International Journal of Spine Surgery最新文献

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: Posterior atlantoaxial arthrodesis is a cornerstone of atlantoaxial instability or dislocation. Open surgery entails extensive soft-tissue dissection, with intraoperative blood loss and postoperative axial pain. Experience from other spinal procedures suggests that one-hole split endoscopy may address these limitations; however, evidence at the craniovertebral junction is lacking.

Surgical technique: This study introduces an innovative, minimally invasive technique for atlantoaxial fusion: one-hole split endoscopy for posterior atlantoaxial lateral mass joint fusion. By delineating the anatomic layers, safety boundaries, and technical points, the technique enables endoscopic lateral mass joint arthrodesis and atlantoaxial screw fixation.

Clinical application: A 12-year-old boy with diagnosed atlantoaxial instability and os odontoideum underwent the one-hole split endoscopy for posterior atlantoaxial lateral mass joint fusion. Early postoperative imaging confirmed anatomic reduction of the joint with stable fixation. At 3 months, computed tomography revealed continuous bony bridging across the lateral mass joint space, indicating early osseous fusion.

Conclusion: This study describes the first clinical application of posterior atlantoaxial lateral mass joint fusion using one-hole split endoscopy, demonstrating clinical feasibility and enhanced visualization and suggesting a potential role for endoscopic fusion at the craniovertebral junction.

Clinical relevance: This technique offers an innovative, minimally invasive option for posterior atlantoaxial fusion and supports the broader application of endoscopic procedures at the craniovertebral junction.

Level of evidence: 4:

Background: Patients with obesity undergoing spine surgery are at increased risk for postoperative complications. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are widely used for diabetes and weight management, but their perioperative impact in spine procedures is not well defined. This study evaluated whether long-term preoperative GLP-1 RA therapy is associated with improved postoperative outcomes after elective laminectomy in overweight adults.

Methods: A retrospective cohort study was performed using the TriNetX research network across 72 US health systems. Overweight or obese adults undergoing elective cervical, thoracic, or lumbar laminectomy were divided into GLP-1 RA users (≥6 months of continuous preoperative therapy) and nonusers. Propensity score matching (1:1) was performed across 33 demographic and clinical variables. Outcomes assessed at 90 days and 1 year included sepsis, acute kidney injury, deep vein thrombosis, myocardial infarction, pneumonia, stroke, wound dehiscence, surgical site infection, postlaminectomy syndrome, and all-cause mortality.

Results: Matched cohorts included 5680 patients per group. GLP-1 RA therapy was associated with significantly lower odds of sepsis (OR 0.38 at 90 days; 0.52 at 1 year), deep vein thrombosis (0.26; 0.41), wound dehiscence (0.38; 0.47), surgical site infection (0.37; 0.43), and mortality (0.30; 0.48; all P < 0.001). Acute kidney injury showed a borderline reduction (OR 0.80; P = 0.046). No significant differences were observed for myocardial infarction, pneumonia, or stroke.

Conclusions: Long-term preoperative GLP-1 RA therapy was associated with reduced postoperative infectious, thrombotic, and wound-related complications, as well as lower mortality, following elective laminectomy in overweight adults. These findings support the potential role of GLP-1 RA use in preoperative optimization strategies for high-risk surgical populations.

Clinical relevance: Identifying modifiable risk factors is essential for improving outcomes in overweight or obese patients undergoing spine surgery. This study suggests that GLP-1 RAs may serve as a practical and effective preoperative optimization tool to reduce complications and enhance postoperative recovery.

Level of evidence: 3:

Current health care strategies trend toward optimizing outcomes and improving cost; the shift from fee-for-service toward value-based care models has enhanced the delivery of medical care to our patients. Value-based care aims to align health care providers in coordinated patient-focused health care rather than an episodic problem-focused response. Meanwhile, episodic care has shifted from hospital-based to outpatient procedures. To achieve these goals, hospital systems and private practices have employed various strategies of cost containment. Prior literature has introduced the concept of specialist-led care. Although focused primarily on orthopedic surgery specialists, the concept of specialist-led care can be broadly applied, whereby surgical specialists, in conjunction with multidisciplinary teams, drive clinical decision-making. Prior literature supports a specialist-led care model that enhances patient outcomes and reduces overall health care costs and physician burnout while minimizing waste. The present article explores the feasibility of achieving a specialist-led care model in orthopedic surgery and in orthopedic or neurosurgical spine practices in the current health care climate. The shifting dynamics and pressures faced by private practitioners and employed physicians, bundled payment and cost containment strategies, and direct-to-employer contracting are examined. By building a collaborative network, a specialist-led care model will drive supply chain decisions, employ direct-to-employer contracts, improve care delivery, reduce health care costs, and assist specialists in maintaining clinical and financial independence.

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: 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: SPECT-CT highlights metabolic activity within skeletal structures, including degenerative arthropathies and other potentially pain-producing abnormalities.

Objectives: Investigate the effectiveness of single-photon emission computed tomography (SPECT-CT) in identifying pain generators and assess its role in clinical and surgical decision-making and planning.

Methods: Prospective study of 110 patients presenting with neck and back pain. SPECT-CT was ordered to identify pain generators and/or guide surgical planning. Pre- and post-SPECT-CT surveys were obtained to assess pain generator identification and subsequent changes to treatment recommendations.

Results: SPECT-CT demonstrated increased uptake in areas corresponding to clinical symptoms in 78.1% of patients. This increased diagnostic specificity reduced the number of diagnostic possibilities per patient and led to a changed diagnosis in 68.1% of patients and a changed treatment plan in 62.7%. The nonoperative group was more likely to have specific, identified targets for injections after SPECT-CT. In 57.7% of surgical candidates, the surgical plan was altered, with 11 patients (42.3%) receiving surgical treatment recommendations involving fewer surgical levels and 4 (15.3%) involving more surgical levels.

Conclusions: SPECT-CT appears to be a valuable diagnostic tool in assessing neck and back pain. It may help identify pain generators and limit the need for further diagnostic workup. It was impactful in guiding treatment strategies and potentially improved surgical planning by specifically targeting the affected areas. Further research is needed to validate these findings and establish clinical guidelines for their use in patients with neck and back pain.

Level of evidence: 4: