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Camino-Willhuber G, Tani S, Kelly MJ, Schonnagel L, Caffard T, Chiapparelli E, Gorgy G, Dalton D, Zhu J, Shue J, Zelenty WD, Cammisa FP, Girardi FP, Hughes AP, Sama AA, Sokunbi G. Discrepancies in recommendations for return to regular activities after cervical spine surgery: A survey study. N Am Spine Soc J 2024; 18:100316. [PMID: 38572467 PMCID: PMC10987327 DOI: 10.1016/j.xnsj.2024.100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/01/2024] [Accepted: 02/12/2024] [Indexed: 04/05/2024]
Abstract
Background The recommended timing for returning to common activities after cervical spine surgery varies widely among physicians based on training background and personal opinion, without clear guidelines or consensus. The purpose of this study was to analyze spine surgeons' responses about the recommended timing for returning to common activities after different cervical spine procedures. Methods This was a survey study including 91 spine surgeons. The participants were asked to complete an anonymous online survey. Questions regarding their recommended time for returning to regular activities (showering, driving, biking, running, swimming, sedentary work, and nonsedentary work) after anterior cervical decompression and fusion (ACDF), cervical disc replacement (CDR), posterior cervical decompression and fusion (PCDF), and laminoplasty were included. Comparisons of recommended times for return to activities after each surgical procedure were made based on surgeons' years in practice. Results For ACDF and PCDF, there were no statistically significant differences in recommended times for return to any activity when stratified by years in practice. When considering CDR, return to non-sedentary work differed between surgeons in practice for 10 to 15 years, who recommended return at 3 months, and all other groups of surgeons, who recommended 6 weeks. Laminoplasty surgery yielded the most variability in activity recommendations, with earlier recommended return (6 weeks) to biking, non-sedentary work, and sedentary work in the most experienced surgeon group (>15 years in practice) than in all other surgeon experience groups (3 months). Conclusions We observed significant variability in surgeon recommendations for return to regular activities after cervical spine surgery.
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Affiliation(s)
- Gaston Camino-Willhuber
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Soji Tani
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Michael J. Kelly
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Lukas Schonnagel
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Thomas Caffard
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Erika Chiapparelli
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - George Gorgy
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - David Dalton
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, United States
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - William D. Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Frank P. Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Federico P. Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Alexander P. Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Andrew A. Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
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2
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Caffard T, Arzani A, Verna B, Tripathi V, Chiapparelli E, Schönnagel L, Zhu J, Medina SJ, Tani S, Camino-Willhuber G, Guven AE, Amoroso K, Tan ET, Carrino JA, Shue J, Dobrindt O, Zippelius T, Dalton D, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Importance of the cervical paraspinal muscles in postoperative patient-reported outcomes and maintenance of sagittal alignment after anterior cervical discectomy and fusion. J Neurosurg Spine 2024:1-10. [PMID: 38701526 DOI: 10.3171/2024.2.spine23926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/13/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE The aim of this study was to investigate the influence of preoperatively assessed paraspinal muscle parameters on postoperative patient-reported outcomes and maintenance of cervical sagittal alignment after anterior cervical discectomy and fusion (ACDF). METHODS Patients with preoperative and postoperative standing cervical spine lateral radiographs and preoperative cervical MRI who underwent an ACDF between 2015 and 2018 were reviewed. Muscles from C3 to C7 were segmented into 4 functional groups: anterior, posteromedial, posterolateral, and sternocleidomastoid. The functional cross-sectional area and also the percent fat infiltration (FI) were calculated for all groups. Radiographic alignment parameters collected preoperatively and postoperatively included C2-7 lordosis and C2-7 sagittal vertical axis (SVA). Neck Disability Index (NDI) scores were recorded preoperatively and at 2 and 4-6 months postoperatively. To investigate the relationship between muscle parameters and postoperative changes in sagittal alignment, multivariable linear mixed models were used. Multivariable linear regression models were used to analyze the correlations between the changes in NDI scores and the muscles' FI. RESULTS A total of 168 patients with NDI and 157 patients with sagittal alignment measurements with a median follow-up of 364 days were reviewed. The mixed models showed that a greater functional cross-sectional area of the posterolateral muscle group at each subaxial level and less FI at C4-6 were significantly associated with less progression of C2-7 SVA over time. Moreover, there was a significant correlation between greater FI of the posteromedial muscle group measured at the C7 level and less NDI improvement at 4-6 months after ACDF. CONCLUSIONS The findings highlight the importance of preoperative assessment of the cervical paraspinal muscle morphology as a predictor for patient-reported outcomes and maintenance of C2-7 SVA after ACDF.
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Affiliation(s)
- Thomas Caffard
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 2Department of Orthopedic Surgery, University of Ulm, Germany
| | - Artine Arzani
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Bruno Verna
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Vidushi Tripathi
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | | | - Lukas Schönnagel
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 3Center for Musculoskeletal Surgery, University of Berlin, Germany
| | - Jiaqi Zhu
- 4Biostatistics Core, Hospital for Special Surgery, New York, New York
| | - Samuel J Medina
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Soji Tani
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 5Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan; and
| | | | - Ali E Guven
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 3Center for Musculoskeletal Surgery, University of Berlin, Germany
| | - Krizia Amoroso
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Ek Tsoon Tan
- 6Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
| | - John A Carrino
- 6Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
| | - Jennifer Shue
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Oliver Dobrindt
- 2Department of Orthopedic Surgery, University of Ulm, Germany
| | - Timo Zippelius
- 2Department of Orthopedic Surgery, University of Ulm, Germany
| | - David Dalton
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Andrew A Sama
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | | | - Frank P Cammisa
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
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3
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Caffard T, Medina SJ, Arzani A, Chiapparelli E, Schönnagel L, Tani S, Camino-Willhuber G, Zhu J, Dalton D, Zippelius T, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Association patterns between lumbar paraspinal muscles and sagittal malalignment in preoperative patients undergoing lumbar three-column osteotomy. Spine Deform 2024; 12:801-809. [PMID: 38472693 DOI: 10.1007/s43390-024-00828-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/13/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE We aim to investigate the associations between lumbar paraspinal muscles and sagittal malalignment in patients undergoing lumbar three-column osteotomy. METHODS Patients undergoing three-column osteotomy between 2016 and 2021 with preoperative lumbar magnetic resonance imaging (MRI) and whole spine radiographs in the standing position were included. Muscle measurements were obtained using a validated custom software for segmentation and muscle evaluation to calculate the functional cross-sectional area (fCSA) and percent fat infiltration (FI) of the m. psoas major (PM) as well as the m. erector spinae (ES) and m. multifidus (MM). Spinopelvic measurements included pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), L1-S1 lordosis (LL), T4-12 thoracic kyphosis (TK), spino-sacral angle (SSA), C7-S1 sagittal vertical axis (SVA), T1 pelvic angle (TPA) and PI-LL mismatch (PI - LL). Statistics were performed using multivariable linear regressions adjusted for age, sex, and body mass index (BMI). RESULTS A total of 77 patients (n = 40 female, median age 64 years, median BMI 27.9 kg/m2) were analyzed. After adjusting for age, sex and BMI, regression analyses demonstrated that a greater fCSA of the ES was significantly associated with greater SS and SSA. Moreover, our results showed a significant correlation between a greater FI of the ES and a greater kyphosis of TK. CONCLUSION This study included a large patient cohort with sagittal alignment undergoing three-column osteotomy and is the first to demonstrate significant associations between the lumbar paraspinal muscle parameters and global sagittal alignment. Our findings emphasize the importance of the lumbar paraspinal muscles in sagittal malalignment.
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Affiliation(s)
- Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Samuel J Medina
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Soji Tani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Gaston Camino-Willhuber
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, USA
| | - David Dalton
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Timo Zippelius
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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4
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Caffard T, Arzani A, Verna B, Tripathi V, Chiapparelli E, Medina SJ, Schönnagel L, Tani S, Camino-Willhuber G, Amoroso K, Guven AE, Zhu J, Tan ET, Carrino JA, Shue J, Awan Malik H, Zippelius T, Dalton D, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Association Between Cervical Sagittal Alignment and Subaxial Paraspinal Muscle Parameters. Spine (Phila Pa 1976) 2024; 49:621-629. [PMID: 38098290 DOI: 10.1097/brs.0000000000004897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/04/2023] [Indexed: 04/11/2024]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE The authors aim to investigate the association between muscle functional group characteristics and sagittal alignment parameters in patients undergoing anterior cervical discectomy and fusion. SUMMARY OF BACKGROUND DATA The relationship between the morphology of cervical paraspinal muscles and sagittal alignment is not well understood. MATERIALS AND METHODS Patients with preoperative cervical magnetic resonance imaging and cervical spine lateral radiographs in standing position who underwent anterior cervical discectomy and fusion between 2015 and 2018 were reviewed. Radiographic alignment parameters included C2 to 7 lordosis, C2 to 7 sagittal vertical axis (SVA), C2 slope, neck tilt, T1 slope, and thoracic inlet angle. Muscles from C3 to C7 were categorized into four functional groups: sternocleidomastoid group, anterior group, posteromedial group, and posterolateral group (PL). A custom-written Matlab software was used to assess the functional cross-sectional area (fCSA) and percent fat infiltration (FI) for all groups. Multivariable linear regression analyses were conducted and adjusted for age, sex, and body mass index. RESULTS A total of 172 patients were included. Regression analyses demonstrated that a greater C2 to 7 SVA was significantly associated with a greater FI of the anterior group from C3 to C5 and with a higher fCSA of the PL group at C3 to C4, and C6 to 7. A larger C2 slope was significantly correlated with a greater FI of the anterior group at C3 to C4 and a higher fCSA of the PL group from C3 to C5. CONCLUSION This work proposes new insights into the complex interaction between sagittal alignment and cervical paraspinal muscles by emphasizing the importance of these muscles in sagittal alignment. The authors hypothesize that with cervical degeneration, the stabilizing function of the anterior muscles decreases, which may result in an increase in the compensatory mechanism of the PL muscles. Consequently, there may be a corresponding increase in the C2 to C7 SVA and a larger C2 slope.
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Affiliation(s)
- Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
| | - Bruno Verna
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
| | - Vidushi Tripathi
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
| | | | - Samuel J Medina
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
| | - Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Soji Tani
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | | | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
| | - Ali E Guven
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY
| | - Ek Tsoon Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
| | | | - Timo Zippelius
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - David Dalton
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
- Department of Orthopedic Surgery, University Hospital Galway, Galway, Ireland
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
| | | | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York City, NY
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5
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Caffard T, Arzani A, Verna B, Tripathi V, Chiapparelli E, Schönnagel L, Zhu J, Medina SJ, Tani S, Camino-Willhuber G, Guven AE, Amoroso K, Tan ET, Carrino JA, Shue J, Kelly MJ, Burkhard MD, Awan Malik H, Zippelius T, Dalton D, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Association Between Severity of Cervical Central Spinal Stenosis and Paraspinal Muscle Parameters in Patients Undergoing Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976) 2024:00007632-990000000-00640. [PMID: 38605673 DOI: 10.1097/brs.0000000000005004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/22/2024] [Indexed: 04/13/2024]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE The aim of this study was to evaluate the association between severity and level of cervical central stenosis (CCS) and the fat infiltration (FI) of the cervical multifidus/rotatores (MR) at each subaxial levels. SUMMARY OF BACKGROUND DATA The relationship between cervical musculature morphology and the severity of CCS is poorly understood. METHODS Patients with preoperative cervical magnetic resonance imaging (MRI) who underwent anterior cervical discectomy and fusion (ACDF) were reviewed. The cervical MR were segmented from C3 to C7 and the percent FI was measured using a custom-written Matlab software. The severity of the CCS at each subaxial level was assessed using a previously published classification. Grade 3, representing a loss of cerebrospinal fluid space and deformation of the spinal cord > 25%, was set as the reference and compared to the other gradings. Multivariable linear regression analyses were conducted and adjusted for age, sex, and body mass index. RESULTS 156 consecutive patients were recruited. A spinal cord compression at a certain level was significantly associated with a greater FI of the MR below that level. After adjustment for the above-mentioned confounders, our results showed that spinal cord compression at C3/4 and C4/5 was significantly associated with greater FI of the MR from C3 to C6 and C5 to C7, respectively. A spinal cord compression at C5/6 or C6/7 was significantly associated with greater FI of the MR at C7. CONCLUSION Our results demonstrated significant correlations between the severity of CCS and a greater FI of the MR. Moreover, significant level-specific correlations were found. A significant increase in FI of the MR at the levels below the stenosis was observed in patients presenting with spinal cord compression. Given the segmental innervation of the MR, the increased FI might be attributed to neurogenic atrophy. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
- Department of Orthopaedic Surgery, University of Ulm, Ulm, Germany
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | - Bruno Verna
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | - Vidushi Tripathi
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | | | - Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, USA
| | - Samuel J Medina
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | - Soji Tani
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | | | - Ali E Guven
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | - Ek Tsoon Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | - Michael J Kelly
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | - Marco D Burkhard
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | | | - Timo Zippelius
- Department of Orthopaedic Surgery, University of Ulm, Ulm, Germany
| | - David Dalton
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
- Department of Orthopedic Surgery, University Hospital Galway, Galway, Ireland
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
| | | | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York City, USA
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6
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Guven AE, Chiapparelli E, Camino-Willhuber G, Zhu J, Schönnagel L, Amoroso K, Caffard T, Erduran A, Shue J, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Assessing paraspinal muscle atrophy with electrical impedance myography: Limitations and insights. J Orthop Res 2024. [PMID: 38594874 DOI: 10.1002/jor.25848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/11/2024]
Abstract
Paraspinal muscle atrophy is gaining attention in spine surgery due to its link to back pain, spinal degeneration and worse postoperative outcomes. Electrical impedance myography (EIM) is a noninvasive diagnostic tool for muscle quality assessment, primarily utilized for patients with neuromuscular diseases. However, EIM's accuracy for paraspinal muscle assessment remains understudied. In this study, we investigated the correlation between EIM readings and MRI-derived muscle parameters, as well as the influence of dermal and subcutaneous parameters on these readings. We retrospectively analyzed patients with lumbar spinal degeneration who underwent paraspinal EIM assessment between May 2023 to July 2023. Paraspinal muscle fatty infiltration (FI) and functional cross-sectional area (fCSA), as well as the subcutaneous thickness were assessed on MRI scans. Skin ultrasound imaging was assessed for dermal thickness and the echogenicities of the dermal and subcutaneous layers. All measurements were performed on the bilaterally. The correlation between EIM readings were compared with ultrasound and MRI parameters using Spearman's correlation analyses. A total of 20 patients (65.0% female) with a median age of 69.5 years (IQR, 61.3-73.8) were analyzed. The fCSA and FI did not significantly correlate with the EIM readings, regardless of frequency. All EIM readings across frequencies correlated with subcutaneous thickness, echogenicity, or dermal thickness. With the current methodology, paraspinal EIM is not a valid alternative to MRI assessment of muscle quality, as it is strongly influenced by the dermal and subcutaneous layers. Further studies are required for refining the methodology and confirming our results.
