Journal of neurosurgery. Spine最新文献

Objective: Atlantoaxial dislocation (AAD) with axis osseous deformity poses significant surgical challenges, particularly in complex anatomical cases. This study compares the efficacy of 2-screw versus 4-screw occipital-cervical fixation in improving neurological outcomes and reducing complications in patients with AAD and axis deformity.

Methods: A retrospective study was conducted on 37 patients with AAD and axis osseous deformity treated at the authors' institution from 2017 to 2023. The cohort included 19 patients treated with bilateral pars screws and translaminar screws (4-screw group) and 18 patients who received traditional pedicle screw (PS) fixation (2-screw group) prior to the application of 4-screw fixation. Radiographic parameters, including atlanto-dental interval (ADI), distance from the tip of the dens above the Chamberlain line (CL), cervico-medullary angle (CMA), and clivo-axial angle (CAA), were measured using radiography, CT, and MRI. Neurological function was assessed using the Japanese Orthopaedic Association (JOA) score. Data on complications and revision surgical procedures were collected and analyzed.

Results: Preoperative demographic and clinical characteristics were comparable between groups. Both techniques effectively improved CAA and CMA and reduced CL, but the 4-screw group demonstrated significantly lower ADI postoperatively (p = 0.001) and at the latest follow-up (p = 0.003). Patients in the 4-screw group also showed significantly higher JOA scores at the latest follow-up (p = 0.027), indicating better neurological recovery. The incidence of postoperative complications was lower in the 4-screw group (1 vs 6, p = 0.037), and no revision surgical procedures were required in this group, whereas 4 patients in the 2-screw group required further surgical interventions (p = 0.046).

Conclusions: Four-screw occipital-cervical fixation offers improved neurological functions and fewer postoperative complications compared to 2-screw fixation in patients with AAD and axis osseous deformity. This technique is particularly beneficial in cases with complex axis anatomy, suggesting its potential as a preferred alternative to traditional fixation methods.

Objective: Cervical spondylotic myelopathy (CSM) can be associated with urinary dysfunction, leading to an inability or marked difficulty with micturition. This study aimed to evaluate the urinary dysfunction, long-term prognosis, and recovery in patients with CSM following surgical intervention.

Methods: The CSM cases of the Quality Outcomes Database SpineCORe study group were analyzed. Urinary control was assessed using the modified Japanese Orthopaedic Association (mJOA) urinary function subscore. Improvement was defined as a minimum improvement of 1 point in the mJOA urinary function subscore at the 2-year follow-up. Univariate and multivariable analyses were conducted as appropriate.

Results: Of 1141 patients, 772 (67.7%) patients were identified with a minimum 2-year follow-up mJOA score, and 249 (32.3%) of these patients reported baseline urinary dysfunction. Of those 249 patients with baseline urinary control problems, 193 (77.5%) had improvement in urinary function postoperatively, and more women than men had improved urinary control after CSM surgery (54.9% vs 45.1%, p = 0.03). Apart from sex, demographic characteristics of patients who experienced urinary function improvement versus those who did not were similar. Patients who experienced urinary function improvement had lower overall baseline mJOA scores (10.2 vs 13, p < 0.01). Both cohorts reported similar rates of postoperative satisfaction (North American Spine Society scores of 1 and 2) (89.1% vs 85.9%, p = 0.26).

Conclusions: Among the one-third of patients with CSM experiencing urinary dysfunction, nearly 78% achieve improved urinary function at the 2-year postoperative follow-up. Women are more likely to experience improvement in this function. Patients with and without improvements in urinary function are equally satisfied with their surgery and report similar outcomes on long-term follow-up.

Objective: Carbon fiber-reinforced polyetheretherketone (CFRP) implants have been used safely in treating spinal oncological disease and promise improved imaging follow-up and radiotherapy planning. However, data on the implant's routine use in the clinical setting with implications for postoperative management are scarce. The aim of this observational study was to provide real-world insight into the current use of CFRP instrumentations in spinal oncological disease and to define their actual relevance for postoperative imaging follow-up and adjuvant treatment planning.

Methods: Datasets of patients treated between 2015 and 2022 with CFRP instrumentations due to spinal oncological disease were collected in a multicentric registry at four participating tertiary spine centers in Germany and Austria. Data on each patient's epidemiology, clinical status, surgery, adjuvant therapy, and outcome was collected retrospectively. Data management was performed using a multicentric REDCap database, and data were reviewed and analyzed descriptively.

Results: A total of 457 patients were enrolled. Most patients received decompression and instrumentation (n = 308 [67%]), with additional cage implantation in 33% (n = 149). In most cases, image-guided navigated screw implantation was performed (n = 321 [70%]). The postoperative complication rate was 13% (n = 61), mostly due to surgical site infections (n = 32 [7%]). Postoperative MRI was performed in 19% (n = 87), with MRI findings prompting revision surgery in 3% (n = 15). In total, 61% of all patients (n = 278) received adjuvant radiotherapy. In those patients, MRI was performed in 6% (18 cases) for procedure planning, while this was mostly based on preinterventional CT (n = 205 [74%]). Of all patients, 27% (n = 124) received routine MRI during follow-up, where relevant local tumor recurrence was detected in 35% (n = 44) at a median follow-up of 6 months.

Conclusions: Low overall complication and low surgical revision rates were reported. Because of the possibility of higher quality MRI follow-up due to CFRP implants, complications or relevant tumor recurrence during follow-up were detected safely and at a high rate in cases where MRI was performed. However, consequent MRI follow-up was not homogeneously performed, and adjuvant radiotherapy was handled rather heterogeneously. These findings lead to the conclusion that until homogeneous adjuvant follow-up and treatment standards are established, the potential benefits available through the use of CFRP implants are not exhausted, and the decision for the use of CFRP implants in comparison to standard titanium implants remains case-to-case based.

Objective: Current treatment options for posttraumatic syringomyelia (PTS) lack clear standardization and often result in common complications. This study aims to introduce a novel minimally invasive technique for a modified subarachnoid-subarachnoid (S-S) bypass procedure for PTS.

Methods: The study included 20 consecutive patients with symptomatic PTS who underwent the modified S-S bypass. The surgical technique of modified S-S bypass involved two-laminae fenestration based on preoperative MRI and myelography results showing normal subarachnoid space above and below the injury site. A passer was used to create a subcutaneous tunnel, and two medical-grade silicone tubes were inserted into the normal subarachnoid space at the cranial and caudal ends. Bypass tubes were placed in the subcutaneous tunnel, and dural closure was achieved using 6-0 nonabsorbable sutures. The mean follow-up period was 14.9 (range 12-18) months, with neurological function assessed using a standard grading system and MRI used to evaluate the change in syrinx size.

Results: Seventeen patients demonstrated clinical improvement, while 3 remained stable. The mean preoperative syrinx length on MRI was 16.9 spinal levels, with a mean Syringomyelia Tension Index (STI) of 58.1%. The postoperative mean STI was 28.4%, significantly lower than preoperative values (p < 0.05).

Conclusions: Modified S-S bypass, which can be performed without myelotomy and without the bypass tubes interfering with the adhesion, was not only a safe and effective surgical technique, but may also be a physiologically better way of treating PTS.

Objective: It is not clear whether smoking impacts patient-reported outcomes (PROs) in patients with cervical spondylotic myelopathy (CSM). The aim of this study was to explore the impact of smoking status on baseline symptom severity and the rate of achieving satisfaction and the minimal clinically important differences (MCIDs) for PROs in patients with CSM.

Methods: This study was an analysis of the prospective Quality Outcomes Database CSM module. Patients aged ≥ 18 years diagnosed with primary CSM who underwent elective surgery were included. PROs (visual analog scale [VAS] neck and arm pain, Neck Disability Index [NDI], modified Japanese Orthopaedic Association [mJOA], and EQ-5D scores and North American Spine Society [NASS] patient satisfaction) were collected at baseline and 24 months of follow-up.

Results: Of the 1141 patients with CSM, 202 (17.7%) were smokers and 939 (82.3%) were nonsmokers. Compared with the nonsmokers, smokers were younger (56.3 ± 11.3 years vs 61.5 ± 11.7 years, p < 0.01) and had a lower BMI (29.3 ± 6.8 vs 30.3 ± 6.3, p = 0.04). A higher proportion of smokers had depression, anxiety, and chronic obstructive pulmonary disease (all p < 0.01). At baseline, smokers had worse pain (VAS neck pain score: 6.0 ± 3.2 vs 5.1 ± 3.3; VAS arm pain score: 5.7 ± 3.2 vs 4.7 ± 3.5), disability (NDI score: 45.2 ± 20.0 vs 37.1 ± 20.6), myelopathy (mJOA score: 11.5 ± 2.9 vs 12.2 ± 2.8), and quality of life (EQ-5D score: 0.51 ± 0.23 vs 0.57 ± 0.22) (all p < 0.01). At the 24-month follow-up, a higher proportion of smokers achieved the MCID in mJOA (69.4% vs 56.6%, p < 0.01) compared with nonsmokers. However, after accounting for significant covariates, there was no significant difference in the baseline disease severity. There was also no difference between the PROs at the 24-month follow-up. The two groups also achieved similar MCIDs for most PROs and were similarly satisfied (NASS score of 1 or 2: smoker 81.2% vs nonsmoker 84.6%, p = 0.29) 24 months after surgery.

Conclusions: Smokers and nonsmokers with CSM had similar baseline disease severity and 24-month PROs. They also achieved similar rates of MCIDs for PROs and satisfaction after surgery. Numerous previous studies have documented the association between tobacco usage and inferior clinical outcomes after spine surgery. However, in the context of severe and debilitating spinal disorders such as cervical myelopathy, meaningful and impactful improvements are still seen in properly selected patients.

Objective: The objective of this study was to discern whether patients who achieve a cranial sagittal vertical axis to the hip (CrSVA-H) < 2 cm at 2 years of follow-up, regardless of mismatch between pelvic incidence and lumbar lordosis (PI-LL), have a greater improvement in patient-reported outcome measures (PROMs).

Methods: This was a retrospective analysis of a prospectively collected single-center database of adult spinal deformity (ASD) patients who underwent corrective surgery with a minimum follow-up of 2 years. Patient demographics, perioperative data, radiographic parameters, and PROMs were collected at baseline and follow-up. Patients were placed into four cohorts: combined aligned (CA) (CrSVA-H < 2 cm, PI-LL < 10°), globally aligned (GA) (CrSVA-H < 2 cm, PI-LL ≥ 10°), regionally aligned (RA) (CrSVA-H ≥ 2 cm, PI-LL < 10°), and completely malaligned (CM) (CrSVA-H ≥ 2 cm, PI-LL ≥ 10°) at final follow-up.

Results: A total of 162 patients were included (71 CA, 58 GA, 11 RA, and 22 CM patients). The CA cohort was younger (mean [standard error of the mean]: 44.1 [2.2] vs 57.6 [1.8] vs 54.7 [3.1] years, p = 0.0003) and had a smaller PI-LL (1.6° [2.3°] vs 27.9° [2.4°] vs 25.0° [4.8°], p < 0.0001) than the GA and CM cohorts. The CrSVA-H differed significantly between the CA and CM cohorts (-1.5 [0.5] vs 4.1 [1.2] cm, p = 0.0012). There was no significant difference in BMI or total instrumented levels across all four cohorts (p > 0.05). The CA and GA cohorts had greater baseline PROMs when compared with the CM cohort, specifically in the SRS-22r total score (p = 0.0025 and p = 0.0244, respectively), self-image (p = 0.0032 and p = 0.0074, respectively), and satisfaction (p = 0.0313 and p = 0.0011, respectively) domains. Baseline Oswestry Disability Index (ODI) scores differed only between the CA and CM cohorts (32.2 [2.5] vs 41.1 [2.4], p = 0.0312). The CA and GA cohorts possessed greater PROMs by the final follow-up, including the aforementioned PROMs (p = 0.0016) and ODI scores (p = 0.0044) when compared with the CM cohort. The mixed-effects model of PROMs demonstrated that the CA and GA cohorts experienced a greater increase in patient-reported outcomes when compared with the CM cohort (p < 0.05).

Conclusions: ASD patients with a CrSVA-H < 2 cm by the final follow-up improved significantly across the majority of PROMs regardless of regional alignment when compared with patients who were both globally and regionally malaligned. These results further emphasize that the position of the head relative to the hips is a vital measure for the long-term improvement of PROMs following ASD surgery.

Objective: Intraoperative antifibrinolytic therapy with tranexamic acid (TXA) is a focus of interest for blood loss reduction in multilevel adult spinal deformity (ASD) correction surgery. There is considerable heterogeneity in the reported findings regarding the safety and efficacy of this therapy. In the present study, the authors aimed to rigorously investigate the safety and efficacy of TXA in multilevel ASD correction surgery and to explore secondary perioperative outcomes.

Methods: This retrospective cohort study used data from the authors' institutional spine deformity database, including records of surgeries performed between January 1, 2013, and December 13, 2021, with a minimum follow-up of 2 years. Adult patients undergoing elective thoracolumbosacral posterior spinal fusion involving 6 or more vertebrae were included. The primary outcome was the safety and efficacy of TXA, with secondary outcomes including postoperative complications and overall outcomes. Propensity-scored stabilized inverse probability of treatment weighting was used to adjust for confounding factors. Subsequent weighted analysis of the treatment effect was performed using regression models for hypothesis testing, with 95% confidence intervals calculated based on weighted means, variances, and standard errors. The p values of primary outcomes and subgroup analyses were adjusted for multiplicity testing with the Benjamini-Hochberg correction at a false discovery rate of 0.05. The conduct and reporting of this study were supported by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Results: The study included 598 patients, with 257 receiving TXA and 341 controls. Weighted analysis revealed that TXA administration was associated with significant reductions in estimated blood loss (p = 0.007), percentage of estimated blood volume lost (p = 0.035), intraoperative total red blood cell transfusion volume (p = 0.035), and postoperative packed red blood cells transfusion volume (p = 0.035). No significant differences were observed in postoperative thromboembolic events (p = 0.397).

Conclusions: TXA was significantly associated with reduced blood loss and transfusion requirements in multilevel ASD correction surgery without increasing the risk of thromboembolic complications.

Objective: Postoperative neurological deficits are a significant concern for surgeons during spinal deformity correction surgery. Preoperative identification of high-risk patients can help ensure that appropriate measures are taken to minimize the risk of neurological deficits during these procedures. Previous studies have shown that patients with large Cobb angles or deformity angular ratios (DARs) are at higher risk for postoperative neurological deficits. However, some curves with similar Cobb angles and DARs may exhibit significantly different risks of neurological deficits during surgery. Existing methods for evaluating the degree of deformity cannot fully or accurately reflect the degree of spinal deformity. The aim of this study was to determine whether the deformity angular distance ratio (DADR) can reliably assess the neurological risks of patients undergoing three-column osteotomy (3CO).

Methods: A consecutive series of 266 patients with a deformity apex at T1-L1 who underwent 3CO at a single academic center from December 2010 to January 2024 were included in the study. Preoperative radiograph measurements were used to calculate DAR and DADR. Binary logistic regression was used to model the relationship between DADR and postoperative neurological deficits. Receiver operating characteristic analysis and the area under the curve (AUC) were used to assess the performance of the model.

Results: The 266 patients had a median (IQR) age of 48.0 (30.0-60.0) years, with 128 (48.1%) females and 138 (51.9%) males. The incidence of postoperative neurological deficits was 11.3% in this series of patients. Among patients undergoing 3CO, sagittal DADR (OR 1.086, 95% CI 1.045-1.129; p < 0.001) and total DADR (OR 1.080, 95% CI 1.046-1.116; p < 0.001) were associated with an increased incidence of postoperative neurological deficits. A total DADR > 30.4 or a sagittal DADR > 26.4 were associated with a 30% incidence of postoperative neurological deficits, which increased to 50% when the total DADR reached 41.4 or the sagittal DADR exceeded 36.6. The overall predictive performances of sagittal DADR (AUC 0.781) and total DADR (AUC 0.799) for postoperative neurological deficits were comparable and considered to be good.

Conclusions: In patients undergoing 3CO for severe spinal deformities, the DADR can be used to quantify the severity of the deformity, which is strongly correlated with the risk of postoperative neurological deficits. Patients with a total DADR > 30.4 or a sagittal DADR > 26.4 are at much higher risk for developing new neurological deficits after surgery.

Objective: Tethered cord syndrome (TCS) is a significant cause of debilitation in patients with spinal dysraphisms or tumors. Management of TCS has historically centered on intradural detethering surgery, which is associated with a substantial risk of retethering, symptom recurrence, and repeat surgery. Vertebral column resection (VCR) has recently gained popularity as a treatment option via spinal shortening, but the literature on long-term outcomes is sparse. The objective of this study was to explore long-term clinical outcomes in a series of patients undergoing VCR for recurrent TCS.

Methods: A retrospective review was conducted of all consecutive patients undergoing VCR for recurrent TCS at a single center between 2014 and 2024. Demographic and radiological characteristics were recorded, including spinal column height reduction as well as symptom improvement rates regarding sensorimotor dysfunction, pain, and incontinence at the latest follow-up. Intra- and postoperative complications were noted, and pre- and postoperative symptomology was compared using McNemar's test at a significance level of p < 0.05 to identify improvements.

Results: Twenty surgeries in 19 patients (median age 19 years) involving 10 males (52.6%) were assessed. The most common etiology of TCS was lipomyelomeningocele (n = 7, 36.8%), followed by lipoma (n = 6, 31.6%). Patients underwent a mean of 3.4 previous detethering procedures. Osteotomy was most commonly performed at the L1 level (n = 11, 55.0%), and the mean spinal column height reduction was 16.5 mm. At a mean follow-up of 43.1 (range 12-101) months, resolution of symptoms was observed in 10 patients with back pain (71.4%; p = 0.043), 10 patients with leg pain (66.7%; p = 0.004), 9 patients with lower extremity weakness (75.0%; p = 0.008), 4 patients with urinary incontinence (44.4%; p = 0.371), and 1 patient with fecal incontinence (33.3%; p > 0.99). Complications included a CSF leak in 1 patient and repeat VCR in 1 patient.

Conclusions: These results suggest that in select patients with recurrent TCS, VCR represents a treatment option with high rates of symptomatic improvement and a relatively low risk of retethering as observed over several years of follow-up. These results add to the body of literature supporting VCR and provide a compelling basis for future prospectively designed studies.