Comparison of the clinical efficacy of percutaneous transforaminal endoscopic discectomy and traditional laminectomy in the treatment of recurrent lumbar disc herniation.

ABSTRACT: A few years ago, percutaneous transforaminal endoscopic discectomy (PTED) began to prevail in clinical treatment of recurrent lumbar disc herniation (RLDH), whereas traditional laminectomy (TL) was treated earlier in RLDH than PTED. This study aimed to compare the clinical efficacy of PTED and TL in the treatment of RLDH.Between November 2012 and October 2017, retrospective analysis of 48 patients with RLDH who were treated at the Cancer Hospital, Chinese Academy of Sciences, Hefei and Department of Orthopaedics, Second Affiliated Hospital of Anhui Medical University. Perioperative evaluation indicators included operation time, the intraoperative blood loss, length of incision and hospitalization time. Clinical outcomes were measured preoperatively, and at 1 days, 3 months, and 12 months postoperatively. The patients' lower limb pain was evaluated using Oswestry disability index (ODI) and visual analog scale (VAS) scores. The ODI is the most widely-used assessment method internationally for lumbar or leg pain at present. Every category comprises 6 options, with the highest score for each question being 5 points. higher scores represent more serious dysfunction. The VAS is the most commonly-used quantitative method for assessing the degree of pain in clinical practice. The measurement method is to draw a 10 cm horizontal line on a piece of paper, 1 end of which is 0, indicating no pain, which the other end is 10, which means severe pain, and the middle part indicates different degree of pain.Compared with the TL group, the operation time, postoperative bed-rest time, and hospitalization time of the PTED group were significantly shorter, and the intraoperative blood loss was also reduced. These differences were statistically significant (P < .01). There were no significant differences in VAS or ODI scores between the two groups before or after surgery (P > .05).PTED and TL have similar clinical efficacy in the treatment of RLDH, but PTED can shorten the operation time, postoperative bed-rest time and hospitalization time, and reduce intraoperative blood loss, so the PTED is a safe and effective surgical method for the treatment of RLDH than TL, but more randomized controlled trials are still required to further verify these conclusions.

A Comparison of the Surgical Outcomes of Laminoplasty and Laminectomy with Fusion in the Treatment of Multilevel Cervical Spondylotic Myelopathy: A Retrospective Cohort Study.

AIM: To compare the effectiveness of laminoplasty and laminectomy with fusion in the treatment of patients with cervical spondylotic myelopathy (CSM). MATERIAL AND METHODS: This study retrospectively reviewed 52 patients diagnosed with CSM who underwent either laminoplasty (LP group) or laminectomy with fusion (LF group). The preoperative and postoperative clinical outcomes were evaluated using Cobb?s angle of cervical lordosis, visual analogue scale (VAS) and modified Japanese Orthopaedic Association (mJOA) scores, and radiographs showing the antero-posterior diameter and area of the spinal canal. RESULTS: The mean age of the LP group was 60.12 years, while that of the LF group was 63.84 years. The pre- and postoperative mean mJOA scores were 11.46 ± 1.27 and 15.27 ± 0.87, respectively, in the LP group and 10.15 ± 1.89 and 14.92 ± 1.23, respectively, in the LF group. The pre- and postoperative Cobb angles were 16.22 ± 6.36° and 14.45 ± 4.50°, respectively, in the LP group and 14.39 ± 5.34° and 15.10 ± 6.21°, respectively, in the LF group. Recovery rates were 58.26% and 60.76% in the LP and LF groups, respectively. The mJOA scores, antero-posterior diameter and area improved significantly after surgery in both groups, while the Cobb angle increased in the LF group and decreased in the LP group. CONCLUSION: Laminoplasty and laminectomy with fusion improved neurological functions in patients diagnosed with CSM. Laminectomy with fusion should be the preferred choice when treating patients with preoperative axial pain as, despite expanding the spinal canal successfully, laminoplasty can also worsen the pain. However, laminectomy with fusion (except for OPLL) should not be the treatment of choice in a mobile spine as it severely restricts neck movements and impairs the Health-Related Quality of Life (HRQoL) of the patient. In the absence of kyphotic deformity, laminoplasty should be the preffered method for treatment.

Outcomes and prognostic indicators in 59 paraplegic medium to large breed dogs with extensive epidural hemorrhage secondary to thoracolumbar disc extrusion.

OBJECTIVE: To evaluate outcomes and prognostic factors after decompressive hemilaminectomy in paraplegic medium to large breed dogs with extensive epidural hemorrhage (DEEH) and thoracolumbar intervertebral disc extrusion (TL-IVDE). STUDY DESIGN: Retrospective, cohort, descriptive study. ANIMALS: Fifty-nine client-owned dogs. METHODS: Medical records and advanced imaging were reviewed for paraplegic dogs with DEEH. Ambulatory status 6 months after surgery and postoperative complications were recorded. Multiple logistic regression models were constructed to explore prognostic factors. RESULTS: Records of 22 dogs with and 37 dogs without pelvic limb pain perception at presentation were included. Median age of dogs was 5 years (interquartile range, 4-7), and mean weight was 26.9 kg (SD, ±9.71). Labradors and Labrador mixes were most common (17/59 [28.8%]). Recovery of ambulation occurred in 17 of 22 (77.3%) dogs with and in 14 of 37 (37.8%) dogs without pain perception prior to surgery. Progressive myelomalacia was recorded in three of 59 (5.1%) dogs, one with pain perception and two without pain perception at presentation. Postoperative complications (14/59 [23.7%]) were common. Factors independently associated with outcome included clinical severity (odds ratio [OR] 0.179, P = .005), number of vertebrae with signal interruption in half Fourier single-shot turbo spin-echo sequences (HASTEi; OR, 0.738; P = .035), and ratio of vertebral sites decompressed to HASTEi (OR, 53.79; P = .03). CONCLUSION: Paraplegic medium to large breed dogs with DEEH have a less favorable outcome after surgical decompression than paraplegic dogs with TL-IVDE. CLINICAL SIGNIFICANCE: Dogs with DEEH can have severe postoperative complications. Loss of pain perception and increased HASTEi are associated with a poor outcome, while more extensive decompression improves outcome.

Improvement in Quality of Life Following Surgical Resection of Benign Intradural Extramedullary Tumors: A Prospective Evaluation of Patient-Reported Outcomes.

BACKGROUND: Historically, symptomatic, benign intradural extramedullary (IDEM) spine tumors have been managed with surgical resection. However, minimal robust data regarding patient-reported outcomes (PROs) following treatment of symptomatic lesions exists. Moreover, there are increasing reports of radiosurgical management of these lesions without robust health-related quality of life data. OBJECTIVE: To prospectively analyze PROs among patients with benign IDEM spine tumors undergoing surgical resection to define the symptomatic efficacy of surgery. METHODS: Prospective, single-center observational cohort study of patients with benign IDEM spine tumors undergoing open surgical resection. Pre- and postoperative Brief Pain Index (BPI) and MD Anderson Symptom Inventory (MDASI) questionnaires were used to quantitatively assess their symptom control after surgical intervention. Matched pairs were analyzed with the Wilcoxon signed-rank test. RESULTS: A total of 57 patients met inclusion criteria with both pre- and postoperative PROs. There were 35 schwannomas, 18 meningiomas, 2 neurofibromas, 1 paraganglioma, and 1 mixed schwannoma/neurofibroma. Most patients were American Spinal Injury Association Impairment (ASIA) E (93%) with high-grade spinal cord compression (77%), and underwent either a 2 or 3 level laminectomy (84%). Surgical resection resulted in statistically significant improvement in all 3 composite BPI constructs of pain-severity, pain-interference, and overall patient pain experience (P < .0001). Surgical resection resulted in statistically significant improvements in all composite scores for the MDASI core symptom severity, spine tumor, and disease interference constructs (P < .01). Three patients (5%) had postoperative complications requiring surgical interventions (2 wound revisions and 1 ventriculo-peritoneal shunt). CONCLUSION: Surgical resection of IDEM spine tumors provides rapid, significant, and durable improvement in PROs.

Penetrating Spinal Cord Injury in civilians: analysis of a national database.

BACKGROUND: Spinal trauma is common in polytrauma; spinal cord injury (SCI) is present in a subset of these patients. Penetrating SCI has been studied in the military; however, civilian SCI is less studied. Civilian injury pathophysiology varies given the generally lower velocity of the projectiles. We sought to investigate civilian penetrating SCI in the United States. METHODS: We queried the National Inpatient Sample for data regarding penetrating spinal cord injury from the past 10 years (2006-2015). The National Inpatient Sample includes data of 20% of discharged patients from U.S. hospitals. We analyzed trends of penetrating SCI regarding its diagnosis, demographics, surgical management, length of stay, and hospital costs. RESULTS: In the past 10 years the incidence of penetrating SCI in all SCI patients has remained stable with a mean of 5.5% (range 4.3%-6.6%). Of the patients with penetrating SCI, only 17% of them underwent a surgical procedure, compared with 55% for nonpenetrating SCI. Patients with penetrating SCI had a longer length of stay (average 23 days) compared with nonpenetrating SCI (15 days). Hospital charges were higher for penetrating SCI: $230,186 compared with $192,022 for closed SCI. Males patients were more affected by penetrating SCI, as well as black and Hispanic populations compared with whites. CONCLUSIONS: Penetrating SCI represents 5.5% of all SCI patients. Men, blacks, and Hispanics are disproportionally more affected by penetrating SCI. Patients with penetrating SCI have fewer surgical interventions, but their overall length of stay and hospital costs are greater compared with nonpenetrating SCI.

Ultrasonic bone scalpel for thoracic spinal decompression: case series and technical note.

BACKGROUND: Thoracic spinal stenosis (TSS) is a rare but intractable disease that fails to respond to conservative treatment. Thoracic spinal decompression, which is traditionally performed using high-speed drills and Kerrison rongeurs, is a time-consuming and technically challenging task. Unfavorable outcomes and high incidence of complications are the major concerns. The development and adaptation of ultrasonic bone scalpel (UBS) have promoted its application in various spinal operations, but its application and standard operating procedure in thoracic decompression have not been fully clarified. Therefore, the purpose of this study is to describe our experience and technique note of using UBS and come up with a standard surgical procedure for thoracic spinal decompression. METHODS: A consecutive of 28 patients with TSS who underwent posterior thoracic spinal decompression surgery with UBS between December 2014 and May 2015 was enrolled in this study. The demographic data, perioperative complications, operation time, estimated blood loss, and pre- and postoperative neurological statuses were recorded and analyzed. Neurological status was evaluated with a modified Japanese Orthopaedic Association (JOA) scale, and the neurological recovery rate was calculated using the Hirabayashi's Method. RESULTS: Thoracic spinal decompression surgery was successfully carried out in all cases via a single posterior approach. The average age at surgery was 49.7 ± 8.5 years. The mean operative time of single-segment laminectomy was 3.0 ± 1.4 min, and the blood loss was 108.3 ± 47.3 ml. In circumferential decompression, the average blood loss was 513.8 ± 217.0 ml. Two cases of instrument-related nerve root injury occurred during operation and were cured by conservative treatment. Six patients experienced cerebrospinal fluid (CSF) leakage postoperatively, but no related complications were observed. The mean follow-up period was 39.7 ± 8.9 months, the average JOA score increased from 4.7 before surgery to 10.1 postoperatively, and the average recovery rate was 85.8%. CONCLUSIONS: The UBS is an optimal instrument for thoracic spinal decompression, and its application enables surgeons to decompress the thoracic spinal cord safely and effectively. This standard operating procedure is expected to help achieve favorable outcomes and can be used to treat various pathologies leading to TSS.

Unilateral Laminectomy by Endoscopy in Central Lumbar Canal Spinal Stenosis: Technical Note and Early Outcomes.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the outcomes and safety of endoscopic laminectomy for central lumbar canal spinal stenosis. SUMMARY OF BACKGROUND DATA: .: Spinal endoscopy is mostly used in the treatment of lumbar disc herniation, while endoscopic laminectomy for lumbar spinal stenosis is rarely reported. METHODS: From January 2016 to June 2017, 38 patients with central lumbar canal spinal stenosis were treated with endoscopic laminectomy. Clinical symptoms were evaluated at 1, 3, 6, and 12 months and the last follow-up after surgery. Functional outcomes were assessed by using the Japanese Orthopedic Association Scores (JOA) and Oswestry Disability Index (ODI). The decompression effect was assessed by using the dural sac cross-sectional area (DSCA). Lumbar stability was evaluated using lumbar range of motion (ROM), ventral intervertebral space height (VH), and dorsal intervertebral space height (DH). RESULTS: The mean age of the cases was 60.8 years, the mean operation time was 66.3 minutes, the blood loss was 38.8 mL, and the length of incision was 19.6 mm. The mean time in bed was 22.3 hours, and the mean hospital stay was 8.8 days. JOA scores were improved from 10.9 to 24.1 (P < 0.05), ODI scores were improved from 79.0 to 27.9 (P < 0.05), DSCA was improved from 55.7 to 109.5 mm (P < 0.05), ROM scores were improved from 5.6° to 5.7° (P < 0.05), and DH scores were reduced from 6.6 to 6.5 mm (P < 0.05). There was no significant difference in VH before and after operation (P > 0.05). There were no serious complications during the follow-ups. CONCLUSION: Endoscopic laminectomy had the advantage of a wider view, which was effective, safe, and less invasive for lumbar spinal stenosis. LEVEL OF EVIDENCE: 5.

Clinical Efficacy and Rehabilitation of Microscopic "Over the Top" for Bilateral Decompression in Degenerative Lumbar Stenosis: A Retrospective Study.

BACKGROUND: Recently, "over the top" (also called ULBD; microscopic unilateral laminotomy for bilateral decompression) is a less invasive technique for symptomatic degenerative lumbar spinal stenosis (LSS), and this minimally invasive surgical technique has demonstrated favorable therapeutic outcomes. However, the risk of postoperative complications remains controversial. OBJECTIVE: This study is aimed at determining the clinical efficacy and complication and rehabilitation of the microscopic "over the top" for degenerative LSS in geriatric patients. Study Design. This was a retrospective study. Setting. All data were obtained from the People's Hospital of a University. METHODS: A retrospective analysis of 39 consecutive elderly patients treated for LSS by microscopic "over the top" between January 2016 and January 2018 was performed. A postoperative rehabilitation program for geriatric patients with restricted weight-bearing was instituted after the microscopic "over the top" treatment. Estimated blood loss, duration of operation, length of hospitalization, and total complications were also evaluated. The CT and MRI examinations of the lumbar spine were collected to evaluate the completeness of the nerve decompression. Clinical data were assessed at 6 months and 12 months after operation utilizing the visual analog scale (VAS), Oswestry Disability Index (ODI), and 36-Item Short-Form Health Survey (SF-36). Preoperative comorbidities, complications, and revision surgery were also recorded. RESULTS: We enrolled a total of 39 degenerative LSS patients (27 male and 12 female patients, mean age of 75.8 ± 9.2 years). Twenty patients had one-level of degenerative LSS; thirteen patients had two-level of LSS; six patients had three-level of LSS. The average follow-up time in our study was 14.6 ± 7.8 months (range, 6-24 months). The overall complication rate was 10.2% (4/39), and the reoperation rates at one year were 2.5% (1/39). VAS back and leg pain score at 6 months were decreased to 1.8 ± 0.7 and 1.4 ± 0.6, respectively, and remained at 1.9 ± 0.3 and 1.2 ± 0.2 at 12 months, respectively. ODI scores improved significantly from 32.26 ± 6.82 to 11.44 ± 2.50 at 6 months and 10.56 ± 2.29 at 12 months. 36-Item Short-Form Health Survey scores revealed a significant improvement throughout follow-up. Postoperative complications included dural tear (n = 2), neurologic deficit (n = 1), and reoperation (n = 1). No infections or hematomas were reported. Limitation. Multicenter research is recommended to confirm our results and investigate the factors related to clinical and radiographic results. CONCLUSIONS: Microscopic "over the top" technique is a safe, effective option in the therapy of degenerative LSS and obtained satisfactory functional outcomes when coupled with aggressive rehabilitation, with a long recurrence-free recovery.

Neurological injury as a complication of spinal surgery: incidence, risk factors, and prognosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the rate, injury site, aetiology and outcomes in elective spinal surgery patients who sustained a spinal cord injury (SCI). SETTING: SCI national centre Toledo, Spain. METHODS: The study sample included patients who sustained an SCI after elective spinal surgery from 2013 to 2017. Oncological patients and patients receiving interventional therapies were excluded. Data collected included: demographics, aetiology, precipitating cause, injury mechanism, injury site, neurological status (AIS), SCIMIII at admission and discharge, hypertension, diabetes mellitus, obesity, dyslipidemia, depression and hospital length of stay. RESULTS: One thousand two hundred and eighty-two patients were admitted in this period of whom 114 met the inclusion criteria with a median (IQR) age of 58 (45-69) years; 46% female. The prevalence of SCI as a complication following spinal surgery in the total number of patients admitted to our centre was 9%. In 43%, the injury was to the dorsal spine with T12 being the most common neurological level of injury (20% of cases following laminectomy secondary to spinal canal stenosis). The most frequent precipitating cause was epidural haematoma (38% of cases). The median (IQR) SCIMIII scores at admission and discharge were (31) points (20-54) and (67) points (34-81), respectively. General AIS at admission were C (35%) and D at discharge (54%). The presence of hypertension, diabetes mellitus, obesity and dyslipidemia adjusted by age was not linked to a higher complication rate. The median (IQR) hospital length of stay was 120 days (60-189). CONCLUSION: In total 8.9% of patients admitted with SCI were the result of elective spinal surgery.

In Degenerative Spondylolisthesis, Unilateral Laminotomy for Bilateral Decompression Leads to Less Reoperations at 5 Years When Compared to Posterior Decompression With Instrumented Fusion: A Propensity-matched Retrospective Analysis.

