Iliolumbar vein: a challenge for the exposure of the L4-5 disc in the anterior approach to the lumbar spine.

PURPOSE: Anterior lumbar spine arthrodesis has been increasingly prescribed. In order to obtain better exposure of the intervertebral discs, it is necessary to identify vascular structures depending on the level to be approached. Systematic ligation of the iliolumbar vein has been suggested for access to the L4-L5 level, which may be technically challenging. The goal of the present study was to determine a safe limit for separating the iliolumbar vein safely without the need for its ligation. METHODS: In total, 2284 patients involving the topography of the iliolumbar vein were included. If this vein was up to 5 mm distant from the inferior border of the L4-L5 intervertebral disc, its ligature was performed. In cases that the distance was greater than 5 mm, only the retraction was performed without ligature. RESULTS: A total of 115 ligatures were necessary (5% of cases). Among the 2169 cases with no ligature, bleeding due to ruptures occurred during traction in only 55 patients (3% of cases). The time taken for ligation ranged from five minutes to thirty-two minutes, with an average of 18.3 min per ligature. In cases in which ligatures were needed (distance less than 5 mm), there was loosening of the ligatures leading to bleeding in 23 cases (20% of ligatures). CONCLUSIONS: Systematic ligature is not necessary for accessing the anterior route to the L4-L5 level, leading to a reduction in the time of surgery and avoiding serious vascular injuries that can occur.

Impact of previous lumbar spine surgery on total hip arthroplasty and vice versa: How long should we be concerned about mechanical failure?

INTRODUCTION: This registry study aims to assess the prevalence and demographic characteristics of patients with lumbar spine (LS) surgical procedures who undergo total hip arthroplasty (THA), to compare the long-term survival and causes of failure of THA in patients who previously underwent LS fusion and non-fusion surgical procedures, and to evaluate the risk of undergoing a revision LS surgery after THA. MATERIALS AND METHODS: Patients who underwent LS surgery followed by THA were identified by cross-referencing data from the Orthopedic Prosthetic Implants Registry and the Regional Hospital Discharge Database. Three groups of THA patients were identified: patients who underwent previous lumbar surgery with fusion (LS fusion-THA), without fusion (LS non-fusion-THA), and a control group with only THA (No LS surgery-THA). Demographic data, THA survival, number and causes of failure, and data on revision procedures on THA and LS were collected. RESULTS: Of the total of 79,984 THA, 2.2% of patients had a history of LS procedures. THA only patients showed better results, while patients in the LS fusion-THA group had worse implant survival at 5-year follow-up. In the LS fusion-THA and LS non-fusion-THA, mechanical THA failures were more frequent in the first two years after implantation. There were no differences between groups regarding the risk of undergoing LS revision surgery. CONCLUSIONS: LS surgery negatively affects THA survivorship. In patients who previously underwent LS fusion and non-fusion surgical procedures, most THA failure occurs in the first two years after implant. The study contributes to the understanding of the relationship between the hip and the LS and provides useful guidance for clinical practice.

Use of biphasic calcium phosphate versus demineralized bone matrix: retrospective clinical and CT analysis of posterolateral fusion results.

PURPOSE: Bone graft extenders have been developed to prevent donor site morbidity associated with iliac crest bone graft, but few studies compared the efficacy of various substitutes. Our purpose was to determine fusion rate and clinical outcome in patients undergoing lumbar arthrodesis using demineralized bone matrix (DBM) and biphasic calcium phosphate (BCP). METHODS: Patients with degenerative spondylolisthesis undergoing one-level or two-level arthrodesis of lumbar spine were retrospectively reviewed. Two treatment groups placed either BCP or DBM, in addition to local autograft in lumbar posterolateral space. Three-dimensional CT exam and dynamic flexion-extension radiographs at postoperative 2-year were assessed for posterolateral fusion status and pain scale and Oswestry Disability Index (ODI) for clinical outcome. RESULTS: Of the 148 patients reviewed (including 23 in one- and 58 patients in two-level in BCP group, and 47 in one- and 20 patients in two-level in DBM group), no significant differences were found in terms of age, sex, BMI, smoking, diabetes, steroids, number of level fused, non-union rate or revision surgery between BCP and DBM groups. Significantly improved pain scale of back and leg and ODI were found in both groups postoperatively without group difference. We found a comparable fusion rate in one-level surgery (100% versus 93.6%) and a superior fusion rate of BCP group in two-level surgery (98.3% versus 80.0%, p = 0.01). CONCLUSION: Being a bone graft extender without osteoinductive property, with local autograft, BCP is comparable to DBM for one- and superior for two-level fusion. No significant difference was found in clinical outcomes.

