Asian Spine Journal最新文献

The spinal instability neoplastic score (SINS) is used to evaluate spinal stability in patients with metastatic vertebrae and to guide treatment selection. SINSs of 13-18 indicate instability typically requiring surgery, while SINSs of 1-6 indicate stability and suitability for radiotherapy. However, the optimal approach for patients with SINSs of 7-12 remains unclear. This systematic review aimed to determine the optimal primary treatment for patients with intermediate SINSs (7-12) and potentially unstable metastatic vertebrae. A systematic literature search was conducted in PubMed, Embase, and Scopus, following the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. Twenty-six studies were included in this review (three A-class and 23 B-class). The A-class studies showed better outcomes with surgery±radiotherapy than radiotherapy alone. Two B-class studies indicated that patients with SINSs ≥10 more frequently underwent surgery, and one study found surgery was less effective for SINSs ≤9. Four studies showed good outcomes of surgery. In another study, 30% of patients became unstable after radiotherapy. In four studies, vertebral compression fractures developed in 20%-30% of patients after stereotactic body radiation therapy or stereotactic ablative body radiotherapy. One study showed that SINSs of 7-12 were correlated with radiotherapy failure, while another study found no such association. This systematic review suggests that surgical intervention alone or in combination with radiation may be superior for patients with SINSs of 7-12 and metastatic spinal tumors. The SINS 7-12 category might be divided into subgroups where surgery or radiotherapy is optimal. SINS ≥10 may indicate a need for surgery, and individual SINS components could be predictive. Further research is warranted to obtain more definitive evidence.

Study design: Retrospective study.

Purpose: This study aimed to evaluate the correlation between postoperative shoulder imbalance (PSI) and distal junctional kyphosis (DJK) in patients with Lenke type 2 adolescent idiopathic scoliosis (AIS).

Overview of literature: Despite reports on several risk factors of postoperative radiographical complications, including PSI, distal adding-on (DA), and DJK in patients with AIS, the correlation between PSI and DJK has not been thoroughly examined.

Methods: This study included 62 patients with Lenke type 2 AIS who underwent posterior correction and fusion surgeries. The patients were categorized into the PSI and non-PSI groups based on their radiographic shoulder height 2 years after surgery. Radiographic parameters, lower end vertebra (LEV), lower instrumented vertebra (LIV), sagittal stable vertebra (SSV), postoperative DA and DJK, and Scoliosis Research Society 22 scores were compared between the two groups using unpaired t -tests or Pearson's chi-square tests.

Results: Twenty-eight patients in the PSI group and 34 in the non-PSI group were evaluated. Three patients had DA in the PSI group and 10 with DA and four with DJK in the non-PSI group. LIV-LEV was higher in the PSI group than in the non-PSI group. Although the LIV-SSV was not significantly different between the two groups, among the three patients with DJK, two had LIV-SSV of -3, one had -1, and one had 0. No significant differences in other examinations were noted between the two groups.

Conclusions: Although more proximal LIV selection might lead to stable DA and DJK, the LIV selection should not be extended distally to prevent DA and DJK because favorable shoulder balance and clinical outcome can still be achieved.

Screw loosening (SL) is a common complication following lumbar interbody fusion (LIF), particularly for degenerative lumbar disease. This study investigated the risk factors for SL following LIF for degenerative lumbar disease and examined the clinical relevance of SL. A PROSPERO-registered systematic search was conducted in the ScienceDirect, PubMed, Google Scholar, Epistemonikos, and Cochrane databases to identify longitudinal studies up to October 2024. Degenerative lumbar diseases included stenosis, spondylolisthesis, and disc herniation. Assessed risk factors were Cobb angle, lumbar lordosis (LL) angle, screw length, fixation to the sacrum, fused levels, and Hounsfield units (HU). Twenty-two studies involving 3,689 participants (56%±5% female; mean age, 61.95±9.55 years) and 17,722 lumbar screws were analyzed. Overall, 10%±2% of screws exhibited loosening in 29%±5% of patients, with 5%±2% undergoing revision surgery. Patients with SL (SL group) and those without SL (non-SL group) had similar sex distribution, body mass index, and comorbidities. The SL group had higher Visual Analog Scale scores for back pain (mean difference [MD], 0.75; 95% confidence interval [CI], 0.42-1.07; p<0.001) and Oswestry Disability Index scores (MD, 3.34; 95% CI, 0.49-6.20; p=0.02), indicating the clinical relevance of SL. The SL group exhibited significantly higher Cobb angle (MD, 2.42; 95% CI, 0.36-4.49; p=0.02), lower LL angle (MD, -3.67; 95% CI, -6.33 to -1.01; p=0.01), and shorter screw length (MD, -1.62; 95% CI, -2.78 to -0.45; p=0.01). Fixation to the sacrum, increased fused levels, and decreased HU were significant risk factors. The area under the curve for HU was 0.80 (0.77-0.84), with a sensitivity of 0.74 (0.67-0.81) and specificity of 0.76 (0.66-0.84), underscoring notable prognostic value. Patients with SL exhibited higher Cobb angles, lower LL angles, and shorter screws. Fixation to sacrum, increased fused levels, and decreased HU were significant risk factors for SL (PROSPERO ID: CRD42024563780).

Metastatic spine cancer (MSC), a common complication of advanced malignancies, poses significant challenges due to pain, neurological deficits, and mechanical instability. While radiation therapy is a cornerstone of treatment, the role of spine surgery is evolving, fueled by advances in surgical techniques and radiation modalities such as stereotactic body radiation therapy (SBRT). This review examines the evolving role of spine surgery in MSC management, focusing on separation surgery, surgical innovations, and future directions. The treatment paradigm for MSC shifted with the advent of SBRT, which delivers high-dose precision radiation, improving local control even in radioresistant tumors. This advancement enabled the adoption of separation surgery, a technique aimed at creating a safe margin between the tumor and neural structures without extensive tumor resection, followed by SBRT to achieve tumor regression. Separation surgery reduces morbidity, shortens operative times, and achieves comparable local control rates to traditional corpectomy procedures. Innovations like minimally invasive surgery, stereotactic navigation, and cement-augmented instrumentation have improved surgical safety and outcomes. Emerging technologies, such as machine learning for predictive modeling and augmented reality for surgical navigation, hold potential for improving decision-making and procedural accuracy. Spine surgery remains integral to MSC treatment, especially for high-grade metastatic epidural spinal cord compression and mechanical instability. Integrating advanced technologies and multidisciplinary collaboration is key to optimizing patient outcomes. Comprehensive, patient-centered strategies addressing both oncological and mechanical aspects can improve survival and quality of life for patients with MSC.

Study design: Retrospective study.

Purpose: To compare clinical and radiographic outcomes of patients undergoing anterior cervical decompression surgery with and without resecting the posterior longitudinal ligament (PLL).

Overview of literature: Resection of the PLL during anterior cervical decompression surgery is still a controversial topic among spine surgeons.

Methods: All patients undergoing anterior cervical decompression surgery from October 2018 to December 2023 were included in this cohort. The PLL was preserved in patients with cervical spondylosis with only axial neck pain, cervical spine injuries with an intact PLL and intervertebral disc, PLL ossification with double layer signs on magnetic resonance imaging studies, and cervical spine metastasis. Clinical outcomes were used to evaluate the visual analog scale for neck pain and a modified Japanese Orthopedic Association score. Radiographs were used to evaluate the device-level Cobb angle (CA), segmental CA, global CA, and sagittal vertical axis, and they were compared with postoperative measurements at 1 year.

Results: A total of 102 patients underwent surgical intervention. In 36 patients, PLL was preserved. The retractor time was shorter in the non-PLL resection group and was statistically significant (p=0.046). The non-PLL resection group had fewer complications, but this was not statistically significant (p=0.787). Both clinical and radiographic outcomes were improved after surgery, and there were no statistically significant outcome differences between the resection and non-resection groups.

Conclusions: Resecting the PLL in patients undergoing anterior cervical spine surgery may prolong retractor time and could potentially result in postoperative complications. However, it does not significantly affect radiographic outcomes regarding cervical spine alignment compared to patients where the PLL was not cut.

Study design: Observational study.

Purpose: Cervical parameters play a vital role in maintaining global spinal sagittal alignment, but their correlation with spinopelvic parameters remains unclear. This study aimed to investigate potential direct correlations between cervical sagittal alignment and spinopelvic alignment in an asymptomatic population.

Overview of literature: Previous studies have demonstrated a direct relationship between pelvic parameters, lumbar lordosis (LL), and thoracic kyphosis (TK), as well as a direct correlation between cervical lordosis (CL) and TK. However, the direct influence of pelvic parameters and LL on cervical parameters remains unclear, warranting further research.

Methods: This study involved 104 asymptomatic adults (females 62 [59.6%]) aged 18-50 years. Whole-spine standing lateral radiographs were obtained, and the pelvic, lumbar, thoracic, cervicothoracic, and cervical parameters were studied. Pearson's correlation coefficient was used to assess correlations, with a significance threshold of p<0.05.

Results: The mean age of participants was 38.27±9.93 years. The pelvic incidence (PI) significantly correlated with C7 slope (r=-0.212, p=0.05). The pelvic tilt (PT) exhibited significant correlations with T1 slope-CL mismatch (r=-0.229, p=0.05) and C2 slope (r=-0.202, p=0.05). Furthermore, PI-LL mismatch showed a significant correlation with TIA (r=-0.197, p=0.05), T1 slope (r=-0.228, p=0.05), and C7 slope (r=-0.251, p=0.05).

Conclusions: This study reveals a significant correlation between cervical and spinopelvic parameters, emphasizing the interconnectedness of pelvic, lumbar, thoracic, and cervical spine parameters.

Study design: Longitudinal cohort study.

Purpose: To investigate factors associated with chronic pain (CP) development following vertebral fracture (VF).

Overview of literature: Factors contributing to CP development after VFs are not well characterized.

Methods: Hospitalized patients with acute VFs underwent assessment of vertebral morphology and paraspinal muscles. Two weeks post-admission, patients were evaluated for pain intensity (using the Verbal Rating Scale [VRS]), pain sensitivity (Pressure Pain Threshold [PPT] and Conditioned Pain Modulation), psychological factors, physical function, and activity levels. At 12 weeks, patients were categorized into CP and non-CP (NCP) groups based on VRS scores. Between-group comparisons and logistic regression analysis were performed to identify predictors of CP development.

Results: The CP group exhibited significantly lower remote PPT and reduced low-intensity physical activity time, but higher Pain Catastrophizing Scale rumination scores and prolonged 5-Times Sit-to-Stand Test (5SST) compared to the NCP group. Logistic regression identified prolonged 5SST and reduced low-intensity physical activity as independent predictors of CP development.

Conclusions: Prolonged 5SST and reduced low-intensity physical activity may predict CP development after VFs. Early assessment of these factors may facilitate CP risk screening in hospitalized patients with VFs.

Study design: Retrospective analysis.

Purpose: To evaluate preoperative bone mineral density (BMD), as quantified by computerized tomography (CT)-derived Hounsfield unit (HU) values, in patients who underwent lumbar fusion and to examine the link between BMD and failed back surgery syndrome (FBSS).

Overview of literature: FBSS is a serious complication affecting 10%-40% of patients undergoing lumbosacral spinal surgery. Given the detrimental impact of FBSS on the psychological and physiological wellbeing of patients, preoperative identification of those at risk for developing FBSS and the implementation of targeted interventions to minimize this complication are highly important.

Methods: Preoperatively, all 115 patients underwent BMD assessments using both CT-derived HUs and dual-energy X-ray absorptiometry and were administered multiple questionnaires, including the Pain Catastrophizing Scale (PCS), Beck Anxiety Inventory (BAI), and Beck Depression Index (BDI). Both pain intensity and pain-related disability were assessed before and after lumbar fusion surgery.

Results: Postoperatively, 14 patients (14/115, 12.2%) experienced FBSS. Multivariate logistic regression was used to examine all preoperative covariates with significant differences between the patients with and without FBSS. The numeric rating pain scale score at rest, BAI score, PCS score, and HU value were found to be independently associated with FBSS (p<0.05).

Conclusions: This study revealed that preoperative BMD, as quantified by CT-derived HU values, may be associated with FBSS. Preoperative assessments of CT-derived HU values might provide additional details for identifying patients susceptible to FBSS, which could help prevent this complication.

Obesity is an escalating health problem that has been increasingly associated with surgical complications. In general, open surgical techniques worsen these complications, because they are more tissue-destructive and associated with a relatively long recovery period. Minimally invasive techniques, such as endoscopic spine surgery, appear to be good substitutes, because they reduce tissue iatrogenic injury and hasten recovery. However, the effect of obesity on the performance of endoscopic spine surgery remains uncertain. This metaanalysis was designed to evaluate the safety and efficacy of endoscopic spine surgery in patients with obesity compared with those without obesity. This study adhered to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. We conducted a thorough search using PubMed, Scopus, and Virtual Health Library. Methodological quality was assessed using the MINORS (Methodological Index for Non-randomized Studies) criteria. Mean differences (MD) and standardized mean differences with 95% confidence intervals (CI) were calculated. Statistical analyses were conducted using Review manager ver. 5.4.1. Seven studies involving 659 participants were analyzed. The obese and nonobese groups had no significant differences in operative time (MD, 9.86 minutes; 95% CI, -4.93 to 24.65); Visual Analog Scale (VAS) scores for back pain at 3 months (MD, 0.26; 95% CI, -0.11 to 0.63), 6 months (MD, 0.26; 95% CI, -0.05 to 0.56), and 12 months (MD, -0.54; 95% CI, -1.70 to 0.62); VAS leg pain scores at 3 months (MD, 0.17; 95% CI, -0.06 to 0.41), 6 months (MD, 0.23; 95% CI, -0.13 to 0.59), and 12 months (MD, 0.18; 95% CI, -0.10 to 0.45); Oswestry Disability Index scores at 3 months (MD, 1.02; 95% CI, -0.14 to 2.18) and 12 months (MD, 0.10; 95% CI, -1.14 to 1.33); and reherniation rate (odds ratio, 1.35; 95% CI, 0.73 to 2.49). Endoscopic surgery demonstrated no significant differences in outcomes between obese and nonobese patients and was safe and effective for this patient population.

Study design: Single-center, retrospective cohort study of patients undergoing adult spinal deformity (ASD) surgery between 2009 and 2021.

Purpose: To identify preoperative and intraoperative risk factors associated with increased estimated blood loss (EBL), operative time, and length of stay (LOS) in ASD surgery.

Overview of literature: Identifying risk factors associated with these outcomes may help improve surgical planning and outcomes in ASD surgery.

Methods: Inclusion criteria: ≥5-level fusion, sagittal/coronal deformity, and minimum 2-year follow-up. Primary outcomes were the highest quartile of EBL (mL), operative time (minutes), and LOS (days). EBL was calculated based on the hemoglobin drop. Bivariate analysis and multivariable logistic regression were performed, controlling for age, comorbidities, and preoperative radiographic parameters.

Results: Among 238 patients (mean age, 63.4±17.4 years), the highest EBL quartile (2,594.0±1,550.5 mL) had more three-column osteotomies (3CO) (30.5% vs. 14.8%, p=0.008). Multivariable predictors of highest EBL were older age (odds ratio [OR], 1.03; p=0.039) and 3CO (OR, 3.60; p=0.007). The highest operative time quartile (618.9±99.4 minutes) had more 3CO (27.1% vs. 15.3%, p=0.041) and higher rod fracture rates (30.5% vs. 15.8%, p=0.014). Multivariable predictors of the highest operative time were higher total instrumented levels (TIL) (OR, 1.26; p<0.001) and older age (OR, 1.05; p=0.003). The highest LOS quartile (14.5±18.5 days) had more 3CO (27.3% vs. 14.3%, p=0.045). The multivariable predictor of highest LOS was higher TIL (OR, 1.23; p<0.001).

Conclusions: Three-column osteotomy was the strongest predictor of perioperative morbidity in ASD surgery, consistently associated with higher blood loss, longer operative times, and prolonged hospital stays. Recognizing its impact can inform surgical strategies to improve patient outcomes.