Practice preference and evidence analysis on topical use of tobramycin powder in lumbar spine surgery: A Multi-National AO spine survey with systematic review of the literature

STUDY DESIGN

Cross-sectional study with systematic review of literature.

OBJECTIVE

There is an increasing interest in the topical use of antibiotics to prevent infection following spine surgery. To extend the antibiotic coverage to the gram-negative spectrum, the usage of tobramycin powder is being considered. We surveyed to analyze the current practice preference on the use of topical tobramycin in lumbar spine surgery and also aimed to analyze the literature for current evidence on the same.

METHODS

A multinational cross-sectional survey was conducted among AO Spine members worldwide to understand the use of topical tobramycin in 1 or 2-level open lumbar fusion surgeries. Also, an independent systematic review of four scientific databases (PubMed, Scopus, clinicaltrials.gov, Web of Science) was performed by two authors to identify relevant articles in adherence to the preferred reporting in systematic reviews and meta-analysis (PRISMA) guidelines. Studies reporting the usage of tobramycin in lumbar spine surgeries were included for analysis.

RESULTS

Among the 231 participating surgeons, only 1.7 %(n = 4) reported utilizing tobramycin in 1 or 2-level open lumbar fusion surgery. Upon systematic review of the literature, two studies with 484 patients were included for analysis. With the usage of tobramycin as a topical antibiotic powder, both studies noted a reduction in the incidence of infection with change in the spectrum of infective organisms.

CONCLUSION

Topical Tobramycin is not the commonly preferred topical antibiotic to prevent SSI among spine surgeons worldwide. There is a lack of sufficient evidence to support the routine use of topical tobramycin in lumbar spine surgery.

Global Practices and Preferences in the Use of Osteobiologics for Anterior Cervical Discectomy and Fusion: A Cross-Sectional Study

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To assess global practices and preferences in the use of osteobiologics for anterior cervical discectomy and fusion (ACDF) and identify factors influencing the choice of specific osteobiologics.

METHODS

An online survey developed by AO Spine was distributed to spine surgeons worldwide. The survey captured demographic characteristics, osteobiologic use and related information (i.e., previous training, practice patterns, etc.), and factors influencing osteobiologic choice in ACDF. Descriptive statistics, Chi-square tests, and multiple logistic regression were used to analyze responses, focusing on the associations between osteobiologic use and variables such as training, cost awareness, and regional practices.

RESULTS

Responses from 458 surgeons revealed regional variability in osteobiologic preferences. Autologous iliac crest bone graft (AICBG) was predominant in Asia Pacific and Middle East, while allograft and demineralized bone matrix were favored in North America and Latin America (P < 0.0001). Over half of the respondents (79.7%) lacked formal training in osteobiologics, and 53.1% were unaware of related costs. Surgeons residing in the Asia Pacific region (OR: 0.47, 95% CI: 0.26-0.84, P = 0.0114), without formal training (OR: 0.53, 95% CI: 0.29-0.97, P = 0.0429), or using cages less often (OR: 0.15, 95% CI: 0.06-0.34, P < 0.0001) were less likely to utilize osteobiologics. Osteobiologic use was also more common when related costs were not an issue for the practitioner (OR: 2.32, 95% CI:1.47-3.70, P = 0.0004).

CONCLUSIONS

Significant variation exists in osteobiologic use in ACDF across global regions, influenced by surgeon training, cost awareness, and institutional resources. Enhanced training and guidelines could improve consistency in osteobiologic application.

Surgical strategies in management of ankylosed bilateral hips and knees in crouched posture

A 26-year-old wheelchair-bound man was brought to our institute with progressive painful deformity of both lower limbs involving bilateral hip and knee for the past 5 years. The patient was wheelchair-bound for the past 18 months. He was only able to crawl to meet his locomotor demands. On examination, the patient was in a crouched posture with mild kyphosis at the thoracolumbar region and ankylosis of bilateral hip and knee in an unfavourable position. Radiological and serological evaluation diagnosed him to be a case of neglected ankylosing spondylosis. We planned for arthroplasty of the bilateral hip and knee for correcting his posture and to regain his locomotor ability. The severity of the deformity mandated extensive releases and the handling of neurovascular structures. Hence, a holistic treatment plan with various surgical strategies was devised to manage his deformities. The patient made a good recovery and regained his locomotor ability without any major complications at a 2-year follow-up.

Next Generation Sequencing in orthopaedic infections - Where is the road headed?

