Trends in Lumbar Fusion Procedure Rates and Associated Hospital Costs for Degenerative Spinal Diseases in the United States, 2004 to 2015

An approach to the diagnosis of lumbar disc herniation using deep learning models

Background: In magnetic resonance imaging (MRI), lumbar disc herniation (LDH) detection is challenging due to the various shapes, sizes, angles, and regions associated with bulges, protrusions, extrusions, and sequestrations. Lumbar abnormalities in MRI can be detected automatically by using deep learning methods. As deep learning models gain recognition, they may assist in diagnosing LDH with MRI images and provide initial interpretation in clinical settings. YOU ONLY LOOK ONCE (YOLO) model series are often used to train deep learning algorithms for real-time biomedical image detection and prediction. This study aims to confirm which YOLO models (YOLOv5, YOLOv6, and YOLOv7) perform well in detecting LDH in different regions of the lumbar intervertebral disc. Materials and methods: The methodology involves several steps, including converting DICOM images to JPEG, reviewing and selecting MRI slices for labeling and augmentation using ROBOFLOW, and constructing YOLOv5x, YOLOv6, and YOLOv7 models based on the dataset. The training dataset was combined with the radiologist's labeling and annotation, and then the deep learning models were trained using the training/validation dataset. Results: Our result showed that the 550-dataset with augmentation (AUG) or without augmentation (non-AUG) in YOLOv5x generates satisfactory training performance in LDH detection. The AUG dataset overall performance provides slightly higher accuracy than the non-AUG. YOLOv5x showed the highest performance with 89.30% mAP compared to YOLOv6, and YOLOv7. Also, YOLOv5x in non-AUG dataset showed the balance LDH region detections in L2-L3, L3-L4, L4-L5, and L5-S1 with above 90%. And this illustrates the competitiveness of using non-AUG dataset to detect LDH. Conclusion: Using YOLOv5x and the 550 augmented dataset, LDH can be detected with promising both in non-AUG and AUG dataset. By utilizing the most appropriate YOLO model, clinicians have a greater chance of diagnosing LDH early and preventing adverse effects for their patients.

Incidence of spine surgery in the South African private healthcare sector: ten-year trends within a large open medical scheme

PURPOSE

Studies from developed countries suggest a dramatic increase in the utilization of spine surgery in recent decades, however less is known about spine surgery rates in the developing world. The aim of this study was to investigate ten-year trends in the incidence of spine surgery within South Africa's largest open medical scheme.

METHODS

This retrospective review included adult inpatient spine surgeries funded by the scheme between 2008 and 2017. The incidence of spine surgery was investigated by age group-overall and for degenerative pathologies, fusion and instrumentation. Surgeons per 100,000 members were determined. Trends were evaluated by linear regression and by crude 10-year change in incidence.

RESULTS

A total of 49,575 spine surgeries were included. The incidence of surgery for lumbar degenerative pathology showed a significant upward trend among 60-79 year olds but declined among 40-59 year olds. The incidence of lumbar fusion and lumbar instrumentation declined significantly among 40-59 year olds with little change among 60-79 year olds. The ratio of orthopaedic spinal surgeons decreased from 10.2 to 6.3 per 100,000 members whereas the ratio of neurosurgeons decreased from 7.6 to 6.5 per 100,000.

CONCLUSION

Spine surgery in the South African private healthcare sector bears some similarity to developed countries in that it is dominated by elective procedures for degenerative pathology. However, the findings did not reflect the marked increases in the utilization of spine surgery reported elsewhere. It is hypothesized that this may be partly related to differences in the supply of spinal surgery.

A Randomized Controlled Trial to Assess the Impact of Enhanced Recovery After Surgery on Patients Undergoing Elective Spine Surgery

OBJECTIVE

To conduct a prospective, randomized controlled trial (RCT) of an enhanced recovery after surgery (ERAS) protocol in an elective spine surgery population.

BACKGROUND

Surgical outcomes such as length of stay (LOS), discharge disposition, and opioid utilization greatly contribute to patient satisfaction and societal healthcare costs. ERAS protocols are multimodal, patient-centered care pathways shown to reduce postoperative opioid use, reduced LOS, and improved ambulation; however, prospective ERAS data are limited in spine surgery.

METHODS

This single-center, institutional review board-approved, prospective RCT-enrolled adult patients undergoing elective spine surgery between March 2019 and October 2020. Primary outcomes were perioperative and 1-month postoperative opioid use. Patients were randomized to ERAS (n=142) or standard-of-care (SOC; n=142) based on power analyses to detect a difference in postoperative opioid use.

RESULTS

Opioid use during hospitalization and the first postoperative month was not significantly different between groups (ERAS 112.2 vs SOC 117.6 morphine milligram equivalent, P =0.76; ERAS 38.7% vs SOC 39.4%, P =1.00, respectively). However, patients randomized to ERAS were less likely to use opioids at 6 months postoperatively (ERAS 11.4% vs SOC 20.6%, P =0.046) and more likely to be discharged to home after surgery (ERAS 91.5% vs SOC 81.0%, P =0.015).

CONCLUSION

Here, we present a novel ERAS prospective RCT in the elective spine surgery population. Although we do not detect a difference in the primary outcome of short-term opioid use, we observe significantly reduced opioid use at 6-month follow-up as well as an increased likelihood of home disposition after surgery in the ERAS group.

Identification of Factors Associated With 30-day Readmissions After Posterior Lumbar Fusion Using Machine Learning and Traditional Models: A National Longitudinal Database Study

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To identify the factors associated with readmissions after PLF using machine learning and logistic regression (LR) models.

SUMMARY OF BACKGROUND DATA

Readmissions after posterior lumbar fusion (PLF) place significant health and financial burden on the patient and overall health care system.

MATERIALS AND METHODS

The Optum Clinformatics Data Mart database was used to identify patients who underwent posterior lumbar laminectomy, fusion, and instrumentation between 2004 and 2017. Four machine learning models and a multivariable LR model were used to assess factors most closely associated with 30-day readmission. These models were also evaluated in terms of ability to predict unplanned 30-day readmissions. The top-performing model (Gradient Boosting Machine; GBM) was then compared with the validated LACE index in terms of potential cost savings associated with the implementation of the model.

RESULTS

A total of 18,981 patients were included, of which 3080 (16.2%) were readmitted within 30 days of initial admission. Discharge status, prior admission, and geographic division were most influential for the LR model, whereas discharge status, length of stay, and prior admissions had the greatest relevance for the GBM model. GBM outperformed LR in predicting unplanned 30-day readmission (mean area under the receiver operating characteristic curve 0.865 vs. 0.850, P <0.0001). The use of GBM also achieved a projected 80% decrease in readmission-associated costs relative to those achieved by the LACE index model.

CONCLUSIONS

The factors associated with readmission vary in terms of predictive influence based on standard LR and machine learning models used, highlighting the complementary roles these models have in identifying relevant factors for the prediction of 30-day readmissions. For PLF procedures, GBM yielded the greatest predictive ability and associated cost savings for readmission.

LEVEL OF EVIDENCE

3.

Immune response to foreign materials in spinal fusion surgery

Spinal fusion surgery is a common procedure used to stabilize the spine and treat back pain. The procedure involves the use of foreign materials such as screws, rods, or cages, which can trigger a foreign body reaction, an immune response that involves the activation of immune cells such as macrophages and lymphocytes. The foreign body reaction can impact the success of spinal fusion, as it can interfere with bone growth and fusion. This review article provides an overview of the cellular and molecular events in the foreign body reaction, the impact of the immune response on spinal fusion, and strategies to minimize its impact. By carefully considering the use of foreign materials and optimizing surgical techniques, the impact of the foreign body reaction can be reduced, leading to better outcomes for patients.

The severity of preoperative anemia escalates risk of poor short-term outcomes after lumbar spine fusion

OBJECTIVE

To evaluate how preoperative anemia severity affects 90-day outcomes of spinal fusion surgery.

METHODS

A retrospective cohort study was conducted on adult lumbar fusion patients at a tertiary medical center. Patients were classified by World Health Organization anemia severity definitions for comparisons. Multivariate regression models were created to control for confounding variables, for all primary outcomes of transfusion requirements, non-home discharge, readmissions, complications, and length of stay.

RESULTS

A total of 2582 patients were included: 2.7% with moderate-severe anemia, 11.0% with mild anemia, and 86.3% without anemia. Moderate-severe patients had the longest hospital stay (5.03 days vs 4.14 and 3.59 days, p < 0.001) and highest risk of transfusion (52.2% vs 13.0% vs 2.69%, p < 0.001), non-home discharge (39.1% vs 27.8% vs 15.4%, p < 0.001), readmission (7.25% vs 5.99% vs 3.36%, p = 0.023), and complications (13.0% vs 9.51% vs 6.20%, p = 0.012). On multivariable logistic regression, both patients with mild and moderate-severe anemia had an increased risk of transfusion (OR: 37.3, p < 0.001; OR: 5.25, p < 0.001, respectively) and non-home discharge (OR: 2.00, p = 0.021; OR: 1.71, p = 0.001, respectively) compared to patients without anemia. Anemia severity was not independently associated with complications or 90-day readmission. On multivariable linear regression, mild anemia (β: 0.37, p = 0.001) and moderate-severe anemia (β: 1.07, p < 0.001) were independently associated with length of hospital stay.

CONCLUSION

Patients with moderate-severe preoperative anemia are at increased risk for longer length of stay, transfusions, and non-home discharge. Improved optimization of preoperative anemia may significantly reduce healthcare utilization, and surgeons should consider these risks in preoperative planning.

