Lateral decubitus single position anterior-posterior (AP) fusion shows equivalent results to minimally invasive transforaminal lumbar interbody fusion at one-year follow-up
PURPOSE/OBJECTIVE:This study compares perioperative and 1-year outcomes of lateral decubitus single position circumferential fusion (L-SPS) versus minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) for degenerative pathologies. METHODS:Multicenter retrospective chart review of patients undergoing AP fusion with L-SPS or MIS TLIF. Demographics and clinical and radiographic outcomes were compared using independent samples t tests and chi-squared analyses with significance set at pâ€‰<â€‰0.05. RESULTS:A total of 445 patients were included: 353 L-SPS, 92 MIS TLIF. The L-SPS cohort was significantly older with fewer diabetics and more levels fused. The L-SPS cohort had significantly shorter operative time, blood loss, radiation dosage, and length of stay compared to MIS TLIF. 1-year follow-up showed that the L-SPS cohort had higher rates of fusion (97.87% vs. 81.11%; pâ€‰=â€‰0.006) and lower rates of subsidence (6.38% vs. 38.46%; pâ€‰<â€‰0.001) compared with MIS TLIF. There were significantly fewer returns to the OR within 1Â year for early mechanical failures with L-SPS (0.0% vs. 5.4%; pâ€‰<â€‰0.001). 1-year radiographic outcomes revealed that the L-SPS cohort had a greater LL (56.6â€‰Â±â€‰12.5 vs. 51.1â€‰Â±â€‰15.9; pâ€‰=â€‰0.004), smaller PI-LL mismatch (0.2â€‰Â±â€‰13.0 vs. 5.5â€‰Â±â€‰10.5; pâ€‰=â€‰0.004). There were no significant differences in amount of change in VAS scores between cohorts. Similar results were seen after propensity-matched analysis and sub-analysis of cases including L5-S1. CONCLUSIONS:L-SPS improves perioperative outcomes and does not compromise clinical or radiographic results at 1-year follow-up compared with MIS TLIF. There may be decreased rates of early mechanical failure with L-SPS.
Spinal exposure for anterior lumbar interbody fusion (ALIF) in the lateral decubitus position: anatomical and technical considerations
PURPOSE/OBJECTIVE:Single position surgery has demonstrated to reduce hospital length of stay, operative times, blood loss, postoperative pain, ileus, and complications. ALIF and LLIF surgeries offer advantages of placing large interbody devices under direct compression and can be performed by a minimally invasive approach in the lateral position. Furthermore, simultaneous access to the anterior and posterior column is possible in the lateral position without the need for patient repositioning. The purpose of this study is to outline the anatomical and technical considerations for performing anterior lumbar interbody fusion (ALIF) in the lateral decubitus position. METHODS:Surgical technique and technical considerations for reconstruction of the anterior column in the lateral position by ALIF at the L4-5 and L5-S1 levels. RESULTS:Topics outlined in this review include: Operating room layout and patient positioning; surgical anatomy and approach; vessel mobilization and retractor placement for L4-5 and L5-S1 lateral ALIF exposure, in addition to comparative technique of disc space preparation, trialing and implant placement compared to the supine ALIF procedure. CONCLUSIONS:Anterior exposure performed in the lateral decubitus position allows safe-, minimally invasive access and implant placement in ALIF. The approach requires less peritoneal and vessel retraction than in a supine position, in addition to allowing simultaneous access to the anterior and posterior columns when performing 360Â° Anterior-Posterior fusion.
Setting for single position surgery: survey from expert spinal surgeons
PURPOSE/OBJECTIVE:To describe a comprehensive setting of the different alternatives for performing a single position fusion surgery based on the opinion of leading surgeons in the field. METHODS:Between April and May of 2021, a specifically designed two round survey was distributed by mail to a group of leaders in the field of Single Position Surgery (SPS). The questionnaire included a variety of domains which were focused on highlighting tips and recommendations regarding improving the efficiency of the performance of SPS. This includes operation room setting, positioning, use of technology, approach, retractors specific details, intraoperative neuromonitoring and tips for inserting percutaneous pedicle screws in the lateral position. It asked questions focused on Lateral Single Position Surgery (LSPS), Lateral ALIF (LA) and Prone Lateral Surgery (PLS). Strong agreement was defined as an agreement of more than 80% of surgeons for each specific question. The number of surgeries performed in SPS by each surgeon was used as an indirect element to aid in exhibiting the expertise of the surgeons being surveyed. RESULTS:Twenty-four surgeons completed both rounds of the questionnaire. Moderate or strong agreement was found for more than 50% of the items. A definition for Single Position Surgery and a step-by-step recommendation workflow was built to create a better understanding of surgeons who are starting the learning curve in this technique. CONCLUSION/CONCLUSIONS:A recommendation of the setting for performing single position fusion surgery procedure (LSPS, LA and PLS) was developed based on a survey of leaders in the field.
Health-related quality of life measures in adult spinal deformity: can we replace the SRS-22 with PROMIS?
PURPOSE/OBJECTIVE:To determine the validity and responsiveness of PROMIS metrics versus the SRS-22r questionnaire in adult spinal deformity (ASD). METHODS:Surgical ASD patients undergoing â‰¥â€‰4 levels fused with complete baseline PROMIS and SRS-22r data were included. Internal consistency (Cronbach's alpha) and test-retest reliability [intraclass correlation coefficient (ICC)] were compared. Cronbach's alpha and ICC values â‰¥â€‰0.70 were predefined as satisfactory. Convergent validity was evaluated via Spearman's correlations. Responsiveness was assessed via paired samples t tests with Cohen's d to assess measure of effect (baseline to 3 months). RESULTS:One hundred and ten pts are included. Mean baseline SRS-22r score was 2.62â€‰Â±â€‰0.67 (domainsâ€‰=â€‰Function: 2.6, Pain: 2.5, Self-image: 2.2, Mental Health: 3.0). Mean PROMIS domainsâ€‰=â€‰Physical Function (PF): 12.4, Pain Intensity (PI): 91.7, Pain Interference (Int): 55.9. Cronbach's alpha, and ICC were not satisfactory for any SRS-22 and PROMIS domains. PROMIS-Int reliability was low for all SRS-22 domains (0.037-0.225). Convergent validity demonstrated strong correlation via Spearman's rho between PROMIS-PI and overall SRS-22r (-â€‰0.61), SRS-22 Function (-â€‰0.781), and SRS-22 Pain (-â€‰0.735). PROMIS-PF had strong correlation with SRS-22 Function (0.643), while PROMIS-Int had moderate correlation with SRS-22 Pain (-â€‰0.507). Effect size via Cohen's d showed that PROMIS had superior responsiveness across all domains except for self-image. CONCLUSIONS:PROMIS is a valid measure compared to SRS-22r in terms of convergent validity, and has greater measure of effect in terms of responsiveness, but failed in reliability and internal consistency. Surgeons should consider the lack of reliability and internal consistency (despite validity and responsiveness) of the PROMIS to SRS-22r before replacing the traditional questionnaire with the computer-adaptive testing.
Comparative Analysis of Inpatient Opioid Consumption Between Different Surgical Approaches Following Single Level Lumbar Spinal Fusion Surgery
STUDY DESIGN/METHODS:Single-center retrospective cohort study. OBJECTIVES/OBJECTIVE:To evaluate inpatient MME administration associated with different lumbar spinal fusion surgeries. METHODS:< .05. RESULTS:= .009). There were no significant differences in MME/hour and incidence of ileus between all groups. CONCLUSION/CONCLUSIONS:Patients undergoing MIS TLIF had lower inpatient opioid intake compared to TP and SP ALIF/LLIF, as well as shorter LOS compared to all groups except SP ALIF/LLIF. Thus, it appears that the advantages of minimally invasive surgery are seen in minimally invasive TLIFs.
Predictive Analytics for Determining Extended Operative Time in Corrective Adult Spinal Deformity Surgery
BACKGROUND:More sophisticated surgical techniques for correcting adult spinal deformity (ASD) have increased operative times, adding to physiologic stress on patients and increased complication incidence. This study aims to determine factors associated with operative time using a statistical learning algorithm. METHODS:Retrospective review of a prospective multicenter database containing 837 patients undergoing long spinal fusions for ASD. Conditional inference decision trees identified factors associated with skin-to-skin operative time and cutoff points at which factors have a global effect. A conditional variable-importance table was constructed based on a nonreplacement sampling set of 2000 conditional inference trees. Means comparison for the top 15 variables at their respective significant cutoffs indicated effect sizes. RESULTS:66 minutes of increased operative time. Increased operative time also correlated with increased hospital length of stay (LOS), increased estimated intraoperative blood loss (EBL), and inferior 2-year Oswestry Disability Index (ODI) scores. CONCLUSIONS:Procedure location and specific surgeon are the most important factors determining operative time, accounting for operative time increases <2 hours. Surgical approach and number of levels fused were also associated with longer operative times, respectively. Extended operative time correlated with longer LOS, higher EBL, and inferior 2-y ODI outcomes. CLINICAL RELEVANCE/CONCLUSIONS:We further identified the poor outcomes associated with extended operative time during surgical correction of ASD, and attributed the useful predictors of time spent in the operating room, including site, surgeon, surgical approach, and the number of levels fused. LEVEL OF EVIDENCE: 3/METHODS/:
Does Low Back Pain Improve Following Total Hip Arthroplasty?
BACKGROUND:Frequently, patients indicated for total hip arthroplasty (THA) present with low back pain (LBP) and hip pain. The purpose of this study was to compare patients whose back pain resolved after THA with those where back pain did not resolve and identify how to predict this using spinopelvic parameters. METHODS:We reviewed a series of 500 patients who underwent THA for unilateral hip osteoarthritis by 2 surgeons. Patients underwent biplanar standing and sitting EOS radiographs pre-operatively. Patients with previous spine surgery or femoral neck fracture were excluded. Demographic data was analyzed at baseline. The Oswestry Disability Index (ODI) scores were calculated pre-operatively and at 1 year postoperatively. Spinopelvic parameters included, pelvic incidence and sacral slope (SS) change from standing to sitting. RESULTS:Two hundred and four patients (41%) had documented LBP before THA. The Oswestry Disability Index (ODI) for patients improved from 38.9 Â± 17.8 pre-operatively to 17.0 Â± 10.6 at 1 year post-operatively (P < .001). At 1- and 2-year follow-up, resolution of back pain occurred in 168 (82.4%) and 187 (91.2%) patients, respectively. Pelvic incidence was not predictive of back pain resolution. All patients whose back pain resolved had a sacral slope change from standing to sitting of >10Â°, while those patients whose back pain did not resolve had a change of <10Â°. CONCLUSION/CONCLUSIONS:This study demonstrates that symptomatic low back pain (LBP) resolves in 82% of patients after THA. The results of this study may be used to counsel patients on back pain and its resolution following total hip replacement.
Anterior column reconstruction of the lumbar spine in the lateral decubitus position: anatomical and patient-related considerations for ALIF, anterior-to-psoas, and transpsoas LLIF approaches
PURPOSE/OBJECTIVE:Circumferential (AP) lumbar fusion surgery is an effective treatment for degenerative and deformity conditions of the spine. The lateral decubitus position allows for simultaneous access to the anterior and posterior aspects of the spine, enabling instrumentation of both columns without the need for patient repositioning. This paper seeks to outline the anatomical and patient-related considerations in anterior column reconstruction of the lumbar spine from L1-S1 in the lateral decubitus position. METHODS:We detail the anatomic considerations of the lateral ALIF, transpsoas, and anterior-to-psoas surgical approaches from surgeon experience and comprehensive literature review. RESULTS:Single-position AP surgery allows simultaneous access to the anterior and posterior column and may combine ALIF, LLIF, and minimally invasive posterior instrumentation techniques from L1-S1 without patient repositioning. Careful history, physical examination, and imaging review optimize safety and efficacy of lateral ALIF or LLIF surgery. An excellent understanding of patient spinal and abdominal anatomy is necessary. Each approach has relative advantages and disadvantages according to the disc level, skeletal, vascular, and psoas anatomy. CONCLUSIONS:A development of a framework to analyze these factors will result in improved patient outcomes and a reduction in complications for lateral ALIF, transpsoas, and anterior-to-psoas surgeries.
Single position lateral decubitus Anterior Lumbar Interbody Fusion (ALIF) and posterior fusion reduces complications and improves perioperative outcomes compared with traditional anterior-posterior lumbar fusion
BACKGROUND CONTEXT/BACKGROUND:Lateral decubitus single position anterior-posterior (AP) fusion utilizing anterior lumbar interbody fusion and percutaneous posterior fixation is a novel, minimally invasive surgical technique. Single position lumbar surgery (SPLS) with anterior lumbar interbody fusion (ALIF) or lateral lumbar interbody fusion (LLIF) has been shown to be a safe, effective technique. This study directly compares perioperative outcomes of SPLS with lateral ALIF vs. traditional supine ALIF with repositioning (FLIP) for degenerative pathologies. PURPOSE/OBJECTIVE:To determine if SPLS with lateral ALIF improves perioperative outcomes compared to FLIP with supine ALIF. STUDY DESIGN/SETTING/METHODS:Multicenter retrospective cohort study. PATIENT SAMPLE/METHODS:Patients undergoing primary AP fusions with ALIF at 5 institutions from 2015 to 2020. OUTCOME MEASURES/METHODS:Levels fused, inclusion of L4-L5, L5-S1, radiation dosage, operative time, estimated blood loss (EBL), length of stay (LOS), perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), and PI-LL mismatch. METHODS:Retrospective analysis of primary ALIFs with bilateral percutaneous pedicle screw fixation between L4-S1 over 5 years at 5 institutions. Patients were grouped as FLIP or SPLS. Demographic, procedural, perioperative, and radiographic outcome measures were compared using independent samples t-tests and chi-squared analyses with significance set at p <.05. Cohorts were propensity-matched for demographic or procedural differences. RESULTS:A total of 321 patients were included; 124 SPS and 197 Flip patients. Propensity-matching yielded 248 patients: 124 SPLS and 124 FLIP. The SPLS cohort demonstrated significantly reduced operative time (132.95Â±77.45 vs. 261.79Â±91.65 min; p <0.001), EBL (120.44Â±217.08 vs. 224.29Â±243.99 mL; p <.001), LOS (2.07Â±1.26 vs. 3.47Â±1.40 days; p <.001), and rate of perioperative ileus (0.00% vs. 6.45%; p =.005). Radiation dose (39.79Â±31.66 vs. 37.54Â±35.85 mGy; p =.719) and perioperative complications including vascular injury (1.61% vs. 1.61%; p =.000), retrograde ejaculation (0.00% vs. 0.81%, p =.328), abdominal wall (0.81% vs. 2.42%; p =.338), neuropraxia (1.61% vs. 0.81%; p =.532), persistent motor deficit (0.00% vs. 1.61%; p =.166), wound complications (1.61% vs. 1.61%; p =.000), or VTE (0.81% vs. 0.81%; p =.972) were similar. No difference was seen in 90-day return to OR. Similar results were noted in sub-analyses of single-level L4-L5 or L5-S1 fusions. On radiographic analysis, the SPLS cohort had greater changes in LL (4.23Â±11.14 vs. 0.43Â±8.07 deg; p =.005) and PI-LL mismatch (-4.78Â±8.77 vs. -0.39Â±7.51 deg; p =.002). CONCLUSIONS:Single position lateral ALIF with percutaneous posterior fixation improves operative time, EBL, LOS, rate of ileus, and maintains safety compared to supine ALIF with prone percutaneous pedicle screws between L4-S1.
Incidence of dysphagia following posterior cervical spine surgery
Abundant literature exists describing the incidence of dysphagia following anterior cervical surgery; however, there is a paucity of literature detailing the incidence of dysphagia following posterior cervical procedures. Further characterization of this complication is important for guiding clinical prevention and management. PatientsÂ â‰¥Â 18Â years of age underwent posterior cervical fusion with laminectomy or laminoplasty between C1-T1. Pre- and post-operative dysphagia was assessed by a speech language pathologist. The patient cohort was categorized by approach: LaminectomyÂ +Â Fusion (LF) and Laminoplasty (LP). Patients were excluded from radiographic analyses if they did not have both baseline and follow-up imaging. The study included 147 LF and 47 LP cases. There were no differences in baseline demographics. There were three patients with new-onset dysphagia in the LF group (1.5% incidence) and no new cases in the LP group (pÂ =Â 1.000). LF patients had significantly higher rates of post-op complications (27.9% LF vs. 8.5% LP, pÂ =Â 0.005) but not intra-op complications (6.1% LF vs. 2.1% LP, pÂ =Â 0.456). Radiographic analysis of the entire cohort showed no significant changes in cervical lordosis, cSVA, or T1 slope. Both group comparisons showed no differences in incidence of dysphagia pre and post operatively. Based on this study, the likelihood of developing dysphagia after LF or LP are similarly low with a new onset dysphagia rate of 1.5%.