Clinical Spine Surgery最新文献

Study design: Technical note and case series.

Objectives: We describe an indirect posterior decompression technique using plate gliding during anterior cervical discectomy and fusion (ACDF) in cervical myelopathy patients with an accompanying posterior pathology.

Summary of background data: ACDF can effectively address an anterior pathology, that is, directly causing cord compression. However, a concurrent posterior pathology, such as hypertrophy or buckling of the ligamentum flavum, is challenging to resolve. Furthermore, occasional worsening of cord compression after ACDF due to aggravation via a posterior pathology may occur.

Materials and methods: We reviewed 6 patients with cervical myelopathy who underwent the plate gliding technique during ACDF in 2023. We assessed radiologic factors, including cord compression from the ligamentum flavum (CCLF) grade and segmental lordosis, before and after surgery. In addition, we evaluated the Japanese Orthopedic Association (JOA) scores preoperatively and 3 months postoperatively.

Results: A postoperative improvement in CCLF grade was observed in all patients alongside a decrease in segmental lordosis. The average recovery rate indicated by the JOA scores at 3 months postoperatively was 65.3%.

Conclusions: An indirect decompression technique using plate gliding during ACDF is beneficial for cervical myelopathy patients accompanied by posterior pathologies such as ligamentum flavum hypertrophy or buckling.

Study design: This was a retrospective study.

Objective: The purposes of this study were to compare the characteristics of odontoid parameters between subjects with and without adolescent idiopathic scoliosis (AIS) and to investigate the correlation between odontoid parameters and other cervical sagittal parameters.

Summary of background data: Previous studies have shown that odontoid parameters are important parameters related to cervical sagittal alignment. However, there are few reports on odontoid parameters in patients with AIS.

Materials and methods: Between November 2022 and November 2023, 42 AIS patients (AIS group) underwent standing erect whole-spine posteroanterior and lateral full-spine digital radiography. Correspondingly, 28 sex- and age-matched normal adolescents (control group) were enrolled. Odontoid parameters and other cervical sagittal parameters, including odontoid incidence (OI), odontoid tilt (OT), C2 slope (C2S), T1 slope (T1S), C0-2 angle, C2-7 angle (CL), and T1S-CL, were measured via standing plain radiographs. Pearson correlation and linear regression were used to compare the sagittal parameters between the 2 groups.

Results: There were no significant differences between the 2 groups in terms of cervical sagittal parameters, including OI, OT, C2S, C0-2 angle, or T1S-CL. After Bonferroni correction, in the AIS group, OI was significantly correlated with C2S ( r =0.37, P <0.05) and T1S-CL ( r =0.34, P <0.05). OI matched with the C0-2 angle ( r2 =0.081), and T1S-CL ( r2 =0.093). In the control group, after Bonferroni correction, OI was significantly correlated with C2S ( r =0.49, P <0.01) and T1S-CL ( r =0.40, P <0.05). OI matched with T1S-CL ( r2 =0.130).

Conclusions: OI is a constant cervical anatomic parameter closely related to other cervical sagittal parameters and was not affected by adolescent idiopathic scoliosis.

Study design: Retrospective case-control study.

Objective: The purpose of this study is to assess how the presence and grade of atlantodental arthrosis impact outcomes of nonoperatively managed type 2 odontoid fractures.

Summary of background data: The nonoperative management of geriatric type 2 odontoid fractures requires consideration of all potential variables that may influence outcomes. The presence of underlying atlantodental arthrosis can create a more rigid lever arm adjacent to the fracture site inducing greater biomechanical strain on an already tenuous healing environment.

Methods: Eighty-one patients with traumatic type 2 odontoid fractures managed nonoperatively were included, with an average follow-up of 180 days after injury. Radiographic evaluation was performed to identify the presence and severity of atlantodental arthrosis on computed tomography (CT) imaging at the time of injury. Electronic medical records were reviewed to report patient demographics, fracture characteristics, and treatment outcomes. The relationship between atlantodental arthrosis and failure of conservative management was primarily assessed.

