Spinal Fusion Research Articles

Glycemic laboratory values are associated with increased length of stay and 90-day revision risk following surgical management of adult spinal deformity

BACKGROUND CONTEXTDiabetes mellitus (DM) is a common comorbidity among patients undergoing spinal fusion for adult spinal deformity (ASD) surgery. An elevated Hemoglobin A1c (HbA1c) and elevated postoperative glucose have been shown to increase the risk of complications following spine and other orthopedic surgeries; however, data is limited for ASD. PURPOSETo investigate glycemic control and ASD surgery to inform surgical decision making, medical optimization, and patient education. STUDY DESIGN/SETTINGRetrospective cohort. PATIENT SAMPLETotal of 106 adult patients undergoing surgical correction for ASD with an HbA1c drawn within 6 months preoperatively or 2 weeks postoperatively and valid plasma glucose levels throughout postoperative hospital stay. OUTCOME MEASURESLength of stay, 90-day wound complication, 90-day readmission, 90-day revision. METHODSAll patients undergoing spinal fusion of seven or more levels between 2021 and 2023 at two large academic medical centers were identified using institutional data acquisition software. Medical charts were then manually reviewed to obtain and confirm demographic, laboratory, and surgical characteristics and outcomes. Laboratory characteristics included preoperative HbA1c, mean postoperative glucose (PG), and maximum PG. Surgical characteristics and outcomes included procedure time, estimated blood loss (EBL), length of inpatient stay (LOS), transfusion requirement, 90-day complications, 90-day revision, and 90-day readmission. Bivariate analysis was performed followed by simple and multiple regression analysis. Odds ratios were established relative to the laboratory threshold values informed by receiver operating characteristics. RESULTSOf 872 original procedures identified, 106 patients (12.2%) were adults with preoperative HbA1c and postoperative plasma glucose measurements who underwent surgery for a diagnosis of ASD. Median patient age was 67 years (IQR 59–72 years), 59 (55.7%) were female, and 96 (90.6%) were of Caucasian race. Median LOS was 7 days (IQR 5–10 years) and median HbA1c was 5.9% (IQR 5.3%–6.5%). Higher preoperative HbA1c was correlated with increased LOS (R=0.22, p=.023). The odds ratio for patients requiring extended LOS was 2.49 (95% CI 1.06–5.86, p=.034) for those with HbA1c ≥6.3%. Multiple regression analysis of LOS identified HbA1c [B= 1.51 (95% CI 0.32–2.70), p=.013] as a positive predictor of LOS and mean PG [B= −0.05 (95% CI −0.10 to (−0.01)), p=.019] as a weakly negative predictor of LOS. Upon simple logistic regression, the odds ratio for 90-day revision was 1.81 (95% CI 1.02–3.19, p=.042) for every unit increase in HbA1c. Patients with mean PG ≥165 mg/dL [OR=5.76 (95% CI 1.28–26.01), p=.024] were at increased risk for 90-day revision. Glycemic laboratory values do not seem to predict 90-day wound complications or 90-day readmission following surgery for ASD. CONCLUSIONElevated preoperative HbA1c is associated with increased LOS and risk for revision within 90 days of ASD surgery. Postoperative hyperglycemia is also associated with increased 90-day revision risk. To our knowledge, this study is the first to evaluate HbA1c and outcomes following ASD surgery. These findings can be leveraged to inform preoperative medical optimization and highlight the importance of glycemic control in ASD patients undergoing corrective surgical intervention.

Spondylolisthesis in Young Patients in a Large National Cohort: Reoperation Rate Depends on Surgical Approach.

The current literature investigating surgical treatments for lumbar spondylolisthesis in adolescent patients is limited by small sample sizes. There are high reoperation rates, and posterior interbody fusion has not been reported to help. The current study aimed to utilize a nationwide database to investigate outcomes of spinal fusion for spondylolisthesis in young patients. The PearlDiver database was queried for patients <21 years old who had undergone lumbar spinal fusion for spondylolisthesis between 2010 and 2020. Patients were divided into 4 cohorts based on surgical approach: (1) posterior spinal fusion with posterior instrumentation (PSF), (2) posterior spinal fusion with posterior instrumentation plus interbody (PSF+I), (3) anterior spinal fusion without posterior instrumentation (ASF), and (4) anterior spinal fusion plus posterior instrumentation (A+PSF). Patients with <2 years of follow-up were excluded. The primary outcome was reoperation. Of 33,945 patients with spondylolisthesis, 578 (1.7%) underwent lumbar spinal fusion: 236 (40.8%) had PSF, 219 (37.9%) had PSF+I, 66 (11.4%) had ASF, and 57 (9.9%) had A+PSF. The mean age was 16.5 ± 1.1 years, and the mean follow-up was 5.4 ± 2.9 years. A higher percentage of girls underwent surgery compared with boys (2.0% versus 1.4%). Survival analysis using all-cause reoperation as the end point demonstrated an overall 5-year reoperation-free survival rate of 85.5% (95% confidence interval [CI]: 82.5% to 88.6%). The overall reoperation rate within 5 years was significantly different depending on the approach, with A+PSF being the lowest at 7.0% (PSF = 11.9%, PSF+I = 10.5%, and ASF = 31.8%). This is the largest reported series of spondylolisthesis surgery in young people. The lowest rate of revisions within 5 years was for a combined approach of A+PSF. The 5-year risk of reoperation of 31.8% for a stand-alone ASF appeared to be unacceptably high compared with other approaches, and was over 4 times higher than A+PSF (7.0%). Consistent with previous clinical series, the addition of an interbody fusion to a PSF did not decrease the reoperation rate and did not appear to offer any advantages to a PSF alone. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Biportal Endoscopic Transforaminal Lumbar Interbody Fusion: The Double-Cage Technique

Biportal endoscopic transforaminal lumbar interbody fusion (BETLIF) is a novel spinal fusion procedure using the unilateral biportal endoscopic technique. The hydrostatic pressure of saline irrigation suppresses bleeding, enabling us to perform delicate surgery in a crystal-clear and magnified surgical field with almost no bleeding. Adequate neural decompression, disc space preparation, and bony endplate preservation can be achieved safely. The sturdy endplate reduces the incidence of cage subsidence and provides good initial stability. We use 2 interbody fusion cages and a large amount of bone graft to promote fusion. Reduction of the spondylolisthesis can also be achieved using a modern pedicle screw system. This article presents a step-by-step demonstration of the BETLIF technique in a 68-year-old patient with degenerative scoliosis and spondylolisthesis at L4-5, including his clinical presentation and treatment results. BETLIF is a safe, effective, and revolutionary minimally invasive solution for spinal fusion. Its advantages include a magnificent surgical field, direct decompression, minimum blood loss, radical discectomy, meticulous endplate preparation, cage insertion under direct visual control, and excellent treatment results with a high fusion rate and few complications.

Can abdominal aortic calcification detected on lateral lumbar radiography predict instrument-related complications in patients undergoing posterior lumbar fusion?

Objective: Abdominal aortic calcification (AAC) is well known as a useful and simple clinical indicator of the risk of fracture and cardiovascular disease. However, no studies have directly compared the postoperative implications of AAC in spinal surgery. The purpose of this study was thus to examine whether extended AAC (scores ≥5) negatively affected clinical outcomes after posterior lumbar fusion with instrumentation for degenerative lumbar stenosis or degenerative spondylolisthesis.Methods: The subjects comprised 101 consecutive patients with spinal stenosis or degenerative spondylolisthesis who underwent posterior lumbar fusion and instrumentation between January 2016 and January 2019 and were followed for over 2 years. Propensity score matching was employed to assemble patient groups with similar baseline characteristics. Postoperative complications and radiologic outcomes were compared between the groups (33 patients in each) divided by extended AAC score.Results: The incidence rates of junctional failure (6.1% vs. 30.3%, P=0.008) and screw-related complications (12.1% vs. 36.4%, P=0.019) were higher in the extended AAC group than in the mild AAC group. However, the rates of adjacent segment disease (24.2% vs. 36.4%, P=0.283) and revision (6.1% vs. 9.1%, P=0.642) were not significantly different between the 2 groups. In terms of postoperative medical complications, cardiovascular and cerebrovascular diseases were significantly more common in the extended AAC group than in the mild AAC group (0% vs. 15.2%, P=0.020).Conclusion: Extended AAC indicates increased risk for postoperative junctional failure and screw-related complications, regardless of age, osteoporosis, and comorbidities.

Effect of cannabis use history on postoperative opioid utilization in lumbar fusion patients: an American retrospective study.

A retrospective cohort study. To examine the effect of cannabis use history on postoperative opioid utilization in patients undergoing one- to three-level lumbar fusion for degenerative spine disease. Strategies to minimize dosing and chronic opioid use are needed for spine surgery given their widespread prescription for postsurgical pain management. In this database study, medical coding was used to identify patients who had undergone one- to three-level lumbar fusions between 2012 and 2021. Propensity score matching was used to create two equal cohorts with respect to cannabis use history. Opioid utilization rates (morphine milligram equivalents [MME]/day) and overuse rates at 6 months post-index procedure were assessed. All pvalues <0.05 were considered statistically significant. Following examination of 153,500 patient records, 1,216 patients were matched into cannabis user and non-cannabis user cohorts. Cannabis users had lower rates of opioid utilization compared to non-cannabis users as early as 2 months after fusion (47.7% vs. 41.1%, p <0.05), a relationship which persisted at 6 months (46.2% vs. 37.7%, p <0.01). Additionally, cannabis users had lower rates of high-dose opioid utilization (≥100 MME per day) during the initial 14-30 days following surgery (6.91% vs. 3.79%, p <0.05). Patients with a history of cannabis use were less likely to be using opioids as early as 2 months postoperatively and had lower rates of high-dose opioid utilization in the immediate postoperative period. Physicians operating on these patients should consider their cannabis use patterns to provide appropriate titration of pain medication over time.

Comparison of RVU Reimbursement in Anterior or Posterior Approach for Single- and Multilevel Cervical Spinal Fusion.

Retrospective database study. This study aims to quantify and compare mean work RVUs (wRVUs), mean operative time (OpTime), and wRVUs/min in single- and multilevel anterior and posterior cervical spine fusions performed between 2011 and 2020. Prior research has demonstrated inconsistencies in technical skill, operative time, and surgical difficulty with reimbursement in various orthopedic subspecialties. Although trends investigating physician effort and reimbursement have been investigated in lumbar spine surgery, less research has examined these relationships with respect to cervical spine procedures. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for Current Procedural Terminology (CPT) codes reflecting anterior cervical discectomy and fusion (ACDF), posterior cervical decompression and fusion (PCDF), and the number of levels involved. The cohort was stratified into 10 groups: single-level, 2-level, 3-level, 4-level, 5+ level anterior or posterior cervical fusions. Mean operative times, mean wRVUs, and wRVU/min were calculated and compared by Student t test. A total of 100,997 patients met inclusion criteria in this study, of which 79,141 (78.36%) underwent ACDF, whereas 21,836 (21.62%) underwent PCDF. One- and 2-level fusions were most common in both ACDF and PCDF. In 1-, 3-, 4-, and 5+ level fusion, the anterior approach demonstrated significantly lower mean wRVU (P<0.001). In 1-, 2-, and 3-level fusions, the anterior approach had significantly lower operation times (P<0.001). The anterior approach demonstrated significantly higher wRVU/min in 1- and 2- levels (P<0.001) but lower wRVU/min in 3- and 4-level fusions (P<0.001). Clear discrepancies exist between surgical approach and levels of fusion in cervical spine procedures incongruous with markers of surgical difficulty, physician effort, or expertise required. These specific results suggest that the complexity of multi-level anterior cervical fusions are not effectively accounted for by existing RVU measures.

Three-Dimensional Fluoroscopic System to Assess Robotically Placed Pedicle Screws: Should We Confirm Robotic Pedicle Screw Placement With Advanced Imaging?

Retrospective cohort study. The purpose of this study is to determine the utility of advanced imaging to confirm the placement of robotic pedicle screws. With increasing robotic adoption, certain institutions and surgeons have developed protocols for obtaining 3D intraoperative imaging after robotic pedicle screw placement to ensure proper hardware placement. No studies have assessed the utility of these protocols relative to the potential risks of increased radiation exposure and operative time. The purpose of this study is to determine if we should be obtaining advanced imaging to confirm the placement of robotic pedicle screws. This is a single institution retrospective cohort study of patients from May 2022 to July 2023 who underwent lumbar spinal fusion by a high-volume orthopedic spine surgeon at a level 1 metropolitan hospital. All cases used combined robotics and navigation systems for pedicle screw placement and intraoperative 3D imaging for evaluation of screw position. Pedicle screw accuracy was assessed using the Gertzbein and Robbins system (GRS). Acceptable pedicle screw position was defined as GRS A or B. Seventy patients with 354 robotically placed pedicle screws were assessed with intraoperative 3D fluoroscopy. All pedicle screws were placed in either a GRS type A or type B position. Three hundred forty-seven were placed in a GRS A classification (99.2%, 351/354), and 3 were placed in a GRS B classification (0.08% 3/354). No patients had screw-related complications. The average radiation dosage of 3D imaging was 289.7±164.6mGy. The robotic system places pedicle screws accurately without 3D intraoperative imaging. Given the increased radiation and operative time associated with 3D imaging protocols 3D imaging scans should only be obtained in cases with heightened clinical concern. Level IV.

Lumbar Fusion Surgical Prophylaxis Using Cefazolin vs. Vancomycin in the Penicillin-Allergic Patient.

Retrospective cohort study. To compare peri- and postoperative infection rates among patients with mild to moderate penicillin allergies who receive cefazolin vs vancomycin as prophylaxis for lumbar fusion. Additionally, we sought to determine if patients receiving cefazolin exhibited any clinical symptoms suggestive of drug-induced hypersensitivity reactions, and to compare those rates to patients who received vancomycin. Cefazolin has been historically linked to hypersensitivity reactions in penicillin-allergic patients due to cross-reactivity. As a result, vancomycin is often given to these patients instead. To our knowledge, no studies have directly compared these two antibiotics in penicillin-allergic patients undergoing lumbar fusion. Patients with mild to moderate documented penicillin allergies who underwent lumbar fusion from 2017-2022 and received prophylactic cefazolin or vancomycin were studied. Demographic, surgical information, and hospital length of stay (LOS) were recorded. We identified drug sensitivity reactions, in hospital infections, 90-day readmissions related to infectious etiologies and need for irrigation and debridement (I&D) to treat a surgical site infection. 222 patients received cefazolin, while 180 received vancomycin. Patients receiving vancomycin had more medical comorbidities, while patients receiving cefazolin had slightly more levels fused. No significant differences existed between cohorts in postoperative infection rate. One patient given cefazolin developed a mild drug-induced skin reaction that was treated with topical steroids. No significant differences existed between cohorts in 90-day readmissions or need for I&D surgery. On bivariate analysis, patients given cefazolin had a longer LOS but this was attributed to confounding variables on multivariate analysis. Cefazolin and vancomycin are comparable at preventing postoperative infections among patients with mild to moderate documented reactions to penicillin. Our findings also suggest that penicillin-allergic patients are not at higher risk of developing drug-related hypersensitivity reactions in response to cefazolin exposure when compared to those who received vancomycin.

Meta-analysis of the efficacy of the erector spinae plane block after spinal fusion surgery.

To investigate the efficacy of erector spinal plane block (ESPB) after spinal fusion surgery in this study. The PubMed, Embase, Cochrane library, and Web of Science databases were searched with a search deadline of March 30, 2024, and Stata 15.0 was used to analyze the data from the included studies. Nine randomized controlled trials involving 663 patients were included. Meta-analysis showed that EPSB could reduce pain scores at 2h (standard mean difference (SMD) = -0.78, 95% CI [-1.38 to -0.19], GRADE: Moderate), 6 h (SMD = -0.81, 95% CI [-1.23 to -0.38], GRADE: Moderate), 12 h (SMD = -0.59, 95% CI [-1.05 to -0.13], GRADE: Moderate), 24 h (SMD = -0.54, 95% CI [-0.86 to -0.21], GRADE: Moderate), 48 h (SMD = -0.40, 95% CI [-0.75 to -0.05], GRADE: Moderate) after spinal fusion surgery, as well as the PCA (analgesia medication use) (SMD = -1.67, 95% CI [-2.67 to -0.67], GRADE: Moderate). However, EPSB had no effect on intraoperative blood loss (SMD = -0.28, 95% CI [-1.03 to 0.47], GRADE: Low) and length of hospital stay (SMD = -0.27, 95% CI [-0.60-0.06], GRADE: Low). Combined with the current findings, EPSB may reduce pain scores in spinal fusion surgery, possibly reducing the use of postoperative analgesics. However, due to the limitations of the study, we need more high-quality, multi-center, large sample randomized controlled trials to merge.

Incorporating Microbial Stimuli for Osteogenesis in a Rabbit Posterolateral Spinal Fusion Model.

Autologous bone grafts are commonly used to repair defects in skeletal tissue, however, due to their limited supply there is a clinical need for alternatives. Synthetic ceramics present a promising option but currently lack biological activity to stimulate bone regeneration. One potential approach to address this limitation is the incorporation of immunomodulatory agents. In this study, we investigate the application of microbial stimuli to stimulate bone formation. Three different microbial stimuli were incorporated in a biphasic calcium phosphate (BCP) ceramic: Bacille Calmette-Guérin (BCG), gamma-irradiated Staphylococcus aureus (γi-S. aureus), or γi-Candida albicans (γi-C. Albicans). The constructs were then implanted in both a rabbit posterolateral spinal fusion (PLF) and an intramuscular implant model for 10 weeks and compared to a nonstimulated control construct. For the PLF model, the formation of a bony bridge was evaluated by manual palpation, micro computed tomography, and histology. While complete fusion was not observed, the BCG condition was most promising with higher manual stiffness and almost twice as much bone volume in the central fusion mass compared to the control (9 ± 4.4% bone area vs. 4.6 ± 2.3%, respectively). Conversely, the γi-S. aureus or γi-C. albicans appeared to inhibit bone formation (1.4 ± 1.4% and 1.2 ± 0.6% bone area). Bone induction was not observed in any of the intramuscular implants. This study indicates that incorporating immunomodulatory agents in ceramic bone substitutes can affect bone formation, which can be positive when selected carefully. The readily available and clinically approved BCG showed promising results, which warrants further research for clinical translation.

Spontaneous recovery of postsurgical progressive cervical spine kyphosis following intramedullary spinal cord tumor resection in a 4-year-old boy: illustrative case.

Postsurgical kyphosis is relatively common in children who have undergone resection of intramedullary spinal cord tumors. Progressive kyphosis almost always requires instrumentation and fusion surgery, which can delay or interfere with adjuvant oncological treatments and can deleteriously impact the long-term performance status of the patient. Here, the authors report a case of near-complete spontaneous recovery (i.e., without spinal fusion surgery) of postsurgical progressive cervical spine kyphosis following intramedullary spinal cord tumor resection and discuss the potential factors that may have contributed to this positive outcome. This case serves as a reminder that spontaneous recovery from postsurgical progressive cervical spine kyphosis can occur and that some patients (i.e., those without neurological deficits) can be monitored closely, with a watch-and-wait approach, before subjecting them to additional surgical risks, delays in other treatments, and potential morbidity. https://thejns.org/doi/10.3171/CASE24187.

Incidence and Risk Factors of Lumbosacral Complications Following Long-Segment Spinal Fusion in Adult Degenerative Scoliosis.

Long-segment spinal fusions are associated with lumbosacral complications (LSC), but the associated risk factors are not known. This study aimed to identify the risk factors for LSC after long-segment instrumented fusion with distal fixation to the L5 vertebral body in adult degenerative scoliosis (ADS). We retrospectively evaluated 294 patients with ADS who underwent long-segment floating fusion between January 2014 and March 2022, with follow-up for at least 2 years. Patients were matched to the baseline data using fusion level > 5 as a grouping variable. Patients who completed matching were divided into two groups according to the presence or absence of LSC. Univariate logistic regression was applied to identify potential risk factors for LSC, and multivariate logistic regression was used to identify independent risk factors for postoperative LSC. The overall incidence of LSC was 21.77% in the 294 patients, with disc degeneration in 28 (9.52%) and radiographic ASD in 44 (14.97%) patients. The mean time to LSC development after surgery was 26.91 ± 8.43 months. A total of 54 pairs of patients were matched and grouped, and the complication group had higher Oswestry Disability Index (ODI) and visual analog scale (VAS) scores at the last follow-up. Multivariate analysis showed that gender (OR = 0.274, p = 0.026 [0.087, 0.859]); levels of fusion > 5 (OR = 3.127, p = 0.029 [1.120, 8.730]), main curve correction rate (OR = 0.009, p = 0.005 [0.000, 0.330]), and postoperative pelvic incidence minus lumbar lordosis (PI-LL) > 15° (OR = 3.346, p = 0.022 [1.195, 9.373]) were independent risk factors for postoperative LSC. The area under the curve value of the prediction model was 0.804, with a 95% confidence interval of 0.715-0.892, indicating that the model had a high prediction accuracy. Collinearity statistics showed no collinearity between variables. Sex, level of fusion > 5, main curve correction rate, and postoperative PI-LL > 15° were independent risk factors for the development of LSC after long-segment floating fusion. These results will improve our ability to predict personal risk conditions and provide better medical optimisation for surgery.

Structural design and biomechanical analysis of a combined titanium and polyetheretherketone cage based on PE-PLIF fusion.

In lumbar spinal fusion, the titanium cage tends to cause stress shielding due to their high elastic modulus, which can lead to degenerative lesions in adjacent spinal segments. Furthermore, polyetheretherketone (PEEK) cages have certain material characteristics that do not promote bone ingrowth and fusion stability. In this study, a new cage was designed, and its biomechanical performance in percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) was analyzed using the finite element (FE) method. A complete model of the L4-L5 lumbar spine was established, and static and harmonic vibration FE analysis models were developed based on it. The biomechanical properties of titanium, PEEK, and combined cage in PE-PLIF fusion were compared. The strain capacity of the combined fusion increased by 9.5% when compared to the titanium fusion. The surgical model under the combined fusion reduces the L5 endplate stress by 12% in the forward flexion condition and the fusion stress by 17% in the vibration condition compared to the model supported by the titanium fusion, and the differences in screw stress and mobility among the three models are not significant in multiple conditions. Consequently, the combined cage demonstrates a certain reduction in the stress-shielding effect when compared to the titanium cage; it has better fusion effect and provides theoretical support and guidance for the design of the clinical fusion cage.

Elevated hospital floor-based HDU (POPUP-HDU): a new safe alternative to PICU for high-risk neuromuscular and syndromic children undergoing scoliosis surgery.

Children undergoing either posterior spinal fusion (PSF) or index insertion of growing rods for neuromuscular or genetic/syndromic scoliosis may require post-operative care on the paediatric intensive care unit (PICU). Demands on this limited resource result in frequent bed shortage related cancellations. In response, an ad-hoc or 'pop-up' ward-based high-dependency unit (POPUP-HDU) was developed. This converts a ward bed to POP-HDUbed for the required time. This study assesses the safety and efficacy of postoperative management that utilises POPUP-HDU as an alternative to a PICU bed. Retrospective review of 111 consecutive children undergoing posterior surgery for scoliosis between June 2016 and April 2023. The inclusion criteria included a diagnosis of genetic/syndromic or neuromuscular scoliosis; PSF or primary insertion of distraction-based growth rods and requirement for postoperative care in a PICU. We excluded those children that were mandated to go to PICU post-operatively for any reason by the anaesthetic team. 49 patients (mean age 13.0years) were managed on PICU, and 62 (mean age 11.4years) on POPUP-HDU. The groups were matched with respect to body weight, curve magnitude, operative duration, type of fusion procedure performed, the presence of cardiac malformations, the use of home breathing support, the number of operated levels, pelvic instrumentation and intraoperative blood loss. 8 patients in the PICU, and 16 in the POP-HDU groups were readmitted back to PICU following step-down to the hospital ward (p = 0.27). The median PICU length of stay was 1day in the PICU group and less than a day in POPUP-HDU (for those that needed to be subsequently admitted to PICU). The median total length of hospital stay was 10days in the PICU group, and 8days in POPUP-HDU (p < 0.05). 14 patients developed medical complications in the PICU group, compared to 19 in POPUP-HDU. There were no bedshortage cancellations in POPUP-HDU, compared to 23 in PICU. For children with neuromuscular, genetic or syndromic scoliosis undergoing PSF or growth rods that are not deemed suitable for immediate ward-level post-operative care, POPUP-HDU provided a safe alternative to PICU for appropriate patients and was associated with shorter hospital stay and fewer cancellations for lack of PICU beds. Therapeutic Level III.

Investigation of Radiation Exposure of Medical Staff During Lateral Fluoroscopy for Posterior Spinal Fusion Surgery.

Background/Objectives: In spinal surgery, it is especially crucial to insert implants in the correct location. Intraoperative fluoroscopy is often necessary to safely perform spinal surgery because of serious complications that can occur if the screw deviates. However, the use of intraoperative fluoroscopy comes at the cost of radiation exposure to the surgeons and operating room staff. Therefore, it is desirable for spinal surgeons to understand the characteristics of radiation in order to minimize patient and medical staff exposure. This study aimed to create an aerial radiation dose distribution map for lateral fluoroscopy, a commonly used technique for posterior spinal fusion. Methods: A human body-equivalent phantom was placed in a prone position on the Jackson Table. The measurement method used was a lateral fluoroscopic evaluation, assuming posterior spinal fusion. Measurements were taken at three levels: 80 (gonadal), 100 (thoracoabdominal), and 150 cm (lens and thyroid). Results: The highest radiation doses were received by primary surgeons. The scrub nurse was the next most exposed. Conclusions: We developed an aerial dose distribution map for lateral fluoroscopy in posterior spinal fusion. Radiation exposure was the highest among primary surgeons.

A study on the effect of platelet-rich plasma (PRP) to promote bone fusion in lateral interbody fusion of the lumbar spine using artificial bone

BackgroundLateral lumbar interbody fusion (LLIF) via a retroperitoneum approach has gained popularity due to minimal invasiveness, which avoids resection of the spinous process and laminae. However, as challenges in grafting autogenous bone persist, artificial bone has been tested in Japan to fill the spinal cage. Platelet-rich plasma (PRP) contains growth factors and anti-inflammatory cytokines to promote cellular proliferation and repair damaged tissues. While the effects of PRP on tendon and ligament repair are widely known, any effects on bone healing are scarcely reported. However, PRP-loaded artificial bone carries potential to improve intervertebral bone fusion.ObjectiveThis study assessed whether PRP enhances intervertebral bone fusion in LLIF surgery using β-tricalcium phosphate artificial bone.MethodsThe current study was a prospective, randomized, controlled trial. We evaluated 13 consecutive patients undergoing LLIF surgery in our hospital. Patients received artificial bone impregnated with PRP or without PRP within the same fusion cage. The primary outcome was the intervertebral bone fusion rate at 6 and 12 months postoperatively, evaluated using CT imaging. The intervertebral bone fusion rates with and without PRP loading and with and without contact part between the endplate and the artificial bone were compared. Secondary outcomes included clinical evaluations using visual analog scale scores for low back pain, buttock-leg pain, and leg numbness from the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOA-BPEQ) and the Oswestry Disability Index (ODI), plus adverse events information.ResultsOf the 13 patients (29 vertebral segments) included, bone fusion was observed in 43.4% of the PRP group and 26.1% of the non-PRP group at 6 months (p = 0.216). At 12 months, fusion rates were 60.9% with PRP and 34.8% without PRP (p = 0.074). The fusion rate was significantly higher in cases with good contact between the vertebral endplate and the artificial bone (p = 0.0004). Clinical scores improved postoperatively. Adverse events were in accordance with expectations from LLIF surgery and no PRP-specific events occurred.ConclusionPRP did not significantly improve intervertebral bone fusion rates in LLIF surgeries, particularly in cases with poor contact between the vertebral endplate and artificial bone. While PRP may have a limited role in enhancing bone fusion, maintaining good contact between the vertebral endplate and artificial bone is crucial for successful outcomes. Further research is needed to explore optimal uses of PRP in spinal fusion surgeries.

Failure of an expandable lumbar interbody spacer - a critical analysis of secondary collapse, pseudoarthrosis and revision rates after thoracolumbar fusion.

To report on the failure rates of an expandable interbody spacer, used for spinal instrumented transforaminal lumbar interbody fusion (TLIF) or posterior thoracolumbar interbody fusion (PLIF). In this retrospective, single-center observational cohort study we reviewed consecutive PLIF/TLIF patients using the Catalyft™ PL and PL40 expandable titanium interbody implant (Medtronic, Minneapolis (USA)) between 07/2022 and 11/2023. We recorded patient demographics, surgical parameters, adverse events, radiological parameters and clinical outcomes according to the MacNab criteria. We identified 53 patients (mean age 68.6 ± 11.5 years; 49.1% female; mean BMI 25.7 ± 4.4kg/m2), in which 92 Catalyft™ spacers were implanted, mostly at L4/5 (n = 35; 38.0%) and L5/S1 (n = 31; 33.7%) for degenerative (n = 44; 83.0%), deformity (n = 7; 13.2%) or other indications (n = 2; 3.8%). We noticed secondary collapse of 20 (21.7%) spacers in 11 patients (20.7%) occurring after a mean time of 4.0 ± 4.1 months postoperatively. Age < 70 years was identified as risk factor for secondary collapse (OR 3.71, 95% CI 1.31-10.5, p = 0.014), but no association was found regarding other patient-specific or surgery-related variables. Pseudarthrosis was evident in seven patients (13.2%), of which four (7.6%) required revision surgery. Clinical outcome at last follow-up (mean 6.4 ± 4.2 months) was excellent/good in 29 (54.7%), fair in 14 (26.4%) and poor in six patients (11.3%). We provide a critical analysis of our series of patients with use of a specific type of expandable interbody spacer. We noticed failure and secondary collapse in an unacceptably high number of implants, some of which required revision surgery.

Implementing enhanced recovery after surgery protocol in elderly patients following multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases.

Enhanced recovery after surgery (ERAS) is an evidence-based multimodal perioperative management strategy. The aim of the present study was to analyze the clinical efficacy of ERAS in elderly patients (> 70 years old) undergoing multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases. Patients older than 70 years undergoing multi-level lumbar or thoracolumbar instrumented fusion for degenerative disk diseases or spinal stenosis from January 2017 to December 2018 (non-ERAS group) and from January 2020 to December 2021 (ERAS group) were enrolled in present study. Patient-specific and procedure-specific clinical characteristics were collected. Univariate and multivariate regression were performed to determine the risk factors related to length of stay (LOS) and complications. A total of 233 patients were enrolled in this study, 70 in non-ERAS group and 163 in ERAS group. There were comparable baseline characteristics between groups. Further there were no significant differences in 90-day readmission rates and complication rates. However, we observed a significant reduction in LOS (14.89 ± 7.78 days in non-ERAS group versus 11.67 ± 7.26 days in ERAS group, p = 0.002) and overall number of complications (38 in non-ERAS group versus 58 in ERAS group, p = 0.008). Univariate linear regression denoted that operation time (p < 0.001), intraoperative blood loss (p < 0.001), intraoperative blood transfusion (p < 0.001), fusion number ≥ 5 (p < 0.001), spinal surgery including the thoracic spine (p < 0.001), CCI > 2 (p = 0.018), ERAS (p = 0.003) and spinal surgery including lumbar (p = 0.030) were associated with LOS. Furthermore, multivariate linear regression showed that ERAS (p = 0.001), CCI > 2 (p = 0.014), and Fusion number ≥ 5 (p = 0.002) were independent risk factors for LOS. Analogously, univariate logistic regression revealed that longer operation time (p = 0.005), more intraoperative blood loss (p < 0.001), more intraoperative blood transfusion (p = 0.001), fusion number ≥ 5 (p = 0.001), ERAS (p = 0.004) and spinal surgery including thoracic spine (p = 0.002) were related to complications, while implementing ERAS was associated with less complications. Multivariate logistic regression denoted that implementation of ERAS (p = 0.003), Intraoperative blood loss (p = 0.003) and Fusion number ≥ 5 (p = 0.008) were independent risk factors for postoperative complications. In conclusion, the present study reported the first ERAS principles performed in multi-level lumbar or thoracolumbar instrumented fusion for degenerative conditions. Our outcomes shown that the implementation of ERAS in these populations is favorable for reducing LOS and decreasing overall number of complications though the comparable complication rates between two groups. Totally, our ERAS protocols were safe and feasible in these populations.

Clinical study of isthmic spondylolisthesis treated with Mis-TLIF assisted by preoperative posture reduction and intraoperative lifting reduction

To investigate the clinical effect of minimally invasive transforaminal lumbar interbody fusion(Mis-TLIF) technique combined with preoperative position reduction in the treatment of spondylolisthesis and summarize its advantages. Between July 2016 and July 2022, 60 patients with lumbar isthmic spondylolisthesis were retrospectively analyzed, including 26 males and 34 females, with an average age of (51.32±4.24) years old ranging from 35 to 72 years old. They were divided into observation group and control group according to the operation methods. There were 30 patients in the observation group, including 12 males and 18 females;the age ranged from 35 to 71 years old with an average of(51.80±6.38) years old, the course of disease ranged from 12 to 60 months with an average of (24.17±1.98) months;there were 18 cases of L4 spondylolisthesis and 12 cases of L5 spondylolisthesis;according to Meyerding classification, there were 20 cases of grade Ⅰ spondylolisthesis and 10 cases of gradeⅡ. The observation group was treated with preoperative postural reduction combined with intraoperative reduction assisted minimally invasive transforaminal lumbar fusion via Quadrant channel(Mis-TLIF). There were 30 patients in the control group, including 14 males and 16 females, with an average of (50.00±4.24) years old ranging from 36 to 72 years old;the course of disease ranged from 12 to 60 months with an average of (23.70±1.53) months;there were 16 cases of L4 spondylolisthesis and 14 cases of L5 spondylolisthesis;according to Meyerding classification, there were 19 cases of grade Ⅰ spondylolisthesis and 11 cases of grade Ⅱ. The control group was treated with open transforaminal lumbar interbody fusion(Open-TLIF). The differences of operation time, intraoperative and postoperative blood loss, hospital stay, radiation exposure time and complications between the two groups were analyzed. Visual analogue scale (VAS), Oswestry disability index (ODI) and Japanese Orthopaedic Association(JOA) score were used to evaluate the clinical effect. X-ray and CT were followed up to evaluate the interbody fusion. All patients were followed up for 12 months. There was no significant difference in operation time, VAS of low back pain, slip angle and slip rate between two groups (P>0.05). The intraoperative and postoperative blood loss in the observation group (165.50±15.56) ml and (59.17±10.59) ml were less than those in the control group (259.33±35.32) ml and (165.33 ±29.56) ml (P<0.05). The length of hospital stay in the observation group (3.53±0.68) days was less than that in the control group (5.20±0.41) days (P<0.05).The intervertebral space height, slip angle, slip rate, ODI, VAS and JOA scores were significantly improved in the two groups at the final follow-up (P<0.05). There were significant differences in ODI [(9.93±1.11)% vs (10.93±1.11)%] and JOA [ (26.07±1.01) points vs (25.43±1.25) points] between the observation group and the control group at the final follow-up (P<0.05). In the treatment of spondylolisthesis, preoperative position reduction combined with intraoperative reduction assisted Mis-Tlif technique has advantages of less trauma, less bleeding and shorter hospitalization period than traditional open surgery. It is a safe and effective technique.

Variability in treatment of postoperative pain in children with severe neurologic impairment.

Treatment of postoperative pain for children with severe neurologic impairment (SNI) is challenging. We describe the type, number of classes, and duration of postoperative pain medications for procedures common among children with SNI, as well as the variability across children's hospitals in pain management with an emphasis on opioid prescribing. This retrospective cohort study included children with SNI ages 0-21 years old who underwent common procedures between January 1, 2019 and December 31, 2019 within 49 children's hospitals in the Pediatric Health Information System. We defined SNI using previously described high-intensity neurologic impairment diagnosis codes and identified six common procedures which included fracture treatment, tracheostomy, spinal fusion, ventriculoperitoneal shunt placement (VP shunt), colostomy, or heart valve repair. Medication classes included benzodiazepines, opioids, and other nonopioid pain medications. Acetaminophen and nonsteroidal anti-inflammatory drugs were excluded from analysis. All findings were summarized using bivariate statistics. A total of 7184 children with SNI underwent a procedure of interest. The median number of classes of pain medications administered varied by procedure (e.g., VP shunt: 0 (interquartile range [IQR] 0-1); tracheostomy: 3 (IQR 2-4)). Across all procedures, opioids and benzodiazepines were the most commonly prescribed pain medications (48.8% and 38.7%, respectively). We observed significant variability in the percentage of postoperative days with opioids across hospitals by procedure (all p < .001). There is substantial variability in the postoperative delivery of pain medications for children with SNI. A standardized approach may decrease the variability in postoperative pain control and enhance care for children with SNI.