Characterizing the Risk and Outcome Profiles of Lumbar Fusion Procedures in Patients With Opioid Use Disorders: A Step Towards Improving Enhanced Recovery Protocols for a Unique Patient Population

Abstract INTRODUCTION This national-level study sought to provide a necessary assessment of the risks and outcomes for different lumbar fusion procedures in patients with opioid use disorders (OUDs) to help guide the future development of targeted enhanced recovery after surgery (ERAS) protocols for this unique population. METHODS Data for patients with or without OUDs who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lateral transverse lumbar interbody fusion (LLIF) for lumbar disc degeneration (LDD) were collected from the 2013 to 2014 National Inpatient Sample. Multivariable logistic regression was implemented to analyze how OUD impacted in-hospital complications, length of hospitalization, discharge disposition, and total charges by procedure type. RESULTS A total of 139 995 patients with LDD were identified, with 1280 patients (0.91%) also having a concurrent OUD diagnosis. Overall complication rates were higher in OUD patients (48.44% vs 31.01%; P < .0001). OUD patients had higher odds of pulmonary (P = .0006), infectious (P < .0001), and hematological complications (P = .0009). Multivariate regression modeling of outcomes by procedure type showed that following ALIF, OUD increased odds of nonhome discharge (P = .0007), extended hospitalization (P = .0002), and greater total charges (P = .0054). This analysis also revealed that OUD increased odds of complication (P = .0149 and P = .0471), extended hospitalization (P = .0439 and P = .0001), and higher total charges (P < .0001) following PLIF and LLIF procedures, respectively. CONCLUSION Obtaining a better understanding of the risks and outcomes that OUD patients face perioperatively is a necessary step towards developing more effective ERAS protocols for this vulnerable population. This study, which sought to characterize outcome profiles for lumbar fusion procedures in OUD patients on a national level, found this population experienced increased odds of complication, extended hospitalization, nonhome discharge, and higher total charges. Results from this study warrant future prospective studies to better understand these associations and further the development of ERAS programs to improve patient care and reduce cost burden.

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Characterizing the risk and outcome profiles of lumbar fusion procedures in patients with opioid use disorders: a step toward improving enhanced recovery protocols for a unique patient population

Neurosurgical FOCUS ◽

10.3171/2019.1.focus18652 ◽

2019 ◽

Vol 46 (4) ◽

pp. E12 ◽

Cited By ~ 8

Author(s):

Michael L. Martini ◽

Dominic A. Nistal ◽

Brian C. Deutsch ◽

John M. Caridi

Keyword(s):

Interbody Fusion ◽

Enhanced Recovery ◽

Lumbar Fusion ◽

National Level ◽

Complication Rates ◽

Lumbar Interbody Fusion ◽

Opioid Use ◽

Opioid Use Disorders ◽

Procedure Type ◽

Total Charges

OBJECTIVEThe authors set out to conduct the first national-level study assessing the risks and outcomes for different lumbar fusion procedures in patients with opioid use disorders (OUDs) to help guide the future development of targeted enhanced recovery after surgery (ERAS) protocols for this unique population.METHODSData for patients with or without OUDs who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lateral transverse lumbar interbody fusion (LLIF) for lumbar disc degeneration (LDD) were collected from the 2013–2014 National (Nationwide) Inpatient Sample database. Multivariable logistic regression was implemented to analyze how OUD status impacted in-hospital complications, length of hospital stay, discharge disposition, and total charges by procedure type.RESULTSA total of 139,995 patients with LDD were identified, with 1280 patients (0.91%) also having a concurrent OUD diagnosis. Overall complication rates were higher in OUD patients (48.44% vs 31.01%, p < 0.0001). OUD patients had higher odds of pulmonary (p = 0.0006), infectious (p < 0.0001), and hematological (p = 0.0009) complications. Multivariate regression modeling of outcomes by procedure type showed that after ALIF, OUD patients had higher odds of nonhome discharge (p = 0.0007), extended hospitalization (p = 0.0002), and greater total charges (p = 0.0054). This analysis also revealed that OUD patients faced higher odds of complication (p = 0.0149 and p = 0.0471), extended hospitalization (p = 0.0439 and p = 0.0001), and higher total charges (p < 0.0001 and p < 0.0001) after PLIF and LLIF procedures, respectively.CONCLUSIONSObtaining a better understanding of the risks and outcomes that OUD patients face perioperatively is a necessary step toward developing more effective ERAS protocols for this vulnerable population. This study, which sought to characterize the outcome profiles for lumbar fusion procedures in OUD patients on a national level, found that this population tended to experience increased odds of complications, extended hospitalization, nonhome discharge, and higher total costs. Results from this study warrant future prospective studies to better the understanding of these associations and to further the development of better ERAS programs that may improve patient care and reduce cost burden.

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Lateral lumbar interbody fusion in revision surgery for restenosis after posterior decompression

Neurosurgical FOCUS ◽

10.3171/2020.6.focus20361 ◽

2020 ◽

Vol 49 (3) ◽

pp. E11 ◽

Cited By ~ 1

Author(s):

Yoshifumi Kudo ◽

Ichiro Okano ◽

Tomoaki Toyone ◽

Akira Matsuoka ◽

Hiroshi Maruyama ◽

...

Keyword(s):

Revision Surgery ◽

Spinal Canal ◽

Interbody Fusion ◽

Decompression Surgery ◽

Complication Rates ◽

Lumbar Interbody Fusion ◽

Posterior Decompression ◽

Lateral Lumbar Interbody Fusion ◽

Significant Difference ◽

Dural Tears

OBJECTIVEThe purpose of this study was to compare the clinical results of revision interbody fusion surgery between lateral lumbar interbody fusion (LLIF) and posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) with propensity score (PS) adjustments and to investigate the efficacy of indirect decompression with LLIF in previously decompressed segments on the basis of radiological assessment.METHODSA retrospective study of patients who underwent revision surgery for recurrence of neurological symptoms after posterior decompression surgery was performed. Postoperative complications and operative factors were evaluated and compared between LLIF and PLIF/TLIF. Moreover, postoperative improvement in cross-sectional areas (CSAs) in the spinal canal and intervertebral foramen was evaluated in LLIF cases.RESULTSA total of 56 patients (21 and 35 cases of LLIF and PLIF/TLIF, respectively) were included. In the univariate analysis, the LLIF group had significantly more endplate injuries (p = 0.03) and neurological deficits (p = 0.042), whereas the PLIF/TLIF group demonstrated significantly more dural tears (p < 0.001), surgical site infections (SSIs) (p = 0.02), and estimated blood loss (EBL) (p < 0.001). After PS adjustments, the LLIF group still showed significantly more endplate injuries (p = 0.03), and the PLIF/TLIF group demonstrated significantly more dural tears (p < 0.001), EBL (p < 0.001), and operating time (p = 0.04). The PLIF/TLIF group showed a trend toward a higher incidence of SSI (p = 0.10). There was no statistically significant difference regarding improvement in the Japanese Orthopaedic Association scores between the 2 surgical procedures (p = 0.77). The CSAs in the spinal canal and foramen were both significantly improved (p < 0.001).CONCLUSIONSLLIF is a safe, effective, and less invasive procedure with acceptable complication rates for revision surgery for previously decompressed segments. Therefore, LLIF can be an alternative to PLIF/TLIF for restenosis after posterior decompression surgery.

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Best versus worst surgical outcomes after single-level posterior lumbar interbody fusion for degenerative spondylolisthesis

Journal of Orthopaedic Surgery ◽

10.1177/2309499020983038 ◽

2021 ◽

Vol 29 (1) ◽

pp. 230949902098303

Author(s):

Se-Jun Park ◽

Keun-Ho Lee ◽

Chong-Suh Lee ◽

Ki-Tack Kim ◽

Dong Hyeon Kim ◽

...

