Clinical Spine Surgery最新文献

Study design: Bibliometric analysis.

Objective: This study explored the current research status, hotspots, and trends in the application of endoscopic techniques for treating lumbar disc herniation (LDH).

Background: Endoscopic techniques are widely used to treat LDH, but there are no bibliometric studies on endoscopic technology and LDH.

Methods: The Web of Science Core Collection database was used as the data source. Based on the principles of bibliometrics, we apply VOSviewer and CiteSpace software to conduct the data statistics and visual analysis.

Results: A total of 965 studies were included, with 11893 citations (12.32 per study). The top 3 countries with the largest number of papers published are China (529), South Korea (164), and the United States (108). Yong Ahn and Jin-Sung Kim are prolific authors in this field. Representative academic journals are World Neuroscience, Pain Physician, and BioMed Research International. The results of keyword cooccurrence analysis indicate that the research topics in this field in the past decade have mainly focused on microdiscectomy, complications, percutaneous endoscopic lumbar discectomy, decompression, and the learning curve. Keyword burst analysis suggested that endoscopic drug injection and the identification of risk factors for LDH are the frontiers and trends for future research.

Conclusion: The application of endoscopic techniques for LDH has received widespread attention from researchers, and research in this field has focused on percutaneous endoscopic lumbar discectomy, endoscopic decompression, complications, and the learning curve of endoscopic techniques. Future research trends will focus on the efficacy of endoscopic drug injection therapy for LDH and the identification of risk factors for LDH treatment failure.

Study design: Intraoperative neurophysiological monitoring (IONM) as a guide to bone layer estimation was examined during posterior cervical spine lamina grinding.

Objective: To explore the feasibility of IONM to estimate bone layer thickness.

Summary of background data: Cervical laminoplasty is a classic operation for cervical spondylosis. To increase safety and accuracy, surgery-assistant robots are currently being studied. It combines the advantages of various program awareness methods to form a feasible security strategy. In the field of spinal surgery, robots have been successfully used to help place pedicle screws. IONM is used to monitor intraoperative nerve conditions in spinal surgery. This study was designed to explore the feasibility of adding IONM to robot safety strategies.

Methods: Chinese miniature pig model was used. Electrodes were placed on the lamina, and the minimum stimulation threshold of DNEP for each lamina was measured (Intact lamina, IL). The laminae were ground to measure the DNEP threshold after incomplete grinding (Inner cortical bone preserved, ICP) and complete grinding (Inner cortical bone grinded, ICG). Subsequently, the lateral cervical mass screw canal drilling was performed, and the t-EMG threshold of the intact and perforated screw canals was measured and compared.

Result: The threshold was significantly lower than that of the recommended threshold of DENP via percutaneous cervical laminae measurement. The DNEP threshold decreases with the process of laminae grinding. The DNEP threshold of the IL group was significantly higher than ICP and ICG group, while there was no significant difference between the ICP group and the ICG group. There was no significant relationship between the integrity of the cervical spine lateral mass screw path and t-EMG threshold.

Conclusions: It is feasible to use DENP threshold to estimate lamina thickness. Cervical lateral mass screw canals by t-EMG showed no help to evaluate the integrity.

Study design: Retrospective cohort.

Objective: The purpose of this study was to evaluate the effect of overdistraction on interbody cage subsidence.

Background: Vertebral overdistraction due to the use of large intervertebral cage sizes may increase the risk of postoperative subsidence.

Methods: Patients who underwent anterior cervical discectomy and fusion between 2016 and 2021 were included. All measurements were performed using lateral cervical radiographs at 3 time points - preoperative, immediate postoperative, and final follow-up >6 months postoperatively. Anterior and posterior distraction were calculated by subtracting the preoperative disc height from the immediate postoperative disc height. Cage subsidence was calculated by subtracting the final follow-up postoperative disc height from the immediate postoperative disc height. Associations between anterior and posterior subsidence and distraction were determined using multivariable linear regression models. The analyses controlled for cage type, cervical level, sex, age, smoking status, and osteopenia.

Results: Sixty-eight patients and 125 fused levels were included in the study. Of the 68 fusions, 22 were single-level fusions, 35 were 2-level, and 11 were 3-level. The median final follow-up interval was 368 days (range: 181-1257 d). Anterior disc space subsidence was positively associated with anterior distraction (beta = 0.23; 95% CI: 0.08, 0.38; P = 0.004), and posterior disc space subsidence was positively associated with posterior distraction (beta = 0.29; 95% CI: 0.13, 0.45; P < 0.001). No significant associations between anterior distraction and posterior subsidence (beta = 0.07; 95% CI: -0.06, 0.20; P = 0.270) or posterior distraction and anterior subsidence (beta = 0.06; 95% CI: -0.14, 0.27; P = 0.541) were observed.

Conclusions: We found that overdistraction of the disc space was associated with increased postoperative subsidence after anterior cervical discectomy and fusion. Surgeons should consider choosing a smaller cage size to avoid overdistraction and minimize postoperative subsidence.

Study design: Prospective observational cohort study.

Objective: To analyze the effect of decompression surgery on gait characteristics in patients with stenosis. Also, to test the hypothesis that patient-reported functional outcomes and gait parameters (spatiotemporal, kinetic, and kinematic measures) will improve postoperatively and achieve normal values when compared with matched healthy controls.

Summary of background data: Lumbar spinal stenosis is one of the leading causes of disability among elderly population. Gait impairment is one of the primary symptoms of degenerative conditions involving lumbar spine. Research suggests that decompressive surgery can positively influence gait parameters in patients with spinal stenosis. Studies have shown improvements in walking speed, stride length, and balance post-surgery.

Methods: Thirty-two patients with single-level lumbar stenosis and 32 healthy volunteers were prospectively recruited. All patients underwent gait analysis preoperatively and 6 months postoperatively as per standard protocol. Spatiotemporal, kinematic, and kinetic parameters were analyzed. Stepwise linear regression models were used to detect significant relationships between changes in functional score (Visual Analogue Scale/Oswestry Disability Index) and gait parameters.

Results: Significant improvement was noted in functional scores(P<0.05) 6 months post-surgery. Spatiotemporal (swing phase, mean velocity, cadence, stride length, step length, and step width) and kinetic parameters (hip, knee, and ankle power) were significantly better after surgery, reaching normal levels. Kinematic parameters significantly improved after surgery but did not reach normal levels when compared with controls. A significant correlation was found between changes in functional scores with changes in certain kinematic parameters (knee-power, ankle plantarflexion, swing time, peak ankle dorsiflexion in swing, peak-hip, and knee flexor moment).

Conclusion: Decompression surgery in lumbar stenosis produces improvement in gait parameters, pain scores, and functional outcomes that significantly improve gait posture and speed.

Study design: Retrospective analysis.

Objective: To assess the incidence of and risk factors for adjacent segment pathology (ASP) requiring surgery among patients previously treated with spinal fusion. Survival of the adjacent segment was compared in patients undergoing open posterior lumbar interbody fusion (O-PLIF) versus minimally invasive transforaminal interbody fusion (MI-TLIF).

Summary of background data: Compared with O-PLIF, MI-TLIF may reduce ASP in the long term by preserving more of the paraspinal muscle and ligamentous structures connected to adjacent segments.

Methods: The study population consisted of 740 consecutive patients who had undergone lumbar spinal fusion of 3 or fewer segments. O-PLIF was performed in 564 patients, and MI-TLIF in 176 patients. The incidence and prevalence of revision surgery for ASP were calculated using the Kaplan-Meier method. A risk factor analysis was performed using the log-rank test and a Cox regression analysis.

Results: After index spinal fusion, 26 patients (3.5%) underwent additional surgery for ASP. Kaplan-Meier analysis predicted a disease-free survival rate of adjacent segments in 87.2% at 10 years after the index operation. The incidence of ASP requiring surgery within 10 years was 16.4% after O-PLIF and 6.1% after MI-TLIF (P=0.045). This result was supported by the Cox regression analysis, which showed a significant difference between MI-TLIF and O-PLIF (P=0.034). The hazard ratio of revision surgery was about 3 times higher with O-PLIF than with MI-TLIF. Patients 65 years or older at the time of the index operation were 2.9 times more likely to undergo revision surgery than those younger than 65 years (P=0.015).

Conclusions: MI-TLIF results in less ASP requiring surgery than O-PLIF. 65 years or older is an independent risk factor for ASP. By preserving the soft tissues, MI-TLIF may result in a lower incidence of ASP than the open technique.

Level of evidence: Level 3.

Study design/setting: Retrospective cohort analysis.

Objective: To determine what factors are associated with high-risk daily morphine milligram equivalent (MME) totals in patients undergoing spinal decompression.

Background: Daily dosages of ≥100 MME/d are associated with an almost 9-fold increased risk of overdose. Current general recommendations endorse the lowest effective dose and ≤50 MME/d.

Materials and methods: Retrospective analysis was conducted on 260 patients who underwent spinal decompressive surgery. Average MME/d was calculated as the sum of qualifying inpatient MMEs administered divided by the sum of inpatient length of stay. Independent variables across demographic, clinical, and surgical domains were subject to comparative and logistic regression analysis.

Results: Overall MME per day was 54.19 ± 39.37, with a range of 1.67-218.34 MME/d. Sixty-six patients were determined to have "high-risk MME." These patients were significantly younger (58.8 ± 13.1 vs 70.53 ± 11.5; P < 0.001) and reported higher preoperative pain visual analog scale (VAS; 4.8 ± 3 vs 2.8 ± 3.3; P = 0.0021) than the patients at low risk. In addition, high-risk patients had significantly higher body mass indexes (BMIs; P < 0.05) and received ketamine as part of anesthesia (P < 0.05). Patients who consumed high-risk dosages of MMEs in the perioperative period were more likely to have been on opioids before surgery and to report higher pain scores at 4-6 week follow-ups (P < 0.05). The final logistics regression model identified independent risk factors to be younger age, higher BMIs and preoperative VAS, and prior use of opioids and intraoperative ketamine.

Conclusions: Patients with high MME per day who underwent spinal decompression were significantly younger with higher BMIs and preoperative VAS with an increased incidence of preoperative opioid use and intraoperative ketamine. A closer look at interaction models revealed that a combination of high preoperative pain and intraoperative ketamine usage were at a significantly increased risk of higher MME consumption. Preoperative opioid risk education and mitigation strategies should be considered in patients with high MME risk, especially in younger patients already utilizing opioids before surgery.

Study design: Review of cohort studies.

Objective: To ascertain if previous hip (THA) or knee (TKA) arthroplasty was associated with patients' outcomes assessments of subsequent lumbar surgery, specifically overall satisfaction, less disability due to pain, and an affective appraisal reflecting emotional assessment of results.

Background: Hip, knee, and lumbar symptoms often co-exist and increasingly are managed with surgery. Whether previous total joint arthroplasty (TJA) impacts patients' perspectives of results of subsequent lumbar surgery is not known.

Methods: Identical and systematically acquired preoperative and postoperative data from 3 studies assessing psychosocial characteristics and outcomes of lumbar surgery were pooled. Data obtained during interviews included preoperative demographic and clinical variables and 2-year postoperative global overall assessment (very satisfied/satisfied, neither, dissatisfied/very dissatisfied) and global affective assessment (delighted/pleased, mostly satisfied/mixed/mostly dissatisfied, unhappy/terrible). Patients completed the ODI and preoperative to postoperative change was analyzed according to an MCID (15 points). At 2 years patients also reported any untoward events since surgery (ie, fracture, infection, or repeat lumbar surgery). Associations with outcomes were assessed with multivariable logistic ordinal regression controlling for untoward events. Type of arthroplasty was evaluated in subanalyses.

Results: Among 1227 patients (mean: 59 y, 50% women), 12% had arthroplasty (+TJA) and 88% did not (-TJA). In multivariable analysis, +TJA was associated with less global satisfaction (OR: 1.9, CI: 1.3-2.7, P=0.0007), worse global affective assessment (OR: 1.6, CI: 1.1-2.2, P=0.009), and not meeting MCID15 (OR: 1.5, CI: 1.0-2.3, P=0.05). Covariables associated with less favorable outcomes were not working, positive depression screen, and prior lumbar surgery. Compared with -TJA, patients with THA had worse affective assessments and patients with TKA had less satisfaction and were less likely to meet MCID15.

Conclusions: Previous hip or knee arthroplasty was associated with less favorable patient-reported outcomes of lumbar surgery. Surgeons and patients should discuss differences between procedures preoperatively and during shared postoperative outcome assessment.

