Is It Cost Effective to Obtain Fungal and Acid-Fast Bacillus Cultures during Spine Debridement?

Lambrechts Mark J.,Clair Devin D. St.,Li Jinpu,Cook James L.,Spence Bradley S.,Leary Emily V.,Choma Theodore J.,Moore Donald K.,Goldstein Christina L. 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.4

Study Design: Retrospective study.Purpose: To identify the rate of positive acid-fast bacillus (AFB) and fungal cultures during spine debridement, determine whether these infections are more common in certain spine segments, identify comorbidities associated with these infections, and determine whether the universal performance of fungal and AFB cultures during spine debridement is cost effective.Overview of Literature: Spine infections are associated with significant morbidity and costs. Spine fungal and AFB infections are rare, but their incidence has not been well documented. As such, guidance regarding sample procurement for AFB and fungal cultures is lacking.Methods: A retrospective review of medical record data from patients undergoing spine irrigation and debridement (I&D) at the University of Missouri over a 10-year period was performed.Results: For patients undergoing spine I&D, there was a 4% incidence of fungal infection and 0.49% rate of AFB infection. Steroid use was associated with a higher likelihood (odds ratio, 5.62; 95% confidence interval, 1.33–23.75) of positive fungal or AFB cultures. Although not significant, patients undergoing multiple I&D procedures had higher rates of positive fungal cultures during each subsequent I&D. Over a 10-year period, if fungal cultures are obtained for each patient, it would cost our healthcare system $12,151.58. This is compared to an average cost of $177,297.64 per missed fungal infection requiring subsequent treatment.Conclusions: Spine fungal infections occur infrequently at a rate of 4%. Physicians should strongly consider obtaining samples for fungal cultures in patients undergoing spine I&D, especially those using steroids and those undergoing multiple I&Ds. Our AFB culture rates mirror the false positive rates seen in previous orthopedic literature. It is unlikely to be cost effective to send for AFB cultures in areas with low endemic rates of AFB.

How Does the Severity of Neuroforaminal Compression in Cervical Radiculopathy Affect Outcomes of Anterior Cervical Discectomy and Fusion

Lambrechts Mark J.,Issa Tariq Z.,Lee Yunsoo,Tran Khoa S.,Heard Jeremy,Purtill Caroline,Fried Tristan B.,Oh Samuel,Kim Erin,Mangan John J.,Canseco Jose A.,Kaye I. David,Rihn Jeffrey A.,Hilibrand Alan S 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.6

Study Design: This study is a retrospective cohort study.Purpose: This study aims to determine whether preoperative neuroforaminal stenosis (FS) severity is associated with motor function patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF).Overview of Literature: Cervical FS can significantly contribute to patient symptoms. While magnetic resonance imaging (MRI) has been used to classify FS, there has been limited research into the impact of FS severity on patient outcomes.Methods: Patients undergoing primary, elective 1–3 level ACDF for radiculopathy at a single academic center between 2015 and 2021 were identified retrospectively. Cervical FS was evaluated using axial T2-weighted MRI images via a validated grading scale. The maximum degree of stenosis was used for multilevel disease. Motor symptoms were classified using encounters at their final preoperative and first postoperative visits, with examinations ≤3/5 indicating weakness. PROMs were obtained preoperatively and at 1-year follow-up. Bivariate analysis was used to compare outcomes based on stenosis severity, followed by multivariable analysis.Results: This study included 354 patients, 157 with moderate stenosis and 197 with severe stenosis. Overall, 58 patients (16.4%) presented with upper extremity weakness ≤3/5. A similar number of patients in both groups presented with baseline motor weakness (13.5% vs. 16.55, <i>p</i> =0.431). Postoperatively, 97.1% and 87.0% of patients with severe and moderate FS, respectively, experienced full motor recovery (<i>p</i> =0.134). At 1-year, patients with severe neuroforaminal stenosis presented with significantly worse 12-item Short Form Survey Physical Component Score (PCS-12) (33.3 vs. 37.3, <i>p</i> =0.049) but demonstrated a greater magnitude of improvement (Δ PCS-12: 5.43 vs. 0.87, <i>p</i> =0.048). Worse stenosis was independently associated with greater ΔPCS-12 at 1-year (β =5.59, <i>p</i> =0.022).Conclusions: Patients with severe FS presented with worse preoperative physical health. While ACDF improved outcomes and conferred similar motor recovery in all patients, those with severe FS reported much better improvement in physical function.

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.

Static versus Expandable Interbody Fusion Devices: A Comparison of 1-Year Clinical and Radiographic Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion

Ledesma Jonathan Andrew,Lambrechts Mark J.,Dees Azra,Thomas Terence,Hiranaka Cannon Greco,Kurd Mark Faisal,Radcliff Kris E.,Anderson David Greg 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.1

Study Design: Retrospective cohort study. Purpose: To compare the radiographic and clinical outcomes of static versus expandable interbody cages in transforaminal lumbar interbody fusion using minimally invasive surgery (MIS-TLIF). Overview of Literature: Expandable interbody cages may potentially improve radiographic and clinical outcomes following MIS-TLIF compared to static pages, but at a potentially higher cost and increased rates of subsidence. Methods: A retrospective chart review of 1- and 2-level MIS-TLIFs performed from 2014 to 2020 was reviewed. Radiographic measurements were obtained preoperatively, 6 weeks postoperatively, and at final follow-up. Patient-reported outcome measures (PROMs) including the Oswestry Disability Index, Visual Analog Scale (VAS) back, and VAS leg were evaluated. Multivariate linear regression analysis determined the effect of cage type on the change in PROMs, controlling for demographic characteristics. Alpha was set at 0.05. Results: A total of 221 patients underwent MIS-TLIF including 136 static and 85 expandable cages. Expandable cages had significantly greater anterior (static: 11.41 mm vs. expandable: 13.11 mm, p<0.001) and posterior disk heights (static: 7.22 mm vs. expandable: 8.11 mm, p<0.001) at 1-year follow-up. Expandable cages offered similar improvements in segmental lordosis at 6 weeks (static: 1.69° vs. expandable: 2.81°, p=0.243), but segmental lordosis was better maintained with expandable cages leading to significant differences at 1-year follow-up (static: 0.86° vs. expandable: 2.45°, p=0.001). No significant differences were noted in total complication (static: 12.5% vs. expandable: 16.5%, p=0.191) or cage subsidence rates (static: 19.7% vs. expandable: 22.4%, p=0.502) groups at 1-year follow-up. Conclusions: Expandable devices provide greater improvements in radiographic measurements including anterior disk height, posterior disk height, and segmental lordosis, but this did not lead to significant improvements in PROMs, complication rates, subsidence rates, or subsidence distance.

Utility of Seated Lateral Radiographs in the Diagnosis and Classification of Lumbar Degenerative Spondylolisthesis

Issa Tariq Z.,Lee Yunsoo,Berthiaume Emily,Lambrechts Mark J.,Zaworski Caroline,Qadiri Qudratallah S.,Spracklen Henley,Padovano Richard,Weber Jackson,Mangan John J.,Canseco Jose A.,Woods Barrett I.,Kay 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.4

Study Design: Retrospective cohort study.Purpose: Our goal was to determine which radiographic images are most essential for degenerative spondylolisthesis (DS) classification and instability detection.Overview of Literature: The heterogeneity in DS requires multiple imaging views to evaluate vertebral translation, disc space, slip angle, and instability. However, there are several restrictions on frequently used imaging perspectives such as flexion-extension and upright radiography.Methods: We assessed baseline neutral upright, standing flexion, seated lateral radiographs, and magnetic resonance imaging (MRI) for patients identified with spondylolisthesis from January 2021 to May 2022 by a single spine surgeon. DS was classified by Meyerding and Clinical and Radiographic Degenerative Spondylolisthesis classifications. A difference of >10° or >8% between views, respectively, was used to characterize angular and translational instability. Analysis of variance and paired chi-square tests were utilized to compare modalities.Results: A total of 136 patients were included. Seated lateral and standing flexion radiographs showed the greatest slip percentage (16.0% and 16.7%), while MRI revealed the lowest (12.2%, <i>p</i> <0.001). Standing flexion and lateral radiographs when seated produced more kyphosis (4.66° and 4.97°, respectively) than neutral upright and MRI (7.19° and 7.20°, <i>p</i> <0.001). Seated lateral performed similarly to standing flexion in detecting all measurement parameters and categorizing DS (all <i>p</i> >0.05). Translational instability was shown to be more prevalent when associated with seated lateral or standing flexion than when combined with neutral upright (31.5% vs. 20.2%, <i>p</i> =0.041; and 28.1% vs. 14.6%, <i>p</i> =0.014, respectively). There were no differences between seated lateral or standing flexion in the detection of instability (all <i>p</i> >0.20).Conclusions: Seated lateral radiographs are appropriate alternatives for standing flexion radiographs. Films taken when standing up straight do not offer any more information for DS detection. Rather than standing flexion-extension radiographs, instability can be detected using an MRI, which is often performed preoperatively, paired with a single seated lateral radiograph.

Significance of Facet Fluid Index in Anterior Cervical Degenerative Spondylolisthesis

Lee Yunsoo,Heard Jeremy C.,Lambrechts Mark J.,Kern Nathaniel,Wiafe Bright,Goodman Perry,Mangan John J.,Canseco Jose A.,Kurd Mark F.,Kaye Ian D.,Hilibrand Alan S.,Vaccaro Alexander R.,Kepler Christophe 대한척추외과학회 2024 Asian Spine Journal Vol.18 No.1

Study Design: Retrospective cohort study.Purpose: To correlate cervical facet fluid characteristics to radiographic spondylolisthesis, determine if facet fluid is associated with instability in cervical degenerative spondylolisthesis, and examine whether vertebral levels with certain facet fluid characteristics and spondylolisthesis are more likely to be operated on.Overview of Literature: The relationship between facet fluid and lumbar spondylolisthesis is well-documented; however, there is a paucity of literature investigating facet fluid in degenerative cervical spondylolisthesis.Methods: Patients diagnosed with cervical degenerative spondylolisthesis were identified from a hospital’s medical records. Demographic and surgical characteristics were collected through a structured query language search and manual chart review. Radiographic measurements were made on preoperative MRIs for all vertebral levels diagnosed with spondylolisthesis and adjacent undiagnosed levels between C3 and C6. The facet fluid index was calculated by dividing the facet fluid measurement by the width of the facet. Bivariate analysis was conducted to compare facet characteristics based on radiographic spondylolisthesis and spondylolisthesis stability.Results: We included 154 patients, for whom 149 levels were classified as having spondylolisthesis and 206 levels did not. The average facet fluid index was significantly higher in patients with spondylolisthesis (0.26±0.07 vs. 0.23±0.08, p <0.001). In addition, both fluid width and facet width were significantly larger in patients with spondylolisthesis (p <0.001 each). Cervical levels in the fusion construct demonstrated a greater facet fluid index and were more likely to have unstable spondylolisthesis than stable spondylolisthesis (p <0.001 each).Conclusions: Facet fluid index is associated with cervical spondylolisthesis and an increased facet size and fluid width are associated with unstable spondylolisthesis. While cervical spondylolisthesis continues to be an inconclusive finding, vertebral levels with spondylolisthesis, especially the unstable ones, were more likely to be included in the fusion procedure than those without spondylolisthesis.