Spine deformity最新文献

Objectives: Opioids are common medications used following spine surgery. However, few studies have assessed the impact of increased inpatient-opioid consumption on outcomes following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to determine the impact of increased inpatient-opioid consumption on hospital length of stay (LOS) following PSF for AIS.

Methods: A retrospective cohort study was performed using the Premier Healthcare Database (2016-2017). Adolescent patients (11-17 years old) who underwent PSF for AIS, identified using ICD-10-CM coding, were stratified by inpatient MME (morphine milligram equivalent) consumption into Low (< 25th percentile for the cohort), Medium (25-75th percentile), and High (> 75th percentile) cohorts. Demographics, comorbidities, intraoperative procedures, perioperative adverse events (AEs), length of hospital stay (LOS), non-routine discharge rates, cost of admission, and 30-day readmission rates were assessed. A logistic multivariate regression analysis was performed to determine the association between inpatient MME consumption and extended LOS.

Results: Of the 1042 study patients, 260 (24.9%) had Low-MME consumption, 523 (50.2%) had Medium-MME consumption, and 259 (24.9%) had High-MME consumption. A greater proportion of patients in the High cohort identified as non-Hispanic white (Low: 46.5% vs Medium: 61.4% vs High: 65.3%, p < 0.001), while the proportion of patients reporting any comorbidity did not vary across the cohorts (p = 0.940). The number of post-operative AEs experienced also did not vary across the cohorts (p = 0.629). A greater proportion of patients in the High cohort had an extended LOS (Low: 6.5% vs Medium: 8.6% vs High: 19.7%, p < 0.001), while a greater proportion of patients in the Low cohort had an increased cost of admission (Low: 33.1% vs Medium: 20.3% vs High: 26.6%, p < 0.001). The High cohort had increased 30-day readmission rates relative to the Low and Medium cohorts (Low: 0.8% vs Medium: 0.2% vs High: 1.5%, p = 0.049). Non-routine discharge rates did not vary among the cohorts (p = 0.441). On multivariate analysis, High-MME consumption was significantly associated with extended LOS, while Medium-MME consumption was not [Medium: aOR: 1.48, CI (0.83, 2.74), p = 0.193; High: aOR: 4.43, CI (2.47, 8.31), p < 0.001].

Conclusions: Our study showed that high post-operative-MME consumption was significantly associated with extended LOS in patients undergoing PSF for AIS. In light of these findings, changes to existing protocols that decrease the reliance on opioids for post-operative analgesia are merited to improve patient outcomes and reduce health-care expenditures.

Purpose: To determine if an improvement in cord-level intraoperative neuromonitoring (IONM) data following data loss results in a reduced risk for new postoperative motor deficit in pediatric and adult spinal deformity surgery.

Methods: A consecutive series of 1106 patients underwent spine surgery from 2015 to 2023 by a single surgeon. Cord alerts were defined by Somatosensory-Evoked Potentials (SSEP; warning criteria: 10% increase in latency or > 50% loss in amplitude) and Motor-Evoked Potentials (MEP; warning criteria: 75% loss in amplitude without return to acceptable limits after stimulation up 100 V above baseline level). Timing of IONM loss and recovery, interventions, and baseline/postoperative day 1 (POD1) lower extremity motor scores were analyzed.

Results: IONM Cord loss was noted in 4.8% (53/11,06) of patients and 34% (18/53) with cord alerts had a POD1 deficit compared to preoperative motor exam. MEP and SSEP loss attributed to 98.1% (52/53) and 39.6% (21/53) of cord alerts, respectively. Abnormal descending neurogenic-evoked potential (DNEP) was seen in 85.7% (12/14) and detected 91.7% (11/12) with POD1 deficit. Abnormal wake-up test (WUT) was seen in 38.5% (5/13) and detected 100% (5/5) with POD1 deficit. Most cord alerts occurred during a three-column osteotomy (N = 23/53, 43%); decompression (N = 12), compression (N = 7), exposure (N = 4), and rod placement (N = 14). Interventions were performed in all 53 patients with cord loss and included removing rods/less correction (N = 11), increasing mean arterial pressure alone (N = 10), and further decompression with three-column osteotomy (N = 9). After intervention, IONM data improved in 45(84.9%) patients (Full improvement: N = 28; Partial improvement: 17). For those with full and partial IONM improvement, the POD1 deficit was 10.7% (3/28) and 41.2% (7/17), respectively. For those without any IONM improvement (15.1%, 8/53), 100% (8/8) had a POD1 deficit, P < 0.001.

Conclusion: A full or partial improvement in IONM data loss after intraoperative intervention was significantly associated with a lower risk for POD1 deficit with an absolute risk reduction of 89.3% and 58.8%, respectively. All patients without IONM improvement had a POD1 neurologic deficit.

Purpose: Our purpose was to determine associations between body mass index (BMI) category and outcomes of vertebral body tethering (VBT), a non-fusion treatment for adolescent idiopathic scoliosis (AIS) and juvenile idiopathic scoliosis (JIS).

Methods: Using a multicenter database, we identified patients with AIS or JIS who underwent VBT from 2012 to 2018 and had minimum 2-year follow-up (median, 3.0 [interquartile range 2.2, 3.8]). BMI percentiles were used to classify patients as overweight (≥ 85th percentile) or non-overweight (< 85th percentile). Univariate and multivariate regressions assessed associations between complication rates and curve correction between groups, controlling for sex, triradiate cartilage closure, and preoperative curve magnitude.

Results: Of 271 patients, 48 (18%) were overweight. Complication rates did not differ between groups. Factors associated with less correction from preoperative to first postoperative-erect imaging were overweight (β = - 10, p < 0.001), male sex (β = - 8.8 p < 0.01), closed triradiate cartilage (β = 6.0, p = 0.01), and smaller preoperative curve (β = 0.3, p < 0.01). Factors associated with a larger curve at latest follow-up were overweight (β = 4.0, p = 0.02) and larger preoperative curve (β = 0.5, p < 0.001), but tether breakage did not differ between groups (p = 0.31).

Conclusion: In patients who were overweight, VBT was associated with less curve correction at first erect imaging and larger final curve. However, complications and curve correction during the modulation phase were not different from those of non-overweight patients. These findings suggest that surgeons should expect less correction with VBT in patients who are overweight but similar correction over time.

Level of evidence: Prognostic, Level III.

Study design: Retrospective cohort study.

Purpose: The impact of neuromuscular disorders such as multiple sclerosis (MS) on outcomes following long segment fusion is underreported. This study evaluates the impact of MS on two-year (2Y) postoperative complications and revisions following ≥ 4-level fusion for adult spinal deformity (ASD).

Methods: Patients undergoing ≥ 4-level fusion for ASD were identified from a statewide database. Patients with a baseline diagnosis of MS were also identified. Patients with infectious/traumatic/neoplastic indications were excluded. Subjects were 1:1 propensity score-matched (MS to no-MS) based on age, sex and race and compared for rates of 2Y postoperative complications and reoperations. Logistic regression models were utilized to determine risk factors for adverse outcomes at 2Y.

Results: 86 patients were included overall (n = 43 per group). Age, sex, and race were comparable between groups (p > 0.05). MS patients incurred higher charges for their surgical visit ($125,906 vs. $84,006, p = 0.007) with similar LOS (8.1 vs. 5.3 days, p > 0.05). MS patients experienced comparable rates of overall medical complications (30.1% vs. 25.6%) and surgical complications (34.9% vs. 30.2%); p > 0.05. MS patients had similar rates of 2Y revisions (16.3% vs. 9.3%, p = 0.333). MS was not associated with medical, surgical, or overall complications or revisions at minimum 2Y follow-up.

Conclusion: Patients with MS experienced similar postoperative course compared to those without MS following ≥ 4-level fusion for ASD. This data supports the findings of multiple previously published case series' that long segment fusions for ASD can be performed relatively safely in patients with MS.

Background: Obesity in the pediatric population has been a growing medical concern over the last few decades with a prevalence of 19.7% as of 2017-2020. Obesity is a risk factor for greater scoliotic curves and failure of conservative therapy for adolescent idiopathic scoliosis (AIS). Establishing a correlation between obesity and a wide variety of adverse outcomes following scoliosis surgery can assist in the preoperative consultation with the family and proper optimization of the patient for scoliosis fusion surgery.

Methods: The National Inpatient Sample (NIS) was used to access inpatient data from 2015 to 2019. Pediatric patients with idiopathic scoliosis admitted for spinal deformity correction via posterior spinal fusion of over 8 levels were identified. Patients were stratified based on the comorbid diagnosis of obesity. Variables that were significantly associated with outcomes (p < 0.05) were used in a multivariable logistic regression to control for confounders. Backwards stepwise p-value removal was used to build the final model and model fit was assessed using the area under the curve.

Results: A total of 855 obese and 17,285 non-obese pediatric patients undergoing posterior instrumented fusion for scoliotic deformity correction were identified. The obese group was associated with a higher rate of SSI (0.6% vs 0.1%, p < 0.001), UTI (1.2% vs. 0.3%, p < 0.001), and AKI (0.6% vs 0.1%, p = 0.12) compared to the normal BMI group. Obese patients were also more likely to have a non-routine discharge when compared to non-obese (4.7% vs. 2.3%, p < 0.001). The rate of having more than one complication occurring postoperatively was higher in the obese group, however, this finding was not significant (0.6%, vs 0.4%, p = 0.385). On multivariate regression analysis, obesity was positively associated with SSI (OR = 2.758, CI = 0.999-7.614, p = 0.050), UTI (OR = 2.221, CI = 1.082-4.560, p = 0.030), non-routine discharge (OR = 1.515, CI = 1.070-2.147, p = 0.019), and an extended LOS (OR = 1.869, CI = 1.607-2.174, p < 0.001).

