International Journal of Spine Surgery最新文献

Background: Transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) are 2 surgical approaches for achieving arthrodesis and restoring alignment. Novel expandable interbody technology may provide an advantage for TLIF procedures. Limited comparative data exist for LLIF with static interbody cages and TLIF with expandable interbody cages. This study aimed to examine the differences in radiographic and clinical outcomes between these procedures.

Methods: This is a retrospective analysis comparing single-level LLIF with static interbody cages and TLIFs with expandable interbody cages performed at our institution. Demographic, operative, radiographic, and patient-reported data were collected. Upright radiographic images were used to assess pre- and postoperative radiographic parameters. Patient-reported outcomes were assessed using the Oswestry Disability Index and minimal clinically important difference (MCID).

Results: A total of 163 patients, 75 in the TLIF group and 88 in the LLIF group, were included in this study (mean age: 63.3 ± 12.0 years; 54.8% women). Mean follow-up was 306.2 ± 161.4 days for the TLIF group and 502.3 ± 308.0 days for the LLIF group (P = 0.021). Both groups demonstrated significant improvements in lumbar lordosis, neuroforaminal height, and disc angle (P < 0.01). LLIF patients demonstrated a significant correction of segmental lordosis (P < 0.01), whereas TLIF patients did not (P > 0.05). Patients in the LLIF group demonstrated a greater increase in segmental lordosis (P = 0.005) and neuroforaminal height (P < 0.001) in comparison to those in the TLIF group. In addition, a modest but significant advantage was observed in overall lumbar lordosis in LLIF (P = 0.049). A significantly greater proportion of patients who underwent LLIF achieved an MCID (80.6% vs 66.7%, P = 0.041). The LLIF group had significantly fewer cases of radiographic subsidence than TLIF (10.2% vs 44%, P < 0.001). TLIF was the only significant predictor of subsidence (OR = 4.630 [1.493-14.364], P < 0.001).

Conclusions: LLIF resulted in greater restoration of neuroforaminal height and segmental lordosis, as well as a modest advantage in lumbar lordosis. In addition, a significantly greater proportion of patients who underwent LLIF achieved MCID. TLIF was a significant predictor of subsidence when controlling for confounding factors.

Clinical relevance: With the advent of expandable interbodies in TLIF, our findings demonstrate suboptimal radiographic and patient-reported outcomes in comparison to LLIF with static interbody cages. Surgeons should exercise caution regarding utilizing expandable interbody technology during TLIF.

Level of evidence: 3:

Background: Minimally invasive surgical techniques have the potential to decrease the morbidity associated with traditional open surgery. However, surgeons may hesitate to implement minimally invasive techniques in their practice due to limited direct visualization and an arduous learning curve. Minimally invasive spine surgery requires precise docking of tubular or endoscopic retractors, which is difficult because without direct visualization of surrounding structures, surgeons may find themselves unable to orient themselves. Finding consistent and reproducible radiographic landmarks may decrease barriers to adoption of MISS techniques. Abd-El-Barr's point is a novel radiographic landmark that is identified on lateral fluoroscopy to help with docking for both tubular and endoscopic spine procedures. The landmark is hypothesized to correlate closely with the caudal aspect of the lamina and serve as a reliable docking target.

Objective: To validate Abd-El-Barr's point as a radiographic landmark for safe, reliable, and consistent docking in minimally invasive lumbar surgery.

Methods: A cadaveric study design: fluoroscopic localization of Abd-El-Barr's point was performed bilaterally from L1 to S1 using a sharply pointed instrument that was inserted slightly into the lamina to mark it with a hole, followed by dissection to measure the distance between the mark and the caudal lamina.

Results: A total of 5 cadaveric specimen data were analyzed. The mean distance from Abd-El-Barr's point to the caudal aspect of the lamina across all measured levels and sides was 5.3 mm (bilaterally).

Conclusion: Abd-El-Barr's point is a reliable radiographic landmark that provides accurate and safe docking during minimally invasive lumbar decompression. Validated through anatomical dissection, it has the potential to standardize docking, provide efficient surgical workflow, and reduce variability across various surgeon experience levels.

Clinical relevance: Using this landmark as a docking point, it is hoped that surgeons can make mininally invasive spine surgery, whether tubular or endoscopic, safer and more efficient, thus helping patients recover faster.

Level of evidence: 5:

Background: Travel distance can serve as an objective, behavioral measure of patient preference in health care. Endoscopic spine surgery is the least invasive surgical option for treating spinal pathology, yet access is limited due to the relatively small number of trained surgeons. This study evaluates travel patterns of patients seeking care at the Endoscopic Spine Institute of New York, a specialized center staffed by 3 fellowship-trained endoscopic spine surgeons.

Methods: We conducted a retrospective analysis of the first 100 consecutive patients undergoing endoscopic spine surgery at Endoscopic Spine Institute of New York. The primary objective was to quantify patient travel distance as a behavioral proxy for preference for specialized, minimally invasive care. Secondary objectives were to characterize spinal pathology, determine revision surgery frequency, and compare travel distances by pathology type and revision status. Travel distances were calculated as straight-line distances from the patient's city of residence to the institute. Descriptive and comparative statistics were performed.

