Clinical Spine Surgery最新文献

Study design: A pilot randomized controlled trial.

Objective: To investigate the effects of a prehabilitation program on early postoperative outcomes in Japanese patients undergoing lumbar spinal stenosis (LSS) surgery.

Summary of background data: Prehabilitation has shown promise for improving postoperative outcomes in various surgical populations. However, its effectiveness in Japanese patients undergoing LSS surgery has not been previously studied.

Methods: Thirty-two of 34 patients scheduled for LSS surgery (mean age: 69.3 y, 17 female) were randomly assigned to the prehabilitation group (15 patients) or control group (17 patients). The primary outcomes were the Oswestry Disability Index (ODI) and 6-minute walk distance (6MWD). The secondary endpoints were the visual analog scale (VAS) scores for back pain, leg pain, and numbness. The intervention group received a 20-30-minute educational session from a physical or occupational therapist using a pamphlet 1 month before surgery, while the control group received a pamphlet handout. Assessments were conducted 1 month before surgery (baseline); 1 day before surgery; and 1, 3, and 6 months postoperatively.

Results: All patients underwent preoperative educational sessions. The prehabilitation group showed significant improvements in 6MWD at 3 months postoperatively compared with the control group (446.8±48.9 m vs. 384.3±58.3 m, P =0.01, Hedges' g=1.11). ODI scores at 1 month postoperatively were lower in the prehabilitation group (10.2±10.9 vs. 19.0±10.7, P =0.04, Hedges' g=-0.77). Low back pain VAS at 3 months postoperatively was also lower in the prehabilitation group (12.5±14.8 vs. 27.5±20.8, P =0.04, Hedges' g=0.75). No adverse events were reported in either of the groups.

Conclusions: Prehabilitation may enhance postoperative recovery and outcomes in patients undergoing surgery for LSS. Further research with a larger sample size is needed to establish the effectiveness of prehabilitation in this population.

Study design: Retrospective multicenter cohort study.

Objective: To investigate the incidence and risk factors of postoperative hip displacement following spinal fusion in nonambulant patients with spastic neuromuscular scoliosis.

Summary of background data: In patients with spastic neuromuscular disorders, spinal deformity, and hip displacement mutually influence each other; however, little is known about the clinical impact of spinal fusion on the incidence of hip displacement.

Methods: We retrospectively analyzed nonambulant patients with spastic neuromuscular disorders undergoing primary fusion with a minimum follow-up of 1 year. The primary outcome was new postoperative hip displacement. To identify potential risk factors for postoperative hip displacement, an association analysis was conducted.

Results: We identified 67 eligible patients (29 males and 38 females) with a mean age of 14.1 years and a mean follow-up period of 49.4 months. Overall, 11 cases of postoperative hip displacement (10 up hip, and 1 down hip) were identified in 11 patients (16.4%). Patients with hip displacement were significantly more skeletally immature at surgery, had a significantly larger preoperative curve magnitude (115.6 vs. 97.5 degrees), larger correction of the Cobb angle (71.0 vs. 56.8 degrees), larger preoperative pelvic obliquity (36.2 vs. 24.3 degrees), and included a significantly higher proportion of cases with pelvic fixation ( P =0.03). Compared with patients with nondislocated stable up hip joints, 10 patients with new up hip displacement had a significantly higher preoperative migration percentage (MP) in the up hip (40.6 vs. 31.4, P =0.047). Receiver operating characteristic curve analysis revealed that the optimal cutoff value of the preoperative MP of the up hip for predicting postoperative displacement was 28.8 (sensitivity, 90.0%; specificity, 47.8%).

Conclusions: When performing spinal fusion in patients with spastic neuromuscular disorders, especially in those with identified potential risk factors, patients and their caregivers should be informed preoperatively about the possibility of subsequent hip displacement.

Level of evidence: Level III.

Study design: Observational cohort study.

Objective: The purpose of this study is to describe the association between 3 prevalent mental health comorbidities and 1-year health care utilization after lumbar fusion surgery.

Summary of background data: The volume of lumbar fusion procedures in the United States is increasing, leading to a substantial postoperative health care burden. Postoperative costs associated with these procedures may be driven by a number of factors, including patient comorbidities.

Methods: A large national commercial claims database (MarketScan, Merative) was analyzed. Patients who underwent a single-level lumbar fusion from January 1, 2018, to December 31, 2018, were included in the study. Patients were categorized based on the presence of a prior diagnosis of opioid dependence, anxiety, or depression. The main outcome was the total cost for postoperative interventions in the 1-year period after lumbar fusion. Interventions examined in this study included: (i) physical therapy, (ii) injections, (iii) pain medication, (iv) imaging, (v) clinic visits, and (vi) subsequent spine surgeries.

Results: The study population included 4245 patients (anxiety, 19.2%; depression; 19.2%; opioid dependence, 2.6%). The average total 1-year postoperative cost per patient was $8641 ± 19,661. Higher-cost patients were more likely to be those with a prior diagnosis of anxiety (OR 1.41, 95% CI 1.18-1.69, P <0.001) or opioid dependence (OR 1.82, 95% CI 1.23-2.69, P <0.01). Anxiety was found to be associated with the largest relative increases in total costs compared with patients without this diagnosis (+$2,272, P =0.003). The cost of pain medication was 4.2 times higher ( P <0.001) among patients with a prior diagnosis of opioid dependence.

Conclusions: Patients undergoing single-level lumbar fusion have varying levels of health care utilization, with a prior diagnosis of anxiety likely to drive higher costs.

Study design: Cohort retrospective study.

Objective: We evaluated and compared the outcomes of anterior cervical discectomy with fusion (CDF) and anterior cervical corpectomy with iliac crest graft and fusion (CCF) in patients with ≥3 level degenerative cervical myelopathy (DCM).

Background: Anterior and posterior approaches are widely employed in DCM when compressive elements predominate in the anterior or posterior spinal cord, respectively. Indications for each approach remain controversial in some contexts.

Methods: Following the STROBE statement, a retrospective enrollment from records of patients who underwent anterior CDF and/or CCF between June 2015 and June 2022. Linear mixed models were applied to establish the effects of the type of surgery according to the follow-up time (mo).

Results: In this study, 73 patients met the inclusion criteria, of which 21 (28.8%) were included in the CDF group and 52 (71.2%) in the CCF group. Twenty surgeries were performed at 3 cervical levels and 53 at 4 levels. There was an improvement in the NDI and VAS score, with an Odom mean of 1.63±0.67 at 12 months of follow-up, with no differences between CDF and CCF. In the CDF group, it was reported a greater C2-7 Cobb angle at the third month of follow-up. In the CCF group, the C2-7 Cobb angle had a negative correlation with the NDI and VAS scales, and a positive correlation with the mJOA scale. Intraoperative estimated blood loss (EBL), surgical time, and postoperative hospital stay were shorter in CDF. There were no differences between the 2 groups in medical complications and other radiologic findings.

Conclusion: Surgery for multilevel DCM using an anterior approach with CDF or CCF showed good clinical outcomes without significant differences between the 2 groups, and equivalent results in medical complications and radiologic parameters. The CDF group had better perioperative results and shorter postoperative hospitalization time.

Study design: Retrospective cross-sectional study aimed to investigate the postoperative outcomes following anterior cervical discectomy and fusion (ACDF) surgery in patients with end-stage renal disease (ESRD) and renal transplant recipients, using data from a large national database. Three patient groups were analyzed: control group, ESRD group, and renal transplant group.

Objective: To investigate the postoperative outcomes following ACDF surgery in patients with ESRD and renal transplant recipients, utilizing data from a large national database.

Background: Patients with ESRD and renal transplant recipients face unique health challenges, and there is a paucity of comprehensive research examining their postoperative surgical experiences, especially in the context of spine surgery.

Materials and methods: Data from 158,101 ACDF procedures performed between 2016 and 2019 were analyzed. Patients were stratified into 3 groups: control, end-stage renal failure, and renal transplant. The primary outcomes included 30-day medical complications, 30-day intensive care unit admissions, 90-day readmissions, and 1-year revision surgery. Multivariable logistic regression was employed for analysis.

Results: Patients with ESRD had significantly higher rates of 30-day medical complications (56%) and 90-day readmissions (38%) compared with the control patients (3% and 3%, respectively). Renal transplant patients also showed elevated rates of medical complications and readmissions, 12% and 10%, respectively, but lower than patients with ESRD. Patients with ESRD had significantly higher odds of intensive care unit admission. There were no significant differences in revision rates among the groups.

Conclusions: Patients with ESRD and renal transplant recipients undergoing ACDF surgery face increased risks of medical complications and readmissions, with patients with ESRD showing surprisingly high rates. Tailored care strategies and close monitoring are crucial for these patient cohorts, emphasizing the need for specialized postoperative care. The study's findings highlight the multifaceted nature of surgical outcomes in medically complex populations and the importance of holistic assessment.

Study design: A retrospective Cohort Study.

Objective: The aim of this study is to investigate the associations between posterior muscle health characteristics and disk geometry parameters between L1 and S1.

Summary of background data: Paralumbar muscle changes have been associated with clinical outcomes. However, the relationship between disk geometry and paralumbar muscle changes has not been defined.

Methods: Axial T2 MRI was analyzed for paralumbar muscle measurements, and lateral radiographs were analyzed for disk geometry parameters in patients with disk degeneration. Associations between disk shape and muscle health at each individual lumbar level were evaluated using a partial correlation controlling for age and sex. Demographic data were compared between the listhesis groups, and an ANCOVA analysis controlling for significant demographic parameters was conducted to evaluate differences in muscle characteristics.

Results: In all, 435 patients were included (age: 55.6±15, BMI: 29.5±6, 60.9% female, 41.3% White). Muscle health median characteristics were CSA/BMI=140, LIV=13, and Goutallier Classification of 1. Partial correlations between focal disk parameters and muscle health controlling for age and sex showed moderate significant positive associations between focal lordosis and lumbar indentation value (LIV) at every level L1-S1 (mean r =0.264 between L1 and L5, P <0.001), weak positive association between focal lordosis and CSA/BMI (mean r =0.113 at L2-L5, P <0.03), and weak negative associations between disk height and Goutallier Classification (mean r =0.158 at L1-L5, P <0.03). Listhesis at L4-S1 was stratified, and ANCOVA controlling for sex and age demonstrated no significant association between S and R groups and CSA/BMI, LIV, or Goutallier classification ( P >0.1).

Conclusions: Posterior muscle health was significantly associated with disk shape, especially disk height and disk lordosis, with larger and more lordotic disks being associated with better muscle health. Disk listhesis was not significantly associated with muscle quality when controlling for demographic characteristics, and no differences in muscle health parameters were observed in patients with spondylolisthesis versus retrolisthesis. Overall, the results highlight important associations between lumbar compensation, disk geometry, and posterior muscle health.

Study design: A retrospective study.

Objectives: To explore the efficacy of short-segment fixation with bone cement augmentation in the treatment of unstable Kümmell disease.

Summary of background data: Kümmell disease, characterized by delayed post-traumatic osteonecrosis of the vertebral body, often results in progressive vertebral collapse and instability, posing challenges for surgical management. Bone cement augmentation combined with short-segment fixation has emerged as a potential solution, but its long-term efficacy and safety require further evaluation.

Methods: From January 2017 to June 2022, retrospective study was conducted on the clinical data of patients with single-segment unstable Kümmell disease. A total of 45 cases unstable Kümmell disease patients with an average age of 71.4±6.0 years were included. The disease duration was 23.1±8.1 months. The bone mineral density (BMD) T-value was -3.5±0.4 SD. Each patient was treated with short-segment fixation with bone cement augmentation and posterolateral bone graft fusion. Evaluation outcomes include the visual analog scale (VAS), Oswestry disability index (ODI), anterior vertebral height, kyphosis Cobb angle.

Results: The operation time was 116.0±21.7 minutes, the intraoperative blood loss was 156.2±54.8 mL. All patients were followed-up for an average of 36.6±8.7 months. Compared with preoperative, VAS, ODI, and kyphosis Cobb angle were significantly decreased postoperative (P<0.05), and anterior vertebral height was significantly increased postoperative (P<0.05). Compared with postoperative, VAS, ODI were significantly decreased last follow-up (P<0.05), and anterior vertebral height, kyphosis Cobb angle was were not significantly changed last follow-up (P<0.05). At the last follow-up, all patients fixed segments were fused. There was no failure of internal fixation during the follow-up.

Conclusions: Short-segment fixation with bone cement augmentation in the treatment of unstable Kümmell disease is feasible and effective, can improve the clinical symptoms of patients, better correct kyphosis, and maintain the height of the injured vertebra, with fewer complications.

Study design: Surgical technique presentation.

Objectives: To introduce a novel full-percutaneous trans-Kambin transforaminal lumbar interbody fusion (pTLIF) procedure for placing a large-footprint interbody cage with manual reamers and optional endoscopic foraminoplasty.

Background: Currently, full-endoscopic/percutaneous trans-Kambin TLIF procedures present with limitations that comprise the requirement to use endoscopic visualization during foraminoplasty; a small footprint and expensive endoscopic interbody cage; and a low surgical time-efficiency due to small and fragile disk preparation instruments. We propose a newly developed trans-Kambin approach system and instrumentation that should allow overcoming these limitations.

Methods: A 73-year-old female presents with persistent low-back pain, bilateral radiating pain, and neurogenic claudication. Preoperative imaging of the lumbar spine shows a spondylolisthesis at L4/L5 and degenerative disks at L3/L4 and L5/S1 with a vacuum sign and severe foraminal and central canal stenosis. Full-endoscopic/percutaneous trans-Kambin TLIF was performed at L5/S1 with a large-footprint expandable interbody cage with posterior screw fixation from L3 to S1.

Results: Postoperatively, the patient showed clinical and functional improvement and was discharged from the hospital after 24 hours without opioid medication. Clinical and radiologic outcome after 1 year postoperative follow-up was favorable.

Conclusions: A novel trans-Kambin procedure and instrumentation allows overcoming most limitations of current, full-endoscopic trans-Kambin fusion procedures, by allowing a time-efficient insertion of a large-footprint interbody cage with standard open-surgery disk preparation instruments under fluoroscopic control only, with optional endoscopic visualization.

Study design: Case series.

Objectives: Anterior cervical discectomy and fusion (ACDF) is the standard treatment for central cervical disc herniation but may cause complications like loss of motion, dysphagia, and adjacent segment degeneration. This study evaluates a novel Biportal Endoscopic Spinal Surgery with trans-pedicle approach (BESS-TPA) as a minimally invasive alternative, preserving cervical mobility by avoiding instrumentation.

Materials and methods: A retrospective analysis of 24 patients with central cervical disc herniation who underwent BESS-TPA at a single center from July 2022 to June 2023 was performed. Clinical outcomes were assessed using the modified Japanese Orthopaedic Association (mJOA) scores, SF-36 pain and physical function domains, and modified MacNab criteria. Radiographic evaluation with X-rays, CT, and MRI examined structural changes and surgical outcomes.

Results: All patients experienced significant symptom relief. Postoperative MRI confirmed complete resection of the herniated disc using the posterior approach.

Conclusions: BESS-TPA provides a safe, effective, and minimally invasive alternative to ACDF for selected central or paracentral cervical disc herniation. It facilitates access to the ventral dura sac, enabling safer central discectomy while maintaining cervical spine mobility.

Study design: Retrospective cohort study.

Objective: The objective of this study was to evaluate the relationship between preoperative thrombocytopenia and thrombocytosis on perioperative anterior cervical discectomy and fusion (ACDF) outcomes.

Summary of background data: Although routine preoperative laboratory testing is completed before ACDF procedures, there is a scarcity of literature exploring the influence of both preoperative thrombocytopenia and thrombocytosis on perioperative outcomes.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone ACDF between 2011 and 2021 using the Current Procedural Terminology code 22551. Patients were categorized into five groups based on their preoperative platelet count: <100k (moderate-to-severe thrombocytopenia), 100-149k (mild thrombocytopenia), 150-199k (low-normal preoperative platelet count), 200-450k (reference cohort, normal), and >450k (thrombocytosis). Patients with missing preoperative platelet counts were excluded from the study. χ2 for categorical values and analysis of variance for continuous variables were performed on demographic variables and preoperative comorbidities. Multivariable logistic regression analysis was subsequently performed to investigate the relationship between preoperative platelet counts and postoperative complications.

Results: A total of 77,796 patients undergoing ACDF between 2011 and 2021 were included in this study. Sixty thousand eleven patients had normal preoperative platelet counts, 430 had moderate-to-severe thrombocytopenia, 2,784had mild thrombocytopenia, 13,808 had low-normal preoperative platelet counts, and 763 had thrombocytosis. The highest prevalence rate of medical complications occurred in the severe thrombocytopenia group. Multivariate logistic regression revealed that only preoperative thrombocytosis independently increased the risk of medical complications and extended length of hospital stay (OR: 2.408, 95% CI: 1.765-3.224; OR: 3.001, 95% CI: 2.024-4.333, respectively).

Conclusion: This study underscores the value of preoperative platelet testing as a predictor of adverse outcomes in ACDF, with thrombocytosis independently associated with increased risk of at least one medical complication or an extended length of hospital stay.

Level of evidence: Level III.