Level-specific comparison of 3D navigated and robotic arm-guided screw placement: an accuracy assessment of 1210 pedicle screws in lumbar surgery.

BACKGROUND CONTEXT: Robotic spine surgery, utilizing 3D imaging and robotic arms, has been shown to improve the accuracy of pedicle screw placement compared to conventional methods, although its superiority remains under debate. There are few studies evaluating the accuracy of 3D navigated versus robotic-guided screw placement across lumbar levels, addressing anatomical challenges to refine surgical strategies and patient safety. PURPOSE: This study aims to investigate the pedicle screw placement accuracy between 3D navigation and robotic arm-guided systems across distinct lumbar levels. STUDY DESIGN: A retrospective review of a prospectively collected registry. PATIENT SAMPLE: Patients undergoing fusion surgery with pedicle screw placement in the prone position, using either via 3D image navigation only or robotic arm guidance. OUTCOME MEASURE: Radiographical screw accuracy was assessed by the postoperative computed tomography (CT) according to the Gertzbein-Robbins classification, particularly focused on accuracy at different lumbar levels. METHODS: Accuracy of screw placement in the 3D navigation (Nav group) and robotic arm guidance (Robo group) was compared using Chi-squared test/Fisher's exact test with effect size measured by Cramer's V, both overall and at each specific lumbosacral spinal level. RESULTS: A total of 321 patients were included (Nav, 157; Robo, 189) and evaluated 1210 screws (Nav, 651; Robo 559). The Robo group demonstrated significantly higher overall accuracy (98.6 vs 93.9%; p<.001, V=0.25). This difference of no breach screw rate was signified the most at the L3 level (No breach screw: Robo 91.3 vs 57.8%, p<.001, V=0.35) followed by L4 (89.6 vs 64.7%, p<.001, V=0.28), and L5 (92.0 vs 74.5%, p<.001, V=0.22). However, screw accuracy at S1 was not significant between the groups (81.1 vs 72.0%, V=0.10). CONCLUSION: This study highlights the enhanced accuracy of robotic arm-guided systems compared to 3D navigation for pedicle screw placement in lumbar fusion surgeries, especially at the L3, L4, and L5 levels. However, at the S1 level, both systems exhibit similar effectiveness, underscoring the importance of understanding each system's specific advantages for optimization of surgical complications.

Heatwave attribution based on reliable operational weather forecasts.

The 2021 Pacific Northwest heatwave was so extreme as to challenge conventional statistical and climate-model-based approaches to extreme weather attribution. However, state-of-the-art operational weather prediction systems are demonstrably able to simulate the detailed physics of the heatwave. Here, we leverage these systems to show that human influence on the climate made this event at least 8 [2-50] times more likely. At the current rate of global warming, the likelihood of such an event is doubling every 20 [10-50] years. Given the multi-decade lower-bound return-time implied by the length of the historical record, this rate of change in likelihood is highly relevant for decision makers. Further, forecast-based attribution can synthesise the conditional event-specific storyline and unconditional event-class probabilistic approaches to attribution. If developed as a routine service in forecasting centres, it could provide reliable estimates of human influence on extreme weather risk, which is critical to supporting effective adaptation planning.

Impact of Preoperative Symptom Duration on Patient-Reported Outcomes Following Cervical Disc Replacement for Cervical Radiculopathy.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the impact of preoperative symptom duration on postoperative functional outcomes after cervical disc replacement (CDR) for radiculopathy. SUMMARY OF BACKGROUND DATA: CDR has emerged as a reliable and efficacious treatment option for degenerative cervical spine pathologies. The relationship between preoperative symptom duration and outcomes after CDR is not well established. METHODS: Patients with radiculopathy without myelopathy who underwent primary 1- or 2-level CDRs were included and divided into shorter (<6 mo) and prolonged (≥6 mo) cohorts based on preoperative symptom duration. Patient-reported outcome measures (PROMs) included neck disability index (NDI), visual analog scale (VAS) neck and arm. Changes in PROM scores and minimal clinically important difference (MCID) rates were calculated. Analyses were conducted on the early (within 3 mo) and late (6 mo-2 y) postoperative periods. RESULTS: A total of 201 patients (43.6±8.7 y, 33.3% female) were included. In both early and late postoperative periods, the shorter preoperative symptom duration cohort experienced significantly greater change from preoperative PROM scores compared with the prolonged symptom duration cohort for NDI, VAS-Neck, and VAS-Arm. The shorter symptom duration cohort achieved MCID in the early postoperative period at a significantly higher rate for NDI (78.9% vs. 54.9%, P =0.001), VAS-Neck (87.0% vs. 56.0%, P <0.001), and VAS-Arm (90.5% vs. 70.7%, P =0.002). Prolonged preoperative symptom duration (≥6 mo) was identified as an independent risk factor for failure to achieve MCID at the latest timepoint for NDI (OR: 2.9, 95% CI: 1.2-6.9, P =0.016), VAS-Neck (OR: 9.8, 95% CI: 3.7-26.0, P <0.001), and VAS-Arm (OR: 7.5, 95% CI: 2.5-22.5, P <0.001). CONCLUSIONS: Our study demonstrates improved patient-reported outcomes for those with shorter preoperative symptom duration undergoing CDR for radiculopathy, suggesting delayed surgical intervention may result in poorer outcomes and greater postoperative disability. LEVEL OF EVIDENCE: Level III.

