Peter Helmig

Circumferential Fusion Improves Outcome in Comparison With Instrumented Posterolateral Fusion : Long-term Results of a Randomized Clinical Trial

Study Design. Prospective randomized clinical study with a 5- to 9-year follow-up period. Objective. The aim of the present study was to analyze the long-term outcome with respect to functional disability, pain, and general health of patients treated by means of circumferential lumbar fusion in comparison with those treated by means of instrumented posterolateral lumbar fusion. Summary of Background Data. Circumferential fusion has become a common procedure in lumbar spinal fusion both as a primary and salvage procedure. However, the claimed advantages of circumferential fusion over conventional posterolateral fusion lack scientific documentation. (The primary report with a 2-year follow-up has been published in Spine in 2002.) Methods. From April 1996 to November 1999, a total of 148 patients (mean age, 45 years) with severe chronic low back pain were randomly selected for either posterolateral lumbar fusion (titanium Cotrel-Dubousset) or circumferential lumbar fusion (instrumented posterolateral fusion with anterior intervertebral support by a Brantigan cage). The primary outcome measure was the Dallas Pain Questionnaire (DPQ). The secondary outcome measures were the Oswestry Disability Index, the SF-36 instrument, and the Low Back Pain Rating Scale. All measures assessed the endpoint outcomes at 5 to 9 years after surgery. Results. The available response rate was 93%. The circumferential group showed a significantly better improvement (P < 0.05) in comparison with the posterolateral group with respect to all four DPQ categories: daily activities, work/leisure, anxiety/depression, and social interest. The Oswestry Disability Index supported these results (P < 0.01). General health, as assessed by means of the SF-36, also showed significantly better physical health (P < 0.01) in the circumferential group, whereas no significant difference was found with respect to mental health compared with the posterolateral group. The circumferential group experienced significantly less back pain (P < 0.05) in comparison with the posterolateral group. In regard to leg pain, no significant difference was found. Conclusion. Circumferential lumbar fusion demands more extensive operative resources compared with posterolateral lumbar fusion. However, 5 to 9 years after surgery, the circumferentially fused patients had a significantly improved outcome compared with those treated by means of posterolateral fusion. These new results not only emphasize the superiority of circumferential fusion in the complex pathology of the lumbar spine but are also strongly supported in all of the validated questionnaires used in the study.

Spondylodiscitis. A retrospective study of 163 patients

Background and purpose Spondylodiscitis may be a serious disease due to diagnostic delay and inadequate treatment. There is no consensus on when and how to operate. We therefore retrospectively analyzed the outcome of a large series of patients treated either nonoperatively or surgically. Patients and methods Between 1992 and 2000, 163 patients (101 males) were hospitalized due to spondylodiscitis. The mean age was 56 (1–83) years. The infection was located in the cervical spine in 13 patients (8%), in the thoracic spine in 62 patients (38%), at the thoracolumbar junction in 10 patients (6%), and in the lumbo-sacral spine in 78 patients (48%). In 67 patients (41%), no microorganisms were detected. Most of the other patients had Staphylococcus aureus infection (53 patients) and/or Mycobacterium tuberculosis (22 patients). The patients were divided into 3 groups: (A) 70 patients who had nonoperative treatment, (B) 56 patients who underwent posterior decompression alone, and (C) 37 patients who underwent decompression and stabilization. Results At 12-month follow-up, nonoperative treatment (A) had failed in 8/70 patients, who had subsequently been operated. 24/56 and 6/37 had been reoperated in groups B and C, respectively. Group A patients had no neurological symptoms. In group B, 11 had neurological deficits and surgery was beneficial for 5 of them; 4 remained unchanged and 2 deteriorated (1 due to cerebral abscess). 11 patients in group C had altered neurogical deficits, which improved in 9 of them. 20 patients had died during the 1-year follow-up, 3 in hospital, directly related with infection. Interpretation Nonoperative treatment was effective in nine-tenths of the patients. Decompression alone had high a reoperation rate compared to decompression and internal stabilization.

Predictive Value of Tokuhashi Scoring Systems in Spinal Metastases, Focusing on Various Primary Tumor Groups : Evaluation of 448 Patients in the Aarhus Spinal Metastases Database

Study Design. We conducted a prospective cohort study of 448 patients with spinal metastases from a variety of cancer groups. Objective. To determine the specific predictive value of the Tokuhashi scoring system (T12) and its revised version (T15) in spinal metastases of various primary tumors. Summary of Background Data. The life expectancy of patients with spinal metastases is one of the most important factors in selecting the treatment modality. Tokuhashi et al formulated a prognostic scoring system with a total sum of 12 points for preoperative prediction of life expectancy in 1990 and revised it in 2005 to a total sum of 15 points. There is a lack of knowledge about the specific predictive value of those scoring systems in patients with spinal metastases from a variety of cancer groups. Methods. We included 448 patients with vertebral metastases who underwent surgical treatment during November 1992 to November 2009 in Aarhus University Hospital NBG. Data were retrieved from Aarhus Metastases Database. Scores based on T12 and T15 were calculated prospectively for each patient. We divided all the patients into different groups dictated by the site of their primary tumor. Predictive value and accuracy rate of the 2 scoring systems were compared in each cancer group. Results. Both the T12 and T15 scoring systems showed statistically significant predictive value when the 448 patients were analyzed in total (T12, P < 0.0001; T15, P < 0.0001). The accuracy rate was significantly higher in T15 (P < 0.0001) than in T12. The further analyses by primary cancer groups showed that the predictive value of T12 and T15 was primarily determined by the prostate (P = 0.0003) and breast group (P = 0.0385). Only T12 displayed predictive value in the colon group (P = 0.0011). Neither of the scoring systems showed significant predictive value in the lung (P > 0.05), renal (P > 0.05), or miscellaneous primary tumor groups (P > 0.05). The accuracy rate of prognosis in T15 was significantly improved in the prostate (P = 0.0032) and breast group (P < 0.0001). Conclusion. Both T12 and T15 showed significant predictive value in patients with spinal metastases. T15 has a statistically higher accuracy rate than T12. Among the various cancer groups, the 2 scoring systems are especially reliable in prostate and breast metastases groups. T15 is recommended as superior to T12 because of its higher accuracy rate.

Impact of instrumentation in lumbar spinal fusion in elderly patients

Background and purpose An increasing number of lumbar fusions are performed using allograft to avoid donor-site pain. In elderly patients, fusion potential is reduced and the patient may need supplementary stability to achieve a solid fusion if allograft is used. We investigated the effect of instrumentation in lumbar spinal fusion performed with fresh frozen allograft in elderly patients. Methods 94 patients, mean age 70 (60–88) years, who underwent posterolateral spinal fusion either non-instrumented (51 patients) or instrumented (43 patients) were followed for 2–7 years. Functional outcome was assessed with the Dallas pain questionnaire (DPQ), the low back pain rating scale pain index (LBPRS), and SF-36. Fusion was assessed using plain radiographs. Results Instrumented patients had statistically significantly better outcome scores in 6 of 7 parameters. Fusion rate was higher in the instrumented group (81% vs. 68%, p = 0.1). Solid fusion was associated with a better functional outcome at follow-up (significant in 2 of 7 parameters). 15 patients (6 in the non-instrumented group and 9 in the instrumented group) had repeated lumbar surgery after their initial fusion procedure. Functional outcome was poorer in the group with additional spine surgeries (significant in 4 of 7 parameters). Interpretation Superior outcomes after lumbar spinal fusion in elderly patients can be achieved by use of instrumentation in selected patients. Outcome was better in patients in which a solid fusion was obtained. Instrumentation was associated with a larger number of additional surgeries, which resulted in a lesser degree of improvement. Instrumentation should not be discarded just because of the age of the patient.

The Effect of Electrical Stimulation on Lumbar Spinal Fusion in Older Patients : A Randomized, Controlled, Multi-Center Trial : Part 1 : Functional Outcome

Study Design. Randomized, controlled, multi-center trial. Objective. To investigate the effect of direct current (DC) electrical stimulation on functional and clinical outcome after lumbar spinal fusion in patients older than 60 years. Summary of Background Data. Older patients have increased complication rates after spinal fusion surgery. Treatments which have the possibility of enhancing functional outcome and fusion rates without lengthening the procedure could prove beneficial. DC-stimulation of spinal fusion has proven effective in increasing fusion rates in younger and “high risk” patients, but functional outcome measures have not been reported. Methods. A randomized, clinical trial comprising 5 orthopedic centers. The study included a total of 107 patients randomized to uninstrumented posterolateral lumbar spinal fusion with or without DC-stimulation. Functional outcome was assessed using Dallas Pain Questionnaire, SF-36, Low Back Pain Rating Scale pain index, and walking distance. Results. Follow-up after 1 year was 95/107 (89%). DC-stimulated patients had significant better outcome in 3 of 4 categories in the Dallas Pain Questionnaire, better SF-36 scores (not significantly), but no difference in pain scores were observed. Median walking distance at latest follow-up was better in the stimulated group (not significant). Walking distance was significantly associated with functional outcome. There was no difference in any of the functional outcome scores between patients who experienced a perioperative complication and those without complications. Conclusion. The achievement of a good functional outcome was heavily dependent on the obtained walking distance. DC-stimulated patients tended to have better functional outcome as compared to controls. No negative effects of perioperative complications could be observed on the short-term functional outcome.

The predictive value of pain drawings in lumbar spinal fusion surgery

BACKGROUND CONTEXT Pain drawings have been used extensively in spine surgery. It has been associated with inferior outcome after disc and stenosis surgery. Results regarding the predictive value in fusion surgery have been conflicting. PURPOSE To evaluate the predictive value of pain drawings in relation to outcome after lumbar spinal fusion. To investigate if there are differences between spondylolisthesis patients and patients with degenerative disease as well as between patients with or without radicular pain. STUDY DESIGN Prospective clinical cohort with a minimum of 1-year follow-up. PATIENT SAMPLE One hundred thirty-five patients undergoing lumbar spinal fusion. Fifty-seven men and 78 women, mean age 44 years (range 21-59 years). OUTCOME MEASURES Dallas Pain Questionnaire (DPQ), Low Back Pain Rating Scale (LBPRS) pain index and patient satisfaction. Minimal clinical important difference was defined for the LBPRS score. METHODS Pain drawings were classified, using the visual inspection method, as organic or nonorganic and correlated to outcomes. Multivariate adjustment for several possible confounding variables was done using logistic regression analysis. RESULTS Thirty-three percent of the drawings were classified as nonorganic. Nonorganic drawings were associated with significantly higher DPQ and LBPRS scores preoperatively and at follow-up. Differences between organic and nonorganic drawings were larger in spondylolisthesis patients than in patients with degenerative disorders. Nonorganic pain drawings were associated with poorer outcome in patients with low back pain and radicular symptoms, however, not in patients without radicular symptoms. A nonorganic pain drawing predicted negative patient satisfaction with odds ratio (OR) 3.01 (95% confidence interval (CI): 1.14-8.55, p=.027) but had no significant predictive value with respect to improvement in the LBPRS pain index OR 1.92 (95% CI: 0.82-4.47, p=.132). CONCLUSIONS A nonorganic pain drawing was a significant risk factor for inferior outcome after spinal fusion surgery. The predictive value did not allow for patient selection.

Degenerative Spondylolisthesis Is Associated with Low Spinal Bone Density: A Comparative Study between Spinal Stenosis and Degenerative Spondylolisthesis

Spinal stenosis and degenerative spondylolisthesis share many symptoms and the same treatment, but their causes remain unclear. Bone mineral density has been suggested to play a role. The aim of this study was to investigate differences in spinal bone density between spinal stenosis and degenerative spondylolisthesis patients. 81 patients older than 60 years, who underwent DXA-scanning of their lumbar spine one year after a lumbar spinal fusion procedure, were included. Radiographs were assessed for disc height, vertebral wedging, and osteophytosis. Pain was assessed using the Low Back Pain Rating Scale pain index. T-score of the lumbar spine was significantly lower among degenerative spondylolisthesis patients compared with spinal stenosis patients (−1.52 versus −0.52, P = 0.04). Thirty-nine percent of degenerative spondylolisthesis patients were classified as osteoporotic and further 30% osteopenic compared to only 9% of spinal stenosis patients being osteoporotic and 30% osteopenic (P = 0.01). Pain levels tended to increase with poorer bone status (P = 0.06). Patients treated surgically for symptomatic degenerative spondylolisthesis have much lower bone mass than patients of similar age treated surgically for spinal stenosis. Low BMD might play a role in the development of the degenerative spondylolisthesis, further studies are needed to clarify this.

Improved patient selection by stratified surgical intervention: Aarhus Spinal Metastases Algorithm

BACKGROUND CONTEXT Choosing the best surgical treatment for patients with spinal metastases remains a significant challenge for spine surgeons. There is currently no gold standard for surgical treatments. The Aarhus Spinal Metastases Algorithm (ASMA) was established to help surgeons choose the most appropriate surgical intervention for patients with spinal metastases. PURPOSE The purpose of this study was to evaluate the clinical outcome of stratified surgical interventions based on the ASMA, which combines life expectancy and the anatomical classification of patients with spinal metastases to inform surgical decision making. STUDY DESIGN/SETTING This is a retrospective study based on a prospective database. PATIENT SAMPLE A consecutive series of 515 spinal metastatic patients who underwent surgically treatment from December 1992 to June 2012 in Aarhus University Hospital were included prospectively and analyzed in detail retrospectively. OUTCOME MEASURES Survival time after surgery was determined for all patients. Neurological function was assessed using the Frankel score preoperatively and postoperatively (at the time of discharge). Complete outcome data were retrieved in 97.5% of this cohort. METHODS Patients with spinal metastases were identified from an institutional database that prospectively collected data since 1992. Survival status data were obtained from a national registry. Neurological function was determined from the same institutional database or local Electronic Patient Journal system. Surgeons evaluated and classified patients into five surgical groups preoperatively by using the revised Tokuhashi score (TS) and the Tomita anatomical classification (TC). RESULTS The overall median survival time of the cohort was 6.8 (95% confidence interval: 6.1-7.9) months. The median survival times in the five surgical groups determined by the ASMA were 2.1 (TS 0-4, TC 1-7), 5.1 (TS 5-8, TC 1-7), 12.1 (TS 9-11, TC 1-7 or TS 12-15, TC 7), 26.0 (TS 12-15, TC 4-6), and 36.0 (TS 12-15, TC 1-3) months. The 30-day mortality rate was 7.5%. Postoperative neurological function was maintained or improved in 469 patients (92.3%). Overall reoperation rate was 13.5%, commonly because of postoperative hematoma and new limb weakness. CONCLUSIONS The ASMA recommends at least two surgical options for a particular patient by determining the preoperative life expectancy and anatomical classification of the spinal metastases. This algorithm could help spine surgeons to discriminate the risks of surgeries. The ASMA provides a tool to guild surgeons to evaluate the spinal metastases patients, select potential optimal surgery, and avoid life-threatening risks.