International Journal of Spine Surgery最新文献

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: Expandable transforaminal lumbar interbody fusion (TLIF) cages could offer an alternative to anterior lumbar interbody fusion (ALIF). Bilateral cage insertion enhances endplate coverage, potentially improving stability and fusion rates and maximizing segmental lordosis. This study aims to compare the biomechanical properties of bilateral expandable TLIF cages to ALIF cages using finite element modeling.

Methods: We used a validated 3-dimensional finite element model of the lumbar spine. ALIF and TLIF cages were created based on available product data. Our focus was on analyzing spinal motion in the sagittal plane, evaluating forces transmitted through the vertebrae, and comparing an ALIF model with various TLIF cage models.

Results: The largest TLIF cage model exhibited a 407.9% increase in flexion motion and a 42.1% decrease in extension motion compared with the ALIF cage. The second largest TLIF cages resulted in more flexion motion and less extension motion compared with ALIF, while smaller cages were inferior to ALIF. ALIF cages were associated with increased adjacent segment motion compared with TLIF cages, primarily in extension. Endplate stress analysis revealed higher stress in the ALIF cage model with a more uniform stress distribution.

Conclusion: ALIF cages excel in stabilizing L5 to S1 during flexion, while largest TLIF cages offer superior stability in extension. Large bilateral TLIF cages may provide biomechanical stability comparable to ALIF, especially in extension and could potentially reduce the risk of adjacent segment disease with lower adjacent segment motion.

Level of evidence: 5:

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.

Background: Perioperative blood glucose control has been demonstrated to influence outcomes following spine surgery, though this association has not been fully elucidated in patients with traumatic spine injuries. This study sought to determine the association between perioperative blood glucose levels and complications or outcomes in patients undergoing spine surgery due to injury.

Methods: A retrospective review was conducted to identify patients who underwent spine surgery due to traumatic injuries between 1 March 2020 and 29 September 2022 at a single academic institution. Descriptive factors, complications, and outcomes were compared between those with a postoperative blood glucose level of <200 mg/dL and those with a preoperative glucose of <200 mg/dL.

Results: Patients with a post- and preoperative blood glucose of ≥200 mg/dL had significantly higher odds of respiratory complications (OR = 2.1, 2.1, P = 0.02, 0.03), skin/wound complications (OR = 2.2, 2.8, P = 0.04, 0.03), and increased hospital length of stay (OR = 9.6, 12.1, P = 0.02, 0.03) compared with those with blood glucose of <200 mg/dL. Those with postoperative glucose ≥200 mg/dL also had significantly higher odds of inpatient mortality (OR = 4.5, P = 0.04) when controlling for confounding factors. Neither pre- nor postoperative blood glucose of ≥200 mg/dL was associated with an improvement in American Spinal Injury Association Impairment Scale score at the final follow-up when controlling for multiple confounding factors (P = 0.44, 0.06).

Conclusion: Elevated blood glucose both pre- and postoperatively was associated with an increased rate of postoperative complications and negative postoperative outcomes. However, there was no association between elevated blood glucose levels and neurological recovery following traumatic spinal injury.

Level of evidence: 3:

Background: To quantify fatty infiltration and degree of paraspinal muscle degeneration in patients submitted to tubular microdiscectomy and conventional open microdiscectomy.

Methods: A prospective cohort of patients was submitted to microdiscectomy for lumbar disc herniation after failure of conservative treatment. Selection of the technique was based on the surgeon's preference. Analysis of the multifidus muscle was performed using the Goutallier system and the percentage of fat in the muscle. Preoperative and 1-year postoperative T2-weighted magnetic resonance imaging was used, and statistical analysis was carried out using the Wilcoxon test and Spearman correlation test using a significance level of 5%.

Results: Thirty-two patients were included in the study. The percentage of fatty infiltration in the muscle increased on both sides of the spine 1 year after surgery, although only the ipsilateral side presented statistical significance in patients submitted to conventional microdiscectomy (43.3% preoperative and 57.8% postoperative). Muscular degeneration increased significantly ipsilateral to the disc herniation according to the Goutallier classification (grades 1-2) for both interventions. No statistically significant difference was found for fatty infiltration scores or for the degree of muscular degeneration of the multifidus in the comparative analysis of the methods.

Conclusions: Muscular damage resulting from surgery of lumbar disc herniation significantly increases fatty infiltration and degeneration of the multifidus. Muscular degeneration was associated with worsening back pain.

Clinical relevance: While no significant difference was found between the techniques, the tubular minimally invasive approach shows a tendency for less muscle damage. These findings highlight the importance of minimizing muscle injury during surgery to improve postoperative recovery and long-term outcomes.

Level of evidence: 4:

Background: Percutaneous pedicle screw (PPS) placement has become a pivotal technique in spinal surgery, increasing surgical efficiency and limiting the invasiveness of surgical procedures. The aim of this study was to analyze the accuracy of computer-assisted PPS placement with a standardized technique in the lateral decubitus position.

Methods: A retrospective review of prospectively collected data was performed on 44 consecutive patients treated between 2021 and 2023 with lateral decubitus single-position surgery. PPS placement was assessed by computed tomography scans, and breaches were graded based on the magnitude and direction of the breach. Facet joint violations were assessed. Variables collected included patient demographics, indication, intraoperative complications, operative time, fluoroscopy time, estimated blood loss, and length of stay.

Results: Forty-four patients, with 220 PPSs were identified. About 79.5% of all patients underwent anterior lumbar interbody fusion only, 13.6% underwent lateral lumbar interbody fusion only, and 6.8% received a combination of both anterior lumbar interbody fusion and lateral lumbar interbody fusion. Eleven screw breaches (5%) were identified: 10 were Grade II breaches (<2 mm), and 1 was a Grade IV breach (>4 mm). All breaches were lateral. About 63.6% involved down-side screws indicating a trend toward the laterality of breaches for down-side pedicles. When analyzing breaches by level, 1.2% of screws at L5, 13% at L4, and 11.1% at L3 demonstrated Grade II breaches. No facet joint violations were noted.

Conclusion: PPS placement utilizing computer-assisted navigation in lateral decubitus single-position surgery is both safe and accurate. An overall breach rate of 5% was found; considering a safe zone of 2 mm, only 1 screw (0.5%) demonstrated a relevant breach.

Clinical relevance: PPS placement is both safe and accurate. Breaches are rare, and when breaches do occur, they are lateral.

Level of evidence: 3:

Background: Approximately 50% of patients with congenital scoliosis will require surgical treatment to prevent further progression. Outcomes following congenital scoliosis are sparse in the literature. The purpose of this study was to identify independent risk factors associated with unplanned readmission and prolonged length of stay (LOS) in patients undergoing primary surgical treatment for congenital scoliosis.

Methods: The National Surgical Quality Improvement Database-Pediatric was queried for database years 2016-2018 to identify patients with congenital scoliosis who underwent primary posterior fusion of the spine. Patient demographics, comorbidities, and operative variables, such as the number of levels fused and the American Society of Anesthesiologists (ASA) classificaiton, were collected. Univariate and multivariate analyses of patient factors were performed to test for association with readmission within 30 days and prolonged LOS (>4 days).

Results: Eight hundred sixteen patients were identified. The average age was 11.3 ± 4.02 years, and the mean postoperative LOS was 4.64 ± 3.71 days. Forty-three patients (5.40%) were readmitted, and 73 patients (8.96%) had prolonged LOS. Independent risk factors associated with prolonged LOS included chronic lung disease (P < 0.001), presence of a tracheostomy (P < 0.001), structural central nervous system abnormality (P = 0.039), oxygen support (P < 0.001), and number of levels fused (P = 0.008). The factors independently associated with unplanned readmission were fusion to the pelvis (P = 0.004) and LOS >4 days (P = 0.008).

Conclusions: Prolonged LOS and readmission are widely being used as quality and performance metrics for hospitals. Congenital scoliosis, which often progresses rapidly resulting in significant deformity, frequently requires surgery at an earlier age than idiopathic and neuromuscular deformity. Nevertheless, 30-day outcomes for surgical intervention have not been thoroughly studied. The present study identifies risk factors for prolonged LOS and readmission, which can facilitate preoperative planning, patient/family counseling, and postoperative care.

Clinical relevance: Congenital scoliosis management poses certain challenges that may be mitigated by understanding the risk factors for adverse outcomes following primary fusion surgery.

Background: Cervical radiculopathy is a spine ailment frequently requiring surgical decompression via anterior cervical discectomy and fusion (ACDF) or posterior foraminotomy/discectomy. While endoscopic posterior foraminotomy/discectomy is gaining popularity, its financial impact remains understudied despite equivalent randomized long-term outcomes to ACDF. In a cohort of patients undergoing ACDF vs endoscopic posterior cervical foraminotomy/discectomy, we sought to compare the total cost of the surgical episode while confirming an equivalent safety profile and perioperative outcomes.

