Journal of neurosurgery. Spine最新文献

Objective: When creating minimally invasive spine fusion constructs, accurate pedicle screw fixation is essential for biomechanical strength and avoiding complications arising from delicate surrounding structures. As research continues to analyze how to improve accuracy, long-term patient outcomes based on screw accuracy remain understudied. The objective of this study was to analyze long-term patient outcomes based on screw accuracy.

Methods: This is a retrospective cohort study of patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion and were queried from a prospectively maintained multisurgeon registry. Pedicle screws were assessed for accuracy and graded as poor, acceptable, or good. Patient demographic characteristics and outcomes including complications, patient-reported outcome measures (PROMs), return to activities, and fusion rates were compared between the cohorts.

Results: A total of 665 pedicle screws in 153 patients were evaluated and included in the final analysis. Of these, 20 (13.1%) patients had poor screws, 63 (41.2%) had acceptable screws, and 70 (45.7%) had good screws. All groups showed similar and significant improvements in all PROMs, although the poor screw group experienced delayed improvement in physical function. A majority of patients in all groups returned to working and driving and discontinued narcotics at similar rates. However, the poor screw group displayed significantly slower return to activities. There were no significant differences in intraoperative or postoperative complications, although the poor screw group experienced significantly lower fusion rates.

Conclusions: Patients with poorly accurate pedicle screws experienced delayed return to activities and decreased fusion rates with similar long-term PROMs. Surgeons should continue to focus on placing accurate pedicle screws, and research should continue to analyze ways to ensure accurate screw placement.

Objective: The potential of robot-assisted (RA) single-position (SP) lateral lumbar interbody fusion (LLIF) warrants further investigation. This study aimed to assess the efficacy of RA-SP-LLIF in improving both clinical and radiographic outcomes in patients undergoing lumbar spinal fusion surgery.

Methods: A total of 59 patients underwent either RA-SP-LLIF (n = 31 cases) or traditional LLIF (n = 28 cases). Surgical parameters including operative duration, estimated blood loss, and fluoroscopy duration were recorded. Clinical outcomes were assessed using the visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and the 36-item Short-Form Health Survey (SF-36). Radiographic parameters were also evaluated.

Results: There were no significant differences between the two groups in terms of postoperative and last follow-up times, but both groups demonstrated significant improvements in VAS scores. Similarly, ODI and SF-36 scores showed comparable improvements. Radiographic parameters did not significantly differ between the groups preoperatively, postoperatively, and at last follow-up (p > 0.05). Neither group showed significant improvements in pelvic tilt and sacral slope parameters compared to baseline postoperatively and at last follow-up (p > 0.05). However, the RA-SP-LLIF group exhibited significantly greater improvements in lumbar lordosis (LL; p < 0.01), segmental lordosis (SL; p < 0.01), and pelvic incidence-LL mismatch (PI-LL; p < 0.01) immediately postoperatively compared to baseline, although these differences were not significant at subsequent evaluations. Similarly, the traditional LLIF group improved the LL, SL, and PI-LL parameters postoperatively. Importantly, there was no statistically significant difference in the Bridwell grade and complications between the two groups (p = 0.83 and p = 0.88, respectively). However, the RA-SP-LLIF group had significantly shorter operative and fluoroscopy durations compared to the traditional LLIF group (p = 0.04 and p < 0.01, respectively).

Conclusions: Both RA-SP-LLIF and traditional LLIF surgeries achieved satisfactory lordotic correction. However, RA-SP-LLIF surgery demonstrated shorter operative and fluoroscopy times compared to traditional LLIF surgery. Therefore, RA-SP-LLIF is a promising technique for enhancing surgical efficiency, safety, and precision in lumbar spinal fusion procedures.

Objective: Cervical spondylotic myelopathy (CSM) shows varying levels of improvement after surgical treatment. While some patients improve soon after surgery, others may take months to years to show any signs of improvement. The goal of this study was to evaluate postoperative improvement, patient-reported outcomes, and patient satisfaction up to 2 years after surgical treatment for CSM, which will help optimize the current treatment strategies and effectively manage patient expectations.

Methods: This was a retrospective study of prospectively collected data using the Quality Outcomes Database. The primary outcomes of interest were achievement of the minimal clinically important difference (MCID) for the numeric rating scale for neck and arm pain, modified Japanese Orthopaedic Association, Neck Disability Index, and EQ-5D scores and postoperative satisfaction (North American Spine Society scale). Early and sustained improvement was defined as MCID achievement in at least one patient-reported outcome measure (PROM) at the 3-, 12-, and 24-month follow-ups. Transient improvement was defined as MCID achievement only at the 3-month and/or 12-month follow-up but not at the 24-month follow-up. Late improvement was defined as MCID achievement in at least one PROM only at the 24-month follow-up.

