Coronal decompensation following thoracic vertebral body tethering in idiopathic scoliosis.

PURPOSE: Post-operative coronal decompensation (CD) continues to be a challenge in the treatment of adolescent idiopathic scoliosis (AIS). CD following selective spinal fusion has been studied. However, there is currently little information regarding CD following Vertebral Body Tethering (VBT). Thus, the goal of this study is to better understand the incidence and risk factors for CD after VBT. METHODS: Retrospective review of a prospective multicenter database was used for analysis. Inclusion criteria were patients undergoing thoracic VBT, a minimum 2-year follow-up, LIV was L1 or above, skeletally immature (Risser ≤ 1), and available preoperative and final follow-up AP and lateral upright radiographs. Radiographic parameters including major and minor Cobb angles, curve type, LIV tilt/translation, L4 tilt, and coronal balance were measured. CD was defined as the distance between C7PL and CSVL > 2 cm. Multiple logistic regression model was used to identify significant predictors of CD. RESULTS: Out of 136 patients undergoing VBT, 94 patients (86 female and 6 male) met the inclusion criteria. The mean age at surgery was 12.1 (9-16) and mean follow-up period was 3.4 years (2-5 years). Major and minor curves, AVR, coronal balance, LIV translation, LIV tilt, L4 tilt were significantly improved after surgery. CD occurred in 11% at final follow-up. Lenke 1A-R (24%) and 1C (26%) had greater incidence of CD compared to 1A-L (4%), 2 (0%), and 3 (0%). LIV selection was not associated with CD. Multivariate logistic regression analysis yielded 1A-R and 1C curves as a predictor of CD with the odds ratio being 17.0. CONCLUSION: CD occurred in 11% of our thoracic VBT patients. Lenke 1A-R and 1C curve types were predictors for CD in patients treated with VBT. There were no other preoperative predictors associated with CD.

Evidence of causality of low body mass index on risk of adolescent idiopathic scoliosis: a Mendelian randomization study.

Introduction: Adolescent idiopathic scoliosis (AIS) is a disorder with a three-dimensional spinal deformity and is a common disease affecting 1-5% of adolescents. AIS is also known as a complex disease involved in environmental and genetic factors. A relation between AIS and body mass index (BMI) has been epidemiologically and genetically suggested. However, the causal relationship between AIS and BMI remains to be elucidated. Material and methods: Mendelian randomization (MR) analysis was performed using summary statistics from genome-wide association studies (GWASs) of AIS (Japanese cohort, 5,327 cases, 73,884 controls; US cohort: 1,468 cases, 20,158 controls) and BMI (Biobank Japan: 173430 individual; meta-analysis of genetic investigation of anthropometric traits and UK Biobank: 806334 individuals; European Children cohort: 39620 individuals; Population Architecture using Genomics and Epidemiology: 49335 individuals). In MR analyses evaluating the effect of BMI on AIS, the association between BMI and AIS summary statistics was evaluated using the inverse-variance weighted (IVW) method, weighted median method, and Egger regression (MR-Egger) methods in Japanese. Results: Significant causality of genetically decreased BMI on risk of AIS was estimated: IVW method (Estimate (beta) [SE] = -0.56 [0.16], p = 1.8 × 10-3), weighted median method (beta = -0.56 [0.18], p = 8.5 × 10-3) and MR-Egger method (beta = -1.50 [0.43], p = 4.7 × 10-3), respectively. Consistent results were also observed when using the US AIS summary statistic in three MR methods; however, no significant causality was observed when evaluating the effect of AIS on BMI. Conclusions: Our Mendelian randomization analysis using large studies of AIS and GWAS for BMI summary statistics revealed that genetic variants contributing to low BMI have a causal effect on the onset of AIS. This result was consistent with those of epidemiological studies and would contribute to the early detection of AIS.

