Seminars in Spine Surgery最新文献

Integrating functional evaluation of adult spinal deformity (ASD) patients is an integral component of clinical evaluation. While the spine community has acknowledged its significance, functional assessment is often absent in academic research due to standardization challenges. This review aims to outline diverse modalities for ASD functional assessment, ranging from simple to complex methods available only in dedicated laboratories. Addressing this gap will enhance our understanding of ASD's functional impact and guides improved research and patient care.

Operative treatment for adult spinal deformity (ASD) commonly involves long posterior instrumented fusions with primary rods spanning from the base of the construct to the upper instrumented vertebra. Over the past decade, additional supplemental rods have been increasingly utilized to bolster the primary instrumentation and mitigate risk of primary rod fracture/pseudarthrosis at areas of high biomechanical stress (e.g., 3-column osteotomy [3CO], multiple posterior column osteotomies [PCOs], lumbosacral junction). Supplemental rods for 3CO include satellite rods (4-rod technique with 2 deeply recessed short rods independently attached to pedicle screws across the 3CO), accessory rods (attached to primary rods via side-to-side connectors), and delta rods (accessory rods contoured only at the proximal and distal attachments to primary rods). Utilizing more than 4 rods across a 3CO may increase posterior construct stability; however, diminished load transfer to the anterior vertebral column may increase risk of nonunion and instrumentation failure. Similar supplemental rod constructs can be utilized to support multiple PCOs and/or the lumbosacral junction. We generally recommend using bilateral accessory rods for a total of 4 rods to support the lumbosacral junction (2 accessory rods and 2 primary rods). The novel “kickstand rod” can help facilitate coronal correction and/or function as an accessory rod distally anchored to an independent iliac screw; appropriate nomenclature is “iliac accessory rod” in cases without true kickstand distraction. In this narrative review, we aim to (1) provide a brief historical overview of supplemental rod constructs, (2) describe current indications for supplemental rods, and (3) report our results from a longitudinal analysis (2008–2020) of supplemental rod constructs used by International Spine Study Group (ISSG) surgeons.

Concepts regarding sagittal plane alignment in adult spinal deformity (ASD) surgery are evolving in the pursuit of individualized care with personalized targets. We have moved past simple targets of mismatch between lumbar lordosis and pelvic incidence, as these ignore the distribution, and the subsequent shape, of lumbar lordosis. Several classification systems and alignment strategies exist, with some proposing alignment to “normal” while others seek age-appropriate spinal alignment. While differences exist, the importance of the pelvic incidence as a fixed parameter from which one may build the spine is common to all theories. The purpose of this narrative review is to summarize the literature regarding the current concepts behind spinal alignment theories and the data supporting these theories.

The purpose of this paper is to discuss development of patient-reported outcomes measures (PROMs) and attributes of PROMs used in adult spinal deformity (ASD) practices. Commonly used PROMs in ASD can be dived into general measures of health (Short Form-36, EuroQol, and PROMIS) and spine-specific measures of health (Oswestry Disability Index and Scoliosis Research Society-22r). Threshold values, including minimum clinically important difference (MCID) and substantial clinical benefit (SCB), may be helpful in interpreting changes in PROM scores. Despite their limitations, PROMs are important tools in a modern spinal deformity practice and will be increasingly important as we move toward a value-based healthcare system.

With the increasing prevalence of hip-spine syndrome, it is crucial to appreciate the biomechanical interplay between hip and spine degeneration or deformity and the consequential compensatory changes. Adult spinal deformity (ASD) patients are uniquely affected as a concomitant hip osteoarthritis (HOA) may impact their baseline and postoperative sagittal alignment. Similarly, severe HOA patients undergoing total hip replacement with concomitant spinal deformity may require personalized surgical planning for the placement of their acetabular component. If surgical intervention is required in ASD patients, the authors’ preferred sequence is to perform spinal realignment first. If major realignment is not planned, we recommend treating the most symptomatic pathology. Further investigation is required to evaluate the impact of hip pathology on radiographic and patient-reported outcomes following ASD surgery and vice versa.

Proximal junctional kyphosis (PJK) is a common post-operative phenomenon among patients with adult spinal deformity. In a subset of cases, PJK can progress to proximal junctional failure (PJF) which is PJK with structural failure and usually requires revision surgery. Many patient and surgical risk factors for PJK have been identified in an attempt to predict and prevent the development of PJF. In this paper, we summarize the existing literature regarding the risk factors for and treatment of PJK and PJF. We further provide evidence guided treatment recommendations for surgeons managing spinal deformity patients.

Background

Oblique lateral interbody fusion (OLIF) is an effective surgical treatment for scoliosis, degenerative disc disease, and spondylolisthesis and is associated with a reported incidence of infection between 0.0 and 4.4%. Recent studies have reported perioperative complications associated with OLIF surgery including surgical site infections, but none described the management of these in detail. The present study describes the management of infections following OLIF surgery.

Methods

We performed a retrospective study of all adult patients (≥18 y-o) who had surgical site infection after undergoing OLIF surgery in combination with posterior long segment spinal fusion for degenerative scoliosis correction in a single spine unit from January 2013 to December 2020 with a minimal two-year follow-up.

Results

Among thirty patients who underwent OLIF surgery in combination with posterior long segment spinal fusion for degenerative scoliosis correction, four patients (2 males, 2 females, mean age: 64.5 years) suffered from surgical site infection. All patients had radiological signs of deep surgical site infection and had positive bacterial culture results. Patients were treated with revision surgery combined with antimicrobial therapy. At follow up all four showed major improvement in pain, ambulatory status, and infection status.

Conclusion

We showed that aggressive surgical debridement, drainage, and irrigation combined with 6-8 weeks of intravenous antibiotics; followed by long-term oral antibiotics in most severe cases; are effective for the management of surgical site infections associated with OLIF surgery. Retention of stable hardware and replacement of unstable fixation in cases of spinal instability and progressive deformity is an adequate strategy.

Technological advancements in the treatment of lumbar spondylolisthesis aim to match the efficacy of conventional methods with reduced surgical morbidity and faster postoperative recovery. Endoscopic surgery, anesthesia enabling awake surgery, enhanced recovery after surgery protocols, and activity monitoring are prime examples of these technologies. Endoscopy for decompression and interbody fusion decreases soft tissue disruption and operative time. Awake surgery eliminates many of the harmful effects associated with general anesthesia. Enhanced recovery after surgery protocols optimizes patient factors in the preoperative, intraoperative, and postoperative periods to reduce pain, reduce morbidity, and speed postoperative recovery. Activity monitoring provides an objective, reliable, and reproducible method of outcome assessment. This chapter reviews each of these innovations, and the profound impact each will have on the treatment of degenerative spine diseases in years to come.

While lumbar spondylolisthesis is one of the most common conditions cared for by spine surgeons, there remains limited evidence guiding its diagnosis, classification, and management. The diversity in its underlying causes, clinical manifestations, and spinal anatomical variations poses a particular challenge in making informed clinical decisions. Machine learning (ML) methods offer novel opportunities to address these challenges by leveraging data-driven approaches. This chapter provides a comprehensive overview of the potential applications of ML in the field of lumbar spondylolisthesis. ML is a branch of artificial intelligence that employs statistical algorithms to mimic human learning behavior. In the domain of diagnosis, ML methods have been applied to detect spondylolisthesis using medical imaging. In particular, deep learning models have shown high accuracy in detecting spondylolisthesis from X-rays and MRIs, suggesting ML's potential as a diagnostic tool. Additionally, ML can aid in distinguishing spondylolisthesis grades and subtypes. Although automatic grading remains challenging, recent advances suggest that emerging ML techniques may be effective in classifying spondylolisthesis subtypes and guiding subsequent decision-making. Already, ML has been used to predict spondylolisthesis treatment outcomes, such as functional recovery and hospital length of stay. While promising, most of these prediction studies used "shallow" ML techniques, suggesting that further gains may be realized by applying deep learning methods to larger, complex datasets. In conclusion, ML advances hold promise in spondylolisthesis diagnosis, classification, and outcome prediction. In the future, these methods may help support more personalized and effective management of lumbar spondylolisthesis.