Spine最新文献

Study design: Multicenter, prospective, randomized trial. Trial Registration: ClinicalTrials.gov Identifier: NCT05813639.

Background: Lumbar facet joint syndrome is a common cause of chronic low back pain, often resistant to conservative treatment. Interventional options such as radiofrequency ablation (RF), cryoablation (Cry), and endoscopic facet denervation (ED) are increasingly used, yet head-to-head comparisons are limited.

Objective: To compare the long-term clinical effectiveness of RFA, Cry, and ED in patients with confirmed facet-mediated low back pain.

Methods: A total of 62 patients with chronic lumbar back pain and ≥70% relief after controlled diagnostic medial branch blocks were randomized to receive RFA (n=19), Cry (n=23), or ED (n=20). Primary outcomes included changes in back and leg pain intensity (Numeric Rating Scale) and functional disability (Oswestry Disability Index) at 3, 6, 12, and 24 months postintervention.

Results: All three treatment groups showed significant and sustained improvements in back pain and functional status over the 2-year follow-up. RFA provided the most consistent long-term relief. Cry showed comparable early and mid-term efficacy, though leg pain relief diminished by 24 months. ED achieved rapid early improvement in back pain, but had limited and less durable effects on referred leg pain. No statistically significant differences were observed between groups in any of the outcome measures.

Conclusions: RF, Cry, and ED are all effective and safe treatment modalities for lumbar facet joint syndrome. While RF remains the most established option, Cry and ED may be considered viable alternatives in appropriately selected patients. Treatment should be tailored based on clinical context, patient preferences, and available resources. Further large-scale studies are needed to refine patient selection and optimize outcomes.

Study design: Retrospective analysis.

Objective: To identify the associations between preoperative paraspinal muscle parameters and postoperative outcomes following cervical disc arthroplasty (CDA), while screening for predictors.

Summary of background data: Paraspinal muscles play a critical role in maintaining cervical alignment, significantly contributing to cervical mobility and stability. To date, there is limited evidence regarding the impact of paraspinal muscles on CDA.

Materials and methods: This study included 185 patients who underwent single-level CDA. Preoperative paraspinal muscle parameters, including fatty infiltration (FI), cross-sectional area ratio (CSA r), and muscle asymmetry (ASY%), were assessed using MRI. Correlation analysis was employed for preliminary screening. Finally, structural equation modeling (SEM) was employed for comprehensive analysis.

Results: Paraspinal muscle degeneration was prevalent in this cohort, with a higher proportion of moderate to severe FI (Goutallier Grade > 2) from the cranial to caudal levels. According to the correlation analysis, at the final follow-up, cervical lordosis was most strongly correlated with CSA r at C4/5 ( P =0.010); SVA was most related to CSA r at C5/6 ( P =0.030); and the T1 slope was associated with CSA r at C4/5 ( P <0.001), C5/6 ( P <0.001), as well as at the surgical level ( P <0.001). Moreover, a positive correlation was observed between preoperative pain scores and FI ( P =0.035). However, no such correlation was identified in the postoperative period. Comparative analysis of SEMs across different muscle variables revealed variations in predictive factors for postoperative sagittal balance parameters, with CSA r emerging as the significant contributor ( P =0.019, estimate=0.176), rather than FI or ASY%.

Conclusions: Compared with postoperative clinical outcomes, mobility, and prosthesis stability, preoperative muscle parameters were most correlated with sagittal balance after CDA. Specifically, CSA r outperformed in predicting postoperative sagittal balance. These findings suggest CDA may be associated with an elevated risk of sagittal imbalance when performed on patients with significant preoperative muscle degeneration.

Level of evidence: Level 3.

Study design: Retrospective cohort study.

Objective: To evaluate opioid utilization and pseudoarthrosis risk following lumbar spinal fusion in patients receiving postoperative ketorolac versus those who did not.

Background: Ketorolac is increasingly used in multimodal pain regimens to reduce opioid use. However, its effect on bone healing, particularly after lumbar fusion, remains unclear.

Materials and methods: Using the TriNetX database, we identified patients undergoing lumbar spinal fusion with ≥30 days of follow-up, excluding those with prior pseudoarthrosis. Patients were grouped by postoperative ketorolac use and matched 1:1 by sex, age, ethnicity, and comorbidities. Primary outcomes included opioid prescriptions at 7, 14, and 30 days. Pseudoarthrosis was assessed at one and two years. Secondary outcomes included bowel regimen use, ileus, DVT, PE, AKI, transfusion, infection, wound disruption, lab values (Hgb, Hct, Cr), readmissions, ED visits, and mechanical complications at one and two years.

Results: After matching, 15,260 patients were included in each group. Ketorolac use was associated with fewer opioid prescriptions at all short-term timepoints ( e.g. 2.5 vs. 2.8 at 7 d, P <0.001) and less bowel regimen use ( P <0.001). DVT, PE, and ileus risk were lower in the ketorolac group ( P <0.05). No increase in AKI, Cr, or transfusion rates was observed. At one and two years, ketorolac users had reduced mechanical complications and comparable pseudoarthrosis rates.

Conclusions: Postoperative ketorolac may reduce short-term opioid use and thromboembolic risk without increasing pseudoarthrosis or mechanical complications. These findings support ketorolac as a potentially safe adjunct in postoperative pain management. Further randomized trials are warranted.

Study design: Prospective multicenter cohort study.

Objective: To evaluate the prevalence, clinical characteristics, and surgical outcomes of neuropathic pain in patients with degenerative cervical myelopathy (DCM), using the Neuropathic Pain Symptom Inventory (NPSI).

Summary of background data: Neuropathic pain is increasingly recognized as a major determinant of quality of life (QOL) in DCM. However, few prospective studies have comprehensively evaluated its distribution, severity, and postoperative trajectory.

Patients and methods: A total of 816 DCM patients from 10 institutions were prospectively enrolled. Preoperative and two-year postoperative assessments included the NPSI, cervical Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS), and 36-Item Short Form Health Survey (SF-36). Correlation and multiple regression analyses were performed to identify associations between NPSI scores and QOL, as well as predictive factors for postoperative improvement.

Results: Preoperatively, 88.5% of patients reported symptoms of neuropathic pain, with paresthesia/dysesthesia being the most prominent subtype. At two years postoperatively, all NPSI subdomains showed significant improvement ( P <0.001), though paresthesia/dysesthesia remained most persistent. Higher preoperative NPSI scores were significantly associated with greater postoperative pain reduction (β=-0.556, P <0.001). Total NPSI scores significantly correlated with all SF-36 subdomains both before and after surgery (all P <0.001), indicating a strong relationship between pain and QOL.

Conclusion: This study provides the first large-scale prospective evaluation of neuropathic pain in DCM. While neuropathic pain is prevalent and improves with surgery, residual symptoms-especially paresthesia/dysesthesia-remain common and impactful. These findings highlight the importance of individualized postoperative pain management strategies to optimize long-term QOL.

Study design: Retrospective study.

Objectives: This study aims to evaluate the effectiveness of temporary fixation through an intermuscular approach in reducing intraoperative blood loss and postoperative pain and preserving suboccipital musculature.

Summary of background data: Odontoid fractures pose significant treatment challenges, particularly regarding the preservation of cervical range of motion and minimizing disruption to the occipitocervical muscles. Conventional posterior open approaches are associated with a high incidence of postoperative occipitocervical pain, dysfunction, and substantial perioperative blood loss. We hypothesized that minimally invasive posterior temporary fixation through an intermuscular approach, which avoids significant disruption of the suboccipital musculature, would offer advantages over the standard open approach.

Materials and methods: This study included patients aged below 65 years old and without osteoporosis who underwent posterior temporary fixation for odontoid fractures between 2015 and 2023. Outcomes measured included fracture healing rate, surgery duration, blood loss, Visual Analog Scale (VAS) scores, narcotic use, postoperative complications, hospital stay duration, and changes in muscle cross-sectional area (CSA).

Results: Forty-five patients were included (26 in the intermuscular group and 19 in the open group). No significant differences were found in fracture healing time or postoperative complications between the groups. The intermuscular group showed significantly lower intraoperative blood loss, shorter hospital stays, reduced postoperative VAS scores, and a decreased need for supplementary narcotics. In addition, the intermuscular approach better preserved key occipitocervical muscles, with less CSA reduction compared with the open approach. No failures of internal fixation were observed in either group.

Conclusions: Minimally invasive posterior temporary fixation through the intermuscular approach offers substantial benefits over traditional open surgery for odontoid fractures. These include reduced blood loss, lower postoperative pain, shorter recovery time, and better preservation of suboccipital musculature, all without compromising fracture healing. This technique provides an effective, muscle-sparing alternative for open temporary fixation in the treatment of odontoid fractures.

Study design: Retrospective cohort study.

Objective: To analyze the demographics, clinical features, and long-term outcomes of patients with nontraumatic spinal cord injury (NTSCI) who underwent surgical treatment.

Summary of background data: The incidence of NTSCI is increasing and exceeds that of traumatic spinal cord injury in some countries, yet the understanding of surgically treated NTSCI patients is limited.

Methods: NTSCI patients undergoing surgery between January 2010 and August 2022 were included. The primary outcomes were American Spinal Injury Association Impairment Scale (AIS) grade improvement and overall survival, analyzed using logistic and Cox regression.

Results: Among 212 patients (58.0% male, mean age 51.6±14.7 yr), the most common etiology was degenerative cervical myelopathy (52.4%). Preoperatively, AIS grades were predominantly AIS D (65.1%), followed by AIS C (22.6%), AIS B (9.4%), and AIS A (2.8%). Postsurgery, 15.6% improved to AIS E, reducing the proportion of AIS A-C patients from 34.9% to 29.2% ( P <0.001). Hospital-based rehabilitation showed significant AIS improvement ( P <0.001), home-based rehabilitation had marginal improvement ( P =0.057), and no significant change was observed in the nonrehabilitation group ( P =0.183). With a mean follow-up of 102.4±53.6 months, 42% of patients achieved AIS E, while AIS A-C decreased from 34.9% to 24%. The 5-year overall survival was 99.1%, and the 10-year survival was 88.7%. Etiology (OR 0.089, 95% CI=0.018-0.440, P =0.003) and history of operation (OR 0.137, 95% CI=0.042-0.454, P =0.001) were independent factors of AIS improvement, while etiology (OR 0.091, 95% CI=0.018-0.447, P =0.003) and time of worsening (OR 0.212, 95% CI=0.051-0.885, P =0.033) were linked to overall survival.

Conclusion: Surgery and rehabilitation significantly improve clinical outcomes in NTSCI patients. Etiology and history of operation are independent prognostic factors for AIS improvement, whereas etiology and time of worsening are independent predictors of overall survival.

Study design: Retrospective study of the prospectively collected data.

Objective: To assess the ability of three artificial intelligence (AI) models to predict attainment of clinically important differences (CIDs) in the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ).

Summary of background data: Accurate prediction of postoperative functional improvement is essential for surgical planning, yet patient-reported outcome-based predictive tools have not been established.

Methods: We retrospectively analyzed 1149 patients from three spine centers. Outcomes were five JOABPEQ domain scores and three visual analog scale (VAS) scores. Three AI models-TabNet, a deep neural network (DNN), and elastic-net penalized logistic regression (ENLR)-were trained and validated on 981 patients from two centers using stratified five-fold cross-validation. External validation was performed on an independent cohort of 168 patients from the third center. Input features included age, sex, preoperative JOABPEQ item responses, domain scores, and VAS scores. Model performance was evaluated by the area under the receiver operating characteristic curve (AUC) and accuracy.

Results: In external validation for JOABPEQ domains, TabNet achieved a mean AUC of 0.79 and accuracy of 0.74; DNN, AUC 0.77 and accuracy 0.73; and ENLR, AUC 0.78 and accuracy 0.74. For VAS outcomes, TabNet yielded a mean AUC of 0.80 and accuracy of 0.74; DNN, AUC 0.77 and accuracy 0.72; and ENLR, AUC 0.78 and accuracy 0.72.

Conclusions: All three AI models reliably predicted postoperative improvements. Such AI-based prediction models may enhance clinical decision-making and patient counseling in lumbar spine surgery.

Study design: Modified Delphi consensus survey.

Objective: To survey expert opinion on postoperative return-to-sport (RTS) decisions in athletes requiring cervical spine surgery.

Summary of background data: Postoperative sport participation recommendations for athletes requiring cervical spine surgery are lacking, and management of these athletes remains challenging.

Methods: A cross-sectional, modified Delphi consensus survey investigating RTS decisions in athletes requiring various cervical spine operations was undertaken. A panel of neurosurgery/orthopedic spine surgeons with sport expertise was identified from the United States and Australia. Single and multilevel cervical spine conditions studied included: anterior cervical discectomy and fusion (ACDF), cervical laminectomy and/or laminoplasty, posterior cervical fusion, occipito-cervical fusion, C1 fracture, and C1-C2 fusion. A 2×2 scheme was used to classify sport risk based on impact forces and frequency: low impact/low frequency, low impact/high frequency, high impact/low frequency, and high impact/high frequency. Consensus was a priori defined at ≥70%. Descriptive statistics were performed.

Results: Of the 34 sports spine surgeons invited (56% neurosurgeons and 44% orthopedic surgeons), survey completion was 100%. Consensus was achieved to recommend return to high-impact/high-frequency sport for individuals with one-level ACDF, one-level cervical laminectomy, one-level posterior cervical fusion, and for a healed C1 fracture treated with open reduction and internal fixation. For individuals with a healed occipito-cervical fusion, consensus was achieved to recommend return to low-impact/low-frequency sport.

Conclusions: Consensus was achieved to recommend return to high-impact/high-frequency sport after surgical treatment of a variety of cervical pathologies in athletes. Certain situations received consensus recommendations to return to low-impact/low-frequency sport, whereas many others did not reach a consensus. These results provide useful data that can help spine surgeons navigate challenging postoperative RTS decisions.

Study design: Literature review.

Objectives: Review updated criteria that categorize patients' bone health for operative and nonoperative patients.

Summary of background data: Osteoporosis is common in spine patients including those with fragility fractures and in the elective surgery population. Untreated osteoporosis is associated with secondary spine fractures and increased likelihood of osteoporotic bone-related complications after elective surgery. Recently, the definition of osteoporosis is expanded beyond use of bone mineral density (BMD) to also include fracture history and fracture risk. Most spine practitioners are not aware of this definition.

Methods: Recent clinical guidelines and recommendations for the diagnosis of osteoporosis are reviewed. Included are the use of dual x-ray absorptiometry (DXA), adjuncts such as trabecular bone score and vertebral fracture assessment, and other factors such as comorbidities, fracture history, and opportunistic use of other imaging studies.

Results: The use of the clinical diagnosis based on BMD, fracture history, and fracture risk increases the diagnosis of osteoporosis in spine patients. BMD is measured using DXA, which is sensitive and precise, although errors in analysis and interpretation are common. Fracture history is a strong predictor of secondary fracture and poor surgical outcomes. Reducing fracture risk is the goal of medical treatment, but it is rarely performed by spine practitioners. Fracture risk can be stratified into low, high, and very high-risk groups. High and very high-risk patients are candidates for medical management. Other clues to the presence of osteoporosis that should prompt further bone health assessment are based on history, height loss, risk factors, and opportunistic use of plain radiographs, CT, and MRI.

Conclusions: Spine practitioners should be aware of newer concepts in the diagnosis of osteoporosis. Utilizing the clinical diagnosis of osteoporosis based on BMD thresholds, fracture history, and fracture risk will identify patients who should be considered for further health assessment and treatment.