Clinical Spine Surgery最新文献

Study design: Systematic review and meta-analysis.

Objective: To compare radiographic outcomes across lumbar interbody fusion (LIF) techniques, assessing segmental and global lumbar lordosis restoration.

Summary of background data: LIF is a commonly utilized procedure to treat various spinal conditions, including degenerative pathology and adult spinal deformity. Common approaches include posterior LIF (PLIF), transforaminal LIF (TLIF), anterior LIF (ALIF), oblique LIF (OLIF), and lateral LIF (LLIF).

Methods: A systematic review and meta-analysis were carried out using PRISMA guidelines with appropriate MeSH terms. Papers were included based on relevance, number of patients, and a minimum of 1-year radiographic follow-up. Radiographic outcomes included segmental lordosis (SL) and lumbar lordosis (LL). Only papers directly comparing SL restoration between two or more LIF techniques were utilized in the systematic review, while all articles meeting the aforementioned criteria were used in the meta-analysis.

Results: Nineteen studies were included in the final systematic review, and 88 papers were included in the meta-analysis. Seven studies in the systematic review showed a significantly higher increase in SL with ALIF versus TLIF, and two showed significantly higher SL gain with ALIF compared with LLIF. When comparing ALIF versus OLIF, one study favored ALIF, while another favored OLIF for SL restoration. OLIF likewise demonstrated superior restoration of SL compared with TLIF. LLIF demonstrated improved SL restoration compared with TLIF in 2 of the 3 studies comparing the 2 procedures. Furthermore, both ALIF and OLIF demonstrated superior LL restoration compared with TLIF in 4 and 3 studies, respectively. The meta-analysis results demonstrated that ALIF provided significantly better restoration of SL than TLIF, LLIF, and OLIF, while TLIF conferred significantly lower SL restoration than ALIF and OLIF. Similarly, LL restoration was significantly reduced with TLIF relative to OLIF and LLIF (all P<0.05).

Conclusions: The included studies demonstrated superior SL and LL restoration with ALIF, OLIF, and LLIF compared with TLIF. ALIF improved SL to a greater extent when directly compared with all other interbody techniques.

Study design: Retrospective cohort study.

Objective: To assess the impact of smoking on outcomes following elective cervical laminoplasty for degenerative cervical myelopathy (DCM).

Summary of background data: The detrimental effect of cigarette smoking on cervical spinal fusion surgery outcomes is well documented. However, the impact of smoking on outcomes following nonfusion cervical spine procedures is unknown. One commonly utilized nonfusion technique for cervical decompression is laminoplasty.

Methods: Adult smokers or nonsmokers who underwent primary elective laminoplasty for DCM were included. The propensity score (PS) was constructed for being a current smoker based on covariates. Only patients contained in the PS overlapped region were included in the analysis set. Patient-reported outcomes (PROs) at baseline and 12 months postoperation included Visual Analog Scale (VAS) neck and arm pain, neck disability index (NDI)%, EuroQol-5 Dimension (EQ-5D), and modified Japanese Orthopedic Association (mJOA) scores. Other outcomes included perioperative complications, 3-month readmissions/reoperations, and patient satisfaction. Wilcoxon and Pearson tests were used to compare outcomes between smokers and nonsmokers.

Results: The study included 132 patients: 30 were smokers (22.7%) and 102 were nonsmokers (77.3%). No significant differences were found at baseline between groups in demographics or medical history. Smokers had significantly worse baseline VAS neck pain (5.7±3.2 vs. 4.4±3.04, P=0.028) and arm pain (5.7±3.5 vs. 4.3±3.2, P=0.045) scores, but all other baseline PROs were not statistically different between groups. No differences were found between smokers and nonsmokers in any 12-month PRO, or in rates of perioperative complications, 3-month readmissions, or 3-month reoperations. On multivariable logistic regression analysis, smoking had no significant impact on any outcome of interest.

Conclusion: Clinical and PROs following elective laminoplasty for DCM are not significantly different between smokers and nonsmokers. Laminoplasty should be considered a good surgical option in smokers presenting with DCM.

Study design: Biomechanical analysis.

Objective: To evaluate the depth of subsidence resulting from an expandable interbody cage at varying bone foam densities.

Summary of background data: Expandable interbody cages have been shown to be associated with increased rates of subsidence. It is critical to evaluate all variables which may influence a patient's risk of subsidence following the placement of an expandable interbody cage.

Methods: In the first stage of the study, subsidence depth was measured with 1 Nm of input expansion torque. In the second stage, the depth of subsidence was measured following 150 N output force exerted by an expandable interbody cage. Within each stage, different bone foam densities were analyzed, including 5, 10, 15, and 20 pounds per cubic foot (PCF). Five experimental trials were performed for each PCF material, and the mean subsidence depths were calculated. Trials which failed to reach 150 N output force were considered outliers and were excluded from the analysis.

Results: There was an overall decrease in subsidence depth with increasing bone foam density. The mean subsidence depths at 150 N output force were 2.0±0.3 mm for 5 PCF, 1.8±0.2 mm for 10 PCF, 1.1±0.2 mm for 15 PCF, and 1.1±0.2 mm for 20 PCF bone foam. The mean subsidence depths at 1 Nm of input torque were 2.3±0.5 mm for 5 PCF, 2.3±0.5 mm for 10 PCF, 1.2±0.2 mm for 15 PCF, and 1.1±0.1 mm for 20 PCF bone foam.

Conclusions: Depth of subsidence was negatively correlated with bone foam density at both constant input torque and constant endplate force. Because tactile feedback of cage expansion into the subsiding bone cannot be reliably distinguished from true expansion of disc space height, surgeons should take bone quality into account when deploying expandable cages.

Study design: Retrospective cohort study.

Objective: To evaluate the feasibility of anterior column support through a posterior approach using an anterior lumbar interbody fusion (ALIF) cage.

Summary of background data: Anterior fusion is an effective way to maintain spinal lordosis; however, it may be technically difficult in some cases.

Methods: Conventional lumbar fusion and spinal deformity correction surgeries were performed using a conventional ALIF cage with a modified extratransforaminal lumbar interbody fusion (ExTLIF). Patients with 1 or 2 fusion levels were classified into group 1, and those with spinal deformity correction were classified into group 2. Radiologic parameters were evaluated during the follow-up periods.

Results: A total of 51 patients underwent this procedure. Thirty-five patients (19 male and 16 female, 69.4±9.6 y old) with 37 fusion sites were in group 1, and 16 patients (3 male and 13 female, 71.4±5.7 y old) were in group 2. The mean follow-up periods of groups 1 and 2 were 12.3±3.4 and 10.7±4.7 months, respectively. In group 1, the mean lumbar lordosis and segmental lumbar lordosis increased significantly during the last follow-up (39.9±13.0 and 20.6±6.0 degrees, respectively, both P<0.001), and the mean disc space also increased at the last follow-up (P<0.001). The same was observed in group 2 with significant increases in the mean lumbar lordosis and segmental lumbar lordosis at the last of the follow-up period (46.8±9.3 and 16.9±8.9 degrees, respectively, both P<0.001). The disc space also increased significantly (P<0.001). Fusion rates were 94.2% and 87.5% in groups 1 and 2, respectively, and the corresponding subsidence rates were 85.4% and 68.8%. In group 1, there was a significant correlation between subsidence and cage height (P=0.046).

Conclusion: This procedure (ExTLIF) can be applied in cases where an anterior approach is contraindicated as well as for deformity correction.

Level of evidence: Level III.

Study design: Retrospective chart review.

Objective: To determine whether there was a difference in postoperative pain among patients undergoing direct lateral interbody fusion (DLIF) who had rib removal compared with those who did not.

Background: DLIF is a minimally invasive, lateral transpsoas surgical approach for spinal fusion that has a lower 2-year pain rating when compared with an open procedure. However, the DLIF surgical approach of the L1/L2 spinal level can be obstructed by the ribs. It is unknown whether patients undergoing a DLIF with rib removal experience more pain than their counterparts without rib removal.

Methods: Patients who underwent a DLIF from an individual spine surgeon at Wesley Medical Center between January 1, 2014 and December 31, 2018 were grouped by rib status: with removal versus without. Postoperative pain, measured by a 0 (no pain) to 10 (worst pain) Visual Analog Scale (VAS), was recorded on the day of discharge.

Results: The analysis included data from 136 patients, 75 with removal and 61 without. Patient demographics did not differ significantly by age, sex, insurance, estimated blood loss, or length of stay. However, number of spinal levels fused was greater when rib removal occurred, 4.5 versus 3.5 (P = 0.008). The mean baseline VAS with rib removal was 6.6 (1.7) and at discharge it was 7.6 (2.1). The mean baseline VAS without removal was 6.7 (2.0) compared with 7.8 (1.8) at discharge. The multivariate model predicting discharge VAS indicated there was no difference in pain by rib removal status (P = 0.180). VAS at discharge was associated with positive morphine milligram equivalents; as the VAS pain score increased so did the morphine dose (P = 0.028).

Conclusion: Patients undergoing a DLIF with rib removal expressed no difference in postoperative pain compared with patients without rib removal.

Study design: A retrospective case-control study.

Objective: To compare the clinical efficacy of endoscopic (Endo) and open posterior lumbar interbody fusion (PLIF) in treating lumbar spondylolisthesis.

Background: Endo-PLIF has emerged as a new technique for treating lumbar spondylolisthesis. We propose Endo-PLIF as an alternative method.

Materials and methods: Sixty-four patients with single-segment lumbar spondylolisthesis underwent Endo-PLIF (n = 39) or open PLIF (n = 25) treatment. Demographic data, perioperative parameters, and radiographic parameters were recorded. Clinical results were evaluated by Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores. The fusion rate was evaluated by computed tomography at 12 months postoperatively. In addition, a case-control process was included to ensure unbiased comparisons.

Results: The average operation time was longer in the Endo-PLIF group. Endo-PLIF showed advantages in reducing blood loss, shortening hospital stay, and early ambulation, but with a longer x-ray exposure time. Both VAS and ODI scores significantly improved in both groups, but the VAS for back pain was lower in the Endo-PLIF group. The radiographic results were similar in both groups. Three patients in the Endo-PLIF group had minor complications. Two patients in the open PLIF group experienced cerebrospinal fluid leakage. Both VAS and ODI scores significantly improved in both groups compared with preoperative scores, but the Endo-PLIF group showed more significant improvement at early follow-up (P < 0.05). There was no significant difference in interbody fusion rate between the two groups.

Conclusion: Both Endo-PLIF and open PLIF are effective for treating single-segment lumbar spondylolisthesis. Endo-PLIF shows advantages in reducing blood loss, shortening hospital stays, and promoting early ambulation, with comparable fusion rates and patient satisfaction to open PLIF. Despite minor complications in the Endo-PLIF group and cerebrospinal fluid leakage in the open PLIF group, both procedures lead to significant improvements in pain and disability scores, with Endo-PLIF demonstrating more significant early improvements.

Introduction: Cervical nerve palsies, most commonly C5, are relatively common following posterior cervical decompression and fusion (PCDF) for the management of cervical myelopathy. However, phrenic nerve palsy following PCDF is a rare complication documented in only one previous case report. The authors present a case of phrenic nerve palsy following PCDF.

Methods and material: The patient is a 51-year-old male who presented with cervical myelopathy and radiculopathy as well as cervicalgia of 1 year's duration. The patient underwent C3-C6 posterior cervical decompression and fusion (PCDF). On postoperative day 5, he was found to have a right C5 nerve palsy, which improved with steroid use and physical therapy. When he returned at 7 weeks postoperatively, the patient had progressive dyspnea. A fluoroscopic exam by pulmonology revealed a right-sided phrenic nerve palsy was the cause of the dyspnea.

Results and discussion: Phrenic nerve palsy causing hemi-diaphragmatic paralysis is a rare complication of cervical spine surgery that requires a high degree of suspicion due to the nonspecific signs and symptoms. Our clinical case suggests that surgeons should bear in mind phrenic nerve palsy as a potential complication in patients with respiratory distress following cervical laminectomy.

Study design: Retrospective review.

Objective: To evaluate how preoperative disability influences patient-reported outcomes (PROs) following primary surgical intervention for cervical herniated disc.

Summary of background data: The effect of baseline disability has been evaluated for various spinal surgeries, but not specifically for primary cervical herniated disc.

Methods: A prospectively maintained single surgeon database was retrospectively reviewed to identify patients who underwent primary cervical spine surgery for herniated nucleus pulposus. Demographics, perioperative data, and baseline/postoperative PROs were collected including Neck Disability Index (NDI), Visual Analog Scale-Arm/Neck (VAS-A/N), 12-Item Short Form Mental/Physical Component Scores (SF-12 MCS/PCS), Patient-Reported Outcome Measure Information System-Physical Function (PROMIS-PF), and 9-Item Patient-Health Questionnaire (PHQ-9). Baseline NDI <50/≥50 defined 2 cohorts. ΔPROs were determined at 6-week postoperatively/final follow-up (average 11.8±7.7 postoperative months). Overall rates of minimal clinically important difference (MCID) achievement were determined for each PRO. Perioperative characteristics/demographics/baseline PROs were compared with χ2 tests (categorical variables)/the Student t test (continuous variables). Intercohort postoperative PROs/ΔPROs/MCID attainment rates were compared with multivariate linear regression (continuous variables)/multivariate logistic regression (categorical variables) accounting for differences in insurance type.

Results: Of 190 patients, there were 69 in the NDI ≥50 group. Patients with NDI ≥50 were more likely to have workers' compensation, or Medicare/Medicaid insurance (P<0.001) and report worse baseline PROs (P≤0.001, all). After controlling for insurance type, NDI ≥50 patients continued to report worse PROs at 6 weeks/final follow-up (P≤0.037, all), except PROMIS-PF at 6 weeks postoperatively. NDI ≥50 patients reported greater NDI improvements at 6 weeks (P=0.007) and final follow-up (P<0.001). NDI ≥50 patients experienced higher overall MCID achievement rates for PHQ-9/NDI (P≤0.015, both).

Conclusions: NDI ≥50 patients reported worse baseline mental/physical health and neck/arm pain and continued to report inferior postoperative outcomes including disability. Despite inferior absolute outcomes, NDI ≥50 patients reported greater improvements/achievement of clinically significant differences in disability through final follow-up. Further, these patients were more likely to experience clinically significant improvements in depressive burden.

Study design: Retrospective study.

Objective: We examined racial disparities in (1) cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) utilization and (2) CDA in-hospital outcomes.

Summary of background data: ACDF and CDA are established treatments for cervical disc disease. While CDA may offer certain advantages over ACDF, its utilization patterns have not been comprehensively explored.

Methods: This study of 2012 to 2019 discharges from the National Inpatient Sample included White, Black, and Hispanic patients aged 18 years and older who underwent elective ACDF or CDA. Patient demographics, comorbidities, cervical spine diagnoses, and hospital characteristics were extracted. Survey-weighted logistic regression modeled the adjusted association between race and CDA (vs. ACDF) utilization; an interaction between race and year examined temporal changes in disparities. For CDA outcomes, multivariable logistic regression was used for binary outcomes (nonhome discharge, combined complications, and dysphagia) and linear regression for length of stay.

Results: The cohort included 712,355 weighted procedures (97.6% ACDF; 84.2% White, 9.7% Black, 6.1% Hispanic). CDA utilization increased from 1.0% of the procedures in 2012 to 3.8% in 2019. Black and Hispanic patients had significantly lower odds than White patients of receiving CDA versus ACDF (OR=0.77, 95% CI: 0.66-0.89, P=0.001; OR=0.80, 95% CI: 0.69-0.93, P=0.003) respectively. There was no statistically significant interaction between race and discharge year (P=0.50). For in-hospital CDA-specific outcomes, Black (vs. White) patients were more likely to experience dysphagia (OR=2.70, 95% CI: 1.53-4.78, P=0.001) and combined complications (OR=3.10, 95% CI: 1.91-5.05, P <0.001). There were no significant differences in any CDA outcome for Hispanic versus White patients.

Conclusions: This study revealed decreased utilization of CDA versus ACDF in minority patients, a pattern that persisted over time despite overall increasing CDA utilization. In addition, a higher burden of dysphagia and combined complications following CDA in Black patients warrants further examination.

Level of evidence: III.

Study design: Retrospective cohort study.

Objective: To investigate the correlation between comorbid chronic obstructive pulmonary disease (COPD), asthma, tobacco use, and the incidence of postoperative hematoma requiring reoperation after anterior cervical discectomy and fusion (ACDF).

Summary of background data: Prior studies have identified general risk factors such as multilevel fusion and coagulopathy. However, specific coughing-related factors like COPD, asthma, and tobacco use have not been extensively investigated.

Methods: Patients who underwent single or multilevel ACDF between 2011 and 2021 were identified using Current Procedural Terminology (CPT) codes in the PearlDiver database. The primary outcome was the occurrence of postoperative hematoma requiring reoperation within 30 days. χ2 tests and t tests compared groups, and multivariable logistic regression identified predictors for postoperative hematoma.

Results: Among 399,900 patients with ACDF, 901 (0.2%) developed postoperative hematoma requiring reoperation within 30 days. Patients with postoperative hematoma were older (58 vs. 55, P<0.001) and predominantly male (62.5% vs. 44.9%, P<0.001). After adjustment, tobacco use and comorbid COPD were associated with postoperative hematoma (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.10-1.47; P<0.001 and OR, 1.41; 95% CI, 1.21-1.64; P<0.001, respectively). Comorbid asthma was not a significant risk factor. Additional risk factors included comorbid hypertension (OR, 1.46; 95% CI, 1.18-1.82; P<0.001), coagulopathy (OR, 1.50; 95% CI, 1.24-1.81; P<0.001), anemia (OR, 1.38; 95% CI, 1.17-1.62; P<0.05), and history of deep vein thrombosis (OR, 1.93; 95% CI, 1.44-2.54; P<0.001).

Conclusion: Tobacco use and COPD were identified as novel risk factors for postoperative hematoma formation requiring reoperation after ACDF. Recognizing these modifiable factors, providers may consider postponing nonemergent ACDFs until patients undergo smoking cessation programs or receive optimal COPD management.