Comparison of the Prevalence of Low Back Pain and Related Spinal Diseases among Smokers and Nonsmokers: Using Korean National Health Insurance Database

Backgroud: To compare the risk of low back pain (LBP) and related spinal diseases between smokers (exposure group) and nonsmokers (non-exposure group). No large registry study has so far investigated the association between smoking and LBP-related spinal diseases such as intervertebral disc disease, spinal stenosis, spinal instability, and spondylolisthesis. Methods: A random sample was taken from the Korean National Health Insurance Research Database. In total, 204,066 men (160,105 smokers, 43,961 nonsmokers) who were followed up between 2002 and 2013 were included in the analysis. Patients with previous back pain or spinal disease in 2003 and 2004, patients with inappropriate data, and women (due to the lower percentage of smokers) were excluded. The Cox proportional hazard model was used to investigate the risk of LBP and related spinal diseases associated with smoking, while adjusting for demographic, clinical, and socioeconomic factors. Results: The overall median follow-up period was 5.6 years (interquartile range, 3.48-8.43 years). Compared to the nonsmoker group, the smoker group had a higher incidence of LBP (p = 0.01), intervertebral disc disease (p < 0.001), spinal stenosis (p = 0.004), spinal instability (p < 0.001), and spondylolisthesis (p = 0.023). Compared to the nonsmoker group, the smoker group had a higher adjusted hazard ratio (HR) per year of LBP (HR, 1.18; 95% confidence interval [CI], 1.15 to 1.21), intervertebral disc disease (HR, 1.25; 95% CI, 1.21 to 1.30), spinal stenosis (HR, 1.52; 95% CI, 1.41 to 1.64), spinal instability (HR, 1.33; 95% CI, 1.24 to 1.44), and spondylolisthesis (HR, 1.49; 95% CI, 1.23 to 1.80). Conclusions: Smokers in male samples were at higher risk for LBP and related spinal diseases than nonsmokers.ope

Early Failure of Cortical-Bone Screw Fixation in the Lumbar Spinal Stenosis

Purpose: Pedicle screw insertion has been traditionally used as a surgical treatment for degenerative lumbar spine disease. As an alternative, the cortical-bone trajectory screw allows less invasive posterior lumbar fixation and excellent mechanical stability, as reported in several biomechanical studies. This study evaluated the clinical and radiological results of a case of early failure of cortical-bone screw fixation in posterior fixation and union after posterior decompression. Materials and Methods: This study examined 311 patients who underwent surgical treatment from 2013 to 2018 using cortical orbital screws as an alternative to traditional pedicle screw fixation for degenerative spinal stenosis and anterior spine dislocation of the lumbar spine. Early fixation failure after surgery was defined as fixation failure, such as loosening, pull-out, and breakage of the screw on computed tomography (CT) and radiographs at a follow-up of six months. Results: Early fixation failure occurred in 46 out of 311 cases (14.8%), screw loosening in 46 cases (14.8%), pull-out in 12 cases (3.9%), and breakage in four cases (1.3%). An analysis of the site where the fixation failure occurred revealed the following, L1 in seven cases (15.2%), L2 in three cases (6.5%), L3 in four cases (8.7%), L4 in four cases (8.7%), L5 in four cases (8.7%), and S1 in 24 cases (52.2%). Among the distal cortical bone screws, fixation failures such as loosening, pull-out, and breakage occurred mainly in the S1 screws. Conclusion: Cortical-bone trajectory screw fixation may be an alternative with comparable clinical outcomes or fewer complications compared to conventional pedicle screw fixation. On the other hand, in case with osteoporosis and no anterior support structure particularly at L5-S1 fusion sites were observed to have result of premature fixation failures such as relaxation, pull-out, and breakage.ope

Medial Pedicle Pivot Point Using Preoperative Computed Tomography Morphometric Measurements for Cervical Pedicle Screw Insertion: A Novel Technique and Case Series

This study describes a new and safe freehand cervical pedicle screw insertion technique using preoperative computed tomography (CT) morphometric measurements as a guide and a medial pedicle pivot point (MPPP) during the procedure. This study included 271 pedicles at 216 cervical spine levels (mean: 4.75 pedicles per patient). A pedicle diameter (PD) ≥ 3.5 mm was the cut-off for pedicle screw fixation. The presence and grade of perforation were detected using postoperative CT scans, where perforations were graded as follows: 0, no perforation; 1, perforation 1.75 mm. The surgical technique involved the use of an MPPP, which was the point at which the lines representing the depth of the lateral mass and total length of the pedicle intersected, deep in the lateral mass. The overall success rate was 96.3% (261/271, Grade 0 or 1 perforations). In total, 54 perforations occurred, among which 44 (81.5%) were Grade 1 and 10 (18.5%) were Grade 2. The most common perforation direction was medial (39/54, 72.2%). The freehand technique for cervical pedicle screw fixation using the MPPP may allow for a safe and accurate procedure in patients with a PD ≥3.5 mm.ope

Delirium after Spinal Surgery: A Pilot Study of Electroencephalography Signals from a Wearable Device

Postoperative delirium after spinal surgery in elderly patients has been a recent concern. However, there has not been a study of delirium after spinal surgery based on electroencephalography (EEG) signals from a compact wearable device. We aimed to analyze differences in EEG signals from a wearable device in patients with and without delirium after spinal surgery. Thirty-seven patients who underwent cervical or lumbar decompression and instrumented fusion for degenerative spinal disease were included. EEG waves were collected from a compact wearable device, and percentage changes from baseline to within 1 week and 3 months after surgery were compared between patients with and without delirium. In patients with delirium, the anxiety- and stress-related EEG waves—including the H-beta (19.3%; p = 0.003) and gamma (18.8%; p = 0.006) waves—and the tension index (7.8%; p = 0.011) increased, and the relaxation-related theta waves (−23.2%; p = 0.016) decreased within 1 week after surgery compared to the non-delirium group. These results will contribute to understanding of the EEG patterns of postoperative delirium and can be applied for the early detection and prompt treatment of postoperative delirium after spinal surgery.ope

Biomechanical Comparison and Three-Dimensional Analysis of Cement Distribution Patterns for Different Pedicle Screw Designs

The purpose of this study to explore strategies for reducing cement leakage during cement-augmented pedicle screw fixation, we compared the cement distribution patterns and biomechanical strengths of different types of cement-augmented fenestrated screws and traditional cement-augmented techniques. We compared five screw groups in this study: (1) Cannulated screws (Cann); (2) distal one-hole screws (D1); (3) distal two-hole screws (D2); (4) middle two-hole screws (M2); and (5) traditional screws with a traditional cement injection technique (Trad). The screws were inserted into cancellous bone blocks using a controlled, adequate cement injection pressure (1.6-2.0 kg), and an appropriate cement viscosity. Center to screw tip distance, three-dimensional distribution, and pull-out strength for cement were compared between groups. The average distance between the cement center and the screw tip was highest in the M2 group, suggesting a higher risk of cement leakage into the spinal canal. The Trad group had the highest migration distance in the z-axis, also reflecting a higher risk of leakage into the spinal canal. The D1 group had the highest pull-out strength (253 ± 48.82 N and 797 ± 58.31 N) in bone blocks representing different degrees of osteoporosis, and the D2 group had the second highest pull-out strength in the severe osteoporosis model. Overall, D1 screws appeared to be the best option for optimizing biomechanical function and minimizing the risk of cement leakage into the spinal canal in patients with osteoporotic bone undergoing spinal surgery.ope

Real-Time Stress Analysis Affecting Nurse during Elective Spinal Surgery Using a Wearable Device

Successful spinal surgery demands high levels of concentration and cooperation from participating health care workers. The intraoperative stress levels and concentration levels of surgeons have been studied previously; however, those of nurses are rarely studied. Therefore, the purpose of this study is to understand the stresses affecting surgical nurses by their participating role during spinal surgery. A total of 160 surgical stress records were obtained during 40 surgeries, including electroencephalography (EEG) signals and heart rate variability (HRV) from three orthopedic spinal surgeons and six nurses; concentration, tension level and physical stress were analyzed. Levels of both concentration and tension were significantly higher in circulating nurses during all surgical stages (p &lt; 0.05). Both beats per minute and low frequency/high frequency ratios, which reflect physical stress, were higher in scrub nurses (p &lt; 0.05). As the surgical experience of scrub nurses increased, the key parameters related to stress tended to decrease (p &lt; 0.01). These results will contribute to understanding the pattern of intraoperative stress of surgical nurses, and therefore help in enhancing the teamwork of the surgical team for optimal outcomes.ope

Headless Autocompression Screw Fixation of Scaphoid Fractures Using Open Dorsal Approach

Purpose: We present the clinical and radiological results of open reduction and internal fixation for scaphoid fracture with retrograde headless screw fixation via dorsal approach. Methods: This study carried out a survey targeting 15 patients who have a retrograde headless screw fixation on nonunion of scaphoid fracture without previous operation, 2 patients who have a retrograde headless screw fixation on nonunion of scaphoid fracture with previous operation and 8 patients who have a trans-scaphoid perilunate dislocation. We figured out a mechanism of injury, and clinical symptom, radiologic findings. The surgery was done with open dorsal approach which is retrograde headless screw fixation internally, with or without bone graft. We analyzed the result by Maudsley method, in terms of bone union, duration for union, radiologic finding, clinical outcomes. Results: After surgery, 22 of 25 patients had union result on fracture and other 3 patients had nonunion result. It took 12 weeks to achieve bone union on average. Based on radiograhs, we had one case of partial avascular necrosis of proximal fragment without clinical symptoms. We had one case of each scaphoid nonunion without previous operation, with operation and trans-scaphoid perilunate dislocation had arthritic change and non-symptomatic nonunion result. In terms of clinical outcome, 22 patients showed satisfactory results and 3 patients had slight limitation of range of motion. Conclusion: Retrograde headless screw fixation with or without bone graft for the treatment of scaphoid fracture is recommendable.ope

Hand grip strength as a surrogate marker for postoperative changes in spinopelvic alignment in patients with lumbar spinal stenosis

There are a few studies on the postoperative changes in sagittal alignment and corresponding factors, including hand grip strength (HGS) and muscle performance tests for lumbar spinal stenosis (LSS). Thus, we aimed to determine whether HGS can be a surrogate marker for global sagittal alignment changes after decompression with fusion surgery for LSS. This retrospective observational study included 91 patients who underwent spine fusion surgery for LSS. Radiological spinopelvic parameters, including sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), global tilt (GT), and T1 pelvic angle (T1PA), were analyzed preoperatively and 1 year after posterior decompression and fusion surgery. To assess muscle performance, the 6-m walk (SMT), timed up and go (TUGT), and sit-to-stand (STS) tests were conducted. The relationship between HGS and postoperative SVA was examined through multiple linear regression analysis. Additionally, the relationship between HGS and preoperative/postoperative radiologic spinopelvic parameters and muscle performance test results was analyzed through Pearson's correlation. HGS was significantly correlated with age, preoperative and postoperative SVA, and the muscle performance tests. Furthermore, HGS was a factor that can significantly influence postoperative SVA changes in multiple linear regression analyses. Therefore, HGS may be a good predictor of postoperative SVA change.ope

Biomechanical Analysis of Allograft Spacer Failure as a Function of Cortical-Cancellous Ratio in Anterior Cervical Discectomy/Fusion: Allograft Spacer Alone Model

The design and ratio of the cortico-cancellous composition of allograft spacers are associated with graft-related problems, including subsidence and allograft spacer failure. Methods: The study analyzed stress distribution and risk of subsidence according to three types (cortical only, cortical cancellous, cortical lateral walls with a cancellous center bone) and three lengths (11, 12, 14 mm) of allograft spacers under the condition of hybrid motion control, including flexion, extension, axial rotation, and lateral bending,. A detailed finite element model of a previously validated, three-dimensional, intact C3–7 segment, with C5–6 segmental fusion using allograft spacers without fixation, was used in the present study. Findings: Among the three types of cervical allograft spacers evaluated, cortical lateral walls with a cancellous center bone exhibited the highest stress on the cortical bone of spacers, as well as the endplate around the posterior margin of the spacers. The likelihood of allograft spacer failure was highest for 14 mm spacers composed of cortical lateral walls with a cancellous center bone upon flexion (PVMS, 270.0 MPa; 250.2%) and extension (PVMS: 371.40 MPa, 344.2%). The likelihood of allograft spacer subsidence was also highest for the same spacers upon flexion (PVMS, 4.58 MPa; 28.1%) and extension (PVMS: 12.71 MPa, 78.0%). Conclusion: Cervical spacers with a smaller cortical component and of longer length can be risk factors for allograft spacer failure and subsidence, especially in flexion and extension. However, further study of additional fixation methods, such as anterior plates/screws and posterior screws, in an actual clinical setting is necessary.ope

Emphysematous osteomyelitis of the spine: A rare case report

Rationale: Emphysematous osteomyelitis is a rare disease caused by gas-forming bacteria. But only 45 cases have been reported in the literature since then. Patient concerns: A 72-year-old female presented to our hospital with severe lower back pain that aggravated 4 days ago. Diagnoses: Computed tomography (CT) revealed intraosseous mottled air in the T12 and L1 vertebral bodies and epidural space. The enhanced T1 and T2 magnetic resonance imaging scans showed heterogeneous signal intensity of vertebral bodies, suggestive of emphysematous osteomyelitis. Interventions: Surgery was performed to identify culture strains and to remove emphysematous lesions of the vertebral body using extensive transpedicular irrigation. Outcomes: Escherichia coli (E coli) was identified in the surgical specimen, and intravenous antibiotic therapy was continued with cefotaxime. The patient had a significant decrease in lower back pain after the surgery and the final CT scan before discharge revealed significantly decreased air at T12 and L1 vertebral bodies and no air density in the epidural space. Lessons: We present a patient diagnosed with emphysematous osteomyelitis in vertebral bodies caused by E coli and successfully treated with surgical intervention.ope