It is the Opioids Not the Spine Surgeon; Dislocation After Total Hip Arthroplasty is Associated With Opioid Use in Patients Who Have Prior Lumbar Spine Fusion.

BACKGROUND: Patients who have prior lumbar spine fusion (LSF) have an increased risk for dislocation after total hip arthroplasty (THA). These patients also have elevated rates of opioid use. We aimed to evaluate the associated risk of dislocation after THA in patients who have prior LSF comparing those who have opioid use to those who do not. METHODS: This was a retrospective review using a large national database of 246,617 primary and 34,083 revision THA cases from 2012 to 2019. There were 1,903 primary THA and 288 revision THA cases identified with LSF prior to THA. Postoperative hip dislocation was our primary outcome variable and patients were stratified to use or nonuse of opioid at THA. Demographic data including age, sex, and obesity were collected. Multivariate analyses evaluated association of opioid use and dislocation after adjusting for demographics. RESULTS: There was increased odds of dislocation for opioid use at THA for both primary (adjusted Odds Ratio [aOR] = 2.29, 95% Confidence Interval [CI] 1.46 to 3.57, P < .0003) and revision THA (aOR = 1.92, 95% CI 1.62 to 3.08, P < .0003), in patients who have prior LSF. Prior LSF without opioid use was associated with increased odds of dislocation (aOR = 1.38, 95% CI 1.01 to 1.88, P = .04), but this was lower than the associated risk of opioid use without LSF (aOR 1.72, 95% CI 1.63 to 1.81, P < .001). CONCLUSION: Increased odds of dislocation were noted with opioid use at time of THA in patients who have prior LSF. Associated risk of dislocation was higher for opioid use than prior LSF. This suggests that dislocation risk is multifactorial and we should look to strategies to reduce opioid use prior to THA.

Posterolateral lumbar spine fusion with unidirectional porous beta-tricalcium phosphate in a canine model.

We investigated the use of the autologous iliac bone and unidirectional porous beta-tricalcium phosphate (UDPTCP) in posterolateral lumbar spine fusion (PLF). Ten canine PLF models were prepared. Using only the autologous bone as the control group, 100%, 75%, 50%, and 25% groups were prepared according to the mixing ratios of UDPTCP. Radiological evaluation and histological analysis were performed 12 weeks after surgery. Bone fusion was evaluated according to anteroposterior plain X-rays and coronal reconstruction CT views using four grades: 0 = no osteogenesis, 1 = only slight discontinuous osteogenesis between transverse processes, 2 = discontinuous osteogenesis between transverse processes, and 3 = continuous osteogenesis between transverse processes. Bone fusion determined by X-ray was 2.8 ± 0.5 in the control group, 0 in the 100% UDPTCP group (p = 0.02), 1.8 ± 0.5 (p = 0.03) in the 75% UDPTCP group, 2.5 ± 0.6 (p = 0.54) in the 50% UDPTCP group, and 2.8 ± 0.5 (p = 1.0) in the 25% UDPTCP group. The bone fusion score was significantly lower in the 75% and 100% UDPTCP groups than in the control group. Bone fusion determined by CT was 2.8 ± 0.5 in the control group, 1.0 ± 0.8 (p = 0.01) in the 100% UDPTCP group, 2.0 ± 0.0 (p = 0.02) in the 75% UDPTCP group, 2.5 ± 0.6 (p = 0.54) in the 50% UDPTCP group, and 2.8 ± 0.5 (p = 1.0) in the 25% UDPTCP group. Similar to the bone fusion determination by X-ray, the bone fusion score was significantly lower in the 75% and 100% UDPTCP groups. These data suggest that, in a canine PLF model, the appropriate mixing ratio of UDPTCP is 50% or less.

