The effect of subcutaneous fat and skin-to-lamina distance on complications and functional outcomes of minimally invasive lumbar decompression.

PURPOSE: Minimally invasive lumbar decompression (MIS) in obese pzatients is technically challenging due to the use of longer tube retractors. The purpose of this study was to evaluate the impact of the thickness of the soft tissue and subcutaneous fat on complications, revisions, and patient-reported functional outcomes after MIS. METHODS: This is a retrospective analysis of 148 consecutive patients who underwent minimally invasive lumbar decompression at our institute between 2013 and 2017 and had at least one year of follow-up. Analysis was performed five times, each time the study group was defined by another measure of adiposity: BMI > 30, skin to lamina distance at the site of surgery and at L4 > 6 cm, and subcutaneous fat thickness at the site of surgery and at L4 > 3 cm. Outcomes included intraoperative complications (durotomy or neurological deficit), possibly inadequate decompression (residual disc, reoperation), length of stay, return to the emergency room or readmission, postoperative medical complications, and functional outcomes: visual analog scores for back and leg pain, and Oswestry Disability Index (ODI). RESULTS: Patients with a thicker layer soft tissue had a significantly higher burden of comorbidities than controls, including higher prevalence of cardiovascular disease (p = 0.002), diabetes (p < 0.001), hypertension (p < 0.001) and higher ASA scores (p = 0.002). Nevertheless, there was no significant difference between the patient groups in surgical and medical complications, functional outcomes, and other assessed outcomes. CONCLUSION: Our results indicate that minimally invasive lumbar decompression is safe and effective for patients with a thick layer of soft tissue and subcutaneous fat.

Facet overhang: A novel parameter in the pathophysiology of multifidus muscle atrophy.

The relationship between degenerative zygapophysial joint (facet) arthropathy and multifidus muscle atrophy has not been rigorously evaluated. The purpose of this study was to determine if specific morphological features of degenerative facet arthropathy are correlated with multifidus muscle atrophy. We retrospectively reviewed medical records and imaging studies of patients with lumbar spinal stenosis. Facet overhang, bridging osteophyte formation, facet effusion, and facet angles were evaluated by univariable and multivariable regression to identify independent associations with deep and superficial parts of the multifidus total cross-sectional area (tCSA), functional cross-sectional area (fnCSA), and fatty infiltration (FI). Facet overhang was classified as severe in 50 females (53.2%) versus 56 males (36.9%) (p = 0.030). Severity of facet overhang and female sex were independently associated with smaller deep part of the multifidus tCSA and fnCSA as well as higher FI, reflecting greater atrophy of the deep region compared to total muscle mass. In comparison, severe facet overhang (p < 0.001; OR = 3.47, 95% CI = 2.13-5.66) and female sex (p < 0.001; OR = 4.19, 95% CI = 2.58-6.79) were independently associated only with higher superficial part of the multifidus FI, reflecting muscle steatosis without significant lean muscle atrophy. In patients with degenerative lumbar spinal stenosis, facet overhang is an independent risk factor for deep part of the multifidus atrophy. Bridging osteophyte formation, facet effusion, and facet angles were not independently associated with deep part of the multifidus atrophy.

Minimally Invasive Resection of Benign Osseous Tumors of the Spinal Column: 10 Years' Experience and Long-Term Outcomes of a Specialized Center.

