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

Aims. As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion. Methods. We retrospectively reviewed 584 patients who had undergone lumbar spinal fusion for degenerative lumbar spinal disease. The 'simple' group (SG) consisted of patients who had undergone one- or two-level posterior lumbar fusion. The 'complex' group (CG) consisted of patients who had undergone fusion over three or more levels, or combined anterior and posterior surgery. On admission, the mFI-5 was calculated and nutritional parameters collected. Results. Complications occurred in 9.3% (37/396) of patients in the SG, and 10.1% (19/167) of patients in the CG. In the SG, the important predictors of complications were age (odds ratio (OR) 1.036; p = 0.002); mFI-5 (OR 1.026 to 2.411, as score increased to 1 ≥ 2 respectively. ;. p = 0.023); albumin (OR 11.348; p < 0.001); vitamin D (OR 2.185; p = 0.032); and total lymphocyte count (OR 1.433; p = 0.011) . In the CG, the predictors of complications were albumin (OR 9.532; p = 0.002) and vitamin D (OR 3.815; p = 0.022). Conclusion. The mFI-5 and nutritional status were effective predictors of postoperative complications in the SG, but only nutritional status was successful in predicting postoperative complications in the CG. The complexity of the surgery, as well as the preoperative frailty and nutritional status of patients, should be considered when determining if it is safe to proceed with lumbar spinal fusion. Cite this article: Bone Joint J 2020;102-B(12):1717–1722

The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP). A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p < 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p < 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-obese patients. Based on these results, obesity is not a contraindication to lumbar spinal fusion. Cite this article: Bone Joint J 2015;97-B:1395–1404

Introduction:. Several reports showed superior fusion rates, as high as 100%, using rhBMP-2 with ALIF cages. This has led to the widespread off-label use of rhBMP-2 in several other lumbar fusion procedures. There is paucity of reports analysing the clinic-radiological outcome of using rhBMP-2 to promote bone union in cases of symptomatic pseudoarthosis following lumbar spine fusion. Methods:. 52 consecutive patients who underwent revision spinal surgery for symptomatic pseudoarthosis utilizing rhBMP-2 between 2008 and 2013 were included in the study. Demographic, and surgical data were collected from medical records. Functional outcomes were recorded using the ODI. All patients had preoperative fine-cut CT scan to confirm pseudoarthosis. Postoperative CT-scan at 6 months was routinely done to confirm fusion. Results:. Average age at time of revision surgery was 54years (range 28–73). Average follow up was 3 years 5 months (range 2–5 years). Overall fusion rate of 92.3% (48/52) was achieved. The average ODI has improved from 56% preoperatively to 49% postoperatively. We had 1 infection case, and 5 complications related to metalwork. One case with neuronal complications was recorded. No rhBMP-2 related complications. There was no record of heterotopic bone formation in the spinal canal or the neuroforamen. Conclusion:. Recombinant BMP-2 is a safe and effective adjunct to revision lumbar spinal fusion surgery to alleviate back pain symptoms from pseudoarthosis. The limitations of the study include: retrospective review, lack of matched cohort utilising iliac crest bone graft, and relatively short follow-up

Introduction. Both intra- and post-operative radiographs are traditionally obtained after instrumented lumbar spinal surgery; however the clinical advantage of routine post operative images has not been demonstrated. Aim. To explore the usefulness of routine pre-discharge postoperative radiographs in patients undergoing instrumented spinal surgery. Methodology. Patients (n = 124) who underwent a lumbar spinal fusion were identified from a retrospective database, 58 patients were excluded. Unaltered intra-operative and pre-discharge post-operative PACS images for 66 patients were reviewed and were scored for: i) Quality (0 = non-diagnostic, 1 = suboptimal, 2 = diagnostic, 3 = good quality), ii) Focus (number of vertebra and disc seen), iii) Centering using a numbered (1–9) grid system, and iv) Rotation. Results. 66 radiographs were analysed for i) Quality: 60 AP and 56 lateral intra-operative images while 57 AP and 39 lateral postoperative images were diagnostic, ii) Focus: average number of unnecessary vertebra seen in intra-operative AP and lateral images were 0.89 and 1.09, while on post-operative AP and lateral images were 8.05 and 6.45 respectively, iii) Centering: 48 AP and 51 lateral intra-operative images, while 27 AP and 20 lateral post-operative images were adequately centered and iv) Rotation was adequate in both intra-operative and post-operative images. Conclusion. Intra-operative images scored higher in all parameters suggesting that routine post-operative pre-hospital discharge radiographs are unnecessary unless specifically indicated and this practice should be discontinued with benefits including reduction of radiation dose (and subsequent sequelae), fiscal burden and length of stay

