Objective
To assess which radiological alignment parameters are associated with a satisfactory long‐term clinical outcome after performing lumbar spinal fusion for treating degenerative ...spondylolisthesis.
Methods
This single‐center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient‐reported outcome using four different questionnaires (COMI, EQ‐5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low‐grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females).
Results
The data of 17 patients after mono‐ or bisegmental lumbar fusion surgery to treat low‐grade lumbar spondylolisthesis and with a follow‐up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m2 and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8–21). The long‐term clinical outcome correlated significantly with the change of the pelvic tilt (rs = −0.515, P < 0.05) and the sagittal rotation (rs = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (rs = 0.637, P < 0.01) and the pelvic incidence (rs = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (rs = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires.
Conclusions
The surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long‐term clinical outcome after lumbar interbody fusion surgery.
Pre‐ and postoperative (PLIF L4/5) lateral standing radiographs of the lumbar spine are used to measure the pelvic tilt. The greater the difference of the pelvic tilt after fusion surgery compared to the preoperative value, the worse is the outcome after 6 years when quantified by the EQ‐5D questionnaire.
Pediatric spondylodiscitis (PSD) is a rare disease with a major impact on mobility and functional status. Data concerning demographic and microbiological characteristics, clinical course, treatment, ...and outcome are scarce. Therefore, the aim of this study was to present clinical experiences of a third-level hospital (2009–2019) in PSD and compare these with adult spondylodiscitis (ASD). Of a total of 10 PSD patients, most of the infants presented with unspecific pain such as hip pain or a limping, misleading an adequate diagnosis of spine origin. Eight patients could be treated conservatively whereas surgery was performed in two cases with one case of tuberculous PSD (tPSD). The causative agent was detected in three of the patients. The diagnosis of PSD is often difficult since clinical symptoms are unspecific and causative pathogens often remain undetected. Nevertheless, empirical anti-infective therapy also seems to be effective. Based on recent studies, clinicians should be encouraged to keep the duration of anti-infective therapy in children short. Since comorbidities are not presented in PSD it is unclear which children suffer from PSD; thus, studies are necessary to identify predisposing factors for PSD. In our study, PSD differs from ASD in diagnostic and especially in therapeutic aspects. Therefore, specific guidelines for PSD would be desirable.
The aim of this retrospective study was to evaluate the outcomes after prosthetic arthroplasty of the proximal interphalangeal joint. Of 73 prostheses, 67 were available for follow-up at a median of ...35 months (range 10–78 months). The median brief Michigan Hand Questionnaire score was 88/100 (interquartile range IQR 69–98), quickDASH 11 (IQR 1–29), pain on the visual analogue scale during activity 0 (IQR 0–2) and at rest 0 (IQR 0). Median range of motion improved from 50° (IQR 40°–70°) to 70° (IQR 53°–88°; p < 0.001). Preoperatively, there was axial deviation of >15° in 15 (23%) joints, with none postoperatively. There were no signs of loosening or migration of the prostheses. Two cases required revision with the implant staying in situ. In two cases, the prosthesis was removed and the joint was fused. Prosthetic arthroplasty of the proximal interphalangeal joint using a modular surface gliding implant is a good option for patients with primary osteoarthritis achieving acceptable pain relief, range of motion and axial stability.
Level of evidence: IV
The aim of this study was to determine differences between patients who underwent surgical treatment and those who underwent nonsurgical treatment of vertebral osteomyelitis (VO) and to identify ...potential factors influencing treatment failure (death and/or recurrence within 1 year).
We performed a retrospective analysis of clinical data prospectively collected from patients treated for VO between 2008 and 2020. The decision between surgical and nonsurgical treatment was made for each patient based on defined criteria. A 1:1 propensity score matching was performed to exclude confounders between the 2 treatments. Univariate and multivariable analyses were performed to identify potential risk factors for death and/or recurrence within the first year after VO diagnosis.
Forty-two patients (11.8%) were treated nonsurgically and 313 patients (88.2%) underwent surgery. A higher percentage of the surgically treated patients than the nonsurgically treated patients had an American Society of Anesthesiologists score of >2 (69.0% versus 47.5%; p = 0.007), and the thoracic spine was affected more often in the surgical group (30.4% versus 11.9%; p = 0.013). Endocarditis was detected significantly more often in the nonsurgically treated patients (14.3% versus 4.2%; p = 0.018). The recurrence rate was 3 times higher in the nonsurgically treated patients (16.7% versus 5.4%; p = 0.017), but this difference was no longer detectable after propensity matching. After matching, the nonsurgically treated patients showed an almost 7-fold higher 1-year mortality rate (25.0% versus 3.7%; p = 0.018) and an almost 3-fold higher rate of treatment failure (42.9% versus 14.8%; p = 0.022). Multivariable analysis revealed nonsurgical treatment and bacteremia to be independent risk factors for treatment failure.
In our matched cohort of patients with VO, surgical intervention resulted in a significantly lower rate of treatment failure (death and/or recurrence within 1 year) compared with nonsurgical intervention. Furthermore, nonsurgical treatment was an independent risk factor for treatment failure.
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Surgical classifications for spondylodiscitis (SD) typically include radiologic features and the status of neurologic impairment. Clinical factors such as preoperative pain, function/disability, ...overall quality of life (QoL), and risk of recurrence and mortality, which are necessary for a comprehensive assessment of SD and measurement of treatment success, are not considered. There is a lack of external validation of SD classifications. The aim of this study was to validate classifications of SD and to correlate these classifications with the above clinical factors.
One hundred fourteen patients from a prospective SD register (2008-2020) with available imaging, preoperative neurologic status, backpain, function/disability data (Oswestry Disability Index and Core Outcome Measures Index), QoL data (Short Form 36, European Quality-of-life Questionnaire), and a 1-year follow-up were retrospectively classified according to Akbar, Homagk, and Pola classifications. Interrater reliability, correlation among classifications, and correlation between classifications and QoL were calculated.
Interrater reliability was κ = 0.83 for Akbar, κ = 0.94 for Homagk, and κ = 0.99 for Pola. The correlation of Akbar with Pola and Homagk was moderate (ρs = 0.47; ρs = 0.46) and high between Pola and Homagk (ρs = 0.7). No notable correlation was observed between any of the classifications and preoperative Oswestry Disability Index, Core Outcome Measures Index, QoL, mortality, and recurrence within 1 year. Only a weak correlation was observed between Homagk and preoperative leg pain and back pain.
Available SD classifications have a very good interrater reliability and moderate-to-high correlation with each other but lack correlation with preoperative pain, function/disability, and overall QoL. Because these factors are important for a comprehensive assessment of SD in severity, decision making, and prognosis, they should be included in future SD classifications. This could allow for more comprehensive treatment algorithms.
Level II. Diagnostic study = prospective cohort study; development of diagnostic criteria.
The data sets used and analyzed during this study are available from the corresponding author on reasonable request.
The application of expandable titanium-cages has gained widespread use in vertebral body replacement for indications such as burst fractures, tumors and infectious destruction. However, torque forces ...necessary for a satisfactory expansion of these implants and for subsidence of them into the adjacent vertebrae are unknown within the osteoporotic spine.
Six fresh-frozen human, osteoporotic, lumbar spines were dorsally instrumented with titanium implants (L2-L4) and a partial corpectomy of L3 was performed. An expandable titanium-cage was inserted ventrally and expanded by both residents and senior surgeons until fixation was deemed sufficient, based on haptic feedback. Torque forces for expansion were measured in Nm. Expansion was then continued until cage subsidence occurred. Torque forces necessary for subsidence were recorded. Strain of the dorsal rods during expansion was measured with strain gauges.
The mean torque force for fixation of cages was 1.17 Nm (0.9 Nm for residents, 1.4 Nm for senior surgeons, p = .06). The mean torque force for subsidence of cages was 3.1 Nm (p = .005). Mean peak strain of the dorsal rods was 970 μm/m during expansion and 1792 μm/m at subsidence of cages (p = .004).
The use of expandable titanium-cages for vertebral body replacement seems to be a primarily safe procedure even within the osteoporotic spine as torque forces required for subsidence of cages are nearly three times higher than those needed for fixation. Most of the expansion load is absorbed by straining of the dorsal instrumentation. Rod materials other than titanium may alter the torque forces found in this study.
•Expansion of expandable titanium cages seems to be safe in the osteoporotic spine.•The margin between satisfactory expansion and overdistraction is large.•Most of the expansion load seems to absorbed by the dorsal instrumentation.
Study Design.
Retrospective cohort study.
Objective.
The aim was to compare the influence of 2 common vertebral osteomyelitis (VO) causing pathogens on treatment failure within the first year of ...diagnosis.
Summary of Background Data.
VO is mainly caused by
Staphylococcus aureus
(SA), while
enterococci
and
streptococci
(ENST) are also responsible for a significant proportion of VO, particularly in elderly patients. Data on VO caused by SA show a tendency for worse outcome, whereas data on VO caused by ENST are scarce. For this purpose, our study compares characteristics of patients with VO caused by SA or ENST in order to analyze risk factors for treatment failure.
Methods.
We conducted a retrospective monocentric study including VO patients from 2008 to 2020. Primary outcome was treatment failure defined as death or relapse within 1 year (T1). We compared patients diagnosed with VO caused by Staphylococcus aureus including MRSA to patients diagnosed with VO caused by Enterococcus and Streptococcus species, which were combined into one group. Polymicrobial infections were excluded. We employed multiple logistic regression analysis to adjust for confounding. To account for moderation, the model was repeated with an included interaction term.
Results.
Data of 130 VO patients (SA=95; ENST=35) were available at T1. Treatment failure occurred in 37% of SA patients and 23% of ENST patients. On multivariate analysis SA odds ratio (OR): 3.12; 95% confidence interval (CI): 1.09–10.53;
P
=0.046, Charlson comorbidity index (OR: 1.31; 95% CI: 1.11–1.58;
P
=0.002) and infectious endocarditis (IE; OR: 4.29; 95% CI: 1.23–15.96;
P
=0.024) were identified as independent risk factors for treatment failure.
Conclusion.
In our cohort every third patient with VO caused by SA or ENST dies within 1 year. Our findings indicate that patients with VO caused by SA, concomitant IE and/or a high Charlson comorbidity index score may be at elevated risk for treatment failure. These findings can be used to individualize patient care and to direct clinical surveillance. This could include echocardiography evaluating for the presence of IE in patients with VO caused by gram-positive pathogens.
Purpose
Spinal injections are increasingly used for back pain treatment. Vertebral osteomyelitis (VO) after spinal injection (SIVO) is rare, but patient characteristics and outcome have not been well ...characterized. The aim of this study was to assess patient characteristics of SIVO in comparison to patients with native vertebral osteomyelitis (NVO) and to determine predictors for 1-year survival.
Methods
This is a single-center cohort study from a tertiary referral hospital. This is a retrospective analysis of Patients with VO who were prospectively enrolled into a spine registry from 2008 to 2019. Student’s
t
-test, Kruskal–Wallis test or Chi-square test were applied for group comparisons. Survival analysis was performed using a log-rank test and a multivariable Cox regression model.
Results
283 VO patients were enrolled in the study, of whom 44 (15.5%) had SIVO and 239 (84.5%) NVO. Patients with SIVO were significantly younger, had a lower Charlson comorbidity index and a shorter hospital stay compared to NVO. They also showed a higher rate of psoas abscesses and spinal empyema (38.6% SIVO vs. 20.9% NVO).
Staphylococcus aureus
(27%) and coagulase-negative staphylococci (CNS) (25%) were equally often detected in SIVO while
S. aureus
was more frequently than CNS in NVO (38.1% vs. 7.9%).Patients with SIVO (
P
= 0.04) had a higher 1-year survival rate (Fig. 1). After multivariate analysis, ASA score was associated with a lower 1-year survival in VO.
Conclusion
The results from this study emphasize unique clinical features of SIVO, which warrant that SIVO should be estimated as a separate entity of VO.
Dural tears (DTs) are a frequent complication after lumbar spine surgery. We sought to determine the incidence of DTs and the related impact on health care expenditures after lumbar discectomies.
In ...this retrospective cohort study, all patients with first-time single-level lumbar discectomies at our institution who underwent minimally invasive surgery from 2015 to 2019 were reviewed. Age, sex, weight, height, body mass index, costs, revenues, length of stay, American Society of Anesthesiologists score, Charlson Comorbidity Index, and operative time (OT) were assessed. Exclusion criteria were age <18 years, previous spine surgery, multiple or traumatic disc herniations, and malignant and infectious diseases.
The follow-up time was at least 12 months postoperatively. Of 358 patients identified with lumbar discectomies, 230 met the inclusion criteria. Incidence of DTs was 3.5%. Mean costs (P < 0.001), economic loss (P < 0.01), and OT (P < 0.0001) were found to be significantly higher in the DT group compared with the control group of patients without a DT. The revenues were not statistically different between the 2 groups (P > 0.05). Further analysis of the control group by profit and loss revealed significantly higher body mass index (P < 0.05), length of stay (P < 0.0001), and OT (P < 0.0001) in the loss group.
DTs represent a significant socioeconomic burden in lumbar spine surgery and cause severe secondary complications. The impact of DTs on health care expenses is primarily based on significantly higher OT and a higher mean length of stay.
While predictors for postoperative survival in spine tumour patients have been identified, there is limited evidence for predictors of postoperative Quality of Life (QoL), pain and functional ...outcome.
One hundred and fifty-three consecutive patients, who had undergone surgery for symptomatic spinal metastases between June 2016 and April 2019, were interviewed preoperatively and during follow-ups at three, six and 12 months using the EQ-5D-3L, COMI, and ODI questionnaires. Differences in means exceeding the specific Minimal Clinically Important Difference (MCID) values were considered clinically significant.
Thirty-three percent of the patients were reported dead after 12 months. Only one metastasis compared to multiple metastases has 7.9 the Odds for an improved EQ-5D-3L score at three months. No neoadjuvant metastatic irradiation has 6.8 the Odds for the improvement at that time against performed radiation. A preoperative ODI score between 50.1 and 100 has 22.0 times the odds compared to the range from 0 to 50 for an improved EQ-5D-3L after three months, and 12.5 times the odds in favour of improved COMI after three months, and 13.6 times the odds for improvement of ODI at the three-month follow-up. A preoperative COMI score ranging from 5.0 to 10 has 21 times the odds of a COMI between 0 and 5 for an improved EQ-5D-3L score and 11 times the odds for an improved ODI after 12 months. Other predictors showed no statistically significant improvement.
An improvement in QoL, pain and spinal function after 12 months can be predicted by a subjective preoperative poor health condition. Impaired spinal function before surgery, a singular metastasis and no previous irradiation is predictive of improved spinal function and quality of life three months after surgery.
•Quality of life within 12 months after spinal tumour surgery is predictable and supports decision making.•One spinal metastasis yields significantly better EQ-5D-3L at three months than multiple metastases.•Neoadjuvant radiation reduces Odds for improved EQ-5D-3L compared to no neoadjuvant radiation.
