Clinical Spine Surgery最新文献

Study design: Retrospective study design.

Study objectives: To assess the prevalence and severity of sleep disturbances among patients with idiopathic scoliosis in Saudi Arabia. To evaluate the impact of surgical intervention on sleep quality in IS patients, comparing preoperative and postoperative sleep patterns.

Background: Idiopathic scoliosis (IS) is a complex spinal deformity that may impact sleep quality due to pain, breathing difficulties, and psychological factors. Surgical intervention is the primary treatment for severe cases, yet its effect on sleep quality remains unclear.

Methods: A retrospective cohort study was conducted on 70 patients who underwent scoliosis surgery at a tertiary center in Riyadh, Saudi Arabia, between 2019 and 2024. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) before and 6 months after surgery.

Results: The prevalence of poor sleep quality decreased significantly postoperatively from 64.2% to 44.2% (P = 0.018). Significant improvements were observed in sleep latency (P = 0.031), duration (P = 0.002), efficiency (P = 0.004), and daytime dysfunction (P = 0.002).

Conclusions: Surgical correction of idiopathic scoliosis significantly improves sleep quality by enhancing sleep parameters and reducing sleep disturbances. Further research is warranted to optimize postoperative care and improve patient quality of life.

Study design: Review.

Objective: To provide an overview of outcome measures used to evaluate cervical spondylotic myelopathy (CSM) and degenerative cervical myelopathy (DCM), emphasizing their diagnostic utility, prognostic value, and limitations.

Summary of background data: DCM and CSM lead to spinal cord compression and neurological impairment. Effective outcome measures are essential for disease monitoring and clinical decision-making.

Methods: A comprehensive literature review was conducted.

Results: The modified Japanese Orthopaedic Association scale (mJOA) and Nurick grading remain standard provider assessments for DCM and CSM but have limitations. The patient-derived mJOA (P-mJOA) is a patient-reported outcome measure (PROM) similar to the European Myelopathy Score (EMS), whereas PROMs such as the Neck Disability Index, Short Form-36, and EuroQol-5D lack disease specificity. Advances in imaging, including diffusion tensor imaging (DTI) and diffusion basis spectrum imaging (DBSI), electrophysiological assessments, and wearable sensors, may enhance diagnostic precision in the future.

Conclusions: Integrating subjective and objective outcome measures can enhance DCM/CSM assessment. A multimodal approach may improve diagnosis, prognostication, and guide treatment recommendations through traditional clinical assessments, evolving patient-reported outcome measures, advanced imaging techniques, and wearable sensor data. Large data sets made possible by these advancements can leverage the power of predictive analytics and artificial intelligence.

Study design: Single-center retrospective cohort study.

Objective: The primary objective was to evaluate the incidence of proximal facet joint violation (FJV) in lumbar and sacral pedicle screw placement, comparing robotic-assisted navigation (RAN) versus augmented reality (AR) guidance systems. Secondary objectives examined risk factor assessment across demographic characteristics, surgical variables, and analysis of vertebral level-specific violation patterns.

Summary of background data: Proximal FJV is a recognized complication of pedicle screw placement, with reported rates ranging from 2% to 42%. Although robotic-assisted techniques are associated with reduced FJV risk, direct comparisons between modern RAN and AR systems remain limited and warrant further investigation.

Methods: Postoperative imaging was analyzed for proximal FJV in patients who underwent either RAN (Mazor X) or AR-guided (Xvision) pedicle screw placement. Patient demographics, surgical characteristics, and FJV rates were compared between groups.

Results: Among 175 patients, a total of 350 proximal facet joints were evaluated, with an FJV rate of 5.8% (n = 11) in the RAN group and 9.4% (n = 15) in the AR group. The highest violation rates occurred at L5 (RAN: 13.2%, n=5; AR: 35.3%, n=12), without reaching statistical significance. Most violations were modified Park grade I (RAN: 6.3%, n=9; AR: 4.4%, n=7) or grade II (RAN: 1.6%, n=2; AR: 5.6%, n=8), with no grade III violations observed. Demographic factors showed no significant association with FJV rates. No revision surgeries were required for screw malposition or FJV.

Conclusions: RAN demonstrated lower proximal FJV rates compared with AR guidance in lumbar and sacral pedicle screw placement, particularly at L5; however, this difference was not statistically significant. Although demographic factors showed no significant association with FJV occurrence, the absence of severe violations in both cohorts demonstrates the overall safety profile of these navigation systems.

Study design: Retrospective cohort.

Objective: Evaluate the impact of insurance type on outcomes of ACDF among patients 65 years or older.

Summary of background data: Despite a 38.7% inflation-adjusted decrease in reimbursement for ACDF procedures in Medicare patients aged 65 years and older over the past decade, ACDF volume has increased by 24%. Value-based care studies have investigated Medicare insurance as a predictor of postoperative outcomes. However, literature examining PROMs by Medicare status, especially for elderly patients, remains limited.

Methods: Patients aged 65 years or older who underwent 1-3 level ACDF (2014-2023) with Medicare, Medicare Advantage, or private insurance were included. Patients were excluded for ACDF performed for trauma/infection/tumor. The area deprivation index (ADI) was used to measure socioeconomic status by ZIP code. Outcomes included 30/90-day readmissions, 1-year reoperations, and PROMs-mental (MCS-12) and physical component summary (PCS-12), visual analog scale (VAS) neck and arm, neck disability index (NDI), and modified Japanese Orthopaedic Association (mJOA) scale. Achievement of the minimum clinically important difference (MCID) was compared between groups.

Results: Three hundred three patients were included. Private insurance patients were younger than Medicare (68.8 vs. 71.8 y, P<0.001) and Medicare Advantage (68.8 vs. 70.6 y, P=0.002) patients, but otherwise the groups were demographically/surgically similar and performed similarly in postoperative outcomes and MCID achievement. Private insurance patients had worse preoperative scores and greater improvement at 1 year in NDI compared with Medicare and Medicare Advantage patients. Delta VAS arm scores were better for private insurance and Medicare Advantage patients compared with Medicare patients. However, linear regression did not show insurance as independently predictive of 1-year delta NDI scores or VAS arm scores when controlling for age, ADI percentile, number of levels fused, and preoperative scores.

Conclusions: Medicare status does not appear to impact short-term adverse outcomes or 1-year revision among elderly ACDF patients. Neither Medicare nor Medicare Advantage insurance was independently predictive of worse improvement on VAS arm or mJOA scores when controlling for relevant confounders.

Study design: This is a retrospective analysis of 142 consecutive single-level transforaminal lumbar interbody fusions (TLIFs) performed by neurosurgeons at a large academic center.

Objective: To integrate patient-reported outcomes (PROs) with time-driven activity-based costing (TDABC) to quantify value at the surgeon-level and procedure-level.

Summary of background data: PRO and cost analyses have become mainstays of clinical research for spine surgery in recent years. To our knowledge, however, few attempts have been made to merge PROs with TDABC to quantify the value of surgical care.

Methods: Intraoperative TDABC was used to estimate both direct and indirect costs. Individual costs were obtained by direct observation, electronic medical records, and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Oswestry Disability Index (ODI) scores were collected at baseline and 3-months after surgery. The operative value index (OVI) was defined as the percent improvement in ODI per $1000 spent intraoperatively. We also divided the total intraoperative cost by the absolute ODI point-change for each case to calculate a unit price for outcomes (UPO). Generalized linear mixed models (GLMM) were built to assess surgeon-level variability in OVI. Three distinct surgeon cohorts were created: surgeon A (n=75 cases), surgeon B (n=39 cases), and "other surgeons" (n=7 surgeons and 28 cases).

Results: One hundred forty-two single-level TLIFs were performed by 9 surgeons from 2017 to 2022. The average total cost of a one-level TLIF was $11,984±$3312. The average OVI and UPO for all cases was 3.2±4.3 and $643±$3929, respectively. On GLMM, "other surgeons" were associated with significantly decreased OVI (P<0.05) compared with Surgeon A, though there was no significant difference in OVI between Surgeon A and Surgeon B (P=0.56).

Conclusion: We present novel metrics that quantify value for single-level TLIF by combining a diagnosis-specific PRO with TDABC. Metrics such as these can help stakeholders identify drivers of variation in the value provided by spine surgeons.

Study design: Retrospective cohort study.

Objectives: The objectives of this study are to (1) measure the association between Cervical Vertebral Bone Quality (C-VBQ) score and subsidence after anterior cervical discectomy and fusion (ACDF), (2) determine whether there is a clinically relevant cutoff for predicting risk, and (3) determine whether ACDF cage construct configuration impacts the utility of C-VBQ.

Summary of background data: Cage subsidence after ACDF can be influenced by patient factors such as age, medical history, cage construct material, and bone quality. Prior research suggests that the recently introduced C-VBQ score, an MRI-based measure of trabecular bone, can precisely predict postoperative subsidence risk. There is no prior research investigating whether cage construct configuration, known to impact subsidence risk, can affect the utility of C-VBQ score.

Methods: One hundred seventeen patients undergoing single-level ACDF for degenerative pathology between 2019 and 2023 were included. C-VBQ was calculated at C2-C7 from preoperative T1-weighted MRI images. Radiographic subsidence was defined as collapse of the interbody cage by greater than one-third of cage height. Receiver operating characteristic (ROC) curves were generated for C-VBQ and subsidence between cage configurations. Inferential and descriptive statistics were performed.

Results: Radiographic subsidence was present in 22 patients (19%). Mean C-VBQ score was significantly higher in the subsidence group (P<0.001). A higher C-VBQ demonstrated greater odds of developing subsidence (OR=15.26, P<0.001). A C-VBQ score of ≥2.59 was 60% sensitive and 82% specific in detecting subsidence (AUC=0.747, P<0.001). C-VBQ score was most predictive with allograft (AUC=0.906, P<0.001), with a score of 2.44 demonstrating 100% sensitivity and 67% specificity, and least predictive with PEEK cage-plate constructs (AUC=0.625, P=0.360).

Conclusions: Preoperative C-VBQ score is effective in predicting cage subsidence risk after ACDF surgery. It demonstrates the greatest utility in patients implanted with allograft cage-plate constructs and is least predictive in those with PEEK configurations.

Study design: This was a retrospective single-center study.

Objectives: To investigate the relationship between intraoperative arterial blood pressure (MAP) changes and the occurrence of C5 palsy.

Summary of background data: C5 palsy is a disabling complication of cervical spine surgery, and its pathophysiology remains unknown. We hypothesized that intraoperative MAP changes might influence the occurrence of postoperative C5 palsy.

Methods: This retrospective study included patients who underwent continuous arterial blood pressure monitoring during elective cervical spine surgery. Patients were divided into 2 groups according to the presence or absence of C5 palsy (defined as a decrease of at least 1 grade in deltoid muscle strength). The demographics, diagnoses, surgical characteristics, and intraoperative MAP parameters were reviewed.

Results: A total of 74 patients were included in this analysis (mean age: 70.5 y; 22 women). Of these patients, 13 developed C5 palsy, which occurred after a mean of 2.2 days following surgery. There were no significant differences between the C5 palsy and control groups in terms of age, sex, diagnosis, preexisting hypertension, and blood pressure on the day before surgery. Patients with C5 palsy showed a greater change in intraoperative MAP than those in the control group (92​​​​​​ vs. 73 mm Hg, P=0.013). The number of episodes of intraoperative hypotension was similar in the C5 palsy and control groups (2.5 vs. 3.1 episodes). After adjustment by a multivariable logistic regression analysis, intraoperative MAP change remained an independent risk factor for C5 palsy (odds ratio 1.03 per 1 mm Hg increase, 95% CI: 1.01-1.05, P=0.03).

Conclusion: A larger change in the intraoperative MAP was associated with C5 palsy after cervical surgery. Our findings suggest a potential role for intraoperative hemodynamic changes in the development of C5 palsy.

Study design: This is a retrospective study.

Objective: To evaluate and compare the clinical efficacy and fusion outcomes of allograft versus hydroxyapatite (HA) as bone graft materials in anterior cervical discectomy and fusion (ACDF) surgery.

Summary of background data: ACDF is used for cervical disc herniation treatment; however, there is no consensus on the optimal bone graft material, particularly between allograft and hydroxyapatite.

Methods: This retrospective study included patients who underwent ACDF at the Third Affiliated Hospital of Southern Medical University between January 2015 and December 2019. A total of 63 patients met the inclusion criteria and were divided into 2 groups: the allograft group (n=39) and the HA group (n=24). Clinical outcomes were assessed using the Visual Analogue Scale (VAS), Japanese Orthopaedic Association (JOA) score, and Neck Disability Index (NDI). Cervical spine radiographs were utilized to evaluate fusion status, intervertebral height, and sagittal alignment parameters.

Results: Both groups demonstrated significant postoperative improvement in VAS, JOA, and NDI scores compared with preoperative values. The magnitude of improvement was similar between the 2 groups, the allograft group exhibited superior final VAS, JOA, and NDI scores relative to the HA group. Radiographic analysis revealed a significantly lower fusion rate and score in the HA group. The incidence of cage subsidence was higher in the HA group, although no significant difference in intervertebral height was observed between groups. Notably, 6 patients (25.0%) in the HA group experienced fusion failure requiring revision surgery, of whom 3 underwent reoperation. No fusion failure or revision surgery was reported in the allograft group.

Conclusion: ACDF remains a widely accepted and effective treatment for cervical disc herniation. While both graft types provide symptomatic relief and functional recovery, the allograft demonstrates superior performance in terms of fusion rate, structural integrity, and lower revision risk.

Study design: Retrospective cohort study.

Objective: To determine independent risk factors for sacral fracture after lumbosacral fusion.

Summary of background data: Sacral fractures are an uncommon complication after lumbosacral fusion, with recent research suggesting that osteoporosis is an independent risk factor. However, there is a paucity of data regarding other potential risk factors.

Methods: This retrospective study (TriNetX) included adults (18 y or above) who underwent first-time lumbosacral fusion between 2005 and 2023, divided into 2 cohorts: the osteoporosis cohort and the no osteoporosis cohort. The primary outcome was the incidence of sacral fracture after lumbosacral fusion over 2 years, estimated using Kaplan-Meier analysis, with hazard ratios (HRs) estimated for each covariate using a multivariable Cox proportional hazards model (P<0.05).

Results: There were 592 sacral fractures (2.3%) among 25,598 adults who underwent lumbosacral fusion, with 470 cases (2.8%) in the osteoporosis cohort and 122 cases (1.3%) in the no osteoporosis cohort. Independent risk factors (P<0.05) for sacral fracture after lumbosacral fusion included previous pelvic radiation [95% CI] (HR: 3.04 [1.26, 7.36]), history of falls (HR: 2.65 [2.21, 3.18]), osteoporosis (HR: 2.02 [1.64, 2.49]), long-term systemic corticosteroid use (HR: 1.47 [1.10, 1.98]), age at index lumbosacral fusion (HR: 1.01 [1.00, 1.02] per year), while protective factors included overweight and/or obesity status (HR: 0.79 [0.65, 0.97]), and male sex (HR: 0.64 [0.48, 0.85]). Variables determined not to be independent risk factors (P>0.05) included nicotine dependence, history of total hip arthroplasty, anterior surgical approach, posterior surgical approach, long lumbosacral spinal fusion with instrumentation (7-12 vertebral levels), diabetes mellitus, bone density medications, inflammatory polyarthropathies, pelvic fixation, vitamin D prescription, chronic kidney disease, and glucagon-like peptide-1 analogues.

Conclusions: Clinically meaningful independent risk factors for sacral fractures after lumbosacral fractures include pelvic radiation, history of falls, osteoporosis, long-term systemic corticosteroid use, and potentially increasing age, whereas being male and overweight or obese are independent protective factors.

Level of evidence: Level III-retrospective case-control study.

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.