International Journal of Spine Surgery最新文献

Introduction: The efficacy of postoperative braces for degenerative lumbar disorders has long been debated, with conflicting reports regarding the promotion of bone fusion and pain relief. The current aspects of postoperative brace prescriptions have been previously reported in Western countries but not in Asia. This study aimed to elucidate prescription practices in Japan and identify factors influencing prescription decisions.

Materials and methods: The survey was conducted at a spine group research meeting comprising spine surgeons from multiple institutions. The questionnaire assessed aspects of postoperative brace prescription, including the type, purpose, and duration of usage, categorized by surgical procedures for degenerative lumbar disorders: endoscopic decompression, open surgery decompression, and fusion involving 1 or more than 3 levels. The respondents' backgrounds, scientific knowledge of postoperative braces, nonscientific reasons, and basis for prescription decisions were also investigated.

Results: There were 63 valid responses. The overall postoperative brace prescription rate was 83%, with 66% for decompression and 98% for fusion procedures, surpassing the rates reported in Western studies. The primary prescription purpose was to slow down patient activity (83%, double the previously reported rates). Prescription rates for endoscopic and open surgical decompression were significantly correlated with facility attributes and annual number of surgeries. Scientific knowledge of postoperative braces was lacking in 56% of respondents, with scientific evidence being the least frequent decision for brace prescription (14%). Nonscientific reasons influenced the prescription decisions of 84% of participants.

Conclusion: The postoperative brace prescription rate among spine surgeons in Japan was significantly higher than that in Western studies, largely due to nonscientific factors such as physician reassurance and the intention to slow down patient activity. Comprehensive, evidence-based guidelines are needed regarding consistent brace usage to optimize patient outcomes.

Clinical relevance: This study highlights the high postoperative brace prescription rates among spine surgeons in Japan, which are significantly influenced by nonscientific factors, such as tradition, physician reassurance, and patient satisfaction, rather than scientific evidence. These findings underscore the need for evidence-based guidelines to improve consistency in postoperative brace usage. The results are particularly relevant in regions with aging populations and a high prevalence of osteoporosis, providing insights for improving postoperative management strategies and patient outcomes in Japan as well as in similar demographic settings globally.

Level of evidence: 4:

Background: The Oswestry Disability Index (ODI) is a well-validated and widely used patient-reported outcome instrument to evaluate lumbar spinal stenosis (LSS) patients' treatment outcomes. The objective of the present study was to determine long the average interval between 2 preoperative measurements can be before a clinically significant difference of 10 points or more might appear.

Methods: This was a retrospective observational study utilizing prospectively collected data from a single university hospital database, which was compatible with the national registry. One hundred and four surgically treated LSS patients were included in this observational study using systematic sampling. The preoperative ODI score was obtained at 2 timepoints. The 2-month mark as a potential turning point was of special interest, as the registry in question excludes preoperative data as outdated if the data are older than 2 months. Possible time dependence of the change in ODI scores was explored using a linear mixed-effects model with ODI as the dependent variable and interval length, sex, age, body mass index (BMI), and the presence of a concomitant disease as fixed effects.

Results: The mean ODI score was 41.7 points (SD = 16.0) at the first and 41.1 points (SD = 15.5) at the second measurement. Mean time between the ODI scores was 74 days (range 8-361). On average, ODI changed by 9.17 points (SD = 7.16) between the 2 measurements, increasing for 48 patients, remaining unchanged for 9 patients, and decreasing for 47 patients. The arithmetic mean of the changes was -0.60 points and the median was 0.00 points. The estimated change in the population mean was -0.0005 points/day (95% CI [-0.022, 0.022], P = 0.97), meaning that we have strong evidence that the change in the mean is not clinically significant for up to 15 months (95% CI between ±10 points). Furthermore, no evidence was found that age, sex, BMI, or concomitant diseases were associated with the change of ODI score over time. Furthermore, the probability to observe a clinically significant change in a patient did not depend on the number of days between the 2 measurements (OR 1.003, 95% CI [0.997, 1.010], P = 0.30). Variance in ODI change did not grow over time.

Conclusions: The probability of observing a clinically significant differences does not depend on the length of the observation interval, and ODI scores can be considered equally reliable for a significantly longer time than 2 months, even up to 1 year.

Clinical relevance: Preoperative ODI scores do not lose reliability up to 1 year in patients undergoing operatively treatment for LSS.

Level of evidence: 3:

Background: Surgeons' reliance on intraoperative fluoroscopy during vertebroplasty procedures has raised concerns regarding the level of patient and surgeon radiation. Navigation systems have shown a potential to reduce the overall patient and medical staff exposure during dose exposure studies. The main objective of this study was to determine whether the Surgivisio platform (eCential Robotics, France), a unified imaging and navigation platform, lowers the patient dose during routine clinical usage as compared with published fluoroscopy and other navigation options that are published in the literature.

Methods: To accomplish this, we evaluated the radiation exposure dose during routine vertebroplasty procedures in which the surgeon was not trying to limit radiation and then compared the results to best-case dose assessment studies. Since a decreased radiation dose can lead to decreased image quality, we also quantified the surgeon's perception of image quality and ease of use. Two hundred and seventy-four Surgivisio-assisted vertebral augmentations were pooled from a broader 1694-patient protocol (not focusing on radiation outcomes) and analyzed.

Results: We measured a median dose-area product and effective dose equal to 3.47 Gy.cm² and 0.81 mSv. The 3-dimensional image acquisitions contributed to 56.3% of the total dose-area product. When screening the literature, fluoroscopy dose levels (8.37-15.1 Gy.cm²) and navigation dose levels (9.12-9.83 Gy.cm²) were generally higher than those delivered with the Surgivisio protocol. Surgeon satisfaction for image quality and overall system experience was 95.8% and 85% for ease of use.

Conclusions: The Surgivisio platform provided surgeons with high-quality images and ease of use. Since the surgeon is out of the room during the 3-dimensional image acquisition, this also substantially decreased their radiation exposure. This study demonstrates the efficiency of the Surgivisio platform to assist surgeons during vertebral augmentations, as the reported radiation levels are reduced in routine cases compared with published scenarios reported for other guidance methods.

Background: Direct vertebral rotation (DVR) effectiveness in improving scoliosis correction outcomes remains unclear and requires further investigation.

Purpose: This study aimed to evaluate the effectiveness of short and extended fusion techniques using en-bloc DVR in correcting adolescent idiopathic scoliosis (AIS) classified as Lenke 5 curve (5C).

Materials and methods: This retrospective study included 90 randomly selected AIS patients with Lenke 5C who underwent posterior spinal instrumentation surgery using en-bloc DVR between 2014 and 2021. Patients were divided into 2 groups: (1) extended fusion, Group A (n = 40): upper instrumented vertebra = upper-end vertebra +1 or +2 or (2) short fusion, Group B (n = 50): upper instrumented vertebra = upper-end vertebra. Radiographic parameters were compared preoperatively and at postoperative follow-ups of 6 months, 3 years, and more.

Results: The mean follow-up duration was 37.5 ± 6 months for Group A and 40.0 ± 8 months for Group B (P = 0.596). The coronal balance correction rate was comparable between the 2 groups, with no significant differences observed at the final follow-up. Significant differences were noted in the fused segment, with Group A having an average fusion rate of 6.8 ± 0 compared with 6.3 ± 0 in Group B (P = 0.001). TK and lumbar lordosis measurements at the final follow-up did not show significant differences between the groups. However, substantial differences were observed in rib hump correction, with Group A demonstrating a better correction rate than Group B at both 6 months and the last follow-up (P = 0.001 for both time points).

Conclusion: Selective DVR spinal instrumentation effectively corrects AIS Lenke 5C. However, extended fusion demonstrates more efficient correction and greater improvement in the patient's cosmetic appearance, including better thoracic curve correction, rib hump correction, and shoulder balance, compared with short-level fusion.

Background: The single-position prone transpsoas (PTP) lateral interbody fusion represents an alternative approach to the traditional lateral lumbar interbody fusion (LLIF) typically performed with the patient in the lateral decubitus position. Advantages of PTP surgery include improved segmental lordosis, single-position surgery, and ease of performing posterior techniques as needed. However, the learning curve of PTP is distinct from that of traditional LLIF surgery performed with the patient in the lateral decubitus position. Here, we highlight the senior author's approach to PTP surgery. The authors review key strategies of the preoperative workup, patient selection, operative techniques, and intraoperative pearls. This technical guide aims to shorten the learning curve for new adopters, optimize workflow for the surgeon, and maximize patient safety.

Methods: A detailed analysis of the PTP approach was conducted, incorporating preoperative imaging and planning strategies and technical adjustments in patient positioning to accommodate access following the senior author's technical pearls. The workflow was structured to streamline transitions between levels, minimize time requirements, and reduce physical strain on the surgical team.

Results: The application of PTP has demonstrated successful segmental lordosis correction and stable fusion across lumbar levels without requiring patient repositioning. The integrated workflow enabled sequential access and mastery of the PTP technique. These technical pearls have improved the efficiency of the PTP approach, according to the surgeon's expertise.

Conclusion: The PTP technical strategies offer a viable and effective alternative to traditional LLIF. Surgeons can enhance the safety and efficiency of the PTP approach, maximize procedural benefits, and minimize potential risks using these technical strategies for preoperative planning, patient positioning, and intraoperative monitoring.

Background: A limited number of studies have compared the outcomes of anterior lumbar interbody fusion (ALIF) to transforaminal lumbar interbody fusion (TLIF) for the treatment of isthmic spondylolisthesis. This study aims to compare postoperative complications between these two surgical approaches.

Methods: A retrospective review was performed using a large national database. The study population included all patients older than 18 years who underwent single-level ALIF or TLIF with a diagnosis of L5 to S1 isthmic spondylolisthesis. A 1:2 propensity score was used to match ALIF and TLIF cohorts for age, sex, and relevant comorbidities, including smoking status. Multivariate logistic regression was used to compare 3-month and 2-year medical and surgical complications, including 5-year reoperation rates.

Results: Five hundred and seventy-eight ALIF patients were paired with 1,156 TLIF patients following the match. The analysis revealed a higher 3-month ileus rate in ALIF patients (P = 0.009) and a lower, though not significant difference in, reoperation rate for ALIF within 2 years at 7.1% compared with TLIF at 7.7% (P = 0.696). Five-year reoperation rates were comparable (9.5% vs 10.8%; P = 0.612).

Conclusions: Aside from the increased rate of ileus in the ALIF group, there was no significant difference in both short- and mid-term complications, including overall reoperation rate, between the 2 techniques. Spine surgeons should select the optimal technique for a given patient.

Clinical relevance: ALIF and TLIF offer comparable mid-term postoperative outcomes for treating 1-level L5/S1 isthmic spondylolisthesis.

Level of evidence: 3:

Background: Correction of adult spinal deformity (ASD) through minimally invasive techniques is a challenging endeavor and has typically been reserved for experienced surgeons. This publication aims to be the first high-resolution technique guide to demonstrate a reproducible technique for ASD correction utilizing circumferential minimally invasive surgery (cMIS) without an osteotomy. The Segmental Interbody, Muscle-Preserving, Ligamentotaxis-Enabled Reduction (SIMPLER) technique is a novel ligamentotaxis-based scoliosis surgery that represents a paradigm shift from traditional osteotomies toward patient-specific correction.

Methods: The senior author's (N.A.) cMIS technique for ASD correction without an osteotomy is described using high-resolution photographs, computer-generated imagery (CGI), and a case example. Step-by-step intraoperative photographs document a novel muscle-preserving posterior spinal exposure, spinal robotic safety protocol for instrumentation, dedicated deformity instrumentation system, rod reduction sequence, and minimally invasive fusion technique. CGI assists to reinforce technical considerations described by intraoperative photographs.

Results: The SIMPLER technique is documented from incision to closure with high-resolution pictures including CGI to highlight concepts documented in photographs. Technical considerations were detailed for all aspects involved in the planning and execution of an osteotomy-free deformity correction.

Conclusion: This represents the first in-depth technical description of ligamentotaxis-based, osteotomy-free, ASD scoliosis correction. The SIMPLER approach is reproducible and minimally invasive and can be done routinely for appropriately selected deformity candidates. This technique serves as a foundation to externally validate previously described cMIS ASD deformity correction outcomes.

Clinical relevance: Circumferential minimally invasive spinal deformity correction is reproducible and can be achieved reliably through the use of the SIMPLER technique, without the use of an osteotomy.

Level of evidence: 5:

Background: Low back pain (LBP) is 1 of the most common problems that present in 80% of people. LBP can be caused by some pathologies, with discogenic pain being 1 source. Pain from LBP can become chronic and also cause disability. Treatment options for LBP varied from conservative to operative, and a novel treatment nowadays is using stem cells therapy to treat with pain from LBP.

Methods: Database searches from Pubmed and ScienceDirect from inception to 13 September 2023. A total of 283 discogenic LBP cases from 8 articles. This study measured clinical outcomes using a visual analog scale (VAS) and Oswestry Disability Index (ODI) obtained from each study.

Results: Functional outcomes in patients treated with stem cell therapy showed significant improvement ODI and VAS (P < 0.00001). Improvement also showed in Pfirrmann grade before and after treatment with stem cells (P = 0.005). Subgroup analyses using bone marrow aspirate concentrate also showed significant differences in both ODI and VAS (P < 0.00001).

Conclusion: Stem cells therapy could be beneficial as an option of treatment for discogenic LBP in improving pain and activity of daily living.

Clinical relevance: Intradiscal stem cell therapy is a promising alternative for managing discogenic low back pain, offering improvements in pain and function.

Level of evidence: 4:

Background: Spinal cord tethering and syringomyelia after trauma are well-known pathologies in patients suffering from spinal cord injury (SCI). In symptomatic cases, various surgical options are available, but untethering and expansion duraplasty is the currently preferred treatment strategy. However, patient outcomes are usually limited by rather high rates of surgical revisions. The aim of the present study was to identify risk factors in SCI patients who underwent multiple surgeries for symptomatic spinal cord tethering and syringomyelia.

Methods: We retrospectively investigated 25 patients who received at least 2 untethering surgeries of the spinal cord. All patients were treated by untethering and expansion duraplasty and/or clinically followed between 2012 and 2022 at the Swiss Paraplegic Center.

Results: A higher location of SCI correlates with a more rapid development of symptomatic spinal cord retethering in need of surgical revision (r = 0.406 and P = 0.044). Interestingly, the extent of spinal cord tethering is lower in those patients who underwent an early surgical intervention (r = 0.462 and P = 0.030), which points toward an increased vulnerability of the spinal cord at higher levels. Ninety-two percent of the patients displayed a potentially chronic inflammatory condition with a mean level of C-reactive protein of 28.4 ± 4.1 mg/L, while the white blood cell count was identified as an independent predictor for surgical interventions in symptomatic cases.

Conclusions: Revision surgery in posttraumatic spinal cord tethering and syringomyelia patients is associated with the location of SCI and the extent of spinal cord tethering. It appears that chronic inflammatory conditions might play an important role in promoting spinal cord retethering and thus warrant further investigation.

Clinical relevance: SCI patients with chronic inflammatory conditions and SCI at upper levels should be clinically monitored more carefully as they appear to be more susceptible to progressive forms of posttraumatic spinal cord tethering and syringomyelia.

Level of evidence: 3:

The lateral transpsoas approach to lumbar interbody fusion has gained widespread adoption for a variety of indications. This approach to the interbody space allows for a favorable fusion environment, disc and neuroforaminal height restoration, and powerful alignment correction. Despite its minimally invasive nature, this procedure carries unique risks, the most severe of which include bowel injury, major vascular injury, and lumbosacral plexopathy. This poses a marked learning curve and requires rigorous attention to detail in technique. In this review, we provide a detailed description of our approach to preoperative imaging, patient positioning, and surgical technique, with an emphasis on patient safety and evidence-based decision-making. A brief description of intraoperative neuromonitoring techniques follows. The lateral transpsoas approach to interbody fusion has demonstrated reliable outcomes in regard to fusion rates, pain and function, and deformity correction, all across a widespread variety of lumbar spine pathologies. Here, we depict techniques, pearls, and pitfalls that are critical for any surgeon considering whether to add this technique to their practice.