LEVEL OF EVIDENCE

III.

Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders

Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.

Patient-Specific Safe Zones for Acetabular Component Positioning in Total Hip Arthroplasty: Mathematically Accounting for Spinopelvic Biomechanics

BACKGROUND

Despite a growing understanding of spinopelvic biomechanics in total hip arthroplasty (THA), there is no validated approach for executing patient-specific acetabular component positioning. The purpose of this study was to (1) validate quantitative, patient-specific acetabular "safe zone" component positioning from spinopelvic parameters and (2) characterize differences between quantitative patient-specific acetabular targets and qualitative hip-spine classification targets.

METHODS

From 2,457 consecutive primary THA patients, 22 (0.88%) underwent revision for instability. Spinopelvic parameters were measured prior to index THA. Acetabular position was measured following index and revision arthroplasty. Using a mathematical proof, we developed an open-source tool translating a surgeon-selected, preoperative standing acetabular target to a patient-specific safe zone intraoperative acetabular target. Difference between the patient-specific safe zone and the actual component position was compared before and after revision. Hip-spine classification targets were compared to patient-specific safe zone targets.

RESULTS

Of the 22 who underwent revision, none dislocated at follow-up (4.6 [range, 1 to 6.9]). Patient-specific safe zone targets differed from prerevision acetabular component position by 9.1 ± 4.2° inclination/13.3 ± 6.7° version; after revision, the mean difference was 3.2 ± 3.0° inclination/5.3 ± 2.7° version. Differences between patient-specific safe zones and the median and extremes of recommended hip-spine classification targets were 2.2 ± 1.9° inclination/5.6 ± 3.7° version and 3.0 ± 2.3° inclination/7.9 ± 3.5° version, respectively.

CONCLUSION

A mathematically derived, patient-specific approach accommodating spinopelvic biomechanics for acetabular component positioning was validated by approximating revised, now-stable hips within 5° version and 3° inclination. These patient-specific safe zones augment the hip-spine classification with prescriptive quantitative targets for nuanced preoperative planning.

Influential literature regarding proximal junctional kyphosis: A bibliometric review

Study design

Retrospective review.

Objective

This bibliometric review summarizes the publication trends and critical information about the most cited Proximal Junction Kyphosis (PJK) articles.

Background

Data: Proximal junctional kyphosis is frequently diagnosed after spinal fusion surgery. However, there continues to be heavy debate regarding the definition, incidence, risk factors, and treatment of this disorder.

Methods

Nine hundred eleven articles were found when searching The Web of Science database with the keywords "Proximal junctional kyphosis" and "proximal junctional failure." The 200 top-cited articles were reviewed and screened to ensure PJK was discussed. The articles were filtered based on the highest to lowest number of citations, and the top 50 articles were chosen. Inclusion criteria included articles that contained a discussion of PJK and outcomes after surgery. Exclusion criteria included articles without mentioning PJK, or that studied non-human subjects. The 50 most cited articles were sorted by level of evidence and their classification for analysis.

Results

The 50 most cited articles in this study were published a total of 6056 times. These articles were cited 71-413 times in the literature, with publications from 1994 to 2018. Most of the top 50 articles (64%) were published in the USA. Specifically, HSS and Washington University are the institutions with the most contributions to the publication of the most cited articles on PJK (n = 16). Lenke was the author that contributed to most publications in the top 50 articles on PJK.

Conclusion

This study provides a framework for the most cited articles published on PJK. Most articles on this topic were in the category of clinical outcomes (36%) and were of a level of evidence III (46%). Most of the top-cited articles came from the journal Spine (68%) and were published in the USA (64%). These top-cited papers are essential to understanding this critical trending topic in spine surgery.

Level of evidence

III.

A Randomised Controlled Study on Epidural Morphine and Bupivacaine for Post-Operative Analgesia After Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Randomised control study.

OBJECTIVE

Different parenteral analgesics are used to alleviate post-operative pain after transforaminal lumbar interbody fusion (TLIF) but limited by their efficacy and side effects. We performed a RCT to evaluate the safety and efficacy of epidural Morphine-Bupivacaine on post-operative pain management after TLIF.

METHODS

Consecutive patients (n=100) of TLIF were divided randomly into study (SG) and control groups (CG). At the end of procedure, SG (n=50) received epidural instillation of morphine 5 mg and bupivacaine .25% - 2 mL, along with 6 mL of .25% bupivacaine infiltration in the deep fascia before wound closure. The functional outcomes were assessed at regular intervals (4, 8, 12, 24, 36, 48, 72, 96 hours) with VAS, nausea and vomiting scale, Ramsay sedation scale and breakthrough analgesia needed, time to ambulation and other complications.

RESULTS

The mean VAS score at 4 hours in SG was significantly less (1.16 ± .88) than the CG (3.32 ± 1.0) (P = .000). This significant difference was maintained at each time point during the first 48 hours (P < .004). Similarly, the mean NRS score in SG at 4 hours was 1.02 ± .89, and in CG 3.3 ± .69 (P = .0000) which was maintained at all intervals of assessment till 48 hours (P = .0137). The mean time to first ambulation was significantly less in the SG (4.46 ± 1.04 hours) than CG (11.64 ± 2.3 hours) (P < .001). There were no drug-related complications.

CONCLUSION

Epidural instillation of bupivacaine and morphine is safe and enables better pain relief in the initial 48 hours which helps in early mobilisation, and enhanced functional recovery.

Trends of Surgical Service Utilization for Lumbar Spinal Stenosis in South Korea: A 10-Year (2010-2019) Cross-Sectional Analysis of the Health Insurance Review and Assessment Service-National Patient Sample Data

Background and Objectives: This retrospective, cross-sectional, and descriptive study used claims data from the Korean Health Insurance Review and Assessment Service (HIRA) between 2010 and 2019 to analyze the trend of surgical service utilization in patients with lumbar spinal stenosis (LSS). Materials and Methods: The national patient sample data provided by the HIRA, which consisted of a 2% sample of the entire Korean population, was used to assess all patients who underwent decompression or fusion surgery at least once in Korea, with LSS as the main diagnosis from January 2010 to December 2019. An in-depth analysis was conducted to examine the utilization of surgical services, taking into account various demographic characteristics of patients, the frequency of claims for different types of surgeries, reoperation rates, the specific types of inpatient care associated with each surgery type, prescribed medications, and the overall expense of healthcare services. Results: A total of 6194 claims and 6074 patients were analyzed. The number of HIRA claims for patients increased from 393 (2010) to 417 (2019) for decompression, and from 230 (2010) to 244 (2019) for fusion. As for the medical expenses of surgery, there was an increase from United States dollar (USD) 867,549.31 (2010) to USD 1,153,078.94 (2019) for decompression and from USD 1,330,440.37 (2010) to USD 1,780,026.48 (2019) for fusion. Decompression accounted for the highest proportion (65.8%) of the first surgeries, but more patients underwent fusion (50.6%) than decompression (49.4%) in the second surgery. Across all sex and age groups, patients who underwent fusion procedures experienced longer hospital stays and incurred higher medical expenses for their inpatient care. Conclusion: The surgical service utilization of patients with LSS and the prescribing rate of opioids and non-opioid analgesics for surgical patients increased in 2019 compared to 2010. From mid-2010 onward, claims for fusion showed a gradual decrease, whereas those for decompression showed a continuously increasing trend. The findings of this study are expected to provide basic research data for clinicians, researchers, and policymakers.

Instrumented Posterior Arthrodesis of the Lumbar Spine: Prospective Study Evaluating Fusion Outcomes in Patients Receiving an Interspinous Fixation Device for the Treatment of Degenerative Spine Diseases

Purpose

Prospective evaluation of radiographic fusion outcomes in patients receiving instrumented posterior arthrodesis of the lumbar spine using a minimally invasive interspinous fixation device.

Patients and Methods

All patients (n = 110) from a single US physician's practice who received instrumented posterior arthrodesis of the lumbar spine with a minimally invasive interspinous fixation device in the calendar year 2020 were invited to return for a follow-up CT scan to radiographically assess fusion. Forty-three patients, representing 69 total treated levels, consented to participate and received a lumbar CT scan at a mean of 459 days post-surgery (177 to 652). The interspinous/interlaminar fusion was assessed by 3 independent radiologists using a novel grading scale. Spinous process fractures were also assessed.

Results

92.8% of the assessed levels were considered fused. There were no intraoperative spinous process fractures. There were 4 spinous process fractures (5.8%) identified on CT imaging, all of which were asymptomatic and healed without subsequent intervention. There were no instances of device mechanical failure or device-related reoperation.

Conclusion

Instrumented posterior arthrodesis of the lumbar spine using a minimally invasive interspinous fixation device provides clinically meaningful fusion rates with no reoperations and a low risk of spinous process fracture or other device-related complications.

Spinal Injections: A Narrative Review from a Surgeon's Perspective

Spinal pain is one of most frequent complaints of the general population, which can cause decreased activities of daily living and absence from work. Among numerous therapeutic methods, spinal injection is one of the most effective treatments for spinal pain and is currently widely applied in the clinical field. In this review, spinal injection is discussed from a surgeon's perspective. Recently, although the number of spinal surgeries has been increasing, questions are arising as to whether they are necessary. The failure rate after spinal surgery is high, and its long-term outcome was reported to be similar to spinal injection. Thus, spinal surgeries should be performed conservatively. Spinal injection is largely divided into diagnostic and therapeutic blocks. Using diagnostic blocks, such as the diagnostic selective nerve root block, disc stimulation test, and diagnostic medial branch block (MBB), the precise location causing the pain can be confirmed. For therapeutic blocks, transforaminal nerve root injection, therapeutic MBB, and percutaneous epidural neuroplasty are used. When unbearable spinal pain persists despite therapeutic spinal injections, spinal surgeries can be considered. Spinal injection is usefully used to identify the precise location prior to a patient undergoing injection treatment or surgery and can reduce pain and improve quality of life, and help to avoid spinal surgery. Pain physicians should treat patients with spinal pain by properly utilizing spinal injection.

Economic Trends in Commonly Used Drugs for Spinal Fusion and Brain Tumor Resection: An Analysis of the Medicare Part D Database

With the incidence of central and peripheral nervous system disorders on the rise, neurosurgical procedures paired with the careful administration of select medications have become necessary to optimize patient outcomes. Despite efforts to decrease the over-prescription of common addictive drugs, such as opioids, prescription costs continue to rise. This study analyzed temporal trends in medication use and cost for spinal fusion and brain tumor resection procedures. The Medicare Part B Database was queried from 2016 to 2020 for data regarding spinal fusion and brain tumor resection procedures, while the Part D Database was used to extract data for two commonly prescribed medications for each procedure. Pearson's correlation coefficient and linear regression were completed for the analyzed variables. The results showed a significant negative correlation between the number of spinal procedure beneficiaries and the cost of methocarbamol, as well as between the annual percent change in spinal beneficiaries and the annual percent change in oxycodone cost. Linear regression revealed that oxycodone cost was the only parameter with a statistically significant model. Moving forward, it is imperative to combat rising drug costs, regardless of trends seen in their usage. Further studies should focus on the utilization of primary data in a multi-center study.

Awake Spinal Fusion Is Associated with Reduced Length of Stay, Opioid Use, and Time to Ambulation Compared to General Anesthesia: A Matched Cohort Study

OBJECTIVE

There is increasing interest in performing awake spinal fusion under spinal anesthesia (SA). Evidence supporting SA has been positive, albeit limited. The authors set out to investigate the effects of SA versus general anesthesia (GA) for spinal fusion procedures on length of stay (LOS), opioid use, time to ambulation (TTA), and procedure duration.

METHODS

The authors performed a retrospective review of a single surgeon's patients who underwent lumbar fusions under SA versus GA from June of 2020 to June of 2022. SA patients were compared to demographically matched GA counterparts undergoing comparable procedures. Analyzed outcomes include operative time, opioid usage in morphine milligram equivalents, TTA, and LOS.

RESULTS

Ten SA patients were matched to 10 GA counterparts. The cohort had a mean age of 66.77, a mean body mass index of 27.73 kg/m2, and a median American Society of Anesthesiologists Physical Status Score of 3.00. LOS was lower in SA versus GA patients (12.87 vs. 50.79 hours, P = 0.001). Opioid utilization was reduced in SA versus GA patients (10.76 vs. 31.43 morphine milligram equivalents, P = 0.006). TTA was reduced in SA versus GA patients (7.22 vs. 29.87 hours, P = 0.022). Procedure duration was not significantly reduced in SA patients compared to GA patients (139.3 vs. 188.2 minutes, P = 0.089).

CONCLUSIONS

These preliminary retrospective results suggest the use of SA rather than GA for lumbar fusions is associated with reduced hospital LOS, reduced opioid utilization, and reduced TTA. Future randomized prospective studies are warranted to determine if SA usage truly leads to these beneficial outcomes.

Assessment of Risk Factors for Postoperative Delirium in Older Adults Who Underwent Spinal Surgery and Identifying Associated Biomarkers Using Exosomal Protein

PURPOSE

With an increase in the aging population, the number of patients with degenerative spinal diseases undergoing surgery has risen, as has the incidence of postoperative delirium. This study aimed to investigate the risk factors affecting postoperative delirium in older adults who had undergone spine surgery and to identify the associated biomarkers.

METHODS

This study is a prospective study. Data of 100 patients aged ≥ 70 years who underwent spinal surgery were analyzed. Demographic data, medical history, clinical characteristics, cognitive function, depression symptoms, functional status, frailty, and nutritional status were investigated to identify the risk factors for delirium. The Confusion Assessment Method, Delirium Rating Scale-R-98, and Nursing Delirium Scale were also used for diagnosing delirium. To discover the biomarkers, urine extracellular vesicles (EVs) were analyzed for tau, ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), neurofilament light, and glial fibrillary acidic protein using digital immunoassay technology.

RESULTS

Nine patients were excluded, and data obtained from the remaining 91 were analyzed. Among them, 18 (19.8%) developed delirium. Differences were observed between participants with and without delirium in the contexts of a history of mental disorder and use of benzodiazepines (p = .005 and p = .026, respectively). Tau and UCH-L1-concentrations of urine EVs-were comparatively higher in participants with severe delirium than that in participants without delirium (p = .002 and p = .001, respectively).

CONCLUSION

These findings can assist clinicians in accurately identifying the risk factors before surgery, classifying high-risk patients, and predicting and detecting delirium in older patients. Moreover, urine EV analysis revealed that postoperative delirium following spinal surgery is most likely associated with brain damage.

Endoscopic anterior to psoas lumbar interbody fusion: indications, techniques, and clinical outcomes

PURPOSE

The retrospective study aimed to report the surgical technique and clinic-radiological outcomes of endoscopic anterior to psoas interbody lumbar fusion through the retroperitoneal approach with direct and indirect decompression.

METHODS

We retrospectively analyzed the results of clinical parameters of patients who underwent endoscopic anterior to psoas interbody lumbar fusion between June 2013 and June 2022. Clinical outcomes were evaluated by the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores. The radiological outcomes were measured and statistically compared in disc height index (DHI), whole lumbar lordosis (WLL), pelvic Incidence (PI), pelvic tilt (PT), Segmental lordosis (SL), the sagittal vertical axis (SVA).

RESULTS

A total of 35 patients were selected for the procedure ranging in age from 51 to 84 years with 17.83 ± 8.85 months follow-up. The mean operation time in lateral position for one level was 162.96 ± 35.76 min (n = 24), and 207.73 ± 66.60 min for two-level fusion. The mean endoscopic time was 32.83 ± 17.71 min per level, with a total estimated blood loss of 230.57 ± 187.22 cc. The mean postoperative VAS back, leg pain score and ODI improved significantly compared to the preoperative values; Radiological data showed significant change in WLL, SL, DHI, PI, PT, and SS; however, there is no significant difference in SVA postoperatively. Subgroup analysis for the radiographic data showed 50 mm length cage has significantly improved for the DHI, SS and SVA compare to 40 mm length cage. The subgroup analysis results showed that hypertensive patients had significantly higher proportion in the incomplete fusion group compare to complete fusion group at one-year follow-up.

OUTCOMES

The endoscopic anterior to psoas interbody lumbar fusion achieves satisfactory indirect and direct decompression. This convergent technique presents an effective choice for treating lumbar instability associated with disc herniations and foraminal stenosis, thus complementing the indications for oblique lumbar interbody fusion.

A Comparison of Radiographic Alignment between Bilateral and Unilateral Interbody Cages in Patients Undergoing Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To compare radiographic outcomes between unilateral and bilateral cage placement in transforaminal lumbar interbody fusions (TLIF) and to determine if the rate of fusion at the 1-year postoperative point was different in patients who received bilateral versus unilateral cages.

OVERVIEW OF LITERATURE

There is no clear evidence to dictate whether bilateral or unilateral cages promote superior radiographic or surgical outcomes in TLIF.

METHODS

Patients >18 years old who underwent primary one- or two-level TLIFs at our institution were identified and propensitymatched in a 3:1 fashion (unilateral:bilateral). Patient demographics, surgical characteristics, and radiographic outcomes, including vertebral endplate obliquity, segmental lordosis, subsidence, and fusion status, were compared between groups.

RESULTS

Of the 184 patients included, 46 received bilateral cages. Bilateral cage placement was associated with greater subsidence (1.06±1.25 mm vs. 0.59±1.16 mm, p=0.028) and enhanced restoration of segmental lordosis (5.74°±14.1° vs. -1.57°±10.9°, p=0.002) at the 1-year postoperative point, while unilateral cage placement was associated with an increased correction of endplate obliquity (-2.02°±4.42° vs. 0.24°±2.81°, p<0.001). Bilateral cage placement was significantly associated with radiographic fusion on bivariate analysis (89.1% vs. 70.3%, p=0.018) and significantly predicted radiographic fusion on multivariable regression analysis (estimate, 1.35; odds ratio, 3.87; 95% confidence interval, 1.51-12.05; p=0.010).

CONCLUSIONS

Bilateral interbody cage placement in TLIF procedures was associated with restoration of lumbar lordosis and increased fusion rates. However, endplate obliquity correction was significantly greater for patients who received a unilateral cage.

Decompression alone versus decompression with instrumented fusion in the treatment of lumbar degenerative spondylolisthesis: a systematic review and meta-analysis of randomised trials

OBJECTIVE

To determine the efficacy of adding instrumented spinal fusion to decompression to treat degenerative spondylolisthesis (DS).

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

MEDLINE, Embase, Emcare, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations & Theses Global, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform from inception to May 2022.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised controlled trials (RCTs) comparing decompression with instrumented fusion to decompression alone in patients with DS. Two reviewers independently screened the studies, assessed the risk of bias and extracted data. We provide the Grading of Recommendations, Assessment, Development and Evaluation assessment of the certainty of evidence (COE).

RESULTS

We identified 4514 records and included four trials with 523 participants. At a 2-year follow-up, adding fusion to decompression likely results in trivial difference in the Oswestry Disability Index (range 0-100, with higher values indicating greater impairment) with mean difference (MD) 0.86 (95% CI -4.53 to 6.26; moderate COE). Similar results were observed for back and leg pain measured on a scale of 0 to 100, with higher values indicating more severe pain. There was a slightly increased improvement in back pain (2-year follow-up) in the group without fusion shown by MD -5·92 points (95% CI -11.00 to -0.84; moderate COE). There was a trivial difference in leg pain between the groups, slightly favouring the one without fusion, with MD -1.25 points (95% CI -6.71 to 4.21; moderate COE). Our findings at 2-year follow-up suggest that omitting fusion may increase the reoperation rate slightly (OR 1.23; 0.70 to 2.17; low COE).

CONCLUSIONS

Evidence suggests no benefits of adding instrumented fusion to decompression for treating DS. Isolated decompression seems sufficient for most patients. Further RCTs assessing spondylolisthesis stability are needed to determine which patients would benefit from fusion.

PROSPERO REGISTRATION NUMBER

CRD42022308267.

Deep Neuromuscular Block Attenuates Chronic Postsurgical Pain and Enhances Long-Term Postoperative Recovery After Spinal Surgery: A Randomized Controlled Trial

INTRODUCTION

The effects of deep neuromuscular block (DNMB) on chronic postsurgical pain (CPSP) have not been conclusively determined. Moreover, a limited number of studies have examined the impact of DNMB on long-term recovery quality after spinal surgery. We investigated the impact of DNMB on CPSP and the quality of long-term recovery in patients who had been subjected to spinal surgery.

METHODS

This was a randomized, controlled, double-blind, single-center study performed from May 2022 to November 2022. A total of 220 patients who underwent spinal surgery under general anesthesia were randomly assigned to receive either DNMB (post-tetanic count at 1-2) (the D group) or moderate NMB (MNMB) (train-of-four at 1-3) (the M group). The primary endpoint was the incidence of CPSP. The secondary endpoints included the visual analogue scale (VAS) score in the post-anesthesia recovery unit (PACU), at 12, 24, 48 h and 3 months after surgery; postoperative opioid consumption; quality of recovery-15 (QoR-15) scores on the second postoperative day, before discharge, and 3 months after surgery.

RESULTS

The incidence of CPSP was significantly lower in the D group (30/104, 28.85%) than in the M group (45/105, 42.86%) (p = 0.035). Besides, VAS scores were significantly reduced at the third month in the D group (p = 0.016). In the PACU and 12 h after surgery, VAS scores were also significantly lower in the D group than in the M group (p < 0.001, p = 0.004, respectively). The total amount of postoperative opioid consumption (expressed in total oral morphine equivalents) was significantly less in D group than M group (p = 0.027). At 3 months after surgery, QoR-15 scores were significantly higher in D group than M group (p = 0.003).

CONCLUSIONS

Compared with MNMB, DNMB significantly reduced CPSP and postoperative opioid consumption in spinal surgery patients. Moreover, DNMB improved the long-term recovery of patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2200058454).

Randomized-controlled trial assessing a digital care program versus conventional physiotherapy for chronic low back pain

Low back pain (LBP) is the world's leading cause of years lived with disability. Digital exercise-based interventions have shown great potential in the management of musculoskeletal conditions, promoting access and easing the economic burden. However, evidence of their effectiveness for chronic LBP (CLBP) management compared to in-person physiotherapy has yet to be unequivocally established. This randomized controlled trial (RCT) aims to compare the clinical outcomes of patients with CLBP following a digital intervention versus evidence-based in-person physiotherapy. Our results demonstrate that patient satisfaction and adherence were high and similar between groups, although a significantly lower dropout rate is observed in the digital group (11/70, 15.7% versus 24/70, 34.3% in the conventional group; P = 0.019). Both groups experience significant improvements in disability (primary outcome), with no differences between groups in change from baseline (median difference: -0.55, 95% CI: -2.42 to 5.81, P = 0.412) or program-end scores (-1.05, 95% CI: -4.14 to 6.37; P = 0.671). Likewise, no significant differences between groups are found for secondary outcomes (namely pain, anxiety, depression, and overall productivity impairment). This RCT demonstrates that a remote digital intervention for CLBP can promote the same levels of recovery as evidence-based in-person physiotherapy, being a potential avenue to ease the burden of CLBP.

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

Importance

Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population.

Objective

To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019.

Design, Setting, and Participants

This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023.

Main Outcome and Measure

The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone.

Results

Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001).

Conclusions and Relevance

In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.

Projected Lifetime Cancer Risk Associated With Intraoperative Computed Tomography for Lumbar Spine Surgery

STUDY DESIGN

Retrospective cross-sectional study.

OBJECTIVE

(1) To determine the incremental increase in intraoperative ionizing radiation conferred by computed tomography (CT) as compared with conventional radiography; and (2) to model different lifetime cancer risks contextualized by the intersection between age, sex, and intraoperative imaging modality.

SUMMARY OF BACKGROUND DATA

Emerging technologies in spine surgery, like navigation, automation, and augmented reality, commonly utilize intraoperative CT. Although much has been written about the benefits of such imaging modalities, the inherent risk profile of increasing intraoperative CT has not been well evaluated.

MATERIALS AND METHODS

Effective doses of intraoperative ionizing radiation were extracted from 610 adult patients who underwent single-level instrumented fusion for lumbar degenerative or isthmic spondylolisthesis from January 2015 through January 2022. Patients were divided into those who received intraoperative CT (n=138) and those who underwent conventional intraoperative radiography (n=472). Generalized linear modeling was utilized with intraoperative CT use as a primary predictor and patient demographics, disease characteristics, and preference-sensitive intraoperative considerations ( e.g. surgical approach and surgical invasiveness) as covariates. The adjusted risk difference in radiation dose calculated from our regression analysis was used to prognosticate the associated cancer risk across age and sex strata.

RESULTS

(1) After adjusting for covariates, intraoperative CT was associated with 7.6 mSv (interquartile range: 6.8-8.4 mSv; P <0.001) more radiation than conventional radiography. (2) For the median patient in our population (a 62-year-old female), intraoperative CT use increased lifetime cancer risk by 2.3 incidents (interquartile range: 2.1-2.6) per 10,000. Similar projections for other age and sex strata were also appreciated.

CONCLUSIONS

Intraoperative CT use significantly increases cancer risk compared with conventional intraoperative radiography for patients undergoing lumbar spinal fusions. As emerging technologies in spine surgery continue to proliferate and leverage intraoperative CT for cross-sectional imaging data, strategies must be developed by surgeons, institutions, and medical technology companies to mitigate long-term cancer risks.

Evaluation of Hospital Compliance With Federal Price Transparency Regulations and Variability of Negotiated Rates for Spinal Fusion

INTRODUCTION

To improve price transparency, the Centers for Medicare & Medicaid Services (CMS) requires hospitals to post accessible pricing data for common elective procedures along with all third-party-negotiated rates. We aimed to evaluate hospital compliance with CMS regulations for both price estimators and machine-readable files for spinal fusions and to evaluate factors contributing to variability in hospital-negotiated pricing.

METHODS

We reviewed the top 100 orthopaedic hospitals ranked by US News & World Report to assess compliance with CMS price transparency regulations for all spine diagnosis-related groups. We recorded gross inpatient charge, cash price, and deidentified maximum and minimum rates for the 11 spine diagnosis-related groups (DRGs). Variability was compared with geographic practice costs (GPCI), expected Medicare reimbursements, and poverty rate and median income ratio.

RESULTS

Only 72% of hospitals were fully compliant in reporting spinal fusions on their price estimator, and 39% were fully compliant in reporting all mandatory rates for spinal fusions. The overall estimated cash price was $96,979 ± $56,262 and $62,595 ± $40,307 for noncervical and cervical fusion, respectively. Cash prices at top 50 hospitals were higher for both noncervical and cervical fusions ( P = 0.0461 and P = 0.0341, respectively). The average minimum negotiated rates ranged from 0.88 to 1.15 times the expected Medicare reimbursement, while maximum and cash prices were 3.41 to 3.90 and 2.53 to 4.08 times greater than Medicare reimbursement. GPCI demonstrated little to no correlation with DRG pricing. However, minimum negotiated rates and cash prices demonstrated weak positive correlations with the median income ratio and weak negative correlations with the poverty rate.

DISCUSSION

Most US hospitals are not fully compliant with CMS price transparency regulations for spinal fusions despite increased overall utilization of price estimators and machine-readable files. Although higher ranked hospitals charged more for spinal fusions, DRG prices remain widely variable with little to no correlation with practice cost or socioeconomic parameters.

Accounting for age in prediction of discharge destination following elective lumbar fusion: a supervised machine learning approach

BACKGROUND CONTEXT

The number of elective spinal fusion procedures performed each year continues to grow, making risk factors for post-operative complications following this procedure increasingly clinically relevant. Nonhome discharge (NHD) is of particular interest due to its associations with increased costs of care and rates of complications. Notably, increased age has been found to influence rates of NHD.

PURPOSE

To identify aged-adjusted risk factors for nonhome discharge following elective lumbar fusion through the utilization of Machine Learning-generated predictions within stratified age groupings.

STUDY DESIGN

Retrospective Database Study.

PATIENT SAMPLE

The American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database years 2008 to 2018.

OUTCOME MEASURES

Postoperative discharge destination.

