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Background: During the preoperative evaluation of a patient being considered for spinal surgery, Dual-energy x-ray absorptiometry (DEXA) has been traditionally used to diagnose poor bone mineral density (BMD) as a risk factor. As ordering a DEXA can add cost and delay diagnosis, spine surgeons have more recently began to use Hounsfield Units (HU) measured on computed tomography scans (CT) as a measure of BMD. The aim of our study was to evaluate associations between DEXA and HU on lumbar spine CT scans. Methods: Forty-two patients (32 female, 10 male, mean age = 67.7 years) with DEXA and lumbar spine CT scans performed within one year of each other were identified. DEXA T-scores were collected from the hip, forearm and L1-L4. HU was determined using the maximum region of interest within the cancellous area in the mid-vertebral body from L1-L4 in the sagittal and axial planes. Results: Using the lowest T-score, 8 (19 %) cases were osteoporotic and 25 (60 %) were osteopenic. Statistically significant differences in HU were seen in osteoporotic cases (Axial HU = 59.2, Sagittal HU = 61.1, p = 0.006) compared to osteopenic (Axial HU = 119.8, Sagittal HU = 122.9) and normal cases (Axial HU = 141.2, Sagittal HU = 142.3). There were moderate associations between the spine T-scores and CT HUs (Axial HU:r2 = 0.50, Sagittal HU:r2 = 0.49, p

Introduction: The Quality of Recovery (QoR-15) score evaluates patient's recovery after surgery and anesthesia. There is a lack of studies focusing on the patients' quality of recovery in the early post-discharge phase after elective lumbar spine surgery. Research question: We aimed to identify the QoR-15 score in patients who underwent surgery for degenerative low back conditions. Furthermore, we aimed to identify the individual items of the QoR-15 that are crucial for the patients’ quality of recovery. Material and methods: The study was conducted at a spine center in Denmark from December 2021 to September 2022. Data were collected, using a mobile health application, preoperatively and at 3 time points after hospital discharge. Descriptive analysis followed by within-subjects longitudinal repeated measures was conducted. The individual items of the QoR-15 score were explored using a heatmap. Results: Data from 46 patients were analysed. The mean QoR-15 sum score at baseline was 105.4 ± 18.3. The mean QoR-15 sum scores were 108.1 ± 19.2 on post-discharge day 1, 118.5 ± 17.4 on day 7, and 120.7 ± 20.9 on day 14. The mean QoR-15 score from day 1 to day 7 improved significantly. Eight of the 15 items influenced the overall QoR-15 score. Discussion and conclusion: This study applied the QoR-15 score in lumbar spine surgery patients. We identified specific items from the QoR-15 scale that are crucial to improving patients’ recovery after hospital discharge. Further research is needed to identify specific needs in the post-discharge period in this group of patients.

Background: Patients with a pseudarthrosis after anterior cervical discectomy and fusion (ACDF) may have concurrent adjacent segment disease (ASD). Although prior studies have shown posterior cervical decompression and fusion (PCDF) is effective in repairing pseudarthrosis, improvement in patient reported outcomes (PROs) has been marginal. The aim of this study is to evaluate the effectiveness of PCDF in achieving symptom relief in patients with pseudarthrosis after ACDF and whether that is altered by the additional treatment of ASD. Methods: Thirty-two patients with pseudarthrosis were compared with 31 patients with pseudarthrosis and concurrent ASD after ACDF who underwent revision PCDF with a minimum 1-year follow-up. Primary outcomes measures included the neck disability index (NDI), and numerical rating scale (NRS) scores for neck and arm pain. Secondary measures included estimated blood loss (EBL), operating room (OR) time, and length of stay. Results: Demographics between cohorts were similar, however there was a significantly higher mean body mass index (BMI) in the group with concurrent ASD (32.23 vs. 27.76, p=.007). Patients with concurrent ASD had more levels fused during PCDF (3.7 vs. 1.9, p

Background: Novel methods of bone density assessment using computed tomography (CT) and magnetic resonance imaging (MRI) have been increasingly reported in the spine surgery literature. Correlations between these newer measurements and traditional Dual-Energy X-ray Absorptiometry (DEXA) is not well known. The purpose of this study is to perform an updated systematic review of correlations between bone mineral density (BMD) from CT or MRI and DEXA. Methods: Articles published between 2011 and 2021 that reported correlations between the CT-HU or MRI measurements to DEXA t-scores or BMD of lumbar spine or hip were included in this systematic review. Results: A total of 25 studies (15 CT, 10 MRI) met the inclusion criteria with a total number of 2,745 patients. The pooled correlation coefficient of spine CT-HU versus spine DEXA, spine CT-HU versus hip DEXA and spine CT-HU versus lowest t-score were 0.60, 0.50 and 0.60 respectively. Regarding spine DEXA parameters, the pooled r2 for spine CT-HU versus spine t-score was 0.684 and spine CT-HU versus spine BMD was 0.598. Furthermore, in patients undergoing spine surgery in four studies, the pooled correlation between spine CT and spine DEXA was (r2: 0.64). In MRI studies, the pooled r2 of spine MRI versus spine DEXA and spine MRI versus hip DEXA were -0.41 and -0.44 respectively. Conclusions: CT-HU has stronger correlations with DEXA than MRI measurements. Lumbar CT-HU has the highest pooled correlation (r2 = 0.6) with both spine DEXA and lowest skeletal t-score followed by lumbar CT-HU with hip DEXA (r2 = 0.5) and lumbar MRI with hip (r2 = 0.44) and spine (r2 = 0.41) DEXA. Both imaging modalities achieved only a moderate correlation with DEXA. Few studies in both modalities have investigated the correlation in spine surgery populations and the available data shows that the correlations are worse in the degenerative spine population. A careful interruption of CT HU and MRI measurement when evaluation of BMD as they only moderately correlated with DEXA scores. At this time, it is unclear which modality is a better predictor of mechanical complications and clinical outcomes in spine surgery patients.

Introduction: Instrumented lumbar fusion by either the anterior or transforaminal approach has different advantages and disadvantages. Few studies have compared PatientReported Outcomes Measures (PROMs) between stand-alone anterior lumbar interbody fusion (SA-ALIF) and transforaminal lumbar interbody fusion (TLIF). Research question: This is a register-based dual-center study on patients with severe disc degeneration (DD) and low back pain (LBP) undergoing single-level SA-ALIF or TLIF. Comparing PROMs, including disability, quality of life, back- and leg-pain and patient satisfaction two years after SA-ALIF or TLIF, respectively. Material and methods: Data were collected preoperatively and at one and two-year follow-up. The primary outcome was Oswestry Disability Index (ODI). The secondary outcomes were patient satisfaction, walking ability, visual analog scale (VAS) scores for back and leg pain, and quality of life (QoL) measured by the European Quality of Life-5 Dimensions (EQ-5D) index score. To reduce baseline differences between groups, propensity-score matching was employed in a 1:1 fashion. Results: 92 patients were matched, 46 S A-ALIF and 46 TLIF. They were comparable preoperatively, with no significant difference in demographic data or PROMs (P > 0.10). Both groups obtained statistically significant improvement in the ODI, QoL and VAS-score (P

Abstract Background Lumbar disc herniation (LDH) is a common problem. When surgical treatment is required, the intervention is typically decompression without fusion. Successful return-to-work (RTW) is a standard expectation with these limited procedures. Occasionally, the size or location of the disc herniation suggests the need for fusion, but the inability to RTW is a significant concern in these cases. The purpose of this study is to determine if the addition of lumbar fusion, as compared to decompression alone, will substantially diminish RTW in patients with lumbar disc herniation. Methods This is a longitudinal cohort study using prospectively collected data from the Quality and Outcomes Database (QOD). Patients with LDH, eligible to RTW (not retired, a student, or on disability) with complete 12-month follow-up data, were identified. Standard demographic and surgical variables, patient-reported outcomes (PROs), and RTW status at 3 and 12 months were collected. Results Of the 5062 patients identified, 4560 (90%) had decompression alone and 502 (10%) had a concurrent fusion. Age and gender were similar in the two groups. The fusion group had worse back pain (NRS 6.52 vs. 5.96) and less leg pain (6.31 vs. 7.01) at baseline compared to the no fusion group. Statistically significant improvement in all PROs was seen in both groups. RTW at 3 months post-op was seen in 85% of decompression cases and 66% of cases with supplemental fusion. At 12 months post-op, RTW increased to 93% and 82%, respectively. Conclusion The need for fusion in LDH cases is unusual, seen in only 10% of cases in this series. The addition of fusion decreased the RTW rate from 85 to 66% at 3 months and from 93 to 82% at 12 months post-op. While the difference is significant, the ultimate deterioration in RTW may be less than anticipated. A reasonable RTW rate can still be expected in the rare patient who requires fusion as part of their treatment for LDH.

Abstract Background Recent work has shed light on the potential benefits of cannabinoids for multimodal pain control following orthopedic procedures. The objective of this review was to summarize the available evidence of analgesic and opioid-sparing effects cannabinoids have in orthopedic surgery and identify adverse events associated with their use. Methods A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines including PubMed, EMBASE, MEDLINE, PsycINFO, and Google Scholar was performed to include all primary, therapeutic studies published on the use of cannabis, and cannabis-derived products in orthopedic surgery. Results The literature review returned 4292 citations. Thirteen publications were found to meet inclusion criteria. Four randomized controlled trials were evaluated while the remaining studies were of quasi-experimental design. Conclusion Research on cannabinoids in orthopedic surgery is mostly of a quasi-experimental nature and is mainly derived from studies where orthopedics was not the primary focus. The overall results demonstrate potential usefulness of cannabinoids as adjunctive analgesics and in mitigating opioid use. However, the current evidence is far from convincing. There is a need to produce rigorous evidence with well-designed randomized controlled trials specific to orthopedic surgery to further establish these effects.

Background: Temperature elevation, a classic marker of infection and local temperature elevation, might be a useful predictor of early infection. However temperature measurement around the spine is not readily accessible. The purpose of this study was to explore whether a temperature sensing implant might reproducibly detect local temperature change associated with peri-implant wound infection, in a rabbit model. Methods: Twelve adult rabbits were implanted with a spinal screw-rod construct. Temperature probes were placed at the implantation site as well as at a separate scapular site away from the surgical site to serve as control. Animals were inoculated with S. aureus: group 1 (saline control), group 2 (low dose 1 × 102 CFU/site), group 3 (medium dose 1 × 104 CFU/site), and group 4 (high dose 1 × 106 CFU/site) and monitored for 7 days prior to euthanasia. Results: The scapular control temperature and implant site temperature in the non-infected animals remained similar throughout the study period. Both the scapular control and implant site temperatures were elevated in the infected animals compared to the non-infected animals. There was a statistically significant difference in the scapular control temperature and implant site temperature in all infected animals but not in the non-infected animals. Difference in temperature elevation between implant site and control scapular site were greatest for the animals with worst clinical appearance during the post-mortem evaluation. Conclusions: This rabbit model demonstrates that local temperature measured in proximity to a spinal implant is elevated in the presence of infection with greater elevations associated with worse infections. Availability of an implantable temperature sensor may yield valuable information for the assessment and treatment of suspected spinal wound infection in the clinical setting.

Abstract Background Shared decision making (SDM) is a systematic approach aimed at improving patient involvement in preference-sensitive health care decisions. Choosing between surgical or non-surgical treatment for lumbar disc herniation, can be difficult as the evidence of a superior treatment is unclear, which makes it a preference-sensitive decision. The objectives of this study was therefore to assess the degree of SDM and afterwards to develop and test a patient decision aid (PtDA) to support SDM during the clinical encounter between surgeon and patient, when patients choose between surgical and non-surgical treatment for Lumbar disc herniation (LDH). Methods The study was conducted in four steps. 1)Assessment of the extent to which SDM was practiced in the spine clinic.2)Development of a PtDA to support SDM.3)Testing its usability and acceptability amongst potential users (patients).4)Pilot-test of its usability in the clinical setting. Results Results from our small baseline study (n = 40) showed that between a third and two-thirds of the patients reported not being fully engaged in a shared decision. A pre-designed template (BESLUTNINGSHJÆLPER™) was adapted to support the decision about whether or not to have surgery for LDH. Testing the prototype with patients led to minor refinements. A subsequent pilot test of its usability in a clinical setting achieved positive responses from both patients and clinicians. Conclusion Our baseline study demonstrated that SDM was not universally practiced in the clinic. The PtDA we have developed was rated as acceptable and usable by both patients and clinicians for helping those with LDH choose between surgical or non- surgical treatment. This tool now requires further testing to assess its effectiveness.

Background: The Romberg test is used to identify balance issues in patients with Cervical Spondylotic Myelopathy (CSM), but has subjective interpretation. The purpose of this study is to evaluate force plate pressure readings during a Romberg test to quantify postural control. Methods: Quantitative Romberg force plate readings with eyes open and closed in patients with CSM were obtained and changes in balance measurements were compared to a normal population (N = 28, mean age 39 ± 7 years). Results: We identified 30 CSM patients with a mean age of 58 ± 10 years. Majority of patients presented with pain (90%) and neurologic symptoms (83%). Cord compression on imaging was identified in 90%. Mean eyes closed Romberg measurements were larger compared to eyes open measurements in CSM patients (p

Objective: Posterior interbody fusion is commonly performed for degenerative lumbar conditions. A minimally invasive technique of midline exposure limited only to the facets and fixation with laterally directed cortical bone trajectory (CBT) screws was introduced with the intent of decreasing surgical morbidity. The purpose of this study was to determine if posterior interbody fusion with this limited midline exposure will have less blood loss and shorter operative times (i.e., can be considered minimally invasive) compared to traditional open transforaminal interbody fusion. Methods: A consecutive single-surgeon series of patients who underwent posterior interbody fusion with either a navigated, midline only exposure (MidLIF) or full, traditional open, exposure of the transverse processes with a posterolateral fusion (open TLIF) were identified. Demographic, peri-operative data, patient reported outcomes (PROs), and reoperation/readmission rates were collected and compared. Results: There were 29 cases in the MidLIF and 27 in the open TLIF group. Both groups were similar with respect to surgical indications, age, BMI, gender, ASA grade and operative level. The MidLIF group had significantly lower estimated blood loss (266 vs. 446 cc, p = 0.003), shorter operative time (170 vs. 210 minutes, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.016) compared to the open TLIF group. A sub-analysis of single-level cases showed similar findings with significantly lower estimated blood loss (247 vs. 411 cc, p = 0.10), shorter operative time (159 vs. 199 min, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.023) in the MidLIF group. Patient reported outcomes at 6 weeks, 3 months, 6 months, 12 months and 24 months post-operative favored MidLIF with significantly greater ODI improvements at both 6 weeks and 12 months; and lower ODI and back pain at both 12 months and 24 months. Conclusions: MidLIF had lower blood loss and shorter operative time compared to the traditional open TLIF technique. These differences compare well to reported values in the literature for tubular minimally-invasive TLIF. Patient reported outcomes from 6 weeks to 24 months post-operative, hospital length of stay, and reoperation/readmission rates all favored MidLIF compared to traditional open TLIF.

Abstract Spinal cord stimulators (SCSs) have long been in use as a modality for the management of numerous pain pathologies. Along with commonly anticipated morbidities such as displacement, failure (due to fracture or breakage), or infection, there have also been rare but well-documented complications of fibrous scarring, resulting in spinal cord compression. This is the first known case that demonstrates osteolysis and bony destruction of the vertebrae adjacent to the SCS along with the foreign-body granulomatous reaction. A 61-year-old man who underwent prior posterior cervical implantation with an SCS followed by multiple revisions presented with progressive paresthesias, numbness, and weakness of his upper extremities 10 years later. The SCS was removed followed by decompression, and instrumented fusion of the cervical spine. Histopathologic analysis reveals foreign-body reaction to the SCS and its silicone debris. Tissue cultures were negative for bacterial, fungal, or mycobacterial infection. No malignancy was seen. The current case illustrates the inherent possibility of foreign-body granulomatous reactions with SCS and its silicone particulate matter, made unique in this instance by the associated bony destruction of the adjacent vertebrae.

STUDY DESIGN.: Retrospective cohort study. OBJECTIVE.: To determine the effect on fusion of adding platelet gel to autologous iliac crest graft. SUMMARY OF BACKGROUND DATA.: Platelet gel is an osteoinductive material prepared by ultra-concentration of platelets and contains multiple growth factors. Proprietary commercial methods are available for harvesting autologous platelet gel concentrates for use as graft supplement in spine fusions. METHODS.: We reviewed 76 consecutive patients who underwent instrumented posterolateral lumbar fusion with autologous iliac crest bone graft mixed with autologous growth factor (AGF). A control group was randomly selected from patients who underwent instrumented posterolateral lumbar fusion with autologous bone graft alone. The groups were matched for age, sex, smoking history, and number of levels fused. Demographic, surgical, and clinical data were collected from medical records. Diagnosis of nonunion was based on exploration during revision surgery or evidence of nonunion on computerized tomography. The Fisher exact test was used to compare fusion rates. RESULTS.: In both groups, mean age was 50 years, and 24% were smokers. The nonunion rate was 25% in the AGF group and 17% in the control group. This difference was not statistically significant (P = 0.18). CONCLUSIONS.: Platelet gel preparation requires blood draws from the patient. This procedure adds to the risk and cost of surgery. The technique for AGF harvest evaluated in this study provides the highest concentration of platelets among the commercially available methods. Despite this, we showed that platelet gel failed to enhance fusion rate when added to autograft in patients undergoing instrumented posterolateral spinal fusion. The authors do not recommend the use of platelet gel to supplement autologous bone graft during instrumented posterolateral spinal fusion. [ABSTRACT FROM AUTHOR]

SUMMARY: STUDY DESIGN Case series.OBJECTIVES The results of surgical treatment of osteomyelitis with anterior debridement and fusion followed by delayed posterior stabilization and fusion are presented.METHODS Forty-two patients with vertebral osteomyelitis are presented. There were 5 cervical, 12 thoracic, 1 thoracolumbar, 19 lumbar, and 5 lumbosacral lesions. The most frequently identified organism was Staphylococcus aureus. Most patients had significant comorbidities, including diabetes, or were immunocompromised. Ninety percent had elevated erythrocyte sedimentation rates and C-reactive proteins, while white blood cell counts were less reliably elevated. Imaging studies included radiographs, CT scans, and MRIs. All patients were treated with anterior debridement and strut grafting followed by 14.4 days of intravenous antibiotics and delayed instrumented posterior fusions and received 6 weeks of intravenous antibiotics after surgery.RESULTS All patients had resolution of their infections with no recurrence. There were two deaths. Neurologic deficits resolved in all patients. The diagnosis of pyogenic vertebral osteomyelitis is frequently delayed and presents a significant surgical challenge. The indications for surgical debridement were neurologic compromise, failed medical treatment, soft tissue extension, extensive vertebral body and disc space destruction, and progressive deformity. Many of these patients were severely ill at presentation and required urgent treatment. Anterior debridement and fusion followed by intravenous antibiotics allows for restoration of anterior column support and control of the infection before posterior instrumentation and fusion.CONCLUSION This study demonstrates that anterior surgical debridement with fusion, followed by a period of intravenous antibiotics and delayed instrumented posterior fusion, is highly effective in the treatment of pyogenic osteomyelitis that has failed medical management. [ABSTRACT FROM AUTHOR]

Background: Controversy exists regarding the ability of posterior (transforaminal) lumbar interbody fusion (PLIF/TLIF) to achieve lordosis. We hypothesized that an interbody device (IBD) designed for positioning in the anterior disc space produces greater lordosis than IBDs designed for straight-in positioning. The purpose of this study is to determine if using either an anterior-position or straight-in position IBD design were associated with successful achievement of postoperative lordosis. Methods: A consecutive series of patients undergoing a undergoing a single-level, posterior open midline (transforaminal) lumbar interbody fusion procedure for degenerative spine conditions during a time period when the two types of interbody devices were being used at surgeon discretion were identified from a multi-surgeon academic training center. Patient demographics and radiographic measures including surgical level lordosis (SLL), anterior disc height, middle disc height, posterior disc height, IBD height, and IBD insertion depth were measured on preop, immediate postop, and one-year postop standing radiographs using PACS. Group comparison and regression analysis were performed using SPSS. Results: Sixty-one patients were included (n=37 anterior, n=34 straight-in). Mean age was 59.8±8.7 years, 32 (52%) were female. There was no difference between IBD type (anterior vs. straight-in) for mean Pre-op SLL (19±7° vs. 20±6°, p=0.7), Post-op SLL (21±5° vs 21±6°, p=0.5), or Change in SLL (2±4° vs. 1±5°, p=0.2). Regression analysis showed that Pre-op SLL was the only variable associated with Change in SLL (Beta = negative 0.48, p=0.000). While the mean Change in SLL could be considered clinically insignificant, there was wide variability: from a loss of 9° to a gain of 13°. Gain of lordosis >5° only occurred when Pre-op SLL was 5° only occurred when Pre-op SLL was >21°. Conclusions: While group averages showed an insignificant change in segmental lordosis following a posterior (transforaminal) interbody fusion regardless of interbody device type, pre-operative lordosis was correlated with a clinically significant change in segmental lordosis. Preoperative hypolordotic discs were more likely to gain significant lordosis, while preoperative hyperlordotic discs were more likely to lose significant lordosis. Surgeon awareness of this tendency can help guide surgical planning and technique.