Clinical Spine Surgery最新文献

Study design: Randomized controlled trials.

Objectives: We conducted this study to compare the clinical efficacy of antiosteoporosis at different starting time points combined with oblique lateral interbody fusion in the treatment of lumbar degenerative disease complicated with patients with osteoporosis.

Background: Seki and colleagues found that perioperative administration of teriparatide was more effective than that of bisphosphonates in preventing complications in osteoporotic females undergoing surgery. Inoue and colleagues found that the injection of teriparatide beginning at least 1 month before surgery was effective in increasing the insertional torque of pedicle screws during surgery in patients with osteoporosis. Ohtori and colleagues concluded that teriparatide improved the quality of the lumbar spine and reduced the incidence of screw loosening.

Materials and methods: Fifty-nine patients were randomly divided into 2 groups: (1) the advanced group (AG; 30 cases) was treated advanced with antiosteoporosis for 3-6 months, followed by surgical treatment, and (2) the simultaneous group (SG; 29 cases) received antiosteoporosis and surgical treatment simultaneously. The primary outcome was cage subsidence rate. Secondary outcomes included screw loosening rate, intervertebral height, Visual Analog Scale, segmental lordosis angle, lumbar lordosis angle, and bone mineral density.

Results: There was no significant difference in the cage subsidence rate (P = 0.76) and screw loosening rate (P = 0.98) between the AG and the SG. The immediate postoperative disk height was significantly different from that before surgery, both in the AG and the SG (P < 0.00001). When compared within the same group at different times, both AG (P < 0.00001) and SG (P < 0.00001) had significantly lower Visual Analog Scale scores after surgery than before. Both of the segmental and lumbar lordosis angles after surgery were significantly higher than that of before. At the final follow-up, bone mineral density was significantly higher than that of presurgery in both groups.

Conclusions: Both starting time points of teriparatide treatment were effective in preventing cage subsidence and screw loosening after oblique lateral interbody fusion, without affecting clinical improvement.

Study design: Retrospective cohort.

Summary of background data: Although fusion surgery is the established recommendation for degenerative lumbar spondylolisthesis (DLS) with instability, a decompression alone might be needed in some cases based on the patient's age, comorbidity burden, surgical fitness, and preference.

Objective: To analyze the outcomes of minimally invasive decompression alone in patients with L4-5 DLS and translational motion ≥2 mm and compare with fusion over short term.

Methods: Patients who underwent minimally invasive decompression or fusion for L4-5 DLS with translational motion ≥2 mm and had a minimum of 1-year follow-up (maximum follow-up of 2 y) were included. Postoperative improvement in patient-reported outcome measures (PROMs) was analyzed. The decompression and fusion groups were compared for improvement in PROMs, minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and response on global rating change (GRC) scale.

Results: Eighty-four patients were included, out of which 60 (71.4%) underwent fusion. The decompression group had a significantly higher average age compared with fusion (69.3 vs. 64.8 y, P=0.036). There was no significant difference between the groups in other demographic variables and preoperative PROMs. The decompression group showed significant improvement in PROM postoperatively. The decompression group had a comparable magnitude of improvement in PROMs and MCID and PASS achievement rates as fusion over short term follow-up. More than 80% of patients reported feeling better compared with preoperative at both the timepoints with no significant difference in the responses between the 2 groups.

Conclusion: Minimally invasive decompression alone does lead to significant postoperative improvement over the short term and may be considered as an option in patients with unstable spondylolisthesis where fusion cannot be done. However, these are preliminary results and future research with a larger sample size and longer follow-up is required to further investigate this topic.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: To evaluate factors associated with long-term pseudoarthrosis and subsidence following L5-S1 anterior lumbar interbody fusion (ALIF).

Summary of background data: Reported fusion rates for ALIF at the lumbosacral junction vary widely.

Methods: Patients undergoing L5-S1 ALIF (November 1, 2016-September 3, 2021) were retrospectively analyzed. Fusion (Bridwell grades: 1-2) or pseudoarthrosis (Bridwell grades: 3-4) and subsidence (Marchi grades: 0-3) were determined using 1-year follow-up computed tomography (CT) studies.