Conclusion: Obesity was associated with postoperative blood transfusion, SSI, UTI, increased length of stay, and non-routine discharge after pediatric AIS deformity surgery. In addition to the increased morbidity seen in obese patients, we also identified the significantly increased cost of care for this group when compared to non-obese patients. These data should be used for a robust preoperative risk assessment and evidence for BMI optimization prior to deformity correction for AIS.

Purpose: To retrospectively report on the clinical presentation, radiological features, indication, and outcome of surgical management of children with posttubercular spinal deformities with long term outcome.

Methods: This retrospective study was conducted in a single center operated by a single surgeon from 2002 to 2022, and data from an electronic medical record was reviewed. The indications for surgery included failure of medical treatment, to prevent deformity (depending on location, extent of bone loss, stabilization patterns (A, B, or C), and the presence of "Spine at Risk" signs) or correct deformity and in the presence of major neurodeficit.

Results: 51 children (< 15 years) of mean age 12.5, and mean follow-up of 7 years (2-15) were included. Pain, deformity/instability, and limb weakness were seen in 34 (66.6%) patients (mean mJOA score was 13.44, which improved to 14.7 and 16.8 at immediate postoperative and latest follow-up), with 17 (33.3%) patients presenting with deformity alone. Dorsal affection was commonest (60.8%), followed by lumbosacral (19.6%) and cervical (19.6%), with multilevel/skip lesions seen in four patients. The mean coronal/sagittal Cobb at presentation was 24.2°/40.96°, which improved to 8.2°/25.6° in the immediate and 8.8°/24.8° at the latest follow-up. Gene Xpert positivity was found in 95%, AFB culture positivity in 84%, and histopathology was positive in 91%. All patients had posterior surgery with an additional anterior reconstruction in 6. The complication rate was 5.8% (N = 3); 2 had implant loosening requiring revision surgery, 1 with prolonged discharging sinus with MDR TB, healed with chemotherapy.

Conclusion: Pediatric post-tuberculous spinal deformities require identification of those who are likely to worsen, and close follow-up is mandatory. Failure of medical management, major destruction of vertebral bodies, type C stabilization pattern, and worsening deformity/neurodeficit require surgery with a good outcome.

Background: Goldenhar syndrome is a rare congenital disease that presents with a spectrum of clinical sequelae related to the vertebrae and other organs. The spinal manifestations of the syndrome are associated with scoliosis for which fusion may be considered. The current study aimed to evaluate the risks of adverse events and reoperations following posterior spinal fusion for those with Goldenhar syndrome relative to those with adolescent idiopathic scoliosis (AIS).

Methods: Patients with Goldenhar syndrome and AIS between the ages of 10 and 17 who underwent posterior spinal fusion were abstracted from the 2010 to 2022 PearlDiver Database. The Goldenhar syndrome patients were matched 1:4 to patients with AIS based on age, sex, and Elixhauser Comorbidity Index. All 90 day postoperative adverse events, readmissions, and 5 year reoperations were identified using administrative coding. Incidence of adverse events between the cohorts were compared using multivariate logistic regression.

Results: A total of 11,742 patients with AIS and 72 (0.61%) Goldenhar syndrome undergoing deformity surgery were identified. On matched comparison, patients with Goldenhar syndromes had higher odds ratio (OR) of respiratory failure (OR: 2.99, p = 0.009), severe adverse events (p = 2.29, p = 0.01), and readmissions (p = 2.26, p = 0.02). Over 5 years, they had a significantly higher incidence of reoperation compared to those with AIS (18.1% versus 5.5%, p = 0.005).

Conclusions: In this national sample of patients with Goldenhar syndrome undergoing posterior spinal fusion, patients with Goldenhar had increased odds of respiratory failure, readmissions, and reoperations. Targeted risk mitigation strategies may be appropriately considered for those with Goldenhar syndrome undergoing such surgeries.

Level of evidence: Level III; Case-control study or retrospective cohort study.

Purpose: To evaluate the variability in intraoperative fluid management during adult spinal deformity (ASD) surgery, and analyze the association with complications, intensive care unit (ICU) requirement, and length of hospital stay (LOS).

Methods: Multicenter comparative cohort study. Patients ≥ 18 years old and with ASD were included. Intraoperative intravenous (IV) fluid data were collected including: crystalloids, colloids, crystalloid/colloid ratio (C/C), total IV fluid (tIVF, ml), normalized total IV fluid (nIVF, ml/kg/h), input/output ratio (IOR), input-output difference (IOD), and normalized input-output difference (nIOD, ml/kg/h). Data from different centers were compared for variability analysis, and fluid parameters were analyzed for possible associations with the outcomes.

Results: Seven hundred ninety-eight patients with a median age of 65.2 were included. Among different surgical centers, tIVF, nIVF, and C/C showed significant variation (p < 0.001 for each) with differences of 4.8-fold, 3.7-fold, and 4.9-fold, respectively. Two hundred ninety-two (36.6%) patients experienced at least one in-hospital complication, and ninety-two (11.5%) were IV fluid related. Univariate analysis showed significant relations for: LOS and tIVF (ρ = 0.221, p < 0.001), IOD (ρ = 0.115, p = 0.001) and IOR (ρ = -0.138, p < 0.001); IV fluid-related complications and tIVF (p = 0.049); ICU stay and tIVF, nIVF, IOD and nIOD (p < 0.001 each); extended ICU stay and tIVF (p < 0.001), nIVF (p = 0.010) and IOD (p < 0.001). Multivariate analysis controlling for confounders showed significant relations for: LOS and tIVF (p < 0.001) and nIVF (p = 0.003); ICU stay and IOR (p = 0.002), extended ICU stay and tIVF (p = 0.004).

Conclusion: Significant variability and lack of standardization in intraoperative IV fluid management exists between different surgical centers. Excessive fluid administration was found to be correlated with negative outcomes.

Level of evidence: III.

Purpose: Two non-fusion devices for adolescent idiopathic scoliosis (AIS) received HDE approval for clinical use in 2019: posterior dynamic distraction device (PDDD) and vertebral body tethering system (VBT). Although indications are similar, there is no comparative study of these devices. We hypothesize that curve correction will be comparable, but PDDD will have better perioperative metrics.

Methods: AIS PDDD patients were prospectively enrolled in this matched multicenter study. Inclusion criteria were Lenke 1 or 5 curves, preoperative curves 35°-60°, correction to ≤30° on bending radiographs, and kyphosis <55°. Patients were matched by age, sex, Risser, curve type and curve magnitude to a single-center cohort of VBT patients. Results were compared at 2 years.

Results: 20 PDDD patients were matched to 20 VBT patients. Blood loss was higher in the VBT cohort (88 vs. 36 ml, p < 0.001). Operative time and postoperative length of stay were longer in the VBT cohort, 177 vs. 115 min (p < 0.001) (2.9 vs. 1.2 days, p < 0.001). Postoperative curve measurement and correction at 6 months were better in the PDDD cohort (15° vs. 24°, p < 0.001; 68% vs. 50%, p < 0.001). At 1-year, PDDD patients had improved Cobb angles (14° vs. 21°, p = 0.001). At 2 years, a correction was improved in the PDDD cohort, with a curve measurement of 17° for PDDD and 22° for VBT (p = 0.043). At the latest follow-up, 3 PDDD patients and 1 VBT patient underwent revision surgery.

Conclusion: Early results show PDDD demonstrates better index correction, reduced operative time, less blood loss, and shorter length of stay but higher rates of revision compared to a matched cohort of VBT patients at two-year follow-up.

Level of evidence: Level II, prospective cohort matched comparative study.

Purpose: Performing laminectomies in patients with achondroplasia-a common skeletal dysplasia-can present unique challenges. There are a limited number of studies that have reported on the adverse effects of laminectomies in patients with achondroplasia. To compare the 90-day postoperative adverse events following laminectomy in patients with and without achondroplasia.

Methods: Retrospective cohort study using the 2010-2020 PearlDiver Mariner 91 administrative database was used to identify patients who underwent thoracic, thoracolumbar, or lumbar laminectomy. Patients with achondroplasia were matched 1:4 to patients without achondroplasia based on age, sex, insurance, and ECI. Univariate and multivariate logistic regression analyses assessed and compared 90-day adverse events. Odds ratios (OR), 95% confidence intervals (CI), and p-values were reported with significance set at p < 0.05.

Results: A multivariate analysis revealed that when laminectomy was performed, patients with achondroplasia were 2.82 times more likely to have 90-day AE compared to those without achondroplasia (p < 0.001). When comparing individual subtypes of adverse events, patients with achondroplasia were found to have significantly greater odds of a transfusion (OR 6.40, p < 0.001), UTI (OR 3.79, p < 0.001), disruption of wound (OR 3.71, p < 0.001), and hematoma (OR 2.94, p = 0.032). Pneumonia, cardiac arrest, AKI, other perioperative events, durotomy, and VTE were not significantly different between the two cohorts.

Conclusion: This study uses one of the largest cohorts to compare patients with and without achondroplasia undergoing laminectomy. Patients with achondroplasia were found to have a significantly greater risk of 90-day adverse events following laminectomy compared to their matched cohort of patients without achondroplasia.