Results: The mean travel distance was 308.4 miles (SD: 494.1), with patients traveling from multiple states and internationally. Surgical interventions included cervical (20%), thoracic (18%), and lumbar (62%) pathologies. Revision surgeries accounted for 29% of cases. Travel distance was significantly greater for revision cases compared with primary cases (P < 0.05). Lumbar pathology cases were associated with slightly longer travel distances compared with cervical and thoracic cases, though differences were not statistically significant.

Conclusions: Patients are willing to travel substantial distances to access specialized, minimally invasive spine surgery. Travel distance serves as a behavioral measure of patient preference, distinct from conventional quality metrics, providing insight into patient priorities in health care utilization and informing the centralization of specialized surgical services.

Clinical relevance: Understanding how far patients will travel for endoscopic spine surgery provides insight into the growing demand for minimally invasive approaches and the regionalization of specialized spine care. This information can help guide resource allocation, referral patterns, and the develpment of centers of excellence.

Level of evidience: 4.

Background: Thoracolumbar spine surgical interventions are often complicated by cage subsidence and screw loosening. The main risk factor for such conditions is poor bone mineral density. Vertebral bone quality (VBQ) and endplate bone quality (EBQ) scores are novel radiation-free magnetic resonance imaging (MRI)-based tools that have shown promise in predicting such conditions. This meta-analysis sought to assess the predictive value of VBQ and EBQ scores in identifying the risk of screw loosening and cage subsidence following thoracolumbar spine surgery.

Methods: PubMed, Scopus, Cochrane Library, and Web of Science databases were searched systematically to retrieve articles assessing the predictive potential of VBQ and EBQ scores for evaluating screw loosening and cage subsidence following thoracolumbar spine surgery. The quality assessment of diagnostic accuracy studies 2 (QUADAS-2) tool was utilized to assess the quality of diagnostic accuracy studies. Data were synthesized using a random-effects model, assessing for potential heterogeneity among the included studies.

Results: 19 studies involving 2768 participants met the inclusion criteria. The cage subsidence and screw loosening groups showed significantly higher VBQ scores than the control group. The cage subsidence group showed significantly higher EBQ scores than the control group.

Conclusions: MRI-based VBQ and EBQ scores demonstrate efficacy as predictive indicators of screw loosening and cage subsidence following surgical procedures for thoracolumbar degenerative disease. Consequently, preoperative assessment of bone quality is imperative for optimizing surgical outcomes.

Level of evidence: 1:

Background: Cervical disc arthroplasty (CDA) represents a promising alternative to anterior cervical discectomy and fusion for the treatment of symptomatic degenerative disc disease in appropriately selected patients. It offers the potential benefits of motion preservation and reduced adjacent segment degeneration. However, like any surgical procedure, CDA has associated risks and complications. Among these, postoperative osteolysis, although rare, warrants further investigation to fully understand its incidence, causes, and optimal management strategies. This study's purpose is to elucidate the current incidence of osteolysis following CDA.

Methods: The Manufacturer and User Facility Device Experience (MAUDE) database was queried using the "Brand Name" function for: "Mobi C," "Mobi-C," "Prodisc -C," "Prodisc C," "Bryan," "PCM," "Secure-C," "Secure C," "Prestige," "M6," and "Simplify" from 1 January 2005 to 30 September 2024. Search results were further queried for the word "osteolysis." Osteolysis percentage was calculated as a proportion of a total number of valid reports. The findings from this study were compared with published literature.

Results: The total number of osteolysis events reported in the MAUDE database for each disc was 2 Mobi-C, 1 Prodisc-C, 3 Bryan, 0 PCM, 0 Secure-C, 2 Prestige, 138 M6, and 16 Simplify. The highest rate of osteolysis was found in the M6 (36.2%) and Simplify discs (25.8%). Results from the MAUDE database were consistent with previously published literature.

Conclusion: While acknowledging the limitations of the MAUDE database, the data presented give rise to substantial concerns regarding the association of osteolysis with the M6 implant. While the reports on the Simplify disc are recent, the current findings indicate a necessity for careful monitoring. Although surgeon participation in the MAUDE database is optional, it is imperative to promptly report any issues with recent technology to ensure fellow surgeons and the public are well informed.

Clinical relevance: This report brings to light a clinical concern of osteolysis in cervical TDR surgeries that was not previously discussed. Using these findings, surgeons can look out for signs of osteolysis in earlier follow-up to provide early treatment.

Level of evidence: 4:

Background: Randomized controlled trials (RCTs) are widely treated as the evidentiary gold standard in spine surgery. Yet their methodological control often underrepresents surgical variability, patient heterogeneity, learning-curve effects, and the iterative nature of procedural innovation, widening the gap between research outputs and real-world practice.

Objective: To propose a hybrid evidence framework that preserves the strengths of RCTs while elevating hypothesis-driven observational research and surgeon-led insights to inform clinically relevant standards, guidelines, and policy in spine care.

