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BACKGROUND: Posterolateral decompression and fusion with internal fixation is a commonly used surgical approach for treating degenerative lumbar spinal stenosis (DLSS). This study aims to evaluate the impact of preserving a portion of the unilateral facet joint during decompression on surgical outcomes and long-term recovery in patients. METHODS: This study analyzed 73 patients with DLSS accompanied by bilateral lower limb neurological symptoms who underwent single-level L4/5 posterolateral decompression and fusion surgery from January 2022 to March 2023. Patients were categorized into two groups based on the type of surgery received: Group A comprised 31 patients who underwent neural decompression without facet joint preservation, while Group B consisted of 42 patients who underwent neural decompression with preservation of partial facet joints on one side. Regular follow-up evaluations were conducted, including clinical and radiological assessments immediately postoperatively, and at 3 and 12 months thereafter. Key patient information was documented through retrospective chart reviews. RESULTS: Most patients in both groups experienced favorable surgical outcomes. However, four cases encountered complications. Notably, during follow-up, Group B demonstrated superior 1-year postoperative interbody fusion outcomes (P < 0.05), along with a trend towards less interbody cage subsidence and slower postoperative intervertebral disc height loss. Additionally, Group B showed significantly reduced postoperative hospital stay (P < 0.05). CONCLUSION: Under strict adherence to surgical indications, the posterior lateral lumbar fusion surgery, which preserves partial facet joint unilaterally during neural decompression, can offer greater benefits to patients.

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BACKGROUND CONTEXT: Lumbar decompression and lumbar fusion are effective methods of treating spinal compressive pathologies refractory to conservative management. These surgeries are typically used to treat different spinal problems, but there is a growing body of literature investigating the outcomes of either approach for patients with lumbar degenerative spondylolisthesis and stenosis. Different operations are associated with different risks and different potential needs for reoperation. Patient acceptance of reoperation rates after spinal surgery is currently not well understood. PURPOSE: The purpose of this study is to identify patient tolerance for reoperation rates following lumbar decompression and lumbar fusion surgery. DESIGN: A qualitative and quantitative survey intended to capture information on patient preferences was administered. PATIENT SAMPLE: Written informed consent was obtained from patients presenting to two spinal clinics. OUTCOME MEASURES: Patients were asked their threshold tolerance for reoperation rates in the context of choosing a smaller (decompression) versus larger (fusion) spinal surgery. METHODS: A survey was administered to patients at two spinal clinics-one surgical and one non-surgical. A consecutive series of new patients over multiple clinic days who agreed to participate in the study and filled out the survey are reported on here. Patients were asked to assess, contemplating a problem that could either be treated with lumbar decompression or lumbar fusion, the level at which 1) the likelihood that needing a repeat surgery within 3-5 years would change their mind about choosing the decompression operation and cause them to choose the fusion operation and then 2) the likelihood of needing a repeat surgery within 3-5 years that would be acceptable to them after the fusion operation. The distribution of patient responses was assessed with histograms and descriptive statistics. RESULTS: Ninety patients were surveyed, and of these, 73 patients (81.1%) returned fully completed questionnaires. The median reoperation acceptance rates after a decompression was <60%, while the median acceptable revision rate when contemplating the fusion surgery was 10%. CONCLUSIONS: Patient acceptance for the potential need for revision surgery is higher when considering a decompression compared to a fusion operation. Reoperation risk rates along with the magnitude of the surgical intervention are important considerations in determining patients' surgical preferences. Understanding patient preferences and risk tolerances can aid clinicians in shared decision-making, potentially improving patient satisfaction and outcomes in the several lumbar pathologies which can be ameliorated with either decompression or fusion.

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Background: This prospective longitudinal study compares outcomes for Medicare beneficiaries receiving outpatient percutaneous image-guided lumbar decompression (PILD) using the mild® procedure to patients undergoing outpatient laminectomy. All patients were diagnosed with lumbar spinal stenosis (LSS) with neurogenic claudication (NC). Methods: All medical claims for 100 % of Medicare beneficiaries were reviewed, with study subjects identified using Centers for Medicare and Medicaid Research Identifiable Files. Baseline data were extracted individually to allow for longitudinal analysis through two-year follow-up. The index procedure was defined as the first mild or outpatient laminectomy during the enrollment period. The rate of subsequent surgical procedures and incidence of harms were used as study outcomes. Results: Cohorts included 2197 mild and 7416 laminectomy patients. mild patients were significantly older (76.7 years versus 73.4 years, respectively; p < 0.0001), and 57.4 % of mild were female, compared to 43.3 % of laminectomy (p < 0.0001). mild patients presented with significantly more baseline comorbidities compared to laminectomy patients (mean of 5.7 versus 4.8, respectively; p < 0.0001). Subsequent surgical procedure rate of 9.0 % for mild was significantly higher than 5.5 % for laminectomy (p < 0.0001). mild experienced harms at a significantly lower rate than laminectomy (1.9 % versus 5.8 %, respectively; p < 0.0001). The composite rate of subsequent surgical procedures and harms was similar between groups at 10.8 % for mild and 11.0 % for laminectomy. Conclusions: mild can be considered a viable option for treatment of LSS with NC as evidenced by real-world data in this study. At two-years, mild patients experienced fewer harms and underwent more subsequent surgical procedures than laminectomy patients. The higher rate of subsequent surgical procedures for mild may be attributable to its position earlier in the LSS treatment algorithm. The overall rate of harms and subsequent surgical procedures was similar between groups, suggesting that mild should be considered as a treatment option, particularly for older patients with multiple comorbidities.

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BACKGROUND CONTEXT: Lumbar spinal fusion is an increasingly common operation to treat symptoms related to degenerative disorders of the spine including radiculopathy and pain. As the volume of spine surgeries grows, it is becoming increasingly common for procedures to take place in non-tertiary care centers, including orthopaedic specialty hospitals (OSH). While previous research demonstrates that surgical outcomes at an OSH are non-inferior to those at a tertiary referral center (TRC), the implications of this difference on patient-reported outcome measures (PROMs) have not been sufficiently assessed. PURPOSE: The objectives of this study were (1) to determine if changes in patient reported outcome measures (PROMs) after elective lumbar spinal fusion surgery differ between patients who undergo surgery at an orthopedic specialty hospital (OSH) and those who undergo surgery at a tertiary referral center (TRC) and (2) to characterize differences in short-term outcomes between hospitals. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients (≥ 18 years old) who underwent primary, elective single-level posterior lumbar decompression and fusion between January 2014 and December 2021 at a tertiary referral center or an orthopaedic specialty hospital. OUTCOME MEASURES: PROMs: Oswestry Disability Index (ODI), Short-form 12 (SF12) Mental Component Summary (MCS); SF12 Physical Component Summary (PCS); Visual Analogue Back and Leg (VAS Back/Leg) METHODS: PROMs were collected preoperatively, 6 months after surgery, and 1 year after surgery. Six-month and 1-year delta PROM values were calculated by subtracting the preoperative PROM score from the 6-month or 1-year score, respectively. Multivariable linear regression analyses were conducted to assess the independent effect of hospital location on postoperative PROM scores. RESULTS: A total of 288 patients were identified as part of the study cohort including 205 patients who underwent surgery at the tertiary hospital and 83 patients who underwent surgery at the OSH. OSH patients had shorter length of stay (1.57 ± 0.72 vs. 3.28 ± 1.32, p<0.001), however there was no difference in discharge disposition or 90-day readmission rates between hospitals (p>0.05). At 6 months, having surgery at the specialty hospital was associated with higher PCS (estimate = 2.96, confidence interval: 0.21 - 5.71, p=0.035). At 1-year postoperatively, the location of surgery no longer demonstrated significant associations with PROM scores. Preoperative PROM scores demonstrated significant associations with 6-month and 1-year scores for each PROM (p<0.05) except VAS leg at 6 months postoperatively. CONCLUSION: To our knowledge, this is one of the largest studies investigating PROMs at OSH versus TRCs for single-level lumbar fusions. We demonstrated that at one-year follow-up, there is not a significant difference in PROM improvement between patients who undergo surgery at a TRC and patients who do so at an OSH.

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PURPOSE: To evaluate the effect of baseline back pain severity on PROMIS mental health outcomes following minimally invasive lumbar decompression (LD). METHODS: Patients undergoing elective, primary, single-level LD were retrospectively reviewed from a prospective single spine surgeon registry. Perioperative characteristics, demographics, and the following patient-reported outcomes (PROs) were extracted: Oswestry Disability Index (ODI)/Patient-Health Questionnaire-9 /PROMIS-Physical Function/Anxiety/Pain Interference/Sleep Disturbance (PROMIS-PF/A/PI/SD). Two cohorts were created: preoperative VAS-B < 7 and VAS-B ≥ 7. Change in PROs (ΔPROs) from baseline to six weeks/final follow-up were determined. Average patient follow-up was 13.4 ± 8.8 months. Minimal clinically important difference (MCID) achievement rates were calculated and compared through multivariable logistic regression. Postoperative scores and ΔPROs, were compared with multivariable linear regression while all other data was compared between groups with inferential statistics. RESULTS: Altogether, 347 patients were included, with 190 in the VAS-B < 7 group. VAS-B ≥ 7 reported worse outcomes preoperatively (p ≤ 0.013, all). At six weeks, VAS-B ≥ 7 reported worse VAS-B (p = 0.017), with no other significant differences. At final follow-up, patients with worse VAS-B reported worse ODI (p = 0.040) and VAS-B while all other PROs were similar (p ≥ 0.078, all). VAS-B ≥ 7 experienced greater 6-week improvements in VAS-B/ODI/PROMIS-PI/PROMIS-SD (p ≤ 0.009, all), greater VAS-B/ODI/PROMIS-SD improvement by final follow-up (p ≤ 0.009, all) and greater MCID achievement in ODI/VAS-B (p ≤ 0.027). CONCLUSION: Patients with worse baseline back pain report inferior baseline scores that converge with those with milder preoperative back pain by 6 weeks after LD and reported greater 6-week improvements in disability, pain interference, and sleep disturbance by 6 weeks, and greater improvements in disability and sleep disturbance by final follow-up.

