Journal List > J Korean Soc Spine Surg > v.24(3) > 1076135

Jang, Ahn, Lee, Choi, Hong, Kang, Cho, and Shin: Outcomes of Degenerative Lumbar Spine Surgery in Patients with Chronic Kidney Disease Undergoing Hemodialysis

Abstract

Study Design

Retrospective study.

Objectives

To analyze the outcomes of degenerative lumbar spine surgery in patients undergoing hemodialysis due to chronic kidney disease (CKD).

Summary of Literature Review

Patients who undergo hemodialysis due to chronic renal disease tend to exhibit accelerated changes in bone quality, deterioration of spinal stenosis, and accompanying neurological degeneration. The surgical treatment of chronic spinal diseases is also becoming more necessary with the increased lifespan of these patients.

Materials and Methods

We reviewed the medical records and radiographs of patients with CKD undergoing hemodialysis who were followed-up for more than 1 year after posterior lumbar spinal surgery. We evaluated clinical, laboratory, and radiologic variables. For a comparative analysis, patients were classified into subgroups according to age (65 years old), duration of hemodialysis (10 years), and type of surgery (simple decompression or fusion).

Results

We included 21 patients (5 men, 16 women) with a mean age of 66.2 years (range, 48–87 years). The mean duration of hemodialysis and follow-up was 18.9 years and 43 months, respectively. Decompressions with fusion were performed in 11 patients and simple decompressions in the other 10. The mean visual analog scale (VAS) of leg pain and the Oswestry Disability Index (ODI) significantly improved after surgery at time of the last follow-up; meanwhile, the mean VAS score for lower back pain did not show a statistically significant improvement. The postoperative ODI was correlated with age (correlation coefficient=0.71, p=0.006). In patients less than 65 years old, the ODI improvement was greater (p=0.035) than in those 65 years of age or older. There was no significant difference in the clinical outcomes according to the duration of hemodialysis. Complications were observed in 11 patients (52.4%, 7 in fusion and 4 in simple decompression), of which 2 cases were infections, and reoperations were performed in 5 patients. The union rate of the fusion cases at the 1-year follow-up was 81.8%.

Conclusions

Appropriate spine surgery improved radicular pain and the ODI in patients with degenerative lumbar disease undergoing hemodialysis. However, postoperative complications were frequent and the improvement of clinical outcomes was minimal, especially in patients over 65 years of age and in those who underwent fusion. Therefore, the surgical treatment of patients with chronic renal disease undergoing hemodialysis requires adequate consideration of age and the duration of hemodialysis.

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Table 1.
Summary of cases
No. Age (yr.) Sex F/U period (mo.) Cause of CKD HD‡ Duration (yr.) BUN (normal range, 6–20 mg/dL) Creatinine (normal range, 0.5-1.2 mg/dL) Hgb (normal range, 12–16 g/dL) Potassium(normal range, 3.5∼5.1 mmol/L) BMD (T-score) PT (INR) aPTT (normal range, 27.8–41.7)
1 80 M 43 Drug 4 47 6.8 12 5.3 -3.5 1.1 28.3
2 73 F 76 PCKD 17 14 3.1 13.1 3.6 -3.3 0.89 40.9
3 59 F 39 DM 30 17 5.3 12.2 4 -4.7 1.18 23.8
4 73 F 13 HTN 21 10 2.8 9.2 3.5   0.96 34.1
5 72 F 43 HTN 23 34 6.7 8.7 4 -5.6 1.26 31.7
6 54 F 12 HTN 17 6 2.9 12.3 3 -3.7 0.92 28.8
7 61 F 78 HTN 34 19 3.7 15 3.7 -2 0.86 26.3
8 67 F 11 DM 20 7 1.6 10.7 3.3   0.97 33.5
9 66 F 40 HTN 14 11 1.7 13.8 3.4 -3.4 0.86 34.0
10 48 F 4 DM 13 29 5.7 11.3 4.4 -2.2 1.20 28.1
11 61 F 12 HTN 26 23 4.7 11.2 4.4 -3.8 1.13 26.1
12 75 M 23 HTN 15 23.2 1.3 14.2 4.3 -2.8 0.92 30.6
13 55 F 6 HTN 17 12 3.6 12.6 3.4 -3.3 0.91 36.3
14 65 M 26 HTN 24 17.2 3.2 12.3 4 -3.7 0.88 33.3
15 69 F 25 HTN 17 15.1 2.9 10.9 3.2 -4.5 0.85 28.3
16 56 F 14 HTN 26 12.4 2.59 10 3.3 -4.2 0.76 28.9
17 87 F 22 DM 5 13.6 2.71 11.5 3.5 -2.1 0.75 27.0
18 66 M 11 Nephritis 13 15.3 3.54 8.5 2.9 -5.2 0.92 31.3
19 68 F 45 HTN 8 18 1.58 10.9 3.4 -4.8 0.81 32.8
20 65 M 21 ? 30 10 2.49 12.8 3.3 -3.3 0.93 27.5
21 71 F 16 DM 13 19 1.38 11.5 3.1 -4.5 0.87 22.7
M: Male, F: Female, HD: Hemodialysis, CKD: Chronic Kidney Disease, BUN: Blood Urea Nitrogen (normal range, 6–20mg/dL), Hgb: Hemoglobin, BMD: Bone Mineral Density, PCKD: Polycystic KidneyDisease, DM: Diabetes Mellitus, HTN: Hypertension, PT: Prothrombin time, INR: International normalized ratio, aPTT: activated partial thromboplastin time.
Table 2.
Operations and complications
No. Diagnosis Level Operation Complications
1 HIVD with spinal stenosis L2-3, L4-5 PD and PLIF  
2 HIVD with degenerative scoliosis L2-3, L3-4 PD and PLIF Nonunion, ASD
3 Spinal stenosis L2-3 PD and PLF Compression fracture
4 Spinal stenosis L3-4, L4-5 PD Hematoma
5 Spinal stenosis L3-4, L4-5 PD  
6 Spondylolisthesis L5-S1 PD and PLIF Nonunion
7 Spinal stenosis L3-4, L4-5, L5-S1 PD and PLIF Compression fracture
8 HIVD L5-S1 Discectomy  
9 HIVD with spinal stenosis L2-3, L3-4, L5-S1 1 Discectomy & PD  
10 Spinal stenosis with HIVD L4-5 PD & Discectomy  
11 Spinal stenosis L4-5 PD Compression fracture
12 Spinal stenosis L3-4, L4-5, L5-S1 1 PD Segmental instability
13 Spinal stenosis L4-5 PD  
14 Spinal stenosis L3-4, L4-5 PD and PLIF Screw loosening
15 Spondylolisthesis with spinal stenosis L3-4, L4-5 PD and PLIF  
16 Spondylolisthesis L4-5 PD and PLIF  
17 Spondylolisthesis with spinal stenosis L4-5 PD Infection (deep)
18 Spondylolisthesis with spinal stenosis L4-5 PD and PLIF Infection (superficial)
19 Spinal stenosis L4-5 PD and PLIF Screw loosening
20 Spinal stenosis L3-4, L4-5 PD  
21 Spinal stenosis L3-4, L4-5 PD and PLIF  

HIVD: Herniated intervertebral disc disease, PD: Posterior decompression, PLF: Posterolateral fusion, PLIF: Posterior lumbar interbody fusion, ASD Adjacent segment degeneration.

Table 3.
Summary of oswestry disability index (ODI) and visual analogue scale (VAS) score for back and leg pain
Variable Preoperative Postoperative p-value
ODI   30.5±4.6 21±9.9 0.009
VAS score        
  Back pain 4.5±3.5 3.6±3.0 0.51
  Leg pain 7.2±2.3 1.7±2.3 <0.001

Values are expressed as means ± standard deviation.

Table 4.
Comparisons of ODI and VAS score of back and leg pain be tween aged (≥65 yrs) group and younger (<65 yrs) group
Variable Preoperative Postoperative p-value
ODI        
  Age <65 28.5±5.5 13.3±8.3 0.035
  Age ≥65 32.3±3.1 28.6±3.7  
VAS score        
Back pain Age <65 3.8±3.6 3.0±2.9 1.000
  Age ≥65 5.1±3.7 4.1±3.3  
Leg pain Age <65 6.8±2.6 1.5±2.3 0.836
  Age ≥65 7.6±2.2 1.9±2.5  

Values are expressed as means±standard deviation.

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