Neurologic Injury after Lateral Lumbar Interbody Fusion

Since the first description of LLIF in 2006, the indications for LLIF have expanded and the rate of LLIF procedures performed in the USA has increased. LLIF has several theoretical advantages compared to other approaches including the preservation of the anterior and posterior annular/ligamentous structures, insertion of wide cages resting on the dense apophyseal ring bilaterally, and augmentation of disc height with indirect decompression of neural elements. Favorable long-term outcomes and a reduced risk of visceral/vascular injuries, incidental dural tears, and perioperative infections have been reported. However, approach-related complications such as motor and sensory deficits remain a concern. In well-indicated patients, LLIF can be a safe procedure used for a variety of indications 1).

Hijji et al. published a systematic review analyzing the complication profile of LLIF. Their study included a total of 63 articles and 6819 patients. The most commonly reported complications were transient neurologic injury (36.07%). The clinical significance of those transient findings, however, is unclear since the rate of persistent neurologic complications was much lower (3.98%) 2)

The risk of lumbar plexus injury is particularly concerning at the L4-5 disc space. Although LLIF is associated with an increased prevalence of anterior thigh/groin pain as well as motor and sensory deficits immediately after surgery, our results support that pain and neurologic deficits decrease over time. The level treated appears to be a risk factor for lumbosacral plexus injury 3).

Interestingly, the use of rhBMP-2 was associated with higher rates of persistent motor deficits, which might be explained by a direct deleterious effect of this agent on the lumbosacral plexus 4).

In a retrospective chart review of 118 patients, Cahill et al. determined the incidence of femoral nerve injury, which is considered one of the worst neurological complications after LLIF. The authors reported an approximate 5% femoral nerve injury rate of all the LLIF procedures performed at L4-5. There were no femoral nerve injuries at any other levels 5).

During a 6-year time period of performing LLIF Aichmair et al., noted a learning curve with a decreasing proportional trend for anterior thigh pain, sensory as well as motor deficits 6)

Le et al. also observed a learning curve with a significant reduction in the incidence of postoperative thigh numbness during a 3-year period (from 26.1 to 10.7%) 7).

Levi AD from the University of Miami Hospital, adopted an exclusive mini-open muscle-splitting approach in LLIF with first-look inspection of the lumbosacral plexus nerve elements taht may improve motor and sensory outcomes in general and the incidence of postoperative groin/thighsensory dysfunction and psoas-pattern weakness in particular 8).

References

1)

Salzmann SN, Shue J, Hughes AP. Lateral Lumbar Interbody Fusion-Outcomes and Complications. Curr Rev Musculoskelet Med. 2017 Dec;10(4):539-546. doi: 10.1007/s12178-017-9444-1. Review. PubMed PMID: 29038952; PubMed Central PMCID: PMC5685966.
2)

Hijji FY, Narain AS, Bohl DD, Ahn J, Long WW, DiBattista JV, Kudaravalli KT, Singh K. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J. 2017 Oct;17(10):1412-1419. doi: 10.1016/j.spinee.2017.04.022. Epub 2017 Apr 26. Review. PubMed PMID: 28456671.
3)

Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014 May 1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 24012428.
4)

Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014 May 1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 24012428.
5)

Cahill KS, Martinez JL, Wang MY, Vanni S, Levi AD. Motor nerve injuries following the minimally invasive lateral transpsoas approach. J Neurosurg Spine. 2012 Sep;17(3):227-31. doi: 10.3171/2012.5.SPINE1288. Epub 2012 Jun 29. PubMed PMID: 22746272.
6)

Aichmair A, Lykissas MG, Girardi FP, Sama AA, Lebl DR, Taher F, Cammisa FP, Hughes AP. An institutional six-year trend analysis of the neurological outcome after lateral lumbar interbody fusion: a 6-year trend analysis of a single institution. Spine (Phila Pa 1976). 2013 Nov 1;38(23):E1483-90. doi: 10.1097/BRS.0b013e3182a3d1b4. PubMed PMID: 23873231.
7)

Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976). 2013 Jan 1;38(1):E13-20. doi: 10.1097/BRS.0b013e318278417c. PubMed PMID: 23073358.
8)

Sellin JN, Brusko GD, Levi AD. Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach. World Neurosurg. 2019 Jan;121:e647-e653. doi: 10.1016/j.wneu.2018.09.180. Epub 2018 Oct 3. PubMed PMID: 30292030.

Minimally invasive lateral lumbar interbody fusion for adult spinal deformity

A multicenter retrospective review of a minimally invasive adult spinal deformity database was queried with a minimum of 2-yr follow-up. Patients were divided into 2 groups as determined by the side of the curve from which the LLIF was performed: concave or convex.

No differences between groups were noted in demographic, and preoperative or postoperative radiographic parameters (all P > .05). There were 8 total complications in the convex group (34.8%) and 21 complications in the concave group (52.5%; P = .17). A subgroup analysis was performed in 49 patients in whom L4-5 was in the primary curve and not in the fractional curve. In this subset of patients, there were 6 complications in the convex group (31.6%) compared to 19 in the concave group (63.3%; P < .05) and both groups experienced significant improvements in coronal Cobb angle, Oswestry Disability Index, and Visual Analog Scale score with no difference between groups.

Patients undergoing LLIF for ADS had no statistically significant clinical or operative complication rates regardless of a concave or convex approach to the curve. Clinical outcomes and coronal plane deformity improved regardless of approach side. However, in cases wherein L4-5 is in the primary curve, approaching the fractional curve at L4-5 from the concavity may be associated with a higher complication rate compared to a convex approach 1).


Park et al., evaluated the clinical and radiological efficacies of supplementing minimally invasive lateral lumbar interbody fusion (LLIF) with open posterior spinal fusion (PSF) in adult spinal deformity (ASD).

To evaluate the advantages of minimally invasive LLIF for ASD, patients who underwent minimally invasive LLIF followed by open PSF (combined group) were compared with patients who only underwent PSF (only PSF group). The clinical and radiological outcomes for deformity correction and indirect decompression were assessed. The occurrence of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) were also evaluated.

