Surgical site infections (SSIs) complicate 1% to 9% of elective spine surgeries. Previously identified risk factors include diabetes mellitus type 2, obesity, and chronic kidney disease. We sought to ...determine whether the use of postoperative surgical site drains is associated with deep SSIs.
We retrospectively identified patients operated for deep SSIs after surgery for degenerative spine pathologies between July 2016 and December 2018. Patients were excluded if the reason for operation was other than deep SSI or if their primary operation was for infection or tumor. Using their index procedure and the electronic medical record, patients were matched to controls based on age, surgical invasiveness, International Classification of Diseases, Tenth Revision, Clinical Modification code, race, and sex. Our main outcome of interest was whether drain retention time, total output, or daily output differed significantly between cases and controls.
We identified 38 patients who met inclusion criteria. Infected patients had a higher body mass index (34.2 vs. 29.9 kg/m
; P = 0.001), higher odds of having diabetes mellitus type 2 (55.3% vs. 18.4%; P = 0.002), longer drain retention time (5.5 vs. 3.5 days; P = 0.02), and longer inpatient stay (9.5 vs. 4.3 days; P = 0.005). Multivariable logistic regression demonstrated that even after controlling for the other risk factors, drain retention time independently predicted postoperative surgical site infection (odds ratio: 1.36; P = 0.02).
Prolonged surgical drain retention correlates with risk of deep SSI after surgery for degenerative spine disease independent of surgical invasiveness, diabetes mellitus type 2 status, and total drain output. Our data suggest early postoperative drain removal may potentially decrease the risk of SSI and shorten duration of hospital stay.
Abstract
BACKGROUND
Novel methods in predicting survival in patients with spinal metastases may help guide clinical decision-making and stratify treatments regarding surgery vs palliative care.
...OBJECTIVE
To evaluate whether the frailty/sarcopenia paradigm is predictive of survival and morbidity in patients undergoing surgery for spinal metastasis.
METHODS
A total of 271 patients from 4 tertiary care centers who had undergone surgery for spinal metastasis were identified. Frailty/sarcopenia was defined by psoas muscle size. Survival hazard ratios were calculated using multivariate analysis, with variables from demographic, functional, oncological, and surgical factors. Secondary outcomes included improvement of neurological function and postoperative morbidity.
RESULTS
Patients in the smallest psoas tertile had shorter overall survival compared to the middle and largest tertile. Psoas size (PS) predicted overall mortality more strongly than Tokuhashi score, Tomita score, and Karnofsky Performance Status (KPS). PS predicted 90-d mortality more strongly than Tokuhashi score, Tomita score, and KPS. Patients with a larger PS were more likely to have an improvement in deficit compared to the middle tertile. PS was not predictive of 30-d morbidity.
CONCLUSION
In patients undergoing surgery for spine metastases, PS as a surrogate for frailty/sarcopenia predicts 90-d and overall mortality, independent of demographic, functional, oncological, and surgical characteristics. The frailty/sarcopenia paradigm is a stronger predictor of survival at these time points than other standards. PS can be used in clinical decision-making to select which patients with metastatic spine tumors are appropriate surgical candidates.
Graphical Abstract
Graphical Abstract
Proximal junctional kyphosis (PJK) is a structural complication of spinal fusion in 5%-61% of patients treated for adult spinal deformity. In nearly one-third of these cases, PJK is progressive and ...requires costly surgical revision. Previous studies have suggested that patient body habitus may predict risk for PJK. Here, the authors sought to investigate abdominal girth and paraspinal muscle size as risk factors for PJK.
All patients undergoing thoracolumbosacral fusion greater than 2 levels at a single institution over a 5-year period with ≥ 6 months of radiographic follow-up were considered for inclusion. PJK was defined as kyphosis ≥ 20° between the upper instrumented vertebra (UIV) and two supra-adjacent vertebrae. Operative and radiographic parameters were recorded, including pre- and postoperative sagittal vertical axis (SVA), sacral slope (SS), lumbar lordosis (LL), pelvic tilt, pelvic incidence (PI), and absolute value of the pelvic incidence-lumbar lordosis mismatch (|PI-LL|), as well as changes in LL, |PI-LL|, and SVA. The authors also considered relative abdominal girth and the size of the paraspinal muscles at the UIV.
