STUDY DESIGN.Retrospective study of prospectively collected data.
OBJECTIVE.To determine if the modified Frailty Index (mFI) could be used to predict postoperative complications in patients ...undergoing surgery for adult spinal deformity (ASD).
SUMMARY OF BACKGROUND DATA.Surgery for patients with ASD is associated with high complication rates and significant concerns present during risk stratification with older patients. The mFI is an evaluation tool to describe the frailness of an individual and how their preoperative status may impact postoperative survival and outcomes. Using a large nationwide database, we assessed the utility of this instrument in patients undergoing surgery for ASD.
METHODS.The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative variables, patient demographics, operative factors, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent fusion for spinal deformity. The previously described mFI was calculated based on the number of positive factors and univariate and multivariate logistic regression analysis were used to analyze the risk factors associated with mortality.
RESULTS.Overall, 1001 patients were identified and the mean mFI score was 0.09 (range0–0.545). Increasing mFI score was associated with higher complication, reoperation, and mortality rates (P < 0.05). mFI of 0.09 and 0.18 was an independent predictor of any complication, mortality, requiring a blood transfusion, pulmonary embolism/deep vein thrombosis, and reoperation (all P < 0.05). In comparison with age >60 years obesity class III, mFI was a superior predictor of several postoperative complications and reoperation.
CONCLUSION.Frailty was an independent predictor of postoperative complications, mortality, and reoperation in patients undergoing surgery for ASD. Preoperative assessment of the mFI in this patient population can be utilized to improve current risk models.Level of Evidence3
Metastatic spine disease (MSD) occurs commonly in cancer patients causing pain, spinal instability, devastating neurological compromise, and decreased quality of life. Oncological patients are often ...medically complex and frail, precluding them form invasive procedures. To address this issue, minimally invasive spinal surgery (MISS) techniques are desirable. The aim of this study is to review published peer-reviewed literature and ongoing clinical trials to provide current state of the art.
A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, assessing MISS in MSD patients for the period 2013-2023. Innovations under development were assessed by querying and reviewing data from currently enrolling U.S. registered clinical trials.
From 3,696 articles, 50 studies on 3,196 patients focused on spinal oncology MISS. The most commonly reported techniques were vertebral augmentation (VA), percutaneous spinal instrumentation, and radiofrequency ablation (RFA). Surgical instrumentation/stabilization techniques were reported in 10/50 articles for a total of 410 patients. The majority of studies focused on pain as a primary outcome measure, with 28/50 studies reporting a significant improvement in pain following intervention. In the United States, 13 therapeutic trials are currently recruiting MSD patients. Their main focus includes radiosurgery, VA and/or RFA, and laser interstitial thermal therapy.
Due to their medical complexity and increased fragility, MSD patients may benefit from minimally invasive approaches. These strategies are effective at mitigating pain and preventing neurological deterioration, while providing other advantages including ease to start/resume systemic/radiotherapy treatment(s).
We sought to predict surgical volumes for 2 common cervical spine procedures from 2020 to 2040.
Using the National Inpatient Sample from 2003–2016, nationwide estimates of anterior cervical ...diskectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) volumes were calculated using International Classification of Diseases, Ninth and Tenth Revision (ICD-9, ICD-10) procedure codes. With data from the U.S. Census Bureau, estimates of the U.S. population were used to create Poisson models controlling for age and sex. Age was categorized into ranges (<25 years old, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and >85), and estimates of surgical volume for each age group were created.
From 2020–2040, increases in surgical volume from 13.3% (153,288–173,699) and 19.3% (29,620–35,335) are expected for ACDF and PCDF, respectively. For ACDF, the largest increases are expected in the 45–54 (42,077–49,827) and 75–84 (8065–14,862) age groups, whereas for PCDF, the largest increases will be seen in the 75–84 (3710–6836) age group. In accordance with an aging population, modest increases will be seen for ACDF (858–1847) and PCDF (730–1573) in the >85-year-old cohort.
As expected, large growth in cervical spine surgical volumes is likely to be seen, which could indicate a need for increased numbers of spinal neurosurgeons and orthopedic surgeons. Further studies are needed to investigate the needs of the field in light of these expected increases in volume.
The frequency of anterior cervical discectomy and fusion (ACDF) has increased up to 400% since 2011, underscoring the need to preoperatively anticipate adverse postoperative outcomes given the ...procedure's expanding use. Our study aims to accomplish two goals: firstly, to develop a suite of explainable machine learning (ML) models capable of predicting adverse postoperative outcomes following ACDF surgery, and secondly, to embed these models in a user-friendly web application, demonstrating their potential utility.
We utilized data from the National Surgical Quality Improvement Program database to identify patients who underwent ACDF surgery. The outcomes of interest were four short-term postoperative adverse outcomes: prolonged length of stay (LOS), non-home discharges, 30-day readmissions, and major complications. We utilized five ML algorithms - TabPFN, TabNET, XGBoost, LightGBM, and Random Forest - coupled with the Optuna optimization library for hyperparameter tuning. To bolster the interpretability of our models, we employed SHapley Additive exPlanations (SHAP) for evaluating predictor variables' relative importance and used partial dependence plots to illustrate the impact of individual variables on the predictions generated by our top-performing models. We visualized model performance using receiver operating characteristic (ROC) curves and precision-recall curves (PRC). Quantitative metrics calculated were the area under the ROC curve (AUROC), balanced accuracy, weighted area under the PRC (AUPRC), weighted precision, and weighted recall. Models with the highest AUROC values were selected for inclusion in a web application.
The analysis included 57,760 patients for prolonged LOS 11.1% with prolonged LOS, 57,780 for non-home discharges 3.3% non-home discharges, 57,790 for 30-day readmissions 2.9% readmitted, and 57,800 for major complications 1.4% with major complications. The top-performing models, which were the ones built with the Random Forest algorithm, yielded mean AUROCs of 0.776, 0.846, 0.775, and 0.747 for predicting prolonged LOS, non-home discharges, readmissions, and complications, respectively.
Our study employs advanced ML methodologies to enhance the prediction of adverse postoperative outcomes following ACDF. We designed an accessible web application to integrate these models into clinical practice. Our findings affirm that ML tools serve as vital supplements in risk stratification, facilitating the prediction of diverse outcomes and enhancing patient counseling for ACDF.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Since the onset of the COVID-19 pandemic, there have been rare reports of spinal cord pathology diagnosed as inflammatory myelopathy and suspected spinal cord ischemia after SARS-CoV-2 infection. ...Herein, we report five cases of clinical myelopathy and myeloradiculopathy in the setting of post-COVID-19 disease, which were all radiographically negative. Unlike prior reports which typically characterized hospitalized patients with severe COVID-19 disease and critical illness, these patients typically had asymptomatic or mild-moderate COVID-19 disease and lacked radiologic evidence of structural spinal cord abnormality. This case series highlights that COVID-19 associated myelopathy is not rare, requires a high degree of clinical suspicion as imaging markers may be negative, and raises several possible pathophysiologic mechanisms.
As increasing numbers of elderly Americans undergo spinal surgery, it is important to identify which patients are at highest risk for poor cognitive and functional recovery. Frailty is a geriatric ...syndrome that has been closely linked to poor outcomes, and short-form screening may be a helpful tool for preoperative identification of at-risk patients.
This study aimed to conduct a pilot study on the usefulness of a short-form screening tool to identify elderly patients at increased risk for prolonged cognitive and functional recovery following elective spine surgery.
This is a prospective, comparative cohort study.
The sample comprised 100 patients over age 65 who underwent elective spinal surgery (cervical or lumbar) at a single, large academic medical center from 2013 to 2014.
Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight (FRAIL) scale, Postoperative Quality of Recovery Scale (PQRS), and instrumental activities of daily living (IADL) scores were the outcome measures.
Included patients were assessed with the FRAIL scale and stratified as robust, pre-frail, or frail. The PQRS and IADL scores were also obtained. Patients were re-examined at 1 day, 3 days, 1 month, and 3 months after surgery for cognitive recovery at 3 months, and secondarily, functional recovery at 3 months.
At 3 months, only 50% of frail patients had recovered to their cognitive baseline compared with 60.7% of pre-frail and 69.2% of robust patients (trend). At 3 months, 66.7% of frail patients had recovered to their functional baseline compared with 57% of pre-frail and 76.9% of robust patients (trend). Using multivariate regression modeling, at 3 months, frail patients were less likely to have recovered to their cognitive baseline compared with pre-frail and robust patients (odds ratio 0.39, confidence interval 0.131–1.161).
This pilot study demonstrates a trend toward poorer cognitive recovery 3 months following elective spinal surgery for frail patients. Frailty screening can help preoperatively identify patients who may experience protracted cognitive and functional recovery.
Retrospective questionnaire analysis.
The goal of this study was to analyze patients' understanding and preferences for minimally invasive spine (MIS) versus open spine surgery.
MIS surgery is ...increasing in prevalence. However, there is insufficient literature to evaluate how the availability of MIS surgery influences the patients' decision-making process and perceptions of spine procedures.
A survey was administered to patients who received a microdiscectomy or transforaminal lumbar interbody fusion between 2016 and 2020. All eligible patients were stratified into two cohorts based on the use of minimally invasive techniques. Each cohort was administered a survey that evaluated patient preferences, perceptions, and understanding of their surgery.
One hundred fifty two patients completed surveys (MIS: 88, Open: 64). There was no difference in time from surgery to survey (MIS: 2.1 ± 1.4 yrs, Open: 1.9 ± 1.4 yrs; P = 0.36) or sex (MIS: 56.8% male, Open: 53.1% male; P = 0.65). The MIS group was younger (MIS: 53.0 ± 16.9 yrs, Open: 58.2 ± 14.6 yrs; P = 0.05). More MIS patients reported that their technique influenced their surgeon choice (MIS: 64.0%, Open: 37.5%; P < 0.00001) and increased their preoperative confidence (MIS: 77.9%, Open: 38.1%; P < 0.00001). There was a trend towards the MIS group being less informed about the intraoperative specifics of their technique (MIS: 35.2%, Open: 23.4%; P = 0.12). More of the MIS cohort reported perceived advantages to their surgical technique (MIS: 98.8%, Open: 69.4%; P < 0.00001) and less reported disadvantages (MIS: 12.9%, Open: 68.8%; P < 0.00001). 98.9% and 87.1% of the MIS and open surgery cohorts reported a preference for MIS surgery in the future.
Patients who received a MIS approach more frequently sought out their surgeons, were more confident in their procedure, and reported less perceived disadvantages following their surgery compared with the open surgery cohort. Both cohorts would prefer MIS surgery in the future. Overall, patients have positive perceptions of MIS surgery.Level of Evidence: 3.
INTRODUCTIONThe 'kickstand screw-rod' technique has been recently described for correction of coronal malalignment. This technique utilizes powerful 'construct-to-ilium' distraction between a fixed ...multi-screw thoracic construct and the ilium, facilitated by a novel 'iliac kickstand screw'. The 'iliac kickstand screw' traverses a previously undescribed osseous corridor in the ilium.OBJECTIVEUsing a radiographic CT study, the objective is to describe a large osseous corridor within the ilium to accommodate the novel iliac kickstand screw.METHODS50 consecutive patients with pelvic CTs at an academic medical center were queried. Simulated iliac kickstand screw trajectories for the left and right hemipelvis were analyzed with 3D visualization software. Maximal screw lengths and dimensions, and trajectories in the osseous corridor were measured.RESULTS50 patients' (31 female, 19 male) pelvic CTs were measured with a total of 100 simulated screws. The mean age was 52.4 years and BMI 28.1 ± 7.9. The average length is 119.7 ± 6.6 mm (range 98.7 - 135.3). The narrowest width (maximum potential screw diameter) is 17.8 ± 2.9 mm (coronal) and 20.8 ± 5.3 mm (sagittal). The starting point to the top of the iliac crest is 66.4 mm lateral to midline, and 15.9° caudal in the sagittal and 6.1° lateral in the coronal planes.CONCLUSIONSThe novel iliac kickstand screw traverses a consistent and large osseous corridor within the ilium. The average simulated screw length is 119.7 mm and maximum potential diameter of 17.8 mm. Starting points relative to the iliac crest are identified.
STUDY DESIGN.Retrospective review.
OBJECTIVE.The aim of this study was to describe thoracic kyphosis (TK) in a normal asymptomatic population and to evaluate the association between TK magnitude and ...its shape.
SUMMARY OF BACKGROUND DATA.Understanding spinal anatomy requires a three-dimensional appreciation of the spineʼs shape, morphology, and proportions. The customary definition of TK is the angle between T4 and T12. However, little is known on the actual shape of TK in adults.
METHODS.Asymptomatic volunteers were recruited; demographic data along with full-body standing radiographs were recorded. Radiographic data such as T1–12 and T4–12 angles were collected. Maximum TK and vertebral orientation/tilt were also collected, in addition to cumulative TK and Centered Kyphosis at T7. The cohort was stratified by T1–12 value (<40°, 40°–60°, and>60°) and comparisons and regressions were performed afterward.
RESULTS.One hundred nineteen subjects were included (average age 50.8 yrs, 81 female). Mean T1–12 kyphosis was 49.5°, mean T4–12 kyphosis 41.5°, and mean maximum TK was 52.6°. T1 was the most anteriorly tilted vertebra, L1 the most posteriorly tilted; T7 was horizontal, independently of T1–12 value or age. Cumulative kyphosis analysis revealed that the apex of kyphosis was located at T6-T7. Regression analysis predicting the value and the percentage of T1–7 both yielded T1–12 as a predictor (Adj. r = 0.32, Adj. r = 0.13).
CONCLUSION.Changes in kyphosis distribution in an asymptomatic population suggest that TK is not a simple circle arcwith low TK, 2/3 of the kyphosis is located in the upper part and when TK increases, the distribution of kyphosis will be symmetric around T7. It is possible to predict the amount of kyphosis in the upper part using total kyphosis value. This could help estimate preoperative compensation and predict reciprocal change.Level of Evidence3
PDF
