Unilateral vs Bilateral Cages in Lumbar Interbody Fusions: A Meta-Analysis of Clinical and Radiographic Outcomes.

BACKGROUND: Bilateral cages are often used for interbody fusion. However, this procedure may not be possible in some cases making unilateral cages a reasonable alternative. The literature remains divided on the clinical and radiological distinctions when comparing unilateral to bilateral cages in lumbar interbody fusion. Thus, this meta-analysis will analyze the clinical and radiographic outcomes between these two groups. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, surgery-related parameters, and patient reported outcomes. RESULTS: Lower rates of pseudoarthrosis, subsidence, were reported in the bilateral cages group (p=0.01, p=0.001, respectively) whereas shorter operative time (OR time), and lower estimated blood loss (EBL) were seen in unilateral cage group (p<0.001, and p=0.003). There was no statistically significant difference in the remaining analyzed outcomes. CONCLUSION: Unilateral cages were shown to be superior due to their reduced OR time and EBL. As for the higher rate of pseudoarthrosis, this outcome may not be related to the cage numbers and it did not affect clinical outcomes. Nevertheless, one must consider other factors such as radiographic sagittal parameters before making a surgical decision.

Intensive Care Unit Admission After Spine Surgery: A Narrative Review.

INTRODUCTION: Intensive care unit (ICU) admissions constitute a substantial financial challenge for health care systems and patients and are linked to various potentially life-altering complications. A wide range of patient-related, surgical, and medical factors are associated with an increased risk of ICU admission following spine surgery. DISCUSSION: The most notable examples include lung, heart, and kidney disease, as well as estimated blood loss and length of surgery. Various scores that include the most significant patient- and procedure-related factors have been described to assess the risk associated with surgery for individual patients. To date, the fusion risk score and the American Society of Anesthesiologists score have been the most useful in predicting postoperative complications and admission to the ICU. However, other risk factors have also been implicated in ICU admission and length of stay. The current scores must further adapt by using the available evidence to fulfill their intended purpose. Moreover, a handful of measures have shown efficacy in decreasing ICU admission and length of stay, with their benefits still to be demonstrated by future research. CONCLUSION: This review underscores the risk factors predictive of ICU admission following spine surgery and will help surgeons and clinicians in patient stratification. However, future studies are needed to validate the role of protective measures in preventing ICU admissions and the significance of certain risk factors.

Implant density in adolescent idiopathic scoliosis: a meta-analysis of clinical and radiological outcomes.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) affects 1-3% of adolescents, and treatment approaches, including the density of constructs in surgical fusion, vary among orthopedic surgeons. Studies have sought to establish whether high-density or low-density constructs offer superior clinical and radiological outcomes, yet conclusive results are lacking. This meta-analysis aims to provide a definitive answer to the controversial and ambiguous question surrounding the efficacy of different pedicle screw densities in treating AIS. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till December 2023. The studied outcomes were Major Cobb angle, major curve correction, lumbar curve, kyphosis (T5-T12), lumbar lordosis, coronal balance, LIV Tilt angle, TAV translation, LAV translation, apical trunk rotation, trunk shift, SRS-22, operative time, blood loss, complications and cost. RESULTS: Twenty-four studies (total of 1985 patients, 1045 in LD group and 940 in HD group) were included in this meta-analysis. A statistically significant better improvement in ATR (p = 0.02) and LIV tilt angle (p = 0.02) was seen in the high-density group. On the other hand, longer operative time (p = 0.002), blood loss (p = 0.0004) and costs (p = 0.02) were seen in the high-density group. No difference was seen in the remaining radiographic and clinical outcomes between both surgeries. CONCLUSION: Both low-density (LD) and high-density (HD) screw constructs show comparable and satisfactory radiographic and QOL for AIS patients. Furthermore, HD constructs had increased costs, operative time, and blood loss associated. However, a definitive conclusion cannot be made and more studies taking into account multiple additional variables are necessary to do so.

Pulsed lavage in joint arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Knee and hip osteoarthritis affects millions of people around the world and is expected to rise even more in frequency as the population ages. Joint arthroplasty is the surgical management of choice in these articulations. Heterotopic ossification and radiolucent lines formation are two frequent problems faced in hip and knee replacements respectively. Some studies show that the usage of pulsed lavage may prevent their formation. AIM: To compare pulsed lavage to standard lavage in joint arthroplasty. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till December 2023. Only comparative studies were included. The clinical outcomes evaluated were the heterotopic ossification formation in hip replacements, radiolucent lines formation, and functional knee scores in knee replacements. RESULTS: Four studies met the inclusion criteria and were included in this meta-analysis. Pulsed lavage was shown to reduce the formation of radiolucent lines (P = 0.001). However, no difference was seen in the remaining outcomes. CONCLUSION: Pulsed lavage reduced the formation of radiolucent lines in knee replacements. No difference was seen in the remaining outcomes. Furthermore, the clinical significance of these radiolucent lines is poorly understood. Better conducted randomized controlled studies and cost-effectivity studies are needed to reinforce these findings.

