Risk Factors for Residual Back Pain After Balloon Kyphoplasty for Osteoporotic Vertebral Fracture.

Background: Balloon kyphoplasty (BKP) is a method for the management of osteoporotic vertebral body fracture (OVF). However, improvement in back pain (BP) is poor in some patients, also previous reports have not elucidated the exact incidence and risk factors for residual BP after BKP. We clarified the characteristics of residual BP after BKP in patients with OVF. Hypothesis: In this study, we hypothesize that some risk factors may exist for residual BP 2 years after the treatment of OVF with BKP. Patients and Methods: A multicenter cohort study was performed where patients who received BKP within 2 months of OVF injury were followed-up for 2 years. BP at 6 months after surgery and final observation was evaluated by Visual Analog Scale (VAS) score. Patients with a score of 40 mm or more were allocated to the residual BP group, and comparisons between the residual back pain group and the improved group were made for bone density, kyphosis, mobility of the fractured vertebral body, total spinal column alignment, and fracture type (fracture of the posterior element, pedicle fracture, presence or absence of posterior wall damage, etc.). Also, Short Form 36 (SF-36) for physical component summary (PCS) and mental component summary (MCS) at the final follow-up was evaluated in each radiological finding. Results: Of 116 cases, 79 (68%) were followed-up for 2 years. Two years after the BKP, 26 patients (33%) experienced residual BP. Neither age nor sex differed between the groups. In addition, there was no difference in bone mineral density, BKP intervention period (period from onset to BKP), and osteoporosis drug use. However, the preoperative height ratio of the vertebral body was significantly worse in the residual BP group (39.8% vs. 52.1%; p = 0.007). Two years after the operation, the vertebral body wedge angle was significantly greater in the residual BP group (15.7° vs. 11.9°; p = 0.042). In the multiple logistic regression model with a preoperative vertebral body height ratio of 50% or less [calculated by receiver operating characteristic (ROC) curve], the adjusted odds ratio for residual BP was 6.58 (95% confidence interval 1.64-26.30; p = 0.007); similarly, patients with vertebral body height ratio less than 50% had a lower score of SF-36 PCS 24.6 vs. 32.2 p = 0.08. Conclusion: The incidence of residual BP 2 years after BKP was 33% in the current study. The risk factor for residual BP after BKP was a preoperative vertebral body height ratio of 50% or less, which should be attentively assessed for the selection of a proper treatment scheme and to provide adequate stabilization. Level of Evidence: III.

The Efficacy of Systemic Transdermal Diclofenac Patch for Postoperative Pain after Lumbar Spinal Surgery.

STUDY DESIGN: A single-center, prospective, comparative study. OBJECTIVE: This study aimed to investigate the efficacy and safety of the systemic transdermal diclofenac patch (DP) for immediate postoperative analgesia after lumbar spinal surgery. SUMMARY OF BACKGROUND DATA: Effective wound pain control after spinal surgery has been shown to lead to favorable outcomes. Using multimodal analgesia may decrease opioid use for postoperative pain. MATERIALS AND METHODS: Patients who underwent posterior lumbar spinal surgery between August 2022 and January 2023 were divided into two groups: patients who underwent surgery on even months and were treated with DP (DP [+] group) and those who underwent surgery on odd months and were not treated with DP (DP [-] group). The demographic data, morphine milligram equivalent (MMEs) within 24 hours, duration of hospitalization, number of rescue analgesics used, visual analog scale (VAS) scores of wound pain, deterioration in renal function, and other complications were compared. Subgroup analysis consisted of subgroups categorized based on surgical procedure (non-fusion or fusion surgery). RESULTS: In total, 111 and 113 patients were enrolled in the DP (+) and DP (-) groups, respectively. There was no significant difference in the deterioration of renal function in the DP (+) group. Overall comparisons demonstrated a significant difference between the DP (+) and DP (-) groups in the number of rescue analgesics used within 1 hour (P=0.046). In the non-fusion surgery subgroups, the MMEs within 24 hours, the number of rescue analgesics used within 1 and 3 hours, as well as the wound pain VAS at 1 and 3 hours postoperatively were significantly lower in the DP (+) group than in the DP (-) group (P=0.010, 0.015, 0.029, 0.005, and 0.048 respectively). CONCLUSION: Systemic transdermal DP may potentially offer safe and effective postoperative analgesia, especially in less invasive procedures such as non-fusion lumbar spinal surgery. LEVEL OF EVIDENCE: Level III.

Impact of malnutrition on mortality and neurological recovery of older patients with spinal cord injury.

This retrospective cohort study established malnutrition's impact on mortality and neurological recovery of older patients with cervical spinal cord injury (SCI). It included patients aged ≥ 65 years with traumatic cervical SCI treated conservatively or surgically. The Geriatric Nutritional Risk Index was calculated to assess nutritional-related risk. Overall, 789 patients (mean follow-up: 20.1 months) were examined and 47 had major nutritional-related risks on admission. One-year mortality rate, median survival time, neurological recovery, and activities of daily living (ADL) at 1 year post-injury were compared between patients with major nutrition-related risk and matched controls selected using 1:2 propensity score matching to adjust for age, pre-traumatic neurological impairment, and activity. In the Kaplan-Meier analysis, the median survival times were 44.9 and 76.5 months for patients with major nutrition-related risk and matched controls, respectively (p = 0.015). Matched controls had more individuals with a neurological improvement of American Spinal Injury Association Impairment Scale ≥ 1 grade (p = 0.039) and independence in ADL at 1 year post-injury than patients with major nutrition-related risk (p < 0.05). In conclusion, 6% of older patients with cervical SCI had major nutrition-related risks; they showed a significantly higher 1 year mortality rate, shorter survival time, poorer neurological improvement, and lower ADL at 1 year post-injury than matched controls.

Neurological recovery rate and predictive factors of incomplete AIS grade C spinal cord injury in the older aged population.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C). SETTINGS: Multi-institutions in Japan. METHODS: We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis. RESULTS: Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness). CONCLUSIONS: Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL. SPONSORSHIP: No funding was received for this study.

Short-Term Risk Factors for Distal Junctional Kyphosis after Spinal Reconstruction Surgery in Patients with Osteoporotic Vertebrae.

STUDY DESIGN: Level 3 retrospective cohort case-control study. PURPOSE: This study aimed to investigate the risk factors for distal junctional kyphosis (DJK) caused by osteoporotic vertebral fractures following spinal reconstruction surgery, with a focus on the sagittal stable vertebra. OVERVIEW OF LITERATURE: Despite the rarity of reports on DJK in this setting, DJK was reported to reduce when the lower instrumented vertebra (LIV) was extended to the sagittal stable vertebra in the posterior corrective fixation for Scheuermann's disease. METHODS: This study included 46 patients who underwent spinal reconstruction surgery for thoracolumbar osteoporotic vertebral fractures and kyphosis and were followed up for 1 year postoperatively. DJK was defined as an advanced kyphosis angle >10° between the LIV and one lower vertebra. The patients were divided into groups with and without DJK. The risk factors of the two groups, such as patient background, surgery-related factors, radiographic parameters, and clinical outcomes, were analyzed. RESULTS: The DJK and non-DJK groups included 14 and 32 patients, respectively, without significant differences in patient background. Those with instability in the distal adjacent LIV disc had a significantly higher risk of DJK occurrence (28.6% vs. 3.2%, p=0.027). DJK occurrence significantly increased in those with the sagittal stable vertebra not included in the fixation range (57.1% vs. 18.8%, p=0.020). Other preoperative radiographic parameters were not significantly different. Instability in the distal adjacent LIV disc (adjusted odds ratio, 14.50; p=0.029) and the exclusion of the sagittal stable vertebra from the fixation range (adjusted odds ratio, 5.29; p=0.020) were significant risk factors for DJK occurrence. CONCLUSIONS: Regarding spinal reconstruction surgery in patients with osteoporotic vertebral fractures, instability in the distal adjacent LIV disc and the exclusion of the sagittal stable vertebra from the fixation range were risk factors for DJK occurrence in the short term.

