Spine最新文献

Study design: Retrospective.

Objective: Evaluate whether the use of vancomycin powder (VP) placed in the surgical site before wound closure prevents delayed deep surgical site infections (DDI).

Summary of background data: DDI after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients remains a significant and major complication. The use of VP to prevent acute surgical site infection has been reported, but the impact on DDI is unknown.

Materials and methods: AIS patients treated over the past 20 years with PSF or instrumentation from a large multicenter registry were reviewed. Patients were divided into two groups: intraoperative vancomycin powder placed in the wound (VP) or no antibiotics placed in the wound (NVP). DDI was defined as an infection that occurred >90 days after surgery and required surgical intervention in the operating room. Patients who developed a DDI had secondary verification of VP use or not. χ 2 and Kaplan-Meier (K-M) survivorship analyses were used to compare demographics and the incident rate of DDI between groups.

Results: Totally, 4145 cases met the inclusion criteria for this study. A total of 43 DDI cases were identified (1.0%). The incidence of DDI for the VP group was 0.2% (4/2111), and 1.9% (39/2034) in the NVP group ( P <0.001). Given the difference in follow-up for the two groups, a cumulative survival and Kaplan-Meier analysis revealed the VP group had significantly better "survival" (no DDI) than the NVP group ( P <0.001).

Conclusion: DDIs are significant adverse events that can greatly complicate patient recovery after PSF for AIS, including rehospitalization. This study found that patients who received VP intraoperatively were 10 times less likely to develop a DDI than those who did not receive VP. Although other advances and changes in surgical techniques may contribute to the significant decrease in infections found in the more recent VP cohort, VP should be considered as a prophylactic measure.

Level of evidence: 4.

Study design: A retrospective analysis.

Objective: This research sought to develop a predictive model for surgical outcomes in patients with cervical ossification of the posterior longitudinal ligament (OPLL) using deep learning and machine learning (ML) techniques.

Summary of background data: Determining surgical outcomes assists surgeons in communicating prognosis to patients and setting their expectations. Deep learning and ML are computational models that identify patterns from large data sets and make predictions.

Methods: Of the 482 patients, 288 patients were included in the analysis. A minimal clinically important difference (MCID) was defined as gain in Japanese Orthopaedic Association (JOA) score of 2.5 points or more. The predictive model for MCID achievement at 1 year postsurgery was constructed using patient background, clinical symptoms, and preoperative imaging features (x-ray, CT, MRI) analyzed through LightGBM and deep learning with RadImagenet.

Results: The median preoperative JOA score was 11.0 (IQR: 9.0-12.0), which significantly improved to 14.0 (IQR: 12.0-15.0) at 1 year after surgery ( P < 0.001, Wilcoxon signed-rank test). The average improvement rate of the JOA score was 44.7%, and 60.1% of patients achieved the MCID. Our model exhibited an area under the receiver operating characteristic curve of 0.81 and the accuracy of 71.9% in predicting MCID at 1 year. Preoperative JOA score and certain preoperative imaging features were identified as the most significant factors in the predictive models.

Conclusion: A predictive ML and deep learning model for surgical outcomes in OPLL patients is feasible, suggesting promising applications in spinal surgery.

Level of evidence: 4.

Study design: Retrospectively matched case-control study.

Objective: To compare intraoperative and postoperative outcomes between separation surgery and corpectomy with anterior reconstruction for patients with metastatic epidural spinal cord compression (MESCC).

Summary of background data: The primary goal of surgery for MESCC is to preserve and improve neurological function. Separation surgery may offer a less invasive alternative that still achieves neurological decompression and restores biomechanical stability, enabling surgeons to forego more invasive surgeries, such as corpectomy with anterior reconstruction. However, there is limited literature comparing these two surgical methods.

Methods: Fifty-six patients aged 18 years or older who underwent either separation surgery followed by stereotactic body radiation therapy (n=28) or corpectomy with anterior reconstruction (n=28) for MESCC from 2017 to 2022 were included. Outcomes included estimated blood loss, operating time, intraoperative blood transfusion and complications. The Mann-Whitney U test was used for continuous data, and Fisher's exact test for categorical data.

Results: Patients undergoing separation surgery compared with anterior reconstruction experienced less blood loss (median 500 ml [IQR 300-1,000] vs. 925 ml [IQR 500-1,425]; P=0.036) and shorter operating times (median 214 minutes [IQR 164-281] vs. 286 minutes [IQR 220-328]; P=0.028). Intraoperative blood transfusion occurred in seven patients (25%) in the separation surgery group versus 14 patients (50%) in the anterior reconstruction group (P=0.10). There were no significant differences between both groups with regard to duration of hospitalization, complications, postoperative transfusions, reoperations, or survival (P<0.05).

Conclusion: Separation surgery was found to have less blood loss and shorter operating times compared with corpectomy with anterior reconstruction. These findings suggest that separation surgery may be a viable therapeutic alternative for MESCC patients currently undergoing more invasive surgical approaches. Future studies should prospectively compare separation surgery and corpectomy with anterior reconstruction to provide additional evidence on their relative effectiveness in managing local tumor control.

Level of evidence: Treatment benefits, Level IV.

Study design: Systematic review.

Objective: Describe the impact of disc height on outcomes following cervical disc replacement (CDR).

Summary of background data: Implant sizing and positioning may impact outcomes following CDR.

Methods: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the EMBASE and PubMed databases. The goal of this review was to assess the impact of postoperative "disc height" on clinical and radiologic outcomes following CDR.

Results: A total of 12 studies were included in the systematic review. In the literature. "disc height" was assessed using multiple different measures: postoperative disc height (DH; n=4), disc height change (DHC; n=4), degree of disc distraction (DDD; n=2), prosthesis height (PH; n=2), functional spinal unit height (FSUH; n=2), and facet distraction (FD; n=1). DH and DHC were the most common measures studied. DHC was associated with statistically and clinically significant differences in several patient-reported outcomes measures (PROMs). However, DH was not associated with any statistically or clinically significant differences in PROMs. With respect to cervical range of motion (ROM), DHC appeared to demonstrate statistically and clinically relevant differences in some of the studies included in this review, while DH was associated with statistically, but not clinically, significant differences. The majority of studies identified DHC <2 mm as an important cutoff to optimize outcomes.

Conclusions: "Disc height," especially as measured by DHC, may be an important intraoperative consideration when selecting implant size during CDR. Maintaining DHC <2 mm may optimize PROMs and ROM. Improving technique and implant sizing may aid in translating ex vivo advantages in implant mobility to in vivo improvements in ROM and PROMs.

Study design: A Two-Sample Mendelian Randomization Analysis.

Objective: This study aimed to investigate the association between genetically predicted hyperlipidemia and ossification of the posterior longitudinal ligament (OPLL) using two-sample Mendelian randomization (MR) analysis.

Summary of background data: Several observational studies suggested associations between hyperlipidemia and OPLL.

Method: Genome-wide association study (GWAS) summary statistics for hyperlipidemia and OPLL were retrieved from the public database. The MR analysis employed the Inverse Variance Weighted (IVW) method, which was supplemented by MR-Egger, weighted median, and weighted mode analyses. Sensitivity analyses, incorporating Cochran's Q test, MR-Egger regression and the MR pleiotropy residual sum and outlier test, additionally assessed the robustness of the findings.

Results: The IVW analysis revealed a significant association between total cholesterol levels and OPLL (OR: 1.44,95% CI:1.06-1.96, P=0.02). Similarly, a significant association was observed between LDL cholesterol and OPLL (OR: 1.31,95%CI:1.05-1.63, P=0.02). Supplementary analyses further supported the significant association of total cholesterol levels and LDL cholesterol on OPLL (P <0.05). In sensitivity analyses, LDL cholesterol exposure showed robust results, with no outliers detected by loo or mrpresso, despite MR-Egger hints at pleiotropy. For total cholesterol exposure, MR-Egger suggested no pleiotropy, though heterogeneity and outliers were present. Outlier removal confirmed the initial positive association, underlining study stability. However, no significant associations were found of hyperlipidemia, triglycerides, HDL cholesterol on OPLL.

Conclusion: This study suggests a association of total cholesterol levels and LDL cholesterol levels on OPLL. Further research is warranted to validate these findings and explore potential therapeutic implications.

Study design: Retrospective analysis of prospective multicenter adult spinal deformity (ASD) database.

Objective: To determine the prevalence and prognosis of postoperative coronal malalignment following LLIF for ASD with Qiu type A coronal alignment.

Summary of background data: Qiu Type A coronal alignment is defined as coronal vertical axis (CVA) <30mm.1 There is concern that circumferential minimally invasive surgery (cMIS) with lateral lumbar interbody fusion (LLIF) is associated with postoperative coronal malalignment in ASD with preoperative Qiu type A patients.

Methods: Qui type A patients undergoing cMIS with LLIF for ASD were included, with ASD defined with at least: maximum CC≥20°, SVA>5 cm, PI-LL≥10°, or PT>20°. Two year (2Y) clinical outcomes were compared for type A with 2Y CVA≥30 mm (MAL) versus <30 mm (ALIGN) and were adjusted for factors reaching P<0.05 on univariate comparisons (age, BMI, and ODI).

Results: 43 patients met inclusion criteria, of which 12 (27.9%) developed coronal malalignment and 31 (72.1%) remained coronally aligned at 2Y. At baseline, MAL were older (73.0 vs. 69.0, P=0.045), had a lower BMI (26.09 vs. 29.45, P=0.047), and were less disabled (ODI 42.83 vs. 51.69, P=0.016). Otherwise, the groups were well-matched for baseline characteristics. At 2Y, MAL had a greater 2Y SVA (mean 54.08 vs 19.00 mm, P=0.01). Clinically, MAL was associated with inferior 2Y SF-36 PCS (34.78 vs. 37.42, adj P=0.043) and 2Y SRS-22r function/activity domain (3.03 vs. 3.36, adj P=0.040), but otherwise similar in other patient-reported-outcome-metrics (adj P>0.05 for all). 2Y complications were similar between groups, including for reoperations and major and minor complications (adj P>0.05 for all).

Conclusions: In Qui type A patients undergoing cMIS with LLIF for ASD, 27.9% develop coronal malalignment, which was associated with worse SF-36 PCS and SRS-22r function/activity. Despite radiographic malalignment, malalignment was not associated with higher 2-year complication rates including reoperations.

Study design: Retrospective analysis of prospectively collected data.

Objective: This study evaluates the impact of knee osteoarthritis (OA) and knee arthroplasty on alignments and patient-reported outcomes measures (PROMS) of patients undergoing adult spinal deformity (ASD) corrective surgery.

Background: The relationship between knee OA and spinal alignment in patients with ASD is incompletely understood. It is also unknown how patients with knee arthroplasty and ASD compare to ASD patients with native knees.

Methods: Baseline full-body radiographs were used, and hip and knee OA were graded by two independent reviewers using the KL classification. Spinopelvic parameters and PROMs were compared across the different knee OA groups and compared between patients with knee replacement and native knees.

Results: 199 patients with bilateral non severe OA (G1), 31 patients with unilateral severe knee OA (G2), and 60 patients with bilateral severe knee OA (G3). Patients with severe knee OA presented with worse spinopelvic parameters. However, after multivariable regression analysis controlling for age, frailty, PI, T1PA, knee OA was an independent predictor of knee flexion (G1:-0.02±7.3, G2: 7.8±9.4, G3: 4.5±8.7, P<0.001), and ankle dorsiflexion (G1: 2.3±4.0, G2: 6.6±4.5, G3: 5.1±4.1, P<0.001). There was no difference in PROMs (P>0.05). Secondary analysis included 96 patients: 48 patients (50%) with non-severe knee OA, and 48 patients (50%) with knee replacement. There was no difference in radiographic parameters or PROMs between the groups.

Conclusion: In this study of complex ASD patients, patients with worse spinal deformity were more likely to have concomitant knee OA. Knee OA was shown to be a predictor of knee flexion and ankle dorsiflexion angles, but was not associated with worse PROMs in this study population. Patients with knee arthroplasty, however, had comparable spinal alignment and PROMs relative to those with mild OA.

Study design: Retrospective cohort study.

Objective: This study aimed to compare perioperative outcomes of Rett syndrome and Cerebral palsy patients undergoing posterior spinal fusion for neuromuscular scoliosis.

Summary of background data: Surgical correction in the treatment of scoliosis for patients with Rett syndrome (RS) has been shown to increase survival rate. Cerebral palsy (CP) patients, like RS patients, are often nonverbal, nonambulatory, with frequent surgical complications.

Methods: Retrospective review of 36 RS and 80 CP patients undergoing PSF from 2005-2023. Data and x-ray measurements were collected pre- and post-operatively. Sub-analysis was performed comparing non-ambulatory patients (GMFCS IV-V). Wilcoxon-Rank Sum, Fisher's Exact, and Chi-square tests were utilized.

Results: The primary outcome measure, complication rates, was similar between the groups (P=0.09). Preoperative Cobb angle, levels fused, fixation points, and LOS were similar (P>0.05). EBL was significantly higher in CP patients as was rate of transfusion (P=0.001) and surgical time (P=0.001). Postoperative Cobb angle (P=0.002) was significantly higher for CP patients. There was no significant difference between CP and RS patients in both preoperative (P=0.383) and postoperative (P=0.051) coronal decompensation. Nonambulatory status was associated with increased odds of having a postoperative complication (OR=6.17, 95% C.I. 1.36 - 28.04). Sub-analysis of non-ambulatory RS and CP patients revealed significantly higher postoperative Cobb (P=0.008), EBL (P=0.019) and surgical time (P=0.017) in CP patients compared to RS patients. There were no significant differences in preoperative Cobb, levels fused, fixation points, hospital stay, or complication rate (P>0.05).

Conclusion: RS patients are shown to have better outcomes to CP patients in terms of surgical, perioperative, and radiographic variables. Ambulatory status was identified as an independent risk factor for complications.

Study design: Retrospective observational study.

Objective: To evaluate the accuracy of eight scoring systems, including the Tomita, modified Tokuhashi, modified Bauer, Rades, Oswestry Spinal Risk index (OSRI), Lei, New England Spinal Metastasis Score, and Skeletal Oncology Research Group (SORG) nomogram, for predicting long-term survival of patients with spinal metastasis.

Summary of background data: Predicting the prognosis of spinal metastasis is vital for surgical decisions, yet the effectiveness of existing scoring systems in identifying long-term survival remains unclear.

Methods: 456 cases were finally included. Prognostic scores were compared with survival outcomes. Receiver operating characteristic (ROC) curves were analyzed for the entire cohort and across three distinct time periods to evaluate the area under the curve (AUC) for 1-year and 2-year survival, alongside Harrell's C-statistic.

Results: The mean patient age was 58.9 years, and the median survival time was 8.6 months. For the entire cohort, the SORG nomogram, OSRI, and modified Tokuhashi scores yielded Harrell's C-index values of 0.64, 0.63, and 0.62, respectively. For 1-year survival prediction, the SORG nomogram, OSRI, and modified Tokuhashi score demonstrated moderate discriminative power, with AUC values of 0.72, 0.71, and 0.70, respectively. Similarly, for 2-year survival prediction, the modified Tokuhashi score, SORG nomogram, and OSRI also revealed moderate discriminative power, with AUC values of 0.73, 0.72, and 0.70, respectively. For patients who underwent surgery in the most recent period, OSRI demonstrated the highest predictive accuracy for 1-year survival, with a Harrell's C-index of 0.63 and an AUC of 0.68, and 2-year survival, with a Harrell's C-index of 0.63 and an AUC of 0.64.

Conclusion: Most scoring systems exhibited low discriminative power, with only the SORG nomogram, OSRI, and modified Tokuhashi scores demonstrating moderate power for predicting long-term survival. In the most recent period, the OSRI demonstrated the highest predictive accuracy for both 1-year and 2-year survival.

Study design: Retrospective.

Objective: Evaluate correlations between preoperative expectations for pain improvement and 12-month functional outcomes and satisfaction following 1-2 level primary anterior cervical surgery.

Summary of background data: Limited data exists evaluating correlations between patients' preoperative expectations for pain relief and subsequent functional and satisfaction outcomes following primary anterior cervical surgery. Understanding correlations between expectations and outcomes may help identify patients most likely to benefit from surgery.

Methods: Patients who underwent 1-2 level primary ACDF or CDA for degenerative disease between 2016-2021 were included. All patients had 12-month NDI data. Preoperative expectations for pain relief were collected at the initial clinic visit using 5-point Likert scales. Preoperative and 12-month postoperative satisfaction were recorded using 7-point Likert scales. Covariates including age, gender, procedure type, smoking status, opioid use, worker's compensation/litigation, BMI, and indication (radiculopathy versus myelopathy). Linear regression models were constructed to assess 12-month NDI change score versus pain relief expectations. Additional regression models assessed expectations versus achievement of MCID at 3- and 12-months and satisfaction at 12-months.

Results: 198 ACDF (56.1% female, median age 57) and 52 CDR patients (55.8% female, median age 51) were included. Regression models found no significant correlations between pain relief expectations and degree of NDI score improvement at the 12-month postoperative timepoint or MCID achievement at the 3- and 12-month postoperative timepoints. There was no association between preoperative expectations and 12-month satisfaction. However, greater preoperative dissatisfaction was significantly associated with greater 12-month improvement in NDI score.

Conclusion: Preoperative pain relief expectations were not associated with functional outcomes or satisfaction following 1-2 level primary ACDF or CDR at 12-month follow-up. Patients' dissatisfaction with their preoperative spinal condition was significantly associated with greater 12-month NDI improvement. Assessing preoperative satisfaction may help identify those most likely to benefit from surgery.