The Effect of Physical Therapy on Time to Discharge After Lumbar Interbody Fusion.

BACKGROUND: With a lesser degree of tissue destruction, patients undergoing minimally-invasive spine surgery are primed to benefit from early mobilization, which can further enhance recovery and hasten rehabilitation. We aimed to determine the role of physical therapy on earlier discharge after minimally-invasive transforaminal lumbar interbody fusion (TLIF). METHODS: Michigan Spine Surgery Improvement Collaborative (MSSIC) provided patients undergoing one- and two-level minimally-invasive TLIF for degenerative lumbar disease. The study population was divided into patients with a one-day length of stay (LOS 1), two days (LOS 2), and three or more days (LOS ≥ 3) to maintain three equal-time cohorts. On POD 0, physical therapy (or, in very rare circumstances, a spine-care-specialized nurse in patients arriving to the in-patient floors late after hours) must evaluate capacity to ambulate. RESULTS: Of the 101 patients, the median day of first ambulation statistically significantly increased from the LOS 1 to LOS ≥ 3 cohort (P = 0.007). Mean distance ambulated decreased from 156.5 ±â€¯123.1 feet in the LOS 1 group, 108.9 ±â€¯83.9 feet in the LOS 2 group, to 69.2 ±â€¯58.3 feet in the LOS ≥ 3 group (P = 0.002). Patient-reported outcomes did not differ among the three cohorts. Following a multivariable ordinal logistical regression controlling for disposition to rehab over home (ORadj = 5.47, P = 0.045), the odds of longer LOS decreased by 39% for every 50-feet ambulated (P = 0.002). CONCLUSIONS: Time to first ambulation independently increases the odds of earlier discharge, regardless of comorbidity burden and surgical determinants.

Facet Arthropathy Following Disc Replacement Versus Rehabilitation: A Prospective Study With 8-Year Follow-Up.

STUDY DESIGN: A prospective study of patients originally randomized to total disc replacement (TDR) or multidisciplinary rehabilitation. OBJECTIVE: To assess the long-term development of facet arthropathy (FA) after TDR versus nonoperative treatment, and to analyze the association between FA and clinical outcome. SUMMARY OF BACKGROUND DATA: FA may appear or increase following TDR, but the natural course of FA is unclear, and no previous study has evaluated the long-term development of FA following TDR compared with nonoperative treatment. METHODS: The study included 126 patients with chronic low back pain and degenerative changes in the lumbar intervertebral discs. The patients underwent pretreatment and 8-year follow-up magnetic resonance imaging (MRI) and 8-year follow-up computed tomography (CT) of the lumbar spine. The primary outcome measure was FA development (yes/no) on MRI at index level L4/L5 or L5/S1, defined as increased FA grade value from pretreatment to follow-up according to Weishaupt grading system. Secondary outcomes included the association between FA (on MRI and CT) and Oswestry Disability Index (ODI) or back pain as well as reoperations. RESULTS: Increased index level FA grade was more frequent after TDR versus nonoperative treatment (36%, 25/69 vs. 2%, 1/57 of patients, P < 0.001), but was not related to change in ODI or back pain. At follow-up, index level FA grades were higher after TDR versus nonoperative treatment (odds ratio 4.0 MRI and 5.9 CT), but were not related to ODI less than or equal to 22. Four patients (6%) treated with TDR and no patients treated nonoperatively were operated for lateral recess stenosis with posterior decompression at the index level during follow-up. CONCLUSION: Index level FA development was more likely after TDR compared with nonoperative treatment but was not associated with the 8-year clinical outcome. Index level FA may have contributed to reoperations in the TDR group. LEVEL OF EVIDENCE: 2.

Perilesional photobiomodulation therapy and physical rehabilitation in post-operative recovery of dogs surgically treated for thoracolumbar disk extrusion.

BACKGROUND: Recent studies have reported contrasting results of the effects of laser therapy on post-operative intervertebral disk herniation, with a lack of evidence-based advantages of this modality within a rehabilitation protocol. The aim of this study was to report the clinical effects of photobiomodulation therapy within a post-operative rehabilitation protocol in dogs submitted to surgery for thoracolumbar disk extrusion. Twenty-four dogs were included in the study (12 dogs treated with laser therapy and rehabilitation protocol and 12 dogs treated with same rehabilitation protocol but without laser therapy). RESULTS: All dogs treated with laser therapy showed improved neurological status (Modified Frankel Score more than 3 within 30 days of physiotherapy starting) if deep nociception on admission was maintained (P = 0.04). However, Kaplan-Meier analysis did not show any statistical difference in time to regain ambulatory ability, although there was a tendency for a shorter mean time of 14.2 ± 8.55 days in the laser group versus 24 ± 18.49 days in the no laser group. CONCLUSIONS: The use of laser therapy in the post-operative rehabilitation of dogs affected by intervertebral disc extrusion and submitted to surgery for spinal decompression could help improve their neurological status.

Case manager-assisted rehabilitation for lumbar spinal fusion patients: an economic evaluation alongside a randomized controlled trial with two-year follow-up.

OBJECTIVE: To examine the cost-effectiveness of case manager-assisted rehabilitation as an add-on to usual physical rehabilitation after lumbar spinal fusion, given the lack of any clinical benefits found on analysing the clinical data. DESIGN: Economic evaluation alongside a randomized controlled trial with two-year follow-up. SETTING: Patients from the outpatient clinics of a university hospital and a general hospital. SUBJECTS: A total of 82 lumbar spinal fusion patients. INTERVENTIONS: Patients were randomized one-to-one to case manager-assisted rehabilitation programme as an add-on to usual physical rehabilitation or to usual physical rehabilitation. MAIN MEASURES: Oswestry Disability Index and EuroQol 5-dimension. Danish preference weights were used to estimate quality-adjusted life years. Costs were estimated from micro costing and national registries. Multiple imputation was used to handle missing data. Costs and effects were presented with means (95% confidence interval (CI)). The incremental net benefit was estimated for a range of hypothetical values of willingness to pay per gain in effects. RESULTS: No impact of case manager-assisted rehabilitation on the Oswestry Disability Index or estimate quality-adjusted life years was observed. Intervention cost was Euros 3984 (3468; 4499), which was outweighed by average reductions in inpatient resource use and sickness leave. A cost reduction of Euros 1716 (-16,651; 20,084) was found in the case manager group. Overall, the probability for the case manager-assisted rehabilitation programme being cost-effective did not exceed a probability of 56%, regardless of willingness to pay. Sensitivity analysis did not change the conclusion. CONCLUSION: This case manager-assisted rehabilitation programme was unlikely to be cost-effective.

Does adding case management to standard rehabilitation affect functional ability, pain, or the rate of return to work after lumbar spinal fusion? A randomized controlled trial with two-year follow-up.

OBJECTIVE: To examine the effect of a case manager-assisted rehabilitation programme as an add-on to usual physical rehabilitation in patients undergoing lumbar spinal fusion. DESIGN: A randomized controlled trial with a two-year follow-up. SETTINGS: Outpatient clinics of a university hospital and a general hospital. SUBJECTS: In total, 82 patients undergoing lumbar spinal fusion. INTERVENTIONS: The patients were randomized one-to-one to case manager-assisted rehabilitation (case manager group) or no case manager-assisted rehabilitation (control group). Both groups received usual physical rehabilitation. The case manager-assisted rehabilitation programme included a preoperative meeting with a case manager to determine a rehabilitation plan, postsurgical meetings, phone meetings, and voluntary workplace visits or roundtable meetings. MAIN MEASURES: Primary outcome was the Oswestry Disability Index. Secondary outcomes were back pain, leg pain, and return to work. RESULTS: Of the 41 patients in the case manager group, 49% were men, with the mean age of 46.1 (±8.7 years). In the control group, 51% were male, with the mean age of 47.4 (±8.9 years). No statistically significant between-group differences were found regarding any outcomes. An overall group effect of 4.1 points (95% confidence interval (CI): -1.8; 9.9) was found on the Oswestry Disability Index, favouring the control group. After two years, the relative risk of return to work was 1.18 (95% CI: 0.8; 1.7), favouring the case manager group. CONCLUSION: The case manager-assisted rehabilitation programme had no effect on the patients' functional disability or back and leg pain compared to usual physical rehabilitation. The study lacked power to evaluate the impact on return to work.

Return to work after surgery for lumbar disc herniation, secondary analyses from a randomized controlled trial comparing supervised rehabilitation versus home exercises.