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Affiliation(s)
- Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York, USA
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
- Universitätsklinikum Ulm, Klinik für Orthopädie, Ulm, Germany
| | - Ada Erduran
- Department of Electrical Engineering, Technical University Berlin, Berlin, Germany
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
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7
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Köhli P, Schönnagel L, Hambrecht J, Zhu J, Chiapparelli E, Güven AE, Evangelisti G, Amoroso K, Duculan R, Michalski B, Shue J, Tsuchiya K, Burkhard MD, Sama AA, Girardi FP, Cammisa FP, Mancuso CA, Hughes AP. The relationship between paraspinal muscle atrophy and degenerative lumbar spondylolisthesis at the L4/5 level. Spine J 2024:S1529-9430(24)00157-8. [PMID: 38570036 DOI: 10.1016/j.spinee.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND/CONTEXT Degenerative lumbar spondylolisthesis (DLS) is a prevalent spinal condition that can result in significant disability. DLS is thought to result from a combination of disc and facet joint degeneration, as well as various biological, biomechanical, and behavioral factors. One hypothesis is the progressive degeneration of segmental stabilizers, notably the paraspinal muscles, contributes to a vicious cycle of increasing slippage. PURPOSE To examine the correlation between paraspinal muscle status on MRI and severity of slippage in patients with symptomatic DLS. STUDY DESIGN/SETTING Retrospective cross-sectional study at an academic tertiary care center. PATIENT SAMPLE Patients who underwent surgery for DLS at the L4/5 level between 2016-2018 were included. Those with multilevel DLS or insufficient imaging were excluded. OUTCOME MEASURES The percentage of relative slippage (RS) at the L4/5 level evaluated on standing lateral radiographs. Muscle morphology measurements including functional cross-sectional area (fCSA), body height normalized functional cross-sectional area (HI) of Psoas, erector spinae (ES) and multifidus muscle (MF) and fatty infiltration (FI) of ES and MF were measured on axial MR. Disc degeneration and facet joint arthritis were classified according to Pfirrmann and Weishaupt, respectively. METHODS Descriptive and comparative statistics, univariable and multivariable linear regression models were utilized to examine the associations between RS and muscle parameters, adjusting for confounders sex, age, BMI, segmental degeneration, and back pain severity and symptom duration. RESULTS The study analyzed 138 out of 183 patients screened for eligibility. The median age of all patients was 69.5 years (IQR 62 to 73), average BMI was 29.1 (SD±5.1) and average preoperative ODI was 46.4 (SD±16.3). Patients with Meyerding-Grade 2 (M2, N=25) exhibited higher Pfirrmann scores, lower MFfCSA and MFHI, and lower BMI, but significantly more fatty infiltration in the MF and ES muscles compared to those with Meyerding Grade 1 (M1). Univariable linear regression showed that each cm2 decrease in MFfCSA was associated with a 0.9%-point increase in RS (95% CI -1.4 to - 0.4, p<.001), and each cm2/m2 decrease in MFHI was associated with an increase in slippage by 2.2%-points (95% CI -3.7 to -0.7, p=.004). Each 1%-point rise in ESFI and MFFI corresponded to 0.17%- (95% CI 0.05-0.3, p=.01) and 0.20%-point (95% CI 0.1-0.3 p<.001) increases in relative slippage, respectively. Notably, after adjusting for confounders, each cm2 increase in PsoasfCSA and cm2/m2 in PsoasHI was associated with an increase in relative slippage by 0.3% (95% CI 0.1-0.6, p=.004) and 1.1%-points (95% CI 0.4-1.7, p=.001). While MFfCSA tended to be negatively associated with slippage, this did not reach statistical significance (p=.105). However, each 1%-point increase in MFFI and ESFI corresponded to increases of 0.15% points (95% CI 0.05-0.24, p=.002) and 0.14% points (95% CI 0.01-0.27, p=.03) in relative slippage, respectively. CONCLUSION This study found a significant association between paraspinal muscle status and severity of slippage in DLS. Whereas higher degeneration of the ES and MF correlate with a higher degree of slippage, the opposite was found for the psoas. These findings suggest that progressive muscular imbalance between posterior and anterior paraspinal muscles could contribute to the progression of slippage in DLS.
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Affiliation(s)
- Paul Köhli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, Berlin 10117, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Charitéplatz 1, Berlin 10117, Germany
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, Berlin 10117, Germany
| | - Jan Hambrecht
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Department of Trauma Surgery, University Hospital Zurich, Ramistrasse 100, Zurich 8091, Switzerland
| | - Jiaqi Zhu
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71th Street, New York, NY 10021, USA
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Ali E Güven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Gisberto Evangelisti
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Instituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, Bologna, BO, 40136, Italy
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | | | - Bernhard Michalski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, Berlin 10117, Germany
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Koki Tsuchiya
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA; Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Marco D Burkhard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 525 East 71st Street, New York City, NY 10021, USA.
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Schönnagel L, Camino-Willhuber G, Braun S, Zhu J, Tani S, Guven AE, Caffard T, Chiapparelli E, Arzani A, Haffer H, Muellner M, Shue J, Duculan R, Bendersky M, Cammisa FP, Girardi FP, Sama AA, Mancuso CA, Hughes AP. Association Between Osteoarthritis Burden and Intervertebral Disk Degeneration in Patients Undergoing Lumbar Spine Surgery for Degenerative Lumbar Spondylolisthesis. Spine (Phila Pa 1976) 2024; 49:478-485. [PMID: 37796191 DOI: 10.1097/brs.0000000000004847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023]
Abstract
STUDY DESIGN A retrospective analysis of prospectively collected data. OBJECTIVE To assess the association between intervertebral disk degeneration and hip and knee osteoarthritis (OA) in patients with degenerative lumbar spondylolisthesis. BACKGROUND The co-occurrence of hip OA and degenerative spinal pathologies was first described as the "hip-spine syndrome" and has also been observed in knee OA. It remains unclear whether both pathologies share an underlying connection beyond demographic factors. MATERIALS AND METHODS Intervertebral disk degeneration was classified by the Pfirrmann Classification and intervertebral vacuum phenomenon. Intervertebral vacuum phenomenon was classified into mild (1 point), moderate (2 points), and severe (3 points) at each level and combined into a lumbar vacuum score (0-15 points). Similarly, a lumbar Pfirrmann grade was calculated (5-25 points). Patients with previous hip or knee replacement surgery were classified as having an OA burden. We used multivariable regression to assess the association between OA and disk degeneration, adjusted for age, body mass index, and sex. RESULTS A total of 246 patients (58.9% female) were included in the final analysis. Of these, 22.3% had OA burden. The multivariable linear regression showed an independent association between OA burden and lumbar vacuum (β = 2.1, P <0.001) and Pfirrmann grade (β = 2.6, P <0.001). Representing a 2.1 points higher lumbar vacuum and 2.6 points higher lumbar Pfirrmann grade after accounting for demographic differences. CONCLUSIONS Our study showed that OA burden was independently associated with the severity of the intervertebral disk degeneration of the lumbar spine. These findings give further weight to a shared pathology of OA of large joints and degenerative processes of the lumbar spine. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Sebastian Braun
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopedics (Friedrichsheim), Goethe University, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, University of Ulm, Ulm, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Henryk Haffer
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | | | - Mariana Bendersky
- Normal Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
- Intraoperative Monitoring, Pediatric Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY
- Weill Cornell Medical College, New York, NY
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
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9
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Schönnagel L, Tani S, Vu-Han TL, Zhu J, Camino-Willhuber G, Dodo Y, Caffard T, Chiapparelli E, Oezel L, Shue J, Zelenty WD, Lebl DR, Cammisa FP, Girardi FP, Sokunbi G, Hughes AP, Sama AA. Predicting conversion of ambulatory ACDF patients to inpatient: a machine learning approach. Spine J 2024; 24:563-571. [PMID: 37980960 DOI: 10.1016/j.spinee.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/29/2023] [Accepted: 11/12/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND CONTEXT Machine learning is a powerful tool that has become increasingly important in the orthopedic field. Recently, several studies have reported that predictive models could provide new insights into patient risk factors and outcomes. Anterior cervical discectomy and fusion (ACDF) is a common operation that is performed as an outpatient procedure. However, some patients are required to convert to inpatient status and prolonged hospitalization due to their condition. Appropriate patient selection and identification of risk factors for conversion could provide benefits to patients and the use of medical resources. PURPOSE This study aimed to develop a machine-learning algorithm to identify risk factors associated with unplanned conversion from outpatient to inpatient status for ACDF patients. STUDY DESIGN/SETTING This is a machine-learning-based analysis using retrospectively collected data. PATIENT SAMPLE Patients who underwent one- or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021. OUTCOME MEASURES Length of stay, conversion rates from ambulatory setting to inpatient. METHODS Patients were divided into two groups based on length of stay: (1) Ambulatory (discharge within 24 hours) or Extended Stay (greater than 24 hours but fewer than 48 hours), and (2) Inpatient (greater than 48 hours). Factors included in the model were based on literature review and clinical expertise. Patient demographics, comorbidities, and intraoperative factors, such as surgery duration and time, were included. We compared the performance of different machine learning algorithms: Logistic Regression, Random Forest (RF), Support Vector Machine (SVM), and Extreme Gradient Boosting (XGBoost). We split the patient data into a training and validation dataset using a 70/30 split. The different models were trained in the training dataset using cross-validation. The performance was then tested in the unseen validation set. This step is important to detect overfitting. The performance was evaluated using the area under the curve (AUC) of the receiver operating characteristics analysis (ROC) as the primary outcome. An AUC of 0.7 was considered fair, 0.8 good, and 0.9 excellent, according to established cut-offs. RESULTS A total of 581 patients (59% female) were available for analysis. Of those, 140 (24.1%) were converted to inpatient status. The median age was 51 (IQR 44-59), and the median BMI was 28 kg/m2 (IQR 24-32). The XGBoost model showed the best performance with an AUC of 0.79. The most important features were the length of the operation, followed by sex (based on biological attributes), age, and operation start time. The logistic regression model and the SVM showed worse results, with an AUC of 0.71 each. CONCLUSIONS This study demonstrated a novel approach to predicting conversion to inpatient status in eligible patients for ambulatory surgery. The XGBoost model showed good predictive capabilities, superior to the older machine learning approaches. This model also revealed the importance of surgical duration time, BMI, and age as risk factors for patient conversion. A developing field of study is using machine learning in clinical decision-making. Our findings contribute to this field by demonstrating the feasibility and accuracy of such methods in predicting outcomes and identifying risk factors, although external and multi-center validation studies are needed.
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Affiliation(s)
- Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Soji Tani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Tu-Lan Vu-Han
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, 541 E. 71st Street, New York, NY 10021, USA
| | - Gaston Camino-Willhuber
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Lisa Oezel
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - William D Zelenty
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Darren R Lebl
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Gbolabo Sokunbi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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10
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Guven AE, Evangelisti G, Burkhard MD, Köhli P, Hambrecht J, Zhu J, Chiapparelli E, Kelly M, Tsuchiya K, Amoroso K, Zadeh A, Shue J, Tan ET, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Asymmetrical atrophy of the paraspinal muscles in patients undergoing unilateral lumbar medial branch radiofrequency neurotomy. Pain 2024:00006396-990000000-00557. [PMID: 38635483 DOI: 10.1097/j.pain.0000000000003223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/31/2024] [Indexed: 04/20/2024]
Abstract
ABSTRACT Lumbar medial branch radiofrequency neurotomy (RFN), a common treatment for chronic low back pain due to facet joint osteoarthritis (FJOA), may amplify paraspinal muscle atrophy due to denervation. This study aimed to investigate the asymmetry of paraspinal muscle morphology change in patients undergoing unilateral lumbar medial branch RFN. Data from patients who underwent RFN between March 2016 and October 2021 were retrospectively analyzed. Lumbar foramina stenosis (LFS), FJOA, and fatty infiltration (FI) functional cross-sectional area (fCSA) of the paraspinal muscles were assessed on preinterventional and minimum 2-year postinterventional MRI. Wilcoxon signed-rank tests compared measurements between sides. A total of 51 levels of 24 patients were included in the analysis, with 102 sides compared. Baseline MRI measurements did not differ significantly between the RFN side and the contralateral side. The RFN side had a higher increase in multifidus FI (+4.2% [0.3-7.8] vs +2.0% [-2.2 to 6.2], P = 0.005) and a higher decrease in multifidus fCSA (-60.9 mm2 [-116.0 to 10.8] vs -19.6 mm2 [-80.3 to 44.8], P = 0.003) compared with the contralateral side. The change in erector spinae FI and fCSA did not differ between sides. The RFN side had a higher increase in multifidus muscle atrophy compared with the contralateral side. The absence of significant preinterventional degenerative asymmetry and the specificity of the effect to the multifidus muscle suggest a link to RFN. These findings highlight the importance of considering the long-term effects of lumbar medial branch RFN on paraspinal muscle health.
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Affiliation(s)
- Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Gisberto Evangelisti
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco D Burkhard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Paul Köhli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Hambrecht
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, United States
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Michael Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Koki Tsuchiya
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Arman Zadeh
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Ek Tsoon Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, United States
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
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Schönnagel L, Chiaparelli E, Camino-Willhuber G, Zhu J, Caffard T, Tani S, Burkhard MD, Kelly M, Guven AE, Shue J, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Spine-specific sarcopenia: distinguishing paraspinal muscle atrophy from generalized sarcopenia. Spine J 2024:S1529-9430(24)00099-8. [PMID: 38432297 DOI: 10.1016/j.spinee.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 02/12/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND CONTEXT Atrophy of the paraspinal musculature (PM) as well as generalized sarcopenia are increasingly reported as important parameters for clinical outcomes in the field of spine surgery. Despite growing awareness and potential similarities between both conditions, the relationship between "generalized" and "spine-specific" sarcopenia is unclear. PURPOSE To investigate the association between generalized and spine-specific sarcopenia. STUDY DESIGN Retrospective cross-sectional study. PATIENT SAMPLE Patients undergoing lumbar spinal fusion surgery for degenerative spinal pathologies. OUTCOME MEASURES Generalized sarcopenia was evaluated with the short physical performance battery (SPPB), grip strength, and the psoas index, while spine-specific sarcopenia was evaluated by measuring fatty infiltration (FI) of the PM. METHODS We used custom software written in MATLAB® to calculate the FI of the PM. The correlation between FI of the PM and assessments of generalized sarcopenia was calculated using Spearman's rank correlation coefficient (rho). The strength of the correlation was evaluated according to established cut-offs: negligible: 0-0.3, low: 0.3-0.5, moderate: 0.5-0.7, high: 0.7-0.9, and very high≥0.9. In a Receiver Operating Characteristics (ROC) analysis, the Area Under the Curve (AUC) of sarcopenia assessments to predict severe multifidus atrophy (FI≥50%) was calculated. In a secondary analysis, factors associated with severe multifidus atrophy in non-sarcopenic patients were analyzed. RESULTS A total of 125 (43% female) patients, with a median age of 63 (IQR 55-73) were included. The most common surgical indication was lumbar spinal stenosis (79.5%). The median FI of the multifidus was 45.5% (IQR 35.6-55.2). Grip strength demonstrated the highest correlation with FI of the multifidus and erector spinae (rho=-0.43 and -0.32, p<.001); the other correlations were significant (p<.05) but lower in strength. In the AUC analysis, the AUC was 0.61 for the SPPB, 0.71 for grip strength, and 0.72 for the psoas index. The latter two were worse in female patients, with an AUC of 0.48 and 0.49. Facet joint arthropathy (OR: 1.26, 95% CI: 1.11-1.47, p=.001) and foraminal stenosis (OR: 1.54, 95% CI: 1.10-2.23, p=.015) were independently associated with severe multifidus atrophy in our secondary analysis. CONCLUSION Our study demonstrates a low correlation between generalized and spine-specific sarcopenia. These findings highlight the risk of misdiagnosis when relying on screening tools for general sarcopenia and suggest that general and spine-specific sarcopenia may have distinct etiologies.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Luisenstraße 64, 10117 Berlin, Germany
| | - Erika Chiaparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA; Asuncion Klinikia, Izaskungo Aldapa, 20400 Tolosa, Spain
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA; Universitätsklinikum Ulm, Klinik für Orthopädie, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Soji Tani
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Tokyo, Japan
| | - Marco D Burkhard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA
| | - Michael Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, 520 E 70th New York, NY 10021, USA.
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Caffard T, Arzani A, Verna B, Tripathi V, Medina SJ, Schönnagel L, Chiapparelli E, Tani S, Camino-Willhuber G, Guven AE, Amoroso K, Zhu J, Tan ET, Carrino JA, Awan Malik H, Zippelius T, Shue J, Dalton DM, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Association between severity of the cervical foraminal stenosis and paraspinal muscle parameters in patients undergoing anterior cervical discectomy and fusion. J Neurosurg Spine 2024; 40:274-281. [PMID: 38134419 DOI: 10.3171/2023.10.spine23658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/11/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The cervical multifidus and rotatores muscles are innervated by the posterior rami of the spinal nerves of the corresponding level, and it has been hypothesized that cervical foraminal stenosis (CFS) affecting the spinal nerves results in changes in these muscles. The purpose of this study was to evaluate the relationship between the severity of CFS and fat infiltration (FI) of the multifidus and rotatores muscles. METHODS Patients who received preoperative cervical MRI, underwent anterior cervical decompression and fusion between 2015 and 2018, and met inclusion and exclusion criteria were included. Multifidus and rotatores muscles were segmented bilaterally from C3 to C7, and the percent FI was measured using custom-written MATLAB software. The severity of the CFS was assessed by the Kim classification. Multivariable linear mixed models were conducted and adjusted for age, sex, BMI, and repeated measures. RESULTS In total, 149 patients were included. Linear mixed modeling results showed that a more severe CFS at C3-4 was correlated with a greater FI of the multifidus and rotatores muscles at C4 (estimate 0.034, 95% CI 0.003-0.064; p = 0.031), a more severe CFS at C4-5 was correlated with a greater FI of the multifidus and rotatores muscles at C5 (estimate 0.037, 95% CI 0.015-0.057; p < 0.001), a more severe CFS at C5-6 was correlated with a greater FI of the multifidus and rotatores muscles at C6 (estimate 0.041, 95% CI 0.019-0.062; p < 0.001) and C7 (estimate 0.035, 95% CI 0.012-0.058; p = 0.003), and a more severe CFS at C6-7 was correlated with a greater FI of the multifidus and rotatores muscles at C7 (estimate 0.049, 95% CI 0.027-0.071; p < 0.001). CONCLUSIONS These results demonstrated level- and side-specific correlations between the FI of the multifidus and rotatores muscles and severity of CFS. Given the segmental innervation of the multifidus and rotatores muscles, the authors hypothesize that the observed increased FI could be reflective of changes due to muscle denervation from CFS.
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Affiliation(s)
- Thomas Caffard
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 2Department of Orthopedic Surgery, University of Ulm, Germany
| | - Artine Arzani
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Bruno Verna
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Vidushi Tripathi
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Samuel J Medina
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Lukas Schönnagel
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 3Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | | | - Soji Tani
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 4Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | | | - Ali E Guven
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 3Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Krizia Amoroso
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Jiaqi Zhu
- 5Biostatistics Core, Hospital for Special Surgery, New York, New York; and
| | - Ek Tsoon Tan
- 6Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
| | - John A Carrino
- 6Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
| | | | - Timo Zippelius
- 2Department of Orthopedic Surgery, University of Ulm, Germany
| | - Jennifer Shue
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - David M Dalton
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Andrew A Sama
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | | | - Frank P Cammisa
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
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13
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Camino-Willhuber G, Schönnagel L, Chiapparelli E, Amoroso K, Tani S, Caffard T, Arzani A, Guven AE, Verna B, Zhu J, Shue J, Zelenty WD, Sokunbi G, Bendersky M, Girardi FP, Sama AA, Cammisa FP, Hughes AP. Association between lumbar intervertebral vacuum phenomenon severity and posterior paraspinal muscle atrophy in patients undergoing spine surgery. Eur Spine J 2024; 33:1013-1020. [PMID: 38267734 DOI: 10.1007/s00586-023-08120-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/15/2023] [Accepted: 12/23/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE Intervertebral vacuum phenomenon (IVP) and paraspinal muscular atrophy are age-related changes in the lumbar spine. The relationship between both parameters has not been investigated. We aimed to analyze the correlation between IVP and paraspinal muscular atrophy in addition to describing the lumbar vacuum severity (LVS) scale, a new parameter to estimate lumbar degeneration. METHODS We analyzed patients undergoing spine surgery between 2014 and 2016. IVP severity was assessed utilizing CT scans. The combination of vacuum severity on each lumbar level was used to define the LVS scale, which was classified into mild, moderate and severe. MRIs were used to evaluate paraspinal muscular fatty infiltration of the multifidus and erector spinae. The association of fatty infiltration with the severity of IVP at each lumbar level was assessed with a univariable and multivariable ordinal regression model. RESULTS Two hundred and sixty-seven patients were included in our study (128 females and 139 males) with a mean age of 62.6 years (55.1-71.2). Multivariate analysis adjusted for age, BMI and sex showed positive correlations between LVS-scale severity and fatty infiltration in the multifidus and erector spinae, whereas no correlation was observed in the psoas muscle. CONCLUSION IVP severity is positively correlated with paraspinal muscular fatty infiltration. This correlation was stronger for the multifidus than the erector spinae. No correlations were observed in the psoas muscle. The lumbar vacuum severity scale was significantly correlated with advanced disc degeneration with vacuum phenomenon.
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Affiliation(s)
- Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Soji Tani
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
- Department of Orthopaedic Surgery, University of Ulm, Ulm, Germany
| | - Artine Arzani
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Ali E Guven
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Bruno Verna
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, USA
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - William D Zelenty
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Gbolabo Sokunbi
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Mariana Bendersky
- III Normal Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
- Intraoperative Monitoring, Pediatric Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St, New York City, NY, 10021, USA.
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14
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Schönnagel L, Caffard T, Zhu J, Tani S, Camino-Willhuber G, Amini DA, Haffer H, Muellner M, Guven AE, Chiapparelli E, Arzani A, Amoroso K, Shue J, Duculan R, Zippelius T, Sama AA, Cammisa FP, Girardi FP, Mancuso CA, Hughes AP. Decision-making Algorithm for the Surgical Treatment of Degenerative Lumbar Spondylolisthesis of L4/L5. Spine (Phila Pa 1976) 2024; 49:261-268. [PMID: 37318098 DOI: 10.1097/brs.0000000000004748] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/06/2023] [Indexed: 06/16/2023]
Abstract
STUDY DESIGN A retrospective analysis of prospectively collected data. OBJECTIVE To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups. BACKGROUND Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed. MATERIALS AND METHODS Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups. RESULTS A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%. CONCLUSIONS The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Dominik A Amini
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Henryk Haffer
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | | | - Timo Zippelius
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY
- Weill Cornell Medical College, New York, NY
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
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15
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Schönnagel L, Zhu J, Camino-Willhuber G, Guven AE, Tani S, Caffard T, Haffer H, Muellner M, Chiapparelli E, Arzani A, Amoroso K, Moser M, Shue J, Tan ET, Carrino JA, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Relationship between lumbar spinal stenosis and axial muscle wasting. Spine J 2024; 24:231-238. [PMID: 37788745 DOI: 10.1016/j.spinee.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/14/2023] [Accepted: 09/26/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND CONTEXT Although the effect of lumbar spinal stenosis (LSS) on the lower extremities is well documented, limited research exists on the effect of spinal stenosis on the posterior paraspinal musculature (PPM). Similar to neurogenic claudication, moderate to severe spinal canal compression can also interfere with the innervation of the PPM, which may result in atrophy and increased fatty infiltration (FI). PURPOSE This study aims to assess the association between LSS and atrophy of the PPM. STUDY DESIGN Retrospective cross-sectional study. PATIENT SAMPLE Patients undergoing MRI scans at a tertiary orthopedic center for low back pain or as part of a preoperative evaluation. OUTCOME MEASURES The functional cross-sectional area (fCSA) and percent fatty infiltration (FI) of the PPM at L4. METHODS Lumbar MRIs of patients at a tertiary orthopedic center indicated due to lower back pain (LBP) or as a presurgical workup were analyzed. Patients with previous spinal fusion surgery or scoliosis were excluded. LSS was assessed according to the Schizas classification at all lumbar levels. The cross-sectional area of the PPM was measured on a T2-weighted MRI sequence at the upper endplate of L4. The fCSA and fatty infiltration (FI) were calculated using custom software. Crude differences in FI and fCSA between patients with no stenosis and at least mild stenosis were tested with the Wilcoxon signed-rank test. To account for possible confounders, a multivariable linear regression model was used to adjust for age, sex, body mass index (BMI), and disc degeneration. A subgroup analysis according to MRI indication was performed. RESULTS A total of 522 (55.7% female) patients were included. The median age was 61 years (IQR: 51-71). The greatest degree of moderate and severe stenosis was found at L4/5, 15.7%, and 9.2%, respectively. Stenosis was the least severe at L5/S1 and was found to be 2% for moderate and 0.2% for severe stenosis. The Wilcoxon test showed significantly increased FI of the PPM with stenosis at any lumbar level (p<.001), although no significant decrease in fCSA was observed. The multivariable regression model showed a significant increase in FI with increased LSS at L1/2, L2/3, and L3/4 (p=.013, p<.01 and p=.003). The severity of LSS at L4/5 showed a positive association with the fCSA (p=.019). The subgroup analysis showed, the effect of LSS was more pronounced in nonsurgical patients than in patients undergoing surgery. CONCLUSIONS In this study, we demonstrated a significant and independent association between LSS and the composition of the PPM, which was dependent on the level of LSS relative to the PPM. In addition to neurogenic claudication, patients with LSS might be especially susceptible to axial muscle wasting, which could worsen LSS due to increased spinal instability, leading to a positive feedback loop.
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Affiliation(s)
- Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, USA
| | | | - Ali E Guven
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Soji Tani
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA; Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA; Universitätsklinikum Ulm, Klinik für Orthopädie, Ulm, Germany
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA; Department of Spine Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA.
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16
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Schönnagel L, Muellner M, Suwalski P, Guven AE, Camino-Willhuber G, Tani S, Caffard T, Zhu J, Haffer H, Arzani A, Chiapparelli E, Amoroso K, Shue J, Duculan R, Sama AA, Cammisa FP, Girardi FP, Mancuso CA, Hughes AP. Association of abdominal aortic calcification and lower back pain in patients with degenerative spondylolisthesis. Pain 2024; 165:376-382. [PMID: 37856648 DOI: 10.1097/j.pain.0000000000003018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/28/2023] [Indexed: 10/21/2023]
Abstract
ABSTRACT Abdominal aortic calcification (AAC) is hypothesized to lead to ischemic pain of the lower back. This retrospective study aims to identify the relationship between AAC and lower back pain (LBP) in patients with degenerative lumbar spondylolisthesis. Lower back pain was assessed preoperatively and 2 years after surgery using the numeric analogue scale. Abdominal aortic calcification was assessed according to the Kauppila classification and was grouped into no, moderate, and severe. A multivariable regression, adjusted for age, sex, body mass index, hypertension, and smoking status, was used to assess the association between AAC and preoperative/postoperative LBP as well as change in LBP after surgery. A total of 262 patients were included in the final analysis. The multivariable logistic regression demonstrated an increased odds ratio (OR) for preoperative LBP ≥ 4 numeric analogue scale (OR = 9.49, 95% confidence interval [CI]: 2.71-40.59, P < 0.001) and postoperative LBP ≥ 4 (OR = 1.72, 95% CI: 0.92-3.21, P = 0.008) in patients with severe AAC compared with patients with no AAC. Both moderate and severe AAC were associated with reduced improvement in LBP after surgery (moderate AAC: OR = 0.44, 95% CI: 0.22-0.85, P = 0.016; severe AAC: OR = 0.41, 95% CI: 0.2-0.82, P = 0.012). This study demonstrates an independent association between AAC and LBP and reduced improvement after surgery. Evaluation of AAC could play a role in patient education and might be considered part of the differential diagnosis for LBP, although further prospective studies are needed.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Phillip Suwalski
- Medical Heart Center of Charité CBF-Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Universitätsklinikum Ulm, Klinik für Orthopädie, Ulm, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, United States
| | - Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Roland Duculan
- Hospital for Special Surgery, New York City, NY, United States
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY, United States
- Weill Cornell Medical College, New York, NY, United States
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, United States
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17
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Camino-Willhuber G, Schönnagel L, Caffard T, Zhu J, Tani S, Chiapparelli E, Arzani A, Shue J, Duculan R, Bendersky M, Zelenty WD, Sokunbi G, Lebl DR, Cammisa FP, Girardi FP, Mancuso CA, Hughes AP, Sama AA. Severe Intervertebral Vacuum Phenomenon is Associated With Higher Preoperative Low Back Pain, ODI, and Indication for Fusion in Patients With Degenerative Lumbar Spondylolisthesis. Clin Spine Surg 2024; 37:E1-E8. [PMID: 37651562 DOI: 10.1097/bsd.0000000000001510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/19/2023] [Indexed: 09/02/2023]
Abstract
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.
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Affiliation(s)
- Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, University of Ulm, Ulm, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | | | - Mariana Bendersky
- III Normal Anatomy Department, School of Medicine, University of Buenos Aires
- Intraoperative Monitoring, Department of Pediatric Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - William D Zelenty
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Gbolabo Sokunbi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Darren R Lebl
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY
- Weill Cornell Medical College, New York, NY
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
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Schönnagel L, Caffard T, Vu-Han TL, Zhu J, Nathoo I, Finos K, Camino-Willhuber G, Tani S, Guven AE, Haffer H, Muellner M, Arzani A, Chiapparelli E, Amoroso K, Shue J, Duculan R, Pumberger M, Zippelius T, Sama AA, Cammisa FP, Girardi FP, Mancuso CA, Hughes AP. Predicting postoperative outcomes in lumbar spinal fusion: development of a machine learning model. Spine J 2024; 24:239-249. [PMID: 37866485 DOI: 10.1016/j.spinee.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/16/2023] [Accepted: 09/30/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND CONTEXT Degenerative lumbar spondylolisthesis (DLS) is a prevalent spinal disorder, often requiring surgical intervention. Accurately predicting surgical outcomes is crucial to guide clinical decision-making, but this is challenging due to the multifactorial nature of postoperative results. Traditional risk assessment tools have limitations, and with the advent of machine learning, there is potential to enhance the precision and comprehensiveness of preoperative evaluations. PURPOSE We aimed to develop a machine-learning algorithm to predict surgical outcomes in patients with degenerative lumbar spondylolisthesis (DLS) undergoing spinal fusion surgery, only using preoperative data. STUDY DESIGN Retrospective cross-sectional study. PATIENT SAMPLE Patients with DLS undergoing lumbar spinal fusion surgery. OUTCOME MEASURES This study aimed to predict the occurrence of lower back pain (LBP) ≥4 on the numeric analogue scale (NAS) 2 years after surgery. LBP was evaluated as the average pain patients experienced at rest in the week before questioning. NAS ranges from 0 to 10, 0 representing no pain and 10 representing the worst pain imaginable. METHODS We conducted a retrospective analysis of prospectively enrolled patients who underwent spinal fusion surgery for degenerative lumbar spondylolistheses at our institution in the United States between January 2016 and December 2018. The initial patient characteristics to be included in the training of the model were chosen by clinical expertise and through a literature review and included demographic characteristics, comorbidities, and radiologic features. The data was split into a training and validation datasets using a 60/40 split. Four different machine learning models were trained, including the modern XGBoost model, logistic regression, random-forest, and support vector machine (SVM). The models were evaluated according to the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. An AUC of 0.7 to 0.8 was considered fair, 0.8 to 0.9 good, and ≥ 0.9 excellent. Additionally, a calibration plot and the Brier score were calculated for each model. RESULTS A total of 135 patients (66% female) were included. A total of 38 (28%) patients reported LBP ≥ 4 after 2 years, representing the positive class. The XGBoost model demonstrated the best performance in the validation set with an AUC of 0.81 (95% CI 0.67-0.95). The other machine learning models performed significantly worse: with an AUC of 0.52 (95% CI 0.37-0.68) for the SVM, 0.56 (95% CI 0.37-0.76) for the logistic regression and an AUC of 0.56 (95% CI 0.37-0.78) for the random forest. In the XGBoost model age, composition of the erector spinae, and severity of lumbar spinal stenosis as were identified as the most important features. CONCLUSIONS This study represents a novel approach to predicting surgical outcomes in spinal fusion patients. The XGBoost demonstrated a better performance compared with classical models and highlighted the potential contributions of age and paraspinal musculature atrophy as significant factors. These findings have important implications for enhancing patient care through the identification of high-risk individuals and modifiable risk factors. As the incorporation of machine learning algorithms into clinical decision-making continues to gain traction in research and clinical practice, our insights reinforce this trajectory by showcasing the potential of these techniques in forecasting surgical results.
