Spine Journal最新文献

Background context: Endoscopic spine surgery (ESS) is rapidly emerging as a viable minimally invasive technique to successfully treat symptomatic degenerative spinal conditions. Widespread adoption has been limited in part due to the learning curve.

Purpose: To systematically review the learning curve for uniportal and biportal ESS and compare the 2 techniques.

Study design/setting: A systematic review based on PRISMA guidelines.

Patient sample: About 29 studies were included with 18 studies investigating uniportal learning curves and 11 biportal studies. There were 1,493 patients across all uniportal studies. There was a total of 1,005 patients across all biportal studies.

Outcome measures: Number of patients, technique type, patient reported outcomes, complications, operative time before the learning curve threshold, operative time after learning curve threshold, number of cases required to meet threshold, number of surgeons in the study, and cases per surgeon were collected and analyzed.

Methods: A comprehensive literature search was conducted using PubMed, Medline, and Embase from 2000 to present date. Data was extracted by 3 independent reviewers.

Results: The learning curve studies were reviewed and summarized. The overall median number of cases to reach the learning curve threshold was significantly less in uniportal vs biportal studies (20 vs. 37.5, p=.0463). When stratifying by various procedures, there was no significant difference between the techniques with number of cases required or improvement of operative time. Operative time for biportal discectomies decreased by a significantly greater amount vs uniportal. (44.5% vs. 21.4%, p=.0332).

Conclusions: The learning curve literature for ESS was systematically reviewed and ways to overcome the learning curve were discussed. The overall median number of cases for the learning curve was significantly fewer in uniportal vs biportal but the improvement in operative time was significantly greater with biportal discectomies, typically the entry level procedure by novice surgeons. Overcoming the learning curve for ESS is a critical factor to widespread adoption and understanding it may aid surgeons in progressing to proficiency while mitigating the risk of complications.

Background context: Significant variability in the management of Adult Spinal Deformity (ASD) has been observed among spine surgeons worldwide. The variability among Canadian spine surgeons, a country with universal public healthcare, remains unknown.

Purpose: The study aims to evaluate areas of variability in the perioperative optimization and surgical management of ASD among Canadian spine surgeons.

Study design/setting: In this cross-sectional study, 25 Canadian spine surgeons, predominantly orthopedic surgeons (20) and neurosurgeons (5) with varying experience, participated in an online survey focused on Adult Spinal Deformity (ASD).

Sample: The study involved 25 Canadian spine surgeons with varying level of experience, representing both orthopedic and neurosurgical specialities.

Outcome measure: The study aimed to evaluate the variability in surgical decision-making and perioperative optimization strategies among Canadian spine surgeons when faced with simulated scenarios of ASD pathologies.

Methods: The online survey presented 4 vignettes with simulated scenarios of the most common ASD pathologies, including High Grade Spondylolisthesis (HGS), Neglected Adolescent Idiopathic Scoliosis (NAIS), Degenerative Scoliosis (DS), and Flat Back Syndrome (FBS). Questions in the vignettes explored ASD surgical decision-making, while additional questions focused on perioperative optimization. Descriptive statistics were used to analyze multiple-choice responses, and open-text responses were categorized into themes.

Results: Variability was observed in the duration conservative treatment across the 4 ASD cases. Surgeons exhibited variability in the use of preoperative osteoporosis treatment. There was varied use of a dedicated anesthesiology team. Surgical goals varied in HGS and NAIS. The primary surgical method was variable in DS and HGS, the type of osteotomy varied in DS and FBS, and level of fixation varied in HGS and NAIS. Consensus was observed in the use of intraoperative monitoring across of all 4 ASD pathologies, the implementation of a team-based approach, and the selection of the primary surgical goal in DS and FBS.

Conclusion: Our cross-sectional study revealed variability among Canadian spine surgeons in the management of ASD, potentially influenced by the uncertain ASD progression, the need for evidence-based nonsurgical guidelines, and insufficient evidence on optimal surgical approaches. These findings will help guide future research to ultimately reduce variability and improve ASD patient management and outcomes.

Background: The vertebral column is the most common site of bony metastasis. When indicated, surgical resection of hypervascular metastatic lesions may be complicated by significant blood loss, the need for blood transfusion, and incomplete tumor resection due to poor visualization and premature abortion of the operation. In select cases, preoperative arterial embolization of hypervascular metastatic tumors may help minimize intraoperative bleeding and reduce operative times.

