Journal of neurosurgery. Spine最新文献

Objective: Carbon fiber instrumentation has gained popularity in spine oncology for its radiographic advantage of reduced artifact on imaging. With its increased use in patients who undergo radiation therapy, the dosimetric accuracy of postoperative radiation with carbon fiber constructs compared to classic titanium instrumentation becomes an important question. The purpose of this study was to compare the dosimetric accuracy of postoperative radiation in carbon fiber-instrumented versus titanium-instrumented cadaveric cervical spines after corpectomy.

Methods: Two cadaveric specimens underwent two-level corpectomy using either titanium or carbon fiber instrumentation. Dosimeter chips were placed circumferentially around the constructs to calculate the dose of radiation to surrounding areas. The cadavers underwent one round of radiation with their respective constructs, and the dose of radiation was calculated and compared to the measured dose in each chip. After the first round of radiation, the instrumentation was switched between cadavers and the radiation therapy was repeated. The difference between the calculated and measured dose in carbon fiber versus that in titanium instrumentation in each cadaveric model was subsequently compared.

Results: There was a significant difference in the dosimetry calculated at the area of the spinal cord dorsal to the corpectomy cage, with 68% less variability between the calculated and measured dose in the carbon fiber construct compared to that of the titanium construct. The mean variation of the measured dose at the spinal cord was 7.73% in titanium versus 4.6% in carbon fiber (p = 0.024, 1-tail; p = 0.048, 2-tail). There was also 30% less variability between the measured and calculated dose in the carbon fiber construct at the dosimeter chips lateral to the spinal cord, with a mean variation in the carbon fiber-instrumented cadaver of 4.94% compared to 6.45% with titanium (p = 0.01, 1-tail; p = 0.02, 2-tail). When all the dosimeters were combined without the control group, there was a statistically significant 14.5% difference in the mean variation of the calculated versus measured doses between the carbon fiber-instrumented cadavers versus titanium-instrumented cadavers (4.8% vs 5.5%, respectively; p = 0.015, 1-tail; p = 0.03, 2-tail).

Conclusions: There is less variation in the calculated versus measured doses of radiation therapy in carbon fiber instrumentation compared to titanium instrumentation. This suggests improved radiation therapy delivering accuracy and complication avoidance in carbon fiber-instrumented spines.

Objective: This review analyzes the current surgical strategies and management modalities for chronic low-back pain (CLBP). In this study, the authors provide a structured review of the current state of surgical treatments for CLBP, including the rationale for surgery, indications, and novel therapies.

Methods: An extensive review of the literature on the surgical management of CLBP was performed using the MEDLINE, Cochrane, Google Scholar, Embase, and Cochrane Central Register of Controlled Trials databases from March 1993 to May 2024. Terms used in the search were ("low back pain/surgery" [MeSH] AND "chronic" AND "lumbar") and ("chronic" AND "low back pain" AND "lumbar spine" AND "surgery"). The search produced 1951 articles, of which 167 were removed as duplicates, leaving 1784 for screening. Of these, 1593 articles were excluded, and 191 were retrieved to evaluate eligibility. After this evaluation, 76 articles were included in the review. No statistical analysis was performed.

Results: This structured review revealed a range of surgical interventions available for CLBP. These interventions included fusion, stabilization, posterior interspinous devices, and nonoperative management, such as intensive rehabilitation and cognitive behavioral therapy. The evidence suggests that although spinal fusions are not superior in terms of Oswestry Disability Index function or pain level, they do outperform nonoperative management without intensive rehabilitation therapy. This finding is significant because it highlights the potential of surgical strategies to complement other treatments, such as pharmacological and noninterventional procedures, in managing CLBP.

Conclusions: The current evidence strongly advocates for a comprehensive approach to the management of CLBP. Patients with CLBP should be evaluated for surgical approaches when anatomical causes have been identified and multidisciplinary strategies have been implemented. It is reassuring to note that emerging multimodal strategies are beginning to complement neurosurgery care, and they should be integrated into the treatment plan as more substantial evidence becomes available. This emphasis on a multidisciplinary approach underscores the importance of considering all available strategies in CLBP management.

Objective: Posterior lumbar fusion (PLF) is a routinely used procedure for treatment of spinal pathology. Several studies have highlighted disparities in reoperation and postoperative complications and demonstrated associations between differing insurance providers, complication rates, and hospital resource utilization in spine surgery. Previous studies have examined broad spinal procedures but have not extended to uninsured patients, or adjusted for sociodemographic factors or comorbidity history. Understanding relationships between payor status and outcomes following fusion procedures is vital to promoting healthcare equity. The objective of this study was to assess whether patients' insurance impacts postoperative outcomes and patient satisfaction following PLF procedures.

Methods: The Stanford University Medical Center inpatient registry was used to retrospectively analyze patients who underwent PLF procedures between 2016 and 2022. Propensity score matching was used to compare privately insured with Medicaid patients, as well as comparing uninsured patients with Medicaid patients based on age, sex, and comorbidities. Outcomes data, including 90-day postoperative complications, reoperation, and patient-reported outcome measures scores (Oswestry Disability Index and Patient Health Questionnaire) were collected.

Results: A total of 1904 patients fulfilled the inclusion criteria. In unmatched comparisons, statistically significant differences existed within specific types of complications including altered mental status, delirium, neurological complications, and pulmonary complications. A total of 292 privately insured patients were matched to 292 Medicaid patients. Within matched patient groups, the Medicaid group had higher rates of altered mental status (6.2% vs 2.7%, p = 0.042); delirium (9.9% vs 5.1%, p = 0.035); renal dysfunction (6.9% vs 4.1%, p = 0.020); and pulmonary complications (8.9% vs 3.8%, p = 0.049) compared to privately insured patients. Privately insured patients had lower postoperative Oswestry Disability Index scores (30.2 vs 34.4, p = 0.018) compared to Medicaid patients. Following propensity score matching of 88 Medicaid patients to 88 uninsured patients, large but not statistically significant differences existed for neurological complications (12.5% vs 5.7%, p = 0.165) and 5-year revision rates (3.4% vs 1.1%, p = 0.353).

Conclusions: The findings indicate that the treatment outcomes, care quality, and patient satisfaction following PLF procedures differ between Medicaid and privately insured patients. Further investigation is warranted to explore relationships between insurance payor status and clinical outcomes in multicenter populations.

Objective: Spinal cord cavernous malformations (SCCMs) are rare vascular malformations with a capricious prognosis. Given the eloquent nature of the spinal cord, considerable surgical morbidity may be encountered. Therefore, conservative management has emerged as a valid alternative, especially for incidental lesions diagnosed on ubiquitous imaging. The aim of this systematic review and meta-analysis was to evaluate the safety and efficacy of surgical versus conservative management of SCCMs.

Methods: Following PRISMA guidelines, this study included articles published in full-text form comparing the outcomes following conservative and surgical management of SCCMs. Collected variables included the total number of patients, spine level, resection, myelotomy, follow-up duration, bleeding, motor weakness, pain, bladder and/or bowel dysfunction, and neurological improvement or deterioration after discharge. The primary outcome of interest was long-term functional outcome.

Results: Eleven articles comprising 515 patients were included, of whom 343 (66.6%) underwent resection and 172 (33.4%) were managed conservatively. Patients who underwent surgery were more likely to have preoperative motor deficits, hemorrhagic episodes, and bladder and/or bowel dysfunction, indicating increased disease severity. Resection was associated with significantly improved long-term functional outcomes (OR 3.27, 95% CI 1.72-6.24) compared with conservative management. There was no significant difference between the two groups regarding odds of long-term clinical deterioration (OR 1.03, 95% CI 0.35-3.03). However, the risk of hemorrhagic episodes during follow-up was higher in the conservative group (17.3%) compared with the surgical group (1.69%). The odds of hemorrhage during follow-up were lower in the surgical group, although not statistically significant (OR 0.24, 95% CI 0.05-1.05).

Conclusions: This study highlights that while surgical management of SCCMs is associated with better long-term functional outcomes and reduced risk of recurrent hemorrhage, treatment decisions must be carefully tailored to the individual patient, particularly given the potential risks associated with surgery. Conservative management, although less invasive, carries a nonnegligible risk of hemorrhage during follow-up, warranting close monitoring. These findings parallel management strategies used for brainstem cavernomas, for which surgery is reserved for cases with low surgical risk and worsening neurological symptoms. However, the limitations of current data, including selection bias and heterogeneity in reporting, emphasize the need for a multi-institutional registry to better define the natural history of SCCMs and inform future management strategies.

Objective: Conventional decompression surgery for beak-type ossification of the posterior longitudinal ligament (OPLL) of the thoracic spine, whether approached anteriorly or posteriorly, poses several challenges, including technical complexity, cerebrospinal fluid leakage, incomplete decompression, and potential neurological deterioration. Therefore, the authors introduce a novel technique, anterior sliding decompression osteotomy (ASDO), for thoracic myelopathy caused by OPLL and evaluate the efficacy and safety of this technique.

Methods: Six patients (4 men and 2 women) who underwent ASDO surgery for beak-type OPLL in the thoracic spine with a follow-up period of at least 2 years were included in the cohort. Clinical and surgical outcomes, including modified Japanese Orthopaedic Association (mJOA) score, neurological recovery rate, canal occupying ratio, operation time, and blood loss, were evaluated.

Results: The mean ± SD follow-up period was 26.5 ± 2.0 months. The mean mJOA score improved from 6.0 to 9.7, with the mean recovery rate reaching 63.6% at 6 weeks postoperatively to 73.9% at 2 years after surgery. Neural decompression was effective in all patients, reducing the mean canal occupying ratio from 70.8% to 29.1% without complications.

Conclusions: ASDO surgery achieves sufficient spinal cord decompression for beak-type OPLL in the thoracic spine. It represents an effective, feasible technique, offering surgeons a familiar view from the conventional posterior approach.

Objective: Smartphones and wearable devices can be effective tools to objectively assess patient mobility and well-being before and after spine surgery. In this retrospective observational study, the authors investigated the relationship between these longitudinal perioperative patient activity data and socioeconomic and demographic correlates, assessing whether smartphone-captured metrics may allow neurosurgeons to distinguish intergroup patterns.

Methods: A multi-institutional retrospective study of patients who underwent spinal decompression with and without fusion between 2017 and 2021 was conducted. Patients' home zip codes were used to determine each patient's Area Deprivation Index (ADI)-an independently validated composite measure of the socioeconomic health of a specific neighborhood relative to the entire United States. Activity data, including steps-taken-per-day across a 2-year perioperative period, were extracted from patient smartphones and statistically normalized to enable interpatient comparisons. Multivariate regression was performed to identify relationships between ADI and patient mobility, while controlling for confounders including age and obesity.

Results: The study included 49 patients. The preoperative activity level of patients living in neighborhoods with an ADI score below the 80th percentile nationally was significantly greater than that of patients living in neighborhoods above the 80th percentile (p = 0.011). A direct positive correlation existed between patients' ADI scores and the number of days with below-average steps-taken-per-day during the preoperative period (adjusted r2 = 0.822, p = 0.049). Postoperatively, patients with ADI scores above the 80th percentile had significantly greater documented activity levels (p = 0.031).

Conclusions: The authors' study demonstrates that individuals living in neighborhoods with an ADI score below the 80th percentile had higher preoperative activity than patients in neighborhoods above the 80th percentile; this disparity diminishes after spine surgery. Though these findings are not generalizable, the authors hypothesized that the relatively faster postoperative recovery of patients living in wealthier neighborhoods is likely multifactorial, possibly due to sustained activity in the preoperative and likely symptomatic period of patients in lower-income neighborhoods, as well as enhanced access to postoperative care for patients in higher-income neighborhoods. Overall, the findings from the authors' study demonstrate that smartphone-captured activity may be utilized as a metric to study socioeconomic disparities in surgical outcomes. Future studies must specifically isolate socioeconomic variables as potential causal factors to inform improvements in healthcare delivery after surgery.

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.