Supplementary stabilization with anterior lumbar intervertebral fusion - A radiologic review

Study designA radiologic assessment of the success of anterior lumbar interbody fusion (ALIF) using thin-section computerized tomography (CT) was performed.ObjectiveTo assess the effect of different types of posterior stabilization on the fusion rate of ALIF.Summary of background dataThin-section CT has shown a higher rate of pseudarthrosis with ALIF than previously reported with standard radiologic methods. Cadaveric studies have shown that posterior stabilization would increase stiffness of the motion segment and is likely to enhance the rate of fusion with ALIF. To our knowledge, the results of thin-section CT of ALIF, with and without posterior stabilization, has not been reported previously.MethodsPatients with discogenic back pain confirmed by diskography underwent ALIF surgery, either as a stand-alone procedure or with posterior stabilization, using translaminar, unilateral pedicle, or bilateral pedicle screws. The 4 cohorts were followed up prospectively, and thin-section CT was used to assess interbody fusion.ResultsThe fusion rate for stand-alone ALIF was 51%, for patients with supplementary stabilization with translaminar screws 58%, with unilateral pedicle screws 89%, and with bilateral pedicle screws 88%. A significant difference in the fusion rate was found when ALIF was combined with pedicle screw stabilization (P ConclusionThe addition of pedicle screw fixation at ALIF produces a significant increase in the rate of interbody fusion.Anjarwalla, Naffis K; Morcom, Russel K; Fraser, Robert

Improving consultations for persistent musculoskeletal low back pain in orthopaedic spine settings: an intervention development

Background There is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking. Aim To develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial. Method The intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention. Results In total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians’ communication skills, during the consultation, in reference to listening skills, validation of patients’ pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients’ clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management. Conclusion The intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients’ perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians

Should smoking habit dictate the fusion technique?

The aim of this study was to evaluate the influence of smoking on the outcome of patients undergoing surgery for degenerative spinal diseases, and to examine whether smoking had a differential impact on outcome, depending on the fusion technique used. The cohort included 120 patients treated with two different fusion techniques (translaminar screw fixation and TLIF). They were categorised with regard to their smoking habits at the time of surgery and completed the Core Outcome Measures Index at baseline and follow-up (FU) (3, 12 and 24 months FU); at FU they also rated the global outcome of surgery. The distribution of smokers was comparable in the two groups. For the TS group, the greater the number of cigarettes smoked, the less the reduction in pain intensity from pre-op to 24 months FU; the relationship was not significant for the TLIF group. The percentage of good global outcomes declined with time in the TS smokers such that by 24 months FU, there was a significant difference between TS smokers and TS-non-smokers. No such difference between smokers and non-smokers was evident in the TLIF group at any FU time. In conclusion, the TS technique was more vulnerable to the effects of smoking than was TLIF: possibly the more extensive stabilisation of the 360° fusion renders the environment less susceptible to the detrimental effects on bony fusion of cigarette smoking

The outcome of spinal decompression surgery 5 years on

Decompression surgery is an increasingly common operation for the treatment of lumbar spinal stenosis. Although good relief from leg pain is expected after surgery, long term results of pain relief and function are more uncertain. This study prospectively followed a cohort of patients presenting with the signs and symptoms of spinal stenosis, who underwent decompression surgery to ascertain the long term outcome with respect to pain and function using visual analogue pain scores, the Oswestry Disability Index, and the Short Form 36, a general health questionnaire. From an initial pool of 84 recruited patients, 7 withdrew from surgical intervention; of the remaining 77, 51 (66%) returned for follow up assessments at 5 years. In these responders, a significant improvement was observed in back and leg pain, which was sustained for at least 1 year (P < 0.01). A significant improvement was also seen in physical function (P < 0.05) as assessed by Oswestry and SF-36. Although an initial improvement was noted in social function, this was not observed at 5 years. This study has demonstrated that decompression surgery is successful in relieving symptoms of lumbar spinal stenosis. Physical function, back and leg pain are significantly improved after 5 years but initial significant improvements in social function diminish over time