Clinical Spine Surgery最新文献

Study design: Retrospective cohort.

Objective: Evaluate the impact of insurance type on outcomes of ACDF among patients 65 years or older.

Summary of background data: Despite a 38.7% inflation-adjusted decrease in reimbursement for ACDF procedures in Medicare patients aged 65 years and older over the past decade, ACDF volume has increased by 24%. Value-based care studies have investigated Medicare insurance as a predictor of postoperative outcomes. However, literature examining PROMs by Medicare status, especially for elderly patients, remains limited.

Methods: Patients aged 65 years or older who underwent 1-3 level ACDF (2014-2023) with Medicare, Medicare Advantage, or private insurance were included. Patients were excluded for ACDF performed for trauma/infection/tumor. The area deprivation index (ADI) was used to measure socioeconomic status by ZIP code. Outcomes included 30/90-day readmissions, 1-year reoperations, and PROMs-mental (MCS-12) and physical component summary (PCS-12), visual analog scale (VAS) neck and arm, neck disability index (NDI), and modified Japanese Orthopaedic Association (mJOA) scale. Achievement of the minimum clinically important difference (MCID) was compared between groups.

Results: Three hundred three patients were included. Private insurance patients were younger than Medicare (68.8 vs. 71.8 y, P<0.001) and Medicare Advantage (68.8 vs. 70.6 y, P=0.002) patients, but otherwise the groups were demographically/surgically similar and performed similarly in postoperative outcomes and MCID achievement. Private insurance patients had worse preoperative scores and greater improvement at 1 year in NDI compared with Medicare and Medicare Advantage patients. Delta VAS arm scores were better for private insurance and Medicare Advantage patients compared with Medicare patients. However, linear regression did not show insurance as independently predictive of 1-year delta NDI scores or VAS arm scores when controlling for age, ADI percentile, number of levels fused, and preoperative scores.

Conclusions: Medicare status does not appear to impact short-term adverse outcomes or 1-year revision among elderly ACDF patients. Neither Medicare nor Medicare Advantage insurance was independently predictive of worse improvement on VAS arm or mJOA scores when controlling for relevant confounders.

Study design: This is a retrospective analysis of 142 consecutive single-level transforaminal lumbar interbody fusions (TLIFs) performed by neurosurgeons at a large academic center.

Objective: To integrate patient-reported outcomes (PROs) with time-driven activity-based costing (TDABC) to quantify value at the surgeon-level and procedure-level.

Summary of background data: PRO and cost analyses have become mainstays of clinical research for spine surgery in recent years. To our knowledge, however, few attempts have been made to merge PROs with TDABC to quantify the value of surgical care.

Methods: Intraoperative TDABC was used to estimate both direct and indirect costs. Individual costs were obtained by direct observation, electronic medical records, and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Oswestry Disability Index (ODI) scores were collected at baseline and 3-months after surgery. The operative value index (OVI) was defined as the percent improvement in ODI per $1000 spent intraoperatively. We also divided the total intraoperative cost by the absolute ODI point-change for each case to calculate a unit price for outcomes (UPO). Generalized linear mixed models (GLMM) were built to assess surgeon-level variability in OVI. Three distinct surgeon cohorts were created: surgeon A (n=75 cases), surgeon B (n=39 cases), and "other surgeons" (n=7 surgeons and 28 cases).

Results: One hundred forty-two single-level TLIFs were performed by 9 surgeons from 2017 to 2022. The average total cost of a one-level TLIF was $11,984±$3312. The average OVI and UPO for all cases was 3.2±4.3 and $643±$3929, respectively. On GLMM, "other surgeons" were associated with significantly decreased OVI (P<0.05) compared with Surgeon A, though there was no significant difference in OVI between Surgeon A and Surgeon B (P=0.56).

Conclusion: We present novel metrics that quantify value for single-level TLIF by combining a diagnosis-specific PRO with TDABC. Metrics such as these can help stakeholders identify drivers of variation in the value provided by spine surgeons.

Study design: Retrospective cohort study.

Objectives: The objectives of this study are to (1) measure the association between Cervical Vertebral Bone Quality (C-VBQ) score and subsidence after anterior cervical discectomy and fusion (ACDF), (2) determine whether there is a clinically relevant cutoff for predicting risk, and (3) determine whether ACDF cage construct configuration impacts the utility of C-VBQ.

