Spinal Fusion Surgery Research Articles

Cervical pedicle screw placement with patient-specific 3D-printed guides: accuracy and safety in a clinical experience.

Cervical pedicle screw (CPS) instrumentation offers significant biomechanical advantages compared to lateral mass or transarticular fixation. Nonetheless, malpositioning complications constitute a relevant concern. Customized patient-specific 3D-printed templates have been developed to improve CPS placement accuracy and safety. The aim of this study is to present our experience with this surgical technique and its accuracy and safety in a clinical setting. This single-center retrospective observational study of prospectively collected data included patients undergoing CPS fixation surgery using a patient-specific 3D template guide system. All patients underwent a 3D-volumetric high-resolution CT scan of the cervical spine for preoperative surgical planning. Postoperative CT scans were used to evaluate pedicle perforation, CPS trajectories, and deviations between the planned and the actual screw position. A total of 115 CPS were implanted in 25 patients, with 107 (93.1%) of the screws completely placed inside the pedicle. Cortical breach within 2mm was observed in 8 (6.9%) cases, with no cases of more severe pedicle infractions or perioperative neurovascular complication. No differences of CPS accuracies were found between each metameric fusion level, and between monolateral or bilateral templates. Mean total deviations were 0.75mm vertically and 0.51mm horizontally at the screw entry point, and 0.72mm vertically and horizontally at the narrowest pedicle point. Mean total sagittal and transverse angular deviations were 2.94° and 3.04°, respectively. Cervical pedicle screw placement using patient-specific guides is safe and accurate, supporting the feasibility of this technique in posterior cervical spine fusion surgery.

Preliminary validation of a diary approach to monitor daily adolescent and parental predictors of post-operative recovery - A longitudinal diary study in adolescents undergoing spinal fusion surgery.

About one in five adolescents undergoing major surgery develops chronic post-surgical pain (CPSP). Various risk and resilience factors for recovery and CPSP have been identified, including parental processes. However, research commonly relies on nomothetic data, while the psychometric properties of diaries assessing pediatric post-surgical recovery in everyday life are understudied. Therefore, this study aimed to evaluate the preliminary reliability, validity, and variability of diary data in adolescents, and their parents, after spinal fusion surgery. Adolescents with Idiopathic Scoliosis (AIS) undergoing spinal fusion surgery, and their parents, were asked to complete daily diaries for seven consecutive days at five time points, i.e., before surgery (T0), at 3-week (T1), 6-week (T2), 6-month (T3) and 12-month (T4) post-surgery. Diaries were developed based on validated questionnaires measuring relevant constructs of pediatric post-surgical recovery. Internal consistency, test-retest reliability, convergent, divergent and concurrent criterion validity, and variability were examined. The sample comprised n=95 adolescents and n=95 parents. Overall compliance rate was approximately 80 % in both adolescents and parents, with a total of 5282 diary entries analysed. Internal consistency for multi-item variables ranged from good to excellent (α=.82-.93) for adolescent data and acceptable to excellent (α=.74-.93) for parent data. All test-retest correlations were significant, and large (ρ=.60-.76) for adolescent data, and medium to large for parent data (ρ=.57-.80). Regarding validity, all but three correlations between diary variables were significant. Furthermore, diary variables generally correlated significantly with corresponding questionnaire data. Variability was low in some variables. The results provide the first evidence for the psychometric properties, with regard to reliability, validity and variability, for diary measures to monitor processes of post-surgical recovery in everyday life in adolescents undergoing spinal fusion surgery. However, replication is suggested, for refinement and further validation, with particular attention to variability and evaluation of sensitivity to change.

Prevalence of and recommendation for measuring chronic postsurgical pain in children: an updated systematic review and meta-analysis.