Keyword(s):

Clinical Outcome ◽

Interbody Fusion ◽

Lumbar Fusion ◽

Degenerative Spondylolisthesis ◽

Individual Treatment ◽

Symptom Duration ◽

Lumbar Interbody Fusion ◽

Characteristic Analysis ◽

Single Level ◽

Patient Reported

Purpose: Previous studies have shown conflicting results regarding the factors affecting the clinical outcome after fusion for degenerative spondylolisthesis. However, no study has compared the best and worst clinical outcome groups using patient-reported outcome measures. We aimed to compare the characteristics of patients with best and worst outcomes following single-level lumbar fusion for degenerative spondylolisthesis. Methods: 200 patients underwent single-level interbody fusion with a minimum 2-years follow-up were included. We excluded patients with surgical complications already-known to be associated with poor postoperative outcomes, including pseudoarthrosis and postoperative infection. According to 2-year postoperative Oswestry disability index scores, patients were divided into two groups; Best and Worst. Demographic, clinical and radiographic variables were compared between the two groups. Results: Compared with patients in the Best group, those in the Worst group were older (59.5 and 67.0 years, respectively; p = 0.012; odds ratio [OR], 1.143; 95% confidence interval [CI], 1.030–1.269) and had a longer duration of pain from onset (2.6 and 7.2 years, respectively; p = 0.041; OR, 1.021; 95% CI, 1.001–1.041). The cutoff value of pain duration from onset was measured as ≥3.5 years on Receiver operating characteristic analysis. Patients in the Worst group had a lower preoperative angular motion compared to those in the Best group (12.7° and 8.3°, respectively; p = 0.016; OR, 0.816; 95% CI, 0.691–0.963). Conclusions: Degenerative spondylolisthesis patients of good clinical outcome after single-level lumbar interbody fusion were relatively young, had a short symptom duration before surgery, and a high preoperative instability compared with the patient having poor postoperative clinical outcome. Therefore, these findings should be considered preoperatively when deciding the appropriate individual treatment plan.

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Retroperitoneal lateral lumbar interbody fusion with titanium threaded fusion cages

Journal of Neurosurgery Spine ◽

10.3171/spi.2002.96.1.0050 ◽

2002 ◽

Vol 96 (1) ◽

pp. 50-55 ◽

Cited By ~ 4

Author(s):

Christopher E. Wolfla ◽

Dennis J. Maiman ◽

Frank J. Coufal ◽

James R. Wallace

Keyword(s):

Interbody Fusion ◽

Lumbar Fusion ◽

Fusion Rate ◽

Lumbar Interbody Fusion ◽

Anterior Longitudinal Ligament ◽

Content Type ◽

Single Cage ◽

Novel Technique ◽

Methodological Problems ◽

Fine Print

Object. Intertransverse arthrodesis in which instrumentation is placed is associated with an excellent fusion rate; however, treatment of patients with symptomatic nonunion presents a number of difficulties. Revision posterior and traditional anterior procedures are associated with methodological problems. For example, in the latter, manipulation of the major vessels from L-2 to L-4 may be undesirable. The authors describe a method for performing retroperitoneal lumbar interbody fusion (LIF) in which a threaded cage is placed from L-2 through L-5 via a lateral trajectory, and they also detail a novel technique for implanting a cage from L-5 to S-1 via an oblique trajectory. Although they present data obtained over a 2-year period in the study of 15 patients, the focus of this report is primarily on describing the surgical procedure. Methods. The lateral lumbar spine was exposed via a standard retroperitoneal approach. Using the anterior longitudinal ligament as a landmark, the L2–3 through L4–5 levels were fitted with instrumentation via a true lateral trajectory; the L5—S1 level was fitted with instrumentation via an oblique trajectory. A single cage was placed at each instrumented level. Fifteen symptomatic patients in whom previous lumbar fusion had failed underwent retroperitoneal LIF. Thirty-eight levels were fitted with instrumentation. There have been no instrumentation-related failures, and fusion has occurred at 37 levels during the 2-year postoperative period. Conclusions. The use of retroperitoneal LIF in which threaded fusion cages are used avoids the technical difficulties associated with repeated posterior procedures. In addition, it allows L2—S1 instrumentation to be placed anteriorly via a single surgical approach. This construct has been shown to be biomechanically sound in animal models, and it appears to be a useful alternative for the management of failed multilevel intertransverse arthrodesis.

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Adjacent-segment effects of lumbar cortical screw–rod fixation versus pedicle screw–rod fixation with and without interbody support

Journal of Neurosurgery Spine ◽

10.3171/2020.11.spine20977 ◽

2021 ◽

pp. 1-7

Author(s):

Piyanat Wangsawatwong ◽

Anna G. U. Sawa ◽

Bernardo de Andrada Pereira ◽

Jennifer N. Lehrman ◽

Luke K. O’Neill ◽

...

Keyword(s):

Pedicle Screw ◽

Interbody Fusion ◽

Lumbar Fusion ◽

Statistical Significance ◽

Adjacent Segment ◽

Lumbar Interbody Fusion ◽

Lateral Bending ◽

Single Level ◽

Cortical Screw ◽

Flexion Extension

OBJECTIVE Cortical screw–rod (CSR) fixation has emerged as an alternative to the traditional pedicle screw–rod (PSR) fixation for posterior lumbar fixation. Previous studies have concluded that CSR provides the same stability in cadaveric specimens as PSR and is comparable in clinical outcomes. However, recent clinical studies reported a lower incidence of radiographic and symptomatic adjacent-segment degeneration with CSR. No biomechanical study to date has focused on how the adjacent-segment mobility of these two constructs compares. This study aimed to investigate adjacent-segment mobility of CSR and PSR fixation, with and without interbody support (lateral lumbar interbody fusion [LLIF] or transforaminal lumbar interbody fusion [TLIF]). METHODS A retroactive analysis was done using normalized range of motion (ROM) data at levels adjacent to single-level (L3–4) bilateral screw–rod fixation using pedicle or cortical screws, with and without LLIF or TLIF. Intact and instrumented specimens (n = 28, all L2–5) were tested using pure moment loads (7.5 Nm) in flexion, extension, lateral bending, and axial rotation. Adjacent-segment ROM data were normalized to intact ROM data. Statistical comparisons of adjacent-segment normalized ROM between two of the groups (PSR followed by PSR+TLIF [n = 7] and CSR followed by CSR+TLIF [n = 7]) were performed using 2-way ANOVA with replication. Statistical comparisons among four of the groups (PSR+TLIF [n = 7], PSR+LLIF [n = 7], CSR+TLIF [n = 7], and CSR+LLIF [n = 7]) were made using 2-way ANOVA without replication. Statistical significance was set at p < 0.05. RESULTS Proximal adjacent-segment normalized ROM was significantly larger with PSR than CSR during flexion-extension regardless of TLIF (p = 0.02), or with either TLIF or LLIF (p = 0.04). During lateral bending with TLIF, the distal adjacent-segment normalized ROM was significantly larger with PSR than CSR (p < 0.001). Moreover, regardless of the types of screw-rod fixations (CSR or PSR), TLIF had a significantly larger normalized ROM than LLIF in all directions at both proximal and distal adjacent segments (p ≤ 0.04). CONCLUSIONS The use of PSR versus CSR during single-level lumbar fusion can significantly affect mobility at the adjacent segment, regardless of the presence of TLIF or with either TLIF or LLIF. Moreover, the type of interbody support also had a significant effect on adjacent-segment mobility.

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A comparative study of functional outcome between posterior lumbar fusion and posterior lumbar interbody fusion in spondylolisthesis

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20211608 ◽

2021 ◽

Vol 7 (3) ◽

pp. 544

Author(s):

Harpreet Singh ◽

Dhruv Patel ◽

Sangam Tyagi ◽

Krushna Saoji ◽

Tilak Patel ◽

...

Keyword(s):

Functional Outcome ◽

Interbody Fusion ◽

Operative Time ◽

Lumbar Fusion ◽

Tertiary Care ◽

Posterior Lumbar Interbody Fusion ◽

Invasive Technique ◽

Lumbar Interbody Fusion ◽

Tertiary Care Centre ◽

Posterior Lumbar Fusion

Background: Spondylolisthesis is condition in which one vertebra slips over other vertebra. This study has been done to compare the functional outcome and complications of two techniques: posterior lumbar fusion (intertransverse fusion) and posterior lumbar interbody fusion.Methods: Total 20 patients with spondylolisthesis admitted in a tertiary care centre in Rajasthan were allotted alternatively in posterior lumbar fusion (PLF) group and posterior lumbar interbody fusion (PLIF) group. In PLF, fusion was done by placing bone graft between transverse processes and around facets. In PLIF, fusion was bone by placing cage in between vertebral bodies.Results: 20 patients were included in our study with female predominance (65%). Mean age was 54.2 years (PLF=58.4 and PLIF=50.2). 70% patients have L4-L5 level spondylolisthesis. Average operative time was less in PLF group, which is statistically significant. Functional outcome was measured by using visual analogue scale (VAS) score and Japanese orthopedics association score (JOAS) at 3 weeks, 3 months and 6 months. There is a significant decrease between preoperative VAS and at 6 months, in both PLF and PLIF group. JOAS was significantly increased at 6 months in both PLF and PLIF group as compared to preoperative score. But difference in JOAS at 6 months is not significant between PLF and PLIF.Conclusions: Both PLF and PLIF are equally effective for spondylolisthesis. Both techniques have same satisfactory results. As PLIF is more invasive technique, more operative time and more complications are seen.

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Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion

Neurosurgical FOCUS ◽

10.3171/2013.5.focus13157 ◽

2013 ◽

Vol 35 (2) ◽

pp. E7 ◽

Cited By ~ 37

Author(s):

Pedro S. Silva ◽

Paulo Pereira ◽

Pedro Monteiro ◽

Pedro A. Silva ◽

Rui Vaz

Keyword(s):

Minimally Invasive ◽

Learning Curve ◽

Interbody Fusion ◽

Operative Time ◽

Pedicle Screws ◽

Transforaminal Lumbar Interbody Fusion ◽

Complication Rates ◽

Lumbar Interbody Fusion ◽

Adjacent Level ◽

Negative Exponential

Object Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has the potential advantage of minimizing soft-tissue damage and reducing recovery time compared to open procedures. A steep learning curve has been described for the technique. The aim of the present study was to define the learning curve that describes the progress of a single surgeon performing the MI-TLIF. Methods One hundred fifty consecutive patients with degenerative lumbar disease who underwent 1- or 2-level MI-TLIF were included in the study. Operative time, corrected operative time per level, and complications were analyzed. The learning curve was assessed using a negative exponential curve-fit regression analysis. Results One hundred ten patients underwent 1-level and 18 patients underwent 2-level MI-TLIF; the remaining 22 underwent a single-level procedure plus an ancillary procedure (decompression at adjacent level, vertebral augmentation through fenestrated pedicle screws, interspinous device at adjacent level). Negative exponential curves appropriately described the relationship between operative time and experience for 1-level surgery and after correction of operative time per level (R2 = 0.65 and 0.57). The median operative time was 140 minutes (interquartile range 120–173 minutes), and a 50% learning milestone was achieved at Case 12; a 90% learning milestone was achieved at Case 39. No patient required transfusion in the perioperative period. The overall complication rate was 12.67% and the most frequent complication was a dural tear (5.32%). Before the 50% and 90% learning milestones, the complication rates were 33% and 20.51%, respectively. Conclusions The MI-TLIF is a reliable and effective option for lumbar arthrodesis. According to the present study, 90% of the learning curve can be achieved at around the 40th case.

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