Spine最新文献

Study design: Prospective cohort study.

Objective: This study aims to define Substantial Clinical Benefit (SCB) thresholds for PROMIS physical function (PF) and pain interference (PI) in lumbar or thoracolumbar spine surgery population.

Summary of background data: Patient-reported outcome measures (PROMs) are widely used in spine surgery to assess treatment efficacy. SCB is a relatively new concept that represents a substantial improvement perceived by the patient.

Methods: This is a prospective study that included adults aged 21-85 years, undergoing lumbar/ thoracolumbar surgery for degenerative spine disease, and reporting at least 3/10 back or leg pain on a numeric rating scale. PROMs including Oswestry Disability Index, PROMIS PF, and PROMIS PI were collected preoperatively and at one year postoperatively. The North American Spine Surgery Patient Satisfaction (NASS) Index was collected one year postoperatively. SCB thresholds of absolute and percentage changes were calculated using anchor-based methods with ODI and NASS index as anchors. ROC analysis was used to determine optimal SCB cutoffs.

Results: We included 137 patients. Using a fixed 19-point reduction in ODI as an anchor yielded SCB thresholds of 6.8 and 11.3 points for PROMIS PF and PI respectively. When using a dynamic anchor based on preoperative disability (50% ODI improvement), SCB thresholds were defined as achieving 18 and 27% of maximum possible improvement for PROMIS PF and PI respectively. Using NASS index, thresholds were 11 points or 24% for PROMIS PF, and 11.2 points or 21% for PROMIS PI. ROC values ranged from 0.81 to 0.9, with the dynamic ODI anchor cutoffs demonstrating the best discrimination.

Conclusion: Our study is the first to define SCB thresholds for PROMIS PF and PROMIS PI using both fixed and dynamic cutoffs based on preoperative disability in lumbar and thoracolumbar patients. These thresholds will help in patient counseling and outcome evaluation for spine surgery research.

Study design: Retrospective cohort study.

Objective: Evaluate the utility of Delirium Risk Assessment Score (DRAS), Delirium Risk Assessment Tool (DRAT), and Delirium Elderly At-Risk (DEAR) in patients undergoing posterior lumbar interbody fusions.

Background: Surgical interventions can place patients at risk for postoperative delirium (POD), an acute and often severe cognitive impairment associated with poor outcomes. However, common risk assessment tools have not been validated in patients undergoing spine surgery.

Methods: Adults who underwent posterior lumbar fusion were queried using PearlDiver. Baseline demographics, comorbidities, and delirium occurrence within 7 days of surgery were extracted. Delirium risk scores were calculated using DRAS (15 points total; threshold 5 points), DRAT (8 points total; threshold 3 points), and DEAR (5 points total; threshold 2 points) scales. Receiver operating characteristic (ROC) curves were generated, and optimal risk scores maximizing Youden's Index were established for each measure.

Results: Among 37,119 patients, 70 patients (0.2%) developed POD. The mean age was 60.1 y, 56.6% were female, and mean Charlson Comorbidity Index (CCI) was 2.1. POD patients had lower mean age and percent female sex, but higher mean CCI and percent medical comorbidities (all P<0.05). ROC curve analyses revealed that a DRAS score of 5 (Sensitivity=62.9%, Specificity=63.9%), DRAT score of 3 (Sensitivity=31.4%, Specificity=81.0%), and DEAR score of 2 (Sensitivity=40.0%, Specificity=82.9%) maximized the Youden's Index value. Patients above these thresholds were 6.0, 2.0, and 3.2 times more likely to develop POD after posterior lumbar fusion, respectively.

Conclusion: Delirium risk assessments tools were found to be useful in stratifying patients at high risk of POD following posterior lumbar fusion. Specifically, patients above the pre-defined thresholds were 2 to 6 times more likely to develop delirium postoperatively. Careful stratification of patients' risk of delirium using highly sensitive and specific tools like DRAS may guide preoperative surgical planning and postoperative management plans.

Level of evidence: IV.

Study design: A cross-sectional analysis of 10,000 cervical spine X-rays.

Objective: This study investigates the variations in C6S and C7S across demographic factors (gender, age, cervical curvature, symptoms) and explores their correlation. Additionally, machine learning models are applied to improve the accuracy of C7S prediction.

Summary of background data: The C7S is crucial for assessing cervical balance but is often limited by visibility issues. This study uses a large sample to validate the feasibility of the C6S as a substitute for C7S across diverse populations with varying ages, genders, symptoms, and cervical curvatures.

Methods: A retrospective study was conducted on 10,000 subjects who underwent cervical sagittal X-ray imaging. Four orthopedic specialists labeled key points, which were cross-validated, and an algorithm was then used to measure C6S and C7S. Pearson correlation coefficients were calculated to assess the relationship between C6S and C7S, and linear regression derived a predictive equation for C7S. Various machine learning models were compared to improve C7S prediction accuracy.

Results: The average angles for C6S and C7S were 15.4° (16.8° in males, 14.7° in females) and 19.1° (21.1° in males, 18.2° in females), respectively, with C7S generally larger than C6S, except in Sigmoid 1 curvature. Males exhibited higher values for both C6S and C7S, and both slopes increased after age 20. Both angles increased significantly with age from 20 to 90 years. A strong positive correlation was found between C6S and C7S (r>0.75, P<0.001), confirmed by linear regression (R²=0.688). Among the machine learning models, both Ridge Regression and Linear Regression performed better than the others, with R²=0.855 in predicting C7S.

Conclusion: The strong correlation between C6S and C7S suggests that C6S can substitute for C7S when visibility is limited. Machine learning models further enhance prediction accuracy, demonstrating promising clinical potential.

Study design: Retrospective observational study.

Objective: To evaluate whether the combined American Spine Registry and Medicare (ASR/CMS) data yields substantially different findings versus ASR data alone with regard to key parameters such as risk stratification, complication rates and readmission rates in lumbar surgery investigated through an analysis of 8,755 spondylolisthesis cases.

Summary of background data: Medicare data correlation has been effective for determining revision rates for other procedures such as total hip replacement. Our aim is to determine whether these findings are translatable in the realm of lumbar spinal surgery investigated through an analysis of 8,755 spondylolisthesis cases.

Methods: The American Spine Registry (ASR) was queried for Medicare-eligible patients who underwent lumbar spinal fusion for lumbar spondylolisthesis. This cohort was analyzed based upon ASR data alone in comparison to the same patients in the combined ASR/Medicare (ASR/CMS) dataset. The primary outcome of interest was readmission at 30 and 90 days postoperatively.

Results: There were 8,755 Medicare-eligible cases with a diagnosis of spondylolisthesis within the ASR. The mean age was 72.7 years, 60.8% were female. Medical comorbidities were more frequently detected in the combined ASR/CMS dataset, reflected by a higher mean Charlson Comorbidity Index score (3.49 vs. 3.27, P<0.001). Hospital readmission rates were significantly higher in the combined ASR/CMS dataset at both 30 days (4.89% vs. 1.83%, P<0.001) and 90 days (7.68% vs. 2.66%, P<0.001), with notable increases in readmissions for infections and medical complications. Discharge disposition remained comparable across datasets, with most patients discharged to home or home health care.

Conclusion: This study demonstrates that integrating patient-identified Medicare data with the ASR provides a more comprehensive assessment of outcomes for lumbar spinal fusion surgery as demonstrated through an analysis of 8,755 spondylolisthesis cases. These findings, establish the importance of multi-source data linkage to overcome the limitations of single-source registries, thereby enhancing data quality for clinical decision-making and quality improvement in spinal surgery.

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

Objective: The aim was to formulate consensus recommendations regarding the natural history, diagnosis, classification and optimal treatment of Os Odontoideum with global applicability.

Summary of background: Os odontoideum (OO) is a rare anomaly of the cranio-vertebral junction (CVJ). Due to the paucity of literature, there is still considerable debate about the clinical management of OO.

Material and method: Using PubMed, the authors reviewed the literature on OO published from 2011 to 2022. Using the Delphi method, a panel expert spine surgeons and members of the WFNS Spine Committee analyzed the strength of the published literature, elaborated and voted statements concerning diagnosis and management.

Result: The diagnosis may be established incidentally. Symptoms may manifest as neck discomfort or encompass occipital-cervical pain, myelopathy, or vertebrobasilar ischemia. Diagnosis is usually made with plain radiographs and CT can. Dynamic x-rays identify C1-C2 instability whereas MRI assess spinal cord integrity and compression. Asymptomatic cases lacking radiologic instability are generally handled through regular observation and serial imaging, until predictors of neurological deterioration necessitate surgical intervention. In the event of atlantoaxial instability or neurological dysfunction, surgical intervention with instrumentation and fusion is required to maintain stability. In irreducible cases, C1-2 joint manipulation and distraction permits re-alignment and deformity correction avoiding decompression, either from anterior or posterior.

Conclusion: The management guidelines for asymptomatic OO are still a grey zone as our understanding of the natural history is still vague. Therefore, we need more large-center studies to investigate this condition further. Whenever symptomatic, unstable or asymptomatic presenting with risk factors, OO is better managed with atlanto-axial fusion avoiding occipital inclusion in the construct. In irreducible OO, C1-2 joint manipulation and distraction is preferred to decompression.

Study design: Radiographic analysis.

Objective: Evaluate the anatomical relationships of the bowel to the lateral surgical corridor and the spine in various surgical positions.

Summary of background data: Retroperitoneal transpsoas lateral lumbar interbody fusion (LLIF) may be performed with patients in the prone position, allowing for lateral and posterior approaches to the spine without repositioning the patient. Few, if any, studies discuss changes of the bowel position during these procedures.

Methods: Ten healthy volunteers underwent MRI in 3 positions: supine, prone with hips extended (prone-extension), and right lateral decubitus (left side up) with hips flexed (lateral decubitus-flexion). Anatomical relationships of the bowel to fixed spinal landmarks were assessed at L1-5, and the changes among participants' positions were compared.

Results: Anterior bowel movement was noted with prone-extension (range: 0.32-1.39 cm) and lateral decubitus-flexion (range: 0.97-2.18 cm) positioning compared with supine positioning. Significant anterior movement of the bowel was observed at L1-2 (P=0.03) and L2-3 (P=0.04) disc levels in participants in the prone position and at L2-3 (P=0.002) and L3-4 (P=0.01) in those in the lateral position when compared with those in the supine position. No differences in bowel movement were found for prone and lateral positioning. The percentages of participants with bowels located in the operative corridor were similar among the surgical positions (all P>0.07). 3D volumetric analysis showed that the magnitude of these changes was greatest for the upper left colon.

Conclusions: The results showed that the bowel was positioned anteriorly at L1-5 disc levels when participants were in prone-extension and lateral decubitus-flexion positions compared with the supine position. Overall, the magnitude of bowel positional change was small and variable. These findings suggest that the bowel does not fall away from the surgical corridor when performing retroperitoneal access for single-position prone surgery compared with the lateral decubitus-flexion position.

Study design: Subgroup analysis of a retrospective clinical and animal trial [Study of different doses of methylprednisolone on functional recovery of spinal cord injury].

Objective: The aimed to investigate the efficacy of low-dose methylprednisolone regimens in promoting neural repair after SCI.

Summary of background data: Spinal cord injury (SCI) can result in sensory, motor, and autonomic nerve dysfunction, often leading to disability or death. Methylprednisolone (MP) is a preferred medication for clinical treatment of SCI. Low-dose regimen may be a safer and more effective approach.

Methods: A subgroup comprising 705 patients with traumatic cervical SCI from four medical centers between January 2015 and December 2020 was retrospectively analyzed. Patients were stratified based on treatment regimen: low-dose methylprednisolone, high-dose methylprednisolone, or no methylprednisolone use. All patients underwent spinal decompression surgery. The degree of neurological recovery and the incidence of complications during follow-up were compared among these three groups. Additionally, we investigated the disparities in neurological function recovery, neuronal death, and neural axon regeneration between the low-dose and high-dose methylprednisolone treatment regimens using a SCI rat model.

Results: Patients receiving the low-dose methylprednisolone regimen exhibited superior neurological recovery compared to those receiving the high-dose regimen and those not receiving methylprednisolone (82.0% vs. 74.0%, P=0.030; 82.0% vs. 63.4%, P=0.001). Moreover, patients in the low-dose methylprednisolone group demonstrated the lowest rates of perioperative pulmonary infections and gastrointestinal bleeding among these three groups. Evaluation of the SCI rat model through Basso-Beattie-Bresnahan (BBB) score, footprint analysis, electrophysiological tests, hematoxylin and eosin (H&E) staining, immunofluorescence staining, and Nissl staining further corroborated that the low-dose methylprednisolone treatment regimen enhanced transport function recovery, reduced neuronal death, and promoted neural axon regeneration.

Conclusion: The low-dose methylprednisolone regimen may have a more positive therapeutic effect on the recovery of neurological function after SCI than other regimens.

Study design: Retrospective Cohort Study.

Objectives: To examine the impact of neighborhood-level socioeconomic factors on the delay of care and severity of disease among DCM patients at initial presentation.

Summary of background data: Degenerative Cervical Myelopathy (DCM) is the most common etiology for spinal cord dysfunction among adults worldwide. Previous literature has suggested that social determinants of health including neighborhood-level socioeconomic status such as Area of Deprivation Index (ADI) may impact spine surgery outcomes in DCM.

Methods: We performed a single-institution retrospective analysis of all patients undergoing spine surgery for the treatment of DCM from 2010 to 2022. Patients were identified using CPT and ICD9/10 codes. Data was collected via review of the electronic medical record. ADI was extracted from patients addresses. Multivariate and univariate analysis was used to assess the relationship between socioeconomic variables and myelopathy characteristics.

