Journal of neurosurgery. Spine最新文献

Objective: Smoking has been shown to negatively impact spinal health, as well as the outcomes of spinal fusion. Published reports show conflicting data regarding whether smoking negatively impacts patient outcomes following lumbar decompression. The objective of this study was to investigate whether smoking affects the outcomes of patients undergoing lumbar decompression for spinal stenosis or herniated disc.

Methods: The Quality Outcomes Database was queried for patients with spinal stenosis or lumbar disc herniation who underwent one- or two-level lumbar decompression without fusion. All patients had preoperative and 12-month outcome measures and were divided into groups of nonsmokers and current smokers. Outcomes were compared between the two groups, as well as the percentage of patients reaching the minimal clinically important difference (MCID) threshold for numeric rating scale (NRS) back and leg pain scores and the Oswestry Disability Index (ODI).

Results: Of 17,271 patients, 14,233 were nonsmokers and 3038 were current smokers. Smokers had worse baseline NRS back and leg pain, ODI, and EQ-5D scores and experienced slightly less improvement in all measures following lumbar decompression (p ≤ 0.009), although changes were largely similar, and a high percentage of patients achieved the MCID thresholds for NRS back pain (78% nonsmokers vs 75% smokers), NRS leg pain (79% nonsmokers vs 73% smokers), and ODI (74% nonsmokers vs 68% smokers). Comparison of propensity-matched cohorts did not identify any difference in outcomes in smokers versus nonsmokers.

Conclusions: In patients undergoing lumbar decompression for spinal stenosis or herniated disc, smokers demonstrated slightly less improvement in outcomes compared with nonsmokers, and a high proportion of both groups achieved meaningful improvement with surgery. While smoking cessation should be strongly encouraged in all patients, lumbar decompression procedures for spinal stenosis and herniated disc should not be denied to smokers.

Objective: Despite efforts toward achieving gender-based equality in clinical trial enrollment, females are frequently underrepresented and gender-specific data analysis is lacking. Identifying and addressing gender bias in medical decision-making and outcome reporting may facilitate more equitable healthcare delivery. This study aimed to determine if gender differences exist in the clinical evaluation and surgical management of patients with degenerative lumbar conditions.

Methods: Consecutive adult patients undergoing spinal surgery for degenerative lumbar conditions (disc herniation [DH], spinal canal stenosis [SCS], and degenerative spondylolisthesis [DS]) were prospectively enrolled across 16 tertiary academic centers. Outcome domains included pain, disability, health-related quality of life (HRQOL), expectations of surgery, and satisfaction with surgical outcome. Covariates pertaining to the preoperative use of healthcare resources, diagnostic testing, and visits to healthcare providers were compared between genders before and after propensity score matching for 13 baseline demographic and procedural variables.

Results: Data were analyzed for 5038 patients (2396 female, 2642 male) with degenerative spinal pathologies including SCS (40.2%), DS (33.2%), and DH (26.6%). Surgical treatment effect was similar for both genders. For all conditions, female patients had worse pre- and postoperative pain, disability, and HRQOL. Significant gender differences were identified for marital status, education, employment status, exercise activities, and disability claims. Female patients were more likely to use select medications, diagnostic imaging tests, and nonsurgical therapeutic interventions, and access various healthcare providers. Findings were similar following post hoc propensity score matching.

Conclusions: In this multicenter, prospective, observational cohort study, male and female patients benefitted similarly from surgery for degenerative lumbar spine disease. However, female patients had worse preoperative clinical assessment scores and were more likely to use select healthcare resources.

Objective: In posterior vertebral column subtraction osteotomy (PVCSO), a section of a thoracic or lumbar vertebra and the adjacent disc are resected to shorten the spinal column, aiming to permanently alleviate tension on the spinal cord in patients with recurrent tethered cord syndrome (TCS). The effects of this procedure on the spinal cord are not well characterized. This study investigated morphometric changes in the cord following PVCSO and assessed associated clinical outcomes in patients with recurrent TCS.

Methods: A retrospective review of patients with recurrent TCS undergoing PVCSO with robotic assistance at the authors' tertiary care institution between 2019 and 2023 was performed. Clinical data were recorded from electronic medical records, and morphometric measurements, including T12-L2 sagittal height, intradural diameter, and the diameters, area, eccentricity, and positioning of the spinal cord, were collected from MRI. Spinal cord dimensions including anteroposterior and lateral diameters, area, eccentricity, positioning, and intradural diameter were compared before and after surgery.

Results: Six patients were included in this study. At 6-week follow-up, all patients had improvement on lower-extremity motor function examinations, 40% had improvement on lower-extremity sensory function examinations, and 83% had improved self-reported pain. Bladder and bowel incontinence were improved in 50% and 60%, respectively. PVCSO reduced the height of the spinal column by a mean of 18.1 ± 5.2 mm. PVCSO increased the mean spinal cord anteroposterior diameter by 0.8 ± 0.5 mm at T12 (p = 0.03) and the mean area by 0.4 ± 0.3 mm2 at T12 (p = 0.03). The mean eccentricity of the spinal cord decreased by 0.15 ± 0.15 at L1 (p = 0.05), indicating that the spinal cord became more circular after surgery. No major complications were reported, although 1 patient experienced atelectasis and pulmonary embolism postoperatively.

Conclusions: This study provides novel insights into the morphometric changes induced by PVCSO and their correlation with clinical outcomes in patients with TCS. The procedure effectively increased spinal cord dimensions, alleviating tension and offering potential benefits in symptom relief. The study underscores the need for objective metrics to guide surgical decision-making and enhance the long-term success of PVCSO in the management of TCS.

The discovery of spine anatomy followed a problem/solution pattern; it took almost 1000 years to transition from nihilism to perfectionism. Before the 16th century, the main issue was accessing and opening the spine. The level of knowledge progressed rapidly when the spinal canal was opened longitudinally during the 16th century. The 17th century was an incubation period that allowed the consolidation of the science of anatomy with the help of art, philosophy, and other sciences. In particular, the conservation of the cadaver was improved. Famous spine anatomists were close to Rembrandt, master of the chiaroscuro technique, which helped to improve the anatomical drawings significantly. Descriptions of the pathological anatomy of the spine were first published early in the 17th century, but progress was slow up to the end of the 18th century due to a lack of occasions for clinical-pathological correlations. Normal anatomy became remarkably accurate in the 18th and 19th centuries when soft tissues and connections (e.g., among the intervertebral discs) were studied in detail. The slow compressions due to underlying diseases and then the degenerative processes were subsequently described.

Objective: There is an increasing need for optimal surgical techniques for older patients with degenerative spine disease. The authors evaluated perioperative complications and clinical and long-term radiographic outcomes in patients older than 75 years after lateral lumbar interbody fusion (LLIF) for degenerative spine disease.

Methods: The authors conducted a single-center, retrospective case series of consecutive patients older than 75 years who underwent single-level or multilevel LLIF between January 1, 2017, and December 31, 2022. Postoperative transient neurapraxia or permanent neurological deficits were documented. Outcomes were assessed using patient-reported outcome scales. Bone density was measured at the femoral neck and L1 vertebra. Sagittal vertical axis (SVA), segmental lordosis (stratified by level), lumbar lordosis (LL), pelvic incidence-LL mismatch, sacral slope, and pelvic tilt were measured on upright radiographs. Fusion status was assessed using the Lenke classification system on CT scans obtained at least 1 year postoperatively. Clinical and radiographic outcomes were assessed using paired t-tests and multivariable regression. The values for continuous variables are expressed as the mean (SD).

Results: Fifty-two patients (mean age 78.6 years; range 75-87 years) met the inclusion criteria; 94 levels were treated in these patients, and the mean follow-up was 12.2 (6.3) months. All outcome measures showed significant improvement at latest follow-up, including the mean changes in scores on the Oswestry Disability Index (-14.5 [17.5]); visual analog scale (VAS) for back pain (-2.2 [3.8]); and VAS for leg pain (-3.3 [3.9]) (all p < 0.001). Age was not associated with perioperative outcomes, except change in VAS score for back pain (r = 0.4, p = 0.03). One year postoperatively, 88% of levels (52 of 59 levels in 31 patients available for follow-up) demonstrated bony fusion. Patients experienced significant improvements in the mean change in SVA (-1 [2.7] cm); segmental lordosis (5.9° [4.1°]); LL (5.3° [9.8°]); and pelvic incidence-LL mismatch (-2.9° [6.4°]) (all p < 0.01). Cage subsidence was observed in 7 of 94 levels (7%). On multivariable regression analysis, increasing age was a significant predictor of reduced radiographic correction with respect to the change in SVA (β 0.43; 95% CI 0.10-0.77; p = 0.01) and the change in LL (β -1.18; 95% CI -2.12 to -0.23; p = 0.02).

Conclusions: This series demonstrates safe clinical outcomes and stable long-term radiographic outcomes in patients older than 75 years undergoing LLIF for degenerative lumbar spine disease.

Objective: Spinal meningiomas (SMs) are relatively rare primary spinal neoplasms, and the increasingly growing mean age and number of older patients presenting with spinal neoplasms raise questions concerning the costs and benefits of proposing surgical intervention. The aim of this study was to analyze the outcomes and complications of a large cohort of older patients with SMs to define the real benefit of surgery in these patients.

Methods: A total of 261 SMs were operated on between 1976 and December 2021, and 156 matched the inclusion criteria for the final cohort. Patients were divided into three groups according to age: < 50 years (group A), between 51 and 74 years (group B), and > 75 years (group C). Neurological and clinical outcomes, resection grade, complications, histology, and possible recurrences were evaluated.

