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  • 1.
    Axén, Iben
    et al.
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, Karolinska Institutet, Stockholm, Sweden.
    Bergström, Gunnar
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, Karolinska Institutet, Stockholm, Sweden.
    Bodin, Lennart
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, Karolinska Institutet, Stockholm, Sweden.
    Using few and scattered time points for analysis of a variable course of pain can be misleading: an example using weekly text message data2014In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 14, no 8, p. 1454-1459Article in journal (Refereed)
    Abstract [en]

    Background context: Because low back pain (LBP) is a fluctuating condition, the diversity in the prediction literature may be due to when the outcome is measured.

    Purpose: The objective of this study was to investigate the prediction of LBP using an outcome measured at several time points.

    Study design/setting: A multicenter clinical observational study in Sweden.

    Patient sample: Data were collected on 244 subjects with nonspecific LBP. The mean age of the subjects was 44 years, the mean pain score at inclusion was 4.4/10, and 51% of the sample had experienced LBP for more than 30 days the previous year.

    Outcome measures: The outcome used in this study was the “number of days with bothersome pain” collected with weekly text messages for 6 months.

    Methods: In subjects with nonspecific LBP, weekly data were available for secondary analyses. A few baseline variables were chosen to investigate prediction at different time points: pain intensity, the presence of leg pain, duration of LBP the previous year, and self-rated health at baseline. Age and gender acted as additional covariates.

    Results: In the multilevel models, the predictive variables interacted with time. Thus, the risk of experiencing a day with bothersome LBP varied over time. In the logistic regression analyses, the predictive variable's previous duration showed a consistent predictive ability for all the time points. However, the variables pain intensity, leg pain, and self-rated health showed inconsistent predictive patterns.

    Conclusions: An outcome based on frequently measured data described the variability in the prediction of future LBP over time. Prediction depended on when the outcome was measured. These results may explain the diversity of the results of the predictor studies in the literature.

  • 2.
    Debono, Bertrand
    et al.
    Paris-Versailles Spine Center (Centre Francilien du Dos), Paris, France; Ramsay Santé-Hôpital Privé de Versailles, Versailles, France.
    Wainwright, Thomas W.
    Research Institute, Bournemouth University, Bournemouth, UK; The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Bournemouth, UK.
    Wang, Michael Y.
    Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA.
    Sigmundsson, Freyr Gauti
    Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Yang, Michael M. H.
    Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta.
    Smid-Nanninga, Henriëtte
    Scientific Institute, Martini General Hospital Groningen, The Netherlands.
    Bonnal, Aurélien
    Department of anesthesiology, Clinique St-Jean- Sud de France, SANTECITE Group. St Jean de Vedas, Montpellier METROPOLE, France.
    Le Huec, Jean-Charles
    Department of Orthopedic Surgery - Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France.
    Fawcett, William J.
    Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery.
    Lonjon, Guillaume
    Department of Orthopedic Surgery, Orthosud, Clinique St-Jean- Sud de France, SANTECITE Group. St Jean de Vedas, Montpellier METROPOLE, France.
    de Boer, Hans D.
    Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, The Netherlands.
    Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations2021In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 21, no 5, p. 729-752Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

    PURPOSE: This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

    STUDY DESIGN: This is a review article.

    METHODS: Under the impetus of the ERAS (R) society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

    RESULTS: Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multi-modal analgesic strategies. The level of evidence for the use of each recommendation is presented.

    CONCLUSION: Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS (R) Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

  • 3.
    Sigmundsson, Freyr Gauti
    et al.
    Department of Orthopedics, Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden.
    Jönsson, Bo
    Department of Orthopedics, Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden.
    Strömqvist, Björn
    Department of Orthopedics, Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden.
    Outcome of decompression with and without fusion in spinal stenosis with degenerative spondylolisthesis in relation to preoperative pain pattern: a register study of 1,624 patients2015In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 15, no 4, p. 638-646Article in journal (Refereed)
    Abstract [en]

    BACKGROUND CONTEXT: Patients with spinal stenosis with concomitant degenerative spondylolisthesis (DS) and predominant back pain (PBP) have been shown to have inferior outcome after surgery. Studies comparing outcome according to preoperative pain predominance and treatment received are lacking.

    PURPOSE: The purpose was to study if adding spinal fusion to the decompression in DS affects outcome in patients with PBP (back pain [BP] Visual Analog Scale [VAS] more than or equal to leg pain [LP] VAS) compared with predominant leg pain (PLP) (BP VAS less than LP VAS).

    PATIENT SAMPLE: The Swedish Spine Register was used and included 1,624 patients operated for DS at the L4-L5 level.

    OUTCOME MEASURES: Self-reported measures were used, including a VAS for BP and LP, the EuroQol-5D (EQ-5D), and the physical and mental component summaries of the Short-Form 36 to estimate health-related quality of life and the Oswestry disability index (ODI) to estimate function.

    METHODS: Inclusion criterion was single-level DS operated on with either decompression only (D) or decompression and instrumented posterolateral fusion (DF). Based on preoperative LP and BP scores, the patients were assigned to one of the two groups: LP predominance or BP predominance. The patients completed the outcome protocol at 1- and 2-year follow-ups. Statistical analysis was performed using linear regression adjusting for multiple potential confounders.

    RESULTS: In the adjusted outcome at the 1-year follow-up, patients with PLP reported a 7.9-mm more improvement on the VAS for BP with fusion, compared with D (95% confidence interval [CI], 0.7-15.2), p=.03. Despite more change in the fused group, the reported BP levels remained similar in the D versus decompressed and fused at the 1-year follow-up (28 vs. 24, p=.77). The patients with PBP benefited from adding fusion in terms of BP 7.1 (95% CI, 0.3-13.9, p=.04), LP 8.8 (2-15.7, p=.01), the ODI 5.7 (1.6-9.9, p=.006), and the EQ-5D 0.09 (1.7-0.02, p=.02) at the 1-year follow-up as the DF group reported greater change in the outcome compared with the D group. At the 2-year follow-up, no significant differences were found between D and decompressed and fused in either the LP or the PBP groups.

    CONCLUSIONS: Patients with PBP operated with DF report better outcomes in terms of pain, function, and health-related quality of life than patients with D. Although these differences are significant on a group level, they may fail to reach minimal clinical significant difference. Patients with PLP report significantly more improvement in terms of BP with DF compared with D, but because of baseline differences in preoperative BP, these improvements may not be explained by the added fusion per se. At the 2-year follow-up, no significant differences were observed between the D and DF patients in either the PBP or PLP groups, but greater loss to follow-up in the DF groups could potentially bias these findings.

  • 4.
    Strömqvist, Fredrik
    et al.
    Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Malmö, Sweden.
    Sigmundsson, Freyr Gauti
    Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Malmö, Sweden.
    Strömqvist, Björn
    Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Malmö, Sweden.
    Jönsson, Bo
    Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Malmö, Sweden.
    Karlsson, Magnus K.
    Clinical and Molecular Osteoporosis Research Unit, Department of Orthopaedics, Lund University, Lund, Sweden; Department of Clinical Sciences, Skåne University Hospital, Malmö, Sweden.
    Incidental durotomy in degenerative lumbar spine surgery: a register study of 64,431 operations2019In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 19, no 4, p. 624-630Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Incidental durotomy (ID) is one of the most common intraoperative complications seen in spine surgery. Conflicting evidence has been presented regarding whether or not outcomes are affected by the presence of an ID.

    PURPOSE: To evaluate whether outcomes following degenerative spine surgery are affected by ID and the incidence of ID with different diagnoses and different surgical procedures.

    MATERIALS: By using SweSpine, the national Swedish Spine Surgery Register, preoperative, surgical and postoperative 1-year follow-up data were obtained for 64,431 surgeries. All patients were surgically treated due to lumbar spinal stenosis (LSS) without or with concomitant degenerative spondylolisthesis (DS) or lumbar disc herniation (LDH) between 2000 and 2015. Gender, age, smoking habits, walking distance, consumption of analgesics, back and leg pain (Visual Analogue Scale [VAS]), quality of life (EuroQol [EQ5D] and Short Form 36 [SF-36]), and disability (Oswestry Disability Index [ODI]) were recorded.

    RESULTS: Overall, incidence of ID during the study period was 5.0%. For the LDH, LSS, and DS subgroups, it was 2.8%, 6.5%, and 6.5%, respectively. Laminectomy was associated with a higher incidence of ID than discectomy (p<.001). ID was more common in all three subgroups if the patient had previously been subjected to spine surgery and with increasing age of the patients (p<.001). LDH patients with an ID reported a higher degree of residual leg pain, inferior mental quality of life (SF-36 MCS), and higher disability (ODI) than LDH patients without ID (all p<.001) 1-year after surgery. LSS patients with an ID reported inferior SF-36 MCS (p<.001) and DS patients with an ID had inferior SF-36 MCS and higher ODI compared to patients with the same diagnosis but without an ID (p<.001). However, these numerical differences are well below references for MCID, for all three subgroups. ID was associated with a higher frequency of patients being dissatisfied with the surgical outcome at 1-year follow-up. In patients who did not improve in back and leg pain following surgery (delta-value), ID was less common than in patients reporting improved back and leg pain from before as compared to following surgery.

    CONCLUSIONS: The overall occurrence of ID in the present study was 5%, with higher figures in LSS and DS and lower figures in LDH. Higher age of the patient and previous surgery were associated with higher frequencies of ID. The outcome at 1 year following surgery was not affected to a clinically relevant extent when an ID was obtained. However, ID was associated with a higher degree of patient dissatisfaction and a longer hospital length of stay.

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