Distal Lumbar Lordosis is Associated With Reoperation for Adjacent Segment Disease After Lumbar Fusion for Degenerative Conditions.

STUDY DESIGN: A single centre retrospective review. OBJECTIVE: Recent studies have suggested that distal lordosis (L4-S1, DL) remains constant across all pelvic incidence (PI) subgroups, whilst proximal lordosis (L1-L4, PL) varies. We sought to investigate the impact of post-operative DL on adjacent segment disease (ASD) requiring reoperation in patients undergoing lumbar fusion for degenerative conditions. METHODS: Patients undergoing 1-3 level lumbar fusion with the two senior authors between 2007-16 were included. Demographic and radiographic data were recorded. Univariate, multivariate binary logistic regression, and Kaplan Meier survivorship analyses were performed. RESULTS: 335 patients were included in the final analysis. Most had single (67%) or two (31%) level fusions. The mean follow-up was 64-month. Fifty-seven patients (17%) underwent reoperation for ASD at an average of 78-month post-operatively (R group). The R group had a significantly lower mean post-operative DL (27.3 vs 31.1 deg, P < .001) and mean PI (55.5 vs 59.2 deg, P < .05). On univariate analysis, patients with a post-operative DL of <35 deg had higher odds of reoperation for ASD than those with a post-operative DL of ≥35 deg (OR 2.7, P = .016). In the multivariate model, post-operative DL, low/average PI, and spondylolisthesis were all significantly associated with reoperation for ASD. CONCLUSION: This study provides preliminary support to an association between post-operative distal lumbar lordosis and risk of reoperation for ASD in patients undergoing fusions for degenerative conditions. Further multicentre prospective study is needed to independently confirm this association and identify the impact of restoration of physiological distal lumbar lordosis on long term patient outcomes.

Development of the cervical myelopathy severity index: a new patient reported outcome measure to quantify impairments and functional limitations.

BACKGROUND CONTEXT: Existing degenerative cervical myelopathy (DCM) severity scales have significant shortcomings, creating a strong impetus for the development of a practical measurement tool with sound psychometric properties. PURPOSE: This work reports the item generation and reduction of the Cervical Myelopathy Severity Index (CMSI), a new DCM patient-reported outcome measure of symptoms and functional limitations. DESIGN: Prospective observational study. PATIENT SAMPLE: Adult DCM patients belonging to one of three distinct treatment groups: (1) observation cohort, (2) preoperative surgical cohort, (3) 6 to 12 months postoperative cohort. OUTCOME MEASURES: Patient-reported outcome measure of symptoms and functional limitations. METHODS: Item generation was performed using semi-structured patient focus groups emphasizing symptoms experienced and functional limitations. Readability was assessed through think-aloud patient interviews. Item reduction involved surveys of DCM patients with a spectrum of disease severity and board-certified spine surgeons experienced in the treatment of DCM. A priori criteria for item removal included: patient median importance/severity <2 (of 4), 30% or more no severity (response of zero), item severity correlations ≤ 0.80 (Spearman), item severity reliability (weighted kappa <0.60) based on a 2-week interval and clinician median importance <2 with retention of items with very high clinical importance. RESULTS: There were 42 items generated from a combination of specialist input and patient focus groups. Items captured sensorimotor symptoms and limitations related to upper and lower extremities as well as sphincter dysfunction. Ninety-eight patients (43, 30, 25 observation, pre- and postsurgery respectively) and 51 surgeons completed the assessment. Twenty-three items remained after application of median importance and severity thresholds and weighted kappa cutoffs. After elimination of highly correlated (>0.80) items and combining two similar items, the final CMSI questionnaire list included 14 items. CONCLUSIONS: The CMSI is a new DCM patient-reported clinical measurement tool developed using patient and clinician input to inform item generation and reduction. Future work will evaluate the reliability, validity, and responsiveness of the CMSI in relation to existing myelopathy measurement indices.

The clinical course of symptoms during wait time for lumbar spinal stenosis surgery and its effect on postoperative outcome: a retrospective cohort study.

BACKGROUND CONTEXT: Wait time for surgeries can be lengthy and its effect on postoperative outcome remains largely unknown. PURPOSE: We evaluated the effect of wait time on postoperative outcome and on clinical course while awaiting surgery for lumbar spinal stenosis. STUDY DESIGN/SETTING: This was a retrospective cohort study. PATIENT SAMPLE: A convenience sample (n=134) from prospective longitudinal studies that provided preoperative Oswestry Disability Index (ODI) data at two different time points and follow-up of ≥12 months. METHODS: Wait time was the period between the initial consultation and immediately preoperatively. OUTCOME MEASURES: The primary outcome was the ODI minimal clinically important difference (MCID) (<30% vs ≥30% improvement) at 1 year. RESULTS: The median wait time was 5.9 (interquartile range (IQR) 8.2) months and postoperative follow-up was 19.2 (IQR 8.1) months. Wait time was not associated with absolute postoperative change in ODI scores, but patients with wait times <12 months were significantly more likely to reach the ODI MCID at last follow-up (66 (73.3%) for <12 months versus 13 (46.4%) for ≥12 months, p=.008; odds ratio=0.29 (95% confidence interval 0.12-0.75), p=.011). During wait time, there was no difference in patients deteriorating above the MCID for each time point (10 [9.7%] versus 5 [16.1%], p=.320). CONCLUSIONS: Longer wait times did not negatively influence postoperative outcome in patients with lumbar spinal stenosis using absolute values, but may impact individual patients' ability to achieve MCID. Patient-reported pain-related disability from the initial surgical consultation to surgery is relatively stable in most patients for at least 6 to 12 months.

Evaluating Instability in Degenerative Lumbar Spondylolisthesis: Objective Variables Versus Surgeon Impressions.

The subjective degenerative spondylolisthesis instability classification (S-DSIC) system attempts to define preoperative instability associated with degenerative lumbar spondylolisthesis (DLS). The system guides surgical decision-making based on numerous indicators of instability that surgeons subjectively assess and incorporate. A more objective classification is warranted in order to decrease variation among surgeons. In this study, our objectives included (1) proposing an objective version of the DSIC system (O-DSIC) based on the best available clinical and biomechanical data and (2) comparing subjective surgeon perceptions (S-DSIC) with an objective measure (O-DSIC) of instability related to DLS. Methods: In this multicenter cohort study, we prospectively enrolled 408 consecutive adult patients who received surgery for symptomatic DLS. Surgeons prospectively categorized preoperative instability using the existing S-DSIC system. Subsequently, an O-DSIC system was created. Variables selected for inclusion were assigned point values based on previously determined evidence quality. DSIC types were derived by point summation: 0 to 2 points was considered stable, Type I); 3 points, potentially unstable, Type II; and 4 to 5 points, unstable, Type III. Surgeons' subjective perceptions of instability (S-DSIC) were retrospectively compared with O-DSIC types. Results: The O-DSIC system includes 5 variables: presence of facet effusion, disc height preservation (≥6.5 mm), translation (≥4 mm), a kyphotic or neutral disc angle in flexion, and low back pain (≥5 of 10 intensity). Type I (n = 176, 57.0%) and Type II (n = 164, 53.0%) were the most common DSIC types according to the O-DSIC and S-DSIC systems, respectively. Surgeons categorized higher degrees of instability with the S-DSIC than the O-DSIC system in 130 patients (42%) (p < 0.001). The assignment of DSIC types was not influenced by demographic variables with either system. Conclusions: The O-DSIC system facilitates objective assessment of preoperative instability related to DLS. Surgeons assigned higher degrees of instability with the S-DSIC than the O-DSIC system in 42% of cases. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

A Model to Implement Standardized Virtual Care for Low Back Pain Amongst a Large Network of Providers in Urban and Rural Settings.

Prior to the COVID-19 pandemic, virtual care (VC) was not routinely offered for assessment of low back pain (LBP), a highly prevalent, disabling condition. COVID-19 related healthcare closures resulted in a rapid backlog of patients referred to a provincial interprofessional LBP program. Without management, these patients were at high risk of experiencing untoward outcomes. Virtual care became a logical option. However, many clinicians lacked experience and confidence with LBP virtual care (LBP-VC); and either were unfamiliar with, or did not have access to, requisite technology. Multi-stakeholder engagement was utilized to understand barriers, identify enablers, and ultimately promote VC for LBP. As a result of the multi-stakeholder engagement, the concept of a toolkit for LBP-VC, including clinical resources and guidelines, emerged. The toolkit contains preparatory steps for VC and a standardized approach to virtual LBP assessment. Key steps in the toolkit have potential applicability to other musculoskeletal populations.

Restricting Branched-Chain Amino Acids within a High-Fat Diet Prevents Obesity.

