Natural History of Degenerative Spondylolisthesis: A Systematic Review and Meta-analysis.

OBJECTIVE: The optimal treatment algorithm for patients with degenerative lumbar spondylolisthesis has not been clarified. Part of the reason for this is that the natural history of degenerative spondylolisthesis (DS) has not been sufficiently studied. Comprehension of the natural history is essential for surgical decision making. We aimed to determine 1) the proportion of patients that develop de novo DS during follow-up; and 2) the proportion of patients with progression of preexistent DS by conducting a systematic review and meta-analysis of the literature. METHODS: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Ovid, EMBASE, and the Cochrane Library were searched from their inception through April 2022. Demographic values of the study populations, grade of slip, rate of slippage before and after the follow-up period, and percentage of patients with slip in the populations at baseline and after follow-up were the extracted parameters. RESULTS: Of the 1909 screened records, eventually 10 studies were included. Of these studies, 5 reported the development of de novo DS and 9 reported on the progression of preexistent DS. Proportions of patients developing de novo DS ranged from 12% to 20% over a period ranging from 4 to 25 years. The proportion of patients with progression of DS ranged from 12% to 34% over a period ranging from 4 to 25 years. CONCLUSIONS: Systematic review and metanalysis of DS on the basis of radiologic parameters revealed both an increasing incidence over time and an increasing progression of the slip rate in up to a third of the patients older than 25 years, which is important for counseling patients and surgical decision making. Importantly, two thirds of patients did not experience slip progression.

Intestinal Bacteremia After Liver Transplantation Is a Risk Factor for Recurrence of Primary Sclerosing Cholangitis.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic progressive pathological process, related to inflammatory bowel disease and subsequent bacterial translocation. Liver transplantation (LT) is the only curative therapy, but outcomes are compromised by recurrence of PSC (rPSC). The aim of the study was to investigate a potential link between intestinal bacteremia, fucosyltransferase-2 (FUT2), and rPSC after LT. METHODS: LT recipients with PSC (n = 81) or without PSC (n = 271) were analyzed for clinical outcomes and positive bacterial blood cultures. A link between bacteremia and the genetic variant of the FUT2 gene was investigated. RESULTS: The incidence of inflammatory bowel disease was significantly higher in PSC recipients but not associated with rPSC. Bacteremia occurred in 31% of PSC recipients. The incidence of rPSC was 37% and was significantly more common in patients with intestinal bacteremia versus no bacteremia (82% versus 30%; P = 0.003). The nonsecretor polymorphism of the FUT2 gene was identified as a genetic risk factor for both intestinal bacteremia and rPSC. Combined FUT2 genotype and intestinal bacteremia in recipients resulted in the highest risk for rPSC (hazard ratio, 15.3; P < 0.001). CONCLUSIONS: Thus, in this article, we showed that bacterial translocation is associated with rPSC after LT and related to the FUT2 nonsecretor status.

Spontaneous externalization of a ventriculoperitoneal shunt tip through the navel.

The authors describe spontaneous externalization of a ventriculo-peritoneal shunt through the navel.

Excessive Fluid in the Lumbar Facet Joint as a Predictor of Radiological Outcomes After Lateral Lumbar Interbody Fusion.

Background Preoperative segmental instability maybe a predictor of postoperative outcomes when treated with lateral lumbar interbody fusion (LLIF). An abnormal collection of fluid within the facet joint has been described as a sign of segmental instability. The potential relationship between this radiological sign and its prognostic relevance for indirect decompression (ID) has not been investigated. Methods Clinical and radiologic results from patients undergoing LLIF in a single institution between 2007 and 2014 were evaluated retrospectively. Patients were divided into two groups: those presenting with excessive fluid (EF) in the facet joints on T2-MRI and those with a normal amount of facet fluid with less than 1mm, which were controls. Radiological parameters were foraminal height, disc height, Cobb angle, and lumbar lordosis. Results A total of 21 patients (43 operated levels) were evaluated pre- and postoperatively. Mean disc height, mean foraminal height, and coronal Cobb angles were statistically significantly improved after LLIF. Only the EF group showed significant improvement in radiological markers after ID; the mean disc height improved from 5.5±2 to 8.8±1mm (p=0.001), mean foraminal height improved from 16.88±3 to 20.53±3mm (p=0.002), and the mean Cobb angle improved from 27.7±16 to 14±13 (p=0.018). Conclusions Patients undergoing LLIF with the radiological findings of EF in the facet joints demonstrated significant improvement in radiological outcomes of ID. Further studies should validate these findings in larger data sets.

Surgeons Learning Curve of Transforaminal Endoscopic Discectomy for Sciatica.

OBJECTIVE: Full-endoscopic spine surgery is gaining interest as a less-invasive alternative to treat sciatica caused by a lumbar disc herniation. Concerns, however, exist with the learning curve as percutaneous transforaminal endoscopic discectomy (PTED) appears to be more difficult to be performed compared to other techniques. In this study, the clinical outcomes during and after the learning curve are presented of 3 surgeons naïve to PTED. METHODS: In the first phase of a randomized controlled, noninferiority trial comparing PTED with microdiscectomy, 3 surgeons were trained in the PTED-procedure by a senior surgeon. After performing up to 20 cases under supervision, they started performing PTED on their own. Results of the early cases were compared to the later cases (>20). Furthermore, complications and reoperations were compared. Finally, differences in clinical outcomes between surgeons were compared. RESULTS: At 12 months of follow-up, 87% of the patients had follow-up data available. In general, there were no significant differences in patient-reported outcomes between the early and later PTED cases. Furthermore, outcomes of the early PTED cases were comparable to the outcomes of microdiscectomy, while the later PTED cases had small, but more favorable outcomes compared to microdiscectomy. Two learning curve surgeons had substantially higher rates of reoperations within 1 year, compared to the senior surgeon or the microdiscectomy group. Duration of surgery was also longer for all learning curve surgeons. Finally, when comparing clinical outcomes of patients undergoing PTED versus microdiscectomy, there appears to be some statistically significant differences in outcomes compared between the senior and 3 learning curve surgeons. CONCLUSION: PTED appears to be safe to be adopted by surgeons naïve to the procedure when they are initially supervised by an experienced senior surgeon. Duration of surgery and risk of repeated surgery are increased during the learning curve, but patient-reported outcomes of the early PTED cases are similar to the outcomes of later PTED cases, and similar to the outcomes of microdiscectomy cases. This study underlines the need for an experienced mentor for surgeons to safely adopt PTED.

Ten-Step 3-Dimensional-Navigated Single-Stage Lateral Surgery With Microtubular Decompression: A Case Series.

BACKGROUND: Single-stage lateral lumbar interbody fusion is a safe and effective procedure that relies on indirect decompression and fusion to treat various lumbar pathologies. This technique, however, has an overall 9% rate of indirect decompression failure, which may require additional surgery to achieve adequate direct decompression. To address this concern, we modified this technique by adding a minimally invasive, direct tubular decompression in lateral position when indicated. No study has described the technical nuances of incorporating a microtubular decompression into the single-stage lateral lumbar interbody fusion workflow (SSLLIF+). OBJECTIVE: To report on the procedural steps and clinical outcomes of the SSLLIF+. METHODS: In this retrospective case series of prospectively collected data, we present the detailed surgical approach of the SSLLIF+ with a single-center case series over a 5-year period. Surgical and clinical outcomes are presented. RESULTS: A total of 7 patients underwent a SSLLIF+ with a total of 18 levels fused and 7 levels decompressed. The SSLLIF+ was successfully performed in all cases without the occurrence of intraoperative complications in this case series. There was 1 revision after 20 months of follow-up because of adjacent segment disease. There was no need for further direct decompression in a delayed fashion. CONCLUSION: SSLLIF with direct microtubular decompression in lateral position is a safe and effective procedure in patients where indirect decompression alone may not achieve the surgical goal. Adherence to minimally invasive spine surgery principles and thoughtful patient selection facilitate the successful management of these patients while demonstrating short hospital stay and low-risk of perioperative complications.

Titanium versus polyetheretherketone versus structural allograft in anterior cervical discectomy and fusion: A systematic review.

Introduction: Anterior cervical discectomy and fusion (ACDF) is a common procedure to address cervical spine pathology. The most common grafts used are titanium, polyetheretherketone (PEEK), or structural allograft. Comparison of fusion rate is difficult due to non-standardized methods of assessment. We stratified studies by method of fusion assessment and performed a systematic review of fusion rates for titanium, PEEK, and allograft. Research question: Which of the common implants used in ACDF has the highest reported rate of fusion? Materials and methods: An experienced librarian performed a five-database systematic search for published articles between 01/01/1990 and 08/07/2021. Studies performed in adults with at least 1 year of radiographic follow up were included. The primary outcome was the rate of fusion. Fusion criteria were stratified into 6 classes based upon best practices. Results: 34 studies met inclusion criteria. 10 studies involving 924 patients with 1094 cervical levels, used tier 1 fusion criteria and 6 studies (309 patients and 367 levels) used tier 2 fusion criteria. Forty seven percent of the studies used class 3-6 fusion criteria and were not included in the analysis. Fusion rates did differ between titanium (avg. 87.3%, range 84%-100%), PEEK (avg. 92.8%, range 62%-100%), and structural allograft (avg. 94.67%, range 82%-100%). Discussion and conclusion: After stratifying studies by fusion criteria, significant heterogeneity in study design and fusion assessment prohibited the performance of a meta-analysis. Fusion rate did not differ by graft type. Important surgical goals aside from fusion rate, such as degree of deformity correction, could not be assessed. Future studies with standardized high-quality methods of assessing fusion, are required.

Lumbar Giant Disk Herniations Treated With a Unilateral Approach for Bilateral Decompression.

BACKGROUND: Disk herniations that obstruct the spinal canal by more than 50% are named "giant disk herniations" (GDHs). GDHs are challenging to treat from a surgical perspective because of their size and the risk of iatrogenic manipulation during resection resulting in additional neurological compromise. As a result, the appropriateness of minimally invasive tubular approaches for the treatment of lumbar GDHs remains controversial. OBJECTIVE: To report our experience in treating lumbar GDHs using tubular minimally invasive surgery. METHODS: A total number of 228 disk herniations were evaluated for the criteria of GDH. In addition, the presence of neurological deficits such as cauda equina syndrome, pain as measured by a visual analog scale, operating time, complications, estimated intraoperative blood loss, and number of surgical revisions were assessed. The standard tubular diskectomy technique was modified to include unilateral laminectomy for bilateral decompression before the diskectomy to create a sufficient working space for removal of the disk fragments. RESULTS: Twenty-three (10%) patients met the criteria for GDH. Clinically significant motor weakness was present in 21 patients (91.3%) before surgery, and 3 patients (13%) presented with cauda equina syndrome. The average mean visual analog scale (±SD) for the preoperative pain score was 8.3 and decreased to 2.4 at follow-up after surgery. All cases of cauda equina syndrome resolved postoperatively. CONCLUSION: Unilateral tubular minimally invasive surgery diskectomy seems to be a safe and effective treatment alternative for lumbar GDHs, combined with the "over-the-top" decompression, which provides bilateral decompression and working space.