bluuebunny/crossref_metadata_2025 huggingface dataset:
Incidence of Compression-Induced Microinjuries in the Cartilage Endplate of the Spine
Authors: Zehr Jackie D. , Quadrilatero Joe , Callaghan Jack P.
Published: February 2023

Study Design.

In vitro biomechanical study.

Objective.

This study investigated the incidence of microstructural endplate injuries caused by cyclic compression loading. The covarying effects of joint posture, loading duration, and peak compression variation were assessed.

Summary of Background Data.

The endplate is physiologically and functionally important for the maintenance of spine health. Despite the ability to radiographically diagnose and classify macroscopic endplate injuries, the mechanical mechanisms of injury initiation and progression remain largely unknown.

Methods.

One hundred and fourteen porcine cervical spinal units were examined. All spinal units were exposed to preconditioning tests, followed by cyclic compression testing that differed by posture (flexed, neutral), loading duration (1000, 3000, 5000 cycles), and peak compression variation (10%, 20%, 40%). Microstructural injuries were examined via immunofluorescence staining for collagen I (i.e., subchondral bone) and collagen II (i.e., hyaline cartilage endplate). From the 678 acquired images, the incidence of node, avulsion, cartilage, and circumferential pore microinjuries were determined. The distribution of microinjuries between postures, spinal levels, and vertebrae were evaluated along with the associations of incidence and size of injuries with loading duration and variation.

Results.

The incidence of avulsion injuries was significantly greater in caudal endplates (92%, P=0.006). No other injuries differed between vertebrae (P≥0.804) and no significant differences were observed between spinal units (P≥0.158). With respect to posture, 100% (P<0.001) and 90% (P<0.001) of avulsion and node injuries, respectively, occurred in flexed postures, whereas 82% (P<0.001) of cartilage microinjuries occurred with neutral postures. Loading duration was significantly associated with microinjury incidence (P<0.001) and lesion size (P≤0.003).

Conclusion.

Mechanical factors such as posture did not appreciably affect the incidence of endplate injury, but microinjury types were differently distributed between flexed and neutral postures. The duration of compression was shown to have an important role in the incidence of microinjury and lesion size.
A Comparison Between Cortical Bone Trajectory Screws And Traditional Pedicle Screws in Patients With Single-Level Lumbar Degenerative Spondylolisthesis: Five-Year Results
Authors: Kwon Ji-Won , Park Yung , Lee Byung Ho , Park Si Young , Lim Chae Kwang , Yang Jae Ho , Ha Joong-Won , Suk Kyung-Soo , Moon Seong-Hwan , Kim Hak-Sun
Published: February 2023

Study Design.

A retrospective observational study.

Objective.

This study investigated the clinical and radiological results of using cortical bone trajectory (CBT) screws versus traditional pedicle (TP) screws in transforaminal lumbar interbody fusion (TLIF) during a five-year follow-up of patients with single-level lumbar degenerative spondylolisthesis.

Summary of Background Data.

Few studies have compared five-year follow-up outcomes between CBT screws and TP screws in TLIF.

Materials and Methods.

We reviewed outcome data of patients with single-level lumbar degenerative spondylolisthesis who underwent TLIF procedures with CBT screws (131 patients) or TP screws (80 patients) between 2011 and 2015. Patient-reported clinical outcome data included Oswestry disability index scores and visual analog scale (VAS) scores for back and leg pain at baseline, six months, and one year, two years, and five years postoperatively. The radiographic fusion rate and prevalence of secondary surgery for adjacent segment disease were also measured.

Results.

During the follow-up over five years, the CBT group had significantly lower VAS scores for back pain (P<0.0001, respectively). At two years after surgery, the CBT group had significantly higher VAS scores for leg pain (P=0.007). At five years postoperatively, no significant differences existed in the VAS score for leg pain or in the Oswestry disability index score between the two groups. Radiographic fusion rates (CBT vs. TP: 95.5% vs. 95.9%; P=0.881) and adverse events during the five years after surgery were not significantly different. At two years postoperatively, the prevalence of secondary surgery to treat adjacent segment disease was significantly different between the two groups (CBT vs. TP: 13.7% vs. 5.0%; P=0.044).

Conclusions.

Our results suggest that, during a five-year followup, CBT screws for TLIF were an effective treatment compared to TP screws in the setting of single-level lumbar degenerative spondylolisthesis. However, when using CBT screws for TLIF, surgeons should consider the higher rate of secondary procedures to treat symptomatic adjacent segment disease.
Observational, Multicenter Study of the Efficacy and Safety of Cervical Disk Arthroplasty With Mobi-C in the Treatment of Cervical Degenerative Disk Disease. Results at 10 years Follow-Up
Authors: Steib Jean-Paul , Dufour Thierry , Beaurain Jacques , Bernard Pierre , Huppert Jean
Published: February 2023

Background.

Cervical disk arthroplasty replacement (CDA) was developed to avoid specific disadvantages of cervical fusion. The purpose of this paper is to provide 10-year follow-up results of an ongoing prospective study after CDA.

Methods.

Three hundred eighty-four patients treated using the Mobi-C (ZimVie, Troyes, France) were included in a prospective multicenter study. Routine clinical and radiologic examinations were reported preoperatively and postoperatively with up to 10-year follow-up. Complications and revision surgeries were also documented.

Results.

