International Journal of Spine Surgery最新文献

Background: Artificial disc replacement (ADR) has become an evidence-based alternative to traditional fusion surgery. Current guidelines for safe return-to-activity (RTA) levels following surgery have yet to be determined. This Modified Delphi study aimed to establish expert-sourced consensus for safe and optimized RTA recommendations following cervical disc arthroplasty.

Methods: Ten expert spine surgeons with an average of 15 years of surgical experience participated in a 3-round Modified Delphi Method. The first round presented experts with 11 clinical cases and 19 multiple-choice questions regarding recommendations for patient RTA following surgery for 1-, 2-, or 3-level arthroplasty. First-round responses were analyzed and presented in second-round surveys to the experts, who repeated 19 multiple-choice questions. The third round presented consensus recommendation statements derived from the second round for the final assessment of the expert agreement.

Results: Experts agreed on 19 of 22 (86.4%) postarthroplasty RTA recommendations. Eight recommendations achieved unanimous agreement; the most robust consensus (95%-100% agreement) included recommendations that patients may return to basic activities such as walking, social activities, sedentary work, air travel, and sexual activity within 2 weeks of arthroplasty surgery and that arthroplasty patients will have a shorter recovery, resuming normal activities sooner than fusion patients. Experts agreed that patients may return to light and heavy physical activity (strong consensus) earlier for 2- and 3-level ADR compared to hybrid constructs. Experts also agreed that ADR patients can resume light physical activity at 4 to 6 weeks and engage in intense conditioning and sport-specific training at 6 weeks. However, a weaker consensus was achieved for returning to physically demanding work at 4 to 6 weeks and high-intensity physical activity/sports at 6 weeks, indicating that individual patient factors and the specific nature of the activity should be considered.

Conclusion: This study provides the first consensus-based recommendations for RTA following cervical disc arthroplasty.

Level of evidence: 4:

Background: To describe a staged surgical protocol combining halo-pelvic traction (HPT) and posterior spinal fusion (PSF) for severe scoliosis in a patient with osteogenesis imperfecta (OI) type IV and to evaluate its outcomes. Given the paucity of population-level data on spinal orthoses in OI, this report highlights a tailored surgical approach for this high-risk population.

Case presentation and management: A 16-year-old girl with OI type IV and progressive scoliosis underwent a 2-stage correction: (1) preoperative HPT for 3 months to reduce coronal deformity and optimize spinal alignment, followed by (2) PSF with all-pedicle-screw instrumentation. The staged protocol achieved successful deformity correction without neurological or implant-related complications. All pedicle screws were safely placed despite osteopenic bone. At follow-up, radiographic outcomes were maintained, and the patient reported improved posture and function. Minor surgical differences and literature review are highlighted for multimodal management.

Conclusion: Progressive scoliosis in patients with OI can be effectively managed through structured, phased therapeutic programs, with the combined approach of HPT and PSF representing a significant surgical intervention strategy.

Clinical relevance: The clinical significance of this approach lies in transforming the management of a challenging rare disease-progressive scoliosis in osteogenesis imperfecta-from an empirical endeavor into a structured, systematic clinical pathway, while providing a validated technical combination for its most critical surgical intervention.

Level of evidence: 5:

Background: This systematic overview investigates prior systematic reviews exploring vertebral body tethering (VBT) in managing adolescent idiopathic scoliosis (AIS). The aim is to assess the quality of literature, present the current best evidence, and formulate recommendations.

Methods: We independently conducted duplicate electronic searches in Embase, Medline, Scopus, and Web of Science until 19 August 2023, for systematic reviews on VBT for AIS. Methodological quality was assessed using Oxford Levels of Evidence, Assessment of Multiple Systematic Reviews (AMSTAR) scoring, and AMSTAR 2 grading. The Jadad decision algorithm was utilized to identify the study with the highest quality, representing the current best evidence for recommendations.

Results: Ten systematic reviews meeting eligibility criteria were included. AMSTAR scores ranged from 4 to 10 (mean: 6.8), indicating varied methodological quality. Most studies had critically low reliability in result summaries per AMSTAR 2 grades. The current best evidence (level IV) suggests VBT as an effective surgical approach for scoliosis, with 73.9% achieving clinical success. However, 15.8% required unplanned reoperations, and 52.2% experienced complications, with a 22% tether failure rate. Thus, patient discussions should address the high reoperation and complication rates associated with this procedure.

Conclusion: The quality of evidence on VBT for AIS is critically low. Despite the systematic overview and identifying the best evidence in the literature, high-quality recommendations for practice could not be generated. Future studies with extended follow-up periods are imperative to comprehend VBT's utility in AIS management.

Clinical relevance: Evidence around the use of VBT for AIS is critically low, hence usage of VBT must be considered with caution in AIS.

Level of evidence: 4:

Spine surgery is a highly skill-dependent specialty, where the surgeon's expertise plays a critical role in determining patient outcomes. Despite the traditional emphasis on randomized controlled trials and meta-analyses as the gold standard for clinical research, these methodologies may fall short in accounting for the variability in surgeon proficiency, which significantly influences success rates in spine surgery. This perspective article examines the limitations of relying solely on randomized controlled trials and meta-analyses in skill-driven fields such as spine surgery and argues for a broader research paradigm that incorporates the role of surgical skill and experience. Alternative methodologies, such as observational studies, surgeon-led outcome tracking, and surgical registries, are proposed to better capture the real-world complexities of spine surgery. This perspective article emphasizes the importance of structured training programs, continuous professional development, and proficiency-based education models in improving surgical outcomes. A call to action is made for policymakers, professional organizations, and academic institutions to shift the focus of spine surgery research toward integrating surgeon expertise alongside traditional evidence-based approaches, ultimately fostering innovation and improving patient care.

Objective: Including conditions like obesity, diabetes, hypertension, and dyslipidemia, metabolic syndrome disrupts metabolic homeostasis and impairs recovery, increasing the risk of surgical complications. This study evaluates the impact of metabolic syndrome on spine surgery outcomes, addressing inconsistencies in the existing literature.

Methods: Four databases were searched until December 2024 for studies comparing the postoperative complication rates of spine surgeries between patients with and without metabolic syndrome. Following deduplication, 2 authors independently reviewed the studies. For each included study, demographics and incidence rates of postoperative complications were extracted separately by 2 authors. Data analysis was performed using R.

Results: After deduplication, 115 studies were evaluated for inclusion in our study. Following the review of full texts, 11 studies were included. No significant differences were found between patients with and without metabolic syndrome in terms of mortality and nonhome discharge, pulmonary thromboendarterectomy, pneumonia, and sepsis (P > 0.05). However, metabolic syndrome was associated with a significantly increased risk of 30-day readmission (RR: 1.5, 95% CI: 1.2-1.8), reoperation (RR: 1.3, 95% CI: 1.1-1.6), cardiac complications (RR: 1.7, 95% CI: 1.5-2.1), respiratory complications (RR: 1.68, 95% CI: 1.17-2.40), cerebrovascular complications (RR: 2.0, 95% CI: 1.4-2.9), renal complications (RR: 4.48, 95% CI: 2.58-7.80), urinary complications (RR: 1.45, 95% CI: 1.41-1.48), venous thromboembolism (RR: 1.3, 95% CI: 1.1-1.6), and wound complications (RR: 1.6, 95% CI: 1.3-1.9).

Conclusions: Metabolic syndrome might significantly increase the risk of some postoperative complications in spine surgery patients. These findings highlight the need for personalized preoperative planning and management strategies to mitigate surgery risks.

Clinical relevance: Identifying and optimizing metabolic syndrome components before surgery may improve patient outcomes and reduce complication rates.

Level of evidence: 2:

Patients suffering from chronic mechanical low back pain secondary to multifidus dysfunction represent a unique and increasingly recognized subset of the overall chronic mechanical low back pain population. Neuromuscular inhibition and fatty infiltration of the dysfunctional multifidus muscle contribute to persistent pain, spinal instability, and disability that fail to resolve with conventional therapy. As of October 2024, the introduction of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code M62.85 provides formal classification of this disease entity and allows providers to diagnose this condition with a higher level of specificity. Permanently implanted restorative neurostimulation systems, of which the ReActiv8 device (Mainstay Medical) is currently the only US Food and Drug Administration (FDA)-approved technology (FDA Product Code QLK), directly target chronic low back pain associated with lumbar multifidus dysfunction to treat the underlying condition. This 2025 International Society for the Advancement of Spine Surgery guideline update (1) summarizes the high-quality clinical data supporting long-term efficacy and safety of restorative neurostimulation, including longitudinal outcomes from a 5-year pivotal study, randomized controlled trials, and other clinical studies, (2) updates all coding guidance to reflect current ICD-10 and FDA device status, and (3) reports on payer trends, including the recent positive Anthem Blue Cross Blue Shield coverage decision. The International Society for the Advancement of Spine Surgery reaffirms its support for coverage of implantable restorative neurostimulation by payers in appropriately selected patients, consistent with the demonstrated evidence.

Objective: To develop consensus-based guidance for bone health optimization in instrumented spine surgery, specifically addressing the limited guidance available in the Thai context.

Methods: The study utilized a modified Delphi technique, engaging 10 orthopedic surgeons from Thailand with expertise in complex spine surgery and osteoporosis management. A targeted literature review was conducted, followed by 2 online surveys and a face-to-face consensus meeting to develop and refine the statements. Twenty-five main statements and 45 substatements that focused on patient evaluation, assessment tools, and risk stratification were drafted for the panel's deliberation.

Results: There was unanimous agreement on the necessity of evaluating bone health before instrumented spine surgery in patients aged ≥60 years, while evaluation was considered optional for those aged 50 to 59 years. The panelists supported using the fracture risk assessment tool score for clinical evaluation and recommended using several assessment tools, including dual-energy x-ray absorptiometry scans for specific age groups, Computed Tomography Hounsfield Unit, Trabecular Bone Score, and vertebral fracture assessment for bone health evaluation if available. Treatment recommendations included bone-forming agents as the first-line therapy for patients at high risk and very high risk and specialized surgical techniques for patients at very high risk. Surgical delay of at least 3 months should also be considered for patients at very high risk/with severe osteoporosis who have been scheduled for instrumented spine surgery.

Conclusion: This guidance includes patient screening, evaluation, and treatment for patients with poor bone health based on risk stratification, including normal/low risk, osteopenia/intermediate risk, osteoporosis/high risk, and severe osteoporosis/very high risk. Spine surgeons should be aware of poor bone health and consider bone health optimization to improve surgical outcomes and prevent osteoporosis-related complications.

Clinical relevance: Bone health optimization is crucial for instrumented spine surgery. Spine surgeons should consider bone health optimization guidance, including patient screening for poor bone health, assessment tools for evaluating bone health, and treatment for patients with poor bone health, to improve surgical results and minimize poor bone health-related complications.

Level of evidence: 5:

Background: Alkaptonuria is a rare metabolic disorder, an autosomal recessive disease caused by the deficiency of an enzyme, homogentisate 1,2-dioxygenase. As a consequence, there is an accumulation of homogentisic acid, which deposits in connective tissues, leading to ochronotic arthropathy.

Case presentation: In this case, a 35-year-old man who was diagnosed as having alkaptonuria in 2023 at the National Institutes of Health, underwent urine analysis that showed a peak homogentisic acid level of 3383 mmol/mol creatinine. He reported that 20 days prior to admission, he woke up at night due to sudden and intense cervical pain (visual analog scale 10), with shock-like pain radiating to the lateral sides of the arms and dorsoradial areas of the forearms, which was associated with weakness in elbow flexion and signs of pyramidal release. He underwent magnetic resonance imaging of the cervical spine, which revealed an acute extruded C5 to C6 disc herniation. He subsequently underwent a C5 to C6 discectomy and anterior arthrodesis, where an ochronotic-pigmented disc was observed intraoperatively. On the first postoperative day, an improvement in elbow flexion strength was noted, and he was discharged 5 days later.

Discussion: There is currently no effective and proven treatment for alkaptonuria; nitisinone has shown potential as the first effective treatment but may lead to corneal issues due to triggered tyrosinemia. The treatment for ochronotic arthropathy is primarily symptomatic, with surgical procedures reserved for more advanced degenerative cases.

Conclusion: This study aims to enhance understanding of the pathophysiology of the spinal column in alkaptonuria and to explore the best surgical therapy strategies for this disease.

Objectives: Hangman's fracture, caused by high-energy hyperextension with axial loading trauma, remains challenging to manage. Unstable types (IIa and III) can be treated by a variety of surgical options. Lag-screw fixation has recently gained attention owing to its compatibility with navigation, minimally invasive instrumentation, and lower surgical morbidity.

Methods: A systematic review and meta-analysis of surgical efficacy and safety of lag screw fixation was undertaken. Nine studies, which included a total of 128 patients, assessed outcomes of lag screw fixation, including neck range of motion, intervertebral angle (C2-C3), postoperative pain (visual analog scale), intraoperative parameters, and complications.

Results: Significant improvements were observed in pooled range of motion (extension: 6.28°, flexion: 5.13°) and correction of the C2 to C3 angle by -3.54° (P < 0.001) vs baseline. Pain decreased across early and late timepoints, although heterogeneity reflects variable follow-up and unreported analgesic/analgesia protocols. Reported complications were low in the included series.

Conclusion: C2 transpedicular lag-screw fixation restores alignment and preserves motion with low reported complications in available case series. Larger comparative trials are needed to define its role relative to fusion techniques.

Clinical relevance: Direct osteosynthesis of unstable hangman's fractures via lag-screw fixation offers a viable motion-preserving alternative to C2-C3 fusion. By avoiding fusion, this technique maintains physiological cervical biomechanics and reduces the risk of adjacent segment disease. However, clinicians must carefully weigh these benefits against the technical demands of screw placement and the current lack of high-level comparative evidence.

Level of evidence: 4: