Perioperative Effects Associated With the Surgical Treatment of Degenerative Spondylolisthesis: Interbody Versus No Interbody.

STUDY DESIGN: This is a retrospective analysis. OBJECTIVE: The purpose of this study was to compare the clinical, radiographic, and perioperative complication profiles of performing an interbody and posterior arthrodesis (CAGE) versus posterolateral lumbar fusion (PLF) alone in patients undergoing surgery for degenerative spondylolisthesis (DS). SUMMARY OF BACKGROUND DATA: DS is a common disorder that, failing nonoperative treatment, may be managed with surgical decompression and concomitant posterior arthrodesis. At present, the risk/benefit ratio of including an additional interbody arthrodesis has not been clearly delineated in the literature. MATERIALS AND METHODS: We reviewed 174 consecutive patients (118 female and 56 male) diagnosed with single-level DS that met the inclusion/exclusion criteria, from January 1, 2000 to August 1, 2011. Clinical outcomes, fusion rates, radiographic outcomes, and complication profiles were recorded. RESULTS: We identified 174 patients who received a single-level lumbar interbody fusion with posterolateral fusion (CAGE, n=89) or posterolateral fusion alone (PLF, n=85). No difference in patient-reported outcomes or fusion rate was detected between the 2 groups. We did identify better segmental lordosis increase (4.9±3.2 vs. 0.9±1.9 degrees; P=0.001) and interdiscal height change (2.1±2.4 vs. 0.6±1.6 mm) in the CAGE group. Operative time, 199.8±36.6 versus 142.6±28.5 minutes (P<0.001); blood loss, 355±216.4 versus 269±28.5 mL (P<0.001); and postoperative radiculitis, 28.9% versus 7.0% (P=0.003) were worse in the CAGE group compared with the PLF group. CONCLUSIONS: The ideal surgical approach when treating patients with DS remains in question. This study suggests, when comparing PLF with or without additional interbody fusion, that the lack of clinical or fusion-related benefit may not justify the higher risk profile including longer surgery, higher blood loss, and increased risk of postoperative radiculitis. Long-term prospective studies are required to further clarify these findings. LEVEL OF EVIDENCE: Level III.

Reoperation and revision rates of 3 surgical treatment methods for lumbar stenosis associated with degenerative scoliosis and spondylolisthesis.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To compare early treatment failures, survivorship, and clinical outcomes of 3 procedures used to treat symptomatic lumbar spinal stenosis and degenerative deformity. SUMMARY OF BACKGROUND DATA: Symptomatic lumbar stenosis is commonly seen in association with degenerative deformity, often leading to more complex surgical treatment, with laminectomy and fusion, supplanting laminectomy alone. More recently, the interspinous process spacer (ISP), developed to treat straightforward spinal stenosis, has been used in patients with spinal deformity to limit morbidity, although no studies have compared outcomes in this patient population. METHODS: A retrospective cohort analysis of 90 consecutive patients, mean age 70 years, with 5-year mean follow-up (minimum, 2 yr), treated for stenosis with associated deformity with ISP device placement, laminectomy alone, or laminectomy and short-segment fusion. Early failure was defined as return to the operating room for revision of the index level or adjacent segment within 2 years. A Kaplan-Meier survival analysis was performed, and clinical outcomes and patient satisfaction was assessed. RESULTS: Reoperation within 2 years was noted in 16.7% of patients treated for spinal stenosis and mild deformity. There was a significantly higher rate of same-level recurrence in the ISP group (33.3%), than the laminectomy (8.3%) and lami/fusion groups (0%) (P< 0.0001). Early reoperation due to adjacent segment pathology (ASP) was most common in the lami/fusion group (13.3%). Kaplan-Meier analysis revealed lowest survival for the ISP group and highest survival in the laminectomy-alone group at 2 years (P= 0.043) and 5 years (P= 0.007). CONCLUSION: Early failure was significantly more common in patients treated with an ISP device for spinal stenosis and lumbar deformity, whereas reoperation due to symptomatic adjacent segment pathology was most common in patients treated with laminectomy and fusion. Laminectomy alone had the highest rate of survival. LEVEL OF EVIDENCE: 3.

Psychological distress in a Department of Veterans Affairs spine patient population.

BACKGROUND CONTEXT: The veteran population presents a unique confluence of biopsychosocial factors in the treatment of spinal conditions. In addition to poorer health status and higher numbers of chronic medical conditions compared with the general population, previous reports have highlighted the high prevalence of psychological disorders within the Department of Veterans Affairs (VA) health system. To our knowledge, no study has specifically evaluated psychological distress in patients with a spinal disorder within the VA health system. PURPOSE: To determine the prevalence of psychological distress among spine patients in a VA hospital and if higher levels of distress correlated with patient demographics and self-reported patient outcome scores. STUDY DESIGN/SETTING: Cross-sectional evaluation of adult patients at a regional VA outpatient orthopedic spine surgery clinic. PATIENT SAMPLE: One hundred forty-nine adult patients presenting for treatment of spine-related disorders. OUTCOME MEASURES: Patients were evaluated using the Distress and Risk Assessment Method (DRAM), a validated survey consisting of the Zung Depression Scale and the Modified Somatic Perception Questionnaire. In addition, self-reported pain, disability, and quality of life were assessed using the visual analog scale (VAS) for neck or back pain and the Neck Disability Index or Oswestry Disability Index (ODI) depending on the patient's location of pain. METHODS: The DRAM survey was used to determine the prevalence of psychological distress by classifying patients into normal, at-risk, and severe distress groups. Visual analog scale scores for neck and back pain, and self-reported disability scores, and demographic data including age, gender, combat experience, and use of antidepressant, anxiolytic, or narcotic medications were obtained at the time of enrollment. RESULTS: The DRAM survey identified 79.9% of patients as having some degree of psychological distress, whereas the remaining 20.1% were classified as normal. Among those with psychological distress, 43.6% of patients were categorized as severe distress. Compared with the normal group, a history of combat was more frequent in all distressed patient groups including the at-risk (p=.04) and severe distress (p=.009) groups. Those in the severe distress category more commonly reported the use of narcotics (p=.043) and antidepressant/anxiolytics medications (p=.0001). Those in the severe distress group had significantly higher ODI scores (p<.0001) and back pain VAS scores (p=.0360) compared with the normal group. CONCLUSIONS: We identified a large number of patients (80%) with some level of psychological distress and 43% with severe distress. The percent of patients with severe psychological distress in the VA was double that previously reported in a non-VA patient setting. Patients with severe distress had higher ODI scores, back pain VAS scores, use of narcotics and antidepressants, and a reported history of combat when compared with those without distress.