Introduction: Surgical management of degenerative lumbar spine disorders is effective at improving patient pain, disability, and quality of life; however, obtaining a durable posterolateral fusion ...after decompression remains a challenge. Interbody fusion technologies are viable means of improving fusion rates in the lumbar spine, specifically various graft materials including autograft, structural allograft, titanium, and polyether ether ketone. This study assesses the effectiveness of Tritanium posterolateral cage in the treatment of degenerative disk disease.Methods: Nearest-neighbor 1:1 matched control transforaminal lumbar interbody fusion with PEEK vs. Tritanium posterior lumbar (PL) cage interbody fusion patients were identified using propensity scoring from patients that underwent elective surgery for degenerative disk diseases. Line graphs were generated to compare the trajectories of improvement in patient-reported outcomes (PROs) from baseline to 3 and 12 months postoperatively. The nominal data were compared via the χ2 test, while the continuous data were compared via Student's t-test.Results: The two groups had no difference regarding either the 3- or 12-month Euro-Qol-5D (EQ-5D), numeric rating scale (NRS) leg pain, and NRS back pain; however, the Tritanium interbody cage group had better Oswestry Disability Index (ODI) scores compared to the control group of the PEEK interbody cage at both 3 and 12 months (p=0.013 and 0.048).Conclusions: Our results indicate the Tritanium cage is an effective alternative to the previously used PEEK cage in terms of PROs, surgical safety, and radiological parameters of surgical success. The Tritanium cohort showed better ODI scores, higher fusion rates, lower subsidence, and lower indirect costs associated with surgical management, when compared to the propensity-matched PEEK cohort.
Study Design. This is a retrospective review of prospectively collected data. Objective. The aim was to evaluate the impact of frailty and sarcopenia on outcomes after lumbar spine surgery. Summary ...of Background Data. Elderly patients are commonly diagnosed with degenerative spine disease requiring surgical intervention. Frailty and sarcopenia result from age-related decline in physiological reserve and can be associated with complications after elective spine surgery. Little is known about the impact of these factors on patient-reported outcomes (PROs). Methods. Patients older than 70 years of age undergoing elective lumbar spine surgery were included. The modified 5-item frailty index (mFI-5) was calculated. Sarcopenia was defined using total psoas index, which is obtained by dividing the mid L3 total psoas area by VB area (L3-TPA/VB). PROs included Oswestry disability index (ODI), EuroQual-5D (EQ-5D), numeric rating scale (NRS)-back pain, NRS leg pain (LP), and North American Spine Society (NASS) at postoperative 12 months. Clinical outcomes included length of stay (LOS), 90-day readmission and complications. Univariate and multivariable regression analyses were performed. Results. Total 448 patients were included. The mean mFI-5 index was 1.6±1.0 and mean total psoas index was 1.7±0.5. There was a significant improvement in all PROs from baseline to 12 months ( P <0.0001). After adjusting for age, body mass index, smoking status, levels fused, and baseline PROs, higher mFI-5 index was associated with higher 12-month ODI ( P <0.001), lower 12-month EQ-5D ( P =0.001), higher NRS-L P ( P =0.039), and longer LOS ( P =0.007). Sarcopenia was not associated with 12-month PROs or LOS. Neither sarcopenia or mFI-5 were associated with 90-day complication and readmission. Conclusions. Elderly patients demonstrate significant improvement in PROs after elective lumbar spine surgery. Frailty was associated with worse 12 months postoperative ODI, EQ-5D, NRS-LP scores, and longer hospital stay. While patients with sarcopenia can expect similar outcomes compared with those without, the mFI-5 should be considered preoperatively in counseling patients regarding expectations for disability, health-related quality of life, and leg pain outcomes after elective lumbar spine surgery. Level of Evidence. 3.
Retrospective.
The purpose of this study is to evaluate the effect of posterior cervical fusion lowest instrumented vertebra (PCF LIV) selection on incidence of mechanical failure, revision surgery, ...and patient-reported outcomes (PROs).
Recent studies indicate that the LIV in PCF may contribute to the risk of mechanical failure. To date, the evidence available to guide spine surgeons in the selection of PCF LIV remains limited.
All patients undergoing PCF at a single institution were prospectively entered into a spine registry which was retrospectively queried. Data collection included demographics, pathology, operative variables, construct LIV, outcomes of mechanical failure, revision surgery, and patient-reported disability, pain, and quality of life.
Of 438 patients undergoing PCF from 2006 to 2019, 106 patients had an LIV of C7, T1, or T2, a minimum of 1-year follow-up, and met all study inclusion criteria. LIV cohorts were C7 LIV (36), T1 LIV (42), and T2 LIV (28). There were no between-group differences in patient demographics, operative variables, or postoperative follow-up across the three LIV cohorts. Mechanical failure rates for C7, T1, and T2 LIV were 30.6%, 23.8%, and 0%, respectively (P = 0.007). Revision rates for C7, T1, and T2 LIV were 25.0%, 11.9%, and 0%, respectively (P = 0.013). No difference was noted in average time to revision/failure between C7 (39.68 months) and T1 (29.85 months) LIV cohorts. No differences in baseline, 3-month, and 12-month postoperative PRO measures were noted in the C7 and T1 LIV cohort when compared to the T2 LIV cohort.
The findings in this study indicate that PCF LIV selection may play a significant role in the development of mechanical complications and need for revision surgery. T2 LIV selection demonstrated a significantly lower rate of mechanical failure and revision surgery. Postoperative PROs up to 36 months are needed to evaluate effect of LIV selection on PROs.Level of Evidence: 3.
In an era of rising health care costs, it is prudent to consider effective use of resources. Given the rapidly expanding elderly population with an anticipated increase in adult spinal deformity, ...identifying the significant cost drivers for the surgical management is an important step in the process of increasing sustainability and cost-effectiveness of adult spinal deformity surgery.
A total of 129 patients undergoing elective spine surgery for thoraco-lumbar deformity were enrolled in a prospective longitudinal registry. Patient-reported resource use during the 3-month postoperative period, including outpatient visits, spine-related diagnostic tests, injections, emergency department room visits, rehabilitation/skilled nursing facility utilization, and use of all medications, was collected in a single-center prospective registry. Multiple linear regression analysis was conducted to find the significant patient coefficient for the cost variability.
The study population showed significant improvement (P < 0.001) in all patient-reported outcomes including disability (Oswestry Disability Index), pain (Numeric Rating Scale for Back Pain and Numeric Rating Scale for Leg Pain), and quality of life (Euro-Qol-5D). In risk-adjusted multiple patient comorbidities including chronic obstructive pulmonary disease and diabetes, preoperative deformity diagnosis, number of levels involved, length of surgery and hospital stay, 90-day readmission and use of inpatient rehabilitation were the significant drivers of the cost.
Our study demonstrates that several patient-specific, surgery-related factors, 90-day readmission and postdischarge inpatient rehabilitation use, were associated with increased cost associated with the adult deformity spine surgery.
•In an era of rising healthcare costs, it is prudent to consider effective use of resources.•We report prospective data identifying the significant cost drivers in corrective procedures for adult spine deformity.•This study is an important step for enhancing sustainability and cost-effectiveness of adult spinal deformity surgery.
Introduction: Posterior cervical spine approaches have been associated with increased rates of wound complications compared to anterior approaches. While barbed suture wound closure for lumbar spine ...surgery has been shown to be safe and efficacious, there is no literature regarding its use in posterior cervical spine surgery. In a cohort of patients undergoing elective posterior cervical spine surgery, we sought to compare postoperative complication rates between barbed and traditional interrupted suture closure.Methods: A retrospective review of demographics, past medical history, and operative and postoperative variables collected from a prospective registry between July 1, 2016, and June 30, 2020 was undertaken. All patients 18 years old and above undergoing elective posterior cervical fusion were included. The primary outcome of interest was wound complications, including surgical site infection (SSI), dehiscence, or hematoma. In addition, numerical rating scale (NRS) neck pain (NP), NRS arm pain (AP), Neck Disability Index (NDI), and operative time were collected. A variety of statistical tests were used to compare the two suture groups.Results: Of 117 patients undergoing posterior cervical fusion, 89 (76%) were closed with interrupted suture and 28 (24%) with barbed suture. The interrupted cohort were more likely to have >1 comorbidity (p<0.001), diabetes mellitus (p=0.013), and coronary artery disease (p=0.002). No difference in postoperative wound complications between interrupted/barbed sutures was observed after univariate (OR 1.07, 95% CI: 0.27-4.25, p=0.927) and multivariable logistic regression analysis (OR 0.77, 95% CI: 0.15-4.00, p=0.756). Univariate logistic regression revealed no differences in achieving minimal clinically important difference (MCID) NRS-NP (OR 0.73, 95% CI: 0.28-1.88, p=0.508) or NRS-AP (OR 0.68, 95% CI: 0.25-1.90, p=0.464) at 3 months between suture groups. The interrupted suture group was less likely to achieve MCID NDI at 3 months (OR 0.29, 95% CI: 0.11-0.80, p=0.016).Conclusions: Barbed suture closure in posterior cervical spine surgery does not lead to higher rates of postoperative wound complications/SSI compared to traditional interrupted fascial closure.
Systemic assessment is a pillar in the neurological, oncological, mechanical, and systemic (NOMS) decision-making framework for the treatment of patients with spinal metastatic disease. Despite this ...importance, emerging evidence relating systemic considerations to clinical outcomes following surgery for spinal metastatic disease has not been comprehensively summarised. We aimed to conduct a scoping literature review of this broad topic. We searched MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, and CINAHL databases from Jan 1, 2000, to July 31, 2021. 61 articles were included, accounting for a total of 22 335 patients. Preoperative systemic variables negatively associated with postoperative clinical outcomes included demographics (eg, older age >60 years, Black race, male sex, low or elevated body-mass index, and smoking status), medical comorbidities (eg, cardiac, pulmonary, hepatic, renal, endocrine, vascular, and rheumatological), biochemical abnormalities (eg, hypoalbuminaemia, atypical blood cell counts, and elevated C-reactive protein concentration), low muscle mass, generalised motor weakness (American Spinal Cord Injury Association Impairment Scale grade and Frankel grade) and poor ambulation, reduced performance status, and systemic disease burden. This is the first comprehensive scoping review to broadly summarise emerging evidence relevant to the systemic assessment component of the widely used NOMS framework for spinal metastatic disease decision making. Medical, surgical, and radiation oncologists can consider these findings when prognosticating spinal metastatic disease-related surgical outcomes on the basis of patients’ systemic condition. These factors might inform a shared decision-making approach with patients and their families.
Introduction: Laminoplasty is a well-established technique used to manage cervical myelopathy (CM). Nevertheless, the degree to which United States surgeons have adopted laminoplasty from Japan to ...treat CM is less clear. The purpose of this study was to compare operative management strategies for CM in the United States (US) with Japan.Methods: This study used a retrospective cohort of 16,084 patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and 389,872 patients from the Japanese Diagnosis Procedure Combination (DPC) database from 2007 to 2015. Patients with the following diagnoses were collected: spondylosis with myelopathy (ICD-19; 721.1, ICD-10; M47.12) and disk herniation with myelopathy (ICD-9; 722.71, ICD-10; M50.00). The proportion of surgeries between Japan and the US was compared using a linear regression model controlling for year.Results: US surgeons utilized anterior procedures in 70% of cases compared to 9% in Japan (p<.001). In contrast, Japan had significantly more laminoplasties than the US (43% vs. 4%, respectively, p<.001). The percentage of laminoplasty in Japan (43%) relative to the percentage in the US (4%) was significantly different (p<.001). Accounting for increases in the number of total surgeries per year seen in the ACS-NSQIP and DPC databases, no specific surgery demonstrated a significant increase or decrease over the 8 years.Conclusions: Japanese surgeons employ laminoplasty to treat CM approximately ten times more frequently than US surgeons who prefer anterior procedures.
A retrospective cohort study.
To evaluate the impact of the upper instrumented vertebral (UIV) screw angle in adult spinal deformity (ASD) surgery on: (1) proximal junctional kyphosis/failure ...(PJK/F), (2) mechanical complications and radiographic measurements, and (3) patient-reported outcome measures (PROMs).
The effect of UIV screw angle in ASD surgery on patient outcomes remains understudied.
A single-institution, retrospective study was undertaken from 2011 to 2017. UIV screw angle was trichotomized into positive: cranially directed screws relative to the superior endplate (2°≤θ), neutral: parallel to the superior endplate (-2°<θ<2°), and negative: caudally directed screws relative to the superior endplate (-2°≥θ). The primary outcome was PJK/F. Secondary outcomes included remaining mechanical complications, reoperation, and PROMs: Oswestry Disability Index, Numeric Rating Scale (NRS) back/leg, and EuroQol. Regression controlled for age, body mass index, postoperative sagittal vertical axis (SVA), and pelvic incidence lumbar-lordosis mismatch.
Among 145 patients undergoing ASD surgery, UIV screw angles were 35 (24.1%) cranially directed, 24 (16.6%) neutral, and 86 (59.3%) caudally directed. PJK occurred in 47(32.4%) patients. Positive screws were independently associated with increased PJK odds ratio (OR)=4.88; 95% CI, 1.85-13.5, P =0.002 and PJF (OR=3.06; 95% CI, 1.32-12.30, P =0.015). Among 108 (74.5%) patients with lower thoracic UIV, PJK occurred in 38 (35.1%). Cranially directed screws were independently associated with an increased odds of PJK (OR=5.56; 95% CI, 1.86-17.90, P =0.003) with a threshold of 0.2° (area under the curve =0.65; 95% CI, 0.54-0.76, P <0.001), above which the risk of PJK significantly increased. No association was found between positive screw angle and PJF (OR=3.13; 95% CI, 0.91-11.40, P =0.073). Because of the low number of patients with an upper thoracic UIV (N=37, 25.5%), no meaningful conclusions could be drawn from this subgroup. There was no association between UIV screw angle and remaining mechanical complications, reoperations, postoperative SVA and T1-pelvic angle, or PROMs.
Cranially directed UIV screw angles increased the odds of PJK in patients with lower thoracic UIV. Meticulous attention should be paid to the lower thoracic UIV screw angle to mitigate the risk of PJK in ASD.
Purpose
The modified Japanese Orthopedic Association (mJOA) score consists of six sub-domains and is used to quantify the severity of cervical myelopathy. The current study aimed to assess for ...predictors of postoperative mJOA sub-domains scores following elective surgical management for patients with cervical myelopathy and develop the first clinical prediction model for 12-month mJOA sub-domain scores.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: Byron F. Last name Stephens, Author 2 Given name: Lydia J. Last name McKeithan, Author 3 Given name: W. Hunter Last name Waddell, Author 4 Given name: Anthony M. Last name Steinle, Author 5 Given name: Wilson E. Last name Vaughan, Author 6 Given name: Jacquelyn S. Last name Pennings, Author 7 Given name: Jacquelyn S. Last name Pennings, Author 8 Given name: Scott L. Last name Zuckerman, Author 9 Given name: Kristin R. Last name Archer, Author 10 Given name: Amir M. Last name Abtahi Also, kindly confirm the details in the metadata are correct.Last Author listed should be Kristin R. Archer
Methods
A multivariable proportional odds ordinal regression model was developed for patients with cervical myelopathy. The model included patient demographic, clinical, and surgery covariates along with baseline sub-domain scores. The model was internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.
Results
The model identified mJOA baseline sub-domains to be the strongest predictors of 12-month scores, with numbness in legs and ability to walk predicting five of the six mJOA items. Additional covariates predicting three or more items included age, preoperative anxiety/depression, gender, race, employment status, duration of symptoms, smoking status, and radiographic presence of listhesis. Surgical approach, presence of motor deficits, number of surgical levels involved, history of diabetes mellitus, workers’ compensation claim, and patient insurance had no impact on 12-month mJOA scores.
Conclusion
Our study developed and validated a clinical prediction model for improvement in mJOA scores at 12 months following surgery. The results highlight the importance of assessing preoperative numbness, walking ability, modifiable variables of anxiety/depression, and smoking status. This model has the potential to assist surgeons, patients, and families when considering surgery for cervical myelopathy.
Level of evidence
Level III.
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