Noninvasive electrical stimulation as an adjunct to fusion procedures: a systematic review and meta-analysis.

OBJECTIVE: Noninvasive electrical stimulation represents a distinct group of devices used to augment fusion rates. However, data regarding outcomes of noninvasive electrical stimulation have come from a small number of studies. The goal of this systematic review and meta-analysis was to determine outcomes of noninvasive electrical stimulation used as an adjunct to fusion procedures to improve rates of successful fusion. METHODS: PubMed, Embase, and the Cochrane Clinical Trials database were searched according to search strategy and PRISMA guidelines. Random-effects meta-analyses of fusion rates with the three main modalities of noninvasive electrical stimulation, capacitively coupled stimulation (CCS), pulsed electromagnetic fields (PEMFs), and combined magnetic fields (CMFs), were conducted using R version 4.1.0 (The R Foundation for Statistical Computing). Both retrospective studies and clinical trials were included. Animal studies were excluded. Risk-of-bias analysis was performed with the Risk of Bias 2 (RoB 2) and Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tools. RESULTS: Searches of PubMed, Embase, and the Cochrane Clinical Trials database identified 8 articles with 1216 participants meeting criteria from 213 initial results. There was a high overall risk of bias identified for the majority of randomized studies. No meta-analysis could be performed for CCS as only 1 study was identified. Meta-analysis of 6 studies of fusion rates in PEMF did not find any difference between treatment and control groups (OR 1.89, 95% CI 0.36-9.80, p = 0.449). Meta-analysis of 2 studies of CMF found no difference in fusion rates between control and treatment groups (OR 0.90, 95% CI 0.07-11.93, p = 0.939). Subgroup analysis of PEMF was limited given the small number of studies and patients, although significantly increased fusion rates were seen in some subgroups. CONCLUSIONS: This meta-analysis of clinical outcomes and fusion rates in noninvasive electrical stimulation compared to no stimulation did not identify any increases in fusion rates for any modality. A high degree of heterogeneity between studies was noted. Although subgroup analysis identified significant differences in fusion rates in certain groups, these findings were based on a small number of studies and further research is needed. This analysis does not support routine use of these devices to augment fusion rates, although the data are limited by a high risk of bias and a small number of available studies.

Super-Pedicle Osteotomy for Correction of Focal Thoracolumbar Kyphosis.

BACKGROUND: Focal thoracolumbar kyphotic deformities require operative correction through osteotomies to restore normal spinal balance. Traditional osteotomies, such as the pedicle subtraction osteotomy, that are often used in the lumbar spine are less useful in the thoracolumbar region. The super-pedicle osteotomy is a pedicle-sparing wedge osteotomy that can be used for correction of kyphosis in patients with thoracolumbar deformities. METHODS: A retrospective review was conducted of 9 consecutive cases using the super-pedicle technique. Clinical data regarding patient age at presentation, etiology of deformity, symptoms, neurological status at presentation, American Society of Anesthesiologists class, type of surgery performed, estimated blood loss during surgery, and complications up to last follow-up were recorded. The primary parameter of interest was the angle at the planned osteotomy site before and after correction. RESULTS: Nine patients with an average age of 64 years were included. All 9 patients had focal thoracic kyphosis either at T11-T12 or T12-L1. All patients underwent thoracolumbar operations with super-pedicle osteotomies at their main level of kyphosis. Estimated blood loss was 600 mL. Average correction at the osteotomy site as measured on preoperative and postoperative radiographs was 31°. At an average follow-up of 338 days, no patients experienced rod fracture, but 1 patient required extension of fusion for proximal junctional kyphosis. CONCLUSIONS: In this small series of patients with thoracolumbar kyphosis, the super-pedicle osteotomy technique was clinically useful. More robust examination is required to determine the safety, utility, and durability of this osteotomy technique.

Early Postoperative Complications for Elderly Patients Undergoing Single-Level Decompression for Lumbar Disc Herniation, Ligamentous Hypertrophy, or Neuroforaminal Stenosis.

BACKGROUND: Lumbar decompression for disc herniation is frequently performed on elderly patients, and this trend will continue as the population ages. Clinical reports on the complications of lumbar discectomy show good results and cost effectiveness in young or middle-aged patients. OBJECTIVE: To assess and compare the morbidity of single-level lumbar disc surgery for radicular pain in a cohort of patients greater than 80 yr of age to that of a middle-aged cohort. METHODS: A total of 9451 patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy were retrospectively selected from a multicenter validated surgical database from the American College of Surgeons National Surgical Quality Improvement Program. A cohort with 485 patients greater than 80 yr of age (80+) was compared with a middle-aged cohort with 8966 patients between 45 and 65 yr. Preoperative comorbidity and postoperative outcome variables observed included mortality, myocardial infarction, return to the operating room, sepsis, deep vein thrombosis, transfusions, cardiac arrest necessitating cardiopulmonary resuscitation, coma greater than 24 h, urinary tract infection, acute renal failure, use of ventilator greater than 24 h, pulmonary embolism, pneumonia, wound dehiscence, and postoperative infection. RESULTS: The preoperative comorbidities and characteristics were significantly different between the middle-aged and the 80+ cohorts, with the older cohort having many more preoperative comorbidities. There was statistically significantly greater postoperative morbidity among the 80+ cohort regarding pulmonary embolism (0.8% vs 0.2%, P = .037), intra/postoperative transfusion requirement (1.9% vs 0.7%, P = .01), urinary tract infection (1.2% vs 0.3%, P = .011), and 30-d mortality (0.4% vs 0.1%, P = .046). CONCLUSION: In this large sample of patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy, elderly patients, particularly with American Society of Anesthesiologists class 3 and 4, had a statistically significant increase in morbidity and mortality, but the overall risk of complications remains low.

Postoperative Complications for Elderly Patients After Single-Level Lumbar Fusions for Spondylolisthesis.

OBJECTIVE: A large-scale study on postoperative complications of lumbar fusion surgery for spondylolisthesis comparing patients >80 years old with younger patients has not been performed. The purpose of this study is to assess the effects of extreme age (>80 years old) on early postoperative outcomes after single-level lumbar fusions for spondylolisthesis. METHODS: From a validated multicenter surgical database, 2475 patients who underwent a single-level lumbar fusion procedure for spondylolisthesis were selected retrospectively. An extreme age cohort with 227 patients >80 years old was compared with a typical age cohort with 2248 patients 45-65 years old. RESULTS: The preoperative characteristics and comorbidities were different between the typical age cohort and the extreme age cohort, with older patients having more preoperative comorbidities, including a lack of independent functional health status before surgery (P < 0.001), severe chronic obstructive pulmonary disease (P <0.020), and hypertension requiring medication (P < 0.001). There was significantly greater morbidity among the >80 cohort regarding urinary tract infection (P = 0.008; odds ratio = 3.30; 95% confidence interval, 1.47-7.40) and intraoperative and postoperative transfusions (P < 0.001; odds ratio = 2.186; 95% confidence interval, 1.54-3.11). There was significantly greater morbidity among the younger cohort regarding cardiac arrest requiring cardiopulmonary resuscitation (P = 0.043; odds ratio = 0.099; 95% confidence interval, 0.014-0.704). CONCLUSIONS: This is the first large study comparing the rates of postoperative complications of lumbar fusion surgery for spondylolisthesis in patients >80 years old versus younger patients. The data support that age alone should not exclude a patient for this procedure. However, extra caution is warranted given the slightly increased morbidity.

Preoperative Predictors of Spinal Infection within the National Surgical Quality Inpatient Database.

BACKGROUND: Surgical-site infections (SSIs) are a major cause of morbidity and mortality, increasing the length and cost of hospitalization. In patients undergoing spine surgery, there are limited large-scale data on patient-specific risk factors for SSIs. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all spinal operations between 2006 and 2012. The rates of 30-day SSIs were calculated, and univariate analysis of selected preoperative risk factors was performed. Multivariate analysis was then used to identify independent predictors of SSIs. RESULTS: A total of 1110 of the 60,179 patients (1.84%) had a postoperative wound infection. There were 527 (0.87%) deep and 590 (0.98%) superficial infections. Patients with infections had greater rates of sepsis, longer lengths of stay, and more return visits to the operating room. Independent predictors of infection were female sex, inpatient status, insulin-dependent diabetes, preoperative steroid use greater than 10 days, hematocrit less than 35, body mass index greater than 30, wound class, American Society of Anesthesiologists class, and operative duration. CONCLUSIONS: Analysis of a large national patient database revealed many independent risk factors for SSIs after spinal surgery. Some of these risk factors can be modified preoperatively to reduce the risk of postoperative infection.

Placement of unilateral lag screw through the lateral mass of C-1: description of a novel technique.

Over the past several decades, many advancements and new techniques have emerged regarding the instrumentation and stabilization of the upper cervical spine. In this article, the authors describe a novel technique in which a unilateral lag screw was placed to reduce and stabilize a progressively widening fracture and nonunion of the right C-1 lateral mass approximately 8 weeks after the initial injury, which was sustained when a large tree branch fell onto the patient's posterior head and neck.

Minimally invasive anterior vertebroplasty for C-2 metastatic lesions.

The authors describe a technique for minimally invasive anterior vertebroplasty for treating metastatic disease of the C-2 vertebra and discuss its application in 2 cases. After a 2-cm lateral neck incision is made, blunt dissection is performed toward the anterior inferior endplate of the C-2 vertebra. An 11-gauge needle is introduced through a tubular sheath and tapped into the inferior endplate of C-2, with biplanar fluoroscopy being performed to confirm position. The needle is subsequently advanced across the fracture line and into the odontoid process. Under fluoroscopic guidance, 2 ml of methylmethacrylate is injected into the odontoid process and vertebral body. This method is advantageous as 1) hyperextension of the neck is not performed, 2) the chance of inadvertent neurovascular or submandibular gland injury is minimized, 3) the possibility of cement leakage is decreased, and 4) hemostasis is better achieved under direct vision.