European Spine Journal最新文献

Study design: Prospective single-center observational cohort study.

Objectives: To assess whether prior arthroscopic experience is associated with a shorter learning curve in uniportal interlaminar endoscopic lumbar discectomy (IELD), primarily in terms of operative efficiency, and to descriptively evaluate perioperative complications and patient-reported outcomes.

Methods: In accordance with STROBE guidelines, 240 consecutive patients with single-level lumbar disc herniation (MSU A/B, non-calcified, symptom duration ≤ 3 months) underwent IELD between 2021 and 2023 at a single academic orthopedic center. Procedures were performed by three spine surgeons without prior endoscopic experience; one surgeon had performed more than 300 shoulder arthroscopies. Operative time was analyzed using cumulative sum (CUSUM) methodology and linear regression. Missing outcome data were handled using last observation carried forward. Complications were recorded descriptively and stratified by learning phase and surgeon. Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores for back and leg pain were assessed preoperatively and at 3 and 12 months.

Results: All surgeons demonstrated a three-phase learning curve consisting of learning, improvement, and stabilization phases. Operative efficiency stabilized after approximately 50 cases across surgeons. The surgeon with prior arthroscopic experience reached the CUSUM inflection point earlier (case 12) compared with the other surgeons (cases 24-26). The overall major complication rate was 9.2% and was highest during the initial learning phase. ODI and VAS scores improved significantly at 3 and 12 months (all p < 0.001), with no statistically significant between-surgeon differences at final follow-up.

Conclusions: Prior arthroscopic experience was associated with earlier adaptation during the initial learning phase of IELD, as measured by operative time. Following procedural stabilization, no statistically significant differences were detected in operative efficiency, major complication rates, or patient-reported outcomes between surgeons. These findings suggest that arthroscopic experience may facilitate early adaptation to endoscopic visualization and workflow but does not independently determine long-term clinical outcomes.

Level of evidence: III.

Purpose: Collagen integrity is essential for connective tissue maintenance, and its deterioration may contribute to postoperative complications. Dermal ultrasound (US) echogenicity has been associated with collagen quality, with changes in echogenicity reflecting alterations in collagen composition. These changes may indicate increased susceptibility to revision surgery in lumbar fusion patients, particularly due to adjacent segment disease (ASD). However, no study has established a specific cutoff value for skin US echogenicity to predict the need for ASD-related revision surgery. This single-center prospective cohort study aimed to evaluate the association between dermal echogenicity and ASD revision, and to determine echogenicity cutoff values that could help identify patients at higher risk of requiring revision surgery.

Methods: Patients undergoing posterior lumbar fusion from 2014 to 2023 were included. US measurements were conducted at two standardized locations on the lumbar back. Echogenicity values for the average dermal (AD), upper dermal (UD), and lower dermal (LD) layers were calculated using our institution's PACS imaging software. Statistical significance set at p < 0.05.

Results: Among 383 patients (51% female, median age 63), those undergoing ASD revision were significantly older (median age 66.8 vs. 62 years, p = 0.012). Higher echogenicity in the LD (OR = 1.03, p = 0.008), UD (OR = 1.03, p = 0.027), and AD (OR = 1.03, p = 0.005) layers was associated with increased ASD risk. The optimal LD echogenicity cutoff was 124.3 (AUC = 0.654, sensitivity = 0.6, specificity = 0.69).

Conclusion: We identify echogenicity cutoff values that correlate with an increased risk of revision surgery for ASD. Higher dermal US echogenicity may reflect alterations in collagen, contributing to poorer tissue quality. These findings support the use of dermal US parameters as a potential biomarker for high-risk lumbar fusion patients.

Purpose: To evaluate 2-year longitudinal patient-reported outcomes from a multisite, prospective observational study involving a real-world German cohort with mechanical chronic low back pain (CLBP) implanted with restorative neurostimulation.

Methods: Patients with refractory, predominantly nociceptive, mechanical CLBP associated with lumbar multifidus dysfunction (N=87) consented to undergo restorative neurostimulation therapy implantation through five German clinics. Outcomes measures for pain (Numeric Pain Rating Scale), disability (Oswestry Disability Index-ODI), and quality of life (Euroqol's EQ-5D) were collected at 90 and 180 days, one year, and two years from therapy activation. The painDETECT scale assessed the likelihood of mixed pain presentation. Sub-cohorts of painDETECT scores ≥19 (High) and <19 (Low) were compared on outcomes to assess mixed pain response.

