Journal of neurosurgery. Spine最新文献

Objective: Obesity is commonly considered a risk factor for patients undergoing spine surgery. While various studies have explored the effects of BMI on clinical outcome measures, current literature examining the effects of BMI on patient-reported outcome measures is lacking. This study aimed to analyze the effects of patient BMI on pre- and postoperative 10-item Patient-Reported Outcomes Measurement Information System (PROMIS-10) global health T-scores for patients undergoing transforaminal lumbar interbody fusion (TLIF).

Methods: A prospectively collected multi-institutional quality registry was retrospectively reviewed. Patients who received a TLIF were categorized as nonobese (BMI < 30 kg/m2), class I obese (BMI 30-34.9 kg/m2), or class II or III obese (BMI ≥ 35 kg/m2). PROMIS-10 T-scores for global physical health (GPH) and global mental health (GMH) were collected at baseline and 3 months and 12 months after surgery. Univariate analyses were performed to compare pre- and postoperative scores and score changes across the three groups.

Results: Of the 315 patients with PROMIS-10 T-scores, there were 142 nonobese, 102 class I obese, and 71 class II or III obese patients. The three groups had similar demographics, although obese patients were younger and more commonly had diabetes. At baseline, nonobese patients had significantly better mean PROMIS-10 GPH T-scores (36.7 ± 6.6) than class II or III obese (33.9 ± 6.2) (p = 0.003) patients. By 3 months, mean GPH T-scores improved significantly in all groups (p < 0.001), with the nonobese group (12.3 ± 8.1) demonstrating similar improvement to class I obese (12.0 ± 8.3, p = 0.7) and class II or III obese (11.0 ± 8.1, p = 0.3) patients. Likewise, mean GMH T-scores improved significantly in all groups by 3 months (p < 0.001), with the nonobese group (7.1 ± 8.7) demonstrating similar T-score improvement to class I (6.5 ± 8.1, p = 0.8) and class II or III (4.3 ± 8.0, p = 0.070) obese patients. Improvements in GPH and GMH T-score changes were maintained at 12 months and continued to show no significant variability between groups.

Conclusions: While BMI may influence baseline health status as reflected by preoperative PROMIS-10 T-scores, patients across all BMI indexes had similar improvements in their PROMIS-10 T-scores at 3 and 12 months following TLIF procedures.

Objective: Prolonged operative time and length of stay (LOS) are associated with increased complications and costs after lumbar fusions. However, with the application of robotic technology to transforaminal lumbar interbody fusions (TLIFs), operative times and LOSs have shortened. Accurate predictions of these metrics are crucial to improving operating room and hospital resource allocation. The objective of this study was to identify predictors of operative time and LOS in robot-assisted TLIF procedures.

Methods: A single-institution retrospective review was performed of patients who underwent pedicle screw placement using the same robotic navigation platform. Patients who underwent TLIF for degenerative spine indications were included. Preoperative demographics, neurological deficits, and comorbidities were extracted. Operative time and LOS outcome variables were categorized as normal or extended (> 75th percentile). Univariable analysis was performed using the Kruskal-Wallis test, and significant variables (p < 0.10) were included in the multivariable analysis. All p values < 0.05 were considered statistically significant.

Results: One hundred seventeen patients were included, who were predominantly female (n = 67, 57%) and had a median age of 64 years. In univariable analysis, revision status (p = 0.063), BMI (p = 0.029), spinal level (p = 0.012), incision type (p = 0.013), number of levels (p = 0.001), and number of screws (p = 0.001) were associated with operative time, while Charlson Comorbidity Index (CCI; p = 0.003), American Society of Anesthesiologists class (p = 0.029), and Frankel grade (p = 0.042) were associated with LOS. Multivariable analysis showed that BMI ≥ 30 kg/m2 (odds ratio [OR] 1.163, 95% confidence interval [CI] 1.024-1.322) and number of levels > 2 (OR 1.655, 95% CI 1.401-1.956) were independently associated with operative time. Frankel grade < E (OR 1.146, 95% CI 1.023-1.283) and CCI > 2 (OR 1.285, 95% CI 1.112-1.486) were independently associated with LOS.

Conclusions: This study shows significant predictors of extended surgical operative time and LOS in robot-assisted TLIF procedures. These findings can help with surgical planning and operating room allocation.

Objective: Patient satisfaction serves as a valuable measure for evaluating outcomes from the patient's perspective. However, the factors critical for predicting satisfaction in patients with adult spinal deformity (ASD) remain elusive. This study aimed to develop and validate predictive models for assessing patient satisfaction 24 months after ASD surgery.

Methods: A total of 213 individuals diagnosed with ASD met inclusion criteria; 128 (60%) patients were randomly selected for model development (training set), and the remaining 85 (40%) were used for internal validation (test set) to assess model robustness. The primary outcome was the satisfaction score from Scoliosis Research Society-22r domains, with scores ≥ 4.5 indicating high satisfaction. Three machine learning (ML) algorithms (least absolute shrinkage and selection operator, recursive feature elimination, and Boruta) were used to identify critical variables for patient satisfaction. A logistic regression model was developed and tested based on these variables to predict personalized satisfaction. Feature importance was ranked using the Shapley Additive Explanations (SHAP) method.

Results: ML algorithms identified 9 key indicators of postoperative satisfaction. The predictive model demonstrated an area under the receiver operating characteristic curve of 0.846 and an accuracy of 0.812 in the test set. SHAP analysis revealed that predictors such as improved postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function, absence of frailty, achievement of minimum clinically important difference in imaging, and enhanced WOMAC function increased the relative functional cross-sectional area, higher postoperative subtotal scores, smaller postoperative sagittal vertical axis, successful pelvic compensation, and reduced fatty infiltration significantly influenced postoperative satisfaction.

Conclusions: The results of this study suggest that the developed models can provide patients with personalized prognostic information. Surgeons should consider these routinely modifiable indicators in clinical practice to guide postoperative rehabilitation.

Objective: Vertebral augmentation (VA), including vertebroplasty and kyphoplasty, has become pivotal in alleviating pain and disability associated with pathological compression fractures of the spine. However, there is no existing guidance informing the ideal timing of radiotherapy (RT) and VA, with a theoretical concern of tumoral seeding if adjuvant. This study compared locoregional cancer recurrence in patients who underwent neoadjuvant versus adjuvant RT.

Methods: The authors conducted a retrospective review of all adult cancer patients treated with VA and RT within 3 months between 2009 and 2023 at the University Health Network in Toronto, Ontario, Canada. They investigated locoregional recurrence (LRR), defined as recurrence within the RT field as well as 1 vertebral body above and below. Time to recurrence was estimated using cumulative incidence analysis and compared using Gray's test. Competing risk regression was used to compare the recurrence risk in the full cohort and in a matched cohort using propensity scores informed by biologically effective dose, radiosensitivity, and vertebral levels.

Results: The authors included 180 patients-45 received adjuvant RT and 135 received neoadjuvant RT. The mean ± SD age of patients was 63.8 ± 12.7 years and about half were female (52%). The mean time between VA and adjuvant RT was 30 ± 26 days and 41 ± 23 days between neoadjuvant RT and VA (p < 0.001). Forty patients (22%) had LRR, with a median (range) time from RT to recurrence of 2.4 (0.1-96) months. Patients who underwent neoadjuvant RT had a reduced risk of LRR (subdistribution hazard ratio [sHR] [95% CI] 0.30 [0.16-0.56], p < 0.001). This observation did not change after propensity score matching (sHR [95% CI] 0.41 [0.19-0.88], p = 0.02).

Conclusions: The authors observed a higher risk of LRR in patients who underwent adjuvant versus neoadjuvant RT in relation to VA. In the setting of painful spine metastases, RT should be considered before VA for improved tumor control.

Objective: Posterior cervical foraminotomy (PCF) for the treatment of radiculopathy can be performed via open, minimally invasive (MIS), or more recently emerging endoscopic approaches. Although proponents of endoscopy cite decreased postoperative pain as an advantage compared with open or MIS approaches, few studies have been performed to evaluate this outcome.

Methods: The authors retrospectively identified all patients undergoing PCF at a single institution from January 1, 2015, to June 1, 2024. Patients were stratified by operative approach (open, MIS, or uniportal endoscopic). The primary outcome was opioid consumption at 6 weeks, 3 months, and 6 months postoperatively, as well as cumulative opioid consumption in morphine milligram equivalents (MME) at each time interval. Secondary outcomes included short-term perioperative outcomes such as complications, operative duration, pain relief, and reoperation.

Results: One hundred thirty-eight patients met inclusion criteria, of whom 37 underwent open, 67 underwent MIS, and 34 underwent uniportal endoscopic procedures. Patients undergoing MIS and endoscopic approaches had lower rates of opioid use at 6 weeks compared with open approaches (relative risk 0.51 and 0.39, respectively). Endoscopic procedures were associated with lower total opioid MME within 6 weeks than both MIS and open procedures (238.4 vs 479.4 vs 753.8), although MIS and endoscopic procedures had similar rates of opioid use at 6 weeks. A subgroup analysis of a propensity score-matched cohort based on preoperative demographic data revealed a similar association between operative approach and total MME, although there were no significant differences between the cohorts in the proportion of patients using opioids at any of the follow-up intervals.

Conclusions: In this retrospective analysis, both endoscopic and MIS PCF were associated with lower overall rates and amount of opioid use with similar rates of short-term complications, reoperations, and pain relief as open approaches.

Objective: Although the mainstay of treatment for lumbar spondylolysis is nonoperative management with activity modification, a sizeable portion of patients will go on to nonunion. The growing use of robotic surgical guidance can allow for placement of pars screws through percutaneous incisions. The objective of this case series was to report on the largest series of adolescent patients with lumbar spondylolysis treated with robot-assisted pars repair to date.

Methods: A retrospective review of a prospectively collected database was performed for all adolescent patients (aged 13-25 years) who underwent pars repairs for treatment of spondylolysis with a single-screw technique. Patient demographic, surgical, and postoperative course information was collected and reported.

Results: Nine patients who underwent robotic pars repair were identified. The mean ± SD duration of activity cessation at initial surgical consultation was 8.6 ± 10.6 months. Seven patients underwent bilateral pars repairs and 2 underwent unilateral pars repairs. With a mean ± SD follow-up of 11.4 ± 9.1 months, 78% of patients had either returned to their baseline activity or were cleared for return to sport at the time of final follow-up.

Conclusions: For patients who fail nonoperative management, robot-assisted pars repair can be a safe and effective treatment option to allow return to activity in as little as 8 weeks. A single screw placed in a lag-by-technique fashion may be as clinically efficacious as open debridement and bone grafting described in prior literature.

Objective: The aim of this study was to investigate the association of home socioeconomic status (SES) with days at home and survival after treatment of spinal metastases.

Methods: This population cohort study included all patients in the Ontario Cancer Registry treated from 2007 to 2019 with surgery or radiation therapy (RT) for spinal metastasis. Ordinal categories of SES (SES1-SES5) were defined using home neighborhood material deprivation scores. Outcomes included adjusted median differences (aMD) in the number of days at home and adjusted hazard ratios (aHRs) of mortality for patients of differing SES. Secondary care access outcomes included receiving stereotactic body RT for treatment, the timing of palliative care initiation, and the distance from home to the nearest cancer center.

Results: There were 35,896 patients (55% male, mean age 64.4 years) identified; 7397 (21%) resided in relatively resource-deprived neighborhoods and 7080 (20%) resided in relatively resource-affluent neighborhoods. Patients living in the lowest SES neighborhoods had the fewest days at home (SES1 vs SES5, aMD -47) and shortest survival (SES1 vs SES5, aHR 1.14). There was significant mediation attributable to differences in primary cancer (days at home [15.6%], survival [25.7%]) and frailty (days at home [5.9%], survival [7.7%]) between neighborhood SES. Patients residing in lower SES neighborhoods were less often treated with stereotactic body RT (adjusted OR 0.38), had later initiation of palliative care (aHR 0.94), and lived farther from cancer centers (adjusted mean difference 16.5 km).

Conclusions: Patients with spinal metastases living in lower SES neighborhoods had fewer days at home and shorter survival, which was partially mediated by differences in primary cancer and possibly posttreatment access to oncology care. These findings will support advocacy efforts championing equity in cancer care.

Objective: The prevalence of degenerative lumbar spondylolisthesis in older adults is increasing, yet the factors influencing surgical outcomes remain unclear. The authors' study used a machine learning approach to identify outcome clusters among older patients operated on for grade I lumbar spondylolisthesis.

Methods: The authors analyzed data from the prospective Quality Outcomes Database (QOD) registry for patients aged ≥ 65 years who underwent surgery for grade I degenerative lumbar spondylolisthesis. Principal components analysis was used to generate a composite outcome score from 5 patient-reported outcomes (PROs) collected 24 months postoperatively. Subsequently, K-means clustering was used to stratify patients by outcome, with the optimal number of clusters decided by silhouette scoring. Multivariable logistic regression and Boruta feature selection were used to assess variable importance.

Results: Of 608 total patients, 233 were at least 65 years of age and met 24-month follow-up. K-means clustering identified two distinct groups: cluster 1 corresponded to more optimal outcomes (less pain and disability, higher satisfaction and quality of life), and cluster 2 corresponded to suboptimal outcomes. Cluster 1 had significantly greater improvements across all PROs at 24 months (p < 0.001), with 87.1% achieving the minimal clinically important difference (MCID) across both EQ-5D and Oswestry Disability Index (ODI) scores versus 48.8% in cluster 2 (p < 0.001). Clusters were similar in age (mean 72.5 vs 73.4 years, p = 0.24), but cluster 1 had lower baseline back and leg pain scores. Notably, patients in the optimal outcomes cluster were significantly more likely to have received a fusion procedure (70.7% vs 51.2%, p = 0.003). In logistic regression predictor analysis, lower baseline Numerical Rating Scale (NRS)-back pain score (OR 0.70, 95% CI 0.50-0.98, p = 0.04) and addition of fusion (OR 1.70, 95% CI 1.24-2.33, p = 0.001) were significant independent predictors of optimal outcomes, which was subsequently confirmed in Boruta analysis.

Conclusions: The authors' analysis of older (≥ 65 years old) patients undergoing surgery for grade I spondylolisthesis revealed two distinct clusters: one with optimal and the other with suboptimal outcomes. The addition of fusion to a procedure was associated with superior outcomes, as patients who received fusion had a 70% increase in the odds of reaching an optimal outcome. Age was not significantly associated with outcome, implying that there is no clear cutoff for surgical eligibility in older patients. These findings may inform decision-making between decompression alone versus decompression with fusion in older patients.

Objective: The aim of this study was to evaluate the clinical and biomechanical effects of distinct anterolateral screw placement angles in oblique lumbar interbody fusion combined with anterolateral fixation (OLIF-AF), focusing on cage subsidence (CS) incidence, spinal stability, and optimal fixation strategies.

Methods: Patients who underwent OLIF-AF at a single center from December 2017 to November 2023 were retrospectively analyzed. Patients were divided into 4 groups (G0, G1, G2, and G3) based on the coronal plane angle (CPA) and relative horizontal plane angle. Preoperative and 1- or 3-day, 3-month, and 12-month postoperative radiological and clinical data were collected. A validated L4-5 finite element model simulated 4 screw configurations under 6 loading conditions.

Results: Eighty patients (49 female, mean age 64.5 ± 7.1 years) were included in the analysis (28, 23, 15, and 14 patients in groups G0, G1, G2, and G3, respectively). CS occurred in 48.75% of patients, with significantly higher rates in the G2 (86.67%) and G3 (71.43%) versus G0 (28.57%) and G1 (34.78%) (p < 0.05) groups. Compared with parallel CPA groups (G0 and G1), nonparallel CPA groups (G2 and G3) exhibited greater disc height (DH) reduction (ΔDH range 3.1-3.4 mm vs 1.4-2.0 mm, p < 0.05), higher cage stress (range 55.50-57.29 MPa vs 53.45-54.96 MPa), increased displacement (range 73.62-78.28 × 10-2 mm vs 72.21-72.37 × 10-2 mm), and elevated range of motion (ROM) in flexion. Clinical scores (visual analog scale and Oswestry Disability Index) were not different between groups.

Conclusions: OLIF-AF with parallel screw placement in the coronal plane (G0 and G1) reduced CS risk and enhanced biomechanical stability by minimizing cage stress, displacement, and ROM. Horizontal screw bifurcation (G1 vs G0) did not demonstrate a statistically significant association with CS risk. Furthermore, there were no significant differences in fusion rates or clinical outcome measurements at different angles of AF.