Journal of spine surgery最新文献

Background: Adolescent idiopathic scoliosis (AIS) often presents with significant spinal curvature and small, anatomically distorted pedicles, particularly in the thoracic spine. These factors make pedicle screw placement technically challenging and elevate the risk of neurovascular injury and poor bone purchase. Intraoperative O-arm navigation has emerged as a promising tool for enhancing screw placement accuracy and minimizing complications. This study aimed to (I) determine the accuracy of pedicle screws placed with intraoperative O-arm guidance at the thoracic and lumbar levels in spinal fusions for AIS; (II) evaluate postoperative curve correction and fusion maintenance; and (III) assess reoperation and complication rates due to screw misplacement.

Methods: A single-institution retrospective review was performed for pediatric patients (<18 years) who underwent posterior spinal instrumentation and fusion (PSIF) for AIS from June 2023 to August 2024. Patients included had Lenke 1AN-6C curves and preoperative Cobb angles >40°. Intraoperative O-arm CT was used for navigation and final assessment of screw positioning. Postoperative X-rays assessed correction and alignment. Chart review identified reoperations and complications attributable to screw malposition.

Results: A total of 227 pedicle screws were placed in 12 AIS patients (mean age: 14 years). All screws (100%) were accurately placed without cortical breach. The Wilcoxon Signed-Rank test showed a large, significant difference between the Pre-Operative Cobb Angles (Mdn =51.5, n=12) and the Post-Operative Cobb Angles (Mdn =19.7, n=12), (W+ =0, P<0.001, r=-1). 0 patients experienced screw-related complications or required reoperation.

Conclusions: In AIS patients with severe curves and narrow pedicles, intraoperative O-arm navigation provides precise, breach-free pedicle screw placement and facilitates safe, durable deformity correction. These results support the use of intraoperative navigation in complex pediatric spinal deformity surgery.

Background: Never before has technology been so universally accepted as the modern-era cell phone, the smartphone. Spine surgeons have noticed a rise in patients in their offices complaining of neck and upper back pain. Many patients are of the younger age group, and one thing they all seem to have in common is prolonged smartphone use. While using a smartphone, the cervical spine demonstrates flexion angles ranging from 15 to 60 degrees, with more pronounced deviations from the neutral position observed during sitting compared to standing, and while texting compared to web browsing or video watching. Nowadays, there is strong evidence that persistent neck pain and radiculopathy are associated with time spent text messaging. While it now seems rather clear that repetitive texting, or similar activity while utilizing a forward flexed neck position, may lead to neck pain or "text neck", what is currently unknown is whether this poses a risk for intervertebral disk degeneration and consequent cervical spondylosis, and if so, at what age the condition will emerge and which levels of the cervical spine will it affect the most. The aim of this study was to evaluate the effects of smartphone texting on cervical spine sagittal alignment in healthy young adults, and to identify which cervical segments are most affected, particularly comparing sitting versus standing postures.

Methods: We took lateral radiographs of the cervical spine of healthy volunteers younger than 40 years old. The radiographs were made while texting on a smartphone and in a neutral position, sitting and standing. Then we measured the disc angles, vertebral angles, and sagittal angles on each radiograph.

Results: When texting while standing, significant (P≤0.05) changes in the intervertebral angles (IVAs) were seen at foramen magnum (FM)-C2, FM-C3, FM-C4, C1-2, C2-4, C2-T1, C3-4, C3-5, C3-6, C3-7 and C3-T1. The significant changes in the interdiscal angles (IDAs) were seen at C3-4, C4-5. No significant changes were seen in the angle of lordosis (AOL). When texting while sitting, the significant (P≤0.05) changes in the IVAs were at IVAs: FM-C2, FM-C3, FM-C4, C1-2, C1-3, C1-4, C2-7, C2-T1, C3-4, C3-5, C3-6 and C5-7. The significant changes in the IDAs were at C3-4, C5-6. No significant changes were seen in the AOL.

Conclusions: Our observation shows that the most significant changes in the cervical spine while texting occur in the upper segments of the cervical spine, more pronounced while sitting.

Background: Anterior cervical discectomy and fusion (ACDF) is a widely used approach for cervical pathologies. However, achieving optimal sagittal alignment with static implants remains challenging. Expandable titanium cages (ETC) may offer the advantage of precise alignment adjustments. This study presents our early clinical experience with ETC in ACDF.

Methods: Between 2019 and 2023, we performed a retrospective analysis at Weill Cornell Medicine, Department of Neurosurgery, New York-Presbyterian Hospital, examining patients who underwent ACDF with ETC. Hospital records, imaging, and pre- and post-operative visits were reviewed. We assessed clinical outcomes using the numeric rating scale (NRS) for arm and neck pain and the neck disability index (NDI). Radiological outcomes included cervical and segmental lordosis, disc height, cage subsidence, and fusion status. For data analysis, we used R Studio, with GraphPad Prism, for data visualization.

Results: Forty-four patients (mean age 53±13 years, 52.3% female) with 77 treated levels were analyzed. C5-6 (39%) was the most treated level, and 61.4% underwent two-level fusions. The median follow-up was 12 months (interquartile range, 11-13 months). Clinical outcomes showed significant improvement: NRS-Arm pain (2 to 0), NRS-Neck pain (6 to 2), and NDI (35 to 9). Radiographically, cervical lordosis improved from 4.4° to 9.0°, segmental lordosis from -0.9° to 2.4°, and anterior disc height from 4.0 to 8.5 mm, all sustained at follow-up. Fusion occurred in 69 of the 77 treated levels (fusion rate: 89.6%). Among 29 patients (65.9%) who completed approximately 12 months of follow-up (range, 11.6-41.2 months) with 53 treated levels, fusion occurred in 51 levels (fusion rate: 96.2%). Subsidence was observed in 16/77 segments (20.8%) overall, and in 10/53 segments (18.9%) within the subgroup with approximately 12-month follow-up. The overall rate of new subsidence decreased significantly over time. There were no revision surgeries or neurological complications.

Conclusions: This study highlights the effectiveness and safety of ETC in achieving sagittal alignment and disc height restoration in ACDF.

Background: Subaxial cervical spine injuries are commonly managed in cervical collars but these may not provide sufficient support for some injuries. Surgical stabilisation carries both immediate and longer-term risks. Halo vest immobilisation (HVI) has been widely documented in the management of upper cervical spine injuries but there is less data regarding its use for subaxial injuries. The objective of this study was to investigate complications and outcomes associated with HVI for subaxial cervical spine injuries.

Methods: A retrospective review of patients with subaxial cervical spine injuries, treated with HVI between 2016 and 2021, and followed-up in a dedicated "halo clinic", was performed. Data relating to demographics, injury and follow-up were collected. Patients in whom HVI was used as an adjunct to surgical management for upper cervical or isolated thoracic injuries were excluded.

Results: 46 patients (67% male) with a median age of 33 years were included. Four (9%) were lost to follow-up. Median time of HVI was 80 days. Three patients (6.5%) underwent subsequent surgery. Two, with multi-level injuries, underwent a single and two-level anterior cervical discectomy and fusion for ongoing instability. One patient underwent multi-level posterior fusion due to early loss of alignment with HVI. Other complications included four pin site infections (9%) and seven pin loosening (15%).

Conclusions: HVI can be utilised to manage subaxial cervical spine injuries with careful follow-up. There may be a role in reducing the requirement for multi-level fusion in multi-level injuries, however, future prospective trials are required to elucidate this. Further investigation is required to ascertain patient reported outcomes comparing HVI to surgical management for subaxial cervical spine injuries in the long term.

Background: Osteoid osteoma (OO) of the spine is a rare benign tumor that can cause significant pain and radiculopathy, particularly when the lesion involves the posterior elements such as the pedicle. Although traditional treatments like radiofrequency ablation (RFA) and open surgery are effective, they pose risks including neural injury and spinal instability. In recent years, full-endoscopic spine surgery has emerged as a minimally invasive alternative, offering precise lesion localization and resection while preserving spinal integrity.

Case description: We present the case of a 20-year-old female who reported a 6-month history of progressive low back pain and severe left-sided L5 radiculopathy. Imaging revealed a nidus in the left L5 pedicle consistent with OO. The lesion was successfully resected using a full-endoscopic pedicle-based approach with the RIWOspine system. The procedure was performed under fluoroscopic guidance, allowing direct visualization and excision of the nidus. The patient experienced immediate symptom relief, and postoperative imaging confirmed complete resection. Histopathological examination confirmed the diagnosis of OO. At 1-year follow-up, she remained asymptomatic with no evidence of recurrence or spinal instability.

Conclusions: Full-endoscopic pedicle-based resection provides a safe, effective, and minimally invasive technique for managing spinal OOs. This approach offers direct nidus visualization, preservation of spinal stability, and excellent clinical outcomes, supporting its utility as a preferred option in select cases. A literature review further supports its utility as a viable first-line surgical option, particularly in young patients with posterior element lesions. Future studies are needed to validate this technique in larger cohorts and to establish standardized protocols.

Background: Anterior cervical discectomy and fusion (ACDF) is widely performed for cervical pathology, yet multilevel anterior constructs are associated with higher rates of dysphagia, pseudoarthrosis, and mechanical failure-particularly at the caudal segment. These complications may arise from stress concentration and load transfer through long anterior cervical plates. Segmentally separated fixation, utilizing multiple short plates rather than a single long plate, may reduce these risks by limiting exposure, shortening operative time, and distributing mechanical loads more evenly. The purpose of this study was to compare the biomechanical behavior of multilevel ACDF constructs stabilized with multiple segmental plates versus a single long plate.

Methods: Twelve fresh-frozen human cadaveric cervical spines (C4-C7) underwent ACDF using either a single long plate or multiple segmental plates. Bone quality was quantified via C7 trabecular Hounsfield units on computed tomography (CT), and specimens were randomized by density. Identical constructs were also tested in polyurethane foam cervical models to minimize biological variability. Specimens were mounted to multiaxial test platforms and subjected to fatigue cycling under flexion-extension, lateral bending, and axial rotation. Construct stiffness was recorded at baseline and after 1,500 cycles in each motion plane. Stiffness loss was analyzed with one-way analysis of variance (ANOVA) and normalized to bone density.

Results: Initial construct stiffness did not differ between groups (P=0.86). After cyclic loading, multiple segmental plates demonstrated significantly greater stiffness retention in axial rotation (51%±10% vs. 88%±4% loss; P<0.001) in synthetic models. No significant differences were found for flexion-extension or lateral bending. In cadaveric specimens, normalized stiffness loss was comparable between groups, likely reflecting greater biological variability.

Conclusions: Segmentally separated anterior fixation for multilevel ACDF preserves rotational stiffness at the caudal segment more effectively than long single-plate constructs in controlled models. This suggests a potential mechanical advantage that may translate to reduced stress concentration and lower failure risk in multilevel anterior cervical reconstructions. Further in-vivo and clinical correlation studies are warranted to validate these biomechanical findings and assess long-term fusion outcomes.

Minimally invasive endoscopic procedures for the treatment of lumbar disc herniations (LDHs) have gained increasing popularity among spine surgeons during the last decade. The majority of LDH cases can be effectively managed using endoscopic techniques, particularly the interlaminar or transforaminal approaches, which allow for direct decompression of the affected nerve root with reduced morbidity compared to conventional open surgery. However, when LDHs migrate cranially or caudally beyond the usual intervertebral disc space, their surgical management becomes significantly more challenging. This difficulty arises from the increased risk of postoperative instability, which is often associated with partial or total facetectomy required to achieve adequate exposure. These migrated herniations, commonly referred to as occurring in the so-called "hidden zone", represent a surgical dilemma due to their limited accessibility and the potential for increased complications. Furthermore, reports in the literature describing their management, particularly through minimally invasive endoscopic routes, remain relatively scarce. In this context, we present a detailed description of the translaminar fully endoscopic approach (TFEA) for the treatment of LDH in the hidden zone. In the authors' opinion, this approach offers a safe and effective minimally invasive alternative that minimizes anatomical disruption, preserves spinal stability, and broadens the spectrum of endoscopic spine surgery applications.

Background: Incidental durotomy and the subsequent cerebrospinal fluid (CSF) leak are well-recognized complications of spine surgery. While primary repair can be effective, persistent symptomatic leaks may necessitate more advanced interventions, and some patients continue to experience refractory headaches after spine surgery-related CSF leak treatment.

Case description: This case report describes two patients who presented with chronic headaches following CSF leak resolution and symptoms indicative of intracranial hypertension (ICH), including tinnitus, visual disturbances, and dizziness. Case 1 was a 46-year-old male who suffered from a continual low-grade headache that intensified when lying down, particularly disturbing him during the early hours of the morning. A myelogram revealed excessive intradural pressure. Case 2 was a 55-year-old female who required a temporary lumbar drain as part of her treatment for a persistent CSF leak; she experienced headaches that were particularly severe at night and worsened with exertion or prolonged activity.

Conclusions: Both patients reported tinnitus and visual changes closely aligned with headache symptoms. They were treated for ICH using a 4 weeks regimen of acetazolamide, followed by a tapering period of 4 weeks. With the initiation of acetazolamide, both patients experienced near-complete relief from their symptoms and were successfully weaned off. It is hypothesized that both individuals may have developed an overproduction of CSF following their prior leaks, leading to ICH, which effectively mitigated Acetazolamide's established role in reducing intracranial pressure.

Background: Adult spinal deformity (ASD) can result in debilitating symptoms and often necessitates surgical intervention. Postoperative complications-including thromboembolic events, proximal junctional kyphosis (PJK), pseudoarthrosis, and rod fracture-are common and can severely impact outcomes. While spinal bracing is commonly employed postoperatively, its' clinical value remains unproven. The aim of this study was to compare complication rates, pain levels, and outcomes between patients who received thoracolumbosacral orthosis (TLSO) bracing and those who did not following ASD surgery.

Methods: We conducted a retrospective review of consecutive ASD surgeries at our tertiary care center between 2016 and 2023. ASD surgery was defined as multilevel fusion involving at least 5 vertebral levels, extending from the pelvis to L2 or above. Surgical approaches included open or minimally invasive methods via different interbodies such as transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), or lateral lumbar interbody fusion (LLIF). Nine surgeons participated in the cohort.

Results: Of 265 patients, 193 (73%) received TLSO bracing postoperatively. Braced patients had a significantly increased risk of rhabdomyolysis [odds ratio (OR) =9.959; P<0.001] and deep vein thrombosis (DVT) (OR =5.960; P=0.007). Long-term opioid use (≥12 months) was more common in braced patients (OR =3.895; P=0.002), and they reported higher postoperative back and leg pain (P<0.05). Bracing was not associated with a reduction in surgical complications, nor did it improve spinopelvic alignment outcomes.

Conclusions: Routine bracing following ASD surgery does not reduce mechanical or surgical complications and may contribute to immobility-related morbidity and prolonged pain management. Forgoing postoperative bracing may improve patient outcomes and reduce healthcare costs. These findings support a reevaluation of routine bracing in ASD care.

Background: Interbody fusion, especially anterior lumbar interbody fusion (ALIF), is a common treatment for spinal conditions like degenerative disc disease (DDD). Various graft materials, including autografts, allografts, and synthetic substitutes, are used to facilitate fusion, though each has limitations. A novel growth factor bioavailability-enhanced allograft (GFBA) has been introduced, which aims to enhance fusion outcomes by unlocking critical growth factors in the bone matrix.

Methods: Consecutive patients who received treatment with GFBA at a single site between January 2022 and December 2022 were invited to participate prior to 12 months postoperative assessment. Those who consented were evaluated prospectively by computed tomography (CT), flexion extension X-ray, and completed questionnaires regarding pain and disability.

Results: Fifty patients (64 treated levels), with a mean age of 61.5 years old, 62.0% female, and a mean body mass index (BMI) of 31.0 kg/m² participated. Thirty-six patients (72.0%) underwent single level ALIF, and 14 (28.0%) underwent two-level ALIFs. All subjects (100%) had less than three degrees of motion upon flexion extension. CT scans showed complete bridging bone with no evidence of supplemental fixation failure for 89.1% of levels (defined as 3A), with the remaining 10.9% showing bone growth from both end plates and no sign of supplemental fixation failure (defined as 2A). Statistically significant improvements were observed in low back pain (60.1 to 29.6), left leg pain (33.8 to 21.4), and right leg pain (40.2 to 18.4), all P<0.05. No GFBA-related complications or revision/reoperations were reported.

Conclusions: This study evaluated a novel GFBA and reported similar fusion rates to published reports of iliac crest bone graft (ICBG). Significant clinical improvements and no GFBA related complications or revision/reoperations were reported. This is the first study evaluating GFBA and demonstrated its safety and efficacy in ALIF procedures for DDD.