The Spine Institute

Fast-acting subperception therapy in spinal cord stimulation (FAST-SCS) uses low-frequency, subthreshold stimulation to engage the dorsal column-mediated surround inhibition mechanism and thereby relieve pain. Our study was performed to better characterize the multidimensional long-term clinical outcomes of FAST-SCS therapy in patients with chronic low back and/or leg pain. Our prospective, multicenter, single-arm, open-label trial, conducted at 12 pain management centers across the USA, included male and female patients with chronic low back pain with/without leg pain refractory to conservative therapy. All eligible patients received an SCS implant. Outcomes evaluated included pain relief, disability, mobility, health-related quality of life, sleep quality, depression, pain catastrophizing, and global impression of change. Fifty-six patients received a permanent SCS implant and 55 were activated with FAST-SCS therapy. At 12months, 89% and 59% of patients achieved ≥ 50% and ≥ 80% pain relief, respectively (p < 0.0001), and pain intensity (verbal numerical rating scale) decreased by 4.9 ± 2.2 points (p < 0.0001). Significant improvements were observed in disability (Oswestry Disability Index - 24 ± 16 points, p < 0.0001) and endurance (6-Minute Walk Test + 73 ± 96m, p < 0.0001), while mobility and balance improved without reaching statistical significance (Timed Up-and-Go test - 7.5 ± 37.5s, p = 0.17). All psychosocial measures improved significantly at 12months compared to baseline, with an increase in the EQ5D-5L index (+ 0.200 ± 0.182, p < 0.0001) and decreases in the Pittsburgh Sleep Quality index (- 3.96 ± 4.31, p < 0.0001), Pain Catastrophizing Score (- 13.3 ± 11.4, p < 0.0001), and Beck Depression Index (- 7.9 ± 10.0, p < 0.0001). At 12months, 87% of patients reported being "much" or "very much" improved. Responses to FAST-SCS were at or above the minimal clinically important differences across all measured clinical dimensions. This prospective study demonstrated that FAST-SCS provided statistically significant, multidimensional benefits across pain, disability, mobility, and psychosocial outcomes over 12months in patients with chronic low back and/or leg pain. These findings support the use of FAST-SCS in this patient population. ClinicalTrials.gov (NCT04618471). https://www. gov/study/NCT04618471 .

Background/Objectives: Lumbar degenerative disease drives numerous elective spine surgeries, and anesthetic choice significantly influences airway risk, hemodynamics, analgesia, mobilization, and recovery. Interest in awake lumbar surgery, typically using spinal anesthesia (SA) with light sedation, has grown as comparative studies suggest comparable safety to general anesthesia (GA) with potential reductions in opioid use, nausea, time to ambulation, and efficiency metrics. However, these benefits may be context-dependent under standardized perioperative care. Therefore, the aim of this umbrella review is to synthesize previously published meta-analyses that compare postoperative outcomes between SA and GA in patients undergoing lumbar spine surgery. Methods: A systematic literature search was executed with defined criteria across PubMed, Embase, and Web of Science. Data analysis was performed using the metaumbrella R package to report equivalent Hedges’ g values. Each meta-analysis was evaluated with the AMSTAR2 tool, and the credibility of the evidence was determined with Ioannidis criteria. Results: Seven meta-analyses were included. Pooled data showed that SA was associated with shorter operative time, reduced length of stay, and lower intraoperative blood loss, supported by class III credibility for operative time and length of stay and class IV for blood loss in the setting of high between study heterogeneity. SA was also associated with lower odds of postoperative nausea and vomiting and reduced postoperative analgesic requirements, both graded as class IV with prediction intervals that encompassed the null. Intraoperative hypotension and bradycardia did not differ significantly between SA and GA, and postoperative pain scores and overall complication rates were similarly neutral. Conclusions: This umbrella review identifies potential advantages of SA in lumbar spine surgery, including shorter operative time, reduced length of stay, lower intraoperative blood loss, and lower postoperative nausea and analgesic requirements, while finding no consistent differences in hemodynamic events or overall complications. These findings suggest SA as an alternative pathway to general anesthesia for selected lumbar procedures but highlight substantial heterogeneity and low-to-intermediate credibility for several endpoints, underscoring the need for additional high-quality, protocolized comparative studies to refine effect sizes and define optimal patient and procedural selection.

Langerhans cell histiocytosis is frequently characterized by lytic calvarial lesions, periodically necessitating cranioplasty in infant patients. Split calvarial bone graft cranioplasty is a feasible, though technically challenging option, which may be augmented with computer-assisted planning. Our case concerns a 14-month-old boy who presented with rapid evolution of soft calvarial masses of the subocciput. Lesional aspiration was pathologically indeterminate, and lesional resection with histopathologic diagnosis and cranioplasty was planned. Virtual surgical planning allowed for identification of the most ideal harvest graft site for successful calvarial splitting. After successful lesional excision, the graft was harvested using custom manufactured osteotomy guides, split, and secured at both donor and lesion sites. The patient did well after surgery and subsequently began oncological chemotherapy. This report represents the unique description of computer-assisted planning applied to split calvarial bone grafting for the treatment of an infantile patient with calvarial Langerhans cell histiocytosis.

Study DesignA retrospective cohort study.PurposeTo assess differences in 30-day morbidity and mortality and postoperative complications between two surgical treatment options.Overview of LiteratureThe choice of decompression with fusion or decompression alone for the management of degenerative spondylolisthesis (DS) is controversial.MethodsThe American College of Surgeons National Quality Improvement Program database was queried for laminectomy or laminotomy with and without fusion from 2015 to 2020. The estimated 30-day mortality and morbidity, 30-day complications, and American Society of Anesthesiologist (ASA) classification were evaluated through chi-square and analysis of variance tests, with the results further stratified according to the ASA classification.ResultsOf the 4,120 patients, 2,384 (58%) underwent a laminectomy or laminotomy without fusion and 1,736 (42%) underwent a laminectomy or laminotomy with fusion. Patients undergoing decompression with fusion had higher mean mortality (estimated probability 0.0034 vs. 0.0027, p<0.001), mean morbidity (estimated probability 0.053 vs. 0.048, p<0.001), mean length of stay (3.62±3.4 days vs. 3.15±4.3 days, p<0.001), and bleeding risk necessitating transfusion (9.5% vs. 7.6%, p=0.038). There was a higher rate of overall 30-day postoperative complications associated with an increasing ASA score for both cohorts.ConclusionsDecompression with fusion was associated with higher estimated mortality, morbidity, and 30-day complications. Decompression alone is an appealing treatment option for lumbar DS, particularly for patients with higher ASA scores and those at higher risk.