Results: The final cohort comprised 156 patients (126 females, 30 males) with a mean ± SD age of 55.93 ± 14.80 years. The mean follow-up was 41.5 ± 11.4 months. Group A was found to have a significantly higher Frankel score at follow-up; there was no significant difference between mean scores for groups B and C. Nevertheless, there was no significant difference between the subgroups in patients who showed improvement from their preoperative neurological condition. Only 3 recurrences were recorded, all in group A. Axial topography, level of the lesions, and preoperative symptoms, including impairment of the sphincter functions, demonstrated no statistically significant interaction in the subgroups.

Conclusions: The present study supports the concept that older age might not be a contraindication for surgical treatment in SMs because of the important improvements in functional status and quality of life achieved in this population subgroup. Older patients can benefit from prompt assessment and early surgery in cases of acute onset, with a complication rate not higher than that of younger patients.

Objective: Some patients treated surgically for grade 1 spondylolisthesis require revision surgery. Outcomes after revision surgery are not well studied. The objective of this study was to determine how revision surgery impacts patient-reported outcomes (PROs) in patients undergoing decompression only or decompression and fusion (D+F) for grade 1 spondylolisthesis within 5 years of the index surgery.

Methods: Patients in the 12 highest Quality Outcomes Database (QOD) enrolling sites with a diagnosis of grade 1 spondylolisthesis were identified and the incidence of revision surgery between the decompression-only and D+F patients were compared. PROs were compared between cohorts requiring revision surgery versus a single index procedure.

Results: Of 608 patients enrolled, 409 had complete 5-year data available for this study. Eleven (13.3%) of 83 patients underwent revision in the decompression-only group as well as 32 (9.8%) of 326 in the D+F group. For the entire cohort, patients requiring revision had significantly worse PROs at 5 years: Oswestry Disability Index (ODI) 27.4 versus 19.4, p = 0.008; numeric rating scale for back pain (NRS-BP) 4.1 versus 3.0, p = 0.013; and NRS for leg pain (NRS-LP) 3.4 versus 2.1, p = 0.029. In the decompression-only group, the change in 5-year PROs was not impacted by revision status: ODI 31.9 versus 24.2, p = 0.287; NRS-BP 1.9 versus 2.9, p = 0.325; and NRS-LP 6.2 versus 3.7, p = 0.011. In the D+F group, the change in 5-year PROs was diminished if patients required revision: ODI 19.1 versus 29.1, p = 0.001; NRS-BP 3.0 versus 4.0, p = 0.170; and NRS-LP 2.3 versus 4.6, p = 0.001.

Conclusions: The most common reasons for reoperation within 5 years in the decompression-only group were repeat decompression and instability, whereas in the D+F group the most common reason was adjacent-segment disease. The need for revision resulted in modestly diminished benefit compared with patients with no revisions. These differences were greater in the fusion cohort compared with the decompression-only cohort. The mean PRO improvement still far exceeded minimal clinically important difference thresholds for all measures for patients who underwent a revision surgery.

Objective: This study aimed to 1) describe the 2-year postoperative trajectories of leg pain and overall clinical outcome after surgery for radiculopathy, 2) identify the preoperative prognostic factors that predict trajectories representing poor clinical outcomes, and 3) develop and internally validate multivariable prognostic models to assist with clinical decision-making.

Methods: This retrospective cohort study included patients enrolled in the Canadian Spine Outcomes and Research Network who were diagnosed with lumbar disc pathology and radiculopathy and had undergone lumbar discectomy at one of 18 spine centers. Potential outcome predictors included preoperative demographic, health-related, and clinical prognostic factors. Clinical outcomes were 1) 2-year univariable latent trajectories of leg pain intensity (numeric pain rating scale) and 2) overall outcomes comprising multivariable trajectories showing the combined postoperative courses of leg and back pain intensity (numeric pain rating scale) together with pain-related disability (Oswestry Disability Index). Each outcome model identified a subgroup of patients classified as experiencing a poor outcome based on minimal change in their clinical status after surgery. Multivariable risk model performance and internal validity were evaluated with discrimination and calibration statistics based on bootstrap shrinkage with 500 resamplings.

Results: The authors included data from 1142 patients (47.6% female). The trajectory models identified 3 subgroups based on the patients' postoperative courses of pain or disability: 88.6% of patients in the leg pain model and 71.9% in the overall outcome model experienced a good-to-excellent outcome. The models classified 11.4% (leg pain outcome) and 28.2% (overall outcome) of patients as experiencing a poor clinical outcome, which was defined as minimal improvement in pain or disability after surgery. Eleven individual demographic, health, and clinical factors predicted patients' poor leg pain and overall outcomes. The performance of the multivariable risk model for leg pain was inadequate, while the overall outcome model had acceptable discrimination, calibration, and internal validity for predicting a poor surgical outcome.

