Journal of spine surgery最新文献

Background: Adult spinal deformity (ASD) poses challenges in achieving optimal spinal alignment, often necessitating rigid lumbosacral fixation. Traditional iliac screw instrumentation has limitations, such as prominent screws, which has led to the exploration of alternative techniques, including sacral-alar-iliac (S2AI) screws. However, S2AI screws have been associated with significant sacroiliac joint pain, as the screw trajectory passes through the normal sacroiliac joint. This study evaluates the feasibility, outcomes, and complications of unilateral S2AI screw fixation in ASD surgery.

Methods: A retrospective review of 80 consecutive ASD patients undergoing unilateral S2AI screw fixation was conducted. This study included patients with a mild-to-moderate sagittal deformity, spine flexibility and a normal pelvic incidence who received unilateral lumbopelvic fixation with an S2AI screw. Clinical and radiographic data were analyzed, including pre- and postoperative measurements, complications, and patient-reported outcomes.

Results: Among the 80 patients, 72 (90%) were women and the mean age was 68.7±6.7 years. Postoperative radiographic improvements were substantial. Complications included screw loosening, proximal junctional kyphosis, infection, S2AI screw-related pain and rod breakage. The overall complication rate was 21%, and the L5/S1 fusion rate at the 2-year follow-up was 95%.

Conclusions: Unilateral S2AI screws appear effective for lumbopelvic fixation in patients with mild to moderate sagittal deformity, achieving outcomes comparable to bilateral fixation. The proposed patient categorization can guide surgical decision-making by aligning fixation methods with patient characteristics. Limitations include the retrospective design and small sample size, underscoring the need for further research to validate these findings and assess the comparative effectiveness of fixation techniques.

Background: Recently, spine surgeons have begun adapting endoscopy to perform decompressive laminectomy which has been reported to provide smaller incisions and potentially lower risk of complications compared to traditional techniques. This study aimed to compare patient characteristics and adverse outcomes between patients undergoing endoscopic vs. open or minimally invasive (MIS) laminectomy using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods: Using the ACS-NSQIP database from 2017 to 2022, Current Procedural Terminology (CPT) code of 63030 or 62380 were used to filter the dataset between open/tubular retractor-based and endoscopic single-level lumbar decompression cases, respectively. Overall, as collected, the endoscopic group consisted of 336 patients and the non-endoscopic group had 55,111 patients. The groups were compared to evaluate the patient characteristics and adverse events within 30 days after their operation. Outcome measures compared were operative time, length of stay (days), adverse outcomes [superficial infection, deep infection, organ/space infection, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, ventilator >48 hours, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke/cerebrovascular accident (CVA) accident, cardiac arrest, myocardial infarction, blood transfusion, deep vein thrombosis (DVT), sepsis, and septic shock], 30-day readmission, return to operating room (OR).

Results: After propensity score adjusting for age, sex, race, body mass index (BMI), American Society of Anesthesiologists (ASA) class, and Charlson Comorbidity Index (CCI), endoscopic patients had less total adverse outcomes than open (1.2% vs. 4.8%, P=0.01), with significantly lower rate of blood transfusions (P<0.05) compared to the non-endoscopic group.

Conclusions: Patients who underwent endoscopic lumbar decompression demonstrated a significantly lower rate of total adverse events and significantly lower rate of blood transfusions compared to their counterparts. This data from the ACS-NSQIP supports the reported benefits of endoscopic technique in the current literature. As endoscopic surgery becomes more widely utilized throughout the United States, more data will become available for further studies.

Background: Postoperative ileus (POI) is a common complication of spine surgery, characterized by a temporary and reversible slowdown in gastrointestinal tract movement following surgery. causes of POI are multifaceted, involving surgical stress, inflammatory agents, natural opioids in the gastrointestinal tract, hormonal alterations, and fluid and electrolyte imbalances. Despite reports on POI incidence and contributing factors, definitive research remains scarce, particularly in the Middle East. This study aims to study the prevalence, risk factors, and implication of POI following spine surgery.

Methods: This case-control study examined patient files from a tertiary specialist center from 2016 to 2022. Patients who developed POI post-spine surgery were compared with a near-matched cohort who did not, using a convenience sampling method. POI was identified based on standard definitions, excluding patients with previous spine surgeries or conditions predisposing to POI. Data collected included demographics, comorbidities, surgical indications, medications, bowel regimens, blood transfusions, perioperative blood work, intensive care unit (ICU) admissions, and mobilization documentation. Bivariable analysis identified risk factors, with categorical data analyzed using chi-square tests and continuous data using Student's t-tests. Multivariate logistic regression models adjusted for risk factors, with P<0.05 considered significant.

Results: Out of 294 spine surgery patients, 40.8% developed POI. Females constituted 75% of POI cases (P<0.001). Mean age was 40.5 years in the POI group vs. 46.1 years in the non-POI group (P=0.03). Asthma was significantly associated with POI development [15% vs. 2.9%, odds ratio (OR) =5.9, P<0.001], while diabetes was found to be protective against POI (20% vs. 33.9%, OR =0.48, P=0.009). Fentanyl use was associated with POI (97.5% vs. 85%, OR =6.89, P<0.001), as was patient-controlled analgesia (PCA) morphine (65% vs. 49.4%, OR =1.9, P=0.008). Scoliosis was strongly associated with POI development (45% vs. 19%, OR =3.49, P<0.001), particularly in the thoracic region (61.7% vs. 36.2%, OR =2.83, P<0.001). Spine fusion and increased surgery duration were also significant risk factors for POI (both P<0.001).

Conclusions: Our study demonstrates that almost half of the spine surgery cases developed POI, with asthma being the most significant risk factor. Diabetes showed a surprising protective effect. From a surgical perspective, scoliosis, particularly in the thoracic region, was strongly associated with POI. These findings emphasize the need for tailored perioperative management strategies to mitigate POI and improve patient outcomes. Further research is required to explore these associations and develop effective prevention strategies.

One of the major challenges in revision spinal surgery lies in restoring segmental lordosis at the level of previous surgery. We have developed a surgical technique that can help to avoid the need for a long surgical procedure, reduce the extent of spinal instrumentation, and eliminate the need for multiple stages of surgery in order to significantly restore lumbar lordosis after a failed previous operation. In this article, we provide our single institutional surgical experience including main indications and contraindications, a step-by-step surgical technique description. Segmental lordosis is restored by enhancing mobility of the lumbar segment. The main step involves total dissection of the annulus fibrosus via a posterior approach under C-arm fluoroscopy. Segmental lordosis is restored using an intervertebral cage placed in the anterior third of the intervertebral space, an operating table set in a head-up feet-up position, and segmental contraction achieved by moving screw heads closer to each other on the rods. We discuss possible complications that may arise from using our technique, including laceration of the retroperitoneal vessels and anterior cage migration following anterior longitudinal ligament release. Finally, we summarize our research experience in this surgical technique. Our institutional experience shows that the restoration of segmental lordosis via a posterior approach is a highly efficient and safe surgical procedure, especially when there is a failed previous fusion at the same level. A surgical instructional video accompanies this article.

Background: The authors present technical notes and describe a case of percutaneous unilateral endoscopic biportal transforaminal decompression in a patient with adjacent segment disease (ASD) following a previous transforaminal lumbar interbody fusion (TLIF).

Case description: A 69-year-old woman with a prior L4/L5 TLIF presented to the clinic with a new onset of right lower limb radiculopathy along the L3 dermatome, as well as numbness in the L2 distribution. Magnetic resonance imaging (MRI) studies revealed adjacent segment degeneration in L2/L3 and L3/L4, with disc-osteophyte complexes impinging onto the exiting L2 and L3 nerve roots, respectively. We opted for a right L2/L3 and L3/L4 unilateral endoscopic biportal transforaminal decompression. The surgery was successful, with the patient being discharged from the hospital on postoperative day 1 with minimal pain. Within 2 weeks, the patient described significant improvement in both back pain and radiculopathy, and the numbness had completely resolved. Oswestry Disability Index was used to objectively quantify outcomes and saw an improvement from 15 to 0. Notably, there were no complications.

Conclusions: This case highlights the successful use of unilateral biportal endoscopic transforaminal decompression to treat multi-level ASD of the lumbar spine, instead of the convention and more opted for revision TLIF. Endoscopic spinal surgery provides a promising alternative to other techniques, which can be worth its steep learning curve. This should be considered in the arsenal of spine surgeons as a minimally invasive alternative.

Background: Intramedullary spinal cord metastases (ISCMs) are rare manifestations of systemic malignancy, accounting for 4-9% of central nervous system metastases. Radio- and chemotherapy are considered first-line therapies. However, certain clinical presentations may require microsurgical resection of ISCM. The optimal treatment strategy remains controversial, particularly in cases with diagnostic uncertainty or rapid neurological deterioration.

Case description: We present a 59-year-old female patient with history of treated breast cancer who developed progressive, burning pain in the left groin radiating to the ventral thigh and knee, accompanied by sensory deficits and gait instability. Magnetic resonance imaging (MRI) revealed a contrast-enhancing intramedullary lesion at T10 with extensive perifocal edema from C7 to L1. Given the unclear etiology and worsening neurological symptoms, microsurgical resection was performed using intraoperative neuromonitoring and ultrasound guidance. Histopathological examination unexpectedly revealed a metastasis from a previously undiagnosed amelanotic melanoma, rather than the suspected breast cancer metastasis. Subsequent screening identified an additional right inguinal lymph node metastasis, which was surgically removed. The patient received adjuvant radiation therapy to T9-11 (13×2.5 Gy) and immunotherapy with nivolumab. At 3 years post-operation, the patient maintains good functional status with no evidence of tumor recurrence.

