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ABSTRACT: Study design. A subanalysis study.Objective. To compare surgical outcomes and complications of multi level decompression and single level fusion to multi level decompression and multi level fusion for patients with multilevel lumbar stenosis and single level degenerative spondylolisthesis.Summary of Background Data. In patients with degenerative spondylolisthesis who are treated surgically, decompression and fusion provides a better clinical outcome than decompression alone. Surgical treatment for multilevel lumbar stenosis and degenerative spondylolisthesis typically includes decompression and fusion of the spondylolisthesis segment and decompression with or without fusion for the other stenotic segments. To date, no study has compared the results of these two surgical options for single level degenerative spondylolisthesis with multilevel stenosis.Methods. The results from a multicenter randomized and observational study, the Spine Patient Outcomes Research Trial (SPORT) comparing multilevel decompression and single level fusion and multi level decompression and multi level fusion for spinal stenosis with spondylolisthesis, were analyzed. The primary outcomes measures were the Bodily Pain and Physical Function scales of the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 1,2, 3 and 4 years postoperatively. Secondary analysis consisted of stenosis bothersomeness index, low back pain bothersomeness, leg pain, patient satisfaction, and self-rated progress.Results. Overall 207 patients were enrolled to the study, 130 had multlilevel decompression with one level fusion and 77 patients had multi level decompression and multi-level fusion. For all primary and secondary outcome measures, there were no statistically significant differences in surgical outcomes between the two surgical techniques. However, operative time and intraoperative blood loss were significantly higher in the multilevel fusion group.Conclusion. Decompression and single level fusion and decompression and multi level fusion provide similar outcomes in patients with multilevel lumbar stenosis and single level degenerative spondylolisthesis.
Spine 11/2012; · 2.08 Impact Factor
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ABSTRACT: Study Design. Retrospective review of a prospectively collected databaseObjective. To examine whether short- and long-term outcomes after surgery for SPS and DS vary across centers.Summary of Background Data. Surgery has been shown to be of benefit for both lumbar stenosis (SPS) and degenerative spondylolisthesis (DS). For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated.Methods. Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of SPS or DS undergoing surgery were followed from baseline at 6 weeks, and 3, 6 and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Baseline characteristics and short- and long-term outcomes were analyzed.Results. 793 patients underwent surgery. Significant differences were found between centers with regard to patient race, body mass index, treatment preference, neurological deficit, stenosis location, severity and number of stenotic levels. Significant differences were also found in operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and wound infection. When baseline differences were adjusted for, significant differences were still seen between centers in changes in patient functional outcome (SF-36 bodily pain and physical function, and Oswestry disability index) at 1 year after surgery. In addition, the cumulative adjusted change in Oswestry disability index score at 4 years significantly differed among centers, with SF-36 scores trending towards significance.Conclusions. There is broad and statistically significant variation in short- and long-term outcomes after surgery for SPS and DS across various academic centers, when statistically significant baseline differences are adjusted for. The findings suggest choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.
Spine 10/2012; · 2.08 Impact Factor
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ABSTRACT: STUDY DESIGN.: Combined prospective randomized controlled trial and observational cohort study of spinal stenosis (SpS) with an as-treated analysis. OBJECTIVE.: To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for SpS using subgroup analysis. SUMMARY OF BACKGROUND DATA.: The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for SpS at the group level. However, individual characteristics may affect TE. No previous studies have evaluated TE modifiers in SpS. METHODS.: SpS patients were treated with either surgery (n = 419) or nonoperative care (n = 235) and were analyzed according to treatment received. Fifty-three baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) over 4 years (TE = ΔODIsurgery - ΔODInonoperative). Variables with significant subgroup × treatment interactions (P < 0.05) were simultaneously entered into a multivariate model to select independent TE predictors. RESULTS.: Other than smokers, all analyzed subgroups including at least 50 patients improved significantly more with surgery than with nonoperative treatment (P < 0.05). Multivariate analysis demonstrated: baseline ODI ≤ 56 (TE -15.0 vs. -4.4, ODI > 56, P < 0.001), not smoking (TE -11.7 vs. -1.6 smokers, P < 0.001), neuroforaminal stenosis (TE -14.2 vs. -8.7 no neuroforaminal stenosis, P = 0.002), predominant leg pain (TE -11.5 vs. -7.3 predominant back pain, P = 0.035), not lifting at work (TE -12.5 vs. -0.5 lifting at work, P = 0.017), and the presence of a neurological deficit (TE -13.3 vs. -7.2 no neurological deficit, P < 0.001) were associated with greater TE. CONCLUSION.: With the exception of smokers, patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of other specific characteristics. However, TE varied significantly across certain subgroups, and these data can be used to individualize shared decision making discussions about likely outcomes. Smoking cessation should be considered before surgery for SpS.
Spine 10/2012; 37(21):1791-802. · 2.08 Impact Factor
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ABSTRACT: : Surgery has been shown to be of benefit for both lumbar stenosis and degenerative spondylolisthesis. For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated.
: Spine Patient Outcomes Research Trial cohort participants with spinal stenosis (SPS) or degenerative spondylolisthesis (DS) undergoing first-time open lumbar laminectomy with or without fusion were followed from baseline at 6 weeks, and 3, 6 and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Mean (SD) follow-up was 45.2 (13.8) months. Median (range) follow-up was 47.4 (1.2, 95.6) months. Baseline characteristics, perioperative events and short- and long-term outcomes were analyzed across the centers.
: 793 patients underwent surgery. Significant differences were found across centers in operative duration and blood loss, incidence of durotomy, length of hospital stay, and wound infection. There were no significant differences between centers in incidence of nerve root injury or post-operative mortality. Significant differences were seen in the adjusted change in all indices of functional outcome (SF-36 BP and PF, and Oswestry disability index) at 1 year after surgery and in cumulative adjusted change in ODI score at 4 years.
: There is broad and statistically significant variation in outcomes after surgery for SPS and DS across various academic centers, when baseline differences are adjusted for. The findings suggest choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.
Neurosurgery 08/2012; 71(2):E545. · 2.79 Impact Factor
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ABSTRACT: : Lumbar discectomy is the most commonly performed spine procedure. Academic spine centers with potentially differing caseloads and experience may have different outcomes.
: To determine whether the choice of center in which surgery is performed affects lumbar discectomy outcomes.
: Spine Patient Outcomes Research Trial participants with a confirmed diagnosis of intervertebral disc herniation undergoing standard first-time open discectomy were followed from baseline at 6 weeks, and 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Patient data from this prospective study were reviewed. Enrollment began in March 2000 and ended in November 2004.
: Seven hundred ninety-two patients underwent first-time lumbar discectomy. Significant differences were found among centers in patient age and race, baseline levels of disability, and treatment preferences. There were no significant differences among the centers in other patient characteristics (eg, sex, body mass index, the prevalence of smoking, diabetes, or hypertension), or disease characteristics (herniation level or type). Some short-term outcomes varied significantly among centers, including operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and reoperation rate. However, there were no differences among the centers in incidence of nerve root injury, postoperative mortality, Short Form 36 scores of body pain or physical function, or Oswestry Disability Index at 4 years.
: Although mean blood loss, risk of durotomy, length of stay, and rate of reoperation vary among academic spine centers performing lumbar discectomy, there appears to be no difference in long-term functional outcomes.
: AUC, area under the curveIDH, intervertebral disc herniationSBI, Sciatica Bothersomeness IndexSF-36, Short Form 36SPORT, Spine Patient Outcomes Research Trial.
Neurosurgery 07/2012; 71(4):833-43. · 2.79 Impact Factor
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ABSTRACT: The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment.
One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group).
There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001).
Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation.
The Journal of Bone and Joint Surgery 06/2012; 94(15):1353-8. · 3.27 Impact Factor
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ABSTRACT: STUDY DESIGN.: Retrospective subgroup analysis of prospectively collected data according to treatment received. OBJECTIVE.: The purpose of this study was to determine whether obesity affects treatment outcomes for lumbar stenosis (SpS) and degenerative spondylolisthesis (DS). SUMMARY OF BACKGROUND DATA.: Obesity is thought to be associated with increased complications and potentially less favorable outcomes after the treatment of degenerative conditions of the lumbar spine. This, however, remains a matter of debate in the existing literature. METHODS.: An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial for the treatment of SpS or DS. A comparison was made between patients with a body mass index (BMI) of less than 30 ("nonobese," n = 373 SpS and 376 DS) and those with a BMI of 30 or more ("obese," n = 261 SpS and 225 DS). Baseline patient characteristics, intraoperative data, and complications were documented. Primary and secondary outcomes were measured at baseline and regular follow-up time intervals up to 4 years. The difference in improvement over baseline between surgical and nonsurgical treatment (i.e., treatment effect) was determined at each follow-up interval for the obese and nonobese groups. RESULTS.: At 4-year follow-up, operative and nonoperative treatment provided improvement in all primary outcome measures over baseline in patients with BMI of less than 30 and 30 or more. For patients with SpS, there were no differences in the surgical complication or reoperation rates between groups. Patients with DS with BMI of 30 or more had a higher postoperative infection rate (5% vs. 1%, P = 0.05) and twice the reoperation rate at 4-year follow-up (20% vs. 11%, P = 0.01) than those with BMI of less than 30. At 4 years, surgical treatment of SpS and DS was equally effective in both BMI groups in terms of the primary outcome measures, with the exception that obese patients with DS had less improvement from baseline in the 36-Item Short Form Health Survey (SF-36) physical function score than nonobese patients (22.6 vs. 27.9, P = 0.022). With nonoperative treatment, patients with SpS with BMI of 30 or more did worse in regard to all 3 primary outcome measures, and patients with DS with BMI of 30 or more had similar SF-36 bodily pain scores but less improvement over baseline in the SF-36 physical function and Oswestry Disability Index scores. Treatment effects for SpS and DS were significant within each BMI group for all primary outcome measures in favor of surgery. Obese patients had a significantly greater treatment effect than nonobese patients with SpS (Oswestry Disability Index, P = 0.037) and DS (SF-36 PF, P = 0.004) largely due to the relatively poor outcome of nonoperative treatment in obese patients. CONCLUSION.: Obesity does not affect the clinical outcome of operative treatment of SpS. There are higher rates of infection and reoperation and less improvement from baseline in the SF-36 physical function score in obese patients after surgery for DS. Nonoperative treatment may not be as effective in obese patients with SpS or DS.
Spine 05/2012; 37(23):1933-46. · 2.08 Impact Factor
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ABSTRACT: A retrospective cohort study.
In this article, we examined the Spine Patient Outcomes Research Trial lumbar stenosis observational cohort to determine baseline patient characteristics that are predictive of the treatment patients chose. We also evaluated cutoff points on validated patient questionnaires that differentiate patients who chose surgery from those who chose nonsurgical management.
Although the evidence from current studies suggests that surgical intervention is effective for lumbar spinal stenosis, the same studies show that nonoperative patients also improve. Thus, the reasons for patients choosing surgery versus nonoperative care are of continuing interest.
Baseline patient and clinical characteristics between those who received operative intervention and those who received nonoperative care were compared to determine baseline predictors of lumbar spinal stenosis management. Also, an evaluation of responses to the 36-Item Short Form Health Survey Bodily Pain (BP), 36-Item Short Form Health Survey Physical Function (PF), and the modified Oswestry Disability Index (ODI) questionnaires was performed to determine the percentage of patients choosing surgical versus nonoperative care relative to their initial questionnaire values.