BACKGROUND CONTEXT: Patients undergoing lumbar discectomy are typically referred for postoperative rehabilitation. However, evidence regarding effectiveness of postoperative rehabilitation to improve surgical outcome and hasten return to work is scarce with conflicting results in the published literature. PURPOSE: This study investigates the effect of postoperative rehabilitation on return to work, duration of sick leave and working ability after surgery for lumbar disc herniation. STUDY DESIGN/SETTING: Single center randomized controlled trial. PATIENT SAMPLE: Patients scheduled for primary discectomy due to lumbar disc herniation were included in the study. OUTCOME MEASURES: Self-reported measures included working ability, work status, and job type defined by the International Standard Classification of Occupations. All outcomes including duration of sick leave were obtained from follow-up questionnaires at 1 and 2 years after surgery. METHODS: This is a secondary analysis from a randomized controlled trial comparing patients who were referred to rehabilitation at the municipal facility starting 4-6 weeks postoperative (REHAB) and patients sent home after surgery without any planned rehabilitation course (HOME). Linear regression was performed to identify baseline characteristics associated with duration of sick leave. RESULTS: One hundred forty-six patients were included and equally distributed between the groups. Follow-up rate was 78% after 1 and 2 years. Both groups had a similar postoperative sick leave period of approximately 9 weeks. After 1 year 79% had returned to work in the HOME-group versus 74% in the REHAB-group, which was not statistically significant. Working ability improved from baseline to 1 year in both groups and this improvement was sustained at 2-year follow-up. Stepwise linear regression showed that preoperative duration of leg pain and working ability was associated with duration of postoperative sick leave. CONCLUSIONS: Referral for unstandardized municipal rehabilitation does not affect duration of postoperative sick leave, return to work or working ability in patients recovering after surgery for lumbar disc herniation. Duration of preoperative leg pain and preoperative working ability was significantly associated with the duration of postoperative sick leave.

Associations between interim patient-reported outcome measures and functional status at discharge from rehabilitation for non-specific lumbar impairments.

PURPOSE: Identify impact of frequency and timing of interim Patient-Reported Outcome Measures (PROMs) assessments during episodes of care for rehabilitation services in outpatient clinical settings on functional status (FS) outcomes at discharge for patients with low back pain. METHODS: FS outcomes of patients who had no interim PROMs were compared to outcomes of six patient groups defined by interim timing (early, mid, late) and frequency (1, 2 or more). For each comparison, patients were matched using propensity score matching for variables known to be associated with FS outcomes and for episode duration (days) and number of visits. FS was assessed using the lumbar computerized adaptive test (LCAT) where scores range from 0 to 100 with higher scores representing better physical function. RESULTS: A sample of 140,336 patients was considered for matching (mean age = 58 [SD = 17] range 18-89; 60% females) with 83,101 patients (59%) having no interim PROMs. Patients who had only one interim PROM, administered during early (first 2 weeks), mid (weeks 3-4), or late (week 5 or later) timing, had 4.6, 2.7, and 1.0 additional FS score points at discharge compared to those without an interim PROM, respectively (p < 0.001). Having two or more interim PROMs was associated with an additional 1.2 FS points compared to having only one interim assessment, but only if the first interim was administered early. CONCLUSIONS: Optimal utilization of interim PROM assessment during clinical practice to enhance treatment outcomes was related to administering the first interim PROM within the first 2 weeks after the initial evaluation.

Discharge Disposition After Anterior Cervical Discectomy and Fusion.

OBJECTIVE: Age and comorbidity burden of patients going anterior cervical discectomy and fusion (ACDF) have increased significantly over the past 2 decades, resulting in increased expenditures. Non-home discharge after ACDF contributes to increased direct and indirect costs of postoperative care. The purpose of this study was to identify independent prognostic factors for discharge disposition in patients undergoing ACDF. METHODS: A retrospective review was conducted at 5 medical centers to identify patients undergoing ACDF for degenerative conditions. The primary outcome was non-home discharge. Additional outcomes considered included discharge to rehabilitation and home discharge with services. Bivariate and multivariable analyses were used to identify independent prognostic factors for non-home discharge. RESULTS: Of 2070 patients undergoing ACDF, 114 (5.5%) had non-home discharge and 63 (3.0%) had discharge to inpatient rehabilitation. Factors independently associated with non-home discharge included older age, marital status, Medicare insurance, Medicaid insurance, previous spine surgery, myelopathy, preoperative comorbidities (hemiplegia/paraplegia, congestive heart failure, cerebrovascular accident), anemia, and leukocytosis. C-statistic for the overall model was 0.85. Results were relatively similar for patients younger than the age of 65 years as well as for discharge to inpatient rehabilitation and discharge home with services. CONCLUSIONS: Numerous sociodemographic and clinical characteristics influence the risk of non-home discharge and discharge to inpatient rehabilitation in patients undergoing ACDF. Policy makers and payers should consider these factors when determining appropriate preoperative adjustment for risk-based reimbursements.

The influence of bilateral pedicle screw fixation on vibration response of the disc degenerated human lumbar spine: A finite element stress analysis.

BACKGROUND: Very few studies have evaluated biomechanical characteristics of the disc degenerated human lumbar spine after bilateral pedicle screw fixation (BPSF) under whole body vibration (WBV) that is typically present in vehicles. OBJECTIVE: To examine the influence of BPSF on stress responses of the disc degenerated human lumbar spine to WBV using finite element (FE) method. METHODS: Two previously validated L1-S1 FE models with different grades of disc degeneration (mild and moderate) at L4-L5 were employed, and the two degenerated models were instrumented with bilateral pedicle screws and rods across the L4-L5 level, respectively. Transit dynamic analyses were performed on all these models under a 400 N compressive follower preload and a 40 N sinusoidal vertical vibration load. Intradiscal pressure (IDP) and von Mises stress (VMS) of the annulus ground substance in all disc levels of the degenerated models and the corresponding implanted models were recorded and compared. RESULTS: BPSF decreased maximum response values and vibration amplitudes of the IDP and annulus VMS in both the degenerated and adjacent levels of the lumbar spine. CONCLUSIONS: Application of the BPSF system is helpful in prevention of further injury of the disc degenerated lumbar spine during WBV.

SURGICAL AND POSTOPERATIVE TREATMENT OF INTERVERTEBRAL DISC DISEASE IN A MOUNTAIN COATI (NASUELLA OLIVACEA) USING BEHAVIORAL MANAGEMENT AND PHYSICAL THERAPY.

A captive 8-yr-old female mountain coati, Nasuella olivacea, presented with intermittent paresis of the pelvic limbs. The coati was anesthetized for radiographs, which showed mineralized discs in the thoracolumbar region. After 3 mo of daily prednisone, its condition further declined. Magnetic resonance imaging confirmed extradural disc herniation, spinal cord compression, and requirement for a left-sided hemilaminectomy. Postoperatively, the coati received prednisolone, gabapentin, tramadol, and clavamox. An established history of positive reinforcement training allowed caretakers to implement physical therapy walks and novel exercises designed for its condition. The coati showed improvement with appropriate proprioceptive positioning and improved balance. Intervertebral disc disease is common in dogs and cats, and although physical therapy is routinely implemented in recovering neurologic patients of those species, it is relatively new in zoologic medicine. This report highlights the benefits of behavioral management in postoperative management of nondomestic species.

Motor Control Training Compared With Transcutaneous Electrical Nerve Stimulation in Patients With Disc Herniation With Associated Radiculopathy: A Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to compare the effectiveness of motor control training and transcutaneous electrical nerve stimulation in relieving pain, reducing functional disability, and improving transversus abdominis activation in patients with lumbar disc herniation with associated radiculopathy. DESIGN: This is a randomized controlled trial. METHODS: Forty patients diagnosed with lumbar disc herniation were randomly divided into two groups: motor control training group (n = 20) and transcutaneous electrical nerve stimulation group (n = 20). INTERVENTIONS: The motor control training group and transcutaneous electrical nerve stimulation group attended 60 mini sessions twice a week for 8 wks, totaling to 16 sessions. MAIN OUTCOME MEASURES: The main outcome measures are pain, functional disability, and transversus abdominis activation capacity. RESULTS: Differences between both groups were observed after 8 wks, favoring the motor control training group. Motor control training was more effective than transcutaneous electrical nerve stimulation in relieving pain (mean difference = 3.3 points, 95% confidence interval = 2.12-4.48), reducing functional disability (mean difference = 8.4 points, 95% confidence interval = 5.44-11.36), improving the quality of pain (mean difference = 17 points, 95% confidence interval = 7.93-26.07), sensory quality of pain (mean difference = 10.3 points, 95% confidence interval = 5.55-15.05), and transversus abdominis activation (mean difference = 1.5 points, 95% confidence interval = 0.90-2.10). CONCLUSIONS: The results suggest that motor control training is more effective than transcutaneous electrical nerve stimulation with respect to relieving pain, reducing functional disability, and improving transversus abdominis activation in patients with lumbar disc herniation.

Adjacent Disc Degeneration After Lumbar Total Disc Replacement or Nonoperative Treatment: A Randomized Study with 8-year Follow-up.

STUDY DESIGN: A randomized controlled multicenter trial with 8-year follow-up. OBJECTIVE: The aim of this study was to assess the long-term development of adjacent disc degeneration (ADD) after lumbar total disc replacement (TDR) or nonoperative treatment, and to analyze the association between ADD development and clinical outcome. SUMMARY OF BACKGROUND DATA: TDR was introduced as a motion-preserving alternative to spinal fusion, which has been reported to increase the risk of ADD. However, ADD may develop naturally regardless of any surgery, and no randomized study has assessed the long-term development of ADD after TDR versus nonoperative treatment. METHODS: The study included 126 of the 173 patients with chronic low back pain (LBP) originally included in a randomized study comparing TDR with multidisciplinary rehabilitation. Magnetic resonance imaging (MRI) of the lumbar spine was performed before treatment and at 8-year follow-up. ADD was categorized as increased or not increased based on an evaluation of Modic changes, disc height reduction, disc contour, herniation size, nucleus pulposus signal, and posterior high intensity zones. We used a χ test or a Fisher exact test to compare crude proportions, and multiple linear regressions to analyze the association between increased ADD (yes/no) and change in Oswestry Disability Index (ODI) from pre-treatment to follow-up. RESULTS: ADD increased (for at least one ADD variable) in 23 of 57 patients (40%) treated nonoperatively, and 29 of 69 patients (42%) treated with TDR (P = 0.86). We found no significant associations between ADD increase and the change in ODI. CONCLUSION: Increased ADD occurred with similar frequency after TDR and after nonoperative treatment, and was not related to the clinical outcome at 8-year follow-up. LEVEL OF EVIDENCE: 1.

Structured postoperative physiotherapy in patients with cervical radiculopathy: 6-month outcomes of a randomized clinical trial.

OBJECTIVE Structured physiotherapy has been suggested as treatment before as well as after surgery to improve clinical outcomes in patients with cervical radiculopathy (CR), but randomized clinical trials to inform evidence-based clinical guidelines for the treatment of patients with CR after surgery are lacking. The aim of this study was to compare the results of structured postoperative physiotherapy combining neck-specific exercises with a behavioral approach to a standard postoperative approach in patients who had undergone surgery for cervical disc disease with CR at 6 months after surgery. METHODS Patients with cervical disc disease and persistent CR who were scheduled for surgery were randomized preoperatively to structured postoperative physiotherapy (n = 101) or a standard postoperative approach (n = 100). The latter included pragmatic physiotherapy in accordance with the usual Swedish postoperative care. Outcome measures included patient-reported neck disability as measured with the Neck Disability Index (NDI), intensity and frequency of neck and arm pain, global outcome of treatment, and expectation fulfillment, as well as enablement. RESULTS Patients who received structured postoperative physiotherapy reported greater expectation fulfillment (p = 0.01), and those who attended at least 50% of the treatment sessions reported less neck pain frequency (p = 0.05), greater expectation fulfillment (p = 0.001), and greater enablement (p = 0.04) compared with patients who received the standard postoperative approach. No other difference between treatment groups was found (p > 0.15). The NDI and neck and arm pain intensity were improved in both groups at 6 months after surgery (p < 0.001). Additional use of postoperative physiotherapy was reported by 61% of the patients who received the standard postoperative approach. CONCLUSIONS The results from this first randomized clinical trial of postoperative physiotherapy showed only minor additional benefit of structured postoperative physiotherapy compared with standard postoperative approach 6 months postoperatively in patients who underwent surgery for cervical disc disease with CR. Patients who received structured postoperative physiotherapy reported higher expectation fulfillment, and many patients in the standard postoperative approach group perceived a need for additional treatments after surgery, suggesting that patients with CR are in need of further postoperative support. The results confirm that neck-specific exercises are tolerated postoperatively by patients with CR, but more studies of postoperative physiotherapy are needed to inform clinical guidelines for this patient group. Clinical trial registration no.: NCT01547611 (clinicaltrials.gov).

Surgical versus non-operative treatment for lumbar disc herniation: a systematic review and meta-analysis.

