Objective To evaluate whether combining clinical frailty with magnetic resonance imaging (MRI)-derived posterior paraspinal muscle degeneration identifies perioperative risk phenotypes in adults aged ≥75 years undergoing lumbar fusion.
Methods We retrospectively studied patients aged ≥75 years undergoing lumbar fusion with preoperative lumbar MRI. Frailty was assessed using the Fried phenotype (frail: score ≥3). Posterior paraspinal muscle degeneration across L1–S1 was quantified using automated segmentation and a composite posterior frailty index (PFI); severe degeneration was defined as the upper quartile of PFI. Patients were classified into 4 frailty×muscle phenotypes. Primary outcomes were any in-hospital complication and prolonged length of stay (LOS ≥16 days).
Results Among 248 patients, phenotypes A–D (A, nonfrail/nonsevere; B, frail/nonsevere; C, nonfrail/severe; D, frail/severe) comprised 132, 54, 20, and 42 patients, respectively. Any in-hospital complication occurred in 18.2% of phenotype A compared with 50.0%–57.1% in phenotypes B–D (p<0.001). Prolonged LOS (≥16 days; cohort 75th percentile) occurred in 0.8% of phenotype A versus 38.9% (B), 35.0% (C), and 78.6% (D) (p<0.001), corresponding to absolute risk increases of +34.2 to +77.8 percentage points. After adjustment, higher-risk phenotypes remained independently associated with increased odds of any complication and prolonged LOS; however, the prolonged-LOS odds estimates were imprecise due to sparse events in the reference group. Phenotype was not independently associated with 90-day readmission. Pain improvement (ΔVAS [visual analogue scale]) was attenuated in phenotypes B and D, while differences in ΔODI (Oswestry Disability Index) were not statistically significant.
Conclusion Integrating frailty and MRI-based posterior paraspinal degeneration provides actionable stratification of complication and prolonged LOS risk after lumbar fusion in older adults.
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Objective To investigate the relationship between C1 screw trajectory and occipital bone erosion in C1–2 posterior fixation.
Methods This retrospective cohort study analyzed 27 patients (54 screws) who underwent C1–2 posterior fixation between March 2018 and March 2023 at a single institution by multiple surgeons. Screws were classified by trajectory: Tan technique (n=39) or Harms-Goel (HG) technique (n=15). Primary outcome was occipital bone erosion; the secondary outcome was breach of inner cortical layer. Per-screw analysis was performed using generalized estimating equations to account for bilateral screw clustering.
Results Mean follow-up was 48.3 (range, 24–84) months. Occipital bone erosion occurred in 51.3% (20 of 39) of Tan screws versus 6.7% (1 of 15) of HG screws (p<0.001). Breach of inner cortical layer occurred exclusively with the Tan technique (10.3% vs. 0%, p=0.302). In mixed Tan+HG cases (n=3), erosion occurred only on the Tan side (2 of 3 screws) with no erosion on HG side (0 of 3 screws). C1 upper line transgression was a critical risk factor; no erosion occurred in screws that did not exceed this anatomical landmark (adjusted relative risk [RR], 6.82; 95% confidence interval [CI], 2.41–19.31). Additional risk factors included height O–C1 ≤4.5 mm (RR, 3.81; 95% CI, 1.51–6.28) and height O–C1 extension ≤1 mm (RR, 4.86; 95% CI, 2.05–11.53). No patients required reoperation for erosion-related symptoms during follow-up.
Conclusion Screw trajectory is the primary determinant of occipital bone erosion following C1–2 fixation. The HG technique demonstrated significantly lower erosion rates (6.7% vs. 51.3%). When anatomically feasible, HG technique may be considered to reduce erosion risk.
Objective To compare perioperative and complication outcomes, focusing on the prevention of sagittal translation (ST), between a novel “prioritized correction with multiple-rod construct” (PC-MRC) technique and traditional multiple-rod constructs (M-RC) in adult spinal deformity (ASD) patients undergoing 3-column osteotomies (3-COs).
