Hashmi, Sohaib

OBJECTIVE While traditional literature in adult spinal deformity (ASD) examining mechanical complications has focused on proximal junctional kyphosis and failure, distal junctional failure (DJF) of constructs ending at the sacrum with or without spinopelvic fixation remains less explored. The current study sought to 1) propose a new DJF classification with a panel of experienced deformity surgeons, and 2) analyze intra- and interreliability of the novel classification. METHODS A prior review study was completed that identified all types of distal complications for lumbosacral fusions. A panel of 25 experienced spinal deformity surgeons used a modified Delphi approach with three rounds of review to create a classification system. Ten deformity surgeons then reviewed a representative series of 14 de-identified cases to assess the interrater reliability of the classification system using the intraclass correlation coefficient (ICC). A second round of review was conducted by each investigator to determine intrarater reliability using Cohen’s kappa coefficient. RESULTS Complications were classified as acute (< 90 days from the date of surgery) or chronic (≥ 3 months from the date of surgery). Acute failures included mechanical failure of the screws or screw-rod interface, such as pelvic set plug dissociation, tulip head dissociation, and fracture of the pelvic screw at any point along its trajectory. Fractures of the rod (proximal vs distal to S1) and distal bony anatomy (sacrum vs pelvis) were included, as was failure of the offset connector. Chronic failures also consisted of pseudarthrosis at distal levels, sacroiliac joint (SIJ) pain, screw halo formation, and painful screw prominence. The intrarater and interrater reliability were both high with Cohen’s kappa of 0.91 and an ICC of 0.98, respectively. CONCLUSIONS These data provide a comprehensive and systematic classification scheme of distal complications following long-segment ASD fusion to the sacrum. This new paradigm will allow for more detailed and consistent reporting of distal junctional complications following spinopelvic fusion, with or without supplemental pelvic fixation and/or concomitant SIJ fusion. This classification scheme resulted in high intra- and interrater reliability.

OBJECTIVE Tranexamic acid (TXA) is an FDA-approved antifibrinolytic that is seeing increased popularity in spine surgery owing to its ability to reduce intraoperative blood loss (IOBL) and allogeneic transfusion requirements. The present study aimed to summarize the current literature on these formulations in the context of short-segment instrumented lumbar fusion including ≥ 1-level posterior lumbar interbody fusion (PLIF). METHODS The PubMed, Cochrane, and Web of Science databases were queried for all full-text English studies evaluating the use of topical TXA (tTXA), systemic TXA (sTXA), or combined tTXA+sTXA in patients undergoing PLIF. The primary endpoints of interest were operative time, IOBL, and total blood loss (TBL); secondary endpoints included venous thromboembolic complication occurrence, and allogeneic and autologous transfusion requirements. Outcomes were compared using random effects. Comparisons were made between the following treatment groups: sTXA, tTXA, and sTXA+tTXA. Given that sTXA is arguably the standard of care in the literature (i.e., the most common route of administration that to this point has been studied the most), the authors compared sTXA versus tTXA and sTXA versus sTXA+tTXA. Study heterogeneity was assessed with the I2 test, and grouped analysis using the Hedge’s g test was performed for measurement of effect size. RESULTS Forty-five articles were identified, of which 17 met the criteria for inclusion with an aggregate of 1008 patients. TXA regimens included sTXA only, tTXA only, and various combinations of sTXA and tTXA. There were no significant differences in operative time, TBL, or postoperative drainage between the sTXA and tTXA groups or between the sTXA and sTXA+tTXA groups. CONCLUSIONS The present meta-analysis suggested clinical equipoise between isolated sTXA, isolated tTXA, and combinatorial tTXA+sTXA formulations as hemostatic adjuvants/neoadjuvants in short-segment fusion including ≥ 1-level PLIF. Given the theoretically lower venous thromboembolism risk associated with tTXA, additional investigations using large cohorts comparing these two formulations within the posterior fusion population are merited. Although TXA has been shown to be effective, there are insufficient data to support topical or systemic administration as superior within the open PLIF population.