International Journal of Spine Surgery最新文献

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: 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: 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: 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:

Background: Minimally invasive surgical techniques have the potential to decrease the morbidity associated with traditional open surgery. However, surgeons may hesitate to implement minimally invasive techniques in their practice due to limited direct visualization and an arduous learning curve. Minimally invasive spine surgery requires precise docking of tubular or endoscopic retractors, which is difficult because without direct visualization of surrounding structures, surgeons may find themselves unable to orient themselves. Finding consistent and reproducible radiographic landmarks may decrease barriers to adoption of MISS techniques. Abd-El-Barr's point is a novel radiographic landmark that is identified on lateral fluoroscopy to help with docking for both tubular and endoscopic spine procedures. The landmark is hypothesized to correlate closely with the caudal aspect of the lamina and serve as a reliable docking target.

Objective: To validate Abd-El-Barr's point as a radiographic landmark for safe, reliable, and consistent docking in minimally invasive lumbar surgery.

Methods: A cadaveric study design: fluoroscopic localization of Abd-El-Barr's point was performed bilaterally from L1 to S1 using a sharply pointed instrument that was inserted slightly into the lamina to mark it with a hole, followed by dissection to measure the distance between the mark and the caudal lamina.

Results: A total of 5 cadaveric specimen data were analyzed. The mean distance from Abd-El-Barr's point to the caudal aspect of the lamina across all measured levels and sides was 5.3 mm (bilaterally).

Conclusion: Abd-El-Barr's point is a reliable radiographic landmark that provides accurate and safe docking during minimally invasive lumbar decompression. Validated through anatomical dissection, it has the potential to standardize docking, provide efficient surgical workflow, and reduce variability across various surgeon experience levels.

Clinical relevance: Using this landmark as a docking point, it is hoped that surgeons can make mininally invasive spine surgery, whether tubular or endoscopic, safer and more efficient, thus helping patients recover faster.

Level of evidence: 5:

Background: Excessive stress on the pedicle screws or inadequate load-sharing with surrounding spinal components increases the mechanical demand and the risk of loosening or breakage. The lumbar interfacet cage (FFX device) is designed to prevent spinal instability and facet motion, enhancing facet joint fusion.

Objective: The present study aimed to compare the biomechanical performance of a lumbar interfacet cage when associated with a pedicle screw construct, compared with pedicle screws alone and pedicle screws associated with lumbar interbody cages, using the FE method.The authors hypothesized that implanting additional lumbar interfacet cages would reduce mechanical stress on pedicle screw constructs.

Study design: Comparative biomechanical study by finite element (FE) method.

Methods: A validated FE model for the lumbar spine was used to assess stress variations on pedicle screw constructs and discs in the prefusion stage following surgery. Modeled scenarios included (1) a short pedicle screw construct (L4/L5), with and without bilateral lumbar interfacet cage device placement and with or without interbody fusion cages, and (2) a long pedicle screw construct (L2-S1), with and without lumbar interfacet cage placement at all levels.

Results: Both facet and interbody cage placement in conjunction with short L4/L5 pedicle screw constructs significantly reduced mechanical loading on pedicle screws and rods compared with the pedicle screw construct alone. The placement of lumbar interfacet cages used in combination with pedicle screw constructs in long L2 to S1 constructs also significantly reduced stress loading on pedicle screws and rods, especially at the lower extremity of the construct.

Conclusions: The placement of facet cages in conjunction with pedicle screws can improve the load distribution of the construct, enhancing its stability and durability. This approach may help reduce the rate of pedicle screw loosening and breakage, which are complications commonly associated with long pedicle screw constructs.

Clinical relevance: Pedicle screw loosening and breakage remain frequent complications in lumbar fusion, especially in long constructs. This finite element analysis demonstrates that adding lumbar interfacet cages to pedicle screw constructs significantly reduces mechanical stress on screws and rods. By improving load distribution in both short and long constructs, the technique may decrease the risk of screw loosening and implant failure before fusion, potentially improving construct durability and reducing reoperation rates.

Level of evidence: 5:

Background: Lateral lumbar interbody fusion has proven effective for various spinal pathologies, and ambulatory surgery centers (ASCs) offer cost-effective alternatives to hospital settings. However, no reports exist regarding single-position lateral interbody fusions with posterior pedicle screw instrumentation performed at ASCs. The primary research question was whether single-position extreme lateral interbody fusion (XLIF) with posterior pedicle screw instrumentation can be safely performed in an ASC setting.

Methods: A retrospective review was conducted on 22 patients who underwent single-level, single-position XLIF with posterior pedicle screw instrumentation at a free-standing ASC without overnight-stay capabilities. Data on operative time, intraoperative complications, length of stay, hospital admissions, and return to the operating room within 6 months were collected and analyzed. Radiographic measurements were performed pre- and postoperatively.

Results: All cases were completed in less than 2 hours with a mean length of stay of 142 minutes (maximum, 220 minutes). No patients required hospital admission or overnight stay. There were no returns to the operating room within 6 months postoperatively. One patient (4.5%) experienced transient hip flexor weakness with no permanent neurological complications. Radiographic analysis showed a significant increase in disc height at the operative level (from 7.3 mm to 12.2 mm, P < 0.001). No significant changes were observed in lumbar lordosis or segmental angle.

Conclusions: This case series demonstrates the feasibility and favorable early safety profile of single-position XLIF with posterior pedicle screw instrumentation performed in an ASC setting for appropriately selected patients. The procedure is associated with short operative times, minimal complications, and no need for hospital admission or early reoperation. Further studies with larger sample sizes and longer follow-up periods are warranted to confirm these findings and evaluate long-term outcomes.

Clinical relevance: This study demonstrates the feasibility of performing single-position XLIF with posterior pedicle screw instrumentation in ASC settings, potentially reducing health care costs while maintaining safety and efficacy.

Level of evidence: 4:

Background: Obesity is linked to increased spinal degenerative pathology and higher perioperative risks in spinal surgery. As the global obesity rates continue to rise, spine surgeons increasingly turn to minimally invasive approaches to theoretically minimize risk, but its outcomes are unclear.

Objective: To evaluate the impact of obesity on perioperative outcomes in minimally invasive surgery (MIS) for the lumbar spine.

Methods: A systematic review and meta-analysis were conducted using the MEDLINE, Embase, and Cochrane databases to examine the effects of obesity on MIS lumbar spine surgeries. Perioperative outcomes were categorized by surgical procedures, specifically lumbar fusion and decompression surgeries. Patients with obesity were further stratified into 2 groups: (1) obese (all classes) vs nonobese, and (2) class II/III obese vs nonobese.

Results: Twenty-six cohort studies met the inclusion criteria. In MIS lumbar fusion procedures, patients with obesity experienced higher blood loss (14 studies, n = 3128; mean difference [MD] 21.54; 95% CI 4.29-38.78), longer surgical times (16 studies, n = 3353; MD 19.41, 95% CI 8.12-30.70), and increased length of hospital stay (13 studies, n = 3222; MD 0.36, 95% CI 0.14-0.58). Similarly, for MIS lumbar decompression surgeries, patients with obesity had higher blood loss (6 studies, n = 1318; MD 17.02, 95% CI 1.23-32.80), longer operative times (8 studies, n = 1294; MD 17.80, 95% CI 4.36-31.25), and extended hospital stays (10 studies, n = 1892; MD 0.41, 95% CI 0.06-0.76). There was an increased rate of revision surgery in patients with obesity undergoing decompression procedures (7 studies, n = 1397; relative risk 1.43, 95% CI 1.04-1.96). Obesity was not associated with increased risks of short-to-mid-term surgical complications, infections, pseudarthrosis, or higher opioid use.

Conclusion: While MIS for obese lumbar spine patients may mitigate perioperative risk, it does not eliminate it. Obesity remains associated with increased blood loss, longer operative times, extended hospital stays, and higher revision rates. Future research should investigate mid- to long-term consequences, including complications, pseudarthrosis, and rates of revision surgery, in patients with obesity undergoing MIS lumbar interventions.

Clinical relevance: Patients should be counseled about the risks associated with obesity, and preoperative weight optimization is recommended to improve outcomes.

Cerebrospinal fluid (CSF) leaks of spinal origin present unique diagnostic and therapeutic challenges. Ventral leaks in particular are technically demanding due to limited exposure, proximity to the spinal cord, and the need for precise dural repair. Traditional management strategies, ranging from laminectomy-based approaches to thoracotomy, carry significant morbidity. Recent advances in full endoscopic spine surgery provide a minimally invasive alternative that allows surgeons to access ventral pathology, remove osteophytes, and perform direct dural closure under continuous irrigation. This article reviews treatment challenges, highlights conventional and emerging strategies, and discusses the role of full endoscopic repair of spinal CSF leaks. Technical considerations unique to endoscopic repair of Type 1 CSF leaks in the thoracic spine are described.