Clinical Spine Surgery最新文献

Study design: Retrospective cohort study.

Objective: Identify factors associated with cervical epidural steroid injection (CESI) receipt before anterior cervical discectomy and fusion (ACDF), posterior cervical decompression and fusion (PCDF), or decompression; evaluate the association between CESI receipt and 90-day postoperative complications; and determine characteristics of CESI associated with complications.

Summary of background data: Previous literature has suggested that a preoperative CESI may increase the risk of postoperative complications. However, these studies were limited in the procedures and complications they evaluated.

Methods: The IBM MarketScan database was queried for patients aged 18 years or older who underwent ACDF, PCDF, or cervical decompression for disc herniation, stenosis, radiculopathy, myelopathy, and/or spondylosis without myelopathy between January 1, 2014 and September 30, 2020. CESI receipt within 12 months preoperatively, injection characteristics, and postoperative complications were extracted. Multivariable logistic regression models were used to investigate associations between patient characteristics and receipt of CESI, receipt of a CESI and each 90-day postoperative complication, and CESI characteristics and each 90-day complication.

Results: Among the unique patients who underwent each procedure, 20,371 ACDF patients (30.93%), 1259 (22.24%) PCDF patients, and 3349 (36.30%) decompression patients received a preoperative CESI. In all 3 cohorts, increasing age, increasing comorbidity burden, smoker status, and diagnosis of myelopathy were associated with decreased odds of preoperative CESI receipt, while female sex and diagnosis of radiculopathy and spondylosis without myelopathy were associated with increased odds. There were no meaningful between-group comparisons or significant associations between preoperative CESI receipt and any 90-day postoperative complications in multivariable models (all P >0.05).

Conclusions: This study elucidated the main determinants of CESI receipt and found no differences in the odds of developing 90-day postoperative complications, but did identify differential outcomes with regard to some injection characteristics.

Level of evidence: Level III.

Study design: This is a retrospective cohort study.

Objective: In patients undergoing elective posterior cervical laminectomy and fusion (PCLF) with a minimum of 5-year follow-up, we sought to compare reoperation rates between patients with an upper instrumented vertebra (UIV) of C2 versus C3/4.

Summary of background data: The long-term outcomes of choosing between C2 versus C3/4 as the UIV in PCLF remain unclear.

Methods: A single-institution, retrospective cohort study from a prospective registry was conducted of patients undergoing elective, degenerative PCLF from December 2010 to June 2018. The primary exposure was UIV of C2 versus C3/4. The primary outcome was reoperation. Multivariable logistic regression controlled for age, smoking, diabetes, and fusion to the thoracic spine.

Results: Of the 68 patients who underwent PCLF with 5-year follow-up, 27(39.7%) had a UIV of C2, and 41(60.3%) had a UIV of either C3/4. Groups had similar duration of symptoms ( P =0.743), comorbidities ( P >0.999), and rates of instrumentation to the thoracic spine (70.4% vs. 53.7%, P =0.210). The C2 group had significantly longer operative time (231.8±65.9 vs. 181.6±44.1 mins, P <0.001) and more fused segments (5.9±1.8 vs. 4.2±0.9, P <0.001). Reoperation rate was lower in the C2 group compared with C3/4 (7.4% vs. 19.5%), though this did not reach statistical significance ( P =0.294). Multivariable logistic regression showed increased odds of reoperation for the C3/4 group compared with the C2 group (OR=3.29, 95%CI=0.59-18.11, P =0.170), though statistical significance was not reached. Similarly, the C2 group had a lower rate of instrumentation failure (7.4% vs. 12.2%, P =0.694) and adjacent segment disease/disk herniation (0% vs. 7.3%, P =0.271), though neither trend attained statistical significance.

Conclusions: Patients with a UIV of C2 had less than half the number of reoperations and less adjacent segment disease, though neither trend was statistically significant. Despite a lack of statistical significance, whether a clinically meaningful difference exists between UIV of C2 versus C3/4 should be validated in larger samples with long-term follow-up.

Level of evidence: Level-3.

Study design: Retrospective Analysis.

Objective: The objective of the study was to assess the impact of academic productivity at both individual and program levels on lifetime industry earnings within US orthopedic spine fellowships.

Summary of background data: Physician-industry transparency was codified by the Physician Payments Sunshine Act (PSSA) in 2010. No study has explored the relationship between academic productivity and industry earnings at the fellowship level.

Methods: Inclusion criteria encompassed physicians with complete academic and industry data from orthopedic spine fellowship programs listed on the North American Spine Society (NASS) 2022-2023 fellowship directory. Academic productivity was defined via H-index on the Scopus website, and industry productivity by total lifetime earnings on the Open Payments Database (OPD).

