Coexisting Lower Back Pain in Patients With Cervical Myelopathy.

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

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

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

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

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

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

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

Tips and Complications of Two-step Open Procedure for Ethanol Sclerosis Therapy for a Venous Hemangioma of the Thoracic Spine: A Case Report.

Introduction: Venous hemangiomas of the thoracic spine are rare tumors that are diagnose based on radiological findings. Ethanol sclerosis therapy through the percutaneous or open approaches has been reported to be useful treatment options. Therefore, radiological examination and the treatment procedure can be performed together. As pathological diagnosis of the tumor is important, a strategy that comprises biopsy followed by definitive treatment is ideal. The tips and complications of the two-step open procedure for ethanol sclerosis therapy have not been discussed in detail. This is the first report of this kind in the literature, especially about the tips and complications. Case Report: A 51-year-old woman presented with pain in the upper part of her back. Radiological examination revealed a hypervascular tumor at the second thoracic vertebra. We first performed an open biopsy along with decompression and fixation surgery, because the patient developed a walking disability with motor weakness in her right leg. The tumor was pathologically diagnosed as a venous hemangioma. Therefore, we performed ethanol sclerosis therapy using the open approach as a curative technique for the tumor 17 days after the initial surgery. A total of 10 mL of a mixture of 100% ethanol and a lipid-soluble contrast medium - which improve visibility - was injected intermittently and slowly. This was followed by the injection of 3 mL of a water-soluble contrast medium to confirm sclerosis. Immediately after the last procedure, the amplitudes of motor-evoked potentials in all bilateral lower extremity muscles disappeared simultaneously. The patient incomplete paralysis of the lower extremity and transient dysuria postoperatively; however, she could walk without assistance after 5 months. Conclusion: This case highlights the following: First, the two-step procedure of open biopsy followed by ethanol injection using the open approach allowed accurate diagnosis and effective treatment. Second, additional injection of a water-soluble contrast medium to confirm sclerosis after ethanol injection can cause paralysis. Third, a mixture of ethanol and a lipid-soluble contrast medium effective improves visibility to identify expansions. These experiences will be useful for following ethanol sclerosis therapy for a venous hemangioma of the thoracic spine.

Ethanol Sclerosis Therapy for Aggressive Vertebral Hemangioma of the Spine: A Narrative Review.

Vertebral hemangiomas of the spine are rare benign tumors. They occur primarily in the thoracic region and are often asymptomatic and found incidentally on radiological examination; however, some are symptomatic, aggressive, and gradually increase in size. Various therapeutic approaches have been proposed for their management. This study aimed to review the therapeutic management, focusing on ethanol sclerosis therapy. The PubMed database was searched from inception to January 2023 using the keywords "hemangioma", "spine OR vertebra", and "ethanol". Twenty studies were retrieved, including two letters. The first report of spinal therapy was published in 1994. Ethanol sclerosis therapy is effective in treating vertebral hemangiomas. It is performed independently or in combination with other techniques, such as vertebroplasty using cement and surgery. The therapy is performed under local or general anesthesia with fluoroscopic or computed tomography guidance. A total of 10-15 mL of ethanol is slowly injected via unilateral or bilateral pedicles. Complications of the therapy include hypotension and arrhythmia during the procedure, paralysis immediately after the procedure, and delayed compression fractures. This review could enable the refinement of knowledge regarding ethanol sclerosis therapy, which is a treatment option that could be adopted.

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

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

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

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

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

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

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

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

Relationship Between Sacroiliac Joint-related Pain and Spinopelvic Mobility.

STUDY DESIGN: A case-control study. OBJECTIVE: To evaluate the relationship between sacroiliac joint-related pain (SIJ-RP) and spinopelvic mobility. SUMMARY OF BACKGROUND DATA: No specific radiological findings are available for the diagnosis of SIJ-RP. A previous study reported that a higher pelvic incidence and sacral slope (SS) values were significantly associated with sacroiliac joint pain. The concept of spinopelvic mobility, which is evaluated by the differences between SS in the standing and sitting positions, has been the focus of hip and spine surgeries in recent years. MATERIALS AND METHODS: The SIJ-RP group comprised patients diagnosed with SIJ-RP based on physical findings and their response to analgesic injections. No other lumbar or hip joint diseases were observed. The non-SIJ-RP group comprised patients with lower back pain for reasons other than SIJ-RP. Radiographs of the lateral view of the pelvis in the standing and sitting positions were evaluated for all patients. We compared and analyzed the backgrounds, SS in the two positions, and difference in SS between the two positions in both groups. RESULTS: In total, 245 patients were included in the study, with 49 and 196 patients in the SIJ-RP and non-SIJ-RP groups, respectively. More female patients experienced SIJ-RP than male patients ( P =0.0361). There were significant differences between the groups for SS in standing ( P =0.0076), sitting ( P =0.0005), and those with a difference between sitting and standing of <5° ( P =0.0278) in the univariate analyses. Logistic regression analyses, after adjustment for age and sex, revealed significant differences between the groups with an SS difference <5° ( P =0.0088; 95% confidence interval, 1.280-5.519), with an odds ratio of 2.7. CONCLUSION: On evaluating spinopelvic mobility, we found that SIJ-RP was related to hypomobility of the sacrum, which could indicate the hypermobility of the sacroiliac joint.

Effect of diabetes on patient-reported outcome measures at one year after laminoplasty for cervical spondylotic myelopathy.

Although patients with diabetes reportedly have more peripheral neuropathy, the impacts of diabetes on postoperative recovery in pain and patient-reported outcome measures (PROMs) after laminoplasty for cervical spondylotic myelopathy (CSM) is not well characterized. The authors aimed to elucidate the effects of diabetes on neck/arm/hand/leg/foot pain and PROMs after laminoplasty CSM. The authors retrospectively reviewed 339 patients (82 with diabetes and 257 without) who underwent laminoplasty between C3 and C7 in 11 hospitals during April 2017 -October 2019. Preoperative Numerical Rating Scale (NRS) scores in all five areas, the Short Form-12 Mental Component Summary, Euro quality of life 5-dimension, Neck Disability Index, and the Core Outcome Measures Index-Neck) were comparable between the groups. The between-group differences were also not significant in NRS scores and PROMs one year after surgery. The change score of NRS hand pain was larger in the diabetic group than the nondiabetic group. The diabetic group showed worse preoperative score but greater improvement in the Short Form-12 Physical Component Summary than the nondiabetic group, following comparable score one year after surgery. These data indicated that the preoperative presence of diabetes, at least, did not adversely affect pain or PROMs one year after laminoplasty for CSM.

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

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

Effect of Antimicrobial Prophylaxis Duration on Health Care-Associated Infections After Clean Orthopedic Surgery: A Cluster Randomized Trial.

Importance: Postoperative health care-associated infections are associated with a greater deterioration in patients' general health status and social and economic burden, with at least 1 occurring in approximately 4% of acute care hospital patients. Antimicrobial prophylaxis prevents surgical site infections in various orthopedic procedures; however, its relationship with health care-associated infections remains unknown. Objective: To examine whether a shorter antimicrobial prophylaxis duration of less than 24 hours after surgery is not inferior to a longer duration in preventing health care-associated infections after clean orthopedic surgery. Design, Setting, and Participants: This open-label, multicenter, cluster randomized, noninferiority clinical trial was conducted in 5 tertiary referral hospitals in greater Tokyo metropolitan area, Japan, from May to December 2018. Adult patients undergoing clean orthopedic surgery were recruited until the planned number of participants was achieved (500 participants per group). Statistical analysis was conducted from July to December 2019. Interventions: Antimicrobial prophylaxis was discontinued within 24 hours after surgery in group 24 and 24 to 48 hours after surgery in group 48. Group allocation was switched every 2 or 4 months according to the facility-based cluster rule. Study-group assignments were masked from participants. Main Outcomes and Measures: The primary outcome was the incidence of health care-associated infections requiring antibiotic therapies within 30 days after surgery. The noninferiority margin was 4%. Results: Of the 1211 participants who underwent cluster allocation, 633 participants were in group 24 (median [IQR] age, 73 [61-80] years; 250 men [39.5%] and 383 women [60.5%]), 578 participants were in group 48 (median [IQR] age, 74 [62-81] years; 204 men [35.3%] and 374 women [64.7%]), and all were eligible for the intention-to-treat analyses. Health care-associated infections occurred in 29 patients (4.6%) in group 24 and 38 patients (6.6%) in group 48. Intention-to-treat analyses showed a risk difference of -1.99 percentage points (95% CI, -5.05 to 1.06 percentage points; P < .001 for noninferiority) between groups, indicating noninferiority. Results of adjusted intention-to-treat, per-protocol, and per designated procedure population analyses supported this result, without a risk of antibiotic resistance and prolonged hospitalization. Conclusions and Relevance: This cluster randomized trial found noninferiority of a shorter antimicrobial prophylaxis duration in preventing health care-associated infections without an increase in antibiotic resistance risk. These findings lend support to the global movement against antimicrobial resistance and provide additional information on adequate antimicrobial prophylaxis for clean orthopedic surgery. Trial Registration: Identifier: UMIN000030929.

Treatment of restenosis after lumbar decompression surgery: decompression versus decompression and fusion.

OBJECTIVE: The aim of this study was to compare perioperative complications and postoperative outcomes between patients with lumbar recurrent stenosis without lumbar instability and radiculopathy who underwent decompression surgery and those who underwent decompression with fusion surgery. METHODS: For this retrospective study, the authors identified 2606 consecutive patients who underwent posterior surgery for lumbar spinal canal stenosis at eight affiliated hospitals between April 2017 and June 2019. Among these patients, those with a history of prior decompression surgery and central canal restenosis with cauda equina syndrome were included in the study. Those patients with instability or radiculopathy were excluded. The patients were divided between the decompression group and decompression with fusion group. The demographic characteristics, numerical rating scale score for low-back pain, incidence rates of lower-extremity pain and lower-extremity numbness, Oswestry Disability Index score, 3-level EQ-5D score, and patient satisfaction rate were compared between the two groups using the Fisher's exact probability test for nominal variables and the Student t-test for continuous variables, with p < 0.05 as the level of statistical significance. RESULTS: Forty-six patients met the inclusion criteria (35 males and 11 females; 19 patients underwent decompression and 27 decompression and fusion; mean ± SD age 72.5 ± 8.8 years; mean ± SD follow-up 18.8 ± 6.0 months). Demographic data and perioperative complication rates were similar. The percentages of patients who achieved the minimal clinically important differences for patient-reported outcomes or satisfaction rate at 1 year were similar. CONCLUSIONS: Among patients with central canal stenosis who underwent revision, the short-term outcomes of the patients who underwent decompression were comparable to those of the patients who underwent decompression and fusion. Decompression surgery may be effective for patients without instability or radiculopathy.

Minimal clinically important difference in patients who underwent decompression alone for lumbar degenerative disease.

BACKGROUND CONTEXT: The minimal clinically important difference (MCID) represents the smallest change in an outcome measure recognized as clinically meaningful to a patient after receiving a clinical intervention. Most studies that discussed the MCIDs for lumbar spinal stenosis (LSS) included mixed pathologies or procedures despite that the MCID value should be different depending on the intervention. Moreover, despite the efficacy of adopting percentage-change improvement for the MCID threshold, there are limited reports and discussions in the field of lumbar surgery. PURPOSE: The aim of the present study was to elucidate the MCIDs for the Oswestry Disability Index (ODI), EuroQOL 5-dimension 3-level (EQ-5D-3L), physical component summary (PCS) of the Short Form of the Medical Outcomes Study, and Numeric Rating Scale (NRS) in patients with degenerative LSS treated with decompression surgery without fusion. STUDY DESIGN/SETTING: A multicenter retrospective cohort study was performed. PATIENT SAMPLE: A total of 422 patients who underwent decompression surgery for LSS and answered a complete set of questionnaires were included in the study. Patients who underwent endoscopic or revision surgery were excluded. OUTCOME MEASURES: Preoperative and 1-year postoperative scores of each health-related quality of life questionnaires (HRQOLs) and patient satisfaction questionnaire response METHODS: The patient satisfaction question was used as an anchor, and the cutoff values were estimated based on absolute point improvement from baseline using a receiver-operating characteristic (ROC) curve analysis and the "mean change" method for MCIDs. The MCID values for percentage-change in HRQOLs were also calculated using ROC curve analysis. The three cutoff values for each HRQOL were validated using the Youden index for determining the most robust MCIDs. RESULTS: Of the patients, 356 (84.4%) were at least "somewhat satisfied" with the treatment results. The two cutoff values of absolute point-change in each HRQOL, which were estimated by two different anchor-based methods, were similar. The area under the curve of the ROC curve for percentage-change tended to be higher than that for absolute point-change. Moreover, the Youden index of the percentage-change in each HRQOL was higher than that of the absolute point-change calculated by either the "mean change" method or the ROC curve analysis. Based on these results, it was proposed that MCID was 42.4% for percentage-change in ODI, 22.0% for EQ-5D-3L, 13.7% for PCS, 25.0% for NRS (low back pain), 55.6% for NRS (leg pain), 22.2% for NRS (leg numbness). CONCLUSIONS: The MCIDs of HRQOLs were calculated in patients with LSS treated with decompression surgery without concomitant fusion procedure. The MCID cutoffs based on percentage-change from baseline were more effective than those of absolute point-change.

Influence of Perioperative Antithrombic Agent Discontinuation in Elective Posterior Spinal Surgery: A Propensity-Score-Matched Analysis.

OBJECTIVE: To investigate the influence of perioperative antithrombotic agent (antiplatelet agents and anticoagulants) discontinuation in elective posterior spinal surgery in terms of bleeding complications, such as epidural hematoma and postoperative thromboembolism. METHODS: We enrolled patients undergoing elective posterior spinal surgery at 9 hospitals between April 2017 and August 2020. We collected data regarding patient baseline characteristics, surgical details, intraoperative estimated blood loss, and postoperative complication rates, including epidural hematoma and thromboembolism. We divided the patients into a discontinuation group, in which antithrombic agents were discontinued perioperatively, and a control group without antithrombic agents. Propensity scores for taking any antithrombic agents were calculated, with 1-to-1 matching based on the estimated propensity scores to adjust for patient baseline characteristics and surgical details. Intraoperative estimated blood loss and 30-day postoperative complication rates were compared between the groups. RESULTS: We enrolled 9853 patients, including 1123 patients (11.4%) who discontinued antithrombic agents perioperatively. One-to-one propensity score matching yielded 1111 pairs with and without antithrombic agents. Intraoperative estimated blood loss per 10 minutes (8.2 mL vs. 8.9 mL) and the incidence of epidural hematoma requiring revision (0.97% vs. 0.72%) were similar between the groups. Although postoperative cardiac events and stroke were observed only in the discontinuation group (0.27% and 0.09%, respectively), these incidences were not significantly different between the groups. CONCLUSIONS: Perioperative antithrombic agent discontinuation in elective posterior spinal surgery normalized the intraoperative bleeding tendency and the incidence of postoperative epidural hematoma and did not influence in a significative way the incidence of postoperative thromboembolism.

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

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

Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis: A Randomized Clinical Trial.

Importance: The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. Objective: To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. Design, Setting, and Participants: This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. Interventions: Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. Main Outcomes and Measures: The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. Results: Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, -4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients). Conclusions and Relevance: These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation. Trial Registration: ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780.

Relative Risks and Benefits of Crossing the Cervicothoracic Junction During Multilevel Posterior Cervical Fusion: A Multicenter Cohort.

OBJECTIVE: To compare the clinical and radiographic outcomes and complications in patients undergoing multilevel posterior cervical fusion surgery, ending at C7 or crossing the cervicothoracic junction (CTJ). METHODS: A total of 96 patients undergoing multilevel posterior cervical fusion surgery ending at C7, T1, or T2 were screened. The patients who fulfilled the inclusion criteria were divided into 2 groups based on the lower instrumented vertebra (LIV) level: group C7 (ending at C7) and group T1-T2 (crossing the CTJ). The radiographic and clinical outcomes were compared between the 2 groups, and the risk factors for instrument failure at LIV were investigated. RESULTS: In total, 73 patients (76%) completed at least 1 year follow-up and divided into group C7 (n = 43) and group T1-T2 (n = 30). Preoperative and postoperative radiographic parameters, the Japanese Orthopaedic Association score, and patient-reported outcomes were not significantly different between the 2 groups. Significantly longer surgical time, increased blood loss, and higher incidence rates of perioperative or postoperative complications were noted in group T1-T2. On the other hand, the incidence of instrument failures at LIV was significantly higher in group C7. Multivariate analysis showed that ending at C7, skipping screw insertion at the proximal vertebra adjacent to LIV, and a large postoperative cervical sagittal vertical axis (>40 mm) were risk factors for instrument failure at LIV. CONCLUSIONS: Crossing the CTJ during multilevel posterior cervical fusion surgery reduced instrument failures at LIV, but increased the surgical invasiveness and perioperative and postoperative complications.