European Spine Journal最新文献

Purpose: Ageing, long illness duration, and poor preoperative Japanese Orthopaedic Association (JOA) score were reported to be risk factors for residual pain after cervical ossification of the posterior longitudinal ligament (cOPLL). In this study, we focused on residual neuropathic pain (NeP) and aimed to elucidate risk factors for residual NeP after cOPLL.

Methods: Total of 234 patients who underwent cOPLL surgery were included. NeP was evaluated using painDETECT (PDQ) and Spine painDETECT (SPDQ) questionnaires. Score of ≥ 13 / ≥ 0 was defined as NeP for PDQ/SPDQ. Patient backgrounds factors, preoperative radiographic factors and surgical factors were reviewed, and comparisons between the NeP(+) and NeP(-) groups were made. Independent risk factors for residual NeP were evaluated using multiple logistic regression analysis.

Results: Prevalence of residual NeP after cOPLL was 22.6% on PDQ and 55.1% on SPDQ. Preoperative JOA score was significantly lower in the NeP(+) group for PDQ compared with that in the NeP(-) group. Additionally, cervical lordosis angle was significantly lower in the NeP(+) group for SPDQ compared with that in the NeP(-) group. Following multiple logistic regression analysis, poor preoperative JOA score was identified as a risk factor for NeP on the PDQ. Poor preoperative JOA score and low cervical lordosis angle were identified as risk factors using the SPDQ.

Conclusions: We found high prevalence of residual NeP after cOPLL. Patients with a poor preoperative JOA score and low cervical lordosis angle might be at risk for residual NeP after surgery evaluated by PDQ or SPDQ and should be monitored with greater care after surgery.

Predictive biomarkers (or moderators of treatment) are features, or more likely feature clusters, that discriminate individuals who are more likely to experience a favourable or unfavourable effect from a specific treatment. Utilization of validated predictive biomarkers for chronic low back pain (CLBP) treatments is a plausible strategy to guide patients more rapidly to effective treatments thereby reducing wastage of finite healthcare funds on treatments that are ineffective (or potentially harmful). Yet, few predictive biomarkers have been successfully validated in clinical studies. This paper summarizes work by the Phenotype/Precision Spine Focus Group of the International Society for the Study of the Lumbar Spine that addressed: (1) relevant definitions for terminology; (2) advantages and disadvantages of different research approaches for the specification of predictive biomarkers; (3) methods for assessment of clinical validity; (4) approaches for their implementation; (5) barriers to predictive biomarker identification; and (6) a prioritised list of recommendations for the development and refinement of predictive biomarkers for CLBP. Key recommendations include the harmonisation of data collection, data sharing, integration of theoretical models, development of new treatments, and health economic analyses to inform cost-benefit of assessments and the application of matched treatments. The complexity of CLBP demands large datasets to derive meaningful progress. This will require coordinated and substantive collaboration involving multiple disciplines and across the research spectrum from the basic sciences to clinical applications.

Objective: To determine the surgical outcomes and prognostic factors in patients with unilateral footdrop secondary to lumbar disc herniation undergoing surgical intervention.

Methods: A comprehensive literature search was conducted across PubMed, Ovid, Scopus, and Web of Science for relevant literature from inception to 26 March 2023. The quality of the studies was evaluated per the NHLBI Quality Assessment Tools. Articles reporting individualised patient data in adult patients with unilateral foot drop secondary to lumbar degenerative disease were included. For inclusion, patients had to be managed with a single-level lumbar discectomy ± laminectomy.

Results: The search returned 1037 studies, of which 96 suitable individual patient records met inclusion criteria with 66 included in meta-analysis. Multivariate analysis revealed that the following factors significantly affected the extent of post-operative motor recovery: Patient age (P = 0.045); Duration of symptoms (P = 0.01); Degree of pre-operative weakness (P = 0.004); and Extent of recovery within the first three months after surgery (P = 0.006). Patients surgically managed within 6 weeks of symptom onset are up to 6 times more likely to demonstrate greater recovery at the final follow-up (median = 12 months). When comparing patients with a pre-operative MRC grade of 0 (complete loss of motor function), those with a pre-operative MRC grade of 2/5 or above were significantly more likely to have greater recovery of post-operative motor function. The extent of recovery within three months post-op also significantly predicted the final outcome. Patients who demonstrate recovery of at least 1 or more MRC power grades at 3 months have approximately a 30-fold probability of continuing to improve compared to those who demonstrate no improvement at this time point.

Conclusion: Our analysis demonstrates that (1) An age ≤ 47, (2) Duration of symptoms ≤ 6 weeks, (3) Pre-operative MRC grade (2/5 or 3/5) and (4) an improvement of at least one MRC grade within 3 months of surgery are positive prognostic factors for motor recovery in patients with unilateral footdrop secondary to lumbar disc herniation undergoing surgical intervention.

Purpose: Genetic factors are considered important in the development of degenerative spine disease. The aim of this study was to determine the twin concordance rates for the common cervical spine diseases cervical disk herniation (CDH), cervical foraminal stenosis (CFS), and degenerative cervical myelopathy (DCM) requiring surgical treatment by studying monozygotic (MZ) and dizygotic (DZ) twin pairs.

Methods: Patients, aged 18-85 years, operated for CDH, CFS, or DCM between 1996 and 2022 were identified in the national Swedish spine register (5962 CDH, 3801 CFS, and 3131 DCM) and matched with the Swedish twin registry to identify MZ and DZ twins. Concordance rates were calculated.

Results: There were 64 twin pairs where one or both twins had surgical treatment for CDH. The corresponding numbers for surgically treated CFS and DCM were 37 twin pairs and 44 twin pairs respectively. For twins with CDH we found one concordant MZ pair and no concordant DZ pair (MZ probandwise concordance rate 0.12 [95% CI 0-0.33]). For twins with CFS we found one concordant MZ pair and no concordant DZ pair (MZ probandwise concordance rate 0.14 [95% CI 0-0.38]). In DCM patients we found no concordant twin pair.

Conclusions: In this national observational study, including 145 twin pairs, the concordance rates were low for surgically treated CDH, CFS, and DCM conditions. Our findings suggest that not only genetic factors, but also environmental factors and personal preferences are important whether a patient goes to surgery for this type of condition.

Purpose: To determine if iatrogenic posterior translation (UIV SPi) at the upper instrumented vertebrae (UIV) is associated with increased mechanical complications and secondarily to generate and validate a UIV SPi threshold for increased complications.

Methods: Two patient databases were utilized: one for generating a UIV SPi threshold and another for validation. Patients with a UIV between T8-L1 and a LIV at ilium were included. A receiver operating curve (ROC) curve analyses was performed to generate a threshold that predicted proximal junctional complications. This UIV SPi angle (-16.0°) was rounded to -15.0° for practical clinical use and validated in a separate cohort. Patients were stratified as above (most translated, MT) or below (least translated, LT) the threshold for comparative demographic and outcomes analyses.

Results: Generation of the threshold on 192 patients (122 LT, 70 MT) revealed that the MT group had higher absolute postoperative UIV SVA (MT=-56.1 ± 23.1 mm vs. LT=-10.4 ± 31.8 mm, p < 0.001), higher PT (25.7° vs. 19.3°, p < 0.001), and 2.8-5.8 times greater odds of postoperative proximal junctional complications at 2-years (p < 0.05). Validation on 135 patients (95 LT, 40 MT) revealed that the MT group had 11.7 times greater odds of radiographic PJK and had 4.5 times greater odds of all-cause reoperations (p < 0.05).

Conclusion: Patients with UIV posterior translation, despite similar PI-LL and T1PA, exhibit a high PT and experience higher odds of proximal junctional complications. Our findings support limiting the UIV SPi to < 15° of posterior translation to mitigate postoperative mechanical complications.

Level of evidence: IV.

Purpose: Semi-rigid spinal stabilization has been explored as an alternative to spinal fusion, and early experience with spinal segment augementation ("vertebropexy") is promising. The main technical challenge is to maintain the integrity of the spinous processes during loading. This study aimed to compare different looping materials and techniques with respect to their performance in maintaining spinous process integrity.

Methods: One hundred and five thoracolumbar vertebrae were tested with various looping materials and techniques; the "Tunnel-only" double-loop technique was tested with a synthetic tape (FiberTape^®), bovine tendon, and a hybrid tape option. Additionally, the performance of the synthetic tape was tested for other augmentation techniques such as the "Figure-of-eight" looping technique, a double-loop combination of tunneling and cortical wrapping, and a double-loop with "Cortical wrapping only". Biomechanical testing was performed by uniaxial caudo-cranial distraction to failure.

Results: The loads required to cause spinous process failure were lowest with the synthetic tape, followed by tendon and hybrid constructs by tendency (419 N vs. 487 N vs. 519 N) in the "Tunnel-only" double-loop technique. The comparison showed that the "Tunnel + cortical wrapping" technique required significantly higher forces to induce failure compared to other techniques, particularly the "Tunnel only" method (p < 0.001).

Conclusion: The choice of the looping technique and material in lumbar interspinous vertebropexy significantly affects the resistance of the spinous process to load. Techniques that incorporate cortical bone and use tendinous material demonstrate superior resistance to higher forces, compared to methods that involve passing synthetic tape through a hole solely within trabecular bone. Additionally, the role of trabecular bone density in the spinous process is relatively minor when cortical bone is utilized as an abutment for the loop.

Purpose: CT is considered the gold standard to assess bone morphology, whereas MRI is the imaging modality of choice to assess soft tissue. To reduce the ionising radiation exposure of the patient from CT, new MRI technologies have been developed to obtain images of bone. Two promising methods include MRI-based synthetic CT (sCT) and T1-weighted isotropic MRI.

Methods: A prospective study including twenty-four adult patients receiving lumbar or sacral spine stabilisation surgery was performed. For each patient, two scans were acquired: a 3D dual echo T1-weighted gradient image, from which a sCT was reconstructed, and a 3D isotropic T1-weighted MRI sequence. Three observers assessed the sCT images for adequate visualisation of relevant vertebral anatomies and confidence using sCT in preoperative planning compared to the isotropic MRI based on a series of statements scored using a Likert-scale. Summary statistics and intraclass correlation coefficients were calculated.

Results: All observers agreed that the sCT provided adequate visualization (94% of cases). Compared to the isotropic MRI, the sCT provided added value (89% of cases) and improved confidence (92% of cases) for the preoperative planning stage. No unexpected poor intraclass correlations were identified. The observers diagnosed patients with spondylolysis, scoliosis, arthrosis, spina bifida occulta, various Castellvi classifications, or without pathology.

Conclusions: sCT adequately visualised vertebral structures relevant for surgical spine planning with good confidence and added value for sCT compared to 3D T1-weighted isotropic MRI is shown. sCT could be a valuable method to reduce the radiation exposure associated with CT.

Purpose: To evaluate the effectiveness of an evidence-based pre-, peri- and postoperative rehabilitation pathway (i.e. the REACT rehabilitation pathway) on disability in patients undergoing lumbar fusion surgery (LFS), compared to usual care.

Methods: A prospective, nonrandomized controlled trial included 72 patients scheduled for one- or two-level LFS for degenerative conditions or adult isthmic spondylolisthesis. Participants were allocated to usual care (N = 36) or the REACT rehabilitation pathway (N = 36). The REACT rehabilitation pathway includes prehabilitation, early mobilization and avoidance of unsubstantiated postoperative restrictions, early postoperative physiotherapy, patient empowerment, case manager guidance, and support towards an early return to activity. The primary outcome was disability; key secondary outcomes were back and leg pain intensity, and return-to-work rate. Additional secondary outcomes included fear of movement, pain catastrophizing, negative emotional states, sit-to-stand performance, analgesic use, length of stay, and adverse events. Data were collected preoperatively and at five time points up to one year postoperatively.

Results: Participants in the REACT group demonstrated significantly greater improvements in disability (p = 0.003), back pain intensity (p = 0.007), and return-to-work rates (88% vs 56%, p = 0.34) compared to the control group. The REACT group also showed greater improvements in fear of movement (p = 0.038), pain catastrophizing (p < 0.001), combined negative emotional states (p = 0.007), sit-to-stand performance (p = 0.021), and reduced analgesic use (p = 0.001). No significant differences were observed in leg pain intensity (p = 0.042), length of hospital stay (p = 0.095) or adverse events (p = 1.00).

Conclusion: The REACT rehabilitation pathway significantly reduced disability in the first postoperative year after LFS compared to usual care. The most promising result is the significantly higher return-to-work rate in the REACT group.

Purpose: Spondylodiscitis is a serious condition requiring prolonged antibiotic therapy. Relevant pharmacokinetic tissue understanding of antibiotics in a spondylodiscitis setting is limited. The study aimed to investigate cefuroxime concentrations in the L4/L5 intervertebral disc, lumbar bone, paravertebral muscle and subcutaneous tissue using microdialysis.

Methods: Eight pigs received 1,500 mg of cefuroxime by intravenous bolus infusion over 10 min. Prior to cefuroxime administration, microdialysis catheters were placed in the L4/L5 intervertebral disc, lumbar bone, paravertebral muscle and adjacent subcutaneous tissue for sampling across an 8-h dosing interval. Plasma samples were obtained for reference. Based on prior time-kill modelling for cefuroxime, 40% of the dosing interval with concentrations above the minimum inhibitory concentration (40% T > MIC) for Staphylococcus aureus was chosen as the primary endpoint.

Results: The 40% T > MIC target exposure was surpassed in all investigated compartments in 5/8 pigs at the lowest MIC-target of 1 [Formula: see text]g/mL. None of the pigs achieved the 40% T > MIC at the clinical breakpoint MIC for S. aureus of 4 [Formula: see text]g/mL. Mean %T > MIC was comparable across the spondylodiscitis relevant tissues at MICs of 1 (range: 43-60%), 2 (range: 30-38%)[Formula: see text] and 4 [Formula: see text]g/mL (range: 16-26%).

Conclusion: Short-infused cefuroxime dosing standards may under-treat S. aureus spondylodiscitis, increasing the risk of inadequate bacterial killing and resistance development. Given the severity of spondylodiscitis, alternate clinical dosing strategies for cefuroxime may be necessary, such as shorter dosing intervals or prolonged/continuous infusion.