OBJECTIVE: To investigate the effects of surgical versus non-operative treatment on the physical function and safety of patients with lumbar disc herniation. DATA SOURCES: PubMed, Cochrane Library, Embase, EBSCO, Web of Science, China National Knowledge Infrastructure and Chinese Biomedical Literature Database were searched from initiation to 15 May 2017. METHODS: Randomized controlled trials that evaluated surgical versus non-operative treatment for patients with lumbar disc herniation were selected. The primary outcomes were pain and side-effects. Secondary outcomes were function and health-related quality of life. A random effects model was used to calculate the pooled mean difference with 95% confidence interval. RESULTS: A total of 19 articles that involved 2272 participants met the inclusion criteria. Compared with non-operative treatment, surgical treatment was more effective in lowering pain (short term: mean difference = -0.94, 95% confidence interval = -1.87 to -0.00; midterm: mean difference = -1.59, 95% confidence interval = -2.24 to -9.94), improving function (midterm: mean difference = -7.84, 95% confidence interval = -14.00 to -1.68; long term: mean difference = -12.21, 95% confidence interval = -23.90 to -0.52) and quality of life. The 36-item Short-Form Health Survey for physical functions (short term: mean difference = 6.25, 95% confidence interval = 0.43 to 12.08) and bodily pain (short term: mean difference = 5.42, 95% confidence interval = 0.40 to 10.45) was also utilized. No significant difference was observed in adverse events (mean difference = 0.82, 95% confidence interval = 0.28 to 2.38). CONCLUSION: Low-quality evidence suggested that surgical treatment is more effective than non-operative treatment in improving physical functions; no significant difference was observed in adverse events. No firm recommendation can be made due to instability of the summarized data.

Cervical stability training with and without core stability training for patients with cervical disc herniation: A randomized, single-blind study.

BACKGROUND: This study aims at evaluating and comparing the effects of cervical stability training to combined cervical and core stability training in patients with neck pain and cervical disc herniation. METHODS: Fifty patients with neck pain and cervical disc herniation were included in the study, randomly divided into two groups as cervical stability and cervical-core stability. Training was applied three times a week in three phases, and lasted for a total duration of 8 weeks. Pain, activation and static endurance of deep cervical flexor muscles, static endurance of neck muscles, cross-sectional diameter of M. Longus Colli, static endurance of trunk muscles, disability and kinesiophobia were assessed. RESULTS: Pain, activation and static endurance of deep cervical flexors, static endurance of neck muscles, cross-sectional diameter of M. Longus Colli, static endurance of trunk muscles, disability and kinesiophobia improved in both groups following the training sessions (p < 0.05). Comparison of the effectiveness of these two training methods revealed that the cervical stability group produced a greater increase in the right transverse diameter of M. Longus Colli (p < 0.05). However, static endurance of trunk muscles and kinesiophobia displayed better improvement in the cervical-core stability group (p < 0.05). CONCLUSIONS: Cervical stability training provided benefit to patients with cervical disc herniation. The addition of core stability training did not provide any additional significant benefit. Further research is required to investigate the efficacy of combining other techniques with cervical stability training in patients with cervical disc herniation. SIGNIFICANCE: Both cervical stability training and its combination with core stability training were significantly and similarly effective on neck pain and neck muscle endurance in patients with cervical disc herniation.

Comprehensive comparing percutaneous endoscopic lumbar discectomy with posterior lumbar internal fixation for treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis: A retrospective case-control study.

The study was to comprehensively compare the postoperative outcome and imaging parameter characters in a short/middle period between the percutaneous endoscopic lumbar discectomy (PELD) and the internal fixation of bone graft fusion (the most common form is posterior lumbar interbody fusion [PLIF]) for the treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis after a previous lumbar internal fixation surgery.In this retrospective case-control study, we collected the medical records from 11 patients who received PELD operation (defined as PELD group) for and from 13 patients who received the internal fixation of bone graft fusion of lumbar posterior vertebral lamina decompression (defined as control group) for the treatment of the lumbar disc prolapse combined with stable retrolisthesis at Department of Spine Surgery, the Third Hospital of Hebei Medical University (Shijiazhuang, China) from May 2010 to December 2015. The operation time, the bleeding volume of perioperation, and the rehabilitation days of postoperation were compared between 2 groups. Before and after surgery at different time points, ODI, VAS index, and imaging parameters (including Taillard index, inter-vertebral height, sagittal dislocation, and forward bending angle of lumbar vertebrae) were compared.The average operation time, the blooding volume, and the rehabilitation days of postoperation were significantly less in PELD than in control group. The ODI and VAS index in PELD group showed a significantly immediate improving on the same day after the surgery. However, Taillard index, intervertebral height, sagittal dislocation in control group showed an immediate improving after surgery, but no changes in PELD group till 12-month after surgery. The forward bending angle of lumbar vertebrae was significantly increased and decreased in PELD and in control group, respectively.PELD operation was superior in terms of operation time, bleeding volume, recovery period, and financial support, if compared with lumbar internal fixation operation. Radiographic parameters reflect lumber structure changes, which could be observed immediately after surgery in both methods; however, the recoveries on nerve function and pain relief required a longer time, especially after PLIF operation.

