Journal of spine surgery最新文献

Background: There is no consensus on the association between final local kyphosis and residual back pain (RBP) after traumatic vertebral fracture. The aim of this study was to investigate whether there is an association between the final local kyphosis angle and RBP in patients with traumatic vertebral fractures at the thoracolumbar junction who underwent single posterior surgery with percutaneous pedicle screws and implant removal after fracture healing. A second goal was to determine the optimal cut-off value for the final local kyphosis angle with and without RBP.

Methods: Twenty-five patients were included in the study. Age, gender, Injury severity score, level of fracture, AO classification, the McCormack Load sharing classification, and range of stabilization were collected. In addition, imaging assessment was performed to evaluate vertebral kyphosis angle, local kyphosis angle (Cobb angle), and the percentage of anterior, middle and posterior vertebral body compression at the time of injury and at the final follow-up after implant removal. The patients were divided into two groups, with and without RBP [Group RBP (+) and Group RBP (-), respectively]. Each variable was compared between groups. Cut-off values were calculated using the Youden index with receiver operating characteristic (ROC) curves.

Results: There were 12 patients in the RBP (+) group and 13 in the RBP (-) group. The two groups were significantly different only for the final local kyphosis angle, with no significant differences for the other variables. The ROC curve of the final local kyphosis angle for RBP had an area under the curve (AUC) of 0.88 (P<0.01). The optimal cut-off value for the final local kyphosis angle for RBP calculated from the Youden index was 15.85°.

Conclusions: There is an association between the final local kyphosis angle and RBP. The optimal cut-off value of the final local kyphosis angle for RBP was approximately 16°.

Background: Robotic-assisted spinal surgery has reportedly improved the accuracy of instrumentation with smaller incisions, improving surgical outcomes and reducing hospital stay. However, robot-assisted spine surgery has thus far been confined to placement of pedicle screw instrumentation only. This pilot study aims to explore the feasibility of utilizing the Mazor™ X Stealth Edition (Medtronic, Sofamor Danek USA), robotic-arm platform in the minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) procedure inclusive of interbody cage placement, in our institution.

Methods: Single-centre, single surgeon prospectively collected case series of 29 patients who were planned for robot-assisted MIS-TLIF (RA-TLIF) with Mazor™ X Stealth system, on patient demographics [age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI)], and post-operative outcomes.

Results: Of the 29 RA-TLIF cases planned, 2 cases were excluded due to software start-up issues. One patient underwent revision surgery for posterior-migrated interbody cage. No loosening of posterior instrumentation was seen in all cases at 6 months follow-up.

Conclusions: Our single-institution pilot study on the Mazor™ X Stealth RA-TLIF has shown high pedicle screw insertion accuracy and relatively low complication rates, comparable to that of conventional MIS-TLIF O-arm navigation system. However, the discerning surgeon should be on the lookout for potential system-related pitfalls, as well as understand the limitations for robotic interbody cage placement. Further studies will also be required on patient outcomes and cost-effectiveness prior to consideration for wide scale implementation.

Background: Currently, there remains a high percentage of complications after lumbar discectomy, while there is no uniform tactic to prevent their development. Purpose of the study was to compare the clinical efficacy and return to work rate (RWR) after total disk replacement (TDR) and microsurgical lumbar discectomy (MLD) in railway workers with lumbar disk herniation (LDH).

Methods: We randomly assigned 75 patients out of a total of 81 patients, between 25 and 35 years of age who had one level LDH to undergo single-level TDR surgery (group I, n=37) or MLD surgery (group II, n=38) in the L4-L5 or L5-S1 segments. The functional state was assessed using the Oswestry Disability Index (ODI), pain severity was analyzed using the Visual Analogue Scale (VAS) for back pain and leg pain, quality of life was assessed according to SF-36 preoperatively, at discharge, and at 3, 6, and 12 months postoperatively. The X-ray assessment was used to assess the efficacy of the respective surgical methods pre-operatively and last follow-up of 1-year. Workload intensity criterions were used to analyze return to work 1 year after surgery. Clinical and radiographic observers were blinded for the assigned treatment during the 12-month follow-up.

Results: As expected, the MLD group had statistically significantly lower duration of surgery and less bleeding than TDR group. At a 1-year follow-up period, the TDR group had significantly better ODI, VAS and SF-36 than the MLD group. The postoperative X-ray revealed a statistically significant difference of the range of motion (ROM) and global lumbar lordosis in TDR group compared to the MLD group. After TDR procedure in light-moderate and heavy-very heavy workload patients groups had a statistically significantly higher RWR compared with MLD. The analysis revealed a comparable number of symptomatic complications in both groups (P=0.47), with a greater frequency of reoperations in the follow-up period in MLD group in comparison TDR group (P=0.04).

Conclusions: The use of single-level TDR in railway workers has made it possible to significantly improve long-term clinical results, reduce the risk of reoperations, restore of segmental mobility at operation level, preserve of global lumbar lordosis and RWR compared to MLD.

Trial registration: Russian Clinical Trial Registry 622011400059-4.

Background: Surgical fusion of the sacroiliac (SI) joint is often performed to manage chronic lower back or buttock pain. When Current Procedural Terminology (CPT) codes were introduced, SI joint fusion procedures were done primarily by orthopaedic surgeons and neurosurgeons. The purpose of this study was to examine the utilization of SI joint fusion CPT codes by physician specialty over time.

Methods: A retrospective cohort study was conducted using the PearlDiver database. The database was queried using CPT codes to identify patients who underwent SI joint fusion via percutaneous, open, or trauma codes. Specialties queried included surgical specialties (orthopaedic surgery and neurosurgery) and non-surgical specialties [physical medicine and rehabilitation (PM&R), neurology, anesthesiology, pain medicine]. Total number and number per year of SI joint fusion procedures were identified for each specialty group. Trends of SI fusion billing for the years 2015 to 2021 were compared between surgical specialties and non-surgical specialties.

Results: Comparing 2015 and 2021, the SI fusion codes submitted across all three groups (percutaneous, open, and trauma) increased for non-surgical specialties compared to surgical specialties. Between 2015 and 2021, the total number of percutaneous procedures submitted by all specialties increased by 294%, while the number of procedures being submitted by non-surgical specialties increased by 25,050%.

Conclusions: Our study demonstrated how quickly and to what degree the procedure market can react to higher work relative value unit (RVU) value codes. Despite requiring less overall time and utilizing an intra-articular rather than a transfixing approach, non-surgical specialties submitted the same CPT code as surgical specialties performing the transfixing procedure at an increasing rate during the study period. With the introduction of new technologies to perform SI fixation and a new code to capture the intra-articular procedure, future studies could examine whether the number of SI fusion procedures performed by the various physician specialties stabilizes over time.

Background: Implant fixation is often the cornerstone of musculoskeletal surgical procedures performed to provide bony fixation and/or fusion. The aim of this study was to evaluate how different design features and manufacturing methods influence implant osseointegration and mechanical properties associated with fixation in a standardized model in cancellous bone of adult sheep.

Methods: We evaluated the in vivo performance of three titanium alloy implants: (A) iFuse-TORQ implant; (B) Fenestrated Sacroiliac Device; and (C) Standard Cancellous Bone Screw in the cancellous bone of the distal femur and proximal tibia in 8 sheep. Group A was produced using additive manufacturing [three-dimensional (3D) printing] while Groups B and C were made with traditional methods. The vivo responses of the implants at the implant-bone interface were examined using mechanical testing (push out and removal torque), polymethyl methacrylate (PMMA) histology combined with fluorochrome labels and quantitative histomorphometry of bone ongrowth, ingrowth and through growth at 3 and 6 weeks.

Results: New bone formed directly on all groups and no adverse reactions were noted. Osseointegration via ongrowth, ingrowth and through growth was a function of implant design. Implant designs that provide osseointegration via ongrowth, ingrowth and through growth improve implant fixation in torsion. The 3D printed surface in group A was rougher and outperformed traditional manufacturing surfaces of groups B and C in torsion. The porous domains and fenestrations in the design of group A allowed for bone ingrowth and through growth, which accounted for the superior torsional properties.

Conclusions: Implant designs that provide osseointegration via ongrowth, ingrowth and through growth improve implant fixation.

Background: Vertebral body tethering (VBT) has shown improvements in coronal and sagittal plane correction in adolescent idiopathic scoliosis (AIS) patients, but axial correction over time remains unexplored. Three-dimensional (3D) spine reconstruction was used to analyse correctional changes in all spinal planes post VBT surgery.

Case description: AIS subjects who underwent thoracic VBT surgery with a minimum 2-year follow-up were assessed. Biplanar radiographs were used for 3D spinal reconstructions, 3D coronal, sagittal thoracic kyphosis (TK), lumbar lordosis (LL), and axial rotation measurements were compared at pre-operative (pre-op), immediate post-operative (post-op), 1-year, and 2-year follow-up. Eight patients (7 females, 1 male) with a mean age of 11.8±1.3 years with right thoracic curves (mean 50.4°±8.1°) were followed for 26.8±4.1 months. Mean coronal Cobb angle showed significant improvement: 28.4°, 19.2°, and 27.1° at post-op, 1-year, and 2-year follow-up (P<0.001). Minimal changes were seen in sagittal plane: TK-35.2°, 39.0°, 31.3°, 37.0°; LL-46.1°, 42.8°, 36.5°, 42.8° (pre-op, post-op, 1-year, 2-year) respectively. Apical axial rotation improved from -5.5°±5.0° to -1.4°±4.8° post-op, then deteriorated to -3.2°±4.9° at 1 year and -7.0°±5.9° at 2 years, with no significant changes.

Conclusions: This is the first case series to use 3D radiographic digital measurements to reveal apical axial rotation progression in thoracic curves despite improved coronal curvature. While larger scales studies with longer follow-up are needed to verify our findings, surgeons and patients should be aware of such findings in their decision to select VBT as their procedure of choice.

Background: Prone lateral spinal surgery for simultaneous lateral and posterior approaches has recently been proposed to facilitate surgical room efficiency. The purpose of this study is to evaluate the feasibility and outcomes of minimally invasive prone lateral spinal surgery using a rotatable radiolucent Jackson table.

Methods: From July 2021 to June 2023, a consecutive series of patients who received minimally invasive prone lateral spinal surgery for various etiologies by the same surgical team were reviewed. A Mizuho Jackson Modular Table System was used for all prone lateral surgeries. All patients received combined lateral and posterior approach surgery on the same day. The lateral approaches were performed with the Jackson table rotated 30-40 degrees away from the surgical side. A table-mounted oblique lumbar interbody fusion (OLIF) retractor was applied in retropleural/retroperitoneal spaces. Minimally invasive lateral procedures such as discectomy or mini-open corpectomy were performed after adequate exposure. Posterior procedures were performed with the Jackson table rotated back horizontally. The disease etiologies, surgical levels, blood loss, operation time, and surgical procedures were collected and analyzed.

Results: The study included 64 patients with a mean age of 61.8 years (range, 26-88 years). The disease etiologies were 11 (17.2%) deformities, 15 (23.4%) degenerations, 25 (39.1%) infections, 9 (14.1%) traumas, and 4 (6.3%) tumors. The mean length of the surgical level was 4.1±2.0 (range, 2-10), with surgical levels ranging from T8 to L5 laterally and T6 to the ilium posteriorly. The mean blood loss was 863±843 mL (range, 50-4,600 mL) and the mean operation time was 314±148 minutes (range, 92-785 minutes). Of the lateral approaches, there were 25 retropleural and 39 retroperitoneal approaches (36 antepsoas approach). Surgical procedures performed included lateral discectomies, mini-open corpectomies, interbody reconstruction and fusion, and various posterior techniques such as pedicle screw instrumentation, cement augmentation, decompression, osteotomy, and spinal endoscopy. Patients who received both prone lateral retropleural and retroperitoneal approaches had significant improvement in the sagittal Cobb angle of the lateral surgical level, Visual Analogue Scale (VAS), and Oswestry Disability Index (ODI) at 1 year postoperatively.

Conclusions: Minimally invasive prone lateral spinal surgery is a feasible option for patients requiring combined lateral and posterior approach spinal surgery. Both lateral retropleural and retroperitoneal antepsoas approaches can be applied in combination with various posterior surgical procedures in the prone position using the rotatable radiolucent Jackson table.

Background: Kyphoplasty (KP) is a well-established procedure with a low complication risk, however, the procedure's safety in patients with comorbidities and in the setting of systemic infection remains uncertain with no clear guidelines. We present a unique case of KP in the setting of recurrent septicemia, which required subsequent salvage vertebrectomy.

Case description: We present a clinical case of a 59-year-old diabetic male patient with a recent foot ulcer, positive for Corynebacterium striatum and Enterococcus. Shortly after discharge, the patient was admitted for signs of septicemia positive for Corynebacterium striatum and Pseudomonas aeruginosa. The patient had also sustained an acute L1 compression fracture at the time of septic presentation. A KP was performed, just 10 days after original septicemia diagnosis. 5 months later, the patient presented with continued incapacitating back pain at the operative site, and a diagnose revealing osteomyelitis at the location of the L1 KP positive for Corynebacterium striatum, treated with vancomycin and daptomycin. The cement and surrounding bone were compromised and instability developed, requiring an L1 vertebrectomy with T9-L4 posterior fusion with allograft. The patient has been followed for 1.5 years postoperatively with full recovery, decreased pain, and improved quality of life. We discuss the importance of KP safety in the setting of recurrent systemic infection.

Conclusions: While current cases in literature discuss the infectious risk of KP, this case emphasizes the extended time in which osteomyelitis can recur in patient with systemic infections. Care must be taken preoperatively and perioperatively to ensure there is minimal risk of further bacterial seeding into implanted materials. Preoperative infection status should be monitored via blood culture and inflammatory markers. Preoperative and perioperative antibiotics should be administered and perioperative cultures should be collected in case of postoperative infection. Further cases, prospective, and retrospective studies are necessary to fully understand the adequate guidelines to performing KP in the setting of systemic infection.

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition that might lead to dysphagia because of massive osteophytes that may be present at multiple levels. Confirming the symptomatic level to guide surgical management and avoid extensive surgery is important, however, there is no globally accepted consensus on the topic.

Case description: We report the case of a 51-year-old man, with no specific past medical history, who has been complaining of a 3-months pain in the left side of the tongue base with sensation of a lump in the throat and dysphagia. Computed tomography scan confirmed DISH between C4 and C7. Barium swallow fluoroscopy demonstrated indentation of the esophagus only at the level of C4-C5, which guided the surgical management that focused on resecting only the major osteophytes at the level of C4-C5, avoiding extensive approach with its subsequent possible complications, and enabling satisfactory clinical and radiological outcomes.

Conclusions: The current case thoroughly illustrated the diagnosis and surgical management in the presence of dysphagia from DISH. Through an anterior pre-vascular approach complete resection of the major osteophytes could be done. Barium swallow fluoroscopy showed very high interest in dynamically demonstrating the main level causing the dysphagia symptoms and also confirming satisfactory esophagus decompression and release after surgery.