Clinical Spine Surgery最新文献

Study design: This study was a case-control study examining the relationship between changes in Facet Joint Orientation and degenerative lumbar spondylolisthesis.

Objective: The causal relationship between sagittal changes in the direction of the head-caudal facet joint and degenerative lumbar spondylolisthesis (DS) was investigated in this study.

Summary of background info: Several radiologic studies have indicated a correlation between DS and an increased sagittal orientation of the facet joints. However, the orientation of the facet joints has only been measured on 1 axial cut of computed tomography scans and magnetic resonance imaging.

Patients and methods: Fifty-six patients with DS only at the L4/L5 level were assigned to the DS group, and 58 patients without DS were assigned to the control group. Two computed tomography scans were performed for the cephalad and caudad portions of the facet joint at L3/L4, L4/L5, and L5/S1 levels, respectively. Delta facet angle was defined as facet angle (cephalad)-facet angle (caudad).

Results: Significant differences were observed in the joint angle of the L4/L5 head and tail processes between the DS group and the control group (P<0.05). The direction of the L4/L5 slipped segment in the DS group was significantly inclined toward the sagittal position. Moreover, significant differences (P<0.05) in the degree of joint degeneration in the L4/L5 head and tail processes were observed between the DS group and the control group, indicating more severe degeneration in the L4/L5 slip segment processes of the DS group.

Conclusions: In the present study, we found that the changes in the sagittal direction of facet joints occur most probably due to lumbar degeneration remodeling rather than their underlying cause.

Study design: Systematic review conducted under PRISMA guidelines.

Objective: To evaluate the impact of preoperative psychological interventions on spine surgery postoperative outcomes.

Summary of background data: Approximately one-third of individuals with chronic back pain report symptoms of preoperative anxiety and depression, which may worsen with surgery. Despite the increased risk for mental health comorbidity, preoperative psychological interventions are not well utilized in spine surgery preoperative care.

Methods: Literature search was conducted using the PubMed, EMBASE, Web of Science, and APA PsycINFO databases until August 22, 2025. The inclusion criteria consisted of adult spine surgery patients, preoperative psychological interventions, and the presence of postoperative outcomes. Primary data extraction factors included study type, patient population and demographics, diagnosis, and the specific psychological intervention used.

Results: Thirteen studies representing 9316 patients were included. Pharmacotherapy showed a significant positive association with pain reduction in 4/6 analyses. No analyses studying pharmacotherapy and disability or mental well-being showed a significant positive association with disability reduction or with mental well-being improvement. All studies of cognitive behavioral therapy (CBT) measuring disability (2/2) showed a positive significant association with disability reduction. The study of CBT measuring mental well-being (1/1) showed a positive significant association with mental well-being improvement. CBT did not have a positively significant association in studies measuring reduction in pain. Stress-relief methods had positive significant associations with better mental well-being in half of studies, and pain reduction in 3 out of 4 studies. No studies measured stress-relief methods' effect on disability.

Conclusions: This systematic review highlights that a range of preoperative psychological interventions have a significant positive association with improved postoperative outcomes. It also describes the current state of literature in an understudied field. Further research is needed to identify optimal timing of interventions and prospective studies are needed to evaluate clinical applicability for implementation.

Level of evidence: Level I.

The applications of new and emerging technologies in spine surgery are constantly expanding. Specifically, machine learning algorithms have seen a rise in utilization in clinical research, allowing for interpretation of large datasets that have the capability of experiential learning. The goal of this work is to present a guide for surgeons to better understand model design, key takeaways, and common pitfalls related to machine learning to ensure accurate and appropriate interpretation of analytical findings in their practice.

Study design: Retrospective case-control study.

Objective: To evaluate whether patients from highly deprived neighborhoods, as defined by the Area Deprivation Index (ADI), undergoing one-level cervical disc arthroplasty (CDA) experience differences in (1) postoperative medical complications, (2) lengths of stay (LOS), emergency department (ED) visits, and readmissions compared with less disadvantaged patients.

Summary of background data: The ADI measures neighborhood-level deprivation at the national level. Little is known about the role of neighborhood deprivation on outcomes after CDA.

Methods: A national insurance claims database was used to identify patients who underwent single-level CDA between 2010 and 2022. Patients from less disadvantaged neighborhoods (ADI <90th percentile) were matched in a 1:5 ratio with patients from more deprived areas (ADI >90th percentile) using propensity score matching on age, sex, and Elixhauser Comorbidity Index (ECI), yielding a final cohort of 25,975 patients: 4331 in the low ADI group and 21,644 in the high ADI group. Multivariable logistic regression models were used to assess odds of 90-day complications, readmissions, and ED visits. t tests compared LOS. P-values<0.05 were significant.