At 10 years showed significant improvement in all clinical outcomes [Neck Disability Index, visual analog scale (VAS) for arm and neck pain, physical component summary of SF36, and mental component summary of SF36). Motion at the index level increased significantly over baseline (mean range of motion=7.6 vs. 8 degrees at five years and 6.0 degrees preoperatively; P<0.001) and 71.3% of the implanted segments remained mobile (range of motion>3 degrees). Adjacent disks were also mobile at 10 years with the same mobility as preoperatively. At 10 years, 20.9% of the implanted segments demonstrated no heterotopic ossification. Thirty-four patients (8.9%) experienced 41 adverse events, with or without reoperation during the first five years. We found only two additional surgeries after five years. We observed an increased percentage of working patients and a decrease in medication consumption. Regarding the overall outcome, 94% of patients were satisfied.

Conclusions.

Our 10-year results showed significant improvement in all clinical outcomes, with low rates of revision or failure. This experience in patients with long-term follow-up after CDA endorses durable, favorable outcomes in properly selected patients.
Eligibility Criteria of Participants in Randomized Controlled Trials Assessing Conservative Management of Cervical Radiculopathy: A Systematic Review
Authors: Plener Joshua , da Silva-Oolup Sophia , To Daphne , Csiernik Ben , Hofkirchner Corey , Cox Jocelyn , Chow Ngai , Hogg-Johnson Sheilah , Ammendolia Carlo
Published: February 2023

Study Design.

Systematic review.

Objective.

The aim of this study was to evaluate the inclusion and exclusion criteria for participants in randomized control trials (RCTs) assessing conservative management for cervical radiculopathy (CR), to determine if any consensus exists within the literature.

Summary of Background Data.

A 2012 systematic review identified a lack of uniformity for the eligibility criteria of participants in RCTs evaluating conservative interventions for CR. Since then, a large number of RCTs have been published, signaling the need for an updated evaluation of this topic.

Materials and Methods.

We electronically searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022, to identify RCTs assessing conservative management of CR. Information extracted was analyzed to determine the level of homogeneity and/or heterogeneity of the inclusion and exclusion criteria across studies.

Results.

Seventy-six RCTs met our inclusion criteria with 68 distinct trials identified. The inclusion of arm pain with or without another symptom (i.e. numbness, paresthesia, or weakness) was required in 69.12% of trials, 50% of trials required participants to exhibit neck symptoms, and 73.53% of studies required some form of clinical examination findings, but inconsistencies existed for the number and type of tests used. Furthermore, 41.18% of trials included imaging, with 33.82% of trials requiring magnetic resonance imaging findings. The most common exclusion criteria included were the presence of red flags and cervical myelopathy in 66.18% and 58.82% of trials, respectively.

Conclusions.

Overall, there is still a lack of uniformity for the inclusion/exclusion criteria of trials assessing the conservative management of CR, with some improvements noted compared with the 2012 review. Based on the current literature assessing the diagnostic utility of clinical symptoms and confirmatory tests, we proposed inclusion criteria for trials assessing conservative interventions. Future research should aim to develop standardized classification criteria to improve consistency among studies.
Patient-Reported Outcomes and Reoperation Rates Following Lumbar Tubular Microdecompression: Six-year Follow-Up
Authors: Bullock Garrett , Sangio Christian A. , Beck Edward C. , Gowd Anirudh K. , Miller Evan , Danelson Kerry , James O’Gara Tadhg
Published: February 2023

Study Design.

Prospective cohort study

Objective.

To report reoperation rates after lumbar tubular microdecompression (LTM) and to compare patient-reported outcomes (PROs) six years after surgery between those who did and did not need revision at the index level.

Summary of Background Data.

Long-term data describing PROs and reoperation rates after LTMs are lacking.

Materials and Methods.

Patients with lumbar spinal stenosis underwent one or more of three LTM procedures. Demographic, PROs [Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain], and reoperation data were collected. Failure of an index LTM was defined as any revision surgery at the index level. Revision LTM at a different level was not considered failure. Failure and revision LTM incidence at a different level and cumulative incidence were prospectively collected up to six years. Mixed effects linear regressions with 95% CIs were performed to assess potential differences in ODI and reported VAS back and leg pain between patients that reported failure and those that did not.

Results.

A total of 418 patients were included with median follow-up of 3.0 (1.9, 4.1) years. In all, 25% had a reoperation by six years. Sixty-five (16%) failed and 35 (9%) underwent a second LTM at another level. Cumulative failure incidence was 9% within the first two years. Failure patients had a statistically higher ODI [12.1 (95% CI, 3.2, 20.1) and VAS back [2.3 (95% CI, 0.9, 3.8)] and leg pain [1.6 (95% CI, 0.2, 3.1)] throughout follow-up. The overall dural tear rate was 7.2%.

Conclusions.

LTM is an effective treatment for lumbar spinal stenosis with sustained six-year PROs. Most failures occur within two years postoperatively and stabilize to 4% yearly incidence by year 5. The yearly incidence of reoperation with LTM stabilizes at 3% by year 6 postoperatively.

Level of Evidence.

2.
Using Electrical Stimulation of the Ulnar Nerve Trunk to Predict Postoperative Improvement in Hand Clumsiness in Patients With Cervical Spondylotic Myelopathy
Authors: Murata Shizumasa , Takami Masanari , Endo Toru , Hashizume Hiroshi , Iwasaki Hiroshi , Tsutsui Shunji , Nagata Keiji , Murakami Kimihide , Taiji Ryo , Kozaki Takuhei , Heller John G. , Yamada Hiroshi
Published: February 2023

Study Design.

A prospective cohort study

Objective.

To investigate whether the immediate and short-term effects of preoperative electrical peripheral nerve stimulation (ePNS) on performance of the 10-second test could predict the early postoperative outcomes of patients with cervical spondylotic myelopathy (CSM).

Summary of Background Data.

Previous studies have shown that early clinical improvement in CSM patients may be because of reversal of spinal cord ischemia after spinal cord compression.

Materials and Methods.

We conducted a 10-second test before surgery, after ePNS, and at discharge (one week after surgery) in 44 patients with CSM who underwent C3-C7 laminoplasty and evaluated their correlations. The effects of the procedures (ePNS or operation) and sides (stimulated or nonstimulated side) for the 10-second test were analyzed using repeated measures analysis of variance. The Pearson correlation coefficient was used to measure the relationship between the 10-second test values according to the method (after ePNS vs. surgery). In addition, the Bland-Altman method was used to evaluate the degree of agreement between the 10-second test obtained after ePNS versus shortly after surgery.

Results.

The preoperative 10-second test showed the most improvement immediately after the administration of ePNS, with a gradual decrease for the first 30 minutes after completion. After the initial 30 minutes, performance decreased rapidly, and by 60 minutes performance essentially returned to baseline. The 10-second post-ePNS had a strong positive correlation with the 10-second test in the early postoperative period (at discharge=one week after surgery). These phenomena were observed with the left hand, the side stimulated with ePNS, as well as the right hand, the side not stimulated.

Conclusions.

Early postoperative outcomes after CSM surgery may be predicted by the results of preoperative ePNS.

Level of Evidence.

Level 3
Trends in Outpatient Cervical Spine Surgery: Are There Emerging Disparities?
Authors: Amen Troy B. , Bovonratwet Patawut , Rudisill Samuel S. , Barber Lauren A. , Jordan Yusef J. , Chatterjee Abhinaba , Mok Jung K. , Varady Nathan H. , Qureshi Sheeraz A.
Published: February 2023

Study Design.

Retrospective analysis on prospectively collected data.

Objective.

The purposes of this study were to (1) assess disparities in relative utilization of outpatient cervical spine surgery between White and Black patients from 2010 to 2019 and (2) to measure how these racial differences have evolved over time.

Summary of Background Data.

Although outpatient spine surgery has become increasingly popularized over the last decade, it remains unknown how racial disparities in surgical utilization have translated to the outpatient setting and whether restrictive patterns of access to outpatient cervical spine procedures may exist.

Methods.

A retrospective cohort study from 2010 to 2019 was conducted using the National Surgical Quality Improvement Program database. Relative utilization of outpatient (same-day discharge) for anterior cervical discectomy and fusion (OP-ACDF) and cervical disk replacement (OP-CDR) were assessed and trended over time between races. Multivariable regressions were subsequently utilized to adjust for baseline patient factors and comorbidities.

Results.

Overall, Black patients were significantly less likely to undergo OP-ACDF or OP-CDR surgery when compared with White patients (P<0.03 for both OP-ACDF and OP-CDR). From 2010 to 2019, a persisting disparity over time was found in outpatient utilization for both ACDF and CDR (e.g. White vs. Black OP-ACDF: 6.0% vs. 3.1% in 2010 compared with 16.7% vs. 8.5% in 2019). These results held in all adjusted analyses.

Conclusions.

To our knowledge, this is the first study reporting racial disparities in outpatient spine surgery and demonstrates an emerging disparity in outpatient cervical spine utilization among Black patients. These restrictive patterns of access to same-day outpatient hospital and surgery centers may contribute to broader disparities in the overall utilization of major spine procedures that have been previously reported. Renewed interventions are needed to both understand and address these emerging inequalities in outpatient care before they become more firmly established within our orthopedic and neurosurgery spine delivery systems.
Trends in Short Construct Lumbar Fusions Over the Past Decade at a Single Institution
Authors: Lambrechts Mark J. , Siegel Nicholas , Issa Tariq Z. , Karamian Brian A. , Bodnar John G. , Canseco Jose A. , Woods Barrett I. , Kaye I. David , Hilibrand Alan S. , Schroeder Gregory D. , Vaccaro Alexander R. , Kepler Christopher K.
Published: February 2023

Study Design.

Retrospective cohort

Objective.

(1) To compare the rates of fusion techniques over the last decade; (2) to identify whether surgeon experience affects a surgeon’s preferred fusion technique; (3) to evaluate differences in complications, readmissions, mortality, and patient-reported outcomes measures (PROMs) based on fusion technique.

Summary of Background Data.

Database studies indicate the number of lumbar fusions have been steadily increasing over the last two decades; however, insufficient granularity exists to detect if surgeons’ preferences are altered based on additive surgical experience.

Methods.

A retrospective review of continuously collected patients undergoing lumbar fusion at a single urban academic center was performed. Rates of lumbar fusion technique: posterolateral decompression fusion (PLDF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion + PLDF (ALIF), and lateral lumbar interbody fusion + PLDF (LLIF) were recorded. Inpatient complications, 90-day readmission, and inpatient mortality were compared with χ2 test and Bonferroni correction. The Δ 1-year PROMs were compared with the analysis of variance.

Results.

