Objective To investigate the correlation between paraspinal sarcopenia (PS) and sagittal imbalance (SI) in degenerative kyphosis (DK), and to explore the correlation between paraspinal muscle (PSM) function loss and morphology change in DK.
Methods One hundred thirty-eight patients with DK and 204 with lumbar spinal stenosis (LSS) were enrolled. The spinopelvic parameters and sagittal vertical axis (SVA) were measured. Patients were divided into the sagittal balance (SB, SVA ≤ 5 cm, n = 61) and SI (SVA > 5 cm, n = 77) groups. Sagittal balanced LSS patients were served as control group. PSM function was evaluated by measuring the maximal voluntary exertion (MVE) and endurance time (ET). Magnetic resonance imaging-derived cross-sectional area (CSA) and fat infiltration rate (FI%) of PSM at T10–L5 were normalized to intervertebral disc CSA. Psoas CSA and FI% were calculated at L3–4 disc level. The correlation assessment using Spearman rank correlation coefficient and multiple linear regression. Logistic regression was used to identify the risk factors of SI.
Results Significantly lower ET, MVE, relative CSA (rCSA) and higher rFI% was found in the SI group than in the SB and control. The PS were correlated with spinopelvic parameters and regional kyphosis, while lack of correlation was found between the rFI% and MVE. Logistic regression and Youden index analysis showed ET < 15.5 seconds, MVE < 1.3 N/kg, and rCSA (L1–5) atrophy to be potential risk factors for SI in DK.
Conclusion DK patients with SI demonstrate acerbated PS that indicated by significant PSM dysfunction and morphological alterations. We highlight the significance of PSM combined evaluation and revealed that PS plays an indispensable role in the progression of SI, providing novel insights into the underlying sagittal compensatory mechanisms.
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Objective The purpose of this study is to describe utilization, demographics, complications, and revisions for patients with degenerative spondylolisthesis (DS) with stenosis undergoing decompression or decompression with fusion in the United States.
Methods A national insurance database was used to identify patients who underwent either decompression and fusion or decompression alone for management of DS from 2010–2022. Utilization trends, demographics, and complications for each procedure were compared.
Results A total of 162,878 patients were identified, of which 78,043 patients underwent combined single-level lumbar decompression and fusion and 84,835 underwent single-level lumbar decompression alone. Between 2010–2021, lumbar decompression and fusion became the predominant surgical intervention for DS in 2016 and continued to account for more than half of all procedures during the remainder of the study period. Factors such as age, sex, comorbidities, geographic region, and physician specialty training were associated with procedure choice. Decompression with fusion was associated with a lower risk of revision surgery up to 5 years postoperatively and an overall lower incidence of 30-day complications.
Conclusion Decompression with fusion has become the most common treatment for lumbar DS over the past decade despite a lack of compelling evidence supporting its use compared to decompression alone. A variety of patient and surgeon-specific factors is associated with procedure choice. After accounting for cofounders, we identified treatment-specific complications that may be valuable when counseling patients.
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Objective This study aimed to elucidate the hand function recovery capacity of degenerative cervical myelopathy (DCM) patients with different severities of hand dexterity impairment.
Methods Hand functional outcome measures such as the 10-second grip and release (10s-G&R) test, modified Japanese Orthopaedic Association (mJOA) upper extremity score and Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) upper extremity function were collected before surgery and at the 1-year follow-up. A total of 102 DCM patients were categorized into mild, moderate and severe group based on the preoperative 10s-G&R test result. Hand functional parameters were compared across the 3 groups. Multivariate linear regression was conducted to explore predictive factors. Receiver operating characteristic curve analysis was performed to assess the predictive efficacy of the preoperative 10s-G&R test and establish the cutoff value for incomplete recovery of hand dexterity.
Results At the 1-year follow-up, significant improvements were observed in all hand functional parameters across all 3 groups. However, the incomplete recovery rates of the mild, moderate, severe groups were 26.67%, 46.88%, and 57.50%, respectively (p < 0.05). Multivariate regression revealed that preoperative 10s-G&R test result, age, Hoffmann sign, duration of symptom, and mJOA Upper score serve as significant predictors for postoperative 10s-G&R test outcomes. Patients with a preoperative 10s-G&R test < 15 cycles have a 1.9 times higher risk of incomplete recovery of hand function (p = 0.005).
Conclusion Most patients, regardless of their preoperative hand function, exhibit potential for improvement in hand dexterity. However, worse initial hand dexterity correlates with poorer outcomes. Surgical treatment is recommended before the 10s-G&R test drops below 15 cycles.
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Objective To evaluate the degeneration patterns of paraspinal muscles in double-level degenerative lumbar spondylolisthesis (dl-DLS) versus single-level degenerative lumbar spondylolisthesis (sl-DLS).
Methods A total of 67 dl-DLS and 73 sl-DLS patients were included. Multifidus (MF), erector spinae (ES), and psoas major (PM)’s fatty infiltration (FI) and relative cross-sectional area (rCSA) were measured. Sagittal parameters such as lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) were also assessed. Comparisons and correlation analysis were performed between the 2 groups.
Results MF atrophy is worse in dl-DLS patients from L3–4 to L5–S1, with higher FI from L1–2 to L5–S1 compared to sl-DLS patients. ES atrophy and FI are more pronounced in dl-DLS patients from L1–2 to L5–S1. PM atrophy is more significant in dl-DLS patients at L2–3 to L5–S1, with heavier FI from L1–2 to L3–4, though no difference in FI from L4–5 to L5–S1. The rCSA and FI of MF and ES show significant differences between adjacent segments in both groups, except for MF rCSA between L3–4 and L4–5 in dl-DLS. In dl-DLS, PM rCSA negatively correlates with PT from L4–5 to L2–3, while FI of MF and ES in L5–S1 positively correlates with LL. In sl-DLS, PM FI in L4–5 and L5–S1 negatively correlates with LL.
Conclusion Degeneration of MF, ES, and PM is more severe in dl-DLS patients, particularly at the spondylolisthesis level. Severe paraspinal muscle degeneration can lead to spinal force imbalance and progression from sl-DLS to dl-DLS. The degradation of PM and ES correlates negatively with PT and SVA, indicating a link to pelvic decompensation and SVA abnormalities, potentially causing disproportionate degenerative changes in dl-DLS patients.
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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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Objective To investigate the correlation between magnetic resonance imaging-based vertebral bone quality (VBQ) score and screw loosening after dynamic pedicle screw fixation with polyetheretherketone (PEEK) rods, and evaluate its predictive value.
Methods A retrospective analysis was conducted on the patients who underwent dynamic pedicle screw fixation with PEEK rods from March 2017 to June 2022. Data on age, sex, body mass index, hypertension, diabetes, hyperlipidemia history, long-term smoking, alcohol consumption, VBQ score, L1–4 average Hounsfield unit (HU) value, surgical fixation length, and the lowest instrumented vertebra were collected. Logistic regression analysis was employed to assess the relationship between VBQ score and pedicle screw loosening (PSL).
Results A total of 24 patients experienced PSL after surgery (20.5%). PSL group and non-PSL group showed statistical differences in age, number of fixed segments, fixation to the sacrum, L1–4 average HU value, and VBQ score (p < 0.05). The VBQ score in the PSL group was higher than that in the non-PSL group (3.56 ± 0.45 vs. 2.77 ± 0.31, p < 0.001). In logistic regression analysis, VBQ score (odds ratio, 3.425; 95% confidence interval, 1.552–8.279) were identified as independent risk factors for screw loosening. The area under the receiver operating characteristic curve for VBQ score predicting PSL was 0.819 (p < 0.05), with the optimal threshold of 3.15 (sensitivity, 83.1%; specificity, 80.5%).
Conclusion The VBQ score can independently predict postoperative screw loosening in patients undergoing lumbar dynamic pedicle screw fixation with PEEK rods, and its predictive value is comparable to HU value.
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Neurospine 2024;21(2):458-473. Published online June 30, 2024
Adult degenerative scoliosis (ADS) is a coronal plane deformity often accompanied by sagittal plane malalignment. Surgical correction may involve the major and/or distally-located fractional curves (FCs). Correction of the FC has been increasingly recognized as key to ameliorating radicular pain localized to the FC levels. The present study aims to summarize the literature on the rationale for FC correction in ADS. Three databases were systematically reviewed to identify all primary studies reporting the rationale for correcting the FC in ADS. Articles were included if they were English full-text studies with primary data from ADS ( ≥ 18 years old) patients. Seventy-four articles were identified, of which 12 were included after full-text review. Findings suggest FC correction with long-segment fusion terminating at L5 increases the risk of distal junctional degeneration as compared to constructs instrumenting the sacrum. Additionally, circumferential fusion offers greater FC correction, lower reoperation risk, and shorter construct length. Minimally invasive surgery (MIS) techniques may offer effective radiographic correction and improve leg pain associated with foraminal stenosis on the FC concavity, though experiences are limited. Open surgery may be necessary to achieve adequate correction of severe, highly rigid deformities. Current data support major curve correction in ASD where the FC concavity and truncal shift are concordant, suggesting that the FC contributes to the patient’s overall deformity. Circumferential fusion and the use of kickstand rods can improve correction and enhance the stability and durability of long constructs. Last, MIS techniques show promise for milder deformities but require further investigation.
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Objective Hand clumsiness and reduced hand dexterity can signal early signs of degenerative cervical myelopathy (DCM). While the 10-second grip and release (10-s G&R) test is a common clinical tool for evaluating hand function, a more accessible method is warranted. This study explores the use of deep learning-enhanced hand grip and release test (DL-HGRT) for predicting DCM and evaluates its capability to reduce the duration of the 10-s G&R test.
Methods The retrospective study included 508 DCM patients and 1,194 control subjects. Propensity score matching (PSM) was utilized to minimize the confounding effects related to age and sex. Videos of the 10-s G&R test were captured using a smartphone application. The 3D-MobileNetV2 was utilized for analysis, generating a series of parameters. Additionally, receiver operating characteristic curves were employed to assess the performance of the 10-s G&R test in predicting DCM and to evaluate the effectiveness of a shortened testing duration.
Results Patients with DCM exhibited impairments in most 10-s G&R test parameters. Before PSM, the number of cycles achieved the best diagnostic performance (area under the curve [AUC], 0.85; sensitivity, 80.12%; specificity, 74.29% at 20 cycles), followed by average grip time. Following PSM for age and gender, the AUC remained above 0.80. The average grip time achieved the highest AUC of 0.83 after 6 seconds, plateauing with no significant improvement in extending the duration to 10 seconds, indicating that 6 seconds is an adequate timeframe to efficiently evaluate hand motor dysfunction in DCM based on DL-HGRT.
Conclusion DL-HGRT demonstrates potential as a promising supplementary tool for predicting DCM. Notably, a testing duration of 6 seconds appears to be sufficient for accurate assessment, enhancing the test more feasible and practical without compromising diagnostic performance.
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Spinal robotics have the potential to improve the consistency of outcomes in adult spinal deformity (ASD) surgery. The objective of this paper is to assess the accuracy of pedicle and S2 alar-iliac (S2AI) screws placed with robotic guidance in ASD patients. PubMed Central, Google Scholar, and an institutional library database were queried until May 2023. Articles were included if they described ASD correction via robotic guidance and pedicle and/or S2AI screw accuracy. Articles were excluded if they described pediatric/adolescent spinal deformity or included outcomes for both ASD and non-ASD patients without separating the data. Methodological quality was assessed using the Newcastle-Ottawa scale. Primary endpoints were pedicle screw accuracy based on the Gertzbein-Robbins Scale and self-reported accuracy percentages for S2AI screws. Data were extracted for patient demographics, operative details, and perioperative outcomes and assessed using descriptive statistics. Five studies comprising 138 patients were included (mean age 66.0 years; 85 females). A total of 1,508 screws were inserted using robotic assistance (51 S2AI screws). Two studies assessing pedicle screws reported clinically acceptable trajectory rates of 98.7% and 96.0%, respectively. Another study reported a pedicle screw accuracy rate of 95.5%. Three studies reported 100% accuracy across 51 total S2AI screws. Eight total complications and 4 reoperations were reported. Current evidence supports the application of robotics in ASD surgery as safe and effective for placement of both screw types. However, due to the paucity of data, a comprehensive assessment of its incremental benefit over other techniques cannot be made. Further work using expanded cohorts is merited.
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Objective The effect on fat infiltration (FI) of paraspinal muscles in degenerative lumbar spinal diseases has been demonstrated except for spinopelvic parameters. The present study is to identify the effect of spinopelvic parameters on FI of paraspinal muscle (PSM) and psoas major muscle (PMM) in patients with degenerative lumbar spondylolisthesis.
Methods A single-center, retrospective cross-sectional study of 160 patients with degenerative lumbar spondylolisthesis (DLS) and lumbar stenosis (LSS) who had lateral full-spine x-ray and lumbar spine magnetic resonance imaging was conducted. PSM and PMM FIs were defined as the ratio of fat to its muscle cross-sectional area. The FIs were compared among patients with different pelvic tilt (PT) and pelvic incidence (PI), respectively.
Results The PSM FI correlated significantly with pelvic parameters in DLS patients, but not in LSS patients. The PSM FI in pelvic retroversion (PT > 25°) was 0.54 ± 0.13, which was significantly higher in DLS patients than in normal pelvis (0.41 ± 0.14) and pelvic anteversion (PT < 5°) (0.34 ± 0.12). The PSM FI of DLS patients with large PI ( > 60°) was 0.50 ± 0.13, which was higher than those with small ( < 45°) and normal PI (0.37 ± 0.11 and 0.36 ± 0.13). However, the PSM FI of LSS patients didn’t change significantly with PT or PI. Moreover, the PMM FI was about 0.10–0.15, which was significantly lower than the PSM FI, and changed with PT and PI in a similar way of PSM FI with much less in magnitude.
Conclusion FI of the PSMs increased with greater pelvic retroversion or larger pelvic incidence in DLS patients, but not in LSS patients.
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Neurospine 2024;21(1):253-260. Published online January 31, 2024
Objective To evaluate preoperative disability’s influence on patient-reported outcomes (PROs) following surgery for degenerative spondylolisthesis (DS).
Methods DS patients who underwent surgical intervention were retrospectively identified from a single-surgeon spine registry. Cohorts based on Oswestry Disability Index (ODI) < 41 (milder disability) and ≥ 41 (severe disability) were created. Demographic differences were accounted for with 1:1 propensity score matching. For the matched sample, perioperative and PRO data were additionally collected. PROs assessed included mental health, physical function, pain, and disability. Pre- and up to 2-year postoperative PROs were utilized. Average time to final follow-up was 15.7 ± 8.8 months. Improvements in PROs and minimal clinically important difference (MCID) rates were calculated. Continuous variables were compared through Student t-test and categorical variables were compared through chi-square tests.
Results Altogether, 214 patients were included with 77 in the milder disability group. The severe disability group had worse postoperative day (POD) 1 pain scores and longer hospital stays (p ≤ 0.038, both). The severe disability group reported worse outcomes pre- and postoperatively (p < 0.011, all), but had greater average improvement in 12-item Short Form health survey mental composite score (SF-12 MCS), 9-Item Patient Health Questionnaire (PHQ-9), visual analogue scale (VAS)-back, and ODI by 6 weeks (p ≤ 0.037, all) and PHQ-9, VAS-back and ODI by final follow-up (p ≤ 0.015, all). The severe disability cohort was more likely to achieve MCID for SF-12 MCS, PHQ-9, and ODI (p ≤ 0.003, all).
Conclusion Patients with greater baseline disability report higher POD 1 pain and discharge later than patients with milder disability. While these patients report inferior physical/mental health before and after surgery, they report greater improvements in mental health and disability postoperatively.
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Objective Using segmental dynamic and static factors, we aimed to elucidate the pathogenesis and relationship between ossification of the posterior longitudinal ligament (OPLL) and the severity of cervical myelopathy.
Methods Retrospective analysis of 163 OPLL patients' 815 segments. Imaging was used to evaluate each segmental space available for the spinal cord (SAC), OPLL diameter, type, bone space, K-line, the C2–7 Cobb angle, each segmental range of motion (ROM), and total ROM. Magnetic resonance imaging was used to evaluate spinal cord signal intensity. Patients were divided into the myelopathy group (M group) and the without myelopathy group (WM group).
Results Minimal SAC (p = 0.043), (C2–7) Cobb angle (p = 0.004), total ROM (p = 0.013), and local ROM (p = 0.022) were evaluated as an independent predictor of myelopathy in OPLL. Different from the previous report, the M group had a straighter whole cervical spine (p < 0.001) and poorer cervical mobility (p < 0.001) compared to the WM group. Total ROM was not always a risk factor for myelopathy, as its impact depended on SAC, when SAC > 5 mm, the incidence rate of myelopathy decreased with the increase of total ROM. Lower cervical spine (C5–6, C6–7) showing increased “Bridge-Formation,” along with spinal canal stenosis and segmental instability (C2–3, C3–4) in the upper cervical spine, could cause myelopathy in M group (p < 0.05).
Conclusion Cervical myelopathy is linked to the OPLL’s narrowest segment and its segmental motion. The hypermobility of the C2–3 and C3–4, contributes significantly to the development of myelopathy in OPLL.
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Objective Facet articular irregularity is associated with rapidly progressive degenerative cervical myelopathy (DCM). However, its significance compared with other known risk factors remains unknown. Therefore, this retrospective study aimed to clarify the potential impact of facet articular irregularity as a risk factor for rapid DCM progression.
Methods This study included 141 consecutive patients with DCM who underwent surgical treatment at our institution. Clinical variables and radiological findings related to DCM progression were collected. Imaging findings were analyzed at the segmental level of myelopathy in each case. The patients were divided into 2 groups based on the presence or absence of rapid DCM progression, and independent risk factors were determined using logistic regression analyses.
Results Overall, 131 patients with a mean age of 63.9 ± 12.6 years were analyzed; 27 patients (20.6%) were classified into the rapid DCM progression group. The mean age was significantly higher in the rapid progression group than in the slow progression group (72.4 ± 9.6 vs. 61.7 ± 12.4, p < 0.001). According to univariate analysis, facet articular irregularity, dynamic segmental translation (≥ 1.6 mm), upper cervical spine involvement above C4–5, history of cerebrovascular events, preceding minor trauma, local lordotic angle (≥ 4.5°), diabetes, hypertension, ligamentum flavum hypertrophy, and age were independent risk factors. Additionally, multivariate analysis showed that facet articular irregularity was the highest risk factor for rapid DCM progression (p = 0.001).
Conclusion Facet articular irregularity is the most clinically significant finding among the known risk factors in patients with rapid DCM progression.
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Objective To evaluate cervical facet joint degeneration using a newly developed classification, investigate its prevalence and relationship with cervical degenerative spondylolisthesis, and clarify its clinical significance in patients with degenerative cervical myelopathy (DCM).
Methods This study included 145 consecutive patients with DCM who underwent surgical treatment. Clinical variables and radiological findings were analyzed. A new 6-grade computed tomography (CT) classification for cervical facet joint degeneration was adapted, and its prevalence was evaluated by categorizing the joints into those at responsible and those at nonresponsible spinal segmental levels. We evaluated the association between rapidly progressive myelopathy and the presence of significant facet joint degeneration or spondylolisthesis at the responsible segmental level.
Results Finally, 140 patients with a mean age of 64.1 ± 12.8 years were analyzed. The prevalence of grade 1, 2, 3, 4, 5A, and 5B classification in all facet joints was 72.0%, 9.5%, 10.9%, 4.3%, 2.9%, and 0.4%, respectively. There was a statistically significant difference in the distribution of CT grades between the joints at the responsible and nonresponsible segmental levels (p < 0.001), with a high prevalence of grade 4 or 5B degeneration at the responsible segmental level, reflecting articular irregularity. There was also a statistically significant relationship between rapidly progressive myelopathy and grade 4 or 5B degeneration at the responsible segmental level (p < 0.001), but not between rapidly progressive myelopathy and spondylolisthesis (p = 0.255).
Conclusion This novel CT classification for facet joints deserves additional evaluation in patients with DCM. Abnormal findings on the articular surfaces might be related to the progression of myelopathy.
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Objective The 5-repetition-sit-to-stand (5R-STS) test is an objective test of functional impairment- commonly used in various diseases, including lumbar degenerative disc diseases. It is used to measure the severity of disease and to monitor recovery. We aimed to evaluate reference values for the test, as well as factors predicting 5R-STS performance in healthy adults.
Methods Healthy adults ( > 18 years of age) were recruited, and their 5R-STS time was measured. Their age, sex, weight, height, body mass index (BMI), smoking status, education level, work situation and EuroQOL-5D Healthy & Anxiety category were recorded. Linear regression analysis was employed to identify predictors of 5R-STS performance.
Results We included 172 individuals with mean age of 39.4 ± 14.1 years and mean BMI of 24.0 ± 4.0 kg/m2. Females constituted 57%. Average 5R-STS time was 6.21 ± 1.92 seconds, with an upper limit of normal of 12.39 seconds. In a multivariable model, age (regression coefficient [RC], 0.07; 95% confidence interval [CI], 0.05/0.09; p < 0.001), male sex (RC, -0.87; 95% CI, -1.50 to -0.23; p = 0.008), BMI (RC, 0.40; 95% CI, 0.10–0.71; p = 0.010), height (RC, 0.13; 95% CI, 0.04–0.22; p = 0.006), and houseworker status (RC, -1.62; 95% CI, -2.93 to -0.32; p = 0.016) were significantly associated with 5R-STS time. Anxiety and depression did not influence performance significantly (RC, 0.82; 95% CI, -0.14 to 1.77; p = 0.097).
Conclusion The presented reference values can be applied as normative data for 5R-STS in healthy adults, and are necessary to judge what constitutes abnormal performance. We identified several significant factors associated with 5R-STS performance that may be used to calculate individualized expected test times.
Citations
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