Results: Patients who failed conservative treatment were more likely to have an atlantodental arthrosis grade >2 ( P <0.001) and increased posterior displacement on index imaging ( P =0.008). Following multivariable regression, grade 3 (OR: 4.4, 95% CI: 1.6-11.9, P =0.004) and grade 4 arthrosis (OR: 13.9, 95% CI: 1.5-127.9, P =0.02) were independently associated with an increased risk for failing conservative management.

Conclusions: The present findings identify the presence of atlantodental arthrosis as a risk factor for treatment failure in conservatively managed geriatric type 2 odontoid fractures. Future prospective studies are necessary to further elucidate the prognostic value of arthrosis severity in determining optimal treatment strategies.

Study design: Radiologic cross-sectional study based on a prospective cohort study (level III).

Objective: Investigate whether lumbar lordosis (LL) and sacral slope (SS) differ significantly on supine magnetic resonance imaging (MRI) versus standing radiographs in nondeformity lumbar spinal stenosis (LSS). Secondly, to quantify the amount of magnification on standing lumbar radiographs.

Summary of background data: Supine MRI is routinely performed when diagnosing LSS. Standing radiographs are often supplemented to measure spinopelvic angles. Little research has been done on whether LL and SS translate from standing radiographs to supine MRI. Previous studies have trended to significant changes in LL and SS; however, none have been performed exclusively in nondeformity LSS.

Materials and methods: Review of preoperative standing lateral lumbar radiographs and midsagittal T2-weighted supine lumbar MRI in 211 patients with LSS without concomitant degenerative spondylolisthesis, measuring LL (L1-S1), segmental lumbar lordosis (sLL) (L4-S1) and SS, in addition to the anteroposterior diameter and height of the L3 vertebral body. We conducted a reliability study and performed a Pearson's correlation analysis. Data was presented in Bland-Altman plots.

Results: Interobserver reliability was good to excellent, with ICC ranging from 0.77 to 0.94 for all parameters. Statistically significant differences were observed in LL and SS between image modalities. The mean radiographic measurements were as follows: LL 48.9 (SD: 12.8), sLL 32.3 (SD: 8.1), and SS 37.3 (SD: 8.7) degrees. The mean MRI measurements were as follows: LL 46.0 (SD: 10.5), sLL 32.3 (SD: 7.1), and SS 38.1 (SD: 7.1) degrees. Mean vertebral body magnification was between 21% and 23% for L3 anteroposterior diameter and height.

Conclusions: Our results suggest that supine lumbar MRI might be a viable alternative to standing lateral lumbar radiographs for measuring LL and SS in routine follow-up for patients with LSS without concomitant spinal deformity. Standing radiographs are recommended as part of the initial investigation for LSS. Standing lumbar radiographs may yield high grades of magnification.

Study design: A systematic review and meta-analysis.

Background summary: Cage subsidence (CS) is a common complication following transforaminal lumbar interbody fusion (TLIF) surgery.

Objective: This study aimed to identify and analyze risk factors associated with CS following TLIF.

Methods: A comprehensive search was conducted across PubMed, Scopus, Embase, and Google Scholar for studies published up to March 31, 2024. Pooled odds ratios (OR), standardized mean differences (SMD), and 95% CI were calculated for each identified risk factor. Interstudy heterogeneity was evaluated using the I ² statistic, and either a random-effects or fixed-effects model was applied as appropriate. Publication bias was assessed through funnel plots.

Results: Nine studies, comprising data on 1403 patients who had undergone TLIF, were included in the final analysis. Significant risk factors for CS included age (SMD=0.27; 95% CI: 0.12-0.41) and bony endplate injury (OR=7.52; 95% CI: 2.08-27.17). However, no significant associations were found with other potential risk factors, such as cage height, body mass index (BMI), bone mineral density, smoking status, diabetes, sex, center point ratio (CPR), disc height (preprocedure and postprocedure), or surgery location.

Conclusion: This meta-analysis identified older age and injury to the bony endplate as significant risk factors for CS after TLIF. These findings may help inform clinical decision-making and guide risk stratification in patients considering TLIF.

Traumatic cervical spinal cord injury (cSCI) is a devastating condition associated with significant morbidity and long-term disability. Surgical decompression remains the cornerstone of management; however, the potential role of duraplasty as an adjunctive procedure remains controversial. Proponents argue that duraplasty alleviates intraspinal pressure, enhances spinal cord perfusion, and reduces secondary ischemic injury by expanding the dural space and mitigating post-traumatic edema. Emerging clinical and preclinical data suggest that duraplasty may improve neurological outcomes by optimizing cerebrospinal fluid dynamics and reducing ischemia-induced neuronal apoptosis. However, critics highlight significant risks, including cerebrospinal fluid leakage, pseudomeningocele formation, infection, and intracranial hypotension, which may outweigh its theoretical benefits. This comparative article critically examines the pathophysiological rationale, existing evidence, and ongoing controversies in favour or against widespread adoption of duroplasty in cervical spinal cord trauma.

Study design: Retrospective cohort study.

Objective: The present study aims to compare outcomes for patients undergoing spinal fusion through PLDF and TLIF and determine whether specific radiographic characteristics, based upon both the CARDS and Meyerding classifications, might influence optimal fusion technique.

Summary of background data: Despite the significant prevalence and high disease burden of degenerative spondylolisthesis (DS), consensus regarding surgical management is still lacking.

Methods: Adult patients (≥18 years old) who underwent primary single-level lumbar fusion for degenerative spondylolisthesis were retrospectively identified. Preoperative flexion-and-extension lateral radiographs were reviewed to classify DS using the Meyerding grading system, as well as the validated Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system. PROM scores were collected preoperatively and 1 year postoperatively and included the Oswestry Disability Index (ODI), Visual Analog Scale back and leg (VAS back and VAS leg, respectively), and the mental and physical component of the short-form 12 survey (MCS and PCS).

Results: A total of 594 patients were identified. Patients with CARDS type A spondylolisthesis experienced greater improvement in ODI (-11.02 vs. -3.06, P =0.005) when they underwent TLIF; however, patients with CARDS class B experienced greater ODI improvement after a PLDF (-14.33 vs. -5.45, P <0.001). Patients with Meyerding grade 1 spondylolisthesis experienced greater improvement in ODI (-10.15 vs. -6.27, P =0.006) and MCS (5.68 vs. 2.87, P =0.011) when they underwent PLDF compared with TLIF. There were no other differences in PROM improvement between approaches for other grades and classes. After controlling for patient characteristics, these differences persisted on linear regression analysis.

Conclusion: Although there are several factors to consider, these results show that PLDF may be the optimal approach for degenerative spondylolisthesis patients with milder degrees of vertebral slippage. Patients with advanced disc collapse, endplate apposition, and kyphosis may benefit more from TLIF.

Study design: This systematic review evaluated prospective studies assessing nonpharmacologic interventions for preoperative anxiety in spine surgery patients.

Objective: To evaluate the effectiveness of nonpharmacologic interventions compared with standard care to reduce preoperative anxiety among spine surgery patients.

Summary of background data: Unaddressed preoperative anxiety negatively impacts recovery following orthopedic spine surgery. Beyond reducing anxiety, nonpharmacologic interventions can minimize pain, decrease reliance on opioids or anxiolytics, improve postoperative outcomes, and enhance patient satisfaction.

Methods: PubMed, Embase, and Scopus databases were searched from database inception to December 2024. We included prospective studies examining the effectiveness of nonpharmacologic interventions delivered the day before or on the day of surgery versus standard care in reducing preoperative anxiety in spinal surgery patients. Data were independently extracted from full-text articles.

Results: The review included 7 studies encompassing 548 patients. Four studies assessed educational techniques: 1 used traditional approaches such as booklets and tours, 3 used technology-based methods, 2 focused on music therapy, and 1 investigated relaxing guided imagery. Of the included studies, all 7 demonstrated statistically significant reductions in preoperative anxiety among patients receiving nonpharmacologic interventions compared with standard care. Most studies noted improvements in other outcomes of patient satisfaction, pain management, length of hospital stays, and sleep quality.

Conclusions: Nonpharmacologic interventions such as educational techniques, music therapy, and guided imagery reduce preoperative anxiety in spine surgery patients. These cost-effective, minimally invasive approaches may offer a low-risk alternative or complement to medication. Continued research and interdisciplinary collaboration are essential to expand the evidence base and further validate these strategies.

Level of evidence: Level I.

Study design: Systematic Review.

Objective: To systematically review cases of pneumocephalus following spinal procedures and evaluate prognosis and effective treatment options for this pathology.

Summary of background data: Pneumocephalus is a rare complication of spinal procedures requiring unique strategies for symptom management and treatment. Intracranial air may cause acute decompensation when intracranial pressure rises rapidly, and therefore, early identification of pneumocephalus is crucial for recovery.

Methods: A systematic review was performed to interrogate PubMed/MEDLINE for clinical and radiologic presentation of cases of pneumocephalus following spinal procedures.

Results: A total of 105 articles were included, with 133 cases of pneumocephalus presenting as a complication of spinal procedures. The most common procedures investigated were epidural injections (38.7%) and decompression surgeries (17.0%). Tension pneumocephalus was reported in 17 cases and conveyed no increased risk of mortality (P=0.59), ICU admission (P=0.76), or persistent symptoms (P=0.71). Patients receiving surgical treatment were significantly more likely to have an ICU stay during their hospital course (P=0.005) but had no difference in symptom improvement (P=0.35), radiologic resolution (P=0.34), or mortality (P=0.62) compared with medically managed patients. Patients with additional neurological sequelae were also more likely to receive surgery (P<0.001). Patients with headache were significantly less likely to experience persistent symptoms (P=0.008), persistent imaging findings (P=0.01), ICU care (P<0.001), and mortality (P=0.04), while altered mental status was associated with significantly greater risk of symptom persistence (P=0.04), ICU stay (P<0.001), and mortality (P=0.049). The overall symptom improvement rate was 86%, and the mortality rate was 5%.

Conclusions: Overall prognosis for pneumocephalus as a complication of spinal procedures is favorable. Insights concerning symptom presentation can help spine surgeons improve communication regarding expected outcomes.

Level of evidence: Level IV.

Study design: Single-center, retrospective cohort study (level III).

Objective: This study evaluates alignment changes and outcomes after C5-C7 ACDF and examines whether the degree of segmental correction is associated with reoperation.

Background: The C5-6 and C6-7 segments are frequently affected in cervical degenerative disc disease due to their mobility and transitional anatomy. Two-level anterior cervical discectomy and fusion (ACDF) is commonly performed at these levels. Although global cervical alignment restoration has been associated with improved functional outcomes and reduced adjacent-segment disease, the specific impact of postoperative lordotic correction at C5-C7 on clinical measures and revision risk remains poorly defined.

Methods: A retrospective cohort study was conducted at a single institution. Patients undergoing 2-level C5-C7 ACDF were evaluated for demographics, sagittal alignment parameters, and complications through 1 year postoperatively. Multivariate logistic regression, controlling for age, sex, Charlson comorbidity index (CCI), and baseline cervical deformity, was used to assess the association between segmental correction and reoperation.

Results: A total of 92 patients underwent C5-C7 ACDF. Mean age was 51.7 years, 57% were female, and mean CCI was 0.5. Significant improvements were observed in C2-C7 lordosis (2.4-7.3 deg.), fused segment alignment (-4.3 to 2.1 deg.), and T1-CL (23.8-20.9 deg.) (all P<0.01). Average correction at fused levels was 6.5 degrees (SD 7.4 deg.). Overall, 12% (11/92) underwent reoperation. Inadequate correction increased reoperation odds 7.2-fold (P=0.028).

Conclusions: C5-C7 ACDF yields significant sagittal correction. However, limited segmental improvement may increase reoperation risk. Achieving sufficient correction is important to optimize outcomes and reduce complications.