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 ... -  《-》

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 ... -  《-》

Composite Treatment Response from a Prospective, Multi-Center Study (US-nPower) Evaluating a Miniature Spinal Cord Stimulator for the Management of Chronic, Intractable Pain.

Desai MJ ，Raju T ，Ung C ，Arulkumar S ，Kapural L ，Gupta M ，Amirdelfan K ，Rosenfeld D ，Calodney A ，Sayed D ，Antony A ，Li S ，Naidu RK ，Ackerman J ，Ball R ，Fishman M ，Staats P ，Heit G ，Kottalgi S ，Makous J ... -  《-》

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 ... -  《-》

Which Components of the Simple Shoulder Test Show Improvement After Scapulothoracic Fusion for Recalcitrant Scapular Winging? Clinical Results at a Minimum of 5 Years of Follow-up.

Scapular winging is an uncommon but important cause of shoulder pain and disability. Surgical management can include soft tissue procedures such as split pectoralis major transfer, the Eden-Lange procedure, or a triple tendon transfer. When these procedures do not alleviate symptomatic winging or are inappropriate, scapulothoracic fusion is an alternative, but data on its longer-term effectiveness are sparse. (1) What changes in outcome scores were observed (VAS, Single Assessment Numeric Evaluation [SANE], and Simple Shoulder Test [SST] scores), and what proportion of the patients improved by an amount larger than the minimum clinically important difference (MCID) for the outcome tool in question? (2) Which components of the SST are patients able to perform at a minimum of 5 years? (3) What complications occurred after surgery? We performed a retrospective study in a single, large, urban referral medical center of patients who underwent scapulothoracic fusion. Between January 2011 and November 2016, 15 patients underwent scapulothoracic fusion to treat symptomatic scapular winging. Only patients with nondystrophic etiology were included in the analysis (n = 13). Of the 13 remaining patients, one patient was lost to follow-up and another patient died during data collection, leaving 11 patients for the final analysis. Six patients had brachial plexus injuries affecting multiple nerve roots and periscapular muscles, and five had persistent symptoms despite prior tendon transfer. The median age of the patients was 43 years (range 20 to 67 years), and there were six male and five female patients. All patients had a minimum of 5 years of follow-up. There was a median follow-up of 79 months (range 61 to 128 months). The VAS pain score (range 0 to 10, higher scores represent more pain; MCID = 2), SST score (range 0 to 12, higher scores represent less pain and better shoulder function; MCID = 2.3), and SANE score (range 0 to 100, higher scores represent better shoulder function; MCID = 28) were recorded before surgery and at the most recent follow-up. We compared scores from before surgery with those taken at the most recent follow-up and ascertained the proportion of patients whose improvement exceeded the MCID. The number of patients achieving fusion (as confirmed by a CT image), complications, and reoperations was recorded via a record review as well as direct patient query by telephone. The median VAS pain score improved from 7 (range 3 to 10) preoperatively to 3 (range 2 to 5) at the latest follow-up (p < 0.001). The median SANE score improved from 30 (range 0 to 60) preoperatively to 65 (range 40 to 85) at the latest follow-up (p < 0.001). The median SST score improved from 0 (range 0 to 9) to 8 (range 5 to 10) at the latest follow-up (p < 0.001). Ten of 11 patients had improvements exceeding the MCID for VAS, six of 11 had improvements for SANE scores, and nine of 11 had improvements for SST. Preoperative to postoperative improvements in these components of the SST were seen (responses of "yes"): comfort at rest (three of 11 improved to 11 of 11; p < 0.001), sleep comfortably (three of 11 improved to 11 of 11; p < 0.001), place coin on shelf (two of 11 improved to 10 of 11; p < 0.001), lift 1 pound above shoulder (two of 11 improved to eight of 11; p = 0.03), and carry 20 pounds with the arm at side (one of 11 improved to nine of 11; p < 0.001). All 11 patients had successful fusion noted on CT images. There were three complications (progression of glenohumeral arthritis, broken wires, and perioperative chest tube placement) and one reoperation for progression of glenohumeral arthritis with subsequent total shoulder arthroplasty. Patients with recalcitrant symptomatic scapular winging often undergo an exhaustive course of clinical examinations, diagnostic tests, physical therapy, and multiple surgical procedures. Those with brachial plexus palsy with involvement of multiple nerves may continue to have symptoms despite nonoperative management and subsequent soft tissue tendon transfers. Scapulothoracic fusion could be considered for patients with persistent pain and decreased function because of recalcitrant scapular winging who are either not candidates for the procedure or have persistent symptoms despite prior soft tissue procedures. Level IV, therapeutic study.

Sharareh B ，Hsu JE ，Matsen FA 3rd ，Warme WJ ... -  《-》