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BACKGROUND: Patients with lumbar spinal pathology often suffer from anxiety and sleep disturbance, but correlations between anxiety and sleep disturbance and other patient-reported outcome measures (PROMs) before and after surgical intervention have not been explored. The purpose of this study is to analyze the correlations between patient-reported anxiety, sleep disturbance, and PROMs before and after lumbar decompression. METHODS: All patients undergoing elective, primary, lumbar decompression were retrospectively queried from a prospectively-maintained single spine surgeon database. Demographic and perioperative data and pre- and postoperative PROMs were extracted. Patient-Reported Outcome Measure Information System (PROMIS)-Anxiety, PROMIS-Sleep Disturbance (SD), PROMIS-Physical Function (PF), 9-Item Patient Health Questionnaire (PHQ-9), Visual Analog Scale (VAS)-Back, VAS-Leg, Oswestry Disability Index (ODI) were obtained preoperatively and through two years postoperatively. Pearson's correlation coefficients were calculated between PROMIS-Anxiety, PROMIS-SD, and the other PROMs of interest. RESULTS: PROMIS-Anxiety was positively correlated with PROMIS-SD (range: r = 0.473-0.828, p ≤ 0.006, all), PHQ-9 (range: r = 0.613--0.890, p ≤ 0.006, all), VAS-Back (range: r = -0.410-0.798, p ≤ 0.039, all), and ODI (range: r = 0.503-0.732, p ≤ 0.033, all) at all timepoints. PROMIS-Anxiety was negatively correlated with PROMIS-PF through 1 year postoperatively (range: r = -0.323- -0.729p ≤ 0.033, all). PROMIS-Anxiety was positively correlated to VAS-Leg at preoperative, 6-week, 12-week, and 2-year postoperative timepoints (range: r = 0.333--0.707, p ≤ 0.022, all). PROMIS-SD was positively correlated with PHQ-9 (range: r = 0.600-0.836), VASBack (range: r = 0.383-0.734), VAS-Leg (range: r = 0.399-0.811), and ODI (range: r = 0.404-0.812) at all timepoints (p ≤ 0.031, all). PROMIS-SD was negatively correlated with PROMIS-PF at all timepoints (range: r = -0.339-0.665, p ≤ 0.035, all). CONCLUSION: Patient-reported anxiety and sleep disturbance are significantly correlated with depressive burden, back pain, disability, and physical function, before and after lumbar decompression. Future studies should aim to determine the directionality of the associations and test interventions to improve health-related quality of life following lumbar decompression.

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Introduction: Laminectomy has long been a "gold standard" to treat symptomatic lumbar spinal stenosis (LSS). Minimal invasive spine surgery (MISS) is widely developed to overcome the limitations of conventional laminectomy to achieve a better outcome with minimal complications. Full endoscopic percutaneous stenoscopic lumbar decompression (FE-PSLD) is the newest MISS technique for spinal canal decompression. We aimed to evaluate and analyze the significance of FE-PSLD in reducing pain and its association with age, duration of symptoms, stenosis level, and operative time (OT). Materials and Methods: A longitudinal cross-sectional study was conducted on 606 LSS patients who underwent FE-PSLD and enrolled from 2020 to 2022. Three-month evaluation of the Visual Analog Scale (VAS) and the modified MacNab criteria were assessed. The significance of changes was analyzed using the Wilcoxon signed-ranks test. Spearman's correlation test was performed to evaluate the significant correlation of several variables (pre-PSLD-VAS, age, symptoms duration, OT, and level of LSS) to post-PSLD-VAS, and multiple regression analysis was conducted. Results: The reduction of VAS was statistically significant (P ≤ 0.005) with an average pre-PSLD-VAS of 6.75 ± 0.63 and post-PSLD-VAS of 2.24 ± 1.04. Pre-PSLD-VAS, age, and stenosis level have a statistically significant correlation with post-PSLD-VAS, while the duration of the symptoms and OT have an insignificant correlation. Multiple regression showed the effect of pre-PSLD-VAS (ß =0.4033, P = 0.000) and stenosis level (ß =0.0951, P = 0.021) are statistically significant with a positive coefficient. Conclusions: FE-PSLD is an efficacious strategy with favorable outcomes for managing LSS, shown by a significant reduction of pain level with a relatively short follow-up time after the procedure. Preoperative pain level, age, and stenosis level are significantly correlated with postoperative pain level. Based on this experimental study, PSLD can be considered a good strategy for treating lumbar canal stenosis in all age groups and all LSS levels.

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Background: The North American Spine Society (NASS) assembled the first ever comprehensive naming system for describing lumbar disc disease, including lumbar disc herniation. The objectives of this study were (1) to determine which NASS descriptors are most predictive of independent patient-reported outcomes after microdiscectomy and (2) to identify the inter-rater reliability of each NASS descriptor. Methods: Adult patients (≥18 years) who underwent a lumbar microdiscectomy from 2014-2021 were retrospectively identified. Patient-reported outcome measures (PROMs) were collected at preoperative, 3-month, and 1-year postoperative time points. Lumbar disc herniations were evaluated and classified on preoperative MRI using the NASS lumbar disc nomenclature specific to disc herniation. Results: About 213 microdiscectomy patients were included in the final analysis. Herniation descriptors exhibiting the greatest reliability included sequestration status (κ=0.83), axial disc herniation area (κ=0.83), and laterality (κ=0.83). The descriptor with the lowest inter-rater reliability was direction of migration (κ=0.53). At 3 months, a sequestered herniation was associated with lower odds of achieving the minimal clinically important difference (MCID) for ODI (p=.004) and MCS (p=.032). At 12 months, a similar trend was observed for Oswestry Disability Index (ODI) MCID achievement (p=.001). At 3 months, a herniation with larger axial area was a predictor of MCID achievement in ODI (p=.004) and the mental component summary (MCS) (p=.009). Neither association persisted at 12 months; however, larger axial disc herniation area was able to predict MCID achievement in the Visual Analogue Scale (VAS) leg (p=.031) at 12 months. Conclusions: The utility of the NASS nomenclature system in predicting postoperative outcomes after microdiscectomy has yet to be studied. We showed that sequestration status and disc area are both reliable and able to predict the odds of achieving MCID in certain clinical outcomes at 3 months and 12 months after surgery. Hence, preoperative imaging analysis of lumbar disc herniations may be useful in accurately setting patient expectations.

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Background: Evidence regarding the frequency and timing of treatment for lumbar spinal stenosis (LSS) fails to offer clear consensus. We describe the LSS care journey from initial diagnosis to first surgical intervention. Methods: Using Medicare claims database from 2009 through 2020, we identified patients who were diagnosed with LSS. The use and timing of conservative and surgical treatments during the entire follow-up from the initial diagnosis were reported. Results: Of the 143,849 patients identified, 68% received conservative care within 8.4 months and 25.3% received a surgical or minimally invasive intervention over 5.7 years following initial diagnosis, with 12.6% undergoing open decompression alone, 10.2% undergoing open decompression with fusion, and 5.1% undergoing fusion surgery alone. Fewer than 1% were provided with interspinous spacers or a percutaneous image-guided lumbar decompression. Conclusion: Approximately three-quarters of patients in the study received no surgical or non-invasive interventions for approximately six years following diagnosis with LSS.

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BACKGROUND CONTEXT: Isolated decompression and decompression with instrumented fusion are accepted surgical treatments for lumbar spondylolisthesis. Although isolated decompression is a less costly solution with similar patient-reported outcomes, it is associated with higher rates of reoperation than primary fusion. PURPOSE: To determine the costs associated with primary decompression, primary fusion, and decompression and fusion for degenerative spondylolisthesis. We further sought to establish at what revision rate is primary decompression still a less costly surgical treatment for degenerative lumbar spondylolisthesis. STUDY DESIGN/SETTING: A retrospective database study of the Medicare Provider Analysis and Review (MEDPAR) limited data set. PATIENT SAMPLE: Patients who underwent single-level fusion or decompression for degenerative spondylolisthesis. OUTCOME MEASURES: Cost of surgical care. METHODS: All inpatient stays that underwent surgery for single-level lumbar/lumbosacral degenerative spondylolisthesis in the 2019 calendar year (n=6,653) were queried from the MEDPAR limited data set. Patients were stratified into three cohorts: primary decompression (n=300), primary fusion (n=5,757), and revision fusion (n=566). Univariate analysis was conducted to determine cost differences between these groups and results were confirmed with multivariable regression. An economic analysis was then done to determine at what revision rate would primary decompression still be a less costly treatment choice. RESULTS: on univariate analysis, the cost of primary single-level decompression for spondylolisthesis was $14,690±9,484, the cost of primary single-level fusion was $26,376±11,967, and revision fusion was $26,686±11,309 (p<0.001). on multivariate analysis, primary fusion was associated with an increased cost of $3,751, and revision fusion was associated with increased cost of $7,502 (95%ci: 2,990-4,512, p<0.001). economic analysis found that a revision rate less than or equal to 43.8% would still result in primary decompression being less costly for a practice than primary fusion for all patients. CONCLUSIONS: Isolated decompression for degenerative lumbar spondylolisthesis is a less costly treatment choice even with rates of revision fusion as high as 43.8%. This was true even with an assumed revision rate of 0% after primary fusion. This study solely looks at cost data, however, and many patients may still benefit from primary fusion when appropriately indicated.

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BACKGROUND: Endoscopic spine surgery has recently grown in popularity due to the potential benefits of reduced pain and faster recovery time as compared to open surgery. Biportal spinal endoscopy has been successfully applied to lumbar disc herniations and lumbar spinal stenosis. Obesity is associated with increased risk of complications in spine surgery. Few prior studies have investigated the impact of obesity and associated medical comorbidities with biportal spinal endoscopy. METHODS: This study was a prospectively collected, retrospectively analyzed comparative cohort design. Patients were divided into cohorts of normal body weight (Bone Mass Index (BMI)18.0-24.9), overweight (BMI 25.0-29.9) and obese (BMI > 30.0) as defined by the World Health Organization (WHO). Patients underwent biportal spinal endoscopy by a single surgeon at a single institution for treatment of lumbar disc herniations and lumbar spinal stenosis. Demographic data, surgical complications, and patient-reported outcomes were analyzed. Statistics were calculated amongst treatment groups using analysis of variance and chi square where appropriate. Statistical significance was determined as p < 0.05. RESULTS: Eighty-four patients were followed. 26 (30.1%) were normal BMI, 35 (41.7%) were overweight and 23 (27.4%) were obese. Patients with increasing BMI had correspondingly greater American Society of Anesthesiologist (ASA) scores. There were no significant differences in VAS Back, VAS Leg, and ODI scores, or postoperative complications among the cohorts. There were no cases of surgical site infections in the cohort. All cohorts demonstrated significant improvement up to 1 year postoperatively. CONCLUSIONS: This study demonstrates that obesity is not a risk factor for increased perioperative complications with biportal spinal endoscopy and has similar clinical outcomes and safety profile as compared to patients with normal BMI. Biportal spinal endoscopy is a promising alternative to traditional techniques to treat common lumbar pathology.

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BACKGROUND CONTEXT: Academic orthopedic journals and specialty societies emphasize the importance of two-year follow-up for patient-reported outcome measures (PROMS) after spine surgery, but there are limited data evaluating the appropriate length of follow-up. PURPOSE: To determine whether PROMs, as measured by the Oswestry Disability Index (ODI), would change significantly after 2-months postoperatively after lumbar decompression surgery for disc herniation or spinal stenosis. STUDY DESIGN: Retrospective analysis of prospectively and consecutively enrolled patients undergoing lumbar decompression surgery between 2020 and 2021 from a single surgeon spine registry. PATIENT SAMPLE: One hundred sixty-nine patients. OUTCOME MEASURES: ODI, achievement of minimum clinically important difference (MCID), revisions. METHODS: Patients without a preoperative baseline score were excluded. Completion of the ODI questionnaire was assessed at the follow-up points. The median ODI was compared at time baseline, 2-month, 1-year and 2-year follow-up. Risk of reoperation was assessed with receiver operating characteristic (ROC) analysis to identify at-risk ODI thresholds of requiring reoperation. RESULTS: Median ODI significantly improved at all time points compared to baseline (median baseline ODI: 40; 2-month ODI: 16, p=.001; 1-year ODI: 11.1, p=.001; 2-year ODI: 8, p=.001). Posthoc analysis demonstrated no difference between 2-months, 1-year and 2-year postoperative ODI (p=.9, p=.468, p=.606). The MCID was met in 87.9% of patients at 2 months, 80.7% at 1 year, and 87.3% at 2 years postoperatively. Twelve patients (7.7%) underwent revision surgery between 2 months and 2 years after the index surgery (median time to revision: 5.6 months). ROC curve analysis demonstrated that an ODI score ≥24 points at 2-months yielded a sensitivity of 85.7% and a specificity of 71.8% for predicting revision after lumbar decompression (AUC=0.758; 95% CI: 0.613-0.903). The Youden optimal threshold value of ≥24 points at 2-month postop ODI yielded an odd ratio (OR) for revision of 15.3 (CI: 1.8-131.8; p=.004). The positive predictive value (PPV) and negative predictive value (NPV) were 15.4% and 98.8%, respectively. CONCLUSION: Two-year clinical follow-up may not be necessary for future peer-reviewed lumbar decompression surgery studies given that ODI plateaus at 8 weeks. Patients with a score ≥24 points at 2-months postoperatively have a higher risk of requiring a second surgery within the first 2 years and warrant continued follow-up.

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OBJECTIVE: Unilateral biportal endoscopic decompression (UBED) offers the advantages of minimal tissue damage, operational flexibility, and clear visualization, positioning it as an innovative and minimally invasive endoscopic technique. Nevertheless, the clinical evidence supporting the use of UBED in the treatment of degenerative lumbar diseases is limited and conflicting. METHODS: As of October 1, 2023, a comprehensive search was conducted across databases including Web of Science, PubMed, Embase, and the Cochrane Library to identify all published studies on minimally invasive UBED for the treatment of degenerative lumbar diseases. Data pertaining to patient demographics, fluoroscopy time, operative duration, intraoperative hemorrhage, hospitalization length, visual analog scale (VAS) score for back and leg pain, MacNab criteria, Oswestry Disability Index (ODI), and complication rates were extracted. The Newcastle-Ottawa scale was utilized to assess the quality. RESULTS: Twelve articles were included, involving 816 patients. The back VAS score (95% confidence interval [CI]: -0.09-0.07, P = 0.75), MacNab criteria (95% CI: 0.52-2.3, P = 0.82), fluoroscopy time (95% CI: -7.03 to -0.4, P = 0.08), and the incidence of complications (95% CI: 0.5-1.73, P = 0.82) were not significantly different, while the leg VAS score (95% CI: 0.01-0.18, P = 0.03), ODI score (95% CI: -1.03 to -0.09, P = 0.02), operation time (95% CI: 5.76-20.62, P = 0.0005), hospitalization length (95% CI: 0.41-2.76, P = 0.008), and intraoperative hemorrhage (95% CI: 21.92-72.44, P = 0.0003) were significantly different. CONCLUSIONS: UBED offers superiority in ODI, flexibility, and visual field clarity. Conversely, percutaneous endoscopic lumbar decompression presents advantages in terms of operation duration, blood loss, hospitalization length, and leg VAS score. These factors should be thoroughly considered when selecting a surgical approach.

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BACKGROUND: With the growing prevalence of lumbar spinal stenosis, endoscopic surgery, which incorporates techniques such as transforaminal, interlaminar, and unilateral biportal (UBE) endoscopy, is increasingly considered. However, the patient selection criteria are debated among spine surgeons. OBJECTIVE: This study used a polytomous Rasch analysis to evaluate the factors influencing surgeon decision-making in selecting patients for endoscopic surgical treatment of lumbar spinal stenosis. METHODS: A comprehensive survey was distributed to a representative sample of 296 spine surgeons. Questions encompassed various patient-related and clinical factors, and responses were captured on a logit scale graphically displaying person-item maps and category probability curves for each test item. Using a Rasch analysis, the data were subsequently analyzed to determine the latent traits influencing decision-making. RESULTS: The Rasch analysis revealed that surgeons' preferences for transforaminal, interlaminar, and UBE techniques were easily influenced by comfort level and experience with the endoscopic procedure and patient-related factors. Harder-to-agree items included technological aspects, favorable clinical outcomes, and postoperative functional recovery and rehabilitation. Descriptive statistics suggested interlaminar as the best endoscopic spinal stenosis decompression technique. However, logit person-item analysis integral to the Rasch methodology showed highest intensity for transforaminal followed by interlaminar endoscopic lumbar stenosis decompression. The UBE technique was the hardest to agree on with a disordered person-item analysis and thresholds in category probability curve plots. CONCLUSION: Surgeon decision-making in selecting patients for endoscopic surgery for lumbar spinal stenosis is multifaceted. While the framework of clinical guidelines remains paramount, on-the-ground experience-based factors significantly influence surgeons' selection of patients for endoscopic lumbar spinal stenosis surgeries. The Rasch methodology allows for a more granular psychometric evaluation of surgeon decision-making and accounts better for years-long experience that may be lost in standardized clinical guideline development. This new approach to assessing spine surgeons' thought processes may improve the implementation of evidence-based protocol change dictated by technological advances was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the International Society for Minimal Intervention in Spinal Surgery (ISMISS), the Mexican Spine Society (AMCICO), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Society (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS).

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BACKGROUND: Opioids are often prescribed for patients who eventually undergo lumbar decompression. Given the potential for opioid-related morbidity and mortality, postoperative weaning is often a goal of surgery. The purpose of this study was to examine the relationship between preoperative opioid use and postoperative complete opioid weaning among lumbar decompression patients. METHODS: We surveyed the IBM Marketscan Databases for patients who underwent lumbar decompression during 2008-2017, had >30 days of opioid use in the year preceding surgery, and consumed a daily average of >0 morphine milligram equivalents in the 3 months preceding surgery. We used multivariable logistic regression and marginal standardization to examine the association between preoperative opioid use duration, average daily dose, and their interactions with complete opioid weaning in the 10-12 months after surgery. RESULTS: Of the 11,114 patients who met inclusion criteria, most (54.7%, n = 6083) had a preoperative average daily dose of 1-20 morphine milligram equivalents. Postoperatively, 6144 patients (55.3%) remained on opioids. For patients with >180 days of preoperative use, the adjusted probability of weaning increased as the preoperative dose decreased. Obesity increased the likelihood of weaning, whereas older age, several comorbidities, female sex, and Medicaid decreased the odds of weaning. CONCLUSIONS: Patients who used opioids for longer preoperatively were less likely to completely wean following surgery. Among patients with >180 days of preoperative use, those with lower preoperative doses were more likely to wean. Weaning was also associated with several clinical and demographic factors. These findings may help shape expectations regarding opioid use following lumbar decompression.

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OBJECTIVE: Obesity is a global epidemic affecting developing countries. The relationship between obesity and perioperative outcomes during elective lumbar spine surgery remains controversial, especially in those without morbid disease. MATERIALS AND METHODS: We retrospectively revised the medical records of patients with lumbar spine degeneration subjected to elective surgery. The data retrieved included demographic and clinical characteristics, body mass index (BMI), obesity status (BMI ≥ 30), surgical interventions, estimated blood loss (EBL), operative time, length of stay (LOS), and post-operative complications. Perioperative outcomes were compared between Grade I-II obese and non-obese individuals. RESULTS: We enrolled 53 patients, 18 with Grade I-II obesity. Their median age was 51, with no differences in gender, comorbidities, laboratory parameters, and surgical procedures received between groups. No clinically relevant differences were found between grade I-II obese and non-obese participants in EBL (300 mL vs. 250 mL, p = 0.069), operative time (3.2 h vs. 3.0 h, p = 0.037), and LOS (6 days vs. 5 days, p = 0.3). Furthermore, BMI was not associated with the incidence of significant bleeding and long stay but showed a modest correlation with operative time. CONCLUSION: Grade I-II obesity does not increase surgical complexity nor perioperative complications during open lumbar spine surgery.

OBJETIVO: La obesidad es una epidemia mundial que afecta a países subdesarrollados. Su relación con los resultados de la cirugía de columna lumbar electiva sigue siendo controvertida, especialmente en obesos sin enfermedad mórbida. MÉTODOS: Se revisaron los expedientes de pacientes con degeneración de la columna lumbar sometidos a cirugía. Los datos recuperados incluyeron características demográficas y clínicas, índice de masa corporal (IMC), estado de obesidad (IMC > 30), intervenciones quirúrgicas, sangrado estimado, tiempo operatorio, tiempo de estancia y complicaciones. Los resultados se compararon entre individuos obesos grado I-II y controles. RESULTADOS: Se incluyeron 53 pacientes, 18 con obesidad de grado I-II. La edad media fue de 51 años, sin diferencias en el sexo, las comorbilidades, los parámetros de laboratorio y los procedimientos quirúrgicos recibidos entre grupos. No se encontraron diferencias relevantes entre los participantes obesos y los no obesos en sangrado (300 vs. 250 mL, p = 0.069), tiempo operatorio (3.2 vs. 3.0 horas, p = 0.037) y estancia (6 vs. 5 días, p = 0.3). El IMC no se asoció con hemorragia y larga estancia, pero mostró una correlación modesta con el tiempo operatorio. CONCLUSIONES: La obesidad grado I-II no predispone a complicaciones durante la cirugía de columna lumbar.

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Background: Lumbar synovial cysts (LSC), best diagnosed on MR studies, may cause symptoms/signs ranging from unilateral radiculopathy to cauda equina compressive syndromes. Attempts at percutaneous treatment of LSC typically fail. Rather, greater safety/efficacy is associated with direct surgical resection with/without fusion. Methods: Treatment of LSC with percutaneous techniques, including cyst aspiration/perforation, injection (i.e., with/without steroids, saline/other), dilatation, and/or disruption/bursting, classically fail. This is because LSCs' tough, thickened, and adherent fibrous capsules cause extensive thecal sac/nerve root compression, and contain minimal central "fluid" (i.e., "crank-case" and non-aspirable). Multiple percutaneous attempts at decompression, therefore, typically cause several needle puncture sites risking dural tears (DT)/cerebrospinal fluid (CSF) leaks, direct root injuries, failure to decompress the thecal sac/nerve roots, infections, hematomas, and over the longer-term, adhesive arachnoiditis. Results: Alternatively, many studies document the success of direct or even partial resection of LSC (i.e., partial removal with marked cyst/dural adhesions with shrinking down the remnant of capsular tissue). Surgical decompressions of LSC, ranging from focal laminotomies to laminectomies, may or may not warrant additional fusions. Conclusions: Symptomatic LSC are best managed with direct or even partial operative resection/decompression with/without fusion. The use of varying percutaneous techniques classically fails, and increases multiple perioperative risks.

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Background: Lumbar discal pseudocysts are uncommon complications that can arise following lumbar spine surgery. It manifests as a fluid-filled sac near the intervertebral disc, causing pain and discomfort. Understanding its causes, symptoms, and management is crucial for patients and healthcare professionals involved in postoperative spinal care. Case Description A: 35-year-old female developed a discal pseudocyst after undergoing laminectomy and discectomy for lumbar disc herniation. The patient presented with recurrent lower back pain, radiculopathy, and neurological deficit two months post-surgery. Imaging revealed a discal pseudo cyst causing compression of the traversing right L5 nerve root. Given the refractory nature of her symptoms, an endoscopic procedure was offered. Using the transforaminal endoscopic technique, the pseudo cyst was identified and removed, leading to immediate symptomatic relief. Conclusion: This article reports the rare occurrence of discal pseudocyst and highlights the use of endoscopic techniques in its surgical management. Surgeons should be aware of the minimally invasive techniques, as they can offer less morbidity, shorter recovery times, and reduced healthcare costs compared to traditional open surgery.

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Background: Lumbar decompression is a commonly performed procedure for the operative management of several degenerative lumbar spinal pathologies. Although open approaches are considered the traditional method, endoscopic techniques represent a relatively novel, less-invasive option to achieve neural element decompression. Here within, we examine if the use of endoscopic techniques decreases the risk of post operative infections. Methods: We performed a retrospective cohort analysis to directly compare patients who underwent either open or endoscopic lumbar decompression at a single institution. Rates of postoperative outcomes such as surgical site infection, hospital length of stay, estimated blood loss, and others were compared between the two treatment groups. A multivariate logistic regression model was constructed using patient comorbidities and procedural characteristics to identify the risk factors for surgical site infection. Results: 150 patients were identified as undergoing lumbar spine decompression surgeries that met inclusion criteria for the study, of whom 108 (72.0%) underwent open and 61 (28.0%) underwent endoscopic approaches. Unpaired analysis revealed positive associations between operative duration, estimated blood loss, drain placement rates. Multivariate logistic regression did not reveal an association between surgical approach (open versus endoscopic) and the development of surgical site infection. Conclusions: Surgical site infections following endoscopic lumbar spine decompression are relatively uncommon, however, after adjusting for baseline differences between patient populations, surgical approach does not independently predict the development of postoperative infection.

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BACKGROUND: Little research has been done to evaluate the prognostic value of short-term postoperative patient-reported outcomes (PROs) on long-term PROs following lumbar decompression (LD). We evaluated the prognostic value of short-term PROs on long-term PROs through 2 years after LD. METHODS: A single spine surgeon database was retrospectively queried for patients undergoing primary LD with 6-week postoperative PROs reported. The demographics, perioperative traits, and preoperative, 6-month, 1-year, and 2-year PROs were recorded. The PROs included the visual analog scale (VAS) for back pain, VAS for leg pain, PRO measure information system for physical function (PROMIS-PF), and Oswestry disability index. Two-step multivariate linear regression was performed to determine the predictive value of 6-week PROs for the 6-month, 1-year, and 2-year PROs. RESULTS: A total of 277 patients were included. The 6-week Oswestry disability index, VAS for leg pain, and 9-item patient health questionnaire (PHQ-9) are all positive predictors for their respective outcomes at 6 months. Additionally, the 6-week PROMIS-PF was a negative predictor of the 6-month PHQ-9. The 6-week PROMIS-PF positively predicted the PROMIS-PF through 1 year, and the PHQ-9 was a positive predictor of the PHQ-9 at 1 and 2 years postoperatively. CONCLUSIONS: The 6-week postoperative PROs are predictive of the same outcomes at 6 months, the PROMIS-PF is predictive through 1 year, and the PHQ-9 is predictive through 2 years. Determining the predictive value of early postoperative PROs can be helpful in understanding the likely postoperative trajectory following LD and informing patient expectations.

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