Objective: Our aim was to evaluate the effectiveness of preoperative arterial embolization of metastatic tumors to the spine.

Study design: A systematic review of the literature with a subsequent metaanalysis of the collected data was conducted to achieve this aim.

Methods: PubMed and MEDLINE were searched since inception until May 22, 2023. The primary outcome of this study was Estimated Blood Loss (EBL), while secondary outcomes included number of patients requiring blood transfusions, duration of operation, and survival.

Results: Twenty-nine studies were included, yielding 14,199 patients, from which 1,134 underwent surgery with adjunctive embolization. Our review demonstrated that preoperative arterial embolization in patients with spinal metastatic tumors can help reduce EBL by a mean of -284.37 mL (95% CI 462.43-276. 21, p=.002) and improve survival by 1.20 months (95% CI 1.14-1.26, p<.001) compared to those without embolization. Upon running subgroup analyses, the reduction in EBL appeared to be mainly driven by the embolization of hypervascular tumors, while that of nonhypervascular ones appeared to have no significant impact. The pooled analysis shows that preoperative embolization did not impact operative time and the need for transfusion.

Conclusions: Preoperative arterial embolization of metastatic tumors to the spine has a relatively mild effect in reducing blood loss and improving patient survival. No effect was observed for preoperative embolization on operative time or the need for transfusion.

Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP), which results in disability worldwide. However, the pathogenesis of IVD degeneration mediating LBP remains unclear. Current conservative treatments and surgical interventions are both to relieve the symptoms and minimise pain; nevertheless, they are unable to reverse the degeneration. Previous studies have shown that inflammation and nociception markers are important indicators of pain mechanisms in IVD degeneration underlying LBP. As such, multiomics profiling allows the discovery of these target markers to understand the key pathological mechanisms mediating IVD degeneration underpinnings of LBP. This article provides insights into a precision medicine approach for identifying and understanding the pathophysiology of IVD degeneration associated with LPB based on the severity of the disease from early and mild to severe degenerative stages. Molecular profiling of key markers in degenerative IVDs based on patient stratification at early, mild, and severe stages will contribute to the identification of target markers associated with signalling pathways in mediating neuroinflammation, innervation, and nociception underlying painful IVD degeneration. This approach will offer an understanding of establishing personalised clinical strategies tailored to the severity of IVD degeneration for the treatment of LBP.

Background: In clinical practice, distinguishing between spinal tuberculosis (STB) and spinal tumors (ST) poses a significant diagnostic challenge. The application of AI-driven large language models (LLMs) shows great potential for improving the accuracy of this differential diagnosis.

Purpose: To evaluate the performance of various machine learning models and ChatGPT-4 in distinguishing between STB and ST.

Study design: A retrospective cohort study.

Patient sample: 143 STB cases and 153 ST cases admitted to Xiangya Hospital Central South University, from January 2016 to June 2023 were collected.

Outcome measures: This study incorporates basic patient information, standard laboratory results, serum tumor markers, and comprehensive imaging records, including Magnetic Resonance Imaging (MRI) and Computed Tomography (CT), for individuals diagnosed with STB and ST. Machine learning techniques and ChatGPT-4 were utilized to distinguish between STB and ST separately.

Method: Six distinct machine learning models, along with ChatGPT-4, were employed to evaluate their differential diagnostic effectiveness.

Result: Among the 6 machine learning models, the Gradient Boosting Machine (GBM) algorithm model demonstrated the highest differential diagnostic efficiency. In the training cohort, the GBM model achieved a sensitivity of 98.84% and a specificity of 100.00% in distinguishing STB from ST. In the testing cohort, its sensitivity was 98.25%, and specificity was 91.80%. ChatGPT-4 exhibited a sensitivity of 70.37% and a specificity of 90.65% for differential diagnosis. In single-question cases, ChatGPT-4's sensitivity and specificity were 71.67% and 92.55%, respectively, while in re-questioning cases, they were 44.44% and 76.92%.

Conclusion: The GBM model demonstrates significant value in the differential diagnosis of STB and ST, whereas the diagnostic performance of ChatGPT-4 remains suboptimal.