Clinical Spine Surgery最新文献

Study design: Cross-sectional study.

Objective: To evaluate agreement between preoperative cervical magnetic resonance imaging (MRI) and CT myelogram (CTM) grading of cervical spinal stenosis on official radiology reports and correlation with quantitative measures.

Summary of background data: Accurate assessment of cervical spinal stenosis is critical for diagnosis and management cervical spondylotic myelopathy (CSM). Radiology reports are directly accessible by patients and used for insurance preauthorization increasing the importance of accurate grading systems.

Methods: Fifty consecutive patients with contemporaneous preoperative cervical MRI and CTM were identified. Grading (no stenosis, mild, moderate, and severe) was recorded from radiology reports. Quantitative measurements of anteroposterior (AP) diameter of the spinal canal and AP diameter of the spinal cord at the point of maximal compression for each anatomic level were performed.

Results: There were 20 males and 30 females, with a mean age of 59.6 years and a mean body mass index of 32.39 kg/m 2 . A total of 191 cervical levels were measured. There was poor agreement between the axial (k=0.528) and sagittal (k=0.516) MRI and CTM stenosis grades. On both the axial and sagittal MRI, the radiologist's stenosis grade was moderately correlated with the AP spinal canal diameter and space available for the cord, yet weakly correlated with the cord:canal ratio. On the axial and sagittal CTM, the stenosis grade was weakly correlated with AP spinal canal diameter, space available for the cord, and cord:canal ratio. Quantitative measures on CTM versus MRI showed moderate correlations on axial views for spinal canal (0.669) and cord (0.630) diameter, moderate correlations on sagittal views for canal diameter (0.640) and cord:canal ratio (0.601) and a strong correlation for spinal cord diameter.

Conclusion: There was poor agreement between radiologists grading of cervical spinal stenosis on contemporaneous MRI and CTM. Grading on both modalities was weakly or moderately correlated with quantitative measurements of stenosis.

Study design: Systematic literature review.

Objective: To summarize the demographics, diagnosis, clinical course, management, and outcomes for implant migration after anterior cervical spine surgery.

Summary of background data: Implant migration following anterior cervical spine surgery is a rare event that may predispose patients to high morbidity due to the proximity of cervical implants to critical structures. Due to the infrequency of this complication, most of the literature on this topic is described in case reports or series.

Methods: We screened the PubMed database for relevant publications from January 1975 to December 2023 using the terms: (screw OR hardware OR plate OR implant OR instrumentation) AND (pull-out OR migration OR displacement OR erosion OR perforation) AND (anterior cervical OR ACDF OR ACCF). The PRISMA systematic review template guided the identification and screening of full-text articles in English.

Results: Fifty-five studies with 76 patients were included. The median age was 50.0 (32.0, 60.0) years, with a median time-to-diagnosis of 15 months (2.0, 60.8). Seventy-five percent were symptomatic, while 20% were asymptomatic. Common symptoms included dysphagia (54%), neck pain (22%), and fever or cervical abscess (13%). Treatments included complete implant removal (59%), partial removal (20%), spontaneous gastrointestinal elimination (11%), and retention of all instrumentation (5%). In addition, 25% underwent revision spinal fusion. Sixty-one percent experienced major complications (eg, perforation, fistula, abscess). However, 84% had resolution of symptoms without further treatment at the most recent follow-up.

Conclusions: Implant migration after anterior cervical spine surgery is rare yet may occur many years after a patient's initial surgery without heralding symptoms. For this reason, surgeons should consider extended routine follow-up with radiographic imaging in these patients, for the first 5 years postoperatively since this complication transpired most frequently within this time frame. We recommend an individualized, patient-centered approach for radiographic follow-up to balance the risk of unnecessary radiation exposure in addition to practical risks like travel-related accidents. Extended routine follow-up may be most beneficial for patients with identified risk factors for late complications or early migration, that is, complex deformity or poor bone quality.

Study design: Retrospective cohort study.

Objective: To assess the impact of preoperative PROMIS PF scores on postoperative pain, narcotics consumption, return to activities, and PROMs following CDR.

