Journal of spine surgery最新文献

Background: Kerrison rongeurs are frequently used during decompressive procedures but carry risks such as incidental dural tears and occupational strain for spine surgeons. High-speed drills are often used for bony decompression. In other surgical specialties, ultrasonic aspirators have been shown to safely remove bone near critical structures like the dura and nerves. However, their application in spine surgery remains underexplored. The aim of this pilot study was to evaluate the safety and efficacy of ultrasonic aspirators as an alternative to high-speed drills and Kerrison rongeurs in minimally invasive laminectomies.

Methods: Twenty-seven patients underwent 40 level of lumbar laminectomies for degenerative spinal stenosis using minimally invasive tubular approaches. Patients were grouped by decompression tool used: high-speed drill only (19 patients, 24 levels), ultrasonic aspirator only (12 patients, 16 levels), or both tools (4 patients). The number of Kerrison bites per level were recorded. Estimated blood loss (EBL) was compared in single-level cases between the ultrasonic aspirator (n=6) and drill only groups (n=10).

Results: The mean number of Kerrison bites was significantly lower in the ultrasonic group (8.06) compared to the drill group (38.25; P<0.001). Among single-level cases, mean EBL was reduced in the ultrasonic group (21 mL) versus the drill group (52 mL; P=0.02). No adverse events were observed with ultrasonic use.

Conclusions: This pilot study suggests ultrasonic aspirators may reduce the need for Kerrison rongeur use and intraoperative blood loss in minimally invasive laminectomies, without increasing operative time. These findings support further prospective evaluation.

Biportal endoscopic spine surgery (BESS) has emerged as a minimally invasive technique for various spinal disorders, but its application in intradural extramedullary tumors (IDEMs) remains limited due to technical challenges. These include maintaining optimal irrigation pressure, ensuring safe and controlled tumor dissection, achieving hemostasis, and preventing cerebrospinal fluid (CSF) leakage. We report the case of a 59-year-old female who presented with progressive lower limb weakness, gait disturbance, and sphincter dysfunction. Magnetic resonance imaging (MRI) revealed a T10-T11 intradural extramedullary schwannoma causing severe spinal cord compression. The tumor was successfully resected using BESS under intraoperative neuromonitoring (IONM). We provide a detailed description of the surgical technique and strategies to overcome the key challenges associated with this approach, including stable irrigation pressure control, dural suspension for field stabilization, two-handed microsurgical dissection, piecemeal tumor removal with careful hemostasis, and watertight dural closure with endoscopic suturing. The operation lasted 150 minutes with an estimated blood loss of 180 mL. Postoperative MRI confirmed total tumor removal without spinal cord injury or CSF leakage. The patient experienced significant neurological recovery, including improved motor function and restoration of bladder control. Continued improvement was observed at the two-month follow-up, with enhanced lower limb strength and resolution of sensory disturbances. This case demonstrates the feasibility of BESS for thoracic IDEMs and suggests it may serve as a viable minimally invasive alternative in selected cases. To improve outcomes, further refinements in endoscopic visualization, microsurgical technique, and instrumentation are essential, and additional studies are warranted to confirm the long-term safety and efficacy of this approach.

Background: Adult scoliosis, marked by degenerative and pathological changes in the spinal column, is a growing health concern, particularly among the elderly, often leading to chronic pain and functional limitations. Initial management typically includes conservative approaches such as physical therapy; however, persistent symptoms frequently necessitate surgical intervention. Recently, lumbar interbody fusion (LIF) techniques, including lateral lumbar interbody fusion (LLIF) and oblique lumbar interbody fusion (OLIF) approaches, have gained attention as less invasive alternatives to traditional open spinal surgery. This study aims to provide a systematic review of the efficacy and safety of lateral interbody fusion of the lumbar spine in the available literature to inform clinical decision-making. We hypothesize that lateral interbody fusion provides a viable surgical option with favorable reductions in postoperative Cobb angle.

Methods: A systematic review was conducted to examine the outcomes of LIF in adult scoliosis patients. PubMed/MEDLINE, Embase, and Scopus were queried in January 2024 to identify relevant articles published since 2010. Articles were screened for inclusion based on predefined criteria, and data extraction was performed to collect demographic, clinical, functional, and radiographic measurements. Statistical analysis was conducted using a random effects model to assess primary outcomes of interest, including changes in Oswestry Disability Index (ODI) scores and Cobb angle measurements before and after LIF surgical intervention. The robvis tool was employed to create standardized visualizations of risk of bias across included studies.

