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  • 1.
    Elmekaty, Mohamed
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Tanta Univ, Tanta, Egypt.
    ElMehy, Emad
    Tanta Univ, Orthoped & Traumatol Dept, Tanta, Egypt.
    Försth, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    MacDowall, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    El Elemi, Ahmed
    Tanta Univ, Orthoped & Traumatol Dept, Tanta, Egypt.
    Hosni, Mohamed
    Tanta Univ, Orthoped & Traumatol Dept, Tanta, Egypt.
    Robinson, Yohan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Safety of a novel modular cage for transforaminal lumbar interbody fusion: clinical cohort study in 20 patients with degenerative disc disease2018In: SICOT-J, ISSN 2426-8887, Vol. 4, article id 24Article in journal (Refereed)
    Abstract [en]

    Introduction: Transforaminal lumbar interbody fusion (TLIF) is used to reconstruct disc height and reduce degenerative deformity in spinal fusion. Patients with osteoporosis are at high risk of TLIF cage subsidence; possibly due to the relatively small footprint compared to anterior interbody devices. Recently, modular TLIF cage with an integral rail and slot system was developed to reduce cage subsidence and allow early rehabilitation. Objective: To study the safety of a modular TLIF device in patients with degenerative disc disorders (DDD) with regard to surgical complications, non-union, and subsidence. Methods: Patients with DDD treated with a modular TLIF cage (Polyetheretherketone(PEEK), VTI interfuse S) were analysed retrospectively with one-year follow-up. Lumbar sagittal parameters were collected preoperatively, postoperatively and at one year follow-up. Cage subsidence, fusion rate, screw loosening and proportion of endplate coverage were assessed in computed tomography scan. Results: 20 patients (age 66 +/- 10 years, 65% female, BMI 28 +/- 5 kg/m(2)) with a total of 37 fusion levels were included. 15 patients had degenerative spondylosis and 5 patients had degenerative scoliosis. The cages covered >60% of the vertebral body diameters. Lumbar lordosis angle and segmental disc angle increased from 45.2 +/- 14.5 and 7.3 +/- 3.6 to 52.7 +/- 9.1 and 10.5 +/- 3.5 (p=0.029 and 0.0002) postoperatively for each parameter respectively without loss of correction at one year follow up. One case of deep postoperative infection occurred (5%). No cage subsidence occurred. No non-union or screw loosening occurred. Conclusions: The modular TLIF cage was safe with regard to subsidence and union-rate. It restored and maintained lumbar lordosis angle, segmental disc angle and disc height, which can be attributed to the large footprint of this modular cage.

  • 2.
    Försth, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    On Surgery for Lumbar Spinal Stenosis2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The incidence of lumbar spinal stenosis (LSS) is steadily rising, mostly because of a noticeably older age structure. In Sweden, LSS surgery has increased continuously over the years and is presently the most common argument to undergo spine surgery. The purpose of the surgery is to decompress the neural elements in the stenotic spinal canal. To avoid instability, there has been a tradition to do the decompression with a complementary fusion, especially if degenerative spondylolisthesis is present preoperatively.

    The overall aims of this thesis were to evaluate which method of surgery that generally can be considered to give sufficiently good clinical results with least cost to society and risk of complications and to determine whether there is a difference in outcome between smokers and non-smokers.

    The Swespine Register was used to collect data on clinical outcome after LSS surgery. In two of the studies, large cohorts were observed prospectively with follow-up after 2 years. Data were analysed in a multivariate model and logistic regression. In a randomised controlled trial (RCT, the Swedish Spinal Stenosis Study), 233 patients were randomised to either decompression with fusion or decompression alone and then followed for 2 years. The consequence of preoperative degenerative spondylolisthesis on the results was analysed and a health economic evaluation performed. The three-dimensional CT technique was used in a radiologic biomechanical pilot study to evaluate the stabilising role of the segmental midline structures in LSS with preoperative degenerative spondylolisthesis by comparing laminectomy with bilateral laminotomies.

    Smokers, in comparison with non-smokers, showed less improvement after surgery for LSS. Decompression with fusion did not lead to better results compared with decompression alone, no matter if degenerative spondylolisthesis was present preoperatively or not; nor was decompression with fusion found to be more cost-effective than decomression alone. The instability caused by a decompression proved to be minimal and removal of the midline structures by laminectomy did not result in increased instability compared with the preservation of these structures by bilateral laminotomies.

    In LSS surgery, decompression without fusion should generally be the treatment of choice, regardless of whether preoperative degenerative spondylolisthesis is present or not. Special efforts should be targeted towards smoking cessation prior to surgery.

    List of papers
    1. Smokers Show Less Improvement Than Nonsmokers Two Years after Surgery for Lumbar Spinal Stenosis: A study of 4555 Patients from the Swedish Spine Register
    Open this publication in new window or tab >>Smokers Show Less Improvement Than Nonsmokers Two Years after Surgery for Lumbar Spinal Stenosis: A study of 4555 Patients from the Swedish Spine Register
    2011 (English)In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 36, no 13, p. 1059-1064Article in journal (Refereed) Published
    Abstract [en]

    Study Design. A cohort study based on the Swedish Spine Register.

    Objective. To determine the relation between smoking status and disability after surgical treatment for lumbar spinal stenosis.

    Summary of Background Data. Smoking and nicotine have been shown to inhibit lumbar spinal fusion and promote disc degeneration. No association, however, has previously been found between smoking and outcome after surgery for lumbar spinal stenosis. A large prospective study is therefore needed.

    Methods. All patients with a completed 2-year follow-up in the Swedish Spine Register operated for central lumbar stenosis before October 1, 2006 were included. Logistic regression was used to assess the association between smoking status and outcomes.

    Results. Of 4555 patients enrolled, 758 (17%) were current smokers at the time of surgery. Smokers had an inferior health-related Quality of Life at baseline. Nevertheless, adjusted for differences in baseline characteristics, the odds ratio (OR) for a smoker to end up dissatisfied at the 2-year follow-up after surgery was 1.79 [95% confidence interval (CI) 1.51-2.12]. Smokers had more regular use of analgesics (OR 1.86; 95% CI 1.55-2.23). Walking ability was less likely to be significantly improved in smokers with an OR of 0.65 (95% CI 0.51-0.82). Smokers had inferior Quality of Life also after taking differences before surgery into account, either when measured with the Oswestry Disability Index (ODI; P < 0.001), EuroQol (P < 0.001) or Short Form (36) Health Survey (SF-36) BP and SF-36 PF (P < 0.001). The differences in results between smokers and nonsmokers were evident, irrespective of whether the decompression was done with or without spinal fusion.

    Conclusion. Smoking is an important predictor for 2-year results after surgery for lumbar spinal stenosis. Smokers had less improvement after surgery than nonsmokers.

    Keywords
    smoking, spinal stenosis, surgical results
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-146290 (URN)10.1097/BRS.0b013e3181e92b36 (DOI)000290750200011 ()21224770 (PubMedID)
    Available from: 2011-02-16 Created: 2011-02-16 Last updated: 2017-12-11Bibliographically approved
    2. Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: a two-year follow-up study involving 5390 patients
    Open this publication in new window or tab >>Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: a two-year follow-up study involving 5390 patients
    2013 (English)In: The Bone & Joint Journal, ISSN 2049-4408, Vol. 95-B, no 7, p. 960-965Article in journal (Refereed) Published
    Abstract [en]

    Whether to combine spinal decompression with fusion in patients with symptomatic lumbar spinal stenosis remains controversial. We performed a cohort study to determine the effect of the addition of fusion in terms of patient satisfaction after decompressive spinal surgery in patients with and without a degenerative spondylolisthesis.                  

    The National Swedish Register for Spine Surgery (Swespine) was used for the study. Data were obtained for all patients in the register who underwent surgery for stenosis on one or two adjacent lumbar levels. A total of 5390 patients fulfilled the inclusion criteria and completed a two-year follow-up. Using multivariable models the results of 4259 patients who underwent decompression alone were compared with those of 1131 who underwent decompression and fusion. The consequence of having an associated spondylolisthesis in the operated segments pre-operatively was also considered.                

    At two years there was no significant difference in patient satisfaction between the two treatment groups for any of the outcome measures, regardless of the presence of a pre-operative spondylolisthesis. Moreover, the proportion of patients who required subsequent further lumbar surgery was also similar in the two groups.                  

    In this large cohort the addition of fusion to decompression was not associated with an improved outcome.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-210450 (URN)10.1302/0301-620X.95B7.30776 (DOI)23814250 (PubMedID)
    Available from: 2013-11-08 Created: 2013-11-08 Last updated: 2018-11-30
    3. Efficacy of fusion surgery for lumbar spinal stenosis- Clinical and economic results from a 2-year multicenter randomised controlled trial in sweden.
    Open this publication in new window or tab >>Efficacy of fusion surgery for lumbar spinal stenosis- Clinical and economic results from a 2-year multicenter randomised controlled trial in sweden.
    2015 (English)In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406Article in journal (Other academic) Submitted
    National Category
    Orthopaedics
    Identifiers
    urn:nbn:se:uu:diva-262518 (URN)
    Available from: 2015-09-16 Created: 2015-09-16 Last updated: 2018-01-11
    4. 3D motion analysis using provocation computed tomography in lumbar spinal stenosis with degenerative spondylolisthesis before and after decompressive surgery: A randomised comparative pilot study of laminectomy versus bilateral laminotomy
    Open this publication in new window or tab >>3D motion analysis using provocation computed tomography in lumbar spinal stenosis with degenerative spondylolisthesis before and after decompressive surgery: A randomised comparative pilot study of laminectomy versus bilateral laminotomy
    (English)Manuscript (preprint) (Other academic)
    National Category
    Orthopaedics
    Identifiers
    urn:nbn:se:uu:diva-262522 (URN)
    Available from: 2015-09-16 Created: 2015-09-16 Last updated: 2018-01-11
  • 3.
    Försth, Peter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Michaëlsson, Karl
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Sandén, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Fusion Surgery for Lumbar Spinal Stenosis REPLY2016In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 375, no 6, p. 599-600Article in journal (Other academic)
  • 4.
    Försth, Peter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Michaëlsson, Karl
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Sandén, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    More on Fusion Surgery for Lumbar Spinal Stenosis2016In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 375, no 18, p. 1806-1807Article in journal (Refereed)
  • 5.
    Försth, Peter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Karolinska Inst, Stockholm Spine Ctr, S-10401 Stockholm, Sweden..
    Olafsson, Gylfi
    Karolinska Inst, Dept Learning Informat Management & Eth, S-10401 Stockholm, Sweden.;Quantify Res, Stockholm, Sweden..
    Carlsson, Thomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Frost, Anders
    Karolinska Inst, Stockholm Spine Ctr, S-10401 Stockholm, Sweden..
    Borgstrom, Fredrik
    Karolinska Inst, Dept Learning Informat Management & Eth, S-10401 Stockholm, Sweden.;Quantify Res, Stockholm, Sweden..
    Fritzell, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Futurum Acad Hlth & Care, Neuroorthoped Ctr, Ryhov, Sweden..
    Öhagen, Patrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Michaelsson, Karl
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Sanden, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis2016In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 374, no 15, p. 1413-1423Article in journal (Refereed)
    Abstract [en]

    BACKGROUND The efficacy of fusion surgery in addition to decompression surgery in patients who have lumbar spinal stenosis, with or without degenerative spondylolisthesis, has not been substantiated in controlled trials.

    METHODS We randomly assigned 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at one or two adjacent vertebral levels to undergo either decompression surgery plus fusion surgery (fusion group) or decompression surgery alone (decompression-alone group). Randomization was stratified according to the presence of preoperative degenerative spondylolisthesis (in 135 patients) or its absence. Outcomes were assessed with the use of patient-reported outcome measures, a 6-minute walk test, and a health economic evaluation. The primary outcome was the score on the Oswestry Disability Index (ODI; which ranges from 0 to 100, with higher scores indicating more severe disability) 2 years after surgery. The primary analysis, which was a per-protocol analysis, did not include the 14 patients who did not receive the assigned treatment and the 5 who were lost to follow-up.

    RESULTS There was no significant difference between the groups in the mean score on the ODI at 2 years (27 in the fusion group and 24 in the decompression-alone group, P = 0.24) or in the results of the 6-minute walk test (397 m in the fusion group and 405 m in the decompression- alone group, P = 0.72). Results were similar between patients with and those without spondylolisthesis. Among the patients who had 5 years of follow-up and were eligible for inclusion in the 5-year analysis, there were no significant differences between the groups in clinical outcomes at 5 years. The mean length of hospitalization was 7.4 days in the fusion group and 4.1 days in the decompression-alone group (P< 0.001). Operating time was longer, the amount of bleeding was greater, and surgical costs were higher in the fusion group than in the decompression-alone group. During a mean follow-up of 6.5 years, additional lumbar spine surgery was performed in 22% of the patients in the fusion group and in 21% of those in the decompression-alone group.

    CONCLUSIONS Among patients with lumbar spinal stenosis, with or without degenerative spondylolisthesis, decompression surgery plus fusion surgery did not result in better clinical outcomes at 2 years and 5 years than did decompression surgery alone.

  • 6.
    Försth, Peter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Svedniark, Per
    Karolinska Inst, Dept Mol Med & Surg, Sect Orthopaed & Sports Med, Karolinska Univ Hosp, Solna, Sweden.
    Noz, Marilyn E.
    NYU, Dept Radiol, Sch Med, 560 1St Ave, New York, NY 10016 USA.
    Maguire Jr, Gerald Q.
    KTH Royal Inst Technol, Sch Informat & Commun Technol, Stockholm, Sweden.
    Zeleznik, Mike P.
    Univ Utah, Coll Engn, Sch Comp, Salt Lake City, UT 84112 USA.
    Sandén, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Motion Analysis in Lumbar Spinal Stenosis With Degenerative Spondylolisthesis A Feasibility Study of the 3DCT Technique Comparing Laminectomy Versus Bilateral Laminotomy2018In: CLINICAL SPINE SURGERY, ISSN 2380-0186, Vol. 31, no 8, p. E397-E402Article in journal (Refereed)
    Abstract [en]

    Study Design: This was a randomized radiologic biomechanical pilot study in vivo. Objective: The objectives of this study was to evaluate if 3-dimensional computed tomography is a feasible tool in motion analyses of the lumbar spine and to study if preservation of segmental midline structures offers less postoperative instability compared with central decompression in patients with lumbar spinal stenosis with degenerative spondylolisthesis. Summary of Background Data: The role of segmental instability after decompression is controversial. Validated techniques for biomechanical evaluation of segmental motion in human live subjects are lacking. Methods: In total, 23 patients (mean age, 68 y) with typical symptoms and magnetic resonance imaging findings of spinal stenosis with degenerative spondylolisthesis (> 3 mm) in 1 or 2 adjacent lumbar levels from L3 to L5 were included. They were randomized to either laminectomy (LE) or bilateral laminotomy (LT) (preservation of the midline structures). Documentation of segmental motion was made preoperatively and 6 months postoperatively with CT in provoked flexion and extension. Analyses of movements were performed with validated software. The accuracy for this method is 0.6 mm in translation and 1 degree in rotation. Patient-reported outcome measures were collected from the Swespine register preoperatively and 2-year postoperatively. Results: The mean preoperative values for 3D rotation and translation were 6.2 degrees and 1.8 mm. The mean increase in 3D rotation 6 months after surgery was 0.25 degrees after LT and 0.7 degrees after LE (P = 0.79) while the mean increase in 3D translation was 0.15 mm after LT and 1.1 mm after LE (P = 0.42). Both surgeries demonstrated significant improvement in patient-reported outcome measures 2 years postoperatively. Conclusions: The 3D computed tomography technique proved to be a feasible tool in the evaluation of segmental motion in this group of older patients. There was negligible increase in segmental motion after decompressive surgery. LE with removal of the midline structures did not create a greater instability compared with when these structures were preserved.

  • 7.
    Robinson, Yohan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Heyde, Cristoph E
    Försth, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Olerud, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Kyphoplasty in osteoporotic vertebral compression fractures: guidelines and technical considerations2011In: Journal of Orthopaedic Surgery and Research, ISSN 1749-799X, E-ISSN 1749-799X, Vol. 6, no 1, p. 43-Article in journal (Refereed)
    Abstract [en]

    Osteoporotic vertebral compression fractures are a menace to the elderly generation causing diminished quality of life due to pain and deformity. At first, conservative treatment still is the method of choice. In case of resulting deformity, sintering and persistent pain vertebral cement augmentation techniques today are widely used. Open correction of resulting deformity by different types of osteotomies addresses sagittal balance, but has comparably high morbidity.

    Besides conventional vertebral cement augmentation techniques balloon kyphoplasty has become a popular tool to address painful thoracic and lumbar compression fractures. It showed improved pain reduction and lower complication rates compared to standard vertebroplasty. Interestingly the results of two placebo-controlled vertebroplasty studies question the value of cement augmentation, if compared to a sham operation. Even though there exists now favourable data for kyphoplasty from one randomised controlled trial, the absence of a sham group leaves the placebo effect unaddressed. Technically kyphoplasty can be performed with a transpedicular or extrapedicular access. Polymethyl methacrylate (PMMA)-cement should be favoured, since calcium phosphate cement showed inferior biomechanical properties and less effect on pain reduction especially in less stable burst fractures. Common complications of kyphoplasty are cement leakage and adjacent segment fractures. Rare complications are toxic PMMA-monomer reactions, cement embolisation, and infection.

  • 8.
    Sandén, Bengt
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Försth, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Michaëlsson, Karl
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Smokers Show Less Improvement Than Nonsmokers Two Years after Surgery for Lumbar Spinal Stenosis: A study of 4555 Patients from the Swedish Spine Register2011In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 36, no 13, p. 1059-1064Article in journal (Refereed)
    Abstract [en]

    Study Design. A cohort study based on the Swedish Spine Register.

    Objective. To determine the relation between smoking status and disability after surgical treatment for lumbar spinal stenosis.

    Summary of Background Data. Smoking and nicotine have been shown to inhibit lumbar spinal fusion and promote disc degeneration. No association, however, has previously been found between smoking and outcome after surgery for lumbar spinal stenosis. A large prospective study is therefore needed.

    Methods. All patients with a completed 2-year follow-up in the Swedish Spine Register operated for central lumbar stenosis before October 1, 2006 were included. Logistic regression was used to assess the association between smoking status and outcomes.

    Results. Of 4555 patients enrolled, 758 (17%) were current smokers at the time of surgery. Smokers had an inferior health-related Quality of Life at baseline. Nevertheless, adjusted for differences in baseline characteristics, the odds ratio (OR) for a smoker to end up dissatisfied at the 2-year follow-up after surgery was 1.79 [95% confidence interval (CI) 1.51-2.12]. Smokers had more regular use of analgesics (OR 1.86; 95% CI 1.55-2.23). Walking ability was less likely to be significantly improved in smokers with an OR of 0.65 (95% CI 0.51-0.82). Smokers had inferior Quality of Life also after taking differences before surgery into account, either when measured with the Oswestry Disability Index (ODI; P < 0.001), EuroQol (P < 0.001) or Short Form (36) Health Survey (SF-36) BP and SF-36 PF (P < 0.001). The differences in results between smokers and nonsmokers were evident, irrespective of whether the decompression was done with or without spinal fusion.

    Conclusion. Smoking is an important predictor for 2-year results after surgery for lumbar spinal stenosis. Smokers had less improvement after surgery than nonsmokers.

1 - 8 of 8
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