Obesity is a global pandemic, but there is yet no effective measure to control it. Recent metabolomics studies have identified a signature of altered amino acid profiles to be associated with obesity, but it is unclear whether these findings have actionable clinical potential. The aims of this study were to reveal the metabolic alterations of obesity and to explore potential strategies to mitigate obesity. We performed targeted metabolomic profiling of the plasma/serum samples collected from six independent cohorts and conducted an individual data meta-analysis of metabolomics for body mass index (BMI) and obesity. Based on the findings, we hypothesized that restriction of branched-chain amino acids (BCAAs), phenylalanine, or tryptophan may prevent obesity and tested our hypothesis in a dietary restriction trial with eight groups of 4-week-old male C57BL/6J mice (n = 5/group) on eight different types of diets, respectively, for 16 weeks. A total of 3397 individuals were included in the meta-analysis. The mean BMI was 30.7 ± 6.1 kg/m2, and 49% of participants were obese. Fifty-eight metabolites were associated with BMI and obesity (all p ≤ 2.58 × 10-4), linked to alterations of the BCAA, phenylalanine, tryptophan, and phospholipid metabolic pathways. The restriction of BCAAs within a high-fat diet (HFD) maintained the mice's weight, fat and lean volume, subcutaneous and visceral adipose tissue weight, and serum glucose and insulin at levels similar to those in the standard chow group, and prevented obesity, adipocyte hypertrophy, adipose inflammation, and insulin resistance induced by HFD. Our data suggest that four metabolic pathways, BCAA, phenylalanine, tryptophan, and phospholipid metabolic pathways, are altered in obesity and restriction of BCAAs within a HFD can prevent the development of obesity and insulin resistance in mice, providing a promising strategy to potentially mitigate diet-induced obesity.

Differentiation of pain-related functional limitations in surgical patients with lumbar spinal stenosis (LSS) using the Oswestry Disability Index: a Canadian Spine Outcomes and Research Network (CSORN) study.

BACKGROUND CONTEXT: The Oswestry Disability Index (ODI) is the most commonly used outcome measure of functional outcome in spine surgery. The ability of the ODI to differentiate pain related functional limitation specifically related to degenerative lumbar spinal stenosis (LSS) is unclear. PURPOSE: The purpose of this study was to determine the ability of the functional subsections of the ODI to differentiate the specific patient limitation(s) from symptomatic LSS and the functional impact of surgery. STUDY DESIGN: Analysis of prospectively collected data from the Canadian Spine Outcomes and Research Network (CSORN). PATIENT SAMPLE: A total of 1,497 lumbar spinal stenosis patients with a dominant complaint of neurogenic claudication, radiculopathy or back pain were identified in the CSORN registry. OUTCOME MEASURES: The ODI questionnaire version 2.0 was assessed as an outcome measure. METHODS: The difference at baseline and the pre-to-post (1-year) surgical change of the ODI individual questions was assessed. Analysis of variance, two-tailed paired sample Student t test were used for statistical analysis. Cohen d was used as an index of effect size, defined as "large" when d ≥0.8. RESULTS: The mean age at surgery was 65 (±11) years and (50.8%) of the patients were female. Preoperatively, highest functional limitations were noted for standing, lifting, walking, pain intensity and social life (mean 3.2, 2.9, 2.5, 2.9, 2.5 respectively). At 1-year follow-up, overall there was a significant improvement in all individual questions and the overall ODI (all p<.001), with similar patterns seen for each dominant complaint. The greatest effect of surgery was noted in the walking, social life and standing domains (all d≥0.81), while personal care, sitting and lifting showed the least improvement (all d≤0.51). In subgroup analyses, the overall ODI baseline scores and subsection limitations were statistically significantly higher in females, those without degenerative spondylolisthesis and those undergoing fusion, although these differences were not considered clinically significant. Preoperative differentiation of LSS specific functional limitation and postoperative changes in all subgroups was similar to the overall LSS cohort. CONCLUSIONS: The results of this study support the ability of the ODI to differentiate the self-reported pain related functional effects of neurogenic claudication, radiculopathy or back pain from LSS and changes associated with surgical intervention. Disaggregated use of the ODI could be a simple tool to aid in preoperative education regarding specific areas of pain related dysfunction and potential for improvement with LSS surgery.

An Exploratory Analysis of Spine Patients' Preoperative Concerns and Decision-making Process: Does What Surgeons Say Matter?

STUDY DESIGN: Cross-sectional, pre-post patient survey. OBJECTIVE: The aim of this study was to determine what factors affect a patient's decision to undergo elective surgery following a surgical consultation. SUMMARY OF BACKGROUND DATA: The surgical consultation is an important step in selecting and preparing patients for elective surgery. Despite the proven effectiveness and low risk of complications, many spine procedure candidates may still choose to forgo surgery after an appropriate discussion and clear surgical indications. METHODS: Survey and open-response questions regarding pre- and post-consultation surgical concerns and overall willingness to undergo surgery were collected and analyzed from 124 patients deemed surgical candidates. Demographics, surgical willingness, and patient concerns were analyzed. Open-ended response data were tallied for surgical concerns and responses were analyzed line-by-line to assess for main themes. Sub-analysis was included on patients who reconsidered their willingness post-consultation. RESULTS: Qualitative thematic analysis of patient's concerns regarding surgery uncovered six major themes: Interference on quality of life (QOL), fear, physical concerns, success, risk, and concerns regarding the surgeon (CS). Success and risk were most commonly mentioned pre-consultation (27%, 26%); risk and QOL were most commonly mentioned post-consultation (22%, 21%). Of 124 patients, 103 were willing to have surgery before consultation and remained willing post-consultation; six patients became unwilling. Twenty-one patients were unwilling to consider surgery before consultation; only five remained unwilling. No differences were found between degenerative and deformity patients regarding initial willingness or changes thereafter. CONCLUSION: The decision to undergo surgery is a multifactorial and complex process with a variety of patient concerns. We grouped these concerns into six categories to aid in future discussion with patients. 87% of patients have made up their mind before attending their surgical consultation. Appropriate understanding of patient-specific willingness and concerns should help facilitate necessary discussion and aid in a more efficient and useful shared decision-making process. LEVEL OF EVIDENCE: 4.

Treatment of Mild Cervical Myelopathy: Factors Associated With Decision for Surgical Intervention.

STUDY DESIGN: Prospective Cohort OBJECTIVE.: The aim of this study was to evaluate which demographic, clinical, or radiographic factors are associated with selection for surgical intervention in patients with mild cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Surgery has not been shown superior to best conservative management in mild CSM comparative studies; trials of conservative management represent an acceptable alternative to surgical decompression. It is unknown what patients benefit from surgery. METHODS: This is a prospective study of patients with mild CSM, defined as modified Japanese Orthopaedic Association Score (mJOA) ≥15. Patients were recruited from seven sites contributing to the Canadian Spine Outcomes Research Network. Demographic, clinical, radiographic and health related quality of life data were collected on all patients at baseline. Multivariate logistic regression modeling was used to identify factors associated with surgical intervention. RESULTS: There were 122 patients enrolled, 105 (86.0%) were treated surgically, and 17 (14.0%) were treated nonoperatively. Overall mean age was 54.8 years (SD 12.6) with 80 (65.5%) males. Bivariate analysis revealed no statistically significant differences between surgical and nonoperative groups with respect to age, sex, BMI, smoking status, number of comorbidities and duration of symptoms; mJOA scores were significantly higher in the nonoperative group (16.8 [SD 0.99] vs. 15.9 [SD 0.89], P < 0.001). There was a statistically significant difference in Neck Disability Index, SF12 Physical Component, SF12 Mental Component Score, EQ5D, and PHQ-9 scores between groups; those treated surgically had worse baseline questionnaire scores (P < 0.05). There was no difference in radiographic parameters between groups. Multivariable analysis revealed that lower quality of life scores on EQ5D were associated with selection for surgical management (P < 0.018). CONCLUSION: Patients treated surgically for mild cervical myelopathy did not differ from those treated nonoperatively with respect to baseline demographic or radiographic parameters. Patients with worse EQ5D scores had higher odds of surgical intervention. LEVEL OF EVIDENCE: 3.

microRNA-181a-5p antisense oligonucleotides attenuate osteoarthritis in facet and knee joints.

OBJECTIVES: We recently identified microRNA-181a-5p (miR-181a-5p) as a critical mediator involved in the destruction of lumbar facet joint (FJ) cartilage. In this study, we tested if locked nucleic acid (LNA) miR-181a-5p antisense oligonucleotides (ASO) could be used as a therapeutic to limit articular cartilage degeneration. METHODS: We used a variety of experimental models consisting of both human samples and animal models of FJ and knee osteoarthritis (OA) to test the effects of LNA-miR-181a-5p ASO on articular cartilage degeneration. Histopathological analysis including immunohistochemistry and in situ hybridisation were used to detect key OA catabolic markers and microRNA, respectively. Apoptotic/cell death markers were evaluated by flow cytometry. qPCR and immunoblotting were applied to quantify gene and protein expression. RESULTS: miR-181a-5p expression was increased in human FJ OA and knee OA cartilage as well as injury-induced FJ OA (rat) and trauma-induced knee OA (mouse) cartilage compared with control cartilage, correlating with classical OA catabolic markers in human, rat and mouse cartilage. We demonstrated that LNA-miR-181a-5p ASO in rat and mouse chondrocytes reduced the expression of cartilage catabolic and chondrocyte apoptotic/cell death markers in vitro. Treatment of OA-induced rat FJ or mouse knee joints with intra-articular injections of in vivo grade LNA-miR-181a-5p ASO attenuated cartilage destruction, and the expression of catabolic, hypertrophic, apoptotic/cell death and type II collagen breakdown markers. Finally, treatment of LNA-miR-181a-5p ASO in cultures of human knee OA chondrocytes (in vitro) and cartilage explants (ex vivo) further demonstrated its cartilage protective effects. CONCLUSIONS: Our data demonstrate, for the first time, that LNA-miR-181a-5p ASO exhibit cartilage-protective effects in FJ and knee OA.

The Need for Multidimensional Stratification of Chronic Low Back Pain (LBP).

MINI: The authors wanted to determine which existing primary-care low back pain stratification schema is associated with distinct subpopulations. Initial stratification by DMPP identified potentially distinct epidemiological groups. DMPP stratification resulted in discrimination beyond that provided by disability or chronicity risk stratification alone. STUDY DESIGN: A cross-sectional study of Canadian patients suffering from low back pain (LBP) seeking primary care. OBJECTIVE: The aim of this study was to determine which existing primary care LBP stratification schema is associated with distinct subpopulations as characterized by easily identifiable primary epidemiological factors. SUMMARY OF BACKGROUND DATA: LBP is among the most frequent reasons for visits to primary care physicians and a leading cause of years lived with disability. In an effort to improve treatment response/outcomes in LBP primary care, different classification systems have been proposed in an effort to provide more tailored treatment with the intent of improving outcomes. Group-specific risk factors and underlying etiology might suggest a need for, or inform, changes to treatment approaches to optimize LBP outcomes. METHODS: Stratification by dominant mechanical pain patterns; chronicity risk; disability severity. Multinomial logistic regression was used to identify the system showing greatest variability in associations with age, sex, obesity, and comorbidity. Once identified, the remaining schemas were incorporated into the model. RESULTS: N = 970; mean age: 50 years (range: 18-93); 56% female. Stratification by pain pattern revealed greater variability. Adjusted analysis: Increasing age was associated with greater odds of intermittent, extension-based back- or leg-dominant pain [odds ratio (OR): 1.02 and 1.06; P < 0.01]; being male with leg-dominant pain (ORs > 2; P < 0.01). Overweight/obesity was associated with extension-based leg-dominant pain (OR = 2.6; P < 0.02) and increasing comorbidity with extension-based back-dominant pain (OR = 1.3; P < 0.01). Severe disability was associated only with constant leg pain (OR = 3.9; P < 0.01), and high chronicity risk with extension-based leg-dominant pain (OR = 0.4; P = 0.03). CONCLUSION: Dominant mechanical symptom stratification resulted in further discrimination of an epidemiologically distinct and a large subgroup of LBP patients not identified by disability or chronicity risk stratification alone. Findings suggest a need for primary care initiated multidimensional stratification in chronic LBP. LEVEL OF EVIDENCE: 3.

Airway adverse events following posterior occipito-cervical spinal fusion.

Management of the airway may be challenging in patients undergoing occipito-cervical spine fusions (OCF). Changes in the occipito-cervical angle (dOC2A) of fusion after surgery may result in acute airway obstruction, dyspnea and/or dysphagia. Objectives of the study were to review the airway management of patients during posterior OCF, determine the incidence, nature and risk factors for postoperative airway adverse events (AEs), and to determine the relationship between airway AEs and the change in dOC2A. In this retrospective cohort of 59 patients, following extubation in the operating room (OR), there were no complications in 43 (73%) patients (Group 1). Sixteen (27%) patients (Group 2) had airway complications; 4 requiring reintubation and 12 having delayed extubation. The number of vertebral levels fused (>6), presence of difficult intubation and duration of surgery (>5h) were significantly associated with AEs. There was no significant difference in the dOC2A between the groups (-1.070±5.527 versus -4.375±10.788, p=0.127). Airway management in patients undergoing OCF poses a challenge for the anesthesiology and surgical teams. The incidence of AEs was 27%. The decision to extubate immediately after surgery needs to be individualized. Factors such as difficult intubation, number of vertebral levels fused and duration of surgery have to be considered. A significant correlation between dOC2A and postoperative AEs could not be established. Risk factors for postoperative AEs are multifactorial and prospective evaluation of these factors is indicated.

Posterior column reconstruction with autologous rib graft after en bloc tumor excision.

STUDY DESIGN: Retrospective review of consecutive case series. OBJECTIVE: To evaluate the efficacy of using autologous rib graft for fusion across long posterior column defects. SUMMARY OF BACKGROUND DATA: Achieving fusion across large posterior column defects after en bloc tumor resection can be difficult. Rib graft can be harvested from the local wound, and its shape and structural properties are well suited for reconstruction of thoracic posterior column deficits. METHODS: After Research Ethics Board approval, a retrospective review of the charts of 17 consecutive patients undergoing posterior column reconstruction after en bloc tumor resections was carried out. Autologous vascularized and nonvascularized rib grafts were utilized in 8 and 9 cases, respectively; 14 patients with malignant tumors and 3 with benign etiology. After surgery, patients underwent routine clinical and radiographic follow-up, with a computed tomographic scan performed at a minimum of 6 months in all surviving patients. Clinical and radiographic films were analyzed. RESULTS: Computed tomographic scans at a minimum of 6 months demonstrated graft incorporation in all surviving cases. There was no obvious difference at 6-month imaging to differentiate vascularized from nonvascularized grafts. There were no cases of graft dislodgement or fracture. Graft site morbidity was difficult to isolate from the morbidity of these large procedures. No complications related to the graft were identified. CONCLUSION: The use of autologous rib graft with a proximal step-cut and distal saddle-cut supplemented with posterior instrumentation allowed immediate stabilization of the posterior column defect created by the en bloc tumor resection. This technique of fashioning the graft and taking advantage of its natural curved structure for immediate press-fit was associated with graft incorporation in our cases.

Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication. SUMMARY OF BACKGROUND DATA: Neurogenic claudication can significantly impact functional ability, quality of life, and independence in the elderly. METHODS.: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and ICL databases up to January 2011 for randomized controlled trials published in English, in which at least 1 arm provided data on nonoperative treatments. Risk of bias in each study was independently assessed by 2 reviewers using 12 criteria. Quality of the evidence was evaluated using Grades of Recommendations, Assessment, Development, and Evaluation (GRADE). RESULTS: From the 8635 citations screened, 56 were assessed and 21 trials with 1851 participants were selected. There is very low-quality evidence from 6 trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome. From single small trials, there is low-quality evidence that prostaglandins, and very low-quality evidence that gabapentin or methylcobalamin, improve walking distance. There is very low-quality evidence from a single trial that epidural steroid injections improve pain, function, and quality of life up to 2 weeks compared with home exercise or inpatient physical therapy. There is low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There is low- and very low-quality evidence from 6 trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion. CONCLUSION: Moderate- and high-GRADE evidence for nonoperative treatment is lacking and thus prohibiting recommendations to guide clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.

Nurse practitioner-led surgical spine consultation clinic.

AIM: This study is a report of a study of patient satisfaction with non-surgical nurse practitioner management of pre-selected spinal referrals. BACKGROUND: Nurse practitioners are linked to particular patient populations or specific physicians in a medical setting. In a universal healthcare delivery system, patients are often faced with long and anxiety-provoking waiting times, particularly for sub-specialized consultations such as spinal surgery. METHOD: A nurse practitioner-led spine consultation ambulatory clinic was implemented at a Canadian neuroscience centre. A prospective patient satisfaction and clinical accuracy study was performed in 2008. All patients assessed by the nurse practitioner completed a post-consultation validated patient satisfaction questionnaire. All patients were reviewed with the surgeon for confirmation of diagnosis and management. RESULTS: A total of 177 pre-selected patients (disc-herniations, spinal stenosis, degenerative disc disease) were assessed by the nurse practitioner. Mean time from referral to nurse practitioner clinic assessment was 12 weeks (range: 9·8-21 weeks) compared with 10-52 weeks if seen in a conventional clinic. Nurse practitioner clinical diagnosis and management plan were in agreement with those of the surgeon (100% and 95% respectively). Patient satisfaction was 97% with the consultation and 94% and with examination thoroughness. Preference for a longer waiting period for direct consultation with the surgeon was 26%. CONCLUSION: Nurse practitioners can play an effective and efficient role in providing care to patients requiring specific disease management in a specialty setting. The nurse practitioner-run clinic offers accurate and earlier assessment, thus facilitating a timelier diagnosis and management plan.

Charcot arthropathy of the lumbar spine treated using one-staged posterior three-column shortening and fusion.

STUDY DESIGN: Case report. OBJECTIVE: We present a case of lumbar Charcot arthropathy successfully treated surgically using posterior 3-column resection, spinal shortening, and fusion. SUMMARY OF BACKGROUND DATA: The operative treatment of Charcot arthropathy of the spine has conventionally been a combination of anterior and posterior surgery. The morbidity associated with these surgical procedures can be considerable. A posterior-only approach to the problem would avoid the additional morbidity associated with an anterior approach. We present a case of lumbar Charcot arthropathy with deformity treated successfully using such a procedure. METHODS: Discussion of the patient's clinical and radiologic history, the technical merits of the operative intervention and a review of the relevant background literature are presented. RESULTS: A multilevel, single-stage, posterior 3-column resection with primary shortening and instrumented fusion augmented with rhBMP2 in a multiply operated patient with deformity provided a optimal biologic and mechanical environment for healing of the Charcot arthropathy and improved the sagittal and coronal profile of the spine. CONCLUSION: A single-stage, multilevel, posterior 3-column resection and primary shortening can be a useful surgical strategy in symptomatic patients with Charcot arthropathy of the spine.

Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity.

STUDY DESIGN: Observational cohort study. Retrospective review of prospectively collected outcomes data. OBJECTIVE: The purpose of this study was to evaluate the clinical efficacy of minimally invasive (MIS) decompression for focal lumbar spinal stenosis (FLSS) in patients with and without deformity. SUMMARY OF BACKGROUND DATA: MIS, facet-preserving decompression has the potential of offering a significantly less morbid alternative to decompression and fusion in patients with leg dominant symptoms from degenerative spondylolisthesis and/or scoliosis. METHODS: Single surgeon, consecutive series (n=75), evaluated over 5 years. All patients had MIS lumbar laminoplasty (bilateral decompression from a unilateral approach) for FLSS (1-2 level). Patients had leg dominant, claudicant/radicular pain. Patients were divided into 4 groups: (A) stenosis with no deformity, n=22; (B) stenosis with spondylolisthesis only, n=25; (C) stenosis with scoliosis, n=16; and (D) stenosis combined with spondylolisthesis and scoliosis, n=12. The primary clinical outcome measures were the Oswestry Disability Index (ODI) and surgical revision rate. Preoperative and postoperative standing radiographs were assessed. RESULTS: The average age was 68 years (40-89) with a mean time from surgery of 36.5 months (18-68). Average clinical improvement in ODI was 49.5% to 23.9% [mean postoperative follow-up of 31.8 months (24-72): group A=mean of 34.6; B=28.9; C=32.7; D=30 months]. Incidence of preoperative grade I spondylolisthesis was 46%. Spondylolisthesis progression (mean=8.4%) occurred in 9 patients and 2 patients developed spondylolisthesis. Overall revision rate was 10% [repeat decompression alone (n=2) and decompression and fusion (n=6)]. Subgroup analysis of preoperative and postoperative ODI and revision rate revealed (A) 48% to 18.7%, 0%; (B) 48% to 24.6%, 4%; (C) 50.7% to 31.5%; 25%; and (D) 53% to 22%, 25%, respectively. The revision rate for patient with scoliosis (C+D) was significant (P=0.0035) compared with those without. Six of the 8 revised patients had a preoperative lateral (rotatory) listhesis (3 in C and 3 in D). CONCLUSION: MIS decompression alone for leg dominant symptoms is a clinically effective procedure in the majority of patients including those with degenerative spondylolisthesis or scoliosis. However, patients with scoliosis, particularly those with lateral listhesis, have a significantly higher revision rate that needs to be considered in operative decision-making.

Spine adverse events severity system: content validation and interobserver reliability assessment.

