Journal of spine surgery最新文献

Background: Os odontoideum is a rare craniocervical osseous anomaly leading to instability and cord compression that may require surgical stabilization. The increased precision and expedited workflow from visible light navigation allows for C1 lateral mass screw placement through the posterior arch while reducing dissection and venous bleeding compared to traditional entry at the arch-lateral mass junction.

Case description: A 57-year-old male presented with progressive myelopathy due to os odontoideum and C1/2 instability. Posterior C1-C2 fusion was performed via C1 through-the-arch screws and bilateral C2 laminar screws, with the assistance of visible light navigation (7D FLASH Navigation). Five weeks postoperatively, he developed progressive right arm pain and weakness. Computed tomography/magnetic resonance imaging (CT/MRI) demonstrated the lateral mass screws to be in situ, but there were bilateral C2 laminar fractures with screw loosening and cord impingement, requiring urgent screw removal with extension of fusion down to C4. Evaluation of the preoperative CT revealed unusually narrow C2 laminar width (3.2-3.4 mm). We posit that cyclic stress may have led to fatigue failure, although the initial C2 navigated screw placement was accurate.

Conclusions: This is the first report of visible light navigation being used for posterior C1/C2 fixation. Navigation, however, cannot compensate for inadequate bony dimensions for screw placement with risk of subsequent mechanical failure. C2 lamina width should be evaluated prior to consideration of laminar screw insertion.

Background: Anterior cervical discectomy and fusion (ACDF) is the standard treatment for single-level cervical myelopathy with anterior compression. However, concomitant posterior pathology such as ligamentum flavum (LF) hypertrophy may limit decompression or cause iatrogenic LF buckling after surgery. This case series highlights surgical considerations and technical modifications for such scenarios.

Case description: Four patients with single-level cervical myelopathy underwent ACDF. Case 1: a 68-year-old man with C3/4 disc herniation and LF hypertrophy was treated with short-plate fixation and high-angle screws, achieving indirect posterior decompression and neurological recovery. Case 2: an 80-year-old woman with C3/4 compression achieved excellent clinical and radiologic outcomes after ACDF. Case 3: a 58-year-old woman with OPLL developed postoperative LF buckling after conventional ACDF method. Case 4: a 77-year-old man with rigid segmental motion failed indirect decompression after ACDF and required staged posterior laminectomy.

Conclusions: ACDF is effective for most single-level myelopathy with anterior compression. Technical modifications, including short anterior plating with high-angle screws, may achieve indirect posterior decompression and prevent LF buckling. In rigid segments or with severe posterior pathology, combined or staged anterior-posterior approaches should be considered. Careful selection and meticulous technique are essential to optimize outcomes.

Background: Traumatic spinal cord injury (SCI) is a catastrophic condition associated with significant morbidity and healthcare utilization. While existing literature has largely focused on long-term sequelae, data on temporal trends in early in-hospital and immobility-related complications are limited. This study aims to evaluate temporal trends in major in-hospital and immobility-related adverse events among patients with acute traumatic SCI.

Methods: We conducted a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2017 to 2022. Patients aged 16 years and older with cervical, thoracic, or lumbar SCI were included. The primary outcome was major adverse events (MAEs), including cardiac arrest, stroke, unplanned intensive care unit (ICU) admission, intubation, and immobility-associated events (IAEs) such as surgical site infection, venous thromboemblism (VTE), pressure ulcers, catheter-associated urinary tract infections (CAUTI). The primary exposure was calendar year of hospital admission. Multivariable logistic regression models assessed associations between calendar year and complications. Subgroup analyses stratified by spinal level and by patients undergoing surgery.

Results: A total of 78,571 patients met the inclusion criteria (mean age: 51.8 years; 75% male). Over the study period, patient age and comorbidity burden increased. The adjusted odds of several MAE increased, including cardiac arrest [odds ratio (OR) 1.05, per year after 2017, 95% confidence interval (CI): 1.02-1.09], stroke (OR 1.08, per year after 2017, 95% CI: 1.02-1.15), unplanned ICU admission (OR 1.07, per year after 2017, 95% CI: 1.04-1.09), intubation (OR 1.04, per year after 2017, 95% CI: 1.01-1.06), and unplanned return to the operating room (OR 1.21, per year after 2017, 95% CI: 1.17-1.26). Among IAE, the odds of deep vein thrombosis (DVT), pulmonary embolism, and pressure ulcers rose, while CAUTI rates declined (OR 0.89, per year after 2017, 95% CI: 0.85-0.93). Subgroup analyses by injury level and among surgically treated patients demonstrated similar temporal patterns. In multivariable models, higher odds of both MAE and IAE were independently associated with increasing year of admission, older age, greater comorbidity burden, complete SCI, fractures, penetrating trauma and lower presenting Glasgow Coma Scale (GCS).

Conclusions: In this contemporary cohort of patients with traumatic SCI, the incidence of several MAE and IAE increased over time. These findings suggest a need for heightened vigilance, enhanced perioperative care, and the development of standardized prevention protocols targeting high-risk populations.

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.