Spine Journal最新文献

Background context: Venous hypertension is a rare cause of myelopathy that can be misdiagnosed as myelitis and be worsened by glucocorticosteroids.

Purpose: This study is aims to identify a fluid biomarker with diagnostic value in Venous Hypertensive Myelopathy (VHM).

Study design: a retrospective diagnostic study PATIENT SAMPLE: The patients diagnosed as having myelopathy between December 2020 and June 2022 were divided into a VHM group (n=71) and an inflammatory myelopathy (IM) group (n=123). A noninflammatory neurological disorders (NIND) group (n=53) was also acquired as baseline control.

Outcome measures: The primary outcome was the diagnostic accuracy of the fluid biomarkers in the VHM and IM groups.

Methods: The albumin, immunoglobulins, oligoclonal bands, neuron-specific enolase, myelin basic protein, and S100β were measured in their cerebrospinal fluid (CSF) and paired serum samples. Potential diagnostic biomarkers were screened through univariate and collinearity analyses. The diagnostic performance of these biomarkers was assessed by plotting the receiver-operating characteristic curves. Additionally, the predictive value of clinical factors and biomarkers for diagnosis was evaluated using multivariable logistic regression analysis.

Results: The quantitative and normalized CSF-S100β values were significantly lower in the VHM group (p<.05). Analysis of receiver-operating characteristic curves adjusted for age and sex showed that the normalized CSF-S100β discriminated between VHM and IM (area under the curve (AUC) 0.884, 95% confidence interval [CI] 0.817-0.938). Particularly, it performed well in the AUC for normalized CSF-S100β (AUC 0.9400, 95% CI 0.8621-1.000) when oligoclonal bands and flow-void sign were negative.

Conclusions: The normalized CSF-S100β can differentiate between VHM and IM.

Background context: Motile cilia dysfunction was reported to lead to scoliosis-like phenotypes in zebrafish models. There is still a lack of population-based study supporting the role of cilia motility associated genes in the etiology of idiopathic scoliosis (IS).

Purpose: To investigate the molecular mechanism underlying the relationship between cilia motility associated genes and the development of adolescent idiopathic scoliosis (AIS).

Study design: Population-based genetic study METHODS: A cohort of 56 female AIS patients and 30 age-matched non-scoliotic controls were included for tissue expression analysis. 28 patients with lower CCDC40 expression were selected for the exon sequencing. The novel variation was replicated in an independent cohort of 1326 AIS patients and 954 healthy controls. Exogenous versions of WT or mutant human CCDC40 mRNAs were expressed in zebrafish and the phenotype of body axis curvature was observed.

Results: CCDC40 was found significantly down-expressed in AIS patients as compared with the nonscoliotic controls. A novel coding variant rs185157579 (c.1459G>A) was found significantly associated with AIS, with the mutant allele A adding to the risk of AIS by 2.44 folds. Zebrafish embryo injected with CCDC40 mRNAs containing mutant c.1459G>A presented significantly higher incidence of scoliosis-like phenotype than the wild group.

Conclusions: The mutation c.1459G>A in the exon 10 of CCDC40 may lead to body axis curvature of zebrafish by impacting mRNA expression. The underlying molecular mechanism is worthy of further investigation.

Clinical significance: Our findings shed a new light on the etiopathogenesis of AIS. The downstream signaling of CCDC40 may be candidate for potential drug targets to prevent the development of AIS. Moreover, the novel variation can be used as a genetic marker of polygenic risk score predicting the risk of AIS.

Background context: Anterior Cervical Discectomy and Fusion (ACDF) is a surgical technique that can be used to treat several conditions of the cervical spine. Small sized studies have reported differences in radiological findings between cage only and cage with plate fusion techniques but no differences in clinical outcome, hence, larger studies are needed.

Purpose: The aim of this study was to compare the outcomes of ACDF between cage only and cage with plate fixation.

Study design: Retrospective study design on prospectively collected registry data.

Patient sample: Individuals treated for cervical degenerative radiculopathy, with ACDF using either cage only or cage with plate fixation were identified in the Swedish Spine registry (Swespine). Included individuals had available baseline and 1-year postoperative data for the Numeric Rating Scale (NRS) for neck and arm pain.

Outcome measures: Patient reported outcome measures (PROMs) included were NRS for neck and arm pain, Neck Disability Index (NDI), and EuroQol-Visual Analogue Scale (EQ-VAS). Complications reported by clinicians and patients were also available in the Swespine registry, as well as the degree of satisfaction at the 1-year follow-up.

Methods: Outcomes at the 1-year follow-up were compared between the cage only or cage with plate groups. In a secondary analysis, one or two levels of surgery was compared between the groups. The number of patients that reached the Minimum Clinically Important Difference (MCID) in improvement after treatment was calculated and compared between the groups. The Mann Whitney-U test was used for continuous variables and the Chi² test for categorical variables.

Results: The groups included 344 individuals instrumented with cage only, and 334 receiving cage with plate fixation. NDI improvement was -14.0 points (95% CI: -12.2-[-15.8]) in the cage only group and -17.9 points (95% CI: -16.1 - [-19.8]) points in the cage with plate group (p=.007). A lower rate of hoarseness post-operatively was reported by the cage only group (OR: 0.65 [0.45-0.93], p=.026). No differences were seen in other outcomes.

Conclusion: Clinical improvement was seen in both groups, but the improvement of NDI was better in the cage with plate group and the rate of hoarseness was lower in the cage only group.

Background context: 3D-printed titanium cage designs can incorporate complex, porous features for bone ingrowth and a greater surface area for minimizing subsidence. In a companion study (Part 1), we determined that increased surface area leads to decreased subsidence; however, it remains unclear how increasing the cage surface area, resulting in a smaller graft aperture, influences fusion.

Purpose: We evaluated the effects of surface area of 3D-printed titanium cages and the use of autologous bone grafts on spinal fusion in sheep.

Study design: In vivo large animal study in 12 sheep.

Methods: Interbody fusion was performed in 12 adult sheep at 24 levels (L2-3 and L4-5) using 3D-printed titanium cages with bilateral pedicle screw fixation. The cage designs varied in aperture: standard (low endplate surface area), small (medium endplate surface area), or none (high endplate surface area). These cages were packed with autologous iliac crest bone grafts (ICBG). A fourth group was implanted without bone grafts, using the no-aperture cage. Fusion was evaluated at 16 weeks via manual palpation, microcomputed tomography (microCT), histology, and histomorphometry.

Results: Standard, small, and no-aperture cages packed with ICBG resulted in high fusion rates (80%, 100%, and 83%, respectively) at 16 weeks by manual palpation, and these results were not significantly different. Implantation without ICBG was associated with a significantly lower fusion rate (33%, p<.05). Histological, histomorphometry, and microCT results supported the findings obtained by manual palpation; findings from these modalities showed new bone spanning the vertebral endplates in the spines graded as fused by manual palpation.

Conclusions: Similar fusion results for standard, small, and no-aperture cage designs packed with ICBG suggest that aperture size does not influence fusion results in the sheep model. However, without ICBG grafting, fusion was significantly decreased, suggesting that graft material is necessary to predictably obtain fusion in this model. When the in vitro subsidence data (companion study, Part 1) is considered with the in vivo fusion data described here, porous 3D-printed titanium cages with maximal surface endplate contact and bone grafting perform favorably, resulting in low subsidence and high fusion rates.

Clinical significance: 3D-printed porous titanium interbody cages are novel devices with increasing clinical use. The study results show that the aperture size of the interbody cage did not influence fusion in a large animal (sheep) model. The use of bone graft material was the most important variable affecting fusion. These data suggest that the clinical use of 3D Ti cages without graft material should be avoided.

Background context: Ropivacaine-Epinephrine-Clonidine-Ketorolac (RECK) cocktail can improve pain control in patients undergoing lumbar decompression. Given the aging population, rising healthcare costs, the opioid epidemic, and associations of acute pain control with long-term opioid use, effective opioid-sparing analgesia following spinal fusion surgery may impart societal benefits.

Purpose: We aimed to investigate whether RECK was an effective local anesthetic for patients undergoing posterior spinal fusion.

Study design/setting: Single-center retrospective cohort study PATIENT SAMPLE: Patients who underwent posterior spinal fusion surgery from June 2019 to June 2021 OUTCOME MEASURES: Primary outcomes of interest were postoperative pain levels as determined by Visual Analog Scale, in-hospital opioid consumption, length-of-stay <4 days, and long-term opioid utilization at 3-months postoperatively. Secondary outcomes of interest were rates of discharge to home, complication rates, readmissions within 90 days.

Methods: We analyzed whether opioid exposure, patient-specific or surgery-specific factors, and administration of RECK (versus another local anesthetic) were associated with postoperative pain levels, in-hospital opioid consumption, length-of-stay, home discharge, long-term opioid utilization, complications, and readmissions within 90 days using multivariable regression.

Results: Of the 162 patients meeting study criteria, 49 (30.2%) received RECK. RECK was significantly associated with decreased pain levels at 2-, 4-, 6-, and 12-hours postoperatively (p≤.001-.01). RECK was associated with decreased total and daily inpatient opioid utilization (as measured by oral morphine equivalents) in multivariable linear regression (B=-159.6, 95% CI:-255.5- -63.6, p=.002 and B=-27.9, 95% CI:-48.9- -7.0, p=.01, respectively). Length-of-stay duration of <4 days was associated with RECK administration (OR 4.1, 95% CI:1.4-13.2, p=.01) and was negatively associated with levels fused (OR 0.4, 95% CI:0.2-0.7, p=.005) and durotomy (OR 0.02, 95% CI:0.0009-0.1, p<.001). Prolonged postoperative opioid utilization was associated with preoperative opioid prescription (OR 3.6, 95% CI:1.7-7.8, p=.001) and was negatively associated with RECK (OR 0.4, 95% CI:0.2-0.9, p=.04). RECK was not associated with readmissions, complications, or home discharge.

Conclusions: In patients undergoing posterior spinal fusion, RECK was superior to other local anesthetics as it improved pain control, decreased length-of-stay, and decreased opioid utilization. RECK was not associated with increased complications, readmissions, or rates of discharge to home.

Background context: The ligamentum flavum (LF) is a crucial structure in maintaining spinal stability; however, hypertrophy of the LF is a significant contributor to lumbar spinal canal stenosis (LSCS). The mechanisms linking LF hypertrophy to the exacerbation of LSCS remain incompletely understood.

Purpose: This study aimed to investigate the cellular proportions and signaling pathways observed in the hypertrophied LF.

Study design: LF tissues were obtained from 3 patients undergoing lumbar decompressive surgery. These patients had been diagnosed with LSCS prior to surgery and had an LF thickness exceeding 3.5 mm.

Methods: Single-cell RNA sequencing was performed following LF tissue dissociation, and data were processed for quality control, dimensional reduction, and clustering. Differential gene expression and gene ontology analyses revealed key molecular pathways driving LF hypertrophy. Cell-cell communication analysis was analyzed to elucidate interactions among various cell types within the LF tissues.

Results: Fibroblasts accounted for 75% of the total cells, followed by endothelial cells, T cells, macrophages, and B cells. Among heterogeneous types of fibroblasts, we identified that a subset of fibroblasts trans-differentiated into myofibroblasts. Two types of macrophages that exhibited phenotypic plasticity akin to M1 and M2 states were observed. We also identified novel signaling pathways involved in fibroblast and immune cell interaction in the hypertrophied LF, such as GAS and GRN, as well as known signaling pathways, such as TGF-β, PDGF, CXCL, and ANGPTL.

Conclusion: Our study shows the changing cellular composition and pathogenic signaling pathways involved during the process of chronic inflammation highlighting the transdifferentiation process from fibroblasts to myofibroblasts in the hypertrophied LF.

Clinical significance: The identification of pathways such as GAS, GRN, TGF-β, ANGPTL, and CXCL, which appear to potentially contribute to LF hypertrophy, could significantly enhance our understanding of the pathogenesis of LSCS.

Background context: There has been no recent updated comprehensive review of measurement properties focused on the 5-repetition sit-to-stand test (5R-STS) in patients with lumbar degenerative disorders (LDD) that could aid in better understanding of its clinical and research applicability.

Purpose: The aim of this systematic review was to summarize evidence on measurement properties of the 5R-STS in patients with LDD according to COnsensus Based Standards for the Selection of Health Measurement INstruments (COSMIN) guidelines.

Design: Systematic review and meta-analysis.

Patient sample: In Step 1 and 2, 3,363 and 1,287 adult patients with suspected or diagnosed either clinically and/or radiologically LDD were included, respectively. Step 2 involved screening studies from Step 1 that passed the full text-stage and including only those that assessed at least 1 COSMIN measurement property.

Outcome measures: Functional Measures (5R-STS, Timed Up and Go Test). Self-report Measures (including Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire, pain scores eg, Visual Analogue Scale) and health-care quality of life questionnaires (eg, EQ-5D-3L)).

Methods: In December 2022 Embase, PubMed/Medline, Web of Science and Scopus were searched for studies of 5R-STS of patients with LDD (PROSPERO: CRD42022383095). Quality of evidence was assessed using GRADE and COSMIN Checklist. Results for measurement error were pooled using the weighted mean method. Random effect meta-analysis was performed for studies on reliability and criterion validity.

Results: Thirty-eight full-text articles were included in Step 1 and 19 in Step 2. The overall intraclass correlation coefficient (ICC) of test-retest reliability and inter-rater reliability of the 5R-STS was 0.93 (95% CI 0.37-1.00) and 0.99 (95% CI 0.83-1.00), respectively. The weighted standard error of measurement (SEM) mean value was 2.8s. Estimated r of 5R-STS and ODI, reflecting insufficient criterion validity (since r <0.70), was 0.53 (95% CI 0.17-0.88). Hypothesis testing for construct validity was confirmed for 40% of predefined hypothesis (graded as insufficient since overall, not >70% hypothesis confirmed). Accounting for limited evidence, responsiveness of the test was adequate.

