Journal of spine surgery最新文献

Background: Quantitative parameters for the diagnosis of congenital lumbar stenosis (CLS) have yet to be universally accepted. This study establishes parameters for congenital stenosis of lumbar neuroforaminal dimensions (LNFD) using computed tomography (CT), assessing the influences of patient sex, race, and ethnicity.

Methods: Measurements of LNFD were performed on CT scans from 1,000 patients aged 18-35 years without spinal pathology.

Results: Irrespective of vertebral level, mean anatomic LNFD measurements were as follows: 8.66±2.1 and 8.76±3.14 mm for left and right widths, 17.76±2.74 and 17.7±3.26 mm for left and right heights, and 133.12±34.72 and 133.4±33.86 mm² for left and right areas. Threshold values for neuroforaminal stenosis, regardless of vertebral level, were: 4.46 and 2.48 mm for left and right foraminal widths, 12.28 and 11.18 mm for left and right foraminal heights, and 63.68 and 65.68 mm² for left and right foraminal areas. Patient sex, race, and ethnicity highlighted significant findings per vertebral level, but not when considered irrespective of vertebral level.

Conclusions: This study reports measurements of LNFD via CT of 1,000 patients to establish quantitative thresholds for diagnosis of neuroforaminal stenosis. Patient sex, race, and ethnicity highlighted significant findings per vertebral level, but not irrespective of vertebral level. These findings may help solidify anatomic thresholds of foraminal stenosis via radiographic imaging and establish the foundation for future research on the diagnosis of lumbar neuroforaminal stenosis.

Background: Degenerative lumbar scoliosis (DLS) often presents with coronal malalignment due to lumbosacral fractional (LSF) curve deformity. While apical vertebral rotation (AVR) has been recognized as a contributor to spinal deformity, its relationship with global coronal alignment correction remains unclear. This study aimed to investigate the correlation between AVR at the LSF curve and global coronal alignment in DLS patients, both pre- and post-operatively.

Methods: This retrospective study included 144 patients with DLS who underwent spinal fusion surgery with a minimum 2-year follow-up. Radiographic software was used to assess coronal balance distance (CBD), fractional apical vertebral rotation (fAVR), spinopelvic parameters, Cobb angles, and L4/L5 tilt angles. Coronal malalignment was categorized, and change in fAVR (ΔfAVR) were analyzed for correlation with changes in global coronal alignment. Subgroup analyses were conducted based on pelvic incidence (PI) and Bao classification (types A, B, and C).

Results: A significant correlation was found between ΔfAVR and improvement in coronal alignment (r=0.6; P<0.05), with moderate correlations with coronal Cobb angle (r=0.51), L4 tilt (r=0.417), and L5 tilt (r=0.403) (P<0.05 for all). Subgroup analysis revealed a strong correlation in patients with low PI and moderate correlation in high PI patients. By Bao classification, the correlation between ΔfAVR and global coronal alignment was strongest in type C (r=0.87), followed by type B (r=0.656) and type A (r=0.506; P<0.05).

Conclusions: AVR at the LSF curve significantly contributes to the improvement of global coronal alignment in DLS. Axial alignment correction plays a foundational role in restoring coronal balance, emphasizing the importance of precise surgical strategies for matching lumbosacral and lumbar/thoracolumbar curves.

Background: Escherichia coli (E. coli)-derived recombinant human bone morphogenetic protein-2 (rhBMP-2) (NOVOSIS^®, CGbio, Inc., Seoul, Republic of Korea) is increasingly used in selected spinal fusion surgeries to promote bony fusion between vertebrae. Older formulations of rhBMP-2 have been associated with various complications, including vertebral endplate osteolysis, which can complicate the diagnosis and management of postoperative patients. We present the first reported case of vertebral endplate osteolysis associated with E. coli-derived rhBMP-2 using the NOVOSIS^® carrier.

Case description: A 54-year-old man who underwent lumbar spinal fusion surgery. Initially treated for delayed onset postsurgical spondylodiscitis, the diagnosis of rhBMP-2 induced vertebral endplate osteolysis was only established after clinical and radiological reassessment. The patient presented with non-specific lower back pain 3 months after surgery. Initial magnetic resonance imaging (MRI) revealed single-level intradiscal fluid with adjacent endplate erosions, mild disc cage subsidence, marrow edema, and a rim-enhancing fluid collection. Biochemical markers were not convincing for spondylodiscitis and blood cultures were negative. Nonetheless, he was treated empirically with oral antibiotics. The patient showed significant improvement 3 weeks after the initial diagnosis was made, with subsequent imaging findings demonstrating the development of endplate osteolysis and implant subsidence.

Conclusions: This case demonstrates the difficulty in diagnosing rhBMP-2 induced endplate osteolysis as it mimics spondylodiscitis on imaging. Clinicians should consider this complication as a differential diagnosis to avoid unnecessary antibiotic treatment and to improve postoperative monitoring protocols, even with newer rhBMP-2 formulations.

Background: Endoscopic decompression (ED) and microscopic decompression (MD) are newer minimally invasive approaches for surgical treatment of lumbar spinal stenosis (LSS). However, the absence of large, high-quality randomized controlled trials raises concerns for the potential of bias, or spin, in studies evaluating these techniques. This study aims to analyze the prevalence of spin in abstracts of systematic reviews and meta-analyses comparing ED and MD as treatments for LSS.

Methods: Studies were identified using the Preferred Reporting Items for Systematic Reviews and Meta Analysis guidelines searching PubMed, Web of Science (WOS), and Scopus. Articles included were: (I) a systematic review with or without a meta-analysis; (II) degenerative etiology; (III) human subjects; (IV) available in English. Abstracts were graded for incidence of the 15 most common types of spin, and full texts were reviewed using AMSTAR 2 classification. General demographics were identified, including study title, author, journal of publication, year of publication, level of evidence (LOE), study design, and funding. Fisher's exact test was used to compare study metrics.

Results: Ten studies were included, all of which contained at least one type of spin. Spin type 12 ("Conclusion claims equivalence or comparable effectiveness for non-statistically significant results with a wide confidence interval") and type 3 (Selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention) were the most common forms of spin, found in 5/10 (50%) of the included studies. All 10 studies received a confidence rating of "critically low" according to the AMSTAR 2 domain. There were no significant associations between incidence of spin type and year of publication, journal of publication, number of citations, LOE, funding, Clarivate impact factor, or ScopusCiteScore.

Conclusions: Spin is highly prevalent in abstracts of systematic reviews and meta-analyses investigating ED versus MD. All ten manuscripts evaluated received a low quality rating according to the AMSTAR 2 domain.

Background: Postoperative activity restrictions are commonly prescribed after spine surgery. However, it is unclear whether postoperative restrictions improve clinical or surgical outcomes after spine surgery. The primary aim of this study was to investigate the effects of postoperative activity restrictions in spine surgery on patient-reported outcomes. The secondary aim of the study was to assess whether these postoperative activity restrictions were associated with recurrence (reherniation), adverse events, and complications after spine surgery.

Methods: This review included studies discussing degenerative spine surgery patients with postoperative activity restrictions, defined as limitations on specific movements such as bending or twisting, or activities such as driving or weightlifting. Electronic searches were conducted using PubMed, CENTRAL, Embase, and Web of Science databases in November 2024. The Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) and Risk Of Bias In Non-randomized Studies - of Interventions, Version 2 (ROBINS-I V2) tools were used to evaluate included studies for risk of bias. Meta-analysis was initially planned but was not performed due to the heterogeneity of the included studies. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to determine the certainty of the body of evidence.

Results: A total of 3,723 studies were screened. Four studies met the inclusion criteria: one randomized controlled trial and two prospective single-arm cohort studies discussing open lumbar discectomy, and one prospective non-randomized two-group cohort study discussing percutaneous endoscopic lumbar discectomy (PELD). Notably, there are no studies discussing restrictions after cervical or thoracic spinal surgery. Pain, function/disability, and data on recurrence (reherniation), adverse events and complications were collected from each study. The certainty of evidence was low for all outcomes analyzed, making it difficult to provide a definitive conclusion for or against the use of postoperative activity restrictions in spine surgery.

