Journal of neurosurgery. Spine最新文献

Objective: The impact of C5 palsy on quality of life (QOL) and its relationship with recovery and overall well-being remain poorly understood. In this study, the authors aimed to examine the effects of postoperative C5 palsy on upper extremity function and QOL in patients undergoing cervical ossification of the posterior longitudinal ligament (C-OPLL) surgery, using both objective clinical assessments and patient-reported outcome measures (PROMs). Additionally, this study aimed to explore the correlation between residual C5 palsy and QOL over a 2-year period.

Methods: This retrospective study, using a prospective multicenter database, included 478 patients with myelopathy caused by C-OPLL, treated between 2014 and 2018, with a 2-year follow-up. Thirty-one patients developed postoperative C5 palsy (C5 palsy group), and their outcomes were compared to those of 389 patients without C5 palsy (non-C5 palsy group) using propensity score matching. Within the C5 palsy group, patients were further classified based on their recovery status at 1 year postoperatively. Neurological status was assessed using the Japanese Orthopaedic Association (JOA) score, while PROMs were evaluated using the JOA Cervical Myelopathy Evaluation Questionnaire, which assesses cervical and upper extremity function, bladder function, and overall QOL. Assessments were conducted at 6 months, 1 year, and 2 years postoperatively.

Results: C5 palsy occurred in 7.4% of patients, with 61.3% achieving full recovery within 1 year. Patients in the C5 palsy group had significantly poorer upper extremity function and shoulder motor scores than those in the non-C5 palsy group at all postoperative time points. However, no significant differences were observed between the groups in QOL, cervical function, lower extremity function, or bladder function. In contrast, patients with residual C5 palsy had worse QOL as well as upper extremity function compared to patients with recovered C5 palsy.

Conclusions: While postoperative C5 palsy continues to affect motor and upper extremity function beyond 1 year, QOL scores were not significantly lower in the C5 palsy group. However, the impact on QOL in patients with residual C5 palsy may continue to slightly improve over time.

Objective: Vertebral compression fractures (VCFs) are associated with significant pain and disability. The current standard of care is expectant medical management; however, there is emerging data encouraging the use of early kyphoplasty or vertebroplasty. The goal of this nationwide study was to investigate the outcomes of patients with acute thoracolumbar VCF who undergo very early (inpatient) kyphoplasty compared with those managed medically.

Methods: This was a retrospective cohort analysis of the Nationwide Readmissions Database from 2016 to 2022. Adult patients admitted nonelectively for thoracolumbar wedge compression fractures were included. Patients were excluded if they had cancer, additional fractures, cord compression, or if they underwent surgery. Those who underwent kyphoplasty or vertebroplasty were 1:1 propensity score matched with those who were managed medically, and Poisson or logistic regression analyses were performed for outcomes. The primary endpoint was discharge to home. Other outcomes included in-hospital death, hospital length of stay (LOS), cost, and major morbidity or mortality after discharge at 180 days.

Results: A total of 69,722 patients were included in the study, of whom 53,142 (76.2%) underwent medical management while 16,580 (23.8%) underwent kyphoplasty or vertebroplasty. After propensity score matching, patients who underwent kyphoplasty/vertebroplasty experienced a significantly higher rate of discharge to home (54.3%) compared with medically managed patients (46.2%) (OR 1.38, 95% CI 1.28-1.50; p < 0.001). Compared with medical management, patients who underwent kyphoplasty/vertebroplasty had significantly lower in-hospital death (0.4% vs 0.9%; OR 0.48, 95% CI 0.32-0.74; p < 0.001) but a slightly longer hospital LOS (median 5 vs 4 days; B = 1.23, 95% CI 1.07-1.38; p < 0.001) and higher cost (B = 8.9, 95% CI 8.4-9.3; p < 0.001). There was no significant difference in inpatient adverse events between the medical management and kyphoplasty/vertebroplasty groups (p > 0.05), and, among patients discharged home, inpatient kyphoplasty/vertebroplasty did not lead to differences in delayed morbidity or mortality within 180 days (p > 0.05). Subgroup analysis revealed that women may derive a greater benefit from kyphoplasty/vertebroplasty (OR 1.47, 95% CI 1.35-1.61; p < 0.001) than men (OR 1.19, 95% CI 1.05-1.35; p = 0.009) (interaction p = 0.003).

Conclusions: Inpatient kyphoplasty/vertebroplasty is associated with higher odds of home discharge and lower odds of mortality. These findings support the use of very early (inpatient) kyphoplasty/vertebroplasty for those with acute thoracolumbar compression fractures.