Methods: A single-center retrospective cohort study of patients with unilateral cervical radiculopathy undergoing ACDF or endoscopic cervical foraminotomy between 2018 and 2023 was undertaken. Primary outcomes included the total cost of care for the initial surgical episode (not charges or reimbursement). Perioperative variables and neurological recovery were recorded. Multivariable analysis tested age, body mass index, race, gender, insurance type, operative time, and length of stay.

Results: A total of 38 ACDF and 17 endoscopic foraminotomy/discectomy operations were performed. All patients underwent single-level surgery except for 2 two-level endoscopic decompressions. No differences were found in baseline characteristics and symptom length except for younger age (46.8 ± 9.4 vs 57.6 ± 10.3, P = 0.002) and more smokers (18.4% vs 11.8%, P = 0.043) in the ACDF group. Actual hospital costs for the episode of surgical care were markedly higher in the ACDF cohort (mean ±95% CI; $27,782 ± $2011 vs $10,103 ± $720, P < 0.001) driven by the ACDF approach (β = $17,723, P < 0.001) on multivariable analysis. On sensitivity analysis, ACDF was never cost-efficient compared with endoscopic foraminotomy, and endoscopic failure rates of 64% were required for break-even cost. ACDF was associated with significantly longer operative time (167.7 ± 22.0 vs 142.7 ± 27.4 minutes, P < 0.001) and length of stay (1.1 ± 0.5 vs 0.1 ± 0.2 days, P < 0.001). No significant difference was found regarding 90-day neurological improvement, readmission, reoperation, or complications.

Conclusion: Compared with patients treated with a single-level ACDF for unilateral cervical radiculopathy, endoscopic posterior cervical foraminotomy/discectomy can achieve a similar safety profile, pain relief, and neurological recovery at considerably less cost. These findings may help patients and surgeons revisit offering the posterior cervical foraminotomy/discectomy utilizing endoscopic techniques.

Clinical relevance: Endoscopic posterior cervical foraminotomy/discectomy offers comparable safety, pain relief, and neurological recovery to traditional methods but at a significantly lower cost.

Level of evidence: 3:

Background: Lateral lumbar interbody fusion (LLIF) is commonly used to address various lumbar pathologies. LLIF using the prone transpsoas (PTP) approach has several potential advantages, allowing simultaneous access to the anterior and posterior columns of the spine. The aim of this study was to report the 1-year outcomes of LLIF via PTP.

Methods: This is a retrospective review of 97 consecutive patients who underwent LLIF via PTP. Radiographic parameters, including lumbar-lordosis, segmental-lordosis, anterior disc height, and posterior disc height, were measured on preoperative, initial-postoperative, and 1-year postoperative imaging. Patient-reported outcomes measures, including Oswestry Disability Index, visual analog scale (VAS), pain EQ5D, and postoperative complications, were reviewed.

Results: Ninety-seven consecutive patients underwent 161 levels of LLIF. Fifty-seven percent underwent 1-level LLIF, 30% 2-level LLIF, 6% 3-level LLIF, and 7% 4-level LLIF. The most common level was L4 to L5 (35%), followed by L3 to L4 (33%), L2 to L3 (21%), and L1 to L2 (11%). Significant improvements were noted at initial and 1-year postoperative periods in lumbar-lordosis (2° ± 10°, P = 0.049; 3° ± 9°, P = 0.005), segmental-lordosis (6° ± 5°, P < 0.001; 5° ± 5°, P < 0.001), anterior disc height (8 mm ± 4 mm, P < 0.001; 7 mm ± 4 mm, P < 0.001), and posterior disc height (3 mm ± 2 mm, P < 0.001; 3 mm ± 2 mm, P < 0.001). Significant improvements were seen in Oswestry Disability Index at 6 weeks (P = 0.002), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively; pain EQ5D at 6 weeks (P < 0.001), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively; and leg and back visual analog scale at 2 weeks (P < 0.001), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively. The average length of stay was 2.5 days, and the most common complications were ipsilateral hip flexor pain (46%), weakness (59%), and contralateral hip flexor pain (29%).

Conclusion: PTP is a novel way of performing LLIF. These 1-year data support that PTP is an effective, safe, and viable approach with similar patient-reported outcome measures and complications profiles as LLIF performed in the lateral decubitus position.

Level of evidence: 4: