Spine最新文献

Study design: A systematic literature review and consensus using Delphi method.

Objectives: This review aims to create recommendations on the surgical indications and approaches to treat Chiari Malformation (CM) with or without syringomyelia.

Summary of background data: Despite the growing body of knowledge on CM, there are diverse and sometimes contradicting perspective about surgical indications and procedures in both pediatric and adult populations.

Methods: The authors reviewed the literature on CM published from 2011 to 2022. Two consensus conferences were organized by WFNS Spine Committee. The first one was held in Sao Paulo, Brazil on August 2022, and the second one was held in Porto, Portugal on December 2022. Using the Delphi method, a panel expert spine surgeons and members of the WFNS Spine Committee examined the strength of the literature, elaborated and voted statements about the surgical management of CM.

Results: We present 11 consensus statements on the surgical management of CM. Surgery is recommended for patients who have symptoms or if MRI shows progression in asymptomatic patients. In pediatrics, osteoligamentous decompression only is indicated, whereas adults can have foramen magnum decompression with duroplasty, which is usually sufficient to control the associated syringomyelia. Syrinx drainage is the last option. Arachnoid opening can be performed in patients who have previously failed surgery or if arachnoid morphological anomalies are identified during the initial procedure. Tonsillar shrinkage provides somewhat better clinical efficacy than decompression alone, but at a larger risk of complications. Only patients with concurrent basilar invagination and atlanto-axial instability are advised to undergo atlanto-axial fixation alone.

Conclusions: The consensus statements created by a collaborative work provide useful information for surgeons treating CM worldwide in order to achieve better surgical outcomes and avoid complications.

Study design: Cross-sectional study.

Objective: The objective of this study was to quantify whether interapical distance and coronal balance measured on 3D ultrasound (3DUS) images differed among ten standing positions of participants with and without adolescent idiopathic scoliosis (AIS).

Summary of background data: Apical vertebral translation (AVT) is an indicator of clinical symptoms and treatment outcomes in AIS. Stereo-radiography simultaneously captures a frontal and lateral image, yet patients are required to elevate their arms during the examination and varied positioning may impact coronal plane measurements. Ultrasound can assess these measurements without exposing participants to radiation.

Methods: Females with and without AIS were recruited from a scoliosis clinic, and email advertisements, respectively. Participants underwent 3DUS scans in ten positions: standing; arms anteriorly supported in 60° of shoulder flexion; fingers to clavicles, chin, zygomatic processes, and eyebrows; shoulders abducted at 90° with hands open and thumbs on shoulders; hands on anterior wall with and without blocks; and hands unsupported. AVT and coronal balance measurements were obtained using custom software. Positions and groups were compared using repeated measures ANOVAs with Sidak pairwise comparisons.

Results: Fifty-nine females had a mean age, height, and weight of 17.5±4.9 years, 162.8±5.8 cm, and 56.2±10.6 kg, respectively. Seventeen single and 14 double curve participants were included with mean maximum curve angles of 26.4°±3.6° and 25.2°±3.1°, respectively. Overall, there were no statistically significant differences in interapical distance or coronal balance among the ten positions, as well as in coronal balance between the groups (P>0.05). The interapical distance of participants without AIS significantly differed from those with single curves in eight positions and from those with double curves in all ten positions.

Conclusions: The positions evaluated may be interchangeable for coronal plane lateral deviation measurements of females with AIS.

Study design: Retrospective case-control study.

Objective: To determine risk factors for recurrence of pediatric lumbar spondylolysis at L5 after return to sport in patients who achieved bone union with conservative treatment.

Summary of background data: Pediatric lumbar spondylolysis is a stress fracture commonly observed in adolescent athletes, particularly at the L5 vertebra. Because some patients experience a recurrence of spondylolysis after bone fusion with conservative treatment, identifying risk factors for recurrence may help athletes continue sports activities, maintain performance levels, and preserve mental health.

Methods: Of the 375 pediatric patients (<18 years of age) who received conservative treatment for lumbar spondylolysis at L5 between 2015 and 2021, 296 patients who achieved bone fusion and returned to their original sports activities were analyzed. Recurrence rate, sports, pathological stage of spondylolysis at initial examination, presence of spina bifida occulta (SBO), duration of conservative treatment for initial spondylolysis, and radiological parameters including lumber lordosis, L5-S1 lordosis, and sacral slope were examined. Recurrence and non-recurrence groups were compared using univariate and multivariate analyses to investigate risk factors for recurrence. A receiver operating characteristic (ROC) curve was drawn to determine cut-off values of the parameters to predict spondylolysis recurrence.

Results: Recurrence was observed in 52 out of 296 patients (17.6%). Multivariate logistic regression analysis revealed that a large L5-S1 lordosis was a significant independent risk factor for recurrence. ROC analysis demonstrated a cut-off value of 24.5° for L5-S1 lordosis. Age, sex, SBO, and duration of conservative treatment for initial spondylolysis were not significant predictors of recurrence.

Conclusion: We identified large L5-S1 lordosis as an independent risk factor for recurrence of pediatric lumbar spondylolysis at L5 following conservative treatment. Intensive athletic rehabilitation to prevent recurrence and follow-up measures to monitor and detect recurrence are recommended for patients with large L5-S1 lordosis.

Study design: retrospective cohort study.

Objective: To investigate the relationship between perioperative Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) and postoperative outcomes after spinal fusion in obese and diabetic patient populations.

Summary of background data: GLP-1 RAs have been shown to be beneficial when used perioperatively in clinical orthopaedic arthroplasty literature. Minimal evidence exists showing efficacy with respect to spinal fusion.

Materials and methods: This retrospective, multi-center study accessed the TriNetX platform, using the research database to identify diabetic patients who underwent spinal fusion between 2008 and 2022. Cohorts were created based on Body-Mass-Index (BMI) and GLP-1 RA usage. Propensity score matching was employed to create balanced cohorts utilizing BMI, Hemoglobin A1c (HbA1c), surgical intervention, as well as other demographic characteristics. Orthopedic outcomes were compared between GLP-1 RA users and non-users. The primary outcomes included post-operative infection, readmission, revision surgery, and quality of life metrics.

Results: After matching, the study cohort consisted of 2,263 patients, with 1,560 classified as obese. GLP-1 RA use was associated with significantly reduced post-operative infection rates (obese: HR=0.168 (0.086, 0.328), not obese: HR=0.250 (0.102, 0.612)), fewer revisions (obese: HR=0.505 (0.368, 0.693), not obese: HR=0.439 (0.272, 0.708)), decreased postoperative readmission rates (obese: HR=0.283 (0.243, 0.329), not obese: HR=0.241 (0.193, 0.301)), and reduced mobility abnormalities (obese: HR=0.355 (0.230, 0.549), not obese: HR=0.508 (0.269, 0.959)). No significant differences were observed in rates of fracture rates between GLP-1 RA users and non-users.

Conclusions: GLP-1 RA use in spinal fusion patients was associated with improved post-operative outcomes, including lower infection rates, fewer revisions, and better quality of life metrics. These findings suggest that GLP-1 RAs may be a valuable adjunctive therapy in managing surgical outcomes in diabetic and obese patients undergoing spinal fusion. Further prospective and animal-based studies are needed to confirm these findings and explore the underlying mechanisms.

Study design: Clinical retrospective study.

Objective: The authors aim to analyze the relationship between paraspinal muscle degeneration and degree of L4-5 Degenerative lumbar spondylolisthesis (DLS).

Summary of background data: While paraspinal muscle degeneration is thought to contribute to spondylolisthesis severity, this relationship has yet to be fully characterized.

Methods: A retrospective analysis was performed of all neurosurgical patients admitted to the Columbia Neurosurgery Spine Division for treatment of L4-5 DLS between January 2018 and March 2024. Preoperative lumbopelvic parameters and slip percentage (SP) were calculated from standing radiographs; paraspinal muscle volume (MV), fatty volume (FV) and fatty infiltration (FI) of posterior paraspinal muscle were derived from MRI images using 3D Slicer (Earth, TX). Correlation and multiple linear regression analyses were used to assess the relationship between SP and paraspinal MV, FV, FI, and spinopelvic parameters.

Results: 221 patients with average SP of 23.74±0.09% were included. The female patients had higher SP, lumbar lordosis (LL), pelvic incidence (PI) and lower IVA than the male patients. However, paraspinal MV was lower and FI was higher in the Meyerding Grade II and female groups compared to the Grade I and male groups (P<0.01). There was a positive correlation between SP and metrics of fat replacement (P<0.01) and a negative correlation between SP and metrics of paraspinal muscles volume (P<0.01) at the L4-5 level. A stepwise multivariate regression ultimately included MFI, IVA, and LL and accounted for 15.2% of the variance in SP.

Conclusion: In this single center retrospective study, greater degree of spondylolisthesis was modestly associated with lower MV and increased FI of the lumbar paraspinal muscles, suggesting that paraspinal muscle degeneration may be one of several important factors in the development of spondylolisthesis.

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.

Materials and 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 2 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 2 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, low postoperative thoracic kyphosis, 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 PTC correction, rather than compromising 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: Level 4.

Study design: Retrospective cohort.

Objective: To identify the predictors of slower and nonimprovement after surgical treatment of L4-5 degenerative lumbar spondylolisthesis (DLS).

Summary of background data: There is limited evidence regarding clinical and radiologic predictors of slower and nonimprovement following surgery for L4-5 DLS.

Methods: Patients who underwent minimally invasive decompression or fusion for L4-5 DLS and had a minimum of 1-year follow-up were included. Outcome measures were: (1) minimal clinically important difference (MCID), (2) patient acceptable symptom state (PASS), and (3) global rating change (GRC). Clinical variables analyzed for predictors were age, gender, body mass index (BMI), surgery type, comorbidities, anxiety, depression, smoking, osteoporosis, and preoperative patient-reported outcome measures (PROMs) (Oswestry disability index, ODI; visual analog scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS). Radiologic variables analyzed were slip percentage, translational and angular motion, facet diastasis/cyst/orientation, laterolisthesis, disc height, scoliosis, main and fractional curve Cobb angles, and spinopelvic parameters.

Results: Two hundred thirty-three patients (37% decompression and 63% fusion) were included. At less than three months, high pelvic tilt (PT) (OR: 0.92, P= 0.02) and depression (OR: 0.28, P= 0.02) were predictors of MCID nonachievement and GRC nonbetterment, respectively. Neither retained significance at above six months and hence, were identified as predictors of slower improvement. At above six months, low preoperative VAS leg (OR: 1.26, P= 0.01) and high facet orientation (OR: 0.95, P= 0.03) were predictors of MCID nonachievement, high L4-5 slip percentage (OR: 0.86, P= 0.03) and L5-S1 angular motion (OR: 0.78, P= 0.01) were predictors of GRC nonbetterment, and high preoperative ODI (OR: 0.96, P= 0.04) was a predictor of PASS nonachievement.

Conclusions: High PT and depression were predictors of slower improvement and low preoperative leg pain, high disability, high facet orientation, high slip percentage, and L5-S1 angular motion were predictors of nonimprovement. However, these are preliminary findings and further studies with homogeneous cohorts are required to establish these findings.

Introduction: The published literature on Cranio-vertebral Junction (CVJ) anomalies lacks a comprehensive appraisal that integrates common diagnostic, management and treatment concepts for different conditions, such as Chiari Malformation (CM), Basilar Invagination (BI), Os Odontoideum (OO) and Syndromic Malformations. The authors aimed to fill this knowledge gap offering guidelines and recommendations with a global outreach and applicability.

Methods: A group of expert spine surgeons and WFNS Spine Committee members, most of which extensively published on CVJ anomalies in the past, reviewed the literature issued from 2011 to 2022. Following a common methodology, based on the Delphi method, the authors analyzed the strength of the literature and voted statements concerning diagnosis and management of these conditions.

