A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy
Background: Endoscopically visualized spine surgery has become an essential tool that aids in identifying and treating anatomical spine pathologies that are not well demonstrated by traditional advanced imaging, including MRI. These pathologies may be visualized during endoscopic lumbar decompressio...
| Main Authors: | , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
MDPI AG
2022-06-01
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| Series: | Journal of Personalized Medicine |
| Subjects: | |
| Online Access: | https://www.mdpi.com/2075-4426/12/7/1065 |
| _version_ | 1797405900985597952 |
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| author | Kai-Uwe Lewandrowski Ivo Abraham Jorge Felipe Ramírez León Albert E. Telfeian Morgan P. Lorio Stefan Hellinger Martin Knight Paulo Sérgio Teixeira De Carvalho Max Rogério Freitas Ramos Álvaro Dowling Manuel Rodriguez Garcia Fauziyya Muhammad Namath Hussain Vicky Yamamoto Babak Kateb Anthony Yeung |
| author_facet | Kai-Uwe Lewandrowski Ivo Abraham Jorge Felipe Ramírez León Albert E. Telfeian Morgan P. Lorio Stefan Hellinger Martin Knight Paulo Sérgio Teixeira De Carvalho Max Rogério Freitas Ramos Álvaro Dowling Manuel Rodriguez Garcia Fauziyya Muhammad Namath Hussain Vicky Yamamoto Babak Kateb Anthony Yeung |
| author_sort | Kai-Uwe Lewandrowski |
| collection | DOAJ |
| description | Background: Endoscopically visualized spine surgery has become an essential tool that aids in identifying and treating anatomical spine pathologies that are not well demonstrated by traditional advanced imaging, including MRI. These pathologies may be visualized during endoscopic lumbar decompression (ELD) and categorized into primary pain generators (PPG). Identifying these PPGs provides crucial information for a successful outcome with ELD and forms the basis for our proposed personalized spine care protocol (SpineScreen). Methods: a prospective study of 412 patients from 7 endoscopic practices consisting of 207 (50.2%) males and 205 (49.8%) females with an average age of 63.67 years and an average follow-up of 69.27 months was performed to compare the durability of targeted ELD based on validated primary pain generators versus image-based open lumbar laminectomy, and minimally invasive lumbar transforaminal interbody fusion (TLIF) using Kaplan-Meier median survival calculations. The serial time was determined as the interval between index surgery and when patients were censored for additional interventional and surgical treatments for low back-related symptoms. A control group was recruited from patients referred for a surgical consultation but declined interventional and surgical treatment and continued on medical care. Control group patients were censored when they crossed over into any surgical or interventional treatment group. Results: of the 412 study patients, 206 underwent ELD (50.0%), 61 laminectomy (14.8%), and 78 (18.9%) TLIF. There were 67 patients in the control group (16.3% of 412 patients). The most common surgical levels were L4/5 (41.3%), L5/S1 (25.0%), and L4-S1 (16.3%). At two-year f/u, excellent and good Macnab outcomes were reported by 346 of the 412 study patients (84.0%). The VAS leg pain score reduction was 4.250 ± 1.691 (<i>p</i> < 0.001). No other treatment during the available follow-up was required in 60.7% (125/206) of the ELD, 39.9% (31/78) of the TLIF, and 19.7% (12/61 of the laminectomy patients. In control patients, only 15 of the 67 (22.4%) control patients continued with conservative care until final follow-up, all of which had fair and poor functional Macnab outcomes. In patients with Excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients (<i>p</i> < 0.001). The overall survival time in control patients was eight months with a standard error of 0.942, a lower boundary of 6.154, and an upper boundary of 9.846 months. In patients with excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients versus control patients at seven months (<i>p</i> < 0.001). The most common new-onset symptom for censoring was dysesthesia ELD (9.4%; 20/206), axial back pain in TLIF (25.6%;20/78), and recurrent pain in laminectomy (65.6%; 40/61) patients (<i>p</i> < 0.001). Transforaminal epidural steroid injections were tried in 11.7% (24/206) of ELD, 23.1% (18/78) of TLIF, and 36.1% (22/61) of the laminectomy patients. The secondary fusion rate among ELD patients was 8.8% (18/206). Among TLIF patients, the most common additional treatments were revision fusion (19.2%; 15/78) and multilevel rhizotomy (10.3%; 8/78). Common follow-up procedures in laminectomy patients included revision laminectomy (16.4%; 10/61), revision ELD (11.5%; 7/61), and multilevel rhizotomy (11.5%; 7/61). Control patients crossed over into ELD (13.4%), TLIF (13.4%), laminectomy (10.4%) and interventional treatment (40.3%) arms at high rates. Most control patients treated with spinal injections (55.5%) had excellent and good functional outcomes versus 40.7% with fair and poor (3.7%), respectively. The control patients (93.3%) who remained in medical management without surgery or interventional care (14/67) had the worst functional outcomes and were rated as fair and poor. Conclusions: clinical outcomes were more favorable with lumbar surgeries than with non-surgical control groups. Of the control patients, the crossover rate into interventional and surgical care was 40.3% and 37.2%, respectively. There are longer symptom-free intervals after targeted ELD than with TLIF or laminectomy. Additional intervention and surgical treatments are more often needed to manage new-onset postoperative symptoms in TLIF- and laminectomy compared to ELD patients. Few ELD patients will require fusion in the future. Considering the rising cost of surgical spine care, we offer SpineScreen as a simplified and less costly alternative to traditional image-based care models by focusing on primary pain generators rather than image-based criteria derived from the preoperative lumbar MRI scan. |
| first_indexed | 2024-03-09T03:17:55Z |
| format | Article |
| id | doaj.art-6017a598ed2643b6b1dcd8a3647e0874 |
| institution | Directory Open Access Journal |
| issn | 2075-4426 |
| language | English |
| last_indexed | 2024-03-09T03:17:55Z |
| publishDate | 2022-06-01 |
| publisher | MDPI AG |
| record_format | Article |
| series | Journal of Personalized Medicine |
| spelling | doaj.art-6017a598ed2643b6b1dcd8a3647e08742023-12-03T15:16:23ZengMDPI AGJournal of Personalized Medicine2075-44262022-06-01127106510.3390/jpm12071065A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open LaminectomyKai-Uwe Lewandrowski0Ivo Abraham1Jorge Felipe Ramírez León2Albert E. Telfeian3Morgan P. Lorio4Stefan Hellinger5Martin Knight6Paulo Sérgio Teixeira De Carvalho7Max Rogério Freitas Ramos8Álvaro Dowling9Manuel Rodriguez Garcia10Fauziyya Muhammad11Namath Hussain12Vicky Yamamoto13Babak Kateb14Anthony Yeung15Fundación Universitaria Sanitas, Clínica Reina Sofía-Clínica Colsanitas, Centro de Columna-Cirugía Mínima Invasiva, Bogotá 104-76, D.C., ColombiaPharmacy Practice and Science, Family and Community Medicine, Clinical Translational Sciences at the University of Arizona, Roy P. Drachman Hall, Rm. B306H, Tucson, AZ 85721, USAMinimally Invasive Spine Center Bogotá D.C. Colombia, Reina Sofía Clinic Bogotá D.C. Colombia, Department of Orthopaedics Fundación Universitaria Sanitas, Bogotá 104-76, D.C., ColombiaDepartment of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI 12321, USAAdvanced Orthopedics, 499 East Central Parkway, Altamonte Springs, FL 32701, USADepartment of Orthopedic Surgery, Arabellaklinik, 81925 Munich, GermanyThe Weymouth Hospital, 42-46 Weymouth Street London, 27 Harley Street, London W1G 9QP, UKPain and Spine Minimally Invasive Surgery Service at Gaffre e Guinle University Hospital, Rio de Janeiro 20270-004 RJ, BrazilOrthopedic Clinics at Gaffrée Guinle University Hospital HUGG, Rio de Janeiro 20270-004 RJ, BrazilOrthopaedic Spine Surgeon, Director of Endoscopic Spine Clinic, Santiago 8330024, ChileSpine Clinic, The American-Bitish Cowdray Medical Center I.A.P. Campus Santa Fe, México City 87501, MexicoSociety for Brain Mapping and Therapeutics (SBMT), Los Angeles, CA 90272, USASociety for Brain Mapping and Therapeutics (SBMT), Los Angeles, CA 90272, USASociety for Brain Mapping and Therapeutics (SBMT), Los Angeles, CA 90272, USASociety for Brain Mapping and Therapeutics (SBMT), Los Angeles, CA 90272, USADesert Institute for Spine Care, Phoenix, AZ 85058, USABackground: Endoscopically visualized spine surgery has become an essential tool that aids in identifying and treating anatomical spine pathologies that are not well demonstrated by traditional advanced imaging, including MRI. These pathologies may be visualized during endoscopic lumbar decompression (ELD) and categorized into primary pain generators (PPG). Identifying these PPGs provides crucial information for a successful outcome with ELD and forms the basis for our proposed personalized spine care protocol (SpineScreen). Methods: a prospective study of 412 patients from 7 endoscopic practices consisting of 207 (50.2%) males and 205 (49.8%) females with an average age of 63.67 years and an average follow-up of 69.27 months was performed to compare the durability of targeted ELD based on validated primary pain generators versus image-based open lumbar laminectomy, and minimally invasive lumbar transforaminal interbody fusion (TLIF) using Kaplan-Meier median survival calculations. The serial time was determined as the interval between index surgery and when patients were censored for additional interventional and surgical treatments for low back-related symptoms. A control group was recruited from patients referred for a surgical consultation but declined interventional and surgical treatment and continued on medical care. Control group patients were censored when they crossed over into any surgical or interventional treatment group. Results: of the 412 study patients, 206 underwent ELD (50.0%), 61 laminectomy (14.8%), and 78 (18.9%) TLIF. There were 67 patients in the control group (16.3% of 412 patients). The most common surgical levels were L4/5 (41.3%), L5/S1 (25.0%), and L4-S1 (16.3%). At two-year f/u, excellent and good Macnab outcomes were reported by 346 of the 412 study patients (84.0%). The VAS leg pain score reduction was 4.250 ± 1.691 (<i>p</i> < 0.001). No other treatment during the available follow-up was required in 60.7% (125/206) of the ELD, 39.9% (31/78) of the TLIF, and 19.7% (12/61 of the laminectomy patients. In control patients, only 15 of the 67 (22.4%) control patients continued with conservative care until final follow-up, all of which had fair and poor functional Macnab outcomes. In patients with Excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients (<i>p</i> < 0.001). The overall survival time in control patients was eight months with a standard error of 0.942, a lower boundary of 6.154, and an upper boundary of 9.846 months. In patients with excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients versus control patients at seven months (<i>p</i> < 0.001). The most common new-onset symptom for censoring was dysesthesia ELD (9.4%; 20/206), axial back pain in TLIF (25.6%;20/78), and recurrent pain in laminectomy (65.6%; 40/61) patients (<i>p</i> < 0.001). Transforaminal epidural steroid injections were tried in 11.7% (24/206) of ELD, 23.1% (18/78) of TLIF, and 36.1% (22/61) of the laminectomy patients. The secondary fusion rate among ELD patients was 8.8% (18/206). Among TLIF patients, the most common additional treatments were revision fusion (19.2%; 15/78) and multilevel rhizotomy (10.3%; 8/78). Common follow-up procedures in laminectomy patients included revision laminectomy (16.4%; 10/61), revision ELD (11.5%; 7/61), and multilevel rhizotomy (11.5%; 7/61). Control patients crossed over into ELD (13.4%), TLIF (13.4%), laminectomy (10.4%) and interventional treatment (40.3%) arms at high rates. Most control patients treated with spinal injections (55.5%) had excellent and good functional outcomes versus 40.7% with fair and poor (3.7%), respectively. The control patients (93.3%) who remained in medical management without surgery or interventional care (14/67) had the worst functional outcomes and were rated as fair and poor. Conclusions: clinical outcomes were more favorable with lumbar surgeries than with non-surgical control groups. Of the control patients, the crossover rate into interventional and surgical care was 40.3% and 37.2%, respectively. There are longer symptom-free intervals after targeted ELD than with TLIF or laminectomy. Additional intervention and surgical treatments are more often needed to manage new-onset postoperative symptoms in TLIF- and laminectomy compared to ELD patients. Few ELD patients will require fusion in the future. Considering the rising cost of surgical spine care, we offer SpineScreen as a simplified and less costly alternative to traditional image-based care models by focusing on primary pain generators rather than image-based criteria derived from the preoperative lumbar MRI scan.https://www.mdpi.com/2075-4426/12/7/1065pain generatorslumbar decompression surgerylumbar foraminal and lateral recess stenosisdurabilitypostoperative natural historyreoperation |
| spellingShingle | Kai-Uwe Lewandrowski Ivo Abraham Jorge Felipe Ramírez León Albert E. Telfeian Morgan P. Lorio Stefan Hellinger Martin Knight Paulo Sérgio Teixeira De Carvalho Max Rogério Freitas Ramos Álvaro Dowling Manuel Rodriguez Garcia Fauziyya Muhammad Namath Hussain Vicky Yamamoto Babak Kateb Anthony Yeung A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy Journal of Personalized Medicine pain generators lumbar decompression surgery lumbar foraminal and lateral recess stenosis durability postoperative natural history reoperation |
| title | A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy |
| title_full | A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy |
| title_fullStr | A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy |
| title_full_unstemmed | A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy |
| title_short | A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy |
| title_sort | proposed personalized spine care protocol spinescreen to treat visualized pain generators an illustrative study comparing clinical outcomes and postoperative reoperations between targeted endoscopic lumbar decompression surgery minimally invasive tlif and open laminectomy |
| topic | pain generators lumbar decompression surgery lumbar foraminal and lateral recess stenosis durability postoperative natural history reoperation |
| url | https://www.mdpi.com/2075-4426/12/7/1065 |
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