One hundred sixty-nine patients met inclusion criteria. On univariate analysis, PJK was associated with a larger preoperative SVA (p < 0.001) and |PI-LL| (p = 0.01), and smaller SS (p = 0.004) and LL (p = 0.001). PJK was also associated with more positive postoperative SVA (p = 0.01), ΔSVA (p = 0.01), Δ|PI-LL| (p < 0.001), and ΔLL (p < 0.001); longer construct length (p = 0.005); larger abdominal girth-to-muscle ratio (p = 0.007); and smaller paraspinal muscles at the UIV (p < 0.001). Higher postoperative SVA (OR 1.1 per cm), smaller paraspinal muscles at the UIV (OR 2.11), and more aggressive reduction in |PI-LL| (OR 1.03) were independent predictors of radiographic PJK on multivariate logistic regression.
A more positive postoperative global sagittal alignment and smaller paraspinal musculature at the UIV most strongly predicted PJK following thoracolumbosacral fusion.
Surgical-site infection (SSI) after spine surgery leads to increased length of stay, reoperation, and worse patient quality of life. We sought to develop a web-based calculator that computes an ...individual's risk of a wound infection following thoracolumbar spine surgery.
We performed a retrospective review of consecutive patients undergoing elective degenerative thoracolumbar spine surgery at a tertiary-care institution between January 2016 and December 2018. Patients who developed SSI requiring reoperation were identified. Regression analysis was performed and model performance was assessed using receiver operating curve analysis to derive an area under the curve. Bootstrapping was performed to check for overfitting, and a Hosmer–Lemeshow test was employed to evaluate goodness-of-fit and model calibration.
In total, 1259 patients were identified; 73% were index operations. The overall infection rate was 2.7%, and significant predictors of SSI included female sex (odds ratio OR 3.0), greater body mass index (OR 1.1), active smoking (OR 2.8), worse American Society of Anesthesiologists physical status (OR 2.1), and greater surgical invasiveness (OR 1.1). The prediction model had an optimism-corrected area under the curve of 0.81. A web-based calculator was created: https://jhuspine2.shinyapps.io/Wound_Infection_Calculator/.
In this pilot study, we developed a model and simple web-based calculator to predict a patient's individualized risk of SSI after thoracolumbar spine surgery. This tool has a predictive accuracy of 83%. Through further multi-institutional validation studies, this tool has the potential to alert both patients and providers of an individual's SSI risk to improve informed consent, mitigate risk factors, and ultimately drive down rates of SSIs.
Spinal robotics have the potential to improve the consistency of outcomes in adult spinal deformity (ASD) surgery. The objective of this paper is to assess the accuracy of pedicle and S2 alar-iliac ...(S2AI) screws placed with robotic guidance in ASD patients. PubMed Central, Google Scholar, and an institutional library database were queried until May 2023. Articles were included if they described ASD correction via robotic guidance and pedicle and/or S2AI screw accuracy. Articles were excluded if they described pediatric/adolescent spinal deformity or included outcomes for both ASD and non-ASD patients without separating the data. Methodological quality was assessed using the Newcastle-Ottawa scale. Primary endpoints were pedicle screw accuracy based on the Gertzbein-Robbins Scale and self-reported accuracy percentages for S2AI screws. Data were extracted for patient demographics, operative details, and perioperative outcomes and assessed using descriptive statistics. Five studies comprising 138 patients were included (mean age 66.0 years; 85 females). A total of 1,508 screws were inserted using robotic assistance (51 S2AI screws). Two studies assessing pedicle screws reported clinically acceptable trajectory rates of 98.7% and 96.0%, respectively. Another study reported a pedicle screw accuracy rate of 95.5%. Three studies reported 100% accuracy across 51 total S2AI screws. Eight total complications and 4 reoperations were reported. Current evidence supports the application of robotics in ASD surgery as safe and effective for placement of both screw types. However, due to the paucity of data, a comprehensive assessment of its incremental benefit over other techniques cannot be made. Further work using expanded cohorts is merited.
Loeys-Dietz syndrome (LDS) is a rare autosomal-dominant connective tissue disorder caused by genetic mutations in the transforming growth factor-β (TGFβ) signaling pathway. In addition to vascular ...malformations, patients with LDS commonly present with bone and tendon abnormalities, including joint laxity. While TGFβ signaling dysregulation has been implicated in many of these clinical manifestations, the degree to which it influences the tendinopathy and tendon healing issues in LDS has not been determined.
Wound healing after patellar tendon transection was compared between wild-type (WT) and Tgfbr2-mutant (LDS) mice (7 mice per group). In all mice, the right patellar tendon was transected at midsubstance, while the left was untouched to serve as a control. Mice were euthanized 6 weeks after surgery. Tendon specimens were harvested for histopathologic grading according to a previously validated scoring metric, and gene expression levels of Mmp2, Tgfb2, and other TGFβ-signaling genes were assayed. Between-group comparisons were made using 1-way analysis of variance with post hoc Tukey honestly significant difference testing.
Expression levels of assayed genes were similar between LDS and WT tendons at baseline; however, at 6 weeks after patellar tendon transection, LDS tendons showed sustained elevations in Mmp2 and Tgfb2 compared with baseline values; these elevations were not seen in normal tendons undergoing the same treatments. Histologically, untreated LDS tendons had significantly greater cellularity and cell rounding compared with untreated WT tendons, and both WT and LDS tendons had significantly worse histologic scores after surgery.
We present the first mechanistic insight into the effect of LDS on tendons and tendon healing. The morphologic differences between LDS and WT tendons at baseline may help explain the increased risk of tendon/ligament dysfunction in patients with LDS, and the differential healing response to injury in LDS may account for the delayed healing and weaker repair tissue.
Level V.
Postoperative C5 palsy affects 8% of patients undergoing posterior cervical decompression. It is associated with a period functional disability that may exceed 12 months and increase direct care ...costs > $2000.
All patients undergoing posterior cervical decompression at a single tertiary-care facility for degenerative conditions were evaluated for preoperative imaging, clinical presentation, surgical operation, and postoperative course. We sought to identify those variables predictive of postoperative C5 palsy.
Of 221 included patients (mean age, 63 years; 54% male), 12.2% experienced C5 palsy. On univariate analysis, C5 palsy was associated with foraminal diameter (P = 0.0005), spinal cord cross-sectional area (P = 0.11), number of levels undergoing laminectomy (P = 0.14), and clinical presentation of dropping objects (P = 0.07), hand clumsiness (P = 0.13), or paresthesias in the upper extremities (P = 0.08). Foraminal diameter (odds ratio, 0.31 per mm increase; 95% confidence interval, 0.16–0.60; P < 0.001) and patient report of gait disturbance (odds ratio, 0.53; 95% confidence interval, 0.33–0.85; P = 0.008) were the only significant predictors on multivariate analysis. A foraminal diameter <2 mm had 2-fold greater odds of postoperative C5 palsy. A receiver operating curve for the multivariate logistic model had an associated C-statistic of 0.7818. The absolute error of this model was 9.3% on internal validation.
Foraminal stenosis most strongly predicted postoperative C5 palsy. A proof-of-concept model incorporating foramen size, as well as clinical complaints of paresthesias, hand clumsiness, and gait abnormality, successfully predicts the occurrence of postoperative palsy with an overall accuracy of 78%.
Laparoscopic anterior lumbar interbody fusion (L-ALIF), which employs laparoscopic cameras to facilitate a less invasive approach, originally gained traction during the 1990s but has subsequently ...fallen out of favor. As the envelope for endoscopic approaches continues to be pushed, a recurrence of interest in laparoscopic and/or endoscopic anterior approaches seems possible. Therefore, evaluating the current evidence base in regard to this approach is of much clinical relevance. To this end, a systematic literature search was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following keywords: "(laparoscopic OR endoscopic) AND (anterior AND lumbar)." Out of the 441 articles retrieved, 22 were selected for quantitative analysis. The primary outcome of interest was the radiographic fusion rate. The secondary outcome was the incidence of perioperative complications. Meta-analysis was performed using RStudio's "metafor" package. Of the 1,079 included patients (mean age, 41.8±2.9 years), 481 were males (44.6%). The most common indication for L-ALIF surgery was degenerative disk disease (reported by 18 studies, 81.8%). The mean follow-up duration was 18.8±11.2 months (range, 6-43 months). The pooled fusion rate was 78.9% (95% confidence interval CI, 68.9-90.4). Complications occurred in 19.2% (95% CI, 13.4-27.4) of L-ALIF cases. Additionally, 7.2% (95% CI, 4.6-11.4) of patients required conversion from L-ALIF to open surgery. Although L-ALIF does not appear to be supported by studies available in the literature, it is important to consider the context from which these results have been obtained. Even if these results are taken at face value, the failure of endoscopy to have a role in the ALIF approach does not mean that it should not be incorporated in posterior approaches.
High-grade spinal glioma (HGSG) is a rare but aggressive tumor that occurs in both adults and children. Histone H3 K27M mutation correlates with poor prognosis in children with diffuse midline ...glioma. However, the role of H3 K27M mutation in the prognosis of adults with HGSG remains unclear owing to the rarity of this mutation, conflicting reports, and the absence of multicenter studies on this topic.
The authors studied a cohort of 30 adult patients with diffuse HGSG who underwent histological confirmation of diagnosis, surgical intervention, and treatment between January 2000 and July 2020 at six tertiary academic centers. The primary outcome was the effect of H3 K27M mutation status on progression-free survival (PFS) and overall survival (OS).
Thirty patients (18 males and 12 females) with a median (range) age of 50.5 (19-76) years were included in the analysis. Eighteen patients had H3 K27M mutation-positive tumors, and 12 had H3 K27M mutation-negative tumors. The median (interquartile range) PFS was 3 (10) months, and the median (interquartile range) OS was 9 (23) months. The factors associated with increased survival were treatment with concurrent chemotherapy/radiation (p = 0.006 for PFS, and p ≤ 0.001 for OS) and American Spinal Injury Association grade C or better at presentation (p = 0.043 for PFS, and p < 0.001 for OS). There were no significant differences in outcomes based on tumor location, extent of resection, sex, or H3 K27M mutation status. Analysis restricted to HGSG containing necrosis and/or microvascular proliferation (WHO grade IV histological features) revealed increased OS for patients with H3 K27M mutation-positive tumors (p = 0.017).
Although H3 K27M mutant-positive HGSG was associated with poor outcomes in adult patients, the outcomes of patients with H3 K27M mutant-positive HGSG were somewhat more favorable compared with those of their H3 K27M mutant-negative HGSG counterparts. Further preclinical animal studies and larger clinical studies are needed to further understand the age-dependent effects of H3 K27M mutation.
Interbody fusion is a workhorse technique in lumbar spine surgery that facilities indirect decompression, sagittal plane realignment, and successful bony fusion. The 2 most commonly employed cage ...materials are titanium (Ti) alloy and polyetheretherketone (PEEK). While Ti alloy implants have superior osteoinductive properties they more poorly match the biomechanical properties of cancellous bones. Newly developed 3-dimensional (3D)-printed porous titanium (3D-pTi) address this disadvantage and are proposed as a new standard for lumbar interbody fusion (LIF) devices. In the present study, the literature directly comparing 3D-pTi and PEEK interbody devices is systematically reviewed with a focus on fusion outcomes and subsidence rates reported in the in vitro, animal, and human literature. A systematic review directly comparing outcomes of PEEK and 3D-pTi interbody spinal cages was performed. PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Mean Newcastle-Ottawa Scale score for cohort studies was 6.4. A total of 7 eligible studies were included, comprising a combination of clinical series, ovine animal data, and in vitro biomechanical studies. There was a total population of 299 human and 59 ovine subjects, with 134 human (44.8%) and 38 (64.4%) ovine models implanted with 3D-pTi cages. Of the 7 studies, 6 reported overall outcomes in favor of 3D-pTi compared to PEEK, including subsidence and osseointegration, while 1 study reported neutral outcomes for device related revision and reoperation rate. Though limited data are available, the current literature supports 3D-pTi interbodies as offering superior fusion outcomes relative to PEEK interbodies for LIF without increasing subsidence or reoperation risk. Histologic evidence suggests 3D-Ti to have superior osteoinductive properties that may underlie these superior outcomes, but additional clinical investigation is merited.
PDF
