International Journal of Spine Surgery最新文献

Background: The effects of epidural steroid (ES) administration following open or minimally invasive surgery lumbar discectomy have been extensively studied. However, no research has investigated the impact of steroids following the unilateral biportal technique endoscopic lumbar discectomy (UBE-D) for lumbar disc herniation. This study aims to evaluate the efficacy of ES administration in controlling postoperative pain and disability scores following UBE-D for single-level lumbar disc herniation.

Methods: This double-blind, randomized, placebo-controlled trial was conducted between June 2021 and June 2023. Eighty-two patients were assessed, and 60 were eligible and randomized to receive either ES (n = 30) or saline (placebo; n = 30) after UBE-D. The Outcome measures included visual analog scale scores for pain, Oswestry Disability Index scores, morphine consumption over 24 hours, serum C-reactive protein levels, and the occurrence of complications over a 6-month follow-up period.

Results: The baseline characteristics were comparable between the 2 groups, with no significant differences observed. Analysis of visual analog scale scores for back and leg pain, as well as Oswestry Disability Index scores, at various postoperative time points (6 hours, 12 hours, 24 hours, 2 weeks, 6 weeks, 3 months, and 6 months), showed no statistically significant differences between the ES and placebo groups (P values ranged from 0.47-0.94). Additionally, no significant differences were found in morphine consumption within the first 24 hours postoperatively (P = 0.85), length of hospital stay (P = 0.36), or C-reactive protein levels at 24 hours and 3 weeks postoperatively (P values ranged from 0.54-0.79) between the 2 groups. Importantly, no postoperative or steroid-related complications were reported in either group within the 6-month follow-up period.

Conclusions: ES administration after UBE-D did not significantly reduce postoperative pain, disability scores, or morphine consumption compared with placebo. The findings suggest that routine use of ESs in this context may not provide additional benefits.

Clinical relevance: Clinicians should reconsider the use of epidural steroids as part of standard postoperative management after UBE-D, as the lack of significant improvement in patient outcomes indicates that alternative pain management strategies may be more effective.

Level of evidence: 1:

Background: Recent studies assessing the importance of various preoperative factors on postoperative outcomes following spine surgery have uncovered several important variables that influence subjective and objective outcomes following cervical spine surgery, but it is still unclear which patients are most likely to benefit from operative management.

Purpose: The objective of this study was to assess whether preoperative patient-reported outcome measures (PROMs) can be used to predict which patients achieve "normal" levels of pain and function after surgery.

Study design: This was a prospective cohort study.

Patient sample: This study included all adult patients undergoing cervical spine surgery by 1 of 7 senior spine surgeons at our institution between 2016 and 2018. Of the 164 patients who were eligible for 6-month follow-up at the time that study data were collected, 139 had available follow-up data and were included in our analysis.

Outcomes measures: Patients completed the Neck Disability Index (NDI) as well as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference computer adaptive tests preoperatively and at 6 months postoperatively.

Methods: Patients who achieved postoperative patient-acceptable symptom state (PASS) for NDI (≤17) and the normative mean (50) for PROMIS were identified. The relationship between preoperative PROMs and the probability of achieving PASS and the normative mean was assessed.

Results: One hundred thirty-nine patients met inclusion criteria with diagnoses of myelopathy (n = 36), radiculopathy (n = 48), and myeloradiculopathy (n = 49). For NDI, a 1-point worsening in the preoperative score resulted in an OR of achieving PASS of 0.96 (P < 0.001) in the overall population. This association held true for patients with radiculopathy (OR 0.96; P = 0.022) but not myelopathy (OR 0.98; P = 0.35). For PROMIS PF, a 1-point improvement in the preoperative score resulted in an OR of achieving the normative mean of 1.10 (P < 0.001). This association held true for patients with radiculopathy (OR 1.14; P = 0.033) but did not reach statistical significance for patients with myelopathy (OR 1.03; P = 0.515).

Conclusions: Preoperative PROMs can predict postoperative benefit for patients undergoing cervical spine surgery, with worse baseline function associated with a lower likelihood of attaining PASS for NDI and the normative mean for PROMIS PF, especially for patients with radiculopathy.

Clinical relevance: Baseline symptoms and function, including myelopathy or radiculopathy-dominant symptoms and preoperative PROMs, may predict postoperative outcomes.

Level of evidence: 3:

Objective: This cohort study aims to evaluate the impact of obesity on the outcomes of full endoscopic lumbar discectomy (FELD) in patients with lumbar disc herniation.

Methods: We conducted a retrospective analysis of 156 adult patients who underwent FELD for lumbar disc herniation from January 2015 to February 2023. Patients were divided into 3 groups: obese endoscopic (n = 71), obese open surgery (n = 31), and nonobese endoscopic (n = 54). Clinical outcomes were assessed using the visual analog scale for leg and back pain, the Oswestry Disability Index, and patient satisfaction rates. Operative time, hospital stay duration, and complication rates were also analyzed.

Results: No significant differences were observed in patient-reported outcome measures, operative time, or complication rates between obese and nonobese patients undergoing FELD. The mean operative time was longer in the endoscopic group compared with the open surgery group (70.2 vs 59.8 minutes), but the hospital stay was significantly shorter for endoscopic patients (1.7 vs 2.4 nights, P = 0.0006). Both obese and nonobese groups showed significant improvements in visual analog scale and Oswestry Disability Index scores at the final follow-up, with satisfaction rates of 85.7% in the endoscopic group reporting good to excellent outcomes.

Conclusions: FELD is a viable and effective alternative to traditional open surgery for obese patients, offering comparable clinical outcomes and the added benefit of a shorter hospital stay. These findings suggest that obesity does not inherently affect surgical outcomes, underscoring the need for further research with larger sample sizes and longer follow-up periods.

Clinical relevance: FELD offers a viable and effective surgical option for obese patients, with outcomes comparable to traditional surgery but with the added benefit of shorter hospital stays.

Level of evidence: 3:

Background: Interspinous process devices (IPDs) introduce a new class of complications to surgical decompression without fusion: hardware-related complications. The purpose of this study was to describe the adverse events associated with IPDs.

Study design: This was a retrospective review of the Food and Drug Administration Manufacturer and User Facility Device Experience database.

Methods: The database was queried from its inception to November 2022 for reports associated with "Prosthesis, Spinous Process Spacer/Plate." Entries were categorized by event type, patient impact, and interventions.

Results: A total of 943 surgery-related adverse events were identified. The most common intraoperative events were implant malfunctions (39.7%, n = 374) and fractures (2.2%, n = 21). The most common postoperative events were persistent pain (26.6%, n = 251), implant migration (19.1%, n = 180), and fracture (6.8%, n = 64). The most common resultant outcome of an adverse event was the need for revision surgery (48.8%, n = 460). The need for revision surgery was common in patients who experienced fracture (47.1%), implant migration (84.5%), infection (76.7%), and neurological complications (76.9%). Implant migration, fracture, and implant malfunction, 3 complications that are unique to decompression with an IPD as compared with traditional laminectomy, accounted for 45.9% of revisions (211/460), and revision was required in 33.0% of cases where 1 of these complications was reported (211/640). Implant malfunction made up 21.2% of Coflex complications, 47.3% of Superion complications, and 5.2% of X-Stop complications.

Conclusions: The most common adverse events were implant malfunction, inadequate efficacy, implant migration, and fracture. Concerningly, these complications require revision surgery in one-third of cases when they occur. Implant-specific assessments demonstrate a high prevalence of implant malfunctions for the Coflex and Superion implants.

Clinical relevance: Interspinous process devices introduce a new class of complications to isolated spinal decompression surgery: implant-related complications. These complications occur both intraoperatively and postoperatively, and they frequently necessitate revision surgery.

Level of evidence: 4:

Background: This study aimed to determine whether the iliac crests are truly at the level of L4 to L5, accounting for patient demographic and anthropometric characteristics.

Methods: We measured the umbilicus and iliac crests relative to the lumbar spine using computed tomography of patients without spinal pathology, accounting for the influences of patient height, weight, body mass index (BMI), sex, race, and ethnicity.

Results: A total of 834 patients (391 men and 443 women) were reviewed. The location of the umbilicus relative to the lumbar spine demonstrated a unimodal distribution pattern clustered at L4, while the iliac crests were most frequently located from L4 to L5. Iliac crests were located above the L4 to L5 disc space 26.5% of the time. Iliac crests were located at the L4 to L5 disc space 29.8% of the time. No correlations were observed between the umbilicus and iliac crests with patient height, weight, or BMI. There was no difference in the location of the umbilicus with respect to patient sex, race, and ethnicity. The locations of the iliac crests were cephalad in women compared with men and in Hispanics compared with African American, Caucasian, and Asian patients.

Conclusions: The iliac crests were located above the level of the L4 to L5 disc space approximately 26% of the time. The umbilicus is most frequently at the level of the L4 vertebral body. Patient height, weight, and BMI do not influence the location of the umbilicus or the iliac crests relative to the lumbar spine. Patient sex and ethnicity influence the location of the iliac crests but not the umbilicus relative to the lumbar spine.

Clinical relevance: Modern neurosurgical techniques require clearance of the iliac crests during anterior and anterolateral approaches. Understanding the level of the iliac crests is crucial in planning for transpsoas fusion approaches.

Level of evidence: 2:

Background: Lumbar disc herniation (LDH) is a common cause of radicular pain with an annual incidence between 5 and 20 cases per 1000 adults. LDH is typically treated by microdiscectomy, of which more than 300,000 are performed in the United States each year. Despite this frequency, 25% to 33% of patients report poor surgical outcomes. This study sought to present a retrospective analysis of patients who underwent microdiscectomy surgery for the treatment of LDH with the aim of identifying demographic, historical, and surgical factors that may contribute to inadequate surgical results.

Methods: A retrospective study of 241 patients at Stony Brook Medicine from 2017 to 2022 was performed, 123 of whom had follow-up of 90 days or more and were included for final analysis. Data collection included demographics, medical/surgical history, and surgical methodology. Good outcomes were defined as meeting the absolute point change threshold (ACT)-3.5pt reduction in pain reported by the Numerical Rating System (NRS) or the resolution of either radicular pain or neurological symptoms.

Results: Univariate analysis revealed that 100% of patients with prior fusion surgery (P = 0.039) and 73.2% who underwent preoperative physical therapy (PT; P = 0.032) failed to meet the ACT. Additionally, 79.1% (P = 0.021) and 82.8% (P = 0.026) of patients who had PT had residual radicular pain and neurological symptoms, respectively. Multivariate logistic regression confirmed correlations between preoperative PT and failure to meet the ACT (P = 0.030, OR = 0.252) and resolution of radicular (P = 0.006, OR = 0.196) and neurological (P = 0.030, OR = 0.177) complaints. ACT directly correlated with higher preoperative NRS scores in univariate (P = 0.0002) and multivariate (P = 0.002, OR = 1.554) analyses.

Conclusion: Our results show that higher preoperative NRS scores, PT, and prior fusion surgery are associated with poorer outcomes. While PT is considered a viable nonoperative treatment for LDH, our findings suggest detrimental effects when preceding surgery, indicating the need for additional research into the effects of PT on patients with high grade LDH.

Background: Low back pain (LBP) is a globally prevalent condition, often attributed to lumbar disc herniation (LDH). Transforaminal percutaneous endoscopic discectomy (TPED) is a minimally invasive surgical approach for LDH, offering distinct advantages. This study aimed to assess the progression of pain in patients who underwent TPED in Kenya, with a focus on the impact of pre-existing factors.

Methods: This retrospective study included 610 patients from the Mediheal Group of Hospitals who underwent TPED between January 2018 and December 2022. Data were collected from medical records, direct patient interactions, and telephone interviews. Statistical analyses, including repeated measures analysis of variance, correlation coefficients, and t tests, were used to examine pain progression and factors influencing outcomes.

Results: Among the 610 included patients, all reported LBP and 87.9% reported leg pain. TPED resulted in significant pain reduction (P < 0.001) for both LBP and leg pain, with sustained improvement over 1 year. Factors such as age, body mass index, and duration of pain correlated with pain outcomes. No significant impact of comorbidities on pre- or postoperative pain was observed. Its retrospective design and the absence of a control group limit the strength of causal inferences.

Conclusions: TPED is an effective treatment for LBP and leg pain in Kenyan patients with LDH. Pain improvement was sustained over 1 year after performing TPED, and pre-existing factors influenced outcomes. This study provides valuable insights into TPED outcomes, contributing to the understanding of LDH management in diverse populations.

Background: Nonoperative management is an appealing option for purely transosseous thoracolumbar flexion-distraction injuries given the prospects of osseous healing and restoration of the posterior tension band complex. This study seeks to examine differences in outcomes following flexion-distraction injuries after operative and nonoperative management.

Methods: This study reviews all patients at a single Level 1 trauma center from 2004 to 2022 with AO Spine B1 thoracolumbar injuries treated operatively vs nonoperatively. Inclusion criteria were age greater than 16 years, computed tomography-confirmed transosseous flexion-distraction injuries, and at least 3 months of follow-up with available imaging. The primary outcome assessed was a change in local Cobb angles, with secondary outcomes consisting of complications, time to return to work, and need for subsequent operative fixation.

Results: Initial Cobb angles in the operative (n = 14) vs nonoperative group (n = 13) were -5° and -13°, respectively (P = 0.225), indicating kyphotic alignment in both cohorts. We noted a significant difference in Cobb angles between cohorts at first follow-up (2.6° and -13.9°, P = 0.015) and within the operative cohort from presentation to first follow-up (P = 0.029). At the second follow-up, there was no significant difference in Cobb angles between cohorts (3.6° and -12.6°, P = 0.07). No significant differences were noted in complication rates (P = 1), time to return to work (P = 0.193), or resolution of subjective back pain (P = 0.193). No crossover was noted.

Conclusions: Nonoperative management of minimally displaced transosseous flexion-distraction injuries is a safe alternative to surgery. Patient factors, such as compliance with follow-up, and location of the injury should be factored into the surgeon's management recommendation.

Clinical relevance: Overall, no significant differences in outcomes and complications were noted following nonoperative management of AO Spine B1 injuries, indicating the potential for these injuries to be managed conservatively.

Level of evidence: 3:

Background: Interbody devices in anterior lumbar interbody fusion (ALIF) are currently a focus of innovation due to their potential to improve clinical outcomes. The purpose of the present study was to analyze complications and changes in spinopelvic parameters after ALIF with the novel Medacta MectaLIF interbody fusion device.

Methods: Patients aged 18 to 80 years who underwent multilevel ALIF using this novel implant were identified. Demographic and surgical data were collected. Patients were divided into short- and long-fusion cohorts. A comparison of outcomes between the short- and long-fusion groups was performed using the Student t test for continuous variables and Fisher's exact test and the χ² test for categorical variables. Analysis of the pre- vs postoperative radiographic data for the entire cohort was performed using the 2-tailed Student t test.

Results: One hundred and eight patients met the inclusion criteria. No significant postoperative change was observed in L1-4 lumbar lordosis (LL). L1-S1 LL increased to a mean of 55.1 ± 12.8 (a mean change of 10.7 ± 14.5), and L4-S1 LL increased to a mean of 38.4 ± 8.7 (a mean increase of 7.5 ± 8.2), with pelvic incidence LL mismatch changing from 8.9 ± 15.1 to 1.1 ± 13.5 (n = 102). Related changes in sacral slope and pelvic tilt were also observed (33.0 ± 11.0 to 37.6 ± 10.9 and 19.6 ± 9.5 to 18.2 ± 9.1 [n = 103], respectively). Five patients (4.6%) experienced implant subsidence, 1 (0.9%) had implant migration, and 6 (5.6%) experienced a nonunion. There was no difference in the rates of complications associated with the novel implant in the short- and long-fusion cohorts.

Conclusion: This novel implant achieves correction of spinopelvic parameters with minimal complications. The ability to modify the implant intraoperatively based on the patient's anatomy can help achieve maximal contact area and therefore help reduce the risk of subsidence.

Clinical relevance: This modular implant can achieve correction of spinopelvic parameters with minimal medical and surgical complications.

Level of evidence: 4:

Background: Mounting evidence demonstrates a promising safety and efficacy profile for spinal fusion procedures using cellular bone allograft (CBA). However, limited data exists on fusion outcomes stratified by surgical approach. The current study investigates the effectiveness of CBA in lumbar spinal fusion by surgical approach (ie, anterior, lateral, and posterior approaches).

Methods: Patients undergoing lumbar spinal fusion with CBA (Trinity Elite) were enrolled into a prospective, multi-center, open-label clinical study (NCT02969616). Fusion status was assessed by an independent review of dynamic radiographs and computed tomography images. Clinical outcome measures included quality of life (QoL; EQ5D), disability (Oswestry Disability Index [ODI]), and pain (visual analog scale [VAS]) for back pain and leg pain). Patient data extending to 24 months were analyzed in a post-hoc analysis.

Results: A total of 252 patients underwent interbody fusion (159 women; 93 men). Patients had a mean age of 58.3 years (SD 12.5), height of 168.3 cm (SD 10.2), and weight of 87.3 kg (SD 20.0) with a body mass index of 30.8 kg/m² (SD 6.5). At 12 months, the overall fusion success rate for bridging bone was 98.5%; fusion success was 98.1%, 100.0%, and 97.9% for anterior, lateral, and posterior approaches, respectively. At 24 months, the overall fusion success rate for bridging bone was 98.9%; fusion success was 97.9%, 100.0%, and 98.8% for anterior, lateral, and posterior approaches, respectively. The surgical approach did not significantly impact fusion success. A significant (P < 0.0001) improvement in QoL, pain, and disability scores was also observed. Significant differences in the ODI, VAS, and EQ5D were observed between the treatment groups (P < 0.05).

Conclusions: CBA represents an attractive alternative to autograft alone, reporting a high rate of successful fusion and clinical outcomes across various surgical approaches.

Clinical relevance: The use of CBA for spinal fusion procedures, regardless of surgical approach, provides high rates of fusion with a favorable safety profile and improved patient outcomes.

Level of evidence: 4:

Trial registration: NCT02969616.