Journal of neurosurgery. Spine最新文献

Objective: Renal cell carcinoma (RCC) spinal metastases can lead to intractable pain and neurological deficits and are traditionally considered radioresistant to conventional radiotherapy. Spinal stereotactic radiosurgery (SRS) has emerged as a minimally invasive management modality to deliver high doses of conformal radiation while sparing critical structures to overcome radioresistance. The aim of this large, single-institution study was to evaluate outcomes following SRS for patients with RCC spinal metastases.

Methods: Eighty-one patients who underwent SRS for 152 primary RCC spinal metastases met inclusion criteria. The primary outcome was local control (LC). Secondary outcomes were overall survival (OS), pain palliation, and adverse radiation effects (AREs). Univariable and multivariable Cox proportional hazards regression analyses were conducted to assess prognostic factors related to study outcomes.

Results: At a median follow-up of 10 (range 1-125) months, 40 lesions (26%) demonstrated radiographic progression. The median time to progression was 9 (range 3-60) months. Following SRS, the 6-month, 1-year, and 2-year crude LC rates were 91%, 78%, and 65%, respectively. The median OS was 15 (range 1-129) months, with rates of 6-month, 1-year, and 2-year OS of 84%, 57%, and 39%, respectively. Tumors with extension into the paraspinal musculature (HR 2.70, 95% CI 1.17-6.26; p = 0.020) and those causing radiographic spinal misalignment (HR 3.79, 95% CI 1.43-10.06; p = 0.008) were associated with worsened LC. No predictors were found for OS. Clinical improvement or stability in pain was observed in 97%, 88%, and 81% of lesions at 1, 3, and 6 months after SRS, respectively. Twenty-six AREs (17%) were observed, including 14 vertebral compression fractures (VCFs, 9%). Baseline VCF at the irradiated level (HR 6.00, 95% CI 1.29-27.87; p = 0.023) was significantly associated with VCF following SRS.

Conclusions: Spinal SRS is a safe and effective treatment modality that confers high rates of tumor control and symptomatic pain relief for patients with RCC spinal metastases.

Objective: Although many authors have shown the safety of outpatient spine surgery, few have compared same-day spine surgery in the ambulatory surgical center (ASC) versus the hospital outpatient department (HOPD). The purpose of this study was to compare the safety of anterior cervical arthrodesis/arthroplasty or lumbar decompression with same-day discharge performed at the ASC versus HOPD.

Methods: After IRB approval, a retrospective, propensity-matched, comparative cohort analysis of a statewide, prospective, multicenter, spine-specific database (Michigan Spine Surgery Improvement Collaborative [MSSIC]) was undertaken. Patients who underwent lumbar decompression or anterior cervical arthrodesis/arthroplasty (1 or 2 levels) with same-day discharge from January 1, 2021, to June 30, 2023, were reviewed. The HOPD/ASC matched cohorts were created at a ratio of 4:1 based on BMI, American Society of Anesthesiologists physical status class (ASA), and operative levels. The primary outcome variables investigated included any complication, return to operating room (OR) within 90 days, and emergency department (ED) visit or readmission within 30 and 90 days. Secondary outcome measures investigated included patient-reported outcome (PRO) measures at 90 days and 1 year and return to work at 90 days and 1 year. Differences between HOPD and ASC patients were tested using univariate comparisons for both the anterior cervical and lumbar decompression cohorts. Multivariate analysis was performed for the lumbar decompression group.

Results: After matching, 3351 patients who underwent outpatient lumbar decompression (2679 HOPD and 672 ASC) and 806 patients who underwent anterior cervical arthrodesis/arthroplasty (644 HOPD and 162 ASC) were included in the analysis. In the univariate analysis for anterior cervical arthrodesis/arthroplasty, there were no differences between HOPD and ASC groups in terms of any complication, PROs at 90 days or 1 year, and return to work at 90 days and 1 year (p > 0.05). In the univariate analysis of the lumbar decompression group, there were higher rates of complications and return to the OR for the ASC group compared to the HOPD group (8% vs 5.5% [p = 0.01] and 4.9% vs 2.1% [p < 0.001], respectively), which remained in the multivariate analysis (incidence rate ratio [IRR] 1.5 [p = 0.001] and IRR 2.3 [p < 0.001], respectively). There were no differences between the groups in terms of PROs at 90 days and 1 year.

