Clinical Spine Surgery最新文献

Study design: Retrospective cohort study.

Objective: To investigate the clinical and radiologic outcomes of unilateral biportal endoscopic lumbar interbody fusion (ULIF) for single-segment lumbar spinal stenosis with instability.

Background: Unilateral biportal endoscopic technology has developed rapidly, and ULIF is a new type of minimally invasive fusion surgery. However, there remains a lack of sufficient evidence regarding its clinical efficacy. By comparing it with posterior lumbar interbody fusion (PLIF) surgery, its clinical efficacy can be evaluated.

Materials and methods: In total, 110 (ULIF group, 54; PLIF group, 56) patients were included. Perioperative indicators were compared between the groups. Clinical efficacy, Visual Analog Scale (VAS) scores for back and leg pain, and Oswestry Disability Index scores were compared. Surgical complications, intraoperative dural tears, nerve root injury, surgical hematoma, and reoperation were assessed. The postoperative clinical test indicators were white blood cell count and C-reactive protein, procalcitonin, and interleukin-6 levels. Imaging results, cage loosening, screw loosening, and intervertebral fusion rate were evaluated.

Results: The surgical time was significantly longer in the ULIF group than in the PLIF group. The postoperative ambulation time, length of hospital stay, and postoperative drainage volume were shorter in the ULIF group than in the PLIF group. There were no differences in the VAS scores for leg pain and Oswestry Disability Index scores, but there were statistically significant differences in the VAS scores for low back pain between the groups. The white blood cell count and C-reactive protein, procalcitonin, and interleukin-6 levels were significantly lower in the ULIF group than in the PLIF group. None of the patients showed any loosening of the fusion cage or any loosening or breakage of the screws. There was no difference in the lumbar interbody fusion rate.

Conclusions: ULIF has several advantages, but its surgical time is significantly prolonged.

Study design: Retrospective multicenter cohort study.

Objective: To investigate the incidence and risk factors of postoperative hip displacement following spinal fusion in nonambulant patients with spastic neuromuscular scoliosis.

Summary of background data: In patients with spastic neuromuscular disorders, spinal deformity, and hip displacement mutually influence each other; however, little is known about the clinical impact of spinal fusion on the incidence of hip displacement.

Methods: We retrospectively analyzed nonambulant patients with spastic neuromuscular disorders undergoing primary fusion with a minimum follow-up of 1 year. The primary outcome was new postoperative hip displacement. To identify potential risk factors for postoperative hip displacement, an association analysis was conducted.

Results: We identified 67 eligible patients (29 males and 38 females) with a mean age of 14.1 years and a mean follow-up period of 49.4 months. Overall, 11 cases of postoperative hip displacement (10 up hip, and 1 down hip) were identified in 11 patients (16.4%). Patients with hip displacement were significantly more skeletally immature at surgery, had a significantly larger preoperative curve magnitude (115.6 vs. 97.5 degrees), larger correction of the Cobb angle (71.0 vs. 56.8 degrees), larger preoperative pelvic obliquity (36.2 vs. 24.3 degrees), and included a significantly higher proportion of cases with pelvic fixation (P=0.03). Compared with patients with nondislocated stable up hip joints, 10 patients with new up hip displacement had a significantly higher preoperative migration percentage (MP) in the up hip (40.6 vs. 31.4, P=0.047). Receiver operating characteristic curve analysis revealed that the optimal cutoff value of the preoperative MP of the up hip for predicting postoperative displacement was 28.8 (sensitivity, 90.0%; specificity, 47.8%).

Conclusions: When performing spinal fusion in patients with spastic neuromuscular disorders, especially in those with identified potential risk factors, patients and their caregivers should be informed preoperatively about the possibility of subsequent hip displacement.

Level of evidence: Level III.

Study design: Narrative review.

Objective: To establish a correlation among the classic C2 classification systems and the new AO upper cervical spine trauma classification system (UCST).

Summary of background data: A multitude of classifications were historically proposed for C2 injuries, none of them with universal acceptation. The new UCST incorporated elements of these prior classifications into this new system to improve their limitations.

