Stereotactic Radiosurgery in Metastatic Spine Disease-A Systemic Review of the Literature.

BACKGROUND: This study investigated the efficacy of stereotactic radiosurgery (SRS) in managing spinal metastasis. Traditionally, surgery was the primary approach, but SRS has emerged as a promising alternative. OBJECTIVE: The study aims to evaluate the efficacy of stereotactic radiosurgery in the management of spinal metastasis in terms of local tumor control, patient survival, and quality of life, identifying both advantages and limitations of SRS. METHODS: Through an extensive literature search in PubMed with cross-referencing, relevant full-text-available papers published between 2012 and 2022 in English or German were included. The search string used was "metastatic spine diseases AND SRS OR stereotactic radiosurgery". RESULTS: There is growing evidence of SRS as a precise and effective treatment. SRS delivers high radiation doses while minimizing exposure to critical neural structures, offering benefits like pain relief, limited tumor growth, and a low complication rate, even for tumors resistant to traditional radiation therapies. SRS can be a primary treatment for certain metastatic cases, particularly those without spinal cord compression. CONCLUSIONS: SRS appears to be a preferable option for oligometastasis and radioresistant lesions, assuming there are no contraindications. Further research is necessary to refine treatment protocols, determine optimal radiation dose and fractionation schemes, and assess the long-term effects of SRS on neural structures.

Medication-based profiling of older orthopedic patients: a multicenter cross-sectional study.

BACKGROUND: Managing medication use in older orthopedic patients is imperative to extend their healthy life expectancy in an aging society. However, the actual situation regarding polypharmacy, the intake of potentially inappropriate medications (PIMs), and fall risk-increasing drugs (FRIDs) among older orthopedic patients is not well characterized. This study aimed to investigate the medication-based profiles of older orthopedic patients to highlight the critical points of concern. METHODS: We retrospectively reviewed the clinical data of consecutive patients aged ≥ 65 years who underwent orthopedic surgery at two acute care hospitals between April 2020 and March 2021. The cutoff number of prescribed drugs for polypharmacy was set at 6. According to the specified guidelines, 19 categories of drugs were identified as PIMs, and 10 categories were classified as FRIDs. RESULTS: A total of 995 older patients with orthopedic surgery were assessed, of which 57.4% were diagnosed with polypharmacy, 66.0% were receiving PIMs, and 41.7% were receiving FRIDs. The prevalence of FRID intake did not significantly differ among patients with degenerative spinal disease (n = 316), degenerative disease of extremities (n = 331), and fractures (n = 272). Compared with patients with degenerative disease of the extremities, the multivariable-adjusted prevalence ratios (PRs) of polypharmacy and PIM intake were significantly higher in patients with degenerative spinal disease (1.26 [confidence intervals (CI): 1.11-1.44] and 1.12 [CI: 1.00-1.25]), respectively. Use of antiemetic drugs (adjusted PR, 13.36; 95% CI: 3.14-56.81) and nonsteroidal anti-inflammatory drugs (adjusted PR, 1.37; 95% CI: 1.05-1.78) was significantly higher in patients with degenerative spinal disease. Among patients with degenerative spinal disease, the prevalence of antiemetic drug intake was 8.7% in lumbar spinal patients and 0% in cervical spinal patients. CONCLUSIONS: More than half of the orthopedic patients in this study were affected by polypharmacy, and approximately two-thirds were prescribed some form of PIMs. Patients with degenerative spinal disease showed a significantly higher prevalence of polypharmacy and PIM use compared with other orthopedic diseases. Particular attention should be paid to the high frequency of antiemetic drugs and nonsteroidal anti-inflammatory drugs intake among patients with degenerative lumbar spine conditions.

Pelvic Fixation for Non-Ambulatory Patients with Neuromuscular Scoliosis Treated with Magnetically Controlled Growing Rods-A 4-Year Comparison of Two Different Fixation Methods.