Limited Improvement With Minimally Invasive Lumbar Decompression Alone for Degenerative Scoliosis With Cobb Angle Over 20°: The Impact of Decompression Location.

STUDY DESIGN: Retrospective review of a prospectively collected multisurgeon registry. OBJECTIVE: To evaluate the outcomes of minimally invasive (MI) decompression in patients with severe degenerative scoliosis (DS) and identify factors associated with poorer outcomes. SUMMARY OF BACKGROUND CONTEXT: MI decompression has gained widespread acceptance as a treatment option for patients with lumbar canal stenosis and DS. However, there is a lack of research regarding the clinical outcomes and the impact of MI decompression location in patients with severe DS exhibiting a Cobb angle exceeding 20°. MATERIALS AND METHODS: Patients who underwent MI decompression alone were included and categorized into the DS or control groups based on Cobb angle (>20°). Decompression location was labeled as "scoliosis-related" when the decompression levels were across or between end vertebrae and "outside" when the operative levels did not include the end vertebrae. The outcomes, including the Oswestry Disability Index (ODI), were compared between the propensity score-matched groups for improvement and minimal clinical importance difference (MCID) achievement at ≥1 year postoperatively. Multivariable regression analysis was conducted to identify factors contributing to the nonachievement of MCID in ODI of the DS group at the ≥1-year time point. RESULTS: A total of 253 patients (41 DS) were included in the study. Following matching for age, sex, osteoporosis status, psoas muscle area, and preoperative ODI, the DS groups exhibited a significantly lower rate of MCID achievement in ODI (DS: 45.5% vs. control 69.0%, P =0.047). The "scoliosis-related" decompression (odds ratio: 9.9, P =0.028) was an independent factor of nonachievement of MCID in ODI within the DS group. CONCLUSIONS: In patients with a Cobb angle >20°, lumbar decompression surgery, even in the MI approach, may result in limited improvement of disability and physical function. Caution should be exercised when determining a surgical plan, especially when decompression involves the level between or across the end vertebrae. LEVEL OF EVIDENCE: 3.

The Impact of Posterior Intervertebral Osteophytes on Patient-Reported Outcome Measures After L5-S1 Anterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: (1) To develop a reliable grading system to assess the severity of posterior intervertebral osteophytes and (2) to investigate the impact of posterior intervertebral osteophytes on clinical outcomes after L5-S1 decompression and fusion through anterior lumbar interbody fusion (ALIF) and minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF). BACKGROUND: There is limited evidence regarding the clinical implications of posterior lumbar vertebral body osteophytes for ALIF and MIS-TLIF surgeries and there are no established grading systems that define the severity of these posterior lumbar intervertebral osteophytes. PATIENTS AND METHODS: A retrospective analysis of patients undergoing L5-S1 ALIF or MIS-TLIF was performed. Preoperative and postoperative patient-reported outcome measures of the Oswestry Disability Index (ODI) and leg Visual Analog Scale (VAS) at 2-week, 6-week, 12-week, and 6-month follow-up time points were assessed. Minimal clinically important difference (MCID) for ODI of 14.9 and VAS leg of 2.8 were utilized. Osteophyte grade was based on the ratio of osteophyte length to foraminal width. "High-grade" osteophytes were defined as a maximal osteophyte length >50% of the total foraminal width. RESULTS: A total of 70 consecutive patients (32 ALIF and 38 MIS-TLIF) were included in the study. There were no significant differences between the two cohorts in patient-reported outcome measures or achievement of MCID for Leg VAS or ODI preoperatively or at any follow-ups. On multivariate analysis, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with leg VAS or ODI scores at any follow-up time point. In addition, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with the achievement of MCID for leg VAS or ODI at 6 months. CONCLUSION: ALIF and MIS-TLIF are both valid options for treating degenerative spine conditions and lumbar radiculopathy, even in the presence of high-grade osteophytes that significantly occupy the intervertebral foramen. LEVEL OF EVIDENCE: 3.

Methane and the Paris Agreement temperature goals.

Meeting the Paris Agreement temperature goal necessitates limiting methane (CH4)-induced warming, in addition to achieving net-zero or (net-negative) carbon dioxide (CO2) emissions. In our model, for the median 1.5°C scenario between 2020 and 2050, CH4 mitigation lowers temperatures by 0.1°C; CO2 increases it by 0.2°C. CO2 emissions continue increasing global mean temperature until net-zero emissions are reached, with potential for lowering temperatures with net-negative emissions. By contrast, reducing CH4 emissions starts to reverse CH4-induced warming within a few decades. These differences are hidden when framing climate mitigation using annual 'CO2-equivalent' emissions, including targets based on aggregated annual emission rates. We show how the different warming responses to CO2 and CH4 emissions can be accurately aggregated to estimate warming by using 'warming-equivalent emissions', which provide a transparent and convenient method to inform policies and measures for mitigation, or demonstrate progress towards a temperature goal. The method presented (GWP*) uses well-established climate science concepts to relate GWP100 to temperature, as a simple proxy for a climate model. The use of warming-equivalent emissions for nationally determined contributions and long-term strategies would enhance the transparency of stocktakes of progress towards a long-term temperature goal, compared to the use of standard equivalence methods. This article is part of a discussion meeting issue 'Rising methane: is warming feeding warming? (part 2)'.

Forecast-based attribution of a winter heatwave within the limit of predictability.

Attribution of extreme weather events has expanded rapidly as a field over the past decade. However, deficiencies in climate model representation of key dynamical drivers of extreme events have led to some concerns over the robustness of climate model-based attribution studies. It has also been suggested that the unconditioned risk-based approach to event attribution may result in false negative results due to dynamical noise overwhelming any climate change signal. The "storyline" attribution framework, in which the impact of climate change on individual drivers of an extreme event is examined, aims to mitigate these concerns. Here we propose a methodology for attribution of extreme weather events using the operational European Centre for Medium-Range Weather Forecasts (ECMWF) medium-range forecast model that successfully predicted the event. The use of a successful forecast ensures not only that the model is able to accurately represent the event in question, but also that the analysis is unequivocally an attribution of this specific event, rather than a mixture of multiple different events that share some characteristic. Since this attribution methodology is conditioned on the component of the event that was predictable at forecast initialization, we show how adjusting the lead time of the forecast can flexibly set the level of conditioning desired. This flexible adjustment of the conditioning allows us to synthesize between a storyline (highly conditioned) and a risk-based (relatively unconditioned) approach. We demonstrate this forecast-based methodology through a partial attribution of the direct radiative effect of increased CO2 concentrations on the exceptional European winter heatwave of February 2019.

Improved calculation of warming-equivalent emissions for short-lived climate pollutants.

Anthropogenic global warming at a given time is largely determined by the cumulative total emissions (or stock) of long-lived climate pollutants (LLCPs), predominantly carbon dioxide (CO2), and the emission rates (or flow) of short-lived climate pollutants (SLCPs) immediately prior to that time. Under the United Nations Framework Convention on Climate Change (UNFCCC), reporting of greenhouse gas emissions has been standardised in terms of CO2-equivalent (CO2-e) emissions using Global Warming Potentials (GWP) over 100-years, but the conventional usage of GWP does not adequately capture the different behaviours of LLCPs and SLCPs, or their impact on global mean surface temperature. An alternative usage of GWP, denoted GWP*, overcomes this problem by equating an increase in the emission rate of an SLCP with a one-off "pulse" emission of CO2. We show that this approach, while an improvement on the conventional usage, slightly underestimates the impact of recent increases in SLCP emissions on current rates of warming because the climate does not respond instantaneously to radiative forcing. We resolve this with a modification of the GWP* definition, which incorporates a term for each of the short-timescale and long-timescale climate responses to changes in radiative forcing. The amended version allows "CO2-warming-equivalent" (CO2-we) emissions to be calculated directly from reported emissions. Thus SLCPs can be incorporated directly into carbon budgets consistent with long-term temperature goals, because every unit of CO2-we emitted generates approximately the same amount of warming, whether it is emitted as a SLCP or a LLCP. This is not the case for conventionally derived CO2-e.

The many possible climates from the Paris Agreement's aim of 1.5 °C warming.

The United Nations' Paris Agreement includes the aim of pursuing efforts to limit global warming to only 1.5 °C above pre-industrial levels. However, it is not clear what the resulting climate would look like across the globe and over time. Here we show that trajectories towards a '1.5 °C warmer world' may result in vastly different outcomes at regional scales, owing to variations in the pace and location of climate change and their interactions with society's mitigation, adaptation and vulnerabilities to climate change. Pursuing policies that are considered to be consistent with the 1.5 °C aim will not completely remove the risk of global temperatures being much higher or of some regional extremes reaching dangerous levels for ecosystems and societies over the coming decades.