Summary of background data: Cage subsidence after ACDF can be influenced by patient factors such as age, medical history, cage construct material, and bone quality. Prior research suggests that the recently introduced C-VBQ score, an MRI-based measure of trabecular bone, can precisely predict postoperative subsidence risk. There is no prior research investigating whether cage construct configuration, known to impact subsidence risk, can affect the utility of C-VBQ score.

Methods: One hundred seventeen patients undergoing single-level ACDF for degenerative pathology between 2019 and 2023 were included. C-VBQ was calculated at C2-C7 from preoperative T1-weighted MRI images. Radiographic subsidence was defined as collapse of the interbody cage by greater than one-third of cage height. Receiver operating characteristic (ROC) curves were generated for C-VBQ and subsidence between cage configurations. Inferential and descriptive statistics were performed.

Results: Radiographic subsidence was present in 22 patients (19%). Mean C-VBQ score was significantly higher in the subsidence group (P<0.001). A higher C-VBQ demonstrated greater odds of developing subsidence (OR=15.26, P<0.001). A C-VBQ score of ≥2.59 was 60% sensitive and 82% specific in detecting subsidence (AUC=0.747, P<0.001). C-VBQ score was most predictive with allograft (AUC=0.906, P<0.001), with a score of 2.44 demonstrating 100% sensitivity and 67% specificity, and least predictive with PEEK cage-plate constructs (AUC=0.625, P=0.360).

Conclusions: Preoperative C-VBQ score is effective in predicting cage subsidence risk after ACDF surgery. It demonstrates the greatest utility in patients implanted with allograft cage-plate constructs and is least predictive in those with PEEK configurations.

Study design: This was a retrospective single-center study.

Objectives: To investigate the relationship between intraoperative arterial blood pressure (MAP) changes and the occurrence of C5 palsy.

Summary of background data: C5 palsy is a disabling complication of cervical spine surgery, and its pathophysiology remains unknown. We hypothesized that intraoperative MAP changes might influence the occurrence of postoperative C5 palsy.

Methods: This retrospective study included patients who underwent continuous arterial blood pressure monitoring during elective cervical spine surgery. Patients were divided into 2 groups according to the presence or absence of C5 palsy (defined as a decrease of at least 1 grade in deltoid muscle strength). The demographics, diagnoses, surgical characteristics, and intraoperative MAP parameters were reviewed.

Results: A total of 74 patients were included in this analysis (mean age: 70.5 y; 22 women). Of these patients, 13 developed C5 palsy, which occurred after a mean of 2.2 days following surgery. There were no significant differences between the C5 palsy and control groups in terms of age, sex, diagnosis, preexisting hypertension, and blood pressure on the day before surgery. Patients with C5 palsy showed a greater change in intraoperative MAP than those in the control group (92​​​​​​ vs. 73 mm Hg, P=0.013). The number of episodes of intraoperative hypotension was similar in the C5 palsy and control groups (2.5 vs. 3.1 episodes). After adjustment by a multivariable logistic regression analysis, intraoperative MAP change remained an independent risk factor for C5 palsy (odds ratio 1.03 per 1 mm Hg increase, 95% CI: 1.01-1.05, P=0.03).

Conclusion: A larger change in the intraoperative MAP was associated with C5 palsy after cervical surgery. Our findings suggest a potential role for intraoperative hemodynamic changes in the development of C5 palsy.

Study design: This is a retrospective study.

Objective: To evaluate and compare the clinical efficacy and fusion outcomes of allograft versus hydroxyapatite (HA) as bone graft materials in anterior cervical discectomy and fusion (ACDF) surgery.

Summary of background data: ACDF is used for cervical disc herniation treatment; however, there is no consensus on the optimal bone graft material, particularly between allograft and hydroxyapatite.

Methods: This retrospective study included patients who underwent ACDF at the Third Affiliated Hospital of Southern Medical University between January 2015 and December 2019. A total of 63 patients met the inclusion criteria and were divided into 2 groups: the allograft group (n=39) and the HA group (n=24). Clinical outcomes were assessed using the Visual Analogue Scale (VAS), Japanese Orthopaedic Association (JOA) score, and Neck Disability Index (NDI). Cervical spine radiographs were utilized to evaluate fusion status, intervertebral height, and sagittal alignment parameters.

Results: Both groups demonstrated significant postoperative improvement in VAS, JOA, and NDI scores compared with preoperative values. The magnitude of improvement was similar between the 2 groups, the allograft group exhibited superior final VAS, JOA, and NDI scores relative to the HA group. Radiographic analysis revealed a significantly lower fusion rate and score in the HA group. The incidence of cage subsidence was higher in the HA group, although no significant difference in intervertebral height was observed between groups. Notably, 6 patients (25.0%) in the HA group experienced fusion failure requiring revision surgery, of whom 3 underwent reoperation. No fusion failure or revision surgery was reported in the allograft group.

Conclusion: ACDF remains a widely accepted and effective treatment for cervical disc herniation. While both graft types provide symptomatic relief and functional recovery, the allograft demonstrates superior performance in terms of fusion rate, structural integrity, and lower revision risk.

Study design: Retrospective case-control study.

Objective: To evaluate whether patients from highly deprived neighborhoods, as defined by the Area Deprivation Index (ADI), undergoing one-level cervical disc arthroplasty (CDA) experience differences in (1) postoperative medical complications, (2) lengths of stay (LOS), emergency department (ED) visits, and readmissions compared with less disadvantaged patients.

Summary of background data: The ADI measures neighborhood-level deprivation at the national level. Little is known about the role of neighborhood deprivation on outcomes after CDA.

Methods: A national insurance claims database was used to identify patients who underwent single-level CDA between 2010 and 2022. Patients from less disadvantaged neighborhoods (ADI <90th percentile) were matched in a 1:5 ratio with patients from more deprived areas (ADI >90th percentile) using propensity score matching on age, sex, and Elixhauser Comorbidity Index (ECI), yielding a final cohort of 25,975 patients: 4331 in the low ADI group and 21,644 in the high ADI group. Multivariable logistic regression models were used to assess odds of 90-day complications, readmissions, and ED visits. t tests compared LOS. P-values<0.05 were significant.

Results: High ADI patients experienced significantly higher odds of total 90-day medical complications compared with less disadvantaged patients (3.54% vs. 2.67%; OR: 1.37; 95% CI: 1.12-1.70; P=0.003). High ADI patients had longer mean hospital stays (1.75 vs. 1.66 d; P<0.01). Ninety-day readmission (1.54% vs. 1.36%; OR: 1.13; P=0.379) and ED visits (1.64% vs. 1.43%; OR: 1.14; P=0.330) were similar between groups.

Conclusions: Neighborhood deprivation is associated with increased lengths of stay and a higher overall rate of medical complications after CDA, despite similar readmission and ED visit rates. These findings emphasize the importance of incorporating socioeconomic context into perioperative care and resource planning.

Level of evidence: Level III.

Study design: A retrospective cohort study.

Objective: To describe the incidence, timing, and reason for ED visits following primary versus revision lumbar fusion.

Summary of background data: Emergency department (ED) presentation and misutilization place a substantial financial strain on patients and the health care system. ED visits following lumbar fusion are common and may be an overlooked target for reducing cost.

Methods: A retrospective cohort study of patients undergoing 1-3 level primary versus revision lumbar fusion was performed. Outcomes included the incidence and characteristics (inpatient admission, discharge home, or reoperation) of ED visits at 2 weeks, 30 days, and 90 days postoperatively. Logistic regression analysis was performed to identify independent predictors of postoperative ED visits.

Results: A total of 2360 patients were included (1852 primary and 508 revision). Rate of 90-day ED visits was higher in the revision group (10.2%) compared with the primary group (6.86%, P=0.014). However, breakdown by 15-day intervals revealed this was only significant between 14 and 30 days postoperatively (1.30% vs. 3.35% for revisions, P=0.004). Reasons for ED visits were similar, with both groups presenting most commonly for pain complaints. Primary patients presenting to the ED were more likely to require admission (48.0% vs. 26.9%; P=0.015). Logistic regression demonstrated that revision surgery (OR: 2.67, P<0.001), Cut-to-close time (OR: 1.003, P=0.028) and LOS (OR: 1.11, P=0.023) independently predicted postoperative ED visits.

Conclusion: Revision lumbar fusion was an independent predictor of visiting the ED, especially from 14 to 30 days postoperatively, but the absolute increase in risk was mild at 3.4%. Cut-to-close time was also statistically predictive, although with an effect size that is not clinically significant. However, visits to the ED after revision surgery were less likely to require readmission compared with visits after primary lumbar surgery. These findings may suggest that patients undergoing lumbar fusion should be appropriately counseled regarding postoperative pain expectations and appropriate acute care utilization, especially in the revision setting.