Methods: Eight classic C2 classification systems-Anderson and D´Alonzo, Roy-Camille, Hadley et al, Grauer et al, Effendi et al, Levine and Edwards, Burke and Harris and Benzel et al were evaluated, and their injury types/subtypes were classified according to the new AO UCST.

Results and conclusions: Most of the injuries were classified as type A in accordance with the new UCST, suggesting that most of the detailed descriptions of specific bone injury patterns may not be implied in different treatment strategies, being treated non-surgical. Those with ligamentous injury (type B) were attributed to some injuries with ligamentous/disc disruption without clear dislocations (type C when dislocations were present). This correlation between the classic morphologies and the new AO UCST may improve the understanding of injury patterns and help in the decision of the best treatment.

Study design: Retrospective case series study.

Objective: To evaluate the safety and efficacy of bilateral-contralateral decompression using unilateral biportal endoscopy (UBE) for treating adjacent segment disease (ASD) after lumbar interbody fusion (LIF).

Summary of background data: ASD is a well-documented complication following LIF, often requiring additional surgical interventions. Traditional decompression techniques risk damaging the facet joints, potentially leading to further instability and degeneration. However, our bilateral-contralateral decompression using UBE focuses on minimizing facet joint resection and reducing the risk of postoperative instability.

Methods: This study included 37 patients who underwent bilateral-contralateral UBE decompression for ASD following LIF at the L4-5 level between September 2020 and March 2022. Radiographic evaluations included measurements of vertebral range of motion (ROM), slip distance, disk height, lumbar lordosis, and facet joint preservation. Clinical assessments were performed using the visual analog scale (VAS) for back and leg pain and the Oswestry disability index (ODI).

Results: The average final follow-up period was 14.5±1.9 mo. The average preoperative ROM was 3.0 degrees, which significantly increased to 4.8° at the final follow-up (P<0.05). Static structure and dynamic stability parameters, including the vertebral slip distance, lumbar lordosis, and disk height, showed no significant differences between the preoperative examination and 1-year postoperative follow-up. The facet joint preservation rate was 97.4±2.1% on average. Significant improvements in VAS scores for leg and back pain and ODI were observed. Despite improvement with conservative treatment in 7 patients with delayed instability, 2 patients required fusion surgery.

Conclusions: Bilateral-contralateral decompression through UBE has proven to be an effective and safe method for treating ASD following LIF. This technique is particularly suitable for patients requiring spinal stability maintenance. The high rates of facet joint preservation and low incidence of reoperation highlight this technique as a compelling alternative treatment for spinal stenosis.

Level of evidence: Level III.

Study design: A pilot randomized controlled trial.

Objective: To investigate the effects of a prehabilitation program on early postoperative outcomes in Japanese patients undergoing lumbar spinal stenosis (LSS) surgery.

Summary of background data: Prehabilitation has shown promise for improving postoperative outcomes in various surgical populations. However, its effectiveness in Japanese patients undergoing LSS surgery has not been previously studied.

Methods: Thirty-two of 34 patients scheduled for LSS surgery (mean age: 69.3 y, 17 female) were randomly assigned to the prehabilitation group (15 patients) or control group (17 patients). The primary outcomes were the Oswestry Disability Index (ODI) and 6-minute walk distance (6MWD). The secondary endpoints were the visual analog scale (VAS) scores for back pain, leg pain, and numbness. The intervention group received a 20-30-minute educational session from a physical or occupational therapist using a pamphlet 1 month before surgery, while the control group received a pamphlet handout. Assessments were conducted 1 month before surgery (baseline); 1 day before surgery; and 1, 3, and 6 months postoperatively.

Results: All patients underwent preoperative educational sessions. The prehabilitation group showed significant improvements in 6MWD at 3 months postoperatively compared with the control group (446.8±48.9 m vs. 384.3±58.3 m, P=0.01, Hedges' g=1.11). ODI scores at 1 month postoperatively were lower in the prehabilitation group (10.2±10.9 vs. 19.0±10.7, P=0.04, Hedges' g=-0.77). Low back pain VAS at 3 months postoperatively was also lower in the prehabilitation group (12.5±14.8 vs. 27.5±20.8, P=0.04, Hedges' g=0.75). No adverse events were reported in either of the groups.

Conclusions: Prehabilitation may enhance postoperative recovery and outcomes in patients undergoing surgery for LSS. Further research with a larger sample size is needed to establish the effectiveness of prehabilitation in this population.

Study design: Retrospective review.

Objective: To review the traumatic spinal injuries in alpine athletes treated at a single level I trauma center.

Summary of background data: Recreational and competitive skiers/snowboarders are prone to spinal injuries, and recent changes in the sport may have led to increases in the incidence and severity of spinal injuries. Currently, there is a paucity of data on the epidemiology of spinal injuries resulting from skiing and snowboarding.

Methods: A review of patients admitted with traumatic spinal injuries from skiing/snowboarding, between January 2015 and March 2019. Data on demographics, spinal region of injury, mechanism of injury, fracture type, presence/absence of spinal cord injury, ASIA score, management, concomitant injuries, and involvement of other surgical services were collected.

Results: Spinal injuries were distributed as 33.3% cervical, 57% thoracic, and 38.0% lumbosacral spine. Seventy-five percent patients injured a single region, 21.7% injured 2 regions, and 3.3% injured all 3. Single-level injuries occurred in 38% patients, II-level in 25%, III-level in 12%, and >3-levels in 28%. Twenty-seven percent patients suffered a spinal cord injury. Eighty-one percent of those had neurological compromise, with a 53.8% rate of full neurological resolution at the time of discharge. 65% fractures were compression-type. Management included operative treatment with decompression and fusion in 32% patients. Cervical spinal injuries were more likely to sustain an extension-distraction type fracture and concomitant spinal cord injury. Thoracic spine injuries were more likely to have multiple vertebral level (>3 vertebrae) involvement. Lumbosacral injuries were more likely to sustain compression type and transverse process fractures. Patients with trauma to all 3 spinal regions were more likely to have translational/rotational injuries, facet fractures, lamina and pedicle fractures, and traumatic anterolistheses.

Conclusion: Skiing/snowboarding injuries can be devastating, potentially resulting in permanent neurological compromise and spinal instability. Surgeons and the general population can benefit from improving their understanding of the dangers of alpine sports as it pertains to spinal trauma.

Study design: This is a systematic review.

Objective: To evaluate anterior cervical discectomy and fusion (ACDF) outcomes and complications as a function of preoperative bone mineral density (BMD).

Summary of background data: Preoperative BMD optimization is commonly initiated before lumbar spinal fusion, but the effects of BMD on ACDF are less known. Consequently, it remains unclear whether preoperative BMD optimization is recommended before ACDF.

Methods: This systematic review included relevant clinical articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Web of Science, SCOPUS, and MEDLINE from database inception until October 1, 2023. Eligible studies included those evaluating low BMD and outcomes after ACDF. All articles were graded using the Methodological Index for Non-Randomized Studies (MINORS) scale and Critical Appraisal Skills Programme (CASP) assessment tools.

Results: The initial retrieval yielded 4271 articles for which 4 articles with 671 patients were included in the final analysis. The mean patient age was 56.4 ± 3.9 years, and 331 patients (49.3%) were female. A total of 265 (39.5%) patients had low BMD (T score<-1.0) before ACDF. Preoperative low BMD was associated with cage subsidence in single-level ACDF (odds ratio (OR) 2.57; P =0.063; 95% Confidence Interval (CI): 0.95-6.95), but this result did not reach statistical significance. Osteoporosis (T score<-2.5) was associated with the development of adjacent segment disease following ACDF (OR 4.41; P <0.01; 95% CI: 1.98-9.83). Low pre-operative BMD was associated with reoperation within 2 years ( P <.05) and strongly associated with pseudarthrosis (OR: 11.01; P =0.002; 95% CI 2.4-49.9).

