Spinal Fusion Research Articles

Untreated Osteoporosis in Lumbar Fusion Surgery Patients: Prevalence, Risk-factors and Effect on Bone Metabolism.

Secondary analysis of a prospective single-center study. To analyze the prevalence and risk factors for untreated osteoporosis in patients undergoing lumbar spinal fusion surgery (LFS) and its impact on bone mineral density (BMD) and bone turnover markers. Osteoporosis is a risk factor for mechanical complications in LFS, which can be mitigated by antiosteoporotic treatment. However, there's limited research on factors leading to untreated osteoporosis before LFS and its impact on preoperative bone status. A secondary analysis of a prospective study enrolling adults undergoing LFS for degenerative conditions (2014-2024) with preoperative quantitative CT osteoporosis screening was performed. Demographic data and medical history were analyzed for prevalence and risk factors of untreated osteoporosis, while BMD, vitamin D, PTH levels, and bone turnover markers were assessed for the effects of lacking treatment. A total of 445 patients (48% female, median age 64) were included, of which 137 patients (31%) had osteoporosis. Of these, 66 (48%) were untreated and 71 (52%) were treated, with 40 (56%) receiving pharmacological and 31 (44%) non-pharmacologic treatment including vitamin D supplementation and lifestyle modifications. Of the untreated patients, 55 (80%) were identified by preoperative screening. 71% of osteoporotic men versus 35% of osteoporotic women were untreated (P<0.001). Multivariable logistic regression confirmed male sex as an significant contributing factor (OR 4.3, 95% CI 1.9-10.1, P<0.001) for untreated osteoporosis. Treated osteoporotic patients had higher BMD (P<0.001), higher VitD levels P=0.023) and lower levels of bone resorption parameters (P=0.004) than untreated patients. Untreated osteoporosis is common before LFS, especially in men, with the untreated having lower BMD and higher bone resorption marker levels than treated patients. Identification of osteoporotic cases and subsequent osteological optimization could potentially reduce the risks of adjacent fractures or screw loosening.

Comparison of postoperative and outpatient opioid use in adolescent idiopathic scoliosis patients treated with posterior spinal fusion surgery and vertebral body tethering.

Surgical treatments for adolescent idiopathic scoliosis (AIS) include posterior spinal fusion (PSF) and vertebral body tethering (VBT), but there is limited data that compares pain between these groups. We aimed to compare postoperative pain between these patients through inpatient opioid use and opioid prescriptions post-discharge. A retrospective review of patients diagnosed with AIS whounderwent PSF or VBT surgery was reviewed to determine LOS, inpatient opioid use, and opioids prescribed post-discharge. Only PSF patients who received liposomal bupivacaine and intrathecal (IT) hydromorphone, and VBT patients who received a paravertebral catheter of lidocaine and in addition toIT hydromorphone were included. Opioid amounts were reported as oral morphine equivalents (OMEs). Of 198 AIS patients that met inclusion, there were 89 PSF and 109 VBT patients. PSF patients had an increased LOS by 0.6 days compared to VBT patients (p < 0.001). Patients in the PSF group were administered a mean of 30.0 OMEs/day compared with the VBT group who received 12.5 OMEs/day (p < 0.001). At discharge, PSF patients were initially prescribed a mean of 227.7 OMEs while VBT patients' mean prescription was 139.7 (p < 0.001). PSF patients received more refills (Χ2 (1, n = 198) = 26.8, p < .001) and had a higher mean total of outpatient OMEs prescribed when compared to VBT patients (359.4 vs 185.8, p < 0.001). In AIS patients undergoing surgical correction, those who underwent PSF had longer LOS, received more inpatient OMEs, and were prescribed more OMEs both at initial discharge and total as an outpatient, when compared to VBT patients. Level III: (retrospective cohort study).

Short-Term Outcomes of a Novel Non-Screw Based Expandable Posterior Interbody Fusion Cage

BackgroundLumbar interbody fusion is a well-established surgical technique for treating various lumbar degenerative pathologies. Expandable cages have been introduced to allow for insertion via the confined access and to improve disc height restoration, though concerns about the stability of the screw-based cages in the expanded state remains a concern. This study aims to evaluate the short-term clinical and radiographic outcomes of a novel non-screw based expandable TLIF cage. MethodsAdult patients who underwent posterior spinal fusion and were implanted the X-PAC TLIF-cage for degenerative lumbar conditions between September 2021 and April 2023 were retrospectively reviewed. Radiographic outcomes, including anterior disc height (ADH), posterior disc height (PDH), and segmental lordosis, were measured preoperatively, postoperatively, and at ≥6-month follow-up. Cage subsidence at follow-up was assessed according to the Marchi classification, along with cage collapse and complications requiring revision surgery. Radiographic outcomes were compared between timepoints using Wilcoxon signed-rank tests and paired t-test depending on distribution. ResultsThe study included 131 patients, implanted with 160 expandable cages. Significant increases in ADH and PDH were observed postoperatively and maintained at follow-up (ADH: 9.8 mm ± 5.4 versus 12.7 mm ± 4.0, and PDH: 3.1 mm (1.3 – 4.9) versus 5.0 mm (3.6 – 6.9) respectively, p < 0.001). Segmental lordosis showed an initial postoperative increase but was not significantly sustained at the 6-month follow-up. Cage subsidence was seen in 9.3% of cases, with no severe subsidence or complete cage collapse. Revision surgery was required in 6.1% of patients, none due to cage-related issues. ConclusionThe novel non-screw-based expandable cage effectively restored and maintained disc height with a low incidence of complications, suggesting it as a safe and effective alternative for lumbar interbody fusion. Further long-term studies are needed to confirm its efficacy and safety.

Perioperative inpatient falls for anterior cervical discectomy and fusion patients are on the rise: Risk factors associated with this “never event”

Background ContextPatients undergoing anterior cervical discectomy and fusion (ACDF) often have brief inpatient stays and may be at risk for inpatient falls (IPFs). Such IPFs should be preventable and have been termed a “never event” by the National Quality Forum, an affiliate of The Joint Commission. Despite increasing attention to IPF prevention, no studies have investigated the incidence, trends, and factors associated with IPFs among ACDF patients. PurposeTo characterize the trends in the incidence of ACDF-related IPFs and their risk factors. Study Design/SettingRetrospective cohort study. Patient SampleAdult patients who underwent inpatient ACDF between 2010 – Q3 2022 were abstracted from a large, national, multi-insurance administrative claims database. Outcome MeasuresIncidence, trends, and factors associated with IPFs. MethodsAdult patients who had undergone single or multi-level inpatient ACDF were identified by administrative coding. Exclusion criteria included: patients < 18 years of age, those who underwent outpatient ACDF, concurrent posterior cervical procedures, thoracic or lumbar fusion, and those with trauma, neoplasm, or infection diagnosed within 90-days prior to surgery. The subset of patients who suffered an IPF were subsequently identified. The annual incidence of IPFs was analyzed over the study years and various risk factors were assessed for their correlation with IPFs by multivariable logistic regression. To determine the association between IPF and length of stay (LOS), patients with relative to without IPF were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI) and compared by multivariable logistic regression. ResultsOf the 294,165 inpatient ACDF patients meeting inclusion criteria, IPFs were identified for 5,548 (1.9%). Between 2010 and Q3 2022, the annual incidence of IPFs increased from 309 (1.1%) to 515 (4.8%) for patients undergoing ACDF (p<0.001). Independent predictors of an IPF were: hospital acquired delirium (odds ratio [OR] 4.50), history of prior falls (OR 3.38), hospital acquired psychosis (OR 3.17), alcohol use disorder (OR 2.68), cervical myelopathy (relative to radiculopathy) (OR 2.66), socioeconomically disadvantaged patients (OR 1.85), history of dementia (OR 1.77), underweight body mass index (BMI <18.5) (OR 1.67), multi-level ACDF (OR 1.43), history of prior cervical surgery (OR 1.41), male sex (OR 1.37), Medicaid insurance (OR 1.34), older age (OR 1.33), patients in the northeast United States (OR 1.15), and obese BMI >30 (OR 1.15) (p<0.001 for all). Relative to patients without IPF, patients who suffered an IPF following ACDF demonstrated incrementally increasing odds of extended LOS (4-5 days [OR 2.63], 6-7 days [OR 3.85], 7+ days [OR 6.78]) (p<0.001 for all). ConclusionIn this robust national sample of patients undergoing inpatient ACDF, IPFs were identified for 1.9%, with an increasing annual incidence over the years. Among these patients, various factors were associated with their occurrence, many of which may be potentially modifiable. These findings have major clinical implications on care pathway optimization regarding early identification of high-risk patients undergoing ACDF and lays a foundation for the refinement of multidisciplinary fall prevention programs.

Multicenter study of OPRM1 A118G and promoter-region DNA methylation associations with opioid outcomes and chronic postsurgical pain after pediatric musculoskeletal surgery

Abstract Introduction: Mu opioid receptor gene (OPRM1) variant rs1799971 introduces a CpG site, which may influence DNA methylation (DNAm) and opioid/pain outcomes. Objectives: In this nested analysis, we investigated both OPRM1 A118G genotype and promoter/immediate downstream blood DNAm sequencing data for associations with opioid effects and chronic postsurgical pain (CPSP) in a surgical cohort. Methods: Prospectively recruited opioid naïve patients undergoing Nuss procedure or spinal fusion with rs1799971 genotypes (Illumina arrays), DNAm (next generation enzymatic methylation sequencing at Chr6:154,039,209-154,039,803) and outcomes—opioid analgesia (integrated opioid use + pain over postoperative days 0 and 1 normalized to surgery type), safety—respiratory depression (RD) in high opioid use groups, and CPSP (Numerical Rating Scale &gt;3/10 2-12 months postsurgery)—were included. Linear and logistic regression were performed to test genetic and epigenetic associations, adjusted for sociodemographics, cell types, and analgesics. Results: In this cohort (N = 112; 15.3 ± 2.0 years, 50% female, 83% White, 55% had CPSP, 13% had RD), DNAm at Chr6:154039216-154039217 was associated with CPSP (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.00-1.57; P = 0.03), Chr6:154039661-154039662 with acute integrated pain (β = −20.9, 95% CI, −40.70 to −1.10, P = 0.04), Chr6:154039520-154039521 (OR, 1.49; 95% CI, 1.09-2.03; P = 0.01), and Chr6:154039571-154039572 (OR, 1.47; 95% CI, 1.08-2.01; P = 0.02) with RD. Significant CpG sites were located in Repressed Polycomb chromatin states. Genotype was not associated with DNAm or outcomes. Conclusion: Our analyses support OPRM1 DNAm as predictors of acute and chronic pain/opioid outcomes in children after painful surgery. Study limitations included absent GG genotype, low sequencing coverage, and lack of correction for multiple testing.

Treatment of scoliosis in children after resection of neuroblastoma—A report of five cases

Purpose: Neuroblastoma (NB) is a common extracranial solid tumor in children, often requiring surgical resection. Post-resection NB near the spine can lead to spinal deformities, but treatment strategies are not well-documented. Methods: We retrospectively reviewed our patients who developed spinal deformities after NB resection at our hospital from 2013 to 2021. Treatment included the traditional growing rod (TGR) technique for patients with growth potential, posterior spinal fusion (PSF) for skeletally mature patients, and intermittent cast therapy for infants. Results: Five female patients underwent chemotherapy and surgical resection for NB, with no recurrence during follow-up. Single curves were seen in Cases 1, 2, 4, and 5, and Case 3 had double curves. NB tumors were on the convex side in Cases 1, 3, and 5, and on the concave side in Cases 2 and 4. TGR was used for Cases 1 and 2 due to growth potential and inadequate height. PSF was chosen for Cases 3 and 4, achieving satisfactory scoliosis and kyphosis correction. Case 5, diagnosed with scoliosis at 16 months, underwent intermittent cast therapy for 2 years, significantly correcting scoliosis and avoiding surgery. The average time from NB resection to scoliosis onset was 65.2 ± 49.3 months, with scoliosis treatment starting at 82.6 ± 58.1 months. The mean follow-up was 38.2 ± 12.1 months. All patients showed significant improvement in spinal deformities, with no significant correction loss at the last follow-up. Conclusions: After NB resection, spinal deformities should be closely monitored, with intervention preferably within 6 months of discovery. TGR, PSF, and casting are effective interventions, with the treatment modality based on the patient's skeletal maturity and height.

Higher Socioeconomic Status is Associated with Greater Rates of Surgical Resource Utilization Prior to Spine Fusion Surgery

Previous research has demonstrated an association between socioeconomic status (SES) and patient health, specifically noting that patients of lower SES have poor health outcomes. Understanding how social factors, including socioeconomic status (SES), relate to disparities in health outcomes is critical to closing gaps in equitable care to patients. While several studies have examined the effect of SES on postoperative spine outcomes, there is limited spine literature evaluating SES in the context of barriers to spine care. The primary objective of this study was to determine if socioeconomic status is associated with resource utilization prior to spine surgery consultation. As part of a sub-analysis, this paper also explores the effect of other social factors on pre-visit resource utilization. Retrospective cohort study. Adult patients who underwent elective cervical or lumbar spinal fusion between 2020 and 2021. Pre-visit resource utilization including 1) epidural steroid injection, 2) opioid use, 3) physical therapy, 4) prior spine surgeon, and 5) prior spine surgery METHODS: Each patient was assigned a "distressed score" using the Distressed Communities Index (DCI) and a socioeconomic status (SES) score using the Social Vulnerability Index (SVI) based on their zip code. Patient charts were manually reviewed to collect data regarding pre-visit resource utilization. The cohort was analyzed based on DCI quintile and SVI quartile. Additional analyses were conducted based on marital status and race. Our study included 996 patients in the final analysis. Based on DCI, patients from prosperous communities were more likely to have previously visited a spine surgeon (13.2% (prosperous) vs. 7.58% vs. 6.92% vs. 9.09% vs. 3.70% (distressed), p=0.015) and to have had prior spine surgery (11.1% (prosperous) vs. 9.57% vs. 9.09% vs. 2.52% vs. 6.36% (distressed), p=0.015). Similarly, when evaluated based on SES SVI, patients who lived in a low-risk community were more likely to have previously visited a spine surgeon (13.0% low-risk vs. 7.26% low-medium risk vs. 16.9% medium-high risk vs. 10.6% high risk, p=0.049) and to have had prior spine surgery (13.0% low-risk vs. 7.26% vs. 16.9% vs. 10.6% high risk, p=0.030). When evaluated based on marital status, there was no difference in any resource utilization. Non-black and non-white patients were more likely to have tried physical therapy compared to their black and white counterparts (76.9% (other) vs. 60.9% (Black) vs. 54.3% (White), p=0.026). This study examined the relationship between socioeconomic status and resource utilization and found a positive correlation between higher social standing and access to spine surgery and spine surgeons. These findings demonstrate a propensity for earlier evaluation of spine-related conditions among patients from prosperous communities compared to patients from less prosperous communities.

Comparative analysis of the efficacy of oblique lateral interbody fusion versus transforaminal lumbar interbody fusion in the treatment of lumbar disc herniation

Lumbar disc herniation (LDH) often necessitates surgical intervention when conservative treatments fail. Oblique Lateral Interbody Fusion (OLIF) and Transforaminal Lumbar Interbody Fusion (TLIF) are two commonly used techniques for treating LDH, each offering distinct surgical approaches. This study aimed to compare the efficacy of OLIF versus TLIF in terms of pain relief, functional outcomes, spinal alignment correction, fusion success, and postoperative recovery. A retrospective study was conducted on 133 patients who underwent either OLIF (n = 68) or TLIF (n = 65) between January 2020 and December 2022. Data on patient demographics, pain and functional outcomes (measured by Visual Analogue Scale [VAS] and Oswestry Disability Index [ODI]), radiological outcomes (sagittal and coronal Cobb angles, apical vertebra deviation), fusion and collapse rates, and postoperative recovery (ambulation time and hospitalization duration) were collected. Statistical analysis was performed using t-tests and chi-square tests, with significance set at P < 0.05. Both groups demonstrated significant postoperative improvements in pain and functional outcomes. OLIF resulted in significantly better long-term pain reduction (VAS 1.99 ± 0.67 vs. 2.29 ± 0.92, P = 0.03) and greater spinal alignment correction, particularly in sagittal Cobb angle and apical vertebra deviation (P < 0.001). The fusion rate was similar between OLIF (97.92%) and TLIF (96.61%, P = 0.56), but OLIF had a lower collapse rate (8.33% vs. 18.64%, P < 0.001). OLIF also facilitated faster postoperative recovery, with earlier ambulation and shorter hospitalization time (P < 0.001 for both). While both OLIF and TLIF are effective for treating LDH, OLIF offers superior long-term pain relief, better spinal alignment correction, reduced collapse rates, and faster recovery. These findings suggest that OLIF may be a more advantageous option for patients requiring lumbar interbody fusion.

Accuracy of Pedicle Screw Placement Using the ExcelsiusGPS Robotic Navigation Platform: An Analysis of 728 Screws.

Robotic platforms have increased in sophistication for pedicle screw placement. Here, we review our institutional experience using ExcelsiusGPS to assess the accuracy rate of pedicle screw placement throughout the spine and characterize predictors of placement inaccuracy. Retrospective cohort study. Patients from 2017 to 2022 undergoing spinal fusion surgery with ExelsiusGPS-assisted screw implantation at a single tertiary center were retrospectively identified. Patient demographics, preoperative symptoms, and operative details were collected. Postoperative computed tomography was used to classify screw placement accuracy according to the Gertzbein and Robbins scale (GRS). A stepwise multivariable ordered logistic regression analysis determined independent risk factors for clinically inaccurate screws (GRS C/D/E). One hundred and seventeen patients were included. Mean age was 60.6 ± 13.2 years, with 57% men, 72% white, and mean body mass index of 29.9 ± 6.4 kg/m2. Seven hundred and twenty-eight screws were placed, predominantly in the thoracic (29.5%) and lumbar (52.6%) regions. Accuracy classification indicated 670 GRS A, 31 GRS B, 22 GRS C, 4 GRS D, and 1 GRS E screws. The clinically acceptable screw placement rate (GRS A/B) was 96%. Male gender (odds ratio [OR]: 2.12, P = 0.03), revision surgery (OR: 2.43, P = 0.02), and thoracic level screw insertion (OR: 2.33, P = 0.01) were independently associated with inaccurate screw placement and explained 8.7% of the variability seen. Of the 728 screws placed, 3 required revision after postoperative imaging revealed loosening or pedicle breach. ExcelsiusGPS-assisted screw insertion has high placement accuracy and low revision rates. Identification of predictors of inaccuracy illustrates that similar variables, such as placement in the thoracic spine and revision surgery status, apply to both freehand and robotic screw placement. Robotic spine surgery is an accurate, reliable tool that can improve patient outcomes. Factors like male gender, thoracic screw placement, and revision surgery status are associated with lower screw placement accuracy, and these factors should inform surgical decision-making when using robotic assistance.

Comparison of fusion rate, radiologic and clinical outcome between CaO-SiO2-P2O5-B2O3 bioactive glass-ceramics 7 (BGS-7) spacer and allograft spacer with iliac bone graft in multilevel ACDF.

CaO-SiO2-P2O5-B2O3 bioactive glass-ceramics7 (BGS-7) are known for their strong integration with bone and stability and are commonly used in spinal fusions. This study aimed to compare fusion rates and radiological and clinical outcomes between BGS-7 and allograft spacers with iliac bone grafts (IBG) in multilevel anterior cervical discectomy and fusion (ACDF) surgeries. This retrospective study was conducted at BRM Medical Center. We included patients who underwent multilevel ACDF at BRM Medical Center between January 2012 and December 2023. The patients had symptoms such as cervical radiculopathy and myelopathy due to cervical disc herniation, stenosis, and spondylosis. We evaluated the preoperative and postoperative Japanese Orthopedic Association (JOA) scores, neck disability index (NDI), functional rating index (FRI), and visual analog scale (VAS) scores for the neck, shoulder, and upper extremities at 6 months and 1 year after surgery. Fusion rates were assessed using dynamic radiography and computed tomography (CT) scans at 1 year postoperatively. Radiological measurements were obtained from preoperative and postoperative plain radiographs. At the 1-year follow-up, the fusion rates were 89.5% for BGS-7 and 92.2% for the allograft cage on dynamic radiographs (p=0.156) and 93.4% and 90.4%, respectively, on CT scans (p=0.319), confirming both internal and external osseointegration. Subsidence rates were 4% for BGS-7 and 10% for the allograft spacer group. Both groups showed increased cervical lordosis (CL), segmental lordosis (SL), and segmental height postoperatively, with maintained lower segmental height (LSH) in the BGS-7 group than in the allograft spacer group at postoperatively 1 year. No adjacent segmental disease (ASD) occurred in either group. The JOA, NDI, and FRI showed significant improvements in both groups. The VAS scores decreased significantly in both groups, indicating improved clinical outcomes. In multilevel ACDF, BGS-7 demonstrated fusion rates comparable to those of the allograft spacer with IBG, experiencing fewer instances of subsidence and cage fracture. Therefore, BGS-7 spacer can be safely utilized in multilevel ACDF as a substitute for traditional allograft spacers, without the need for additional IBG.

Early versus late construct failure in spine metastatic disease: implications for surgical strategy and oncologic outcome.

This study aimed to identify variables that portend early construct failure requiring surgical revision in patients undergoing instrumented fusion for spine metastases. A detailed retrospective chart review was performed. Demographic, surgical, and oncologic variables were collected and analyzed via independent samples t-testing, chi-square testing, and Kaplan-Meier method with log-rank testing. Significance was determined as p < 0.05. 482 spinal fusion operations for solid tumor metastases were performed between 2012 and 2022. Of these, 24 (5.0%) required revision surgery for construct failure. There were no major differences between the revision and non-revision patients in terms of several surgical characteristics. Thirteen (54.1%) were revised within 3 months of index surgery. These early construct failures were more likely to have functional neurological deficits at surgery (6/13 vs. 0/11 [p = 0.009]), longer constructs (mean 6.4±2.4 vs. 4.2 ± 1.4 levels [p = 0.015]), and cement-augmented pedicle screws (4/13 vs. 0/11 [p = 0.044)) compared to late construct failures (> 3 months after index surgery). Additionally, 17 symptomatic failures were identified, compared to 7 asymptomatic failures which were identified incidentally with routine follow-up imaging. All 7 asymptomatic construct failures occurred in the early revisions group [p = 0.004]. Revision surgery for early construct failure was associated with significantly reduced median overall survival compared to late failure (p = 0.010). Construct failures in our cohort were not associated with any classical characteristics of patients undergoing revision spine surgery. Early revision (< 3 months) portends a reduction in overall survival when compared with late revisions, and early revised patients were more likely to have had more extensive surgery and poorer neurological status at the time of index cases.

The use of the psoas-to-lumbar vertebrae index and modified frailty index in predicting postoperative complications in degenerative spine surgery: can sarcopenia or frailty be underestimated?

Degenerative spine disease (DSD) is increasingly prevalent due to aging populations, leading to higher surgical interventions and associated complications. This necessitates a comprehensive preoperative assessment, evaluating frailty through tools such as the modified Frailty Index 5 and modified Frailty Index 11 (mFI-5 and mFI-11). Despite the utility of mFI-5 and mFI-11 in predicting postoperative complications, these indices do not account for sarcopenia, a syndrome related to but distinct from frailty, which is associated with higher complication rates. This paper aims to retrospectively evaluate the influence of sarcopenia and frailty on postoperative adverse events in a cohort of patients who underwent posterior spine fusion for degenerative disease of the lumbar spine. A retrospective review of 286 patients who underwent posterior lumbar spine fusion for DSD was conducted. Frailty was measured using mFI-5 and mFI-11, while sarcopenia was assessed through Psoas to Lumbar Vertebral Index (PLVI) on magnetic resonance images. Primary outcomes included postoperative complications within 30 days. Statistical analysis involved univariate and multivariate models to determine the predictors of complications. Higher frailty scores were significantly associated with increased postoperative complications (p < .05). However, sarcopenia showed no significant correlation with postoperative complications rates, except for pneumological complications (p = .031). Multivariate analysis confirmed frailty as a strong independent predictor of postoperative complications, while sarcopenia had limited impact. Frailty is a robust predictor of postoperative complications in DSD surgeries, while sarcopenia, appears to play a lesser role. The findings suggest that frailty alone provide a more comprehensive assessment of risk than sarcopenia.

Smoking Does Not Negatively Impact Outcomes Following Cervical Laminoplasty: A Quality Outcomes Database Study.

Retrospective cohort study. To assess the impact of smoking on outcomes following elective cervical laminoplasty for degenerative cervical myelopathy (DCM). The detrimental effect of cigarette smoking on cervical spinal fusion surgery outcomes is well documented. However, the impact of smoking on outcomes following nonfusion cervical spine procedures is unknown. One commonly utilized nonfusion technique for cervical decompression is laminoplasty. Adult smokers or nonsmokers who underwent primary elective laminoplasty for DCM were included. The propensity score (PS) was constructed for being a current smoker based on covariates. Only patients contained in the PS overlapped region were included in the analysis set. Patient-reported outcomes (PROs) at baseline and 12 months postoperation included Visual Analog Scale (VAS) neck and arm pain, neck disability index (NDI)%, EuroQol-5 Dimension (EQ-5D), and modified Japanese Orthopedic Association (mJOA) scores. Other outcomes included perioperative complications, 3-month readmissions/reoperations, and patient satisfaction. Wilcoxon and Pearson tests were used to compare outcomes between smokers and nonsmokers. The study included 132 patients: 30 were smokers (22.7%) and 102 were nonsmokers (77.3%). No significant differences were found at baseline between groups in demographics or medical history. Smokers had significantly worse baseline VAS neck pain (5.7±3.2 vs. 4.4±3.04, P=0.028) and arm pain (5.7±3.5 vs. 4.3±3.2, P=0.045) scores, but all other baseline PROs were not statistically different between groups. No differences were found between smokers and nonsmokers in any 12-month PRO, or in rates of perioperative complications, 3-month readmissions, or 3-month reoperations. On multivariable logistic regression analysis, smoking had no significant impact on any outcome of interest. Clinical and PROs following elective laminoplasty for DCM are not significantly different between smokers and nonsmokers. Laminoplasty should be considered a good surgical option in smokers presenting with DCM.

Biomineralized PEEK cages containing osteoinductive CaP bioceramics promote spinal fusion in goats

Interbody fusion devices are critical in spinal surgery to restore spinal stability, reduce pain and improve function. Polyetheretherketone (PEEK) has become a commonly used alternative material for fusion cages owing to its excellent mechanical properties and biocompatibility, but its biological inertness limits bone regeneration and may lead to poor fusion. In this study, a novel strategy for preparing bioactive biomineralized PEEK cages was developed using a unique combination of osteoinductive CaP bioceramic fillings in the cage window, acid sulfonation and simulated body fluid incubation. In vitro experiments showed that biomineralized PEEK cages and CaP bioceramics regulate immunity and promote angiogenesis and bone integration via activation of hypoxia-inducible factor 1-alpha and cyclic guanosine monophosphate/protein kinase G signaling pathways. In vivo goat spinal fusion experiments demonstrated that PEEK cages filled with CaP bioceramics resulted in good bone growth and spinal fusion. Therefore, the high mechanical strength and good biocompatibility of biomineralized PEEK cages, together with the excellent bioactivity and degradation properties of CaP bioceramics, provide an ideal microenvironment for bone fusion. The development of this composite material not only addresses some of the limitations of existing fusion devices but also will facilitate the development of spinal fusion technology.

Chronic Gabapentinoid Use and Lumbar Fusion Outcomes

Study Design. Retrospective comparative cohort study Objectives. To examine the effects of chronic use of gabapentinoids (alone or with opiods) on the outcomes of lumbar fusions. Summary of Background Data. Opioids have historically been the mainstay medications for pain management, but the ongoing opioid epidemic led physicians to look for alternatives. Gabapentinoids (GPs) are used various indications, and chronic use for any indication may lead to a higher risk of adverse events, especially when combined with opioids. Methods. Patients ≥18 years of age who underwent posterior fusion of the lumbosacral spine and ≥1 year follow-up were included.Patients were grouped according to their preoperative chronic GP and opioid usage as GP and opioid non-user (-/-), GP user opioid non-user (+/-), GP non-user and opioid user (-/+) and GP and opioid user (+/+). Results. A total of 563 patients (M/F%=41/59, mean age 61.1 y) were included. 280 (49%) patients were in group -/-; while 110 (19%) were in +/-, 78 (15%) were in -/+ and 95 (17%) were in +/+. For ODI, back pain and leg pain, +/+ had the worst outcomes at all time points, while -/- had the best. Chronic GP users (+/-) showed back pain improvement similar to the -/- group, however the improvements in leg pain and ODI were considerably less. GP use resulted in increased postoperative opioid requirements, although not as much as chronic opioid use. Complication rates were similar. Conclusions. Chronic preoperative use of GPs may lead to inferior outcomes when compared with GP-naïve patients, and this is significantly accentuated when taken concurrently with opioids. Patients who are using both GPs and opioids had the worst results for almost every outcome measure. Given the significantly worse surgical outcomes documented in this study, concurrent use with opioids should be avoided.

Anterior Column Support With Anterior Lumbar Interbody Fusion Cage Through Posterior Approach Maneuver: A Technical Note and Preliminary Radiologic Report.

Retrospective cohort study. To evaluate the feasibility of anterior column support through a posterior approach using an anterior lumbar interbody fusion (ALIF) cage. Anterior fusion is an effective way to maintain spinal lordosis; however, it may be technically difficult in some cases. Conventional lumbar fusion and spinal deformity correction surgeries were performed using a conventional ALIF cage with a modified extratransforaminal lumbar interbody fusion (ExTLIF). Patients with 1 or 2 fusion levels were classified into group 1, and those with spinal deformity correction were classified into group 2. Radiologic parameters were evaluated during the follow-up periods. A total of 51 patients underwent this procedure. Thirty-five patients (19 male and 16 female, 69.4±9.6y old) with 37 fusion sites were in group 1, and 16 patients (3 male and 13 female, 71.4±5.7y old) were in group 2. The mean follow-up periods of groups 1 and 2 were 12.3±3.4 and 10.7±4.7 months, respectively. In group 1, the mean lumbar lordosis and segmental lumbar lordosis increased significantly during the last follow-up (39.9±13.0 and 20.6±6.0 degrees, respectively, both P<0.001), and the mean disc space also increased at the last follow-up (P<0.001). The same was observed in group 2 with significant increases in the mean lumbar lordosis and segmental lumbar lordosis at the last of the follow-up period (46.8±9.3 and 16.9±8.9 degrees, respectively, both P<0.001). The disc space also increased significantly (P<0.001). Fusion rates were 94.2% and 87.5% in groups 1 and 2, respectively, and the corresponding subsidence rates were 85.4% and 68.8%. In group 1, there was a significant correlation between subsidence and cage height (P=0.046). This procedure (ExTLIF) can be applied in cases where an anterior approach is contraindicated as well as for deformity correction. Level III.

Clinical outcomes of revision posterior lumbar interbody fusion for late deterioration after laminotomy assessed with the Zurich Claudication Questionnaire.

A retrospective analysis of prospectively collected data. There have been a few studies comparing surgical outcomes between revision lumbar fusion surgery and the same primary surgery. Using the Zurich Claudication Questionnaire (ZCQ), we compared clinical outcomes of revision posterior lumbar interbody fusion (PLIF) for late deterioration after laminotomy with those of primary PLIF to examine whether surgical outcomes of revision PLIF for late deterioration after laminotomy are inferior to those of primary PLIF. Sixteen consecutive patients undergoing revision single-level PLIF for late deterioration after single-level laminotomy (R group) and 61 consecutive patients undergoing primary single-level PLIF during the same period as the R group (P group) were enrolled. Before PLIF surgery and at 2-year postoperatively, clinical outcomes were assessed using the ZCQ. Achievement rates of the minimum clinically important difference (MCID) of each domain [Symptom severity (SS) and Physical function (PF)] on the ZCQ were calculated in each group. In the R group, mean SS and PF before revision PLIF and at 2-year after surgery were 3.429 and 2.8, and 1.946 and 1.6, respectively. In the P group, mean SS and PF before primary PLIF and at postoperative 2-year were 3.438 and 2.5, and 2.194 and 1.6, respectively. Both SS and PF significantly improved at postoperative 2-year in the both groups, and SS both before and after PLIF and PF at 2-year postoperatively showed no significant differences between the 2 groups. Achievement rates of the MCID of SS and PF were 81.3% and 68.8% in the R group, and 59.0% and 59.0% in the P group, respectively. None of the MCID achievement rates of SS and PF showed significant differences between the 2 groups. Clinical outcomes of revision PLIF for late deterioration after laminotomy were equivalent to those of primary PLIF assessed with the ZCQ at 2 years after PLIF surgery.

Comparison of three sacral screw internal fixation techniques in the treatment of L4-S1 lumbar degenerative disease with osteoporosis: a retrospective observational study.

Patients with L4-S1 lumbar degenerative disease (LDD) with osteoporosis are prone to sacral-screw loosening during spinal internal fixation. We aimed to compare the clinical efficacy and imaging results of sacral bicortical, tricortical, and polymethylmethacrylate (PMMA)-augmented pedicle-screw fixation in the treatment of L4-S1 LDD with osteoporosis. This is a retrospective study, 72 patients were enrolled and divided into three groups according to the S1-screw fixation method: PMMA-augmented pedicle-screw fixation (Group A, n = 26), bicortical fixation (Group B, n = 22), and tricortical fixation (Group C, n = 24). The visual analog scale (VAS) and Oswestry disability index (ODI) were recorded preoperatively and at the last follow-up, and the postoperative complications, screw-loosening rate, and fusion rate were compared between the three groups. Upon the last follow-up, the VAS and ODI scores of the three groups were significantly improved compared with those recorded preoperatively. The VAS and ODI scores of Group A were significantly smaller than those of Groups B and C (P < 0.05), with no significant difference between Groups B and C. Moreover, the screw-loosening rate of Group A was significantly lower than that of Groups B and C (P < 0.05), with no significant difference between Groups B and C. No significant difference was noted in postoperative complications, bone-cement leakage rates, and intervertebral fusion rates among the three groups. Furthermore, we found that osteoporosis and change of lumbar lordosis(LL) value were independent risk factors for sacral-screw loosening in patients with L4-S1 LDD with osteoporosis. When patients with L4-S1 LDD with osteoporosis undergo lumbosacral fusion and fixation, the use of S1 pedicle screws with PMMA augmentation has better stability and less screw loosening. Furthermore, we recommend this surgery for patients with osteoporosis, and the LL should be increased as much as possible during the operation to restore the matching of lumbar and pelvic parameters.

Outcomes and Complications After Elective Thoracic and Lumbar Spinal Fusion in Elderly Patients: A Comparison of Methods to Predict Adverse Events.

Retrospective study. The current study compares the ability of the modified Frailty Index (mFI), the American Society of Anesthesiologists (ASA) classification, the modified Charleston Comorbidity Index (mCCI), the American College of Surgeons Surgical Risk Calculator (SRC), and the Fusion Risk Score (FRS) to predict perioperative outcomes. Comorbidity indices were calculated for patients undergoing elective thoracic and lumbar spinal fusion at a single institution and assessed for their discriminative ability in predicting the desired outcomes using an area under the curve (AUC) analysis. 393 patients met the inclusion and exclusion criteria. Patients being treated for adult spinal deformity (ASD) had the highest rate of complications (44.4%). The FRS had acceptable discrimination (AUC >0.7) and the highest ability among the methods studied to predict any adverse effects, new neurological deficit, return to OR within 90 days, and surgical site infection. It had good discrimination ability (AUC >0.8) predicting durotomy, respiratory failure (RF) requiring intubation, hemodynamic instability, and sepsis. The SRC had acceptable discrimination and highest ability to predict deep venous thrombosis (DVT). The mCCI had excellent and the highest ability to predict acute renal failure (ARF). For the other outcomes, the indices had either poor predictive ability (AUC 0.6-0.7) or no discriminative ability (AUC <0.6). The FRS had a better ability than the ASA, mCCI, mFI, and SRC to predict the most perioperative adverse events and reoperation. Further study is needed to develop preoperative indices with better predictive ability of postoperative outcomes.

Clinical Outcomes of Revision Lumbar Fusion in the Aging Population

Study Design. Retrospective Cohort Objective. To examine the profile of older patients undergoing revision lumbar fusion and to evaluate the impact that advancing age may have on outcomes following revision lumbar fusion. Summary of Background Data. The proportion of older patients undergoing revision lumbar fusion is increasing, however, the benefit of revision lumbar fusion in an aging demographic is not well documented. Methods. Patients aged 55+ who underwent revision lumbar between 2011 and 2022 were included and were stratified into age groups: 55-64, 65-74, and 75+. Primary outcomes consisted of postoperative emergency department (ED) visits, 30- and 90-day readmissions, all-cause reoperations, and the need for secondary revisions. Secondary outcomes included patient-reported outcome measures (PROMs) obtained preoperatively, and at three months and one year postoperatively. Results. A total of 914 patients were included: 55-64 years (n=512, mean: 61.1 years), 65-74 years (n=296, mean:69.1 years), and 75+ (n=106, mean:78.9 years). Adjacent segment disease as a revision indication significantly increased with age(P=0.001). A circumferential approach was used most (N=200, 39.7%) in patients 55-64, while a posterior-only approach was used in 86.3% of patients 75+(P&lt;0.001). Levels decompressed increased with age, from 1.67 in the youngest group to 2.04 in the oldest (P&lt;0.001). The number of levels fused showed no significant difference (P=0.068). 90-day readmissions and the need for secondary revisions did not vary by age. Age groups were not independently associated with ΔPROMs at one year, but the oldest groups continued to experience improvement in PROMs in line with their younger counterparts. Conclusion. Patients 75 years and older derive similar benefits from revision lumbar fusion compared to their younger counterparts with no increased risk of ED visits, readmissions, or reoperations. Clinicians should be advised that there remains significant value in revising older patients when indicated. Level of Evidence. 3