According to the prior 2017 review (Rabbitts et al), approximately 20% of children and adolescents develop chronic postsurgical pain (CPSP; ie, pain persisting >3 months after surgery) after major surgeries, which is associated with adverse functional and psychological consequences. A major barrier was that definitions of CPSP applied were highly variable. Since that prior review was conducted (n=4 studies in meta-analysis), numerous relevant studies have been published warranting an update. The aims of this current review were to: (1) provide an updated prevalence estimate for pediatric CPSP and (2) examine definitions of pediatric CPSP applied in current research. Prospective, observational studies examining CPSP using a validated self-report pain intensity measure in children were included. 4884 unique publications were screened with 20 articles meeting inclusion criteria. Risk of bias using Quality in Prognostic Study tool ranged from low to high. The pooled prevalence of CPSP among mostly major surgeries was 28.2% (95% CI 21.4% to 36.1%). Subgroup analysis of spinal fusion surgeries identified a prevalence of 31% (95% CI 21.4% to 43.5%). Using Grading of Recommendations, Assessment, Development, and Evaluation, the certainty in prevalence estimates was moderate. Studies used a range of valid pain intensity measures to classify CPSP (eg, Numeric Rating Scale), often without pain interference or quality of life measures. The overall prevalence of pediatric CPSP is higher than estimated in the prior review, and quality of studies generally improved though with some heterogeneity. Standardizing the measurement of CPSP will facilitate future efforts to combine and compare data across studies. CRD42022306340.

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.

Staged versus Simultaneous Surgery for Adult Spinal Deformity - A Systematic Review and Meta-analysis.

Systematic review and meta analysis. To assess the safety and efficacy of staged versus same-day spinal fusion surgeries in Adult spinal deformity (ASD). ASD surgeries are associated with high complication rates, ranging from 10% to 40%. Among the strategies to enhance safety, staging the procedure into two smaller procedures has been evaluated as an effective alternative. A systematic literature review following PRISMA guidelines was conducted using PubMed, Cochrane, Scopus, and Embase. Studies comparing staged and same-day spinal fusion for ASD were included. Perioperative data, patient-reported outcomes (ODI, SRS), radiological outcomes, and complication rates were analysed. The extracted data was analyzed and forest plots were generated to draw comparisons between the staged and the same day groups. Eleven studies, including 1323 patients (541 staged, 782 same-day) were analyzed. Staged surgeries were associated with longer operative time and length of hospital stay. There was no significant difference in estimated blood loss, clinical and radiological outcomes, or overall complication rates between groups. However, venous thrombo-embolism (VTE) rates were significantly higher in staged surgeries (odds ratio=4.33). In the staged group, surgical site infections was the most common complication with a rate of 10.5%, whereas neurological complications were the most frequent group of complications in same-day group. Staged surgeries for ASD result in longer operative time, length of hospital stay and increased VTE risk but show similar efficacy in clinical and radiological outcomes compared to same-day surgeries. Careful patient selection is crucial to balance risks and optimize outcomes in ASD surgical planning.

Linking American Spine Registry (ASR) and Medicare Data:an analysis of 8,755 Lumbar Fusion Cases.

Retrospective observational study. To evaluate whether the combined American Spine Registry and Medicare (ASR/CMS) data yields substantially different findings versus ASR data alone with regard to key parameters such as risk stratification, complication rates and readmission rates in lumbar surgery investigated through an analysis of 8,755 spondylolisthesis cases. Medicare data correlation has been effective for determining revision rates for other procedures such as total hip replacement. Our aim is to determine whether these findings are translatable in the realm of lumbar spinal surgery investigated through an analysis of 8,755 spondylolisthesis cases. The American Spine Registry (ASR) was queried for Medicare-eligible patients who underwent lumbar spinal fusion for lumbar spondylolisthesis. This cohort was analyzed based upon ASR data alone in comparison to the same patients in the combined ASR/Medicare (ASR/CMS) dataset. The primary outcome of interest was readmission at 30 and 90 days postoperatively. There were 8,755 Medicare-eligible cases with a diagnosis of spondylolisthesis within the ASR. The mean age was 72.7 years, 60.8% were female. Medical comorbidities were more frequently detected in the combined ASR/CMS dataset, reflected by a higher mean Charlson Comorbidity Index score (3.49 vs. 3.27, P<0.001). Hospital readmission rates were significantly higher in the combined ASR/CMS dataset at both 30 days (4.89% vs. 1.83%, P<0.001) and 90 days (7.68% vs. 2.66%, P<0.001), with notable increases in readmissions for infections and medical complications. Discharge disposition remained comparable across datasets, with most patients discharged to home or home health care. This study demonstrates that integrating patient-identified Medicare data with the ASR provides a more comprehensive assessment of outcomes for lumbar spinal fusion surgery as demonstrated through an analysis of 8,755 spondylolisthesis cases. These findings, establish the importance of multi-source data linkage to overcome the limitations of single-source registries, thereby enhancing data quality for clinical decision-making and quality improvement in spinal surgery.

Association of Alcohol Use Disorder and Perioperative Complications and Adverse Events After Spinal Fusion Surgery During the In-hospital Period: An Analysis of the National Inpatient Sample (NIS) Database.

Alcohol use disorder carries major effects shown to limit social support, increase recovery times, and lead to a higher incidence of surgical complications. This retrospective cohort study investigated the influence of AUD on perioperative outcomes and adverse events after spinal fusions in the largest sample size to date and spanning 11 years. Data for adult (>18 years old) patients who underwent a spinal fusion as their primary surgery were identified from the Nationwide Inpatient Sample (NIS) database for the years 2009-2020. Patients were separated into an AUD cohort and a no AUD (control) cohort. Univariable and multivariable linear and logistic regression analyses were utilized to highlight statistically significant differences in their perioperative complications and adverse events. A total of 4,896,757 patients who underwent spinal fusion were identified. AUD was present in 97,565 (2.0%) patients, with the remaining patients serving as a control group. On multivariable analysis, patients with AUD had significantly increased odds of longer length of stay (odds ratio [OR]=3.40; 95% confidence interval [CI][3.24-3.57]p<0.001, and of the following perioperative complications and adverse events: neurologic injury (OR=3.24; 95% CI[3.05-3.44]p<0.001), respiratory-related (OR=3.06; 95% CI[2.91-3.21]p<0.001), systemic infectious (OR=2.79; 95% CI[2.48-3.13]p<0.001), neurologic (stroke) (OR=2.73; 95% CI[2.22-3.35])p<0.001, urinary-related (OR=2.23; 95% CI[2.11-2.36]p<0.001), venous thrombotic-related (OR=2.12; 95%[1.87-2.40]p<0.001), gastrointestinal-related (OR:1.91; 95% CI[1.79-2.03]p<0.001), wound-related (OR=2.32; 95% CI[2.10-2.56]p<0.001), cardiac-related (OR=1.44; 95% CI[1.34-1.55]p<0.001), and fusion disorders (OR=1.22; 95% CI[1.15-1.2]p<0.001). We found that AUD carries a significantly negative influence over perioperative outcomes and adverse events after spinal fusion in a large database population.

Enhanced recovery pathway in adult patients with spinal deformity undergoing open thoracolumbar surgery

PurposeThe poor prognosis of adult patients with spinal deformity following long-segment spinal fusion surgery remains a major concern. Our study aims to investigate the impact of an Enhanced Recovery After Surgery (ERAS) protocol on the prognosis of adult patients with spinal deformity.MethodsThis study focused on a retrospective review of a database of previous adult spinal deformity. Adult patients with spinal deformity who underwent long-segment fusion surgery from July 2016 to July 2022 were evaluated, from July 2016 to July 2019 for the pre-ERAS patient group and from July 2019 to July 2022 for the ERAS group. Demographic data, radiological sagittal parameters, and intraoperative data were collected from all patients. The length of hospital stay, postoperative complications, and 90-day readmission rates were compared between the two groups. Additionally, multivariate regression models were used to analyze the predictors of postoperative length of stay, postoperative complications, and 90-day readmission rates.ResultsA total of 215 patients were included in this study, 102 patients in the pre-ERAS group and 113 patients in the ERAS group. Postoperative outcomes in the ERAS group included significantly lower postoperative length of stay (LOS) (13.09 ± 4.57 vs. 11.13 ± 4.16, P = 0.001); significantly lower rate of postoperative complications (52.0% vs. 29.2%, P < 0.001) and significantly lower 90-day readmission rates (14.7% vs. 6.19%, P = 0.040). Multivariate linear regression showed that fewer ERAS (P = 0.022), later drain placement (P = 0.027), and more complications (P = 0.002) were significantly associated with longer postoperative LOS. Multivariate logistic regression showed that fewer ERAS (P = 0.015) and later drain removal (P = 0.041) were significantly associated with more complications, and more ERAS (P = 0.009), earlier postoperative LOS (P = 0.020), and earlier urinary catheter removal (P = 0.034) were significantly associated with the 90-day readmission rates.ConclusionsAccording to the results of our study, it is necessary to implement an ERAS protocol for adult patients with spinal deformity undergoing long-segment fusion surgery. The ERAS protocol is effective in reducing postoperative hospital length of stay, incidence of surgical complications, and 90-day readmission rates.

Clinical and radiographic comparison of robot-assisted single-position versus traditional dual-position lateral lumbar interbody fusion.

The potential of robot-assisted (RA) single-position (SP) lateral lumbar interbody fusion (LLIF) warrants further investigation. This study aimed to assess the efficacy of RA-SP-LLIF in improving both clinical and radiographic outcomes in patients undergoing lumbar spinal fusion surgery. A total of 59 patients underwent either RA-SP-LLIF (n = 31 cases) or traditional LLIF (n = 28 cases). Surgical parameters including operative duration, estimated blood loss, and fluoroscopy duration were recorded. Clinical outcomes were assessed using the visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and the 36-item Short-Form Health Survey (SF-36). Radiographic parameters were also evaluated. There were no significant differences between the two groups in terms of postoperative and last follow-up times, but both groups demonstrated significant improvements in VAS scores. Similarly, ODI and SF-36 scores showed comparable improvements. Radiographic parameters did not significantly differ between the groups preoperatively, postoperatively, and at last follow-up (p > 0.05). Neither group showed significant improvements in pelvic tilt and sacral slope parameters compared to baseline postoperatively and at last follow-up (p > 0.05). However, the RA-SP-LLIF group exhibited significantly greater improvements in lumbar lordosis (LL; p < 0.01), segmental lordosis (SL; p < 0.01), and pelvic incidence-LL mismatch (PI-LL; p < 0.01) immediately postoperatively compared to baseline, although these differences were not significant at subsequent evaluations. Similarly, the traditional LLIF group improved the LL, SL, and PI-LL parameters postoperatively. Importantly, there was no statistically significant difference in the Bridwell grade and complications between the two groups (p = 0.83 and p = 0.88, respectively). However, the RA-SP-LLIF group had significantly shorter operative and fluoroscopy durations compared to the traditional LLIF group (p = 0.04 and p < 0.01, respectively). Both RA-SP-LLIF and traditional LLIF surgeries achieved satisfactory lordotic correction. However, RA-SP-LLIF surgery demonstrated shorter operative and fluoroscopy times compared to traditional LLIF surgery. Therefore, RA-SP-LLIF is a promising technique for enhancing surgical efficiency, safety, and precision in lumbar spinal fusion procedures.

The Association of Bone Mineral Density with Distal Junctional Kyphosis and Distal Junctional Failure After Multilevel Spine Fusions: A Systematic Review and Meta-Analysis.

Distal junctional kyphosis (DJK) and distal junctional failure (DJF) are known complications of adult multilevel spinal fusion surgery. Previous literature has extensively investigated proximal junctional kyphosis and proximal junctional failure, but DJK and DJF are relatively understudied. This study investigates the association between bone mineral density (BMD) and DJK/DJF via a systematic review and meta-analysis. A literature search was conducted across PubMed, Cochrane, Web of Science, Embase, and Scopus to find studies reporting DJK, DJF, and BMD. A 12-month minimum follow-up and radiographic biomarker for BMD (Hounsfield units [HU] or a T-score) individually reported for each patient type were required for inclusion. Studies that did not report individualized biomarkers but provided averaged estimates of the effect of BMD on DJK/DJF development were used for systematic review. Our search yielded 12 unique studies with 1094 patients, of which 5 studies with a total of 519 patients were suitable for comparison by meta-analysis. Patients who developed DJK/DJF had significantly lower HUs (113.17±33.86) than patients who did not develop DJK/DJF (142.51±41.39). No significant difference was found with regard to dual-energy X-ray absorptiometry measurements, age, or body mass index between patients who did and did not develop DJK/DJF. Patients who developed DJK/DJF had significantly lower computed tomography-measured HU as compared to those without DJK/DJF. Our findings highlight the potential importance of BMD evaluation with computed tomography prior to multilevel spine fusion surgery, though further research would be helpful to evaluate the significance of dual-energy X-ray absorptiometry-based BMD measurements on DJK/DJF development.

Relationship between diffuse idiopathic skeletal hyperostosis and lumbar paravertebral muscle fat infiltration: a CT-based retrospective study.

Plentiful evidence points to a significant correlation between paravertebral muscles and spinal diseases. Yet, no reports are available detailing the association between paravertebral muscle status and diffuse idiopathic skeletal hyperostosis (DISH). The purpose of this retrospective study was to assess the link between paravertebral muscle area as well as fat infiltration and DISH based on computer tomography. Data were obtained from patients with acute vertebral fractures who presented to a single spine center. All participants had whole spine lateral x-ray radiography for DISH diagnosis. Those with a history of spinal disease, fusion surgery, or tumors were excluded. Patients with or without DISH were propensity-matched by age, sex, and body mass index (BMI). Appropriate Mann-Whitney U-tests or independent t-tests were performed to evaluate the correlation between muscle area or fat infiltration of the L3 level paravertebral muscles and DISH. A total of 114 DISH and 114 non-DISH patients were assessed. The fat infiltration in the paravertebral muscles was remarkably higher in the DISH group than in the non-DISH (p < 0.05), whereas there was no statistical difference in the muscle area of the two (p > 0.05). In conclusion, the fat infiltration of the paravertebral muscles was significantly associated with DISH.

Trigeminal neuralgia as a presentation of high cervical stenosis: a systematic review of the literature.

An atypical presentation of cervical spondylopathy (CS), trigeminal neuralgia (TN) is attributable to the extension of trigeminal nuclei into the spinal cord and is frequently overlooked, leading to limited discussion with patients regarding potential anterior cervical surgery. Our systematic review assesses the effectiveness of cervical surgery for concurrent trigeminal neuralgia in cases of cervical spondylopathy. A systematic review exploring cases of trigeminal neuralgia related to cervical spondylopathy was conducted searching on PubMed, Scopus and Embase databases for article in English. The authors excluded literature reviews and paediatric studies. Abstracts from articles were initially screened, followed by a detailed review of full-text papers. We included studies that documented cases of trigeminal neuralgia unrelated to cranial pathologies in patients with cervical spondylopathy. Following the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) protocol, 6 studies were included covering 30 patients (20 male, 10 female) with a mean age of 60.75years and average symptom duration was 18months. The most affected branches were V2 (41%) and V3 (49%), evenly distributed between left and right sides (55% vs 45%). Motor weakness (60%) and paresthesia (27%) were common non-trigeminal symptoms. The predominant compression levels were C2-C3 (38%) and C3-C4 (34%). After anterior cervical surgery (30% of patients), 100% experienced immediate resolution of trigeminal neuralgia, with no recrudescence at an average 7-month follow-up. Besides common manifestations, high cervical stenosis can cause trigeminal neuralgia. This case report and systematic review confirms spinal decompression and fusion surgery may be effective in select cases. Surgeons should raise the possibility of cervical spine involvement when counseling patients with this disease.

Assessing equity in preventing central line-associated bloodstream infections and surgical site infections in pediatric patients.

Central line-associated bloodstream infections (CLABSIs) and surgical site infections (SSIs) are major healthcare-associated infections that can be prevented by consistently applying evidence-based infection prevention practices. To assess equity in preventing CLABSIs and SSIs in pediatric patients at a free-standing pediatric hospital, where evidence-based infection prevention practices are consistently implemented. This observational study evaluated 2 cohorts of pediatric patients under 18 years. The CLABSI cohort included inpatients with a central line between 1/1/2016 and 12/31/2022, and the SSI cohort included patients undergoing colon, ventricular shunt, or spinal fusion surgeries between 1/1/2016 and 10/31/2022. The CLABSI rate per 1000 central line days and SSI rate per 100 surgeries were compared across different racial, ethnic, and gender groups. In the CLABSI cohort of 8575 patients, encompassing 243,803 central line days, there were 156 CLABSIs. There was no statistical difference in CLABSI rate across race, ethnicity, and/or gender groups. The SSI cohort included 68 SSIs among 1710 patients who underwent 2230 procedures, including 714 colon, 749 ventricular shunt, and 767 spinal fusion procedures. The SSI rate was statistically higher in multiracial (9.9) and Asian (8.6) groups, compared to Caucasian (2.4) and Black (2.2) groups. A nested case-control study of the SSI cohort showed a higher SSI rate in Asians, compared to Caucasians (Odds Ratio: 3.3; 95% CI: 1.3-8.3). Equity in preventing CLABSIs is achievable through standardized central-line care. Further study is warranted to assess if improvement opportunities exist for achieving equity in preventing SSIs.

Posterior Decompression Surgery for Degenerative Lumbar Disease:Basic Principles and Advantages/Disadvantages of Exoscopic Surgery

This paper examines advancements in minimally invasive posterior decompression techniques for lumbar degenerative diseases. It focuses on the unilateral approach for bilateral decompression and bilateral approach for contralateral decompression, in which the entry side is determined independently of the symptomatic side to achieve a facet joint preservation rate of ≥ 70%, while also emphasizing contralateral foraminal decompression(CFD). These techniques address spinal instability by minimizing facet joint resection, reducing postoperative instability. CFD is noteworthy because it enables single-stage decompression in the same surgical field as foraminal stenosis, which frequently coexists with spinal canal stenosis. Additionally, this paper discusses the effectiveness of real-time 3D CT navigation in enhancing surgical precision, especially in complex cases, to improve long-term outcomes by minimizing postoperative instability. Furthermore, exoscopic surgery is evaluated as a future standard, highlighting its superior ergonomics and flexible viewing angles, including steep oblique angles, which are challenging with conventional microscopes. Although exoscopic technology offers many advantages, it also has certain drawbacks and remains in the developmental stage; however, it holds the potential to become a new paradigm in spinal surgery. Balancing minimally invasive approaches with spinal stability remains critical for optimizing patient recovery, reducing complications, and minimizing reliance on spinal fusion surgery.

Pre-Operative Anemia is an Unsuspecting Driver of Machine Learning Prediction of Adverse Outcomes after Lumbar Spinal Fusion.

Pre-operative risk assessment remains a challenge in spinal fusion operations. Predictive modeling provides data-driven estimates of post-surgical outcomes, guiding clinical decisions and improving patient care. Moreover, automated machine learning models are both effective and user-friendly, allowing healthcare professionals with minimal technical expertise to identify high-risk patients who may need additional pre-operative support. This study investigated the use of automated machine learning models to predict discharge disposition, length of hospital stay, and readmission post-surgery by analyzing pre-operative patient electronic medical record data and identifying key factors influencing adverse outcomes. Retrospective cohort study. The sample includes electronic medical records of 3,006 unique surgical events from 2,855 patients who underwent lumbar spinal fusion surgeries at a single institution. The adverse outcomes assessed were discharge disposition (non-home facility), length of hospital stay (extended stay), and readmission within 90 days post-surgery. We employed several inferential and predictive approaches, including the automated machine learning tool TPOT2 (Tree-based Pipeline Optimization Tool-2). TPOT2, which uses genetic programming to select optimal machine learning pipelines in a process inspired by molecular evolution, constructed, optimized and identified robust predictive models for all outcomes. Feature importance values were derived to identify major pre-operative predictive features driving optimal models. Adverse outcome rates were 25.9% for discharge to non-home facilities, 23.9% for extended hospital stay, and 24.7% for readmission within 90 days post-surgery. TPOT2 delivered the best-performing predictive models, achieving balanced accuracies ((Sensitivity [true positive rate] + Specificity [true negative rate)]) / 2) of 0.72 for discharge disposition, 0.72 for length of stay, and 0.67 for readmission. Notably, preoperative hemoglobin emerged as a consistently strong predictor in best-performing models across outcomes. Patients with severe anemia (hemoglobin <80g/dL) demonstrated higher associations with all adverse outcomes and common comorbidities associated with frailty (e.g., hypertension, type II diabetes, and chronic pain). Additional patient variables and comorbidities, including body mass index, age, and mental health status, influencing post-surgical outcomes were also highly predictive. This study demonstrates the effectiveness of automated machine learning in predicting post-surgical adverse outcomes and identifying key pre-operative predictors associated with such outcomes. While factors like age, BMI, insurance type, and specific comorbidities showed notable effects on outcomes, preoperative hemoglobin consistently emerged as a significant predictor across outcomes, suggesting its critical role in pre-surgical assessment. These findings underscore the potential of enhancing patient care and preoperative assessment through advanced predictive modeling.

Maintenance of intraoperative correction with multi-rod constructs in adult long construct spine fusion surgery.

The purpose of this study was to evaluate the risk factors for loss of intraoperative correction, as measured by lumbar lordosis (LL), with an emphasis on rod characteristics. A retrospective study identified patients at least 50 years of age who underwent instrumented fusion with an upper instrumented vertebrae (UIV) in the upper thoracic spine (T1-T6) or thoracolumbar junction (T10-L2) to the pelvis. Inclusion criteria included intraoperative x-rays that allowed for LL measurement, postop standing x-rays, and a minimum follow up of 24 months with the original rods still in place. One hundred and twelve patients (69 % women) were included with an average (SD) follow up of 58 months (29). Twenty-two patients (20 %) had a 10° change in LL from intraoperative to postoperative, and risk factors included a two-rod compared to multi rod (>2) construct (23 % vs 0 %, p = 0.04), male sex (34 % vs 13 %, p = 0.02), UIV near the thoracolumbar junction (28 % vs 8 %, p = 0.02), and higher L4-S1 intraoperative lordosis (41° vs 36°, p = 0.024). Forty-one patients (37 %) had a 10° change in LL at two years, and risk factors included male sex (60 % vs 26 %, p < 0.001) and a UIV near the thoracolumbar junction (48 % vs 21 %, p = 0.003). Risk factors for loss of LL between intraoperative and postoperative alignment include two-rod constructs, male sex, lower UIV, and greater intraoperative LL. Multi-rod (3 +) constructs may be a modifiable surgical technique that better maintains the spinal alignment that was achieved in the operating room.

Cost-Effectiveness Analyses of Bone Morphogenetic Protein 2 (rhBMP-2) in Spinal Fusion: A Systematic Review.

Systematic Review Study. The objective of this study is to assess the cost-effectiveness and cost-utility of rhBMP-2 in spine surgeries. PubMed, MEDLINE, OVID and CENTRAL (Cochrane Central Register of Controlled Trials) databases were systematically searched for studies reporting the use of rhBMP-2 for spinal procedures in comparison to autograft and/or allograft and alternative graft materials under consideration of cost-effectiveness, cost-benefit, cost minimization, and/or cost-utility analysis. Relevant data points were extracted and compiled. The standardization of the selected studies was graded using the CHEERS criteria. Of the 88 eligible publications, 17 met the inclusion criteria. Overall, 8 studies showed a favorable cost-analysis profile. Three studies performed cost-consequence analyses, none of which reported positive findings. Among 7 cost-utility analyses and 7 cost-effectiveness analyses, 3 and 5, respectively, reported a likely benefit to the usage of rhBMP-2. The CHEERS scores for the included studies ranged from 15 to 23 out of 24 points, with a median score of 19. There is no consensus regarding the cost-effectiveness or cost-utility of rhBMP-2 in spinal fusion. rhBMP-2 may function as a cost-effective adjunct in spinal fusion surgeries in select cases.

State-of-the-Art Review: Diagnosis and Management of Spinal Implant Infections.

Spinal implant infections are a serious complications of instrumented spinal fusion surgeries, carrying high morbidity and complex management challenges. Early postoperative infections may manifest with wound-healing issues, back pain, and fevers. Magnetic resonance imaging (MRI) is the preferred imaging modality, but can be limited by metal artifacts. For cases with stable implants, surgical debridement with implant retention combined with at least 12 weeks of antibiotics is currently considered appropriate treatment. Staphylococcal infections are ideally treated with biofilm-active antibiotics. Suppressive antibiotic therapy can be considered when surgical debridement has been delayed or is incomplete, and for those who are poor surgical candidates for another surgery. Chronic infections may present insidiously with implant failure or pseudarthrosis; implant removal or revision is generally pursued. As current guidance is heavily based on the periprosthetic joint infection literature and low-level studies on spinal implant infections, further research on optimizing diagnostic and treatment approaches is needed.

The Potential Elimination of Blood Transfusions in Lumbar Spine Fusion Surgery: Clinical Case Series of 620 Consecutive Minimally Invasive TLIF Surgeries and Review of the Literature

Background Lumbar spine fusion is one of the most common surgical procedures performed in the operative management of adult degenerative spine disorders. The dual incision, mini-open TLIF surgery uses a minimally invasive surgical technique that decompresses neural elements through placement of an anterior interbody disc spacer and posterior stabilization with pedicle screws. It is well established that this approach results in significantly less muscle dissection than the open technique used in conventional TLIF, however a quantitative assessment of the need for blood transfusions during this procedure has been limited to relatively small case series. The aim of this study was to assess the incidence of blood transfusion amongst a large group of patients undergoing a mini-open dual incision TLIF procedure over an extended amount of time. A retrospective study was completed of 620 consecutive patients surgically treated with the Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF) procedure, the largest such study completed by a single surgeon at multiple institutions from 2004 to 2020. Methods The study sample comprises 620 patients who underwent a mini-open TLIF procedure through a dual incision technique for treatment of lumbar degenerative diseases from January 2004 to October 2020. No patients who underwent the procedure were excluded from the series. Surgical and medical record review was conducted to determine whether patients required blood transfusions during their hospitalization. No patients were lost to three-month follow up. Results The study group consisted of 620 patients, 332 women and 288 men. Ages ranged from 20 to 88 years old with a mean age of 54 years. No patients in the series required a blood transfusion during their surgery, hospitalization, or 3-month postoperative period. Conclusions The dual incision MIS Mini-open transforaminal lumbar interbody fusion allows for decompression of neural elements, pedicle screw instrumentation, and placement of an anterior interbody cage while potentially eliminating the need for blood transfusions. While previous studies have shown the potential for reduced blood loss with the mini-open technique compared to the open technique, this study adds a significant volume of data-driven evidence to support this conclusion. As such, this study represents the largest single-surgeon case series to show consistent absence of blood transfusions with a mini-open TLIF technique over sixteen years.

Multimodal prehabilitation combined with perioperative enhanced recovery after surgery care for older patients undergoing spinal fusion surgery in China: protocol for a multicentre randomised controlled trial (PRACTICE trial)

IntroductionBesides the comorbid risk factors shared by older and younger patients, older individuals may also experience malnutrition, as well as cognitive or functional impairments. The accumulation of frailty and various...