Spine最新文献

Study design: Scoping review for historical perspective.

Objective: We sought to provide a comprehensive review of the number of physicians and support staff assigned to Role II and Role III facilities, and performance over the course of the 20th and 21st centuries. We sought to use the historical experience to lay the groundwork for reform efforts in anticipation of large-scale combat.

Summary of background data: The conflicts in Iraq and Afghanistan were characterized by air superiority for US forces, asymmetric engagements, and irregular combat operations. Large-scale combat operations (LSCO) that are anticipated in the future will differ in both scale and tactics-with anticipated higher numbers of severely injured personnel and spine trauma.

Materials and methods: We performed a scoping review of the available literature on Role II and Role III facilities in the US Military Health System from 1900 to the present. Compiled data included the types of Role II and III units (or military medical units that filled similar roles) in the time period 1900 to present, their assigned personnel, and performance in combat operations.

Results: The current composition and use of Role II and III surgical facilities primarily reflect the nature of combat experience in Iraq and Afghanistan. The lack of air superiority, increased reliance on ground transportation, and the volume of high-acuity combat casualties, including those with spine trauma, are anticipated to be major challenges to Role II and III facilities in the context of future LSCO. The "Golden Hour" principle that was successfully implemented during the Iraq and Afghanistan conflicts will be difficult to adhere to without adjusting the composition and capabilities of Role II and III units. Increased flexibility, interoperability, and mobility, with a reliance on larger cadres of surgical and intensive care specialists with greater familiarity with military techniques, spine trauma care, and operational medicine, are anticipated to be necessary.

Conclusions: We anticipate less of a "one-size fits all" capability for military medical units in the future and the need for robust medical units as close to the front lines as possible, with an emphasis on prolonged casualty care, including the management of complex spine trauma.

Study design: Systematic review and proportional meta-analysis.

Objective: To quantify overall and specific complication rates associated with tubular minimally invasive spine surgery (MISS) for lumbar pathologies over the past decade.

Summary of background data: Tubular MISS is widely used for lumbar pathologies due to its reduced tissue disruption and faster recovery compared with open surgery. However, reported complication rates vary, and pooled estimates for specific complications remain limited.

Materials and methods: A systematic search of PubMed, Medline, Embase, and the Cochrane Library (January 2013-March 2024) was conducted following PRISMA guidelines. Studies were included if they involved 10 adult patients undergoing tubular lumbar MISS and provided extractable complication data. A random-effects model was used to pool complication rates, and study quality was assessed using the Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale. All analyses were done using R studio.

Results: Seventy-five studies involving ∼12,600 patients were included in the analysis. The complication rate was 10% (95% CI: 8%-14%, I2=93%). Specific complication rates were: dural tears 4% (95% CI: 3%-5%, I2=69%) in 56 studies (6651 patients); nerve injuries 1% (95% CI: 1%-3%, I2=70%) in 41 studies (5278 patients); postoperative hematoma 1% (95% CI: 1%-2%, I2=31%) in 19 studies (2454 patients); surgical site infections 1% (95% CI: 0%-1%, I2=27%) in 46 studies (10,439 patients); revision surgeries 2% (95% CI: 2%-3%, I2=77%) in 43 studies (8948 patients); and disc reherniation 3% (95% CI: 1%-7%, I2=84%) in 14 studies (1928 patients).

Conclusion: This meta-analysis provides a comprehensive overview of complication rates in tubular lumbar MISS, revealing generally low rates but significant heterogeneity across studies. These findings offer valuable insights for patient counseling and surgical planning, though individual patient factors and surgeon experience should be considered.

Study design: Retrospective Cohort.

Objective: To investigate impact of controlled/uncontrolled sub-stratification of modified frailty index (MFI-5) on postoperative outcomes after lumbar fusion for degenerative disease.

Background: mFI-5 outperforms age as a predictor of postoperative risk. Sub-stratification of mFI-5 by controlled versus uncontrolled frailty has allowed for better risk prognostication in spinal deformity cases.

Methods: Adult patients who underwent elective, single-level lumbar fusion (2017-2021) were identified. Fusions for infection/trauma/tumor/revision were excluded. Patients were classified as frail/non-frail based on having any mFI-5 criteria (history of chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF], diabetes mellitus [DM], hypertension [HTN] requiring medication, and functional status). Frailty was considered controlled unless patients had a COPD exacerbation within 3 months prior to surgery, preoperative hemoglobin A1c >7, or HTN ≥140/90 mmHg for ≥2 visits.

Results: 1,286 patients were included (controlled/uncontrolled/non-frail-804/159/323). Uncontrolled frailty patients had more 31-90 day ED visits (9.43% vs. 4.13%,P=0.009), 0-30 day readmissions (5.66% vs. 2.49%,P=0.042), and renal complications (13.2% vs. 6.38%,P=0.005) compared to controlled frailty patients. Controlled frailty patients were older (56.3 vs. 62.9, P<0.001) and had more 0-30 day ED visits (2.19% vs. 5.63%,P=0.021) compared to non-frail patients. Uncontrolled frailty patients were older (56.3 vs. 63.8,P<0.001), and had higher 0-30 (2.19% vs. 7.55%,P=0.010) and 31-90 day ED visits (1.88% vs. 9.43%,P<0.001), 0-30 day readmissions (0.93% vs. 5.66%,P=0.003), and renal complications (3.76% vs. 13.2%,P<0.001) compared to non-frail patients. Multivariable regression demonstrated that uncontrolled frailty alone was independently associated with 30-day ED visits (odds ratio [OR]-3.68,P=0.030), any ED visit (OR-3.33,P=0.008), 90-day readmission (OR-5.42,P=0.047) and any readmission (OR-5.41,P=0.005).

Conclusion: Multivariable regression demonstrated that uncontrolled frailty was an independent risk factor for ED visits and readmission after single-level lumbar fusion. Further work is needed to identify the best pre- and postoperative strategies to optimize outcomes for this vulnerable population.

Study design: Cadaveric validation study.

Objective: To evaluate the accuracy of a structured four-step ultrasound (US)-guided workflow for lumbar spinal level identification (SLI) using cadaveric specimens.

Summary of background data: Despite the routine use of fluoroscopic verification, wrong-level spinal surgery continues to be a documented and concerning complication. Fluoroscopy exposes patients and staff to ionizing radiation and requires specialized personnel and infrastructure. US has been utilized for SLI in obstetric and anesthetic applications but remains underexplored in surgical workflows.

Methods: Ten fresh-frozen cadavers underwent US imaging to identify lumbar levels. A newly developed four-step protocol was employed: (1) Midline localization, (2) Sacral surface tracing, (3) S1-Superior articular process (SAP) recognition, (4) Interlaminar space enumeration. Five spinal needles were placed under US guidance in each specimen (L1-2 through L5-S1), with one needle per level. Fluoroscopic imaging was then used to confirm needle placement accuracy. A level was defined as misidentified if the projected trajectory from the needle tip violated predefined radiographic boundaries.

Results: A total of 50 lumbar levels were assessed across ten cadaveric specimens, with 25 procedures performed from the right side and 25 from the left. Fluoroscopic validation demonstrated accurate level identification in 49/50 cases, yielding an accuracy rate of 98%. The single misidentification occurred at the L5-S1 level during the third step of the workflow, where the S1 SAP was erroneously interpreted as the L5 inferior articular process. No systematic error patterns were observed, and the four-step protocol proved reproducible across specimens.

Conclusion: This cadaveric feasibility study establishes a high accuracy of US-guided lumbar level identification. A structured and reproducible workflow for level localization was established, integrating a novel four-step protocol. These findings represent a first step toward a radiation-free alternative for preoperative lumbar level verification in spinal surgery. Further investigations are warranted to validate these results in clinical settings.

Study design: Cohort study of pooled data from patients enrolled in a behavior randomized trial (RCT) that successfully increased physical activity after complex lumbar surgery.

Objective: To assess associations between increased energy expenditure from walking and general functional status and lumbar-specific disability 12 months after enrollment.

Background: Many postoperative patients retain preoperative sedentary lifestyles and thus do not obtain general health and spine-related benefits of physical activity.

Methods: Three months after complex lumbar surgery (i.e. fusion, ≥3 levels) patients were enrolled in a behavior RCT aimed at increasing physical activity from walking measured by the Paffenbarger Physical Activity and Exercise Index (PAEI) in kcals/week. Data were pooled for this analysis to assess associations between kcals/week at 12 months and change in general functional status (RAND 12-Item Physical Component Summary score, PCS) and lumbar-specific disability (Oswestry Disability Index, ODI). Covariates considered included age, sex, body mass index, back pain, surgical complexity, depressive symptoms, and enrollment PCS, ODI and kcals/week.

Results: Among 231 patients (mean age 64, 47% women) enrollment walking was 1361±1294 kcals/week and increased to 1935±1979 kcals/week at 12 months, mean within-patient change 574 kcals/week (P<.0001). Enrollment PCS score was 37±10 and improved to 44±11 at 12 months, exceeding a clinically important difference (CID). Change in PCS score was associated with kcals/week at 12 months in multivariable analysis controlling for enrollment kcals/week and PCS score (coefficient .002, 95% CI .001-.003, P<.0001). Enrollment ODI score was 34±16 and improved to 27±19 at 12 months, exceeding a CID. Change in ODI score was associated with kcals/week at 12 months in multivariable analysis controlling for enrollment kcals/week and ODI score (coefficient .01, 95% CI 0.002-.005, P<0.0001).

Conclusions: Increased postoperative energy expenditure from walking at 12 months was associated with improvement in general functional status and reduced lumbar-specific disability in patients after complex lumbar surgery.

Study design: Prospective cohort study.

Objective: To identify patient factors that predict changes in adjacent segment kinematics three years after ACDF.

Summary of background data: Approximately 25% of patients who undergo anterior cervical discectomy and fusion (ACDF) develop symptomatic adjacent segment disease (ASD) requiring reoperation within 10 years. Studies have found associations between ASD and patient genetics, age, BMI, psychiatric history, and preoperative disc degeneration. Few studies have linked these factors to mechanical changes to explain ASD.

Methods: Patients performed flexion/extension and axial rotation captured by biplane radiography before, one year after, and three years after ACDF (3YR-POST). Digitally reconstructed cervical radiographs were matched to the biplane radiographs to calculate intervertebral kinematics and preoperative disc height. Patient age, sex, BMI, smoking, diabetes, psychiatric history, inciting event, length of symptoms, preoperative disc bulge, and NDI were collected. Multivariate linear regression identified patient factors associated with changes in adjacent segment kinematics and NDI 3YR-POST.

Results: 62 patients completed testing. Younger age (1.1° per 10 years, 95% CI [0.04, 1.8], P=0.011), female sex (1.8°, 95% CI [0.5, 3.1], P=0.016), lower BMI (1.4° per 10 kg/m², 95% CI [0.4, 2.5], P=0.019), and no superior adjacent disc bulge (1.4°, 95% CI [0.0, 2.7], P=0.035) predicted larger increase in superior adjacent segment flexion/extension range of motion (ROM) 3YR-POST. Lack of superior adjacent disc bulge (1.2°, 95% CI [0.2, 2.2], P=0.025) predicted larger increase in superior adjacent segment axial rotation ROM. No patient factors were associated with changes in inferior adjacent segment ROM.

Conclusion: Greater increase in superior adjacent segment motion 3YR-POST is predicted in younger, lower BMI, female patients with healthier preoperative discs. These results support the theory that disc degeneration progresses from early instability in younger, healthier discs to stabilization in older, less healthy discs.

Study design/setting: Retrospective study at a single academic tertiary care center.

Objective: To evaluate osseous and vascular structures at C1 on preoperative MRIs and CTAs.

Background data: No prior studies have compared the diagnostic accuracy between magnetic resonance imaging (MRI) and computed tomography angiography (CTA) to assess C1 and internal carotid artery (ICA) anatomy prior to surgical instrumentation.

Methods: We retrospectively reviewed adult patients who underwent both cervical spine CTA and MRI between 2007 and 2018. Patients with prior cervical surgery or MRIs not extending to the atlas were excluded. Ten standardized osseous and vascular measurements were performed on both modalities using anatomical landmarks at C1. Paired t-tests and intraclass correlation coefficients (ICCs) assessed differences and agreement. A sub-analysis normalized measurements to anterior-posterior C1 length to account for potential modality-based scaling differences.

Results: Of 209 patients reviewed, 119 met inclusion criteria (mean age 65.1 years; 56% female). The agreement between CTA and MRI across 10 anatomical measurements was low, with ICCs ranging from 0.006 to 0.427. All measurements except the distance from the end of the ideal screw trajectory to the anterior plane of C1 demonstrated statistically significant differences between CTA and MRI (P<0.05). After standardizing values to anterior-posterior C1 length, ICCs for the nine measurements remained low (0.012 to 0.305), with only standardized measurements, distance from the end of the ideal screw trajectory to the anterior plane of C1 and the distance from the origin of the ideal screw trajectory to the ICA showing no statistically significant differences.

Conclusions: This study evaluated the accuracy of preoperative CTA and MRI in assessing C1 and ICA anatomy for atlantoaxial fusion planning, revealing variability in measurement agreement between the two. The findings highlight the need to tailor imaging choices to each clinical scenario, balancing diagnostic value, radiation exposure and surgical risk.