Update 03/15/18: In the initial article, it was stated that “your surgeon and his/her team will follow you forever”. The onus is on the patients to return for post-operative appointments as recommended by their surgeon. After the first few years post-op, the visits are generally less frequent and eventually only every 5-10 years. If a long-term study is being done, letters will often be sent to patients that had the type of surgery that is included in the study to ask them to return for an evaluation. If patients haven’t been to the office for a long time or their contact information is not current, that makes it difficult. Regular x-rays and visits are important to catch and treat problems before they become too serious. For example, if changes are noted that indicate early flatback syndrome, a revision surgery may be recommended to keep the spine in an optimal position and prevent worsening and chronic pain. If a patient was told years ago that nothing could be done, that may not be true today – the patient should see a spine specialist for a new evaluation and possible treatment.
When we mentioned in a previous post that once you have spine surgery your surgeon and his/her team would like to follow you forever, the following study is a good example of that! This was the first paper presented at the SRS Annual Meeting in Philadelphia this past September. I have gone through and spelled out abbreviations and explained different terms to make it more understandable for those reading it.
(When a research study is done and the results written in an abstract and submitted in the hope of being chosen to be presented at one of the SRS meetings, there are specific guidelines that need to be followed, one of which is how many characters - including spaces! - are allowed. So, there are ‘tricks of the trade’ to stay within that limit but much of it wouldn’t be clear to non-medical readers.)
This study compares patients who had fusion and instrumentation to or above L3, the 3rd of 5 vertebrae in the lumbar spine, to those whose surgery extended lower in the spine to L4 (4th lumbar vertebra) and below. They looked at reoperation rates and the answers the patients gave on the questionnaires to analyze the differences in the 2 groups. They reported that patients with instrumentation extending into the lower part of the lumbar spine had more functional difficulties and a higher rate of repeat surgery. Keep in mind, however, that the instrumentation used on these patients was vastly different than what is used today. A Harrington rod was a straight rod attached to the spine with just 1 hook at each end. Although this was the original instrumentation used in the spine, surgeons learned that inserting a straight rod was not the best idea. Current instrumentation techniques involve inserting 2 or more rods and using multiple screws and hooks to attach them to the spine. The rods are bent and contoured to the spine to restore and maintain the natural curves which resemble a mild ‘S’ shape when viewed from the side. This is a much better position for the spine to be in, thereby avoiding the problems leading to reoperation that were seen in many Harrington rod patients.
Hundreds of abstracts are submitted each year for consideration of being presented. A team of reviewers reads and evaluates each submission and scores it, and approximately 130 with the highest scores are accepted for presentation. The reviewers like to see long-term follow-up and high percentages of the original groups included in the follow-up studies. So keep your information up to date at your surgeon’s office because you never know when they will try to get in touch with you to participate in a long-term study!!
Correlation of Lowest Level of Instrumentation to Functional Outcomes and Risk of Further Spine Surgery in AIS with Minimum 40 Year Follow-up
Sarah T. Lander, MD; Caroline Thirukumaran; Krista Noble, BS; Ahmed Saleh, MD; Addisu Mesfin, MD; Paul T. Rubery, MD; James O. Sanders, MD
In long-term follow up of patients undergoing a posterior spinal fusion with Harrington instrumentation comparing the lowest instrumented vertebra (LIV) with patient reported outcome measures and the need for additional surgery, patients with a lower LIV had a higher rate of additional surgery and lower functional outcomes than those with higher LIVs. This could be because of the instrumentation, the fusion, or the nature of curves requiring instrumentation lower on the spine.
The lower the level of instrumentation the more likely the patient is to receive an additional spine surgery and the lower the patient reported functional outcomes.
There is uncertainty in adolescent idiopathic scoliosis (AIS) instrumentation and fusion how the long-term outcomes relate to the level of instrumentation including pain and the need for further surgery.
We identified records of 314 patients treated by Louis A. Goldstein with Harrington instrumentation and fusion between 1961 and 1977. A search was performed identifying the patients who were then contacted for various assessments including patient related outcomes. This analysis compares the lowest level of fusion with the Oswestry Disability Index (ODI) and the SRS-7 using bivariate and multivariate analysis. (The ODI and SRS forms are two questionnaires given to patients after surgery so see how they are doing. The answers are scored, combined and then analyzed with a statistical program. With the ODI, lower scores indicate better function and with the SRS form, higher scores are best.)
We identified 91 living and 6 deceased patients with follow-up from 40 to 56 years and current patient age from 52 to 71 years old. 81 completed the outcome questionnaires. In those without additional surgery, those with LIV L3 and above had average ODI of 14.12 and SRS-7 of 23.3 compared to LIV L4 and below having 17.9 and 22.7 respectively. 6/47 or 12.8% with LIV L3 and above had further surgery compared to 13/34 or 38.2% L4 and below. Those with LIV L4 and below had 2.4 times higher odds of receiving additional surgery. Patients receiving additional surgery compared to those who did not had an average ODI of 22.8 vs 12.8 and SRS-7 of 19.6 vs 23.1. ODI disability comparison comparing those without to those with additional surgery showed 73% vs. 42% minimum disability, 23% vs. 53% moderate disability, and 2% vs. 5% severe disability.
In long-term follow up patients with lower instrumentation levels had a higher rate of receiving additional surgery and lower functional outcomes than those with an LIV higher on the spine. Those who received additional surgery had lower functional outcomes than those without. There were higher ODI and lower SRS scores in those with LIV L4 or lower compared to L3 and above in patients not receiving additional surgery, but differences were not large or statistically significant.