Effect of Interbody Composition on the Development of Pseudarthrosis Following Anterior Cervical Discectomy and Fusion

D’Antonio Nicholas,Lambrechts Mark James,Heard Jeremy,Bertiaume Emily,Toci Gregory,Karamian Brian Abedi,Breyer Garrett,Bodnar John,Canseco Jose,Hilibrand Alan,Schroeder Gregory,Vaccaro Alexander Richa 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.3

Study Design: Retrospective cohort study.Purpose: To determine if polyetheretherketone (PEEK) or titanium alloy cages increase the rate of pseudarthrosis development or revision surgery rate compared with structural allograft following anterior cervical discectomy and fusion (ACDF) and identify if the cage type results in differences in patient-reported outcome measures (PROMs) versus structural allograft.Overview of Literature: PEEK and titanium alloy cages have become popular options for ACDF intervertebral spacers. However, while data is beginning to emerge on how cage types affect arthrodesis rates, the effect of their composition on PROMs is less clear.Methods: All patients aged >18 years who underwent primary one- to four-level ACDF at a single institution were retrospectively identified. Propensity matching was performed to compare patients’ PEEK or titanium alloy cages with structural allograft. Multivariate logistic regression analysis was performed to measure the effect of interbody spacer composition on the likelihood of pseudarthrosis development.Results: Of the 502 patients who received structural allograft and had 1-year postoperative dynamic radiographs, 96 patients were propensity matched to 32 patients who received a PEEK cage, and 162 patients were propensity matched to 54 patients who received a titanium alloy cage. Multivariate logistic regression analysis identified that PEEK cage implants (odds ratio [OR], 3.34; p =0.007) predicted pseudarthrosis development compared with structural allograft implantation. Titanium alloy cage (OR, 1.64; p =0.156) implantation was not predictive of pseudarthrosis. One-year postoperative PROMs were not significantly different between patients who received PEEK or titanium alloy cages and those who received structural allograft (all p >0.05).Conclusions: Compared with structural allograft, receiving a PEEK cage increased the risk of pseudarthrosis development following ACDF, whereas receiving a titanium alloy cage had no significant effect on pseudarthrosis development. One-year postoperative patient-reported outcomes were similar between patients who received structural allograft, PEEK, and titanium alloy interbody spacers.

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.

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.

Correction of Spinal Sagittal Alignment after Posterior Lumbar Decompression: Does Severity of Central Canal Stenosis Matter?

Trenchfield Delano,Lee Yunsoo,Lambrechts Mark J.,D’Antonio Nicholas,Heard Jeremy,Paulik John,Somers Sydney,Rihn Jeffrey A.,Kurd Mark,Kaye David,Canseco Jose,Hilibrand Alan,Vaccaro Alexander Richard,Ke 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.6

Study Design: This study adopted a retrospective study design.Purpose: Our study aimed to investigate the impact of central canal stenosis severity on surgical outcomes and lumbar sagittal correction after lumbar decompression.Overview of Literature: Studies have evaluated sagittal correction in patients with central canal stenosis after lumbar decompression and the association of stenosis severity with worse preoperative sagittal alignment. However, none have evaluated the impact of spinal stenosis severity on sagittal correction.Methods: Patients undergoing posterior lumbar decompression (PLD) of ≤4 levels were divided into severe and non-severe central canal stenosis groups based on the Lee magnetic resonance imaging (MRI) grading system. Patients without preoperative MRI or inadequate visualization on radiographs were excluded. Surgical characteristics, clinical outcomes, and sagittal measurements were compared. Multivariate logistic regression was performed to determine the predictors of pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and pelvic incidence minus lumbar lordosis (PI–LL).Results: Of the 142 patients included, 39 had severe stenosis, and 103 had non-severe stenosis. The mean follow-up duration for the cohort was 4.72 months. Patients with severe stenosis were older, had higher comorbidity indices and levels decompressed, and longer lengths of stay and operative times (<i>p</i> <0.001). Although those with severe stenosis had lower lordosis, lower SS, and higher PI–LL mismatch preoperatively, no differences in Delta LL, SS, PT, or PI–LL were observed between the two groups (<i>p</i> >0.05). On multivariate regression, severe stenosis was a significant predictor of a lower preoperative LL (estimate=−5.243, <i>p</i> =0.045) and a higher preoperative PI–LL mismatch (estimate=6.192, <i>p</i> =0.039). No differences in surgical or clinical outcomes were observed (<i>p</i> >0.05).Conclusion: Severe central lumbar stenosis was associated with greater spinopelvic mismatch preoperatively. Sagittal balance improved in both patients with severe and non-severe stenosis after PLD to a similar degree, with differences in sagittal parameters remaining after surgery. We also found no differences in postoperative outcomes associated with stenosis severity.

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.