Publications by authors named "Christopher S Bailey"

75 Publications

Time to return to work after elective lumbar spine surgery.

J Neurosurg Spine 2021 Sep 24:1-9. Epub 2021 Sep 24.

1Combined Neurosurgical and Orthopedic Spine Service, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia.

Objective: Time to return to work (RTW) after elective lumbar spine surgery is variable and dependent on many factors including patient, work-related, and surgical factors. The primary objective of this study was to describe the time and rate of RTW after elective lumbar spine surgery. Secondary objectives were to determine predictors of early RTW (< 90 days) and no RTW in this population.

Methods: A retrospective analysis of prospectively collected data from the multicenter Canadian Spine Outcomes and Research Network (CSORN) surgical registry was performed to identify patients who were employed and underwent elective 1- or 2-level discectomy, laminectomy, and/or fusion procedures between January 2015 and December 2019. The percentage of patients who returned to work and the time to RTW postoperatively were calculated. Predictors of early RTW and not returning to work were determined using a multivariable Cox regression model and a multivariable logistic regression model, respectively.

Results: Of the 1805 employed patients included in this analysis, 71% returned to work at a median of 61 days. The median RTW after a discectomy, laminectomy, or fusion procedure was 51, 46, and 90 days, respectively. Predictors of early RTW included male gender, higher education level (high school or above), higher preoperative Physical Component Summary score, working preoperatively, a nonfusion procedure, and surgery in a western Canadian province (p < 0.05). Patients who were working preoperatively were twice as likely to RTW within 90 days (HR 1.984, 95% CI 1.680-2.344, p < 0.001) than those who were employed but not working. Predictors of not returning to work included symptoms lasting more than 2 years, an increased number of comorbidities, an education level below high school, and an active workers' compensation claim (p < 0.05). There were fourfold odds of not returning to work for patients who had not been working preoperatively (OR 4.076, 95% CI 3.087-5.383, p < 0.001).

Conclusions: In the Canadian population, 71% of a preoperatively employed segment returned to work after 1- or 2-level lumbar spine surgery. Most patients who undergo a nonfusion procedure RTW after 6 to 8 weeks, whereas patients undergoing a fusion procedure RTW at 12 weeks. Working preoperatively significantly increased the likelihood of early RTW.
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http://dx.doi.org/10.3171/2021.2.SPINE202051DOI Listing
September 2021

Minimally Invasive vs. Open Surgery for Lumbar Spinal Stenosis in Patients with Diabetes - A Canadian Spine Outcomes and Research Network Study.

Global Spine J 2021 Aug 31:21925682211042576. Epub 2021 Aug 31.

Canada East Spine Centre, Saint John, NB, Canada.

Study Design: Retrospective cohort.

Objectives: To compare outcomes of minimally invasive surgery (MIS) vs open surgery (OPEN) for lumbar spinal stenosis (LSS) in patients with diabetes.

Methods: Patients with diabetes who underwent spinal decompression alone or with fusion for LSS within the Canadian Spine Outcomes and Research Network (CSORN) database were included. MIS vs OPEN outcomes were compared for 2 cohorts: (1) patients with diabetes who underwent decompression alone (N = 116; MIS n = 58 and OPEN n = 58), (2) patients with diabetes who underwent decompression with fusion (N = 108; MIS n = 54 and OPEN n = 54). Modified Oswestry Disability Index (mODI) and back and leg pain were compared at baseline, 6-18 weeks, and 1-year post-operation. The number of patients meeting minimum clinically important difference (MCID) or minimum pain/disability at 1-year was compared.

Results: MIS approaches had less blood loss (decompression alone difference 100 mL, = .002; with fusion difference 244 mL, < .001) and shorter length of stay (LOS) (decompression alone difference 1.2 days, = .008; with fusion difference 1.2 days, = .026). MIS compared to OPEN decompression with fusion had less patients experiencing adverse events (AEs) (difference 13 patients, = .007). The MIS decompression with fusion group had lower 1-year mODI (difference 14.5, 95% CI [7.5, 21.0], < .001) and back pain (difference 1.6, 95% CI [.6, 2.7], = .002) compared to OPEN. More patients in the MIS decompression with fusion group exceeded MCID at 1-year for mODI (MIS 75.9% vs OPEN 53.7%, = .028) and back pain (MIS 85.2% vs OPEN 70.4%, = .017).

Conclusions: MIS approaches were associated with more favorable outcomes for patients with diabetes undergoing decompression with fusion for LSS.
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http://dx.doi.org/10.1177/21925682211042576DOI Listing
August 2021

Low-back pain after lumbar discectomy for disc herniation: what can you tell your patient?

J Neurosurg Spine 2021 Aug 27:1-7. Epub 2021 Aug 27.

2Division of Spine Surgery, Vancouver General Hospital and the University of British Columbia, Vancouver, British Columbia.

Objective: Lumbar discectomy (LD) is frequently performed to alleviate radicular pain resulting from disc herniation. While this goal is achieved in most patients, improvement in low-back pain (LBP) has been reported inconsistently. The goal of this study was to characterize how LBP evolves following discectomy.

Methods: The authors performed a retrospective analysis of prospectively collected patient data from the Canadian Spine Outcomes and Research Network (CSORN) registry. Patients who underwent surgery for lumbar disc herniation were eligible for inclusion. The primary outcome was a clinically significant reduction in the back pain numerical rating scale (BPNRS) assessed at 12 months. Binary logistic regression was used to model the relationship between the primary outcome and potential predictors.

Results: There were 557 patients included in the analysis. The chief complaint was radiculopathy in 85%; 55% of patients underwent a minimally invasive procedure. BPNRS improved at 3 months by 48% and this improvement was sustained at all follow-ups. LBP and leg pain improvement were correlated. Clinically significant improvement in BPNRS at 12 months was reported by 64% of patients. Six factors predicted a lack of LBP improvement: female sex, low education level, marriage, not working, low expectations with regard to LBP improvement, and a low BPNRS preoperatively.

Conclusions: Clinically significant improvement in LBP is observed in the majority of patients after LD. These data should be used to better counsel patients and provide accurate expectations about back pain improvement.
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http://dx.doi.org/10.3171/2021.2.SPINE201625DOI Listing
August 2021

National adverse event profile after lumbar spine surgery for lumbar degenerative disorders and comparison of complication rates between hospitals: a CSORN registry study.

J Neurosurg Spine 2021 Aug 20:1-6. Epub 2021 Aug 20.

1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia.

Objective: Previous works investigating rates of adverse events (AEs) in spine surgery have been retrospective, with data collection from administrative databases, and often from single centers. To date, there have been no prospective reports capturing AEs in spine surgery on a national level, with comparison among centers.

Methods: The Spine Adverse Events Severity system was used to define the incidence and severity of AEs after spine surgery by using data from the Canadian Spine Outcomes and Research Network (CSORN) prospective registry. Patient data were collected prospectively and during hospital admission for those undergoing elective spine surgery for degenerative conditions. The Spine Adverse Events Severity system defined minor and major AEs as grades 1-2 and 3-6, respectively.

Results: There were 3533 patients enrolled in this cohort. There were 85 (2.4%) individual patients with at least one major AE and 680 (19.2%) individual patients with at least one minor AE. There were 25 individual patients with 28 major intraoperative AEs and 260 patients with 275 minor intraoperative AEs. Postoperatively there were 61 patients with a total of 80 major AEs. Of the 487 patients with minor AEs postoperatively there were 698 total AEs. The average enrollment was 321 patients (range 47-1237 patients) per site. The rate of major AEs was consistent among sites (mean 2.9% ± 2.4%, range 0%-9.1%). However, the rate of minor AEs varied widely among sites-from 7.9% to 42.5%, with a mean of 18.8% ± 9.7%. The rate of minor AEs varied depending on how they were reported, with surgeon reporting associated with the lowest rates (p < 0.01).

Conclusions: The rate of major AEs after lumbar spine surgery is consistent among different sites but the rate of minor AEs appears to vary substantially. The method by which AEs are reported impacts the rate of minor AEs. These data have implications for the detection and reporting of AEs and the design of strategies aimed at mitigating complications.
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http://dx.doi.org/10.3171/2021.2.SPINE202150DOI Listing
August 2021

Effectiveness of Surgical Decompression in Patients With Degenerative Cervical Myelopathy: Results of the Canadian Prospective Multicenter Study.

Neurosurgery 2021 Aug 12. Epub 2021 Aug 12.

Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, Canada.

Background: Conflicting evidence exists regarding the effectiveness of surgery for degenerative cervical myelopathy (DCM), particularly in mild DCM.

Objective: To prospectively evaluate the impact of surgery on patient-reported outcomes in patients with mild (modified Japanese Orthopaedic Association [mJOA] ≥ 15), moderate (mJOA 12-14), and severe (mJOA < 12) DCM.

Methods: Prospective, multicenter cohort study of patients with DCM who underwent surgery between 2015 and 2019 and completed 1-yr follow-up. Outcome measures (mJOA, Neck Disability Index [NDI], EuroQol-5D [EQ-5D], Short Form [SF-12] Physical Component Score [PCS]/Mental Component Score [MCS], numeric rating scale [NRS] neck, and arm pain) were assessed at 3 and 12 mo postoperatively and compared to baseline, stratified by DCM severity. Changes in outcome measures that were statistically significant (P < .05) and met their respective minimum clinically important differences (MCIDs) were deemed clinically meaningful. Responder analysis was performed to compare the proportion of patients between DCM severity groups who met the MCID for each outcome measure.

Results: The cohort comprised 391 patients: 110 mild, 163 moderate, and 118 severe. At 12 mo after surgery, severe DCM patients experienced significant improvements in all outcome measures; moderate DCM patients improved in mJOA, NDI, EQ-5D, and PCS; mild DCM patients improved in EQ-5D and PCS. There was no significant difference between severity groups in the proportion of patients reaching MCID at 12 mo after surgery for any outcome measure, except NDI.

Conclusion: At 12 mo after surgery, patients with mild, moderate, and severe DCM all demonstrated improved outcomes. Severe DCM patients experienced the greatest breadth of improvement, but the proportion of patients in each severity group achieving clinically meaningful changes did not differ significantly across most outcome measures.
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http://dx.doi.org/10.1093/neuros/nyab295DOI Listing
August 2021

Variation in surgical treatment of degenerative spondylolisthesis in Canada: surgeon assessment of stability and impact on treatment.

Eur Spine J 2021 Jul 29. Epub 2021 Jul 29.

University of Toronto Faculty of Medicine, Toronto, ON, Canada.

Introduction: Controversy exists regarding the optimal surgical treatment of degenerative lumbar spondylolisthesis (DS). Not all DS patients are the same, and the degree to which inherent stability may dictate treatment is unknown. The purpose of this study was to determine the variability in surgical approach relative to surgeon classified stability. The secondary objective was to compare patient-reported outcomes (PROs) across different surgical techniques and grades of stability.

Methods: Patients prospectively enrolled from eleven tertiary care institutions and followed from 2015 to 2019. The surgical technique was at the surgeon's discretion. Surgeons were asked to grade the degree of instability based on the degenerative spondylolisthesis instability classification system (DSIC). DSIC categorizes three different types (I-stable, II-potentially unstable, and III-unstable). One-year changes in PROs were compared between each group. Multivariable regression was used to identify any characteristics that explained variability in treatment.

Results: There were 323 patients enrolled in this study. Surgeons' stability classification versus procedure [decompression alone (D)/decompression and posterolateral fusion (D-PL)/and decompression with posterior/transforaminal lumbar interbody fusion (D-PLIF/TLIF)] were as follows: type I (n = 91): D-41%/D-PL-13%/D-PLIF/TLIF-46%; type II (n = 175): D-23%/D-PL-17%/D-PLIF/TLIF-60%; and type III (n = 57):(D-0%/D-PL-14%/D-PLIF/TLIF-86%). Type I patients undergoing D-PL had some improvements in EQ-5D and NRS versus those undergoing D-PLIF/TLIF but otherwise there were no other significant differences between groups. Regression analysis demonstrated advanced age (OR = 1.06, CI 1.02-10.12) and type I (OR = 2.61, CI 1.17-5.81) were associated with receiving decompression surgery alone.

Conclusions: There exists considerable variation in surgical management of DS in Canada. Given similar PROs in two of the three groups, there is potential to tailor surgical intervention and improve resource utilization.
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http://dx.doi.org/10.1007/s00586-021-06928-8DOI Listing
July 2021

Minimally Invasive Tubular Lumbar Discectomy Versus Conventional Open Lumbar Discectomy: An Observational Study From the Canadian Spine Outcomes and Research Network.

Global Spine J 2021 Jul 9:21925682211029863. Epub 2021 Jul 9.

University of Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada.

Study Design: Retrospective cohort study.

Objective: We evaluated the effectiveness of minimally invasive (MIS) tubular discectomy in comparison to conventional open surgery among patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN).

Methods: We performed an observational analysis of data that was prospectively collected. We implemented Minimum Clinically Important Differences (MCIDs), and we adjusted for potential confounders with multiple logistic regression. Adverse events were collected according to the Spinal Adverse Events Severity (SAVES) protocol.

Results: Three hundred thirty-nine (62%) patients underwent MIS tubular discectomy and 211 (38%) underwent conventional open discectomy. There were no significant differences between groups for improvement of leg pain and disability, but the MIS technique was associated with reduced odds of achieving the MCID for back pain (OR 0.66, 95% CI 0.44 to 0.99, < 0.05). We identified statistically significant differences in favor of MIS for each of operating time (MIS mean (SD) 72.2 minutes (30.0) vs open 93.5 (40.9)), estimated blood loss (MIS 37.9 mL (36.7) vs open 76.8 (71.4)), length of stay in hospital (MIS 73% same-day discharge vs open 40%), rates of incidental durotomy (MIS 4% vs open 8%), and wound-related complications (MIS 3% vs open 9%); but not for overall rates of reoperation.

Conclusions: Open and MIS techniques yielded similar improvements of leg pain and disability at up to 12 months of follow-up, but MIS patients were less likely to experience improvement of associated back pain. Small differences favored MIS for operating time, blood loss, and adverse events but may have limited clinical importance.
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http://dx.doi.org/10.1177/21925682211029863DOI Listing
July 2021

Factors associated with using an interbody fusion device for low-grade lumbar degenerative versus isthmic spondylolisthesis: a retrospective cohort study.

