International Journal of Spine Surgery最新文献

Background: There are limited data available to understand the value of bioactive glass for spinal fusion procedures. Bone morphogenic protein-2 (BMP-2) is an established graft that has been on the market for roughly 24 years, while bioactive glass represents a newer class of graft technology. The objective of this study is to compare economic, health care utilization, and postoperative outcomes associated with the use of a bioactive glass vs BMP-2.

Methods: A retrospective, comparative study was conducted to compare a bioactive glass, FIBERGRAFT (DePuy Synthes, Raynham, MA), to BMP-2. The Premier hospital billing database was used. Patients who underwent lumbar fusion from 2016 to 2024 with bioactive glass or BMP-2 were included. The primary study outcome was index hospital cost. The exploratory outcomes were length of stay, operation room time, and 1-year pseudarthrosis, spinal infection overall (defined as the presence of spinal infection or surgical site infection), and surgical site infection only. Patients in each graft group were balanced using propensity score matching. Analyses were conducted for the overall cohort (primary) and, as a sensitivity analysis, for a subset of patients based on primary procedure and diagnosis.

Results: The group sizes for each cohort before balancing were 1,013 and 59,394 patients for bioactive glass and BMP-2, respectively. After matching, the group sizes for both grafts were 1013 patients for a total of 2026 patients in the matched cohort. In the matched cohort, 65 to 74 years was the most frequent age group (34% in each cohort), and more than half were women (57% bioactive glass, 56% BMP-2). The mean (95% CI) index hospital costs were $40,187 ($39,132, $41,241) for bioactive glass and $45,010 ($43,809, $46,211) for BMP-2, representing a mean difference (95% CI) of -$4823 ($-6382, $-3265), P < 0.001. The exploratory endpoints were similar for both grafts. Both the primary and sensitivity analyses demonstrated consistent results.

Conclusion: This study suggests that patients who undergo lumbar fusion with bioactive glass have lower index costs and similar health care resource utilization and postoperative outcomes compared with those who receive BMP-2. Results from this study may help payers, health care systems, and providers make value-based decisions regarding product utilization.

Clinical relevance: This research provides an understanding of hospital costs, health care resource utilization, and 1-year outcomes of bioactive glass used in lumbar fusion surgery using a comparative study design.

Level of evidence: 3:

Background: Surgical site infections (SSIs) in spinal surgery are a severe complication with a considerable impact on patient quality of life and healthcare costs. Despite the established efficacy of negative pressure wound therapy (NPWT) in preventing surgical wound complications, there is a lack of strong evidence supporting its use in spinal surgery. The objective of this research is to assess the efficacy and economic impact of prophylactic NPWT using PICO-7 dressings in preventing SSIs after posterior lumbar fusion.

Methods: A retrospective matched case-control study was conducted, including 100 adult patients who underwent 1- or 2-level instrumented posterior lumbar fusion for degenerative spinal stenosis between 2020 and 2023. Fifty patients received PICO-7 dressings, while 50 matched controls received conventional compressive dressings. Demographic, perioperative, and postoperative variables were analyzed. SSI was defined by clinical signs, laboratory markers, and positive intraoperative cultures. A cost-benefit analysis was performed from the hospital perspective.

Results: The incidence of SSI was significantly lower in the PICO-7 group compared to controls (4% vs 18%; OR = 0.19; 95% CI: 0.03-0.92). NPWT was also associated with reduced rates of wound dehiscence (0% vs 6%; P = 0.08) and hospital readmission (0% vs 10%; OR = 0.08; 95% CI: 0.04-0.92), as well as a shorter median length of stay (4 vs 4.5 days; P = 0.04). Greater intraoperative blood loss was independently associated with increased SSI risk (d = 0.39; 95% CI: -1.5 to -0.08) but did not modify the protective effect of PICO-7. The cost-benefit analysis showed a net savings of $171,545 and a cost-benefit ratio of 4.21. Sensitivity analysis confirmed the robustness of these findings.

Conclusion: Prophylactic use of PICO-7 dressings significantly reduces SSI incidence and associated morbidity in posterior lumbar fusion with substantial economic benefits. These results support the integration of NPWT into standard postoperative wound management protocols for selected spinal procedures.

Clinical relevance: This study offers a comprehensive set of clinical and economic data that serves as a valuable foundation for the development of prospective studies on the standardized implementation of NPWT in wound management in spinal surgery.

Level of evidence: 3b.

Background: Spinal lipomas of the conus medullaris and filum terminale are the most common forms of occult spinal dysraphism. Clinical presentations vary based on anatomic location and size. Filum terminale lipomas occur in up to 5% of the general population based on cadaveric and magnetic resonance imaging studies. Most filum terminale lipomas are asymptomatic and rarely require treatment.

Case presentation: This is the first known reported case of a 64-year-old woman presenting with lumbar radiculopathy with cascading spondylolisthesis at L3 to L4 and L4 to L5, synovial facet cyst at L4 to L5, and concurrent large filum terminale lipoma. After nonoperative management strategies failed, an extensive discussion about the source of her symptoms was completed. It was believed that the primary driver of her radicular pain was the synovial cyst and spondylolisthesis at L4 to L5, despite the large size of the lipoma. Surgical treatment entailed an L4 to L5 anterior lumbar interbody fusion, posterior spinal instrumentation and fusion using robotic-assisted navigation, and decompression of the synovial cyst through a transfacet approach. Postoperatively, the patient's buttock and leg pain was resolved. She returned to work with no restrictions and reported no pain or neurological symptoms at her final follow-up.

Conclusions: Incidental filum terminale lipomas may be safely observed when surgically managing a patient with a concurrent, adjacent, and symptomatic degenerative lumbar spondylolisthesis and synovial facet cyst.

Clinical relevance: In patients undergoing surgery for symptomatic degenerative lumbar spondylolisthesis with an associated synovial facet cyst, an incidentally identified, adjacent intradural filum terminale lipoma without tethered cord symptoms can generally be managed nonoperatively, avoiding unnecessary intradural exploration and its associated risks.

Level of evidence: 5:

Background: Pelvic incidence (PI) is often used to predict ideal lumbar lordosis in an individual. To date, no study has considered the potential influence of Māori ethnicity (Māori are the indigenous people of New Zealand). Identifying variation in key surgical measurements may aid in reducing health care inequities. The aim of this study was to compare static pelvic parameters according to ethnicity from a New Zealand cohort.

Methods: A total of 500 computed tomography scans obtained for major trauma assessment were analyzed, and static pelvic parameters were measured, including PI, pelvisacral angle, femorosacral pelvic angle, sacropelvic angle, sacral table angle, sacral anatomic orientation, pelvic thickness, and L5 segmental angle. Analysis was performed comparing age, gender, and ethnicity cohorts.

Results: The mean age of the entire cohort was 42.6 years (SD 18.7). There were 323 men (65%). Only the L5 segmental lordosis differed significantly between the genders. Among the cohort, 287 indicated they were New Zealand European (NZE), 159 Māori, 20 Pacifica, and 34 "Other." Age differences were present between the predominant ethnic groups NZE and Māori (6.95 years; P < 0.001). Significant differences were also seen between these 2 groups for PI (Māori 3° greater), pelvisacral angle, pelvic thickness, sacropelvic angle, sacral table angle, and L5 segmental angle (Māori 1.2° less).

Conclusions: In this first large-scale analysis from New Zealand including Māori, significant differences in a majority of parameters are evident. This reflects significant variation in pelvic morphology and possible differences in normal spinal alignment that should now be a focus of future studies.

Clinical relevance: Pelvic morphology in Māori differs from that of non-Māori. Efforts are needed to establish normative values in Māori and thus reduce health care inequities.

Level of evidence: 3:

Background: In recent years, bone health optimization, including vitamin D supplementation, has increasingly been advocated in spinal surgery to improve surgical outcomes. Nevertheless, few studies have explored the connection between blood vitamin D levels and surgical outcomes for lumbar spinal canal stenosis (LSS). The purpose of this study was to investigate the prevalence of vitamin D deficiency among patients with LSS and whether vitamin D levels were associated with surgical outcomes for LSS.

Methods: In this retrospective study, we investigated the association between recovery rate and factors including vitamin D levels using univariate and multivariate regression analyses.

Results: A total of 154 patients (83 men and 71 women) were included in this study. Among them, 71% were diagnosed with vitamin D deficiency. Multivariable linear regression analysis identified preoperative serum vitamin D levels as an independent factor associated with the recovery rate after surgery for LSS (P = 0.02). Patients with vitamin D deficiency exhibited lower recovery rates compared with those with sufficient vitamin D levels (P = 0.01).

Conclusions: Preoperative vitamin D levels were associated with surgical outcomes for LSS. Further studies are warranted to examine the optimal threshold of vitamin D levels associated with clinical outcomes in spine surgery and whether therapeutic interventions could improve postoperative outcomes.

Clinical relevance: This study highlights that vitamin D deficiency is highly prevalent in patients with LSS and is significantly associated with poorer postoperative recovery.

Level of evidence: 4:

Background: Current techniques for surgical correction of spinal deformities impart realigning the deviated vertebrae along a rigid rod. Solid rods are a major restricting factor to vertebral manipulation, leading to incomplete, imprecise, and less predictable 3-dimensional (3D) correction. Additionally, forceful manual nonquantifiable maneuvers may result in potential implant failures and increased incidence of complications. We are introducing a machine-operated device for digitized segmental 6 degrees of freedom (6 DOF) correction of individual vertebral deviations.

Methods: We manufactured a 3D coupler incorporating multiple self-locking uniaxial joints. The device's precision was tested by comparing targeted vs delivered motions. For functionality testing, we used computed tomography-based 3D-printed vertebral models to verify the device's ability to manipulate the vertebra in each direction of motion.

Results: In all tested motions, the coupler accurately and repeatedly delivered the predicted targeted motions. The device could mobilize 2 vertebral models relative to each other in 4 out of 6 DOF.

Conclusions: The novel 3D coupler can deliver machine-driven, precise, and predictable multiplanar motion; it could manipulate the vertebral model in rotation and translation.

Clinical relevance: The novel device addresses a crucial unmet need in spinal surgery by offering digital precision, true 6 DOF correction, and supporting robotic execution of surgical actions.

Level of evidence: 5:

Background: A recent advance in spine surgery instrumentation is the awl-tipped screw, which allows for a reduction in the number of steps during a procedure. This innovation has the potential to decrease surgical time and affect overall efficiency. The purpose of the present study was to determine whether the use of awl-tipped pedicle screws reduces surgical time and blood loss compared with the use of conventional pedicle screws.

Methods: Using a retrospective records review, 410 patients who underwent open posterior lumbar spinal fusion surgery were analyzed. We compared 205 cases that used awl-tipped screws to 205 matched controls that used conventional pedicle screws that required tapping. The awl-tipped screw and control groups were matched for instrumented spine levels fused and were equivalent regarding other patient characteristics.

Results: Surgeries with awl-tipped pedicle screws took less time (mean [SD] = 94.35 [24.09] minutes) than surgeries with conventional screws that required tapping (mean [SD] = 111.11 [33.00] minutes; t ₄₀₈ = 5.87, P < 0.001). The amount of blood loss did not differ significantly between the 2 groups but trended in the expected direction.

Conclusion: Clinicians who use pedicle screws in their practice should consider utilizing awl-tipped screws rather than traditional ones, as the reduced surgical time they can provide may translate into benefits for patients.

Background: Thoracic disc herniations (TDHs) are rare, comprising <1% of all disc herniations, but when symptomatic can cause severe neurological dysfunction. Traditional open and mini-open approaches allow for ventral canal decompression but are associated with high morbidity, including pulmonary complications, chest tube placement, and frequent need for fusion. Full-endoscopic thoracic discectomy has emerged as an ultra-minimally invasive alternative with reduced complications and faster recovery, but its application to midline or calcified thoracic discs remains technically demanding.

Case presentation: We report the case of a 54-year-old man with progressive chest wall pain and lower-extremity hyperreflexia who was found to have a T6 to T7 central disc herniation with mild calcification and spinal cord signal change. The patient underwent an outpatient right-sided full-endoscopic transforaminal discectomy. Complete decompression was achieved without spinal cord retraction or manipulation. The patient had complete resolution of his preoperative pain and was discharged home within 2 hours.

Discussion: Compared with open thoracic discectomy, endoscopic approaches significantly lower complication rates, blood loss, hospital stay, and cost while preserving motion segments. Our case highlights strategies for addressing technically challenging central TDHs, including lateralized access, controlled bony resection, and angled instrumentation. These methods align with growing evidence demonstrating the safety and efficacy of endoscopy in thoracic pathology, though the technique requires advanced endoscopic expertise and careful patient selection.

Conclusion: Full-endoscopic transforaminal discectomy provides a safe, effective, and minimally invasive option for central TDHs in selected cases. With proper planning and advanced technical execution, endoscopic surgery can achieve decompression comparable to open surgery while minimizing morbidity and expediting recovery.

Background: Lateral lumbar interbody fusion is a widely used technique to address degenerative lumbar conditions but can be associated with injury to the psoas, lumbar plexus, and abdominal wall owing to retractor usage. We describe a minimally invasive endoscopic lateral lumbar interbody fusion (ELLIF) procedure that aims to reduce these complications by avoiding prolonged muscle retraction, preparing the disc space under direct endoscopic vision, and shortening the surgical time.

Methods: Between 2019 and 2024, 35 patients underwent ELLIF at a single center. Discectomy, endplate preparation, and iliac crest harvest were done via a working-channel endoscope without expandable retractors. Neurophysiological monitoring was used to minimize nerve injury. Outcomes included complications, visual analog scale scores for pain, and Oswestry Disability Index (ODI).

Results: Of the 35 patients (mean age 60 years), 26 had preoperative radicular pain and 9 had neurological deficits. Six minor complications occurred in 4 patients (11.4%), all managed conservatively without permanent deficits. No patients developed new radiculopathy or paresis, and there were no infections or reoperations. ODI improved by 57% at 1 month and by 88% at 1 year (both P < 0.001). By the 3-year follow-up in 9 patients, ODI scores remained near normal, and visual analog scale was reduced by 93% from baseline.

Clinical relevance: We present a minimally invasive, ELLIF, and decompression technique that provides patients with minimal complications and excellent functional recovery.

Conclusion: ELLIF offers a safe, minimally invasive alternative for patients with lumbar degenerative disease. This technique minimizes direct retraction on the psoas and lumbar plexus, resulting in a low complication rate and substantial functional recovery at short- and medium-term follow-up.

Level of evidence: 4: