Clinical Spine Surgery最新文献

Study design: A retrospective cohort study.

Objective: To identify factors associated with minimally invasive surgery (MIS) utilization and compare inpatient outcomes between MIS and open fusion for traumatic thoracic vertebral fractures using a multicenter trauma registry.

Summary of background data: MIS is increasingly utilized in spine surgery due to its potential to reduce perioperative morbidity. However, its role in managing traumatic thoracic vertebral fractures remains unclear, and large-scale comparisons of MIS versus open fusion in this setting are limited.

Methods: Adult patients (≥18 y) who underwent thoracic fusion for traumatic thoracic fractures between 2019 and 2021 were identified from the American College of Surgeons Trauma Quality Program database using ICD-10 codes. Patients were stratified by surgical approach (MIS vs. open), and demographic, injury, and clinical characteristics-as well as inpatient outcomes-were compared using chi-squared and t-tests. Multivariable logistic regression was performed to identify patient and injury factors associated with MIS utilization. A P-value < 0.05 was considered statistically significant.

Results: Of 8999 patients undergoing thoracic fusion, 370 (4.1%) received MIS. MIS utilization was associated with older age, lower Injury Severity Scores, and less severe neurological impairment. The number of vertebral levels fused did not differ by approach. MIS patients had significantly shorter length of stay, higher home discharge rates, and lower rates of complications, intensive care unit admission, and mechanical ventilation.

Conclusion: This multicenter cohort study identifies key patient and injury characteristics associated with MIS utilization in thoracic trauma. While MIS was associated with some favorable inpatient outcomes, this may be due to selection bias rather than procedural effect. Further prospective studies are needed to clarify appropriate indications and long-term outcomes.

Study design: Retrospective cohort study.

Objective: To evaluate the impact of patient age on complication rates, radiographic alignment, and patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF).

Summary of background data: ACDF is one of the most common and effective spinal procedures in the United States. However, as a rising number of elderly patients undergo ACDF, age-related differences in outcomes such as subsidence, adjacent segment disease, and PROs remain poorly defined.

Methods: A retrospective review was conducted on 302 patients who underwent ACDF between 2020 and 2022 at a single academic institution. Patients were stratified into 4 age groups: younger than 50, 50-59, 60-69, and 70 years or older. Univariate regression analyses compared cervical sagittal alignment and PROs, while multivariate analyses assessed perioperative characteristics and complications.

Results: Compared with the younger-than-50 cohort, patients aged 50-59 exhibited a significantly higher rate of subsidence (29.6% vs. 13.7%, P=0.001). The 60-69 group showed a similar outcome (24.6%, P=0.033) and a significantly longer length of stay (1.34 vs. 0.96 d, P=0.023). Patients aged 70 years or older experienced the most pronounced changes: subsidence occurred in 42.1% (P=0.044), LOS increased to 1.74 days (P=0.001), and SVA increased by an average of 0.83 cm preoperatively, unlike younger cohorts, in whom SVA stabilized. In addition, patients aged 70 years or older reported a significant resurgence of neck pain at 1- and 2-year follow-ups. In contrast, this group also exhibited the greatest improvement in brief resilience scale scores, ultimately reporting the highest resilience at 1 year postoperatively (P=0.0162).

Conclusions: Advanced age is associated with increased subsidence, sagittal imbalance, longer hospitalization, and recurrence of neck pain following ACDF. These findings are important to consider when planning ACDF, particularly in patients aged 70 years or older. Nonetheless, improvements in resilience among older patients highlight their capacity for meaningful recovery.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: To compare the advantages and disadvantages of two different foraminoplasty methods.

Summary of background data: Foraminoplasty is one of the most important steps in FELD surgery. In recent years, different surgical instruments for foraminoplasty have been invented, mainly, including reamer/trephine and bone drill. Different foraminoplasty methods have different effects and limitations on the surgical outcome.The aim of this study was to compare surgical outcomes, anesthesia satisfaction, and learning curves between two different foraminoplasty procedures.

Patients and methods: A total of 109 patients with lumbar disc herniation (LDH) treated with full endoscopic lumbar discectomy (FELD) by the same group of physicians from October 2020 to February 2022. Patients underwent foraminoplasty with bone drill were divided into group A, while foraminoplasty with trephine as group B. Back and leg visual analogue scale (VAS), Oswestry disability index (ODI) were evaluated at different time follow-up for evaluating surgical outcomes. Different types of anesthesia were recorded, and patients' intraoperative pain assessment was evaluated. Learning curve was presented with operation time in chronological order.

Results: There were statistically differences between VAS-back postoperative (P=0.0077) on 6 months. There was also a statistical difference in back pain symptom scores under the interaction between groups and time (P=0.147). The intraoperative VAS score of group A was significantly higher group B (P=0.008). Migration herniated discs and foraminoplasty method were the main factors affecting intraoperative pain. The operation time of group A was shorter than that of group B, while there was no statistical difference (P=0.782).

Conclusions: Both surgical techniques can achieve good curative effect (excellent rate: 87.7% vs. 89.1%). Patients in group A recovered faster on postoperative function. Patients in group B had better intraoperative experience.

Study design: Retrospective cohort study.

Objective: The purpose of our study is to identify CT characteristics of unilateral cervical spine facet fractures that are predictive of instability on MRI.

Summary of background data: Management of isolated subaxial cervical spine facet fractures is typically based on the neurological status of the patient and perceived stability of the injury. It has been shown that the degree of ligamentous instability can help predict instability and need for surgery, and MRIs are increasingly being used to evaluate these injuries, but not always. While there are studies that evaluate radiographic characteristics of facet fractures on CT, there are few that specify which CT findings predict instability on MRI.

Methods: A retrospective review of 49 patients with unilateral cervical facet fractures during a 7-year period from a level I trauma center was performed. All patients had a CT and an MRI performed. Measurements of fracture fragments were obtained from CT scans. MRIs were examined by an independent radiologist and assigned an instability score. CT measurements were compared with MRI instability scores to determine which parameters were predictive of the need for operative stabilization.

Results: Forty-nine patients were identified with unilateral cervical spine facet fractures. Thirty patients initially were treated nonoperatively, and 19 patients underwent surgical stabilization. One patient failed nonoperative management, having neurological deficits and pain at follow-up, and underwent a C6-C7 ACDF later. The average instability score in the operative group was 3.34, versus 1.06 in the conservative treatment group ( P <0.001). Fracture displacement ( P =0.013), multifragmentary fractures ( P <0.001) and MRI instability score ( P <0.001) were correlated with a statistically significant increased likelihood of operative necessity.

Conclusions: Fracture size did not directly correlate with ligamentous injury. Displacement and multifragmentary fractures on CT scan were had the highest correlation with instability scores on MRI. This suggests that patients with subaxial cervical facet fractures that are comminuted or have significant displacement may require operative stabilization.

Level of evidence: Level III.

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.