What’s New in Spine Surgery

The orthopaedic community continues to struggle with the impact of COVID-19 across our profession. Although our society is moving forward, we still see the impact in nursing staffing shortages across hospitals and trends toward outpatient procedures to reduce costs and hospitalization demand. Additionally, we continue to see the effects that COVID-19 had on the research community. Clinical trials were paused and research meetings and conferences were reduced to decrease the risk of COVID-19 transmission. Although almost all clinical trials and meetings have resumed, this gap in our knowledge growth will have a long-lasting impact. Furthermore, it will be years before the nursing staffing levels meet the current demand. These trends will continue to impact our profession for years to come. This year’s annual update on spine surgery focuses on peer-reviewed literature with the highest Levels of Evidence while also surveying the abstracts presented at national meetings over the past 12 months since our last update. The spine surgery literature continues to grow exponentially, with the greatest growth seen within technical articles and case series. However, the number of randomized controlled trials (RCTs), which are difficult to perform in all surgical specialties, continues to grow slowly and in areas that lend themselves to their performance. Lumbar Spine The optimal surgical management for lumbar disc herniation, lumbar spinal stenosis, and degenerative spondylolisthesis has been studied extensively in the past year. Hermansen et al. performed a randomized clinical trial of 437 patients with spinal stenosis without concomitant spondylolisthesis1. They compared unilateral laminotomy (with crossover), bilateral laminotomy, and laminectomy with spinous process osteotomy as treatment options and found no differences in outcomes or complication rates. In the Swedish Spinal Stenosis Study (SSSS), Karlsson et al. compared the rates of stenosis recurrence, at the adjacent or operative level, on 2-year magnetic resonance imaging (MRI) between groups treated with decompression alone or decompression with fusion2. Of the 211 patients originally included, 176 had MRI scans available for review. Karlsson et al. found that new stenosis at the operative and adjacent levels occurred significantly more frequently in the fusion group. This finding persisted even in the presence of preoperative spondylolisthesis. The authors concluded that decompression without fusion is the preferred surgical treatment for lumbar spinal stenosis as well as degenerative spondylolisthesis. In contrast, in a prospective randomized study, Inose et al. reported on long-term (mean follow-up of 12.3 years) outcomes after decompression alone, decompression and fusion, or decompression with stabilization for spondylolisthesis3. The authors included 66 of the initial 85 patients and found that the inclusion of instrumentation did not improve patient-reported back pain on the visual analog scale (VAS) at the final follow-up; however, instrumentation was associated with improvements in other outcome measures such as vitality, social functioning, and mental health. Cheng et al. conducted a prospective randomized trial evaluating transforaminal lumbar interbody fusion (TLIF) treated with isolated foraminal stenosis, with either unilateral or bilateral pedicle screw stabilization4. They found significant improvements in the height of the intervertebral disc space and foramen, and in segmental lordosis, regardless of the instrumentation type; however, the bilateral pedicle screw group had significantly longer operative time and higher blood loss. Fusion rates were similar between groups, although, with only 48 patients in total, the study was likely underpowered to detect a difference in pseudarthrosis rates. Patient-reported outcomes were also statistically similar. The authors used these results to argue that unilateral pedicle screw constructs with anterior column support provided similar results to bilateral pedicle screw instrumentation. Glennie et al. examined the cost-effectiveness of surgical management of lumbar disc herniation causing chronic (defined as 4 to 12 months) radiculopathy from a third-party payer perspective, as determined by the single-payer Canadian health-care system5. The authors found that early microdiscectomy was cost-effective for chronic radiculopathy, in that the cost of 1 quality-adjusted life-year (QALY) was lower than the stated $50,000 Canadian dollars willingness-to-pay threshold. The upfront costs were higher, but the outcomes were better overall with the surgical procedure. Therefore, the authors concluded that: “Decision-makers should ensure adequate funding to allow timely access to surgical care given that it is highly likely that early surgical intervention is potentially cost-effective in single-payer systems.” Coric et al. reported the results of their multicenter, prospective, randomized study of a new posterior lumbar facet arthroplasty device for the treatment of degenerative spondylolisthesis6. The study was an investigational device exemption (IDE) trial performed for the U.S. Food and Drug Administration (FDA) and was designed to compare the outcomes of the Total Posterior Spine (TOPS) System device, which preserves facet joint motion after decompression for stenosis caused by spondylolisthesis, with those of traditional TLIF. Coric et al. found that segmental motion was preserved in the TOPS System group and the outcomes were similar, with the TOPS group reporting a significantly higher overall composite measure for clinical success. The authors concluded that the TOPS System is safe and efficacious as a surgical treatment option for degenerative spondylolisthesis. Blood Loss and Pain Control Two randomized trials compared the use of topical tranexamic acid (TXA) to reduce blood loss after lumbar fusion. Jiang et al. injected a multifunctional cocktail of topical anesthetic and topical TXA after fascial closure in the experimental group and injected an equal volume of normal saline solution in the same location in the control group7. The experimental group had lower total blood loss (postoperative, total, and hidden) and higher hemoglobin levels on postoperative day 3. In contrast, Maethungkul et al. found that the addition of topical TXA did not reduce postoperative blood loss compared with placebo in patients undergoing palliative decompressive thoracolumbar spinal metastasis surgery8. The authors concluded that topical TXA did not provide any additional benefit to reduce blood loss in this patient subpopulation and that prophylactic intravenous TXA was sufficient. Clohisy et al. compared 2 dosing protocols for intravenous TXA administration in patients undergoing adult spinal deformity surgery: a low dose (10-mg/kg bolus, 1-mg/kg/hr infusion) and a high dose (50-mg/kg bolus, 5-mg/kg/hr infusion)9. Fifty-two patients undergoing a minimum of 10 fusion levels or a planned 3-column osteotomy for adult spinal deformity were included. Overall, the high-dose group demonstrated a decreased total blood volume loss compared with the low-dose group. There were no differences in serious adverse events between groups. Infection Salimi et al. performed a randomized, prospective study examining the effect of local vancomycin therapy at wound closure on infection rates10. They included 375 patients undergoing any type of lumbar spine surgery, including decompression alone and instrumented fusion. They found no significant differences between the groups with and without vancomycin, although gram-negative organisms were more common in the vancomycin group. The authors ultimately concluded that topical vancomycin powder has no demonstrated benefit and may increase the relative rate of gram-negative infections. Cervical Spine The optimal surgical treatment for cervical radiculopathy remains controversial. Using a noninferiority study design, the authors of the Foraminotomy ACDF Cost-Effectiveness Trial (FACET) RCT compared patient outcomes between anterior cervical discectomy and fusion (ACDF) and posterior foraminotomy in the setting of unilateral, single-level radiculopathy11. In this randomized and blinded study of 265 patients, the primary outcome measures were the Odom score and the VAS arm pain score. The 1-year data, with a 90% follow-up rate, demonstrated that posterior foraminotomy was noninferior to ACDF, with a 10% noninferiority margin. The secondary outcomes demonstrated small between-group differences, most importantly for dysphagia in the anterior group and wound infections in the posterior group. Reoperation rates trended slightly higher in the posterior group (5% compared with 3%). This study suggested adequate short-term outcomes for posterior foraminotomy; however, the study was limited by a lack of longer-term follow-up assessing the durability of these outcomes. Pain control following posterior cervical surgery remains an active area of research. Standard care currently relies on multimodal analgesia. Two recent studies evaluated augmentation with an erector spinae plane block (ESPB). In a prospective, double-blinded RCT, Kanna et al. evaluated patients who underwent posterior cervical surgery and received standard multimodal analgesia and compared those who had an addition of an ESPB and those who did not12. The ESPB group fared significantly better in all primary outcomes, demonstrating improved intraoperative opiate consumption, postoperative pain score, sedation score, and time to mobilization. The authors did not identify any complications with the ESPB administered at the T1 level transverse process using ultrasound guidance. Similarly, Mostafa et al. performed a double-blinded RCT in patients who underwent posterior cervical surgery, with the study group receiving an inter-semispinal plane (ISP) block at the C5 level13. The ISP group demonstrated superior outcomes with regard to intraoperative fentanyl consumption, postoperative VAS scores within 12 hours, and the amount of and time to rescue analgesic administration. These studies supported the use of ESPB as a useful adjunct for pain management for posterior cervical surgery. Prophylaxis for dysphagia and odynophagia after ACDF is also a continued area of interest. A double-blinded RCT compared outcomes following administration of intravenous dexamethasone preoperatively for ACDF with those in a saline solution group14. Odynophagia outcome scores and VAS odynophagia scores were significantly better in the dexamethasone group up to 72 hours postoperatively; these results were no longer significant at 2 weeks postoperatively. Notably, the study did not address any potential long-term implications of dexamethasone administration. The debate with regard to the optimal implant for ACDF continues. Recent studies have added to the literature with regard to polyetheretherketone (PEEK) compared with allograft implants and anterior plating compared with stand-alone cages. In a prospective RCT, Villavicencio et al. examined the clinical and radiographic outcomes in patients undergoing ACDF with either PEEK or allograft implants15. The authors did not identify a difference in pseudarthrosis rate (10.2% in PEEK compared with 6.5% in allograft) at 24 months. They observed an equivalent rate of subsidence as well. This study largely conformed to the available literature suggesting a minimal difference in the fusion rate between the 2 implant materials. The debate with regard to stand-alone cervical cages was addressed in an RCT performed by Zavras et al.16. This prospective randomized trial compared clinical and radiographic outcomes in 1 or 2-level ACDF with or without anterior cervical plating. Fusion and subsidence rates were equivalent across groups. The plating group demonstrated worse rates of dysphagia. However, the 2-level, stand-alone group demonstrated slightly worse patient-reported outcome measures in the early postoperative period. The authors postulated that plating may impact dysphagia rates, but the added stability, particularly in 2-level constructs, may lead to superior patient-reported outcomes in the early recovery period. Mitigating the risk of subsidence remains a surgical goal for ACDF. The implant-to-bone surface area ratio was evaluated as a potential surgical variable that could impact subsidence rates by Godlewski et al., who determined that subsidence was inversely correlated with the implant-to-bone surface area ratio17. The study was limited in that it did not include a comparison with preoperative disc height, bone mineral density, or the type of material used. However, the data suggested that maximizing implant coverage on the vertebral end plate is associated with lower rates of subsidence. Postoperative Pain Management and Rehabilitation Protocols Postoperative pain control in the acute and delayed postoperative period in lumbar surgery remains a topic of active research. The use of multimodal analgesia aimed at reducing opioid consumption, postoperative pain scores, and mobilization time is a staple of enhanced recovery after surgery (ERAS) protocols. The ESPB, an expansion on traditional modalities for postoperative pain control, was described by Forero et al. in 201618 and its use in lumbar surgery continues to develop. In a randomized clinical trial, Nashibi et al.19 examined the efficacy of ultrasound-guided ESPB in postoperative lumbar pain control. The authors found that preoperative ESPB after the induction of general anesthesia significantly reduced pain scores, the need for rescue analgesia, and opioid consumption compared with controls. Preoperative ultrasound-guided ESPB compared with intraoperative anesthetic local infiltration was examined by Vergari et al.20 in 24 patients undergoing lumbar fusion randomly assigned to guided bilateral ESPB or intraoperative intrawound infiltration. The authors found a significant decrease in patient-reported numeric rating pain scores in the recovery room in the ultrasound-guided ESPB group compared with the intraoperative infiltration group. The total amount of requested opioids during hospitalization was also reduced in the guided ESPB group, with no difference noted in adverse events or length of stay. Renewed interest in the study of ultrasound-guided ESPB with medium and short-acting local anesthetics has led to further investigation of ESPB optimization. Dexmedetomidine is a highly selective, short-acting, alpha-2 agonist with an inhibitory sympathetic and hypotonic effect and its addition to standard peripheral nerve blocks has increased the duration of analgesia and has decreased morphine consumption21,22. In a group of 120 randomly assigned patients undergoing open lumbar fusion, Yi-Han et al.23 found that the addition of 1-μg/kg dexmedetomidine to 20-mL ropivacaine ESPB compared with only 20-mL ropivacaine resulted in greater pain reduction, with notably lower VAS pain scores at 12, 24, and 48 hours postoperatively. The addition of dexmedetomidine did not result in any adverse reactions, increased mean arterial pressure, or changes in heart rate compared with the controls. In addition to perioperative analgesia, intraoperative epidural analgesic injections have been used to decrease postoperative pain. Thepsoparn et al.24 compared lower thoracic epidural blocks to controls in patients undergoing lumbar laminectomy and fusion in a blinded RCT. The experimental group demonstrated reduced recovery numeric pain scores, 24-hour morphine consumption, and length of hospital stay. The authors showed no difference in adverse events, although there was a significantly higher incidence of intraoperative hypotension in the intervention group. Along with expected postoperative pain, a portion of patients may have continued radicular pain following lumbar spine surgery. 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