STUDY DESIGN: Multicenter retrospective cohort study. OBJECTIVE: The aim of this study was to compare reoperation rates at 5-year follow-up of unilateral laminotomy for bilateral decompression (ULBD) versus posterior decompression with instrumented fusion (Fusion) for patients with low-grade degenerative spondylolisthesis (DS) with lumbar spinal stenosis (LSS) in a multicenter database. SUMMARY OF BACKGROUND DATA: Controversy exists regarding whether fusion should be used to augment decompression surgery in patients with LSS with DS. For years, the standard has been fusion with standard laminectomy to prevent postoperative instability. However, this strategy is not supported by Level 1 evidence. Instability and reoperations may be reduced or prevented using less invasive decompression techniques. METHODS: We identified 164 patients with DS and LSS who underwent ULBD between January 2007 and December 2011 in a multicenter database. These patients were propensity score-matched on age, sex, race, and smoking status with patients who underwent Fusion (n = 437). Each patient required a minimum of 5-year follow-up. The primary outcome was 5-year reoperation. Secondary outcome measures included postoperative complication rates, blood loss during surgery, and length of stay. Logistic regression models were used to estimate the odds ratio of the 5-year reoperation rate between the two surgical groups. RESULTS: The reoperation rate at 5-year follow-up was 10.4% in the ULBD group and 17.2% in the Fusion group. ULBD reoperations were more frequent at the index surgical level; Fusion reoperations were more common at an adjacent level. The two types of operations had similar postoperative complication rates, and both groups tended to have fusion reoperations. CONCLUSION: For patients with stable DS and LSS, ULBD is a viable, durable option compared to fusion with decreased blood loss and length stay, as well as a lower reoperation rate at 5-year follow-up. Further prospective studies are required to determine the optimal clinical scenario for ULBD in the setting of DS. LEVEL OF EVIDENCE: 3.

Comparison of laminectomy and fusion vs laminoplasty in the treatment of multilevel cervical spondylotic myelopathy: A meta-analysis.

PURPOSE: The purpose of this study is to evaluate the clinical safety and efficacy between laminectomy and fusion (LF) versus laminoplasty (LP) for the treatment of multi-level cervical spondylotic myelopathy (CSM). METHODS: The authors searched electronic databases using PubMed, MEDLINE, Embase, Cochrane Controlled Trial Register, and Google Scholar for relevant studies that compared the clinical effectiveness of LF and LP for the treatment of patients with multilevel CSM. The following outcome measures were extracted: the Japanese Orthopaedic Association (JOA) scores, cervical curvature index (CCI), visual analog scale (VAS), Nurich grade, reoperation rate, complications, rate of nerve palsies. Newcastle Ottawa Quality Assessment Scale (NOQAS) was used to evaluate the quality of each study. Data analysis was conducted with RevMan 5.3. RESULTS: A total of 14 studies were included in our meta-analysis. No significant difference was observed in terms of postoperative Japanese Orthopaedic Association score (P = .29), visual analog scale neck pain (P = .64), cervical curvature index (P = .24), Nurich grade (P = .16) and reoperation rate (P = .21) between LF and LP groups. Compared with LP group, the total complication rate (OR 2.60, 95% CI 1.85, 3.64, I = 26%, P < .00001) and rate of nerve palsies (OR 3.18, 95% CI 1.66, 6.11, I = 47%, P = .0005) was higher in the LF group. CONCLUSIONS: Our meta-analysis reveals that surgical treatments of multilevel CSM are similar in terms of most clinical outcomes using LF and LP. However, LP was found to be superior than LF in terms of nerve palsy complications. This requires further validation and investigation in larger sample-size prospective and randomized studies.

Anterior and Posterior Approaches for Cervical Myelopathy: Clinical and Radiographic Outcomes.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of this study was to identify advantages and disadvantages of the anterior and posterior approaches in the treatment of cervical stenosis and myelopathy. SUMMARY OF BACKGROUND DATA: Both anterior and posterior surgical approaches for cervical stenosis and myelopathy have been shown to result in improvement in health-related outcomes. Despite the evidence, controversy remains regarding the best approach to achieve decompression and correct deformity. METHODS: We retrospectively reviewed patients with cervical stenosis and myelopathy who had undergone anterior cervical fusion and instrumentation (n = 38) or posterior cervical laminectomy and instrumentation (n = 51) with at least 6 months of follow-up. Plain radiographs, magnetic resonance imaging, and computed tomography scans, as well as health-related outcomes, including Visual Analog Scale for neck pain, Japanese Orthopedic Association score for myelopathy, Neck Disability Index, and Short Form-36 Health Survey, were collated before surgery and at follow-up (median 12.0 and 12.1 months for anterior and posterior group, respectively). RESULTS: Both anterior and posterior approaches were associated with significant improvements in all studied quality of life parameters with the exception of general health in the anterior group and energy and fatigue in the posterior group. In the anterior group, follow-up assessment revealed a significant increase in C2-7 lordosis. Both approaches were accompanied by significant increases in C2-7 sagittal balance [sagittal vertical axis (SVA)]. There were two complications in the anterior group and nine complications in the posterior group; the incidence of complications between the two groups was not significantly different. CONCLUSION: When the benefits of one approach over the other are not self-evident, the anterior approach is recommended, as it was associated with a shorter hospital stay and more successful restoration of cervical lordosis than posterior surgery. LEVEL OF EVIDENCE: 3.

Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Program for Minimally Invasive Lumbar Decompression Spine Surgery: Initial Experience.

STUDY DESIGN: A retrospective cohort study of prospectively collected data. OBJECTIVE: The aim of this study was to describe the development of and early experience with an evidence-based enhanced recovery after surgery (ERAS) pathway for lumbar decompression. SUMMARY OF BACKGROUND DATA: ERAS protocols have been consistently associated with improved patient experience and outcomes, and reduced cost and length of hospital stay (LoS). Despite successes in other orthopedic subspecialties, ERAS has yet to be established in spine surgery. Here, we report the development of and initial experience with the first comprehensive ERAS pathway for MIS lumbar spine surgery. METHODS: An evidence-based review of the literature was performed to select components of the ERAS pathway. The pathway was applied to 61 consecutive patients presenting for microdiscectomy or lumbar laminotomy/laminectomy between dates. Data collection was performed by review of the electronic medical record. We evaluated compliance with individual ERAS process measures, and adherence to the overall pathway. The primary outcome was LoS. Demographics, comorbidities, perioperative course, prevalence of opioid tolerance, and factors affecting LoS were also documented. RESULTS: The protocol included 15 standard ERAS elements. Overall pathway compliance was 85.03%. Median LoS was 279 minutes [interquartile range (IQR) 195-398 minutes] overall, 298 minutes (IQR 192-811) for lumbar decompression and 285 minutes (IQR 200-372) for microdiscectomy. There was no correlation between surgical subtype or duration and LoS. Overall, 37% of the cohort was opioid-tolerant at the time of surgery. There was no significant effect of baseline opioid use on LoS, or on the total amount of intraoperative or PACU opioid administration. There were four complications (6.5%) resulting in extended LoS (>23 hours). CONCLUSION: This report comprises the first description of a comprehensive, evidence-based ERAS for spine pathway, tailored for lumbar decompression/microdiscectomy resulting in short LoS, minimal complications, and no readmissions within 90 days of surgery. LEVEL OF EVIDENCE: 3.

Optimizing the Volume-Value Relationship in Laminectomy: An Evidence-Based Analysis of Outcomes and Economies of Scale.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of the present study was to establish evidence-based volume thresholds for surgeons and hospitals predictive of enhanced value in the setting of laminectomy. SUMMARY OF BACKGROUND DATA: Previous studies have attempted to characterize the relationship between volume and value; however, none to the authors' knowledge has employed an evidence-based approach to identify thresholds yielding enhanced value. METHODS: In total, 67,758 patients from the New York Statewide Planning and Research Cooperative System database undergoing laminectomy in the period 2009 to 2015 were included. We used stratum-specific likelihood ratio analysis of receiver operating characteristic curves to establish volume thresholds predictive of increased length of stay (LOS) and cost for surgeons and hospitals. RESULTS: Analysis of LOS by surgeon volume produced strata at: <17 (low), 17 to 40 (medium), 41 to 71 (high), and >71 (very high). Analysis of cost by surgeon volume produced strata at: <17 (low), 17 to 33 (medium), 34 to 86 (high), and >86 (very high). Analysis of LOS by hospital volume produced strata at: <43 (very low), 43 to 96 (low), 97 to 147 (medium), 148 to 172 (high), and >172 (very high). Analysis of cost by hospital volume produced strata at: <43 (very low), 43 to 82 (low), 83 to 115 (medium), 116 to 169 (high), and >169 (very high). LOS and cost decreased significantly (P < 0.05) in progressively higher volume categories for both surgeons and hospitals. For LOS, medium-volume surgeons handle the largest proportion of laminectomies (36%), whereas very high-volume hospitals handle the largest proportion (48%). CONCLUSION: This study supports a direct volume-value relationship for surgeons and hospitals in the setting of laminectomy. These findings provide target-estimated thresholds for which hospitals and surgeons may receive meaningful return on investment in our increasingly value-based system. Further value-based optimization is possible in the finding that while the highest volume hospitals handle the largest proportion of laminectomies, the highest volume surgeons do not. LEVEL OF EVIDENCE: 3.

Short-term and long-term revision rates after lumbar spine discectomy versus laminectomy: a population-based cohort study.

BACKGROUND/OBJECTIVE: Degenerative diseases of the lumbar spine were managed with discectomy or laminectomy. This study aimed to compare these two surgical treatments in the postoperative revision rates. DESIGN: A population-based cohort study from analysis of a healthcare database. SETTING: Data were gathered from the Taiwan National Health Insurance Research Database (NHIRD). PARTICIPANTS: We enrolled 16 048 patients (4450 women and 11 598 men) with a mean age of 40.34 years who underwent lumbar discectomy or laminectomy for the first time between 1 January 1997 and 31 December 2007. All patients were followed up for 5 years or until death. RESULTS: Revision rate within 3 months of the index surgery was significantly higher in patients who underwent discectomy (2.75%) than in those who underwent laminectomy (1.18%; p<0.0001). This difference persisted over the first year following the index surgery (3.38% vs 2.57%). One year afterwards, the revision rates were similar between the discectomy (9.75%) and laminectomy (9.69%) groups. The final spinal fusion surgery rates were also similar between the groups (11.25% vs 12.08%). CONCLUSION: The revision rate after lumbar discectomy was higher than that after laminectomy within 1 year of the index surgery. However, differences were not identified between patient groups for the two procedures with respect to long-term revision rates and the proportion of patients who required final spinal fusion surgery.

Return-to-Duty Rates Following Minimally Invasive Spine Surgery Performed on Active Duty Military Patients in an Ambulatory Surgery Center.

BACKGROUND: Low back pain is a primary health care utilization driver in the US population. Health care evaluation visits for low back pain are as common as medical evaluation for the common cold. Low back pain is the most common reason for reductions in activities of daily living and work activity in the general population. Although these statistics are compelling, in the military population, there is arguably a significantly greater economic impact on the military population, as the cost to train, retain, and deploy a service member is a tremendous cost. METHODS: The current study retrospectively examines surgical outcomes, return to duty, and patient-centric outcomes among 82 active duty or reserve military patients who underwent an outpatient minimally invasive spine surgery Laminotomy Foraminotomy Decompression for the treatment of lumbar spinal stenosis in an ambulatory surgery center. FINDINGS: Overall, our results indicate that within the 82 active duty military service members, 100% of the service members return to duty within 3 mo. Additionally, there was a significant reduction in self-reported pain and disability 12 mo postoperative, whereas the average length of surgery was 62 min with an average estimated blood loss of 30.64 mL. DISCUSSION: The current study indicates that minimally invasive procedures for the treatment of lumbar spinal stenosis in an ambulatory surgery center setting are an effective option for active duty servicemen to reduce return-to-duty rates and symptomatic back-related pain and disability.

Time Attributable to Obesity in Surgery: A Multi-specialty Report on Day-of-Surgery Resource Utilization from 189,264 Cases.

BACKGROUND: Obesity presents a unique challenge in caring for surgical patients and has been shown to adversely affect outcomes for several operative procedures. However, quantitative data on surgical resource utilization attributable to obesity are scarce. The aim of this study was to quantify day-of-surgery resource utilization by degree of obesity. METHODS: Patients undergoing one of 14 common surgical procedures at our multicenter institution between 2008 and 2017 were identified from our operating room management databank. Multiple-variable regression analysis (MVRA) was performed to quantify the independent effect of body mass index (BMI) category on day-of-surgery resource utilization variables including procedure time, non-operative OR time, PACU time, number of unique staff and number of supplies used. Trends in mean BMI were examined for each procedure studied. RESULTS: MVRA of the 189,264 cases in the database revealed consistently significant (p < 0.05) stepwise increase in procedure time by BMI category for all procedures studied. Non-operative OR time was also significantly prolonged, though to a lesser degree. There was no significant impact on number of unique staff, supplies utilized or PACU time by BMI category. Procedures most impacted by BMI category in terms of resource utilization were ventral hernia repair, laminectomy and hysterectomy. CONCLUSION: Our study quantified day-of-surgery resource utilization for 14 major surgical procedures by BMI category. The need for additional resources to accommodate patients in higher BMI groups was consistent across all procedures studied and was primarily reflected by lengthened operative times.

Results and limitations of outpatient and overnight stay laminectomies for lumbar spinal stenosis.

BACKGROUND: At our centre, laminectomies have been traditionally performed as inpatient surgery. A gradual change in practice occurred between 2010 and 2013 to try to do these procedures as outpatient or overnight stay surgery. METHODS: We conducted a retrospective cohort study of consecutive patients having laminectomies over 2 18-month periods: before the change in practice and after full implementation of the outpatient/overnight stay protocol. We collected information on patient characteristics (age, sex, American Society of Anesthesiologists [ASA] classification, home address, number of laminectomy levels, estimated blood loss) and patient outcome (complications, hospital length of stay, 30-day readmissions). RESULTS: We found no significant difference in age, sex, ASA classification, number of laminectomy levels, or estimated blood loss between the 2 cohorts. There was a change in the number of outpatient (from 0 to 25) and overnight stay laminectomies (from 0 to 13). There was an increase in total (inpatient, overnight stay and outpatient) laminectomies from 41 to 82, and an increase in patients from out of our region from 15% to 32%. There was 1 readmission within 30 days that occurred in the first cohort. CONCLUSION: We found that outpatient and overnight stay laminectomies can be done safely, with no patients requiring postoperative admission to hospital or readmissions within 30 days. They can be done in patients from out of town who need to travel home postoperatively. It is possible to safely reduce the level of resources used for spine surgery by carrying out laminectomies as outpatient or overnight stay surgery in select patients.

CONTEXTE: Par le passé, les laminectomies effectuées dans notre centre nécessitaient l'hospitalisation des patients. Un changement graduel de la pratique a toutefois eu lieu entre 2010 et 2013, et les laminectomies constituent maintenant, dans la mesure du possible, une chirurgie d'un jour, ou une chirurgie dont la durée de séjour se limite à une seule nuit. MÉTHODES: Nous avons mené une étude de cohorte rétrospective sur des patients ayant subi consécutivement une laminectomie au cours d'une des 2 périodes de 18 mois suivantes : avant le changement de pratique ou après celui-ci, c'est-à-dire après la mise en œuvre du protocole de chirurgie d'un jour ou de chirurgie exigeant un séjour d'une nuit. Nous avons recueilli des données sur les caractéristiques des patients (âge, sexe, classification selon l'American Society of Anesthesiologists [ASA], adresse du domicile, nombre de vertèbres touchées par la laminectomie, perte sanguine estimée) et sur les résultats des patients (complications, durée du séjour à l'hôpital, réadmission dans les 30 jours). RÉSULTATS: Aucune différence significative n'a été observée entre les 2 cohortes du point de vue de l'âge, du sexe, de la classification de l'ASA, du nombre de vertèbres touchées par la laminectomie et de la perte sanguine estimée. Il y a toutefois eu une augmentation du nombre de patients se présentant pour une chirurgie d'un jour (de 0 à 25) ou pour une chirurgie exigeant un séjour d'une nuit (de 0 à 13). Le nombre total de laminectomies (patients hospitalisés, chirurgie d'un jour et chirurgie exigeant un séjour d'une nuit) a également augmenté (de 41 à 82), tout comme la proportion de patients venant de l'extérieur de notre région (de 15 % à 32 %). Il n'y a eu qu'une seule réadmission dans les 30 jours suivant une laminectomie, survenue dans la première cohorte. CONCLUSION: Nous avons constaté que les laminectomies effectuées comme chirurgie d'un jour ou comme chirurgie exigeant un séjour d'une nuit peuvent être réalisées de façon sûre, sans que les patients aient besoin d'être hospitalisés en période postopératoire ou d'être réadmis dans les 30 jours suivant l'intervention. Les patients demeurant à l'extérieur de la ville et devant rentrer à la maison en période postopératoire peuvent subir une laminectomie. Il est donc possible de réduire de façon sûre les ressources utilisées pour réaliser des laminectomies en effectuant ces interventions comme chirurgie d'un jour ou comme chirurgie exigeant un séjour d'une nuit chez certains patients.

Geographic and Hospital Variation in Cost of Lumbar Laminectomy and Lumbar Fusion for Degenerative Conditions.

BACKGROUND: Spinal surgery costs vary significantly across hospitals and regions, but there is insufficient understanding of what drives this variation. OBJECTIVE: To examine the factors underlying the cost variation for lumbar laminectomy/discectomy and lumbar fusions. METHODS: We obtained patient information (age, gender, race, severity of illness, risk of mortality, population of county of residence, median zipcode income, insurance status, elective vs nonelective admission, length of stay) and hospital data (region, hospital type, bed size, wage index) for all patients who underwent lumbar laminectomy/discectomy (n = 181 267) or lumbar fusions (n = 433 364) for degenerative conditions in the 2001 to 2013 National Inpatient Sample database. We performed unadjusted and adjusted analyses to determine which factors affect cost. RESULTS: Mean costs for lumbar laminectomy/discectomy and lumbar fusion increased from $8316 and $21 473 in 2001 (in inflation-adjusted 2013 dollars), to $11 405 and $29 438, respectively, in 2013. There was significant regional variation in cost, with the West being the most expensive region across all years and showing the steepest increase in cost over time. After adjusting for patient and hospital factors, the West was 23% more expensive than the Northeast for lumbar laminectomy/discectomy, and 25% more expensive than the Northeast for lumbar fusion ( P < .01). Higher wage index, smaller hospital bed size, and rural/urban nonteaching hospital type were also associated with higher cost for lumbar laminectomy/discectomy and fusion ( P < .01). CONCLUSION: After adjusting for patient factors and wage index, the Western region, hospitals with smaller bed sizes, and rural/urban nonteaching hospitals were associated with higher costs for lumbar laminectomy/discectomy and lumbar fusion.