Factors associated with increased length of stay and risk of complications in 336 patients submitted to spine surgery. The role of a validated capture system (SAVES v2) as a first-line tool to properly face the problem.

PURPOSE: In this study, we analyzed the use of a validated capture system (Spinal Adverse Events Severity system, SAVES V2) as a first non-technical skill to properly face the relevant problem of surgical complications (SCs) and adverse events (AEs) in spinal surgery. METHODS: We retrospectively collected AEs occurring in a tertiary referral center for spine surgery from January 2017 to January 2018 and classified them according to SAVES V2 system. We compared this collection of AEs with a prospective collection performed without any classification system. Univariate and multivariate logistic regression models were used to determined odds ratio (ORs) for selected potential risk factors of AEs and prolonged length of stay. RESULTS: Overall a higher number of AEs was retrospectively recorded using SAVES system compared to the prospective recording without the use of any capture system (97/336 vs 210/336, p < 0.001). The length of stay (LOS) increased in the group of complicated patients for all the procedures examined. In the non-oncological group, LOS was significantly higher for complicated patients compared to uncomplicated patients (F = 44.11, p = 0.0000). Similar results have been obtained in the oncological group of patients. In the multivariate regression model surgical time and postoperative AEs emerged as risk factors for prolonged LOS, while only the presence of previous surgeries was confirmed as risk factor for AEs. CONCLUSION: Considering that the rate of AEs and SCs in spinal surgery is still high despite the improvement of technical skills, we suggest the use of SAVES V2 capture system as a first-line tool to face the problem.

Association between skin ultrasound parameters and revision surgery after posterior spinal fusion.

PURPOSE: The literature is scarce in exploring the role of imaging parameters like ultrasound (US) as a biomarker for surgical outcomes. The purpose of this study is to investigate the associations between skin US parameters and revision surgery following spine lumbar fusion. METHODS: Posterior lumbar fusion patients with 2-years follow-up were assessed. Previous fusion or revision not due to adjacent segment disease (ASD) were excluded. Revisions were classified as cases and non-revision were classified as controls. US measurements conducted at two standardized locations on the lumbar back. Skin echogenicity of the average dermal (AD), upper 1/3 of the dermal (UD), lower 1/3 of the dermal (LD), and subcutaneous layer were measured. Echogenicity was calculated with the embedded echogenicity function of our institution's imaging platform (PACS). Statistical significance was set at p < 0.05. RESULTS: A total of 128 patients (51% female, age 62 [54-72] years) were included in the final analysis. 17 patients required revision surgery. AD, UD, and LD echogenicity showed significantly higher results among revision cases 124.5 [IQR = 115.75,131.63], 128.5 [IQR = 125,131.63] and 125.5 [IQR = 107.91,136.50] compared to the control group 114.3 [IQR = 98.83,124.8], 118.5 [IQR = 109.28,127.50], 114 [IQR = 94.20,126.75] respectively. CONCLUSION: The findings of this study demonstrate a significant association between higher echogenicity values in different layers of the dermis and requiring revision surgery. The results provide insights into the potential use of skin US parameters as predictors for revision surgery. These findings may reflect underlying alterations in collagen. Further research is warranted to elucidate the mechanisms driving these associations.

Abdominal aortic calcification is an independent predictor of perioperative blood loss in posterior spinal fusion surgery.

OBJECTIVE: Abdominal aortic calcification (AAC), often found incidentally on lateral lumbar radiographs, is increasingly recognized for its association with adverse outcomes in spine surgery. As a marker of advanced atherosclerosis affecting cardiovascular dynamics, this study evaluates AAC's impact on perioperative blood loss in posterior spinal fusion (PSF). METHODS: Patients undergoing PSF from March 2016 to July 2023 were included. Estimated blood loss (EBL) and total blood volume (TBV) were calculated. AAC was assessed on lateral lumbar radiographs according to the Kauppila classification. Predictors of the EBL-to-TBV ratio (%EBL/TBV) were examined via univariable and multivariable regression analyses, which adjusted for parameters such as hypertension and aspirin use. RESULTS: A total of 199 patients (47.2% female) were analyzed. AAC was present in 106 patients (53.3%). AAC independently predicted %EBL/TBV, accounting for an increase in blood loss of 4.46% of TBV (95% CI 1.17-7.74, p = 0.008). CONCLUSIONS: This is the first study to identify AAC as an independent predictor of perioperative blood loss in PSF. In addition to its link to degenerative spinal conditions and adverse postoperative outcomes, the relationship between AAC and increased blood loss warrants attention in patients undergoing PSF.

