Spinal Instrumentation Surgery Research Articles

Contribution of the patient microbiome to surgical site infection and antibiotic prophylaxis failure in spine surgery.

Despite modern antiseptic techniques, surgical site infection (SSI) remains a leading complication of surgery. However, the origins of SSI and the high rates of antimicrobial resistance observed in these infections are poorly understood. Using instrumented spine surgery as a model of clean (class I) skin incision, we prospectively sampled preoperative microbiomes and postoperative SSI isolates in a cohort of 204 patients. Combining multiple forms of genomic analysis, we correlated the identity, anatomic distribution, and antimicrobial resistance profiles of SSI pathogens with those of preoperative strains obtained from the patient skin microbiome. We found that 86% of SSIs, comprising a broad range of bacterial species, originated endogenously from preoperative strains, with no evidence of common source infection among a superset of 1610 patients. Most SSI isolates (59%) were resistant to the prophylactic antibiotic administered during surgery, and their resistance phenotypes correlated with the patient's preoperative resistome (P = 0.0002). These findings indicate the need for SSI prevention strategies tailored to the preoperative microbiome and resistome present in individual patients.

A Sodium Oxychlorosene-Based Infection Prevention Protocol Safely Decreases Postoperative Wound Infections in Adult Spinal Deformity Surgery.

This study sought to determine the efficacy of a complex multi-institutional sodium oxychlorosene-based infection protocol for decreasing the rate of surgical site infection after instrumented spinal surgery for adult spinal deformity (ASD). Infection prevention protocols have not been previously studied in ASD patients. A retrospective analysis was performed of patients who underwent posterior instrumented spinal fusion of the thoracic or lumbar spine for deformity correction between January 1, 2011, and May 31, 2019. The efficacy of a multi-modal infection prevention protocol was examined. The infection prevention bundle consisted of methicillin-resistant Staphylococcus aureus testing, chlorhexidine gluconate bathing preoperatively, sodium oxychlorosene rinse, vancomycin powder placement, and surgical drain placement at the time of surgery. About 254 patients fit the inclusion criteria. Among these patients, nine (3.5%) experienced post-surgical deep-wound infection. Demographics and surgical characteristics amongst infected and non-infected cohorts were similar, although diabetes trended towards being more prevalent in patients who developed a postoperative wound infection (p=0.07). Among 222 patients (87.4%) who achieved a minimum of two years of follow-ups, 184 patients (82.9%) experienced successful fusion, comparing favorably with pseudarthrosis rates in the ASD literature. Rates of pseudarthrosis and proximal junction kyphosis were similar amongst infected and non-infected patients. An intraoperative comprehensive sodium oxychlorosene-based infection prevention protocol helped to provide a low rateof infection after major deformity correction without negatively impacting other postoperative procedure-related metrics.

A meta-analysis examining the impact of intrawound treatment on reducing deep surgical site infections during instrumented spine surgery.

The purpose of the meta-analysis was to evaluate and compare the effect of intrawound management on decreasing deep surgical site infections (SSIs) in instrumented spinal surgery (SS). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random or fixed effect models. For the current meta-analysis, 29 examinations spanning from 2006 to 2022 were included, encompassing 11 181 people who had instrumented SS. Intrawound management had a significantly lower deep SSI when using vancomycin (OR, 0.34; 95% CI, 0.25-0.44, p < 0.001) and povidone-iodine as intrawound management (OR, 0.24; 95% CI, 0.13-0.42, p < 0.001) compared to control in instrumented SS subjects. The data that was looked at showed that using vancomycin and povidone-iodine as intrawound management had a much lower deep SSI than using a control group of instrumented SS subjects. However, given that some studies included a small number of subjects, attention should be given to their values.

Postoperative lordosis distribution index, patient reported outcome measures, and revision surgery following transforaminal lumbar interbody fusion

ObjectiveLordosis Distribution Index (LDI) is a new radiographic parameter associated with postoperative residual symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Recently, it has been applied on patients undergoing instrumented spine surgery, however not correlated to Patient Related Outcome Measures (PROMs). This study investigates whether the obtained the postoperative LDI after TLIF surgery correlates with the clinical outcome measured with PROMs. MethodsThis study was based on prospectively obtained data in patients undergoing TLIF throughout 2017 at a Danish university hospital. Medical records and the DaneSpine Database were accessed to obtain preoperative, operative and follow-up data. Primary outcome was Oswestry Disability Index (ODI) 12 months postoperatively. Secondary outcomes included revision rate and additional PROMs. Results126 patients were included. 70 patients were classified with normolordosis (56 %), 42 hypolordosis (33 %) and 14 hyperlordosis (11 %). All groups experienced significant radiological changes undergoing surgery. Average reduction in ODI at 12 months postoperatively was −15.3 (±20.0). Minimally clinical important difference was achieved in 68 patients (54.0 %). No significant difference in PROMs between LDI-groups was observed in unadjusted or adjusted analyses. Revision surgery was performed in 8 patients with normolordosis (11.4 %), 7 hypolordosis (16.7 %) and 4 hyperlordosis (28.6 %). ConclusionsWe found no significant correlation between postoperative LDI subgroups of normolordotic, hypo- or hyperlordotic patients and the clinical outcome of posterolateral fusion and TLIF surgery. A trend towards lower rate of revision surgery in the normolordotic group compared to the hypo- and hyperlordotic group was observed.

Effects of Preoperative Use of Povidone-Iodine–Impregnated Dressing on Postoperative Rate of Surgical Site Infection in Patients Undergoing Posterolateral Lumbar Spinal Fusion Surgery: A Randomized, Nonblinded, Active-Controlled Trial

BACKGROUND AND OBJECTIVES: No study has evaluated the efficacy of using preoperative antiseptic dressings in reducing the rate of surgical site infection (SSI) in spine surgery thus far. To investigate the efficacy of the use of preoperative povidone-iodine–impregnated antiseptic dressings in patients undergoing instrumented posterolateral lumbar spinal fusion. METHODS: This was a randomized, nonblinded, active-controlled, parallel-group clinical trial. Patients were randomly assigned to the 2 study groups, including treatment and control. Patients in the treatment group received povidone-iodine–impregnated antiseptic dressing applied to the anticipated incision site 12 hours before the operation. The control group merely received the standard perioperative care with no additional intervention or placebo. Patients were followed up for 90 days, and SSIs were recorded. RESULTS: A total of 200 patients were included in this study (100 in each arm). Three cases of SSI were observed in the treatment group compared with 12 in the control one. A significant reduction in the postoperative rate of SSI was observed in the treatment group compared with the control one (P = .029). In addition to study intervention (P = .029), body mass index (P = .005), smoking status (P = .005), duration of the procedure (P = .003), American Society of Anesthesiologists class (P = .002), and diabetes mellitus (P &lt; .001) were significantly associated with the postoperative rate of SSI. CONCLUSION: To the best of our knowledge, this study for the first time showed that preoperative use of antiseptic dressings is significantly effective in reducing the rate of SSI in instrumented posterior lumbar spinal fusion surgery. Future studies are warranted to evaluate the efficacy of different preparations or the effectiveness of the present one in patients undergoing spine procedures with other surgical characteristics.

Letter to editor regarding "The Efficacy and Safety of Topical Saline Irrigation with Tranexamic Acid on Perioperative Blood Loss in Patients Treated with PELD".