Next-generation sequencing (NGS) has emerged as a game changer in the field of orthopaedic diagnostics, notably in the detection and management of infections associated with prosthetic joints and implants. This paper conducts an exhaustive examination of the pivotal role, outcomes, and prospective future uses of NGS in diagnosing orthopaedic infections. In comparison to conventional culture-based methods, NGS offers a marked improvement in sensitivity thereby facilitating prompt and comprehensive identification of pathogens. This encompasses the ability to detect polymicrobial infections, antibiotic-resistant strains, and previously imperceptible microorganisms. Furthermore, this article delves into the technology's contribution to advancing personalized medicine and promoting judicious antibiotic use. Nonetheless, the seamless integration of NGS into routine clinical practice is impeded by challenges such as substantial financial outlays, the requisite for specialized equipment and expertise, and the intricacy associated with data analysis. Notwithstanding these impediments, the potential for NGS to revolutionize orthopaedic diagnostics remains substantial, with ongoing advancements poised to address current limitations and broaden its scope within clinical applications.

Where Do We Stand in Stem Cell Therapy for the Management of Diabetes Mellitus?-A Scientometric Research Trend Analysis from 1990 to 2020

Stem cell therapy has been considered a promising strategy in the management of both type I and type II diabetes mellitus (DM) because of its immunomodulatory and regenerative capability to restore the beta cell number and function. Various modalities of cellular therapy like transplantation of pancreatic islet cells, transplantation of pancreatic ductal stem cells, and mesenchymal stromal cell transplantation have been tried, and the modality is undergoing rapid advancements that may become the reality in the near future. In the course of its evolution, it is essential to have a comprehensive summary of the progress for a greater capacity to refine our future directives. With technological developments like data mining, graphic drawing, and information analytics combined with computational statistics, visualization of scientific metrology has become a reality. With a newer perspective, we intend to use scientometric tools including text mining, co-word analysis, word frequency analysis, co-citation analysis, cluster network analysis, to perform a systematic and comprehensive analysis of the research trend in stem cell therapy in the management of DM over the past three decades (1990-2020) and to identify the future research hotspots.

What Radiographic and Spinopelvic Parameters do Spine Surgeons Consider in Decision-Making for Treatment of Degenerative Lumbar Spondylolisthesis?

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

Surgical treatment of degenerative lumbar spondylolisthesis is remarkably varied due to heterogeneity of clinical-radiological presentations. This study aimed to assess which spinopelvic radiological parameters were considered for decision-making.

METHODS

Survey distributed to International AO Spine members to analyze surgeons' considerations for treatment. Data collected includes demographics, training background, years of experience, and treatment decisions based on various radiographical findings, including segmental and global spinopelvic parameters.

RESULTS

From 479 responses, the most frequently radiological parameter considered was slippage on dynamic X-rays (79.1%), followed by disc height (78.9%), global sagittal balance SVA (71.4%), and PI-LL mismatch (69.7%), while the least important was absolute spondylolisthesis on static lateral radiograph (22.8%). Fellowship-trained surgeons were likelier to use SVA (OR = 1.73, 95% CI = 1.02-2.99, P = 0.049), and disc height (2.13, 1.14-3.98, P < 0.05). There was no difference between orthopedics and neurosurgery in applying SVA and PI-LL mismatch. Surgeons from Asia Pacific emphasizes segmental lordosis (2.39, 1.11-5.15, P = 0.026) as from Latin America (2.55, 1.09-5.95, P = 0.030) and Middle East (4.33, 1.66-11.28, P = 0.003). However, surgeons from Latin America and Middle East also significant consider disc height (2.95, 1.07-8.15, P = 0.037) and (3.03, 1.04-8.83, P = 0.043), respectively. Additionally, the surgeons' age was associated with using angular motion on flexion-extension radiographs, and volume of treated cases yearly with consideration for disc height.

CONCLUSIONS

Treatment of degenerative lumbar spondylolisthesis was influenced by slippage on dynamic radiographs, disc height, global alignment, and PI-LL mismatch. Surgeons' age and Region, fellowship-trained, and volume of treated cases were significantly associated to apply these radiological parameters.

Surgeon Preferences Worldwide in Wound Drain Utilization in Open Lumbar Fusion Surgery for Degenerative Pathologies

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

Although literature does not recommend routine wound drain utilization, there is a disconnect between the evidence and clinical practice. This study aims to explore into this controversy and analyze the surgeon preferences related to drain utilization, and the factors influencing drain use and criterion for removal.

METHODS

A survey was distributed to AO Spine members worldwide. Surgeon demographics and factors related to peri-operative drain use in 1 or 2-level open fusion surgery for lumbar degenerative pathologies were collected. Multivariate analyses by drain utilization, and criterion of removal were conducted.

RESULTS

231 surgeons participated, including 220 males (95.2%), orthopedics (178, 77.1%), and academic/university-affiliated (114, 49.4%). Most surgeons preferred drain use (186, 80.5%) and subfascial drains (169, 73.2%). Drains were removed based on duration by 52.87% of the surgeons, but 27.7% removed drains based on outputs. On multivariable analysis, significant predictors of drain use were surgeon's aged 35-44 (OR = 11.9, 95% CI = 1.2-117.2, P = .034), 45-54 (29.1, 3.1-269.6, P = .003), 55-64 (8.9, 1.4-56.5, .019), and wound closure using coaptive films (6.0, 1.2-29.0, P = .025). Additionally, surgeons from Asia Pacific (OR = 5.19, 95% CI = 1.65-16.38, P = .005), Europe (3.55, 1.22-10.31, P = .020), and Latin America (4.40, 1.09-17.83, .038) were more likely to remove drain based on time duration, but surgeons <5 years of experience (10.23, 1.75-59.71, P = .010) were more likely to remove drains based on outputs.

CONCLUSIONS

Most spine surgeons worldwide prefer to place a subfascial wound drain for degenerative open lumbar surgery. The choice for drain placement is associated with the surgeon's age and use of coaptive films for wound closure, while the criterion for drain removal is associated with the surgeons' region of practice and experience.

Conservative Treatment for Spontaneous Resolution of Postoperative Symptomatic Thoracic Spinal Epidural Hematoma-A Case Report

Introduction: Postoperative epidural hematomas of the cervical and thoracic spine can pose a great risk of rapid neurological impairment and sometimes require immediate decompressive surgery. Case Report: We present the case of a young patient operated on for stabilization of a two-level thoracic vertebra fracture who developed total paralysis due to an epidural hematoma postoperatively. The course of epidural hematoma was quickly reversed with the help of a conservative technique that prevented revision surgery. The patient regained complete neurologic function very rapidly, and has been well on every follow-up to date. Conclusion: There is a role of similar maneuvers as described in this case to be employed in the management of postoperative epidural hematomas. However, prolonged watchful waiting should still be discouraged, and patients should remain ready for revision surgery if there are no early signs of rapid recovery.

Global, regional, and national burden of suicide, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Deaths from suicide are a tragic yet preventable cause of mortality. Quantifying the burden of suicide to understand its geographical distribution, temporal trends, and variation by age and sex is an essential step in suicide prevention. We aimed to present a comprehensive set of global, regional, and national estimates of suicide burden.

METHODS

We produced estimates of the number of deaths and age-standardised mortality rates of suicide globally, regionally, and for 204 countries and territories from 1990 to 2021, and disaggregated these results by age and sex. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 estimates of deaths attributable to suicide were broken down into two comprehensive categories: those by firearms and those by other specified means. For this analysis, we also produced estimates of mean age at the time of death from suicide, incidence of suicide attempts compared with deaths, and age-standardised rates of suicide by firearm. We acquired data from vital registration, verbal autopsy, and mortality surveillance that included 23 782 study-location-years of data from GBD 2021. Point estimates were calculated from the average of 1000 randomly selected possible values of deaths from suicide by age, sex, and geographical location. 95% uncertainty intervals (UIs) were derived from the 2·5th and 97·5th percentiles from a 1000-draw distribution.

FINDINGS

Globally, 746 000 deaths (95% UI 692 000-800 000) from suicide occurred in 2021, including 519 000 deaths (485 000-556 000) among males and 227 000 (200 000-255 000) among females. The age-standardised mortality rate has declined over time, from 14·9 deaths (12·8-15·7) per 100 000 population in 1990 to 9·0 (8·3-9·6) per 100 000 in 2021. Regionally, mortality rates due to suicide were highest in eastern Europe (19·2 [17·5-20·8] per 100 000), southern sub-Saharan Africa (16·1 [14·0-18·3] per 100 000), and central sub-Saharan Africa (14·4 [11·0-19·1] per 100 000). The mean age at which individuals died from suicide progressively increased during the study period. For males, the mean age at death by suicide in 1990 was 43·0 years (38·0-45·8), increasing to 47·0 years (43·5-50·6) in 2021. For females, it was 41·9 years (30·9-46·7) in 1990 and 46·9 years (41·2-52·8) in 2021. The incidence of suicide attempts requiring medical care was consistently higher at the regional level for females than for males. The number of deaths by suicide using firearms was higher for males than for females, and substantially varied by country and region. The countries with the highest age-standardised rate of suicides attributable to firearms in 2021 were the USA, Uruguay, and Venezuela.

INTERPRETATION

Deaths from suicide remain variable by age and sex and across geographical locations, although population mortality rates have continued to improve globally since the 1990s. This study presents, for the first time in GBD, a quantification of the mean age at the time of suicide death, alongside comprehensive estimates of the burden of suicide throughout the world. These analyses will help guide future approaches to reduce suicide mortality that consider a public health framework for prevention.

FUNDING

Bill & Melinda Gates Foundation.

Combating antimicrobial resistance in osteoarticular infections: Current strategies and future directions

The emergence of antimicrobial resistance (AMR) has profoundly impacted the management of osteoarticular infections (OAIs), presenting significant challenges for healthcare systems worldwide. This review provides a comprehensive overview of the current landscape of AMR in OAIs, emphasizing the necessity for assertive and innovative strategies to combat this escalating health threat. It discusses the evolution of resistance among key pathogens, including ESKAPEE organisms, and the implications for treatment protocols and healthcare outcomes. The importance of antibiotic stewardship programs (ASPs) is highlighted as a core strategy to optimize antibiotic use and mitigate the development of resistance. Additionally, the review explores the potential of pharmacological approaches, including novel antibiotic regimens and combination therapies, alongside surgical interventions and alternative therapies such as bacteriophage-based treatments and probiotics, in managing these complex infections. The role of rapid diagnostic methods in improving treatment accuracy and the critical need for global surveillance to track AMR trends are also examined. By integrating insights from recent literature and expert recommendations, this review underscores the multifaceted approach required to address the challenge of AMR in OAIs effectively. It calls for a concerted effort among clinicians, researchers, and policymakers to foster innovation in treatment strategies, enhance diagnostic capabilities, and implement robust stewardship and surveillance programs. The goal is to adapt to the evolving landscape of OAIs and ensure optimal patient care in the face of rising AMR.

Internet of Things enabled open source assisted real-time blood glucose monitoring framework

Regular monitoring of blood glucose levels is essential for the management of diabetes and the development of appropriate treatment protocols. The conventional blood glucose (BG) testing have an intrusive technique to prick the finger and it can be uncomfortable when it is a regular practice. Intrusive procedures, such as fingerstick testing has negatively influencing patient adherence. Diabetic patients now have an exceptional improvement in their quality of life with the development of cutting-edge sensors and healthcare technologies. intensive care unit (ICU) and pregnant women also have facing challenges including hyperglycemia and hypoglycemia. The worldwide diabetic rate has incited to develop a wearable and accurate non-invasive blood glucose monitoring system. This research developed an Internet of Things (IoT) - enabled wearable blood glucose monitoring (iGM) system to transform diabetes care and enhance the quality of life. The TTGOT-ESP32 IoT platform with a red and near-infrared (R-NIR) spectral range for blood glucose measurement has integrated into this wearable device. The primary objective of this gadget is to provide optimal comfort for the patients while delivering a smooth monitoring experience. The iGM gadget is 98.82 % accuracy when used after 10 hours of fasting and 98.04 % accuracy after 2 hours of breakfast. The primary objective points of the research were continuous monitoring, decreased risk of infection, and improved quality of life. This research contributes to the evolving field of IoT-based healthcare solutions by streaming real-time glucose values on AWS IoT Core to empower individuals with diabetes to manage their conditions effectively. The iGM Framework has a promising future with the potential to transform diabetes management and healthcare delivery.

Global pattern, trend, and cross-country inequality of early musculoskeletal disorders from 1990 to 2019, with projection from 2020 to 2050

BACKGROUND

This study aims to estimate the burden, trends, forecasts, and disparities of early musculoskeletal (MSK) disorders among individuals ages 15 to 39 years.

METHODS

The global prevalence, years lived with disabilities (YLDs), disability-adjusted life years (DALYs), projection, and inequality were estimated for early MSK diseases, including rheumatoid arthritis (RA), osteoarthritis (OA), low back pain (LBP), neck pain (NP), gout, and other MSK diseases (OMSKDs).

FINDINGS

More adolescents and young adults were expected to develop MSK disorders by 2050. Across five age groups, the rates of prevalence, YLDs, and DALYs for RA, NP, LBP, gout, and OMSKDs sharply increased from ages 15-19 to 35-39; however, these were negligible for OA before age 30 but increased notably at ages 30-34, rising at least 6-fold by 35-39. The disease burden of gout, LBP, and OA attributable to high BMI and gout attributable to kidney dysfunction increased, while the contribution of smoking to LBP and RA and occupational ergonomic factors to LBP decreased. Between 1990 and 2019, the slope index of inequality increased for six MSK disorders, and the relative concentration index increased for gout, NP, OA, and OMSKDs but decreased for LBP and RA.

CONCLUSIONS

Multilevel interventions should be initiated to prevent disease burden related to RA, NP, LBP, gout, and OMSKDs among individuals ages 15-19 and to OA among individuals ages 30-34 to tightly control high BMI and kidney dysfunction.

FUNDING

The Global Burden of Disease study is funded by the Bill and Melinda Gates Foundation. The project is funded by the Scientific Research Fund of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital (2022QN38).

Mechanical Basis of Lumbar Intervertebral Disk Degeneration

The etiology of degenerative disk disease (DDD) is multifactorial. Among the various factors, mechanical processes contributing to endplate or discal injuries have been discussed as the initiating events in the degenerative cascade. DDD encompasses the multitudinous changes undergone by the different structures of the spinal segment, namely intervertebral disk (IVD), facet joints, vertebral end plate (VEP), adjoining marrow (Modic changes), and vertebral body. It has been etiologically linked to a complex interplay of diverse mechanisms. Mechanically, two different mechanisms have been proposed for intervertebral disk degeneration (IVDD): endplate-driven, especially in upper lumbar levels, and annulus-driven degeneration. VEP is the weakest link of the lumbar spine, and fatigue damage can be inflicted upon them under physiological loads, leading to the initiation of DDD. Disk calcification has been put forth as another initiator of inflammation, stiffening, and abnormal stresses across the IVD. The initial mechanical disruption leads to secondary IVDD through unfavorable loading of the nucleus pulposus and annulus fibrosis. The final degenerative cascade is then propagated through a combination of biological, inflammatory, autoimmune, or metabolic pathways (impaired transport of metabolites or nutrients). Abnormal spinopelvic alignment, especially pelvic incidence, also significantly impacts the degenerative process. Hence, the etiology of DDD is multifactorial. Mechanical pathways, including VEP injuries, increased disk stiffness, and abnormal spinopelvic alignment, play a significant role in the initiation of IVDD.

Chondrogenic Potential of Umbilical Cord-Derived Mesenchymal Stromal Cells: Insights and Innovations

BACKGROUND

The advent of tissue engineering and regenerative medicine has introduced innovative approaches to treating degenerative and traumatic injuries, particularly in cartilage, a tissue with limited self-repair capabilities. Among the various stem cell sources, umbilical cord-derived mesenchymal stromal cells (UC-MSCs) have garnered significant interest due to their non-invasive collection, minimal ethical concerns, and robust regenerative potential, particularly in cartilage regeneration.

METHODS

A comprehensive literature review was conducted using multiple databases, including PubMed, Scopus, Web of Science, and Google Scholar. Search terms focused on "umbilical cordderived mesenchymal stromal cells," "chondrogenesis," "cartilage regeneration," and related topics. Studies published in the past two decades were included, with selection criteria emphasizing methodological rigor and relevance to UC-MSC chondrogenesis. The review synthesizes findings from various sources to provide a thorough analysis of the potential of UC-MSCs in cartilage tissue engineering.

RESULTS

UC-MSCs exhibit significant chondrogenic potential, supported by their ability to differentiate into chondrocytes under specific conditions. Recent advancements include the development of biomaterial scaffolds and the application of genetic engineering techniques, such as CRISPR/Cas9, to enhance chondrogenic differentiation. Despite these advancements, challenges remain in standardizing cell isolation techniques, scaling up production for clinical use, and ensuring the long-term functionality of regenerated cartilage.

CONCLUSION

UC-MSCs offer a promising solution for cartilage regeneration in the field of regenerative medicine. Ongoing research is focused on overcoming current challenges through the use of advanced technologies, including bioreactors and gene editing. Collaborative efforts among researchers, clinicians, and bioengineers are essential to translating the potential of UC-MSCs into effective clinical therapies, which could significantly advance tissue regeneration and therapeutic innovation.

The efficiency of machine learning-assisted platform for article screening in systematic reviews in orthopaedics

PURPOSE

With the development of machine learning and artificial intelligence, various platforms were developed to aid in the time-consuming process of article screening in systematic reviews. We aim to analyze the efficiency of a machine learning-assisted platform as an end-user to aid in the screening of the articles for selection into systematic review in orthopaedic surgery.

METHODS

We included three previously published systematic reviews in the field of orthopaedics of increasing levels of difficulty in the structure of the research question to assess the efficiency of a platform with active-learning technology for article screening. We compared the efficiency of the platform compared to the traditional screening and also across the various scenarios tested. We performed five iterations for each review analyzed. The outcome parameters analyzed were the work saved at 95% recall (WSS-95), work saved at 100% recall (WSS-100), and relevant records found after screening the first 30% of the total records (RRF-30).

RESULTS

The machine learning-assisted screening significantly improved the rate of identifying the relevant records compared to the traditional screening method (p<0.001). The WSS-95 for the easy, intermediate, and advanced screening scenarios were 78%, 59%, and 38%, respectively. The WSS-100 for the easy, intermediate, and advanced screening scenarios were 75%, 48%, and 7%, respectively. The RRF-30 for the easy, intermediate, and advanced screening scenarios were 97%, 86%, and 64%, respectively. We noted a significant reduction (p<0.001) in the efficiency with the increasing level of difficulty of the screening scenarios.

CONCLUSION

The machine learning platform is significantly better than the traditional method as an assistive technology to aid in article screening. However, the efficiency of the platform significantly decreases as the complexity of the research question increases.

Sexual Dysfunction in Cervical Spondylomyelopathy and Its Prognosis Following Surgical Decompression: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

While the occurrence of sexual dysfunction in patients sustaining traumatic cervical or thoracic injuries is well acknowledged, the evidence regarding its prevalence and outcome in individuals with degenerative cervical myelopathy (DCM) is still limited. The current systematic review was planned to comprehensively evaluate the existing literature regarding the prevalence, patterns, presentation, and outcome of sexual dysfunction in patients presenting with DCM.

METHODS

A thorough search of the literature was performed on October 15, 2024, using 5 different databases (Google Scholar, Embase, PubMed, Web of Science and Cochrane Library). Studies on sexual dysfunction in DCM published until 2024 were scrutinized. Narrative or systematic reviews, opinions, letters to the editor, and manuscripts published in non-English languages were excluded.

RESULTS

Overall, the literature search yielded a total of 384 articles of which 7 articles with 910 patients were included in the analysis. The overall prevalence of erectile dysfunction (ED) in CSM ranges between 3 and 6%. 82% of patients with preoperative ED had an abnormal psychogenic erection while the remaining had an abnormal reflexogenic erectile function. The erectile function was reported to improve substantially following decompressive surgery (68% recovery rate; P = 0.05). The presence of preoperative sexual dysfunction has been associated with poorer neurological outcomes (50% recovery rate; including poorer gait recovery). The data regarding ejaculatory disturbances and female sexual dysfunction in DCM patients are still limited.

CONCLUSION

ED occurs in 3 to 6% of patients with DCM, with a majority of patients suffering from ED from psychogenic origin. Surgical decompression can significantly improve the sexual recovery in these patients. Patients with ED have overall poorer neurological recovery.

Comparison of Revision Rates Among Patients Undergoing 2-Level ACDF, CDR, and Hybrid Constructs

STUDY DESIGN

Retrospective database study.

OBJECTIVE

Compare the revision rates of 2-level ACDF, CDR, and hybrid ACDF/CDR.

SUMMARY OF BACKGROUND DATA

While single-level CDR has been extensively studied, multilevel CDR and hybrid ACDF/CDR constructs have been less well studied.

METHODS

This study utilized a large commercial insurance database of patients 65 years old or younger. Patients undergoing 2-level ACDF, 2-level CDR, and hybrid 2-level ACDF/CDR were identified. Patients age 18 years or older with malignant, infectious, or neoplastic etiologies were excluded, as were those undergoing revision surgery or any concomitant posterior cervical surgery. Study follow-up was terminated at 5 years postoperatively. The primary outcome was revision surgery, including anterior and posterior decompression, fusion, and arthroplasty.

RESULTS

A total of 99,282 patients were included. The mean age was 51.3 years old (SD 8.1). The mean maximum follow-up was 2.1 years (SD 1.7). In all 3.2% (n=3197) underwent 2-level CDR, 0.5% (n=448) underwent hybrid 2-level ACDF/CDR, and 96.3% (n=95,637) underwent 2-level ACDF. At 5 years postoperatively, in Kaplan-Meier analysis, revision occurred in 10.0% of the CDR group, 12.4% of the hybrid group, and 10.0% of the ACDF group. In multivariable regression analysis, no significant differences in revision occurrence were observed between the CDR, hybrid, and ACDF groups (P<0.15 for all comparisons). In multivariable regression analysis stratified by plate versus stand-alone cage, patients with plated hybrid constructs had higher revision rates than those with both plated ACDF constructs (HR: 1.5, P=0.0387) and 2-level CDR (HR: 1.5, P=0.0477).

CONCLUSIONS

In this retrospective database study of patients 65 years old or younger undergoing 2-level anterior cervical surgery, there were no significant differences at 5-year follow-up in revision rates for patients undergoing 2-level CDR, 2-level ACDF, and hybrid ACDF/CDR surgeries. In subanalysis, patients specifically with a plated hybrid ACDF/CDR had a higher occurrence of revision versus those undergoing plated 2-level ACDF or 2-level CDR. Future multicenter, prospective research is necessary to further assess these findings.

Complications With Demineralized Bone Matrix, Hydroxyapatite and Beta-Tricalcium Phosphate in Single and Two-Level Anterior Cervical Discectomy and Fusion Surgery

STUDY DESIGN

Systematic literature review.

OBJECTIVES

To analyze the evidence available reporting complications in single or two-level anterior cervical discectomy and fusion (ACDF) using a demineralized bone matrix (DBM), hydroxyapatite (HA), or beta-tricalcium phosphate (β-TCP).

METHODS

A systematic review of the literature using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases was performed in August 2020 to identify studies reporting complications in one or two-level ACDF surgery using DBM, HA, or β-TCP. The study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

RESULTS

A total of 1857 patients were included, 981 male and 876 female, across 17 articles; 5 prospective, and 12 retrospectives. We noted heterogeneity among the included studies concerning the study design and combination of graft materials utilized in them. However, we noted a higher incidence of adjacent segment disease (17.7%) and pseudoarthrosis (9.3%) in fusion constructs using DBM. Studies using β-TCP reported a higher incidence of pseudoarthrosis (28.2%) and implant failures (17.9%).

CONCLUSIONS

Degenerative cervical conditions treated with one or two-level ACDF surgery using DBM, HA, or β-TCP with or without cervical plating are associated with complications such as adjacent segment disease, dysphagia, and pseudarthrosis. However, consequent to the study designs and clinical heterogeneity of the studies, it is not possible to correlate these complications accurately with any specific graft material employed. Further well-designed prospective studies are needed to correctly know the related morbidity of each graft used for achieving fusion in ACDF.

Rate of Reoperation Following Decompression-Only Procedure for Lumbar Degenerative Spondylolisthesis: A Systematic Review of Literature

BACKGROUND

Management of lumbar degenerative spondylolisthesis with decompression-only procedure has been performed for its added benefit of a shorter duration of surgery, lower blood loss, and shorter hospital stay. However, reported failure rates for decompression-only procedures vary depending on the methods utilized for decompression. Hence, we aim to identify the failure rates of individual methods of decompression-only procedures performed for degenerative lumbar spondylolisthesis.

METHODS

An independent systematic review of 4 scientific databases (PubMed, Scopus, clinicaltrials.gov, Web of Science) was performed to identify relevant articles as per the preferred reporting in systematic reviews and meta-analysis guidelines. Studies reporting on failure rates defined by reoperation at the index level following decompression-only procedure for degenerative lumbar spondylolisthesis were included for analysis. Studies were appraised using ROBINS tool of Cochrane, and analysis was performed using the Open Meta[Analyst] software.

RESULTS

The overall failure rate of decompression-only procedure was 9.1% (95% confidence interval [CI] [6.5-11.7]). Furthermore, open decompression had failure rate of 10.9% (95% CI [6.0-15.8]), while microendoscopic decompression had failure rate of 6.7% (95% CI [2.9-10.6]). The failure rate gradually increased from 6.9% (95% CI [2.0-11.7]) at 1 year to 7% (95% CI [3.6-10.3]), 11.7% (95% CI [4.5-18.9]), and 11.7% (95% CI [6.6-16.7]) at 2, 3, and 5 years, respectively. Single level decompression had a failure rate of 9.6% (95% CI [6.3-12.9]), while multilevel decompression recorded a failure rate of 8.7% (95% CI [5.6-11.7]).

CONCLUSION

High-quality evidence on the decompression-only procedure for degenerative spondylolisthesis is limited. The decompression-only procedure had an overall failure rate of 9.1% without significant differences between the decompression techniques.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Trending Literature in Spinal Tuberculosis: Bibliographic Analysis of Top 250 Cited Articles

BACKGROUND

This bibliographic analysis aims to identify the top 250 cited articles on spinal tuberculosis (TB) and report on their impact on the spinal field.

METHODS

All databases included in the Thomson Reuters Web of Science were searched for publications on spinal TB. The most cited articles published between 1950 and 2019, with the main focus on orthopaedic surgery, were identified using a multistep approach, and a total of 250 articles were included and analyzed for title, year of publication, total citations, citations in 2019, citation density, article age, journal, first author, senior author, geographic origin, and level of evidence.

RESULTS

The number of citations ranged from 31 to 257, with an average of 65.38. Studies were published from 31 different countries and published in 83 different journals. The top 3 countries, India, United States, and China published a total of 57.8% (n = 145) of all articles. Indian and Chinese researchers seem to be the most resourceful, as 17 of the 31 (54.8%) prospective studies were conducted by them. African centers produced only 3.2% (n = 8) of all included articles. Only 3.2% (n = 8) were of Level 1 evidence on the subject. A total of 37.8% (n = 95) were on diagnosis, while 46.6% (n = 117) dealt with surgery, and only 15.1% (n = 38) were about conservative management. Anil K Jain followed by S Rajasekaran were the most published authors on the subject.

CONCLUSIONS

Indian and Chinese researchers dominate evidence in spinal TB. Regions with high disease burden, such as Africa, do not contribute their data to the literature. Though these are the top cited articles in the subject, their level of evidence needs improvement for better impact of their results.

AO Spine Guideline for the Use of Osteobiologics (AOGO) in Anterior Cervical Discectomy and Fusion for Spinal Degenerative Cases

STUDY DESIGN

Guideline.

OBJECTIVES

To develop an international guideline (AOGO) about the use of osteobiologics in anterior cervical discectomy and fusion (ACDF) for treating degenerative spine conditions.

METHODS

The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus.

RESULTS

Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about the use of osteobiologic for single- or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 (BMP-2) in common clinical situations. Surgeons are recommended to choose 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials.

CONCLUSION

This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore, high-quality clinical evidence is demanded to improve the guideline.

Is platelet-rich plasma better than steroids as epidural drug of choice in lumbar disc disease with radiculopathy? Meta-analysis of randomized controlled trials

The current meta-analysis was performed to analyze the efficacy and safety of platelet-rich plasma (PRP) as an epidural injectate, in comparison with steroids in the management of radiculopathy due to lumbar disc disease (LDD). We conducted independent and duplicate searches of the electronic databases (PubMed, Embase and Cochrane Library) in March 2024 to identify randomized controlled trials (RCTs) analyzing the efficacy of epidural PRP for pain relief in the management of LDD. Animal or in vitro studies, clinical studies without a comparator group, and retrospective or non-randomised clinical studies were excluded. Diverse post-intervention pain scores [visual analog score (VAS)] and functional scores [Oswestry Disability Index (ODI), SF-36], as reported in the reviewed studies, were evaluated. Statistical analysis was performed using STATA 17 software. 5 RCTs including 310 patients (PRP/Steroids = 153/157) were included in the analysis. The included studies compared the efficacy and safety of epidural PRP and steroids at various time-points including 1, 3, 6, 12, 24, and 48 weeks. Epidural PRP injection was found to offer comparable pain relief (VAS; WMD = -0.09, 95% CI [-0.66, 0.47], p = 0.641; I2 = 96.72%, p < 0.001), functional improvement (ODI; WMD = 0.72, 95% CI [-6.81, 8.25], p = 0.524; I2 = 98.73%, p < 0.001), and overall health improvement (SF-36; WMD = 1.01, 95% CI [-1.14, 3.17], p = 0.224; I2 = 0.0%, p = 0.36) as epidural steroid injection (ESI) at all the observed time points in the included studies without any increase in adverse events or complications. Epidural administration of PRP offers comparable benefit as epidural steroid injection (ESI) in the management of radiculopathy due to LDD. The safety profile of the epidural PRP is also similar to ESI.