Journal of spine surgery最新文献

Background: Spinal cord injuries (SCIs) resulting from gunshot wounds (GSWs) and motor vehicle accidents (MVAs) differ in mechanism, injury severity, and care pathways. Insurance coverage may further influence access to inpatient rehabilitation (IPR) and post-acute services, thereby affecting recovery trajectories. In the United States, MVA-related SCIs are frequently covered by no-fault auto insurance with broad benefits, whereas GSW-related SCIs are more commonly covered by Medicaid, which may limit rehabilitation duration and intensity. The objective of this study was to assess the association between insurance status and post-rehabilitation outcomes in patients with SCI due to GSWs compared with MVAs.

Methods: This Institutional Review Board (IRB)-approved retrospective cohort study included 40 patients with traumatic SCI treated at a single IPR center, including 20 GSW-related and 20 MVA-related SCIs, all with at least 1 year of follow-up. Demographic characteristics, insurance type, injury severity, and social determinants of health were collected, including Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) scores. Primary outcomes included IPR length of stay (LOS), inpatient complications, and healthcare utilization [emergency department (ED) visits and hospital readmissions] within 1 year of discharge. Between-group comparisons were performed using independent t-tests.

Results: GSW patients were significantly younger than MVA patients (mean age 27.45 vs. 46.00 years, P<0.001) and were more frequently insured by Medicaid (85% vs. 45%, P=0.004). In contrast, auto insurance coverage was present in 50% of MVA patients and 0% of GSW patients (P<0.001). Neighborhood disadvantages were similar between groups (ADI 88.45 vs. 83.30, P=0.14; SVI 0.77 vs. 0.68, P=0.14). GSW patients had more severe neurologic injury, with lower mean American Spinal Injury Association (ASIA) scores (1.90 vs. 2.74, P=0.01), lower rates of surgical intervention (45% vs. 85%, P=0.004), and shorter IPR stays (32 vs. 46 days, P=0.004). GSW patients experienced more inpatient complications (6.35 vs. 4.80 per patient, P=0.03) and greater post-discharge healthcare utilization, including higher ED visits (1.60 vs. 0.50, P=0.01) and hospital readmissions (1.25 vs. 0.25, P=0.04) within 1 year.

Conclusions: Insurance disparities influence orthopedic surgical decision-making, IPR length, and complication burden in SCI patients. Patients with GSW-related SCIs, despite being younger, experienced more severe injuries, lower surgical intervention rates, and higher post-discharge healthcare utilization. These findings highlight the need for equitable access to spine surgery, rehabilitation, and follow-up care to optimize outcomes across trauma mechanisms.

Background: Spinal surgeries have become common procedures due to greater life expectancy and the increasing elderly population. Failed fusion, or nonunion, may be influenced by patient risk factors and can lead to a myriad of complications. Pulsed electromagnetic field (PEMF) stimulation is a noninvasive post-operative adjunct therapy that has been shown to influence underlying cellular processes that may improve osteogenesis to promote successful fusion following spinal surgery. The aim of the study was to evaluate the effect of PEMF on lumbar fusion in patients with risk factors for nonunion.

Methods: The current study employed a prospective, multicenter study to investigate PEMF as an adjunct therapy following lumbar spinal fusion procedures in subjects with risk factors for failed fusion. A retrospective control arm was used as a comparator. Subjects were enrolled with at least one of the following risk factors: prior failed fusion, multi-level fusion, nicotine use, osteoporosis, advanced age (>65 years), body mass index >30 kg/m², and diabetes. PEMF was delivered for 6-months following surgery. Overall fusion status and influence of risk factors were assessed. Successful fusion was determined by radiographic imaging.

Results: Fusion status was compared at a 12-month follow-up in subjects treated with PEMF (n=142) vs. control (n=47). Successful fusion was observed in 88.0% (n=125/142) of PEMF subjects and 68.1% (n=32/47) of control subjects. PEMF therapy resulted in statistically improved fusion rates in subjects with prior failed fusion (P=0.04), multi-level fusion surgery (P<0.001), and advanced age (P<0.001) when compared to control. PEMF therapy resulted in statistically improved fusion rates in subjects who had at least one risk factor (P=0.002), ≥2 risk factors (P<0.001), and ≥3 risk factors (P=0.003) compared to control. Linear regression analyses showed a significant treatment effect of PEMF across all risk factors and presentations (P=0.003). A favorable safety profile was observed with PEMF therapy.

Conclusions: PEMF therapy improved fusion success in subjects following lumbar spinal surgery and represents a beneficial adjunct treatment resulting in significant improvements in subjects having risk factors for nonunion.

Background: There has been a continued search for synthetic graft materials to replace iliac crest bone graft and allograft in spinal fusion. Recently, there has been interest in bioactive glasses (BGs) as graft substitutes, but a confusing landscape of current literature creates difficulty in evaluating their clinical effectiveness. As such, we conducted an updated systematic review on BG use in cervical and lumbar spinal fusion.

Methods: A systematic review of the MEDLINE, Cochrane, Embase, and Web of Science databases was conducted on March 26^th, 2024. Studies were included if they pertained to BGs and spine fusion. Risk of bias for included studies was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2). Only prospective clinical studies and randomized controlled trials were ultimately included. Data were analyzed narratively.

Results: Five studies with low bias, four with some concerns for bias, and three with high bias were included in the final review. Sample sizes ranged from 17-74 patients, and BG types included BGS-7, S53P4, 45S5, Chitra-HABg, and apatite- and wollastonite-containing glass-ceramic (AWGC). Procedures included posterolateral lumbar fusion (PLF), posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and anterior cervical discectomy and fusion (ACDF). When BGs were used as standalone grafts, fusion rates ranged 0-70.6% at >1-year follow-up. In one study of PLF, grafts composed of AWGC and autograft mixtures resulted in fusion rates between 81.8-83.3%. 45S5 showed comparable fusion to autograft at 1 year postoperatively in ALIF. When BGS-7 was used as a cage material, fusion rates varied from 75.0-95.0% at >1-year follow-up, compared to 65.4-100% for titanium, allograft, or polyether ether ketone (PEEK) cages.

Conclusions: When used as standalone fusion grafts in PLF, pure Chitra-HABg and S53P4 are ineffective compared to autograft. However, grafts made of 45S5 or mixtures of AWGC with autograft show fusion rates comparable to autograft alone. BGS-7 cages showed noninferior fusion rates to titanium, allograft, and PEEK cages. Additional prospective studies with quality methodologies are necessary to validate these results.

Background: Spinal subdural hematoma (SSDH) is a rare but potentially serious condition characterized by a compressive accumulation of blood within the thecal sac. It may result from trauma, surgery, or underlying vascular abnormalities, often associated with anticoagulant use. In this case, SSDH was diagnosed post-implantation of a spinal cord stimulation (SCS). Current estimates suggest that a neuraxial (including epidural) hematoma following SCS occurs in about 0.32% of cases, with no reported sub/intradural pathology from uncomplicated SCS procedures.

Case description: We report a case of SSDH in a 78-year-old male, diagnosed after a percutaneous dorsal column stimulator trial for chronic postherpetic thoracic neuralgia. The patient presented with days of weakness and gait instability, 1 month post-SCS trial. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed an intrathecal lower lumbar T1/short tau inversion recovery (STIR) signal, fluid-fluid level, and cauda equina enhancement suggestive of a subarachnoid hemorrhage, as well as a well-circumscribed, compressive T2-T3 subdural collection consistent with hematoma, later confirmed by pathology. Notably, bleeding occurred in the absence of coagulopathy or dural puncture. A spinal angiogram ruled out vascular lesions. The patient underwent a successful laminectomy and intradural hematoma evacuation, resulting in gradual functional recovery.

Conclusions: To our knowledge, this is the first reported case of SSDH following uncomplicated SCS. Possible etiology includes epidural trauma from SCS lead placement, causing shear stress, leading to an angiogenic/inflammatory response with eventual neomembrane formation and space-occupying hematoma responsible for the subacute myelopathic presentation. Prompt diagnosis and treatment are crucial to prevent permanent neurological damage due to spinal compression.

Background: Cauda equina neuroendocrine tumors (CE-NETs) are rare intradural extramedullary (IDEM) tumours that are hard to differentiate from other IDEM tumours such as schwannomas and ependymomas on imaging. While literature surrounding CE-NET and other IDEM tumours continues to grow, evidence on complications such as intra-tumoural hemorrhage remains rare, with few cases reported in the literature.

Case description: We report a rare case of intra-tumoural hemorrhage in a 35-year-old Caucasian male with newly-diagnosed CE-NET. The patient presented with acute lower back pain with L1 radiculopathy complicated by acute retention of urine. Magnetic resonance imaging (MRI) detected an IDEM mass lesion adjacent to the conus medullaris at the T12-L1 level with heterogenous enhancement. The patient underwent T12/L1 laminectomy and excision of lesion, with histology and immunohistochemical evaluation supporting the diagnosis of a well-differentiated neuroendocrine tumour. The patient made a complete recovery and was discharged on postoperative day 5. A systematic review was conducted for similar cases of intra-tumoural hemorrhage in IDEM tumours, with 36 cases of intra-tumoural hemorrhage in IDEM tumours reported to date.

Conclusions: Intra-tumoural hemorrhage in IDEM tumours is rare, especially in a CE-NET tumour. While symptoms can be debilitating and range from severe back pain to significant neurologic deficit, early identification via radiological and histological evaluation as well as early surgical resection leads to good prognosis.

Background: Lumbar fusion (LF) is a common surgical intervention for degenerative spinal conditions but carries significant short- and long-term risks. Preoperative malnutrition, characterized by low serum albumin or leukocyte counts, impairs wound healing and increases susceptibility to infection, yet its influence on LF outcomes remains underexplored. This study evaluates the association between preoperative malnutrition and long-term postoperative outcomes following LF.

Methods: Adult patients undergoing LF between 2003 and 2023 were identified in the TriNetX US Collaborative Network. Malnutrition was defined as serum albumin <3.5 g/dL or leukocyte count <1,500/mm³ within 1 year preoperatively. A 1:1 propensity score match was performed for demographics, comorbidities, surgical approach, and body mass index (BMI), yielding two cohorts (n=20,693 each). Ninety-day and 5‑year postoperative outcomes were compared using hazard ratios (HRs) with 95% confidence intervals (CIs).

Results: Malnourished patients experienced significantly higher 90‑day rates of transfusion (8.4% vs. 4.5%; HR 1.87, 95% CI: 1.73-2.02), wound complications (2.6% vs. 1.5%; HR 1.70, 95% CI: 1.48-1.95), infection (3.2% vs. 2.3%; HR 1.37, 95% CI: 1.22-1.54), and hospital readmission (17.3% vs. 13.8%; HR 1.26, 95% CI: 1.20-1.32). At 5 years, malnourished patients had higher rates of pseudoarthrosis (25.8% vs. 20.5%; HR 1.32, 95% CI: 1.26-1.38), revision surgery (16.2% vs. 11.9%; HR 1.41, 95% CI: 1.34-1.49), and compression fractures (5.8% vs. 3.7%; HR 1.60, 95% CI: 1.46-1.76). All-cause mortality was lower in the malnourished cohort (4.3% vs. 5.8%; HR 0.75, 95% CI: 0.69-0.82), likely reflecting selection bias.

Conclusions: Preoperative malnutrition is independently associated with increased postoperative complications, reoperations, and impaired long-term surgical success after LF. Routine nutritional assessment and optimization should be considered in preoperative planning to reduce morbidity and healthcare utilization.

Background: Traumatic coronal spondyloptosis (TCS) describes complete coronal subluxation of a vertebral body relative to an adjacent segment secondary to high-energy trauma. TCS commonly associates with orthopedic, intraabdominal, and thoracic solid organ injury, nuancing overall management. Surgery is indicated for subluxation reduction, deformity correction, and stabilization. Thoracolumbar junctional TCS has a sparse description in the literature. As a complex deformity encounterable by spinal surgeons regularly managing spinal cord injury and spinal trauma, appropriate surgical management requires an understanding of the various operative approaches as well as available intraoperative technical adjuncts. We accordingly discuss our surgical technique for subluxation reduction, deformity correction, and stabilization, and review approaches employed for similar reported cases.

Case description: We describe the case of a 36-year-old female presenting to Temple University Hospital after an automotive versus pedestrian injury. She demonstrated gross traumatic spinal deformity, secondary intraabdominal injuries, and was paraplegic on initial neurologic examination. After abdominal solid organ injury management and hemodynamic stabilization, the patient underwent standard pedicle screw fixation spanning the thoracolumbar junction from T9-L4, with complete coronal spondyloptosis correction achieved via manual caudal reduction after completion of a single-level unilateral facetectomy at T12-L1.

Conclusions: This complex traumatic spinal deformity underwent reduction and stabilization via techniques accessible to most spinal surgeons. Paraplegia on presentation obviated the need for intraoperative neuromonitoring and enabled muscle relaxant use to facilitate deformity correction. When requiring either neuromonitoring or a higher magnitude of distraction, we advise usage of distraction instrumentation and consideration of vertebrectomy for safe reduction. Understanding the variety of surgical options in the operative management of TCS is critical for safe and effective correction.

Background: Surgical site infections (SSIs) remain a significant complication in spine surgery, leading to increased morbidity, prolonged hospital stays, and substantial healthcare costs. While local vancomycin powder has shown promise in reducing SSIs, its efficacy and economic impact remain understudied, particularly in resource-constrained settings. This study aims to evaluate the impact of local vancomycin powder on SSI rates and associated costs in patients undergoing spine surgery.

Methods: A retrospective cohort study was conducted at Hospital Barros Luco Trudeau, Chile, including 205 patients who underwent instrumented spinal surgery between January 2017 and December 2019. Patients were divided into two groups: a control group (n=84) that did not receive vancomycin powder and a vancomycin group (n=121) that received suprafascial vancomycin powder during surgery. Data on SSI rates, hospitalization costs, antibiotic costs, and reoperation costs were extracted from electronic medical records. SSIs were defined according to the Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) guidelines. Statistical analyses included independent t-tests, Chi-squared tests, and Mann-Whitney U tests, with a P value <0.05 considered significant.

Results: The overall SSI rate was 6.3% (13/205), with a significantly higher rate in the control group (11.9%, n=10) compared to the vancomycin group (2.48%, n=3; P<0.05). Cultures were positive in six cases in the control group, while all cultures in the vancomycin group were negative. The most common pathogens were Klebsiella pneumoniae and Staphylococcus aureus. The average hospitalization cost was significantly lower in the vancomycin group [USA dollar (USD) 1,314] compared to the control group (USD 1,481; P<0.05). Vancomycin prophylaxis resulted in an average cost savings of USD 17,368 per 100 patients.

Conclusions: Local vancomycin powder significantly reduces SSI rates and associated healthcare costs in spine surgery. These findings support the use of vancomycin powder as a cost-effective prophylactic measure, particularly in resource-constrained settings. Further prospective studies are needed to validate these results and establish standardized guidelines for its use.

Background: Degenerative lumbar spinal stenosis (DLSS) is a leading cause of low back and leg pain in the elderly. While conventional posterior lumbar interbody fusion (PLIF) is effective, it remains associated with significant tissue trauma and a relatively high incidence of chronic postoperative low back pain, even when empowered by current robotic-assisted technologies. Existing evidence suggests that robotic-assisted midline lumbar interbody fusion with cortical bone trajectory (RA-MIDLIF-CBT) may offer advantages in terms of minimal invasiveness. However, there is a lack of high-quality evidence regarding its non-inferiority in efficacy compared to the equally robotic-assisted PLIF technique, as well as its potential for enhancing accelerated recovery after surgery.

Methods: A single-center, prospective, randomized controlled, non-inferiority trial will be conducted. Seventy-four patients aged 60-80 years with single-level DLSS refractory to conservative treatment and meeting definitive criteria for lumbar interbody fusion will be enrolled and randomly assigned (1:1 ratio) to either Group A (control): Robot-assisted PLIF with pedicle screw fixation, or Group B (experimental): Robot-assisted MIDLIF-CBT. The primary outcome measure is the Oswestry Disability Index (ODI). Secondary outcomes include Visual Analog Scale (VAS) scores for low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, operative time, intraoperative blood loss, radiation exposure, screw placement accuracy, compliance with enhanced recovery after surgery (ERAS) protocols, and health economic parameters. Patients will be followed up for 12 months postoperatively.

Discussion: This study will be the first to provide high-level evidence on the non-inferiority of RA-MIDLIF-CBT compared to robot-assisted PLIF for treating DLSS. Leveraging the foundational platform of robotic assistance, the findings have the potential to establish RA-MIDLIF-CBT as a novel fusion technique that balances minimal invasiveness, safety, and cost-effectiveness. Additionally, the results will contribute evidence-based support for optimizing ERAS pathways in geriatric spine surgery.

Trial registration: The trial protocol was registered at Chinese Clinical Trial Registry (www.chictr.org.cn, Registration Number: ChiCTR2500095896).

Background: The prevalence of cervical spondylotic myelopathy (CSM) is increasing annually and represents a large burden of disability. Anterior cervical discectomy and fusion (ACDF), posterior cervical decompression (PCD), and PCD and fusion (PCDF) are commonly used surgical approaches to address this pathology. This single-institution retrospective cohort of ACDFs, PCDFs, and PCDs compares readmission rates and the incidence/indication for reoperation at 90-day, 1-year, and 2-year follow-up.

Methods: Patients undergoing ACDF, PCD, or PCDF between 2013 and 2019 were identified using CPT codes. Charts were reviewed for demographics, surgical characteristics, and reoperations. Statistical analysis included t-tests for continuous variables and χ² testing for categorical variables.

Results: A total of 366 patients undergoing 175 ACDFs, 86 PCDFs, and 105 PCDs were included. Initial analysis of complications by surgical approach showed that the rate of reoperation was significantly higher in the PCDF group at 30-day and 1-year (P<0.001, P=0.003) with no difference at 2-year. Overall readmission rate over 1 year was 30.6%, and there was no significant difference between groups. Subsequent analyses demonstrated that patients undergoing PCDF or PCD had significantly higher Charleston Comorbidity Indices (CCI) than ACDF patients (P<0.001). Upon controlling for CCI in regression analyses, neither reoperation nor readmission rates varied significantly by surgical approach.

Conclusions: In our cohort, we observe advantages and limitations for each surgical approach. On examination of patient factors, patients undergoing PCDF and PCD tended to have a higher burden of comorbidities compared to those treated via an anterior approach. Upon controlling for comorbidity index, the observed difference in reoperation rates was no longer apparent. Thus, patient comorbidities, rather than surgical approach, may be the major driver for postoperative complications for treatment of CSM.