Transabdominal motor evoked potential neuromonitoring of lumbosacral spine surgery.

BACKGROUND CONTEXT: Transcranial Motor Evoked Potentials (TcMEPs) can improve intraoperative detection of femoral plexus and nerve root injury during lumbosacral spine surgery. However, even under ideal conditions, TcMEPs are not completely free of false-positive alerts due to the immobilizing effect of general anesthetics, especially in the proximal musculature. The application of transcutaneous stimulation to activate ventral nerve roots directly at the level of the conus medularis (bypassing the brain and spinal cord) has emerged as a method to potentially monitor the motor component of the femoral plexus and lumbosacral nerves free from the blunting effects of general anesthesia. PURPOSE: To evaluate the reliability and efficacy of transabdominal motor evoked potentials (TaMEPs) compared to TcMEPs during lumbosacral spine procedures. DESIGN: We present the findings of a single-center 12-month retrospective experience of all lumbosacral spine surgeries utilizing multimodality intraoperative neuromonitoring (IONM) consisting of TcMEPs, TaMEPs, somatosensory evoked potentials (SSEPs), electromyography (EMG), and electroencephalography. PATIENT SAMPLE: Two hundred and twenty patients having one, or a combination of lumbosacral spine procedures, including anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), posterior spinal fusion (PSF), and/or transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES: Intraoperative neuromonitoring data was correlated to immediate postoperative neurologic examinations and chart review. METHODS: Baseline reliability, false positive rate, true positive rate, false negative rate, area under the curve at baseline and at alerts, and detection of preoperative deficits of TcMEPs and TaMEPs were compared and analyzed for statistical significance. The relationship between transcutaneous stimulation voltage level and patient BMI was also examined. RESULTS: TaMEPs were significantly more reliable than TcMEPs in all muscles except abductor hallucis. Of the 27 false positive alerts, 24 were TcMEPs alone, and 3 were TaMEPs alone. Of the 19 true positives, none were detected by TcMEPs alone, 3 were detected by TaMEPs alone (TcMEPs were not present), and the remaining 16 true positives involved TaMEPs and TcMEPs. TaMEPs had a significantly larger area under the curve (AUC) at baseline than TcMEPs in all muscles except abductor hallucis. The percent decrease in TcMEP and TaMEP AUC during LLIF alerts was not significantly different. Both TcMEPs and TaMEPs reflected three preexisting motor deficits. Patient BMI and TaMEP stimulation intensity were found to be moderately positively correlated. CONCLUSIONS: These findings demonstrate the high reliability and predictability of TaMEPs and the potential added value when TaMEPs are incorporated into multimodality IONM during lumbosacral spine surgery.

Degenerative Cervical Myelopathy: A Concept Review and Clinical Approach.

STUDY DESIGN: Narrative review. OBJECTIVE: To provide an overview of the evaluation and diagnosis of degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: DCM describes several etiologies of degenerative, nontraumatic spinal cord impairment. Early diagnosis and intervention can decrease neurological decline. METHODS: An extensive literature review was conducted. RESULTS: The incidence and prevalence of DCM are increasing worldwide. Asymptomatic spinal cord compression can progress to cervical myelopathy. Static and dynamic factors contribute to spinal cord compression. Patients frequently present with decreased manual dexterity, gait instability, and neck pain. On physical exam, patients frequently present with upper motor neuron signs, a Lhermitte sign, a failed Romberg test, global proprioceptive dysfunction, and decreased pain sensation. Anatomic variation may complicate physical exam interpretation. The modified Japanese Orthopaedic Association Scale and Nurick Classification, based on functional impairment, provide diagnostic utility. Magnetic Resonance Imaging imaging is useful in narrowing the differential diagnosis, evaluating the severity of neurological impairment, and predicting disease progression. CONCLUSIONS: Understanding the pathophysiology of DCM and the diagnostic utility of the signs and symptoms of DCM is critical. The decision for anterior cervical discectomy and fusion (ACDF), laminoplasty, or combined ACDF and posterior cervical fusion is individualized for each patient.

Response to Letter Regarding "Predictive Value of Preoperative Serum Albumin in Patients With Metastatic Spine Diseases: A Statistical Comment".

We thank the authors for their interest in and commentary on "Preoperative Serum Albumin Level Predicts Length of Stay and Perioperative Adverse Events Following Vertebral Corpectomy and Posterior Stabilization for Metastatic Spine Disease." We appreciate the opportunity to respond to their comments herein.

Customized 3-dimensional-printed Vertebral Implants for Spinal Reconstruction After Tumor Resection: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To examine the outcomes of customized 3-dimensional (3D) printed implants for spinal reconstruction after tumor resection. SUMMARY OF BACKGROUND DATA: Various techniques exist for spinal reconstruction after tumor resection. Currently, there is no consensus regarding the utility of customized 3D-printed implants for spinal reconstruction after tumor resection. MATERIALS AND METHODS: A systematic review was registered with PROSPERO and performed according to "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines. All level I-V evidence studies reporting the use of 3D-printed implants for spinal reconstruction after tumor resection were included. RESULTS: Eleven studies (65 patients; mean age, 40.9 ± 18.1 y) were included. Eleven patients (16.9%) underwent intralesional resections with positive margins and 54 patients (83.1%) underwent en bloc spondylectomy with negative margins. All patients underwent vertebral reconstruction with 3D-printed titanium implants. Tumor involvement was in the cervical spine in 21 patients (32.3%), thoracic spine in 29 patients (44.6%), thoracolumbar junction in 2 patients (3.1%), and lumbar spine in 13 patients (20.0%). Ten studies with 62 patients reported perioperative outcomes radiologic/oncologic status at final follow-up. At the mean final follow-up of 18.5 ± 9.8 months, 47 patients (75.8%) had no evidence of disease, 9 patients (14.5%) were alive with recurrence, and 6 patients (9.7%) had died of disease. One patient who underwent C3-C5 en bloc spondylectomy had an asymptomatic subsidence of 2.7 mm at the final follow-up. Twenty patients that underwent thoracic and/or lumbar reconstruction had a mean subsidence of 3.8 ± 4.7 mm at the final follow-up; however, only 1 patient had a symptomatic subsidence that required revision surgery. Eleven patients (17.7%) had one or more major complications. CONCLUSION: There is some evidence to suggest that using customized 3D-printed titanium or titanium alloy implants is an effective technique for spinal reconstruction after tumor resection. There is a high incidence of asymptomatic subsidence and major complications that are similar to other methods of reconstruction. LEVEL OF EVIDENCE: Level V, systematic review of level I-V studies.

Ninety day adverse events following single level posterior lumbar interbody fusion in patients with sickle cell disease.

BACKGROUND CONTEXT: Sickle cell disease (SCD) is an inherited disorder of red blood cells caused by mutation in the hemoglobin beta chain and is the most common inherited genetic disorder in the United States. Postoperative outcomes following single-level posterior lumbar interbody fusion (PLIF) in patients with SCD are not well characterized. PURPOSE: To examine 90-day postoperative outcomes among a matched cohort of patients with and without SCD who underwent single level PLIF utilizing a national administrative database. STUDY DESIGN/SETTING: Retrospective database study. PATIENT SAMPLE: Adult patients without and with SCD who underwent single level PLIF from 2010 to 2021 Q1 were identified and matched 10:1 based on age, sex and ECI. Exclusion criteria included: age <18 years old, recent history of infection, neoplasm, or trauma, as well as not being active in the database for 90 days following their procedure. OUTCOME MEASURES: Ninety-day postoperative adverse events and emergency department (ED) visits. METHODS: The matched cohorts were defined, and 90-day adverse event and ED visit rates were compared with univariable analyses and multivariable logistic regression, controlling for age, sex, and Elixhauser comorbidity index (ECI). RESULTS: Overall, 191,765 PLIF patients were identified, of which SCD was noted for 76 (0.04%). On multivariable analysis of the matched populations, patients with SCD were at increased odds ratio (OR) of the following (in decreasing OR order): transfusion (OR 17.69), pneumonia (OR 6.30), sepsis (OR 4.86), aggregated minor adverse events (OR 4.65), aggregated all adverse events (OR 3.87), ED visits (OR 3.53), and aggregated severe adverse events (OR 2.80) (p<.05 for all). CONCLUSIONS: The current study examined a relatively small, but largest to date, cohort of SCD patients undergoing PLIF. Patients with this condition were at greater odds of several perioperative adverse events, and these findings may be helpful for patient counselling and surgical planning.

Comparison of Staged vs Same-Day Circumferential Spinal Fusions for Adult Spinal Deformity.

BACKGROUND: Patients often undergo circumferential (anterior and posterior) spinal fusions to maximize adult spinal deformity (ASD) correction and achieve adequate fusion. Currently, such procedures are performed in staged (ST) or same-day (SD) procedures with limited evidence to support either strategy. This study aims to compare perioperative outcomes and costs of ST vs SD circumferential ASD corrective surgeries. METHODS: This is a retrospective review of patients undergoing circumferential ASD surgeries between 2013 and 2018 in a single institution. Patient characteristics, preoperative comorbidities, surgical details, perioperative complications, readmissions, total hospital admission costs, and 90-day postoperative care costs were identified. All variables were tested for differences between ST and SD groups unadjusted and after applying inverse probability weighting (IPW), and the results before and after IPW were compared. RESULTS: The entire cohort included a total of 211 (ST = 50, SD = 161) patients, 100 of whom (ST = 44, SD = 56) underwent more than 4 levels fused posteriorly and anterior lumbar interbody fusion (ALIF). Although patient characteristics and comorbidities were not dissimilar between the ST and SD groups, both the number of levels fused in ALIF and posterior spinal fusion (PSF) were significantly different. Thus, using IPW, we were able to minimize the cohort incongruities in the number of levels fused in ALIF and PSF while maintaining comparable patient characteristics. In both the whole cohort and the long segment fusions, postoperative pulmonary embolism was more common in ST procedures. After adjustment utilizing IPW, both groups were not significantly different in disposition, 30-day readmissions, and reoperations. However, within the whole cohort and the long segment fusion cohort, the ST group continued to show significantly increased rates of pulmonary embolism, longer length of stay, and higher hospital admission costs compared with the SD group. CONCLUSIONS: Adjusted comparisons between ST and SD groups showed staging associated with significantly increased length of stay, risk of pulmonary embolism, and admission costs.

Short-term and Long-term Complications of Cervical Disc Arthroplasty.

STUDY DESIGN: A narrative review. OBJECTIVE: This review discusses the short and long-term complications associated with cervical disc arthroplasty (CDA). SUMMARY OF BACKGROUND DATA: CDA is a safe and effective motion-sparing alternative to fusion for the treatment of cervical disc pathology in patients with cervical radiculopathy or myelopathy. Although CDA offers advantages over fusion within a narrower set of indications, it introduces new technical challenges and potential complications. METHODS: A systematic search of several large databases, including Cochrane Central, PubMed, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry, was conducted from January 2005 to August 2023 to identify published studies and clinical trials evaluating cervical disc replacement complications and outcomes. RESULTS: Short-term complications are primarily related to surgical approach and include dysphagia reported as high as ~70%, laryngeal nerve injury ~0%-1.25%, Horner syndrome ~0.06%, hematoma ~0.01%, gross device extrusion ~0.3%, whereas long-term complications include adjacent segment disease reported at ~3.8%, osteolysis ~44%-64%, heterotopic ossification ~7.3%-69.2%, implant failure ~3.3%-3.7%, and implant wear, which varies depending on design. CONCLUSIONS: Approaches for mitigating complications broadly include meticulous dissection, intraoperative techniques, and diligent postoperative follow-up. This review emphasizes the need for a comprehensive understanding and management of complications to enhance the safety, reproducibility, and success of CDA. As CDA continues to evolve, there remains a critical need for ongoing research to delve deeper into evaluating risk for complications and long-term patient outcomes.

Preoperative Serum Albumin Level Predicts Length of Stay and Perioperative Adverse Events Following Vertebral Corpectomy and Posterior Stabilization for Metastatic Spine Disease.

STUDY DESIGN: Retrospective review of a prospectively collected national database. OBJECTIVES: To determine the association between preoperative serum albumin levels and perioperative adverse events (AEs) following vertebral corpectomy and posterior stabilization for metastatic spine disease. METHODS: The 2010 to 2019 American College of Surgeons' National Surgical Quality Improvement (ACS-NSQIP) database was used to identify all patients undergoing vertebral corpectomy and posterior stabilization for metastatic spine disease. Receiver operative characteristic (ROC) curve analysis was used to determine preoperative serum albumin cut-off values for predicting perioperative AEs. Low preoperative serum albumin was defined as serum albumin below this cut-off value. RESULTS: A total of 301 patients were included in the study. ROC curve analysis demonstrated serum albumin < 3.25 g/dL as a cut-off value for predicting perioperative AEs. The low serum albumin group had a higher overall perioperative AEs (P = .041), longer post-operative LOS (P < .001), higher 30-day reoperation rate (P = .014), and a higher in-hospital mortality rate (P = .046). Multivariate analysis demonstrated that low preoperative serum albumin was associated with higher perioperative AEs. CONCLUSIONS: Low serum albumin level is associated with higher perioperative AEs, longer postoperative LOS, and higher rates of 30-day reoperation and in-hospital mortality among patients undergoing vertebral corpectomy and posterior stabilization for metastatic spine disease. Strategies to improve preoperative nutritional status in patients undergoing this procedure may improve these perioperative outcome measures within this surgical population. LEVEL OF EVIDENCE: III.

Preoperative Predictors of Survival in Patients With Spinal Metastatic Disease.

BACKGROUND: There remains a number of factors thought to be associated with survival in spinal metastatic disease, but evidence of these associations is lacking. In this study, we examined factors associated with survival among patients undergoing surgery for spinal metastatic disease. METHODS: We retrospectively examined 104 patients who underwent surgery for spinal metastatic disease at an academic medical center. Of those patients, 33 received local preoperative radiation (PR) and 71 had no PR (NPR). Disease-related variables and surrogate markers of preoperative health were identified, including age, pathology, timing of radiation and chemotherapy, mechanical instability by spine instability neoplastic score, American Society of Anesthesiologists (ASA) classification, Karnofsky performance status (KPS), and body mass index (BMI). We performed survival analyses using a combination of univariate and multivariate Cox proportional hazards models to assess significant predictors of time to death. RESULTS: Local PR (Hazard Ratio [HR] = 1.84, P = 0.034), mechanical instability (HR = 1.11, P = 0.024), and melanoma (HR = 3.60, P = 0.010) were significant predictors of survival on multivariate analysis when controlling for confounders. PR vs NPR cohorts exhibited no statistically significant differences in preoperative age (P = 0.22), KPS (P = 0.29), BMI (P = 0.28), or ASA classification (P = 0.12). NPR patients had more reoperations for postoperative wound complications (11.3% vs 0%, P < 0.001). CONCLUSIONS: In this small sample, PR and mechanical instability were significant predictors of postoperative survival, independent of age, BMI, ASA classification, and KPS and in spite of fewer wound complications in the PR group. It is possible that PR was a surrogate of more advanced disease or poor response to systemic therapy, independently portending a worse prognosis. Future studies in larger, more diverse populations are crucial for understanding the relationship between PR and postoperative outcomes to determine the optimal timing for surgical intervention. CLINICAL RELEVANCE: These findings are clinically relevent as they provide insight into factors associated with survival in metastatic spinal disease.

Clinical Outcomes of Bariatric Surgery Before Spinal Fusion: A Systematic Review.

INTRODUCTION: Morbidly obese patients are at increased risk for intraoperative and postoperative complications following spinal fusion. Preoperative weight loss can improve clinical outcomes. The present systematic literature review is aimed to evaluate the hypothesis that bariatric surgery before spinal fusion surgery is associated with higher rates of complications and revisions. METHODS: Three databases were queried for literature pertaining to bariatric surgery prior to spinal fusion. A 2-author screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Methodologic index for non-randomized studies criteria was used to objectively assess the methodologic quality of the studies reviewed. Retrospective cohort studies in which the patients underwent bariatric surgery were included. RESULTS: Four retrospective cohort studies consisting of a total of 180,090 patients were included. Length of stay was significantly shorter for the bariatric surgery (BS) group patients than the control (C) groups patients (P = 0.009). There were no significant differences in 1-year mortality rate (P = 1.0), readmission rate (P = 0.86), overall postoperative complications (P = 0.83), and postoperative infections (P = 0.97) between the BS and C groups. CONCLUSIONS: There were no consistent differences in rates of postoperative complications, infections, hospital readmission, and mortality between obese patients with bariatric surgery prior to spinal fusion and control group patients. The present study does not support the hypothesis that bariatric surgery before spinal fusion contributes to a higher rate of postoperative complications in patients undergoing spinal fusion.

Do Prophylactic Inferior Vena Cava Filters Affect the Rates of Venous Thromboembolism and Pulmonary Embolism in Patients Undergoing Major Spine Surgery?

STUDY DESIGN: Retrospective Analysis. BACKGROUND: Venous thromboembolism (VTE) represents a significant cause of morbidity and mortality in major spine surgery. Placement of prophylactic inferior vena cava filters (IVCF) in patients undergoing major spine surgery was previously adopted at our institution. This study reports our experience and compares VTE rates between patients with and without preoperative IVCF placement. METHODS: A Retrospective comparative study was conducted on adult patients who underwent IVCF placement and those who did not prior to their spinal fusion procedure, between 2013 and 2016. Thoracolumbar fusions (anterior and/or posterior) of 7 or more levels, spinal osteotomies, and a minimum of a 3-month follow-up were included. Traumatic, oncologic, and cervical pathology were excluded. Primary outcomes measured included the incidence of overall VTE (DVT/PE), death, IVCF related complications, and IVCF retrieval. RESULTS: 386 patients who underwent major spine surgery, 258 met the eligibility criteria. Of those patients, 105 patients (40.7%) had prophylactic IVCF placement. All patients had postoperative SCDs and chemoprophylaxis. The presence of an IVCF was associated with an increased rate of overall VTE (14.3% vs 6.5%, P ≤ .05) and DVT episodes (8.6% vs 2.6%, P = .04). The rate of PE for the IVCF group and non-IVCF group was 8.6% and 4.6%, respectively, which was not statistically significant (P = .32). The all-cause mortality rate overall of 2.3% was statistically similar between both groups (P = 1.0). The IVCF group had higher rates of hematoma/seroma vs the non-IVCF group (12.4% vs 3.9%, P ≤ .05). 99 IVCFs were retrievable designs, and 85% were successfully retrieved. Overall IVCF-related complication rate was 11%. CONCLUSIONS: No statistical difference in PE or mortality rates existed between the IVCF and the control group. Patients with IVCF placement experienced approximately twice the rate of VTE and three times the rate of DVT compared to those without IVCF. The IVCF-related complication rate was 11%. Based on the results of this study, the authors recommend against the routine use of prophylactic IVCFs in adults undergoing major spine surgery. LEVEL OF EVIDENCE: III.

Anterior lumbar spinal fusion surgery associated with lower risk of stroke, pneumonia, and infection compared to posterior lumbar spinal fusion surgery.

Background: Prior studies, comparing anterior and posterior approaches to lumbar fusion surgery, found similar fusion rates and clinical outcomes, but are limited by sample size. Further evaluation of the postoperative complications of each approach is necessary. Methods: The MSpine database by PearlDiver was queried using ICD-9, ICD-10, and CPT codes to identify patients who had undergone single-level anterior or posterior lumbar interbody fusion surgery. Readmission rates, ileus, lower extremity DVT, infection, pneumonia, and stroke were used to compare post-operative complications of an anterior vs. posterior approach. Results: 112,023 patients were included in this study, with 38,529 (34.4%) in the anterior group (ALIF/LLIF) and 73,494 (65.6%) in the posterior group (PLIF/TLIF). At both 30 and 90-days postoperative, patients undergoing an anterior approach to lumbar interbody fusion had a higher odds ratio of lower extremity DVT (30-day OR: 1.19, 90-day OR: 1.16; P<0.05) and ileus complication (30-day OR: 1.87, P= <.05; 90-day OR: 1.81, P<.05). At both 30 and 90-days postoperative, patients undergoing a posterior approach had a higher odds ratio of stroke (30-day: OR: 0.79, 90-day OR: 0.87; P<0.05), transfusion (30-day OR: 0.66, 90-day OR: 0.69; P<.05), infection (30-day OR: 0.88, 90-day OR: 0.91; P <.05), and pneumonia (30-day OR: 0.85, 90-day OR: 0.90; P<.05). There was no statistically significant difference in myocardial infarction or pulmonary embolism between both approaches at 30 and 90-days postoperative. Conclusions: Anterior and posterior approaches for lumbar interbody fusion were associated with differences in postoperative complications at 30 and 90-days. The complication profiles associated with each approach can inform surgeon treatment decisions based on patient profiles.

Intracranial hemorrhage after spinal surgery: a literature review.

Background and Objective: Intracranial hemorrhage following spinal surgery is an infrequent but severe complication. Due to its rarity, the etiology, clinical characteristics, and treatment have not yet been fully elucidated. This literature review analyzed the incidence, clinical manifestations, hemorrhage location, current therapeutic strategies, location of operation, and interval time between surgery and bleeding. The objectives of the article were to provide insights for clinicians to promptly identify and prevent potential cases of intracranial hemorrhage. Methods: The authors queried PubMed and Web of Science databases using predefined keywords and included published literature reporting on intracranial hemorrhage after spinal surgery. Relevant case reports, case series, and reviews describing the mechanism of intracranial hemorrhage after spinal surgery and meeting diagnostic criteria for intracranial hemorrhage related to spinal surgery were included. Clinico-demographc data, presentations symptoms, location, index surgery type, and neurological outcomes after brain hemorrhage. Oxford Centre Level of Evidence guidelines was used to evaluate the quality of included studies. Descriptive statistics were used to synthesize the results. Key Content and Findings: A total of 80 publications of level of evidence IV involving 108 patients with median age at diagnosis was 58.5 years (inter-quartile range: 6-85) were analyzed. The incidence of intracranial hemorrhage was 0.08-0.37% among patients who underwent spinal surgery, and this complication occurred predominantly within 48 hours postoperatively. The initial presentation included headache, reduced level of consciousness, dysarthria, nausea, vomiting, hearing loss, blurred vision, neck rigidity, and delayed recovery from anesthesia. More than half (58.3%) of patients improved, while 23.1% still experienced neurological dysfunctions, and 7.4% died. Conclusions: The present study is limited by the levels of evidence of the included studies. There is heterogeneity among cases with respect to patient demographics and medical history. Angiography is critical in assessing the presence and extent of underlying vascular diseases. Intracranial hemorrages may be caused by intraoperative or postoperative cerebrospinal fluid leakage that will lead to intracranial pressure change and induced by intracranial venous or arterial bleeding. The treatment strategies include conservative medical management and surgical treatment. Individualized treatment should be emphasized.

Comparison of postoperative outcomes in patients with and without osteoporosis undergoing single-level anterior cervical discectomy and fusion.

Background: Osteoporosis is ubiquitous in elderly populations, such as those undergoing ACDF. Short- and longer-term outcomes might be affected in the setting of osteoporosis related to graft subsidence, bony union, and stresses on adjacent segments. Better understanding the potential correlation of osteoporosis and outcomes after ACDF might affect patient counseling and surgical planning. The current study compares 90-day adverse events and 5-year reoperations following single-level anterior cervical discectomy and fusion (ACDF) between patients with and without osteoporosis. Methods: Single-level ACDF procedures were identified in a national administrative database. Exclusion criteria included age under 18 years, less than 90 days of follow-up in the database, multi-level procedures, posterior concomitant procedures, and surgeries performed for trauma, neoplasm, or infection. After matching based on patient characteristics, 90-day perioperative adverse events were compared with multivariate analyses and five-year reoperations were compared with log-rank analysis. Reasons for reoperations were also evaluated. Results: Relative to age, sex, and comorbidity-matched patients without osteoporosis, those with osteoporosis had a small but statistically greater incidence of experiencing any 90-day adverse event (10.9% vs 9.4%, p < 0.001) and 5-year reoperations (19.1% vs 17.0%, p < 0.001). Of those requiring reoperation, those in the osteoporosis group had a greater proportion for nonunion (7.5% vs 5.6% p = 0.003). Conclusions: Following single-level ACDF, patients with osteoporosis experience slightly greater 90-day adverse events and 5-year reoperations. These results suggest the importance of recognizing osteoporosis in the ACDF population and accounting for this with surgical planning and patient counselling.

A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease.

Background: Following orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology. Methods: The 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD. Results: After weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality. Conclusions: After matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.

Demographic and economic trends in vertebral fracture surgeries throughout the United States.

Background: Vertebral fractures, frequently resulting from high-impact trauma to the spine, are an increasingly relevant public health concern. Little is known about the long-term economic and demographic trends affecting patients undergoing surgery for such fractures. This study examines national economic and demographic trends in vertebral fracture surgery in the United States to improve value-based care and health care utilization. Methods: The National Inpatient Sample (NIS) was queried for patients who underwent surgical treatment of a vertebral fracture (ICD-9-CM-3.53) (excluding kyphoplasty and vertebroplasty) between 1993 and 2015. Demographic data included patient age, sex, income, insurance type, hospital size, and location. Economic data including aggregate charge, aggregate cost, hospital cost, and hospital charge were analyzed. Results: The number of vertebral fracture surgeries, excluding kyphoplasty and vertebroplasty, increased 461% from 3,331 in 1993 to 18,675 in 2014, while inpatient mortality increased from 1.9% to 2.5%.The mean age of patients undergoing vertebral fracture surgeries increased from 42 in 1993 to 53 in 2015. The aggregate cost of surgery increased from $189,164,625 in 2001 to $1,060,866,580 in 2014, a 461% increase. Conclusions: The significant increase in vertebral fracture surgeries between 1993 and 2014 may reflect an increased rate of fractures, more surgeons electing to treat fractures surgically, or a combination of both. The increasing rate of vertebral fracture surgery, coupled with increasing hospital costs and mortality, signifies that the treatment of vertebral fractures remains a challenging issue in healthcare. Further research is necessary to determine the underlying cause of both the increase in surgeries and the increasing mortality rate.

Improvement in sagittal alignment and mechanical low-back pain following deep brain stimulation for Parkinson's disease: illustrative case.

BACKGROUND: Parkinson's disease (PD) is a common neurogenerative disease marked by the characteristic triad of bradykinesia, rigidity, and tremor. A significant percentage of patients with PD also demonstrate postural abnormalities (camptocormia) that limit ambulation and accelerate degenerative pathologies of the spine. Although deep brain stimulation (DBS) is a well-established treatment for the motor fluctuations and tremor seen in PD, the efficacy of DBS on postural abnormalities in these patients is less clear. OBSERVATIONS: The authors present a patient with a history of PD and prior lumbosacral fusion who underwent bilateral subthalamic nucleus DBS and experienced immediate improvement in sagittal alignment and subjective relief of mechanical low-back pain. LESSONS: DBS may improve postural abnormalities seen in PD and potentially delay or reduce the need for spinal deformity surgery.

The language of all medical publications and spine publications from 1950 to 2020.

Background: Excellent research in all fields, including spine surgery, exists in many different regions and languages. This study seeks to determine the relative number of spine related peer-reviewed publications throughout the world based on language. Methods: Peer-reviewed publications from the eleven most prolific languages in regard to both the number of peer-reviewed spine publications indexed in PubMed and total peer-reviewed publications from 1950-2020 were identified in PubMed. Results: 29,711,547 peer-reviewed publications were analyzed for the languages of interest with 870,404 (3.0%) of those being spine related peer-reviewed publications. Between 1988 and 2019, non-English language peer-reviewed publications decreased annually for both all peer-reviewed publications and spine related peer-reviewed publications by 44% and 36%, respectively. All medical and spine specific peer reviewed publications in English compared to non-English publications have increased by 7.22 and 6.35 times since 1988, respectively. While the ratio of non-English to English spine related publications decreased in all eleven countries, the percentage of the number of spine specific publications written in Chinese (462%), Portuguese (378%), and Spanish (88%) have increased by the listed percentages. Conclusion: While the proportion of peer-reviewed publications in the field of spine surgery written in English have increased over the past several decades, there are many non-English language peer-reviewed publications each year, particularly in Chinese. Although the rapid increase in the proportion of English spine related publications is beneficial to English speaking physicians and researchers, further research is necessary to understand the impact on non-English speaking physicians and researchers.

Attitudes and trends in the use of radiolucent spinal implants: A survey of the North American Spine Society section of spinal oncology.

Background: In spinal oncology, titanium implants pose several challenges including artifact on advanced imaging and therapeutic radiation perturbation. To mitigate these effects, there has been increased interest in radiolucent carbon fiber (CF) and CF-reinforced polyetheretherketone (CFR-PEEK) implants as an alternative for spinal reconstruction. This study surveyed the members of the North American Spine Society (NASS) section of Spinal Oncology to query their perspectives regarding the clinical utility, current practice patterns, and recommended future directions of radiolucent spinal implants. Methods: In February 2021, an anonymous survey was administered to the physicians of the NASS section of Spinal Oncology. Participation in the survey was optional. The survey contained 38 items including demographic questions as well as multiple-choice, yes/no questions, Likert rating scales, and short free-text responses pertaining to the "clinical concept", "efficacy", "problems/complications", "practice pattern", and "future directions" of radiolucent spinal implants. Results: Fifteen responses were received (71.4% response rate). Six of the participants (40%) were neurosurgeons, eight (53.3%) were orthopedic surgeons, and one was a spinal radiation oncologist. Overall, there were mixed opinions among the specialists. While several believed that radiolucent spinal implants provide substantial benefits for the detection of disease recurrence and radiation therapy options, others remained less convinced. Ongoing concerns included high costs, low availability, limited cervical and percutaneous options, and suboptimal screw and rod designs. As such, participants estimated that they currently utilize these implants for 27.3% of anterior and 14.7% of all posterior reconstructions after tumor resection. Conclusion: A survey of the NASS section of Spinal Oncology found a lack of consensus with regards to the imaging and radiation benefits, and several ongoing concerns about currently available options. Therefore, routine utilization of these implants for anterior and posterior spinal reconstructions remains low. Future investigations are warranted to practically validate these devices' theoretical risks and benefits.

Etiologies, incidence, and demographics of lumbar vertebral fractures in U.S. emergency departments.

Background: Lumbar vertebral fractures are debilitating injuries widely associated with significant patient deformity, disability, pain, and potentially neurological deficit. This cross-sectional database study investigates the most frequent annual etiologies of lumbar vertebral fractures presented to emergency departments throughout the United States (U.S.) from 2010-2018. Methods: The National Electronic Injury Surveillance System (NEISS) database was used to identify all patients who visited participating emergency departments between 2010-2018 and were diagnosed with a lumbar spine fracture. Population estimates by age (18+) were obtained from annual U.S. Census estimates and used to calculate annual incidence rates of lumbar fractures per 100,000 people. Results: The annual incidence rate of total lumbar fractures in the U.S. increased from 14.6 to 22.5 per 100,000 people from 2010-2018 (54%). From 2010-2018, there were 382,914 [95% confidence interval (CI): 382,855-382,973] lumbar fractures in the U.S. This increased from 34,328 (95% CI: 34,277-34,379) in 2010 to 57,098 (95% CI: 57,044-57,152) in 2018 (66.3%). Men composed 40.2% and women made up 59.8% of patients. Mean patient age increased by 2.96 years from 65.5 (95% CI: 65.38-65.62) years in 2010 to 68.4 (95% CI: 68.32-68.48) years in 2018 (4.5%). From 2010-2018, floors, stairs/steps, and ladders were the most common etiologies of lumbar fractures. Estimated sum of floor-related fractures was 80,054 (95% CI: 79,986-80,122), stair/step-related fractures was 48,274 (95% CI: 48,209-48,339), and ladder-related fractures was 31,053 (95% CI: 30,987-31,119). The increase in these three etiologies accounted for 48% of the total increase of all-cause lumbar fractures between 2010 and 2018. Conclusions: The volume of lumbar vertebral fracture has increased over the last near decade (66.3%), and approximately half (48%) of these fractures can be attributed to accidents caused by flooring, stairs/steps, and ladder-related injuries. The increasing mean patient age, as well as accidents involving ladders, were found to be statistically correlated with the rise in total lumbar fracture volume.