Background and Objectives: Benign osseous tumors of the spinal column comprise about 10% of all spinal tumors and are rare cause for surgery. However, these tumors pose various management challenges and conventional surgery may be associated with significant morbidity. Previous reports on minimally invasive resection of these lesions are rare. We report a series of patients managed by total resection of benign osseous spine tumors using MIS techniques. Surgical decisions and technical considerations are discussed. Materials and Methods: A retrospective evaluation of prospectively collected data of patients who underwent minimally invasive surgery for removal of benign osseous vertebral tumors. Demographic, clinical and radiographic features, operative details and final pathological reports were summarized. Primary outcomes were completeness of tumor resection and pain relief assessed by VAS for back and leg pain. Secondary outcome measures were recurrence of tumor on repeat post-operative MRI and postoperative unstable deformity on standing scoliosis X-rays. Results: This series included 32 cases of primary osseous spine tumors resected by minimally invasive techniques. There were 17 males and 15 females aged 5-68 years (mean 23.3). The follow-up period was 8-90 months (mean 32 months) and the preoperative symptoms duration was 9-96 months. Axial spinal pain was the presenting symptom in all the patients. Five patients also complained about radicular pain and four patients had antalgic scoliosis. The tumor involved the thoracic spine in 12 cases, the lumbar segment in 11, the cervical in 5 and the sacral area in 4 cases. Complete tumor removal was performed in all patients. No procedure-related complications were encountered. Histopathology showed osteoid osteoma in 24 patients, osteoblastoma in 5 patients, and fibrous dysplasia, fibroadenoma and eosinophilic granuloma in one case each. All patients experienced significant pain relief after surgery, and had stopped pain medications by 12 months postoperatively. No patient suffered from tumor recurrence or spinal deformity. Conclusions: Minimally invasive surgery is feasible for total removal of selected benign vertebral tumors and may have some advantages over conventional surgical techniques.

Stable Low-Grade Degenerative Spondylolisthesis Does Not Compromise Clinical Outcome of Minimally Invasive Tubular Decompression in Patients with Spinal Stenosis.

Background and Objectives: In recent literature, the routine addition of arthrodesis to decompression for lumbar spinal stenosis (LSS) with concomitant stable low-grade degenerative spondylolisthesis remains controversial. The purpose of this study is to compare the clinical outcome, complication and re-operation rates following minimally invasive (MIS) tubular decompression without arthrodesis in patients suffering from LSS with or without concomitant stable low-grade degenerative spondylolisthesis. Materials and Methods: This study is a retrospective review of prospectively collected data. Ninety-six consecutive patients who underwent elective MIS lumbar decompression with a mean follow-up of 27.5 months were included in the study. The spondylolisthesis (S) group comprised 53 patients who suffered from LSS with stable degenerative spondylolisthesis, and the control (N) group included 43 patients suffering from LSS without spondylolisthesis. Outcome measures included complications and revision surgery rates. Pre- and post-operative visual analog scale (VAS) for both back and leg pain was analyzed, and the Oswestry Disability Index (ODI) was used to evaluate functional outcome. Results: The two groups were comparable in most demographic and preoperative variables. VAS for back and leg pain improved significantly following surgery in both groups. Both groups showed significant improvement in their ODI scores, at one and two years postoperatively. The average length of hospital stay was significantly higher in patients with spondylolisthesis (p-value< 0.01). There was no significant difference between the groups in terms of post-operative complications rates or re-operation rates. Conclusions: Our results indicate that MIS tubular decompression may be an effective and safe procedure for patients suffering from LSS, with or without degenerative stable spondylolisthesis.

Long-Term Pain Characteristics and Management Following Minimally Invasive Spinal Decompression and Open Laminectomy and Fusion for Spinal Stenosis.

Background and Objectives: To compare the long-term pain characteristics and its chronic management following minimally invasive spinal (MIS) decompression and open laminectomy with fusion for lumbar stenosis. Materials and Methods: The study cohort included patients with a minimum 5-year postoperative follow-up after undergoing either MIS decompression or laminectomy with fusion for spinal claudication. The primary outcome of interest was chronic back and leg pain intensity. Secondary outcome measures included pain frequency during the day, chronic use of non-opioid analgesics, narcotic medications, medical cannabinoids, and continuous interventional pain treatments. Results: A total of 95 patients with lumbar spinal stenosis underwent one- or two-level surgery for lumbar spinal stenosis between April 2009 and July 2013. Of these, 50 patients underwent MIS decompression and 45 patients underwent open laminectomy with instrumented fusion. In the fusion group, a higher percentage of patients experienced moderate-to-severe back pain with 48% compared to 21.8% of patients in the MIS decompression group (p < 0.01). In contrast, we found no significant difference in the reported leg pain in both groups. In the fusion group, 20% of the patients described their back and leg pain as persistent throughout the day compared to only 2.2% in the MIS decompression group (p < 0.05). A trend toward higher chronic dependence on analgesic medication and repetitive pain clinic treatments was found in the fusion group. Conclusions: MIS decompression for the treatment of degenerative spinal stenosis resulted in decreased long-term back pain and similar leg pain outcomes compared to open laminectomy and instrumented fusion surgery.