Identification of a Functional Susceptibility Variant for Adolescent Idiopathic Scoliosis that Upregulates Early Growth Response 1 (EGR1)-Mediated UNCX Expression.

Adolescent idiopathic scoliosis (AIS) is a serious health problem affecting 3% of live births all over the world. Many loci associated with AIS have been identified by previous genome wide association studies, but their biological implication remains mostly unclear. In this study, we evaluated the AIS-associated variants in the 7p22.3 locus by combining in silico, in vitro, and in vivo analyses. rs78148157 was located in an enhancer of UNCX, a homeobox gene and its risk allele upregulated the UNCX expression. A transcription factor, early growth response 1 (EGR1), transactivated the rs78148157-located enhancer and showed a higher binding affinity for the risk allele of rs78148157. Furthermore, zebrafish larvae with UNCX messenger RNA (mRNA) injection developed body curvature and defective neurogenesis in a dose-dependent manner. rs78148157 confers the genetic susceptibility to AIS by enhancing the EGR1-regulated UNCX expression. © 2022 American Society for Bone and Mineral Research (ASBMR).

Development and validation of machine learning-based predictive model for clinical outcome of decompression surgery for lumbar spinal canal stenosis.

BACKGROUND CONTEXT: Although the results of decompression surgery for lumbar spinal canal stenosis (LSS) are favorable, it is still difficult to predict the postoperative health-related quality of life of patients before surgery. PURPOSE: The purpose of this study was to develop and validate a machine learning model to predict the postoperative outcome of decompression surgery for patients with LSS. STUDY DESIGN/SETTING: A multicentered retrospective study. PATIENT SAMPLE: A total of 848 patients who underwent decompression surgery for LSS at an academic hospital, tertiary center, and private hospital were included (age 71±9 years, 68% male, 91% LSS, level treated 1.8±0.8, operation time 69±37 minutes, blood loss 48±113 mL, and length of hospital stay 12±5 days). OUTCOME MEASURES: Baseline and 2 years postoperative health-related quality of life. METHODS: The subjects were randomly assigned in a 7:3 ratio to a model building cohort and a testing cohort to test the models' accuracy. Twelve predictive algorithms using 68 preoperative factors were used to predict each domain of the Japanese Orthopedic Association Back Pain Evaluation Questionnaire and visual analog scale scores at 2 years postoperatively. The final predictive values were generated using an ensemble of the top five algorithms in prediction accuracy. RESULTS: The correlation coefficients of the top algorithms for each domain established using the preoperative factors were excellent (correlation coefficient: 0.95-0.97 [relative error: 0.06-0.14]). The performance evaluation of each Japanese Orthopedic Association Back Pain Evaluation Questionnaire domain and visual analog scale score by the ensemble of the top five algorithms in the testing cohort was favorable (mean absolute error [MAE] 8.9-17.4, median difference [MD] 8.1-15.6/100 points), with the highest accuracy for mental status (MAE 8.9, MD 8.1) and the lowest for buttock and leg numbness (MAE 1.7, MD 1.6/10 points). A strong linear correlation was observed between the predicted and measured values (linear correlation 0.82-0.89), while 4% to 6% of the subjects had predicted values of greater than±3 standard deviations of the MAE. CONCLUSIONS: We successfully developed a machine learning model to predict the postoperative outcomes of decompression surgery for patients with LSS using patient data from three different institutions in three different settings. Thorough analyses for the subjects with deviations from the actual measured values may further improve the predictive probability of this model.

Minimally Invasive Scoliosis Surgery Is a Feasible Option for Management of Idiopathic Scoliosis and Has Equivalent Outcomes to Open Surgery: A Meta-Analysis.

