Clinical Spine Surgery最新文献

Study design: A retrospective cohort study.

Objective: To describe the incidence, timing, and reason for ED visits following primary versus revision lumbar fusion.

Summary of background data: Emergency department (ED) presentation and misutilization place a substantial financial strain on patients and the health care system. ED visits following lumbar fusion are common and may be an overlooked target for reducing cost.

Methods: A retrospective cohort study of patients undergoing 1-3 level primary versus revision lumbar fusion was performed. Outcomes included the incidence and characteristics (inpatient admission, discharge home, or reoperation) of ED visits at 2 weeks, 30 days, and 90 days postoperatively. Logistic regression analysis was performed to identify independent predictors of postoperative ED visits.

Results: A total of 2360 patients were included (1852 primary and 508 revision). Rate of 90-day ED visits was higher in the revision group (10.2%) compared with the primary group (6.86%, P=0.014). However, breakdown by 15-day intervals revealed this was only significant between 14 and 30 days postoperatively (1.30% vs. 3.35% for revisions, P=0.004). Reasons for ED visits were similar, with both groups presenting most commonly for pain complaints. Primary patients presenting to the ED were more likely to require admission (48.0% vs. 26.9%; P=0.015). Logistic regression demonstrated that revision surgery (OR: 2.67, P<0.001), Cut-to-close time (OR: 1.003, P=0.028) and LOS (OR: 1.11, P=0.023) independently predicted postoperative ED visits.

Conclusion: Revision lumbar fusion was an independent predictor of visiting the ED, especially from 14 to 30 days postoperatively, but the absolute increase in risk was mild at 3.4%. Cut-to-close time was also statistically predictive, although with an effect size that is not clinically significant. However, visits to the ED after revision surgery were less likely to require readmission compared with visits after primary lumbar surgery. These findings may suggest that patients undergoing lumbar fusion should be appropriately counseled regarding postoperative pain expectations and appropriate acute care utilization, especially in the revision setting.

Study design: A case-series study.

Objectives: To acquire diagnostic insights to distinguish between intradural extramedullary spinal metastases (IESM) and benign spinal tumors by comparing patients with IESM and those with schwannoma or spinal meningioma.

Summary of background data: IESM constitute a rare category of spinal metastases. As the outcome of IESM is usually poor without intervention, early diagnosis and treatment are particularly important for better prognosis. As few studies have clearly addressed the features of IESM, it is necessary to gain comprehensive diagnostic insights into the characteristics of the disease.

Methods: Included in this study were 14 IESM patients who underwent gross total tumor resection. IESM and schwannoma or meningioma were compared in a ratio of 1:2. Differences in clinical and imaging presentations between them were analyzed statistically, and survival curves were plotted using the Kaplan-Meier method.

Results: IESM presented an unclear boundary (P=0.005), an irregular shape (P=0.035), and A low probability of cystic degeneration (P=0.028) as compared with schwannoma. Compared with IESM, meningioma tended to have a clear boundary (P=0.001), a wide base (P=0.047), high calcification possibility (P=0.040), and homogeneous enhancement on MRI (P=0.016). The estimated mean overall survival of IESM patients was 16.80±3.94 months.

Conclusion: This study demonstrated the characteristics of IESM and clarified the distinguishing points between IESM and intradural extramedullary benign tumors. Early warning features drawn from this study may be able to help clinicians to identify patients with IESM.

Summary of background data: Previous studies comparing the anterior versus posterior approach for the treatment of degenerative cervical myelopathy (DCM) report similar neurological outcomes. Although multilevel DCM is frequently combined with foraminal stenosis, previous studies have analyzed the outcomes of myelopathy without specifically addressing the outcomes of combined radicular symptoms.

Objective: To compare the outcomes following anterior and posterior decompressive procedures for DCM combined with multilevel foraminal stenosis.

Study design: A retrospective study.

Methods: A cohort of patients with DCM with multilevel foraminal stenosis (>3 levels) who underwent decompression was analyzed. In the anterior group (group A), multilevel anterior cervical decompression and fusion were performed, and the posterior group (group P) consisted of laminoplasty with foraminotomies. Nurick grade, visual analogue scale (VAS) of neck and arm pain, neck disability index (NDI), short-form 36 (SF-36), complications, clinical adjacent segment pathologies (CASP), and additional operations performed were analyzed. C2-7 angle and range of motion, and Kellgren grade of radiographic adjacent segment pathology (RASP) were evaluated.

Results: A total of 96 patients were enrolled (M:F=53:43, mean age 60.8 y, A: P=54:42, mean 36.6 mo follow-up). All clinical parameters showed significant improvement from preoperative neurological status without significant difference between the 2 groups at the final follow-up. Both RASP grade and incidence of CASP were higher in the anterior group (A: 42.6% vs. P: 19.2%, P=0.014). The incidence of additional procedures was similar (A: 9.3% vs. P: 16.7%, P=0.276); however, the etiology was mainly CASP in the anterior group (4-5 cases) and persistent radicular symptoms in the posterior group (6-7 cases).

Conclusions: Anterior and posterior decompressive surgeries are reliable for the surgical treatment of DCM with multilevel foraminal stenosis and showed similar outcomes for both myelopathy and upper extremity radicular symptoms. The major etiology compromising the clinical outcome was a higher incidence of CASP in the anterior group and persistent or recurrent upper extremity radicular symptoms in the posterior group.

Study design: Single-institution, retrospective cohort study.

Objective: Determine whether preoperative and intraoperative computed tomography (CT) Hounsfield units (HU) were reliable, consistent, and had similar diagnostic ability for detecting osteoporosis.

Summary of background data: Osteoporosis is common in spine surgical patients and associated with adverse outcomes. Opportunistic use of preoperative CT HU has been shown to estimate bone quality and fracture risk. Spinal navigation systems utilize intraoperative CT, which may offer an opportunity for osteoporosis assessment.

Methods: From January 2021 to December 2022, 166 patients who underwent thoracolumbar surgery using spinal navigation and had both preoperative and intraoperative CT scans were included. Regions of interest (ROI) measuring 200 mm2 were placed in the centroid of the L1 vertebral body to measure HU, with HU values >150 indicating normal bone, 110-150 osteopenia, and <110 osteoporosis. Preoperative and intraoperative CT HU were compared using the Pearson correlation. Bland-Altman and Cohen kappa analysis were used to determine agreement.

Results: Mean (SD) age was 61.11 (8.79), BMI was 30.26 (6.09), and 54% were female. Mean preoperative and intraoperative L1 HU were 150.66 (58.33) and 148.41 (57.59), respectively, which were not significantly different (P=0.339). On the basis of HU, normal bone, osteopenia, and osteoporosis were present in 41%, 39%, and 20% of patients based on preoperative CT compared with 37%, 38%, and 25% on intraoperative CT, k=0.91 [95% CI: 0.87-0.95]. Preoperative and intraoperative CT HU had a strong, positive correlation (r=0.982, P<0.001). Bland-Altman demonstrated agreement between preoperative and intraoperative CT HU, with a mean difference of 2.23 [95% CI: -19.70 to 24.16], P=0.427.

Conclusions: Preoperative and intraoperative CT HU values were reliable, consistent, and demonstrated similar diagnostic ability for osteoporosis. Intraoperative HU may be useful for identifying patients at high risk for fracture or adverse surgical outcomes with probable osteoporosis who may require further postoperative bone health evaluation.

Mendelian randomization (MR) is a statistical method that is rising in popularity. Although randomized controlled trials (RCTs) remain the gold standard in terms of inferring causality, they are not always feasible due to time, ethical, and resource constraints. Therefore, MR can be used to establish causality through observational and noninterventional data coupled with large and quickly growing genome-wide association studies (GWAS), thereby overcoming the confounding limitations of observational studies. This article aims to provide the reader with a better understanding of Mendelian randomization and expand on how this method investigates causal relationships and provides examples relevant to orthopedic surgery.

Study design: Systematic review and meta-analysis.

Objective: To evaluate the impact of erector spinae plane (ESP) blocks on perioperative outcomes in pediatric scoliosis surgery.

Summary of background data: The ESP block is an increasingly utilized regional anesthesia technique in spine surgery, yet its efficacy in pediatric posterior spinal fusion for scoliosis correction remains incompletely characterized.

Methods: A systematic database search was performed following PRISMA guidelines. Studies were included if they compared outcomes between pediatric patients receiving ESP blocks (ESP-B) and those undergoing standard care (control) undergoing posterior instrumented fusion. Data on postoperative pain scores, opioid consumption, time to PCA use, length of stay (LOS), and functional outcomes were extracted and synthesized using fixed-effects meta-analysis.

Results: Six studies (4-level I, 2-level III) comprising 178 ESP-B patients and 197 controls were included. The ESP-B cohort had significantly lower postoperative pain scores at all assessed time points, including immediately postoperative (MD=-0.93, P=0.0035), 12 hours postoperative (MD=-2.15, P<0.001), and 48 hours postoperative (MD=-1.09, P<0.0001). In the ESP-B cohort, the time to PCA initiation was significantly delayed (MD=4.05 h, P<0.0001), total opioid consumption was lower (MD=-10.83 mg oral morphine equivalents, P<0.0001), and the incidence of postoperative nausea or vomiting was lower (OR=0.12, P=0.0008). The ESP-B cohort also had shorter postoperative LOS (MD=-1.34 d, P<0.0001). Though only reported in one study each, ESP-B experienced fewer opioid-related side effects, greater ambulation distances, and higher inpatient satisfaction scores.

Conclusion: There is moderate evidence suggesting ESP blocks are effective in improving postoperative pain and reducing opioid requirements in pediatric patients undergoing posterior spinal fusion. These findings support the integration of ESP blocks into multimodal analgesia protocols for pediatric scoliosis correction.

Study design: Retrospective cohort.

Objective: To evaluate surgical outcomes and opioid consumption among patients undergoing a C3-T1 posterior cervical decompression and fusion (PCDF) with lateral mass or pedicle screw fixation at C7.

Background: Biomechanical work has suggested that junctional pedicle screws provide more robust fixation during cervicothoracic fixation at the expense of increased technical risk compared with lateral mass screws. However, minimal data exist directly comparing these 2 hardware options.

Methods: Adult patients who underwent primary C3-T1 PCDF (2017-2022) with C7 lateral mass versus pedicle screw fixation were compared. Patient demographics, surgical characteristics, and surgical outcomes were collected. Outpatient opioid utilization and morphine milligram equivalents (MMEs) from 1-year preoperatively to 1-year postoperatively were obtained from Pennsylvania Prescription Drug Monitoring Program. In-hospital MME data were also collected.

Results: Thirty patients received lateral mass fixation, and 50 patients received pedicle screw fixation at C7. These groups were demographically similar, with similar average length of follow-up between the lateral mass (748±364 d) and pedicle screw (853±402 d, P=0.28) groups. Despite requiring a greater number of decompressed levels (4.17 vs. 3.74, P=0.002), cut-to-close time was shorter for the lateral mass group compared with the pedicle screw group (168±37.6 vs. 191±41.3 min, P=0.015). However, both groups were similar regarding surgical outcomes and preoperative and 1-year postoperative opioid consumption.

Conclusions: Despite a greater number of decompressed levels among the lateral mass group, these patients experienced a shorter average operative time during C3-T1 PCDF. However, short-term surgical outcomes and opioid consumption up to a year postoperatively were similar between groups. Thus, there does not appear to be short-term safety or pain drawbacks to C7 pedicle screws that would justify the decreased biomechanical advantages of lateral mass screws.

Study design: Retrospective cohort study.

Objective: We studied patients who underwent minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) to those to who received open TLIF to compare revision rates, functional outcomes, and satisfaction at 5 years after surgery.

Summary of background data: MI procedures have recognized advantages over open procedures. However, if the decompression is inadequate or if implants are not optimally placed (for examples), a revision may subsequently be necessary. Various studies have demonstrated that there is no difference between these approaches at more than 12 months of follow-up.

Methods: We studied adults who received transforaminal lumbar interbody fusion at 1 or 2 levels mainly for degenerative spondylolisthesis or stenosis. Patient records were reviewed surgery time, estimated blood loss, intraoperative duration of imaging radiation, and length of stay in the hospital. Pre- and postoperative function outcomes (Oswestry Disability Index, ODI), satisfaction rating at last follow-up, sagittal alignment, and revision rates were also collected.

Results: At 5 years postoperatively, we found no differences between open and MI-TLIF in ODI and satisfaction. Among MI-TLIF patients, 22% required revision surgery compared with 28% of open patients. This difference was not statistically significant (P=0.5). The median time until revision was longer for MI-TLIF patients (102 wk) compared with open TLIF patients (56 wk), but the difference was not statistically significant at 5 years (P=0.07). Surgical time, blood loss, and length of stay were better for the MI group but radiation exposure was greater compared with the open group.

Conclusions: About one fourth of open and MI-TLIF patients may expect a revision surgery within 5 years of their index procedure.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: The purpose of this study was to establish preoperative albumin thresholds to stratify the risk of 30-day complications after PCF.

Summary of background data: Over the past 2 decades, rates of posterior cervical fusion (PCF) have risen significantly, coinciding with advancements in surgical techniques and an aging population, but with complications occurring in up to 25% of cases. Hypoalbuminemia may increase risk for complications after spine surgery, but there are no studies that utilize data-driven methods to derive precise thresholds to risk-stratify patients. Although the association between malnutrition and subpar outcomes has been investigated, there remains a paucity of literature examining PCF.

Methods: A retrospective cohort analysis was performed using a national database. Patients with a preoperative measurement of albumin before PCF were included, whereas patients undergoing multilevel PCF were excluded. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven albumin strata that minimized the likelihood of complications within 30 days of PCF. Multivariable regression was utilized to stratify the risk of 30-day major and minor complications after PCF.

Results: SSLR analysis identified 3 albumin strata: 1-3.2g/dL, 3.2-3.6g/dL, and 3.6+g/dL before surgery. Compared with the 3.6+ g/dL stratum, the 1-3.2g/dL (OR: 3.02) and 3.2-3.6g/dL (OR: 1.65) cohorts had significant and sequentially increasing odds of 30-day all-cause complications after PCF ( P < 0.05 for all).

Conclusions: This study established data-driven preoperative albumin thresholds that correlate with an increased risk of 30-day all-cause complications after PCF. To the best of our knowledge, this is the first study to demonstrate the variable and stratifiable risk of complications on the basis of preoperative albumin levels. These findings assist spine surgeons in stratifying patient risk based on preoperative albumin levels, enabling more informed decision-making and potentially improving patient outcomes.

Study design: Retrospective cohort study.

Objective: To investigate the surgical outcomes of patients receiving regular weak opioids preoperatively in posterior decompression surgery for cervical spondylotic myelopathy.

Summary of background data: Several studies have reported that regular preoperative opioid intake is a risk factor for poor patient outcomes after spine surgery. However, the effect of preoperative weak opioid intake on the outcomes of patients with cervical spondylotic myelopathy, particularly those undergoing posterior decompression surgery without fusion remains unknown.

Methods: We reviewed 211 patients with cervical myelopathy who underwent posterior cervical decompression surgery and divided them into 2 groups based on regular preoperative weak opioid intake. The Numerical Rating Scale (NRS score, 0-10) for neck pain, Neck Disability Index (NDI), and Euro-Quality of Life 5-Dimensions (EQ-5D) scores were compared between the 2 groups. Preoperative oral analgesic intake was also assessed.

Results: All twenty patients who had taken opioids regularly were using tramadol. Patients were divided into tramadol (+) or tramadol (-) group based on regular preoperative tramadol intake. The tramadol (+) group was more likely to receive pregabalin/mirogabalin or duloxetine. Tramadol (+) group showed worse neck pain, NDI, and EQ-5D scores preoperatively and worse NDI and EQ-5D 1 year postoperatively than tramadol (-) group. However, after propensity score matching, the improvement rate of the NRS for neck pain, and the minimal clinically important difference achievement for the NDI and EQ-5D were comparable between the 2 groups.

Conclusion: Patients receiving regular weak opioids preoperatively can achieve successful surgical outcomes after posterior decompression surgery for cervical spondylotic myelopathy.