Conclusions: Patients with lumbar radiculopathy experience heterogeneous postoperative trajectories of pain and disability after lumbar discectomy. Individual preoperative factors are associated with postoperative outcomes and can be combined within a multivariable risk model to predict overall patient outcome. These results may inform clinical practice but require external validation before confident clinical implementation.

Objective: Semaglutide, a novel glucagon-like peptide-1 receptor agonist, has transformed the therapeutic landscape for type 2 diabetes mellitus. However, its effect on osteoclast activity and its potential to induce weight-related muscle loss raises concerns about its impact on spine surgery outcomes. As such, evaluating semaglutide's influence on transforaminal lumbar interbody fusion (TLIF) is imperative, given the procedure's reliance on successful bony fusion to prevent postoperative instability and further interventions.

Methods: Using an all-payer database (MARINER), the authors analyzed data from patients with type 2 diabetes mellitus who were 18-74 years of age and who underwent short-segment fusion (≤ 3-level) TLIFs between January 2018 and October 2022. Patients were either exposed to semaglutide or not. A comprehensive 1:3 (exposure vs no exposure) matching was performed based on age, sex, obesity, hypertension, coronary artery disease, chronic kidney disease, smoking status, osteoporosis, levels of surgery, and basal-bolus insulin dependence. Kaplan-Meier survival curves and log-rank testing were performed to study the probability of additional lumbar fusion surgery within 1 year.

Results: After the 1:3 matching, 1781 patients were identified, with 447 in the semaglutide-exposed cohort and 1334 in the nonexposed cohort. Most patients in both groups were 55-69 years old, and 59.3% were female. Analysis showed that the likelihood of undergoing additional lumbar fusion surgery within 1 year post-TLIF was significantly higher in the semaglutide-exposed group than in the nonexposed group (OR 11.79, 95% CI 8.17-17.33). Kaplan-Meier plots and log-rank testing further confirmed a statistically significant divergent probability in the need for additional surgery within 1 year between the cohorts (log-rank, p < 0.001).

Conclusions: Semaglutide exposure appears to be associated with a higher likelihood of additional lumbar fusion surgeries within 1 year post-TLIF, especially in patients receiving the medication for longer durations. Although the mechanisms remain speculative, potential impacts on bone turnover and the onset of muscle loss may be contributory factors. Further research is needed to elucidate the exact mechanisms and to develop strategies for optimizing surgical outcomes in these patients.

Objective: The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) assessment is the gold standard for evaluation of neurological function after spinal cord injury (SCI). Although it is an invaluable tool for diagnostic and research purposes, it is time consuming and can be impractical in acute injury settings. Clinical neurosurgery motor examinations (NMEs) could serve as an expeditious surrogate for SCI research when ISNCSCI motor examinations are not feasible. The aim of this study was to evaluate the agreement between motor examinations performed by the neurosurgery clinical team and ISNCSCI examiners.

Methods: The multicenter prospective Transforming Research and Clinical Knowledge in Spinal Cord Injury (TRACK-SCI) registry was queried to identify patients with recorded neurosurgery and research motor examinations within 24 hours of each other. Pearson correlations and modified Bland-Altman analyses were performed using data from matching upper-extremity, lower-extremity, and combined examinations. Kappa analysis was used to test interrater reliability with respect to determination of American Spinal Injury Association Impairment Scale (AIS) grade.

Results: There were 72 pairs of matching clinical and research examinations in 63 patients. NME scores were strongly correlated with ISNCSCI motor scores (R = 0.962, p < 0.001). Both upper- and lower-extremity NME scores were strongly correlated with upper- and lower-extremity ISNCSCI motor scores, respectively (R = 0.939, p < 0.001; and R = 0.959, p < 0.001, respectively). In modified Bland-Altman analyses, total, upper-extremity, and lower-extremity NME scores and ISNCSCI motor scores showed low systematic bias and high agreeability (total: bias = 0.3, limit of agreement [LoA] = 36.6; upper extremity: bias = -0.5, LoA = 17.6; lower extremity: bias = 0.8, LoA = 24.0). There were 66 pairs of examinations that had thorough sensory and rectal examinations for AIS grade calculation. Using kappa analysis to test the interrater reliability of AIS grade calculation using NME versus ISNCSCI motor scores, the authors found a weighted kappa of 0.883 (SE 0.061, 95% CI 0.736-0.976), indicating strong agreement.

Conclusions: Overall, this study suggests that ISNCSCI motor scores and NME scores are strongly correlated and highly agreeable. When conducting SCI research, a thorough clinical motor examination may be a useful surrogate when ISNCSCI examinations are missing.