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Affiliation(s)
- Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Universitätsklinikum Ulm, Klinik für Orthopädie, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Tu-Lan Vu-Han
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Isaac Nathoo
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Kyle Finos
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Gaston Camino-Willhuber
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Soji Tani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Ali E Guven
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Henryk Haffer
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Maximilian Muellner
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Roland Duculan
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Timo Zippelius
- Universitätsklinikum Ulm, Klinik für Orthopädie, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Carol A Mancuso
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Moser M, Adl Amini D, Albertini Sanchez L, Oezel L, Zhu J, Nevzati E, Carrino JA, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The Reciprocal Relationship Between Lumbar Intervertebral Disc Degeneration and the MRI-Based Vertebral Bone Quality Score. Spine (Phila Pa 1976) 2024:00007632-990000000-00568. [PMID: 38270377 DOI: 10.1097/brs.0000000000004937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/18/2024] [Indexed: 01/26/2024]
Abstract
STUDY DESIGN Retrospective longitudinal study. OBJECTIVE To investigate the association between lumbar intervertebral disc degeneration (DD) and the vertebral bone quality (VBQ) score. SUMMARY OF BACKGROUND DATA The VBQ score that is based on magnetic resonance imaging (MRI) has been proposed as a measure of lumbar spine bone quality and is a significant predictor of healthy versus osteoporotic bone. However, the role of segmental contributing factors on VBQ is unknown. METHODS Non-surgical patients who underwent repeated lumbar MRI scans, at least three years apart primarily for low back pain were retrospectively included. VBQ was assessed as previously described. DD was assessed using the Pfirrmann grading (PFG) scale. PFG grades were summarized as PFGL1-4 for the upper three lumbar disc levels, as PFGL4-S1 for the lower two lumbar disc levels, and as PFGL1-S1 for all lumbar disc levels. Multivariable linear mixed models were used with adjustments for age, sex, race, body mass index (BMI), and the clustering of repeated measurements. RESULTS 350 patients (54.6% female, 85.4% Caucasian) were included in the final analysis, with a median age at baseline of 60.1 years and a BMI of 25.8 kg/m2. VBQ significantly increased from 2.28 at baseline to 2.36 at follow-up (P = 0.001). In the unadjusted analysis, a significant positive correlation was found between PFGL1-4, PFGL1-S1, and VBQ at baseline (P < 0.05) that increased over time (P < 0.005). In the adjusted multivariable analysis, PFGL1-4 (β = -0.0195; P = 0.021), PFGL4-S1 (β = -0.0310; P = 0.007), and PFGL1-S1 (β = -0.0160; P = 0.012) were independently and negatively associated with VBQ. CONCLUSION More advanced and long-lasting DD is associated with lower VBQ indicating less bone marrow fat content and potentially stronger bone. VBQ score as a marker of bone quality seems affected by DD.
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Affiliation(s)
- Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
- Department of Neurosurgery, Cantonal Hospital Graubünden, Loëstrasse 170, 7000 Chur, Switzerland
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Leonardo Albertini Sanchez
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
- Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
- Department of Orthopedic Surgery and Traumatology, University Hospital Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
| | - Edin Nevzati
- Department of Neurosurgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne, Switzerland
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA
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Iyer S, Steinhaus ME, Kazarian GS, Zgonis EM, Cunningham ME, Farmer JC, Kim HJ, Lebl DR, Huang RC, Lafage V, Schwab FJ, Qureshi S, Girardi FP, Rawlins BA, Beckman JD, Varghese JJ, Muzammil H, Lafage R, Sandhu HS. Intravenous Ketorolac Substantially Reduces Opioid Use and Length of Stay After Lumbar Fusion: A Randomized Controlled Trial. Spine (Phila Pa 1976) 2024; 49:73-80. [PMID: 37737686 PMCID: PMC10872662 DOI: 10.1097/brs.0000000000004831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
STUDY DESIGN A randomized, double-blinded, placebo-controlled trial. OBJECTIVE To examine the effect of intravenous ketorolac (IV-K) on hospital opioid use compared with IV-placebo (IV-P) and IV acetaminophen (IV-A). SUMMARY OF BACKGROUND DATA Controlling postoperative pain while minimizing opioid use after lumbar spinal fusion is an important area of study. PATIENTS AND METHODS Patients aged 18 to 75 years undergoing 1 to 2 level lumbar fusions between April 2016 and December 2019 were included. Patients with chronic opioid use, smokers, and those on systemic glucocorticoids or contraindications to study medications were excluded. A block randomization scheme was used, and study personnel, hospital staff, and subjects were blinded to the assignment. Patients were randomized postoperatively. The IV-K group received 15 mg (age > 65) or 30 mg (age < 65) every six hours (q6h) for 48 hours, IV-A received 1000 mg q6h, and IV-P received normal saline q6h for 48 hours. Demographic and surgical details, opioid use in morphine milliequivalents, opioid-related adverse events, and length of stay (LOS) were recorded. The primary outcome was in-hospital opioid use up to 72 hours. RESULTS A total of 171 patients were included (58 IV-K, 55 IV-A, and 58 IV-P) in the intent-to-treat (ITT) analysis, with a mean age of 57.1 years. The IV-K group had lower opioid use at 72 hours (173 ± 157 mg) versus IV-A (255 ± 179 mg) and IV-P (299 ± 179 mg; P = 0.000). In terms of opiate use, IV-K was superior to IV-A ( P = 0.025) and IV-P ( P = 0.000) on ITT analysis, although on per-protocol analysis, the difference with IV-A did not reach significance ( P = 0.063). When compared with IV-P, IV-K patients reported significantly lower worst ( P = 0.004), best ( P = 0.001), average ( P = 0.001), and current pain ( P = 0.002) on postoperative day 1, and significantly shorter LOS ( P = 0.009) on ITT analysis. There were no differences in opioid-related adverse events, drain output, clinical outcomes, transfusion rates, or fusion rates. CONCLUSIONS By reducing opioid use, improving pain control on postoperative day 1, and decreasing LOS without increases in complications or pseudarthrosis, IV-K may be an important component of "enhanced recovery after surgery" protocols.
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Affiliation(s)
- Sravisht Iyer
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael E. Steinhaus
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Gregory S. Kazarian
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Evangelia M Zgonis
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Matthew E. Cunningham
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - James C. Farmer
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Darren R. Lebl
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Russel C. Huang
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Frank J. Schwab
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz Qureshi
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Federico P. Girardi
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Bernard A. Rawlins
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - James D. Beckman
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Jeffrey J. Varghese
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Hamna Muzammil
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Harvinder S. Sandhu
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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21
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Schönnagel L, Zhu J, Guven AE, Camino-Willhuber G, Tani S, Caffard T, Haffer H, Muellner M, Chiapparelli E, Amoroso K, Arzani A, Moser M, Shue J, Tan ET, Carrino JA, Jöns T, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Understanding the Interplay Between Paraspinal Muscle Atrophy and Lumbar Endplate Degeneration: A 3-Year Longitudinal Study. Spine (Phila Pa 1976) 2023; 48:1627-1634. [PMID: 37698271 DOI: 10.1097/brs.0000000000004826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/04/2023] [Indexed: 09/13/2023]
Abstract
STUDY DESIGN Retrospective analysis of longitudinal data. OBJECTIVE To assess the association between the paraspinal musculature (PM) and lumbar endplate degeneration. BACKGROUND The PM is essential for spinal stability, while the vertebral endplate is pivotal for nutrient transport and force distribution. The clinical importance of both has been highlighted in recent literature, though little is known about their interaction. METHODS We identified patients with lumbar MRI scans due to low back pain, with a 3-year interval between MRI scans. Endplate damage was assessed by the total endplate score (TEPS) at each lumbar level. The PM was evaluated for its functional cross-sectional area and fatty infiltration (FI) at the L4 level. We used a generalized mixed model to analyze the association between PM parameters and TEPS at timepoint one, adjusting for age, sex, BMI, diabetes, hypertension, and smoking status. The association with the progression of endplate damage was analyzed through an ordinal regression model, additionally adjusted for TEPS at baseline. RESULTS In all, 329 patients were included, with a median follow-up time of 3.4 years. Participants had a median age of 59 and a BMI of 25.8 kg/m 2 . In the univariate analysis, FI of the posterior PM was significantly associated with TEPS at baseline (β: 0.08, P <0.001) and progression of TEPS [Odds Ratio (OR): 1.03, P =0.020] after adjustment for confounders. The β and OR in this analysis are per percent of FI. In a binary analysis, patients with FI≥40% had an OR of 1.92 ( P =0.006) for the progression of TEPS. CONCLUSIONS This is the first longitudinal study assessing the relationship between PM and endplate degeneration, demonstrating the association between PM atrophy and the progression of endplate degeneration. This insight may aid in identifying patients at risk for degenerative lumbar conditions and guide research into preventive measures.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Manuel Moser
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
- Department of Neurosurgery, Cantonal Hospital Graubünden, Loëstrasse, Chur, Switzerland
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY
| | - Thomas Jöns
- Berlin Simulation & Training Center, Department of Anatomy Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY
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Fong AM, Duculan R, Endo Y, Carrino JA, Cammisa FP, Hughes AP, Lebl DR, Farmer JC, Huang RC, Sandhu HS, Mancuso CA, Girardi FP, Sama AA. Differences in imaging and clinical characteristics are associated with higher rates of decompression-fusion versus decompression-alone in women compared to men for lumbar degenerative spondylolisthesis. Eur Spine J 2023; 32:4184-4191. [PMID: 37796286 DOI: 10.1007/s00586-023-07958-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/31/2023] [Accepted: 09/16/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE The goals were to ascertain if differences in imaging/clinical characteristics between women and men were associated with differences in fusion for lumbar degenerative spondylolisthesis. METHODS Patients had preoperative standing radiographs, CT scans, and intraoperative fluoroscopic images. Symptoms and comorbidity were obtained from patients; procedure (fusion-surgery or decompression-alone) was obtained from intraoperative records. With fusion surgery as the dependent variable, men and women were compared in multivariable logistic regression models with clinical/imaging characteristics as independent variables. The sample was dichotomized, and analyses were repeated with separate models for men and women. RESULTS For 380 patients (mean age 67, 61% women), women had greater translation, listhesis angle, lordosis, and pelvic incidence, and less diastasis and disc height (all p ≤ 0.03). The rate of fusion was higher for women (78% vs. 65%; OR 1.9, p = 0.008). Clinical/imaging variables were associated with fusion in separate models for men and women. Among women, in the final multivariable model, less comorbidity (OR 0.5, p = 0.05), greater diastasis (OR 1.6, p = 0.03), and less anterior disc height (OR 0.8, p = 0.0007) were associated with fusion. Among men, in the final multivariable model, opioid use (OR 4.1, p = 0.02), greater translation (OR 1.4, p = 0.0003), and greater diastasis (OR 2.4, p = 0.0002) were associated with fusion. CONCLUSIONS There were differences in imaging characteristics between men and women, and women were more likely to undergo fusion. Differences in fusion within groups indicate that decisions for fusion were based on composite assessments of clinical and imaging characteristics that varied between men and women.
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Affiliation(s)
- Alex M Fong
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | - Roland Duculan
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | - Yoshimi Endo
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | - John A Carrino
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | - Frank P Cammisa
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | | | - Darren R Lebl
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | - James C Farmer
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | - Russel C Huang
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | | | - Carol A Mancuso
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA.
- Weill Cornell Medical College, New York, NY, USA.
| | | | - Andrew A Sama
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
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Muellner M, Haffer H, Chiapparelli E, Dodo Y, Shue J, Tan ET, Zhu J, Pumberger M, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Fat infiltration of the posterior paraspinal muscles is inversely associated with the fat infiltration of the psoas muscle: a potential compensatory mechanism in the lumbar spine. BMC Musculoskelet Disord 2023; 24:846. [PMID: 37891498 PMCID: PMC10604445 DOI: 10.1186/s12891-023-06967-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The function of the paraspinal muscles and especially the psoas muscle in maintaining an upright posture is not fully understood. While usually considered solely as a hip flexor, the psoas muscle and its complex anatomy suggest that the muscle has other functions involved in stabilizing the lumbar spine. The aim of this study is to determine how the psoas muscle and the posterior paraspinal muscles (PPM; erector spinae and multifidus) interact with each other. METHODS A retrospective review including patients undergoing posterior lumbar fusion surgery between 2014 and 2021 at a tertiary care center was conducted. Patients with a preoperative lumbar magnetic resonance imaging (MRI) scan performed within 12 months prior to surgery were considered eligible. Exclusion criteria included previous spinal surgery at any level, lumbar scoliosis with a Cobb Angle > 20° and patients with incompatible MRIs. MRI-based quantitative assessments of the cross-sectional area (CSA), the functional cross-sectional area (fCSA) and the fat area (FAT) at L4 was conducted. The degree of fat infiltration (FI) was further calculated. FI thresholds for FIPPM were defined according to literature and patients were divided into two groups (< or ≥ 50% FIPPM). RESULTS One hundred ninetypatients (57.9% female) with a median age of 64.7 years and median BMI of 28.3 kg/m2 met the inclusion criteria and were analyzed. Patients with a FIPPM ≥ 50% had a significantly lower FI in the psoas muscle in both sexes. Furthermore, a significant inverse correlation was evident between FIPPM and FIPsoas for both sexes. A significant positive correlation between FATPPM and fCSAPsoas was also found for both sexes. No significant differences were found for both sexes in both FIPPM groups. CONCLUSION As the FIPPM increases, the FIPsoas decreases. Increased FI is a surrogate marker for a decrease in muscular strength. Since the psoas and the PPM both segmentally stabilize the lumbar spine, these results may be indicative of a potential compensatory mechanism. Due to the weakened PPM, the psoas may compensate for a loss in strength in order to stabilize the spine segmentally.
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Affiliation(s)
- Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA.
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany.
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Yusuke Dodo
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, USA
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, New York City, NY, USA
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24
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Tani S, Okano I, Dodo Y, Camino-Willhuber G, Caffard T, Schönnagel L, Chiapparelli E, Amoroso K, Tripathi V, Arzani A, Oezel L, Shue J, Zelenty WD, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sokunbi G, Sama AA. Risk Factors for Unexpected Conversion From Ambulatory to Inpatient Admission Among One-level or Two-level ACDF Patients. Spine (Phila Pa 1976) 2023; 48:1427-1435. [PMID: 37389987 DOI: 10.1097/brs.0000000000004767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Abstract
STUDY DESIGN/SETTING A retrospective observational study. OBJECTIVE The aim of this study was to investigate the factors associated with the conversion of patient status from ambulatory anterior cervical discectomy and fusion (ACDF) to inpatient. SUMMARY OF BACKGROUND DATA Surgeries are increasingly performed in an ambulatory setting in an era of rising healthcare costs and pressure to improve patient satisfaction. ACDF is a common ambulatory cervical spine surgery, however, there are certain patients who are unexpectedly converted from an outpatient procedure to inpatient admission and little is known about the risk factors for conversion. MATERIALS AND METHODS Patients who underwent one-level or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021 were included. Baseline demographics, surgical information, complications, and conversion reasons were compared between patients with ambulatory surgery or observational stay (stay <48 h) and inpatient (stay >48 h). RESULTS In total, 662 patients underwent one-level or two-level ACDF (median age, 52 yr; 59.5% were male), 494 (74.6%) patients were discharged within 48 hours and 168 (25.4%) patients converted to inpatient. Multivariable logistic regression analysis demonstrated that females, low body mass index <25, American Society of Anesthesiologists classification (ASA) ≥3, long operation, high estimated blood loss, upper-level surgery, two-level fusion, late operation start time, and high postoperative pain score were considered independent risk factors for conversion to inpatient. Pain management was the most common reason for the conversion (80.0%). Ten patients (1.5%) needed reintubation or remained intubated for airway management. CONCLUSIONS Several independent risk factors for prolonged hospital stay after ambulatory ACDF surgery were identified. Although some factors are unmodifiable, other factors, such as procedure duration, operation start time, and blood loss could be potential targets for intervention. Surgeons should be aware of the potential for life-threatening airway complications in ambulatory-scheduled ACDF.
