[Low Back Pain - When Is Surgical Therapy Promising?] / Kreuzschmerzen.

Low Back Pain - When Is Surgical Therapy Promising? Abstract. Low back pain is the number one widespread disease and leads to a high socioeconomic burden. In most cases, low back pain has a non-specific cause, which can be treated conservatively. For low back pain with specific pathoanatomical causes, surgery is usually only indicated for cases refractory to conservative measures or for patients presenting with neurological deficits or mechanical instability. Especially in patients with herniated discs, spinal canal stenosis and spondylolisthesis, surgical treatment has been shown to lead to good or very good long-term patient outcomes. However, careful patient selection and education are critical for successful postoperative patient outcome.

Neuropathic Pain Was Associated with Central Sensitivity Syndrome in Patients with Preoperative Lumbar Spinal Stenosis Using the painDETECT and Central Sensitization Inventory Questionnaires: A Cross-Sectional Study.

Background: Lumbar spinal stenosis (LSS) patients have been reported to have neuropathic pain and central sensitivity syndrome (CSS). These associations have been reported in other diseases but are unknown in preoperative LSS patients. We aimed to investigate the association between neuropathic pain and CSS in preoperative LSS patients using the painDETECT and the Central Sensitization Inventory (CSI) questionnaires. Methods: This cross-sectional study was conducted from November 2021 to March 2022. The data were collected regarding demographics and pain, including neuropathic pain, numbness, LSS severity, physical function, quality of life, and CSS. Patients were divided into two groups, patients with acute and chronic pain, and further classified into three categories based on the clinical phenotype of patients in each group. Independent variables included age, gender, type of LSS (bilateral or unilateral symptoms), Numerical Rating Scale of leg pain, CSI, and the Zurich Claudication Questionnaire (ZCQ) for symptom severity and physical function. The dependent variable was painDETECT. Multiple regression analysis using the forced entry method examined the association between painDETECT and CSI. Results: Of the 119 patients with preoperative LSS, 106 were included. The mean age of the participants was 69.9 years, and 45.3% were female. Neuropathic pain was present in 19.8%, and CSS was present in 10.4%. The CSI (ß = 0.468, p < 0.001) and ZCQ for symptom severity (ß = 0.304, p < 0.01) were significantly associated with the painDETECT, explaining 47.8% of the variance in the painDETECT score. Conclusions: There is an association between neuropathic pain and CSS in patients with preoperative LSS using the painDETECT and CSI questionnaires.

[Observation of early clinical efficacy of unilateral biportal endoscopy technique in the treatment of lumbar postoperative adjacent segmental diseases].

OBJECTIVE: To investigate early clinical efficacy of unilateral biportal endoscopy technique for the treatment of lumbar postoperative adjacent segmental diseases. METHODS: Fourteen patients with lumbar postoperative adjacent segmental diseases were treated with unilateral biportal endoscopy technique from June 2019 to June 2020. Among them, there were 9 males and 5 females, aged from 52 to 73 years old, and the interval between primary and revision operations ranged from 19 to 64 months. Adjacent segmental degeneration occurred after lumbar fusion in 10 patients and after lumbar nonfusion fixation in 4 patients. All the patients received unilateral biportal endoscopy assisted posterior unilateral lamina decompression or unilateral approach to the contralateral decompression. The operation time, postoperative hospital stay and complications were observed. The visual analogue scale (VAS) of low back pain and leg pain, Oswestry Disability Index (ODI), modified Japanese Orthopaedic Association (mJOA) score were recorded before operation and at 3 days, 3 months, and 6 months after operation. RESULTS: All procedures were successfully completed. Surgical duration ranged from 32 to 151 min. Postoperative CT showed adequate decompression and preservation of most joints. Out of bed walking 1 to 3 days after surgery, postoperative hospital stay was 1 to 8 days, and postoperative follow-up was 6 to 11 months. All 14 patients returned to normal life within 3 weeks after surgery, and VAS, ODI, and mJOA scores improved significantly at 3 days and 3, 6 months after surgery. One patient occurred cerebrospinal fluid leak after operation, received local compression suture, and the wound healed after conservative treatment. One patient occurred postoperative cauda equina neurologic deficit, which was gradually recovered about 1 month after rehabilitation therapy. One patients advented transient pain of lower limbs after surgery, and the symptoms were relieved after 7 days of treatment with hormones, dehydration drugs and symptomatic management. CONCLUSION: Unilateral biportal endoscopy technique has a good early clinical efficacy in the treatment of lumbar postoperative adjacent segmental diseases, which may provide a new minimally invasive, non-fixation option for the treatment of adjacent segment disease.

[Comparison of clinical effect and muscle injury imaging between oblique lateral lumbar interbody fusion and transforaminal lumbar interbody fusion in the treatment of single-segment degenerative lumbar spinal stenosis].

OBJECTIVE: To compare the efficacy and muscle injury imaging between oblique lateral lumbar interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis. METHODS: The clinical data of 60 patients with single-segment degenerative lumbar spinal stenosis who underwent surgical treatment from January 2018 to October 2019 was retrospectively analyzed. The patients were divided into OLIF groups and TLIF group according to different surgical methods. The 30 patients in the OLIF group were treated with OLIF plus posterior intermuscular screw rod internal fixation. There were 13 males and 17 females, aged from 52 to 74 years old with an average of (62.6±8.3) years old. And 30 patients in the TLIF group were treated with TLIF via the left approach. There were 14 males and 16 females, aged from 50 to 81 years old with an average of (61.7±10.4) years old. General data including operative time, intraoperative blood loss, postoperative drainage volume, and complications were recorded for both groups. Radiologic data including disc height (DH), the left psoas major muscle, multifidus muscle, longissimus muscle area, T2-weighted image hyperintensity changes and interbody fusion or nonfusion were observed. Laboratory parameters including creatine kinase (CK) values on postoperative 1st and 5th days were analyzed. Visual analogue scale(VAS) and Oswestry disability index(ODI) were used to assess clinical efficacy. RESULTS: There was no significant difference in the operative time between two groups(P>0.05). The OLIF group had significantly less intraoperative blood loss and postoperative drainage volume compared to the TLIF group(P<0.01). The OLIF group also had DH better recovery compared to the TLIF group (P<0.05). There were no significant differences in left psoas major muscle area and the hyperintensity degree before and after the operation in the OLIF group (P>0.05). Postoperativly, the area of the left multifidus muscle and longissimus muscle, as well as the mean of the left multifidus muscle and longissimus muscle in the OLIF group, were lower than those in the TLIF group (P<0.05) .On the 1st day and the 5th day after operation, CK level in the OLIF group was lower than that in the TLIF group(P<0.05). On the 3rd day after operation, the VAS of low back pain and leg pain in the OLIF group were lower than those in the TLIF group (P<0.05). There were no significant differences in the ODI of postoperative 12 months, low back and leg pain VAS at 3, 6, 12 months between the two groups(P>0.05). In the OLIF group, 1 case of left lower extremity skin temperature increased after the operation, and the sympathetic chain was considered to be injured during the operation, and 2 cases of left thigh anterior numbness occurred, which was considered to be related to psoas major muscle stretch, resulting in a complication rate of 10% (3/30). In the TLIF group, one patient had limited ankle dorsiflexion, which was related to nerve root traction, two patients had cerebrospinal fluid leakage, and the dural sac was torn during the operation, and one patient had incision fat liquefaction, which was related to paraspinal muscle dissection injury, resulting in a complication rate of 13% (4/30). All patients achieved interbody fusion without cage collapse during the 6- month follow-up. CONCLUSION: Both OLIF and TLIF are effective in the treatment of single-segment degenerative lumbar spinal stenosis. However, OLIF surgery has obviously advantages, including less intraoperative blood loss, less postoperative pain, and good recovery of intervertebral space height. From the changes in laboratory indexes of CK and the comparison of the left psoas major muscle, multifidus muscle, longissimus muscle area, and high signal intensity of T2 image on imaging, it can be seen that the degree of muscle damage and interference of OLIF surgery is lower than that of TLIF.

A Study of 179 Patients with Degenerative Stenosis of the Lumbosacral Spine to Evaluate Differences in Quality of Life and Disability Outcomes at 12 Months, Between Conservative Treatment and Surgical Decompression.

BACKGROUND This prospective study included 179 patients with degenerative stenosis of the lumbosacral spine and aimed to evaluate the outcomes of conservative treatment and surgical decompression on quality of life and disability over 12 months. MATERIAL AND METHODS The surgery group consisted of 96 patients with degenerative stenosis of the lumbosacral spine who qualified for surgical decompression, while the conservative-treatment group included 83 patients who qualified for conservative treatment. We used the Satisfaction with Life Scale questionnaire, the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire, the Visual Analog Scale to assess the severity of pain, the Oswestry Low Back Pain Disability Questionnaire to assess the degree of disability, and the Sexual Satisfaction Scale at 0, 1, 6, and 12 months after treatment. RESULTS Statistical analysis showed a positive relationship between conservative and surgical treatment and quality of life (P<0.05). A significant reduction in the severity of pain (P<0.05) and the degree of disability (P<0.05) were both recorded during the 12-month followup period in both groups. Women of both groups declared significantly lower satisfaction than men at every time point (P<0.05). CONCLUSIONS Most patients in both groups declared an improvement in their quality of life, with the surgery group showing a higher percentage of responses that their quality of life had improved. Based on the results obtained from the FACIT-F questionnaire, degenerative stenosis of the lumbosacral spine had a non-root effect on the patients' lives in the surgery group.

Impact of Sarcopenia on Percutaneous Epidural Balloon Neuroplasty in Patients with Lumbar Spinal Stenosis: A Retrospective Analysis.

Background and Objectives: With the aging population, the incidence of degenerative lumbar spinal stenosis (LSS) is increasing. Sarcopenia is an age-related muscular decrease. Although epidural balloon neuroplasty is effective in patients with LSS refractory to conventional treatments, its effect has not been assessed in patients with sarcopenia. Therefore, this study evaluated the effect of epidural balloon neuroplasty in patients with LSS and sarcopenia. Materials and Methods: This retrospective study reviewed the following details from the electronic medical records: patient characteristics, including sex, age, body mass index, diabetes, hypertension, stenosis grading, pain duration, location, pain intensity, and medications. Back and leg pain intensity was evaluated before and after the procedure at one, three, and six months during the follow-up period. A generalized estimating equations model was used at six months follow-up. Patients were divided into sarcopenia and non-sarcopenia groups using the cross-sectional area of the psoas muscle at the level of L3 on magnetic resonance imaging. Results: A total of 477 patients were included (sarcopenia group: 314 patients, 65.8%; non-sarcopenia group: 163 patients, 34.2%). Age, sex, body mass index, and medication quantification scale III were statistically different between both groups. The generalized estimating equations analyses-with unadjusted and adjusted estimation-revealed a significantly reduced pain intensity after the procedure compared to the baseline in both groups. The difference in pain intensity between both groups was not statistically different. Conclusions: Percutaneous epidural balloon neuroplasty may be considered for patients with chronic lumbar LSS regardless of accompanying sarcopenia.

Enhancing endoscopic foraminal decompression in adult isthmic spondylolisthesis: the potential influence of lateral recess isthmic spur and our case series of an innovative craniocaudal interlaminar approach via unilateral biportal endoscopic spinal surgery.

BACKGROUND: The NASS guideline cannot recommend any of the surgical treatment options toward adult isthmic spondylolisthesis (AIS) since 2014. After the introduction of endoscopic decompression, instead of treating the spondylolysis itself, treatment can specifically target the refractory radicular pain developed during the degeneration progress without devastating the peripheral soft tissue. However, we noticed that endoscopic transforaminal decompression seems to be less effective in AIS compared to other types of degenerative spondylolisthesis. Thus, we came up with a novel craniocaudal interlaminar approach, utilizing the proximal adjacent interlaminar space to perform bilateral decompression and observed the pathoanatomy of pars defect directly and tried to identify the cause of decompression failure. METHODS: From January 2022 to June 2022, 13 patients with AIS underwent endoscopic decompression via the endoscopic craniocaudal interlaminar approach and were followed up for at least 6 months. Visual Analogue Scale, Oswestry Disability Index and MacNab scores were recorded to monitor patients' clinical recovery. All endoscopic procedures were recorded and reviewed to illustrate the pathoanatomy. RESULTS: Four patients required minor revision via the same technique. One of them required it due to incomplete isthmic spur resection, two due to neglected disc protrusion, and the other due to root subpedicular kinking in higher grade anterolisthesis. All patients' clinical condition improved significantly subsequently. After reviewing the endoscopic video, we have observed that the hook-like, ragged spur originating from the isthmic defect extends beyond the region around the foramen. Instead, it extends proximally into the adjacent lateral recess, resulting in impingement along the fracture edge above the index foramen and, in some cases, even in the extraforaminal area. CONCLUSIONS: The broad spanning isthmic spur extending to the proximal adjacent lateral recess might be the reason why the transforaminal approach yielded less satisfactory results due to the incomplete decompression result from approach related restriction. Our study demonstrated an optimistic outcome by applying decompression from the upper level. Therefore, we propose that the craniocaudal interlaminar approach might be a better route for decompression in adult isthmic spondylolisthesis.

Short-Term Patient Outcomes Using the Interlaminar Endoscopic Surgical System Ilessys® Delta System versus Bilateral Laminotomy: A Single-Center Study of 80 Patients with Degenerative Lumbar Spinal Stenosis.

BACKGROUND This study from a single center aimed to compare short-term patient outcomes from the Interlaminar Endoscopic Surgical System iLESSYS® Delta system vs bilateral laminotomy in 80 patients with degenerative lumbar spinal stenosis (DLSS). MATERIAL AND METHODS We selected 80 patients with DLSS for the study. Of these, 40 were treated with the iLESSYS® Delta system and 40 were treated with bilateral laminotomy. We followed these patients for 1 year. We recorded and compared data on incision length, operation time and intraoperative blood loss, hospitalization time, postoperative complications, the visual analog scale (VAS), and Oswestry Disability Index (ODI) before, 1 week, 3 months, 6 months, and 12 months after surgery, and the Modified Macnab evaluation criteria. RESULTS The incision length, intraoperative blood loss, and hospitalization time were significantly better in group A than in group B (P<0.05); however, the operation time in group B was shorter than that in group A, and the differences were statistically significant (P<0.05). The VAS and ODI in both groups improved significantly after surgery compared with before the operation. The VAS and ODI in group A patients after surgery were lower than those in group B, and only at 1 week after surgery,(P<0.05). The excellent rate of modified MacNab criteria was not statistically significant between groups A and B (P>0.05). CONCLUSIONS Use of the Interlaminar Endoscopic Surgical System iLESSYS® Delta system can effectively manage DLSS and speed patient recovery.

Intra-Operative Neurophysiological Monitoring in Patients with Thoracic Spinal Stenosis: Its Feasibility and High-Risk Factors for New Neurological Deficit.

OBJECTIVE: Considering the high risk of postoperative neurological complications for patients with thoracic spinal stenosis (TSS), intra-operative neurophysiological monitoring (IONM) has been used for detecting possible iatrogenic injury timely. However, the IONM waveforms are often unreliable. This article is designed to determine the test performance of somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) during surgical thoracic decompression in patients with TSS, and to investigate the risk factors associated with deteriorated neurologic function at immediate postoperation. METHODS: Patients undergoing posterior spinal fusion from February 2009 to December 2020 were retrospectively reviewed. Patients were divided into the deteriorated neurologic function (DNF) group and the improved/intact neurological function (INF) group based on the postoperative neurological status. Demographic parameters such as gender, age, height, weight, etiology and IONM data were compared between groups. Demographics and IONM data between DNF and INF groups were compared by independent t or nonparametric tests. The incidence of abnormal SEP was analyzed by Chi-square test. RESULTS: A total of 108 patients (63 males, 45 females) with an average age of 53.5 ± 14.0 years were included. The SEP and MEP records were available in 94 and 98 patients, with the overall success rates being 87.0% and 90.7%, respectively. The sensibilities and specificities were 100% and 88.2% for SEP, 100% and 98.8% for MEP, respectively. There were 17 patients in DNF group and 91 patients in INF group. High weight (79.1 ± 14.6 vs 69.7 ± 15.7 kg, P = 0.024), high inter-side difference of MEP amplitude (899.1 ± 997.5 vs 492.3 ± 512.4 µV, P = 0.013) and high incidence of abnormal SEP (94.1% vs 64.8%, P = 0.024) were observed in the DNF group. Fourteen (82.4%) patients in the DNF group showed improvement in neurological status during follow-up. CONCLUSIONS: The overall success rates were 87.0% for SEP and 90.7% for MEP in patients with TSS.

Unilateral biportal endoscopy versus microscopic decompression in the treatment of lumbar spinal stenosis: A meta-analysis.

BACKGROUND: The aim of this study was to evaluate whether there is a superior clinical effect of unilateral biportal endoscopy compared with microscopic decompression in the treatment of lumbar spinal stenosis. METHODS: We searched CNKI, WANFANG, CQVIP, CBM, PubMed, and Web of Science up to January 2022, and selected studies that met our inclusion criteria. RESULTS: The results of this meta-analysis indicated that unilateral biportal endoscopy was demonstrated to be more beneficial for patients compared with microscopic decompression for the following outcomes: Operation time [standardized mean difference (SMD) = -0.943, 95% confidence interval (CI) (-1.856, -0.031), P = .043], hospital stays [SMD = -2.652, 95% CI (-4.390, -0.914), P = .003], EuroQol 5-Dimension questionnaire [SMD = 0.354, 95% CI (0.070, 0.638), P = .014], back pain visual analogue score [SMD = -0.506, 95% CI (-0.861, -0.151), P = .005], leg pain visual analogue score [SMD = -0.241, 95% CI (-0.371, -.0112), P = .000], the C-reactive protein level [SMD = -1.492,95% CI (-2.432, -0.552), P = .002]. Other outcomes demonstrated no significant differences between the 2 groups. CONCLUSION: For patients with lumbar spinal stenosis, unilateral biportal endoscopy was found to be more superior than microscopic decompression in terms of operation time, hospital stays, EuroQol 5-Dimension questionnaire, back visual analogue score, leg visual analogue score and the C-reactive protein level. There was no significant difference between the 2 groups in other outcome indicators.

The association of rod curvature with postoperative outcomes in patients undergoing posterior lumbar interbody fusion for spinal stenosis: a retrospective case-control study.

BACKGROUND: Restoration of sagittal balance is a crucial consideration in posterior lumbar interbody fusion (PLIF) surgery and adverse postoperative outcomes are associated with inadequate restoration of sagittal alignment. However, there remains a shortage of substantial evidence regarding the effect of rod curvature on both sagittal spinopelvic radiographic parameters and clinical outcomes. METHOD: A retrospective case-control study was conducted in this study. Patient demographics (age, gender, height, weight and BMI), surgical characteristics (number of fused levels, surgical time, blood loss and hospital stay) and radiographic parameters (lumbar lordosis [LL], sacral slope [SS], pelvic incidence [PI], pelvic tilt [PT], PI-LL, Cobb angle of fused segments [Cobb], rod curvature [RC], Posterior tangent angle of fused segments [PTA] and RC-PTA) were analyzed. RESULTS: Patients in the abnormal group had older mean age and suffered more blood loss than those in the normal group. In addition, RC and RC-PTA were significantly lower in the abnormal group compared to the normal group. Multivariate regression analysis revealed that lower age (OR = 0.94; 95% CI: 0.89-0.99; P = 0.0187), lower PTA (OR = 0.91; 95% CI: 0.85-0.96; P = 0.0015) and higher RC (OR = 1.35; 95% CI: 1.20-1.51; P < 0.0001) were related to higher odds of better surgical outcomes. The receiver operating characteristic curve analysis showed that the ROC curve (AUC) for predicting outcomes of surgery by RC classifier was 0.851 (0.769-0.932). CONCLUSIONS: In patients who underwent PLIF surgery for lumbar spinal stenosis, those who had a satisfactory postoperative outcome tended to be younger, had lower blood loss, and higher values of RC and RC-PTA compared to those who had poor recovery and required revision surgery. Additionally, RC was found to be a reliable predictor of postoperative outcomes.

Value of nerve root sedimentation sign in diagnosis and surgical indication of lumbar spinal stenosis.

BACKGROUND: Lumbar spinal stenosis (LSS) is a prevalent and disabling cause of low back and leg pain in elderly people and nerve root sedimentation sign (NRSS) has been demonstrated to have high sensitivity and specificity in diagnosing LSS in selected patients. The purpose of this study was to investigate the diagnosis of LSS and the predictive value of NRSS. METHODS: The clinical and imaging data of 176 patients diagnosed with LSS and 156 patients with non-specific low back pain (LBP) were analyzed retrospectively. Transverse magnetic resonance images (MRI) of the narrowest spinal canal in all patients were acquired and graded by two experienced doctors using the Braz classification, Schizas classification and Chen Jia classification. Receiver operating curve (ROC) was used to compare the diagnostic efficacy of the three classifications. Univariate and multivariate logistic regression models were established to predict the surgical indications of LSS patients. RESULT: The diagnostic efficacy of Schizas classification (AUC:0.943; 95%CI:0.918,0.969) and Chen Jia classification (AUC:0.942; 95%CI:0.918,0.966) was significantly higher than that of Braz classification (AUC:0.853; 95%CI:0.808,0.898). Chen Jia classification had the highest correlation with the degree of dural sac cross-sectional area (DCSA) stenosis. In the multivariate analysis of LSS surgical indications, Chen Jia classification (odds ratio [OR], 2.127; 95%CI:1.596,2.835), DCSA (OR,0.398; 95%CI:0.169,0.802) and intermittent claudication (OR,9.481; 95%CI:3.439,26.142) were associated with surgical indications. CONCLUSION: Among the three types, it is found that Chen Jia classification has better diagnostic efficacy in differentiating LSS from LBP. In addition, Chen Jia classification is simple to be implemented in clinical practice and has high clinical application value. Hence, Chen Jia classification can be used as an effective surgical treatment indicator for LSS patients.

[Skip corpectomy in surgical treatment of cervical spondylotic myelopathy]. / Metod «skip corpectomy¼ pri khirurgicheskom lechenii tservikal'noi spondilogennoi mielopatii.

OBJECTIVE: To evaluate the effectiveness and safety of skip corpectomy in surgical treatment of cervical spondylotic myelopathy. MATERIAL AND METHODS: The study included 7 patients with cervical myelopathy following extended cervical spine stenosis. All patients underwent skip corpectomy. Clinical examination included degree of neurological disorders according to the modified scale of the Japanese Orthopedic Association (JOA) with assessment of recovery rate and Nurick score, as well as VAS score of pain syndrome. Verification of diagnosis was based on the data of spondylography, magnetic resonance and computed tomography. The indications for surgical treatment were conduction disorders and their spondylotic genesis confirmed by neuroimaging methods. RESULTS. VAS: Score of pain syndrome decreased by 2-4 points (mean 3.1) in long-term postoperative period. The JOA, Nurick scores and recovery rate (mean 42.5%) demonstrated significant improvement of neurological status in all patients. In all cases, the follow-up examination confirmed adequate decompression and spinal fusion. CONCLUSION: Skip corpectomy provides adequate spinal cord decompression in case of extended cervical spine stenosis and minimizes the risk of complications typical for multilevel corpectomy. Recovery rate indicates the effectiveness of this method in surgical treatment of cervical myelopathy caused by multilevel stenosis. However, further studies on sufficient clinical material are needed.

sPinal coRd stimulatiOn coMpared with lumbar InStrumEntation for low back pain after previous lumbar decompression (PROMISE): a prospective multicentre RCT.

INTRODUCTION: Persistent spine pain syndrome type 2 (PSPS2) represents a significant burden to the individual and society. Treatment options include revision surgery, stabilisation surgery of the spine, neuromodulation, analgesics and cognitive behavioural therapy. Nevertheless, structured treatment algorithms are missing as high-level evidence on the various treatments is sparse. The aim of this study is to compare higher frequency neuromodulation with instrumentation surgery in patients suffering from PSPS2. METHODS AND ANALYSIS: The sPinal coRd stimulatiOn coMpared with lumbar InStrumEntation for low back pain after previous lumbar decompression (PROMISE) trial is a prospective randomised rater blinded multicentre study. Patients suffering from PSPS2 with a functional burden of Oswestry Disability Index (ODI) >20 points are randomised to treatment via spinal cord stimulation or spinal instrumentation. Primary outcome is back-related functional outcome according to the ODI 12 months after treatment. Secondary outcomes include pain perception (visual analogue scale), Short Form-36, EuroQOL5D, the amount of analgesics, the length of periprocedural hospitalisation and adverse events. Follow-up visits are planned at 3 and 12 months after treatment. Patients with previous lumbar instrumentation, symptomatic spinal stenosis, radiographical apparent spinal instability or severe psychiatric or systemic comorbidities are excluded from the study. In order to detect a significant difference of ≥10 points (ODI) with a power of 80%, n=72 patients need to be included. The recruitment period will be 24 months with a subsequent 12 months follow-up. The beginning of enrolment is planned for October 2022. ETHICS AND DISSEMINATION: The PROMISE trial is the first randomised rater blinded multicentre study comparing the functional effectiveness of spinal instrumentation versus neuromodulation in patients with PSPS2 in order to achieve high-level evidence for these commonly used treatment options in this severely disabling condition. Patient recruitment will be performed at regular outpatient clinic visits. No further (print, social media) publicity is planned. The study is approved by the local ethics committee (LMU Munich, Germany) and will be conducted according to the Declaration of Helsinki. TRIAL REGISTRATION NUMBER: NCT05466110.

Evaluation of the efficacy and safety of conventional and interlaminar full-endoscopic decompressive laminectomy to treat lumbar spinal stenosis (ENDO-F trial): Protocol for a prospective, randomized, multicenter trial.

Lumbar spinal stenosis is a common spinal degenerative condition. Minimally invasive interlaminar full-endoscopic decompressive laminectomy provides greater patient satisfaction and faster recovery than open decompressive laminectomy. The aim of our randomized controlled trial will be to compare the safety and efficacy of interlaminar full-endoscopic laminectomy and open decompressive laminectomy. Our trial will include 120 participants (60 per group) who will undergo surgical treatment for lumbar spinal stenosis. The primary outcome will be the Oswestry Disability Index measured at 12 months postoperatively. Secondary patient-reported outcomes will include back and radicular leg pain measured via a visual analog scale; the Oswestry Disability Index; the Euro-QOL-5 Dimensions score measured at 2 weeks and at 3, 6, and 12 months postoperatively; and patient satisfaction. The functional measures will include time to return to daily activities postoperatively and walking distance/time. The surgical outcomes will include postoperative drainage, operation time, duration of hospital stay, postoperative creatine kinase (an indicator of muscle injury) level, and postoperative surgical scarring. Magnetic resonance and computed tomography images and simple radiographs will be obtained for all patients. The safety outcomes will include surgery-related complications and adverse effects. All evaluations will be performed by a single assessor at each participating hospital who will be blinded to group allocation. The evaluations will be conducted preoperatively and at 2 weeks and 3, 6, and 12 months postoperatively. The randomized, multicenter design of the trial, blinding, and justification of the sample size will reduce the risk of bias in our trial. The results of the trial will provide data regarding the use of interlaminar full-endoscopic laminectomy as an alternative to open decompressive laminectomy that results in similar surgical findings with less invasiveness. Trial registration: This trial is registered at cris.nih.go.kr. (KCT0006198; protocol version 1; 27 May 2021).

The reliability, correlation with clinical symptoms and surgical outcomes of dural sac cross-sectional area, nerve root sedimentation sign and morphological grade for lumbar spinal stenosis.

BACKGROUND: No study had directly compared the reliability, correlation with clinical symptoms, and surgical outcomes of dural sac cross-sectional area (DCSA), nerve root sedimentation sign (SedSign), and morphological grade for lumbar spinal stenosis (LSS). METHODS: From January 2017 to December 2020, 202 patients with LSS were retrospectively analyzed. The narrowest segments were assessed via T2-weighted cross-sectional images using DCSA, morphological grade, and SedSign by two independent observers. Three classifications' reliabilities were evaluated. Correlations between three classifications and between each of the classifications and symptoms or surgical outcomes 12 months postoperatively were evaluated. RESULTS: There were 144 males and 58 females; 23, 52, and 127 patients had the narrowest segment in L2-3, L3-4, and L4-5, respectively. The intra-observer reliability of DCSA ranged from 0.91 to 0.93, and the inter-observer reliability was 0.90. The intra-observer reliability of SedSign ranged from 0.83 to 0.85, and the inter-observer reliability was 0.75. The intra-observer reliability of morphological grade ranged from 0.72 to 0.78, and the inter-observer reliability was 0.61. Each of these classifications was correlated with the other two (P < 0.01). For preoperative symptoms, DCSA was correlated with leg pain (LP) (r = - 0.14), Oswestry Disability Index (ODI) (r = - 0.17), and claudication (r = - 0.19). Morphological grade was correlated with LP (r = 0.19) and claudication (r = 0.27). SedSign was correlated with ODI (r = 0.23). For postoperative outcomes, morphological grade was correlated with LP (r = - 0.14), and SedSign was correlated with ODI (r = 0.17). CONCLUSIONS: Substantial to almost perfect intra and inter-observer reliabilities for the three classifications were found; however, these classifications had either weak correlations with symptoms and surgical outcomes or none at all. Based on our findings, using one of them without conducting other tests for LSS will have limited or uncertain value in surgical decision-making or evaluating the prognostic value.

Thoracic spondylotic myelopathy in diffuse idiopathic skeletal hyperostosis: a comparative study.

BACKGROUND: To explore the characteristics and clinical management of thoracic spinal stenosis with diffuse idiopathic skeletal hyperostosis (DISH). METHODS: The patients diagnosed with thoracic spondylotic myelopathy who underwent spinal decompression and fusion surgery in a single center between 2012 and 2020 were retrospectively analyzed. All the patients were followed up for at least 2 years. Patients were classified into DISH and non-DISH groups. Demographic, radiographic and clinical parameters were compared between the two groups. RESULTS: A total of 100 thoracic spondylotic myelopathy patients were included in the study. 22 patients were diagnosed with DISH. The proportion of male patients in the DISH group was higher, and the average BMI was larger. The incidence of upper thoracic vertebrae with ossification of posterior longitudinal ligament (OPLL) (P < 0.05) and lumbar spine with ossification of ligamentum flavum (OLF) was higher (P < 0.05) in DISH the group. The proportion of patients received staged surgery is higher in the DISH group (P < 0.1). There were no significant differences between the two groups in the amount of surgical bleeding, the ratio of cerebrospinal fluid leakage, the time duration of drainage tube placement and the JOA scores. CONCLUSION: Thoracic spinal stenosis with DISH occurred more in male patients with larger BMI. The posterior decompression and fusion surgery could achieve comparable satisfying clinical outcomes between DISH and non-DISH patients. More proportion of patients received staged surgery in the DISH group; the underline mechanism may be DISH caused more OPLL in the upper thoracic spine and more OLF in the lumbar spine because of mechanical stress.

Efficacy of surgical treatment on polypharmacy of elderly patients with lumbar spinal canal stenosis: retrospective exploratory research.

BACKGROUND: Polypharmacy is a growing public health problem occurring in all healthcare settings worldwide. Elderly patients with lumbar spinal canal stenosis (LSS) who manifest low back and neuropathic pain and have a high frequency of comorbidity are predicted to take many drugs. However, no studies have reported polypharmacy in elderly patients with LSS. Thus, we aimed to review the polypharmacy among elderly LSS patients with elective surgeries and examine how the surgical treatment reduces the polypharmacy. METHODS: We retrospectively enrolled all the patients aged ≥ 65 years who underwent spinal surgery for LSS between April 2020 and March 2021. The prescribed drugs of participants were directly checked by pharmacists in the outpatient department preoperatively and 6-month and 1-year postoperatively. The baseline characteristics were collected beside the patient-based outcomes including Roland-Morris Disability Questionnaire, Zurich Claudication Questionnaire, and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). The cutoff number of drugs for polypharmacy was defined as 6. The prescription drugs were divided into 9 categories: drugs for neuropsychiatric, cardiovascular, respiratory, digestive, endocrine metabolic, and urinary renal diseases; blood products; pain relief medication; and others. RESULTS: A total of 102 cases were finally analyzed, with a follow-up rate of 78.0%. Of the participants, the preoperative polypharmacy prevalence was 66.7%. The number of drugs 6-month and 1-year postoperatively was significantly less than the preoperative one. The proportions of polypharmacy at 6 months and 1 year after surgery significantly decreased to 57.8% and 55.9%, respectively. When the prescribed drugs were divided into 9 categories, the number of drugs for pain relief and digestive diseases was significantly reduced after surgery. The multi-variable analysis revealed that a higher score in the psychological disorder of JOABPEQ was associated with 3 or more drugs decreased 1-year postoperatively (OR, 2.5; 95% CI: 1.0-6.1). CONCLUSION: Polypharmacy prevalence was high among elderly LSS patients indicated for lumbar spinal surgery. Additionally, our data showed that lumbar spinal surgery was effective in reducing polypharmacy among elderly LSS patients. Finally, the multi-variable analysis indicated that better psychological condition was associated with the reduction of prescribed drugs after lumbar spinal surgery.

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis.

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming more common. Full-endoscopic spinal surgeries have the advantages of being less invasive and offering a shorter recovery time. Here, we describe the technique of the full-endoscopic interlaminar approach for the decompression of lateral recess stenosis. The full-endoscopic interlaminar approach for the lateral recess stenosis procedure took approximately 51 min (range of 39-66 min). Blood loss could not be measured due to continuous irrigation. However, no drainage was required. There were no dura mater injuries reported in our institution. Furthermore, there were no injuries to the nerves, no cauda equine syndrome, and no hematoma formation. The patients were mobilized on the same day as surgery and discharged the next day. Therefore, the full-endoscopic technique for lateral recess stenosis decompression is a feasible procedure that lowers the operational time, complications, traumatization, and rehabilitation duration.

Impact of the number of previous lumbar operations on patient-reported outcomes after surgery for lumbar spinal stenosis or lumbar disc herniation.

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS. The proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends. We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery.