Frank Kleinstück
Queen's University
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Featured researches published by Frank Kleinstück.
Spine | 2006
Frank Kleinstück; Jiri Dvorak; Anne F. Mannion
Study Design. Prospective study. Objective. To examine the association between structural abnormalities recorded on magnetic resonance imaging (MRI) and outcome after evidence-based conservative treatment in patients with chronic nonspecific low back pain (LBP). Summary of Background Data. In most guidelines for the management of LBP, MRI is not recommended unless the diagnostic triage suggests serious spinal pathology or nerve root involvement for which surgical treatment is foreseen. This is because many structural changes seen on MRI appear to be as common in asymptomatic individuals as in people with LBP and are, therefore, considered of little value in either explaining the cause of pain or deciding the subsequent course of management. However, to our knowledge, no studies have assessed whether the presence of such MRI abnormalities influences the outcome of the conservative treatment that patients with chronic nonspecific LBP typically receive. Methods. T2-weighted, 4-mm spin-echo MRI sequences of the lumbar spine were obtained from 53 patients with chronic nonspecific LBP before a 3-month program of exercise therapy. Disc degeneration, disc bulging, high intensity zones, and endplate/bone marrow changes were assessed for each lumbar segment. Back pain (average and worst) and disability (Roland Morris score) were assessed before and after therapy, and 12 months later, and the improvements were examined in relation to the presence or absence of baseline MRI “abnormalities.” Results. Eighty-nine percent of patients had severe disc degeneration (grade 4 or 5), 74% had disc bulging, 60% had high intensity zones, and 62% had endplate/bone marrow changes in at least 1 lumbar segment. Only 11% patients had none of these changes at any level. The MRI abnormalities showed only minimal association with baseline symptoms. In multivariate regression analyses, in which age, gender, and baseline symptoms were controlled for, only 1 significant association between the MRI variables and outcome was observed: the presence of a high intensity zone in any vertebral segment was associated with lower average pain at the 12-month follow-up (standardized &bgr; −0.376, P = 0.006, 16.5% variance accounted for). Conclusion. In the patient group examined, the presence of common “structural abnormalities” on MRI had no significant negative influence on the outcome after therapy.
Spine | 2009
Frank Kleinstück; Dieter Grob; Friederike Lattig; Viktor Bartanusz; François Porchet; Dezsö Jeszenszky; David O’Riordan; Anne F. Mannion
Study Design. Prospective study with 12-month follow-up. Objective. To examine how the relative severity of low back pain (LBP) to leg/buttock pain (LP) influences the outcome of decompression surgery for spinal stenosis. Summary of Background Data. Decompression surgery is a common treatment for lumbar spinal canal stenosis, with generally good outcome. However, concomitant LBP at presentation can make it difficult to decide whether decompression alone will result in a good overall outcome. Methods. The Spine Society of Europe Spine Tango system was used to acquire the data from 221 patients. Inclusion criteria were lumbar degenerative spinal stenosis, first-time surgery, maximum 3 affected levels, and decompression as the only procedure. Before and 12 months after surgery, patients completed the multidimensional Core Outcome Measures Index (COMI; includes 0–10 LP and LBP scales); at 12 months, global outcome was rated on a Likert-scale and dichotomized into “good” and “poor” groups. Results. There was a low but significant positive correlation between baseline LP-minus-LBP scores and both improvement in the multidimensional COMI score after 12 months (r = 0.21, P = 0.003) and the score on the 12-month global outcome scale (r = 0.19, P = 0.007). In the good outcome group, mean baseline LP was 2.3 (±3.7) points higher than LBP; in the poor group, the corresponding value was 0.8 (±3.4) (P = 0.01 between groups). In multivariate regression analyses (controlling for age, gender, comorbidity), baseline LBP intensity was the most significant predictor of the 12-month COMI score, and preoperative LP-minus-LBP score of the global outcome (each P < 0.05). Conclusion. Overall, greater back pain relative to LP at baseline was associated with a significantly worse outcome after decompression. This finding seems intuitive, but has rarely been quantified in the many predictor studies conducted to date. Consideration of relative LBP and LP scores may assist in clinical decision-making and in establishing realistic patient expectations.