Results: High ADI patients experienced significantly higher odds of total 90-day medical complications compared with less disadvantaged patients (3.54% vs. 2.67%; OR: 1.37; 95% CI: 1.12-1.70; P=0.003). High ADI patients had longer mean hospital stays (1.75 vs. 1.66 d; P<0.01). Ninety-day readmission (1.54% vs. 1.36%; OR: 1.13; P=0.379) and ED visits (1.64% vs. 1.43%; OR: 1.14; P=0.330) were similar between groups.

Conclusions: Neighborhood deprivation is associated with increased lengths of stay and a higher overall rate of medical complications after CDA, despite similar readmission and ED visit rates. These findings emphasize the importance of incorporating socioeconomic context into perioperative care and resource planning.

Level of evidence: Level III.

Study design: A retrospective cohort study.

Objective: To describe the incidence, timing, and reason for ED visits following primary versus revision lumbar fusion.

Summary of background data: Emergency department (ED) presentation and misutilization place a substantial financial strain on patients and the health care system. ED visits following lumbar fusion are common and may be an overlooked target for reducing cost.

Methods: A retrospective cohort study of patients undergoing 1-3 level primary versus revision lumbar fusion was performed. Outcomes included the incidence and characteristics (inpatient admission, discharge home, or reoperation) of ED visits at 2 weeks, 30 days, and 90 days postoperatively. Logistic regression analysis was performed to identify independent predictors of postoperative ED visits.

Results: A total of 2360 patients were included (1852 primary and 508 revision). Rate of 90-day ED visits was higher in the revision group (10.2%) compared with the primary group (6.86%, P=0.014). However, breakdown by 15-day intervals revealed this was only significant between 14 and 30 days postoperatively (1.30% vs. 3.35% for revisions, P=0.004). Reasons for ED visits were similar, with both groups presenting most commonly for pain complaints. Primary patients presenting to the ED were more likely to require admission (48.0% vs. 26.9%; P=0.015). Logistic regression demonstrated that revision surgery (OR: 2.67, P<0.001), Cut-to-close time (OR: 1.003, P=0.028) and LOS (OR: 1.11, P=0.023) independently predicted postoperative ED visits.

Conclusion: Revision lumbar fusion was an independent predictor of visiting the ED, especially from 14 to 30 days postoperatively, but the absolute increase in risk was mild at 3.4%. Cut-to-close time was also statistically predictive, although with an effect size that is not clinically significant. However, visits to the ED after revision surgery were less likely to require readmission compared with visits after primary lumbar surgery. These findings may suggest that patients undergoing lumbar fusion should be appropriately counseled regarding postoperative pain expectations and appropriate acute care utilization, especially in the revision setting.

Malpractice litigation is a persistent challenge in spinal surgery, with a significant number of claims involving procedural errors, inadequate informed consent, and wrong-level surgeries. These cases often have serious implications for both patient care and the careers of surgeons. This study combines a review of the literature with the analysis of 4 real-world cases to identify patterns and offer practical recommendations to reduce legal risks. The author (S.R.) served as an expert witness in all 4 cases, providing a unique perspective on the legal, clinical, and professional elements involved in each situation. The key findings highlight the importance of thorough preoperative planning, the use of advanced imaging techniques during surgery, and consistent postoperative follow-up to detect and address complications early. Transparent communication with patients, especially when complications occur, is critical for maintaining trust and avoiding legal disputes. In addition, avoiding blame-shifting among surgeons is essential to uphold professional integrity and patient safety. By addressing these factors and fostering a culture of transparency and accountability, surgeons can improve patient outcomes and minimize exposure to litigation. This study provides practical strategies to help spinal surgeons navigate legal challenges effectively and maintain a focus on high-quality patient care.

Study design: A case-series study.

Objectives: To acquire diagnostic insights to distinguish between intradural extramedullary spinal metastases (IESM) and benign spinal tumors by comparing patients with IESM and those with schwannoma or spinal meningioma.

Summary of background data: IESM constitute a rare category of spinal metastases. As the outcome of IESM is usually poor without intervention, early diagnosis and treatment are particularly important for better prognosis. As few studies have clearly addressed the features of IESM, it is necessary to gain comprehensive diagnostic insights into the characteristics of the disease.

Methods: Included in this study were 14 IESM patients who underwent gross total tumor resection. IESM and schwannoma or meningioma were compared in a ratio of 1:2. Differences in clinical and imaging presentations between them were analyzed statistically, and survival curves were plotted using the Kaplan-Meier method.

Results: IESM presented an unclear boundary (P=0.005), an irregular shape (P=0.035), and A low probability of cystic degeneration (P=0.028) as compared with schwannoma. Compared with IESM, meningioma tended to have a clear boundary (P=0.001), a wide base (P=0.047), high calcification possibility (P=0.040), and homogeneous enhancement on MRI (P=0.016). The estimated mean overall survival of IESM patients was 16.80±3.94 months.

