OBJECTIVE: Spinal fusion surgery is known to be an expensive intervention. Although innovative technologies in the field aim at improving operative efficiency and outcomes, total costs must be considered. The authors hope to elucidate any differences between robot-assisted (RA) and computed tomography navigation (CT-nav) or freehand fluoroscopy-guided (FFG) pedicle screw placement in relation to patient outcomes and cost-effectiveness in lumbar fusion surgery (LFS).
METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the authors performed a systematic review to identify studies comparing clinical outcomes between CT-nav or RA versus FFG in LFS patients. All included studies utilized bilateral pedicle screws. Statistical analysis was performed using R.
RESULTS: Of the 1162 identified studies, 5 were included in the analysis. Direct evidence showed that RA decreased hospital length of stay when compared to FFG (mean difference [MD]: -2.67 days; 95% confidence interval [CI]: -4.25 to -1.08; P < 0.01). Indirect evidence showed that RA decreased operative time when compared to CT-nav (MD: -65.57 minutes; 95% CI: -127.7 to -3.44; P < 0.05). For estimated blood loss, direct evidence showed that RA was superior to FFG (MD: -120.62 mL; 95% CI: -206.39 to -34.86; P < 0.01). However, no significant difference was found between RA and CT-nav for estimated blood loss (MD: 14.88 mL; 95% CI: -105.54 to 135.3; P > 0.05). There were no other significant differences in Oswestry Disability Index, visual analog scale, or complication or reoperation rates between RA and FFG or CT-nav.
CONCLUSIONS: This study shows that RA pedicle screw placement in LFS provides similar patient outcomes to CT-nav and FFG. Robot-assisted operations were found to give rise to cost savings via decreased length of stay when compared to both CT-nav and FFG techniques. Cost-savings of $4086-$4865/patient and $7317-$9654/patient could be achieved when utilizing RA over CT-nav and FFG, respectively. However, extra upfront and maintenance costs may impact full adoption of RA in LFS.

UNASSIGNED: Adults undergoing spine surgery often have underlying osteoporosis, which may be a risk factor for postoperative complications. Although these associations have been described, osteoporosis remains profoundly underdiagnosed and undertreated in the spine surgery population. A thorough, comprehensive systematic review summarizing the relationships between bone mineral density (BMD) and specific complications of lumbar fusion surgery could be a valuable resource for raising awareness and supporting clinical practice changes.
UNASSIGNED: PubMed, Embase, and Web of Science databases were searched for original clinical research articles reporting on BMD, or surrogate measure, as a predictor of complications in adults undergoing elective lumbar fusion for degenerative disease or deformity. Endpoints included cage subsidence, screw loosening, pseudarthrosis, vertebral fracture, junctional complications, and reoperation.
UNASSIGNED: A total of 71 studies comprising 12,278 patients were included. Overall, considerable heterogeneity in study populations, methods of bone health assessment, and definition and evaluation of clinical endpoints precluded meta-analysis. Nevertheless, low BMD was associated with higher rates of implant failures like cage subsidence and screw loosening, which were often diagnosed with concomitant pseudarthrosis. Osteoporosis was also a significant risk factor for proximal junctional kyphosis, particularly due to fracture. Many studies found surgical site-specific BMD to best predict focal complications. Functional outcomes were inconsistently addressed.
UNASSIGNED: Our findings suggest osteoporosis is a significant risk factor for mechanical complications of lumbar fusion. These results emphasize the importance of preoperative osteoporosis screening, which allows for medical and surgical optimization of high-risk patients. This review also highlights current practical challenges facing bone health evaluation in patients undergoing elective surgery. Future prospective studies using standardized methods are necessary to strengthen existing evidence, identify optimal predictive thresholds, and establish specialty-specific practice guidelines. In the meantime, an awareness of the surgical implications of osteoporosis and utility of preoperative screening can provide for more informed, effective patient care.

OBJECTIVE: To compare the efficacy and safety of cortical bone trajectory (CBT) screw and pedicle screw (PS) internal fixation in the treatment of adjacent segment degeneration (ASD) after lumbar fusion.
METHODS: This study was registered on International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42023484937). We searched PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wan Fang Database, and Wei Pu Database by computer to collect controlled clinical studies on the efficacy and safety of cortical bone trajectory (CBT) screw and pedicle screw (PS) internal fixation in the treatment of adjacent segment degeneration (ASD) after lumbar fusion from database establishment to November 2023. Two researchers screened the literature, extracted data and evaluated the risk of bias of the included studies, recorded the authors, and sample size, and extracted the intraoperative blood loss, operation time, Oswestry disability index (ODI), Visual analogue scale (VAS), disc height (DH), hospital length stay and complications in each study. Meta-analysis was performed using Revman 5.4 software provided by Cochrane Library.
RESULTS: A total of 6 cohort studies (CS) and 1 randomized controlled study with a total of 420 patients were included in this study, including 188 patients in the CBT group and 232 patients in the PS group. The CBT group had lower intraoperative blood loss than the PS group [mean difference (MD) = -129.38, 95% CI (-177.22, -81.55), P < 0.00001] and operation time was shorter than that of the PS group [MD = -1.42, 95% CI (-2.63, -0.20), P = 0.02]. Early postoperative back and leg pain improved more significantly in the CBT group [MD = -0.77, 95% CI (-1.35, -0.19), P = 0.01; MD = -0.24, 95% CI (-0.37, -0.10), P = 0.0005].
CONCLUSIONS: Compared with PS, CBT for adjacent segment degeneration after lumbar fusion has the advantages of less intraoperative blood loss, shorter operation time, and less back and leg pain in the early postoperative period.

This study presents a systematic literature review and meta-analysis of pseudarthrosis risk factors following lumbar fusion procedures. The odds ratio (OR) and 95% confidence interval (95% CI) were used for outcome measurements. The objective of this study was to identify the independent risk factors for pseudarthrosis after lumbar spinal fusion, which is crucial for mitigating morbidity and reoperation. Systematic searches in PubMed, Embase, and Scopus (1990-July 2021) were conducted using specific terms. The inclusion criteria included prospective and retrospective cohorts and case‒control series reporting ORs with 95% CIs from multivariate analysis. The quality assessment utilized the Newcastle-Ottawa scale. Meta-analysis, employing OR and 95% CI, assessed pseudarthrosis risk factors in lumbar fusion surgery, depicted in a forest plot. Of the 568 abstracts identified, 12 met the inclusion criteria (9 retrospective, 2006-2021). The 17 risk factors were categorized into clinical, radiographic, surgical, and bone turnover marker factors. The meta-analysis highlighted two significant clinical risk factors: age (95% CI 1.02-1.11; p = 0.005) and smoking (95% CI 1.68-5.44; p = 0.0002). The sole significant surgical risk factor was the number of fused levels (pooled OR 1.35; 95% CI 1.17-1.55; p < 0.0001). This study identified 17 risk factors for pseudarthrosis after lumbar fusion surgery, emphasizing age, smoking status, and the number of fusion levels. Prospective studies are warranted to explore additional risk factors and assess the impact of surgery and graft type.

OBJECTIVE: A systematic review and meta-analysis was conducted to compare the efficacy and safety of cortical bone trajectory (CBT) screws and traditional pedicle screws in lumbar fusion.
METHODS: Randomized controlled studies and cohort studies on CBT versus pedicle screws in lumbar fusion were searched in China Biology Medicine, China National Knowledge Infrastructure, Wanfang, VIP Database for Chinese Technical and Science Periodicals, PubMed, Cochrane Library, and Web of Science databases. The search period spanned from the establishment of the databases to December 2023. The Cochrane bias risk assessment tool and Newcastle-Ottawa scale were applied to assess the quality of the literature included. Clinical and imaging data as well as surgical outcomes, recovery, and postoperative complications were extracted from the relevant literature.
RESULTS: A total of 6 randomized controlled trials and 26 cohort studies were included after screening by inclusion and exclusion criteria with a total of 2478 patients. The meta-analysis demonstrated significant discrepancies between the CBT and TPS groups in Japanese Orthopaedic Association score at 3 and 6 months and final follow-up. Moreover, the TPS group exhibited a higher Oswestry disability index at final follow-up, a greater VAS for low back pain at both 1 week and final follow-up, as well as a higher VAS for leg pain at 1 month. Differences were also noted in surgical and recovery outcomes. However, there was no significant difference between the 2 groups in postoperative complications.
CONCLUSIONS: CBT and TPS have analogous safety profiles when applied to lumbar fusion, but the clinical efficacy of CBT is superior to that of TPS to some extent, and the procedure is less invasive with faster recovery.

BACKGROUND: Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments.
METHODS: The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria.
RESULTS: The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis.
CONCLUSIONS: There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.

Spinal fusion procedures are used to treat a wide variety of spinal pathologies. Diabetes mellitus (DM) has been shown to be a significant risk factor for several complications following these procedures in previous studies. To the authors\' knowledge, this is the first systematic review and meta-analysis elucidating the relationship between DM and complications occurring after spinal fusion procedures.
Systematic literature searches of PubMed and EMBASE were performed from their inception to October 1, 2022, to identify studies that directly compared postfusion complications in patients with and without DM. Studies met the prespecified inclusion criteria if they reported the following data for patients with and without DM: (1) demographics; (2) postspinal fusion complication rates; and (3) postoperative clinical outcomes. The included studies were then pooled and analyzed.
Twenty-eight studies, with a cumulative total of 18,853 patients (2695 diabetic patients), were identified that met the inclusion criteria. Analysis showed that diabetic patients had significantly higher rates of total number of postoperative complications (odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12-1.58; P = 0.001), postoperative pulmonary complications (OR=2.01; 95%CI=1.31-3.08; P = 0.001), postoperative renal complications (OR=2.20; 95%CI=1.27-3.80; P = 0.005), surgical site infection (OR=2.65; 95%CI=2.19-3.20; P < 0.001), and prolonged hospital stay (OR=1.67; 95%CI=1.47-1.90; P < 0.001).
Patients with DM had a significantly higher risk of developing complications after spinal fusion, particularly pulmonary and renal complications, in addition to surgical site infections and had a longer length of stay. These findings are important for informed discussions of surgical risks with patients and families before surgery.

OBJECTIVE: This meta-analysis aims to refine the understanding of the optimal choice between different cage shapes in transforaminal lumbar interbody fusion (TLIF) by systematically comparing perioperative data, radiological outcomes, clinical results, and complications associated with banana-shaped and straight bullet cages.
METHODS: A meticulous literature search encompassing PubMed, Embase, Scopus, Web of Science, China Knowledge Network, and Wanfang Data was executed up to October 5, 2023. Inclusion criteria focused on studies comparing banana-shaped and straight bullet cages in TLIF. The quality of included studies was assessed using appropriate tools such as the Newcastle-Ottawa Scale (NOS) for nonrandomized studies. Rigorous evaluations were performed for radiographic outcomes, including disc height (DH), segmental lordosis (SL), lumbar lordosis (LL), subsidence, and fusion rates. Clinical outcomes were meticulously evaluated using visual analogue scale (VAS), Oswestry Disability Index (ODI), and complications.
RESULTS: The analysis incorporated 7 studies, involving 573 patients (297 with banana-shaped cages, 276 with straight cages), all with NOS ratings exceeding 5 stars. No statistically significant differences were observed in operative time, blood loss, or hospitalization between the 2 cage shapes. Banana-shaped cages exhibited greater changes in DH (p = 0.001), SL (p = 0.02), and LL (p = 0.01). Despite statistically higher changes in ODI for straight cages (26.33, p < 0.0001), the actual value remained similar to banana-shaped cages (26.15). Both cage types demonstrated similar efficacy in VAS, complication rates, subsidence, and fusion rates.
CONCLUSIONS: Although banana-shaped cages can excel in restoring DH, SL, and LL, straight bullet cages can provide comparable functional improvements, pain relief, and complication rates.

BACKGROUND: Sacroiliac joint dysfunction (SIJD) after lumbar/lumbosacral fusion has become increasingly recognized as the utilization of lumbar fusion has grown. Despite the significant morbidity associated with this condition, uncertainty regarding its diagnosis and treatment remains. We aim to update the current knowledge of the etiology, diagnosis, and treatment of post-lumbar surgery SIJD.
METHODS: PRISMA guidelines were used to search the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, and OVID databases for literature published in the last 10 years. The ROBIS tool was utilized for risk of bias assessment. Statistical analyses were performed using the R foundation. A Fisher\'s exact test was performed to determine the risk of SIJD based on operative technique, gender, and symptom onset timeline. Odds ratios were reported with 95% confidence intervals. A p-value [Formula: see text] 0.05 was considered statistically significant.
RESULTS: Seventeen publications were included. The incidence of new onset SIJD was 7.0%. The mean age was 56 years, and the follow-up length was 30 months. SIJD was more common with fixed lumbar fusion vs floating fusion (OR = 1.48 [0.92, 2.37], p = 0.083), fusion of [Formula: see text] 3 segments (p < 0.05), and male gender increased incidence of SIJD (OR = 1.93 [1.27, 2.98], p = 0.001). Intra-articular injection decreased the Visual Analogue Scale (VAS) score by 75%, while radiofrequency ablation (RFA) reduced the score by 90%. An open approach resulted in a 13% reduction in VAS score versus 68 and 29% for SIJ fixation using the iFuse and DIANA approaches, respectively.
CONCLUSIONS: Lumbar fusion predisposes patients to SIJD, likely through manipulation of the SIJ\'s biomechanics. Definitive diagnosis of SIJD remains multifaceted and a newer modality such as SPECT/CT may find a future role. When conservative measures are ineffective, RFA and SIJ fixation using the iFuse System yield the greatest improvement VAS and ODI.

UNASSIGNED: To date, the available guidance on venous thromboembolism (VTE) prevention in elective lumbar fusion surgery is largely open to surgeon interpretation and preference without any specific suggested chemoprophylactic regimen.
UNASSIGNED: This study aimed to comparatively analyze the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) with the use of commonly employed chemoprophylactic agents such as unfractionated heparin (UH) and low molecular weight heparin (LMWH) in lumbar fusion surgery.
UNASSIGNED: An independent systematic review of four scientific databases (PubMed, Scopus, clinicaltrials.gov, Web of Science) was performed to identify relevant articles as per the preferred reporting in systematic reviews and meta-analysis (PRISMA) guidelines. Studies reporting on DVT/PE outcomes of lumbar fusion surgery in adult patients with UH or LMWH chemoprophylaxis were included for analysis. Analysis was performed using the Stata software.
UNASSIGNED: Twelve studies with 8495 patients were included in the analysis. A single-arm meta-analysis of the included studies found a DVT incidence of 14% (95%CI [8%-20%]) and 1% (95%CI [-6% - 8%]) with LMWH and UH respectively. Both the chemoprophylaxis agents prevented PE with a noted incidence of 0% (95%CI [0%-0.1%]) and 0% (95%CI [0%-1%]) with LMWH and UH respectively. The risk of bleeding-related complications with the usage of LMWH and UH was 0% (95% CI [0.0%-0.30%]) and 3% (95% CI [0.3%-5%]) respectively.
UNASSIGNED: Both LMWH and UH reduces the overall incidence of DVT/PE, but there is a paucity of evidence analyzing the comparative effectiveness of the chemoprophylaxis regimens in lumbar fusion procedures. The heterogeneity in data prevents any conclusions, as there remains an evidence gap. We recommend future high-quality randomized controlled trials to investigate in this regard to help develop recommendations on thromboprophylaxis usage.