STUDY DESIGN Retrospective propensity score-matched cohort study. OBJECTIVE To determine whether triple-class psychotropic exposure before single-level lumbar fusion is associated with different postoperative outcomes than selective serotonin reuptake inhibitor (SSRI) monotherapy in patients carrying a psychiatric diagnosis. SUMMARY OF BACKGROUND DATA Psychiatric illness is common before spine surgery and associated with inferior outcomes, but is usually analyzed as a single categorical variable. Whether regimen complexity carries independent prognostic information is unclear. METHODS Adults with a psychotic-spectrum or mood disorder (ICD-10-CM, F20-F39) undergoing primary single-level posterior lumbar arthrodesis were identified in TriNetX. Exposure was ascertained 365 to 1 day preoperatively; postoperative prescriptions did not contribute. Patients receiving an SSRI, benzodiazepine and antipsychotic were matched 1:1 on 75 preoperative characteristics to SSRI monotherapy. Pseudarthrosis and surgical site infection were co-primary outcomes; revision, readmission, emergency department visits and opioid use were secondary, assessed at 3 and 6 months and 1, 3 and 5 years (Bonferroni P<0.025). RESULTS Among 638 matched pairs, all but one characteristic achieved a standardized mean difference <0.10. Surgical site infection was more frequent at every interval (5 y, 14.73% vs 8.31%; RR 1.77, 95% CI 1.29-2.44; P=0.0003), as was readmission (5 y, 67.40% vs 57.99%; RR 1.16, 1.07-1.27; P=0.0005). Revision was approximately twofold higher from 1 year onward (5 y, 8.62% vs 4.39%; RR 1.96, 1.26-3.06; P=0.0022). Pseudarthrosis was more frequent at every interval but met the corrected threshold only at 1 year (16.87% vs 12.38%; RR 1.36, 1.04-1.78; P=0.0224). The proportion receiving any opioid was identical (97.49%). CONCLUSION Triple-class exposure was associated with higher infection, readmission and revision than SSRI monotherapy. These associations do not establish causation and may reflect illness severity, unmeasured surgical factors or detection bias. The regimen is a risk marker warranting closer perioperative surveillance, not a treatment target.
Study Design: Multicenter prospective observational study. Objective: To characterize the application and outcome profiles of TELD, IELD, and UBE in routine clinical practice. Summary of Background Data: Full-endoscopic lumbar surgery has been widely used in the treatment of lumbar disc herniation, yet multicenter prospective evidence on patient outcomes in real-world clinical practice remains limited. Methods: This multicenter prospective real-world study was conducted across 10 medical centers in four regions of China. Perioperative parameters, complications, and patient-reported outcome measures at postoperative day 1 and at 3, 6, and 12 months were recorded. Descriptive group comparisons were supplemented by adjusted repeated-measures analyses accounting for baseline outcome values, clinical covariates, operative level, and center. Results: A total of 623 patients were included: 105 in the TELD group, 109 in the IELD group, and 409 in the UBE group. Preoperative pain intensity, operative-level distribution, sensory deficit, and center distribution differed among groups. In adjusted analyses, TELD was associated with lower back-pain VAS than UBE at 3 months (mean difference, -0.73; 95% CI, -1.06 to -0.40; Holm P <0.001), 6 months (-0.51; -0.82 to -0.21; P =0.005), and 12 months (-0.77; -0.96 to -0.57; P <0.001). These differences were below the 3-point VAS MCID. Conclusions: TELD, IELD, and UBE were associated with favorable safety and midterm outcomes in this multicenter cohort. TELD was associated with modestly lower postoperative back-pain scores than UBE after adjustment for measured differences; however, the absolute differences did not reach the prespecified MCID and do not establish causal or universal procedural superiority. Level of Evidence: Level 3
Study Design. Retrospective cohort study with propensity score matching. Objective. To evaluate the impact of perioperative aspirin continuation on surgical and postoperative outcomes following minimally invasive anterior-to-psoas (MIS-ATP) lumbar fusion. Summary of Background Data. Perioperative aspirin management in spine surgery remains controversial, with concerns centered on bleeding risk versus thrombotic complications associated with discontinuation. Evidence specific to minimally invasive lumbar fusion techniques, particularly the MIS-ATP approach, is limited. Materials and Methods. Adult patients who underwent MIS-ATP lumbar fusion with supplemental posterior percutaneous fixation at a single academic medical center (2014–2020) were included. Patients who continued low-dose aspirin through the perioperative period were compared with those who discontinued aspirin preoperatively. Propensity score matching (1:1 nearest-neighbor) incorporated age, sex, BMI, race/ethnicity, fusion levels, comorbidities (hypertension, diabetes mellitus, CAD, COPD, and CKD), smoking, alcohol use, and preoperative laboratory values. Primary outcomes included operative time, estimated blood loss (EBL), postoperative day-1 hemoglobin, and length of stay. A subanalysis compared aspirin continuers with patients who held aspirin ≥7 days preoperatively. Results. Of 455 eligible patients, 134 (29.5%) continued aspirin and 321 (70.5%) discontinued. Propensity matching yielded 86 well-balanced pairs (n=172). Operative time (224.7±97.9 vs . 228.6±90.1 min; P =0.79), EBL (244.4±456.0 vs . 278.4±418.7 mL; P =0.62), postoperative day-1 hemoglobin (10.88±1.49 vs . 11.08±1.76 g/dL; P =0.41), and length of stay (4.83±3.72 vs . 4.20±2.49 d; P =0.22) did not differ significantly. Transfusion rates (18.6% vs . 15.1%; P =0.54) and retroperitoneal hematoma (1.2% vs . 1.2%; P =1.00) were comparable. The ≥7-day-hold subanalysis (15 matched pairs) showed no outcome advantage over continuation. Conclusion. Perioperative continuation of low-dose aspirin in appropriately selected patients undergoing MIS-ATP lumbar fusion was not associated with increased surgical morbidity or postoperative complications, supporting an individualized, approach-specific approach to perioperative antiplatelet management.
Study Design. Retrospective single-center study. Objective. To compare the discriminative ability of the sagittal age-adjusted score (SAAS) and the T4-L1PA mismatch for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) after adult spinal deformity (ASD) surgery. Summary of Background Data. The SAAS and the T4-L1-Hip axis are two contemporary alignment schemes, but no study has directly compared their discriminative ability for proximal junctional complications. Materials and Methods. We analyzed 401 patients (mean age, 70 yr; 87% female) who underwent surgery for degenerative adult spinal deformity with ≥6-vertebrae fusion to the pelvis and two-year follow-up. The SAAS, the T4-L1PA mismatch, and their components were evaluated as continuous variables. Discrimination for PJK/F, PJK, and PJF was assessed by area under the curve (AUC) and compared using the DeLong test. Nested multivariable logistic regression tested the incremental value of each scheme over clinical risk factors, expressed as the change in −2 log likelihood (Δ−2LL). Results. Proximal junctional complications occurred in 140 patients (34.9%; 113 PJK, 27 PJF). For PJK/F and PJK, the two schemes discriminated comparably (DeLong P =0.401 and 0.962) and both independently improved the adjusted models (SAAS Δ−2LL 4.8 and 5.3; T4-L1PA mismatch Δ−2LL 12.7 and 7.9; all P <0.05). For PJF, the T4-L1PA mismatch was significantly superior (area under the curve: 0.702 vs . 0.503; DeLong P =0.019) and added value in the nested model (Δ−2LL 10.8; P =0.001), whereas the SAAS did not (Δ−2LL 0.3; P =0.580). Component analysis showed that only the PI-LL offset drove the SAAS, while the L1PA was associated with all outcomes; for PJF, the composite T4-L1PA mismatch outperformed the L1PA alone. Conclusions. The SAAS and the T4-L1PA mismatch discriminated PJK comparably, but the T4-L1PA mismatch was more discriminative for PJF, although the overall discrimination remained modest. Correcting the lumbar segment addresses PJK, whereas optimal restoration of the T4-to-L1 relationship is additionally required to prevent PJF.