Letter: We have read the recent article published by Zhang et al titled "The Efficacy and Safety of Topical Saline Irrigation with Tranexamic Acid on Perioperative Blood Loss in Patients Treated with Percutaneous Endoscopic Interlaminar Diskectomy: A Retrospective Study". In this retrospective study, authors performed interlaminar endoscopic lumbar discectomy (IELD) for L5-S1 disc herniations, categorizing patients into two groups. One group underwent IELD with saline irrigation fluid containing 0.33 gm of tranexamic acid (TXA) per 1L of saline, while the other group received only saline irrigation fluid. We appreciate the authors' efforts in shedding light on the use of TXA in irrigation fluid, which currently has limited literature available. However, we wish to highlight several points of concern that, in our view, warrant further discussion. Upon reviewing the manuscript, our initial concern centers on the reported amount of blood loss, a crucial outcome in this study. The blood loss figures presented in this study appear significantly higher compared to the existing literature. In both study groups, the authors indicate total blood loss (TBL) exceeding 300 ml and intraoperative blood loss (IBL) surpassing 40 ml. In contrast, a systematic review and meta-analysis by Jitpakdee et al. (1) reported a range of blood loss from 10.9 ml to 23.35 ml for interlaminar endoscopic discectomy without any systemic or local use of tranexamic acid. Accurately assessing blood loss in endoscopic spine surgery poses a challenge, and the accuracy of indirect calculation methods is questionable, particularly when bleeding is minimal. Endoscopic discectomy has been proven benefits by minimal tissue damage and negligible blood loss. Another significant concern we would like to address is related to the safety and efficacy of topical tranexamic acid (TXA) use in endoscopic spine surgery. The existing literature generally accepts the safety profile and efficacy of use of intravenous TXA in open spine surgery where the blood loss incurred is substantial (2, 3). However, when it comes to the safety of topical TXA, it is important to note that TXA is known to have neurotoxic and epileptogenic properties when applied to central nervous system (CNS) tissue (5, 6). This is due to its interference with central GABAA receptors and glycine receptors (7). In endoscopic spine surgeries, small dural tears can sometimes go unnoticed due to continuous irrigation fluid pressure. In such cases, the potential CNS side effects associated with topical TXA could pose a real danger. Furthermore, even when dural tears are identified during surgery, it can be challenging to completely washout all the irrigation fluid containing TXA from the surgical field. The accumulation of excessive epidural or intrathecal TXA, especially after a dural tear, can lead to life-threatening conditions such as seizures or arrhythmias, significantly increasing morbidity and mortality in what is often intended as a day-care procedure. Moreover, the authors have not mentioned any exclusion criteria for patients with conditions that are suspected to elevate risk of developing TXA-related side effects, such as a history of thromboembolic events and/or coagulopathy, convulsive disorders and dural disruption. Lastly, in terms of the efficacy of TXA, there are limited studies demonstrating the use of local TXA in spine surgeries to reduce blood loss. For example, Krohn et al(4) used topical TXA irrigation in open instrumented spinal fusion surgery before wound closure. Their study showed a reduction in postoperative blood loss, with drain output decreasing from 525 ml in the non-TXA group to 252 ml in the TXA group. However, it had no significant effect on intraoperative blood loss. We would like to raise a pertinent question regarding endoscopic discectomy procedures, which are characterized by minimal blood loss and are often conducted as day-care surgeries. It becomes a matter of concern whether the potential advantages of using topical TXA in reducing blood loss outweigh the associated risks of neurological damage to the central nervous system (CNS) and other potentially life-threatening complications.

Assessment of Navigated Pedicle Screws From Intraoperative Imaging: A Prospective Study of Accuracy and Agreement.

Intraoperative (IO) image guidance surgery using 3-dimensional fluoroscopic navigation methods, such as the O-arm system, has improved the accuracy of pedicle screw placement in instrumented spine surgery. IO and postoperative (PO) validation of the implant's correct position from radiological images is a decisive step to ensure patient safety and avoidance of complications related to implant misplacement. In this prospective single-center study, the authors investigated the accuracy and agreement of assessment of pedicle screws from IO O-arm images in comparison to PO computed tomography images. This study aimed to determine whether final evaluation of pedicle screws can safely be conducted from IO images that supersedes the PO computed tomography control. A prospective single-center study was carried out at the Spine Unit in the Department of Orthopedics at Umeå University Hospital between 2019 and 2021. All patients enrolled in the study underwent instrumented thoracolumbar spine surgery using navigation. Imaging data were obtained from IO and PO examinations. Four reviewers-2 attending senior spine surgeons, 1 final year resident in orthopedics, and 1 attending neuroradiologist-classified pedicle screws using the Gertzbein and Robbins classification system. Agreement and accuracy of the reviewers were studied to evaluate the assessment of pedicle screws from IO and PO images. A total of 70 patients (422 screws) were included in the study. There was high accuracy among surgeons both on IO and PO images (0.96-0.97, 95% CI [0.94-0.99] and 0.97, 95% CI [0.94-0.99], respectively), and the overall agreement between all raters was 92% to 98% (95% CI [0.90, 1.00]). The discrepancy in assessment between optimal (Group 1) and suboptimal (Group 2) screws between IO and PO images was as low as 1% to 1.7%, which indicates that very few suboptimal screws are missed in the assessment of IO images. The assessment of navigated pedicle screws using IO images is safe and reliable and may replace the need for further assessment using PO imaging.

Development of a bupivacaine sustained release formulation for non-opioid analgesia following instrumented spinal surgery

Development of a bupivacaine sustained release formulation for non-opioid analgesia following instrumented spinal surgery

Robot-navigated pedicle screw insertion can reduce intraoperative blood loss and length of hospital stay: analysis of 1,633 patients utilizing propensity score matching

Background contextNavigation and robotic technologies have emerged as an alternative option to conventional freehand techniques for pedicle screw insertion. However, the effectiveness of these technologies in reducing the perioperative complications of spinal fusion surgery remains limited due to the small cohort size in the existing literature. PurposeTo investigate whether utilization of robotically navigated pedicle screw insertion can reduce the perioperative complications of spinal fusion surgery—including reoperations—with a sizeable cohort. Study DesignRetrospective study. Patient SamplePatients who underwent primary lumbar fusion surgery between 2019 and 2022. Outcome measuresPerioperative complications including readmission, reoperation, its reasons, estimated blood loss, operative time, and length of hospital stay. MethodsPatients’ data were collected including age, sex, race, body mass index, upper-instrumented vertebra, lower-instrumented vertebra, number of screws inserted, and primary procedure name. Patients were classified into the following two groups: freehand group and robot group. The variable-ratio greedy matching was utilized to create the matched cohorts by propensity score and compared the outcomes between the two group. ResultsA total of 1,633 patients who underwent primary instrumented spinal lumbar fusion surgery were initially identified (freehand 1,286; robot 347). After variable ratio matching was performed with age, sex, body mass index, fused levels, and upper instrumented vertebrae level, 694 patients in the freehand group and 347 patients in robot groups were selected. The robot group showed less estimated blood loss (418.9±398.9 vs 199.2±239.6 ml; p<.001), shorter LOS (4.1±3.1 vs 3.2±3.0 days; p<.001) and similar operative time (212.5 vs 222.0 minutes; p=.151). Otherwise, there was no significant difference in readmission rate (3.6% vs 2.6%; p=.498), reoperation rate (3.2% vs 2.6%; p=.498), and screw malposition requiring reoperation (five cases, 0.7% vs one case, 0.3%; p=1.000). ConclusionSPerioperative complications requiring readmission and reoperation were similar between fluoroscopy guided freehand and robotic surgery. Robot-guided pedicle screw insertion can enhance surgical efficiency by reducing intraoperative blood loss and length of hospital stay without extending operative time.

Risk factors for reoperation after surgical treatment for degenerative spinal disease in Poland: a nationwide retrospective study of 38,953 hospitalisations.

Degenerative spinal disease (DSD) is one of the most common musculoskeletal conditions and a leading cause of sickness absence. It also contributes significantly to the global burden of disease. The aim of this study was to assess the frequency of reoperation after surgical treatment of DSDs in Poland, and to identify risk factors for reoperation. A retrospective analysis of hospitalisations for DSD in 2018 that were reported to Poland's National Health Fund (NHF) was performed. Reoperations reported within 365 days of hospital discharge were identified. Demographic factors and multimorbidities were included in the analysis. A logistic regression model was then performed to assess risk factors for reoperations. In 2018, 38,953 surgical hospitalszations for DSD were reported. A total of 3,942 hospitalised patients (10.12%) required reoperation within 365 days. Patients requiring reoperation were predominantly female (female-to-male ratio 1.34:1) and elderly (mean age of reoperated patients 56.66 years, mean age of other patients 53.24). The percentage reoperated upon correlated with multiple diseases (from 8.81% in the group of patients without comorbidities to 15.31% in the group of patients with three or more comorbidities). The risk of reoperation was most increased by comorbid depression, neurological diseases, obesity, and older age. The risk of reoperation was reduced by instrumented spinal surgery, surgery in a neurosurgical unit, and hospitalisations other than same-day surgery. Reoperations within a year after DSD surgical treatment are common. Identifying risk factors for reoperation, including those related to the presence of comorbidities and the phenomenon of multimorbidity, can be an important tool in reducing reoperation rates.

Vertebral osteomyelitis after spine instrumentation surgery: risk factors and management

Vertebral osteomyelitis after spine instrumentation surgery (pVOM) is a rare complication. Most cases of infection occur early after surgery that involve skin and soft tissue and can be managed with debridement, antibiotics, and implant retention (DAIR). To identify pVOM risk factors and evaluate management strategies. From a multicentre cohort of deep infection after spine instrumentation (IASI) cases (2010-2016), pVOM cases were compared with those without vertebral involvement. Early and late infections were defined (<60 days and >60 days after surgery, respectively). Multivariate analysis was used to explore risk factors. Among 410 IASI cases, 19 (4.6%) presented with pVOM, ranging from 2% (7/347) in early to 19.1% (12/63) in late IASIs. After multivariate analysis, age (adjusted odds ratio (aOR): 1.10; 95% confidence interval (CI): 1.03-1.18), interbody fusion (aOR: 6.96; 95% CI: 2-24.18) and coagulase-negative staphylococci (CoNS) infection (aOR: 3.83; 95% CI: 1.01-14.53) remained independent risk factors for pVOM. Cases with pVOM had worse prognoses than those without (failure rate; 26.3% vs 10.8%; P = 0.038). Material removal was the preferred strategy (57.9%), mainly in early cases, without better outcomes (failure rate; 33.3% vs 50% compared with DAIR). Late cases managed with removal had greater success compared with DAIR (failure rate; 0% vs 40%; P = 0.067). Risk factors for pVOM are old age, use of interbody fusion devices and CoNS aetiology. Although the diagnosis leads to a worse prognosis, material withdrawn should be reserved for late cases or when spinal fusion is achieved.

Delayed successful interbody fusion after initially failed midline lumbar interbody fusion spinal arthrodesis in a patient with degenerative lumbar spondylolisthesis and severe osteoporosis.

Introduction. Dual x-ray absorptiometry (DEXA) scan has been the gold standard for assessing bone mineral density prior to spinal instrumentation surgery. DEXA scans, on the other hand, can produce falsely elevated measurements in patients with severe degenerative changes, compression fractures, and aortic calcification, which can lead to incorrect patient selection and failed interbody fusion. Materials and methods. Detailed anamnesis of disease development, thorough clinical examination, patient-reported outcome measures (pain VAS, ODI, SF-12), preoperative and postoperative bone-window CT of the spine (interbody fusion status assessment), vertebral bone mineral density assessment by DEXA scan, vertebral bone density measurement in Hounsfield units by computer tomography, and the review of published literature were analysed. Results. A 67-year-old woman was diagnosed with L4-L5 degenerative spondylolisthesis. DEXA scan revealed normal bone mineral density in the lumbar vertebrae. The patient underwent midline lumbar interbody fusion (MIDLIF). The postoperative course was complicated by the occurrence of clinical and radiographic signs of pseudarthrosis. She refused revision surgery and was lost to follow-up. Three years postoperatively, she presented in good physical condition, with significant improvement in pain and functional disability. A CT scan showed delayed successful interbody fusion with complete resolution of radiolucency around implants. Conclusions. This case report summarizes some of the possible errors in diagnosis and surgical treatment in patients with degenerative pathology associated with severe vertebral osteoporosis.

Incidence and Recurrence of Deep Spine Surgical Site Infections: A Systematic Review and Meta-analysis.

Systematic review and meta-analysis. To determine a pooled incidence rate for deep surgical site infection (SSI) and compare available evidence for deep SSI management among instrumented spinal fusions. Deep SSI is a common complication of instrumented spinal surgery associated with patient morbidity, poorer long-term outcomes, and higher health care costs. We systematically searched Medline and Embase and included studies with an adult patient population undergoing posterior instrumented spinal fusion of the thoracic, lumbar, or sacral spine, with a reported outcome of deep SSI. The primary outcome was the incidence of deep SSI. Secondary outcomes included persistent deep SSI after initial debridement, mean number of debridements, and microbiology. The subsequent meta-analysis combined outcomes for surgical site infection using a random-effects model and quantified heterogeneity using the χ 2 test and the I2 statistic. In addition, a qualitative analysis of management strategies was reported. Of 9087 potentially eligible studies, we included 54 studies (37 comparative and 17 noncomparative). The pooled SSI incidence rate was 1.5% (95% CI, 1.1%-1.9%) based on 209,347 index procedures. Up to 25% of patients (95% CI, 16.8%-35.3%), had a persistent infection. These patients require an average of 1.4 (range: 0.8-1.9) additional debridements. Infecting organisms were commonly gram-positive, and among them, staphylococcus aureus was the most frequent (46%). Qualitative analysis suggests implant retention, especially for early deep SSI management. Evidence was limited for other management strategies. The pooled incidence rate of deep SSI post-thoracolumbar spinal surgery is 1.5%. The rate of recurrence and repeat debridement is at least 12%, up to 25%. Persistent infection is a significant risk, highlighting the need for standardized treatment protocols. Our review further demonstrates heterogeneity in management strategies. Large-scale prospective studies are needed to develop better evidence around deep SSI incidence and management in the instrumented thoracolumbar adult spinal fusion population.

Safety and Osteointegration of Titanium Screws Coated with a Fibroblast Growth Factor-2-Calcium Phosphate Composite Layer in Non-Human Primates: A Pilot Study.

Spinal instrumentation surgery for older patients with osteoporosis is increasing. Implant loosening may occur due to inappropriate fixation in osteoporotic bone. Developing implants that achieve stable surgical results, even in osteoporotic bone, can reduce re-operation, lower medical costs, and maintain the physical status of older patients. Fibroblast growth factor-2 (FGF-2) promotes bone formation; thus, coating pedicle screws with an FGF-2-calcium phosphate (FGF-CP) composite layer is hypothesized to enhance osteointegration in spinal implants. We designed a long-term implantation pilot study that estimated the safety and bone-forming efficacy of pedicle screws coated with an FGF-CP composite layer in cynomolgus monkeys. Titanium alloy screws, either uncoated (controls) or aseptically coated with an FGF-CP composite layer, were implanted in the vertebral bodies of six female adult cynomolgus monkeys (three monkeys per group) for 85 days. Physiological, histological, and radiographic investigations were performed. There were no serious adverse events, and no radiolucent areas were observed around the screws in either group. The bone apposition rate in the intraosseous region was significantly higher in the FGF-CP group than in the controls. Moreover, as analyzed by Weibull plots, the bone formation rate of the FGF-CP group exhibited a significantly higher regression line slope than the control group. These results demonstrated that there was significantly less risk of impaired osteointegration in the FGF-CP group. Our pilot study suggests that FGF-CP-coated implants could promote osteointegration, be safe, and reduce the probability of screw loosening.

Effect of Instrumented Spine Surgery on Length of Stay

Total joint arthroplasty studies have identified that surgeries that take place later in the week have a longer length of stay compared with those earlier in the week. This has not been demonstrated in studies focused on anterior cervical diskectomy and fusions or minimally invasive lumbar laminectomies. All-inclusive instrumented spine surgeries, however, have not been analyzed. The purpose of this study was to determine whether day of surgery affects length of stay and whether there are predictive patient characteristics that affect length of stay in instrumented spine surgery.All instrumented spine surgeries in 2019 at a single academic tertiary center were retrospectively reviewed. Patients were categorized for surgical day and discharge disposition to home or a rehabilitation facility. Differences by patient characteristics in length of stay and discharge disposition were compared using Kruskal-Wallis and chi square tests along with multiple comparisons.Seven hundred six patients were included in the analysis. Excluding Saturday, there were no differences in length of stay based on the day of surgery. Age older than 75 years, female, American Society of Anesthesiology (ASA) classification of 3 or 4, and an increased Charlson Comorbidity Index were all associated with a notable increase in length of stay. While most of the patients were discharged home, discharge to a rehabilitation facility stayed, on average, 4.7 days longer (6.8 days compared with 2.1 days, on average) and were associated with an age older than 66 years old, an ASA classification of 3 or 4, and a Charlson Comorbidity Index of 1 to 3.Day of surgery does not affect length of stay in instrumented spine surgeries. Discharge to a rehabilitation facility, however, did increase the length of stay as did age older than 75 years, higher ASA classification, and increased Charlson Comorbidity Index classification.

MRI-based vertebral bone quality score compared to quantitative computed tomography bone mineral density in patients undergoing cervical spinal surgery.

The vertebral bone quality (VBQ) score based on magnetic resonance imaging (MRI) was introduced as a bone quality marker in the lumbar spine. Prior studies showed that it could be utilized as a predictor of osteoporotic fracture or complications after instrumented spine surgery. The objective of this study was to evaluate the correlation between VBQ scores and bone mineral density (BMD) measured by quantitative computer tomography (QCT) in the cervical spine. Preoperative cervical CT and sagittal T1-weighted MRIs from patients undergoing ACDF were retrospectively reviewed and included. The VBQ score in each cervical level was calculated by dividing the signal intensity of the vertebral body by the signal intensity of the cerebrospinal fluid on midsagittal T1-weighted MRI images and correlated with QCT measurements of the C2-T1 vertebral bodies. A total of 102 patients (37.3% female) were included. VBQ values of C2-T1 vertebrae strongly correlated with each other. C2 showed the highest VBQ value [Median (range) 2.33 (1.33, 4.23)] and T1 showed the lowest VBQ value [Median (range) 1.64 (0.81, 3.88)]. There was significant weak to moderate negative correlations between and VBQ Scores for all levels [C2: p < 0.001; C3: p < 0.001; C4: p < 0.001; C5: p < 0.004; C6: p < 0.001; C7: p < 0.025; T1: p < 0.001]. Our results indicate that cervical VBQ scores may be insufficient in the estimation of BMDs, which might limit their clinical application. Additional studies are recommended to determine the utility of VBQ and QCT BMD to evaluate their potential use as bone status markers.

Cutibacterium spp. Infections after Instrumented Spine Surgery Have a Good Prognosis Regardless of Rifampin Use: A Cross-Sectional Study

Infection after spinal instrumentation (IASI) by Cutibacterium spp. is being more frequently reported. The aim of this study was to analyse the incidence, risk factors, clinical characteristics, and outcome of a Cutibacterium spp. IASI (CG) compared with non-Cutibacterium IASI (NCG) infections, with an additional focus on the role of rifampin in the treatment. All patients from a multicentre, retrospective, observational study with a confirmed IASI between January 2010 and December 2016 were divided into two groups: (CG and NCG) IASI. Baseline, medical, surgical, infection treatment, and follow-up data were compared for both groups. In total, 411 patients were included: 27 CG and 384 NCG. The CG patients were significantly younger. They had a longer median time to diagnosis (23 vs. 13 days) (p = 0.025), although 55.6% debuted within the first month after surgery. Cutibacterium patients were more likely to have the implant removed (29.6% vs. 12.8%; p = 0.014) and received shorter antibiotic regimens (p = 0.014). In 33% of Cutibacterium cases, rifampin was added to the baseline therapy. None of the 27 infections resulted in treatment failure during follow-up regardless of rifampin use. Cutibacterium spp. is associated with a younger age and may cause both early and late IASIs. In our experience, the use of rifampin to improve the outcome in the treatment of a Cutibacterium spp. IASI is not relevant since, in our series, none of the cases had therapeutic failure regardless of the use of rifampin.

Effects of extended oral antibiotic prophylaxis on surgical site infections after instrumented spinal fusion: a cohort study of 901 patients with a minimum follow-up of 1 year.

We aimed to determine whether an extended oral antibiotic prophylaxis protocol may reduce the rate of surgical site infection (SSI) in patients undergoing instrumented spinal fusion. This retrospective cohort study comprise 901 consecutive patients subjected to spinal fusion between September 2011 and December 2018 with a minimum 1-year follow-up. 368 patients operated on between September 2011 and August 2014 were administered standard intravenous prophylaxis. 533 patients operated on between September 2014 and December 2018 were administered an extended protocol with 500 mg of oral cefuroxime axetil every 12 hours (clindamycin or levofloxacin in allergic individuals) until the removal of sutures. SSI was defined following the Centers for Disease Control and Prevention criteria. The association between risk factors and the incidence of SSI was evaluated by odds ratio (OR) with a multiple logistic regression model. The bivariate analysis showed a statistically significant association between SSI and the type of prophylaxis used ("extended"' = 1.7% vs. "standard" = 6.2%, p= 0.001), with a lower proportion of superficial SSIs with the extended regimen (0.8% vs. 4.1%, p = 0.001). The multiple logistic regression model showed an OR = 0.25 (95% confidence interval [CI] 0.10-0.53) for extended prophylaxis and an OR = 3.5 (CI 1.3-8.1) for non-beta-lactams antibiotics. Extended antibiotic prophylaxis seems to be associated with a reduction in the incidence of superficial SSI in instrumented spine surgery.

Role of Decompressive Surgery in Neurologically Intact Patients with Low to Intermediate Intraspinal Metastatic Tumor Burden.

Surgical decompression (SD) followed by radiotherapy (RT) is superior to RT alone in patients with metastatic spinal disease with epidural spinal cord compression (ESCC) and neurological deficit. For patients without neurological deficit and low- to intermediate-grade intraspinal tumor burden, data on whether SD is beneficial are scarce. This study aims to investigate the neurological outcome of patients without neurological deficit, with a low- to intermediate-ESCC, who were treated with or without SD. This single-center, multidepartment retrospective analysis includes patients treated for spinal epidural metastases from 2011 to 2021. Neurological status was assessed by Frankel grade, and intraspinal tumor burden was categorized according to the ESCC scale. Spinal instrumentation surgery was only considered as SD if targeted decompression was performed. ESCC scale was determined in 519 patients. Of these, 190 (36.6%) presented with no neurological deficit and a low- to intermediate-grade ESCC (1b, 1c, or 2). Of these, 147 (77.4% were treated with decompression and 43 (22.65%) without. At last follow-up, there was no difference in neurological outcome between the two groups. Indication for decompressive surgery in neurologically intact patients with low-grade ESCC needs to be set cautiously. So far, it is unclear which patients benefit from additional decompressive surgery, warranting further prospective, randomized trials for this significant cohort of patients.

Vitamin D deficiency during the perioperative period increases the rate of hardware failure and the need for revision fusion in adult patients undergoing single-level lumbar spine instrumentation surgery

Vitamin D has been shown to play important roles in both calcium homeostasis and bone healing. Only three studies have directly examined the relationship between vitamin D deficiency and hardware failure, nonunion, and/or revision surgery. Results are contradictory and none were large enough to provide the statistical power necessary to make definitive conclusions. A retrospective analysis was performed utilizing the PearlDiver national insurance claims database consisting of 91 million individual patient records. Patients aged 30 and over who underwent a non-segmental posterior lumbar fusion procedure (CPT-22840) in 2012-2019 were included. Data collected included, hardware failure, revision surgery occurrence, and vitamin D deficiency. Hardware failure and revision rates were compared between vitamin D deficient and non-deficient groups. We ran a logistic regression analysis using the following variables: age, Charlson Comorbidity Index (CCI), gender, vitamin D deficiency, obesity, tobacco use, diabetes, osteoporosis, rheumatoid arthritis, and Crohn's disease. 108,137 patients matching inclusion criteria were identified, with an overall hardware failure rate of 2.7% and revision rate of 4.1%. Failure rates were significantly higher for patients diagnosed with vitamin D deficiency during the full queried period (3.3% vs. 2.6%, OR=1.26; p < 0.0001), as were revision rates (4.3% vs 3.5%, OR=1.25; p < 0.0001). Patients diagnosed with deficiency pre-surgery, higher failure (3.1% vs 2.6%, OR=1.19; p < 0.01) and rates of revision (4.4% vs 3.5%, OR=1.27; p < 0.0001) were increased compared to the non-deficient group. In the logistic regression analysis, vitamin D deficiency remains a significant contributor to hardware failure and revision surgery. These results demonstrate that pre- and/or post-operative vitamin D deficiency is independently correlated with risk for hardware failure and revision surgery in single-level lumbar fusion patients.