Will ChatGPT be Able to Replace a Spine Surgeon in the Clinical Setting?

OBJECTIVE: This study evaluates ChatGPT's performance in diagnosing and managing spinal pathologies. METHODS: Patients underwent evaluation by two spine surgeons (and the case was discussed and a consensus was reached) and ChatGPT. Patient data, including demographics, symptoms, and available imaging reports, were collected using a standardized form. This information was then processed by ChatGPT for diagnosis and management recommendations. The study assessed ChatGPT's diagnostic and management accuracy through descriptive statistics, comparing its performance to that of experienced spine specialists. RESULTS: A total of 97 patients with various spinal pathologies participated in the study, with a gender distribution of 40 males and 57 females. ChatGPT achieved a 70% diagnostic accuracy rate and provided suitable management recommendations for 95% of patients. However, it struggled with certain pathologies, misdiagnosing 100% of vertebral trauma and facet joint syndrome, 40% of spondylolisthesis, stenosis, and scoliosis, and 22% of disc-related pathologies. Furthermore, ChatGPT's management recommendations were poor in 53% of cases, often failing to suggest the most appropriate treatment options and occasionally providing incomplete advice. CONCLUSIONS: While helpful in the medical field, ChatGPT falls short in providing reliable management recommendations, with a 30% misdiagnosis rate and 53% mismanagement rate in our study. Its limitations, including reliance on outdated data and the inability to interactively gather patient information, must be acknowledged. Surgeons should use ChatGPT cautiously as a supplementary tool rather than a substitute for their clinical expertise, as the complexities of healthcare demand human judgment and interaction.

Approaches in Anterior Column Support in Adult Spinal Deformity Surgery: A Meta-Analysis of Clinical and Radiologic Outcomes.

OBJECTIVE: This meta-analysis was conducted to compare anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) in terms of postoperative complications, improvement in radiographic parameters, and patient-reported outcomes. METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) databases were searched up to June 2023. The studied outcomes were the rate of rod failures, rod failures requiring revision surgery, all complications, all revision surgeries, the change in pelvic tilt, sacral slope, Cobb angle, lumbar lordosis (LL), sagittal vertical axis, the postoperative pelvic incidence-LL, and LL, and the improvement in back pain and Oswestry Disability Index (ODI). RESULTS: Six studies were included in this meta-analysis. ALIF showed higher postoperative lordosis (P = 0.003) and better improvement in ODI (P = 0.0001). No difference was seen in the remaining outcomes between ALIF and TLIF. CONCLUSIONS: Although ALIF had better improvement in ODI, the mean difference was 6.5 points, which is below the minimal clinically important difference, stripping this result of any clinical value. Furthermore, even though ALIF had better postoperative lordosis, the change in LL postoperatively was not different between ALIF and TLIF. With no difference in complications, sagittal and coronal alignment, and patient-reported outcomes, TLIF was shown in this study to be favored instead of ALIF in adult spinal deformity surgery to avoid all the double approach-related comorbidity.

Tyrosine kinase inhibitors in osteosarcoma: Adapting treatment strategiesa.

Osteosarcoma (OS) is an aggressive primary bone malignancy that metastasizes rapidly. The standard of care has changed little over the previous four decades, and survival rates have plateaued. In this context, tyrosine kinase inhibitors (TKIs) emerge as potential treatments. A literature search was conducted to collect data related to receptor tyrosine kinase genetic alterations and expression in OS specimens. Gene amplification and protein expression of these receptors were linked to prognosis and tumor behavior. Relevant TKIs were evaluated as monotherapies and as parts of combination therapies. Certain TKIs, such as apatinib, regorafenib, and cabozantinib, present a potential therapeutic avenue for OS patients, especially when combined with chemotherapy. Producing long-lasting responses and enhancing quality of life remain key goals in OS treatment. To this effect, optimizing the use of TKIs by identifying biomarkers predictive of response and assessing promising TKIs in larger-scale trials to validate the efficacy and safety outcomes relative to these drugs reported in phase II clinical trials. To this effect, it is necessary to identify biomarkers predictive of response to TKIs in larger-scale trials and to validate the efficacy and safety of these drugs reported in phase II clinical trials.

