Journal of spine surgery最新文献

Background: Endoscopic spine surgery has emerged as a significant advancement in minimally invasive spinal procedures, with advantages including reduced tissue trauma, faster recovery, and improved patient outcomes. A critical component of these surgeries is effective haemostasis, essential for maintaining visual clarity, ensuring surgical efficiency, and minimising perioperative complications. A scoping review was conducted to examine current clinical practices and research on haemostasis in endoscopic spine surgery, with the aim of synthesising existing knowledge into a practical framework to guide surgeons in managing intraoperative bleeding in endoscopic spine surgery.

Methods: A comprehensive literature search was conducted across PubMed, Embase and Cochrane Library, guided by the Population-Concept-Context (PCC) framework. Studies were included if they reported on techniques to achieve haemostasis in endoscopic spine procedures. Data were extracted on study design, surgical technique, haemostatic tools or agents used, and bleeding-related outcomes.

Results: The review identified various haemostatic methods including bipolar and radiofrequency cautery, tranexamic acid, gelatin-thrombin matrix sealants, bone wax, irrigation pressure modulation, and absorbable hemostatic agents. The review highlights that no single haemostatic method can be applied to all cases of endoscopic spine surgery. Instead, a multimodal approach is necessary to effectively achieve haemostasis. Based on this synthesis, we propose the FIBRE protocol, encompassing fluid management, initial exposure, bone bleeding control, red-out scenarios, and extra considerations, as a practical framework for managing haemostasis.

Conclusions: The proposed FIBRE protocol is a framework for controlling bleeding, improving visualisation, and enhancing surgical outcomes. By integrating these practices, surgeons can refine their techniques and contribute to enhanced patient outcomes in minimally invasive spine surgery.

Background: Aneurysmal bone cyst (ABC) is a rare, benign, and highly vascular osteolytic lesion characterized by expansile cystic spaces filled with blood and surrounded by thinned cortical bone. ABC is most commonly found in the vertebral column, most specifically in the posterior element of the lumbar spine. Management of spinal ABCs poses a challenge to the treating physician given its proximity to the neural structures. Surgical intervention, radiation therapy, cryotherapy, and embolization are effective treatment methods. However, no treatment protocol has been established in the literature, particularly when the tumor is uncommonly large.

Case description: We present the case of a 12-year-old female with a flank mass and abdominal fullness, imaging showed a gigantic expansile lytic lesion with left sided extension to the visceral organs at the level of L4 with mild scoliotic deformity. A biopsy confirmed an ABC. Patient underwent embolization and sclerotherapy which failed to achieve tumor control. Patient was taken for anterior tumor intralesional excision with posterior instrumented fusion. Postoperatively patient symptoms, deformity and her overall alignment improved.

Conclusions: The current case described the largest ABC spine tumor of the current pediatric literature. Multidisciplinary surgical management enabled satisfactory clinical and radiological outcomes with no recurrence at the last follow-up.

Background: Cervical myelopathy is a clinical syndrome resulting from cord compression at the level of the cervical spine characterized by fine motor, sphincter, and gait dysfunction, for which early surgical management is the mainstay of therapy. Identification of techniques to monitor for and facilitate early management of rare but serious neurologic complications following cervical spine surgery is of the utmost importance. Intraoperative neuromonitoring (IONM) is one such technique that may be employed to identify neurologic injury in a timely manner including those events occurring remote to the operative levels.

Case description: In this report, we describe the case of a 77-year-old male with a complicated medical history who sustained intraoperative spinal cord injury caudal to the instrumented levels during a cervical laminoplasty. Neurologic change was detected on IONM leading to emergent imaging. Spinal epidural hematoma was identified, which led to prompt surgical intervention resulting in return to preoperative neurologic baseline within 24 hours postoperatively.

Conclusions: IONM facilitates early identification and allows for prompt management of potential neurologic adverse events including those caudal to operative levels during spine surgery and may reduce or reverse associated morbidity and mortality. We hope this case highlights the importance of further study into this modality to determine its optimal use in elective spine surgery.

Ganglioneuroma is a rare pathology of neural crest lineage that typically presents outside the spine, with common symptoms including weakness, gait disorder, and back pain. This condition is frequently associated with neurofibromatosis 1 and typically presents in younger female patients with a mean age of 40 years. We report a video resection of bilateral C2 "dumbbell" ganglioneuroma in an older male patient with symptomatic cervical myelopathy. The patient is an 83-year-old male with several months of progressive symptoms of cervical myelopathy including upper extremity weakness and bladder incontinence. His imaging was remarkable for bilateral C2 nerve sheath lesions with canal stenosis and significant cord compression bilaterally, resulting in cord edema and myelomalacia changes. To our knowledge, a case of bilateral cervical ganglioneuroma with myelopathic symptoms in a patient aged 80 years has not been previously reported in the literature. Older patients with myelopathic symptoms must be managed urgently to prevent irreversible spinal cord injury. Our patient was successfully managed with complete surgical excision of the tumors, and resolution of symptoms was seen at follow-up, representing a successful treatment paradigm for similar cases.

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.