Spine最新文献

Study design: A prospective single-arm clinical study.

Objective: To explore the clinical utility of an intervertebral motion metric by determining the proportion of patients for whom it changed their surgical treatment plan from decompression only to decompression with fusion or vice versa .

Summary of background data: Lumbar spinal stenosis from degenerative spondylolisthesis is commonly treated with decompression only or decompression with additional instrumented fusion. An objective diagnostic tool capable of establishing abnormal motion between lumbar vertebrae to guide decision-making between surgical procedures is needed. To this end, a metric based on the vertebral sagittal plane translation-per-degree-of-rotation calculated from flexion-extension radiographs was developed.

Materials and methods: First, spine surgeons documented their intended surgical plan. Subsequently, the participants' flexion-extension radiographs were taken. From these, the translation-per-degree-of-rotation was calculated and reported as a sagittal plane shear index (SPSI). The SPSI metric of the spinal level intended to be treated was used to decide if the intended surgical plan needed to be changed or not.

Results: SPSI was determined for 75 participants. Of these, 51 (68%) had an intended surgical plan of decompression only and 24 (32%) had decompression with fusion. In 63% of participants, the SPSI was in support of their intended surgical plan. For 29% of participants, the surgeon changed the surgical plan after the SPSI metric became available to them. A suggested change in the surgical plan was overruled by 8% of participants. The final surgical plan was decompression only for 59 (79%) participants and decompression with fusion for 16 (21%) participants.

Conclusion: The 29% change in intended surgical plans suggested that SPSI was considered by spine surgeons as an adjunct metric in deciding whether to perform decompression only or to add instrumented fusion. This change exceeded the a priori defined 15% considered necessary to show the potential clinical utility of SPSI.

Study design: Retrospective cohort study.

Objective: To evaluate whether frailty scoring is associated with adverse outcomes and management of thoracolumbar fractures (TLF) patients.

Summary of background data: Trauma patients with TLF often face longer recovery. The Canadian Study of Health and Aging clinical frailty scale (CSHA-CFS) predicts outcomes in older trauma patients.

Methods: Adult trauma patients admitted from 2017 to 2021 who presented with TLF were included. Frailty was scored using CSHA-CFS. Endpoints were in-hospital mortality, hospital length of stay, surgery, complications, and discharge disposition. Multivariate analyses adjusting for baseline characteristics were performed. P<0.05 was considered significant.

Results: Overall, 1456 patients were included; 1013 fit, 240 pre-frail, and 203 frail. Frail patients underwent fewer surgeries (OR=0.5 [0.32-0.77], P=0.002). TL fusion was associated with lower mortality (OR=0.31 [0.11-0.85], P=0.024). Pre-frailty and frailty were associated with increased risk of pneumonia (OR=2.522 [1.428-4.456], P=0.001; OR=2.93 [1.32-6.54], P=0.008, respectively) and death (OR=3.581 [1.853-6.921], P<0.001; OR=2.46 [1.07-5.67], P=0.035). Pre-frail and frail patients were more likely to discharge to skilled nursing facilities (OR=1.687 [1.024-2.780], P=0.04; OR=4.89 [2.66-9.0]), P<0.001).

Conclusions: Pre-frailty and frailty were associated with poor outcomes and higher level of care at discharge. Frail patients were less likely to undergo TL fusion, despite its association with improved survival. This suggests frailty should not discourage surgeons from performing thoracolumbar fusion. Frailty scoring upon admission may help guide management and set realistic expectations for patients and their families.

Study design: This was a multicenter retrospective cohort study.

Objective: We investigated the incidence of postoperative shoulder imbalance (PSI) and its risk factors in patients with Lenke types 1 and 2 scoliosis corrected using vertebral coplanar alignment (VCA).

Summary of background data: PSI in scoliosis affects patient quality of life. While other correction methods have reported a high correction rate for the main thoracic curve (MTC) in relation to PSI, this correlation has not been confirmed for the VCA technique.

Methods: We studied 176 patients with Lenke types 1 and 2 scoliosis who underwent posterior corrective fusion surgery using the VCA technique at 11 institutions. At two years postoperatively, patients were divided into two groups based on radiographic shoulder height (RSH): PSI- (RSH<2 cm) and PSI+ (RSH≧2 cm) groups. We analyzed the risk factors for PSI.

Results: The overall incidence of PSI two years postoperatively was 11.4% (20/176), with 9.2% (11/119) and 15.8% (9/57) in patients with Lenke types 1 and 2, respectively. Contrary to a previous study, a high MTC correction rate did not emerge as a risk factor for PSI. Instead, preoperative left shoulder elevation and low postoperative thoracic kyphosis and greater T1 tilt and high apical vertebral body-to-rib ratio were associated with PSI in patients with Lenke type 1. Preoperative left shoulder elevation and a low postoperative proximal thoracic curve (PTC) correction rate were identified as risk factors for PSI in patients with Lenke type 2.

Conclusion: Our results suggest that proper correction of the PTC, rather than compromise MTC correction, may help prevent PSI in the VCA technique. This method is particularly advantageous for addressing Lenke type 1 scoliosis and yields favorable outcomes in shoulder balance. Patients with preoperative left shoulder elevation, especially Lenke type 2, are at high risk of developing PSI.

Level of evidence: 4.

Study design: This retrospective study included patients who underwent primary one-level minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar spine conditions.

Objective: To identify early predictors of failing to achieve the Oswestry Disability Index (ODI) minimum clinically important difference (MCID) one-year post-surgery.

Summary of background data: Early identification of patients at risk of failing to achieve ODI-MCID is crucial for early intervention and improved postoperative counseling. Currently, no specific thresholds guide patient follow-up for optimal recovery.

Methods: The assessment included demographic information, surgical details, and patient-reported outcome measures (PROMs). PROMs were collected postoperatively at 2-, 6-, and 12-week time points, as well as at 6- and 12-months.

Results: The study included 166 patients, with 34% failing to achieve ODI-MCID at one year. Early VAS back and leg scores were found to be significant predictors of ODI-MCID achievement. The optimal thresholds identified were 2.25 for early VAS back and 4.25 for early VAS leg. A rerun regression identified the thresholds as independent predictors of ODI-MCID, with odds ratios of 0.31 for both measures.

Conclusion: VAS back and leg score thresholds at 6-12 weeks can predict ODI-MCID achievement one year after MIS TLIF. Patients exceeding the identified thresholds may be at risk of failing ODI-MCID and should be monitored closely.

Level of evidence: Level 3.

Study design: Literature Review.

Objective: The goal of this study was to provide a comprehensive outline of spinal injuries that may transpire over the course of military service from traumatic to repetitive stress injuries and chronic sequalae. We considered studies that assessed spinal injuries in the combat and non-combat settings as reported in the literature over the last 15-20 years.

Summary of background data: Military service places servicemembers under substantial physical demands, while also exposing them to dangerous, unpredictable environments. As a result, servicemembers are at an increased risk of spinal injuries from combat-related trauma and other causes. They may have different care needs and recovery profiles when compared to civilians with spinal disorders.

Methods: We performed a review of the available literature on spinal injuries and spinal care in the Military Health System from 2001-present.

Results: The studies discussed in this review were primarily focused on the conflicts in both Iraq and Afghanistan from over ten years ago and do not fully capture the present-day advancements in military technology that may have an impact on the potential for spinal injuries. The long-term effects of sustained military service and the relative influence of high demand versus sedentary military occupations on the development of spinal disorders remains poorly understood. Given the changing nature of military service, both with respect to the demographic in uniform and the ever-evolving nature of modern combat, we believe that only a long-term prospective observational study dedicated to the surveillance of spinal problems could effectively answer these questions.

Conclusion: Further research into the present-day characterization of spinal injuries is warranted given the advancements in both military technology and spine care that have occurred over the last ten years.

Study design: Biomechanical Testing.

Objective: Investigate the optimal construct for stabilization of the spine during vertebral column resection (VCR).

Summary of background data: VCR is a powerful technique for achieving correction in severe cases of spinal deformity. However, this also creates an unstable spine which requires stable fixation to prevent iatrogenic neurologic injury. It is common practice to place a temporary unilateral rod configuration to achieve this stability during surgery but no study to date has investigated the optimal construct configuration.

Methods: A unilateral VCR model representing an acute 50° kyphotic deformity with a standardized 30 mm resection was created. Three conditions underwent testing: 1) Rod material and diameter, 2) rod configuration, and 3) number of fixation points. Six unique samples were tested in each group in both flexion-extension. Prior to testing a 10N preload and underwent cyclical testing in flexion/extension. System stiffness was calculated and compared across groups.

Results: Assessment of rod size and composition using a single screw construct (2 total screws) demonstrated that for Titanium (Ti) rods, increasing rod size significantly increased the construct stiffness (P=0.001). Although Cobalt-chromium (Co-Cr) rods where significantly stiffer than the corresponding sized Ti rods, there was no significant difference between rod diameters for Co-Cr (P=0.98). However, when tested using a dual screw (4 total screws) construct, these constructs were significantly stiffer than the corresponding single screw constructs (P<0.0001). Of the various rod configurations, the dual rod demonstrated the greatest stiffness (34.8±2.1 N/mm; P<0.0001).

Conclusion: Surgical construct stiffness during a VCR is multifactorial. Larger rod diameter, increased number of fixation points, stiffer rod material, and increased number of rods across the resection site increase the construct stiffness. With minimal points of fixation using Co-Cr rods, increasing rod diameter does not impart greater construct stiffness unless additional fixation points are included.

Study design: Retrospective cohort study.

Objective: To compare peri- and postoperative infection rates among patients with mild to moderate penicillin allergies who receive cefazolin vs vancomycin as prophylaxis for lumbar fusion. Additionally, we sought to determine if patients receiving cefazolin exhibited any clinical symptoms suggestive of drug-induced hypersensitivity reactions, and to compare those rates to patients who received vancomycin.

Summary of background data: Cefazolin has been historically linked to hypersensitivity reactions in penicillin-allergic patients due to cross-reactivity. As a result, vancomycin is often given to these patients instead. To our knowledge, no studies have directly compared these two antibiotics in penicillin-allergic patients undergoing lumbar fusion.

Methods: Patients with mild to moderate documented penicillin allergies who underwent lumbar fusion from 2017-2022 and received prophylactic cefazolin or vancomycin were studied. Demographic, surgical information, and hospital length of stay (LOS) were recorded. We identified drug sensitivity reactions, in hospital infections, 90-day readmissions related to infectious etiologies and need for irrigation and debridement (I&D) to treat a surgical site infection.

Results: 222 patients received cefazolin, while 180 received vancomycin. Patients receiving vancomycin had more medical comorbidities, while patients receiving cefazolin had slightly more levels fused. No significant differences existed between cohorts in postoperative infection rate. One patient given cefazolin developed a mild drug-induced skin reaction that was treated with topical steroids. No significant differences existed between cohorts in 90-day readmissions or need for I&D surgery. On bivariate analysis, patients given cefazolin had a longer LOS but this was attributed to confounding variables on multivariate analysis.

Conclusions: Cefazolin and vancomycin are comparable at preventing postoperative infections among patients with mild to moderate documented reactions to penicillin. Our findings also suggest that penicillin-allergic patients are not at higher risk of developing drug-related hypersensitivity reactions in response to cefazolin exposure when compared to those who received vancomycin.

Study design: Retrospective single-center comparative analysis.

Objective: To develop a nomogram model for predicting late-onset neurological deficits (LONDs) in patients with kyphosis or kyphoscoliosis.

Summary of background data: Patients with kyphosis or kyphoscoliosis might suffer from LONDs, and surgical correction may improve neurological function. Nevertheless, there exists a significant gap in the identification of predictive factors for LONDs in these patients.

Methods: A consecutive series of 244 patients with kyphosis or kyphoscoliosis who underwent corrective surgery between April 2010 and June 2024 were included in our study. Relevant measurements, including the Cobb angle, deformity angular ratio (DAR), and level of the apex were assessed and calculated using X-ray imaging. Spinal cord morphology at the apex of the major curve was evaluated using preoperative axial T2-weighted magnetic resonance imaging (MRI) to categorize patients into three types based on the spinal cord shape classification system (SCSCS). To identify independent risk factors associated with LONDs, we employed univariate analysis followed by backward stepwise multivariate logistic regression analysis. A nomogram was established based on the identified independent risk factors to predict the likelihood of LONDs in patients with kyphosis or kyphoscoliosis.

Results: The mean age of the 244 patients was 46.4±17.8 years, with an observed incidence of LONDs at 57.8%. The backward stepwise multivariate logistic regression analysis indicated that age, etiological diagnosis and SCSCS were independent predictors of LONDs. Utilizing these independent risk factors, we constructed a nomogram model to estimate the probability of LONDs. The concordance index (C-index) of the model was 0.912 (95% CI, 0.876-0.947), indicating a satisfactory level of accuracy in predicting the likelihood of LONDs.

Conclusion: The predictive factors for LONDs include age, etiological diagnosis and SCSCS. We developed a nomogram model to predict LONDs, which could be useful for patient counseling and facilitating treatment-related decision-making.

Study design: A systematic review and meta-analysis.

Objective: To conduct a meta-analysis of studies that compared surgery with or without radiotherapy to radiotherapy alone for patients with malignant spinal cord compression, and a subgroup analysis of patients stratified by hematologic and solid malignancies.

Summary of background data: Two previous meta-analyses showed that surgery with or without radiotherapy was better than radiotherapy alone in patients with malignant spinal cord compression. Nevertheless, there was no stratification by tumor type, leading to uncertainty regarding best approach for patients with hematologic malignancies.

Methods: We searched PubMed, Scopus, and Web of Science, for studies comparing surgery with or without radiotherapy to radiotherapy alone in patients with malignant spinal cord compression. The primary outcomes were improvement in ambulatory status and survival at 12 months. For neurological outcomes, we included studies involving both locally advanced primary malignancies of the spine and metastatic tumors. We restricted our analysis to studies on metastases for survival outcomes.

Results: We included 2536 patients from 18 studies. Surgery was performed in 890 (35%) patients. The pooled analysis of all studies revealed that improvement in ambulatory status (OR 2.65; 95% CI 1.60-4.39) and survival at 12 months (OR 1.66; 95% CI 1.10-2.52) were significantly higher in patients who underwent surgery with or without radiotherapy. Improvement in ambulatory status (OR 1.92; 95% CI 1.19-3.09) and survival at 12 months (OR 4.24; 95% CI 2.35-7.66) were significantly higher in patients with hematologic malignancies in the surgical arm. The primary outcomes were not significantly different between patients with solid malignancies.

Conclusion: Surgical intervention demonstrates superior neurological outcomes and increased survival compared with radiotherapy alone. Subgroup analysis revealed that patients with hematologic malignancies on surgery group experienced superior primary outcomes; however, high risk of bias of the included studies preclude definitive changes in standard care based on this data. These findings underscore the need for further research regarding the efficacy of surgical versus radiotherapeutic approaches for specific tumor types.

Level of evidence: 2.