Results: There were 630 patients included in the comparative analysis. A total of 463 (73.5%) patients achieved early and sustained improvement, 105 (16.7%) patients experienced transient improvement with subsequent decline, 25 (4.0%) patients reported late improvement, and 37 (5.9%) patients did not report any clinically meaningful improvement after surgery. Patients with an anterior approach were more likely to be in the early and sustained improvement group. African American patients (OR 2.98, 95% CI 1.14-7.76; p = 0.03) were more likely to report late improvement when compared with White patients. The overall satisfaction rate at the 24-month follow-up was 87.8%.

Conclusions: These findings indicate that 73.5% of patients achieve early and sustained improvement, and 87.8% of patients are satisfied with surgery 24 months postoperatively.

Objective: The goal of this study was to compare the impact of using a lower thoracic (LT) versus upper lumbar (UL) level as the upper instrumented vertebra (UIV) on clinical and radiographic outcomes following minimally invasive surgery for adult spinal deformity.

Methods: A multicenter retrospective study design was used. Inclusion criteria were age ≥ 18 years, and one of the following: coronal Cobb angle > 20°, sagittal vertical axis > 50 mm, pelvic tilt > 20°, pelvic incidence-lumbar lordosis mismatch > 10°. Patients were treated with circumferential or hybrid minimally invasive techniques at ≥ 3 spinal levels and had a 2-year minimum follow-up. They were then divided into 2 groups depending on whether the UIV was in the UL region, defined as a UIV location of L1-2, or the LT region, defined as T10-12.

Results: A total of 114 of 223 patients met the inclusion criteria (68 LT and 46 UL). The UL group was older (67.5 vs 62.3 years; p = 0.015). Preoperative spinopelvic parameters were similar, except for sacral slope, which was higher in the UL group (30.5° vs 26.5°; p < 0.001). The percentage of patients with fixation crossing the lumbosacral junction was also similar (70.6% vs 67.4%; p = 0.717). Postoperative lumbar lordosis (42.5° vs 35.5°; p = 0.01) and change in coronal Cobb angle (-23.2° vs -9.6°; p < 0.001) were greater in the LT group, but other changes in postoperative spinopelvic parameters and changes in health-related quality-of-life scores were similar between groups. Reoperation rates were lower in the UL group (17.4% vs 36.8%; p = 0.025), largely associated with fewer radiographic failures (UL = 10.9% vs LT = 26.5%; p = 0.042); however, overall complication rates were not significantly different (UL = 43.5% vs LT = 60.3%; p = 0.077).

Conclusions: Selecting a UL vertebra for UIV in minimally invasive surgical correction of adult spinal deformity results in lower reoperation rates compared to extending fixation to the LT region. This choice also correlates with shorter operating room times and reduced estimated blood loss. Although extending fixation to the LT region is associated with slightly greater lumbar lordosis and a greater change in the coronal Cobb angle, clinical outcomes were similar between the LT and UL groups for UIV.

Objective: Awake, endoscopic spinal fusion has been utilized as an ultra-minimally invasive surgery technique to accomplish the goals of spinal fixation, fusion, and disc height restoration. While many techniques exist for this approach, this series represents a single institution's experience with a large cohort and the evolution of this method.

Methods: The medical records of a consecutive series of 400 patients treated over a 10-year period were retrospectively reviewed. Endoscopic decompression, expandable intervertebral spacer deployment, and percutaneous screws were combined with liposomal bupivacaine to allow for the surgery to be performed without general endotracheal anesthesia (GETA) in the vast majority of cases. Clinical and radiographic postoperative results were reviewed with special attention to surgical complications, in particular dorsal root ganglion (DRG) irritation.

Results: All patients underwent surgery successfully without conversion to an open operation. Their mean age was 69.1 ± 10.4 years, and 42% of the patients were male. A total of 509 levels were fused, with the most common indication being spondylolisthesis (67.5%). The mean operative time was 84.6 ± 31.4 minutes, the mean intraoperative blood loss was 98 ± 63 ml, and the mean hospital length of stay was 1.93 ± 1.1 nights. Overall, 4.3% of the patients underwent planned GETA due to comorbidities, and 2% were converted to GETA intraoperatively. Eighty percent of the patients experienced > 75% improvement in leg pain, and 52% experienced > 75% improvement in axial back pain. Complications included transient DRG irritation (23%), adjacent-level disease requiring reoperation (3.5%), inadequate decompression (2.3%), and nonunion (1.8%).

Conclusions: This large case series demonstrates that awake, endoscopic spinal fusion is a viable option with acceptable clinical and radiographic results in a select patient population. Meticulous attention to detail is required to limit the rate of DRG irritation, achieve interbody height restoration, and mitigate nonunions.

Objective: The objective of this study was to assess the complicated relationship between frailty, perioperative complications, and patient-reported outcomes (PROs) in elderly patients (≥ 75 years old) undergoing lumbar spine fusion (LSF).

Methods: Consecutive patients who underwent LSF between March 2019 and December 2021 were recruited in this study. Frail patients (modified frailty index [mFI] score ≥ 2) were propensity score matched to nonfrail patients (mFI score 0-1) on the basis of age, sex, and the number of fused levels. Perioperative complications were collected and assessed according to the comprehensive complication index. Subgroups were further subdivided on the basis of the presence of major complications. The data from SF-36, Oswestry Disability Index (ODI), and North American Spine Society Satisfaction Questionnaire (NASS) at baseline and 1- and 2-year follow-up evaluations were compared between groups. Furthermore, the minimal clinically important difference (MCID) achievement rate was also compared.

Results: The final analysis included 631 patients: 344 in the frail group and 287 in the nonfrail group. Frail patients were older (79.7 ± 5.1 years vs 76.4 ± 4.8 years, p < 0.001), with a higher proportion of females (68.9% vs 57.8%, p = 0.004) and those with malnutrition (17.7% vs 11.1%, p = 0.020). After propensity score matching for age, sex, and number of fused levels, 402 patients (201 in each group) were analyzed. Frail patients were more prone to have delirium (7.5% vs 3.0%, p = 0.044), blood transfusion (43.3% vs 30.3%, p = 0.007), and surgical site infection (6.0% vs 2.0%, p = 0.041). In addition, frail patients had a higher proportion of major complications (29.4% vs 16.9%, p = 0.003). Although they had worse PROs at baseline, frail patients obtained higher mean improvements and higher rates of MCID achievement by the 1- and 2-year follow-up evaluations than their nonfrail counterparts. Major complications did not seem to affect PROs in frail and nonfrail patients.

Conclusions: Despite being associated with worse baseline PROs, frail patients gained greater mean improvement in PROs and higher rates of MCID achievement by the 1- and 2-year follow-up evaluations than nonfrail patients. In addition, the presence of major complications did not affect PROs at the 1- and 2-year follow-ups. Although associated with major complications, elderly patients with frailty could benefit from LSF.

Objective: Malalignment following cervical spine deformity (CSD) surgery can negatively impact outcomes and increase complications. Despite the growing ability to plan alignment, it remains unclear whether preoperative goals are achieved with surgery. The objective of this study was to assess how good surgeons are at achieving their preoperative goal alignment following CSD surgery.

Methods: Adult patients with CSD were prospectively enrolled into a multicenter registry. Surgeons documented alignment goals prior to surgery, including C2-7 sagittal vertical axis (SVA), C2-7 sagittal Cobb angle, T1 slope minus cervical lordosis (TS-CL), and C7-S1 SVA. Goals were compared with achieved alignment, and the offsets (achieved goal) were calculated. General linear models were created for offset magnitude for each alignment parameter, controlling for baseline deformity and surgical factors.

Results: The 88 enrolled patients had a mean age of 63.6 ± 13.0 years. The mean number of anterior and posterior instrumented levels was 3.5 ± 1.0 and 10.6 ± 4.5, respectively. Surgeons failed to achieve their preoperative alignment goals by an average of 17.2 (range 0.1-75.4) mm for C2-7 SVA, 10.3° (range 0.1°-45.5°) for C2-7 sagittal Cobb angle, 15.6° (range 0.0°-42.9°) for TS-CL, and 34.2 (range 0.3-113.7) mm for C7-S1 SVA. The sagittal alignment parameters with the highest rate of extreme outliers were TS-CL and C7-S1 SVA, with 32.2% exceeding 20° and 60.8% exceeding 20 mm from goal alignment, respectively. After controlling for baseline deformity and operative parameters, the only factor associated with achieving targeted alignment for C2-7 sagittal Cobb angle was greater baseline thoracic kyphosis (TK; B = -0.148, 95% CI -0.288 to -0.007, p = 0.040), and for TS-CL, the only associated factor was lower baseline TS-CL (B = 0.187, 95% CI 0.027-0.347, p = 0.022). Both lower TK and greater TS-CL may reflect increased baseline deformity through greater thoracic compensation and increased TS-CL mismatch, respectively. No significant associations were identified for C2-7 SVA and C7-S1 SVA.

Conclusions: Surgeons failed to achieve their preoperative alignment goals by an average of 17.2 mm for C2-7 SVA, 10.3° for C2-7 sagittal Cobb angle, 15.6° for TS-CL, and 34.2 mm for C7-S1 SVA. The few factors identified that were associated with offset between goal and achieved alignment suggest that achievement of goal alignment was most challenging for more severe deformities. Further advancements are needed to enable more consistent translation of preoperative alignment goals into the operating room for adult CSD correction. Clinical trial registration no.: NCT01588054 (ClinicalTrials.gov).

Objective: Mixed-reality (MR) applications provide opportunities for technical rehearsal, education, and estimation of surgical performance without the risk of patient harm. In this study, the authors provide a structured literature review on the current state of MR applications and their effects on neurosurgery training. They also introduce an MR prototype for neurosurgical spine training.

Methods: An extensive review of the literature based on MR, education, and neurosurgery was performed using the MEDLINE, Cochrane, Scopus, and Embase databases from January 1, 2013, to October 5, 2023. The terms used for the search included "augmented reality," "mixed reality," "education," "neurosurgery," and "neurosurgical procedures." After evaluating the results in the literature, the authors designed an MR prototype to investigate the use of 3D models, haptic feedback, and virtual reality (VR) in an educational module for freehand pedicle screw placement training.

Results: Of the 1089 articles found in the databases, 111 duplicate articles were removed, and 978 articles were screened for MR and neurosurgery. Forty articles were selected to explore the relationship between MR environments and neurosurgery. Of these, 25 described cranial MR use, 13 described spine MR use, and 2 described cranial and spine MR training and education modules. The structured review exposed the relationships between MR environments in neurosurgical education, procedures, functional outcomes, novel technologies, and medical training limitations. These studies revealed favorable feedback for MR modules in neurosurgical education, training, and surgical operative outcomes, warranting further investigation to compare MR-based complementary curriculums, standard training methods, and the underlying advantages and disadvantages of MR modules for neurosurgical pedagogy. Based on this literature review, the authors developed an early MR prototype using a 3D model of scoliosis, a surgical tool tracking system, and conductive material for freehand pedicle screw placement.

Conclusions: The technological features, cost-effectiveness, and limitations of MR are currently being adapted to complement education, surgical optimization, and forecasting applications in neurosurgery. An MR surgical spine prototype was developed as a complementary educational tool.

Objective: The aim of this study was to evaluate the association of neighborhood-level and individual-level measures of socioeconomic status with readmission, complication rates, and postoperative length of stay of patients with cervical spondylotic myelopathy (CSM) in the Deep South.

Methods: The authors identified all patients undergoing surgical intervention for the treatment of CSM from November 2010 to February 2022 using Current Procedural Terminology and ICD-9/ICD-10 codes. Patient demographic, socioeconomic, perioperative, and postoperative data for each patient were collected via review of the electronic medical record. Patient addresses underwent geospatial analysis and were used to extract the Area of Deprivation Index (ADI). Patients with ADIs greater than 75 were considered highly deprived. Univariate comparison and multivariate logistic regressions were used to analyze the relationship between socioeconomic variables and outcomes of interest.

Results: In total, 490 patients with CSM met the inclusion and exclusion criteria. The median age at the time of surgery was 60 (IQR 54-68) years. The median ADI was 75 (IQR 57-90). On multivariate regression analysis, unemployment was found to predict readmission within 1 year of index surgery (OR 4.08, 95% CI 1.87-9.61; p < 0.001). Having high ADI (OR 0.53, 95% CI 0.29-0.94; p = 0.033) and being African American (OR 0.51, 95% CI 0.26-0.97; p = 0.043) were found to be independently protective of readmission. Unemployment was found to be an independent predictor of postoperative complications (OR 3.65, 95% CI 1.52-9.82; p = 0.006). On multivariate regression analysis, high ADI (OR 1.69, 95% CI 1.02-2.81; p = 0.042) and living in a skilled nursing facility/residential facility (OR 8.84, 95% CI 3.08-28.5, p < 0.001) were independent predictors of prolonged length of hospital stay postoperatively.

Conclusions: This is the first single-institution study investigating the influence of neighborhood-level and employment status on readmission, complications, and lengths of stay in patients with CSM in the Deep South. Neighborhood-level measures of socioeconomic status play complex and unique roles in CSM patient outcomes in the Deep South, highlighting the Deep South as a potentially unique geographic region in terms of neurosurgical outcomes. Further research is needed to evaluate methods of alleviating these disparities and improve patient outcomes.