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.

Inhibition of Neurogenic Inflammatory Pathways Associated with the Reduction in Discogenic Back Pain

Canseco Jose A.,Levy Hannah A.,Karamian Brian Abedi,Blaber Olivia,Chang Michael,Patel Neil,Curran John,Hilibrand Alan S.,Schroeder Gregory D.,Vaccaro Alexander R.,Markova Dessislava Z.,Surrey David E. 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.6

Study Design: Retrospective cohort study.Purpose: This study aimed to determine whether the initiation of anti-calcitonin gene-related peptide (CGRP inhibitor) medication therapy for migraines was also associated with improvements in back/neck pain, mobility, and function in a patient population with comorbid degenerative spinal disease and migraine.Overview of Literature: CGRP upregulates pro-inflammatory cytokines such as tumor necrosis factor-α, interleukin-6, brain-derived neurotrophic factor, and nerve growth factor in spinal spondylotic disease, which results in disc degeneration and sensitization of nociceptive neurons. Although CGRP inhibitors can quell neurogenic inflammation in migraines, their off-site efficacy as a therapeutic target for discogenic back/neck pain conditions remains unknown.Methods: All adult patients diagnosed with spinal spondylosis and migraine treated with CGRP inhibitors at a single academic institution between 2017 and 2020 were retrospectively identified. Patient demographic and medical data, follow-up duration, migraine severity and frequency, spinal pain, functional status, and mobility before and after the administration of CGRP inhibitors were collected. Paired univariate analysis was conducted to determine significant changes in spinal pain, headache severity, and headache frequency before and after the administration of CGRP inhibitors. The correlation between changes in the spinal pain score and functional or mobility improvement was assessed with Spearman’s rho.Results: In total, 56 patients were included. The mean follow-up time after the administration of CGRP inhibitors was 123 days for spinal pain visits and 129 days for migraine visits. Back/neck pain decreased significantly (<i>p</i> <0.001) from 6.30 to 4.36 after starting CGRP inhibitor therapy for migraine control. As recorded in the spine follow-up notes, 25% of patients experienced a functional improvement in the activities of daily living, and 17.5% experienced mobility improvement while taking CGRP inhibitors. Change in back/ neck pain moderately correlated (ρ=−0.430) with functional improvement but was not correlated with mobility improvement (ρ=−0.052).Conclusions: Patients taking CGRP inhibitors for chronic migraines with comorbid degenerative spinal conditions experienced significant off-target reduction of back/neck pain.

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.

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.