Clinical Spine Surgery最新文献

Study design: Single-institution retrospective cohort study.

Objective: Determine the impact of graft height and material on radiographic pseudarthrosis, pseudarthrosis requiring reoperation, and patient-reported outcome measures (PROMs).

Summary of background data: The success of an anterior cervical discectomy and fusion (ACDF) depends on obtaining solid bony fusion to achieve stability and restore disc height. While various interbody graft options exist, the impact of graft height and material on fusion rate remains an area of ongoing investigation.

Methods: Patients who underwent 1-3 level primary ACDF between 2010 and 2021 were studied. Graft height and material (structural allograft vs. prosthetics) were the primary independent variables. The primary outcome was pseudarthrosis, defined as interspinous motion >2 mm on flexion-extension lateral x-rays at 1-year postoperatively. PROMs included Numeric Rating Scale-Arm/Neck and Neck Disability Index. Multivariable logistic regression was performed. A subanalysis was conducted for prosthetic submaterial (PEEK vs. titanium).

Results: One hundred fifty-three patients were included (mean age: 51.8±11.0 y; 42.5% male). Most patients had 1-2 levels operated on and 33.3% had structural allograft as the interbody implant. Prosthetic implants were used in 66.7% of patients, with PEEK being the most common (80.4%). At 1-year postoperatively, 11.1% of patients developed pseudarthrosis, and 2.0% underwent reoperation. There were no significant differences in graft height, material, or prosthetic submaterial between patients with and without pseudarthrosis. Multivariable logistic regression also did not show any significant associations between graft height, material, or prosthetic submaterial with pseudarthrosis, reoperation, or PROMs (all P >0.05).

Conclusion: This study found that graft height and material did not significantly affect pseudarthrosis, reoperation, or PROMs in patients undergoing primary ACDF. While graft height and composition alone may not be critical determinants for fusion success in ACDF, Other factors, such as patient-specific characteristics and surgical technique may contribute to the risk of pseudarthrosis and should be explored in future studies.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: To analyze national trends in the management of acute traumatic central cord syndrome.

Summary of background data: Acute traumatic central cord syndrome (ATCCS) is the most common incomplete spinal cord injury. Initial management involves decompression and stabilization of the cervical spinal cord. On the basis of mixed literature regarding operative timing for ATCCS, we aimed to evaluate trends in early, late, and delayed surgery over the last 5-10 years and compare their respective outcomes.

Methods: Data were obtained from the National Inpatient Sample (NIS) using specific ICD-10 codes. Baseline demographics, comorbidities, and outcomes were evaluated. These patients were grouped based on whether central cord syndrome (CCS) operative treatment was early (within 24h of admission), late (between 24 and 48h of admission), or delayed (after 48h of admission).

Results: A total of 21,265 patients underwent operative management for ATCCS; 16.7% received early operative management, 35.6% received late operative management, and 47.6% received delayed operative management. Compared with the total cohort, the delayed operative management group was more likely to contain patients with obesity (7.1% vs. 6.3%, P <0.001), chronic obstructive pulmonary disease (COPD) (12.9% vs. 11.1%, P <0.001), and diabetes mellitus (28.1% vs. 26.1%, P <0.001). Early operative management was more likely in patients with plegia (24.7% vs. 17%, P <0.001) and bowel/bladder dysfunction (14.6% vs. 9.5%, P <0.001) and was independently associated with lower rates of prolonged length of stay (LOS) (OR=0.71) and acute kidney injury (AKI) (OR=0.696).

Conclusions: Our analysis of the trends in operative timing for ATCCS demonstrated an overall increase in the rate of early operative management and a decrease in the rate of delayed operative management. These findings mirror the current evolution of the literature on the topic. Nuances in early versus late outcomes should be used to help decision making related to operative timing in ATCCS.

Level of evidence: Level III.

Study design: Descriptive study.

Summary of background data: Patients commonly use online patient education materials (PEM) to learn about anterior cervical discectomy and fusion (ACDF).

Objective: The purpose of this study is to evaluate the readability of patient education materials on anterior cervical discectomy and fusion.

Methods: The Google search engine was queried using the term "Anterior Cervical Discectomy and Fusion patient information." The first 25 websites meeting inclusion criteria for this term were evaluated. Readability scores were automatically calculated by transferring the texts to http://www.readabilityformulas.com . Descriptive statistics were calculated for each measure using SPSS version 28.0.0.

Results: The mean average reading level was 9.2±2.4. The mean readability score out of 100 for the FK Reading Ease Score was 55.2±8.6. The remaining scores were: Gunning Fog, 12.7±2.2; FK Grade Level, 8.9±2.0; The Coleman Liau Index, 11.0±1.7; SMOG Index, 48.1±197.0; Automated Readability Index, 8.1±3.11; Linsear Write Formula, 9.8±2.1. Only 2 of the PEMs were written at or below a sixth grade level and only 7 were written at or below an eighth grade reading level.

Conclusion: Patient readability is an important component of patient care and the current readability level of ACDF PEMs is insufficient. At their current state, PEMs may not allow a significant portion of the population to understand the nature of their condition and procedure properly.

Level of evidence: Level III.

Study design: Prospective survey study.

Objective: To address a gap that exists concerning ChatGPT's ability to respond to various types of questions regarding cervical surgery.

Summary of background data: Artificial Intelligence (AI) and machine learning have been creating great change in the landscape of scientific research. Chat Generative Pre-trained Transformer(ChatGPT), an online AI language model, has emerged as a powerful tool in clinical medicine and surgery. Previous studies have demonstrated appropriate and reliable responses from ChatGPT concerning patient questions regarding total joint arthroplasty, distal radius fractures, and lumbar laminectomy. However, there is a gap that exists in examining how accurate and reliable ChatGPT responses are to common questions related to cervical surgery.

Materials and methods: Twenty questions regarding cervical surgery were presented to the online ChatGPT-3.5 web application 3 separate times, creating 60 responses. Responses were then analyzed by 3 fellowship-trained spine surgeons across 2 institutions using a modified Global Quality Scale (1-5 rating) to evaluate accuracy and utility. Descriptive statistics were reported based on responses, and intraclass correlation coefficients were then calculated to assess the consistency of response quality.

Results: Out of all questions proposed to the AI platform, the average score was 3.17 (95% CI, 2.92, 3.42), with 66.7% of responses being recorded to be of at least "moderate" quality by 1 reviewer. Nine (45%) questions yielded responses that were graded at least "moderate" quality by all 3 reviewers. The test-retest reliability was poor with the intraclass correlation coefficient (ICC) calculated as 0.0941 (-0.222, 0.135).

Conclusion: This study demonstrated that ChatGPT can answer common patient questions concerning cervical surgery with moderate quality during the majority of responses. Further research within AI is necessary to increase response.

Study design: Retrospective cohort study.

Objectives: Identify and compare racial/ethnic disparities in ambulatory versus inpatient surgical care utilization for single-level lumbar spine surgery.

Summary of background data: The proportion of spine surgeries performed in the ambulatory setting has dramatically increased over the past 2 decades. However, few studies have investigated whether this shift has resulted in racial/ethnic disparities in surgical care utilization, particularly for outpatient lumbar spine surgery, compared with the inpatient setting.

Materials and methods: Utilizing the 2019 National Inpatient Sample and Nationwide Ambulatory Surgical Sample discharge, we included patients who had undergone a single-level lumbar discectomy, laminectomy, and/or fusion, were of Black, White, or Hispanic race/ethnicity, were covered under Medicare, Medicaid, or private insurance, and were aged 18 years or above. The primary outcome was the rate ratio (RR) of patients from the aforementioned 3 racial/ethnic groups undergoing lumbar surgical care, in the ambulatory and inpatient settings. US Bureau of Labor Statistics data were utilized to offset the model for population-based variations in sociodemographic factors utilizing nested coefficients.

Results: Among 397,173 cases, 220,250 (55.5%) were inpatient, and 176,923 (44.5%) were ambulatory. Compared with White patients, Black (RR: 0.54, 95% CI: 0.53-0.55) and Hispanic (RR: 0.61, 95% CI: 0.60-0.62) patients had lower utilization rates of ambulatory surgical care. More pronounced patterns were observed for Black (RR: 0.44 95% CI: 0.44-0.45) and Hispanic (RR: 0.55, 95% CI: 0.54-0.56) inpatient surgical utilization; all P < 0.001.

Conclusions: Racial/ethic disparities in single-level lumbar surgical care utilization exist in both the ambulatory and the inpatient setting.

Level of evidence: Level 3.

Study design: A prospective, randomized study.

Objective: The goal of this study was to evaluate the impact that subcutaneous drains have on patient satisfaction and postoperative recovery after a lumbar fusion surgery.

Summary of background data: The use of drains following lumbar fusion surgery is controversial. Current literature shows that there are both benefits and drawbacks to using deep drains, however, there are no reports on the utility of superficial drains.

Methods: One hundred ten patients undergoing a 1 to 3-level fusion by a single surgeon were randomly selected to receive either a subcutaneous drain (55 patients) or no drain (55 patients). Drain output was collected 1, 3, and 5 days after the procedure. Drains were removed 5 days after the surgery so long as the output was <50 ccs in a 24-hour period. Patient demographics, drain outputs, and questionnaire data from 10, 30, and 60 days after the procedure were compared.

Results: Patients receiving a superficial drain were significantly less likely to have incisional drainage ( P <0.01) and tended to be less anxious about their wound healing ( P =0.06). There was no difference between drain and no drain groups in terms of postoperative complications, wound care satisfaction, level of independence, or need for outside medical assistance. Body mass index (BMI) and wound thickness did not impact the volume of drain output or other results.

Conclusions: Subcutaneous drains significantly decrease incisional leakage and tend to decrease patient anxiety regarding wound healing. The presence of a postoperative drain does not diminish patient satisfaction with wound healing.

Study design: Randomized control trial.

Objective: To examine erector spinae plane block on a large, comprehensive scale, and investigate the management of postoperative pain and recovery process after lumbar spine surgery using this block.

Summary of background data: Pain management is a key aspect of a patient's care and overall surgical outcome regarding spinal surgery. While most patients have no issues when undergoing spinal surgery, many have pain that will persist postoperation. Our goal was to evaluate the efficacy of erector spinae plane (ESP) blocks before lumbar arthrodesis in helping manage the persisting pains and opioid consumption postsurgery.

Methods: A single-blinded randomized control trial was designed and executed on patients who were to undergo lumbar spine fusion. Before their surgical intervention, patients were randomly assigned to receive the erector spinae plane block or the normal anesthesia/pain management routine.

Results: Of a total of 49 patients, 23 (47%) underwent a spinal block before their respective lumbar spine procedure. Patients with spinal block required fewer supplemental opioids postoperatively (69.9±6.66 vs. 71.7±5.70, P = 0.0002) while reporting less severe pain on VAS pain scoring throughout the first 3 postoperative days ( P < 0.0001).

Conclusions: The patient population that received the erector spinae block had significantly lower pain scores on days 1-3 postsurgery, showing that the spine block is effective in helping patients recover from spinal surgery quicker and with less persisting pain. In addition, the number of patients who filled their first opioid prescription was approaching significance, with the ESP block group filling those prescriptions less frequently. ESP blocks appear to be efficacious at reducing pain and opioid consumption in the immediate postoperative period. No additional complications or readmissions were apparent between subgroups.

Study design: Retrospective analysis.

Objective: The purpose of this study is to quantify the rate at which the atlantoaxial level is omitted from official cervical magnetic resonance imaging (MRI) radiologic reports and to identify potential missed pathology, emphasizing the need for improved standardization of evaluation.

Summary of background data: MRI is a readily utilized modality for evaluating the axial skeleton. In our experience, the atlantoaxial level of the cervical spine is often overlooked on MRI radiologic reports in the absence of trauma or obvious pathology.

Methods: The preoperative MRIs and associated radiologic reports of 219 patients undergoing cervical decompression and fusion in a single year were collected. The inclusion or omission of distinct evaluation at the atlantoaxial level within each radiologic report was recorded. All imaging was then reviewed. The atlantoaxial level was specifically evaluated, and any pathology was noted and compared with the official radiologic reports. The rates of atlantoaxial evaluation omission from the radiologic reports and missed pathology at this level were primarily and secondarily reported.

Results: MRI studies were performed at 101 different institutions, with reports issued by 126 individual radiologists. Specific documentation of atlantoaxial evaluation was noted in 32 (14.6%) radiology reports, with the remaining 187 cases (85.4%) including no mention of this level. Upon independent re-review of the imaging, pathology was noted at the atlantoaxial level in 18 patients (8.2%), totaling 19 abnormal findings. Such findings were absent from the official reports in 13 of these cases (5.9% of the total study population).

Conclusions: In our study, formal documentation was omitted from 85% of reports resulting in missed pathology in nearly 6% of cases. This study underscores the importance of thorough imaging interpretation and clinical correlation with patient symptoms. In addition, it highlights the need for standardized reporting of these studies to prevent potential morbidity associated with a missed diagnosis.

Study design: Retrospective study.

Objective: To correlate the changes in the dural area on MRI and clinical outcome after unilateral biportal endoscopic (UBE) decompression.

Summary of background data: Clinical outcomes after UBE decompression have been published for up to 2 years for patients with isolated spinal stenosis at 1 level. Serial dural expansion after UBE decompression has not been published as well as correlation to clinical outcomes.

Method: We retrospectively reviewed the clinical and radiologic outcomes of 86 patients who underwent UBE decompression for spinal stenosis. Preoperative and postoperative visual analog score (VAS) and Oswestry Disability Index (ODI) were analyzed, and MRI was used for radiologic evaluation before surgery, 3 days after surgery, and 2 years after surgery. The correlation of dural spinal area CSA (preoperative-final) and difference of clinical outcome (preoperative-final) were analyzed.

Result: None of the 86 patients had permanent neurological complications. Back VAS, leg VAS, and ODI showed improvement in symptoms postoperatively and 2 years postoperatively. The postoperative CSA of the dural sac on MRI was statistically significantly increased after surgery at all time points. VAS leg was moderately correlated with change in CSA, while ODI and VAS back were weakly correlated. Correlations were all statistically significant.

Conclusion: UBE decompression showed good clinical outcomes similar to previous studies, and the CSA of ​​the dural sac on MRI significantly increased in the late postoperative phase compared with the early postoperative phase. This technique is viable option to achieve radiographic dural expansion and improvement in clinical outcomes in degenerative lumbar spinal stenosis. However, there is at best only a moderate correlation with change in CSA and clinical outcomes.

Study design: Retrospective cohort study.

Objective: To assess the efficacy of tranexamic acid (TXA) on reducing perioperative blood loss and blood transfusion requirements in nonidiopathic scoliosis patients undergoing primary posterior spinal fusion.

Summary of background data: Posterior spinal fusion for correcting scoliosis in pediatric patients is associated with substantial volumes of perioperative blood loss and high transfusion requirements. Patients with nonidiopathic scoliosis typically experience greater blood loss than those with idiopathic scoliosis.

Methods: We retrospectively reviewed patients who underwent primary posterior fusion for nonidiopathic scoliosis between November 2014 and December 2020. Patients were assigned to the TXA or no-TXA group depending on intraoperative administration of TXA.

Results: Despite longer surgical duration ( P =0.009) and more spinal levels fused ( P =0.014), perioperative blood loss [2602 (810-9262) mL in the TXA group vs. 2058 (1019-4170) mL in the no-TXA group, P =0.554] and allogenic red blood cell transfusion rates (63% in the TXA group vs. 55% in the no-TXA group, P =0.508) were similar in the TXA and the no-TXA groups. After adjustments, TXA administration was found to have a significant negative effect on estimated blood loss (Est=-513.73, 95% CI=-925.41 to 125.3, P =0.045).

Conclusions: Significant perioperative blood loss and high transfusion rates remain a challenge in the surgical treatment of nonidiopathic scoliosis patients. Given the demonstrated negative effect of TXA on estimated blood loss, its routine application may be considered in the perioperative blood management of pediatric nonidiopathic scoliosis patients.

Level of evidence: Level III.