Background/Objectives: This study aims to analyze the efficacy and safety of the two pelvic fixation systems, S-hooks (SH) and lumbar-sacral-alar-iliac (SAI) screws, when used in association with magnetically controlled growing rods (MCGRs) in non-ambulatory children with severe neuromuscular scoliosis (NMS). Methods: Forty-one patients were retrospectively examined and subdivided corresponding to ilium hook fixation or SAI screws. The major curve correction (%) and pelvic obliquity (PO) correction (%) were assessed utilizing scoliosis plain film radiographs over time. Complications and unplanned return to the operating room (UPROR) were recorded. Patient-specific pre- and postoperative values were included in a backward stepwise regression model to assess UPROR. Results: Mean age at index intervention was 9.4 years. Preoperative main curve was 81° and PO was 22°. 21 and 20 patients were categorized into the SH and SAI subgroups, respectively. Initial curve correction was significantly better in the SAI subgroup (63 vs. 42% in the SH, p = 0.045), while PO correction was equally good. Curve and PO correction were maintained throughout the follow-up period of 55 months. UPROR rate was 38% in the SH subgroup, and 5% in the SAI subgroup (p = 0.010). Regression analysis identified postoperative curve correction as predictive value for UPROR (p = 0.006). Conclusions: SAI screw fixation has a low UPROR rate and achieves superior curve correction. S-hooks are a viable option to correct PO and NMS in children with high operative risk to reduce operative time, but revision surgery is not uncommon.

The Efficacy of a Multidisciplinary Approach and Diagnostic-Therapeutic Algorithm for Vertebral Metastases with Spinal Cord Compression.

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic-therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail.

Rethinking Strategies for Multi-Metastatic Patients: A Comprehensive Retrospective Analysis on Open Posterior Fusion Versus Percutaneous Osteosynthesis in the Treatment of Vertebral Metastases.

Background: Managing vertebral metastases (VM) is still challenging in oncology, necessitating the use of effective surgical strategies to preserve patient quality of life (QoL). Traditional open posterior fusion (OPF) and percutaneous osteosynthesis (PO) are well-documented approaches, but their comparative efficacy remains debated. Methods: This retrospective study compared short-term outcomes (6-12 months) between OPF and PO in 78 cancer patients with spinal metastases. This comprehensive evaluation included functional, clinical, and radiographic parameters. Statistical analysis utilized PRISM software (version 10), with significance set at p < 0.05. Results: PO demonstrated advantages over OPF, including shorter surgical durations, reduced blood loss, and hospital stay, along with lower perioperative complication rates. Patient quality of life and functional outcomes favored PO, particularly at the 6-month mark. The mortality rates at one year were significantly lower in the PO group. Conclusions: Minimally invasive techniques offer promising benefits in VM management, optimizing patient outcomes and QoL. Despite limitations, this study advocates for the adoption of minimally invasive approaches to enhance the care of multi-metastatic patients with symptomatic VM.

Analysis of surgical treatment of cervical spondylotic amyotrophy.

Background: Cervical spondylotic amyotrophy (CSA) is a special type of cervical spondylosis based on cervical degeneration, which is mainly manifested by weakness and atrophy of upper limb muscles without obvious sensory impairment. Various diagnostic and treatment strategies used; however, discrepancies exist. We tried to discuss diagnosing and treating CSA. Methods: 15 patients with CSA were diagnosed in the Orthopedics Department of the First Affiliated Hospital of Zhengzhou University, aged 42-70 years old. The duration of preoperative symptoms of amyotrophy was 6 to 240 months. 12 patients received surgical treatment, and 3 patients received conservative treatment. The patients were divided into two groups according to the site of preoperative amyotrophy. The manual muscle test was used to evaluate the patients' muscle strength pre-and postoperatively. Results: During postoperative follow-up, the muscle strength of 12 patients improved to different degrees compared to before surgery. The improvement effect was excellent in 2 cases, good in 6, and moderate in 4. There was no decrease in postoperative muscle strength compared with that before surgery. The satisfaction rate of the effect was 66.7%. The two groups had no statistically significant difference in preoperative muscle strength. The postoperative muscle strength of the proximal group was significantly better than that of the distal group. Conclusion: The surgical effect of CSA of the proximal type is significantly better than that of the distal type. The recovery effect of amyotrophy after surgery for distal type CSA is poor; thus, surgical treatment should be carefully considered.

Frailty is not an independent risk factor for worse clinical outcomes in lumbar spinal surgery: a prospective cohort study.