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Affiliation(s)
- Soji Tani
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Ichiro Okano
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | | | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Vidushi Tripathi
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Lisa Oezel
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | | | - Darren R Lebl
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | | | | | - Gbolabo Sokunbi
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York, NY
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25
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Schönnagel L, Guven AE, Camino-Willhuber G, Caffard T, Tani S, Zhu J, Haffer H, Muellner M, Zadeh A, Sanchez LA, Shue J, Duculan R, Schömig F, Sama AA, Cammisa FP, Girardi FP, Mancuso CA, Hughes AP. Examining the Role of Paraspinal Musculature in Post-Operative Disability after Lumbar Fusion Surgery for Degenerative Spondylolisthesis. Spine (Phila Pa 1976) 2023:00007632-990000000-00482. [PMID: 37796163 DOI: 10.1097/brs.0000000000004840] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively enrolled patients. OBJECTIVE To evaluate the relationship between paraspinal muscle (PM) atrophy and Oswestry Disability Index (ODI) improvement after spinal fusion surgery for degenerative lumbar spondylolisthesis (DLS). BACKGROUND Atrophy of the PM is linked to multiple spinal conditions, sagittal malalignment, and increased postoperative complications. However, only limited evidence for the effect on patient-reported outcomes exists. METHODS Patients with DLS undergoing decompression and fusion surgery were analyzed. Patients with missing follow-up, no imaging, or inadequate image quality were excluded. The Oswestry Disability Index (ODI) was assessed preoperatively and two years postoperatively. A cross-sectional area of the PM was measured on a T2-weighted Magnetic Resonance Imaging (MRI) sequence at the upper endplate of L4. Based on the literature, a 10-point improvement cut-off was defined as the minimum clinically important difference (MCID). Patients with a baseline ODI below the MCID were excluded. Logistic regression was used to calculate the association between fatty infiltration (FI) of the PM and improvement in ODI, adjusted for age, sex, and body mass index (BMI). RESULTS 133 patients were included in the final analysis, with only two lost to follow-up. The median age was 68 years (IQR 62 - 73). The median preoperative ODI was 23 (IQR 17 - 28), and 76.7% of patients showed improvement in their ODI score by at least 10 points. In the multivariable regression, FI of the erector spinae and multifidus increased the risk of not achieving clinically relevant ODI improvement (P=0.01 and P<0.001, respectively). No significant association was found for the psoas muscle (P=0.158). CONCLUSIONS This study demonstrates that FI of the erector spinae and multifidus, is significantly associated with less likelihood of clinically relevant ODI improvement following decompression and fusion. Further research is needed to assess the effect of interventions.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Universitätsklinikum Ulm, Klinik für Orthopädie, Ulm, Germany
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, USA
| | - Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Arman Zadeh
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Leonardo Albertine Sanchez
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | | | - Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Carol A Mancuso
- Hospital for Special Surgery, New York City, NY, USA
- Weill Cornell Medical College, New York, NY
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
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26
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Schönnagel L, Muellner M, Suwalski P, Zhu J, Guven AE, Caffard T, Tani S, Camino-Willhuber G, Haffer H, Chiapparelli E, Amoroso K, Arzani A, Moser M, Shue J, Tan ET, Sama AA, Girardi FP, Cammisa FP, Hughes AP. Abdominal aortic calcification is independently associated with lumbar endplate degeneration. Eur Spine J 2023; 32:3387-3393. [PMID: 37584697 DOI: 10.1007/s00586-023-07871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Abdominal aortic calcification (AAC) is associated with lower back pain, reduced bone mineral density of the spine. Vascular changes could also affect the already sparsely perfused intervertebral endplate and intervertebral disc. METHODS Lumbar MRIs and lateral radiographs of patients with lower back pain were retrospectively analyzed. AAC was assessed on lateral lumbar radiographs according to the Kauppila score, with a maximum score of 24. Patients were grouped into no (AAC = 0), moderate (AAC 1 to ≤ 4), and severe AAC (AAC ≥ 5). Endplate and disc degeneration were classified according to the total endplate score (TEPS) and Pfirrmann classification. The associations between AAC and degenerative changes was analyzed with a generalized mixed model and was adjusted for age, sex, body mass index as well as diabetes mellitus, and smoking status. RESULTS A total of 217 patients (47.9% female) were included in the analysis, totaling 1085 intervertebral levels. Of those, 45 (20.7%) patients had moderate, and 39 (18%) had severe AAC. The results of the generalized mixed model showed no significant association between AAC and disc degeneration (p > 0.05). In contrast, a significant positive association between AAC and the severity of TEPS (β: 0.51, 95% CI: 1.92-2.12, p = 0.004) was observed in the multivariable analysis. CONCLUSIONS This study demonstrates an independent association between AAC and endplate degeneration. These findings expand our knowledge about the degenerative cascade of the lumbar spine and suggest that AAC might be a modifiable risk factor for endplate changes.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Phillip Suwalski
- Medical Heart Center of Charité CBF, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, USA
| | - Ali E Guven
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Universitätsklinikum Ulm, Klinik Für Orthopädie, Ulm, Germany
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Manuel Moser
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Ek Tsoon Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA.
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Moser M, Albertini Sanchez L, Adl Amini D, Oezel L, Salzmann SN, Muellner M, Haffer H, Tan ET, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Correlation between MRI-based spinal muscle parameters and the vertebral bone quality score in lumbar fusion patients. Brain Spine 2023; 3:102684. [PMID: 38021001 PMCID: PMC10668100 DOI: 10.1016/j.bas.2023.102684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023]
Abstract
Introduction The vertebral bone quality (VBQ) score that is based on non-contrast enhanced T1-weighted MRI was recently introduced as a novel measure of bone quality in the lumbar spine and shown to be a significant predictor of healthy versus osteopenic/osteoporotic bone. Research question This study aimed to assess possible correlations between the VBQ score and the functional cross-sectional area (FCSA) of psoas and lumbar spine extensor muscles. Material and methods Patients who underwent fusion surgery between 2014 and 2017 and had lumbar MRI and CT scans within 6 months prior to surgery were included. The FCSA was assessed at L3-L5 using a pixel intensity threshold method. The VBQ score was calculated by dividing the signal intensity (SI) of the vertebrae L1-L4 through the SI of the cerebrospinal fluid at L3. Volumetric bone mineral density (vBMD) was assessed by quantitative CT. Results 80 patients (58.8% female, median age 68.8 years) were included. Overall prevalence of osteopenia/osteoporosis was 66.3%, with no significant differences between men and women. The mean (SD) VBQ score was significantly smaller in men, at 2.26 (0.45) versus women at 2.59 (0.39) (p = 0.001). After adjusting for age and BMI, a significant negative correlation was seen between the VBQ score and psoas FCSA at L3 (β = -0.373; p = 0.022), but only in men. Conclusion Our results highlight sex differences in the VBQ score that were not demonstrated by vBMD and suggest a potential role of this novel measure to assess not only bone quality, but also spinal muscle quantity.
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Affiliation(s)
- Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Neurosurgery, Cantonal Hospital Graubuenden, Loestrasse 170, 7000, Chur, Switzerland
| | - Leonardo Albertini Sanchez
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Stephan N. Salzmann
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ek T. Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew A. Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P. Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P. Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P. Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
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28
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Camino-Willhuber G, Tani S, Shue J, Zelenty WD, Sokunbi G, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sama AA. Lumbar lateral interbody fusion: step-by-step surgical technique and clinical experience. J Spine Surg 2023; 9:294-305. [PMID: 37841793 PMCID: PMC10570643 DOI: 10.21037/jss-23-54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/24/2023] [Indexed: 10/17/2023]
Abstract
Lateral lumbar interbody fusion (LLIF) is a minimally invasive surgical approach used to treat a variety of degenerative and deformity conditions of the lumbar spine such as advanced degenerative disease, degenerative scoliosis, foraminal and central stenosis. It has emerged as an alternative to the traditional posterior and anterior lumbar approaches with some potential benefits such as lower blood loss and shorter hospital stay. In this article, we provide our single institutional surgical experience including main indications and contraindications, a step-by-step surgical technique description, a detailed preoperative imaging assessment with a focus on magnetic resonance imaging (MRI) psoas anatomy, operative room (OR) setup and patient positioning. A descriptive surgical technical note of the following steps is provided: positioning and fluoroscopic confirmation, incision and intraoperative level confirmation, discectomy and endplate preparation, implant size selection and insertion and final fluoroscopic control, hemostasis check and wound closure along with an instructional surgical video with tips and pearls, postoperative patient care recommendations, common approach-related complications, along with our historical clinical institutional group experience. Finally, we summarize our research experience in this surgical approach with a focus on LLIF as a standalone procedure. Based on our experience, LLIF can be considered an effective surgical technique to treat degenerative lumbar spine conditions. Proper patient selection is mandatory to achieve good outcomes. Our institutional experience shows higher fusion rates with good clinical outcomes and a relatively low rate of complications.
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Affiliation(s)
| | - Soji Tani
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - William D Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Darren R Lebl
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
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Muellner M, Haffer H, Chiapparelli E, Dodo Y, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Abdominal aortic calcification assessed on standard lateral lumbar radiographs as a screening tool for impaired bone status in spine surgery. Eur Spine J 2023; 32:3030-3038. [PMID: 37450043 PMCID: PMC10601426 DOI: 10.1007/s00586-023-07846-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/24/2023] [Accepted: 06/24/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE The aim of this study was to determine whether the presence of abdominal aortic calcification (AAC) can predict patient bone status, represented by volumetric bone mineral density (vBMD) assessed with quantitative computed tomography (QCT). METHODS Patients undergoing lumbar fusion surgery at a tertiary care center between 2014 and 2021, with a preoperative lumbar CT-scan and lateral lumbar radiographs were retrospectively reviewed. A semi-quantitative measurement method for AAC (AAC 4, 8 and 24) was performed. QCT measurements were made for L1 and L2. Patients were divided into two groups depending on whether AAC was present. A one-way analysis of covariance was conducted to adjust for age. A multiple linear regression model was used to test if age, sex, BMI, diabetes, hypertension, smoking and presence of AAC could predict the vBMD. A receiver operating characteristic (ROC) analysis was conducted for predicting impaired bone status. RESULTS 267 patients with a median age of 65.1 years and BMI of 29.8 kg/m2 were analyzed, 59.6% of patients had AAC. The group comparison showed that vBMD was significantly lower in patients with the presence of AAC (97.8 mg/cm3 vs. 121.5 mg/cm3). Age (β = - 0.360; p < 0.001) and presence of AAC (β = -0.206; p = 0.005) significantly predict vBMD as independent variables. Impaired bone status could be discriminated using AAC 4, 8 and 24 (cut off value 0.5) with a sensitivity of 70.1% and a specificity of 60.2%. CONCLUSION The presence of AAC may identify patients at risk for impaired bone status. Preoperative evaluation of standard lumbar radiographs could be used as a potential diagnostic tool in assessing bone status.
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Affiliation(s)
- Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA
| | - Yusuke Dodo
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York City, NY, 10021, USA.
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Schönnagel L, Muellner M, Caffard T, Tani S, Camino-Willhuber G, Zhu J, Haffer H, Suwalski P, Arzani A, Chiapparelli E, Amoroso K, Moser M, Shue J, Tan ET, Carrino JA, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Abdominal aortic calcification is independently associated with increased atrophy and fatty infiltration of the lumbar paraspinal muscles: a retrospective cross-sectional study. Eur Spine J 2023; 32:3002-3008. [PMID: 37273032 DOI: 10.1007/s00586-023-07783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/26/2023] [Accepted: 05/14/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Aortic abdominal calcification (AAC) is associated with spine-related conditions, such as lower back pain and reduced bone mineral density. Similar to peripheral vascular disease, AAC possibly reduces blood flow to the lumbar posterior paraspinal muscles (PPM) which may lead to atrophy and increased fatty infiltration. METHODS Imaging of patients with lower back pain was analyzed. AAC was assessed on lateral lumbar radiographs according to the Kauppila classification. The cross-sectional area of the PPM was measured on a T2-weighted axial MRI sequence and the functional cross-sectional area (fCSA) and fatty infiltration (FI) were calculated with custom software. The association of AAC and FI as well as AAC and fCSA was assessed by multivariable linear regression, adjusted for age, sex, body mass index (BMI), diabetes, and smoking. RESULTS Two hundred and thirty patients (47.8% female) with a median age of 60 years (IQR 48-68) were analyzed. In patients, without AAC the median FI of the PPM was 33.3% (IQR 29.1-37.6%), compared to 44.6% (IQR 38.5-54.3%) in patients with AAC (p < 0.001). In the multivariable linear regression, both fCSA and FI of the PPM were significantly and independently associated with the degree of AAC (p = 0.037 and p = 0.015, respectively). CONCLUSIONS This is the first study to demonstrate a significant and independent association between AAC and PPM morphology. The results of this study improve our understanding of the interaction between AAC and spinal musculature, with AAC being a reason for atrophy of the PPM.
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Affiliation(s)
- Lukas Schönnagel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Caffard
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Klinik Für Orthopädie, Universitätsklinikum Ulm, Ulm, Germany
| | - Soji Tani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Gaston Camino-Willhuber
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, New York City, NY, USA
| | - Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Phillip Suwalski
- Medical Heart Center of Charité CBF - Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Artine Arzani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Krizia Amoroso
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Manuel Moser
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Ek Tsoon Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA.
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Muellner M, Haffer H, Moser M, Amoroso K, Wang Z, Arzani A, Tan ET, Chiapparelli E, Dodo Y, Shue J, Pumberger M, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Changes of the posterior paraspinal and psoas muscle in patients with low back pain: a 3-year longitudinal study. Eur Spine J 2023; 32:3290-3299. [PMID: 37378708 DOI: 10.1007/s00586-023-07814-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/23/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE This study aimed to investigate the changes of the posterior paraspinal muscles (PPM) and psoas muscle in patients with low back pain (LBP) over time. METHODS Patients with LBP who had a repeat lumbar MRI with a minimum of 3-years apart at a tertiary referral center were analyzed. MRI-based quantitative assessments of the PPM and the psoas muscle were conducted for the baseline and follow-up MRI. The cross sectional area (CSA), the functional cross sectional area (fCSA) and the fat area (FAT) were calculated using a dedicated software program. The fatty infiltration (FI,%) of the regions of interest was calculated. Differences between the 1st and 2nd MRI were calculated for all assessed muscular parameters. RESULTS A total of 353 patients (54.4%female) with a median age of 60.1 years and BMI of 25.8 kg/m2 at baseline were analyzed. The mean time between the 1st and 2nd MRI was 3.6 years. The fCSAPPM declined in both sexes significantly from the 1st to the 2nd MRI, whereas the FATPPM increased. In line with this result, the FIPPM increased in both males (29.9%) and females (19.4%). Females had a higher FIPPM and FIPsoas than males in both MRIs. In females, no significant changes were found for the psoas muscle. The CSAPsoas and fCSAPsoas in males were significantly smaller in the 2nd MRI. With increasing age, a significant trend in a decrease in ∆FIPPM was observed for both sexes. CONCLUSION The study revealed significant quantitatively muscular changes in males and females, especially in the posterior paraspinal muscles in only three years' time.
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Affiliation(s)
- Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Zhaorui Wang
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA
| | - Artine Arzani
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Yusuke Dodo
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA.
