Journal of neurosurgery. Spine最新文献

Objective: Lumbar spinal fusion is a common intervention performed for the treatment of degenerative spinal disease. Recent literature has identified disparities in lumbar fusion outcomes relative to socioeconomic status; however, the underlying mechanisms remain unclear. The authors hypothesized that access to primary healthcare services could be significantly associated with increased complications and reoperation rates in patients undergoing elective lumbar fusion. They sought to assess the association of low access to primary healthcare with readmissions, reoperations, and complications following spinal fusion.

Methods: All adult patients who underwent open and minimally invasive lumbar spine fusion procedures at a single institution between 2011 and 2023 were retrospectively identified using Current Procedural Terminology and ICD-9/-10 codes. Patient addresses underwent geospatial analysis to retrieve census tract codes. Medically underserved area (MUA) designations for census tracts were made according to the Health Resources Services Administration. MUA designation is calculated based on access to primary care services in a designated census tract. Both matched analysis and multivariate analyses were performed to assess the effect of residence in an MUA and other variables on readmission and reoperation rates.

Results: A total of 1567 operations were included. The median age at the time of surgery was 64 (56-70) years, and 154 (9.8%) resided in an MUA. In multivariate regression adjusting for clinical and other socioeconomic variables, low access to care was associated with increased odds of 30-day (OR 1.86, 95% CI 1.13-2.97; p = 0.011) and 90-day (OR 1.84, 95% CI 1.20-2.77; p = 0.004) readmissions. After exact matching by age, race, Area Deprivation Index, surgical characteristics, income, and comorbidity burden, patients with low access to care had increased rates of readmission due to surgical complications within 30 days (13% vs 4.6%, p = 0.002) and 90 days (15% vs 7.4%, p = 0.011) and had increased rates of reoperation within 30 days (9.1% vs 3.7%, p = 0.024) and 90 days (12% vs 5.1%, p = 0.015).

Conclusions: The authors' results suggest that access to a primary care provider could be an underlying driver of disparities in lumbar fusion surgery complications. Utilization of this novel metric might serve as a useful tool for preoperative risk stratification and represent an opportunity for optimization to minimize unplanned readmissions.

Objective: While preoperative embolization (PrE) is known to reduce blood loss during spinal surgery for histopathologically hypervascular metastases, its efficacy in nonhypervascular spinal metastases remains underexplored. This study aimed to evaluate the effectiveness of PrE in patients with nonhypervascular spinal metastatic tumors, focusing primarily on estimated blood loss (EBL) and secondarily on perioperative outcomes.

Methods: This retrospective study included 152 patients diagnosed with nonhypervascular thoracolumbar spinal metastases who underwent surgery between January 2018 and December 2022. Propensity score matching was performed to balance surgical indications and clinicodemographic characteristics, resulting in 55 matched pairs (110 patients) with or without PrE. Surgical outcomes (overall EBL, perioperative blood transfusion, operation time, reoperation rate, massive EBL [defined as ≥ 2500 mL], and 30- and 90-day mortality) were compared. Prespecified subgroup analyses were also conducted.

Results: The matched PrE group had significantly lower overall EBL (median 600 [IQR 300-1200] mL) compared with the matched non-PrE group (median 900 [IQR 500-1800] mL) (p = 0.02). The incidence of massive EBL was also lower in the PrE group (3 patients [5.5%]) than in the non-PrE group (10 patients [18.2%], p = 0.03; OR 0.26 [95% CI 0.06-0.91]). No significant differences were observed between groups regarding perioperative transfusion, operation time, reoperation rate, 30-day mortality, or 90-day mortality. However, 1 case of PrE-related spinal cord infarction occurred. Subgroup analyses revealed that PrE was more effective in reducing massive EBL among patients with hyperenhancement on preoperative CT-digital subtraction angiography and those undergoing highly invasive surgery (pinteraction = 0.02 and 0.03, respectively).

Conclusions: After adjusting for clinicodemographic factors, PrE was associated with reduced EBL in patients with nonhypervascular thoracolumbar spinal metastases. Moreover, patients with radiological hyperenhancement or undergoing highly invasive surgery may derive greater benefit from PrE in mitigating massive EBL.

Objective: Pedicle screw placement in the cervical spine is a very demanding technique that may lead to critical complications due to the surrounding neurovascular structures. The aim of this investigator-initiated study was to test whether radiation-free, MRI-based, synthetic CT (sCT)-guided spinal navigation is noninferior to CT-guided spinal navigation in terms of safety and accuracy of cervical pedicle screw placement in a cadaveric model.

Methods: The cervical spines of 5 cadavers were scanned with both thin-slice CT and the sCT-MRI sequence. From MRI, sCT scans were artificial intelligence-generated with a previously validated model. Preoperatively, screw trajectories were planned on both CT and sCT. Four spine surgeons performed surface matching and navigated Kirschner wire placement from levels C2 to T2 bilaterally. Randomization (1:1 ratio) was performed for modality, surgeon, and side. Postoperative CT scans were acquired and virtual screws with predefined sizes were projected on the wires. Distance and angulation between intra- and postoperative virtual screw positions were analyzed. Medial and lateral breaches were assessed by an independent researcher using the Gertzbein-Robbins classification, with grades A and B considered satisfactory (< 2 mm).

Results: Eighty virtual screws were planned. Surface matching was successful in 75 virtual screws (94%). For planning with both modalities, the mean (SD) distance between planned screw trajectories was 1.3 (SD 0.9) mm and 9.2° (SD 4.7°) for the maximum angulation. The mean distance between intra- and postoperative virtual screw positions was 2.2 (SD 1.4) mm for CT and 2.3 (SD 1.9) mm for sCT (p > 0.05). The mean angulation was 4.6° (SD 2.5°) for CT and 5.4° (SD 2.9°) for sCT (p > 0.05). Of the CT-guided virtual screws, 84% were grade A, 13% grade B, and 3% grade C. Of the sCT-navigated virtual screws, 86% were grade A and 14% grade B.

Conclusions: A complete radiation-free cervical pedicle screw navigation using MRI-based synthetic CT scans in a cadaveric experiment is feasible and as safe and accurate as conventional CT-guided navigation.

Objective: Endoscopic management of L4-5 rostrally migrated lumbar disc herniation (LDH) poses technical challenges. The aim of this study was to compare the clinical outcomes and safety profiles of percutaneous endoscopic transforaminal discectomy (PETD), percutaneous endoscopic interlaminar discectomy (PEID), and unilateral biportal endoscopic discectomy (UBED) for treating this condition.

Methods: A retrospective analysis of 81 patients who underwent PETD (n = 19), PEID (n = 36), or UBED (n = 26) from April 2019 to October 2022 at a single center was conducted. Over a 24-month follow-up, clinical evaluations included the visual analog scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopaedic Association (JOA) scores, as well as the modified MacNab criteria. Surgical parameters, facet joint integrity, and paraspinal muscle loss were analyzed.

Results: All three groups demonstrated significant postoperative improvement in VAS (low back pain and leg pain), ODI, and JOA scores. The UBED group had higher VAS scores for incision pain compared with the other two groups. Within 1 week after the procedure, both the PEID and UBED groups had lower VAS scores for leg pain and higher JOA scores. Notably, the PEID group exhibited the lowest ODI at the 1-week follow-up. At the final follow-up, no significant differences were observed in VAS, ODI, and JOA scores among these groups. No significant differences were observed in modified MacNab evaluation, complication rates, recurrence rates, or the loss ratio of paraspinal muscles. However, PEID and PETD demonstrated advantages in operative time, total incision length, intraoperative blood loss, fluoroscopy injection time, duration of the postoperative hospital stay, total hospitalization expenditure, and serum C-reactive protein and creatine phosphokinase levels. PEID showed optimal performance in preserving the integrity of L4-5 facet joints.

Conclusions: PETD, PEID, and UBED demonstrated comparable and satisfactory long-term efficacy in treating rostrally migrated L4-5 LDH over a 2-year follow-up period. PEID emerged as the preferred approach for early postoperative recovery, offering superior preservation of L4-5 facet joint integrity and reduced surgical invasiveness.

Objective: Hundreds of thousands of Americans undergo decompression for lumbar spinal stenosis annually. The mild (minimally invasive lumbar decompression) procedure was developed as a potentially less invasive alternative to open decompression; however, much of the evidence has been gathered from industry-sponsored studies. The present study sought to compare real-world clinical outcomes between the mild procedure and open decompression for lumbar spinal stenosis.

Methods: All patients who underwent the mild procedure at a single-institution, multisite, tertiary care center from 2005 to October 2024 were included. One-to-one propensity score matching was used to identify patients who underwent open decompression at the same institution, with age, sex, smoking, and comorbidities as covariates. Primary outcomes were change in pain on the numeric rating scale (NRS), surgical reoperation, and perioperative complications. For pain, the minimal clinically important difference (MCID) was defined as a 30% improvement in NRS score.

Results: A total of 175 patients who underwent the mild procedure (mean age 76.3 ± 8.7 years; 44.6% female) were matched to 175 patients treated with open decompression (mean age 75.4 ± 8.7 years; 44.0% female). Among patients with at least 60 days of follow-up, those treated with open decompression were more likely to achieve the MCID for pain (43.1% vs 22.2%, p < 0.001). Patients treated with mild were more likely to require reoperation (46.2% vs 29.3%, p = 0.008). Those who underwent the mild procedure experienced lower rates of durotomies (0% vs 2.9%, p = 0.024) but had higher rates of neurological deficits (6.3% vs 0.6%, p = 0.003).

Conclusions: For patients with symptomatic lumbar stenosis, those who underwent open decompression were more likely to achieve pain improvement and less likely to require reoperation compared with those who underwent the mild procedure.

Objective: Depression and anxiety affect 10%-20% of the population, are leading causes of nonfatal disease, and are underdiagnosed globally. Mental health can play a significant role in surgical outcomes, including treatment of degenerative spinal conditions. Understanding the relationships between mental health and spinal surgery outcomes is critical for optimizing perioperative care.

Methods: Consecutive patients without a prior diagnosis of anxiety or depression and scheduled to undergo single-level lumbar fusion surgery were prospectively administered a quality of life survey, the EQ-5D tool (n = 1771). The EQ-5D anxiety/depression score (EAS) (subscore range 1-3) was calculated for each patient. Coarsened exact matching was used to perform a 1:1 match of patients with the highest EAS to those with the lowest EAS while controlling for patient characteristics known to impact outcomes. Primary outcomes included intraoperative durotomy, length of stay, discharge disposition, and 30- and 90-day emergency department (ED) visits, readmissions, reoperations, and mortality.

Results: After exactly matching patients with an EAS of 3 and 1, an elevated risk of anxiety and depression (EAS 3, n = 85 vs EAS 1, n = 85) was associated with significantly increased duration of hospital stay (4.03 days vs 3.23 days, p < 0.001), nonhome discharge (OR 3.28 [95% CI 1.40-7.66], p = 0.004), 30- and 90-day readmission (OR 5.0 [1.10-22.82], p = 0.021 and OR 3.66 [1.02-13.14], p = 0.033, respectively), and 90-day ED visits (OR 9.0 [1.14-71.03], p = 0.011). No significant differences in durotomy rates or 30- or 90-day reoperation rates existed between cohorts.

Conclusions: Risk of undiagnosed depression and anxiety, as measured by the EAS, is associated with greater odds of short-term postoperative healthcare utilization, but not rate of durotomy or reoperation. Depression and anxiety screening tools, such as the EAS, may help guide targeted risk-mitigation strategies among patients undergoing spinal fusion surgery.

Objective: The implementation of robotics and spinal anesthesia (SA) in spine surgery is rapidly expanding, offering significant benefits for an increasingly complex and aging patient population with degenerative spinal disease. Here, the authors present the largest cohort to date evaluating the combined use of these two techniques in minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF).

Methods: The authors retrospectively analyzed surgical outcomes of a series of patients who underwent robot-assisted (RA)-MIS TLIF under SA and general anesthesia (GA) at their institution from 2018 to 2024. Primary outcomes included operative times and postoperative pain intensity. Secondary outcomes included estimated blood loss, intraoperative complications, postoperative functional status, length of stay (LOS), and discharge status. To address potential confounders, a 1:1 propensity score-matching and regression analysis was implemented. Statistical analyses were conducted using Python.

Results: A total of 209 patients underwent RA-MIS TLIF, with 31 (14.83%) receiving SA and 178 (85.17%) GA. After propensity score matching, the SA cohort demonstrated significantly shorter median total operating room (OR) time, total procedure time, time from entering the OR to skin incision, and time from closure to leaving the OR (all p < 0.01). Additionally, postoperative pain scores were significantly lower (p < 0.01), and LOS was significantly shorter (p < 0.01) in the SA cohort. Regression analysis, adjusting for potential confounders, further supported these findings.

Conclusions: RA-MIS TLIF fusion under SA is a safe and effective approach that significantly reduces operative time, postoperative pain, and hospital LOS in patients undergoing surgery for degenerative lumbar spine disease.

Objective: Erector spinae plane block (ESPB) is a relatively new regional analgesic technique used during spine surgery. Its role in anterior lumbar surgery remains unknown. The aim of this study was to evaluate the effectiveness of ESPB in reducing perioperative pain, opioid use (OU), and hospital length of stay (LOS) in patients undergoing anterior-only lumbar surgery.

Methods: This is a retrospective study of consecutive patients who underwent spine surgery from January 2020 to December 2024 at a single center. Patients were grouped based on ESPB administration. Outcomes included the in-hospital self-reported pain score, OU measured in morphine milligram equivalents (MMEs), time to ambulation, LOS, and opioid-related complications.

Results: Overall, 179 patients (mean age 55.9 years) who underwent spine surgery with or without ESPB were included in the analysis. Both groups were similar at baseline except for lower preoperative OU in the ESPB group (23.0% vs 36.7%, p = 0.045). The multivariable analysis showed that ESPB was associated with a lower pain score on the day of surgery (β = -0.56, p = 0.035), as well as early ambulation (β = -4.44, p = 0.015) and LOS (β = -0.61, p = 0.022). Older age and preoperative OU were associated with lower OU overall; older age and multilevel surgery were associated with a longer time to ambulation; and female sex and multilevel surgery were associated with a higher pain score on the day of surgery. A subset of patients in the ESPB group with a shorter LOS (< 2 days) had earlier ambulation, a lower MME and pain score on POD 1, and a lower inpatient MME (p < 0.0001). In another ESPB subgroup, baseline OU was associated with higher incidence of urinary retention and high inpatient OU, including the total daily MME (p = 0.001), in-hospital total MME (p = 0.034), and POD 1 total and average MME (p = 0.003, p = 0.021, respectively).

Conclusions: These findings suggest that ESPB is a valuable adjunct to anterior-only lumbar surgery, demonstrating its effectiveness in reducing pain scores on the day of surgery while also facilitating early ambulation and shortened LOS. Patients who received ESPB and had shorter hospital stays were found to have reduced OU and early ambulation. In the ESPB group, baseline OU was associated with higher inpatient OU and urinary retention.

Objective: Naloxegol, a peripherally acting mu-opioid receptor antagonist, is used to treat opioid-induced constipation. However, its effectiveness following adult spinal deformity surgery remains poorly understood. The objective of this study was to examine naloxegol's impact on postoperative bowel function in patients undergoing adult spinal deformity surgery.

Methods: A retrospective analysis was conducted of consecutive spinal deformity surgeries from a single surgeon's practice, comparing outcomes before and after the introduction of universal postoperative naloxegol administration (12.5 mg daily for 7 days). Multivariable logistic regression and propensity score-matched analyses were used to evaluate the relationship between naloxegol use and markers of postoperative ileus (POI).

Results: Two hundred thirty-four patients (72.2% female, mean age 60.7 [SD 15.8] years, mean BMI 28.8 [SD 5.1]) were analyzed. One hundred fifty-four (65.8%) of these patients were opioid-naïve and 80 (34.1%) received naloxegol. The naloxegol group had significantly lower odds of lateral lumbar interbody fusion (OR 0.13, p = 0.0001) and shorter operative times (5.65 vs 6.75 hours, p = 0.0008). There was no statistical association between naloxegol and postoperative abdominal imaging, nasogastric tube placement, or gastroenterology consultation in either the matched or multivariate analyses (p > 0.05). A gastroenterology consultation (n = 15 patients, 6.5%) was positively associated with anterior lumbar interbody fusion (OR 5.54, p = 0.010) and diabetes (OR 12.37, p = 0.001) and negatively associated with preoperative opioid use (OR 0.18, p = 0.036). Postoperative abdominal imaging correlated positively with the number of vertebrae fused (OR 1.09, p = 0.031) and negatively with preoperative opioid use (OR 0.44, p = 0.026). Weighted time-to-event analysis found a difference in time to first flatus (p = 0.0282), but not in time to bowel movement (p = 0.5600) with naloxegol.

Conclusions: Postoperative naloxegol had no significant impact on bowel function recovery or markers of POI after spinal deformity surgery. Patients with a history of opioid exposure required fewer consultations and imaging. Further research is required to understand whether pre-induction administration impacts POI and return to bowel function.