International Journal of Spine Surgery最新文献

Background: Biportal endoscopic transforaminal lumbar interbody fusion (BE-TLIF) is a minimally invasive TLIF (MIS-TLIF) technique, commonly performed with various cage types. Expandable cages are particularly effective in achieving segmental lordosis (SL) and disc height (DH) elevation in minimally invasive TLIF. However, the published literature lacks details regarding how these outcomes can be accomplished using BE-TLIF with an expandable cage.

Methods: Nine cases (10 levels) of BE-TLIF with an expandable cage were reviewed. Procedures including unilateral laminotomy and bilateral decompression, cage expansion trials, and bilateral facetectomies were carried out under biportal endoscopy to achieve SL and DH elevation. Postoperative standing x-ray images at 3 months and reconstructed computed tomography images were analyzed. The sublaminar decompression angle-measured as the angle between the spinous process and the sublaminar decompression line on axial computed tomography-was used to evaluate contralateral sublaminar decompression.

Results: All procedures were completed without changes to the surgical methods. Eight patients underwent single-level fusion, with 4 of them receiving additional decompression at adjacent levels. One patient underwent a 2-level fusion. Four cases utilized 12° lordotic cages, while the rest employed 20° hyperlordotic cages. The total time for each fusion was 152.5 ± 38.5 minutes. Segmental lordosis increased by 5.1°, with anterior and posterior DH elevations of 4.8 ± 1.7 mm and 3.1 ± 1.8 mm, respectively. No endplate injuries or early cage subsidence occurred. The mean sublaminar decompression angle was 31.8° ± 7.0°.

Conclusions: BE-TLIF with an expandable cage may offer benefits in SL correction and DH elevation. These advantages are attributed to the use of more lordotic expandable cages, combined with contralateral facetectomies and careful endplate preparation-key features of the BE-TLIF technique.

Clinical relevance: SL correction and DH elevation can be achieved through BE-TLIF, which helps to reduce the recurrence of symptoms and improves the lumbar lordotic curve.

Level of evidence: 4:

Background: Previous analyses have suggested variations in cervical spine canal morphology according to ethnicity, possibly in part due to variations in the posterior elements. The potential for these variations to affect the placement of instrumentation is uncertain. The aim of this study was to report on the feasibility of C2 lamina screw insertion in a New Zealand cohort including analysis of Māori, the indigenous people of New Zealand.

Methods: A trauma computed tomography database was accessed to identify suitable images. On axial images, where the isthmus was at its widest, the outer diameter (OD) and inner diameter (ID) of the lamina were measured. Screw length was measured from a proposed entry point to the contralateral junction of the lamina and lateral mass. The spinolaminar angle was measured as the angle subtended by the screw trajectory and midsagittal plane. A 5.5-mm OD was accepted as a threshold for the feasibility of lamina screw placement.

Results: One hundred eighty-seven images were assessed: 115 New Zealand European and 72 Māori. The mean age of the cohort was 41.9 years (SD 19.6), and most patients (64%) were men. For the entire cohort, mean OD was 6.6 and 6.8 mm on the right and left, respectively; the mean inner diameter was 3.5 and 3.8 mm; mean screw length was 31.5 and 31.5 mm; and mean spinolaminar angle was 46.0° and 46.1°. C2 lamina screw placement was feasible in a majority of patients. Considering only Māori patients, placement was feasible in 96% of right and 94% of left laminae in men but 72% of right and 72% of left laminae in women.

Conclusions: In a majority of patients, C2 lamina screw placement is feasible. However, advanced imaging must be carefully assessed preoperatively because data suggest that Māori women may not necessarily have optimal anatomy.

Clinical relevance: Care needs to be taken when assessing and planning surgery inpatients of different ethnicities because variations may exist in the morphology of the posterior elements of C2, leading to variation in optimal fixation strategy.

Level of evidence: 3:

Background: Atlantoaxial transarticular fixation, also called the Magerl technique, is said to be the most robust biomechanical method of fixation of the atlantoaxial vertebrae. However, the procedure carries a risk of spinal cord and vertebral artery injury during the insertion process, especially in patients with a high-riding vertebral artery. In this study, a computed tomography (CT)-based navigation system was used for preoperative planning and insertion. This investigation sought to determine the rate and direction of screw perforation as well as the incidence of screw loosening in computer-assisted atlantoaxial transarticular fixation.

Methods: Sixty patients (31 men and 29 women; mean ± SD age: 65.3 ± 19.6 years) who received atlantoaxial transarticular screw insertion with preoperative CT navigation were analyzed. We investigated screw position and loosening by CT at the final follow-up.

Results: Of the 108 screws inserted, the rate of Grade 2 or higher perforation was 4.6% (5/108). Nine of 81 (11.1%) screws inserted into the 44 patients who were followed for at least 6 months showed loosening. Logistic regression analysis revealed that unilateral insertion (odds ratio: 8.50, 95% confidence interval: 1.53-47.2, P = 0.014) was significantly associated with the incidence of screw loosening.

Conclusions: The screw perforation rate of Grade 2 or higher in computer-assisted atlantoaxial transarticular screw fixation was 4.6%, with comparable frequencies of perforation direction. Unilateral insertion was a significant independent factor associated with screw loosening, which occurred in 11.1% of insertions.

Clinical relevance: Spine surgeons should follow up with patients with caution because screws with unilateral insertion are prone to loosening.

Level of evidence: 4:

Background: Biportal endoscopic spine surgery (BESS) has become widely recognized as a minimally invasive method for spinal decompression and discectomy. However, postoperative epidural hematoma (POEH) presents a significant risk in spinal surgery due to its potential to compress neural elements and lead to neurological deficits. This study compares the clinical and radiological outcomes of BESS with those of conventional microscopic surgery.

Methods: In this single-center, single-blinded, actively controlled randomized clinical trial, 46 patients undergoing single-level posterior decompression or discectomy for spinal stenosis or herniated intervertebral discs were enrolled. Participants were randomly allocated to either the conventional microscopic surgery group or the BESS group. Experienced spine surgeons performed all procedures. Postoperative magnetic resonance imaging assessments were conducted following the removal of the drain system. Outcome measures included the cross-sectional area (CSA) of the dura sac and POEH, as well as the incidence of neurological deficits.

Results: The demographic and baseline characteristics of the patients were similar across the 2 groups, with 24 in the conventional group and 22 in the BESS group. There were no significant differences in the preoperative and postoperative CSA of the dura sac between the groups. However, the BESS group exhibited a significantly larger CSA of POEH (0.36 ± 0.34 cm²) compared with the conventional group (0.17 ± 0.15 cm², P = 0.033). Despite this higher incidence of POEH, there was no corresponding increase in neurological deficits or revision surgeries.

Conclusion: The findings indicate that while BESS achieves decompression comparable to that of conventional microscopic surgery, it is associated with a higher incidence of epidural hematomas. Importantly, these hematomas did not result in an increased rate of neurological deterioration or the need for surgical interventions. Further studies with larger sample sizes and extended follow-up are required to confirm these results and further refine the BESS technique.

Clinical relevance: Despite a higher incidence of epidural hematomas, BESS offers comparable decompression to microscopic surgery without increased neurological risks, making it a viable, less invasive option for patient care.

Level of evidence: 2:

Introduction: Breast asymmetry (BA) is a common condition in patients with adolescent idiopathic scoliosis (AIS). Physicians may misdiagnose a patient with a unilateral breast tumor as a normal condition related to scoliosis. The present report describes the case of a patient with a breast tumor that was detected incidentally after surgical correction of scoliosis.

Patient presentation and outcomes: A 21-year-old woman was diagnosed as having AIS and reported to our institute for management. Thoracic third to lumbar second vertebra instrumented spine de-rotation and associated fusion surgery were performed to correct the deformity. After the operation, enlargement of left breast volume and obvious BA were noted. Breast sonography was performed, and a large tumor was found. Finally, the biopsy revealed a fibroadenoma of the left breast.

Conclusions: In managing patients with scoliosis and BA, comprehensive consideration of other possible etiologies is crucial to prevent misdiagnosis. This article reminds physicians that breast tumors can be concealed by BA related to AIS.

