlation analysis revealed at most medium correlation between radiographic outcome and self-rated (SRS-22r) self-image (Spearman's rank correlation coefficient 0.3). The agreement between patient and surgeon-rated trunk appearance was poor (Cohen's kappa 0.2). CONCLUSIONS: Photographic evaluation of the trunk deformity in high-grade spondylolisthesis is unreliable. There were only weak correlations between patient self-assessed trunk appearance and radiographic parameters. The results reflect the pronounced subjectivity of cosmesis, and that the trunk deformity in high-grade spondylolisthesis is not easily observed. LEVEL OF EVIDENCE: IV.
Assuntos
Escoliose , Fusão Vertebral , Espondilolistese , Humanos , Vértebras Lombares , Reprodutibilidade dos Testes , Escoliose/diagnóstico por imagem , Escoliose/cirurgia , Fusão Vertebral/efeitos adversos , Espondilolistese/diagnóstico por imagem , Espondilolistese/cirurgiaRESUMO
Introduction: Symptoms of dizziness or imbalance are often present in individuals with a variety of neck-disorders. The aims of this study were to determine the prevalence of patient-reported balance problems and dizziness 10-13 years after surgery for cervical degenerative disc disease; evaluate associations with neck pain and health-related quality of life; and investigate how these individuals described dizziness. Material and methods: Sixty-eight individuals, 10 years or more after anterior cervical decompression and fusion surgery, who previously participated in a randomized controlled trial were included. Participants completed questionnaires including ratings of dizziness and balance problems, the Dizziness Handicap Inventory, and an open-ended question regarding their experience of dizziness. Secondary outcomes were neck pain and quality of life. Results: Seventy-two percent experienced occasional or daily symptoms of unsteadiness and/or dizziness. Intensity ratings for dizziness during movement and for balance problems were similar and rather low, but had an impact on quality of life. Ratings of dizziness at rest were even lower. Dizziness ratings were associated with neck pain. Strenuous activities were related to dizziness and dizziness was primarily described as intermittent and non-rotatory. Conclusions: Dizziness or balance problems in the long-term after surgery for cervical degenerative disc disease are common and have an impact on daily life. Ratings of problem frequency and intensity were usually low. Dizziness and balance problems may affect quality of life. Patients' descriptions of these problems are in line with common symptoms of cervicogenic dizziness.
Assuntos
Vértebras Cervicais/cirurgia , Tontura/epidemiologia , Tontura/fisiopatologia , Degeneração do Disco Intervertebral/cirurgia , Cervicalgia/cirurgia , Equilíbrio Postural/fisiologia , Idoso , Estudos Transversais , Descompressão Cirúrgica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Prevalência , Qualidade de Vida , Fusão Vertebral , Inquéritos e Questionários , Suécia/epidemiologiaRESUMO
STUDY DESIGN: Observational study. OBJECTIVES: To evaluate adjacent segment disk degeneration (ASD) after fusion without attempted reduction at a young age for high-grade isthmic spondylolisthesis. The clinical relevance of ASD remains unclear. Previous studies have shown that spinal fusion is associated with increased ASD but without influence on clinical outcome. Since high-grade spondylolisthesis is a severe kyphotic deformity, one could hypothesize that fusion without attempted reduction in young patients leads to accelerated adjacent segment disk degeneration in adult life. METHODS: Anterior and posterior disk heights were evaluated on supine radiographs of the spine 8 years and 29 years after fusion without attempted reduction for high-grade spondylolisthesis and also on standing radiographs 8 years and 33 years after surgery. Pelvic parameters were evaluated on standing radiographs obtained 33 years after surgery. Health-related quality of life was evaluated with the Scoliosis Research Society (SRS)-22r questionnaire. RESULTS: One segment above fusion the anterior disk height significantly decreased on standing radiographs. Two segments above the fusion, the anterior disk height significantly decreased on supine as well as on standing radiographs. The largest reduction was found two segments above the fusion where the disk height was reduced from 33 to 28% of anterior vertebral height between the measurements at mean 8 years and mean 33 years after surgery. There were no statistically significant decreases in posterior disk heights in any measurement. The disk height showed a moderate negative correlation to PT. There was no correlation between disk height reduction and SRS-22r outcome. CONCLUSIONS: In our long-term follow-up of fusion without attempted reduction for high-grade spondylolisthesis in young patients, we found only a minor but statistically significant reduction in adjacent segment disk height which had no apparent impact on clinical outcome. LEVEL OF EVIDENCE: Level IV.
Assuntos
Degeneração do Disco Intervertebral , Complicações Pós-Operatórias , Fusão Vertebral/métodos , Coluna Vertebral/cirurgia , Espondilolistese/cirurgia , Adolescente , Adulto , Fatores Etários , Criança , Feminino , Seguimentos , Humanos , Degeneração do Disco Intervertebral/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Qualidade de Vida , Radiografia , Coluna Vertebral/diagnóstico por imagem , Espondilolistese/diagnóstico por imagem , Inquéritos e Questionários , Fatores de Tempo , Adulto JovemRESUMO
The existence and importance of an accelerated adjacent segment disc degeneration (ASD) after lumbar fusion have previously not been demonstrated by RCTs. The objectives of this study were, to determine whether lumbar fusion in the long term accelerates degenerative changes in the adjacent disc and whether this affects the outcome, by using a prospective randomised design. A total of 111 patients, aged 18-55, with isthmic spondylolisthesis were randomised to exercise (EX, n = 34) or posterolateral fusion (PLF, n = 77), with (n = 37) or without pedicle screw instrumentation (n = 40). The minimum 10 years FU rate was 72%, with a mean FU time of 12.6 years (range 10-17 years). Three radiographic methods of ASD quantification were used, i.e. two digital radiographic measurement methods and the semi quantitative UCLA grading scale. One digital measurement method showed a mean disc height reduction by 2% in the EX group and by 15% in the PLF group (p = 0.0016), and the other showed 0.5 mm more disc height reduction in the PLF compared to the Ex group (ns). The UCLA grading scale showed normal discs in 100% of patients in the EX group, compared to 62% in the PLF group (p = 0.026). There were no significant differences between instrumented and non-instrumented patients. In patients with laminectomy we found a significantly higher incidence of ASD compared to non laminectomised patients (22/47 vs. 2/16 respectively, p = 0.015). In the longitudinal analysis, the posterior and anterior disc heights were significantly reduced in the PLF group, whereas in the EX group only the posterior disc height was significantly reduced. Except for global outcome, which was significantly better for patients without ASD, the clinical outcome was not statistically different in patients with and without ASD. In conclusion, the long-term RCT shows that fusion accelerates degenerative changes at the adjacent level compared with natural history. The study suggests that not only fusion, but also laminectomy may be of pathogenetic importance. The clinical importance of ASD seems limited, with only the more severe forms affecting the outcome.
Assuntos
Deslocamento do Disco Intervertebral/epidemiologia , Vértebras Lombares/cirurgia , Complicações Pós-Operatórias/epidemiologia , Fusão Vertebral/efeitos adversos , Espondilolistese/cirurgia , Adolescente , Adulto , Parafusos Ósseos/efeitos adversos , Progressão da Doença , Feminino , Humanos , Deslocamento do Disco Intervertebral/diagnóstico , Laminectomia/efeitos adversos , Laminectomia/métodos , Vértebras Lombares/patologia , Vértebras Lombares/fisiopatologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/métodos , Estudos Prospectivos , Fusão Vertebral/instrumentação , Fusão Vertebral/métodos , Resultado do Tratamento , Adulto JovemRESUMO
STUDY DESIGN: Observational study. OBJECTIVES: To evaluate self-image after in situ fusion for high-grade isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: Certain clinical findings such as short trunk or waistline skin folds are often seen in high-grade spondylolisthesis. Since treatment with spinal fusion in situ does not address appearance, self-image and also health-related quality of life might be negatively affected in the short-term as well as the long-term perspective. This observational study evaluated health-related quality of life outcome including self-image three decades after in situ fusion for high-grade isthmic spondylolisthesis in relation to healthy controls. METHODS: Thirty-eight of 39 consecutive patients, fused in situ for high-grade isthmic spondylolisthesis at a young age, completed the Scoliosis Research Society (SRS)-22r questionnaire 28-41 years after surgery. The results were compared with the results of an age- and gender-matched control group. RESULTS: We found that the SRS-22r self-image domain scores were statistically significantly lower in patients than in controls whereas the pain and mental health scores were similar in patients and controls. Also, the SRS-22r function domain scores were statistically significantly lower in patients but the difference in means was small. We found no correlation between severity of slip and SRS-22r outcome. CONCLUSIONS: In situ fusion for high-grade isthmic spondylolisthesis is a safe treatment option in the long term from a function and pain perspective, but the results of our study suggest that self-image is negatively affected long into adult life. LEVEL OF EVIDENCE: Level IV.
Assuntos
Qualidade de Vida , Autoimagem , Fusão Vertebral/psicologia , Espondilolistese/psicologia , Espondilolistese/cirurgia , Adolescente , Adulto , Fatores Etários , Criança , Feminino , Humanos , Masculino , Índice de Gravidade de Doença , Inquéritos e Questionários , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: This case series of consecutive patients evaluated sagittal balance and health-related quality of life (HRQoL) 3 decades after in situ arthrodesis for high-grade isthmic spondylolisthesis. METHODS: Global sagittal balance, pelvic parameters, and compensatory mechanisms were evaluated on standing lateral radiographs of the spine and pelvis for 28 of 39 consecutive patients, 28 to 41 years after in situ arthrodesis for high-grade L5 to S1 spondylolisthesis. The mean age at surgery was 14 years (range, 9 to 24 years), and the mean age at the time of follow-up was 48 years (range, 39 to 59 years). A subset of the radiographic parameters was compared with the corresponding data from an 8-year follow-up examination of the same patients. HRQoL was evaluated with the Scoliosis Research Society (SRS)-22r questionnaire. RESULTS: We found that 3 of the 28 patients had a global sagittal imbalance (T1 spinopelvic inclination of >0°). Signs of compensatory mechanisms, such as reduced thoracic kyphosis and pelvic retroversion, were frequent. There was a significant decrease in sacral slope compared with 8-year follow-up data (p = 0.01). The median SRS-22r subscore was on the same level as Swedish normative data. We found no association between radiographic parameters and SRS-22r outcome. CONCLUSIONS: Three decades after in situ arthrodesis for high-grade spondylolisthesis, radiographic signs of noncompensated sagittal imbalance were observed in only a few individuals. The patients had normal SRS-22r scores. There was no association between any radiographic parameter and SRS-22r outcome. The findings are relevant in the controversial discussion on whether to perform a reduction procedure to treat high-grade spondylolisthesis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Artrodese , Equilíbrio Postural/fisiologia , Qualidade de Vida , Adulto , Artrodese/métodos , Feminino , Humanos , Vértebras Lombares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Sacro/diagnóstico por imagem , Espondilolistese/fisiopatologia , Espondilolistese/cirurgiaRESUMO
BACKGROUND CONTEXT: The posterior ligamentous complex (PLC) is thought to contribute significantly to the stability of thoracolumbar spine. Obvious translation or dislocation of an interspace clearly denotes injury to the PLC. A recent survey of the Spine Trauma Study Group indicated that plain radiographic findings, if present, are most helpful in determining PLC injury. However, confusion exists when plain radiography shows injury to the anterior spinal column without significant kyphosis or widening of the posterior interspinous space. PURPOSE: The objective of this study is to identify imaging parameters that may suggest a disruption of the posterior ligamentous complex of the thoracolumbar spine in the setting of normal-appearing plain radiographs. This study was performed, in part, as a pilot study to determine critical imaging parameters to be included in a future prospective, randomized, multicenter study. STUDY DESIGN/SETTING: Survey analysis of the Spine Trauma Study Group. PATIENT SAMPLE: None. OUTCOME MEASURES: Compilation and statistical analysis of survey results. METHODS: Based on a systematic review of the English literature from 1949 to present, we identified a series of traits not found on plain X-rays that were consistent with PLC injury. This included five imaging findings on either computed tomography (CT) scans or magnetic resonance imaging (MRI) and several physical examination features. These items were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important in representing an injury to the PLC in the setting of normal-appearing plain radiographs. RESULTS: Thirty-three of 47 surveys were returned for final analysis. Thirty-nine percent (13/33) of the members ranked "disrupted PLC components (i.e., interspinous ligament, supraspinous ligament, ligamentum flavum) on T1 sagittal MRI" as the most important factor in determining disruption of PLC. When analyzed with a point-weighted system, "diastasis of the facet joints on CT" received the most points, indicating that this category was ranked high by the majority of the members of the group. The members were also given freedom to add other criteria that they believed were important in determining PLC integrity in the setting of normal-appearing plain radiograph. Of the other criteria suggested, one included a physical finding and the other a variant of MR sequencing. CONCLUSIONS: In a setting of normal-appearing plain radiographs, PLC injury as displayed on T1-weighted MRI and diastasis of the facet joints on CT scan seem to be the most popular determinants of probable PLC injury among members of the Spine Trauma Study Group. Between MRI and CT scan, most members feel that various characteristics on MRI studies were more helpful.