Results: Overall, 101 patients were analyzed [mean (SD) age, 62.8 (13.3) y; 51 (50.5%) men]. Bone morphogenic protein (BMP) was used in 59 patients (58.4%), demineralized bone matrix in 44 (43.6%), and cellular allograft in 57 (56.4%). Oswestry Disability Index and Short-Form 36 scores improved postoperatively (P≤0.01). At L5-S1, 79 patients (78.2%) had fusion at 1 year. Patients receiving 3D-printed porous [89.5% (17/19)] and solid titanium [100% (14/14)] interbody cages were significantly more likely to have fusion than those receiving polyetheretherketone [70.6% (48/68)] interbody cages (P=0.02). Adjusted multivariate analyses found that titanium interbody cages were associated with fusion (odds ratio=5.42, P=0.04). Patients with subsidence [n=17 (16.8%)] were significantly older than patients without subsidence [n=84 (83.2%)]: 70.2 (4.7) years vs. 61.3 (14.0) years (P<0.001).

Conclusions: The 1-year postoperative CT findings showed that 78.2% of the cohort achieved fusion. Fusion was more common among patients with 3D-printed and solid titanium implants than among those with polyetheretherketone implants. Subsidence was more common among older patients. No differences in fusion or subsidence were found based on surgical indication, allograft type, or other patient characteristics.

Study design: Retrospective analysis.

Objective: To compare sarcopenia to frailty and socioeconomic deprivation as preoperative predictors of mortality and complications in thoracolumbar spine trauma.

Summary of background data: Sarcopenia is a progressive musculoskeletal disorder characterized by the loss of muscle mass and function. Recently, it has gained recognition as an important surgical risk factor. Prior studies have demonstrated its association with adverse outcomes in spine surgery for degenerative, deformity, and neoplastic indications. Currently, there is a dearth of literature investigating the role of sarcopenia in thoracolumbar trauma.

Methods: Adult patients undergoing instrumentation and stabilization of thoracolumbar spine trauma were identified at an urban academic level-1 trauma center. Sarcopenia was measured using the L3 total psoas area over vertebral body area (L3-TPA/VBA) measured from perioperative computed tomography (CT) scans. Area deprivation index (ADI) was determined according to the publicly available Neighborhood Atlas data set. Frailty was measured using the modified 5-factor frailty index (mFI-5). Statistical analysis consisted of Pearson χ2 tests, univariate logistic regression, determination of Spearman correlation coefficient (rs), and multivariable logistic regression controlling for demographics and polytraumatic injuries.

Results: A total of 276 patients were included. A total of 22 mortalities occurred (7.7%), with 18 (6.3%) occurring within 90-days postoperatively. On univariate analysis, only the mFI-5 scale was associated with 1-month (OR=2.42, P<0.001), 3-month (OR=2.61, P<0.001), and overall mortality (OR=2.29, P<0.001). On multivariate analysis, none of the sarcopenia, ADI, or mFI-5 were independently associated with mortality, the occurrence of postoperative complications, or revision.

Conclusions: Frailty is a better predictor of mortality in thoracolumbar trauma when compared with sarcopenia and ADI. However, an mFI threshold of 2+ may act synergistically with sarcopenia to increase mortality rates.

Level of evidence: Level III.

Study design: A retrospective chart review.

Objective: The authors aim to investigate the role of clinical and radiographic parameters in patients who underwent posterior cervical surgery, and their association with C5 palsy severity and time to recovery.

Background: Postoperative C5 palsy affects 1%-30% of patients undergoing posterior decompression, with or without fusion. Causation and avoidance of this complication remain widely debated.

Materials and methods: A single institution review of patients who underwent posterior cervical spine surgery was focused on using specific Common Procedural Technology codes associated with the patient population of interest. Patients were excluded if they had inadequate pre and postoperative imaging, as well as a history of prior cervical spine surgery, concurrent anterior surgery, intradural pathology, spinal tumor, or spinal trauma. Radiographic measurements of the pre and postoperative images were completed with subsequent intraclass correlation coefficient analysis to confirm the precision of measurements.

Results: Out of 105 total patients, 35 (33%) patients developed a C5 palsy. Twenty-four (69%) of those palsies completely resolved, with a median time to recovery of 8 months. Preoperative demographics and radiographic parameters demonstrated heterogeneity among those patients who did and did not have a resolution of palsy. Patients with increased change in C2-C7 lordosis ( P = 0.011) after surgery were associated with decreased likelihood of recovery. Patients without a smoking history ( P = 0.009) had an increased likelihood of recovering from C5 palsy.

Conclusions: The degree of increased lordosis in the treatment of degenerative cervical disease plays a role in the rate of recovery from C5 palsy. This should be considered during preoperative planning in determining the amount of lordosis desired. In addition, patients without a smoking history were associated with a higher rate of recovery.

Level of evidence: Level IV.

