Journal of Craniovertebral Junction and Spine最新文献

Context: Obesity is a recognized risk factor for adverse outcomes in cervical spine surgery. While cervical disc arthroplasty (CDA) has emerged as an alternative to anterior cervical discectomy and fusion (ACDF), comparative outcomes among obese patients remain underexplored.

Aims: The aim of this study is to compare nonroutine discharge rates and other postoperative outcomes between obese patients undergoing single-level ACDF and CDA.

Settings and design: Retrospective cohort study using a national database.

Subjects and methods: The National Inpatient Sample was queried to identify obese patients who underwent single-level ACDF or CDA between 2016 and 2020. Inclusion and exclusion criteria were applied. Propensity score matching (1:3) was performed based on age, sex, race, Elixhauser Comorbidity Index, and primary diagnosis to create comparable cohorts. Outcomes included nonroutine discharge, length of stay (LOS), total cost, and postoperative complications.

Statistical analysis used: Chi-square tests and Student's t-tests were used for categorical and continuous outcomes, respectively, with significance set at P < 0.05.

Results: After matching, 1455 ACDF and 485 CDA cases were analyzed. Obese patients undergoing ACDF had significantly higher nonroutine discharge rates (11.3% vs. 4.1%, P = 0.037). ACDF patients had lower total costs ($16,400 vs. $19,400, P = 0.003), with similar LOS (1.4 ± 0.1 days, P = 0.931) and adverse event rates (7.6% vs. 8.2%, P = 0.827).

Conclusions: Obese patients undergoing ACDF experience higher nonroutine discharge rates compared to those receiving CDA. While CDA is associated with higher costs, it may offer superior discharge outcomes in this high-risk population.

Context: Cervical fusion outcomes are influenced by bone quality, with osteopenia increasing the risk of implant failure and revision surgery. The impact of teriparatide in this population remains unclear.

Aims: The aim of this study was to investigate the association between teriparatide use and 90-day medical complications, 2-year surgical complications, and hospital readmissions in this population.

Settings and design: A retrospective cohort analysis using the PearlDiver Mariner database from 2010 to 2022.

Subjects and methods: Patients undergoing cervical fusion were stratified by teriparatide use. Propensity score matching (1:5) was performed based on age, gender, Elixhauser Comorbidity Index, obesity, and bisphosphonate use. Primary outcomes included 90-day medical complications, 2-year surgical complications, surgical revisions, and hospital readmissions.

Statistical analysis used: Logistic regression models were used to calculate odds ratios (ORs) with a Bonferroni-corrected significance level of P < 0.004.

Results: Ninety-eight teriparatide-treated patients were matched to 487 controls. Teriparatide use was significantly associated with higher rates of 2-year implant failure (4.1% vs. 1.0%, P = 0.003) and surgical revisions (54.1% vs. 4.7%, P < 0.001). Logistic regression demonstrated increased odds of 2-year implant failure (OR 6.63, 95% confidence interval [CI]: 1.93-23.78, P = 0.002) and surgical revisions (OR 27.83, 95% CI: 15.34-52.58, P < 0.001) in the teriparatide group. No differences were observed in 90-day medical complications or readmission rates (P > 0.004).

Conclusions: Teriparatide use in osteopenic patients undergoing cervical fusion is associated with increased risks of 2-year implant failure and surgical revisions. These findings suggest that while teriparatide improves bone quality, its efficacy may be limited in this population. Future research should explore tailored interventions to optimize surgical outcomes in osteopenic patients.

Background: Postlaminoplasty kyphotic deformity (PKD) is a complication affecting roughly 20% of patients undergoing cervical laminoplasty. Identification of preoperative risk factors for PKD could allow surgeons to adapt treatment plans to reduce PKD.

Objective: The aim of this study was to investigate the ability of the Charlson Comorbidity Index (CCI), 5-item Modified Frailty Index (5i-mFi), and Administrative Risk Analysis Index (RAI-A) to predict for the development of PKD in patients with cervical spondylotic myelopathy (CSM) undergoing laminoplasty.

Materials and methods: We retrospectively reviewed CSM patients who underwent laminoplasty at an academic tertiary care center between January 1, 2016, and January 30, 2022, and had a complete set of anterolateral cervical X-rays at 1-year follow-up. Angular kyphosis was defined as the loss of cervical lordosis by more than - 10° after surgery when measuring the difference between pre- and post-operative C2-7 Cobb angles. Regression and receiver operating characteristic (ROC) curve analysis were used to assess the ability of the frailty assessments to predict for PKD.

Results: Seventy-six CMS patients were eligible, 11.8% of which developed PKD. The cohort consisted of 54 males and 22 females with a mean age of 59.5 years and body mass index of 29.2 kg/m². No CCI, 59-mFi, or RAI-A frailty subgroup was associated with kyphotic development and ROC curve analysis showed that neither CCI (P = 0.81), 5i-mFi (P = 0.59), nor RAI-A (P = 0.63) predicted for PKD. None of these assessments were a superior prognosticator of PKD.

