European Spine Journal最新文献

Introduction: Cauda Equina Syndrome (CES) is a surgical emergency and an intimidating medico-legal challenge. Poor clinical specificity leads to a high rate of negative (normal/No-CES) MRI scans, placing additional burden on emergency services. A proportion of patients re-present with CES-like symptoms. The aim of this study was to assess this cohort of patients and identify the incidence, clinical risk factors, comparative MRI-findings and predictive factors for subsequent True-CES.

Methods: Retrospective review of prospective data of patients aged 18-65 years, who first attended with suspected-CES with a normal MRI, between January 2019-December 2022; and re-presented with suspected-CES within one year. Patients with True-CES or abnormal MRI pathology at first attendance were excluded. Clinical, bladder scan and MRI findings from first and re-presentation visits were recorded and statistically analysed.

Results: 922 patients were included, 56 (6%) had True-CES on MRI and 356 met exclusion criteria, leaving 510 patients with normal MRI on initial presentation. 43 patients (8%) re-presented within one year (mean interval 152 days), and 7 presented a third time (mean interval 126 days). There was no significant difference in clinical symptoms, gender and bladder scans between presentations. No patient showed True-CES on re-presentation MRI, all demonstrating the same MRI findings as the initial scan.

Conclusion: This is the largest series of patients that evaluates re-presentations of suspected-CES after initial attendance with normal/No-CES MRI. There were no significant clinical/radiological differences between presentations. No patient showed True-CES on re-presentation MRI, and therefore, no predictive factors were identified.

Objectives: Multiple myeloma (MM) is frequently associated with bone loss, yet the clinical significance of vertebral body bone loss measured in Hounsfield Unit (HU) decline remains underexplored. This study aimed to investigate longitudinal changes in vertebral HU on routine CT scans, and their associations with disease-related parameters, postural alignment, function and survival.

Methods: In this retrospective study, 79 MM patients with three sequential whole-body CT scans were analyzed. HU values at vertebral level L1-L4 were assessed, and a ≥ 35% decline was identified via ROC analysis as a clinically relevant threshold influencing clinical outcomes. Subgroup analyses examined the influence of disease activity, steroid use, osteoprotective therapy, renal function, and nutritional status. Associations with pain, spinopelvic sagittal alignment, and survival were evaluated.

Results: HU values declined markedly over time, from 148.6 ± 11.3 HU at baseline to 120.1 ± 10.3 HU at tCT2 and 86.5 ± 11.8 HU at tCT3 (p < 0.0001). Patients with high disease activity showed greater HU loss than those with low activity (- 49.5 ± 8.7% vs. -38.7 ± 11.0%, p < 0.001). Steroid therapy accelerated HU decline (- 47.1 ± 7.6% vs. -40.4 ± 8.4%, p < 0.001), whereas osteoprotective treatment mitigated it (- 36.8 ± 7.2% vs. -42.3 ± 8.9%, p = 0.02). The ROC-derived threshold for clinically relevant bone loss was ≥ 35%, identifying patients with higher pain (VAS 7 vs. 4, p < 0.001), greater analgesic use (WHO score 2 vs. 1, p < 0.001), and more pronounced postural deterioration (ΔTK + 8.3° vs. -0.7°, p < 0.001; ΔLL - 10.6° vs. -2.4°, p < 0.001). In multivariate analysis, ≥ 35% HU loss was independently predicted by high disease activity (OR 2.62, p = 0.006) and steroid exposure (OR 2.11, p = 0.027), while osteoprotective therapy was protective (OR 0.53, p = 0.031). Exploratory survival analysis showed reduced overall survival in patients with ≥ 35% HU decline (p = 0.04).

Conclusion: CT-based HU measurement enables longitudinal assessment of vertebral bone quality and identifies patients at risk for pain, functional decline, and poorer overall prognosis. Furthermore, HU decline increases with disease progression and might serve as additional marker for disease burden and activity.

Background: Adolescent idiopathic scoliosis (AIS) can be associated with restrictive lung disease. Brace wearing is also associated with restrictive lung disease. Due to external compression, bracing could alter the biomechanical function of the rib cage. The aim of this work was to test the feasibility of using biplanar radiography to study the impact of the brace on the rib cage kinematics during breathing.

Materials and methods: Twelve patients with moderate AIS, treated with Cheneau-Toulouse-Munster (CTM) brace, underwent pulmonary function test and biplanar radiography at two lung volumes: normal breathing and full inspiration with and without brace. Their spine and rib cage were reconstructed in 3D from the radiographs.

Results: Lung volumes were reduced after application of the brace, both by pulmonary function test and 3D reconstruction. The reduction in the rib cage volume appeared to be due to changes in rib cage width, in relation to the pressure pads. Costo-vertebral strategy did not seem to be modified by brace wearing. The brace tended to increase the correction of the cobb angle in maximum inspiration.

Conclusions: This study confirms the relevance of assessing respiratory function using biplanar radiography and 3D reconstruction. By reducing lung volumes without changing the costo-vertebral strategy, the impact of the Cheneau brace on ventilation remains to be clarified.

Level of evidence: III, prospective.

Objectives: Enhanced Recovery After Surgery (ERAS) protocols aim to improve surgical outcomes, by mitigating postoperative stress through multimodal perioperative care. In spinal surgery, such protocols may reduce pain, hospital length of stay (LoS), and opioid use. However, prior retrospective studies often suffer from heterogeneity in patient populations and surgical procedures, limiting interpretability. This trial was designed to evaluate the impact of an ERAS protocol on short-term clinical outcomes and LoS in patients undergoing elective single-level lumbar arthrodesis for degenerative spondylolisthesis.

Methods: This single center randomized controlled trial included 42 patients allocated to ERAS (n = 18) or standard care (n = 24). The ERAS protocol included preoperative Gabapentin administration, intraoperative multimodal analgesia, same-day physiotherapy, and early nutritional intake. The primary outcome was LoS. Secondary outcomes included pain at discharge, opioid consumption, postoperative complications, and unplanned readmissions occurring within 11 days after discharge. Data were analyzed using univariate statistical tests and multivariable regression models.

Results: Median LoS was 3 days in both groups (p = .685). Pain scores at discharge were lower in the ERAS group (mean 2.5 ± 1.5) versus control (3.1 ± 2.2), though not statistically significant (p = .079). Multivariate analysis identified World Health Organization (WHO) pain medication level as a significant predictor of LoS (p = .025), and postoperative nausea and vomiting (PONV) as a predictor of discharge pain (p = .031). No significant differences were observed in complications or readmission rates.

Conclusion: ERAS protocol did not reduce LoS in single level lumbar arthrodesis. Discharge pain and PONV had a significant impact on recovery, suggesting that these could be potential focal points for protocol refinement. Larger, procedure-specific trials with long-term follow-up are warranted.

Purpose: Intradural migration of a lumbar disc prosthesis is an infrequent and previously unreported complication. We aimed to describe the clinical presentation, surgical management, and outcome of this unique case and to review relevant literature.

Methods: A 70-year-old man presented with progressive low back pain radiating to the right leg and foot drop, ten years after undergoing L3-4 total disc replacement. Magnetic resonance imaging and computed tomography demonstrated intradural migration of the prosthesis. The patient underwent L3-4 total laminectomy, durotomy with intradural prosthesis removal, and L3-L5 posterior stabilization.

Results: Radicular pain resolved immediately after surgery. Postoperative rehabilitation was initiated early, and the 3-month follow-up achieved complete recovery of foot dorsiflexion. Postoperative imaging confirmed the appropriate positioning of the hardware and the complete removal of the migrated prosthesis.

Conclusion: It is essential to note that these complications can occur even years after disc arthroplasty. Radiologic follow-up is recommended at 3 and 6 months, then annually during the first 5 years, and in selected patients at longer intervals thereafter. This case represents the first documented instance of intradural migration of a lumbar disc prosthesis. It highlights the technical nuances of intradural removal and demonstrates that complete neurological recovery is possible with prompt surgical intervention.

Purpose: To determine whether obesity (body mass index ≥ 30 kg/m²) is associated with differences in complication rates, operative parameters, pain/disability outcomes, and hospital length of stay after anterior lumbar interbody fusion (ALIF) for degenerative lumbar pathology.

Methods: We conducted a systematic review and Bayesian meta-analysis following PRISMA 2020. PubMed, Embase, and Scopus were searched from January 1, 2010, to April 1, 2025, for retrospective or prospective studies comparing obese versus non-obese ALIF cohorts. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Newcastle-Ottawa Scale. A hierarchical Bayesian framework synthesized continuous outcomes (Visual Analog Scale [VAS] for back/leg pain, Oswestry Disability Index [ODI], hospital stay, blood loss, operative time) and binomial complication data. Sensitivity analyses excluded a large supine-position study and varied prior distributions.

Results: Twenty-two studies met inclusion criteria. Obesity was associated with higher odds of complications (median odds ratio ≈ 1.5; 95% credible interval [CrI] 1.1-2.0) and longer hospital stay (mean difference ≈ + 1.3 days; 95% CrI + 0.8 to + 1.9). Postoperative pain modestly favored non-obese patients: back pain mean difference ≈ + 0.4 points (95% CrI 0.0 to + 0.8) and leg pain ≈ + 0.8 points (95% CrI + 0.4 to + 1.2) in obese cohorts. ODI effects showed substantial between-study heterogeneity. Blood loss and operative time findings were inconclusive due to high variability across centers. Sensitivity analyses preserved effect direction.

Conclusion: Obesity modestly increases complication risk and length of stay after ALIF, yet obese patients still achieve meaningful postoperative pain relief. Preoperative risk-factor optimization, careful exposure strategies, and multidisciplinary perioperative care may mitigate these risks. Further prospective research with standardized outcome definitions is warranted to refine patient selection and surgical technique.