Instrumented fusion for lumbar degenerative spondylolisthesis (LDS) has been challenged recently with high impact trials demonstrating similar changes in health-related quality of life (HRQOL) and less morbidity/cost with laminectomy alone. Randomized trials often fail, however, to evaluate a heterogeneous population of patients. A standardized clinical assessment and management plan (SCAMP) was created as a decision aid for surgeons based on the radiographic stability and clinical presentation of patients. The purpose of this study was to compare outcomes of those patients who followed the decision aid with respect to fusion/no fusion to those who did not.

Patients were prospectively enrolled from eleven different Canadian institutions and followed from 2015–2019. A degenerative spondylolisthesis instability classification system (DSIC) was created using best available evidence stratifying patients into three different subtypes (1. stable degenerative spondylolisthesis, 2. potentially unstable spondylolisthesis and 3. unstable spondylolisthesis). The decision aid recommends laminectomy alone for group 1 patients, posterolateral fusion with pedicle screws in type 2 patients and pedicle screw and interbody fusion for type 3 patients. One year changes in HRQOL, length of hospital stay (LOS), medication use and surgical time were compared between each group and in context of whether the treatment fell within the decision aid recommendation. Statistics were performed with STATA software.

There were 394 patients initially enrolled and 334 (84.8%) with full one year data available for comparison. There were 95 type 1 (stable), 224 type 2 (potentially unstable) and 75 type 3 (unstable) patients initially classified. Baseline Ostwestry disability index (ODI), EQ-5D, and SF-12 MCS scores were significantly worse for type 3 patients versus type 1 patients. One hundred and eight patients were treated within the recommendations of the DSIC system (108/334, 32.3%). Surgeons performed interbody fusions in 141 patients (42%) rather than follow DSIC recommending a less invasive approach. There were no significant differences EQ-5D, SF-12 PCS/MCS, PHQ-9 or ODI at one year between patient groups. There was a trend towards shorter operating times for those patients following the DSIC system (195 minutes non-followers versus 180 followers, p=0.078) and reduced hospital stay (4.46 days non-followers versus 3.98 followers, p=0.065).

There were no significant clinical differences in outcome at 1 year whether patients underwent decompression alone, decompression/posterolateral fusion or interbody fusion regardless of the stability classification. Surgeons were more likely to perform potentially unnecessary interbody fusions even in those patients with stable or potentially unstable spondylolisthesis. Although not statistically significant, there is some suggestion that following the DSIC system based on best evidence recommendations leads to more judicious/responsible use of hospital resources. Further study is required to determine why surgeons are more likely to choose more invasive, higher rigidity constructs in patients with LDS.

Lower-extremity orthopaedic procedures may be performed under either regional or general anaesthesia, or a combination of both techniques. There is a growing body of evidence supporting the benefits of regional anaesthesia, with meta-analyses of randomised controlled trials and registry data suggesting decreases in deep surgical site infections, thromboembolic events, cardiopulmonary complications and length of stay associated with use of regional anaesthesia. In patients undergoing foot and ankle surgery specifically, there is evidence demonstrating decreased post-operative pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports an increased role for the use in regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict the type of anaesthetic used in patients undergoing foot and ankle surgery.

Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analysed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used.

General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p<0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure (<0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 +/− 77 minutes, whereas patients provided with regional anaesthesia had a mean length of procedure 83 +/− 64 minutes.

With increasing evidence supporting the benefits of regional anaesthesia in patients undergoing lower extremity surgery, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure may be a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be considered candidates for regional anaesthesia.

In the current health care climate, there is an increasing focus on cost savings and resource management. As such, there is an emphasis on decreasing length of stay and performing surgery on an outpatient basis. Consequently, some patients will have unanticipated intra-operative or post-operative adverse events that will necessitate an unplanned post-operative hospital admission or a readmission after discharge. These unplanned admissions or readmissions represent an increased burden on health care systems and can cause cancellation of other scheduled procedures. The purpose of this study is to investigate whether pre-operative patient risk factors or intra-operative events could predict unplanned admission or readmission following discharge in patients undergoing either elective or emergency foot and ankle surgery.

Data was prospectively collected on a total of 889 patients. The patients were divided into two groups: patients without readmissions (N=791) and patients who had an unplanned admission or readmission (N=98). We also collected and analysed the following variables: age, gender, BMI, diabetes, ASA class, surgery start time, length of surgery, regional vs. general anesthetic, elective vs. trauma surgery and type of procedure. Logistic regression models were used to identify risk factors that could independently predict unplanned admissions or readmissions to hospital following foot and ankle surgery.

Factors that could be used to independently predict readmission were length of surgery (p 0.0154, Odds Ratio 1.004) and trauma surgery (0.0167; 1.978). For every 1-hour increase in length of surgery, the odds of unplanned admission/readmission increase by 1.27 times. The odds of patients undergoing surgery for acute traumatic injuries getting readmitted are 1.978 times higher than for elective surgery patients.

In conclusion, our study showed that pre-operative patient risk factors including BMI, diabetes, and ASA status were unable to predict whether patients would have an unplanned admission or readmission. The two factors that were able to predict whether patients would have an unplanned admission or readmission were length of the procedure and trauma surgery – both of which are not readily modifiable. Our results showed that in spite of institutional measures to ensure timely discharge, only 11% of patients required an unplanned admission or readmission.

The primary objective of this study was to determine if surgical treatment for spinal stenosis is comparable to total hip and knee arthroplasty in improving patients’ self-reported quality of life. An age, sex and time of surgery matched cohort of patients who had undergone elective primary one-two level spinal decompression (n=90) with (n=26 /90) or without fusion for spinal stenosis (n=40 with degenerative spondylolisthesis) and elective primary total hip (n=90) and knee (n = 90) arthroplasty for osteoarthritis were compared. The primary outcome measure was the preoperative and two year postoperative Medical Outcomes Study Short Form-36 (SF-36) questionnaire.

There was no significant difference in the mean pre-operative Physical Component Summary (PCS) / Mental Component Summary between groups [Spine −32/43; Hip − 30/45; Knee 31/46 (p > 0.5)]. With the exception of the knee MCS (p=0.2), postoperative scores were significantly improved for all groups [Spine −40/53; Hip − 43/51; Knee 39/48 (p < 0.001)]. Overall the hip surgery had the great impact on PCS and the spine surgery on MCS.

Studies have shown the significant impact on overall patient quality of life and cost-effectiveness of primary total joint arthroplasty. The results of this unique study show that surgical intervention for spinal stenosis has a similar positive effect at two year follow up. This study provides data that supports the need advocacy regarding waiting time initiatives and surgical resources for the treatment of patients with symptomatic spinal stenosis with a similar demographic to those with primary OA of the hip or knee.

To evaluate the clinical accuracy of computer-assisted fluoroscopy for the placement of percutaneous lumbosacral (LS) pedicle screws.

A prospective computed tomographic (CT) analysis was performed in forty consecutive patients. Three independent observers were utilised. Postoperative CT scans of one hundred and fifty-nine titanium pedicle screws (n = 6(L3); thirty-eight(L4); sixty-five(l5) and fifty(S1)) were reviewed. All screws were percutaneously placed using the two-dimensional FluoroNavTM system. The relative position of the screw to the pedicle was graded as follows: I-completely in; II – < 2mm breach; III - = 2–4mm breach; IV – > 4mm breach. The direction of the breach was further classified as well as its trajectory.

Correlation between observers was near perfect. The three observers rated 74.2%, 78.6%, and 78.0% of screws were completely contained within the pedicle. The data from the observer with the most significant pedicle breaches is as follows: thirty-five (22%) pedicle breaches (grade II -n=30; III - n=4; IV - n=1/n= 11 medial; n=19 lateral; 5 superior). Only one clinically significant breach occurred medially (grade III) at L5. This required screw revision (performed with a minimal access technique) with complete resolution of acute post-op L5 radiculopathy.

The in-vivo percutaneous pedicle breach rate in this study was higher than that reported for similar open navigational techniques. The majority (85.7%) of breaches were minor (< 2mm) and over half (54.3%) were lateral with no potential for clinical squealae. This high lateral breach rate is due to a modified lateral starting point required for the percutaneous technique. However, there is concern that this technique resulted in one clinically significant medial breach and highlights the increased risk associated with percutatneous pedicle screw placement. The findings of this study suggest that improved screw placement accuracy for minimal access instrumented fusions is required.

Purpose: The purpose of this study was to demonstrate the feasibility and early outcomes of one- and two-level lumbar decompression performed as an outpatient procedure.

Methods: A retrospective review was performed comparing lumbar “laminoplasty” (bilateral decompression from a unilateral approach) using a minimally invasive (MIS-group) technique (MetRxTM tubular retractor system) to open laminoplasty (Open Group). Comparison between groups was performed for patient demographics, radiographic and operative parameters, postoperative pain (VAS), analgesic use and adverse events.

Results: A total of 67 (Open–n=37/ MIS-n=30 [n=20: out patients] patient with a minimum follow-up of 6 months were analyzed. There was no statistically significant difference between groups for age, sex, BMI and radiographic parameters. The MIS group demonstrated a statistically significant reduction (mean = 24minutes) in operative time, estimated blood loss (63mls vs. 227mls), recovery room VAS scores (1.4 vs. 4.4) and total analgesic requirements by %50. None of the MIS group procedures performed on an outpatient basis required readmission. The length of stay for the n=10 inpatient MIS group (elderly patients) was also reduced compared to the open group (2.6 vs. 4.7 days, P= 0.035). The groups were comparable in operative and postoperative adverse events. No progression of preexisting spondylolisthesis has been noted in either group during the follow-up period. Furthermore, only one patient has required reoperation for mechanical low back pain in the MIS group and one patient for recurrent leg pain in the open group.

Conclusions: Minimally invasive outpatient decompression for 1–2 level spinal stenosis is feasible, provides acute perioperative patient and resource utilization benefits and appears to have comparable short-term clinical efficacy compared to open decompression. Long-term follow-up and validated outcomes assessments are currently being assessed.

Funding : Commerical funding

Funding Parties : Medtronic-Sofamor Danek

Purpose: Report results of patients undergoing en-bloc resection of thoracic tumours with local invasion of the spinal column

Methods: Retrospective chart and outcome review

Results: The mean age was 59.1 (range 26–75) years. Patients underwent pre-operative radiation±chemotherapy. Anterior and posterior approaches were performed in all cases, staged a mean 16.2 days apart (range 4–51 days) in nine patients. There were eight non-small cell lung carcinoma, and four sarcomas. The mean total operative time was 12.8 hours(range 9–15). All patients survived the operative procedures and were discharged home. Mean hospital stay was 30.3 days(range 11–97). Positive tumour margins were present in 2 patients. Complications include need for revision thoracotomy, prolonged post-op intubation, one case of fatal PE, one superficial wound infection. Two patients died at four months post-operatively, (2/2 negative tumour margins) and one at 13 months(positive margin). Four patients were disease-free at > 1 year (range 13–40 months). The remaining patients have less than 1 yr f/u with 4/5 disease-free. Oswestry scores are 54.5 at latest f/u compared to 11.3 pre-op(p=0.007). SF-36 PCS and MCS were 35.5 and 51.1 pre-op compared to 25.6(p=0.3) and 38.3(p=0.03) post-op.

Conclusions: En-bloc resections offer curative resections at the expense of worse ODI and SF-36 scores. Staged surgeries allowed for an easier technical resection during the second stage.

Purpose: To determine the results and safety of patients undergoing|spinal cord level (SCL) pedicle subtraction osteotomy (PSO) for thetreatment of thoracic kyphosis.

Methods: Retrospective chart and radiographic review of 25 patients with severe thoracic kyphosis.

Results: The underlying diagnoses were: tumour (8), Scheuermann’s Kyphosis (4), degenerative/osteoporosis (3), fracture (3), inflammatory|(2), neurofibromatosis (2), congenital kyphosis (1), tuberculosis (1), and infected tumour (1). The osteotomy was combined with a lumbar PSO in|five patients. Three patients were treated with double thoracic|osteotomies. Two PSOs were extended transdiscally to debride the|infected disc. The mean focal PSO correction was 33.6° (range 9°–73°). The overall thoracic kyphosis measured from T5 to T12 improved from a|mean of 58.3° preoperatively to 37.1° postoperatively. Estimated blood|loss ranged from 400cc to 12500cc. All patients presenting with spinal|cord dysfunction neurologically improved postoperatively. There were 2 major neurological complications. One patient developed postoperative | progressive paraplegia following a prolonged period of intra- and | postoperative severe hypotension and coagulopathy. The other developed a| pseudoarthrosis five months postoperatively and suffered an incomplete|spinal cord injury during the subsequent revision. Other complications included: T3 radicular pain (1) -resolved; dural tears (2); respiratory failure -prolonged ICU admission(1); fractures proximal to the thoracic (2) and distal to lumbar (1) instrumentation; incomplete corrections of the sagittal alignment despite double osteotomies (2); wound breakdown associated with preoperative radiation (1).|

Conclusions: SCL-PSO is a feasible option for severe thoracic kyphosis. This procedure eliminates the need for anterior surgery; however, it does not reduce the potential for significant morbidity.