Of 3938 lumbar fusions, 1647 (41.8%) were PLDFs, 1356 (34.4%) were TLIFs, 885 (21.7%) were ALIFs, and 80 (2.0%) were lateral lumbar interbody fusions. Lumbar fusion rates increased but interbody fusion rates (2012: 57.3%; 2019: 57.6%) were stable across the study period. Surgeons with <10 years of experience performed more PLDFs and less ALIFs, whereas surgeons with >10 years’ experience used ALIFs, TLIFs, and PLDFs at similar rates. Patients were more likely to be discharged home over the course of the decade (2012: 78.4%; 2019: 83.8%, P<0.001). No differences were observed between the techniques in regard to inpatient mortality (P=0.441) or Δ (postoperative minus preoperative) PROMs.

Conclusions.

Preferred lumbar fusion technique varies by surgeon preference, but typically remains stable over the course of a decade. The preferred fusion technique did not correlate with differences in PROMs, inpatient mortality, and patient complication rates.

Levels of Evidence.

3—treatment.
Long-Term Clinical, Radiographic, and Cost Analysis of Corrective Spine Surgery for Adult Symptomatic Lumbar Deformity With a Mean of 7.5 years Follow-Up
Authors: Yagi Mitsuru , Shimizu Toshiyuki , Suzuki Satoshi , Takahashi Yohei , Ozaki Masahiro , Tsuji Osahiko , Nagoshi Narihito , Yato Yoshiyuki , Matsumoto Morio , Nakamura Masaya , Watanabe Kota ,   Keio Spine Research Group
Published: February 2023

Study Design.

Multicenter retrospective study.

Objective.

This study reports long-term clinical and radiographic outcomes in surgically treated patients with adult symptomatic lumbar deformity (ASLD).

Summary of Background Data.

The short-term results of corrective spinal surgery for ASLD are often favorable despite a relatively high complication profile. However, long-term outcomes have not been completely characterized.

Methods.

A total of 169 surgically treated consecutive ASLD patients (≥50 yr) who achieved minimum 5 year follow-up were included (average 7.5 yr observation window, average age 67±8 yr, 96% female). The subjects were stratified by current age (50s, 60s, and 70s) and compared. Kaplan-Meier analysis was used to estimate the cumulative incidence of unplanned reoperation stratified by age group. Initial and overall direct costs of surgery were also analyzed.

Results.

The SRS-22 at final follow-up was similar among the three groups (50s, 60s, and 70s; 4.0±0.5 vs. 3.8±0.7 vs. 3.8±0.7, respectively). The overall major complication rate was 56%, and 12% experienced late complications. The cumulative reoperation rate was 23%, and 4% required late reoperation. Patients in their 70s had a significantly higher reoperation rate (33%) and overall complication rate (65%). However, the late complication rate was not significantly different between the three groups (9% vs. 12% vs. 13%). Sagittal alignment was improved at two years and maintained to the final follow-up, whereas reciprocal thoracic kyphosis developed in all age groups. The direct cost of initial surgery was $45K±9K and increased by 13% ($53K±13K) at final follow-up.

Conclusions.

Long-term surgical outcomes for ASLDs were favorable, with a relatively low rate of late-stage complications and reoperations, as well as reasonable direct costs. Despite the higher reoperation and complication rate, ASLD patients of more advanced age achieved similar improvement to those in the younger age groups.
Treatment With Opioids Is Not Associated With Poor Outcomes Among Older Adults With Lumbar Spinal Stenosis Receiving Epidural Injections
Authors: Kolodge Gavin , Gold Laura S. , Jarvik Jeffrey G. , Turner Judith , Hansen Ryan N. , Heagerty Patrick J. , Suri Pradeep , Friedly Janna
Published: February 2023

Study Design.

Secondary analysis of a randomized controlled trial.

Objective.

To assess how baseline treatment with opioids is associated with pain and function in older adults with lumbar spinal stenosis who receive epidural injections.

Summary of Background Data.

Data were obtained from the Lumbar Epidural Steroid injections for Spinal Stenosis trial, a double-blind, multisite, randomized controlled trial.

Methods.

Baseline treatment with opioids was assessed from electronic medical record prescription pharmacy data or from health utilization records collected from patients. We calculated adjusted changes in back pain numerical rating scale, leg pain numerical rating scale, and back-related disability (Roland Morris Disability Questionnaire scores) from baseline to three weeks and to six weeks among patients treated and not treated with opioids at baseline using generalized linear regression.

Results.

Baseline treatment with opioids was not significantly associated with back pain intensity (adjusted difference in means at three weeks of follow-up between patients treated with opioids at baseline versus not [±95% CI, 0.1 (−0.7, 0.7)], leg pain intensity [−0.2 (−0.9, 0.4)], or back-related function [−0.8 (−2.1, 0.4)]. We found similar results at six weeks of follow-up.

Conclusions.

Among older adults with lumbar spinal stenosis who are receiving epidural injections, those treated with opioids at baseline had similar outcomes to those who were not.
Cervical Disc Arthroplasty Usage Has Leveled Out From 2010 to 2021
Authors: Ratnasamy Philip P. , Rudisill Katelyn E. , Maloy Gwyneth C. , Grauer Jonathan N.
Published: February 2023

Study Design.

Descriptive epidemiologic study.

Objective.

To compare trends in utilization and predictive factors for single-level cervical disc arthroplasty (CDA) relative to anterior cervical discectomy and fusion (ACDF) over the years.

Background.

CDA is an alternative to ACDF for the treatment of cervical spine pathologies. With both procedures performed for similar indications, controversy on best practices exists.

Materials and Methods.