Conclusions: Patients with low BMD who undergo ACDF have higher rates of subsidence, adjacent segment disease, and pseudarthrosis than those with normal BMD. Given the individual and system-wide burdens associated with these complications, some patients may benefit from preoperative BMD screening and optimization before undergoing ACDF.

Study design: Level III evidence-retrospective cohort.

Objective: The purpose of this study was to (1) determine whether longer CDA operative time increases the risk of 30-day postoperative complications, (2) analyze the association between operative time and subsequent health care utilization, and (3) discharge disposition.

Background: Cervical disk arthroplasty (CDA) most commonly serves as an alternative to anterior cervical discectomy and fusion (ACDF) to treat cervical spine disease, however, with only 1600 CDAs performed annually relative to 132,000 ACDFs, it is a relatively novel procedure.

Methods: A retrospective query was performed identifying patients who underwent single-level CDA between January 2012 and December 2018 using a nationwide database. Differences in baseline patient demographics were identified through univariate analysis. Multivariate logistic regression was performed to identify associations between operative time (reference: 81-100 min), medical/surgical complications, and health care utilization.

Results: A total of 3681 cases were performed, with a mean patient age of 45.52 years and operative time of 107.72±49.6 minutes. Higher odds of length of stay were demonstrated starting with operative time category 101-120 minutes (odds ratio: 2.164, 95% CI: 1.247-3.754, P =0.006); however, not among discharge destination, 30-day unplanned readmission, or reoperation. Operative time <40 minutes was associated with 10.7x odds of nonhome discharge, while >240 minutes was associated with 4.4 times higher odds of LOS>2 days ( P <0.01). Increased operative time was not associated with higher odds of wound complication/infection, pulmonary embolism, deep venous thrombosis, or urinary tract infections.

Conclusions: Prolonged CDA operative time above the reference 81-100 minutes is independently associated with increased length of stay, but not other significant health care utilization parameters, including discharge disposition, readmission, or reoperation. There was no association between prolonged operative time and 30-day medical/surgical complications, including wound complications, infections, pulmonary embolism, or urinary tract infection.

Study design: Retrospective observational study.

Objective: To scrutinize screw motion used in semiconstrained rotational plate systems for anterior cervical discectomy and fusion (ACDF).

Summary of background data: Semiconstrained rotational plate systems are supposed to control graft subsidence and facilitate lordosis acquisition and maintenance by toggling the instrumented vertebrae via variable-angle screws. However, their benefits may be unrealized if the screws move within the vertebrae.

Methods: We reviewed medical records of 119 patients who underwent 1-level, 2-level, 3-level, or 4-level ACDF, divided them into the short-segment (n=62, 1-level or 2-level ACDF) and long-segment (n=59, 3- level or 4-level ACDF) groups, and investigated their immediate and 1-year postoperative lateral radiographs. We measured the fused segmental angle, screw angles at the upper-instrumented vertebra (UIV) and lower-instrumented vertebra (LIV), distance from the screw base to the endplate of UIV/LIV (SBE), and distance from the screw tip to the endplate of UIV/LIV (STE) to analyze the screw motion used in these plate systems. The differences between the immediate and 1-year postoperative values were statistically analyzed. The nonunion level was also investigated.

Results: Screw angle and SBE at the LIV significantly decreased in the long-segment group (-14.5±9.8 degrees and -2.8±1.8 mm, respectively) compared with those in the short-segment group (-4.6±6.0 degrees and -1.0±1.5 mm, respectively). Thus, the long-segment group could not maintain the immediate-postoperative segmental angle. Overall, 27 patients developed nonunion, with 19 (70.4%) in the long-segment group and 21 (77.8%) at the lowest fused level.

Conclusions: Semiconstrained rotational plate systems provide only vertical forces to the fused segment rather than toggling the instrumented vertebrae. Postoperatively in multilevel ACDF, LIV screws migrate caudally, suggesting that these plate systems are not always effective in maintaining lordosis. Moreover, LIV screws and the anterior wall of the LIV are subject to overloading, resulting in a high rate of nonunion at the lowest fused level.

Level of evidence: Level III.