Elsevier

The Spine Journal

Volume 23, Issue 1, January 2023, Pages 54-63
The Spine Journal

Clinical Study
Practical answers to frequently asked questions in minimally invasive lumbar spine surgery

https://doi.org/10.1016/j.spinee.2022.07.087Get rights and content

Abstract

BACKGROUND CONTEXT

Surgical counseling enables shared decision-making (SDM) by improving patients’ understanding.

PURPOSE

To provide answers to frequently asked questions (FAQs) in minimally invasive lumbar spine surgery.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Patients who underwent primary tubular minimally invasive lumbar spine surgery in form of transforaminal lumbar interbody fusion (MI-TLIF), decompression alone, or microdiscectomy and had a minimum of 1-year follow-up.

OUTCOME MEASURES

(1) Surgical (radiation exposure and intraoperative complications) (2)Immediate postoperative (length of stay [LOS] and complications) (3) Clinical outcomes (Visual Analog Scale- back and leg, VAS; Oswestry Disability Index, ODI; 12-Item Short Form Survey Physical Component Score, SF-12 PCS; Patient-Reported Outcomes Measurement Information System Physical Function, PROMIS PF; Global Rating Change, GRC; return to activities; complications/reoperations)

METHODS

The outcome measures were analyzed to provide answers to ten FAQs that were compiled based on the authors’ experience and a review of literature. Changes in VAS back, VAS leg, ODI, and SF-12 PCS from preoperative values to the early (<6 months) and late (>6 months) postoperative time points were analyzed with Wilcoxon Signed Rank Tests. % of patients achieving minimal clinically important difference (MCID) for these patient-reported outcome measures (PROMs) at the two time points was evaluated. Changes in PROs from preoperative values too early (<6 months) and late (≥6 months) postoperative time points were analyzed within each of the three groups. Percentage of patients achieving MCID was also evaluated.

RESULTS

Three hundred sixty-six patients (104 TLIF, 147 decompression, 115 microdiscectomy) were included. The following FAQs were answered: (1) Will my back pain improve? Most patients report improvement by >50%. About 60% of TLIF, decompression, and microdiscectomy patients achieved MCID at ≥6 months. (2) Will my leg pain improve? Most patients report improvement by >50%. 56% of TLIF, 67% of decompression, and 70% of microdiscectomy patients achieved MCID at ≥6 months. (3) Will my activity level improve? Most patients report significant improvement. Sixty-six percent of TLIF, 55% of decompression, and 75% of microdiscectomy patients achieved MCID for SF-12 PCS. (4) Is there a chance I will get worse? Six percent after TLIF, 14% after decompression, and 5% after microdiscectomy. (5) Will I receive a significant amount of radiation? The radiation exposure is likely to be acceptable and nearly insignificant in terms of radiation-related risks. (6) What is the likelihood that I will have a complication? 17.3% (15.4% minor, 1.9% major) for TLIF, 10% (9.3% minor and 0.7% major) for decompression, and 1.7% (all minor) for microdiscectomy (7) Will I need another surgery? Six percent after TLIF, 16.3% after decompression, 13% after microdiscectomy. (8) How long will I stay in the hospital? Most patients get discharged on postoperative day one after TLIF and on the same day after decompression and microdiscectomy. (9) When will I be able to return to work? >80% of patients return to work (average: 25 days after TLIF, 14 days after decompression, 11 days after microdiscectomy). (10) Will I be able to drive again? >90% of patients return to driving (average: 22 days after TLIF, 11 days after decompression, 14 days after microdiscectomy).

CONCLUSIONS

These concise answers to the FAQs in minimally invasive lumbar spine surgery can be used by physicians as a reference to enable patient education.

Introduction

The increasing significance of evidence-based, patient-centered care has led to the introduction of the concept of shared decision-making (SDM). SDM has been defined as: “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences” [1]. Its benefits include increased patient knowledge leading to realistic expectations and better satisfaction, reduced decisional conflict, reduced rate of choosing surgery, and potentially reduced costs by reducing unnecessary procedures that do not align with patient preferences [2].