Malpractice litigation is a persistent challenge in spinal surgery, with a significant number of claims involving procedural errors, inadequate informed consent, and wrong-level surgeries. These cases often have serious implications for both patient care and the careers of surgeons. This study combines a review of the literature with the analysis of 4 real-world cases to identify patterns and offer practical recommendations to reduce legal risks. The author (S.R.) served as an expert witness in all 4 cases, providing a unique perspective on the legal, clinical, and professional elements involved in each situation. The key findings highlight the importance of thorough preoperative planning, the use of advanced imaging techniques during surgery, and consistent postoperative follow-up to detect and address complications early. Transparent communication with patients, especially when complications occur, is critical for maintaining trust and avoiding legal disputes. In addition, avoiding blame-shifting among surgeons is essential to uphold professional integrity and patient safety. By addressing these factors and fostering a culture of transparency and accountability, surgeons can improve patient outcomes and minimize exposure to litigation. This study provides practical strategies to help spinal surgeons navigate legal challenges effectively and maintain a focus on high-quality patient care.

Study design: A case-series study.

Objectives: To acquire diagnostic insights to distinguish between intradural extramedullary spinal metastases (IESM) and benign spinal tumors by comparing patients with IESM and those with schwannoma or spinal meningioma.

Summary of background data: IESM constitute a rare category of spinal metastases. As the outcome of IESM is usually poor without intervention, early diagnosis and treatment are particularly important for better prognosis. As few studies have clearly addressed the features of IESM, it is necessary to gain comprehensive diagnostic insights into the characteristics of the disease.

Methods: Included in this study were 14 IESM patients who underwent gross total tumor resection. IESM and schwannoma or meningioma were compared in a ratio of 1:2. Differences in clinical and imaging presentations between them were analyzed statistically, and survival curves were plotted using the Kaplan-Meier method.

Results: IESM presented an unclear boundary (P=0.005), an irregular shape (P=0.035), and A low probability of cystic degeneration (P=0.028) as compared with schwannoma. Compared with IESM, meningioma tended to have a clear boundary (P=0.001), a wide base (P=0.047), high calcification possibility (P=0.040), and homogeneous enhancement on MRI (P=0.016). The estimated mean overall survival of IESM patients was 16.80±3.94 months.

Conclusion: This study demonstrated the characteristics of IESM and clarified the distinguishing points between IESM and intradural extramedullary benign tumors. Early warning features drawn from this study may be able to help clinicians to identify patients with IESM.

Summary of background data: Previous studies comparing the anterior versus posterior approach for the treatment of degenerative cervical myelopathy (DCM) report similar neurological outcomes. Although multilevel DCM is frequently combined with foraminal stenosis, previous studies have analyzed the outcomes of myelopathy without specifically addressing the outcomes of combined radicular symptoms.

Objective: To compare the outcomes following anterior and posterior decompressive procedures for DCM combined with multilevel foraminal stenosis.

Study design: A retrospective study.

Methods: A cohort of patients with DCM with multilevel foraminal stenosis (>3 levels) who underwent decompression was analyzed. In the anterior group (group A), multilevel anterior cervical decompression and fusion were performed, and the posterior group (group P) consisted of laminoplasty with foraminotomies. Nurick grade, visual analogue scale (VAS) of neck and arm pain, neck disability index (NDI), short-form 36 (SF-36), complications, clinical adjacent segment pathologies (CASP), and additional operations performed were analyzed. C2-7 angle and range of motion, and Kellgren grade of radiographic adjacent segment pathology (RASP) were evaluated.

Results: A total of 96 patients were enrolled (M:F=53:43, mean age 60.8 y, A: P=54:42, mean 36.6 mo follow-up). All clinical parameters showed significant improvement from preoperative neurological status without significant difference between the 2 groups at the final follow-up. Both RASP grade and incidence of CASP were higher in the anterior group (A: 42.6% vs. P: 19.2%, P=0.014). The incidence of additional procedures was similar (A: 9.3% vs. P: 16.7%, P=0.276); however, the etiology was mainly CASP in the anterior group (4-5 cases) and persistent radicular symptoms in the posterior group (6-7 cases).

Conclusions: Anterior and posterior decompressive surgeries are reliable for the surgical treatment of DCM with multilevel foraminal stenosis and showed similar outcomes for both myelopathy and upper extremity radicular symptoms. The major etiology compromising the clinical outcome was a higher incidence of CASP in the anterior group and persistent or recurrent upper extremity radicular symptoms in the posterior group.