Inferior long-term outcomes after surgery for lumbar disc herniation in patients with prior lumbar spine surgery.

BACKGROUND: Previous lumbar spine surgery is a frequent exclusion criterion for studies evaluating lumbar surgery outcomes. In real-life clinical settings, this patient population is important, as a notable proportion of patients evaluated for lumbar spine surgery have undergone prior lumbar surgery already previously. Knowledge about the long-term outcomes after microdiscectomy on patients with previous lumbar surgery and how they compare to those of first-time surgery is lacking. METHODS: The original patient cohort for screening included 615 consecutive patients who underwent surgery for lumbar disc herniation, with a median follow-up time of 18.1 years. Of these patients, 89 (19%) had undergone lumbar spine surgery prior to the index surgery. Propensity score matching (based on age, sex, and follow-up time) was utilized to match two patients without prior surgery with each patient with a previous surgery. The primary outcome measure was the need for further lumbar spine surgery during the follow-up period, and the secondary outcome measures consisted of present-time patient-reported outcome measures (Oswestry Disability Index, EuroQol-5D) and present-time ability to carry out employment. RESULTS: Patients who received previous lumbar surgeries had a higher need for further surgery (44% vs. 28%, p = 0.009) and had a shorter time to further surgery than the propensity score-matched cohort (mean Kaplan-Meier estimate, 15.7 years vs. 19.8 years, p = 0.008). Patients with prior surgery reported inferior Oswestry Disability Index scores (13.7 vs. 8.0, p = 0.036). and EQ-5D scores (0.77 vs. 0.86, p = 0.01). In addition, they had a higher frequency of receiving lumbar spine-related disability pensions than the other patients (12% vs. 1.9%, p = 0.01). CONCLUSIONS: Patients with previous lumbar surgery had inferior long-term outcomes compared to patients without prior surgery. However, the vast majority of these patients improved quickly after the index surgery. Furthermore, the difference in the patients' reported outcomes was small at the long-term follow-up, and they reported high satisfaction with the results of the study surgery. Hence, surgery for these patients should be considered if surgical indications are met, but special care needs must be accounted for when deliberating upon their indications for surgery.

Comparable long-term outcomes in patients undergoing total disc replacement or anterior cervical discectomy and noninstrumented fusion.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is the leading surgical treatment for cervical radiculopathy. However, ACDF surgery has been suggested for to accelerate the degeneration of the adjacent cervical discs, which causes so-called adjacent segment disease (ASD). Over the past 2 decades, total disc replacement (TDR)/cervical disc arthroplasty (CDA) has become an increasingly common method for treating degenerative cervical diseases. The rationale is that a synthetic disc prosthesis may preserve motion at the operated level, which is expected to lead to reduced stress on the other cervical levels and thus decrease the risk of developing ASD. However, since the method was first introduced in the early 2000s, the long-term outcome after it is still not completely understood. PURPOSE: Our goal was to compare the long-term outcomes of TDR and ACDF procedures. STUDY DESIGN: Retrospective case-control study. PATIENT SAMPLE: All patients who underwent TDR due to degenerative cervical disease at Helsinki University Hospital between 2006 and 2012 (38 patients) and matched control patients who underwent ACDF during this period (76 patients) for degenerative disc disease. OUTCOME MEASURES: The primary outcome measure was the rate of reoperations and further cervical surgeries. Secondary outcome measures included neck symptoms (Neck Disability Index, or NDI), health-related quality of life (EQ-5D-3L), satisfaction with the surgery, radiological outcomes, and employment status. METHODS: The medical records of all patients who underwent TDR due to degenerative cervical disease at Helsinki University Hospital between 2006 and 2012 and those of the matched control patients were analyzed retrospectively. Questionnaires were sent to all available patients at the end of the follow-up (median 14 years) to evaluate their employment status, levels of satisfaction with the surgery, current neck symptoms, and health-related quality of life. Radiological outcomes were evaluated from the cervical plain radiographs, which were taken either at the end of the follow-up as a part of the present study or earlier on for other clinical reasons, but at least 2 years after index surgery. RESULTS: The total rate of reoperations and further cervical surgeries during the follow-up of a median of 14 years was 7/38 (18%) in the TDR group and 6/76 (8%) in the ACDF group (p=.096, ns.). Total disc replacement patients were reoperated earlier, and the 5-year reoperation rate was significantly higher in the TDR group (11% vs 1.3%, p=.026). None of the TDR patients underwent further cervical surgery more than 6 years after index surgery, whereas 5/6 (83%) of the reoperated ACDF patients were reoperated after that time. There were no significant differences in the NDIs between the patient groups. The employment rate and health-related quality of life were slightly higher in the TDR group, but the differences were statistically nonsignificant. TDR was significantly better at maintaining the angular range of motion at the operated level, and the fusion rate was significantly lower among this group. CONCLUSIONS: There were no significant differences in the long-term outcomes of ACDF and TDR when measured by reoperation rates, employment status, NDI, EuroQoL, and satisfaction with surgery. Reoperation rate and, on the other hand, employment rate and health-related quality of life, were higher in the TDR group, but the differences were statistically nonsignificant. However, TDR patients were reoperated earlier, and the 5-year reoperation rate was significantly higher in the TDR group. Randomized long-term studies in which these methods are compared are needed to further clarify the differences between them.