Management of Displaced Metacarpal Shaft Fractures: A Systematic Review and Meta-analysis.

Background: Affecting mainly the working population, metacarpal shaft fractures account for up to 31% of hand fractures. To manage this entity, conservative management can be equal to operative management. However, surgeons tend to favor operative management in order to reduce the rate of complications, such as shortening and malunion. This meta-analysis was conducted to compare conservative to operative management of displaced metacarpal shaft fractures. Methods: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched until August 2023. The clinical outcomes consisted of postoperative shortening, Disabilities of Arm, Shoulder, and Hand (DASH) score, and mean grip strength. Results: Only three studies were included in this meta-analysis. Operative management was shown to reduce postoperative shortening (p<0.00001). However, conservative management had a better postoperative DASH score (p=0.001). Conclusion: Better DASH scores were seen in the conservative group, but there was a higher postoperative shortening. However, studies have shown that the shortening has no effect on the functional outcome. Nevertheless, more randomized controlled studies and cost-effectiveness studies are needed to confirm these findings.

Management of Bennett's fracture: A systematic review and meta-analysis.

Background: First described in 1882, Bennett's fracture is an intra-articular fracture of the first metacarpal associated with a dislocation of the carpometacarpal joint. Usually, open reduction internal fixation is used to manage such fractures. However, closed reduction has shown good outcomes recently. This meta-analysis compares closed reduction to open reduction internal fixation in the management of Bennett's fracture. Methods: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched until August 2023. The clinical outcomes consisted of post-traumatic arthritis, grip and pinch strengths, range of motion, functional scores, and mean adduction deformity. Results: Six retrospective studies were included in this meta-analysis. Our results show higher grip and pinch strengths, better extension and flexion of the thumb, and lower mean adduction deformity in the open reduction internal fixation group. Conclusion: Higher grip and pinch strengths, better extension and flexion of the carpometacarpal joint, and a smaller mean adduction deformity of the thumb in the open reduction internal fixation group. No differences were seen in the remaining outcomes. However, a higher rate of complications is associated with open reduction internal fixation. Nevertheless, more randomized controlled studies are needed to confirm such results. Level of evidence: III.

Epidemiology of bone tumors in Lebanon: a retrospective study from 2000 to 2022 at a tertiary center.

Aim: Bone tumors are rare and have an uneven geographic distribution. Methods: 730 patients diagnosed with bone tumors were included in this retrospective analysis. Results: With a 64% rate of malignancy, the most common tumors were metastasis (40%) mostly in the axial skeleton, Osteosarcoma (9%) mostly in the femur, Osteochondroma (8%) mostly in the femur, giant cell tumors (7%) mostly in the knee, and Ewing's sarcoma (6%) mostly in the axial skeleton. Conclusion: Even though a some of the tumors have a predilection for certain localizations in the human body, they may differ in the middle-eastern population. One must also pay attention to the higher rates of malignancies as compared with other cohorts.

With significant morbidity and mortality, bone tumors incidence is low and varies geographically. In our Lebanese population, Seven-hundred-thirty patients with bone tumors were identified with a 64% rate of malignancy with osteosarcoma being the most common primary bone cancer and metastasis being the overall most prevalent bone malignancy. This higher rate of malignancy compared with other populations should be taken into consideration when evaluating Lebanese or Middle eastern patients.

Exceptional Spinal Mobility Caused by Charcot Disease: Case Description with Several Years of Follow-Up.

A spinal cord injury is now the most common cause of Charcot Spinal Arthropathy (CSA). Paraplegia, loss of pain sensation, laminectomies, and spinal fusions involving more than 5 levels are all risk factors for developing this condition. Low back pain and spinal abnormalities are common symptoms. Circumferential arthrodesis is the chosen treatment. Implant failure and new-onset CSA, which necessitates re-instrumentation, are some of the risks associated with this treatment. This is the case of a patient with a post-traumatic spinal cord injury presenting with spinal Charcot disease with a very long follow-up. We report a unique complication with the replacement of the discal space and portions of the vertebral bodies by fibrotic tissue with an extraordinary spinal movement in the coronal and sagittal planes. Recurrent Charcot disease at the same level or at a caudal level is a devastating complication in spinal surgery. Since this disease naturally exposes the patient to iterative surgeries, it would be wise to limit the extent of the arthrodesis to an optimal number of levels sufficient to ensure perfect stability of the construct and not to be very extensive from the first surge. The risk would increase the fused levels which limit the availability of mobile buffer levels and increase the stress on the remaining levels. Regular follow-ups to the patient should be done to detect recurrence at the same site or distal to the instrumentation.

Transforaminal lumbar interbody fusion using banana-shaped and straight cages: meta-analysis of clinical and radiological outcomes.

PURPOSE: Transforaminal lumbar interbody fusion (TLIF) surgery rate increased over the last decade. There is no consensus about the better shape of cage to use in TLIF. This meta-analysis was conducted to compare the shape focusing on bony union, lordosis restoration as well as perioperative complications. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till September 2022. The clinical outcomes consisted of the bony union, segmental and lumbar lordosis restoration, quality of life, and operation-related outcomes. RESULTS: Only 5 studies were included in this meta-analysis. Straight-shaped cages tended to have a lower subsidence rate compared to banana-shaped cages (p = 0.10), had a better restoration of segmental lordosis (p < 0.0001), better disc height restoration (p = 0.01), as well as a higher Oswestry Disability Index decrease (p = 0.0002). CONCLUSION: Straight-shaped cages had a better restoration of lumbar lordosis, disc height, and a lower subsidence rate when compared to banana-shaped cages. This may be explained by the absence of the optimal placement of the curved cages, which is at the most anterior part of the disc space. Better conducted randomized controlled trial could strengthen these findings.

Molecular and biologic biomarkers of Ewing sarcoma: A systematic review.

With an annual incidence of less than 1%, Ewing sarcoma mainly occurs in children and young adults. It is not a frequent tumor but is the second most common bone malignancy in children. It has a 5-year survival rate of 65-75%; however, it has a poor prognosis when it relapses in patients. A genomic profile of this tumor can potentially help identify poor prognosis patients earlier and guide their treatment. A systematic review of the articles concerning genetic biomarkers in Ewing sarcoma was conducted using the Google Scholar, Cochrane, and PubMed database. There were 71 articles discovered. Numerous diagnostic, prognostic, and predictive biomarkers were found. However, more research is necessary to confirm the role of some of the mentioned biomarkers. .

What is the best referral strategy for axial spondyloarthritis? A prospective multicenter study in patients with suspicious chronic low back pain.

OBJECTIVE: To assess the value of referral strategies for axial spondyloarthritis (axSpA) in patients with suspicious chronic inflammatory low back pain (LBP), to estimate the value of inflammatory back pain (IBP) for referral, and to identify the predictive factors of the final diagnosis of axSpA in Middle Eastern Arab countries. METHODS: The study was multicentric, prospective, and conducted in LBP first-line clinics (rheumatology, internal, family medicine, orthopedic surgery, neurosurgery, and neurology). Consecutive adult patients aged under 45years were included in case of LBP suspicious of inflammatory nature according to the first-line physician. The rheumatologist's final diagnosis was the gold standard. The diagnostic properties of ten referral strategies (Brandt I, II, III, Hermann, RADAR, RADAR 2/3, MASTER, Braun, CAFASPA, and ASAS) and of IBP were calculated. A multivariable logistic regression identified the clinical predictive factors of axSpA. RESULTS: In 515 referred patients, axSpA was confirmed in 48%, refuted in 43%, and diagnosis remained inconclusive in 9%. The optimal referral strategy was the MASTER (PLR 3.3), which comprises IBP, good response to NSAIDs, positive HLA-B27, and SpA family history. Considering strategies without HLA-B27, the RADAR 2/3 had a PLR of 2.9 (IBP, good response to NSAIDs, any extra-musculoskeletal manifestation). The predictive factors for axSpA were MRI sacroiliitis, positive HLA-B27, high CRP, psoriasis, IBP, and longer symptom duration. Of all patients, 35% were self-referred, 16% were referred by primary care physicians, and 15% by neuro/orthopedic surgeons. CONCLUSION: Optimizing physicians' awareness of these clinical features may enhance referral in axSpA.

Vertebroplasty versus Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: A Meta-Analysis.

BACKGROUND: One of the most frequent consequences of osteoporosis is osteoporotic vertebral compression fractures, which makes it one of the most prevalent health care crises in the world. Two things are needed to manage them: 1) pain management, and 2) fracture stabilization. To take care of both, 2 methods are commonly used: 1) vertebroplasty and 2) kyphoplasty (KP) without a clear consensus on which is the better one. A meta-analysis was done comparing both techniques in the management of osteoporotic vertebral compression fractures. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched updated to October 2022. Two reviewers determined the eligibility of the studies independently. Only 8 studies were included in the meta-analysis. The clinical outcomes consisted of the complications (cement leakage, adjacent level fractures), the visual analog scale scores, Oswestry disability index, kyphotic wedge angle, and vertebral body height restoration. RESULTS: KP was shown to be superior to vertebroplasty in terms of reducing cement leakage, and increasing postoperative vertebral body height. The comparison of the rest of the outcomes was statistically insignificant between both techniques. CONCLUSIONS: Although KP could significantly increase postoperative vertebral body height and decrease the risk of cement leakage, the fact that it is more costly and has a longer operative time raises the question about the cost effectiveness of the procedure.

Scheuermann's kyphosis: update on pathophysiology and surgical treatment.

Scheuermann's Kyphosis (SK) is a rigid spinal kyphosis. Several theories have been proposed concerning its pathogenesis, but it is, to this day, still unknown. It has a prevalence of 0.4-8.3% in the population with a higher incidence in females. Clinical examination with x-rays is needed to differentiate and confirm this diagnosis. Non-surgical management is reserved for smaller deformities and in skeletally immature patients, whereas surgery is recommended for higher deformities. Combined anterior and posterior approach was considered the gold standard for the surgical treatment of this disease, but there is an increasing trend toward posterior-only approaches especially with use of segmental fixation. This study reviews the pathophysiology of SK while proposing a treatment algorithm for its management.

Congenital scoliosis: a narrative review and proposal of a treatment algorithm.

Congenital scoliosis (CS) is a spinal deformity resulting from underlying spinal malformations with an incidence of 0.5-1/1000 births. CS makes up 10% of scoliotic deformities, of which 25% do not progress, 25% progress mildly and 50% need treatment depending on the age, curve characteristics and magnitude and type of anomaly. CS is associated with non-vertebral anomalies (genitourinary, musculoskeletal, cardiac, ribs anomalies, etc.) and intraspinal anomalies (syrinx and tethered cord). Imaging should include whole spine X-rays, CT scanner with reconstruction to better delineate the vertebral anomalies and MRI to visualize the neural elements. Treatment of CS in the majority of cases is non-surgical and relies on fusion techniques (in situ fusion and hemiepiphysiodeis), resection techniques (hemiverterba resection), and growth-friendly techniques (distraction and instrumentation without fusion).

Posterior scoliosis correction with thoracoplasty: effect on pulmonary function with a mean follow-up of 4.8 years.

PURPOSE: To perform a study to investigate the influence of posterior scoliosis surgery and thoracoplasty on pulmonary function. METHODS: This was a retrospective observational study of 37 patients with AIS who underwent posterior instrumented surgical correction with thoracoplasty. There was a minimum of 2 years follow-up. Clinical outcomes were measured using the SRS-22 questionnaires. Radiological outcomes were evaluated using standing posteroanterior and lateral radiographs. All patients had pulmonary function tests to evaluate pulmonary volume and flow (forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC)) both before surgery and at the final follow-up. RESULTS: There were three males and 34 females. The mean age of patients was 14.6 years (range 11-21 years). The mean length of follow was 58 months (range 24-124 months). The average main thoracic Cobb angle in the coronal plane was corrected from 50.0° ± 12.4° preoperatively to 16.6° ± 6.3° postoperatively. The average thoracolumbar Cobb angle in the coronal plane was corrected from 28.2° ± 10.6° preoperatively to 10.1° ± 7.2°. The average thoracic kyphosis angle was corrected from 17.4° ± 11.0° preoperatively to 21.8° ± 10.5°. In terms of the Quality of life Outcomes (QoL), there was a significant increase (p < 0.001) in the mean SRS 22 scores from 3.8 preoperatively to 4.3 postoperatively. A statistically significant increase in the absolute forced expiratory volume in one second (FEV1) from pre-operative values with a p value < 0.001 was seen. There was a statistically significant increase in percentage predicted forced expiratory volume in one second from preoperative values with a p value of 0.008. There was also a statistically significant increase in the absolute forced vital capacity (FVC) from preoperative values with a p value < 0.001. The average percentage predicted forced vital capacity did increase on final follow-up from before surgery, but the increase was not statistically significant. CONCLUSIONS: We have demonstrated that pulmonary function post-thoracoplasty not only reaches pre-operative levels, but significantly surpasses it with regards to the majority of the pulmonary parameters measured in this study. We also demonstrated satisfactory radiological correction and clinical outcomes.