Dublin welcomed EUROSPINE, the Spine Society of Europe, for its 19th annual meeting, taking place from 11-13 October, 2017
The local hosts Ciaran Bolger and Frank Dowling welcomed a record number of 2,331 registered delegates and a total number of 3,684 attendees to Dublin and EUROSPINE 2017 in October and, for the first time in the history of EUROSPINE a head of state, the president of Ireland Michael D Higgins, welcomed the participants to the congress and to Dublin. In his specially recorded video message. He emphasised the importance of this meeting coming to Ireland and the significant contribution its members make towards the treatment of patients with spinal disorders.
Margareta Nordin, EUROSPINE President 2016-2017 and first female president of the society, drew a conclusion of her presidency during the congress. The focus of her presidential speech was the importance of research and how that influences clinical practice, be it by randomised controlled trials, cohorts, registries or big data. Careful research will change our practice based on evidence and EUROSPINE as a society is taking a leading role in promoting best-practice education and research, thereby enhancing treatments for our patients.
The packed programme over the three days featured many topic focuses, including epidemiology, non-operative treatment and patient safety, plus debates aimed to stimulate thinking and discussions in the areas of controversy and to explore areas of consensus. The debate titles included: “To screen or not to screen for psychological distress and surgical spine intervention” and “Lumbar disc herniation: Do we operate too early or should we operate earlier?”. The debates were hot topics and certainly one of the congress highlights.
To follow up on our feature in the last issue of SSN, where we focused on three of the five submitted abstracts for the Best of Show award paper, where five of the best rated abstracts were chosen by the EUROSPINE Programme Committee to qualify for the Best Podium Award. During the session it was left to the audience to decide the final winner. All five presented their nominated papers, before the audience had 20 minutes to make up their mind. EUROSPINE would like to thank the numerous voters, which made Peter Försth’s paper: “No long time benefit from fusion in decompressive surgery for lumbar spinal stenosis. Five-year results from the Swedish spinal stenosis study, a multicenter RCT of 233 patients” become this year’s winning title.
EUROSPINE Best Podium Award 2017
Peter Försth talks to EUROSPINE about his winning title
What is the research that won the award about?
It is about the role of fusion in decompressive surgery for lumbar spinal stenosis and degenerative spondylolisthesis.
What is the outlook of your research?
We will continue the follow-up of the 233 operated patients in the study in regards to clinical outcome and re-operations. Especially interesting is to identify the reasons for the need of a subsequent lumbar surgery. This leads us further to see if we can identify preoperative clinical and radiological predictors for an inferior outcome and the need for secondary surgery. If we can identify a subgroup in great risk of developing, for example instability, these patients might be offered to have a fusion in addition to the decompression at the time of the index surgery. In recent years, the finding of a degenerative spondylolisthesis on pre-op radiology has been considered as a predictor of instability after decompression and has, according to many surgeons, been an almost mandatory reason to do a fusion.
Our research shows that whether or not the decompression is complemented with a fusion, it does not influence the results in patients with degenerative spondylolisthesis preoperatively. Furthermore, patients with degenerative spondylolisthesis did not have more disability or pain than patients without this finding at baseline. Therefore, the importance of the finding of a degenerative spondylolisthesis on pre-op radiological examination has been overrated.
In what respect do you consider this prize valuable for your future research?
The award is an encouragement for further efforts and a welcome recognition of our studies that have been questioned among surgeons in environments were fusion in degenerative lumbar disorders have been an obvious first choice of treatment, even despite the fact that a foundation in evidence for this regime has been lacking.
In recent years, studies that support our results have been published from researchers in Canada, Norway and Switzerland.
Submitted abstract of the study
Title: No long time benefit from fusion in decompressive surgery for lumbar spinal stenosis. Five-year results from the Swedish spinal stenosis study, a multicenter rct of 233 patients
Authors: Peter Försth, Thomas Carlsson, Karl Michaélsson, Bengt Sandén, Department of Orthopaedics, Uppsala University Hospital, Sweden
Introduction
The role of fusion in surgery for lumbar spinal stenosis (LSS) is a controversy in spine surgery. The aim of this study was to examine if additional fusion improves the outcome after decompression for LSS with or without preoperative degenerative spondylolisthesis (DS). The clinical results after two years from this study (published in New England Journal of Medicine in April 2016) showed no benefit from fusion.
Methods
From 2006 to 2012, 233 patients aged 50-80 years with spinal stenosis on one or two adjacent lumbar levels on MRI were included and operated in the study. Randomisation was made between decompression with concomitant fusion (DF) and decompression alone (D). The material was stratified for the existence of pre-op DS ≥3 mm on plain X-ray. 135 (58 per cent) of the patients had pre-op DS (mean 7.4 mm). The primary outcome measure was ODI. MRI was repeated two years post-op. The follow-up rate after five years was 91 per cent.
Results
At the five-year follow-up, there were significant improvements in all outcome measures compared to preoperative regardless of treatment group. For patients without DS, ODI was 27 in both treatment groups (p=0.80), back pain (VAS) 37 in the D group and 38 in the DF group (p=0.84), and leg pain 32 vs. 34 (p=0.75). In the group with pre-op DS ODI was 23 in the D group and 28 in the DF group (p=0.15), back pain 33 vs. 38 (p=0.30) and leg pain 32 vs. 34 (p=0.77).
No differences were found in EQ-5D regardless of the presence of DS. In the DS group 58 per cent in the D group and 53 per cent in the DF group reported better walking ability compared to preoperatively, OR 1.2 (95 per cent CI 0.6-2.6). Satisfaction with surgery was reported by 69 per cent in the D group and 67 per cent after fusion, OR 1.1 (95 per cent CI 0.5-2.3). Following MRI after two years, recurrent stenosis on operated level was present in 8 per cent after D and 1 per cent after DF (p=0.06). Adjacent level stenosis was present in 16 per cent after D and 40 per cent after DF (p=0.0005). The overall proportions of new stenosis in the lumbar spine (index level or adjacent level) was 23 per cent after D and 40 per cent after DF (p=0.017). The proportion of patients who had subsequent lumbar surgery within five years was 24 per cent in the D group and 25 per cent in the DF group, regardless of the presence of DS, OR 1.0 (95 per cent CI 0.6-1.8).
Reasons for a second operation was predominantly recurrent stenosis on index level after decompression alone and stenosis in the upper adjacent segment after decompression plus fusion.
Summary and conclusions
In this multicentre RCT, we found no long time benefit from fusion in decompressive surgery for LSS, regardless if DS was present pre-op or not. These results confirm the two-year results published in 2016. The development of new stenosis on MRI in the lumbar spine was significantly more common after decompression plus fusion, compared to decompression alone. Due to the progressive degenerative nature of lumbar spinal stenosis, as many as up to 25 per cent of operated patients had repeated lumbar surgery within five years.
In this elderly population with lumbar spinal stenosis, surgery should be limited to the less invasive procedure of decompression alone in order to decrease the number of complications and costs for the society. The pre-op presence of degenerative spondylolisthesis has by many surgeons been considered an indication for fusion. This study does not support that regime.
Caption: Peter Forsth receiving his award. Credit: EUROSPINE/APACE PLC
If you missed out this year, make sure to be part of EUROSPINE Spring Speciality Meeting 2018 in Vienna, Austria and EUROSPINE 2018 in Barcelona, Spain. For details visit, www.eurospinemeeting.org