METHODS

ACS-NSQIP was queried to identify adult patients undergoing elective lumbar spinal fusion from 2008 to 2018. Patients were then stratified into the following age ranges: 30 to 44 years, 45 to 64 years, and ≥65 years. These groups were then analyzed by eight ML algorithms, each tasked with predicting post-operative discharge destination.

RESULTS

Prediction of NHD was performed with average AUCs of 0.591, 0.681, and 0.693 for those aged 30 to 44, 45 to 64, and ≥65 years respectively. In patients aged 30 to 44, operative time (p<.001), African American/Black race (p=.003), female sex (p=.002), ASA class three designation (p=.002), and preoperative hematocrit (p=.002) were predictive of NHD. In ages 45 to 64, predictive variables included operative time, age, preoperative hematocrit, ASA class two or class three designation, insulin-dependent diabetes, female sex, BMI, and African American/Black race all with p<.001. In patients ≥65 years, operative time, adult spinal deformity, BMI, insulin-dependent diabetes, female sex, ASA class four designation, inpatient status, age, African American/Black race, and preoperative hematocrit were predictive of NHD with p<.001. Several variables were distinguished as predictive for only one age group including ASA Class two designation in ages 45 to 64 and adult spinal deformity, ASA class four designation, and inpatient status for patients ≥65 years.

CONCLUSIONS

Application of ML algorithms to the ACS-NSQIP dataset identified a number of highly predictive and age-adjusted variables for NHD. As age is a risk factor for NHD following spinal fusion, our findings may be useful in both guiding perioperative decision-making and recognizing unique predictors of NHD among specific age groups.

Perioperative Management of Comorbidities in Spine Surgery

The number of spinal operations performed in the United States has significantly increased in recent years. Along with these rising numbers, there has been a corresponding increase in the number of patient comorbidities. The focus of this article is to review comorbidities in Spine surgery patients and outline strategies to optimize patients and avoid complications.

Provider Referral Patterns and Surgical Utilization Among New Patients Seen in Spine Clinic

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

The objective of this study was to elucidate the demographics of patient referrals from different sources and identify factors that affect a patient's likelihood of undergoing surgery.

SUMMARY OF BACKGROUND DATA

Despite baseline factors for surgical consideration, such as attempting conservative management, surgeons encounter many patients who are not surgically indicated. Overreferrals, that is, a patient referred to a surgeon that does not need surgery, can result in long wait times, delayed care, worse outcomes, and resource waste.

MATERIALS AND METHODS

All new patients at a single academic institution seen in the clinic by eight spine surgeons between January 1, 2018, and January 1, 2022, were analyzed. Referral types included self-referral, musculoskeletal (MSK), and non-MSK provider referral. Patient demographics included age, body mass index (BMI), zip code as a proxy for socioeconomic status, sex, insurance type, and surgical procedures undergone within 1.5 years postclinic visit. Analysis of variance and a Kruskal-Wallis test was used to compare means among normally and non-normally disturbed referral groups, respectively. Multivariable logistic regressions were run to assess demographic variables associated with undergoing surgery.

RESULTS

From 9356 patients, 84% (7834) were self-referred, 3% (319) were non-MSK, and 13% (1203) were MSK. A statistically significant association with ultimately undergoing surgery was observed with MSK referral type compared with non-MSK referral [odds ratio (OR)=1.37, CI: 1.04-1.82, P =0.0246]. Additional independent variables observed to be associated with patients undergoing surgery included older age (OR=1.004, CI: 1.002-1.007, P =0.0018), higher BMI (OR=1.02, CI: 1.011-1.029, P <0.0001), high-income quartile (OR=1.343, CI: 1.177-1.533, P <0.0001), and male sex (OR=1.189, CI: 1.085-1.302, P =0.0002).

CONCLUSIONS

A statistically significant association with undergoing surgery was observed with a referral by an MSK provider, older age, male sex, high BMI, and a high-income quartile home zip code. Understanding these factors and patterns is critical for optimizing practice efficiency and reducing the burdens of inappropriate referrals.

A practical method for the retrieval of tulip-head polyaxial pedicle screw by reusing the rod in revision and implants removal surgery: introduction of technique and evaluation of clinical outcomes

BACKGROUND

The removal of spinal implants is needed in revision surgery or in some cases whose fracture had healed or fusion had occurred. The slip of polyaxial screw or mismatch of instruments would make this simple procedure intractable. Here we introduce a simple and practical method to address this clinical dilemma.

METHODS

This is a retrospective study. The patients underwent new technique for retrieving the implants from July 2019 to July 2022 were labeled as group A, while the patients underwent traditional implants retrieval technique from January 2017 to January 2020 were labeled as group B. Patients in each group were subdivided into revision surgery group (r group) and simple implants removal group (s group) according to the surgery fashion. For the new technique, the retrieved rod was cut off to a proper length which was matched with the size of tulip head, and was replaced into the tulip head. After tightened with nut, a monoaxial screw-rod "construct" was formed. Then the "construct" can be retrieved by a counter torque. The operation duration, intraoperative blood loss, post-operative bacteria culture, hospital stay and costs were analyzed.

RESULTS

A total of 116 polyaxial screws with difficult retrieval (43 screws in group A, 73 screws in group B) in 78 patients were recorded, in which 115 screws were successfully retrieved. Significant differences were found in the mean operation duration, intraoperative blood loss when comparing the r group in group A and B, as well as the s group in group A and B (P < 0.05). There were no significant differences in hospital stay and costs between group A and B. Three patients were found positive bacteria culture of drainage tube/tape in group A (3/30), while 7 patients in group B (7/48). The most prevalent bacteria was Propionibacterium acnes.

CONCLUSION

This technique is practical and safe in retrieving tulip head poly-axial screw. Reduced operation duration and intraoperative bloods loss may potentially alleviate the hospitalization burden of patients. Positive bacterial cultivation results are common after implants removal surgery, but they rarely represent an organized infection. A positive culture with P. acnes or S. epidermidis should be interpreted with caution.

Biomechanics after spinal decompression and posterior instrumentation

PURPOSE

The aim of this study was to elucidate segmental range of motion (ROM) before and after common decompression and fusion procedures on the lumbar spine.

METHODS

ROM of fourteen fresh-frozen human cadaver lumbar segments (L1/2: 4, L3/4: 5, L5/S1: 5) was evaluated in six loading directions: flexion/extension (FE), lateral bending (LB), lateral shear (LS), anterior shear (AS), axial rotation (AR), and axial compression/distraction (AC). ROM was tested with and without posterior instrumentation under the following conditions: 1) native 2) after unilateral laminotomy, 3) after midline decompression, and 4) after nucleotomy.

RESULTS

Median native ROM was FE 6.8°, LB 5.6°, and AR 1.7°, AS 1.8 mm, LS 1.4 mm, AC 0.3 mm. Unilateral laminotomy significantly increased ROM by 6% (FE), 3% (LB), 12% (AR), 11% (AS), and 8% (LS). Midline decompression significantly increased these numbers to 15%, 5%, 21%, 20%, and 19%, respectively. Nucleotomy further increased ROM in all directions, most substantially in AC of 153%. Pedicle screw fixation led to ROM decreases of 82% in FE, 72% in LB, 42% in AR, 31% in AS, and 17% in LS. In instrumented segments, decompression only irrelevantly affected ROM.

CONCLUSIONS

The amount of posterior decompression significantly impacts ROM of the lumbar spine. The here performed biomechanical study allows creation of a simplified rule of thumb: Increases in segmental ROM of approximately 10%, 20%, and 50% can be expected after unilateral laminotomy, midline decompression, and nucleotomy, respectively. Instrumentation decreases ROM by approximately 80% in bending moments and accompanied decompression procedures only minorly destabilize the instrumentation construct.

A systematic review of anterior lumbar interbody fusion (ALIF) versus posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), posterolateral lumbar fusion (PLF)

PURPOSE

The rate of elective lumbar fusion has continued to increase over the past two decades. However, there remains to be a consensus on the optimal fusion technique. This study aims to compare stand-alone anterior lumbar interbody fusion (ALIF) with posterior fusion techniques in patients with spondylolisthesis and degenerative disc disease through a systematic review and meta-analysis of the available literature.

METHODS

A systematic review was performed by searching the Cochrane Register of Trials, MEDLINE, and EMBASE from inception to 2022. In the two-stage screening process, three reviewers independently reviewed titles and abstracts. The full-text reports of the remaining studies were then inspected for eligibility. Conflicts were resolved through consensus discussion. Two reviewers then extracted study data, assessed it for quality, and analysed it.

RESULTS

After the initial search and removal of duplicate records, 16,435 studies were screened. Twenty-one eligible studies (3686 patients) were ultimately included, which compared stand-alone ALIF with posterior approaches such as posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), and posterolateral lumbar fusion (PLF). A meta-analysis showed surgical time and blood loss was significantly lower in ALIF than in TLIF/PLIF, but not in those who underwent PLF (p = 0.08). The length of hospital stay was significantly shorter in ALIF than in TLIF, but not in PLIF or PLF. Fusion rates were similar between the ALIF and posterior approaches. The Visual Analogue Scale (VAS) scores for back and leg pain were not significantly different between the ALIF and PLIF/TLIF groups. However, VAS back pain favoured ALIF over PLF at one year (n = 21, MD - 1.00, CI - 1.47, - 0.53), and at two years (2 studies, n = 67, MD - 1.39, CI - 1.67, - 1.11). The VAS leg pain scores (n = 46, MD 0.50, CI 0.12 to 0.88) at two years significantly favoured PLF. The Oswestry Disability Index (ODI) scores at one year were not significantly different between ALIF and the posterior approaches. At two years, ODI scores were also similar between the ALIF and the TLIF/PLIF. However, the ODI scores at two years (2 studies, n = 67, MD - 7.59, CI - 13.33, - 1.85) significantly favoured ALIF over PLF (I2 = 70%). The Japanese Orthopaedic Association Score (JOAS) for low back pain at one year (n = 21, MD - 0.50, CI - 0.78) and two years (two studies, n = 67, MD - 0.36, CI - 0.65, - 0.07) significantly favoured ALIF over PLF. No significant differences were found in leg pain at the 2-year follow-up. Adverse events displayed no significant differences between the ALIF and posterior approaches.

CONCLUSIONS

Stand-alone-ALIF demonstrated a shorter operative time and less blood loss than the PLIF/TLIF approach. Hospitalisation time is reduced with ALIF compared with TLIF. Patient-reported outcome measures were equivocal with PLIF or TLIF. VAS and JOAS, back pain, and ODI scores mainly favoured ALIF over PLF. Adverse events were equivocal between the ALIF and posterior fusion approaches.

Evaluation of instrumentation and pedicle screw design for posterior lumbar fixation: A pre-clinical in vivo/ex vivo ovine model

Background

Stabilization procedures of the lumbar spine are routinely performed for various conditions, such as spondylolisthesis and scoliosis. Spine surgery has become even more common, with the incidence rates increasing ~30% between 2004 and 2015. Various solutions to increase the success of lumbar stabilization procedures have been proposed, ranging from the device's geometrical configuration to bone quality enhancement via grafting and, recently, through modified drilling instrumentation. Conventional (manual) instrumentation renders the excavated bony fragments ineffective, whereas the "additive" osseodensification rotary drilling compacts the bone fragments into the osteotomy walls, creating nucleating sites for regeneration.

Methods

This study aimed to compare both manual versus rotary Osseodensification (OD) instrumentation as well as two different pedicle screw thread designs in a controlled split animal model in posterior lumbar stabilization to determine the feasibility and potential advantages of each variable with respect to mechanical stability and histomorphology. A total of 164 single thread (82 per thread configuration), pedicle screws (4.5 × 35 mm) were used for the study. Each animal received eight pedicles (four per thread design) screws, which were placed in the lumbar spine of 21 adult sheep. One side of the lumbar spine underwent rotary osseodensification instrumentation, while the contralateral underwent conventional, hand, instrumentation. The animals were euthanized after 6- and 24-weeks of healing, and the vertebrae were removed for biomechanical and histomorphometric analyses. Pullout strength and histologic analysis were performed on all harvested samples.

Results

The rotary instrumentation yielded statistically (p = 0.026) greater pullout strength (1060.6 N ± 181) relative to hand instrumentation (769.3 N ± 181) at the 24-week healing time point. Histomorphometric analysis exhibited significantly higher degrees of bone to implant contact for the rotary instrumentation only at the early healing time point (6 weeks), whereas bone area fraction occupancy was statistically higher for rotary instrumentation at both healing times. The levels of soft tissue infiltration were lower for pedicle screws placed in osteotomies prepared using OD instrumentation relative to hand instrumentation, independent of healing time.

Conclusion

The rotary instrumentation yielded enhanced mechanical and histologic results relative to the conventional hand instrumentation in this lumbar spine stabilization model.

Association of Frailty and Preoperative Hypoalbuminemia with the Risk of Complications, Readmission, and Mortality After Spine Surgery

BACKGROUND

Frailty status and hypoalbuminemia have been associated with higher rates of complications after spine surgery. However, the combination of both conditions has not been fully analyzed. The objective of this study was to assess the effect of frailty and hypoalbuminemia on the risk of complications after spine surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2009 to 2019 was used. Frailty status was calculated using the modified 5-item frailty index (mFI-5). Patients were classified into nonfrail (mFI = 0), pre-frail (mFI = 1), and frail (mFI ≥2) groups and also based on albumin levels into normal (≥3.5 g/dL) and hypoalbuminemia groups (<3.5 g/dL). The latter group was also subclassified into mild and severe hypoalbuminemia groups. Multivariable analysis was used. A Spearman ρ correlation between albuminemia and mFI-5 was also performed.

RESULTS

A total of 69,519 patients (36,705 men [52.8%] and 32,814 women [47.2%]) with a mean age of 61.0 ± 13.2 years were included. Patients were classified as nonfrail (n = 24,897), pre-frail (n = 28,897), and frail groups (n = 15,725). Hypoalbuminemia was significantly higher in the frail group (11.4%) compared with the nonfrail group (4.3%). An inverse correlation was observed between albumin levels and frailty status (ρ = -0.139; P < 0.0001). Frail patients with severe hypoalbuminemia had significantly higher risk of complications (odds ratio [OR], 5.0), reoperation (OR, 3.3), readmission (OR, 3.1), and mortality (OR, 31.8) compared with patients without hypoalbuminemia.

CONCLUSIONS

The combination of frailty and hypoalbuminemia significantly increases the risk of complications after spine surgery. The prevalence of hypoalbuminemia in the frailty group was significantly higher than in nonfrail patients (11.4% vs. 4.3%). Both conditions should be evaluated preoperatively.

Bone microstructure and volumetric bone mineral density in patients with global sagittal malalignment

PURPOSE

Sagittal spinal malalignment often leads to surgical realignment, which is associated with major complications. Low bone mineral density (BMD) and impaired bone microstructure are risk factors for instrumentation failure. This study aims to demonstrate differences in volumetric BMD and bone microstructure between normal and pathological sagittal alignment and to determine the relationships among vBMD, microstructure, sagittal spinal and spinopelvic alignment.

METHODS

A retrospective, cross-sectional study of patients who underwent lumbar fusion for degeneration was conducted. The vBMD of the lumbar spine was assessed by quantitative computed tomography. Bone biopsies were evaluated using microcomputed tomography (μCT). C7-S1 sagittal vertical axis (SVA; ≥ 50 mm malalignment) and spinopelvic alignment were measured. Univariate and multivariable linear regression analysis evaluated associations among the alignment, vBMD and μCT parameters.

RESULTS

A total of 172 patients (55.8% female, 63.3 years, BMI 29.7 kg/m2, 43.0% with malalignment) including N = 106 bone biopsies were analyzed. The vBMD at levels L1, L2, L3 and L4 and the trabecular bone (BV) and total volume (TV) were significantly lower in the malalignment group. SVA was significantly correlated with vBMD at L1-L4 (ρ = -0.300, p < 0.001), BV (ρ = - 0.319, p = 0.006) and TV (ρ = - 0.276, p = 0.018). Significant associations were found between PT and L1-L4 vBMD (ρ = - 0.171, p = 0.029), PT and trabecular number (ρ = - 0.249, p = 0.032), PT and trabecular separation (ρ = 0.291, p = 0.012), and LL and trabecular thickness (ρ = 0.240, p = 0.017). In the multivariable analysis, a higher SVA was associated with lower vBMD (β = - 0.269; p = 0.002).

CONCLUSION

Sagittal malalignment is associated with lower lumbar vBMD and trabecular microstructure. Lumbar vBMD was significantly lower in patients with malalignment. These findings warrant attention, as malalignment patients may be at a higher risk of surgery-related complications due to impaired bone. Standardized preoperative assessment of vBMD may be advisable.

Evaluating the potential impact of spinal anesthesia use in lumbar surgery on global healthcare cost and climate change

Introduction

Despite recent evidence demonstrating its safety and efficacy, spinal anesthesia remains a seldom-utilized anesthetic modality in lumbar surgical procedures. In addition, numerous clinical advantages, such as reduced cost, blood loss, operative time, and inpatient length of stay have been consistently demonstrated with spinal anesthesia over general anesthesia.

Research question

In this report we aim to examine the differences between spinal anesthesia and general anesthesia with regard to accessibility and climate impact and determine whether wider adoption of spinal anesthesia would have a meaningful impact on the global population. Materials and Methods: The climate impact of spinal fusions performed under spinal and general anesthesia were obtained from recent studies published in the literature. Cost of spinal fusions was obtained from an unpublished study performed at our institution. Volume of spinal fusions performed in several countries were ascertained from published reports. Data on cost and carbon emissions were extrapolated based on volume of spinal fusions in each of the nations.

Results

In the U.S., use of spinal anesthesia for lumbar fusions would have resulted in savings of 343 million dollars in 2015. A similar reduction in cost was seen with each country studied. Additionally, spinal anesthesia was associated with 12,352 ​kg carbon dioxide equivalents (CO₂e) while general anesthesia produced 942,872 ​kg CO₂e. Similar reduction in carbon emissions was seen with each country studied.

Discussion and conclusion

Spinal anesthesia is safe and effective for both simple and complex spine surgeries, it reduces carbon emissions, permits lower operative times, and decreases cost.

Robotic-navigated assistance in spine surgery

The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system. The authors reviewed the prospectively collected data on 196 adult patients who had pedicle screws implanted with robot-navigated assistance (RNA) using the Mazor X Stealth system between June 2019 and March 2022. Pedicle screws were implanted by one experienced spinal surgeon after completion of a learning period. The accuracy of pedicle screw placement was determined using intraoperative 3D fluoroscopy. A total of 1,123 pedicle screws were implanted: 1,001 screws (89%) were placed robotically, 63 (6%) were converted from robotic placement to a freehand technique, and 59 (5%) were planned to be implanted freehand. Of the robotically placed screws, 942 screws (94%) were determined to be Gertzbein and Robbins grade A with median deviation of 0.8 mm (interquartile range 0.4 to 1.6). Skive events were noted with 20 pedicle screws (1.8%). No adverse clinical sequelae were noted in the 90-day follow-up. The mean fluoroscopic exposure per screw was 4.9 seconds (SD 3.8). RNA is highly accurate and reliable, with a low rate of abandonment once mastered. No adverse clinical sequelae occurred after implanting a large series of pedicle screws using the latest generation of RNA. Understanding of patient-specific anatomical features and the real-time intraoperative identification of risk factors for suboptimal screw placement have the potential to improve accuracy further.

Bone collagen quality in lumbar fusion patients: the association between volumetric bone mineral density and advanced glycation endproducts

PURPOSE

The sole determination of volumetric bone mineral density (vBMD) is insufficient to evaluate overall bone integrity. The accumulation of advanced glycation endproducts (AGEs) stiffens and embrittles collagen fibers. Despite the important role of AGEs in bone aging, the relationship between AGEs and vBMD is poorly understood. We hypothesized that an accumulation of AGEs, a marker of impaired bone quality, is related to decreased vBMD.

METHODS

Prospectively collected data of 127 patients undergoing lumbar fusion were analyzed. Quantitative computed tomography (QCT) measurements were performed at the lumbar spine. Intraoperative bone biopsies were obtained and analyzed with confocal fluorescence microscopy for fluorescent AGEs, both trabecular and cortical. Spearman's correlation coefficients were calculated to examine relationships between vBMD and fAGEs, stratified by sex. Multivariable linear regression analysis with adjustments for age, sex, body mass index (BMI), race, diabetes mellitus and HbA1c was used to investigate associations between vBMD and fAGEs.

RESULTS

One-hundred and twenty-seven patients (51.2% female, 61.2 years, BMI of 28.7 kg/m2) with 107 bone biopsies were included in the final analysis, excluding patients on anti-osteoporotic drug therapy. In the univariate analysis, cortical fAGEs increased with decreasing vBMD at (r = -0.301; p = 0.030), but only in men. In the multivariable analysis, trabecular fAGEs increased with decreasing vBMD after adjusting for age, sex, BMI, race, diabetes mellitus and HbA1c (β = 0.99;95%CI=(0.994,1.000); p = 0.04).

CONCLUSION

QCT-derived vBMD measurements were found to be inversely associated with trabecular fAGEs. Our results enhance the understanding of bone integrity by suggesting that spine surgery patients with decreased bone quantity may also have poorer bone quality.

Impact of postoperative fatigue following minimally-invasive lumbar spine surgery

BACKGROUND

Postoperative fatigue is a distressing symptom and can have a major impact on the patient's quality of life after surgery. We investigate the extent of postoperative fatigue following minimally invasive spine surgery under general anesthesia (GA), and its impact on patients' quality of life (QOL) and activities of daily living (ADLs).

METHODS

We surveyed patients that underwent minimally-invasive lumbar spine surgery under GA within the previous year. A five-point Likert scale ("very much", "quite a bit", "somewhat", "a little bit", "not at all") was used to assess the extent of fatigue during the first postoperative month, its impact on QOL, and ADLs.

RESULTS

The survey was completed by 100 patients, 61% were male, mean age 64.6 ± 12.5 years, 31% underwent MIS-TLIF, 69% lumbar laminectomy. During the first postoperative month 45% of patients referred significant fatigue ("very much" or "quite a bit"); for 31% of patients fatigue significantly impacted their QOL; significantly limited their ADLs in 43% of patients. MIS-TLIF was associated with higher rate of postoperative fatigue compared to laminectomy (61.3% versus 37.7%, p = 0.02). Patients 65 years old or older had higher rates of fatigue compared to younger patients (55.6% versus 32.6%, p = 0.02). We did not observe a significant difference in postoperative fatigue between male and female patients.

CONCLUSIONS

Our study revealed a substantial incidence of postoperative fatigue in patients that underwent minimally-invasive lumbar spine surgery under GA, with a significant impact on QOL and ADLs. There is a need to research new strategies to reduce fatigue after spine surgery.

Stand-Alone Oblique Lumbar Interbody Fusion (OLIF) for the Treatment of Adjacent Segment Disease (ASD) after Previous Posterior Lumbar Fusion: Clinical and Radiological Outcomes and Comparison with Posterior Revision Surgery

Background: Radiological evidence of adjacent segment disease (ASD) has been reported to have a prevalence of more than 30% and several risk factors have been reported. The aim of this study is to evaluate the clinical and radiological outcomes of patients with symptomatic ASD treated with stand-alone OLIF and compare results with a posterior revision surgery cohort. Methods: This is a retrospective case-control study. Clinical-patient-reported outcomes were obtained at preoperative, postoperative and final follow-up visits using the Short Form (SF-36) scale, the Oswestry Disability Index (ODI) and the visual analog scale (VAS). Radiological measures include lumbar lordosis (LL), segmental lordosis (SL), pelvic incidence-lumbar lordosis (PI-LL) mismatch, segmental coronal Cobb angle and intervertebral disc height (DH). The data are compared with a retrospective series of patients that underwent a posterior revision surgery for ASD. Results: Twenty-eight patients in the OLIF group and 25 patients in the posterior group meet inclusion criteria. The mean ages at the time of the surgery are 65.1 years and 67.5, respectively. The mean follow-up time is 36.1 months (range of 14-56). The clinical outcomes significantly improve from preoperative values from the surgery in both groups. The radiological parameters are significantly improved postoperatively and were maintained at the last follow-up in both groups. A statistically significant difference is observed between the two groups for minor complication rate, length of surgery, blood loss and DH restoration. Conclusions: Stand-alone OLIF is an effective and safe technique with low morbidity and complication rates for the treatment of selected patients with symptomatic ASD following a previous lumbar fusion.

Surgical Site Infection After Primary Spinal Fusion Surgery for Adolescent Idiopathic Scoliosis: An Analysis of Risk Factors From a Nationwide Insurance Database

STUDY DESIGN

Retrospective review.

OBJECTIVE

The purpose of this study was to quantify the incidence and factors associated with surgical site infection (SSI) in pediatric patients undergoing spinal fusion for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Infection is a morbid complication after spinal fusion. The incidence of SSI after pediatric spinal fusion is likely underestimated; the use of a national database allows for a comprehensive assessment of this rare outcome.

MATERIALS AND METHODS

The PearlDiver Database was used to identify AIS patients who underwent primary instrumented spinal fusion between 2010 and 2019 and relevant patient records were queried to identify infections within 7, 30, and 90 postoperative days. Patients with nonidiopathic scoliosis were excluded. Logistic regression was used to evaluate risk factors associated with postoperative infection.

RESULTS

Out of 9801 patients who underwent primary fusion for AIS, 44 patients (0.4%) developed an infection within 7 postoperative days. The 30 days and 90 days incidences were 1.9% and 2.7%, respectively. Within 90 days, 154 (57.7%) of the patients with infection had undergone reoperation, of whom 72 underwent multiple reoperations. Obesity and male sex ( P < 0.05) were significantly associated with postoperative infection. The length of fusion was not a significant factor in the development of SSI ( P > 0.05). Eleven patients underwent an operation requiring hardware removal within 90 days. There were no significant factors associated with those undergoing hardware removal compared with those undergoing surgical debridement.

CONCLUSIONS

The study identified a 2.7% 90 days incidence of SSI after posterior spinal fusion for AIS, with 57.7% of all infections requiring a return to the operating room. Preoperative patient-related characteristics associated with increased risk of postoperative SSI were male sex and obesity. The current study can be used to provide preoperative counseling regarding the risk of this postoperative complication.

LEVEL OF EVIDENCE

Level III.

Creation of a Risk Calculator for Predicting New-Onset Cardiac Arrhythmias in Patients Undergoing Lumbar Fusion

INTRODUCTION

As an increasing number of lumbar fusion procedures are being conducted at specialty hospitals and surgery centers, appropriate patient selection and risk stratification is critical to minimizing patient transfers. Postoperative cardiac arrhythmia has been linked to worse patient outcomes and is a common cause of patient transfer. Therefore, we created a risk calculator to predict a patient's likelihood of developing a new-onset postoperative cardiac arrhythmia after lumbar spinal fusion, which may improve preoperative facility selection.

METHODS

A retrospective review was conducted of patients who undergoing lumbar fusion from 2017 to 2021 at a single academic center. Patients were excluded if they had any medical history of a cardiac arrhythmia. Multivariable regression was conducted to determine independent predictors of inpatient arrhythmias. The final regression was applied to a bootstrap to validate an arrhythmia prediction model. A risk calculator was created to determine a patient's risk of new-onset cardiac arrhythmia.

RESULTS

A total of 1,622 patients were included, with 45 patients developing a new-onset postoperative arrhythmia. Age (OR = 1.05; 95% CI, 1.02 to 1.09; P = 0.003), history of beta-blocker use (OR = 2.01; 95% CI, 1.08 to 3.72; P = 0.027), and levels fused (OR = 1.59; 95% CI, 1.20 to 2.00; P = 0.001) were all independent predictors of having a new-onset inpatient arrhythmia. This multivariable regression produced an area under the curve of 0.742. The final regression was applied to a bootstrap prediction modeling technique to create a risk calculator including the male sex, age, body mass index, beta-blocker use, and levels fused (OR = 1.04, [CI = 1.03 to 1.06]) that produced an area under the curve of 0.733.

CONCLUSION

A patient's likelihood of developing postoperative cardiac arrhythmias may be predicted by comorbid conditions and demographic factors including age, sex, body mass index, and beta-blocker use. Knowledge of these risk factors may improve appropriate selection of an outpatient surgical center or orthopaedic specialty hospital versus an inpatient hospital for lumbar fusions.

Preservation of Motion in Spine Surgery

The number of spinal procedures and spinal fusions continues to grow. Although fusion procedures have a high success rate, they have inherent risks such as pseudarthrosis and adjacent segment disease. New innovations in spine techniques have sought to eliminate these complications by preserving motion in the spinal column. Several techniques and devices have been developed in the cervical and lumbar spine including cervical laminoplasty, cervical disk ADA, posterior lumbar motion preservation devices, and lumbar disk ADA. In this review, advantages and disadvantages of each technique will be discussed.

Instagram and Spine Fusion: An Analysis of Social Media and Its Relationship to Patient Perception of Surgery

STUDY DESIGN

Cross sectional study.

OBJECTIVES

To analyze posts shared on Instagram referencing spinal fusion for tone, gender, activities of daily living (ADLs), rehabilitation, incision, pain, neurological injury, and content of post.

METHODS

Public instragram posts, which were isolated and evaluated using the hashtags "#spinefusion" and "#spinalfusion." All posts were analyzed by the authors for the variables previously listed. In total, 264 posts were included for investigation and analysis of patient perception of spine fusion through social media.

RESULTS

Of all included posts, approximately 86% of posts had a positive tone. There was statistical significance between positive tone and activities of daily living (ADLs) (P = 0.047), as well as negative tone and persistent pain (P = 0.008). Adequate return to activities of daily living is perceived by patients as a positive outcome after surgery: odds ratio (OR) (95% CI) of 2.11 (1.01-4.39). Persistent post operative pain results negatively on perceived outcomes after surgery OR = 0.38 (0.18-0.78).

CONCLUSIONS

Reported outcomes after spine fusion has not been evaluated through social media avenues. This analysis of patients sharing their experience on social media after spinal fusion demonstrates that returning to activities of daily living is of the utmost importance to patients. Additionally, post-operative pain is a strong metric utilized by patients with their satisfaction after surgery.

Radiological outcomes of PEEK rods in patients with lumbar degenerative diseases: A minimum 5-year follow-up

Purpose

To determine the long-term radiological outcomes of PEEK rods in patients with lumbar degenerative diseases.

Methods

Radiological outcomes of cohort cases with lumbar degenerative diseases following PEEK rods were retrospectively studied. Disc height index (DHI) and range of motion (ROM) were measured by x-rays. The CT scans and reconstruction were used to determine screw breakage, rods fracture, screw loosening and intervertebral bony fusion status. The MRI scans were used to evaluate the changes of intervertebral discs at the non-fusion segments and adjacent segments in terms of Pfirrmann Classification.

Results

A total of 40 patients completed the mean of 74.8 ± 9.6 months follow-up, with 32 patients undergoing hybrid surgery and 8 patients undergoing non-fusion surgery. The mean DHI changed from preoperative 0.34 to 0.36 at the final follow-up and the ROM declined from 8.8° preoperatively to 3.2° at the final visit, however, both had no statistical differences. Of the 40 levels underwent non-fusion procedure, 9 levels showed disc rehydration with 7 patients from Grade 4 to Grade 3 and 2 patients from Grade 3 to Grade 2. The other 30 cases did not show distinctive change. No screw loosening or rods breakage were detected during the follow-up periods.

Conclusion

PEEK rods have obvious protective effects on degenerated intervertebral disc of non-fusion segments and the incidence of complications related to internal fixation is low. PEEK rods pedicle screw system is safe and effective in the treatment of lumbar degenerative diseases.

Imaging analysis and predictive nomogram construction for degenerative lumbar spondylolisthesis with severe clinical symptom based on propensity score matching

Intervertebral disc degeneration, local lumbar segmental morphology changes, and atrophy of multifidus muscle have been considered to be associated with degenerative lumbar spondylolisthesis. However, there remains a great deal of controversy. To further investigate their relationship with degenerative lumbar spondylolisthesis, we conducted a retrospective study that included 67 patients with degenerative spondylolisthesis and 182 control subjects. Propensity score matching was employed to match the case group and the control group. Disc height was evaluated by the anterior disc height index (DHIA) and posterior disc height index (DHIP). Local lumbar segmental morphology was assessed by segmental lordosis (SL). The fatty infiltration and atrophy of multifidus muscle was evaluated by multifidus muscle net content (MFNC). Our results indicate that DHIA, DHIP, SL, and MFNC in the case group were significantly lower than in the control group. Furthermore, the DHIA, DHIP, and MFNC of the slipped segment (L4/5) were lower than those of the non-slipped segment (L3/4). Correlation analysis showed a high relationship between DHIA and MFNC and the degree of degenerative lumbar spondylolisthesis. Logistic regression analysis revealed that DHIA and MFNC might act as protective factors against the development of degenerative lumbar spondylolisthesis. Additionally, a prognostic nomogram was developed and validated to assess the likelihood of patients with severe symptoms requiring surgical intervention.

TLIF Online Videos for Patient Education-Evaluation of Comprehensiveness, Quality, and Reliability

Over the last few decades, the number of lumbar interbody fusion surgeries performed has been constantly increasing, with transforaminal lumbar interbody fusion (TLIF) being one of the most common surgical techniques. Due to easy accessibility, patients frequently use YouTube to obtain information on health-related issues. Consequently, online video platforms may be a valuable tool for patient education. The aim of this study was to assess the quality, reliability, and comprehensiveness of online videos on TLIF. We screened 180 videos on YouTube, yielding a total of 30 videos that met the inclusion criteria. These videos were evaluated using Global Quality Scale, DISCERN reliability tool, and JAMA Benchmark Score, and assessed in regard to their comprehensiveness and coverage of relevant aspects. At the time of rating, the videos had between 9188 and 1,530,408 views and between 0 and 3344 likes. The median rater assessment for all videos was "moderate quality". GQS and subjective grades showed a moderate to strong statistically significant association with views and likes. Considering this association of GQS and subjective grade with views and likes, these criteria could be used by laypersons to identify good-quality content. Nevertheless, there is an urgent need for peer-reviewed content that covers all of the relevant aspects.

IL-1β contributes to the secretion of sclerostin by osteocytes and targeting sclerostin promotes spinal fusion at early stages

BACKGROUND

Despite extensive research, there is still a need for safe and effective agents to promote spinal fusion. Interleukin (IL)-1β is an important factor which influences the bone repair and remodelling. The purpose of our study was to determine the effect of IL-1β on sclerostin in osteocytes and to explore whether inhibiting the secretion of sclerostin from osteocytes can promote spinal fusion at early stages.

METHODS

Small-interfering RNA was used to suppress the secretion of sclerostin in Ocy454 cells. MC3T3-E1 cells were cocultured with Ocy454 cells. Osteogenic differentiation and mineralisation of MC3T3-E1 cells were evaluated in vitro. SOST knock-out rat generated using the CRISPR-Cas9 system and rat spinal fusion model was used in vivo. The degree of spinal fusion was assessed by manual palpation, radiographic analysis and histological analysis at 2 and 4 weeks.

RESULTS

We found that IL-1β level had a positive association with sclerostin level in vivo. IL-1β promoted the expression and secretion of sclerostin in Ocy454 cells in vitro. Inhibition of IL-1β-induced secretion of sclerostin from Ocy454 cells could promote the osteogenic differentiation and mineralisation of cocultured MC3T3-E1 cells in vitro. The extent of spinal graft fusion was greater in SOST-knockout rats than in wild-type rats at 2 and 4 weeks.

CONCLUSIONS

The results demonstrate that IL-1β contributes to a rise in the level of sclerostin at early stages of bone healing. Suppressing sclerostin may be an important therapeutic target capable of promoting spinal fusion at early stages.

Trends in Orthopedic Device Innovation: An Analysis of 510(k) Clearances and Premarket Approvals From 2000 to 2019

The objective of this study was to characterize recent trends in orthopedic device development across different subspecialty areas. Orthopedic 510(k) clearances, premarket approvals (PMAs; together, "authorizations"), and new market entrants from 2000 to 2019 were analyzed as markers of research and development activity. Data were extracted from the US Food and Drug Administration website and stratified into one of 9 "subspecialty" groups: spine, trauma, hip arthroplasty, knee arthroplasty, shoulder, hand/elbow, foot/ankle, cement/filler/graft, and other. Descriptive statistics were used to analyze the data. Growth rates were calculated from trailing 3-year averages. During the study period, there were 9906 orthopedic 510(k) clearances and 1409 PMAs, of which 61 were for original PMA submissions. The preponderance of 510(k) clearances were for devices used in spine (36%) and trauma (30%) surgery, followed by hip (11%) and knee (8%) arthroplasty. Annual 510(k) clearances for spine and trauma devices grew by 232% and 44%, respectively, whereas annual hip and knee arthroplasty clearances declined. Paralleling these findings, the influx of new manufacturers of orthopedic devices was greatest for the trauma surgery (438), spine surgery (383), and cement/filler/graft (181) markets. Spinal surgery and orthopedic trauma have become leading priorities in orthopedic product development during the past two decades. Meanwhile, hip and knee arthroplasty products have proportionally become a smaller category of new devices over time. These findings demonstrate changing priorities within orthopedic innovation. [Orthopedics. 2023;46(2):e98-e104.].