Results: The systematic review identified 46 articles that met the inclusion criteria, of which eight studies, encompassing a total of 424 patients, were selected for final analysis. Five of these eight studies, involving 289 patients, specifically examined outcomes for those who underwent LIF. Meta-analysis of available data revealed a statistically significant reduction in postoperative Cobb angle following LIF (mean decrease: 9.50 degrees, 95% confidence interval: -11.47 to -7.52), indicating effective deformity correction. Heterogeneity was observed across studies, likely attributed to variations in surgical techniques and measurement methods.

Conclusions: LLIF demonstrates efficacy in adult scoliosis management, with favorable outcomes in terms of deformity correction and functional improvement. The minimally invasive nature of LLIF contributes to reduced surgical morbidity and accelerated recovery, underscoring its significance as an alternative to traditional open surgery of the lumbar spine. Limitations include heterogeneity present across studies, which warrant continued research to evaluate these outcomes. Nevertheless, LLIF holds promise as an effective surgical approach.

Background: With the increasing use of artificial intelligence (AI) chatbots like ChatGPT for online patient education, Generative Pre-trained Transformer 4 (GPT-4) has emerged as a significant tool for providing accurate health information. This study aims to compare Google and GPT-4 in terms of (I) question types, (II) initial response readability, (III) ChatGPT's ability to modify responses for increased readability, and (IV) numerical response accuracy for the top 10 most frequently asked questions (FAQs) related to cervical disc arthroplasty (CDA).

Methods: "Cervical disc arthroplasty" was searched on Google and GPT-4 on December 18, 2023. The top 10 FAQs were recorded and analyzed using the Rothwell system for categorization and Journal of the American Medical Association (JAMA) criteria for source quality. Readability was assessed by Flesch Reading Ease and Flesch-Kincaid grade level. GPT-4 was prompted to revise text for low-literacy readability. We used Student's t-tests for a comparative analysis between GPT-4 and Google, setting significance at P<0.05.

Results: FAQs from Google predominantly related to technical details and evaluation of surgery, paralleling GPT-4's focus, which also included indications/management. No significant differences were found in readability between GPT-4 and Google, displaying a similar Flesch-Kincaid grade level (13.06 vs. 12.24, P=0.41) and Flesch Reading Ease score (36.87 vs. 40.05, P=0.53). Upon prompting GPT-4 to improve the readability of its responses, GPT-4 showed a lower Flesch-Kincaid grade level (6.58 vs. 13.06 vs. 12.24, P<0.001) and a higher Flesch Reading Ease score (76.20 vs. 36.87 vs. 40.05, P<0.001). Numerically, 60% of responses differed, with GPT-4 suggesting a broader recovery period for CDA.

Conclusions: GPT-4 has the potential to enhance patient education about CDA by customizing complex information for users with lower health literacy levels. This highlights GPT-4's ability to address existing gaps in online resources, benefiting those with lower health literacy.

Background and objective: Anterior lumbar spine surgery (ALSS) provides multiple benefits for the patient with spinal pathology. Vascular complications are uncommon and usually managed with simple surgical techniques and ancillary products. Rarely, confronting massive haemorrhage can occur after a venous injury which endangers the patient. We aimed to review the anatomical basis and risk factors for venous injury, propose a staged, systematic approach for management and discuss open surgical techniques, instruments, products, and strategies in detail for each of the stages.

Methods: This was a narrative review. A systematic approach was used. A review of national databases (PubMed, Ovid Medline, and Google Scholar) was performed using literature from 2000 to 2024 in English. Keywords included terms "anterior", "lumbar", "spine", "haemorrhage", "venous injury", "vascular", "repair", "ligation", "damage control", and "venous thromboembolism". Studies that aimed to describe the anatomy, risk factors, incidence, surgical techniques, complications, clinical and radiological outcomes of ALSS were included. Other generalised searches, not included in the initial systematic search, were conducted and included in our narrative review.

Key content and findings: This review considers the relevant anatomy, risk factors, patient work-up, lists possibly useful instruments and consumables, the broad stages of open management, specific operative strategies and techniques, and the post-operative management of the patient.

Conclusions: Massive venous injury (MVI) in ALSS is a rare but potentially life-threatening complication. Multiple open surgical techniques can be employed to control and manage the injury(s). The surgical and anaesthetic teams should have formulated a unified contingency plan against the eventuality of massive venous haemorrhage. The best outcome is only achieved with a team approach to the situation, recruitment of the necessary personnel and the deployment of the necessary equipment to enable the open management.

Background: Lumbar degenerative disc disease (LDDD) is a widespread condition contributing to chronic lower back pain and impaired mobility. While spinal fusion has been the conventional treatment, it poses drawbacks including extended recovery periods and the risk of adjacent segment degeneration. Lumbar disc arthroplasty (LDA) has emerged as a motion-preserving alternative with the potential to mitigate these risks. This study aimed to assess how factors such as hospital size, regional location, and patient characteristics influence hospitalization charges during the initial admission for LDA.

Methods: This retrospective study utilized the National Inpatient Sample (NIS) database from 2016 to 2020 to identify patients who underwent LDA. The primary endpoint was total hospitalization charges for the initial surgical admission. Variables analyzed included demographic data, hospital attributes, and economic indicators at the regional level. Both multivariate linear regression and machine learning (ML) techniques-logistic regression, random forest, and gradient boosting-were applied to evaluate predictive factors for cost. A significance threshold was set at P<0.05.

Results: A total of 568 patients met the inclusion criteria, consisting of 526 single-level and 42 multi-level LDA procedures. The average admission charge was $124,946, with high-cost admissions defined as those exceeding $155,770. The mean hospital stay was 2.3 days. Key predictors of increased charges included longer length of stay, treatment at large hospitals, and for-profit hospital ownership. Among the models tested, the random forest algorithm yielded the highest predictive accuracy [area under the receiver operating characteristic curve (AUC) =0.836], followed by gradient boosting (AUC =0.826) and logistic regression (AUC =0.822).

Conclusions: Charges associated with LDA are significantly influenced by institutional and patient-level factors. ML models effectively predicted cost variability and hold promise for informing cost-effective strategies in spine surgery. Integrating these models into clinical workflows may enhance both financial planning and patient care.

Transdiscal screw fixation with pedicle screws at the upper level has shown promising results for lumbosacral spondylolisthesis, but there are few reports of clinical use of isolated transdiscal fixation. This case series presents our technique of direct foraminal decompression for vertical foraminal stenosis and stand-alone transdiscal screw fixation with fully threaded 7.3 mm cannulated screws and grafting for grade 2-3 L5-S1 isthmic spondylolisthesis. Demographics, complications, revisions, radiographic measurements, and Visual Analog Scale (VAS) pain and Oswestry Disability Index (ODI) scores were collected. Five patients were included: two females and three males. Mean age was 81.6 (range, 69-93) years. Three patients had a prior decompression. Mean follow-up was 18 (range, 12-24) months. There were no complications or revisions. Mean pre-operative ODI was 46 (range, 26-60). Mean postoperative ODI was 26 (range, 4-51). Mean pre-operative VAS was 8 (range, 6-9), which improved to mean 6-week VAS of 3 (range, 0-8), mean 3-month VAS of 1 (range, 0-4), and mean 6-month VAS of 1 (range, 0-4). Mean 12-month VAS was 0.6 (0-3). Direct foraminal decompression and standalone transdiscal screw fixation with grafting is a safe and useful minimally invasive method of achieving fusion for patients with high-grade isthmic spondylolisthesis, relatively collapsed disc space, and acceptable sagittal balance.

Background: The management of gunshot wounds to the spine remains controversial, given the limited number of cases, variability of injuries, and lack of standard treatment protocols. This study presents data from a major urban, academic, level 1 U.S. trauma center, with the aim of investigating the management pathways of spinal gunshot wounds.

Methods: We performed a retrospective single-center study spanning from 2011-2023. Thirty-nine patients with gunshot wounds to the spine were identified.

Results: Patients were predominantly male (92.3%) with a mean age of 25 years. Demographics included Black (78.4%), Hispanic (18.9%), and Caucasian (2.7%). American Spinal Injury Association Impairment Scale (AIS) scores on presentation were: 31.6% A, 0.0% B, 5.3% C, 18.4% D, 44.7% E. The primary location of the lodged bullet was the lumbar spine (45.5%), followed by thoracic (27.3%) and cervical (21.2%). Prophylactic antibiotics were used in 79.5%. Of the patients, 12.8% developed wound infections unrelated to the spinal column. Four patients underwent surgery (10.3%). The remaining five patients (12.8%) were managed without bracing. Outcomes upon discharges were: modified Rankin scale (mRS) of 0-2 (47.4%) or 3-4 (44.7%), AIS A (23.7%), C (7.9%), D (23.7%) and E (44.7%), with 44.1% sensation intact. Motor status from presentation to discharge was largely unchanged in 40.0% compared to worse or improved (10.0% each). Median follow-up was 2.1 months (0.9-11.6 months), with unchanged AIS scores. There was considerable variation within AIS category D.

Conclusions: Most patients were managed conservatively, with largely unchanged functional outcomes. Further studies with a larger sample size and standardized data collection may provide further insight to determine the efficacy of treatment options of gunshot wounds to the spine.

Background: Manual contouring and insertion of spinal rods during corrective spinal fusion surgery are critical but challenging aspects that heavily rely on the surgeon's skill and experience. Variability in rod manipulation techniques can lead to prolonged surgery times, increased risks, and potential complications such as rod breakage or screw loosening. This case series reviews current literature and presents observational data on intraoperative rod manipulation across nine surgeries, providing insights that are crucial to improving surgical precision and outcomes.

Case description: The case series involves nine spinal surgery cases with patients ranging from pediatric to adult. Each case was observed for the number of rod bending and cutting maneuvers, time spent on these tasks, and the tools used. Results indicated that the total time spent on rod manipulation ranged up to 29 minutes, with 77.8% of cases requiring more than one attempt to achieve the correct rod length. Inefficiencies in rod length measurement and excessive bending attempts were commonly noted, leading to potential complications such as rod notching. The study concluded that these challenges significantly contribute to prolonged surgery times, increased risk of infection, and the potential for mechanical failure of the rods. By identifying specific areas of inefficiency and variability, this case series underscores the critical need for more standardized techniques and the development of more precise, easy-to-use tools that can improve surgical outcomes.

Conclusions: This case series highlights significant variability and inefficiency in current spinal rod manipulation techniques, underscoring the need for standardized, precise methods that can reduce surgery time and improve patient outcomes. The findings provide a foundation for further research into simpler, more adaptable tools that could enhance the accuracy and efficiency of rod insertion in spinal surgeries.

Background: Surgical site infections (SSIs), biofilm formation, and periprosthetic joint infections (PJIs) are critical complications in orthopaedic surgery, impacting patient outcomes and increasing healthcare costs. While evidence supports the efficacy of a novel citrate-based irrigation solution in joint arthroplasty, its applications in spine surgery remain underexplored. This study aims to evaluate literature supporting its role in infection prevention for joint arthroplasty, and explores potential indications, benefits, and application techniques for spine surgery.

Methods: A systematic review was conducted following preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, searching PubMed-MEDLINE and Cochrane Library databases (January 1, 2020 to November 1, 2024). Studies on the safety/efficacy of citrate-based irrigation solutions were included, focusing on infection rates, biofilm disruption, and recovery outcomes. Quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) and Newcastle-Ottawa Scale. Out of 64 studies screened, nine met inclusion criteria.

Results: The reviewed studies demonstrated that the solution disrupts biofilms by chelating metal ions critical for biofilm stability, reducing microbial loads by up to six logs for planktonic bacteria and four to eight logs for biofilms. Clinical findings in joint arthroplasty included reduced infection rates, reduced swelling, increased range of motion, and faster opioid weaning. Applications for use in spine surgery include multi-level fusions, posterior cervical surgeries, deformity corrections, and procedures in patients with infection risk factors like diabetes or smoking. Techniques include pre-implantation cleansing, periodic irrigation during surgery, and extended antimicrobial protection with a no-rinse protocol to prevent biofilm formation on hardware and tissues.

Conclusions: The citrate-based solution shows promise for infection prevention in orthopedic and spine surgeries, offering biofilm disruption and reduced toxicity. Future randomized trials are necessary to confirm its safety and efficacy, with the potential for broader adoption in surgical protocols.