Decompression Surgery Research Articles

Analysis of Early Post-Radiation Surgical Management of Metastatic Spinal Tumors

Background/Objectives: Radiotherapy is one of the various treatment options for patients with metastatic spinal tumors (MST). However, it is difficult to say that this is definitely an optimal treatment for MST, and there are several patients who need surgical treatment because pain or neurologic deficits occur even after radiotherapy. Therefore, this study aimed to analyze which patients received early operative treatment after radiotherapy. Methods: We included 81 patients who underwent decompression and fusion surgery after radiotherapy for MST. Patients who underwent surgery within 6 months after radiotherapy were classified as the early operation group (group E, n = 47), while surgery cases after 6 months after radiotherapy were assigned to the late operation group (group L, n = 34). Risk factor analysis using multivariate regression analysis for early operative treatment after radiotherapy was performed. Also, we analyzed the period from radiotherapy to surgery according to the Bilsky grade. Results: In multivariate analysis, pathologic fractures and semirigid (thoracic) lesions were more frequent in group E than group L (adjusted odds ratio, 4.282, 10.524; p = 0.001, 0.039). In subgroup analysis, there was a difference in the period from radiotherapy to surgery in Bilsky grades above 2 than Bilsky grade 1 (grade 1, 13.6 ± 11.4 months, grade 2, 6.9 ± 6.8 months, grade 3, 6.6 ± 7.5 months; grade 1 vs. 2, p = 0.049, grade 1 vs. 3, p = 0.047). Conclusions: Although the information in this study may only be limited to patients who underwent surgery, early operative treatment after radiotherapy is highly likely for patients with MST accompanied by a Bilsky grade above 2, pathologic fracture and thoracic lesion. In these patients, surgical treatment could be considered as the primary treatment.

The importance of the posterior osteoligamentous complex of the lumbar spine: dogma changing biomechanical insights.

During full flexion of the spine, the paraspinal muscles are largely inactive. This suggests that passive structures like the posterior osteoligamentous complex (POLC), consisting of interspinous and supraspinous ligaments and the spinous processes, play a key role in spinal stability and protection of the spinal column. The POLC, however, is often resected or damaged during spinal decompression surgeries, whereas the biomechanical implications of this resection or damage are not yet fully understood. A stepwise reduction study was performed on three fresh frozen cadaveric torsi (aged 30-78 years) using a custom setup which only allows sagittal plane motion. After preloading and locking in full flexion, the posterior lumbar structures were gradually resected in the following order: Skin, fascia, musculature, facet joints, ligamentum flavum, posterior ligamentous complex, and posterior longitudinal ligaments. Load cells measured force increase on the fixation frame after each resection step. The load increased sequentially with each resection, demonstrating load transfer from the passive structures onto the fixation frame. The POLC, including the supraspinous and interspinous ligaments at L2-L5, accounted for 69 - 74% of the measured passive load resistance in full flexion, representing the largest contribution. Facet joints with their capsules contributed 10-18%, while muscular contributions were negligible (< 2%). The experiment indicates that the POLC is the primary passive stabilizer of the fully flexed lumbar spine. Surgical resection of this structure can redistribute loads and increase stresses on remaining spinal tissues, potentially leading to spinal instability, accelerated degeneration, and poor clinical long-term outcomes.

Hollow‐Tube‐Whisker‐Modified Biphasic Calcium Phosphate Ceramics Loaded with SDF‐1α and EPCs for Steroid‐Induced Osteonecrosis of Femoral Head

AbstractSteroid‐induced osteonecrosis of the femoral head (SONFH) remains a significant challenge in orthopedic clinical treatment. In this study, a novel 3D hollow‐tube‐whisker‐modified biphasic calcium phosphate ceramic (H‐BCP) is successfully fabricated using an in‐situ growth technique. Compared to conventional BCP ceramics, H‐BCP exhibited increased specific surface area, enhanced mechanical strength, and improved biocompatibility. Utilizing the hollow‐tube whisker structure, H‐BCP is functionalized with stromal cell‐derived factor‐1α (SDF‐1α) to construct the H‐BCP@SDF‐1α sustained‐release system. In vitro studies demonstrated that H‐BCP@SDF‐1α effectively recruited bone marrow stromal cells (BMSCs), promoted their osteogenic differentiation, and supported the angiogenic differentiation of endothelial progenitor cells (EPCs). Furthermore, EPC‐loaded H‐BCP@SDF‐1α (H‐BCP@SDF‐1α/EPC) is used to construct vascularized tissue‐engineered bone and implanted into a SONFH rabbit model following core decompression surgery. At 12 weeks post‐surgery, animals implanted with H‐BCP@SDF‐1α/EPC exhibited significant new bone formation, bone integration, and in situ revascularization. Additionally, it is found that H‐BCP@SDF‐1α/EPC activated the PI3K/AKT signaling pathway in BMSCs, upregulating osteogenic gene expression. This study explores a novel material system integrating mechanical support, bioactivity, and drug delivery, offering a promising approach for SONFH treatment.

Anterior clinoid process metastasis with sudden loss of vision: role of emergency optic nerve decompression

Abstract Background Anterior clinoid process metastases are rare. We present an unusual case of anterior clinoid process metastasis with sudden deterioration of visual function requiring emergency optic nerve decompression, resulting in visual recovery. Case presentation We report the case of a 41-year-old male patient with a diagnosis of radius leiomyosarcoma, who underwent surgery in 2014, with bone and lung metastases, who had been treated with chemotherapy and appeared to have the disease controlled at his last follow-up. 6 years later, he developed a one month history of progressive unilateral loss of visual acuity and visual field defect (initially quadrantanopia that progressed to nasal hemianopia). Brain imaging showed a contrast-enhancing lesion affecting the left anterior clinoid process with extension to the cavernous sinus and sphenoid sinus, causing compression of the left optic nerve. Although the lesion could have suggested a meningioma given the location, in the context of the patient’s oncological history, the diagnosis of metastasis was considered more likely. The patient was admitted to hospital and, during the hospital stay, developed sudden left retro-orbital pain progressing to left amaurosis over approximately 8 h. Urgent surgery was performed: a pterional craniotomy with partial tumor removal and optic nerve decompression with extradural anterior clinoidectomy. After surgery, the patient had an immediate but partial improvement in visual acuity and in the visual field defect. Conclusions Metastasis to the anterior clinoid process is very uncommon, with only one case previously reported in the literature. In cases of visual impairment, symptoms may deteriorate rapidly to complete loss of vision, so urgent decompressive surgery of the optic nerve may be indicated to recover visual function, although recovery may be partial.

Lesser Occipital Nerve Decompression Through a Single Vertical Midline Incision Reduces Reoperation Rates.

Nerve decompression surgery for occipital neuralgia (ON) of the lesser occipital nerve (LON) is oftentimes performed in combination with treatment of the greater and third occipital nerves (GON and TON). The traditional surgical approach requires multiple separate incisions. This study describes combined GON/LON approach through a single vertical midline incision and reports on the postoperative outcomes. Among 1713 patients who were screened for nerve decompression surgery between 2011 and 2023, those who underwent combined GON/LON decompression for treatment of ON were identified retrospectively. Patients who underwent LON decompression through the vertical midline incision were compared to those who underwent LON decompression through a separate incision. Outcomes included postoperative complications, LON reoperation, pain frequency (days/month), intensity (scale 0-10), duration (hours), and Migraine Head Index (MHI) at final follow-up. A total of 124 patients underwent 184 combined GON/LON surgeries. LON decompression was performed through a midline incision in 91 (73.4%) patients and through a separate incision in 33 (26.6%). LON reoperation rates for pain recurrence were higher in the separate incision group as compared to the midline incision group (15.2% versus 4.4%, p<0.05). At a median follow-up of 17.9 months after the last intervention, reductions in pain frequency, intensity, duration and MHI were comparable between both techniques (p>0.05). Postoperative complications were not significantly different between both groups (p>0.05). During combined GON/LON surgery, approaching the LON through the midline incision is feasible and allows for safe and effective LON decompression or neurectomy, with lower reoperation rates for recurrent pain.

The Cost of Providing Mechanical Thrombectomy for Patients in Private Hospitals Across India: A Macro-costing Study

Purpose The benefits of using mechanical thrombectomy (MT) to treat large vessel occlusion stroke in terms of clinical efficacy and cost-effectiveness have been widely recognised. However, the cost of delivering MT to treat large vessel occlusion stroke in private tertiary care centres in India is unclear. This study aimed to determine the cost of MT and analyse cost-influencing factors. Methods A retrospective cost analysis of stroke patients who underwent MT with or without intravenous thrombolysis (IVT) was conducted at multiple centres (January–December 2022). The macro-costing method was used to examine the discharge bills and identify cost-influencing factors. The study gathered data on patients treated according to normal clinical procedures at four skilled and frequently performing thrombectomy centres. Results The study was conducted on 115 stroke patients who underwent MT with or without IVT. Results showed an average total cost of ₹555,399 (95% confidence interval: 246,306–864,492) per patient. Key cost drivers were length of hospital stay (9.7 ± 7.0 days, p &lt; .01), modified Rankin Scale (mRS) score at discharge (3.6 ± 1.6, p &lt; .01) and use of decompressive surgery (10.7/115, p &lt; .03). Lower costs were seen in patients with mRS scores 1, 2 or 6 on day 3 after MT (57/115, 50.4%, p &lt; .01). Neither MT type nor concomitant use of IVT had a significant cost impact. Conclusion In conclusion, the mRS score is a critical factor in determining the cost of acute stroke therapy with MT in India. Efforts must be made to identify patients with poor mRS as early as 3 days after MT and devise a strategy to reduce their stay in the ICU and in the hospital, which would, in turn, help reduce their hospitalisation costs. It is crucial to gather accurate and comprehensive data on micro-costing to inform policies and allocate resources effectively.

The emerging field of ultrasound-guided nerve decompression surgery: a narrative review.

The development of high-frequency ultrasound technology has transformed musculoskeletal diagnostic practices, offering detailed, multi-plane visualization of superficial structures with remarkable precision and comfort. This non-invasive, pain-free modality is particularly suited for patients of all ages, including children. Ultrasound serves as a valuable adjunct to clinical evaluations by facilitating the identification of conditions such as tumours, tenosynovitis, fractures, and nerve entrapments. Portable ultrasound devices have further expanded its utility to clinical, surgical, and emergency settings. Dynamic assessments, such as nerve gliding and entrapment detection, benefit from its precision, enabling targeted therapeutic interventions with minimal risks. The integration of ultrasound into surgical techniques, termed ultrasonosurgery, allows for minimally invasive management of conditions like carpal tunnel syndrome and other nerve compressions. By leveraging high-resolution imaging, these procedures can be performed under local anaesthesia, minimizing traditional surgical complications. This innovative approach aligns with contemporary healthcare trends emphasizing wide-awake surgeries, office-based care, mini-invasive procedures, and technological advancements. Such practices not only streamline patient care but also reduce costs and improve outcomes.

Analysis of Prognostic Factors and Treatment Outcomes in Indirect Traumatic Optic Neuropathy: A Retrospective Review of 105 Patients

Purpose To identify risk factors for vision recovery in indirect traumatic optic neuropathy (TON) and to analyze the outcomes associated with surgical treatment for TON. Methods Between 2020 and 2023, a total of 105 patients diagnosed with traumatic optic neuropathy (TON) at Shanghai Ninth People’s Hospital and Shanghai Minhang Hospital were included in a retrospective study. These individuals underwent optic nerve decompression surgery as part of their treatment. To collect comprehensive data, both preoperative and postoperative information was gathered. For analytical purposes, only those patients who had a minimum of one month follow-up post-treatment were considered. The statistical analysis incorporated the use of median values, odds ratios (OR), and 95% confidence intervals (CI) to interpret the data. Any p-values less than 0.05 were deemed to indicate statistical significance, underlining the rigorous criteria set for this study. Results A total of 105 patients, with a mean age of 31.8 ± 14.9 years, met the inclusion criteria; 89.5% (94) were men, and 10.5% (11) were women. The median time to seek medical attention after injury was 4 days (range: 1 to 15 days). Prognostic factors associated with visual acuity (VA) improvement included a gradual VA loss pattern (OR: 2.22, 95% CI: 0.91–5.67, p = 0.045), while canal fractures (OR: 0.31, 95% CI: 0.095–0.933, p = 0.019) significantly correlated with poor VA outcomes. Conclusions This study suggested that surgical interventions benefit TON patients with low vision. Gradual VA loss, rather than sudden loss after injury, may be a potential prognostic factor for favorable VA outcomes, while canal fractures, as detected on computed tomography (CT) imaging—especially complex canal fractures, are associated with poor VA outcomes. In the future, more definitive prospective treatment trials are required to identify optimal treatment strategies for TON.

An Application of Combined Transpetrosal Approach with Micro-neurovascular Transposition in Recurrent Trigeminal Neuralgia caused by Dolichoectatic Vertebral Artery

PurposeIn general, the superior cerebellar artery (SCA) is the most prevalent vessel that compresses the trigeminal nerve root exit zone (TGNREZ) and is responsible for trigeminal neuralgia (TGN). Nevertheless, the surgical outcome is less efficacious when the offending vessel is a dolichoectatic vertebrobasilar vessel (DVB). In addition, the potential for post-procedural adhesion and fibrosis renders recurrent TGN after prior surgery an extremely challenging operation. MethodsWe describe our surgical strategy and procedure that effectively resolved recurrent TGN in a patient whose offending vessel was a large DVB following standard microvascular decompression surgery. The size and nature of the offending DVB indicated that there was limited space for mobilization away from the TGNREZ, as evidenced by previous operative findings. Consequently, the patient's TGN may not be effectively treated by re-operating with the same standard lateral suboccipital approach. ResultsOur surgical approach comprised the creation of an expanded area to facilitate the mobilization of the DVB from the TGNREZ, as well as the untethering of the trigeminal nerve and its subsequent mobilization from the DVB using the transposition technique. ConclusionA combined transpetrosal approach with micro-neurovascular transposition technique was selected to achieve all objectives. A case illustration with a surgical video is demonstrated.

Risk factors for progression of nucleus pulposus degeneration in the lumbar intervertebral disc: A retrospective analysis using the disc signal intensity index.

Degenerative disc changes are associated with low back pain and negatively impact quality of life. Disc degeneration process usually starts with nucleus pulposus change. There is uncertainty about the risk factors associated with the progression of disc nucleus degeneration due to the lack of an objective evaluation method. Pfirrmann grade, which assesses the morphological characteristics of a disc on T2-weighted MRI images on a scale of 1 to 5, is one of the most frequently used assessment systems. This method inherently has a degree of subjectivity that may lead to inaccurate and inconsistent grading. A recent study introduced the disc signal intensity index (DSI2) for quantitative assessment of nucleus pulposus degeneration with promising results in identifying of risk factors for progression of disc degeneration. The aim of this study was to investigate the risk factors for the progression of nucleus pulpous degeneration in the lumbar vertebral disc on longitudinal MRI data using DSI2. Retrospective longitudinal study PATIENT SAMPLE: Patients with lumbar MRIs at least three years apart and did not undergo the lumbar spine surgery between both time points were included. Potential contributing factors were collected that included age, biological sex, race, body mass index (BMI), current smoking status, alcohol consumption, history of previous lumbar decompression surgery, and comorbidities such as congestive heart failure (CHF), myocardial infarction, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and rheumatoid arthritis. Disc nucleus degeneration was assessed using the DSI2 and Pfirrmann grade on T2- weighted MRI. The DSI2 values are based on the mean signal of disc spaces within a circular region of interest (ROI), which was adjusted by the signal intensity of cerebrospinal fluid (CSF) on the midsagittal plane. Three ROIs were set per disc (anterior 1/3, middle, posterior 1/3), and the mean values of all three measurements from L1/2 to L5/S1 disc space were utilized. Discs with complete collapse and no space for ROI selection were excluded. The difference in DSI2 scores between these two time points were compared. Multivariate linear mixed regression analysis was conducted to determine the factors associated with disc degenerative changes. A total of 325 patients and 1439 discs were included in the final analysis. 173 patients (53.2%) were female and the median age of all patients was 60.1 years. The mean (SD) DSI2 score was 0.177 (0.074) for thefirst MRI and 0.184 (0.081) for the second MRI. The Pfirrmann grading for the first MRI timepoint were as follows: 23 discs (1.42%) were Grade 1, 377 discs (23.2%) were Grade 2, 583 discs (35.9%) were Grade 3, 456 discs (28.1%) were Grade 4, and 186 discs (11.5%) were Grade 5. Multivariable linear mixed regression analysis demonstrated that older age (p=0.030) and the presence of congestive heart failure (p<0.001) were significant risk factors for disc nucleus degenerative progression. The present study demonstrated that age and congestive heart failure were risk factors for progression of disc nucleus degeneration. These insights may aid in identifying patients at risk for degenerative lumbar conditions and guide further studies about preventive measures. The DSI2 method offers a promising alternative evaluation method for future disc research.

Motion Capture-based 3-Dimensional Measurement of Range of Motion in Patients Undergoing Cervical Laminoplasty.

A prospective study. To measure 3-dimensional cervical range of motion (ROM) by noninvasive optical tracking-based motion-capture technology in patients undergoing laminoplasty, and to elucidate the postoperative effects of laminoplasty on cervical mobility. Cervical laminoplasty is a motion-sparing decompression surgery for degenerative cervical myelopathy. Unlike cervical laminectomy and fusion, the true postoperative impact of laminoplasty on neck motion has not been well studied. Participants comprised 25 patients undergoing double-door cervical laminoplasty for degenerative cervical myelopathy in a single center. Maximum flexion/extension, left/right rotation, and left/right side bending were recorded using the motion-capture device preoperatively and 3 months postoperatively. ROMs in 3 orthogonal axes were calculated. Preoperative differences in C2-7 Cobb angles on lateral flexion/extension x-rays were also measured as the radiologic ROM to assess reliability. Preoperative and 1-year postoperative Japanese Orthopaedic Association score, Neck Disability Index [NDI], and Euro-QOL were recorded, and correlations with ROMs were assessed. Preoperative mean (±SD) ROMs for flexion/extension, rotation, and side bending were 90±17, 107±16, and 53±17 degrees, respectively. Although radiologic sagittal ROM measurement showed a smaller range than motion capture, averaging 36±13 degrees, a moderate to strong correlation between radiologic and motion capture values was observed (R=0.57, P =0.003). Preoperative NDI showed a negative correlation with coronal ROM (rho=-0.547, P =0.02). Postoperative ROM showed a significant reduction in rotation (95±16 degrees, P =0.002) but not in flexion/extension or side bending. Three-dimensional motion-capture analysis allowed reliable measurement of cervical ROM. Rotational ROM was significantly reduced after laminoplasty, showing that cervical kinematics are still significantly altered.

Intraoperative neuromonitoring is not a useful adjunct for Chiari malformation decompressive surgery: a cost-benefit and legal analysis.

Posterior fossa decompression is currently an operative treatment of choice for Chiari Malformation I (CM1). However, there is controversy surrounding the possible benefits of employing intraoperative neuromonitoring (INM) for this type of procedure. In addition to presenting our single-center experience on the use of INM, we analyze the cost associated with INM in Chiari Malformation (CM) decompression surgery using the Healthcare Cost and Utilization Project (HCUP) database and discuss the legal implications of somatosensory evoked potentials (SSEP) monitoring during decompression for CM1. We conducted a retrospective review of all patients undergoing CM1 decompression with SSEP neuromonitoring from 2011 to 2018. We collected patient characteristics, hospital charges, and surgical cost data from the HCUP database for patients undergoing CM decompression. Finally, we performed a review within the Thompson Reuters Westlaw Edge database for reported litigation involving INM for CM decompression. None of the 110 patients submitted to surgery for CM1 at our institution had any significant SSEP changes intraoperatively or developed post-operative neurological deterioration. There were higher mean total hospital charges and surgical costs associated with INM ($31,272) for patients who received INM compared to patients who did not receive INM ($24,112). A careful review of the Westlaw database with multiple-word search strategies revealed no reported medical malpractice claims regarding the absence of SSEP neuromonitoring in a CM decompression procedure. Using data collected at our institution and the HCUP national database, we showed that intraoperative neuromonitoring did not affect surgical planning and decision-making or post operative care, while adding unnecessary costs to CM decompression procedures. The absence of reported malpractice claims targeting the lack of neuromonitoring in CM cases suggests that SSEP neuromonitoring during CM may be unnecessary. We propose that neuromonitoring should not be used for routine CM decompression.

Risk prediction model of pedicle screw loosening within 2 years after decompression and instrumented fusion surgery for degenerative lumbar disease.

Pedicle screw loosening (PSL) after spinal fusion surgery is one of the most frequently reported complications and leads to poor clinical outcomes. This study aimed to develop and validate a risk prediction model for PSL within two years in patients undergoing lumbar instrumented fusion surgery based on their risk profiles. Retrospective, observational study. Patients who underwent lumbar instrumented fusion surgery at a single academic institution between May 2015 and February 2019. Risk assessment of PSL and development of a rating score based on patient characteristics. The demographic profiles and radiographic parameters using computed tomography were obtained. These factors were analyzed to determine possible risk factors related to postoperative PSL after 2 years. A scoring system was developed using these independent risk factors and validated using prospectively collected data from another center between May 2019 and December 2021. The occurrence of PSL within 2 years postoperation was 12.7% (40/315). PSL was significantly predicted by smoking, low Hounsfield units (HU) of the pedicle tract at the index level (P), and a low psoas-lumbar vertebral index (PLVI). The risk of PSL according to the categories of the risk score was 1.1% for those with a score of 0-1, 15.1% for a score of 2-3, and 61.5% for a score of 4-6. In validation, this model demonstrated both good discrimination and calibration results. The area under the curve was 0.887 (95% CI 0.830-0.938) for the derivation cohort and 0.835 (95% CI 0.738-0.918) for the external validation cohort. This PSL risk score, including smoking, Index P HU, and PLVI, is a novel approach to predict PSL 2 years post-surgery. This approach highlights the role of factors associated with osteoporosis and sarcopenia in the development of PSL and could aid in preoperative decision-making and surgical planning.

Achondroplasia Status and Adverse Short-Term Postoperative Outcomes in Elective Spinal Decompression Surgery: A Propensity Score-Matched Case-Control Study.

Achondroplasia is the most common form of skeletal dysplasia, affecting approximately 1 in 25,000 individuals in the US. Previous research suggests that achondroplasia patients undergoing spine surgery have worse postoperative outcomes. Most of these findings are based on small, single-center retrospective studies and describe the impact of achondroplasia status on only one or two outcomes. We sought to assess the association between achondroplasia and a comprehensive battery of postoperative care outcomes in a national cohort. The Merative™ Marketscan® Commercial Database and the accompanying Medicare Supplement were queried for adult patients diagnosed with achondroplasia who underwent elective thoracic/thoracolumbar or lumbar decompression +/- fusion surgery between 2006 and 2023. Propensity score matching was used to identify an equal number of age and sex-matched controls without achondroplasia. Outcomes of interest were length of hospital stay, non-home discharge disposition, 90-day readmission and postoperative medical or surgical complications. Bivariate analyses were conducted to examine the distribution of baseline characteristics based on achondroplasia status. Multivariate regression was employed to assess the association between achondroplasia status and short-term postoperative outcomes. Overall, 111 achondroplasia cases and an equal number of age- and sex-matched controls were included. Compared to controls, those with achondroplasia were more likely to have a longer length of hospital stay (B-coefficient=3.34, 95% confidence interval [95% CI]=1.00-4.70), non-home discharge (odds ratio [OR]=20.51, [5.78-72.73]) and a higher complication rate (OR = 3.63, [1.49-8.87]). The association between achondroplasia status and 90-day readmission did not reach statistical significance (p=0.48). Patients with achondroplasia undergoing spinal surgery experience worse overall short-term postoperative outcomes compared to their age- and sex-matched counterparts. Patient-specific factors may contribute to the higher complication rates observed. While the presence of achondroplasia is unchangeable, surgeons should be prepared for increased risks in their management plans. These findings highlight the need for tailored preoperative assessments and enhanced postoperative strategies to improve outcomes in this vulnerable population.

Retraction Note: Letter to editor: Comments on, "Factors influencing discharge against medical advice (DAMA) in traumatic brain injury patients requiring decompressive surgery: a comprehensive analysis".

Retraction Note: Letter to editor: Comments on, "Factors influencing discharge against medical advice (DAMA) in traumatic brain injury patients requiring decompressive surgery: a comprehensive analysis".

Postoperative Brace Prescription Practices for Elective Lumbar Spine Surgery: A Questionnaire-Based Study of Spine Surgeons in Japan.

The efficacy of postoperative braces for degenerative lumbar disorders has long been debated, with conflicting reports regarding the promotion of bone fusion and pain relief. The current aspects of postoperative brace prescriptions have been previously reported in Western countries but not in Asia. This study aimed to elucidate prescription practices in Japan and identify factors influencing prescription decisions. The survey was conducted at a spine group research meeting comprising spine surgeons from multiple institutions. The questionnaire assessed aspects of postoperative brace prescription, including the type, purpose, and duration of usage, categorized by surgical procedures for degenerative lumbar disorders: endoscopic decompression, open surgery decompression, and fusion involving 1 or more than 3 levels. The respondents' backgrounds, scientific knowledge of postoperative braces, nonscientific reasons, and basis for prescription decisions were also investigated. There were 63 valid responses. The overall postoperative brace prescription rate was 83%, with 66% for decompression and 98% for fusion procedures, surpassing the rates reported in Western studies. The primary prescription purpose was to slow down patient activity (83%, double the previously reported rates). Prescription rates for endoscopic and open surgical decompression were significantly correlated with facility attributes and annual number of surgeries. Scientific knowledge of postoperative braces was lacking in 56% of respondents, with scientific evidence being the least frequent decision for brace prescription (14%). Nonscientific reasons influenced the prescription decisions of 84% of participants. The postoperative brace prescription rate among spine surgeons in Japan was significantly higher than that in Western studies, largely due to nonscientific factors such as physician reassurance and the intention to slow down patient activity. Comprehensive, evidence-based guidelines are needed regarding consistent brace usage to optimize patient outcomes. This study highlights the high postoperative brace prescription rates among spine surgeons in Japan, which are significantly influenced by nonscientific factors, such as tradition, physician reassurance, and patient satisfaction, rather than scientific evidence. These findings underscore the need for evidence-based guidelines to improve consistency in postoperative brace usage. The results are particularly relevant in regions with aging populations and a high prevalence of osteoporosis, providing insights for improving postoperative management strategies and patient outcomes in Japan as well as in similar demographic settings globally.

Effect of Low-Dose Methylprednisolone in Promoting Neurological Function Recovery after Spinal Cord Injury: Clinical and Animal Studies.

Subgroup analysis of a retrospective clinical and animal trial [Study of different doses of methylprednisolone on functional recovery of spinal cord injury]. The aimed to investigate the efficacy of low-dose methylprednisolone regimens in promoting neural repair after SCI. Spinal cord injury (SCI) can result in sensory, motor, and autonomic nerve dysfunction, often leading to disability or death. Methylprednisolone (MP) is a preferred medication for clinical treatment of SCI. Low-dose regimen may be a safer and more effective approach. A subgroup comprising 705 patients with traumatic cervical SCI from four medical centers between January 2015 and December 2020 was retrospectively analyzed. Patients were stratified based on treatment regimen: low-dose methylprednisolone, high-dose methylprednisolone, or no methylprednisolone use. All patients underwent spinal decompression surgery. The degree of neurological recovery and the incidence of complications during follow-up were compared among these three groups. Additionally, we investigated the disparities in neurological function recovery, neuronal death, and neural axon regeneration between the low-dose and high-dose methylprednisolone treatment regimens using a SCI rat model. Patients receiving the low-dose methylprednisolone regimen exhibited superior neurological recovery compared to those receiving the high-dose regimen and those not receiving methylprednisolone (82.0% vs. 74.0%, P=0.030; 82.0% vs. 63.4%, P=0.001). Moreover, patients in the low-dose methylprednisolone group demonstrated the lowest rates of perioperative pulmonary infections and gastrointestinal bleeding among these three groups. Evaluation of the SCI rat model through Basso-Beattie-Bresnahan (BBB) score, footprint analysis, electrophysiological tests, hematoxylin and eosin (H&E) staining, immunofluorescence staining, and Nissl staining further corroborated that the low-dose methylprednisolone treatment regimen enhanced transport function recovery, reduced neuronal death, and promoted neural axon regeneration. The low-dose methylprednisolone regimen may have a more positive therapeutic effect on the recovery of neurological function after SCI than other regimens.

Impact of Antiplatelet Medication Continuation on Surgical Outcomes after Minimally Invasive Posterior Lumbar Decompression Surgery: Retrospective Cohort Study.

Retrospective cohort study. Spinal surgeons face a dilemma regarding the continuation or discontinuation of antiplatelet agents during the perioperative period. Guidelines recommend considering the balance between thrombotic and bleeding risks. However, no consensus exists for the use of these agents for patients who undergo minimally invasive lumbar decompression. This study aimed to assess the effect of continued antiplatelet medication on minimally invasive posterior lumbar decompression surgery outcomes, focusing on perioperative outcomes and 1-year postoperative clinical results. This study included 106 patients who underwent minimally invasive posterior lumbar decompression between 2017 and 2022 and were taking antiplatelet medications before spinal surgery. Patient characteristics, antiplatelet medication type, and perioperative data were analyzed. Patients were divided into "continuation" and "discontinuation" groups based on preoperative antiplatelet medication status. Univariate and multivariate linear regression analyses were performed. No significant differences were observed between groups in terms of surgical time, intraoperative blood loss, postoperative drain volume, complication rates, and Japanese Orthopedic Association scores and EuroQoL-5 dimensions 5-level at 1 year postoperatively. Similar results were noted in groups focusing exclusively on patients treated with aspirin. Multivariate linear regression revealed that surgical time per level was significantly associated with total blood loss, whereas antiplatelet medications did not show a significant relationship (operative time per level, P < 0.01; antiplatelet drugs, P = 0.459). This study suggests that minimally invasive posterior lumbar spine decompression can be performed safely and effectively under continuous antiplatelet medication. Further studies with more evidence are required to validate our findings.

Pudendal Neuralgia: A Review of the Current Literature.

This paper aims to review pudendal neuralgia pathophysiology, risk factors, diagnosis, and treatment options. Conservative and pharmacologic options are first line treatments for the treatment of pudendal neuralgia. Interventional treatment such as, pudendal nerve blocks can be tried if first line treatments feel to provide adequate analgesia. If pudendal nerve blocks provide sufficient relief but have a short duration, decompressive surgery may be considered. Neuromodulation is also a viable option. Emerging techniques such as pulsed radiofrequency ablation, cryotherapy, lipofilling, and repetitive transcranial magnetic stimulation are promising; however, more studies are needed to evaluate safety and effectiveness. Current study data is generally poor, and unstandardized. Further research is needed to identify the optimal treatment approach and evaluate the effects of pudendal neuralgia on mental health and quality of life.

Endoscopic transfacet Decompression for Severe Lumbar Spinal Stenosis: A Technical Note, Illustrative Clinical Series, and Surgeon Survey Regarding Post-Decompression Instability

Background: Lumbar spinal stenosis (LSS) remains a predominant cause of debilitating back and leg pain, affecting many aging populations. Traditional decompression surgeries can be invasive and pose significant risks and recovery time. This study elucidates the techniques and preliminary outcomes of endoscopic transfacet decompression in treating severe LSS. Methods: A retrospective review was performed on 65 patients with severe LSS who underwent endoscopic transfacet decompression. The patient outcomes were analyzed using the VAS for leg pain and the modified Macnab criteria. Pre-operative and post-operative scores were compared, and any complications were analyzed. An online survey was administered to 868 surgeons using Likert-scale ratings to evaluate surgeons’ experience with endoscopic decompression in patients with painful spondylolisthesis. The survey responses were analyzed using descriptive statistics and Polytomous Rasch analysis to evaluate surgeon endorsement. Results: The study included 65 patients, of which 29 (44.6%) were female and 36 (55.4%) were male, with a mean age of 65.79 ranging from 38 to 84 years. The available mean post-operative follow-up period was 31.44 months, ranging from 24 to 39 months. The VAS score for leg pain reduced significantly from pre-operative 7.54 ± 1.67 to 2.20 ± 1.45 by 5.34 ± 2.03 (p &lt; 0.001) with a large effect size (Cohen’s d = 2.626). At the final follow-up, functional Macnab outcomes were reported as excellent by 20 (30.8%), good by 37 (56.9%), fair by 5 (7.7%), and poor by 3 (4.6%) of patients. There were no incidental durotomies, nerve root injuries, wound complications, or instances of post-operative instability. Only five patients (7.7%) developed post-operative dysesthesia. Incomplete decompression led to fair and poor outcomes in 8 (12.3%) patients. No revision surgeries were performed. post-operative instability was not observed. The surgeon survey corroborated these observations, where the polytomous Rasch analysis showed consensus on the effectiveness of the percutaneous endoscopic decompression of low-grade spondylolisthesis. Differential item functioning (DIF) analysis showed no significant bias in item responses between orthopaedic and neurosurgeons. Conclusions: The endoscopic transfacet decompression technique delineated herein showcased excellent Macnab outcomes in managing severe LSS, with a combined success rate of 87.7%. Patients also experienced a statistically significant reduction in leg pain. Dysesthesia rates were lower than with the transforaminal approach, likely because of limited exiting and traversing nerve root manipulation. This technique might represent a viable, less invasive alternative to open microsurgical dissection and decompression for patients with severe LSS, where fusion may be required. This approach was found to be highly accepted among endoscopic spine surgeons.