OBJECTIVE The authors of this study aimed to compare the surgical outcomes and complication profiles of posterior vertebral column resection (pVCR) performed at the apical vertebra (AV) versus the subapical vertebra (SAV) in patients with rigid tuberculotic angular kyphosis (TAK). They hypothesized that an SAV resection would reduce the incidence of neurological complications without compromising radiographic correction. METHODS They conducted a retrospective analysis of patients with TAK who underwent single-level pVCR (Schwab grade 5 osteotomy) between June 2010 and June 2023. Patients were divided into 2 groups, an AV group and SAV group. Demographic, surgical, radiographic, and health-related quality of life (HRQOL) data were collected. Radiographic parameters included sagittal Cobb angle, pelvic incidence, lumbar lordosis, and sagittal vertical axis. HRQOL outcomes were assessed using the visual analog scale, Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) functional assessment, and SF-36. Complications, including dural tears, intraoperative neuromonitoring (IONM) alerts, neurological deficits, etc., were recorded and compared. RESULTS One hundred patients were eligible for study inclusion, of whom 65 were included in the AV group and 35 in the SAV group. Both groups attained and maintained significant correction of the sagittal Cobb angle postoperatively, with no significant differences in radiographic outcomes between groups. However, the SAV group demonstrated significantly lower rates of dural tears (11.4% vs 29.2%, p = 0.044), IONM alerts (22.9% vs 44.6%, p = 0.032), and neurological complications (17.1% vs 36.9%, p = 0.040), particularly motor deficits (11.4% vs 29.2%, p = 0.044). HRQOL outcomes showed better ODI and JOA scores in the SAV group at the final follow-up (both p < 0.001). CONCLUSIONS This study provides clinical evidence that the SAV constitutes a safer and more strategic resection site, as it avoids the severely pathological kyphotic apex and facilitates a more physiologically tolerable correction. Therefore, the subapical VCR strategy is recommended as a viable alternative for managing severe TAK, one that prioritizes patient safety without substantially compromising deformity correction.
OBJECTIVE:In this study, the authors aimed to evaluate the safety and efficacy of short-term, low-dose ketorolac following minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) with bone morphogenetic protein (BMP), specifically assessing its impact on fusion rates and postoperative opioid consumption in a randomized, double-blind, placebo-controlled, noninferiority trial. METHODS:Adult patients undergoing elective 1- to 3-level MIS TLIF with BMP between October 2017 and April 2024 were randomized to receive perioperative ketorolac or placebo in addition to a standardized multimodal analgesic regimen. The primary outcome was radiographic fusion at 1 year, assessed by independent neuroradiologists using dynamic radiographs and CT scans as needed. A noninferiority margin of -0.15 was prespecified. Secondary outcomes were 48-hour and total in-hospital opioid consumption (intravenous morphine milligram equivalents [MME]) and length of stay (LOS). Patient-reported outcomes (PROs) were collected at baseline and postoperative intervals. Analyses were performed per protocol with significance set at an α value of 0.025. RESULTS:Of 420 randomized patients, 31 in the ketorolac group and 34 in the placebo group were excluded due to surgery cancellation, protocol violations, or withdrawal of consent. One hundred sixty-seven patients remained in the ketorolac group and 188 in the placebo group. The per-protocol analysis included 364 levels (1 year) and 395 levels (2 years) for fusion assessment, and 355 patients for secondary outcomes (MME and LOS). Baseline demographics and intraoperative characteristics were comparable between groups. The fusion rate did not significantly differ at 6 months (Δ = 0.8, 95% CI -5.6 to 7.1; p = 0.51), 1 year (Δ = 2.5, 95% CI -3.4 to 8.2; p = 0.39), or 2 years (Δ = 2.6, 95% CI -2.6 to 7.7; p = 0.49). The lower bounds of the 95% confidence intervals for differences in solid fusion rates did not cross the -0.15 noninferiority margin at any time point, confirming the noninferiority of ketorolac. The mean total in-hospital MME (Δ = 22.65, 95% CI 12.27-33.04; p < 0.001) and 48-hour MME (Δ = 17.19, 95% CI 9.24-25.13; p < 0.001) were significantly reduced in the ketorolac group. Patients receiving ketorolac demonstrated significantly lower mean visual analog scale pain scores over the first 48 hours (Δ = 0.52, 95% CI 0.18-0.86; p = 0.003) and shorter LOS (Δ = 0.73 days, 95% CI 0.39-1.07 days; p < 0.001). There were no significant differences in complications, revision surgery, or PROs. CONCLUSIONS:Short-term, low-dose ketorolac following MIS TLIF with BMP maintained noninferior fusion rates while providing significant reductions in opioid requirements, hospital stay, and early postoperative pain. Clinical trial registration no.: NCT03278691 (ClinicalTrials.gov).