Use of dual mobility cups in patients undergoing primary total hip arthroplasty with prior lumbar spine fusion.

BACKGROUND: Patients undergoing primary total hip arthroplasty (THA) with prior lumbar spine fusion (LSF) are a high-risk group for instability with reported incidence of dislocation as high as 8.3% using fixed bearing femoral heads. Purpose of this study was to determine risk of post-operative instability in patients undergoing primary THA with a history of prior LSF using dual mobility acetabular cups. METHODS: This was a multicenter retrospective study with 93 patients undergoing primary THA using a dual mobility cup with a prior history of instrumented LSF. There were 56 females and 47 males with an average age of 66 years (46-87) and average BMI of 30 with mean follow-up of 2.7 years (range 12-124 months). Surgical approach included posterior (63), direct lateral (15), anterior (11), and direct superior (4). Forty-four percent had one level lumbar fusion, 29% with two levels, and 15% with three or more levels fused. The primary outcome investigated was instability. RESULTS: There were no cases of instability or prosthetic joint infection in this group of patients with prior lumbar spine fusion undergoing primary THA using a dual mobility cup. There was one intra-operative periprosthetic femur fracture and one case of aseptic acetabular cup loosening. CONCLUSION: Patients undergoing THA with prior LSF are at increased risk for instability due to loss of normal spinopelvic relationship. The use of dual mobility cups in patients with prior LSF undergoing primary THA appears promising with no cases of instability in this high-risk group of patients.

A validated preoperative score for predicting 30-day readmission after 1-2 level elective posterior lumbar fusion.

PURPOSE: To develop a model to predict 30-day readmission rates in elective 1-2 level posterior lumbar spine fusion (PSF) patients. METHODS: In this retrospective case control study, patients were identified in the State Inpatient Database using ICD-9 codes. Data were queried for 30-day readmission, as well as demographic and surgical data. Patients were randomly assigned to either the derivation or the validation cohort. Stepwise multivariate analysis was conducted on the derivation cohort to predict 30-day readmission. Readmission after posterior spinal fusion (RAPSF) score was created by including variables with odds ratio (OR) > 1.1 and p < 0.01; value assigned to each variable was based on the OR and calibrated to 100. Linear regression was performed between readmission rate and RAPSF score to test correlation in both cohorts. RESULTS: There were 92,262 and 90,257 patients in the derivation and validation cohorts. Thirty-day readmission rates were 10.9% and 11.1%, respectively. Variables in RAPSF included: age, female gender, race, insurance, anterior approach, cerebrovascular disease, chronic pulmonary disease, congestive heart failure, diabetes, hemiplegia/paraplegia, rheumatic disease, drug abuse, electrolyte disorder, osteoporosis, depression, obesity, and morbid obesity. Linear regression between readmission rate and RAPSF fits the derivation cohort and validation cohort with an adjusted r2 of 0.92 and 0.94, respectively, and a coefficient of 0.011 (p < 0.001) in both cohorts. CONCLUSION: The RAPSF can accurately predict readmission rates in PSF patients and may be used to guide an evidence-based approach to preoperative optimization and risk adjustment within alternative payment models for elective spine surgery. LEVEL OF EVIDENCE: 3. These slides can be retrieved under Electronic Supplementary Material.

Does Timing of Primary Total Hip Arthroplasty Prior to or After Lumbar Spine Fusion Have an Effect on Dislocation and Revision Rates?

BACKGROUND: Patients undergoing primary total hip arthroplasty (THA) following lumbar spine fusion have an increased incidence of dislocation compared to those without prior lumbar fusion. The purpose of this study is to determine if timing of THA prior to or after lumbar fusion would have an effect on dislocation and revision incidence in patients with both hip and lumbar spine pathology. METHODS: One hundred percent Medicare inpatient claims data from 2005 to 2015 were used to compare dislocation and revision risks in patients with primary THA with pre-existing lumbar spine fusion vs THA with subsequent lumbar spine fusion within 1, 2, and 5 years after the index THA. A total of 42,300 patients met inclusion criteria, 28,668 patients of which underwent THA with pre-existing lumbar spinal fusion (LSF) and 13,632 patients who had prior THA and subsequent LSF. Patients who had THA first followed by LSF were further stratified based on the interval between index THA and subsequent LSF (1, 2, and 5 years), making 4 total groups for comparison. Multivariate cox regression analysis was performed adjusting for age, socioeconomic status, race, census region, gender, Charlson score, pre-existing conditions, discharge status, length of stay, and hospital characteristics. RESULTS: Patients with prior LSF undergoing THA had a 106% increased risk of dislocation compared to those with LSF done 5 years after THA (P < .001). Risk of revision THA was greater in the pre-existing LSF group by 43%, 41%, and 49% at 1, 2, and 5 years post THA compared to the groups with THA done first with subsequent LSF. Dislocation was the most common etiology for revision THA in all groups, but significantly higher in the prior LSF group (26.6%). CONCLUSION: Results of this study demonstrate that sequence of surgical intervention for concomitant lumbar and hip pathology requiring LSF and THA respectively significantly impacts the fate of the THA performed. Patients with prior LSF undergoing THA are at significantly higher risk of dislocation and subsequent revision compared to those with THA first followed by delayed LSF. LEVEL OF EVIDENCE: 3.

Total Hip Arthroplasty in Patients With Previous Lumbar Fusion Surgery: Are There More Dislocations and Revisions?

BACKGROUND: The purpose of this study was to determine whether the risk of dislocation and/or revision following THA is increased in patients with a history of prior lumbar fusion given the alterations in dynamic pelvic motion following LSF. METHODS: A total of 62,387 patients (5% Medicare part B claims database) were identified from 1997 to 2014 with primary THA. From this group, 1809 patients (2.9%) were stratified to identify those with prior lumbar fusion within 5 years of primary THA to compare risk of dislocation and revision with those without lumbar fusion. Multivariate cox regression analysis was performed adjusting for age, socioeconomic status, race, census, region, gender, Charlson score, preexisting conditions, and type of fusion. RESULTS: Between years 2002 and 2014, there was a 293% increase in the number of patients with prior lumbar fusion undergoing THA. Prevalence of hip dislocation in patients with lumbar fusion before THA was 7.4% compared to 4.8% without fusion, P < .001. There was an 80% increase in dislocation in the fusion group at 6 months, 71% at 1 year, and 60% at 2 years. There was a 48% increased risk of failure leading to revision hip surgery in patients with fusion at 6 months, 41% at 1 year, and 47% at 2 years. Dislocation was the most common mode of failure leading to revision in both the fusion group (20.8%) and the nonfusion group (16%). CONCLUSION: Results of this study demonstrate that lumbar fusion before THA is an independent risk factor for dislocation leading to increased risk of revision THA.

Quality of life and disability: can they be improved by active postoperative rehabilitation after spinal fusion surgery in patients with spondylolisthesis? A randomised controlled trial with 12-month follow-up.

PURPOSE: The aim of the study was to investigate the effectiveness of the postoperative 12-month exercise program compared to usual care on disability and health-related quality of life (HRQoL) in patients after lumbar spine fusion surgery (LSF). METHODS: Altogether, 98 patients with isthmic (31) or degenerative (67) spondylolisthesis were randomised to exercise therapy group (EG) (n = 48) or usual care group (UCG) (n = 50) 3 months after LSF. EG patients had home-based progressive strength and aerobic training program for 12 months. UCG patients received only oral and written instructions of exercises. Oswestry Disability Index (ODI) and HRQoL (RAND-36) were evaluated at the time of randomization, at the end of the intervention and 1 year after intervention. RESULTS: The mean ODI score decreased from 24 (12) to 18 (14) in the EG and from 18 (12) to 13 (11) in the UCG during intervention (between-groups p = 0.69). At 1-year follow-up, 25 % of the EG and 28 % of the UCG had an ODI score ≥20. No between-group differences in HRQoL change were found at any time point. The mean (95 % CI) physical functioning dimension of the HRQoL improved by 10.0 (4.6-15.3) in the EG and by 7.8 (2.5-13.0) in the UCG. In addition, the role physical score improved by 20.0 (7.7-32.3) in the EG and by 16.4 (4.4-28.4) in the UCG during the intervention. CONCLUSIONS: The exercise intervention did not have an impact on disability or HRQoL beyond the improvement achieved by usual care. However, disability remained at least moderate in considerable proportion of patients.

Prior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty.

BACKGROUND: Degenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). METHODS: Medicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). RESULTS: Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months (P < .001). CONCLUSION: The interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.

[Nursing Care of Lumbar Spine Fusion Surgery Using a Semi-Rigid Device (ISOBAR)].

Aging frequently induces degenerative changes in the spine. Patients who suffer from lumbar degenerative disease tend to have lower back pain, neurological claudication, and neuropathy. Furthermore, incontinence may be an increasing issue as symptoms become severe. Lumbar spine fusion surgery is necessary if clinical symptoms continue to worsen or if the patient fails to respond to medication, physical therapy, or alternative treatments. However, this surgical procedure frequently induces adjacent segment disease (ASD), which is evidenced by the appearance of pathological changes in the upper and lower sections of the spinal surgical sites. In 1997, ISOBAR TTL dynamic rod stabilization was developed for application in spinal fusion surgery to prevent ASD-related complications. The device has proven effective in reducing pain in the lower back and legs, decreasing functional disability, improving quality of life, and retarding disc degeneration. However, the effectiveness of this intervention in decreasing the incidence of ASD requires further research investigation, and relevant literature and research in Taiwan is still lacking. This article discusses lumbar degenerative disease, its indications, the contraindications of lumbar spine fusion surgery using ISOBAR, and related postoperative nursing care. We hope this article provides proper and new knowledge to clinical nurses for the care of patients undergoing lumbar spine fusion surgery with ISOBAR.

Analyzing Large Language Models' Responses to Common Lumbar Spine Fusion Surgery Questions: A Comparison Between ChatGPT and Bard.

OBJECTIVE: In the digital age, patients turn to online sources for lumbar spine fusion information, necessitating a careful study of large language models (LLMs) like chat generative pre-trained transformer (ChatGPT) for patient education. METHODS: Our study aims to assess the response quality of Open AI (artificial intelligence)'s ChatGPT 3.5 and Google's Bard to patient questions on lumbar spine fusion surgery. We identified 10 critical questions from 158 frequently asked ones via Google search, which were then presented to both chatbots. Five blinded spine surgeons rated the responses on a 4-point scale from 'unsatisfactory' to 'excellent.' The clarity and professionalism of the answers were also evaluated using a 5-point Likert scale. RESULTS: In our evaluation of 10 questions across ChatGPT 3.5 and Bard, 97% of responses were rated as excellent or satisfactory. Specifically, ChatGPT had 62% excellent and 32% minimally clarifying responses, with only 6% needing moderate or substantial clarification. Bard's responses were 66% excellent and 24% minimally clarifying, with 10% requiring more clarification. No significant difference was found in the overall rating distribution between the 2 models. Both struggled with 3 specific questions regarding surgical risks, success rates, and selection of surgical approaches (Q3, Q4, and Q5). Interrater reliability was low for both models (ChatGPT: k = 0.041, p = 0.622; Bard: k = -0.040, p = 0.601). While both scored well on understanding and empathy, Bard received marginally lower ratings in empathy and professionalism. CONCLUSION: ChatGPT3.5 and Bard effectively answered lumbar spine fusion FAQs, but further training and research are needed to solidify LLMs' role in medical education and healthcare communication.

Evaluating the safe zone for lumbar pedicle screws: are midline crossing screws indicative of pedicle breach?

BACKGROUND CONTEXT: Pedicle screw breach (PSB) is not uncommon following lumbar instrumentation, and in some instances, it may lead to vascular and/or neurologic complications. Previous literature suggested that screws crossing the vertebral midline on an anterior-posterior (AP) radiograph (or midsagittal on CT) are concerning for medial pedicle breach. OBJECTIVE: Our primary aim was to map out the safe zones (SZ) of bilateral pedicle instrumentation and their relationship at each lumbar vertebral level. Our secondary aim was to evaluate the presence of SZs' intersection at each lumbar level, denoting safe midline pedicle screw crossing not otherwise associated with medial pedicle breach. STUDY DESIGN/SETTING: Retrospective Anatomical Study. PATIENT SAMPLE: Adult patients in the from "The Cancer Imaging Archive" (TCIA) database who have not had thoraco-lumbo-sacral fusion. OUTCOME MEASURES: Physiologic measures obtained through 3D analysis of CT images and virtual pedicle screws. METHOD: CT scans of 51 patients were randomly selected from "The Cancer Imaging Archive" (TCIA) online database for analysis. The Sectra 3D Spine software was used to create 3D renderings, place virtual screws, and make measurements. At each lumbar vertebra, the right and left pedicle corridors were mapped. At each pedicle, two screw positions were templated, the "medial limit screw" (MLS) and the "lateral limit screw" (LLS). Each limit screw was the most extreme position that the screw could exist in without causing a medial or lateral breach. The safe zone was defined as the zone between MLS and LLS. Measurements were taken for each level (between L1 and L5) and side (Left, Right). RESULTS: A total of 253 lumbar vertebrae from 51 patients (mean age 53.1, 56.9% male) were included. Two vertebrae from two patients were removed for poor image quality. Out of the 506 screw positions analyzed in our study, 97.4% had overlapping SZ and crossed the midplane without medial pedicle breach. The significant factors (p<.01) for safe midplane-crossing screws included: the screw length (L1-L5); the laterality of the screw entry point (L1-L4); and the pedicle diameter (L2 and L5). CONCLUSIONS: A midline crossing pedicle screw on a lumbar AP radiograph is not necessarily indicative of a medial pedicle screw breach. Anatomical (ie, larger pedicle diameter) and technical (ie, longer screws, and lateral entry points) factors allow for safety zone intersections and indicate safe midline crossing by pedicle screws.

Diabetes increases risk of lumbar spinal fusion complications: association with altered structure of newly formed bone at the fusion site.

Diabetes predisposes to spine degenerative diseases often requiring surgical intervention. However, the statistics on the prevalence of spinal fusion success and clinical indications leading to the revision surgery in diabetes are conflicting. The purpose of the presented retrospective observational study was to determine the link between diabetes and lumbar spinal fusion complications using a database of patients (n = 552, 45% male, age 54 ± 13.7 years) residing in the same community and receiving care at the same health care facility. Outcome measures included clinical indications and calculated risk ratio (RR) for revision surgery in diabetes. Paravertebral tissue recovered from a non-union site of diabetic and nondiabetic patients was analyzed for microstructure of newly formed bone. Diabetes increased the RR for revision surgery due to non-union complications (2.80; 95% CI, 1.12-7.02) and degenerative processes in adjacent spine segments (2.26; 95% CI, 1.45-3.53). In diabetes, a risk of revision surgery exceeded the RR for primary spinal fusion surgery by 44% (2.36 [95% CI, 1.58-3.52] vs 1.64 [95% CI, 1.16-2.31]), which was already 2-fold higher than diabetes prevalence in the studied community. Micro-CT of bony fragments found in the paravertebral tissue harvested during revision surgery revealed structural differences suggesting that newly formed bone in diabetic patients may be of compromised quality, as compared with that in nondiabetic patients. In conclusion, diabetes significantly increases the risk of unsuccessful lumbar spine fusion outcome requiring revision surgery. Diabetes predisposes to the degeneration of adjacent spine segments and pseudoarthrosis at the fusion sites, and affects the structure of newly formed bone needed to stabilize fusion.

Is Timing of Total Hip Arthroplasty and Lumbar Spine Fusion Associated With Risk of Hip Dislocation?

Background: In patients with concomitant hip and lumbar spine disease, the question of which surgery-total hip arthroplasty (THA) or lumbar spine fusion (LSF)-to address first has not been adequately answered. We aimed to evaluate the risk of dislocation after THA in patients with LSF first or after THA. Methods: Retrospective review utilizing the PearlDiver database querying Current Procedural Terminology codes for LSF in the year prior (LSF first) or in the year after primary or revision THA (THA first). International Classification of Disease codes identified postoperative hip dislocation as our primary outcome variable. Demographic data collected included age, sex, and obesity. Dislocation rates were described as a proportion of the cohort and compared with chi-square tests. Results: We identified 280,857 primary THA and 42,314 revision THA cases from 2012-2019. Of these, 2090 underwent primary THA and LSF, and 283 underwent revision THA and LSF within a year of each procedure. No differences in age, sex, or obesity between groups were noted. No difference in rate of all-time dislocation for primary THA was noted for the LSF first 51/1429 (3.6%) compared to the THA first 30/661 (4.0%) groups (P = .34), or for revision THA with LSF first 48/204 (23.5%) compared to THA first 27/117 (23.1%) groups (P = 1.0). Conclusions: There was no difference in the risk of dislocation after primary or revision THA if LSF occurred prior to or after the THA. These findings can help surgeons as they counsel patients with concomitant lumbar spine and hip degeneration.

Benefits of lumbar spine fusion surgery reach 10 years with various surgical indications.

Background Context: Lumbar spine fusion (LSF) surgery is a viable form of treatment for several spinal disorders. Treatment effects are preferably to be endorsed in real-life settings. Methods: This prospective study evaluated the 10-year outcomes of LSF. A population-based series of elective LSFs performed at 2 spine centers between January 2008 and June 2012 were enrolled. Surgeries for tumor, acute fracture, or infection, neuromuscular scoliosis, or postoperative conditions were excluded. The following patient-reported outcome measures (PROMs) were collected at baseline, and 1, 2, 5, and 10 years postsurgery: VAS for back and leg pain, ODI, SF-36. Longitudinal measures of PROMs were analyzed using mixed-effects models. Results: A total of 683 patients met the inclusion criteria, and 630 (92%) of them completed baseline and at least 1 follow-up PROMs, and they constituted the study population. Mean age was 61 (SD 12) years, 69% women. According to surgical indication, patients were stratified into degenerative spondylolisthesis (DS, n=332, 53%), spinal stenosis (SS, n=102, 16%), isthmic spondylolisthesis (IS, n=97, 15%), degenerative disc disease (DDD, n=52, 8%), and deformity (DF, n=47, 7%).All diagnostic cohorts demonstrated significant improvement at 1 year, followed by a partial loss of benefits by 10 years. ODI baselines and changes at 1 and 10 years were: (DS) 45, -21, and -14; (SS) 51, -24, and -13; (IS) 41, -24, and -20; (DDD) 50, -20, and -20; and (DF) 50, -21, and -16, respectively. Comparable patterns were seen in pain scores. Significant HRQoL achievements were recorded in all cohorts, greatest in physical domains, but also substantial in mental aspects of HRQoL. Conclusions: Benefits of LSF were partially lost but still meaningful at 10 years of surgery. Long-term benefits seemed milder with degenerative conditions, reflecting the progress of the ongoing spinal degeneration. Benefits were most overt in pain and physical function measures.

Characteristics, comorbidities, and complications in multiple sclerosis (MS) and non-MS patients undergoing lumbar fusion for deformity.