Conclusion: This COSMIN systematic review summarizes 5R-STS measurement properties in patients with LDD, including pooled estimates of ICC for reliability, SEM, and correlation between 5R-STS and ODI. The 5R-STS is a reliable and responsive instrument reflecting a new dimension of functional impairment in patients with LDD.

Background/context: The assessment of disc degeneration remains a significant challenge in clinical research. Pfirrmann grade is a frequently used classification for lumbar disc degeneration on MRI. However, there has been no gold standard for cervical spine disc degeneration. Recently, we introduced the Disc Signal Intensity Index (DSI2) as a quantitative disc assessment for the lumbar spine, which is easily measurable in the cervical spine.

Purpose: The aim of this study was to apply DSI2 in the cervical intervertebral disc and investigate the factors associated with the cervical disc degeneration.

Study design/setting: Cross-sectional study using retrospectively collected data.

Patient sample: Cervical MRIs from a database of patients undergoing ACDF between 2015 and 2018 were retrospectively reviewed.

Outcome measures: Demographic variables included age, sex, body mass index (BMI), race, smoking status, and comorbidities such as diabetes, chronic kidney disease, and coronary artery disease.

Methods: DSI2 measurements were performed on midsagittal T2-weighted MRI images by determining the intensity within regions of interest (ROI). One ROI was set in the cerebrospinal fluid (CSF) and three ROIs were set per disc at the anterior, middle, and posterior third. The mean of the three measurements per disc was then divided by that of the CSF to calculate the DSI2 score. Multivariable linear regression analyses with mixed model were conducted to determine the potential contributing factors for disc degeneration.

Results: A total of 149 patients and 770 discs were included in the final analysis. Ninety-three patients (37.6%) were female and the mean (SD) age was 55.6 (11.7) years. The distribution of DSI2 scores among the different Pfirrmann grades was as follows: Grade 1: 0.259±NA; Grade 2: 0.226±0.090; Grade 3: 0.175±0.070; Grade 4: 0.136±0.060; Grade 5: 0.131±0.050. Multivariable linear mixed-effect regression analysis, setting with DSI2 as the objective variable, demonstrated that age (β=-0.130, p<.05), BMI (β=-2.06, p<.05), Modic changes (Type1 β= -2.70, p<.01) were independent contributors to disc degeneration. The segments C4/5 and C7/T1 were less prone to disc degeneration (C4/5: β=1.37, p<.001; C7/T1: β=2.63, p<.001) and the history of diabetes (β=5.31, p<.01) was associated with high DSI2.(p<.01).

Conclusions: The present study provides valuable insights for identifying risk factors in degenerative cervical conditions utilizing the DSI2. The DSI2 method emerges as a promising alternative for future disc research, excelling in the detection of subtle progressions of degeneration and distinguishing itself from the subjective Pfirrmann grading system.

Background and context: Unplanned readmission within 30 days following elective spine surgery is a key indicator of quality of care, as readmissions often signal early complications or poor recovery. The Hospital Readmission Reduction Program (HRRP) and the Centers for Medicare and Medicaid Services (CMS) utilizes this metric to assess hospital and surgeon performance.

Purpose: Here we aim to delineate quality of care metrics for full-endoscopic spine surgery (FESS) compared to traditional spine surgery.

Design: The study was a retrospective multicenter analysis comparing outcomes of propensity matched cohorts.

Patient sample: The study included 908 FESS patients operated between 2014 and 2023 and a matched cohort of 73,906 non-FESS patients.

Outcome measures: Our primary outcome measures were postoperative 30-day hospital readmissions and revision surgery. Furthermore, demographic data, hospitalization, surgical details and comorbidities were included.

Methods: Data were collected from 6 participating institutions. Patients older than 18 years undergoing noninstrumented FESS spine surgeries for degenerative lumbar spinal pathologies from 2016 to 2023 were included. A matched non-FESS cohort was identified in the ACS-NSQIP database (2015-2019). Propensity-score matching was used to compare the cohorts.

Results: Before matching, the 30-day readmission rate was significantly lower in the FESS cohort (1.1% vs. 4.4%, p <.001), which remained consistent after matching (1.1% vs. 4.5%, p<.001). The rate of 30-day surgical revisions was similar between cohorts (1.0% vs. 1.1%, p=.63). Multivariate analysis indicated a significant correlation between FESS and reduced 30-day readmissions (odds ratio [OR] 0.28, 95% CI 0.14-0.57, p<.001).

Conclusion: This study is the first to compare 30-day hospital readmissions between FESS and nonendoscopic surgeries in a large, matched multicenter cohort. FESS significantly reduces both the length of postoperative hospital stay and 30-day readmission rates compared to nonendoscopic approaches, underscoring the safety and effectiveness of outpatient FESS. Future studies are needed to define the role of FESS in more complex spine procedures.