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Clinical Spine Surgery - Current Issue

Clinical Spine Surgery - Current Issue
  1. Insertional Torque in Cervical Vertebrae Lateral Mass Screw Fixation: Magerl Technique Versus Roy-Camille Technique
    imageStudy Design: This is a prospective multicenter comparison study. Objective: To measure the insertional torque (IT) for cervical vertebra lateral mass screw (LMS) fixation using the Magerl and Roy-Camille methods, at the discretion of the surgeon. Summary of Background Data: Current fixation methods for patients with preoperative cervical spine instability use LMSs; however, few studies have closely examined intraoperative IT. Patients’ bone quality was not measured. Methods: A total of 637 posterior cervical multiaxial screws were inserted for LMS (C3–C6) (Magerl technique, 423; Roy-Camille technique, 214) in 107 cases. Patients’ mean age was 66 years. Patients treated with the Magerl method were divided into 2 groups, with the men in the MM group and the women in the MF group. Similarly, patients treated with the Roy-Camille method were divided into 2 groups, with the men in the RM group and the women in the RF group. The contralateral cortex was penetrated, and the IT at cerclage was measured at the last time. Results: IT of the lateral mass screw was 53.8±22.4, 45.4±21, 45.5±16.9, and 34±16.4 cN.m in the MM group (258), MF group (165), RM group (163), and RF group (51), respectively. The MM group had a significantly higher IT than the other 3 groups, and the RM group had a significantly higher IT than the RF group. When the correlation between screw length and IT was evaluated, IT was significantly (P<0.05) higher with a longer screw by the Magerl method. Conclusions: The IT was higher with the Magerl method with a longer screw. Screw length and IT were not correlated with the Roy-Camille method; furthermore, the Roy-Camille method went through bilateral cortical bone perpendicularly, so that IT was determined by the fixation power in the cortical part of the bone, which was not thought to be affected by screw length. Level of Evidence: Level III.



  2. Palliative Surgery for Spinal Metastases Using Posterior Decompression and Fixation Combined With Intraoperative Vertebroplasty
    imageStudy Design: Retrospective study. Objective: To evaluate the clinical outcome of palliative surgery using posterior decompression and fixation combined with intraoperative vertebroplasty (PDFIV) for the treatment of spinal metastases, and analyze the indications for PDFIV using a neurological, oncologic, mechanical, and systemic framework. Summary of Background Data: Palliative surgery is widely used to spinal metastatic patients with poor condition for enough postoperative recovery. PDFIV which is a new palliative surgery is rarely reported its efficacies and indications. Methods: A retrospective analysis of 26 consecutive patients with spinal metastases treated by PDFIV was performed. The group includes 18 men and 8 women with an average age of 55.7 years (range, 47–79 y). All patients presented with local pain, 18 patients had compressive myelopathy, and 9 had radiculopathy. The total segments involved were 32. Postoperative imaging was used to evaluate cement leakage, the status of fixation, and recurrence. The visual analogue score and Frankel grade were used to identify neurological function. Results: There were no intraoperative neurological or vascular injuries. The mean operative time was 173 minutes (range, 125–245 min), the mean blood loss was 659 mL (range, 350–2500 mL), and the average amount of cement used in the vertebrae was 4.1 mL (range, 2.0–5.5 mL). All patients were followed for an average of 25 months (range, 6–56 mo). The visual analogue score decreased from 8.1 preoperatively to 2.1 postoperatively. Fifteen of 18 patients with compressive myelopathies had improved Frankel grades. Postoperative computed tomography scans showed cement leakage in 3 patients (11.5%); however, all of the leakages were clinically asymptomatic. There were local tumor recurrences requiring reoperation in 2 patients. Conclusions: Palliative surgery using PDFIV can improve neurological function and alleviate pain effectively, and allow low cement leakage and timely disposal of leakage combined with intraoperative visual vertebroplasty.



