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Abstract Purpose The relationship between delayed ambulation (DA) and postoperative adverse events (AEs) following transforaminal lumbar interbody fusion (TLIF) in elderly patients remains elusive. The aim of our study was to evaluate the effects of DA on the postoperative AEs including complications, readmission and prolonged length of hospital stay (LOS). Methods This was a retrospective analysis of a prospectively established database of elderly patients (aged 65 years and older) who underwent TLIF surgery. The early ambulation (EA) group was defined as patients ambulated within 48 h after surgery, whereas the delayed ambulation (DA) group was patients ambulated at a minimum of 48 h postoperatively. The DA patients were 1:1 propensity-score matched to the EA patients based on age, gender and the number of fused segments. Univariate analysis was used to compare postoperative outcomes between the two groups, and multivariate logistic regression analysis was used to identify risk factors for adverse events and DA. Results After excluding 125 patients for various reasons, 1025 patients (≤ 48 h: N = 659 and > 48 h: N = 366) were included in the final analysis. After propensity score matching, there were 326 matched patients in each group. There were no significant differences in the baseline data and the surgery-related variables between the two groups (p > 0.05). The patients in the DA group had a significant higher incidence of postoperative AEs (46.0% vs. 34.0%, p = 0.002) and longer LOS (p = 0.001). Multivariate logistic regression identified that age, operative time, diabetes, and DA were independently associated with postoperative AEs, whereas greater age, higher international normalized ratio, and intraoperative estimated blood loss were identified as independent risk factors for DA. Conclusions Delayed ambulation was an independent risk factor for postoperative AEs after TLIF in elderly patients. Older age, increased intraoperative blood loss and worse coagulation function were associated with delayed ambulation.

Abstract Objective To generate a compensatory classification to evaluate sagittal spinal malalignment with lumbar degeneration. Methods We included 162 patients with low back pain who underwent full-length spinal radiography in our hospital from August 2019 to October 2021. Using full-length spine X-rays, we measured pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), thoracic kyphosis (TK), lumbar lordosis (LL), C7 slope (C7S), thoracolumbar kyphosis (TLK), and C7 sagittal vertical axis (SVA). We also recorded the Oswestry Disability Index (ODI) and visual analog scale (VAS). Patients were divided into four groups based on the SRS-Schwab classification and four other groups based on the compensatory classification. Results ODI correlated with age, SS, LL, TK, C7-SVA, SRS-Schwab classification, and compensatory classification. Lumbar VAS score correlated with LL, TK, C7-SVA, SRS-Schwab classification, and compensatory classification. Leg VAS score only correlated with LL. Hidden imbalance and imbalance with compensation had more significant PT and larger TK than balance patients. The symptoms of the four compensatory classification groups gradually worsened. Conclusion The spinal-pelvic sagittal balance in patients with lumbar degeneration based on pelvic and thoracic compensation can reflect spinal balance and symptoms. This parameter might help evaluate spine sagittal alignment in elderly patients with lumbar degeneration.

Abstract Purpose To investigate the effect of interlaminar Coflex stabilization (ICS) at various segments in the topping-off procedure on local and global spinal sagittal alignment. Methods Eighty-nine consecutive patients with degenerative lumbar spinal stenosis (DLSS) who underwent ICS and transforaminal lumbar interbody fusion (TLIF) were retrospectively reviewed. They were divided into Group A (L4-L5 ICS + L5-S1 TLIF), Group B (L3-L4 ICS + L4-S1 TLIF), and Group C (L2-L3 ICS + L3-S1 TLIF) according to their fusion levels. The measured local sagittal parameters included the implanted segmental angle (ISA), intervertebral disc angle (IDA), intervertebral foreman height (IFH), and disc height. The assessed global sagittal parameters included thoracic kyphosis, lumbar lordosis (LL), the fused segment angle (FSA), the sacral slope, the pelvic tilt, pelvic incidence, and the sagittal vertical axis. The Oswestry Disability Index (ODI) and visual analog scales (VAS) were recorded to evaluate the clinical outcomes. Results Regarding the local alignment parameters, the ISA and IDA decreased immediately after surgery in Groups A and B, followed by an increase at the last follow-up (all, P

Abstract Purpose The prevalence of degenerative spinal deformity (DSD) and the increased cost of correction surgery impose substantial burdens on the health care and insurance system. The aim of our study was to investigate the effects of the implementation of Enhanced Recovery After Surgery (ERAS) protocol on postoperative outcomes after complex spinal surgery. Methods A retrospective analysis of prospectively established database of DSD was performed. The consecutive patients who underwent open correction surgery for degenerative spinal deformity between August 2016 and February 2022 were reviewed. We extracted demographic data, preoperative radiographic parameters, and surgery-related variables. The ERAS patients were 1:1 propensity-score matched to a historical cohort by the same surgical team based on age, gender, BMI, and number of levels fused. We then compared the length of hospital stay (LOS), physiological functional recovery, and the rates of complications and readmissions within 90 days after surgery between the groups. Results There were 108 patients included, 54 patients in the ERAS cohort, and 54 patients matched control patients in the historical cohort. The historical and ERAS cohorts were not significantly different regarding demographic characteristics, comorbidities, preoperative parameters, operative time, and reoperation rate (P > 0.05). Patients in the ERAS group had significantly shorter postoperative LOS (12.0 days vs. 15.1 days, P = 0.001), average days of drain and urinary catheters placement (3.5 days vs. 4.4 days and 1.9 days vs 4.8 days, respectively), and lower 90-day readmission rate (1.8% vs. 12.9%, P = 0.027). The first day of assisted-walking and bowel movement occurred on average 1.9 days (2.5 days vs. 4.4 days, P = 0.001) and 1.7 days (1.9 days vs. 3.6 days, P = 0.001) earlier respectively in the ERAS group. Moreover, the rate of postoperative urinary retention (3.7% vs. 16.7%, P = 0.026) and surgical site infection (0% vs. 7.4%, P = 0.046) were significantly lower with ERAS protocol applied. Conclusions Our study confirmed that the ERAS protocol was safe and essential for patients undergoing thoracolumbar deformity surgery for DSD. The ERAS protocol was associated with a shorter postoperative LOS, a lower rate of 90-day readmission, less rehabilitation discharge, and less postoperative complications.

Abstract Study design Retrospective case–control study. Objectives Proximal junctional kyphosis (PJK) is a postoperative complication involving the proximal segments which is commonly seen in patients with degenerative spine diseases (DSD). The purpose of the present study was to identify predictive factors for postoperative PJK in elderly patients with DSD. Methods We reviewed elderly patients with DSD who underwent thoracolumbar fusion involving no less than 3 levels. Patients who developed PJK were propensity score-matched with patients with DSD who received the same procedure but did not develop PJK. Demographic characteristics, sagittal vertical axis (SVA), computed tomography (CT) value (Hounsfield unit), and paraspinal muscle parameters were compared between PJK and non-PJK groups. Results Eighty-three PJK and non-PJK patients were selected by propensity score matching for age, sex, history of smoking, body mass index, number of fused segments, and upper instrumented vertebra (UIV) location. SVA showed no significant difference between the two groups. In PJK group, fatty infiltration (FI) in erector spinae and multifidus was significantly greater, while the relative cross-sectional area (rCSA) of erector spinae was significantly smaller than that in non-PJK group. CT value was significantly lower in PJK group. Lower erector spinae rCSA and CT value of the UIV, higher erector spinae FI and multifidus FI were identified as predictors of postoperative PJK. Conclusions PJK is a common complication in older patients with DSD. Paraspinal muscle degeneration and low bone mineral density of the UIV are predictors of PJK. Protective measures targeting paraspinal muscles and the UIV may help prevent postoperative PJK.

Abstract Background Measurement of T1 slope (T1S) can be difficult due to the anatomical positioning of the shoulders. And thoracic inlet angle (TIA) was a morphological parameter and not changed by the position. We proposed a new parameter, TIA minus C0-7 angle (TIA-C07), to evaluate C2-7 SVA in order to overcome the T1S imperfection. Methods This was a retrospective radiological analysis of symptomatic subjects. The following cervical parameters were measured: Cervical lordosis angle (CL), C0-7 angle (C0-7), occiput-C2 lordosis angle (O-C2), C2-7 sagittal vertical axis (C2–7 SVA), TIA and TIA-C07. The Pearson correlation test was calculated, and the stepwise multiple regression analysis was conducted to determine the best predictor for C2-7 SVA. A paired sample t test was used to compare the predicted and measured C2-7 SVA. Results The mean age of 113 patients was 60.02 ± 9.67. The average O-C2, CL, C0-7, TIA, TIA-C07 and C2-C7 SVA was 29.24 ± 8.48°, 13.67 ± 11.22°, 42.91 ± 11.44°, 76.07 ± 9.54°, 33.16 ± 13.18° and 21.34 ± 11.42 mm. The predictive formula was founded: C2-7 SVA = 2.80 + 0.56 * (TIA—C07) (R = 0.645, R2 = 0.416). There was no statistical difference between the predicted and the measured C2-7 SVA (t = 0.085, P = 0.933). Conclusions TIA and C0-7 mismatch may significantly impact cervical alignment, and a greater T1A-C07 was related to a greater degree of C2-7 SVA. TIA-C07 may be a more important predictor for C2-7 SVA.

Abstract Background Enhanced recovery after surgery (ERAS) program is an evidence-based improvement over non-ERAS traditional care. The aim of the present study was to analyze the safety, feasibility, and efficacy of an ERAS program in patients over 70 years undergoing lumbar arthrodesis by comparison with non-ERAS traditional care. Methods During January 2018 to December 2018, patients enrolled received non-ERAS traditional care, while the ERAS program was implemented from January to December 2019. Demographic characteristics, comorbidities, surgical data and postoperative recovery parameters were collected from all patients. Postoperative pain scores were evaluated by visual analog scales (VAS). The clinical outcomes were length of stay (LOS), postoperative complications and postoperative pain scores. Compliance results were also collected. Result A total of 127 patients were enrolled, including 67 patients in the non-ERAS traditional care group and 60 patients in the ERAS group. The demographic characteristics and comorbidities of the two groups showed no significant differences. The LOS of patients treated with ERAS program (13.6 ± 4.0 days) was significantly less than that of patients treated with non-ERAS traditional care (15.6 ± 3.9 days) (p = 0.034). Complication rate was 8.3% in the ERAS group versus 20.9% in the non-ERAS traditional care group (p = 0.048). VAS (back) in the ERAS group was significantly lower on postoperative day (POD) 1 and POD2. Postoperative recovery parameters were improved in the ERAS group. The overall compliance with the ERAS program was 94%. Conclusions Based on our results, ERAS program is safer and more effective for elderly patients over 70 undergoing lumbar arthrodesis than non-ERAS traditional care.