Spine Journal最新文献

Background: Over the past decade, the prevalence of obesity has risen in the United States, in parallel with the demand for anterior cervical discectomy with fusion (ACDF). Prior studies have evaluated the role of obesity classes in cervical spine surgery in smaller patient populations. We aimed to evaluate any potential correlation to a national population sample by utilizing a large multicenter database.

Purpose: The purpose of this study was to analyze obesity level's influence on perioperative complication rates in patients undergoing ACDF.

Study design/setting: A retrospective cohort, large multicenter database study.

Patient sample: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify patients who had undergone an elective ACDF procedure between 2011 and 2020 using Current Procedural Terminology (CPT) code 22551.

Outcome measures: Medical and surgical complications within thirty days of operation.

Methods: Patients were categorized into four BMI groups: nonobese (BMI 18.5-29.9 kg/m²), obese class I (BMI 30-34.9 kg/m²), obese class II (BMI 35-39.9 kg/m²), and obese class III (BMI ≥40 kg/m²). A univariate analysis conducted for demographic variables and preoperative comorbidities identified age, sex, race, smoking status, hypertension requiring medication, diabetes, history of congestive heart failure, history of bleeding disorder, and chronic obstructive pulmonary disease as risk factors. Chi-square test was used to compare incidence of complications among groups. A multivariable logistic regression analysis was subsequently performed to adjust for these preoperative risk factors and compare obesity classes I-III to nonobese patients.

Results: About 64,718 patients were identified of whom 33,365 were nonobese, 17,190 were obese class I, 8,608 were obese class II, and 5,555 were obese class III. Obese classes I-III patients had a higher incidence of surgical site infections (0. 33%, 0.36%, 0.41%, vs 0.24%, p=.039) and pulmonary embolism (PE) (0.25%, 0.31, 0.29 vs 0.15%, p=.003). Obese classes I-III had a lower incidence of blood transfusion (0.23%, 0.17%, 0.27% vs 0.4%, p<.001) obese class I, obese class II, and obese class III independently increased the risk for PE (OR: 1.716, 95% CI (1.129-2.599); OR: 2.213, 95% CI (1.349-3.559); OR: 2.207, 95% CI (1.190--3.892), respectively).

Conclusions: Risk for postoperative PEs after an ACDF was significantly higher for obese classes I-III compared to nonobese patients. These findings may further support the use of additional prophylaxis measures and precaution in the perioperative setting.

Background context: Expandable transforaminal lumbar interbody fusion (TLIF) cages have become popular in recent years due to anticipated advantages of increased disc height, improved segmental lordosis, and ease of implantation. Such benefits have not been conclusively demonstrated in the literature.

Purpose: To determine whether expandable cages increase disc height and segmental lordosis in a durable way following surgery and compare complication profiles between cage types.

Study design/setting: Retrospective cohort study conducted within a large academic health system involving 31 different spine surgeons.

Patient sample: Adults undergoing single-level TLIF for an indication other than infection, tumor, trauma, or revision instrumentation from 2021 to 2023.

Outcome measures: Our primary outcomes were changes in segmental disc height, segmental lordosis, and L4-S1 lordosis at 2 weeks, 6 months, and 1 year following surgery relative to baseline. Our secondary outcomes were frequencies of incidental durotomies, surgical site infections, readmissions, death, subsidence, and unplanned return to the operating room.

Methods: Radiographic variables were collected from our institutional imaging registry. Demographics and surgical characteristics were abstracted from chart review. Generalized linear modeling was used for each primary outcome, with cage type (expandable vs static) as our primary predictor and age, biologic sex, race, CCI, year of surgery, duration of surgery, invasiveness of surgery, surgeon specialty (Orthopedics vs Neurosurgery), and level of surgery as covariates.

Results: Our cohort consisted of 417 patients with a mean age of 62. Static cages were used in 306 patients and expandable cages in 111. Expandable cages were associated with increased changes in disc height relative to static cages at 2 weeks (1.1 mm [0.2-1.9]; p=.01) and 6 months (1.2 mm [0.2-2.3]; p=.02) following surgery, but differences were no longer significant at 1 year (0.4 mm [-0.9-1.8]; p=.4). Expandable cages were found to subside more commonly than static cages (14.1% vs 6.6%; p=.04). No significant differences between cage types were identified in lordotic parameters at any timepoint (p=0.25 to p=0.97).

Conclusions: Expandable cages were associated with an initial increase in disc height relative to static cages, but this difference diminished with the first year of surgery, likely due to a higher rate of subsidence within the expandable cohort.

Background context: A deep learning (DL) model for degenerative cervical spondylosis on MRI could enhance reporting consistency and efficiency, addressing a significant global health issue.

Purpose: Create a DL model to detect and classify cervical cord signal abnormalities, spinal canal and neural foraminal stenosis.

Study design/setting: Retrospective study conducted from January 2013 to July 2021, excluding cases with instrumentation.

Patient sample: Overall, 504 MRI cervical spines were analyzed (504 patients, mean=58 years±13.7[SD]; 202 women) with 454 for training (90%) and 50 (10%) for internal testing. In addition, 100 MRI cervical spines were available for external testing (100 patients, mean=60 years±13.0[SD];26 women).

Outcome measures: Automated detection and classification of spinal canal stenosis, neural foraminal stenosis, and cord signal abnormality using the DL model. Recall(%), inter-rater agreement (Gwet's kappa), sensitivity, and specificity were calculated.

Methods: Utilizing axial T2-weighted gradient echo and sagittal T2-weighted images, a transformer-based DL model was trained on data labeled by an experienced musculoskeletal radiologist (12 years of experience). Internal testing involved data labeled in consensus by 2 musculoskeletal radiologists (reference standard, both with 12-years-experience), 2 subspecialist radiologists, and 2 in-training radiologists. External testing was performed.

Results: The DL model exhibited substantial agreement surpassing all readers in all classes for spinal canal (κ=0.78, p<.001 vs κ range=0.57-0.70 for readers) and neural foraminal stenosis (κ=0.80, p<.001 vs κ range=0.63-0.69 for readers) classification. The DL model's recall for cord signal abnormality (92.3%) was similar to all readers (range: 92.3-100.0%). Nearly perfect agreement was demonstrated for binary classification (grades 0/1 vs 2/3) (κ=0.95, p<.001 for spinal canal; κ=0.90, p<.001 for neural foramina). External testing showed substantial agreement using all classes (κ=0.76, p<.001 for spinal canal; κ=0.66, p<.001 for neural foramina) and high recall for cord signal abnormality (91.9%). The DL model demonstrated high sensitivities (range:83.7%-92.4%) and specificities (range:87.8%-98.3%) on both internal and external datasets for spinal canal and neural foramina classification.

Conclusions: Our DL model for degenerative cervical spondylosis on MRI showed good performance, demonstrating substantial agreement with the reference standard. This tool could assist radiologists in improving the efficiency and consistency of MRI cervical spondylosis assessments in clinical practice.

Background context: Randomized trials have demonstrated the superiority of intraosseous basivertebral nerve ablation (BVNA) compared with sham and standard care in terms of improvements in pain, disability, and health-related quality of life in patients with vertebrogenic chronic low back pain (cLBP).

Purpose: To assess the cost effectiveness of BVNA in patients with vertebrogenic cLBP compared to standard care alone.

Study design/setting: A model-based economic analysis.

Patient sample: Base case analysis used INTRACEPT, a randomized trial comparing BVNA with standard care in 140 patients with vertebrogenic cLBP, recruited from 23 sites across the United States, with a follow-up, up to 5 years. Scenario analyses compared data from the Surgical Multicenter Assessment of Radiofrequency Ablation for the Treatment of Vertebrogenic Back Pain (SMART) randomized trial against a sham control, and a single-arm study.

Outcome measures: Costs and quality-adjusted life years (QALYs) were calculated to determine the incremental cost-effectiveness ratio (ICER).

Methods: A cost-effectiveness model was built in Microsoft Excel to evaluate the costs and health outcomes of patients undergoing BVNA using the Intracept Procedure (Relievant Medsystems) to treat vertebrogenic cLBP from a US payor perspective. Alternative scenario sensitivity analyses and probabilistic sensitivity analyses were conducted to assess the robustness of the model results. QALYs were discounted at 3.0% per year.

Results: Base case analysis showed that BVNA relative to standard care alone was a cost-effective strategy for the management of patients with vertebrogenic cLBP, with an ICER of US$11,376 per QALY at a 5-year time horizon from introduction of the procedure. Modeling demonstrated a >99% probability that this was cost effective in the US, based on a willingness-to-pay threshold of US$100,000 to US$150,000. Various sensitivity and scenario analyses produced ICERs that all remained below this threshold.

Conclusions: BVNA with the Intracept Procedure offers patients with vertebrogenic cLBP, clinicians, and healthcare systems a cost-effective treatment compared to standard care alone.

Background context: Lumbar decompression and lumbar fusion are effective methods of treating spinal compressive pathologies refractory to conservative management. These surgeries are typically used to treat different spinal problems, but there is a growing body of literature investigating the outcomes of either approach for patients with lumbar degenerative spondylolisthesis and stenosis. Different operations are associated with different risks and different potential needs for reoperation. Patient acceptance of reoperation rates after spinal surgery is currently not well understood.

Purpose: The purpose of this study is to identify patient tolerance for reoperation rates following lumbar decompression and lumbar fusion surgery.

Design: A qualitative and quantitative survey intended to capture information on patient preferences was administered.

Patient sample: Written informed consent was obtained from patients presenting to 2 spinal clinics.

Outcome measures: Patients were asked their threshold tolerance for reoperation rates in the context of choosing a smaller (decompression) versus larger (fusion) spinal surgery.

Methods: A survey was administered to patients at 2 spinal clinics-1 surgical and 1 nonsurgical. A consecutive series of new patients over multiple clinic days who agreed to participate in the study and filled out the survey are reported on here. Patients were asked to assess, contemplating a problem that could either be treated with lumbar decompression or lumbar fusion, the level at which 1) the likelihood that needing a repeat surgery within 3 to 5 years would change their mind about choosing the decompression operation and cause them to choose the fusion operation and then 2) the likelihood of needing a repeat surgery within 3 to 5 years that would be acceptable to them after the fusion operation. The distribution of patient responses was assessed with histograms and descriptive statistics.

Results: Ninety patients were surveyed, and of these, 73 patients (81.1%) returned fully completed questionnaires. The median reoperation acceptance rates after a decompression was <60%, while the median acceptable revision rate when contemplating the fusion surgery was 10%.

Conclusions: Patient acceptance for the potential need for revision surgery is higher when considering a decompression compared to a fusion operation. Reoperation risk rates along with the magnitude of the surgical intervention are important considerations in determining patients' surgical preferences. Understanding patient preferences and risk tolerances can aid clinicians in shared decision-making, potentially improving patient satisfaction and outcomes in the several lumbar pathologies which can be ameliorated with either decompression or fusion.