Level of evidence: 5:

Cervical intradural meningioma are rare central nervous system neoplasms. Surgical resection is the primary treatment due to the tumor's benign nature and clear demarcation from the spinal cord, although the posterior surgical approach can result in complications such as neurological deficits and cerebrospinal fluid leaks. We present a case of a 78-year-old woman with progressive clumsiness, gait disturbance, and weakness. She was diagnosed with an intradural extramedullary meningioma at the C2 to C3 level through magnetic resonance imaging. The tumor was excised using a cervical biportal endoscopic spine surgery approach, a minimally invasive technique that utilizes 2 small portals for endoscope and instrument access. The procedure, performed under general anesthesia, involved a hemilaminectomy and partial laminectomy to access and remove the tumor. Postoperative assessments indicated significant neurological recovery, with the patient regaining independent mobility and fine motor skills. Follow-up magnetic resonance images at 18 months confirmed the absence of tumor recurrence. This case demonstrates the efficacy of cervical biportal endoscopic spine surgery in managing high cervical intradural tumors, highlighting its potential for reducing surgical complications and promoting rapid patient recovery.

Background: Venous thromboembolism (VTE) is a well-known complication after spine surgery. As many cases of cervical spine disease result in severe gait disturbance due to myelopathy, it may harbor a higher risk of VTE than other spinal disorders. However, few studies have focused primarily on cervical spine surgery to date. This investigation sought to determine the prevalence of VTE after cervical spine surgery and identify patient-based risk factors.

Methods: The medical data of 341 consecutive patients (240 men and 101 women; mean age, 68.1 years) who underwent cervical spine surgery were retrospectively examined. Logistic regression models were employed to examine the prevalence, characteristics, and risk factors of postoperative VTE.

Results: In this study, 2.6% of cervical spine surgery patients experienced postoperative VTE. In comparisons of VTE and non-VTE groups, significant differences were found for age (79.6 years vs 67.7 years, P < 0.01), 1-week postoperative D-dimer level (10.6 μg/mL vs 2.7 μg/mL, P < 0.01), and cardiovascular disease (44.4% vs 11.1%, P = 0.011). Multivariate analysis identified elevated postoperative D-dimer level and cardiovascular disease as significantly associated with postsurgical VTE with respective odds ratios of 1.54 and 9.52.

Conclusion: Postoperative VTE in cervical spine surgery was seen in 2.6% of cases. Patients with elevated postoperative D-dimer level and cardiovascular disease may be at increased risk of VTE and may require additional observation.

Clinical relevance: Spine surgeons should take into account that patients with elevated postoperative D-dimer levels and cardiovascular disease may be at increased risk for VTE.

Level of evidence: 4:

Background: Nowadays, minimally invasive lateral lumbar interbody fusion (LLIF) is used to treat degenerative lumbar spine disease. Many studies have proven that LLIF results in less soft tissue destruction and rapid recovery compared with open posterior lumbar interbody fusion (PLIF). Our recent cost-utility study demonstrated that LLIF was not cost-effective according to the Thai willingness-to-pay threshold, primarily due to the utilization of an expensive bone substitute: bone morphogenetic protein 2. Therefore, this study was designed to use less expensive tricalcium phosphate combined with iliac bone graft (TCP + IBG) as a bone substitute and compare cost-utility analysis and clinical outcomes of PLIF in Thailand.

Methods: All clinical and radiographic outcomes of patients who underwent single-level LLIF using TCP + IBG and PLIF were retrospectively collected. Preoperative and 2-year follow-up quality of life from EuroQol-5 Dimensions-5 Levels and health care cost were reviewed. A cost-utility analysis was conducted using a Markov model with a lifetime horizon and a societal perspective.

Results: All enrolled patients were categorized into an LLIF group (n = 30) and a PLIF group (n = 50). All radiographic results (lumbar lordosis, foraminal height, and disc height) were improved at 2 years of follow-up in both groups (P < 0.001); however, the LLIF group had a dramatic significant improvement in all radiographic parameters compared with the PLIF group (P < 0.05). The fusion rate for LLIF (83.3%) and PLIF (84%) was similar and had no statistical significance. All health-related quality of life (Oswestry Disability Index, utility, and EuroQol Visual Analog Scale) significantly improved compared with preoperative scores (P < 0.001), but there were no significant differences between the LLIF and PLIF groups (P > 0.05). The total lifetime cost of LLIF was less than that of PLIF (15,355 vs 16,500 USD). Compared with PLIF, LLIF was cost-effective according to the Thai willingness-to-pay threshold, with a net monetary benefit of 539.76 USD.

Conclusion: LLIF with TCP + IBG demonstrated excellent radiographic and comparable clinical health-related outcomes compared with PLIF. In economic evaluation, the total lifetime cost was lower in LLIF with TCP + IBG than in PLIF. Furthermore, LLIF with TCP + IBG was cost-effective compared with PLIF according to the context of Thailand.

Clinical relevance: LLIF with less expensive TCP + IBG as bone graft results in better clinical and radiographic outcomes, less lifetime cost, and cost-effectiveness compared with PLIF. This suggests that LLIF with TCP + IBG could be utilized in lower- and middle-income countries for treating patients with degenerative disc disease.

Level of evidence: 3:

Background: Interest in the correlation between the spinopelvic complex and its radiographic parameters in early total hip arthroplasty has been increasing. This study investigated whether radiological spinopelvic parameters are risk factors for early total hip replacement (THR) within 1 year of spinal fusion surgery. The primary research question focused on identifying specific spinopelvic changes that may lead to early THR.

Methods: We retrospectively analyzed patients who underwent lumbar spinal fusion between 2016 and 2021. The patients were divided into 2 groups: patients who underwent early THR (n = 35) and patients who did not (n = 213). Spinopelvic parameters, including pelvic incidence (PI), sacral slope (SS), pelvic tilt, lumbar lordosis, thoracolumbar kyphosis (TLK), sagittal vertical axis, and thoracic kyphosis (TK), were measured before and after surgery. The statistical analyses included inverse probability of treatment weighting, independent t tests, χ ² tests, and logistic regression analyses.

Results: A total of 248 patients were included in the study. The pre- and postoperative TLK and TK angles were significantly smaller in the early THR group than in the late THR group. Increases in the PI and SS after surgery were significant risk factors. The use of interbody fusion techniques was associated with a higher rate of early THR. The difference in the PI minus lumbar lordosis before and after surgery was also significantly correlated with early THR.

Conclusions: Abnormal spinopelvic parameters, especially reduced TLK and TK angles and increased PI and SS, are risk factors for early THR.

Clinical relevance: Changes in spinopelvic parameters can lead to rapid hip joint destruction, which highlights the need for careful preoperative evaluation and postoperative monitoring of patients to prevent early THR.

Level of evidence: 3:

Background: Studies were reviewed and collected to compare different image guidance systems for pedicle screw placement (PSP) regarding accuracy and safety outcomes. Included were conventional, navigation, robot-assisted, and recent technology such as augmented reality (AR) guiding systems.

Methods: This network meta-analysis obtained human comparative studies and randomized controlled trials (RCTs) regarding PSP found in 3 databases (Cochrane, PubMed, and Scopus). Data extraction for accuracy, safety, and clinical outcomes were collected. The network meta-analysis was analyzed, and a surface under the cumulative ranking curve (SUCRA) was used to rank the treatment for all outcomes.

Results: The final 61 studies, including 13 RCTs and 48 non-RCTs, were included in the meta-analysis. These studies included a total of 17,023 patients and 35,451 pedicle screws. The surface under the cumulative ranking curve ranking demonstrated the supremacy of robotics in almost all accuracy outcomes except for the facet joint violation. Regarding perfect placement, the risk difference for AR was 19.1 (95% CI: 8.1-30.1), which was significantly higher than the conventional method. The robot-assisted and navigation systems had improved outcomes but were not significantly different in accuracy vs the conventional technique. There was no statistically significant difference concerning safety or clinical outcomes.

Conclusions: The accuracy of PSP achieved by robot-assisted technology was the highest, whereas the safety and clinical outcomes of the different methods were comparable. The recent AR technique provided better accuracy compared with navigation and conventional methods.

Level of evidence: 2: