Association of Untreated Pre-surgical Depression With Pain and Outcomes After Spinal Surgery.

STUDY DESIGN: Prospective Cohort Study. OBJECTIVE: Untreated pre-surgical depression may prolong post-surgical pain and hinder recovery. However, research on the impact of untreated pre-surgical depression on post-spinal surgery pain is lacking. Therefore, this study aimed to assess pre-surgical depression in patients and analyze its relationship with post-surgical pain and overall post-surgical outcomes. METHODS: We recruited 100 patients scheduled for lumbar spine surgery due to spondylolisthesis, degenerative lumbar disc diseases, and herniated lumbar disc diseases. Psychiatrists evaluated them for the final selection. We assessed the Beck Depression Inventory (BDI), Japanese Orthopaedic Association (JOA), Oswestry Disability Index (ODI), and EuroQoL 5 Dimensions (EQ-5D) scores, numerical back and leg pain scales, and medication dosage data collected before and at 6 weeks, 3 months, and 6 months after surgery. RESULTS: Ninety-one patients were included in this study; 40 and 51 were allocated to the control and depression groups, respectively. The pre- and post-surgical leg pain, back pain, and functional scores were not different. However, the depression group showed higher ODI and EQ-5D and lower JOA scores than the control group 3 months post-surgery. Partial correlation analysis revealed an inverse correlation between the JOA and BDI scores and a positive correlation between the EQ-5D and BDI scores at 3 months postoperatively. CONCLUSION: Untreated depression can prolong postoperative pain and hinder recovery. Detecting and treating depression in patients before spine surgery may improve their overall quality of life and functional recovery.

Proximity Between Screw and Endplate of Upper Instrumented Vertebra Using a Cortical Bone Trajectory Screw can Increase Radiographic Adjacent Segment Degeneration Risks in Patients With Lumbar Spinal Stenosis.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To determine the proximity between screw and endplate of the upper instrumented vertebra (UIV) using a cortical bone trajectory (CBT) screw as a predictive factor for radiographic adjacent segment degeneration (ASD) in patients surgically treated with transforaminal lumbar interbody fusion (TLIF) with CBT screws (CBT-TLIF) with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: The risk factors for radiographic ASD after CBT-TLIF remain unknown. METHODS: Among patients surgically treated with CBT-TLIF at a single institute, 239 consecutive patients (80 males and 159 females) were enrolled. ASD was defined by the presence of one or more of the following three radiologic criteria on the adjacent segment: >3 mm anteroposterior translation, >10° segmental kyphosis, or >50% loss of disc height comparing immediate postoperative and 1-year follow-up radiographs. Clinical and radiological features associated with the development of ASD were retrospectively measured. Univariate and multivariate analyses were performed to identify risk factors associated with radiographic ASD. RESULTS: Radiographic ASD was observed in 71 (29.7%) cases at 1-year postoperative follow-up. The preoperative Pfirrmann grade of the adjacent segment (>grade 2), multi-level fusion (>2 levels), and proximity between the tip of CBT screws and endplate on the UIV were significantly associated with radiographic ASD (OR = 3.98, 95% CI [1.06-15.05], P=0.042 versus OR = 3.03, 95% CI [1.00-9.14], P=0.049 versus OR = 0.53, 95% CI [0.40-0.72], P<0.001). The cut-off value of the distance between the tip of the screw and endplate on UIV for radiographic ASD was approximately 2.5 mm (right-sided CBT screw; cut-off value 2.48 mm/ left-sided CBT screw; cut-off value 2.465 mm). CONCLUSION: Radiographic adjacent segment degeneration progression can occur when the cortical trajectory bone screw is close to the endplate of the upper instrumented vertebrae in patients with lumbar spinal stenosis undergoing fusion surgery.

The effect of high perioperative inspiratory oxygen fraction for abdominal surgery on surgical site infection: a systematic review and meta-analysis.

Guidelines from the World Health Organization strongly recommend the use of a high fraction of inspired oxygen (FiO2) in adult patients undergoing general anesthesia to reduce surgical site infection (SSI). However, previous meta-analyses reported inconsistent results. We aimed to address this controversy by focusing specifically on abdominal surgery with relatively high risk of SSI. Medline, EMBASE, and Cochrane CENTRAL databases were searched. Randomized trials of abdominal surgery comparing high to low perioperative FiO2 were included, given that the incidence of SSI was reported as an outcome. Meta-analyses of risk ratios (RR) were performed using a fixed effects model. Subgroup analysis and meta-regression were employed to explore sources of heterogeneity. We included 27 trials involving 15977 patients. The use of high FiO2 significantly reduced the incidence of SSI (n = 27, risk ratio (RR): 0.87; 95% confidence interval (CI): 0.79, 0.95; I2 = 49%, Z = 3.05). Trial sequential analysis (TSA) revealed that z-curve crossed the trial sequential boundary and data are sufficient. This finding held true for the subgroup of emergency operations (n = 2, RR: 0.54; 95% CI: 0.35, 0.84; I2 = 0%, Z = 2.75), procedures using air as carrier gas (n = 9, RR: 0.79; 95% CI: 0.69, 0.91; I2 = 60%, Z = 3.26), and when a high level of FiO2 was maintained for a postoperative 6 h or more (n = 9, RR: 0.68; 95% CI: 0.56, 0.83; I2 = 46%, Z = 3.83). Meta-regression revealed no significant interaction between SSI with any covariates including age, sex, body-mass index, diabetes mellitus, duration of surgery, and smoking. Quality of evidence was assessed to be moderate to very low. Our pooled analysis revealed that the application of high FiO2 reduced the incidence of SSI after abdominal operations. Although TSA demonstrated sufficient data and cumulative analysis crossed the TSA boundary, our results should be interpreted cautiously given the low quality of evidence.Registration: https://www.crd.york.ac.uk/prospero (CRD42022369212) on October 2022.

Risk estimation for idiopathic normal-pressure hydrocephalus: development and validation of a brain morphometry-based nomogram.

OBJECTIVES: To develop and validate a nomogram based on MRI features for predicting iNPH. METHODS: Patients aged ≥ 60 years (clinically diagnosed with iNPH, Parkinson's disease, or Alzheimer's disease or healthy controls) who underwent MRI including three-dimensional T1-weighted volumetric MRI were retrospectively identified from two tertiary referral hospitals (one hospital for derivation set and the other for validation set). Clinical and imaging features for iNPH were assessed. Deep learning-based brain segmentation software was used for 3D volumetry. A prediction model was developed using logistic regression and transformed into a nomogram. The performance of the nomogram was assessed with respect to discrimination and calibration abilities. The nomogram was internally and externally validated. RESULTS: A total of 452 patients (mean age ± SD, 73.2 ± 6.5 years; 200 men) were evaluated as the derivation set. One hundred eleven and 341 patients were categorized into the iNPH and non-iNPH groups, respectively. In multivariable analysis, high-convexity tightness (odds ratio [OR], 35.1; 95% CI: 4.5, 275.5), callosal angle < 90° (OR, 12.5; 95% CI: 3.1, 50.0), and normalized lateral ventricle volume (OR, 4.2; 95% CI: 2.7, 6.7) were associated with iNPH. The nomogram combining these three variables showed an area under the curve of 0.995 (95% CI: 0.991, 0.999) in the study sample, 0.994 (95% CI: 0.990, 0.998) in the internal validation sample, and 0.969 (95% CI: 0.940, 0.997) in the external validation sample. CONCLUSION: A brain morphometry-based nomogram including high-convexity tightness, callosal angle < 90°, and normalized lateral ventricle volume can help accurately estimate the probability of iNPH. KEY POINTS: • The nomogram with MRI findings (high-convexity tightness, callosal angle, and normalized lateral ventricle volume) helped in predicting the probability of idiopathic normal-pressure hydrocephalus. • The nomogram may facilitate the prediction of idiopathic normal-pressure hydrocephalus and consequently avoid unnecessary invasive procedures such as the cerebrospinal fluid tap test, drainage test, and cerebrospinal fluid shunt surgery.

T-cell specific antibody induction versus corticosteroid induction immunosuppression for liver transplant recipients: a meta-analysis.

Corticosteroids remain the mainstay of immunosuppression for liver transplant recipients despite several serious complications including infection, hepatitis C virus (HCV) recurrence, diabetes mellitus (DM), and hypertension. We attempted to compare the safety and efficacy of T-cell specific antibody induction with complete corticosteroid avoidance. We searched MEDLINE, EMBASE, and Cochrane central library. Randomized controlled trials comparing T-cell specific antibody induction with corticosteroid induction immunosuppression were included. Our primary outcome was the incidence of biopsy-proven acute rejection. Eleven trials involving 1683 patients were included. The incidence of acute rejection was not significantly different between the antibody and steroid induction groups (risk ratio [RR] 0.85, 95% confidence interval [CI] 0.72, 1.01, P = 0.06, I2 = 0%). However, T-cell specific antibody induction significantly reduced the risk of cytomegalovirus infection (RR 0.48, 95% CI 0.33, 0.70, P = 0.0002, I2 = 3%), HCV recurrence (RR 0.89, 95% CI 0.80, 0.99, P = 0.03, I2 = 0%), DM (RR 0.41, 95% CI 0.32, 0.54, P < 0.0001, I2 = 0%) and hypertension (RR 0.71, 95% CI 0.55, 0.90, P = 0.005, I2 = 35%). Trial sequential analysis for acute rejection showed that the cumulative z-curve did not cross the Trial sequential boundary and the required information size was not reached. T-cell specific antibody induction compared to corticosteroid induction seems to significantly reduce opportunistic infections including cytomegalovirus infection and HCV recurrence and metabolic complications including DM and hypertension. However, given the insufficient study power, low quality of evidence, and heterogeneous immunosuppressive regimens, our results should be cautiously appreciated.

Arthroscopic debridement for septic arthritis of the shoulder joint: post-infectious arthritis is an inevitable consequence?

PURPOSE: The purpose of this study was to compare clinical outcomes and development of post-infectious arthritis of the shoulder joint after single (Group S) or repeated (Group R) arthroscopic debridement surgeries. We hypothesized that (1) repeated surgeries might be attributable to initial subchondral involvement resulting from septic arthritis and (2) the repeated surgery group would exhibit a higher incidence of post-infectious arthritic changes and inferior clinical outcomes due to prolonged resolution of the infection. METHODS: This study included 42 patients (single surgery, n = 29; repeated surgery, n = 13) who underwent arthroscopic debridement for septic arthritis and had a minimum of 2 years of postoperative follow-up data. All patients underwent preoperative magnetic resonance imaging (MRI) with gadolinium enhancement to evaluate subchondral bone involvement suspicious for osteomyelitis secondary to septic arthritis and extension of infection around the glenohumeral joint. Functional and radiological outcomes were assessed. RESULTS: Group S experienced a shorter duration (25.4 days) of infection than Group R (39.7 days) (p = 0.002). Increased signal intensity in the subchondral bone on preoperative MRI was identified in 9 patients (31%) in Group S and 5 patients (38%) in Group R. Post-infectious arthritic changes developed in 6 (21%) and 5 (38%) in Groups S and R, respectively. However, there were no significant differences between groups. At the final follow-up, there were no significant differences in functional assessments. CONCLUSION: Despite a prolonged period of infection in the repeated surgery group, there was no significant difference in development of post-infectious arthritic changes or clinical outcomes in patients requiring single or repeated surgeries. LEVEL OF EVIDENCE: Retrospective comparative study, III.

Atypical traumatic anterior shoulder instability with excessive joint laxity: recurrent shoulder subluxation without a history of dislocation.

BACKGROUND: No previously published studies have examined recurrent traumatic incomplete events in patients with excessive joint laxity. The purpose of this study is to investigate outcomes after arthroscopic stabilization for recurrent traumatic shoulder subluxation in patients with excessive joint laxity but no history of dislocation. METHODS: This study included 23 patients with glenoid bone defects less than 20% who underwent arthroscopic stabilization of recurrent shoulder subluxation and were available for at least 2 years follow-up. Outcomes were assessed with the subjective shoulder value (SSV), University of California Los Angeles (UCLA) shoulder score, Rowe score, and sports/recreation activity level. RESULTS: Postoperatively, overall functional scores improved significantly (p <  0.001), compared to preoperative scores: SSV improved from 49.1 to 90.4; Rowe score improved from 36.7 to 90.2; and UCLA shoulder score improved from 26.3 to 32.5. Patient satisfaction rate was 87% (20/23 patients). Sports/recreation activity level (return to premorbid activity level; grade I = 100% to grade IV = less than 70%) was grade I in 7 patients, grade II in 11, grade III in 3, grade IV in 2. The incidence of any glenoid bone defect was 61% (14/23 patients), and the mean glenoid bone defect size was 8%; among these 14 patients, 8 (35%) exhibited 15-20% glenoid bone defects. Instability reoccurred in 2 patients (9%) who had 15-20% glenoid bone defect. CONCLUSION: Despite excessive joint laxity, overall functional outcomes after arthroscopic stabilization of recurrent shoulder subluxation were satisfactory. However, arthroscopic Bankart repair may not be reliable in patients with excessive joint laxity plus a glenoid bone defect size of more than approximately 15%.