Factors associated with increased length of stay and risk of complications in 336 patients submitted to spine surgery. The role of a validated capture system (SAVES v2) as a first-line tool to properly face the problem.

PURPOSE: In this study, we analyzed the use of a validated capture system (Spinal Adverse Events Severity system, SAVES V2) as a first non-technical skill to properly face the relevant problem of surgical complications (SCs) and adverse events (AEs) in spinal surgery. METHODS: We retrospectively collected AEs occurring in a tertiary referral center for spine surgery from January 2017 to January 2018 and classified them according to SAVES V2 system. We compared this collection of AEs with a prospective collection performed without any classification system. Univariate and multivariate logistic regression models were used to determined odds ratio (ORs) for selected potential risk factors of AEs and prolonged length of stay. RESULTS: Overall a higher number of AEs was retrospectively recorded using SAVES system compared to the prospective recording without the use of any capture system (97/336 vs 210/336, p < 0.001). The length of stay (LOS) increased in the group of complicated patients for all the procedures examined. In the non-oncological group, LOS was significantly higher for complicated patients compared to uncomplicated patients (F = 44.11, p = 0.0000). Similar results have been obtained in the oncological group of patients. In the multivariate regression model surgical time and postoperative AEs emerged as risk factors for prolonged LOS, while only the presence of previous surgeries was confirmed as risk factor for AEs. CONCLUSION: Considering that the rate of AEs and SCs in spinal surgery is still high despite the improvement of technical skills, we suggest the use of SAVES V2 capture system as a first-line tool to face the problem.

Abdominal aortic calcification is an independent predictor of perioperative blood loss in posterior spinal fusion surgery.

OBJECTIVE: Abdominal aortic calcification (AAC), often found incidentally on lateral lumbar radiographs, is increasingly recognized for its association with adverse outcomes in spine surgery. As a marker of advanced atherosclerosis affecting cardiovascular dynamics, this study evaluates AAC's impact on perioperative blood loss in posterior spinal fusion (PSF). METHODS: Patients undergoing PSF from March 2016 to July 2023 were included. Estimated blood loss (EBL) and total blood volume (TBV) were calculated. AAC was assessed on lateral lumbar radiographs according to the Kauppila classification. Predictors of the EBL-to-TBV ratio (%EBL/TBV) were examined via univariable and multivariable regression analyses, which adjusted for parameters such as hypertension and aspirin use. RESULTS: A total of 199 patients (47.2% female) were analyzed. AAC was present in 106 patients (53.3%). AAC independently predicted %EBL/TBV, accounting for an increase in blood loss of 4.46% of TBV (95% CI 1.17-7.74, p = 0.008). CONCLUSIONS: This is the first study to identify AAC as an independent predictor of perioperative blood loss in PSF. In addition to its link to degenerative spinal conditions and adverse postoperative outcomes, the relationship between AAC and increased blood loss warrants attention in patients undergoing PSF.

Association between skin ultrasound parameters and revision surgery after posterior spinal fusion.

PURPOSE: The literature is scarce in exploring the role of imaging parameters like ultrasound (US) as a biomarker for surgical outcomes. The purpose of this study is to investigate the associations between skin US parameters and revision surgery following spine lumbar fusion. METHODS: Posterior lumbar fusion patients with 2-years follow-up were assessed. Previous fusion or revision not due to adjacent segment disease (ASD) were excluded. Revisions were classified as cases and non-revision were classified as controls. US measurements conducted at two standardized locations on the lumbar back. Skin echogenicity of the average dermal (AD), upper 1/3 of the dermal (UD), lower 1/3 of the dermal (LD), and subcutaneous layer were measured. Echogenicity was calculated with the embedded echogenicity function of our institution's imaging platform (PACS). Statistical significance was set at p < 0.05. RESULTS: A total of 128 patients (51% female, age 62 [54-72] years) were included in the final analysis. 17 patients required revision surgery. AD, UD, and LD echogenicity showed significantly higher results among revision cases 124.5 [IQR = 115.75,131.63], 128.5 [IQR = 125,131.63] and 125.5 [IQR = 107.91,136.50] compared to the control group 114.3 [IQR = 98.83,124.8], 118.5 [IQR = 109.28,127.50], 114 [IQR = 94.20,126.75] respectively. CONCLUSION: The findings of this study demonstrate a significant association between higher echogenicity values in different layers of the dermis and requiring revision surgery. The results provide insights into the potential use of skin US parameters as predictors for revision surgery. These findings may reflect underlying alterations in collagen. Further research is warranted to elucidate the mechanisms driving these associations.

The Association between prior arthroplasty and Paraspinal Muscle Degeneration in patients undergoing elective lumbar surgery.

PURPOSE: Spinal and lower extremity degeneration often causes pain and disability. Lower extremity osteoarthritis, eventually leading to total knee- (TKA) and -hip arthroplasty (THA), can alter posture through compensatory mechanisms, potentially causing spinal misalignment and paraspinal muscle (PM) atrophy. This study aims to evaluate the association between prior THA or TKA and PM-degeneration in patients undergoing elective lumbar surgery for degenerative conditions. METHODS: A retrospective analysis of patients undergoing lumbar surgery for degenerative conditions was conducted. Patients were categorized based on prior THA, TKA, or both. Quantitative analysis of functional cross-sectional area (fCSA) and fat infiltration (FI) of psoas, multifidus (MF), and erector spinae (ES) muscles at L4-level was performed using T2-weighted MRI images. The association between the FI and fCSA of the PM and prior arthroplasty was investigated. Differences were assessed using ANOVA and multivariable linear regression. RESULTS: Overall, 584 patients (60% female, 64 ± 12 years) were included. 66 patients (11%) had prior TKA, 36 patients (6%) THA, and 15 patients (3%) both TKA and THA. Patients with arthroplasty were mostly female (57%) and notably older (p < 0.001). The FI of the MF and the ES was significantly higher in the arthroplasty-group (both p < 0.001). Patients with prior TKA showed significantly higher FI (Est = 4.3%, p = 0.013) and lower fCSA (Est=-0.9 cm2, p = 0.012) in the MF compared to the non-arthroplasty-group. CONCLUSION: This study demonstrates a significant lower fCSA and higher FI in the MF among individuals with prior TKA. This highlights the complex knee-spine relationship and how these structures interact with each other.

MRI in differential diagnosis between tuberculous and pyogenic spondylodiscitis.

PURPOSE: The aim of the study was to investigate whether MRI findings together with epidemiological data could help in differentiating between tuberculous and pyogenic spondylodiscitis. METHODS: Clinical records of 260 patients with a suspicion of spondylodiscitis were analysed. Patients were selected using the following inclusion criteria: confirmed diagnosis of spondylodiscitis either from pyogenic bacteria or from Mycobacterium tuberculosis and contrast-enhanced MRI performed before treatment. Clinical data concerning age, sex and country-of-origin were also collected. For each patient, several MRI-features were evaluated by two-expert musculoskeletal radiologists. A chi-squared test and a multiple logistic regression were used to find the best predictors of tuberculous or pyogenic spondylodiscitis. RESULTS: 114 patients were retrospectively enrolled, 30 with tuberculous and 84 with pyogenic spondylodiscitis. We found 18 MRI-features, significantly different between the two groups. Among these, the most strongly associated with tuberculous spondylodiscitis were: heterogeneous vertebral signal on T1w-sequences (Odds Ratio(OR) = 205.759-p < 0.001), presence of epidural abscess (OR = 86.221-p < 0.001), severe vertebral destruction (OR = 10.017-p < 0.001) and absence of epidural phlegmon (OR = 86.221-p < 0.001). Moreover, patients coming from countries with a middle-high prevalence of tuberculosis were more frequently affected by tuberculous spondylodiscitis than others were (OR = 229.136-p < 0.001). The best prediction model demonstrated a correct classification rate of 94.7%. CONCLUSION: To the best of our knowledge this is the largest study comparing MRI-features of tuberculous and pyogenic spondylodiscitis. The above-mentioned MRI-features and epidemiological data are crucial in the differential diagnosis between these two entities, guiding the choice of the appropriate therapy, especially when a pathogen cannot be clearly identified with other modalities.

The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review.

PURPOSE: Spinal bone tumors include a heterogeneous broad of primary or metastatic lesions that may present as incidental findings or manifest with painful symptoms and pathological fractures. Optimal management of spine bone lesions is often difficult and treatment algorithms are usually solidly based on surgery. We aimed to evaluate the contribution of trans-arterial embolization in this field, with particular attention to the procedure efficacy, technical difficulties and complications. METHODS: We present a literature review on the role of trans-arterial embolization in the management of spinal bone tumors, both primary and metastatic, evaluating its contribution as preoperative treatment, palliative procedure and standalone curative strategy. RESULTS: Trans-arterial embolization provides an important contribution to reducing surgery hemorrhagic risks, offering a better visualization of the operating field, and possibly increasing tumor susceptibility to chemotherapy or radiation therapy. Nonetheless, it plays an important part in pain palliation, with the unquestionable advantage of being easily repeatable in case of necessity. Its curative role as a standalone therapy is still subject of debate, and at the present time, satisfactory results have been recorded only in the treatment of aneurysmal bone cysts. CONCLUSION: Percutaneous trans-arterial embolization has established as a highly useful minimally invasive procedure in the management of spinal bone lesions, particularly as adjuvant preoperative therapy and palliative treatment.

Histological examination of a retrieved custom-made 3D-printed titanium vertebra : Do the fine details obtained by additive manufacturing really promote osteointegration?

PURPOSE: In the present report it is described the design, the manufacturing and the successful surgical implant of one of the first 3D custom titanium vertebra realized with Additive Manufacturing technique and its use for the spinal reconstruction after en-bloc resection for primary osteogenic sarcoma. METHODS: Clinical case presentation and the design of the 3D custom titanium vertebra was reported. It was also described the complex procedures adopted to evaluate the retrieved device from the histological point of view, as a tumor relapse hit the patient, one year after the reconstruction procedure. RESULTS: The histological evaluation confirmed that the resection technique exerts an important role in promoting bone formation: vertebral body osteotomies favored the reconstruction procedure and maximized the contact area between host bone/vertebral prosthesis thus favoring the bone tissue penetration and device colonization. CONCLUSION: The sharing of these results is very important as they represent the starting point for improving the knowledge starting from the evidence obtained in a challenging clinical condition and with post-operative treatments that could be never reproduced in preclinical model.

Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them?

PURPOSE: To investigate whether the World Health Organization Safety Surgical Checklist (SSC) is an effective tool to reduce complications in spinal surgery. METHODS: We retrospectively evaluated the clinical and radiological charts prospectively collected from patients who underwent a spinal surgery procedure from January 2010 to December 2012. The aim of this study was to compare the incidence of complications between two periods, from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist's effectiveness. RESULTS: The sample size was 917 patients with an average of 30-month follow-up. The mean age was 52.88 years. The majority of procedures were performed for oncological diseases (54.4%) and degenerative diseases (39.8%). In total, 159 complications were detected (17.3%). The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. No correlation was observed between the type of pathology and the complication incidence. We observed a reduction in the overall incidence of complications following the introduction of the SSC: In 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%). CONCLUSIONS: The SSC seems to be an effective tool to reduce complications in spinal surgery. We propose to extend the use of checklist system also to the preoperative and postoperative phases in order to further reduce the incidence of complications. These slides can be retrieved under Electronic Supplementary Material.

Metastatic epidural spinal cord compression: does timing of surgery influence the chance of neurological recovery? An observational case-control study.