  3. Comparison of Curvature Between the Zero-P Spacer and Traditional Cage and Plate After 3-Level Anterior Cervical Discectomy and Fusion: Mid-term Results
    imageStudy Design: A retrospective study. Objective: To compare clinical and radiologic outcomes of 3-level anterior cervical discectomy and fusion between a zero-profile (Zero-P) spacer and a traditional plate in cases of symptomatic cervical spine spondylosis. Summary of Background Data: Anterior cervical decompression and fusion is indicated for patients with anterior compression or stenosis of the spinal cord. The Zero-P spacers have been used for anterior cervical interbody fusion of 1 or 2 segments. However, there is a paucity of published clinical data regarding the exact impact of the device on cervical curvature of 3-level fixation. Methods: Clinical and radiologic data of 71 patients undergoing 3-level anterior cervical discectomy and fusion from January 2010 to January 2012 were collected. Zero-P spacer was implanted in 33 patients, and in 38 cases stabilization was accomplished using an anterior cervical plate and intervertebral cage. Patients were followed for a mean of 30.8 months (range, 24–36 mo) after surgery. Fusion rates, changes in cervical lordosis, and degeneration of adjacent segments were analyzed. Dysphagia was assessed using the Bazaz score, and clinical outcomes were analyzed using the Neck Disability Index and Japanese Orthopedic Association scoring system. Results: Neurological outcomes did not differ significantly between groups. Significantly less dysphagia was seen at 2- and 6-month follow-up in patients with the Zero-P implant (P<0.05); however, there was significant less cervical lordosis and the lordosis across the fusion in patients with the Zero-P implant (both P<0.05). Degenerative changes in the adjacent segments occurred in 4 patients in the Zero-P group and 6 patients in the standard-plate group (P=0.742); however, no revision surgery was done. Conclusions: Clinical results for the Zero-P spacer were satisfactory. The device is superior to the traditional plate in preventing postoperative dysphagia; however, it is inferior at restoring cervical lordosis. It may not provide better sagittal cervical alignment reconstruction in 3-level fixation. Prospective randomized trials with more patients and longer follow-up periods are required to confirm these observations.



  4. Is 1-stage Posterior Corpectomy More Favorable Compared With Decompression With Fusion to Control Thoracic Cord Compression by Metastasis?
    imageStudy design: A retrospective comparative study Objective: To compare 1-stage posterior corpectomy to decompression with fusion for the control of thoracic cord compression due to a metastatic tumor. Summary of Background Data: Thoracic cord compression by a metastatic tumor can cause back pain, paralysis, and urinary/bowel dysfunction and is generally treated by palliative decompressive surgery. However, no studies have assessed the advantages of 1-stage posterior corpectomy compared with decompression with fusion. Methods: We studied 18 patients who underwent surgery for thoracic cord compression due to metastatic tumors between September 2009 and August 2013. Neurological examination was performed preoperatively and postoperatively. Data on operative time, blood loss during surgery, postoperative complications, and survival time were retrospectively retrieved from electronic medical records. Patients were divided into 2 groups based on treatment: decompression and corpectomy (corpectomy group, n=8) and decompression with fusion (decompression-fusion group, n=10). Data were statistically compared between the 2 groups. Results: The mean age of the patients was 61±12 years. Motor weakness and urinary/bowel dysfunction were observed in 15 and 9 cases, respectively. Five patients, who could walk before surgery, could walk at 1 month following surgery. However, only 3 of the 13 patients who could not walk before surgery regained the ability to walk. No difference was found in the degree of muscle strength recovery between the 2 groups. However, the corpectomy group showed higher blood loss (2200 vs. 710 mL, P=0.037) and longer operative time (281 vs. 217 min, P=0.029) than the decompression-fusion group. Conclusions: There is no significant advantage of 1-stage posterior corpectomy over decompression with fusion. Furthermore, more blood loss and longer operative time may increase the risk of postoperative complications following corpectomy. For this reason, 1-stage posterior corpectomy to control thoracic metastasis should be considered with caution.



  5. Comparison of Clinical Outcomes After Anterior Cervical Discectomy and Fusion Versus Cervical Total Disk Replacement in Patients With Modic-2 Changes on MRI
    imageStudy Design: A retrospective investigation. Objective: The aim of this research is to compare the clinical and radiologic outcomes of patients with Modic-2 changes who underwent anterior cervical discectomy and fusion (ACDF) or cervical total disk replacement (TDR) in single level. Summary of Background Data: There were few studies focused on the clinical and radiologic outcomes of patients with Modic-2 changes who underwent ACDF or cervical TDR in single level. Materials and Methods: A total of 76 patients with Modic-2 changes who underwent TDR or ACDF with complete follow-up data were analyzed retrospectively. Patients with chronic axial symptoms resulting from single-level cervical spine disease manifested as radiculopathy or myelopathy following 6 months of invalid conservative treatment. Clinical evaluations were performed preoperatively and repeated at 5 years after operation. Results: In this study, a total of 72 patients (94.7%) with a minimum of 5 years of follow-up data were available for analysis. There were 35 (18 men and 17 women) in the TDR group and 37 (20 men and 17 women) in the ACDF group. There was no difference in preoperative Japanese Orthopedic Association, Neck Disability Index, range of motion (ROM), and Visual Analogue Scale (VAS), on arm pain and neck pain between the 2 groups (P=0.663), but the TDR group showed significant differences in VAS for neck pain and ROM compared with that of the ACDF group at the last follow-up (P<0.05). Both groups reported significant improvements in Japanese Orthopedic Association, Neck Disability Index, ROM, and VAS, on arm pain and neck pain from the preoperative means (P<0.05). Conclusions: Patients with Modic-2 changes in TDR group received a large discectomy and leading to the removal of the majority of the inflammatory disk tissue. TDR is a significantly better maintenance of index-level ROM than ACDF. The mid-term outcomes demonstrated that the both TDR and ACDF groups maintain favorable clinical results on patients with Modic-2 changes, who received TDR have significantly better maintenance of ROM than ACDF.