J Neurosurg Spine 2021 Jul 2:1-9. Epub 2021 Jul 2.

1Division of Orthopaedics, Department of Surgery, Western University/London Health Sciences Centre, London, Ontario.

Objective: Many studies have utilized a combined cohort of patients with degenerative spondylolisthesis (DS) and isthmic spondylolisthesis (IS) to evaluate indications and outcomes. Intuitively, these are very different populations, and rates, indications, and outcomes may differ. The goal of this study was to compare specific patient characteristics associated with the utilization of a posterior lumbar interbody device between cohorts of patients with DS and IS, as well as to compare rates of interbody device use and patient-rated outcomes at 1 year after surgical treatment.

Methods: The authors included patients who underwent posterior lumbar interbody fusion or instrumented posterolateral fusion for grade I or II DS or IS and had been enrolled in the Canadian Spine Outcomes and Research Network registry from 2009 to 2016. The outcome measures were score on the Oswestry Disability Index, scores for back pain and leg pain on the numeric rating scale, and mental component summary (MCS) score and physical component summary score on the 12-Item Short-Form Health Survey. Descriptive statistics were used to compare spondylolisthesis groups, logistic regression was used to compare interbody device use, and the chi-square test was used to compare the proportions of patients who achieved a minimal clinically important difference (MCID) at 1 year after surgery.

Results: In total, 119 patients had IS and 339 had DS. Patients with DS were more commonly women, older, less likely to smoke, and more likely to have neurogenic claudication and comorbidities, whereas patients with IS more commonly had radicular pain, neurological deficits, and worse back pain. Spondylolisthesis was more common at the L4-5 level in patients with DS and at the L5-S1 level in patients with IS. Similar proportions of patients had an interbody device (78.6% of patients with DS vs 82.4% of patients with IS, p = 0.429). Among patients with IS, factors associated with interbody device utilization were BMI ≥ 30 kg/m2 and increased baseline leg pain intensity. Factors associated with interbody device utilization in patients with DS were younger age, increased number of total comorbidities, and lower baseline MCS score. For each outcome measure, similar proportions of patients in the surgical treatment and spondylolisthesis groups achieved the MCID at 1 year after surgery.

Conclusions: Although the demographic and patient characteristics associated with interbody device utilization differed between cohorts, similar proportions of patients attained clinically meaningful improvement at 1 year after surgery.
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http://dx.doi.org/10.3171/2020.11.SPINE201261DOI Listing
July 2021

The Impact of Surgical Site Infection on Patient Outcomes After Open Posterior Instrumented Thoracolumbar Surgery for Degenerative Disorders.

J Bone Joint Surg Am 2021 Jun 18. Epub 2021 Jun 18.

Lawson Health Research Institute, London, Ontario, Canada.

Background: Few reports in the literature have described the long-term outcome of postoperative infection from the patient perspective. The aim of the present study was to determine if complicated surgical site infection (SSI) affects functional recovery and surgical outcomes up to 2 years after posterior instrumented thoracolumbar surgery for the treatment of degenerative disorders.

Methods: This retrospective cohort study involved patients who had been enrolled in a previous randomized controlled trial that examined antibiotic use for open posterior multilevel thoracolumbar or lumbar instrumented fusion procedures. In the present study, patients who had SSI (n = 79) were compared with those who did not (n = 456). Patient-reported outcome measures (PROMs) included the Oswestry Disability Index (ODI), leg and back pain scores on a numeric rating scale, Short Form-12 (SF-12) summary scores, and satisfaction with treatment at 1.5, 3, 6, 12, and 24 months. Surgical outcomes included adverse events, readmissions, and additional surgery.

Results: The median time to infection was 15 days. Of the 535 patients, 31 (5.8%) had complicated infections and 48 (9.0%) had superficial infections. Patients with an infection had a higher body mass index (BMI) (p = 0.001), had more commonly received preoperative vancomycin (p = 0.050), were more likely to have had a revision as the index procedure (p = 0.004), had worse preoperative mental functioning (mental component summary score, 40.7 ± 1.6 versus 44.1 ± 0.6), had more operatively treated levels (p = 0.024), and had a higher rate of additional surgery (p = 0.001). At 6 months after surgery, patients who developed an infection scored worse on the ODI by 5.3 points (95% confidence interval [CI], 0.4 to 10.1 points) and had worse physical functioning by -4.0 points (95% CI, -6.8 to -1.2 points). Comparison between the groups at 1 and 2 years showed no difference in functional outcomes, satisfaction with treatment, or the likelihood of achieving the minimum clinically important difference (MCID) for the ODI.

Conclusions: SSI more than doubled the post-discharge emergency room visit and additional surgery rates. Patients with SSI initially (6 months) had poorer overall physical function representing the delay to recovery; however, the negative impact resolved by the first postoperative year.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.02141DOI Listing
June 2021

Biomechanical comparison of 3 types of transdiscal fixation implants for fixing high-grade L5/S1 spine spondylolisthesis.

Spine J 2021 Sep 30;21(9):1587-1593. Epub 2021 Apr 30.

London Health Science Centre, Victoria Hospital, London, N6A 5W9, Canada; Dept. of Surgery (Div. of Orthopaedic Surgery), Western University, London, N6A 3K7, Canada.

Background Context: There are several options for the stabilization of high-grade lumbosacral spondylolisthesis including transdiscal screws, the Bohlman technique (transdiscal fibular strut) and the modified Bohlman technique (transdiscal titanium mesh cage). The choice of an optimum construct remains controversial; therefore, we endeavoured to study and compare the biomechanical performance of these 3 techniques.

Purpose: The aim of this study was to compare 3 types of transdiscal fixation biomechanically in an in vitro porcine lumbar-sacral spine model.

Study Design/setting: Porcine cadaveric biomechanical study.

Methods: 18 complete lumbar-sacral porcine spines were split into 3 repair groups, transdiscal screws (TS), Bohlman technique, and a modified Bohlman technique (MBT). Range of motion (L3 - S1) was measured in an intact and repaired state for flexion, extension, left/right lateral bending, and left/right torsion. To recreate a high-grade lumbosacral spondylolisthesis a bilateral L5/S1 facetectomy, removing the intervertebral disc completely, and the L5 body was displaced 50%-60% over the sacral promontory. Results were analyzed and compared to intact baseline measurements. Standard quasi-static moments (5 Nm) were applied in all modes.

Results: All range of motion (ROM) were in reference to intact baseline values. TS had the lowest ROM in all modes (p=.006-.495). Statistical difference was found only in extension for TS vs. BT (p=.011) and TS vs. MBT (p=.014). No bone or implant failures occurred.

Conclusion: TS provided the lowest ROM in all modes of loading compared to Bohlman technique and MBT. Our study indicates that TS results in the most biomechanically stable construct.

Clinical Significance: Knowledge of the biomechanical attributes of various constructs could aid physicians in choosing a surgical construct for their patients.
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http://dx.doi.org/10.1016/j.spinee.2021.04.017DOI Listing
September 2021

The Development of Novel 2-in-1 Patient-Specific, 3D-Printed Laminectomy Guides with Integrated Pedicle Screw Drill Guides.

World Neurosurg 2021 05 1;149:e821-e827. Epub 2021 Feb 1.

London Health Science Centre, Victoria Hospital-London, Ontario, Canada.

Objective: To determine if 2-in-1 patient-specific laminectomy and drill guides can be safely used to perform laminectomy and pedicle screw insertion.

Methods: This was a cadaveric study designed to test novel 2-in-1 patient-specific laminectomy guides, with modular removable pedicle screw drill guides. Three-dimensional (3D) printing has not been applied to laminectomy. This cadaveric study tests novel 2-in-1 patient-specific laminectomy guides, with modular removable pedicle screw drill guides. Computed tomography (CT) scans of 3 lumbar spines were imported into 3D Slicer. Spinal models and patient-specific guides were created and 3D printed. The bones were cleaned to visualize and record the under surface of the lamina during laminectomy. Pedicle screws and laminectomies were performed with the aid of patient-specific guides. CT scans were performed to compare planned and actual screw and laminectomy positions.

Results: Thirty screws were inserted in 15 lumbar vertebrae by using the integrated 2-in-1 patient-specific drill guides. There were no cortical breaches on direct examination, or on postoperative CT. Digital video analysis revealed the burr tip did not pass deep to the inner table margin of the lamina in any of the 30 laminectomy cuts. Average surgical time was 4 minutes and 46 seconds (standard deviation, 1 min 38 sec).

Conclusions: This study has explored the development of novel 2-in-1 patient-specific, 3D-printed laminectomy guides with integrated pedicle screw drill guides, which are accurate and safe in the laboratory setting. These instruments have the potential to simplify complex surgical steps, and improve accuracy, time, and cost.
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http://dx.doi.org/10.1016/j.wneu.2021.01.092DOI Listing
May 2021

Back Dominant Pain Has Equal Outcomes to Radicular Dominant Pain Following Posterior Lumbar Fusion in Adult Isthmic Spondylolisthesis: A CSORN Study.

Global Spine J 2021 Jan 7:2192568220985471. Epub 2021 Jan 7.

Division of Orthopaedics, Department of Surgery, Western University /London Health Sciences Centre, London, Ontario, Canada.

Study Design: Retrospective Cohort Study.

Objectives: This study aimed to determine how the surgeon-determined and patient-rated location of predominant pain influences patient-rated outcomes at 1-year after posterior lumbar fusion in adult isthmic spondylolisthesis.

Methods: We retrospectively reviewed consecutive patients prospectively enrolled in the Canadian Spine Outcomes and Research Network national registry between 2009 and 2017 that underwent posterior lumbar fusion for isthmic spondylolisthesis. Using longitudinal mixed-model repeated-measures analysis the change from baseline in patient-reported outcome measures (PROMs) at 1 year after surgery was compared between surgeon-determined groups (back vs. radicular) and between patient-rated pain groups (back, leg, and equal) derived from preoperative pain scores on the numerical rating scale (NRS).

Results: 83/252 (33%) patients had a surgeon-determined chief complaint of back pain, while 103 (41%) patients rated their back pain as the predominant pain location, and 78 (31%) rated their back and leg pain to be equal. At baseline patients in the surgeon-determined radicular group had worse NRS-leg pain than those in the back-pain group but equal NRS-back pain. At baseline patients in the patient-rated equal pain group had similar back pain compared to the patient-rated back pain group and similar leg pain compared to the patient-rated leg pain group. All PROMs improved post-operatively and were not different between the 2 groups at 1 year.

Conclusions: Our study found no difference in outcome, irrespective of whether a surgeon determines the patient's primary pain complaint back or radicular dominant, or the patient rates pain in one location greater than another.
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http://dx.doi.org/10.1177/2192568220985471DOI Listing
January 2021

Lumbar Fusion Surgery for Patients With Back Pain and Degenerative Disc Disease: An Observational Study From the Canadian Spine Outcomes and Research Network.

Global Spine J 2021 Jan 7:2192568220985470. Epub 2021 Jan 7.

University of Calgary Spine Program, University of Calgary, Alberta, Canada.

Study Design: Uncontrolled retrospective observational study.

Objectives: Surgery for patients with back pain and degenerative disc disease is controversial, and studies to date have yielded conflicting results. We evaluated the effects of lumbar fusion surgery for patients with this indication in the Canadian Spine Outcomes and Research Network (CSORN).

Methods: We analyzed data that were prospectively collected from consecutive patients at 11 centers between 2015 and 2019. Our primary outcome was change in patient-reported back pain at 12 months of follow-up, and our secondary outcomes were satisfaction, disability, health-related quality of life, and rates of adverse events.

Results: Among 84 patients, we observed a statistically significant improvement of back pain at 12 months that exceeded the threshold of Minimum Clinically Important Difference (MCID) (mean change -3.7 points, SD 2.6, p < 0.001, MCID = 1.2; 77% achieved MCID), and 81% reported being "somewhat" or "extremely" satisfied. We also observed improvements of Oswestry Disability Index (-17.3, SD 16.6), Short Form-12 Physical Component Summary (10.3, SD 9.6) and Short Form-12 Mental Component Summary (3.1, SD 8.3); all p < 0.001). The overall rate of adverse events was 19%.

Conclusions: Among a highly selective group of patients undergoing lumbar fusion surgery for degenerative disc disease, most experienced a clinically significant improvement of back pain as well as significant improvements of disability and health-related quality of life, with high satisfaction at 1 year of follow-up. These findings suggest that surgery for this indication may provide some benefit, and that further research is warranted.
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http://dx.doi.org/10.1177/2192568220985470DOI Listing
January 2021

Factors Associated With Return to Work After Surgery for Degenerative Cervical Spondylotic Myelopathy: Cohort Analysis From the Canadian Spine Outcomes and Research Network.

Global Spine J 2020 Oct 16:2192568220958669. Epub 2020 Oct 16.

Vancouver General Hospital, Vancouver, British Columbia, Canada.

Study Design: Retrosepctive analysis of prospectively collected data from the multicentre Canadian Surgical Spine Registry (CSORN).

Objective: Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in North America. Few studies have evaluated return to work (RTW) rates after DCM surgery. Our goals were to determine rates and factors associated with postoperative RTW in surgically managed patients with DCM.

Methods: Data was derived from the prospective, multicenter Canadian Spine Outcomes and Research Network (CSORN). From this cohort, we included all nonretired patients with at least 1-year follow-up. The RTW rate was defined as the proportion of patients with active employment at 1 year from the time of surgery. Unadjusted and adjusted analyses were used to identify patient characteristics, disease, and treatment variables associated with RTW.

Results: Of 213 surgically treated DCM patients, 126 met eligibility, with 49% working and 51% not working in the immediate period before surgery; 102 had 12-month follow-up data. In both the unadjusted and the adjusted analyses working preoperatively and an anterior approach were associated with a higher postoperative RTW ( < .05), there were no significant differences between the postoperative employment groups with respect to age, gender, preoperative mJOA (modified Japanese Orthopaedic Association) score, and duration of symptoms ( > .05). Active preoperative employment (odds ratio = 15.4, 95% confidence interval = 4.5, 52.4) and anterior surgical procedures (odds ratio = 4.7, 95% confidence interval = 1.2, 19.6) were associated with greater odds of RTW at 1 year.

Conclusions: The majority of nonretired patients undergoing surgery for DCM had returned to work 12 months after surgery; active preoperative employment and anterior surgical approach were associated with RTW in this analysis.
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http://dx.doi.org/10.1177/2192568220958669DOI Listing
October 2020

Factors Associated with Recovery in Motor Strength, Walking Ability, and Bowel and Bladder Function after Traumatic Cauda Equina Injury.

J Neurotrauma 2021 02 2;38(3):322-329. Epub 2020 Nov 2.

Physical Medicine and Rehabilitation, Dalhousie University Faculty of Medicine, Stan Cassidy Centre for Rehabilitation, Fredericton, New Brunswick, Canada.

Traumatic cauda equina injury (TCEI) is usually caused by spine injury at or below L1 and can result in motor and/or sensory impairments and/or neurogenic bowel and bladder. We examined factors associated with recovery in motor strength, walking ability, and bowel and bladder function to aid in prognosis and establishing rehabilitation goals. The analysis cohort was comprised of persons with acute TCEI enrolled in the Rick Hansen Spinal Cord Injury Registry. Multi-variable regression analysis was used to determine predictors for lower-extremity motor score (LEMS) at discharge, walking ability at discharge as assessed by the walking subscores of either the Functional Independence Measure (FIM) or Spinal Cord Independence Measure (SCIM), and improvement in bowel and bladder function as assessed by FIM-relevant subscores. Age, sex, neurological level and severity of injury, time from injury to surgery, rehabilitation onset, and length of stay were examined as potential confounders. The cohort included 214 participants. Median improvement in LEMS was 4 points. Fifty-two percent of participants were able to walk, and >20% recovered bowel and bladder function by rehabilitation discharge. Multi-variable analyses revealed that shorter time from injury to rehabilitation admission (onset) was a significant predictor for both improvement in walking ability and bowel function. Longer rehabilitation stay and being an older female were associated with improved bladder function. Our results suggest that persons with TCEI have a reasonable chance of recovery in walking ability and bowel and bladder function. This study provides important information for rehabilitation goals setting and communication with patients and their families regarding prognosis.
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http://dx.doi.org/10.1089/neu.2020.7303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7826419PMC
February 2021

A Comparison of Patient and Surgeon Expectations of Spine Surgical Outcomes.

Global Spine J 2021 Apr 10;11(3):331-337. Epub 2020 Mar 10.

70401University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada.

Study Design: Ambispective cohort study.

Objective: Limited data exists comparing surgeon and patient expectations of outcome following spine surgery. The objective of this study was to elicit whether any differences exist between patient and surgeon expectations for common spine surgeries.

Methods: Ten common age-appropriate clinical scenarios were generated and sent to Canadian spine surgeons to determine surgeon expectations for standard spine surgeries. Patients in the Canadian Spine Outcomes and Research Network (CSORN) registry matching the clinical scenarios were identified. Aggregated patient expectations were compared with surgeon responses for each scenario. A χ analysis was then completed to determine discrepancies between surgeon and patient expectations for each scenario.

Results: A total of 51 Canadian spine surgeons completed the survey on surgical expectations. A total of 919 patients from multiple centers were identified within the CSORN database that matched the clinical scenarios. Our results demonstrated that patients tend to be more optimistic about the expected outcomes of surgery compared with the treating surgeon. The majority of patients in all clinical scenarios anticipated improvement in back or neck pain after surgery, which differed from surgeon expectations. Results also highlighted the effect of patient age on both patient and surgeon expectations. Discrepancies between patient and surgeon expectations were higher for older patients.

Conclusion: We present data on patient and surgeon expectations for spine surgeries and show that differences exist particularly concerning the improvement of neck or back pain. Patient age plays a role in the agreement between the treating physicians and patients in regard to surgical expectations. The reasons for the discrepancies remain unclear.
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http://dx.doi.org/10.1177/2192568220907603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013940PMC
April 2021

Back pain in surgically treated degenerative lumbar spondylolisthesis: what can we tell our patients?

Spine J 2020 12 19;20(12):1940-1947. Epub 2020 Aug 19.

Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada.

Of Background Data: Surgery for degenerative lumbar spondylolisthesis (DLS) has traditionally been indicated for patients with neurogenic claudication. Surgery improves patients' disability and lower extremity symptoms, but less is known about the impact on back pain.

Objective: To evaluate changes in back pain after surgery and identify factors associated with these changes in surgically-treated DLS.

Study Design: Retrospective review of prospectively collected data.

Methods: There were 486 consecutive patients with surgically-treated DLS who were enrolled in the Canadian Spine Outcomes Research Network prospective registry and identified for this study. Patients had demographic data, clinical information, disability (Oswestry Disability Index), and back pain rating scores collected prospectively at baseline, and 12 months follow-up RESULTS: Of the 486 DLS patients, 376 (77.3%) were successfully followed at 12 months. Mean age at baseline was 66.7 (standard deviation [SD] 9.2) years old, and 63% were female. Back pain improved significantly at 12 months, compared with baseline (p<.001). Improvement in Numeric Rating Scale (NRS)-back pain ratings was on average 2.97 (SD 2.5) points at one year and clinically significant improvement in back pain was observed in 75% of patients (minimal clinically important difference (MCID) NRS-Pain 1.2 points). Multivariable logistic regression revealed five factors associated with meeting MCID NRS-back pain at 12 month follow up: higher baseline back pain, better baseline physical function (higher SF-12 Physical Component Score), symptoms duration less than 1 to 2 years, and having no intraoperative adverse events.

Conclusions: Back pain improved significantly for patients treated surgically for DLS at 1-year follow-up.
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http://dx.doi.org/10.1016/j.spinee.2020.08.009DOI Listing
December 2020

In-Hospital Mortality for the Elderly with Acute Traumatic Spinal Cord Injury.

J Neurotrauma 2020 11 26;37(21):2332-2342. Epub 2020 Aug 26.

Department of Orthopaedics, Vancouver Spine Surgery Institute, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

As the incidence of traumatic spinal cord injury (tSCI) in the elderly rises, clinicians are increasingly faced with difficult discussions regarding aggressiveness of management, likelihood of recovery, and survival. Our objective was to outline risk factors associated with in-hospital mortality in elderly surgical and non-surgical patients following tSCI and to determine those unlikely to have a favorable outcome. Data from elderly patients (≥ 65 years of age) in the Canadian Rick Hansen SCI Registry from 2004 to 2017 were analyzed using descriptive analysis. Survival and mortality groups in each of the surgical and non-surgical group were compared to explore factors associated with in-hospital mortality and their impact, using logistical regression. Of 1340 elderly patients, 1018 had surgical data with 826 having had surgery. In the surgical group, the median time to death post-injury was 30 days with 75% dying within 50 days compared with 7 days and 20 days, respectively, in the non-surgical group. Significant predictors for in-hospital mortality following surgery are age, comorbidities, neurological injury severity (American Spinal Injury Association [ASIA] Impairment Scale [AIS]), and ventilation status. The odds of dying 50 days post-surgery are six times higher for patients ≥77 years of age versus those 65-76 years of age, five times higher for those with AIS A versus those with AIS B/C/D, and seven times higher for those who are ventilator dependent. An expected probability of dying within 50 days post-surgery was determined using these results. In-hospital mortality in the elderly after tSCI is high. The trend with age and time to death and the significant predictors of mortality identified in this study can be used to inform clinical decision making and discussions with patients and their families.
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http://dx.doi.org/10.1089/neu.2019.6912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585611PMC
November 2020

Surgery versus Conservative Care for Persistent Sciatica. Reply.

N Engl J Med 2020 07;383(1):90-91

Lawson Health Research Institute, London, ON, Canada.

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http://dx.doi.org/10.1056/NEJMc2010782DOI Listing
July 2020

Clinical predictors of achieving the minimal clinically important difference after surgery for cervical spondylotic myelopathy: an external validation study from the Canadian Spine Outcomes and Research Network.

J Neurosurg Spine 2020 Apr 10:1-9. Epub 2020 Apr 10.

1University of Calgary Spine Program, University of Calgary, Alberta.

Objective: Recently identified prognostic variables among patients undergoing surgery for cervical spondylotic myelopathy (CSM) are limited to two large international data sets. To optimally inform shared clinical decision-making, the authors evaluated which preoperative clinical factors are significantly associated with improvement on the modified Japanese Orthopaedic Association (mJOA) scale by at least the minimum clinically important difference (MCID) 12 months after surgery, among patients from the Canadian Spine Outcomes and Research Network (CSORN).

Methods: The authors performed an observational cohort study with data that were prospectively collected from CSM patients at 7 centers between 2015 and 2017. Candidate variables were tested using univariable and multiple binomial logistic regression, and multiple sensitivity analyses were performed to test assumptions about the nature of the statistical models. Validated mJOA MCIDs were implemented that varied according to baseline CSM severity.

Results: Among 205 patients with CSM, there were 64 (31%) classified as mild, 86 (42%) as moderate, and 55 (27%) as severe. Overall, 52% of patients achieved MCID and the mean change in mJOA score at 12 months after surgery was 1.7 ± 2.6 points (p < 0.01), but the subgroup of patients with mild CSM did not significantly improve (mean change 0.1 ± 1.9 points, p = 0.8). Univariate analyses failed to identify significant associations between achieving MCID and sex, BMI, living status, education, smoking, disability claims, or number of comorbidities. After adjustment for potential confounders, the odds of achieving MCID were significantly reduced with older age (OR 0.7 per decade, 95% CI 0.5-0.9, p < 0.01) and higher baseline mJOA score (OR 0.8 per point, 95% CI 0.7-0.9, p < 0.01). The effects of symptom duration (OR 1.0 per additional month, 95% CI 0.9-1.0, p = 0.2) and smoking (OR 0.4, 95% CI 0.2-1.0, p = 0.06) were not statistically significant.

Conclusions: Surgery is effective at halting the progression of functional decline with CSM, and approximately half of all patients achieve the MCID. Data from the CSORN confirmed that older age is independently associated with poorer outcomes, but novel findings include that patients with milder CSM did not experience meaningful improvement, and that symptom duration and smoking were not important. These findings support a nuanced approach to shared decision-making that acknowledges some prognostic uncertainty when weighing the various risks, benefits, and alternatives to surgical treatment.
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http://dx.doi.org/10.3171/2020.2.SPINE191495DOI Listing
April 2020

Plasma metabolomic profiling of healthy pregnant mares and mares with experimentally induced placentitis.

Equine Vet J 2021 Jan 15;53(1):85-93. Epub 2020 Apr 15.

College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA.

Background: Metabolomics may represent an avenue for diagnosis of equine ascending placentitis.

Objectives: To characterise the plasma metabolomic profile in healthy mares and mares with induced ascending placentitis, with the goal of identifying metabolites with potential clinical value for early diagnosis of placentitis.

Study Design: Controlled in vivo experiment.

Methods: Placentitis was induced in 10 late-term pregnant pony mares via Streptococcal equi subsp. zooepidemicus inoculation in five mares between days 285 and 290 of gestation, while five mares served as healthy controls. Repeated ultrasound examinations and jugular venipuncture were performed to obtain combined thickness of the uterus and placenta (CTUP) and plasma for NMR spectroscopy. Mares with increased CTUP were diagnosed with placentitis and treated in accordance with published therapeutic recommendations. NMR metabolomic analysis was performed to identify and quantify plasma metabolites at each time point. Concentrations were compared using ANOVA with repeated-measures and PLS-DA analysis.

Results: Four hours post-inoculation, a significant increase was detected in the metabolites alanine, phenylalanine, histidine, pyruvate, citrate, glucose, creatine, glycolate, lactate and 3-hydroxyisobutyrate that returned to baseline by 12 hours. On day 4, a significant reduction in the metabolites alanine, phenylalanine, histidine, tyrosine, pyruvate, citrate, glycolate, lactate and dimethylsulfone was seen in infected mares compared with controls.

Main Limitations: There were small numbers of mares within groups. In addition, this work compares healthy animals with animals treated with multimodal therapeutics following diagnosis of placentitis without an untreated cohort.

Conclusions: Two phases of metabolite changes were noted after experimental infection: An immediate rise in metabolite concentration involved in energy, nitrogen, hydrogen and oxygen metabolism within 4 hours after inoculation that was followed by a decrease in metabolite concentrations involved in energy and nitrogen metabolism at 4 days, coinciding with ultrasonographic diagnosis of placentitis.
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http://dx.doi.org/10.1111/evj.13262DOI Listing
January 2021

A natural solution to photoprotection and isolation of the potent polyene antibiotic, marinomycin A.

Chem Sci 2019 Aug 21;10(32):7549-7553. Epub 2019 May 21.

Department of Chemistry , BSRC , University of St Andrews , St Andrews , KY16 9ST , UK . Email:

The photoprotection and isolation of marinomycin A using sporopollenin exine capsules (SpECs) derived from the spores of the plant is described. The marinomycins have a particularly short half-life in natural light, which severely impacts their potential biological utility given that they display potent antibiotic and anticancer activity. The SpEC encapsulation of the marinomycin A increases the half-life of the polyene macrodiolide to the direct exposure to UV radiation by several orders of magnitude, thereby making this a potentially useful strategy for other light sensitive bioactive agents. In addition, we report that the SpECs can also be used to selectively extract culture broths that contain the marinomycins, which provides a significantly higher recovery than with conventional XAD resins and provides concomitant photoprotection.
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http://dx.doi.org/10.1039/c9sc01375jDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761879PMC
August 2019

The Effect of Prolonged Postoperative Antibiotic Administration on the Rate of Infection in Patients Undergoing Posterior Spinal Surgery Requiring a Closed-Suction Drain: A Randomized Controlled Trial.

J Bone Joint Surg Am 2019 Oct;101(19):1732-1740

Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.

Background: Closed-suction drains are frequently used following posterior spinal surgery. The optimal timing of antibiotic discontinuation in this population may influence infection risk, but there is a paucity of evidence. The aim of this study was to determine whether postoperative antibiotic administration for 72 hours (24 hours after drain removal as drains were removed on the second postoperative day) decreases the incidence of surgical site infection compared with postoperative antibiotic administration for 24 hours.

Methods: Patients undergoing posterior thoracolumbar spinal surgery managed with a closed-suction drain were prospectively randomized into 1 of 2 groups of postoperative antibiotic durations: (1) 24 hours, or (2) 24 hours after drain removal (72 hours). Drains were discontinued on the second postoperative day. The duration of antibiotic administration was not blinded. All subjects received a single dose of preoperative antibiotics, as well as intraoperative antibiotics if the surgical procedure lasted >4 hours. The primary outcome was the rate of complicated surgical site infection (deep or organ or space) within 1 year of the surgical procedure.

