Clinical Spine Surgery最新文献

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.

Study design: Prospective study (level II evidence).

Objective: The objective of this study was to assess recall accuracy and bias through PROMIS-PF (physical function) and PI (pain interference) scores in patients undergoing cervical or lumbar spine surgery.

Summary of background data: Patient-reported outcomes (PROs) have improved quantitative data availability; however, the interpretation of results may remain susceptible to confounding factors including recall accuracy. No studies to date have reported the accuracy of patient recall using PROMIS outcomes in spine patients.

Methods: Patients who underwent elective lumbar or cervical spine surgery were identified at a single tertiary, academic institution. PROMIS-PF and PI CAT (computer adaptive tests) were administered preoperatively. After a minimum 2-year follow-up, patients were administered these questionnaires and asked to answer with their recalled preoperative status. Recall accuracy was assessed by comparing recalled and actual baseline PROMIS scores. Regression analyses were conducted to evaluate the agreement between actual and recalled scores. Multivariate logistic regression was performed to determine potential demographic and temporal sources of bias.

Results: Lumbar surgery patients recalled significantly worse preoperative function (Δ -1.5, 95% CI (-2.8 to -0.3), P <0.05) and severe pain [Δ 2.1, 95% CI (0.5-3.6), P <0.01] than reported before surgery. Patients in the cervical cohort, in contrast, were more accurate in recall for both domains [PF Δ 1.8, 95% (CI -1.4 to 5.0), P >0.05 and PI Δ 0.0, 95% CI (-3.0 to 3.0), P >0.05]. The correlation between recalled and actual scores was moderate in both cohorts. Demographic and temporal variables did not significantly influence recall accuracy. Lumbar cohort patients who met PI MCID were more likely to accurately recall baseline pain scores.

Conclusion: Recall inaccuracy is present in patients who undergo spine surgery; however, patients on average recall significantly worse preoperative status as measured by PROMIS PF and PI scores. Accurate recollection of preoperative status may influence patient perception of care.

Study design: This is a narrative review and case report.

Objective: To summarise and share relevant treatment experiences by analysing the clinical features of lymphatic leakage occurring after oblique approach retroperitoneal lumbar interbody fusion (OLIF), with a view to providing reference and guidance for clinical practice.

Methods: Clinical data of 3 patients with lymphatic leakage after OLIF surgery from December 2018 to April 2024 in the International Zhuang Medicine Hospital affiliated to Guangxi University of Traditional Chinese Medicine and the First Affiliated Hospital of Guangxi University of Traditional Chinese Medicine were retrospectively analysed.

Results: Through postoperative bed rest, change of body position, regulation of diet and other treatments, postoperative lymphatic leakage was effectively controlled, and all 3 patients recovered and were discharged from the hospital.

Conclusion: Surgical operation damage to lymphatic vessels is an important cause of postoperative lymphatic leakage, nonsurgical treatment should be the first choice for treating lymphatic leakage, and strengthening high-protein diet is the key to treating lymphatic leakage.

Study design: Operative video and supplemental manuscript.

Objective: To present a step-by-step approach to performing lamina-preserving lumbar posterior column osteotomies (PCO) for correction of adult thoracolumbar scoliosis.

Summary of background data: Outcomes of operations for adult thoracolumbar spinal deformities are dictated by adequate neural decompression, restoration of appropriate alignment, and achievement of fusion. A surgical strategy that optimizes attainment of all 3 of these goals is important to understand.

Methods: A step-by-step approach to performing lamina-preserving lumbar PCOs is provided through a case example and surgical technique video, Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A393 .

Results: Lamina-preserving PCOs performed at multiple levels are a particularly useful surgical strategy to correct adult thoracolumbar scoliosis, as they provide significant mobilization of the spine and allow for wide decompression of neural elements centrally and in the lateral recess and foramen while maintaining significant central osseous surfaces for interlaminar fusion.

Conclusions: Multilevel lamina-preserving PCOs allow for excellent neural decompression, powerful restoration of appropriate sagittal and coronal spinal alignment through release of the lumbar spine, and facilitate interlaminar union, all of which are critical to optimal outcomes of operations for adult thoracolumbar scoliosis.

The future of space exploration will include a prolonged presence on the Moon, commercial low-orbit spaceflight, and long-range missions to Deep Space, including a prolonged Martian presence. Understanding the effects the space environment will have on astronauts' musculoskeletal system is mission critical and include both microgravity and space radiation. In spaceflight, crewmembers are exposed to a vast mixture of radiation species and energies including cosmic rays (CR) from galactic cosmic radiation (GCR), solar ejections, and neutrons. Any trip beyond the protection of the Earth's electromagnetic field will expose astronauts to the near-maximum levels of lifetime allowable radiation exposure. We have previously reviewed how microgravity induces pathophysiological adaptations in the spine and how countermeasure strategies can play a role in minimizing astronaut morbidity. Now, through the National Aeronautics and Space Administration's (NASA) Human Research Roadmap (HRR), there is a renewed interest in characterizing and mitigating the effects of radiation as astronauts prepare for the Artemis missions and beyond. Thus, our aim in this critical narrative review is to focus on how the second greatest challenge to crewmembers' health, radiation, and identify how potential countermeasures will affect the spine.

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 χ 2 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: Secondary analysis of a prospective cross-sectional study at an academic tertiary spine care center.

Objectives: To examine the prevalence and risk factors for preoperative Vitamin D (VitD) deficiency and secondary hyperparathyroidism (SHPT), and to assess the seasonal variation of metabolic bone laboratory parameters in patients undergoing lumbar fusion surgery (LFS).

Summary of background data: LFS relies on adequate connective tissue quality and bone healing capacity. VitD deficiency and SHPT significantly impact bone metabolism and are linked to lower fusion rates and poorer bone quality. However, their seasonal variation in LFS patients remains unexplored.

Methods: Patients undergoing LFS for degenerative conditions received preoperative VitD, parathyroid hormone (PTH), and bone turnover markers laboratory routinely from December 2014 to December 2023. Descriptive and comparative statistics, logistic regression, and univariable and multivariable cosinor regression models were used to evaluate VitD status, SHPT prevalence, their risk-factors and seasonal variations in VitD, PTH, and bone turnover markers.

Results: Data from 431 patients (49% female, median age 64 y) was analyzed. VitD insufficiency (<30 ng/mL) was observed in 34% of patients, ranging from 48% in winter to 25% in summer. SHPT was present in 24%, with winter prevalence at 28%. Surgery during winter and spring was associated with a 7.5-fold increased risk of VitD deficiency and a 2.1-fold increased risk of SHPT. Seasonal changes with peaks for VitD, PTH, and bone-specific alkaline phosphatase were observed in July, February, and November, respectively, with no significant annual variation in other bone metabolism markers.

Conclusions: The prevalence of VitD deficiency and SHPT in LFS patients is high, especially during winter and spring. Seasonal variations in VitD and bone metabolism markers suggest that single-timepoint laboratory evaluations may not reflect bone metabolism throughout the year, highlighting the need for further studies investigating whether seasonal factors in preoperative assessments could affect outcomes.