A Comparison of Radiographic Alignment between Bilateral and Unilateral Interbody Cages in Patients Undergoing Transforaminal Lumbar Interbody Fusion

Lambrechts Mark James,Heard Jeremy,D’Antonio Nicholas,Bodnar John,Schneider Gregory,Bloom Evan,Canseco Jose,Woods Barrett,Kaye Ian David,Kurd Mark Faisal,Rihn Jeffrey,Hilibrand Alan,Schroeder Gregory 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.4

Study Design: Retrospective cohort study.Purpose: To compare radiographic outcomes between unilateral and bilateral cage placement in transforaminal lumbar interbody fusions (TLIF) and to determine if the rate of fusion at the 1-year postoperative point was different in patients who received bilateral versus unilateral cages.Overview of Literature: There is no clear evidence to dictate whether bilateral or unilateral cages promote superior radiographic or surgical outcomes in TLIF.Methods: Patients >18 years old who underwent primary one- or two-level TLIFs at our institution were identified and propensitymatched in a 3:1 fashion (unilateral:bilateral). Patient demographics, surgical characteristics, and radiographic outcomes, including vertebral endplate obliquity, segmental lordosis, subsidence, and fusion status, were compared between groups.Results: Of the 184 patients included, 46 received bilateral cages. Bilateral cage placement was associated with greater subsidence (1.06±1.25 mm vs. 0.59±1.16 mm, <i>p</i>=0.028) and enhanced restoration of segmental lordosis (5.74°±14.1° vs. −1.57°±10.9°, <i>p</i>=0.002) at the 1-year postoperative point, while unilateral cage placement was associated with an increased correction of endplate obliquity (−2.02°±4.42° vs. 0.24°±2.81°, <i>p</i><0.001). Bilateral cage placement was significantly associated with radiographic fusion on bivariate analysis (89.1% vs. 70.3%, <i>p</i>=0.018) and significantly predicted radiographic fusion on multivariable regression analysis (estimate, 1.35; odds ratio, 3.87; 95% confidence interval, 1.51–12.05; <i>p</i>=0.010).Conclusions: Bilateral interbody cage placement in TLIF procedures was associated with restoration of lumbar lordosis and increased fusion rates. However, endplate obliquity correction was significantly greater for patients who received a unilateral cage.

Serotonin Reuptake Inhibitor Increases Pseudarthrosis Rates in Anterior Cervical Discectomy and Fusions

Lambrechts Mark James,D'Antonio Nicholas,Toci Gregory,Karamian Brian,Pezzulo Josuhu,Farronato Dominic,Canseco Jose,Kaye Ian David,Woods Barrett,Rihn Jeffrey,Kurd Mark,Lee Joseph,Hilibrand Alan,Kepler 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.2

Study Design: Retrospective cohort.Purpose: To determine (1) the effects of serotonin reuptake inhibitors in pseudarthrosis rates after anterior cervical decompression and fusion (ACDF) and (2) to identify patient-reported outcome measures in patients taking serotonin reuptake inhibitors. Overview of Literature: Recent literature suggests that selective serotonin reuptake inhibitors (SSRIs) may inhibit fracture healing via downregulation of osteoblast differentiation. Spinal fusion supplementation with osteoblast-rich substances enhances spinal fusion, thus SSRIs may be detrimental.Methods: Patients with 1-year postoperative dynamic cervical spine radiographs following ACDF were grouped into serotonin reuptake inhibitor prescriptions (SSRI, serotonin-norepinephrine reuptake inhibitor [SNRI], or tricyclic antidepressant [TCA]) and no prescription (atypical antidepressant or no antidepressant). Pseudarthrosis was defined as ≥1 mm interspinous process motion on dynamic radiographs. Logistic regression models were controlled for confounding to analyze pseudarthrosis rates. Alpha was set at p - values of <0.05.Results: Of the 523 patients who meet the inclusion criteria, 137 (26.2%) were prescribed an SSRI, SNRI, or TCA. Patients with these prescriptions were more likely to have pseudarthrosis (p =0.008) but not a revision surgery due to pseudarthrosis (p =0.219). Additionally, these patients had worse 1-year postoperative mental component summary (MCS)-12 (p =0.015) and Neck Disability Index (NDI) (p =0.006). The multivariate logistic regression analysis identified SSRI/SNRI/TCA use (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.11–2.99; p =0.018) and construct length (OR, 1.91; 95% CI, 1.50–2.44; p <0.001) as pseudarthrosis predictors. A SSRI/SNRI/TCA prescription was a revision surgery predictor due to adjacent segment disease on univariate analysis (OR, 2.51; p =0.035) but not on multivariate logistic regression analysis (OR, 2.24; p =0.10).Conclusions: Patients taking serotonin reuptake-inhibiting antidepressants are at increased risk of worse postoperative outcome scores, including NDI and MCS-12, likely due to their underlying depression. This may contribute to their greater likelihood of having adjacent segment surgery. Additionally, preoperative use of serotonin reuptake inhibitors in patients undergoing an ACDF is a predictor of radiographic pseudarthrosis but not pseudarthrosis revision.

Incidence, Risk Factors, and Outcomes of Incidental Durotomy during Lumbar Spine Decompression with or without Fusion

Toci Gregory,Lambrechts Mark James,Issa Tariq,Karamian Brian Abedi,Siegel Nicholas,Antonio Nicholas D’,Canseco Jose,Kurd Mark,Woods Barrett,Kaye Ian David,Hilibrand Alan,Kepler Christopher,Vaccaro Ale 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.4

Study Design: Retrospective cohort study.Purpose: The primary objective of this study was to determine the incidence and risk factors for incidental durotomies during lumbar decompression surgeries. In addition, we aimed to determine the changes in patient-reported outcome measures (PROMs) based on incidental durotomy status.Overview of Literature: There is limited literature investigating the affect of incidental durotomy on patient reported outcome measures. While the majority of research does not suggest differences in complications, readmission, or revision rates, many studies rely on public databases, and their sensitivity and specificity for identifying incidental durotomies is unknown.Methods: Patients undergoing lumbar decompression with or without fusion at a single tertiary care center were grouped based on the presence of a durotomy. Multivariate analysis was performed for length of stay (LOS), hospital readmissions, and changes in PROMs. To identify surgical risk factors for durotomy, 3:1 propensity matching was performed using stepwise logistic regression. The sensitivity and specificity of the International Classification of Disease, 10th revision (ICD-10) codes (G96.11 and G97.41) were also assessed.Results: Of the 3,684 consecutive patients who underwent lumbar decompressions, 533 (14.5%) had durotomies, and a complete set of PROMs (preoperative and 1-year postoperative) were available for 737 patients (20.0%). Incidental durotomy was an independent predictor of increased LOS but not hospital readmission or worse PROMs. The durotomy repair method was not associated with hospital readmission or LOS. However, repair with collagen graft and suture predicted reduced improvement in Visual Analog Scale back (<i>β</i> =2.56, <i>p</i>=0.004). Independent risk factors for incidental durotomies included revisions (odds ratio [OR], 1.73; <i>p</i><0.001), levels decompressed (OR, 1.11; <i>p</i>=0.005), and preoperative diagnosis of spondylolisthesis or thoracolumbar kyphosis. The sensitivity and specificity of ICD-10 codes were 5.4% and 99.9%, respectively, for identifying durotomies.Conclusions: The durotomy rate for lumbar decompressions was 14.5%. No differences in outcomes were detected except for increased LOS. Database studies relying on ICD codes should be interpreted with caution due to the limited sensitivity in identifying incidental durotomies.

Modified Frailty Index as a Predictor of Postoperative Complications and Patient-Reported Outcomes after Posterior Cervical Decompression and Fusion

Lambrechts Mark James,Tran Khoa,Conaway William,Karamian Brian Abedi,Goswami Karan,Li Sandi,O'Connor Patrick,Brush Parker,Canseco Jose,Kaye Ian David,Woods Barrett,Hilibrand Alan,Schroeder Gregory,Vac 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.2

Study Design: A retrospective cohort study.Purpose: To determine whether the 11-item modified frailty index (mFI) is associated with readmission rates, complication rates, revision rates, or differences in patient-reported outcome measures (PROMs) for patients undergoing posterior cervical decompression and fusion (PCDF).Overview of Literature: mFI incorporates preexisting medical comorbidities and dependency status to determine physiological reserve. Based on previous literature, it may be used as a predictive tool for identifying postoperative clinical and surgical outcomes.Methods: Patients undergoing elective PCDF at our urban academic medical center from 2014 to 2020 were included. Patients were categorized by mFI scores (0–0.08, 0.09–0.17, 0.18–0.26, and ≥0.27). Univariate statistics compared demographics, comorbidities, and clinical/surgical outcomes. Multiple linear regression analysis evaluated the magnitude of improvement in PROMs at 1 year.Results: A total of 165 patients were included and grouped by mFI scores: 0 (n=36), 0.09 (n=62), 0.18 (n=42), and ≥0.27 (n=30). The severe frailty group (mFI ≥0.27) was significantly more likely to be diabetic (<i>p</i> <0.001) and have a greater Elixhauser comorbidity index (<i>p</i> =0.001). They also had worse baseline Physical Component Score-12 (PCS-12) (<i>p</i> =0.011) and modified Japanese Orthopaedic Association (mJOA) (<i>p</i> =0.012) scores and worse 1-year postoperative PCS-12 (<i>p</i> =0.008) and mJOA (<i>p</i> =0.001) scores. On regression analysis, an mFI score of 0.18 was an independent predictor of greater improvement in ΔVisual Analog Scale neck (<i>β</i> =−2.26, <i>p</i> =0.022) and ΔVAS arm (<i>β</i> =−1.76, <i>p</i> =0.042). Regardless of frailty status, patients had similar 90-day readmission rates (<i>p</i> =0.752), complication rates (<i>p</i> =0.223), and revision rates (<i>p</i> =0.814), but patients with severe frailty were more likely to have longer hospital length of stay (<i>p</i> =0.006) and require non-home discharge (<i>p</i> <0.001).Conclusions: Similar improvements across most PROMs can be expected irrespective of the frailty status of patients undergoing PCDF. Complication rates, 90-day readmission rates, and revision rates are not significantly different when stratified by frailty status. However, patients with severe frailty are more likely to have longer hospital stays and require non-home discharge.