Predictors of extended length of stay, discharge to inpatient rehab, and hospital readmission following elective lumbar spine surgery: introduction of the Carolina-Semmes Grading Scale.

OBJECTIVE Extended hospital length of stay (LOS), unplanned hospital readmission, and need for inpatient rehabilitation after elective spine surgery contribute significantly to the variation in surgical health care costs. As novel payment models shift the risk of cost overruns from payers to providers, understanding patient-level risk of LOS, readmission, and inpatient rehabilitation is critical. The authors set out to develop a grading scale that effectively stratifies risk of these costly events after elective surgery for degenerative lumbar pathologies. METHODS The Quality and Outcomes Database (QOD) registry prospectively enrolls patients undergoing surgery for degenerative lumbar spine disease. This registry was queried for patients who had undergone elective 1- to 3-level lumbar surgery for degenerative spine pathology. The association between preoperative patient variables and extended postoperative hospital LOS (LOS ≥ 7 days), discharge status (inpatient facility vs home), and 90-day hospital readmission was assessed using stepwise multivariate logistic regression. The Carolina-Semmes grading scale was constructed using the independent predictors for LOS (0-12 points), discharge to inpatient facility (0-18 points), and 90-day readmission (0-6 points), and its performance was assessed using the QOD data set. The performance of the grading scale was then confirmed separately after using it in 2 separate neurosurgery practice sites (Carolina Neurosurgery & Spine Associates [CNSA] and Semmes Murphey Clinic). RESULTS A total of 6921 patients were analyzed. Overall, 290 (4.2%) patients required extended LOS, 654 (9.4%) required inpatient facility care/rehabilitation on hospital discharge, and 474 (6.8%) were readmitted to the hospital within 90 days postdischarge. Variables that remained as independently associated with these unplanned events in multivariate analysis included age ≥ 70 years, American Society of Anesthesiologists Physical Classification System class > III, Oswestry Disability Index score ≥ 70, diabetes, Medicare/Medicaid, nonindependent ambulation, and fusion. Increasing point totals in the Carolina-Semmes scale effectively stratified the incidence of extended LOS, discharge to facility, and readmission in a stepwise fashion in both the aggregate QOD data set and when subsequently applied to the CNSA/Semmes Murphey practice groups. CONCLUSIONS The authors introduce the Carolina-Semmes grading scale that effectively stratifies the risk of prolonged hospital stay, need for postdischarge inpatient facility care, and 90-day hospital readmission for patients undergoing first-time elective 1- to 3-level degenerative lumbar spine surgery. This grading scale may be helpful in identifying patients who may require additional resource utilization within a global period after surgery.

Fat in the lumbar multifidus muscles - predictive value and change following disc prosthesis surgery and multidisciplinary rehabilitation in patients with chronic low back pain and degenerative disc: 2-year follow-up of a randomized trial.

BACKGROUND: Evidence is lacking on whether fat infiltration in the multifidus muscles affects outcomes after total disc replacement (TDR) surgery and if it develops after surgery. The aims of this study were 1) to investigate whether pre-treatment multifidus muscle fat infiltration predicts outcome 2 years after treatment with TDR surgery or multidisciplinary rehabilitation, and 2) to compare changes in multifidus muscle fat infiltration from pre-treatment to 2-year follow-up between the two treatment groups. METHODS: The study is secondary analysis of data from a trial with 2-year follow-up of patients with chronic low back pain (LBP) and degenerative disc randomized to TDR surgery or multidisciplinary rehabilitation. We analyzed (aim 1) patients with both magnetic resonance imaging (MRI) at pre-treatment and valid data on outcome measures at 2-year follow-up (predictor analysis), and (aim 2) patients with MRI at both pre-treatment and 2-year follow-up. Outcome measures were visual analogue scale (VAS) for LBP, Oswestry Disability Index (ODI), work status and muscle fat infiltration on MRI. Patients with pre-treatment MRI and 2-year outcome data on VAS for LBP (n = 144), ODI (n = 147), and work status (n = 137) were analyzed for prediction purposes. At 2-year follow-up, 126 patients had another MRI scan, and change in muscle fat infiltration was compared between the two treatment groups. Three radiologists visually quantified multifidus muscle fat in the three lower lumbar levels on MRI as <20% (grade 0), 20-50% (grade 1), or >50% (grade 2) of the muscle cross-section containing fat. Regression analysis and a mid-P exact test were carried out. RESULTS: Grade 0 pre-treatment multifidus muscle fat predicted better clinical results at 2-year follow-up after TDR surgery (all outcomes) but not after rehabilitation. At 2-year follow-up, increased fat infiltration was more common in the surgery group (intention-to-treat p = 0.03, per protocol p = 0.08) where it was related to worse pain and ODI. CONCLUSIONS: Patients with less fat infiltration of multifidus muscles before TDR surgery had better outcomes at 2-year follow-up, but findings also indicated a negative influence of TDR surgery on back muscle morphology in some patients. The rehabilitation group maintained their muscular morphology and were unaffected by pre-treatment multifidus muscle fat. TRIAL REGISTRATION: NCT 00394732 (retrospectively registered October 31, 2006).

