Emerging Techniques in Degenerative Thoracolumbar Surgery

The Utility of the Validated Intraoperative Bleeding Scale in Thoracolumbar Spine Surgery: A Single-Center Prospective Study

STUDY DESIGN

Prospective, single-center study.

OBJECTIVE

To evaluate the clinical relevance of the validated intraoperative bleeding severity scale (VIBe) in thoracolumbar spine surgery.

METHODS

Adult patients aged 18 through 88 undergoing elective decompression, instrumentation, and fusion of the thoracolumbar spine were prospectively enrolled after informed consent was provided and written consent was obtained. Validated intraoperative bleeding severity scores were recorded intraoperatively. Univariate analysis consisted of Student T-tests, Pearson's χ2 Tests, Fisher's Exact Tests, linear regression, and binary logistic regression. Multivariable regression was conducted to adjust for baseline characteristics and potential confounding variables.

RESULTS

A total of N = 121 patients were enrolled and included in the analysis. After adjusting for confounders, VIBe scores were correlated with an increased likelihood of intraoperative blood transfusion (β = 2.46, P = .012), postoperative blood transfusion (β = 2.36, P = .015), any transfusion (β = 2.49, P < .001), total transfusion volume (β = 180.8, P = .020), and estimated blood loss (EBL) (β = 409, P < .001). Validated intraoperative bleeding severity scores had no significant association with length of hospital stay, 30-day readmission, 30-day reoperation, 30-day emergency department visit, change in pre- to post-op hemoglobin and hematocrit, total drain output, or length of surgery.

CONCLUSION

The VIBe scale is associated with perioperative transfusion rates and EBL in patients undergoing thoracolumbar spine surgery. Overall, the VIBe scale has clinically relevant meaning in spine surgery, and shows potential utility in clinical research.

LEVEL OF EVIDENCE

Level II.

Machine learning-based preoperative predictive analytics for lumbar spinal stenosis

OBJECTIVEPatient-reported outcome measures (PROMs) following decompression surgery for lumbar spinal stenosis (LSS) demonstrate considerable heterogeneity. Individualized prediction tools can provide valuable insights for shared decision-making. The authors aim to evaluate the feasibility of predicting short- and long-term PROMs, reoperations, and perioperative parameters by machine learning (ML) methods.METHODSData were derived from a prospective registry. All patients had undergone single- or multilevel mini-open facet-sparing decompression for LSS. The prediction models were trained using various ML-based algorithms to predict the endpoints of interest. Models were selected by area under the receiver operating characteristic curve (AUC). The endpoints were dichotomized by minimum clinically important difference (MCID) and included 6-week and 12-month numeric rating scales for back pain (NRS-BP) and leg pain (NRS-LP) severity and the Oswestry Disability Index (ODI), as well as prolonged surgery (> 45 minutes), extended length of hospital stay (> 28 hours), and reoperations.RESULTSA total of 635 patients were included. The average age was 62 ± 10 years, and 333 patients (52%) were male. At 6 weeks, MCID was seen in 63%, 76%, and 61% of patients for ODI, NRS-LP, and NRS-BP, respectively. At internal validation, the models predicted MCID in these variables with accuracies of 69%, 76%, and 85%, and with AUCs of 0.75, 0.79, and 0.92. At 12 months, 66%, 63%, and 51% of patients reported MCID; the observed accuracies were 62%, 74%, and 66%, with AUCs of 0.68, 0.72, and 0.79. Reoperations occurred in 60 patients (9.5%), of which 27 (4.3%) occurred at the index level. Overall and index-level reoperations were predicted with 69% and 63% accuracy, respectively, and with AUCs of 0.66 and 0.61. In 15%, a length of surgery greater than 45 minutes was observed and predicted with 78% accuracy and AUC of 0.54. Only 15% of patients were admitted to the hospital for longer than 28 hours. The developed ML-based model enabled prediction of extended hospital stay with an accuracy of 77% and AUC of 0.58.CONCLUSIONSPreoperative prediction of a range of clinically relevant endpoints in decompression surgery for LSS using ML is feasible, and may enable enhanced informed patient consent and personalized shared decision-making. Access to individualized preoperative predictive analytics for outcome and treatment risks may represent a further step in the evolution of surgical care for patients with LSS.

Current concepts and recent advances in understanding and managing lumbar spine stenosis

Lumbar spinal stenosis is a degenerative process that is extremely frequent in today's aging population. It can result in impingement on the nerves of the cauda equina or on the thecal sac itself, and lead to debilitating symptoms such as severe leg pain, or restriction in the perimeter of ambulation, both resulting in dependency in daily activities. The impact of the disease is global and includes financial repercussions because of its involvement in the active work force group. Risk factors for the disease include some comorbidities such as obesity or smoking, daily habits such as an active lifestyle, but also genetic factors that are not completely elucidated yet. The diagnosis of lumbar stenosis can be difficult, and involves a combination of radiological and clinical findings. Treatment ranges from conservative measures with physical therapy and core strengthening, to steroid injections in the facet joints or epidural space, to a more radical solution with surgical decompression. The evidence available in the literature regarding the causes, diagnosis and treatment of lumbar spine stenosis can be confusing, as no level I recommendations can be provided yet based on current data. The aim of this manuscript is to provide a comprehensive and updated summary to the reader addressing the multiple aspects of this disease.

Complications on minimally invasive oblique lumbar interbody fusion at L2-L5 levels: a review of the literature and surgical strategies

Fusion is the cornerstone in the treatment of an unstable degenerative lumbar spinal disease. Various techniques have been developed. Amongst these techniques exists the oblique lumbar interbody fusion (OLIF), which is the ante-psoas approach. Adequate restoration of disc height with large cages placed in the intervertebral space, indirect decompression, and correction of sagittal and coronal alignment can be achieved with OLIF procedure with the advantage of minimal risk for the psoas muscle and lumbar plexus. Nevertheless, this technique entails complications directly associated with the anatomical location where the fusion takes place. This surgical area is a window between the left lateral border of the aorta, or the left common iliac artery, and the anterior belly of the left psoas muscle. Vascular complications associated with the injury of the main vessels, segmental artery or iliolumbar vein of the lumbar spine have been reported, as well as urologic lesions due to ureter transgression, amongst others. Although these complications have been described in the literature, an article that complements this information with technical advice for its avoidance is yet to be published. This article is a review of the most frequent complications associated with the OLIF procedure in L2-L5 lumbar levels, as well as a description of technical strategies for the prevention of such complications.

Future Advances in Spine Surgery: The AOSpine North America Perspective

This focus issue highlights state-of-the-art techniques, equipment, and practices in the modern era of spine surgery while providing a glimpse into the next generation of patient care. A broad range of topics are presented to cover the full spectrum of the field. Degenerative diseases are discussed in a series of 3 articles on (1) pathophysiology, management, and surgical approaches to degenerative cervical myelopathy; (2) novel approaches to degenerative thoracolumbar disease (eg, interspinous process spacers, minimally invasive/endoscopic approaches); and (3) animal models and emerging therapeutics in degenerative disk disease. Also included is a unique study aiming to establish the critically important cost-benefit relationship for spine procedures with perspectives on how value is defined and how to address variability.Primary and metastatic spine oncology are reviewed with a focus on upcoming targeted biologics, subspecialized radiotherapy (eg, proton-beam, carbon-ion, stereotactic radiosurgery), genetic profiling to stratify risk, and morbidity-reducing surgical approaches (eg, minimally invasive/endoscopic resections, percutaneous instrumentation). Trauma is discussed in 2 high-quality papers on controversies in spinal trauma and neuroprotective/neuroregenerative interventions for traumatic spinal cord injury. A stimulating article on cervical, thoracolumbar, and pediatric deformity highlights the rapid evolution of deformity surgery with a look at innovative tools (eg, high-fidelity 3-dimensional reconstructions, magnetically controlled growing rods) and their impact on quality of life. Additionally, a must-read article on surgical site infections discusses key risk factors and evidence-based preventative techniques to remain aware of. Finally, cutting-edge technologies, including computer-assisted navigation, shared-control robotics, neuromodulation, novel osteobiologics, and biomaterials, are covered in detail in a series of 3 fascinating papers on the next generation of the field.Each section intends to highlight the salient literature and afford insights from multiple key thought leaders in an effort to minimize bias and provide varied perspectives. Overall, we hope this issue provides high-quality, evidence-based data relevant to trainees and practicing surgeons while also stimulating excitement about the future of spine surgery.