Clinical Spine Surgery最新文献

Study design: A narrative review.

Objective: To summarize relevant data from representative studies investigating upper limb restorative therapies for cervical spinal cord injury.

Summary of background data: Cervical spinal cord injury (SCI) is a debilitating condition resulting in tetraplegia, lifelong disability, and reduced quality of life. Given the dependence of all activities on hand function, patients with tetraplegia rank regaining hand function as one of their highest priorities. Recovery from cervical SCI is heterogeneous and often incomplete; currently, various novel therapies are under investigation to improve neurological function and eventually better quality of life in patients with tetraplegia.

Methods: In this article, a narrative literature review was performed to identify treatment options targeting the restoration of function in patients with cervical SCI. Studies were included from available literature based on the availability of clinical data and whether they are applicable to restoration of arm and hand function in patients with cervical SCI.

Results: We describe relevant studies including indications and outcomes with a focus on arm and hand function. Different treatment modalities described include nerve transfers, tendon transfers, spinal cord stimulation, functional electrical stimulation, non-invasive brain stimulation, brain-machine interfaces and neuroprosthetics, stem cell therapy, and immunotherapy. As the authors' institution leads one of the largest clinical trials on nerve transfers for cervical SCI, we also describe how patients undergoing nerve transfers are managed and followed at our center.

Conclusions: While complete recovery from cervical spinal cord injury may not be possible, novel therapies aimed at the restoration of upper limb motor function have made significant progress toward the realization of complete recovery.

Atlanto-occipital dissociation (AOD) is an extremely common injury but often fatal. In a systematic review from 2010, AODs were present in almost 20% of blunt trauma fatalities. It is an injury many patients do not survive; therefore, few are treated, even at high volume trauma centers. In survivors, his injury is often missed or the diagnosis is often delayed. Mortality rates commonly reach beyond 60% when injury patterns go unrecognized. Approximately 50% of patients with AOD sustain blunt cerebrovascular injury and nearly 20% of patients present with traumatic brain injury (TBI) or stroke. This pathology was once considered uniformly fatal. However, over the last 20 years, significant advancements have been made both clinically and radiographically, to better identify and manage this injury pattern. Despite improvements in clinical comprehension and improved time to diagnosis, less than 75% of cases are currently recognized within 24 hours. Less than 40% of patients who suffer AOD are independent with functionality, without neurological impairment. This article reviews current literature regarding AOD in hopes to improve timing to diagnosis, subsequent prognosis, timing to fixation or stabilization, and postoperative recovery.

Study design: Systematic review and meta-analysis.

Objective: The purpose of this study is to examine the cost of CLP versus CF stratified by approach to guide decision-making.

Summary of background data: Cervical laminoplasty (CLP) and cervical fusion (CF) are viable alternatives for surgical management of cervical spine myelopathy, with no clear consensus on clinical superiority. However, despite clinical equivalence in patient outcomes, there is limited data on the relative costs between CLP and CF.

Methods: This study searched PubMed, CINAHL, MEDLINE, and Web of Science databases. Inclusion criteria were articles that examined the cost between CLP and any type of CF (stratified by anterior, posterior, or combined approach). A random-effects continuous model for meta-analysis was performed using standardized mean difference (SMD).

Results: Eleven articles were included. Patients (n = 21,033) had an average age of 56.0 ± 3.6 years and underwent either CLP (n = 4364), posterior CF (n = 3529), anterior CF (n = 13,084), or combined CF (n = 56). The mean reported cost among patients who underwent CLP (n=3742) was significantly lower compared with patients who underwent CF (n = 6329), irrespective of the approach for CF (P = 0.028; SMD = -2.965). For subgroup analysis by surgical approach, the mean reported cost among patients treated with CLP was significantly lower as compared with patients treated with posterior CF (P = 0.013; SMD = -1.861) and anterior CF (P < 0.001; SMD = -0.344). Patients who underwent CLP had a significantly lower mean hardware cost than patients who underwent posterior CF (P < 0.001; SMD = -3.275).