Conclusions: This case highlights the value of microsurgical resection in providing both therapeutic benefit and definitive diagnosis and the importance of comprehensive histopathological evaluation even when a likely primary tumor exists. Larger, multicenter data collections are required to better delineate the role of microsurgery in ISCM treatment and to establish evidence-based guidelines for patient selection.

Background: The incidence of traumatic spinal cord injury (tSCI) in the elderly is increasing in the setting of an ageing population. We aim to present and define the clinical course of tSCI in the elderly Australian cohort with this cohort study to identify pertinent predictors for mortality thereby improving risk stratification in this potentially devastating disease.

Methods: A review of the prospectively maintained Victorian State Trauma Registry (VSTR) database was performed to identify patients who sustained a tSCI between 2007 and 2021. Patients aged 65 years and older were included. Demographic, treatment, disposition and outcome data were all obtained from the database and supplemented from the patient's medical record as required. A primary outcome of death at 6 months was defined. Secondary outcomes were collated for Extended Glasgow Outcome Score (GOS-E) at 6 months, length of stay in hospital, and discharge disposition.

Results: A total of 169 elderly patients with tSCI were identified, with 168 followed up to completion (mean age 73.5 years, 73.4% male). The majority (52.7%) were secondary to low-impact falls, and 67.5% underwent surgery for their injury. 19.6% (n=33) of the cohort were dead at 6 months. The likelihood of death at 6 months was significantly associated with increasing age [odds ratio (OR) 1.22 per year increase in age; 95% confidence interval (CI): 1.09-1.36; P=0.001], Injury Severity Score (ISS) (OR 1.11 per unit ISS; 95% CI: 1.05-1.18; P=0.001), and complete injuries. The level of injury, surgical management and Charlson Comorbidity Index (CCI) of 1 or greater did not reach significance. Age was also associated with worsening GOS-E at 6 months and prospects of being discharged home, but not with length of stay.

Conclusions: tSCI in the elderly is a challenging condition. Increasing age is significantly associated with increased risk of mortality and poorer GOS-E scores at 6 months.

Background: Lateral lumbar interbody fusion (LLIF) is gaining popularity as a minimally invasive surgical option for patients with degenerative lumbar conditions. However, given the minimally invasive nature, surgical trainees and assistants struggle to visualise the procedure from the surgeon's perspective. Hence, this study aims to assess the educational benefits of using an extracorporeal telescope (exoscope) during LLIF.

Methods: This survey was conducted in Changi General Hospital. All junior surgical doctors (JSDs) and scrub nurses (ScNs) who participated in LLIF cases with and without the usage of an exoscope were included in the survey. They answered a set of seven questions (scored 1 to 5) to evaluate their learning experience when the exoscope was used. The median of the scores was reported with interquartile range (IQR).

Results: A total of 12 participants were included. They reported enhanced visualisation of anatomy during both superficial dissection [median score =4.5 (IQR, 4-5)] and deep dissection [median score =5 (IQR, 5-5)]. Similar ratings were given for understanding disc space anatomy [median score =5 (IQR, 5-5)] and overall appreciation of the surgery [median score =5 (IQR, 4.25-5)]. Participants found the exoscope to be more ergonomic for visualizing the surgery [median score =5 (IQR, 4-5)] and noted significant knowledge improvement in LLIF procedures [median score =5 (IQR, 4-5)]. They expressed a strong preference for its use in future LLIF cases [median score =5 (IQR, 4.25-5)].

Conclusions: The exoscope is a valuable asset for lateral access spinal procedures, enhancing the educational experience for JSDs and ScNs.

The article aims to describe the novel surgical technique of filling anterior spine cavitations in pyogenic spondylodiscitis (PS) using bioactive glass S53P4 (BAG-S53P4) (BonAlive^®) in association with posterior spinal stabilization alone and its results in the first three patients. The technique starts with a posterior approach and instrumentation of the spine, total or partial laminectomy (when needed), debridement of the intervertebral space and cavity filling with BAG-S53P4, without any additional anterior instrumentation (i.e., meshes/cages). We retrospectively reviewed the first three cases of spondylodiscitis surgically treated with this technique at the department of orthopaedic surgery of the ASST-Ovest Milanese, Legnano Hospital (Italy). Functional outcomes, pain level, and C-reactive protein (CRP) trends were reported. Serial plain radiographs were collected, and a computed tomography (CT) scan was performed after a period of 2-3 years. A rapid improvement and healing from infection were observed in all cases with progressive spinal fusion and restoration of the previous quality of life. We did not observe major adverse events. BAG-S53P4 can be safely introduced in the disk space through a posterior approach to fill vertebral cavitation when the posterior wall is almost intact. It may be considered a safe and useful biomaterial in the surgical treatment of spondylodiscitis, helping in the eradication of the infection and promoting progressive spinal fusion. With this technique, anterior instrumentation and double approaches could be avoided in case of limited bone defects and moderate spinal deformity.