Degeneration of Cervical Multifidus Muscles Negatively Affects Physical Activity-related Quality of Life After Laminoplasty for Degenerative Cervical Myelopathy.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The study aimed to investigate the related factors affecting physical activity-related quality of life (QOL) after 2 years of cervical laminoplasty for degenerative cervical myelopathy (DCM), focusing on the degree of preoperative degeneration of the cervical multifidus muscles. SUMMARY OF BACKGROUND DATA: The association between paraspinal muscle degeneration and clinical outcomes after spinal surgery is being investigated. The effect of preoperative degeneration of the cervical multifidus muscles in patients undergoing cervical laminoplasty is ambiguous. METHODS: Patients who underwent laminoplasty for DCM and followed up for more than 2 years were reviewed. To evaluate physical QOL, the physical component summary (PCS) of the 36-Item Short-Form Health Survey (SF-36) was recorded at 2 years postoperatively. The degree of preoperative degeneration in the multifidus muscles at the C4 and C7 levels on axial T2-weighted magnetic resonance imaging (MRI) was categorized according to the Goutallier grading system. The correlation between 2-year postoperative PCS and each preoperative clinical outcome, radiographic parameter, and MRI finding, including Goutallier classification, was analyzed. Variables with a P value <0.10 in univariate analysis were included in multiple linear regression analysis. RESULTS: In total, 106 consecutive patients were included. The 2-year postoperative PCS demonstrated significant correlation with age (R=-0.358, P=0.002), preoperative JOA score (R=0.286, P=0.021), preoperative PCS (R=0.603, P<0.001), C2-C7 lordotic angle (R=-0.284, P=0.017), stenosis severity (R=-0.271, P=0.019), and Goutallier classification at the C7 level (R=-0.268, P=0.021). In multiple linear regression analysis, sex (ß=-0.334, P=0.002), age (ß=-0.299, P=0.013), preoperative PCS (ß=0.356, P=0.009), and Goutallier classification at the C7 level (ß=-0.280, P=0.018) were significantly related to 2-year postoperative PCS. CONCLUSIONS: Increased degeneration of the multifidus muscle at the C7 level negatively affected physical activity-related QOL postoperatively. These results may guide spine surgeons in predicting physical activity-related QOL in patients with DCM after laminoplasty. LEVEL OF EVIDENCE: Level III.

Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: A retrospective multicenter study.

BACKGROUND: Although previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury. METHODS: In this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery. RESULTS: The relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement. CONCLUSIONS: Although further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly.

Residual Paresthesia After Surgery for Degenerative Cervical Myelopathy: Incidence and Impact on Clinical Outcomes and Satisfaction.

STUDY DESIGN: Multicenter, prospective cohort study. OBJECTIVE: The current study aimed to identify the incidence of residual paresthesias after surgery for degenerative cervical myelopathy (DCM), and to demonstrate the impact of these symptoms on clinical outcomes and patient satisfaction. SUMMARY OF BACKGROUND DATA: Surgery for DCM aims to improve and/or prevent further deterioration of physical function and quality-of-life (QOL) in the setting of DCM. However, patients are often not satisfied with their treatment for myelopathy when they have severe residual paresthesias, even when physical function and QOL are improved after surgery. MATERIALS AND METHODS: The authors included 187 patients who underwent laminoplasty for DCM. All patients were divided into two groups based on their visual analog scale score for paresthesia of the upper extremities at one year postoperatively (>40 vs. ≤40 mm). Preoperative factors, changes in clinical scores and radiographic factors, and satisfaction scales at one year postoperatively were compared between groups. The authors used mixed-effect linear and logistic regression modeling to adjust for confounders. RESULTS: Overall, 86 of 187 patients had severe residual paresthesia at one year postoperatively. Preoperative patient-oriented pain scale scores were significantly associated with postoperative residual paresthesia ( P =0.032). A mixed-effect model demonstrated that patients with severe postoperative residual paresthesia showed significantly smaller improvements in QOL ( P =0.046) and myelopathy ( P =0.037) than patients with no/mild residual paresthesia. Logistic regression analysis identified that residual paresthesia was significantly associated with lower treatment satisfaction, independent of improvements in myelopathy and QOL (adjusted odds ratio: 2.5, P =0.010). CONCLUSION: In total, 45% of patients with DCM demonstrated severe residual paresthesia at one year postoperatively. These patients showed significantly worse treatment satisfaction, even after accounting for improvements in myelopathy and QOL. As such, in patients who experience higher preoperative pain, multidisciplinary approaches for residual paresthesia, including medications for neuropathic pain, might lead to greater clinical satisfaction. LEVEL OF EVIDENCE: 3.

SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY.

Introduction: The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY". Research question: Not applicable. Material and methods: Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. Results: Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. Discussion and conclusion: SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

Risk of Revision After Vertebral Augmentation for Osteoporotic Vertebral Fracture: A Narrative Review.

Osteoporotic vertebral fractures (OVFs) can hinder physical motor function, daily activities, and the quality of life in elderly patients when treated conservatively. Vertebral augmentation, which includes vertebroplasty and balloon kyphoplasty, is a commonly used procedure for OVFs. However, there have been reports of complications. Although serious complications are rare, there have been instances of adjacent vertebral fractures, cement dislocation, and insufficient pain relief due to cement failure, sometimes necessitating revision surgery. This narrative review discusses the common risks associated with vertebral augmentation for OVFs, such as cement leakage and adjacent vertebral fractures, and highlights the risk of revision surgery. The pooled incidence of revision surgery was 0.04 (0.02-0.06). The risks for revision are reported as follows: female sex, advanced age, diabetes mellitus, cerebrovascular disease, dementia, blindness or low vision, hypertension, hyperlipidemia, split type fracture, large angular motion, and large endplate deficit. Various treatment strategies exist for OVFs, but they remain a subject of controversy. Current literature underscores the lack of substantial evidence to guide treatment strategies based on the risks of vertebral augmentation. In cases with a high risk of failure, other surgeries and conservative treatments should also be considered as treatment options.

Prognosis of Cervical Diffuse Idiopathic Skeletal Hyperostosis-Related Spine Injuries in Elderly Patients: Analyses of Both Fracture and Spinal Cord Injury Without Fracture.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVE: The purpose of this study was to compare the prognosis of elderly patients with injuries related to cervical diffuse idiopathic skeletal hyperostosis (cDISH) to matched control for each group, with and without fractures. METHODS: The current multicenter study was a retrospective analysis of 140 patients aged 65 years or older with cDISH-related cervical spine injuries; 106 fractures and 34 spinal cord injuries without fracture were identified. Propensity score-matched cohorts from 1363 patients without cDISH were generated and compared. Logistic regression analysis was performed to determine the risk of early mortality for patients with cDISH-related injury. RESULTS: Patients with cDISH-related injuries with fracture did not differ significantly in the incidence of each complication and ambulation or severity of paralysis compared to matched controls. In patients with cDISH-related injury without fracture, those who were nonambulatory at discharge comprised 55% vs 34% of controls, indicating significantly poorer ambulation in those with cDISH-related injuries (P = .023). There was no significant difference in the incidence of complications and ambulation or paralysis severity at 6 months as compared with controls. Fourteen patients died within 3 months. Logistic regression analysis identified complete paralysis (odds ratio [OR] 36.99) and age (OR 1.24) as significant risk factors for mortality. CONCLUSIONS: The current study showed no significant differences in the incidence of complications, ambulation outcomes between patients with cDISH-related injury with fracture and matched controls, and that the ambulation at discharge for patients with cDISH-related injury without fractures were significantly inferior to those of matched controls.

Factors Predicting the Final Diagnosis in Image-Guided Percutaneous Needle Biopsy for Suspected Spinal Tumors.

In cases of suspected spinal tumors on imaging studies, a biopsy is often necessary for establishing the diagnosis. Predictive factors for tumors or malignancies may help in scheduling biopsies or avoiding unnecessary ones. However, there have been few studies on determining these factors. We aimed to determine the factors associated with the final diagnosis in cases requiring spinal biopsy. This study included 117 patients who underwent image-guided (fluoroscopy- or computed tomography [CT]-guided) needle biopsy of the spine. Data on patient demographic, pathological diagnoses, and final diagnoses were retrospectively collected from the medical records. The imaging features and location of lesions were also evaluated on CT and magnetic resonance imaging. Furthermore, factors related to tumors or malignancies were analyzed. The diagnostic accuracy of biopsy was 94.0%, and there was no difference in the diagnostic accuracy between the fluoroscopic and CT-guided biopsies. Sixty-six and fifty-six patients were diagnosed with spinal tumors and malignant tumors, respectively. Multivariate analysis revealed that a history of malignant tumors and the presence of pedicle lesions and/or extravertebral lesions were related factors for both tumors or malignancy in the final diagnosis. These findings can help determine the necessity for or timing of biopsy in patients with suspected spinal tumors.

The Impact of Multidisciplinary Approaches to Social Functioning on Surgical Outcomes After Surgery for Cervical Myelopathy.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To identify the effects of multidisciplinary approaches (MAs) to improve social functioning (SF) on 1-year surgical outcomes in patients with cervical myelopathy. SUMMARY OF BACKGROUND DATA: Despite significant improvement in cervical myelopathy, a patient's quality of life (QOL) sometimes does not improve postoperatively. A previous study revealed that SF, rather than myelopathy severity, correlated with QOL improvement after decompression surgery for cervical myelopathy. PATIENTS AND METHODS: This study compared two prospective cohorts in Japan. Patients who underwent cervical laminoplasty for cervical myelopathy from 2018 to 2020 were enrolled in the control cohort. Patients who underwent the same surgery with the same indications between 2020 and 2021 were enrolled in the MA cohort. Patients in the control cohort were treated with a standard care protocol, and those in the MA cohort were treated with a multidisciplinary protocol that focused on SF improvement. The changes in the total Japanese Orthopedic Association (JOA) score and in the domains of the JOA scores (upper limb function, lower limb function, upper limb sensory, and lower limb sensory) from preoperatively to 1 year postoperatively were compared between the control and MA cohorts using a mixed-effect model. RESULTS: The control and MA cohorts comprised 140 and 31 patients, respectively. The improvement in the JOA score was significantly better in the MA cohort than in the control cohort ( P = 0.040). In analyses of each JOA score domain, the improvement of upper limb function was significantly better in the MA cohort than in the control cohort ( P = 0.033). Similarly, the MA cohort demonstrated significantly higher patient-reported outcomes for upper extremity function than the control cohort ( P < 0.001). In addition, the self-care domain of QOL score at 1 year postoperatively was significantly higher in the MA cohort than in the control cohort ( P = 0.047). CONCLUSION: MAs to improve/rebuild a patient's SF were effective in improving cervical myelopathy and the self-care domain of QOL. This study is the first to demonstrate the effectiveness of postoperative MAs in patients with cervical myelopathy. LEVEL OF EVIDENCE: Level 3.

Prognostic impact of respiratory dysfunction in elderly patients with cervical spinal cord injury and/or fractures: a multicenter survey.

PURPOSE: To investigate the impact of early post-injury respiratory dysfunction for neurological and ambulatory ability recovery in patients with cervical spinal cord injury (SCI) and/or fractures. METHODS: We included 1,353 elderly patients with SCI and/or fractures from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were included in the respiratory dysfunction group, which was further classified into mild and severe respiratory groups based on respiratory weaning management. Patient characteristics, laboratory data, neurological impairment scale scores, complications at injury, and surgical treatment were evaluated. We performed a propensity score-matched analysis to compare neurological outcomes and mobility between groups. RESULTS: Overall, 104 patients (7.8%) had impaired respiratory function. In propensity score-matched analysis, the respiratory dysfunction group had a lower home discharge and ambulation rates (p = 0.018, p = 0.001, respectively), and higher rate of severe paralysis (p < 0.001) at discharge. At the final follow-up, the respiratory dysfunction group had a lower ambulation rate (p = 0.004) and higher rate of severe paralysis (p < 0.001). Twenty-six patients with severe disability required respiratory management for up to 6 months post-injury and died of respiratory complications. The mild and severe respiratory dysfunction groups had a high percentage of severe paraplegic cases with low ambulatory ability; there was no significant difference between them. The severe respiratory dysfunction group tended to have a poorer prognosis. CONCLUSION: Respiratory dysfunction in elderly patients with SCI and/or cervical fracture in the early post-injury period reflects the severity of the condition and may be a useful prognostic predictor.

Risk Factors for Poor Outcome after Palliative Surgery for Metastatic Spinal Tumors.

Palliative surgery is performed to improve the quality of life of patients with spinal metastases. However, it is sometimes difficult to achieve the expected results because the patient's condition, and risk factors related to poor outcomes have not been well elucidated. This study aimed to evaluate the functional outcomes and investigate the risk factors for poor outcomes after palliative surgery for spinal metastasis. We retrospectively reviewed the records of 117 consecutive patients who underwent palliative surgery for spinal metastases. Neurological and ambulatory statuses were evaluated pre- and post-operatively. Poor outcomes were defined as no improvement or deterioration in functional status or early mortality, and the related risk factors were analyzed using multivariate logistic regression analysis. The results showed neurological improvement in 48% and ambulatory improvement in 70% of the patients with preoperative impairment, whereas 18% of the patients showed poor outcomes. In the multivariate analysis, low hemoglobin levels and low revised Tokuhashi scores were identified as risk factors for poor outcomes. The present results suggest that anemia and low revised Tokuhashi scores are related not only to life expectancy but also to functional recovery after surgery. Treatment options should be carefully selected for the patients with these factors.

Effects of Dementia on Outcomes after Cervical Spine Injuries in Elderly Patients: Evaluation of 1512 Cases in a Nationwide Multicenter Study in Japan.

We aimed to retrospectively investigate the demographic characteristics and short-term outcomes of traumatic cervical spine injuries in patients with dementia. We enrolled 1512 patients aged ≥ 65 years with traumatic cervical injuries registered in a multicenter study database. Patients were divided into two groups according to the presence of dementia, and 95 patients (6.3%) had dementia. Univariate analysis revealed that the dementia group comprised patients who were older and predominantly female and had lower body mass index, higher modified 5-item frailty index (mFI-5), lower pre-injury activities of daily living (ADLs), and a larger number of comorbidities than patients without dementia. Furthermore, 61 patient pairs were selected through propensity score matching with adjustments for age, sex, pre-injury ADLs, American Spinal Injury Association Impairment Scale score at the time of injury, and the administration of surgical treatment. In the univariate analysis of the matched groups, patients with dementia had significantly lower ADLs at 6 months and a higher incidence of dysphagia up to 6 months than patients without dementia. Kaplan-Meier analysis revealed that patients with dementia had a higher mortality than those without dementia until the last follow-up. Dementia was associated with poor ADLs and higher mortality rates after traumatic cervical spine injuries in elderly patients.

Delirium Risk Score in Elderly Patients with Cervical Spinal Cord Injury and/or Cervical Fracture.

The number of elderly patients with cervical trauma is increasing. Such patients are considered to be at high risk for delirium, which is an acute neuropsychological disorder that reduces the patient's capacity to interact with their environment due to impairments in cognition. This study aimed to establish a risk score that predicts delirium in elderly patients with cervical SCI and/or cervical fracture regardless of treatment type. This retrospective cohort study included 1512 patients aged ≥65 years with cervical SCI and/or cervical fracture. The risk factors for delirium according to treatment type (surgical or conservative) were calculated using multivariate logistic regression. A delirium risk score was established as the simple arithmetic sum of points assigned to variables that were significant in the multivariate analyses. Based on the statistical results, the delirium risk score was defined using six factors: old age (≥80 years), hypoalbuminemia, cervical fracture, major organ injury, dependence on pre-injury mobility, and comorbid diabetes. The score's area under the curve for the prediction of delirium was 0.66 (p < 0.001). Although the current scoring system must be validated with an independent dataset, the system remains beneficial because it can be used after screening examinations upon hospitalization and before deciding the treatment strategy.

Deep Learning Algorithm for Identifying Cervical Cord Compression Due to Degenerative Canal Stenosis on Radiography.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: Validate the diagnostic accuracy of a deep-learning algorithm for cervical cord compression due to degenerative canal stenosis on radiography. SUMMARY OF BACKGROUND DATA: The diagnosis of degenerative cervical myelopathy is often delayed, resulting in improper management. Screening tools for suspected degenerative cervical myelopathy would help identify patients who require detailed physical evaluation. MATERIALS AND METHODS: Data from 240 patients (120 with cervical stenosis on magnetic resonance imaging and 120 age and sex-matched controls) were randomly divided into training (n = 198) and test (n = 42) data sets. The deep-learning algorithm, designed to identify the suspected stenosis level on radiography, was constructed using a convolutional neural network model called EfficientNetB2, and radiography and magnetic resonance imaging data from the training data set. The accuracy and area under the curve of the receiver operating characteristic curve were calculated for the independent test data set. Finally, the number of correct diagnoses was compared between the algorithm and 10 physicians using the test cohort. RESULTS: The diagnostic accuracy and area under the curve of the deep-learning algorithm were 0.81 and 0.81, respectively, in the independent test data set. The rate of correct responses in the test data set was significantly higher for the algorithm than for the physician's consensus (81.0% vs . 66.2%; P = 0.034). Furthermore, the accuracy of the algorithm was greater than that of each individual physician. CONCLUSIONS: We developed a deep-learning algorithm capable of suggesting the presence of cervical spinal cord compression on cervical radiography and highlighting the suspected levels on radiographic imaging when cord compression is identified. The diagnostic accuracy of the algorithm was greater than that of spine physicians. LEVEL OF EVIDENCE: Level IV.

Characteristics of the cervical spine and cervical cord injuries in older adults with cervical ossification of the posterior longitudinal ligament.

Although the incidence of cervical spinal cord injury (CSCI) with ossification of the posterior longitudinal ligament (OPLL) has increased in older adults, its etiology and neurological outcomes remain unknown. We identified OPLL characteristics and determined whether they influence neurological severity and improvement of CSCI in older patients. This multicenter retrospective cohort study identified 1512 patients aged ≥ 65 years diagnosed with CSCI on admission during 2010-2020. We analyzed CSCI etiology in OPLL patients. We performed propensity score-adjusted analyses to compare neurological outcomes between patients with and without OPLL. Cases were matched based on variables influencing neurological prognosis. The primary neurological outcome was rated according to the American Spine Injury Association (ASIA) impairment scale (AIS) and ASIA motor score (AMS). In 332 OPLL patients, the male-to-female ratio was approximately 4:1. Half of all patients displayed low-energy trauma-induced injury and one-third had CSCI without a bony injury. Propensity score matching created 279 pairs. There was no significant difference in the AIS grade and AMS between patients with and without OPLL during hospitalization, 6 months, and 12 months following injury. OPLL patients tended to exhibit worse neurological findings during injury; nevertheless, OPLL was not associated with poor neurological improvement in older CSCI patients.

A decision tree analysis to predict clinical outcome of minimally invasive lumbar decompression surgery for lumbar spinal stenosis with and without coexisting spondylolisthesis and scoliosis.

BACKGROUND CONTEXT: Implementing machine learning techniques, such as decision trees, known as prediction models that use logical construction diagrams, are rarely used to predict clinical outcomes. PURPOSE: To develop a clinical prediction rule to predict clinical outcomes in patients who undergo minimally invasive lumbar decompression surgery for lumbar spinal stenosis with and without coexisting spondylolisthesis and scoliosis using a decision tree model. STUDY DESIGN/SETTING: A retrospective analysis of prospectively collected data. PATIENT SAMPLE: This study included 331 patients who underwent minimally invasive surgery for lumbar spinal stenosis and were followed up for ≥2 years at 1 institution. OUTCOME MEASURES: Self-report measures: The Japanese Orthopedic Association (JOA) scores and low back pain (LBP)/leg pain/leg numbness visual analog scale (VAS) scores. Physiologic measures: Standing sagittal spinopelvic alignment, computed tomography, and magnetic resonance imaging results. METHODS: Low achievement in clinical outcomes were defined as the postoperative JOA score at the 2-year follow-up <25 points. Univariate and multiple logistic regression analysis and chi-square automatic interaction detection (CHAID) were used for analysis. RESULTS: The CHAID model for JOA score <25 points showed spontaneous numbness/pain as the first decision node. For the presence of spontaneous numbness/pain, sagittal vertical axis ≥70 mm was selected as the second decision node. Then lateral wedging, ≥6° and pelvic incidence minus lumbar lordosis (PI-LL) ≥30° followed as the third decision node. For the absence of spontaneous numbness/pain, sex and lateral olisthesis, ≥3mm and American Society of Anesthesiologists physical status classification system score were selected as the second and third decision nodes. The sensitivity, specificity, and the positive predictive value of this CHAID model was 65.1, 69.8, and 64.7% respectively. CONCLUSIONS: The CHAID model incorporating basic information and functional and radiologic factors is useful for predicting surgical outcomes.