Conclusions: Current literature prevents a definitive conclusion regarding the effectiveness of postoperative restrictions in spine surgery. Future studies should address the limitations and heterogeneity of the current literature to provide the basis for standardized, evidence-based postoperative activity restriction protocols.

Background: Patients with Marfan syndrome (MFS) can experience spinal deformity characterized by thoracolumbar kyphoscoliosis, severe spondylolisthesis, dural ectasia, vertebral body scalloping, and hypoplastic pedicles. These unique anatomical features complicate conventional spinal instrumentation techniques, rendering robotic navigation assistance (RNA) a viable option in such cases.

Case description: A 41-year-old woman diagnosed with MFS presented with progressive mid-thoracic and low back pain spanning over two decades. Imaging revealed characteristic findings of MFS, including severe leftward thoracolumbar kyphotic scoliosis, dural ectasia, hypoplastic pedicles (1 mm), and vertebral body scalloping. Due to debilitating pain and impaired function, a two-stage thoracolumbar fusion was planned. The 1^st stage involved posterior fusion from T10 to S1, along with a planned L2 pedicle subtraction osteotomy (PSO), guided by RNA. RNA enabled accurate placement of juxtapedicular, cortical-bone-trajectory (CBT), and bilateral S2 alar-iliac (S2AI) screws, accommodating the patient's severely hypoplastic pedicles while ensuring adequate fixation. The 2^nd stage occurred one month postoperatively and involved a L3-L5 lateral lumbar interbody fusion (LLIF) and a L5-S1 anterior lumbar interbody fusion (ALIF), also guided by RNA.

Conclusions: At the six-month and three-year follow-ups, the patient reported significant improvements in back pain and functionality, with imaging demonstrating progressive fusion without loosening of the implants. RNA effectively addressed the unique anatomical challenges of hypoplastic pedicles and sacral body scalloping in a patient with MFS-associated spinal deformity. This technology enabled an individualized surgical approach through preoperative planning of instrumentation at each spinal level, allowing for precise placement of juxtapedicular and S2AI screws to achieve stable fixation in anatomically constrained regions.

Background: Anterior cervical discectomy and fusion (ACDF) surgery is a treatment for cervical disk herniation, a condition that may contribute to compression upon the spinal cord or the exiting nerve roots. The primary goals of this surgery are to decompress the neurological structures while stabilizing segments that are either unstable intrinsically or unstable by way of decompression. More recently, total disk arthroplasty (TDA) and anterior decompression has been introduced as an alternative to ACDF. Pneumothorax is caused by air filling the pleural cavity between the parietal pleura and the lung, causing the lung to collapse from the loss of negative pressure in that space, impairing lung function. The development of pneumothorax is a rare event during anterior approaches to the cervical spine, but the authors are not aware of the development during surgery of a pneumothorax contralateral to the side of approach.

Case description: A 27-year-old female patient with cervical disc disease associated with C5-C6 and C6-C7. The patient has a history of smoking, an incomplete right bundle branch block, postural orthostatic tachycardia syndrome, premature ventricular contraction, and fibromyalgia, presented to the operating room for anterior decompression and TDA of C5-C6 and C6-C7 for cervical disk disease. There was no history of soft tissue disease.

Conclusions: During anterior cervical spine surgery, contralateral pneumothorax can occur. This may happen due to the 30-degree positioning, positive pressure ventilation with positive end-expiratory pressure/continuous positive airway pressure, and potential pressure differential separating the tracheoesophageal complex from the pre-vertebral potential space. There are no current preventative measures for pneumothorax during anterior cervical spine surgery with standard techniques, but it is important not to dismiss the condition based solely on initial negative imaging results. Spontaneous contralateral pneumothorax is not commonly recognized as a complication of anterior cervical spine surgery; however, physicians should be aware of the possibility of its occurrence.

Background: Tissue exposed to theatre air is susceptible to evaporative heat and moisture loss. The resulting local hypothermia and desiccation disrupts the internal milieu of the patient and may lead to delayed healing and increase the risk of surgical site infections (SSIs). HumiGard for orthopaedic surgery was developed to deliver warmed, humidified air to an open surgical incision site to mitigate heat and moisture loss from an open wound. This study aims to evaluate the efficacy of surgical humidification in preventing local tissue cooling and desiccation during open spinal procedures by delivering warmed, humidified air (37 ℃, 100% relative humidity) over the surgical site.

Methods: Twenty-eight patients undergoing elective 1-2 level open spinal decompression were equally randomised to receive standard of care (Control) or HumiGard [n=8 for version 1 (V1), n=6 for version 2 (V2)]. The primary outcome was the temperature of the incision site measured at fifteen-minute intervals using a thermal camera.

Results: Surgical wounds in open spinal surgeries cooled significantly, with an average temperature of 32.7±4.0 ℃ at 15 min post-incision and 28.5±0.9 ℃ at 90 min (P<0.01). Intra-operative application of HumiGard facilitated the maintenance of wound temperature near or within the normothermic range (~37 ℃), with an average of 35.4±3.9 (15-min) and 33.5±0.9 ℃ (90-min) with HumiGard V1 and 38.4±1.7 (15-min) and 36.8±1.5 ℃ (90-min) with HumiGard V2. At 15-min post-incision, the average wound temperature with HumiGard V2 was 5.7 ℃ higher than the Control group (P<0.001). This thermal advantage persisted throughout the procedure, resulting in a mean wound temperature difference of 8.3 ℃ compared to the Control group at 90-min (P=0.03). Supplementary observations by surgeons indicated that, with the use of HumiGard tissues appeared subjectively more hydrated, with improved redness, suggesting better preservation of tissue integrity throughout the procedure.

Conclusions: This first in-human randomised controlled trial (RCT) demonstrated that a significant drop in local tissue temperature occurs in the surgical wound during open orthopaedic surgery. Intraoperative use of HumiGard mitigated this issue by delivering localised warmth and humidification, thereby maintaining physiological tissue temperatures throughout open orthopaedic procedures without disrupting the surgical workflow.

Trial registration: ANZCTR: ACTRN12620001321932; UTN: U1111-1257-0011.

Background: Cauda equina syndrome (CES) is a rare but critical surgical emergency, with a global incidence of 1-3 cases per 100,000 annually. Despite its rarity, CES has paradoxically emerged as one of the most common referral diagnoses to tertiary spinal centres. This discrepancy between referral rates and the actual prevalence of CES raises concerns about potential over-referral and inefficiencies in clinical pathways. This study aimed to evaluate compliance with national guidelines from the British Association of Spine Surgeons (BASS) and Getting It Right First Time (GIRFT) concerning the streamlined referral pathways and timely magnetic resonance imaging (MRI) utilisation for suspected CES at a major tertiary spinal centre in the UK.

Methods: A retrospective audit was conducted on all urgent and emergency CES referrals (n=353) received by a tertiary spinal centre via an electronic referral system over a 15-week period (June-September 2023). Electronic patient records were retrospectively reviewed to assess compliance with national CES pathway standards, particularly the proportion of patients receiving MRI scans prior to referral and within 24 hours of symptom presentation. Data analysis was performed using IBM SPSS.

Results: Of the 353 urgent and emergency referrals, 102 (29%) were for suspected CES, but only 6 cases (1.7%) were confirmed and required surgical intervention. MRI scans were completed before referral in 48% of suspected CES cases, with 94% being within 24 hours of presenting with symptoms. Compliance rates significantly differed between daytime (72%) and out-of-hours referrals (31%).

Conclusions: Despite clear national guidelines, adherence to recommended CES pathways remains suboptimal, particularly regarding timely MRI access and pre-referral imaging. Variations in guideline compliance, especially out-of-hours, highlight the need for improved access and workforce adjustments to optimise resource utilisation, reduce inappropriate referrals, and prioritise care for true CES patients.