Letter to the editor: Prospective analysis of STRATAFIX™ symmetric PDS plus suture for fascial closure in spinal surgery: a pilot study.

Spine surgery is essential for restoring alignment, stability, and function in patients with cervical spine injuries, especially when instability, pain, deformity, or progressive nerve damage is present. Effective wound closure is vital in these procedures, aiming to promote rapid healing, reduce infection risks, enable early mobilization, and ensure satisfactory cosmetic results. However, there is limited evidence on the optimal wound closure technique for posterior spine surgery, highlighting the need for innovative approaches. A study by Glener et al. evaluated the effectiveness of STRATAFIX™ Symmetric barbed sutures compared to traditional braided absorbable sutures in spinal surgery. In a randomized trial involving 20 patients, the STRATAFIX™ group demonstrated a shorter mean closure time and significantly fewer sutures used, though without a statistically significant reduction in closure time. No significant differences were observed in postoperative complications between the groups during a six-month follow-up. While the findings suggest potential cost savings and efficiency improvements with STRATAFIX™, the study's small sample size and short follow-up period limit its generalizability. Furthermore, AI-based models, such as the Xception deep learning model, show promise in improving suture training accuracy for medical students, which could enhance surgical outcomes and reduce complications. Despite the promising results, further research with larger sample sizes, extended follow-up periods, and multi-center trials is necessary to validate the effectiveness of barbed sutures like STRATAFIX™ in neurosurgery. The integration of AI in surgical training and continued exploration of innovative techniques are essential to advancing the field and optimizing patient care in spinal surgery.

"Evaluating wound closure innovations in spinal surgery: impacts on efficiency and patient outcomes".

This study evaluates contemporary wound closure techniques in spinal surgery, focusing on the efficacy of barbed sutures, skin staples, and negative-pressure wound therapy (NPWT), compared to traditional methods. Barbed sutures, like STRATAFIX™ Symmetric, and skin staples demonstrate significant advantages, including reduced wound closure time, lower infection rates, and improved surgical outcomes, particularly in multilevel or revisional procedures. In contrast, plastic surgery closures do not show a substantial reduction in postoperative complications despite being used in more complex cases. NPWT is highlighted as an effective adjunct therapy for managing surgical site infections and reducing the need for hardware removal. The findings suggest that while modern techniques offer clear benefits, traditional methods remain valuable in specific contexts. The review advocates for further research through large-scale, long-term studies and emphasizes the need for personalized wound closure strategies based on individual patient risk factors.

Comparison of robotic or computer-assisted navigation versus fluoroscopic freehand techniques in the accuracy of posterior cervical screw placement during cervical spine surgery: a meta-analysis.

OBJECTIVE: Robot guidance (RG) and computer-assisted navigation (CAN) have been increasingly utilized for posterior cervical screw placement in cervical spine surgery, and cervical screw malposition may contribute to catastrophic complications. However, the superiority of the navigation using RG or CAN compared with conventional freehand (FH) techniques remains controversial, and no meta-analysis comparing the two methods in cervical spine surgery has been performed. METHODS: The PubMed, Embase, Web of Science, Cochrane, China National Knowledge Infrastructure, and Wanfang databases were searched for eligible literature. Studies reporting the primary outcomes of the accuracy of cervical screw placement using RG or CAN compared with FH techniques were included. Bias was evaluated using the Cochrane risk of bias criteria and the Newcastle-Ottawa Scale. The outcomes were evaluated in terms of odds ratio or standardized mean difference and corresponding 95% confidence interval. RESULTS: One randomized controlled trial and 18 comparative cohort studies published between 2012 and 2023 consisting of 946 patients and 4163 cervical screws were included in this meta-analysis. The RG and CAN techniques were associated with a substantially higher rate of optimal and clinically acceptable cervical screw accuracy than FH techniques. Furthermore, compared with the FH group, the navigation group showed fewer postoperative adverse events, less blood loss, shorter hospital lengths of stay, and lower postoperative Neck Disability Index scores. However, the navigation and FH groups had equivalent intraoperative times and postoperative visual analog scale and Japanese Orthopaedic Association scores at the final follow-up. CONCLUSIONS: Both RG and CAN are superior to FH techniques in terms of the accuracy of cervical screw placement. Navigation techniques, including RG and CAN methods, are accurate, safe, and feasible in cervical spine surgery.

Arthroscopic-assisted uni-portal spinal surgery combined with modified unilateral laminotomy with bilateral decompression for the treatment of lumber epidural lipomatosis: Case report and new therapeutic method.

Background: Lumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by the pathological proliferation of adipose tissue in the epidural space of the spinal canal. This study presents the case of a 59-year-old male with lumbar SEL treated effectively in the short term through arthroscopic-assisted uniportal spinal surgery (AUSS) combined with a modified circle-drawing unilateral laminotomy with bilateral decompression (ULBD) technique. Methods: A modified circle-drawing ULBD procedure was executed via AUSS for a patient with SEL. The procedure involved the excision of diseased adipose tissue from the spinal canal, enlargement and decompression of the spinal canal, liberation of nerves, and post-operative evaluation of imaging results and clinical outcomes. Results: The patient exhibited improvements in the dural sac cross-sectional area, low back pain Visual Analogue Score (VAS, leg pain VAS, lumbar spine Japanese Orthopaedic Association (JOA), and EQ-5D post-surgery. Conclusions: AUSS offers comprehensive visualization, straightforward positioning, facilitating a broad field of view and precise lesion management. The modified circle-drawing ULBD technique characterized by its simplicity, operational freedom, and extensive decompression range, contributes to symptom alleviation and patient recovery.

[Analysis of risk factors for postoperative delirium in elderly patients undergoing spinal surgery].

OBJECTIVE: To investigate the risk factors of postoperative delirium in elderly patients undergoing spine surgery. METHODS: The basic case data of 566 patients who underwent spine surgery under general anesthesia from January 2021 to January 2023 were retrospectively analyzed. There were 296 males and 270 females with an average age of (71.58 ± 4.21) years old. There were 195 cases of cervical spine surgery, 26 cases of thoracic spine surgery and 345 cases of lumbar spine surgery.According to the occurrence of postoperative delirium, the patients were divided into postoperative delirium group(41 patients) and non-delirium group (525 patients). Univariate analysis was used to analyze the possible influencing factors such as gender, age, weight, smoking history, drinking history, surgical site, preoperative anxiety, intraoperative hypotension times, blood loss and so on, and binary Logistic regression was used to analyze the univariate factors with P<0.05. RESULTS: A total of 41 patients developed postoperative delirium. Univariate analysis showed that age (P=0.000), duration of surgery (P=0.039), preoperative anxiety (P=0.001), blood loss (P=0.000), history of opioid use (P=0.003), history of stroke (P=0.005), C-reactive protein (P=0.000), sodium ion(P=0.000) were significantly different between delirium group and non-delirium group. These factors were included in the binary Logistic regression analysis, and the results showed that age [OR=0.729, 95%CI(0.569, 0.932), P=0.012], opioid use [OR=21.500, 95%CI(1.334, 346.508), P=0.031], blood loss [OR=0.932, 95%CI(0.875, 0.993), P=0.029], C-reactive protein [OR=0.657, 95%CI(0.485, 0.890), P=0.007], preoperative anxiety [OR=23.143, 95%CI(1.859, 288.090), P=0.015], and sodium [OR=1.228, 95%CI(1.032, 1.461), P=0.020] were independent risk factors for the development of delirium after spinal surgery in elderly patients. CONCLUSION: Age, opioid use, blood loss, preoperative anxiety, elevated c-reactive protein, and hyponatremia are independent risk factors for the development of postoperative delirium in elderly patients undergoing spinal surgery.

Systematic Review and Critical Appraisal of Cauda Equina Syndrome Management During Pregnancy.

Cauda equina during pregnancy represents a rare entity, with data regarding optimal treatment being very scarce in the pertinent literature. Given the scarcity of current evidence on the topic, this study conducts a systematic review and analysis of existing literature concerning cauda equina syndrome (CES) management in pregnant women. A comprehensive search was performed across multiple databases, yielding 26 level IV peer-reviewed articles that met the inclusion criteria. These studies collectively encompassed 30 pregnant patients with CES, with a mean age of 31.2 years and an average gestational age of 26 weeks. Disc herniation emerged as the primary cause in 73% of cases. Regarding surgical interventions, the prone position was utilised in 70% of cases, with 73% receiving general anaesthesia. Notably, third-trimester spinal surgeries exhibited a higher complete recovery rate compared to earlier trimesters. Minimally invasive spinal surgery demonstrated superior outcomes in terms of complete recovery and reduced risk of persistent post-operative symptoms when compared to open approaches. Moreover, patients undergoing caesarean section (CS) after spinal surgery reported higher rates of symptom resolution and lower symptom persistence compared to those with CS before spinal surgery or vaginal delivery post-spinal surgery. Despite these study's findings, the overall evidence base remains limited, precluding definitive conclusions. Consequently, the study underscores the importance of multidisciplinary team discussions to formulate optimal treatment strategies for pregnant individuals presenting with CES. This highlights a critical need for further research to expand the knowledge base and improve the guidance available for managing CES in pregnant populations.

A review: artificial intelligence in image-guided spinal surgery.

INTRODUCTION: Due to the complex anatomy of the spine and the intricate surgical procedures involved, spinal surgery demands a high level of technical expertise from surgeons. The clinical application of image-guided spinal surgery has significantly enhanced lesion visualization, reduced operation time, and improved surgical outcomes. AREAS COVERED: This article reviews the latest advancements in deep learning and artificial intelligence in image-guided spinal surgery, aiming to provide references and guidance for surgeons, engineers, and researchers involved in this field. EXPERT OPINION: Our analysis indicates that image-guided spinal surgery, augmented by artificial intelligence, outperforms traditional spinal surgery techniques. Moving forward, it is imperative to collect a more expansive dataset to further ensure the procedural safety of such surgeries. These insights carry significant implications for the integration of artificial intelligence in the medical field, ultimately poised to enhance the proficiency of surgeons and improve surgical outcomes.

Wound closure techniques for spinoplastic surgery: a review of the literature.

PURPOSE: The approach to skin closure in spinal surgery is dependent on surgeon preference and experience. Wound complications, including dehiscence and surgical site infection (SSI), are common following spine surgery. The authors reviewed various wound closure techniques employed in spinal surgery. METHODS: A systematic review was conducted to identify articles comparing wound closure techniques after posterior spinal surgery. Articles that employed experimental or observational cohort study designs and reported rates of SSI, dehiscence, or scarring following spinal surgery were included. RESULTS: Eight studies examining closure techniques of the skin were identified: five retrospective cohort studies and three randomized-controlled trials. No differences in the incidence of SSI were reported based on suture technique, although staples were associated with higher SSI rates in single level spinal fusion, and barbed suture resulted in decreased wound complications. The use of intracutaneous sutures was associated with a higher incidence of wound dehiscence when compared to tension-relieving far-near near-far suture (FNS) and far-near near-far interrupted point (FNP) sutures. However, the latter two also resulted in the highest rates of delayed wound healing (i.e., time to fully heal). Modified Allgöwer-Donati suture (MADS) resulted in smaller scar area when compared to vertical mattress suture. CONCLUSION: Significant differences exist in wound healing when comparing suture techniques in spinal surgery. Surgical staples allow for faster closing time, but are also associated with higher wound complications. Intracutaneous sutures appear to have higher rates of dehiscence compared to vertical mattress suture but display faster wound healing. Future studies are necessary to elucidate contributory factors, including local ischemia and changes in tensile forces. LEVEL OF EVIDENCE: Level IV.

[Orthopedic robot-assisted endoscopic transforaminal lumbar interbody fusion for lumbar disc herniation with lumbar instability].

OBJECTIVE: To explore the safety and effectiveness of the robot-assisted system for transforaminal percutaneous endoscopic in the treatment of lumbar disc herniation with lumbar instability. METHODS: From October 2021 to March 2023, 26 patients with single-segment lumbar disc herniation and lumbar spinal instability were treated with robot-assisted system for transforaminal percutaneous endoscopic. The operation time, intraoperative blood loss, incision length, postoperative drainage volume, postoperative ambulation activity time, postoperative hospitalization time were record. The intervertebral space height and the lumbar lordosis angle before and after surgery were observed and compared. Pain level was evaluated using the visual analogue scale(VAS). The clinical efficacy was evaluated by Oswestry disability index(ODI). The interbody fusion was evaluated by Brantigan Steffee criteria. RESULTS: All patients successfully completed the operation, the operation time ranged form 105 to 109 min with an average of (150.8±24.1) min. Intraoperative blood loss ranged form 35 to 88 ml with an average of (55.5±16.4) ml. Incision length ranged form 1.4 to 3.5 cm with an average of (2.3±0.8) cm. Postoperative drainage volume ranged form 15 to 40 ml with an average of (28.5±7.8) ml. Postoperative ambulation time ranged form 15 to 30 h with an average of (22.8±4.5) h. Postoperative hospitalization time was 3 to 7 d with an average of (4.2±1.3) d. Total of 26 patients were followed up, the duration ranged from 12 to 16 months with an average of (14.0±1.3) months. The VAS and ODI at 1 week [(2.96±0.72) points, (41.63±4.79)%] and 12 months[(1.27±0.60) points, (13.11±2.45)%] were significantly different from those before surgery[(6.69±0.93) points, (59.12±5.92)%], P<0.01. The height of the intervertebral space (11.95±1.47) mm and lumbar lordosis (57.46±7.59)° at 12 months were significantly different from those before surgery [(6.67±1.20) mm, (44.08±7.79)°], P<0.01. At 12 months after surgery, all patients had no pedicle screw rupture or dislocation of the fusion cage, and the intervertebral fusion was successful. According to Brantigan-Steffee classification, 17 cases were grade D and 9 cases were grade E. CONCLUSION: Robot-assisted system for transforaminal percutaneous endoscopic for the treatment of single-segment lumbar disc herniation with lumbar instability improved the accuracy and safety of the operation, and the clinical effect of early follow-up is accurate.

The insert and revolve technique: a novel approach for inserting cages during unilateral biportal endoscopic assisted fusion surgery for effective spinal alignment restoration.

STUDY DESIGN: Retrospective study. PURPOSE: This study aimed to propose a method of performing unilateral biportal endoscopy (UBE)-assisted interbody cage insertion for fusion using the "insert and revolve" technique and analyze the clinico-radiological outcomes. OVERVIEW OF LITERATURE: UBE-assisted lumbar interbody fusion (ULIF) is a rapidly evolving technique combining the advantages of minimally invasive technique with ease of learning. The limited size of cages was a result of the narrow insertion channel. We propose a technique in which large extreme lateral interbody fusion cages can be inserted through the same opening. METHODS: This study included 104 patients who underwent ULIF using the "insert and revolve technique" between July 2019 and September 2022. The patients were followed up for at least 12 months postoperatively. The clinical outcomes were assessed using the Visual Analog Scale (VAS) for leg pain and back pain, Oswestry Disability Index (ODI), and modified McNab's criteria. Changes in segmental lordosis (SL), intervertebral disc height (IVDH), segmental coronal alignment (SCA), cage subsidence, and fusion grade were evaluated at 6- and 12-month follow-up. RESULTS: The VAS scores for leg and back pain and ODI score showed significant improvement. Based on the Macnab's criteria, 97 patients showed excellent outcomes and seven demonstrated good outcomes at 12 months. The mean IVDH increased from 6.3±2 to 10±2.1 mm immediately after surgery and 10±1.1 mm at 6 months. SL improved from 9.3°±11.5° to 17.78°±8.1°, while SCA improved from 7.7°±2.1° to 3.4°±1.2° at 1 year. Moreover, 92 and 11 patients showed grade 1 and 2 fusion, respectively, according to the Bridwell grading at 1 year. CONCLUSIONS: The "insert and revolve technique" facilitates the successful insertion of large cages, contributing to the restoration of disc height and coronal and sagittal spinal correction with favorable fusion rates.

The right lymphatic duct: basic anatomy and clinical relevance.

The anatomical variability of the thoracic duct and the right lymphatic duct predisposes them to inadvertent damage following head and neck surgery thereby leading to chyle leak which is an uncommon complication with potentially significant associated morbidity. Although chyle leak is predominately associated with left-sided neck surgery, it also occurs as a complication of the right-sided neck dissection. Variable figures concerning chyle leakage after right-sided neck dissections were reported, ranging from 0 per cent to higher prevalences such as 14%, 24%, 33% and 60% of total cases of chyle leakages associated with neck surgery. The right-sided complications may implicate the right lymphatic duct and right-sided terminations of the thoracic duct into the venous system which occur in about 1-6% of humans. Other clinically relevant conditions involving the right-sided major lymphatic vessels include chyle leaks following right anterior cervical spine surgery, cysts of the right lymphatic duct and dilatation of the right lymphatic duct in the setting of recurrent cervical swelling. This article presents a review of the literature concerning the basic anatomy and the clinical relevance of the right lymphatic duct and the right-sided terminations of the thoracic duct into the venous circulation.

Effectiveness and Safety of High-Dose Tranexamic Acid in Adolescent Idiopathic Scoliosis Surgery: A Meta-Analysis and Systematic Review.

OBJECTIVE: This systematic review and meta-analysis of randomized controlled trials and retrospective controlled studies aims to evaluate the efficacy and safety of high-dose tranexamic acid (TXA) in spinal correction surgery for adolescent idiopathic scoliosis patients. METHODS: In March 2024, a comprehensive search was conducted in PubMed, Web of Science, Embase, and Cochrane databases to identify randomized controlled trials and retrospective controlled studies comparing the effects of high-dose TXA on blood loss and transfusion requirements during spinal correction surgery. RESULTS: This meta-analysis included 10 studies encompassing a total of 741 patients. The pooled results indicated that the use of high-dose TXA significantly reduced intraoperative blood loss [weighted mean difference (WMD) = -519.83, 95% CI (-724.74, -314.92), P < 0.00001], transfusion rate [RR = 0.28, 95% CI (0.17, 0.45), P < 0.00001], total blood loss [WMD = -891.09, 95% CI (-1623.92, -158.26), P = 0.02], and postoperative blood loss [WMD = -105.91, 95% CI (-141.29, -70.52), P < 0.00001]. There was no significant difference in operative time [WMD = -18.96, 95% CI (-40.20, 2.28), P = 0.08] and blood loss per segment [WMD = -50.51, 95% CI (-102.19, 1.17), P = 0.06]. Both groups had a comparable incidence of thromboembolic events. CONCLUSIONS: Our meta-analysis suggests that the use of high-dose TXA reduces intraoperative blood loss, transfusion rate, total blood loss, and postoperative blood loss in spinal correction surgery for adolescent idiopathic scoliosis patients. However, there were no significant differences in operative time and blood loss per segment.

"Revolutionising spinal surgery: the impact of STRATAFIX™ symmetric barbed sutures on closure time and costs".

Spinal surgery, crucial for correcting structural abnormalities, involves decompressing nerve structures, realigning or stabilizing vertebral segments, and replacing damaged components to restore spinal integrity. Effective wound closure is vital in these procedures, as it prevents infections, minimizes wound dehiscence, and ensures optimal cosmetic results. Recent advancements, particularly in barbed suture technology like STRATAFIX™ Symmetric, offer promising improvements in surgical outcomes. A study by Steven R. Glener et al. evaluated STRATAFIX™ Symmetric for fascial closure in spinal surgery, comparing it to traditional braided absorbable sutures. Although the difference in closure time was not statistically significant, STRATAFIX™ demonstrated a higher closure rate and required significantly fewer sutures, reducing post-surgical material counts and the risk of accidental needle sticks. No adverse events were observed in either group over a 6-month follow-up period. Despite their benefits in reducing operating room time and costs, barbed sutures remain underutilized in neurosurgery. Studies indicate that barbed sutures can significantly decrease wound closure time, particularly in complex or multilevel spinal surgeries, without compromising clinical outcomes. These findings suggest that adopting barbed suture technology in spinal surgery could enhance surgical efficiency and patient care. Further research with larger sample sizes and multicenter studies is necessary to validate these benefits and refine surgical practices, ultimately improving patient outcomes.

Intravenous versus topical tranexamic acid in spinal surgery: a systematic review and meta-analysis.

BACKGROUND: The administration of tranexamic acid (TXA) during spinal surgery has been shown to reduce blood loss. However, the efficacy and safety of intravenous TXA (ivTXA) and topical TXA (tTXA) are poorly documented. The present meta-analysis aimed to compare the efficacy and safety of ivTXA and tTXA administration in spinal surgery. METHODS: Potentially relevant academic articles were identified from PubMed, Ovid, Cochrane Library, CNKI database, and Wanfang Data from the date of inception until March 1, 2024. Randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) were included in our meta-analysis if they compared the efficacy and safety of ivTXA versus tTXA administration during spinal surgery. Secondary sources were identified from the references of the included literature. The meta-analysis was performed in accordance with the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Data were summarized using RevMan 5.3 software from Denmark. RESULTS: Four RCTs and one non-RCT met our inclusion criteria. The pooled outcomes demonstrated that ivTXA groups compared with tTXA groups had significantly less amount of total blood loss [weighted mean difference (WMD)=-159.55, 95% CI (-181.91,-137.19), P < 0.00001], hidden blood loss [WMD=-132.27, 95% CI (-159.81, -104.72), P < 0.00001], intraoperative blood loss [WMD=-86.22, 95% CI (-99.13, -73.31), P < 0.00001, I2 = 96%], and more high postoperative hemoglobin level [WMD = 8.96, 95% CI (5.18, 12.75), P < 0.00001, I2 = 29%], and less transfusion rate [risk ratio (RR) = 1.11, 95% CI (0.81,1.52), P = 0.50, I2 = 94%]. The pooled results showed no significant difference in thromboembolic events (deep venous thrombosis and pulmonary embolism) between the two groups. CONCLUSION: Our meta-analysis demonstrated that ivTXA was more effective than tTXA in inducing hemostatic effect during spinal surgery. However, the risk of a thrombotic event was not different between the two administration methods of TXA. More high quality RCTs are needed to further confirm our conclusions.

Predictors of return to work after spinal surgery : systematic review and Meta-analysis.

PURPOSE: To analyze the situation and influencing factors of patients returning to work after spinal surgery, and to provide reference for clinical intervention measures of patients returning to work after spinal surgery. METHODS: A computer search was conducted in Chinese and English database on the situation and influencing factors of patients returning to work after spinal surgery from the establishment of the database to February 2023. Meta-analysis was performed using RevMan 5.3 and StataMP 17.0 software. RESULTS: A total of 10 literatures were included, involving 11,548 subjects. Meta-analysis results showed that 58% of patients returned to work after spinal surgery [95%CI (0.47-0.69)]. Gender [OR = 2.41, 95%CI (1.58-3.37)], age [OR = 1.32, 95%CI (1.03-1.51)], job nature [OR = 5.94, 95%CI (3.54-9.62)], education level [OR = 0.23, 95%CI (0.06-0.48)], fear of disease progression [OR = 0.82, 95%CI (0.84-0.95)], and social support [OR = 1.21, 95%CI (1.12-1.37)] were the influencing factors for patients returning to work after spinal surgery. CONCLUSION: The rate of patients returning to work after spinal surgery is low, and is affected by many factors. Medical personnel should pay comprehensive attention to the above high-risk groups and give timely intervention and support.

Dose-response relationship between perioperative allogeneic blood transfusion and surgical site infections following spinal surgery.

BACKGROUND CONTEXT: Perioperative allogeneic transfusion was generally considered to be safe. However, there had been some literatures reporting a potential association between surgical site infections (SSI) and blood transfusion. PURPOSE: To determine whether perioperative blood transfusion increased the risk of SSI and to further explored whether there was a dose-response relationship. DESIGN: Retrospective nested case-control study. PATIENT SAMPLE: We retrospectively analyzed consecutive patients who underwent spinal fusion surgery at our institution between July 2011 and July 2021. OUTCOME MEASURE: In the current study, the primary outcome measure was SSI. METHODS: All consecutive patients who underwent elective spinal surgery at our institution between July 2011 and July 2021 formed the retrospective cohort. Electronic patient record and radiographic data were reviewed retrospectively in our electronic database. To examine the effects of mismatched variables, we further adjusted for possible confounding factors using conditional logistic regression models. Then, we explored the nonlinear relationship between perioperative blood transfusion and SSI by a smoothed curve, with the adjustments for potential confounders. If a nonlinear relationship was observed, a two-piecewise regression model would be performed to calculate the threshold effect. RESULTS: The average time from surgery to diagnosis of SSI was 20.5 days. We matched 248 controls to 124 SSI cases. Of the 124 patients who developed SSI, 84 patients (67.7%) had deep SSI, 40 patients (32.3%) had superficial SSI. In the fully adjusted model, the risk of SSI increased by 27% for each additional unit of blood transfusion. It can be seen from the curve fitting plot that the risk of SSI has a greater increase after blood transfusion >3U. Subsequent piecewise regression identified an inflection point of 3U. CONCLUSION: We determined that 3U was a threshold volume of allogeneic blood transfusion that shifted the risk of SSI following spinal surgery, and there was a dose-response effect.

Validation of a surgical simulator and establishment of quantitative performance thresholds-RealSpine simulation system for open lumbar decompressions.

BACKGROUND CONTEXT: The majority of surgical training is conducted in real-world operations. High-fidelity surgical simulators may provide a safer environment for surgical training. However, the extent that it reflects real-world operations and surgical ability is often poorly characterized. PURPOSE: (1) Assess the validity and fidelity of a surgical simulator; (2) Examine the quantitative relationship between simulation performance and markers of real-world ability; (3) Establish thresholds for surgical expertise, and estimate their external validity and accuracy. STUDY DESIGN/SETTING: A cohort study of surgeons at a British neurosurgical center. STUDY SAMPLE: Ten early-career "novice" surgeons and 8 board-certified "expert" neurosurgeons. OUTCOMES MEASURES: (1) Face and content validity, and visual and haptic fidelity; (2) Construct validity; (3) Predictive and discriminative utility of quantitative performance thresholds. METHODS: Participants performed unilateral lumbar decompressions on high-fidelity spinal simulators that replicate the bony and soft tissue anatomy along with physiological processes such as bleeding and CSF leaks. Operating times, measured from first surgical action to either self-perceived satisfactory decompression or the end of allocated time, were recorded. The performance was also assessed independently by 2 blinded spinal subspecialist neurosurgeons using OSATS, a validated surgical assessment tool that utilizes 5-point scales on a variety of technical domains to grade the overall technical proficiency. Validity and fidelity were assessed by expert neurosurgeons using quantitative questionnaires. Construct validity was assessed by ordinal regression of simulation performance against real-world surgical grade and portfolio. Thresholds of expert status by simulation performance was established, and their predictive and discriminative utility assessed by crossvalidation accuracy and AUC-ROC. RESULTS: Operating time and expert assessments of simulation performance (OSATS) were strong and significant prdictors of surrogate markers of real-world surgical ability. The thresholds for expert status were operating time of 15 minutes and modified OSATS score of 15/20. These thresholds predicted expert status with 84.2% and 71.4% accuracy respectively. Strong discriminative ability was demonstrated by AUC-ROC of 0.95 and 0.83 respectively. All expert surgeons agreed that RealSpine simulators demonstrate high face validity, and high visual and haptic fidelity, with overall scores showing statistically significant agreement on these items (all scores at least 4/5, p<.0001). There was less consensus on content validity, but with still significant overall agreement (average score: 3.75/5, p=.023). CONCLUSIONS: Real-world surgical ability and experience can be accurately predicted by defining objective quantitative thresholds on high-fidelity simulations. The thresholds established here, along with other data presented in this paper, may inform objectives and standards to be established in a spinal surgical training curriculum.

Efficacy and safety of topical tranexamic acid in spinal surgery: a systematic review and meta-analysis.

Purpose: This study aimed to assess the effects of topical tranexamic acid (tTXA) in spinal surgery to provide reliable clinical evidence for its usefulness. Methods: The PubMed, EMBASE, Medline, and Cochrane Central Register of Controlled Trials databases were comprehensively searched to identify randomized controlled trials and non-randomized controlled trials evaluating the effect of tTXA on blood loss during spine surgery. The observation indexes were intraoperative blood loss, total blood loss, output and duration of postoperative drainage, postoperative hematological variables, length of postoperative hospital stay, blood transfusion rate, and complication rate. Results: A total of 21 studies involving 1774 patients were included. Our results showed that the use of tTXA during spinal surgery significantly reduced the total blood loss, postoperative drainage volume, postoperative transfusion rate, duration of postoperative drainage, and postoperative hospital stay, and increased the serum hemoglobin concentration, thereby providing better clinical outcomes for surgical patients. However, tTXA had no effect on intraoperative blood loss and associated complications. Conclusion: On the basis of the available evidence, the present results provide strong clinical evidence of the clinical value of tTXA in spinal surgery and provide an important reference for future research and clinical decision-making.

Breaking Boundaries in Spinal Surgery: GPT-4's Quest to Revolutionize Surgical site Infection Management.

BACKGROUND: Surgical site infection (SSI) is a common and costly complication in spinal surgery. Identifying risk factors and preventive strategies is crucial for reducing SSIs. GPT-4 has evolved from a simple text-based tool to a sophisticated multimodal data expert, invaluable for clinicians. This study explored GPT-4's applications in SSI management across various clinical scenarios. METHODS: GPT-4 was employed in various clinical scenarios related to SSIs in spinal surgery. Researchers designed specific questions for GPT-4 to generate tailored responses. Six evaluators assessed these responses for logic and accuracy using a 5-point Likert scale. Inter-rater consistency was measured with Fleiss' kappa, and radar charts visualized GPT-4's performance. RESULTS: The inter-rater consistency, measured by Fleiss' kappa, ranged from 0.62 to 0.83. The overall average scores for logic and accuracy were 24.27±0.4 and 24.46±0.25 on 5-point Likert scale. Radar charts showed GPT-4's consistently high performance across various criteria. GPT-4 demonstrated high proficiency in creating personalized treatment plans tailored to diverse clinical patient records and offered interactive patient education. It significantly improved SSI management strategies, infection prediction models, and identified emerging research trends. However, it had limitations in fine-tuning antibiotic treatments and customizing patient education materials. CONCLUSIONS: GPT-4 represents a significant advancement in managing SSIs in spinal surgery, promoting patient-centered care and precision medicine. Despite some limitations in antibiotic customization and patient education, GPT-4's continuous learning, attention to data privacy and security, collaboration with healthcare professionals, and patient acceptance of AI recommendations suggest its potential to revolutionize SSI management, requiring further development and clinical integration.

Understanding the role of surgical intervention for patients with concomitant degenerative spinal disease without deformity and Parkinson's disease: a meta-analysis.

INTRODUCTION: Parkinson's disease is a common neurodegenerative disease. With an aging population, co-existent degenerative diseases of the spine in these patients will become more prevalent. RESEARCH QUESTION: This systematic review and meta-analysis aims to establish the incidence and risk of adverse outcomes following spinal surgery in patients with Parkinson's disease. Material and Methods A literature review was carried out in order to identify studies assessing the outcomes of adult patients with Parkinson's disease undergoing spinal surgery for degenerative conditions. Studies with less than ten subjects or those assessing surgery for spinal deformity or trauma were excluded. RESULTS: Of 74 studies identified, seven were included for meta-analysis. In the 689,578 participants, there was a significantly higher incidence, but not higher risk, of complications (0.54 95% CI [0.19-0.85] vs 0.07 95% CI [0.01-0.41]; p = 0.048) and revision surgery (0.6 95% CI [0.25-0.88] vs 0.1 95% CI [0.05-0.19]; p = 0.003) amongst patients with Parkinson's disease compared to controls. We also demonstrated a significantly lower incidence but not lower risk of clinical improvement (0.27 95% CI [0.16-0.41] vs 0.57 95% CI [0.36-0.76]; p = 0.02) after surgery in patients with Parkinson's disease. There was no difference in the incidence or risk of death following surgery. DISCUSSION AND CONCLUSION: Spinal surgery for concomitant degenerative diseases in patients with Parkinson's disease is associated with a lower incidence of clinical improvement and a higher incidence of complications. Medical management should be optimised before an individually tailored and well-considered surgical intervention is implemented.