Assuntos
Ligamento Amarelo/lesões , Ligamentos Longitudinais/lesões , Vértebras Lombares , Imageamento por Ressonância Magnética , Vértebras Torácicas , Tomografia Computadorizada por Raios X , Humanos , Projetos Piloto , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/diagnóstico por imagemAssuntos
Osteogênese por Distração/efeitos adversos , Osteotomia/métodos , Complicações Pós-Operatórias/cirurgia , Escoliose/cirurgia , Fusão Vertebral/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Osteogênese por Distração/instrumentação , Fusão Vertebral/instrumentação , Síndrome , Fatores de TempoRESUMO
OBJECTIVE The clinical outcomes and complications of patients who underwent pedicle subtraction osteotomy (PSO) for various diagnoses were compared. More specifically, the purpose was to identify if outcomes differed between patients with flat-back syndrome after lumbar fusion (FBS-LF) versus patients who underwent surgery for adult spinal deformity (ASD). METHODS A retrospective analysis of 104 patients who underwent a PSO for sagittal plane imbalance was performed. There were 28 patients with FBS-LF and 76 patients with various forms of ASD. Outcome was measured using visual analog scale (VAS)-back, VAS-leg, Oswestry Disability Index (ODI) (range 0-100 for all scales), and EQ-5D scores (range 0-1). Patients also rated their global outcomes as much better, better, unchanged, or worse at follow-up. The minimum follow-up was 1 year (range 1-4 years). Clinical outcomes and complications were compared between the 2 groups of patients. RESULTS The most common level of PSO was L-3 and L-2; 100 single and 4 double PSOs were performed. The average local correction by PSO itself was 27.2°. The sagittal vertical axis (SVA) improved from a mean preoperative value of 74 ± 23 mm to 49 ± 20 mm at the final follow-up. The VAS-back, ODI, and EQ-5D scores improved significantly for the entire group by 33, 16, and 0.31 points, respectively. In total, 57% of patients reported that they were "much better" or "better" than before surgery. Preoperatively, as well as postoperatively, the FBS-LF patients reported significantly worse VAS scores. According to VAS-back results, the ASD group improved by 34 points compared with 29 points in FBS-LF patients. ODI scores were similar between the 2 groups preoperatively but improved significantly more in the ASD group (18 points) compared with the FBS-LF group (13 points). The EQ-5D scores improved from 0.07 to 0.35 in FBS-LF patients, and from 0.21 to 0.56 on average in ASD patients. Similarly, a "much better" or "better" outcome compared with before surgery was reported by 72% of patients in the ASD group compared with 24% of patients in the FBS-LF group (p < 0.001). The overall reoperation rate was 31%: 46% of patients in the FBS-LF group compared with 25% of patients in the ASD group. There were 19 (18%) dural tears, 14 (13.5%) surgical site infections, 12 (11.5%) instances of pseudarthrosis, 15 (14%) proximal junctional failures, and 2 distal junctional failures. The 12 (11%) neurological complications were dominated by partial weakness of hip flexion and knee extension, and all but 2 of these were temporary. CONCLUSIONS PSO is a safe and effective method for correcting sagittal plane imbalance due to multiple etiologies. The authors found patient satisfaction to be high, and health-related quality of life was greatly improved by the procedure in patients with ASD. In contrast, in FBS-LF patients, a suboptimal outcome was observed and the cautious use of PSO seems warranted in this subset of patients.
Assuntos
Osteotomia , Curvaturas da Coluna Vertebral/etiologia , Curvaturas da Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Avaliação da Deficiência , Feminino , Seguimentos , Humanos , Tempo de Internação , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Medição da Dor , Satisfação do Paciente , Complicações Pós-Operatórias/cirurgia , Qualidade de Vida , Estudos Retrospectivos , Curvaturas da Coluna Vertebral/diagnóstico por imagem , Fusão Vertebral/efeitos adversos , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE Pedicle subtraction osteotomy (PSO) is commonly performed for correction of spinal sagittal plane deformities. The PSO results in complex, multiple changes of the spinopelvic alignment. The influence of the variability of individual pelvic morphology has not been fully analyzed in previous outcome studies of sagittal imbalance. The aim of this study was to define radiological variables affecting the outcome after PSO in adult spinal deformities, with special emphasis on the variability of pelvic morphology. METHODS Clinical and radiographic outcomes were analyzed in a retrospective analysis of 104 patients who underwent a PSO at a single center. The radiographic variables studied were sagittal vertical axis (SVA), T1SPI (T-1 spinopelvic inclination), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). To control for the individual variation of pelvic morphology, the LL/PI, PT/PI, and SS/PI ratios were calculated. Clinical outcome was assessed using the visual analog scale for pain, Oswestry Disability Index, and EQ-5D preoperatively and at a minimum 1-year follow-up. Correlation coefficients were calculated between each individual radiographic variable and the outcome measures. The importance of LL mismatch to TK, reflecting the importance of a harmonious spine, was analyzed by comparing the outcome of patients with a TK+LL+PI ≤ 45° to those with a sum > 45°. RESULTS SVA and T1SPI demonstrated the strongest correlation with the clinical outcome scores (r = 0.4-0.5, p < 0.001). LL correlated weakly with the clinical outcome (r = 0.2-0.3, p < 0.003). Mismatch of LL to PI, however, did not correlate significantly with the outcome. Similarly, only weak and inconsistent correlation was observed between PT, SS, PT/PI, SS/PI, and functional outcome. Patients with a TK+LL+PI ≤ 45° had a significantly lower ODI score (33 vs 44) and a significantly higher EQ-5D score (0.64 vs 0.40) than patients with a sum > 45° (LL is a negative value). CONCLUSIONS PSO resulted in a substantial correction of sagittal imbalance and improved outcome in most patients in this study. Correction of the global sagittal balance appears to be a necessary precondition for a good outcome. A harmonious spine with a TK and an LL of similar magnitude seems to add to a positive outcome.
Assuntos
Vértebras Lombares/cirurgia , Osteotomia , Pelve/diagnóstico por imagem , Curvaturas da Coluna Vertebral/diagnóstico por imagem , Curvaturas da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Idoso , Feminino , Seguimentos , Humanos , Vértebras Lombares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Estudos Retrospectivos , Vértebras Torácicas/diagnóstico por imagemRESUMO
BACKGROUND CONTEXT: Posterior ligamentous complex (PLC), consisting of supraspinous ligament (SSL), interspinous ligament (ISL), ligamentum flavum (LF), and the facet joint capsules is thought to contribute significantly to the stability of thoracolumbar spine. Currently, no consensus exists on radiographic imaging parameters that may indicate injury to the posterior ligamentous complex. PURPOSE: To identify imaging parameters that may suggest a disruption of the PLC of the thoracolumbar spine. STUDY DESIGN/SETTING: A survey analysis of members of the Spine Trauma Study Group. PATIENT SAMPLE: None. OUTCOMES MEASURES: Compilation of survey results. METHODS: An extensive review of the literature from 1949 to the present was performed to identify key radiographic elements that have been suggested as indicators of PLC injury. Twelve items identified as such were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important, and the results were compiled for analysis. RESULTS: Twenty-eight surveys were returned for final analysis. Fifty-percent (14/28) of the members ranked "vertebral body translation" on plain radiographs as the most important factor in determining disruption of PLC. Plain radiographic signs were ranked higher than computed tomography or magnetic resonance imaging indicators, and history of the mechanism ranked lowest. The members were also given freedom to add other criteria that they felt were important in determining PLC integrity. "Interspinous spacing 7 mm greater than that of level above or below on antero posterior plain X-rays" was the only new category that was suggested. CONCLUSION: Plain radiographic findings were felt to be most helpful in determining PLC injury by the members of the Spine Trauma Study Group. Physical examination findings and history of the mechanism of injury were ranked lower than imaging studies. Future analysis should focus on indicators of PLC injury when plain radiographic findings are either subtle or not present.
Assuntos
Ligamento Amarelo/lesões , Ligamentos Longitudinais/lesões , Vértebras Lombares/patologia , Traumatismos da Coluna Vertebral/diagnóstico , Vértebras Torácicas/patologia , Ferimentos e Lesões/diagnóstico , Consenso , Coleta de Dados , Humanos , Escala de Gravidade do Ferimento , Vértebras Lombares/lesões , Traumatismos da Coluna Vertebral/classificação , Traumatismos da Coluna Vertebral/fisiopatologia , Vértebras Torácicas/lesões , Ferimentos e Lesões/fisiopatologiaRESUMO
BACKGROUND CONTEXT: Current literature suggests that in the long-term, fusion of the lumbar spine in chronic low back pain (CLBP) does not result in an outcome clearly better than structured conservative treatment modes. PURPOSE: This study aimed to assess the long-term outcome of lumbar fusion in CLBP, and also to assess methodological problems in long-term randomized controlled trials (RCTs). STUDY DESIGN: A prospective randomized study was carried out. PATIENT SAMPLE: A total of 294 patients (144 women and 150 men) with CLBP of at least 2 years' duration were randomized to lumbar fusion or non-specific physiotherapy. The mean follow-up time was 12.8 years (range 9-22). The follow up rate was 85%; exclusion of deceased patients resulted in a follow-up rate of 92%. OUTCOME MEASURES: Global Assessment (GA) of back pain, Oswestry Disability Index (ODI), visual analogue scale (VAS) for back and leg pain, Zung depression scale were determined. Work status, pain medication, and pain frequency were also documented. METHODS: Standardized outcome questionnaires were obtained before treatment and at long-term follow-up. To optimize control for group changers, four models of data analysis were used according to (1) intention to treat (ITT), (2) "as treated" (AT), (3) per protocol (PP), and (4) if the conservative group automatically classify group changers as unchanged or worse in GA (GCAC). The initial study was sponsored by Acromed (US$50,000-US$100,000). RESULTS: Except for the ITT model, the GA, the primary outcome measure, was significantly better for fusion. The proportion of patients much better or better in the fusion group was 66%, 65%, and 65% in the AT, PP, and GCAC models, respectively. In the conservative group, the same proportions were 31%, 37%, and 22%, respectively. However, the ODI, VAS back pain, work status, pain medication, and pain frequency were similar between the two groups. CONCLUSIONS: One can conclude that from the patient's perspective, reflected by the GA, lumbar fusion surgery is a valid treatment option in CLBP. On the other hand, secondary outcome measures such as ODI and work status, best analyzed by the PP model, indicated that substantial disability remained at long-term after fusion as well as after conservative treatment. The lack of objective outcome measures in CLBP and the cross-over problem transforms an RCT to an observational study, that is, Level 2 evidence. The discrepancy between the primary and secondary outcome measures prevents a strong conclusion on whether to recommend fusion in non-specific low back pain.
Assuntos
Dor Lombar/cirurgia , Vértebras Lombares/cirurgia , Fusão Vertebral/efeitos adversos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia/efeitos adversos , Complicações Pós-Operatórias , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Inquéritos e Questionários , Suécia , Resultado do TratamentoRESUMO
BACKGROUND: Today there is some evidence-based medicine support for a positive short-term treatment effect of fusion in chronic low back pain in spondylolisthesis and in nonspecific degenerative lumbar spine disorders. The long-term effect is, however, unknown. PURPOSE: To determine the long-term outcome of lumbar fusion in adult isthmic spondylolisthesis. STUDY DESIGN: Prospective, randomized controlled study comparing a 1-year exercise program with instrumented and non-instrumented posterolateral fusion with average long-term follow-up of 9 years (range, 5-13). PATIENT SAMPLE: 111 patients aged 18 to 55 years with adult lumbar isthmic spondylolisthesis at L5 or L4 level of all degrees, and at least 1-year's duration of severe lumbar pain with or without sciatica. OUTCOME MEASURES: Pain and functional disability was quantified by pain (VAS), the Disability Rating Index (DRI), the Oswestry Disability Index (ODI) work status, and global assessment of outcome by the patient into much better, better, unchanged or worse. Quality of life was assessed by the SF-36. METHODS: The patients were randomly allocated to treatment with 1) a 1-year exercise program (n=34), 2) posterolateral fusion without pedicle screw instrumentation (n=37), or 3) posterolateral fusion with pedicle screw instrumentation (n=40). Long-term follow-up was obtained in 101 (91%) patients. Nine patients in the exercise group were eventually operated on. RESULTS: Longitudinal analysis: At long-term follow-up pain and functional disability were significantly better than before treatment in both surgical groups. No significant differences were observed between instrumented and non-instrumented patients in any variable studied. In the exercise group the pain was significantly reduced but not the functional disability. Compared with the 2-year follow-up a significant increase in functional disability was observed, as measured by the DRI, but not the ODI, in the surgical group at long term. In the exercise group no significant changes were observed between the 2-year and the long-term follow-up. Cross-sectional analysis: Between the surgical and conservative group no significant differences were observed in any outcome measurement at long-term follow-up except for global assessment, which was significantly better for surgical patients. Of surgical patients 76% classified the overall outcome as much better or better compared with 50% of conservatively treated patients (p=0.015). Quality of life as estimated by the SF-36 at long term was not different between treatment groups in any of the eight domains studied but was considerably lower than for the normal population. CONCLUSIONS: Posterolateral fusion in adult lumbar isthmic spondylolisthesis results ina modestly improved long-term outcome compared with a 1-year exercise program. Although the results show that some of the previously reported short-term improvement is lost at long term, patients with fusion still classify their global outcome as clearly better than conservatively treated patients. Furthermore, because the long-term outcome of the patients conservatively treated most likely reflects the natural course, one can also conclude that no considerable spontaneous improvement should be expected over time in adult patients with symptomatic isthmic spondylolisthesis. Substantial pain, functional disability and a reduced quality of life will in most patients most likely remain unaltered over many years.
Assuntos
Fixadores Internos , Vértebras Lombares , Fusão Vertebral/instrumentação , Espondilolistese/diagnóstico , Espondilolistese/cirurgia , Atividades Cotidianas , Adolescente , Adulto , Distinções e Prêmios , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Prognóstico , Estudos Prospectivos , Recuperação de Função Fisiológica , Medição de Risco , Índice de Gravidade de Doença , Perfil de Impacto da Doença , Fusão Vertebral/métodos , Fusão Vertebral/reabilitação , Fatores de Tempo , Resultado do TratamentoRESUMO
Study Design Randomized controlled trial. Objective Despite a large number of publications of outcomes after spinal fusion surgery, there is still no consensus on the efficacy of the several different fusion methods. The aim of this study was to determine whether transforaminal lumbar interbody fusion (TLIF) results in an improved clinical outcome compared with uninstrumented posterolateral fusion (PLF) in the surgical treatment for chronic low back pain. Methods This study included 135 patients with degenerative disk disease (n = 96) or postdiskectomy syndrome (n = 39). Inclusion criteria were at least 1 year of back pain with or without leg pain in patients aged 20 to 65 with one- or two-level disease. Exclusion criteria were sequestration of disk hernia, psychosocial instability, isthmic spondylolisthesis, drug abuse, and previous spine surgery other than diskectomy. Pain was assessed by visual analog scale (pain index). Functional disability was quantified by the disability rating index and Oswestry Disability Index. The global outcome was assessed by the patient and classified as much better, better, unchanged, or worse. The patients were randomized to conventional uninstrumented PLF (n = 67) or TLIF (n = 68). PLF was performed in a standardized fashion using autograft. TLIF was performed with pedicle titanium screw fixation and a porous tantalum interbody spacer with interbody and posterolateral autograft. The clinical outcome measurements were obtained preoperatively and at 12 and 24 months postoperatively. The 2-year follow-up rate was 98%. Results The two treatment groups improved significantly from preoperatively to 2 years' follow-up. At final follow-up, the results in the TLIF group were significantly superior to those in the PLF group in pain index (2.0 versus 3.9, p = 0.007) and in disability rating index (22 versus 36, p = 0.003). The Oswestry Disability Index was better in the TLIF group (20 versus 28, p = 0.110, not significant). The global assessment was clearly superior in the TLIF group: 63% of patients scored "much better" in the TLIF group as compared with 48% in the PLF group (p = 0.017). Conclusions The results of the current study support the use of TLIF rather than uninstrumented PLF in the surgical treatment of the degenerative lumbar spine. The less optimal outcome after uninstrumented PLF may be explained by the much higher reoperation rate.