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

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

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

The objective of this paper is to demonstrate the difference in post-operative complication rates between Computer-assisted surgery (CAS) and conventional techniques in spine surgery. Several studies have shown that the accuracy of pedicle screw placement significantly improves with use of CAS. Yet, few studies have compared the incidence of post-operative complications between CAS and conventional techniques. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent posterior lumbar fusion from 2011 to 2013. Multivariate analysis was conducted to demonstrate the difference in post-operative complication rates between CAS and conventional techniques in spine surgery. Out of 15,222 patients, 14,382 (95.1%) were operated with conventional techniques and 740 (4.90%) were operated with CAS. Multivariate analysis showed that patients in the CAS group had less odds to experience adverse events post-operatively (OR 0.57, P <0.001). This paper examined the complications in lumbar spinal surgery with or without the use of CAS. These results suggest that CAS may provide a safer technique for implant placement in lumbar fusion surgeries

Hemorrhage and transfusion requirements in spine surgery are common. This is especially true for thoracic and lumbar fusion surgeries. The purpose of this papersi to determine predictive factors for transfusion and their effect on short-term post-operative outcomes for thoracic and lumbar fusions. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent lumbar or thoracic fusion surgery from 2010 to 2013. Univariate and multivariate regression analysis was used to determine predictive factors and post-operative complications associated with transfusion. A total of 14,249 patients were included in this study; 13,586 had lumbar fusion and 663 had thoracic fusion surgery. The prevalence of transfusion was 35% for thoracic fusion and 17.5% for lumbar fusion. The multivariate analysis showed that age between 50–60 (OR 1.38, CI: 1.23–1.54), age between 61–70 (OR 1.65, CI: 1.40–1.95), dyspnea (OR 1.11, CI: 1.02–1.23), hypertension (OR 1.14, CI: 1.02–1.27), ASA class (OR 1.73, 1.18–1.45), pre-operative blood transfusion (OR 1.91, CI: 1.04–3.49), and extended surgical time (OR 4.51, CI: 4.09–4.98) were predictors of blood transfusion requirements for lumbar fusion. While only pre-operative BUN (OR 1.04, CI: 1.01–1.06) and extended surgical time (OR 4.70, CI: 3.12–6.96) were predictors of transfusion for thoracic fusion. In contrast, higher pre-operative hematocrit was protective against transfusion. Patients transfused who underwent lumbar fusion had an increased risk to develop superficial wound infection, deep wound infection, venous thromboembolism, myocardial infarction and had longer length of hospital stay. Patients transfused who underwent thoracic fusion were more likely to have venous thromboembolism and extended length of hospital stay. However, mortality was not associated with blood transfusion. This study used a large database to characterise the incidence, predictors and post-operative complications associated with blood transfusion in thoracic and lumbar fusion surgeries. Pre- and post-operative planning for patients deemed to be at high-risk of requiring blood transfusion should be considered to reduce post-operative complication in this population

Background. Surgical site infection following spine surgery is associated with increased morbidity, mortality and increased cost for the health care system. The reported pooled incidence is 3%. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and often involve the lumbar spine. Accordingly, the objective was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column of the same lumbar vertebra using microdialysis in an experimental porcine model. Method. The lumbar vertebral column was exposed in 8 female pigs. Microdialysis catheters were placed for sampling in the anterior column (vertebral body) and posterior column (posterior arch) within the same vertebra (L5). Cefuroxime (1.5 g) was administered intravenously over 10 min. Microdialysates and plasma samples were continuously obtained over 8 hours. Cefuroxime concentrations were quantified by Ultra High Performance Liquid Chromatography Tandem Mass Spectrometry. Microdialysis is a catheter-based pharmacokinetic tool, that allows dynamic sampling of unbound and pharmacologic active fraction of drugs e.g., cefuroxime. The primary endpoint was the time with cefuroxime above the clinical breakpoint minimal inhibitory concentration (T>MIC) for Staphylococcus aureus of 4 µg/mL as this has been suggested as the best predictor of efficacy for cefuroxime. The secondary endpoint was tissue penetration (AUC. tissue. /AUC. plasma. ). Results. Mean T>MIC 4 µg/mL (95% confidence interval) was 123 min (105–141) in plasma, 97 min (79–115) in the anterior column and 93 min (75–111) in the posterior column. Tissue penetration (95% confidence interval) was incomplete for both the anterior column 0.48 (0.40–0.56) and posterior column 0.40 (0.33–0.48). Conclusions. Open lumbar spine surgery often involves extensive soft tissue dissection, stripping and retraction of the paraspinal muscles which may impair the local blood flow exposing the lumbar vertebra to postoperative infections. A single intravenous administration of 1.5 g cefuroxime resulted in comparable T>MIC between the anterior and posterior column of the lumbar spine. Mean cefuroxime concentrations decreased below the clinical breakpoint MIC for S. aureus of 4 µg/mL after 123 min (plasma), 97 min (anterior column) and 93 min (posterior column). This is shorter than the duration of most lumbar spine surgeries, and therefore alternative dosing regimens should be considered in posterior open lumbar spine surgeries lasting more than 1.5 hours

Introduction. Functional deficits persist in a significant percentage of total hip arthroplasties (THA), leading to patient dissatisfaction. Spinal stenosis is a leading cause of chronic disability and lower extremity weakness. Although previous studies have evaluated the potential benefit of THA on back pain, none have reported the effects of spine disability on functional outcomes and patient satisfaction with THA. Methods. 244 primary THAs (233 patients) with minimum 2-year follow-up rated their satisfaction, return to activity, and standard hip outcomes using the Oxford Hip Score (OHS). History of lumbar spine pain, lumbar surgery, and daily activity limitations was documented and an Oswestry Disability Index (ODI) score was calculated. Results. 151 of 244 (62%) patients reported a history of back problems: 35 patients (14%) – history of lumbar surgery, 91 (37%) – daily low back pain, and 97 (40%) – back pain that limited activity. Patients with a history of back problems had lower OHS scores than those without, p=0.0001. Pain relief was reported by 93% versus resumption of activities in 82% of THA patients, p=0.025. Increasing spine disability, as determined by ODI, correlated with poor OHS, p<0.0001. Spine disability (ODI) was directly associated with patient dissatisfaction for pain relief (R=0.41, p<0.0001), return to activity (R=0.34, p<0.0001), and overall surgical results (ODI, R=0.38, p<0.0001) at 2 years after THA. Patient age, gender, and BMI were not associated with poor THA outcomes. Conclusions. The majority of THA patients have a history of lumbar spine problems. The Oswestry Spine Disability Index, which is the primary outcome measure of spinal disorders, correlated strongly with poor THA outcomes. Moderate and severe lumbar spine disability directly correlated with worse Oxford Hip Scores. Spine disability was directly associated with THA dissatisfaction

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Purpose of study. This RCT is to determine whether or not there is a clinical benefit from inserting a dynamic stabilising implant such as the Wallis ligament on the functional recovery of patients who have undergone lumbar decompression surgery. This Interspinous implant was developed as an anatomically conserving procedure without recourse to lumbar spinal fusion surgery. The biomechanical studies have shown that unloading the disc and facet joints reduces intradiscal pressures at same and adjacent levels. The aim of this study was to identify a patential Wallis affect. Methods. Ethicallly approved. Patients were randomized into 2 groups, decompression alone or decompression with wallis interspinous ligament stabilisation. Patients were assessed pre operatively and post operatively every 6 months by VAS pain score and Oswestry Disability Index. Summary of findings. A total of 60 patients were recriuted the study from October 2005. Equal number had been randomized into two groups. The mean age of 54 (24–85) and the average follow is 36 months (6–48). The results were significantly better in decompression plus Wallis group compared to decompression alone, showing a minimal clinical difference compared to the control group. Relationship between findings and existing knowledge: Our results deomonstrate that clincial outcomes are significantly better when a Wallis implant was used in lumbar deompression. Patients experienced less back pain. Overall significance of findings: The Wallis implant represents a successful non fusion stabilisation device in the treatment of degenerative lumbar spine disease with canal stenosis. Minimal soft tissue dissection, quick rehabilitation, low morbidity. The Wallis ligament sucessfully treats spinal stenosis by reducing pain score, preserving mobility, and function

Background. The factors that are considered to be associated with successful clinical outcome fallowing cervical arthroplasty surgery are patient selection, absence of facet joint changes and lack of pre-operative kyphosis. Even though many studies have cited the pre-operative demographic details of their patient groups, the effect of associated psychological co-morbidities (Depression/Anxiety), smoking history, gender, social benefits and employment status on the clinical outcome measures have not been reported. The aim of the study was to assess the influence of pre-operative patient characteristics on the clinical outcomes following cervical disc replacement. Methods. We included 126 patients who underwent single or multiple level cervical arthroplasty in our unit were included in the study. The clinical outcome measures such as Visual Analogue Score for neck pain (VAS-NP) and arm pain (VAS-AP); Neck disability Index (NDI), Hospital depression and anxiety scale and Bodily pain component of Short Form 36 questionnaires (SF-36 P) were recorded pre and post operatively. Statistical analysis was completed using SPSS 16.0 statistical package (SPSS Inc, Chicago, IL). Results. There were 60 males and 63 females. Average duration of follow up was 18 months (Range 10–51). Out of 123 patients, 37 patients had a history of anxiety/depression, 25 patients gave history of smoking, 64 were actively working at the time of operation and 27 were receiving social benefits. We have found that gender; smoking status, associated co-morbidities, working and benefit status had no statistically significant contribution to clinical outcome measures in the follow up period. Conclusion. This is has been a first ever attempt to analyse the affect these psychosocial factors on the clinical outcomes following cervical arthroplasty. In our study, contrary to studies related lumbar surgeries, we conclude that there is no statistically significant contribution of associated psychosocial factors on the clinical outcomes in the early follow up period

Metal Ion Levels Not Useful in Failed M-O-M Hips: Systematic Review; Revision of Failed M-O-M THA at a Tertiary Center; Trunnionosis in Metal-on-Poly THA?; Do Ceramic Heads Eliminate Trunnionosis?; Iliopsoas Impingement After 10 THA; Pain in Young, Active Patients Following THA; Pre-operative Injections Increase Peri-prosthetic THA Infection; Debridement and Implant Retention in THA Infection; THA after Prior Lumbar Spinal Fusion; Lumbar Back Surgery Prior to THA Associated with Worse Outcomes; Raising the Joint Line Causes Mid-Flexion Instability in TKA; No Improvement in Outcomes with Kinematic Alignment in TKA; Botox For TKA Flexion Contracture; Intra-operative Synovitis Predicts Worse Outcomes After TKA for OA; When is it Safe for Patients to Drive After Right TKA?; Alpha-Defensin for Peri-prosthetic Joint Infection; Medial Tibia Overhang and Pain Score After TKA

During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19.

Although patient-reported outcomes (PROs) have become increasingly important in the evaluation of spine surgery patients, interpretability may be limited by a patient's ability to recall pre-intervention impairment. The accuracy of patient recall of preoperative back pain, leg pain, and disability after spine surgery remains unknown. We sought to characterise the accuracy of patient recall of preoperative symptoms in a cohort of lumbar spine surgery patients. We analysed consecutive patients undergoing lumbar decompression or decompression and fusion for lumbar radiculopathy by a single surgeon over a four-year period. Using standardised questionnaires, we recorded back and leg numeric pain scores (NPS) and Oswestry Disability Indices (ODI) preoperatively and asked patients to recall their preoperative status at a minimum of one-year following surgery. We then statistically compared and characterised patient recall of their pre-operative status and their actual pre-operative status. Patients with incomplete follow up or diagnoses other than degenerative lumbar stenosis were excluded. Sixty-seven patients with a mean age of 66.1 years (55% female) were included in the final analysis. All cases were either posterior or combined anterior/ posterior procedures. Mean levels of surgery was 1.7 and 93.8% of all cases were instrumented. Mean duration of preoperative symptoms was 44.5 months (3.7 years). Preoperative vs postoperative PROs improved with regards to NPS back (5.2 vs 2.2, p= to 2 point difference), exceeding the minimal clinical important difference (MCID) for NPS. This pattern was maintained across age, gender, and duration of preoperative symptoms. We also observed cases of symptom minimisation recall bias, and cases in which back and leg pain predominance were switched in severity during recall bias. Significant recall bias of preoperative symptoms exists in patients undergoing spine surgery, potentially limiting accurate assessment and interpretation of PROs. An understanding of PROs and their limitations is essential to assess treatment efficacy of spinal procedures

Introduction. Kinematics analyses of the spine have been recognized as an effective method for functional analysis of the spine. CT is suitable for obtaining bony geometry of the vertebrae but radiation is a clinical concern. MRI is noninvasive but it is difficult to detect bone edges especially at endplates and processes where soft tissues attach. Kinematics analyses require tracking of solid bodies; therefore, bony geometry is not always necessary for kinematics analysis of the spine. This study aimed to develop a reliable and robust method for kinematics analysis of the spine using an innovative MRI-based 3D bone-marrow model. Materials and Methods. This IRB-approved study recruited 17 patients undergoing lumbar decompression surgery to treat a single-level symptomatic herniation as part of a clinical trial for a new dynamic stabilization device. T1 & T2 sagittal MRI scans were acquired as part of the pre-operative evaluation in three positions: supine and with the shoulders rotated 45° to the left and right to induce torsion of the lumbar spine. 3D bone-marrow models of L5 and S1 at the neutral and rotated positions were created by selecting a threshold level of the bone-marrow intensity at bone-marrow/bone interface. Validated 3D-3D registration techniques were used to track movements of L5 and S1. Segmental movements at L5/S1 during torsion were calculated. Results. Bone-marrow models were created not only in the vertebral body but also in superior/inferior, transverse and spinous processes, pedicles and laminae. Segmental rotation (mean±SD) at L5/S1 was shown to be symmetric for both left and right motions (p=0.149; Left: 1.04°±0.93° and Right: 1.33°±0.80°). The range of motion recorded was: left [0.05°-3.70°] and right [0.35°-3.25°]. These values were equivalent to previously reported values of axial lumbar rotation measured by 3D CT lumbar models. Conclusions. This study demonstrated feasibility of kinematic analyses using the 3D bone-marrow model created with clinical MRI. The bone-marrow model shows the bone-marrow/bone interface geometry –the internal structure of the vertebra rather than outside geometry usually used for kinematic analyses– that is easily and consistently detected due to its high-contrast interface MRI intensity, which does not require lengthy manual tracing of the bony contour. The bone-marrow model includes key elements of the vertebra including posterior elements and the 3D-3D registration technique used for 3D-CT model can be applied (Fig.1). This type of methodology can be used in the clinic to evaluate with sufficient accuracy subject-specific spinal kinematics without exposure to additional radiation. The MRI-based 3D bone-marrow model may also be useful for kinematic analyses of other major joints such as hip, knee, ankle and shoulder joints

Aim. To evaluate morbidity and outcome associated with lumbar spine decompression for central spinal stenosis in the elderly compared with younger age groups. Patients & methods. Case notes review of patients with symptomatic and MRI proven central lumber canal stenosis, under the care of a single surgeon. The study population was 3 age groups: patients < 60 year of age (Group 1, n=21), patients between 60 and 79 years (Group 2, n=54), and > age of 80 years (Group 3, n=15). Data with regard to intra- and post-operative complications and subjective outcome variables were collected. These included pain (VAS), walking distance, Oswestry Disability score (ODI) and patient satisfaction scores. Results. There was a statistically significant improvement in VAS score for leg pain (p<0.05) and back pain (p<0.05) after surgery for each group. All three groups reported improvement in their walking distance. The average walking distance improved by factor 5 in groups 1 and 2 and by factor 2.5 in group 3 (p< 0.05). However the improvement in group 3 was not statistically significant. There was a statistically significant improvement in ODI for all three groups (mean ODI improvement in Group 1, 16 points, Group 2, 23 points and Group 3, 15 points). Overall 96% of patients were satisfied and would consider the same treatment again under similar circumstances. The overall complication was 19% in group 1, 18% in group 2, and 33% in group 3. Conclusions. Surgery for neurogenic claudication in the octogenarian is associated with a higher complication rate. The outcomes however in this patient group are comparable to younger patients. Lumbar decompression surgery in octogenarians is a worthwhile procedure

We reported the first single surgeon series comparing outcome of microscopic and open primary single level unilateral lumbar decompression or discectomy. We aimed to determine any difference in outcomes between the two techniques. Forty-six decompressions were performed with use of an operating microscope (microscopic), and forty without (open) at two different hospitals. All procedures were performed by the senior author. Information was obtained by analysis of the patients' notes. The average age of the patients in both groups was comparable. Operating time was shorter in the microscopic group (68min, range 30-130) compared to the open group (83 mins, range 30-180). Dural tear rate was 4.3% with use of a microscope (0% symptomatic dural tear rate) and 7.5% without (2.5% symptomatic dural tear rate). Nerve damage incidence was 0% with use of a microscope and 5% (two patients) without. One of these was a neurapraxia and the patient made a full recovery. Wound infection rates, diagnosed on grounds of clinical suspicion, were 4.3% and 2.5% for microscopic and open respectively. There were no incidences of deep infection or post-operative discitis. Average inpatient stay was under 48 hours in both groups. Using the modified Macnab criteria, results using the microscope were 0% poor, 14% fair, 32% good, and 55% excellent. The results for the open group were 0% poor, 10% fair, 37% good and 53% excellent. Average follow-up was six months (1-19) for the microscope group, and seven months (2-16) for the open group. We conclude that primary single level unilateral lumbar decompressive surgery, performed without the use of a microscope, has a higher dural tear rate than the same surgery performed with the benefit of an operating microscope. Surgical time and incidence of nerve damage are also reduced by use of the microscope