PURPOSE: Recently, many studies revealed that frailty affects unfavorably on postoperative outcomes in lumbar spinal diseases. This study aimed to investigate the relationship between frailty and clinical outcomes while identifying risk factors associated with worse clinical outcomes following lumbar spinal surgery. METHODS: From March 2019 to February 2021, we prospectively enrolled eligible patients with degenerative lumbar spinal diseases requiring surgery. Frailty was assessed preoperatively. To identify the impact of frailty on lumbar spinal diseases, clinical outcomes, which were measured with patient-reported outcomes (PROs) and postoperative complications, were compared according to the frailty. PROs were assessed preoperatively and one year postoperatively. In addition, risk factors for preoperative and postoperative worse clinical outcomes were investigated. RESULTS: PROs were constantly lower in the frail group than in the non-frail group before and after surgery, and the change of PROs between before and after surgery and postoperative complications were not different between the groups. In addition, frailty was a persistent risk factor for postoperative worse clinical outcome before and after surgery in lumbar spinal surgery. CONCLUSION: Frailty persistently affects the clinical outcome negatively before and after surgery in lumbar spinal surgery. However, as the change of the clinical outcome is not different between the frail group and the non-frail group, it is difficult to interpret whether the frail patients are vulnerable to the surgery. In conclusion, frailty is not an independent risk factor for worse clinical outcome in lumbar spinal surgery.

Transforaminal epidural steroid injection for radiculopathy and the evolution to surgical treatment: a pragmatic prospective observational multicenter study.

Aim: The aim of this study is to analyze the real-world outcomes of transforaminal epidural steroid injections (TFESIs) in all patients with radiculopathy and their long-term outcomes. Methods: Patients with radiculopathy and failure of conservative treatment were included in a prospective, multicenter, observational cohort study. Results: In total, 117 patients were treated with one or two TFESIs. The mean duration of follow-up was 116 (±14) weeks. In total 19,6% (95% CI: 12.9-28.0%) patients were treated with surgery after insufficient symptom improvement. The evolution to surgery was not associated with etiology, symptom duration or previous spine surgery. Conclusion: Real-world data confirms that TFESIs is an effective treatment with satisfactory results in about 80% of patients for a period of 2 years.

This study focusses on evaluating the real-world effectiveness of transforaminal epidural steroid injections (TFESIs) in treating radiculopathy, a condition characterized by back and leg pain due to compressed spinal nerves. This nerve compression can originate from different problems.A total of 117 patients with radiating leg pain were included in this study. The infiltrations were administered, and the primary outcome was the need for spinal surgery within 2 years. The findings revealed that approximately 20% of patients eventually required surgery due to unsatisfactory results after injections. However, for patients with satisfactory outcomes, there was a notable reduction in back and leg pain, disability and pain medication usage, along with an improved quality of life.Importantly, the results suggested that TFESIs could be considered as a treatment option in daily clinical practice, also after a prolonged duration of symptoms.Despite certain limitations, such as the absence of a control group undergoing immediate surgical treatment, the real-world data supported the effectiveness of TFESIs in treating radiculopathy. This information provides valuable insights for spine surgeons and pain physicians in understanding the prognosis of TFESIs across diverse patient scenarios.

Development and validation of a web-based artificial intelligence prediction model to assess massive intraoperative blood loss for metastatic spinal disease using machine learning techniques.

BACKGROUND CONTEXT: Intraoperative blood loss is a significant concern in patients with metastatic spinal disease. Early identification of patients at high risk of experiencing massive intraoperative blood loss is crucial as it allows for the development of appropriate surgical plans and facilitates timely interventions. However, accurate prediction of intraoperative blood loss remains limited based on prior studies. PURPOSE: The purpose of this study was to develop and validate a web-based artificial intelligence (AI) model to predict massive intraoperative blood loss during surgery for metastatic spinal disease. STUDY DESIGN/SETTING: An observational cohort study. PATIENT SAMPLE: Two hundred seventy-six patients with metastatic spinal tumors undergoing decompressive surgery from two hospitals were included for analysis. Of these, 200 patients were assigned to the derivation cohort for model development and internal validation, while the remaining 76 were allocated to the external validation cohort. OUTCOME MEASURES: The primary outcome was massive intraoperative blood loss defined as an estimated blood loss of 2,500 cc or more. METHODS: Data on patients' demographics, tumor conditions, oncological therapies, surgical strategies, and laboratory examinations were collected in the derivation cohort. SMOTETomek resampling (which is a combination of Synthetic Minority Oversampling Technique and Tomek Links Undersampling) was performed to balance the classes of the dataset and obtain an expanded dataset. The patients were randomly divided into two groups in a proportion of 7:3, with the most used for model development and the remaining for internal validation. External validation was performed in another cohort of 76 patients with metastatic spinal tumors undergoing decompressive surgery from a teaching hospital. The logistic regression (LR) model, and five machine learning models, including K-Nearest Neighbor (KNN), Decision Tree (DT), XGBoosting Machine (XGBM), Random Forest (RF), and Support Vector Machine (SVM), were used to develop prediction models. Model prediction performance was evaluated using area under the curve (AUC), recall, specificity, F1 score, Brier score, and log loss. A scoring system incorporating 10 evaluation metrics was developed to comprehensively evaluate the prediction performance. RESULTS: The incidence of massive intraoperative blood loss was 23.50% (47/200). The model features were comprised of five clinical variables, including tumor type, smoking status, Eastern Cooperative Oncology Group (ECOG) score, surgical process, and preoperative platelet level. The XGBM model performed the best in AUC (0.857 [95% CI: 0.827, 0.877]), accuracy (0.771), recall (0.854), F1 score (0.787), Brier score (0.150), and log loss (0.461), and the RF model ranked second in AUC (0.826 [95% CI: 0.793, 0.861]) and precise (0.705), whereas the AUC of the LR model was only 0.710 (95% CI: 0.665, 0.771), the accuracy was 0.627, the recall was 0.610, and the F1 score was 0.617. According to the scoring system, the XGBM model obtained the highest total score of 55, which signifies the best predictive performance among the evaluated models. External validation showed that the AUC of the XGBM model was also up to 0.809 (95% CI: 0.778, 0.860) and the accuracy was 0.733. The XGBM model, was further deployed online, and can be freely accessed at https://starxueshu-massivebloodloss-main-iudy71.streamlit.app/. CONCLUSIONS: The XGBM model may be a useful AI tool to assess the risk of intraoperative blood loss in patients with metastatic spinal disease undergoing decompressive surgery.

Is Age a Risk Factor for Early Postoperative Cage Subsidence After Transforaminal Lumbar Interbody Fusion? A Retrospective Study in 170 Patients.

STUDY DESIGN: Retrospective observational study. OBJECTIVES: We aim to evaluate whether age is a risk factor for cage subsidence, and whether other patient characteristics, preoperative radiological or imaging parameters are associated with cage subsidence and the need for revision surgery in patients undergoing transforaminal lumbar interbody fusion (TLIF). METHODS: Patient demographics and surgery-related information were extracted. Cage subsidence was evaluated using upright standing sagittal plane X-rays and defined as more than 2 mm migration of the cage into the adjacent vertebral body. Patients who received revision surgery within 1 year for any reason were recorded. Radiographic parameters were measured. Univariable logistic regression models were used to evaluate the risk factors for cage subsidence and need for revision surgery. RESULTS: At 3-month and 1-year follow-up, cage subsidence was observed in 28 patients (16.5%) and 58 patients (34.1%), respectively. Twenty-seven patients received revision surgery within the first year after TLIF. Age (odds ratio (OR): 1.07 per year) and male sex (OR: 2.76) had a significantly increased odds ratio for cage subsidence 3 months after TLIF. Male sex (OR: 2.55) but not age was a significant risk factor for cage subsidence 1 year after TLIF. Of all assessed risk factors, only BMI (OR: 1.11 per kg/m2) had a significantly increased risk for the need of revision surgery. CONCLUSIONS: Age was associated with cage subsidence 3 months but not 1 year after TLIF suggesting that age is only a risk factor for early cage subsidence and not in a longer follow-up.

Understanding the management of pediatric spondylodiscitis based on existing literature; a systematic review.

