Global Spine Journal

Literature review of key topics related to degenerative cervical myelopathy (DCM) with critical appraisal and clinical recommendations.

This article summarizes several key current topics related to the management of DCM.

Recent literature related to the management of DCM was reviewed. Four articles were selected and critically appraised. Recommendations were graded as Strong or Conditional.

Article 1: The Relationship Between pre-operative MRI Signal Intensity and outcomes. Conditional recommendation to use diffusion-weighted imaging MR signal changes in the cervical cord to evaluate prognosis following surgical intervention for DCM. Article 2: Efficacy and Safety of Surgery for Mild DCM. Conditional recommendation that surgery is a valid option for mild DCM with favourable clinical outcomes. Article 3: Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial. Strong recommendation that there is equipoise in the outcomes of anterior vs posterior surgical approaches in cases where either technique could be used. Article 4: Machine learning-based cluster analysis of DCM phenotypes. Conditional recommendation that clinicians consider pain, medical frailty, and the impact on health-related quality of life when counselling patients.

DCM requires a multidimensional assessment including neurological dysfunction, pain, impact on health-related quality of life, medical frailty and MR imaging changes in the cord. Surgical treatment is effective and is a valid option for mild DCM. In patients where either anterior or posterior surgical approaches can be used, both techniques afford similar clinical benefit albeit with different complication profiles.

Case-control study.

Degenerative Cervical Myelopathy (DCM) is a progressive neurological condition caused by mechanical stress on the cervical spine. Surgical exposure in the preceding months to a DCM diagnosis is a common theme of Patient and Public Involvement (PPI) discussions. Such a relationship has biological plausibility (e.g. neck positioning, cord perfusion) but evidence to support this association is lacking.

We analysed UK Hospital Episode Statistics (HES) data for participants in the UK BioBank cohort. We defined cases as those episodes with a primary diagnosis of DCM and generated controls using non-DCM HES episodes. Cases and controls were propensity score-matched by age, sex and date of episode, and a directed acyclic graph was used to robustly control for confounders. We defined the exposure as any surgical procedure under general or regional anaesthetic occurring within the 6-24 months prior to the episode.

We analysed 806 DCM and 2287432 non-DCM hospital episodes. On multivariable logistic regression analysis, the odds ratio (95% CI) for the effect of a binarised (0 vs ≥ 1) exposure on risk of developing DCM was 1.20 (1.02-1.41), and for categorised (0 vs 1 and 0 vs ≥ 2) exposure was 1.11 (0.882-1.39) & 1.33 (1.075-1.65).

This study supports the patient narrative of surgery as a risk factor for the development of DCM. The association displays temporality, dose-response relationship, and biological plausibility. Further work is needed to confirm this in other cohorts, explore mediating mechanisms, and identify those at greatest risk.

Retrospective cohort study.

Using propensity match score to remove those confounding bias and focuses on age factor to compare clinical outcomes and perioperative complications following spinal surgery in cohort of Korean octogenarians treated at a single tertiary hospital.

We classified patients of 80s as the octogenarian group (group O), those 65 and older, and under 80 as the elderly group (group E). We strategically employed the Propensity Score Matching (PSM) analysis as a method to counteract potential confounding variables. 1: 1 nearest-neighbor PSM for fusion level, estimated blood loss (EBL), transfusion, body mass index (BMI), American society of anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI) surgical method and operation time was performed. After PSM, 98 patients are categorized each group evenly (group O, n = 49 vs group E, n = 49). Demographics, clinical, radiologic and postoperative complications were analyzed.

The clinical outcomes showed no significant differences in the VAS and ODI preoperatively or postoperatively. And most of hospitalization related factors shows no differences between 2 groups. However, follow-up period was longer in group E (1053.37 ± 684.14 days) than group O (640.29 ± 496.68, P = 0.001) and group O has higher incidences of medical complication (38.77% vs 16.32%, P = 0.013), especially in delirium (34.69% vs 6.12%, P = 0.001) than group E.

With the preparation for the prevention and treatment of postoperative delirium, age itself should not be a reason to hesitate in performing the spinal surgery.

Rat subjects were randomly assigned to control, local, and systemic esomeprazole groups (n = 4-6 per group).

Excessive scar formation after laminectomy can cause nerve entrapment and postoperative pain and discomfort. A rat laminectomy model determined whether topical application and systemic administration of esomeprazole can prevent epidural fibrosis.

Laminectomy alone was performed in the control group. Topical esomeprazole was introduced to the laminectomy area in the local esomeprazole group. Intraperitoneal esomeprazole was introduced in the systemic esomeprazole group following laminectomy. Macroscopic and histopathologic examinations were performed four weeks after laminectomy.

In the systemic esomeprazole group, the macroscopic epidural fibrosis score was less than the control group (P < 0.001). Microscopic epidural fibrosis score and fibroblast cell density classification scores in local and systemic esomeprazole groups did not significantly differ. Fibrosis thickness was significantly lower in the local and systemic esomeprazole groups compared to the control group (P < 0.01, P < 0.001, respectively).

Esomeprazole reduced the formation of epidural fibrosis in the rat laminectomy model.

Experimental spinal cord lesion study.

To evaluate the effects of erythropoietin at different doses on neural regeneration in rats undergoing spinal cord injury.

Anesthetized Wistar rats were submitted to standardized spinal cord injury and randomized into eight groups, receiving different magnitudes of trauma and single or repeated doses of intraperitoneal erythropoietin (500 or 5000 IU/kg of body weight). We evaluated motor function using BBB scores and sensorimotor behavior by observing the rats walking on a horizontal ladder (at 2, 4, and 6 weeks) and performed histological analysis of the spinal cord after euthanasia. We compared the scores between groups using analysis of variance (ANOVA) and Bonferroni multiple comparisons.

The experiments were conducted with 10 animals per group (n = 80), none of which died or were excluded. BBB scores increased over time (meaning recovery) in all groups (P < 0.001 for all). From the fourth week, animals receiving lower trauma and higher erythropoietin doses had higher BBB scores than those receiving lower doses. The total number of steps and correct steps taken on the horizontal ladder increased, and slips decreased over time with treatment in all groups. Although the number of errors was different between moments (P < 0.001), it was not different between groups (P = 0.707). Rats receiving higher impact lesions had more spinal cord necrosis and worse recovery of neuronal fibers than the rest.

Animals receiving a higher dose of erythropoietin and suffering minor trauma showed better and faster neurological recovery. Repeating erythropoietin after a week showed no benefit.

Retrospective radiological database analysis.

The aim of this study was to assess the value of functional radiography (FRF = flexion; FRE = extension) compared to MRI and standing sagittal plane full spine radiography (SP) with low-grade spondylolisthesis.

Sagittal translation (ST) and rotation (SR) were measured between all lumbar levels to assess instability. The differences for ST and SR of SP and FRE as well as MRI and FRF were calculated. In addition, the lumbar lordosis, the sacral slope, the pelvic tilt and the pelvic incidence were measured.

Radiological datasets of 55 patients with 165 lumbar segments fulfilled inclusion criteria. Instability was diagnosed in 20 segments (12.1%) with SP/MRI compared to 14 segments (8.5%) using FRF/FRE with ST. SR functional radiographs showed instability in 41 segments (25%) and 23 segments (14%) using SP/MRI. The intraclass correlation coefficients (ICC) of ST between SP and FRE for L3/L4, L4/L5, and L5/S1 were 0.74, 0.84 and 0.97, respectively, indicating moderate to excellent agreement between imaging methods. For SP/FRE, the ICCs of the SR were 0.72, 0.61 and 0.64, respectively with moderate agreement. The ICCs of the ST for L3/4, L4/5, and L5/S1 showed moderate to good agreement between MRI and FRF with values of 0.52, 0.77, and 0.80, respectively. Regarding SR, poor agreement between MRI and FRF was observed. The ICCs for L3/4, L4/5, L5/S1 were 0.16, 0.23 and 0.23.

Based on our results, instability may also be diagnosed by calculating the difference in the ST in SP and MRI without additional functional radiographs. However, FRF showed translational instability more clearly than MRI in some patients and might still be an asset in borderline cases.

Cross-sectional survey.

Surgical treatment of degenerative lumbar spondylolisthesis is remarkably varied due to heterogeneity of clinical-radiological presentations. This study aimed to assess which spinopelvic radiological parameters were considered for decision-making.

Survey distributed to International AO Spine members to analyze surgeons’ considerations for treatment. Data collected includes demographics, training background, years of experience, and treatment decisions based on various radiographical findings, including segmental and global spinopelvic parameters.

From 479 responses, the most frequently radiological parameter considered was slippage on dynamic X-rays (79.1%), followed by disc height (78.9%), global sagittal balance SVA (71.4%), and PI-LL mismatch (69.7%), while the least important was absolute spondylolisthesis on static lateral radiograph (22.8%). Fellowship-trained surgeons were likelier to use SVA (OR = 1.73, 95% CI = 1.02-2.99, P = 0.049), and disc height (2.13, 1.14-3.98, P < 0.05). There was no difference between orthopedics and neurosurgery in applying SVA and PI-LL mismatch. Surgeons from Asia Pacific emphasizes segmental lordosis (2.39, 1.11-5.15, P = 0.026) as from Latin America (2.55, 1.09-5.95, P = 0.030) and Middle East (4.33, 1.66-11.28, P = 0.003). However, surgeons from Latin America and Middle East also significant consider disc height (2.95, 1.07-8.15, P = 0.037) and (3.03, 1.04-8.83, P = 0.043), respectively. Additionally, the surgeons’ age was associated with using angular motion on flexion-extension radiographs, and volume of treated cases yearly with consideration for disc height.

Treatment of degenerative lumbar spondylolisthesis was influenced by slippage on dynamic radiographs, disc height, global alignment, and PI-LL mismatch. Surgeons’ age and Region, fellowship-trained, and volume of treated cases were significantly associated to apply these radiological parameters.

Retrospective Matched Cohort Study.

Optimization of medical comorbidities is an essential part of preoperative management. However, the isolated effects of individual comorbidities have not been evaluated within a homogenous spine surgery population. This exact matching study aims to assess the independent effects of cancer on outcomes following single-level lumbar fusions for non-cancer surgery.

4680 consecutive patients undergoing single-level posterior-only lumbar fusion were retrospectively enrolled. Univariate statistics and coarsened exact matching (CEM) were computed to evaluate outcomes between cancer patients and those without comorbidities.

By logistic regression, malignancy conferred a higher risk of surgical complication (P = 0.016, OR = 2.64, CI = [1.200,5.790]), 30- and 90- day readmission (P = 0.012, OR = 2.025, CI = [1.170-3.510]; P < 0.001, OR = 2.34, CI = [1.430, 3.830], respectively), 90-day reoperation (P < 0.001, OR = 2.16, [1.110, 4.200]), and death at 90-days (P = 0.032, OR = 8.27, CI = [1.200, 56.850]). After matching, malignancy was associated with increased odds of incidental durotomy (6 vs 0 cases, P = 0.048) and death at both 30 and 90 days (both: OR = 8.0, P = 0.020, CI = [1.00, 63.960]). No cases of durotomy occurred in cases with mortality in the matched sample, suggesting independent relationships. There were no differences in length of stay, non-home discharge, ED evaluation, readmission, or reoperations.

Among otherwise exact-matched patients undergoing single level lumbar fusion, history of malignancy conferred a higher risk of short-term mortality, but not other outcomes suggestive of surgical failure. Increased mortality after lumbar fusion should be studied further and may play a role in surgical decision-making and patient discussions.

Retrospective cohort study.

This study aimed to examine the incidence and risk factors for recurrent proximal junctional failure (R-PJF) in adult spinal deformity (ASD) surgery.

Among 482 patients receiving ≥ five-level fusion to the pelvis for ASD, 60 patients who underwent fusion extension surgery for PJF were included in the study cohort. R-PJF was defined as the performance of re-revision surgery after revision surgery for PJF. Various clinical and radiographic variables were compared between no R-PJF and R-PJF groups. Stepwise multivariate logistic analysis was performed to identify the risk factors for R-PJF.

Of the 60 patients, there were 51 women (85.0%) and 9 men (15.0%) with a mean age of 72.4 ± 6.7 years. The mean fusion length at the index surgery was 7.3 ± 1.6 levels and an average of 4.1 ± 1.3 levels was extended during the revision surgery. Among them, R-PJF developed in 17 patients (28.3%). Multivariate analysis revealed that overcorrection relative to age-adjusted pelvic incidence (PI) – lumbar lordosis (LL) at the index surgery and high total sum of proximal junctional kyphosis severity scale (PJKSS) at the revision surgery were significant risk factors for R-PJF development. The cutoff value for the PJKSS sum was calculated as 8.5 points.

R-PJF was developed in 17 patients (28.3%). PI–LL overcorrection should be avoided during the index surgery to mitigate the R-PJF. In addition, timely surgical intervention is required in patients with PJF, considering that the PJF severity tends to increase over time.

Retrospective cohort study.

De novo postoperative urinary retention (POUR) after lumbar posterior decompression surgery for lumbar spinal canal stenosis (LSCS) is a statistically known but uncommon complication for both patients and spine surgeons. The aim of this study is to review clinical data and imaging findings and identify preoperative predictors of de novo POUR.

The subjects were 738 surgically treated patients with LSCS, without preoperative bladder dysfunction or perioperative complications. Univariate and multivariate analyses using propensity score matching were performed to identify prognostic factors for POUR lasting for at least 1 week after postoperative urinary catheter removal.

POUR occurred in 23 patients (3.1%). The median recovery time was 41 days and only 12 patients (52.2%) showed improvement within 3 months. Patients with POUR were significantly older, and the lumbar Cobb angle, location of compressed dura mater (ventral or dorsal), and type of cauda equina redundancy (curve-type) were identified as independent prognostic factors. POUR had no association with sex, comorbidities, surgical procedures, number of decompressed segments, or degree of dura mater compression.

This study suggests that older age and curve-type stenosis with ventral or dorsal compression of the dura mater are risk factors for development of de novo POUR. Such preoperative imaging findings may indicate a higher risk of intraoperative thermal and nerve injuries, and possible uneven cauda equina flow improvement after decompression.

Retrospective cohort study.

The objective of this study was to characterize the association between cell-salvage and allogeneic transfusion rate in pediatric patients undergoing posterior arthrodesis for scoliosis.

NSQIP Pediatric database years 2016-2022 was used. Patients under the age of 18 who received posterior arthrodesis with 7 or more surgical levels for spinal deformity correction were included. Rates of cell-salvage and allogeneic transfusion were determined. We assessed the impact of cell-salvage on the rate of allogeneic transfusion using chi-square test and multivariable logistic regression.

There were 34,241 patients in this study. The rate of allogeneic transfusion was 21.6% (n = 7407). The allogeneic transfusion rates for idiopathic, neuromuscular, and congenital/syndromic scoliosis were 12.3%, 50.8%, and 25.9%, respectively. Cell-salvage was used in 71.1% of patients (n = 24,344). In the multivariable regression analysis, longer operative time (P < .001), non-idiopathic scoliosis (P < .001), hematocrit less than 35 (P < .001), and ≥13 surgical levels (P < .001) were associated with higher odds of allogeneic transfusion. Use of cell-salvage (P < .001), increasing age (P < .001), and increasing patient weight (P < .001) were associated with significantly lower odds of allogeneic transfusion. In a subanalysis, use of cell-salvage was associated with reduced rate of allogeneic transfusion in patients with idiopathic scoliosis. Cell-salvage was not associated with reduced rates of allogeneic transfusion in neuromuscular and congenital/syndromic scoliosis.

This is the largest study investigating the impact of cell-salvage on rate of allogeneic transfusion in pediatric spinal deformity surgery. Use of cell-salvage is associated with reduced allogeneic transfusion rates in idiopathic scoliosis surgery.

Randomized controlled trial.

In this study, we hypothesize administering fixed-dose intravenous steroid (Methylprednisolone) intraoperatively would reduce neuroinflammation and enhance functional and radiological outcomes in decompressive surgeries for DCM. Primary objectives were to assess effect of intraoperative MP on modified Japanese Orthopedic Association (mJOA) score, Nurick grade, and MRI signal changes.

This prospective triple-blinded randomized controlled trial included 65 patients allocated into MP (n = 33) and control (n = 32) groups. MP (dose-1g) was administered intraoperatively at the beginning of decompression. Clinical outcome measures included mJOA score, Nurick grading, mJOA recovery rate (mJOA RR), Nurick recovery rate (NRR), and complication rates in both groups at 1-, 3-and 24-month follow-up. Radiological outcome was assessed by analyzing regression of T2W and T1W SI changes on MRI scans as per Chen’s grading at 24-months follow-up.

MP group exhibited greater improvement in mJOA scores at 24-months (mean improvement: +6.69 vs +6.42; difference: +0.27, 95% CI: −0.37 to +0.91) but was statistically insignificant (P = .107). Similarly, mJOA-RR showed a moderate effect size of 0.42 (95% CI: 0.04 to 0.80) and 0.37 (95% CI: −0.01 to 0.75) at 1-and 3-months follow-up respectively. NRR improvements were observed, with effect sizes of 0.40 (95% CI: 0.02 to 0.78) and 0.49 (95% CI: 0.11 to 0.87) at 1- and 3-months respectively, but not statistically significant (P = .28). At 24-months, MP group had significantly better MRI outcome (Chen grading: mean change +1.15 vs +0.83; effect size: −0.71, 95% CI: −1.09 to −0.33; P = .038).Complication rates were comparable between both groups, emphasizing safety of MP administration.

Although null hypothesis was not proven, intraoperative MP administration in DCM surgery demonstrated safety and suggested potential neuroprotective benefits to enhance clinical recovery and reduce spinal cord signal changes. However, further large-scale, multicentric studies are needed to validate these findings and optimize its dose.

Retrospective case serie.

Assess the correlation between pedicle screw (PS) position of the first instrumented vertebra (FIV) with proximal adjacent segment degeneration (ASD) development or progression.

Patients ≥55 years who have undergone lumbar fusion with a minimum 2-year follow-up were included. Radiographic PS position was assessed by the angle between the first PS and the upper vertebral endplate (VE) and by the PS tip-VE distance. Radiographic parameters of ASD included: disc height, disc angle, and vertebral listhesis. ASD magnetic resonance imaging (MRI) parameters included: disc degeneration and lumbar stenosis. ROC curve analysis was performed to identify the best cut-off points in correlation with lumbar stenosis.

Forty-eight patients were included with an average follow-up of 6 years. All 48 included patients developed some degree of ASD whether on radiographic or MRI parameters. PS tip-VE distance and PS-VE angle were both positively correlated with: (1) Delta (Δ) lumbar stenosis; (2) Δ Disc degeneration; and (3) Δ Disc height. ROC curve analysis correlating PS tip-VE distance and PS-VE angle with an increase in the canal stenosis severity ≥2° resulted in a cut-off point of 36% and 9.5°, respectively.

The cranial orientation (PS-VE angle) of the pedicle screw in the first instrumented vertebra, along with a shorter pedicle screw tip-vertebral endplate distance (PS tip-VE), positively correlated with ASD progression at an average 6-year follow-up. Protective values against lumbar stenosis were identified as a PS tip-VE distance ≥36% of the first instrumented vertebra height and a PS-VE angle ≤9.5° relative to the upper vertebral endplate.

Retrospective Cohort Study.

Despite innovations in minimally invasive (MI) techniques for sacroiliac joint fusion (SIJF), trends in utilization and associated costs remain unclear. In this study, we assessed these trends and costs in a database of privately insured patients.

Records of open and MI SIJFs were queried from the 2007-2021 MarketScan Databases with CPT codes. Net payments made by insurance carriers were identified, as were out-of-pocket payments made by patients for each encounter. Regression was used to model utilization, payments, and costs.

4124 SIJFs were identified, 1626 (39.4%) of which were MI SIJF. SIJF utilization increased by 1176.2% throughout the study period (P < .001). However, open SIJF utilization peaked in 2012. Open SIJF utilization was not significantly associated with time (P = .18). By contrast, the peak utilization for MI procedures occurred in 2021. Spine surgeons’ volume of MI SIJF increased by 258% over the study period (P < .001), while nonsurgeon volume of MI SIJF increased by 990.9% (P < .001).

Privately insured patients have increasingly utilized SIJF over the past several years. This is predominantly due to the adoption of MI techniques by spine surgeons and nonsurgeons.

Retrospective cohort study.

Limited clinical literature addresses potential differences in fusion features between Oblique lumbar interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF). We observed that in OLIF, there are many cases with the appearance of extra-vertebral bone bridges (EVB), a phenomenon distinct from traditional TLIF fusion. This study aims to compare fusion rates, cage subsidence, and fusion features among OLIF stand-alone (OLIF-SA), OLIF with posterior pedicle screw fixation (OLIF-PS), and TLIF.

We retrospectively analyzed 198 patients (311 levels) undergoing OLIF-SA, OLIF-PS, or TLIF from July 2017 to June 2021. We assessed patient-reported outcomes, cage subsidence, fusion rate, and fusion features on CT scans.

The study included 64 OLIF-SA patients (102 levels), 60 OLIF-PS patients (99 levels), and 74 TLIF patients (110 levels). Cage settling rates were 33.3% (OLIF-SA), 17.2% (OLIF-PS), and 32.8% (TLIF), with significant differences between OLIF-PS and TLIF (P < 0.05). Cage subsidence rates showed no significant difference: 11.8% (OLIF-SA), 9.1% (OLIF-PS), and 12.7% (TLIF) (P > 0.05). Fusion rates were 100% (OLIF-SA), 97.0% (OLIF-PS), and 96.4% (TLIF) (P = 0.167). Lateral fusion rates significantly differed: 49.0% (OLIF-SA), 30.3% (OLIF-PS), and 10.9% (TLIF) (P < 0.001). Preoperative osteophytes strongly promote lateral fusion (P < 0.001). VAS and ODI scores improved significantly post-surgery (P < 0.01).

OLIF-SA, OLIF-PS, and TLIF surgeries show satisfactory results with comparable fusion rates. Notably, distinctive differences exist in fusion features between OLIF and TLIF surgeries, with lateral fusion more prevalent in OLIF, particularly in OLIF-SA surgeries.

Prospective analysis of retrospective data.

To analyse the clinical and radiological outcomes of thoracic and thoracolumbar TB kyphosis by a posterior-only approach using kyphosis classification.

Patients with thoracic and thoracolumbar spinal TB who underwent posterior-only surgical correction for kyphotic deformity >30° were categorized into Group: A (Active TB) and Group B (Healed TB). Demographic, clinical and radiological data were collected, and kyphotic deformity was classified according to Rajasekaran classification.

52 patients with a minimum 2-year follow-up were included. Group A included 25 patients with mean preop kyphosis of 39.5° (31.2°-53.7°), and Group B included 27 patients with mean preop kyphosis of 85° (44.2°-125.2°). Among 25 patients in Group A, 19 were Type IIIA, and 6 were Type IIA kyphosis. In Group B, 18 patients were Type IIIB, 5 were Type III C, 3 were Type IIA, and 1 was IIIA kyphosis. All patients in group A underwent posterior column shortening by Smith-Peterson Osteotomy, with 14 patients requiring additional anterior column reconstruction. Patients in Group B required Closing-Opening Wedge Osteotomy (18), Halo followed by vertebral column resection (6), disc bone osteotomy (2) and pedicle subtraction osteotomy (1). Mean kyphosis at 2 years follow-up was 20.8° (11.2°-32.8°) in Group A and 53.5° (8.1°- 96.4°) in Group B.

Correction of kyphosis in spinal TB involves completely different strategies in active and healed disease. Hence, a posterior-only treatment approach using Rajasekaran’s kyphosis classification can help surgeons in appropriate decision-making.

Observational comparative study.

To study the role of magnetic resonance spectroscopy (MRS) and T2 relaxometry (T2r) as imaging biomarkers for identifying early lumbar disc degeneration.

We evaluated 236 discs in normal volunteers and 215 discs in low back pain (LBP) patients by MRS and T2r to document the molecular spectra of various metabolites as well as disc hydration and collagen content, respectively. All volunteer discs were Pfirrmann grade 1 (PF1), whereas patients with LBP had PF 1 (n = 156) and PF 2 (n = 59). The study population was compared in three age groups: A (20-30 years), B (30-40 years), and C (40-50 years).

T2r, an indicator of collagen and hydration, was higher in volunteers (121.8 ± 31.1), compared to PF 1 patients (110.68 ± 23.96) and PF 2 patients (90.15 ± 25.81) (P = 0.001). Proteoglycan assessed by MRS was more stable for volunteers (3.39 ± 1.69) and PF 1 patients (3.6 ± 1.69) but reduced in PF 2 patients (2.86 ± 1.47), showing that structural molecules did not alter within the PF 1. However, lactate and other metabolites showed a difference even within PF1 between volunteers and LBP patients. We were able to identify a unique subset of PF 1 that had a normal value of proteoglycan and T2r but altered metabolite distribution, which may represent early disc degeneration (DD).

MRS and T2r can be used as imaging biomarkers for early DD by identifying altered metabolic activity with an intact matrix.

Retrospective cohort study.

To analyze the efficacy and safety of Halo-femoral traction (HFT) following spinal release, and preoperative Halo-gravity traction (HGT) in patients with severe spinal kyphoscoliosis and spinal cord risk classification (SCRC) type 3 at the apex.

A total of 73 patients (24 males, 49 females, mean age 22.4 ± 6.4 years) and 56 patients (15 males, 41 females, mean age 22.9 ± 10.4 years) were included in the HFT and HGT group, respectively. Radiographic parameters were measured at the initial assessment, post-traction, post-final surgery, and during each follow-up. Neurologic function was assessed using the Frankel score system. IONM alerts and all complications were documented. Quality-of-life was evaluated using the SF-36 questionnaire.

In the HFT vs HGT group, the total correction rates were 39.9 ± 7.2% v.s. 41.3 ± 6.8% for the major Cobb and 36.6 ± 9.3% v.s. 44.4 ± 9.2% for global kyphosis (GK) after final surgery, respectively. The traction contributions were 57.6 ± 11.1% v.s. 52.3 ± 9.3% for major Cobb and 70.1 ± 10.5% v.s. 63.9 ± 11.1% for global kyphosis (GK), respectively. More than half of the total correction can be achieved gradually and safely through preoperative traction with patients in an awake state. No deterioration in neurological function was found post-final surgery. During the last follow-up, SF-36 questionnaire scores improved significantly in both groups (P < .05).

Significant outcomes can be expected in patients with severe kyphoscoliosis, even with spinal cord risk classification (SCRC) type 3 at the apex undergoing HFT and HGT.

cross-sectional survey.

To evaluate AO Spine members’ practices and comfort in managing metastatic and primary spine tumors, explore the use of decision-support and patient assessment tools, and identify knowledge gaps and future needs in spine oncology.

An online survey was distributed to AO Spine members to query comfort levels with key decisions in spinal oncology management, utilization of decision frameworks and spine oncology-specific instruments, and educational material preferences.

Responses were obtained from 381 members across 82 countries. Most respondents were orthopedic spine surgeons (62%) or neurosurgeons (36%), with 42% performing 100-200 spine surgeries per year. Extradural primary and metastatic tumors were managed by 84% and 95% of respondents, respectively, with survival and frailty assessment tools used for both. While most surgeons felt comfortable determining when emergency surgery was needed (81% for primary and 82% for metastatic tumors), nuanced decisions about surgical timing were more challenging. Surgeons also noted challenges in tailoring the oncologic surgical plan to what the patient could safely tolerate. There was a strong desire for guidelines on tumor-related spinal pain (85%), treatment timing (85%), stabilization (85%), and glucocorticoid use for symptomatic extradural metastatic tumors (77%). Interest was high for classification systems for spine tumor pain (65%) and stabilization decisions (80%).

Additional support is needed in decision-making regarding surgical timing, patient selection, and tailoring treatment invasiveness to life expectancy and frailty. Surgeons seek further guidance to prevent neurologic deterioration and optimize recovery. Guidelines and classification systems were highly coveted for daily practice.

Systematic review and Meta-analysis.

To quantify the association of preoperative depression on patient reported outcome measures (PROMS) after cervical spine surgery.

We systematically searched PubMed, Cochrane, Embase, Scopus, PsychInfo, Web of Science, and ClinicalTrials.gov until September 14, 2023. Studies including adults undergoing cervical spine surgery and comparing PROMs between depressed and non-depressed patients were included. The primary outcome was the postoperative change in disability, pain, and physical function. Secondary outcomes included absolute disease severity before and after surgery. We conducted random-effects meta-analysis.

After screening 3813 articles, 20 studies were included, encompassing 3964 patients (mean age 57, 51% males) with median follow-up duration of 12 months. There was significant heterogeneity in estimates of the primary outcome (I ² = 81%). While patients with depression had a greater magnitude of improvement compared with patients without depression, it was not statistically significant (SMD = 0.04, [95% CI: −0.07, 0.16], I ² = 80%; P = 0.48). However, patients with depression exhibited worse absolute disease severity preoperatively (SMD = −0.31, [-0.44, −0.19], I ² = 84%; P < 0.001) and postoperatively (SMD = −0.31, [−0.48, −0.15], I ² = 89%; P < 0.002). Sensitivity analyses with meta-regression found that older age, sex (male-to-female ratio), percentage of comorbidities, study quality, follow-up duration, number of adjusted factors in the analysis, and surgical approach were significant sources of heterogeneity.

Patients with depression experienced similar improvements in disability, pain, and physical function after cervical surgery compared to patients without depression. However, patients with depression exhibited worse disease severity before and after surgery.

Systematic review.

While the occurrence of sexual dysfunction in patients sustaining traumatic cervical or thoracic injuries is well acknowledged, the evidence regarding its prevalence and outcome in individuals with degenerative cervical myelopathy (DCM) is still limited. The current systematic review was planned to comprehensively evaluate the existing literature regarding the prevalence, patterns, presentation, and outcome of sexual dysfunction in patients presenting with DCM.

A thorough search of the literature was performed on October 15, 2024, using 5 different databases (Google Scholar, Embase, PubMed, Web of Science and Cochrane Library). Studies on sexual dysfunction in DCM published until 2024 were scrutinized. Narrative or systematic reviews, opinions, letters to the editor, and manuscripts published in non-English languages were excluded.

Overall, the literature search yielded a total of 384 articles of which 7 articles with 910 patients were included in the analysis. The overall prevalence of erectile dysfunction (ED) in CSM ranges between 3 and 6%. 82% of patients with preoperative ED had an abnormal psychogenic erection while the remaining had an abnormal reflexogenic erectile function. The erectile function was reported to improve substantially following decompressive surgery (68% recovery rate; P = 0.05). The presence of preoperative sexual dysfunction has been associated with poorer neurological outcomes (50% recovery rate; including poorer gait recovery). The data regarding ejaculatory disturbances and female sexual dysfunction in DCM patients are still limited.

ED occurs in 3 to 6% of patients with DCM, with a majority of patients suffering from ED from psychogenic origin. Surgical decompression can significantly improve the sexual recovery in these patients. Patients with ED have overall poorer neurological recovery.

A systematic review and meta-analysis.

This study aimed to determine whether rheumatoid arthritis (RA) is associated with clinical outcomes following spinal surgery for lumbar spinal disorders.

MEDLINE, Embase, the Cochrane Library, and the International Clinical Trials Registry Platform were comprehensively searched for observational studies comparing clinical outcomes after lumbar spine surgery in patients with and without RA (>18 years). Quality assessment was conducted using the Quality in Prognosis Studies assessment tool. Pooled odds ratios (ORs) and hazard ratios were calculated for reoperation and surgical site infection by using a random effects model. Subgroup analyses were conducted to examine the effect of surgery type.

Seven studies with 72,969 patients, including 7518 patients with RA, were analyzed. All studies had a moderate risk of bias. Patients with RA had a significantly higher odds of reoperation (OR: 5.57; 95% confidence interval [CI]: 1.10-28.26; I2 = 92%; P = 0.04) and higher odds of surgical site infection (OR: 1.47; 95% CI: 1.28-1.69; I2 = 2%; P < 0.01). No statistically significant difference was found in reoperation-free survival between patients with RA and those without RA (hazard ratio: 1.15; 95% CI: 0.94-1.40; I2 = 100%; P = 0.16). Patients with RA had higher complication rates, with incidence rates ranging from 13.5% to 57%, compared with those without RA.

Compared with patients without RA, patients with RA may be more likely to undergo reoperations and suffer from complications following surgery for lumbar spine lesions.

Among patients undergoing elective spine surgery, psychological processes such as kinesiophobia and pain catastrophizing are associated with postoperative disability and poor quality of life. These represent risk factors which could be modified to improve surgical outcomes. We reviewed perioperative interventions to modify psychological processes and their effects on psychological and surgery-related outcomes.

We searched MEDLINE, EMBASE, and Cochrane databases for studies examining any interventions for modifying psychological processes in adult patients undergoing spine surgery. Two reviewers screened studies for eligibility, extracted data in duplicate, and performed risk of bias assessments. Outcomes included pain, disability, quality of life, kinesiophobia, self-efficacy, and pain catastrophizing.

368 titles and abstracts were retrieved, of which 27 studies underwent full-text screening. We included 12 studies which reported on 1263 patients. Eight were randomized controlled trials. Interventions included preoperative and postoperative cognitive behavioural therapy, cognitive-behavioural-based physical therapy, a web-based interactive platform, an information booklet, and music therapy. The psychological and surgery-related outcomes of interventions were variable, with some studies reporting significant benefits and others reporting no differences between groups. The greatest potential benefits were found in studies of post-operative cognitive-behavioural-based physical therapy. Risk of bias among studies was high due primarily to lack of blinding and limited standardization of interventions.

Several interventions to potentially modify psychological processes in patients undergoing spine surgery have been reported. Post-operative cognitive-behavioural-based physical therapy might be associated with improved outcomes, but confidence is limited by inconsistency, risk of bias, and limited long-term follow-up.

Narrative Review.

Endoscopic spine surgery is becoming an increasingly popular approach to treat spinal disease due to its minimally invasive nature. Although certain adverse events are well-reported within the literature, there is a scarcity of information for complications that are rare but still potentially serious. The purpose of this study is to describe these rare complications of endoscopic spine surgery and discuss management and prevention strategies.

A search was conducted in PubMed and Embase to review the literature for all adverse events following endoscopic spine surgery, with no restrictions on publication year. Cohort and case report studies describing infrequently reported complications were collected for analysis.

A total of 38 studies were included which described rare complications in 93 patients following endoscopic spine surgery. These included neurological events (seizure, pseudomeningocele, pneumocephalus, upper limb palsy), vascular events (hemorrhage, hematoma, arteriovenous fistula), mechanical events (cage migration, guidewire breakage), and additional events (discal pseudocyst, pulmonary edema, arrhythmia, total spinal anesthesia).

Endoscopic spine surgery is rapidly evolving and emerging as a popular alternative to conventional approaches. Though regarded as a generally safe form of surgery, it is imperative that surgeons are aware of all complications which may occur, even those that may be infrequently reported in the literature.

Systematic Review and Meta-analysis.

This systematic review and meta-analysis aimed to: (1) synthesize the prevalent application ratios of 2 radiographic spinal flexibility assessment methods in AIS patients treated with PSF or bracing; and (2) quantitatively evaluate the accuracy of these methods in predicting post-intervention correction outcomes.

A systematic search was conducted across 5 electronic databases: CINAHL, Embase, Ovid, PubMed, and Web of Science. Meta-analyses were performed to investigate the accuracy of the spinal flexibility rate in predicting the post-intervention correction rate in AIS patients treated with PSF surgery or bracing, using RevMan 5.4.1 software.

The results of 31 studies, involving 1868 AIS patients, showed that the side-bending method was utilized more frequently than the fulcrum-bending method in both treatments. Meanwhile, the spinal flexibility evaluated by the fulcrum-bending method may provide a more accurate prediction of post-surgical correction compared to the side-bending approach, particularly for main curves. For the bracing treatment, only a few studies have preliminarily reported good capability of the side-bending method in predicting the initial in-brace correction.

This review quantitatively assessed the clinical application ratio and effectiveness of side-bending and fulcrum-bending radiographs in predicting post-intervention curve corrections in AIS patients undergoing surgical or bracing treatments. The results of the current review supported to adopt the fulcrum-bending approach for AIS patients undergoing PSF surgery with main thoracic curves, and the side-bending approach for those with thoracolumbar/lumbar curves. For patients receiving bracing treatment, further research is still needed to confirm the clinical value of the side-bending method.