Degenerative conditions represent a broad category of lumbar spine pathology with an unclear demarcation between the choices of treatment modalities. Whether to opt for surgery or not largely depends on the extent of symptoms the patient has and the impact of these symptoms on his/her daily life. Patient's preferences and expectations play a major role in decision-making. Considering the requirement of a highly individualized approach for the treatment of lumbar spine degenerative pathology, it is important that physicians have a detailed discussion with the patients and thus, facilitate patient education and SDM.

The advent of minimally invasive spine surgery (MISS) has further broadened the range of treatment options for the treatment of degenerative lumbar pathology [3], [4], [5], [6]. MISS remains a relatively new concept which expectedly leads to queries regarding its risks and benefits. The purpose of this study was, therefore, to provide practical answers to the frequently asked questions (FAQs) patients have when considering minimally invasive lumbar spine surgery for the treatment of degenerative lumbar spine pathology.

Section snippets

Study design and population

This study was an Institutional Review Board-approved retrospective review of prospectively collected data from a multi-surgeon surgical database. Consecutive patients who underwent primary tubular minimally invasive lumbar spine surgery for degenerative conditions in form of transforaminal lumbar interbody fusion (TLIF), decompression alone (unilateral laminectomy for bilateral decompression, ULBD), or tubular microdiscectomy (TMD) between April 2017 and May 2020 at a single institute were

Patient demographics

One hundred four patients were included in the TLIF group (mean age 58.8 years, 53% female, mean BMI 27.5 kg/m2), 147 patients in the decompression group (mean age 64.5 years, 65% male, mean BMI 26.9 kg/m2), and 115 patients in the microdiscectomy group (mean age 45.2 years, 65% male, mean BMI 26.9 kg/m2).

FAQ1: Will my back pain improve?

Back pain had reduced by about 50% after decompression and >50% after TLIF and microdiscectomy. There was a significant improvement in VAS back (p<.001) with most patients achieving MCID

Discussion

From being a legal doctrine focused almost exclusively on the physician's disclosure of information to becoming a process of shared decision-making (SDM) based upon mutual respect and participation, informed consent in health care has evolved incredibly over time. SDM enriches the process of informed consent by emphasizing patients’ understanding and prioritizing of various treatment modalities according to their own values, experiences, and expectations. Beyond improving informed consent, SDM

Declarations of Competing Interests

One or more of the authors declare financial or professional relationships on ICMJE-NASSJ disclosure forms.

Acknowledgments

No direct funding was received for this study. However, the study used REDCap (Research Electronic Data Capture) hosted at Weill Cornell Medicine Clinical and Translational Science Center supported by the National Center For Advancing Translational Science of the National Institute of Health (NIH) under award number: UL1 TR002384.

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    Author disclosure: PS: Nothing to disclose. ASV: Nothing to disclose. EM: Nothing to disclose. JKM: Nothing to disclose. SD: Nothing to disclose. JS Nothing to disclose. DJS: Nothing to disclose. DM: Nothing to disclose. KA: Nothing to disclose. HU: Nothing to disclose. AS: Nothing to disclose. VL: Royalties: Nuvasive (C); Stock Ownership: Nemaris Inc. (20%); Stock Ownership: VFT Solutions LLC (50%); Consulting: Globus Medical (F); Consulting: Implanet (B); Consulting: Depuy Synthes Spine (C); Consulting: Stryker (C); Scientific Advisory Board/Other Office: ISSG. (0%) SAQ: Royalties: Globus Medical (C); Private Investments: Tissue Differentiation (F); Private Investments: HS2, LLC (D); Consulting: Globus Medical (E); Consulting: StrykerK2M: (E); Scientific Advisory Board/Other Office: Simplify Medical, Inc. (B). SI: Consulting: Globus Medical, Inc. (C); Consulting: Elliquence (A); Research Support (Investigator Salary, Staff/Materials)^: Innovasive (D).

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