Minimally Invasive Transforaminal Versus Lateral Lumbar Interbody Fusion for Degenerative Spinal Pathology: Clinical Outcome Comparison in Patients With Predominant Back Pain.

Retrospective review. To compare perioperative and postoperative clinical outcomes between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and lateral lumbar interbody fusion (LLIF) in patients presenting with predominant back pain. Two popular techniques utilized for lumbar arthrodesis are MIS-TLIF and LLIF. Both techniques have reported high fusion rates and suitable postoperative clinical outcomes. Scarce literature exists, however, comparing these 2 common fusion techniques in a subset population of patients presenting with predominant back pain preoperatively. A retrospective review of lumbar procedures performed between November 2005 and December 2021 was conducted using a prospectively maintained single-surgeon database. Inclusion criteria were set as primary, elective, single, or multilevel MIS-TLIF or LLIF procedures for degenerative spinal pathology in patients with predominant preoperative back pain [visual analog scale (VAS) back pain preoperative score > VAS leg preoperative score]. Patients undergoing a revision procedure, single-level procedure at L5-S1, or surgery indicated for infectious, malignant, or traumatic etiologies were excluded. In addition, patients with VAS leg preoperative scores ≥ to VAS back preoperative scores were excluded. Patient demographics, perioperative characteristics, postoperative complications, and patient-reported outcome measures (PROMs) were collected. PROMs included VAS for back and leg pain, Oswestry Disability Index (ODI), and Short Form-12 (SF-12) Item Survey Mental (MCS) and Physical (PCS) Composite Scores with all values collected at the preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year follow-up time point. Patients were grouped into 2 cohorts, depending on whether a patient underwent a MIS-TLIF or LLIF. Demographic and perioperative characteristics were compared between groups using χ 2 and Student t test for categorical and continuous variables, respectively. Mean PROM scores were compared between cohorts at each time point utilizing an unpaired Student t test. Postoperative improvement from preoperative baseline within each cohort was assessed with paired samples t test. Achievement of minimum clinical important difference (MCID) was determined by comparing ΔPROM scores to previously established threshold values. MCID achievement rates were compared between groups with χ 2 analysis. Statistical significance was noted as a P value <0.05. Eligible study cohort included 153 patients, split into 106 patients in the MIS-TLIF cohort and 47 patients in the LLIF cohort. The mean age was 55.9 years, the majority (57.5%) of patients were males, the mean body mass index was 30.8 kg/m 2 , and the majority of the included cohort were nondiabetic and nonhypertensive. No significant demographic differences were noted between cohorts. The MIS-TLIF cohort had a significantly greater proportion of patients with preoperative spinal pathology of recurrent herniated nucleus pulposus, whereas a significantly greater proportion of patients in the LLIF cohort demonstrated isthmic spondylolisthesis ( P < 0.046, all). No significant differences were noted between cohorts for operative duration, estimated blood loss, 1-year rate of arthrodesis, postoperative length of stay, postoperative VAS pain scores on postoperative day 0 or 1, and postoperative narcotic consumption on postoperative day 0 or 1. Patients in the LLIF cohort showed greater rates of postoperative ileus (4.3% vs 0.0%). No other significant differences were noted between cohorts for postoperative complications. Between cohorts, preoperative PROM scores did not significantly differ. The following significant postoperative mean PROM scores were demonstrated: VAS back at 12 weeks and ODI at 12 weeks with both mean scores favoring the LLIF cohort. The MIS-TLIF cohort reported significant improvement from preoperative baseline to the 2-year time point for all PROMs collected at all individual postoperative time points except SF-12 MCS at 6 weeks ( P < 0.0, all). LLIF cohort reported significant improvement from preoperative baseline to the 1-year time point for all PROMs collected at all individual postoperative time points except for ODI at 6 weeks, 1 year, and 2 years, SF-12 MCS at 6 weeks and 2 years, and SF-12 PCS at 2 years( P < 0.042, all). The majority of patients in both cohorts achieved overall MCID for VAS back, VAS leg, ODI, and SF-12 PCS. A significantly greater proportion of patients in the LLIF cohort achieved MCID for SF-12 PCS at 12 weeks (94.4% vs 61.1%; P < 0.008). Patients with predominant back pain undergoing MIS-TLIF or LLIF for degenerative spinal pathology demonstrated similar 2-year mean clinical outcomes for physical function, disability, leg pain, and back pain. At the 12-week time point, mean outcome scores for back pain and disability favored the lateral approach with concurrent higher rates of MCID achievement for physical function at that time point.

Jacob KC ，Patel MR ，Hartman TJ ，Nie JW ，Parsons AW ，Ribot MA ，Prabhu M ，Pawlowski H ，Vanjani N ，Singh K ... -  《-》

Surgical Innovation: Comparative Efficacy of Navigation-Assisted Modified Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) and Traditional MIS-TLIF in Treating Low-Grade Isthmic Spondylolisthesis in the Elderly.

To compare the efficacy of navigation-assisted modified minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and MIS-TLIF in the treatment of low-grade isthmic spondylolisthesis in the elderly. We retrospectively included elderly patients with low-grade isthmic spondylolisthesis who underwent surgical treatment at our hospital from January 2019 to January 2022. Based on the surgical method chosen according to the patient's personal preference, the patients were divided into the modified MIS-TLIF group and the MIS-TLIF group. The modified MIS-TLIF group underwent navigation-assisted MIS-TLIF, while the MIS-TLIF group underwent conventional MIS-TLIF. A total of 54 patients (34 males and 20 females) were included in this study, with 26 cases in the modified MIS-TLIF group and 28 cases in the MIS-TLIF group. Relevant data for this study were collected by an independent observer. The demographic characteristics, including age, gender, body mass index, comorbidities, surgical level, Meyerding grade, and duration of symptoms before admission, were recorded and compared between the 2 groups. Perioperative parameters, such as operative time, intraoperative blood loss, postoperative drainage volume, bed rest time, and hospital stay, were also recorded and compared. The lumbar pain visual analog scale, Oswestry Disability Index, and lumbar Japanese Orthopaedic Association scores were recorded preoperatively and at 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively to evaluate functional recovery in both groups. At 12 months postoperatively, patient satisfaction was assessed using the Macnab criteria (with satisfaction defined as the number of excellent and good outcomes divided by the total number in the group × 100%). The rate of vertebral slippage was recorded preoperatively, 1 week postoperatively, and 12 months postoperatively. The accuracy of screw placement was evaluated by CT scan at 1 week postoperatively, and interbody fusion was assessed by CT scan at 12 months postoperatively. Surgical complications were recorded, and their incidence was calculated. The intraoperative blood loss, postoperative drainage volume, bed rest time, and hospital stay in the modified MIS-TLIF group were less than those in the MIS-TLIF group (P < 0.05). The back pain visual analog scale, Oswestry Disability Index, and Japanese Orthopaedic Association modified MIS-TLIF groups improved significantly compared with the MIS-TLIF group at 1 week, 1 month, 3 months, and 6 months after surgery, and the differences between groups were statistically significant (P < 0.05). The excellent and good rate of modified MIS-TLIF group was higher than that of MIS-TLIF group, and the difference had statistical significance (P < 0.05). The accuracy of screw placement in the modified MIS-TLIF group was higher than that in the MIS-TLIF group, and the difference was statistically significant (P < 0.05). The fusion rate in the modified MIS-TLIF group was higher than that in the MIS-TLIF group at 12 months after surgery, and the difference was statistically significant (P < 0.05). There was no statistical difference in the incidence rate of complications between the 2 groups. Compared with MIS-TLIF, navigation-assisted modified MIS-TLIF has the advantages of less trauma, rapid recovery, accurate screw placement, high fusion rate, high surgical satisfaction, and good safety.

Liu C ，Xu C ，Liang J ，Xie B ... -  《-》

Predictors of time to achieve clinically significant improvements following lateral lumbar interbody fusion.

As lateral lumbar interbody fusions (LLIF) are increasingly performed, our understanding of postoperative clinical trajectories is important in informing preoperative patient expectations. While minimum clinically important difference (MCID) rates are widely utilized in spine surgery literature, there is less published on how long it takes for patients to achieve MCID following LLIF. To evaluate the length of time it takes for patients to report MCID achievement for back pain, leg pain, disability, and physical function and evaluate predictors of time to achieve MCID. Patients undergoing elective LLIF by the senior author with baseline and postoperative patient-reported outcomes (PROs) recorded were retrospectively identified. Data on potential predictors of time to MCID achievement were gathered including demographics, comorbidities, diagnostic information, and baseline PROs. MCID achievement rates for Oswestry Disability Index (ODI), Visual Analog Scale-Back (VAS-Back), VAS-Leg, and Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF) were calculated at six-, twelve, 6 month- 1 year- and 2-year postoperative timepoints. A Kaplan-Meier survival analysis was conducted to determine the proportion of patients achieving MCID at each time point. A multivariate Cox regression determined predictors of time to MCID achievement. One hundred-five patients were included in the analysis. The mean time to achieve MCID for PROMIS-PF was 44.7 weeks, for VAS-Back was 38.5 weeks, for VAS-Leg was 36.7 weeks, and for ODI was 38.3 weeks. Worse baseline VAS-Back significantly predicted earlier MCID achievement for VAS-Back (HR: 1.55), while diabetes was predictive of later MCID achievement (HR: 0.21). Higher body mass index and worse preoperative ODI predicted earlier MCID achievement for ODI (HR: 1.04-1.08), and higher VAS-Leg score and two-level fusion were predictive of later MCID achievement for ODI, (HR:0.26-0.81). Worse preoperative VAS-Leg, isthmic spondylolisthesis, and three-level fusion were predictors of earlier achievement of MCID for VAS-Leg (HR: 1.27-6.47). Herniated nucleus pulposus and foraminal stenosis were early predictors (HR: 2.92-3.23) and workers' compensation was a late predictor of MCID attainment for PROMIS-PF (HR: 0.13). Select demographic variables, comorbidities, spinal pathology, and preoperative PROs influenced the time it took for patients to report clinically significant improvements in pain, disability, and physical function scores. These findings can be used to prognosticate outcomes for patients undergoing LLIF and inform patient expectations of postoperative recovery.

Anwar FN ，Roca AM ，Vasudevan V ，Ilyas Y ，Loya AC ，Medakkar SS ，Federico VP ，Singh K ... -  《-》

One year patient reported outcomes after single-level lumbar fusion at orthopedic specialty hospital compared to tertiary referral center.

Narayanan R ，Ezeonu T ，Heard JC ，Lee Y ，Dees A ，Yalla G ，Canseco JA ，Kurd MF ，Kaye ID ，Woods BI ，Hilibrand AS ，Vaccaro AR ，Schroeder GD ，Kepler CK ... -  《-》

Comparison of Two Modern Survival Prediction Tools, SORG-MLA and METSSS, in Patients With Symptomatic Long-bone Metastases Who Underwent Local Treatment With Surgery Followed by Radiotherapy and With Radiotherapy Alone.

Survival estimation for patients with symptomatic skeletal metastases ideally should be made before a type of local treatment has already been determined. Currently available survival prediction tools, however, were generated using data from patients treated either operatively or with local radiation alone, raising concerns about whether they would generalize well to all patients presenting for assessment. The Skeletal Oncology Research Group machine-learning algorithm (SORG-MLA), trained with institution-based data of surgically treated patients, and the Metastases location, Elderly, Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy model (METSSS), trained with registry-based data of patients treated with radiotherapy alone, are two of the most recently developed survival prediction models, but they have not been tested on patients whose local treatment strategy is not yet decided. (1) Which of these two survival prediction models performed better in a mixed cohort made up both of patients who received local treatment with surgery followed by radiotherapy and who had radiation alone for symptomatic bone metastases? (2) Which model performed better among patients whose local treatment consisted of only palliative radiotherapy? (3) Are laboratory values used by SORG-MLA, which are not included in METSSS, independently associated with survival after controlling for predictions made by METSSS? Between 2010 and 2018, we provided local treatment for 2113 adult patients with skeletal metastases in the extremities at an urban tertiary referral academic medical center using one of two strategies: (1) surgery followed by postoperative radiotherapy or (2) palliative radiotherapy alone. Every patient's survivorship status was ascertained either by their medical records or the national death registry from the Taiwanese National Health Insurance Administration. After applying a priori designated exclusion criteria, 91% (1920) were analyzed here. Among them, 48% (920) of the patients were female, and the median (IQR) age was 62 years (53 to 70 years). Lung was the most common primary tumor site (41% [782]), and 59% (1128) of patients had other skeletal metastases in addition to the treated lesion(s). In general, the indications for surgery were the presence of a complete pathologic fracture or an impending pathologic fracture, defined as having a Mirels score of ≥ 9, in patients with an American Society of Anesthesiologists (ASA) classification of less than or equal to IV and who were considered fit for surgery. The indications for radiotherapy were relief of pain, local tumor control, prevention of skeletal-related events, and any combination of the above. In all, 84% (1610) of the patients received palliative radiotherapy alone as local treatment for the target lesion(s), and 16% (310) underwent surgery followed by postoperative radiotherapy. Neither METSSS nor SORG-MLA was used at the point of care to aid clinical decision-making during the treatment period. Survival was retrospectively estimated by these two models to test their potential for providing survival probabilities. We first compared SORG to METSSS in the entire population. Then, we repeated the comparison in patients who received local treatment with palliative radiation alone. We assessed model performance by area under the receiver operating characteristic curve (AUROC), calibration analysis, Brier score, and decision curve analysis (DCA). The AUROC measures discrimination, which is the ability to distinguish patients with the event of interest (such as death at a particular time point) from those without. AUROC typically ranges from 0.5 to 1.0, with 0.5 indicating random guessing and 1.0 a perfect prediction, and in general, an AUROC of ≥ 0.7 indicates adequate discrimination for clinical use. Calibration refers to the agreement between the predicted outcomes (in this case, survival probabilities) and the actual outcomes, with a perfect calibration curve having an intercept of 0 and a slope of 1. A positive intercept indicates that the actual survival is generally underestimated by the prediction model, and a negative intercept suggests the opposite (overestimation). When comparing models, an intercept closer to 0 typically indicates better calibration. Calibration can also be summarized as log(O:E), the logarithm scale of the ratio of observed (O) to expected (E) survivors. A log(O:E) > 0 signals an underestimation (the observed survival is greater than the predicted survival); and a log(O:E) < 0 indicates the opposite (the observed survival is lower than the predicted survival). A model with a log(O:E) closer to 0 is generally considered better calibrated. The Brier score is the mean squared difference between the model predictions and the observed outcomes, and it ranges from 0 (best prediction) to 1 (worst prediction). The Brier score captures both discrimination and calibration, and it is considered a measure of overall model performance. In Brier score analysis, the "null model" assigns a predicted probability equal to the prevalence of the outcome and represents a model that adds no new information. A prediction model should achieve a Brier score at least lower than the null-model Brier score to be considered as useful. The DCA was developed as a method to determine whether using a model to inform treatment decisions would do more good than harm. It plots the net benefit of making decisions based on the model's predictions across all possible risk thresholds (or cost-to-benefit ratios) in relation to the two default strategies of treating all or no patients. The care provider can decide on an acceptable risk threshold for the proposed treatment in an individual and assess the corresponding net benefit to determine whether consulting with the model is superior to adopting the default strategies. Finally, we examined whether laboratory data, which were not included in the METSSS model, would have been independently associated with survival after controlling for the METSSS model's predictions by using the multivariable logistic and Cox proportional hazards regression analyses. Between the two models, only SORG-MLA achieved adequate discrimination (an AUROC of > 0.7) in the entire cohort (of patients treated operatively or with radiation alone) and in the subgroup of patients treated with palliative radiotherapy alone. SORG-MLA outperformed METSSS by a wide margin on discrimination, calibration, and Brier score analyses in not only the entire cohort but also the subgroup of patients whose local treatment consisted of radiotherapy alone. In both the entire cohort and the subgroup, DCA demonstrated that SORG-MLA provided more net benefit compared with the two default strategies (of treating all or no patients) and compared with METSSS when risk thresholds ranged from 0.2 to 0.9 at both 90 days and 1 year, indicating that using SORG-MLA as a decision-making aid was beneficial when a patient's individualized risk threshold for opting for treatment was 0.2 to 0.9. Higher albumin, lower alkaline phosphatase, lower calcium, higher hemoglobin, lower international normalized ratio, higher lymphocytes, lower neutrophils, lower neutrophil-to-lymphocyte ratio, lower platelet-to-lymphocyte ratio, higher sodium, and lower white blood cells were independently associated with better 1-year and overall survival after adjusting for the predictions made by METSSS. Based on these discoveries, clinicians might choose to consult SORG-MLA instead of METSSS for survival estimation in patients with long-bone metastases presenting for evaluation of local treatment. Basing a treatment decision on the predictions of SORG-MLA could be beneficial when a patient's individualized risk threshold for opting to undergo a particular treatment strategy ranged from 0.2 to 0.9. Future studies might investigate relevant laboratory items when constructing or refining a survival estimation model because these data demonstrated prognostic value independent of the predictions of the METSSS model, and future studies might also seek to keep these models up to date using data from diverse, contemporary patients undergoing both modern operative and nonoperative treatments. Level III, diagnostic study.

Lee CC ，Chen CW ，Yen HK ，Lin YP ，Lai CY ，Wang JL ，Groot OQ ，Janssen SJ ，Schwab JH ，Hsu FM ，Lin WH ... -  《-》