Results: This analysis included 75 orthopedic spine fellowship programs with 320 individual physicians. Median individual physician lifetime earnings were $86,852.71 (mean: $666,580.23 ± $1,887,734.64; minimum-maximum: $10.86-$27,164,431.49) and the median individual physician (n=320 physicians) H-index was 17.0 (mean: 21.82 ± 19.28; minimum-maximum: 0-109). Median combined physician H-index per fellowship (n=75 fellowships) was 65.0 (mean: 93.08 ± 85.67; minimum-maximum: 3-434) and median combined physician lifetime earnings was $927,771.60 (mean: $2,844,075.64 ± $4,942,089.56; minimum-maximum: $1,112.32-$29,983,900.69). A positive correlation was observed between academic productivity and industry productivity at an individual level ( P <0.001; Spearman's rho = 0.467). This correlation was stronger at the fellowship level ( P <0.001; Spearman's rho = 0.734). There was no significant difference in total lifetime earnings ( P =0.369) or H-index per fellowship ( P =0.232) when stratified by region of the fellowship program in the United States.

Conclusion: Orthopedic spine surgery fellowship programs in the United States exhibit a positive correlation between academic productivity and nonresearch industry lifetime earnings at both individual and program levels. This correlation is stronger at the program level, and regional differences among fellowship programs do not significantly impact academic or industry productivity.

Study design: Retrospective cohort study using prospective database.

Objective: This study aimed to establish a risk-scoring system for predicting severe complications after pyogenic spondylodiscitis surgery.

Summary of background data: Pyogenic spondylodiscitis surgery can cause severe complications.

Methods: Grades III, IV, and V complications in the CD classification were defined as severe complications. A predictive scoring system for severe complications was developed using 7 risk factors identified from a cohort of 143 PS surgery patients from January 2013 to December 2017 described in a previous study. External validation used a separate cohort of 70 patients from 9 institutions identified from January 2018 to December 2021.

Results: This first study proposed a risk predictive scoring system for severe complications [updated Charlson comorbidity index (≥3), 2; chronic pulmonary disease, 3; diabetes, 1; Gram-negative bacteria, 3; pyogenic osteoarthritis, 3; preoperative white blood count (≥1.0×104/μL), 2; preoperative platelet count (≤2.4×105/μL), 2]. The scoring system could well predict severe complications [area under the receiver operating curve (AUROC) value of 0.851]. There was classification into 3 risk groups: low-moderate risk (≤4), high risk (5 or 6), and very high risk (≥7), further simplified by the scoring system. Complication rates were 5.2% (low-moderate), 40.1% (high), and 84.2% (very high). In addition, external validation showed a very good AUROC value of 0.820.

Conclusions: We developed a simple, externally validated scoring system for predicting severe complications after pyogenic spondylodiscitis surgery that will be helpful for clinicians involved in informed consent and intensive care unit management of high-risk patients.

Study design: Retrospective study.

Objective: We aim to determine the influence of preoperative Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF) scores on perioperative and postoperative outcomes, the latter determined through patient-reported outcome measures (PROMs) and the degree of achievement rates of minimum clinically important difference (MCID) following single-level cervical disc replacement (CDR).

Background: Several studies have examined the relationship between preoperative PROMIS-PF as a prognostic factor for postoperative outcomes. Few studies have examined this relationship as it applies to CDR.

Methods: Patients undergoing single-level CDR with preoperative PROMIS-PF scores were identified retrospectively using a single-surgeon database. Patients undergoing surgery for infection/fracture/malignancy were excluded. Patients were divided by mean preoperative PROMIS-PF score: lower-functioning (PROMIS-PF <40) and higher-functioning (PROMIS-PF ≥40). Patient-Reported Outcomes Measurement Information System (PROMIS-PF), 12-item Short Form Physical Component Score (SF-12 PCS), Visual Acuity Scale (VAS) scores for neck and arm, and Neck Disability Index scores, collected at preoperative, 6-week, 12-week, 6-month, and 1-year time points.

Results: Fifty-seven patients were included with 33 considered higher functioning. Operative times were increased in the higher-functioning group (P = 0.003). The lower-functioning cohort saw improvement in all 6-week/12-week/6-month PROMs. The higher-functioning cohort saw improvement in all PROMs except SF-12 PCS. Between groups, the higher-functioning cohort reported greater postoperative PROMIS-PF at multiple time points, preoperative SF-12 PCS, 12-week/preoperative VAS-neck, and preoperative VAS-arm (P ≤ 0.036, all). The lower-functioning group had greater preoperative/6-week Neck Disability Index (P ≤ 0.027, all) and had greater MCID achievement at 6-month SF-12 PCS/12-week VAS arm (P ≤ 0.026, all).

Conclusion: Independent of preoperative function, both groups reported improvement in all outcomes except for SF-12 PCS in the higher-functioning cohort. Between groups, the higher-functioning cohort had significantly better outcomes; however, this significance was not seen past 12 weeks for any PROM. MCID achievement rates were significantly greater in the lower-functioning group in the SF-12 PCS and VAS arm. Patients with lower preoperative PROMIS-PF scores may experience greater rates of clinically noticeable improvements in function/arm pain postoperatively.

Study design: Retrospective cohort study.

Objective: To determine hospital length of stay (LOS) and long-term opioid consumption among patients who received inpatient multimodal analgesia following lumbar spine surgery, as opposed to those who received opioids alone.

Summary of background data: Opioids have long been the historical choice for managing postoperative pain. The use of multimodal analgesia has become more commonplace in recent years as it is thought to achieve similar levels of pain control while simultaneously diminishing opioid consumption and decreasing LOS.

Materials and methods: Patients who underwent 1 or 2-level lumbar fusion from 2018 to 2019 were included. Patients who received opioids on an as-needed basis were propensity-matched to a cohort who received multimodal analgesia based on demographics, surgical approach, and levels fused. LOS was collected for each patient. One year preoperative to 2 postoperative opioid use was obtained from the Pennsylvania Prescription Drug Monitoring Program and included total prescriptions and total morphine milligram equivalents (MMEs). A subanalysis was also performed comparing preoperative, perioperative, and postoperative tramadol consumption during this time frame.

Results: A total of 69 patients received an opioid-only pain regimen, while 207 patients received multimodal analgesia. Patients receiving a multimodal pain regimen consumed a higher daily tramadol MME but a comparable total in-hospital MME to patients in the opioid-only cohort. No statistically significant differences existed between cohorts with regards to LOS, preoperative, perioperative, and postoperative opioid consumption, though multimodal patients consumed more tramadol from 0 to 30 days postoperatively.

Conclusions: Patients who received a multimodal pain regimen consumed comparable quantities of opioids to those who received opioids alone and did not have a longer LOS following 1 and 2-level lumbar fusion.

Study design: Retrospective cohort study.

Objective: To develop parameter thresholds obtainable from cervical radiographs that correlate with concomitant thoracolumbar malalignment.

Summary of background data: T1 slope (T1S) is typically discussed in the context of cervical deformity and correlated with health-related quality of life outcomes. Prior research suggests that T1S is related to global alignment; however, a definition for "high" T1S has not been established. Most patients undergoing cervical surgery do not undergo full-spine imaging; therefore, obtaining a parameter associated with thoracolumbar malalignment from cervical radiographs would be beneficial.

Methods: A database of preoperative adult spinal deformity (ASD) patients was analyzed. Measures obtained from standing lateral radiographs included T1S, thoracic kyphosis (TK), sagittal vertical axis (SVA), T1-pelvic angle (TPA), pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI-LL). Decision tree analysis was then used to determine the T1S corresponding to published thresholds for high TK (40 degrees), SVA (40 mm), TPA (25 degrees), and PT (25 degrees). Alignment between high and normal T1S patients was compared.

Results: Two hundred twenty-six preoperative patients were included (mean: 58±16 y 62%F). Larger T1S was correlated with greater SVA (r=0.365), TPA (r=0.302), TK (r=0.606), and PT (r=0.230) (all P<0.001). Decision tree analysis yielded a threshold of 30 degrees for high T1S, which 50% of patients had. Compared with patients with T1S <30 degrees, those with T1S >30 degrees had higher TK (41.5 vs. 25.8 degrees), SVA (78.7 vs. 33.7 mm), TPA (27.6 vs. 18.3 degrees), and PT (26.3 vs. 20.8 degrees), and PI-LL (18.2 vs. 11.7 degrees) (all P<0.05). Seventy-nine percent of patients with high T1S had high TK (T1S <30=13%), 69% had high SVA (T1S <30=38%), 66% had high TPA (T1S <30=37%), 60% had PT >25 degrees (T1S <30=42%), and 47% had PI-LL >20 degrees (T1S <30=34%) (all P<0.05).

Conclusion: Higher T1S was associated with worse global alignment. T1S was most strongly associated with TK. A T1S=30 degrees corresponded to high TK, SVA, TPA, and PT thresholds. Therefore, surgeons should consider obtaining full-spine radiographs if a T1S >30 degrees is present on cervical imaging.

Background: Early-term complications may not predict long-term success after adult cervical deformity (ACD) correction.

Objective: Evaluate whether optimal realignment results in similar rates of perioperative complications but achieves longer-term cost-utility.

Study design: Retrospective cohort study.

Methods: ACD patients with 2-year data included. Outcomes: distal junctional failure (DJF), good clinical outcome (GCO):[Meeting 2 of 3: (1) NDI>20 or meeting MCID, (2) mJOA≥14, (3)NRS-Neck improved≥2]. Ideal Outcome defined as GCO without DJF or reoperation. Patient groups were stratified by correction to 'Optimal radiographic outcome', defined by cSVA 9 (<40 mm) AND TS-CL (<15 deg) upon correction. Cost calculated by CMS.com definitions, and cost-per-QALY was calculated by converting NDI to SF-6D. Multivariable analysis controlling for age, baseline T1-slope, cSVA, disability, and frailty, was used to assess complication rates, clinical outcomes, and cost-utility based on meeting optimal radiographic outcome.

Results: One hundred forty-six patients included: 52 optimal radiographic realignment (O) and 94 not optimal (NO). NO group presented with higher cSVA and T1-slope. Adjusted analysis showed O group suffered similar 90-day complications (P>0.8), but less DJK, DJF (0% vs. 18%; P<0.001) and reoperations (18% vs. 35%; P=0.02). Patients meeting optimal radiographic criteria more often met Ideal outcome [odds ratio: 2.2, (1.1-4.8); P=0.03]. Despite no differences in overall cost, O group saw greater clinical improvement, translating to a better cost-utility [mean difference: $91,000, ($49,000-$132,000); P<0.001].

Conclusion: Despite similar perioperative courses, patients optimally realigned experienced less junctional failure, leading to better cost-utility compared with those sub-optimally realigned. Perioperative complication risk should not necessarily preclude optimal surgical intervention, and policy efforts might better focus on long-term outcome measures in adult cervical deformity surgery.

Level of evidence: Level III.

Study design: Cohort retrospective study.

Objective: We evaluated and compared the outcomes of anterior cervical discectomy with fusion (CDF) and anterior cervical corpectomy with iliac crest graft and fusion (CCF) in patients with ≥3 level degenerative cervical myelopathy (DCM).

Background: Anterior and posterior approaches are widely employed in DCM when compressive elements predominate in the anterior or posterior spinal cord, respectively. Indications for each approach remain controversial in some contexts.

Methods: Following the STROBE statement, a retrospective enrollment from records of patients who underwent anterior CDF and/or CCF between June 2015 and June 2022. Linear mixed models were applied to establish the effects of the type of surgery according to the follow-up time (mo).

Results: In this study, 73 patients met the inclusion criteria, of which 21 (28.8%) were included in the CDF group and 52 (71.2%) in the CCF group. Twenty surgeries were performed at 3 cervical levels and 53 at 4 levels. There was an improvement in the NDI and VAS score, with an Odom mean of 1.63±0.67 at 12 months of follow-up, with no differences between CDF and CCF. In the CDF group, it was reported a greater C2-7 Cobb angle at the third month of follow-up. In the CCF group, the C2-7 Cobb angle had a negative correlation with the NDI and VAS scales, and a positive correlation with the mJOA scale. Intraoperative estimated blood loss (EBL), surgical time, and postoperative hospital stay were shorter in CDF. There were no differences between the 2 groups in medical complications and other radiologic findings.

Conclusion: Surgery for multilevel DCM using an anterior approach with CDF or CCF showed good clinical outcomes without significant differences between the 2 groups, and equivalent results in medical complications and radiologic parameters. The CDF group had better perioperative results and shorter postoperative hospitalization time.

Study design: This was a narrative review.

Objective: The objective of this review was to summarize the current evidence and knowledge gaps regarding anesthesia and pain management for scoliosis surgery, including multimodal analgesia, and identify the best anesthetic approach to scoliosis surgery that ensures patient safety and pain relief even in the postoperative period, with minimal influence on SSEP monitoring.

Summary of background data: Spinal surgeries and fusions for scoliosis are associated with high pain levels. Inadequate analgesia can cause patient dissatisfaction, delay recovery, and increase the risk of chronic pain. Despite serious side effects, opioids are the mainstay of pain medication after scoliosis surgery. However, increasing emphasis on minimizing opioids and accelerating recovery has increased the adoption of multimodal analgesic therapy.

Materials and methods: The literature review was performed on standards of care, a pain management protocol, current therapeutic options, and innovative treatment options for patients undergoing scoliosis surgery. The literature was reviewed through 4 electronic databases: PubMed, Cochrane Library, Google Scholar, and Embase.

Results: The initial search yielded 994 articles. Forty-seven relevant articles were selected based on relevance, recentness, search quality, and citations. Ten studies described the influence of different methods of anesthesia on neuromonitoring. Twenty-one researchers studied the effect of analgesics and coanalgesics on pain relief protocol. Nine studies treated regional anesthesia and its influence on pain management.

Conclusions: The most suitable anesthetic approach that does not disturb the neuromonitoring is obtained by combining total intravenous anesthesia (TIVA) with remifentanil and propofol with regional anesthesia, particularly erector spinae plane block (ESPB), as a part of a multimodal analgesia protocol.

Level of evidence: Level II.