Methods In this retrospective study, 101 ASD patients with a minimum 2-year follow-up after 3-COs were divided into 2 groups: PC-MRC (n=65) and M-RC (n=36). The PC-MRC technique involved initial osteotomy closure with short rods followed by global alignment correction with long rods. Radiographic and clinical parameters were assessed preoperatively, postoperatively, and at final follow-up.
Results The PC-MRC group had significantly shorter operation time and lower estimated blood loss (p=0.045 and p=0.007, respectively). Major coronal and kyphotic deformity correction rates were similar between groups. No significant correction loss occurred at the final follow-up. Crucially, the incidence of ST was significantly lower in the PC-MRC group (1.5% vs. 25.0%, p<0.001). Correspondingly, the overall rate of neurological injury was lower in the PC-MRC group (7.7% vs. 22.2%, p=0.037).
Conclusion The PC-MRC technique offers a versatile and rigid fixation for 3-COs in ASD patients, facilitating significant correction of global deformity. This straightforward technique effectively prevents massive blood loss and ST caused by 3-COs, while minimizing the risk of neurological complication.
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Objective To investigate the incidence of postoperative neurological complications among patients who underwent spinal deformity surgery and to determine the significant risk factors for postoperative neurological complications.
Methods Six databases PubMed, Web of Science, Scopus, MEDLINE, Embase, and Cochrane Library have been searched to identify observational studies from inception until January 2025. Inclusion criteria were patients aged ≥10 years with postoperative neurological complications after spinal deformity surgery. Stata/MP18.0 was used to conduct the meta-analysis in this review. The summary incidence estimates, proportion with 95% confidence intervals (CIs) and weights were pooled by the random-effects restricted maximum likelihood model.
Results The search strategy identified 53 articles with 40,958 patients for final review. Overall incidence of postoperative neurological complications was 7% (95% CI, 5.0%–9.0%; p < 0.001; I2 = 98.34%) in which incidence estimates for patients with adult spinal deformity and underwent 3-column spinal osteotomies were 12% (95% CI, 9%–16%; p < 0.001; I2 = 93.17%) and 18% (95% CI, 8%–31%; p < 0.001; I2 = 94.68%) respectively. Preoperative neurological deficit was the risk factor with highest overall odds ratio (OR, 2.86; 95% CI, 1.85–4.41; p = 0.01; I2 = 76.20%), followed by the presence of kyphosis (OR, 1.13; 95% CI, 0.75–1.70; p = 0.02; I2 = 81.80%) and age at surgery (OR, 1.04; 95% CI, 1.01–1.08; p = 0.04; I2 = 68.80%).
Conclusion Preoperative neurological deficit, the presence of kyphosis and age at surgery were significant risk factors for postoperative neurological complications. Therefore, comprehensive preoperative assessment and surgical planning are crucial to minimize the risk of developing postoperative neurological complications or the deterioration of pre-existing neurologic deficits.
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Neurospine 2024;21(3):770-803. Published online September 30, 2024
Objective Minimally invasive spine surgery (MISS) employs small incisions and advanced techniques to minimize tissue damage while achieving similar outcomes to open surgery. MISS offers benefits such as reduced blood loss, shorter hospital stays, and lower costs. This review analyzes complications associated with MISS over the last 10 years, highlighting common issues and the impact of technological advancements.
Methods A systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines was conducted using PubMed, MEDLINE, Embase via OVID, and Cochrane databases, covering publications from January 2013 to March 2024. Keywords related to MISS and complications were used. Studies on adult patients undergoing MISS with tubular, uniportal, or biportal endoscopy, reporting intraoperative or postoperative complications, were included. Non-English publications, abstracts, and small case series were excluded. Data on MISS approach, patient demographics, and complications were extracted and reviewed by 2 independent researchers.
Results The search identified 880 studies, with 137 included after screening and exclusions. Key complications in cervical MISS were hematomas, transient nerve root palsy, and dural tears. In thoracic MISS, complications included cerebrospinal fluid leaks and durotomy. In lumbar MISS, common complications were incidental dural injuries, postoperative neuropathic conditions, and disc herniation recurrences. Complications varied by surgical approach.