Approach: This perspective synthesizes conceptual and methodological arguments, drawing on examples from surgical innovation pathways and on evaluative tools (e.g., GRADE and Rasch-based methodologies). It examines how case series, prospective cohorts, registries, and conceptual models-when rigorously designed and transparently reported-can complement RCTs. Key insights include:Practicing surgeons are uniquely positioned to detect emerging techniques, define phenotypes, and iteratively refine indications through case series and cohort observations.Applying structured appraisal frameworks (GRADE) and measurement models (Rasch) can enhance the validity, comparability, and policy-readiness of observational data.Professional societies should formalize forums and pathways for early-stage innovation, coupled with standards for data quality, outcome harmonization, and ethical oversight.A hybrid model-integrating RCTs with high-quality real-world evidence-provides a more agile and clinically responsive basis for guideline development and payer/regulatory decisions.

Recommendations: Establish society-endorsed research dissemination; guideline development; professional collaboration with core outcome sets; incentivize transparent, prospective observational designs; adopt GRADE for guideline synthesis that includes non-randomized data; and deploy Rasch-informed assessment where appropriate to improve measurement precision.

Conclusions: A recalibrated, hybrid evidence ecosystem-combining RCT rigor with systematically evaluated observational science-can better capture the realities of spine surgery, accelerate safe innovation, and keep patient needs at the center of evidence generation.

Background: Traumatic cervical spine fractures with dislocation are often caused by high-energy injuries, typically from motor vehicle accidents. Hangman's fracture constitutes 4% to 5% of cervical fractures and is usually accompanied by anteroposterior dislocation and/or neurological deficits. However, lateral vertebral dislocation without neurological symptoms is extremely rare. We present a case of C2 to C3 lateral dislocation with C3 fracture in a patient who only reported neck pain and limited mobility.

Methods: This study reports a case of a 42-year-old woman who presented with neck pain after a traffic accident. The patient remained fully conscious throughout the incident, and the patient did not experience any loss of consciousness. Preoperative imaging clearly revealed a split fracture of the right C3 body-pedicle junction and the right vertebral plate, along with anterolateral dislocation of the C2 vertebral body. After a closed reduction of the affected segment, an anterior cervical discectomy and fusion (ACDF) was performed to restore segmental stability of the C2 to C3 level.

Results: A satisfied closed reduction was achieved after a fixed cervical traction. An ACDF was performed to successfully restore the segmental stability of the C2 to C3 level without surgical-related complications. The patient reported alleviation of neck pain (visual analog scale score decreased from 7 preoperatively to 2 postoperatively). Postoperative imaging revealed a satisfactory reduction of fracture-dislocation. At a 2-month follow-up after discharge, the patient had returned to work.

Conclusion: This case demonstrates the feasibility of ACDF as a standalone approach for treating single-stage cervical fractures with associated lateral dislocation following precise and sustained traction reduction. Compared with posterior or combined approaches, the anterior-only technique offers significant advantages, providing a minimally invasive alternative for the management of complex cervical spine trauma.

Clnical relevance: This case highlights that prompt recognition and surgical stabilization of C3 vertebral body fracture with C2-C3 spondylolisthesis can prevent neurological deterioration and improve functional recovery. It provides practical evidence to support early surgical decision-making in rare but severe cervical spine injuries.

Level of evidence: 5:

Background: Cervical spondylodiscitis is a rare condition that easily causes neurological deficits. This study aimed to evaluate the safety and efficacy of anterior debridement and fusion (ADF) with plating for cervical spondylodiscitis.

Method: We retrospectively analyzed the medical records of 24 patients who underwent ADF with plating and antibiotics for cervical spondylodiscitis at our institution from June 2005 to June 2023. The neurologic status was evaluated using the Japanese Orthopedic Association scoring system and Hirabayashi recovery rate. Radiological parameters were assessed, including C2 to C7 angle, angle and height of the fused segment, and fusion status.

Results: Mean follow-up time was 50.1 (range 12-162) months. The Japanese Orthopedic Association score increased from 13.2 preoperatively to 15.8 at the final follow-up, with a mean Hirabayashi recovery rate of 79.3%. Recovery outcomes were excellent in 17 (70.8%) cases, good in 3 (12.5%), acceptable in 1 (4.2%), and unchanged in 3 (12.5%). Postoperative C2 to C7 angles and the angle and height of the fused segment were significantly improved compared with preoperative measures. However, height loss of the fused segments occurred in all cases during the follow-up period, especially in ADF with titanium mesh. One patient received revision with posterior fixation because of a pathological fracture in the cephalic vertebral body of the fused segment in the early postoperative phase. Infection resolution and solid bony fusion were achieved in all patients.

Conclusion: ADF with plating can achieve satisfactory clinical outcomes for cervical spondylodiscitis.

Clinical relevance: Poor bone quality secondary to infection, excessive intraoperative cervical distraction, and the choice of fusion material may be associated with the loss of fused segmental height and angle, as well as potential instrumentation failure, after ADF with plating.

Level of evidence: 4: