Clinical Spine Surgery最新文献

Study design: Systematic review.

Objective: To evaluate the statistical robustness of TXA use in spine surgery as a potential contributor to controversies in this field.

Summary of background data: Tranexamic acid (TXA) is an antifibrinolytic medication administered during spinal surgery to limit blood loss. Existing randomized controlled trials (RCTs) on the efficacy of TXA contain varied results, particularly when reporting outcomes related to blood transfusion rates and thromboembolic events. By calculating the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ), statistical robustness was quantified and compared across all included RCTs.

Methods: PubMed, Embase, and MEDLINE were systematically searched for recent RCTs (January 1, 2000-August 1, 2023) assessing TXA use in patients undergoing spine surgery. The FI and rFI were calculated for each outcome, representing the number of event reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI/rFI by the study sample size.

Results: Of the 297 RCTs screened, 31 studies were included for analysis, yielding 80 dichotomous outcomes. Across these outcomes, the median FI (mFI) was 5.0, with an associated median FQ (mFQ) of 0.060. Nine outcomes were statistically significant (mFQ=0.018), and 71 were nonsignificant (mFQ=0.064). The most common outcome categories included blood/platelet transfusions (38 outcomes), thromboembolic events (15 outcomes), and other adverse events (27 outcomes), resulting in mFQs of 0.056, 0.049, and 0.064, respectively.

Conclusions: Outcomes examining TXA in spinal surgery demonstrated statistical fragility, with significant and thromboembolic outcomes proving the most fragile. Among all outcomes, there was a lack of significant results. To better guide future research on TXA use in spine surgery, this study recommends RCTs report fragility statistics along with P values and include these metrics when proposing clinical implications.

Level of evidence: Level III.

Study design: Retrospective case series.

Objective: To explore the clinical efficacy and safety of unilateral biportal endoscopy (UBE) combined with oblique lumbar interbody fusion (OLIF) in the treatment of lumbar infectious spondylitis (LIS).

Background: In recent years, there has been a notable increase in the incidence of LIS. Patients typically present with back pain, tenderness, and stiffness, which may be accompanied by fever, which significantly reduces their quality of life.

Patients and methods: This study selected 25 patients with LIS treated by UBE with OLIF from January 2018 to March 2023 in our hospital, including 14 males and 11 females. During the perioperative phase, key indicators such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein were monitored to evaluate the efficacy of the infection treatment. Surgical-related indicators and the frequency of complications were systematically recorded. Functional and imaging indicators before and after the operation were compared.

Results: The surgical intervention was successful in all 25 patients. The average operation time was 155.2 ± 23.5 minutes, the average blood loss was 265.6 ± 46.8 mL, and the average follow-up time was 18.8 ± 6.9 months. Bacterial cultures of 12 patients were positive, and postoperative pathologic examination of all patients showed inflammation. Postoperative patients exhibited significant clinical symptom improvement, characterized by a gradual decrease in erythrocyte sedimentation rate, C-reactive protein, and white blood cell count, ultimately returning to normal levels. The Visual Analog Scale scores, Japanese Orthopedic Association scores, and Oswestry Disability Index were significantly improved after the operation ( P < 0.001). In addition, the height of the intervertebral space and the angle of lumbar lordosis were optimally restored. At the last follow-up, the fusion rate of bone graft was 96%.

Conclusion: The combined treatment of LIS with UBE and OLIF is effective, thereby establishing itself as an effective, safe, and viable surgical technique.

Study design: Observational-ecologic study.

Introduction: Spine and pelvis undergo modifications in alignment so that the individual can maintain an orthostatic position, but to date there is no evidence as to the contribution of each lumbar segment and the change that occurs in them when moving from orthostasis to supine position.

Objective: To identify the difference in the contribution of the lumbar segments and pelvis to the formation of lumbar lordosis in both positions (orthostasis and supine) and how each one alters in this change.

Summary of background data: lumbar lordosis adapts to the individual's body position and can be physiological or pathologic.

Materials and methods: Retrospective cohort study that included 174 patients: the segments total lumbar lordosis (LL), L1-L4, L4-S1, L4-L5, L5-S1, and sacral slope were measured on x-rays (orthostasis) and MRI (supine). We obtained the mean values, correlations and models proposed for the relationship between the values found.

Results: The SS, LL, L1-L4, L4-S1, and L4-L5 had their angular value reduced, and L5-S1 had its contribution to lordosis significantly increased when lying down. Moderate and strong correlations were obtained between SS × LL, L1-L4 and L4-S1, and between LL versus L1-L4 and L4-S1 in both positions. When using linear regression, proposed models were obtained with a high coefficient of determination between LL versus SS, L1-L4 and L4-S1 in orthostasis, for the same measurements and SS versus L4-S1 in supine, as well as for lordosis when comparing the 2 positions.

Conclusions: The L5-S1 segment has no change in angular value when lying in supine and is thus the largest contributor to lordosis in supine. L1-L4 increases its angular value when standing in orthostasis, the position in which it is the greatest contributor to lordosis.

Study design: This is a retrospective cohort study.

Objective: The primary objective was to determine the accuracy of the Risk Assessment and Prediction Tool (RAPT) score-based discharge disposition prediction among patients undergoing spine surgery within an Enha Recovery After Surgery (ERAS) program. The secondary objective was to determine if using RAPT to initiate preoperative referrals to home services expedited care.

Summary of background data: The RAPT score has been applied to spine surgery patients but has not been validated among participants in an ERAS program.

Methods: All patients undergoing elective spine surgery within an ERAS program over a 1-year period received a preoperative social work evaluation incorporating the generation of RAPT score. Patients predicted to be discharged home with services received a preoperative referral for home services. The predicted versus actual discharge destination was compared, and the association of preoperative home services referral with the timing of home services initiation was assessed.

Results: Four hundred eight patients received a preoperative social work evaluation with RAPT score calculation. Two hundred seven (50.7%) patients had an accurately predicted postoperative discharge disposition based on RAPT score. Among the patients who received home services following discharge, the mean time to receipt of home services was shorter among patients who had a correct discharge disposition prediction compared with patients who had an incorrect prediction, but this difference was not statistically significant [31.3 (SD: 15.6) vs. 42.0 h (SD: 44.2), P =0.24].

Conclusions: This study supports the feasibility of integrating RAPT score calculation into a preoperative social work evaluation. However, the traditional tiers of RAPT scores had limited accuracy in predicting discharge disposition in this cohort of patients undergoing spine surgery within an ERAS program.

Level of evidence: Level III.

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 the clinical implications of an incomplete fusion status as determined by CT imaging at 1-year follow-up in patients who underwent anterior cervical discectomy and fusion.

Background: Despite the advanced capabilities of CT imaging, a notable proportion of patients assessed at a 1-year follow-up are classified as having an incomplete fusion status. While neck pain is the most common symptom of pseudarthrosis after cervical fusion surgery, not all patients are symptomatic. Understanding the clinical relevance of this intermediate fusion status is essential to correctly interpret patient-reported outcome measurement instruments and patient-centered care.

Methods: Retrospective data from patients who underwent 1-level or 2-level anterior cervical discectomy and fusion between 2017 and 2022 at our tertiary spine center were reviewed, assessing a total of 77 segments. Data collected included demographic information, 1-year follow-up CT fusion rate, patient-reported outcome measurements, complications, or revision surgery. Follow-up evaluations were conducted at postoperative, short-term, and long-term intervals. A backward stepwise logistic regression was utilized to identify independent predictors of fusion status.

Results: At 1 year, 54% of patients showed signs of successful fusion, whereas 45% were categorized as incompletely fused. No significant differences were found between the fusion status groups regarding the achievement of minimal clinically important difference and patient-acceptable symptom state for clinical outcomes, including Neck Disability Index, Numeric Rating Scale arm/neck, and Short-Form 12 Physical Component Questionnaire scores. Although a higher percentage of IF patients were former smokers and, on average, had more levels fused, logistic regression did not identify these demographics, or any other variables, as significant independent predictors of fusion status.

Conclusions: Patients achieved meaningful pain relief during follow-up that was independent of their 1-year CT-graphic fusion status. Trends suggest that former smoking status and the number of fused levels may influence fusion outcomes, warranting further investigation.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: The objective of this study is to identify factors of early minimal clinically important difference (MCID) failure after anterior cervical discectomy and fusion (ACDF).

Summary of background data: Research on predictors of MCID failure after ACDF is limited.

Methods: Patients undergoing primary, elective ACDF were selected from a single spine surgeon database. Demographics, perioperative characteristics, and Visual Analog Scale Neck (VAS-N), VAS-Arm (VAS-A), Neck Disability Index (NDI), patient-reported outcome measurement information system-physical function (PROMIS-PF), 12-item Short Form (SF-12) Mental Component Score (MCS), SF-12 Physical Component Score (SF-12 PCS), and 9-item Patient Health Questionnaire (PHQ-9) scores were collected. A 2-step multivariable logistic regression was performed to determine predictors of MCID failure.

Results: A total of 240 patients were included. Preoperative VAS-N and diagnosis of foraminal stenosis were significant positive predictors of failure. Workers' compensation (WC) was a negative predictor, whereas smoker status and preoperative VAS-A were positive predictors. Preoperative PROMIS-PF, preoperative SF-12 PCS/MCS, and postoperative day 0 narcotic consumption were negative predictors, and length of stay was a positive predictor.

Conclusion: The variations in follow-up compliance among spine surgery patients highlight the importance of identifying predictors of early MCID failure rates to avoid less than favorable patient experiences. In our study, we identified data to suggest that positive predictors of early failure may be associated with higher preoperative neck pain, smoker status, and longer length of stay. In comparison, negative predictors are related to WC insurance, better preoperative physical function and mental health, or postoperative narcotic consumption.

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: Systematic review and meta-analysis.

Objective: To determine whether venous thromboembolism (VTE) prophylaxis is necessary after spine trauma and to assess the efficacy and safety profiles of anticoagulation agents.

Summary of background data: Venous stasis, endothelial disruption, hypercoagulability, and orthopedic injury in spine trauma predispose 12%-64% of patients to deep vein thrombosis (DVT). Recent guidelines provide insufficient evidence to support or oppose routine VTE prophylaxis in this population.

Methods: A systematic search was conducted in Medline, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials from inception to March 2023. Controlled vocabulary, key terms, and synonyms related to spinal trauma and anticoagulation were used. Studies comparing different classes of anticoagulants or anticoagulation versus no anticoagulation were included. Four reviewers independently performed abstract screening, full-text review, and data extraction, resolving conflicts by consensus. The primary outcomes were deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and mortality.

Results: Our search yielded 2948 articles, with 103 advancing to full-text review and 16 meeting inclusion criteria. Bias assessment using MINORS for 10 retrospective studies resulted in an average score of 16.8 ± 1.6, whereas 6 prospective studies had NOS scores >6, indicating high-quality evidence. Anticoagulation was significantly associated with lower odds of DVT (OR: 0.40; P =0.0013), with low heterogeneity (I² = 2%). Low-molecular-weight heparin (LMWH) was associated with significantly lower odds of DVT (OR: 0.78; P =0.0050) and PE (OR: 0.66; P =0.0013) compared with unfractionated heparin (UH). No significant difference in major bleeding was found (OR: 0.52; P =0.1397). LMWH was linked to reduced mortality (OR: 0.43; P <0.0001).

Conclusion: Chemical anticoagulants reduce DVT risk in spine trauma patients. LMWH provides superior protection against DVT, pulmonary embolism, and mortality compared with UH, with no significant increase in major bleeding.

Study design: Retrospective database study.

Objective: Compare the revision rates of 2-level ACDF, CDR, and hybrid ACDF/CDR.

Summary of background data: While single-level CDR has been extensively studied, multilevel CDR and hybrid ACDF/CDR constructs have been less well studied.

Methods: This study utilized a large commercial insurance database of patients 65 years old or younger. Patients undergoing 2-level ACDF, 2-level CDR, and hybrid 2-level ACDF/CDR were identified. Patients age 18 years or older with malignant, infectious, or neoplastic etiologies were excluded, as were those undergoing revision surgery or any concomitant posterior cervical surgery. Study follow-up was terminated at 5 years postoperatively. The primary outcome was revision surgery, including anterior and posterior decompression, fusion, and arthroplasty.

Results: A total of 99,282 patients were included. The mean age was 51.3 years old (SD 8.1). The mean maximum follow-up was 2.1 years (SD 1.7). In all 3.2% (n=3197) underwent 2-level CDR, 0.5% (n=448) underwent hybrid 2-level ACDF/CDR, and 96.3% (n=95,637) underwent 2-level ACDF. At 5 years postoperatively, in Kaplan-Meier analysis, revision occurred in 10.0% of the CDR group, 12.4% of the hybrid group, and 10.0% of the ACDF group. In multivariable regression analysis, no significant differences in revision occurrence were observed between the CDR, hybrid, and ACDF groups ( P <0.15 for all comparisons). In multivariable regression analysis stratified by plate versus stand-alone cage, patients with plated hybrid constructs had higher revision rates than those with both plated ACDF constructs (HR: 1.5, P =0.0387) and 2-level CDR (HR: 1.5, P =0.0477).

Conclusions: In this retrospective database study of patients 65 years old or younger undergoing 2-level anterior cervical surgery, there were no significant differences at 5-year follow-up in revision rates for patients undergoing 2-level CDR, 2-level ACDF, and hybrid ACDF/CDR surgeries. In subanalysis, patients specifically with a plated hybrid ACDF/CDR had a higher occurrence of revision versus those undergoing plated 2-level ACDF or 2-level CDR. Future multicenter, prospective research is necessary to further assess these findings.