Seminars in Spine Surgery最新文献

For appropriately selected patients with cervical radiculopathy and myelopathy, 2-level cervical disc arthroplasty (CDA) is at least statically non-inferior vs 2-level anterior cervical discectomy and fusion (ACDF) in the short term and statistically superior with long term follow up.

Background

Efforts are underway to shift an increasing number of procedures to outpatient procedures. The literature has demonstrated high rates of safety, cost savings and patient satisfaction for various spine procedures performed in the outpatient setting. Cervical Disc Arthroplasty (CDA) has become an acceptable surgical treatment option for cervical myelopathy and or radiculopathy. While this procedure has been shown to be safe when performed in an inpatient setting, the safety of performing multilevel CDA in the outpatient setting requires careful assessment.

Methods and Results

We searched the Pubmed database using following search keywords: “cervical disc replacement,” “cervical disc arthroplasty,” “multilevel,” “outpatient,” “ambulatory.” Four retrospective cohort studies and one meta-analysis were identified and relevant to the topic. The literature was critically evaluated.

Conclusion

Multilevel CDA can be safely performed in the outpatient setting, with lower complication rates, shorter operating times, and similar readmission and reoperation rates compared with inpatient CDA. When choosing to perform this procedure in the ambulatory setting each surgeon should consider their own skill set and familiarity with CDA. While no evidence-based guidelines exist regarding which patients are optimal candidates to perform this procedure on in the outpatient setting, careful patient selection is important. Further prospective randomized studies with larger sample sizes are needed to generate evidence-based protocols for patient selection in order to optimize outcomes and the safety of performing multilevel cervical disc arthroplasty in the outpatient setting.

Level of Evidence

V

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Recent years have seen significant advancements in the implementation of computer-assisted surgery in spine. Enabling technologies like robots and navigation have been refined to compliment the field's shift towards minimally invasive techniques and to fit more seamlessly into the existing workflow. Robotic-surgery and navigation in deformity can be particularly helpful in cases where the severe curves of the spinal column or the abnormal pedicle anatomy make pedicle screw placement challenging with the use of traditional anatomic landmarks. Furthermore, the ability to pre-plan patient specific rods has opened the door for greater precision in rod contouring. Drawbacks of robotic-assisted surgery include the steep upfront cost, the need for additional staff and training and the lack of tactile feedback. This review will discuss the current state of navigation and robotics, with a specific focus on their applications to deformity surgery.

Adult spinal deformity (ASD) is common and has a significant impact on health-related quality of life. Identification of risk factors for perioperative complications in ASD surgery is a priority for ensuring cost-effectiveness. Preoperative optimization of significant patient risk factors can benefit patient outcome. Establishing benchmarks for expected complications based upon known risk factors is an important goal for future studies on quality of care.

Spinal deformity can occur at any age from either congenital or acquired etiologies leading to coronal or sagittal imbalance. Regardless of etiology, deformity and imbalance lead to both functional and psychological impairment. For fixed deformities, osteotomies provide a powerful tool for realignment. In this review, the clinical and radiographic indications for osteotomies are outlined. Along with indications, specific considerations with regard to planning and executing Smith Peterson Osteotomies, Pedicle Subtraction Osteotomies, and Vertebral Column Resections will be detailed.

Artificial intelligence (AI) refers to computer-based technologies that seek to replicate human intelligence by allowing software to make decisions and provide recommendations based on the analysis of large datasets. Present applications of AI in spine deformity surgery have focused on improving safety and efficacy by automating, standardizing, and facilitating data guided approaches. In this review, the authors focus on 3 types of AI technology: 1) Surgical classification, 2) individualized outcome prediction, and 3) surgical planning. It is anticipated that AI will become an essential part of the preoperative, intraoperative, and postoperative phases of adult spinal deformity surgery.

Adult spinal deformity is a complex pathology requiring careful consideration of patient-related parameters, comorbidities, overall clinical and radiographic alignment to determine individualized treatment. There has been an advent of interbody fusion techniques, advancements in fusion devices, and various approaches to insert spacers to achieve optimal sagittal and coronal balance. However, there is lack of clear evidence to support superiority of one technique versus others with minor differences in fusion outcomes across techniques and ability to correct deformity parameters. Ultimately, the decision is based on surgeon familiarity with techniques, fusion devices, and approaches.

Proximal junctional kyphosis (PJK) is a complication following surgical treatment for adult spinal deformity. Most PJK occurs early within the postoperative period with reported rates ranging from 20% to 40%. Proximal junctional failure is a more severe form of PJK. Many risk factors have been identified suggesting multifactorial causation. Methods to prevent PJK include surgical techniques, reducing the rigidity of the construct, preserving surrounding tissue, constructing, and adhering to age-adjusted alignment goals, vertebroplasty, ligament augmentation, and teriparatide. Revision surgery sometimes results in recurrent PJK and is associated with substantial surgical and financial burdens which highlight the importance of prevention strategies and continued study.