Journal of neurosurgery. Spine最新文献

Objective: The Patient-Reported Outcomes Measurement Information System Global Health-10 (PROMIS-10) has not been validated for use in anterior cervical spine surgery (ACSS). The PROMIS-10 distinctly measures global physical health (GPH) and global mental health (GMH) domains, setting it apart from other patient-reported outcome measures (PROMs). This study aimed to validate the PROMIS-10 and identify minimum clinically important differences (MCIDs) in PROMIS-10 GPH and GMH scores in ACSS.

Methods: A prospectively collected quality registry was retrospectively reviewed. PROMIS-10 scores were obtained from patients undergoing ACSS at baseline, 3 months, and 12 months postoperatively. Other validated PROMs assessing quality of life (QOL) were also collected, including the Neck Disability Index (NDI), EuroQol 5-Dimension (EQ-5D) Index, EuroQol visual analog scale (EQ-VAS), and visual analog scales for neck (NP-VAS) and arm pain (AP-VAS). Pearson correlation coefficients assessed the relationship between the PROMIS-10 and other PROMs at baseline (r0) and 12 months (r12), as well as changes from baseline to 12 months (rΔ12). Cronbach's alpha was used to evaluate the internal consistency of PROMIS-10 GPH and GMH at the same time points (α0, α12, and αΔ12). MCIDs were calculated for GPH and GMH using 4 established anchor-based methods, with North American Spine Society patient satisfaction index scores as the anchor.

Results: A total of 700 patients completed baseline and 12-month PROMIS-10 questionnaires. GPH demonstrated moderate to strong correlations with the EQ-5D (r0 = 0.68, r12 = 0.75, rΔ12 = 0.49), NDI (r0 = -0.66, r12 = -0.67, rΔ12 = -0.52), EQ-VAS (r0 = 0.58, r12 = 0.68, rΔ12 = 0.51), NP-VAS (r0 = -0.50, r12 = -0.57, rΔ12 = -0.46), and AP-VAS (r0 = -0.38, r12 = -0.47, rΔ12 = -0.37). GMH had moderate correlations with the EQ-5D (r0 = 0.58, r12 = 0.68, rΔ12 = 0.45), NDI (r0 = -0.49, r12 = -0.54, rΔ12 = -0.37), EQ-VAS (r0 = 0.55, r12 = 0.63, rΔ12 = 0.44), NP-VAS (r0 = -0.32, r12 = -0.45, rΔ12 = -0.31), and AP-VAS (r0 = -0.24, r12 = -0.36, rΔ12 = -0.21). Strong internal consistency reliability was observed in GPH (α0 = 0.71, α12 = 0.78, αΔ12 = 0.60) and GMH (α0 = 0.76, α12 = 0.87, αΔ12 = 0.74). Based on 12-month score changes, MCID thresholds ranged from 4.4 to 10.1 for GPH and 4.7 to 8.6 for GMH. The receiver operating characteristic (ROC) approach was deemed most appropriate for calculating MCIDs.

Conclusions: PROMIS-10 GPH and GMH have strong validity and reliability, with moderate to strong correlations to established PROMs and high internal consistency. Based on the ROC approach, MCID thresholds were 9.05 for GPH and 7.25 for GMH. These findings support the use of the PROMIS-10 in capturing QOL in patients undergoing ACSS.

Objective: The objective of this study was to determine minimal clinically important difference (MCID) values for patient-reported outcomes (PROs) including the 12-Item Short-Form Health Survey (SF-12) Physical Component Summary (PCS), SF-12 Mental Component Summary (MCS), and Neck Disability Index (NDI) in patients with degenerative cervical myelopathy (DCM) undergoing surgery, and to assess whether MCID values vary by baseline disease severity.

Methods: The authors retrospectively analyzed prospectively collected data from the Canadian Spine Outcomes and Research Network for DCM patients treated surgically between 2015 and 2023. Inclusion required a baseline modified Japanese Orthopaedic Association (mJOA) score and 3- or 12-month follow-up PROs with domain-specific anchor responses. Patients were stratified by baseline mJOA score into mild (score ≥ 15), moderate (score 12-14), and severe (score < 12) groups. MCID values for the SF-12 PCS, SF-12 MCS, and NDI were calculated using anchor-based receiver operating characteristic curve analysis, with responder status defined by anchor questions. Discriminative performance was assessed via area under the curve, and 95% confidence intervals were estimated by bootstrapping.

Results: Among 290 patients meeting inclusion criteria, 77 (26.6%) were classified as having mild myelopathy, 120 (41.4%) moderate, and 93 (32.1%) severe. In the overall cohort, the MCID values were estimated as 8.9 (95% CI 7.5-10.9) for SF-12 PCS, 4.3 (95% CI 2.3-5.6) for SF-12 MCS, and 13.5 (95% CI 11.5-15.5) for NDI. Stratified SF-12 PCS MCID values increased from an estimated 4.8 (95% CI 1.1-7.7) in mild cases to 8.4 (95% CI 6.1-11.3) in moderate and 14.8 (95% CI 10.4-17.7) in severe cases. The NDI MCID values similarly rose from 10.5 (95% CI 6.5-12.5) to 15.0 (95% CI 10.5-19.0) to 17.5 (95% CI 14.5-21.0) across the mild, moderate, and severe groups, respectively. In contrast, the SF-12 MCS MCID values were 4.5 (95% CI 1.4-7.4) for mild, 3.8 (95% CI 0.4-5.8) for moderate, and 4.4 (95% CI 1.9-8.3) for severe patients, which did not differ significantly across severities.

Conclusions: MCID values for PROs in DCM patients undergoing surgery increase with baseline severity. These findings indicate the importance of stratifying patients by disease severity to enhance the clinical relevance of MCID values, facilitate personalized treatment goals, and improve outcome assessments.

Objective: The objective of this study was to investigate the incidence and postoperative clinical outcomes of lateral interbody cage migration (LCM) in patients undergoing multilevel stand-alone lateral lumbar interbody fusion (LLIF) compared with an aged-matched cohort undergoing LLIF with posterior pedicle screw instrumentation.

Methods: A retrospective review was conducted of the medical records of patients who underwent multilevel LLIF between 2017 and 2024 at a single institution and had ≥ 1 year of follow-up and postoperative radiographic follow-up. Demographic, operative, and postoperative data were collected and analyzed. Statistical analyses were performed using the chi-square test and independent-sample t-tests to assess the differences between continuous and categorical variables comparing both cohorts (stand-alone vs posterior instrumentation). Age-matched cohort analysis was performed, evaluating the distribution of both cohorts using a frequency matching analysis with the posterior instrumentation cohort as the control group and confirming equal distribution with the chi-square statistical test. Confounding factors were evaluated using logistic regression analyses.

Results: Eighty-seven patients met the inclusion criteria (43 in the stand-alone cohort, 44 in the posterior instrumentation cohort). For the stand-alone cohort, the mean (SD) age was 70.2 (8.2) years (30 [70%] males, 13 [30%] females). For the posterior instrumentation cohort, the mean (SD) age was 69.6 (7.1) years (28 [64%] females, 16 [36%] males). In the stand-alone cohort, 43 surgeries were performed involving the following 110 levels: L1-2 (n = 9), L2-3 (n = 36), L3-4 (n = 42), L4-5 (n = 23), and L5-S1 (n = 0). In the posterior instrumentation cohort, 44 surgeries were performed involving the following 112 levels: L1-2 (n = 6), L2-3 (n = 21), L3-4 (n = 44), L4-5 (n = 41), and L5-S1 (n = 0). The incidence of LCM was 7% in the stand-alone cohort and 5% in the posterior instrumentation cohort, with no statistically significant differences observed between the 2 cohorts. There were no statistically significant confounding factors. Patient-related outcomes, including Oswestry Disability Index and visual analog scale scores, showed postoperative improvement in both cohorts.

Conclusions: The difference in the incidence of LCM between the stand-alone cohort and the posterior instrumentation cohort was not statistically significant. Although posterior instrumentation has traditionally been used to enhance construct stability, multilevel stand-alone LLIF can be a safe procedure. Prospective study designs are warranted to validate these findings and elucidate factors contributing to cage migration in multilevel stand-alone LLIF versus LLIF with posterior pedicle screw instrumentation procedures.

Objective: Older patients are increasingly undergoing anterior cervical discectomy and fusion (ACDF). Although studies have examined complication rates in older patients, the correlation between age and achieving specific patient-reported outcomes (PROs) is lacking. The authors sought to determine whether older patients undergoing ACDF are independently associated with lower odds of achieving minimal clinically important difference (MCID) for pain and physical function.

Methods: The authors queried the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry for patients who underwent 1- to 4-level ACDF (March 2014 to July 2019) for degenerative conditions. PROs were measured at baseline, 90 days, 1 year, and 2 years using the neck and arm numerical rating scale (NRS), Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), EQ-5D, and North American Spine Society (NASS) satisfaction index. Patients were divided into older (≥ 70 years old) versus younger (< 70 years) groups. The authors used univariate analysis to compare demographic characteristics, operative characteristics, and proportions that achieved MCID between the age groups.

Results: This study included 7732 patients (6887 [89.1%] < 70 years old and 845 [10.9%] ≥ 70 years old). Unadjusted results demonstrated that older patients had a significantly higher rate of any complication within 90 days (26% vs 19%, p < 0.001), longer length of stay (2.6 days vs 1.7 days, p < 0.001), higher rates of MCID in neck NRS score at any time (76.9% vs 70.3%, p = 0.02) and at 90 days (71.3% vs 60.6%, p = 0.002), and lower rates of MCID in PROMIS-PF score at 1 year (52.7% vs 59.6%, p = 0.044) and 2 years (45.9% vs 57.7%, p = 0.002). Age was not independently associated with any PRO. Independent preoperative ambulation (OR 1.80, p < 0.001) and ambulation at postoperative day 0 (OR 1.25, p < 0.001) were independently associated with significantly increased odds of achieving MCID in PROMIS-PF score. Minor complications within 90 days (OR 0.67, p < 0.001) and lower baseline PROMIS-PF score (OR 0.89, p < 0.001) were independently associated with significantly decreased odds of achieving PROMIS-PF score. For the older subgroup, independent preoperative ambulation (OR 2.11, 95% CI 1.44-3.09, p < 0.001) had significantly increased odds of achieving MCID in PROMIS-PF score.

Conclusions: Unadjusted results demonstrated that older patients had significantly longer length of stay and complication rates within 90 days. Adjusted analyses demonstrated that advanced age was not independently associated with PROs in patients undergoing ACDF. However, independent early postoperative and preoperative ambulation were associated with significantly increased odds of improved PROs following ACDF.

Objective: Glucagon-like peptide-1 (GLP-1) agonists are established therapeutics for weight loss that are increasingly used for BMI optimization prior to spine surgery. However, emerging evidence has suggested that GLP-1 agonists might reduce bone mineral density (BMD), increasing the risk of postoperative biomechanical complications. CT-based Hounsfield units (HUs) have gained popularity as a method for measuring spinal BMD. The aim of this study was to evaluate the effects of GLP-1 agonist-induced weight loss on spinal BMD as measured by opportunistic CT-based HUs.

Methods: Patients who were treated with any GLP-1 agonist (2017-2022) for > 3 months were retrospectively identified. Patient body weight (BW), BMI, and HU measurements in the L1 vertebral body were measured before and after GLP-1 therapy. Patients were grouped according to the percentage of weight loss during GLP-1 therapy. One-way ANOVA was used to compare the mean changes in spinal HUs across the groups.

Results: Among the 102 included patients, the mean ± standard error of the mean BW reduction was 14.5 ± 2.5 kg over 15.9 ± 1.2 months of GLP-1 agonist therapy. Of these, 7 patients (6.9%) lost > 20% BW (mean decrease of 31.9 ± 7.0 HU, p = 0.011), 14 (13.7%) lost 15%-20% BW (mean decrease of 19.1 ± 8.3 HU, p = 0.038), 14 (13.7%) lost 10%-15% BW (mean decrease of 12.2 ± 5.1 HU, p = 0.036), 24 (23.5%) lost 5%-10% BW (mean decrease of 15.7 ± 3.3 HU, p < 0.0001), 26 (25.5%) lost < 5% BW (mean decrease of 14.7 ± 6.0 HU, p = 0.022), and 17 (16.7%) gained BW during GLP-1 therapy (mean decrease of 6.3 ± 5.0 HU, p = 0.229). One-way ANOVA testing did not show a significant difference in HU reduction across the weight loss groups (F = 1.12, p = 0.355). In addition, there was a significant correlation between the decrease in L1 HUs and the duration of GLP-1 therapy (r = -0.38, p = 0.0001) but not the amount of weight loss (r = -0.18, p = 0.070). In the multivariate analysis, the duration of GLP-1 therapy (p = 0.032) was a significant independent predictor of vertebral HU reduction, but the amount of weight loss (p = 0.664) was not.

Conclusions: Despite similar pretreatment BW and HU measurements, all weight loss groups had significant decreases in vertebral HUs following GLP-1 agonist therapy, with a significant correlation observed between HU reduction and treatment duration. This suggests that long-term GLP-1 agonist therapy can significantly diminish spinal BMD regardless of the amount of weight loss achieved.

Objective: While health-related quality of life (HRQOL) measures have been extensively quantified in cervical deformity (CD), this clinical dimension has not yet been fully integrated into understanding CD radiographic subtypes prior to surgery. The aim of this study was to identify distinct patterns of HRQOL deficits among patients with CD by focusing on clinical scores and to examine the association of these patterns with radiographic morphotypes of CD.

Methods: This was a retrospective analysis of a prospective multicenter database of patients with CD aged 18 years or older. Patient-reported outcome measures consisted of the Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scale, and Swallowing Quality of Life (SWAL-QOL) questionnaire. After performing a principal component analysis on the individual questions of the NDI, mJOA, and SWAL-QOL, 4 factors with eigenvalues > 1 were retained and included in a cluster analysis to assign patients into homogeneous groups of outcomes. Moreover, a subgroup of patients with severe deformity was described and analyzed.

Results: Overall, 134 patients (59% female, mean age ± SD 60.9 ± 10.8 years) were included in this analysis. The mean HRQOL scores were NDI, 49.1 ± 17.6; mJOA, 13.5 ± 2.7; and EQ-5D, 0.7 ± 0.1). The factor analysis involving NDI, SWAL-QOL, and mJOA revealed 4 clusters. Cluster A represented patients with a predominant sleep problem. Cluster B was patients with the lowest neck disability. Cluster C represented the most disabled patients in terms of dysphagia and neck disability. Cluster D represented patients with myelopathy. Among the 71 patients with severe deformity, the distribution of cervical morphotypes significantly differed across the 4 clusters of disability (p = 0.009). Cluster C mainly consisted of patients with cervicothoracic deformity (66.7%, p = 0.002). Cluster D had a large proportion of patients (66.7%) with focal deformity (p = 0.007). In clusters A and B, 57.9% and 46.4% of patients, respectively, presented with "flat neck" deformity (p = 0.02).

Conclusions: Distinct patterns of HRQOL deficits were observed across a heterogeneous population of patients with CD, and these patterns were associated with specific radiographic morphotypes. These findings provide a framework for the next generation of CD classification, wherein HRQOL measures are combined with radiographic parameters.

Objective: Sacral amputations for en bloc resection of malignant spinal tumors are associated with significant morbidity, especially wound complications, and require complex plastic surgery reconstructions to achieve wound closure. In this study, the authors investigate wound healing related to early postoperative mobilization (≤ 3 days of bed rest) compared with delayed postoperative mobilization (> 3 days of bed rest). The primary outcome was 30-day postoperative wound complications.

Methods: This is a retrospective study of patients who underwent sacral amputation at a single institution with a single neurosurgeon between 2018 and 2023. Demographic information, comorbid conditions, pathological diagnosis, surgical characteristics, length of bed rest, and postoperative wound complications were collected for each patient. Univariate analysis followed by stepwise multivariable logistic regression was utilized to identify independent predictors of 30-day postoperative wound complications, defined as reoperation, infection, or dehiscence at the surgical site.

Results: Forty-three patients were included in the analysis. Thirty-one patients were placed on standard bed rest (> 3 days; mean 5.9 [SD 2.4] days), while 12 were mobilized early (≤ 3 days; mean 2.3 [SD 1.4] days). The overall wound complication rate was 37.2%. Of the patients with delayed mobilization, 15 (48.4%) experienced wound complications, while 1 (8.3%) with early mobilization experienced wound complications. On multivariable analysis, early mobilization was independently associated with reduced odds of 30-day wound complications (OR 0.035, 95% CI 0.002-0.689; p = 0.0275).

Conclusions: These data show that early mobilization after sacral amputation is associated with a decreased incidence of wound complications compared with delayed mobilization. Further prospective studies investigating early mobilization after sacral amputation are warranted.

Objective: Paraspinal involvement has been consistently reported as a negative predictor of local control following stereotactic body radiation therapy (SBRT) for spinal metastases. The aim of this study was to investigate the characteristics of paraspinal disease and determine the impact on outcomes.

Methods: Patients who underwent SBRT for spinal metastases with paraspinal involvement, identified from a single-institutional prospective database, were retrospectively reviewed. Those with prior radiation therapy/surgery were excluded. The treated clinical target volume (CTV) was segmented into paraspinal (CTV_PS), neuroforaminal (CTV_NF), epidural (CTV_EP), and osseous bone (CTV_bone) components. The extent of extraosseous disease was classified according to the involvement of rib, neuroforamina, and muscle. Volume and dosimetric parameters were collected and dichotomized using recursive binary partitioning. The outcomes of interest were the cumulative incidence of local failure (LF), overall survival (OS), and reirradiation rates.

Results: One hundred fourteen patients with 125 treated spinal sites were identified. There were 38% (47/125), 66% (82/125), and 19% (24/125) treated spinal sites with involvement of rib, neuroforamina, and muscle, respectively. The median follow-up duration of the cohort was 17.34 months (IQR 7.79-40.11 months). The 12-month and 24-month cumulative incidence rates of LF were 19.5% (95% CI 12.6%-27.4%) and 29.8% (95% CI 21.4%-38.7%), respectively. The 12-month cumulative incidence rates of LF were 12.0% (95% CI 5.9%-20.5%) and 36.3% (95% CI 20.2%-52.6%) for patients with CTV_PS < 42.9 mL and those with ≥ 42.9 mL (p < 0.001), respectively, and 55.6% (95% CI 28.7%-75.8%) and 12.2% (95% CI 6.5%-19.9%) for patients with and without muscle invasion (p = 0.001), respectively. In the multivariable analysis, only CTV_PS remained statistically associated with LF. CTV_PS ≥ 42.9 mL was associated with 2.3 times (95% CI 1.13-4.83, p = 0.02) increased risk of LF compared with CTV_PS < 42.9 mL. The 12-month and 24-month OS rates were 56% (95% CI 47%-65%) and 41% (95% CI 32%-50%), respectively. Patients with an Eastern Cooperative Oncology Group performance status score < 1 and oligometastatic disease (≤ 5 metastases) were associated with better OS in the multivariable analysis. The 12-month and 24-month reirradiation rates were 7.3% (95% CI 3.4%-13.3%) and 16.5% (95% CI 10.2%-24.1%), respectively.

Conclusions: Spinal metastases with high-volume paraspinal involvement were associated with increased risk of LF following SBRT, and strategies to optimize local control are required.