Thermographic assessment of skin temperature after lumbar spine surgery: Useful method for detection of wound complications? A pilot study.

BACKGROUND: Wound complications after lumbar spine surgery may result in prolonged hospitalization and increased morbidity. Early identification can trigger appropriate management. OBJECTIVE: The aim of this study was to investigate the efficacy of infrared-based wound assessment (FLIR) after lumbar spine surgery in the context of identifying wound healing disorders. METHODS: 62 individuals who underwent lumbar spine surgery were included. The immediate postoperative course was studied, and the patient's sex, age, body mass index (BMI), heart rate, blood pressure, body temperature, numeric rating scale for pain (NRS), C-reactive protein (CRP), leukocyte, and hemoglobin levels were noted and compared to thermographic measurement of local surface temperature in the wound area. RESULTS: Measurement of local surface temperature in the wound area showed a consistent temperature distribution while it was uneven in case of wound healing disorder. In this instance, the region of the wound where the wound healing disorder occured had a lower temperature than the surrounding tissue (p> 0.05). CONCLUSIONS: This study demonstrates the ongoing importance of clinical wound assessment for early detection of complications. While laboratory parameter measurement is crucial, FLIR may serve as a cost-effective supplemental tool in clinical wound evaluation. Patient safety risks appear minimal since local ST is measured without touch.

Preoperative Performance Status Threshold for Favorable Surgical Outcome in Metastatic Spine Disease.

BACKGROUND AND OBJECTIVES: Surgical treatment is an integral component of multimodality management of metastatic spine disease but must be balanced against the risk of surgery-related morbidity and mortality, making tailored surgical counseling a clinical challenge. The aim of this study was to investigate the potential predictive value of the preoperative performance status for surgical outcome in patients with spinal metastases. METHODS: Performance status was determined using the Karnofsky Performance Scale (KPS), and surgical outcome was classified as "favorable" or "unfavorable" based on postoperative changes in neurological function and perioperative complications. The correlation between preoperative performance status and surgical outcome was assessed to determine a KPS-related performance threshold. RESULTS: A total of 463 patients were included. The mean age was 63 years (range: 22-87), and the mean preoperative KPS was 70 (range: 30-100). Analysis of clinical outcome in relation to the preoperative performance status revealed a KPS threshold between 40% and 50% with a relative risk of an unfavorable outcome of 65.7% in KPS ≤40% compared with the relative chance for a favorable outcome of 77.1% in KPS ≥50%. Accordingly, we found significantly higher rates of preserved or restored ambulatory function in KPS ≥50% (85.7%) than in KPS ≤40% (48.6%; P < .001) as opposed to a significantly higher risk of perioperative mortality in KPS ≤40% (11.4%) than in KPS ≥50% (2.1%, P = .012). CONCLUSION: Our results underline the predictive value of the KPS in metastatic spine patients for counseling and decision-making. The study suggests an overall clinical benefit of surgical treatment of spinal metastases in patients with a preoperative KPS score ≥50%, while a high risk of unfavorable outcome outweighing the potential clinical benefit from surgery is encountered in patients with a KPS score ≤40%.

Increased stability due to symmetric cement volume in augmented pedicle screws? A biomechanical study.

Pedicle screw instrumentation has become "state of the art" in surgical treatment of many spinal disorders. Loosening of pedicle screws due to poor bone mineral density is a frequent complication in osteoporotic patients. As prevalence of osteoporosis and spinal disorders are increasing with an aging demographic, optimizing the biomechanical properties of pedicle screw constructions and therefore outcome after spinal surgery in osteoporotic patients is a key factor in future surgical therapy. Therefore, this biomechanical study investigated the stability of polymethylmethacrylate (PMMA)-augmented pedicle screw-rod constructions under a deviating distribution of PMMA applied to the instrumentation in osteoporotic human cadaveric vertebrae. We showed that PMMA-augmented pedicle screw-rod constructions tend to be more stable than those with non-augmented pedicle screws. Further, there appears to be a larger risk of screw loosening in unilateral augmented pedicle screws than in non-augmented, therefore a highly asymmetrically distributed PMMA should be avoided.

Local Recurrence and Development of Spinal Cord Syndrome during Follow-Up after Surgical Treatment of Metastatic Spine Disease.

BACKGROUND: Surgical decompression (SD), with or without posterior stabilization followed by radiotherapy, is an established treatment for patients with metastatic spinal disease with epidural spinal cord compression (ESCC). This study aims to identify risk factors for occurrence of neurological compromise resulting from local recurrence. METHODS: All patients who received surgical treatment for metastatic spinal disease at our center between 2011 and 2022 were included in this study. Cases were evaluated for tumor entity, surgical technique for decompression (decompression, hemilaminectomy, laminectomy, corpectomy) neurological deficits, grade of ESCC, time interval to radiotherapy, and perioperative complications. RESULTS: A total of 747 patients were included in the final analysis, with a follow-up of 296.8 days (95% CI (263.5, 330.1)). During the follow-up period, 7.5% of the patients developed spinal cord/cauda syndrome (SCS). Multivariate analysis revealed prolonged time (>35 d) to radiation therapy as a solitary risk factor (p < 0.001) for occurrence of SCS during follow-up. CONCLUSION: Surgical treatment of spinal metastatic disease improves patients' quality of life and Frankel grade, but radiation therapy needs to be scheduled within a time frame of a few weeks in order to reduce the risk of tumor-induced neurological compromise.

Patient-related risk factors and lifestyle factors for lumbar degenerative disc disease: a systematic review.

OBJECTIVE: Back pain is a very widespread disease pattern and is one of the most frequent causes for consultation of a physician in general. In most cases, discogenic changes are the pathomorphological correlate of back pain. Numerous risk factors have been identified for these degenerative changes, but the influence and significance of the risk factors remain unclear, which was the aim of this systematic review. METHODS: A systematic literature search of the commonly used Pubmed database was performed using specific MESH terms. Further selection of the included studies was performed according to the PRISMA scheme, taking into account scientific merit as well as the relation to the research question. RESULTS: A total of 111 studies out of 1035 found were finally included in the literature search. 134 risk factors for disc degeneration and disc herniation were identified. These were divided into (1) patient-specific risk factors (n░=░34), (2) radiological risk factors (n░=░31), (3) lifestyle risk factors (n░=░6), (4) workplace-related risk factors (n░=░12), (5) genetic risk factors (n░=░50), and (6) other risk factors (n░=░1). Non-adjustable risk factors were age >50 years (OR 1.7/year), female gender (OR 1.41), family disposition (OR 4.0), comorbidities like atherosclerosis (OR 2.24), arthritic changes in other joints (OR 3.1) and history of injuries of the back (OR 3.1). Adjustable factors were elevated BMI (OR 2.77), comorbidities like hypertension (OR 1.25), dyslipidemia (OR 1.26) and diabetes mellitus (OR 6.8), as well as lifestyle habits like smoking (OR 3.8). DISCUSSION: In summary, intervertebral disc degenerations and herniations represent multifactorial events whose risk factors can be partly influenced and partly not influenced. This systematic review highlights the current state of knowledge as a basis for creating patient-specific algorithms to calculate risk for the development or progression of degenerative disc changes and disc herniations.

Severity of spinal degeneration does not affect the pain reduction under continuous epidural analgesia.

PURPOSE: To outline clinical effectiveness of continuous epidural analgesia (CEA) in patients with failed back surgery syndrome (FBSS) or lumbar spinal stenosis (LSS) depending on severity of spinal degeneration. METHODS: In this retrospective cohort study, all patients with FBSS or LSS who underwent CEA within an inpatient rehabilitation program were evaluated. The pain reduction was measured by VAS on an hourly basis. Substantial pain reduction was defined as a minimal clinically important difference (MCID) > 50%. Severity of spinal degeneration, side effects and patient-specific characteristics were documented. RESULT: We included a total of 148 patients with 105 patients suffering from FBSS and 48 with LSS. The average pain reduction was - 37.6 ± 19.2 in FBSS and - 38.1 ± 17.8 in LSS group (p < .001 and p < .001, respectively). In the FBSS group, sensory deficits (p = .047) and numbness (p = .002), and in the LSS group, a severe disability measured by ODI (38.2 ± 15.4 vs. 57.3 ± 11.3, p < .001) significantly contributed to a worse outcome. The severity of the spinal degeneration and psychological disorders did not affect the pain reduction in terms of MCID. CONCLUSIONS: This study provides new evidence about CEA in the treatment of FBSS and LSS. CEA provides a significant pain reduction even under intensified physiotherapeutic exercising in patients with severe spinal degeneration and a broad variety of secondary diagnoses. Neurologic deficits in case of FBSS and severe disability in case of LSS may be risk factors for less favorable outcome.

Digital droplet PCR-based quantification of ccfHPV-DNA as liquid biopsy in HPV-driven cervical and vulvar cancer.

PURPOSE: More than 99% of cervical cancers and up to 40% of vulvar cancers are human papillomavirus (HPV) related. HPV 16 and 18 are the most relevant subtypes. Novel technologies allow the detection of minimal amounts of circulating cell-free HPV DNA (ccfHPV-DNA). The aim of this study was to evaluate ccfHPV-DNA assessed by droplet digital PCR (ddPCR) as a biomarker for molecular therapy monitoring in early, advanced, relapsed and metastatic HPV-driven cervical and vulvar cancer. METHODS: Inclusion criteria of the study were histologically proven HPV 16/18-driven cervical and vulvar cancer with first diagnosed disease, newly diagnosed recurrence, or progression of disease. Blood samples were taken pre- and post-therapeutically. Circulating cell-free HPV DNA was quantified using ddPCR and the results were correlated with clinical data. RESULTS: The mean copy number of ccfHPV-DNA was 838.6 (± 3089.1) in pretreatment and 2.3 (± 6.4) in post-treatment samples (p < 0.05). The copy number of ccfHPV-DNA increased with higher FIGO stages (p < 0.05), which are commonly used for clinical staging/assessment. Furthermore, we compared the distribution of copy numbers between T-stage 1 versus T-stage 2/3. We could show higher copy number level of ccfHPV-DNA in T-stage 2/3 (p < 0.05). CONCLUSIONS: Therapy monitoring with determination of ccfHPV-DNA by ddPCR with a small amount of plasma reflects response to therapy and appears feasible for patients in advanced cancer stages of cervical and vulvar cancer. This promising tool should be examined as marker of therapy monitoring in particular in novel HPV-directed therapies.

Postoperative Surgical Site Infections in Spine Surgery: Can the Duration of Surgery Predict the Pathogen Spectrum?

BACKGROUND/AIM: Surgical site infection (SSI) is a severe complication of spinal surgery, which typically results in prolonged length of hospital stay, an increased number of revision surgeries, re-hospitalizations, worse clinical functional outcomes, and increased healthcare costs. The aim of the present study was to analyse if the duration of surgery can predict the spectrum of pathogens causing SSI in orthopaedic spine surgery. PATIENTS AND METHODS: We conducted a retrospective study over a period of two years at the University Hospital of Cologne in which all patients with postoperative surgical site infections were included. In addition to descriptive characteristics (such as sex, age, BMI), the duration of the surgery, the administration of intra-operative antibiotics, the main diagnosis, the postoperative course of the infection parameters (CRP & WBC) and the responsible pathogens were analysed. RESULTS: A total of 75 patients were included with a median age of 64 years. The mean time of operation time was 131.52±70.91 min (range=23-285 min). The most frequently isolated germs in the postoperative blood culture were S. aureus (n=7), S. haemolyticus and S. hominis (n=2). There was a significant correlation between the duration of the primary surgical intervention and the postoperatively detected pathogens (p=0.002). CONCLUSION: A significant correlation was shown between the duration of surgery and the species of pathogens detected causing postoperative SSI. The use of perioperative antibiotics, the use of longer-lasting antibiotics or the repeated intravenous administration of prophylactic antibiotics should be evaluated.

The Amyloid Precursor Protein Regulates Synaptic Transmission at Medial Perforant Path Synapses.

The perforant path provides the primary cortical excitatory input to the hippocampus. Because of its important role in information processing and coding, entorhinal projections to the dentate gyrus have been studied in considerable detail. Nevertheless, synaptic transmission between individual connected pairs of entorhinal stellate cells and dentate granule cells remains to be characterized. Here, we have used mouse organotypic entorhino-hippocampal tissue cultures of either sex, in which the entorhinal cortex (EC) to dentate granule cell (GC; EC-GC) projection is present, and EC-GC pairs can be studied using whole-cell patch-clamp recordings. By using cultures of wild-type mice, the properties of EC-GC synapses formed by afferents from the lateral and medial entorhinal cortex were compared, and differences in short-term plasticity were identified. As the perforant path is severely affected in Alzheimer's disease, we used tissue cultures of amyloid precursor protein (APP)-deficient mice to examine the role of APP at this synapse. APP deficiency altered excitatory neurotransmission at medial perforant path synapses, which was accompanied by transcriptomic and ultrastructural changes. Moreover, presynaptic but not postsynaptic APP deletion through the local injection of Cre-expressing adeno-associated viruses in conditional APPflox/flox tissue cultures increased the neurotransmission efficacy at perforant path synapses. In summary, these data suggest a physiological role for presynaptic APP at medial perforant path synapses that may be adversely affected under altered APP processing conditions.SIGNIFICANCE STATEMENT The hippocampus receives input from the entorhinal cortex via the perforant path. These projections to hippocampal dentate granule cells are of utmost importance for learning and memory formation. Although there is detailed knowledge about perforant path projections, the functional synaptic properties at the level of individual connected pairs of neurons are not well understood. In this study, we investigated the role of APP in mediating functional properties and transmission rules in individually connected neurons using paired whole-cell patch-clamp recordings and genetic tools in organotypic tissue cultures. Our results show that presynaptic APP expression limits excitatory neurotransmission via the perforant path, which could be compromised in pathologic conditions such as Alzheimer's disease.

Microglial Cytokines Mediate Plasticity Induced by 10 Hz Repetitive Magnetic Stimulation.

Microglia, the resident immune cells of the CNS, sense the activity of neurons and regulate physiological brain functions. They have been implicated in the pathology of brain diseases associated with alterations in neural excitability and plasticity. However, experimental and therapeutic approaches that modulate microglia function in a brain region-specific manner have not been established. In this study, we tested for the effects of repetitive transcranial magnetic stimulation (rTMS), a clinically used noninvasive brain stimulation technique, on microglia-mediated synaptic plasticity; 10 Hz electromagnetic stimulation triggered a release of plasticity-promoting cytokines from microglia in mouse organotypic brain tissue cultures of both sexes, while no significant changes in microglial morphology or microglia dynamics were observed. Indeed, substitution of tumor necrosis factor α (TNFα) and interleukin 6 (IL6) preserved synaptic plasticity induced by 10 Hz stimulation in the absence of microglia. Consistent with these findings, in vivo depletion of microglia abolished rTMS-induced changes in neurotransmission in the mPFC of anesthetized mice of both sexes. We conclude that rTMS affects neural excitability and plasticity by modulating the release of cytokines from microglia.SIGNIFICANCE STATEMENT Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique that induces cortical plasticity. Despite its wide use in neuroscience and clinical practice (e.g., depression treatment), the cellular and molecular mechanisms of rTMS-mediated plasticity remain not well understood. Herein, we report an important role of microglia and plasticity-promoting cytokines in synaptic plasticity induced by 10 Hz rTMS in organotypic slice cultures and anesthetized mice, thereby identifying microglia-mediated synaptic adaptation as a target of rTMS-based interventions.

Correlation between kidney function and mortality in pyogenic spondylodiscitis: the glomerular filtration rate (GFR) as new predictive parameter?

OBJECTIVE: Pyogenic spondylodiscitis is a severe medical condition, often requiring surgical intervention. Numerous risk factors are known, such as obesity, neurological impairment and old age. In-hospital mortality remains high, therefore other factors may be contributing to the increased mortality. To evaluate kidney function as a risk factor for increased morbidity of pyogenic spondylodiscitis, the glomerular filtration rate (GFR) was correlated with the patients' clinical course. MATERIALS AND METHODS: We retrospectively reviewed the cases of 366 patients and 255 were included for analysis. Clinical, laboratory and surgical data were recorded with a minimum follow-up of three months. For clinical outcome measurement, mortality, length of stay and perioperative complications were analysed. RESULTS: The study included 255 patients (173 men, 82 women; mean age 66.3 years). Patients with a GFR < 59 mL/min spent an average of 5 days longer in the hospital than those with a GFR ≥ 60 mL/min (p = 0.071). The mortality rate increased significantly with a decrease in GFR: A GFR of 30-59 mL/min had a mortality rate of 17.6%, whereas a GFR of < 29 mL/min had one of 30.4% (p = 0.003). Patients with impaired GFR showed an increased rate of postoperative complications (OR 4.7 p = 0.002) and higher rate of intensive care unit (ICU) stay (OR 8.7 p = < 0.001). DISCUSSION: Preoperative GFR values showed a significant correlation with in-hospital mortality in patients with spondylodiscitis, when graded according to the KDIGO stages. Furthermore, a GFR of < 29 ml/mL contributes to a longer ICU stay, postoperative complications and a longer total hospital stay. Therefore, the preoperative GFR could be a marker of kidney function and as a valuable predictive risk factor regarding the clinical in-hospital course of patients suffering from pyogenic spondylodiscitis.

Projections From Surgical Use Models in Germany Suggest a Rising Number of Spinal Fusions in Patients 75 Years and Older Will Challenge Healthcare Systems Worldwide.

BACKGROUND: Spinal fusion is a well-established procedure in the treatment of degenerative spinal diseases. Previous research shows that the use of this operative treatment has been growing in recent decades in industrialized countries and has become one of the most cost-intensive surgical procedures. It seems that in some countries such as Germany-with its large, industrialized, European population-this increase is mainly driven by demographic changes with low fertility rates, increasing life expectancy, and an aging population. Based on current projections, however, Germany faces a population trend that many other countries are likely to follow within a few decades. An increasingly shrinking and aging working population may eventually put the healthcare system under enormous pressure, with greater demands for spinal fusions and associated higher costs. Thus, we aimed to provide reliable projections regarding the future demand for posterior spinal fusion procedures including age- and gender-related trends up to 2060, which will be necessary for future resource planning and possible improvements in actual treatment strategies. QUESTIONS/PURPOSES: (1) How is the use of posterior spinal fusions in Germany expected to change from 2019 through 2060, if currents trends continue? (2) How is the use of posterior spinal fusions in Germany expected to change depending on patients' age and gender during this time period? METHODS: Comprehensive nationwide data provided by the Federal Statistical Office, the official institution for documenting all data on operations and procedures performed in Germany, were used to quantify posterior spinal fusion rates as a function of calendar year, age, and gender. Because there is a lack of evidence regarding future trends in the use of posterior spinal fusions, an autoregressive integrated moving average model on historical procedure rates from 2005 to 2019 in relation to official population projections from 2020 to 2060 was chosen to forecast future absolute numbers and incidence rates of this procedure in Germany. Long-term forecasting is more prone to unexpected disruptions than forecasting over short-term periods; however, longer spans facilitate estimates of how trends may challenge future healthcare systems if those trends continue, and thus are useful for research and planning. RESULTS: The incidence rate of posterior spinal fusion was projected to increase by approximately 83% (95% CI 28% to 139%) to 102% per 100,000 inhabitants (95% CI 71% to 133%) in 2060, with a 1.3-fold higher rate of women undergoing surgery in terms of absolute numbers. The highest increase identified by the model occurred in patients 75 years and older with 38,974 (95% CI 27,294 to 50,653) posterior spinal fusions in 2060, compared with 14,657 in 2019. This trend applied for both women and men, with a 246% (95% CI 138% to 355%) increase in the total number of posterior spinal fusions for women 75 years and older and a 296% (95% CI 222% to 370%) increase for men 75 years and older. At the same time, posterior spinal fusions in all age groups younger than 55 years were projected to follow a constant or even negative trend up to 2060. CONCLUSION: Our findings suggest that increasing use of posterior spinal fusion, particularly in patients 75 years and older, will challenge healthcare systems worldwide if current trends persist. This study may serve as a model for many other industrialized countries facing similar demographic and procedure-specific developments in the future. This emphasizes the need to focus on frailty research as well as appropriate financial and human resource management. Effective perioperative medical management, multidisciplinary treatment, and interinstitutional protocols are warranted, especially in older patients as we attempt to manage these trends in the future. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

When to remove? Evaluation of postoperative drainage volume after single-level posterior lumbar interbody fusion.

Study design: prospective, observational. Background: Wound drainage's indwelling duration and general use are the centre of ongoing discussion. The aim of our prospective observational study was to evaluate the total drainage volume postoperatively and its course after lumbar interbody fusion surgeries to define an ideal point in time for drainage removal. Methods: We included all patients who underwent monosegmental lumbar interbody fusion via transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). After application of the exclusion criteria, 27 patients were included in our study. Drainage volume was measured three times a day and at the time of drain removal. Results: The PLIF group reached higher total drainage volume (337.14 ml) than the TLIF group (215.5 ml) (p = 0.047. Drainage volume's plateau was reached after 33.0 h (±1.8 h) in the TLIF group and 25.3 h (±1.7 h) in the PLIF group following surgery. Conclusions: Our study shows, that drainage volume did not increase significantly after the evening of the first postoperative day at latest. This was on average 33.0 h after surgery. Therefore, extraction of the drainage tube hereafter can be assumed to be safe.

Role of Decompressive Surgery in Neurologically Intact Patients with Low to Intermediate Intraspinal Metastatic Tumor Burden.

BACKGROUND: Surgical decompression (SD) followed by radiotherapy (RT) is superior to RT alone in patients with metastatic spinal disease with epidural spinal cord compression (ESCC) and neurological deficit. For patients without neurological deficit and low- to intermediate-grade intraspinal tumor burden, data on whether SD is beneficial are scarce. This study aims to investigate the neurological outcome of patients without neurological deficit, with a low- to intermediate-ESCC, who were treated with or without SD. METHODS: This single-center, multidepartment retrospective analysis includes patients treated for spinal epidural metastases from 2011 to 2021. Neurological status was assessed by Frankel grade, and intraspinal tumor burden was categorized according to the ESCC scale. Spinal instrumentation surgery was only considered as SD if targeted decompression was performed. RESULTS: ESCC scale was determined in 519 patients. Of these, 190 (36.6%) presented with no neurological deficit and a low- to intermediate-grade ESCC (1b, 1c, or 2). Of these, 147 (77.4% were treated with decompression and 43 (22.65%) without. At last follow-up, there was no difference in neurological outcome between the two groups. CONCLUSIONS: Indication for decompressive surgery in neurologically intact patients with low-grade ESCC needs to be set cautiously. So far, it is unclear which patients benefit from additional decompressive surgery, warranting further prospective, randomized trials for this significant cohort of patients.

Influence of rotator cuff preload on fracture configuration in proximal humerus fractures: a proof of concept for fracture simulation.

INTRODUCTION: In regard of surgical training, the reproducible simulation of life-like proximal humerus fractures in human cadaveric specimens is desirable. The aim of the present study was to develop a technique that allows simulation of realistic proximal humerus fractures and to analyse the influence of rotator cuff preload on the generated lesions in regards of fracture configuration. MATERIALS AND METHODS: Ten cadaveric specimens (6 left, 4 right) were fractured using a custom-made drop-test bench, in two groups. Five specimens were fractured without rotator cuff preload, while the other five were fractured with the tendons of the rotator cuff preloaded with 2 kg each. The humeral shaft and the shortened scapula were potted. The humerus was positioned at 90° of abduction and 10° of internal rotation to simulate a fall on the elevated arm. In two specimens of each group, the emergence of the fractures was documented with high-speed video imaging. Pre-fracture radiographs were taken to evaluate the deltoid-tuberosity index as a measure of bone density. Post-fracture X-rays and CT scans were performed to define the exact fracture configurations. Neer's classification was used to analyse the fractures. RESULTS: In all ten cadaveric specimens life-like proximal humerus fractures were achieved. Two III-part and three IV-part fractures resulted in each group. The preloading of the rotator cuff muscles had no further influence on the fracture configuration. High-speed videos of the fracture simulation revealed identical fracture mechanisms for both groups. We observed a two-step fracture mechanism, with initial impaction of the head segment against the glenoid followed by fracturing of the head and the tuberosities and then with further impaction of the shaft against the acromion, which lead to separation of the tuberosities. CONCLUSION: A high energetic axial impulse can reliably induce realistic proximal humerus fractures in cadaveric specimens. The preload of the rotator cuff muscles had no influence on initial fracture configuration. Therefore, fracture simulation in the proximal humerus is less elaborate. Using the presented technique, pre-fractured specimens are available for real-life surgical education. LEVEL OF EVIDENCE: III.

Complications associated to wound drainages in tumor spine surgery: a multicenter surveillance study from the German Spine Registry (DWG-Register).

There is an ongoing debate whether a surgical drainage is beneficial to prevent local accumulation of hematoma and to reduce the rate of wound infections, and neurological deficits. Data from the German Spine Society (DWG) registry were filtered for surgically treated spine tumor cases between 2017 and 2021. Cases were categorized into with (Group I) and without (Group II) placement of a surgical drainage. Subgroups were compared for demographic data, type of surgery, experience of the surgeon and postoperative surgical complications. 10,029 cases were included into final analysis (Group I: 3007; Group II: 7022). There was no significant difference between both groups regarding age or gender distribution. Average morbidity of patients was significantly elevated in Group I (p < 0.05) and the rates of invasive surgery were significantly increased in this group (p < 0.001). Overall complication rates were reported with 12.0% (Group I) and 8.5% (Group II). There were significantly more epidural hematoma (p < 0.001) and motor dysfunction (p = 0.049) as well as deep wound infections (p < 0.001) and implant failures (p = 0.02) in Group I. A surgical wound drainage cannot prevent epidural hematoma.

Impact of Spinal Instrumentation on Neurological Outcome in Patients with Intermediate Spinal Instability Neoplastic Score (SINS).

Background: Adequate assessment of spinal instability using the spinal instability neoplastic score (SINS) frequently guides surgical therapy in spinal epidural osseous metastases and subsequently influences neurological outcome. However, how to surgically manage 'impending instability' at SINS 7−12 most appropriately remains uncertain. This study aimed to evaluate the necessity of spinal instrumentation in patients with SINS 7−12 with regards to neurological outcome. Methods: We screened 683 patients with spinal epidural metastases treated at our interdisciplinary spine center. The preoperative SINS was assessed to determine spinal instability and neurological status was defined using the Frankel score. Patients were dichotomized according to being treated by instrumentation surgery and neurological outcomes were compared. Additionally, a subgroup analysis of groups with SINS of 7−9 and 10−12 was performed. Results: Of 331 patients with a SINS of 7−12, 76.1% underwent spinal instrumentation. Neurological outcome did not differ significantly between instrumented and non-instrumented patients (p = 0.612). Spinal instrumentation was performed more frequently in SINS 10−12 than in SINS 7−9 (p < 0.001). The subgroup analysis showed no significant differences in neurological outcome between instrumented and non-instrumented patients in either SINS 7−9 (p = 0.278) or SINS 10−12 (p = 0.577). Complications occurred more frequently in instrumented than in non-instrumented patients (p = 0.016). Conclusions: Our data suggest that a SINS of 7−12 alone might not warrant the increased surgical risks of additional spinal instrumentation.

Clinical outcome after lumbar spinal fusion surgery in degenerative spondylolisthesis: a 3-year follow-up.

INTRODUCTION: Lumbar spinal fusion surgery is a widely accepted surgical treatment in degenerative causes of lumbar spondylolisthesis. The benefit of reduction of anterior displacement and restoration of sagittal parameters is still controversially debated. Purpose of the underlying publication was to analyze the influence of radiographic sagittal parameters of the spine in aspects of changes in postoperative clinical outcome. MATERIALS AND METHODS: By prospective analysis, we included patients with low-grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) with mono- or bisegmental fusion surgery with a minimum follow-up data of 3 years. For clinical outcome measures, COMI, ODI and EQ-5D were used. Spinopelvic parameters (sacral inclination, pelvic tilt, sacral slope and pelvic incidence, lumbar lordosis and lumbar index as well as anterior displacement and sagittal rotation) were measured on plain radiographs. RESULTS: We could observe a significant benefit in clinical outcome after lumbar fusion surgery in low-grade spondylolisthesis in our mid-term follow-up data including 32 patients. By surgical reduction, we could see significant restoration of anterior displacement and sagittal rotation. Interestingly, a significant correlation between restoration of both sagittal rotation and sacral inclination and clinical outcome score was observed in the 3-year follow-up. CONCLUSION: In low-grade spondylolisthesis, spinal fusion surgery is a well-established surgical procedure; however, the impact of sagittal parameters and reduction of anterior displacement remains controversial. Within our findings, restoration of sagittal parameters showed significant correlation to improvement in clinical outcome in our mid-term follow-up data.

Comparison of Different Approaches in Lumbosacral Spinal Fusion Surgery: A Systematic Review and Meta-Analysis.

We aimed to systematically review the literature to analyze the differences in posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and transforaminal lumbar interbody fusion (TLIF), focusing on the complications, risk factors, and fusion rate of each approach. Spinal fusion surgery is a well-established surgical procedure for a variety of indications, and different approaches developed. The various approaches and their advantages, as well as approach-related pathology and complications, are well investigated in spinal surgery. Focusing only on lumbosacral fusion, the comparative studies of different approaches remain fewer in numbers. We systematically reviewed the literature on the complications associated with lumbosacral interbody fusion. Only the PLIF, ALIF, or TLIF approaches and studies published within the last decade (2007-2017) were included. The exclusion criteria in this study were oblique lumbar interbody fusion, extreme lateral interbody fusion, more than one procedure per patient, and reported patient numbers less than 10. The outcome variables were indications, fusion rates, operation time, perioperative complications, and clinical outcome by means of Visual Analog Scale, Oswestry Disability Index, and Japanese Orthopaedic Association score. Five prospective, 17 retrospective, and two comparative studies that investigated the lumbosacral region were included. Mean fusion rates were 91,4%. ALIF showed a higher operation time, while PLIF resulted in greater blood loss. In all approaches, significant improvements in the clinical outcome were achieved, with ALIF showing slightly better results. Regarding complications, the ALIF technique showed the highest complication rates. Lumbosacral fusion surgery is a treatment to provide good results either through an approach for various indications as causes of lower back pain. For each surgical approach, advantages can be depicted. However, perioperative complications and risk factors are numerous and vary with ALIF, PLIF, and TLIF procedures, as well as with fusion rates.

Complications Within 6 Months After Arthroscopic Rotator Cuff Repair: Registry-Based Evaluation According to a Core Event Set and Severity Grading.

PURPOSE: To report complications after arthroscopic rotator cuff repairs (ARCRs) in a large patient cohort based on clinical application of a newly defined core event set (CES) and severity grading. METHODS: Consecutive primary ARCRs documented in a local clinical registry between February 2010 and September 2016 were included. Clinicians documented adverse events (AEs) reported until the final, 6-month postoperative follow-up according to the CES. The CES is an organized list of relevant AEs sorted into 3 intraoperative event groups (device, osteochondral, and soft tissue) and 9 postoperative event groups (device, osteochondral, pain, rotator cuff, surgical-site infection, peripheral neurologic, vascular, superficial soft tissue, and deep soft tissue). Severity was determined using an adaptation of the Clavien-Dindo classification. Cumulative complication risks were calculated per event group and stratified by severity and rotator cuff tear extent. RESULTS: A total of 1,661 repairs were documented in 1,594 patients (mean age, 57 years [standard deviation, 9 years]; 38% women); 21% involved partial tears. All events were recorded according to the CES. Intraoperative events occurred in 2.2% of repairs. We identified 329 postoperative events in 307 repairs (305 patients); 93% had 1 AE. The cumulative AE risk at 6 months was 18.5%; AE risks were 21.8% for partial tears, 15.8% for full-thickness single-tendon tears, 18.0% for tears with 2 ruptured tendons, and 25.6% for tears with 3 ruptured tendons. AE risks per event group were as follows: 9.4% for deep soft tissue, with shoulder stiffness (7.6%) being the most common event; 3.4% for persistent or worsening pain; 3.1% for rotator cuff defects; 1.7% for neurologic lesions; 0.8% for surgical-site infection; 0.7% for device; 0.4% for osteochondral; 0.2% for superficial soft tissue, and 0.1% for vascular. Most AEs had severity grades I (160 [49%]) and II (117 [36%]). CONCLUSIONS: Comprehensive local AE documentation according to the CES and severity grading was possible and showed that about one-fifth of ARCRs were affected, mostly by one AE of low severity. Shoulder stiffness was the most frequent event. LEVEL OF EVIDENCE: Level IV, case series.