Clinical and radiologic outcomes of posterior column extension, pedicle subtraction, and vertebral column resection osteotomies in adult chin on chest deformity: A systematic review.

Background: Chin-on-chest deformity is a rare and severely disabling condition characterized by kyphotic deformity in the cervicothoracic spine. To treat this deformity, various osteotomy techniques were described. Methods: A comprehensive literature search of biomedical databases including MEDLINE (via PubMed), Scopus (via Elsevier), Embase (via Elsevier), and Cochrane Library in English from 1/1/1990 to 3/31/2022 was conducted using a combination of text and Medical Subject Headings (MeSH). Results: The final analysis included 16 studies. All the studies were assigned a level of evidence of four. Except for two articles, all of the articles were non-comparative studies. A total of 288 patients were included in this review. Of the 288 patients, 107 underwent posterior column extension osteotomy (PCEO), 108 underwent pedicle subtraction osteotomy (PSO), and 33 underwent vertebral column resection osteotomy (VCRO). The most common osteotomy level in fifteen of the studies was C7/T1. The studies included in this review described several techniques for cervical sagittal balance correction. The range of preoperative and postoperative visual analogue scale (VAS) scores was 5.5-8.6 to 1.7-4.91, respectively. The range of preoperative and postoperative neck disability index (NDI) was 34.2-65.4 to 22.1-51.3, respectively. The most common complications were upper extremity paresthesia and hand numbness through the C8 dermatome distribution. Conclusions: Corrective osteotomies provide satisfactory results in patients with chin-on-chest deformity; however, the quality of the included studies limits the evidence.

Preoperative cross-sectional area of psoas muscle correlates with short-term functional outcomes after posterior lumbar surgery.

PURPOSE: To determine the optimal level for the measurement of psoas cross-sectional area and examine the correlation with short-term functional outcomes of posterior lumbar surgery. METHODS: Patients who underwent minimally invasive posterior lumbar surgery were included in this study. The cross-sectional area of psoas muscle was measured at each intervertebral level on T2-weighted axial images of preoperative MRI. Normalized total psoas area (NTPA) (mm2/m2) was calculated as total psoas area normalized to patient height. Intraclass Correlation Coefficient (ICC) was calculated for the analysis of inter-rater reliability. Patient reported outcome measures including Oswestry disability index (ODI), visual analog scale (VAS), short form health survey (SF-12) and patient-reported outcomes measurement information system were collected. A multivariate analysis was performed to elucidate independent predictors associated with failure to reach minimal clinically important difference (MCID) in each functional outcome at 6 months. RESULTS: The total of 212 patients were included in this study. ICC was highest at L3/4 [0.992 (95% CI: 0.987-0.994)] compared to the other levels [L1/2 0.983 (0.973-0.989), L2/3 0.991 (0.986-0.994), L4/5 0.928 (0.893-0.952)]. Postoperative PROMs were significantly worse in patients with low NTPA. Low NTPA was an independent predictor of failure to reach MCID in ODI (OR = 2.68; 95% CI: 1.26-5.67; p = 0.010) and VAS leg (OR = 2.43; 95% CI: 1.13-5.20; p = 0.022). CONCLUSION: Decreased psoas cross-sectional area on preoperative MRI correlated with functional outcomes after posterior lumbar surgery. NTPA was highly reliable, especially at L3/4.

Early Clinical Outcomes of the Prone Transpsoas Lumbar Interbody Fusion Technique.

BACKGROUND: The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a relatively novel technique. Currently, little is known about its associated complications and early patient-reported outcomes. The aim of this study was to investigate the effect of LLIF performed via the PTP approach on sagittal radiographic parameters, patient-reported outcome measures (PROMs), and rates of complications. METHODS: A retrospective review was performed of 82 consecutive patients who underwent LLIF via a PTP technique. Lumbar lordosis (LL), segmental lordosis (SL), anterior disc height (ADH), and posterior disc height (PDH) were measured on preoperative, initial postoperative, and 3-month postoperative radiographs. PROMs including the Oswestry Disability Index (ODI); the visual analog scale (VAS); and pain portions of the EQ5D, VAS back, and VAS leg ratings were collected at the preoperative and subsequent postoperative visits. Length of hospital stay and postoperative complications related to the procedure were recorded. RESULTS: Significant improvements were seen at the initial (4.5° ± 8.6°, P < 0.001) and 3-month (4.4° ± 7.2°, P < 0.001) postoperative periods for LL, as well as SL (6.8° ± 4.8°, P < 0.001; 6.7° ± 4.4°, P < 0.001), ADH (8.0 mm ± 3.6, P < 0.001; 7.4 mm ± 3.6, P < 0.001), and PDH (3.3 mm ± 2.4, P < 0.001; 3.1 mm ± 2.5, P < 0.001). Significant improvements were seen at 3 months postoperatively for ODI (P < 0.001), EQ5D pain (P = 0.016), VAS leg (P < 0.001), and VAS back (P < 0.001). The average length of stay was 2.7 ± 4.5 days. The most common complications were ipsilateral thigh pain/numbness (45.1%), ipsilateral hip flexor weakness (39.0%), and contralateral thigh pain/numbness (14.6%). CONCLUSIONS: While early PROMs and correction of sagittal radiographic parameters show promising results for the PTP approach for LLIF, it is not without risks. CLINICAL RELEVANCE: PTP interbody fusion is an emerging technique that allows for simultaneous access to the anterior and posterior columns of the lumbar spine. This early case series demonstrates significant improvement in functional outcomes and lumbar lordosis with a safety profile comparable to other well-established techniques.

Does loss of spondylolisthesis reduction impact clinical and radiographic outcomes after minimally invasive transforaminal lumbar interbody fusion?

BACKGROUND CONTEXT: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a common operative approach to address degenerative lumbar stenosis and spondylolisthesis which has failed nonoperative care. Compared to open TLIF, MI-TLIF relies to a greater extent on indirect decompression resulting in a heightened awareness of spondylolisthesis reduction among MI surgeons. To what extent intraoperative reduction is achieved as well as the rate and clinical impact of loss or reduction and slip recurrence remain unknown. PURPOSE: To determine the rate and clinical impact of slip recurrence after MI-TLIF with expandable cage technology STUDY DESIGN/SETTING: Retrospective Cohort Study PATIENT SAMPLE: Patients undergoing MI-TLIF for degenerative spondylolisthesis using an articulating, expandable cage OUTCOME MEASURES: Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) for back/leg pain, Short Form-12 (SF-12), and PROMIS Physical Function (PF) METHODS: Patients undergoing MI-TLIF for degenerative spondylolisthesis using articulating, expandable cages from 2017 to 2019 were retrospectively studied. Lateral radiographs were reviewed and evaluated for the presence or absence of spondylolisthesis preoperatively, intraoperatively, and at follow-up times including 2 weeks, 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Spondylolisthesis was measured from the posterior inferior corner of the cephalad vertebra to the posterior superior corner of the caudal vertebra, with any measurement >1 mm classified as spondylolisthesis, and Meyerding grade was noted. Intraoperative reduction was measured, and loss of reduction was defined as >1 mm increase in spondylolisthesis comparing follow-up imaging to intraoperative films. PROMs were recorded at the preoperative and follow-up time points. Fusion was assessed at 1 year postoperatively via CT. RESULTS: A total of 63 patients and 70 levels were included, with mean age 59.8 years (SD,13.8). 19 levels (27.1%) had complete reduction intraoperatively, 40 (57.1%) had partial reduction, and 11 (15.7%) had no reduction. Of the 30 levels with loss of reduction (50.8%), 20 (66.7%) occurred by 2 weeks postoperatively and 28 (93.3%) occurred by 12 weeks postoperatively. At 6 months, there were significant differences between those who had loss of reduction and those who did not in VAS back pain (3.0 vs. 0.9, p = .017) and SF-12 PCS (41.5 vs. 50.0, p = .035), but no differences were found between the groups for any instruments at any other time points. The overall fusion rate was 82.1% (32/39) at 1 year postoperatively. There was no significant difference in fusion rate between the loss of reduction (16/20) and no loss of reduction (20/23) groups. Patients with loss of reduction had no difference in reoperation rate (1/28) compared to those without loss of reduction (2/24). CONCLUSIONS: While a majority of patients demonstrated reduction intraoperatively, 51% had loss of reduction, most commonly in the acute postoperative period. There were few differences in PROMs between patients who had loss of reduction and those who did not, suggesting that radiographic loss of reduction after MI-TLIF in the setting of degenerative spondylolisthesis may not be clinically meaningful.

Development and Initial Internal Validation of a Novel Classification System for Perioperative Expectations Following Minimally Invasive Degenerative Lumbar Spine Surgery.

STUDY DESIGN: This was a prospective consecutive clinical cohort study. OBJECTIVE: The purpose of our study was to develop and provide an initial internal validation of a novel classification system that can help surgeons and patients better understand their postoperative course following the particular minimally invasive surgery (MIS) and approach that is utilized. SUMMARY OF BACKGROUND DATA: Surgeons and patients are often attracted to the option of minimally invasive spine surgery because of the perceived improvement in recovery time and postsurgical pain. A classification system based on the impact of the surgery and surgical approach(es) on postoperative recovery can be particularly helpful. METHODS: Six hundred thirty-one patients who underwent MIS lumbar/thoracolumbar surgery for degenerative conditions of the spine were included. Perioperative outcomes-operative time, estimated blood loss, postsurgical length of stay (LOS), 90-day complications, postoperative day zero narcotic requirement [in Morphine Milligram Equivalent (MME)], and need for intravenous patient-controlled analgesia (IV PCA). RESULTS: Postoperative LOS and postoperative narcotic use were deemed most clinically relevant, thus selected as primary outcomes. Type of surgery was significantly associated with all outcomes (P<0.0001), except intraoperative complications. Number of levels for fusion was significantly associated with operative time, in-hospital complications, 24 hours oral MME, and the need for IV PCA and LOS (P<0.0001). Number of surgical approaches for lumbar fusion was significantly associated with operative time, 24 hours oral MME, need for IV PCA and LOS (P<0.001). Based on these parameters, the following classification system ("Qureshi-Louie classification" for MIS degenerative lumbar surgery) was devised: (1) Decompression-only; (2) Fusion-1 and 2 levels, 1 approach; (3) Fusion-1 level, 2 approaches; (4) Fusion-2 levels, 2 approaches; (5) Fusion-3+ levels, 2 approaches. CONCLUSIONS: We present a novel classification system and initial internal validation to describe the perioperative expectations following various MIS surgeries in the degenerative lumbar spine. This initial description serves as the basis for ongoing external validation.

Combining Expandable Interbody Cage Technology With a Minimally Invasive Technique to Harvest Iliac Crest Autograft Bone to Optimize Fusion Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery.

STUDY DESIGN: This was a retrospective cohort review. OBJECTIVE: The objective of this study was to determine the rate of fusion associated with an expandable cage and iliac crest bone graft in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) surgery. SUMMARY OF BACKGROUND DATA: MI-TLIF is a commonly performed procedure, but challenges inherent in MI-TLIF technique can make achieving an interbody fusion difficult. METHODS: A retrospective review was performed on consecutive patients treated with an MI-TLIF for degenerative lumbar pathology. Patients that completed patient-reported outcome measures and 1-year computed tomography (CT)-scans for fusion analysis were included. Fusion morphology was analyzed by evaluating CT scans for location of bridging trabecular bone in relation to the cage. Patients with bridging bone were considered fused. Preoperative and postoperative health-related quality of life scores were compared. A Kolmogrov-Smirnoff test was used to determine normality of health-related outcome scores. A Friedman 2-way analysis of variance by ranks with pairwise comparisons to determine statistical significance of differences between the date of a follow-up examination and preoperative examination was done. RESULTS: Of 75 patients evaluated 23 patients were excluded due to loss to follow-up, adjacent segment degeneration, inability to obtain a CT scan, or reoperation for nonfusion related symptoms. Of 61 disk spaces that were included, 55 had bridging bone through the intervertebral cage, resulting in an overall fusion rate of 90.2%. There was a higher rate of fusion at L5-S1 as compared to L4-L5. There was mean improvement in patient-reported outcome measures for Oswestry Disability Index, Short Form-12 Physical Component Score, Visual Analog Scale Back/Leg pain, and Patient-Reported Outcome Measurement Information System Physical Function. There were no complications associated with iliac crest bone graft harvesting. CONCLUSION: Combining an expandable cage with iliac crest autograft bone harvested through a minimally invasive technique can allow for improved fusion rates without graft-site complications in MI-TLIF surgery.

Impact of Nonlordotic Sagittal Alignment on Short-term Outcomes of Cervical Disc Replacement.

OBJECTIVE: To evaluate outcomes of cervical disc replacement (CDR) in patients with nonlordotic alignment. METHODS: Patients who underwent CDR were retrospectively reviewed and divided into 3 cohorts: (1) neutral/lordotic segmental and C2-7 Cobb angle (L), (2) nonlordotic segmental Cobb angle, lordotic C2-7 Cobb angle (NL-S), and (3) nonlordotic segmental and C2-7 Cobb angle (NL-SC). Radiographic and patient-reported outcomes (PROMs) were compared. RESULTS: One-hundred five patients were included (L: 37, NL-S: 30, NL-SC: 38). A significant gain in segmental lordosis was seen in all cohorts at < 6 months (L: -1.90° [p = 0.007]; NL-S: -5.16° [p < 0.0001]; NL-SC: -6.00° [p < 0.0001]) and ≥ 6 months (L: -2.07° [p = 0.031; NL-S: -6.04° [p < 0.0001]; NL-SC: -6.74° [p < 0.0001]), with greater lordosis generated in preoperatively nonlordotic cohorts (p < 0.0001). C2-7 lordosis improved in the preoperatively nonlordotic cohort (NL-SC: 8.04°) at follow-up of < 6 months (-4.15°, p = 0.003) and ≥ 6 months (-6.40°, p = 0.003), but not enough to create lordotic alignment (< 6 months: 3.89°; ≥ 6 months: 4.06°). All cohorts showed improvement in Neck Disability Index, visual analogue scale (VAS) neck, and VAS arm, without significant difference among groups in the amount of improvement ( ≥ 6-month PROMs follow-up = 69%). CONCLUSION: In patients without major kyphotic deformity, CDR has the potential to generate and maintain lordosis and improve PROMs in the short-term, and can be an effective treatment option for patients with nonlordotic alignment.