Journal of neurosurgery. Spine最新文献

Objective: Spondylodiscitis is classically believed to reflect intravenous drug use in urban centers, hemodialysis-associated complications, and generalized poor medical care, but these associations may be more complex and reflect underlying systemic societal problems. The authors sought to characterize socioeconomic and demographic elements associated with spondylodiscitis to better understand community factors placing patients at risk of this infection.

Methods: All cases of spondylodiscitis at an urban, tertiary-level academic hospital since 2015 were surveyed. The zip code of residence for all patients with spondylodiscitis was captured and a referral map of the authors' urban center was created, demonstrating whether these areas had spondylodiscitis cases as well as the case density. A validated database of public data was used to compare demographic and socioeconomic factors between zip codes with and without cases of spondylodiscitis.

Results: Two-hundred sixty-two cases with complete datasets between September 2015 and July 2021 were identified. Thirty-seven of the 56 zip codes within the authors' urban center had discitis cases, ranging from 1 to 4 (median 2) per zip code. Zip codes with spondylodiscitis cases had a higher median housing density (2.4 vs 1.8, p = 0.004), higher percentage of minority residents (59.0% vs 31.9%, p = 0.011), greater proportion of residents younger than 20 years (26.8% vs 16.2%, p = 0.001), higher rates of residents below the poverty level (17.4% vs 8.8%, p = 0.007), lower median annual income ($52,193 vs $103,173, p < 0.001), lower median rent and home value (p < 0.001 and p = 0.021, respectively), and lower rates of high school graduation and higher education (both p < 0.001).

Conclusions: This is the first time that the incidence of spondylodiscitis has been demonstrated to be strongly associated with regions of poverty and worse socioeconomic indicators, independent of healthcare referral patterns. Long-term interventions may depend on improving general living conditions for this at-risk population.

Objective: Variations exist among surgeons in the treatment of recurrent lumbar disc herniation (LDH), generating major issues in decision-making models. The authors aimed to identify international nuances in surgical treatment patterns, highlight the differences in responses in each country group and different treatment trends across countries, and identify factors that influence surgical decisions.

Methods: An online survey with preformulated answers was submitted to 292 orthopedic surgeons and 223 neurosurgeons from 16 countries regarding 3 clinical vignettes (recurrence without low back pain, recurrence with severe low back pain, and recurrence with 2-level disc disease). The variability for each country was calculated according to the index of qualitative variation (IQV; ranging from 0 [no variability] to 1 [maximum variability]). To integrate the surgeons' perspectives, 2 Likert-type queries were submitted concerning the specific criteria for fusion and overall decision-making for each clinical case.

Results: Except for the case of first recurrence with pure radiculopathy without instability or inflammatory disc disease, where the variability was low (mean IQV 0.24, redo discectomy 86.2%), the other cases showed high variability (mean IQV range 0.63-0.71), with frequent proposals for surgery with implants. For countries with low variability, a high rate of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) procedures (55.3%) and low rates of anterior/combined procedures (5.9%) and posterolateral fusion (4.9%) were observed. For countries with high variability, a lower rate of PLIF/TLIF procedures was observed (33.1%), with alternate proposals for anterior/combined procedures (20.8%) and posterolateral fusion without interbody fusion (12.8%). Orthopedic surgeons performed significantly more procedures with implants compared with neurosurgeons (p < 0.01). Age, practice type, and the annual number of surgery cases did not play a significant role in the choice of procedures. The most important criteria for fusion were lumbar pain symptoms associated with radiculopathy (77.9% strongly agreed) and the existence of inflammatory disc disease (73.0%). Furthermore, 62.1% of the respondents strongly agreed with performing fusion for all second recurrences. For the final decision, surgeons agreed with following the literature (81.9%), selecting low-morbidity procedures (78.6%), and using a familiar technique (78.6%). Patient preference was an important and/or very important decision factor for 64.1% of respondents.

Conclusions: Significant differences existed between spine surgeons in the surgical treatment of recurrent LDH. Intra- and intergroup variations were observed, reflecting the lack of consensus in the literature and the challenge of adapting differences in habits and training to the few existing guidelines.

Objective: The objective of this study was to introduce and evaluate foraminoplastic inferior pedicle subtraction osteotomy (FiPSO), a novel technique that involves downward resection of the pedicle and vertebral body, aimed at addressing rigid lower lumbar kyphosis.

Methods: The clinical records were reviewed of the patients who underwent corrective surgery from January 2012 through December 2021 for adult spinal deformity using a combination of procedures: pedicle subtraction osteotomy (PSO) at the lumbar level and spinopelvic fixation. Inclusion criteria included patients older than 40 years with sagittal imbalance symptoms and significant radiographic findings: sagittal vertical axis (SVA) > 50 mm, pelvic tilt (PT) > 25°, or pelvic incidence (PI) minus lumbar lordosis (LL) > 10°. Patients were categorized into three groups: L1-3 PSO, L4-S1 PSO, and FiPSO. The authors assessed thoracic kyphosis, LL, lower LL (LLL), PI, PT, sacral slope, SVA, global tilt (GT), and Global Alignment and Proportion (GAP) score preoperatively, postoperatively, and at the last follow-up. Complications were also analyzed.

Results: A total of 65 patients were included in the final analysis: 25 in the L1-3 PSO group, 29 in the L4-S1 PSO group, and 11 in the FiPSO group. The FiPSO group showed significantly larger postoperative LLL (39.2° ± 7.7° vs 29.7° ± 10.7°, p < 0.05) and smaller PI-LL mismatch (9.6° ± 10.3° vs 24.6° ± 13.4°, p < 0.01) compared to the L4-S1 PSO groups. At the last follow-up, the FiPSO group maintained larger LLL (38.3° ± 8.9° vs 27.1° ± 10.0°, p < 0.05), lower PT (23.1° ± 9.9° vs 33.3° ± 10.7°, p < 0.05), and good global sagittal alignment (SVA, 64.0 ± 43.8 mm vs 106.8 ± 55.7 mm, p < 0.05; GT, 28.7° ± 13.9° vs 43.5° ± 15.5°, p < 0.05) compared to the L4-S1 PSO group. The FiPSO group had higher nerve deficits (45%) but lower proximal junctional kyphosis (18%) and revision surgery rates (9.1%) than the L1-3 or L4-S1 PSO groups. However, the differences were not statistically significant.

Conclusions: FiPSO provides effective lower lumbar correction and long-term sagittal alignment with comparable complication rates, offering a valuable option for overcoming the challenges associated with PSO in the lower lumbar spine.

Objective: The aim of this study was to compare the predictive efficacy of quantitative CT (QCT)-based endplate volumetric bone mineral density (EP-vBMD) and MRI-based endplate vertebral bone quality (EBQ) score for cage subsidence (CS) after lateral lumbar interbody fusion (LLIF).

Methods: A retrospective study was conducted on patients who underwent single-level LLIF in conjunction with pedicle screw fixation at the authors' institution between January 2019 and April 2023. The volumetric bone mineral density (vBMD) was measured based on preoperative CT using phantom-less QCT software. Measurement of the VBQ score was based on preoperative MRI. CS was defined as a decrease of more than 2 mm in the midpoint height of the intervertebral space. The receiver operating characteristic (ROC) curve of the EP-vBMD and EBQ for predicting CS was drawn, and the predictive efficacy of the two methods was compared using the Delong test. Clinical outcomes, including the visual analog scale for low back pain (VAS-BP), VAS for leg pain (VAS-LP), and Oswestry Disability Index (ODI) scores were assessed preoperatively, postoperatively, and at the 1-year follow-up.

Results: Ninety-seven patients who underwent LLIF were included in this study, including 31 patients with CS and 66 patients with no CS (NCS). No significant differences were observed between the two groups in VAS-BP, VAS-LP, or ODI scores preoperatively, postoperatively, or at the 1-year follow-up (all p > 0.05). The EP-vBMD of the CS group was lower than that of the NCS group, and EBQ was higher than that of the NCS group. The area under the ROC curve (AUC) of EP-vBMD for predicting CS was larger than that of global and segmental vBMD. The AUC of the EBQ for predicting CS was larger than that of global and segmental VBQ, and the AUC of EP-vBMD was larger than that of the EBQ. The combined prediction model of EP-vBMD and EBQ had the largest AUC value (0.899), but it was not significantly different from EP-vBMD alone (p = 0.547).

Conclusions: The regional endplate BMD assessment based on QCT and MRI can effectively predict CS after LLIF, and it has better predictive efficiency than the global or surgical segmental vertebrae BMD measurement. EP-vBMD is superior to EBQ in predicting CS. The prediction efficiency of EP-vBMD combined with EBQ was better than EBQ alone, but not better than EP-vBMD.

Objective: Multipoint pelvic fixation with multirod constructs is increasingly used for long-segment deformity constructs to reduce rates of distal failure. However, more robust distal fixation may negatively impact proximal junction biomechanics, and this potential relationship has not been extensively studied.

Methods: Standard nondestructive flexibility tests (7.5 Nm) were performed on 7 cadaveric specimens (L1-pelvis) to assess intervertebral flexibility (range of motion [ROM]), rod strain, and screw bending moments along a posterior fusion construct (pedicle screw and rod [PSR]) spanning L2-S1, supplemented by bilateral primary S2 alar-iliac (S2AI) fixation (2 S2AI screws and 2 rods), followed by additional S2AI screw placement and bilateral accessory rod placement spanning L4-S2AI (4 S2AI screws and 4 rods). Four conditions were tested for each specimen: 1) intact; 2) L2-S1 PSR; 3) L2-S2AI PSR; and 4) L2-S2AI plus L4-S2AI. Data were analyzed using repeated-measures ANOVA.

Results: Seven cadaveric specimens were included. Proximal rod strain at the L2-3 level did not change across the varying test conditions in the 7 specimens tested (p > 0.05 for all conditions). There was no significant difference detected in proximal screw strain across conditions (p > 0.05). Finally, no significant difference was found in L2-3 ROM (p > 0.05) across instrumented variations, all of which were more rigid than intact specimens.

Conclusions: Pelvic fixation with 2 or 4 screws and 2 or 4 rods, respectively, did not significantly alter proximal junction screw or rod strain in a cadaveric model. Robust pelvic fixation might protect against distal failure without deleterious effects on the proximal junction.

On the screen, Christopher Reeve was Superman. Off-screen, Reeve was an avid equestrian who experienced arguably one of the most famous horse riding accidents to date when a fall from the saddle led to comminuted C1 and C2 fractures with an associated spinal cord injury that left him quadriplegic. Reeve publicly endured a grueling rehabilitation including personalized training plans and experimental treatments coupled with severe depression. With his family and friends by his side, Reeve shocked everyone when he was able to lift a finger on his left hand and feel the hugs of his family several years after being diagnosed with an American Spinal Injury Association grade A injury. He went on to establish the Christopher & Dana Reeve Foundation to advocate for research funding and quality-of-life programs for patients with spinal cord injury. Unfortunately, Christopher Reeve died in 2004. However, his legacy lives on in the lasting impact he made in spinal cord injury awareness and in the continued work of his children through the Christopher & Dana Reeve Foundation. To the authors' knowledge, this is the first comprehensive look at the life, injury, and legacy of Christopher Reeve and his foundation now 30 years after such a fateful accident.

Objective: Anterior cervical discectomy and fusion (ACDF) is an established treatment for cervical degenerative disc disease; however, the procedure can cause loss of cervical spine range of motion and potentially accelerate adjacent segment degeneration. Cervical disc arthroplasty (CDA) seeks to preserve native motion of the cervical spine, which can theoretically reduce the incidence of adjacent level degeneration. The literature regarding the relative efficacy of ACDF versus CDA remains inconsistent. In this study, the authors investigate the difference in outcomes between ACDF and CDA and identify factors contributing to the heterogeneity in the literature.

Methods: The Ovid, Embase, Scopus, Cochrane, and ClinicalTrials.gov databases were systematically searched from inception to September 5, 2023, for randomized controlled trials (RCTs) comparing ACDF and CDA for degenerative disc disease. Studies were extracted by two authors and verified by a third. Random-effects meta-analysis was performed. The primary outcome was the difference in clinical outcomes between the two surgical groups. The secondary outcomes were the differences in radiological outcomes, surgical characteristics, complication rates, and hospital lengths of stay. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration no. CRD42023469204) and adhered to the PRISMA guidelines.

Results: From 584 articles uploaded to the Covidence platform for screening, 35 studies derived from 25 RCTs were included in this systematic review and meta-analysis. A total of 4530 patients were treated with ACDF (2081) and CDA (2449). Forty-six percent of the patients (2063) were male, and the mean age of the study cohort was 45 ± 3 years. In terms of the primary outcome, CDA showed higher rates of neurological and overall success. Regarding the secondary outcomes, CDA demonstrated a significantly lower rate of adjacent level disease, higher rate of heterotopic ossification, and greater range of motion at the operated level. Additionally, CDA had lower rates of reoperation but significantly longer operative times than ACDF. The inclusion of myelopathic patients and variations in follow-up between the surgical groups contributed to the observed effect heterogeneity among studies.

Conclusions: In this study, CDA showed comparable or potentially greater success in overall and neurological outcomes, along with a lower incidence of adjacent level degeneration and reoperation rates but longer operative times.

Objective: The aim of this retrospective study was to investigate the relationship between postoperative Roussouly sagittal profile changes and patient outcomes.

Methods: From a prospectively collected, single-center database, the authors reviewed the records of patients with adult spinal deformity (ASD) who had clinical and radiographic data from baseline to 2 years after surgery. The patients were stratified by their Roussouly curve type (current sacral slope-based and "theoretical" pelvic incidence-based types). Means comparison tests (ANOVA and chi-square) were used to assess differences among Roussouly groups. Backstep logistic regression analyses were used to analyze associations between Roussouly sagittal profile changes and patient outcomes, including minimum clinically important differences (MCIDs) in functional metrics.

Results: Five hundred twenty-five patients, 79% of whom were female, were included in this study. The mean age of the cohort was 60.8 ± 14.1 years, BMI was 27.2 ± 5.5 kg/m2, and Charlson Comorbidity Index score was 1.72 ± 1.68. According to the Roussouly classification, 8.3% of patients had a Roussouly type 1 (R1) curve, 53.6% type 2 (R2), 26.3% type 3 (R3), and 11.9% type 4 (R4). Overall, 39% of patients had a changed Roussouly shape postoperatively: 59% had R1, 58.5% R2, 48.1% R3, and 26.7% R4 (p < 0.001). Forty-eight percent of patients matched the theoretical Roussouly type postoperatively (41% R1, 41.5% R2, 51.9% R3, and 73.3% R4, p < 0.001). When controlling for baseline clinical and radiographic differences, the Roussouly type changes associated with a higher risk of proximal junctional kyphosis or proximal junctional failure were as follows: R1 to R2 (OR 2.5, 95% CI 1.1-5.6, p = 0.024), R2 to R4 (OR 2.8, 95% CI 1.1-7.7, p = 0.039), and R3 to R4 (OR 2.3, 95% CI 1.1-4.9, p = 0.033). R4 to R3 switches had the highest mechanical complication risks (OR 3.4, 95% CI 1.2-9.4, p = 0.016). R1 to R2 changes had the highest rate of attaining an MCID in the Oswestry Disability Index at 6 weeks (23.5%, p = 0.004). Roussouly type changes were not associated with differences in the MCID on the refined 22-item Scoliosis Research Society patient outcome questionnaire (SRS-22r) up to 2 years after surgery.

Conclusions: While a significant portion of patients matched their postoperative theoretical Roussouly type, many of those matched at baseline were prone to become unmatched postoperatively. Postoperative Roussouly shape changes influence patient outcomes and should be accounted for when planning ASD surgery.

Objective: The Spinal Laminectomy Versus Instrumented Pedicle Screw trial reported the superiority of fusion compared to laminectomy alone for patients with grade 1 degenerative spondylolisthesis. However, it remains unclear if the advantages of fusion extend to using minimally invasive surgical (MIS) techniques. This study compared 60-month outcomes following minimally invasive transforaminal lumbar interbody fusion (TLIF) versus decompression for grade 1 spondylolisthesis.

Methods: The authors analyzed patients who underwent single-segment MIS TLIF or MIS tubular decompression for grade 1 degenerative lumbar spondylolisthesis from the prospective Quality Outcomes Database's 12 highest enrolling sites (SpineCORe team). Uni- and multivariable analyses compared outcomes including the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain (NRS-BP), NRS for leg pain (NRS-LP), EuroQol-5D (EQ-5D), North American Spine Society (NASS) satisfaction score, and cumulative related reoperation rate.

Results: Of 608 total patients, 143 underwent MIS TLIF (n = 72, 50.3%) or MIS decompression (n = 71, 49.7%). The overall study cohort's 60-month follow-up rate was 86.8%. The MIS TLIF cohort was significantly younger (mean 62.1 ± 10.6 vs 72.3 ± 9.7 years), had lower rates of diabetes (9.7% vs 22.5%), higher rates of private insurance utilization (65.3% vs 26.8%), was more likely to be employed preoperatively (54.2% vs 23.9%), and had higher baseline NRS-BP scores (mean 6.9 ± 2.6 vs 5.6 ± 3.2, p < 0.05). Otherwise, the cohorts were similar in baseline characteristics. Sixty months postoperatively, both cohorts had significant mean improvements in ODI, NRS-LP, NRS-BP, and EQ-5D scores compared to their respective baselines (p < 0.05). MIS TLIF had a significantly lower reoperation rate (2.8% vs 15.5%, p = 0.008). The minimal clinically important difference rates for the ODI, NRS-LP, NRS-BP, and EQ-5D were equivalent (p > 0.05). MIS TLIF demonstrated significantly larger reductions in NRS-BP scores (-4.0 ± 3.5 vs -2.2 ± 3.4) and higher rates of satisfaction (NASS score 1 or 2 = 87.7% vs 74.5%; p < 0.05) but similar absolute 60-month ODI, NRS-LP, NRS-BP, and EQ-5D scores (p > 0.05). On multivariable analyses, fusion significantly reduced the odds of reoperation (OR 0.07, 95% CI 0.008-0.39; p = 0.006), but fusion status was neither a significant predictor of ODI, NRS-LP, NRS-BP, or EQ-5D scores, nor NASS satisfaction scores.

Conclusions: Regardless of the surgical approach, a dorsal-based MIS technique was associated with clinical benefits in patients with grade 1 spondylolisthesis. These 60-month results demonstrate that MIS TLIF and MIS decompression are associated with similar patient-reported outcomes. However, MIS TLIF is associated with significantly fewer reoperations.