Results: A total of 490 patients (Mean age: 60.3±11.3 y) were identified. Residence in rural areas was associated with higher Nurick score (OR 2.48,P=0.011), and lower mJOA score (OR 2.51, P=0.014) at presentation, and longer times to presentation (HR 0.48, P=0.003). Having high ADI was independently associated with shorter times to presentation (HR 1.46,P<0.001), but predicted higher Nurick score (OR 1.6, P=0.021) and lower mJOA score (OR 1.86,P=0.002). Unemployment was associated with longer times to presentation (HR 0.66,P<0.001), higher Nurick score (OR 4.5,P<0.001), and lower mJOA score (OR 4.51, P<0.001), while race was not.

Conclusions: This is the first single institution study investigating the influence of neighborhood-level measures such as ADI on presentation status and disease burden in patients with DCM. High ADI predicts shorter disease duration but more severe DCM symptoms. Rural residence, unemployment, and non-private insurance were independently associated with prolonged and more severe DCM symptoms while race was not.

Level of evidence: 3.

Study design: A retrospective cohort study.

Objective: To determine if there is a difference in reoperations for adjacent segment disease (operative ASD) and nonunion (operative nonunion) in lumbar fusions that stop at T10/T11/T12 versus L1.

Summary of background data: Current lumbar spine surgery is based on the belief that ASD occurs if fusions are stopped at L1 although there is varying evidence to support this assumption.

Methods: We conducted a cohort study using data from a US-based integrated healthcare system's Spine Registry of adult patients ≥18 years old with degenerative disc disease/adult lumbar deformity who underwent primary lumbar fusions. The exposure of interest was lumbar fusions stopping at L1 versus T10/T11/T12. Propensity score-weighted Cox proportional hazards regressions were used to evaluate reoperation risk for ASD and for nonunion.

Results: The study cohort included 227 lumbar fusions that stop at L1 and 228 stop at T10/T11/12. Mean age for the cohort was 68.4 years with mean follow-up time of 6.3 years. For caudal level at L5 and S1, we found no statistical differences between operative ASD stopping at L1 versus T10/11/12 (HR=1.03, 95% CI=0.53-2.02, P=0.93 and HR=0.67, 95% CI=0.27-1.67, P=0.39, respectively). For the Short-segment fusions (caudal level: L3,4,5) and Long-segment fusions (L5, S1. S1+ilium) we also found no statistical difference in operative ASD (HR=1.44, 95% CI=0.68-3.09, P=0.34 and HR=0.83, 95% CI=0.52-1.30, P=0.41, respectively). For Long-segment fusions we also found no statistical difference in operative nonunion (HR=0.65, 95% CI=0.20-2.11, P=0.47).

Conclusion: Our study provides some evidence against crossing the thoracolumbar junction (TLJ) for individual constructs terminating at S1, as well as for Long-segment fusions, based on comparisons of operative ASD and operative nonunion. However, further research is needed to determine whether this finding holds true for individual constructs with caudal levels at L2, L3, L4, and S1+ilium.

Study design: This was an observational study.

Objective: Assessing the global burden of disease for low back pain (LBP) using the 2021 GBD (Global Burden of Disease) database.

Summary of background data: LBP is a leading cause of workforce loss and disability. With societal aging and changes in lifestyle and work habits, the incidence of LBP is expected to rise. This study comprehensively analyzes the epidemiological trends of global LBP from 1990 to 2021.

Methods: Data publicly available from the 2021 GBD study were utilized, and a systematic analysis was conducted to assess the global burden and epidemiological trends of LBP.

Results: From 1990 to 2021, the age-standardized prevalence, incidence, and Years Lived with Disability (YLD) rates of LBP have slightly declined globally. However, the number of affected individuals, new cases, and YLD numbers have significantly increased, making LBP a leading cause of YLD in 2021. The number of affected individuals increases with age, peaking in both men and women between the ages of 50 and 54. Worldwide, women have a higher prevalence of LBP than men, and this increases with age, with both genders reaching peak prevalence between 80 and 84 years in 2021. Overall, over the past 3 decades, age-standardized YLD rates have shown a positive correlation with the Socio-demographic Index (SDI). In terms of region and nation, Tropical Latin America and Kingdom of Sweden have seen the greatest increase in age-standardized prevalence rates from 1990 to 2021.

Conclusion: Globally, LBP remains a notable public health concern, carrying a consistently high burden. To alleviate the future impact of this disease, it is imperative to increase public awareness regarding its risk factors and to implement preventive measures.