Long-term comparison of anterior (ALIF) versus transforaminal (TLIF) lumbar interbody fusion: a propensity score-matched register-based study.

PURPOSE: Anterior (ALIF) and transforaminal (TLIF) lumbar interbody fusion have shown similar clinical outcomes at short- and medium-term follow-ups. Possible advantages of ALIF in the long run could be better disc height and lumbar lordosis and reduced risk of adjacent segment disease. We aimed to study if ALIF could be associated with superior clinical outcomes than TLIF at long-term follow-up. METHODS: We analysed 535 patients treated with ALIF or TLIF of the L5-S1 spinal segment between 2007 and 2017 who completed long-term follow-up in a national spine registry database (NORspine). We defined treatment success after surgery as at least 30% improvement in Oswestry Disability Index (ODI) at long-term follow-up. Patients treated with ALIF and TLIF and who responded at long term were balanced by propensity score matching. The proportions of successfully treated patients within each group were compared by numbers and percentages with corresponding relative risk. RESULTS: The mean (95%CI) age of the total study population was 50 (49-51) years, and 264 (49%) were females. The mean (95%CI) preoperative ODI score was 40 (39-42), and 174 (33%) had previous spine surgery. Propensity score matching left 120 patients in each treatment group. At a median (95%CI) of 92 (88-97) months after surgery, we found no difference in proportions successfully treated patients with ALIF versus TLIF (68 (58%) versus 77 (65%), RR (95%CI) = 0.88 (0.72 to1.08); p = 0.237). CONCLUSIONS: This propensity score-matched national spine register study of patients treated with ALIF versus TLIF of the lumbosacral junction found no differences in proportions of successfully treated patients at long-term follow-up. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Minimally invasive surgery versus standard posterior approach in the treatment of adolescent idiopathic scoliosis: a 2-year follow-up retrospective study.

PURPOSE: This is a monocentric retrospective controlled study that compares the safety and efficacy of posterior minimally invasive surgery (MISS) to standard posterior spinal fusion (PSF) surgery in adolescent idiopathic scoliosis (AIS). METHODS: We retrospectively collected 111 patients with Lenke type 1-6 AIS who were treated with MIS (n = 47) or PSF (n = 64) between February 2019 and January 2021 with a 2-year clinical and radiological follow-up. MIS technique was applied via two midline noncontiguous skin incisions ranging from 3 to 7 cm in length, so we obtained the arthrodesis only in the exposed tract, passing the rods below the fascia, avoiding the complete muscular sparing. Values of Cobb angles degrees were collected to study the correction rate of the structural major curve. Postoperative AP direct radiography and preoperative AP direct radiography were compared with the last follow-up examination. Operative time, preoperative hemoglobin (Hb) and second postoperative day Hb, full length of hospitalization, time to achieve verticalization and time to remove the drainage were recorded. NRS medium score was assessed immediately after surgery and during the whole postoperative rehabilitation treatment to estimate pain reduction. Complications were collected postoperatively and throughout the whole follow-up period. RESULTS: There was no significant difference between the two groups in terms of radiographic and clinical features. The correction rates of the structural curve resulted to be not significantly different between MISS and PSF (64.6 ± 11.7 vs 60.9 ± 13.2, p = 0.1292) as well as for the correction rate of the secondary curve between the two compared techniques (59.1 ± 13.2 vs 59.2 ± 12.4, p = 0.9865). The two groups had comparable operative time (210 min vs 215 min). The MIS group had a significantly lower reduction of postoperative Hb in comparison with PSF group (2.8 ± 1.3 mg/dl vs 4.3 ± 1.5 mg/dl, p < 0.0001). The postoperative NRS score was lower in MIS group (1.9 ± 0.8 vs 3.3 ± 1.3). PSF group was observed to have a significantly longer period of hospitalization than MIS (5.2 ± 1.4 days vs 6.3 ± 2.9 days, p = 0.206). Complications were more frequent in PSF group rather than in MFS group. CONCLUSIONS: MISS is a safe and capable alternative to PSF for AIS patients with curves < 70°, with analogue capacity of scoliosis correction and same operative time and with advantages in blood loss, length of stay and postoperative pain.

Iliolumbar vein: a challenge for the exposure of the L4-5 disc in the anterior approach to the lumbar spine.

PURPOSE: Anterior lumbar spine arthrodesis has been increasingly prescribed. In order to obtain better exposure of the intervertebral discs, it is necessary to identify vascular structures depending on the level to be approached. Systematic ligation of the iliolumbar vein has been suggested for access to the L4-L5 level, which may be technically challenging. The goal of the present study was to determine a safe limit for separating the iliolumbar vein safely without the need for its ligation. METHODS: In total, 2284 patients involving the topography of the iliolumbar vein were included. If this vein was up to 5 mm distant from the inferior border of the L4-L5 intervertebral disc, its ligature was performed. In cases that the distance was greater than 5 mm, only the retraction was performed without ligature. RESULTS: A total of 115 ligatures were necessary (5% of cases). Among the 2169 cases with no ligature, bleeding due to ruptures occurred during traction in only 55 patients (3% of cases). The time taken for ligation ranged from five minutes to thirty-two minutes, with an average of 18.3 min per ligature. In cases in which ligatures were needed (distance less than 5 mm), there was loosening of the ligatures leading to bleeding in 23 cases (20% of ligatures). CONCLUSIONS: Systematic ligature is not necessary for accessing the anterior route to the L4-L5 level, leading to a reduction in the time of surgery and avoiding serious vascular injuries that can occur.

The severity of preoperative anemia escalates risk of poor short-term outcomes after lumbar spine fusion.

OBJECTIVE: To evaluate how preoperative anemia severity affects 90-day outcomes of spinal fusion surgery. METHODS: A retrospective cohort study was conducted on adult lumbar fusion patients at a tertiary medical center. Patients were classified by World Health Organization anemia severity definitions for comparisons. Multivariate regression models were created to control for confounding variables, for all primary outcomes of transfusion requirements, non-home discharge, readmissions, complications, and length of stay. RESULTS: A total of 2582 patients were included: 2.7% with moderate-severe anemia, 11.0% with mild anemia, and 86.3% without anemia. Moderate-severe patients had the longest hospital stay (5.03 days vs 4.14 and 3.59 days, p < 0.001) and highest risk of transfusion (52.2% vs 13.0% vs 2.69%, p < 0.001), non-home discharge (39.1% vs 27.8% vs 15.4%, p < 0.001), readmission (7.25% vs 5.99% vs 3.36%, p = 0.023), and complications (13.0% vs 9.51% vs 6.20%, p = 0.012). On multivariable logistic regression, both patients with mild and moderate-severe anemia had an increased risk of transfusion (OR: 37.3, p < 0.001; OR: 5.25, p < 0.001, respectively) and non-home discharge (OR: 2.00, p = 0.021; OR: 1.71, p = 0.001, respectively) compared to patients without anemia. Anemia severity was not independently associated with complications or 90-day readmission. On multivariable linear regression, mild anemia (ß: 0.37, p = 0.001) and moderate-severe anemia (ß: 1.07, p < 0.001) were independently associated with length of hospital stay. CONCLUSION: Patients with moderate-severe preoperative anemia are at increased risk for longer length of stay, transfusions, and non-home discharge. Improved optimization of preoperative anemia may significantly reduce healthcare utilization, and surgeons should consider these risks in preoperative planning. LEVEL OF EVIDENCE: III.

Use of biphasic calcium phosphate versus demineralized bone matrix: retrospective clinical and CT analysis of posterolateral fusion results.

PURPOSE: Bone graft extenders have been developed to prevent donor site morbidity associated with iliac crest bone graft, but few studies compared the efficacy of various substitutes. Our purpose was to determine fusion rate and clinical outcome in patients undergoing lumbar arthrodesis using demineralized bone matrix (DBM) and biphasic calcium phosphate (BCP). METHODS: Patients with degenerative spondylolisthesis undergoing one-level or two-level arthrodesis of lumbar spine were retrospectively reviewed. Two treatment groups placed either BCP or DBM, in addition to local autograft in lumbar posterolateral space. Three-dimensional CT exam and dynamic flexion-extension radiographs at postoperative 2-year were assessed for posterolateral fusion status and pain scale and Oswestry Disability Index (ODI) for clinical outcome. RESULTS: Of the 148 patients reviewed (including 23 in one- and 58 patients in two-level in BCP group, and 47 in one- and 20 patients in two-level in DBM group), no significant differences were found in terms of age, sex, BMI, smoking, diabetes, steroids, number of level fused, non-union rate or revision surgery between BCP and DBM groups. Significantly improved pain scale of back and leg and ODI were found in both groups postoperatively without group difference. We found a comparable fusion rate in one-level surgery (100% versus 93.6%) and a superior fusion rate of BCP group in two-level surgery (98.3% versus 80.0%, p = 0.01). CONCLUSION: Being a bone graft extender without osteoinductive property, with local autograft, BCP is comparable to DBM for one- and superior for two-level fusion. No significant difference was found in clinical outcomes.