Patients who underwent single-level CDA or ACDF were identified in the 2010 through 2021 PearlDiver M151Ortho data set. The yearly number of CDAs performed and proportionality was assessed. Predictive patient factors for undergoing CDA as opposed to ACDF were determined. Kaplan Meyer survival analysis with an endpoint of cervical spine reoperation compared 5-year outcomes between CDA and ACDF.

Results.

From 2010 to 2021, 19,301 single-level CDAs and 181,476 single-level ACDFs were identified. The proportional utilization of CDA relative to ACDF increased from 4.00% in 2010 to 14.15% in 2018 (P < 0.0001), after which there was a plateau between 2018 and 2021 where proportional utilization was 14.47% (P = 0.4654). Multivariate analysis identified several predictors of undergoing CDA rather than ACDF, including: younger age [odds ratio (OR) per decade decrease: 1.72], having surgery performed in the Midwest, Northeast, or West (relative to South, OR: 1.16, 1.13, 2.26, respectively), having Commercial insurance (relative to Medicare, OR: 1.75), and having surgery performed by an orthopedic surgeon (relative to a neurological surgeon, OR: 1.54) (P < 0.0001 for each). There was no statistically significant difference in 5-year survival to further cervical spine surgery between CDA and ACDF at 5 years (97.6% vs. 97.7%, P = 0.4249).

Conclusions.

Although the use of CDA relative to ACDF rose from 2010 to 2018, its use has subsequently plateaued between 2018 and 2021 and remained a relatively low percentage of the single-level anterior cervical surgeries performed (14.47% in 2021). The causes for such changes in the trend are unclear.
The Effect of Local Administration of Vancomycin Suspended in Fibrin Glue for Prevention of Surgical Site Infection After Spinal Instrumentation: Comparison by Probability of Treatment Weighting Model
Authors: Higashi Takayuki , Kobayashi Naomi , Ide Manabu , Uchino Yosuke , Inoue Tetsuhiko , Inaba Yutaka
Published: February 2023

Study Design.

A retrospective cohort study.

Objective.

To compare the surgical site infection (SSI) rate in patients undergoing spinal instrumentation surgery who received vancomycin suspended in fibrin glue at the surgical site and those who did not.

Summary of Background Data.

The intrawound application of vancomycin powder for preventing SSI after spinal surgery remains controversial. Vancomycin suspended in fibrin glue is another option for local administration that may be effective. The present study assessed whether vancomycin suspended in fibrin glue could prevent SSI after spinal instrumentation surgery.

Materials and Methods.

We enrolled patients who underwent posterior spinal instrumentation surgery with or without fusion for degenerative conditions, spinal trauma, or tumor. A multiple logistic regression model with inverse probability of treatment weighting based on propensity score was used to assess the efficacy of vancomycin suspended in fibrin glue and to account for confounding. A secondary multivariate logistic regression analysis was performed to identify the risk factors associated with SSI.

Results.

Of the 264 patients enrolled in this study, 134 underwent application of vancomycin suspended in fibrin glue at the surgical site and 130 did not. The incidence of SSI was lower in patients who were treated with vancomycin suspended in fibrin glue (2.2% vs. 8.5%) even after inverse probability of treatment weighting adjustment (adjusted odds ratio: 0.25; 95% CI, 0.0768–0.91; P=0.03). Multivariate logistic regression analysis showed that the treatment with vancomycin suspended in fibrin glue was significantly associated with a lower odds of SSI (odds ratio: 0.2; 95% CI, 0.05–0.85; P=0.03).

Conclusions.

The administration of vancomycin suspended in fibrin glue was significantly associated with a lower likelihood of SSI in patients undergoing spinal instrumentation surgery.
Spine Surgeon Assessments of Patient Psychological Distress are Inaccurate and Bias Treatment Recommendations
Authors: Moon Andrew S. , Menendez Mariano E. , Moverman Michael A. , Proal Joshua D , Kim David H. , Ohaegbulam Chima , Kwon Brian
Published: February 2023

Study Design.

Prospective cohort study.

Objective.

This study determined (1) the surgeon accuracy of psychological assessment in patients in spine clinic, (2) the impact of psychological distress on surgical recommendation, and (3) the correlation between patient-reported disability and psychological distress.

Summary of Background Data.

Psychological distress is common among patients presenting for spine surgery. Surgeon estimations of patients’ distress may influence treatment recommendations, but little is known as to whether these assessments accurately mirror patient-perceived psychological distress.

Methods.

A sample of new patients was recruited from an academic spine center. Prior to their initial consultation, patients completed the Modified Somatic Perception Questionnaire and Zung Depression Index to assess mental and physical manifestations of distress, which generated a Distress and Risk Assessment Method (DRAM) score of N (normal), R (at risk), or D (distressed). The Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores were also collected. Surgeons provided their estimates of the DRAM score after the visit and indicated their surgery recommendation.

Results.

Of 296 patients, 40.5% reported some level of psychological distress (DRAM=R) and 15.9% had a high level of distress (DRAM=D). All three surgeons’ ability to accurately assess the participant DRAM score was poor, with an overall kappa of 0.13 (0.08-0.18), biased towards underestimating the patient’s true level of psychological distress. Patients rated as normal (N) by the surgeon were 3.78 times more likely to be recommended for surgery compared to those assessed as distressed (D) (P=0.007). Patients with higher DRAM scores had higher ODI (P=0.008) and NDI (P=0.005) scores compared to those with lower DRAM scores.

Conclusions.

Spine surgeons have limited ability to detect psychological profiles in patients, with a tendency to underestimate levels of distress. The finding that these inaccurate assessments influence surgical recommendations underscores the importance of limiting surgeon bias in the decision-making process.

Level of Evidence.

Diagnostic Level II
Spine Metastasis: Patients With Poor Performance Status (ECOG) Could benefit From Palliative Surgical Care! A Prospective Cohort Study
Authors: Amelot Aymeric , Terrier Louis-Marie , Le Nail Louis-Romée , Buffenoir Kévin , Cook Ann-Rose , François Patrick , Marie-Hardy Laura , Mathon Bertrand
Published: February 2023

Study Design.

This study used a French prospective national multi-center database of patients with spine metastasis (SpM).

Objective.

The main challenge was to clarify if SpM patients presenting poor ECOG-PS could benefit from a surgical intervention.

Background.

Spine metastases (SpM) are debilitating lesions commonly found in the evolution of cancer. At present, patients with poor ECOG-PS do not benefit from surgical care.

Materials and Methods.

Between 2014 and 2017, 176 SpM patients with poor initial ECOG-PS (3 or 4) were identified.

Results.

The median overall survival of patients was 2.1 months (SD 0.2). Seventy-one patients (40.3%) underwent surgery: for 49 patients (27.8%) the intervention consisted of a simple decompression and for 22 patients (12.5%) the previous was associated with an osteosynthesis. Patients who underwent surgery demonstrated significantly longer median overall survival than those who did not: 3.5 months (SD 0.4) versus 1.6 (SD 0.2) (P<0.0001). No significant differences between operated/nonoperated patients were noted concerning median age (66.4 vs. 64.2 y, P=0.897), the median number of SpM (4.1 vs. 4.2, P=0.374), ECOG-PS 4 ratio (41.6 vs. 39.3%, P=0.616), or for primary tumors (P=0.103). Patients who underwent surgery statistically improved their neurological impairment according to the Frankel score: 5/11 (45.4%) from A to C, 5/17 (29.4%) from B to C or D, 6/11 (54.5%) from C to D and 2/4 (50%). Twelve patients (16.9%) presented a postoperative complication.

Conclusion.

Patients with poor ECOG-PS could benefit from surgery. Even though survival gain is small, it permits the preservation of their neurological function. By making ambulation possible, pain is decreased during the last months of their lives.
External Validation of SpineNet, an Open-Source Deep Learning Model for Grading Lumbar Disk Degeneration MRI Features, Using the Northern Finland Birth Cohort 1966
Authors: McSweeney Terence P. , Tiulpin Aleksei , Saarakkala Simo , Niinimäki Jaakko , Windsor Rhydian , Jamaludin Amir , Kadir Timor , Karppinen Jaro , Määttä Juhani
Published: February 2023

Study Design.

This is a retrospective observational study to externally validate a deep learning image classification model.

Objective.

Deep learning models such as SpineNet offer the possibility of automating the process of disk degeneration (DD) classification from magnetic resonance imaging (MRI). External validation is an essential step to their development. The aim of this study was to externally validate SpineNet predictions for DD using Pfirrmann classification and Modic changes (MCs) on data from the Northern Finland Birth Cohort 1966 (NFBC1966).

Summary of Data.

We validated SpineNet using data from 1331 NFBC1966 participants for whom both lumbar spine MRI data and consensus DD gradings were available.

Materials and Methods.

SpineNet returned Pfirrmann grade and MC presence from T2-weighted sagittal lumbar MRI sequences from NFBC1966, a data set geographically and temporally separated from its training data set. A range of agreement and reliability metrics were used to compare predictions with expert radiologists. Subsets of data that match SpineNet training data more closely were also tested.

Results.

Balanced accuracy for DD was 78% (77%–79%) and for MC 86% (85%–86%). Interrater reliability for Pfirrmann grading was Lin concordance correlation coefficient=0.86 (0.85–0.87) and Cohen κ=0.68 (0.67–0.69). In a low back pain subset, these reliability metrics remained largely unchanged. In total, 20.83% of disks were rated differently by SpineNet compared with the human raters, but only 0.85% of disks had a grade difference >1. Interrater reliability for MC detection was κ=0.74 (0.72–0.75). In the low back pain subset, this metric was almost unchanged at κ=0.76 (0.73–0.79).

Conclusions.

In this study, SpineNet has been benchmarked against expert human raters in the research setting. It has matched human reliability and demonstrates robust performance despite the multiple challenges facing model generalizability.
Vertebral Bone Quality Score as a Predictor of Pedicle Screw Loosening Following Surgery for Degenerative Lumbar Disease
Authors: Li Wenshuai , Zhu Houze , Hua Zijian , Miao Dechao , Wang Feng , Tong Tong , Wang Linfeng
Published: February 2023

Study Design.

Retrospective study.

Objective.

To investigate whether magnetic resonance imaging-based vertebral bone quality (VBQ) score can predict pedicle screw loosening in patients who underwent pedicle screw fixation, and to compare, which measurement, the VBQ score or the Hounsfield unit (HU) value, is more predictive of pedicle screw loosening.

Summary of Background Data.

In clinical work, we found that patients with screw loosening had higher VBQ scores. In addition, some studies have found a correlation between VBQ scores and osteoporosis.

Patients and Methods.

Patients who were treated with lumbar pedicle screw fixation were reviewed. The VBQ score was measured using magnetic resonance imaging scans. The HU value for L1 to L4 lumbar bone mineral density was measured with computed tomography scans. Logistic regression analysis was used to identify factors associated with pedicle screw loosening. Receiver-operating characteristic curve analysis was used to evaluate the value of VBQ scores in predicting pedicle screw loosening.

Results.

A total of 156 patients were included in the final analysis. The pedicle screw loosening rate was 35% (55 of 156 patients). The postoperative low-back pain visual analog scale score was higher in the loosening group (3.0 ± 2.0 vs. 2.4 ± 1.8; P < 0.05). The VBQ score was higher in the loosening group than in the nonloosening group (3.28 ± 0.58 vs. 2.82 ± 0.50; P < 0.01). In multivariable analysis, nonsingle segment fixation [odds ratio (OR): 3.992; 95% CI: 1.643–9.701; P = 0.002], lowest instrumented vertebrae at S1 (OR: 3.378; 95% CI: 1.387–8.226; P = 0.007), HU value (OR: 0.988; 95% CI: 0.976–1.000; P = 0.047), and VBQ score (OR: 3.908; 95% CI: 1.624–9.405; P = 0.002) were factors associated with screw loosening. The areas under the curve for using the VBQ score and HU value to predict pedicle screw loosening were 0.720 and 0.702, respectively. The optimal VBQ score threshold was 3.05 for predicting pedicle screw loosening (sensitivity: 0.655; specificity: 0.713).

Conclusions.

The VBQ score was an influential factor associated with lumbar pedicle screw loosening, and a higher VBQ score was significantly correlated with a higher risk of screw loosening. The VBQ score was a better predictor of pedicle screw loosening than the HU value in patients who underwent pedicle screw fixation for degenerative lumbar disease.
How Sagittal Spinal Parameters Predict Anterolateral Spinal Ossification Severity: A Study Based on CT Classification
Authors: Sun Qingyu , Wang Lianlei , Chen Xing , Zhang Yuchen , Tian Yonghao , Yuan Suomao , Liu Xinyu
Published: February 2023

Study Design.

Retrospective observational study.

Objective.

The purpose of this study was to establish a CT classification system of anterolateral spinal ossification and analyze the effects of sagittal spinal parameters on ossification.

Summary of Background Data.

Patients with diffuse idiopathic skeletal hyperostosis often present with anterolateral ossification of the spine. Few reports consider anterolateral spinal ossification at each spinal level or explore the influence of sagittal alignment.

Materials and Method.

One hundred and twenty patients (79 males and 41 females) over 60 years old who underwent whole spinal CT scans from October 2018 to November 2021 were analyzed. Volume rendering technique images were used to assess the degree of anterolateral spinal ossification in each intervertebral space, and a classification system was established. Sagittal parameters, such as thoracic kyphosis, lumbar lordosis (LL), cervical lordosis, sacral slope, and thoracolumbar junction angle of the patients were measured. Multifactor stepwise linear regression analysis and ordered logistic regression analysis were used to study the effects of the sagittal parameters on ossification grades.

Results.

The median age of the study population was 67 years (63–72 IQR). The new classification system classifies the severity of anterolateral spinal ossification in each intervertebral space into grades 0 to 3 with an intra-observer intraclass correlation coefficient value of 0.909 and inter-observer intraclass correlation coefficient value of 0.900. Multivariate stepwise linear regression analysis showed that age (OR=1.30, P<0.001), weight (OR=1.23, P=0.013), and cervical lordosis (OR=1.19, P<0.001) were significantly correlated with total ossification grade. Multifactor ordered logistic regression analysis showed that there was a statistically significant correlation between cervical lordosis and the ossification grades of each intervertebral space of T1~T4 (P≤0.005), between thoracic kyphosis and each intervertebral space in T4~T12 (P≤0.019), and between thoracolumbar junction angle and each intervertebral space in T10~L3 (P≤0.025). LL was significantly and positively correlated with the ossification grades of each intervertebral space in T7~T11 (P≤0.041). LL and sacral slope were significantly negatively correlated with the ossification grades of each intervertebral space in L3~S1 (P≤0.047).

Conclusion.

Our new classification scheme demonstrated good accuracy and reliability for the evaluation of the severity of anterolateral spinal ossification. The effect of sagittal parameters on anterolateral spinal ossification was position-specific. The greater the kyphosis or the smaller the lordosis of a spinal region, the more severe the degree of ossification in the corresponding region.

Level of Evidence.

3
An Analysis of a Decade of Lumbar Interbody Cage Failures in the United States: A MAUDE Database Study
Authors: Piple Amit S. , Ungurean Victor , Raji Oluwatodimu R. , Rowland Andrea , Schlauch Adam , Kondrashov Dimitriy G. , Hsu Ken , Zucherman James
Published: February 2023

Study Design.

A retrospective case series.

Objective.

This study aims to assess the rates of lumbar interbody cage failures based on their material and manufacturer.

Summary of Background Data.

Perioperative lumbar interbody cage malfunctions are underreported events in the spine literature and may result in complications. Although the Food and Drug Administration ensures the safety of these devices under physiological conditions after implantation, these devices may experience nonphysiological conditions during implantation, which may be overlooked.

Materials and Methods.

The MAUDE database was examined for reports of lumbar cage device malfunctions from 2012 to 2021. Each report was categorized based on failure type and implant design. A market analysis was performed by dividing the total number of failures per year for each manufacturer by their approximate yearly revenue from spinal implants in the United States. Outlier analysis was performed to generate a threshold value above which failure rates were defined as greater than the normal index.

Results.