Results: The trial was terminated at an interim analysis, when 552 patients were enrolled, for futility with respect to the primary outcome. In this study, 282 patients were randomized to postoperative antibiotics for 24 hours and 270 patients were randomized to postoperative antibiotics for 72 hours. A complicated infection developed in 17 patients (6.0%) in the 24-hour group and in 14 patients (5.2%) in the 72-hour group (p = 0.714). The superficial infection rate did not differ between the groups (p = 0.654): 9.6% in the 24-hour group compared with 8.1% in the 72-hour group. Patients in the 72-hour group had a median hospital stay that was 1 day longer (p < 0.001). At 1 year, patient-rated outcomes including leg and back pain and physical and mental functioning were not different between the groups.

Conclusions: The extension of postoperative antibiotics for 72 hours, when a closed-suction drain is required, was not associated with a reduction in the rate of complicated surgical site infection after posterior thoracolumbar spinal surgery.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of Levels of Evidence.
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http://dx.doi.org/10.2106/JBJS.19.00009DOI Listing
October 2019

Treatment of Mild Cervical Myelopathy: Factors Associated With Decision for Surgical Intervention.

Spine (Phila Pa 1976) 2019 Nov;44(22):1606-1612

Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia.

Study Design: Prospective Cohort OBJECTIVE.: The aim of this study was to evaluate which demographic, clinical, or radiographic factors are associated with selection for surgical intervention in patients with mild cervical spondylotic myelopathy (CSM).

Summary Of Background Data: Surgery has not been shown superior to best conservative management in mild CSM comparative studies; trials of conservative management represent an acceptable alternative to surgical decompression. It is unknown what patients benefit from surgery.

Methods: This is a prospective study of patients with mild CSM, defined as modified Japanese Orthopaedic Association Score (mJOA) ≥15. Patients were recruited from seven sites contributing to the Canadian Spine Outcomes Research Network. Demographic, clinical, radiographic and health related quality of life data were collected on all patients at baseline. Multivariate logistic regression modeling was used to identify factors associated with surgical intervention.

Results: There were 122 patients enrolled, 105 (86.0%) were treated surgically, and 17 (14.0%) were treated nonoperatively. Overall mean age was 54.8 years (SD 12.6) with 80 (65.5%) males. Bivariate analysis revealed no statistically significant differences between surgical and nonoperative groups with respect to age, sex, BMI, smoking status, number of comorbidities and duration of symptoms; mJOA scores were significantly higher in the nonoperative group (16.8 [SD 0.99] vs. 15.9 [SD 0.89], P < 0.001). There was a statistically significant difference in Neck Disability Index, SF12 Physical Component, SF12 Mental Component Score, EQ5D, and PHQ-9 scores between groups; those treated surgically had worse baseline questionnaire scores (P < 0.05). There was no difference in radiographic parameters between groups. Multivariable analysis revealed that lower quality of life scores on EQ5D were associated with selection for surgical management (P < 0.018).

Conclusion: Patients treated surgically for mild cervical myelopathy did not differ from those treated nonoperatively with respect to baseline demographic or radiographic parameters. Patients with worse EQ5D scores had higher odds of surgical intervention.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003124DOI Listing
November 2019

Decompression alone vs. decompression plus fusion for claudication secondary to lumbar spinal stenosis.

Spine J 2019 10 10;19(10):1633-1639. Epub 2019 Jun 10.

Vancouver General Hospital, University of British Columbia, Blusson Spinal Cord Center, 6th floor, 818 West 10th Avenue, Vancouver, British Columbia, Canada V5Z 1M9.

Background: Degenerative lumbar spinal stenosis is a common condition, predominantly affecting middle-aged and elderly people. This study focused on patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity.

Purpose: To determine whether the addition of fusion to decompression resulted in improved clinical outcomes at 3, 12, and 24 months postsurgery.

Study Design/setting: The Canadian Spine Outcomes and Research Network (CSORN) prospective database that includes pre- and postoperative data from tertiary care hospitals.

Patient Sample: The CSORN database was queried for consecutive spine surgery cases of degenerative lumbar stenosis receiving surgical decompression for neurogenic claudication or radiculopathy. Neurogenic claudication patients with baseline and 2-year follow-up data, from four sites, formed the study sample (n=306). The sample was categorized into two groups: (1) those that had decompression alone, and (2) those that underwent decompression plus fusion.

Outcome Measures: Change in modified Oswestry Disability Index (ODI), numerical rating scale for back/leg pain, the EuroQol EQ5D, the SF-12 physical, and mental component scores. The primary outcome measure was the ODI at 2 years postoperative.

Methods: We conducted a multicenter, ambispective review of consecutive spine surgery patients enrolled between October 2012 and January 2018.

Results: Baseline characteristics were comparable between groups except for female sex and multilevel pathology (both with greater proportion in the decompression plus fusion group). The decompression plus fusion group had clinically meaningfully more operative time, blood loss, rate of perioperative complication, and length of hospital stay (p<.05). These differences were preserved following adjustment for baseline differences between the groups. Both decompression and decompression plus fusion had a large clinically meaningful impact on generic and disease-specific patient-reported outcome measures within 3 months of surgery which was maintained out to 24-month follow-up. At any follow-up time point, there was no statistical evidence of a difference in these effects favoring decompression plus fusion over decompression alone.

Conclusions: The addition of fusion to decompression did not result in improved outcomes at 3-, 12-, or 24-month follow-up. The addition of fusion to decompression provides no advantage to decompression alone for the treatment of patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity.
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http://dx.doi.org/10.1016/j.spinee.2019.06.003DOI Listing
October 2019

Effect of preoperative symptom duration on outcome in lumbar spinal stenosis: a Canadian Spine Outcomes and Research Network registry study.

Spine J 2019 09 21;19(9):1470-1477. Epub 2019 May 21.

University of Calgary, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada.

Background Context: Lumbar degenerative stenosis is one of the most common spine pathologies for which surgical intervention is indicated. There is some evidence that a prolonged duration of neurological compression could lead to a failure of surgery to alleviate symptoms.

Purpose: Determination of whether longer symptom duration was associated with worse postoperative disability outcomes after decompressive surgery for lumbar degenerative stenosis.

Study Design/setting: The Canadian Spine Outcomes and Research Network (CSORN) prospective database includes pre- and postoperative data from 18 tertiary care hospitals.

Patient Sample: The CSORN database was queried for all cases of degenerative lumbar stenosis receiving surgical decompression for neurogenic claudication or radiculopathy. Patients with tumor, infection, fracture, or previous surgery were excluded. Patients were divided into groups based on symptom duration (<6 weeks, 6-12 weeks, 3-6 months, 6-12 months, 1-2 years, and >2 years).

Outcome Measures: Change between preoperative and 12-month postoperative Oswestry Disability Index (ODI) was compared between symptom duration groups. Secondary outcomes included SF12 physical component score (PCS), and numeric rating scales for leg and back pain. Outcomes were also assessed at 3 months and 24 months postoperatively.

