Post-operative shift in pain profile following fusion surgery for adult spinal deformity: a cluster analysis.

PURPOSE: Adult spinal deformity (ASD) is associated with a combination of back and leg pain of various intensities. The objective of the present study was to investigate the diverse reaction of pain profiles following ASD surgery as well as post-operative patient satisfaction. METHODS: Multicenter surveillance collected data for patients ≥ 19 years old who underwent primary thoracolumbar fusion surgery at > 5 spinal levels for ASD. Two-step cluster analysis was performed utilizing pre-operative numeric rating scale (NRS) for back and leg pain. Radiologic parameters and patient-reported outcome (PRO) scores were also obtained. One-year post-operative outcomes and satisfaction rates were compared among clusters, and influencing factors were analyzed. RESULTS: Based on cluster analysis, 191 ASD patients were categorized into three groups: ClusterNP, mild pain only (n = 55); ClusterBP, back pain only (n = 68); and ClusterBLP, significant back and leg pain (n = 68). ClusterBLP (mean NRSback 7.6, mean NRSleg 6.9) was the oldest 73.4 years (p < 0.001) and underwent interbody fusion (88%, p < 0.001) and sacral/pelvic fixation (69%, p = 0.001) more commonly than the other groups, for the worst pelvis incidence-lumbar lordosis mismatch (mean 43.7°, p = 0.03) and the greatest sagittal vertical axis (mean 123 mm, p = 0.002). While NRSback, NRSleg and PRO scores were all improved postoperatively in ClustersBP and BLP, ClusterBLP showed the lowest satisfaction rate (80% vs. 80% vs. 63%, p = 0.11), which correlated with post-operative NRSback (rho = -0.357). CONCLUSIONS: Cluster analysis revealed three clusters of ASD patients, and the cluster with the worst pain back and leg pain had the most advanced disease and showed the lowest satisfaction rate, affected by postoperative back pain.

Predictors for hemostatic thrombin-gelatin matrix usage in spine surgery: a multicenter observational study.

STUDY DESIGN: A prospective cohort study. OBJECTIVES: Thrombin-gelatin matrix (TGM) is a rapid and potent hemostatic agent, but it has some limitations, including the cost and its preparation time. The purpose of this study was to investigate the current trend in the use of TGM and to identify the predictors for TGM usage in order to ensure its proper use and optimized resource allocation. METHODS: A total of 5520 patients who underwent spine surgery in a multicenter study group within a year were included in the study. The demographic factors and the surgical factors including spinal levels operated, emergency surgery, reoperation, approach, durotomy, instrumented fixation, interbody fusion, osteotomy, and microendoscopy-assistance were investigated. TGM usage and whether it was routine or unplanned use for uncontrolled bleeding were also checked. A multivariate logistic regression analysis was used to identify predictors for unplanned use of TGM. RESULTS: Intraoperative TGM was used in 1934 cases (35.0%), among which 714 were unplanned (12.9%). Predictors of unplanned TGM use were female gender (adjusted odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.02-1.43, p = 0.03), ASA grade ≥ 2 (OR: 1.34, 95% CI: 1.04-1.72, p = 0.02), cervical spine (OR: 1.55, 95% CI: 1.24-1.94, p < 0.001), tumor (OR: 2.02, 95% CI: 1.34-3.03, p < 0.001), posterior approach (OR: 1.66, 95% CI: 1.26-2.18, p < 0.001), durotomy (OR: 1.65, 95% CI: 1.24-2.20, p < 0.001), instrumentation (OR: 1.30, 1.03-1.63, p = 0.02), osteotomy (OR: 5.00, 2.76-9.05, p < 0.001), and microendoscopy (OR: 2.24, 1.84-2.73, p < 0.001). CONCLUSIONS: Many of the predictors for unplanned TGM use have been previously reported as risk factors for intraoperative massive hemorrhaging and blood transfusion. However, other newly revealed factors can be predictors of bleeding that is technically challenging to control. While routine usage of TGM in these cases will require further justification, these novel findings are valuable for implementing preoperative precautions and optimizing resource allocation.

Does surgical site infection affect patient-reported outcomes after spinal surgery? A multicenter cohort study.

BACKGROUND: Surgical site infections are common in spinal surgeries. It is uncertain whether outcomes in spine surgery patients with vs. without surgical site infection are equivalent. Therefore, we assessed the effects of surgical site infection on postoperative patient-reported outcomes. METHODS: We enrolled patients who underwent elective spine surgery at 12 hospitals between April 2017 and February 2020. We collected data regarding the patients' backgrounds, operative factors, and incidence of surgical site infection. Data for patient-reported outcomes, namely numerical rating scale, Neck Disability Index/Oswestry Disability Index, EuroQol Five-Dimensional questionnaire, and 12-Item Short-Form Health Survey scores, were obtained preoperatively and 1 year postoperatively. We divided the patients into with and without surgical site infection groups. Multivariate logistic regression analyses were performed to identify the risk factors for surgical site infection. Using propensity score matching, we obtained matched surgical site infection-negative and -positive groups. Student's t-test was used for comparisons of continuous variables, and Pearson's chi-square test was used to compare categorical variables between the two matched groups and two unmatched groups. RESULTS: We enrolled 8861 patients in this study; 74 (0.8 %) developed surgical site infections. Cervical spine surgery and American Society of Anesthesiologists physical status classification ≥3 were identified as risk factors; microendoscopy was identified as a protective factor. Using propensity score matching, we compared surgical site infection-positive and -negative groups (74 in each group). No significant difference was found in postoperative pain or dysesthesia of the lower back, buttock, leg, and plantar area between the groups. When comparing preoperative with postoperative pain and dysesthesia, statistically significant improvement was observed for both variables in both groups (p < 0.01 for all variables). No significant differences were observed in postoperative outcomes between the matched surgical site infection-positive and -negative groups. CONCLUSIONS: Patients with surgical site infections had comparable postoperative outcomes to those without surgical site infections.

Postoperative outcomes after degenerative lumbar spine surgery in rheumatoid arthritis patients -a propensity score-matched analysis.

BACKGROUND: Although treatment options for rheumatoid arthritis (RA) have evolved significantly since the introduction of biologic agents, degenerative lumbar disease in RA patients remains a major challenge. Well-controlled comparisons between RA patients and their non-RA counterparts have not yet been reported. The objective of the present study was to compare postoperative outcomes of lumbar spine surgery between RA and non-RA patients by a retrospective propensity score-matched analysis. METHODS: Patients who underwent primary posterior spine surgery for degenerative lumbar disease in our prospective multicenter study group between 2017 and 2020 were enrolled. Demographic data including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, diabetes mellitus, smoking, steroid usage, number of spinal levels involved, and preoperative patient-reported outcome (PRO) scores (numerical rating scale [NRS] for back pain and leg pain, Short Form-12 physical component summary [PCS], EuroQOL 5-dimension [EQ-5D], and Oswestry Disability Index [ODI]) were used to calculate a propensity score for RA diagnosis. One-to-one matching was performed and 1-year postoperative outcomes were compared between groups. RESULTS: Among the 4567 patients included, 90 had RA (2.0%). RA patients in our cohort were more likely to be female, with lower BMI, higher ASA grade and lower current smoking rate than non-RA patients. Preoperative NRS scores for leg pain, PCS, EQ-5D, and ODI were worse in RA patients. Propensity score matching generated 61 pairs of RA and non-RA patients who underwent posterior lumbar surgery. After background adjustment, RA patients reported worse postoperative PCS (28.4 vs. 37.2, p = 0.008) and EQ-5D (0.640 vs. 0.738, p = 0.03), although these differences were not significant between RA and non-RA patients not on steroids. CONCLUSIONS: RA patients showed worse postoperative quality of life outcomes after posterior surgery for degenerative lumbar disease, while steroid-independent RA cases showed equivalent outcomes to non-RA patients.

Surgical outcomes between posterior decompression alone and posterior decompression with fusion surgery among patients with Meyerding grade 2 degenerative spondylolisthesis: a multicenter cohort study.

BACKGROUND: Whether lumbar decompression with fusion surgery is effective against Meyerding grade 2 degenerative spondylolisthesis (DS) is unknown. Therefore, the current study aimed to compare the surgical outcomes between posterior decompression alone and posterior decompression with fusion surgery among patients with grade 2 DS with central canal stenosis. METHODS: This retrospective cohort study included prospectively registered patients (n = 3863) who underwent surgery for degenerative lumbar spinal canal stenosis at nine high-volume spine centers from April 2017 to July 2019. Patients with grade 2 DS and central canal stenosis were included in the analysis. Patients with radiculopathy, including foraminal stenosis, degenerative scoliosis, and concomitant anterior spinal fusion, and those with a previous history of lumbar surgery were excluded. The participants were divided into the decompression alone group (group D) and decompression with fusion surgery group (group F). Data about patient-reported outcomes, including Numeric Rating Scale (low back pain, leg pain, leg numbness, and foot numbness), Oswestry Disability Index, EuroQol Five-Dimensional questionnaire, and 12-Item Short-Form Health Survey scores, were obtained preoperatively and 2 years postoperatively. RESULTS: In total, 2354 (61%) patients, including 42 (1.8%) with grade 2 DS (n = 18 in group D and n = 24 in group F), completed the 2-year follow-up. Group D had a higher proportion of female patients than group F. However, the two groups did not significantly differ in terms of other baseline demographic characteristics. Group D had a significantly shorter surgical time and lower volume of intraoperative blood loss than group F. Postoperative patient-reported outcomes did not significantly differ between the two groups, although the preoperative degree of low back pain was higher in group F than in group D. The slip degree of group D did not worsen during the follow-up period. CONCLUSION: The surgical outcomes were similar regardless of the addition of fusion surgery among patients with grade 2 DS. Decompression alone was superior to decompression with fusion surgery as it was associated with a lower volume of intraoperative blood loss and shorter surgical time.

Minimum clinically important change for outcome scores among patients aged 75 or over undergoing lumbar spine surgery.

PURPOSE: To elucidate the minimum clinically important change (MCIC) of the physical component summary (PCS) of the Short Form-12, Oswestry Disability Index (ODI), EuroQOL-5 dimensions (EQ-5D), and the Core Outcome Measures Index (COMI) in patients aged ≥ 75 years undergoing lumbar spine surgery. METHODS: We retrospectively reviewed patients aged ≥ 75 years with degenerative lumbar spine disease who underwent lumbar spine decompression or fusion surgery within three levels between April 2017 and June 2018. We also evaluated patients aged < 75 years in the same period as reference. We evaluated the baseline and postoperative PCS, ODI, EQ-5D, and COMI scores. Patients were asked to answer an anchor question regarding health transition for MCICs using the anchor-based method. RESULTS: A total of 247 patients aged ≥ 75 years and 398 patients aged < 75 years were included for analysis. Of patients aged ≥ 75 years, 83.4% showed at least "somewhat improved" outcomes, while 91.0% of patients aged < 75 years reported this outcome. PCS change score was not adequately correlated to health transition in patients aged ≥ 75 years. Receiver operating characteristic curve analyses revealed MCICs of 17.8 for ODI, 0.18 for EQ-5D, and 1.6 for COMI in patients aged ≥ 75 years, and 12.7 for ODI, 0.19 for EQ-5D, and 2.3 for COMI in patients aged < 75 years. CONCLUSION: In patients aged ≥ 75 years, PCS may not be feasible for evaluation of health transition. The MCIC value for ODI score was higher and that for EQ-5D/COMI score was lower in patients aged ≥ 75 years, compared with those in patients aged < 75 years.

Validity of the Japanese core outcome measures index (COMI)-neck for cervical spine surgery: a prospective cohort study.

PURPOSE: To investigate the psychometric properties of the Japanese version of the Core Outcome Measures Index-Neck (COMI-Neck) in patients undergoing cervical spine surgery. METHODS: A total of 177 patients undergoing cervical spine surgery for spinal disorders from April to December 2017 were enrolled. Patient-reported outcomes (PROs) included EuroQOL, Neck Disability Index, and treatment satisfaction. To address whether the questionnaire's scores relate to other outcomes based on a predefined hypothesis, the correlations between the COMI-Neck and the other PROs were measured (Spearman's rank correlation coefficients). The minimum clinically important difference (MCID) of the COMI summary score was calculated using the receiver operating characteristic (ROC) curve with a 7-point Likert scale of satisfaction with the treatment results. To assess reproducibility, another group of 59 volunteers with chronic neck pain were asked to reply to the COMI-Neck twice with an interval of 7-14 days. RESULTS: The COMI summary score showed no floor or ceiling effects preoperatively or postoperatively. Each of the COMI domains and the COMI summary score correlated to the hypothesized extent with the scores of the reference questionnaires (ρ = 0.40-0.79). According to the ROC curve with satisfaction (including "very satisfied" and "satisfied"), the area under the curve and MCID of the COMI summary score were 0.78 and 2.1. The intraclass correlation coefficient and the minimum detectable change (MDC 95%) of the COMI summary score were 0.97 and 0.77. CONCLUSION: The Japanese version of the COMI-Neck is valid and reliable for Japanese-speaking patients with cervical spinal disorders.

Risk factors for worsening sexual function after lumbar spine surgery and characteristics of non-responders to the questionnaire of sex life.

PURPOSE: To precisely assess the Oswestry Disability Questionnaire (ODQ) and its total score (Oswestry Disability Index: ODI) and reveal characteristics of non-responders of the 8th item of ODQ (ODI-8) relating to sexual function. Furthermore, we evaluated risk factors for aggravation of postoperative sexual function. METHODS: We enrolled patients undergoing lumbar spine surgery at eight hospitals between April 2017 and November 2018. Patients' background data and operative factors were collected. We also assessed pain or dysesthesia (lower back, buttock, leg, and plantar area) on a numerical rating scale, EuroQol 5 Dimension, core outcome measures index back, and ODI before and 1 year after surgery. Factor analysis was conducted for the ODQ. Non-responders of the ODI-8 were compared with full-responders using propensity score matching. Risk factors for worsening ODI-8 were evaluated by multivariate logistic regression analysis. RESULTS: Of the 2,610 patients enrolled, 601 (23.0%) answered all but the ODI-8 item; these patients were likely to show better preoperative clinical symptoms than full-responders, even after adjusting for age and gender using propensity scores. Age, spinal deformity, and the American Society of Anesthesiologists physical status (ASA-PS) 3/4 were significant risk factors for postoperative aggravation of the ODI-8. Factor analysis revealed that the ODQ was composed of dynamic and static activities; the ODI-8 was considered a dynamic activity. CONCLUSION: Almost a fourth of the patients skipped the ODI-8. Age, the presence of spinal deformity, and worse ASA-PS were found to be risk factors for postoperative aggravation of sexual function. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Risk factors for deep surgical site infection following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine: a multicenter, observational cohort study of 2913 consecutive cases.

PURPOSE: Surgical site infection (SSI) is one of the most devastating complications following spinal instrumented fusion surgeries because it may lead to a significant increase in morbidity, mortality, and poor clinical outcomes. Identifying the risk factors for SSI can help in developing strategies to reduce its occurrence. However, data on the risk factors for SSI in degenerative diseases are limited. This study aimed to identify risk factors for deep SSI following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine in adult patients. METHODS: This was a multicenter, observational cohort study conducted at 10 study hospitals between July 2010 and June 2015. The subjects were consecutive adult patients who underwent posterior instrumented fusion surgery for degenerative diseases in the thoracic and/or lumbar spine and developed SSI. Detailed patient-specific and procedure-specific potential risk variables were prospectively recorded using a standardized data collection chart and retrospectively reviewed. RESULTS: Of the 2913 enrolled patients, 35 developed postoperative deep SSI (1.2%). Multivariable regression analysis identified three independent risk factors: male sex (P = 0.002) and American Society of Anesthesiologists (ASA) score of ≥ 3 (P = 0.003) as patient-specific risk factors, and operation including the thoracic spine (P = 0.018) as a procedure-specific risk factor. CONCLUSION: Thoracic spinal surgery, an ASA score of ≥ 3, and male sex were risk factors for deep SSI after routine thoracolumbar instrumented fusion surgeries for degenerative diseases. Awareness of these risk factors can enable surgeons to develop a more appropriate management plan and provide better patient counseling.

Comparison between microendoscopic laminectomy and open posterior decompression surgery for single-level lumbar spinal stenosis: a multicenter retrospective cohort study.

BACKGROUND: Microendoscopic laminectomy (MEL), in which a 16-mm tubular retractor with an internal scope is used, has shown excellent surgical results for patients with lumbar spinal canal stenosis. However, no reports have directly compared MEL with open laminectomy. This study aimed to elucidate patient-reported outcomes (PROs) and perioperative complications in patients undergoing MEL versus open laminectomy. METHODS: This is a multicenter retrospective cohort study of prospectively registered patients who underwent lumbar spinal surgery at one of the six high-volume spine centers between April 2017 and September 2018. A total of 258 patients who underwent single posterior lumbar decompression at L4/L5 were enrolled in the study. With regard to demographic data, we prospectively used chart sheets to evaluate the diagnosis, operative procedure, operation time, estimated blood loss, and complications. The follow-up period was 1-year. PROs included a numerical rating scale (NRS) for lower back pain and leg pain, the Oswestry Disability Index (ODI), EuroQol 5 Dimension (EQ-5D), and patient satisfaction with the treatment. RESULTS: Of the 258 patients enrolled, 252 (97%) completed the 1-year follow-up. Of the 252, 130 underwent MEL (MEL group) and 122 underwent open decompression (open group). The MEL group required a significantly shorter operating time and sustained lesser intraoperative blood loss compared with the open group. The MEL group showed shorter length of postoperative hospitalization than the open group. The overall complication rate was similar (8.2% in the MEL group versus 7.7% in the open group), and the revision rate did not significantly differ. As for PROs, both preoperative and postoperative values did not significantly differ between the two groups. However, the satisfaction rate was higher in the MEL group (74%) than in the open group (53%) (p = 0.02). CONCLUSIONS: MEL required a significantly shorter operating time and resulted in lesser intraoperative blood loss compared with laminectomy. Postoperative PROs and complication rates were not significantly different between the procedures, although MEL demonstrated a better satisfaction rate.

Microendoscope-Assisted Versus Open Posterior Lumbar Interbody Fusion for Lumbar Degenerative Disease: A Multicenter Retrospective Cohort Study.

Background and objectives: Minimally invasive surgery has become popular for posterior lumbar interbody fusion (PLIF). Microendoscope-assisted PLIF (ME-PLIF) utilizes a microendoscope within a tubular retractor for PLIF procedures; however, there are no published reports that compare Microendoscope-assisted to open PLIF. Here we compare the surgical and clinical outcomes of ME-PLIF with those of open PLIF. Materials and Methods: A total of 155 consecutive patients who underwent single-level PLIF were registered prospectively. Of the 149 patients with a complete set of preoperative data, 72 patients underwent ME-PLIF (ME-group), and 77 underwent open PLIF (open-group). Clinical and radiographic findings collected one year after surgery were compared. Results: Of the 149 patients, 57 patients in ME-group and 58 patients in the open-group were available. The ME-PLIF procedure required a significantly shorter operating time and involved less intraoperative blood loss. Three patients in both groups reported dural tears as intraoperative complications. Three patients in ME-group experienced postoperative complications, compared to two patients in the open-group. The fusion rate in ME-group at one year was lower than that in the open group (p = 0.06). The proportion of patients who were satisfied was significantly higher in the ME-group (p = 0.02). Conclusions: ME-PLIF was associated with equivalent post-surgical outcomes and significantly higher rates of patient satisfaction than the traditional open PLIF procedure. However, the fusion rate after ME-PLIF tended to be lower than that after the traditional open method.

Association Between Normothermia at the End of Surgery and Postoperative Complications Following Orthopedic Surgery.

BACKGROUND: Maintaining perioperative normothermia is recommended by recent guidelines for the prevention of surgical site infections (SSIs). However, the majority of supporting data originates outside the field of orthopaedic surgery. METHODS: The effect of normothermia was explored using the prospectively collected data of consecutive patients who underwent single-site surgery in 7 tertiary referral hospitals between November 2013 and July 2016. SSIs, urinary tract infections (UTIs), respiratory tract infections (RTIs), cardiac and cerebral events (CCE), and all-cause mortality rates within 30 days after surgery were compared between patients with normothermia (body temperature ≥36°C) and those with hypothermia (<36°C) at the end of surgery, after closure. Multivariable adjusted and inverse-probability weighted regression analyses were performed. RESULTS: The final cohort included 8841 patients. Of these, 11.4% (n = 1008) were hypothermic. More than 96% were evaluated in person by the physicians. After adjusting for multiple covariates, normothermia was not significantly associated with SSIs (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI] 0.59-2.33), UTIs (aOR 1.14, 95% CI 0.66-1.95), RTIs (aOR 0.60, 95% CI 0.31-1.19), or CCE (aOR 0.53, 95% CI 0.26-1.09). In contrast, normothermia was associated with a lower risk of 30-day mortality (aOR 0.26, 95% CI 0.11-0.64; P < .01; weighted hazard ratio 0.21, 95% CI 0.07-0.68; P = .002). In a subgroup analysis, normothermia was associated with reduced mortality in all types of surgical procedures. CONCLUSIONS: Whereas our findings suggest no clear association with SSI risks following orthopedic surgery, our study supports maintaining perioperative normothermia, as it is associated with reduced 30-day mortality.

A sliding scale to predict postoperative complications undergoing posterior spine surgery.

BACKGROUND: There is a lack of consensus of operative time (OT) and estimated blood loss (EBL) for elderly patients based on the predicted risk of complications after posterior spine surgery. The purpose of this study was to evaluate the effect of age, OT, and EBL on the postoperative complication risk and to develop a simple sliding scale. METHODS: We explored prospectively collected data of consecutive patients who underwent posterior spine surgery in seven tertiary referral hospitals from November 2013 to May 2016. Age (<70, 70-74, 75-79, 80-84, ≥85 years), OT (<2, 2-<3, 3-<4, 4-<5, ≥5 h), and EBL (<500, 500-<1000, 1000-<1500, 1500-<2000, ≥2000 ml) were categorized ranging from 1 (lowest) to 5 (highest). The association between the crude cumulative categories' number and the incidence of complications was analyzed. We further evaluated the association by re-categorizing the cumulative number into three groups (3-4, 5-10, ≥11). RESULTS: Total of 2416 patients (median age: 70 years old) were enrolled and major complications were observed in 75 (3.1%) patients. Age, OT, and EBL showed similar odds ratio (1.18-1.19) as each category increased. The cumulative categories' number fitted the estimate complication risk (Hosmer-Lemeshow P = 0.87), and statistically significant trend was observed between predicted and actual complication rates (Cochran-Armitage test, P < 0.001). When cumulative categories' numbers were stratified into three groups, significant increasing trend of risk were observed (Mantel-Haenszel P < 0.001). Based on the categorical numbers, we proposed a simple sliding scale. CONCLUSION: Our data indicated that the risk of postoperative complication was associated with cumulative score based on increased age, OT, and EBL. A simple sliding scale was developed based on these factors, which may be useful to predict complication risk after posterior spine surgery.

Coexisting Lower Back Pain in Patients With Cervical Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of the present study is to investigate the coexisting lower back pain (LBP) in patients with cervical myelopathy and to evaluate changes in LBP after cervical spine surgery. SUMMARY OF BACKGROUND DATA: Only a few studies with a small number of participants have evaluated the association between cervical myelopathy surgery and postoperative improvement in LBP. METHODS: Patients who underwent primary cervical decompression surgery with or without fusion for myelopathy and completed preoperative and 1-year postoperative questionnaires were reviewed using a prospectively collected database involving 9 tertiary referral hospitals. The questionnaires included the patient-reported Japanese Orthopaedic Association (PRO-JOA) score and Numerical Rating Scales (NRS). The minimum clinically important difference (MCID) for NRS-LBP was defined as >30% improvement from baseline. Patient demographics, characteristics, and PRO-JOA score were compared between patients with and without concurrent LBP, and the contributor to achieving the MCID for LBP was analyzed using logistic regression analysis. RESULTS: A total of 786 consecutive patients with cervical myelopathy were included, of which 525 (67%) presented with concurrent LBP. LBP was associated with a higher body mass index ( P <0.001) and worse preoperative PRO-JOA score ( P <0.001). Among the 525 patients with concurrent LBP, the mean postoperative NRS-LBP significantly improved from 4.5±2.4 to 3.4±2.7 ( P <0.01) postoperatively, with 248 (47%) patients reaching the MCID cutoff. Patients with a PRO-JOA recovery rate >50% were more likely to achieve MCID compared with those with a recovery rate <0% (adjusted odd ratio 4.02, P <0.001). CONCLUSIONS: More than 50% of patients with myelopathy reported improvement in LBP after cervical spine surgery, and 47% achieved the MCID for LBP, which was positively correlated with a better PRO-JOA recovery rate. Treating cervical myelopathy in patients with concomitant LBP may be sufficient to mitigate concomitant LBP. LEVEL OF EVIDENCE: Level III.

Comparative Analysis of Microendoscopic and Open Laminectomy for Single-Level Lumbar Spinal Stenosis at L1-L2 or L2-L3.

BACKGROUND: Several reports have highlighted comparable surgical outcomes between microendoscopic laminectomy (MEL) and open laminectomy (open) for lumbar spinal stenosis. However, the unilateral approach in MEL may present challenges for the upper lumbar levels, where facet joints are located deeper inside. Our objective was to compare surgical outcomes and radiographic evaluations for single-level decompression cases at L1-L2 or L2-L3 between MEL and open laminectomy. METHODS: We analyzed patients who underwent single-level decompression for upper lumbar spinal stenosis at 12 distinguished spine centers from April 2017 to September 2021. Baseline demographics, preoperative, and 1-year postoperative patient-reported outcomes, along with imaging parameters, were compared between the MEL and open groups. To account for potential confounding, patients' backgrounds were adjusted using the inverse probability weighting method based on propensity scores. RESULTS: Among the 2487 patients undergoing decompression surgery, 118 patients (4.7%) underwent single-level decompression at L1-L2 or L2-L3. Finally, 80 patients (51 in the MEL group, 29 in the open group) with postoperative data were deemed eligible for analysis. The MEL group exhibited significantly improved postoperative EuroQol 5-Dimension values compared to the open group. Additionally, the MEL group showed a lower facet preservation rate according to computed tomography examination, whereas the open group had a higher incidence of retrolisthesis. CONCLUSIONS: Although overall surgical outcomes were similar, the MEL group demonstrated potential advantages in enhancing EuroQol 5-Dimension scores. The MEL group's lower facet preservation rate did not translate into a higher postoperative instability rate.

A Propensity Score-matched Analysis of Clinical Outcomes Between Single-level and Multilevel Intervertebral Decompression for Cervical Radiculopathy.

STUDY DESIGN: Retrospective multicenter study with propensity score matching. OBJECTIVE: To compare the clinical outcomes of single-level and multilevel intervertebral decompression for cervical degenerative radiculopathy. SUMMARY OF BACKGROUND DATA: In patients with cervical radiculopathy, physical examination findings are sometimes inconsistent with imaging data. Multilevel decompression may be necessary for multiple foraminal stenosis. Additional decompression is more invasive yet expected to comprehensively decompress all suspected nerve root compression areas. However, the surgical outcomes of this approach compared with that of single-level decompression remain unknown. MATERIALS AND METHODS: The data of patients with spinal surgery for pure cervical radiculopathy were collected. Patients were categorized into the single-level (SLDG) or multilevel (MLDG) intervertebral decompression group at C3/C4/C5/C6/C7/T1. Demographic data and patient-reported outcome scores, including the Neck Disability Index (NDI) and Numerical Rating Scale (NRS) scores for pain and numbness in the neck, upper back, and arms, were collected. The NDI improvement rates and changes in NRS scores were analyzed one year postoperatively at patient-reported outcome evaluation. Propensity score matching was performed to compare both groups after adjusting for baseline characteristics, including the preoperative NDI and NRS scores. RESULTS: Among the 357 patients in this study, SLDG and MLDG comprised 231 and 126 patients, respectively. Two groups (n=112, each) were created by propensity score matching. Compared with the MLDG, the SLDG had a higher postoperative NDI improvement rate ( P =0.029) and lower postoperative arm numbness NRS score ( P =0.037). Other outcomes tended to be more favorable in the SLDG than in the MLDG, yet no statistical significance was detected. CONCLUSIONS: In patients with cervical radiculopathy, the surgical outcomes of the SLDG showed better improvement in clinical outcomes than those of the MLDG. Numbness remained on the distal (arms) rather than the central (neck and upper back) areas in patients receiving multilevel decompression.

Impact of the COVID-19 pandemic on surgical volume and outcomes in spine surgery: a multicentre retrospective study in Tokyo.

OBJECTIVES: To investigate the effect of the COVID-19 pandemic on surgical volume and outcomes in spine surgery. DESIGN: A retrospective cohort study using prospectively collected data. SETTING AND PARTICIPANTS: A total of 9935 patients who underwent spine surgery between January 2019 and December 2021 at eight high-volume spine centres in the Greater Tokyo metropolitan area were included. OUTCOME MEASURES: The primary outcome measures were the number of surgical cases, perioperative complications and patient-reported outcomes, including numerical rating scales for each body part, Euro quality of life 5-dimension (EQ5D), Neck Disability Index and Oswestry Disability Index (ODI). RESULTS: The total number of surgeries in 2020 and 2021 remained lower than that of 2019, with respective percentages of 93.1% and 95.7% compared with the prepandemic period, with a marked reduction observed in May 2020 compared with the same period in 2019 (56.1% decrease). There were no significant differences between the prepandemic and postpandemic groups in the incidence of perioperative complications, although the frequency of reoperation tended to be higher in the postpandemic group (3.04% vs 3.76%, p=0.05). Subgroup analysis focusing on cervical spine surgery revealed significantly worse preoperative EQ5D scores in the postpandemic group (0.57 vs 0.54, p=0.004). Similarly, in lumbar spine surgery, the postpandemic group showed higher levels of leg pain (5.7 vs 6.1 to 0.002) and worse ODI scores (46.2 vs 47.7 to 0.02). However, postoperative outcomes were not different between pre and post-pandemic groups. CONCLUSIONS: The COVID-19 pandemic has significantly impacted spinal surgeries in Japan, leading to a decrease in surgical volumes and changes in patient characteristics and surgical procedures. However, surgical outcomes remained comparable between the pre and postpandemic periods, indicating the resilience and adaptability of healthcare systems.

Impact of body mass index on outcomes after lumbar spine surgery.

The impact of body mass index (BMI) on outcomes after lumbar spine surgery is currently unknown. Previous studies have reported conflicting evidence for patients with high BMI, while little research has been conducted on outcomes for underweight patients. This study aims to examine the impact of BMI on outcomes after lumbar spine surgery. This prospective cohort study enrolled 5622 patients; of which, 194, 5027, and 401 were in the low (< 18.5 kg/m2), normal (18.5-30), and high (≥ 30) BMI groups, respectively. Pain was assessed via the numerical pain rating scale (NPRS) for the lower back, buttock, leg, and plantar area. Quality of life was assessed via the EuroQol 5 Dimension (EQ-5D) and Oswestry Disability Index (ODI). Inverse probability weighting with propensity scores was used to adjust patient demographics and clinical characteristics between the groups. After adjustment, the 1-year postoperative scores differed significantly between groups in terms of leg pain. The proportion of patients who achieved a 50% decrease in postoperative NPRS score for leg pain was also significantly different. Obese patients reported less improvement in leg pain after lumbar spine surgery. The outcomes of patients with low BMI were not inferior to those of patients with normal BMI.

The clinical utility of a one-shot energy subtraction method for thoracic spine radiography.

BACKGROUND: The interpretation of thoracic spine X-rays is difficult because these images cannot clearly visualize the thoracic spine because of the overlap with soft tissues, such as the heart and pulmonary blood vessels. Thus, to improve the clarity of thoracic spine radiographs using existing radiograph equipment, we have investigated a one-shot energy subtraction method to visualize thoracic spine radiographs. Our objective was to evaluate whether the thoracic spine radiographs generated using this method could visualize the spine more clearly than the corresponding original thoracic spine radiographs. METHODS: This study included 29 patients who underwent thoracic spine radiographs. We used a one-shot energy subtraction method to improve the clarity of thoracic spine radiographs. Image definition was evaluated using vertebrae sampled from each region of the thoracic spine. Specifically, these were: Th1, Th5, Th9, and Th12. Image definition was assessed using a three-point grading system. The conventional and processed computed radiographs (both frontal and lateral views) of all 29 study patients were evaluated by 5 spine surgeons. RESULTS: In all thoracic regions on both frontal and lateral views, the processed images showed statistically significantly better clarity than the corresponding conventional images, especially at all sampling sites on the frontal view and T5 and 9 on the lateral view. CONCLUSIONS: Thoracic spine radiographs generated using this method visualized the spine more clearly than the corresponding original thoracic spine radiographs. The greatest advantages of this image processing technique were its ability to clearly depict the whole thoracic spine on frontal views and the middle thoracic spine on lateral views.

Surgical Treatment of Chondrodysplasia Punctata Tibial-Metacarpal Type Until Skeletal Maturity: A Case Report.

CASE: An infant boy with chondrodysplasia punctata tibial-metacarpal type (CDP-TM) was followed up till skeletal maturity. The patient underwent surgeries for bilateral patellar dislocations at the age of 9 years of age, left leg length discrepancy at 12 years, and atlantoaxial subluxation at 14 years. At the final follow-up at 18 years, he had no complaints or limitation of his daily life activities. CONCLUSION: CDP-TM may require multiple orthopedic surgeries such as patellofemoral instability, limb length discrepancy, and upper cervical dysplasia until skeletal maturity, and should be followed in order to identify them early.