OBJECTIVE:The aim of this study was to develop and validate a machine learning (ML) algorithm to predict the delayed need for syrinx shunt placement following posterior fossa decompression (PFD) for Chiari malformation type I (CM-I) with concurrent syringomyelia. METHODS:This multicenter retrospective cohort study utilized the TriNetX network to identify patients undergoing index PFD for CM-I and syringomyelia (2010-2020) with at least 2 years of continuous follow-up. The primary outcome was unplanned syringosubarachnoid, syringopleural, or syringoperitoneal shunt placement. Five supervised ML classifiers were trained on 30 preoperative clinical and demographic variables using the Synthetic Minority Over-Sampling Technique to address class imbalance. RESULTS:Of 3112 patients (62.3% female, median age 28.4 years) with a median follow-up of 5.1 years, 271 (8.7%) experienced refractory syringomyelia requiring a shunt. The CatBoost classifier achieved the highest discriminative performance on the independent validation set, yielding an area under the curve of 0.87, accuracy of 83%, sensitivity of 0.78, and specificity of 0.82. Shapley Additive Explanations analysis identified adolescent idiopathic scoliosis, prolonged symptom duration, age > 40 years, and preoperative opioid dependency as the strongest predictors of delayed shunt placement. Notably, partial dependence analysis revealed that every 1-month delay in surgical intervention increased the absolute probability of shunting by approximately 0.8%-1.0%. CONCLUSIONS:The CatBoost ML algorithm accurately predicted the delayed need for syrinx shunting after PFD. The prominent risk associated with concomitant scoliotic deformity and surgical delay provides actionable intelligence, strongly supporting early operative intervention and guiding highly individualized long-term postoperative surveillance.
OBJECTIVE:Minimally invasive surgery (MIS) is a reasonable treatment option for lumbar spondylolisthesis, but its long-term cost-effectiveness is not well established. Herein, the authors describe the 5-year cost-effectiveness of posterior MIS using prospective data from the multicenter Quality Outcomes Database (QOD). METHODS:Patients from the Spine COReTM study group's multicenter, prospectively collected QOD grade 1 lumbar spondylolisthesis dataset who had undergone single-stage posterior surgery were included. Gains in quality-adjusted life years (QALYs) were quantified using EQ-5D scores across 60 months. Costs from index surgeries and related reoperations were estimated using Medicare rates for inpatient care and Current Procedural Terminology rates for outpatient care. Validation was achieved via price transparency diagnosis-related group (DRG) charges and charge/cost ratios (CCRs). The cost per QALY gained was ultimately calculated. RESULTS:Of the 608 patients identified as having undergone single- or multiple-stage surgery, 559 underwent single-stage posterior surgery, 242 via MIS (mean age 64.3 ± 11.7 years, 71.1% arthrodesis rate) and 317 via open surgical approaches (mean age 61.3 ± 12.2 years, 78.5% arthrodesis rate). Length of stay (LOS) was 2.3 ± 1.9 days for patients in the MIS group and 3.1 ± 1.7 days for those in the open surgery group (p < 0.0001). Operative duration was similar between the groups (171.7 ± 93.3 vs 174.2 ± 72.3 minutes, p = 0.739), whereas estimated blood loss was 108.3 ± 102.2 mL for the MIS group and 251.9 ± 230.6 mL for the open surgery group (p < 0.0001). Moreover, 6.2% of patients in the MIS group and 7.9% in the open surgery group underwent related reoperations; 5.0% and 7.6% of patients, respectively, had complications. Thirty-day readmission was required in 1.2% of patients in the MIS group and 2.5% in the open surgery group. DRG costs were stable between our model and the CCR-based model, providing external validation. The mean QALY gain was 1.06 (95% CI 0.92-1.20) for MIS and 0.94 (95% CI 0.83-1.05) for open surgery (p = 0.191); the mean QALY gain was 1.09 (95% CI 0.92-1.25) versus 0.95 (95% CI 0.82-1.08), respectively, among those who underwent arthrodesis (p = 0.193) and 0.99 (95% CI 0.71-1.28) versus 0.90 (95% CI 0.64-1.16) among those who underwent decompression only (p = 0.628). The mean cost of MIS was significantly lower ($31,822) than that of open surgery ($39,151; p = 0.001). Among those who underwent arthrodesis, the mean cost was $41,916 for MIS versus $46,626 for open surgery (p = 0.031). Among patients who underwent decompression only, the mean respective cost was $7021 versus $11,780 (p = 0.004). The mean cost per QALY gained was $29,995 for MIS and $41,635 for open surgery (p = 0.0017), $38,501 versus $48,998 among those who underwent arthrodesis (p = 0.0193), and $7073 versus $13,100 among those who underwent decompression only (p = 0.0123). CONCLUSIONS:MIS for grade 1 lumbar spondylolisthesis demonstrated a 60-month cost per QALY gained of $29,995, which was significantly lower than open surgery's $41,635. Differences were driven by LOS, complications, and reoperations, and MIS remained more cost-effective even after stratification for arthrodesis. However, both surgical approaches remained below the $100,000 willingness-to-pay threshold, highlighting overall long-term cost-effectiveness.
