European Spine Journal最新文献

Background & objectives: Basilar invagination (BI) represents a complex anomaly of the craniovertebral junction, characterized by the displacement of the odontoid process towards the foramen magnum. Current surgical interventions include anterior decompression and combined anterior-posterior decompression with posterior fusion. Traditional methods for odontoid resection encompass transoral, transnasal, and endonasal approaches. However, these techniques are fraught with significant risks. Furthermore, the restricted exposure provided by the endonasal corridor's anatomical limitations hampers surgical manipulation, prompting spine surgeons to seek alternative techniques. This report details a case of BI managed through an endoscopic posterolateral odontoidotomy, showcasing an innovative surgical approach. We aim to describe our experience in partially removing the odontoid via posterolateral approach with a novel endoscopic technique, preventing the need for additional approach and related complications.

Methods: A 16-year-old male patient presented with complaints of imbalance and difficulty swallowing. Clinical examination revealed upper extremity muscle weakness, ataxic gait, and dysphagia. Upon the diagnosis of BI, a posterior occipito-cervical fusion was performed. However, six months postoperatively, the patient returned with exacerbated symptoms. During the subsequent surgical intervention, the odontoid body was resected using a posterolateral transmass endoscopic approach. Due to the patient's neck and shoulder anatomy, cranial angulation of the endoscope was restricted, necessitating the retention of the odontoid tip.

Results: Post-operative CT revealed that the tip was closer to the base and a subarachnoid space was formed. Follow-up CT after a year showed a complete migration of the tip to the base of C2 with a clear decompression of the brainstem.

Conclusion: Our findings demonstrate that partial or total resection of the odontoid process via a posterolateral approach is feasible using endoscopic techniques. The endoscopic posterolateral transmass odontoidotomy should be considered a viable alternative method and route for patients necessitating partial or total odontoidectomy.

Purpose: No studies have explored the reliability of the Rigo classification system using surface topography (ST), which would allow optimization without radiation exposure. This study aims to measure and compare the intra- and inter-observer reliability (Kappa values) and accuracy of the Rigo system between ST and X-ray for overall types and subtypes.

Methods: X-ray and ST images of 31 adolescent idiopathic scoliosis patients were selected. Three investigators were blinded to assess images using the Rigo system, twice for each patient on different weeks, with 372 overall image readings. Afterwards, all investigators agreed upon the correct Rigo scores for finalized classifications.

Results: For Rigo types, the average intra-observer Kappa value was slightly better for ST (0.77, p<0.001) than X-ray (0.75, p<0.001). For Rigo subtypes, the average intra-observer Kappa value was again slightly better for ST (0.74, p<0.001) than X-ray (0.65, p<0.001). The inter-observer reliability was expectedly lower than intra-observer, with ST (0.53, p<0.001) comparable to X-ray (0.54, p<0.001) for the type. For subtype inter-observer reliability, ST (0.43, p<0.001) was slightly better than X-ray (0.36, p<0.001). For the type, the overall accuracy of the observers was slightly lower for ST (77.96%) than X-ray (79.57%). For the subtype, the accuracy of observers was slightly higher for ST (70.97%) than X-ray (65.05%).

Conclusion: ST-based Rigo system demonstrates very good intra-rater reproducibility and moderately good inter-rater reproducibility. Surface topography is comparable to X-ray for the Rigo system, and therefore can be considered a reliable alternative in clinical application.

Objective: For anterior cervical discectomy and fusion (ACDF), stand-alone anchored spacers (SAAS) and cage-plate system (CPS) are currently employed. However, controversy remains over the effectiveness and security of these two apparatuses in multilevel ACDF. The aim of this study was to demonstrate the global long-term effectiveness and safety of SAAS versus CPS with multilevel ACDF.

Methods: We conducted a systematic review of studies comparing SAAS with CPS for multilevel ACDF using four electronic databases. Data from this meta-analysis were analyzed with Stata MP 17.0.

Results: A total of nine trials comprising 584 patients were selected for inclusion. SAAS significantly reduced operative time, intraoperative bleeding and the incidence of postoperative dysphagia compared with CPS. The SAAS group exhibited significantly smaller cervical sagittal angle (CSA) and fusion segmental height (FSH) compared to CPS group. At final follow-up, the rate of cage sinking was higher in SAAS group compared to CPS group. At the endpoint, there was no difference in JOA score, NDI score, fusion rate or the incidence of adjacent segment degeneration (ASD).

Conclusions: SAAS provided comparable long-term effectiveness and safeness for multilevel ACDF regarding JOA scores, NDI scores, fusion rates and ASD rates at endpoint compared to CPS. In comparison to CPS, SAAS demonstrated significant advancement in the reduction of operative time, intraoperative blood loss and the incidence of postoperative dysphagia. As a consequence, SAAS appeared more desirable than CPS among people who needed multilevel ACDF. Yet in long-term observation, SAAS was inferior to CPS in maintaining CSA and FSH and in preventing cage descent. However, whether or not radiographic abnormality has an impact on clinical presentation awaits confirmation from research with more longitudinal follow-up.

Purpose: To investigate the relationship between spinal cord anatomy and the risk of curve progression in mild to moderate adolescent idiopathic scoliosis (AIS).

Methods: We prospectively included patients presenting with mild or moderate AIS (< 40 degrees). Irrespective of curve severity, patients underwent 3-dimensional MRI and were followed until skeletal maturity or surgery. Retrospectively, we measured the true lateral cord space (LCS) ratio on transverse cuts of the curve apex. This is a measure of the lateral displacement of the medulla in the spinal canal. The primary outcome measure was curve progression defined as a Cobb angle increase ≥ 10 degrees at follow-up.

Results: Of the 64 included patients, 18 (28%) progressed more than 10 degrees during follow-up. At baseline, mean age in the progression and non-progression group was 13.1 ± 1.6 vs. 15.8 ± 1.5 years (p < 0.001), and mean Cobb angle was 32 ± 7 vs. 26 ± 9 degrees (p < 0.001). The time from baseline x-ray to MRI was 1.3 ± 3 months vs. 1.7 ± 3.6 months (p = 0.738). LCS ratio was 1.5 (IQR: 1.1-1.7) in the progression group and 1.0 (IQR:0.8-1.3) in the non-progression group (p < 0.001). When matched according to baseline Cobb angle and age, median LCS ratio was 1.5 [1.1, 1.7] and 0.9 [0.7-1.2] in the progression and non-progression group, respectively (p < 0.001).

Conclusions: We found significant displacement of the medulla towards the concavity of the curve in progressive AIS. This finding supports the theory of a neuro-osseous growth mismatch as a part of the etiopathophysiology of AIS and may play a predictive role in prognosis of milder cases of AIS.

Purpose: To evaluate the complications and postoperative outcomes of implant removal after posterior fixation in adolescent idiopathic scoliosis.

Methods: We retrospectively reviewed the data of patients who underwent implant removal after posterior corrective fixation for adolescent idiopathic scoliosis between 2002 and 2014. Complications were evaluated in the 116 patients who underwent implant removal at their choice. Radiological evaluations were performed and analyzed in 71 patients who were followed up for > 2 years after implant removal. Moreover, the patients were divided into two groups: those with increased thoracic kyphosis after implant removal and those without.

Results: Overall, 14 of the 116 patients had complications. Two of the three patients with fractures required reoperation. Radiological examination revealed no significant difference in the scoliosis curvature in the coronal plane after implant removal. In the sagittal plane, the lowest instrumented vertebral tilt, cervical lordosis, T1 slope, T1-12 kyphosis angle, and T5-12 kyphosis angle were significantly increased. Moreover, patients with an increased T5-12 kyphosis angle after implant removal had greater pelvic incidence (PI) and sacral slope (SS) before implant removal.

Conclusion: The prevalence of complications after implant removal in adolescent idiopathic scoliosis was 12.1%. Spinal alignment is more variable in the sagittal plane than in the coronal plane, and patients with increased thoracic kyphosis after implant removal have greater preoperative PI and SS. Sufficient preoperative explanation is necessary if a patient wishes to undergo implant removal.

Purpose: The purpose of this systematic review and meta-analysis was to examine the clinical outcomes and complication rates for fusion procedures of adult spinal deformity (ASD) performed via an anterior-posterior approach as compared to a posterior-only approach to guide surgical decision-making. Numerous surgical techniques exist for operative management of ASD; however, no systematic review and meta-analysis exists comparing combined anterior-posterior approaches to posterior-only approach, despite significant interest in the current literature.

Methods: Four databases were used to collect articles from database inception until September 9th, 2023. Inclusion criteria was articles that examined both anterior-posterior or posterior only surgical approach, adult patients, comparative studies, and articles in English.

Results: Seven comparative articles met the inclusion criteria. Included patients had a frequency weighted (FW) mean age of 60.2 ± 5.1 years and a FW mean follow-up of 40.4 ± 12.5 months. Qualitative data did not favor either group in terms of length of stay, radiographic outcomes, or functional outcomes. There was a total of 306 complications in the Anterior-Posterior group with a complication rate per patient of 1.0 ± 0.9 complications whereas there was a total of 380 complications in the Posterior Only group with a complication rate per patient of 1.0 ± 1.2 complications. Meta-analysis of specific complications found no significant difference in revision rate, dural tear rate, neurological complication rate, infection rate, or pseudoarthrosis rate.

Conclusion: Surgical management for ASD may provide comparable results in terms of surgical parameters, radiographic outcomes, functional outcomes, and complication rates, irrespective of surgical approach.

Purpose: To translate and culturally adapt the Core Outcome Measures Index for the back (COMI-back) into Thai and to evaluate its psychometric properties in Thai-speaking patients with low back pain (LBP).

Methods: The translation process followed a standardized forward-backward method with two independent translators, followed by synthesis and back-translation. An expert committee reviewed the translations for cultural and conceptual equivalence. Pre-testing was done with Thai patients to refine the questionnaire. The validation study included 131 patients with LBP, who completed the Thai COMI-Back along with other validated questionnaires like the Oswestry Disability Index (ODI), and EQ-5D-5L. Reliability was assessed using Cronbach's alpha and intraclass correlation coefficients (ICC). Construct validity was determined by correlating COMI scores with those of reference scales.

Results: The Thai COMI-Back exhibited strong reliability, with Cronbach's alpha values from 0.89 to 0.93 and ICC values over 0.80 for all domains. Construct validity was supported by significant correlations with reference scales, with Spearman's rho values ranging from 0.47 to 0.84. Floor and ceiling effects were acceptable for most items, with notable exceptions for symptom-specific well-being and work disability.

Conclusion: The Thai COMI-Back shows strong psychometric properties, making it suitable for clinical and research use in Thailand.

Objective: To evaluate the modified vertebral bone quality (VBQ) method on the magnetic resonance imaging (MRI) T1-weighted (T1w), T2-weighted (T2w), and fat suppression (FS) series in evaluating bone mineral density (BMD) for patients with degenerative lumbar disease.

Methods: We reviewed preoperative data of postmenopausal female patients aged ≥ 50 years hospitalized to undergo lumbar surgery for degenerative lumbar disease with available MRI and dual-energy X-ray absorptiometry (DEXA). Patients were categorized into three groups according to T-score. The VBQ_CSF score was calculated as the L1-L4 median signal intensity (SI) divided by the L3 CSF SI. One-way analysis of variance was applied to assess the discrepancy between groups. The diagnostic performance of VBQ scores for distinguishing low BMD was analyzed using receiver operating characteristic (ROC) analysis.

Results: The study included 253 patients. T2 VBQ_CSF was significantly different between groups (p < 0.001). The interclass correlation coefficient for inter and intra-rater reliability was 0.767 (95%CI 0.650-0.849) and 0.893 (95%CI 0.834-0.932), respectively. The T2 VBQ_CSF showed moderate correlations with DEXA BMD (r =  - 0.442, p < 0.001). The area under the ROC curve indicated a predictive accuracy of 76%. A sensitivity of 59.0% with a specificity of 87.5% was achieved for distinguishing low BMD by setting the T2 VBQ_CSF cutoff at 0.607.

Conclusion: Compared to the traditional VBQ score, T2 VBQ_CSF is a more promising tool for distinguishing poor bone quality in patients with degenerative lumbar disease. A T2 VBQ_CSF score > 0.607 can identify patients who require additional diagnostic evaluation.

Purpose: This study investigates the relationship between surgical levels and coronal deformity to identify risk factors for failing to achieve a minimal clinically important difference (MCID) in the Oswestry Disability Index (ODI) following short-segment isolated decompression or fusion surgery in patients with degenerative scoliosis (DS) and concurrent lumbar canal stenosis (LCS), without severe sagittal deformity malalignment.

Methods: Patients with degenerative scoliosis who underwent 1- or 2-level lumbar isolated decompression or fusion surgery were included. Surgical level was labeled as "Cobb-related" when decompression or surgical levels spanned or were between end vertebrae, and "outside" when the operative levels did not include the end vertebrae. Logistic regression analysis was conducted to assess the factor associated with MCID achievement in ODI at 1 year postoperatively.

Results: A total of 129 DS patients with LCS and preoperative ODI > 30 were included. At 1-year follow-up, 91 patients (70.5%) achieved MCID in ODI. No significant differences were found in demographics or overall spinal alignment between patients who did and did not achieve MCID. Logistic regression analysis revealed that Cobb-related decompression was independently associated with decreased odds of achieving MCID in ODI (adjusted Odds Ratio 0.18, 95% CI 0.42-0.79, P = 0.025).

Conclusion: In patients with mild to moderate coronal deformity and minimal sagittal deformity, decompression alone at or across end vertebrae significantly lowers the likelihood of achieving the MCID in ODI compared to fusion surgery, with an 84% reduction in odds. No significant difference in MCID achievement was observed between decompression and fusion surgeries outside the Cobb angle.