Conclusions: CLP appears to be associated with statistically significant and clinically relevant lower reported costs than CF, irrespective of the approach based on meta-analysis of low or moderate-quality retrospective studies. CLP may also have lower reported costs than both posterior CF and anterior CF.

Level of evidence: IV.

Study design: Narrative review.

Objective: To provide an updated overview of pediatric cervical spine trauma.

Summary of background data: Pediatric cervical spine trauma can cause debilitating morbidity and mortality and neurological impairment. The unique anatomic features of the developing cervical spine can predispose children to injuries.

Methods: We reviewed the pediatric cervical spine trauma literature in PubMed and EMBASE.

Results: Pediatric cervical spine injury occurs in 1%-2% of pediatric trauma. The most frequent cause is motor vehicle collisions, with sports-related injuries being more common in older children. Larger head-to-body ratios and tissue elasticity can predispose young children to a greater risk of injury higher in the craniocervical junction and cervical spine. Standardized protocols and classification systems, such as the Pediatric Cervical Spine Clearance Working Group protocol and the AO Spine Injury and Subaxial Cervical Spine Injury Classifications, are valuable in triage as well as for assessing the need for operative versus nonoperative management. In general, operative approaches and principles are similar to those in adults, with modern instrumentation and fusion techniques achieving high rates of successful arthrodesis.

Conclusions: Effective management and treatment of pediatric cervical spine injuries depends on early and accurate diagnosis, a thorough understanding of pediatric spinal anatomy, and a versatile surgical armamentarium.

Study design: Retrospective database study.

Objective: This study aims to quantify and compare mean work RVUs (wRVUs), mean operative time (OpTime), and wRVUs/min in single- and multilevel anterior and posterior cervical spine fusions performed between 2011 and 2020.

Summary of background data: Prior research has demonstrated inconsistencies in technical skill, operative time, and surgical difficulty with reimbursement in various orthopedic subspecialties. Although trends investigating physician effort and reimbursement have been investigated in lumbar spine surgery, less research has examined these relationships with respect to cervical spine procedures.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for Current Procedural Terminology (CPT) codes reflecting anterior cervical discectomy and fusion (ACDF), posterior cervical decompression and fusion (PCDF), and the number of levels involved. The cohort was stratified into 10 groups: single-level, 2-level, 3-level, 4-level, 5+ level anterior or posterior cervical fusions. Mean operative times, mean wRVUs, and wRVU/min were calculated and compared by Student t test.

Results: A total of 100,997 patients met inclusion criteria in this study, of which 79,141 (78.36%) underwent ACDF, whereas 21,836 (21.62%) underwent PCDF. One- and 2-level fusions were most common in both ACDF and PCDF. In 1-, 3-, 4-, and 5+ level fusion, the anterior approach demonstrated significantly lower mean wRVU (P<0.001). In 1-, 2-, and 3-level fusions, the anterior approach had significantly lower operation times (P<0.001). The anterior approach demonstrated significantly higher wRVU/min in 1- and 2- levels (P<0.001) but lower wRVU/min in 3- and 4-level fusions (P<0.001).

Conclusions: Clear discrepancies exist between surgical approach and levels of fusion in cervical spine procedures incongruous with markers of surgical difficulty, physician effort, or expertise required. These specific results suggest that the complexity of multi-level anterior cervical fusions are not effectively accounted for by existing RVU measures.

Study design: Retrospective cohort study.

Objective: The purpose of this study is to determine the utility of advanced imaging to confirm the placement of robotic pedicle screws.

Summary of background data: With increasing robotic adoption, certain institutions and surgeons have developed protocols for obtaining 3D intraoperative imaging after robotic pedicle screw placement to ensure proper hardware placement. No studies have assessed the utility of these protocols relative to the potential risks of increased radiation exposure and operative time. The purpose of this study is to determine if we should be obtaining advanced imaging to confirm the placement of robotic pedicle screws.

Methods: This is a single institution retrospective cohort study of patients from May 2022 to July 2023 who underwent lumbar spinal fusion by a high-volume orthopedic spine surgeon at a level 1 metropolitan hospital. All cases used combined robotics and navigation systems for pedicle screw placement and intraoperative 3D imaging for evaluation of screw position. Pedicle screw accuracy was assessed using the Gertzbein and Robbins system (GRS). Acceptable pedicle screw position was defined as GRS A or B.

Results: Seventy patients with 354 robotically placed pedicle screws were assessed with intraoperative 3D fluoroscopy. All pedicle screws were placed in either a GRS type A or type B position. Three hundred forty-seven were placed in a GRS A classification (99.2%, 351/354), and 3 were placed in a GRS B classification (0.08% 3/354). No patients had screw-related complications. The average radiation dosage of 3D imaging was 289.7±164.6 mGy.

Conclusion: The robotic system places pedicle screws accurately without 3D intraoperative imaging. Given the increased radiation and operative time associated with 3D imaging protocols 3D imaging scans should only be obtained in cases with heightened clinical concern.

Level of evidence: Level IV.

Study design: Retrospective cohort study.

Objective: The purpose of this study was to (1) evaluate recent trends in the use of intraoperative neuromonitoring (IONM) for anterior cervical discectomy and fusion (ACDF) in the United States, (2) assess regional variations in the use of IONM, and (3) assess the association between IONM and clinical outcomes.

Summary of background data: IONM is frequently used during anterior cervical procedures to mitigate the risk of neurological injury. Prior studies have demonstrated decreasing utilization of IONM in ACDFs. However, no recent studies have re-assessed these trends.

Methods: Cases of cervical myelopathy and radiculopathy that underwent ACDF from 2011 to 2021 were identified through the PearlDiver Patient Record Database. Rates of IONM were compared based on patient age, gender, income, and region. Complications, 30-day readmissions, and reimbursement rates were also assessed.

Results: We identified 285,939 patients undergoing isolated ACDF, with 45,943 (16.1%) of these cases using IONM. There was a significant increase in the use of IONM for ACDFs over the study period (R2=0.87, P<0.001). Significant regional variability was observed in the utility of IONM (Northeast; 21.2%, Midwest; 16.3%, South; 14.7%, West; 14.2%; P<0.001). Younger age and higher patient income were associated with increased utility of IONM (P<0.001). IONM was associated with significantly higher costs but no reduction in rates of postoperative neurological complications (P<0.001 and 0.29, respectively).

Conclusion: This study demonstrates a significant increase in IONM utilization during ACDFs over the past decade. Considerable differences exist in IONM use concerning patient demographics, income, and geographic region, with the highest utilization in the Northeast. Notably, despite the association of IONM with over a 20% increase in reimbursement rates, its implementation was not associated with a reduction in rates of neurological complications.

Study design: Retrospective review.

Objective: To use opportunistic computed tomography (CT) screening to determine the prevalence of osteoporosis (OP) in patients presenting with spinal fractures and the rate of identification and treatment at our institution.

Background: OP remains a highly underdiagnosed and undertreated disease. Opportunistic abdominopelvic CT scans offer a feasible, accessible, and cost-effective screening tool for OP.

Methods: Retrospective review of 519 patients presenting as trauma activation to the emergency department of a Level 1 Trauma Center after a spinal fracture. Patients were excluded if under the age of 18 or lacking a CT scan upon arrival in the emergency department. Hounsfield Units (HU) were measured at the L1 vertebral level on CT scans to determine bone density levels. Values of ≤100 HU were considered osteoporotic, whereas 101-150 HU were osteopenic.

