Defining the relative utility of lumbar spine surgery: A systematic literature review of common surgical procedures and their impact on health states.

Degenerative lumbar spondylosis is a common indication for patients undergoing spine surgery. As healthcare costs rise, measuring quality of life (QOL) gains after surgical procedures is critical in assessing value. We set out to: 1) compare baseline and postoperative EuroQol-5D (EQ-5D) scores for lumbar spine surgery and common surgical procedures to obtain post-operative quality-adjusted life year (QALY) gain, and 2) establish the relative utility of lumbar spine surgery as compared to other commonly performed surgical procedures. A systematic literature review was conducted to identify all studies reporting preoperative/baseline and postoperative EQ-5D scores for common surgical procedures. For each study, the number of patients included and baseline/preoperative and follow-up mean EQ-5D scores were recorded, and mean QALY gained for each intervention was calculated. A total of 67 studies comprising 95,014 patients were identified. Patients with lumbar spondylosis had the worst reported QOL at baseline compared to other surgical cohorts. The greatest QALY gain was seen in patients undergoing hip arthroplasty (0.38), knee arthroplasty (0.35) and lumbar spine surgery (0.32), nearly 2.5-fold greater QALY gained than for all other procedures. The low preoperative QOL, coupled with the improvements offered with surgery, highlight the utility and value of lumbar spine surgery compared to other common surgical procedures.

Effect of Depression on Patient-Reported Outcomes Following Cervical Epidural Steroid Injection for Degenerative Spine Disease.

Objective: To assess the effect depression has on outcomes after cervical epidural steroid injections (CESIs). Design: Retrospective review of a prospectively collected database. Setting: Single institution tertiary care center. Subjects: Fifty-seven patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first were included. Methods: Twenty-one of 57 (37%) patients with depression (defined as Zung Depression Scale >33) were included. Patient-reported outcomes including Neck Disability Index (NDI), numeric rating scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and three-month follow-up. Minimal clinically important differences were then calculated to provide dichotomous outcome measures of success. Results: Overall, 24 and 28 patients achieved at least 50% improvement in AP and NP, respectively. In terms of disability, 25/57 (43.9%) patients achieved >13.2-point improvement on the NDI overall. In patients with depression, 4/21 (19.0%) and 5/21 (23.8%) achieved at least 50% improvement on the NRS for AP and NP, respectively, compared with 20/36 (55.5%) and 23/36 (63.8%) in patients without depression. This difference was statistically significant for both pain measures (P < 0.002 AP, P < 0.006 NP). Statistically fewer patients, 5/21 (24%), with depression achieved ≥13.2-point improvement on the NDI compared with 20/36 (55%) nondepressed patients (P < 0.01). There was no difference in outcomes between groups on the EQ-5D. Conclusions: Patients with cervical spondylosis and comorbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared with nondepressed patients at three months.

Patient-reported outcomes after lumbar epidural steroid injection for degenerative spine disease in depressed versus non-depressed patients.

BACKGROUND CONTEXT: Medical interventional modalities such as lumbar epidural steroid injections (LESIs) are often used in the setting of lumbar spine disorders where other conservative measures have failed. Concomitant depression can lead to worse outcomes in lumbar spine pathology. A number of studies have demonstrated an association between preoperative depression and poor outcomes following surgery, but the effect of depression on outcomes following medical interventional modalities is poorly understood. PURPOSE: To evaluate the differences in patient-reported outcomes (PROs) between depressed and non-depressed patients undergoing LESI. STUDY DESIGN/SETTING: This study is an analysis of a prospective longitudinal registry database at a single academic institution. PATIENT SAMPLE: All patients undergoing LESI from 2012 to 2014 were eligible for enrollment into a prospective, web-based registry. Eligible patients had radicular pain, correlative imaging findings of degenerative pathology, and failed 6 weeks of conservative care. OUTCOME MEASURES: The PROs measured included the (1) numeric rating scale for back pain (NRS-BP), (2) numeric rating scale for leg pain (NRS-LP), (3) disease-specific physical disability-Oswestry Disability Index (ODI), and (4) preference-based health status-EuroQol-5D (EQ-5D). MATERIALS AND METHODS: Patients who met the inclusion criteria underwent LESI. Patient-reported outcomes were collected at baseline and at 12 months following treatment. Based on previously validated values for the Zung Depression Scale (ZDS) as a screening tool for depression, patients were dichotomized into non-depressed (ZDS score ≤33) and depressed (ZDS score >33). The PRO change scores from baseline to 12 months were calculated. The mean absolute and change scores between the groups were compared using Student t test. Multivariable linear regression analysis for ODI, EQ-5D, NRS-LP, and NRS-BP was performed. RESULTS: A total of 161 patients with complete 12-month follow-up were included. Seventy-one patients (44%) were classified as depressed and 90 patients (56%) were classified as non-depressed. The mean baseline PRO scores were significantly worse in depressed patients compared with non-depressed patients: ODI (p<.001), NRS-BP (p=.013), NRS-LP (p<.001), and EQ-5D (p=.001). The mean absolute scores at 12 months were significantly lower in the depressed versus non-depressed patients: ODI (p<.001), NRS-BP (p=.001), NRS-LP (p=.05), and EQ-5D (p=.003). However, there was no difference in mean change scores observed at 12 months between the depressed and non-depressed cohorts: ODI (p=.42), NRS-BP (p=.31), NRS-LP (p=.25), EQ-5D (p=.14). Adjusting for pre-procedure variables, the higher ZDS score was associated with higher disability (ODI) at 12 months. CONCLUSIONS: Depression led to worse absolute scores for PROs and is associated with higher disability following LESI. However, patients with depressive symptoms can expect similar improvement in PROs at 12 months.

Surgeons agree to disagree on surgical options for degenerative conditions of the cervical and lumbar spine.

STUDY DESIGN: This is a survey study designed to evaluate agreement among spine surgeons regarding treatment options for six clinical scenarios involving degenerative conditions of the cervical and lumbar spine. OBJECTIVES: The purpose was to evaluate whether or not surgeons agree on which cases require operative intervention and what type of surgery should be performed. SUMMARY OF BACKGROUND DATA: Agreement between spine surgeons on when to operate and what procedure to perform is a subject that has received increasing attention. This is an important question in the field of spine surgery, where "gold standards" that are based on large clinical trials are relatively sparse. METHODS: Six clinical vignettes were presented to 19 members of the Degenerative Spine Study Group. Each vignette was accompanied by a series of radiographs and/or magnetic resonance imagings, followed by treatment options in multiple-choice format. Two months later, the same vignettes were sent out with identical instructions except that they were now told they were treating a close family member. RESULTS: More than 76% of surgeons agreed on whether or not to recommend surgical intervention for the following four cases: lumbar degenerative spondylolisthesis with stenosis, cervical herniated nucleus pulposus, lumbar spondylosis, and lumbar herniated nucleus pulposus. Two scenarios had approximately 50% surgeon agreement: cervical stenosis and lumbar spondylolysis. However, despite good inter-rater agreement about who needed surgery, there was poor agreement regarding what procedure to perform if surgery was recommended. When repeating the survey in the setting of operating on a family member, only 17 (17.7%) of 96 recommendations were changed. CONCLUSION: Spine surgeons in this survey generally agreed on when to operate but failed to agree on what type of procedures to perform.

Postoperative infections of the spine.

The incidence of postoperative infections after spinal surgery ranges from less than 1% to 15%. This rate can vary based on several surgical- and patient-related risk factors, such as the type and duration of the procedure, nutritional status, immunosuppression, and comorbidities of the patient. Most surgeons routinely administer intravenous antibiotics prophylactically, and may employ other measures in an effort to prevent postoperative infection. Multiple diagnostic modalities, in conjunction with examination findings, should be utilized in the assessment of possible postoperative spinal infections. In particular, wound discharge or erythema, and an elevation in the erythrocyte sedimentation rate and C-reactive protein beyond expected postoperative values should raise a clinician's level of suspicion for an infection. The diagnosis of a postoperative spine infection can be difficult to confirm with diagnostic imaging, given findings are not all that different from normal postoperative changes. When suspected, the preferred treatment for a postoperative spinal infection is open irrigation and aggressive debridement of all necrotic tissue and bone, followed by antibiotic treatment based on culture sensitivity.

Use of a collagen-platelet rich plasma scaffold to stimulate healing of a central defect in the canine ACL.

The anterior cruciate ligament (ACL) of the knee fails to heal after primary repair. Here we hypothesize that a beneficial biologic repair response can be induced by placing a collagen-platelet rich plasma (collagen-PRP) material into a central ACL defect. A collagen-PRP scaffold was used to treat a central ACL defect in vivo. In the first experiment, the histologic response in treated and untreated defects was evaluated at 3 (n = 5) and 6 weeks (n = 5). In the second experiment, biomechanical testing of the treated ligaments (n = 8) was performed at 6 weeks and compared with the results of biomechanical testing of untreated defects at the same time-point (n = 6). The percentage filling of the defects in the treated ACLs was significantly higher at both the 3- and 6-week time-points when compared with the untreated contralateral control defects (50 +/- 21% vs. 2 +/- 2% at 3 weeks, and 43 +/- 11% vs. 23 +/- 11 at 6 weeks; all values mean +/- SEM. Biomechanically, the treated ACL defects had a 40% increase in strength at 6 weeks, which was significantly higher than the 14% increase in strength previously reported for untreated defects (p < 0.02). Placement of a collagen-PRP bridging scaffold in a central ACL defect can stimulate healing of the ACL histologically and biomechanically.