The anterior-to-psoas approach for interbody fusion at the L5-S1 segment: clinical and radiological outcomes.

OBJECTIVE: Over the last few decades, many surgical techniques for lumbar interbody fusion have been reported. The anterior-to-psoas (ATP) approach is theoretically supposed to benefit from the advantages of both anterior and lateral approaches with similar complication rates, even in L5-S1. At this segment, the anterior lumbar interbody fusion (ALIF) requires retroperitoneal dissection and retraction of major vessels, whereas the iliac crest does not allow the lateral transpsoas approach. This study aimed to investigate clinical-radiological outcomes and complications of the ATP approach at the L5-S1 segment in a single cohort of patients. METHODS: This is a prospective single-center study, conducted from 2016 to 2019. Consecutive patients who underwent ATP at the L5-S1 segment for degenerative disc disease or revision surgery after previous posterior procedures were considered for eligibility. Complete clinical-radiological documentation and a minimum follow-up of 12 months were set as inclusion criteria. Clinical patient-reported outcomes, such as the visual analog scale for low-back pain, Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) scores, as well as spinopelvic parameters, were collected preoperatively, 6 weeks after surgery, and at the last follow-up visit. Intraoperative and perioperative complications were recorded. The fusion rate was evaluated on CT scans obtained at 12 months postoperatively. RESULTS: Thirty-two patients met the inclusion criteria. The mean age at the time of surgery was 57.6 years (range 44-75 years). The mean follow-up was 33.1 months (range 13-48 months). The mean pre- and postoperative visual analog scale (7.9 ± 1.3 vs 2.4 ± 0.8, p < 0.05), Oswestry Disability Index (52.8 ± 14.4 vs 22.9 ± 6.0, p < 0.05), and SF-36 (37.3 ± 5.8 vs 69.8 ± 6.1, p < 0.05) scores significantly improved. The mean lumbar lordosis and L5-S1 segmental lordosis significantly increased after surgery. The mean pelvic incidence-lumbar lordosis mismatch and pelvic tilt significantly decreased. No intraoperative complications and a postoperative complication rate of 9.4% were recorded. The fusion rate was 96.9%. One patient needed a second posterior revision surgery for residual foraminal stenosis. CONCLUSIONS: In the present case series, ATP fusion for the L5-S1 segment has resulted in valuable clinical-radiological outcomes and a relatively low complication rate. Properly designed clinical and comparative trials are needed to further investigate the role of ATP for different L5-S1 conditions.

Long-term clinical outcomes after bilateral laminotomy or total laminectomy for lumbar spinal stenosis: a single-institution experience.

OBJECTIVELumbar spinal stenosis (LSS) is the most common spinal disease in the geriatric population, and is characterized by a compression of the lumbosacral neural roots from a narrowing of the lumbar spinal canal. LSS can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Different surgical techniques with or without fusion are currently treatment options. The purpose of this study was to provide a description of the long-term clinical outcomes of patients who underwent bilateral laminotomy compared with total laminectomy for LSS.METHODSThe authors retrospectively reviewed all the patients treated surgically by the senior author for LSS with total laminectomy and bilateral laminotomy with a minimum of 10 years of follow-up. Patients were divided into 2 treatment groups (total laminectomy, group 1; and bilateral laminotomy, group 2) according to the type of surgical decompression. Clinical outcomes measures included the visual analog scale (VAS), the 36-Item Short-Form Health Survey (SF-36) scores, and the Oswestry Disability Index (ODI). In addition, surgical parameters, reoperation rate, and complications were evaluated in both groups.RESULTSTwo hundred fourteen patients met the inclusion and exclusion criteria (105 and 109 patients in groups 1 and 2, respectively). The mean age at surgery was 69.5 years (range 58-77 years). Comparing pre- and postoperative values, both groups showed improvement in ODI and SF-36 scores; at final follow-up, a slightly better improvement was noted in the laminotomy group (mean ODI value 22.8, mean SF-36 value 70.2), considering the worse preoperative scores in this group (mean ODI value 70, mean SF-36 value 38.4) with respect to the laminectomy group (mean ODI 68.7 vs mean SF-36 value 36.3), but there were no statistically significant differences between the 2 groups. Significantly, in group 2 there was a lower incidence of reoperations (15.2% vs 3.7%, p = 0.0075).CONCLUSIONSBilateral laminotomy allows adequate and safe decompression of the spinal canal in patients with LSS; this technique ensures a significant improvement in patients' symptoms, disability, and quality of life. Clinical outcomes are similar in both groups, but a lower incidence of complications and iatrogenic instability has been shown in the long term in the bilateral laminotomy group.

Cost-effectiveness of adult spinal deformity surgery in a military healthcare system.

OBJECTIVEAdult spinal deformity surgery is an effective way of treating pain and disability, but little research has been done to evaluate the costs associated with changes in health outcome measures. This study determined the change in quality-adjusted life years (QALYs) and the cost per QALY in patients undergoing spinal deformity surgery in the unique environment of a military healthcare system (MHS).METHODSPatients were enrolled between 2011 and 2017. Patients were eligible to participate if they were undergoing a thoracolumbar spinal fusion spanning more than 6 levels to treat an underlying deformity. Patients completed the 36-Item Short Form Health Survey (SF-36) prior to surgery and 6 and 12 months after surgery. The authors used paired t-tests to compare SF-36 Physical Component Summary (PCS) scores between baseline and postsurgery. To estimate the cost per QALY of complex spine surgery in this population, the authors extended the change in health-related quality of life (HRQOL) between baseline and follow-up over 5 years. Data on the cost of surgery were obtained from the MHS and include all facility and physician costs.RESULTSHRQOL and surgical data were available for 49 of 91 eligible patients. Thirty-one patients met additional criteria allowing for cost-effectiveness analysis. Over 12 months, patients demonstrated significant improvement (p < 0.01) in SF-36 PCS scores. A majority of patients met the minimum clinically important difference (MCID; 83.7%) and substantive clinical benefit threshold (SCBT; 83.7%). The average change in QALY was an increase of 0.08. Extended across 5 years, including the 3.5% discounting per year, study participants increased their QALYs by 0.39, resulting in an average cost per QALY of $181,649.20. Nineteen percent of patients met the < $100,000/QALY threshold with half of the patients meeting the < $100,000/QALY mark by 10 years. A sensitivity analysis showed that patients who scored below 60 on their preoperative SF-36 PCS had an average increase in QALYs of 0.10 per year or 0.47 over 5 years.CONCLUSIONSWith a 5-year extended analysis, patients who receive spinal deformity surgery in the MHS increased their QALYs by 0.39, with 19% of patients meeting the $100,000/QALY threshold. The majority of patients met the threshold for MCID and SCBT at 1 year postoperatively. Consideration of preoperative functional status (SF-36 PCS score < 60) may be an important factor in determining which patients benefit the most from spinal deformity surgery.

Tubular microdiscectomy: techniques, complication avoidance, and review of the literature.

OBJECTIVE Microendoscopic discectomy is a minimally invasive surgery technique that was initially described in 1997. It allows surgeons to work with 2 hands through a small-diameter, operating table-mounted tubular retractor, and to apply standard microsurgical techniques in which a small skin incision and minimal muscle dissection are used. Whether the surgeon chooses to use an endoscope or a microscope for visualization, the technique uses the same type of retractor and is thus called tubular microdiscectomy. The goal in this study was to review the current literature, examine the level of evidence supporting tubular microdiscectomy, and describe surgical techniques for complication avoidance. METHODS The authors performed a systematic PubMed review using the terms "microdiscectomy trial," "tubular and open microdiscectomy," "microendoscopic open discectomy," and "minimally invasive open microdiscectomy OR microdiskectomy." Of 317 references, 10 manuscripts were included for analysis based on study design, relevance, and appropriate comparison of open to tubular discectomy. RESULTS Similar and very favorable clinical outcomes can be expected from tubular and standard microdiscectomy. Studies have demonstrated equivalent operating times for both procedures, with lower blood loss and shorter hospital stays associated with tubular microdiscectomy. Furthermore, postoperative analgesic usage has been shown to be significantly lower after tubular microdiscectomy. Overall rates of complications are no different for tubular and standard microdiscectomy. CONCLUSIONS Prospective randomized trials have been used to evaluate outcomes of common minimally invasive lumbar spine procedures. For lumbar discectomy, Level I evidence supports equivalently good outcomes for tubular microdiscectomy compared with standard microdiscectomy. Likewise, Level I data indicate similar safety profiles and may indicate lower blood loss for tubular microdiscectomy. Future studies should examine the comparative value of these procedures.

Potential of predictive computer models for preoperative patient selection to enhance overall quality-adjusted life years gained at 2-year follow-up: a simulation in 234 patients with adult spinal deformity.

OBJECTIVE Patients with adult spinal deformity (ASD) experience significant quality of life improvements after surgery. Treatment, however, is expensive and complication rates are high. Predictive analytics has the potential to use many variables to make accurate predictions in large data sets. A validated minimum clinically important difference (MCID) model has the potential to assist in patient selection, thereby improving outcomes and, potentially, cost-effectiveness. METHODS The present study was a retrospective analysis of a multiinstitutional database of patients with ASD. Inclusion criteria were as follows: age ≥ 18 years, radiographic evidence of ASD, 2-year follow-up, and preoperative Oswestry Disability Index (ODI) > 15. Forty-six variables were used for model training: demographic data, radiographic parameters, surgical variables, and results on the health-related quality of life questionnaire. Patients were grouped as reaching a 2-year ODI MCID (+MCID) or not (-MCID). An ensemble of 5 different bootstrapped decision trees was constructed using the C5.0 algorithm. Internal validation was performed via 70:30 data split for training/testing. Model accuracy and area under the curve (AUC) were calculated. The mean quality-adjusted life years (QALYs) and QALYs gained at 2 years were calculated and discounted at 3.5% per year. The QALYs were compared between patients in the +MCID and -MCID groups. RESULTS A total of 234 patients met inclusion criteria (+MCID 129, -MCID 105). Sixty-nine patients (29.5%) were included for model testing. Predicted versus actual results were 50 versus 40 for +MCID and 19 versus 29 for -MCID (i.e., 10 patients were misclassified). Model accuracy was 85.5%, with 0.96 AUC. Predicted results showed that patients in the +MCID group had significantly greater 2-year mean QALYs (p = 0.0057) and QALYs gained (p = 0.0002). CONCLUSIONS A successful model with 85.5% accuracy and 0.96 AUC was constructed to predict which patients would reach ODI MCID. The patients in the +MCID group had significantly higher mean 2-year QALYs and QALYs gained. This study provides proof of concept for using predictive modeling techniques to optimize patient selection in complex spine surgery.

Relative lumbar lordosis and lordosis distribution index: individualized pelvic incidence-based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis.

OBJECTIVE The subtraction of lumbar lordosis (LL) from the pelvic incidence (PI) offers an estimate of the LL required for a given PI value. Relative LL (RLL) and the lordosis distribution index (LDI) are PI-based individualized measures. RLL quantifies the magnitude of lordosis relative to the ideal lordosis as defined by the magnitude of PI. LDI defines the magnitude of lower arc lordosis in proportion to total lordosis. The aim of this study was to compare RLL and PI - LL for their ability to predict postoperative complications and their correlations with health-related quality of life (HRQOL) scores. METHODS Inclusion criteria were ≥ 4 levels of fusion and ≥ 2 years of follow-up. Mechanical complications were proximal junctional kyphosis/proximal junctional failure, distal junctional kyphosis/distal junctional failure, rod breakage, and implant-related complications. Correlations between PI - LL, RLL, PI, and HRQOL were analyzed using the Pearson correlation coefficient. Mechanical complication rates in PI - LL, RLL, LDI, RLL, and LDI interpreted together, and RLL subgroups for each PI - LL category were compared using chi-square tests and the exact test. Predictive models for mechanical complications with RLL and PI - LL were analyzed using binomial logistic regressions. RESULTS Two hundred twenty-two patients (168 women, 54 men) were included. The mean age was 52.2 ± 19.3 years (range 18-84 years). The mean follow-up was 28.8 ± 8.2 months (range 24-62 months). There was a significant correlation between PI - LL and PI (r = 0.441, p < 0.001), threatening the use of PI - LL to quantify spinopelvic mismatch for different PI values. RLL was not correlated with PI (r = -0.093, p > 0.05); therefore, it was able to quantify divergence from ideal lordosis for all PI values. Compared with PI - LL, RLL had stronger correlations with HRQOL scores (p < 0.05). Discrimination performance was better for the model with RLL than for PI - LL. The agreement between RLL and PI - LL was high (κ = 0.943, p < 0.001), moderate (κ = 0.455, p < 0.001), and poor (κ = -0.154, p = 0.343), respectively, for large, average, and small PI sizes. When analyzed by RLL, each PI - LL category was further divided into distinct groups of patients who had different mechanical complication rates (p < 0.001). CONCLUSIONS Using the formula of PI - LL may be insufficient to quantify normolordosis for the whole spectrum of PI values when applied as an absolute numeric value in conjunction with previously reported population-based average thresholds of 10° and 20°. Schwab PI - LL groups were found to constitute an inhomogeneous group of patients. RLL offers an individualized quantification of LL for all PI sizes. Compared with PI - LL, RLL showed a greater association with both mechanical complications and HRQOL. The use of RLL and LDI together, instead of PI - LL, for surgical planning may result in lower mechanical complication rates and better long-term HRQOL.

Early experience with endoscopic foraminotomy in patients with moderate degenerative deformity.

OBJECTIVE Asymmetrical degeneration of the disc is one of the most common causes of primary degenerative scoliosis in adults. Coronal deformity is usually less symptomatic than a sagittal deformity because there is less expenditure of energy and hence less effort to maintain upright posture. However, nerve root compression at the fractional curve or at the concave side of the main curve can give rise to debilitating radiculopathy. METHODS This study was a retrospective analysis of 16 patients with coronal deformity of between 10° and 20°. All patients underwent endoscopic foraminal decompression surgery. The pre- and postoperative Cobb angle, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36), and Oswestry Disability Index scores were measured. RESULTS The average age of the patients was 70.0 ± 15.5 years (mean ± SD, range 61-86 years), with a mean followup of 7.5 ± 5.3 months (range 2-14 months). The average coronal deformity was 16.8° ± 4.7° (range 10°-41°). In 8 patients the symptomatic foraminal stenosis was at the level of the fractional curve, and in the remaining patients it was at the concave side of the main curve. One of the patients included in the current cohort had to undergo a repeat operation within 1 week for another disc herniation at the adjacent level. One patient had CSF leakage, which was repaired intraoperatively, and no further complications were noted. On average, preoperative VAS and SF-36 scores showed a tendency for improvement, whereas a dramatic reduction of VAS, by 65% (p = 0.003), was observed in radicular leg pain. CONCLUSIONS Patients with mild to moderate spinal deformity are often compensated and have tolerable levels of back pain. However, unilateral radicular pain resulting from foraminal stenosis can be debilitating. In select cases, an endoscopic discectomy or foraminotomy enables the surgeon to decompress the symptomatic foramen with preservation of essential biomechanical structures, delaying the need for a major deformity correction surgery.

Endoscopic minimally invasive transforaminal interbody fusion without general anesthesia: initial clinical experience with 1-year follow-up.

OBJECTIVE One of the principal goals of minimally invasive surgery has been to speed postoperative recovery. In this case series, the authors used an endoscopic technique for interbody fusion combined with percutaneous screw fixation to obviate the need for general anesthesia. METHODS The first 10 consecutive patients treated with a minimum of 1 year's follow-up were included in this series. The patients were all treated using endoscopic access through Kambin's triangle to allow for neural decompression, discectomy, endplate preparation, and interbody fusion. This was followed by percutaneous pedicle screw and connecting rod placement using liposomal bupivacaine for long-acting analgesia. No narcotics or regional anesthetics were used during surgery. RESULTS All patients underwent the procedure successfully without conversion to open surgery. The patients' average age was 62.2 ± 9.0 years (range 52-78 years). All patients had severe disc height collapse, and 60% had a Grade I spondylolisthesis. The mean operative time was 113.5 ± 6.3 minutes (range 105-120 minutes), and blood loss was 65 ± 38 ml (range 30-190 ml). The mean length of hospital stay was 1.4 ± 1.3 nights. There were no intraoperative or postoperative complications. Comparison of preoperative and final clinical metrics demonstrated that the Oswestry Disability Index improved from 42 ± 11.8 to 13.3 ± 15.1; the 36-Item Short Form Health Survey (SF-36) Physical Component Summary improved from 47.6 ± 3.8 to 49.7 ± 5.4; the SF-36 Mental Component Summary decreased from 47 ± 3.9 to 46.7 ± 3.4; and the EQ-5D improved from 10.7 ± 9.5 to 14.2 ± 1.6. There were no cases of nonunion identified radiographically on follow-up imaging. CONCLUSIONS Endoscopic fusion under conscious sedation may represent a feasible alternative to traditional lumbar spine fusion in select patients. Larger clinical series are necessary to validate that clinical improvements are sustained and that arthrodesis rates are successful when compared with open surgery. This initial experience demonstrates the possible utility of this procedure.

Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management.

OBJECT: The overall evidence for nonoperative management of patients with traumatic thoracolumbar burst fractures is unknown. There is no agreement on the optimal method of conservative treatment. Recent randomized controlled trials that have compared nonoperative to operative treatment of thoracolumbar burst fractures without neurological deficits yielded conflicting results. By assessing the level of evidence on conservative management through validated methodologies, clinicians can assess the availability of critically appraised literature. The purpose of this study was to examine the level of evidence for the use of conservative management in traumatic thoracolumbar burst fractures. METHODS: A comprehensive search of the English literature over the past 20 years was conducted using PubMed (MEDLINE). The inclusion criteria consisted of burst fractures resulting from a traumatic mechanism, and fractures of the thoracic or lumbar spine. The exclusion criteria consisted of osteoporotic burst fractures, pathological burst fractures, and fractures located in the cervical spine. Of the studies meeting the inclusion/exclusion criteria, any study in which nonoperative treatment was used was included in this review. RESULTS: One thousand ninety-eight abstracts were reviewed and 447 papers met inclusion/exclusion criteria, of which 45 were included in this review. In total, there were 2 Level-I, 7 Level-II, 9 Level-III, 25 Level-IV, and 2 Level-V studies. Of the 45 studies, 16 investigated conservative management techniques, 20 studies compared operative to nonoperative treatments, and 9 papers investigated the prognosis of conservative management. CONCLUSIONS: There are 9 high-level studies (Levels I-II) that have investigated the conservative management of traumatic thoracolumbar burst fractures. In neurologically intact patients, there is no superior conservative management technique over another as supported by a high level of evidence. The conservative technique can be based on patient and surgeon preference, comfort, and access to resources. A high level of evidence demonstrated similar functional outcomes with conservative management when compared with open surgical operative management in patients who were neurologically intact. The presence of a neurological deficit is not an absolute contraindication for conservative treatment as supported by a high level of evidence. However, the majority of the literature excluded patients with neurological deficits. More evidence is needed to further classify the appropriate burst fractures for conservative management to decrease variables that may impact the prognosis.

Bracing for thoracolumbar fractures.

Traumatic fractures of the thoracolumbar spine are relatively common occurrences that can be a source of pain and disability. Similarly, osteoporotic vertebral fractures are also frequent events and represent a significant health issue specific to the elderly. Neurologically intact patients with traumatic thoracolumbar fractures can commonly be treated nonoperatively with bracing. Nonoperative treatment is not suitable for patients with neurological deficits or highly unstable fractures. The role of operative versus nonoperative treatment of burst fractures is controversial, with high-quality evidence supporting both options. Osteoporotic vertebral fractures can be managed with bracing or vertebral augmentation in most cases. There is, however, a lack of high-quality evidence comparing operative versus nonoperative fractures in this population. Bracing is a low-risk, cost-effective method to treat certain thoracolumbar fractures and offers efficacy equivalent to that of surgical management in many cases. The evidence for bracing of osteoporotic-type fractures is less clear, and further investigation will be necessary to delineate its optimal role.

Exploring Functional Impairment in Light of Prolonged Grief Disorder: A Prospective, Population-Based Cohort Study.

Background: Functional impairment is essential in the diagnostic criteria for prolonged grief disorder (PGD) in the ICD-11. It refers to the negative impact on everyday life, including inability to maintain the usual level of functioning. We aimed to assess the extent of functional impairment, emotion-related role limitation, and impaired social functioning before and after bereavement, and to explore associations with PGD, as measured by the 13-item Prolonged Grief Scale (PGDPG13). Method: Relatives of terminally ill patients (n = 1,622) completed a questionnaire before and after bereavement. The questionnaire assessed "overall functional impairment" (PG-13 item) and "aspects of functional impairment" measured by mean scores of the 36-item Short Form Survey (SF-36) subscales emotional role and social functioning (0: worst; 100: best). We analyzed associations between PGDPG13 and functional impairment prior to bereavement using logistic regression models adjusted for age, gender, personal relation, education, time interval to patient's death, and pre-loss grief. Results: In total, 51% reported overall functional impairment before bereavement, 27% reported functional impairment at 6 months after bereavement, and 19% reported functional impairment at 3 years after bereavement. The mean emotional role score was 47.5 (95%CI: 45.4-49.7) before bereavement, increasing to 77.4 (95%CI: 75.7-79.0) at 3 years after bereavement, compared to 85.1 (95%CI: 77.6-92.6) in a reference sample. Mean social functioning score increased gradually reaching the mean of the reference sample at 3 years after bereavement. PGDPG13 was present in 26% of those with overall functional impairment at 6 months after bereavement, decreasing to 11% at 3 years after bereavement. Pre-bereavement measures of emotional role and social functioning were associated with PGDPG13at 6 months and 3 years after bereavement. Discussion: Overall functional impairment was prevalent as reflected in low scores on daily activities and social functioning compared to a reference sample. Functioning may be an important factor during caregiving and bereavement and pre-bereavement functional impairment was associated with PGDPG13. Future studies should investigate if maintaining daily activities and social functioning before bereavement could be key in early supportive care. Moreover, the role of functional impairment in bereavement interventions should be explored.

Minimally invasive foramen magnum durectomy and obexostomy for treatment of craniocervical junction-related syringomyelia in adults: case series and midterm follow-up.

OBJECTIVE: Craniocervical junction-related syringomyelia (CCJS) is the most common form of syringomyelia. Approximately 30% of patients treated with foramen magnum decompression (FMD) will show persistence, recurrence, or progression of the syrinx. The authors present a pilot study with a new minimally invasive surgery technique targeting the pathophysiology of CCJS in adult patients. METHODS: The authors retrospectively analyzed the clinical and radiological features of a consecutive series of patients treated for CCJS. An FMD and FM durectomy were performed through a 1.5- to 2-cm skin incision. Then arachnoid adhesions were cleared, creating a permanent communication from the fourth ventricle to the new paraspinal extradural cavity (obexostomy) and with the spinal subarachnoid space. The hypothesis was that the new CSF pouch acts like a pressure leak, interrupting the CCJS pathogenesis. RESULTS: Twenty-four patients (13 female, 21-61 years old) were treated between 2014 and 2018. The etiology of CCJS was Chiari malformation type I (CM-I) in 20 patients (83.3%), Chiari malformation type 0 (CM-0) in 2 patients (8.3%), and CCJ arachnoiditis in 2 patients (8.3%). Two patients underwent reoperations after failed FMD for CM-I at other institutions. No major surgical complication occurred. One patient had postoperative meningitis with no CSF fistula. On postoperative MRI, shrinkage of the syrinx was seen in all patients. No patients experienced recurrence of the CCJS. No patient required a subsequent operation. The mean duration of surgery was 72 ± 11 minutes (mean ± SD), and blood loss was 35-80 ml (mean 51 ml). Follow-up ranged from 12 to 58 months. The average overall improvement in modified Japanese Orthopaedic Association scores was 10% (p < 0.001). The Odom scale showed that 19 patients (79.1%) were satisfied, 4 (16.7%) remained the same, and 1 (4.2%) reported a poor outcome. All patients experienced postoperative improvement in perception of quality of life (p < 0.001). CONCLUSIONS: Minimally invasive FM durectomy and obexostomy is a safe and effective treatment for CCJS and for patients who have not responded to other treatment.

Factors associated with chronic opioid use after cervical spine surgery for degenerative conditions.

OBJECTIVE: Opioids are commonly prescribed after surgery for painful spinal conditions, yet little is known about postoperative opioid use. The relationship between chronic opioid use and patient-reported outcomes and satisfaction with surgery is also unclear. The purpose of this study was to evaluate factors associated with opioid use 1 year after elective cervical spine surgery for degenerative conditions causing radiculopathy and myelopathy. The authors hypothesized that patients with preoperative opioid use would be more likely to report postoperative opioid use at 1 year, and that postoperative opioid use would be associated with patient-reported outcomes and dissatisfaction with surgery. METHODS: The authors performed a retrospective study of a prospective cohort of adult patients who underwent elective cervical spine surgery for degenerative changes causing radiculopathy or myelopathy. Patients were prospectively and consecutively enrolled from a single academic center after the decision for surgery had been made. Postoperative in-hospital pain management was conducted using a standardized protocol. The primary outcome was any opioid use 1 year after surgery. Secondary outcomes were the Neck Disability Index (NDI); 36-Item Short-Form Health Survey (SF-36) physical function (PF), bodily pain (BP), and mental component summary (MCS) scores; the modified Japanese Orthopaedic Association (mJOA) score among myelopathy patients; and patient expectations surveys. Patients with and without preoperative opioid use were compared using the chi-square and Student t-tests, and multiple logistic regression was used to study the associations between patient and surgical characteristics and postoperative opioid use 1 year after surgery. RESULTS: Two hundred eleven patients were prospectively and consecutively enrolled, of whom 39 were lost to follow-up for the primary outcome; 43.6% reported preoperative opioid use. Preoperative NDI and SF-36 PF and BP scores were significantly worse in the preoperative opioid cohort. More than 94% of both cohorts rated expectations of pain relief as extremely or somewhat important. At 1 year after surgery, 50.7% of the preoperative-opioid-use cohort reported ongoing opioid use, and 17.5% of patients in the no-preoperative-opioid-use cohort reported ongoing opioid use. Despite this, both cohorts reported similar improvements in NDI as well as SF-36 PF, BP, and MCS scores. More than 70% of both cohorts also reported being extremely or somewhat satisfied with pain relief after surgery. Predictors of 1-year opioid use included preoperative opioid use, duration of symptoms for more than 9 months before surgery, tobacco use, and higher comorbidity index. CONCLUSIONS: One year after elective cervical spine surgery, patients with preoperative opioid use were significantly more likely to report ongoing opioid use. However, patients in both groups reported similar improvements in patient-reported outcomes and satisfaction with pain relief. Interventions targeted at decreasing opioid use may need to focus on patient factors such as preoperative opioid use or duration of symptoms before surgery.

SF-36 scores predict postoperative delirium after surgery for cervical spondylotic myelopathy.

OBJECTIVECervical spondylotic myelopathy (CSM) is one of the most common causes of spinal cord dysfunction. Surgery for CSM is generally effective, but postoperative delirium is a potential complication. Although there have been some studies that investigated postoperative delirium after spine surgery, no useful tool for identifying high-risk patients has been established, and it is unknown if 36-Item Short Form Health Survey (SF-36) scores can predict postoperative delirium. The objective of this study was to evaluate the correlation between preoperative SF-36 scores and postoperative delirium after surgery for CSM.METHODSSixty-seven patients who underwent surgery for CSM at the authors' institution were enrolled in this study. Medical records of these patients were retrospectively reviewed. Patient background, preoperative laboratory data, preoperative SF-36 scores, the preoperative Japanese Orthopaedic Association (JOA) score for the evaluation of cervical myelopathy, and perioperative factors were selected as potential risk factors for postoperative delirium. These factors were evaluated using univariable and multivariable logistic regression analysis.RESULTSTen patients were diagnosed with postoperative delirium. Univariable analysis revealed that the physical functioning score (p = 0.01), general health perception score (p < 0.01), and vitality score (p < 0.01) of the SF-36 were significantly lower in patients with postoperative delirium than in those without. The total number of medications was significantly higher in the delirium group compared with the no-delirium group (p = 0.02). In contrast, there were no significant differences between the delirium group and the no-delirium group in cervical JOA scores (p = 0.20). Multivariable analysis revealed that a low general health perception score was an independent risk factor for postoperative delirium (p = 0.02; odds ratio 0.810, 95% confidence interval 0.684-0.960).CONCLUSIONSSome of the SF-36 scores were significantly lower in patients with postoperative delirium than in those without. In particular, the general health perception score was independently correlated with postoperative delirium. SF-36 scores could help identify patients at high risk for postoperative delirium and aid in the development of prevention strategies.

Posterior revision surgery using an intraarticular distraction technique with cage grafting to treat atlantoaxial dislocation associated with basilar invagination.

OBJECTIVE: The treatment of atlantoaxial dislocation (AAD) and basilar invagination (BI) is challenging, especially in symptomatic patients with a history of previous surgery. Although seldom reported, posterior revision surgery to revise prior constructs can be advantageous over an anterior or combined approach. The authors describe their experience in performing posterior revision surgery using Goel's technique. METHODS: The authors reviewed patients with AAD and BI who had undergone previous posterior surgery at the cranio-cervical junction between January 2016 and September 2017. All of these patients underwent revision surgery from a posterior approach. The Japanese Orthopaedic Association (JOA) score was used to assess clinical symptoms before and after surgery. The distance from the tip of the odontoid to Chamberlain's line, atlantodental interval (ADI), and clivus-canal angle (CCA) were used for radiographic assessment before and after surgery. RESULTS: Twelve consecutive patients were reviewed. Prior surgeries were as follows: 4 patients (4/12) with posterior osseous decompression without fusion, 7 (7/12) with reduction and fusion without decompression, and 1 (1/12) with posterior osseous decompression and reduction and fusion. With the use of Goel's technique for revision in these cases, distraction using facet spacers afforded release of the anterior soft tissue from a posterior approach. The occiput was fixated to C2 using a cantilever technique, and autologous cancellous bone was grafted into the intraarticular joints. In all 12 patients, complete reduction of BI and AAD were achieved without injury to nerves or vessels. All patients had evidence of bony fusion on CT scans within 18 months of follow-up. CONCLUSIONS: Posterior revision surgery using Goel's technique is an effective and safe revision salvage surgery for symptomatic patients with AAD and BI.

The Patient-Reported Outcomes Measurement Information System in spine surgery: a systematic review.

OBJECTIVEThe Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to provide a standardized measure of clinical outcomes that is valid and reliable across a variety of patient populations. PROMIS has exhibited strong correlations with many legacy patient-reported outcome (PRO) measures. However, it is unclear to what extent PROMIS has been used within the spine literature. In this context, the purpose of this systematic review was to provide a comprehensive overview of the PROMIS literature for spine-specific populations that can be used to inform clinicians and guide future work. Specifically, the authors aimed to 1) evaluate publication trends of PROMIS in the spine literature, 2) assess how studies have used PROMIS, and 3) determine the correlations of PROMIS domains with legacy PROs as reported for spine populations.METHODSStudies reporting PROMIS scores among spine populations were identified from PubMed/MEDLINE and a review of reference lists from obtained studies. Articles were excluded if they did not report original results, or if the study population was not evaluated or treated for spine-related complaints. Characteristics of each study and journal in which it was published were recorded. Correlation of PROMIS to legacy PROs was reported with 0.1 ≤ |r| < 0.3, 0.3 ≤ |r| < 0.5, and |r| ≥ 0.5 indicating weak, moderate, and strong correlations, respectively.RESULTSTwenty-one articles were included in this analysis. Twelve studies assessed the validity of PROMIS whereas 9 used PROMIS as an outcome measure. The first study discussing PROMIS in patients with spine disorders was published in 2012, whereas the majority were published in 2017. The most common PROMIS domain used was Pain Interference. Assessments of PROMIS validity were most frequently performed with the Neck Disability Index. PROMIS domains demonstrated moderate to strong correlations with the legacy PROs that were evaluated. Studies assessing the validity of PROMIS exhibited substantial variability in PROMIS domains and legacy PROs used for comparisons.CONCLUSIONSThere has been a recent increase in the use of PROMIS within the spine literature. However, only a minority of studies have incorporated PROMIS for its intended use as an outcomes measure. Overall, PROMIS has exhibited moderate to strong correlations with a majority of legacy PROs used in the spine literature. These results suggest that PROMIS can be effective in the assessment and tracking of PROs among spine populations.

The relevant psychological burden of having a benign brain tumor: a prospective study of patients undergoing surgical treatment of cranial meningiomas.

OBJECTIVE: Meningiomas are the most common intracranial neoplasm. Evidence concerning surgical management and outcome is abundant, while the implications for the quality of life (QOL) of a patient confronted with the diagnosis and undergoing surgery are unclear. The authors conducted a prospective study to evaluate QOL in relation to psychological comorbidities comorbidities. METHODS: A prospective study of patients undergoing elective surgery for the removal of an intracranial meningioma was performed. The authors evaluated depression (Allgemeine Depressionsskala K score) and anxiety (Post-Traumatic Stress Scale-10 [PTSS-10]; State Trait Anxiety Inventory-State Anxiety and -Trait Anxiety [STAI-S and STAI-T]; and Anxiety Sensitivity Index-3 [ASI-3]) scores before surgery and at 3 and 12 months after surgery. The correlation between preoperative psychological burden and postoperative QOL as measured by the 36-Item Short Form Health Survey and EQ-5L questionnaires was analyzed. Incidence and influence of these psychiatric comorbidities on clinical outcome were examined. RESULTS: A total of 78 patients undergoing resection of a meningioma between January 2013 and September 2017 participated in the preoperative psychological screening and 71 patients fully completed postoperative follow-up examination after 1 year of follow-up. At presentation, 48 patients (67.7%) had abnormal anxiety scores, which decreased to 29.6% (p = 0.003). On follow-up at 12 months, mean EQ-5L visual analog scale scores were significantly lower in patients with pathological scores on the PTSS-10 (0.84 vs 0.69; p = 0.004), STAI-S (0.86 vs 0.68; p = 0.001), and STAI-T (0.85 vs 0.71; p = 0.011). Neurological status (modified Rankin Scale) improved slightly and showed some correlation with psychological comorbidities QOL scores (p = 0.167). There was a nonsignificant increase of EQ-5L scores over the period of follow-up (p = 0.174) in the repeated-measures analysis. In the regression analysis, impaired QOL and physical disability on follow-up correlated with elevated preoperative anxiety and depression levels. CONCLUSIONS: The QOL and physical disability of patients undergoing resection of an intracranial meningioma highly depend on preoperative anxiety and depression levels. Stress and anxiety scores generally decrease after the resection, which leads us to conclude that there is a tremendous emotional burden caused by an upcoming surgery, necessitating close psychooncological support in order to uphold functional outcome and health-related QOL in the postoperative course.

Patient-Reported Outcomes Measurement Information System physical function and pain interference in spine surgery.

OBJECTIVEThe Patient-Reported Outcomes Measurement Information System (PROMIS) is an adaptive, self-reported outcomes assessment tool that utilizes item response theory and computer adaptive testing to efficiently and precisely evaluate symptoms and perceived health status. Efforts to implement and report PROMIS outcomes in spine clinical practice remain limited. The objective of this retrospective cohort study is to evaluate the performance and psychometric properties of PROMIS physical function (PF) and pain interference (PI) among patients undergoing spine surgery.METHODSThe authors identified all patients who underwent spine surgery at their institution between 2016 and 2018, and for whom there was retrievable PROMIS data. Descriptive statistics were calculated to summarize demographics, operative characteristics, and patient-reported outcomes. Assessments were evaluated preoperatively, and postoperatively within 2 months (early), 6 months (intermediate), and up to 2 years (late). Pairwise change scores were calculated to evaluate within-subjects differences and construct responsiveness over time. Pearson's correlation coefficients were used to evaluate the association between PROMIS PF and PI domains. Subgroup analysis was performed based on the primary diagnoses of cervical radiculopathy, cervical myelopathy, or lumbar degenerative disease.RESULTSA total of 2770 patients (1395 males, 50.4%) were included in the analysis. The mean age at the time of surgery was 57.3 ± 14.4 years. Mean postoperative follow-up duration was 7.6 ± 6.2 months. Preoperatively, patients scored an average 15.1 ± 7.4 points below the normative population (mean 50 ± 10 points) in PF, and 15.8 ± 6.8 points above the mean in PI. PROMIS PF required a mean of 4.1 ± 0.6 questions and median 40 seconds (interquartile range [IQR] 29-58 seconds) to be completed, which was similar to PI (median 4.3 ± 1.1 questions and 38 seconds [IQR 27-59 seconds]). Patients experienced clinically meaningful improvements in PF and PI, which were sustained throughout the postoperative course. PROMIS instruments were able to capture anticipated changes in PF and PI, although to a lesser degree in PF early postoperatively. There was a strong negative correlation between PROMIS PF and PI scores at baseline (Pearson's r = -0.72) and during follow-up appointments (early, intermediate, and late |r| > 0.6, each). Subgroup analysis demonstrated similar results within diagnostic groups compared to the overall cohort. However, the burden of PF limitations and PI was greater within the lumbar spine disease subgroup, compared to patients with cervical radiculopathy and myelopathy.CONCLUSIONSPatients receiving care at a tertiary spine surgery outpatient clinic experience significant overall disability and PI, as measured by PROMIS PF and PI computer adaptive tests. PROMIS PF and PI health domains are strongly correlated, responsive to changes over time, and facilitate time-efficient evaluations of perceived health status outcomes in patients undergoing spine surgery.

Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance.

OBJECTIVE Surgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)-only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF). METHODS The medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of < 10 cm, and underwent a minimum of 2 years' follow-up. Those who underwent a 3-column osteotomy were excluded. Three groups of patients were compared on the basis of the procedure performed, LLIF+PSF, ALIF+PSF, and PSF only. Perioperative spinal deformity parameters, complications, and HRQoL outcome scores (Oswestry Disability Index [ODI], Scoliosis Research Society 22-question Questionnaire [SRS-22], 36-Item Short Form Health Survey [SF-36], visual analog scale [VAS] for back/leg pain) from each group were assessed and compared with each other using ANOVA. The minimal clinically important differences used were -1.2 (VAS back pain), -1.6 (VAS leg pain), -15 (ODI), 0.587/0.375/0.8/0.42 (SRS-22 pain/function/self-image/mental health), and 5.2 (SF-36, physical component summary). RESULTS A total of 221 patients (58 LLIF, 91 ALIF, 72 PSF only) met the inclusion criteria. Average deformities consisted of a SVA of < 10 cm, a pelvic incidence-lumbar lordosis (LL) mismatch of > 10°, a pelvic tilt of > 20°, a lumbar Cobb angle of > 20°, and a thoracic Cobb angle of > 15°. Preoperative SVA, LL, pelvic incidence-LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score. CONCLUSIONS Satisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.

Craniotomy for perisellar meningiomas: comparison of simple (appropriate for endoscopic approach) versus complex anatomy and surgical outcomes.

OBJECTIVE Microsurgical resection of perisellar meningiomas has remained the gold standard for treatment, with extended endoscopic endonasal surgery emerging as a viable alternative. Historical microsurgical series do not distinguish based on tumor anatomy, but are being used as a comparison against endonasal surgery. In this study, the authors retrospectively reviewed and compared the anatomy of perisellar meningiomas seen at their institution. The tumors were separated into 2 groups based on whether they would be appropriate for endoscopic resection, and the authors compared the surgical outcomes. METHODS Between 2001 and 2013, 53 patients (73.6% women) with perisellar meningiomas underwent open microsurgical resection at Vancouver General Hospital performed by the senior author (R.A.). These tumors were separated into 2 groups based on their anatomy, and the authors analyzed the resection rates, surgical results, patient quality of life, and complications. RESULTS Among the 53 patients who presented with perisellar meningiomas, the authors were able to identify 18 lesions with "simple" anatomy suitable for endoscopic resection and 35 lesions with "complex" anatomy suitable for craniotomy resection. The mean age of patients in the study cohort was 57.4 years (range 33-91 years), and most patients presented with visual loss (68.0%) and visual field restriction (64.2%). There were no major differences in patient demographic data between the 2 groups. Patients with simple anatomy had smaller lesions (2.1 vs 3.5 cm; p = 0.004), no optic canal invasion (89% vs 26%; p < 0.0001), minimal vascular encasement (cortical cuff 83% vs 9%; p < 0.0001), and a rounded tumor shape (100% vs 31.8%; p = 0.0001) when compared with those with complex anatomy. The majority of lesions originated from the tuberculum sellae and planum sphenoidale. A greater degree of resection was achieved in the favorable anatomy group (99% vs 87.1%; p < 0.0001). Vision was improved or normalized in 96.6% of patients. Patients in the cohort with complex anatomy had more transient complications; there were no incidents of surgical-site infection, meningitis, or death in this series. One patient who underwent removal of a recurrent lesion experienced a CSF leak that required endoscopic repair. The overall persisting complications rate was higher in the group with complex anatomy (11.1% vs 37.1%; p = 0.0498); overall, 28.3% of patients experienced disabling complications. Patient-perceived quality of life improved in the simple anatomy group following surgery (ΔSF-36 +16.6 vs -8.4; p = 0.0045). CONCLUSIONS Extended endoscopic surgery is emerging as a viable alternative to microsurgical resection of perisellar meningiomas. The authors identified 2 patient groups based on tumor anatomy, with distinctly separate surgical outcomes. In the future, patients considered for endoscopic resection should be compared against the surgical group with simple anatomy that includes smaller tumors, no vascular encasement, and limited optic canal invasion.