Level of evidence: Level II.

Study design: Cross-sectional study.

Objective: To assess the potential role of degenerative myelopathy as a risk factor for major fragility fractures in older patients.

Background: Degenerative cervical myelopathy (DCM) stands as the foremost spinal disorder affecting adults, significantly impacting patients' quality of life. However, it is often underdiagnosed, with its prevalence traditionally considered low (0.06%-0.112%). Despite the rising prevalence of hip fractures with an aging population and the identification of numerous risk factors, DCM is not typically regarded as a primary risk factor for such fractures. In 2015, an American study revealed an unexpectedly high rate of 18% of undiagnosed DCM in patients with hip fractures within a small cohort. We sought to replicate this study in a larger cohort of a European population.

Materials and methods: Our cross-sectional study targeted patients older than 65 years with hip fractures and aimed to identify cases of DCM at the time of fracture. Exclusions were made for patients with preexisting DCM diagnoses, neurological disorders, prior cervical surgeries, and instances of high-energy trauma. Comprehensive demographic, clinical, and radiologic data were collected, followed by descriptive and statistical analysis.

Results: In our study, 147 patients (mean age: 82.9 y) were included. Through a combination of clinical assessment and physical examination, 23 patients (15.6%) were identified as indicative of myelopathy. Confirmation through magnetic resonance imaging led to an estimated overall prevalence of DCM at 10.5%. Logistic regression analysis revealed that the presence of hypertonic reflexes, cervical pain, or cervicobrachialgia were specific and valuable indicators for diagnosing myelopathy.

Conclusion: This study marks the first investigation of its kind in a European population, highlighting the notably high prevalence of undiagnosed DCM among older patients who have experienced hip fractures. This underscores DCM as a potential risk factor for hip fractures in the elderly, despite its underdiagnosis and undertreatment.

Level of evidence: Level III.

The minimal clinically important difference (MCID) is a threshold above which a score change would represent a change in symptoms that is noticeable by patients, and it has become a standard approach in the interpretation of clinical relevance of changes in PROMs at a population level. Given the lack of a methodological gold standard, high variability is the main limitation of MCID. Reporting both anchor and distribution-based MCID estimates is a strategy that guarantees both patient-perceived clinical relevance and statistical significance.

Study design: Cross-sectional, observational study.

Objective: Investigate the frequency of intraoperative neuromonitoring (IONM) utilization among Medicare patients diagnosed with cervical spondylosis (CS), both with and without myelopathy.

Background: IONM is widely used as a tool in spine surgery. However, the overall prevalence of neuromonitoring utilization among CS undergoing surgical intervention is not well characterized.

Methods: This study observed neuromonitoring usage in CS patients who had cervical spinal procedures from 2012 to 2020, using a 5% random sample of Medicare data. Logistic regression compared patient characteristics between those who received neuromonitoring and those who did not. The model included age, sex, region, Elixhauser Comorbidity Index score, year of surgery, elective status, and procedure type. Odds ratios with a 95% CI were generated for each covariate.

Results: Of the 6224 patients who underwent cervical procedures for CS, 4053 were included in the study, with 2845 having myelopathy and 1208 without. Myelopathy patients had a higher number of hospitalizations (2884) compared with non-myelopathy patients (1229). Among myelopathy patients, the prevalence of neuromonitoring increased from 49.2% in 2012 to 56.5% in 2020. The range of utilization for each type of monitoring was: 96.4%-100% for somatosensory evoked potential, 73.2%-86.1% for electromyography, 70.0%-86.1% for motor evoked potential, and 17.6%-33.6% for other modalities. For non-myelopathy patients, neuromonitoring prevalence increased from 33.1% in 2012 to 43.3% in 2020. The range of utilization for each type of monitoring was: 93.0%-100% for somatosensory evoked potential, 68.9%-89.7% for electromyography, 55.8%-77.4% for motor evoked potential, and 17.8%-36.4% for other modalities.

Conclusions: This study investigates the utilization of IONM during cervical spinal surgeries in Medicare patients with cervical spondylotic myelopathy or CS between 2012 and 2020. Although IONM is employed in cervical spine procedures, its adoption and standardization appear to vary across the country and different health care settings.