Conclusion: CCI, 5i-mFi, and RAI-A frailty assessments were not associated with the development of PKD in CSM patients.

Background: Anemia is a risk factor for increased transfusions. However, various definitions of anemia have been described in scientific literature and a consensus on how to appropriately diagnose anemia or who to preoperatively optimize is lacking. We aimed to compare multiple anemia definitions and evaluate if any threshold best predicts transfusion requirements and surgical outcomes following spinal fusion.

Methods: We conducted a retrospective cohort study of 1-2 level posterior spinal fusions. Preoperative hemoglobin was defined based on preoperative laboratories within 28 days of surgery. Anemia was diagnosed using the World Health Organization (WHO), the American Society of Hematology (ASH), and the Cleveland Clinic (CC) thresholds. Youden's index and multivariable regressions were utilized to analyze associations of anemia with postoperative outcomes.

Results: A total of 2257 patients were included. Patients who received a transfusion were more likely anemic regardless of definition (WHO: 60.0% vs. 14.0%, P < 0.001; ASH: 61.0% vs. 17.8%; CC: 70.0% vs. 26.6%; all, P < 0.001). On multivariable regression, all anemia definitions were independently associated with transfusions and nonhome discharge. WHO anemia was associated with the highest odds of transfusion (odds ratio [OR]: 7.48, P < 0.001), followed by ASH anemia (OR: 6.63, P < 0.001), ASH preoperative anemia (OR: 6.45, P < 0.001), and CC anemia (OR: 5.92, P < 0.001). Only WHO anemia was associated with complications (OR: 1.55, P = 0.045). Receiver operating characteristic curves suggest that every anemia threshold was acceptable (area under the curve [AUC] >0.70) for identifying patients needing a postoperative transfusion: ASH preoperative demonstrated the greatest AUC (AUC: 0.746), followed by WHO anemia (AUC: 0.730). All performed poorly in predicting complications (AUC: 0.541-0.553), readmissions (AUC: 0.525-0.535), and nonhome discharge (AUC: 0.561-0.596).

Conclusions: Small variations in anemia definitions do not significantly impact the identification of patients necessitating a transfusion. However, the more discriminative WHO definition may best predict postoperative complications for lumbar fusions.

Objectives: Vertebral artery injury (VAI) is an uncommon, but potentially devastating, complication following cervical spine trauma. Posterior circulation ischemia (POCS) can result from a disruption to the vertebral arteries and potentially lead to long-term morbidity and mortality for these patients. This study aimed to describe the outcomes for patients with POCS as a result of VAI.

Methods: Six hundred and twenty patients who sustained a cervical spine fracture with or without dislocation were identified from the years 2011 to 2017. Demographic data, injury details, and imaging results were collected with inpatient and outpatient records on the regional electronic care record. Patients with VAI were identified (n = 20) and screened for subsequent POCS. Their outcome was recorded from inpatient and outpatient records.

Results: POCS was identified in 6 patients who had sustained a VAI (30%). Of those 6 patients, 5 had long-term neurological deficits following their injury and POCS. Two patients died within 30 days and 3 patients had died by 60 days following injury.

Conclusions: POCS occurred in 30% of patients who sustained a VAI in this study. It carried significant morbidity and mortality for the patients who suffered this potentially devastating complication. Clinicians involved in the care of patients with cervical spine trauma should be aware of the risk factors for VAI and ensure to be suspicious of POCS in patients who have proven VAI.

Background: Lumbar spine surgery procedures have been increasing amid a growing population with diabetes mellitus (DM) with limited studies available focusing exclusively on insulin dependence as a risk factor. The objective of this study was to evaluate the differential impact of insulin dependence on perioperative outcomes following lumbar spine surgery.

Materials and methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone lumbar spine surgery between 2011 and 2022. The study population was divided into three distinct groups based on diabetic status: insulin-dependent DM (IDDM), insulin-independent DM (NIDDM), and no DM (non-DM). One-way analysis of variance for continuous variables and Chi-square tests for categorical variables were used to identify differences in perioperative variables between the three groups. Multivariable logistic regression analysis assessed the effect of DM status on postoperative surgical outcomes.

Results: A total of 349,520 lumbar spine patients were identified, of whom 20,159 were IDDM, 43,402 were NIDDM, and 285,959 were non-DM. Both IDDM (odds ratio [OR]: OR: 1.134, 95% CI [1.059-1.214]) independently increased the risk for surgical complications, whereas only IDDM increased the risk for medical (OR: 1.256, 95% CI [1.194-1.320] complications following a multivariate logistic regression analysis.

Conclusions: This study highlights the increased risk of surgical and medical complications in patients with IDDM undergoing lumbar spine surgery. Both NIDDM and IDDM are independent risk factors for postoperative medical and surgical complications. These findings can be used to improve preoperative management and risk stratification for insulin dependent DM patients.

Aims and objectives: Noncontiguous degenerative cervical disc disease (NCDDD) is characterized by cervical disc prolapse involving nonadjacent segments. This study aims to determine if skip discectomy and fusion technique compared to contiguous discectomy and fusion while preserving adjacent segment disease in uninvolved intermediate segments leads to equivalent or better clinical and radiological outcomes.

Methods: Fifty-two patients who underwent management of NCDDD and two-level contigious disc disease (CDD) over 6 years from 2014 to 2020 were included in the study. There were 44 male and 8 female patients with a mean age of 46.75 years. These patients were divided into two groups: Those who underwent contiguous discectomy and those who underwent skip discectomy with either anterior cervical discectomy (ACD) alone, ACD and fusion (ACDF), or ACDF with plating based on individual pathology and surgeon preference. Outcomes were assessed using clinical parameters such as modified Japanese Orthopaedic Association Score (mJOAS) and Nurick grade and radiological parameters such as disc height improvement, spinal alignment change, and fusion rates.

Results: The overall mean duration of follow-up was 15.23 ± 23.69 months, with a clinical follow-up period of 23.87 ± 21.51 months and a radiological follow-up period of 7.57 ± 5.91 months, with follow-up in Group 1 being 24.67 ± 23.17 months and in Group 2 being 20.03 ± 10.53 months. The mean blood loss in Group 1 was 200.47 mL; in Group 2, it was 172 mL. The preoperative mJOAS was 10.19 ± 3.16, and the postoperative mJOAS was 12.73 ± 2.92 (P = 0.001). Nurick grade showed improvement from a preoperative mean score of 4.23 ± 1.02-3.65 ± 0.88 postoperatively (P < 0.001). Statistically significant improvement in intervertebral height at superior and inferior levels was observed. Outcomes for Skip discectomy regarding mJOAS, Nurick grade, radiological parameters, fusion, and complication rates were noninferior to contiguous discectomy and fusion.

Conclusion: Skip discectomy has a similar benefit and risk profile and is noninferior compared to contiguous discectomy in addition to the preservation of intermediate disc integrity.

Background: The parameter of T1 slope (T1S) minus C2-7 cervical lordosis (CL) is relevant to the surgical management of cervical degenerative diseases (CDD), but whether it contributes to cervical approaches decision-making has not been reported in the literature prior.

Purpose: The purpose of this study was to investigate surgical approach optimization based on T1S minus C2-7 CL in the perioperative management of CDD.

Materials and methods: Three hundred sixty-six patients diagnosed with CDD were enrolled from 2018 to 2023. Grouped based on T1S-CL, a value of T1S-CL <20° defined as a matching group, and a value of T1S-CL >20° comprised a matching group. All patients underwent only cervical anterior or posterior approach surgery. Clinical indexes of the Japanese Orthopedic Association (JOA) score, Visual Analog Scale (VAS) and neck disability index (NDI), and radiologic parameters of T1S, CL, and sagittal vertical axis (C2-7 SVA) were recorded and analyzed.

Results: Before surgery, there were significant differences in factors between the two groups for CL, T1S, and T1S-CL (P < 0.05). Postoperatively, clinical indexes and radiological parameters changed significantly (P < 0.001) in each group. There are significant correlations indicated between T1S and CL (P < 0.05) except for one in a mismatching group of posterior approach (P > 0.05) postoperatively. There are significant correlations indicated between T1S-CL and T1S, CL (P < 0.05) in two groups of anterior approaches except for posterior approaches (P > 0.05).

Conclusion: T1S-CL-based surgical approaches indicate that cervical anterior approaches are superior to posterior paths in improving and optimizing sagittal alignment. Posterior approaches may impair alignment in situations of T1S-CL <20°, and deteriorate malalignment established with conditions of T1S-CL >20°.

Idiopathic scoliosis (IS) is frequently associated with Chiari malformation (CM) and syringomyelia, conditions thought to share a common underlying cause: Atlantoaxial instability. Atlantoaxial stabilization has recently emerged as a novel treatment option. A 4-year-old girl presented with progressive scoliosis (Cobb angle of 28.6°), neck pain, CM, and syringomyelia. The patient was diagnosed with central or axial atlantoaxial instability and underwent C1-C2 fixation. Postoperatively, she experienced significant relief from neck pain. Follow-ups demonstrated progressive syrinx reduction, while X-rays revealed a Cobb angle decrease to 21° in 18 months. This case highlights the potential of atlantoaxial stabilization to halt scoliosis progression in IS patients with CM and syringomyelia. Unlike traditional multisegmental stabilization, C1-C2 fixation offers a minimally invasive approach and preserves spinal mobility in growth-age patients. Atlantoaxial instability should be considered in IS cases with CM and syringomyelia. Atlantoaxial stabilization alone may provide effective treatment with favorable clinical and radiological outcomes.