Overall, 1875 lumbar cage malfunctions were identified. Of these, 1230 (65.6%) were cage breakages, 257 (13.7%) were instrument malfunctions, 177 (9.4%) were cage migrations, 143 (7.6%) were assembly failures, 70 (4.5%) were screw-related failures, and 21 (1.1%) were cage collapses. Of the breakages, 923 (74.9%) occurred during insertion or impaction and 97 entries detailed a medical complication or a retained foreign body. Of the migrations, 155 (88.6%) were identified postoperatively, of which 73 (47.1%) detailed complications and 52 (33.5%) required a revision procedure. Market analysis demonstrated that Medtronic, Zimmer Biomet, Stryker, Seaspine, and K2M exceeded the calculated threshold.

Conclusions.

Lumbar cages with polyether ether ketone core material failed more frequently by breakage, whereas titanium surface cages failed more frequently by migration. Failure rates varied depending on the manufacturer. Most cage breakages identified in the present study occurred intraoperatively during implantation. These findings call for a more detailed Food and Drug Administration evaluation of these intraoperative malfunctions before commercial approval.

Level of Evidence.

Level 4.
A Simple Preoperative Score Predicting Failure Following Decompression Surgery for Degenerative Lumbar Spinal Stenosis
Authors: Dimitriou Dimitris , Winkler Elin , Weber Sabrina , Haupt Samuel , Betz Michael , Farshad Mazda
Published: February 2023

Background Context.

Proper patient selection is crucial for the outcome of surgically treated degenerative lumbar spinal stenosis (DLSS). Nevertheless, there is still not a clear consensus regarding the optimal treatment option for patients with DLSS.

Purpose.

To investigate the treatment failure rate and introduce a simple, preoperative score to aid surgical decision-making.

Study Design/Setting.

Retrospective observational study

Patient Sample.

Four hundred forty-five patients who underwent surgical decompression for DLSS.

Outcome Measures.

Treatment failure (defined as conversion to a fusion of a previously decompressed level) of lumbar decompression

Materials and Methods.

Several risk factors associated with worse outcomes and treatment failures, such as age, body mass index, smoking status, previous surgery, low back pain (LBP), facet joint effusion, disk degeneration, fatty infiltration of the paraspinal muscles, the presence of degenerative spondylolisthesis and the facet angulation, were investigated.

Results.

At a mean follow-up of 44±31 months, 6.5% (29/445) of the patients underwent revision surgery with spinal fusion at an average of 3±9 months following the lumbar decompression due to low back or leg pain. The baseline LBP (≥7) [odds ratio (OR)=5.4, P<0.001], the presence of facet joint effusion (>2 mm) in magnetic resonance imaging (OR=4.2, P<0.001), and disk degeneration (Pfirrmann >4) (OR=3.2, P=0.03) were associated with an increased risk for treatment failure following decompression for DLSS. The receiver operating characteristic curve analysis demonstrated that a score≥6 points yielded a sensitivity of 90% and specificity of 64% for predicting a treatment failure following lumbar decompression for DLSS in the present cohort.

Conclusions.

The newly introduced score quantifying amounts of LBP, facet effusions, and disk degeneration, could predict treatment failure and the need for revision surgery for DLSS patients undergoing lumbar decompression without fusion. Patients with scores >6 have a high chance of needing fusion following decompression surgery.

Level of Evidence.

Retrospective observational study, Level III
Surgery on the Day of Admission Decreases Postoperative Complication Rates for Patients With Central Cord Syndrome
Authors: Smith Spencer , Somogyi Rita , Wright James , Lin Clifford , Yoo Jung
Published: February 2023

Study Design:

Retrospective review.

Objective:

This study was undertaken to determine what constitutes “early optimal timing” of surgical management of central cord syndrome (CCS) with respect to a reduction of medical complications.

Summary of Background Data:

Data varies on the optimal time for surgical treatment of CCS with some studies favoring early intervention and others advocating that surgery can or should be delayed for 2–6 weeks.

Methods:

This IRB-approved study was a retrospective cross-sectional review of surgical management outcomes for patients diagnosed with CCS using the National Surgical Quality Improvement Program database, which consists of anonymized medical record data from the year 2010 to 2020. Patient data included age, sex, American Society of Anesthesiologists score, current procedural terminology codes, length of stay, and postoperative complications. Patients were grouped into admission-day surgery, next-day surgery, and late-surgery groups.

Results:

A total of 738 patients who underwent surgery to treat CCS were identified in the National Surgical Quality Improvement Program database from 2010 to 2020 and included in this study. Admission-day surgery compared with next-day surgery was associated with a decreased postoperative complication rate after multivariate analysis (odds ratio: 0.52; 95% CI: 0.28–0.97; P=0.0387) as well as shorter length of stay (P <0.0001). Complication rates between the next-day-surgery cohort and late-surgery cohort did not differ after multivariate analysis (odds ratio: 1.02; 95% CI: 0.63–1.65; P=0.9451), but the length of stay was shorter for next-day surgery (P <0.0001). Two-year rolling averages for the admission-day-surgery rate and next-day-surgery rate show a compound annual growth rate of 2.52% and 4.10%, respectively.

Conclusions:

In patients admitted for surgical treatment of CCS, those who receive admission-day surgery have significantly reduced 30-day complication rates as well as shorter length of stays. Therefore, we advocate that “early surgery” should be defined as surgery on the day of admission and should occur in as timely a manner as possible. Prior studies, which define “early surgery” as within 24 hours might, unfortunately, fall short of reaching the optimal threshold for the reduction of 30-day medical complications associated with the treatment of patients with CCS.