Favorable long-term health-related quality of life after surgery for lumbar disc herniation in young adult patients.

BACKGROUND: Lumbar disc herniation is often managed conservatively; nevertheless, surgical intervention can be required. Majority of patients experience a drastic relief of symptoms after surgery, but previous studies have reported that their health-related quality of life remains inferior compared to the general population for several years. There may be a major cumulative loss of health-related quality of life for young patients as they have long expected life ahead of them. METHODS: A total of 526 eligible adult patients under the age of 40 underwent surgery for lumbar disc herniation from 1990 to 2005. Patients' baseline characteristics were acquired by chart review to confirm eligibility to the study. Follow-up quality of life data was acquired by sending patients EQ-5D questionnaire at median 18 years after index surgery, and those 316 patients responding to the questionnaire (60%) were included in the study. Propensity score matching was utilized to match every study patient with two general population sample participants from a large Finnish population health study. Primary objective was to compare the quality of life to that of the control population. Secondary objective was to explore which patient characteristics lead to inferior outcome. RESULTS: The mean EQ-index for the patient cohort was 0.86, while it was 0.84 for the age and gender-matched general population sample (difference 0.02, 95% CI - 0.0004 to 0.049). Within the patient cohort, an increasing number of lifetime lumbar surgeries was associated with progressively deteriorating EQ-index scores (p = 0.049) and longer duration of symptoms prior to the surgery correlated with lower score (p = 0.013). CONCLUSION: Patients who underwent surgery for lumbar disc herniation nearly two decades ago reported quality of life comparable to the age and gender-matched general population. However, patients who had undergone numerous lumbar surgeries had significantly worse outcome. Therefore, possible ways to prevent cumulation of lumbar surgeries could improve long-term health-related quality of life.

Favorable long-term outcome in young adults undergoing surgery for lumbar disc herniation.

PURPOSE: The purpose of the study was to evaluate the long-term outcome after surgery for lumbar disc herniation in a young adult population. METHODS: A total of 526 consecutive patients between 18 and 40 years of age who underwent surgery for lumbar disc between 1990 and 2005 were included in the study. The primary outcomes were the need for new lumbar spine surgery during the follow-up and secondary outcomes were short-term subjective outcome, the Oswestry Disability Index (ODI) score, and the ability to carry out employment at the end of the long-term follow-up. RESULTS: A total of 96% of the patients had a reduction in their symptoms at the clinical follow-up (median of 50 days post-surgery). Twenty-one patients (4.0%) had a reoperation within 28 days. Excluding these early reoperations, 136 patients (26%) had additional lumbar spine surgery and 18 patients (3.4%) underwent lumbar fusion during the follow-up of median 18 years. The annual risk for new surgery was 1.4%. In total, 316 patients (60%) returned the ODI questionnaire, and their mean score was 8.1. Patients with a higher number of additional lumbar spine surgeries (p < 0.001) reported deteriorating ODI scores. CONCLUSION: Patients showed excellent short-term recovery from their symptoms. In the long term, the mean ODI score for the patients was comparable to the normative population. However, a notable proportion of the patients required additional lumbar surgery during the follow-up period, and a higher number of lumbar surgeries was associated with poor ODI scores.

Long-Term Follow-Up After Cervical Laminectomy without Fusion for Cervical Spondylotic Myelopathy.

OBJECTIVE: The objectives were to study the effect of cervical laminectomy without fusion on the incidence of further cervical surgeries, the risk for cervical misalignment, and current functional status. METHODS: We retrospectively analyzed the clinical data of 340 patients who had undergone simple laminectomy for cervical spondylotic myelopathy (CSM) at Helsinki University Hospital between 2000 and 2011. RESULTS: Forty-one patients (12.1%) had later undergone another cervical surgery during the follow-up of a mean of 8.5 years (maximum, 17.5 years). The most common indication for further surgery was residual stenosis at adjacent or other cervical levels (34%). Five patients (1%) required further surgery for correction of a sagittal balance problem. The mean Neck Disability Index was 28% at a median of 9.0 years after laminectomy. The mean EQ-5D (EuroQol 5 Dimension 3 Level) index score was 58.8 for patients and 77.2 for age-matched and gender-matched general population controls (P = 0.000), indicating patients' reduced health-related quality of life. Worse preoperative condition in the Nurick score was related to a lower (i.e., worse) EQ-5D score. In an additional arm of the study with radiographic imaging (40 patients), the mean change in sagittal alignment was 4.0° toward lordotic, and a newly developed kyphosis was found in 7.5% of patients. CONCLUSIONS: Because CSM is a serious degenerative progressive condition resulting in decreased health-related quality of life even after surgical treatment, the low rate of corrective surgery needed for alignment issues per se indicates that simple laminectomy can be a viable treatment option in treating multilevel CSM.

Young adults undergoing ACDF surgery exhibit decreased health-related quality of life in the long term in comparison to the general population.

BACKGROUND CONTEXT: The leading surgical treatment of cervical radiculopathy is anterior cervical discectomy and fusion (ACDF). However, it has been suggested that ACDF procedures could lead to accelerated degeneration of the adjacent cervical discs (adjacent segment disease, or ASD) and the effect of ACDF surgery on neck symptoms and quality of life in the long term is not fully understood. Patients operated on at young ages generally have a long life expectancy and a long number of working years ahead of them. Thus, this patient group is of special interest when considering the accumulation of cervical problems due to possible ASD, the overall progressive nature of cervical degeneration in the long term, and their effects on related quality of life. PURPOSE: Our goal was to study the health-related quality of life in the long-term follow-up after ACDF surgery in the young adult population between the ages of 18 and 40. STUDY DESIGN: A retrospective cohort study with propensity matched controls. PATIENT SAMPLE: All patients between 18 and 40 years of age at the time of the surgery who underwent ACDF due to degenerative cervical disease at Helsinki University Hospital between the years 1990 and 2005 who had filled in the quality of life questionnaires 12 to 28 years after the surgery (281 patients), and a propensity matched control cohort of the general population selected based on age, sex, and smoking status. OUTCOME MEASURES: Quality of life measured by the EuroQol questionnaire (EQ-5D-3L and EQ-VAS). METHODS: The medical records of all patients who underwent ACDF due to degenerative cervical disease at the age of 18 to 40 years at Helsinki University Hospital between 1990 and 2005 were analyzed retrospectively. The EuroQol questionnaire was sent to all patients whose contact information could be obtained (443 patients) at the end of the follow-up (median 17.5 years) to assess their current quality of life. A total of 281 patients returned the questionnaires and were included in this study. Quality of life was compared to that in the general Finnish population using a similar sized control cohort selected through propensity matching. RESULTS: The patients who had undergone ACDF surgery reported significantly more problems than the general population cohort in three out of five dimensions that were assessed in the EQ-5D questionnaire, including mobility, usual activities, and pain/discomfort. Similarly, the overall EQ-5D-3L index calculated from the dimensional values was lower (0.74 vs. 0.83, p=.000), depicting a generally decreased health-related quality of life among patients. Spondylosis as a primary diagnosis, clinical myelopathy, and further cervical surgeries were associated with lower quality of life in the subgroup analyses of the patients. Similarly, in the EQ-VAS assessment, patient subgroups with spondylosis as a primary diagnosis, at least one reoperation, operation on more than one level, and clinical myelopathy were associated with lower scores and lower quality of life. The mean EQ-VAS score among patients was 73%. Regardless of the decreased health-related quality of life, there was no statistically significant difference in the concurrent employment status between the patient and control groups. CONCLUSIONS: The health-related life quality measured by the EQ-5D-3L was lower in the patient population than in the general population. Patients had more problems with mobility and usual activities and more pain/discomfort. However, satisfaction with the surgery was very high, and there was no significant difference in employment status between the patients and the control population. Patients with spondylosis as a primary diagnosis had lower quality of life compared to patients with disc herniation. Also, clinical myelopathy and further cervical surgeries during follow-up were associated with lower quality of life in the subgroup analyses of the patients. It must also be kept in mind that we do not know what the situation could have been without surgery and with conservative treatment only.