PURPOSE: Metastatic epidural spinal cord compression (MESCC) is radiologically defined as an epidural metastatic lesion causing the displacement of the spinal cord from its normal position in the vertebral canal. The purpose of this paper is the evaluation of the influence of timing of surgery on the chance of neurological recovery. METHODS: This is a retrospective observational case-control study performed on patients with MESCC from solid tumors surgically treated at our institute from January 2010 to December 2016. Patients included were divided in two groups depending on surgery that was performed within or after 24 h the admission to the hospital. Neurological status was assessed with American Spine Injury Association (ASIA) Impairment Scale. RESULTS: No statistically significant difference was observed in the variation of ASIA if surgery is performed within or after 24 h from the admission to the hospital. A statistically significant difference was observed after surgery in each group in the improvement of neurological status. A statistically significant difference was reported in the early post-operative complications in patients surgically treated within 24 h. CONCLUSION: MESCC management is challenge for spine surgeons and may represent an oncologic emergency and if not promptly diagnosed can lead to a permanent neurological damage. According to this study, there is no difference in the chance of neurological recovery if surgery is performed within or after 24 h the admission to hospital, but there is a greater rate of early post-operative complications when surgery is performed within 24 h from the admission to the hospital.

Cryosurgery in the excision of a giant local recurrent sacral chordoma: a case report and literature review.

PURPOSE: Chordoma is a low-grade malignant tumor with recurrence and metastasis tendency that originates from embryonic notochordal remnants. The sacrococcygeal region is the most commonly involved site. The aim of this paper is to report the results of the use of cryosurgery in the excision of a giant recurrent sacral chordoma and review of pertinent literature. METHODS: A 64 years old female patient with a locally recurrent sacral chordoma came to our attention after ten interventions performed at another institute. A surgical treatment was performed using argon cryosurgery. RESULTS: In this case, it was not possible to perform a marginal or wide excision, but it was intralesional with the removal of three major blocks. The fragments sent for the histological analysis measured total 35 × 30 × 8 cm with a weight of 4.260 g. CONCLUSIONS: Given the gelatinous structure of the tumor and the possibility of contamination of operatory field, cryosurgery may be indicated when previous surgeries and the dimensions of tumor mass do not allow a resection with negative margins improving radiotherapy efficacy in the local control of tumor.

Biomimetic 3D-printed custom-made prosthesis for anterior column reconstruction in the thoracolumbar spine: a tailored option following en bloc resection for spinal tumors : Preliminary results on a case-series of 13 patients.

PURPOSE: Various techniques for anterior column reconstruction have been described after en bloc resection of spinal tumors. Limited evidence exists regarding one being superior to another. The purpose of this study is to evaluate 3D-printed vertebral bodies for spinal reconstruction after en bloc resection in the thoracolumbar spine. METHODS: Prospective observational study on custom-made 3D-printed titanium reconstruction of vertebral bodies after en bloc resection for spinal tumor was conducted between November 2015 and June 2017. 3D-printed vertebral bodies were monitored for mechanical complications such as (1) migration, (2) subsidence into the adjacent vertebral bodies, and/or (3) breakage. Complications and related details were recorded. RESULTS: Thirteen patients (7 females and 6 males) were enrolled, and reconstruction of the anterior column was performed using custom-made 3D-printed titanium prosthesis after en bloc resection for spinal tumor (8 primary bone tumors and 5 solitary metastases). Subsidence into the adjacent vertebral bodies occurred in all patients at both proximal and distal bone-implant interfaces; however, it was clinically irrelevant (asymptomatic, and no consequences on posterior instrumentation), in 11 out of 12 patients (92%). In 1 patient (#4), severity of the subsidence led to revision of the construct. At an average 10-month follow-up (range 2-16), 1 implant was removed due to local recurrence of the disease and 1 was revisioned due to progressive distal junctional kyphosis. CONCLUSION: Preliminary results from this series suggest that 3D printing can be effectively used to produce custom-made prosthesis for anterior column reconstruction. These slides can be retrieved under Electronic Supplementary Material.

Peroneal Tubercle Hypertrophy: A Case Report.

The peroneal tubercle is an osseous prominence present on the calcaneus bone at the junction between the middle and the anterior third of its lateral surface. It is a bony septum which divides the tendons of the peroneus brevis and the peroneus longus and offers insertion to the inferior peroneal retinaculum. A hypertrophy of this prominence causes pain in the lateral and the posterior part of the foot while wearing shoes, rarely peroneal tenosynovitis can even cause it to break. In the following pages, we will describe a case of peroneal tubercle hypertrophy, visible even at clinical examination, in a 26-year-old male patient without apparent causes nor previous trauma.

Determinants of outcome after endovascular therapy for critical limb ischemia with tissue loss.

BACKGROUND: In this study we examine outcomes of endovascular therapy for critical limb ischemia with tissue loss and identify risk factors for failure of endovascular therapy across a panel of outcome metrics. METHODS: A retrospective review (2006-2010) of patients undergoing endovascular therapy for critical limb ischemia with tissue loss provided data for multivariate models of overall survival, amputation-free survival, limb salvage (LS), and wound healing. RESULTS: One hundred six patients underwent endovascular therapy for Rutherford class 5 (88%) or class 6 (12%) ischemia with ulceration and/or gangrene of the heel (15%), forefoot (16%), toe(s) (43%), calf/ankle (11%), or multiple locations (15%). Sustained limb salvage at 1 year was 87%. One-year overall survival and amputation-free survival were 65% and 49%, respectively. Multivariate regression models identified independent risk factors for reduced primary patency: Rutherford 6 ischemia (P = 0.008; HR 4.7 [95% confidence interval 1.5-14.8]) and infrapopliteal intervention (P = 0.03; HR 2.58 [95% CI 1.08-6.14]). Rutherford class 6 ischemia was independently associated with reduced assisted patency (P = 0.004; HR 5.39 [95% CI 1.74-16.73]). Wound healing was adversely affected by diabetes (P = 0.02; HR 7.0 [95% CI 1.4-36.2]), continued smoking (P = 0.04; HR 5.3 [95% CI 1.1-26.3]), and patency loss (P = 0.04; HR 4.8 [95% CI 1.1-22.30]). Rutherford class 6 ischemia was independently associated with reduced limb salvage (P < 0.0001; HR 35.1 [95% CI 5.4-231.2]) and amputation-free survival (P = 0.007; HR 3.61 [95% CI 1.4-9.18]), in addition to COPD (P = 0.01; 3.58 [95% 1.28-9.55]). Independent predictors of poor overall survival included end-stage renal disease (P = 0.03; HR 2.99 [95% CI 1.1-8.05]), history of angina (P = 0.02; HR 5.08 [95% CI 1.28-20.29]), and COPD (P = 0.001; HR 3.77 [95% CI 1.76-8.34]). CONCLUSIONS: Both increasing severity of tissue loss as well as the presence of severe medical comorbidities are associated with poorer outcomes of endovascular therapy in these patients. Although sustained limb salvage in patients with tissue loss may be achieved with endovascular therapy, this is due to poor overall survival and a competing mortality hazard.

Denosumab Re-Challenge and Long-Term Efficacy for Aneurysmal Bone Cyst of the Spine: Enhanced Treatment Algorithm.

Background/Objective: Surgical treatment of aneurysmal bone cysts (ABCs) can be challenging, especially in the spine. Non-surgical treatments such as with denosumab have shown promising results in different osteolytic pathologies. This retrospective observational study aimed to evaluate the long-term clinical and radiologic response of patients with ABCs of the mobile spine treated with denosumab and propose an updated treatment algorithm. Methods: Six patients with relapsed and symptomatic ABCs of the mobile spine were treated with denosumab (120 mg subcutaneously on days 1, 8, 15, 29, and every 4 weeks thereafter) between 2012 and 2023. Disease assessments were conducted using CT and MRI at 3, 6, 9, and 12 months post-treatment. Clinical data, including pain levels, symptoms, and adverse events, were documented from patients' charts. Results: Patients underwent an initial phase of treatment with denosumab, receiving a mean of 22 administrations (range 13-42) over a median follow-up period of 41 months (range 15-98 months). Clinical improvement was observed in all patients after 4 weeks of treatment, and all patients demonstrated a radiological response after 12-24 weeks on denosumab. Three patients were progression-free after discontinuing denosumab following 13, 15, and 42 administrations, respectively. At the last follow-up, after 38, 43, and 98 months, these patients remained stable without relapse of the disease. Three patients had a relapse of disease after denosumab; two of them underwent denosumab re-challenge, while one patient received one mesenchymal stem cells (MSCs) injection. All patients showed clinical and radiological improvement and were resulted to be disease-free at the last follow-up. Conclusions: This study demonstrates the long-term efficacy and safety of denosumab in treating ABCs of the mobile spine, as well as the potential of re-challenge in managing recurrence. A treatment algorithm is proposed, positioning denosumab as a viable therapeutic option after other local treatments. Careful patient selection, monitoring, and further research are necessary to optimize denosumab use for ABCs.

What is the Association of the Subsections of the Oswestry Disability Index and Overall Improvement Two Years after Lumbar Surgery for Degenerative Lumbar Spondylolisthesis?

STUDY DESIGN: Retrospective review of a prospective cohort study. OBJECTIVE: To identify the association between Oswestry Disability Index (ODI) subsections and overall improvement 2 years after lumbar surgery for degenerative lumbar spondylolisthesis (DLS). BACKGROUND: DLS often necessitates lumbar surgery. The ODI is a trusted measure for patient-reported outcomes (PROMs) in assessing spinal disorder outcomes. Surgeons utilize the ODI for baseline functional assessment and post-surgery progress tracking. However, it remains uncertain if and how each subsection influences overall ODI improvement. METHODS: This retrospective cohort study analyzed patients who underwent lumbar surgery for DLS between 2016 and 2018. Preoperative and 2-year postoperative ODI assessments were conducted. The study analyzed postoperative subsection scores and defined ODI improvement as ODIpreop-ODIpostop >0. Univariate linear regression was applied, and receiver operating characteristic (ROC) analysis determined cut-offs for subsection changes and postoperative target values to achieve overall ODI improvement. RESULTS: 265 patients (60% female, mean age 67±8 y) with a baseline ODI of 50±6 and a postoperative ODI of 20±7 were included. ODI improvement was noted in 91% (242 patients). Achieving a postoperative target score of ≤2 in subsections correlated with overall ODI improvement. Walking had the highest predictive value for overall ODI improvement (AUC 0.91, sensitivity 79%, specificity 91%). Pain intensity (AUC 0.90, sensitivity 86%, specificity 83%) and changing degree of pain (AUC 0.87, sensitivity 86%, specificity 74%) were also highly predictive. Sleeping had the lowest predictability (AUC 0.79, sensitivity 84%, specificity 65%). Except for sleeping, all subsections had a Youden-index >50%. CONCLUSION: These findings demonstrate how the different ODI subsections associate with overall improvement post-lumbar surgery for DLS. This understanding is crucial for refining preoperative education, addressing particular disabilities, and evaluating surgical efficacy. Additionally, it shows that surgical treatment does not affect all subsections equally.

The Impact of the COVID-19 Pandemic on Ambulatory Lumbar Spine Decompression Surgery.

Background Only a few studies have examined the impact of the coronavirus disease 2019 pandemic on spine ambulatory surgeries and changes in trends. Therefore, we investigated trends during the pre-pandemic period and three pandemic stages in patients undergoing lumbar decompression procedures in the ambulatory surgery (AMS) setting. Methodology A total of 2,670 adult patients undergoing one- or two-level lumbar decompression surgery were retrospectively reviewed. Patients were categorized into the following four groups: 1: pre-pandemic (before the pandemic from January 1, 2019, to March 16, 2020); 2: restricted period (when elective surgery was canceled from March 17, 2020, to June 30, 2020); 3: post-restricted 2020 (July 1, 2020, to December 31, 2020, before vaccination); and 4: post-restricted 2021 (January 1, 2021 to December 31, 2021 after vaccination). Simple and multivariable logistic regression analyses as well as retrospective interrupted time series (ITS) analysis were conducted comparing AMS patients in the four periods. Results Patients from the restricted pandemic period were younger and healthier, which led to a shorter length of stay (LOS). The ITS analysis demonstrated a significant drop in mean LOS at the beginning of the restricted period and recovered to the pre-pandemic levels in one year. Multivariable logistic regression analyses indicated that the pandemic was an independent factor influencing the LOS in post-restricted phases. Conclusions As the post-restricted 2020 period itself might be independently influenced by the pandemic, these results should be taken into account when interpreting the LOS of the patients undergoing ambulatory spine surgery in post-restricted phases.

The Impact of Paraspinal Muscle Degeneration on Oswestry Disability Index Subsections Two Years After Spinal Surgery for Degenerative Lumbar Spondylolisthesis.

STUDY DESIGN: Secondary analysis of prospective study. OBJECTIVE: To investigate the impact of fatty infiltration (FI) in the paraspinal muscles (PM) on postoperative Oswestry Disability Index (ODI) subsection-scores in patients undergoing elective lumbar surgery for degenerative lumbar spondylolisthesis (DLS). BACKGROUND: DLS can increase FI in the PM like the multifidus (MF), erector spinae (ES), and psoas (PS), leading to greater spinal disability and higher ODI-scores. It is unclear if increased PM FI affects all ODI subsections equally. METHODS: This study reviewed data from a single-center cohort of DLS-patients who underwent elective lumbar surgery. Overall ODI and the subsection scores were prospectively assessed before and 2 years post-surgery. FI of the PS, MF, and ES was measured using T2-weighted MRI images. The relationship between PM FI and postoperative ODI subsections were analyzed, using multivariable linear regression analysis. RESULTS: Overall, 229 patients (59% female, mean age of 67±8 y) were included with an overall baseline ODI of 50[40-62] and a postoperative ODI of 16.[2-34] The highest preoperative subsection-scores were seen in pain intensity (4[2-4]), changing degree of pain (4[3-4]), lifting (4[1-5]), and standing (4[3-4]). PM-measurements showed a mean FI of 41±10% for ES, 58±15% for MF, and 6±5% for PS. Patients with increased ES FI were more likely to show higher postoperative scores in all ODI subsections and in the overall ODI (Est=0.45, 95%CI 0.20-0.71, P=0.004). Increased MF FI was significantly associated with higher postoperative ODI subsection scores in standing (Est=0.02, 95%CI 0.01-0.03, P=0.033) and walking (Est=0.02, 95%CI 0.01-0.03, P=0.017). CONCLUSION: Increased erector spinae fatty infiltration is significantly associated with higher ODI scores across all subsections 2 years after lumbar surgery, while higher multifidus fatty infiltration is linked to greater disability in standing and walking. These findings underscore the need to maintain paraspinal muscle health to improve surgical planning, improve rehabilitation outcomes, and reduce postoperative disability.

The Disaggregated Oswestry Disability Index: What is the Most Predictive Subsection for Patient Satisfaction After Lumbar Surgery?

STUDY DESIGN: Retrospective review of cohort studies. OBJECTIVE: To analyze how different ODI subsections and their improvement affect patient satisfaction 2 years after elective lumbar surgery for degenerative lumbar spondylolisthesis (DLS). BACKGROUND: The Oswestry Disability Index (ODI) is crucial in evaluating outcomes of spinal disorders and provides valuable insights into a patient's preoperative status. There is limited information available on the individual characteristics of its subsections and their relation to postoperative patient satisfaction. METHODS: Pre- and 2-year postoperative ODI and patient satisfaction were assessed. The analysis included preoperative scores and improvements in each ODI subsection 2 years postoperatively. Satisfaction was rated on a scale of 1 to 5, with scores ≥4 deemed satisfactory. Univariate linear regression and ROC analysis established cutoffs for subsection improvement and postoperative target values to achieve postoperative satisfaction. RESULTS: 265 patients (60% female, 67±8 years) were included. ODI improvement was achieved in 91%, and postoperative patient satisfaction in 73%. Patients with lower postoperative subsection scores and greater differences between pre- and postoperative scores were more likely to be satisfied (all P<0.001). A postoperative subsection target score of ≤1 was associated with patient satisfaction. Change in degree of pain was the most predictive subsection for satisfaction, with an AUC of 0.84 (sensitivity 79%, specificity 86%). Walking (AUC 0.83, sensitivity 87%, specificity 65%), pain intensity (AUC 0.82, sensitivity 79%, specificity 79%), personal care (AUC 0.82, sensitivity 83%, specificity 68%), and standing (AUC 0.82, sensitivity 83%, specificity 83%) all had an AUC greater than 0.80. The postoperative subsection with the lowest predictability was sleeping (AUC 0.69). CONCLUSION: Pain domains, walking, standing, and personal care were the subsections with the highest predictability for patient satisfaction. These findings on the correlation between different ODI subscales and patient satisfaction are valuable for improving preoperative education, addressing disability, and ensuring postoperative satisfaction.

Prolonged operative time significantly impacts on the incidence of complications in spinal surgery.

BACKGROUND: In spinal surgery adverse events (AE) and surgical complications (SC) significantly affect patient's outcome and quality of life. The duration of surgery has been investigated in different surgical field as risk factor for complications. The aim of this study is to analyze the correlation between operative time and adverse events in spinal surgery. METHODS: We retrospectively analyzed data collected prospectively in a cohort of 336 patients surgically treated for spinal diseases of oncological and degenerative origin in a single center, between January 2017 to January 2018. Demographics and clinical data were collected. Adverse events were classified using Spinal Adverse Events Severity System version 2 (SAVES-V2) capture system. Focusing on degenerative patients, bivariate analysis and univariate logistic regression were used to determine the association between operative time and complications. RESULTS: A total of 105/336 patients experienced an AE related to surgery, respectively 38% in the oncological group and 28% in the degenerative group. The average age at surgery was 60.3 years (SD 17.1) and the mean operative time was 164.8 ± 138 min. A total of 206 adverse events (30 intraoperative, 135 early postoperative and 41 late postoperative AEs) were recorded. Early post-operative complications accounted for the most recorded AEs (55.5% in the oncological group and 73.2% in the degenerative group). Univariate logistic regression analyses confirmed that operative time correlated with increased risk of intra-operative (p-value = 0.0008), early post-operative (p-value < 0.001) and late post-operative (p-value < 0.001) adverse events. CONCLUSIONS: This study highlights the strong correlation between the occurrence of adverse events in spinal surgery and prolonged operative time and suggests that efforts should be made to minimize the duration of surgical procedures while prioritizing patient's safety, without compromising the technical achievement of the procedure.

Intentional Enneking-inappropriate surgery and high-energy particle therapy for unresectable osteogenic sarcoma of the spine: a retrospective study.

OBJECTIVE: The aim of this study was to compare the outcome of intralesional gross-total resection (GTR) followed by high-energy particle therapy with en bloc and intralesional resections. METHODS: A retrospective study of patients diagnosed with primary osteogenic sarcoma (OGS) of the spine between 2009 and 2020 was conducted. Demographic information, including age, affected site, tumor volume, and Weinstein-Boriani-Biagini stage, was collected. Additionally, information on metastases at diagnosis, length of stay, operating time, complications, planned surgical treatment, and radiotherapy was also collected. Outcome measures, including local recurrence (LR) and disease-specific survival (DSS), were compared using Kaplan-Meier curves. RESULTS: In total, 20 patients with a median age of 38 (IQR 23-60) years were included. The median follow-up was 15.7 (IQR 6.3-36.9) months. Eight patients underwent en bloc resection with a 38% (3 patients) LR rate and a median DSS of 26.4 months. Four patients received adjuvant high-energy particle therapy after planned GTR. Their median follow-up was 36 months; none of these patients experienced LR. Both the 1-year and 3-year DSSs were 100%. Another 8 patients underwent intralesional resection. Six of the 8 patients (75%) died of their disease, with a median survival of 7.3 (IQR 4.7-14) months. CONCLUSIONS: GTR combined with adjuvant high-energy particle therapy appears to be a safe and effective alternative approach for patients with OGS of the spine when en bloc resection is not feasible. The results demonstrated a 3-year DSS of 100% and no major surgical complications.