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OBJECTIVE: Anterior approaches to the lumbar spine have been used extensively for various indications but they are also associated with unique complications and have been linked with higher incisional morbidity.This study aimsto evaluate incisional morbidity related to anterior lumbar surgeries and to assess how incisional outcomes correlate with patient and surgery-related factors. METHODS: Patients ≥18 years old and with planned anterior lumbar fusions from L1 to S1 were prospectively enrolled. Follow-up ended at two years, and patients who did not complete the follow-up were excluded. Incision was assessed for general appearance, width, color, cross-hatching, hypertrophy, and pain by using a validated scoring system and a visual analog scale (VAS). Patient and surgery-related factors were analyzed for possible correlations with complications or wound-related parameters. RESULTS: A total of 205 patients with a mean age of 54.4 ± 11.5 were included. Significant improvements were seen in color, hypertrophy, pain, and appearance of the incision. At two years, the mean patient-based VAS for appearance was 8.6 while surgeon-based VAS was 8.8. The total rate of complications was 9%, with no incisional hernia or bulging. No significant relation was found between incision-related parameters and the demographic and surgical variables. CONCLUSION: This study reports acceptable cosmetic results and no chronic pain after anterior lumbar surgery, which is contrary to previous reports. Together with a low total rate of complications, anterior approaches are safe when carefully executed, and have low morbidity.
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STUDY DESIGN: Diagnostic accuracy study. OBJECTIVE: To establish a simple method of phantomless bone mineral density (BMD) measurement by using preoperative lumbar Computed Tomography (CT) scans, and compare the accuracy of reference tissue combinations to diagnose low BMD against uncalibrated Hounsfield units (HUs). SUMMARY OF BACKGROUND DATA: HUs are used as a measure of BMD; however, associations between HU and T-scores vary widely. Quantitative CT (qCT) scans are more accurate, but they require density calibration with an object of known density (phantom), which limits feasibility. As an emerging technique, phantomless (internal) calibration of routine CT scans may provide a good opportunity for screening. METHODS: Patients who were scheduled to undergo lumbar surgery, with a preoperative CT scan, and a dual-energy x-ray absorptiometry (DXA) scan within six months were included. Four tissues were selected for calibration: subcutaneous adipose (A), erector spinae (ES), psoas (P) and aortic blood (AB). The HUs of these tissues were used in linear regression against ground-truth values. Calibrations were performed by using two different internal tissues at a time to maintain simplicity and in-office applicability.Volumetric bone mineral densities (vBMD) derived from internally calibrated CT scans were analyzed for new threshold values for low bone density. Areas under the curve (AUC) were calculated with 95% confidence intervals (CI). RESULTS: 45 patients were included (M/F=10/35, mean age:63.3). Calibrated vBMDs had stronger correlations with DXA T-scores when compared with HUs, with L2 exhibiting the highest coefficients. Calibration by using A and ES with the threshold of 162 mg/cm3 had a sensitivity of 90% in detecting low BMD (AUC=0.671). CONCLUSIONS: This novel method allows simple, in-office calibration of routine preoperative CT scans without the use of a phantom. Calibration using adipose and erector spinae with a threshold of 162 mg/cm3 is proposed for low bone density screening with high sensitivity (90%). LEVEL OF EVIDENCE: Level III.
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STUDY DESIGN: Retrospective review. OBJECTIVES: To determine if change in position of upper instrumented vertebral (UIV) screw between intraoperative prone and immediate postoperative standing radiographs is a predictor for proximal junctional kyphosis or failure (PJK/PJF). SUMMARY OF BACKGROUND DATA: Cranially directed UIV screws on post-operative radiographs have been found to be associated with PJK. Change in the screw position between intraoperative and immediate postoperative radiographs has not been studied. METHODS: Patients with posterior fusion ≥3 levels and UIV at or distal to T8, and minimum 2-year follow-up were identified from a single center database. Primary outcomes were radiographic PJK/PJF or revision for PJK/PJF. Demographic, surgical and radiographic variables, including intraoperative screw-vertebra (S-V) angle, change in S-V angle, direction of UIV screw (cranial-neutral-caudal) and rod-vertebra (R-V) angle were collected. RESULTS: 143 cases from 110 patients were included with a mean age of 62.9 years and a follow-up of 3.5 years. 54 (38%) cases developed PJK/PJF, of whom 30 required a revision. Mean S-V angle was -0.9°±5.5° intraoperative and -2.8°±5.5° postoperative. The group with PJK/PJF had a mean S-V angle change of -2.5°±2.4 while the rest had a change of -1.0°±1.6 (P=0.010). When the change in S-V angle was <5°, 33% developed PJK, this increased to 80% when it was ≥5° (P=0.001). Revision for PJK/PJF increased from 16% to 60% when S-V angle changed ≥5° (P=0.001). Regression analysis showed S-V angle change as a significant risk factor for PJK/PJF (P=0.047, OR=1.58) and for revision due to PJK/PJF (P=0.009, OR=2.21). CONCLUSIONS: Change in the S-V angle from intraop prone to immediate postop standing radiograph is a strong predictor for PJK/PJF and for revision. For each degree of S-V angle change, odds of revision for PJK/PJF increases by 2.2x. A change of 5° should alert the surgeon to the likely development of PJK/PJF requiring revision.
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STUDY DESIGN: Case-control study. OBJECTIVE: To introduce a classification system that will include the major types of degenerative changes and failures related to the proximal junction, and to determine the clinical course and characteristics for the different types of proximal junctional degeneration (PJD). SUMMARY OF BACKGROUND DATA: Proximal junctional kyphosis (PJK) and failures are well recognized after adult spinal fusion, however, a standardized classification is lacking. METHODS: The proposed system identified four different patterns of PJD: Type 1 (multi-level symmetrical collapse), Type 2 (Single adjacent level collapse), Type 3 (fracture) and Type 4 (spondylolisthesis). A single center database was reviewed from 2018 to 2021. Patients ≥18 years of age, who underwent posterior spinal fusion of ≥3 levels with an upper instrumented vertebral level between T8-L2, and a follow-up of ≥2 years were included. Radiographic measurements, revision surgery and time to revision were the primary outcomes. RESULTS: 150 patients were included with a mean age of 65.1 (±9.8) years and a mean follow-up of 3.2 (±1) years. 69 patients (46%) developed significant degenerative changes in the proximal junction, and were classified accordingly. 20 (13%) were Type 1, 17 (11%) were Type 2, 22 (15%) were Type 3 and 10 (7%) were Type 4. Type 3 had a significantly shorter time to revision with a mean of 0.9 (±0.9) years. Types 3 and 4 had greater preoperative sagittal vertical axis, and Types 1 and 3 had greater final follow-up lumbar lordosis. Bone density measured by Hounsfield units showed lower measurements for Type 3. Types 1 and 4 had lower rates of developing PJK. Type 1 had the lowest revision rate with 40% (types 2, 3 and 4 were 77%, 73% and 80%, respectively, P=0.045). CONCLUSION: This novel classification system defines different modes of degeneration and failures at the proximal junction, and future studies with larger sample sizes are needed for validation. LEVEL OF EVIDENCE: 3.
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OBJECTIVE: Hounsfield unit (HU) measurements of bone density on CT are increasingly used for preoperative planning in spine surgery. Postmyelogram CT is another common preoperative diagnostic study. However, there is no current literature evaluating whether HU measurements on CT are affected by the presence of myelography dye. The purpose of the current study was to determine if the presence of myelography dye affects HU measurements of bone density in CT studies. METHODS: Twenty-nine preoperative spine surgery patients who underwent both standard and postmyelography CT performed within 6 months of each other were identified. HU measurements were obtained from an elliptical region of interest using the available software on a standard PACS. Measurements were obtained on the axial cut at the midvertebral body on all lumbar vertebrae on three separate occasions and an average value was calculated for comparative analysis. A 6-week gap was used between measurements of the CT scans and the CT myelograms to diminish bias. RESULTS: The mean age of the cohort was 69 years and the average BMI was 32 kg/m2. Five patients were male and 24 were female. Six of the patients had instrumentation placed prior to the initial CT scan. The average HU measurements for CT levels L1-5 were 165, 171, 145, 154, and 225, respectively, whereas HU measurements for CT myelography of levels L1-5 were 168, 177, 148, 170, and 239, respectively. Strong correlations were noted between the HU measured on CT and CT myelography for L1 (r2 = 0.951), L2 (r2 = 0.966), L4 (r2 = 0.820), and L5 (r2 = 0.900), and moderate for L3 (r2 = 0.668). CONCLUSIONS: The presence of myelography dye had no clear effect on CT HU measurements of bone density. The results of this study support the use of CT myelograms for bone density assessment in the absence of standard CT images.
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Densidade Óssea , Osteoporose , Humanos , Masculino , Feminino , Idoso , Absorciometria de Fóton/métodos , Tomografia Computadorizada por Raios X/métodos , Vértebras Lombares/diagnóstico por imagem , Mielografia , Estudos RetrospectivosRESUMO
STUDY DESIGN: Retrospective chart review. OBJECTIVE: To provide reference values for Hounsfield unit (HU) measured on computed tomography (CT) scans of children and adolescents. SUMMARY OF BACKGROUND DATA: Spine surgeons increasingly use HU on spine CT as a measure of bone mineral density (BMD). This has not been described in children and adolescents. PATIENTS AND METHODS: Pediatric patients who had a spine CT between 2012 and 2022 were identified. Patients who had more than 1 comorbidity or were syndromic were excluded. Using the bone window, 3 axial images (cephalad, middle, and caudal) of each vertebra were selected. In each axial view, the HU was measured using a "region of interest" (ROI) that included the total cancellous bone area and an ROI excluding the radiolucency present in the posterior vertebral body ("total" vs . "limited"). HU values were compared between total and limited areas and between the axial images at the cephalad, middle, and caudal levels. Each age category data were estimated and stratified. RESULTS: A total of 144 patients (79 females and 65 males) from 2 to 17 years old were included. Mean limited HU was consistently lower than total HU across all images and lumbar levels except for L1. Limited HU taken mid-vertebral body was also consistently lower than those taken cephalad or caudad. Mean limited HU across all ages including all levels was 227 ± 50 (range: 109-357). Stratifying by age showed a gradual decrease in BMD from age 2 to 10 followed by an increase. CONCLUSIONS: This is the first study to measure HU on lumbar CTs in children and adolescents. The technique of measuring BMD in adults should be modified in children by using an ROI that excludes the rarefaction present in the posterior vertebral body. Further studies are needed to evaluate the age-dependent changes in BMD seen in this study.
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Densidade Óssea , Osteoporose , Adulto , Masculino , Feminino , Humanos , Adolescente , Criança , Pré-Escolar , Estudos Retrospectivos , Vértebras Lombares , Tomografia Computadorizada por Raios X/métodos , Absorciometria de Fóton/métodosRESUMO
STUDY DESIGN: Retrospective cross-sectional. OBJECTIVES: To determine associations between Hounsfield Units (HU) within a Region of interest (ROI) on CT scans and Dual Energy X-ray Absorptiometry (DEXA) measurements in children and adolescents. SUMMARY OF BACKGROUND DATA: HU on CT scans as a proxy for bone mineral density (BMD) is widely used in adults. However, the utility of CT as a proxy for BMD have not been evaluated in children and adolescents. METHODS: Patients younger than 18 years with a lumbar spine CT scan and a DEXA within 6 months of each other were identified. A ROI was used to measure the HU at each lumbar vertebral body on mid-axial cuts. Charts were reviewed for demographics, medical co-morbidities and DEXA reports. Correlation coefficients were calculated between mean DEXA Z-score and HU value. Patients were also stratified by Z-score (≥ -1.0, between -1.0 and -2.0, and ≤-2.0) and matched by age and BMI to a cohort of healthy children and compared. RESULTS: A moderate correlation between mean DEXA Z-score and mean HU on CT was found (r2=0.42, P<0.001). After matching for age and BMI, 21 patients in each group between the age of 4 and 17 years were analyzed. The mean HU value of the control group was 231.69. When stratified by Z-score (≥ -1.0, between -1.0 and -2.0, and ≤-2.0), the mean HU values were 244.59, 216.50, and 176.54, respectively. Patients with a Z-score of ≤-2.0 had a significantly lower mean HU than age matched controls. CONCLUSIONS: HU on lumbar CT in children and adolescents with DEXA Z-scores less than -2.0, were lower when compared to healthy age and BMI matched controls. This study suggests that HU on opportunistic CT scans of the spine may be used as a reasonable proxy for BMD in the pediatric population.
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STUDY DESIGN: A retrospective chart review. OBJECTIVE: The objective of this study is to investigate whether direct pars repair achieves bone healing and symptom relief in patients with spondylolitic spondylolisthesis. SUMMARY OF BACKGROUND DATA: While most cases of spondylolysis can be managed non-operatively, a small percentage of patients require surgical intervention. The outcome of direct pars repair via a standard pedicle-screw with wiring technique is controversial in patients with lumbar spondylolitic spondylolisthesis. METHODS: Medical records of patients who had undergone an open surgical pars repair were retrospectively reviewed. Standard demographic and surgical parameters were collected. All patients underwent a primary repair of the pars with autograft or bone morphogenetic protein and instrumentation using a pedicle-screw with spinous process wiring. At 6-12 months after surgery, patient's pain symptoms and postoperative CT scans were independently reviewed to assess healing; graded as non-union, partial union, or solid union. RESULTS: There were 68 patients identified (33 male and 35 female) with an average age of 18.6 years. Mean estimated blood loss was 139 ml, and mean length of hospital stay was 3.7 days. CT evaluation revealed 35 (52%) solid unions, 21 (31%) partial unions, and 12 (18%) non-unions requiring revisions. Thirty-four (50%) patients had no postop pain, 24 (35%) had mild pain, 10 (15%) had persistent pain. The majority of patients with non-unions on CT had mild or persistent pain. Patients with no or mild pain tended to be younger than those with persistent pain (17.5 years vs 24.6 years, P=0.163). CONCLUSION: This study demonstrated a partial or complete union rate of 82% and a postoperative persistent pain rate of 15%. These figures are comparable to the previous study and this pedicle-screw with wiring technique can be worth trying before interbody fusion for spondylolytic spondylolisthesis to preserve anatomical lumbar motion.
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Adult spinal deformity (ASD) is common and the complication rate in ASD surgery is high due to its invasiveness. There are several factors that increase the risk of complications with ASD surgery. These include age, past medical history, frailty, osteoporosis, or operative invasiveness. Risk factors for perioperative complications can be categorized as modifiable and non-modifiable. The purpose of this article is to present the current available evidence on risk factors for perioperative complications, with a focus on frailty, osteoporosis, surgical site infection prevention, and hip-spine syndrome. In addition, we present the latest evidence for patient-specific surgical risk assessment and surgical planning.
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Fragilidade , Osteoporose , Adulto , Humanos , Fatores de Risco , Medição de Risco , Procedimentos NeurocirúrgicosRESUMO
There are a range of anterior-based approaches to address flexible adult spinal deformity from the thoracic spine to the sacrum, with each approach offering access to a range of vertebral levels. It includes the transperitoneal (L5-S1), paramedian anterior retroperitoneal (L3-S1), oblique retroperitoneal (L1-2 to L5-S1), the thoracolumbar transdiaphragmatic approach (T9-10 to L4-5), and thoracotomy approach (T4-T12). The lumbar and lumbosacral spine is especially favorable for anterior-based approaches given the relative mobility of the peritoneal organs and position of the vasculature.
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Região Lombossacral , Pelve , Adulto , Humanos , Região Sacrococcígea , SacroRESUMO
Background: Patients with a pseudarthrosis after anterior cervical discectomy and fusion (ACDF) may have concurrent adjacent segment disease (ASD). Although prior studies have shown posterior cervical decompression and fusion (PCDF) is effective in repairing pseudarthrosis, improvement in patient reported outcomes (PROs) has been marginal. The aim of this study is to evaluate the effectiveness of PCDF in achieving symptom relief in patients with pseudarthrosis after ACDF and whether that is altered by the additional treatment of ASD. Methods: Thirty-two patients with pseudarthrosis were compared with 31 patients with pseudarthrosis and concurrent ASD after ACDF who underwent revision PCDF with a minimum 1-year follow-up. Primary outcomes measures included the neck disability index (NDI), and numerical rating scale (NRS) scores for neck and arm pain. Secondary measures included estimated blood loss (EBL), operating room (OR) time, and length of stay. Results: Demographics between cohorts were similar, however there was a significantly higher mean body mass index (BMI) in the group with concurrent ASD (32.23 vs. 27.76, p=.007). Patients with concurrent ASD had more levels fused during PCDF (3.7 vs. 1.9, p<.001), greater EBL (165 cc vs. 106 cc, p=.054), and longer OR time (256 minutes vs. 202 minutes, p<.000). Preoperative PROs for NDI (56.7 vs. 56.5, p=.954), NRS arm pain (5.9 vs. 5.7, p=.758), and NRS neck pain (6.6 vs. 6.8, p=.726) were similar in both cohorts. At 12 months patients with concurrent ASD experienced a slightly greater, but not statistically significant, improvement in PROs (Δ NDI 4.40 vs. -1.44, Δ NRS neck pain 1.17 vs. 0.42, Δ NRS arm pain 1.28 vs. 0.10, p=.107). Conclusions: PCDF is a standard procedure for treatment of pseudarthrosis following ACDF, however improvements in PROs are marginal. Slightly greater improvements were seen in patients whose indication for surgery also included concurrent ASD, rather than a diagnosis of pseudarthrosis alone.
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Background: Novel methods of bone density assessment using computed tomography (CT) and magnetic resonance imaging (MRI) have been increasingly reported in the spine surgery literature. Correlations between these newer measurements and traditional Dual-Energy X-ray Absorptiometry (DEXA) is not well known. The purpose of this study is to perform an updated systematic review of correlations between bone mineral density (BMD) from CT or MRI and DEXA. Methods: Articles published between 2011 and 2021 that reported correlations between the CT-HU or MRI measurements to DEXA t-scores or BMD of lumbar spine or hip were included in this systematic review. Results: A total of 25 studies (15 CT, 10 MRI) met the inclusion criteria with a total number of 2,745 patients. The pooled correlation coefficient of spine CT-HU versus spine DEXA, spine CT-HU versus hip DEXA and spine CT-HU versus lowest t-score were 0.60, 0.50 and 0.60 respectively. Regarding spine DEXA parameters, the pooled r2 for spine CT-HU versus spine t-score was 0.684 and spine CT-HU versus spine BMD was 0.598. Furthermore, in patients undergoing spine surgery in four studies, the pooled correlation between spine CT and spine DEXA was (r2: 0.64). In MRI studies, the pooled r2 of spine MRI versus spine DEXA and spine MRI versus hip DEXA were -0.41 and -0.44 respectively. Conclusions: CT-HU has stronger correlations with DEXA than MRI measurements. Lumbar CT-HU has the highest pooled correlation (r2â¯=â¯0.6) with both spine DEXA and lowest skeletal t-score followed by lumbar CT-HU with hip DEXA (r2â¯=â¯0.5) and lumbar MRI with hip (r2â¯=â¯0.44) and spine (r2â¯=â¯0.41) DEXA. Both imaging modalities achieved only a moderate correlation with DEXA. Few studies in both modalities have investigated the correlation in spine surgery populations and the available data shows that the correlations are worse in the degenerative spine population. A careful interruption of CT HU and MRI measurement when evaluation of BMD as they only moderately correlated with DEXA scores. At this time, it is unclear which modality is a better predictor of mechanical complications and clinical outcomes in spine surgery patients.
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STUDY DESIGN: Delphi method. OBJECTIVE: To gain consensus on the following questions: (1) When should anticoagulation/antiplatelet (AC/AP) medication be stopped before elective spine surgery?; (2) When should AC/AP medication be restarted after elective spine surgery?; (3) When, how, and in whom should venous thromboembolism (VTE) chemoprophylaxis be started after elective spinal surgery? SUMMARY OF BACKGROUND DATA: VTE can lead to significant morbidity after adult spine surgery, yet postoperative VTE prophylaxis practices vary considerably. The management of preoperative AC/AP medication is similarly heterogeneous. MATERIALS AND METHODS: Delphi method of consensus development consisting of three rounds (January 26, 2021, to June 21, 2021). RESULTS: Twenty-one spine surgeons were invited, and 20 surgeons completed all rounds of questioning. Consensus (>70% agreement) was achieved in 26/27 items. Group consensus stated that preoperative Direct Oral Anticoagulants should be stopped two days before surgery, warfarin stopped five days before surgery, and all remaining AC/AP medication and aspirin should be stopped seven days before surgery. For restarting AC/AP medication postoperatively, consensus was achieved for low-risk/medium-risk/high-risk patients in 5/5 risk factors (VTE history/cardiac/ambulation status/anterior approach/operation). The low/medium/high thresholds were POD7/POD5/POD2, respectively. For VTE chemoprophylaxis, consensus was achieved for low-risk/medium-risk/high-risk patients in 12/13 risk factors (age/BMI/VTE history/cardiac/cancer/hormone therapy/operation/anterior approach/staged separate days/staged same days/operative time/transfusion). The one area that did not gain consensus was same-day staged surgery. The low-threshold/medium-threshold/high-threshold ranges were postoperative day 5 (POD5) or none/POD3-4/POD1-2, respectively. Additional VTE chemoprophylaxis considerations that gained consensus were POD1 defined as the morning after surgery regardless of operating finishing time, enoxaparin as the medication of choice, and standardized, rather than weight-based, dose given once per day. CONCLUSIONS: In the first known Delphi study to address anticoagulation/antiplatelet recommendations for elective spine surgery (preoperatively and postoperatively); our Delphi consensus recommendations from 20 spine surgeons achieved consensus on 26/27 items. These results will potentially help standardize the management of preoperative AC/AP medication and VTE chemoprophylaxis after adult elective spine surgery.
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Tromboembolia Venosa , Adulto , Humanos , Tromboembolia Venosa/etiologia , Complicações Pós-Operatórias/etiologia , Anticoagulantes/uso terapêutico , Coluna Vertebral/cirurgia , Inibidores da Agregação Plaquetária , Fatores de RiscoRESUMO
STUDY DESIGN: A retrospective study. OBJECTIVES: Curve flexibility in patients with adolescent idiopathic scoliosis (AIS) can be evaluated using different techniques. This study aimed to determine whether the combination of side-bending (SB) and traction (TX) radiographs influences preoperative planning for AIS than either radiograph alone. METHODS: Thirty-two spine surgeons were asked to review 30 AIS Lenke type 1 cases and select an upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) for the posterior spinal instrumentation of each case. Each rater reviewed the cases 3 times in each round. The raters were provided with the full-length posteroanterior (PA) and lateral standing and SB radiographs for round 1; PA, lateral, and TX radiographs for round 2; and PA, lateral, SB, and TX radiographs for round 3. Intra- and inter-rater reliabilities were evaluated using Kappa statistics. RESULTS: The intra-rater reliability for UIV and LIV was 0.657 and 0.612 between rounds 1 and 2, 0.634 and 0.692 between rounds 1 and 3, and 0.659 and 0.638 between rounds 2 and 3, respectively, which indicated substantial agreement between rounds. The inter-rater kappa reliabilities for UIV and LIV selection were 0.103 and 0.412 for round 1, 0.121 and 0.380 for round 2, and 0.125 and 0.368 for round 3, indicating slight to moderate agreement between raters. CONCLUSIONS: Whether raters used either SB or TX radiography, or both in addition to PA and lateral standing radiographs, did not influence the decision making for UIV or LIV of AIS Lenke type 1 surgery.
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The use of anterior spinal surgery for the treatment of spinal pathology has experienced a dramatic increase over the past decade. Long relegated to treat complicated anterior pathologies it has returned to mainstream spine surgery techniques for all types of conditions, providing a significant boost to the spine surgeons' armamentarium to address a wide variety of types of spinal diseases more effectively. Anterior surgery is useful whenever there is significant spinal pathology that requires direct visualization of the anterior vertebral column to best restore spinal alignment, structural integrity and neurologic function. These pathologies include spinal deformities, tumors, burst fractures, infections, vertebral avascular necrosis, pseudoarthrosis and other miscellaneous indications. Currently available approaches to the spine include transabdominal, paramedian retroperitoneal, lateral oblique retroperitoneal, thoracotomy, and thoracolumbar extensile. Most of the lumbar approaches are now done through a muscle splitting, minimalistic approach that has decreased their morbidity or more recently via tubular approaches, such as lateral lumbar interbody fusions or other ante-psoas approaches. New retractors, instrumentation, hyperlordotic implants, approved biologics and even image guidance for disc preparation and precise implant placement are all recent advances that will hopefully improve surgical outcomes in patients following anterior spinal surgery. Most importantly, these approaches require added expertise and training with a dedicated team consisting of an anteriorly trained spine surgeon working simultaneously with a dedicated vascular surgeon to ensure maximum safety and superior patient outcomes. This state of the review is dedicated to familiarizing practicing spine surgeons with the most commonly used anterior spinal approaches along with cutting-edge instrumentation and fusion techniques to improve their options for the treatment of difficult spinal pathologies.
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Pseudoartrose , Doenças da Coluna Vertebral , Fusão Vertebral , Humanos , Vértebras Lombares/cirurgia , Pseudoartrose/etiologia , Espaço Retroperitoneal/cirurgia , Doenças da Coluna Vertebral/etiologia , Doenças da Coluna Vertebral/cirurgia , Fusão Vertebral/métodosRESUMO
BACKGROUND CONTEXT: Computed tomography (CT) measurement of Hounsfield Units (HU) has been described as a tool for assessing BMD. For surgeons considering a revision lumbar fusion, knowledge of the BMD of the UIV is of value for surgical planning. However, the presence of metal artifact from instrumentation presents a potential confounder, and prior studies have not validated measurements of HU in this setting. PURPOSE: To determine if HU can be measured reliably at the supra-adjacent and upper instrumented levels of a lumbar fusion. STUDY DESIGN: Retrospective observational cohort PATIENT SAMPLE: Consecutive series of patients who had lumbar CT scans after an instrumented posterior lumbar fusion. OUTCOME MEASURES: Hounsfield Units at the upper instrumented vertebra and levels proximal. METHODS: We analysed pre- and postoperative CT scans of 50 patients who underwent L2 and distal instrumented lumbar fusion whose scans were no greater than 1 year apart, obtaining HU measurements of analogous axial cuts at the upper instrumented level (immediately caudal to the halo of the pedicle screw), as well as additional control levels above the construct. RESULTS: The HU at the pre-and postoperative UIV exhibited a strong correlation (r=0.917, p<.001), as did one (r=0.887, p<.001) and two (r=0.853, p<.001) levels above the UIV. There were significant but predictable reductions in the postoperative HU compared to preoperative at one (-9.0±26.2) and two (-12.2±30.2) levels above the UIV, as well as T12 (-13.9±42.2). There was no significant difference in HU at the UIV (4.6±34.1). CONCLUSIONS: Postoperative HU at the UIV was strongly correlated with and not significantly different from the preoperative HU. Although the HU in the vertebrae proximal to the UIV were slightly lower postoperatively, this change was predictable using a correction factor.
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Fusão Vertebral , Densidade Óssea , Humanos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Estudos Retrospectivos , Fusão Vertebral/métodos , Vértebras Torácicas/cirurgia , Tomografia Computadorizada por Raios X/métodosRESUMO
STUDY DESIGN: Expert consensus study. OBJECTIVE: This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to elective spinal reconstruction. SUMMARY OF BACKGROUND DATA: Currently, no guidelines exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. Untreated osteoporosis in spine reconstruction surgery is associated with higher complications and worse outcomes. METHODS: A multidisciplinary panel with 18 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Surveys and discussions regarding the current literature were held according to Delphi method until a final set of guidelines was created with over 70% consensus. RESULTS: Panelists agreed that bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic glucocorticoid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are considered first line therapy due to their bone building properties as compared with antiresorptive medications. Medications should be administered preoperatively for at least 2âmonths and postoperatively for minimum 8âmonths. CONCLUSION: Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also established guidelines on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population.Level of Evidence: 5.
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Conservadores da Densidade Óssea , Fraturas Ósseas , Osteoporose , Absorciometria de Fóton , Adulto , Idoso , Densidade Óssea , Humanos , Osteoporose/diagnóstico por imagem , Coluna Vertebral/diagnóstico por imagem , Coluna Vertebral/cirurgiaRESUMO
Symptomatic postoperative epidural hematomas are rare, with an incidence of 0.10% to 0.69%. Risk factors have varied in the literature, but multiple studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors for hematoma. The role of pharmacologic anticoagulation after spine surgery remains unclear, but multiple studies suggest it can be done safely with a low risk of epidural hematoma. Prophylactic suction drains have not been found to lower hematoma incidence. Most symptomatic postoperative epidural hematomas present within the first 24 to 48 hours after surgery but can present later. Diagnosis of a symptomatic hematoma requires correlation of clinical signs and symptoms with a compressive hematoma on MRI. Patients will usually first complain of a marked increase in axial pain, followed by radicular symptoms in the extremities, followed by motor weakness and sphincter dysfunction. An MRI should be obtained emergently, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation.
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Hematoma Epidural Espinal/etiologia , Complicações Pós-Operatórias/etiologia , Doenças da Coluna Vertebral/cirurgia , Hematoma Epidural Espinal/diagnóstico , Hematoma Epidural Espinal/terapia , Humanos , Incidência , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Fatores de RiscoRESUMO
BACKGROUND CONTEXT: Excessive use of postoperative imaging after lumbar surgery has been documented, becoming a target for cutting costs. This must be balanced with the patient's need for information and allay their postoperative concerns. PURPOSE: To determine the incidence and associated costs of patient interactions with the healthcare system, outside the standard follow up routine, in the first postoperative year. STUDY DESIGN: Retrospective longitudinal cohort. PATIENT SAMPLE: Consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 from a multi-surgeon single tertiary spine center. OUTCOME MEASURES: All healthcare encounters: phone calls, office and emergency department visits, and additional testing METHODS: A consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 were identified. All non-routine healthcare encounters: phone calls, office and emergency department visits, and additional testing were collected. Direct costs for all healthcare services were determined using the Medicare Allowable rates. Indirect costs were determined using local, median income, length of office visits, and distance from the clinic to the patient's home. RESULTS: Of 200 patients, 14 with thoracic fusion were excluded. The mean age of the 186 included patients was 58.26 years and 85 (46%) were male. Forty-seven percent (87/186) had only routine postoperative visits and 24 had revision surgery. Seventy-five patients made a total of 102 phone calls, 55 office visits, leading to 38 diagnostic studies none of which led to an additional intervention. Using Medicare Allowable rates, the mean direct cost was $776 per patient and the using a median income of $16/h the mean indirect cost was $124 per patient. There were no differences in the baseline characteristics among the patients who only had routine post-op encounters, had non-routine encounters or had a repeat surgery. CONCLUSIONS: Forty percent of the patients undergoing lumbar surgery had a healthcare encounter outside their routine follow up that did not result in additional intervention after their index operation. These potentially unnecessary encounters create additional cost and inconvenience to both the patient and healthcare system. Providing patient reassurance is important and providers should identify ways to reduce associated costs through patient education, virtual visits, or new technologies to monitor patient's postoperative progress.
Assuntos
Fusão Vertebral , Idoso , Humanos , Vértebras Lombares/cirurgia , Masculino , Uso Excessivo dos Serviços de Saúde , Medicare , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Estados UnidosRESUMO
The development of the spine and spinal cord occurs at the earliest weeks of gestation. Their development not only affects each other but also are most likely associated with anomalies in other systems. It is essential to recognize the stages of spine development to understand the cause of congenital spinal deformities and their influences on the postnatal growing spine. A vast majority of congenital spinal problems are not evident clinically. For instance, the presence of neural axis abnormalities, such as spinal dysraphism or syringomyelia, may be so subtle that patients never seek medical care. Certain vertebral formation disorders such as hemivertebrae may remain asymptomatic throughout life if they are balanced while those with congenital bars may develop severe deformity. Major defects in the spine are often associated with abnormalities of the other organs such as cardiovascular and genital urinary system that warrants close attention by multidisciplinary specialists. A thorough understanding of the basics of embryology, which serves as a window into the development of the spine, is necessary to enable the practitioner to appreciate why, when, and where the numerous spine deformities develop in utero. Besides, certain developmental defects manifest in adulthood including spondylolysis, degenerative disc disease, congenital spinal stenosis, and even tumors like cordoma. Thus, understanding embryology can assist to establish the proper diagnosis and ensure optimal treatment.