The role of physical therapy and rehabilitation after lumbar fusion surgery for degenerative disease: a systematic review.

OBJECTIVE The purpose of this study was to provide a systematic and comprehensive review of the existing literature regarding postfusion rehabilitation. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the authors conducted an exhaustive review of multiple electronic databases. Potential articles were screened using inclusion/exclusion criteria. Two authors independently analyzed these studies using predefined data fields, including study quality indicators such as level of evidence and availability of accepted patient-reported outcomes measures. These findings were synthesized in a narrative format. A third author resolved disagreements regarding the inclusion of a study. RESULTS Twenty-one articles with I or II levels of evidence were included in the review. The authors divided the findings of the literature review into several groups: rehabilitation terminology, timing and duration of postfusion rehabilitation, the need for rehabilitation relative to surgery-related morbidity, rehabilitation's relationship to outcomes, and cognitive and psychosocial aspects of postsurgical rehabilitation. Current evidence generally supports formal rehabilitation after lumbar fusion surgery. Starting physical therapy at the 12-week postoperative mark results in better outcomes at lower cost than an earlier, 6-week start. Where available, psychosocial support improves outcomes. However, a number of the questions could not be answered with high-grade evidence. In these cases, the authors used "best evidence available" to make recommendations. There are many cases in which different types of caregivers use clinical terminology differently. The data supporting an optimal protocol for postfusion rehabilitation remains elusive but, using the data available, the authors have crafted recommendations and a model protocol, which is currently undergoing prospective study. CONCLUSIONS Rehabilitation has long been a common feature in the postoperative management of patients undergoing spinal fusion. Although caregivers from multiple disciplines agree that the majority of their patients will benefit from this effort, the supporting data remain sparse. In creating a model protocol for postlumbar fusion rehabilitation, the authors hope to share a starting point for future postoperative lumbar fusion rehabilitation research.

A Rehabilitation Protocol for Patients with Lumbar Degenerative Disc Disease Treated with Posterior Transpedicular Dynamic Stabilization.

AIM: To evaluate the efficacy of the rehabilitation protocol on patients with lumbar degenerative disc disease after posterior transpedicular dynamic stabilization (PTDS) surgery. MATERIAL AND METHODS: Patients (n=50) with single level lumbar degenerative disc disease were recruited for this study. Patients had PTDS surgery with hinged screws. A rehabilitation program was applied for all patients. Phase 1 was the preoperative evaluation phase. Phase 2 (active rest phase) was the first 6 weeks after surgery. During phase 3 (minimal movement phase, 6-12 weeks) pelvic tilt exercises initiated. In phase 4 (dynamic phase, 3-6 months) dynamic lumbar stabilization exercises were started. Phase 5 (return to sports phase) began after the 6th month. The primary outcome criteria were the Visual Analogue Pain Score (VAS) and the Oswestry Disability Index (ODI). Patients were evaluated preoperatively, postoperative 3rd, 12th and 24th months. RESULTS: The mean preoperative VAS and ODI scores were 7.52±0.97 and 60.96±8.74, respectively. During the 3rd month, VAS and ODI scores decreased to 2.62±1.05 and 26.2±7.93, respectively. VAS and ODI scores continued to decrease during the 12th month after surgery to 1.4±0.81 and 13.72±6.68, respectively. At the last follow-up (mean 34.1 months) the VAS and ODI scores were found to be 0.68±0.62 and 7.88±3.32, respectively. (p=0.0001). CONCLUSION: The protocol was designed for a postoperative rehabilitation program after PTDS surgery for patients with lumbar degenerative disc disease. The good outcomes are the result of a combination of very careful and restrictive patient selection, surgical technique, and the presented rehabilitation program.