Imaging of Degenerative and Infectious Conditions of the Spine

The impact of frailty on clinical outcomes of older patients undergoing enhanced recovery after lumbar fusion surgery: a prospective cohort study

BACKGROUND

Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. Enhanced recovery after surgery (ERAS) can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains.

MATERIALS AND METHODS

An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes, and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay after surgery.

RESULTS

A total of 245 patients (age of 79.8±3.4 year) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between nonfrail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery.

CONCLUSION

Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults.

MR imaging differentiating features between lytic and degenerative lumbosacral spondylolisthesis

Spondylolisthesis is characterized by the displacement of one vertebral body in relation to the adjacent vertebra. It is commonly observed in the lower lumbar region and can be caused by a variety of factors, including spondylolysis (a fracture in the pars interarticularis) or degenerative disease. Magnetic resonance imaging (MRI) is becoming increasingly popular as the primary modality for evaluation of low back pain and is often used in the absence of radiographs or Computed Tomography. However, it can be challenging for radiologists to differentiate between the two types of spondylolisthesis based on MRI alone. The goal of this article is to identify key imaging features on MRI that can aid radiologists in differentiating between spondylolysis and degenerative spondylolisthesis on MRI. Five key concepts are discussed: the "step-off" sign, the "wide canal" sign, T2 cortical bone signal on MRI, epidural fat interposition, and fluid in the facet joints. The utility, limitations and potential pitfalls of these concepts are also discussed to provide a comprehensive understanding of their use in differentiating between the two types of spondylolisthesis on MRI.

ACR Appropriateness Criteria® Suspected Spine Infection

Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Coexisting Spine Lesions on Whole Spine T2 Sagittal MRI in Evaluating Spinal Degenerative Disease

BACKGROUND

Studies have reported on the usefulness of whole spine magnetic resonance imaging (MRI) in evaluating specific diseases such as spinal tuberculosis, spinal trauma, spondyloarthropathies, and multiple myeloma. In studies concerning degenerative spinal disease, sample sizes were small and some did not provide information on how symptomatic coexisting lesions were treated. We evaluated the types and prevalence of coexisting spine lesions found on whole spine T2 sagittal screening performed at the time of routine cervical and lumbar spine MRI and evaluated the efficacy of such screening in degenerative diseases of the cervical and lumbar spine.

METHODS

We reviewed 1,757 and 2,266 consecutive cases where whole spine T2 sagittal screening had been performed with routine cervical and lumbar spine MRI, respectively, in patients with cervical and lumbar spinal degenerative diseases. Coexisting spine lesions were documented and statistical analysis was performed to investigate significant differences according to sex, age, and initial diagnosis. Electronic medical records were reviewed to determine whether additional interventions were necessary following such findings.

RESULTS

We reviewed 1,252 and 1,689 consecutive cases of routine cervical and lumbar spine MRI respectively, with whole spine T2 sagittal screening. Of the 1,252, 419 (33.5%) patients with cervical spinal degenerative disease had coexisting lesions in the thoracolumbar spine. Patients with ligament ossification disease of the cervical spine showed a higher prevalence of coexisting spine lesions. Sixty of the 419 (14.3%) patients with coexisting spine lesions warranted additional intervention or surgical treatment. Four hundred and eighty-one of 1,689 (28.5%) patients with lumbar degenerative disease had coexisting spine lesions in the cervicothoracic spine. Forty-eight of the 481 (10.0%) patients with coexisting spine lesions warranted additional intervention. In both patient groups, older patients showed a significantly higher prevalence of coexisting spine lesions than younger patients.

CONCLUSION

Considering the minimal extra time and cost in performing whole spine screening, its application to routine spine MRI can be considered in evaluating cervical and lumbar spinal degenerative diseases.

Pediatric spinal infections-a review of non-tuberculous infections

Pediatric spinal infection includes spinal epidural abscess, spondylodiscitis and intradural (extramedullary and intramedullary) spinal infections. However, these entities are extremely rare and no clear guidelines exist for their management. Pertinent literature was searched and a detailed narrative review of this topic is presented.