MRI Vertebral Bone Quality Correlates With Interbody Cage Subsidence After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective observational study of consecutive patients. OBJECTIVE: The purpose of the study was to evaluate VBQ as a predictor of interbody subsidence and to determine threshold values that portend increased risk of subsidence. SUMMARY OF BACKGROUND DATA: Many risk factors have been reported for the subsidence of interbody cages in anterior cervical discectomy and fusion (ACDF). MRI Vertebral Bone Quality (VQB) is a relatively new radiographic parameter that can be easily obtained from preoperative MRI and has been shown to correlate with measurements of bone density such as DXA and CT Hounsfield Units. METHODS: All patients who underwent 1- to 3-level ACDF using titanium interbodies with anterior plating between the years 2018 and 2020 at our tertiary referral center were included. Subsidence measurements were performed by 2 independent reviewers on CT scans obtained 6 months postoperatively. VBQ was measured on pre-operative sagittal T1 MRI by 2 independent reviewers, and values were averaged. RESULTS: Eight-five fusion levels in 44 patients were included in the study. There were 32 levels (38%) with moderate subsidence and 12 levels with severe subsidence (14%). The average VBQ score in those patients with severe subsidence was significantly higher than those without subsidence (3.80 vs. 2.40, P<0.01). A threshold value of 3.2 was determined to be optimal for predicting subsidence (AUC=0.99) and had a sensitivity of 100% and a specificity of 94.1% in predicting subsidence. CONCLUSIONS: VBQ strongly correlates with the subsidence of interbody grafts after ACDF. A threshold VBQ score value of 3.2 has excellent sensitivity and specificity for predicting subsidence. Spine surgeons can use VBQ as a readily available screening tool to identify patients at higher risk for subsidence. LEVEL OF EVIDENCE: Level-IV.

Unplanned returns to the operating room: a quality improvement methodology for the comparison of institutional outcomes to national benchmarks.

OBJECTIVE: Unplanned returns to the operating room (RORs) constitute an important quality metric in surgical practice. In this study, the authors present a methodology to compare a department's unplanned ROR rates with national benchmarks in the context of large-scale quality of care surveillance. METHODS: The authors identified unplanned RORs within 30 days from the initial surgery at their institution during the period 2014-2018 using an institutional documentation platform that facilitates the collection of reoperation information by providers in the clinical setting. They divided the procedures into 28 groups by Current Procedural Terminology and International Classification of Diseases, 9th and 10th Revision codes. They estimated national benchmarks of unplanned RORs for these procedure groups via querying the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) registry during the period 2014-2018. Finally, they numerically assessed the unplanned ROR rates at their institution compared with those calculated from the ACS NSQIP registry. RESULTS: Using the above methodology, the authors were able to classify 12,575 of the cases performed in their department during the period of interest, including 6037 (48%) cranial cases and 6538 (52%) spinal or peripheral nerve cases. Among those, 161 (1.3%) presented with complications that required an unplanned ROR within 30 days from the initial surgery. The respective cumulative unplanned ROR rate in the ACS NSQIP registry during the same timeframe was 3.6%. Among 15 categories of cranial procedures, the cumulative unplanned ROR rate was 1.3% in the authors' department and 5.6% in the ACS NSQIP registry. Among 13 categories of spinal and peripheral nerve procedures, the cumulative unplanned ROR rate was 1.3% in the authors' department and 2.8% in the ACS NSQIP registry. Unplanned ROR rates at the authors' institution were lower than the national average for each of the 28 procedure groups of interest. Yearly analysis of institutional ROR rates for the five most commonly performed procedures showed lower reoperation rates compared with the national benchmarks. CONCLUSIONS: Using an institutional documentation tool and a widely available national database, the authors developed a reproducible and standardized method of comparing their department's outcomes with national benchmarks per procedure subgroup. This methodology accommodates longitudinal quality surveillance across the different subspecialties in a neurosurgical department and may illuminate potential shortcomings of care delivery in the future.

Bone Quality as Measured by Hounsfield Units More Accurately Predicts Proximal Junctional Kyphosis than Vertebral Bone Quality Following Long-Segment Thoracolumbar Fusion.

OBJECTIVE: To compare the prognostic power of Hounsfield units (HU) and Vertebral Bone Quality (VBQ) score for predicting proximal junctional kyphosis (PJK) following long-segment thoracolumbar fusion to the upper thoracic spine (T1-T6). METHODS: Vertebral bone quality around the upper instrumented vertebrae (UIV) was measured using HU on preoperative CT and VBQ on preoperative MRI. Spinopelvic parameters were also categorized according to the Scoliosis Research Society-Schwab classification. Univariable analysis to identify predictors of the occurrence of PJK and survival analyses with Kaplan-Meier method and Cox regression were performed to identify predictors of time to PJK (defined as ≥10° change in Cobb angle of UIV+2 and UIV). Sensitivity analyses showed thresholds of HU < 164 and VBQ > 2.7 to be most predictive for PJK. RESULTS: Seventy-six patients (mean age 66.0 ± 7.0 years; 27.6% male) were identified, of whom 15 suffered PJK. Significant predictors of PJK were high postoperative pelvic tilt (P = 0.038), high postoperative T1-pelvic angle (P = 0.041), and high postoperative PI-LL mismatch (P = 0.028). On survival analyses, bone quality, as assessed by the average HU of the UIV and UIV+1 was the only significant predictor of time to PJK (odds ratio [OR] 3.053; 95% CI 1.032-9.032; P = 0.044). VBQ measured using the UIV, UIV+1, UIV+2, and UIV-1 vertebrae approached, but did not reach significance (OR 2.913; 95% CI 0.797-10.646; P = 0.106). CONCLUSIONS: In larger cohorts, VBQ may prove to be a significant predictor of PJK following long-segment thoracolumbar fusion. However, Hounsfield units on CT have greater predictive power, suggesting preoperative workup for long-segment thoracolumbar fusion benefits from computed tomography versus magnetic resonance imaging alone to identify those at increased risk of PJK.

Significant Reduction in Bone Density as Measured by Hounsfield Units in Patients with Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis.

Background: Multisegmental pathologic autofusion occurs in patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH). It may lead to reduced vertebral bone density due to stress shielding. Methods: This study aimed to determine the effects of autofusion on bone density by measuring Hounsfield units (HU) in the mobile and immobile spinal segments of patients with AS and DISH treated at a tertiary care center. The mean HU was calculated for five distinct regions-cranial adjacent mobile segment, cranial fused segment, mid-construct fused segment, caudal fused segment, and caudal adjacent mobile segment. Means for each region were compared using paired-sample t-tests. Multivariable regression was used to determine independent predictors of mid-fused segment HUs. Results: One hundred patients were included (mean age 76 ± 11 years, 74% male). The mean HU for the mid-construct fused segment (100, 95% CI [86, 113]) was significantly lower than both cranial and caudal fused segments (174 and 108, respectively; both p < 0.001), and cranial and caudal adjacent mobile segments (195 and 115, respectively; both p < 0.001). Multivariable regression showed the mid-construct HUs were predicted by history of smoking (-30 HU, p = 0.009). Conclusions: HUs were significantly reduced in the middle of long-segment autofusion, which was consistent with stress shielding. Such shielding may contribute to the diminution of vertebral bone integrity in AS/DISH patients and potentially increased fracture risk.

Optimal Implant Sizing Using Machine Learning Is Associated With Increased Range of Motion After Cervical Disk Arthroplasty.

BACKGROUND AND OBJECTIVES: Cervical disk arthroplasty (CDA) offers the advantage of motion preservation in the treatment of focal cervical pathology. At present, implant sizing is performed using subjective tactile feedback and imaging of trial cages. This study aims to construct interpretable machine learning (IML) models to accurately predict postoperative range of motion (ROM) and identify the optimal implant sizes that maximize ROM in patients undergoing CDA. METHODS: Adult patients who underwent CDA for single-level disease from 2012 to 2020 were identified. Patient demographics, comorbidities, and outcomes were collected, including symptoms, examination findings, subsidence, and reoperation. Affected disk height, healthy rostral disk height, and implant height were collected at sequential time points. Linear regression and IML models, including bagged regression tree, bagged multivariate adaptive regression spline, and k-nearest neighbors, were used to predict ROM change. Model performance was assessed by calculating the root mean square error (RMSE) between predicted and actual changes in ROM in the validation cohort. Variable importance was assessed using RMSE loss. Area under the curve analyses were performed to identify the ideal implant size cutoffs in predicting improved ROM. RESULTS: Forty-seven patients were included. The average RMSE between predicted and actual ROM was 7.6° (range: 5.8-10.1) in the k-nearest neighbors model, 7.8° (range: 6.5-10.0) in the bagged regression tree model, 7.8° (range: 6.2-10.0) in the bagged multivariate adaptive regression spline model, and 15.8° (range: 14.3-17.5°) in a linear regression model. In the highest-performing IML model, graft size was the most important predictor with RMSE loss of 6.2, followed by age (RMSE loss = 5.9) and preoperative caudal disk height (RMSE loss = 5.8). Implant size at 110% of the normal adjacent disk height was the optimal cutoff associated with improved ROM. CONCLUSION: IML models can reliably predict change in ROM after CDA within an average of 7.6 degrees of error. Implants sized comparably with the healthy adjacent disk may maximize ROM.

Decompression Alone Versus Interspinous/Interlaminar Device Placement for Degenerative Lumbar Pathologies: Systematic Review and Meta-Analysis.

INTRODUCTION: Interspinous devices (ISDs) and interlaminar devices (ILDs) are marketed as alternatives to conventional surgery for degenerative lumbar conditions; comparisons with decompression alone are limited. The present study reviews the extant literature comparing the cost and effectiveness of ISDs/ILDs with decompression alone. METHODS: Articles comparing decompression alone with ISD/ILD were identified; outcomes of interest included general and disease-specific patient-reported outcomes, perioperative complications, and total treatment costs. Outcomes were analyzed at <6 weeks, 3 months, 6 months, 1 year, 2 years, and last follow-up. Analyses were performed using random effects modeling. RESULTS: Twenty-nine studies were included in the final analysis. ILD/ISD showed greater leg pain improvement at 3 months (mean difference, -1.43; 95% confidence interval, [-1.78, -1.07]; P < 0.001), 6 months (-0.89; [-1.55, -0.24]; P = 0.008), and 12 months (-0.97; [-1.25, -0.68]; P < 0.001), but not 2 years (P = 0.22) or last follow-up (P = 0.09). Back pain improvement was better after ISD/ILD only at 1 year (-0.87; [-1.62, -0.13]; P = 0.02). Short-Form 36 physical component scores or Zurich Claudication Questionnaire (ZCQ) symptom severity scores did not differ between the groups. ZCQ physical function scores improved more after decompression alone at 6 months (0.35; [0.07, 0.63]; P = 0.01) and 12 months (0.23; [0.00, 0.46]; P = 0.05). Oswestry Disability Index and EuroQoL 5 dimensions scores favored ILD/ISD at all time points except 6 months (P = 0.07). Reoperations (odds ratio, 1.75; [1.23, 2.48]; P = 0.002) and total care costs (standardized mean difference, 1.19; [0.62, 1.77]; P < 0.001) were higher in the ILD/ISD group; complications did not differ significantly between the groups (P = 0.41). CONCLUSIONS: Patient-reported outcomes are similar after decompression alone and ILD/ISD; the observed differences do not reach accepted minimum clinically important difference thresholds. ISD/ILDs have higher associated costs and reoperation rates, suggesting current evidence does not support ILD/ISDs as a cost-effective alternative to decompression alone.

Reduced Bone Density Based on Hounsfield Units After Long-Segment Spinal Fusion with Harrington Rods.

BACKGROUND: Long-segment instrumentation, such as Harrington rods, offloads vertebrae within the construct, which may result in significant stress shielding of the fused segments. The present study aimed to determine the effects of spinal fusion on bone density by measuring Hounsfield units (HUs) throughout the spine in patients with a history of Harrington rod fusion. METHODS: Patients with a history of Harrington rod fusion treated at a single academic institution were identified. Mean HUs were calculated at 5 spinal segments for each patient: cranial adjacent mobile segment, cranial fused segment, midconstruct fused segment, caudal fused segment, and caudal adjacent mobile segment. Mean HUs for each level were compared using a paired-sample t test, with statistical significance defined by P < 0.05. Hierarchic multiple regression, including age, gender, body mass index, and time since original fusion, was used to determine predictors of midfused segment HUs. RESULTS: One hundred patients were included (mean age, 55 ± 12 years; 62% female). Mean HUs for the midconstruct fused segment (110; 95% confidence interval [CI], 100-121) were significantly lower than both the cranial and caudal fused segments (150 and 118, respectively; both P < 0.05), as well as both the cranial and caudal adjacent mobile segments (210 and 130, respectively; both P < 0.001). Multivariable regression showed midconstruct HUs were predicted only by patient age (-2.6 HU/year; 95% CI, -3.4 to -1.9; P < 0.001) and time since original surgery (-1.4 HU/year; 95% CI, -2.6 to -0.2; P = 0.02). CONCLUSIONS: HUs were significantly decreased in the middle of previous long-segment fusion constructs, suggesting that multilevel fusion constructs lead to vertebral bone density loss within the construct, potentially from stress shielding.

The Predictors of Incidental Durotomy in Patients Undergoing Pedicle Subtraction Osteotomy for the Correction of Adult Spinal Deformity.

Background: Pedicle subtraction osteotomy (PSO) is a powerful tool for sagittal plane correction in patients with rigid adult spinal deformity (ASD); however, it is associated with high intraoperative blood loss and the increased risk of durotomy. The objective of the present study was to identify intraoperative techniques and baseline patient factors capable of predicting intraoperative durotomy. Methods: A tri-institutional database was retrospectively queried for all patients who underwent PSO for ASD. Data on baseline comorbidities, surgical history, surgeon characteristics and intraoperative maneuvers were gathered. PSO aggressiveness was defined as conventional (Schwab 3 PSO) or an extended PSO (Schwab type 4). The primary outcome of the study was the occurrence of durotomy intraoperatively. Univariable analyses were performed with Mann-Whitney U tests, Chi-squared analyses, and Fisher's exact tests. Statistical significance was defined by p < 0.05. Results: One hundred and sixteen patients were identified (mean age 61.9 ± 12.6 yr; 44.8% male), of whom 51 (44.0%) experienced intraoperative durotomy. There were no significant differences in baseline comorbidities between those who did and did not experience durotomy, with the exception that baseline weight and body mass index were higher in patients who did not suffer durotomy. Prior surgery (OR 2.73; 95% CI [1.13, 6.58]; p = 0.03) and, more specifically, prior decompression at the PSO level (OR 4.23; 95% CI [1.92, 9.34]; p < 0.001) was predictive of durotomy. A comparison of surgeon training showed no statistically significant difference in durotomy rate between fellowship and non-fellowship trained surgeons, or between orthopedic surgeons and neurosurgeons. The PSO level, PSO aggressiveness, the presence of stenosis at the PSO level, nor the surgical instrument used predicted the odds of durotomy occurrence. Those experiencing durotomy had similar hospitalization durations, rates of reoperation and rates of nonroutine discharge. Conclusions: In this large multisite series, a history of prior decompression at the PSO level was associated with a four-fold increase in intraoperative durotomy risk. Notably the use of extended (versus) standard PSO, surgical technique, nor baseline patient characteristics predicted durotomy. Durotomies occurred in 44% of patients and may prolong operative times. Additional prospective investigations are merited.

Comparison of Hounsfield units and vertebral bone quality score for the prediction of time to pathologic fracture in mobile spine metastases treated with radiotherapy.

OBJECTIVE: Spine metastases are commonly treated with radiotherapy for local tumor control; pathologic fracture is a potential complication of spinal radiotherapy. Both Hounsfield units (HUs) on CT and vertebral bone quality (VBQ) on MRI have been argued to predict stability as measured by odds of pathologic fracture, although it is unclear if there is a difference in the predictive power between the two methodologies. The objective of the present study was to examine whether one methodology is a better predictor of pathologic fracture following radiotherapy for mobile spine metastases. METHODS: Patients who underwent radiotherapy (conventional external-beam radiation therapy, stereotactic body radiation therapy, or intensity-modulated radiation therapy) for mobile spine (C1-L5) metastases at a tertiary care center were retrospectively identified. Details regarding underlying pathology, patient demographics, and tumor morphology were collected. Vertebral involvement was assessed using the Weinstein-Boriani-Biagini (WBB) system. Bone quality of the non-tumor-involved bone was assessed on both pretreatment CT and MRI. Univariable analyses were conducted to identify independent predictors of fracture, and Kaplan-Meier analyses were used to identify significant predictors of time to pathologic fracture. Stepwise Cox regression analysis was used to determine independent predictors of time to fracture. RESULTS: One hundred patients were included (mean age 62.7 ± 11.9 years; 61% male), of whom 35 experienced postradiotherapy pathologic fractures. The most common histologies were lung (22%), prostate (21%), breast (14%), and renal cell (13%). On univariable analysis, the mean HUs of the vertebrae adjacent to the fractured vertebra were significantly lower among those experiencing fracture; VBQ was not significantly associated with fracture odds. Survival analysis showed that average HUs ≤ 132, nonprostate pathology, involvement of ≥ 3 vertebral body segments on the WBB system, Spine Instability Neoplastic Score (SINS) ≥ 7, and the presence of axial pain all predicted increased odds of fracture (all p < 0.001). Cox regression found that HUs ≤ 132 (OR 2.533, 95% CI 1.257-5.103; p = 0.009), ≥ 3 WBB vertebral body segments involved (OR 2.376, 95% CI 1.132-4.987; p = 0.022), and axial pain (OR 2.036, 95% CI 0.916-4.526; p = 0.081) predicted increased fracture odds, while prostate pathology predicted decreased odds (OR 0.076, 95% CI 0.009-0.613; p = 0.016). Sensitivity analysis suggested that an HU threshold of ≤ 132 and a SINS of ≥ 7 identified patients at increased risk of fracture. CONCLUSIONS: The present results suggest that bone density surrogates as measured on CT, but not MRI, can be used to predict the risk of pathologic fracture following radiotherapy for mobile spine metastases. More extensive vertebral body involvement and the presence of mechanical axial pain additionally predict increased fracture odds.

Intraoperative Surgeon Assessment of Bone: Correlation to Bone Mineral Density, CT Hounsfield units and Vertebral Bone Quality.

STUDY DESIGN: Retrospective observational study of consecutive patients. OBJECTIVE: The purpose of the study is to determine if a surgeon's qualitative assessment of bone intraoperatively correlates with radiologic parameters of bone strength. SUMMARY OF BACKGROUND DATA: Preoperative radiologic assessment of bone can include modalities such as CT Hounsfield Units (HUs), dual-energy x-ray absorptiometry bone mineral density (DXA BMD) with trabecular bone score (TBS) and MRI vertebral bone quality (VBQ). Quantitative analysis of bone with screw insertional torque and pull-out strength measurement has been performed in cadaveric models and has been correlated to these radiologic parameters. However, these quantitative measurements are not routinely available for use in surgery. Surgeons anecdotally judge bone strength, but the fidelity of the intraoperative judgement has not been investigated. METHODS: All adult patients undergoing instrumented posterior thoracolumbar spine fusion by one of seven surgeons at a single center over a 3-month period were included. Surgeons evaluated the strength of bone based on intraoperative feedback and graded each patient's bone on a 5-point Likert scale. Two independent reviewers measured preoperative CT HUs and MRI VBQ. BMD, lowest T-score and TBS were extracted from DXA within 2 years of surgery. RESULTS: Eighty-nine patients were enrolled and 16, 28, 31, 13 and 1 patients had Likert grade 1 (strongest bone), 2, 3, 4, and 5 (weakest bone), respectively. The surgeon assessment of bone correlated with VBQ (τ=0.15, P=0.07), CT HU (τ=-0.31, P<0.01), lowest DXA T-score (τ=-0.47, P<0.01), and TBS (τ=-0.23, P=0.06). CONCLUSION: Spine surgeons' qualitative intraoperative assessment of bone correlates with preoperative radiologic parameters, particularly in posterior thoracolumbar surgeries. This information is valuable to surgeons as this supports the idea that decisions based on feel in surgery have statistical foundation.

Opportunistic CT-Based Hounsfield Units Strongly Correlate with Biomechanical CT Measurements in the Thoracolumbar Spine.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Hounsfield units (HUs) are known to correlate with clinical outcomes, no study has evaluated how they correlate with BCT and DXA measurements. SUMMARY OF BACKGROUND: Low bone mineral density (BMD) represents a major risk factor for fracture and poor outcomes following spine surgery. Dual-energy x-ray absorptiometry (DXA) can provide regional BMD measurements but has limitations. Opportunistic HUs provide targeted BMD estimates; however, they are not formally accepted for diagnosing osteoporosis in current guidelines. More recently, biomechanical computed tomography (BCT) analysis has emerged as a new modality endorsed by the International Society for Clinical Densitometry (ISCD) for assessing bone strength. METHODS: Consecutive cases from 2017-2022 at a single institution were reviewed for patients who underwent BCT in the thoracolumbar spine. BCT-measured vertebral strength, trabecular BMD, and the corresponding American College of Radiology (ACR) Classification were recorded. DXA studies within three months of the BCT were reviewed. Pearson Correlation Coefficients were calculated, and receiver-operating characteristic curves were constructed to assess the predictive capacity of HUs. Threshold analysis was performed to identify optimal HU values for identifying osteoporosis and low BMD. RESULTS: Correlation analysis of 114 cases revealed a strong relationship between HUs and BCT vertebral strength (r=0.69; P<0.0001; R2=0.47) and trabecular BMD (r=0.76; P<0.0001; R2=0.58). However, DXA poorly correlated with opportunistic HUs and BCT measurements. HUs accurately predicted osteoporosis and low BMD (Osteoporosis: C=0.95, 95% CI 0.89-1.00; Low BMD: C=0.87, 95% CI 0.79-0.96). Threshold analysis revealed that 106 and 122 HUs represent optimal thresholds for detecting osteoporosis and low BMD. CONCLUSION: Opportunistic HUs strongly correlated with BCT-based measures, while neither correlated strongly with DXA-based BMD measures in the thoracolumbar spine. HUs are easy to perform at no additional cost and provide accurate BMD estimates at non-instrumented vertebral levels across all ACR-designated BMD categories.

Risk factors for sacral fracture following en bloc chordoma resection.

OBJECTIVE: The purpose of this study was to analyze risk factors for sacral fracture following noninstrumented partial sacral amputation for en bloc chordoma resection. METHODS: A multicenter retrospective chart review identified patients who underwent noninstrumented partial sacral amputation for en bloc chordoma resection with pre- and postoperative imaging. Hounsfield units (HU) were measured in the S1 level. Sacral amputation level nomenclature was based on the highest sacral level with bone removed (e.g., S1 foramen amputation at the S1-2 vestigial disc is an S2 sacral amputation). Variables collected included basic demographics, patient comorbidities, surgical approach, preoperative radiographic details, neoadjuvant and adjuvant radiation therapy, and postoperative sacral fracture data. RESULTS: A total of 101 patients (60 men, 41 women) were included; they had an average age of 69 years, BMI of 29 kg/m2, and follow-up of 60 months. The sacral amputation level was S1 (2%), S2 (37%), S3 (44%), S4 (9%), and S5 (9%). Patients had a posterior-only approach (77%) or a combined anterior-posterior approach (23%), with 10 patients (10%) having partial sacroiliac (SI) joint resection. Twenty-seven patients (27%) suffered a postoperative sacral fracture, all occurring between 1 and 7 months after the index surgery. Multivariable logistic regression analysis demonstrated S1 or S2 sacral amputation level (p = 0.001), combined anterior-posterior approach (p = 0.0064), and low superior S1 HU (p = 0.027) to be independent predictors of sacral fracture. The fracture rate for patients with superior S1 HU < 225, 225-300, and > 300 was 38%, 15%, and 9%, respectively. An optimal superior S1 HU cutoff of 300 was found to maximize sensitivity (89%) and specificity (42%) in predicting postamputation sacral fracture. In addition, the fracture rate for patients who underwent partial SI joint resection was 100%. CONCLUSIONS: Patients with S1 or S2 partial sacral amputations, a combined anterior-posterior surgical approach, low superior S1 HU, and partial SI joint resection are at higher risk for postoperative sacral fracture following en bloc chordoma resection and should be considered for spinopelvic instrumentation at the index procedure.

The association between bone mineral density and proximal junctional kyphosis in adult spinal deformity: a systematic review and meta-analysis.

OBJECTIVE: Proximal junctional kyphosis (PJK) is a complication of surgical management for adult spinal deformity (ASD) with a multifactorial etiology. Many risk factors are controversial, and their relative importance is not fully understood. The authors aimed to elucidate the association between bone mineral density (BMD) and PJK. METHODS: A systematic literature search was performed using PubMed and Web of Science keywords of "Proximal Junctional Kyphosis [MeSH] OR Proximal Junctional Failure [MeSH]" AND "Bone Mineral Density [MeSH] OR Hounsfield Units [MeSH] OR DEXA [MeSH]" set to the date range of January 2002 to July 2022. Studies required a minimum of 10 patients and 12 months of follow-up. Articles were included if they were in the English language and presented a primary retrospective cohort that included a comparison of patients with and without PJK, as well as a radiographic biomarker for BMD, such as Hounsfield units (HU) or T-score. RESULTS: A total of 18 unique studies with 2185 patients who underwent ASD surgery were identified. Of these, 537 patients (24.6%) developed PJK. Eight studies provided T-scores that were amenable to comparison, which found that patients who developed PJK were found to have lower BMD T-scores by a mean of -0.69 (95% CI -0.88 to -0.50; I2 = 63.9%, p < 0.001). The HU at the UIV among patients with the PJK group (n = 101) compared with the non-PJK group (n = 156) was found to be significantly lower (mean difference -32.35, 95% CI -46.05 to -18.65; I2 = 28.7%, p < 0.001). CONCLUSIONS: This meta-analysis suggests that low preoperative BMD as measured by T-score and a diagnosis of osteoporosis were associated with higher postoperative PJK. Additionally, lower HU on CT at the UIV were found to be significant risk factors for postoperative PJK as well. These findings suggest that more attention to preoperative BMD is a risk factor for PJK among ASD patients is warranted.

Paraspinal Sarcopenia is Associated With Worse Patient-Reported Outcomes Following Laminoplasty for Degenerative Cervical Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The present study is the first to assess the impact of paraspinal sarcopenia on patient-reported outcome measures (PROMs) following cervical laminoplasty. BACKGROUND: While the impact of sarcopenia on PROMs following lumbar spine surgery is well-established, the impact of sarcopenia on PROMs following laminoplasty has not been investigated. METHODS: We performed a retrospective review of patients undergoing laminoplasty from C4-6 at a single institution between 2010 and 2021. Two independent reviewers utilized axial cuts of T2-weighted magnetic resonance imaging sequences to assess fatty infiltration of the bilateral transversospinales muscle group at the C5-6 level and classify patients according to the Fuchs Modification of the Goutalier grading system. PROMs were then compared between subgroups. RESULTS: We identified 114 patients for inclusion in this study, including 35 patients with mild sarcopenia, 49 patients with moderate sarcopenia, and 30 patients with severe sarcopenia. There were no differences in preoperative PROMs between subgroups. Mean postoperative neck disability index scores were lower in the mild and moderate sarcopenia subgroups (6.2 and 9.1, respectively) than in the severe sarcopenia subgroup (12.9, P =0.01). Patients with mild sarcopenia were nearly twice as likely to achieve minimal clinically important difference (88.6 vs. 53.5%; P <0.001) and six times as likely to achieve SCB (82.9 vs. 13.3%; P =0.006) compared with patients with severe sarcopenia. A higher percentage of patients with severe sarcopenia reported postoperative worsening of their neck disability index (13 patients, 43.3%; P =0.002) and Visual Analog Scale Arm scores (10 patients, 33.3%; P =0.03). CONCLUSION: Patients with severe paraspinal sarcopenia demonstrate less improvement in neck disability and pain postoperatively and are more likely to report worsening PROMs following laminoplasty. LEVEL OF EVIDENCE: 3.

Is Severe Neck Pain a Contraindication to Performing Laminoplasty in Patients With Cervical Spondylotic Myelopathy?

STUDY DESIGN: Retrospective review. OBJECTIVE: The purpose of this study was to investigate the surgical outcomes in a cohort of patients with severe preoperative axial neck pain undergoing laminoplasty for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: No study has investigated whether patients with severe axial symptoms may achieve satisfactory neck pain and disability outcomes after laminoplasty. METHODS: We performed a retrospective review of 91 patients undergoing C4-6 laminoplasty for CSM at a single academic institution between 2010 and 2021. Patient-reported outcome measures (PROMs), including Neck Disability Index (NDI), visual analog scale (VAS) Neck, and VAS Arm, were recorded preoperatively and at 6 months and 1 year postoperatively. Patients were stratified as having mild pain if VAS neck was 0-3, moderate pain if 4-6, and severe pain if 7-10. PROMs were then compared between subgroups at all the perioperative time points. RESULTS: Both the moderate and severe neck pain subgroups demonstrated a substantial improvement in VAS neck from preoperative to 6 months postoperatively (-3.1±2.2 vs. -5.6±2.8, respectively; P <0.001), and these improvements were maintained at 1 year postoperatively. There was no difference in VAS neck between subgroups at either the 6-month or 1-year postoperative time points. Despite the substantially higher mean NDI in the moderate and severe neck pain subgroups preoperatively, there was no difference in NDI at 6 months or 1 year postoperatively ( P =0.99). There were no differences between subgroups in the degree of cord compression, severity of multifidus sarcopenia, sagittal alignment, or complications. CONCLUSIONS: Patients with moderate and severe preoperative neck pain undergoing laminoplasty achieved equivalent PROMs at 6 months and 1 year as patients with mild preoperative neck pain. The results of this study highlight the multifactorial nature of neck pain in these patients and indicate that severe axial symptoms are not an absolute contraindication to performing laminoplasty in well-aligned patients with CSM.

Sagittal Spinal Deformity in Patients with Idiopathic Normal Pressure Hydrocephalus.

AIM: To measure the baseline spinopelvic parameters and characterize the sagittal, and coronal plane deformities in patients with idiopathic normal pressure hydrocephalus (iNPH). MATERIAL AND METHODS: We analyzed a series of patients at one academic institution who underwent ventriculoperitoneal shunting for iNPH with pre-shunt standing full length x-rays. The series of patients was enrolled consecutively to minimize selection bias. We quantified comorbid sagittal plane spinal deformity based on the Scoliosis Research Society-Schwab classification system by assessing pelvic incidence and lumbar lordosis mismatch (PI-LL), pelvic tilt (PT), and sagittal vertical axis (SVA). RESULTS: Seventeen patients (59% male) were included in this study. Mean (± standard deviation) age was 74 ± 5.3 years with a body mass index (BMI) of 30 ± 4.5 kg/m < sup > 2< sup > . Six patients (35%) had marked sagittal plane spinal deformity by at least one parameter: five (29%) had greater than 20˚ PI-LL mismatch, three (18%) had > 9.5 cm SVA, and one (6%) had PT greater than 30˚. Additionally, the thoracic kyphosis exceeded the lumbar lordosis in nine patients (53%). CONCLUSION: Positive sagittal balance, with thoracic kyphosis exceeding lumbar lordosis, is common in iNPH patients. This may lead to postural instability, especially in patients whose gait does not improve following shunting. These patients may warrant further investigation and workup, including full length standing x-rays. Future studies should assess for improvement in the sagittal plane parameters following shunt placement.

Characterizing the Current Clinical Trial Landscape in Spinal Deformity: A Retrospective Analysis of Trends in the ClinicalTrials.gov Registry.

BACKGROUND: The management of adult spinal deformity (ASD) relies upon retrospective data, but there have been calls for prospective trials to improve the evidentiary base. This study sought to define the state of the spinal deformity clinical trials and highlight trends to guide future research. METHODS: The ClinicalTrials.gov database was queried for all ASD trials initiated since 2008. ASD was defined as adults (>18 years) and defined by the trial. All identified trials were categorized by enrollment status, study design, funding source, start and completion dates, country, outcomes examined, among many other study characteristics. RESULTS: Sixty trials were included, of which 33(55.0%) started within the past 5 years of the query date. Most trials were sponsored by academic centers (60.0%) followed by industry (48.3%). Notably, 16 (27%) trials had multiple funding sources, all included collaboration with an industry entity. Only one trial had funding from a government agency. There were 30 (50%) interventional and 30 (50%) observational studies. The average time to completion was 50.8 ± 49.1 months. A total of 23 (38.3%) studies investigated a new procedural innovation, while 17 (28.3%) studies examined the safety or efficacy of a device. Study publications were associated with 17 (28.3%) trials in the registry. CONCLUSIONS: The number of trials has increased significantly over the past 5 years, with the bulk of trials being funded by academic centers and industry and a notably lack by government agencies. Most trials focused on device or procedural investigation. Despite growing interest in ASD clinical trials, there remain many points for improvement in the current evidentiary base.

Lower Hounsfield Units and Severe Multifidus Sarcopenia Are Independent Predictors of Increased Risk for Proximal Junctional Kyphosis and Failure Following Thoracolumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of the present study was to assess the impact of sarcopenia on the development of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following thoracolumbar spine fusion surgery using opportunistic evaluation of paraspinal fatty degeneration on preoperative magnetic resonance imaging. SUMMARY OF BACKGROUND DATA: While paraspinal sarcopenia has been shown to have detrimental consequences following posterior cervicothoracic fusions, the impact of paraspinal sarcopenia on PJK and PJF following thoracolumbar spine fusion surgery remains unknown. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent posterior spine fusion surgery that extended caudally to the pelvis and terminated cranially between T10 and L2 between 2010 and 2017. The cohort was divided into three groups: (1) patients without PJK or PJF, (2) patients with PJK but no PJF, and (3) patients with PJF. Univariate and multivariate analyses were performed to determine risk factors for the development of proximal junctional complications. RESULTS: We identified 150 patients for inclusion in this study. Mean Hounsfield Units at the upper instrumented vertebra (UIV) was 148.3±34.5 in the cohort of patients without PJK or PJF, which was substantially higher than values recorded in the PJK (117.8±41.9) and PJF (118.8±41.8) subgroups (P<0.001). Severe multifidus sarcopenia was identified at a much higher rate in the subgroups of patients who developed PJK (76.0%) and PJF (78.9%) than in the subgroup of patients who developed neither PJK nor PJF (34.0%; P<0.001). Multivariate analysis demonstrated both low HU at the UIV and moderate-severe multifidus sarcopenia to be risk factors for the development of PJK and PJF. CONCLUSION: The results of this study suggest severe paraspinal sarcopenia and diminished bone density at the UIV impart an increased risk of developing PJK and PJF, while markers of systemic frailty such as modified Frailty Index and Charlson Comorbidity Index are not associated with an increased risk of these complications. LEVEL OF EVIDENCE: III.

Surgical Management of Hirayama Disease (Monomelic Amyotrophy): Systematic Review and Meta-Analysis of Patient-Level Data.

BACKGROUND: Hirayama disease or juvenile-onset monomelic amyotrophy is a clinical syndrome that disproportionately affects young males. Standard of care revolves around conservative management, but some patients experience disease progression that may benefit from surgical intervention. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of previous reports of surgical treatment for Hirayama disease was performed. Studies were included if they provided individual patient-level data, described the clinical presentation and surgical intervention, and reported neurological improvement at last follow-up. Comparison between those who improved and those with stable symptoms at last follow-up was performed. Decision-tree analysis was used to identify the best predictors of neurological improvement by last follow-up. RESULTS: Of 624 unique articles, 30 were included in the qualitative review and 23 in the meta-analysis. Among the 70 patients in the meta-analysis, mean age was 21.2 ± 6.3 years, 91% were male, and mean symptom duration at presentation was 43.3 ± 61.8 months. Fifty-nine patients (84.3%) had improvement in their neurological symptoms by last follow-up. Univariable analysis showed the only significant predictor of improvement in neurological symptoms by last follow-up was the use of stabilization-alone versus decompression with or without stabilization. Baseline clinical symptoms nor radiographic features predicted outcome. Decision-tree analysis showed surgical strategy (stabilization-alone vs. decompression ± stabilization), age (<20 vs. ≥20), and surgical approach (anterior-only vs. posterior-only or anterior-posterior) predicted a higher likelihood of neurological improvement by last follow-up. CONCLUSIONS: Nearly 85% of patients experienced improvement in neurological symptoms. Improvement was best for those who underwent stabilization-alone, and decision-tree analysis suggested that the likelihood of improvement was also superior for patients under 20 years of age and those treated with an anterior versus posterior or staged approach.

Titanium Cervical Cage Subsidence: Postoperative Computed Tomography Analysis Defining Incidence and Associated Risk Factors.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Substantial variability in both the measurement and classification of subsidence limits the strength of conclusions that can be drawn from previous studies. The purpose of this study was to precisely characterize patterns of cervical cage subsidence utilizing computed tomography (CT) scans, determine risk factors for cervical cage subsidence, and investigate the impact of subsidence on pseudarthrosis rates. METHODS: We performed a retrospective review of patients who underwent one- to three-levels of anterior cervical discectomy and fusion (ACDF) utilizing titanium interbodies with anterior plating between the years 2018 and 2020. Subsidence measurements were performed by two independent reviewers on CT scans obtained 6 months postoperatively. Subsidence was then classified as mild if subsidence into the inferior and superior endplate were both ≤2 mm, moderate if the worst subsidence into the inferior or superior endplate was between 2 to 4 mm, or severe if the worst subsidence into the inferior or superior endplate was ≥4 mm. RESULTS: A total of 51 patients (100 levels) were included in this study. A total of 48 levels demonstrated mild subsidence (≤2 mm), 38 demonstrated moderate subsidence (2-4 mm), and 14 demonstrated severe subsidence (≥4 mm). Risk factors for severe subsidence included male gender, multilevel constructs, greater mean vertebral height loss, increased cage height, lower Taillard index, and lower screw tip to vertebral body height ratio. Severe subsidence was not associated with an increased rate of pseudarthrosis. CONCLUSION: Following ACDF with titanium cervical cages, subsidence is an anticipated postoperative occurrence and is not associated with an increased risk of pseudarthrosis.