OBJECTIVE:Foraminal stenosis (FS) is commonly identified in patients undergoing lumbar decompression, but its clinical significance when deemed "asymptomatic" remains unclear. Minimally invasive surgery techniques for decompression, including unilateral laminotomy for bilateral decompression, aim to relieve neural compression while preserving soft tissue. However, the impact of preoperative FS on postoperative outcomes following minimally invasive decompression is not well-established. The aim of this study was to evaluate the effect of preoperative FS on patient-reported outcome measures (PROMs) and revision surgery rates following single-level minimally invasive lumbar decompression. METHODS:Patients who underwent primary single-level minimally invasive decompression for degenerative lumbar conditions between February 2017 and September 2022 at a single institution were included. Preoperative FS severity was graded from 0 (none) to 3 (severe) on MRI, and patients were stratified into FS+ (any FS ≥ grade 1) and FS- (no FS) groups. Patients in the FS+ and FS- groups were matched 1:1 based on demographic characteristics and preoperative radiographic parameters and compared for all outcome measures. Outcomes included PROMs (Oswestry Disability Index [ODI], visual analog scale [VAS] for back and leg pain, and SF-12 Physical Component Score [PCS]) at short-term and long-term follow-up time points and revision surgery rates. Multivariable logistic regression analysis was conducted for predictors of nonachievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS). RESULTS:Of 320 patients included in the analysis, FS was present in 234 (73.1%, mean age 68.52 years). After matching, the FS+ group (n = 71) and FS- group (n = 71) were compared. Both groups demonstrated significant postoperative improvement in PROMs; however, patients with FS had worse ODI (p = 0.001), VAS-back (p = 0.003), and SF-12 PCS (p = 0.004) outcomes at long-term follow-up. In addition, the FS+ group had higher revision surgery rates at the index level (p = 0.003) and greater likelihood of requiring fusion (p = 0.005). An FS grade of 2 or 3 independently predicted failure to achieve the MCID for ODI, VAS Back, SF-12 PCS and the PASS for ODI. CONCLUSIONS:Radiographic FS, even when deemed asymptomatic, was associated with worse long-term functional outcomes and higher revision rates following minimally invasive decompression. These findings underscore the need for careful preoperative assessment and surgical planning, particularly for patients with moderate-to-severe FS, to optimize long-term outcomes.
OBJECTIVE:Postoperative dysphagia occurs frequently after anterior cervical surgery. In this study, dysphagia incidence and duration were assessed in a multicenter cohort of patients who had undergone short-segment anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), or cervical disc arthroplasty (CDA). The authors hypothesized that CDA would demonstrate the lowest dysphagia burden; ACCF, the highest; and ACDF, an intermediate burden. METHODS:Authors retrospectively analyzed consecutive adult patients who underwent short-segment anterior cervical surgery, including CDA, ACDF, and ACCF, from 2010 to 2020 at three institutions. The 10-item Eating Assessment Tool (EAT-10) was used to assess for the occurrence of dysphagia and its persistence, the primary outcomes. An EAT-10 score ≥ 3 was defined as the threshold for dysphagia. Assessment for predictors of postoperative dysphagia was the secondary outcome. Univariate and regression analyses were performed. RESULTS:Authors identified 1466 patients who had been treated with 1- or 2-level ACDF (n = 1296), 1-level ACCF (n = 50), or 1- or 2-level CDA (n = 120). Significant differences in age, BMI, race, comorbidities, education level, and surgical characteristics were observed between and among surgical techniques. Preoperatively, the mean EAT-10 score was 1.6 for the whole cohort, increasing to 6.0 at 1 month after surgery and then decreasing to 2.5 and 2.4 at 3 and 12 months, respectively. At 1 month, dysphagia was present in 57% of patients after ACDF, 61% after ACCF, and 42% after CDA; at 12 months, dysphagia rates were 24%, 37%, and 17%, respectively. In patients without preexisting dysphagia (n = 1261), mean EAT-10 scores were 0.1 at baseline, increasing to 5.1 at 1 month and decreasing to 2.0 and 1.8 at 3 and 12 months, respectively. Within this patient subset at 1 month, dysphagia was present in 52% after ACDF, 60% after ACCF, and 39% after CDA; at 12 months, rates were 18%, 36%, and 12%, respectively. Compared to patients without preexisting dysphagia, those with baseline dysphagia had increased risks for postoperative dysphagia at the 1-month (OR 4.53, 95% CI 2.66-7.72), 3-month (OR 4.81, 95% CI 3.31-6.99), and 12-month (OR 6.69, 95% CI 4.40-10.2) follow-ups. At 3 months after surgery, other predictors of dysphagia were ACCF (OR 2.31, 95% CI 1.10-4.85) and diabetes (OR 1.71, 95% CI 1.22-2.41), whereas antithrombotic use indicated lower odds of dysphagia (OR 0.66, 95% CI 0.46-0.93). At the 12-month follow-up, female sex (OR 1.73, 95% CI 1.24-2.43), coronary artery disease (OR 2.25, 95% CI 1.29-3.93), and chronic pulmonary disease (OR 1.83, 95% CI 1.11-3.00) indicated greater odds of dysphagia. CONCLUSIONS:Although dysphagia resolved in the great majority of patients, a not insignificant portion had residual symptoms at the 12-month follow-up. Various risk factors for dysphagia, including greater age, female sex, ACCF, and comorbidities such as diabetes, cardiac disease, and pulmonary disease, were observed. CDA compared to ACDF was not found to reduce the risk of dysphagia. These findings can help inform shared decision-making and postoperative counseling.
OBJECTIVE:Multisegmental pathological autofusion is a hallmark feature of ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), creating a rigid, brittle spine highly susceptible to three-column fractures and devastating neurological injury. This study aimed to evaluate survival outcomes in this patient population and identify clinical and demographic predictors of mortality. METHODS:Adults with DISH or AS who sustained a fracture and were admitted to a single tertiary care center for spinal fracture were retrospectively identified using ICD-10 diagnostic codes. Data were extracted on demographics, clinical presentation, fracture characteristics, and details of treatment. RESULTS:A total of 383 patients (median age 78 years, 75.2% male) were included. Over a median follow-up of 17.3 months, overall mortality was 38.1%, in-hospital mortality was 5.2%, 30-day mortality was 5.7%, and 1-year mortality was 18.0%. Initial treatment consisted of external orthosis in 220 (57.4%) and surgery in 144 (37.6%), while 19 (5.0%) were left untreated. Patients who died were older (median 83 vs 74 years, p < 0.001), had a lower BMI (29.4 vs 32.3 kg/m2, p < 0.001), had higher frailty on the 5-item modified frailty index (mFI-5), and more commonly had congestive heart failure (CHF), cancer, functional dependency, and chronic kidney disease (CKD) (all p < 0.01). Mortality was not associated with fracture location, mechanism of injury, fracture number, or the presence of neurological deficits. Univariable time-to-event analysis showed that decreased survival was predicted by older age (HR 1.08, p < 0.0001), lower BMI (HR per kg/m2 0.93, p < 0.0001), functional dependency (HR 2.05, p < 0.001), cancer (HR 1.55 p = 0.01), CKD (HR 1.48, p = 0.019), CHF (HR 2.18, p < 0.001), and higher mFI-5 score (HR per point 1.34, p < 0.001). On multivariable analysis, older age (HR 1.06 per year, p < 0.001), lower BMI (HR per kg/m2 0.95, p < 0.001), and mFI-5 score (HR per patient 1.37, p < 0.001) remained significant independent predictors of mortality. Treatment modality did not predict mortality. CONCLUSIONS:AS- or DISH-associated spinal fractures have a high associated mortality, regardless of mechanism or severity. Treatment modality did not affect odds of survival, suggesting that nonoperative management with an external orthosis may be an appropriate option, particularly in older and medically complex patients.
OBJECTIVE:Anterior cervical discectomy and fusion (ACDF) is among the most frequently performed spinal procedures in the US. Despite high success rates, complications such as pseudarthrosis, dysphagia, and revision surgery remain clinically significant, particularly in patients with diabetes mellitus (DM) and obesity. Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) have demonstrated anti-inflammatory and bone-modulating properties in existing clinical and laboratory orthopedic research, yet their relationship to cervical fusion outcomes remains unclear, especially regarding therapy timing. The aim of this study was to evaluate the association between GLP-1 RA use and pseudarthrosis, dysphagia, and revision surgery, as well as perioperative complications, following ACDF surgery. METHODS:TriNetX, a global health research network, was queried (2014-2024) for patients undergoing ACDF surgery (CPT code 22551) with GLP-1 RA exposure. Subcohort analyses were conducted based on overall therapy timing (preoperative, perioperative, and postoperative) and further stratified by initiation and discontinuation timing. Postoperative initiators were analyzed using a landmark approach to mitigate immortal time bias. Each subcohort was 1:1 propensity score-matched to controls by age, sex, race, smoking, DM, BMI, and uremia. Ninety-day outcomes included deep vein thrombosis, pulmonary embolism, emergency department visit, inpatient hospitalization, sepsis, surgical site infection, and wound disruption. Two-year outcomes included pseudarthrosis, dysphagia, and revision surgery. Odds ratios with 95% confidence intervals were calculated using chi-square analysis. RESULTS:Among 2345 patients with GLP-1 RA exposure within 2 years after undergoing ACDF, overall use was associated with reduced pseudarthrosis and dysphagia, but not revision surgery. Preoperative GLP-1 RA use was associated with increased odds of dysphagia when discontinued > 12 months before surgery. Continuous perioperative use was associated with increased odds of dysphagia and revision surgery, as well as reduced odds of sepsis. Postoperative initiation was associated with reduced odds of pseudarthrosis and dysphagia in the overall subcohort, reduced odds of pseudarthrosis in patients with DM, and increased odds of dysphagia in those with multilevel fusion surgeries. CONCLUSIONS:GLP-1 RA use demonstrated timing-dependent associations with outcomes following ACDF surgery. Postoperative initiation of therapy was associated with reduced pseudarthrosis, particularly in patients with DM, and dysphagia, while continuous perioperative exposure increased the risk of dysphagia and revision. These findings suggest a potential role for temporally targeted GLP-1 RA therapy during postoperative healing. Prospective studies are required for validation and to determine causal relationships.
OBJECTIVE:This study aimed to develop a novel 3D Hounsfield unit (HU) technique for assessing volumetric bone mineral density (vBMD) using routine preoperative CT scans. It was designed to enable opportunistic osteoporosis screening by leveraging existing imaging data. The diagnostic accuracy of this approach was rigorously evaluated against quantitative CT (QCT). METHODS:The authors retrospectively analyzed the records of spine surgery patients who underwent both spinal CT and QCT within a 1-week period. Patients were divided into 3 groups (osteoporosis, osteopenia, and normal bone mineral density [BMD]) based on QCT-vBMD. Baseline characteristics and radiological parameters were compared among the 3 groups. Three-dimensional HU measurements were obtained from lumbar CT scans. Multivariable logistic regression, Pearson correlation analysis, and receiver operating characteristic (ROC) analysis were used to assess the relationships between vBMD and 3D-HU. To evaluate interscanner reliability, a subset of patients received additional CT scanning using both GE and Philips systems. Bland-Altman analysis was used to assess agreement between 3D-HU measurements from different scanner platforms. RESULTS:Among 264 enrolled patients, 94 were classified as osteoporotic, 114 as osteopenic, and 56 as having normal BMD. Multivariable logistic regression analyses identified lower 3D-HU as an independent predictor of both osteoporosis (OR 0.723, 95% CI 0.618-0.806; p < 0.0001) and osteopenia (OR 0.698, 95% CI 0.564-0.799; p < 0.0001). Three-dimensional HU demonstrated a strong correlation with QCT-vBMD (T12, r = 0.979; L1, r = 0.968; L2, r = 0.962). ROC analysis demonstrated that 3D-HU achieved diagnostic accuracy comparable to QCT for both osteoporosis and osteopenia. Specifically, for osteoporosis, the area under the ROC curve (AUC) was 99.1% (sensitivity 94.7%, specificity 98.3%); for osteopenia, the AUC was 98.5% (sensitivity 93.9%, specificity 94.6%). Bland-Altman analysis demonstrated excellent interscanner agreement (mean difference 0.13; 95% limits of agreement -8.23 to 8.50), with only 2% of measurements falling outside the agreement limits. CONCLUSIONS:Three-dimensional HU represents a novel vBMD assessment methodology that achieves diagnostic parity with QCT. Crucially, this precision is attained using conventional CT scanners without extra radiation exposure or specialized equipment. This study demonstrated that precise, universally accessible osteoporosis screening is now achievable, promising a transformative advance in public bone health.
OBJECTIVE:Intraoperative hypotension is common during adult spinal deformity (ASD) surgery, occurring because of blood loss and sometimes requested by surgeons during exposure, but its impact on postoperative complications is unclear. In patients who underwent ASD surgery, the authors sought to evaluate the relationships between intraoperative hypotension and 1) medical complications, 2) length of hospital stay (LOS), 3) discharge disposition, or 4) reoperation. METHODS:The authors performed a retrospective cohort study of patients who underwent ASD surgery from 2009 to 2023 and had a 2-year follow-up. The primary exposure variable was intraoperative hypotension, defined as mean arterial pressure (MAP) < 65 mm Hg for at least 30 minutes. The primary outcomes were 1) complications, 2) reoperation, 3) LOS, and 4) discharge disposition. Multivariable logistic regression controlled for age, sex, BMI, comorbidities, and operative time. RESULTS:Among 277 patients who underwent ASD surgery, 70 (25%) were males and the mean age was 62.5 ± 17.5 years. Intraoperative hypotension was observed in 122 patients (44%) for a mean duration of 45.4 ± 47.6 minutes, with most of these patients (66%) having hypotension in the second half of surgery. Patients with intraoperative hypotension had a greater incidence of postoperative medical complications (28% vs 17%, p = 0.026), including pulmonary complications (12% vs 3%, p = 0.003), yet no difference was seen in reoperation rates (39% vs 32%, p = 0.278). Neither was there a difference in LOS (7 ± 7 vs 7 ± 12 days, respectively, p = 0.814) or home discharge (p = 0.097) between groups. On multivariable logistic regression, intraoperative hypotension was an independent risk factor for any medical complications (OR 2.0, 95% CI 1.0-3.9, p = 0.047), especially pulmonary complications (OR 5.1, 95% CI 1.5-17.0, p = 0.008). CONCLUSIONS:In ASD surgery, intraoperative hypotension (MAP < 65 mm Hg for ≥ 30 minutes) was independently associated with medical complications, particularly pulmonary complications. These findings highlight the importance of avoiding prolonged hypotension in ASD surgery.
OBJECTIVE:Adult spinal deformity (ASD) surgery patients maintain upright posture by using numerous compensatory mechanisms. The distribution of this compensation throughout the skeleton has not been fully investigated. METHODS:Patients with lumbar deformity curves undergoing fusion from T10 to the pelvis were included. Groups were stratified by Scoliosis Research Society (SRS)-Schwab sagittal deformity severity (mild, moderate, and severe). Compensation was determined based on the published values of asymptomatic individuals by Bao et al. (2018), with patients outside 1 standard deviation of the mean values deemed to be compensating. Adequate deformity correction was determined based on matching published sagittal age-adjusted score (SAAS) criteria. Means comparisons tests assessed differences between cohorts at each time point. RESULTS:In total, 379 ASD patients were included (mean age 66.7 ± 10.2 years, body mass index 28.4 ± 5.4 kg/m2, Charlson Comorbidity Index 1.20 ± 1.73). In total, 23.8% of patients had mild deformity, 19.2% moderate, and 57% severe. The severe deformity cohort generally demonstrated the highest rates of compensation across all regions at different time points. At baseline, the severe and moderate cohorts demonstrated predominantly lower limb-dominant compensation, with the highest frequencies of compensation seen at the knee and pelvis. In the mild cohort, knee compensation was relieved by 1 year when adequate correction was achieved. For the moderate cohort, hip and pelvic compensation were relieved first, with knee compensatory relief occurring by 2 years. For the severe cohort, pelvic compensation was relieved first, with global lower limb and thoracic compensation subsequently occurring. CONCLUSIONS:There is notable variation in how ASD patients compensate as the severity of their deformity progresses. There is also variation in how these patterns are altered postoperatively.
OBJECTIVE:Both open and minimally invasive surgery (MIS) approaches for degenerative low-grade lumbar spondylolisthesis have been shown to improve patient-reported outcomes (PROs). Recent studies, however, have suggested that MIS may offer superior, more durable benefits due to less soft tissue dissection and expedited recovery. Unfortunately, data demonstrating whether or when such divergences in long-term PROs may arise are limited. METHODS:The authors utilized the prospective multicenter Spine CORe™ Quality Outcomes Database grade 1 lumbar spondylolisthesis dataset to evaluate longitudinal outcomes over 60 months. PROs included Oswestry Disability Index (ODI), EuroQol-5D, and numeric rating scale for back pain and leg pain scores. Outcomes were compared between MIS and open approaches using univariate and multivariable analyses. Minimal clinically important differences (MCIDs) were assessed using established thresholds. RESULTS:Of 608 patients, 265 (43.6%) underwent MIS while 343 (56.4%) underwent open surgery. MIS patients were older (64.1 ± 11.6 vs 60.7 ± 12.2 years, p < 0.001) and had lower BMI (29.7 ± 5.8 vs 30.9 ± 6.7 kg/m2, p = 0.0180). Overall, 72.8% of MIS and 80.2% of open patients underwent arthrodesis (p = 0.0330). Other variables, including baseline PROs, were similar. After surgery, MIS was associated with less blood loss (104.2 ± 100.4 vs 249.1 ± 233.3 mL, p < 0.001) and shorter length of stay (2.3 ± 1.9 vs 3.1 ± 1.7 days, p < 0.001); there were no differences in readmission, complication, or 60-month related reoperation rates. In univariate analyses, at the 3-month and 12-month follow-ups, there were no differences in magnitude of change or MCID achievement for any PRO. MIS, however, demonstrated superior improvements in ODI score at 24 months (-25.8 ± 20.6 vs -20.9 ± 20.0, p = 0.0116) and 60 months (-24.4 ± 20.9 vs -19.8 ± 21.1, p = 0.0162), with greater MCID rates (24 months: 72.8% vs 61.1%, p = 0.0090; 60 months: 68.1% vs 58.8%, p = 0.0363). After multivariable analysis, these significant differences in ODI score persisted (24-month change: β = -6.2, p = 0.0014; 60-month change: β = -4.6, p = 0.0216; 24-month MCID: OR 2.0, p = 0.0022; 60-month MCID: OR 1.6, p = 0.0302). After stratification, these multivariable results were consistent in patients undergoing arthrodesis but not in those undergoing decompression alone. CONCLUSIONS:In this prospective multicenter study, there were no differences in early disability or quality of life outcomes between MIS and open surgery for low-grade spondylolisthesis. By 24 months, trajectories diverged: MIS yielded greater improvements in ODI score that persisted at the 60-month follow-up, especially with arthrodesis. While open surgery remains essential in many contexts, MIS may offer more meaningful long-term improvement in appropriately selected patients.
OBJECTIVE:Use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac (Toradol) after spinal fusion surgery remains controversial due to concerns about increased pseudarthrosis rates. However, no prior studies have specifically examined this outcome in anterior lumbar interbody fusion (ALIF). The aim of this study was to investigate whether postoperative ketorolac is associated with pseudarthrosis after ALIF. The authors hypothesized that short-term ketorolac use does not significantly increase pseudarthrosis risk. METHODS:The TriNetX database was queried from 2003 to 2023 for adults (≥ 18 years) undergoing primary ALIF (Current Procedural Terminology code 22558) with ≥ 6 months of follow-up. Patients were grouped by postoperative ketorolac or acetaminophen (control) administration within 48 hours. Propensity score matching controlled for demographics, comorbidities, medication use, and surgical indications. Baseline characteristics were compared using t-tests and chi-square tests as appropriate. Outcomes were assessed using relative risk (RR) with 95% confidence intervals; significance was considered at p < 0.05. RESULTS:There were 2408 patients per cohort who met criteria after matching. After 2 years of follow-up, there was no increase in pseudarthrosis rate with exposure to ketorolac; in fact, ketorolac appeared to have a protective effect on this outcome (3.99% vs 5.44% control; RR 0.733 [95% CI 0.567-0.948], p = 0.017). There was no difference in reoperation rate (4.82% vs 5.31%; RR 0.906 [0.709-1.158], p = 0.430). At 90 days postoperatively, no patients in either group experienced severe postoperative bleeding, postoperative hematoma/seroma, acute surgical site infection, or postoperative ileus. There was no significant difference in bowel regimen utilization. There was no difference in risk of oral opioid prescriptions (21.7% vs 21.8%; RR 0.998 [0.897-1.111], p = 0.972) or in mean narcotic prescription count (mean number of instances at 90 days 0.61 vs 0.62, p = 0.87). CONCLUSIONS:Ketorolac is a safe adjunct to pain control following ALIF. Administration was not found to be associated with increased pseudarthrosis or reoperation rates at the 2-year follow-up. There were no significant differences in acute postoperative events at 90 days postoperatively. Further studies are warranted to evaluate the effect of postoperative NSAIDs on outcomes in anterior lumbar fusion surgery.
OBJECTIVE:Precise restoration of sagittal balance is a critical goal in adult spinal deformity surgery. Computer-assisted planning allows for patient-specific alignment targets and rod pre-bending, theoretically improving the accuracy of surgical correction. However, the correlation between planned and achieved alignment goals using pre-bent rods remains unclear. The aim of this study was to evaluate the accuracy of alignment correction in patients undergoing lumbar pedicle subtraction osteotomy (PSO) using UNiD-derived pre-bent rods, and to compare software-generated preoperative alignment targets with actual postoperative radiographic parameters. METHODS:A retrospective cohort study was performed of adults who underwent lumbar PSO with long-segment thoracolumbar fusion (≥ 6 levels) at a single academic center between 2018 and 2022. Inclusion criteria required UNiD preoperative planning, PSO performed at the planned level, use of patient-specific pre-bent rods, and complete radiographic data. Planned alignment targets were obtained from the UNiD platform and compared with immediate postoperative standing lateral radiographs. Absolute differences between preoperative-to-planned and preoperative-to-postoperative values were compared using paired t-tests. Effect sizes (Cohen's d) were calculated and post hoc power analysis was performed, with primary focus on pelvic incidence (PI), sagittal vertical axis, pelvic tilt, and PI minus lumbar lordosis (PI-LL). RESULTS:Twenty patients (60% female, median age 66.8 years) were included. The planned PSO angle closely matched the achieved correction (mean -24.2° planned vs -24.02° ± 7.31° postoperative, p = 0.94). Lumbar lordosis and L4-S1 lordosis exceeded planned correction, with a significant but modest increase at L4-S1 (p = 0.03). Pelvic parameters demonstrated the largest deviations from plan. Pelvic tilt correction exceeded predictions by a mean of 8.97° ± 7.10° (p < 0.01); the sagittal vertical axis was undercorrected by a mean of 36.37 ± 48.30 mm (p < 0.01); and PI changed more than anticipated (p = 0.01). PI-LL improved substantially from a mean of 29.73° ± 15.76° preoperatively to -3.23° ± 10.95° postoperatively (p < 0.001). The planned and achieved L1 pelvic angle did not differ significantly. CONCLUSIONS:Computer-assisted planning with patient-specific rods accurately reproduced the intended PSO and segmental lumbar correction but did not reliably predict global sagittal parameters. These findings suggest that current planning tools might require refinement to improve the accuracy of predicted postoperative alignment using pre-bent rods and to minimize the risk of suboptimal outcomes.
OBJECTIVE:Rates of revision surgery following operative treatment for adult symptomatic lumbar scoliosis (ASLS) are high, mostly due to mechanical complications, including proximal junctional failure (PJF) and pseudarthrosis/rod fracture (RF). How these revisions impact long-term clinical outcomes remains unclear. The aim of this study was to assess revision rates for the two most common mechanical complications (PJF and RF) and the potential impact of these revisions on patient-reported outcome measures over 8 years of follow-up for operatively treated patients with ASLS. METHODS:This retrospective review used data from a multicenter prospective ASLS study to assess operative versus nonoperative ASLS treatment. Patients were 40-80 years of age with ASLS (Cobb ≥ 30° and Oswestry Disability Index [ODI] score ≥ 20 or revised Scoliosis Research Society 22-item questionnaire [SRS-22r] score ≤ 4.0 in pain, function/activity, and/or self-image domains). Patients who underwent long-segment posterior fusion (thoracic spine to sacrum) were assessed for the impact of revision due to mechanical complications on outcomes (SRS-22r subscore and ODI score). RESULTS:Overall, 160 patients (141 female, median age 61.31 years) met inclusion criteria. Of these, 53 (33.1%) required revision (71 revisions, 25 for PJF and 46 for RF) for mechanical complications, with 1, 2, and 3 revisions in 39, 10, and 4 patients, respectively. By 8 years of follow-up, patients had a 38% estimated risk of revision for mechanical complications. The mean time to the first and second revisions was 3.0 years (SD 2.1) and 4.8 years (SD 2.3), respectively. In unadjusted analyses, patients with ≥ 1 revision had a significant negative impact on their 8-year ODI score (mean difference 9.40, 95% CI 3.68-15.13; p = 0.0013) and SRS-22r subscore (mean difference -0.27, 95% CI -0.49 to -0.05; p = 0.0141). Patients with ≥ 2 revisions experienced the greatest impact on both their ODI score (mean difference 14.48, 95% CI 4.89-24.07; p = 0.0031) and SRS-22r subscore (mean difference -0.38, 95% CI -0.74 to -0.02; p = 0.0361), with the impact exceeding the minimum detectable measurement difference for the ODI score (7) but not the SRS-22r subscore (0.4). In adjusted analyses, these differences were attenuated for patients with ≥ 2 revisions: ODI score (mean difference 14.14, 95% CI 4.52-23.75; p = 0.0040) and SRS-22r subscore (mean difference -0.30, 95% CI -0.67 to 0.06; p = 0.1001). CONCLUSIONS:By the 8-year follow-up, revision surgery for mechanical complications was required in an estimated 38% of operative ASLS patients. Patients who underwent ≥ 1 revision had a significant negative impact on ODI score and SRS-22r subscore, and this impact was greatest with ≥ 2 revisions. These findings emphasize the need for better techniques to reduce mechanical complications in ASLS surgery.
OBJECTIVE:The aim of this study was to evaluate whether trauma center level is associated with in-hospital mortality among patients undergoing operative management for spine trauma and to determine whether this relationship differs according to triage pathway. METHODS:A retrospective cohort study was performed using the 2023 National Trauma Data Bank. Adult patients undergoing operative treatment for spine trauma at American College of Surgeons-verified level I or level II trauma centers were identified. Patients with polytrauma or incomplete clinical data were excluded. Demographics, injury characteristics, comorbidities, arrival physiology, and hospital factors were compared between trauma center levels. Multivariable logistic regression models were constructed to assess the association between trauma center level and in-hospital mortality, stratified by triage pathway (direct admission vs interfacility transfer) and adjusted for demographic, injury severity, physiological, and hospital covariates. Significance was set at the p < 0.05 level. RESULTS:A total of 12,516 operative spine trauma encounters were included, with 8548 treated at level I centers and 3968 at level II centers. Level I centers managed patients with greater injury severity and higher comorbidity burden and received a larger proportion of interfacility transfers. Among directly admitted patients, treatment at a level I trauma center was associated with significantly lower adjusted odds of in-hospital mortality compared with level II centers (adjusted OR 0.62, 95% CI 0.39-0.97; p = 0.037). No significant mortality difference was observed among transferred patients (adjusted OR 0.88, 95% CI 0.47-1.68; p = 0.693). CONCLUSIONS:Level I trauma center care was associated with reduced adjusted mortality among directly admitted operative spine trauma patients but not among transferred patients. These findings suggest that early access to specialized multidisciplinary spine trauma care, rather than trauma center designation alone, may drive improved survival and highlight the importance of optimized prehospital triage and direct transport strategies.
OBJECTIVE:Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive sarcomas with peripheral nerve differentiation. Surgical management of MPNSTs entails wide resection with negative margins, although the extent of resection required to achieve oncological control may result in postoperative neurological morbidity. The association between postoperative neurological deficits and survival outcomes in patients with MPNSTs remains poorly defined. In this study, the authors evaluated the association between new or worsening postoperative neurological deficits and overall survival (OS) following resection for MPNSTs. METHODS:A retrospective review of all patients who underwent resection for MPNSTs at Johns Hopkins Hospital between 2010 and 2024 was performed. Postoperative neurological deficits were defined as new or worsened motor or sensory impairment documented on postoperative examination compared with preoperative baseline. Deficits were classified as transient if they resolved within 3 months or permanent if they persisted beyond 3 months. OS was assessed using Kaplan-Meier analysis. Uni- and multivariable Cox proportional hazards models were used to evaluate the association between postoperative neurological deficits and OS, adjusting for tumor characteristics and extent of resection. RESULTS:A total of 116 patients underwent resection during the study period, 49 (42.2%) of whom developed a postoperative neurological deficit. The median overall follow-up duration was 20.6 (interquartile range 8.6-56.2) months. Permanent neurological deficits were more common among patients with spinal tumors (35.3% vs 11.9%, p = 0.046). The presence of a permanent deficit was associated with worse OS (hazard ratio [HR] 3.64, 95% CI 1.97-6.72) compared with transient or no deficits. When stratified by extent of resection, patients who underwent gross-total resection (GTR) without a neurological deficit demonstrated the longest OS, followed by GTR with a deficit, subtotal resection (STR) without a deficit, and STR with a deficit. On multivariable analysis, the development of a permanent postoperative neurological deficit remained independently associated with worse OS (HR 8.50, 95% CI 2.77-14.59). CONCLUSIONS:In patients undergoing resection for MPNSTs, the development of a permanent postoperative neurological deficit was independently associated with decreased OS. These findings underscore the importance of balancing maximal oncological resection with preservation of neurological function to optimize long-term outcomes in patients with MPNSTs.
OBJECTIVE:Revision surgery is a known risk factor for postoperative dysphagia. This study aimed to assess the association of revision surgeries indicated to treat adjacent segment disease (ASD) with pre- and postoperative dysphagia rates. METHODS:A prospectively collected quality registry for anterior cervical spine surgery was retrospectively reviewed. Eating Assessment Tool-10 (EAT-10) dysphagia questionnaire responses were collected at baseline and at 1, 3, and 12 months postoperatively, using scores ≥ 3 to represent dysphagia. Revision surgeries indicated for ASD were compared against primary surgeries, and univariate analysis assessed differences in patient demographics, surgical information, and patient-reported outcome measures. Fixed-effects logistic regressions were performed to assess the independent impact of ASD on postoperative dysphagia and to identify risk factors within revision surgery. RESULTS:Of the 1713 patients in the cervical spine registry meeting the inclusion criteria, 279 (16.3%) had preoperative ASD while 1434 (83.7%) were primary surgeries. ASD was associated with a higher incidence of dysphagia at 1 (65% vs 57%, p = 0.024), 3 (43% vs 30%, p < 0.001), and 12 months (35% vs 26%, p = 0.018), but not at baseline (15% vs 12%, p = 0.11). Among patients without baseline dysphagia, patients with ASD were significantly more likely to report new dysphagia at 3 months (38% vs 26%, p < 0.001) but not at 1 (59% vs 54%, p = 0.2) or 12 months (26% vs 21%, p = 0.2). Among patients with baseline dysphagia, the average EAT-10 score improved from baseline to 12 months postoperatively, but patients with ASD experienced significantly less improvement (-1.414 [SD 8.399] vs -5.793 [SD 9.217], p = 0.011). In the multivariable analyses of all patients, ASD was an independent predictor of dysphagia at 3 months (OR 1.11, p < 0.001) but not at 1 (OR 1.03, p = 0.4) or 12 months (OR 1.05, p = 0.2). Among patients with ASD, 3-month dysphagia was independently predicted by baseline dysphagia (OR 1.42, p < 0.001), C3-4 exposure (OR 1.27, p = 0.004), and re-exposure of prior levels (OR 1.16, p = 0.024), while an otolaryngologist-assisted approach predicted a lower risk (OR 0.77, p = 0.022). CONCLUSIONS:ASD did not significantly impact baseline dysphagia rates, but revision surgery for ASD was a significant independent risk factor for delayed recovery from initial postoperative dysphagia beyond 3 months following anterior cervical spine surgery. Exposure-related variables further stratified risk within ASD revision surgery. Preoperative patient counseling should manage patient expectations accordingly.