  6. Is a Drain Tip Culture Required After Spinal Surgery?
    imageStudy Design: The efficacy of use of a drain tip culture for early detection of surgical-site infection (SSI) was investigated in 329 patients after spinal surgery. Objective: To examine the efficacy of a wound drain tip culture for detection of SSI in spinal surgery. Summary of Background Data: A complication of SSI after spinal surgery has high associated morbidity and mortality, and is often difficult to treat. Materials and Methods: The subjects were patients who underwent spinal surgery at our institution between January 2010 and March 2013. All subjects were treated with antimicrobial prophylaxis based on evidence-based guidelines and were followed for at least 6 months after surgery. Data from culture studies using the distal tip of the wound drain were used for analysis. Results: Drain tip cultures were positive in 34 cases and there were 19 SSIs. Ten of the 34-tip culture-positive wounds developed SSI. Drain tip cultures had a sensitivity of 52%, specificity of 92%, positive predictive value (PPV) of 29%, and negative predictive value of 97% for predicting a wound infection. The association between a positive suction tip culture and wound infection was significant (P<0.05). The PPV for SSI was 60% in cases in which methicillin-resistant bacteria were detected in a drain tip, and the SSI rate in these cases differed significantly compared with those with non–methicillin-resistant bacteria (P=0.01). Conclusions: A drain tip culture is useful for early detection of SSI caused by methicillin-resistant bacteria.



  7. Vertebral Body Hounsfield Units are Associated With Cage Subsidence After Transforaminal Lumbar Interbody Fusion With Unilateral Pedicle Screw Fixation
    imageObjective: To assess the association between Hounsfield units (HU) measurement and cage subsidence after lumbar interbody fusion. Background: Transforaminal lumbar interbody fusion (TLIF) with unilateral fixation becomes a popular treatment modality for lumbar degenerative disease. Cage subsidence is a potentially devastating complication after lumbar interbody fusion with unilateral fixation. Recently, a new technique for assessing bone mineral density using HU values from computed tomography has been proposed. Bone quality is believed to be one of the important factors that cause cage subsidence after TLIF. Materials and Methods: Cage subsidence after single-level (L4/5) TLIF with unilateral fixation was prospectively documented at a single institution between 2013 and 2014. Patients with cage subsidence were matched 1:1 to a control cohort without cage subsidence on the basis of age and sex. HU values were measured from the preoperative computed tomography. All patients received computed tomographic scans at a minimum of 6 months postoperatively. Sagittal images were evaluated for evidence of cage subsidence. Results: Eighteen patients with cage subsidence were well matched 1:1 to a cohort without cage subsidence and had complete imaging data. The global lumbar HU values were significantly lower in patients with cage subsidence than in the controls (112.4±10.08 vs. 140.2±10.17; P=0.0015). Similarly, a regional assessment of HU across the fusion levels was significantly lower in patients with cage subsidence (113.4±10.47 vs. 127.9±8.13; P=0.0075). The areas under the receiver operating characteristic cure were 0.715 and 0.636 for global and regional assessment, respectively. The best cut-offs for global and regional assessment were 132 (sensitivity: 83.3%; specificity: 61.1%) and 122 (sensitivity: 72.2%; specificity: 55.6%), respectively. Conclusions: Lower preoperative HU values is associated with cage subsidence after TLIF with unilateral fixation. HU measurement may be used as a predictor of cage subsidence after unilateral fixation, which also should be incorporated in preoperative planning.



