Costs and effects in lumbar spinal fusion. A follow-up study in 136 consecutive patients with chronic low back pain

PubMed Central

Christensen, Finn Bjarke; Christiansen, Terkel; Bünger, Cody

2006-01-01

Although cost-effectiveness is becoming the foremost evaluative criterion within health service management of spine surgery, scientific knowledge about cost-patterns and cost-effectiveness is limited. The aims of this study were (1) to establish an activity-based method for costing at the patient-level, (2) to investigate the correlation between costs and effects, (3) to investigate the influence of selected patient characteristics on cost-effectiveness and, (4) to investigate the incremental cost-effectiveness ratio of (a) posterior instrumentation and (b) intervertebral anterior support in lumbar spinal fusion. We hypothesized a positive correlation between costs and effects, that determinants of effects would also determine cost-effectiveness, and that posterolateral instrumentation and anterior intervertebral support are cost-effective adjuncts in posterolateral lumbar fusion. A cohort of 136 consecutive patients with chronic low back pain, who were surgically treated from January 2001 through January 2003, was followed until 2 years postoperatively. Operations took place at University Hospital of Aarhus and all patients had either (1) non-instrumented posterolateral lumbar spinal fusion, (2) instrumented posterolateral lumbar spinal fusion, or (3) instrumented posterolateral lumbar spinal fusion + anterior intervertebral support. Analysis of costs was performed at the patient-level, from an administrator’s perspective, by means of Activity-Based-Costing. Clinical effects were measured by means of the Dallas Pain Questionnaire and the Low Back Pain Rating Scale at baseline and 2 years postoperatively. Regression models were used to reveal determinants for costs and effects. Costs and effects were analyzed as a net-benefit measure to reveal determinants for cost-effectiveness, and finally, adjusted analysis (for non-random allocation of patients) was performed in order to reveal the incremental cost-effectiveness ratios of (a) posterior instrumentation and

Application of Resorbable Poly(Lactide-co-Glycolide) with Entangled Hyaluronic Acid as an Autograft Extender for Posterolateral Intertransverse Lumbar Fusion in Rabbits

PubMed Central

Oliver, Rema A.; Gage, Gary; Yu, Yan; Bell, David; Bellemore, Jeremy; Adkisson, Huston Davis

2011-01-01

Facilitating fusion between bony segments in a reliable and reproducible manner using a synthetic bone graft material has a number of benefits for the surgeon as well as the patient. Although autograft remains the gold standard, associated comorbidities continue to drive the development of new biomaterials for use in spinal fusion. The ability of autograft alone and autograft combined with a radiolucent biomaterial composed of resorbable osteoconductive poly(lactide-co-glycolide) with entangled hyaluronic acid to facilitate fusion was examined in a single-level noninstrumented posterolateral intertransverse lumbar fusion model in New Zealand White rabbits. Progressive bone formation was demonstrated radiographically for the extender group (synthetic biomaterial plus autograft) between 3 and 6 months. Computed tomography revealed a new cortical shell in the fusion mass at 3 and 6 months for both study groups. Tensile testing at 6 months demonstrated that the quality of bone formed between the intertransverse space was equivalent for both study groups. Histologic evaluation of the fusion mass revealed new bone on and adjacent to the transverse processes with the synthetic biomaterial group that extended laterally, supporting the osteoconductive nature of the material. Histological evidence of endochondral bone growth in the intertransverse space was observed for the autograft plus synthetic biomaterial group. Bone remodeling, new marrow spaces, and peripheral cortices were observed for each study group at 3 months that matured by 6 months. These findings support the use of a radiolucent biosynthetic material comprising poly(lactide-co-glycolide) with integrated hyaluronic acid as an autograft extender for lumbar intertransverse fusion. PMID:20712417

Clinical evaluation of an allogeneic bone matrix containing viable osteogenic cells in patients undergoing one- and two-level posterolateral lumbar arthrodesis with decompressive laminectomy.

PubMed

Musante, David B; Firtha, Michael E; Atkinson, Brent L; Hahn, Rebekah; Ryaby, James T; Linovitz, Raymond J

2016-05-27

Trinity Evolution® cellular bone allograft (TE) possesses the osteogenic, osteoinductive, and osteoconductive elements essential for bone healing. The purpose of this study is to evaluate the radiographic and clinical outcomes when TE is used as a graft extender in combination with locally derived bone in one- and two-level instrumented lumbar posterolateral arthrodeses. In this retrospective evaluation, a consecutive series of subject charts that had posterolateral arthrodesis with TE and a 12-month radiographic follow-up were evaluated. All subjects were diagnosed with degenerative disc disease, radiculopathy, stenosis, and decreased disc height. At 2 weeks and at 3 and 12 months, plain radiographs were performed and the subject's back and leg pain (VAS) was recorded. An evaluation of fusion status was performed at 12 months. The population consisted of 43 subjects and 47 arthrodeses. At 12 months, a fusion rate of 90.7 % of subjects and 89.4 % of surgical levels was observed. High-risk subjects (e.g., diabetes, tobacco use, etc.) had fusion rates comparable to normal patients. Compared with the preoperative leg or back pain level, the postoperative pain levels were significantly (p < 0.0001) improved at every time point. There were no adverse events attributable to TE. Fusion rates using TE were higher than or comparable to fusion rates with autologous iliac crest bone graft that have been reported in the recent literature for posterolateral fusion procedures, and TE fusion rates were not adversely affected by several high-risk patient factors. The positive results provide confidence that TE can safely replace autologous iliac crest bone graft when used as a bone graft extender in combination with locally derived bone in the setting of posterolateral lumbar arthrodesis in patients with or without risk factors for compromised bone healing. Because of the retrospective nature of this study, the trial was not registered.