Summary of background data: There is limited data regarding the impact of baseline PROMIS PF on outcomes for patients undergoing CDR.

Methods: Patients undergoing primary 1- or 2-level CDR for degenerative pathology with minimum 6-month follow-up were included and separated into a high disability group (≤40 preoperative PROMIS PF) and a low disability group (>40 preoperative PROMIS PF). Analyses were conducted for the early (<6 mo) and late (≥6 mo) postoperative timepoints. Linear and logistic regressions were performed to determine the association of preoperative PROMIS PF group with postoperative pain, narcotics consumption, time to discontinue narcotics, return to driving and working, PROMs, and MCID achievement.

Results: A total of 93 patients were included. Patients in the high disability group were younger (41.5±8.4 vs. 45.3±7.6, P =0.026) and had a higher proportion of female patients (58.7% vs. 25.6%, P =0.001). Patients with higher disability experienced similar postoperative pain scores, narcotics consumption, time to discontinue narcotics, and return to driving and working timelines as patients with lower disability but demonstrated poorer PROM scores at early follow-up. However, patients with higher disability experienced greater changes in NDI and PROMIS PF scores at both early and late follow-up, VAS-Neck and Arm and SF-12 PCS scores at late follow-up, and also achieved the MCID at a higher rate for multiple PROMs.

Conclusion: Patients with higher preoperative disability, as determined by PROMIS PF, experience similar postoperative pain scores, narcotics consumption, time to discontinue narcotics, and return to activities as compared with patients with lower preoperative disability undergoing CDR as well as greater absolute improvements and MCID achievement rates for most PROMs. These findings may be useful in setting postoperative expectations for outcomes following CDR.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: To assess the epidemiology, procedural risk factors, and associated complications of postoperative footdrop following posterior lumbar fusion.

Summary of background data: Footdrop is an uncommon complication following spine surgery that is associated with functional impairments. Understanding the epidemiology and risk factors of postoperative footdrop may allow for early implementation of preventive measures before and during surgery.

Methods: Adults who underwent posterior lumbar fusion were identified using PearlDiver. Eligible patients were stratified by the development of footdrop within 90 days of surgery. Epidemiological trends in footdrop were evaluated by age groups and year between 2010 and 2022. Patient demographics, comorbidities, procedural characteristics, hospital outcomes, and occurrence of intraoperative and postoperative complications were compared.

Results: In total, 2988 (0.6%) footdrop and 473,129 (99.4%) no footdrop patients were included, with a mean age of 60.9 years and 57.6% female sex. Postoperative footdrop rates increased from 0.4% to 0.8% between 2010 to 2022 and increased with age. Preoperatively, footdrop patients more frequently reported prior posterior spine surgery and medical comorbidities (all P <0.05). Intraoperatively, they had higher rates of 2 or more level fusion, osteotomy, dural tear, and nerve injury (all P <0.01). Postoperatively, they had higher rates of acute kidney injury, deep venous thrombosis, urinary tract infection, wound-related, hematoma, transfusion, and site-related complications, as well as higher rates of 90-day readmissions (all P <0.001).

Conclusion: Patients developing footdrop following lumbar spinal fusion were older, had more comorbidities, and frequently underwent complex multilevel procedures. They also had other postoperative complications, higher hospital readmissions, and increased health care expenditures. This data provides valuable insights into the risk factors and associated adverse outcomes for postoperative footdrop after lumbar spinal fusion.

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: Retrospective cohort study.

Objectives: To compare 90-day complication rates and clinical outcomes in patients undergoing minimally invasive lumbar fusion with and without inflammatory arthritis.

Summary of background data: Patients with inflammatory arthritis are at special risk of developing spinal pathology. There is a paucity of literature investigating outcomes following minimally invasive lumbar fusion in patients with inflammatory arthritis.

Methods: Patients who had undergone minimally invasive fusion between 2017 and 2023 for the treatment of degenerative pathology of the lumbar spine with a minimum of 6 months follow-up were included and separated into inflammatory arthritis (IA) or noninflammatory arthritis (non-IA) cohorts. Patient demographics, perioperative variables, 90-day complications, patient-reported outcome measures, and rates of MCID achievement were compared between the IA cohort and the unmatched and 3:1 case-control matched non-IA cohort at early (<6 mo) and late (≥6 mo) follow-up.

