Identifying subsets of patients with single-level degenerative disc disease for lumbar fusion: the value of prognostic tests in surgical decision making.

BACKGROUND CONTEXT: Fusion surgery for degenerative disc disease (DDD) has become a standard of care, albeit not without controversy. Outcomes are inconsistent and a superiority over conservative treatment is debatable. Proper patient selection is key to clinical success, and a comprehensive understanding of prognostic tests does not currently exist. PURPOSE: This study aimed to investigate the value of prognostic tests and sociodemographic factors in predicting outcomes following lumbar fusion surgery for DDD. STUDY DESIGN: This is a retrospective analysis of prospectively collected data. PATIENT SAMPLE: We included patients who underwent fusion surgery for DDD between 2010 and 2016. OUTCOME MEASURES: The outcome measures included pre- and postoperative visual analog scale and Oswestry Disability Index scores. MATERIALS AND METHODS: Prospectively collected patient data were reviewed for preoperative tests, perioperative data, and clinical outcomes. Prognostic tests used were discography, pantaloon cast test (PCT), Modic changes, and a summary of physical symptoms, coined "loading factor." By means of multivariate stepwise regression, prognostic factors that were useful in predicting outcomes were identified. RESULTS: A total of 91 patients fit the inclusion criteria, with a mean follow-up of 33±16 months. Discography, Modic changes, and loading factor were of no value for predicting outcome scores (p>.05). A positive PCT predicted improved outcomes in back pain severity, but only in patients without prior surgery (p=.02). Demographic factors that showed a consistent reduction in back pain were female sex (p=.021) and no prior surgery at index level (p=.009). No other sociodemographic factors were of predictive value (p>.05). CONCLUSIONS: In patients without prior surgery, the PCT appears to be the most promising prognostic tool. Other prognostic selection tools such as discography and Modic changes yield disappointing results. In this study, female patients and those without prior spine surgery appear to be most likely to benefit from fusion surgery for DDD.

Minimally invasive transaxial lumbosacral interbody fusion: a ten year single-centre experience.

PURPOSE: Our aim was to evaluate mid- and long-term results in a cohort of patients who underwent minimally invasive transaxial lumbosacral fixation and to identify clinical and other parameters that can aid in proper patient selection. METHODS: Over a period of ten years, we assessed 164 patients who had a complete follow-up of a minimum of one year (average 54 months). On follow-up, we recorded clinical status, fusion status, visual analogue scale (VAS), Oswestry Lower Back Pain Disability Index (ODI) scores and patient satisfaction. RESULTS: There were no intra- or peri-operative complications. Overall clinical success rate was 73.8 %. Only sex (female), working status (still working), body mass index (BMI) (lower) and presence of Modic II changes (absent) were correlated with a good result. CONCLUSIONS: Transaxial fixation is a safe, minimally invasive technique that can offer good results in patients with single-level degenerative disc disease (DDD) at the lumbosacral level, with minimal operative risk.

Dutch Multidisciplinary Guideline for Invasive Treatment of Pain Syndromes of the Lumbosacral Spine.

OBJECTIVES: When conservative therapies such as pain medication or exercise therapy fail, invasive treatment may be indicated for patients with lumbosacral spinal pain. The Dutch Society of Anesthesiologists, in collaboration with the Dutch Orthopedic Association and the Dutch Neurosurgical Society, has taken the initiative to develop the guideline "Spinal low back pain," which describes the evidence regarding diagnostics and invasive treatment of the most common spinal low back pain syndromes, that is, facet joint pain, sacroiliac joint pain, coccygodynia, pain originating from the intervertebral disk, and failed back surgery syndrome. METHODS: The aim of the guideline is to determine which invasive treatment intervention is preferred for each included pain syndrome when conservative treatment has failed. Diagnostic studies were evaluated using the EBRO criteria, and studies on therapies were evaluated with the Grading of Recommendations Assessment, Development and Evaluation system. For the evaluation of invasive treatment options, the guideline committee decided that the outcome measures of pain, function, and quality of life were most important. RESULTS: The definition, epidemiology, pathophysiological mechanism, diagnostics, and recommendations for invasive therapy for each of the spinal back pain syndromes are reported. DISCUSSION: The guideline committee concluded that the categorization of low back pain into merely specific or nonspecific gives insufficient insight into the low back pain problem and does not adequately reflect which therapy is effective for the underlying disorder of a pain syndrome. Based on the guideline "Spinal low back pain," facet joint pain, pain of the sacroiliac joint, and disk pain will be part of a planned nationwide cost-effectiveness study.

Axial lumbar interbody fusion: a 6-year single-center experience.

INTRODUCTION: The aim of this study is to report our 6-year single-center experience with L5-S1 axial lumbar interbody fusion (AxiaLIF). METHODS: A total of 131 patients with symptomatic degenerative disc disease refractory to nonsurgical treatment were treated with AxiaLIF at L5-S1, and were followed for a minimum of 1 year (mean: 21 months). Main outcomes included back and leg pain severity, Oswestry Disability Index score, working status, analgesic medication use, patient satisfaction, and complications. Computed tomography was used to determine postoperative fusion status. RESULTS: No intraoperative complications, including vascular, neural, urologic, or bowel injuries, were reported. Back and leg pain severity decreased by 51% and 42%, respectively, during the follow-up period (both P < 0.001). Back function scores improved 50% compared to baseline. Clinical success, defined as improvement ≥30%, was 67% for back pain severity, 65% for leg pain severity, and 71% for back function. The employment rate increased from 47% before surgery to 64% at final follow-up (P < 0.001). Less than one in four patients regularly used analgesic medications postsurgery. Patient satisfaction with the AxiaLIF procedure was 83%. The fusion rate was 87.8% at final follow-up. During follow-up, 17 (13.0%) patients underwent 18 reoperations on the lumbar spine, including pedicle screw fixation (n = 10), total disc replacement of an uninvolved level (n = 3), facet screw fixation (n = 3), facet screw removal (n = 1), and interbody fusion at L4-L5 (n = 1). Eight (6.1%) reoperations were at the index level. CONCLUSION: Single-level AxiaLIF is a safe and effective means to achieve lumbosacral fusion in patients with symptomatic degenerative disc disease.

[Multidisciplinary practice guideline 'Invasive treatment of spine related low back pain']. / Multidisciplinaire richtlijn 'Wervelkolomgerelateerde pijnklachten van de lage rug'.

The practice guideline 'Invasive treatment of spine related low back pain' describes the state of the art regarding the diagnosis and value of invasive treatment after failure of conservative treatment in patients with pain symptoms of facet joint pain, pain in the sacroiliac joint, coccygodynia, discogenic pain and the 'failed back surgery syndrome'. There is no consensus on definitions and a classification system for chronic low back pain symptoms. The classification in specific and nonspecific low back pain provides insufficient insight and is unable to show which therapy is effective for which disorder. The guideline working group advises a new classification system for chronic low back pain in degenerative and non-degenerative disorders. After failure of conservative treatment, several specific invasive treatments are recommended; some of these treatments should only be performed in study related settings. Some of the treatments that are currently used in daily practice are inadvisable.