Journal of spine surgery最新文献

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.

Background: Pseudohypoxic brain swelling, or postoperative intracranial hypotension with associated venous congestion is a rare phenomenon described after neurologic and lumbar surgery that can be associated with or without a concomitant subdural hematoma (SDH).

Case description: We aim to describe a report of two cases of patients without a history of bleeding disorders or head trauma, but with a history of severe chronic lumbar spinal stenosis who developed intracranial hypotension with SDH following spine surgery without evidence of cerebrospinal fluid (CSF) leak/dural trauma both intraoperatively and on immediate postoperative laboratory studies and drain outputs. Both patients developed significant neurologic symptoms (generalized tonic-clonic seizures, coma) in the immediate postoperative setting with head computed tomography (CT) showing findings mimicking hypoxic brain injury. Both patients were treated with prompt medical management. One patient required surgical intervention in the form of craniotomy to evacuate a large SDH. In both cases the high-volume shift in CSF appeared to have been into an intact, but expanded dural tube as a result of generous lumbar decompression. While observed/confirmed high-volume CSF leak can complicate spine surgery and lead to intracranial hypotension, the possibility that clinically significant CSF diversion from the ventricles could occur in the setting of an intact dural tube has not been reported following multi-segment lumbar decompression surgery.

Conclusions: Pseudohypoxic brain swelling is a rare but serious potential complication of lumbar spine surgery. Imaging may be misinterpreted as hypoxia, but it is critical to differentiate these as the treatment is opposite. While both patients in this series demonstrated early and significant recovery of neurologic function postoperatively, demonstrating favorable outcomes for this rare phenomenon, these cases highlight the importance of early identification and multidisciplinary management of these patients, which often will require antiseizure medications and flat head position. These cases well exemplify this rare but serious complication of common lumbar spinal decompression surgery.

Background: Many patients refer to internet-based patient education materials (PEMs) to learn about lumbar disc replacement. The purpose of this study is to assess the readability of PEMs on lumbar disc replacement.

Methods: The Google search engine was queried with the phrase "lumbar disc replacement patient information". Readability scores were calculated for the initial 25 websites that met inclusion criteria by copying the PEM to http://www.readabilityformulas.com. SPSS version 28.0.0 was used to calculate descriptive statistics for each measure.

Results: The mean average reading level was 12.08±1.73. The mean readability score for Flesch-Kincaid Reading Ease Score was 45.60±9.16. Additional scores include Gunning Fog, 14.50±2.06; Flesch-Kincaid Grade Level (FKGL), 10.94±2.14; The Coleman Liau Index, 12.82±1.50; Simple Measure of Gobbledygook (SMOG) Index, 10.51±1.56; Automated Readability Index, 11.81±2.46; Linsear Write Formula, 11.08±3.49. Zero PEMs were found to be below the 6th-grade or 8th-grade reading level.

Conclusions: PEM readability is a crucial part of the patient care experience, and the current readability of lumbar disc replacement PEMs is not at an acceptable level. Given their current state, PEMs can make it difficult for a sizable proportion of the general population to comprehend the nature of their medical condition and how to appropriately treat it.

Background: Multiple-level contiguous vertebral compression fractures (VCFs) are typically associated with osteoporosis or pathological conditions. The occurrence of such fractures in individuals with normal bone mineral density following high-energy trauma is exceedingly rare.

Case description: We report the case of a 64-year-old male construction worker who sustained a fall from a height of approximately 4 meters, landing on his feet. He presented with severe back and right heel pain but exhibited no neurological deficits. Imaging studies revealed acute compression fractures at L1, L2, and L3 vertebral bodies, with the most significant collapse at L2. Additionally, a displaced intra-articular fracture of the right calcaneus was identified. Bone mineral density assessment demonstrated normal bone health (T-score: 0.3). The patient underwent open reduction and internal fixation (ORIF) for the calcaneal fracture and posterior spinal instrumentation spanning T12 to L4 to stabilize the spinal injuries. At the 1-year follow-up, he returned to full activity without neurological deficits, and imaging confirmed successful fracture healing.

Conclusions: This case highlights a rare pattern of traumatic multilevel contiguous vertebral compression fractures with preserved bone mineral density and an associated calcaneal fracture. Such spinal injury patterns are rarely reported and underscore the need for high suspicion even in patients with normal bone health. A comprehensive evaluation, including bone density assessment and thorough imaging, is essential to differentiate these cases from fractures caused by underlying pathologies. In patients with unstable fractures, progressive collapse, or high functional demand, early surgical intervention can promote stabilization and recovery, as demonstrated in this case.

Background: Neurological compromise due to extramedullary hematopoiesis is a rare occurrence, typically associated with myeloproliferative disorders such as thalassemia or hereditary spherocytosis. Few cases have been reported in the setting of sickle cell anemia, and there is no established consensus on optimal treatment. Management strategies range from exchange transfusion to radiotherapy and surgical decompression. This case report presents a rare case of stenosis compression caused by extramedullary hematopoiesis in a patient with sickle cell anemia and highlights the therapeutic efficacy of low dose radiotherapy as a non-surgical, stand-alone intervention.

Case description: We report the case of a 52-year-old female with known sickle cell anemia who presented with acute L2-3 stenosis and radiculopathy due to an epidural lesion caused by extramedullary hematopoiesis. She experienced progressively worsening low back pain, right anterolateral thigh numbness, and motor weakness over several days, refractory to conservative analgesics. Magnetic resonance imaging (MRI) confirmed the diagnosis, and she was treated with radiation therapy, leading to a complete resolution of neurologic symptoms and radiographic findings on MRI within 3 months.

Conclusions: Cases of successfully treated neurologic compression from extramedullary hematopoietic deposits in the setting of sickle cell anemia are exceedingly rare. This case highlights the efficacy of radiotherapy as a standalone treatment, demonstrating an optimal outcome without the need for surgical intervention.

Background and objective: Systematic reviews and meta-analyses are crucial in spine surgery, offering a robust approach to integrating evidence from multiple studies and guiding clinical decision-making. These reviews resolve inconsistencies across studies and increase statistical power, making them indispensable for assessing the effectiveness and safety of surgical interventions. This review serves as a comprehensive guide on how to: (I) design; (II) implement; and (III) publish a systematic review in spine surgery.

Methods: We conducted a narrative review by searching key databases, including PubMed, Embase, Cochrane Library, Scopus, and Web of Science, to identify studies that demonstrate the best practices in conducting systematic reviews in spine surgery. Studies were selected for their methodological rigor and adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The included systematic reviews were evaluated based on how they applied standardized quality assessment tools, such as the Cochrane risk of bias (RoB) tool for randomized controlled trials (RCTs) and the Methodological Index for Non-Randomized Studies (MINORS) criteria or Newcastle-Ottawa Scale (NOS) for non-randomized studies. A narrative synthesis was performed to summarize the findings and highlight best practices.

Key content and findings: Systematic reviews stand at the pinnacle of the evidence-based hierarchy in spine surgery, integrating findings from various primary investigations. This study explores techniques for evaluating data quality using tools such as the Cochrane RoB, the MINORS criteria, and the NOS. We detail methods for interpreting and analyzing data, and we outline the process of transforming the findings into a publishable manuscript, with reference to a previously published example. Adhering to the PRISMA guidelines is advocated as a standard across all scientific literature, inclusive of spine surgery. Presenting data through pooled analyses with Forest Plots, along with odds ratios and 95% confidence intervals, is a customary practice.

Conclusions: In the manuscript preparation phase, it is vital to address and debate the intrinsic limitations of systematic reviews, such as their selection criteria and the overall quality, which may be constrained by the caliber of the included studies (e.g., publication bias, heterogeneity, search/selection bias).

Background: Far lateral disc herniations (FLDHs) are foraminal and extra-foraminal disc prolapses that comprise only 7-12% of all lumbar disc herniations. They compress the exiting nerve root and dorsal root ganglion (DRG) accounting for an increased severity of pain and neurological deficit compared to standard posterolateral and medial foraminal disc prolapses. There is a paucity of data on the mid-to-long-term outcomes and reoperation rates following a far lateral microdiscectomy (FLMD) operation. We report mid-term follow-up of patients undergoing FLMD using a Wiltse muscle-splitting approach that optimises approach angle to the lateral and foraminal disc with minimal facet joint removal and preservation of the pars interarticularis. The aim of this study is to report the mid-to-long-term outcomes and reoperation rates in a cohort of patients undergoing FLMD via a Wiltse approach.

Methods: Single centre, single surgeon, retrospective analysis of consecutive patients underwent lumbar FLMD. A cohort of 50 patients from one senior spine surgeon were included. Patient-reported outcome measures (PROMs), visual analogue scale (VAS back and leg), Oswestry Disability Index (ODI) and short-form-12 (SF-12), patient satisfaction using Odom's criteria, recurrence and reoperation rates were evaluated preoperatively, at 6 weeks postoperatively, and at last follow-up. All consecutive patients underwent a lumbar FLMD via a paramedian Wiltse approach from January 2010 to December 2021. Minimum follow-up was 3 years.

Results: The mean patient age was 60.6±14.1 years, body mass index (BMI) 27.9±2.6 kg/m², and 25 (50.0%) were male. The mean operation time was 77±17 minutes and the mean follow-up was 5.2 years (range, 3-14 years). All PROMs improved significantly from the pre-operative consultation to the last post-operative follow-up (P<0.001). Forty-two (84%) reported excellent or good outcomes. There were no dural tears, nerve root injuries, residual neuropathic pain or infections, and no known iatrogenic pars defects or facet fractures. Eight (16%) patients needed reoperation. Two patients had a revision FLMD within 2 weeks postoperatively. Six patients had interbody fusions at a mean 1.9 years (range, 0.17-3 years) post-index FLMD.

Conclusions: FLMD via a Wiltse approach is safe and effective for decompressing the exiting nerve root and the DRG, providing excellent visualisation of the pathology and the exiting root, while requiring minimal bone removal. This mid-term follow-up demonstrated over 80% of patients reported early mobilization with excellent or good outcomes. Subsequent interbody fusions were performed for either symptomatic disc degeneration, foraminal stenosis, or both, rather than for instability.