STUDY DESIGN: Meta-analysis. OBJECTIVE: To compare outcomes between minimally invasive scoliosis surgery (MISS) and traditional posterior instrumentation and fusion in the correction of adolescent idiopathic scoliosis (AIS). METHODS: A literature search was performed using MEDLINE, PubMed, EMBASE, Google scholar and Cochrane databases, including studies reporting outcomes for both MISS and open correction of AIS. Study details, demographics, and outcomes, including curve correction, estimated blood loss (EBL), operative time, postoperative pain, length of stay (LOS), and complications, were collected and analyzed. RESULTS: A total of 4 studies met the selection criteria and were included in the analysis, totaling 107 patients (42 MIS and 65 open) with a mean age of 16 years. Overall there was no difference in curve correction between MISS (73.2%) and open (76.7%) cohorts. EBL was significantly lower in the MISS (271 ml) compared to the open (527 ml) group, but operative time was significantly longer (380 min for MISS versus 302 min for open). There were no significant differences between the approaches in pain, LOS, complications, or reoperations. CONCLUSION: MISS was associated with less blood loss but longer operative times compared to traditional open fusion for AIS. There was no difference in curve correction, postoperative pain, LOS, or complications/reoperations. While MISS has emerged as a feasible option for the surgical management of AIS, further research is warranted to compare these 2 approaches.

Etiology and treatment of cervical kyphosis: state of the art review-a narrative review.

OBJECTIVE: To provide state of the art review regarding cervical kyphosis. BACKGROUND: Cervical spine kyphosis has been increasingly common due to the growing elderly population. Clinicians should comprehensively understand its symptoms, biomechanics, etiology, radiographic evaluation, classification, and treatment options and complications of each treatment. Comprehensive review will help clinicians improve the management for patients with cervical kyphosis. METHODS: The available literature relevant to cervical kyphosis was reviewed. PubMed, Medline, OVID, EMBASE, and Cochrane were used to review the literature. CONCLUSIONS: This article summarizes current concepts regarding etiology, evaluation, surgical treatment, complications and outcomes of cervical kyphosis. Major etiologies of cervical kyphosis include degenerative, post-laminectomy, and ankylosing spondylitis. Clinical presentations include neck pain, myelopathy, radiculopathy, and problems with horizontal gaze, swallowing and breathing. Cervical lordosis, C2-7 sagittal vertical axis, chin-brow to vertical angle, and T1 slope should be evaluated from upright lateral 36-inch film. The most widely used classification system includes a deformity descriptor and 5 modifiers. A deformity descriptor provides a basic grouping of the deformity consisting of five types, cervical, cervicothoracic, thoracic, coronal cervical deformity, and cranio-vertebral junction deformity. The 5 modifiers include C2-7 sagittal vertical axis, chin-brow to vertical angle, T1 slope minus cervical lordosis, myelopathy based on modified Japanese Orthopaedic Association score, and SRS-Schwab classification for thoracolumbar deformity. Current treatment options include anterior discectomy and fusion, anterior osteotomy, Smith-Peterson osteotomy, pedicle subtraction osteotomy, or a combination of these based on careful preoperative evaluation.

Impact of leg numbness on patient satisfaction following decompression surgery for lumbar spinal stenosis.

Decompression surgery is the most common surgical treatment for lumbar spinal stenosis (LSS). Relatively low satisfaction rate was reported. Patients often complaint of residual numbness despite significant pain relief. We hypothesized that numbness had a significant impact on patient satisfaction, but had not been evaluated, which is associated with low satisfaction rate. This study aimed to examine how much numbness is associated with patient satisfaction. We retrospectively reviewed prospectively collected data from consecutive patients who underwent decompression without fusion for LSS. We evaluated the Numeric Rating Scale (NRS) scores of low back pain (LBP), leg pain, and leg numbness preoperatively and at the final follow-up visit. Improvement was evaluated using minimum clinically important differences (MCIDs). Patient satisfaction was evaluated using the question, "How satisfied are you with the overall result of your back operation?". There are four possible answers consisting of "very satisfied (4-point)", "somewhat satisfied (3-point)", "somewhat dissatisfied (2-point)", or "very dissatisfied (1-point)". Spearman correlation was used to evaluate the association between patient satisfaction and reaching MCIDs. A total of 116 patients were included. All three components had correlation with patient satisfaction with the correlation efficient of 0.30 in LBP, 0.22 in leg pain, and 0.33 in numbness. Numbness had greatest correlation efficient value. We showed that numbness has a greater impact than leg/back pain on patient satisfaction in patients undergoing decompression for LSS. We suggest not only LBP and leg pain but also numbness should be evaluated pre- and postoperatively.

Polygenic Risk Score of Adolescent Idiopathic Scoliosis for Potential Clinical Use.

Adolescent idiopathic scoliosis (AIS) is a common disease causing three-dimensional spinal deformity in as many as 3% of adolescents. Development of a method that can accurately predict the onset and progression of AIS is an immediate need for clinical practice. Because the heritability of AIS is estimated as high as 87.5% in twin studies, prediction of its onset and progression based on genetic data is a promising option. We show the usefulness of polygenic risk score (PRS) for the prediction of onset and progression of AIS. We used AIS genomewide association study (GWAS) data comprising 79,211 subjects in three cohorts and constructed a PRS based on association statistics in a discovery set including 31,999 female subjects. After calibration using a validation data set, we applied the PRS to a test data set. By integrating functional annotations showing heritability enrichment in the selection of variants, the PRS demonstrated an association with AIS susceptibility (p = 3.5 × 10-40 with area under the receiver-operating characteristic [AUROC] = 0.674, sensitivity = 0.644, and specificity = 0.622). The decile with the highest PRS showed an odds ratio of as high as 3.36 (p = 1.4 × 10-10 ) to develop AIS compared with the fifth in decile. The addition of a predictive model with only a single clinical parameter (body mass index) improved predictive ability for development of AIS (AUROC = 0.722, net reclassification improvement [NRI] 0.505 ± 0.054, p = 1.6 × 10-8 ), potentiating clinical use of the prediction model. Furthermore, we found the Cobb angle (CA), the severity measurement of AIS, to be a polygenic trait that showed a significant genetic correlation with AIS susceptibility (rg = 0.6, p = 3.0 × 10-4 ). The AIS PRS demonstrated a significant association with CA. These results indicate a shared polygenic architecture between onset and progression of AIS and the potential usefulness of PRS in clinical settings as a predictor to promote early intervention of AIS and avoid invasive surgery. © 2021 American Society for Bone and Mineral Research (ASBMR).

Drivers of in-hospital opioid consumption in patients undergoing lumbar fusion surgery.

BACKGROUND: With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions. METHODS: This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use. RESULTS: A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type. CONCLUSIONS: Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.

Improvement of Lower Back Pain in Lumbar Spinal Stenosis After Decompression Surgery and Factors That Predict Residual Lower Back Pain.

STUDY DESIGN: Retrospective observational study. OBJECTIVES: There is no consensus to predict improvement of lower back pain (LBP) in lumbar spinal stenosis after decompression surgery. The aim of this study was to evaluate the improvement of LBP and analyze the preoperative predicting factors for residual LBP. METHODS: We retrospectively reviewed 119 patients who underwent lumbar decompression surgery without fusion and had a minimum follow-up of 1 year. LBP was evaluated using the numerical rating scale (NRS), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) LBP score, and Roland-Morris Disability Questionnaire (RMDQ). All patients were divided into LBP improved group (group I) and LBP residual group (group R) according to the NRS score. Radiographic images were examined preoperatively and at the final follow-up. We evaluated spinopelvic radiological parameters and analyzed the differences between group I and group R. RESULTS: LBP was significantly improved after decompression surgery (LBP NRS, 5.7 vs 2.6, P < .001; JOABPEQ LBP score, 41.3 vs 79.6, P < .001; RMDQ, 10.3 vs 3.6, P < .001). Of 119 patients, 94 patients were allocated to group I and 25 was allocated to group R. There was significant difference in preoperative thoracolumbar kyphosis between group I and group R. CONCLUSIONS: Most cases of LBP in lumbar spinal stenosis were improved after decompression surgery without fusion. Preoperative thoracolumbar kyphosis predicted residual LBP after decompression surgery.

Incidence of Proximal Junctional Kyphosis With Pedicle Screws at Upper Instrumented Vertebrae in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Longitudinal cohort. OBJECTIVES: Posterior spinal fusion (PSF) using all-pedicle screw constructs has become the standard procedure in the treatment of adolescent idiopathic scoliosis (AIS). However, there have been several reports that all-pedicle screw constructs or the use of pedicle screws at the upper instrumented vertebrae (UIV) increases the incidence of proximal junctional kyphosis (PJK). We aimed to evaluate the impact of instrumentation type on the incidence of PJK following PSF for AIS. METHODS: We performed a stratified random sampling from 3654 patients enrolled in a multicenter database of surgically treated AIS to obtain a representative sample from all Lenke types. Patients were then allocated into 3 groups based on the instrumentation type: all-pedicle screw (PS), hook at UIV with pedicle screws distally (HT), and hybrid constructs (HB). We measured proximal junctional angle (PJA) and defined PJK as PJA ≥ 10° and PJA progression of >10° at the final follow-up. RESULTS: Fifteen (4.3%) of 345 cases had PJK. PJK was significantly more common in PS (11%) compared with HB (1%) and HT (0%) (P < .001). PJK patients were similar to non-PJK patients regarding age, sex, curve type, UIV, and preoperative coronal Cobb angle. Thoracic kyphosis was significantly higher in the PJK group before surgery. Patients who developed PJK had a statistically significantly larger negative sagittal balance compared with the non-PJK group. CONCLUSION: The incidence of PJK was 4.3% and was more common in all-pedicle screw constructs. Using hooks at UIV might be a treatment strategy to limit PJK.

Practical answers to frequently asked questions for shared decision-making in adult spinal deformity surgery.

OBJECTIVE: The shared decision-making (SDM) process provides an opportunity to answer frequently asked questions (FAQs). The authors aimed to present a concise list of answers to FAQs to aid in SDM for adult spinal deformity (ASD) surgery. METHODS: From a prospective, multicenter ASD database, patients enrolled between 2008 and 2016 who underwent fusions of 5 or more levels with a minimum 2-year follow-up were included. All deformity types were included to provide general applicability. The authors compiled a list of FAQs from patients undergoing ASD surgery and used a retrospective analysis to provide answers. All responses are reported as either the means or the proportions reaching the minimal clinically important difference at the 2-year follow-up interval. RESULTS: Of 689 patients with ASD who were eligible for 2-year follow-up, 521 (76%) had health-related quality-of-life scores available at the time of that follow-up. The mean age at the initial surgery was 58.2 years, and 78% of patients were female. The majority (73%) underwent surgery with a posterior-only approach. The mean number of fused levels was 12.2. Revision surgery accounted for 48% of patients. The authors answered 12 FAQs as follows:1. Will my pain improve? Back and leg pain will both be reduced by approximately 50%.2. Will my activity level improve? Approximately 65% of patients feel improvement in their activity level.3. Will I feel better about myself? More than 70% of patients feel improvement in their appearance.4. Is there a chance I will get worse? 4.1% feel worse at 2 years postoperatively.5. What is the likelihood I will have a complication? 67.8% will have a major or minor complication, with 47.8% having a major complication.6. Will I need another surgery? 25.0% will have a reoperation within 2 years.7. Will I regret having surgery? 6.5% would not choose the same treatment.8. Will I get a blood transfusion? 73.7% require a blood transfusion.9. How long will I stay in the hospital? You need to stay 8.1 days on average.10. Will I have to go to the ICU? 76.0% will have to go to the ICU.11. Will I be able to return to work? More than 70% will be working at 1 year postoperatively.12. Will I be taller after surgery? You will be 1.1 cm taller on average. CONCLUSIONS: The above list provides concise, practical answers to FAQs encountered in the SDM process while counseling patients for ASD surgery.

Drivers for nonhome discharge in a consecutive series of 1502 patients undergoing 1- or 2-level lumbar fusion.

OBJECTIVE: Unexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion. METHODS: The electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors. RESULTS: A total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001). CONCLUSIONS: Increased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.

Factors Influencing Patient Satisfaction After Decompression Surgery Without Fusion for Lumbar Spinal Stenosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Decompression without fusion is a standard surgical treatment for lumbar spinal stenosis (LSS) with reasonable surgical outcomes. Nevertheless, some studies have reported low patient satisfaction (PS) following decompression surgery. The cause of the discrepancy between reasonable clinical outcomes and PS is unknown; moreover, the factors associated with PS are expected to be complex, and little is known about them. This study aimed to identify satisfaction rate and to clarify the factors related to PS following decompression surgery in LSS patients. METHODS: We retrospectively reviewed 126 patients who underwent lumbar decompression with a minimum follow-up of 1 year. Patients were divided into 2 groups based on the PS question. The Japanese Orthopaedic Association (JOA) scores, and the Numeric Rating Scale (NRS) scores of low back pain (LBP), leg pain, and leg numbness were compared between the 2 groups preoperatively and at the latest visit. To identify the prognostic factors for dissatisfaction, multiple logistic regression analysis was performed. RESULTS: Overall satisfaction rate was 75%. The JOA recovery rate, NRS improvement, and Short Form-8 (SF-8) were significantly higher in the satisfied group. Postoperative NRS scores of LBP, leg pain, and leg numbness were significantly lower in the satisfied group. Multivariate logistic regression analysis showed that smoking and scoliosis were significant risk factors for dissatisfaction. CONCLUSIONS: Overall satisfaction rate was 75% in patients with LSS undergoing decompression surgery. This study found that smoking status and scoliosis were associated with patient dissatisfaction following decompression in LSS patients.

Minimum clinically important difference of major patient-reported outcome measures in patients undergoing decompression surgery for lumbar spinal stenosis.

OBJECTIVE: A minimum clinically important difference (MCID) has been increasingly well known in the current era of patient-centered care because it reflects a smallest change that is meaningful for patients following a clinical intervention. Previous studies suggested MCID values are disease and/or procedure dependent. No MCID values have been reported on the lumbar spinal stenosis (LSS) following decompression surgery despite LSS is the most common spinal disease and the main treatment is decompression surgery. Therefore, this study aimed to determine the MCID values as major outcome measures including the Numeric Rating Scale (NRS) of back pain, leg pain and numbness, Roland-Morris Disability Questionnaire (RMDQ), and Physical Component Summary (PCS) and Mental Component Summary (MCS) of Short Form 8 (SF-8) for patients with LSS undergoing decompression surgery. PATIENTS AND METHODS: This is a retrospective cohort study using prospectively collected data from consecutive patients who underwent lumbar decompression without fusion for LSS at a single institution between May 2014 and March 2016. Inclusion criteria were 1) minimum 1-year follow-up 2) a complete set of preoperative and final follow-up questionnaires available, including the NRS, RMDQ, and SF-8. Revision surgery or non-degenerative etiology such as infection or tumor was excluded. MCIDs of each outcome measure were determined using two major approaches, distribution- and anchor-based methods. The distribution-based method uses the distributional characteristics of the sample. This method expresses the observed degree of variation to obtain a standardized metric such as the standard deviation or standard error of measurement. The anchor-based method uses an external criterion known as anchor to determine the factors that should be considered by patients for an important improvement. Anchor-based methods assess how much changes in the measurement instrument correspond with a minimal important change defined on the anchor. We used symptom severity, physical function, and satisfaction scores from Zurich Claudication Questionnaire as anchors for NRS and RMDQ, PCS, and MCS, respectively. RESULTS: A total of 126 patients were included. From the anchor-based method, MCIDs were determined to be 2 points for back pain, 4 points for leg pain and numbness, 5 points for RMDQ, 5 points for PCS, and 2 points for MCS. From the distribution-based method, MCIDs were determined to be 2 points for back pain, leg pain and numbness, 3-4 points for RMDQ, 6 points for PCS, and 5 points for MCS. CONCLUSION: We first identified the MCIDs of the NRS, RMDQ, and SF-8 specific to patients undergoing decompression surgery for LSS.

Risk factors for persistent numbness following decompression surgery for lumbar spinal stenosis.

OBJECTIVE: Decompression surgery is a mainstay of surgical treatment for lumbar spinal stenosis (LSS). However, up to 30% of patients have low satisfaction due to residual symptoms. In the clinical setting, improvements in leg pain are more significant than those in leg numbness. Residual numbness could be related to the relatively low satisfaction rate. However, few studies have focused on numbness; thus, elucidating the risk factors and rate of residual numbness would benefit surgeons and patients. This study aimed to clarify the risk factors for and rate of residual numbness after decompression surgery. PATIENTS AND METHODS: We retrospectively reviewed prospectively collected data from consecutive patients who underwent lumbar decompression without fusion for LSS at a single institution between January 2014 and March 2016. Patients were included if preoperative and final follow-up questionnaires and radiographs were available. A minimum one-year follow-up was required. We evaluated the Numeric Rating Scale (NRS) scores of low back pain, leg pain, and leg numbness preoperatively and at the final follow-up visit. Residual numbness was defined as a postoperative NRS ≥ 1, whereas persistent numbness was defined as a postoperative NRS ≥ 5. We compared the clinical data of patients with or without residual numbness to those of patients with or without persistent numbness. Multivariate logistic regression analysis was performed to identify risk factors for residual and persistent numbness. RESULTS: A total of 116 patients (73 men, 43 women) were included. Of them, 60% had residual numbness with a mean follow-up period of 25 months. Only durotomy differed significantly between patients with and those without residual numbness. However, the significance did not persist after logistic regression analysis. A total of 16% had persistent numbness. Diabetes mellitus, intraoperative durotomy, and preoperative NRS of numbness were identified as risk factors. There were no differences in smoking status, presence of spondylolisthesis or scoliosis, or severity of stenosis. CONCLUSIONS: We found three risk factors for persistent numbness following decompression surgery for LSS; diabetes mellitus and durotomy were modifiable, whereas preoperative numbness was not. Our findings would help surgeons minimize the incidence of persistent numbness by adequately controlling diabetes and avoiding durotomy during surgery. Providing information about the potential for residual numbness during the informed consent process is important to ensuring realistic patient expectations.

Comparison of Pulmonary Function After Selective Anterior Versus Posterior Fusion for the Correction of Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To compare the selective anterior spinal fusion (ASF) versus posterior spinal fusion (PSF) on postoperative pulmonary function testing (PFT) whether thoracotomy with separation of the diaphragm by anterior approach influences the PFT in thoracolumbar and lumbar adolescent idiopathic scoliosis (AIS). METHODS: A multicenter series of AIS patients who underwent selective spinal fusion were retrospectively reviewed. Seventy-nine female patients were included (mean 15.8 years). There were 35 patients in the ASF group and 44 patients in the PSF group. Patient demographics, radiographic measurements, and PFT data from preoperative to 2-year follow-up were analyzed. RESULTS: Preoperatively, there were no significant differences in PFTs between the groups. The ASF group patients were more likely to undergo shorter fusions (4.5 instrumented vertebral levels) than those in the PSF group (5.2 levels). At 2-year follow-up, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) in ASF group were statistically lower than those in PSF group. When comparing preoperative and 2-year changes on each procedure, only %FVC showed significant difference in ASF while FVC, FEV1, and %FEV1 did not. Meanwhile, the ASF group showed a significant decrease in FVC at 6 and 12 months compared to preoperative values. In PSF group, there was a decrease at 6 months, returned to preoperative value at 1-year follow-up. CONCLUSIONS: Pulmonary function after ASF and PSF was similar at 2 years; however, anterior group did not return to the baseline at 6 months and 1 year suggesting anterior approach may affect early postoperative pulmonary function.

Cost-effectiveness of surgical treatment of adult spinal deformity: comparison of posterior-only versus anteroposterior approach.

BACKGROUND CONTEXT: Considerable debate exists regarding the optimal surgical approach for adult spinal deformity (ASD). It remains unclear which approach, posterior-only or combined anterior-posterior (AP), is more cost-effective. Our goal is to determine the 2-year cost per quality-adjusted life year (QALY) for each approach. PURPOSE: To compare the 2-year cost-effectiveness of surgical treatment for ASD between the posterior-only approach and combined AP approach. STUDY DESIGN: Retrospective economic analysis of a prospective, multicenter database PATIENT SAMPLE: From a prospective, multicenter surgical database of ASD, patients undergoing five or more level fusions through a posterior-only or AP approach were identified and compared. METHODS: QALYs gained were determined using baseline, 1-year, and 2-year postoperative Short Form 6D. Cost was calculated from actual, direct hospital costs including any subsequent readmission or revision. Cost-effectiveness was determined using cost/QALY gained. RESULTS: The AP approach showed significantly higher index cost than the posterior-only approach ($84,329 vs. $64,281). This margin decreased at 2-year follow-up with total costs of $89,824 and $73,904, respectively. QALYs gained at 2 years were similar with 0.21 and 0.17 in the posterior-only and the AP approaches, respectively. The cost/QALY at 2 years after surgery was significantly higher in the AP approach ($525,080) than in the posterior-only approach ($351,086). CONCLUSIONS: We assessed 2-year cost-effectiveness for the surgical treatment through posterior-only and AP approaches. The posterior-only approach is less expensive both for the index surgery and at 2-year follow-up. The QALY gained at 2-years was similar between the two approaches. Thus, posterior-only approach was more cost-effective than the AP approach under our study parameters. However, both approaches were not cost-effective at 2-year follow-up.

Outcome measures reflecting patient satisfaction following decompression surgery for lumbar spinal stenosis: Comparison of major outcome measures.

OBJECTIVE: Decompression surgery is the standard treatment for lumbar spinal stenosis (LSS); however, despite the good clinical outcomes reported for this procedure, a relatively high dissatisfaction rate has been reported. We hypothesized that the previously used outcome measures do not accurately reflect patient satisfaction (PS). This study aimed to examine which outcome measures reflect PS accurately in patients undergoing decompression for LSS. PATIENTS AND METHODS: Patients with LSS treated with lumbar decompression surgery between January 2014 and March 2016 were enrolled if they had the preoperative and final follow-up questionnaires including the Numeric Rating Scale (NRS), Roland-Morris Disability Questionnaire (RMDQ), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), and Short Form-8 (SF-8). PS was evaluated using the question, "How satisfied are you with the overall result of your back operation?". There are four possible answers consisting of "very satisfied (4-point)", "somewhat satisfied (3-point)", "somewhat dissatisfied (2-point)", or "very dissatisfied (1-point)". The Spearman correlation coefficient between PS and each questionnaire was calculated. RESULTS: Postoperative JOABPEQ had strong correlation with PS (r > 0.6) whereas NRS, RMDQ and SF-8 had moderate correlation (0.4

Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption.

BACKGROUND: The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF). METHODS: This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs). RESULTS: In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs. CONCLUSIONS: The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%.