Results: A total of eight papers were produced: (1) Chiari Malformation diagnosis, classifications, natural history, and conservative management, (2) Chiari malformation: indications for surgery and surgical options, (3) Pediatric Chiari malformation, (4) Syndromic atlanto-axial instability, (5) Os odontoideum, (6) Basilar invagination: diagnosis, radiology, and classification, (7) Surgical treatment of Basilar Invagination, and (8) Basilar invagination with associated Chiari malformation.

Conclusions: Despite grey zones on natural history of CVJ anomalies and controversies on timing and type of surgical treatments, whenever atlantoaxial instability is present, C1-C2 stabilization through instrumentation and fusion is necessary. If only recurrent pain and neurological dysfunction occurs, surgical decompression is appropriate. If no atlantoaxial instability is present, Down's patients can participate in competitive sports. In general, contact sports are not recommended.

Study design: A systematic literature review and consensus using Delphi method.

Objective: This review aims to outline the therapeutic criteria and clarify the best surgical options for the different types of basilar invagination (BI).

Summary of background: BI is a complex developmental malformation for which many surgical remedies have been proposed without clear consensus.

Material and methods: Using PubMed, the authors reviewed the literature on the surgical treatment of BI published from 2011 to 2022 looking at different surgical options. A panel of spine surgeons and members of the WFNS Spine Committee used the Delphi technique to assess the strength of literature, elaborate, and vote on statements regarding the surgical management of BI.

Results: Thirteen recommendations were issued covering the most relevant topics related to the surgical treatment of BI. Posterior fossa decompression alone is an option to treat BI without instability. Most cases of BI and AAI can be treated by C1-C2 fixation. In selected cases, distraction of the atlantoaxial joint may be required. Current evidence is lacking which technique is better to correct irreducible BI. OCF can be used in case of atlas assimilation, dysgenesis of C1 lateral mass, in irreducible cases, odontoidectomy and revision of failed C1-C2 fixation. Complications of the OCF may reach up to 50%. The role for anterior fusion for treatment of BI need to be better assessed by further studies. In the setting of irreducible anterior compression caused by BI, the anterior odontoidectomy can be indicated supplemented by C1-C2/occipital-cervical fusion.

Conclusions: There are multiple surgical options for basilar invagination depending on the existence of compression, AAD or irreducibility. The WFNS spine committee proposed consensus recommendations based on relevant literature published after 2011 to help surgeons standardize the level of care and improve outcomes following treatment across the globe.

Study design: Systematic review and meta analysis.

Objective: To assess the safety and efficacy of staged versus same-day spinal fusion surgeries in Adult spinal deformity (ASD).

Background: ASD surgeries are associated with high complication rates, ranging from 10% to 40%. Among the strategies to enhance safety, staging the procedure into two smaller procedures has been evaluated as an effective alternative.

Methods: A systematic literature review following PRISMA guidelines was conducted using PubMed, Cochrane, Scopus, and Embase. Studies comparing staged and same-day spinal fusion for ASD were included. Perioperative data, patient-reported outcomes (ODI, SRS), radiological outcomes, and complication rates were analysed. The extracted data was analyzed and forest plots were generated to draw comparisons between the staged and the same day groups.

Results: Eleven studies, including 1323 patients (541 staged, 782 same-day) were analyzed. Staged surgeries were associated with longer operative time and length of hospital stay. There was no significant difference in estimated blood loss, clinical and radiological outcomes, or overall complication rates between groups. However, venous thrombo-embolism (VTE) rates were significantly higher in staged surgeries (odds ratio=4.33). In the staged group, surgical site infections was the most common complication with a rate of 10.5%, whereas neurological complications were the most frequent group of complications in same-day group.

Conclusion: Staged surgeries for ASD result in longer operative time, length of hospital stay and increased VTE risk but show similar efficacy in clinical and radiological outcomes compared to same-day surgeries. Careful patient selection is crucial to balance risks and optimize outcomes in ASD surgical planning.