This analysis looked at the 356 patients in the observational spinal stenosis cohort of Spine Patient Outcomes Research Trial who completed at least 1 follow-up visit. Patients choosing surgery were younger (P = 0.022), had worse BP (P < 0.001), worse PF (P < 0.001), worse ODI (P < 0.001), worse Stenosis Bothersomeness Index (P < 0.001), were dissatisfied with their symptoms (P = 0.001), and had a worse self-assessed health trend (P < 0.001). Patients tended to choose surgery if they had lateral recess stenosis (P = 0.022). Kaplan-Meier curves demonstrate that patients with a BP score of 32 or less, PF score of 30 or less, and ODI greater than 29 chose surgery 75% of the time.
A greater understanding of baseline characteristics that influence patient choices in the treatment of lumbar spinal stenosis can aid the patient and the surgeon during the shared decision-making process.
Spine 03/2012; 37(19):1702-7. · 2.08 Impact Factor
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ABSTRACT: Retrospective review of a prospectively collected multi-institutional database.
In the present analysis, we investigate the impact of incidental durotomy on outcome in patients undergoing surgery for lumbar degenerative spondylolisthesis.
Surgery for lumbar degenerative spondylolisthesis has several potential complications, one of the most common of which is incidental durotomy. The effect of incidental durotomy on outcome, however, remains uncertain.
Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of lumbar degenerative spondylolisthesis undergoing standard first-time open decompressive laminectomy, with or without fusion, were followed from baseline at 6 weeks, at 3, 6, 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean (standard deviation [SD]) follow-up among all analyzed degenerative spondylolisthesis patients was 46.6 months (SD = 13.1) (no durotomy: 46.7 vs. had durotomy: 45.2, P = 0.49). The median (range) follow-up time among all analyzed degenerative spondylolisthesis patients was 47.6 months (SD = 2.5-84).
A 10.5% incidence of durotomy was detected among the 389 patients undergoing surgery. No significant differences were observed with or without durotomy in age, race, the prevalence of smoking, diabetes and hypertension, decompression level, number of levels, or whether a fusion was performed. There were no differences in incidence of nerve root injury, postoperative mortality, additional surgeries, 36-Item Short Form Health Survey (SF-36) scores of body pain or physical function, or Oswestry Disability Index at 1, 2, 3, and 4 years.
Incidental durotomy during first-time surgery for lumbar degenerative spondylolisthesis does not appear to impact outcome in affected patients.
Spine 03/2012; 37(5):406-13. · 2.08 Impact Factor
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ABSTRACT: Consensus has emerged on the need to slow Medicare spending growth, but there is no agreement on how best to do so. Although many approaches have been suggested, Congress is almost certain to consider across-the-board cuts in reimbursement rates. It is not hard to understand why: cuts are easy to implement and appear to deliver clear savings. But cuts in fees are a poor long-term solution to the problem of increasing health care costs. They make it more likely that physicians will decide not to accept new Medicare patients; further penalize already efficient systems; cause some to increase utilization to make up for revenue losses; and—most importantly—do little to encourage the collaborative efforts needed to improve health, better coordinate care, reduce regional duplication, and help beneficiaries avoid unnecessary care.
JAMA The Journal of the American Medical Association 01/2012; 307(1):43-4. · 30.03 Impact Factor
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James N. Weinstein
Spine 12/2011; 37(1):1. · 2.08 Impact Factor
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Anna N A Tosteson,
Tor D Tosteson,
Jon D Lurie,
William Abdu,
Harry Herkowitz,
Gunnar Andersson,
Todd Albert,
Keith Bridwell,
Wenyan Zhao,
Margaret R Grove,
Milton C Weinstein, James N Weinstein
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ABSTRACT: Cost-effectiveness analysis of a randomized plus observational cohort trial.
Analyze cost-effectiveness of Spine Patient Outcomes Research Trial data over 4 years comparing surgery with nonoperative care for three common diagnoses: spinal stenosis (SPS), degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH).
Spine surgery rates continue to rise in the United States, but the safety and economic value of these procedures remain uncertain.
Patients with image-confirmed diagnoses were followed in randomized or observational cohorts with data on resource use, productivity, and EuroQol EQ-5D health state values measured at 6 weeks, 3, 6, 12, 24, 36, and 48 months. For each diagnosis, cost per quality-adjusted life year (QALY) gained in 2004 US dollars was estimated for surgery relative to nonoperative care using a societal perspective, with costs and QALYs discounted at 3% per year.
Surgery was performed initially or during the 4-year follow-up among 414 of 634 (65.3%) SPS, 391 of 601 (65.1%) DS, and 789 of 1192 (66.2%) IDH patients. Surgery improved health, with persistent QALY differences observed through 4 years (SPS QALY gain 0.22; 95% confidence interval, CI: 0.15, 0.34; DS QALY gain 0.34, 95% CI: 0.30, 0.47; and IDH QALY gain 0.34, 95% CI: 0.31, 0.38). Costs per QALY gained decreased for SPS from $77,600 at 2 years to $59,400 (95% CI: $37,059, $125,162) at 4 years, for DS from $115,600 to $64,300 per QALY (95% CI: $32,864, $83,117), and for IDH from $34,355 to $20,600 per QALY (95% CI: $4,539, $33,088).
Comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with nonoperative care over 4 years.
Spine 11/2011; 36(24):2061-8. · 2.08 Impact Factor
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ABSTRACT: The purpose of the present study was to determine if the duration of symptoms affects outcomes following the treatment of intervertebral lumbar disc herniation.
An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial (SPORT) for the treatment of intervertebral lumbar disc herniation. Randomized and observational cohorts were combined. A comparison was made between patients who had had symptoms for six months or less (n = 927) and those who had had symptoms for more than six months (n = 265). Primary and secondary outcomes were measured at baseline and at regular follow-up intervals up to four years. The treatment effect for each outcome measure was determined at each follow-up period for the duration of symptoms for both groups.
At all follow-up intervals, the primary outcome measures were significantly worse in patients who had had symptoms for more than six months prior to treatment, regardless of whether the treatment was operative or nonoperative. When the values at the time of the four-year follow-up were compared with the baseline values, patients in the operative treatment group who had had symptoms for six months or less had a greater increase in the bodily pain domain of the Short Form-36 (SF-36) (mean change, 48.3 compared with 41.9; p < 0.001), a greater increase in the physical function domain of the SF-36 (mean change, 47.7 compared with 41.2; p < 0.001), and a greater decrease in the Oswestry Disability Index score (mean change, -41.1 compared with -34.6; p < 0.001) as compared with those who had had symptoms for more than six months (with higher scores indicating less severe symptoms on the SF-36 and indicating more severe symptoms on the Oswestry Disability Index). When the values at the time of the four-year follow-up were compared with the baseline values, patients in the nonoperative treatment group who had had symptoms for six months or less had a greater increase in the bodily pain domain of the SF-36 (mean change, 31.8 compared with 21.4; p < 0.001), a greater increase in the physical function domain of the SF-36 (mean change, 29.5 compared with 22.6; p = 0.015), and a greater decrease in the Oswestry Disability Index score (mean change, -24.9 compared with -18.5; p = 0.006) as compared with those who had had symptoms for more than six months. Differences in treatment effect between the two groups related to the duration of symptoms were not significant.
Increased symptom duration due to lumbar disc herniation is related to worse outcomes following both operative and nonoperative treatment. The relative increased benefit of surgery compared with nonoperative treatment was not dependent on the duration of the symptoms.
The Journal of Bone and Joint Surgery 10/2011; 93(20):1906-14. · 3.27 Impact Factor
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ABSTRACT: Retrospective subgroup analysis of prospectively collected data according to treatment received.
The purpose of this study is to determine whether the duration of symptoms affects outcomes after the treatment of spinal stenosis (SS) or degenerative spondylolisthesis (DS).
The Spine Outcomes Research Trial (SPORT) study was designed to provide scientific evidence on the effectiveness of spinal surgery versus a variety of nonoperative treatments.
An as-treated analysis was performed on the patients enrolled in SPORT for the treatment of SS or DS. A comparison was made between patients with SS with 12 or fewer months' (n = 405) and those with more than 12 months' (n = 227) duration of symptoms. A comparison was also made between patients with DS with 12 or fewer months' (n = 397) and those with more than 12 months' (n = 204) duration of symptoms. Baseline patient characteristics were documented. Primary and secondary outcomes were measured at baseline and at regular follow-up time intervals up to 4 years. The difference in improvement among patients whose surgical or nonsurgical treatment began less than or greater than 12 months after the onset of symptoms was measured. In addition, the difference in improvement with surgical versus nonsurgical treatment (treatment effect) was determined at each follow-up period for each group.
At final follow-up, there was significantly less improvement in primary outcome measures in SS patients with more than 12 months' symptom duration. Primary and secondary outcome measures within the DS group did not differ according to symptom duration. There were no statistically significant differences in the treatment effect of surgery in SS or DS patients.
Patients with SS with fewer than 12 months of symptoms experienced significantly better outcomes with surgical and nonsurgical treatment relative to those with symptom duration greater than 12 months. There was no difference in the outcome of patients with degenerative spondylolisthesis according to symptom duration.
Spine 09/2011; 36(25):2197-210. · 2.08 Impact Factor
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ABSTRACT: Incidental durotomy is an infrequent but well-recognized complication during lumbar disc surgery. The effect of a durotomy on long-term outcomes is, however, controversial. The authors sought to examine whether the occurrence of durotomy during surgery impacts long-term clinical outcome.
Spine Patient Outcomes Research Trial (SPORT) participants who had a confirmed diagnosis of intervertebral disc herniation and were undergoing standard first-time open discectomy were followed up at 6 weeks and at 3, 6, and 12 months after surgery and annually thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean (± SD) duration of follow-up among all of the intervertebral disc herniation patients whose data were analyzed was 41.5 ± 14.5 months (41.4 months in those with no durotomy vs 40.2 months in those with durotomy, p < 0.68). The median duration of follow-up among all of these patients was 47 months (range 1-95 months).
A total of 799 patients underwent first-time lumbar discectomy. There was an incidental durotomy in 25 (3.1%) of these cases. There were no significant differences between the durotomy and no-durotomy groups with respect to age, sex, race, body mass index, herniation level or type, or the prevalence of smoking, diabetes, or hypertension. When outcome differences between the groups were analyzed, the durotomy group was found to have significantly increased operative duration, operative blood loss, and length of inpatient stay. However, there were no significant differences in incidence rates for nerve root injury, postoperative mortality, additional surgeries, or SF-36 scores for Bodily Pain or Physical Function, or Oswestry Disability Index scores at 1, 2, 3, or 4 years.
Incidental durotomy during first-time lumbar discectomy does not appear to impact long-term outcome in affected patients.
Journal of neurosurgery. Spine 03/2011; 14(5):647-53. · 1.61 Impact Factor
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ABSTRACT: Incidental durotomy is a familiar encounter during surgery for lumbar spinal stenosis. The impact of durotomy on long-term outcomes remains a matter of debate.
To determine the impact of durotomy on the long-term outcomes of patients in the Spine Patient Outcomes Research Trial (SPORT).
The SPORT cohort participants with a confirmed diagnosis of spinal stenosis, without associated spondylolisthesis, undergoing standard, first-time, open decompressive laminectomy, with or without fusion, were followed up from baseline at 6 weeks, and 3, 6, and 12 months and yearly thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean follow-up among all analyzed patients was 43.8 months.
Four hundred nine patients underwent first-time open laminectomy with or without fusion. Thirty-seven of these patients (9%) had an incidental durotomy. No significant differences were observed with or without durotomy in age; sex; race; body mass index; the prevalence of smoking, diabetes mellitus, and hypertension; decompression level; number of levels decompressed; or whether an additional fusion was performed. The durotomy group had significantly increased operative duration, operative blood loss, and inpatient stay. There were, however, no differences in incidence of nerve root injury, mortality, additional surgeries, or primary outcomes (Short Form-36 Bodily Pain or Physical Function scores or Oswestry Disability Index) at yearly follow-ups to 4 years.
Incidental durotomy during first-time lumbar laminectomy for spinal stenosis did not impact long-term outcomes in affected patients.
Neurosurgery 02/2011; 69(1):38-44; discussion 44. · 2.79 Impact Factor
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ABSTRACT: Secondary analysis within a large clinical trial.
To evaluate the changes in treatment preference before and after watching a video decision aid as part of an informed consent process.
A randomized trial with a similar decision aid in herniated disc patients had shown decreased rate of surgery in the video group, but the effect of the video on expressed preferences is not known.
Subjects enrolling in the Spine Patient Outcomes Research Trial (SPORT) with intervertebral disc herniation, spinal stenosis, or degenerative spondylolisthesis at 13 multidisciplinary spine centers across the United States were given an evidence-based videotape decision aid viewed prior to enrollment as part of informed consent.
Of the 2505 patients, 86% (n = 2151) watched the video and 14% (n = 354) did not. Watchers shifted their preference more often than nonwatchers (37.9% vs. 20.8%, P < 0.0001) and more often demonstrated a strengthened preference (26.2% vs. 11.1%, P < 0.0001). Among the 806 patients whose preference shifted after watching the video, 55% shifted toward surgery (P = 0.003). Among the 617 who started with no preference, after the video 27% preferred nonoperative care, 22% preferred surgery, and 51% remained uncertain.
After watching the evidence-based patient decision aid (video) used in SPORT, patients with specific lumbar spine disorders formed and/or strengthened their treatment preferences in a balanced way that did not appear biased toward or away from surgery.
Spine 02/2011; 36(18):1501-4. · 2.08 Impact Factor
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ABSTRACT: A secondary analysis comparing diabetic patients with nondiabetic patients enrolled in the Spine Patient Outcomes Research Trial (SPORT).
To compare surgical outcomes and complications between diabetic and nondiabetic spine patients.
Patients with diabetes are predisposed to comorbidities that may confound the diagnosis and treatment of patients with spinal disorders.
Baseline characteristics and outcomes of 199 patients with diabetes were compared with those of the nondiabetic population in a total of 2405 patients enrolled in the Spine Patient Outcomes Research Trial for the diagnoses of intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS). Primary outcome measures include the 36-Item Short Form Health Survey (SF-36) Health Status questionnaire and the Oswestry Disability Index.
Patients with diabetes were significantly older and had a higher body mass index than nondiabetic patients. Comorbidities, including hypertension, stroke, cardiovascular disease, and joint disease, were significantly more frequent in diabetic patients than in nondiabetic patients. Patients with diabetes and IDH did not make significant gains in pain and function with surgical intervention relative to diabetic patients who underwent nonoperative treatment. Diabetic patients with SpS and DS experienced significantly greater improvements in pain and function with surgical intervention when compared with nonoperative treatment. Among those who had surgery, nondiabetic patients with SpS achieved marginally significantly greater gains in function than their diabetic counterparts (SF-36 physical function, P = 0.062). Among patients who had surgery for DS, diabetic patients did not have as much improvement in pain or function as did the nondiabetic population (SF-36 bodily pain, P = 0.003; physical function, P = 0.002). Postoperative complications were more prevalent in patients with diabetes than in nondiabetic patients with SpS (P = 0.002). There was an increase in postoperative (P = 0.028) and intraoperative (P = 0.029) blood replacement in DS patients with diabetes.
Diabetic patients with SpS and DS benefited from surgery, though older SpS patients with diabetes have more postoperative complications. IDH patients with diabetes did not benefit from surgical intervention.
Spine 02/2011; 36(4):290-307. · 2.08 Impact Factor
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ABSTRACT: Randomized trial with concurrent observational cohort. A total of 1171 patients were divided into subgroups by educational attainment: high school or less, some college, and college degree or above.
To assess the influence of education level on outcomes for treatment of lumbar disc herniation.
Educational attainment has been demonstrated to have an inverse relationship with pain perception, comorbidities, and mortality.
The Spine Patient Outcomes Research Trial enrolled surgical candidates (imaging-confirmed disc herniation with at least 6 weeks of persistent signs and symptoms of radiculopathy) from 13 multidisciplinary spine clinics in 11 US states. Treatments were standard open discectomy versus nonoperative treatment. Outcomes were changes from baseline for 36-Item Short Form Health Survey (SF-36), bodily pain (BP), and physical function (PF) scales and the modified Oswestry Disability Index (ODI) at 6 weeks, 3 months, 6 months, and yearly through 4 years.
Substantial improvement was seen in all patient cohorts. Surgical outcomes did not differ by level of education. For nonoperative outcomes, however, higher levels of education were associated with significantly greater overall improvement over 4 years in BP (P = 0.007), PF (P = 0.001), and ODI (P = 0.003). At 4 years a "dose-response" type relationship was shown for BP (high school or less = 25.5, some college = 31, and college graduate or above = 36.3, P = 0.004) and results were similar for PF and ODI. The success of nonoperative treatment in the more educated cohort resulted in an attenuation of the relative benefit of surgery.
Patients with higher educational attainment demonstrated significantly greater improvement with nonoperative treatment while educational attainment was not associated with surgical outcomes.
Spine 02/2011; 36(26):2324-32. · 2.08 Impact Factor
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ABSTRACT: Retrospective case series.
To examine and document the change in rates and the geographic variation in procedure type and utilization of plating by orthopedic surgeons for anterior cervical discectomy-fusion.
Age- and sex-adjusted rates of cervical spine surgery have not increased, but the rate of cervical spinal fusion has, accounting for 41% of all fusion procedures in 2004.
Records were selected from the American Board of Orthopedic Surgeons part II examination from 1999 to 2008. Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision, Clinical Modification (ICDM-9-CM) codes were used to determine utilization of structural allograft, autograft/interbody devices, and anterior cervical plating over time and within geographic region. Main outcome measures were physician workforce, and rates and variation of procedure types.
From 1999 to 2008, the number of self-declared orthopedic spine surgeon candidates increased 24%. Over this period, the annual number of discectomies with fusions for degenerative cervical disc disease increased by 67%, whereas the number of such operations per surgeon operating on at least 1 such case increased 48% (P = 0.018). Interbody device (0%-31%; P < 0.0001), anterior cervical plating (39%-79%; P < 0.0001), and allograft (14%-59%; P < 0.0001) use increased, whereas autograft use decreased (86%-10%; P < 0.0001). The Southwest and Southeast were more likely than the Midwest to use interbody devices (OR: 2.42 and 1.66, respectively). The Southwest and Northeast were more likely than the Midwest to use autograft (OR: 1.55 and 1.49). The Southwest, Northeast, and Southeast were less likely to use allograft than the Midwest (OR: 0.408, 0.742, and 0.770). The Northeast was less likely and the Southeast more likely than the Midwest to utilize anterior cervical plating (OR: 0.67 and 1.33). Surgical complications were more often associated with autograft compared with allograft (OR: 1.61).
From 1999 to 2008, the number of orthopedic surgeon candidates performing spine surgery has increased. These surgeons are performing more fusions and utilizing more structural allografts, interbody devices, and/or anterior cervical plates. Regional variations also remain in the types of constructs utilized.
Spine 02/2011; 37(1):57-66. · 2.08 Impact Factor