Objective: Surgery for cervical spondylotic myelopathy (CSM) is becoming increasingly common and costly. Using propensity score matching to rigorously control for demographic, clinical, and surgical confounders, the authors provide the most refined assessment yet of the impact of discharge to subacute rehabilitation (SAR) or home with health services on excess length of stay (LOS) and inpatient expense following surgery for CSM.

Methods: The prospective Quality Outcomes Database was used to assess patients undergoing surgery for CSM. Propensity score matching was used to balance 12 covariates between patients discharged home and those discharged to SAR, as well as between patients discharged home and those discharged home with health services. The mean LOS, complications, and patient-reported outcomes (at baseline and 3, 12, and 24 months postoperatively) were compared between discharge destinations. Excess LOS was multiplied by the adjusted expense per inpatient day to calculate excess expense.

Results: After matching, there were no significant baseline differences between discharge cohorts. Discharge to SAR was associated with a mean excess LOS of 2.7 days and an additional inpatient expense of $8168, while discharge home with health services resulted in a mean excess LOS of 0.9 days and an additional inpatient expense of $2723. Patients discharged to SAR had lower patient satisfaction at 3 months, worse EQ-5D scores at 12 and 24 months, and worse modified Japanese Orthopaedic Association scores at 3 months. Those discharged home with health services had lower patient satisfaction and EQ-5D scores at 12 months postoperatively.

Conclusions: These findings underscore the need for proactive, targeted discharge planning to minimize prolonged LOS and reduce healthcare costs, particularly in the context of increasingly common elective CSM surgery and the emergence of alternative payment models. By optimizing discharge processes, payors and hospital administrators can improve resource utilization, enhance patient satisfaction, and reduce financial burdens on healthcare systems.

Objective: Enhanced recovery after surgery (ERAS) has demonstrated benefits across various surgical specialties. However, a significant research-practice gap remains, with fewer than half of spine surgeons incorporating ERAS principles into daily practice. A key barrier to ERAS implementation in spine surgery is postoperative compliance, as patients often express concerns about worsening pain. To address these challenges, the authors developed a standardized, delivery-focused ERAS clinical pathway (CP) for oblique lumbar interbody fusion (OLIF). This study prospectively evaluated whether ERAS-CP can improve postoperative compliance without compromising pain control compared with conventional ERAS.

Methods: This prospective, randomized noninferiority trial involved 41 patients undergoing OLIF from July 2023 to February 2024. Patients were randomized to either the ERAS-CP group (n = 21) or the control (conventional ERAS) group (n = 20). The ERAS-CP comprised a CP system integrated into the electronic health record system, patient education manual, and dedicated medical personnel support. The control group (conventional ERAS) followed standard ERAS principles but lacked these structured compliance-enhancing interventions. The primary outcome was back pain at discharge measured by the numeric rating scale. Secondary outcomes included ERAS compliance, pain management, and patient satisfaction.

Results: Demographics were similar between the groups. The ERAS-CP group demonstrated noninferiority in back pain at discharge compared with the control group in the intent-to-treat analysis (difference -0.1, 95% CI -1.4 to 1.1) and the per-protocol analysis (difference -0.3, 95% CI -1.6 to 1.0). The ERAS-CP group achieved earlier ambulation (median 2 [range 1-9] vs 3.5 [range 2-18] hours, p = 0.011) and longer daily ambulation times (mean 91.7 vs 68.2 minutes/day, p = 0.047). Nonopioid analgesic use was higher in the ERAS-CP group on postoperative days 1 and 2 (p < 0.05), with no difference in opioid use. Both groups reported high satisfaction with pain management (78%). No significant differences were found in complication rates, length of stay, or 3-month clinical outcomes.

Conclusions: The ERAS-CP for OLIF demonstrated noninferiority in pain management while improving adherence to key ERAS components. By reinforcing postoperative compliance through structured interventions, ERAS-CP may enhance recovery in lumbar spinal fusion surgery.

Objective: Primary spinal oligodendrogliomas (sODGs) are an exceptionally rare subset of oligodendrogliomas (ODGs). As such, there is a limited understanding of their natural history, optimal treatment approaches, and long-term outcomes. This systematic review aimed to better characterize the presentation and management of sODGs.

Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was performed using the PubMed, EMBASE, Web of Science, and Cochrane databases from inception to December 2024. The review included case reports and case series, and data extraction focused on patient demographics, clinical presentation, diagnostic features, treatment modalities, and outcomes.

Results: The review identified 38 sODG cases from 33 studies. The median age at diagnosis was 22.5 years, with a male predominance (57.9%). Common presenting symptoms included extremity weakness (59.4%), back pain (25%), and sensory deficits (25%). MRI was the primary diagnostic tool (76.7%). Resection was the primary treatment, with 36.7% achieving total resection. Adjuvant therapy was administered to 57.1% of patients. The recurrence or progression rate was 52.2%, with a median follow-up of 28.5 months.

Conclusions: Spinal ODGs present unique challenges in diagnosis, management, and prognosis compared with their cranial counterparts. The findings support considering sODGs in the differential diagnosis for patients with progressive myelopathic symptoms in the absence of obvious compressive spondylosis. Future research should focus on long-term outcomes, optimal treatment strategies, and molecular characterization of these rare tumors.

Objective: Prior studies on spinal ependymoma typically group patients based on tumor pathology, often combining myxopapillary ependymomas and other ependymoma subtypes into a single cohort. This study aimed to evaluate differences in patient presentation and long-term functional outcomes between cervical/thoracic and conus/filum ependymomas. The authors hypothesized that these variations are location specific and warrant further stratification.

Methods: The medical records of adult patients who underwent resection for spinal ependymoma at a single tertiary-care institution between 2006 and 2023 were retrospectively reviewed.

Results: A total of 146 patients with pathologically confirmed spinal ependymoma were included, with a mean follow-up of 2.2 ± 3.1 years. The cohort was divided into two groups: cervical/thoracic ependymomas (n = 101) and conus/filum ependymomas (n = 45). The tumors in the cervical/thoracic group were predominantly located in the cervical region (68.3%) and were intramedullary (100%), while the conus/filum group tumors were mostly found in the lumbar region (88.9%) and were primarily extramedullary (86.7%) (p < 0.001). Preoperative symptoms varied significantly between the two groups. Sensory disturbances were more common in the cervical/thoracic group (82.2% vs 40%, p < 0.001), while pain was more frequent in the conus/filum group (95.6% vs 74.3%, p = 0.003). Preoperative weakness was significantly more prevalent in the cervical/thoracic group (49.5% vs 20.0%, p < 0.001), and gait instability was also more common in this intramedullary group (p = 0.03). A higher proportion of patients in the cervical/thoracic group required nonhome discharge (35.7% vs 8.9%, p = 0.003). At the last follow-up, sensory deficits were more prevalent in the cervical/thoracic group (57.4% vs 11.1%, p < 0.001), while functional independence was significantly higher in the conus/filum group (95.6% vs 90.1%, p < 0.001). Multivariable analysis revealed that female sex, non-White race, and lumbar tumor location were significant predictors of pain at last follow-up. Additionally, the presence of a conus/filum tumor was associated with significantly lower odds of sensory disturbances at last follow-up.

Conclusions: The authors' data demonstrate that tumor location significantly influences symptom presentation, functional improvement over time, and overall outcomes, highlighting the importance of location-based stratification in future research and treatment strategies.

Objective: Spontaneous intracranial hypotension (SIH) with a ventral CSF leak (type 1) is believed to be caused by discogenic microspurs. Recently, this hypothesis was questioned, in which Hofmann's ligament, a fibrous connective tissue between the dura and posterior longitudinal ligament, was claimed to be the cause of a spinal dural tear. The primary objective of this study was to determine whether SIH type 1 lesions arise from a discogenic source or from fibrotic tissue.

Methods: Patients with ventral CSF leaks treated at the authors' institution, in whom histopathological reports on microspurs were available, were included. All histopathological analyses were repeated and tissues classified into either a fibrotic (Hofmann's ligament) or discogenic group. Correlation analysis of microspur localization in the spine and their origin was conducted. Microspur length and Hounsfield units (HUs) on CT were compared between both groups.

Results: Twenty-seven patients (19 women, 8 men) with a median age of 57 (IQR 46-64) years were analyzed. Nine microspurs were identified originating from fibrous tissues (Hofmann's ligament) and 13 microspurs were of discogenic origin, while 5 microspurs could not be classified into either group. Nine microspurs were found at the cervicothoracic or thoracolumbar junction, while 18 were located within the midthoracic spine. The location of the microspurs did not correlate with the histopathological origin of the microspur (p = 0.29). The length of a microspur (p = 0.29) as well as its density measured in HUs (p = 0.90) did not show a statistically significant difference between the fibrous and discogenic groups.

Conclusions: These findings confirm that microspurs in patients with ventral CSF leaks originate from both the intervertebral disc and fibrous epidural ligament, suggestive of Hofmann's ligament.

Objective: The aim of this study was to characterize patient demographics, injury characteristics, clinical management, and inpatient hospital course of victims of gunshot wounds (GSWs) to the spine to describe a "natural history" of disease following this injury.

Methods: A retrospective analysis was conducted of patients with GSWs to the spine at a level I trauma center in a major urban center from January 2016 to December 2021. Data on demographics, injury grades/characteristics, and treatment course were analyzed using descriptive and comparative statistics.

Results: Of 237 identified cases, patients were predominantly male (210, 88.6%) with a mean age of 26.3 ± 9 years. The most common injury site was the thoracic spine (36.7%), followed by lumbar (30.0%). Most patients (126, 53.2%) had a neurological deficit. A significant number of patients had either bullet fragments (34, 14.3%) or bone fragments (31, 13.1%) in the canal on imaging. Nonoperative management was the primary treatment strategy, with only 2 patients requiring decompressive spinal surgery; no patient underwent fusion. Conventional mean arterial pressure (MAP) goals were maintained in 60 patients (25.3%) for a mean of 5.04 ± 1.86 days, and 4 patients (1.7%) received prophylactic antibiotics for spinal injury. Patients with neurological deficits were more likely to have a neurosurgical consultation and were significantly more likely to have MAP goals as part of their management (p < 0.001). The mean hospital length of stay was 11.5 ± 11.4 days with a mean follow-up time of 7.85 ± 14.74 months, suggesting a minimum postinjury survival period. Most patients were discharged home (141, 59.5%) with a mean modified Rankin Scale score of 2.6 ± 1.8.

Conclusions: This study represents the largest continuous series of GSWs to the spine in contemporary literature, suggesting a natural history of survivorship and disability in this patient population and characterizing common treatment paradigms at a major urban trauma center.

In this review article, the authors describe the thought process, alternatives, and approaches to adult spinal deformity. Although fusion of the entire major curve of scoliosis is certainly reasonable and necessary in certain cases, the authors discuss conditions in which shorter constructs may be considered. They also discuss when it is important to fuse both the major and fractional curves and when shorter constructs are not ideal. Factors that favor choosing an upper instrumented vertebral level in the upper thoracic, lower thoracic, or lumbar spine are discussed. Case examples are presented, and decision-making considerations are discussed.

Objective: Symptomatic, low-grade spondylolisthesis is usually well treated by surgical intervention. While some patients obtain less than optimal improvement, low-grade spondylolisthesis deteriorates in a few patients. The purpose of this study was to investigate what factors predict deterioration in back pain scores after surgical treatment of low-grade spondylolisthesis.

Methods: The Quality Outcomes Database (QOD) was queried for patients who underwent single-level surgery for management of grade 1 spondylolisthesis, including decompression with fusion and decompression alone. Patient-reported outcomes (PROs) were collected at baseline and then 3 months, 1 year, 2 years, and 5 years postoperatively, including numeric rating scale (NRS) back and leg pain, Oswestry Disability Index (ODI), and EuroQol-5D scores. Patients were categorized based on NRS back pain scores compared to baseline as ≥ 0 (improved or no worse) versus < 0 (worsened). These two groups were compared with respect to factors that predicted postoperative deterioration in NRS back pain scores.

Results: Of 608 cases enrolled, 369 met inclusion criteria for the 24-month cohort. Three hundred twenty-four patients had improved or stable back pain scores (of whom 79% underwent fusion), while 45 reported worse back pain at 24 months (of whom 49% underwent fusion). In the 60-month cohort (n = 429), 376 had improved or stable back pain scores (of whom 81% underwent fusion), while 53 reported worse back pain (of whom 49% underwent fusion). On multivariate analysis, lower baseline NRS back pain scores were associated with back pain deterioration at both time points. Less ODI improvement at 3 months postoperatively and persistent leg pain at 12 months postoperatively were also associated with ultimate deterioration in back pain scores.

Conclusions: Most patients (88%) improved after surgery while deterioration was only reported in a few patients (12%). Patients with better back pain scores at baseline were more likely to report deterioration in back pain scores at 2 and 5 years postoperatively. There also appeared to be a trend toward deterioration in those who underwent decompression alone without fusion. These findings highlight the risks of operating on patients with less severe symptoms, as well as the need to improve the understanding of which patients would benefit from fusion. Persistent leg pain and less ODI improvement were also associated with deterioration in back pain scores.