Outcomes following outpatient anterior cervical discectomy and fusion for the treatment of myelopathy

IntroductionAnterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of degenerative cervical disease. With continued increase in U.S. healthcare expenditure, surgeons have begun to more closely examine the benefits of performing ACDF in an outpatient setting to increase efficiency, reduce the overall financial burden on patients/providers, and provide streamlined care for these patients. The purpose of this study was to analyze outcomes following outpatient ACDF for the treatment of myelopathy.Methods14,490 patients who had undergone ACDF for myelopathy from 2010 to 2018 were included in this retrospective study, of which 2956 (20.40%) patients were considered to have undergone outpatient surgery. Pearson chi-squared tests and Fischer’s Exact Tests were used to analyze differences in categorical variables of demographics, preoperative comorbidities, and postoperative complications, while Mann-Whitney-U-Tests were used to compare mean values of continuous variables. Coarsened-exact-matching (CEM) was implemented to control for baseline differences in demographics and comorbidities, and post-matching diagnostics included multivariate and univariate imbalance measure assessment. Outcomes were compared between the CEM-matched inpatient and outpatients ACDF cohorts.ResultsUpon CEM-matching (L1-statistic <0.001), the outpatient cohort (n = 2610, 25.13%) demonstrated significantly lower rates of any complication (p < 0.001), minor complications (p = 0.001), urinary tract infections (p = 0.029), blood transfusions (p < 0.001), major complications (p < 0.001), deep incisional surgical site infections (p = 0.017), ventilator dependence (p = 0.027), cardiac arrest (p = 0.028), unplanned reoperations (p = 0.001), and mortality (p = 0.006) in the 30-day postoperative period when compared to inpatient controls (n = 7774, 74.87%).ConclusionACDF has been a target amongst spinal procedures as a prime candidate for outpatient surgery. However, no previous reports have described complication rates and perioperative parameters in the sub-population of outpatient ACDF patients with myelopathy. In addition to shorter times from admission to operating room, operative time, and LOS, our study also demonstrated lower rates of major and overall complications in outpatient ACDF’s for myelopathy in comparison to their inpatient counterparts. Performing ACDF’s for myelopathy in an outpatient setting may help to curb costs, improve outcomes, and serve as a valuable learning resource for graduate medical education with rapid turnovers and shorter operative times.     

Significance of long corrective fusion to the ilium for physical function in patients with adult spinal deformity

BackgroundWe aimed to investigate the impact of long corrective fusion to the ilium on the physical function in elderly patients with adult spinal deformity and its correlation with spinopelvic parameters and health-related quality of life outcomes.MethodsWe included 60 female patients who underwent long corrective fusion from T9 or T10 to the pelvis for adult spinal deformities (mean age of 69.8 years, range 55–78 years). The radiographic parameters, health-related quality of life outcomes using the Scoliosis Research Society Outcome Instrument-22 and physical function assessments were reviewed preoperatively and at 1-year postoperatively.ResultsAll spinopelvic parameters, except for thoracolumbar kyphosis, and all domains of the Scoliosis Research Society Outcome Instrument-22 significantly improved at 1-year postoperatively (p < 0.0001). Physical function results, including those for one-leg standing time, timed up-and-go test, and 6-min walk tests, significantly improved at 1-year postoperatively (p < 0.005). Based on forward stepwise multivariate logistic regression, the predicted timed up-and-go test and 6-min walk test outcomes at 1-year postoperatively were as follows: timed up-and-go test, 7.8 + 0.47 × preoperative timed up-and-go test – 0.21 × 1-year postoperative grasping power +0.015 × 1-year postoperative C1 sagittal vertical axis (R2 = 0.6209, p < 0.0001); 6-min walk test, 309.2–9.1 × body mass index + 11.6 × 1-year postoperative grasping power + 3.3 × 1-year postoperative thoracolumbar kyphosis – 0.59 × 1-year postoperative C1 sagittal vertical axis (R2 = 0.4409, p < 0.0001).ConclusionsCorrective long fusion surgery for adult spinal deformity in normalizing sagittal alignment improves trunk balance and gait performance. Postoperative physical function depends on the preoperative physical performance status and skeletal muscle status; thus, preoperative interventions for improved physical function are recommended.     

