Introduction. Due to co-morbidities in elderly like atherosclerosis and approach-related risks, anterior lumbar surgery is mainly recommended for younger patients. We reviewed approach-related complications in anterior lumbar surgery in senior patients for complex reconstructions. Materials and Methods. Retrospective review of 12 patients (8 female and 4 male), mean age 65.5±4.9 years, treated with anterior fusion mainly for degenerative scoliosis and lumbar kyphosis in between 2007-10. 9(75%) patients had multilevel procedures. Most common co-morbidities were atherosclerosis (CT-proven in 7 patients), coronary heart disease and COPD. Renal impairment was present preoperatively in 3 patients. Results. Mean duration of surgery was 260±120.8 min and mean blood loss 403.3±348.0 ml in the whole group (157±49.1 min and 240.0±162.0 ml in single ALIF; 334.0±100.0 min and 520.0±408.0 ml in multilevel procedures). Retractor related ischaemia occurred in 8 patients (27.3±29.1 min); perfusion of the leg returned immediately after release (confirmed via pulse-oxymetry). 2 patients had a direct vessel suture (2 common iliac veins); hypotension during surgery occurred in 1 patient due to anaesthetic problems. 5 patients needed ICU support after the procedure. Superficial wound infection was reported in one patient. One case of incisional hernia and one case of lymphocele was noticed. Conclusion. In this retrospective review, no specific complications concerning age or co-morbidities occurred in senior patients. In this group, atherosclerosis was the most common co-morbidity. However, no arterial embolism or perfusion deficit occurred. In the future, more and more elderly are to be treated by spinal surgeons. Anterior lumbar surgery is an alternative treatment option even for complex cases in the elderly. This limited group of patients need further investigations and prospective studies regarding anterior lumbar surgery

Purpose: Purpose of this study was to evaluate the results of elective lumbar spinal surgery as it relates to patient expectations for outcome and outcome as quantified by patient derived generic and disease specific measures. Methods: Prospectively collected patient derived generic health status (SF-36) and disease specific outcome measures (Oswestry) were quantified in all patients prior to surgery, and at serial postoperative clinical follow-ups. Patient expectations for their surgery were also measured; (pain relief, sleep, recreational and daily activities of living, return to work). Postoperatively, patients completed a questionnaire regarding the results of their spinal surgery as it related to meeting their expectations. Multivariate analysis of variance was used to evaluate for factors that influenced the results of surgery relating to patient expectations. Results: Between 1998 and 2002 one hundred and forty three consecutive patients were evaluated. Average age was 52 (range 18–84). Diagnosis was disc herniation 43%, spondylitic spondylolisthesis 10%, degenerative spondylolisthesis 30%, spondylosis 6%, other 11%. The mean preoperative SF-36 mental component and physical component scores were 42.1 and 22.3 respectively (1.2 and 3.4 standard deviations below age and gender matched norms). Postoperative SF-36 scores were 48.1 and 38.6. The mean Oswestry disability scores were 48.7% preoperatively vs. 23.1% postoperatively. 81% (116/143) had their expectations met. Of the 19% (27 patients) who did not meet their expectations, they reported lower preoperative SF-36 general health and vitality domain scores. Patients were also less likely to have their expectations met if they had prior lumbar surgery, were involved in worker compensation or litigation. Patients who reported either back or back > leg symptoms were less satisfied than patients who presented with predominantly leg symptoms. Conclusions: Patient factors inclusive of mental, (as measured by general health perception and vitality), physical (predominance of leg vs back pain), and social (presence of compensation, litigation), all contribute to patient satisfaction and outcomes following lumbar spinal surgery for degenerative conditions

Introduction and Objectives: Bleeding during lumbar surgery requires the use of blood products for its management. Autotransfusions are an alternative to blood transfusions, since these are not free of risk. Although autotransfusion is a very effective technique, its efficiency is conditioned by its high cost and the fact that a large number of autodonations have to be destroyed when the patients do not require them during the postoperative period. We wanted to discover the factors that determine the use of blood products during the postoperative period so as to obtain blood autodonations from these patients. Materials and Methods: We carried out a retrospective study of 143 patients that underwent surgery for degenerative conditions of the lumbar spine. We assessed different variables: Age, sex, lumbar level operated on, operation time, pre and postoperative hemoglobin and associated conditions (Charlson comorbidity index and ASA scale). Results: We found a significant statistic correlation with female sex, age over 60, ASA 3, preoperative hemoglobin < 136 gr/l. Using logistic regression we found that the combination woman, ASA 3 was the most important prognostic factor with a specificity above 90%. We also found that the possibility of requiring a transfusion in a woman/ASA 3, was 61% and at the other end of the spectrum 1.1% in a man/ASA< 3,. Discussion and Conclusions: If we plan an autotransfusion in a woman with ASA 3, there is a probability of 61% that she will require a transfusion with specificity greater than 90%

In 2000 the Ulrich ALIF cage for lumbar surgery was introduced. We evaluated the effectiveness and safety of this new implant device by determining fusion rate, cost and complications. Twenty patients undergoing anterior spinal surgery for failed posterior fusions were offered the option of receiving the implant device and entered into this prospective study. In all patients, the approach was either anterior retroperitoneal or left lateral retroperitoneal. The procedures were done under C-arm control. The mean operating time was 80 minutes. Blood loss was less than 400 ml. Mobilised the day after surgery, all patients used a soft lumbosacral brace for at least six weeks. Follow-up radiographs were taken on the third postoperative day and at six and 12 weeks. The large bone graft surface of the cage allows excellent bone grafting and radiological visualisation. We encountered no complications related to the cage. One case of anterior subluxation of 1 cm occurred when a patient stumbled on the third day after surgery

The purpose of this study was to evaluate retrospectively the results of urgent lumbar surgery performed due to severe neurologic deficit. Eight patients underwent urgent lumbar surgery: 7 patients underwent surgery less than 12 hours from the onset of the symptoms. One patient was operated on less than 24 hours from symptoms initiation. 6 Pts. had Cauda Equina Syndrome, 2 pts. had radicular deficiency presented with drop foot. All patients underwent lumbar decompression. The patients were followed up for at least 2 years. Mean follow up was 3 years and 8 months. 5 of the 6 that had Cauda Equina Syn (CER). had complete neurological recovery. One patient had no improvement. The cause of the CER was undifferentiated carcinoma. The two patients operated on because of drop foot had no improvement. Our results confirmed the good outcome of early intervention in patients having CER due to disc herniation No improvement was seen following surgery due to nerve root paresis

Introduction. An important number of factors affecting the outcome of surgical treatment have been identified, and these factors can affect the patient's selection for lumbar surgery. Study Design. Retrospective study with data collected prospectively on patients undergoing surgery for degenerative lumbar pathology (DLP). Purpose. Identification and evaluation of epidemiological factors that influence the quality of life improvement, disability and chronic pain. Outcome measures. Visual Analogue Scale (VAS) to assess pain in lower back and extremities, Short Form-36v2 (SF-36), Oswestry Disability Index (ODI) and Core Outcome Measures Index (COMI). Method. 263 patients were included in our study, with a mean age of 54.0 years (22–86 years). 131 patients were women (49.8%). Questionnaires were completed in the preoperative visit and 2 years after surgery. Epidemiological data collected were age, sex, educational level, employment status, diagnosis, treatment, and comorbidity measure by ASA. The most frequent diagnostics were degenerative discal disease (36,5%) and lumbar stenosis (30,4%) and a main surgical treatment was TLIF (31,9 %). To compare means we used t-Student and Pearson's coefficient or Spearman's test was used to assess the correlation, and, finally, linear regression study (ANOVA) was performed with variables that showed statistically significant correlation. SPSS 15.0 statistical package. Results. Sex and employment status was correlated with the improvement of COMI (r=− 0.257, p <0.05, r=0.272, p <0.05). Employment status was correlated with in ODI (r=0.249, p <0.05) and the degree of improvement physical component of SF-36 (PCS, r=− 0.254, p <0.05). Linear regression showed statistically significant influence of the age (r=0.334, p <0.05) and employment status (r=14.146, p <0.01) on ODI. COMI is statistically influenced by sex (r=− 0.869, p <0.01), age (r=0.027, p <0.05) and employment status (r=0.830, p <0.05). PCS is statistically influenced by the employment status (r=− 8.568, p <0.01), age (r=− 0.228, p <0.05) and sex (r=5.525, p <0.05). Conclusions. According to the present study we observed that the perception of change in the quality of life and disability after surgery of the lumbar spine is independent of the initial pathology, the type of surgery and previous pain and disability; but sex, age and employment status have an important influence

Aims. People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

Lumbar fusion surgery is an established procedure for the treatment of several spinal pathologies. Despite numerous techniques and existing devices, common surgical trends in lumbar fusion surgery are scarcely investigated. The purpose of this Canada-based study was to provide a descriptive portrait of current surgeons’ practice and implant preferences in lumbar fusion surgery while comparing findings to similar investigations performed in the United Kingdom. Canadian Spine Society (CSS) members were sampled using an online questionnaire which was based on previous investigations performed in the United Kingdom. Fifteen questions addressed the various aspects of surgeons’ practice: fusion techniques, implant preferences, and bone grafting procedures. Responses were analyzed by means of descriptive statistics. Of 139 eligible CSS members, 41 spinal surgeons completed the survey (29.5%). The most common fusion approach was via transforaminal lumber interbody fusion (TLIF) with 87.8% performing at least one procedure in the previous year. In keeping with this, 24 surgeons (58.5%) had performed 11 to 50 cases in that time frame. Eighty-six percent had performed no lumbar artificial disc replacements over their last year of practice. There was clear consistency on the relevance of a patient specific management (73.2%) on the preferred fusion approach. The most preferred method was pedicle screw fixation (78%). The use of stand-alone cages was not supported by any respondents. With regards to the cage material, titanium cages were the most used (41.5%). Published clinical outcome data was the most important variable in dictating implant choice (87.8%). Cage thickness was considered the most important aspect of cage geometry and hyperlordotic cages were preferred at the lower lumbar levels. Autograft bone graft was most commonly preferred (61.0%). Amongst the synthetic options, DBX/DBM graft (64.1%) in injectable paste form (47.5%) was preferred. In conclusion, findings from this study are in partial agreement with previous work from the United Kingdom, but highlight the variance of practice within Canada and the need for large-scale clinical studies aimed to set specific guidelines for certain pathologies or patient categories

Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes. Our objective was to determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day post-operative complication rates. This study was a multicenter retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. All anterior cervical or posterior lumbar fusion surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery and emergency surgery were excluded. Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay and 30 day post-operative complication rates. 1441 patients met the inclusion criteria: 1142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertile of predicted surgery duration, cervical or lumbar surgery, instrumentation, inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, lumbar fusion surgery and inpatient surgery. There were no significant differences reported for any other factors. After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates, length of hospital stay or surgical duration of more routine surgical cases. We found that resident involvement in surgical cases that were generally more complexed resulted in increased surgery time. Further study is required to determine the relationship between surgery complexity and the effect of resident involvement on surgery duration

Background and Purpose. The UK's NIHR and Australia's NHMRC have funded two randomised controlled trials (RCTs) to determine if lumbar fusion surgery (LFS) is more effective than best conservative care (BCC) for adults with persistent, severe low back pain (LBP) attributable to lumbar spine degeneration. We aimed to describe clinicians’ decision-making regarding suitability of patient cases for LFS or BCC and level of equipoise to randomise participants in the RCTs. Methods. Two online cross-sectional surveys distributed via UK and Australian professional networks to clinicians involved in LBP care, collected data on clinical discipline, practice setting and preferred care of five patient cases (ranging in age, pain duration, BMI, imaging findings, neurological signs/symptoms). Clinicians were also asked about willingness to randomise each patient case. Results. Of 174 responses (73 UK, 101 Australia), 70 were orthopaedic surgeons, 34 neurosurgeons, 65 allied health professionals (AHPs), 5 others. Most worked in public health services only (92% UK, 45% Australia), or a mix of public/private (36% Australia). Most respondents chose BCC as their first-choice management option for all five cases (81–93% UK, 83–91% Australia). For LFS, UK surgeons preferred TLIF (36.4%), whereas Australian surgeons preferred ALIF (54%). Willingness to randomise cases ranged from 37–60% (UK mean 50.7%), and 47–55% (Australian mean 51.9%); orthopaedic and neuro-surgeons were more willing than AHPs. Conclusion. Whilst BCC was preferred for all five patient cases, just over half of survey respondents in both the UK and Australia were willing to randomise cases to either LFS or BCC, indicating clinical equipoise (collective uncertainty) needed for RCT recruitment. Conflicts of interest. None. Sources of funding. No specific funding obtained for the surveys. DB, SA, AG and NEF have funding from the National Institute for Health Research (NIHR) UK (FORENSIC-UK NIHR134859); NEF, DB and SA have funding from the Australian National Health and Medical Research Council (NHMRC FORENSIC-Australia GA268233). AG has funding from Orthopaedic Research UK (combined with British Association of Spine Surgeons and British Scoliosis Society) and Innovate UK. NEF is funded through an Australian National Health and Medical Research Council (NHMRC) Investigator Grant (ID: 2018182)

Background: A common complication of lumbar spine surgery is incidental tear of the dural sac and subsequent leakage of the cerebrospinal fluid intraoperatively. Studies have reported a wide variation in the rates of dural tears in spine surgery (1%–17%). The rates were higher after revision surgery. Objective: To establish a baseline rate of incidence of dural tears after lumbar surgery in Morriston Hospital Neurosurgical Unit and to compare it with the results reported in the literature. Methods and Results: A prospective review of the operation notes of 65 consecutive patients who had undergone lumbar surgery (Primary lumbar discectomy, primary lumbar laminectomy and revision lumbar discectomy) over a period of 3 months from Jan 2008. Patients were operated on by different neurosurgical consultants. 40 patients had primary lumbar discectomy of which 2 (5%) had dural tears. 20 patients had primary lumbar laminectomy of which 1 (5%) had a dural tear and 5 patients had revision lumbar discectomy of which 1 (20%) had a dural tear. All dural tears were repaired intraoperatively. Conclusion: This study shows that the highest percentage of incidental durotomy was in revision lumbar surgery which was also slightly higher than the reported rates (8.1%–17.4%). The percentage of dural tears after primary discectomy and primary laminectomy was within range of the percentages reported in the literature (1%–7.1%) and (3.1%–13%) respectively. A multicentre prospective larger study which includes all different surgical procedures performed on the lumbar spine is needed to establish a more accurate incidence rate for this common complication

The problems arising at the levels above or below a previous successful fusion are well known. The aim of this study was to determine the incidence of junctional disk degeneration and/or stenosis and to attempt to establish preventative measures.

Between July 1993 and December 2000, a single surgeon performed lumbosacral fusions on 938 patients. The primary fusion was subsequently extended in 26 men and 16 women (2.8%). The mean age of patients at the time of the second fusion was 52 years. The mean time from the primary to a second procedure was three years. Initial data showed that seven patients had mild to moderate degeneration of the disc and/or facet joints above the level of intended fusion. No other risk factors were identified.

At 2.8%, it would appear that extension of a fusion is necessary less often than anticipated. The need for extension may have been prevented in seven patients had the primary fusion been extended.

There is increasing knowledge regarding the functional outcome of patients following posterior lumbar spinal surgery for degenerative conditions of the spine. There is less known regarding the expectations patients have for spinal surgery and how that may relate to commonly reported surgical outcome measures. It was the purpose of this study to evaluate the results of elective lumbar spinal surgery as it relates to patient expectations for outcome. and outcome as quantified by both physician reported outcome and patient derived generic and disease-specific measures. Patient expectations for surgery were evaluated in one hundred and fifty-five consecutive patients undergoing posterior lumbar surgery for degenerative conditions (single institution, two surgeons). SF-36+Oswestry disability was quantified preoperatively, and serially postoperatively. Preoperative expectations (pain relief, sleep, recreational, ADL, work return) were documented and postoperative expectations quantified at time of anticipated maximal medical improvement (6mos decompressions,1yr with fusions). Mean preoperative SF-36 MCS and PCS scores were 3.4 and 1.2 S.D. below age/gender matched Canadian norms. Although patients reported improvements in SF-36+Oswestry scores following surgery, mean SF-36 MCS and PCS scores were still 2 and 1.5 S.D. below norms. Mean Oswestry disability improved from 48.7%±1.7% to 23.1±1.9%. Expectations for surgery were met in 81%(responders:143/155). Of 19%(27/143) where expectations were not met, 6/27 have either nonunion, technical, or medical factors. There was no difference in mean age, gender, comorbidity, procedure type and follow-up comparing patients where expectations were met to those that were not. Patients where expectations were not met reported lower preoperative SF-36 (GH and VT) domain scores (p=0.02 and 0.04, respectively), however, preoperative Oswestry, SF-36 MCS and PCS scores were not significantly different. Patients were less satisfied if they had prior lumbar surgery (p=0.02) or involved in WCB/litigation (p< 0.001). We note 15%(21/143) where expectations were not met and there were no apparent surgical or medical confounds to account. There are likely other factors that may influence patient perception and expectation for treatment which requires further study

Background:. Following lumbar spine surgery patients with a high BMI appear to have increased post-operative complications including surgical site infections (SSI), urinary complications, increased anaesthetic/operative time and a greater need for post-operative blood transfusion. There is no current evidence, however, analysing the effect of BMI on functional outcome. Purpose:. We aimed to analyse the effect of BMI on functional outcome following lumbar spine surgery. Study Design:. Retrospective Cohort Study. Patient Sample:. 131. Outcome Measures:. Outcome measures included mean post-operative Oswestry Disability Index (ODI) at six and twelve months, the incidence of SSI, mean operative time and the requirement for post-operative blood transfusion. Methods:. Patients that underwent lumbar spinal surgery between September 2010 and November 2013 were identified retrospectively and categorised into discectomy, decompression, fusion and revision is created. A BMI threshold of 30 was used to group patients as non-obese or obese. Univariate analysis was used to compare the effect of BMI on the above outcome measures. Results:. Post-operative complication rates were higher in the obese group in each category. However, there was no significant difference in the post-operative ODI at six ad twelve months post-operatively. Conclusions:. Increased BMI is related to increased post-operative complications but is not associated with a poorer functional outcome in the short to mid-term

Lumbar spinal surgery may be associated with considerable pain in the early postoperative period. This often leads to a delay in patient mobilisation and a consequent increase in the risk of developing perioperative complications. Several studies have demonstrated the efficacy of intrathecal opioids for analgesia following spinal surgery. 1. –. 3. Morphine has been the most widely studied opioid and although improved analgesia has been reported with its use the risk of serious side effects such as respiratory depression has resulted in patients having to be nursed postoperatively in a high dependency unit. 2. Intrathecal diamorphine has been widely used for analgesia following lower limb joint replacement where it is an effective analgesic agent with a good safety profile. 4. –. 5. Its use for analgesia following lumbar spinal surgery has never been reported. We present our experience of using intrathecal diamorphine for analgesia following lumbar spinal surgery. Data were collected on all patients undergoing surgery who received intrathecal diamorphine and stored on a database (Microsoft Access). Results: 194 patients received intrathecal diamorphine following spinal surgery over a 30 month period. All patients underwent lower lumbosacral decompressive and/or fusion surgery. Mean dose of diamorphine administered was 1.6mg (range 1–4mg or 20–50mcg/kg). In all cases intrathecal diamorphine was administered by the anaesthetist once the patient was anaesthetised. Only 9% of patients had a pain score of 2 or greater within the first 24 hours (using a verbal rating scale 0–10). No patients required rescue analgesia with intravenous opiates. All patients except one were nursed on a regular orthopaedic ward. Side effects were rare. Respiratory depression occurred in one patient necessitating supplemental oxygen and monitoring in a high dependency unit for 12 hours. Hypotension was an infrequent finding (3.5%) but was most common upon return to the ward and in the following 24 hours. It was easily treated with the administration of intravenous fluids and vasopressors were never required. Sedation occurred in 4 of the patients whilst in the recovery ward but the incidence was nil once patients had been discharged to the orthopaedic ward. The most common complication recorded was pruritis, occurring in 9% of patients within the first 12 hours. Conclusion: Intrathecal diamorphine is an effective and safe method of providing analgesia following lumbar spinal surgery. High Dependency nursing care is not required as the incidence of serious side effects is low

Introduction. This study investigates the effect of somatisation on results of lumbar surgery. Methods. Pre- and post-operative data of all primary discectomies and posterior lumbar decompressions were prospectively collected. Pain using the Visual Analogue Score (VAS) and disability using the Oswestry Disability Index (ODI) were measured. Psychological assessment used the Distress Risk Assessment Method (DRAM). Follow-up was at 1 year. Results. There were a total of 320 patients (average age 49.7 years). Pre-operatively there were 61 Somatising and 75 psychologically Normal patients. 47 of the pre-operative Somatisers were available for follow-up. All pre-operative parameters were significantly higher compared with the Normal group (back pain VAS 6.3 and 3.8; leg pain VAS 7 and 4.7; ODI 61 and 34.4 respectively). At 1 year follow-up, 23% of the somatising patients became psychologically Normal; 36% became At Risk; 11% became Distressed Depressed; and 30% remained Distressed Somatisers. The post-operative VAS for back and leg pain of the 11 patients who had become psychologically Normal was 3.4 (pre-op 6.8) and 3.2 (pre-op 6.6) respectively. In the 14 patients who remained Distressed Somatisers the corresponding figures were 5.6 (pre-op 7.8) and 6.7 (pre-op 7.0). The post-operative ODI of the 11 patients who had become psychologically Normal was 26.4 (pre-op 55.5). In the 14 patients who remained Distressed Somatisers the corresponding figures were 56.7 (pre-op 61.7). These differences are statistically significant. Discussion. Patients with features of somatisation are severely functionally impaired pre-operatively. One year following lumbar spine surgery, 60% (28) had improved psychologically, 23% (11) were defined as psychologically normal. This was associated with a significant improvement in function and back and leg pain. The 14 (30%) patients who did not improve psychologically and remained somatisers had a poor functional outcome. Our results demonstrate that psychological distress is not an absolute contraindication to lumbar spinal decompressive surgery

Introduction: This study investigates the effect of soma-tisation on results of lumbar surgery. Methods: Pre- and postoperative data of all primary discectomies and posterior lumbar decompressions was prospectively collected. Pain using the Visual Analogue Score (VAS) and disability using the Oswestry Disability Index (ODI) were measured. Psychological assessment used the Distress Risk Assessment Method (DRAM). Follow-up was at 1 year. Results: There were a total of 320 patients (average age 49.7 years). Preoperatively there were 61 Somatising and 75 psychologically Normal patients. 47 of the pre-operative Somatisers were available for follow-up. All pre-operative parameters were significantly higher compared with the Normal group (back pain VAS 6.3 and 3.8; leg pain VAS 7 and 4.7; ODI 61 and 34.4 respectively). At 1 year follow-up, 23% of the somatising patients became psychologically Normal; 36% became At Risk; 11% became Distressed Depressed; and 30% remained Distressed Somatisers. The postoperative VAS for back and leg pain of the 11 patients who had become psychologically Normal was 3.4 (pre-op 6.8) and 3.2 (pre-op 6.6) respectively. In the 14 patients who remained Distressed Somatisers the corresponding figures were 5.6 (pre-op 7.8) and 6.7 (pre-op 7.0). The postoperative ODI of the 11 patients who had become psychologically Normal was 26.4 (pre-op 55.5). In the 14 patients who remained Distressed Somatisers the corresponding figures were 56.7 (pre-op 61.7). These differences are statistically significant. Discussion: Patients with features of somatisation are severely functionally impaired preoperatively. One year following lumbar spine surgery, 60%(28) had improved psychologically, 23%(11) were defined as psychologically normal. This was associated with a significant improvement in function and back and leg pain. The 14(30%) patients who did not improve psychologically and remained somatisers had a poor functional outcome. Our results demonstrate that psychological distress is not an absolute contraindication to lumbar spinal decompressive surgery

Purpose. The behavioural change wheel methodology and social cognitive theory were combined to inform and develop a rehabilitation programme following lumbar fusion surgery (REFS). This qualitative study evaluated participant's experiences of lumbar fusion surgery, including REFS, to identify valued programme content (‘active ingredients’). Background. A feasibility-RCT suggested REFS achieved a meaningful impact in disability and pain self-efficacy compared to ‘usual care’ (p=0.014, p=0.007). In keeping with MRC guidance a qualitative evaluation was undertaken to understand possible mechanisms of action. Methods. Thematic analysis was utilised on data from semi-structured, face-to-face interviews, in a purposive sample (REFS n=10, ‘usual care’ n=10). Results. Three themes (8 sub-themes) were identified, which illuminated the experiences of 1) the impact of living with a chronic lumbar disorder 2) reflections on recovery, and 3) the experience of rehabilitation with(out) REFS. REFS participants identified valued programme content including the opportunity for vicarious learning, the shared rehabilitation experience, and expert physiotherapy. They were unable to identify pre-eminent programme content, in keeping with inter-dependent ‘active ingredients’. Abstraction with the overarching theme of ‘loss of self’ was evident for analysis across all themes. Conclusion. In conclusion the findings were theoretically congruous with other published works e.g. recent mega-ethnographic review of patients experience of chronic non-malignant pain. Two emergent areas were identified to inform future REFS iterations and better understand potential mechanisms of action. 1-Participants fear of harm appears directly attributable to the instillation of metalware, this association is mediated by inadequate advice. 2-Lumbar fusion surgery is not perceived as elective. No conflicts of interest. Funding; NIHR (Doctoral fellowship, awarded to J Greenwood)

Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS. In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS

An independent audit of Lumbar Spinal surgery performed by a single surgeon over a 4 year period is presented. The three groups evaluated included Lumbar fusion, decompression and discectomy. Patients were assessed using the Oswestry Disability Questionairre and five other questions related to overall outcome and patient satisfaction. The minimum follow-up was 6 months. Patient response rate was 74%. The overall outcome was 81% Excellent/Good vs 19% Fair/Poor. The best outcomes were in the discectomy group. The decompression group showed a variable and unpredictable outcome. Complications encountered in the three subgroups are discussed. Lumbar spinal surgery offers lasting and predictable outcomes to a large majority of well selected patients. Independent surgical audits form an important part of evaluating one’s surgical practice