Conclusion: This study demonstrated the characteristics of IESM and clarified the distinguishing points between IESM and intradural extramedullary benign tumors. Early warning features drawn from this study may be able to help clinicians to identify patients with IESM.

Summary of background data: Previous studies comparing the anterior versus posterior approach for the treatment of degenerative cervical myelopathy (DCM) report similar neurological outcomes. Although multilevel DCM is frequently combined with foraminal stenosis, previous studies have analyzed the outcomes of myelopathy without specifically addressing the outcomes of combined radicular symptoms.

Objective: To compare the outcomes following anterior and posterior decompressive procedures for DCM combined with multilevel foraminal stenosis.

Study design: A retrospective study.

Methods: A cohort of patients with DCM with multilevel foraminal stenosis (>3 levels) who underwent decompression was analyzed. In the anterior group (group A), multilevel anterior cervical decompression and fusion were performed, and the posterior group (group P) consisted of laminoplasty with foraminotomies. Nurick grade, visual analogue scale (VAS) of neck and arm pain, neck disability index (NDI), short-form 36 (SF-36), complications, clinical adjacent segment pathologies (CASP), and additional operations performed were analyzed. C2-7 angle and range of motion, and Kellgren grade of radiographic adjacent segment pathology (RASP) were evaluated.

Results: A total of 96 patients were enrolled (M:F=53:43, mean age 60.8 y, A: P=54:42, mean 36.6 mo follow-up). All clinical parameters showed significant improvement from preoperative neurological status without significant difference between the 2 groups at the final follow-up. Both RASP grade and incidence of CASP were higher in the anterior group (A: 42.6% vs. P: 19.2%, P=0.014). The incidence of additional procedures was similar (A: 9.3% vs. P: 16.7%, P=0.276); however, the etiology was mainly CASP in the anterior group (4-5 cases) and persistent radicular symptoms in the posterior group (6-7 cases).

Conclusions: Anterior and posterior decompressive surgeries are reliable for the surgical treatment of DCM with multilevel foraminal stenosis and showed similar outcomes for both myelopathy and upper extremity radicular symptoms. The major etiology compromising the clinical outcome was a higher incidence of CASP in the anterior group and persistent or recurrent upper extremity radicular symptoms in the posterior group.

Study design: Single-institution, retrospective cohort study.

Objective: Determine whether preoperative and intraoperative computed tomography (CT) Hounsfield units (HU) were reliable, consistent, and had similar diagnostic ability for detecting osteoporosis.

Summary of background data: Osteoporosis is common in spine surgical patients and associated with adverse outcomes. Opportunistic use of preoperative CT HU has been shown to estimate bone quality and fracture risk. Spinal navigation systems utilize intraoperative CT, which may offer an opportunity for osteoporosis assessment.

Methods: From January 2021 to December 2022, 166 patients who underwent thoracolumbar surgery using spinal navigation and had both preoperative and intraoperative CT scans were included. Regions of interest (ROI) measuring 200 mm2 were placed in the centroid of the L1 vertebral body to measure HU, with HU values >150 indicating normal bone, 110-150 osteopenia, and <110 osteoporosis. Preoperative and intraoperative CT HU were compared using the Pearson correlation. Bland-Altman and Cohen kappa analysis were used to determine agreement.

Results: Mean (SD) age was 61.11 (8.79), BMI was 30.26 (6.09), and 54% were female. Mean preoperative and intraoperative L1 HU were 150.66 (58.33) and 148.41 (57.59), respectively, which were not significantly different (P=0.339). On the basis of HU, normal bone, osteopenia, and osteoporosis were present in 41%, 39%, and 20% of patients based on preoperative CT compared with 37%, 38%, and 25% on intraoperative CT, k=0.91 [95% CI: 0.87-0.95]. Preoperative and intraoperative CT HU had a strong, positive correlation (r=0.982, P<0.001). Bland-Altman demonstrated agreement between preoperative and intraoperative CT HU, with a mean difference of 2.23 [95% CI: -19.70 to 24.16], P=0.427.

Conclusions: Preoperative and intraoperative CT HU values were reliable, consistent, and demonstrated similar diagnostic ability for osteoporosis. Intraoperative HU may be useful for identifying patients at high risk for fracture or adverse surgical outcomes with probable osteoporosis who may require further postoperative bone health evaluation.

Mendelian randomization (MR) is a statistical method that is rising in popularity. Although randomized controlled trials (RCTs) remain the gold standard in terms of inferring causality, they are not always feasible due to time, ethical, and resource constraints. Therefore, MR can be used to establish causality through observational and noninterventional data coupled with large and quickly growing genome-wide association studies (GWAS), thereby overcoming the confounding limitations of observational studies. This article aims to provide the reader with a better understanding of Mendelian randomization and expand on how this method investigates causal relationships and provides examples relevant to orthopedic surgery.