Search

Introduction: Hip, knee, and lumbar spine surgeries are prevalent with arthroplasty often preceding lumbar surgery. The objective of this analysis was to ascertain whether previous arthroplasty was associated with patients' postlumbar surgery fulfillment of expectations., Methods: Identical systematically acquired data were pooled from 3 prospective studies that included assessments of preoperative expectations of lumbar surgery and 2-year postoperative assessment of fulfillment of expectations using a valid survey with points assigned for amount of improvement expected for symptoms and function. The proportion of expectations fulfilled was defined as total points for improvement received postoperatively divided by total points for improvement expected preoperatively (range 0 [no expectations fulfilled] to >1 [expectations surpassed]). Enrollment data included the expectations survey, demographic/clinical characteristics, Oswestry Disability Index (ODI) scores, and previous hip/knee arthroplasty. Postoperative data included follow-up expectations survey, ODI scores, and any spine complications. The proportion was the dependent variable in multivariable linear regression with demographic/clinical independent variables., Results: 1137 patients were included (mean age 59 years, 51% male); 993 (87%) did not have previous arthroplasty, and 144 (13%) had arthroplasty (51 hip only, 77 knee only, 16 both hip/knee). Patients with any arthroplasty had similarly high expectations compared with patients with no arthroplasty but lower proportion of expectations fulfilled (0.69 versus 0.76, P = 0.03). In multivariable analysis, variables associated with a lower proportion of expectations fulfilled were greater preoperative expectations ( P < 0.0001), not working ( P < 0.0001), positive depression screen ( P = 0.0002), previous lumbar surgery ( P < 0.0001), previous arthroplasty ( P = 0.03), surgery on ≥3 vertebrae ( P = 0.007), less preoperative-to-postoperative ODI improvement ( P < 0.0001), and postoperative complications ( P < 0.0001)., Conclusions: After accounting for a spectrum of highly associated covariates, patients with previous arthroplasty still had less fulfillment of expectations of subsequent lumbar surgery. For patients with previous arthroplasty, surgeons should discuss potential differences between arthroplasty and lumbar surgery during preoperative evaluations and during shared postoperative assessments of the outcome., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Robotic-assisted spine surgery has been reported to improve the accuracy and safety of pedicle screw placement and to reduce blood loss, hospital length of stay, and early postoperative pain 1 . Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a procedure that is well suited to be improved by recent innovations in robotic-assisted spine surgery. Heretofore, the capability of robotic navigation and software in spine surgery has been limited to assistance with pedicle screw insertion. Surgical decompression and decortication of osseous anatomy in preparation for biological fusion had historically been outside the scope of robotic-assisted spine surgery. In 2009, early attempts to perform surgical decompressions in a porcine model utilizing the da Vinci Surgical Robot for laminotomy and laminectomy were limited by the available technology 2 . Recent advances in software and instrumentation allow registration, surgical planning, and robotic-assisted surgery on the posterior elements of the spine. A human cadaveric study assessed the accuracy of robotic-assisted bone laminectomy, revealing precision in the cutting plane 3 . Robotic-assisted facet decortication, decompression, interbody cage implantation, and pedicle screw fixation add automation and accuracy to MI-TLIF., Description: A surgical robotic system comprises an operating room table-mounted surgical arm with 6 degrees of freedom that is physically connected to the patient's osseous anatomy with either a percutaneous Steinmann pin to the pelvis or a spinous process clamp. The Mazor X Stealth Edition Spine Robotic System (Version 5.1; Medtronic) is utilized, and a preoperative plan is created with use of software for screw placement, facet decortication, and decompression. The workstation is equipped with interface software designed to streamline the surgical process according to preoperative planning, intraoperative image acquisition, registration, and real-time control over robotic motion. The combination of these parameters enables the precise execution of preplanned facet joint decortication, osseous decompression, and screw trajectories. Consequently, this technique grants the surgeon guidance for the drilling and insertion of screws, as well as guidance for robotic resection of bone with a bone-removal drill., Alternatives: The exploration of robotically guided facet joint decortication and decompression in MI-TLIF presents an innovative alternative to the existing surgical approaches, which involve manual bone removal and can be less precise. Other robotic systems commonly utilized in spine surgery include the ROSA (Zimmer Biomet), the ExcelsiusGPS (Globus Medical), and the Cirq (Brainlab) 4 ., Rationale: The present video article provides a comprehensive guide for executing robotic-assisted MI-TLIF, including robotic facet decortication and osseous decompression. The introduction of advanced robotic technology capable of both decompressing bone and providing implant guidance represents a considerable advancement in robotic-assisted spine surgery. Software planning for robotic-assisted decortication of fused surfaces, surgical decompression, interbody cage placement, and pedicle screw placement allows for a less invasive and more precise MI-TLIF., Expected Outcomes: Anticipated outcomes include reduction in low back and leg pain, improved functional status, and successful spinal fusion. Radiographic outcomes are expected to show restored foraminal height and solid bony fusion. Further, enhanced surgical precision, reduced approach-related morbidity by expanded robotic capabilities in spinal fusion surgery, and a shift from manual bone removal to precise mechanized techniques can be expected. The introduction of robotic-assisted facet joint decortication and decompression represents a notable milestone in spine surgery, enhancing patient care and technological advancement., Important Tips: Although robotic systems were initially predominantly employed for thoracic or lumbar pedicle screw insertion, recent advancements in robotic technology and software have allowed registration of the posterior elements. This advancement has expanded the utility of robotic systems to the initiation of spinal decompression and the decortication of facet joint surfaces, enhancing fusion procedures.Maintaining anatomical precision and preventing the need for re-registration are critical considerations in this surgical procedure. It is recommended to follow a consistent surgical workflow: facet decortication, decompression, modular screw placement, discectomy, insertion of an interbody cage, placement of reduction tabs, rod insertion, and set screw locking.The incorporation of robotic assistance in MI-TLIF is not exempt from a set of challenges. These encompass issues that pertain to dependability of the setup process, occurrences of registration failures, logistical complexities, time constraints, and the unique learning curve associated with the novel capability of robotic decompression of bone and facet joints., Acronyms and Abbreviations: MI-TLIF= minimally invasive transforaminal lumbar interbody fusionOR = operating roomPSIS= posterior superior iliac spineCT = computed tomographyAP = anteroposterior., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A476)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

For years, anterior cervical diskectomy and fusion has been considered the benchmark for patients with cervical radiculopathy/myelopathy. However, concerns regarding adjacent segment pathology have promoted the popularity of cervical disk arthroplasty (CDA) with its motion-preserving properties. To replicate the natural cervical disk's six degrees of freedom and compressibility in cervical spine implants, designers need to carefully consider the level of constraint for stability and material selection. Recent CDA designs have incorporated strategies to facilitate unrestricted or semirestricted motion, deploying various articulating components and materials with distinct wear and compressibility properties. To optimize outcomes, patient selection considering additional degeneration of the cervical spine is critical. Clinical long-term studies have been reported in industry-funded FDA investigational device exemption and nonindustry-funded data for one-level and two-level CDA. There are limited data available on three-level and four-level CDA. Adverse events such as heterotopic ossification, osteolysis, migration, subsidence, and failure have been described, where analysis from explanted devices yields insight into in vivo wear and impingement performance. CDA has shown short-term cost advantages, such as decreased procedural expenses. Nonetheless, long-term analysis is necessary to assess possible economic tradeoffs. Advancements in designs may lead to improved implant longevity while evidence-based decision making will guide and responsibly manage the rapid advancement in CDA technology., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Study Design: Review of cohort studies., Objective: To ascertain if previous hip (THA) or knee (TKA) arthroplasty was associated with patients' outcomes assessments of subsequent lumbar surgery, specifically overall satisfaction, less disability due to pain, and an affective appraisal reflecting emotional assessment of results., Background: Hip, knee, and lumbar symptoms often co-exist and increasingly are managed with surgery. Whether previous total joint arthroplasty (TJA) impacts patients' perspectives of results of subsequent lumbar surgery is not known., Methods: Identical and systematically acquired preoperative and postoperative data from 3 studies assessing psychosocial characteristics and outcomes of lumbar surgery were pooled. Data obtained during interviews included preoperative demographic and clinical variables and 2-year postoperative global overall assessment (very satisfied/satisfied, neither, dissatisfied/very dissatisfied) and global affective assessment (delighted/pleased, mostly satisfied/mixed/mostly dissatisfied, unhappy/terrible). Patients completed the ODI and preoperative to postoperative change was analyzed according to an MCID (15 points). At 2 years patients also reported any untoward events since surgery (ie, fracture, infection, or repeat lumbar surgery). Associations with outcomes were assessed with multivariable logistic ordinal regression controlling for untoward events. Type of arthroplasty was evaluated in subanalyses., Results: Among 1227 patients (mean: 59 y, 50% women), 12% had arthroplasty (+TJA) and 88% did not (-TJA). In multivariable analysis, +TJA was associated with less global satisfaction (OR: 1.9, CI: 1.3-2.7, P=0.0007), worse global affective assessment (OR: 1.6, CI: 1.1-2.2, P=0.009), and not meeting MCID15 (OR: 1.5, CI: 1.0-2.3, P=0.05). Covariables associated with less favorable outcomes were not working, positive depression screen, and prior lumbar surgery. Compared with -TJA, patients with THA had worse affective assessments and patients with TKA had less satisfaction and were less likely to meet MCID15., Conclusions: Previous hip or knee arthroplasty was associated with less favorable patient-reported outcomes of lumbar surgery. Surgeons and patients should discuss differences between procedures preoperatively and during shared postoperative outcome assessment., Level of Evidence: Level II., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective study of prospective collected data., Objective: To analyze the association between intervertebral vacuum phenomenon (IVP) and clinical parameters in patients with degenerative spondylolisthesis., Summary of Background Data: IVP is a sign of advanced disc degeneration. The correlation between IVP severity and low back pain in patients with degenerative spondylolisthesis has not been previously analyzed., Methods: We retrospectively analyzed patients with degenerative spondylolisthesis who underwent surgery. Vacuum phenomenon was measured on computed tomography scan and classified into mild, moderate, and severe. A lumbar vacuum severity (LVS) scale was developed based on vacuum severity. The associations between IVP at L4/5 and the LVS scale, preoperative and postoperative low back pain, as well as the Oswestry Disability Index was assessed. The association of IVP at L4/5 and the LVS scale and surgical decision-making, defined as decompression alone or decompression and fusion, was assessed through univariable logistic regression analysis., Results: A total of 167 patients (52.7% female) were included in the study. The median age was 69 years (interquartile range 62-72). Overall, 100 (59.9%) patients underwent decompression and fusion and 67 (40.1%) underwent decompression alone. The univariable regression demonstrated a significantly increased odds ratio (OR) for back pain in patients with more severe IVP at L4/5 [OR=1.69 (95% CI 1.12-2.60), P =0.01]. The univariable regressions demonstrated a significantly increased OR for increased disability with more severe L4/L5 IVP [OR=1.90 (95% CI 1.04-3.76), P =0.04] and with an increased LVS scale [OR=1.17 (95% CI 1.02-1.35), P =0.02]. IVP severity of the L4/L5 were associated with higher indication for fusion surgery., Conclusion: Our study showed that in patients with degenerative spondylolisthesis undergoing surgery, the severity of vacuum phenomenon at L4/L5 was associated with greater preoperative back pain and worse Oswestry Disability Index. Patients with severe IVP were more likely to undergo fusion., Competing Interests: A.A.S. reports royalties from Ortho Development, Corp.; private investments for Vestia Ventures MiRUS Investment, LLC, IVY II, LLC, ISPH II, LLC, ISPH 3, LLC, HSS ASC Development Network, LLC, and Centinel Spine (Vbros Venture Partners V); consulting fee from Depuy Synthes Products, Inc., Clariance, Inc., Kuros Biosciences AG, Ortho Development Corp., Medical Device Business Service, Inc.; speaking and teaching arrangements of DePuy Synthes Products, Inc.; membership of scientific advisory board of Depuy Synthes Products, Inc., Clariance, Inc., and Kuros Biosciences AG; Medical Device Business Service, Inc. and trips/travel of Medical Device Business; research support from Spinal Kinetics, Inc., outside the submitted work. F.P.C. reports royalties from NuVasive, Inc. Accelus; ownership interest for 4WEB Medical/4WEB, Inc.; Healthpoint Capital Partners, LP; ISPH II, LLC; ISPH 3 Holdings, LLC; Ivy Healthcare Capital Partners, LLC; Medical Device Partners II, LLC; Medical Device Partners III, LLC; Orthobond Corporation; Spine Biopharma, LLC; Tissue Differentiation Intelligence, LLC; VBVP VI, LLC; VBVP X, LLC; Woven Orthopedics Technologies; consulting fees from 4WEB Medical/4WEB, Inc., DePuy Synthes, NuVasive, Inc., Spine Biopharma, LLC, and Synexis, LLC, Accelus; membership of scientific advisory board/other office of Healthpoint Capital Partners, Medical Device Partners II, LLC, Orthobond Corporation, Spine Biopharma, LLC, and Woven Orthopedic Technologies; and research support from 4WEB Medical/4WEB, Inc., Mallinckrodt Pharmaceuticals, Camber Spine, and Centinel Spine, outside the submitted work. F.P.G. reports royalties from Lanx, Inc., and Ortho Development Corp.; private investments for BCIMD; and stock ownership of Healthpoint Capital Partners, LP, outside the submitted work. A.P.H. reports research support from Kuros Biosciences AG; and fellowship support from NuVasive, Inc. and Kuros Biosciences BV, outside the submitted work. G.S. receives consulting fees from Stryker and Camber spine. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This is a prospective observational study., Objective: The aim of this study is to determine the rate of occult infection after instrumented spine surgery in presumed aseptic patients., Summary of Background Data: The reported incidence rate of delayed/occult infection determined by positive culture swabs after instrumented spine surgery in prospective studies is 0.2%-6.9%. However, this rate may be higher as delayed infections are challenging to diagnose. Fever can be absent and inflammatory markers are often normal. If indolent organisms exist in low concentrations surrounding the instrumentation, these organisms can possibly avoid detection and disrupt bone formation leading to instrumentation loosening, pain generation, and/or failure of a solid fusion., Materials and Methods: This study included 50 consecutive presumed aseptic patients undergoing a posterior revision requiring removal of instrumentation at least 6 months following their index procedure. Common markers of infection were examined preoperatively. Multiple culture swabs were taken directly from the removed instrumentation and cultured for 14 days., Results: Of the 50 patients, 19 (38%) were culture-positive (CP) for bacteria upon removal of their instrumentation, with 14 patients (28%) having ≥2 positive specimens of the same organism. The average length of time between the index procedure and the revision surgery was 4.55 years (range: 0.53-21 y). Polymicrobial infections were found in 26% (5/19) of CP patients. The most prevalent microorganism found was Propionibacterium acnes, in 63% (12/19) of CP patients. There was no significant difference between CP and culture-negative patients regarding preoperative markers for infection, age, or length between index and revision procedures., Conclusions: The results of this study indicate a positive culture rate of 38% in presumed aseptic patients who had previously undergone instrumented spine surgery. These results are consistent with other retrospective studies and are >6 times greater than any previous prospective study utilizing culture swabs., Level of Evidence: Level-III., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Spondylotic degeneration in the cervical spine may result in static and/or dynamic spinal cord compression that can lead to the associated signs and symptoms of myelopathy. Clinical examination combined with appropriate imaging studies help to confirm the diagnosis. Classic natural history and basic science studies suggest a pernicious course of demyelination and neurologic decline in a large subset of patients. The characterization of disease severity and progression in patients with cervical spondylotic myelopathy has improved in recent years with imaging and data from prospective and multicenter studies. Additionally, advances in surgical techniques, implants, and imaging modalities have improved the identification of surgical candidates with cervical spondylotic myelopathy and associated treatment strategies. Surgical treatment, via an anterior, posterior, or a combined approach, is primarily intended to arrest neurologic progression, although it can improve function in many patients. Alignment and the characteristics and location of spinal cord compression help determine the ideal surgical approach. Distinct complications associated with each technique may be mitigated by appropriate patient selection and should be discussed preoperatively to ensure informed decision making., (Copyright 2015 by the American Academy of Orthopaedic Surgeons.)