Spine | 2015
Nils H. Ulrich; Frank Kleinstück; Christoph M. Woernle; Alexander Antoniadis; Sebastian Winklhofer; Jakob M. Burgstaller; Mazda Farshad; J. Oberle; François Porchet; Kan Min
Study Design. This is a prospective, multicenter cohort study including 8 medical centers in the metropolitan area of the Canton Zurich, Switzerland. Objectives. To examine whether outcome and quality of life might improve after decompression surgery for degenerative lumbar spinal stenosis (DLSS) even in patients older than 80 years and to compare data with a younger patient population from our own patient collective. Summary and Background Data. Lumbar decompression surgery without fusion has been shown to improve quality of life in lumbar spinal canal stenosis. In the population older than 80 years, treatment recommendations for DLSS show conflicting results. Methods. Eight centers in the metropolitan area of Zurich, Switzerland agreed on the classification of DLSS, surgical principles, and follow-up protocols. Patients were followed from baseline, at 6 months, and 12 months. Baseline characteristics were analyzed with 5 different questionnaires “Spinal Stenosis Measure, Feeling Thermometer, Numeric Rating Scale, 5D-3L, and Roland and Morris Disability Questionnaire.” In addition, our study population was compared with a younger control group. Furthermore, we calculated the minimal clinically important differences. Results. Thirty-seven patients with an average age of 82.5 ± 2.5 years reached the 12-month follow-up. Spinal Stenosis Measure scores, the Feeling Thermometer, the Numeric Rating Scale, and the Roland and Morris Disability Questionnaire showed significant improvements at the 6-month and 12-month follow-ups (P < 0.001). One EQ-5D-3Lsubgroup “anxiety/depression” showed no significant improvement (P = 0.109) at 12-month follow-up. The minimal clinically important difference for the “Symptom Severity scale” in the Spinal Stenosis Measure was achieved with improvement of 70% in the older patient population. Conclusion. Patients 80 years or older can expect a clinically meaningful improvement after lumbar decompression for symptomatic DLSS. Our patient population showed significant positive development in quality of life in the short- and long-term follow-ups. Level of Evidence: 3
Journal of Bone and Joint Surgery, American Volume | 2017
Caglar Yilgor; Nuray Sogunmez; Louis Boissiere; Yasemin Yavuz; Ibrahim Obeid; Frank Kleinstück; Francisco Javier Sanchez Perez-Grueso; Emre Acaroglu; Sleiman Haddad; Anne F. Mannion; Ferran Pellisé; Ahmet Alanay
Background: The restoration of normal sagittal alignment is a critical goal in adult spinal deformity surgery to achieve favorable outcomes and prevent mechanical complications. Schwab sagittal modifiers have been accepted as targets for appropriate alignment, but addressing these targets does not always prevent high mechanical complication or revision rates. This may be because the linear absolute numerical parameters do not cover the whole pelvic incidence spectrum and the distribution of lordosis, pelvic anteversion, and negative malalignment are not considered as potential causes of failure. The aim of the present study was to develop and validate a score based on pelvic-incidence-based proportional parameters to better predict mechanical complications. Methods: Two hundred and twenty-two patients (168 women and 54 men) followed for ≥2 years after posterior fusion at ≥4 levels were included in the study. The mean age (and standard deviation) was 52.2 ± 19.3 years (range, 18 to 84 years), and the mean duration of follow-up was 28.8 ± 8.2 months (range, 24 to 62 months). The global alignment and proportion (GAP) score was developed and validated in groups of patients randomly assigned to derivation (n = 148, 66.7%) and validation (n = 74, 33.3%) cohorts. GAP score parameters were relative pelvic version (the measured minus the ideal sacral slope), relative lumbar lordosis (the measured minus the ideal lumbar lordosis), lordosis distribution index (the L4-S1 lordosis divided by the L1-S1 lordosis multiplied by 100), relative spinopelvic alignment (the measured minus the ideal global tilt), and an age factor. Proximal and distal junctional kyphosis and/or failure, rod breakage, and other implant-related complications were considered mechanical complications. The predictive accuracy of the GAP score was analyzed using receiver operating characteristic (ROC) analyses. Associations between GAP categories and mechanical complications and revisions were analyzed using Cochran-Armitage tests. Results: In the validation cohort, 32 patients (43%) experienced mechanical complications and 17 (23%) underwent mechanical revision. The area under curve for the GAP score predicting mechanical complications was 0.92 (standard error [SE] = 0.034, p < 0.001, 95% [confidence interval [CI] = 0.85 to 0.98). Postoperatively, patients with a proportioned spinopelvic state according to the GAP score had a mechanical complication rate of 6% while those with a moderately or severely disproportioned spinopelvic state had rates of 47% and 95%, respectively. Conclusions: The GAP score is a new pelvic-incidence-based proportional method of analyzing the sagittal plane that predicts mechanical complications in patients undergoing surgery for adult spinal deformity. Setting surgical goals according to the GAP score may decrease the prevalence of mechanical complications.
Spine | 2017
Go Yoshida; Louis Boissiere; Daniel Larrieu; Anouar Bourghli; Jean Marc Vital; Olivier Gille; Vincent Pointillart; Vincent Challier; Rémi Mariey; Ferran Pellisé; Alba Vila-Casademunt; Francisco Javier Sanchez Perez-Grueso; Ahmet Alanay; Emre Acaroglu; Frank Kleinstück; Ibrahim Obeid
Study Design. Prospective multicenter study of adult spinal deformity (ASD) surgery. Objective. To clarify the effect of ASD surgery on each health-related quality of life (HRQOL) subclass/domain. Summary of Background Data. For patients with ASD, surgery offers superior radiological and HRQOL outcomes compared with nonoperative care. HRQOL may, however, be affected by surgical advantages related to corrective effects, yielding adequate spinopelvic alignment and stability or disadvantages because of long segment fusion. Methods. The study included 170 consecutive patients with ASD from a multicenter database with more than 2-year follow-up period. We analyzed each HRQOL domain/subclass (short form-36 items, Oswestry Disability Index, Scoliosis Research Society-22 [SRS-22] questionnaire), and radiographic parameters preoperatively and at 1 and 2 years postoperatively. We divided the patients into two groups each based on lowest instrumented vertebra (LIV; above L5 or S1 to ilium) or surgeon-determined preoperative pathology (idiopathic or degenerative). Improvement rate (%) was calculated as follows: 100 × |pre.–post.|/preoperative points (%) (+, advantages; –, disadvantages). Results. The scores of all short form-36 items and SRS-22 subclasses improved at 1 and 2 years after surgery, regardless of LIV location and preoperative pathology. Personal care and lifting in Oswestry Disability Index were, however, not improved after 1 year. These disadvantages were correlated to sagittal modifiers of SRS-Schwab classification similar to other HRQOL. The degree of personal care disadvantage mainly depended on LIV location and preoperative pathology. Although personal care improved after 2 years postoperatively, no noticeable improvements in lifting were recorded. Conclusion. HRQOL subclass analysis indicated two disadvantages of ASD surgery, which were correlated to sagittal radiographic measures. Fusion to the sacrum or ilium greatly restricted the ability to stretch or bend, leading to limited daily activities for at least 1 year postoperatively, although this effect may subside after another year. Consequently, spinal surgeons should note the effect of surgical treatment on each HRQOL domain and counsel patients about the implications of surgery. Level of Evidence: 4
The Spine Journal | 2016
Peter Wilhelm Ferlic; Anne F. Mannion; Deszö Jeszenszky; François Porchet; Tamas F. Fekete; Frank Kleinstück; Daniel Haschtmann
BACKGROUND CONTEXT Spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of fat tissue in the spinal canal that can have a compressive effect, leading to clinical symptoms. This condition has a distinct pathology from spinal stenosis associated with degeneration of the intervertebral discs, ligaments, and facet joints. Several different conservative and surgical treatment strategies have been proposed for SEL, but its treatment remains controversial. There is a lack of evidence documenting the success of surgical decompression in SEL, and no previous studies have reported the postoperative outcome from the patients perspective. PURPOSE The aim of the present study was to evaluate patient-rated outcome after surgical decompression in SEL. STUDY DESIGN A retrospective analysis of prospectively collected data was carried out. PATIENT SAMPLE A total of 22 patients (19 males; age: 68.2±9.9 years) who had undergone spine surgery for SEL were identified from our local Spine Surgery Outcomes Database, which includes a total of 10,028 spine surgeries recorded between 2005 and 2012. Inclusion criteria were epidural lipomatosis confirmed by preoperative magnetic resonance imaging (MRI) scans and subsequent decompression surgery without spinal fusion. OUTCOME MEASURES The Core Outcome Measures Index (COMI) was used to assess patient-rated outcome. The COMI includes the domains pain (separate 0-10 scales for back and leg pain), back-specific function, symptom-specific well-being, general quality of life (QOL), work disability, and social disability. METHODS The questionnaires were completed preoperatively and at 3, 12, and 24 months postoperatively. Surgical data were retrieved from the patient charts and from our local Spine Surgery Outcomes Database, which we operate in connection with the International Spine Tango Registry. Differences between pre- and postoperative scores were analyzed using paired t tests and repeated measures analysis of variance. RESULTS At 3-months follow-up, the COMI score and scores for leg pain and back pain had improved significantly compared with their preoperative values (p<.005). The mean decrease in COMI score after 3 months was 2.6±2.4 (range: -1.3 to 6.5) points: from 7.5±1.7 (range: 3.5-10) to 4.9±2.5 (range: 0.5-9.6). A total of 11 patients (50%) had an improvement of the COMI of more than the minimal clinically important change (MCIC) score of 2.2 points. The mean decrease in leg pain after 3 months was 2.4±3.5 (-5 to 10) points. Overall, 17 patients (77.3%) reported a reduced leg pain, 12 (54.6%) of whom by at least the MCIC score of 2 points. The significant reductions from baseline in COMI and leg and back pain scores were retained up to 2 years postoperatively (p<.02). The general QOL item of the COMI improved significantly after surgery (p<.0001). Over 80% of the cohort rated their preoperative QOL as bad (n=13) or very bad (n=5), whereas 3 months after surgery, only 7 patients rated their QOL as bad, and one as very bad (36%). CONCLUSIONS The present study is the first to demonstrate that surgical decompression is associated with a statistically significant improvement in patient-rated outcome scores in patients with symptomatic SEL, with a clinically relevant change occurring in approximately half of them. Surgical decompression hence represents a reasonable treatment option for SEL, although the reason behind the less good response in some patients needs further investigation.
The Spine Journal | 2017
Louis Boissiere; Mitsuru Takemoto; Anouar Bourghli; Jean-Marc Vital; Ferran Pellisé; Ahmet Alanay; Caglar Yilgor; Emre Acaroglu; Francisco Javier Sanchez Perez-Grueso; Frank Kleinstück; Ibrahim Obeid
BACKGROUND CONTEXT Many radiological parameters have been reported to correlate with patients disability including sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI-LL). European literature reports other parameters such as lumbar lordosis index (LLI) and the global tilt (GT). If most parameters correlate with health-related quality of life scores (HRQLs), their impact on disability remains unclear. PURPOSE This study aimed to validate these parameters by investigating their correlation with HRQLs. It also aimed to evaluate the relationship between each of these sagittal parameters and HRQLs to fully understand the impact in adult spinal deformity management. STUDY DESIGN A retrospective review of a multicenter, prospective database was carried out. PATIENT SAMPLE The database inclusion criteria were adults (>18 years old) presenting any of the following radiographic parameters: scoliosis (Cobb ≥20°), SVA ≥5 cm, thoracic kyphosis ≥60° or PT ≥25°. All patients with complete data at baseline were included. OUTCOME MEASURES Health-related quality of life scores, demographic variables (DVs), and radiographic parameters were collected at baseline. METHODS Differences in HRQLs among groups of each DV were assessed with analyses of variance. Correlations between radiographic variables and HRQLs were assessed using the Spearman rank correlation. Multivariate linear regression models were fitted for each of the HRQLs (Oswestry Disability Index [ODI], Scoliosis Research Society-22 subtotal score, or physical component summaries) with sagittal parameters and covariants as independent variables. A p<.05 value was considered statistically significant. RESULTS Among a total of 755 included patients (mean age, 52.1 years), 431 were non-surgical candidates and 324 were surgical candidates. Global tilt and LLI significantly correlated with HRQLs (r=0.4 and -0.3, respectively) for univariate analysis. Demographic variables such as age, gender, body mass index, past surgery, and surgical or non-surgical candidate were significant predictors of ODI score. The likelihood ratio tests for the addition of the sagittal parameters showed that SVA, GT, T1 sagittal tilt, PI-LL, and LLI were statistically significant predictors for ODI score even adjusted for covariates. The differences of R2 values from Model 1 were 1.5% at maximum, indicating that the addition of sagittal parameters to the reference model increased only 1.5% of the variance of ODI explained by the models. CONCLUSION GT and LLI appear to be independent radiographic parameters impacting ODI variance. If most of the parameters described in the literature are correlated with ODI, the impact of these radiographic parameters is less than 2% of ODI variance, whereas 40% are explained by DVs. The importance of radiographic parameters lies more on their purpose to describe and understand the malalignment mechanisms than their univariate correlation with HRQLs.
Spine | 2017
Javier Pizones; Mar Pérez Martin-Buitrago; Francisco Javier Sanchez Perez-Grueso; Alba Vila-Casademunt; Ahmet Alanay; Ibrahim Obeid; Frank Kleinstück; Emre Acaroglu; Ferran Pellisé
Study Design. A retrospective two-cohort comparative analysis of data collected prospectively in an adult deformity multicenter database. Objective. The aim of this study was to define the radiographic and clinical parameters that motivate adult thoracolumbar (TL) scoliosis patients to undergo surgery. Summary of Background Data. TL curves are a primary concern in adulthood, and it is necessary to establish why patients are motivated to seek surgical intervention. Methods. Patients with only main TL/lumbar (TL/L) idiopathic curves were included, defined as Schwab type L curves and Schwab type D curves in which thoracic curves were <40° and the difference between the TL/L-MT Cobb was ≥15°. Demographic data, health-related quality of life (HRQOL) questionnaires, and 14 different radiological preoperative parameters were assessed. Surgical versus conservative cohorts were compared with the Student t test, Chi-square, and the Mann-Whitney U test. Results. A total of 184 patients met the inclusion criteria. Ninety-four were treated conservatively (C), while 90 underwent surgery (S). No differences were found between groups in terms of demographic or radiographic preoperative data. Age (C: 57.5 ± 18 vs. S: 54.2 ± 18 yr; P = 0.18), coronal TL/L Cobb (C: 52.3° ± 15 vs. S: 50.6° ± 13; P = 0.61), and sagittal alignment (SVA C: 3.1 cm ± 5.7 vs. S: 4.9 cm ± 6.4; P = 0.054) were similar. No differences were found in pelvic parameters (pelvic incidence, pelvic tilt, sacral slope), apical translation, coronal balance, lumbar rotatory subluxation, or lumbar lordosis. However, significant differences were found in HRQOL questionnaires. Surgical patients initially had worse COMI scores (C: 4.6 ± 2.3 vs. S: 6 ± 2.3; P = 0.001), worse ODI scores (C: 27.7 ± 16 vs. S: 38.9 ± 20; P = 0.000), worse SF-36 physical (C: 40.9 ± 8.5 vs. S: 36 ± 9.5; P = 0.001) and mental scores (C: 45.8 ± 12 vs. S: 42.2 ± 11.8; P = 0.032), and worse SRS-22 scores in all domains with mean values under 3.1 points (range = 2.4–3.1). In both SF-36 physical and SRS-22 function, differences between groups were higher than the minimum clinically important difference. Conclusion. After analyzing a large multicenter database, we found that only clinical factors—particularly function impairment—motivated adult TL scoliosis patients to undergo surgery. Demographic and radiographic parameters did not seem to influence decision-making. Level of Evidence: 3
Acta Orthopaedica et Traumatologica Turcica | 2017
Emre Acaroglu; Ümit Özgür Güler; Aysun Cetinyurek-Yavuz; Selcen Yüksel; Yasemin Yavuz; Selim Ayhan; Montse Domingo-Sabat; Ferran Pellisé; Ahmet Alanay; Francesco Sanchez Perez Grueso; Frank Kleinstück; Ibrahim Obeid
Objective The aim of this study was to analyze the impact of treatment complications on outcomes in adult spinal deformity (ASD) using a decision analysis (DA) model. Methods The study included 535 ASD patients (371 with non-surgical (NS) and 164 with surgical (S) treatment) from an international multicentre database of ASD patients. DA was structured in two main steps; 1) Baseline analysis (Assessing the probabilities of outcomes, Assessing the values of preference -utilities-, Combining information on probability and utility and assigning the quality adjusted life expectancy (QALE) for each treatment) and 2) Sensitivity analysis. Complications were analyzed as life threatening (LT) and nonlife threatening (NLT) and their probabilities were calculated from the database as well as a thorough literature review. Outcomes were analyzed as improvement, no change and deterioration. Death/complete paralysis was considered as a separate category. Results All 535 patients were analyzed in regard to complications. Overall, there were 78 NLT and 12 LT complications and 3 death/paralysis. Surgical treatment offered significantly higher chances of clinical improvement but also was significantly more prone to complications (31.7% vs. 11.1%, p < 0.001). Conclusion Surgical treatment of ASD is more likely to cause complications compared to NS treatment. On the other hand, surgery has been shown to provide a higher likelihood of improvement in HRQoL scores. So, the decision on the type of treatment in ASD needs to take both chances of improvement and burden associated with S or NS treatments and better be arrived by the active participation of patients and physicians equipped with the present information. Level of evidence Level II, Decision analysis.
The Spine Journal | 2017
Susana Núñez-Pereira; Alba Vila-Casademunt; Montse Domingo-Sabat; Juan Bagó; Emre Acaroglu; Ahmet Alanay; Ibrahim Obeid; Francisco Javier Sanchez Perez-Grueso; Frank Kleinstück; Ferran Pellisé
BACKGROUND CONTEXT Revision surgery represents a major event for patients undergoing adult spinal deformity (ASD) surgery. Previous reports suggest that ASD surgery has minimal or no impact on health-related-quality of life (HRQOL) outcomes. PURPOSE The present study aims to investigate the impact of early reoperations within the first year on HRQOL and on the likelihood of reaching the minimally clinically important difference (MCID) after ASD surgery. DESIGN This is a retrospective analysis of prospectively collected data from consecutive surgically treated adult deformity surgery patients included in a multicenter, international database. PATIENT SAMPLE The present study included 280 patients from a multicenter international prospective database. OUTCOME MEASURE Oswestry Disability Index (ODI), Short Form-36 (SF-36), Scoliosis Research Society-22 (SRS-22), MCID were evaluated in this work. METHODS Consecutive surgical patients with ASD recruited prospectively in six different centers from four countries with a minimum 2-year follow-up were stratified into two groups: R (revision surgery within the first year) and NR (no revision). Health-related-quality of life (ODI, SF-36, SRS-22) was assessed and compared at 6-month, 1-year, and 2-year follow-up stages. Statistical analysis included chi-square tests, Student t tests, and linear mixed models. RESULTS Forty-three patients (R Group) received 46 revision surgeries. Nineteen patients (41.3%) had implant-related complications, 9 patients (19.6%) had deep surgical site infections, 9 patients (19.6%) had proximal junctional kyphosis, 3 patients (6.5%) had hematoma, and 6 patients (13%) had other complications. Baseline characteristics differed between groups. At 6 months, all HRQOL scores improved in both groups, except in the SF-36 Mental Component Summary and SRS-22 mental health domain in the R Group. At 1 year, ODI and SRS-22 improvement was significantly greater in the NR Group, exceeding the reported MCID. At the 2-year follow-up, ODI, SRS-22, SF-36 MCS, and SF-36 PCS improvement was similar in both groups. However, postoperative change was only above the MCID for SF-36 PCS, ODI, and SRS-22 in the NR Group. CONCLUSIONS Early unanticipated revision surgery has a negative impact on mental health at 6 months and reduces the chances of reaching an MCID improvement in SRS-22, SF-36 PCS, and ODI at the 2-year follow-up.