Results: A total of 424 patients were included. The average HU was 204.8 ± 74.3 HU. Of the patients, 16.7% were diagnosed as osteopenic and 9.9% as osteoporotic. The mean age was 65 ± 14 years for osteopenic patients and 77 ± 11 years for osteoporotic. A statistically significant inverse relationship was found between age and bone density. Of the patients, 42.5% with low bone density HU measurements had a previously documented history of OP/osteopenia. There was a statistically significant association between females and low bone density. Patients injured in a fall were statistically significantly more likely to have lower bone densities than those in motor vehicle accidents. Of the osteoporotic patients, 9.5% were treated by our institution's fragility fracture team.

Conclusions: Our study shows that among a cohort of patients with spinal fractures, 58% of patients with radiographic signs of OP are currently undiagnosed, resulting in a low treatment rate of OP. Increasing and standardizing the use of opportunistic CT scans would allow an increase in the diagnosis and treatment of OP in patients with spinal fractures. Further, opportunistic CT scans could also be useful for a broader orthopedic population at high risk of fragility fractures.

Level of evidence: Level II-therapeutic.

Study design: Case series.

Objective: Endoscopic posterior cervical foraminotomy gains attention for cervical radiculopathy due to its feasibility, better outcomes, and lower complications than traditional approaches, enabling efficient multilevel decompression in a single operation while avoiding anterior cervical diskectomy and fusion-related issues. However, with multilevel decompression, the remnant lamina becomes thin and fragile. We propose craniolateral inclinatory foraminotomy to minimize bone removal during laminotomy, reducing the risk of iatrogenic or postoperative lamina fractures in tandem decompression.

Materials and methods: From 2021 to 2022, 8 consecutive patients underwent the procedure and were followed up for at least 6 months. The VAS, NDI, and MacNab scores were recorded for clinical recovery and patient satisfaction evaluations. Preoperative and postoperative CT scans were utilized to measure the lamina preservation percentage at each level.

Results: The clinical outcomes improved significantly in every patient. No postoperative neck pain, segmental instability, or lamina fracture were observed. The mean lamina preservation percentages of C5, C6, C7, and all vertebrae were 68.8%, 73.22%, 71.86%, and 72.18%, respectively.

Conclusions: Ongoing technical adjustments will accompany endoscopic technique development to decrease complications and enhance benefits. Our reported technique avoids extensive laminotomy in multilevel tandem decompression, aiming to prevent lamina fractures and anticipate a reduction in postoperative neck pain.

Level of evidence: Level IV.

Study design: Single-institution retrospective review.

Objective: To establish baseline ranges and variability of 7 radiographic measurements of the cervical spine in a healthy patient population as potential diagnostic tools for craniocervical instability.

Summary of background data: Craniocervical instability, common in patients with connective tissue disease such as Ehlers-Danlos Syndrome, often presents with a wide range of symptoms, including neck pain. Current diagnostic methods employ a range of clinical and radiographic features, but diagnostic challenges remain due to missed indications on static imaging and a lack of standardized measurement values and normalized variance.

Methods: Seventy-two healthy patients with cervical imaging were analyzed. Surgimap software was used to annotate supine computed tomography images, flexion, extension, and neutral x-ray images for measurement. These measurements included the atlanto-dental interval, clival-axial angle, basion-dens interval, basion-axis interval, perpendicular basion to the inferior aspect of C2, also known as Grabb Oakes measurement, and the hard palate to C1 and hard palate to C2. Statistical analysis assessed differences among imaging modalities, and coefficients of variation were calculated for each measurement.

Results: Our cohort consisted of a total of 72 patients with a mean age of 64 (SD: 13.54). All measurements except for the basion-axial interval and atlanto-dental interval demonstrated a significant difference between extension and flexion x-ray measurements. clivo-axial angle, hard palate to C1, and hard palate to C2 demonstrated the lowest coefficients of variance across imaging modalities.

Conclusion: Understanding normal variance in cervical measurements is invaluable for accurate CCI diagnosis. Using a cohort of healthy patients, this study delineates the distribution and spread of 7 cervical measurements, delineating reference values and variability in these key measurements and highlighting their potential for use as imaging markers for CCI.

Level of evidence: Level III.