Impact of previous lumbar spine surgery on total hip arthroplasty and vice versa: How long should we be concerned about mechanical failure?

INTRODUCTION: This registry study aims to assess the prevalence and demographic characteristics of patients with lumbar spine (LS) surgical procedures who undergo total hip arthroplasty (THA), to compare the long-term survival and causes of failure of THA in patients who previously underwent LS fusion and non-fusion surgical procedures, and to evaluate the risk of undergoing a revision LS surgery after THA. MATERIALS AND METHODS: Patients who underwent LS surgery followed by THA were identified by cross-referencing data from the Orthopedic Prosthetic Implants Registry and the Regional Hospital Discharge Database. Three groups of THA patients were identified: patients who underwent previous lumbar surgery with fusion (LS fusion-THA), without fusion (LS non-fusion-THA), and a control group with only THA (No LS surgery-THA). Demographic data, THA survival, number and causes of failure, and data on revision procedures on THA and LS were collected. RESULTS: Of the total of 79,984 THA, 2.2% of patients had a history of LS procedures. THA only patients showed better results, while patients in the LS fusion-THA group had worse implant survival at 5-year follow-up. In the LS fusion-THA and LS non-fusion-THA, mechanical THA failures were more frequent in the first two years after implantation. There were no differences between groups regarding the risk of undergoing LS revision surgery. CONCLUSIONS: LS surgery negatively affects THA survivorship. In patients who previously underwent LS fusion and non-fusion surgical procedures, most THA failure occurs in the first two years after implant. The study contributes to the understanding of the relationship between the hip and the LS and provides useful guidance for clinical practice.

It is the Opioids Not the Spine Surgeon; Dislocation After Total Hip Arthroplasty is Associated With Opioid Use in Patients Who Have Prior Lumbar Spine Fusion.

BACKGROUND: Patients who have prior lumbar spine fusion (LSF) have an increased risk for dislocation after total hip arthroplasty (THA). These patients also have elevated rates of opioid use. We aimed to evaluate the associated risk of dislocation after THA in patients who have prior LSF comparing those who have opioid use to those who do not. METHODS: This was a retrospective review using a large national database of 246,617 primary and 34,083 revision THA cases from 2012 to 2019. There were 1,903 primary THA and 288 revision THA cases identified with LSF prior to THA. Postoperative hip dislocation was our primary outcome variable and patients were stratified to use or nonuse of opioid at THA. Demographic data including age, sex, and obesity were collected. Multivariate analyses evaluated association of opioid use and dislocation after adjusting for demographics. RESULTS: There was increased odds of dislocation for opioid use at THA for both primary (adjusted Odds Ratio [aOR] = 2.29, 95% Confidence Interval [CI] 1.46 to 3.57, P < .0003) and revision THA (aOR = 1.92, 95% CI 1.62 to 3.08, P < .0003), in patients who have prior LSF. Prior LSF without opioid use was associated with increased odds of dislocation (aOR = 1.38, 95% CI 1.01 to 1.88, P = .04), but this was lower than the associated risk of opioid use without LSF (aOR 1.72, 95% CI 1.63 to 1.81, P < .001). CONCLUSION: Increased odds of dislocation were noted with opioid use at time of THA in patients who have prior LSF. Associated risk of dislocation was higher for opioid use than prior LSF. This suggests that dislocation risk is multifactorial and we should look to strategies to reduce opioid use prior to THA.

The survey of bone allograft transplantation in a Japanese regional bone bank.

BACKGROUND: In reconstructive surgery for large bone defects, the demand for bone allografts has increased over the years; however, it is unclear how the supply and demand in Japanese regional bone banks have evolved over time. This study investigated the 15-year supply and demand of bone allografts stored in a regional bone bank, along with assessing the screening process's effectiveness. METHODS: The target period was 15 years from April 2005 to March 2020. The period was subdivided into three 5-year periods: first, second, and third. The study items included the number of bone allografts donated, the number of bone allografts used, donor and user facilities, surgical methods using bone allografts, and the number of bone allografts discarded. We used the Cochran-Armitage test for statistical analysis. RESULTS: A total of 1852 bone allografts were donated to the bone bank, and a total of 1721 were used. A total of 677 bone allografts grafts were provided in the first period, 738 in the second period, and 525 in the third period, indicating a decreasing trend. The average number of allografts per surgery was 2.8 in the first, 3.1 in the second, and 1.7 in the third, showing a decreasing trend. Concerning the percentage of each surgery using bone allografts, spine fusion decreased in the third period but not significantly, whereas primary hip arthroplasty increased significantly in the third period. The total number of discarded bone allografts was 4.8% of the total number of donated bone allografts, largely because of a lack of screening tests. CONCLUSION: Although the number of allogeneic bone surgeries has been increasing over time, the number of allogeneic bone donations has shown a decreasing trend, and there is a need to develop a system that can provide surgeons with sufficient bone allografts.

Cement discoplasty for managing lumbar spine pseudarthrosis in elderly patients: a less invasive alternative approach for failed posterior lumbar spine interbody fusion.

PURPOSE: A retrospective cohort study was performed to evaluate pseudoarthrosis treatment results by injection of cement in disc space of failed fusion in posterior lumbar interbody fusion in patients above 65 years. METHODS: Forty-five patients above 65 years with symptomatic pseudarthrosis after lumbar spine fusion were treated by cement injection in the affected disc space. RESULTS: There were 30 females and 15 males. The mean age at the operation was 74 ± 6.5 years (range 65-89). Discoplasty was performed after the primary fusion operations after a mean of 14 ± 1.3 months (range 12-24). The mean preoperative VAS was 7.5 (range 6-9), and ODI was 36 (range 30-45). Cement injection was done at one level in most of the cases (35 patients). In seven cases, two injection levels were done, and in three cases, three levels. Twenty-three patients had discoplasty only, while 22 had discoplasty and screws change, including 14 cases of extension of the instrumentation. The mean postoperative follow-up was 32 ± 6.5 months. The VAS improved to 3.5 (range 2-5) (p = 0.02) and ODI to 12.3 (range 5-35) (p = 0.001). Reoperation was indicated in two (4%) patients by screws loosening. Asymptomatic cement leakage occurred in the paravertebral space in seven cases (15.5%). CONCLUSION: Cement discoplasty offers a less invasive reliable surgical solution in elderly patients with symptomatic lumbar pseudarthrosis in the elderly patients. In cases with screw loosening, discoplasty should be combined with screw revision.

Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis.

PURPOSE: Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery. METHODS: We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale. RESULTS: Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses. CONCLUSION: Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates. LEVEL OF EVIDENCE: II.

Onset of mental disorders in patients who developed failed back surgery syndrome.

PURPOSE: Failed back surgery syndrome (FBSS) is a complex and multifaceted condition associated with significant disability and morbidity. The purpose of this study was to investigate the association between FBSS with new incidences of mental health disorders. METHODS: Our cohort included patients diagnosed with FBSS within 12 months of a posterior fusion, laminectomy, or discectomy, identified using The International Classification of Disease, both Ninth and Tenth Revisions (ICD-9 and ICD-10). In the next step, both non-FBSS and FBSS-diagnosed patients were queried for the diagnosis of first-time occurrence of mental health disorders. The incidence of new mental health disorders was determined within 12-months following FBSS diagnosis. RESULTS: FBSS patients were significantly at greater risk than non-FBSS patients of developing all included mental health pathologies: Depression: OR 1.9, 95% CI 1.8-2.0, p < 0.0001); Anxiety: OR 1.5, 95% CI 1.4-1.6, p < 0.0001; Sleep Disorder: OR 1.9, 95% CI 1.7-2.0, p < 0.0001; Bipolar Disorder: OR 1.7, 95% CI 1.5-2.0 p < 0.0001; PTSD: OR 1.5, 95% CI 1.3-1.8, p < 0.0001; Panic Disorder: OR 1.8, 95% CI 1.5-2.1, p < 0.0001; Suicidal Disorder: OR 1.7 95% CI 1.4-2.0, p < 0.0001, ADHD: OR 1.3, 95% CI 1.0-1.5, p = 0.0367. CONCLUSIONS: In the current study, patients diagnosed with FBSS were at a significantly greater risk of developing mental health pathologies. While other studies have suggested pre-surgical psychological support and treatment, the current results suggest that a post-operative psychologic care may also be warranted. By identifying potential psychosocial unforeseen obstacles that occur in patients diagnosed with FBSS, more precise treatment pathways can be developed leading to improved patient outcomes.

Need of vascular surgeon and comparison of value for anterior lumbar interbody fusion (ALIF) in lateral decubitus: Delphi consensus.

BACKGROUND AND PURPOSE: Anterior lumbar approaches are recommended for clinical conditions that require interbody stability, spinal deformity corrections or a large fusion area. Anterior lumbar interbody fusion in lateral decubitus position (LatALIF) has gained progressive interest in the last years. The study aims to describe the current habit, the perception of safety and the perceptions of need of vascular surgeons according to experienced spine surgeons by comparing LatALIF to the standard L5-S1 supine ALIF (SupALIF). METHODS: A two-round Delphi method study was conducted to assess the consensus, within expert spine surgeons, regarding the perception of safety, the preoperative planning, the complications management and the need for vascular surgeons by performing anterior approaches (SupALIF vs LatALIF). RESULTS: A total of 14 experts voluntary were involved in the survey. From 82 sentences voted in the first round, a consensus was reached for 38 items. This included the feasibility of safe LatALIF without systematic involvement of vascular surgeon for routine cases (while for revision cases the involvement of the vascular surgeon is an appropriate option) and the appropriateness of standard MRI to evaluate the accessibility of the vascular window. Thirteen sentences reached the final consensus in the second round, whereas no consensus was reached for the remaining 20 statements. CONCLUSIONS: The Delphi study collected the consensus on several points, such as the consolidated required experience on anterior approaches, the accurate study of vascular anatomy with MRI, the management of complications and the significant reduction of the surgical times of the LatALIF if compared to SupALIF in combined procedures. Furthermore, the study group agrees that LatALIF can be performed without the need for a vascular surgeon in routine cases.

Lumbar surgical drains do not increase the risk of infections in patients undergoing spine surgery.

PURPOSE: The aim of this study was to characterize if the use of surgical drains or length of drain placement following spine surgery increases the risk of post-operative infection. METHODS: Records of patients undergoing elective spinal surgery at a tertiary care center were collected between May 5, 2016 and August 16, 2018. Pre-operative baseline characteristics were recorded including patient's demographics and comorbidities. Intraoperative procedure information was documented related to procedure type, blood loss, and antibiotics used. Following surgery, patients were then further subdivided into two groups: patients who were discharged with a spinal surgical site drain and patients who did not receive a drain. Post-operative surgical variables included length of stay (LOS), drain length, number of antibiotics given, and type of post-operative infection. Univariate and multivariate statistical analysis was conducted. RESULTS: A total of 671 patients were included in the current study, 386 (57.5%) with and 285 (42.5%) without the drain. The overall infection rate was 5.7% with 6.22% among patients with the drain compared to 4.91% in patients without drain. The univariate analysis identified the following variables to be significantly associated with the infection: total number of surgical levels, spinal region, blood loss, redosing of antibiotics, length of stay, length of drain placement, and number of antibiotics (P < 0.05). However, the multivariate analysis none of the predictors was significant. CONCLUSIONS: The current study shows that the placement of drain does not increase rate of infection, irrespective of levels, length of surgery, or approach.

Self-reported pain during the initial postoperative period following open lumbar spine fusion surgery does not correlate with the number of levels fused: A prospective trial of 40 patients.

BACKGROUND: Current spine postoperative pain control protocols consider the expected pain following spine fusion surgery to correlate with surgical extent, that is, the greater the number of operated vertebrae, the greater the postoperative pain. Due to this assumption, Enhanced Recovery After Surgery (ERAS) protocols are principally applied to minimally invasive and percutaneous spine surgery and less to open extensive spine fusion operations. The aim of this study was to determine whether postoperative pain does in fact correlate with the surgical extent, potentially opening the door to non-narcotic postoperative pain protocols for this patient subset. MATERIALS AND METHODS: Forty consecutive patients, undergoing open posterior spine surgery, were evaluated for postoperative pain during the first 72 after surgery. All patients were then divided into two groups according to the number of spine levels fused, and the correlation between the number of fusion levels and self-reported pain was analyzed statistically. RESULTS: Self-reported pain levels were not found to correlate with the extent of the spine operation. CONCLUSIONS: As "bigger operation" does not necessarily equate with "bigger pain," adequate postoperative pain control after extensive spine fusion surgery might be achieved without the routine use of narcotic medication, as practiced after minimally invasive and percutaneous surgery. Additional prospective randomized trials are needed to further substantiate this conclusion.

Assessment of the efficacy of teriparatide treatment for osteoporosis on lumbar fusion surgery outcomes: a systematic review and meta-analysis.

Treatment of osteoporosis with medications like teriparatide, a parathyroid hormone, is known to improve bone density and reduce the risk of osteoporotic vertebral fractures. Anecdotal and limited surgical series have described the utility of this treatment for osteoporotic patients prior to spinal fusion surgery, but there is variability in adoption of this strategy as well as consensus regarding optimal treatment duration before and after surgery. In this study, the clinical results of the use of teriparatide for this application are reviewed and critically examined. We conducted a systematic review of electronic databases using different MeSH terms from 1980 to 2020. Pooled and subgroup analyses were performed using fixed and random effect models based upon the heterogeneity (I2). The results were reported as either mean difference (MD) or odds ratio (OR) with 95% confidence interval (CI). A total of 771 patients from 12 studies were identified. Three hundred seventy-seven patients (90.8% females) were treated with teriparatide. Lumbar spinal fusion rates were significantly higher among patients who received teriparatide compared to the non-teriparatide group (OR 2.15, 95%CI 1.56-2.97, p < 0.00001). Subgroup analysis revealed that patients receiving teriparatide demonstrated 2.12-fold and 2.23-fold higher likelihood of fusion compared to those in the bisphosphonate (OR 2.12, 95%CI 1.45-3.11, p = 0.0001) and placebo (OR 2.23, 95%CI 1.22-4.08, p = 0.009) cohorts, respectively. The treatment effect of teriparatide was associated with significantly reduced subsequent vertebral fractures (OR 0.16, 95%CI 0.06-0.41, p = 0.0002), sagittal malalignment (MD - 3.85, 95%CI: -6.49 to - 1.21, p = 0.004), limb visual analogue score (VAS) (MD - 0.36, 95%CI - 0.64 to - 0.09, p = 0.008), and spinal VAS (MD - 0.24, 95%CI - 0.44 to - 0.04, p = 0.02) compared to the non-teriparatide group. Patients using teriparatide had 30% less likelihood of screw loosening at last follow-up compared to the non-teriparatide group; however, this was not statistically significant (OR 0.70, 95%CI 0.43-1.14, p = 0.15). There did not exist any statistically significant difference between the two comparative groups in terms of pseudoarthrosis (OR 0.54, 95%CI 0.24-1.21, p = 0.13), cage subsidence (OR 1.30, 95%CI 0.38-4.52, p = 0.68), and bone mineral density (MD 0.04, 95%CI - 0.19-0.29, p = 0.74) at last follow-up examination. This meta-analysis corroborates the effectiveness of teriparatide resulting in higher fusion rates. Further study is required to determine the optimal duration of treatment and timing of surgery.

Advances in surgical hemostasis: a comprehensive review and meta-analysis on topical tranexamic acid in spinal deformity surgery.

Tranexamic acid (TXA) is an effective and commonly used hemostatic agent for perioperative blood loss in various surgical specialties. It is being increasingly used in spinal deformity surgery. We aimed to evaluate the safety and efficacy of topical TXA (tTXA) compared to both placebo and/or intravenous (IV) TXA in patients undergoing spinal deformity surgery. We conducted a systematic review of the electronic databases using different MeSH terms from January 1970 to August 2019. Pooled and subgroup analysis was performed using fixed and random-effect model based upon the heterogeneity (I2). A total of 609 patients (tTXA: n = 258, 42.4%) from 8 studies were included. We found that there was a statistically significant difference in terms of (i) postoperative blood loss [mean difference (MD) - 147.1, 95% CI - 189.5 to - 104.8, p < 0.00001], (ii) postoperative hemoglobin level (MD 1.09, 95% CI 0.45 to 1.72, p = 0.0008), (iii) operative time (MD 7.47, 95% CI 2.94 to 12.00, p < 0.00001), (iv) postoperative transfusion rate [odds ratio (OR) 0.39, 95% CI 0.20 to 0.78, p = 0.007], postoperative drain output (MD, - 184.0, 95% CI - 222.03 to - 146.04, p < 0.00001), and (v) duration of hospital stay (MD - 1.14, 95% CI - 1.44 to - 0.85, p < 0.00001) in patients treated with tTXA compared to the control group. However, there was no significant difference in terms of intraoperative blood loss (p = 0.13) and complications (p = 0.23) between the two comparative groups. Furthermore, low-dose (250-500 mg) tTXA (p < 0.00001) reduced postoperative blood loss more effectively compared to high-dose tTXA (1-3 g) (p = 0.001). Our meta-analysis corroborates the effectiveness and safety of tTXA in spinal deformity surgery.

The impact of bisphosphonates on postoperative complication rates in osteoporotic patients undergoing posterior lumbar fusion.

PURPOSE: To elucidate the effects of bisphosphonates on complications following posterior lumbar fusion (PLF) with a large database study. METHODS: The PearlDiver Patient Record Database was queried to identify adult patients who had undergone posterior lumbar fusion (PLF). Those patient cohorts were divided based on a diagnosis of osteoporosis prior to surgery and bisphosphonate usage. This yielded three groups: Osteo+Bisph+, Osteo+Bisph-, and Osteo-Bisph-. The primary outcome of the present study was revision rates at 6 months and 1 year following surgery. Incidence of postoperative complications was analyzed, and statistical analysis was conducted using Pearson chi-square analysis. RESULTS: Patients taking bisphosphonates did not have significantly different rates of revision surgery at 6 months and 1 year, instrumentation complications, or post-vertebral fractures than patients not taking bisphosphonates. Additionally, osteoporotic patients did not have significantly different rates of these complications than patients without osteoporosis. CONCLUSION: Bisphosphonate usage did not significantly affect the rates of postoperative complications following posterior lumbar fusion. Further research is required to fully elucidate the effects of bisphosphonates on outcomes and complications following spine surgery.

Risk factors for blood transfusion in adolescent patients with scoliosis undergoing scoliosis surgery: a study of 722 cases in a single center.

BACKGROUND: To assess the risk factors for blood transfusion in a great number of adolescent cases with different types of scoliosis who received scoliosis surgery. METHODS: Data of patients who were diagnosed as scoliosis and received one-stage posterior correction and spinal fusion from January 2014 to December 2017 were prospectively collected and retrospectively analyzed. Patients' demographic characteristics, segments of spinal fusion, Cobb angle of the major curve,osteotomy pattern, preoperative and postoperative levels of hemoglobin, and allogeneic blood transfusion (ABT) were recorded and analyzed. RESULTS: In this study, 722 cases with adolescent scoliosis were included, of whom 32.8% (237/722) received ABT. Risk factors included diagnosis: neurofibromatosis (OR = 5.592), syndromic (OR = 3.029),osteotomy: Ponte osteotomy (OR = 5.997), hemivertebrae resection (OR = 29.171), pedicle subtraction osteotomy (PSO)(OR = 8.712), vertebral column resection (VCR)(OR = 32.265);fusion segments (OR = 1.224) and intraoperative blood loss (OR = 1.004). In the subgroup analysis of cases with idiopathic scoliosis, Ponte osteotomy (OR = 6.086), length of segments of spinal fusion (OR = 1.293), and intraoperative blood loss (OR = 1.001) were found as risk factors for ABT. Results of receiver operating characteristic (ROC) curve analysis revealed that length of segments of spinal fusion equal to 11.5 vertebrae was the best cutoff value for cases with idiopathic scoliosis who did not receive osteotomy in both ABT group and non-ABT group. In the subgroup analysis of congenital scoliosis, Ponte osteotomy (OR = 5.087), hemivertebra resection (OR = 5.457), PSO (OR = 4.055), VCR (OR = 6.940), and intraoperative blood loss (OR = 1.004) were risk factors for ABT. CONCLUSIONS: Method of diagnosis, osteotomy pattern, segments of spinal fusion, and intraoperative blood loss were risk factors for ABT in cases with adolescent scoliosis. In cases with idiopathic scoliosis, Ponte osteotomy and segments of spinal fusion longer than 11.5 vertebrae were risk factors for ABT. In cases with congenital scoliosis, osteotomy pattern was the main risk factor for ABT. LEVEL OF EVIDENCE: Level III.

Epidural hematoma in patients with ankylosing spondylitis requiring surgical stabilization: a single-institution retrospective review with literature analysis.

OBJECTIVE: Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the sacroiliac joints and axial spine that is closely linked with human leukocyte antigen-B27. There appears to be an increased frequency of associated epidural hematomas in spine fractures in patients with AS. The objective was to review the incidence within the literature and a single-institution experience of the occurrence of epidural hematoma in the context of patients with AS requiring spine surgery. METHODS: Deep 6 AI software was used to search the entire database of patients at a single level I trauma center (since the advent of the institution's modern electronic health record system) to look at all patients with AS who underwent spinal surgery and who had a diagnosis of epidural hematoma. Additionally, a systemic literature review was performed of all papers evaluating the incidence of epidural hematoma in patients with spine fractures. RESULTS: A single-institution, retrospective review of records from 2009 to 2020 yielded a total of 164 patients with AS who underwent spine surgery. Of those patients, 17 (10.4%) had epidural hematomas on imaging, with the majority requiring surgical decompression. These spine fractures occurred close to the cervicothoracic or thoracolumbar junction. The patients ranged in age from 51 to 88 years, and there were 14 males and 3 females in the cohort. Eight patients were administered an antiplatelet and/or anticoagulant agent, and the rest were not. All patients required surgical stabilization, with 64.7% of patients also requiring decompressive laminectomies for evacuation of the hematoma and spinal cord decompression. Only 1 death was reported in the series. There was a tendency toward neurological improvement after surgical intervention. CONCLUSIONS: AS has been a well-described pathologic process that leads to an increased risk of three-column injury in spine fracture, with an increased incidence of symptomatic epidural hematoma compared with patients without AS. Early recognition of this entity is important to ensure that appropriate surgical management includes addressing compression of the neural elements in addition to surgical stabilization.

Real-time navigation guidance with intraoperative CT imaging for pedicle screw placement using an augmented reality head-mounted display: a proof-of-concept study.

OBJECTIVE: Augmented reality (AR) has the potential to improve the accuracy and efficiency of instrumentation placement in spinal fusion surgery, increasing patient safety and outcomes, optimizing ergonomics in the surgical suite, and ultimately lowering procedural costs. The authors sought to describe the use of a commercial prototype Spine AR platform (SpineAR) that provides a commercial AR head-mounted display (ARHMD) user interface for navigation-guided spine surgery incorporating real-time navigation images from intraoperative imaging with a 3D-reconstructed model in the surgeon's field of view, and to assess screw placement accuracy via this method. METHODS: Pedicle screw placement accuracy was assessed and compared with literature-reported data of the freehand (FH) technique. Accuracy with SpineAR was also compared between participants of varying spine surgical experience. Eleven operators without prior experience with AR-assisted pedicle screw placement took part in the study: 5 attending neurosurgeons and 6 trainees (1 neurosurgical fellow, 1 senior orthopedic resident, 3 neurosurgical residents, and 1 medical student). Commercially available 3D-printed lumbar spine models were utilized as surrogates of human anatomy. Among the operators, a total of 192 screws were instrumented bilaterally from L2-5 using SpineAR in 24 lumbar spine models. All but one trainee also inserted 8 screws using the FH method. In addition to accuracy scoring using the Gertzbein-Robbins grading scale, axial trajectory was assessed, and user feedback on experience with SpineAR was collected. RESULTS: Based on the Gertzbein-Robbins grading scale, the overall screw placement accuracy using SpineAR among all users was 98.4% (192 screws). Accuracy for attendings and trainees was 99.1% (112 screws) and 97.5% (80 screws), respectively. Accuracy rates were higher compared with literature-reported lumbar screw placement accuracy using FH for attendings (99.1% vs 94.32%; p = 0.0212) and all users (98.4% vs 94.32%; p = 0.0099). The percentage of total inserted screws with a minimum of 5° medial angulation was 100%. No differences were observed between attendings and trainees or between the two methods. User feedback on SpineAR was generally positive. CONCLUSIONS: Screw placement was feasible and accurate using SpineAR, an ARHMD platform with real-time navigation guidance that provided a favorable surgeon-user experience.