International Journal of Spine Surgery最新文献

Background: Transforaminal lumbar interbody fusion (TLIF) achieves anterior and posterior spinal arthrodesis through a single approach. Minimally invasive surgery (MIS) methods reduce surgical morbidity while achieving positive outcomes.

Methods: The major MIS-TLIF techniques, from tubular to endoscopic approaches, are reviewed with a discussion on the incorporation of new technologies and a comparative review of their outcomes.

Results: MIS-TLIF approaches span a spectrum of visualization methods, with technical nuances related to patient and surgeon-specific factors determining optimal fit. To date, the superiority of 1 technique has yet to be definitively determined. Existing techniques may be integrated in a personalized manner to optimize surgical utility.

Conclusions: Selection of an MIS-TLIF modality relies on a calculus between patient characteristics and surgeon faculty; proper selection can offer significant benefits to patients with spine disease.

Clinical relevance: Emerging technologies for MIS-TLIF comprise a major source of development and clinical translation, while the safe and effective use of these techniques promises greater patient benefit in the right populations.

Background: Navigation increases the precision and safety of pedicle screw placement and has been used to place interbody cages for lateral lumbar interbody fusion. Single-position surgery shortens its duration and that of anesthesia. The aim of this study was the feasibility of simultaneous cage and screw placement in a single prone position using intraoperative navigation without the need for additional fluoroscopy and a detailed technical description of this procedure.

Methods: We retrospectively analyzed 15 patients who underwent simultaneous navigated lateral lumbar interbody fusion and posterior instrumentation in a single prone position. A detailed technical description of the procedure is provided. Surgery duration, blood loss, complications, and radiographic parameters were recorded.

Results: A total of 24 cages were placed in 15 patients. The mean time taken for cage placement was 21 ± 6.70 minutes, and there were no major complications. Mean surgery duration and blood loss per case, including posterior instrumentation, were 263 ± 94 minutes and 315 ± 143 mL, respectively. There were significant improvements in pre- to postoperative Oswestry Disability Index scores (51.38 ± 15.93 vs 32.81 ± 17.18, P < 0.001) and segmental lordosis (3.26° ± 8.97° vs 13.09° ± 15.25°, P < 0.001).

Conclusion: The present study's results showed the feasibility of lateral lumbar interbody fusion using simultaneous posterior pedicle screw instrumentation and intraoperative navigation in a single prone position.

Clinical relevance: Navigated lateral lumbar interbody fusion and posterior instrumentation in a single prone position possibly reduces operating time and blood loss and reduces exposure of operation room personnel to radiation.

Level of evidence: 4:

Background: Full endoscopic spine surgery (FESS) champions a rapid recovery and a low rate of overall complications. However, its efficacy in geriatric patients that might yield additional benefits from minimized invasiveness remains underexplored.

Methods: A multi-institutional prospective cohort study was conducted involving patients undergoing elective lumbar FESS. Participants were categorized into nongeriatric (18-69 years old) and geriatric (≥70 years old) groups. Studied variables included demographics, medical comorbidities, operative details, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI). A mobile application was leveraged to collect real-time data pre- and postoperatively.

Results: One hundred and sixty-four patients were included and divided into nongeriatric (N = 125) and geriatric (N = 39) cohorts. No group differences were observed between sex (P = 0.404), body mass index (P = 0.372), procedure duration (P = 0.350), or blood loss (P = 0.384). Nongeriatric patients received discectomy more frequently (P < 0.001), while older patients underwent more decompressive procedures (P < 0.001). Characterization of pain and functional outcome revealed that nongeriatric and geriatric patients follow a similar recovery trajectory and both appreciate significant improvements from baseline to 3 months postoperatively (P < 0.001 for VAS back, VAS leg, and ODI). There were no differences in the rate of improvement between age groups at any time point (P > 0.05 for VAS back, VAS leg, and ODI).

Conclusions: FESS significantly improves pain and function in both geriatric and nongeriatric adults with degenerative lumbar conditions, with no difference in the degree of improvement between groups.

Clinical relevance: These findings underscore the efficacy of FESS as a minimally invasive surgical option for elderly patients. Mobile application technology is useful for collecting patient-reported data in spine surgery clinical research.

Level of evidence: 3:

Background: Full endoscopic spine surgery via a transforaminal approach (FESS-TFA) offers a minimally invasive approach for spinal decompression. However, it carries a risk of nerve root irritation or injury. Existing intraoperative neuromonitoring primarily provides retrospective warnings of potential nerve disturbance.

Objective: To introduce the use of stimulated electromyography neuromonitoring dilators in FESS-TFA for proactive nerve protection, enhanced localization, and potential reduction in radiation exposure.

Methods: This technical note describes the first use of neuromonitoring dilators in FESS-TFA. A 6-mm dilator tipped with a stimulation electrode is introduced to provide real-time directional feedback regarding nerve proximity, allowing the surgeon to actively avoid accidental injury to the exiting nerve root. With the creation of a safe tract, subsequent introduction of working instruments would theoretically reduce the risk of neural injury.

Results: The technique was successfully applied in a case of T11/T12 severe spinal stenosis, facilitating safe instrument passage and nerve localization. We describe the surgical technique and provide illustrative intraoperative details.

Conclusion: Neuromonitoring dilators represent a promising innovation in FESS-TFA with the potential to enhance patient safety and possibly streamline the procedure. Larger-scale studies are warranted to quantify the true impact of this technique on complication rates, operative time, and radiation exposure.

Clinical relevance: This technique highlights a significant advancement in reducing neural complications during minimally invasive spinal surgeries. By proactively preventing nerve irritation or injury and reducing radiation exposure, it contributes to optimizing surgical workflows and improving patient outcomes.

Level of evidence: 5:

Background: There is a paucity of data examining anterior lumbar interbody fusion (ALIF) with pedicle-screw fixation (ALIF-PSF) or without (standalone, sa-ALIF) for the treatment of low-grade isthmic spondylolisthesis (IS). Treating pathology with sa-ALIF reduces costs, operative times, and posterior access morbidity. This study aimed to investigate the clinical and radiographic outcomes of sa-ALIF for the management of low-grade IS compared with an ALIF-PSF cohort.

Methods: Retrospective analysis of prospectively collected data. Consecutive patients from 1 senior spine surgeon performing sa-ALIF or ALIF-PSF for management of low-grade IS. Patient-reported outcome measures (PROMs) were collected at baseline, then postoperatively at 6 weeks, 6 months, 12 months, and a final follow-up timepoint. Computed tomography was conducted at 6 months, 12 months, or until interbody fusion was confirmed.

Results: Two cohorts comprised 51 patients (sa-ALIF 22 and ALIF-PSF 29). Both cohorts' PROMs improved from baseline to 12 months postoperatively. There were no significant differences (P = 0.05) in PROMs between the 2 cohorts at 6 months postoperatively, 12 months postoperatively, or at a final follow-up timepoint. There were no significant differences in mean fusion rates 12 months postoperatively (sa-ALIF 82% and ALIF-PSF 88%). Compared with preoperative measurements in sa-ALIF and ALIF-PSF cohorts, listhesis and segmental lordosis showed no significant changes, while disc height significantly increased (P = 0.0001). There were no significant differences in disc L5/S1 radiographic measurements between the cohorts at 12 months. There were 12 complications (sa-ALIF 2 and ALIF-PSF 10). Only 1 patient in the ALIF-PSF cohort required revision surgery.

Conclusions: In appropriately selected patients with normal bone density, sacral slope <40°, and a body mass index <35, sa-ALIF is a safe and effective treatment option for grade I IS. The additional morbidity and cost of PSF may not be justified given the satisfactory clinical and radiographic outcomes of sa-ALIF for grade I IS.

Clinical relevance: Clinically, this research continues to suggest that sa-ALIF is a safe and effective method of treatment for low grade IS.

Level of evidence: 4:

Background: Anterior column realignment is an attractive minimally invasive treatment for sagittal imbalance. Expandable spacers offer controlled tensioning of the anterior longitudinal ligament (ALL) during release, which could optimize correction and anterior column stability. This study investigated the biomechanical and radiographic effects of single-level anterior-to-psoas lumbar interbody fusion (ATP-LIF) with expandable spacers and sequential ALL release.

Methods: In vitro range of motion tests were performed on 7 fresh-frozen cadaveric spines (L2-L5) with a ±7.5 Nm load applied in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). After testing intact spines, single-level (L3-L4) ATP-LIFs were performed and supplemented with posterior screws, rods, and integrated lateral screws and tested after (1) no ALL release (ATP-LIF); (2) resection of 1/3 the ALL's width (1/3 ALL release); (3) resection of 2/3 the ALL's width (2/3 ALL release); and (4) complete ALL resection (3/3 ALL release). Following each partial ALL release, rods were removed, and spacers were expanded until the torque limit was reached. Rods were then reapplied, and lateral radiographs were taken to analyze changes in intervertebral angle (IVA), foraminal height, foraminal area, and posterior and anterior disc height (PDH and ADH).

Results: In ATP-LIF constructs, range of motion decreased in FE (18% intact), LB (14% intact), and AR (30% intact), while IVA, PDH, ADH, foraminal height, and foraminal area increased. PDH and ADH increased linearly with sequential ALL release and spacer expansion, while LB and AR remained stable. FE increased slightly (+15%-16% intact, <1°) following 2/3 ALL release but remained stable afterward. IVA increased exponentially with sequential ALL release, gaining 8.8° ± 3.2° with complete release.

Conclusions: The present study found improved biomechanics and radiographic parameters following ATP-LIF with intact ALL, minimal biomechanical differences between partial and complete ALL release, and greater correction and height restoration with complete release. Future clinical testing is necessary to determine the impact of this finding on patient outcomes.

Clinical relevance: Controlled tensioning of the ALL before and after ligament release allows for potential optimization between restoring sagittal balance and maximizing construct stability in a minimally invasive approach.

Level of evidence: 5:

Background: Robotic platforms have increased in sophistication for pedicle screw placement. Here, we review our institutional experience using ExcelsiusGPS to assess the accuracy rate of pedicle screw placement throughout the spine and characterize predictors of placement inaccuracy.

Study design: Retrospective cohort study.

Methods: Patients from 2017 to 2022 undergoing spinal fusion surgery with ExelsiusGPS-assisted screw implantation at a single tertiary center were retrospectively identified. Patient demographics, preoperative symptoms, and operative details were collected. Postoperative computed tomography was used to classify screw placement accuracy according to the Gertzbein and Robbins scale (GRS). A stepwise multivariable ordered logistic regression analysis determined independent risk factors for clinically inaccurate screws (GRS C/D/E).

Results: One hundred and seventeen patients were included. Mean age was 60.6 ± 13.2 years, with 57% men, 72% white, and mean body mass index of 29.9 ± 6.4 kg/m². Seven hundred and twenty-eight screws were placed, predominantly in the thoracic (29.5%) and lumbar (52.6%) regions. Accuracy classification indicated 670 GRS A, 31 GRS B, 22 GRS C, 4 GRS D, and 1 GRS E screws. The clinically acceptable screw placement rate (GRS A/B) was 96%. Male gender (odds ratio [OR]: 2.12, P = 0.03), revision surgery (OR: 2.43, P = 0.02), and thoracic level screw insertion (OR: 2.33, P = 0.01) were independently associated with inaccurate screw placement and explained 8.7% of the variability seen. Of the 728 screws placed, 3 required revision after postoperative imaging revealed loosening or pedicle breach.

Conclusion: ExcelsiusGPS-assisted screw insertion has high placement accuracy and low revision rates. Identification of predictors of inaccuracy illustrates that similar variables, such as placement in the thoracic spine and revision surgery status, apply to both freehand and robotic screw placement.

Clinical relevance: Robotic spine surgery is an accurate, reliable tool that can improve patient outcomes. Factors like male gender, thoracic screw placement, and revision surgery status are associated with lower screw placement accuracy, and these factors should inform surgical decision-making when using robotic assistance.

Level of evidence: 4: