Journal of neurosurgery. Spine最新文献

Objective: The purpose of this study was to propose a refined coronal classification with subgroup analysis of degenerative scoliosis (DS) patients with a type A coronal pattern and to ascertain its implications on postoperative coronal imbalance (CIB).

Methods: A total of 239 DS patients who underwent spinal correction surgery were recruited for this study. Patients were divided into types A, B, and C based on the Nanjing CIB classification system. Patients with type A CIB were further divided into three subtypes according to the coronal balance distance (CBD) and the trunk inclination tendency: type Aa, CBD ≤ 1 cm; type Ab, CBD > 1 cm and C7 plumb line (C7PL) shifted to the concave side of the curve; and type Ac, CBD > 1 cm and C7PL shifted to the convex side. Scoliosis Research Society-22 questionnaire scores were analyzed, and the incidence of postoperative CIB was compared across groups.

Results: The incidence of postoperative CIB was 23% (32/139) in the type A group, 18% (11/60) in the type B group, and 58% (23/40) in the type C group (p < 0.001). Among patients with type A coronal alignment, 54 patients had type Aa, 46 had type Ab, and 39 had type Ac. After surgery, 32 patients had postoperative CIB, with 5 (9%) patients in the type Aa group, 5 (11%) patients in the type Ab group, and 22 (56%) patients in the type Ac group. Postoperative coronal malalignment was found to be more prevalent in type Ac patients (p < 0.001).

Conclusions: Patients with type Ac CIB are at greater risk of postoperative CIB following surgery compared with patients with type Aa or Ab alignment. The modified CIB classification highlights the high risk of CIB in type Ac, similar to the type C CIB pattern. These findings provide a more comprehensive delineation of coronal alignment phenotypes and introduce a refined system for stratifying the risk of postoperative CIB.

Objective: Lordotic devices have garnered increased attention for improving the segmental lordosis (SL) achieved with transforaminal lumbar interbody fusion (TLIF). However, it is unclear the degree to which surgeons maximize the "ideal" or listed lordosis of the interbody device.

Methods: Patients undergoing one- or two-level TLIF for degenerative pathologies were identified and data were extracted on demographics, baseline lumbopelvic radiographic parameters, and TLIF details. The primary outcome of interest was the degree to which postoperative SL approximated the listed cage lordosis (Δtarget). Change in SL was a secondary outcome. Linear mixed-effects modeling was used to identify significant predictors of the percentage of ideal lordosis achieved.

Results: A total of 239 treated levels were included (median patient age 66.6 years; 56.9% female); 151 levels were part of single-level TLIF constructs. The median segmental corrections were a 2.8° increase in SL and 2.8 mm in disc height. The median difference between listed cage lordosis and postoperative SL (Δtarget) was 0.5°. However, only 56.1% of levels achieved at least the listed cage lordosis. Linear mixed-effects modeling found that independent predictors of Δtarget were lower implant lordosis (estimate -1.01° [95% CI -1.15° to -0.87°] per degree, p < 0.001), greater preoperative SL (estimate 0.38° [95% CI 0.28°-0.48°] per degree, p < 0.001), greater preoperative PI (estimate 0.06° [95% CI 0.02°-0.11°] per degree, p = 0.007), and closer approximation of the anterior apophyseal ring of the caudal vertebrae (estimate -0.27° [95% CI -0.39° to -0.15°] per mm, p < 0.001). Similarly, independent predictors of postoperative SL were larger implant lordosis (estimate 0.16° [95% CI 0.05°-0.27°] per degree, p = 0.004), lower preoperative SL (estimate -0.70° [95% CI -0.79° to -0.62°] per degree, p < 0.001), greater preoperative PI (estimate 0.08° [95% CI 0.04°-0.12°] per degree, p < 0.001), and closer approximation of the anterior apophyseal ring of the cranial vertebrae (estimate -0.15° [95% CI -0.28° to -0.03°] per mm, p = 0.014).

Conclusions: The present results suggest that while lordosing, only 56% TLIF operations obtain the listed interbody lordosis ("target" lordosis). Anterior placement within the disc space is the only modifiable intraoperative technical factor for maximizing lordosis for a given interbody, highlighting the importance of effective disc space exenteration.

Objective: Cervical disc arthroplasty (CDA) is an emerging procedure aimed at addressing cervical disc degeneration while preserving motion at the affected spinal segment. This study examined how frailty, measured by the Hospital Frailty Risk Score (HFRS), affects in-hospital outcomes and readmissions post-CDA.

Methods: The authors conducted an analysis of the US Nationwide Readmissions Database (2016-020) for adults undergoing CDA. Patients were categorized by HFRS into higher and lower risk groups. The study outcomes included in-hospital mortality, complications, and readmission rates at 30 and 90 days. Propensity score matching and logistic regression analyses were used to determine the associations.

Results: After matching, data from 1017 patients (higher frailty risk: 339; lower frailty risk: 678) were analyzed, representing a total of 1726 individuals in the entire US after weighting. Compared with patients at lower risk, those at higher frailty risk had significantly higher risks of complications (OR 3.57, 95% CI 2.60-4.91). Specific complications included dysphagia (OR 3.79, 95% CI 2.41-5.96), infections (OR 2.56, 95% CI 1.55-4.24), urinary tract infections (OR 5.97, 95% CI 2.94-12.15), and cerebrovascular accidents (CVAs; OR 8.03, 95% CI 3.58-18.02) (all p < 0.001). However, frailty did not significantly affect 30-day or 90-day readmission rates. The most frequent readmission diagnoses were spondylopathies (30-day: 17.2%; 90-day: 24.2%), followed by complications of other surgical or medical care, and septicemia.

Conclusions: This study shows that frailty, assessed by HFRS, significantly raises the risk of postoperative complications in patients undergoing CDA in US hospitals. These findings emphasize the need for preoperative evaluation of frailty for optimizing postsurgical care.

Objective: Spinal metastases pose a significant challenge in oncology, with incidence rates increasing alongside improved survival rates. Radiation therapy (RT) has played a crucial role in managing spinal disease progression and reducing associated neurological morbidity. However, management of spinal metastases for which prior RT failed is challenging, and there are limited data regarding the safety and efficacy of stereotactic body radiotherapy (SBRT) for reirradiation. The authors present the largest series to date of patients undergoing SBRT for reirradiation of spinal metastases.

Methods: The medical records of patients treated with spine SBRT for reirradiation at a target that overlapped or abutted a previous radiation field between 2010 and 2021 were retrospectively reviewed. The cumulative constraint to the neural avoidance structures was a biologically effective dose with an α/β value of 3 of 75 Gy (above the conus) or 106 Gy (below the conus), accounting for 25% repair at 6 months and 50% repair at 1 year following the first course of RT. Radiographic local recurrence was defined according to Spine Response Assessment in Neuro-Oncology criteria as progressive disease in the treatment volume or at the margin of the treatment field on CT or MRI compared with imaging studies before SBRT. Cumulative incidence of local recurrence was reported with death as a competing event, and overall survival was estimated using Kaplan-Meier analysis. Toxicity grades were determined according to National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0.

Results: A total of 224 vertebral segments from 89 lesions treated with SBRT reirradiation in 83 patients were included in this analysis. The median age at SBRT reirradiation was 63 years, with a median follow-up of 8.0 months. The most common primary cancer types were non-small cell lung cancer (18%), gastrointestinal cancer (16%), renal cell carcinoma (15%), and prostate cancer (15%). Lesions predominantly occurred in the thoracic spine (52%). The median time between initial RT and SBRT reirradiation was 15.4 months. Prior radiation techniques included 3D or 2D conformal RT (52%), SBRT (43%), and intensity-modulated radiotherapy (4%). Reirradiation SBRT prescription doses varied by fractionation, with a median planning target volume of 179.1 cm3. Immunotherapy use was associated with improved local control and, notably, no increase in toxicity. No cases of radiation myelopathy were observed.

Conclusions: SBRT reirradiation for progressive or recurrent spinal metastases appears to be a safe and effective treatment option, offering durable local control and pain relief with low toxicity. Future prospective and multi-institutional studies are warranted to validate these findings.

Objective: The objective of this study was to quantify the perioperative postural imbalance of subjects with degenerative cervical myelopathy (DCM) and to identify associated factors.

Methods: This prospective study included consecutive subjects with DCM (n = 70) and cervical radiculopathy (i.e., controls) (n = 20) who were managed surgically according to standard of care guidelines. The DCM and control subjects had similar demographic characteristics. Eligible patients with DCM were 18 years or older with a modified Japanese Orthopaedic Association (mJOA) score ≤ 16. Control patients had mJOA score ≥ 17 without signs of myelopathy. All included subjects had a minimum 6-month postoperative follow-up. Postural balance was measured using force plate assessments during quiet upright standing. Specific measures were used to assess the trajectory of the center of pressure (CoP), including the 95% confidence ellipse area (EA), root mean squared CoP excursion (RMSml), and mean CoP velocity (MVEL). Multivariate analyses were performed to identify factors associated with changes in postural balance after surgery.

Results: Postoperative assessments revealed significant improvements in EA (p < 0.001), RMSml (p < 0.001), MVEL (p < 0.001), numerical rating scale (NRS) scores for neck pain (p < 0.001), and mJOA scores at both 6 and 12 months (p < 0.001). Multivariate regression showed that baseline balance measures were strong predictors of the degree of postoperative stability improvement (p < 0.001). Baseline NRS scores for neck pain independently influenced postural balance recovery at 6 months (p < 0.05) but not at 12 months.

Conclusions: The authors' study identified significant improvement in postural balance at 6 and 12 months after decompressive surgery for DCM, particularly in patients with more profound initial imbalance. Baseline postural balance and neck pain both significantly predicted the degree of functional lower extremity recovery, indicating their potential relevance as prognosticating measures.

Objective: Mid- to long-term data on the natural history of degenerative lumbar spinal stenosis (LSS) remain limited as surgery is increasingly favored. The aim of this study was to characterize the prevalence of clinical deterioration over long-term follow-up and to identify risk and protective factors.

Methods: In this retrospective cohort study, adult patients with symptomatic LSS and a follow-up period ≥ 5 years were analyzed. Clinical deterioration was defined by at least one of the following factors: myotomal lower limb weakness, sphincter disturbance, or a decrease in walking tolerance to ≤ 10 minutes due to neurogenic claudication. Radiological assessment included standing lumbar radiographs and lumbosacral MR images obtained after symptom onset. A univariate analysis was performed, with variables demonstrating significance levels of p < 0.1 included in the subsequent multivariable logistic regression analysis. Receiver operating characteristic (ROC) curves and Kaplan-Meier survival curves were plotted for statistically significant risk factors.

Results: A total of 202 patients with symptomatic LSS and adequate follow-up were included. The mean age was 65.2 ± 4.2 years at the onset of neurological symptoms and the mean follow-up duration was 121 ± 40 months. Clinical deterioration occurred in 39 patients (19.3%). Among those with deterioration, 36 (92.3%) reported reduced walking tolerance due to neurogenic claudication, 8 (20.5%) had myotomal weakness, and 2 (5.1%) experienced sphincter disturbance. Upon multivariate analysis, the presence of lumbar developmental spinal stenosis was a risk factor for deterioration (p = 0.031), while an increased dural sac area was protective (p = 0.045); adjusted hazard ratios were 10.11 and 0.98, respectively. A dural sac area < 55 mm2 had an area under the ROC curve of 0.781 for predicting clinical deterioration within 5 years of symptom onset.

Conclusions: Patients with lumbar stenosis and neurogenic claudication mostly remained ambulatory without developing motor deficits or sphincter dysfunction. Conservative management is an option for patients with tolerable symptomatology and low functional expectations, especially in the absence of the identified risk factors of developmental narrowing of lumbar canal dimensions and critically reduced dural sac area over the most stenotic level.

Objective: The evidence on ankylosing spinal disorders (ASDs), including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), in the context of spinal fracture stems from studies with relatively small sample sizes. There are no studies addressing the patient-reported outcome measures (PROMs) and health-related quality of life (HRQOL) outcomes associated with spinal fracture in this population. The aim of this study was to investigate differences in complications, mortality, PROMs, and HRQOL in patients with and without ASD who had been treated for spinal fracture.

Methods: This is a nationwide multicenter retrospective study of prospectively collected data from the Swedish Fracture Register. All patients with fractures of the cervical, thoracic, or lumbar spine treated surgically and conservatively between January 2015 and December 2021 were eligible for inclusion. Two groups of patients were formed based on the presence or absence of concomitant ASD. Primary outcomes of interest included death and PROMs. For surgically treated patients, data on complications and reoperation rates were retrieved. Propensity score matching with a ratio of 1:1 was used to balance the groups prior to intergroup comparison. Variables included in the matching process were age, sex, mechanism of injury, neurological function on admission (Frankel grade), injury type (high vs low energy), fracture type, injured spinal level, time to treatment, and type of treatment (surgical vs conservative). Kaplan-Meier analyses were used to study overall survival following injury.

Results: A total of 14,604 patients without ASD and 1368 patients with ASD were included in this study. High-energy injuries were less frequent in patients with ASD (13% vs 24%, p < 0.001). Moreover, patients with ASD were less likely to be neurologically intact on admission (90% vs 94%, p < 0.001). There were 1707 surgically treated patients without ASD and 559 with the disorder. After matching, a higher overall risk of reoperation was found among patients with ASD (9.1% vs 3.4%, p = 0.007). Surgical site infections requiring reoperation (p = 0.012), but not construct failure or CSF leakage requiring reoperation (p ≥ 0.05), were more common among the patients with ASD. Postmatching, there were no differences in overall survival between ASD and non-ASD cases (p > 0.05). Moreover, patients with and without ASD had similar PROMs, as indicated by the EQ-5D-3L index at 1 year after injury (p = 0.59).

Conclusions: Self-reported recovery 1 year after spinal fracture occurred to a similar extent in patients with and without ASD. Moreover, ASD alone was not a significant risk factor for death. Finally, surgically treated patients with ASD experienced higher rates of postoperative complications and reoperations following surgery.

Objective: Spondylodiscitis is classically believed to reflect intravenous drug use in urban centers, hemodialysis-associated complications, and generalized poor medical care, but these associations may be more complex and reflect underlying systemic societal problems. The authors sought to characterize socioeconomic and demographic elements associated with spondylodiscitis to better understand community factors placing patients at risk of this infection.

Methods: All cases of spondylodiscitis at an urban, tertiary-level academic hospital since 2015 were surveyed. The zip code of residence for all patients with spondylodiscitis was captured and a referral map of the authors' urban center was created, demonstrating whether these areas had spondylodiscitis cases as well as the case density. A validated database of public data was used to compare demographic and socioeconomic factors between zip codes with and without cases of spondylodiscitis.

Results: Two-hundred sixty-two cases with complete datasets between September 2015 and July 2021 were identified. Thirty-seven of the 56 zip codes within the authors' urban center had discitis cases, ranging from 1 to 4 (median 2) per zip code. Zip codes with spondylodiscitis cases had a higher median housing density (2.4 vs 1.8, p = 0.004), higher percentage of minority residents (59.0% vs 31.9%, p = 0.011), greater proportion of residents younger than 20 years (26.8% vs 16.2%, p = 0.001), higher rates of residents below the poverty level (17.4% vs 8.8%, p = 0.007), lower median annual income ($52,193 vs $103,173, p < 0.001), lower median rent and home value (p < 0.001 and p = 0.021, respectively), and lower rates of high school graduation and higher education (both p < 0.001).

Conclusions: This is the first time that the incidence of spondylodiscitis has been demonstrated to be strongly associated with regions of poverty and worse socioeconomic indicators, independent of healthcare referral patterns. Long-term interventions may depend on improving general living conditions for this at-risk population.

Objective: Variations exist among surgeons in the treatment of recurrent lumbar disc herniation (LDH), generating major issues in decision-making models. The authors aimed to identify international nuances in surgical treatment patterns, highlight the differences in responses in each country group and different treatment trends across countries, and identify factors that influence surgical decisions.

Methods: An online survey with preformulated answers was submitted to 292 orthopedic surgeons and 223 neurosurgeons from 16 countries regarding 3 clinical vignettes (recurrence without low back pain, recurrence with severe low back pain, and recurrence with 2-level disc disease). The variability for each country was calculated according to the index of qualitative variation (IQV; ranging from 0 [no variability] to 1 [maximum variability]). To integrate the surgeons' perspectives, 2 Likert-type queries were submitted concerning the specific criteria for fusion and overall decision-making for each clinical case.

Results: Except for the case of first recurrence with pure radiculopathy without instability or inflammatory disc disease, where the variability was low (mean IQV 0.24, redo discectomy 86.2%), the other cases showed high variability (mean IQV range 0.63-0.71), with frequent proposals for surgery with implants. For countries with low variability, a high rate of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) procedures (55.3%) and low rates of anterior/combined procedures (5.9%) and posterolateral fusion (4.9%) were observed. For countries with high variability, a lower rate of PLIF/TLIF procedures was observed (33.1%), with alternate proposals for anterior/combined procedures (20.8%) and posterolateral fusion without interbody fusion (12.8%). Orthopedic surgeons performed significantly more procedures with implants compared with neurosurgeons (p < 0.01). Age, practice type, and the annual number of surgery cases did not play a significant role in the choice of procedures. The most important criteria for fusion were lumbar pain symptoms associated with radiculopathy (77.9% strongly agreed) and the existence of inflammatory disc disease (73.0%). Furthermore, 62.1% of the respondents strongly agreed with performing fusion for all second recurrences. For the final decision, surgeons agreed with following the literature (81.9%), selecting low-morbidity procedures (78.6%), and using a familiar technique (78.6%). Patient preference was an important and/or very important decision factor for 64.1% of respondents.

Conclusions: Significant differences existed between spine surgeons in the surgical treatment of recurrent LDH. Intra- and intergroup variations were observed, reflecting the lack of consensus in the literature and the challenge of adapting differences in habits and training to the few existing guidelines.

Objective: The objective of this study was to introduce and evaluate foraminoplastic inferior pedicle subtraction osteotomy (FiPSO), a novel technique that involves downward resection of the pedicle and vertebral body, aimed at addressing rigid lower lumbar kyphosis.

Methods: The clinical records were reviewed of the patients who underwent corrective surgery from January 2012 through December 2021 for adult spinal deformity using a combination of procedures: pedicle subtraction osteotomy (PSO) at the lumbar level and spinopelvic fixation. Inclusion criteria included patients older than 40 years with sagittal imbalance symptoms and significant radiographic findings: sagittal vertical axis (SVA) > 50 mm, pelvic tilt (PT) > 25°, or pelvic incidence (PI) minus lumbar lordosis (LL) > 10°. Patients were categorized into three groups: L1-3 PSO, L4-S1 PSO, and FiPSO. The authors assessed thoracic kyphosis, LL, lower LL (LLL), PI, PT, sacral slope, SVA, global tilt (GT), and Global Alignment and Proportion (GAP) score preoperatively, postoperatively, and at the last follow-up. Complications were also analyzed.

Results: A total of 65 patients were included in the final analysis: 25 in the L1-3 PSO group, 29 in the L4-S1 PSO group, and 11 in the FiPSO group. The FiPSO group showed significantly larger postoperative LLL (39.2° ± 7.7° vs 29.7° ± 10.7°, p < 0.05) and smaller PI-LL mismatch (9.6° ± 10.3° vs 24.6° ± 13.4°, p < 0.01) compared to the L4-S1 PSO groups. At the last follow-up, the FiPSO group maintained larger LLL (38.3° ± 8.9° vs 27.1° ± 10.0°, p < 0.05), lower PT (23.1° ± 9.9° vs 33.3° ± 10.7°, p < 0.05), and good global sagittal alignment (SVA, 64.0 ± 43.8 mm vs 106.8 ± 55.7 mm, p < 0.05; GT, 28.7° ± 13.9° vs 43.5° ± 15.5°, p < 0.05) compared to the L4-S1 PSO group. The FiPSO group had higher nerve deficits (45%) but lower proximal junctional kyphosis (18%) and revision surgery rates (9.1%) than the L1-3 or L4-S1 PSO groups. However, the differences were not statistically significant.

Conclusions: FiPSO provides effective lower lumbar correction and long-term sagittal alignment with comparable complication rates, offering a valuable option for overcoming the challenges associated with PSO in the lower lumbar spine.