Complications after spinal fixation surgery for osteoporotic vertebral collapse with neurological deficits: Japan Association of Spine Surgeons with ambition multicenter study

BackgroundThere have been few reports on the incidence and risk factors of the complications after spinal fixation surgery for osteoporotic vertebral collapse (OVC) with neurological deficits. This study aimed to identify the incidence and risk factors of the complications after OVC surgery.MethodsIn this retrospective multicenter study, a total of 403 patients (314 women and 89 men; mean age 73.8 years) who underwent spinal fixation surgery for OVC with neurological deficits between 2005 and 2014 were enrolled. Data on patient demographics were collected, including age, sex, body mass index, smoking, steroid use, medical comorbidities, and surgical procedures. All postoperative complications that occurred within 6 weeks were recorded. Patients were classified into two groups, namely, complication group and no complication group, and risk factors for postoperative complications were investigated by univariate and multivariate analyses.ResultsPostoperative complications occurred in 57 patients (14.1%), and the most common complication was delirium (5.7%). In the univariate analysis, the complication group was found to be older (p = 0.039) and predominantly male (p = 0.049), with higher occurrence rate of liver disease (p = 0.001) and Parkinson's disease (p = 0.039) compared with the no-complication group. In the multivariate analysis, the significant independent risk factors were age (p = 0.021; odds ratio [OR] 1.051, 95% confidence interval [CI] 1.007–1.097), liver disease (p < 0.001; OR 8.993, 95% CI 2.882–28.065), and Parkinson's disease (p = 0.009; OR 3.636, 95% CI 1.378–9.599).ConclusionsComplications after spinal fixation surgery for OVC with neurological deficits occurred in 14.1%. Age, liver disease, and Parkinson's disease were demonstrated to be independent risk factors for postoperative complications.     

Surgical delay for traumatic recurrent shoulder dislocations leads to inferior functional outcomes

BackgroundThe effect of time interval between injury and surgery on outcomes of Bankart repair surgery has not been published previously. The purpose of this study was to assess the effect of surgical delay on functional outcomes after arthroscopic Bankart repair.MethodOne hundred and five athletes who underwent arthroscopic Bankart repair ± remplissage were enrolled in the study. Patients were divided into 2 groups depending upon the injury to surgery time- < 12 months (n = 19), and ≥12 months (n = 86). Depending upon the number of episodes of dislocation, patients were further categorized into 2 groups- <10 episodes (n = 66) and ≥10 episodes (n = 39). All patients were assessed post-operatively for functional outcomes (Modified Rowe's score, Constant Murley score) and return to sports at a minimum of 2 years of follow-up.ResultsThe mean injury to surgery time was 31.7 ± 23.1 months. The average number of episodes of dislocation before surgery were 10 (range 3–50). 49/105 (46.7%) patients returned to sports after a mean post-operative duration of 10.9 months. Athletes operated after a surgical delay of ≥12 months had inferior functional outcomes (Modified Rowe's score-89.5 ± 8.9 vs.77.4 ± 21.4; p = 0.02), lower rate of return to sports (14/19 vs. 35/86; p = 0.02) and higher mean time to return to sports (8.7 ± 1.9 vs. 11.5 ± 2.6; p < 0.05). Similarly, athletes who had ≥10 dislocations before surgery had inferior functional outcomes (Modified Rowe's score-84.5 ± 15.2 vs.72.9 ± 25.6; p = 0.004), lower rate of return to sports (37/66 vs. 12/39; p = 0.02) and higher mean time to return to sports (10.3 ± 2.4 vs. 12.6 ± 2.5; p < 0.05).ConclusionA delay in surgery (≥12 months) or dislocation episodes of ≥10 are associated with inferior functional outcomes, lower rate of return to sports and higher surgical failure rate.Level of evidenceLevel III; Prospective cohort study.     

A comparative analysis of clinical,functional and radiographic outcomes of patients with and without fusion between the first and second metatarsals after the lapidus procedure