MRI in differential diagnosis between tuberculous and pyogenic spondylodiscitis.

PURPOSE: The aim of the study was to investigate whether MRI findings together with epidemiological data could help in differentiating between tuberculous and pyogenic spondylodiscitis. METHODS: Clinical records of 260 patients with a suspicion of spondylodiscitis were analysed. Patients were selected using the following inclusion criteria: confirmed diagnosis of spondylodiscitis either from pyogenic bacteria or from Mycobacterium tuberculosis and contrast-enhanced MRI performed before treatment. Clinical data concerning age, sex and country-of-origin were also collected. For each patient, several MRI-features were evaluated by two-expert musculoskeletal radiologists. A chi-squared test and a multiple logistic regression were used to find the best predictors of tuberculous or pyogenic spondylodiscitis. RESULTS: 114 patients were retrospectively enrolled, 30 with tuberculous and 84 with pyogenic spondylodiscitis. We found 18 MRI-features, significantly different between the two groups. Among these, the most strongly associated with tuberculous spondylodiscitis were: heterogeneous vertebral signal on T1w-sequences (Odds Ratio(OR) = 205.759-p < 0.001), presence of epidural abscess (OR = 86.221-p < 0.001), severe vertebral destruction (OR = 10.017-p < 0.001) and absence of epidural phlegmon (OR = 86.221-p < 0.001). Moreover, patients coming from countries with a middle-high prevalence of tuberculosis were more frequently affected by tuberculous spondylodiscitis than others were (OR = 229.136-p < 0.001). The best prediction model demonstrated a correct classification rate of 94.7%. CONCLUSION: To the best of our knowledge this is the largest study comparing MRI-features of tuberculous and pyogenic spondylodiscitis. The above-mentioned MRI-features and epidemiological data are crucial in the differential diagnosis between these two entities, guiding the choice of the appropriate therapy, especially when a pathogen cannot be clearly identified with other modalities.

The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review.

PURPOSE: Spinal bone tumors include a heterogeneous broad of primary or metastatic lesions that may present as incidental findings or manifest with painful symptoms and pathological fractures. Optimal management of spine bone lesions is often difficult and treatment algorithms are usually solidly based on surgery. We aimed to evaluate the contribution of trans-arterial embolization in this field, with particular attention to the procedure efficacy, technical difficulties and complications. METHODS: We present a literature review on the role of trans-arterial embolization in the management of spinal bone tumors, both primary and metastatic, evaluating its contribution as preoperative treatment, palliative procedure and standalone curative strategy. RESULTS: Trans-arterial embolization provides an important contribution to reducing surgery hemorrhagic risks, offering a better visualization of the operating field, and possibly increasing tumor susceptibility to chemotherapy or radiation therapy. Nonetheless, it plays an important part in pain palliation, with the unquestionable advantage of being easily repeatable in case of necessity. Its curative role as a standalone therapy is still subject of debate, and at the present time, satisfactory results have been recorded only in the treatment of aneurysmal bone cysts. CONCLUSION: Percutaneous trans-arterial embolization has established as a highly useful minimally invasive procedure in the management of spinal bone lesions, particularly as adjuvant preoperative therapy and palliative treatment.

Histological examination of a retrieved custom-made 3D-printed titanium vertebra : Do the fine details obtained by additive manufacturing really promote osteointegration?

PURPOSE: In the present report it is described the design, the manufacturing and the successful surgical implant of one of the first 3D custom titanium vertebra realized with Additive Manufacturing technique and its use for the spinal reconstruction after en-bloc resection for primary osteogenic sarcoma. METHODS: Clinical case presentation and the design of the 3D custom titanium vertebra was reported. It was also described the complex procedures adopted to evaluate the retrieved device from the histological point of view, as a tumor relapse hit the patient, one year after the reconstruction procedure. RESULTS: The histological evaluation confirmed that the resection technique exerts an important role in promoting bone formation: vertebral body osteotomies favored the reconstruction procedure and maximized the contact area between host bone/vertebral prosthesis thus favoring the bone tissue penetration and device colonization. CONCLUSION: The sharing of these results is very important as they represent the starting point for improving the knowledge starting from the evidence obtained in a challenging clinical condition and with post-operative treatments that could be never reproduced in preclinical model.

Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them?

PURPOSE: To investigate whether the World Health Organization Safety Surgical Checklist (SSC) is an effective tool to reduce complications in spinal surgery. METHODS: We retrospectively evaluated the clinical and radiological charts prospectively collected from patients who underwent a spinal surgery procedure from January 2010 to December 2012. The aim of this study was to compare the incidence of complications between two periods, from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist's effectiveness. RESULTS: The sample size was 917 patients with an average of 30-month follow-up. The mean age was 52.88 years. The majority of procedures were performed for oncological diseases (54.4%) and degenerative diseases (39.8%). In total, 159 complications were detected (17.3%). The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. No correlation was observed between the type of pathology and the complication incidence. We observed a reduction in the overall incidence of complications following the introduction of the SSC: In 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%). CONCLUSIONS: The SSC seems to be an effective tool to reduce complications in spinal surgery. We propose to extend the use of checklist system also to the preoperative and postoperative phases in order to further reduce the incidence of complications. These slides can be retrieved under Electronic Supplementary Material.

Metastatic epidural spinal cord compression: does timing of surgery influence the chance of neurological recovery? An observational case-control study.

PURPOSE: Metastatic epidural spinal cord compression (MESCC) is radiologically defined as an epidural metastatic lesion causing the displacement of the spinal cord from its normal position in the vertebral canal. The purpose of this paper is the evaluation of the influence of timing of surgery on the chance of neurological recovery. METHODS: This is a retrospective observational case-control study performed on patients with MESCC from solid tumors surgically treated at our institute from January 2010 to December 2016. Patients included were divided in two groups depending on surgery that was performed within or after 24 h the admission to the hospital. Neurological status was assessed with American Spine Injury Association (ASIA) Impairment Scale. RESULTS: No statistically significant difference was observed in the variation of ASIA if surgery is performed within or after 24 h from the admission to the hospital. A statistically significant difference was observed after surgery in each group in the improvement of neurological status. A statistically significant difference was reported in the early post-operative complications in patients surgically treated within 24 h. CONCLUSION: MESCC management is challenge for spine surgeons and may represent an oncologic emergency and if not promptly diagnosed can lead to a permanent neurological damage. According to this study, there is no difference in the chance of neurological recovery if surgery is performed within or after 24 h the admission to hospital, but there is a greater rate of early post-operative complications when surgery is performed within 24 h from the admission to the hospital.

Cryosurgery in the excision of a giant local recurrent sacral chordoma: a case report and literature review.

PURPOSE: Chordoma is a low-grade malignant tumor with recurrence and metastasis tendency that originates from embryonic notochordal remnants. The sacrococcygeal region is the most commonly involved site. The aim of this paper is to report the results of the use of cryosurgery in the excision of a giant recurrent sacral chordoma and review of pertinent literature. METHODS: A 64 years old female patient with a locally recurrent sacral chordoma came to our attention after ten interventions performed at another institute. A surgical treatment was performed using argon cryosurgery. RESULTS: In this case, it was not possible to perform a marginal or wide excision, but it was intralesional with the removal of three major blocks. The fragments sent for the histological analysis measured total 35 × 30 × 8 cm with a weight of 4.260 g. CONCLUSIONS: Given the gelatinous structure of the tumor and the possibility of contamination of operatory field, cryosurgery may be indicated when previous surgeries and the dimensions of tumor mass do not allow a resection with negative margins improving radiotherapy efficacy in the local control of tumor.

Biomimetic 3D-printed custom-made prosthesis for anterior column reconstruction in the thoracolumbar spine: a tailored option following en bloc resection for spinal tumors : Preliminary results on a case-series of 13 patients.

PURPOSE: Various techniques for anterior column reconstruction have been described after en bloc resection of spinal tumors. Limited evidence exists regarding one being superior to another. The purpose of this study is to evaluate 3D-printed vertebral bodies for spinal reconstruction after en bloc resection in the thoracolumbar spine. METHODS: Prospective observational study on custom-made 3D-printed titanium reconstruction of vertebral bodies after en bloc resection for spinal tumor was conducted between November 2015 and June 2017. 3D-printed vertebral bodies were monitored for mechanical complications such as (1) migration, (2) subsidence into the adjacent vertebral bodies, and/or (3) breakage. Complications and related details were recorded. RESULTS: Thirteen patients (7 females and 6 males) were enrolled, and reconstruction of the anterior column was performed using custom-made 3D-printed titanium prosthesis after en bloc resection for spinal tumor (8 primary bone tumors and 5 solitary metastases). Subsidence into the adjacent vertebral bodies occurred in all patients at both proximal and distal bone-implant interfaces; however, it was clinically irrelevant (asymptomatic, and no consequences on posterior instrumentation), in 11 out of 12 patients (92%). In 1 patient (#4), severity of the subsidence led to revision of the construct. At an average 10-month follow-up (range 2-16), 1 implant was removed due to local recurrence of the disease and 1 was revisioned due to progressive distal junctional kyphosis. CONCLUSION: Preliminary results from this series suggest that 3D printing can be effectively used to produce custom-made prosthesis for anterior column reconstruction. These slides can be retrieved under Electronic Supplementary Material.

Peroneal Tubercle Hypertrophy: A Case Report.

The peroneal tubercle is an osseous prominence present on the calcaneus bone at the junction between the middle and the anterior third of its lateral surface. It is a bony septum which divides the tendons of the peroneus brevis and the peroneus longus and offers insertion to the inferior peroneal retinaculum. A hypertrophy of this prominence causes pain in the lateral and the posterior part of the foot while wearing shoes, rarely peroneal tenosynovitis can even cause it to break. In the following pages, we will describe a case of peroneal tubercle hypertrophy, visible even at clinical examination, in a 26-year-old male patient without apparent causes nor previous trauma.

Determinants of outcome after endovascular therapy for critical limb ischemia with tissue loss.

BACKGROUND: In this study we examine outcomes of endovascular therapy for critical limb ischemia with tissue loss and identify risk factors for failure of endovascular therapy across a panel of outcome metrics. METHODS: A retrospective review (2006-2010) of patients undergoing endovascular therapy for critical limb ischemia with tissue loss provided data for multivariate models of overall survival, amputation-free survival, limb salvage (LS), and wound healing. RESULTS: One hundred six patients underwent endovascular therapy for Rutherford class 5 (88%) or class 6 (12%) ischemia with ulceration and/or gangrene of the heel (15%), forefoot (16%), toe(s) (43%), calf/ankle (11%), or multiple locations (15%). Sustained limb salvage at 1 year was 87%. One-year overall survival and amputation-free survival were 65% and 49%, respectively. Multivariate regression models identified independent risk factors for reduced primary patency: Rutherford 6 ischemia (P = 0.008; HR 4.7 [95% confidence interval 1.5-14.8]) and infrapopliteal intervention (P = 0.03; HR 2.58 [95% CI 1.08-6.14]). Rutherford class 6 ischemia was independently associated with reduced assisted patency (P = 0.004; HR 5.39 [95% CI 1.74-16.73]). Wound healing was adversely affected by diabetes (P = 0.02; HR 7.0 [95% CI 1.4-36.2]), continued smoking (P = 0.04; HR 5.3 [95% CI 1.1-26.3]), and patency loss (P = 0.04; HR 4.8 [95% CI 1.1-22.30]). Rutherford class 6 ischemia was independently associated with reduced limb salvage (P < 0.0001; HR 35.1 [95% CI 5.4-231.2]) and amputation-free survival (P = 0.007; HR 3.61 [95% CI 1.4-9.18]), in addition to COPD (P = 0.01; 3.58 [95% 1.28-9.55]). Independent predictors of poor overall survival included end-stage renal disease (P = 0.03; HR 2.99 [95% CI 1.1-8.05]), history of angina (P = 0.02; HR 5.08 [95% CI 1.28-20.29]), and COPD (P = 0.001; HR 3.77 [95% CI 1.76-8.34]). CONCLUSIONS: Both increasing severity of tissue loss as well as the presence of severe medical comorbidities are associated with poorer outcomes of endovascular therapy in these patients. Although sustained limb salvage in patients with tissue loss may be achieved with endovascular therapy, this is due to poor overall survival and a competing mortality hazard.

What is the Association of the Subsections of the Oswestry Disability Index and Overall Improvement Two Years after Lumbar Surgery for Degenerative Lumbar Spondylolisthesis?

STUDY DESIGN: Retrospective review of a prospective cohort study. OBJECTIVE: To identify the association between Oswestry Disability Index (ODI) subsections and overall improvement 2 years after lumbar surgery for degenerative lumbar spondylolisthesis (DLS). BACKGROUND: DLS often necessitates lumbar surgery. The ODI is a trusted measure for patient-reported outcomes (PROMs) in assessing spinal disorder outcomes. Surgeons utilize the ODI for baseline functional assessment and post-surgery progress tracking. However, it remains uncertain if and how each subsection influences overall ODI improvement. METHODS: This retrospective cohort study analyzed patients who underwent lumbar surgery for DLS between 2016 and 2018. Preoperative and 2-year postoperative ODI assessments were conducted. The study analyzed postoperative subsection scores and defined ODI improvement as ODIpreop-ODIpostop >0. Univariate linear regression was applied, and receiver operating characteristic (ROC) analysis determined cut-offs for subsection changes and postoperative target values to achieve overall ODI improvement. RESULTS: 265 patients (60% female, mean age 67±8 y) with a baseline ODI of 50±6 and a postoperative ODI of 20±7 were included. ODI improvement was noted in 91% (242 patients). Achieving a postoperative target score of ≤2 in subsections correlated with overall ODI improvement. Walking had the highest predictive value for overall ODI improvement (AUC 0.91, sensitivity 79%, specificity 91%). Pain intensity (AUC 0.90, sensitivity 86%, specificity 83%) and changing degree of pain (AUC 0.87, sensitivity 86%, specificity 74%) were also highly predictive. Sleeping had the lowest predictability (AUC 0.79, sensitivity 84%, specificity 65%). Except for sleeping, all subsections had a Youden-index >50%. CONCLUSION: These findings demonstrate how the different ODI subsections associate with overall improvement post-lumbar surgery for DLS. This understanding is crucial for refining preoperative education, addressing particular disabilities, and evaluating surgical efficacy. Additionally, it shows that surgical treatment does not affect all subsections equally.

The Impact of the COVID-19 Pandemic on Ambulatory Lumbar Spine Decompression Surgery.

Background Only a few studies have examined the impact of the coronavirus disease 2019 pandemic on spine ambulatory surgeries and changes in trends. Therefore, we investigated trends during the pre-pandemic period and three pandemic stages in patients undergoing lumbar decompression procedures in the ambulatory surgery (AMS) setting. Methodology A total of 2,670 adult patients undergoing one- or two-level lumbar decompression surgery were retrospectively reviewed. Patients were categorized into the following four groups: 1: pre-pandemic (before the pandemic from January 1, 2019, to March 16, 2020); 2: restricted period (when elective surgery was canceled from March 17, 2020, to June 30, 2020); 3: post-restricted 2020 (July 1, 2020, to December 31, 2020, before vaccination); and 4: post-restricted 2021 (January 1, 2021 to December 31, 2021 after vaccination). Simple and multivariable logistic regression analyses as well as retrospective interrupted time series (ITS) analysis were conducted comparing AMS patients in the four periods. Results Patients from the restricted pandemic period were younger and healthier, which led to a shorter length of stay (LOS). The ITS analysis demonstrated a significant drop in mean LOS at the beginning of the restricted period and recovered to the pre-pandemic levels in one year. Multivariable logistic regression analyses indicated that the pandemic was an independent factor influencing the LOS in post-restricted phases. Conclusions As the post-restricted 2020 period itself might be independently influenced by the pandemic, these results should be taken into account when interpreting the LOS of the patients undergoing ambulatory spine surgery in post-restricted phases.

The relationship between paraspinal muscle atrophy and degenerative lumbar spondylolisthesis at the L4/5 level.

BACKGROUND/CONTEXT: Degenerative lumbar spondylolisthesis (DLS) is a prevalent spinal condition that can result in significant disability. DLS is thought to result from a combination of disc and facet joint degeneration, as well as various biological, biomechanical, and behavioral factors. One hypothesis is the progressive degeneration of segmental stabilizers, notably the paraspinal muscles, contributes to a vicious cycle of increasing slippage. PURPOSE: To examine the correlation between paraspinal muscle status on MRI and severity of slippage in patients with symptomatic DLS. STUDY DESIGN/SETTING: Retrospective cross-sectional study at an academic tertiary care center. PATIENT SAMPLE: Patients who underwent surgery for DLS at the L4/5 level between 2016-2018 were included. Those with multilevel DLS or insufficient imaging were excluded. OUTCOME MEASURES: The percentage of relative slippage (RS) at the L4/5 level evaluated on standing lateral radiographs. Muscle morphology measurements including functional cross-sectional area (fCSA), body height normalized functional cross-sectional area (HI) of Psoas, erector spinae (ES) and multifidus muscle (MF) and fatty infiltration (FI) of ES and MF were measured on axial MR. Disc degeneration and facet joint arthritis were classified according to Pfirrmann and Weishaupt, respectively. METHODS: Descriptive and comparative statistics, univariable and multivariable linear regression models were utilized to examine the associations between RS and muscle parameters, adjusting for confounders sex, age, BMI, segmental degeneration, and back pain severity and symptom duration. RESULTS: The study analyzed 138 out of 183 patients screened for eligibility. The median age of all patients was 69.5 years (IQR 62 to 73), average BMI was 29.1 (SD±5.1) and average preoperative ODI was 46.4 (SD±16.3). Patients with Meyerding-Grade 2 (M2, N=25) exhibited higher Pfirrmann scores, lower MFfCSA and MFHI, and lower BMI, but significantly more fatty infiltration in the MF and ES muscles compared to those with Meyerding Grade 1 (M1). Univariable linear regression showed that each cm2 decrease in MFfCSA was associated with a 0.9%-point increase in RS (95% CI -1.4 to - 0.4, p<.001), and each cm2/m2 decrease in MFHI was associated with an increase in slippage by 2.2%-points (95% CI -3.7 to -0.7, p=.004). Each 1%-point rise in ESFI and MFFI corresponded to 0.17%- (95% CI 0.05-0.3, p=.01) and 0.20%-point (95% CI 0.1-0.3 p<.001) increases in relative slippage, respectively. Notably, after adjusting for confounders, each cm2 increase in PsoasfCSA and cm2/m2 in PsoasHI was associated with an increase in relative slippage by 0.3% (95% CI 0.1-0.6, p=.004) and 1.1%-points (95% CI 0.4-1.7, p=.001). While MFfCSA tended to be negatively associated with slippage, this did not reach statistical significance (p=.105). However, each 1%-point increase in MFFI and ESFI corresponded to increases of 0.15% points (95% CI 0.05-0.24, p=.002) and 0.14% points (95% CI 0.01-0.27, p=.03) in relative slippage, respectively. CONCLUSION: This study found a significant association between paraspinal muscle status and severity of slippage in DLS. Whereas higher degeneration of the ES and MF correlate with a higher degree of slippage, the opposite was found for the psoas. These findings suggest that progressive muscular imbalance between posterior and anterior paraspinal muscles could contribute to the progression of slippage in DLS.

Asymmetrical atrophy of the paraspinal muscles in patients undergoing unilateral lumbar medial branch radiofrequency neurotomy.

ABSTRACT: Lumbar medial branch radiofrequency neurotomy (RFN), a common treatment for chronic low back pain due to facet joint osteoarthritis (FJOA), may amplify paraspinal muscle atrophy due to denervation. This study aimed to investigate the asymmetry of paraspinal muscle morphology change in patients undergoing unilateral lumbar medial branch RFN. Data from patients who underwent RFN between March 2016 and October 2021 were retrospectively analyzed. Lumbar foramina stenosis (LFS), FJOA, and fatty infiltration (FI) functional cross-sectional area (fCSA) of the paraspinal muscles were assessed on preinterventional and minimum 2-year postinterventional MRI. Wilcoxon signed-rank tests compared measurements between sides. A total of 51 levels of 24 patients were included in the analysis, with 102 sides compared. Baseline MRI measurements did not differ significantly between the RFN side and the contralateral side. The RFN side had a higher increase in multifidus FI (+4.2% [0.3-7.8] vs +2.0% [-2.2 to 6.2], P = 0.005) and a higher decrease in multifidus fCSA (-60.9 mm2 [-116.0 to 10.8] vs -19.6 mm2 [-80.3 to 44.8], P = 0.003) compared with the contralateral side. The change in erector spinae FI and fCSA did not differ between sides. The RFN side had a higher increase in multifidus muscle atrophy compared with the contralateral side. The absence of significant preinterventional degenerative asymmetry and the specificity of the effect to the multifidus muscle suggest a link to RFN. These findings highlight the importance of considering the long-term effects of lumbar medial branch RFN on paraspinal muscle health.

How much improvement in Oswestry Disability Index is Necessary to make your Patient Satisfied after Lumbar Surgery?

STUDY DESIGN: Retrospective review of cohort studies. OBJECTIVE: To clarify the necessary ODI improvement for patient satisfaction two years after lumbar surgery. BACKGROUND: Evaluating elective lumbar surgery care often involves patient-reported outcomes (PRO). While postoperative functional improvement measured by ODI is theoretically linked to satisfaction, conflicting evidence exists regarding this association. METHODS: Baseline ODI and 2-year postoperative ODI were assessed. Patient satisfaction, measured on a scale from 1 to 5, with scores ≥4 considered satisfactory, was evaluated. Patients with incomplete follow-up were excluded. Statistical analyses included Mann-Whitney-U and multivariable logistic regression adjusted for age, sex, and BMI. Receiver operating characteristic (ROC) analysis determined threshold values for ODI improvement and postoperative target ODI indicative of patient satisfaction. RESULTS: 383 patients were included (mean age 65±10 y, 57% female). ODI improvement was observed in 91% of patients, with 77% reporting satisfaction scores ≥4. Baseline ODI (median 62, IQR 46-74) improved to a median of 10 (IQR 1-10) 2 years postoperatively. Baseline (OR 0.98, P=0.015) and postoperative ODI scores (OR 0.93, P<0.001), as well as the difference between them (OR 1.04, P< 0.001), were significantly associated with patient satisfaction. Improvement of ≥38 ODI points or a relative change of ≥66% was indicative for patient satisfaction, with higher sensitivity (80%) and specificity (82%) for the relative change versus the absolute change (69%, 68%). With a sensitivity of 85% and a specificity of 77%, a postoperative target ODI of ≤24 indicated patient satisfaction. CONCLUSION: Lower baseline ODI and greater improvements in postoperative ODI are associated with an increased likelihood of patient satisfaction. A relative improvement of ≥66% or achieving a postoperative ODI score of ≤24 were the most indicative thresholds for predicting patient satisfaction, proving more sensitivity and specificity than an absolute change of ≥38 points.

Computer tomography prototyping and virtual procedure simulation in difficult cases of hip replacement surgery.

Each year approximately 1 million total hip replacements (THR) are performed worldwide. A percentage of failure due to surgical approach and imprecise implant placement still exists. These result in several serious complications. We propose an approach to plan, to simulate, and to assist prosthesis implantation for difficult cases of THR based on 3-D virtual models, generated by segmenting patients' CT images, 3-D solid models, obtained by rapid prototyping (RP), and virtual procedure simulation. We carried out 8 THR with the aid of 3-D reconstruction and RP. After each procedure a questionnaire was submitted to the surgeon to assess the perceived added value of the technology. In all cases, the surgeon evaluated the 3-D model as useful in order to perform the planning. The clinical results showed a mean increase in the Harris Hip Score of about 42.5 points. The mean time of prototyping was 7.3 hours, (min 3.5 hours, max 9.3 hours). The mean surgery time was 65 minutes (min 50 minutes, max 88 minutes). Our study suggests that meticulous preoperative planning is necessary in front of a great aberration of the joint and in absence of normal anatomical landmarks, CT scan is mandatory, and 3-D reconstruction with solid model is useful.

Carbon Fiber-Reinforced PolyEtherEtherKetone (CFR-PEEK) Instrumentation in Degenerative Disease of Lumbar Spine: A Pilot Study.

CFR-PEEK is gaining popularity in spinal oncological applications due to its reduction of imaging artifacts and radiation scattering compared with titanium, which allows for better oncological follow-up and efficacy of radiotherapy. We evaluated the use of these materials for the treatment of lumbar degenerative diseases (DDs) and considered the biomechanical potential of the carbon fiber in relation to its modulus of elasticity being similar to that of bone. Twenty-eight patients with DDs were treated using CRF-PEEK instrumentation. The clinical and radiographic outcomes were collected at a 12-month FU. Spinal fusion was evaluated in the CT scans using Brantigan scores, while the clinical outcomes were evaluated using VAS, SF-12, and EQ-5D scores. Out of the patients evaluated at the 12-month FU, 89% showed complete or almost certain fusion (Brantigan score D and E) and presented a significant improvement in all clinical parameters; the patients also presented VAS scores ranging from 6.81 ± 2.01 to 0.85 ± 1.32, EQ-5D scores ranging from 53.4 ± 19.3 to 85.0 ± 13.7, SF-12 physical component scores (PCSs) ranging from 29.35 ± 7.04 to 51.36 ± 9.75, and SF-12 mental component scores (MCSs) ranging from 39.89 ± 11.70 to 53.24 ± 9.24. No mechanical complications related to the implant were detected, and the patients reported a better tolerance of the instrumentation compared with titanium. No other series of patients affected by DD that was stabilized using carbon fiber implants have been reported in the literature. The results of this pilot study indicate the efficacy and safety of these implants and support their use also for spinal degenerative diseases.

Indications and Limits of Surgery for Spinal Metastases Derived from Lung Cancer: A Single-Center Experience.

Lung cancer is the second most frequently diagnosed cancer in the world, and surgery is an integral part of the treatment for spinal metastases. The aims of this retrospective study were to assess the overall survival of surgically treated patients affected by lung cancer spinal metastases and identify any factors related to a better survival rate. We recruited 56 consecutive patients (34 male and 22 female) surgically treated for metastatic lung cancer in the spine from 2009 to 2019. Surgical indications were based on a previously published and validated flow chart following a multidisciplinary evaluation. We assessed the localization of vertebral metastases, the presence of other bone or visceral metastases, neurological status according to the Frankel score, ambulatory autonomy, and general status, measured with the Karnofsky performance scale. The expected prognosis was retrospectively assessed according to the revised Tokuhashi score. The median survival was 8.1 months, with over a third of patients surviving more than 1 year. We observed a global improvement in all clinical parameters after surgical treatment. The Tokuhashi predictive score did not correlate with survival after surgery. The results of this study suggest that the surgical treatment of symptomatic spinal metastases from lung cancer can improve quality of life, even in patients with a shorter life expectancy, by controlling pain and improving autonomy.