[JBJS Review] Overview of important clinical research results in spine surgery in the previous year

Cervical degenerative disease

 Compound spinal stenosis refers to damage to the diameter of the spinal canal in at least two different areas of the spine, usually involving cervical and lumbar stenosis.  For symptomatic patients, decompressive surgery is recommended.  Ahorukomeye et al conducted a systematic literature review on staging and concurrent surgical treatment of patients with spinal stenosis.  The study included 831 patients and found no significant differences in blood loss, mJOA score, ODI, and Nurick grade between the staged and simultaneous surgery groups.  Study results indicate that staged and simultaneous surgery have similar functional and neurologic outcomes, with concurrent surgery having shorter cumulative operative time.  However, study limitations include a possible bias toward patients with better health status, affecting the reporting of complication rates.  Therefore, simultaneous surgery in carefully selected patients may help reduce combined surgery and recovery time.

Degenerative cervical spondylotic myelopathy

 Degenerative cervical myelopathy is one of the leading causes of spinal cord dysfunction in adults, and its incidence will continue to increase as the population ages.  Surgical decompression is the primary treatment, but recently there has been increasing interest in Cerebrolysin as an adjunctive treatment.  Studies have found that short-term use of Cerebrolysin after surgery can help patients with cervical spondylotic myelopathy recover function without adverse reactions.  In a study involving 90 patients, the cerebrolysin group had significantly higher functional scores and greater neurological improvement than the placebo group at one year follow-up.  These results suggest that short-term application of cerebrolysin may be a promising adjunctive treatment after decompressive surgery for degenerative cervical myelopathy.

 Ossification of the posterior longitudinal ligament (OPLL)

 Treatment of spinal cord compression caused by ossification of the posterior longitudinal ligament (OPLL) is controversial among spine surgeons.  A prospective RCT study compared the efficacy of anterior cervical en bloc resection and posterior laminectomy and fusion in patients with ossification of the posterior longitudinal ligament (OPLL).  The study results showed that for patients with K-lines >50% or negative, anterior surgery showed higher JOA scores and recovery rates in the first two years after surgery.  For patients whose proportion was <50% or whose K-line was positive, there was no significant difference between the two surgical methods in terms of efficacy, cervical spine mobility, and complications within 2 years.

Cost-Effectiveness of Anterior Cervical Spine Surgery

 The Dutch Neck Kinetics (NECK) trial conducted a cost-utility analysis comparing anterior cervical discectomy, anterior cervical discectomy and fusion (ACDF), and anterior cervical disc arthroplasty (ACDA) for the treatment of cervical nerve roots. disease effects.  Patient Outcomes.  According to the net benefit approach, there were no significant differences in quality-adjusted life years (QALYs) between the three treatment strategies.  Although total medical costs in the first year were significantly higher in the ACDA group, there were no significant differences in total social costs between the three strategies.  ACDF is considered the most cost-effective strategy at most willingness-to-pay thresholds, primarily due to its lower initial surgical costs rather than subsequent costs.

Lumbar degenerative disease

 The necessity and type of fusion for the treatment of degenerative spondylolisthesis remain controversial.  Recent studies have shown that laminectomy plus fusion improves postoperative pain and disability but increases operative time and hospital stay compared with laminectomy alone.  Another study found no significant differences in patient-reported outcomes between the instrumented and non-instrumented fusion groups in a randomized controlled trial in Scandinavia, but the non-instrumented group had higher rates of non-fusion and re-operation. Surgery rates are low.  higher.  These studies support an instrument-fusion approach to treatment.

Drainage after lumbar surgery

 It is common practice to use drains after surgery to reduce the incidence of postoperative hematoma.  Currently, there is no conclusive evidence to support the use of drains during degenerative lumbar spine surgery to avoid complications.  In a multicenter randomized controlled trial, Molina et al aimed to evaluate clinical outcomes, complications, hematocrit levels, and length of stay in patients after lumbar fusion with or without drainage.  Ninety-three patients who underwent up to three levels of lumbar fusion were randomly assigned to a group with or without postoperative drainage and had a final follow-up one month postoperatively.  No differences in complications were found.  The authors concluded that after excluding high-risk patients, patients without drains had shorter hospital stays, better outcome scores, and similar complication rates.

Postoperative management

 The study by Saleh et al.  Studies have found that perioperative nutritional supplementation can significantly reduce the incidence of minor complications and reoperation rates in malnourished patients during spine surgery.  Furthermore, a double-blind RCT by Hu et al showed that daily supplementation of 600 mg calcium citrate and 800 IU vitamin D3 in patients undergoing lumbar fusion surgery shortened fusion time and reduced pain scores.  Additionally, a study by Iyer et al showed that intravenous ketorolac administered within 48 hours postoperatively reduced opioid use and hospital stay.  Finally, the animal experimental study by Karamian et al.  The study found that varenicline can reduce the negative impact of nicotine on postoperative fusion rates, suggesting the importance of controlling nicotine use and nutritional status during the perioperative period of spine surgery.

Quick recovery after surgery

 In recent years, there has been continued scholarly interest in clinical pathways and care approaches designed to promote recovery from pain, blood loss, and functional limitations after lumbar spine surgery and to mitigate the impact of surgical intervention.  Contartese et al conducted a systematic review examining the impact of fast-track protocols in patients undergoing spinal surgery.  The review found that common fast-track elements include patient education, multimodal analgesia, thromboprophylaxis and antibiotic prophylaxis, which can help shorten hospital stays and reduce opioid use.  Findings suggest that fast track spine surgery is associated with shorter hospital stays and faster functional recovery but does not increase complications or readmission rates.  Larger prospective randomized controlled trials are needed to further validate the conclusions.

Postoperative recovery

 Research shows that a rehabilitation program that combines exercise and behavioral therapy may be effective in improving function in patients after lumbar fusion surgery.  The RCT study by Shaygan et al included 70 patients who underwent single-level fusion for lumbar stenosis and/or instability, and the intervention group received seven 60- to 90-minute postoperative pain management training sessions.  Multivariate analysis of pain intensity, anxiety and functional disability scores showed significant differences between intervention groups in these areas (p<0.001).  The reduction in pain intensity in the intervention group exceeded the minimal detectable change, and the results highlight the important role of comprehensive pain management education in improving function and recovery after lumbar fusion.

Adult spinal deformity

 Appropriate patient selection, preoperative optimization, and reduction of complication risk continue to be the focus of the adult spinal deformity literature over the past year.  A retrospective study compared the Charlson Comorbidity Index (CCI) with the Seattle Spine Score (SSS), the Adult Spinal Deformity Comorbidity Score (ASD-CS), and the modified 5-item Frailty Index (mFI-5). When applied preoperatively, mFI-5 was found to be superior to CCI in predicting complications after adult spinal deformity surgery.  Therefore, preoperative frailty assessment may benefit patient selection and care optimization, and this study adds to the literature supporting the use of frailty as a predictor of surgical outcome.

 One study used data from the Adult Symptomatic Lumbar Scoliosis Phase I (ASLS-1) trial to evaluate proximal connection failure after surgery for symptomatic lumbar scoliosis in adults.  The study found that higher body mass index, preoperative thoracic kyphosis, and lower preoperative proximal connection angle were associated with an increased risk of proximal connection failure.  However, the use of hooks at the upper end of the instrumented spine significantly reduces the risk of proximal connection failure.  Additionally, a meta-analysis found that proximal junctional kyphosis was associated with lower vertebral bone density T-scores and/or Hounsfield unit measurements of the upper instrumented spine.  Therefore, preoperative optimization of bone density may help reduce the risk of long-term proximal connection failure.

 A study of 157 patients undergoing adult spinal deformity surgery found that approximately half of the patients achieved surgical durability at 1 and 3 years, with key predictors including pelvic fusion, resolution of lumbar mismatch, and surgical invasiveness .  However, approximately half of the study population did not meet durable surgical outcome criteria.  Another international study compared different surgical methods for achieving optimal alignment after deformity correction and found that L5-S1 anterior lumbar interbody fusion had better results for complex realignments and proximal connection failures, whereas TLIF and/or three-column osteotomy can restore physiological lordosis and pelvic compensations.

 Another meta-analysis study found that among patients who underwent long-segment fusion, implant failure rates were similar between those treated with iliac screw fixation and S2-wing-iliac (S2AI) screw fixation, but the S2AI group had fewer wound problems. Better, screw protrusion and overall revision rate.  Another study compared patients with multi-rod (>2) and dual-rod configurations and found that the multi-rod group had lower revision rates, fewer mechanical complications, greater improvement in quality of life, and better restoration of sagittal alignment. .  These results were also confirmed in another systematic review, random effects, and Bayesian meta-analysis, showing that multirod construction was associated with lower rates of pseudarthrosis, rod fracture, and reoperation.

Non-surgical treatment

 Intravertebral nerve ablation is a treatment for chronic vertebral low back pain, and the INTRACEPT trial was designed to evaluate its effectiveness in patients with Modic type I or type II changes.  140 patients were randomized into two groups to receive nerve ablation plus standard care or standard care alone.  An interim analysis showed that the nerve ablation group performed significantly better than the standard care group.  In the spinal nerve ablation group, mean improvement in ODI was 20.3 points and 25.7 points at 3 and 12 months, respectively, VAS pain was reduced by 3.8 cm, and 29% of patients reported complete pain relief.  Study results indicate that spinal nerve ablation is an effective treatment option for chronic vertebral low back pain.

 Cervical ESI plays an important role in spinal surgical treatment, but transforaminal ESI has a higher risk of adverse events.  The study by Lee et al compared the efficacy and safety of transforaminal ESI and transforaminal ESI and found that in terms of pain control, the two ESIs had similar results at 1 month and 3 months, but transforaminal ESI Hole ESI has a slight advantage in pain control.  1 month.  Adverse events were similar and included vascular uptake of contrast material and transiently increased pain.  The findings are limited by low-quality evidence and the choice of injection type should be discussed between surgeons and treating providers.