Spinal manifestations of Neurofibromatosis type 1.

BACKGROUND: Neurofibromatosis type 1 (NF1) patients may present a wide spectrum of spinal pathologies. Osseous changes may lead to severe deformities with significant implications on growth and quality of life. Neurogenic tumors and soft tissue abnormalities may cause neuropathic pain and dysfunction ranging from minor paresthesias to profound motor and sensory deficits. Advanced imaging such as whole-body MRI, and volumetric tumor burden assessment have an evolving role in the evaluation and follow-up of patients with high spinal tumor load. Novel biological agents that target the hyperactivated ras pathway are currently under investigation and are reshaping current and future treatment paradigms. Surgical interventions for benign and malignant tumors, as well as deformity correction remain pivotal in treatment frameworks and require careful assessment by a dedicated multidisciplinary team. PURPOSE: In this manuscript we review the various spinal manifestations of NF1 patients, indication for surgical intervention and oncological treatments.

Acute Presentation of Cervical Myelopathy Following Manipulation Therapy.

BACKGROUND: Spinal manipulation therapy (SMT) is commonly used as an effective therapeutic modality for a range of cervical symptoms. However, in rare cases, cervical manipulation may be associated with complications. In this review we present a series of cases with cervical spine injury and myelopathy following therapeutic manipulation of the neck, and examine their clinical course and neurological outcome. We conducted a search for patients who developed neurological symptoms due to cervical spinal cord injury following neck SMT in the database of a spinal unit in a tertiary hospital between the years 2008 and 2018. Patients were assessed for the clinical course and deterioration, type of manipulation used and subsequent management. A total of four patients were identified, two men and two women, aged 32-66 years. In three patients neurological deterioration appeared after chiropractic adjustment and in one patient after tuina therapy. Three patients were managed with anterior cervical discectomy and fusion while one patient declined surgical treatment. Assessment for subjective and objective evidence of cervical myelopathy should be performed prior to cervical manipulation, and suspected myelopathic patients should be sent for further workup by a specialist familiar with cervical myelopathy (such as a neurologist, a neurosurgeon or orthopedic surgeon who specializes in spinal surgery). Nevertheless, manipulation therapy remains an important and generally safe treatment modality for a variety of cervical complaints. This review does not intend to discard the role of SMT as a significant part in the management of patients with neck related symptoms, rather it is meant to draw attention to the need for careful clinical and imaging investigation before treatment.

Effect of Fibromyalgia Symptoms on Outcome of Spinal Surgery.

Objectives: To evaluate the effect of presurgical symptoms characteristic of fibromyalgia on the postsurgical outcome of patients undergoing spinal surgery. Methods: In this observational cohort study, participants were patients scheduled for spinal surgery, including cervical or lumbar laminectomy and foraminectomy. Presurgical evaluation included physical examination and manual dolorimetry. Questionnaires included the widespread pain index (WPI), symptom severity scale (SSS), and SF-36. Postsurgical evaluation performed at 10-12 weeks included questionnaires, physical examination, and dolorimetry. Results: Forty patients (21 male, 19 female) were recruited. Four patients (10%) fulfilled American College of Rheumatology (ACR) 1990 fibromyalgia; nine patients fulfilled 2010 criteria (22.5%). Overall, a significant 34% reduction in WPI was observed postsurgically ( P < 0.01), but no significant change was observed in SSS. Comparing outcomes for patients fulfilling and not fulfilling fibromyalgia criteria, fibromyalgia syndrome (FMS)-negative patients experienced highly significant reductions of both SSS and WPI (-50.1% and -42.9%, respectively, P < 0.01), while FMS-positive patients experienced no reduction of SSS symptoms and only a marginally significant reduction in WPI (-20.3%, P = 0.04). A significant negative correlation was observed between results of presurgical WPI and change in physical role functioning SF-36 component postsurgically. A significant negative correlation was observed between presurgical SSS and change in composite physical functioning SF-36 component. Regression analysis demonstrated a difference in trend between FMS-positive and FMS-negative patients regarding postop changes in SSS, as well as a difference in trend regarding the general health role limitation due to emotional problems and pain components of the SF-36. Conclusions: Fibromyalgia symptoms were highly prevalent among patients scheduled for spinal surgery. A negative correlation was observed between presurgical severity of fibromyalgia symptoms and components of postsurgical SF-36. Patients with symptoms typical of fibromyalgia may have a less favorable outcome after spinal surgery. The clinical utility of surgical intervention in such patients should be carefully evaluated, and treatment specific for fibromyalgia might be considered before embarking on a surgical course.

Prevalence and awareness of sacroiliac joint alterations on lumbar spine CT in low back pain patients younger than 40 years.

Background Computed tomography (CT) examinations of the lumbar spine are commonly performed in patients aged ≤40 years due to low back pain (LBP). Purpose To investigate the prevalence and awareness of radiologists for the presence of structural post-inflammatory/other sacroiliac joint (SIJ) alterations on lumbar spine CTs of young patients with LBP. Material and Methods A total of 484 lumbar spine CT examinations (272 men, 212 women; average age, 31 years; age range, 18-40 years) of patients with LBP in which the entire SIJs were visualized were retrospectively reviewed. SIJs were scored (consensus) by two senior radiologists (study reading) for the presence of post-inflammatory structural SIJ findings or other SIJs alterations. The original reports were compared to the study reading. Fifty CT examinations were re-evaluated for reliability assessment (intra-class correlation coefficient [ICC]). Results A total of 150 (31%) abnormal SIJ examinations were registered (ICC: r = 0.7-0.8; P < 0.0001): suspected sacroiliitis = 50 (10.2%); definite sacroiliitis = 16 (3.3%); osteitis-condensans-ilii = 38 (7.8%); diffuse idiopathic skeletal hyperostosis = 24 (5%); degenerative changes = 22 (4.5%); accessory SIJ = 22 (4.5%); and tumor = 1. The SIJs were referenced 39 times (8.0%) in the original readings: pathological findings (n = 15); and normal SIJ (n = 24). Total diagnostic accuracy for these reports only and for the entire readings were 49% and 69%, respectively, and 13% and 1.3%, respectively, for the pathological findings. Conclusion Sacroiliitis and other SIJ alterations are prevalent in young individuals with LBP, albeit, the majority of these alterations are not recognized nor reported by senior radiologists thus may delay efficacious treatment.

Electrophysiological monitoring during preoperative angiography to guide decisions regarding permanent occlusion of major radicular arteries in patients undergoing total en bloc spondylectomy.

OBJECTIVE Preoperative embolization is performed before spine tumor surgery when significant intraoperative hemorrhage is anticipated. Occlusion of radicular and segmental arteries may result in spinal ischemia. The goal of this study was to check whether neurophysiological monitoring during preoperative angiography in patients scheduled for total en bloc spondylectomy (TES) of spine tumors improves the safety of vessel occlusion. METHODS This was a case series study of patients who underwent tumor embolization under somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring in preparation for TES in treating spine tumors. The angiography findings, the embolized vessels, and the results are presented. RESULTS Five patients whose ages ranged from 33 to 75 years and who had thoracic spine tumors are reported. Four patients suffered from primary tumor and 1 patient had a metastatic tumor. Radicular arteries at the tumor level, 1 level above, and 1 level below were permanently occluded when SSEPs and MEPs were preserved during temporary occlusion. No complications were encountered during or after the angiography procedure and embolization. CONCLUSIONS Temporary occlusion with electrophysiological monitoring during preoperative angiography may improve the safety of permanent radicular artery occlusion, including the artery of Adamkiewicz in patients undergoing TES for the treatment of spine tumors.

Total en bloc spondylectomy for vertebral tumors.

BACKGROUND: Most spine tumors are resistant to radiation and chemotherapy. Complete surgical removal provides the best chance for long-term control of the tumor. Total en bloc spondylectomy (TES) is a radical new technique that entails total removal of the tumor and affected vertebras with clean margins. OBJECTIVES: To review our initial experience with TES, focusing on feasibility, surgical challenges and the short-term outcome. METHODS: We retrospectively reviewed the hospitalization charts and follow-up data of all patients treated with TES for spine tumors in the spine unit at Tel Aviv Medical Center. RESULTS: TES was performed in 12 patients aged 13-78 years. Nine patients had primary spinal tumors and three had metastasis. Total en bloc removal was achieved in all cases with spondylectomy of one to three affected vertebras. There was no perioperative mortality and only one major intraoperative complication of injury to a major blood vessel. Late complications were mainly related to hardware failure. CONCLUSIONS: Total en bloc spondylectomy is feasible and effective for the management of selected patients with extradural spinal tumors. Since the surgical procedure is demanding and carries significant risk, careful preoperative evaluation and collaboration with colleagues from other specialties are crucial.

Spinal ependymoma with regional metastasis at presentation.

BACKGROUND: Ependymomas are the most common glial neoplasms in the spinal cord. However, spinal cord ependymomas presenting with regional dissemination along the neuroaxis are rare, with a yet undetermined standard of care. We retrospectively evaluated the management and outcomes of patients who were diagnosed with spinal ependymoma with regional metastases at presentation (SERMP). METHODS: Between 2002 and 2012, 16 patients with regionally metastatic spinal ependymomas were diagnosed and treated. The patients were retrospectively divided into two groups according to tumor grading and histological features. Nine patients were diagnosed with myxopapillary ependymomas (MPE), and seven patients were diagnosed with other low-grade ependymomas. RESULTS: With a median follow-up of 46.4 months, 13 out of 16 patients had no postsurgical recurrence/progression of the disease. In three patients, the disease recurred/progressed, leading to death in one patient. There was no correlation between gross total removal (GTR) of the main tumor, or resection of the main lesion and the metastatic foci and increased progression free survival in patients of the MPE group. There was an advantage for patients diagnosed with other low-grade ependymomas. Adjuvant radiotherapy did not prove beneficial. CONCLUSIONS: SERMP has a relatively benign course. Achieving GTR of both the main lesion and the metastases is preferable, but should not be achieved at any cost, especially in MPE interfering with the conus medullaris. The benefit of adjuvant radiotherapy remains unproven.

Differentiating spinal pathologies by deep learning approach.

BACKGROUND CONTEXT: Spinal pathologies are diverse in nature and, excluding trauma and degenerative diseases, includes infectious, neoplastic (either extradural or intradural), and inflammatory conditions. The preoperative diagnosis is made with clinical judgment incorporating lab findings and radiological studies. When the diagnosis is uncertain, a biopsy is almost always mandatory since the treatment is dictated by the type of pathology. This is an invasive, timely, and costly process. PURPOSE: The aim of this study was to develop a deep learning (DL) algorithm, based on preoperative MRI and post-operative pathological results, to differentiate between leading spinal pathologies. STUDY DESIGN: We retrospectively collected and analyzed clinical, radiological, and pathological data of patients who underwent spinal surgery or biopsy for various spinal pathologies between 2008 and 2022 at a tertiary center. The patients were stratified according to their pathological reports (the threshold for inclusion was set to 25 patients per diagnosis). METHODS: Preoperative MRI, clinical data, and pathological results were processed by a deep learning model built on the Fast.ai framework on top of the PyTorch environment. RESULTS: A total of 231 patients diagnosed with carcinoma (80), infection (57), meningioma (52), or schwannoma (42), were included in our model. The mean overall accuracy was 0.78±0.06 for the validation, and 0.93±0.03 for the test dataset. CONCLUSION: Deep learning algorithm for differentiation between the aforementioned spinal pathologies, based solely on clinical MRI, proves as a feasible primary diagnostic modality. Larger studies should be performed to validate and improve this algorithm for clinical use. CLINICAL SIGNIFICANCE: This study provides a proof-of-concept for predicting spinal pathologies solely by MRI based DL technology, allowing for a rapid, targeted, and cost-effective work-up and subsequent treatment.

Delayed diagnosis of cervical spondylotic myelopathy by primary care physicians.

OBJECT: A retrospective study analyzing medical files of patients who had undergone surgical management for cervical spondylotic myelopathy (CSM) at a single tertiary hospital was performed to determine the time needed by community care physicians to reach a diagnosis of CSM in patients presenting with typical myelopathic signs and symptoms, and to establish the reasons for the delayed diagnosis when present. Previous studies have documented that early diagnosis and surgical treatment of CSM may improve patients' neurological as well as general outcome. However, patients complaining of symptoms compatible with CSM may undergo lengthy medical investigations and treatments by community-based physicians before a correct diagnosis is made. The authors have found no published data on the process and time frame involved in attaining a diagnosis of CSM in the community setting. METHODS: The medical records of 42 patients were retrospectively reviewed for demographic data, symptoms, time to diagnosis, physician specialty, number of visits involved in the diagnostic process, and neurological status prior to surgery. RESULTS: The mean time delay from initiation of symptoms to diagnosis of CSM was 2.2 ± 2.3 years. The majority of symptomatic patients (90.4%) initially presented to a family practitioner (69%) or an orthopedic surgeon (21.4%), with fewer patients (9.6%) referring to other disciplines (for example, the emergency department) for initial care. In contrast, the diagnosis of CSM was most often made by neurosurgeons (38.1%) and neurologists (28.6%), and less frequently by orthopedic surgeons (19%) or family physicians (4.8%). CONCLUSIONS: The diagnosis of CSM in the community is frequently delayed, leading to late referral for surgery. A higher index of suspicion for this debilitating entity is required from family practitioners and community-based orthopedic surgeons to prevent neurological sequelae.

Spinal epidural abscess: in search of reasons for an increased incidence.

BACKGROUND: Spinal epidural abscess (SEA) is a rare disease with a potentially devastating outcome, and a reported incidence traditionally estimated at 0.2-2 cases/10,000 hospital admissions. Since the implementation in October 2007 of a program to increase medical personnel's awareness of SEA, we have documented a sharp increase in the incidence of SEA at our medical center OBJECTIVES: To investigate the cause of the increased incidence of SEA. METHODS: All cases diagnosed with SEA during the period 1998-2010 were retrospectively reviewed. Cases diagnosed before 2007 were compared with those diagnosed thereafter. RESULTS: From January 1998 to October 2007 SEA was diagnosed in 22 patients (group A), giving an annual incidence of 0.14-0.6 cases per 10,000 admissions. During the period November 2007 to April 2010, 26 additional patients were diagnosed (group B), yielding an incidence of 0.81-1.7 cases per 10,000 admissions (P < 0.01). The two groups did not differ significantly in epidemiological, clinical or laboratory characteristics, or in the causative bacteria isolated. CONCLUSIONS: The threefold rise in the incidence of SEA observed at a tertiary medical center in Tel Aviv since November 2007 was not explained by different host characteristics or by more virulent bacterial isolates. We suggest that heightened awareness of the clinical presentation and timely utilization of MR imaging has resulted in more cases being identified.

Synergy-S stereotactic radiosurgery for spinal tumors.

BACKGROUND: Radiation treatment of spinal and paraspinal tumors has been limited by the tolerance of the spinal cord. As such, therapeutic options are restricted to surgically accessible lesions or the use of suboptimal dosing of external beam irradiation. OBJECTIVES: To evaluate the safety and applicability of the Elekta Synergy-S radiation unit for the treatment of spinal tumors. METHODS: We retrospectively reviewed all patients treated with stereotactic radiosurgery for spinal tumors between November 2007 and June 2011. RESULTS: Thirty-four patients were treated for 41 lesions. Treatment indications were local tumor control and pain palliation. The mean follow-up was 10.8 +/- 11.6 months (range 0.5-38 months). No acute radiation toxicity or new neurological deficits occurred during the follow-up period. Local tumor control was achieved in 21 of the 24 lesions (87.5%) available for radiological follow-up at a median of 9.8 months (range 3-32 months). Good analgesia was achieved in 24/30 lesions (80%) that presented with intractable pain. CONCLUSIONS: The safety and feasibility of delivering single and multiple-fraction stereotactic spinal irradiation was demonstrated and became a standard treatment option in our institution.

Does Tobacco Smoking Affect the Postoperative Outcome of MIS Lumbar Decompression Surgery?

BACKGROUND: Tobacco smoking is a major cause of morbidity and mortality worldwide. Several authors reported a significant negative impact of smoking on the outcome of spinal surgeries. However, comparative studies on the effect of smoking on the outcome of minimally invasive (MIS) spinal decompression are rare with conflicting results. In this study, we aimed to evaluate clinical outcomes and postoperative complications following MIS decompression in current and former smoking patients compared to those of non-smoking patients. METHODS: We used our prospectively collected database to retrospectively analyse the records of 188 consecutive patients treated with MIS lumbar decompression at our institution between November 2013 and July 2017. Patients were divided into groups of smokers (S), previous smokers (PS) and non-smokers (N). The S group and the PS group comprised 31 and 40 patients, respectively. The N group included 117 patients. The outcome measures included perioperative complications, revision surgery and length of stay. Patient-reported outcome measures included a visual analogue scale (VAS) for back pain and leg pain, as well as the Oswestry disability index (ODI) for evaluating functional outcomes. RESULTS: Demographic variables, comorbidity and other preoperative variables were comparable between the three groups. A comparison of perioperative complications and revision surgery rates showed no significant difference between the groups. All groups showed significant improvement in their ODI and VAS scores at 12 and 24 months following surgery. As shown by a multivariate analysis, current smokers had lower chances of improvement, exceeding the minimal clinical important difference (MCID) in ODI and VAS for leg pain at 12 months but not 24 months postoperatively. CONCLUSIONS: Our findings show that except for a possible delay in improvement in leg pain and disability, tobacco smoking has no substantial adverse impact on complications and revision rates following MIS spinal decompressions.

Low Back Pain Patients' Perceptions Regarding Their Own Radiology Reports: Pre-Intervention Survey.

Purpose: While advanced medical technology and unlimited access to medical information might benefit and empower patients, these same advantages may pose some risks, especially in the cases where patients have direct access to advanced imaging studies. The aim of this work was to evaluate three domains related to patients with lower back pain: the patients' perceptions, misconceptions and the experience of anxiety-related symptoms following direct access to their thoraco-lumbar spine radiology report. An additional aim was the assessment of possible associations with catastrophization. Patients and Methods: Patients who were referred to the spine clinic, following the completion of a CT or MRI of their thoraco-lumbar spine were surveyed. Patient perceptions of the importance of having direct access to their imaging report and of the concern they attribute to the medical terms found in their report were evaluated using a set of questionnaires. The medical terms severity scores were then correlated to a reference clinical score created for the same medical terms by spine surgeons. Lastly, patients' anxiety-related symptoms and Pain Catastrophizing Scale (PCS) after reading their radiology report were evaluated. Results: Data from 162 participants (44.6% female), with mean age of 53.1 ± 15.6 years, were collected. Sixty-three percent of the patients stated that reading their report helped them gain better understanding of their medical condition and 84% agreed that having early access to the report helped improve communication with the physician. Patients' degree of concern associated with the medical terms in their imaging report ranged between 2.07 and 3.75, on a scale of 1-5. The patient's degree of concerns were significantly higher for six common medical terms and significantly lower in one, when compared to experts' opinions. A mean (± SD) of 2.86±2.79 anxiety-related symptoms was reported. The mean Pain Catastrophizing Scale (PSC) score was 29.18 ±11.86, ranging from 2 to 52. Both the degree of concerns and the number of symptoms reported were significantly associated with the PCS. Conclusion: Direct access to radiology reports might provoke anxiety symptoms, especially in patients with a tendency for catastrophic thinking. Increasing awareness amongst spine clinicians and radiologist about possible risks associated with direct access to radiology reports could contribute to preventing patients' misconceptions and unnecessary anxiety-related symptoms.

Is the Erector Spinae Plane Block Effective for More than Perioperative Pain? A Retrospective Analysis.

Introduction: The thoracic Erector Spinae Plane Block (ESPB) is an ultrasound-guided block that has gained popularity and is widely used in acute pain setups. However, data regarding its role in chronic and cancer-related pain are anecdotal. Material and Methods: The study is a retrospective analysis of patients who underwent ESPB. The cohort was divided into subgroups based on three determinants: etiology, pain type, and chronicity. Results: One hundred and ten patients were included, and genders were affected equally. The average age was 61.2 ± 16.1 years. The whole group had a statistically significant reduction in a numerical rating scale (NRS) (7.4 ± 1.4 vs. 5.0 ± 2.6, p-value > 0.001). NRS reduction for 45 patients (41%) exceeded 50% of the pre-procedural NRS. The mean follow-up was 7.9 ± 4.6 weeks. Baseline and post-procedure NRS were comparable between all subgroups. The post-procedural NRS was significantly lower than the pre-procedural score within each group. The proportion of patients with over 50% improvement in NRS was lower for those with symptom duration above 12 months (p-value = 0.02). Conclusions: Thoracic ESPB is a simple and safe technique. The results support the possible role of ESPB for chronic as well as cancer-related pain.

Gender differences in multifidus fatty infiltration, sarcopenia and association with preoperative pain and functional disability in patients with lumbar spinal stenosis.

BACKGROUND: In patients with lumbar spinal stenosis, female gender has been associated with higher pain and functional disability. Sarcopenia and multifidus atrophy have also been associated with symptomatic severity. PURPOSE: The purpose of this study was to determine if gender differences in sarcopenia and multifidus atrophy are associated with gender disparities in disease symptomatology. STUDY DESIGN: Prospectively collected medical records and imaging studies were retrospectively reviewed. PATIENT SAMPLE: We retrospectively reviewed medical records and imaging studies for 63 patients with clinically and radiologically defined lumbar spinal stenosis at L3/4 or L4/5 who underwent minimally invasive decompression. OUTCOME MEASURES: Pain and functional disability were measured using the Oswestry Disability Index (ODI) and visual analogue scores for back pain (VASB) and leg pain (VASL). METHODS: Multifidus total cross sectional area (tCSA), multifidus functional cross sectional area (fnCSA), multifidus fatty infiltration (FI), psoas tCSA, and psoas relative cross sectional area (rCSA) were evaluated by univariable and multivariable regression to identify gender linked and gender independent predictors of higher ODI, VASB, and VASL. RESULTS: Female gender was significantly associated with lower multifidus fnCSA (p < .001), higher multifidus FI (p < .001), lower psoas tCSA (p < .001), lower psoas rCSA (p = .002), and higher preoperative ODI (p = .008). Lower psoas rCSA (p = .044) and psoas tCSA in the lowest sex specific quartile (p = .034) were significantly associated with higher preoperative VASB and psoas rCSA less than the sex specific median (p = .050) was significantly associated with higher preoperative VASL after controlling for age and gender. Multifidus FI was significantly associated with preoperative ODI after adjusting for age (p = .048) but not after controlling additionally for gender (p = .651). CONCLUSIONS: Female patients with lumbar spinal stenosis may develop more severe and functionally significant multifidus atrophy, resulting in a more severe clinical course with higher functional disability. Sarcopenia was significantly associated with higher preoperative back pain and leg pain in both male and female patients with lumbar spinal stenosis.