STUDY DESIGN: A prospective validation study, preliminary single-center report. OBJECTIVE: The purpose of this study was to assess the content validity and interobserver reliability of a simple severity classification system for adverse events (AEs) associated with spinal surgery. SUMMARY OF BACKGROUND DATA: In the surgical literature what is defined as an AE, the severity of an AE, and the reporting of AEs are variable. Consequently, valid comparison of AEs within or among specialties or surgical centers for the same or different procedures is often impossible. METHODS: Since 2002, a Spine Adverse Events Severity system (SAVES) has been locally developed and prospectively used. AEs were graded as I (requires none/minimal treatment, minimal effect [<1-2 days] on length of stay [LOS]), II (requires treatment and/or increases LOS [3-7 days] with no long-term sequelae), III (requires treatment and/or increased LOS [>7 days] with long-term sequelae [>6 months]), and IV (death). Content validity of the grading system was assessed using the hospital chart abstraction (current defacto gold standard) compared with the SAVES from 200 randomly selected patients. Interobserver reliability was assessed in consecutive operative cases for 1 spine surgeon during a 1-year period (2006) using 3 raters (staff surgeon, fellow, and/or resident). RESULTS: The prospectively administered form reported a higher number of surgical AEs (n = 43 vs. n = 30) and a similar number of medical AEs (n = 31 vs. n = 27). Compared with the chart, the AE form displayed substantial agreement for number (70%; weighted Kappa [wK] = 0.60) and type (75%; wK = 0.67) of AE. The interobserver reliability was near perfect (kappa = 0.8) for the actual grade of AE and moderate (kappa = 0.5) for the criteria behind the grading (i.e., clinical effect of the AE or the effect of the AE on LOS or both). CONCLUSION: The result of this study demonstrates improved capture of surgical AEs using SAVES. Excellent interobserver reliability between surgeons at different level of training was demonstrated with minimal education or training regarding the use of SAVES.

Admission and acute complication rate for outpatient lumbar microdiscectomy.

OBJECTIVE: Specialization is generally independently associated with improved outcomes for most types of surgery. This is the first study comparing the immediate success of outpatient lumbar microdiscectomy with respect to acute complication and conversion to inpatient rate. Long-term pain relief is not examined in this study. METHODS: Two separate prospective databases (one belonging to a neurosurgeon and brain tumor specialist, not specializing in spine (NS) and one belonging to four spine surgeons (SS)) were retrospectively reviewed. All acute complications as well as admission data of patients scheduled for outpatient lumbar microdiscectomy were extracted. RESULTS: In total, 269 patients were in the NS group and 137 patients were in the SS group. The NS group averaged 24 cases per year while the SS group averaged 50 cases per year. Chi-square tests revealed no difference in acute complication rate [NS (6.7%), SS (7.3%)] (p > 0.5) and admission rate [NS (4.1%), SS (5.8%)] (p = 0.4) while the SS group had a significantly higher proportion of patients undergoing repeat microdiscectomy [NS (4.1%), SS (37.2%)] (p < 0.0001). Excluding revision operations, there was no statistically significant difference in acute complication [NS (5.4%), SS (1.2%)] (p = 0.09) and conversion to inpatient [NS (4.3%), SS (4.6%)] (p > 0.5) rate. The combined acute complication and conversion to inpatient rate was 6.9% and 4.7% respectively. CONCLUSION: Based on this limited study, outpatient lumbar microdiscectomy can be apparently performed safely with similar immediate complication rates by both non-spine specialized neurosurgeons and spine surgeons, even though the trend favored the latter group for both outcome measures.

Tranexamic Acid reduces perioperative blood loss in adult patients having spinal fusion surgery.

BACKGROUND: Spinal reconstructive surgery in adults can be associated with significant blood loss, often requiring allogeneic blood transfusion. The objective of this randomized, prospective, double-blind, multicenter study was to evaluate the efficacy of tranexamic acid (TXA) in reducing perioperative blood loss and transfusion in adult patients having elective posterior thoracic/lumbar instrumented spinal fusion surgery. METHODS: One hundred fifty-one adult patients were randomized to receive either a bolus of 10 mg/kg IV of TXA after induction followed by a maintenance infusion of 1 mg/kg/hr of TXA, or an equivalent volume of placebo (normal saline). The primary outcome was the total perioperative estimated and calculated blood loss intraoperatively and 24 h postoperatively. Secondary outcomes were incidence of allogeneic blood exposure, and duration of hospital stay. RESULTS: Four patients were withdrawn for identifiable surgical bleeding, therefore 147 patients were included in the analysis. The total estimated and calculated perioperative blood loss was approximately 25% and 30% lower in patients given TXA versus placebo (1592 +/- 1315 mL vs 2138 +/- 1607 mL, P = 0.026; 3079 +/- 2558 vs 4363 +/- 3030, P = 0.017), respectively. There was no difference in the amounts of blood products transfused, and length of stay between the two groups. TXA, surgical duration, and number of vertebrae fused were independent factors related to perioperative blood loss. Predictors for the need for allogeneic red blood cell transfusion were ASA classification, surgical duration and number of levels fused. CONCLUSIONS: TXA significantly reduced the estimated and calculated total amount of perioperative blood loss in adult patients having elective posterior thoracic/lumbar instrumented spinal fusion surgery.