Global Spine Journal最新文献

Study design: Reliability study.

Objectives: The radiographic diagnosis of non-union is not standardized. Prior authors have suggested using a cutoff of <1 mm interspinous process motion (ISPM) on flexion-extension radiographs, but the ability of practicing surgeons to make these measurements reliably is not clear.

Methods: 29 practicing spine surgeons measured ISPM on 19 levels of ACDF from 9 patients. Surgeons relied on these measurements to report on fusion status. Inter-observer correlation co-efficients (ICC), standard error (SEM) and the minimum detectable difference (MD) of these measurements were calculated. We screened for clerical errors by checking measurements more than one standard deviation from the group mean.

Results: The ICC for ISPM was .76 (.64; .88) with a SEM of 1 mm and a MD of 2.76 mm. Agreement on fusion status was moderate, with an ICC of .6 (.44; .76). After screening for and removing clerical errors, the ICC improved to .82 (.71; .91), SEM improved to .83 mm, and MD improved to 2.29 mm. Six reviewers had an ICC >.9. The ICC from these high performing reviewers was .94 (.9; .97), SEM was .45 mm, and MD was 1.26 mm.

Conclusions: The MD of 2.29 mm in our study group was not precise enough to support a cutoff of <1 mm ISPM as the sole measurement technique in screening for non-union after ACDF, and there was only moderate agreement amongst surgeons on fusion status based on dynamic radiographs. More stringent techniques are necessary to avoid mis-diagnosing non-union in clinical studies. Future studies should consider auditing measurements to identify clerical errors.

Study design: Retrospective Matched Cohort Study.

Objectives: Optimization of medical comorbidities is an essential part of preoperative management. However, the isolated effects of individual comorbidities have not been evaluated within a homogenous spine surgery population. This exact matching study aims to assess the independent effects of cancer on outcomes following single-level lumbar fusions for non-cancer surgery.

Methods: 4680 consecutive patients undergoing single-level posterior-only lumbar fusion were retrospectively enrolled. Univariate statistics and coarsened exact matching (CEM) were computed to evaluate outcomes between cancer patients and those without comorbidities.

Results: By logistic regression, malignancy conferred a higher risk of surgical complication (P = 0.016, OR = 2.64, CI = [1.200,5.790]), 30- and 90- day readmission (P = 0.012, OR = 2.025, CI = [1.170-3.510]; P < 0.001, OR = 2.34, CI = [1.430, 3.830], respectively), 90-day reoperation (P < 0.001, OR = 2.16, [1.110, 4.200]), and death at 90-days (P = 0.032, OR = 8.27, CI = [1.200, 56.850]). After matching, malignancy was associated with increased odds of incidental durotomy (6 vs 0 cases, P = 0.048) and death at both 30 and 90 days (both: OR = 8.0, P = 0.020, CI = [1.00, 63.960]). No cases of durotomy occurred in cases with mortality in the matched sample, suggesting independent relationships. There were no differences in length of stay, non-home discharge, ED evaluation, readmission, or reoperations.

Conclusion: Among otherwise exact-matched patients undergoing single level lumbar fusion, history of malignancy conferred a higher risk of short-term mortality, but not other outcomes suggestive of surgical failure. Increased mortality after lumbar fusion should be studied further and may play a role in surgical decision-making and patient discussions.

Study design: Systematic review and meta-analysis.

Objective: This meta-analysis aimed to evaluate the learning curve in endoscopic spinal surgery, including the time to mastery and challenges faced by novice surgeons, to improve learning and surgical outcomes.

Methods: Data extraction included the learning curve period and a comparison of surgeons with more experience or late period of the learning curve (late) and surgeons with less experience and in the early period of the learning curve (early) with respect to demographic, surgical, hospitalization, functional, and complication variables. Statistical analysis was performed using Review Manager 5.4.1 software.

Results: This meta-analysis included 16 studies (n = 1902). The average number of cases required to reach the learning curve was 32.5 ± 10.5. The uniportal technique required fewer cases (30.1 ± 10.2) than biportal technique (38.7 ± 10.3). There were no significant differences in demographic variables, operation level, or duration of symptoms between the advanced and novice surgeons. Advanced surgeons showed better outcomes in VAS leg pain at less than 6 months (SMD 0.18, 95% CI 0.01-0.34) and >6 months (SMD 0.14, 95% CI 0.02-0.27), as well as VAS back pain at > 6 months (SMD 0.16, 95% CI 0.04-0.29). The incidence of total complications was significantly higher in the novice surgeon group. The specific complications did not differ significantly between the 2 groups.

Conclusions: The average number of cases required to reach the learning curve was 32.5 ± 10.5. Experienced surgeons had shorter surgery and fluoroscopy times, better outcomes in leg and back pain, and a lower incidence of complications than novice surgeons.

Study design: Cross-sectional survey.

Objective: Surgical treatment of degenerative lumbar spondylolisthesis is remarkably varied due to heterogeneity of clinical-radiological presentations. This study aimed to assess which spinopelvic radiological parameters were considered for decision-making.