BackgroundThe aim of this study was to compare the clinical, functional and radiographic outcomes in patients who underwent the original Lapidus procedure (OLP) with fusion and undesired non-fusion between the first (M1) and second (M2) metatarsals.MethodsA retrospective and comparative analysis of 29 patients (38 feet) who underwent the OLP was performed. They were divided in two groups: (1) 23 feet in which fusion occurred and (2) 15 with undesired non-fusion. Clinical and functional data were assessed with the VAS for pain, AOFAS, LEFS and SF-12. SF-12 comprises physical and mental health scales (PCS-12 and MCS-12). Radiographic parameters assessed were bony and soft tissue forefoot widths (BSFW), intermetatarsal-angle (IMA) and HV-angle (HVA).ResultsSeparately, the groups presented significant improvements in all questionnaires (p < 0.001), except on MCS-12 (fusion p = 0.08 and non-fusion p = 0.27). When comparing both groups, patients with fusion had higher AOFAS scores (p < 0.05). Both groups presented the same improvements on BSFW, IMA and HVA (p = 0.09, p = 0.16, p = 0.52 and p = 0.63).ConclusionExcellent results were observed, even when without fusion between M1 and M2. Patients who evolved with fusion between the M1 and M2 showed greater improvements in the AOFAS score.Level of evidenceIII, retrospective comparative study.     

Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery

IntroductionSpinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies, discectomies, and microdiscectomies. However, the use of SA in spinal fusion surgery has been very scarcely documented in the current literature. Here we present a comparison of SA to GA in lumbar fusion surgery in terms of perioperative outcomes and cost.MethodsThe authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2018. Data collected included demographics, operative and recovery times, nausea/vomiting, postoperative pain, and opioid requirement. Costs were included in the analysis if they were: 1) non-fixed; 2) incurred in the operating room (OR); and 3) directly related to patient care. All cost data represents net costs and was obtained from the hospital revenue cycle team. Patients were grouped for statistical analysis based on anesthetic modality.ResultsA total of 29 patients received SA and 46 received GA. Both groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and medical comorbidities. The SA group spent less time in the OR (163.86 ± 9.02 vs. 195.63 ± 11.27 min, p < 0.05), PACU (82.00 ± 7.17 vs. 102.98 ± 8.46 min, p < 0.05), and under anesthesia (175.03 ± 9.31 vs. 204.98 ± 10.15 min, p < 0.05) than the GA group. Post-surgery OR time was significantly less with SA than with GA (6.00 ± 1.09 vs. 17.26 ± 3.05 min, p < 0.05); however, pre-surgery OR time was similar between groups (50.17 ± 3.08 vs. 56.17 ± 5.34 min, p = 0.061). The SA group also experienced less maximum postoperative pain (3.31 ± 1.41 out of 10 vs. 5.96 ± 0.84/10, p < 0.05) and required less opioid analgesics (2.38 ± 1.37 vs. 5.39 ± 0.84 doses, p < 0.05). Both groups experienced similar nausea or vomiting rates and adverse events postoperatively. Net operative cost was found to be $812.31 (5.6%) less with SA than with GA, although this difference was not significant (p = 0.225).Discussion/conclusionTo our knowledge, SA is almost never used in lumbar fusion, and a cost-effectiveness comparison with GA has not been recorded. In this retrospective study, we demonstrate that the use of SA in lumbar fusion surgery leads to significantly shorter operative and recovery times, less postoperative pain and opioid usage, and slight cost savings over GA. Thus, we conclude that this anesthetic modality represents a safe and cost-effective alternative to GA in lumbar fusion.     

Risk factors for delayed diagnosis of spinal fracture associated with diffuse idiopathic skeletal hyperostosis: A nationwide multiinstitution survey

BackgroundPatients with DISH are susceptible to spinal fractures and subsequent neurological impairment, including after minor trauma. However, DISH is often asymptomatic and fractures may have minimal symptoms, which may lead to delayed diagnosis. The purpose of this study was to identify risk factors for delayed diagnosis of spinal fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH).MethodsThe subjects were 285 patients with DISH surgically treated at 18 medical centers from 2005 to 2015. Cause of injury, imaging findings, neurological status at the times of injury and first hospital examination, and the time from injury to diagnosis were recorded. A delayed diagnosis was defined as that made >24 h after injury.ResultsMain causes of injury were minor trauma due to a fall from a standing or sitting position (51%) and high-energy trauma due to a fall from a high place (29%) or a traffic accident (12%). Delayed diagnosis occurred in 115 patients (40%; 35 females, 80 males; mean age 76.0 ± 10.4 years), while 170 (60%; 29 females, 141 males; mean age 74.6 ± 12.8 years) had early diagnosis. Delayed group had a significantly higher rate of minor trauma (n = 73, 63% vs. n = 73, 43%), significantly more Frankel grade E (intact neurological status) cases at the time of injury (n = 79, 69% vs. n = 73, 43%), and greater deterioration of Frankel grade from injury to diagnosis (34% vs. 8%, p < 0.01). In multivariate analysis, a minor trauma fall (OR 2.08; P < 0.05) and Frankel grade E at the time of injury (OR 2.29; P < 0.01) were significantly associated with delayed diagnosis.ConclusionIn patients with DISH, it is important to keep in mind the possibility of spinal fracture, even in a situation in which patient sustained only minor trauma and shows no neurological deficit. This is because delayed diagnosis of spinal fracture can cause subsequent neurological deterioration.     

Simple oncoplastic breast defect closure improves long-term cosmetic outcome of breast conserving surgery for breast cancer: A randomised controlled trial

IntroductionBreast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure.MethodsA randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the “reshaping” group (closure of excision defect with mobilised breast tissue; n = 124) and to the “control” group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ).ResultsThere were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of “good” or “excellent” by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001).ConclusionsSimple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes.     

A prospective study comparing three different all-posterior surgical techniques in the management of thoracolumbar spinal tuberculosis

BackgroundPosterior only surgery has been widely performed in the treatment of thoracic and lumbar spinal tuberculosis. Surgical options include debridement with posterior instrumentation only or combined with anterior reconstruction. The aim of this study is to investigate and compare the clinical, functional and radiological outcomes using a single-stage posterior only surgery in thoracolumbar spinal tuberculosis by three different surgical techniques.MethodsPatients undergoing posterior only surgery for thoracic and lumbar spinal tuberculosis were followed up prospectively and included. Three different procedures, Group-A: Posterior instrumentation with anterior cage reconstruction (n = 49), Group-B: Posterior instrumentation and anterior autologous bone-grafting (n = 21) and Group-C: Posterior column shortening without anterior-reconstruction (n = 52) were compared for kyphosis correction achieved, kyphosis at final follow-up and degree of correction lost. Neurological assessment was done using ASIA impairment Scale(AIS) grades. Functional assessment was done using Visual analogue score (VAS), Modified McNab criteria and NASS satisfaction score.ResultsA total of 122 patients were included in the study, Group-A (49), Group-B (21) and Group-C (52). Radiological correction of kyphotic deformity in anterior reconstruction, Group-A (20.17 ± 9.25⁰) was higher than 13.97⁰ ± 6.06⁰ and 14.27⁰ ± 6.47⁰ achieved in Groups B and C respectively. There was no significant difference in correction lost amongst the three groups (p-value, 0.76). Surgical duration, blood loss and hospital stay were significantly higher in the anterior reconstruction group (p-value, 0.001). Similarly, no significant difference was noted between the three groups in neurological and functional outcomes at 2 years.ConclusionPosterior only approach is eminently satisfactory for treating Thoracolumbar Spinal Tuberculosis (STB). All three groups had similar functional and neurological outcomes. However there was a better correction of deformity in patients with anterior cage reconstruction.     

Adult thoracolumbar and lumbar scoliosis treated with long vertebral fusion to the sacropelvis: a comparison between new hybrid selective spinal fusion versus anterior-posterior spinal instrumentation

Background contextCombined anteroposterior spinal fusion with instrumentation has been used for many years to treat adult thoracolumbar/lumbar scoliosis. This surgery remains a technical challenge to spine surgeons, and current literature reports high complication rates.PurposeThe purpose of this study is to validate a new hybrid technique (a combination of single-rod anterior instrumentation and a shorter posterior instrumentation to the sacrum) to treat adult thoracolumbar/lumbar scoliosis.Study designThis study is a retrospective consecutive case series of surgically treated patients with adult lumbar or thoracolumbar scoliosis.Patient sampleThis is a retrospective study of 33 matched pairs of patients with adult scoliosis who underwent two different surgical procedures: a new hybrid technique versus a third-generation anteroposterior spinal fusion.Outcome measuresPreoperative and postoperative outcome measures include self-report measures, physiological measures, and functional measures.MethodsIn a retrospective case-control study, 33 patients treated with the hybrid technique were matched with 33 patients treated with traditional anteroposterior fusion based on preoperative radiographic parameters. Mean follow-up in the hybrid group was 5.3 years (range, 2–11 years), compared with 4.6 years (range, 2–10 years) in the control group. Operating room (OR) time, estimated blood loss, and levels fused were collected as surrogates for surgical morbidity. Radiographic parameters were collected preoperatively, postoperatively, and at final follow-up. The Scoliosis Research Society Patient Questionnaire (SRS-22r) and Oswestry Disability Index (ODI) scores were collected for clinical outcomes.ResultsOperating room time, EBL, and levels fused were significantly less in the hybrid group compared with the control group (p<.0001). The postoperative thoracic Cobb angle was similar between the hybrid and control techniques (p=.24); however, the hybrid technique showed significant improvement in the thoracolumbar/lumbar curves (p=.004) and the lumbosacral fractional curve (p<.0001). The major complication rate was less in the hybrid group compared with the control group (18% vs. 39%, p=.01). Clinical outcomes at final follow-up were not significantly different based on overall SRS-22r scores and ODI scores.ConclusionThe new hybrid technique demonstrates good long-term results, with less morbidity and fewer complications than traditional anteroposterior surgery select patients with thoracolumbar/lumbar scoliosis. This study received no funding. No potential conflict of interest-associated bias existed.     

