Spine最新文献

Study design: Systematic review and meta-analysis.

Objective: To compare perioperative, radiographic, and functional outcomes between open and percutaneous posterior fixation following anterior or lateral lumbar interbody fusion (ALIF/LLIF).

Background: Posterior fixation enhances construct stability after ALIF or LLIF, yet the optimal approach, open versus percutaneous, remains debated. While minimally invasive surgery (MIS) reduces tissue disruption, open fixation may offer superior sagittal correction, particularly in adult spinal deformity (ASD). Prior meta-analyses have not isolated ALIF/LLIF procedures.

Methods: Following PRISMA guidelines, PubMed, Embase, and Google Scholar were searched (January 2000-January 2025). Comparative studies evaluating open versus percutaneous posterior fixation after ALIF/LLIF were included. Outcomes included sagittal parameters, perioperative variables, postoperative events and patient-reported outcomes. Meta-analyses were performed using random- or fixed-effects models depending on heterogeneity (I² >50%).

Results: Thirteen studies (912 patients; 454 open, 458 percutaneous) met inclusion criteria. For radiographic outcomes: No overall difference in Δ Lumbar Lordosis(LL), Δ Pelvic Incidence-LL, or Δ Sacral Slope; however, open fixation achieved greater sagittal correction in ASD (ΔLL=12.9° [95% CI 0.01 - 25.87, P=0.05] , PI-LL=-4.1° [95% CI -7.88 - -0.38, P=0.03] , SS=+2.5° [95% CI 0.38 - 4.58, P=0.02]). For perioperative outcomes, percutaneous fixation reduced EBL (-387 mL [95% CI -575.72 - -197.71, P <0.0001]), OR time (-65 min [95% CI -93.90 - -15.82, P=0.006]), LOS (-1.7 d [95% CI -2.42 -1.01, P < 0.00001]), and transfusion risk (OR 0.26 [95% CI 0.11 - 0.58, P=0.001]). For postoperative outcomes, no significant differences in reoperation, fusion, or adjacent segment disease incidence; percutaneous fixation improved pain-medication independence (OR 4.29 [95% CI 1.20 - 15.36, P=0.03]). For patient-reported outcomes, percutaneous fixation yielded superior ODI (-7.1 [95% CI -11.07 - -3.21, P=0.0004]) improvements early; at two years, it maintained minimally better VAS Back (-0.31 [95% CI -0.54 - -0.08, P=0.009]) and ODI (-2.9 [95% CI -5.04 - -0.68, P=0.01]) scores.

Conclusions: Percutaneous posterior fixation after ALIF/LLIF offers clear perioperative advantages, reduced blood loss, operative time, LOS, and transfusion need, without compromising fusion or long-term outcomes. Open fixation remains preferable for ASD cases requiring extensive sagittal realignment. Surgical approach should therefore be individualized based on deformity rigidity and alignment goals.

Study design: A retrospective study utilizing a prospectively collected database.

Objective: To compare postoperative recovery trajectories of disability following adult spinal deformity (ASD) surgery among patients with different upper instrumented vertebra (UIV) selections.

Summary of background data: Choosing the UIV is crucial decision making in ASD surgery. The added morbidity by fusing to the upper versus lower thoracic spine remains unknown.

Material and methods: This study involved patients who had primary ASD surgery from UIV at L2 or above to pelvis. The primary outcome measured was the Oswestry Disability Index (ODI), collected longitudinally. Multivariable mixed-effects regression model with restricted cubic splines were used to evaluate recovery trajectories across three UIV locations: upper thoracic (UT=T2-T5), lower thoracic (LT=T9-T12), and upper lumbar (UL=L1-L2).

Results: Of 222 patients (UT, 58; LT, 135; UL, 29), preoperative demographics and clinical characteristics differed significantly in age (UT, 62.6 vs. LT, 65.7 vs. UL, 70.3 y, P=0.001), body mass index (UT, 26.2 vs. LT, 26.5 vs. UL, 29.5, P=0.039), length of stay (8.4 vs. 5.4 vs. 5.3 d, P <0.001), and estimated blood loss (UT, 1634 vs. LT, 917 vs. UL, 714 ml; P <0.001). A multivariable model adjusting for background differences suggested that the recovery trajectory significantly differed by UIV groups (P=0.017). UT group exhibited a significantly steeper early postoperative increase in disability, with ODI peaking at 48.7 points on day 55, compared to earlier and lower peaks in the LT (41.5 on day 35) and UL (44.2 on day 30) groups.

Conclusion: Patients undergoing ASD surgery with UIV fixation in the upper thoracic spine (T2-T5) experience a delayed initial functional recovery compared to those with fixation to the lower thoracic or upper lumbar spine.

Evidence level: Level 3.

Study design: Retrospective study design on prospectively collected registry data.

Objective: To compare clinical outcomes and complication rates between anterior cervical discectomy and fusion (ACDF) using iliac crest bone graft with plate or cage with plate.

Summary of background data: ACDF is an effective surgical treatment for cervical degenerative radiculopathy. Restoring the disk space with iliac crest bone graft yields good outcomes; however, it is associated with donor site pain and complications. The alternative, using an interbody cage, may delay bony union.

Material and methods: Patients who underwent ACDF for cervical degenerative radiculopathy using either iliac crest bone graft with plate or cage with plate were identified in the Swedish Spine Registry. Patient-reported outcome measures (PROMs) included the Neck disability index (NDI), quality of life and numeric pain rating scale scores. PROM improvements after two years of follow-up as well as postoperative complications and reoperations, were compared between the iliac crest bone graft and cage groups. Multivariable mixed-effects regression analyses were used to analyze factors associated with NDI improvement, complications and reoperations while accounting for inter-facility variability.

Results: Included participants were 225 in the iliac crest group and 1,288 in the cage group. Both groups achieved comparable postoperative PROMs, with a median NDI improvement of -20 (iliac crest) and -18 (cage) points, respectively. The rate oflatereoperations (after 30 d) was significantly lower in the cage group than in the iliac crest group (odds ratio: 0.19, 95% CI: 0.05-0.76, P =0.02).

Conclusion: At two-years of follow-up, ACDF with a cage and plate achieved postoperative outcomes comparable to those of with an iliac crest bone graft and plate. Moreover, the study findings suggest that the cage represents a safer alternative to the iliac crest bone graft.

Level of evidence: Level 3.

Study design: Retrospective cohort study.

Objective: To characterize the success rate of anti-osteoporosis treatment for patients with spine fracture that otherwise confers eligibility for treatment. We also evaluated factors associated with successful initiation of treatment.

Summary of background data: Thoracic and lumbar spine fractures in patients ≥50 years of age after low energy injuries confer a diagnosis of osteoporosis and indicate eligibility for bone health treatment. Despite this, there is little information available regarding the extent to which these patients receive appropriate treatment and underlying factors that influence this decision.

Methods: We included patients ≥50 years of age treated at one of four medical centers within a single system for Type A thoracic or lumbar spine fractures from low energy trauma between 2015- 2021. Clinical, radiographic, sociodemographic, and medication data were abstracted from the medical record. Patients were noted to have successful treatment if they had de novo initiation of bone health treatment, addition of a new bone health agent to a prior osteoporosis regimen, or switched between anti-osteoporosis agents within 90 days (90d) of injury. Bivariate statistics and logistic multivariable regression were utilized to identify factors associated with successful osteoporosis treatment while adjusting for potential confounders.

Results: In total, 409 patients with complete data and 90d of follow-up were included. Only 41 (10%) patients had successful treatment initiation of bone health medications. In both bivariate and multivariable analyses, surgical intervention was the only factor significantly associated with bone health treatment. Patients treated with surgery demonstrated a more than 3-fold increase in the odds of receiving osteoporosis treatment (OR 3.35, 95%CI 1.42-7.58, P=0.003).

Conclusion: Appropriate osteoporosis treatment after low energy spine fracture was uncommon in our cohort, occurring in just 10% of patients. Active engagement on the part of spine surgeons increased the likelihood of receipt of bone health medications. This may represent a scalable intervention that can improve patient care.

Level of evidence: Level III.

Study design: Retrospective cohort study.

Objective: To establish the maximal outcome improvement (MOI) threshold for moderate-to-severe spinal deformity.

Background: Interpretation of patient-reported outcome measures (PROMs) is often limited by ceiling effects and inadequate consideration of baseline status when determining clinically meaningful thresholds.

Methods: One hundred and seven patients who underwent surgery for moderate-to-severe spinal deformity and completed ≥ 2-year follow-up were retrospectively included. The Scoliosis Research Society-22 revised (SRS-22r) was administered preoperatively and at ≥ 2-year follow-up to determine the MOI threshold using the anchor-based method. Anchor questions were derived from the SRS-22r satisfaction domain, with postoperative satisfaction defined as scores ≥ 4 on both questions. The MOI was calculated as the changes in SRS-22r scores relative to the total possible improvement. Receiver operating characteristic (ROC) curve analysis identified the optimal MOI threshold. Logistic regression analysis evaluated predictors associated with achieving the MOI threshold.

Results: Significant radiographic and clinical improvements were obtained at ≥ 2-year follow-up. Dissatisfied patients had lower postoperative SRS-22r satisfaction (3.1±0.4 vs. 4.5±0.4, P <0.001) and subtotal scores (3.7±0.4 vs. 4.0±0.3, P <0.001). The determined MOI threshold for the SRS-22r score was 43.5%. Adolescents demonstrated a significantly higher mean MOI percentage than adults (50.3% vs. 42.8%, P =0.001), although the proportion achieving the MOI threshold was comparable between groups (73.4% vs. 62.8%, P =0.242). Male sex (OR=0.8, P =0.022) and surgical complications (OR=0.7, P <0.001) significantly decreased the likelihood of achieving the MOI threshold. Conversely, preoperative neurological deficits were associated with increased odds of meeting this threshold (OR=1.6, P =0.041).

Conclusions: The MOI threshold for the SRS-22r in moderate-to-severe spinal deformity was 43.5%. Male sex and perioperative complications were negative predictors, while preoperative neurological deficits increased the probability of achieving clinically meaningful improvement.

Study design: Retrospective cohort study.

Objective: To identify factors associated with heterotopic ossification (HO) formation following cervical disc arthroplasty (CDA), including postoperative non-steroidal anti-inflammatory drug (NSAID) use.

Summary of background data: CDA preserves segmental motion in treating cervical degenerative disc disease but is susceptible to HO formation, which may compromise surgical outcomes. While NSAID prophylaxis is well-established in total hip arthroplasty to reduce HO risk, its role in CDA remains underexplored.

Methods: A retrospective review was conducted at a single academic center using a maintained surgical registry. Patients undergoing CDA with at least 1-2 years of radiographic follow-up were included. Demographic variables, BMI, implant type, operative levels, and NSAID use (any reason vs. specifically for HO prophylaxis) within 48 hours postoperatively were collected. Radiographs were graded for HO severity using the McAfee classification. Two logistic regression analyses assessed associations between variables and HO formation. Patient-reported outcome measures (PROMs) and rates of complications and reoperations were compared between HO-positive and HO-negative groups.

Results: Among 140 patients, 43.6% developed HO. HO presence was associated with higher age (P=0.025), higher BMI (P=0.002), and lower NSAID use both overall (P=0.018) and specifically for HO prophylaxis (P=0.005). Logistic regression confirmed that higher BMI was associated with increased HO risk, while postoperative NSAID use was associated with reduced risk. Clinical outcomes and PROMs improved significantly over time in both HO+ and HO- groups, with no significant differences in outcomes, complications, or reoperations.

Conclusion: Following multivariate analysis, higher BMI is associated with increased risk of HO following CDA, while early postoperative NSAID use is associated with a lower incidence. Clinical outcomes were similar between HO presence and absence groups. These findings support the potential role of NSAID prophylaxis in reducing HO development and guiding postoperative management following CDA.

Level of evidence: 3.

Study design: Anatomical and histological study of human cadaveric specimens.

Objective: To clarify the detailed anatomy of the cervical ligamentum flavum (LF), evaluate its presence at the craniocervical junction, and describe novel cervicodural ligaments with potential clinical implications.

Summary of background data: The cervical ligamentum flavum is clinically important yet remains anatomically controversial, particularly regarding its presence and morphology at C1.

Methods: Twelve adult cadaveric necks were examined (six gross dissections, six histological analyses). Specimens were sectioned coronally, sagittally, and axially. Masson's trichrome staining was used to identify ligamentous structures and their relationships with adjacent tissues.

Results: A distinct LF was consistently present between C2 and C7 vertebrae, attaching to adjacent laminae, blending laterally with the capsular ligament, and posteriorly with the interspinous ligament. No LF was identified at C0-C1. Instead, fibrous connections extended from the posterior arch of C1 and the lamina of C2 to the dura, forming previously undescribed atlantodural and axiodural ligaments. These cervicodural ligaments created a thickened dural region at C1-C2 and contained muscle fibers corresponding to the myodural bridge. A midline gap was observed between the right and left LF, traversed by vascular structures supplying the posterior cervical elements.

Conclusions: The cervical LF is absent at C0-C1 (i.e. posterior atlanto-occipital membrane), where novel cervicodural ligaments connect C1-C2 to the dura. These findings refine the surgical anatomy of the craniocervical junction and may provide an anatomical basis for cervicogenic headache.

Study design: A prospective cohort study (Level 3).

Objective: To develop and validate a clinical scoring system (Osteoporotic Vertebral Fracture Conservative Treatment Prognosis Score, OVF-CTPS) for predicting the prognosis of conservative treatment in patients with osteoporotic vertebral fractures (OVFs), addressing clinical uncertainty in treatment selection.

Summary of background data: OVFs face uncertainty in choosing conservative vs. surgical management. 10-40% of patients have conservative treatment failure (e.g., non-union, collapse). Existing classification systems lack prognostic value, highlighting the need for a practical predictive tool.

Methods: 201 patients with acute OVFs undergoing conservative treatment were prospectively followed for 6 months. Baseline assessments included demographics, pain, quality of life measures, and multimodal imaging (X-ray, CT, MRI). The primary outcome was conservative treatment failure. Independent predictors were identified using multivariate logistic regression and weighted to create the OVF-CTPS, which was validated using receiver operating characteristic (ROC) analysis.

Results: The conservative treatment failure rate was 29.9%. Six independent predictors were identified: Sugita "bow-shaped" or "concave" type, standing vertebral collapse degree <80%, middle column/posterior wall injury, T2WI "diffuse low" signal, STIR linear black signal, and basivertebral foramen involvement. The OVF-CTPS (range 0-13) demonstrated excellent predictive performance (AUC=0.918). At an optimal cutoff score of 6, the sensitivity was 91.3% and specificity was 84.0%. The low-risk group (score <6) had a 96.3% treatment success rate, while the high-risk group (score ≥6) had a success rate of 32.3.

Conclusion: The OVF-CTPS is a validated prognostic tool that integrates fracture morphology, injury severity, and MRI-based perfusion markers. It accurately stratifies patients based on their risk of conservative treatment failure, enabling clinicians to identify low-risk patients suitable for conservative care and high-risk patients who may benefit from early surgical evaluation.

Study design: Retrospective cohort study from a single academic institution.

