Frailty is not an independent risk factor for worse clinical outcomes in lumbar spinal surgery: a prospective cohort study.

PURPOSE: Recently, many studies revealed that frailty affects unfavorably on postoperative outcomes in lumbar spinal diseases. This study aimed to investigate the relationship between frailty and clinical outcomes while identifying risk factors associated with worse clinical outcomes following lumbar spinal surgery. METHODS: From March 2019 to February 2021, we prospectively enrolled eligible patients with degenerative lumbar spinal diseases requiring surgery. Frailty was assessed preoperatively. To identify the impact of frailty on lumbar spinal diseases, clinical outcomes, which were measured with patient-reported outcomes (PROs) and postoperative complications, were compared according to the frailty. PROs were assessed preoperatively and one year postoperatively. In addition, risk factors for preoperative and postoperative worse clinical outcomes were investigated. RESULTS: PROs were constantly lower in the frail group than in the non-frail group before and after surgery, and the change of PROs between before and after surgery and postoperative complications were not different between the groups. In addition, frailty was a persistent risk factor for postoperative worse clinical outcome before and after surgery in lumbar spinal surgery. CONCLUSION: Frailty persistently affects the clinical outcome negatively before and after surgery in lumbar spinal surgery. However, as the change of the clinical outcome is not different between the frail group and the non-frail group, it is difficult to interpret whether the frail patients are vulnerable to the surgery. In conclusion, frailty is not an independent risk factor for worse clinical outcome in lumbar spinal surgery.

Quantitative Analysis of the Effect of Stereotactic Radiosurgery for Postoperative Residual Cervical Dumbbell Tumors: A Multicenter Retrospective Cohort Study.

OBJECTIVE: Stereotactic radiosurgery (SRS) has been performed for spinal tumors. However, the quantitative effect of SRS on postoperative residual cervical dumbbell tumors remains unknown. This study aimed to quantitatively evaluate the efficacy of SRS for treating postoperative residual cervical dumbbell tumors. METHODS: We retrospectively reviewed cases of postoperative residual cervical dumbbell tumors from 1995 to 2020 in 2 tertiary institutions. Residual tumors underwent SRS (SRS group) or were observed with clinical and magnetic resonance imaging (MRI) follow-up (observation group). Tumor regrowth rates were compared between the SRS and observation groups. Additionally, risk factors for tumor regrowth were analyzed. RESULTS: A total of 28 cervical dumbbell tumors were incompletely resected. Eight patients were in the SRS group, and 20 in the observation group. The mean regrowth rate was not significantly lower (p = 0.784) in the SRS group (0.18 ± 0.29 mm/mo) than in the observation group (0.33 ± 0.40 mm/mo). In the multivariable Cox regression analysis, SRS was not a significant variable (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.18-1.79; p = 0.336). CONCLUSION: SRS did not significantly decrease the tumor regrowth rate in our study. We believe that achieving maximal resection during the initial operation is more important than postoperative adjuvant SRS.

Discharge Transition Experience for Lumbar Fusion Patients: A Qualitative Study.

ABSTRACT: BACKGROUND: Support should be provided to individuals who are ready to be discharged; however, quantitative research is lacking in understanding the challenges of postsurgery lumbar fusion patients' discharge and transition. This article delves into the in-depth experience of lumbar fusion patients with discharge transitions. METHODS: We conducted semistructured individual interviews with 11 patients who had lumbar fusion surgery at one of Korea's most equipped general hospitals. These interviews focused on the patients' discharge transition experiences. The data were analyzed using phenomenological analysis. RESULTS: Lumbar fusion patients' experiences of discharge transition fit into 4 categories: anticipation of surgical transition, the process of transition to discharge, the difficult process of recovery, and recovery strategy. CONCLUSION: To further expedite the discharge process and make better use of cooperative hospital resources, conducting preoperative treatment planning, identifying family and social support systems, and sharing treatment procedures are all required. Furthermore, thorough health information services and step-by-step courses on predicted problems and everyday living after surgery should be considered for postoperative education. It is critical to broadening the scope of preoperative and postoperative education programs, as well as assistance for the social support system, such as the family-based support system and cooperative hospitals.

Effect of CCL11 on In Vitro Myogenesis and Its Clinical Relevance for Sarcopenia in Older Adults.

BACKGROUND: The C-C motif chemokine ligand 11 (CCL11) has been receiving attention as a potential pro-aging factor. Accordingly, it may be involved in muscle metabolism and sarcopenia, a key component of aging phenotypes. To clarify this potential, we investigated the effects of CCL11 on in vitro muscle biology and its clinical relevance for sarcopenia parameters in older adults. METHODS: Myogenesis was induced in mouse C2C12 myoblasts with 2% horse serum. Human blood samples were collected from 79 participants who underwent a functional assessment. Thereafter, CCL11 level was measured using a quantikine ELISA kit. Sarcopenia was defined using the Asian-specific guideline. RESULTS: Recombinant CCL11 treatment significantly stimulated myogenesis in a dose-dependent manner, and consistently increased the expression of myogenic differentiation markers. Among the C-C chemokine receptors (CCRs), CCR5, not CCR2 and CCR3, was predominantly expressed in muscle cells. Further, the CCR5 inhibitor blocked recombinant CCL11-stimulated myogenesis. In a clinical study, serum CCL11 level was not significantly different according to the status of sarcopenia, low muscle mass, weak muscle strength, and poor physical performance, and was not associated with skeletal muscle index, grip strength, short physical performance battery score, gait speed, and time to complete 5 chair stands, after adjusting for sex, age, and body mass index. CONCLUSION: Contrary to expectations, CCL11 exerted beneficial effects on muscle metabolism at least in vitro system. However, its impact on human muscle health was not evident, suggesting that circulating CCL11 may not be a useful biomarker for sarcopenia risk assessment in older adults.

Serum GDF15 Level Is Independent of Sarcopenia in Older Asian Adults.

BACKGROUND: Growth differentiation factor 15 (GDF15), induced by tissue inflammation and mitochondrial stress, has received significant attention as a biomarker of mitochondrial dysfunction and has been implicated in various age-related diseases. However, the association between circulating GDF15 and sarcopenia-associated outcomes in older adults remains to be established. AIM: To validate previous experimental data and to investigate the possible role of GDF15 in aging and muscle physiology in humans, this study examined serum GDF15 levels in relation to sarcopenia-related parameters in a cohort of older Asian adults. METHODS: Muscle mass and muscle function-related parameters, such as grip strength, gait speed, chair stands, and short physical performance battery score were evaluated by experienced nurses in 125 geriatric participants with or without sarcopenia. Sarcopenia was diagnosed using the Asian-specific cutoff points. Serum GDF15 levels were measured using an enzyme immunoassay kit. RESULTS: Serum GDF15 levels were not significantly different according to sarcopenia status, muscle mass, muscle strength, and physical performance and were not associated with the skeletal muscle index, grip strength, gait speed, time to complete 5 chair stands, and short physical performance battery score, regardless of adjustments for sex, age, and BMI. CONCLUSIONS: These findings indicate that the definite role of GDF15 on muscle metabolism observed in animal models might not be evident in humans and that elevated GDF15 levels might not predict the risk for sarcopenia, at least in older Asian adults.

Association between serum FGF21 level and sarcopenia in older adults.

BACKGROUND: With emerging basic research evidence suggesting that fibroblast growth factor (FGF) 21 is a catabolic molecule on muscle metabolism, we aimed to analyze the serum FGF21 level in relation to sarcopenia in older adults. METHODS: Blood samples were collected from 125 participants who underwent evaluation for muscle mass and function in an outpatient geriatric clinic of a teaching hospital. Sarcopenia and related components were determined using cutoff values for the Asian population. The serum FGF21 level was measured using enzyme linked immunosorbent assay. RESULTS: After controlling for age, sex, and body mass index (BMI), participants with sarcopenia, low muscle mass, and weak muscle strength had 2.3-, 2.0-, and 1.5-fold higher serum FGF21 levels than controls, respectively (p = .033 to <0.001). The serum FGF21 level was positively correlated with sarcopenia phenotype score and inversely correlated with skeletal muscle mass index and grip strength by both crude and multivariate analysis adjusting potential confounders (p = .017 to <0.001). Consistently, higher serum FGF21 level was significantly associated with increased odds for sarcopenia, low muscle mass, and low muscle strength after adjusting for age, sex, and BMI (odds ratio, 1.53-2.61; p = .048 to <0.001). CONCLUSIONS: Higher circulating FGF21 was associated with the likelihood of sarcopenia, lower muscle mass, and worse grip strength in older adults, supporting a potential catabolic role of FGF21 on human muscle health.

The association of circulating kynurenine, a tryptophan metabolite, with frailty in older adults.

Despite the accumulating evidence from in vitro and animal experiments supporting the role of kynurenine (a tryptophan metabolite) in a number of degenerative age-related changes, the relationship between kynurenine and frailty in older adults is not well understood. We collected blood samples from 73 participants who underwent a comprehensive geriatric assessment, measuring kynurenine levels using liquid chromatography-tandem mass spectrometry. We assessed the phenotypic frailty and the deficit accumulation frailty index using widely validated approaches proposed by Fried et al. and Rockwood et al., respectively. After adjusting for sex, age, and body mass index, the frail participants presented 52.9% and 34.3% higher serum kynurenine levels than those with robustness and prefrailty, respectively (P = 0.005 and 0.014, respectively). Serum kynurenine levels were positively associated with the frailty index, time to complete 5 chair stands, and patient health questionnaire-2 score and inversely associated with grip strength and gait speed (P = 0.042 to <0.001). Furthermore, the odds ratio per increase in serum kynurenine level for phenotypic frailty was approximately 2.62 (95% confidence interval = 1.22-5.65, P = 0.014). These data provide clinical evidence that circulating kynurenine might be a potential biomarker for assessing the risk of frailty in humans.

Lack of association between circulating apelin level and frailty-related functional parameters in older adults: a cross-sectional study.

BACKGROUND: Apelin, an active endogenous peptide, has been recently receiving great attention as a promising target for antiaging intervention, primarily based on results from genetically altered mice. To validate previous experimental data and investigate the possible role of apelin in humans, in this study, we examined serum apelin level in relation to frailty and its associated parameters in a cohort of ambulatory, community-dwelling older adults. METHODS: Blood samples were collected from 80 participants who underwent a comprehensive geriatric assessment, and apelin level was measured using an enzyme immunoassay kit. Phenotypic frailty and deficit-accumulation frailty index (FI) were assessed using widely validated approaches, proposed by Fried and Rockwood groups, respectively. RESULTS: After adjustment for sex, age, and body mass index, serum apelin level was found to be not significantly different according to phenotypic frailty status (P = 0.550) and not associated with FI, grip strength, gait speed, time to complete 5 chair stands, and muscle mass (P = 0.433 to 0.982). To determine whether the association between serum apelin level and frailty has a threshold effect, we divided the participants into quartiles according to serum apelin level. However, there were no differences in terms of frailty-related parameters and the risk for frailty among the quartile groups (P = 0.248 to 0.741). CONCLUSIONS: The serum apelin level was not associated with both phenotypic frailty and functional parameters in older adults, despite its beneficial effects against age-related physiologic decline in animal models. Further large-scale longitudinal studies are necessary to understand the definite role of circulating apelin in frailty risk assessment.

Lower Serum n-3 Fatty Acid Level in Older Adults with Sarcopenia.

The n-3 fatty acid (FA) has evoked considerable interest as a modifiable factor for maintenance of muscle health owing to its anti-inflammatory properties. To clarify this possibility, we investigated circulating n-3 FA level, a reliable biomarker of FA status in the body, in relation to sarcopenia in a cohort of Asian older adults. Blood samples were collected from 125 participants who underwent comprehensive assessment of muscle mass and function. Serum FA level was measured by gas chromatography/mass spectrometry. Sarcopenia was diagnosed using the cut-off points specified for the Asian population. After adjusting for sex, age, and body mass index, subjects with sarcopenia and those with low muscle strength had 36.5% and 32.4% lower serum n-3 levels (P = 0.040 and 0.030), respectively, than controls. The odds ratios per standard deviation increment in serum n-3 level for sarcopenia and low muscle strength were 0.29 and 0.40 (P = 0.015 and 0.028), respectively. A higher serum n-3 level was significantly associated with greater muscle strength (P = 0.038). These findings suggest a possible protective effect of n-3 FA on human muscle homeostasis. Further well-designed large-scale longitudinal studies are necessary to understand the definite role of circulating n-3 FA level in sarcopenia risk assessment.

Effects of Localized Heating on Pain, Skin Perfusion, and Wound Healing After Lumbar Decompression.

BACKGROUND: Current evidence regarding the effectiveness and safety of localized heating after spinal surgery for pain, peripheral tissue perfusion, and wound healing is conflicting. METHODS: This study was a prospective, single-blind, randomized controlled trial; 58 adult patients were randomized to an experimental group or a control group after spinal decompression surgery. All participants received localized cooling on postoperative days 1 and 2. The experimental group received localized heating at the surgical wound on postoperative days 3 and 4, and the control group kept normothermia without localized heating. Outcome variables were evaluated 1 hour after surgery and on day 4. RESULTS: Postoperative pain was significantly lower in the experimental versus control group (13.8 vs 23.0, P = .01). Skin perfusion was better in the experimental versus control group (4.7 vs 2.8, P = .001). There was no statistically significant difference in the wound healing status between the groups. CONCLUSION: Localized heating can effectively relieve postoperative pain and improve skin perfusion. These results suggest that localized heating tailored to the wound healing process may be beneficial for patients undergoing spinal surgery.

Prognostic factor analysis after surgical decompression and stabilization for cervical spinal-cord injury.

INTRODUCTION: Several studies have demonstrated the role of decompression surgery in preventing secondary injury and improving the neurological outcome after spinal cord injury (SCI). We retrospectively analyzed the prognostic factors affecting the outcomes of decompression surgery in patients with SCI. METHODS: We performed one-level decompression and fusion surgery on 73 patients with cervical SCI. We classified all patients based on their interval to decompression, sex, age, surgical level, presence of high signal intensity, American Spinal Injury Association Impairment scale (AIS) before surgery, blood pressure at admission, the amount of cord compression, surgical time, estimated blood loss during surgery, and steroid use. We considered an improvement to have occurred if the patient showed an AIS improvement of ≥1 grade. RESULTS: Among the 73 patients with SCI we analyzed, 27 and 35 showed ≥1 grade of AIS improvement immediately and 3 months after surgery, respectively. Using multivariate analysis, the mean arterial blood pressure (MAP) was a significant prognostic factor affecting recovery in the SCI patients during the immediate post-operative period. In the late recovery period at 3 months after surgery, the AIS before surgery and the MAP were significant prognostic factors affecting recovery. CONCLUSIONS: Prognostic factors for AIS improvement include the initial neurological status before surgery and hemodynamic MAP at admission. The interval between decompression surgery and trauma does not affect the neurological outcome.

Advantages of Direct Insertion of a Straight Probe Without a Guide Tube During Anterior Odontoid Screw Fixation of Odontoid Fractures.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of this study was to compare the anterior odontoid screw fixation (AOSF) with a guide tube or with a straight probe. SUMMARY OF BACKGROUND DATA: AOSF associates with several complications, including malpositioning, fixation loss, and screw breakage. Screw pull-out from the C2 body is the most common complication. METHODS: All consecutive patients with type II or rostral shallow type III odontoid fractures who underwent AOSFs during the study period were enrolled retrospectively. The guide-tube AOSF method followed the standard published method except C3 body and C2-3 disc annulus rimming was omitted to prevent disc injury; instead, the guide tube was anchored at the anterior inferior C2 vertebra corner. After 2 screw pull-outs, the guide-tube cohort was analyzed to identify the cause of instrument failure. Thereafter, the straight-probe method was developed. A guide tube was not used. A small pilot hole was made on the most anterior side of the inferior endplate, followed by insertion of a 2.5 mm straight probe through the C2 body. Non-union and instrument failure rates and screw-direction angles of the guide-tube and straight-probe groups were recorded. RESULTS: The guide-tube group (n = 13) had 2 screw pull-outs and 1 non-union. The straight-probe group (n = 8) had no complications and significantly larger screw-direction angles than the guide-tube group (60.5 ±â€Š4.63 vs. 54.8 ±â€Š3.82 degrees; P = 0.047). CONCLUSION: Straight-probe AOSF yielded larger direction angles without injuring bone and disc. Complications were absent. The procedure was easier than guide-tube AOSF and assured sufficient engagement, even in horizontal fracture orientation cases. LEVEL OF EVIDENCE: 3.

A unilateral open door laminoplasty technique: prospective analysis of the relationship between midline extensor muscle preservation and postoperative neck pain.

Since laminoplasty was first introduced, several techniques have been developed to reduce postoperative neck pain and progressive kyphosis following this procedure. We describe the importance of deep muscle preservation to prevent postoperative neck pain following cervical posterior surgery, using the inter-muscular plane. We performed cervical laminoplasty on 10 patients from March to July 2012. The mean follow-up duration was 14.6 (range 12-18) months, and the mean age was 58.8 (48-68) years. There were eight men and two women in the study cohort, which consisted of eight cases of cervical spondylotic myelopathy and two cases of ossification of the posterior longitudinal ligament. The Japanese Orthopaedic Association (JOA) score and neck disability index (NDI) score were assessed before and at 6 and 12 months after surgery. The numeric rating scale (NRS) for neck pain was evaluated at 1, 3, 6, and 12 months after surgery. CT scan was performed immediately after the operation, and a radiograph was performed preoperatively and during the follow-up evaluation at 1, 3, 6, and 12 months after surgery. The preoperative JOA and NDI scores improved in all patients. Although there were two patients who complained of moderate postoperative neck pain (NRS 4 and 5), their condition gradually improved. Seven patients had mild or no neck pain (below NRS 3) at the 12 month follow-up. In addition, the cervical alignment was well maintained in all but one patient. Although larger prospective cohorts, longer follow-up periods, and comparative analyses are still needed, the clinical and radiological outcomes observed in the short 12 month period in this small cohort are promising.

The safety and accuracy of freehand pedicle screw placement in the subaxial cervical spine: a series of 45 consecutive patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the safety and accuracy of subaxial cervical pedicle screw placement with freehand technique and to report the technical nuances. SUMMARY OF BACKGROUND DATA: Although the efficacy and safety of freehand screw fixation in thoracic and lumbar vertebrae is proven, reports on this technique of screw insertion in the subaxial cervical spine are lacking. METHODS: From March 2012 to September 2013, 45 consecutive patients underwent posterior cervical fusion. The diagnoses were trauma (22 patients), degenerative disease (18 patients), discitis/osteomyelitis (2 patients), pathological fracture (2 patients), and postlaminoplasty kyphosis (1 patient). Preoperative computed tomography (CT) was performed in all patients. We included patients whose outer diameter of the pedicle was greater than 3.0 mm. The standard entry points were modified according to the CT anatomy of each patient. A small pilot hole was fashioned at a predetermined entry point. Then, a 2.5-mm diameter curved pedicle probe was slowly inserted with a medial trajectory into the pedicle. After ball-tip probing and tapping, the screw was inserted. If ball-tip probing was suggestive of risk to neurovascular structures, conversion to a lateral mass screw was performed. Postoperatively, a CT scan was performed in all patients and the conversion rate from pedicle to lateral mass screw was recorded. The breech rate of pedicle screws was also analyzed. RESULTS: There were 256 planned pedicle screws and 20 incidences (7.8%) of conversion to lateral mass screws. Lateral wall violation was observed in 14 pedicle screws (accuracy rate: 94.1%) on the postoperative CT scan. No medial, superior, and inferior pedicle wall violations were observed. There was no patient who developed symptoms related to vertebral artery stenosis. CONCLUSION: Adherence to the surgical tips presented in this article may lead to safe and effective freehand placement of cervical pedicle screws. LEVEL OF EVIDENCE: 3.

Evaluation of efficacy and safety of fentanyl transdermal patch (Durogesic D-TRANS) in chronic pain.

PURPOSE: Opioids are used in controlling several types of pain. This study was designed to evaluate the efficacy and safety of the fentanyl transdermal patch-type system (Durogesic® D-TRANS). METHODS: Patients who complained of chronic moderate to severe pain were enrolled. Administration dosages of fentanyl patch started from 12.5 µg/h and could be increased by 12.5 µg/h or 25 µg/h, if the average pain score of 4 or higher occurred within 72 h. The total administration period was 12 weeks. The type, location, characteristics, and duration of pain were evaluated. Also, on day 0, weeks of 4, 8, and 12, the physician's assessment of pain intensity, the patient's assessment of pain intensity, the assessment of impact of pain on functions, and the assessment of the impact of pain on sleep were assessed. In addition, side effects were evaluated during the study duration. RESULTS: A total of 65 cases were enrolled, and the final evaluated cases were 41. Before treatment, the average physician's assessment of pain intensity was 6.70 ± 1.41, and the average patient's assessment of pain intensity was 7.02 ± 1.63. In the final visit, the average physician's assessment of pain intensity was 2.58 ± 1.72, and the average patient's assessment of pain intensity was 2.86 ± 1.78. CONCLUSIONS: This prospective study shows that the fentanyl patch is effective in alleviating moderate to severe chronic noncancer pain including neuropathic pain down to mild pain. Therefore, the fentanyl patch should be considered before other invasive intervention procedures in chronic moderate to severe noncancer pain.