  8. Transpedicular Corpectomy and Cage Placement in the Treatment of Traumatic Lumbar Burst Fractures
    imageStudy Design: Retrospective review. Objective: To review the feasibility of a posterior-only approach for instrumented reconstruction in lumbar burst fractures. Background: Burst fractures of the lumbar spine have been treated through a variety of techniques, including anterior, posterior, or combined approaches. Here we review series of patients undergoing posterior-only transpedicular corpectomy with instrumented fusion for traumatic lumbar burst fracture. Methods: All patients treated at the Los Angeles County+University of Southern California (LAC+USC) Medical Center who had sustained traumatic lumbar burst fractures from February 2005 to February 2014 were reviewed. Results: A total of 178 traumatic lumbar burst fractures were identified of which 89 required operative intervention. Of those 89 operations, 7 patients underwent posterior-only approach for transpedicular corpectomy. Levels operated on were at L1 (4 patients), L2 (1 patient), and L4 (2 patients). The mean age was 35 years of age (range, 21–56 y), and mechanism of injury was either motor vehicle accident (5 patients) or fall (2 patients). Initial neurological examination was American Spinal Injury Association (ASIA) B in 3 patients, ASIA D in 3 patients, and 1 patient was neurologically intact. Mean thoracolumbar injury classification and severity score on presentation was 6.4 (range, 5–8), whereas the mean load sharing classification score was 7.4 (range, 7–9). Of patients who were not immediately lost to follow-up on hospital discharge, mean clinical follow-up was 45.3 months (range, 18.8–68.6 mo), whereas mean radiographic follow-up was 28.8 months (range, 1.3–63.6 mo). At the last known radiographic follow-up, no patient had gross hardware fracture, pseudoarthrosis, or adjacent segment disease. One patient with the longest radiographic follow-up of 63.6 months was noted to have some minimal subsidence of his cage with no other change in his other hardware. Conclusion: A posterior-only approach for transpedicular corpectomy and instrumented fusion is a viable treatment option for lumbar burst fracture which allows for reconstruction of the anterior column while avoiding many of the risks and complications associated with an anterior or combined approach.



  9. Life Expectancy and Metastatic Spine Scoring Systems: An Academic Institutional Experience
    imageStudy Design: A retrospective data collection study with application of metastatic spine scoring systems. Objectives: To apply the Tomita and revised Tokuhashi scoring systems to a surgical cohort at a single academic institution and analyze spine-related surgical morbidity and mortality rates. Summary of Background Data: Surgical management of metastatic spine patients requires tools that can accurately predict patient survival, as well as knowledge of morbidity and mortality rates. Methods: An Oregon Health & Science University (OHSU) Spine Center surgical database was queried (years 2002–2010) to identify patients with an ICD-9 code indicative of metastatic spine disease. Patients whose only surgical treatment was vertebral augmentation were not included. Scatter plots of survival versus the Tomita and revised Tokuhashi metastatic spine scoring systems were statistically analyzed. Spine-related morbidity and mortality rates were calculated. Results: Sixty-eight patients were identified: 45 patients’ (30 male patients, mean age 45 y) medical records included operative, morbidity, and mortality statistic data and 38 (26 male patients, mean age 54 y) contained complete metastatic spine scoring system data. Of the 38 deceased spine metastatic patients, 8 had renal cell, 7 lung, 4 breast, 2 chondrosarcoma, 2 prostate, 11 other, and 4 unknown primary cancers. Linear regression analysis revealed R2 values of 0.2570 and 0.2009 for the revised Tokuhashi and Tomita scoring systems, respectively. Overall transfusion, infection, morbidity, and mortality rates were 33% and 9%, and 42% and 9%, respectively. Conclusions: Application of metastatic prognostic scoring systems to a retrospective surgical cohort revealed an overall poor correlation with the Tomita and revised Tokuhashi predictive survival models. Morbidity and mortality rates concur with those in the medical literature. This study underscores the difficulty in utilizing metastatic spine scoring systems to predict patient survival. We believe a scoring system based on cancer type is needed to account for changes in treatment paradigms with improved patient survival over time.



  10. Percutaneous Kyphoplasty for the Treatment of Osteoporotic Vertebral Fractures With Intravertebral Fluid or Air: A Comparative Study
    imageStudy Design: A retrospective comparative study. Objective: To compare the characteristics of osteoporotic vertebral fractures (OVFs) with intravertebral fluid (IVF) and those with intravertebral air (IVA), and the efficacy of percutaneous balloon kyphoplasty (PKP) in treating OVFs with these 2 different intravertebral components. Summary of Background Data: Previous studies have focused on the efficacy of percutaneous vertebroplasty (PVP) and PKP in treating OVFs with intravertebral cleft. However, no prior studies investigated the impact of the different components of cleft on the therapeutic effect of PVP or PKP. Methods: On the basis of the presence of IVF or IVA signal on preoperative MR images, 22 patients were classified into IVF group and 13 patients into IVA group. The characteristics of patients with IVF and those with IVA were compared. The anterior and middle heights of the involved vertebrae, the kyphotic angles, the Visual Analogue Scale (VAS), and Oswestry Disability Index (ODI) scores were recorded preoperatively, 1 day after surgery, and at last follow-up. Results: Severe collapse of involved vertebrae (P=0.024) and the gap appearance of clefts (P=0.004) were significantly more common in IVA group than in IVF group. The vertebral heights, the local kyphotic angles, the VAS, and ODI scores were all significantly improved after PKP in both groups. However, the vertebral height restoration and kyphotic deformity correction were more significant in IVF group than in IVA group (P<0.001). No significant differences regarding VAS and ODI scores were detected between the 2 groups at each follow-up time. Conclusions: PKP is an effective treatment strategy for both OVFs with IVF and with IVA, whereas vertebral height restoration and kyphotic deformity correction are much more significant in vertebrae with IVF. Presence of IVA without fluid filling-in on MR images may indicate an advanced stage of intravertebral osteonecrosis.


  11. Compressive Myelopathy in Congenital Kyphosis of the Upper Thoracic Spine: A Retrospective Study of 6 Cases
    imageStudy Design: A retrospective study. Objective: The goal of this retrospective study was to describe the uncommon presentation of neurological deficits in patients with congenital kyphosis of the upper thoracic spine (T1–T4). Summary of Background Data: Congenital kyphosis is an uncommon deformity but can potentially lead to spinal cord compression and paraplegia, particularly in type I (failure of formation) deformities. Few reports have described compressive myelopathy associated with congenital kyphosis of the upper thoracic spine. Methods: Six patients with congenital kyphosis of the upper thoracic spine, including 2 adults and 4 pediatric patients, developed progressive or sudden onset of paraplegia. Angles of kyphosis ranged from 75 to 120 degrees. Magnetic resonance imaging demonstrated spinal cord thinning and compression at the kyphotic apex in all patients. All patients underwent decompressive and correctional surgery by single-stage posterior vertebral column resection or 2-stage anterior corpectomy fusion and posterior fixation. Neurological status was evaluated using the ASIA impairment classification and the motor score. Results: Postoperatively, all patients had 25%–80% correction of kyphosis. All patients improved neurologically between 0 and 2 ASIA scales after surgery. Among them, an adolescent patient presenting as acute ASIA A improved to ASIA E within 1 year after surgery. Another adolescent patient deteriorated from preoperative ASIA C to ASIA A in the immediate postoperative period but improved to ASIA D within 1 year after surgery. Conclusions: Congenital kyphosis of the upper thoracic spine has a high incidence of compressive myelopathy. Duration from onset of paraplegia to surgical intervention and severity of preoperative paraplegia are 2 key factors in determining neurological prognosis after surgery.



  12. Utility of the Surgical Apgar Score for Patients Who Undergo Surgery for Spinal Metastasis
    imageStudy Design: Retrospective review of patients who underwent surgery for spinal metastasis between 2005 and 2011. Objective: To assess the utility of the surgical Apgar score (SAS) in patients who underwent surgery for spinal metastasis. Summary of Background Data: Surgery for spinal metastasis can be associated with relatively high morbidity and mortality. Consequently, identifying patients at risk for major postoperative complications is important. Several studies have validated SAS for predicting 30-day complication risk. Methods: SASs were calculated and patients stratified into 5 groups: scores 0–2, 3–4, 5–6, 7–8, 9–10 points. Multivariate logistic regression assessed whether SAS was an independent predictor of major complication 30 days after surgery. Multivariate analysis of covariance assessed whether SAS was independently associated with length of stay. Results: Ninety-seven patients with a variety of metastatic tumors were analyzed. There was no obvious trend in complication rates, or significant association between SAS and complication rate (P=0.413). Complication rates were 25.0% for SASs 0–2, 33.3% for 3–4, 18.4% for 5–6, 10.0% for 7–8, and 33.3% for 9–10 points. On multivariate analysis, SAS was not independently associated with complications; age above 65 years (odds ratio 4.19; 95% confidence interval, 1.31–52.27; P=0.028) and preoperative Karnofsky Performance Score of 10–40 (odds ratio 9.13; 95% confidence interval, 1.42–58.63; P=0.020) were associated with higher odds of complication. SASs 0–2 were an independent predictor of longer hospital stay (P=0.004). Conclusions: Our findings suggest that SAS is not a significant predictor of major perioperative complications after spinal metastasis surgery; preoperative functional status and age are stronger predictors. The need continues for a preoperative scoring system to reliably predict risk for perioperative complications after spinal metastasis surgery.



