Non-linear Effect of Preexisting Cranial Adjacent Disc Degeneration on Cumulative 12-year Revision Risk Following Lumbar Fusions.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To evaluate how preexisting adjacent segment degeneration status impacts revision risk for adjacent segment disease (ASD) after lumbar fusions. SUMMARY OF BACKGROUND DATA: ASD incurs late reoperations after lumbar fusion surgeries. ASD pathogenesis is multifactorial. Preexisting adjacent segment degeneration measured by Pfirrmann is suggested as one of the predisposing factors. We sought to find deeper insights into this association by using a more granular degeneration measure, the Combined imaging score (CIS). METHODS: A total of 197 consecutive lumbar fusions for degenerative pathologies were enrolled in a prospective follow-up (median 12 years). Preoperative cranial adjacent segment degeneration status was determined using Pfirrmann and CIS, which utilizes both radiographs and magnetic resonance imaging. Based on CIS, patients were trichotomized into tertiles (CIS <7, CIS 7-10, and CIS >10). The cumulative ASD revision risk was determined for each tertile. After adjusting for age, sex, body mass index, sacral fixation, and fusion length, hazard ratios (95% confidence intervals, CI) for ASD revisions were determined for each Pfirrmann and CIS score. RESULTS: Patients in the intermediate CIS tertile had a cumulative ASD revision risk of 25.4% (17.0% to 37.0%), while both milder degeneration (CIS <7) [13.2% (6.5% to 25.8%)] and end-stage degeneration (CIS >10) [13.6% (7.0% to 25.5%)] appeared to be protective against surgical ASD. Pfirrmann failed to show a significant association with ASD revision risk. Adjusted analysis of CIS suggested increased ASD revisions after CIS 7, which turned contrariwise after CIS 10. CONCLUSIONS: The effect of preexisting adjacent segment degeneration on ASD reoperation risk is not linear. The risk seems to increase with advancing degeneration but diminish with end-stage degeneration. Therefore, end-stage degenerative segments may be considered to be excluded from fusion constructs. LEVEL OF EVIDENCE: Therapeutic Level III.

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.

Postoperative Sagittal Balance Has Only a Limited Role in the Development of Adjacent Segment Disease After Lumbar Spine Fusion for Degenerative Lumbar Spine Disorders: A Subanalysis of the 10-year Follow-up Study.

STUDY DESIGN: Retrospective additional analysis of a prospective follow-up study. OBJECTIVES: We aimed to find out whether poor postoperative sagittal alignment increases revisions for adjacent segment disease (ASD) after lumbar spine fusion (LSF) performed for degenerative lumbar spine disease. SUMMARY OF BACKGROUND DATA: Revisions for ASD accumulate over time after LSF for degenerative lumbar spine disease. The etiology of ASD is considered multifactorial. Yet, the role of postoperative sagittal balance in this process remains controversial. MATERIALS AND METHODS: A total of 215 consecutive patients who had undergone an elective LSF surgery for spinal stenosis with (80%) or without (20%) spondylolisthesis were analyzed. Spinal reoperations were collected from the hospital records. Preoperative and postoperative sagittal alignment were evaluated from standing radiographs. The risk of revisions for ASD was evaluated by Cox proportional hazards regression models. RESULTS: We did not find the poor postoperative balance [pelvic incidence-lumbar lordosis (LL) >9°] to significantly increase the risk of revisions for ASD: crude hazard ratio (HR)=1.5 [95% confidence interval (CI): 0.8-2.7], adjusted (by age, sex, pelvic incidence, fusion length, and the level of the caudal end of fusion): HR=1.7 (95% CI: 0.9-3.3). We found higher LL outside the fusion segment (LL-segmental lordosis) to decrease the risk of revisions for ASD: HR=0.9 (95% CI: 0.9-1.0). CONCLUSION: Poor sagittal balance has only a limited role as a risk factor for the revisions for ASD among patients with degenerative spinal disease. However, the risk for ASD might be the greatest among patients with reduced spinal mobility.

Gorham-Stout disease with life-threatening pleural effusion treated with a pleuro-peritoneal shunt: a case report.

Summary: Gorham-Stout disease (GSD) is a rare bone disease characterized by massive osteolysis and lymphatic proliferation. The origin of the condition is unknown, and no established treatment protocol exists. Massive pleural effusion is a frequent complication of GSD in the thoracic region. We present the case of a 23-year-old male with thoracic GSD, subsequent paraparesis, and life-threatening pleural effusion. The patient was managed by a multidisciplinary team with a good recovery. The pleural effusion was successfully treated with a pleuro-peritoneal shunt. This is the first report of the use of this mini-invasive technique in the management of pleural effusion related to GSD. Further, we present the potential role of interleukin-6 and bone resorption markers in the measurement of the disease activity. Learning points: Multidisciplinary approach is important in the management of rare and severe disorders such as Gorham-Stout disease. Pleuro-peritoneal shunting is a valuable option in the treatment of pleural effusion related to GSD. Interleukin-6 and bone resorption markers appear useful in measuring the disease activity of GSD.

Isthmic Spondylolisthesis is Associated with Less Revisions for Adjacent Segment Disease After Lumbar Spine Fusion Than Degenerative Spinal Conditions: A 10-Year Follow-Up Study.

STUDY DESIGN: Prospective, follow-up study. OBJECTIVE: We aim to compare the rate of revisions for ASD after LSF surgery between patients with IS and DLSD. SUMMARY OF BACKGROUND DATA: ASD is a major reason for late reoperations after LSF surgery. Several risk factors are linked to the progression of ASD, but the understanding of the underlying mechanisms is imperfect. If IS infrequently becomes complicated with ASD, it would emphasize the role of the ongoing degenerative process in spine in the development of ASD. METHODS: 365 consecutive patients that underwent elective LSF surgery were followed up for an average of 9.7 years. Surgical indications were classified into 1) IS (n = 64), 2) DLSD (spinal stenosis with or without spondylolisthesis) (n = 222), and 3) other reasons (deformities, postoperative conditions after decompression surgery, posttraumatic conditions) (n = 79). All spinal reoperations were collected from hospital records. Rates of revisions for ASD were determined using Kaplan-Meier methods. RESULTS: Altogether, 65 (17.8%) patients were reoperated for ASD. The incidences of revisions for ASD in subgroups were 1) 4.8% (95% CI: 1.6%-22.1%); 2) 20.5% (95% CI: 15.6%-26.7%); 3) 20.6% (95% CI: 12.9%-31.9%). After adjusting the groups by age, sex, fusion length, and the level of the caudal end of fusion, when comparing with IS group, the other groups had significantly higher hazard ratios (HR) for the revision for ASD [2) HR (95% CI) 3.92 (1.10-13.96), P = 0.035], [3) HR (95% CI) of 4.27 (1.11-15.54), P = 0.036]. CONCLUSION: Among patients with IS, the incidence of revisions for ASD was less than a 4th of that with DLSD. Efforts to prevent the acceleration of the degenerative process at the adjacent level of fusion are most important with DLSD.Level of Evidence: 3.

Disability, Health-Related Quality of Life and Mortality in Lumbar Spine Fusion Patients-A 5-Year Follow-Up and Comparison With a Population Sample.

STUDY DESIGN: Prospective follow-up study. OBJECTIVES: We aimed to assess the effect of lumbar spine fusion (LSF) on disability, health-related quality of life and mortality in a 5-year follow-up, and to compare these results with the general population. METHODS: 523 consecutive LSF operations were included in a prospective follow-up. Disability was assessed by the Oswestry Disability Index (ODI), and HRQoL by the 36-item Short Form (SF-36) questionnaire using the physical and mental summary scores (PCS and MCS). The patients were compared with an age-, sex-, and residential area matched general population cohort. RESULTS: The preoperative ODI in the patients was 46 (SD 16), and the change at 5 years was -26 (95% CI: -24 to -28), p < 0.001. In the population, ODI (baseline 13, SD 16) remained unchanged. The preoperative PCS in the patients was 27 (SD 7), in the population 45 (SD 11), and the increase in the patients at 5 years was 8 (95% CI: 7 to 9), p < 0.001. The patients did not reach the population in ODI or PCS. The baseline MCS in the patients was 47 (SD 13), and the change at 5 years 4 (95% CI: 3 to 7), p < 0.001. MCS of the females reached the population at 5-year follow-up. When analyzing short and long fusions separately, comparable changes were seen in both subgroups. There was no difference in mortality between the patients (3.4%) and the population (4.8%), hazard ratio (HR) 0.86. CONCLUSIONS: Although the patients who had undergone LSF benefited from surgery still at 5 years, they never reached the physical level of the population.

Influence of Depressive Symptoms on the Outcome of Lumbar Spine Fusion-A 5-year Follow-up Study.

STUDY DESIGN: Prospective follow-up study. OBJECTIVE: The aim of this study was to assess whether depressive symptoms change the outcome of lumbar spine fusion (LSF) surgery at a 5-year follow-up. SUMMARY OF BACKGROUND DATA: Previous reports of the influence of depressive symptoms on the results of spine surgery are controversial, but the patient characteristics and indications for surgery varied widely between the studies. The influence of depressive symptoms on the 5-year outcome of LSF has not been studied. METHODS: The study was based on data from a local LSF database from two hospitals comprising 392 consecutive patients (mean age 61 years, 277 women) who underwent an instrumented LSF and fulfilled the 5-year follow-up. At the 5-year follow-up, the patients were compared with a control group from the general population (n = 477, age-, sex-, and residential area-matched) extracted from Official Statistics of Finland. The prevalence of depressive symptoms was evaluated using the Depression Scale (DEPS; 0-30) and disability was evaluated by the Oswestry Disability Index (ODI; 0-100%). A DEPS score ≥12 was considered to indicate depressive symptoms. RESULTS: Before surgery, 35% of the patients had depressive symptoms. The proportion diminished to 13% at 3 months postoperatively and increased to 24% at 5 years. In the population, the prevalence was 11% at baseline and 10% at the 5-year follow-up. The preoperative ODI was 54 in the patients with depressive symptoms, and it was 41 in the patients with no depressive symptoms. The changes at 5-year follow-up were -20 and -18, correspondingly. The same congruence was preserved when analyzing short and long fusions separately. These changes were statistically and clinically significant. In the control population, the ODI remained around 24 in depressive people and 10 in nondepressive people. CONCLUSION: Our data suggest that patients with and without depressive symptoms may benefit equally well from LSF. LEVEL OF EVIDENCE: 3.

Incidence of Spine Fracture Hospitalization and Surgery in Finland in 1998-2017.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to assess the incidence and trends of the spine fracture hospitalization and surgery in Finland in 1998-2017. SUMMARY OF BACKGROUND DATA: Traumatic spine fractures are rare, yet they are known to cause significant long-term disability and therefore social, functional, and financial burden. The incidence of spine fractures and related mortality has been suggested to have declined during recent years. However, there are no population-based studies investigating the incidence of surgical treatment of spine fractures. METHODS: The data for this study was obtained from the Finnish nationwide National Hospital Discharge Register. The study population covered all patients 20 years of age or over in Finland during a 20-year period from January 1, 1998 to December 31, 2017. RESULTS: A total of 54,612 patients were hospitalized for a spine fracture in Finland in 1998-2017, and 7138 (13%) of the patients underwent surgery. The annual population-based incidence of spine fracture hospitalization increased 57% during the 20-year period, from 57 per 100,000 person-years to 89 per 100,000 person-years. In addition, the incidence of spine fracture surgery increased 65%, from 5.3 per 100,000 person-years to 8.8 per 100,000 person-years. The incidence of cervical spine fracture surgery tripled, and thoracic spine surgery doubled from 1998 to 2017, while incidence of lumbar fracture surgery declined by 13%. Among patients 60 years of age or older, the incidence of cervical spine fracture surgery increased 400%. CONCLUSION: Incidences of cervical, thoracic, and lumbar fracture hospitalizations increased constantly in Finland during 1998-2017. Accordingly, incidence of cervical and thoracic spine fracture surgery increased rapidly, whereas the incidence of lumbar fracture surgery even decreased, during this 20-year period. LEVEL OF EVIDENCE: 3.