Preoperative and Postoperative, Three-dimensional Gait Analysis in Surgically Treated Patients With High-grade Spondylolisthesis.

BACKGROUND: High-grade spondylolisthesis (HGS) (Myerding grade III-V) in adolescents can lead to a marked alteration of gait pattern and maybe the presenting symptom in these patients. This characteristic gait pattern in patients with HGS has been referred to as the "pelvic waddle." Modern 3-dimensional (3D) gait analysis serves an important tool to objectively analyze the different components of this characteristic gait preoperatively and postoperatively and is an objective measure of postoperative improvement.This study demonstrates the use of 3D gait analysis preoperatively and postoperatively in a cohort of 4 consecutive patients with HGS treated surgically at a single tertiary referral center and utilize this to objectively evaluate outcome of surgical treatment in these patients. This has not been reported previously in a cohort of patients. METHODS: This is a prospective analysis of patients with HGS who underwent surgical intervention for spondylolisthesis at a single institution. Patient demographics, clinical, and radiologic assessment were recorded, and all patients underwent 3D gait analysis before and after surgical intervention. Kinetic, kinematic, and spatial parameters were recorded preoperatively and postoperatively for all patients. This allowed the outcome of change in gait deviation index, before and after surgical treatment, to be evaluated. RESULTS: We were able to review complete records of 4 adolescent patients who underwent surgical treatment for HGS. Mean age at surgery was 13.5 years with a minimum follow-up of 2.5 years postoperatively (average 40 mo). Preoperative gait analysis revealed marked posterior pelvic tilt in 2 patients, reduced hip and knee extension in all 4 patients and external foot progression in 3 of the 4 patients. Along with an observed improvement in gait, there was an objective improvement in gait parameters postoperatively in all 4 patients. Gait deviation index score improved significantly from 78.9 to 101.3 (mean). CONCLUSIONS: Preoperative gait abnormalities exist in HGS and can be objectively analyzed with gait analysis. Surgical intervention may successfully resolve these gait abnormalities and gait analysis is a useful tool to assess the outcome of surgery and quantify an otherwise intangible benefit of surgical intervention. LEVEL OF EVIDENCE: Level IV-case series.

Perioperative adverse events following surgery for primary bone tumors of the spine and en bloc resection for metastases.

OBJECTIVE: Surgical treatment of primary bone tumors of the spine and en bloc resection for isolated metastases are complex and challenging. Operative care is fraught with complications, though the true incidence and predictors of adverse events (AEs), length of stay (LOS), and mortality in this population remain poorly understood. The primary objective of this study was to describe the incidence and predictors of perioperative AEs in these patients. Secondary objectives included the determination of the incidence and predictors of admission to the intensive care unit (ICU), unanticipated reoperation during the same admission, hospital LOS, and mortality. METHODS: In this retrospective analysis of prospectively collected data, the authors included consecutive patients at a single quaternary care referral center (January 1, 2009, to September 30, 2018) who underwent either surgery for a primary bone tumor of the spine or an en bloc resection for an isolated spinal metastasis. Information on perioperative AEs, demographic data, primary tumor histology, neurological status, surgical variables, pathological margins, Enneking appropriateness, LOS, ICU stay, reoperation during the same admission period, and in-hospital mortality was collected prospectively in the institutional database. The modified frailty score was extracted retrospectively. RESULTS: One hundred thirteen patients met the inclusion criteria: 98 with primary bone tumors and 15 with isolated metastases. The cohort was 59% male, and the mean age was 49 years (SD 19 years). Overall, 79% of the patients experienced at least 1 AE. The median number of AEs per patient was 2 (IQR 0-4 AEs), and the median LOS was 16 days (IQR 9-32 days). No in-hospital deaths occurred in the cohort. Thirty-two patients (28%) required an ICU stay and 19% underwent an unanticipated second surgery during their admission. A longer surgical duration was associated with a higher likelihood of AEs (OR 1.21/hour, 95% CI 1.06-1.37, p = 0.005), longer ICU stay (OR 1.35/hour, 95% CI 1 1.20-1.52, p < 0.001), and reoperation (OR 1.001/hour, 95% CI 1.0003-1.003, p = 0.012). Longer hospital LOS was independently predicted by older age, female sex, upper cervical and sacral location of the tumor, surgical duration, preoperative neurological deficit, presence of AEs, and higher modified frailty index score. CONCLUSIONS: Surgeries for primary bone tumors and en bloc resection for metastatic tumors are associated with a high incidence of perioperative AEs. Surgical duration predicts complications, reoperation, LOS, and ICU stay.

Effect of spinal decompression on back pain in lumbar spinal stenosis: a Canadian Spine Outcomes Research Network (CSORN) study.

BACKGROUND CONTEXT: Surgical decompression is usually offered for improvement of neurogenic claudication in patients with symptomatic lumbar canal stenosis. These patients often have associated low back pain (LBP) and little is known about the effect of decompression on this symptom. PURPOSE: The goal of the present study is to specifically quantify the improvement in LBP following surgical decompression for lumbar canal stenosis and to identify factors associated with changes in LBP in this population. STUDY DESIGN: This is a multicenter, retrospective review of consecutive spine surgery patients enrolled by the Canadian Spine Outcomes and Research Network. PATIENT SAMPLE: Consecutive patients who underwent surgical treatment for symptomatic lumbar spine stenosis without instability between 2014 and 2017. OUTCOME MEASURES: Change in LBP on the Numeric Rating Scale (NRS). METHODS: Patient-reported outcomes were collected at baseline and at 3, 12, and 24 months after surgery. The primary outcome was change in LBP on the NRS. Multivariable logistic regression was used to model the relationship between the outcome and potential factors associated with achieving minimal clinical important difference in back pain using a backward selection procedure. RESULTS: In all, 1,221 patients were included in the analysis. Mean age was 64 years and 58% were males. Baseline back pain scores were available in 1,133 patients and follow-up evaluations were available in 968/1,133 (85%) patients at 3 months, 649/903 (72%) patients at 12 months, and 331/454 (73%) at 24 months. LBP significantly improved 3 months after surgery and the improvement was sustained at 24 months (p<.001). We found that 74% of patients reached the minimal clinical important difference in back pain. Predictive factors for sustained improvement (12 and 24 months) in LBP after surgical intervention were absence of narcotic usage or compensation claims and increased severity of LBP before surgery (high NRS). CONCLUSIONS: Alleviation of clinically significant LBP was observed at 3 months after lumbar decompression surgery for neurogenic claudication and was maintained at 12 and 24 months after surgery in the majority of patients.

Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine. While AIS can progress during growth and cause a surface deformity, it is usually not symptomatic. However, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased. Interventions for the prevention of AIS progression include scoliosis-specific exercises, bracing, and surgery. The main aims of all types of interventions are to correct the deformity and prevent further deterioration of the curve and to restore trunk asymmetry and balance, while minimising morbidity and pain, allowing return to full function. Surgery is normally recommended for curvatures exceeding 40 to 50 degrees to stop curvature progression with a view to achieving better truncal balance and cosmesis. Short-term results of the surgical treatment of people with AIS demonstrate the ability of surgery to improve various outcome measures. However there is a clear paucity of information on long-term follow-up of surgical treatment of people with AIS. OBJECTIVES: To examine the impact of surgical versus non-surgical interventions in people with AIS who have severe curves of over 45 degrees, with a focus on trunk balance, progression of scoliosis, cosmetic issues, quality of life, disability, psychological issues, back pain, and adverse effects, at both the short term (a few months) and the long term (over 20 years). SEARCH METHODS: We searched the Cochrane Back Review Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, four other databases, and three trials registers up to August 2014 with no language limitations. We also checked the reference lists of relevant articles and conducted an extensive handsearch of the grey literature. SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) and prospective controlled trials comparing spinal fusion surgery with non-surgical interventions in people with AIS with a Cobb angle greater than 45 degrees. We were interested in all types of instrumented surgical interventions with fusion that aimed to provide curve correction and spine stabilisation. DATA COLLECTION AND ANALYSIS: We found no RCTs or prospective controlled trials that met our inclusion criteria. MAIN RESULTS: We did not identify any evidence comparing surgical to non-surgical interventions for AIS with severe curves of over 45 degrees. AUTHORS' CONCLUSIONS: We cannot draw any conclusions.

Symptomatic lumbar disc protrusion causing progressive myelopathy in a low-lying cord.

Low-lying cord is an uncommon entity, and cord compression due lumbar disc disease is rarely encountered. We discuss our experience with a case of lumbar cord compression secondary to a large disc protrusion, which caused myelopathy in a low-lying/tethered cord. A 77-year-old woman with known spina bifida occulta presented with 6-week history of severe low back pain and progressive paraparesis. Magnetic resonance imaging showed a low-lying tethered cord and a large disc prolapse at L2/3 causing cord compression with associated syringomyelia. Medical comorbidities precluded her from anterior decompression, and therefore a posterior decompression was performed. She recovered full motor power in her lower limbs and could eventually walk unaided. She had a deep wound infection, which was successfully treated with debridement, negative pressure therapy (vacuum-assisted closure pump), and antibiotics. Six months after surgery, her Oswestry Disability Index improved from 55% preoperatively to 20%. Posterior spinal cord decompression for this condition has been successful in our case, and we believe that the lumbar lordosis may have helped indirectly decompress the spinal cord by posterior decompression alone.

Lumbar microdiscectomy versus sequesterectomy/free fragmentectomy: a long-term (>2 y) retrospective study of the clinical outcome.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the long-term outcome of microdiscectomy versus sequestrectomy/free fragmentectomy for lumbar disc herniation. SUMMARY OF BACKGROUND DATA: Conventional lumbar microdiscectomy involves substantial excision of disc material from the intervertebral disc space to prevent reherniation. However, in selected patients removal of free-disc fragment sequestrectomy, without clearing the disc space can be as beneficial as conventional microdiscectomy. METHODS: During the study period, we performed 196 lumbar microdiscectomies for disc herniation. Of these 101 patients met the inclusion criteria for this study. Seventy-seven of 101 patients underwent microdiscectomy and the remaining 24 patients received microscopic sequestrectomy. The following parameters were compared in these 2 groups: operating time, perioperative complications, the pre- and postoperative Visual Analog Scale (VAS), reherniation rate, and the use of analgesics at the time of follow-up. The patients were assessed at the final follow-up. Mean follow-up was 33.4 (24 to 47) months in the sequestrectomy group and 32.4 (24 to 45) months in the microdiscectomy group. RESULTS: The operating time for the microdiscectomy patients was longer than that for the sequestrectomy patients, 32 (19 to 51) versus 24 (15 to 40) minutes. The reherniation rate was slightly lower in the sequestrectomy group than in the microdiscectomy group, 4.17% versus 5.56%. (P=1.00). The complication rate was higher in the microdiscectomy population, 6.4% versus 4.17%. Postoperative improvement in pain in the sequestrectomy group was slightly better than that in the microdiscectomy cohort, VAS 1.6 versus VAS 1.2. (P=0.06). CONCLUSIONS: We argue that microscopic sequestrectomy is more successful with lesser operating time, fewer intraoperative complications, and lesser reherniation rate compared with conventional microdiscectomy in which patients are selected according to well-defined criteria, which is largely dependent on the competence of the annulus/posterior longitudinal ligament.

Clinical outcomes of sacroplasty in sacral insufficiency fractures: a review of the literature.

Sacral insufficiency fractures (SIFs) are an increasingly recognised cause of back pain in the elderly. They can cause significant pain and disability in the elderly population and until recently, the mainstay of treatment has been analgesia and physical therapy. We undertook a review of the literature looking at the outcome with various operative techniques currently used in the treatment of SIF. A thorough literature search was undertaken to identify the various techniques used in the surgical treatment of SIF and their outcome. Keywords used included sacroplasty, SIF and cement augmentation. We analysed the number of cases presented, surgical technique, follow-up and clinical outcome. The techniques described include sacroplasty (injection of cement into fractured sacrum) and augmented iliosacral (trans-sacral) screws. Fifteen papers were published in the English literature between 2002 and 2008. No Level I, II or III evidence was available. In total, 108 patients were included. Computerised tomography combined with fluoroscopy was the most common image guidance technique used (80 patients). Where documented, there was significant improvement in mean visual analogue score (VAS) from 8.9 to 2.6 (P < 0.001, paired Student's t test). In conclusion, cement augmentation techniques such as sacroplasty with or without iliosacral screw fixation can produce significant improvements in VAS scores. They appear to be a suitable alternative to analgesia and rehabilitation. However, more robust evidence is required to validate these promising early results with cement augmentation techniques.