Methods: Survey distributed to International AO Spine members to analyze surgeons' considerations for treatment. Data collected includes demographics, training background, years of experience, and treatment decisions based on various radiographical findings, including segmental and global spinopelvic parameters.

Results: From 479 responses, the most frequently radiological parameter considered was slippage on dynamic X-rays (79.1%), followed by disc height (78.9%), global sagittal balance SVA (71.4%), and PI-LL mismatch (69.7%), while the least important was absolute spondylolisthesis on static lateral radiograph (22.8%). Fellowship-trained surgeons were likelier to use SVA (OR = 1.73, 95% CI = 1.02-2.99, P = 0.049), and disc height (2.13, 1.14-3.98, P < 0.05). There was no difference between orthopedics and neurosurgery in applying SVA and PI-LL mismatch. Surgeons from Asia Pacific emphasizes segmental lordosis (2.39, 1.11-5.15, P = 0.026) as from Latin America (2.55, 1.09-5.95, P = 0.030) and Middle East (4.33, 1.66-11.28, P = 0.003). However, surgeons from Latin America and Middle East also significant consider disc height (2.95, 1.07-8.15, P = 0.037) and (3.03, 1.04-8.83, P = 0.043), respectively. Additionally, the surgeons' age was associated with using angular motion on flexion-extension radiographs, and volume of treated cases yearly with consideration for disc height.

Conclusions: Treatment of degenerative lumbar spondylolisthesis was influenced by slippage on dynamic radiographs, disc height, global alignment, and PI-LL mismatch. Surgeons' age and Region, fellowship-trained, and volume of treated cases were significantly associated to apply these radiological parameters.

Study design: Systematic Review and Meta-Analyses.

Objective: To assess the 30- and 90-day readmission rates after a traumatic spinal cord injury (SCI).

Methods: A systematic search of MEDLINE and Embase was performed. The period was from inception to June 2022, with no language restrictions. All studies investigating the 30- and/or 90-day readmission rate following traumatic SCI were included. A random-effects model to combine effect sizes in our meta-analysis was applied.

Results: Seven out of 2959 reports met eligibility. The mean age of the patients was 50.2 ± 19.9, with a male-to-female ratio of 2.4:1. The most common traumatic SCI was cervical injury (55.3%). The meta-analysis model revealed a 30-day readmission rate of 14.2% after traumatic SCI, with heterogeneity in the studies. The 90-day readmission rate was 35.7%, with homogeneity in the studies. The meta-regression analysis found significant positive associations between cervical and thoracolumbar injuries and patient age and the 30-day readmission rate, while male sex demonstrated a negative association with the 30-day readmission rate. The 30-day readmission rate following index admission was 13.1% and the 30-day readmission rate after rehabilitation facilities was 15.8%. The study found that the 30-day readmission rate in the USA was 14.0%.

Conclusions: There is no doubt that readmission is an adverse health outcome. The outcome is also complex and multifaceted, which makes it difficult to predict. Injury level is 1 of the predictors that affect readmission, making it essential to consider factors during discharge planning for high-risk people to reduce 30-day readmission rates.

Study design: Human cadaver study.

Objectives: To provide a qualitative and quantitative evaluation by demonstrating measurements of the proximity of vital structures involved and assessed injuries during a T12-corpectomy and cage implantation via a far lateral approach.

Material and methods: Six fresh-frozen adult cadaveric specimens were dissected according to standardized protocol. A formal left-sided far lateral T12-corpectomy was carried out by trained experienced spine fellows. Upon completion of the procedure, a cage was placed between T11 and L1. We then turned the patient supine and performed a formal celiotomy and sternotomy to allow for an open anterior central inspection of all structures concerned. Vital structures as in vessels, diaphragm, pleural membranes, neural elements, important foramina of the diaphragm (Bochdalek, Morgagni) and the thoracic duct were identified. Any injuries to these structures were recorded and proximity to key relevant structures to this exposure were measured.

Results: We were able to quantify the actual diaphragm excursions and describe its origins to the spine. There was no actual diaphragm injury in any of the cadavers and there were no injuries to the neurovascular structures. We found expected parietal but no visceral pleural injuries.

Conclusion: Our cadaver study identified the feasibility of performing a T12-corpectomy through a far lateral approach with no violation of the actual diaphragm and expected limited injuries to the parietal pleura only.

Study design: Rat subjects were randomly assigned to control, local, and systemic esomeprazole groups (n = 4-6 per group).

Objective: Excessive scar formation after laminectomy can cause nerve entrapment and postoperative pain and discomfort. A rat laminectomy model determined whether topical application and systemic administration of esomeprazole can prevent epidural fibrosis.

Methods: Laminectomy alone was performed in the control group. Topical esomeprazole was introduced to the laminectomy area in the local esomeprazole group. Intraperitoneal esomeprazole was introduced in the systemic esomeprazole group following laminectomy. Macroscopic and histopathologic examinations were performed four weeks after laminectomy.

Results: In the systemic esomeprazole group, the macroscopic epidural fibrosis score was less than the control group (P < 0.001). Microscopic epidural fibrosis score and fibroblast cell density classification scores in local and systemic esomeprazole groups did not significantly differ. Fibrosis thickness was significantly lower in the local and systemic esomeprazole groups compared to the control group (P < 0.01, P < 0.001, respectively).

Conclusions: Esomeprazole reduced the formation of epidural fibrosis in the rat laminectomy model.

Study design: systematic review.

Objective: To evaluate risk factors associated with failure of non-operative management of isolated unilateral facet fractures of the subaxial cervical spine in neurologically intact patients.

Methods: A systematic review of the PubMed, Embase, LILACS, and Cochrane Library databases was conducted in order to determine risk factors associated with failure of non-operative management in isolated unilateral facet fractures of the subaxial cervical spine without facet and/or vertebral displacement, in neurologically intact patients. Our research was in line with the PRISMA Statement and registered on PROSPERO (CRD42023405699).

Results: A total of 1639 studies were identified through a database search on May 5, 2023. In total, 7 studies from the databases were included, along with 1 study found through a manual citation search. The evidence showed high clinical heterogeneity, a serious risk of bias according to the ROBINS-I tool, and a predominance of retrospective cohort studies. In comparison to less complex facet fractures, lateral floating mass fractures were found to have 5.41 times higher odds of failure of non-operative management (OR = 5.41; 95% CI = 1.32, 22.19). We calculated the potential association between lower absolute fracture height and non-operative treatment success [Fracture height (percentage) Mean Difference = -17.51 (-28.22, -6.79 95% CI); Absolute height Mean Difference: -0.46 (-0.60, -0.31 95% CI)]. Other risk factors were not included in the meta-analysis due to lack of data. The level of certainty was rated as "very low".

Conclusions: Lateral floating mass cervical facet fractures and larger fracture fragment size (measured either in absolute terms or as a percentage) are significant risk factors for failure of non-operative treatment.

Study design: Case-control study.

Objectives: Degenerative Cervical Myelopathy (DCM) is a progressive neurological condition caused by mechanical stress on the cervical spine. Surgical exposure in the preceding months to a DCM diagnosis is a common theme of Patient and Public Involvement (PPI) discussions. Such a relationship has biological plausibility (e.g. neck positioning, cord perfusion) but evidence to support this association is lacking.

Methods: We analysed UK Hospital Episode Statistics (HES) data for participants in the UK BioBank cohort. We defined cases as those episodes with a primary diagnosis of DCM and generated controls using non-DCM HES episodes. Cases and controls were propensity score-matched by age, sex and date of episode, and a directed acyclic graph was used to robustly control for confounders. We defined the exposure as any surgical procedure under general or regional anaesthetic occurring within the 6-24 months prior to the episode.

Results: We analysed 806 DCM and 2287432 non-DCM hospital episodes. On multivariable logistic regression analysis, the odds ratio (95% CI) for the effect of a binarised (0 vs ≥ 1) exposure on risk of developing DCM was 1.20 (1.02-1.41), and for categorised (0 vs 1 and 0 vs ≥ 2) exposure was 1.11 (0.882-1.39) & 1.33 (1.075-1.65).

Conclusions: This study supports the patient narrative of surgery as a risk factor for the development of DCM. The association displays temporality, dose-response relationship, and biological plausibility. Further work is needed to confirm this in other cohorts, explore mediating mechanisms, and identify those at greatest risk.

Study design: Retrospective cohort study.

Objective: Decompression for the treatment of lumbar spinal stenosis (LSS) has shown excellent clinical outcomes. In patients with symptomatic single level stenosis and asymptomatic adjacent level disease, it is unknown whether decompressing only the symptomatic level is sufficient. The objective of this study is to compare outcomes between single level and dual level minimally invasive (MIS) decompression in patients with adjacent level stenosis.

Methods: The current study is a retrospective review of patients undergoing primary single or dual level MIS decompression for LSS. Radiographic stenosis severity was graded using the Schizas grading. Patients undergoing single level decompression (SLD) with moderate stenosis at the adjacent level were compared with patients undergoing dual level decompression (DLD) for multi-level LSS. Clinical outcomes, complications, and reoperations were compared. Subgroup analysis was performed on patients with the same Schizas grade at the adjacent level in the SLD group and the second surgical level in the DLD group.

Results: 148 patients were included (126 SLD, 76 DLD). There were no significant differences in patient reported outcomes between the two groups at any timepoint up to 2 years postoperatively, including in the matched stenosis severity subgroups. Operative time was longer in the DLD cohort (P < 0.001). There were no significant differences in complications or reoperation rates.

Conclusion: In patients with single level symptomatic LSS and adjacent level stenosis, decompression of only the symptomatic level provided equivalent clinical outcomes compared to dual level decompression. The additional operative time and potential incremental risk of dual level surgery may not be justified.