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Comparison of sleep improvement in patients undergoing lumbar spine decompression

Ryan McNassor, Jennifer Yang, Michael D. Shost, and Deborah L. Benzil

OBJECTIVE

Degenerative spine conditions affect many people each year. These conditions have been shown to negatively impact pain, function, and patient quality of life (QOL), which often require surgical intervention. It is understood that sleep plays an important role in all of these factors. However, the relationship between sleep disruption and lumbar surgery is not well understood. The objective of this study was to use a large database to understand the relationship between sleep quality and lumbar spine surgery outcomes.

METHODS

The surgical database of the authors’ institute was used to identify all patients undergoing lumbar spine surgery for degenerative spine disease from January 1, 2012, through December 31, 2021. Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance scores were collected, and only patients with both pre- and postoperative scores were included. Additional measures related to disability, pain, and depression were also obtained. Chart review was performed to collect patient demographics, health risk factors, and information related to sleep disturbances such as sleep medication usage and prior sleep condition diagnosis.

RESULTS

The study had 674 patients who met the criteria. At 3, 6, and 12 months postoperatively, there was a significant decrease in sleep disruption scores (i.e., sleep improvement), although these decreases were not greater than the minimal clinically important difference (MCID). When stratified based on preoperative sleep quality, patients with poor preoperative scores (PROMIS sleep disruption > 63.04) showed a significant decrease in sleep disruption by 8.17 at 3 months, 7.99 at 6 months, and 7.21 at 12 months. All of these decreases were greater than the sleep disruption MCID of 6.5. Multivariate analysis showed high preoperative sleep disruption and improvement in PROMIS physical health were most associated with decreased postoperative sleep disruption at all postoperative time points.

CONCLUSIONS

In patients with degenerative spine conditions, lumbar spine surgery offers improvement in sleep disruption for all patients. Those with poor preoperative sleep quality are more likely to see clinical improvement in their sleep disruption.

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Ideal length of accessory rod for the prevention of rod fracture after pedicle subtraction osteotomy in adult spinal deformity: short or long?

Ki Young Lee, Jung-Hee Lee, Kyung-Chung Kang, Seong Jin Cho, and Woo Jae Jang

OBJECTIVE

Pedicle subtraction osteotomy (PSO) is an effective surgical procedure for adult spinal deformity (ASD). However, the complexity of the procedure and its associated complications including rod fracture (RF) remain challenging issues. Among several RF reduction methods, the accessory rod (AR) is an important surgical technique. To date, knowledge about the ideal length and configuration of the AR is limited. This study aimed to assess the influence of the connection levels and configuration of the AR on RF occurrence in patients with ASD who underwent long level constructs and PSO.

METHODS

The authors retrospectively selected 57 consecutive patients (mean age 70.6 years) who underwent deformity correction including PSO and the AR technique with a minimum 2-year follow-up. The patients were classified into a non-RF group (n = 49) and an RF group (n = 8). Along with analysis of patient and radiological factors in the 2 groups, comparative studies were performed including configuration of the AR (D shaped vs linear shaped) and the connection levels of AR (long AR [the lower end below S1–2] vs short AR [above L5–S1]).

RESULTS

The overall rate of RF incidence was 14% (8/57 cases) at an average of 42.5 months (2 patients with unilateral RF and 6 with bilateral RF). RF occurred most commonly at the L4–5 level, below the lower end of the AR: 6 below the lower end of the AR and 2 at the PSO site. There were no significant differences in patient and radiological factors between the groups. Comparisons between the 2 groups indicated that more RFs occurred when the configuration of the AR was a linear shape (p = 0.016) and when the distal end of the AR was above L5–S1 (p = 0.025).

CONCLUSIONS

In this study the authors found that the D-shaped configuration of the AR and lower end of the AR below S1–2 (i.e., long AR) could be preventive methods for reducing RF after deformity correction performed using PSO and the AR technique for ASD. Here, the authors have provided the first comprehensive outline for the AR technique. These findings could establish effective guidelines for spine surgeons.

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Is it necessary to extend fusion to L4 when correcting pediatric L5–S1 spondylolisthesis?

Jiahao Jiao, Xiaohan Ye, Dong Guo, Jun Cao, Xuejun Zhang, Shengru Wang, Jianguo Zhang, and Ziming Yao

OBJECTIVE

The objective of this study was to investigate whether extending fusion to L4 is imperative in the surgical treatment of pediatric L5–S1 spondylolisthesis.

METHODS

This retrospective analysis encompassed 68 pediatric cases of dysplastic L5–S1 spondylolisthesis who underwent posterior lumbar interbody fusion surgery at two hospitals. Patients were categorized into two groups based on the upper instrumented vertebra (group L4 and group L5). Data were collected from medical records and radiological images obtained preoperatively and at last follow-up. Radiographic parameters including slip percentage (SP), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), Spinal Deformity Study Group dysplastic lumbosacral angle (SDSG-LSA), pelvic tilt (PT), Dubousset’s lumbosacral angle (Dub-LSA), sacral slope (SS), and severity index (SI) were measured. Surgery-related data and complication data were also collected. The incidence rates of complications were compared, including those of neurological deficit, adjacent-segment instability (ASI), and other complications. ASI was defined as progression of slippage > 3 mm or posterior opening > 5° in the adjacent segment. Clinical outcomes were assessed with the numeric rating scale (NRS) and the Oswestry Disability Index (ODI) scores. The follow-up period for all patients lasted a minimum of 2 years.

RESULTS

Among all 68 patients, group L4 consisted of 15 patients and group L5 comprised 53 patients. The patients included in both groups had comparable baseline demographic characteristics and radiographic parameters. Postoperative SP and SDSG-LSA were significantly lower in group L5 (p < 0.05). No other postoperative radiographic differences were observed between groups. One patient in group L4 and 3 patients in group L5 experienced transient neurological deficits (p > 0.05). There were 13 cases of ASI in group L5 compared with none in group L4 (24.5% vs 0%, p > 0.05). Of the 13 patients with ASI, 4 underwent revision surgery due to L4–5 level instability and clinical symptoms. The remaining individuals exhibited no symptoms, and regular annual follow-up assessments are being conducted for all patients. The NRS and ODI scores at final follow-up did not exhibit any significant differences between the two groups.

CONCLUSIONS

Fusion to L5 could achieve comparable satisfactory results to fixation to L4, albeit with increased likelihood of ASI. Extension of fusion to L4 may not be necessary for most patients with pediatric L5–S1 spondylolisthesis.

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Modified Clavien-Dindo-Sink Classification System for operative complications in adult spine surgery

Dominic Ridolfi, Anthony A. Oyekan, Melissa Yunting Tang, Stephen R. Chen, Christopher J. Como, Jonathan Dalton, Emmett J. Gannon, Keith L. Jackson II, Jesse E. Bible, Christopher Kowalski, S. Joseph de Groot, William F. Donaldson III, Joon Y. Lee, and Jeremy D. Shaw

OBJECTIVE

Currently there is no standardized mechanism to describe or compare complications in adult spine surgery. Thus, the purpose of the present study was to modify and validate the Clavien-Dindo-Sink complication classification system for applications in spine surgery.

METHODS

The Clavien-Dindo-Sink complication classification system was evaluated and modified for spine surgery by four fellowship-trained spine surgeons using a consensus process. A distinct group of three fellowship-trained spine surgeons completed a randomized electronic survey grading 71 real-life clinical case scenarios. The survey was repeated 2 weeks after its initial completion. Fleiss’ and Cohen’s kappa (κ) statistics were used to evaluate interrater and intrarater reliabilities, respectively.

RESULTS

Overall, interobserver reliability during the first and second rounds of grading was excellent with a κ of 0.847 (95% CI 0.785–0.908) and 0.852 (95% CI 0.791–0.913), respectively. In the first round, interrater reliability ranged from good to excellent with a κ of 0.778 for grade I (95% CI 0.644–0.912), 0.698 for grade II (95% CI 0.564–0.832), 0.861 for grade III (95% CI 0.727–0.996), 0.845 for grade IV-A (95% CI 0.711–0.979), 0.962 for grade IV-B (95% CI 0.828–1.097), and 0.960 for grade V (95% CI 0.826–1.094). Intraobserver reliability testing for all three independent observers was excellent with a κ of 0.971 (95% CI 0.944–0.999) for rater 1, 0.963 (95% CI 0.926–1.001) for rater 2, and 0.926 (95% CI 0.869–0.982) for rater 3.

CONCLUSIONS

The Modified Clavien-Dindo-Sink Classification System demonstrates excellent interrater and intrarater reliability in adult spine surgery cases. This system provides a useful framework to better communicate the severity of spine-related complications.

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Effect of urgent surgery within 8 hours compared to surgery between 8 and 24 hours on perioperative complications and neurological prognosis in patients older than 70 years with cervical spinal cord injury: a propensity score–matched analysis

Tomoaki Shimizu, Kota Suda, Satoko Matsumoto Harmon, Miki Komatsu, Masahiro Ota, Hiroki Ushirozako, Kento Inomata, Akio Minami, Katsuhisa Yamada, Tsutomu Endo, Masahiko Takahata, Norimasa Iwasaki, Hiroshi Takahashi, Masao Koda, and Masashi Yamazaki

OBJECTIVE

This study aimed to investigate the effect of surgery within 8 hours on perioperative complications and neurological prognosis in older patients with cervical spinal cord injury by using a propensity score–matched analysis.

METHODS

The authors included 87 consecutive patients older than 70 years who had cervical spinal cord injury and who had undergone posterior decompression and fusion surgery within 24 hours of injury. The patients were divided into two groups based on the time from injury to surgery: surgery within 8 hours (group 8 hours) and between 8 and 24 hours (group 8–24 hours). Following the preliminary study, the authors established a 1:1 matched model using propensity scores to adjust for baseline characteristics and neurological status on admission. Perioperative complication rates and neurological outcomes at discharge were compared between the two groups.

RESULTS

Preliminary analysis of 87 prematched patients (39 in group 8 hours and 48 in group 8–24 hours) revealed that the motor index score (MIS) on admission was lower for lower extremities (12.3 ± 15.5 vs 20.0 ± 18.6, respectively; p = 0.048), and total extremities (26.7 ± 27.1 vs 40.2 ± 30.6, respectively; p = 0.035) in group 8 hours. In terms of perioperative complications, group 8 hours had significantly higher rates of cardiopulmonary dysfunction (46.2% vs 25.0%, respectively; p = 0.039). MIS improvement (the difference in scores between admission and discharge) was greater in group 8 hours for lower extremities (15.8 ± 12.6 vs 9.0 ± 10.5, respectively; p = 0.009) and total extremities (29.4 ± 21.7 vs 18.7 ± 17.7, respectively; p = 0.016). Using a 1:1 propensity score–matched analysis, 29 patient pairs from group 8 hours and group 8–24 hours were selected. There were no significant differences in baseline characteristics, neurological status on admission, and perioperative complications between the two groups, including cardiopulmonary dysfunction. Even after matching, MIS improvement was significantly greater in group 8 hours for upper extremities (13.0 ± 10.9 vs 7.8 ± 8.3, respectively; p = 0.045), lower extremities (14.8 ± 12.7 vs 8.3 ± 11.0, respectively; p = 0.044) and total extremities (27.8 ± 21.0 vs 16.0 ± 17.5, respectively; p = 0.026).

CONCLUSIONS

Results of the comparison after matching demonstrated that urgent surgery within 8 hours did not increase the perioperative complication rate and significantly improved the MIS, suggesting that surgery within 8 hours may be efficient, even in older patients.

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Lordosis distribution index for predicting mechanical complications after long-level fusion surgery: comparison of Global Alignment and Proportion score and Roussouly classification

Min-Hyeong Moon, Myung-Hoon Shin, Seung-Chan Yoo, Doo-Yong Choi, and Jong-Tae Kim

OBJECTIVE

Both the Global Alignment and Proportion (GAP) score and Roussouly classification account for the lordosis distribution index (LDI), but the LDI of the GAP score (G-LDI) is typically set to 50%–80%, while the LDI of the Roussouly classification (R-LDI) varies depending on the degree of pelvic incidence (PI). The objective of this study was to validate the ability of the G-LDI to predict mechanical complications and compare it with the predictive probability of R-LDI in patients with long-level fusion surgery.

METHODS

A total of 171 patients were divided into two groups: 93 in the nonmechanical complication group (non-MC group) and 78 in the mechanical complication group (MC group). The mean age of the participants was 66.79 ± 8.56 years (range 34–83 years), and the mean follow-up period was 45.49 ± 16.20 months (range 24–62 months). The inclusion criteria for the study were patients who underwent > 4 levels of fusion and had > 2 years of follow-up. The predictive models for mechanical complications using the G-LDI and R-LDI were analyzed using binomial logistic regression and receiver operating characteristic analyses.

RESULTS

There was a significant correlation between R-LDI and PI (r = −0.561, p < 0.001), while there was no correlation between G-LDI and PI (r = 0.132, p = 0.495). In reference to G-LDI, most patients in the non-MC group were classified as having alignment (72, 77.4%), while the MC group had an inhomogeneous composition (aligned: 34, 43.6%; hyperlordosis: 37, 47.4%). The agreement between the G-LDI and R-LDI was moderate (κ = 0.536, p < 0.001) to fair (κ = 0.383, p = 0.011) for patients with average or large PI, but poor (κ = −0.255, p = 0.245) for those with small PI. The areas under the curve for the G-LDI and R-LDI were 0.674 (95% CI, 0.592–0.757) and 0.745 (95% CI, 0.671–0.820), respectively.

CONCLUSIONS

The R-LDI, which uses a PI-based proportional parameter, enables individual quantification of LL for all PI sizes and has been shown to have a higher accuracy in classifying cases and a stronger correlation with the risk of mechanical complications compared with G-LDI.

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Relationship between the postoperative variations of paraspinal muscles and adjacent-segment degeneration in patients with degenerative lumbar spinal stenosis after posterior instrumented lumbar fusion

Fei Xu, Siyu Zhou, Zhuoran Sun, Shuai Jiang, Gengyu Han, and Weishi Li

OBJECTIVE

This study aimed to quantify pre- and postoperative paraspinal muscular variation following posterior lumbar interbody fusion (PLIF) in patients with degenerative lumbar spinal stenosis (DLSS) and measure the association of this variation with adjacent-segment degeneration (ASD).

METHODS

Data from 149 patients who underwent L4–S1 PLIF for DLSS were collected. Patients were divided into radiologically confirmed ASD and control groups according to follow-up radiological findings. MRI was performed before surgery and at the last follow-up. Muscular parameters including the relative cross-sectional area (rCSA), relative functional cross-sectional area (rFCSA), relative total cross-sectional area (rTCSA), and fatty infiltration (FI) of the multifidus (MF), erector spinae (ES), and psoas major (PM) muscles were measured on preoperative and follow-up L2–S1 MR images. Logistic regression was used to investigate risk factors for ASD.

RESULTS

The rate of radiological ASD was 42.3% at the final follow-up (mean 25.71 ± 8.35 months). At surgical levels, the rFCSA and rTCSA of the MF and ES muscles decreased. The FI of the MF from L2–3 to L5–S1 and ES muscles at L5–S1 significantly increased after surgery, while the rFCSA and rTCSA of the PM muscle increased and its FI decreased. At adjacent levels, the rFCSA and rTCSA of the MF muscle and rTCSA of the ES muscle decreased and the FI of the MF muscle increased postoperatively (p < 0.05), but the rFCSA and rTCSA of the PM muscle increased and its FI decreased (p < 0.05). The FIs of the MF, ES, and PM muscles at adjacent levels significantly differed between the ASD and control groups. Logistic regression analysis indicated that higher BMI (p = 0.002) and FI of the PM muscle at adjacent levels (p = 0.025) were significant risk factors for ASD.

CONCLUSIONS

The functional area decreased in the MF and ES muscles and increased in the PM muscle after L4–S1 PLIF. A compensatory postoperative decrease in FI of the PM muscle at the adjacent level was a protective factor for ASD in DLSS patients after PLIF.

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Does the number of social factors affect long-term patient-reported outcomes and satisfaction in those with cervical myelopathy? A QOD study

Christine Park, Christopher I. Shaffrey, Khoi D. Than, Erica F. Bisson, Brandon A. Sherrod, Anthony L. Asher, Domagoj Coric, Eric A. Potts, Kevin T. Foley, Michael Y. Wang, Kai-Ming Fu, Michael S. Virk, John J. Knightly, Scott Meyer, Paul Park, Cheerag Upadhyaya, Mark E. Shaffrey, Avery L. Buchholz, Luis M. Tumialán, Jay D. Turner, Nitin Agarwal, Andrew K. Chan, Dean Chou, Nauman S. Chaudhry, Regis W. Haid Jr., Praveen V. Mummaneni, Georgios D. Michalopoulos, Mohamad Bydon, and Oren N. Gottfried

OBJECTIVE

It is not clear whether there is an additive effect of social factors in keeping patients with cervical spondylotic myelopathy (CSM) from achieving both a minimum clinically important difference (MCID) in outcomes and satisfaction after surgery. The aim of this study was to explore the effect of multiple social factors on postoperative outcomes and satisfaction.

METHODS

This was a multiinstitutional, retrospective study of the prospective Quality Outcomes Database (QOD) CSM cohort, which included patients aged 18 years or older who were diagnosed with primary CSM and underwent operative management. Social factors included race (White vs non-White), education (high school or below vs above), employment (employed vs not), and insurance (private vs nonprivate). Patients were considered to have improved from surgery if the following criteria were met: 1) they reported a score of 1 or 2 on the North American Spine Society index, and 2) they met the MCID in patient-reported outcomes (i.e., visual analog scale [VAS] neck and arm pain, Neck Disability Index [NDI], and EuroQol-5D [EQ-5D]).

RESULTS

Of the 1141 patients included in the study, 205 (18.0%) had 0, 347 (30.4%) had 1, 334 (29.3%) had 2, and 255 (22.3%) had 3 social factors. The 24-month follow-up rate was > 80% for all patient-reported outcomes. After adjusting for all relevant covariates (p < 0.02), patients with 1 or more social factors were less likely to improve from surgery in all measured outcomes including VAS neck pain (OR 0.90, 95% CI 0.83–0.99) and arm pain (OR 0.88, 95% CI 0.80–0.96); NDI (OR 0.90, 95% CI 0.83–0.98); and EQ-5D (OR 0.90, 95% CI 0.83–0.97) (all p < 0.05) compared to those without any social factors. Patients with 2 social factors (outcomes: neck pain OR 0.86, arm pain OR 0.81, NDI OR 0.84, EQ-5D OR 0.81; all p < 0.05) or 3 social factors (outcomes: neck pain OR 0.84, arm pain OR 0.84, NDI OR 0.84, EQ-5D OR 0.84; all p < 0.05) were more likely to fare worse in all outcomes compared to those with only 1 social factor.

CONCLUSIONS

Compared to those without any social factors, patients who had at least 1 social factor were less likely to achieve MCID and feel satisfied after surgery. The effect of social factors is additive in that patients with a higher number of factors are less likely to improve compared to those with only 1 social factor.

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The status of spine surgery in social media platforms: a call to action

Nima Alan, James J. Zhou, S. Harrison Farber, and Juan S. Uribe

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The effect of myelography dye on bone density measurements utilizing Hounsfield units on CT

Ryan Weegens, Charles H. Crawford III, Steven D. Glassman, John R. Dimar II, Jeffrey L. Gum, and Leah Y. Carreon

OBJECTIVE

Hounsfield unit (HU) measurements of bone density on CT are increasingly used for preoperative planning in spine surgery. Postmyelogram CT is another common preoperative diagnostic study. However, there is no current literature evaluating whether HU measurements on CT are affected by the presence of myelography dye. The purpose of the current study was to determine if the presence of myelography dye affects HU measurements of bone density in CT studies.

METHODS

Twenty-nine preoperative spine surgery patients who underwent both standard and postmyelography CT performed within 6 months of each other were identified. HU measurements were obtained from an elliptical region of interest using the available software on a standard PACS. Measurements were obtained on the axial cut at the midvertebral body on all lumbar vertebrae on three separate occasions and an average value was calculated for comparative analysis. A 6-week gap was used between measurements of the CT scans and the CT myelograms to diminish bias.

RESULTS

The mean age of the cohort was 69 years and the average BMI was 32 kg/m2. Five patients were male and 24 were female. Six of the patients had instrumentation placed prior to the initial CT scan. The average HU measurements for CT levels L1–5 were 165, 171, 145, 154, and 225, respectively, whereas HU measurements for CT myelography of levels L1–5 were 168, 177, 148, 170, and 239, respectively. Strong correlations were noted between the HU measured on CT and CT myelography for L1 (r2 = 0.951), L2 (r2 = 0.966), L4 (r2 = 0.820), and L5 (r2 = 0.900), and moderate for L3 (r2 = 0.668).

CONCLUSIONS

The presence of myelography dye had no clear effect on CT HU measurements of bone density. The results of this study support the use of CT myelograms for bone density assessment in the absence of standard CT images.