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PURPOSE: The demand for SIJ fusion among obese patients has grown substantially. However, the clinical relevance of obesity in the context of SI joint fusion has not been well investigated specifically, whether there is a BMI cutoff above which the benefit-risk ratio is low. METHODS: Adult patients ≥ 21 years of age who underwent minimally invasive SIJ fusion between 2020 and 2023. Participants were classified using the National Institutes for Health body mass index (BMI). Patients with a BMI of 30 to 39 with no significant comorbidity are considered obese, patients with a BMI of 35 to 39 with a significant comorbidity or a BMI of 40 or greater are considered morbidly obese. All subjects completed the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) at baseline and 12 months. One-way analysis of variance was used to examine the impact of BMI category on score changes. RESULTS: Overall, mean VAS improved at 12 months by 2.5 points (p < .006). Over the 12-month follow-up period, BMI category did not impact mean improvement in VAS (ANOVA p = .08). Mean ODI at 12 months improved by 23.2 points (p < .001). BMI category did impact mean improvement in ODI (ANOVA p = .03). CONCLUSION: This study demonstrates similar benefits across all BMI categories. This data suggests that obese patients do benefit from minimally invasive SIJ fusion, specifically the 35-40 BMI cohort of patients, and should not be denied this procedure based on arbitrary healthcare organizations BMI criteria.
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BACKGROUND: A novel pelvic fixation screw fusion device (iFuse Bedrock Granite implant) was designed to promote bony fusion through self-harvesting fenestrations throughout the outer screw shank. Bone on-growth and in-growth using this design have been demonstrated in a sheep model, but data from human subjects have not been reported. A 66-year-old medically complex female with 2 prior spine fusions developed spondylodiscitis cephalad to a prior fusion, requiring the removal of instrumentation, which included screw fusion devices. OBSERVATIONS: Within this case report, the authors present a novel bone-preserving technique for the removal of well-fixed screw fusion devices. One screw backed out with a driver, and the other 3 had to be trephined out. One screw sheared off the T30 torque driver, implying a removal torque greater than 270 inch-lbs (30.5 Nm). In addition, the removed implants were analyzed using microcomputed tomography (micro-CT) and demonstrated bone on-growth, in-growth, and through-growth in all 4 screws. LESSONS: Micro-CT clearly demonstrated osseous integration of the screw fusion devices and provided significant support for the use of these implants for lumbopelvic fixation. The authors' hope is that the novel bone-preserving technique will help other surgeons when faced with the difficult removal of well-fixed screw fusion devices. https://thejns.org/doi/10.3171/CASE24274.
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STUDY DESIGN: Prospective multicenter database post-hoc analysis. OBJECTIVES: Opioids are frequently prescribed for painful spinal conditions to provide pain relief and to allow for functional improvement, both before and after spine surgery. Amidst a current opioid epidemic, it is important for providers to understand the impact of opioid use and its relationship with patient-reported outcomes. The purpose of this study was to evaluate pre-/postoperative opioid consumption surrounding ASD and assess patient-reported pain outcomes in older patients undergoing surgery for spinal deformity. METHODS: Patients ≥60 years of age from 12 international centers undergoing spinal fusion of at least 5 levels and a minimum 2-year follow-up were included. Patient-reported outcome scores were collected using the Numeric Rating Scale for back and leg pain (NRS-B; NRS-L) at baseline and at 2 years following surgery. Opioid use, defined based on a specific question on case report forms and question 11 from the SRS-22r questionnaire, was assessed at baseline and at 2-year follow-up. RESULT: Of the 219 patients who met inclusion criteria, 179 (81.7%) had 2-year data on opioid use. The percentages of patients reporting opioid use at baseline (n = 75, 34.2%) and 2 years after surgery (n = 55, 30.7%) were similar (P = .23). However, at last follow-up 39% of baseline opioid users (Opi) were no longer taking opioids, while 14% of initial non-users (No-Opi) reported opioid use. Regional pre- and postoperative opioid use was 5.8% and 7.7% in the Asian population, 58.3% and 53.1% in the European, and 50.5% and 40.2% in North American patients, respectively. Baseline opioid users reported more preoperative back pain than the No-Opi group (7.0 vs 5.7, P = .001), while NRS-Leg pain scores were comparable (4.8 vs 4, P = .159). Similarly, at last follow-up, patients in the Opi group had greater NRS-B scores than Non-Opi patients (3.2 vs 2.3, P = .012), but no differences in NRS-Leg pain scores (2.2 vs 2.4, P = .632) were observed. CONCLUSIONS: In this study, almost one-third of surgical ASD patients were consuming opioids both pre- and postoperatively world-wide. There were marked international variations, with patients from Asia having a much lower usage rate, suggesting a cultural influence. Despite both opioid users and nonusers benefitting from surgery, preoperative opioid use was strongly associated with significantly more back pain at baseline that persisted at 2-year follow up, as well as persistent postoperative opioid needs.
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OBJECTIVE: The goal of this study was to analyze our initial experience using a novel porous fusion/fixation screw (PFFS) for pelvic fixation and determine our rate of screw malposition requiring intraoperative repositioning. METHODS: We reviewed 83 consecutive patients who underwent sacropelvic fixation with PFFS at our institution from June 1, 2022 to June 30, 2023 using intraoperative computed tomography-based computer-assisted navigation via an open posterior approach. Following PFFS insertion, intraoperative computed tomography scans were obtained to assess screw positioning. Demographic data were collected, and operative reports and patient images were reviewed to determine what implants were used and if any PFFS required repositioning. RESULTS: Seventy-four patients (26M:48F) were included, and 57 (77.0%) had a prior sacroiliac joint or lumbar spine surgery. A stacked screw configuration was used in 62/74 cases (83.8%). A total of 235 PFFS were used and six (2.6%) were malpositioned. Of 88 cephalic screws placed in stacked configuration, 4 were malpositioned (4.5%) and 1/123 caudal screws were malpositioned (0.8%). One of 24 sacral-alar-iliac screws placed in a stand-alone configuration was malpositioned (4.2%). Malpositions included 4 medial, 1 lateral, and 1 inferior, and all were revised intraoperatively without major sequela. CONCLUSIONS: Although PFFSs are larger than traditional sacropelvic fixation screws, stacked sacral-alar-iliac instrumentation can be done safely with computer-assisted navigation. We found a low malposition rate in our initial series of patients, the majority being the cephalad screw in a stacked configuration. This isn't surprising, as these are placed after the caudal screws, which reduces the available corridor size and increases the placement difficulty.
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STUDY DESIGN: Modified Delphi consensus study. OBJECTIVE: To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the peri-operative period are not available. METHODS: A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuro-electrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculo-peritoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologists participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of three survey rounds and one virtual meeting were conducted. RESULTS: Consensus was reached on 39 total postulates across six IPD types. Postulates addressed general spine surgery considerations, use of intraoperative monitoring and cautery, use of magnetically-controlled growing rods (MCGRs), and use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4-100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types. CONCLUSION: Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. Final postulates from this study can inform the peri- and post-operative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs. LEVEL OF EVIDENCE: V- Expert opinion.
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PURPOSE: Pelvic incidence (PI) is commonly used to determine sagittal alignment. Historically, PI was believed to be a fixed anatomic parameter. However, recent studies have suggested that there is positionally-dependent motion that occurs through the sacroiliac joint (SIJ) resulting in changes in PI. METHODS: We reviewed 100 consecutive adult spinal deformity (ASD) patients seen at our academic tertiary referral center. Two reviewers measured pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL) on standing radiographs and scout computed tomography scans (CT). Unilateral, bilateral, or absent SIJ vacuum sign (VS) was determined using CTs. RESULTS: Eighty-six patients (42 M:44 F) were included with an average age of 64.1 years and BMI of 28.8 kg/m2. Standing PI was low (< 50°) in 35 patients (40.7%), average (50°-60°) in 22 (25.6%), and high (> 60°) in 29 (33.7%). Average and high PI patients had significant PI changes of 3.0° (p = 0.037) and 4.6° (p = 0.005), respectively. Bilateral SIJ VS was seen in 68 patients, unilateral VS in 9, and VS was absent in 9. The average change in PI between standing and supine was 2.1° in bilateral SIJ VS patients (p = 0.045), 2.2° in unilateral SIJ VS (p = 0.23), and - 0.1° in patients without SIJ VS (p = 0.93). The average absolute difference in PI between supine and standing was 5.5° ±5.5° (p < 0.001). CONCLUSION: There is a change in PI from supine to standing. In patients with high PI and bilateral VS on CT, the change from supine to standing is significant, perhaps representing instability of the SIJ.
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INTRODUCTION: The prevalence of sacroiliac joint (SIJ) pathology generating lower back pain is increasing, often requiring SI joint fusion in refractory cases. Similarly, total hip arthroplasty (THA) is an increasing procedure in the older growing population. Prior SIJ fusion in patients undergoing THA has increased hip dislocation. This study aims to determine the prevalence of preexisting THA in SIJ fusion patients at our institution. METHODS: After institutional review board approval, we completed a retrospective review of consecutive SIJ fusion cases performed by fellowship-trained orthopaedic spine surgeons between October 2019 and June 2022. The senior surgeon reviewed pelvis radiographs to determine whether a THA was present. Patient demographics, surgical history, SIJ fusion date, and laterality information from study participants' medical records were collected and analyzed. RESULTS: We screened 157 consecutive cases and excluded 45 not meeting the inclusion criteria. One hundred twelve radiographs were reviewed, with seven additional patients excluded. The final analysis consisted of 105 patients (33M:72F). The mean age was 50.4 ± 13.8 years, and the mean body mass index was 29.1 ± 6.1 kg/m2. SIJ fusion laterality included 51 right (48.6%), 44 left (41.9%), and 10 bilateral (9.5%). One patient (0.95%) had a preexisting right THA, and two patients (1.9%) underwent ipsilateral THA after SIJ fusion. CONCLUSIONS: This study demonstrated a low prevalence (0.95%) of preexisting THA in SIJ fusion patients at our institution, similar to the THA prevalence of the total US population. Additional research is needed to determine the outcomes of patients with preexisting THA undergoing SIJ fusion.
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PURPOSE: The spine, hip, and knee are anatomically and biomechanically connected. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly employed to treat degenerative changes in the hip and knee, while fusion is used for spine degeneration. Spine deformity correction results in changes in sagittal alignment and pelvic parameters, and patients with stiff spines have higher rates of THA dislocation and revision due to instability. The goal of this study was to determine the prevalence of total joint arthroplasty (TJA) in adult spinal deformity (ASD) patients at our institution. METHODS: Following Institutional Review Board approval, we retrospectively reviewed a list of cases performed by the senior author from 4/2017 to 5/2021. Patients > 18 years old undergoing preoperative evaluation for symptomatic lumbar degeneration or ASD were included. Patients < 18 years old, those diagnosed with adolescent idiopathic scoliosis, and non-fusion cases were excluded. Perioperative full-length standing EOS images were examined for the presence or absence of THA, TKA, or both. Demographic data was collected from patient electronic medical records, and statistical analyses were completed. RESULTS: 572 consecutive cases were reviewed, and 322 were excluded. 250 cases (97M:153F) were included in the final analysis, with a mean age of 61.8 ± 11.2 years. A total of 74 patients had a TJA (29.4%). THA was present in 41 patients (16.4%), and TKA was present in 49 patients (19.6%). Males had a higher prevalence of TJA, THA, and TKA (29.9%, 16.5%, and 21.6%) than females (29.4%, 16.3%, and 18.3%). CONCLUSIONS: This study revealed a high prevalence TJA rate of 29.4% in ASD at our institution. This rate surpasses the prevalence rate reported among the general population in previous studies. High prevalence of patients with ASD and TJA may merit special surgical consideration.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Prevalencia , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/métodos , Anciano , Curvaturas de la Columna Vertebral/cirugía , Curvaturas de la Columna Vertebral/epidemiología , Adulto , Escoliosis/cirugía , Escoliosis/epidemiologíaRESUMEN