Conclusion MISS offers reduced anatomical disruption compared to open surgery, potentially decreasing nerve injury risk. However, complications such as nerve injuries, durotomies, and hardware misplacement still occur. Intraoperative neuromonitoring and advanced technologies like navigation can help mitigate these risks. Despite variability in complication rates, MISS remains a safe, effective alternative with ongoing advancements enhancing its outcomes.
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Objective Poor bone quality is a risk factor for postoperative complications after degenerative lumbar fusion surgery. The magnetic resonance imaging-based vertebral bone quality (VBQ) score is a good tool for assessing bone quality, and this is the first meta-analysis performed to summarize the predictive value of the VBQ score for cage subsidence and screw loosening in patients undergoing degenerative lumbar surgery.
Methods Studies were comprehensively searched in electronic databases. The quality of the studies was assessed. The pooled sensitivity, specificity and summary receiver operating characteristic curve were calculated. Publication bias was assessed and meta-regression was conducted.
Results We ultimately included 9 studies with a total of 1,404 patients with a mean age of 60.4 years and a percentage of females of 57.0%. According to the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool to assess methodological quality, the quality of the included studies was relatively low and risks of bias might exist. Results showed that a high VBQ was significantly associated with cage subsidence and screw loosening, and risk factor analysis revealed that the merged odds ratio was 5.37 for cage subsidence and 3.87 for screw loosening. With a VBQ cutoff value of 3.34±0.45, the pooled sensitivity and specificity for the diagnosis of postoperative complications were 0.75 and 0.75, respectively, and the area under the curve was 0.82 (95% confidence interval, 0.78–0.85).
Conclusion A high VBQ was associated with a high risk of cage subsidence and screw loosening in patients who underwent degenerative lumbar surgery. The VBQ score could be considered for identifying high-risk patients for further evaluation.
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This review aims to systematically evaluate the incidence, management strategies, and clinical outcomes of iatrogenic durotomy (ID) in endoscopic spine surgery and to propose a management flowchart based on the tear size and associated complications. A comprehensive literature search was conducted, focusing on studies involving endoscopic spinal procedures and incidental durotomy. The selected studies were analyzed for management techniques and outcomes, particularly in relation to the size of the dural tear and the presence of nerve root herniation. Based on these findings, a flowchart for intraoperative management was developed. A total of 14 studies were included, encompassing 68,546 patients. Varying incidences of ID, with management strategies largely dependent on the size of the dural tear, were found. Small tears (less than 5 mm) were often left untreated or managed with absorbable hemostatic agents, while medium (5–10 mm) and large tears (greater than 10 mm) required more complex approaches like endoscopic patch repair or open surgery. The presence of nerve root herniation necessitated immediate action, often influencing the decision to convert to open repair. Effective management of ID in endoscopic spine surgery requires a nuanced approach tailored to the size of the tear and specific intraoperative challenges, such as nerve root herniation. The proposed flowchart offers a structured approach to these complexities, potentially enhancing clinical outcomes and reducing complication rates. Future research with more rigorous methodologies is necessary to refine these management strategies further and broaden the applications of endoscopic spine surgery.
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Objective To identify risk factors and establish radiographic criteria for distal junctional failure (DJF) in patients with adult spinal deformity (ASD), who underwent fusion surgery stopping at L5.
Methods This retrospective study was undertaken from January 2016 to December 2020. Patients with ASD who underwent fusion surgery (≥5 levels) stopping at L5 were analyzed. DJF was defined as symptomatic adjacent segment pathology at the lumbosacral junction necessitating consideration for revision surgery. Demographic data and radiographic measurements were compared between the DJF and non-DJF groups. Receiver operating characteristic curve analysis was performed to identify the radiographic cutoff value for DJF.
Results Among 76 patients, 16 (21.1%) experienced DJF. DJF was associated with older age, antidepressant/anxiolytic medication, longer level of fusions, and worse preoperative sagittal alignment. Antidepressant/anxiolytic medication (odds ratio, 5.60) and preoperative pelvic incidence (PI)–lumbar lordosis (LL) mismatch>40° (odds ratio, 5.87) were independent risk factors for DJF. Without both factors, the incidence of DJF has been greatly reduced (9.1%). Two radiographic criteria were determined for DJF: last distal junctional angle (DJA)>-5° and Δ last DJA–post DJA>5°. When both criteria were met, the sensitivity and specificity of the DJF were 93.3% and 91.7%, respectively.
Conclusion Use of antidepressant/anxiolytic medication and preoperative PI–LL mismatch >40° were independent risk factors for DJF. DJF could be diagnosed using postoperative changes in the DJA. If both criteria were met, DJF could be strongly suggested.
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Objective To avoid the most offending surgical instrument for dural tears, we develop a “no-punch” decompression technique for unilateral biportal endoscopic (UBE) spine surgery.
Methods This retrospective study enrolled 68 consecutive patients with degenerative lumbar spinal stenosis segments. The treatment results were evaluated using the visual analogue scale (VAS) for low back and leg pain, the Japanese Orthopaedic Association (JOA) scores, and the Oswestry Disability Index (ODI). Radiological outcomes were evaluated using the preoperative and postoperative magnetic resonance imaging.
Results This study included 36 male and 32 female patients who received 109 segments of decompression, with an average age of 68.7 (37–90 years). The average operation time was 52.2 minutes. The average hospital stay was 3.1 days. There were no dural tears but 3 minor surgical complications, all treated conservatively. The VAS for low back and leg pain improved from 4.6 and 7.0 to 0.8 and 1.2. The JOA score improved from 16.2 to 26.8, with an improvement rate of 82.0%. The ODI improved from 50.1 to 18.7. All these improvements were statistically significant. The cross-sectional dural area improved from 61.1 to 151.3 mm2, with an average increase of 90.2 mm2 and 205.3%. 87.1% of the ipsilateral facet joints and 84.7% of the contralateral facet joints were preserved. In 61% of the decompressed segments, the ipsilateral facet joints were preserved better than the contralateral facet joints.
Conclusion The UBE “no-punch” decompression technique effectively avoids the dural tears. It provides effective neural decompression, excellent facet joint preservation, and good treatment outcomes.
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Objective To evaluate C2 muscle preservation effect and the radiological and clinical outcomes after C2 recapping laminoplasty.
Methods Fourteen consecutive patients who underwent C2 recapping laminoplasty around C1–2 level were enrolled. To evaluate muscle preservation effect, the authors conducted a morphological measurement of extensor muscles between the operated and nonoperated side. Two surgeons measured the cross-sectional area (CSA) of obliquus capitis inferior (OCI) and semispinalis cervicis (SSC) muscle before and after surgery to determine atrophy rates (ARs). Additionally, we examined range of motion (ROM), sagittal vertical axis (SVA), neck visual analogue scale (VAS), Neck Disability Index (NDI), and Japanese Orthopaedic Association (JOA) score to assess potential changes in alignment and consequent clinical outcomes following posterior cervical surgery.
Results We measured the CSA of OCI and SSC before surgery, and at 6 and 12 months postoperatively. Based on these measurements, the AR of the nonoperated SSC was 0.1% ± 8.5%, the AR of the operated OCI was 2.0% ± 7.2%, and the AR of the nonoperated OCI was -0.7% ± 5.1% at the 12 months after surgery. However, the AR of the operated side’s SSC was 11.2% ± 12.5%, which is a relatively higher value than other measurements. Despite the atrophic change of SSC on the operated side, there were no prominent changes observed in SVA, C0–2 ROM, and C2–7 ROM between preoperative and 12 months postoperative measurements, which were 11.8 ± 10.9 mm, 16.3° ± 5.9°, and 48.7° ± 7.7° preoperatively, and 14.1 ± 11.6 mm, 16.1° ± 7.2°, and 44.0° ± 10.3° at 12 months postoperative, respectively. Improvement was also noted in VAS, NDI, and JOA scores after surgery with JOA recovery rate of 77.3% ± 29.6%.
Conclusion C2 recapping laminoplasty could be a useful tool for addressing pathologies around the upper cervical spine, potentially mitigating muscle atrophy and reducing postoperative neck pain, while maintaining sagittal alignment and ROM.
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Neurospine 2023;20(4):1469-1476. Published online December 31, 2023
Objective Two commonly used techniques for spinopelvic fixation in adult deformity surgery are iliac screw (IS) and sacral 2 alar-iliac screw (S2AI) fixations. In this article, we systematically meta-analyzed the complications of sacropelvic fixation for adult deformity surgery comparing IS and S2AI.
Methods The PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched until March 29, 2023. The proportion of postoperative complications, including implant failure, revision, screw prominence, and wound complications after sacropelvic fixation, were pooled with a random-effects model. Subgroup analyses for the method of sacropelvic fixation were conducted.
Results Ten studies with a total of 1,931 patients (IS, 925 patients; S2AI, 1,006 patients) were included. The pooled proportion of implant failure was not statistically different between the IS and S2AI groups (21.9% and 18.9%, respectively) (p = 0.59). However, revision was higher in the IS group (21.0%) than that in the S2AI group (8.5%) (p = 0.02). Additionally, screw prominence was higher in the IS group (9.6%) than that in the S2AI group (0.0%) (p < 0.01), and wound complication was also higher in the IS group (31.7%) than that in the S2AI group (3.9%) (p < 0.01).
Conclusion IS and S2AI fixations showed that both techniques had similar outcomes in terms of implant failure. However, S2AI was revealed to have better outcomes than IS in terms of revision, screw prominence, and wound complications.
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Adult spinal deformity (ASD) surgery aims to correct abnormal spinal curvature in adults, leading to improved functionality and reduced pain. However, this surgery is associated with various complications, one of which is proximal junctional failure (PJF). PJF can have a significant impact on a patient’s quality of life, necessitating a comprehensive understanding of its causes and the development of effective management strategies. This review aims to provide an in-depth understanding of PJF in ASD surgery. PJF is a complex complication resulting from a multitude of factors including patient characteristics, surgical techniques, and postoperative management. Age, osteoporosis, overcorrection of sagittal alignment, and poor bone quality are identified as significant risk factors. The clinical implications of PJF are substantial, often requiring revision surgery and causing a considerable decrease in patients’ quality of life. Prevention strategies include careful preoperative planning, appropriate patient selection, and optimization of surgical techniques. Treatment often necessitates a multifaceted approach, including surgical intervention and the management of underlying risk factors. Predictive modeling is an emerging field that may offer a promising avenue for the risk stratification of patients and individualized preventive strategies. A thorough understanding of PJF’s pathogenesis, risk factors, and clinical implications is essential for surgeons involved in ASD surgery. Current preventive measures and treatment strategies aim to mitigate the risk and manage the complications of PJF, but the complication cannot be entirely prevented. Future research should focus on the development of more effective preventive and treatment strategies, and predictive models could be valuable in this pursuit.
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Osteoporotic vertebral fractures (OVFs) can hinder physical motor function, daily activities, and the quality of life in elderly patients when treated conservatively. Vertebral augmentation, which includes vertebroplasty and balloon kyphoplasty, is a commonly used procedure for OVFs. However, there have been reports of complications. Although serious complications are rare, there have been instances of adjacent vertebral fractures, cement dislocation, and insufficient pain relief due to cement failure, sometimes necessitating revision surgery. This narrative review discusses the common risks associated with vertebral augmentation for OVFs, such as cement leakage and adjacent vertebral fractures, and highlights the risk of revision surgery. The pooled incidence of revision surgery was 0.04 (0.02–0.06). The risks for revision are reported as follows: female sex, advanced age, diabetes mellitus, cerebrovascular disease, dementia, blindness or low vision, hypertension, hyperlipidemia, split type fracture, large angular motion, and large endplate deficit. Various treatment strategies exist for OVFs, but they remain a subject of controversy. Current literature underscores the lack of substantial evidence to guide treatment strategies based on the risks of vertebral augmentation. In cases with a high risk of failure, other surgeries and conservative treatments should also be considered as treatment options.
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