Presence or absence of adjacent vertebral fractures has no effect on long-term global alignment and quality of life in patients with osteoporotic vertebral fractures treated with balloon kyphoplasty

BackgroundGlobal sagittal malalignment after osteoporotic vertebral fracture is correlated with decreased quality of life. Balloon kyphoplasty promotes short-term global alignment, but long-term correction is difficult in patients with such fractures. Adjacent vertebral fracture is one of the major complications of balloon kyphoplasty. We investigated the correlation of the incidence of adjacent vertebral fracture with the loss of global alignment correction after balloon kyphoplasty.MethodsForty patients were enrolled in this retrospective study. Adjacent vertebral fracture occurred in 17 patients. Sagittal vertical axis, the angle between the two vertebrae above and below the balloon kyphoplasty site (local alignment angle), and the vertebral kyphotic angle at the kyphoplasty site were measured pre- and post-operatively. Clinical results were assessed.ResultsThere were no significant differences between the sagittal vertical axis before and after balloon kyphoplasty in groups with (+) or without (−) adjacent vertebral fracture. Local alignment angles decreased soon after balloon kyphoplasty, but increased during follow-up in both groups. Vertebral kyphotic angles decreased significantly soon after balloon kyphoplasty in both groups; although this increased significantly in the adjacent vertebral fracture (−) group, but not in the adjacent vertebral fracture (+) group, during follow-up. Correction loss of alignment was found in both adjacent vertebral fracture (+) and (−) groups, attributed to adjacent vertebral fracture in the former and re-collapse of the balloon kyphoplasty site in the latter. No significant differences in clinical results were observed between the groups, although these were strongly correlated with sagittal vertical axis before balloon kyphoplasty.ConclusionsThe adjacent vertebral fracture (+) and (−) groups exhibited similar correction loss of alignment and improved quality of life. The presence or absence of adjacent vertebral fractures had no effect on long-term global alignment and patient quality of life.     

Decompression alone for the treatment of degenerative lumbar spondylolisthesis

The purpose of this chapter is to present decompression surgery alone as a reasonable consideration in the treatment of degenerative spondylolisthesis with spinal stenosis. This procedure may be better than laminectomy and fusion in select patients. We review and highlight several clinical scenarios in which this might be the case. Recently published studies have advocated this treatment approach for particular patient profiles. Several surgical techniques and patient characteristics favorable for decompression alone are discussed.     

Readmission in elective spine surgery: Will short stays be beneficial to patients

There has been limited discussion as to whether spine surgery patients are benefiting from shorter in-patient hospital stays or if they are incurring higher rates of readmission and complications secondary to shortened length of stays. Included in this study were 237,446 spine patients >18yrs and excluding infection. Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission after initial surgery in all years at 12.44 ± 9.03 days. Pearson bivariate correlations between LOS ≤ 1 day and decreasing days to readmission was the strongest in 2016.). Logistic regression analysis found that LOS ≤ 1 day showed an overall increase in the odds of hospital readmission from 2012 to 2016 (2.29 [2.00–2.63], 2.33 [2.08–2.61], 2.35 [2.11–2.61], 2.27 [2.06–2.49], 2.33 [2.14–2.54], all p < 0.001).     

The “slide technique”: an improvement on the “funnel technique” for safe pedicle screw placement in the thoracic spine

Study design

Technical note.

Objectives

To report and describe a new free-hand technique for pedicle screw placement in the thoracic spine especially in severe deformities.

Summary of background data

Because of distortion of anatomic landmarks scoliosis, this free-hand placement technique based on pedicle access through the decancelled transverse process is a safe procedure.

Methods

Transverse process is widely exposed and its posterior cortex is decorticated. The cancellous bone content of the transverse process is completely removed using a small curette. Bone wax is applied to avoid local bleeding and then the decancelled transverse process is inspected. The entry of the pedicle is then easily identified by the presence of remaining cancellous bone. A pedicular probe is then inserted and gently advanced. During pedicle probe insertion, the cortex of the anterior aspect of transverse process and the lateral margin of the pedicle act as a “slide” to permit safe insertion of the instrument.

Results

In our experience, no patient required additional procedures for screw revision, and no neurologic deficit occurred stemming from malpositioning of pedicle screws. The key point of the “slide technique” is to use the cortex of the anterior aspect of transverse process and the lateral margin of the pedicle as a “slide” to permit correct probe positioning during pedicle probe insertion.

Conclusions

This technique is very close to the “funnel technique”. The “funnel” and then the “slide” technique are mostly useful in complex spinal deformities as in neuromuscular patients. The “slide technique” is a safe, effective and cost-effective technique for pedicle screw placement in the thoracic spine especially in severe deformities.

Level of evidence

IV.

     

Editorial Commentary: Augmenting Suture Anchor Fixation: Why Has It Not Caught on?

Biomechanical studies with reliable clinical applicability are challenging to carry out. The results can be heavily dependent on the materials being tested (condition and ages of specimens), environmental conditions (temperature, moisture), magnitude and direction of loading, loading characteristics (static, dynamic), loading cycles and frequency, and how one measures and defines failure. The interested reader gains more confidence in the results and recommendations of a biomechanics study if the methodology reasonably models real-world scenarios and multiple studies from different labs all come to the same general conclusion.     

Association between the 25-question Geriatric Locomotive Function Scale score and the incidence of certified need of care in the long-term care insurance system: The TOEI study

BackgroundThe Geriatric Locomotive Function Scale is a screening tool to identify the risk of locomotive syndrome in the elderly. We aimed to clarify the association of Geriatric Locomotive Function Scale scores with the incidence of certified need of care in the long-term care insurance system in a prospective longitudinal observational study (the TOEI Study).MethodsParticipants were individuals aged ≥50 years from a mountainous area who had undergone medical check-ups by the National Health Insurance in Toei. The Geriatric Locomotive Function Scale questionnaire, physical performance tests, and radiographs were completed by participants. The primary endpoint was the incidence of certified need of care in the long-term care insurance system. The secondary endpoint was the incidence of either one of the following events: certified need of care or death.ResultsWe enrolled 681 subjects (271 men and 410 women). The mean age was 72.9 (range, 50–92) years. The incidences of certified need of care and either one of the two events were 104 and 130, respectively, during the average 4.9-year follow-up. The cumulative incidence rates of certified need of care by groups of the Geriatric Locomotive Function Scale, namely, Group 0 (score 0–6), Group 1 (score 7–15), and Group 2 (score 16–) were 7.5%, 14%, and 35%, respectively. The cumulative incidence rates of either one of the two events by group were 11%, 18%, and 39%, respectively. There was a significant association between higher Geriatric Locomotive Function Scale scores and survival rates (not achieved at each endpoint) for the primary and secondary endpoints.ConclusionsHigher Geriatric Locomotive Function Scale score was associated with greater incidence of certified need of care in the long-term care insurance system as well as either one of the two aforementioned events. This scale might enable prediction of prognosis among elderly patients.     

Comparison of surgical invasiveness and morbidity of adult spinal deformity surgery to other major operations

Background ContextAdult spinal deformity (ASD) surgeries are complex, involving long operative times and surgical morbidity. It is currently unclear how the invasiveness of ASD surgery compares to other major operations.PurposeTo: (1) develop a quantitative score of surgical morbidity and invasiveness, and (2) compare this score between ASD surgery and other major operations.Study DesignRetrospective review of prospectively collected data.Patient SampleA prospective surgical registry was used to identify all patients undergoing ASD surgery involving ≥ 7 segments. Seventeen additional procedures were included: coronary artery bypass grafting (CABG), pancreatectomy, and esophagectomy, among others.Outcome MeasuresPerioperative factors (operative time, transfusions, ventilation) and complications were collected and combined with a previously validated Postoperative Morbidity Survey to create a Surgical Invasiveness and Morbidity Score (SIMS).MethodsComputed scores were compared across surgeries using Welch's t-test. Multiple linear regression modeling was used to compare the SIMS of major surgeries relative to ASD while controlling for patient demographics and comorbidities.ResultsA total of 1,245,282 surgical patients were included, 4,656 of which underwent ASD surgery. After multiple regression modeling controlling for patient demographics and comorbidities, ASD surgery ranked fourth in SIMS. ASD surgery had a significantly greater SIMS than 13 other major procedures including 6th esophagectomy (adjusted mean difference=-0.05, 95%CI -0.01-0.09, p<.001), 8th pancreatectomy (-0.40, 0.37-0.44, p<.001), 11th craniotomy for tumor (-1.01, 0.98-1.04, p<.001), and 12th sacral chordoma resection (-1.31, 1.26-1.37, p<.001).ConclusionsASD surgery was associated with significantly greater SIMS than many other major operations, even when controlling for important perioperative factors. These data have implications for patient counseling, resource allocation, and informed consent.