Objective: To describe 2 cases with pathologic expansion of lumbosacral dura mater exerting compression on lumbosacral nerves treated with placement of lumboperitoneal shunt (LPS). Although dural ectasia (DE) is asymptomatic in most cases, a systematic review of the literature was performed focusing on the management when it causes symptoms.

Methods: Pubmed/Medline and Embase databases were searched for the surgical management of DE. Both pediatric and adult patients were included. The presence of a cerebrospinal fluid leak was considered an exclusion criterion. An additional search was performed to provide a more complete picture of the DE spectrum considering meningoceles as a severe form of dural expansion.

Results: Differentiating DE from meningocele, only 20 patients were treated for symptomatic DE. Surgical management varied according to presentation and etiopathogenesis: blood patch or fibrin glue were attempted in case of intracranial hypotension, followed eventually by LPS or marsupialization or dura reduction in cases of failure, whereas LPS or spinal decompression were proposed in cases of radiculopathy or cauda equina syndrome.

Conclusion: DE is a rare condition mostly associated with connective tissue disorders. The different etiopathogenesis may explain how it causes symptoms in specific conditions. Treatments should be chosen according to this and may be proposed at the appearance of symptoms since dural expansion is a self-sustained mechanism.

Study design: A systematic review.

Objective: We characterized the rates of sociodemographic data and social determinants of health (SDOH) reported in spinal surgery randomized control trials (RCTs) and the association between these RCTs' characteristics and their rates of reporting on race, ethnicity, and SDOH variables.

Summary of background data: Although numerous institutions maintain guidelines and recommendations regarding the inclusion and reporting of sociodemographic and SDOH variables in RCTs, the proportion of studies that ultimately report such information is unclear, particularly in spine surgery.

Materials and methods: We searched the MEDLINE, PubMed, and Embase databases for published results from spinal surgery RCTs from January 2002 through December 2022, and screened studies according to prespecified inclusion criteria regarding analysis and reporting of sociodemographic and SDOH variables.

Results: We analyzed 421 studies. Ninety-six studies (22.8%) reported race, ethnicity, or SDOH covariates. On multivariate analysis, study size [rate ratio (RR)=1.18; 95% CI, 1.06-1.32], public/institutional funding (RR=2.28; 95% CI, 1.29-4.04), and private funding (RR=3.27; 95% CI, 1.87-5.74) were significantly associated with reporting race, ethnicity, or SDOH variables. Study size (RR=1.26; 95% CI, 1.07-1.48) and North American region (RR=21.84; CI, 5.04-94.64) were associated with a higher probability of reporting race and/or ethnicity. Finally, study size (RR=1.27; 95% CI, 1.10-1.46), public/institutional funding (RR=2.68; 95% CI, 1.33-5.39), focus on rehabilitation/therapy intervention (RR=2.70; 95% CI, 1.40-5.21), and nonblinded study groups (RR=2.70; 95% CI, 1.40-5.21) were associated with significantly higher probability of reporting employment status.

Conclusion: Rates of reporting race, ethnicity, and SDOH variables were lower in the spinal surgery RCTs in our study than in RCTs in other medical disciplines. These reporting rates did not increase over a 20-year period. Trial characteristics significantly associated with higher rates of reporting were larger study size, North American region, private or public funding, and a focus on behavioral/rehabilitation interventions.

Level of evidence: Level III.

Summary of background data: Although pseudoangina is most commonly caused by cervical disc herniation, several cases have been described where thoracic herniation produced symptoms of pseudoangina. If thoracic herniation can produce angina-like pain, then it is important to consider whether pathology of the thoracolumbar spine, in general, can trigger false pain syndromes distinct from pseudoangina.

Objective: We seek to provide the most comprehensive study regarding the diagnosis and treatment of spinal conditions causing false pain syndromes.

Study design: Systematic review of the current literature using PRISMA 2020 recommendations.

Methods: We queried the literature and systematically selected relevant studies according to PRISMA guidelines.

Results: Across 22 selected studies, the sample size was 30 patients, and a total of 26 met the criteria for statistical analysis. Seven (26.9%) of these patients presented with a chief complaint of pseudoangina resulting from thoracic disc herniation. 73.1% (19/26) of patients exhibited pain mimicking visceral origin. Overall, 13/19 (68.4%) patients exhibited thoracic spine disease only and 4/19 (21.1%) patients were affected at lumbar levels only, while 2 (10.5%) patients exhibited thoracolumbar herniation. Presentations included abdominal pain (11/19) mimicking appendicitis or pancreatitis, flank pain mimicking renal colic (8/19), and 2 cases of scrotal pain/orchalgia. Symptom durations ranged from acute (<24 h) to 7 years. Treatments were reported for 18/19 patients and all treated patients reported alleviated pain. Seven out of 18 patients were managed conservatively while 11/18 were treated surgically. Misdiagnosis resulted in unnecessary surgery (pancreaticojejunostomy) or other invasive procedures.

Conclusions: In spinal disorders manifesting with atypical pain syndromes, delay in proper diagnosis and unnecessary treatments can, unfortunately, cause prolonged patient suffering and increased cost of health care. As a result, some have proposed that spinal screening should be incorporated into clinical examinations involving false pain syndromes.

Study design: A retrospective case-control study.

Objective: To compare the clinical efficacy of endoscopic (Endo) and open posterior lumbar interbody fusion (PLIF) in treating lumbar spondylolisthesis.

Background: Endo-PLIF has emerged as a new technique for treating lumbar spondylolisthesis. We propose Endo-PLIF as an alternative method.

Materials and methods: Sixty-four patients with single-segment lumbar spondylolisthesis underwent Endo-PLIF (n = 39) or open PLIF (n = 25) treatment. Demographic data, perioperative parameters, and radiographic parameters were recorded. Clinical results were evaluated by Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores. The fusion rate was evaluated by computed tomography at 12 months postoperatively. In addition, a case-control process was included to ensure unbiased comparisons.

Results: The average operation time was longer in the Endo-PLIF group. Endo-PLIF showed advantages in reducing blood loss, shortening hospital stay, and early ambulation, but with a longer x-ray exposure time. Both VAS and ODI scores significantly improved in both groups, but the VAS for back pain was lower in the Endo-PLIF group. The radiographic results were similar in both groups. Three patients in the Endo-PLIF group had minor complications. Two patients in the open PLIF group experienced cerebrospinal fluid leakage. Both VAS and ODI scores significantly improved in both groups compared with preoperative scores, but the Endo-PLIF group showed more significant improvement at early follow-up ( P < 0.05). There was no significant difference in interbody fusion rate between the two groups.

Conclusion: Both Endo-PLIF and open PLIF are effective for treating single-segment lumbar spondylolisthesis. Endo-PLIF shows advantages in reducing blood loss, shortening hospital stays, and promoting early ambulation, with comparable fusion rates and patient satisfaction to open PLIF. Despite minor complications in the Endo-PLIF group and cerebrospinal fluid leakage in the open PLIF group, both procedures lead to significant improvements in pain and disability scores, with Endo-PLIF demonstrating more significant early improvements.

Study design: Retrospective.

Objective: To report radiologic and clinical outcomes of single-level unilateral biportal endoscopic (UBE) decompression over 5 years for degenerative lumbar spinal stenosis (LSS) without instability.

Summary of background data: UBE decompression has recently been introduced as a surgical treatment for LSS without instability. UBE has been shown in studies to have advantages in the prevention of infection and early rehabilitation. However, there is no long-term follow-up study.

Methods: One hundred twenty-seven patients who underwent UBE decompression for single-level LSS with at least 5 years of follow-up were analyzed. Clinical outcomes including Oswestry Disability Index (ODI), Visual analog system (VAS), modified MacNab criteria, time to ambulation, operative time, and length of hospital stay were investigated. The radiologic outcome was assessed by dynamic plain radiographs.

Results: ODI improved from 63.2±10.7 before surgery to 18.8±9.2 after 5 years of follow-up (P<0.001). Leg VAS decreased from 7.3±0.7 before surgery to 1.75±0.5 at the last follow-up (P<0.001). Per modified Macnab criteria, only 9.4% (12/127) showed poor clinical results. There were no infections, but there were 4 cases (3%) of dura tear and 1 case (0.07%) of transient palsy. Intervertebral angle showed significant change from preoperative to final follow-up, 6.3 ±3.2-5.2 ±3.5 degrees. (P=0.012). The intervertebral distance also showed a significant difference from 10.5±2.3 mm before surgery to 9.1±2.2 mm after surgery. (P=0.005). No significant changes in dynamic stability occurred. Among 127 patients, revision surgery was performed in 9 cases (7%).

Conclusions: UBE decompression of LSS without instability demonstrated good clinical outcomes over 5 years and did not show significant segmental instability after surgery. Although revision surgery was performed after UBE decompression, there were no severe complications, and revision rates were similar to other techniques. UBE is considered to be an alternative technique to microscopic and traditional decompression in LSS.