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Moser M, Adl Amini D, Albertini Sanchez L, Oezel L, Haffer H, Muellner M, Zhu J, Carrino JA, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The association between vertebral endplate defects, subchondral bone marrow changes, and lumbar intervertebral disc degeneration: a retrospective, 3-year longitudinal study. Eur Spine J 2023; 32:2350-2357. [PMID: 36773077 DOI: 10.1007/s00586-023-07544-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 10/22/2022] [Accepted: 01/13/2023] [Indexed: 02/12/2023]
Abstract
PURPOSE To investigate the influence of vertebral endplate defects and subchondral bone marrow changes on the development of lumbar intervertebral disc degeneration (DD). METHODS Patients > 18 y/o without any history of lumbar fusion who had repeat lumbar magnetic resonance imaging scans primarily for low back pain (LBP) performed at a minimum of 3 years apart at a single institution, and no spinal surgery in between scans were included. Total endplate score (TEPS), Modic changes (MC), and Pfirrmann grading (PFG) per lumbar disc level were assessed. DD was defined as PFG ≥ 4. RESULTS Three hundred and fifty-three patients (54.4% female) were included in the final analysis, comprising 1765 lumbar intervertebral discs. The patient population was 85.6% Caucasian with a median age of 60.1 years and a body mass index (BMI) of 25.8 kg/m2. A cutoff score of 5 was identified for the TEPS above which both the prevalence of DD and the odds of developing DD increased. The probability of developing DD did not differ significantly between lumbar disc levels (P = 0.419). In the multivariable analysis with adjustments for age, sex, race, body mass index (BMI), MC, TEPS cutoff > 5, and spinal level, only age (OR = 1.020; P = 0.002) was found to be an independent risk factor for developing intervertebral DD. CONCLUSION Our results suggest that TEPS does not unequivocally predict intervertebral DD in patients with LBP, since higher degrees of endplate defects might also develop secondarily to DD, and MC tend to occur late in the cascade of degeneration.
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Affiliation(s)
- Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Leonardo Albertini Sanchez
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA
| | - Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Jiaqi Zhu
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA.
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Camino-Willhuber G, Haffer H, Muellner M, Dodo Y, Chiapparelli E, Tani S, Amoroso K, Sarin M, Shue J, Soffin EM, Zelenty WD, Sokunbi G, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sama AA. Frailty stratification using the Modified 5-item frailty index: Significant variation within frailty patients in spine surgery. World Neurosurg 2023:S1878-8750(23)00785-4. [PMID: 37315893 DOI: 10.1016/j.wneu.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Frailty status has been associated with higher rates of complications after spine surgery. However, frailty patients constitute an heterogeneous group based on the combinations of comorbidities. The objective of this study is to compare the combinations of variables that compose the modified 5-factor frailty index score (mFI-5) based on the number of comorbidities in terms of complications, reoperation, readmission, and mortality after spine surgery. METHODS The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database from 2009-2019 was used to identify patients who underwent elective spine surgery. The mFI-5 item score was calculated and patients were classified according to number and combination of comorbidities. Multivariable analysis was used to assess the independent impact of each combination of comorbidities in the mFI-5 score on the risk of complications. RESULTS A total of 167, 630 patients were included with a mean age of 59.9 ± 13.6 years. The risk of complications was the lowest in patients with diabetes + hypertension (OR=1.2) and highest in those with the combination of CHF, diabetes, COPD, and dependent status (OR=6.6); there was a high variation in complication rate based on specific combinations. CONCLUSION There is high variability in terms of relative risk of complications based on the number and combination of different comorbidities, especially with CHF and dependent status. Therefore, frailty status encompasses a heterogeneous group and sub-stratification of frailty status is necessary to identify patients with significantly higher risk of complications.
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Affiliation(s)
| | - Henryk Haffer
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maximilian Muellner
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Erika Chiapparelli
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Soji Tani
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA; Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Krizia Amoroso
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Michele Sarin
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - William D Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Darren R Lebl
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA.
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Dodo Y, Okano I, Kelly NA, Haffer H, Muellner M, Chiapparelli E, Shue J, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sokunbi G, Sama AA. The anatomical positioning change of retroperitoneal organs in prone and lateral position: an assessment for single-prone position lateral lumbar surgery. Eur Spine J 2023; 32:2003-2011. [PMID: 37140640 DOI: 10.1007/s00586-023-07738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/20/2023] [Accepted: 04/22/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE There are reports that performing lateral lumbar interbody fusion (LLIF) in a prone, single position (single-prone LLIF) can be done safely in the prone position because the retroperitoneal organs reflect anteriorly with gravity. However, only a few study has investigated the safety of single-prone LLIF and retroperitoneal organ positioning in the prone position. We aimed to investigate the positioning of retroperitoneal organs in the prone position and evaluate the safety of single-prone LLIF surgery. METHODS A total of 94 patients were retrospectively reviewed. The anatomical positioning of the retroperitoneal organs was evaluated by CT in the preoperative supine and intraoperative prone position. The distances from the centre line of the intervertebral body to the organs including aorta, inferior vena cava, ascending and descending colons, and bilateral kidneys were measured for the lumbar spine. An "at risk" zone was defined as distance less than 10 mm anterior from the centre line of the intervertebral body. RESULTS Compared to supine preoperative CTs, bilateral kidneys at the L2/3 level as well as the bilateral colons at the L3/4 level had statistically significant ventral shift with prone positioning. The proportion of retroperitoneal organs within the at-risk zone ranged from 29.6 to 88.6% in the prone position. CONCLUSIONS The retroperitoneal organs shifted ventrally with prone positioning. However, the amount of shift was not large enough to avoid risk for organ injuries and substantial proportion of patients had organs within the cage insertion corridor. Careful preoperative planning is warranted when considering single-prone LLIF.
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Affiliation(s)
- Yusuke Dodo
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Ichiro Okano
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | | | - Henryk Haffer
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Maximilian Muellner
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Erika Chiapparelli
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Darren R Lebl
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, 535 E 70th st., New York, NY, 10021, USA.
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Haffer H, Muellner M, Chiapparelli E, Dodo Y, Moser M, Zhu J, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Bone microstructure and volumetric bone mineral density in patients with global sagittal malalignment. Eur Spine J 2023; 32:2228-2237. [PMID: 37115283 DOI: 10.1007/s00586-023-07654-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 02/28/2023] [Accepted: 03/12/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Sagittal spinal malalignment often leads to surgical realignment, which is associated with major complications. Low bone mineral density (BMD) and impaired bone microstructure are risk factors for instrumentation failure. This study aims to demonstrate differences in volumetric BMD and bone microstructure between normal and pathological sagittal alignment and to determine the relationships among vBMD, microstructure, sagittal spinal and spinopelvic alignment. METHODS A retrospective, cross-sectional study of patients who underwent lumbar fusion for degeneration was conducted. The vBMD of the lumbar spine was assessed by quantitative computed tomography. Bone biopsies were evaluated using microcomputed tomography (μCT). C7-S1 sagittal vertical axis (SVA; ≥ 50 mm malalignment) and spinopelvic alignment were measured. Univariate and multivariable linear regression analysis evaluated associations among the alignment, vBMD and μCT parameters. RESULTS A total of 172 patients (55.8% female, 63.3 years, BMI 29.7 kg/m2, 43.0% with malalignment) including N = 106 bone biopsies were analyzed. The vBMD at levels L1, L2, L3 and L4 and the trabecular bone (BV) and total volume (TV) were significantly lower in the malalignment group. SVA was significantly correlated with vBMD at L1-L4 (ρ = -0.300, p < 0.001), BV (ρ = - 0.319, p = 0.006) and TV (ρ = - 0.276, p = 0.018). Significant associations were found between PT and L1-L4 vBMD (ρ = - 0.171, p = 0.029), PT and trabecular number (ρ = - 0.249, p = 0.032), PT and trabecular separation (ρ = 0.291, p = 0.012), and LL and trabecular thickness (ρ = 0.240, p = 0.017). In the multivariable analysis, a higher SVA was associated with lower vBMD (β = - 0.269; p = 0.002). CONCLUSION Sagittal malalignment is associated with lower lumbar vBMD and trabecular microstructure. Lumbar vBMD was significantly lower in patients with malalignment. These findings warrant attention, as malalignment patients may be at a higher risk of surgery-related complications due to impaired bone. Standardized preoperative assessment of vBMD may be advisable.
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Affiliation(s)
- Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Manuel Moser
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jiaqi Zhu
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA.
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Oezel L, Okano I, Jones C, Salzmann SN, Shue J, Adl Amini D, Moser M, Chiapparelli E, Sama AA, Carrino JA, Cammisa FP, Girardi FP, Hughes AP. MRI-based vertebral bone quality score compared to quantitative computed tomography bone mineral density in patients undergoing cervical spinal surgery. Eur Spine J 2023; 32:1636-1643. [PMID: 36882579 DOI: 10.1007/s00586-023-07570-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/18/2023] [Accepted: 01/30/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE The vertebral bone quality (VBQ) score based on magnetic resonance imaging (MRI) was introduced as a bone quality marker in the lumbar spine. Prior studies showed that it could be utilized as a predictor of osteoporotic fracture or complications after instrumented spine surgery. The objective of this study was to evaluate the correlation between VBQ scores and bone mineral density (BMD) measured by quantitative computer tomography (QCT) in the cervical spine. METHODS Preoperative cervical CT and sagittal T1-weighted MRIs from patients undergoing ACDF were retrospectively reviewed and included. The VBQ score in each cervical level was calculated by dividing the signal intensity of the vertebral body by the signal intensity of the cerebrospinal fluid on midsagittal T1-weighted MRI images and correlated with QCT measurements of the C2-T1 vertebral bodies. A total of 102 patients (37.3% female) were included. RESULTS VBQ values of C2-T1 vertebrae strongly correlated with each other. C2 showed the highest VBQ value [Median (range) 2.33 (1.33, 4.23)] and T1 showed the lowest VBQ value [Median (range) 1.64 (0.81, 3.88)]. There was significant weak to moderate negative correlations between and VBQ Scores for all levels [C2: p < 0.001; C3: p < 0.001; C4: p < 0.001; C5: p < 0.004; C6: p < 0.001; C7: p < 0.025; T1: p < 0.001]. CONCLUSION Our results indicate that cervical VBQ scores may be insufficient in the estimation of BMDs, which might limit their clinical application. Additional studies are recommended to determine the utility of VBQ and QCT BMD to evaluate their potential use as bone status markers.
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Affiliation(s)
- Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Conor Jones
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Stephan N Salzmann
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Spine Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - John A Carrino
- Department of Radiology and Imaging, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Moser M, Adl Amini D, Echeverri C, Oezel L, Haffer H, Muellner M, Tan ET, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Changes in psoas and posterior paraspinal muscle morphology after standalone lateral lumbar interbody fusion: a quantitative MRI-based analysis. Eur Spine J 2023; 32:1704-1713. [PMID: 36884111 DOI: 10.1007/s00586-023-07579-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 01/04/2023] [Accepted: 02/04/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE Standalone lateral lumbar interbody fusion (SA-LLIF) without posterior instrumentation can be an alternative to 360° fusion in selected cases. This study aimed to investigate quantitative changes in psoas and paraspinal muscle morphology that occur on index levels after SA-LLIF. METHODS Patients undergoing single- or multi-level SA-LLIF at L2/3 to L4/5 who had preoperative and postoperative lumbar MRI scans, the latter performed between 3 and 18 months after surgery for any reason, were retrospectively included. Muscle measurements were performed of the psoas and posterior paraspinal muscles (PPM; erector spinae and multifidus) on index levels using manual segmentation and an automated pixel intensity threshold method to differentiate muscle from fat signal. Changes in the total cross-sectional area (TCSA), the functional cross-sectional area (FCSA), and the percentage of fat infiltration (FI) of these muscles were assessed. RESULTS A total of 67 patients (55.2% female, age 64.3 ± 10.6 years, BMI 26.9 ± 5.0 kg/m2) with 125 operated levels were included. Follow-up MRI scans were performed after an average of 8.7 ± 4.6 months, primarily for low back pain. Psoas muscle parameters did not change significantly, irrespective of the approach side. Among PPM parameters, the mean TCSA at L4/5 (+ 4.8 ± 12.4%; p = 0.013), and mean FI at L3/4 (+ 3.1 ± 6.5%; p = 0.002) and L4/5 (+ 3.0 ± 7.0%; p = 0.002) significantly increased. CONCLUSION Our study demonstrated that SA-LLIF did not alter psoas muscle morphology, underlining its minimally invasive nature. However, FI of PPM significantly increased over time despite the lack of direct tissue damage to posterior structures, suggesting a pain-mediated response and/or the result of segmental immobilization.
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Affiliation(s)
- Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Cristian Echeverri
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA.
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Haffer H, Chiapparelli E, Muellner M, Moser M, Dodo Y, Reisener MJ, Adl Amini D, Salzmann SN, Zhu J, Han YX, Donnelly E, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Bone collagen quality in lumbar fusion patients: the association between volumetric bone mineral density and advanced glycation endproducts. Eur Spine J 2023; 32:1678-1687. [PMID: 36922425 PMCID: PMC10623215 DOI: 10.1007/s00586-023-07589-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/06/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE The sole determination of volumetric bone mineral density (vBMD) is insufficient to evaluate overall bone integrity. The accumulation of advanced glycation endproducts (AGEs) stiffens and embrittles collagen fibers. Despite the important role of AGEs in bone aging, the relationship between AGEs and vBMD is poorly understood. We hypothesized that an accumulation of AGEs, a marker of impaired bone quality, is related to decreased vBMD. METHODS Prospectively collected data of 127 patients undergoing lumbar fusion were analyzed. Quantitative computed tomography (QCT) measurements were performed at the lumbar spine. Intraoperative bone biopsies were obtained and analyzed with confocal fluorescence microscopy for fluorescent AGEs, both trabecular and cortical. Spearman's correlation coefficients were calculated to examine relationships between vBMD and fAGEs, stratified by sex. Multivariable linear regression analysis with adjustments for age, sex, body mass index (BMI), race, diabetes mellitus and HbA1c was used to investigate associations between vBMD and fAGEs. RESULTS One-hundred and twenty-seven patients (51.2% female, 61.2 years, BMI of 28.7 kg/m2) with 107 bone biopsies were included in the final analysis, excluding patients on anti-osteoporotic drug therapy. In the univariate analysis, cortical fAGEs increased with decreasing vBMD at (r = -0.301; p = 0.030), but only in men. In the multivariable analysis, trabecular fAGEs increased with decreasing vBMD after adjusting for age, sex, BMI, race, diabetes mellitus and HbA1c (β = 0.99;95%CI=(0.994,1.000); p = 0.04). CONCLUSION QCT-derived vBMD measurements were found to be inversely associated with trabecular fAGEs. Our results enhance the understanding of bone integrity by suggesting that spine surgery patients with decreased bone quantity may also have poorer bone quality.
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Affiliation(s)
- Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Manuel Moser
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Marie-Jacqueline Reisener
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dominik Adl Amini
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stephan N Salzmann
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Jiaqi Zhu
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Yi Xin Han
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
| | - Eve Donnelly
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
- Musculoskeletal Integrity Program, Research Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA.
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Duculan R, Fong AM, Cammisa FP, Sama AA, Hughes AP, Lebl DR, Farmer JC, Huang RC, Sandhu HS, Mancuso CA, Girardi FP. Emerging Need for PROMs to Measure the Impact of Spine Disorders on Overall Health and Well-being: Measuring Expectations as an Example for Lumbar Degenerative Spondylolisthesis. HSS J 2023; 19:163-171. [PMID: 37065099 PMCID: PMC10090837 DOI: 10.1177/15563316221146123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/02/2022] [Indexed: 01/15/2023]
Abstract
Background: Assessing the impact of spine disorders such as lumbar degenerative spondylolisthesis (LDS) on overall health is a component of quality of care that may not be comprehensively captured by spine-specific and single-attribute patient-reported outcome measures (PROMs). Purpose: We sought to compare PROMs to the Lumbar Surgery Expectations Survey ("Expectations Survey"), which addresses multiple aspects of health and well-being, and to compare the relevance of surgeon-selected versus survey-selected Patient-Reported Outcomes Measurement Information System (PROMIS) items to LDS. Methods: In a cross-sectional study, 379 patients with LDS preoperatively completed the Expectations Survey, Numerical Rating Pain Scales, Oswestry Disability Index (ODI), and PROMIS computer-adaptive physical function, pain, and mental health surveys. Expectations Survey scores were compared to PROMs with correlation coefficients (indicating strengths of relationships) and probability values (indicating associations by chance). Surgeons reviewed physical function questions to identify those particularly relevant to LDS. Results: Patients' mean age was 67 years, 64% were women, and 83% had single-level and 17% had multiple-level LDS. Probability values between the Expectations Survey and PROMs were reliable, but strengths of relationships were only mild to moderate, indicating PROMs did not comprehensively capture the impact of LDS. None of the surgeon-selected PROMIS physical function questions were posed to patients. Conclusion: This cross-sectional study found PROMs to be reliably associated but not strongly correlated with the Expectations Survey, which addresses the whole-patient impact of LDS. New measures that complement PROMIS and ODI should be developed to capture the whole-person effects of LDS and permit attribution of LDS treatments to overall health.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Carol A. Mancuso
- Hospital for Special Surgery, New York,
NY, USA
- Weill Cornell Medical College, New
York, NY, USA
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Paek S, Zelenty WD, Dodo Y, Sarin M, Shue J, Soffin EM, Cammisa FP, Girardi FP, Sama AA, Lyman S, Hughes AP. Up to 10-year surveillance comparison of survivability in single-level cervical disc replacement versus anterior cervical discectomy and fusion in New York. J Neurosurg Spine 2023:1-10. [PMID: 37086159 DOI: 10.3171/2023.3.spine221377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/15/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE Cervical disc replacement (CDR) is an alternative treatment to anterior cervical discectomy and fusion (ACDF), which is the current gold standard, for degenerative cervical diseases such as cervical spondylotic myelopathy and cervical radiculopathy. CDR has several theoretical benefits over ACDF, including preservation of motion, earlier return to unrestricted activity, and potentially a lower risk of adjacent-segment disease. Recent literature has reported positive clinical results for CDR, but few studies have investigated the long-term risk of revision surgery of CDR versus ACDF. The purpose of this study was to identify and analyze the epidemiological, clinical, and operative risk factors that affect revision rates following single-level CDR and ACDF procedures. METHODS A retrospective cohort was extracted from the Statewide Planning and Research Cooperative System using ICD-9 and CPT codes. Inclusion criteria were adult patients undergoing primary, subaxial (C3-7), single-level ACDF or CDR for cervical radiculopathy and/or cervical spondylotic myelopathy between 2005 and 2013. Survivability was defined as the time between the index procedure and the presence of a subsequent discharge record for cervical spinal fusion or disc replacement. Statistical analyses were performed using chi-square tests, t-tests, Cox proportional hazards models, and a Kaplan-Meier plot. RESULTS A total of 7450 patients were included in this study (6615 ACDF and 835 CDR). When adjusted for patient demographics, the hazard ratios showed no significant differences in the incidence of revision risk between the two cohorts. The CDR cohort had a higher incidence of postoperative dysphagia (p < 0.05). Patients undergoing ACDF had a longer average hospital stay (2.8 vs 1.9 days, p < 0.001). There was no significant difference in time to revision surgery (p = 0.486). CONCLUSIONS CDR and ACDF have both been shown to be effective treatments for cervical spine disease. CDR patients had a shorter average inpatient hospital stay compared with ACDF patients but tended to experience dysphagia more frequently. There was a tendency toward increased survivability of CDR; however, this was not found to be statistically significant at any time point. The large size and heterogeneity of each cohort and the availability of > 10 years of surveillance data differentiate this study from other published literature. This investigation has limitations inherent to large data analysis studies, including the implementation and inaccuracy of diagnosis and procedural coding; however, this reflects real-world use of coding by practitioners.
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Affiliation(s)
- Samuel Paek
- 1Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - William D Zelenty
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
| | - Yusuke Dodo
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
- 3Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Michele Sarin
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
| | - Jennifer Shue
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
| | - Ellen M Soffin
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
| | - Frank P Cammisa
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
| | - Federico P Girardi
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
| | - Andrew A Sama
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
| | - Stephen Lyman
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
| | - Alexander P Hughes
- 2Department of Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York; and
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Dodo Y, Okano I, Zelenty WD, Paek S, Sarin M, Haffer H, Muellner M, Chiapparelli E, Shue J, Soffin E, Lebl DR, Cammisa FP, Girardi FP, Sokunbi G, Sama AA, Hughes AP. The Utilization of Intraoperative Neurophysiological Monitoring for Lumbar Decompression and Fusion Surgery in New York State. Spine (Phila Pa 1976) 2023:00007632-990000000-00316. [PMID: 37040475 DOI: 10.1097/brs.0000000000004603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/16/2023] [Indexed: 04/13/2023]
Abstract
STUDY DESIGN Retrospective database analysis. OBJECTIVE To elucidate trends in the utilization of IONM during elective lumbar surgery procedures and to investigate the association between the use of IONM and surgical outcomes. SUMMARY OF BACKGROUND DATA The routine use of Intraoperative Neurophysiological Monitoring (IONM) in elective lumbar spine procedures has recently been called into question due to longer operative time, higher cost and other substitute advanced technologies. METHODS The Statewide Planning and Research Cooperative System (SPARCS) database was accessed to perform this retrospective study. The trends of IONM use for lumbar decompression and fusion procedures were investigated from 2007 to 2018. The association between IONM use and surgical outcomes was investigated from 2017 to 2018. Multivariable logistic regression analyses as well as propensity score matching (PS-matching) were conducted to assess IONM association in neurological deficits reduction. RESULTS The utilization of IONM showed an increase in a linear fashion from 79 cases in 2007 to 6,201 cases in 2018. A total of 34,592 (12,419 monitored and 22,173 unmonitored) patients were extracted, and 210 patients (0.6%) were reported for postoperative neurological deficits. Unadjusted comparisons demonstrated that the IONM group was associated with significantly fewer neurological complications. However, multivariable analysis indicated that IONM was not a significant predictor of neurological injuries. After PS-matching of 23,642 patients, the incidence of neurological deficits was not significantly different between IONM and non-IONM patients. CONCLUSION The utilization of IONM for elective lumbar surgeries continues to gain popularity. Our results indicated that IONM use was not associated with a reduction in neurological deficits and will not support routine use of IONM for all elective lumbar surgery.
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Affiliation(s)
- Yusuke Dodo
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - William D Zelenty
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Samuel Paek
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
- Geisinger Commonwealth School of Medicine, Scranton, PA
| | - Michele Sarin
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | | | | | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Ellen Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Darren R Lebl
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | | | - Gbolabo Sokunbi
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
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Haffer H, Muellner M, Chiapparelli E, Dodo Y, Zhu J, Han YX, Donnelly E, Tan ET, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Osteosarcopenia in the Spine Beyond Bone Mineral Density: Association between Paraspinal Muscle Impairment and Advanced Glycation Endproducts. Spine (Phila Pa 1976) 2023:00007632-990000000-00306. [PMID: 37036285 PMCID: PMC10330153 DOI: 10.1097/brs.0000000000004683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
STUDY DESIGN Prospective cross-sectional study. OBJECTIVE To determine if an accumulation of advanced glycation endproducts (AGEs) is associated with impaired paraspinal muscle composition. SUMMARY OF BACKGROUND DATA Impaired bone integrity and muscle function are described as osteosarcopenia. Osteosarcopenia is associated with falls, fragility fractures and reduced quality of life. Bone integrity is influenced by bone quantity (bone mineral density) and quality (microarchitecture&collagen). The accumulation of AGEs stiffens collagen fibers and increases bone fragility. The relationship between paraspinal muscle composition and bone collagen properties has not been evaluated. METHODS Intraoperative bone biopsies from the posterior superior iliac spine were obtained and evaluated with multiphoton microscopy for fluorescent AGE crosslink density (fAGEs). Preoperative MRI measurements at level L4 included the musculus (m.) psoas and combined m. multifidus and m. erector spinae (posterior paraspinal musculature,PPM). Muscle segmentation on axial images (cross-sectional area,CSA) and calculation of an pixel intensity threshold method to differentiate muscle (functional cross-sectional area,fCSA) and intramuscular fat (FAT). Quantitative computed tomography was performed at the lumbar spine. Univariate and multivariable regression models were used to investigate associations between fAGEs and paraspinal musculature. RESULTS 107 prospectively enrolled patients (50.5% female,age 60.7 y,BMI 28.9 kg/m2) were analyzed. 41.1% and 15.0% of the patients demonstrated osteopenia and osteoporosis. Univariate linear regression analysis demonstrated a significant association between cortical fAGEs and CSA in the psoas (ρ=0.220,P=0.039), but not in the PPM. Trabecular fAGEs revealed no significant associations to PPM or psoas musculature. In the multivariable analysis, higher cortical fAGEs were associated with increased FAT (β=1.556;P=0.002) and CSA (β=1.305;P=0.005) in the PPM after adjusting for covariates. CONCLUSION This is the first investigation demonstrating that an accumulation of non-enzymatic collagen cross-linking product fAGEs in cortical bone is associated with increased intramuscular fat in the lumbar paraspinal musculature.
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Affiliation(s)
- Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Jiaqi Zhu
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Yi Xin Han
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
| | - Eve Donnelly
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
- Musculoskeletal Integrity Program, Research Institute, Hospital for Special Surgery, Weill Cornell Medicine New York City, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
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Muellner M, Chiapparelli E, Haffer H, Dodo Y, Salzmann SN, Adl Amini D, Moser M, Zhu J, Carrino JA, Tan ET, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The association between paraspinal muscle parameters and vertebral pedicle microstructure in patients undergoing lumbar fusion surgery. Int Orthop 2023; 47:1051-1060. [PMID: 36562815 PMCID: PMC10661537 DOI: 10.1007/s00264-022-05659-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/19/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Lumbar fusion surgery has become a standard procedure in spine surgery and commonly includes the posterior placement of pedicle screws. Bone quality is a crucial factor that affects pedicle screw purchase. However, the relationship between paraspinal muscles and the bone quality of the pedicle is unknown. The aim of the study was to determine the relationship between paraspinal muscles and the ex vivo bony microstructure of the lumbar pedicle. METHODS Prospectively, collected data of patients undergoing posterior lumbar fusion for degenerative spinal conditions was analyzed. Pre-operative lumbar magnetic resonance imaging (MRI) scans were evaluated for a quantitative assessment of the cross-sectional area (CSA), functional cross-sectional area (fCSA), and the proportion of intramuscular fat (FI) for the psoas muscle and the posterior paraspinal muscles (PPM) at L4. Intra-operative bone biopsies of the lumbar pedicle were obtained and analyzed with microcomputed tomography (µCT) scans. The following cortical (Cort) and trabecular (Trab) bone parameters were assessed: bone volume fraction (BV/TV), trabecular number (Tb.N), trabecular thickness (Tb.Th), connectivity density (CD), bone-specific surface (BS/BV), apparent density (AD), and tissue mineral density (TMD). RESULTS A total of 26 patients with a mean age of 59.1 years and a mean BMI of 29.8 kg/m2 were analyzed. fCSAPPM showed significant positive correlations with BV/TVTrab (ρ = 0.610; p < 0.001), CDTrab (ρ = 0.679; p < 0.001), Tb.NTrab (ρ = 0.522; p = 0.006), Tb.ThTrab (ρ = 0.415; p = 0.035), and ADTrab (ρ = 0.514; p = 0.007). Cortical bone parameters also demonstrated a significant positive correlation with fCSAPPM (BV/TVCort: ρ = 0.584; p = 0.002; ADCort: ρ = 0.519; p = 0.007). FIPsoas was negatively correlated with TMDCort (ρ = - 0.622; p < 0.001). CONCLUSION This study highlights the close interactions between the bone microstructure of the lumbar pedicle and the paraspinal muscle morphology. These findings give us further insights into the interaction between the lumbar pedicle microstructure and paraspinal muscles.
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Affiliation(s)
- Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Yusuke Dodo
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Stephan N Salzmann
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, 1090, Vienna, Austria
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jiaqi Zhu
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA.
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Zelenty WD, Paek S, Dodo Y, Sarin M, Shue J, Soffin E, Lebl DR, Cammisa FP, Girardi FP, Sokunbi G, Sama AA, Hughes AP. Utilization Trends of Intraoperative Neuromonitoring for Anterior Cervical Discectomy and Fusion in New York State. Spine (Phila Pa 1976) 2023; 48:492-500. [PMID: 36576864 DOI: 10.1097/brs.0000000000004569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/04/2022] [Indexed: 12/29/2022]
Abstract
STUDY DESIGN Retrospective cohort analysis. OBJECTIVE To elucidate trends in the utilization of intraoperative neuromonitoring (IONM) during anterior cervical discectomy and fusion (ACDF) procedures in NY state using the Statewide Planning and Research Cooperative System and to determine if utilization of IONM resulted in a reduction in postoperative neurological deficits. SUMMARY OF BACKGROUND DATA IONM has been available to spinal surgeons for several decades. It has become increasingly prevalent in all facets of spinal surgery including elective ACDF procedures. The utility of IONM for preventing a neurological deficit in elective spine procedures has recently been called into question. MATERIALS AND METHODS The Statewide Planning and Research Cooperative System database were accessed to perform a retrospective cohort study comparing monitored versus unmonitored ACDF procedures between 2007 and 2018 as defined by the International Classification of Disease-9 and 10 Procedural Coding System (ICD-9 PCS, ICD-10 PCS) codes. Patient demographics, medical history, surgical intervention, pertinent in-hospital events, and urban versus rural medical centers (as defined by the United States Office of Management and Budget) were recorded. Propensity-score-matched comparisons were used to identify factors related to the utilization of IONM and risk factors for neurological deficits after elective ACDF. RESULTS A total of 70,838 [15,092 monitored (21.3%) and 55,746 (78.7%) unmonitored] patients' data were extracted. The utilization of IONM since 2007 has increased in a linear manner from 0.9% of cases in 2007 to 36.7% by 2018. Overall, baseline characteristics of patients who were monitored during cases differed significantly from unmonitored patients in age, race/ethnicity, insurance type, presence of myelopathy or radiculopathy, and Charlson Comorbidity Index; however, only race/ethnicity was statistically significant when analyzed using propensity-score-matched. When comparing urban and rural medical centers, there is a significant lag in the adoption of the technology with no monitored cases in rural centers until 2012 with significant fluctuations in utilization compared with steadily increasing utilization among urban centers. From 2017 to 2018, reporting of neurological deficits after surgery resembled literature-established norms. Pooled analysis of these years revealed that the incidence of neurological complications occurred more frequently in monitored cases than in unmonitored (3.0% vs. 1.4%, P < 0.001). CONCLUSIONS The utility of IONM for elective ACDF remains uncertain; however, it continues to gain popularity for routine cases. For medical centers that lack similar resources to centers in more densely populated regions of NY state, reliable access to this technology is not a certainty. In our analysis of intraoperative neurological complications, it seems that IONM is not protective against neurological injury.
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Affiliation(s)
- William D Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Samuel Paek
- Geisinger Commonwealth School of Medicine, Scranton, PA
| | - Yusuke Dodo
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Michele Sarin
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Ellen Soffin
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Darren R Lebl
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
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Camino-Willhuber G, Tani S, Schonnagel L, Caffard T, Haffer H, Chiapparelli E, Sarin M, Shue J, Soffin EM, Zelenty WD, Sokunbi G, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sama AA. Association of frailty and preoperative hypoalbuminemia with the risk of complications, readmission, and mortality after spine surgery. World Neurosurg 2023:S1878-8750(23)00417-5. [PMID: 36972901 DOI: 10.1016/j.wneu.2023.03.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Frailty status and hypoalbuminemia have been associated with higher rates of complications after spine surgery. However, the combination of both conditions has not been fully analyzed. The objective of this study was to assess the effect of frailty and hypoalbuminemia on the risk of complications after spine surgery. METHODS The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database from 2009-2019 was used. Frailty status was calculated using the mFI-5 index. Patients were classified into non-frail (mFI=0), pre-frail (mFI=1), and frail (mFI≥2) groups and also based on albumin levels into normal (≥3.5 g/dl) and hypoalbuminemia groups (<3.5 g/dl). The latter group was also subclassified into mild and severe hypoalbuminemia groups. Multivariable analysis was used. Spearman Rho correlation between albuminemia and mFI-5 was also performed. RESULTS 69,519 patients (males=36,705/52.8%, females=32,814/47.2%) with a mean age of 61.0 ±13.2 years were included. Patients were classified as non-frail (n=24,897), pre-frail (n=28,897), and frail groups (n=15,725). Hypoalbuminemia was significantly higher in the frail group (11.4%) compared to the non-frail group (4.3%). An inverse correlation was observed between albumin levels and frailty status (Rho=-.139; p<.0001). Frail patients with severe hypoalbuminemia had significantly higher risk of complications (OR=5.0), reoperation (OR=3.3), readmission (OR=3.1), and mortality (OR=31.8) compared to patients without hypoalbuminemia. CONCLUSION The combination of frailty and hypoalbuminemia significantly increases the risk of complications after spine surgery. The prevalence of hypoalbuminemia in frailty group was significantly higher than non-frail patients (11.4% vs 4.3%). Both conditions should be evaluated preoperatively.
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Affiliation(s)
| | - Soji Tani
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA; Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Lukas Schonnagel
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Thomas Caffard
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Henryk Haffer
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Michele Sarin
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - William D Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Darren R Lebl
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA.
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Sokunbi G, Camino-Willhuber G, Paschal PK, Olufade O, Hussain FS, Shue J, Abjornson C, Zelenty WD, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sama AA. Is Diastasis recti abdominis associated with low back pain? - A systematic review. World Neurosurg 2023; 174:119-125. [PMID: 36894002 DOI: 10.1016/j.wneu.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Low back pain (LBP) is a common cause of disability worldwide, multiple causes and risk factors have been proposed in the genesis of back pain. Some studies reported an association between diastasis recti abdominis (DRA), a surrogate for decreased core strength muscle, and low back pain. We aimed to investigate the relationship between DRA and LBP through a systematic review. METHODS A systematic review of the literature of clinical studies in English literature was conducted. PubMed, Cochrane and Embase databases were used to conduct the search up to January 2022. The strategy included the following keywords: "Lower Back Pain" AND "Diastasis Recti" OR "Rectus abdominis" OR "abdominal wall" OR "paraspinal musculature". RESULTS From 207 records initially found, 34 were suitable for full review. 13 studies were finally included in this review with a total of 2820 patients. 5 studies found a positive association between DRA and LBP (5/13=38.5%) whereas 8 studies did not find any association between DRA and LBP (8/13=61.5%). CONCLUSION 61.5% of the studies included in this systematic review did not find an association between DRA and LBP whereas a positive correlation was observed in 38.5% of studies included. Based on the quality of the studies included in our review, better studies are warranted to understand the association between DRA and LBP.
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Affiliation(s)
- Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA.
| | | | - Philip K Paschal
- Hospital for Special Surgery Research Institute, Hospital for Special Surgery, New York, NY, USA
| | - Oluseun Olufade
- Department of Orthopedics, Emory University, Atlanta, GA 30329, USA
| | - Farah S Hussain
- Department of Orthopedics, Emory University, Atlanta, GA 30329, USA
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Celeste Abjornson
- Hospital for Special Surgery Research Institute, Hospital for Special Surgery, New York, NY, USA
| | - William D Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Darren R Lebl
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY, USA
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Haffer H, Chiapparelli E, Moser M, Muellner M, Dodo Y, Adl Amini D, Zhu J, Miller TT, Han YX, Donnelly E, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Dermal ultrasound measurements for bone quality assessment : An investigation of advanced glycation endproducts derived from confocal fluorescence microscopy. J Orthop Res 2023; 41:345-354. [PMID: 35470915 PMCID: PMC9596615 DOI: 10.1002/jor.25350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023]
Abstract
Bone quality is increasingly being recognized in the assessment of fracture risk. Nonenzymatic collagen cross-linking with the accumulation of advanced glycation end products stiffens and embrittles collagen fibers thus increasing bone fragility. Echogenicity is an ultrasound (US) parameter that provides information regarding the skin collagen structure. We hypothesized that both skin and bone collagen degrade in parallel fashion. Prospectively collected data of 110 patients undergoing posterior lumbar fusion was analyzed. Preoperative skin US measurements were performed in the lumbar region to assess dermal thickness and echogenicity. Intraoperative bone biopsies from the posterior superior iliac spine were obtained and analyzed with confocal fluorescence microscopy for fluorescent advanced glycation endproducts (fAGEs). Pearson's correlation was calculated to examine relationships between (1) US and fAGEs, and (2) age and fAGEs stratified by sex. Multivariable linear regression analysis with adjustments for age, sex, body mass index (BMI), diabetes mellitus, and hemoglobin A1c (HbA1c) was used to investigate associations between US and fAGEs. One hundred and ten patients (51.9% female, 61.6 years, BMI 29.8 kg/m2 ) were included in the analysis. In the univariate analysis cortical and trabecular fAGEs decreased with age, but only in women (cortical: r = -0.32, p = 0.031; trabecular: r = -0.32; p = 0.031). After adjusting for age, sex, BMI, diabetes mellitus, and HbA1c, lower dermal (β = 1.01; p = 0.012) and subcutaneous (β = 1.01; p = 0.021) echogenicity increased with increasing cortical fAGEs and lower dermal echogenicity increased with increasing trabecular fAGEs (β = 1.01; p = 0.021). This is the first study demonstrating significant associations between skin US measurements and in vivo bone quality parameters in lumbar fusion patients. As a noninvasive assessment tool, skin US measurements might be incorporated into future practice to investigate bone quality in spine surgery patients.
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Affiliation(s)
- Henryk Haffer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Manuel Moser
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Maximilian Muellner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Dominik Adl Amini
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jiaqi Zhu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Theodore T. Miller
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Yi Xin Han
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
| | - Eve Donnelly
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
- Musculoskeletal Integrity Program, Research Institute, Hospital for Special Surgery, New York City, NY, USA
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Andrew A. Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P. Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P. Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Alexander P. Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
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Amoroso K, Okano I, Sarin M, Hughes AP, Zelenty WD, Shue J, Sama AA, Cammisa FP, Girardi FP, Soffin EM. Comparative effectiveness of anesthetic technique on outcomes after lumbar spine surgery: a retrospective propensity score-matched analysis of the National Surgical Quality Improvement Program, 2009-2019. Reg Anesth Pain Med 2023; 48:343-348. [PMID: 36650026 DOI: 10.1136/rapm-2022-104098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/08/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The impact of anesthetic technique on spine surgery outcomes is controversial. Using a large national sample of patients, we compared outcomes after lumbar decompression under regional anesthesia (RA: spinal or epidural) or general anesthesia (GA). METHODS A retrospective population-based study of American College of Surgeons National Surgical Quality Improvement Program data (2009-2019). Patients were propensity score (PS) matched 3:1 (GA:RA) on demographic and surgical variables. The primary outcome was the association between anesthetic type and any complication (cardiac, pulmonary, renal, transfusion, stroke, infectious, deep vein thrombosis/pulmonary embolus). Secondary outcomes included the association between anesthetic type and individual complications, readmission and length of stay (LOS). Unadjusted comparisons (OR, 95% CI), logistic regression and adjusted generalized linear modeling (parameter estimate, PE, 95% CI) were performed before and after PS matching. RESULTS Of 1 51 010 cases, 149 996 (99.3%) were performed under GA, and 1014 (0.67%) under RA. After matching, 3042 patients with GA were compared with 1014 patients with RA. On unadjusted analyses, RA was associated with lower odds of complications (OR 0.43, 0.3 to 0.6, p<0.001), shorter LOS (RA: 1.1±3.8 days vs GA: 1.3±3.0 days; p<0.001) and fewer blood transfusions (RA: 3/1014, 0.3% vs GA: 40/3042, 1.3%; p=0.004). In adjusted analyses, RA was associated with fewer complications (PE -0.43, -0.81 to -0.06, p=0.02) and shorter LOS (PE -0.76, -0.90 to -0.63, p<0.001). There was no significant association between anesthetic type and readmission (PE -0.34, -0.74 to 0.05, p=0.09). CONCLUSIONS Compared with GA, RA was associated with fewer complications, less blood transfusion and shorter LOS after spine surgery. Although statistically significant, the magnitude of effects was small and requires further prospective study.
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Affiliation(s)
| | - Ichiro Okano
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Michele Sarin
- Hospital for Special Surgery, New York, New York, USA
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - William D Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
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Duculan R, Fong AM, Cammisa FP, Sama AA, Hughes AP, Lebl DR, Mancuso CA, Girardi FP. High preoperative expectations and postoperative fulfillment of expectations two years after decompression alone and decompression plus fusion for lumbar degenerative spondylolisthesis. Spine J 2023; 23:665-674. [PMID: 36642255 DOI: 10.1016/j.spinee.2023.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/18/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND CONTEXT Fulfillment of expectations is a patient-centered outcome that has not been assessed based on fusion status for lumbar degenerative spondylolisthesis (LDS). PURPOSE To compare preoperatively cited expectations and 2-year postoperative fulfillment of expectations between patients undergoing decompression alone (no-fusion) vs. decompression plus fusion (fusion) for LDS. STUDY DESIGN Longitudinal cohort. PATIENT SAMPLE 357 patients. OUTCOME MEASURES Postoperative version of Lumbar Spine Surgery Expectations Survey, Oswestry Disability Index (ODI), satisfaction with surgery. METHODS Preoperatively patients completed the 20-item Expectations Survey measuring amount of 'improvement expected' for symptoms, physical function, and psychosocial well-being (score range 0-100); two years postoperatively patients completed the follow-up Survey measuring 'improvement received'. The proportion of expectations fulfilled was calculated as 'improvement received' divided by 'improvement expected' (<1 some expectations fulfilled, >1 expectations surpassed). Patients also completed the ODI, SF-12 mental health subscale, satisfaction with surgery, and measures of comorbidity and psychosocial status, including social support (i.e. help at home) and prior orthopedic surgery (i.e. hip/knee arthroplasty). RESULTS Patients' mean age was 67 years, 61% were women, 82% had single-level LDS, 73% had fusion, and mean follow-up was 26.2 months. Compared to patients with no-fusion, patients with fusion had more pain, spinal instability, use of opioids, disability, and greater preoperative Expectations Survey scores (69 vs 74, p=.008). The proportion of expectations fulfilled postoperatively was high and similar for both groups (.82 vs. .79, p=.40), but more variable for fusion (IQR .32 vs. .40). In multivariable analysis with the proportion as the dependent variable, fulfilled expectations was associated with better mental well-being (coeff=1.1, 95% CI 0.6-1.7, p=.0001) and more social support (coeff=3.3, 95% CI 1.1-5.6, p=.004) and unfulfilled expectations was associated with prior arthroplasty (coeff=-8.6, 95% CI -15.4-(-1.9), p=.01) and subsequent lumbar surgery (coeff=-15.6, 95% CI -25.2-(-6.0), p=.002). Similar associations were found for change in ODI and satisfaction. CONCLUSIONS Patients had high preoperative expectations of surgery with greater expectations for decompression-fusion compared to decompression-alone. Although more variable for the fusion group, both groups had high proportions of expectations fulfilled. This study highlights the spectrum of clinical and psychosocial variables that impacts fulfillment of expectations for both decompression-alone and decompression-fusion for LDS surgery.
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Affiliation(s)
- Roland Duculan
- Hospital for Special Surgery, Department of Orthopedic Surgery, 535 East 70th Street, New York, NY
| | - Alex M Fong
- Hospital for Special Surgery, Department of Orthopedic Surgery, 535 East 70th Street, New York, NY
| | - Frank P Cammisa
- Hospital for Special Surgery, Department of Orthopedic Surgery, 535 East 70th Street, New York, NY
| | - Andrew A Sama
- Hospital for Special Surgery, Department of Orthopedic Surgery, 535 East 70th Street, New York, NY
| | - Alexander P Hughes
- Hospital for Special Surgery, Department of Orthopedic Surgery, 535 East 70th Street, New York, NY
| | - Darren R Lebl
- Hospital for Special Surgery, Department of Orthopedic Surgery, 535 East 70th Street, New York, NY
| | - Carol A Mancuso
- Hospital for Special Surgery, Department of Medicine, 535 East 70th Street, New York, NY; Weill Cornell Medical College, Department of Medicine, 1300 York Avenue, New York, NY.
| | - Federico P Girardi
- Hospital for Special Surgery, Department of Orthopedic Surgery, 535 East 70th Street, New York, NY
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50
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Moser M, Adl Amini D, Jones C, Zhu J, Okano I, Oezel L, Chiapparelli E, Tan ET, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The predictive value of psoas and paraspinal muscle parameters measured on MRI for severe cage subsidence after standalone lateral lumbar interbody fusion. Spine J 2023; 23:42-53. [PMID: 35351664 DOI: 10.1016/j.spinee.2022.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/03/2022] [Accepted: 03/22/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND CONTEXT The effect of psoas and paraspinal muscle parameters on cage subsidence after minimally invasive techniques, such as standalone lateral lumbar interbody fusion (SA-LLIF), is unknown. PURPOSE This study aimed to determine whether the functional cross-sectional area (FCSA) of psoas and lumbar spine extensor muscles (multifidus and erector spinae), and psoas FCSA normalized to the vertebral body area (FCSA/VBA) differ among levels with severe cage subsidence after SA-LLIF when compared to levels without severe cage subsidence. STUDY DESIGN Retrospective single center cohort study. PATIENT SAMPLE Patients who underwent SA-LLIF between 2008 and 2020 for degenerative conditions using exclusively polyetheretherketone (PEEK) cages, had a lumbar magnetic resonance imaging (MRI) scan within 12 months, a lumbar computed tomography (CT) scan within 6 months prior to surgery, and a postoperative clinical and radiographic follow-up at a minimum of 6 months were included. OUTCOME MEASURES Severe cage subsidence. METHODS MRI measurements included psoas and combined multifidus and erector spinae (paraspinal) FCSA and FCSA/VBA at the L3-L5 pedicles. Following manual segmentation of muscles on axial T2-weighted images using ITK-SNAP (version 3.8.0), the FCSA was calculated using a custom written program on Matlab (version R2019a, The MathWorks, Inc.) that used an automated pixel intensity threshold method to differentiate between fat and muscle. Mean volumetric bone mineral density (vBMD) at L1/2 was measured by quantitative CT. The primary endpoint was severe cage subsidence per level according to the classification by Marchi et al. Multivariable logistic regression analysis was performed using generalized linear mixed models. All analyses were stratified by biological sex. RESULTS 95 patients (45.3% female) with a total of 188 operated levels were included in the analysis. The patient population was 92.6% Caucasian with a median age at surgery of 65 years. Overall subsidence (Grades 0-III) was 49.5% (53/107 levels) in men versus 58.0% (47/81 levels) in women (p=.302), and severe subsidence (Grades II-III) was 22.4% (24/107 levels) in men versus 25.9% (21/81 levels) in women (p=.608). In men, median psoas FCSA and psoas FCSA/VBA at L3 and L4 were significantly greater in the severe subsidence group when compared to the non-severe subsidence group. No such difference was observed in women. Paraspinal muscle parameters did not differ significantly between non-severe and severe subsidence groups for both sexes. In the multivariable logistic regression analysis with adjustments for vBMD and cage length, psoas FCSA at L3 (OR 1.002; p=.020) and psoas FCSA/VBA at L3 (OR 8.655; p=.029) and L4 (OR 4.273; p=.043) were found to be independent risk factors for severe cage subsidence in men. CONCLUSIONS Our study demonstrated that greater psoas FCSA at L3 and psoas FCSA/VBA at L3 and L4 were independent risk factors for severe cage subsidence in men after SA-LLIF with PEEK cages. The higher compressive forces the psoas exerts on lumbar segments as a potential stabilizer might explain these findings. Additional pedicle screw fixation might be warranted in these patients to avoid severe cage subsidence.
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Affiliation(s)
- Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Spine Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne, Switzerland
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Orthopedic Surgery and Traumatology, Charité University Hospital Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Conor Jones
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Jiaqi Zhu
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA; Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th St, New York, NY 10021, USA.
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