Sarcopenia Is an Independent Risk Factor for Proximal Junctional Disease Following Adult Spinal Deformity Surgery

Study Design: Retrospective cohort study. Objectives: Sarcopenia is a risk factor for medical complications following spine surgery. However, the role of sarcopenia as a risk factor for proximal junctional disease (PJD) remains undefined. This study evaluates whether sarcopenia is an independent predictor of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following adult spinal deformity (ASD) surgery. Methods: ASD patients who underwent thoracic spine to pelvis fusion with 2-year clinical and radiographic follow-up were reviewed for development of PJK and PJD. Average psoas cross-sectional area on preoperative axial computed tomography or magnetic resonance imaging at L4 was recorded. Previously described PJD risk factors were assessed for each patient, and multivariate linear regression was performed to identify independent risk factors for PJK and PJF. Disease-specific thresholds were calculated for sarcopenia based on psoas cross-sectional area. Results: Of 32 patients, PJK and PJF occurred in 20 (62.5%) and 12 (37.5%), respectively. Multivariate analysis demonstrated psoas cross-sectional area to be the most powerful independent predictor of PJK (P = .02) and PJF (P = .009). Setting ASD disease–specific psoas cross-sectional area thresholds of <12 cm2 in men and <8 cm2 in women resulted in a PJF rate of 69.2% for patients below these thresholds, relative to 15.8% for those above the thresholds. Conclusions: Sarcopenia is an independent, modifiable predictor of PJK and PJF, and is easily assessed on standard preoperative computed tomography or magnetic resonance imaging. Surgeons should include sarcopenia in preoperative risk assessment and consider added measures to avoid PJF in sarcopenic patients

Minimally Invasive Lateral Corpectomy of the Thoracolumbar Spine: A Case Series of 20 Patients.

Study designRetrospective case series.ObjectiveTo report our experience with corpectomy of the thoracolumbar (TL) spine through a minimally invasive lateral retropleural or retroperitoneal approach.MethodsThis is a retrospective case series of 20 consecutive patients who underwent minimally invasive TL corpectomy and spinal reconstruction. Electronic medical records were reviewed for demographic, operative, and clinical outcome data.ResultsBetween 2015 and 2019, 20 consecutive cases of minimally invasive TL corpectomy were performed, comprising 12 men (60%) and 8 women (40%) with a mean age of 54.3 years. Indications for surgery were infection (n = 6, 30%), metastatic disease (n = 2, 10%), fracture (n = 6, 30%), and calcified disc herniation (n = 6, 30%). Partial and complete corpectomy was performed in 5 patients (25%) and 15 patients (75%), respectively. Mean operative time and estimated blood loss was 276.2 minutes and 558.4 mL, respectively. Mean length of stay from admission and surgery were 14.6 and 11.4 days, respectively. Mean length of stay from surgery for elective cases was 4.2 days. Mean follow-up time was 330.4 days. Visual analogue scale score improved from 7.7 to 4.5 (P &lt; .01). There were a total of 3 postoperative complications in 2 patients, including 1 mortality for urosepsis. One patient had revision spinal surgery for adjacent segment disease.ConclusionsCorpectomy and reconstruction of the TL spine is feasible and safe using a minimally invasive lateral retropleural or retroperitoneal approach. Since this is a relatively new technique, more studies are needed to compare the short- and long-term radiographic and clinical outcomes between minimally invasive versus open corpectomy of the TL spine

The Utility of Magnetic Resonance Imaging for Detecting Unstable Cervical Spine Injuries in the Neurologically Intact Traumatized Patient Following Negative Computed Tomography Imaging.

BackgroundNeurologically intact blunt trauma patients with persistent neck pain and negative computed tomography (CT) imaging frequently undergo magnetic resonance imaging (MRI) for evaluation of occult cervical spine injury. There is a paucity of data to support or refute this practice. This study was therefore performed to evaluate the utility of cervical spine MRI in neurologically intact blunt trauma patients with negative CT imaging.MethodsA retrospective review was performed of all neurologically intact blunt trauma patients presenting to a level 1 trauma center from 2005 to 2015 with persistent neck pain and negative CT imaging. The proportion of patients with positive MRI findings, subsequent treatment, and time required to obtain MRI results was evaluated.ResultsOf 223 patients meeting inclusion criteria, 11 had positive MRI findings; however, no patients were found to have unstable injuries requiring surgical treatment. The process for a complete evaluation of unstable cervical spine injury from the time of obtaining a CT scan was 19 hours and 43 minutes.ConclusionsEleven patients had positive MRI findings, yet these findings did not alter treatment. In contrast, the time required to obtain MRI results may substantially delay patient care.Level of evidenceIV (retrospective case series) CLINICAL RELEVANCE: Our results demonstrate that MRI has limited utility in neurologically intact blunt trauma patients with negative CT imaging

Variability in Opioid Prescription Following Primary Single-Level Lumbar Microdiscectomy.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To evaluate the variability in opioid prescription following primary single-level lumbar microdiscectomy. METHODS: We retrospectively reviewed consecutive patients who underwent primary single-level lumbar microdiscectomy. Only opioid-naïve patients ≥18 years old were included. Patients who had revision microdiscectomy, multilevel decompression, and/or any complication requiring prolonged hospital stay (&gt;2 days) were excluded. The primary outcomes were the maximum daily dosage of opioids prescribed in morphine milligram equivalents (MME) and the number of pills prescribed (equivalent to 5 mg hydrocodone). RESULTS: Between 2014 and 2019, 169 patients (90 men, 79 women) met inclusion criteria, with a mean age of 46.9 years. Surgery resulted in a statistically significant improvement in VAS (Visual Analogue Scale) score (6.4 to 2.5, P &lt; .01). At discharge, 8 patients (4.7%) did not receive any opioid prescription. Of the remaining 161 patients, 1 patient (0.01%) received hydromorphone, 30 (18.6%) Percocet, 43 (26.7%) oxycodone, and 87 Norco (54.0%). The length of opioid prescription was 6.7 days. The maximum daily dosage of opioids prescribed was 70.4 MME (SD 32.1). The total number of pills prescribed was 89.4 (SD 54.7). Twenty-five patients (15.5%) received a refill prescription. Multivariate analysis demonstrated the operating service, prescriber, and hospital admission were statistically significant predictors of maximum daily MME. The prescriber and hospital admission were statistically significant predictors of total number of pills prescribed. CONCLUSIONS: We found significant variability in opioid prescription following primary single-level lumbar microdiscectomy. For standard spinal procedures like lumbar microdiscectomy, opioid-prescribing guidelines should be established to standardize postoperative pain management

Preserving privacy in big data research: the role of federated learning in spine surgery

PurposeIntegrating machine learning models into electronic medical record systems can greatly enhance decision-making, patient outcomes, and value-based care in healthcare systems. Challenges related to data accessibility, privacy, and sharing can impede the development and deployment of effective predictive models in spine surgery. Federated learning (FL) offers a decentralized approach to machine learning that allows local model training while preserving data privacy, making it well-suited for healthcare settings. Our objective was to describe federated learning solutions for enhanced predictive modeling in spine surgery.MethodsThe authors reviewed the literature.ResultsFL has promising applications in spine surgery, including telesurgery, AI-based prediction models, and medical image segmentation. Implementing FL requires careful consideration of infrastructure, data quality, and standardization, but it holds the potential to revolutionize orthopedic surgery while ensuring patient privacy and data control.ConclusionsFederated learning shows great promise in revolutionizing predictive modeling in spine surgery by addressing the challenges of data privacy, accessibility, and sharing. The applications of FL in telesurgery, AI-based predictive models, and medical image segmentation have demonstrated their potential to enhance patient outcomes and value-based care

Clinical and Radiographic Comparison Between Open Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion With Bilateral Facetectomies.

Study designAge- and sex-matched cohort study.ObjectivesTo compare outcomes after open versus minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with bilateral facetectomies.MethodsWe retrospectively compared patients who underwent single- or 2-level MIS-TLIF with an age- and sex-matched open-TLIF cohort. Surgical data was collected for operative time, estimated blood loss (EBL), and drain use. Clinical outcomes included the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), length of stay (LOS), complications, and reoperations. Lumbar radiographs were measured for changes in global lumbar lordosis (LL) and segmental lordosis (SL).ResultsBetween 2016 and 2020, 38 MIS-TLIF patients were compared with 38 open-TLIF patients. No subfascial drain was used in the MIS-TLIF group (P &lt; .001). The MIS-TLIF group had longer operative time (310.8 vs 276.5 minutes; P = .046) but less EBL (282.4 vs 420.8 mL; P = .007). LOS (P = .15), complication rates (P = .50), and revision rates (P = .17) were equivalent. VAS and ODI improved but did not differ between groups. In the open-TLIF group, LL and SL were restored or improved in 81.6% and 86.9% of cases, respectively. In the MIS-TLIF group, LL and SL were restored or improved in 86.8% and 97.4% of cases, respectively. There were no differences in changes in LL and SL between groups.ConclusionsCompared with the age- and sex-matched open-TLIF cohort, patients undergoing MIS-TLIF had reduced EBL and subfascial drain use but increased operative time. There were no differences in complications, reoperations, or LOS. Both groups demonstrated improvement in VAS and ODI. MIS-TLIF with bilateral facetectomies provided equivalent improvements in global and segmental LL

Povidone-iodine irrigation combined with Vancomycin powder lowers infection rates in pediatric deformity surgery.

BackgroundSurgical site infection is a morbid, devastating complication after spinal procedures. Studies have investigated the effect of wound lavage with 3.5% Povidone-iodine solution or the use of intrawound Vancomycin powder. We examined the effect of Povidone-iodine irrigation, intrawound Vancomycin powder, or a combination of both agents in a tertiary care Pediatric Hospital.MethodsWe queried our health system database for patients undergoing spinal surgery over an eight-year span between January 2008 and June 2016 and identified patient cohorts who received no intervention, intrawound Vancomycin alone, Povidone-iodine irrigation alone, or a combination of both agents. Infection rates were determined. The effect of treatment on outcome was analyzed using a logistic regression model.Results475 patients were identified who met study inclusion criteria. 88 non-neuromuscular patients received no intra-operative agent. The surgical site infection (SSI) rate in this group of patients was 10%. For the 194 non-neuromuscular scoliosis patients who received Povidone-iodine and Vancomycin powder, the infection rate was reduced to 0.7%. The SSI rate in the 180 non-neuromuscular patients who were treated with Vancomycin powder alone was 1.4%. 13 patients were treated with Povidone-iodine lavage only, with a small sample size precluding statistical comparison. Infection rate in the 132 neuromuscular disease patients decreased from 14 to 7% overall during this time span: while the odds ratio of infection was reduced in all neuromuscular treatment groups receiving intra-operative measures, statistical significance was not reached in any neuromuscular group studied.ConclusionsA protocol using combined 3.5% weight/volume Povidone-iodine and Vancomycin powder was associated with the lowest infection rate in our non-neuromuscular patient population and should be considered as a low cost intervention in pediatric patients undergoing spinal deformity procedures.Level of evidenceLevel II

High- versus low-dose tranexamic acid as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing surgery for adolescent idiopathic scoliosis

PurposeThe administration of tranexamic acid (TXA) has been shown to be beneficial in reducing blood loss during surgery for adolescent idiopathic scoliosis (AIS), but optimal dosing has yet to be defined. This retrospective study compared high- versus low-dose TXA as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing posterior spine fusion surgery.MethodsClinical records were reviewed for 223 patients with AIS who underwent posterior spinal fusion of five or more levels during a 6-year time period. We compared normalized blood loss, total estimated blood loss (EBL), and the need for transfusion between patients receiving high-dose TXA (loading dose of ≥ 30&nbsp;mg/kg) versus low-dose TXA&nbsp;(loading dose &lt; 30&nbsp;mg/kg). Both groups received maintenance TXA infusions of 10&nbsp;mg/kg/h until skin closure.ResultsPatient demographics, curves, and surgical characteristics were similar in both groups. The high-dose TXA group had a 36% reduction in normalized blood loss (1.8&nbsp;cc/kg/level fused versus 2.8&nbsp;cc/kg/level fused, p &lt; 0.001) and a 37.5% reduction in total EBL (1000&nbsp;cc versus 1600&nbsp;cc, p &lt; 0.001). Patients in the high-dose group had a 48% reduction in PRBC transfusion, with only 19% receiving a transfusion of PRBC compared to 67% in the low-dose group (p &lt; 0.001).ConclusionWhen combined with other proven Patient Blood Management strategies, the use of high-dose TXA compared to low-dose TXA may be beneficial in reducing blood loss for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery.Level of evidenceLevel III, retrospective cohort

Ligament Augmentation With Mersilene Tape Reduces the Rates of Proximal Junctional Kyphosis and Failure in Adult Spinal Deformity.

ObjectiveTo investigate prevention of proximal junctional kyphosis (PJK) and failure (PJF) following adult spinal deformity (ASD) surgery utilizing a novel technique of posterior ligament augmentation with polyester fiber tether.MethodsThis study evaluated ASD adult patients who underwent posterior decompression and instrumented fusion from the thoracolumbar junction (T9-L1) to the pelvis from 2011-2017. Basic demographic data were obtained. Radiographic outcomes included proximal junctional angle (PJA), sagittal vertical axis, PJK, and PJF. The study population was divided into patients who had ASD surgery with and without ligamentous augmentation.ResultsA total of 43 subjects were evaluated, including 20 without and 23 with ligamentous augmentation. PJA increased over time for both groups. PJA was smaller for the augmented group, and rate of increase in PJA was slower in the augmented group (p &lt; 0.0001). The rate of PJK was significantly higher in the nonaugmented group (p = 0.01). PJF was significantly less common in the augmented group (p = 0.003). Time to revision surgery was lower in the nonaugmented group (p = 0.003).ConclusionOur novel ligament augmentation technique utilizing polyethylene tape is an effective technique to slow progression of the PJA and lower the risk for proximal junctional disease in ASD surgery

Efficacy, Cost, and Complications of Demineralized Bone Matrix in Instrumented Lumbar Fusion: Comparison With rhBMP-2.

Study designRetrospective cohort study.ObjectivesTo evaluate demineralized bone matrix as an adjunct for instrumented lumbar spine fusion compared with recombinant human bone morphogenetic protein-2 (rhBMP-2).MethodsClinical and radiographic review was performed of 43 patients with degenerative spine disease treated with posterolateral spinal fusion with or without posterior or transforaminal lumbar interbody fusion. Final analysis included sixteen patients treated with demineralized bone matrix (DBM; Accell Evo3, SeaSpine) compared with a retrospective matched group of 21 patients treated with rhBMP-2 (rhBMP-2, Infuse, Medtronic). All patients were followed for 24 months. Fusion was evaluated by computed tomography and/or x-ray. Clinical outcomes included visual analogue scale (VAS), Oswestry Disability Index (ODI), and Short Form 12 (SF-12).ResultsOverall fusion rate, including posterolateral and/or interbody fusion, was 100% for both groups, though the fusion rates in the posterolateral space alone were 93.5% and 100% for the DBM and rhBMP-2 groups, respectively. Clinical outcomes were similar between groups, with the DBM group showing greater improvement in ODI. The rhBMP-2 group showed higher rates of radiographic complications with 7 of 21 patients (33.3%) demonstrating either adjacent level fusion or ectopic bone formation, compared with zero in the DBM group. Average biologic cost per level was $1522 for DBM and$3505 for rhBMP-2.ConclusionsDBM and rhBMP-2 demonstrated similar radiographic and clinical outcomes in instrumented lumbar fusions. rhBMP-2 was associated with higher rates of radiographic complications and significantly higher costs