  13. Psychogenic Low-Back Pain and Hysterical Paralysis in Adolescence
    imageStudy Design: A retrospective review. Objective: The purpose of this study was to investigate the clinical outcomes in adolescents diagnosed with psychogenic low-back pain and hysterical paralysis and to evaluate the efficacy of differential diagnosis methods. Summary of Background Data: The incidence of low-back pain in adolescence is similar to that in adults, but the causes of low-back pain are difficult to determine in most cases. For these patients, a definitive diagnosis of psychogenic low-back pain and hysterical paralysis as well as adequate treatment are clinically important to avoid unnecessary surgical treatment. Methods: Eleven patients (3 males and 8 females; mean age, 16.5 years; range, 13–19 y) diagnosed with psychogenic low-back pain and hysterical paralysis were followed up for 2–10.25 years (mean, 4.67 y). Nonorganic signs were observed in almost all patients. For the purpose of excluding organic disorders, the thiopentone pain study was used in patients who complained mainly of pain, and motor evoked potentials using transcranial magnetic stimulation were measured in patients experiencing primarily muscle weakness. Results: The psychiatric diagnosis was neurosis in 9 patients, whereas it was psychosomatic disorder in 2 patients. Conservative treatment, such as physiotherapy, was performed, and at the final follow-up evaluation, outcomes were regarded as excellent in 7 patients and good in 4 patients. Conclusions: The prognosis of psychogenic low-back pain and hysterical paralysis in adolescence is relatively good. However, it is important to understand the characteristics of psychogenic low-back pain and hysterical paralysis in childhood and young adulthood and to perform accurate diagnosis by screening for nonorganic signs and excluding organic disorders by using the thiopentone pain study and motor evoked potentials obtained using transcranial magnetic stimulation.



  14. Metastatic Spine Tumor Surgery: A Comparative Study of Minimally Invasive Approach Using Percutaneous Pedicle Screws Fixation Versus Open Approach
    imageStudy Design: Prospective cohort study. Summary of Background Data: Minimally invasive spinal surgery (MISS) has been gaining recognition in patients with metastatic spine disease (MSD). The advantages are reduction in blood loss, hospital stay, and postoperative morbidity. Most of the studies were case series with very few comparing the outcomes of MISS to open approaches. Objective: To evaluate and compare the clinical and perioperative outcomes of MISS versus open approach in patients with symptomatic MSD, who underwent posterior spinal stabilization and/or decompression. Patients and Methods: Our study included 45 MSD patients; 27 managed by MISS and 18 by open approach. All patients had MSD presenting with symptoms of neurological deficit, spinal instability, or both. Preoperative, intraoperative, and postoperative data were collected for comparison of the 2 approaches. All patients were followed up until the end of study period (maximum up to 4 years from time of surgery) or till their demise. The clinical outcome measures were pain control, neurological and functional status, whereas perioperative outcomes were blood loss, operative time, length of hospital stay, and time taken to initiate radiotherapy/chemotherapy after index surgery. Results: Majority of patients in both groups showed improvement in pain, neurological status, independent ambulation, and ECOG score in the postoperative period with no significant differences between the 2 groups. There was a significant reduction in intraoperative blood loss (621 mL less, P<0.001) in the MISS group. The average time to initiate radiotherapy after surgery was 13 days (range, 12–16 d) in MISS and 24 days (range, 16–40 d) in the open group. This difference was statistically significant (P<0.001). Operative time and duration of hospital stay were also favorable in the MISS group, although the differences were not significant. Conclusions: MISS is comparable with open approach demonstrating similar improvements in clinical outcomes, that is pain control, neurological and functional status. MISS approaches have also shown promising results due to lesser intraoperative blood loss and allowing earlier radiotherapy/chemotherapy.



  15. Semirigid Waved Rod System for the Treatment of the Degenerative Lumbar Diseases
    imageBackground: The semirigid pedicle screw instrumentation has gained wide popularity in recent decennium in lumbar fusion surgery. However, few data were documented to compare the clinical efficacy between semirigid and traditional rigid pedicle screw systems. Materials and Methods: A total of 96 patients with degenerative lumbar diseases were selected to perform operations between 2008 and 2013. The patients were prospectively randomized into 2 groups: 50 patients were managed by semirigid waved rod systems and 46 patients were intervened by traditional rigid straight stiff rod systems. X-rays and computed tomography were utilized to examine the interbody fusion status in the follow-up in detail. Surgical parameters such as operative time, blood loss, and total hospital stay were calculated and compared. Visual Analog Scale and Oswestry Disability Index were used to assess clinical efficacy postoperatively. Results: No significant differences were found about demographic data between groups. There were no significant differences regarding the surgical parameters including operative time, blood loss, and total hospital stay. Visual Analog Scale and Oswestry Disability Index postoperatively were also similar between the 2 instrumentations (P>0.05). The fusion rate was higher in the semirigid group (45/50) than in the traditional group (34/46) (P=0.039) at the final follow-up. Conclusions: Waved rod may be better in facilitating interbody fusion compared with traditional straight rod, although waved rod and straight stiff rod can both get similar clinical efficacy. Meanwhile, waved rod is likely superior in alleviating adjacent degeneration segments.


  16. White Blood Cell Count and C-Reactive Protein Variations After Posterior Surgery With Intraoperative Radiotherapy for Spinal Metastasis
    imageStudy Design: Retrospective case series. Objective: To evaluate the feasibility of blood test parameters [white blood cell (WBC) count and C-reactive protein (CRP)] for predicting and diagnosing postoperative infection after posterior surgery with intraoperative radiotherapy (IORT) for spinal metastasis. Summary of Background Data: Posterior surgery with IORT is effective for treating spinal metastasis, as we previously reported. However, the procedure requires that the patient be transferred from the operating room to the irradiation room. In addition, the patient’s general status is often poor, and the risk of postoperative infection is high. Materials and Methods: A total of 279 patients who underwent IORT for the treatment of spinal metastasis between August 2004 and June 2013 were included in this study. The WBC count (/103 μL) and CRP level (mg/dL) were recorded in all patients preoperatively and on alternative days for up to 7 days after surgery. We assessed the development of surgical-site infection (SSI) for up to 1 month after surgery. Results: SSI occurred in 41 patients (14.7%). The preoperative WBC count and CRP level did not differ between the infected and noninfected patients. The WBC counts on postoperative day (POD) 1 and POD 7 and the CRP levels on POD 7 were significantly higher in the infected patients (8.8 vs. 10.0, P=0.04; 6.1 vs. 8.8, P=0.002; 3.89 vs. 9.50, P<0.001). A receiver-operating characteristic curve analysis of the WBC count and CRP level for detecting SSI showed cutoff values of 9.6 (WBC count, POD 1), 6.5 (WBC count, POD 7), and 5.0 (CRP level, POD 7). Conclusions: A high WBC count and CRP level on POD 7 may be used to predict or detect SSI. In particular, a CRP level of 5.0 mg/dL on POD 7 strongly suggests the future development of SSI (sensitivity: 78%, specificity: 74%).



  17. Patient Satisfaction is Not Associated With Self-reported Disability in a Spine Patient Population
    imageStudy Design: This is a retrospective review. Objective: To evaluate the relationship between patient functional status and self-assessment of disability as measured by 3 commonly used clinical assessment instruments—the Oswestry Disability Index (ODI), the Neck Disability Index (NDI), and the EuroQol (EQ)-5D and patient satisfaction scores in a spine surgery clinic population. Summary of Background Data: Patient satisfaction surveys, which measure the “patient experience of care” are becoming an increasingly important measure of the quality of medical care. Despite the widespread use of patient satisfaction surveys, little is known about the relationship between patient satisfaction and patient functional status or self-assessed level of disability. Materials and Methods: We retrospectively reviewed records of 231 consecutive patients presenting to a single academic spine surgery center between February 2011 and October 2013 who completed both a patient satisfaction survey as well as one or more patient-reported outcome questionnaires (NDI, ODI, and/or EQ-5D) for a single clinical encounter. Statistical analysis was performed to determine if an association exists between the overall patient satisfaction score and each patient-reported outcome score. Results: Spearman correlation coefficients demonstrated no correlation between any patient-reported outcome score and the patient satisfaction score [NDI=−0.113 (−0.409 to 0.207) P=0.489] [ODI=−0.008 (−0.149 to 0.133) P=0.912] [EQ-5D=0.011 (−0.119 to 0.140) P=0.872] for a single clinical encounter. Conclusions: These results provide evidence against an association between patient-reported functional status or self-assessed level of disability and patient satisfaction in a spine patient population.



  18. Prospective Cohort Study of Performance Status and Activities of Daily Living After Surgery for Spinal Metastasis
    imageStudy Design: A prospective cohort study of performance status (PS) and activities of daily living (ADL) in patients with spinal metastasis. Objective: To identify the effect of spinal surgery on PS and ADL in patients with spinal metastasis. Summary of Background Data: Spinal metastasis causes severe neurological deficits, resulting in drastic loss of patients’ PS and ADL. However, the effect of spine surgery on PS and ADL is not well known. Materials and Methods: Seventy patients with spinal metastasis were enrolled in this study. Forty-six patients desired and underwent spine surgery (“surgery” group) and 24 patients did not desire surgery (“nonsurgery” group). Both groups received optimal treatments, including radiation, chemotherapy, and palliative care services. Evaluation was performed at 1, 3, and 6 months after study enrollment using the Eastern Cooperative Oncology Group PS, the Barthel index (BI) for ADL, and Frankel classification for neurological status. Results: There was no significant difference in baseline PS, the BI, or Frankel classification between the groups. The surgery group showed significant improvement in PS, maintaining grade 2 or less throughout the duration of the study, as well as in ADL, exceeding 70 points of the BI, compared with the nonsurgery group (P<0.05). Significantly improved neurological condition was also observed in the surgery group over the following 6 months. More than 95% of patients who underwent surgery improved their PS, the BI, and neurological status. Furthermore, >80% of these patients maintained improvement in PS, the BI, and neurological status for at least 6 months. In contrast, PS, the BI, and neurological status of patients in the “nonsurgery” group deteriorated throughout the study period. Conclusions: Spine surgery improves PS, ADL, and neurological status in patients with spinal metastasis for a minimum 6 months. This indicates that these patients can acquire an independent daily life.



  19. A Retrospective Cohort Study Comparing the Safety and Efficacy of Minimally Invasive Versus Open Surgical Techniques in the Treatment of Spinal Metastases
    imageStudy Design: A retrospective cohort study. Objective: This study was conducted to assess the invasiveness, efficacy, and safety of minimally invasive spine stabilization (MISt) for metastatic spinal tumor patients with short life expectancy. Summary of Background Data: Conventional open surgery for metastatic spinal tumors has the disadvantages of significant blood loss, potential infection, damage to back muscles, and extended hospital stays. The minimally invasive spine surgery has changed the treatment of metastatic spinal tumors radically and fundamentally. Materials and Methods: We retrospectively reviewed data from 50 consecutive patients registered with the Keio Spine Research Group (KSRG) who underwent posterior palliative surgery for metastatic spinal tumors from January 2009 to June 2015. Of these, 25 patients underwent MISt surgery (M group), and 25 underwent conventional open surgery (C group). The patients were assessed by demographic data, surgical invasiveness, complications, pain improvement, and neurological recovery. Results: The 2 groups did not differ significantly in baseline characteristics. The M group had significantly less blood loss (M, 340.1 mL; C, 714.3 mL; P=0.005), less postoperative drainage (M, 136.0 mL; C, 627.0 mL; P<0.001), lower rates of red blood cell transfusion (M, 3 cases; C, 10 cases; P=0.029), and a shorter postoperative period of bed rest (M, 2.0 d; C, 3.6 d; P<0.001), compared with the C group. The perioperative complication rates were significantly lower (P=0.012) in the M group (3 patients, 12%) than in the C group (11 patients, 44%). Neurological deficits and pain improved significantly and comparably in the 2 groups after surgery. Conclusions: MISt is a less invasive and effective alternative surgery to conventional open surgery for metastatic spinal tumors. MISt should be considered as a valid option for the treatment of metastatic spinal tumor patients with a short life expectancy. Level of Evidence: Level 3.



  20. Anterior Versus Posterior Approaches for Odontoid Fracture Stabilization in Patients Older Than 65 Years: 30-day Morbidity and Mortality in a National Database
    imageStudy Design: Retrospective cohort analysis. Objective: To compare 30-day perioperative clinical outcomes of surgical odontoid stabilization by an anterior or posterior operative approach in elderly patients. Summary of Background Data: Surgical stabilization of odontoid fractures is superior to nonoperative management in geriatric patients. How elderly patients with odontoid fractures fare after anterior and posterior approaches, however, is not well defined. Materials and Methods: Retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database (2005–2013). Elderly patients (≥65 y) with odontoid fractures who underwent odontoid stabilization through anterior or posterior approaches were identified by International Classification of Diseases 9th Revision/Common Procedure Terminology codes. Exclusion criteria included concomitant subaxial spine surgery, instrumentation noncontiguous with the atlantoaxial interval, and combined approaches. Baseline demographics and perioperative details were compared. Adverse events, mortality, reoperation, discharge, and readmission rates within 30 days of operation were compared using bivariate and multivariate generalized linear regressions. Results: One hundred forty-one patients (male—81; female—60; average age: 77.8±6.5 y; anterior approach—48; posterior approach—93) were analyzed. Patients scheduled to have a posterior approach had significantly more nonunions preoperatively and higher body mass indices. Operative times for posterior surgeries were significantly longer. Age, comorbidities, functional dependence, time to surgery, and length of hospital stay were similar between groups. There were no significant differences in the relative risk (RR) of the composite outcome of “any adverse event” after adjusting for differences in baseline characteristics. Patients who underwent an anterior approach were more likely to have an unplanned hospital readmission (RR=8.95; 95% confidence interval, 2.21–36.29; P=0.002) and have significantly more revision operations (RR=19.51; 95% confidence interval, 2.49–152.62; P=0.005) than patients who had a posterior operation. Conclusions: An anterior approach for odontoid fracture stabilization in patients ≥65 years old were associated with shorter operative times and greater RRs of unplanned readmissions and revision operations within 30 days of surgery relative to a posterior approach.


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