Conclusions: Although both outpatient anterior cervical surgery and lumbar decompression can be performed safely and effectively in ASC and HOPD, there is a slightly higher risk of return to the OR for patients who undergo lumbar decompression in the ASC. Given similar outcomes, future studies should focus on patient and payer cost differences between ASC and HOPD.

Objective: Thoracic disc herniation (TDH) remains a complex surgical challenge due to its ventral location, frequent calcification, and potential for severe neurological compromise. Anterior and lateral approaches, though effective, are associated with significant morbidity and technical demands. Posterior approaches offer a familiar alternative but have historically been limited in access and safety. The integration of intraoperative ultrasound (IOUS) and ultrasonic aspiration (UA) may enhance the safety and efficacy of posterior decompression techniques. The objective of this study was to evaluate the safety, efficacy, and versatility of a posterior partial transpedicular approach using IOUS and UA for symptomatic TDH in a large single-surgeon cohort.

Methods: A retrospective review was performed on 108 consecutive patients (137 TDHs) who underwent posterior partial transpedicular discectomy using IOUS and UA by a single surgeon between 2012 and 2024. Clinical, radiographic, and operative data were collected. Frankel grades were assessed preoperatively, at 3-6 months, and at final follow-up. Multivariate regression was used to identify predictors of neurological improvement.

Results: The mean ± SD age was 58.6 ± 13.8 years, and 54.7% of patients were female. Most patients presented with myelopathy (86.1%) and giant disc herniations (> 40% stenosis) (68.6%). IOUS and UA facilitated safe decompression in all cases. The mean Frankel grade improved from 3.77 preoperatively to 4.54 at last follow-up (p < 0.001), with 61.1% of patients improving by at least 1 grade. The complication rate requiring reoperation was 9.3%. Comorbidities such as diabetes and obesity were associated with less neurological improvement.

Conclusions: This large single-surgeon series demonstrated that the posterior partial transpedicular approach augmented with IOUS and UA is a safe, effective, and widely applicable technique for TDH, including large and calcified lesions. The method provides significant neurological improvement with an acceptable complication profile and can be readily adopted by general spine surgeons.

Objective: Functional outcome after resection of spinal meningiomas (SMs) is mostly considered satisfactory. However, patients with nonresolving neurological symptoms show a reduced quality of life. This study examined factors that determine full neurological recovery after resection of SMs.

Methods: A single-center retrospective analysis of consecutive patients undergoing surgery on SM between 2007 and 2022 integrated clinical and surgical data with MRI-based automated volumetric tumor analyses. Patients with a favorable outcome (Frankel grade E) were compared to patients with nonresolving neurological symptoms (Frankel grade A-D) at final follow-up.

Results: A total of 202 patients with a histologically diagnosed SM were included. The cohort consisted of 159 females (78.7%) and had a median age of 65 (interquartile range [IQR] 55-74) years. Upon admission, clinical examination in 97 patients (48.0%) revealed a Frankel grade of A-D. Gross-total resection was achieved in 193 patients (95.5%) with a surgical complication rate of 8.9% (n = 18). After a median follow-up of 479 (IQR 193-1049) days, 135 patients (66.8%) showed intact neurological function (Frankel grade E). A univariate analysis revealed an overrepresentation of advanced age (OR for age ≤ 60 years = 0.14, p < 0.0001) and higher rates of preoperative neurological deficits (OR 7.39, p < 0.0001) in patients without complete recovery. No significant differences were noted in tumor volume between both groups (mean 2.34 [SD 1.69] vs 2.36 [SD 1.75] cm3, p = 0.962). In a multivariate analysis, age > 60 years, preoperative Frankel grade A-D, and Ki-67/MIB-1 index < 5% were significantly associated with nonresolving deficits at the final follow-up.

Conclusions: This volumetry-informed series of patients with SM revealed older age and a low Ki-67 index, along with preoperative neurological deficits, constitute a higher risk of nonresolving neurological symptoms after resection. An early surgical intervention in oligosymptomatic young patients could therefore help preserve excellent long-term neurological function.

Objective: This study analyzed a cohort of adult patients who underwent intrathecal baclofen (ITB) pump and catheter implantation at a large tertiary neurorehabilitation center. The objectives were 1) to describe the rate and types of ITB-associated complications in patients with diverse neurological conditions, 2) to compare baseline clinical and demographic characteristics between patients with spinal cord injury (SCI) who experienced a complication and those who did not, and 3) to identify potential risk factors associated with the occurrence of complications in patients with SCI.

Methods: This retrospective cohort study included patients who underwent ITB implantation at a single center (1989-2025). Patients with SCI who had complications were compared with those without complications across multiple baseline variables, including age, sex, ambulation status, BMI, diabetes status, neurological level of injury, American Spinal Injury Association Impairment Scale (AIS) grade, and motor Functional Independence Measure (FIM). Cox proportional hazards models were used to assess the association between patient-related factors and the risk of experiencing a first complication event.

Results: Among 281 patients (205 male, mean age 43.1 years) who underwent ITB pump implantation, the most prevalent conditions were SCI (203/281, 72.2%), multiple sclerosis (29/281, 10.3%), and cerebrovascular accident (16/281, 5.7%). Overall, 22.4% of patients experienced an ITB-related complication. Complications included device erosion (20/281, 7.1%), catheter malfunction (16/281, 5.7%), infection (14/281, 5.0%), CSF leakage (10/281, 3.6%), and pump malfunction (8/281, 2.8%). Additionally, 28 patients (10.0%) had "other" complications, which included a range of issues (e.g., seromas and hematomas). Among the patients with SCI, those with a complication (25.1%) were significantly younger at the time of implantation (mean age 38.1, SD 14.4, years) compared with those without a complication (mean age 45.3, SD 15.7, years; p = 0.004). No significant differences were observed between groups in terms of AIS grade, ambulation, diabetes, BMI, or neurological level. Patients who developed complications had a higher motor FIM score at baseline (mean 51.3 [SD 24.9] vs 44.4 [SD 25.0]), although this difference did not reach statistical significance (p = 0.056). Multivariable Cox proportional hazards analysis identified younger age at implantation as the only significant predictor of complication risk (HR 0.97 [95% CI 0.95-0.99], p = 0.013; C-index = 0.714).

Conclusions: One in four patients with SCI had complications, half of which occurred within the first year. Younger patients were at higher risk, likely due to increased activity, emphasizing the need for early monitoring and targeted prevention strategies.

Objective: Degenerative cervical myelopathy (DCM) is a common condition caused by cervical spinal cord compression and produces diverse symptoms and neurological deficits. Diagnosis is clinical and corroborated by imaging, yet formal diagnostic criteria and consensus on relevant symptoms are lacking. The aim of this study was to describe the onset and chronology of early symptoms in patients who were already diagnosed with DCM to improve understanding and inform future development of diagnostic criteria.

Methods: The authors conducted a prospective cross-sectional study of consecutive patients with DCM at their initial spine surgery visit. They recorded detailed histories of headache, neck and back pain, hand incoordination, gait imbalance, urinary and fecal dysfunction, saddle numbness, sexual dysfunction, and upper extremity (UE) and lower extremity (LE) pain, weakness, and numbness. For each symptom, they captured duration, severity, frequency (days/week), laterality, pattern, progression, and order of onset. The authors assessed Pearson correlations between symptom duration or severity and modified Japanese Orthopaedic Association (mJOA) score.

Results: A total of 138 patients were included in the study. The most common symptoms were neck pain (84.1%), back pain (72.5%), UE numbness (66.7%), gait imbalance (58.0%), and UE incoordination (57.2%). Symptoms most frequently recalled as first were back pain (40.6%), neck pain (31.9%), UE numbness (19.6%), and UE pain (15.2%). The longest mean ± SD pain durations were back pain (8.6 ± 11.7 years), LE pain (6.6 ± 10.9 years), neck pain (6.3 ± 9.5 years), and UE pain (6.2 ± 8.6 years). The most bothersome symptoms were saddle numbness (5.8/10), UE pain (5.2/10), UE weakness (5.1/10), and back pain (5.1/10). Most symptoms occurred frequently (approximately 6 days/week). Common co-occurrences were neck and back pain (65.2%), neck pain and UE numbness (57.2%), and neck pain and gait imbalance (50.7%).

Conclusions: DCM frequently presents with a prodrome of pain before neurological symptoms, with neck and back pain representing the most common and earliest symptoms, while arm pain, leg pain, and headache are also common. Further research is needed to understand the importance of these nonspecific symptoms, which could be early clues that help achieve earlier diagnosis of DCM.

Objective: Previous studies have identified decreased esophageal blood flow during anterior cervical surgery as a contributing factor to postoperative dysphagia. However, the effects of antithrombotic agents on esophageal blood flow during recovery from surgery have yet to be explored. This study examines the relationship between antithrombotic medication use and postoperative dysphagia in patients undergoing anterior cervical spine procedures.

Methods: A prospectively collected multi-institutional quality registry was retrospectively reviewed. Patients undergoing cervical spine surgery were categorized based on preoperative antithrombotic drug usage and propensity score matched by age, race, sex, and other baseline characteristics. Dysphagia rates were compared between groups using Eating Assessment Tool-10 questionnaires. Univariate analyses were used to examine the effects of antithrombotic medications on the rates of postoperative dysphagia.

Results: Of 1661 patients meeting inclusion criteria, 629 (37.9%) reported taking antithrombotic agents preoperatively. Propensity score matching yielded 784 patients, with 392 (50%) who took prescription antithrombotic medications. Patients taking antithrombotic agents experienced significantly lower rates of postoperative dysphagia at 1 (48% vs 58%, p = 0.049), 3 (21% vs 28%, p = 0.033), and 12 (19% vs 26%, p = 0.048) months after surgery compared with those who did not. After separating the cohorts by surgical approach, patients taking antithrombotic medications who underwent anterior cervical surgery experienced significantly lower rates of dysphagia at 3 months (21% vs 30%, p = 0.019) but not at 1 month (51% vs 59%, p = 0.2) or 12 months (19% vs 26%, p = 0.058) postoperatively, while rates for patients undergoing a posterior approach were similar regardless of antithrombotic drug use.

Conclusions: Patients taking antithrombotic medications experience significantly lower rates of dysphagia after anterior cervical surgery. Antithrombotic drugs may enhance microcirculation within the esophagus postoperatively, protecting against the detrimental effects of prolonged esophageal retraction during anterior cervical surgery that have been found to contribute to postoperative dysphagia. This novel finding warrants further investigation.

Objective: The authors propose a formula to calculate the angle required for cervical kyphosis correction and validate its utility in achieving and maintaining optimal cervical alignment.

Methods: The authors introduce a novel radiographic parameter, the necessary cervical kyphosis correction angle (NeckCA), defined as NeckCA = C2 slope (C2S) + center of gravity - T1 tilt (COG-T1 tilt) - 15. Using this formula, the authors retrospectively reviewed 29 cervical spinal deformity (CSD) correction surgical procedures performed at a single center from 2012 to 2024. Patients were categorized into two groups based on their radiological outcome: favorable (F group) and unfavorable (U group). The following criteria defined the U group: 1) T1 slope (T1S) - cervical lordosis (CL) > 25°; 2) C2-7 sagittal vertical axis (SVA) > 70 mm; or 3) segmental angle change > 10°. The authors compared clinical and radiological parameters between the groups and evaluated the discriminatory capacity of NeckCA using receiver operating characteristic (ROC) curve analysis.

Results: Among the 29 patients (19 degenerative, 6 oncological, and 4 infectious etiologies), 17 were classified into the F group and 12 into the U group. Preoperative radiological parameters such as CL, C2S, and segmental angle did not differ significantly between groups, except for C2-7 SVA, which was much greater in the U group. ROC curve analysis showed that NeckCA served as a critical predictor of radiological outcomes, with an area under the curve of 0.806 (p = 0.006).

Conclusions: In CSD correction, increasing CL alone to meet a T1S - CL < 15° often results in compensatory increases in T1S, leading to undercorrection. To counteract this, preoperative planning should include an additional corrective angle represented by the COG-T1. The authors' analysis of 29 cases confirms the use of NeckCA as a practical and predictive parameter for achieving optimal cervical alignment.