Clinical Spine Surgery最新文献

Study design: Retrospective database study.

Objective: To evaluate whether dexamethasone utilized in the immediate postoperative setting after 1- or 2-level posterior lumbar spinal fusion (PLSF) leads to an increased rate of wound and instrumentation complications in the diabetic population.

Background: Dexamethasone is widely utilized in the postoperative setting in patients undergoing PLSF for pain control and/or persistent radiculopathy. There is a paucity of literature evaluating the effects of dexamethasone in the diabetic population, who are more prone to postoperative surgical site infections (SSIs) and instrumentation complications.

Methods: Patients undergoing 1- or 2-level PLSF with a diagnosis of type II diabetes mellitus who received dexamethasone within 3 days postoperatively were retrospectively identified using the PearlDiver database. Diabetic patients receiving dexamethasone were propensity-matched in a 1:10 ratio to diabetic patients undergoing the same procedure who did not receive dexamethasone. SSIs, instrumentation complications, and medical complications were assessed at 30 days, 90 days, and 1 year.

Results: A total of 7865 were included in this study. The test group consisted of 715 patients who received dexamethasone, and the control group included 7150 patients who did not receive dexamethasone. SSIs were significantly elevated in the test group at 30 days [OR=1.51 (1.01-2.13), P=0.019], 90 days [OR=1.38 (1.00-1.91), P=0.047], and 1 year [OR=1.36 (1.01-1.84), P=0.046]. Instrumentation complications were also significantly elevated in the test group at all time points: 30 days [OR=2.0 (1.16-3.43), P=0.012], 90 days [OR=2.18 (1.45-3.28), P<0.001], and 1 year [OR=1.63 (1.22-2.19), P=0.001].

Conclusion: Administration of dexamethasone in the postoperative period after 1- or 2-level PLSF may be associated with a higher risk of SSI and instrumentation complications at 30 days, 90 days, and 1 year in diabetic patients undergoing elective 1- or 2-level lumbar fusion.

Study design: Retrospective cohort study.

Objective: To evaluate the influence of smoking on 30-day postoperative complications following anterior cervical discectomy with fusion (ACDF) surgery.

Summary of background data: Although smoking can have significant negative effects on bone healing in orthopaedic surgery, there is currently conflicting literature regarding the effect of smoking on patients undergoing ACDF surgery.

Methods: Patients who underwent an ACDF procedure between 2011 and 2021 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database by CPT code 22551 from 2011 to 2021. The study population was divided into 2 groups: smokers and nonsmokers. Chi-square tests for categorical variables and t-tests for continuous variables were used to identify differences in perioperative variables between groups. Multivariable logistic regression analysis assessed smoking status effect on postoperative outcomes after adjusting for these factors.

Results: A total of 85,758 patients who underwent ACDF surgery were identified, of whom 22,223 (25.9%) were smokers and 63,535 (74.1%) were non-smokers. Smokers were younger than the non-smoker cohort (51.84 vs. 56.74 years, p<0.001). Smokers had a significant odds ratio (OR) for extended length of hospital stay (OR: 1.240, 95% CI: 1.114-1.380, p<0.001) and reoperation (OR: 1.144, 95% CI: 1.007-1.298, p=0.038), following a multivariate logistic regression analysis.

Conclusions: Patients with a history of smoking within the past year were at an increased risk for reoperation and extended length of stay after ACDF. These findings can enhance informed consent for patients with a smoking history. Future studies should evaluate patient-reported outcomes and pseudoarthrosis rates to further elucidate the role of smoking in cervical spine surgery.

Study design: Retrospective cohort study.

Objective: To assess the impact of preoperative PROMIS PF scores on postoperative pain, narcotics consumption, return to activities, and PROMs following CDR.

Summary of background data: There is limited data regarding the impact of baseline PROMIS PF on outcomes for patients undergoing CDR.

Methods: Patients undergoing primary 1- or 2-level CDR for degenerative pathology with minimum 6-month follow-up were included and separated into a high disability group (≤40 preoperative PROMIS PF) and a low disability group (>40 preoperative PROMIS PF). Analyses were conducted for the early (<6 mo) and late (≥6 mo) postoperative timepoints. Linear and logistic regressions were performed to determine the association of preoperative PROMIS PF group with postoperative pain, narcotics consumption, time to discontinue narcotics, return to driving and working, PROMs, and MCID achievement.

Results: A total of 93 patients were included. Patients in the high disability group were younger (41.5±8.4 vs. 45.3±7.6, P=0.026) and had a higher proportion of female patients (58.7% vs. 25.6%, P=0.001). Patients with higher disability experienced similar postoperative pain scores, narcotics consumption, time to discontinue narcotics, and return to driving and working timelines as patients with lower disability but demonstrated poorer PROM scores at early follow-up. However, patients with higher disability experienced greater changes in NDI and PROMIS PF scores at both early and late follow-up, VAS-Neck and Arm and SF-12 PCS scores at late follow-up, and also achieved the MCID at a higher rate for multiple PROMs.

Conclusion: Patients with higher preoperative disability, as determined by PROMIS PF, experience similar postoperative pain scores, narcotics consumption, time to discontinue narcotics, and return to activities as compared with patients with lower preoperative disability undergoing CDR as well as greater absolute improvements and MCID achievement rates for most PROMs. These findings may be useful in setting postoperative expectations for outcomes following CDR.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: To compare the functional cross-sectional area (FCSA) of paraspinal muscles in patients undergoing single-level open transforaminal lumbar interbody fusion (Open-TLIF) versus minimally invasive TLIF (MIS-TLIF) and to assess correlations between muscle changes and clinical outcomes, including lumbar Visual Analogue Scale (VAS), leg VAS, and Oswestry Disability Index (ODI).

Summary of background data: Paraspinal muscle atrophy is linked to poorer outcomes after lumbar spine surgery. Minimally invasive techniques may reduce muscle damage. Understanding the degree of muscle preservation and its relationship to recovery can guide surgical decision-making.

Methods: This study included 129 patients (Open-TLIF: 60; MIS-TLIF: 69) who underwent single-level TLIF between September 2020 and December 2024, with at least 1 year of follow-up. Computed tomography (CT) measured FCSA of the multifidus, erector spinae, and psoas muscles at index and adjacent levels. Correlation and regression analyses evaluated relationships between FCSA changes, surgical method, and clinical outcomes (lumbar VAS, leg VAS, ODI).

Results: Open-TLIF patients had significantly greater reductions in FCSA of the index and adjacent multifidus and index erector spinae muscles. MIS-TLIF patients showed lower lumbar VAS and ODI scores at final follow-up. Index multifidus FCSA loss correlated with worse lumbar VAS (r = -0.253, P = 0.004) and ODI (r = -0.477, P<0.001). MIS-TLIF was significantly associated with multifidus preservation (r = 0.837, P<0.001). Increased psoas FCSA correlated positively with ODI improvement (r = 0.229, P = 0.009) but negatively with erector spinae FCSA (r = -0.221, P = 0.033).

Conclusions: MIS-TLIF is associated with significantly less paraspinal muscle atrophy and better lumbar VAS and ODI outcomes compared with Open-TLIF. Preservation of the multifidus muscle is strongly linked to clinical improvement, and increased psoas FCSA contributes to better disability outcomes.

Level of evidence: Level II.

Study design: Retrospective clinical study.

Objectives: To study the differences in effectiveness of unilateral biportal endoscopic lumbar interbody fusion (ULIF) and percutaneous endoscopic posterolateral transforaminal lumbar interbody fusion (PE-PTLIF) in the treatment of lumbar degenerative diseases (LDD).

Background: While minimally invasive spine surgeries are gaining popularity, research on the comparative effectiveness of ULIF and PE-PTLIF remains limited.

Materials and methods: From January 2021 to January 2022, 52 patients with LDD were retrospectively recruited into the PE-PTLIF and ULIF groups. The operation time, true total blood loss, length of hospital stay, postoperative incision and drainage, postoperative complications, hospitalization cost, perioperative blood biochemical indexes, visual analog scale (VAS) score, Oswestry Disability Index (ODI), modified MacNab criteria, intervertebral disc height (DH), segmental lordosis (SL), lumbar lordosis (LL), dural sac cross-sectional area (DSCA), multifidus muscle fat infiltration score (MAIS) and multifidus muscle atrophy rate (MAR) were used as the evaluation indices.

Results: The surgical time, bleeding, and postoperative drainage volume in the PE-PTLIF group were less than those in the ULIF group. The average serum creatine kinase (CK), C-reactive protein (CRP), and hemoglobin (Hb) differences in the PE-PTLIF group were lower than those in the ULIF group on the first and third day after surgery. The VAS score of lower back pain and ODI (%) at 3 days and 1 month after surgery in the PE-PTLIF group were much lower than those in the ULIF group. At the last follow-up, the MAR and MAIS in the ULIF group were higher than in the PE-PTLIF group.

Conclusion: PE-PTLIF has less damage to muscle and other soft tissues, faster recovery, but longer operation time. The incidence of complications of the 2 endoscopic-assisted lumbar fusions is less, and both are safe and effective surgical methods.

Study design: Retrospective cohort study.

Objective: The aim of this study was to evaluate the association between preoperative opioid use and postoperative health care utilization following elective lumbar spine surgery, and to characterize differences in surgical indications and procedures between opioid-naive (ON) and opioid-experienced (OE) patients.

Summary of background data: The U.S. opioid crisis continues to cause thousands of deaths yearly. Despite fewer prescriptions nationally, opioids remain common for pain control in spine surgery, where over half of the patients use them preoperatively.

Methods: Adults who underwent elective lumbar decompression with or without fusion between 2013 and 2018 at a single academic center were retrospectively reviewed. Patients were classified as OE if they had at least one opioid prescription within 60 days preoperatively. Demographics, surgical details, and postoperative health care utilization within 1 year, which included imaging, urgent care visits, physical therapy, pain referrals, and neuromodulator prescriptions, were compared between the OE and ON groups. Unadjusted and adjusted multivariable regression and sensitivity analyses were conducted to assess independent associations.

Results: Among 433 patients, 70.5% were OE and 29.5% were ON. On unadjusted analysis, OE patients had significantly higher rates of neuromodulator prescriptions at 180 days (P<.0001) and total imaging studies at 1 year (P=.0014). After multivariable adjustment, preoperative opioid use remained independently associated with increased neuromodulator prescriptions at 180 days (β=0.23, P=.0069) and higher odds of persistent opioid use at 1 year (OR: 2.35, 95% CI: 1.15-4.83, P=.0196). No significant differences were observed in total imaging, lumbar x-ray imaging, or urgent care utilization after adjustment.

Conclusions: Preoperative opioid use is associated with increased postoperative neuromodulator use and a higher risk of long-term opioid persistence following lumbar spine surgery. These findings highlight the need for targeted perioperative interventions to improve surgical outcomes.

Study design: Systematic review.

Objective: To evaluate the statistical robustness of TXA use in spine surgery as a potential contributor to controversies in this field.

Summary of background data: Tranexamic acid (TXA) is an antifibrinolytic medication administered during spinal surgery to limit blood loss. Existing randomized controlled trials (RCTs) on the efficacy of TXA contain varied results, particularly when reporting outcomes related to blood transfusion rates and thromboembolic events. By calculating the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ), statistical robustness was quantified and compared across all included RCTs.

Methods: PubMed, Embase, and MEDLINE were systematically searched for recent RCTs (January 1, 2000-August 1, 2023) assessing TXA use in patients undergoing spine surgery. The FI and rFI were calculated for each outcome, representing the number of event reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI/rFI by the study sample size.

Results: Of the 297 RCTs screened, 31 studies were included for analysis, yielding 80 dichotomous outcomes. Across these outcomes, the median FI (mFI) was 5.0, with an associated median FQ (mFQ) of 0.060. Nine outcomes were statistically significant (mFQ=0.018), and 71 were nonsignificant (mFQ=0.064). The most common outcome categories included blood/platelet transfusions (38 outcomes), thromboembolic events (15 outcomes), and other adverse events (27 outcomes), resulting in mFQs of 0.056, 0.049, and 0.064, respectively.

Conclusions: Outcomes examining TXA in spinal surgery demonstrated statistical fragility, with significant and thromboembolic outcomes proving the most fragile. Among all outcomes, there was a lack of significant results. To better guide future research on TXA use in spine surgery, this study recommends RCTs report fragility statistics along with P values and include these metrics when proposing clinical implications.

Level of evidence: Level III.

Study design: Retrospective case series.

Objective: To explore the clinical efficacy and safety of unilateral biportal endoscopy (UBE) combined with oblique lumbar interbody fusion (OLIF) in the treatment of lumbar infectious spondylitis (LIS).

Background: In recent years, there has been a notable increase in the incidence of LIS. Patients typically present with back pain, tenderness, and stiffness, which may be accompanied by fever, which significantly reduces their quality of life.

Patients and methods: This study selected 25 patients with LIS treated by UBE with OLIF from January 2018 to March 2023 in our hospital, including 14 males and 11 females. During the perioperative phase, key indicators such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein were monitored to evaluate the efficacy of the infection treatment. Surgical-related indicators and the frequency of complications were systematically recorded. Functional and imaging indicators before and after the operation were compared.

Results: The surgical intervention was successful in all 25 patients. The average operation time was 155.2 ± 23.5 minutes, the average blood loss was 265.6 ± 46.8 mL, and the average follow-up time was 18.8 ± 6.9 months. Bacterial cultures of 12 patients were positive, and postoperative pathologic examination of all patients showed inflammation. Postoperative patients exhibited significant clinical symptom improvement, characterized by a gradual decrease in erythrocyte sedimentation rate, C-reactive protein, and white blood cell count, ultimately returning to normal levels. The Visual Analog Scale scores, Japanese Orthopedic Association scores, and Oswestry Disability Index were significantly improved after the operation ( P < 0.001). In addition, the height of the intervertebral space and the angle of lumbar lordosis were optimally restored. At the last follow-up, the fusion rate of bone graft was 96%.

Conclusion: The combined treatment of LIS with UBE and OLIF is effective, thereby establishing itself as an effective, safe, and viable surgical technique.

Study design: Observational-ecologic study.

Introduction: Spine and pelvis undergo modifications in alignment so that the individual can maintain an orthostatic position, but to date there is no evidence as to the contribution of each lumbar segment and the change that occurs in them when moving from orthostasis to supine position.

Objective: To identify the difference in the contribution of the lumbar segments and pelvis to the formation of lumbar lordosis in both positions (orthostasis and supine) and how each one alters in this change.

Summary of background data: lumbar lordosis adapts to the individual's body position and can be physiological or pathologic.

Materials and methods: Retrospective cohort study that included 174 patients: the segments total lumbar lordosis (LL), L1-L4, L4-S1, L4-L5, L5-S1, and sacral slope were measured on x-rays (orthostasis) and MRI (supine). We obtained the mean values, correlations and models proposed for the relationship between the values found.

Results: The SS, LL, L1-L4, L4-S1, and L4-L5 had their angular value reduced, and L5-S1 had its contribution to lordosis significantly increased when lying down. Moderate and strong correlations were obtained between SS × LL, L1-L4 and L4-S1, and between LL versus L1-L4 and L4-S1 in both positions. When using linear regression, proposed models were obtained with a high coefficient of determination between LL versus SS, L1-L4 and L4-S1 in orthostasis, for the same measurements and SS versus L4-S1 in supine, as well as for lordosis when comparing the 2 positions.

Conclusions: The L5-S1 segment has no change in angular value when lying in supine and is thus the largest contributor to lordosis in supine. L1-L4 increases its angular value when standing in orthostasis, the position in which it is the greatest contributor to lordosis.