Results: Six hundred sixty-nine patients were included (IA cohort, n=23; non-IA cohort, n=646). Patient demographics and perioperative characteristics did not differ significantly between the two cohorts except for IA patients reporting a higher age-adjusted Charlson comorbidity index (P=0.004). There were no significant differences in 90-day complications, reoperations, or readmissions. The IA cohort demonstrated significant improvements in most PROMs at the early and late postoperative time points. PROM scores, magnitudes of improvement in PROMs, MCID achievement rates, and time to achieve MCID for most PROMs were not significantly different between the 2 cohorts. After 3:1 case-control matching, there were no significant differences in complications, reoperations or admissions. In addition, there were no significant differences between the two cohorts in most PROM scores or rates of MCID achievement. Magnitudes of improvement and time to achieve MCID were comparable between the two cohorts for all PROMs.

Conclusion: Patients with inflammatory arthritis undergoing minimally invasive lumbar fusion have similar clinical outcomes as compared with controls.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: To assess the utility of whole-body imaging in diagnosing lower extremity osteoarthritis (LEOA), evaluate the association of LEOA with radiculopathy, and determine the impact of LEOA on postoperative recovery.

Summary of background data: Whole-body imaging offers rapid, low-radiation assessment of both spinal and lower extremity pathology. This modality may be pivotal in helping clinicians better understand how lower extremity pathology influences clinical presentation and recovery among patients with degenerative lumbar conditions.

Methods: Patients with preoperative whole-body imaging who underwent lumbar spine surgery for degenerative conditions between 2017 and 2022 were included. The Kellgren and Lawrence (KL) score was implemented to grade joint osteoarthritis (OA) as mild (KL ≤2) or severe (KL ≥3). Length of stay (LOS) and side of radiculopathy were assessed. The Oswestry disability index (ODI), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS), visual analog scale (VAS), and Short Form-12 (SF-12) Physical/Mental Component Scales (PCS/MCS) were recorded at preoperative, early-postoperative (2, 6, 12 weeks), and late-postoperative (6, 12, 24 months) timepoints. The association of HOA/KOA with PROMs and minimum clinically important difference (MCID) was evaluated.

Results: Totally, 207 patients were included (HOA: n=130 mild, n=62 severe; KOA: n=141 mild, n=53 severe). Patients with severe OA were significantly older compared with patients with mild OA ( P <0.05). OA laterality was not associated with side of radiculopathy. After controlling for age, LOS was ∼50% greater for severe HOA ( P =0.031) and severe KOA ( P =0.013) compared with mild OA. Severe KOA exhibited worse PROMIS at the early-postoperative timepoint ( P =0.013), and worse PROMIS ( P =0.049), VAS-back ( P =0.009), and SF-12-PCS ( P =0.025) at the late-postoperative timepoint. Severe HOA and KOA reduced the likelihood of achieving MCID for SF-12-PCS (OR: 0.44; P =0.049) and PROMIS (OR: 0.37; P =0.027), respectively.

Conclusions: Whole-body imaging may help improve patient-specific counseling on expectations after lumbar spine surgery.

Study design: Prospective study.

Objective: This study aims to describe a workflow and custom instruments for robotic-assisted cervical pedicle screw placement using the MazorX Stealth Edition.

Summary of background data: Posterior cervical spinal instrumentation using pedicle screws offers biomechanical advantages but carries risks of injury to the vertebral artery and nerve roots. Fluoroscopic and navigation aids exist, yet robotic assistance for cervical pedicle screw placement lacks a defined workflow. While previous generations of spine robots have been used in placing pedicle screws, there are no papers in literature that described the use of third-generation spine robots in placing them.

Methods: Twenty-two patients undergoing cervical pedicle screw placement with custom instruments and robotic assistance were included. Screw trajectories were planned and executed by the robotic arm, with postoperative O-arm scans assessing accuracy. Clinical and radiologic outcomes at 3-month follow-up were measured.

Results: A total of 206 screws were placed with a 98.1% accuracy rate. Four screws breached the pedicle without resulting in nerve root injury. Average surgical time was 190 minutes, with 6 minutes per screw insertion. Blood loss averaged 180 mL. NDI scores improved from 42.3 to 28.2. Complications included superficial wound infections in 2 patients, deep wound infection in 1, and 1 nondominant vertebral artery injury.

Conclusions: Robotic-assisted cervical pedicle screw placement demonstrates high accuracy and significant clinical improvements, validating the workflow and custom instruments developed.

Study design: Retrospective study.

Objectives: To investigate the risk factors for revision surgery after proximal junctional fracture (PJFx) development in adult spinal deformity (ASD) surgery.

Summary of background: Not all cases with PJFx require revision surgery, particularly in patients without acute neurological deficit. Therefore, identifying the risk factors for revision surgery after PJFx occurrence is necessary to establish proper management strategies.

Methods: Of 509 patients who underwent ≥5-level fusion surgery to pelvis, those who developed PJFx without acute neurological deficit were included in this study. Patients were divided into a revision group (R group) and a nonrevision group (NR group) according to the performance of the revision surgery. Various clinical and radiographic variables were compared between these 2 groups to identify the factors for revision surgery.

Results: A total of 102 patients composed the final study cohort. There were 93 women (91.2%) with a mean age of 72.1 years. On average, 7.9 levels were fused. PJFx was found at a mean of 8.8 months after surgery, and revision surgery was performed for 39 patients (38.2%) at a mean of 8.5 months after PJFx identification. Multivariate analysis revealed that overcorrection relative to the age-adjusted pelvic incidence (PI)-lumbar lordosis (LL) after index surgery [odds ratio (OR)=4.038, 95% CI=1.638-9.958, P =0.002] and high initial proximal junctional angle (PJA) (OR=1.149, 95% CI=1.072-1.230, P <0.001) were significant risk factors for revision surgery after PJFx development. The PJA cutoff value was calculated as 24 degrees.

Conclusion: Overcorrection relative to the age-adjusted PI-LL at the index surgery and an initial PJA of ≥24 degrees at the time of PJFx increased likelihood for revision surgery for PJFx. Therefore, an early revision surgery should be considered for high-risk patients, while a close observation can be allowed for low-risk patients.

Study design: Descriptive study.

Objective: To determine national trends in utilization of endoscopic spine surgery from 2017 to 2022.

Summary of background data: Endoscopic spine surgery (ESS) has emerged as a potential, minimally invasive approach to treat certain symptomatic spinal pathology. The benefits of ESS have not been well established; however, small case series suggest possible improvement in postoperative complications rates, decreased length of stay, and improved outcomes in comparison to traditional techniques. Despite this, adoption of ESS is not widespread in the United States.

Methods: Patients undergoing ESS were identified using the CPT code 62380 in the PearlDiver M165Ortho database from 2017 to 2022. Demographic factors extracted included: (1) age, (2) sex, (3) Elixhauser comorbidity index (ECI), (4) Charlson comorbidity index (CCI), (5) geographic region of surgery, (6) type of insurance plan (Commercial, Medicaid, Medicare), and (7) timing of the surgery.

Results: A total of 1886 patients who have undergone ESS were identified from 2017 to 2022. The utilization of ESS peaked in 2018 but reached a plateau after. The largest proportion of patients receiving ESS were over the age of 70 (30%) with 51% female (n=968). In addition, the majority of ESS were performed in the South (47.8%), and most payers utilized commercial health insurance (70.9%). Comorbidity indices for ESS patients were tracked: mean ECI +/- SD: 5.04+/-3.68; median ECI: 4 and mean CCI: 2.06; median CCI: 2.

Conclusions: The limited widespread adoption of ESS can be multifactorial. As with all new technologies, there is hesitation for early adoption, additionally the lack of standardized surgeon education, limited scope of procedure, and need for advanced surgical tools serve as possible reasons contributing to the trends in usage.