Methods: Change in ODI, and secondary outcome measures, were compared between different symptom duration groups. Multiple regression analysis was used to identify factors interacting with symptom duration to predict change in ODI.

Results: Four hundred and seventy-eight cases of lumbar stenosis with 12-month postoperative data were identified. Longer symptom duration correlated with less improvement in ODI (p<.001). Patients with >1 year of symptoms were less likely to achieve a Minimal Clinically Significant Difference in ODI (54.4% vs. 66.1%; p=.03) and were more likely to experience no improvement or worse disability, postoperatively (22.1% vs. 11.3%; p=.008). Similar results were found at 3- and 24-month timepoints. Smaller postoperative improvements in SF12 PCS and leg pain scales were also correlated with longer symptom duration (p<.05).

Conclusions: Multicenter registry data provides important real-world evidence to guide consent, surgical planning, and health resource management. Longer symptom duration was found to correlate with less improvement in pain and disability after lumbar stenosis surgery suggesting that these patients may benefit from earlier treatment.
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http://dx.doi.org/10.1016/j.spinee.2019.05.008DOI Listing
September 2019

Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study.

J Neurosurg Spine 2019 May;31(3):430-439

1Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre.

Objective: This proof-of-concept study was conducted to determine whether negative-pressure wound therapy, through the use of incisional vacuum-assisted closure (VAC), is associated with a reduction in surgical site infections (SSIs) when compared to standard wound dressings in patients undergoing open posterior spinal fusion who have a high risk of infection.

Methods: A total of 64 patients were examined; 21 patients received incisional VAC application (VAC group) versus 43 diagnosis-matched patients who received standard wound dressings (control group). Patients in the VAC group were prospectively enrolled in a consecutive series between March 2013 and March 2014 if they met the following diagnostic criteria for high risk of infection: posterior open surgery across the cervicothoracic junction; thoracic kyphosis due to metastatic disease; high-energy trauma; or multilevel revision reconstructive surgery. Patients in the VAC group also met one or more comorbidity criteria, including body mass index ≥ 35 or < 18.5, diabetes, previous radiation at surgical site, chemotherapy, steroid use, bedridden state, large traumatic soft-tissue disruption, or immunocompromised state. Consecutive patients in the control group were retrospectively selected from the previous year by the same high-risk infection diagnostic criteria as the VAC group. All surgeries were conducted by the same surgeon at a single site. The primary outcome was SSI. All patients had 1 year of follow-up after their surgery. Baseline demographics, intraoperative parameters, and postoperative wound infection rates were compared between groups.

Results: Patient demographics including underlying comorbidities were similar, with the exception that VAC-treated patients were malnourished (p = 0.020). VAC-treated patients underwent longer surgeries (p < 0.001) and required more postoperative ICU admissions (p = 0.039). The median length of hospital stay was not different between groups. In total, 9 control patients (21%) developed an SSI, versus 2 VAC-treated patients (10%).

Conclusions: Patients in this cohort were selected to have an increased risk of infection; accordingly, the rate of SSI was high. However, negative-pressure wound therapy through VAC application to the postoperative incision resulted in a 50% reduction in SSI. No adverse effects were noted secondary to VAC application. The preliminary data confirm the authors' proof of concept and strongly support the need for a prospective randomized trial.
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http://dx.doi.org/10.3171/2019.2.SPINE18947DOI Listing
May 2019

Consultation and Surgical Wait Times in Cervical Spondylotic Myelopathy.

Can J Neurol Sci 2019 07 3;46(4):430-435. Epub 2019 May 3.

Combined Neurosurgery and Orthopaedic Spine Program,University of British Columbia,Vancouver, British Columbia,Canada.

Background: Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord impairment. In a public healthcare system, wait times to see spine specialists and eventually access surgical treatment for CSM can be substantial. The goals of this study were to determine consultation wait times (CWT) and surgical wait times (SWT), and identify predictors of wait time length.

Methods: Consecutive patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) prospective and observational CSM study from March 2015 to July 2017 were included. A data-splitting technique was used to develop and internally validate multivariable models of potential predictors.

Results: A CSORN query returned 264 CSM patients for CWT. The median was 46 days. There were 31% mild, 35% moderate, and 33% severe CSM. There was a statistically significant difference in median CWT between moderate and severe groups; 207 patients underwent surgical treatment. Median SWT was 42 days. There was a statistically significant difference in SWT between mild/moderate and severe groups. Short symptom duration, less pain, lower BMI, and lower physical component score of SF-12 were predictive of shorter CWT. Only baseline pain and medication duration were predictive of SWT. Both CWT and SWT were shorter compared to a concurrent cohort of lumbar stenosis patients (p <0.001).

Conclusions: Patients with shorter duration (either symptoms or medication) and less neck pain waited less to see a spine specialist in Canada and to undergo surgical treatment. This study highlights some of the obstacles to overcome in expedited care for this patient population.
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http://dx.doi.org/10.1017/cjn.2019.34DOI Listing
July 2019

Ectopic spinal calcification associated with diffuse idiopathic skeletal hyperostosis (DISH): A quantitative micro-ct analysis.

J Orthop Res 2019 03 28;37(3):717-726. Epub 2019 Feb 28.

Physiology and Pharmacology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.

Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory spondyloarthropathy identified radiographically by calcification of the ligaments and/or entheses along the anterolateral aspect of the vertebral column. The etiology and pathogenesis of calcifications are unknown, and the diagnosis of DISH is currently based on radiographic criteria associated with advanced disease. To characterize the features of calcifications associated with DISH, we used micro-computed tomographic imaging to evaluate a cohort of 19 human cadaveric vertebral columns. Fifty-three percent of the cohort (n = 10; 3 females, 7 males, mean age of death = 81 years, range 67-94) met the radiographic criteria for DISH, with calcification of four or more contiguous vertebral segments. In almost all cases, the lower thoracic regions (T8-12) were affected by calcifications, consisting primarily of large, horizontal outgrowths of bony material. In contrast, calcifications localized to the upper thoracic regions demonstrated variability in their presentation and were categorized as either "continuous vertical bands" or "discontinuous-patchy" lesions. In addition to the variable morphology of the calcifications, our analysis demonstrated remarkable heterogeneity in the densities of calcifications, ranging from internal components below the density of cortical bone to regions of hyper-dense material that exceeded cortical bone. These findings establish that the current radiographic criteria for DISH capture heterogeneous presentations of ectopic spine calcification that can be differentiated based on morphology and density. These findings may indicate a naturally heterogenous disease, potential stage(s) in the natural progression of DISH, or distinct pathologies of ectopic calcifications. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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http://dx.doi.org/10.1002/jor.24247DOI Listing
March 2019

Clinical outcomes research in spine surgery: what are appropriate follow-up times?

J Neurosurg Spine 2018 12;30(3):397-404

1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia.

In BriefThe time course required for the patient-reported outcomes of pain, physical function, and mental health to reach a recovery plateau after elective lumbar spine surgery was assessed utilizing a prospectively maintained multicenter registry. The work is important as it demonstrates that specific health dimensions follow different recovery plateaus and it provides evidence that a 2-year postoperative follow-up is not required to accurately assess the treatment effect of established surgeries for lumbar spinal pathologies.
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http://dx.doi.org/10.3171/2018.8.SPINE18715DOI Listing
December 2018
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