No significant differences were observed in the clinical outcomes of the Oswestry Disability Index (ODI), visual analog scale, and major complications including reoperations between the groups. No additional advantage was found for coronal deformity correction, but the restoration of lumbar lordosis in the combined group was significantly higher postoperatively (15.3° vs. 8.87°, P = 0.003) and last follow-up (6.69° vs. 1.02°, P = 0.029) compared to that of the only PSF group. In the subgroup analysis for indirect decompression for the combined group, a significant increase of canal area (104 vs. 122 mm) and foraminal height (16.2 vs. 18.5 mm) was noted. The occurrence of PJK or PJF was significantly higher in the combined group than in the only PSF group (P = 0.039).

LLIF has advantages of indirect decompression and greater improvements of sagittal correction compared to only posterior surgery. LLIF should be conducted considering the above-mentioned benefits and complications including PJK or PJF in ASD 2).

References

1)

Kanter AS, Tempel ZJ, Agarwal N, Hamilton DK, Zavatsky JM, Mundis GM, Tran S, Chou D, Park P, Uribe JS, Wang MY, Anand N, Eastlack R, Mummaneni PV, Okonkwo DO. Curve Laterality for Lateral Lumbar Interbody Fusion in Adult Scoliosis Surgery: The Concave Versus Convex Controversy. Neurosurgery. 2018 Dec 1;83(6):1219-1225. doi: 10.1093/neuros/nyx612. PubMed PMID: 29361052.
2)

Park HY, Ha KY, Kim YH, Chang DG, Kim SI, Lee JW, Ahn JH, Kim JB. Minimally Invasive Lateral Lumbar Interbody Fusion for Adult Spinal Deformity: Clinical and Radiological Efficacy With Minimum Two Years Follow-up. Spine (Phila Pa 1976). 2018 Jul 15;43(14):E813-E821. doi: 10.1097/BRS.0000000000002507. PubMed PMID: 29215493.

Lumbar spinal stenosis case series

A successive series of 102 patients with lumbar spinal stenosis from Aachen (with and without previous lumbar surgery) were treated with decompression alone during a 3-year period. Data on pre- and postoperative back pain and leg pain (numerical rating scale [NRS] scale) were retrospectively collected from questionnaires with a return rate of 65% (n = 66). The complete cohort as well as patients with first-time surgery and re-decompression were analyzed separately. Patients were dichotomized to short-term follow-up (< 100 weeks) and long-term follow-up (> 100 weeks) postsurgery.

Overall, both back pain (NRS 4.59 postoperative versus 7.89 preoperative; p < 0.0001) and leg pain (NRS 4.09 versus 6.75; p < 0.0001) improved postoperatively. The short-term follow-up subgroup (50%, n = 33) showed a significant reduction in back pain (NRS 4.0 versus 6.88; p < 0.0001) and leg pain (NRS 2.49 versus 6.91: p < 0.0001). Similar results could be observed for the long-term follow-up subgroup (50%, n = 33) with significantly less back pain (NRS 3.94 versus 7.0; p < 0.0001) and leg pain (visual analog scale 3.14 versus 5.39; p < 0.002) postoperatively. Patients with previous decompression surgery benefit significantly regarding back pain (NRS 4.82 versus 7.65; p < 0.0024), especially in the long-term follow-up subgroup (NRS 4.75 versus 7.67; p < 0.0148). There was also a clear trend in favor of leg pain in patients with previous surgery; however, it was not significant.

Decompression of lumbar spinal stenosis without fusion led to a significant and similar reduction of back pain and leg pain in a short-term and a long-term follow-up group. Patients without previous surgery benefited significantly better, whereas patients with previous decompression benefited regarding back pain, especially for long-term follow-up with a clear trend in favor of leg pain 1).


A total of 25 patients between May 2015 and June 2016 affected by radiologically demonstrated one-level lumbar spinal stenosis (LSS) with facet joint degeneration and grade I spondylolisthesis were included in this prospective study. All the patients underwent laminectomyforaminotomy, and one-level facet fixation (Facet-Link, Inc., Rockaway, New Jersey, United States). Pre- and postoperative clinical (Oswestry Disability Index[ODI], Short Form 36 [SF-36]) and radiologic (radiographs, magnetic resonance imaging, computed tomography) data were collected and analyzed.

Mean follow-up was 12 months. The L4L5 level was involved in 18 patients (72%) and L5S1 in 7 patients (28%); the average operative time was 80 minutes (range: 65-148 minutes), and the mean blood loss was 160 mL (range: 90-200 mL). ODI and SF-36 showed a statistically significant (p < 0.05) improvement at last follow-up.

Transfacet fixation is a safe and effective treatment option in patients with single-level LSS, facet joint degeneration, and mild instability 2).

2017

A retrospective matched-pair cohort study included a total of 144 patients who underwent surgery for bisegmental spinal stenosis at the levels L3-4 and L4-5 between 2008 and 2012. There were 72 matching pairs that corresponded in sex, year of birth, and width of the stenosed segments. The patients’ impairments were reported before, immediately after, and 6 and 12 months after surgery using the Oswestry Disability Questionnaire (ODQ-D) and the EuroQol-5D (EQ-5D). The data were evaluated statistically. Results The comparison of both surgical procedures regarding walking ability (walking a distance with and without a walking aid) revealed a significant difference. Patients who underwent hemilaminectomy had better postoperative results. The individual criteria of the ODQ-D and EQ-5D revealed no significant differences between 2-level fenestration and hemilaminectomy; however, there is always significant postoperative improvement in comparison with preoperative status. Age, sex, body mass index, comorbidities, smoking, and alcohol consumption had no influence on the surgical results. The reoperation rate was between 13% and 15% for both surgical techniques, not being significantly different. Conclusion Fenestration and hemilaminectomy are equivalent therapies for bisegmental lumbar spinal canal stenosis. Regarding walking, the study revealed better results for hemilaminectomy than for fenestration in this cohort of patients. Pain intensity, personal care, lifting and carrying of objects, sitting, social life, and travel all improved significantly postoperatively as compared with preoperatively. In both groups, health status as the decisive predictor improved considerably after surgery. We could show that both surgical methods result in significant postoperative improvement of all the individual criteria of the ODQ-D and the EQ-5D 3).

2016

726 patients with lumbar stenosis (without spondylolisthesis or scoliosis) and a baseline back pain score ≥ 5 of 10 who underwent surgical decompression only. No patient was reported to have significant spondylolisthesis, scoliosis, or sagittal malalignment. Standard demographic and surgical variables were collected, as well as patient outcomes including back and leg pain scores, Oswestry Disability Index (ODI), and EuroQoL 5D (EQ-5D) at baseline and 3 and 12 months postoperatively. RESULTS The mean age of the cohort was 65.6 years, and 407 (56%) patients were male. The mean body mass index was 30.2 kg/m2, and 40% of patients had 2-level decompression, 29% had 3-level decompression, 24% had 1-level decompression, and 6% had 4-level decompression. The mean estimated blood loss was 130 ml. The mean operative time was 100.85 minutes. The vast majority of discharges (88%) were routine home discharges. At 3 and 12 months postoperatively, there were significant improvements from baseline for back pain (7.62 to 3.19 to 3.66), leg pain (7.23 to 2.85 to 3.07), EQ-5D (0.55 to 0.76 to 0.75), and ODI (49.11 to 27.20 to 26.38). CONCLUSIONS Through the 1st postoperative year, patients with lumbar stenosis-without spondylolisthesis, scoliosis, or sagittal malalignment-and clinically significant back pain improved after decompression-only surgery 4).

2015

88 patients with LSS (47 men and 41 women) who ranged in age from 39 to 86 years (mean age 68.7 years). All patients had undergone microendoscopic laminotomy at Osaka City University Graduate School of Medicine from May 2008 through October 2012. The minimum duration of clinical and radiological follow-up was 6 months. All patients were evaluated by Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) scores for low back painleg pain, and leg numbness before and after surgery.

The distance between the C7 plumb line and the posterior corner of the sacrum (sagittal vertical axis [SVA]) was measured on lateral standing radiographs of the entire spine obtained before surgery.

Radiological factors and clinical outcomes were compared between patients with a preoperative SVA ≥ 50 mm (forward-bending trunk [F] group) and patients with a preoperative SVA < 50 mm (control [C] group).

A total of 35 patients were allocated to the F group (19 male and 16 female) and 53 to the C group (28 male and 25 female).

The mean SVA was 81.0 mm for patients in the F group and 22.0 mm for those in the C group. At final follow-up evaluation, no significant differences between the groups were found for the JOA score improvement ratio (73.3% vs 77.1%) or the VAS score for leg numbness (23.6 vs 24.0 mm); the VAS score for low-back pain was significantly higher for those in the F group (21.1 mm) than for those in the C group (11.0 mm); and the VAS score for leg pain tended to be higher for those in the F group (18.9 ± 29.1 mm) than for those in the C group (9.4 ± 16.0 mm).

Preoperative alignment of the spine in the sagittal plane did not affect JOA scores after microendoscopic laminotomy in patients with LSS. However, low-back pain was worse for patients with preoperative anterior translation of the C-7 plumb line than for those without 5).1) Geiger MF, Bongartz N, Blume C, Clusmann H, Müller CA. Improvement of Back and Leg Pain after Lumbar Spinal Decompression without Fusion. J Neurol Surg A Cent Eur Neurosurg. 2018 Dec 5. doi: 10.1055/s-0038-1669473. [Epub ahead of print] PubMed PMID: 30517963.2) Trungu S, Pietrantonio A, Forcato S, Tropeano MP, Martino L, Raco A. Transfacet Screw Fixation for the Treatment of Lumbar Spinal Stenosis with Mild Instability: A Preliminary Study. J Neurol Surg A Cent Eur Neurosurg. 2018 Sep;79(5):358-364. doi: 10.1055/s-0038-1655760. Epub 2018 Jul 16. PubMed PMID: 30011420.3) Schüppel J, Weber F. Retrospective Matched-Pair Cohort Study on Effect of Bisegmental Fenestration versus Hemilaminectomy for Bisegmental Spinal Canal Stenosis at L3-L4 and L4-L5. J Neurol Surg A Cent Eur Neurosurg. 2017 Jan 9. doi: 10.1055/s-0036-1597617. [Epub ahead of print] PubMed PMID: 28068753.4) Crawford CH 3rd, Glassman SD, Mummaneni PV, Knightly JJ, Asher AL. Back pain improvement after decompression without fusion or stabilization in patients with lumbar spinal stenosis and clinically significant preoperative back pain. J Neurosurg Spine. 2016 Nov;25(5):596-601. PubMed PMID: 27285666.5) Dohzono S, Toyoda H, Matsumoto T, Suzuki A, Terai H, Nakamura H. The influence of preoperative spinal sagittal balance on clinical outcomes after microendoscopic laminotomy in patients with lumbar spinal canal stenosis. J Neurosurg Spine. 2015 Jul;23(1):49-54. doi: 10.3171/2014.11.SPINE14452. Epub 2015 Apr 3. PubMed PMID: 25840041.

Degenerative Spinal Deformity: Creating Lordosis in the Lumbar Spine, An Issue of Neurosurgery Clinics of North America (The Clinics: Surgery)

Degenerative Spinal Deformity: Creating Lordosis in the Lumbar Spine, An Issue of Neurosurgery Clinics of North America (The Clinics: Surgery)

This issue of Neurosurgery Clinics, edited by Drs. Sigurd Berven and Praveen V. Mummaneni, will cover Degenerative Spinal Deformity: Creating Lordosis in the Lumbar Spine. Topics will include, but are not limited to, Spinopelvic Parameters; Location of lordosis (priority for L4-S1) and Age Adjustments; Approach Selection; Nuances of Pedicle Subtraction Osteotomy; Preventing Pseudarthrosis and PJK; The Challenge of Creating Lordosis in High Grade Dysplastic Spondylolisthesis; Sacropelvic Fixation; Evolution of the MISDEF Algorithm; Transpsoas Approach Nuances; Lateral Prepsoas Approach Nuances; Anterior Column Release; Navigation assisted MIS deformity correction; MIS TLIF; MIS PSO; and The challenge of L4-S1- fractional curves.

 

UpToDate: Lumbar lordosis

Lumbar lordosis

Angle between the top of S1 and the top of L1.

Normal 20-40 º

Alignment objective LL = Pelvic incidence +/- 9º

In the spinal regional division, the strong correlation of pelvic incidence and lumbar lordosis has been noted in several studies 1).

The normal, anteriorly convex curvature of the lumbar segment of the vertebral column; lumbar lordosis is a secondary curvature of the vertebral column, acquired postnatally as the upright posture is assumed when one learns to walk.

Measurement of Spino-pelvic sagittal parameters. Lumbar lordosis (LL) measured using the Cobb anglebetween the superior endplate of the L1 and S1. The pelvic tilt angle (PT) defined as the angle between a straight line connecting the midpoint of the bilateral femoral head centre to the midpoint of the sacral plate and the plumb line. The pelvic incidence angle (PI) defined as the angle between the perpendicular line of the sacral plate and the line of the midpoint of the superior endplate of S1 joining with the center of the hip axis. The sacral slope (SS) is defined as the angle formed by the upper endplate of S1 and the horizontal plane

Classification

see Roussouly classification.

In the surgical treatment of a spinal deformity, the importance of restoring lumbar lordosis is well recognized.

Smith Petersen osteotomy (SPOs) yield approximately 10° of lordosis per level, whereas pedicle subtraction osteotomies result in as much as 30° increased lumbar lordosis. Recently, selective release of the anterior longitudinal ligament (ALL) and placement of lordotic interbody grafts using the minimally invasive lateral retroperitoneal transpsoas approach (XLIF) has been performed as an attempt to increase lumbar lordosis while avoiding the morbidity of osteotomy.


The goal of a study from the Mount Sinai Hospital, in New York, was to conduct an evidence-based, quantitative assessment of the correction of lumbar lordosis achieved by each of the three principle lumbar interbody fusion techniques: anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (L-LIF), and transforaminal lumbar interbody fusion (TLIF).

systematic review of the literature was conducted to identify studies containing degrees of correction of lumbar lordosis achieved by ALIF, L-LIF, and TLIF as demonstrated on standing lumbar x-rays at least six weeks following surgical intervention. Pooled and Forest plot analyses were performed for the studies that met inclusion criteria.

For ALIF, 21 studies were identified with mean correction 4.67° (SD +/- 4.24) and median correction 5.20°. 15 studies were identified that met criteria for forest plot analysis with mean correction 4.90° (SEM +/- 0.40). For L-LIF, 17 studies were identified with mean correction 4.47° (SD +/- 4.80) and median correction 4.00°. 9 studies were identified that met criteria for forest plot analysis with mean correction 2.91° (SEM +/- 0.56). For TLIF, 31 studies were identified with mean correction 3.89° (SD +/- 4.33) and median correction 3.50°. 25 studies were identified that met criteria for forest plot analysis with mean correction 5.33° (SEM+/- 0.27) 2).

1)

Knott PT, Mardjetko SM, Techy F. The use of the T1 sagittal angle in predicting overall sagittal balance of the spine. Spine J. 2010;10:994–998.
2)

Rothrock RJ, McNeill IT, Yaeger K, Oermann EK, Cho SK, Caridi JM. Lumbar Lordosis Correction with Interbody Fusion: Systematic Literature Review and Analysis. World Neurosurg. 2018 Jul 4. pii: S1878-8750(18)31432-3. doi: 10.1016/j.wneu.2018.06.216. [Epub ahead of print] Review. PubMed PMID: 29981462.

Update: Rehabilitation after lumbar disc surgery

Rehabilitation after lumbar disc surgery

Studies have shown late post-operative physical disability and residual pain in patients following lumbar disc surgery despite growing evidence of its beneficial effects. Therefore, rehabilitation is required to minimise the late postoperative complications.
Several rehabilitation programmes are available for individuals after lumbar disc surgery.
Cochrane review in 2009 showed that exercise programs starting 4 to 6 weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the reoperation rate after first-time lumbar surgery 1) 2).


metaanalysis in 2014 showed considerable variation in the content, duration and intensity of the rehabilitation programmes, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed 3).


A Multicentre, randomised, controlled trial, and economic evaluation with concealed allocation and intention-to-treat-analysis in adults who underwent discectomy for a herniated lumbar disc, confirmed by magnetic resonance imaging, and signs of nerve root compression corresponding to the herniation level.
Early rehabilitation (exercise therapy) for 6 to 8 weeks, versus no referral, immediately after discharge.
In line with the recommended core outcome set, the co-primary outcomes were: functional status (Oswestry Disability Index); leg and back pain (numerical rating scale 0 to 10); global perceived recovery (7-point Likert scale); and general physical and mental health (SF12), assessed 3, 6, 9, 12 and 26 weeks after surgery. The outcomes for the economic evaluation were quality of life and costs, measured at 6, 12 and 26 weeks after surgery.
There were no clinically relevant or statistically significant overall mean differences between rehabilitation and control for any outcome adjusted for baseline characteristics: global perceived recovery (OR 1.0, 95% CI 0.6 to 1.7), functional status (MD 1.5, 95% CI -3.6 to 6.7), leg pain (MD 0.1, 95% CI -0.7 to 0.8), back pain (MD 0.3, 95% CI -0.3 to 0.9), physical health (MD -3.5, 95% CI -11.3 to 4.3), and mental health (MD -4.1, 95% CI -9.4 to 1.3). After 26 weeks, there were no significant differences in quality-adjusted life years (MD 0.01, 95% CI -0.02 to 0.04 points) and societal costs (MD -€527, 95% CI -2846 to 1506). The maximum probability for the intervention to be cost-effective was 0.75 at a willingness-to-pay of €32 000/quality-adjusted life year.
Early rehabilitation after lumbar disc surgery was neither more effective nor more cost-effective than no referral 4).

Case series

2017

Twenty-one patients aged 25-65 years undergoing lumbar microdiscectomy were randomly assigned to the rehabilitation group (n = 14) or active control group (n = 7) by simple randomisation. Eight rehabilitation sessions were initiated 2-3 weeks after surgery. Thirty-minute sessions were conducted twice weekly for four weeks. Post-operative physical disability and pain were assessed at baseline and at the two-year follow-up.
Post-operative physical disability improved more in patients who had undergone rehabilitation than in those who had received control care (63% vs. -23%, P< 0.05). Post-operative residual low back and leg pain were alleviated in the treatment group (26% and 57%, respectively), but intensified in the control group (-5% and -8%, respectively).
This study demonstrated the potential of manipulative rehabilitation and importance of post-operative management after lumbar disc surgery. Definitive trials with larger sample sizes are required to confirm the feasibility and potential therapeutic effectiveness of this approach 5).


A study aimeds to investigate (1) motives, motivations and expectations regarding the choice for a specific rehabilitation setting after herniated disc surgery and (2) how rehabilitation-related motivations and expectations are associated with rehabilitation outcome (ability to work, health-related quality of life and satisfaction with rehabilitation) three months after disc surgery.
The longitudinal cohort study refers to 452 disc surgery patients participating in a subsequent rehabilitation. Baseline interviews took part during acute hospital stay (pre-rehabilitation), follow-up interviews three months later (post-rehabilitation). Binary logistic regression and multiple linear regression analyses were applied.
(1) Motives, motivations and expectations: Inpatient rehabilitation (IPR) patients stated “less effort/stress” (40.9%), more “relaxation and recreation” (39.1%) and greater “intensity of care and treatment” (37.0%) regarding their setting preference, whereas outpatient rehabilitation (OPR) patients indicated “family reasons” (45.3%), the wish for “staying in familiar environment” (35.9%) as well as “job-related reasons” (11.7%) as most relevant. IPR patients showed significantly higher motivation/expectation scores regarding regeneration (p < .001), health (p < .05), coping (p < .001), retirement/job (p < .01), psychological burden (p < .05) and physical burden (p < .001) compared to OPR patients. (2) Associations with rehabilitation outcome: Besides other factors (e.g. age, gender and educational level) rehabilitation-related motivations/expectations were significantly associated with rehabilitation outcome measures. For example, patients with less motivations/expectations to achieve improvements regarding “physical burden” showed a better health-related quality of life (p < .01) three months after disc surgery. Less motivations/expectations to achieve improvements regarding “psychological burden” was linked to a better mental health status (p < .001) and a greater satisfaction with rehabilitation (OR = .806; p < .05).
Rehabilitation-related motivations and expectations differed substantially between IPR and OPR patients before rehabilitation and were significantly associated with rehabilitation outcome. Taking motivational and expectation-related aspects into account may help to improve allocation procedures for different rehabilitation settings and may improve rehabilitation success 6).

2016

Twenty-one patients aged 25-69 years who underwent lumbar microdiscectomy were randomised to either the manipulative rehabilitation treatment group or the active control group. Rehabilitation was initiated 2-3 weeks after surgery, twice a week for 4 weeks. Each session was for 30 minutes. Primary outcomes were the Roland-Morris disability questionnaire and the visual analogue pain scale. Outcome measures were assessed at baseline and post-intervention.
Early post-operative physical disability was improved with a 55% reduction by early individualised manipulative rehabilitation, compared to that of control care with a 5% increase. Early post-operative residual leg pain decreased with rehabilitation (55%) and control care (9%).
This pilot study supports the feasibility of a future definitive randomised control trial and indicates this type of rehabilitation may be an important option for post-operative management after spinal surgery 7).

References

1)

Ostelo RW, Costa LO, Maher CG, de Vet HC, van Tulder MW. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD003007. doi: 10.1002/14651858.CD003007.pub2. Review. Update in: Cochrane Database Syst Rev. 2014;3:CD003007. PubMed PMID: 18843637.
2)

Ostelo RW, Costa LO, Maher CG, de Vet HC, van Tulder MW. Rehabilitation after lumbar disc surgery: an update Cochrane review. Spine (Phila Pa 1976). 2009 Aug 1;34(17):1839-48. doi: 10.1097/BRS.0b013e3181abbfdf. Review. PubMed PMID: 19602996.
3)

Oosterhuis T, Costa LO, Maher CG, de Vet HC, van Tulder MW, Ostelo RW. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2014 Mar 14;(3):CD003007. doi: 10.1002/14651858.CD003007.pub3. Review. PubMed PMID: 24627325.
4)

Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, Vleggeert-Lankamp CL, Arts MP, van Tulder MW. Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation. J Physiother. 2017 Jul;63(3):144-153. doi: 10.1016/j.jphys.2017.05.016. Epub 2017 Jun 28. PubMed PMID: 28668558.
5)

Kim BJ, Kim T, Ahn J, Cho H, Kim D, Yoon B. Manipulative rehabilitation applied soon after lumbar disc surgery improves late post-operative functional disability: A preliminary 2-year follow-up study. J Back Musculoskelet Rehabil. 2017 May 5. doi: 10.3233/BMR-169546. [Epub ahead of print] PubMed PMID: 28505954.
6)

Löbner M, Stein J, Luppa M, Konnopka A, Meisel HJ, Günther L, Meixensberger J, Stengler K, Angermeyer MC, König HH, Riedel-Heller SG. Choosing the right rehabilitation setting after herniated disc surgery: Motives, motivations and expectations from the patients’ perspective. PLoS One. 2017 Aug 22;12(8):e0183698. doi: 10.1371/journal.pone.0183698. eCollection 2017. PubMed PMID: 28829828.
7)

Kim BJ, Ahn J, Cho H, Kim D, Kim T, Yoon B. Early individualised manipulative rehabilitation following lumbar open laser microdiscectomy improves early post-operative functional disability: A randomized, controlled pilot study. J Back Musculoskelet Rehabil. 2016;29(1):23-9. doi: 10.3233/BMR-150591. PubMed PMID: 25792303.

Book: Modern Thoraco-Lumbar Implants for Spinal Fusion

Modern Thoraco-Lumbar Implants for Spinal Fusion

Modern Thoraco-Lumbar Implants for Spinal Fusion
List Price: $119.00
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This book presents an updated perspective on spinal implants currently used in thoraco-lumbar spine surgery, leading to a rigid or dynamic spine fusion. The development of new surgical devices and techniques is mostly focused on a spinal fusion for lumbar instability due to trauma, tumours or degenerative or infectious diseases. Pedicle-screw fixation and fusion are currently considered to be the gold standard for most of the above-mentioned pathologies, and modern implants are designed to improve the accuracy of pedicle-screw placement and to allow the use of new surgical techniques and minimally invasive approaches. The content is relevant for surgeons, orthopaedic specialists, neurosurgeons, physiotherapists and osteopaths.


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  • Published on: 2017-08-08
  • Original language: English
  • Number of items: 1
  • Dimensions: 9.30″ h x .0″ w x 6.10″ l,
  • Binding: Hardcover
  • 190 pages

Editorial Reviews

About the Author
Prof. Roberto Delfini is a specialist in Neurosurgery at the Policlinico Umbreto I and chair of the University La Sapeinza of Rome as well as head of the School of Specialization in Neurosurgery. He is a Member of the Italian Society of Neurosurgery, where he held the position of Director, Treasurer, Secretary and President (currently past president). And he is also member of other national and international Societies of Neurosurgery and related disciplines as well as member of the World Academy of Neurosurgeons. In 2014 he was awarded the Prize Boniface VIII. He is author of over 300 scientific articles and book chapters on national laws and international neurosurgery. Prof. Delfini performed as first operator over 6,000 surgeries covering most of neurological diseases. His main fields of interest and activities are: the surgery of intracranial tumors in general and in particular tumors of the skull base; surgery of the brain and spinal vascular malformations; surgery of vertebrobasilar medullary cancer and degenerative and traumatic.

Book: Neuro Spinal Surgery Operative Techniques: Micro Lumbar Discectomy: The Gold Standard

Neuro Spinal Surgery Operative Techniques: Micro Lumbar Discectomy: The Gold Standard
By Jkbc Parthiban

Neuro Spinal Surgery Operative Techniques: Micro Lumbar Discectomy: The Gold Standard
List Price: $114.00
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Neuro Spinal Surgery Operative Techniques – Anterior Cervical Discectomy and Fusion is the latest book in the Neuro Spinal Surgery Operative Techniques series. This book covers Anterior Cervical Discectomy and Fusion (ACDF) in eight concise chapters. This surgical procedure involves decompressing the spinal cord and nerve roots in the neck. The first chapter covers the basic anatomy and approaches to ACDF, with illustrated guidance on microdiscectomy and bone grafting. Further chapters cover decompression of the nerve root and cord, interbody grafting technique, corpectomy and fusion, with the most current information on each procedure. The important technique of sinking’ the graft in the disc space to prevent graft migration is covered in detail. The final chapter provides information on instruments used in ACDF procedures. Neuro Spinal Surgery Operative Techniques – Anterior Cervical Discectomy and Fusion is enhanced by nearly 200 full colour images, making this an ideal quick reference guide for spine surgeons. Key Points Latest in Neuro Spinal Surgery Operative Techniques series Other topics in the series include Lateral Mass Fixation in Sub-axial Cervical Spine, and Cervical Laminoplasty 197 full colour images and illustrations


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  • Published on: 2017-08-01
  • Original language: English
  • Dimensions: 9.50″ h x .0″ w x 6.20″ l, 2.20 pounds
  • Binding: Paperback
  • 182 pages

Editorial Reviews

About the Author
JKBC Parthiban MCh (Neurosurgery) FNS Senior Consultant (Neurosurgery and Spine Neurosurgery), Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India

Update: Lumbar discectomy

Lumbar discectomy is one of the most common spinal surgery worldwide.

The traditional midline bone-destructive procedures together with approaches requiring extreme muscular retraction are being replaced by muscle sparing, targeted, stability-preserving surgical routes. The increasing speculation on LDHs and the innovative corridors described to treat them have lead to an extensive production of papers frequently treating the same topic but adopting different terminologies and reporting contradictory results.
Through the analysis of papers by Lofrese et al. it was possible to identify ideal surgical corridors for ILDHs, ELDHs, and IELDHs, distinguishing for each approach the exposure provided and the technical advantages/disadvantages in terms of muscle trauma, biomechanical stability, and nerve root preservation. A significant disproportion was noted between studies discussing traditional midline approaches or variants of the posterolateral route and those investigating pros and cons of simple or combined alternative corridors. Although rarely discussed, these latter represent valuable strategies particularly for the challenging IELDHs, thanks to the optimal compromise between herniation exposure and bone-muscle preservation.
The integration of adequate mastery of traditional approaches together with a greater confidence through unfamiliar surgical corridors can improve the development of combined mini-invasive procedures, which seem promising for future targeted LDH excisions. 1).

Indications

Lumbar discectomy is an effective therapy for neurological decompression in patients suffering from lumbar disc herniation, which can be safely performed via minimal invasive procedures 2) 3).

History

In 1908 the first successful lumbar discectomy was initiated and performed by the German neurologist Heinrich Oppenheim (1858-1919) and the surgeon Fedor Krause (1857-1937); however, neither recognized the true pathological condition of discogenic nerve compression syndrome. With the landmark report in The New England Journal of Medicine in 1934, the two American surgeons William Jason Mixter (1880-1958) and Joseph Seaton Barr (1901-1963) finally clarified the pathomechanism of lumbar disc herniation and furthermore, propagated discectomy as the standard therapy. Since then interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. The surgical procedures changed over time and were continuously being refined.

Microsurgery

The introduction of microsurgical techniques in 1977 and 1978 was introduced for spinal surgery by the work of the famous neurosurgeon Mahmut Gazi Yasargil 4) and Wolfhard Caspar 5) and so-called microdiscectomy was introduced and represented an important evolution in lumbar disc surgery.
see Lumbar microdiscectomy

Chemonucleolysis

Besides open discectomy other interventional techniques were developed to overcome the side effects of surgical procedures.
In 1964 the American orthopedic surgeon Lyman Smith (1912-1991) introduced chemonucleolysis, a minimally invasive technique consisting only of a cannula and the proteolytic enzyme chymopapain, which is injected into the disc compartment to dissolve the displaced disc material.

Percutaneous discectomy

see also percutaneous endoscopic lumbar discectomy.
In 1975 the Japanese orthopedic surgeon Sadahisa Hijikata described percutaneous discectomy for the first time, which was a further minimally invasive surgical technique. Further variants of minimally invasive surgical procedures, such as percutaneous laser discectomy in 1986 and percutaneous endoscopic microdiscectomy in 1997, were also introduced; however, open discectomy, especially microdiscectomy remains the therapeutic gold standard for lumbar disc herniation 6).
Discectomy surgery has evolved from wide open to microscopic and now endoscopic.

Herniotomy

Microsurgery is considered a standard procedure. However, since the herniated fragment was identified as the offending agent, it has always considered necessary to remove fragment only or the entire disc. This dogma is based on the assumption that increased rates of recurrent disc herniations would follow sequestrectomy alone. For the small subgroup of patients with a free fragment compressing the nerve root, Williams was the first to report encouraging results following minimal removal of tissue from the intervertebral disc space 7).
The frequency of herniotomy is gradually increasing in LDH treatment. Herniotomy used to be synonymous with fragmentectomy or sequestrectomy. The term ‘herniotomy’ is defined as removal of the herniated disc fragment only, and the ‘conventional discectomy’ as removal of the herniated disc and degenerative nucleus from the intervertebral disc space.

Minimally invasive discectomy

Minimally invasive discectomy (MID) may be inferior in terms of relief of leg pain, LBP and re-hospitalisation; however, differences in pain relief appeared to be small and may not be clinically important. Potential advantages of MID are lower risk of surgical site and other infections. MID may be associated with shorter hospital stay but the evidence was inconsistent. Given these potential advantages, more research is needed to define appropriate indications for MID as an alternative to standard MD/OD.
In the U.S., it has been estimated that the Medicare system spends over $300 million annually on lumbar discectomies.

Technique


In conjunction with the traditional discectomy, a laminotomy is often involved to permit access to the intervertebral disc. In this procedure, a small piece of bone (the lamina) is removed from the affected vertebra, allowing the surgeon to better see and access the area of disc herniation.

Types

Outcome

More than 10% of these patients report persistent pain after surgery.
Quality of Life (QOL), pain and disability, and psychosocial outcomes improved after primary and revision discectomy, but the improvement diminished after revision discectomy 8).


From 371 abstracts, 85 full-text articles were reviewed, of which 21 studies were included. Visual analogue scales indicated that surgery helped the majority of patients experience significantly less pain. Recovery from disc surgery mainly occurred within the short-term period and later changes of pain intensity were minor. Postsurgical back and leg pain was predominantly associated with depression and disability. Preliminary positive evidence was found for somatization and mental well-being.
Patients scheduled for lumbar disc surgery should be selected carefully and need to be treated in a multimodal setting including psychological support 9).
see Lumbar discectomy in obesity

Reoperation

retrospective study includes 53 patients who underwent reoperation after failure of lumbar disc surgery to relieve pain. All patients had leg painbefore reoperation, which was successful in 28% of cases. Most clinical features, such as persistence or mode of recurrence of pain, radicular quality of pain, positive straight leg raise, and myelographic root sleeve defects, were not helpful in predicting successful and unsuccessful reoperations. However, a significantly larger percentage of women than men had successful reoperations. Patients who had past or pending compensation claims, who had sensory loss involving more than one dermatome, or who failed to have myelographic dural sac indentations resembling those caused by a herniated disc did poorly with reoperation. A very convincing myelographic defect appears to be needed to justify reoperation at a previously unoperated location. Excision of scar alone or dorsal rhizotomy was of no avail in these cases 10).

Rehabilitation

Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed 11).

Case series

2017

Fifty patients who were scheduled for lumbar disc surgery were divided into 2 groups, namely patients who accepted the surgery at the first offer and those who wanted to think over. Educational level information was obtained and patients were asked whether they had searched their disorder and offered surgery on the Internet. Then, a questionnaire was administered and the reliability of the websites was evaluated. Correction: The first 30 websites on the first 3 pages of Google® search engine, the most commonly used search engine in Turkey, were evaluated with the DISCERN® instrument.
Of 50 patients, 33 (66%) had conducted a search for the surgery on the Internet. All university graduates, 88.2% of high school graduates, and 18.7% of primary-secondary school graduates had conducted an Internet search. The quality and reliability of the information was high (4.5 points) for 2 (7.1%) websites, moderate (2.3 points) for 6 websites (21.4%) and poor (1 point) for 20 websites (71.4%) as scored with the DISCERN® instrument. The mean DISCERN® score of was 1.1 for websites of health-related institutions or healthcare news, 2.75 for personal websites of physicians and 2.5 for personal websites of non-physicians. The mean DISCERN® score of all websites was 1.5.
Most of the patients undergoing lumbar disc surgery at our clinic had searched information about the surgical procedure on the Internet. We found that 92.9% of the websites evaluated with the DISCERN® instrument had inadequate information, suggesting low-level reliability 12).

2016

The full set of prospectively gathered Medicare insurance data (2005-2012) was retrospectively reviewed. Patients who underwent primary lumbar discectomy for lumbar disc herniations from 2009 to quarter 3 of 2012 were selected. This cohort (n = 41,655) was then divided into two subgroups: those who were diagnosed with incidental durotomy on the day of surgery (n = 2,052) and those who were not (control population). To select a more effective control population, patients of a similar age, gender, smoking status, diabetes mellitus status, chronic pulmonary disease status, and body-mass-index were chosen at random from the control population to create a control cohort. In-hospital costs, length of stay, and rates of 30-day readmission, 90-day wound complications, and 90-day serious adverse effects were compared.
An incidental durotomy rate of 4.9% was observed. Higher rates of wound infection (2.4 vs 1.3%; OR 1.88; 95% CI: 1.31 – 2.70; p < 0.001), wound dehiscence (0.9 vs 0.4%; OR 2.39; 95% CI: 1.31 – 4.37; p = 0.004), and serious adverse events related to incidental durotomy (0.9 vs 0.2%; OR 4.10; 95% CI: 2.05 – 8.19; p < 0.0001) were observed in incidental durotomy patients. In-hospital costs were increased by over $4,000 in patients with incidental durotomy (p < 0.0001).
Incidental durotomies occur in almost one in every twenty elderly patients treated with primary lumbar discectomy. Given the increased hospital costs and complication rates, this complication must be viewed as anything but benign 13).


127 patients (of 148 total) with data collected 3 months postoperatively. The patients’ average age at the time of surgery was 46 ± 1 years, and 66.9% of patients were working 3 months postoperatively. Statistical analyses demonstrated that the patients more likely to return to work were those of younger age (44.5 years vs 50.5 years, p = 0.008), males (55.3% vs 28.6%, p = 0.005), those with higher preoperative SF-36 physical function scores (44.0 vs 30.3, p = 0.002), those with lower preoperative ODI scores (43.8 vs 52.6, p = 0.01), nonsmokers (83.5% vs 66.7%, p = 0.03), and those who were working preoperatively (91.8% vs 26.2%, p < 0.0001). When controlling for patients who were working preoperatively (105 patients), only age was a statistically significant predictor of postoperative return to work (44.1 years vs 51.1 years, p = 0.049).
In this cohort of lumbar discectomy patients, preoperative working status was the strongest predictor of postoperative working status 3 months after surgery. Younger age was also a predictor. Factors not influencing return to work in the logistic regression analysis included sex, BMI, SF-36 physical function score, ODI score, presence of diabetes, smoking status, and systemic illness. Clinical trial registration no.: 01220921 ( clinicaltrials.gov ) 14).
1)

Lofrese G, Mongardi L, Cultrera F, Trapella G, De Bonis P. Surgical treatment of intraforaminal/extraforaminal lumbar disc herniations: Many approaches for few surgical routes. Acta Neurochir (Wien). 2017 Jul;159(7):1273-1281. doi: 10.1007/s00701-017-3198-9. Epub 2017 May 22. Review. PubMed PMID: 28534073.
2)

Hansson E, Hansson T. The cost-utility of lumbar disc herniation surgery. Eur Spine J. 2007;16(3):329–337.
3)

Yeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am. 2007;38(3):363–372.
4)

Yasargil M. Lumbar Disc Adult Hydrocephalus. Springer; 1977. Microsurgical operation of herniated lumbar disc; p.
5)

Caspar W, Campbell B, Barbier DD, Kretschmmer R, Gotfried Y. The Caspar microsurgical discectomy and comparison with a conventional standard lumbar disc procedure. Neurosurgery. 1991;28:78–86. discussion 86-87.
6)

Gruber P, Böni T. [Sciatica : From stretch rack to microdiscectomy]. Unfallchirurg. 2015 Nov 16. [Epub ahead of print] German. PubMed PMID: 26573291.
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Williams RW. Microlumbar discectomy: a conservative surgical approach to the virgin herniated lumbar disc. Spine (Phila Pa 1976) 1978;3:175–182.
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Lubelski D, Senol N, Silverstein MP, Alvin MD, Benzel EC, Mroz TE, Schlenk R. Quality of life outcomes after revision lumbar discectomy. J Neurosurg Spine. 2015 Feb;22(2):173-8. doi: 10.3171/2014.10.SPINE14359. Epub 2014 Dec 5. PubMed PMID: 25478822.
9)

Dorow M, Löbner M, Stein J, Konnopka A, Meisel HJ, Günther L, Meixensberger J, Stengler K, König HH, Riedel-Heller SG. Risk Factors for Postoperative Pain Intensity in Patients Undergoing Lumbar Disc Surgery: A Systematic Review. PLoS One. 2017 Jan 20;12(1):e0170303. doi: 10.1371/journal.pone.0170303. PubMed PMID: 28107402.
10)

Law JD, Lehman RA, Kirsch WM. Reoperation after lumbar intervertebral disc surgery. J Neurosurg. 1978 Feb;48(2):259-63. PubMed PMID: 146731.
11)

Oosterhuis T, Costa LO, Maher CG, de Vet HC, van Tulder MW, Ostelo RW. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2014 Mar 14;3:CD003007. doi: 10.1002/14651858.CD003007.pub3. Review. PubMed PMID: 24627325.
12)

Atci IB, Yilmaz H, Kocaman U, Samanci MY. An evaluation of internet use by neurosurgery patients prior to lumbar disc surgery and of information available on internet. Clin Neurol Neurosurg. 2017 Apr 25;158:56-59. doi: 10.1016/j.clineuro.2017.04.019. [Epub ahead of print] PubMed PMID: 28460344.
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Puvanesarajah V, Hassanzadeh H. The True Cost of a Dural Tear: Medical and Economic Ramifications of Incidental Durotomy During Lumbar Discectomy in Elderly Medicare Beneficiaries. Spine (Phila Pa 1976). 2016 Aug 31. [Epub ahead of print] PubMed PMID: 27584677.
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Than KD, Curran JN, Resnick DK, Shaffrey CI, Ghogawala Z, Mummaneni PV. How to predict return to work after lumbar discectomy: answers from the NeuroPoint-SD registry. J Neurosurg Spine. 2016 Mar 18:1-6. [Epub ahead of print] PubMed PMID: 26989977.

The effect of renal dysfunction on short-term outcomes after lumbar fusion

Serum creatinine (a blood measurement) is an important indicator of renal health because it is an easily measured byproduct of muscle metabolism that is excreted unchanged by the kidneys. Creatinine itself is produced via a biological system involving creatine, phosphocreatine (also known as creatine phosphate), and adenosine triphosphate (ATP, the body’s immediate energy supply).
If contrast-enhanced computed tomography (CT) or arteriography is planned, it is appropriate to obtain a baseline creatinine concentration.
Patients with low estimated glomerular filtration rate (GFR) and elevated creatinine levels were associated with higher perioperative morbidity 1).

1) Purvis TE, Kessler RA, Boone C, Elder BD, Goodwin CR, Sciubba DM. The effect of renal dysfunction on short-term outcomes after lumbar fusion. Clin Neurol Neurosurg. 2016 Dec 6;153:8-13. doi: 10.1016/j.clineuro.2016.12.002. [Epub ahead of print] PubMed PMID: 27992823.
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