Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, co-author Jacob M. Buchowski, MD, selected the 5 most clinically compelling findings from the >30 studies summarized in the June 17, 2020 “What’s New in Spine Surgery.”
Adult Spinal Deformity
—A recent randomized controlled trial compared operative vs nonoperative treatment among 63 adult patients with symptomatic lumbar scoliosis. An additional 223 patients were included in an observational arm of the study. At 2 years, 64% of the randomized patients in the nonoperative group had crossed over to the operative group. In an as-treated analysis, surgery was associated with superior improvement, but the high crossover rate precludes making firm comparative conclusions.
Spinal Cord Injuries
—A small study of 3 subjects1 who had sustained a spinal cord injury investigated the delivery of spatially selective stimulation to posterior nerve roots innervating the lumbosacral spinal cord through an implantable pulse generator with real-time triggering capability. This method reestablished adaptive control over previously paralyzed muscles, and subjects were eventually able to walk or bike during spatiotemporal stimulation.
—A prospective study of >700 patients with degenerative cervical myelopathy2 examined the impact of surgical management on neck pain outcomes. Using the Neck Disability Index at baseline and at 6, 12, and 24 months postoperatively, researchers found significant improvement in functional and pain scores that met or exceeded the minimum clinically important difference at all follow-up time points.
—A retrospective study of >1,800 patients with symptomatic lumbar stenosis3 investigated whether pain improvements could be obtained surgically with decompression alone without fusion. At 1 year after surgery, decompression alone was associated with significant improvement in all patient-reported outcomes, suggesting that a concomitant fusion may not be required in such cases.
—A retrospective study of nearly 29,000 patients4 examined the effects of chronic preoperative opioid therapy on medium- and long-term outcomes after lumbar arthrodesis surgery. Postoperatively, chronic opioid use prior to surgery was associated with an increased risk of 90-day emergency department visits and prolonged 1- and 2-year narcotic use.
- Wagner FB, Mignardot JB, Le Goff-Mignardot CG, Demesmaeker R, Komi S, Capogrosso M, Rowald A, Se´añez I, Caban M, Pirondini E, Vat M, McCracken LA, Heimgartner R, Fodor I, Watrin A, Seguin P, Paoles E, Van Den Keybus K, Eberle G, Schurch B, Pralong E, Becce F, Prior J, Buse N, Buschman R, Neufeld E, Kuster N, Carda S, von Zitzewitz J, Delattre V, Denison T, Lambert H, Minassian K, Bloch J. Courtine G. Targeted neurotechnology restores walking in humans with spinal cord injury. Nature. 2018 Nov;563(7729):65-71. Epub 2018 Oct 31.
- Schneider MM, Tetreault L, Badhiwala JH, Zhu MP, Wilson J, Fehlings MG. 42. The impact of surgical decompression on neck pain outcomes in patients with degenerative cervical myelopathy: results from the multicenter prospective AOSpine studies. Spine J. 2019 Sep;19(9):S21.
- Bech-Azeddine R, Fruensgaard S, Andersen M, Carreon LY. 215. Outcomes of decompression without fusion in patients with lumbar spinal stenosis with back pain. Spine J. 2019 Sep;19(9):S106.
- Eisenberg JM, Kalakoti P, Hendrickson NR, Saifi C, Pugely AJ. 142. Impact of preoperative chronic opioid therapy on long-term outcomes, reoperations, complications and resource utilization after lumbar arthrodesis. Spine J. 2019 Sep; 19(9):S68-9.
Spinal epidural hematoma is a rare condition. Because the etiology is often unclear and the medical history is frequently innocuous, a high index of suspicion is required in order to maximize the chances of a successful outcome.
This month’s “Case Connections” spotlights 4 cases of spinal epidural hematoma involving 2 elderly women, a male Olympic-caliber swimmer, and a preadolescent boy.
In the springboard case, from the March 22, 2017, edition of JBJS Case Connector, Yamaguchi et al. report on a 90-year-old woman with a history of transient ischemic attacks (TIAs) and combined aspirin-dipyridamole therapy in whom a large spontaneous spinal epidural hematoma (SSEH) developed rapidly after she shifted her position in bed. The authors concluded that their case emphasized that “early diagnosis of an SSEH and prompt surgical intervention can avoid catastrophic and permanent neurological deterioration and compromise.”
Three additional JBJS Case Connector case reports summarized in the article focus on:
- An 82-year-old woman who developed an epidural hemorrhage and acute paraplegia following vertebroplasty
- A 22-year-old male collegiate swimmer who underwent an emergent operative spinal decompression procedure within 4 hours after presentation to the ED with searing back pain and decreased leg strength
- A 12-year-old boy who presented to the hospital with intense back pain along with numbness, tingling, and loss of motor function in the lower extremities 3 weeks after he had been pushed into a wall at school
Among the take-home points from this “Case Connections” article: MRI is the gold standard for the diagnosis of spinal epidural hematomas, and treatment typically involves operative decompression consisting of laminectomies and evacuation of the hematoma.
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
Almost 50 years ago, in a classic 1968 JBJS paper, Leon Wiltse and co-authors described a novel and innovative access route to the lumbar spine. At that time, the vast majority of approaches to the lumbar spine were performed through midline incisions. Wiltse´s approach, however, utilized a more lateral access route to the spine. In this beautifully illustrated paper, the authors described a curved incision of the fascia and the skin with direct access to the transverse processes, pedicles, and the lateral masses.
The advantages of this novel access were multifold. Although wide midline laminectomies represented the gold-standard decompression technique at that time, the lateral approach served to avoid a more challenging and risky midline revision access, adding an elegant access for salvage procedures. Two goals of Wiltse’s approach were to achieve solid, posterolateral fusions and to decompress the neural structures. Graft harvest from the posterior iliac crest was easily facilitated with this approach.
Additional advantages included reduced blood loss and less muscle ischemia, and the preservation of spinous processes and intra-/supraspinous ligaments, which served to maintain the stability of the lumbar spine. The main downside was the necessity of performing two skin incisions as opposed to just one midline incision.
Since its introduction, Wiltse´s approach and the anatomic planes have been studied in great detail.1,2 Considering the vast developments in spine surgery over the last years and decades, the Wiltse approach has stood the test of time, as it still represents one of the main access routes to the lumbar spine that any skilled spine surgeon needs to master.
With the arrival of instrumentation, Wiltse´s approach was later employed in interbody fusion and minimally invasive transforaminal lumbar interbody fusion (TLIF) techniques, as it allowed direct access to the pedicles and the disc space. It has also been used for various techniques of direct pars repair.3
With the addition of some minor modifications, Wiltse´s approach still reflects the main access for minimally invasive, microsurgical treatment of foraminal and extraforaminal disc herniations, including bony decompression of the neuroforamen.4 The far lateral access permits sufficient decompression of the exiting nerve roots while preserving the facet joints, which serves to avoid more invasive fusion techniques for a considerable number of patients.
Overall, Wiltse´s innovative approach advanced spinal care by reducing access–related morbidity. Dr. Wiltse passed away at age 92 in 2005. His major achievements in spine surgery and his great accomplishments will remain in our memories and will continue to impact spine surgery over the coming decades.
Christoph J. Siepe, MD
JBJS Deputy Editor
- Vialle R, Court C, Khouri N, et al. Anatomical study of the paraspinal approach to the lumbar spine. Eur Spine J. 2005;14(4):366-71.
- Palmer DK, Allen JL, Williams PA, et al. Multilevel magnetic resonance imaging analysis of multifidus-longissimus cleavage planes in the lumbar spine and potential clinical applications to Wiltse’s paraspinal approach. Spine (Phila Pa 1976). 2011;36(16):1263-7.
- Xing R, Dou Q, Li X, et al. Posterior Dynamic Stabilization With Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel Surgery. Spine (Phila Pa 1976). 2016;41(8):E494-502.
- Mehren C, Siepe CJ. Neuroforaminal decompression and intra-/extraforaminal discectomy via a paraspinal muscle-splitting approach. Eur Spine J. 2016.
Two interesting investigations into lumbar spinal stenosis (LSS) appeared in the general medical literature recently.
—A registry-based observational study of nearly 900 patients in the BMJ found that microdecompression techniques were as effective as open laminectomy in improving disability scores 12 months after surgery. The two techniques yielded similar quality-of-life scores at the one-year point, but the microdecompression patients had shorter hospital stays.
—In Annals of Internal Medicine, a multisite randomized study of 170 patients 50 or older with lumbar spinal stenosis found that those receiving surgical decompression and those receiving physical therapy (2 PT visits per week for six weeks focused on lumbar flexion and general conditioning) had essentially the same functional outcomes at time points ranging from 10 weeks to two years after enrollment. However, 57% of patients assigned to PT crossed over to surgery—some due to high copays for physical therapy, said study co-author Anthony Delitto, PT. In an editorial accompanying the study, JBJS Deputy Editor for Methodology and Biostatistics Jeffrey Katz, MD, concluded, “Because long-term outcomes are similar for both treatments yet short-term risks differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS.”