International Journal of Spine Surgery最新文献

Background: Measurement of screw insertional torque (SIT) can be valuable to predict rigid pedicle screw (PS) fixation without instrumentation failure. Numerous biomechanical studies support this concept; however, the value of measuring intraoperative SIT has not been well investigated. The aim of this study was to identify the relationship between the SIT values in PS fixation surgery and clinical factors in lumbar degenerative surgery.

Methods: We conducted a retrospective analysis of 492 PSs in 114 patients who underwent lumbar fusion surgery between July 2014 and April 2022. Intraoperative SIT values were measured using an analog torque wrench. Patient characteristics, radiological factors, and the accuracy of PS insertion were analyzed to assess their associations with the strength of the SIT.

Results: Intraoperative SIT showed significant correlations with age (r = -0.196, P < 0.001), bone mineral density (r = 0.399, P < 0.001), and body mass index (r = 0.165, P < 0.001). The torque ratio, reflecting bilateral SIT difference within the same vertebra, was significantly higher in cases with unilateral PS deviation >2 mm compared with ≤2 mm.

Conclusions: The findings suggest that patient-related factors play a role in screw fixation strength, and the torque ratio may serve as a useful indicator for assessing PS placement accuracy.

Clinical relevance: Intraoperative screw insertional torque measurement correlates with bone mineral density, age, and body mass index and may help predict fixation rigidity and prevent instrumentation failure in lumbar fusion surgery.

Level of evidence: 3:

Background: Endoscopic spine surgery is a minimally invasive technique that can treat spinal conditions while resulting in less pain and faster recovery than alternative techniques. However, achieving precise navigation is challenging without significant radiation exposure and increased surgical times. Fluoroscopy-based 2-dimensional navigation (2DNAV) is an emerging technology that offers real-time navigation using intraoperative fluoroscopy. This study evaluated the clinical efficiency and radiation safety of 2DNAV in biportal endoscopic spine surgery as compared with conventional C-arm fluoroscopy.

Methods: This prospective comparative cohort study included 20 biportal endoscopic patients using 2DNAV and 20 case-matched control patients using C-arm fluoroscopy. Primary outcomes included operative time, number of fluoroscopic images, radiation exposure time, and total radiation dose. Additionally, a visual analog scale for back and leg pain and the Oswestry Disability Index were obtained.

Results: Mean operative time in the 2DNAV group (67.95 ± 14.4 minutes) was significantly shorter compared with the control group (83.0 ± 16.0 minutes, P = 0.003). The mean number of fluoroscopic images required was significantly less in the 2DNAV group (3.15 ± 1.6 images) with vs control group (17.95 ± 5.7 images, P < 0.001). Total radiation exposure time was significantly lower in the 2DNAV group (mean 1.9 ± 1.1 min:sec) vs the control group (mean 9.21 ± 5.6 min:sec, P < 0.001). 2DNAV group experienced mean radiation dose of 0.77 ± 0.4 mGy vs 6.21 ± 3.8 mGy in control (P < 0.001). There were no significant differences in clinical outcomes.

Conclusions: 2DNAV significantly reduced operative times and required significantly fewer fluoroscopic images with lower radiation exposure for patients. 2DNAV allowed for the successful completion of the procedures with no difference in clinical outcomes.

Clinical relevance: 2DNAV provides real-time instrument tracking and computer navigation during endoscopic spine surgery with significantly decreased operative time and radiation exposure with similar clinical outcomes as conventional fluoroscopy.

Level of evidence: 2:

Background: The management of spine-related pain with narcotics, both before and after surgery, poses major challenges, including drug diversion, limited effectiveness, and worsening of pain symptoms over time. Chronic opioid use is associated with hypodopaminergia-induced hyperalgesia, whereby dopamine depletion increases pain sensitivity. Patients with inherently low dopaminergic function are particularly predisposed to hyperalgesia and reduced pain tolerance.

Methods: An alternative therapeutic strategy centers on genetically guided pro-dopamine regulation, which aims to transmodulate dopaminergic signaling to mitigate hyperalgesia. Early identification of predisposition through genetic testing, combined with pharmacogenetic and pharmacogenomic monitoring, is proposed to optimize treatment approaches.

Results: Pro-dopamine regulators have demonstrated promising results across 43 clinical studies, showing potential to reduce stress, craving, and relapse rates, while improving emotional well-being and attenuating pain sensitivity. These findings suggest that pro-dopamine regulation may serve as a viable frontline therapy for managing chronic pain and associated Reward Deficiency Syndrome behaviors, offering a significant reduction in the adverse effects commonly observed with chronic opioid therapy.

Conclusions: Given the limitations of dopaminergic blockade through chronic opioid agonist therapy, there is a critical need to reevaluate current pain management practices. The induction of dopamine homeostasis via pro-dopamine regulation represents a novel and potentially transformative strategy. Spine surgeons, pain specialists, and addiction medicine practitioners are urged to consider this approach as a promising alternative for improving long-term outcomes in patients suffering from chronic pain.

Background: Obesity is often associated with worse outcomes after lumbar fusion surgery, but its impact on patient-reported outcomes in spondylolisthesis remains unclear. This study assesses the effect of body mass index (BMI) on outcomes for degenerative and isthmic spondylolisthesis patients undergoing lumbar fusion.

Methods: We conducted a retrospective analysis of 86 patients with low-grade lumbar degenerative and isthmic spondylolisthesis, categorized by BMI into nonobese (<30 kg/m²), obesity class I (30.0-34.9 kg/m²), obesity class II (35.0-39.9 kg/m²), and obesity class III (≥40.0 kg/m²). Outcomes were measured using the visual analog scale (VAS) for pain and the Oswestry Disability Index (ODI) at baseline and 12 months postoperatively. Statistical analyses included a 1-way analysis of variance, Bonferroni post hoc comparisons, and Kruskal-Wallis tests.

Results: Significant disability improvements (mean ODI improvement: 15.6 points, P < 0.001) were observed across all BMI categories, while pain improvements were less pronounced (mean VAS improvement: 2.1 points, P < 0.001). Nonobese and class II patients maintained improvements at 12 months. Degenerative spondylolisthesis patients showed better ODI outcomes compared with isthmic patients (P = 0.019), while VAS outcomes were similar (P = 0.251).

Conclusion: Lumbar fusion results in significant disability reduction across BMI categories, with sustained improvements in nonobese and obesity class II patients. These findings suggest that obesity should not be a contraindication for lumbar fusion in well-selected patients, as meaningful improvements can be achieved, particularly in disability outcomes.

Clinical relevance: Clinically, this supports a more individualized approach to surgical candidacy, emphasizing functional goals and symptom burden over BMI alone, thereby promoting equitable access to care and helping guide preoperative counseling and shared decision-making.

Level of evidence: 3:

Background: The transforaminal (TF) approach in full endoscopic spine surgery (FESS) is the least invasive spinal surgery, as it can be performed under local anesthesia with only an 8-mm skin incision. Transforaminal FESS-based foraminotomy was first performed in the early 2000s for the decompression of foraminal stenosis. The technique has improved year by year over the past 2 decades. In our hospital, full endoscopic lumbar foraminotomy (FELF) has been performed since 2015. Since our development of the FESS undercutting laminectomy procedures in 2019, the size of the decompressed area achieved by FELF has increased.

Objective: To estimate the technical alteration of FELF over time by comparing the pre- and postoperative osseous foraminal areas (FAs) between traditional and advanced FELF techniques.

Methods: Fifty-two cases were retrospectively reviewed. In the early phase of FELF before 2019, partial or total resection of the superior articular process (SAP) was performed. Twenty-six of the patients were treated using the traditional FELF procedure (SAP-ectomy group). The remaining 26 underwent advanced FELF procedures, including SAP-ectomy, undercutting laminectomy, and removal of the ligamentum flavum (advanced FELF group). Clinical outcomes were assessed using the modified MacNab score. Pre- and postoperative osseous FAs were measured on sagittal computed tomography, and data were compared between the SAP-ectomy and advanced FELF groups. Paired and unpaired t tests were used for statistical analysis.

Results: By the modified MacNab score, the excellent/good rate was 82.6% in the SAP-ectomy group and 95.5% in the advanced FELF group. The improvement was greater in advanced FELF but not significantly. FA prior to surgery was 87.5 ± 27.0 mm² in the SAP-ectomy group and 95.7 ± 34.3 mm² in the advanced FELF group, with postoperative increases to 151.4 ± 45.5 mm² and 195.3 ± 39.1 mm², respectively (P < 0.05). FA increased by 63.9% and 99.6% in the SAP-ectomy and advanced FELF groups, respectively.

Conclusion: Full endoscopic foraminotomy techniques have evolved over time. The recently developed advanced FELF technique appears to safely and effectively achieve better clinical outcomes by significantly enlarging FA.

Clinical relevance: The advanced FELF technique contributes to improved decompression of the exiting nerve root.

Level of evidence: 3:

Patients with symptomatic lumbar disc herniation with radiculopathy where there is a large residual annular defect following discectomy are at greater risk of reherniation with symptom recurrence and revision surgery. These patients may benefit from primary annular repair. In 2019, the International Society for the Advancement of Spine Surgery published clinical guidelines supporting the use of bone-anchored annular closure in patients with large annular defects who are at greater risk for recurrent disc herniation. This 2025 update is provided to (1) summarize the current, increased clinical evidence for bone-anchored annular closure with greater follow-up durations and (2) update guidance for coding in light of new diagnostic and upcoming current procedural terminology codes. Based on accumulating clinical evidence, the International Society for the Advancement of Spine Surgery reiterates its position that in patients with symptomatic lumbar disc herniation with radiculopathy undergoing primary discectomy with large (≥6 mm wide) annular defects, bone-anchored annular closure may be used to sustain the treatment benefits of discectomy.