Journal of spine surgery最新文献

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.

Background: Long segment fusion for adult spinal deformity (ASD) has a significant rate pseudoarthrosis, which may be in part due to the mechanical forces across the lumbosacral junction (LSJ). Placement of an interbody cage at the L5-S1 disc space and iliac fixation are two strategies to decrease strain at the L5-S1 level. This study assesses the current literature on biomechanics of the LSJ as it pertains to instrumentation in the context of long segment fusion for ASD.

Methods: A systematic review of MEDLINE via the PubMed database and EMBASE was performed by two independent reviewers. Studies were included if they featured human cadaveric studies that had undergone multilevel spinal fusion involving the L5-S1 junction, and studies that measured biomechanical differences with and without iliac fixation and interbody fixation at L5-S1.

Results: From a biomechanical standpoint, anterior lumbar interbody fusion (ALIF) and iliac fixation are similar in their reduction in range of motion (ROM) about the L5-S1 joint as well as S1 screw strain, compared to pedicle screws alone. Iliac fixation appears to reduce screw strain in more directions compared to ALIF. However, iliac fixation significantly increases posterior rod strain. No studies showed statistically significant biomechanical differences with concurrent iliac and interbody fixation, although 4 of 7 studies reported a trend towards decreased L5-S1 ROM.

Conclusions: Both iliac fixation and ALIF cages decrease S1 screw strain and L5-S1 ROM in the setting of multilevel fusion constructs to the LSJ. There is no biomechanical evidence that concurrent iliac fixation and ALIF cages provide significant additional benefit. Larger biomechanical and clinical studies are warranted to better understand the relationship between the two strategies of reduction strain and successful arthrodesis across the LSJ.

Background: The use of social media in spine surgery is becoming increasingly prevalent as patients aim to navigate the complex system of spine surgeons, physician networks, and hospitals. The purpose of this study is to gather data via surveys administered to spine surgery clinic patients in order to assess (I) differences in how often patients who are self-referred versus those who are referred to a spine surgeon by a primary care physician (PCP) or other physician/department use social media to search the spine surgeon prior to their first clinic visit; and (II) how often these searches result in a change in behavior in terms which spine surgeon a patient chooses to see.

Methods: This survey study was performed at an academic tertiary referral center's outpatient orthopedic spine clinics. Surveys were administered to all willing new patients at their first clinic visit with a spine surgeon.

Results: A total of 181 surveys were collected, and 169 surveys were used for final analysis after meeting the inclusion criteria. Average patient age was 59 years (range, 24-87 years), and 86.3% were White. Most patients, whether PCP-referred or self-referred, stated that social media platforms and online search engines played no role in selecting their spine surgeon. Patients who did an online search mostly used Google and the hospital-sponsored physician profile page. One patient in the PCP-referred group requested a different spine surgeon based on their online reading, and one patient in the self-referred group did so. For patients who seek information about their surgeon, Google and the hospital-sponsored physician profile are the most visited.

Conclusions: Social media platforms and online search engines overall played little to no role in selecting a spine surgeon for the vast majority of new spine clinic patients. From the patients who did use online search engines prior to their first clinic visit, Google and the hospital-sponsored physician profile were the most visited.

Background and objective: Anterior column lumbar interbody fusion using an anterior lumbar interbody fusion (ALIF), oblique lumbar interbody fusion (OLIF)/anterior-to-psoas fusion (ATP), lateral lumbar interbody fusion (LLIF), or combination technique allows insertion of a wide-footprint interbody cage and provides immediate segmental stability, indirect neural decompression, lower risk of subsidence, access for disc preparation, the ability to use a large volume of graft, and restoration of coronal and sagittal balance. Blood loss is usually less than with posterior fusion procedures, except for rare cases of severe vascular injury. The objective of this review was to compare the ALIF, OLIF/ATP, and LLIF techniques to provide a contemporary pragmatic guide for spine surgeons.

Methods: PubMed and Ovid Medline databases were searched to identify English-language studies published from 2000 to 2024. The search terms were "anterior", "fusion", "interbody", "lateral", "lumbar", and "oblique". We included studies describing the indications, approaches, patient positioning, surgical technique, learning curve, complications, radiation exposure, need for supplemental fixation, and clinical and radiologic outcomes of ALIF, OLIF/ATP, and LLIF procedures.

Key content and findings: This review compared the ALIF, OLIF/ATP, and LLIF techniques regarding patient factors, anesthetic factors, surgical factors, operative efficiency, surgical risks, and economic factors. We focused on differences between techniques to help clinicians choose between procedures and identified the preferred procedure(s) at each spinal level. We supplemented data from the literature with practical information obtained from our substantial clinical experience with these procedures.

Conclusions: ALIF, OLIF/ATP, and LLIF are all effective techniques for anterior interbody fusion, which provide very good long-term clinical outcomes, excellent fusion rates, and low but specific complication rates.

Background and objective: Ankylosing spondylitis (AS) spinal fractures pose unique diagnostic and therapeutic challenges due to the altered biomechanics, rigid ankylosed spine, and risk for extensive neurologic injury. The optimal practice is not established with rising clinical occurrences. This article aims to review the current literature regarding diagnosis, classification, and operative and non-operative treatment paradigms of spinal fractures due to AS in adults and present a cohesive perspective to facilitate evidence-based clinical practice.

Methods: A narrative systematic review was conducted on the basis of the PubMed database, including English-language papers from January 2000 to May 2025. Keywords included "AS", "spinal fracture", "vertebral trauma", "surgical management", and "neurological outcomes". Studies identified were evaluated based on clinical relevance, level of evidence, and representation of evolving concepts in diagnosis and management.

Key content and findings: The review discusses the specific biomechanical frailties of the ankylosed spine, recent classification methods like AO Spine and Denis classifications, and recent imaging modalities for diagnosis. It highlights operative decision-making approaches, posterior-only, anterior, and combination, in fracture morphology, neurologic status, and patient comorbidities. It discusses perioperative concerns such as positioning issues, blood loss, and complications like hardware failure and infection. Four summary tables provide insight into imaging preference, surgical interventions, outcomes, and complication profiles.

Conclusions: Prompt diagnosis and personalized treatment of AS-related spinal fractures are essential to reducing morbidity and mortality. Emerging literature supports the use of posterior-only methods in selected cases, but highly context-specific surgical choices must remain. The review stresses the importance of prospective studies as a guide to standard treatment protocols and improved outcomes for this difficult patient group.

Background: Anchored standalone cages for anterior cervical discectomy and fusion (ASC-ACDF) are easier to implant but have higher subsidence rates compared to anterior plating constructs. Smoking is a known risk factor for subsidence, however, there are conflicting reports on its effect on functional outcomes. This study aims to evaluate the impact of smoking on radiological and functional outcomes of patients undergoing ASC-ACDF.

Methods: Patients who underwent primary single- and double-level ASC-ACDF between 2015-2022 were reviewed. Inclusion: diagnosis of cervical myelopathy, radiculopathy or myeloradiculopathy, age range 40-90 years old. Exclusion: previous cervical spine surgery, diagnosis of tumor or infection. Patients were divided into non-smokers (NS) or current and ex-smokers (CES). Data was collected radiological outcomes [postoperative subsidence rates, Δtotal intervertebral height (TIH), Δlordotic angle] at 1-year and functional outcomes [Japanese Orthopedic Association (JOA) score, Neck Disability Index (NDI), Visual Analogue Scores for Neck Pain (VASNP) and Upper Limb Pain (VASLP)] at 6 months and 2 years postoperatively.

Results: A total of 71 patients were included (CES: 23; NS: 48). CES had higher subsidence rates at 1-year (60.9% vs. 35.4%, P=0.043) with greater TIH loss (ΔTIH -2.4 vs. -1.7 mm, P=0.038). Fusion rates (91.3% vs. 89.5%, P=0.82) and change in lordosis (-4.1° vs. -3.8°, P=0.78) were insignificantly different. Both groups demonstrated significant improvement in all functional scores after surgery (P<0.05) at similar rates (P<0.05). JOA scores were unaffected by smoking. However, CES consistently had higher NDI, VASNP, and VASLP scores at all timepoints.

Conclusions: Subsidence rates and functional scores (NDI, VASNP and VASLP) are nearly double in smokers after surgery. In ASC-ACDF, while smokers and NS benefit from surgery, smoking is associated with higher disability and pain scores.