INTRODUCTION: Despite modern fixation techniques, spinopelvic fixation failure (SPFF) after adult spinal deformity (ASD) surgery ranges from 4.5 to 38.0%, with approximately 50% requiring reoperation. Compared to other well-studied complications after ASD surgery, less is known about the incidence and predictors of SPFF. AIMS/OBJECTIVES: Given the high rates of SPFF and reoperation needed to treat it, the purpose of this systematic review and meta-analysis was to report the incidence and failure mechanisms of SPF after ASD surgery. MATERIALS/METHODS: The literature search was executed across four databases: Medline via PubMed and Ovid, SPORTDiscus via EBSCO, Cochrane Library via Wiley, and Scopus. Study inclusion criteria were patients undergoing ASD surgery with spinopelvic instrumentation, report rates of SPFF and type of failure mechanism, patients over 18 years of age, minimum 1-year follow-up, and cohort or case-control studies. From each study, we collected general demographic information (age, gender, and body mass index), primary/revision, type of ASD, and mode of failure (screw loosening, rod breakage, pseudarthrosis, screw failure, SI joint pain, screw protrusion, set plug dislodgment, and sacral fracture) and recorded the overall rate of SPF as well as failure rate for each type. For the assessment of failure rate, we required a minimum of 12 months follow-up with radiographic assessment. RESULTS: Of 206 studies queried, 14 met inclusion criteria comprising 3570 ASD patients who underwent ASD surgery with pelvic instrumentation (mean age 65.5 ± 3.6 years). The mean SPFF rate was 22.1% (range 3-41%). Stratification for type of failure resulted in a mean SPFF rate of 23.3% for the pseudarthrosis group; 16.5% for the rod fracture group; 13.5% for the iliac screw loosening group; 7.3% for the SIJ pain group; 6.1% for the iliac screw group; 3.6% for the set plug dislodgement group; 1.1% for the sacral fracture group; and 1% for the iliac screw prominence group. CONCLUSION: The aggregate rate of SPFF after ASD surgery is 22.1%. The most common mechanisms of failure were pseudarthrosis, rod fracture, and iliac screw loosening. Studies of SPFF remain heterogeneous, and a consistent definition of what constitutes SPFF is needed. This study may enable surgeons to provide patient specific constructs with pelvic fixation constructs to minimize this risk of failure.
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Fusión Vertebral , Humanos , Fusión Vertebral/métodos , Fusión Vertebral/efectos adversos , Fusión Vertebral/instrumentación , Curvaturas de la Columna Vertebral/cirugía , Curvaturas de la Columna Vertebral/diagnóstico por imagen , Insuficiencia del Tratamiento , Adulto , Reoperación/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
Scheuermann kyphosis can be treated surgically to restore proper sagittal alignment. Thoracic curves >70° are typically indicated for surgical intervention. However, patients who have reached their natural limit of compensatory lumbar hyperlordosis are at risk of accelerated degeneration. This can be determined by comparing lumbar lordosis on standing neutral radiographs and supine extension radiographs. Minimal additional lordosis in extension compared with neutral, abutment of the spinous processes, or greater lumbar lordosis standing than with attempted extension suggest the patient is maximally compensated. We present a case of an adolescent boy with Scheuermann kyphosis who had reached the limit of his hyperlordosis compensation reserve. He subsequently underwent a T4 to L2 posterior spinal fusion with T7 to T11 Ponte Smith-Petersen grade two osteotomies. He tolerated the procedure well with no intraoperative complications or neuromonitoring changes. The patient has continued to do well and progressed to normal activity at 5-month follow-up.
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Lordosis , Enfermedad de Scheuermann , Fusión Vertebral , Adolescente , Masculino , Animales , Humanos , Enfermedad de Scheuermann/diagnóstico por imagen , Enfermedad de Scheuermann/cirugía , Lordosis/diagnóstico por imagen , Lordosis/cirugía , Complicaciones Intraoperatorias , OsteotomíaRESUMEN
Purpose: Although many techniques exist, spinopelvic fixation continues to present challenges in the management of adult spinal deformity. Shear forces, complex anatomy, and bone quality are common reasons why spine surgeons continue to explore options for fixation. Methods: A retrospective chart reviewed of patients receiving pelvic fixation for adult spinal deformity over a 12-year period was conducted. Patients were divided into 3 cohorts based on date of surgery: (1) 2010 to 2013, (2) 2014 to 2017, and (3) 2018 to 2021. Pelvic fixation constructs in the study included traditional iliac screws, stacked S2-alar-iliac (S2AI screws), and triangular titanium implants. Results: Of the 494 patients with multiple implant constructs who met the inclusion criteria for this study, patients undergoing pelvic fixation surgery who received at least 2 implants increased by approximately 5% every 4 years (90.2%, 94.6%, 99.1% respectively). Over the 12-year span, the implementation of the S2AI screw grew 120%. Conclusion: At our institution, there is a trend toward using multiple bilateral implant constructs for pelvic fixation, with nearly a tenfold percentage increase between the most recent cohorts. These include iliac screws with S2AI screws, multiple stacked S2AI screws, and S2AI screws used in conjunction with triangular titanium implants in hopes to decrease implant failure.
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¼ The sacroiliac joint (SIJ) is a common cause of low back pain and should be included in the differential diagnosis.¼ Nonoperative treatment of sacroiliac pain is always the first line of therapy; however, when it is unsuccessful and becomes chronic, then recurrent nonoperative treatment becomes expensive.¼ Surgical treatment is cost-effective in appropriately selected patients. High-quality clinical trials have demonstrated statistically and clinically significant improvement compared with nonsurgical management in appropriately selected patients.¼ Spinal fusion to the sacrum increases degeneration of the SIJ and frequency of SIJ pain.
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Dolor de la Región Lumbar , Fusión Vertebral , Humanos , Artralgia/etiología , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/etiología , Dolor de la Región Lumbar/terapia , Articulación Sacroiliaca/diagnóstico por imagen , Articulación Sacroiliaca/cirugía , Fusión Vertebral/efectos adversos , Columna VertebralRESUMEN
INTRODUCTION: Spinal measurements play an integral role in surgical planning for a variety of spine procedures. Full-length imaging eliminates distortions that can occur with stitched images. However, these images take radiologists significantly longer to read than conventional radiographs. Artificial intelligence (AI) image analysis software that can make such measurements quickly and reliably would be advantageous to surgeons, radiologists, and the entire health system. MATERIALS AND METHODS: Institutional Review Board approval was obtained for this study. Preoperative full-length standing anterior-posterior and lateral radiographs of patients that were previously measured by fellowship-trained spine surgeons at our institution were obtained. The measurements included lumbar lordosis (LL), greatest coronal Cobb angle (GCC), pelvic incidence (PI), coronal balance (CB), and T1-pelvic angle (T1PA). Inter-rater intra-class correlation (ICC) values were calculated based on an overlapping sample of 10 patients measured by surgeons. Full-length standing radiographs of an additional 100 patients were provided for AI software training. The AI algorithm then measured the radiographs and ICC values were calculated. RESULTS: ICC values for inter-rater reliability between surgeons were excellent and calculated to 0.97 for LL (95% CI 0.88-0.99), 0.78 (0.33-0.94) for GCC, 0.86 (0.55-0.96) for PI, 0.99 for CB (0.93-0.99), and 0.95 for T1PA (0.82-0.99). The algorithm computed the five selected parameters with ICC values between 0.70 and 0.94, indicating excellent reliability. Exemplary for the comparison of AI and surgeons, the ICC for LL was 0.88 (95% CI 0.83-0.92) and 0.93 for CB (0.90-0.95). GCC, PI, and T1PA could be determined with ICC values of 0.81 (0.69-0.87), 0.70 (0.60-0.78), and 0.94 (0.91-0.96) respectively. CONCLUSIONS: The AI algorithm presented here demonstrates excellent reliability for most of the parameters and good reliability for PI, with ICC values corresponding to measurements conducted by experienced surgeons. In future, it may facilitate the analysis of large data sets and aid physicians in diagnostics, pre-operative planning, and post-operative quality control.
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Algoritmos , Inteligencia Artificial , Radiografía , Humanos , Radiografía/métodos , Radiografía/estadística & datos numéricos , Reproducibilidad de los Resultados , Adulto , Femenino , Masculino , Columna Vertebral/diagnóstico por imagen , Columna Vertebral/cirugía , Lordosis/diagnóstico por imagen , Persona de Mediana Edad , Variaciones Dependientes del Observador , Curvaturas de la Columna Vertebral/diagnóstico por imagen , Curvaturas de la Columna Vertebral/cirugíaRESUMEN
CASE: A 49-year-old woman presented with left leg radiculopathy and posterior pelvic pain. Subsequent evaluation demonstrated metastatic multiple myeloma with an impending left S1 sacral fracture. Immediate posterior pelvic ring stabilization was recommended to prevent fracture and disruption of her oncologic recovery. This was performed percutaneously with computer-assisted navigation using a novel cannulated screw design. CONCLUSION: The patient was treated with prophylactic percutaneous posterior pelvic ring fixation with a novel cannulated screw design that provided a durable construct for immediate weight-bearing. The fixation prevented a pathologic fracture and allowed immediate return to activity.
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Fracturas Óseas , Fracturas Espontáneas , Huesos Pélvicos , Fracturas de la Columna Vertebral , Femenino , Humanos , Persona de Mediana Edad , Huesos Pélvicos/diagnóstico por imagen , Huesos Pélvicos/cirugía , Huesos Pélvicos/lesiones , Fijación Interna de Fracturas , Sacro/diagnóstico por imagen , Sacro/cirugía , Sacro/lesiones , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/cirugíaRESUMEN
PURPOSE: The sacroiliac (SI) joint is recognized as a source of low back pain in 15-30% of patients. Though randomized controlled trials have shown clinical improvement following SI joint fusion in 83.1% of patients, revision rates of 2.9% within 2 years have been reported. There is a paucity of literature reviewing this small yet significant population of patients requiring revision surgery. METHODS: Following IRB approval, retrospective review of patients, who underwent a revision SI joint fusion from 2009 to 2021 was completed. Patient-reported outcomes were measured before and at each clinic visit after surgery with visual analoge scale (VAS) for back pain and Oswestry Disability Index (ODI). Patient characteristics (chronic opiate use and prior lumbar fusion) and surgical factors (operative approach, type/number of implants and use of bone graft) were recorded. Patient-reported outcomes were evaluated with Paired t and Wilcoxon signed rank tests. Univariate and multivariate logistic regression determined if patients met the minimally clinical important differences (MCID) for VAS-back pain and ODI scores at 1 year. RESULTS: Fifty-two patients (77% female) with an average age of 49.1 (SD ± 11.1) years met inclusion criteria. Forty-four had single sided revisions and eight bilateral revisions. At 1 year follow-up there was no significant improvement in VAS-Back (p = 0.06) or ODI (p = 0.06). Patients with chronic opioid use were 8.5 times less likely to achieve the MDC for ODI scores (OR 0.118, p = 0.029). There was no difference in outcomes when comparing the different surgical approaches (p = 0.41). CONCLUSION: Our study demonstrates patients undergoing revision surgery have moderate improvement in low back pain, however, few have complete resolution of their symptoms. Specific patient factors, such as chronic opiate use and female sex may decrease the expected improvement in patient-reported outcomes following surgery. Failure to obtain relief may be due to incorrect indications, lack of biologic fusion and/or presence of co-pathologies. Further clinical examination and consistent long-term follow-up, clarify the role revision surgery plays in long-term patient outcomes.
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Dolor de la Región Lumbar , Alcaloides Opiáceos , Enfermedades de la Columna Vertebral , Humanos , Femenino , Persona de Mediana Edad , Masculino , Dolor de la Región Lumbar/cirugía , Estudios Retrospectivos , Articulación Sacroiliaca/cirugía , ArtrodesisRESUMEN
PURPOSE: Our institution employs a multimodal approach to manage postoperative pain after spine surgery. It involves continuous intravenous (IV) lidocaine until the morning of postoperative day two. This study aimed to determine the rate and reasons for early discontinuation of IV lidocaine in our spine patients. METHODS: We conducted a retrospective chart review and included pediatric patients who underwent ≥ 3-level spine surgery and received postoperative IV lidocaine from November 2019 to September 2022. For each case, we recorded the side effects of IV lidocaine, adverse events, time to discontinuation, and discontinuation rate. Subsequently, we used the same methodology to generate an adult cohort for comparison. RESULTS: We included 52 pediatric (18M:34F) and 50 (21M:29F) adult patients. The pediatric cohort's mean age was 14 years (8-18), and BMI 23.9 kg/m2 (13.0-42.8). The adult cohort's mean age was 61 years (29-82), and BMI 28.8 kg/m2 (17.2-44.1). IV lidocaine was discontinued prematurely in 21/52 (40.4%) of the pediatric cases and 26/50 (52.0%) of the adult cases (RR = 0.78, p = 0.2428). The side effects noted in the pediatric cases vary, including numbness, visual disturbance, and obtundation, but no seizures. The most common adverse events were fever and motor dysfunction. CONCLUSION: The early discontinuation rate of IV lidocaine use after spine surgery for children in our institution does not differ significantly from that of adults. The nature of the side effects and the reasons for discontinuation between the groups were similar. Thus, the safety profile of IV lidocaine for pediatric spine patients is comparable to adults.
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Anestésicos Locales , Lidocaína , Adulto , Humanos , Niño , Adolescente , Persona de Mediana Edad , Lidocaína/efectos adversos , Anestésicos Locales/efectos adversos , Estudios Retrospectivos , Administración Intravenosa , Dolor Postoperatorio/tratamiento farmacológicoRESUMEN
BACKGROUND: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS: We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS: In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS: In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Cifosis , Escoliosis , Fusión Vertebral , Humanos , Adolescente , Escoliosis/cirugía , Resultado del Tratamiento , Tornillos Óseos , Cifosis/cirugía , Fusión Vertebral/métodos , Vértebras Torácicas/cirugía , Estudios RetrospectivosRESUMEN
PURPOSE: To evaluate the sagittal alignment of the lumbar spine in patients with degenerative spondylolisthesis at the L4-5 level. METHODS: Patients with untreated degenerative spondylolisthesis at L4-5 were retrospectively identified from the clinical practice of spine surgeons at an academic medical center. All patients had standing X-rays that were reviewed by the senior surgeon to confirm the presence of degenerative spondylolisthesis at L4-5. Radiographs were analyzed for the following: lumbar lordosis (LL), lower lumbar lordosis (L4-S1; LLL), L5-S1 lordosis, pelvic incidence (PI), and pelvic tilt (PT). From these measurements, lumbar distribution index (LLL/LL × 100; LDI), ideal lumbar lordosis (PI × 0.62 + 29; ILL), PI-LL mismatch, and relative lumbar lordosis (LL-ILL; RLL) were calculated. These parameters were used to evaluate the sagittal alignment of the lumbar spine. Normal alignment was defined based on previous studies and clinical experience. RESULTS: 117 participants met inclusion criteria, with an average age of 67.2 years. The majority of the cohort demonstrated hypolordotic sagittal alignment of the L5-S1 segment when assessed in relation to ILL, PI, and LL (73.5%, 61.5%, and 50.4% respectively). Evaluation of the lower lumbar spine (L4-S1) demonstrated normal sagittal alignment when evaluated via LDI and LLL (65%, 52.1%, respectively), suggesting the presence of compensatory hyperextension at L4-5 in response to the L5-S1 hypolordosis. Consequently, normal sagittal alignment of the regional lumbar spine was maintained when evaluated using LL, PI-LL mismatch, and RLL (51.3%, 47%, and 62.4% respectively). CONCLUSIONS: This study demonstrates that there is a high incidence of relative hypolordosis at the L5-S1 level among patients who present with degenerative spondylolisthesis at L4-5. The L5-S1 hypolordosis is associated with L4-5 hyperlordosis, such that the lower lumbar lordosis (L4-S1; LLL) and regional lumbar lordosis (LL) are still within normal range. It is probable that L5-S1 hypolordosis was the initial pathologic event that incited compensatory L4-5 hyperlordosis, which in turn may have led to facet degeneration and laxity, and eventually to development of spondylolisthesis.
Asunto(s)
Lordosis , Espondilolistesis , Humanos , Anciano , Espondilolistesis/diagnóstico por imagen , Espondilolistesis/cirugía , Lordosis/diagnóstico por imagen , Lordosis/complicaciones , Estudios Retrospectivos , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/cirugía , RadiografíaRESUMEN
BACKGROUND CONTEXT: Etiology of adolescent idiopathic scoliosis (AIS) is still unknown. Prior in vitro research suggests intervertebral disc pathomorphology as a cause for the initiation and progression of the spinal deformity, however, this has not been well characterized in vivo. PURPOSE: To quantify and compare lumbar disc health and morphology in AIS to controls. STUDY DESIGN/SETTING: Cross-sectional study. METHODS: All lumbar discs were imaged using a 3T MRI scanner. T2-weighted and quantitative T2* maps were acquired. Axial slices of each disc were reconstructed, and customized scripts were used to extract outcome measurements: Nucleus pulposus (NP) signal intensity and location, disc signal volume, transition zone slope, and asymmetry index. Pearson's correlation analysis was performed between the NP location and disc wedge angle for AIS patients. ANOVAs were utilized to elucidate differences in disc health and morphology metrics between AIS patients and healthy controls. α=0.05. RESULTS: There were no significant differences in disc health metrics between controls and scoliotic discs. There was a significant shift in the NP location towards the convex side of the disc in AIS patients compared to healthy controls, with an associated increase of the transition zone slope on the convex side. Additionally, with increasing disc wedge angle, the NP center migrated towards the convex side of the disc. CONCLUSIONS: The present study elucidates morphological distinctions of intervertebral discs between healthy adolescents and those diagnosed with AIS. Discs in patients diagnosed with AIS are asymmetric, with the NP shifted towards the convex side, which was exacerbated by an increased disc wedge angle. CLINICAL SIGNIFICANCE: Investigation of the MRI signal distribution (T2w and T2* maps) within the disc suggests an asymmetric pressure gradient shifting the NP laterally towards the convexity. Quantifying the progression of these morphological alterations during maturation and in response to treatment will provide further insight into the mechanisms of curve progression and correction, respectively.
Asunto(s)
Degeneración del Disco Intervertebral , Disco Intervertebral , Cifosis , Escoliosis , Humanos , Adolescente , Escoliosis/diagnóstico por imagen , Estudios Transversales , Disco Intervertebral/diagnóstico por imagen , Degeneración del Disco Intervertebral/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Vértebras Lumbares/diagnóstico por imagenRESUMEN
OBJECTIVE: Proximal junctional failure following surgical correction for adult spinal deformity significantly impacts quality of life and increases the economic burden of treating underlying spinal deformity. The objective of this cadaver study was to determine optimal tension parameters in junctional tethers for proximal junctional kyphosis prevention. METHODS: Cadaveric specimens were used to establish the optimal tension range in polyethylene tethering devices, such as the VersaTie (NuVasive) used in this study. Three specimens were instrumented to test tether tensions of 0, 75, and 150 Newtons (N) at L1-L2, T9-T10, and T3-T4. An optical tracking system was used to measure when specimens reached proximal junctional kyphosis, experienced instrumentation or tissue failure, or reached a cap of 2500 cycles. Radiographs were obtained before and after testing. RESULTS: At all levels, use of a tether at tension forces of 75 N and 150 N elicited a protective effect. The only level in which a higher tension on the tether resulted in more protection was at T3-T4. When averaged, the use of a tether at tension forces of 75 N and 150 N showed 1000 cycles of protection at L1-L2, 2000 cycles at T9-T10, and 1426 cycles at T3-T4. Radiographic analysis corroborated these findings. CONCLUSIONS: The use of a tether in a cadaveric model prevents the development of proximal junctional kyphosis across all tested levels and an increased tension force of 150 N is protective at the proximal thoracic spine. These data can be used to develop further models for a tether system that reproducibly applies a fixed tension force above the thoracolumbar rod construct.