Spine最新文献

Study design: Retrospective study.

Objective: Assess the impact of curve magnitude on the complexity of surgery, resources utilized, and outcomes during surgical management of neuromuscular scoliosis (NMS).

Background: Despite previous attempts to determine the impact of curve magnitude on outcomes after posterior spinal fusion (PSF) in NMS, equipoise remains regarding optimal surgical timing.

Materials and methods: Patients aged 7 to 21 years with NMS and fusion to the pelvis at a single tertiary hospital were retrospectively reviewed. Patient demographics, surgical parameters, complications, and radiographic measurements were collected. Clinical and radiographic outcomes were compared between patients with preoperative curves ≥80° and <80°.

Results: Three hundred thirty-seven patients met the inclusion criteria with a mean curve of 83.1° ± 26.5°. Patients with curves ≥80° had greater blood loss (994 ± 607 vs . 764 ± 535 mL, P = 0.0003), transfusion requirement (795 ± 647 vs . 478 ± 482 mL, P < 0.0001), surgical time (418 ± 117 vs . 338 ± 117 min, P < 0.0001), anesthesia time (552 ± 123 vs . 472 ± 122 min, P < 0.0001), and ICU stay (3 ± 2 vs . 2 ± 1 d, P = 0.009) compared with patients with curves <80°. Continued intubation was 2.4 times more likely (OR: 2.4; 95% CI: 1.5, 3.9; P = 0.0002) and the odds of utilizing adjunctive surgical techniques ( i.e. , intraoperative halo traction, temporary rods, and/or staged procedures) were 4 times more likely for patients with curves ≥80° (OR: 4.1; 95% CI: 2.5, 6.6; P < 0.0001). The use of spinal osteotomies was more likely among patients with larger curves (OR: 4.6; 95% CI: 2.8, 7.2; P < 0.0001). Residual curve magnitude (44.7° ± 20.5° vs . 22.6° ± 13.6°, P < 0.0001) and pelvic obliquity (10.2° ± 12.6° vs . 4.8°± 8.7°, P < 0.0001) were higher in the ≥80° group. Those with curves ≥80° were 3 times more likely to experience a change in neuromonitoring signals during surgery (OR: 3.07; 95% CI: 1.40, 6.73; P = 0.003).

Conclusion: Curve magnitude ≥80° was associated with larger residual curves despite increased surgical complexity and greater resource utilization in the management of NMS.

Study design: Cross-sectional study.

Objective: This study proposes a novel stratification framework for individuals with low back pain (LBP). The method integrates Northern Finland Birth Cohort data comprising imaging biomarkers from deep learning (DL)-based analysis of lumbar spine MRI with the data on smoking status, demographics (sex and BMI), self-reported data from Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) short and the STarT Back Tool (SBT). Furthermore, the utility of this stratified approach was validated by demonstrating a superior net benefit compared with "treat-all" strategy.

Background: Current risk stratification for individuals with LBP relies on ÖMPSQ short and SBT among others. While these tools are invaluable for capturing psychosocial characteristics predictive of future disability and functional outcomes, LBP's multifactorial nature necessitates a more comprehensive framework for effective risk stratification.

Materials and methods: A method for multimodal unsupervised patient stratification has been developed that allows for the integration of imaging biomarkers of disc degeneration (DD) and facet tropism (FT), extracted using DL models, with nonimaging data. The framework utilized robust K-Means clustering to stratify individuals. Clusters were characterized using LBP frequency and bothersomeness, and their robustness was validated with a multi-class logistic regression model. Net benefit was assessed through decision curve analysis.

Results: Three distinct subgroups were characterized by LBP frequency and bothersomeness. One subgroup was dominated by psychosocial characteristics (psychosocial risk P  < 0.05), the second by physical degenerative changes (DD P  < 0.05), and the third by a mix of both. Predictive models for cluster assignment were robust, achieving high mean accuracies (SBT-based: 0.89; ÖMPSQ-short-based: 0.87). The net benefit is superior throughout a range of threshold probabilities compared with a "treat-all" strategy.

Conclusion: A novel framework was developed that integrates multimodal data to identify distinct subgroups differentiated by their physical and psychosocial characteristics in a population-based cohort, demonstrating potential for advancing personalized care.

Study design: A retrospective multicenter study.

Objectives: To analyze symptom-specific surgical outcomes in patients with mild degenerative cervical myelopathy (DCM) and identify predictors of postoperative residual symptoms.

Summary of background data: DCM is the most common cause of spinal cord impairment in adults. While surgical intervention is recommended for moderate to severe DCM, optimal treatment strategies for mild DCM remain unclear. Previous studies have focused on total Japanese Orthopaedic Association (JOA)/modified JOA (mJOA) score without detailed symptom-specific analyses.

Materials and methods: We reviewed 679 consecutive patients who underwent surgical decompression with or without fusion for DCM across three institutions in Japan. Among them, 104 patients with mild DCM (JOA score 14.5-16.5) were included. We assessed demographic data, radiographic factors, magnetic resonance imaging parameters, and clinical scores. Symptom-specific analyses were conducted using preoperative and 2-year postoperative JOA scores, and the predictors of persistent symptoms were analyzed using multivariable logistic regression.

Results: The mean maximum canal compromise was 49.7%, and maximum spinal cord compression was 37.2%. The most common factors leading to surgery was symptom deterioration (94.2%). In symptom-specific analysis, 60.9% of patients exhibited persistent upper extremity sensory impairment, significantly higher than other domains. Multivariable analysis identified angular-edged deformity of the spinal cord on axial MRI as an independent predictor of persistent upper extremity sensory impairment (odds ratio: 4.264, 95% CI: 1.312-13.854, P =0.016).

Conclusion: The majority of mild DCM patients who underwent surgery had severe spinal cord compression, with symptom progression serving as the trigger for surgical intervention. While surgical intervention improves overall function, upper extremity sensory impairments frequently persisted postoperatively, even in mild cases. Angular-edged deformity was a significant predictor for postoperative upper extremity sensory deficits, emphasizing the need for careful preoperative evaluation of spinal cord morphology to better inform prognosis and guide treatment decisions in patients with mild DCM.

Level of evidence: Level 4.

Study design: Prospective, multicenter study.

Objective: To compare and characterize complications in adult spinal deformity (ASD) patients with and without 3-column osteotomy (3CO).

Summary of background data: Although 3CO is associated with increased risk of neurologic adverse events, no study has, to our knowledge, compared and characterized sensory and motor neurologic complications in ASD patients with vs. without 3CO.

Materials and methods: Demographics, surgical characteristics, and neurologic complications were collected for 553 ASD patients. Lower extremity motor scores (LEMSs) were compared at baseline and postoperatively. Multivariate analysis was performed to identify risk factors associated with neurologic adverse events.

Results: Among 553 ASD patients, 130 (23.5%) underwent 3CO. More patients with 3CO were revision patients (67.7% vs. 35.0%; P<0.001), presented with sagittal deformity (43.9% vs. 31.0%; P=0.008), and had longer operative times (455.6 vs. 407.3 min; P=0.001) and greater estimated blood loss (EBL) (1,650 vs. 1,000 mL; P<0.001) than patients without 3CO. The incidence of neurologic adverse events was greater among patients with vs. without 3CO (23.1% vs. 15.4%; P=0.04). Multivariate analysis revealed that older age (odds ratio [OR] 1.288 per 10-year increase, 95% confidence interval [CI] 1.060-1.565, P=0.01) and longer operative time (OR 1.088, 95% CI 1.001-1.004, P=0.01) were significant predictors of neurologic adverse events. No between-group difference in LEMS was observed at 6-week (49.0 vs. 49.0; P=0.90) or 1-year (49.4 vs. 49.3; P=0.71) follow-up. By 1-year follow-up, 20.5% of 3CO patients and 21.6% of patients without 3CO had residual motor deficit.

Conclusions: Compared with patients who did not undergo 3CO, more patients with 3CO had prior instrumentation, presented with sagittal deformity, had longer operative time and greater EBL, and were more likely to have a neurologic adverse event. At 1-year follow-up, there was no significant difference in LEMS between the two groups.

Level of evidence: III.

Study design: Retrospective cohort study.

Objectives: To evaluate the clinical utility of confirmatory Navigational CT (NavCT) spins after pedicle screw placement in one- to two-level posterior lumbar fusions.

Summary of background data: Navigational CT improves pedicle screw accuracy and reduces blood loss; however, some surgeons perform an additional confirmatory CT spin after screw placement to verify trajectory prior to closure. Confirmatory imaging increases operative time, cost, and radiation exposure, and its benefit in routine lumbar fusion remains unclear.

Methods: Adult patients undergoing one- to two-level posterior instrumented lumbar fusion between January 2020 and June 2021 were identified and stratified into three cohorts: no navigation (NoNav), navigation only (NavCT), and navigation with confirmatory spin (NavCT+C). Primary outcomes included intraoperative screw repositioning and return to the operating room for screw revision. Secondary outcomes included operative duration, estimated blood loss (EBL), discharge disposition, perioperative complications, and one-year follow-up events.

Results: A total of 339 patients were included (117 NoNav, 162 NavCT, 60 NavCT+C). Screw-related complications were rare; intraoperative repositioning (1 vs. 2 vs. 0, P=0.683) and reoperation for screw revision (1 vs. 1 vs. 0, P=0.780) did not differ across groups. The absolute risk reduction for reoperation with confirmatory imaging was 0.72%, yielding an NNT of 138.5. Operative time differed significantly (199.3 vs. 176.5 vs. 205.4 min, P=0.01). EBL was significantly lower in both NavCT groups compared with NoNav (P <0.001). Perioperative complications and length of stay were similar. Confirmatory imaging increased radiation exposure and operative duration without improving screw-related outcomes.

Conclusion: In one- to two-level lumbar fusions, confirmatory NavCT spins provide minimal additional clinical value. Given increased radiation, time, and cost with no observed improvement in screw accuracy or reoperation rates, confirmatory imaging should be used selectively rather than routinely.

Study design: Retrospective cohort study.

Objective: To determine the 5-year incidence and risk factors of radiological adjacent segment disease (R-ASD) and symptomatic adjacent segment disease (S-ASD) after transforaminal lumbar interbody fusion (TLIF) using patient- and segment-based analyses.

Summary of background data: Adjacent segment disease (ASD) remains a major concern after lumbar fusion surgery. Although previous studies have reported variable incidence rates, differences between R-ASD and S-ASD and segment-specific risk factors remain unclear. Particularly, evidence comparing cranial and caudal adjacent segments after TLIF with uniform mid-term follow-up is limited.

Methods: Patients who underwent TLIF at two institutions and completed a minimum 5-year follow-up were retrospectively reviewed. The study cohort consisted of 183 patients (mean age, 68.0±9.6 y). Patient-based and segment-based analyses were performed. Potential risk factors including demographic variables, and spinopelvic alignment parameters, preoperative adjacent segment status, and surgical interventions at adjacent levels, were evaluated.

Results: At 5-year follow-up, patient-based incidence of R-ASD and S-ASD was 31.1% and 18.6%. Segment-based analysis demonstrated that R-ASD occurred more frequently at the cranial segment than at the caudal segment (25.4% vs. 8.1%, P<0.001), whereas S-ASD incidence did not differ significantly. Multivariate analysis identified preoperative disc degeneration (OR 3.13, 95% CI 1.06-9.23) and additional decompression at the adjacent segment (OR 2.42, 95% CI 1.14-5.13) as independent risk factors for cranial R-ASD. Spinopelvic alignment parameters and preoperative foraminal stenosis were not significantly associated with the development of R-ASD and S-ASD.

Conclusion: Segment-specific analysis revealed that cranial R-ASD is predominantly influenced by local degenerative changes and surgical intervention rather than global alignment parameters. Careful preoperative assessment of adjacent disc degeneration and cautious postoperative consideration of additional decompression may be important in surgical planning to mitigate ASD development after short-segment TLIF.

Study design: Longitudinal nationwide register study.

Objective: To examine use of opioids and neuropathic pain medications after primary anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease (DCSD), and to identify independent factors associated with postoperative use.

Summary of background data: ACDF is used for cervical radiculopathy and myelopathy, yet many patients continue analgesic use postoperatively. Prolonged opioid use is associated with dependence, poorer clinical outcomes, and reduced return-to-work rates. Evidence on postoperative medication trajectories and their predictors in population-based cohorts remains limited.

Methods: Data were obtained from the nationwide FinSpine register and the Finnish prescription database, which records all outpatient prescription drug purchases. Consecutive patients undergoing primary ACDF for DCSD between 2017 and 2022 were included. Repeated purchases were defined as at least two purchases of the same drug during months 2-12 postoperatively. New strong-opioid users were defined as patients who were strong-opioid naïve six months preceding surgery and met the repeated postoperative purchase criterion. Multivariable logistic regression was used to identify independently associated covariates.

Results: The cohort included 4366 patients. Preoperatively, 41.9% (n=1830) purchased opioids and 41.2% (n=1798) gabapentinoids. Repeated postoperative purchases were observed in 16.5% for opioids and 15.6% for gabapentinoids. Among preoperative opioid and gabapentinoid users, cessation rates were 69.5% and 70.9%, respectively. In previously strong-opioid naïve patients, the incidence of new repeated strong-opioid purchases was 2.2% after ACDF. Independent predictors of repeated postoperative purchases included preoperative pain duration of more than one year, smoking, higher baseline NDI, central canal stenosis, adverse working status, and preoperative purchases of the same drug class.

Conclusion: A considerable proportion of patients continued to purchase opioids and gabapentinoids during the first postoperative year after ACDF. New strong-opioid initiation postoperatively was uncommon. Nationwide prescription data offer an objective and complete measure of postoperative medication dispensing for outcome assessment.

Study design: Prospective observational multicenter cohort study.

Objective: To evaluate and compare functional outcomes, as measured by AO Spine Patient Reported Outcome Spine Trauma (PROST), in neurologically intact patients with thoracolumbar (TL) burst fractures treated operatively or nonoperatively.

Summary of background data: The optimal management of these patients remains debated.

Methods: This investigation was part of a prospective observational international multicenter cohort study. Neurologically intact adults (18-65 y) with acute (≤10 d) TL burst fractures were included from various sites across the world. Provided treatment was determined by the local standard of care. PROST was administered at multiple prospective timepoints from baseline up to 2-years post-injury. Descriptive statistics were used to analyze patient and clinical characteristics. Multivariable mixed models for repeated measures were used to assess differences in treatment groups and between the fracture types.

Results: A total of 93 patients were included (mean age 41 y, 57% male). Most sustained high-energy trauma (73.1%) and had type A3 fractures (63.4%), with 61.3% treated nonoperatively. Both nonsurgical (34.2 to 86.0) and surgical (39.9 to 85.6), as well as fracture types (A4: 38.4 to 85.6; A3: 36.4 to 87.3) demonstrated significant improvements in PROST scores over time (P<0.001). No statistically significant differences in PROST scores were found between treatment groups or fracture types. Although, surgically treated patients showed higher PROST scores within the first 3 months, and nonsurgical patients had marginally higher scores hereafter, these differences were not statistically significant and converged by 2 years.

Conclusion: Both surgical and nonsurgical treatment of neurologically intact TL burst fracture patients resulted in comparable long-term functional outcomes as measured by AO Spine PROST. A descriptive trend was observed with surgically treated patients showing higher mean PROST scores up to 3 months post-treatment, however, between-group differences were not statistically significant and equalized by two years.