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Background Context: Previous studies suggest that a postoperative symptom state with Oswestry Disability Index (ODI)≤20 and pain Numeric Rating Scales (NRS)≤2 following surgery for lumbar degenerative conditions are reasonable thresholds for best outcomes in which patients will be unlikely to seek additional medical care or require additional health-care resources., Purpose: To identify prognostic factors that predict a "best outcome," defined as postoperative ODI≤20 and pain NRS≤2 following fusion for lumbar degenerative conditions., Study Design: Longitudinal observational cohort., Patient Sample: A total of 396 patients from a single site enrolled in the Quality Outcomes Database who underwent fusion for lumbar degenerative conditions., Outcome Measures: Oswestry Disability Index, Back and Leg Pain NRS (0-10)., Methods: Collected and analyzed variables included age, sex, body mass index, American Society of Anesthesia grade, number of surgical levels, surgical time, preoperative ODI, preoperative back pain, preoperative leg pain, workmen compensation status, surgical approach, smoking status, and principal diagnosis., Results: A total of 74 patients (19%) reported a minimal symptom state at 1-year postoperative (ODI≤20, back pain NRS≤2, and leg pain NRS≤2) and were included in the best outcomes group. Patients in the best outcomes group were older (62 vs. 57 years, p=.001), had lower preoperative ODI (43 vs. 56, p=.000), lower preoperative back pain (6.5 vs. 7.5, p=.000). They had fewer surgical levels (1.25 vs. 1.47, p=.005) and shorter operative times [OR] times (208 vs. 241 minutes, p=.002). They were more likely to have a preoperative diagnosis of spondylolisthesis or disc herniation and less likely to have a diagnosis of adjacent segment disease or mechanical disc collapse (p=.001). Stepwise forward regression analysis revealed diagnosis (p=.023, OR=0.75), age (p=.000, OR=1.04), baseline ODI (p=.000, OR=0.96), and number of levels (p=.019, OR=0.53) as predictive variables., Conclusion: Achieving a minimal symptom state, defined here as a postoperative ODI≤20 and pain NRS≤2, following fusion for lumbar degenerative conditions is more likely in an older patient with a lower baseline ODI undergoing a single level lumbar fusion for spondylolisthesis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Context: Transforaminal lumbar interbody fusion (TLIF) and dual-approach anteroposterior (AP) are common techniques to achieve circumferential fusion for lumbar spondylolisthesis. It is unclear which approach is more cost-effective., Purpose: Our goal was to determine the incremental cost-effectiveness ratio (ICER) by calculating the cost per quality-adjusted life year (QALY) for each approach., Study Design/setting: This study is a propensity-matched cost-effectiveness comparison., Patient Sample: Patients with lumbar spondylolisthesis undergoing single-level AP fusion or TLIF and enrolled in a prospective observational surgical database were included in this study., Outcome Measures: The outcome measures in this study were the Oswestry Disability Index (ODI) and the Short Form-6D (SF-6D)., Methods: From a prospective surgical database, patients with lumbar spondylolisthesis undergoing single-level AP fusion were propensity matched to a TLIF cohort based on age, gender, body mass index, smoking status, workers compensation, preoperative ODI, and back and leg pain numeric scores. Quality-adjusted life years gained were determined using baseline and 1- and 2-yearpostoperative SF-6D scores. Cost was calculated from actual, direct hospital costs and included subsequent postsurgical costs (epidural spinal injections, spine-related emergency department visits, readmissions, and revision surgery)., Results: Thirty-one cases of AP fusions were identified and propensity matched to 31 TLIF patients. Patients undergoing TLIF had a shorter mean operative time (270 vs. 328 minutes, p=.039) but no difference in estimated blood loss (526 vs. 548 cc, p=.804) or hospital length of stay (4.5 vs. 6.1 days, p=.146). Quality-adjusted life years gained at 2 years were also similar (0.140 vs. 0.130, p=.672). The mean index surgery and the total 2-year costs were lower for TLIF compared with AP (index: $29,428 vs. $31,466; final: $30,684 vs. $331,880). As overall costs were lower and QALYs gained were similar for TLIF compared with AP fusion, TLIF was the dominant intervention with an ICER of $116,327., Conclusions: Under our study parameters, surgical treatment of lumbar spondylolisthesis with TLIF is more cost-effective compared with AP fusion. Because of the short-term follow-up, the longevity of this should be further investigated., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Context: Although lumbar disc herniation (LDH) classically presents with lower extremity radiculopathy, there are patients who have substantial associated back pain., Purpose: The present study aims to determine if patients with LDH with substantial back pain improve with decompression alone., Study Design: This is a longitudinal observational cohort study., Patient Sample: Patients enrolled in the Quality and Outcomes Database with LDH and a baseline back pain score of ≥5 of 10 who underwent single- or two-level lumbar discectomy only., Outcome Measures: Back and leg pain scores (0-10), Oswestry Disability Index (ODI), and EuroQoL 5D were measured., Methods: Standard demographic and surgical variables were collected, as well as patient-reported outcomes at baseline and at 3 and 12 months postoperatively., Results: The mean age of the cohort was 49.8 years and 1,195 (52.8%) were male. Mean body mass index was 30.1 kg/m 2 . About half of the patients (1,103, 48.8%) underwent single-level discectomy and the other half (1,159, 51.2%) had two-level discectomy. Average blood loss was 44 cc. Most of the patients (2,217, 98%) were discharged home with routine postoperative care. The average length of stay was 0.53 days. At 3 and 12 months postoperatively, there were statistically significant (p<.000) improvements in back pain (from 7.7 to 2.9 to 3.2), leg pain (from 7.5 to 2.3 to 2.5), and ODI (from 26.2 to 11.6 to 11.2). Patients with a single-level discectomy, compared with patients with a two-level discectomy, had similar improvements in 3- and 12-month back pain, leg pain, and ODI scores., Conclusions: Patients with LDH who have substantial back pain can be counseled to expect improvement in their back pain scores 12 months after a discectomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Context: Obesity is a growing problem in health care. Studies have demonstrated similar functional outcomes but higher complication rates after spine surgery in obese patients., Purpose: This study aimed to compare patient-reported outcomes and revision rates 5 years after instrumented posterior lumbar fusion between normal, overweight, and obese patients., Study Design: Propensity matched case control., Patient Sample: Patients who had posterior instrumented lumbar spinal fusion from 2001 to 2008 from a single spine specialty center with complete preoperative and 5-year postoperative outcome measures were identified., Outcome Measures: Oswestry Disability Index (ODI), Back Pain (0-10) and Leg Pain (0-10) Numeric Rating Scales, and Short Form-36 Physical Composite Summary Scores (SF-36 PCS)., Methods: Three comparison groups, one with body mass index (BMI) ≥20-25 kg/m 2 (normal), another with ≥25-<30 kg/m 2 (overweight), and another with ≥30-40 kg/m 2 (obese) were created using propensity matching techniques based on demographics, baseline clinical outcome measures, and surgical characteristics. Five-year postoperative outcome measures and revision rates in the three groups were compared. One-way analysis of variance was used to compare continuous variables, and Fisher exact test was used to compare categorical variables between the groups. Significance was set at p<.01., Results: There were 82 cases matched in each cohort. Estimated blood loss (440 cc vs. 702 cc vs. 798 cc, p=.000) and operative time (234 minutes vs. 263 minutes vs. 275 minutes, p=.003) were significantly greater in the overweight and obese patients. Improvements in ODI (14.2 vs. 9.6 vs. 10.4, p=.226), SF-36 PCS (5.9 vs. 2.9 vs. 3.5, p=.361), back pain (3.0 vs. 2.0 vs. 2.1, p=.028), and leg pain (3.0 vs. 2.3 vs. 2.3, p=.311) scores were similar among the groups. Revision rates (14 vs. 15 vs. 13, p=.917), and time between index and revision surgery (p=.990) were similar among the three groups as well., Conclusion: When considering a subset of patient-reported outcomes and revision surgery after 5 years, patients with an elevated BMI >25 at baseline did not appear to have worse outcomes than those with a normal BMI of 20-25 when undergoing posterior lumbar fusion surgery. Obesity should not be considered a contraindication to surgery in patients with appropriate surgical indications., (Copyright © 2016 Elsevier Inc. All rights reserved.)