Objective: To identify clinical and radiographic predictors for sacral extension (SE) during revision lumbar fusion.

Background: Lumbar fusion is common, with revision rates up to 25.9% within two years. When planning a revision of lumbar fusion, surgeons may extend constructs from L5 to the sacrum to improve stability, decompression, or alignment, but sacral extension alters biomechanics and increases risks such as pseudoarthrosis, adjacent segment disease, and proximal junctional kyphosis. Predictors for sacral extension during revision remain poorly defined.

Methods: Adult patients undergoing anterior or transforaminal lumbar interbody fusion (ALIF or TLIF) between 2017-2022 at a single academic institution, and those referred for revision with sacral extension, were reviewed. Eligible patients had an index fusion spanning L1-L4 to L5 or above. Sacral extension was defined as instrumentation to S1 or the pelvis within two years. Demographics, frailty indices, radiographic parameters, and complications were collected. Operative notes were reviewed to identify indications. Analyses included t-tests, chi-square, and multivariable logistic regression.

Results: Of 181 patients, 50 (27.6%) underwent SE and 131 (72.4%) remained fused between L1-L5. SE patients had higher frailty scores (MFI-5, P=0.018) and lower L4-L5 lordosis (P=0.020). Independent predictors included increased frailty (OR 7.015, P=0.032), greater fusion length (OR 1.796, P=0.012), and reduced L4-S1 lordosis (OR 1.137, P=0.007). Closer alignment of L1PA to ideal was protective (OR 0.81 per degree, P=0.009). Common indications were distal junctional degeneration (58%), foraminal stenosis (40%), and pseudoarthrosis (38%).

Conclusion: Frailty, longer constructs, and inadequate caudal lordosis independently predicted sacral extension during revision, while optimal L1PA alignment was protective. The most common indications were distal junctional degeneration, pseudoarthrosis, foraminal stenosis, and spondylolisthesis. These findings may aid preoperative risk stratification and surgical planning.

Study design: Prospective questionnaire development and validation study.

Objective: To develop and validate a new "Forgotten Spine Surgery Score for Cervical Spine Surgery" (FS3-C) to assess patient outcomes after CDR beyond the traditional measures: the ability to forget the presence of the implanted disc in daily life.

Summary of background data: The Forgotten Joint Score (FJS) has demonstrated superior discrimination in high-functioning total joint arthroplasty patients due to low ceiling and floor effects compared to legacy patient-reported outcome measures (PROMs). To date, there is no similar outcome measure to assess "forgottenness" following spine surgery. Such measures may be critical for evaluating subtle differences in high-performance surgeries like cervical disc replacement (CDR).

Methods: A 20-item pilot questionnaire was developed based on published patient expectations and expert opinion, utilizing a 5-point Likert scale. This was administered to 41 patients who underwent primary one- or two-level CDR (minimum 3-month follow-up, 2016-2023) for item selection and internal validity assessment. The final 12-item FS3-C was validated in 97 patients and correlated with the neck disability index (NDI) to determine convergent validity.

Results: In the pilot cohort (mean age 44.7±7.9 y), four items were excluded due to high missing responses or ceiling effects. In the pilot cohort (mean age 44.7±7.9 y), four items were excluded due to high missing responses or ceiling effects. The remaining 16 items demonstrated high internal consistency (Cronbach's alpha 0.95-0.96). Pairwise correlation analysis reduced the questionnaire to 12 items. In the validation cohort (mean age 44.3±9.0 y, 56.7±24.2 mo post-surgery), FS3-C demonstrated high internal consistency with minimal ceiling effects. Mean FS3-C and NDI scores were 86.4±18.9 and 9.8±12.6, respectively, with strong correlation (r=-0.606, P<0.001).

Conclusion: The FS3-C demonstrates high internal consistency, low ceiling effects, and strong convergent validity with NDI, enabling spine surgeons to evaluate CDR success beyond traditional symptom improvement measures.

Level of evidence: II.