Mid-term functional outcomes following reoperation after total ankle arthroplasty: A retrospective cohort study

BackgroundDespite a significant reported rate of non-revision reoperation after total ankle arthroplasty (TAA), it is uncertain if these subsequent procedures have an impact on the longer term outcomes. This study aimed to compare minimum five-year functional outcomes of patients who had undergone reoperation after TAA to those who did not require reoperation.MethodsSeventy-six ankles (74 patients) who underwent TAA with the Salto Talaris fixed bearing system between 2007 and 2014 were allocated into two groups based on presence (n = 16) or absence of reoperation (n = 60). Reoperations included all secondary procedures after index TAA, excluding revision surgeries requiring removal or exchange of the original prosthesis. The foot and ankle outcome score (FAOS) at preoperative and minimum five-year follow-up was compared between the groups. Additionally, improvements in FAOS subscales were compared. Preoperative deformity, postoperative implant alignment, number of periprosthetic cysts, and subsidence between groups were compared using standard weightbearing radiographs.ResultsThe most common cause of reoperation was gutter impingement (n = 11), followed by stress fracture of the medial malleolus (n = 2), tarsal tunnel syndrome (n = 1), periprosthetic cyst (n = 1), and infection (n = 1). In comparison to the non-reoperation group, all FAOS subscales except for the Sports and Recreational Activities subscale were significantly lower in the reoperation group at final follow-up. The reoperation group exhibited significantly less improvement in the Pain, Symptoms, and Quality of Life subscales at final follow-up (p < 0.05). There were no statistical differences in the radiographic parameters between both groups.ConclusionsPatients who underwent reoperation after TAA demonstrated inferior functional outcomes at mid-term follow-up. An emphasis should be placed on preventing possible causes of reoperations to achieve favorable patient outcomes. Additionally, if a reoperation is deemed necessary, a thorough evaluation and surgical correction of underlying causes should be achieved.     

Financial analysis of circumferential fusion versus posterior-only with thoracic pedicle screw constructs for main thoracic idiopathic curves between 70° and 100°

Purpose Reports on thoracic pedicle screw (TPS) constructs have demonstrated their safety and efficacy; however, concerns exist regarding their increased cost. This is a review of adolescents with main thoracic scoliosis surgically treated with anterior release and posterior fusion or posterior fusion only. The objectives were to compare the radiographic outcomes and financial data of two surgical treatments: anterior/posterior spinal fusion (APSF) versus posterior spinal fusion (PSF-TPS) alone with TPSs, in patients with large 70–100° main thoracic adolescent idiopathic scoliosis (AIS) curves. Methods We identified 43 patients with main thoracic Lenke type 1–4 AIS curves between 70 and 100° who had been treated with either APSF or PSF-TPS. Results Both groups had equivalent radiographic corrections postoperatively. The PSF-TPS group patients had higher implant charges, but the APSF group had higher surgeon procedural charges, operating room charges, anesthesia charges, and inpatient room charges. Total charges were $75,295 for the APSF group and $71,236 for the PSF-TPS group (P > 0.05). Analyses of two subgroups of the APSF group, anterior release via thoracotomy versus VATS and same-day versus staged surgeries, failed to change any of the above findings. Conclusion Based on this financial analysis, there was no statistically significant differences between the APSF and PSF-TPS groups, with equivalent radiographic corrections.     

Evaluating flexibility and predicting curve correction using fulcrum-bending radiographs in Lenke type 2 adolescent idiopathic scoliosis

BackgroundFulcrum-bending (FB) correction is considered to provide the best estimation of main thoracic (MT) curve flexibility and postoperative correction in surgical treatment for adolescent idiopathic scoliosis (AIS). However, few studies evaluated the usefulness of FB radiographs for proximal thoracic (PT) curve. We aimed to perform flexibility assessments using both active side-bending (SB) and FB radiographs and evaluate surgical outcomes after posterior spinal fusion (PSF) for Lenke type 2 AIS.MethodsThis study included 38 consecutive patients with Lenke type 2 AIS who underwent PSF using a pedicle screw construct with a minimum 2-year follow-up. Radiographic parameters, including correction rate, SB and FB flexibility, and FB correction index (FBCI: [correction rate/FB flexibility] × 100), were evaluated preoperatively, immediately after surgery, and at the 2-year follow-up. The clinical outcomes were preoperatively evaluated using the Scoliosis Research Outcomes Instrument-22 and at the follow-up.ResultsAll scoliosis curves significantly improved and shoulder balance shifted toward left shoulder elevation (all comparisons, p < 0.0001). There were significant differences between the SB and FB corrections in the PT and MT curves (p < 0.0001). The magnitudes of the discrepancies between the SB and FB corrections in the PT and MT curves were 11.2° ± 5.2° and 11.6° ± 7.2°, respectively. FB correction did not differ from postoperative Cobb angles correction immediately after surgery or at the 2-year follow-up; the mean FBCIs in the PT and MT curves were 98.8% and 105.5%, respectively. The self-image domain SRS-22 scores had significantly increased at the 2-year follow-up (p < 0.0001).ConclusionsThere were significant differences between the SB and FB corrections, and FB correction tended to approximate the postoperative curve correction (FBCI = 100%) for PT and MT curves in patients with Lenke type 2 AIS. FB flexibility is more reliable than SB flexibility in evaluating actual curve flexibility even for the PT curve.     

Characteristic imaging findings predicting the risk of conservative treatment resistance in fresh osteoporotic vertebral fractures with poor prognostic features on magnetic resonance imaging

BackgroundRecent studies have reported that confined high-intensity and diffuse low-intensity on sagittal T2-weighted magnetic resonance imaging (MRI) are distinctive features that are highly predictive of delayed union or nonunion on osteoporotic vertebral fracture (OVF). The objective of this study was to identify the characteristics of imaging findings predicting the risk for requiring surgical treatment in fresh OVF with poor prognostic features on MRI.MethodsWe conducted a retrospective study of 74 patients (17 men and 57 women with a mean age of 81.1 years) of OVF with the poor prognostic MRI findings. We compared the imaging findings between the surgery group (16 patients) and the conservative group (58 patients): vertebral instability defined as the difference between the vertebral collapse ratio in dynamic X-rays, and the grade of posterior wall injury (Grade I, no spinal canal encroachment; Grade II, <2 mm; Grade III, ≥2 mm) as well as the presence or absence of pedicle fracture (Grade I, none; Grade II, unilateral; Grade III, bilateral) on computed tomography.ResultsThe mean vertebral instability was 24.0% ± 10.1% in the surgery group and 13.0% ± 7.8% in the conservative group, which was significantly different. Posterior wall injury in the surgery and conservative groups was Grade I in 0 and 29 cases, Grade II in 5 and 21 cases, and Grade III in 11 and 8 cases, respectively, constituting a significant difference. Pedicle fracture in the surgery and conservative groups was Grade I in 5 and 55 cases, Grade II in 6 and 2 cases, and Grade III in 5 and 1 case, respectively, also constituting a significant difference.ConclusionsThe most high-risk OVF patients with poor prognostic MRI findings who required surgical treatment were those who exhibited greater vertebral instability as well as either more severe posterior wall injury or pedicle fracture.Study designRetrospective clinical study.     

Bilateral ultrasound-guided erector spinae plane block in patients undergoing lumbar spinal fusion: A randomized controlled trial

Study objectiveSpinal fusion surgery is associated with severe postoperative pain. We examined whether bilateral ultrasound-guided erector spinae plane block could alleviate postoperative pain in patients undergoing lumbar spinal fusion.DesignBlinded, randomized, controlled study.SettingTertiary university hospital, operating room, postoperative recovery room and ward.PatientsSixty patients with American Society of Anesthesiologists grade I or II scheduled for lumbar spinal fusion surgery were randomized into the erector spinae plane block group (ESPB group) and the control group in a 1:1 ratio.InterventionsPre-operative ultrasound-guided bilateral erector spinae plane block was performed in the ESPB group, while sham subcutaneous infiltration was performed in the control group.MeasurementsThe primary outcome was pain intensity at rest within 12 h postoperatively using the Numeric Rating Scale (NRS). Secondary outcomes included NRS pain scores at rest and on movement, postoperative opioid consumption and proportions of patients requiring opioid during the first 48 h after surgery.Main resultsThe ESPB group (n = 30) showed significantly lower pain scores at rest at 4 h after surgery (estimated mean difference − 1.6, 95% confidence interval [CI] -2.4 to −0.8, p < 0.001), at 8 h (−1.3, 95% CI -1.9 to −0.6, p < 0.001), and at 12 h (−0.7, 95% CI -1.3 to −0.1, p = 0.023). The two groups showed similar pain scores at rest at 24 h after surgery (estimated mean difference − 0.2, 95% CI -0.8 to 0.5) and 48 h (−0.3, 95% CI -0.8 to 0.2). The ESPB group also showed significantly lower pain score on movement at 4 h after surgery (−1.5, 95% CI -2.5 to −0.6). The ESPB group showed a significantly smaller proportion of patients requiring sufentanil within 12 h after surgery (p = 0.020), and the group consumed significantly less sufentanil during that period (p = 0.042).ConclusionsBilateral ultrasound-guided erector spinae plane block improves postoperative analgesia in patients undergoing lumbar spinal fusion.     

Additional vertebral augmentation with posterior instrumentation for unstable thoracolumbar burst fractures

BackgroundTo investigate the role of vertebral augmentation in kyphosis reduction, vertebral fracture union, and correction loss after surgical management of thoracolumbar burst fracture.DesignRetrospective chart and radiographic review.SettingLevel 1 trauma center.MethodsThe analysis included patients treated between April 2007 and June 2015, who received pedicle-screw-rod distraction and reduction within two days following acute traumatic thoracolumbar burst fracture with a load sharing score >6. Medical records were retrospectively reviewed for data regarding operative details, imaging and laboratory findings, neurological function, and functional outcomes.InterventionNot applicable.Main outcome measuresSagittal index, pain score, loss of correction, and implant failure rate.ResultsNineteen patients were enrolled in this study (mean age, 37.2 ± 13 years; age range, 17–62 years; female/male ratio: 10/9). Of the five patients who received only reduction (no augmentation), one underwent revision surgery because of implant failure and pedicle screw backing out. Compared to patients who received only reduction, those who received both reduction and augmentation showed better sagittal alignment after the operation, with better sagittal index immediately postoperatively and during the follow-up (p < 0.05).ConclusionsTranspedicular vertebral augmentation with calcium sulfate/phosphate-based bone cement may reinforce thoracolumbar burst fracture stability, partially restore vertebral body height, and reduce pedicle screw bending and movement, thereby preventing early implant failure and late loss of correction, especially in patients with excellent fracture reduction.Level of evidence: Therapeutic level III, retrospective chart review     

Influence of contoured versus straight rod on clinical outcomes and sagittal parameters in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) at L4/5 level-more than 5 years follow-up

BackgroundMinimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is among the most commonly performed surgical procedure to treat lumbar degenerative disorders. In open TLIF procedure, usually rods were contoured to restore normal lumbar sagittal alignment. However, in MIS-TLIF procedure, contoured rods sometimes were easier to rotate and harder to be locked at the satisfactory position due to instrumentation design and limited exposure. Thus, straight rods had been used in single-level MIS-TLIF in our institution. However, the effect of rod contouring on sagittal parameters and clinical outcomes remains unclear. In the present study, we aim to evaluate the effects of single-segment MIS-TLIF with contoured versus straight rods on sagittal parameters and clinical outcomes.MethodsA retrospective review of MIS-TLIF at L4/5 was performed between 2009 and 2013 in our hospital. Seventy-six cases were divided into contoured rod group (CR group, n = 35) and straight rod group (SR group, n = 41). Clinical outcomes and radiographic measurements at five years’ follow-up were evaluated by visual analog score (VAS), Oswestry disability index (ODI) and Japanese Orthopaedic Association (JOA) score, spino-pelvic parameters, disc height and fused segment angle. Fusion rate and cage subsidence were also measured.ResultsPreoperative VAS, JOA, ODI and radiographic parameters were comparable between two groups. The average follow-up was 63.72 ± 3.86 months. VAS, JOA and ODI were significantly improved at 5-year follow-up in both groups, and there were no significant differences between two groups(P > 0.05). Fused segment angle (FSA) was greater in CR group than SR group (P = 0.024), while the other radiographic parameters were not significantly different(P > 0.05). Rod process, fusion rate and cage subsidence were not risk factors of post-surgical malalignment, patients with pre-surgical sagittal imbalance was more prone to show post-surgical malalignment (P < 0.05).ConclusionsBoth CR and SR groups acquired satisfactory clinical results. Although contoured rods had better fused segment angle, contoured or straight rods at single L4/5 level had little effect on global spino-pelvic parameters and clinical outcomes in a 5-year follow-up.     

Adjacent vertebral Hounsfield unit value of acute osteoporotic vertebral fracture is a risk factor for concomitant domino osteoporotic vertebral fractures

BackgroundMost patients with acute osteoporotic vertebral fracture (AOVF) are successfully treated conservatively. However, the optimal management method and prognosis for multiple AOVFs are unclear. This study aimed to investigate the prevalence of multiple AOVFs and identify the associated risk factors.MethodsThis study enrolled 134 hospitalized patients (mean age 83 ± 7.6 years, 66% women) with AOVF treated conservatively between 2017 and 2020. The fractures were diagnosed by magnetic resonance imaging (MRI). The AOVFs were divided into two groups; single osteoporotic vertebral fractures (OVF) and domino OVFs (at least two OVFs). The adjacent vertebral Hounsfield unit values (HU) of the OVF and dual x-ray absorptiometry (DXA) of the lumbar spine or hip were used to evaluate the bone mineral density (BMD). Logistic regression analysis was performed to identify the risk factors for domino OVFs.ResultsDomino OVFs were noted in 21 (15.7%) of 134 patients. There were 10 cases of adjacent level and 11 cases of remote level. The BMI (18.5 ± 4.2 vs. 21.2 ± 4.6, p = 0.025) and adjacent vertebral HU value of OVF (57.3 ± 17.5 vs. 76.6 ± 24.1, p = 0.008) were significantly lower in the domino OVFs group than in the single OVF group. Logistic regression analysis revealed the adjacent vertebral HU value of the OVF as an independent risk factor for domino OVFs, (odds ratios (OR) 0.96, p = 0.012). The domino OVF group had a significantly higher decline in gait ability (76% vs. 48%, p = 0.017).ConclusionsThe adjacent vertebral HU value of AOVF is a useful tool for evaluating BMD for domino OVFs. The optimal treatment for osteoporosis should be considered to prevent subsequent domino OVFs.     

Video-Assisted Simulation Training in Burn Management: A Comparative Cohort Study on the Assessment of Technical and Non-technical Competencies

BackgroundWritten material remains one of the most common methods of education, however the current generation of learners may benefit from additional different media. In our study, we aim to quantify the effects of an innovative video instruction on subsequent resident performance in a burn patient simulation.MethodsFollowing IRB approval, 60 Plastic Surgery residents were randomly assigned to two groups. The control group (“non-video” group) (n = 30) was given only written material as preparation. The experimental group (“video” group) (n = 30) was provided access to video training materials in addition to the written material on technical and non-technical skills. Their videotaped performances on simulation were evaluated by a blinded surgical faculty member. The comparison of variables between the two groups was performed using a Mann-Whitney test for non-normal distributions of quantitative variables, and Fisher's Exact Probability test for qualitative data. Statistical significance was set at p < 0.05.ResultsCompared to the non-video group, the video group achieved significantly higher scores in the technical skills of assessment of breathing (p = 0.015), disability (p = 0.023), and exposure (p = 0.005) and in the non-technical skills of decision-making (p = 0.035).ConclusionsIn residents participating in burn patient simulations, video training in advance of the simulation significantly improved their assessments of breathing, disability, and exposure as well as decision-making. Our video is a valuable tool to enhance trainees’ technical and non-technical competencies in managing burn patient simulations.