Background: We compared the characteristics, comorbidities, and complications in spinal deformity patients with and without multiple sclerosis (MS) undergoing primary lumbar spine fusion. Methods: We used the Nationwide Inpatient Sample (NIS) from 2003 to 2014, International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes to create experimental MS (842 patients) and non-MS control (165,726 patients) cohorts undergoing primary lumbar spine fusion. Characteristics, comorbidities, and complications in spinal deformity patients with and without MS were evaluated using univariate and bivariate analysis. Results: MS spinal deformity patients undergoing primary lumbar spine fusion were younger, more likely to be female and more likely to undergo surgery at urban teaching hospitals. They also exhibited higher rates of depression and lower rates of diabetes without chronic complications, hypertension, and renal failure. However, no significant differences were found in mortality or total perioperative complication rates between MS and nonMS patients. Conclusion: We found that MS versus non-MS patients undergoing primary lumbar fusion for spinal deformity were younger, more likely to be female and had higher rates of depression but lower rates of diabetes, hypertension, and renal failure. Notably, both groups experienced comparable mortality and perioperative complication rates.

Adoption of Enhanced Surgical Recovery (ESR) Protocol for Lumbar Fusion Decreases In-Hospital Postoperative Opioid Consumption.

STUDY DESIGN: Retrospective observational cohort. OBJECTIVES: We sought to evaluate the impact of ESR on in-hospital and 90-day postoperative opioid consumption, length of stay, urinary catheter removal and postoperative ambulation after lumbar fusion for degenerative conditions. METHODS: We evaluated patients undergoing lumbar fusion surgery at a single, multi-surgeon center in the transition period prior to (N = 174) and after (N = 116) adoption of ESR, comparing in-hospital and 90-day postoperative opioid consumption. Regression analysis was used to control for confounders. Secondary analysis was preformed to evaluate the association between ESR and length of stay, urinary catheter removal and ambulation after surgery. RESULTS: Mean age study participants was 52.6 years with 62 (47%) females. Demographic characteristics were similar between the Pre-ESR and ESR groups. ESR patients had better 3-month pain scores, ambulated earlier, had urinary catheters removed earlier and decreased in-hospital opioid consumption compared to Pre-ESR patients. There was no difference in 90-day opioid consumption between the 2 groups. Regression analysis showed that ESR was strongly associated with in-hospital opioid consumption, accounting for 30% of the variability in Morphine Milligram Equivalents (MME). In-hospital opioid consumption was also associated with preoperative pain scores, number of surgical levels, and insurance type (private vs government). Pre-op pain sores were associated with 90-day opioid consumption. Secondary analysis showed that ESR was associated with a shorter length of stay and earlier ambulation. CONCLUSIONS: This study showed ESR has the potential to improve recovery after lumbar fusion for degenerative conditions with reduced in-hospital opioid consumption and improved postoperative pain scores.

Comparison of standard and modified prone positioning for lateral lumbar spine fusion: a feasibility study to reduce lumbar plexus injury.

Single-prone-lateral (PL) positioning is a new technique that allows for simultaneous anterior and posterior lumbar spine surgery. However, there is a concern regarding the risk of lumbar plexus injury in PL positioning. This study compared the risk of lumbar plexus damage and the overall safety profile of a modified PL (mPL) position to the standard PL (sPL) position for lateral lumbar spine fusion surgery. A crossover soft cadaveric study was conducted with two raters examining the comparative outcomes of position A: sPL and position B: mPL. The mPL position differs from the sPL position in that the ipsilateral arm is placed at the side of the body rather than above the head. To assess positive results (no lumbar plexus injury) between positions A and B, a mixed effects logistic regression model was utilized. The odds ratio of a good result between positions B and A was also determined. The odds ratio of the favorable outcome between position B and A was 1.77, indicating significantly higher odds of a favorable outcome in the modified position B than in the control or position A. The mPL positioning outperformed the sPL positioning in terms of safety and efficacy for lateral lumbar spine fusion. The mPL positioning may reduce the risk of lumbar plexus injury by allowing for a more direct approach to the lumbar spine and by avoiding excessive stretching of the lumbar plexus.