BACKGROUND: Spondylodiscitis (SD), a rare disease in children, poses diagnostic challenges due to non-specific presenting symptoms, scarcity in incidence, and difficulty expressing pain in non-verbal children. METHOD: A comprehensive search was conducted on three databases, including PubMed/Medline, Web of Science, and Scopus until March 2023. The inclusion criteria were studies that investigated the clinical characteristics, treatment, and complications of children's spondylodiscitis. Full text of cross-sectional and cohort studies were added. The quality assessment of cohort studies was conducted using the Newcastle-Ottawa Quality Assessment Scale. The search, screening, and data extraction were performed by two researchers independently. RESULT: Clinical manifestations of discitis in children are nonspecific, such as back pain, fever, reduced ability or inability to walk or sit, limping, and reduced range of movements. The mean delay in the time of diagnosis was 4.8 weeks. The most affected site of all the studies was the lumbar spine. 94% of studies reported increased inflammatory markers such as white blood cell count, C-reactive protein, and erythrocyte sedimentation rate. Less than 30% of patients had positive blood cultures and biopsy findings. The most common microbiological results (64%) were Staphylococcus Aureus and Kingella kingae. In radiographic evaluation, intervertebral disk narrowing, lumbar lordosis reduction, loss of disk height, and destruction of the vertebral body have been reported. In all studies, antibiotic therapy was initiated; in 52% immobilization was employed, and 29% of studies reported surgery was performed, and the follow-up period differed from 1.5 months to 156 months. 94% of studies reported complications such as vertebral body destruction, back pain, kyphosis, reduced range of movement, scoliosis, and neurological complications. CONCLUSION: Spondylodiscitis is an uncommon, heterogeneous, multifactorial disease with resulting difficult and delayed diagnosis. Due to its morbidity, it is essential to investigate children with refusal to walk, gait disturbances, or back pain, particularly when associated with elevated inflammatory markers.

Management of Spinal Metastasis by Minimally Invasive Surgical Techniques: Surgical Principles and Indications-A Literature Review.

BACKGROUND: Spinal metastasis is becoming more frequent. This raises the topics of pain and neurological complications, which worsen the functional and survival prognosis of oncological population patients. Surgical treatment must be as complete as possible in order to decompress and stabilize without delaying the management of the oncological disease. Minimally invasive spine surgical techniques inflict less damage on the musculocutaneous plan than opened ones. METHODS: Different minimally invasive techniques are proposed in this paper for the management of spinal metastasis. We used our experience, developed degenerative and traumatic pathologies, and referred to many authors, establishing a narrative review of our local practice. RESULTS: Forty-eight articles were selected, and these allowed us to describe the different techniques: percutaneous methods such as vertebro/kyphoplasty, osteosynthesis, mini-open surgery, or that through a posterior or anterior approach. Also, some studies detail the contribution of new technologies, such as intraoperative CT scan and robotic assistance. CONCLUSIONS: It seems essential to offer a lasting solution to a spinal problem, such as in the form of pain relief, stabilization, and decompression. Our department has embraced a multidisciplinary and multidimensional approach to MISS, incorporating cutting-edge technologies and evidence-based practices.

Technical Feasibility and Early Clinical Outcome of Biportal Endoscopic Transforaminal Lumbar Interbody Fusion Using Larger Cage.

BACKGROUND: Transforaminal lumbar interbody fusion with biportal endoscopic guidance (BE-TLIF) has been previously reported with promising clinical results. However, complications such as delayed union or subsidence occurred as with open surgery. We assumed using larger cages would result in less occurrence of such complications. We aimed to analyze the clinical outcome and technical feasibility of BE-TLIF using larger cages, initially designed for oblique lumbar interbody fusion. METHODS: We enrolled cases that underwent single-level BE-TLIF between January 2021 and January 2022. Polyetheretherketone cages that were larger than the conventional size were used. Diagnoses were degenerative spondylolisthesis or isthmic spondylolisthesis. Visual analog scale scores of the back and leg and Oswestry Disability Index were collected perioperatively. Modified Macnab criteria were used to evaluate the patients at the final follow-up. Radiologic outcome of interbody fusion rate and perioperative complications were analyzed. RESULTS: A total of 35 cases were included in this study. The mean age was 67.5 ± 8.4 and consisted of 13 male patients, and the mean follow-up duration was 18.3 ± 3.7 months. The majority (32/35, 91.3%) of the index level was located within the lower lumbar region, L4-S1. Oswestry Disability Index scores improved from 65.4 ± 5.4 preoperatively to 15.4 ± 6.1 at the final follow-up (P < 0.001). Visual analog scale scores of the leg decreased from 7.9 ± 1.5 to 1.7 ± 1.5 at the final follow-up (P < 0.001). Per the modified Macnab criteria on the final follow-up, 94% of the patients reported good/excellent. Most (94.2%) of the patients showed fusion grade I and II at the 1-year follow-up. No patient showed subsidence or other postoperative complication. CONCLUSIONS: BE-TLIF using a larger cage was safely performed without risk of subsidence during the 1-year follow-up. A cage with a larger footprint may be advantageous in BE-TLIF in the aspect of interbody fusion and subsidence.

