Journal of neurosurgery. Spine最新文献

Objective: The aim of this study was to determine predictors of the minimum clinically important difference (MCID) in the Neck Disability Index (NDI) following cervical spinal deformity surgery.

Methods: A retrospective review was performed of a prospective, multicenter adult cervical spinal deformity database. All patients had baseline and 1-year NDI scores. Patients met MCID with an improvement of NDI by 7 points between baseline and 1 year, as previously established. Baseline demographics, comorbidities, and both baseline and 1-year spinopelvic parameters were evaluated for statistical significance in a univariate logistic regression analysis. Significant variables, in addition to baseline NDI, were analyzed in a multivariable logistic regression model by backward selection with Akaike information criterion minimization.

Results: A total of 122 patients were included with a median age of 62 (IQR 56, 69) years; 62% of patients were female. Of the 122 patients, 72 (59%) achieved NDI MCID at 1 year. Predictors of achieving MCID on univariate analysis included a lower Charlson Comorbidity Index (CCI) total score (OR 0.70, p = 0.03), depression as a comorbidity (OR 2.9, p = 0.02), lower C2 tilt at the 1-year follow-up (OR 0.92, p = 0.02), and a greater difference between 1-year postoperative C2-7 sagittal vertical axis (SVA) and preoperative C2-7 SVA (OR 0.98, p = 0.0495). On multivariable logistic regression analysis, predictors of achieving MCID included a lower CCI (OR 0.62, p = 0.03), depression as a comorbidity (OR 3.1, p = 0.059), a greater change in C2-7 SVA at the 1-year follow-up compared with baseline (OR 0.97, p = 0.055), and baseline NDI (OR 1.02, p = 0.24) with an area under the curve of 0.74.

Conclusions: The best-fit multivariable model included higher baseline NDI, a greater change in C2-7 SVA, patient-reported baseline depression, and lower CCI as important factors in predicting NDI MCID.

Objective: Postoperative dorsal column dysfunction (DCD) has been observed in 43.6%-55.1% of patients who have undergone surgery for intramedullary spinal cord tumors (IMSCTs). There is a paucity of evidence regarding the prognosticators of its occurrence. The objective of the present study was to ascertain the prognostic factors associated with long-term DCD following IMSCT resection, with a particular emphasis on the role of the myelotomy technique and intraoperative neuromonitoring (IONM).

Methods: A case-control study was conducted on consecutive patients. Patients were stratified based on the surgical technique used for midline myelotomy: dorsal column (DC) dissection and preservation technique (group A) and midline coagulation and incision technique (group B). Somatosensory evoked potentials (SSEPs) were categorized as either present or absent. The groups were then analyzed with respect to the Short Form Health Survey 36 (SF-36), the McCormick Scale (MMS), Douleur Neuropathique 4 Questions, and a 3-domain numeric rating scale for investigating DCD, named the Dorsal-Columns Questionnaire (DCQ). Univariate analyses were conducted for MMS and DCQ scores, with data regarding demographics; neurological examination; symptoms; surgery, including extent of resection, tumor histology, tumor location, myelotomy, and tumor extension; hemosiderin cap, cleavage plane presence; and IONM taken into consideration. IONM was recorded at three time points during the surgical procedure: baseline intraoperative, worst intraoperative, and final intraoperative.

Results: In total, 37 patients were included. Groups A and B had nonsignificantly different demographic parameters. Group A had superior outcomes in MMS (p = 0.002), SF-36 (p = 0.001), and DCQ (p = 0.031) scores at the last follow-up. Group B experienced a significantly higher incidence of worst intraoperative (p = 0.002) and final intraoperative (p = 0.026) SSEP loss. Univariate analysis documented the following major prognostic factors: myelotomy technique (p = 0.012), capillary hemangioma histology (p = 0.045), and worst intraoperative SSEPs (p = 0.034) for the DCQ; myelotomy technique (p < 0.001), intraoperative (p < 0.001) and final intraoperative (p < 0.001) SSEPs, and follow-up bowel-bladder dysfunction (p = 0.02) for the MMS. Final operative SSEPs were not among DCQ prognosticators (p = 0.213).

Conclusions: The DC dissection and preservation myelotomy technique is associated with lower long-term DCD and intraoperative SSEP loss and better health-related quality of life and disability when compared with the midline coagulation and incision technique. The myelotomy technique and intraoperative SSEP disappearance, even if transient, are major determinants of long-term disability and DCDs.

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: 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: 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: 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.