The Fragility Index: Understanding its Application in Clinical Research.

With the vast increase in spinal surgery research and accessibility, critical evaluation of studies is paramount. Historically, P values and confidence intervals have been the gold standard, but more recently, the inclusion of the Fragility Index has brought a more holistic approach. The Fragility Index aims to communicate the robustness of a trial and how tenuous statistical significance may be. It can be used in conjunction with more traditional methods for evaluating research.

The Effect of Patient Resilience on Postoperative Scores After One- and Two-Level Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To investigate the association between resilience and outcomes of pain and neck-related disability after single- and double-level anterior cervical discectomy and fusion (ACDF). METHODS: Patients who underwent single- or double-level ACDF were sent a survey between 6 months and 2 years after surgery. The survey included the Brief Resilience Scale (BRS), visual analogue scale (VAS) for pain, Neck Disability Index (NDI), and Pain Self-Efficacy Questionnaire (PSEQ-2). Patients completed the VAS and NDI twice, once describing preoperative pain and disability and once describing current pain and disability. Respondents were classified as high resilience (HR), medium resilience (MR), or low resilience (LR). Demographics, PSEQ-2 scores, pre- and postoperative VAS and NDI scores, and change in VAS (ΔVAS) and NDI (ΔNDI) scores were compared between groups. RESULTS: Thirty-three patients comprised the HR group, 273 patients comprised the MR group, and 47 patients comprised the LR group. All groups demonstrated postoperative improvement in VAS and NDI scores that exceeded previously established MCID values. The HR group demonstrated greater improvement in pain compared with the LR group (ΔVAS: -5.8 for HR vs. -4.4 for LR, P = 0.05). Compared with the MR group, the LR group demonstrated greater postoperative pain (VAS: 3.2 for LR vs. 2.5 for MR, P = 0.02) and disability (NDI: 11.9 for LR vs. 8.6 for MR, P = 0.02). CONCLUSIONS: Patients demonstrated improvement in pain and neck-related disability after single- and double-level ACDF, regardless of resilience score. Patients with greater resilience may be expected to demonstrate more improvement in pain after ACDF.

Physical and Psychological Impact of Scar Cosmesis After Cervical Spine Fusion Surgery.

INTRODUCTION: Patients' and surgeons' perceptions of cutaneous scarring can vary, causing unpleasant physical and psychological outcomes. This study aims to bridge the current scientific literature gap and understand the impact of patient-perceived scar cosmesis after anterior and posterior cervical spine surgery. METHODS: Retrospective review of patients ≥18 years old who underwent anterior or posterior cervical spine surgery from 2017 to 2022 at a large, urban academic group. To select patients with adequate time for surgical scar maturation, only patients who were greater than 6 months postsurgery were included. The Scar Questionaire Survey (SCAR-Q) survey, a surgical scar assessment tool, was administered to patients to assess patient perceptions of scar symptomatology, appearance, and psychosocial impact. Scores range from 0 to 100, with 100 as the best outcome. An additional 5-item Likert scale question was administered to assess overall surgical satisfaction. RESULTS: All 854 respondents who completed the survey were stratified into 2 groups "Unsatisfied vs. Satisfied." Patients who were "unsatisfied" with their surgery had the lowest outcome scores for SCAR-Q appearance, symptom, and psychosocial scores than those who were "Satisfied" (P < 0.001). Females had significantly "higher/more favorable" responses for SCAR-Q Appearance (77.5 vs. 82.8 P < 0.001) and Psychosocial (87.4 vs. 94.3 P < 0.001) scores compared to males. Regression analysis performed for each component score showed that increases in all 3 component scores were significant in patients in the satisfied group. CONCLUSIONS: Our study demonstrates that cervical spine surgery patients unsatisfied with their surgical outcome have lower scar-related scores, highlighting the impact of cosmetic closure and appearance.

Risk of noise-induced hearing loss in the spine surgeon.

Background: Occupation-related noise-induced hearing loss (NIHL) has both negative economic and quality of life implications. The risk spine surgeons undertake in regards to NIHL during operative intervention is unknown. Governing bodies, including the National Institute for Occupational Safety and Health, have recommended exposure limits not to exceed 85 decibels (dB) over 8 hours. The purpose of this study is to characterize noise exposure to spine surgeons in the operating room (OR). Methods: Prospective collection of intraoperative recordings of spinal surgeries (cervical and thoracic/lumbar) was undertaken. Data gathered included procedure, operative duration, presence of background music, and noise information. Noise information included maximum decibel level (MDL), Peak level (LCPeak), Equivalent continuous sound pressure level, time weighted average (TWA), dose, and projected dose. Noise measurements were compared with baseline controls with and without music (empty ORs). Results: Two hundred seven noise recordings were analyzed. One hundred eighteen of those being spinal surgeries, 49 baseline recordings without music, and 40 with music. Maximum decibel level reached a maximum value of 111.5 dBA, with an average amongst surgical recordings of 103 dBA. Maximum decibel level exceeded 85 dBA in 100% of cases and was greater than 100 dBA in 78%. The maximum LCPeak recorded was 132.9 dBC with an average of 120 dBC. Furthermore, the average dose was 7.8% with an average projected dose of 26.5%. The highest dose occurred during a laminectomy at 72.9% of daily allowable noise. Maximum projected dose yielded 156% during a 3-level anterior cervical discectomy and fusion. Conclusions: Spine surgeons are routinely exposed to damaging noise levels (>85 dBA) during operative intervention. With spine surgeons often performing multiple surgeries a day, the cumulative risk of noise exposure cannot be ignored. The synergistic effects of continuous and impact noise places spine surgeons at risk for the development of occupation-related NIHL.

Evidence-Based Medicine and Observational Studies.

Evidence-based medicine drives medical decision-making in the modern era, which has historically favored randomized control trials. Despite their notoriety, randomized control trials have multiple disadvantages when applied to spinal surgery. Observational studies are popular in spinal surgery literature and are seen in various forms, such as retrospective studies and prospective cohort studies. For researchers, learners, and practicing spine surgeons, this paper describes options for study design when applied to spinal surgery.

Bone Strength Is Improved with Genistein Treatment in Mice with Diet-Induced Obesity.

BACKGROUND: High caloric intake of saturated fat and refined sugars accelerates the development of obesity and diabetes and increases bone fracture risk. Some evidence suggests that consumption of a diet rich in phytoestrogens like genistein has the potential to strengthen bone biomechanical properties. Its bone-strengthening properties may mitigate fracture risk associated with metabolic conditions like obesity and diabetes, especially when combined with exercise. OBJECTIVE: In this study, we test the effects of genistein, exercise training, and combination treatment on biomechanical properties of cortical bone in mice fed a high-fat, high-sugar (HFHS) diet. METHODS: Eighty C67BL6 mice (40 females, 40 males) aged 6 wk were treated for 12 wk with an HFHS diet containing 60% fat and drinking water with 4.2 g/L sugar (55% sucrose, 45% fructose). Subgroups of the mice were also treated with genistein and/or moderate exercise (treadmill running). Genistein was incorporated into the HFHS diet (600 mg genistein/kg HFHS) and exercise was performed daily for 30 min, 5 d/wk (n = 10 females, 10 males per group). Three-point bending mechanical testing and quantitative fluorescence microscopy were conducted on femurs to measure bone strength and matrix quality. RESULTS: Mechanical testing revealed HFHS-fed mice treated with genistein, either alone or combined with exercise, had femurs that exhibited increased postyield displacement and reduced stiffness during 3-point bending in comparison with mice only treated with the HFHS diet. Femurs of genistein-treated mice also exhibited greater ultimate force required to achieve fracture. Quantitative fluorescence showed genistein reduced advanced glycation end product accumulation in bone matrix. Exercise treatment alone had no effect. CONCLUSIONS: Treatment with genistein, either alone or in combination with exercise, improves fracture resistance in mice fed an HFHS diet by improving bone matrix quality and increasing bone strength.

High-fat, high-sugar diet induces splenomegaly that is ameliorated with exercise and genistein treatment.

OBJECTIVE: We tested the effect of exercise training and genistein treatment on splenomegaly in mice fed a high-fat, high-sugar diet (HFSD). RESULTS: Male and female C57BL6 mice fed HFSD containing 60% fat along with drinking water containing 42 g/L sugar (55% sucrose/45% fructose) for 12 weeks exhibited significant obesity, hyperglycemia, and elevated plasma IL-6 levels. This was accompanied by splenomegaly characterized by spleen weights 50% larger than mice fed standard chow (P < 0.05) with enlarged rad and white pulps. Mice fed HFSD and treated with a combination of exercise (30 min/day, 5 days/week) and genistein (600 mg genistein/kg diet) had reduced spleen weight (P < 0.05). The decrease in spleen weight was associated with a significant improvement in red-to-white pulp area ratio and plasma glucose and IL-6 (P < 0.05). Our findings indicate that reversal of splenomegaly by regular exercise and genistein treatment may be important in the clinical management of HFSD-induced obesity.