Rates, Predictive Factors, and Adverse Outcomes of Fusion Surgery for Lumbar Degenerative Disorders in Ontario, Canada, Between 2006 and 2015: A Retrospective Cohort Study.

BACKGROUND: The addition of fusion surgery to the decompression for lumbar degenerative disorders remains controversial. The purpose of this study is to compare the rate and outcome of decompression and fusion versus decompression alone. METHODS: This population-based retrospective cohort study used several linked administrative databases to identify patients who underwent spinal decompression surgery in Ontario, Canada, from 2006 to 2015. Patients who had previous spine surgery, concurrent lumbar disc replacement, or a diagnosis other than degenerative disc disease were excluded. Adjusted logistic regression was used to assess our outcomes. RESULTS: We identified 33,912 patients, of whom 9748 (28.74%) underwent fusion. Overall, fusion rates increased from 27.66% to 31.33% over the study period (P = 0.025). Factors associated with fusion included: older age, female sex, American Society of Anesthesiologists score ≥3, previous total joint replacement, and surgery by an orthopedic surgeon. Fusion surgery was associated with increased odds of 30-day mortality (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.01-3.09; P = 0.046), 30-day (OR 1.94, 95% CI 1.53-2.46; P < 0.0001) and 90-day reoperation (OR 1.66, 95% CI 1.35-2.05; P < 0.0001), and 30-day readmission (OR 1.23, 95% CI 1.02-1.49; P = 0.027) when adjusting for confounding variables. The odds of suffering a complication after fusion and decompression surgery vs. decompression surgery alone were 4.3-fold greater (95% CI 3.78-5.09; P < 0.0001). CONCLUSIONS: As compared with decompression alone, spinal fusion for degenerative lumbar disorders is associated with increased odds of adverse outcomes. These findings highlight the need for spine surgeons to consider carefully their indications for fusion procedures in the setting of degenerative spinal disorders.

Clinical outcomes, complications and fusion rates in endoscopic assisted intraforaminal lumbar interbody fusion (iLIF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): systematic review and meta-analysis.

This meta-analysis aims to determine the clinical outcomes, complications, and fusion rates in endoscopic assisted intra-foraminal lumbar interbody fusion (iLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative diseases. The MEDLINE, Embase, and Cochrane Library databases were searched. The inclusion criteria were: five or more consecutive patients who underwent iLIF or MI-TLIF for lumbar degenerative diseases; description of the surgical technique; clinical outcome measures, complications and imaging assessment; minimum follow-up of 12 months. Surgical time, blood loss, and length of hospital stay were extracted. Mean outcome improvements were pooled and compared with minimal clinically important differences (MCID). Pooled and direct meta-analysis were evaluated. We identified 42 eligible studies. The iLIF group had significantly lower mean intra-operative blood loss, unstandardized mean difference (UMD) 110.61 mL (95%CI 70.43; 150.80; p value < 0.0001), and significantly decreased length of hospital stay (UMD 2.36; 95%CI 1.77; 2.94; p value < 0.0001). Visual analogue scale (VAS) back, VAS leg and Oswestry disability index (ODI) baseline to last follow-up mean improvements were statistically significant (p value < 0.0001), and clinically important for both groups (MCID VAS back > 1.16; MCID VAS leg > 1.36; MCID > 12.40). There was no significant difference in complication nor fusion rates between both cohorts. Interbody fusion using either iLIF or MI-TLIF leads to significant and clinically important improvements in clinical outcomes for lumbar degenerative diseases. Both procedures provide high rates of fusion at 12 months or later, without significant difference in complication rates. iLIF is associated with significantly less intraoperative blood loss and length of hospital stay. Study registration: PROSPERO international prospective register of systematic reviews: Registration No. CRD42020180980, accessible at https://www.crd.york.ac.uk/prospero/ April 2020.

Focused versus conventional radiotherapy in spinal oncology: is there any difference in fusion rates and pseudoarthrosis?

INTRODUCTION: Radiotherapy is considered standard of care for adjuvant peri-operative treatment of many spinal tumors, including those with instrumented fusion. Unfortunately, radiation treatment has been linked to increased risk of pseudoarthrosis. Newer focused radiotherapy strategies with enhanced conformality could offer improved fusion rates for these patients, but this has not been confirmed. METHODS: We performed a retrospective analysis of patients at three tertiary care academic institutions with primary and secondary spinal malignancies that underwent resection, instrumented fusion, and peri-operative radiotherapy. Two board certified neuro-radiologists used the Lenke fusion score to grade fusion status at 6 and 12-months after surgery. Secondary outcomes included clinical pseudoarthrosis, wound complications, the effect of radiation timing and radiobiological dose delivered, the use of photons versus protons, tumor type, tumor location, and use of autograft on fusion outcomes. RESULTS: After review of 1252 spinal tumor patients, there were 60 patients with at least 6 months follow-up that were included in our analyses. Twenty-five of these patients received focused radiotherapy, 20 patients received conventional radiotherapy, and 15 patients were treated with protons. There was no significant difference between the groups for covariates such as smoking status, obesity, diabetes, intraoperative use of autograft, and use of peri-operative chemotherapy. There was a significantly higher rate of fusion for patients treated with focused radiotherapy compared to those treated with conventional radiotherapy at 6-months (64.0% versus 30.0%, Odds ratio: 4.15, p = 0.036) and 12-months (80.0% versus 42.1%, OR: 5.50, p = 0.022). There was a significantly higher rate of clinical pseudoarthrosis in the conventional radiotherapy cohort compared to patients in the focused radiotherapy cohort (19.1% versus 0%, p = 0.037). There was no difference in fusion outcomes for any of the secondary outcomes except for use of autograft. The use of intra-operative autograft was associated with an improved fusion at 12-months (66.7% versus 37.5%, OR: 3.33, p = 0.043). CONCLUSION: Focused radiotherapy may be associated with an improved rate of fusion and clinical pseudoarthrosis when compared to conventional radiation delivery strategies in patients with spinal tumors. Use of autograft at the time of surgery may be associated with improved 12-month fusion rates. Further large-scale prospective and randomized controlled studies are needed to better stratify the effects of radiation delivery modality in these patients.

How old is too old?: Matched analysis of geriatric patients undergoing anterior lumbar interbody fusion.

STUDY DESIGN: Retrospective Review INTRODUCTION/OBJECTIVE: The aim of this study is to utilize a national database to identify how age affects patient outcomes following anterior lumbar interbody fusion (ALIF). There are no established age guidelines for the geriatric population within the spine specialty, which makes patient selection challenging. Furthermore, there are conflicting studies for the risks of performing spine surgeries in the elderly. METHODS: A retrospective review of the Mariner Claims Database was conducted on patients who underwent a single level ALIF (CPT 22558) between 2010 and 2018. Patients were separated into three groups by age: 50-64, 65-74, and 75-84 and matched with respect to gender, smoking, and comorbidity burden. Multivariable logistic regression was used to determine the independent effect of outpatient surgery on the postoperative outcomes after adjusting for demographic factors and pertinent comorbidities. Statistical significance was set at p < 0.05. RESULTS: The study identified 8459 matched patients (3350 50-64; 3350 65-74; and 1759 75-84). Compared with patients aged 50-64, patients aged 65-74 and 75-84 had significantly increased risks of pneumonia (65-74: OR 1.53, 95% CI 1.06-2.24, p = 0.025; 75-84: OR 1.62, 95% CI 1.07-2.42, p = 0.022), sepsis (65-74: OR 2.20, 95% CI 1.36-3.76, p = 0.002; 75-84: OR 2.42, 95% CI 1.43-4.13, p = 0.001), and major complications (65-74: OR 1.35, 95% CI 1.05-1.74, p = 0.021; 75-84: OR 1.48, 95% CI 1.11-1.95, p = 0.006) (Table 2). There were no significant differences between patients aged 65-74 and 75-84 for risks of postoperative pneumonia, sepsis, and major complications (p > 0.05). There were no differences between any groups in terms of long-term outcomes such as pseudoarthrosis, implant related complications, or reoperation (p > 0.05) (Table 3). DISCUSSION/CONCLUSION: The study showed that those older than 65 had a significant increase in risk of pneumonia, sepsis, and major complications following ALIF. In the two cohorts above the age of 65 (65-74 and 75-84) there was no significant differences in postoperative outcomes. LEVEL OF EVIDENCE: 3.

Outcomes of anterior vs. posterior approach to single-level lumbar spinal fusion with interbody device: An analysis of the nationwide inpatient sample.

BACKGROUND: Interbody devices have revolutionized lumbar spinal fusion surgery by improving mechanical stability and maximizing fusion potential. Several approaches for interbody fusion exist with two of the most common being anterior lumbar interbody fusion (ALIF) and posterior lumbar interbody fusion (PLIF). This study aims to compare patient data, hospital outcomes, and post-operative complications between an anterior vs. posterior approach to lumbar interbody fusion. METHODS: This retrospective cohort study utilized the Nationwide Inpatient Sample (NIS) and International Classification of Diseases, 10th edition (ICD10) codes to identify patients (18 +) from 2016 to 2018 who underwent lumbar interbody fusion under an anterior or posterior approach. Patients missing identifiers were excluded from this study. Patients were further investigated by demographic data and the presence of comorbidities. Hospital outcome data was investigated by length of stay (LOS), total hospital charges, mortality, and post-operative complications. RESULTS: 373,585 patients were included in this study. 257,975 (69%) underwent fusion via a posterior approach, and 115,610 (31%) via an anterior approach. Patients undergoing posterior approach were found to have a greater number of comorbidities than anterior (3.5 vs. 2, respectively, p = <0.001). The posterior approach was associated with decreased LOS (3.59 vs 4.19 days, p = <0.0001) and decreased total hospital charges ($141,700 vs $211,015, p = <0.0001). A posterior approach was found to have lower rates of post-operative complications. For the anterior approach cohort, tobacco dependence (OR=1.31 [1.20-1.42, p = <0.001], diabetes (OR=2.41 [2.33-2.49, p = <0.001], and osteoporosis (OR=1.42 [1.30-1.54, p = <0.001] were found to be significant independent predictors of post-operative pseudoarthrosis. Obesity (OR=1.28 [1.14-1.42, p = <0.001], tobacco dependence (OR=1.48 [1.40-1.56, p = <0.001], diabetes (OR=2.21 [2.10-2.32, p = <0.001], congestive heart failure (OR=1.20 [1.01-1.39, p = 0.04], and osteoporosis (OR=1.65 [1.55-1.75, p = <0.001], were found to be independent predictors of post-operative pseudoarthrosis in the posterior cohort. CONCLUSIONS: Patients who underwent the anterior approach suffered from increased hospital charges, length of stay, and increased risk of post-operative complications including mortality, wound dehiscence, hematoma/seroma, and pseudoarthrosis. Comorbid disease plays a significant role in the outcome of successful fusion with variable effect depending on the surgical approach. Increasing due diligence in patient selection should be considered when choosing an approach in pre-operative planning.

A 24-month retrospective update: follow-up hospitalization charges and readmissions in US lumbar fusion surgeries using a cellular bone allograft (CBA) versus recombinant human bone morphogenetic protein-2 (rhBMP-2).

BACKGROUND: The objectives of this study were to build upon previously-reported 12-month findings by retrospectively comparing 24-month follow-up hospitalization charges and potentially-relevant readmissions in US lumbar fusion surgeries that employed either recombinant human bone morphogenetic protein-2 (rhBMP-2) or a cellular bone allograft comprised of viable lineage-committed bone cells (V-CBA) via a nationwide healthcare system database. METHODS: A total of 16,172 patients underwent lumbar fusion surgery using V-CBA or rhBMP-2 in the original study, of whom 3,792 patients (23.4%) were identified in the current study with all-cause readmissions during the 24-month follow-up period. Confounding baseline patient, procedure, and hospital characteristics found in the original study were used to adjust multivariate regression models comparing differences in 24-month follow-up hospitalization charges (in 2020 US dollars) and lengths of stay (LOS; in days) between the groups. Differences in potentially-relevant follow-up readmissions were also compared, and all analyses were repeated in the subset of patients who only received treatment at a single level of the spine. RESULTS: The adjusted cumulative mean 24-month follow-up hospitalization charges in the full cohort were significantly lower in the V-CBA group ($99,087) versus the rhBMP-2 group ($124,389; P < 0.0001), and this pattern remained in the single-level cohort (V-CBA = $104,906 vs rhBMP-2 = $125,311; P = 0.0006). There were no differences between groups in adjusted cumulative mean LOS in either cohort. Differences in the rates of follow-up readmissions aligned with baseline comorbidities originally reported for the initial procedure. Subsequent lumbar fusion rates were significantly lower for V-CBA patients in the full cohort (10.12% vs 12.00%; P = 0.0002) and similar between groups in the single-level cohort, in spite of V-CBA patients having significantly higher rates of baseline comorbidities that could negatively impact clinical outcomes, including bony fusion. CONCLUSIONS: The results of this study suggest that use of V-CBA for lumbar fusion surgeries performed in the US is associated with substantially lower 24-month follow-up hospitalization charges versus rhBMP-2, with both exhibiting similar rates of subsequent lumbar fusion procedures and potentially-relevant readmissions.

Significance of Hospital Size in Outcomes of Single-Level Elective Anterior Cervical Discectomy and Fusion: A Nationwide Readmissions Database Analysis.

OBJECTIVE: To elucidate risk factors for 90-day readmission in anterior cervical discectomy and fusion (ACDF) for small, medium, and large hospitals. To assess differences in length of stay, charges, and complication rates across hospitals of different size. METHODS: A retrospective analysis was performed using elective, single-level ACDF data from 2016 to 2018 in the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Elective single-level ACDF cases were stratified into 3 groups by hospital bed size (small, medium, and large). All-cause complication rates, mean charges, length of stay, and 90-day readmission rates were compared across hospital size. Frequencies of specific comorbidities were compared between readmitted and nonreadmitted patients for each hospital size. Comorbidities significant on univariate analysis were evaluated as independent risk factors for 90-day readmission for each hospital size using multivariate regression. RESULTS: The overall 90-day readmission rate was 6.43% in 36,794 patients, and the rates for small, medium, and large hospitals were 6.25%, 6.28%, and 6.56%, respectively (P = 0.537). Length of stay increased significantly with hospital size (P < 0.001), and small hospitals had the lowest charges (P < 0.001). Although different independent predictors of 90-day readmission were identified for each hospital size, cardiac arrhythmia, chronic pulmonary disease, neurologic disorders, and rheumatic disease were identified as risk factors for hospitals of all sizes. CONCLUSIONS: Hospital size is a determining factor for charges and length of stay associated with elective single-level ACDF. Variation in risk factors for readmission exists across hospital size in context of similar 90-day readmission rates.

Cervical spine alignment and clinical outcomes after multilevel anterior cervical decompression and fusion with or without plate: A minimal 5-year follow-up of a CONSORT-compliant article.

ABSTRACT: It was reported imperative on cervical sagittal alignment reconstruction after anterior multilevel procedures with self-locked stand-alone cage (SSC) or anterior cage-with-plate (ACP) system multilevel while there was little knowledge about the relationship on cervical alignment and clinical outcomes.To identify the importance of cervical sagittal alignment after 3-level anterior cervical discectomy and fusion on cervical spondylotic myelopathy with SSC and ACP system.Seventy-seven patients with SSC system (SSC group) and 52 cases with ACP system (ACP group) from February 2007 to September 2013 were enrolled with well-matched demographics. Cervical alignment included C2-7 lordosis (CL), operated-segment cervical lordosis (OPCL), upper and lower adjacent-segment cervical lordosis, range of motion of upper and lower adjacent segment at preoperation, immediate postoperation, and the final follow-up. Clinical outcomes contained the neck disability index (NDI), the Japanese Orthopaedic Association (JOA) score, visual analogous scale (VAS) of arm and neck and adjacent segment degeneration (ASD). Patients were then divided into CL improved subgroup (IM subgroup) and non-improved subgroup (NIM subgroup).There were improvements on CL and OPCL in both groups. The change of CL and OPCL larger in ACP group (P < .05) but upper adjacent-segment cervical lordosis/lower adjacent-segment cervical lordosis and range of motion of upper adjacent segment/range of motion of lower adjacent segment were of no significance. NDI, JOA, and VAS got improvement in both groups at immediate postoperation and the final follow-up while ASD was in no difference between SSC and ACP group. A total of 80 patients (39 vs 41) acquired CL improvement with a larger population in ACP group. There were no differences on the rate of ASD, NDI, JOA, VAS, and their change between IM and NIM subgroup. The changes of CL were not correlated to NDI, JOA, VAS, and their change.SSC and ACP group both provide improved OPCL and efficacy on 3-level cervical spondylotic myelopathy with little impact on adjacent segment. The change of CL is not correlated to clinical outcomes.

The Effect of Smoking on the Fusion Rate of Spinal Fusion Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis comparing the fusion rate after spinal fusion surgery between smokers and nonsmokers. METHODS: We searched PubMed, Embase, Cochrane Library, and Web of Science electronic databases through March 10, 2021 for cohort and case-control studies assessing the effect of smoking on the fusion rate of spinal fusion surgery. Two researchers independently screened the literature and extracted data according to the inclusion and exclusion criteria. Statistical analysis was performed using RevMan, version 5.4. RESULTS: A total of 26 studies, including 4 case-control studies and 22 cohort studies, with 4409 patients, were included in the present meta-analysis. Follow-up was at least 6 months. Overall, the pooled results demonstrated that the fusion rate of smokers after spinal fusion was significantly lower than that of nonsmokers. The odds ratio (OR) was 0.55 (95% confidence interval [CI] 0.45-0.67, P < 0.0001). Subgroup analyses by fusion level showed the adverse effect of smoking on the fusion rate at single level (OR 0.61, 95% CI 0.41-0.91, P = 0.02) was more significant than that of multiple levels (OR 0.55, 95% CI 0.38-0.80, P = 0.0010). Subgroup analysis according to the type of bone graft revealed an apparent association between smoking and fusion rate in the autograft subgroup (OR 0.47, 95% CI 0.33-0.66, P < 0.0001) but not in the allograft subgroup (OR 0.69, 95% CI 0.47-1.01, P = 0.06). CONCLUSIONS: The fusion rate of smokers is significantly lower than that of nonsmokers in spinal fusion surgery. Smokers should be encouraged to quit smoking to improve the outcome of spinal fusion surgery.

The Influence of Body Mass Index in Obese and Morbidly Obese Patients on Complications and 30- and 90-day Readmissions Following Lumbar Spine Fusion.

STUDY DESIGN: Retrospective cohort study using the 2013-2017 National Readmission Database. OBJECTIVE: The aim of this study was to quantify the influence of body mass index (BMI) on complication and readmission rates following lumbar spine fusion. SUMMARY OF BACKGROUND DATA: Compared to controls, patients with BMI ≥35 had greater odds of readmission, infection, and wound complications following lumbar spine fusion. METHODS: Patients who underwent elective lumbar spine fusion within the population-based sample were considered for inclusion. Exclusion criteria included nonelective lumbar spine fusions, malnourished, anorexic, or underweight patients, and surgical indications of trauma or neoplasm. Patients were grouped by BMI: 18.5 to 29.9 (controls), 30 to 34.9 (obesity I), 35 to 39.9 (obesity II), and ≥40 (obesity III). Multivariate regression was performed to analyze differences in complications and readmissions between groups. Predictive modeling was conducted to estimate the impact of BMI on 30- and 90-day infection, wound complication, and readmissions rates. RESULTS: A total of 86,697 patients were included for analysis, with an average age of 58.9 years and 58.9% being female. The obesity II group had significantly higher odds of infection (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.28-2.62, P = 0.001), wound dehiscence (OR: 3.08, 95% CI: 1.70-6.18, P = 0.0006), and 30-day readmission (OR: 1.32, 95% CI: 1.11-1.58, P = 0.002), whereas the obesity III group had significantly higher odds of acute renal failure (OR: 2.14, 95% CI: 1.20-4.06, P = 0.014), infection (OR: 2.43, 95% CI: 1.72-3.48, P < 0.0001), wound dehiscence (OR: 3.76, 95% CI: 2.08-7.51, P < 0.0001), 30-day readmission (OR: 1.62, 95% CI: 1.36-1.93, P < 0.0001), and 90-day readmission (OR: 1.53, 95% CI: 1.31-1.79, P < 0.0001) compared with controls. Predictive modeling showed cumulative increases of 6.44% in infection, 3.69% in wound dehiscence, and 1.35% in readmission within 90-days for each successive BMI cohort. CONCLUSION: Progressively higher risks for infection, wound complications, and hospital readmission were found with each progressive BMI level.Level of Evidence: 3.

Management and results of early-onset scoliosis with dual magnetically controlled growing rods: Additional preliminary results of spinal fusion surgery.

OBJECTIVES: The aim of this study was to evaluate the clinical and radiographic outcomes and complications of dual magnetically controlled growing rods (MCGRs) in the treatment of early-onset scoliosis (EOS) and to investigate the results of patients with definitive spinal fusion following MCGR. PATIENTS AND METHODS: A total of 15 patients (7 males, 8 females; mean age: 8.7±1.7 years; range, 6 to 10 years) with EOS who underwent dual MCGR and were prospectively followed between February 2013 and March 2019 were included in this retrospective study. The Cobb angle, thoracic kyphosis, and the length of the spine between T1-T12 and T1-S1 were measured on preoperative, postoperative, and follow-up radiographs. The 24-Item Early-Onset Scoliosis Questionnaire (EOSQ-24) was used to assess the functional outcomes before and after the operation. All complications during the treatment were recorded. RESULTS: The mean follow-up was 27.8±10.4 (range, 12 to 60) months. The mean curve correction immediately after the index surgery and latest follow-up was 47.6% and 42.4%, respectively (p>0.05). At the last follow-up, there were no significant changes in mean Cobb and kyphosis angles. The mean T1-T12 length increase was 26.2±7.1 (range, 16 to 40) mm, while the mean T1-S1 length increase was 43.3±15.0 (range, 24 to 70) mm. Complications developed in four (26.6%) of 15 patients. Definitive spinal fusion surgery was performed in seven patients. Total mean Cobb angle difference between the final follow-up and fusion surgery was 9.3° (p=0.016) and kyphosis angle difference was -2.1° (p=0.349). After fusion surgery, total lengthening in T1-T12 and T1-S1 distance was 10.5 mm (p=0.036) and 15.0 mm (p=0.022), respectively. A significant increase in all subdomain scores of the EOSQ-24 (p<0.05), except for financial impact, was recorded in all patients. CONCLUSION: Dual MCGR technique is an effective, reliable, and robust treatment alternative for primary EOS. However, surgeons should be aware of the relatively high rate of complications. In addition, residual deformity can be corrected successfully with definitive surgery.

What does the SRS-22 outcome measure tell us about spinal deformity surgery for Adolescent Idiopathic Scoliosis in the UK?

INTRODUCTION: The purpose of this study was to analyse SRS-22 outcomes measures recorded on the British Spine Registry (BSR) for adolescent idiopathic scoliosis (AIS) surgery in the UK. METHODS: All cases having completed an SRS-22 outcome score and labelled with a diagnosis code of 'AIS' on the BSR were analysed. The SRS-22 score for primary cases was analysed by both individual domains and as a total score over time following surgery. RESULTS: A total of 3,860 cases were labelled as AIS recorded from 3,481 individuals. For primary cases, surgery improved the SRS-22 scores in every domain and as a total score, and this was maintained over time. There was no significant change in the scores recorded between 1 and 2 years of follow up apart from in function (and thus total score) for primary cases. CONCLUSIONS: Surgery for AIS in the UK improves quality of life assessed using SRS-22. Mandatory follow up to 2 years postoperatively adds little information not already known at 1 year. We recommend that the Best Practice Tariff incorporates the collection of outcomes data as this is likely to reduce missing data.

Diagnostic Role of Selective Spinal Nerve Block in Treatment of Lumbar Spine Diseases by Percutaneous Endoscopic Technique.

AIM: To assess the role of our modified selective spinal nerve block (SSNB) procedure to predict the results of the subsequent Percutaneous endoscopic transforaminal lumbar surgeries (PETLS). MATERIAL AND METHODS: We retrospectively analyzed data of patients who underwent our modified SSNBs before PETLS from February 2013 to March 2018 Clinical outcome data were collected 3 days after PETLS and at follow-up visits. RESULTS: A total of 120 modified SSNB procedures (transforaminal-78 paravertebral-24, and interlaminar-18) in 92 patients presented positive response. The median follow-up period was 30.6 months. Based on Macnab criteria, the overall success rate (excellent and good results) was 83.7%. Fair and poor outcomes were observed in 10 and 5 patients, respectively. Patients with atypical extraforaminal herniations, and patients with two-level or multiple-level lumbar disc herniations or stenosis achieved desirable results after PETLS. There was significant improvement in the average VAS score for the leg three days after surgery (7.38±0.97 vs. 1.96 ±1.17, p < 0.05) and on follow-up visits (1.21 ± 0.83, p < 0.05). ODI was also significantly improved three days after surgery (37.20 ± 2.36 vs. 10.95 ± 2.25, p < 0.05 and at follow-up visits (8.90 ± 1.72, p < 0.05) CONCLUSION: The needle tip should be located closely near the intended compressed nerve via suitable approach combined with slowly injecting 1 ml lidocaine (1%) when performing our modified SSNB technique. It presents an alternative diagnostic procedure to identify the origin of pain of complicated lumbar diseases and to predict PETLS outcomes.

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.

Predicting the Failure Risk of Internal Fixation Devices in Chinese Patients Undergoing Spinal Internal Fixation Surgery: Development and Assessment of a New Predictive Nomogram.

The current study is aimed at developing and validating a nomogram of the risk of failure of internal fixation devices in Chinese patients undergoing spinal internal fixation. We collected data from a total of 1139 patients admitted for spinal internal fixation surgery at the First Affiliated Hospital of Guangxi Medical University from May 2012 to February 2019. Of these, 1050 patients were included in the spinal internal fixation group and 89 patients in the spinal internal fixation device failure group. Patients were divided into training and validation tests. The risk assessment of the failure of the spinal internal fixation device used 14 characteristics. In the training test, the feature selection of the failure model of the spinal internal fixation device was optimized using the least absolute shrinkage and selection operator (LASSO) regression model. Based on the characteristics selected in the LASSO regression model, multivariate logistic regression analysis was used for constructing the model. Identification, calibration, and clinical usefulness of predictive models were assessed using C-index, calibration curve, and decision curve analysis. A validation test was used to validate the constructed model. In the training test, the risk prediction nomogram included gender, age, presence or absence of scoliosis, and unilateral or bilateral fixation. The model demonstrated moderate predictive power with a C-index of 0.722 (95% confidence interval: 0.644-0.800) and the area under the curve (AUC) of 0.722. Decision curve analysis depicted that the failure risk nomogram was clinically useful when the probability threshold for internal fixation device failure was 3%. The C-index of the validation test was 0.761. This novel nomogram of failure risk for spinal instrumentation includes gender, age, presence or absence of scoliosis, and unilateral or bilateral fixation. It can be used for evaluating the risk of instrumentation failure in patients undergoing spinal instrumentation surgery.

Smoking Is an Independent Risk Factor for 90-Day Readmission and Reoperation Following Posterior Cervical Decompression and Fusion.

BACKGROUND: Posterior cervical decompression and fusion (PCF) is a common procedure used to treat various cervical spine pathologies, but the 90-d outcomes following PCF surgery continue to be incompletely defined. OBJECTIVE: To identify risk factors associated with 90-d readmission and reoperation following PCF surgery. METHODS: Adults undergoing PCF from 2012 to 2020 were identified. Demographic and radiographic data, surgical characteristics, and 90-d outcomes were collected. Univariate analysis was performed using Student's t-test, chi square, and Fisher exact tests as appropriate. Multivariable logistic regression models with lasso penalty were used to analyze various risk factors. RESULTS: A total of 259 patients were included. The 90-d readmission and reoperation rates were 9.3% and 4.6%, respectively. The most common reason for readmission was surgical site infection (SSI) (33.3%) followed by new neurological deficits (16.7%). Patients who smoked tobacco had 3-fold greater odds of readmission compared to nonsmokers (odds ratio [OR]: 3.48; 95% CI 1.87-6.67; P = .0001). Likewise, the most common reason for reoperation was SSI (33.3%) followed by seroma and implant failure (25.0% each). Smoking was also an independent risk factor for reoperation, associated with nearly 4-fold greater odds of return to the operating room (OR: 3.53; 95% CI 1.53-8.57; P = .003). CONCLUSION: Smoking is a significant predictor of 90-d readmission and reoperation in patients undergoing PCF surgery. Smoking cessation should be strongly considered preoperatively in elective PCF cases to minimize the risk of 90-d readmission and reoperation.

Cost-Effectiveness of Bariatric Surgery Prior to Posterior Lumbar Decompression and Fusion in an Obese Population with Degenerative Spondylolisthesis.

STUDY DESIGN: Cost-effectiveness analysis. OBJECTIVE: To determine if bariatric surgery prior to posterior lumbar decompression and fusion (PLDF) for degenerative spondylolisthesis (DS) is a cost-effective strategy. SUMMARY OF BACKGROUND DATA: Obesity poses significant perioperative challenges for DS. Treated operatively, obese patients achieve worse outcomes relative to non-obese peers. Concomitantly, they fare better with surgery than with nonoperative measures. These competing facts create uncertainty in determining optimal treatment algorithms for obese patients with DS. The role of bariatric surgery merits investigation as a potentially cost-effective optimization strategy prior to PLDF. METHODS: We simulated a Markov model with two cohorts of obese individuals with DS. 10,000 patients with body mass index (BMI) more than or equal to 30 in both arms were candidates for both bariatric surgery and PLDF. Subjects were assigned either to (1) no weight loss intervention with immediate operative or nonoperative management ("traditional arm") or (2) bariatric surgery 2 years prior to entering the same management options ("combined protocol").Published costs, utilities, and transition probabilities from the literature were applied. A willingness to pay threshold of $100,000/QALY was used. Sensitivity analyses were run for all variables to assess the robustness of the model. RESULTS: Over a 10-year horizon, the combined protocol was dominant ($13,500 cheaper, 1.15 QALY more effective). Changes in utilities of operative and nonoperative treatments in non-obese patients, the obesity cost-multiplier, cost of bariatric surgery, and the probability of success of nonoperative treatment in obese patients led to decision changes. However, all thresholds occurred outside published bounds for these variables. CONCLUSION: The combined protocol was less costly and more effective than the traditional protocol. Results were robust with thresholds occurring outside published ranges. Bariatric surgery is a viable, cost-effective preoperative strategy in obese patients considering elective PLDF for DS.Level of Evidence: 3.

Utilization Trends of Recombinant Human Bone Morphogenetic Protein in the United States.

STUDY DESIGN: Retrospective. OBJECTIVE: The aim of this study was to explore the utilization trends of recombinant human bone morphogenetic protein (rh-BMP) in the United States using the largest inpatient administrative database. SUMMARY OF BACKGROUND DATA: Since 2002, the rh-BMP has been widely used by the surgical spine community in fusion surgery. In light of the rising evidence regarding the safety and efficacy of this novel and expensive bone biological technology, a comprehensive examination of its utilization in the American population is warranted. METHODS: We queried the 2002-Q3 2015 National Inpatient Sample for patients that underwent spinal fusion with rh-BMP. We calculated population-level estimates of rh-BMP utilization trends per 100,000 spinal fusions. Trends were estimated for the overall use as well as broken down by primary versus revision fusion, fusion type, number of levels, age category, US region, and hospital type. RESULTS: A total of 5,563,282 fusions were performed, of which 19.9% (n = 1,108,984) utilized rh-BMP. We detected an increase in rh-BMP use in spinal fusion surgery from 0.7% in 2002 to a peak of 29.5% in 2010, followed by a gradual decline till Q3 2015, where it represented 14.7% of all fusion surgeries. These trends paralleled all fusion types. It was most commonly used in fusions spanning two to three levels. The South remained the most common region, whereas West has recently surpassed the Midwest. Its use is becoming more pervasive among older patients, particularly in the 65- to 74 years' age group. CONCLUSION: Further studies are needed to provide insights into the correlation of these trends with the technology's safety and efficacy profile in contemporary series.Level of Evidence: 3.

Long-term Radiographic Outcome of Occipitocervical Fixation: An Analysis of Fusion Rate and Spontaneous Subaxial Alignment Change at an Average 7-year Follow-up.

STUDY DESIGN: Retrospective case series. OBJECTIVE: The aim of this study was to investigate the long-term radiographic outcome of patients who underwent occipitocervical fixation (OCF) using a modern screw/rod system. SUMMARY OF BACKGROUND DATA: Few studies have reported fusion rates and radiographic alignment changes in unfused subaxial segments after OCF at a long-term follow-up. METHODS: We retrospectively reviewed 22 patients who underwent OCF with a modern screw-based construct. The patients satisfied the minimum 2-year radiographic follow-up. Baseline demographics and the following pre- and postoperative sagittal alignment parameters were investigated. McGregor slope, O-C2 angle (OC2A), and C2-7 Cobb angle (CL). We grouped patients into those whose OC2A increased postoperatively (OC2A-increase group) and those whose OC2A decreased postoperatively (OC2A-decrease group). The postoperative sagittal alignment change was compared between the 2 groups at the final follow-up. The perioperative complications as well as fusion status based on computed tomography (CT) were investigated. RESULTS: The average follow-up period was 89.7 months. The lowest instrumented vertebra was at C2 (63.6%), C3 (18.1%), or C4 (18.1%). The fusion rate at the final follow-up was 77.2%. Postoperative dysphasia occurred in two patients (16.6%) in the OC2A-decrease group, whereas distal junctional kyphosis was observed in two patients (20.0%) in the OC2A-increase group. The OC2A-increase group demonstrated a mean 4.8° decrease in CL as a compensation for the 5.1° increase in OC2A. In contrast, the OC2A-decrease group showed a mean 9.2° increase in CL as a compensation for the 6.3° decrease in OC2A. CONCLUSION: The CT-confirmed fusion rate of OCF was 77.2% over an average 89.7-month follow-up. Compensatory sagittal alignment change can occur in the unfused subaxial segments in conjunction with the alignment change in the instrumented OC segments, whereas the horizontal gaze was maintained. Strong consideration for the intraoperative measurement of the OC2A should be given during OCF to minimize both early and long-term complications.Level of Evidence: 4.

Very Low Residual Dystrophin Quantity Is Associated with Milder Dystrophinopathy.

OBJECTIVE: This study was undertaken to determine whether a low residual quantity of dystrophin protein is associated with delayed clinical milestones in patients with DMD mutations. METHODS: We performed a retrospective multicentric cohort study by using molecular and clinical data from patients with DMD mutations registered in the Universal Mutation Database-DMD France database. Patients with intronic, splice site, or nonsense DMD mutations, with available muscle biopsy Western blot data, were included irrespective of whether they presented with severe Duchenne muscular dystrophy (DMD) or milder Becker muscular dystrophy (BMD). Patients were separated into 3 groups based on dystrophin protein levels. Clinical outcomes were ages at appearance of first symptoms; loss of ambulation; fall in vital capacity and left ventricular ejection fraction; interventions such as spinal fusion, tracheostomy, and noninvasive ventilation; and death. RESULTS: Of 3,880 patients with DMD mutations, 90 with mutations of interest were included. Forty-two patients expressed no dystrophin (group A), and 31 of 42 (74%) developed DMD. Thirty-four patients had dystrophin quantities < 5% (group B), and 21 of 34 (61%) developed BMD. Fourteen patients had dystrophin quantities ≥ 5% (group C), and all but 4 who lost ambulation beyond 24 years of age were ambulant. Dystrophin quantities of <5%, as low as <0.5%, were associated with milder phenotype for most of the evaluated clinical outcomes, including age at loss of ambulation (p < 0.001). INTERPRETATION: Very low residual dystrophin protein quantity can cause a shift in disease phenotype from DMD toward BMD. ANN NEUROL 2021;89:280-292.