Risk factors for reoperation after surgical treatment for degenerative spinal disease in Poland: a nationwide retrospective study of 38,953 hospitalisations.

INTRODUCTION: Degenerative spinal disease (DSD) is one of the most common musculoskeletal conditions and a leading cause of sickness absence. It also contributes significantly to the global burden of disease. The aim of this study was to assess the frequency of reoperation after surgical treatment of DSDs in Poland, and to identify risk factors for reoperation. MATERIAL AND METHODS: A retrospective analysis of hospitalisations for DSD in 2018 that were reported to Poland's National Health Fund (NHF) was performed. Reoperations reported within 365 days of hospital discharge were identified. Demographic factors and multimorbidities were included in the analysis. A logistic regression model was then performed to assess risk factors for reoperations. RESULTS: In 2018, 38,953 surgical hospitalszations for DSD were reported. A total of 3,942 hospitalised patients (10.12%) required reoperation within 365 days. Patients requiring reoperation were predominantly female (female-to-male ratio 1.34:1) and elderly (mean age of reoperated patients 56.66 years, mean age of other patients 53.24). The percentage reoperated upon correlated with multiple diseases (from 8.81% in the group of patients without comorbidities to 15.31% in the group of patients with three or more comorbidities). The risk of reoperation was most increased by comorbid depression, neurological diseases, obesity, and older age. The risk of reoperation was reduced by instrumented spinal surgery, surgery in a neurosurgical unit, and hospitalisations other than same-day surgery. CONCLUSIONS: Reoperations within a year after DSD surgical treatment are common. Identifying risk factors for reoperation, including those related to the presence of comorbidities and the phenomenon of multimorbidity, can be an important tool in reducing reoperation rates.

Risk factors for postoperative complaints in patients following lumbar decompression and fusion: Analyses focusing on preoperative symptoms.

BACKGROUND: Several patients complained of residual symptoms following lumbar decompressive surgery for lumbar degenerative disease (LDD). However, few studies analyze this dissatisfaction by focusing on preoperative patients' symptoms. This study was conduct to determine the factors that could predict the patients' postoperative complaints by focusing on their preoperative symptoms. METHODS: Four hundred and seventeen consecutive patients who underwent lumbar decompression and fusion surgery for LDD were included. Postoperative complaint was defined by at least twice same complaint during the outpatient follow-up of 6,12, 18 and 24 months after surgery. A comparative analysis was performed between complaint group (group C, N = 168) and non-complaint group (group NC, N = 249). Demographic, operative, symptomatic, and clinical factors were compared between the groups by univariate and multivariate analyses. RESULTS: The main preoperative chief complaints were radiating pain (318/417, 76.2%). However, most common postoperative complaint was residual radiating pain (60/168, 35.7%) followed by tingling sensation (43/168, 25.6%). The presence of psychiatric disease (adjusted odds ratio [aOR], 4.666; P = 0.017), longer pain duration (aOR, 1.021; P < 0.001), pain to below the knee (aOR, 2.326; P = 0.001), preoperative tingling sensation (aOR, 2.631; P < 0.001), preoperative sensory and motor power decrease (aOR, 2.152 and 1.678; P = 0,047 and 0.011, respectively) were significantly correlated with postoperative patients' complaints in multivariate analysis. CONCLUSIONS: The postoperative patients' complaints could be predicted and explained in advance by checking the preoperative characteristics of patients' symptoms, including the duration and site carefully. This could be helpful to enhance the understanding of the surgical results preoperatively, which could control the anticipation of the patients.

The use of red flags during the referral chain of patients surgically treated for symptomatic spinal metastases.

Background: The use of so-called "red flags" may be beneficial in identifying patients with metastatic spinal disease. This study examined the utility and efficacy of these red flags in the referral chain of patients surgically treated for spinal metastases. Methods: The referral chains from the onset of symptoms until surgical treatment for all patients receiving surgery for spinal metastases between March 2009 and December 2020 were reconstructed. The documentation of red flags, as defined by the Dutch National Guideline on Metastatic Spinal Disease, was assessed for each healthcare provider involved. Results: A total of 389 patients were included in the study. On average, 33.3% of red flags were documented as present, 3.6% were documented as absent, and 63.1% were undocumented. A higher rate of red flags documented as present was associated with a longer time to diagnosis, but a shorter time to definitive treatment by a spine surgeon. Moreover, red flags were documented as present more often in patients who developed neurological symptoms at any point during the referral chain than those who remained neurologically intact. Conclusions: The association of red flags with developing neurological deficits highlights their significance in clinical assessment. However, the presence of red flags was not found to decrease delays prior to referral to a spine surgeon, indicating that their relevance is currently not sufficiently recognized by healthcare providers. Raising awareness of symptoms indicative of spinal metastases may expedite timely (surgical) treatment and thus improve treatment outcome.

Three-Dimensional Hounsfield Units Measurement of Pedicle Screw Trajectory for Predicating Screw Loosening in Lumbar Fusion Surgery.

Purpose: Dual-energy X-ray absorptiometry (DXA) is commonly used for evaluation of bone mineral density before spinal surgery, but frequently leads to overestimation in degenerative spinal diseases due to osteoproliferation factors. We introduce a novel method to compare the predictive ability of Hounsfield Units (HU) and DXA methods to predict screw loosening after lumbar interbody fusion surgery in degenerative spinal diseases by measuring HU of pedicle screw trajectory on computed tomography (CT) images preoperatively. Patients and Methods: This retrospective study was conducted on patients who underwent posterior lumbar fusion surgery for degenerative diseases. CT HUs measurement was performed using medical imaging software, including the cancellous region on cross-sections of the vertebral body and three-dimensional pedicle screw trajectory. Receiver operating characteristic (ROC) curve analyses were performed for the risk of pedicle screw loosening in association with the Hounsfield scale and preoperative BMD, and the area under the curve (AUC) and the cutoff values were calculated. Results: A total of 90 patients were enrolled and were divided into loosening (n = 33, 36.7%) and non-loosening groups (n = 57, 63.3%). No significant differences in age, gender, length of fixation and preoperative BMD were found between both groups. The loosening group showed lower CT HU values in the vertebral body and screw trajectory than the non-loosening group. Screw trajectory HU (ST-HU) exhibited a higher AUC value than vertebral body HU (B-HU). The cutoff values of B-HU and ST-HU were 160 and 110 HUs, respectively. Conclusion: Three-dimensional pedicle screw trajectory HU values yields a stronger predictive value than vertebral body HU values and BMD and may provide more guidance for surgery. The risk of screw loosening is significantly increased at ST-HU <110 or B-HU <160 at L5 segment.

Trend of unplanned reoperation rates after lumbar degenerative surgery from 2011 to 2019: a large patient population study.

BACKGROUND: Unplanned reoperation is commonly performed due to postoperative complications. Previous studies have reported the incidence of unplanned reoperation following lumbar spinal surgery. But few study focused on the trend of reoperation rates, and the reasons of unplanned reoperation were not clear. In this study, we conducted a retrospective study to determine the trend of unplanned reoperation rates after degenerative lumbar spinal surgery from 2011 to 2019, and the reasons and risk factors of unplanned reoperation were also determined. METHODS: Data of patients who were diagnosed with degenerative lumbar spinal disease and underwent posterior lumbar spinal fusion surgery in our institution from January 2011 to December 2019 were reviewed. Those who received unplanned reoperation during the primary admission were identified. The demographics, diagnosis, surgical segments and postoperative complications of these patients were recorded. The rates of unplanned reoperation from 2011 to 2019 were calculated, and the reasons of unplanned reoperation were statistically analysed. RESULTS: A total of 5289 patients were reviewed. Of them, 1.91% (n = 101) received unplanned reoperation during the primary admission. The unplanned reoperation rates of degenerative lumbar spinal surgery firstly increased from 2011 to 2014, with a peak rate in 2014 (2.53%). Then, the rates decreased from 2014 to 2019, with the lowest one in 2019 (1.46%). Patients with lumbar spinal stenosis have a higher rate of unplanned reoperation (2.67%) compared with those diagnosed as lumbar disc herniation (1.50%) and lumbar spondylolisthesis (2.04%) (P < 0.05). The main reasons for unplanned reoperation were wound infection (42.57%), followed by wound hematoma (23.76%). Patients who underwent 2-segment spinal surgery had a higher unplanned reoperation rate (3.79%) than those receiving other segments surgery (P < 0.001). And different spine surgeons had different reoperation rates. CONCLUSIONS: The rates of unplanned reoperation after lumbar degenerative surgery increased at first and then decreased during past 9 years. Wound infection was the major reason for unplanned reoperation. 2-segment surgery and surgeon's surgical skills were related to the reoperation rate.

Comparison of robot-assisted versus fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar spinal diseases: 2-year follow-up.

This study was performed to prospectively compare the clinical and radiographic outcomes between robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA MIS-TLIF) and fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion (FA MIS-TLIF) in patients with degenerative lumbar spinal diseases. One hundred and twenty-three patients with lumbar degenerative diseases (lumbar spinal stenosis with instability and spondylolisthesis [degenerative spondylolisthesis or isthmic spondylolisthesis]) who underwent MIS-TLIF in our hospital were included in this study. Sixty-one patients underwent RA MIS-TLIF (Group A) and 62 patients underwent FA MIS-TLIF (Group B). Group A was further divided into Subgroup AI (46 single-level procedures) and Subgroup AII (15 double-level procedures). Group B was further divided into Subgroup BI (45 single-level procedures) and Subgroup BII (17 double-level procedures). The clinical outcome parameters were the visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, operative time, number of intraoperative fluoroscopies, blood loss, postoperative hospital stay, and postoperative complications. The radiographic change measures were the accuracy of screw placement, facet joint violation (FJV), fusion status, and change in disc height at the proximal adjacent segment at the 2-year follow-up. There were no significant differences in the VAS and ODI scores, blood loss, or postoperative hospital stay between Groups A and B (p > 0.05). The operative time was longer in Group A than B (p = 0.018). The operative time was longer in Subgroup AI than BI (p = 0.001). However, there was no significant difference between Subgroups AII and BII (p > 0.05). There was no significant difference in the number of intraoperative fluoroscopies for patients between Groups A and B (p > 0.05). Although the number of intraoperative fluoroscopies for patients was significantly higher in Subgroup AI than BI (p = 0.019), there was no significant difference between Subgroups AII and BII (p > 0.05). The number of intraoperative fluoroscopies for the surgeon was significantly lower in Group A than B (p < 0.001). For surgeons, the difference in the average number of intraoperative fluoroscopies between Subgroups AI and AII was 2.98, but that between Subgroups BI and BII was 10.73. In Group A, three guide pins exhibited drift and one patient developed a lateral wall violation by a pedicle screw. One pedicle screw perforated the anterior wall of the vertebral body and another caused an inner wall violation in Group B. The rate of a perfect screw position (grade A) was higher in Group A than B (p < 0.001). However, there was no significant difference in the proportion of clinically acceptable screws (grades A and B) between the two groups. The mean FJV grade was significantly higher in Group B than A (p < 0.001). During at 2-year postoperative follow-up, there was no significant difference in the fusion status between the two groups (p > 0.05); however, the decrease in disc height at the proximal adjacent segment was significantly less in Group A than B (p < 0.001). Robot-assisted percutaneous pedicle screw placement is a safer and more accurate alternative to conventional freehand fluoroscopy-assisted percutaneous pedicle screw insertion in MIS-TLIF.