Anterior cervical discectomy and fusion in young adults leads to favorable outcome in long-term follow-up.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) procedures is thought to lead to accelerated degeneration of the adjacent cervical discs and in some cases can be symptomatic (adjacent segment disease, or ASD). The occurrence of ASD is of particular interest when treating young individuals, as the cumulative disease burden may become increasingly significant during their expectedly long lifetime. However, the overall impact of a surgical intervention on the lifetime prognosis of ASD remains unclear. PURPOSE: Our goal was to study the long-term outcomes of ACDF surgery among those members of the young adult population who have been operated on between the ages of 18 and 40. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: All patients between 18 and 40 years of age at the time of surgery who underwent ACDF due to degenerative cervical disorders at Helsinki University Hospital between the years of 1990 and 2005 (476 patients). OUTCOME MEASURES: Cervical reoperation rate, satisfaction with the surgery, employment status, Neck Disability Index (NDI). METHODS: We retrospectively analyzed the medical records of all patients between 18 and 40 years of age at the time of surgery who underwent ACDF due to degenerative cervical disorders at Helsinki University Hospital between the years of 1990 and 2005. We sent questionnaires to all available patients at the end of the follow-up (median 17.5 years) to assess their current neck symptoms, general situations, and levels of satisfaction with the surgery. Furthermore, we compared the results for different types of ACDF surgeries (ie, discectomy only vs. synthetic cage or bone autograft implantation for fusion) in propensity-score-matched groups. RESULTS: Of the 476 patients who were included in the study, surgery was performed in 72% of the cases due to intervertebral disc herniation and in 28% due to spondylotic changes. The total reoperation rate during the entire follow-up (median 17.5 years) was 24%, and 19.5% if early reoperations (<28 days from index surgery) were excluded. At 10 years postsurgery, the total reoperation rate was 16.8% and 12.8% with early reoperations excluded. The probability of surgery for adjacent level disease was 10.3% at 10 years and 16.8% for the duration of the entire follow-up, with the annual incidence rate of 1.1% for those with ASD requiring surgery. Statistically significant risk factors leading to the need for further cervical surgery included central spinal cord compression and smoking at the time of the index operation. After propensity score matching, there was no significant difference found between the outcomes of different types of surgery. A total of 443 patients were still able to be contacted 12-28 years after the surgery. Of the 281 patients responding to the questionnaires, 92% were still satisfied with the results. With respect to employment, 67% of patients were working, 7% were unemployed, and 7% were on disability due to cervical problems. The median NDI score was 12%, with 56% of patients having an NDI score lower than 15%; it has been suggested that this latter NDI score serves as a cut-off value for significant neck morbidity. The NDI scores were significantly higher among female patients, patients with spondylosis, and patients having undergone further cervical surgeries during the follow-up. CONCLUSIONS: Long-term satisfaction with the surgery was very high, and the employment rate among patients resembled that of the general population in Finland. Thus, the long-term prognosis after having ACDF surgery at a younger age seems to be good, even though nearly half of the patients experienced some persistent neck symptoms later in life.

Finnish Trial on Practices of Anterior Cervical Decompression and Fusion (FACADE): a protocol for a prospective randomised non-inferiority trial comparing outpatient versus inpatient care.

INTRODUCTION: Although a great majority of patients with cervical radiculopathy syndrome can successfully be treated non-operatively, a considerable proportion experience persistent symptoms, severe enough to require neurosurgical intervention. During the past decade, cervical spine procedures have increasingly been performed on an outpatient basis and retrospective database analyses have shown this to be feasible and safe. However, there are no randomised controlled studies comparing outpatient care with inpatient care, particularly with emphasis on the patients' perception of symptom relief and their ability to return to normal daily activities and work. METHODS AND ANALYSIS: This is a prospective, randomised, controlled, parallel group non-inferiority trial comparing the traditional hospital surveillance (inpatient, patients staying in the hospital for 1-3 nights after surgery) with outpatient care (discharge on the day of the surgery, usually within 6-8 hours after procedure) in patients who have undergone anterior cervical decompression and fusion procedure. To determine whether early discharge (outpatient care) is non-inferior to inpatient care, we will randomise 104 patients to these two groups and follow them for 6 months using the Neck Disability Index (NDI) as the primary outcome. We expect that early discharge is not significantly worse than the current care in terms of change in NDI. Non-inferiority will be declared if the mean improvement for outpatient care is no worse than the mean improvement for inpatient care, by a margin of 17.3%. We hypothesise that a shorter hospital stay results in more rapid return to normal daily activities, shorter duration of sick leave and decreased secondary costs to healthcare system. Secondary outcomes in our study are arm pain and neck pain using the Numeric Rating Scale, operative success (Odom's criteria), patient's satisfaction to treatment, general quality of life (EQ-5D-5L), Work Ability Score, sickness absence days, return to previous leisure activities and complications. ETHICS AND DISSEMINATION: The study was approved by the institutional review board of the Helsinki and Uusimaa Hospital District on 6 June 2019 (1540/2019) and duly registered at ClinicalTrials.gov. We will disseminate the findings of this study through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03979443.