Objectives. Loss of motion following spine segment fusion results in increased strain in the adjacent motion segments. However, to date, studies on the biomechanics of the cervical spine have not assessed the role of coupled motions in the lumbar spine. Accordingly, we investigated the biomechanics of the cervical spine following cervical fusion and lumbar fusion during simulated whiplash using a whole-human finite element (FE) model to simulate coupled motions of the spine. Methods. A previously validated FE model of the human body in the driver-occupant position was used to investigate cervical hyperextension injury. The cervical spine was subjected to simulated whiplash exposure in accordance with Euro NCAP (the European New Car Assessment Programme) testing using the whole human FE model. The coupled motions between the cervical spine and lumbar spine were assessed by evaluating the biomechanical effects of simulated cervical fusion and lumbar fusion. Results. Peak anterior longitudinal ligament (ALL) strain ranged from 0.106 to 0.382 in a normal spine, and from 0.116 to 0.399 in a fused cervical spine. Strain increased from cranial to caudal levels. The mean strain increase in the motion segment immediately adjacent to the site of fusion from C2-C3 through C5-C6 was 26.1% and 50.8% following single- and two-level cervical fusion, respectively (p = 0.03, unpaired two-way t-test). Peak cervical strains following various lumbar-fusion procedures were 1.0% less than those seen in a healthy spine (p = 0.61, two-way ANOVA). Conclusion. Cervical arthrodesis increases peak ALL strain in the adjacent motion segments. C3-4 experiences greater changes in strain than C6-7. Lumbar fusion did not have a significant effect on cervical spine strain. Cite this article: H. Huang, R. W. Nightingale, A. B. C. Dang. Biomechanics of coupled motion in the cervical spine during simulated whiplash in patients with pre-existing cervical or lumbar spinal fusion: A Finite Element Study. Bone Joint Res 2018;7:28–35. DOI: 10.1302/2046-3758.71.BJR-2017-0100.R1

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.

To assess implant performance, to evaluate fusion and to assess clinical and radiologic outcome of circumferential fusion using porous tantalum cages for ALIF in a 360-degree fusion.

A retrospective cohort study was performed over a 4-year period that included the implantation of 280 tantalum cages in 98 patients by the technique of anterior lumbar interbody fusion (ALIF) and posterolateral spondylodesis. Radiographic follow-up was performed to document any implant related problems. Preoperative and postoperative clinical outcome measures were assessed.

No neurological, vascular or visceral injuries were reported. There were no rod breakages and no symptomatic non-unions. One revision procedure was performed for fracture. Mean VAS back pain score in our patient cohort improved from 7.5 preoperatively to 1.9 at latest follow-up, mean VAS leg pain score improved from 6.2 to 1.1 and mean ODI score improved from 51.1 to 18.3.

Porous tantalum cages have high strength and flexibility, in addition to having similar biomaterial properties to cancellous bone. Their use in 360-degree spondylodesis to treat degenerative lumbar spine deformity has been demonstrated to be very safe and effective, with excellent clinical and functional outcomes.

Increasing numbers of posterior lumbar fusions are being performed. The purpose of this study was to identify trends in demographics, mortality and major complications in patients undergoing primary posterior lumbar fusion. We accessed data collected for the Nationwide Inpatient Sample for each year between 1998 and 2008 and analysed trends in the number of lumbar fusions, mean patient age, comorbidity burden, length of hospital stay, discharge status, major peri-operative complications and mortality. An estimated 1 288 496 primary posterior lumbar fusion operations were performed between 1998 and 2008 in the United States. The total number of procedures, mean patient age and comorbidity burden increased over time. Hospital length of stay decreased, although the in-hospital mortality (adjusted and unadjusted for changes in length of hospital stay) remained stable. However, a significant increase was observed in peri-operative septic, pulmonary and cardiac complications. Although in-hospital mortality rates did not change over time in the setting of increases in mean patient age and comorbidity burden, some major peri-operative complications increased. These trends highlight the need for appropriate peri-operative services to optimise outcomes in an increasingly morbid and older population of patients undergoing lumbar fusion.

Purpose and background. Lumbar spinal fusion (LSF) is frequently and increasingly used in lumbar degenerative disorders despite conflicting results and recommendations. Further understanding of patient outcomes after LSF is required to inform decisions regarding surgery and to improve post-surgery management. The objective was to evaluate the course of pain and disability in patients with degenerative disorders of the lumbar spine (spinal stenosis, spondylolisthesis, disc herniation, discogenic low back pain) after first-time LSF. Methods and results. A systematic review and meta-analysis of pain and disability outcomes in prospective cohort studies after first time LSF for degenerative disorders. Two independent researchers searched key databases, determined study eligibility, extracted data and assessed risk of bias (modified Quality in Prognostic Studies tool). A third reviewer mediated at each stage. N weighted pooled estimates were calculated. Twenty-five articles (n=1,777 participants) were included. 17 studies were at unclear risk of bias and 8 at high risk. Back pain (12 studies) decreased modestly and irregularly at follow-up intervals. The n weighted mean VAS back pain decreased from 65.4 (±3.3) pre-surgery to 22.2 (±3.1) at 23 months, but then 45.0 (±not reported; 2 studies at risk of bias) at 42 months. In contrast, leg pain (12 studies) improved substantially short and long-term. Disability (20 studies) improved steadily over time with the exception of the 42-months and 48-months intervals. Conclusion. The overall improvement of leg pain and disability after first-time LSF in degenerative disorders is promising in contrast to back pain outcomes. Further research is needed to analyse outcomes in patients of different diagnostic subgroups. Conflicts of interest. None. Sources of funding. None

Fracture of a pedicle is a rare complication of spinal instrumentation using pedicular screws, but it can lead to instability and pain and may necessitate extension of the fusion. Osteosynthesis of the fractured pedicle by cerclage-wire fixation and augmentation of the screw fixation by vertebroplasty or temporary elongation of the fixation, allows stabilisation without sacrifice of the adjacent healthy segment. We describe three patients who developed a fracture of the pedicle in the most caudal instrumented vertebra early after lumbar spinal fusion. During revision surgery the pedicles were reduced and secured by a soft cerclage wire bilaterally. Fusion was obtained at the site of the primary instrumentation and healing of the pedicles was achieved. Cerclage wiring of the fractured pedicle seems to be safe and avoids permanent extension of the fusion without the sacrifice of an otherwise healthy segment

Background. For bone grafting procedures, the use of autologous bone is considered the gold standard, as it is has a better healing capacity compared to other alternatives as allograft and synthetic bone substitutes. However, as there are several drawbacks related to autografting (infection, nerve- or vascular damage, chronic pain problems, abdominal herniation), there has been a targeted effort to improve the healing capacities of synthetic bone substitutes. Aim. To evaluate the performance of a carbonated osteoionductive hydroxyapatite (CHA) scaffold of clinical relevant size (Ø=15mm, H=50mm) in a sheep model of multi level posterolateral intertransverse lumbar spine fusion after activation with autologous bone marrow nuclear cells (BMNC) in a flow perfusion bioreactor. Method. Two groups were included in the study, autograft (n=6) and CHA scaffold (n=6) CHA. A paired design was used between and within the groups as lumbar posterolateral arthrodesis was performed in sheep on two levels (L2-L3, L5-L6) +/− BMNC, respectively. Before implantation, the CHA scaffold was cultured in a flow perfusion bioreactor system with BMNC for 21 days, and the autograft group was supplemented with isolated BMNC during the procedure. Micro tomography was used to evaluate fusion rate and the microarchitectural properties of the explants after an observation period of four months. Results. In the autograft group, the healing rate was 83.3% irrespective of the presence BMNC, and in the CHA group, 66.7% fused in the presence of BMNC, and 33.3% without. The microarchitectural data suggested the autograft group to be superior to the CHA scaffold regarding mechanical properties, however porosity decreased significantly (p=0.001) in the CHA scaffold group suggesting deposition of mineralized bone matrix. Conclusion. Based on the fusion rate and micro architectural properties, we consider the CHA scaffold fully capable of new bone formation, and that the presence of BMNC has a positive effect on the fusion rate in a challenging model of bone healing

Aims

The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system.

Introduction. Lumbar spinal pain can be a consequence of discogenic pain. After failure of conservative management, lumbar fusions are popular and considered the gold standard. However, these techniques are associated with significant morbidity. A percutaneous trans-sacral technique may address these for L4/L5 and/or L5/S1 alone spinal fusions. Our unit has adopted this technique and presents our initial experience of 51 patients and preliminary results. Method. Patients with a confirmed clinical and radiological evidence of degenerate intervertebral disc with or without prior surgical intervention were selected. Patients with a history of pelvic surgery/radiotherapy were excluded. Data was collected prospectively using the Global Patient Outcome Scoring System and Oswestry Disability Index (ODI) scores at clinical follow-up. Results. 51 patients received the procedure and 30 achieving a minimum of 6 months follow-up. Patients had a median age of 46(range 20-78) and included 19 male and 32 females with on average 40 months of pain. The mean ODI score improved after surgery from pre-operative levels 52.9(SEM 3.0) to 6 month scores of 38.4(SEM 3.9), t(29)=4.2, p<0.0002 . This difference remained statistically significant at 12 month follow-up with a mean ODI scores 34.3 (SEM 5.2), t(18)=4.37, P<0.0004 (Mean difference of 21.1 SEM 4.8). A sub-analysis of confounding factors identified patients with previous surgery, claiming state benefits, pursuing litigation, mainly leg pain and requiring pedicular fusion failed to achieve statistical significance. Patients receiving a 360 degree fusion with facet screws alone improved sooner and achieving a mean difference in ODI score of 27.6(SEM 8.2). Conclusion. Our initial results confirm this to be an effective alternative treatment modality for lumbar spine fusion in the management of primary discogenic back pain. Patients receiving 360 degree fusion and not claiming state benefits or pursuing litigation appear to have a better outcome

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Aims

Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse.

Aims

Chronic low back pain due to degenerative disc disease is sometimes treated with fusion. We compared the outcome of three different fusion techniques in the Swedish Spine Register: noninstrumented posterolateral fusion (PLF), instrumented posterolateral fusion (IPLF), and interbody fusion (IBF).

Objectives

We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis.

Aims

We compared the clinical and radiological outcomes of using a polyetheretherketone cage with (TiPEEK) and without a titanium coating (PEEK) for instrumented transforaminal lumbar interbody fusion (TLIF).

The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre.

Cite this article: 2015; 97-B:1102–5.