Results: Among patients with complete (n=74) and imputed data, all outcomes improved significantly at two years. Over 75% achieved pain reduction by ≥30%, 64% met the minimal clinically important difference for ODI, and EQ-5D improved by 0.233. High and Low painDETECT groups showed similar recovery patterns. No lead migrations nor unanticipated adverse device effects occurred over the two years.

Conclusion: This two-year real-world analysis of German patients with CLBP due to multifidus dysfunction treated with restorative neurostimulation showed sustained improvements in pain and function. Patients with mixed pain responded similarly to those with predominantly nociceptive pain, though supplemental conservative strategies may be needed to optimize functional recovery.

Background: Currently, reliable preoperative methods for predicting vertebral artery (VA) invasion are lacking. The authors develop a novel model based on MRI radiomic signatures combined with clinical and imaging features for predicting intraoperative vertebral artery injury in patients with primary cervical tumors.

Methods: Included in this retrospective study were 168 patients who received surgical resection for primary cervical tumors. They were randomly assigned to a training set (n = 117) and a test set (n = 51) . Least absolute shrinkage and selection operator logistic regression was applied for feature selection and radiomic signature construction. A multilayer perceptron (MLP) model and 10 machine learning models were used to develop diverse prediction models. Independent risk factors of clinical variables were screened by Logistic regression, based on which a clinical model was constructed. A combined model was established by combining the radiomic signatures and clinical factors. The predictive performance of the combined model was evaluated in both training and test sets using Hosmer-Lemeshow test and decision curve analysis (DCA).

Results: According to the scoring system, the MLP model obtained the highest total score of 87, meaning that its prediction performance was the best of all evaluated models, so the MLP was selected to construct the radiomics model. The AUC of the combined model in the training and test cohorts was 0.951 and 0.950 respectively, and both were higher than that of the radiomics model (AUC 0.900 in training set, p = 0.010, AUC 0.780 in test set, p = 0.001) and the clinical model (AUC 0.740 in training set, p < 0.001, AUC 0.781 in test set, p = 0.008) alone.

Conclusion: The present study presents a nomogram that incorporates radiomic signatures and clinical features, which could be used to predict the risk of intraoperative VA injury in patients with primary cervical tumors.

Objective: Lower limbs can play a major compensating role for sagittal malalignment; however, little is known about the different types of compensation. This study aimed to identify different patterns of lower limb compensation and to determine which parameters may affect the recruitment of knee flexion versus hip extension.

Methods: This study included adult spinal deformity (ASD) patients with full-body X-rays in erect position from a multicentric prospective database. All parameters were measured at baseline: demographics, clinical scores and radiographic parameters: pelvic parameters, pelvic incidence-lumbar lordosis (PI-LL) mismatch, T1 pelvic angle (TPA), sacro-femoral angle (SFA), knee flexion angle (KA), ankle dorsi-flexion angle (AA), pelvic shift (PSh), hip and knee osteoarthritis (OA) grade. A K-means cluster analysis was conducted to identify patterns of lower limb compensation based on SFA and KA. The optimal number of clusters was determined using the silhouette score. The different parameters were then compared across clusters.

Results: 871 ASD patients were included, of whom 66.9% were females. Mean age was 62.3±14.6 years, mean BMI was 27.7±5.5 kg.m^-2. Four patterns of lower limb compensations were identified: "No compensators", "Recliners" (mainly hip extension), "Squatters" (mainly knee flexion) and "Mixed compensators" (both)."Mixed" and "Squatters" had significantly larger BMI. The proportion of females was the least in the "Squatters" cluster (47.0%) while it was the highest in the "Recliners" group (79.3%) (p<0.001). The proportion of patients with severe hip OA was the lowest in the "Recliners" (38.5%) while it was the highest in the "Squatters" group (71.9%). Knee OA rate was the highest in the"Squatters" group (72.7%). "Mixed compensators" had the greatest PI-LL mismatch (30.4±20.0°) and "No compensators" the lowest (5.3±21.3°). Pelvic incidence values were the highest in "Recliners" and "Mixed compensators" (59.2±13.1° and 57.0±14.1° respectively). TPA values were the highest in the "Mixed compensators" and the lowest in the "No compensators" (33.3±11.7° versus 16.1±11.5°). The "Squatters" presented the significantly poorest values for disability, frailty, and SRS score.

Conclusions: Cluster analysis determined four types of lower limb compensation:"Recliners" using only hip extension, "Squatters" using only knee flexion,"Mixed compensators" and "No compensators". Lower limb compensatory mechanisms recruitment is multifactorial and varies with age, sex, BMI, frailty, knee and hip OA, pelvic incidence, and spinal alignment.