Does Discontinuing Teriparatide Treatment and Replacing It with Bisphosphonate Maintain the Volume of the Bone Fusion Mass after Lumbar Posterolateral Fusion in Women with Postmenopausal Osteoporosis?

PubMed

Ohtori, Seiji; Orita, Sumihisa; Yamauchi, Kazuyo; Eguchi, Yawara; Aoki, Yasuchika; Nakamura, Junichi; Suzuki, Miyako; Kubota, Gou; Inage, Kazuhide; Shiga, Yasuhiro; Abe, Koki; Fujimoto, Kazuki; Kanamoto, Hirohito; Inoue, Masahiro; Kinoshita, Hideyuki; Furuya, Takeo; Koda, Masao

2017-04-01

Retrospective case series. The purpose of this study was to determine whether discontinuing teriparatide treatment and replacing it with bisphosphonate treatment maintains the volume of the fusion mass after posterolateral fusion (PLF) in women with postmenopausal osteoporosis. Clinical data support the efficacy of parathyroid hormone (PTH) for lumbar PLF. However, the use of PTH is limited to 2 years. We treated 19 women diagnosed with osteoporosis and degenerative spondylolisthesis with teriparatide (20 µg daily subcutaneously). All patients underwent one-level instrumented PLF. Teriparatide was used during 2 months prior to surgery and more than 8 months after surgery. After discontinuing teriparatide treatment, all patients used bisphosphonate (17.5 mg risedronate weekly, oral administration). Area of the fusion mass across the transverse processes at one segment was determined on an anteroposterior radiograph at 1, 2, and 3 years after surgery. We followed 19 patients for 3 years. The average duration of teriparatide treatment was 11.5 months. The bone union rate was 95%. The average area of the bone fusion mass was not significantly different between the right and left sides at 1, 2, or 3 years after surgery ( p >0.05). This study showed that replacing teriparatide treatment with bisphosphonate maintained the bone fusion mass volume after PLF in women with postmenopausal osteoporosis.

Lumbar spinal fusion. Outcome in relation to surgical methods, choice of implant and postoperative rehabilitation.

PubMed

Christensen, Finn Bjarke

2004-10-01

were included in the investigation from 1979 to 1999. Each had prior to inclusion at least 2 years of CLBP and had therefore been subjected to most of the conservative treatment leg pain, due to localized isthmic spondylolisthesis grades I-II or primary or secondary degeneration. PATIENT-BASED FUNCTIONAL OUTCOME: Patients' self-reported parameters should include the impact of CLBP on daily activity, work and leisure time activities, anxiety/depression, social interests and intensity of back and leg pain. Between 1993 and 2003 approximately 1400 lumbar spinal fusion patients completed the Dallas Pain Questionnaire under prospective design studies. In 1996, the Low Back Pain Rating scale was added to the standard questionnaire packet distributed among spinal fusion patients. In our experience, these tools are valid instruments for clinical assessment of candidates for spinal fusion procedures. It is extremely difficult to interpret radiographs of both lumbar posterolateral fusion and anterior interbody fusion. Plain radiographs are clearly not the perfect media for analysis of spinal fusion, but until new and better diagnostic methods are available for clinical use, radiographs will remain the golden standard. Therefore, the development of a detailed reliable radiographic classification system is highly desirable. The classification used in the present thesis for the evaluation of posteroalteral spinal fusion, both with and without instrumentation, demonstrated good interobserver and intraobserver agreement. The classification showed acceptable reliability and may be one way to improve interstudy and intrastudy correlation of radiologic outcomes after posterolateral spinal fusion. Radiology-based evaluation of anterior lumbar interbody fusion is further complicated when cages are employed. The use of different cage designs and materials makes it almost impossible to establish a standard radiological classification system for anterior fusions. BONE-SCREW INTERFACE

Postoperative Complications Associated With rhBMP2 Use in Posterior/Posterolateral Lumbar Fusion.

PubMed

Esmail, Nabil; Buser, Zorica; Cohen, Jeremiah R; Brodke, Darrel S; Meisel, Hans-Joerg; Park, Jong-Beom; Youssef, Jim A; Wang, Jeffrey C; Yoon, S Tim

2018-04-01

Retrospective database review. Posterior/posterolateral lumbar fusion (PLF) is an effective treatment for a variety of spinal disorders; however, variations in surgical technique have different complication profiles. The aim of our study was to quantify the frequency of various complications in patients undergoing PLF with and without human recombinant bone morphogenetic protein 2 (rhBMP2). We queried the orthopedic subset of the Medicare database (PearlDiver) between 2005 and 2011 for patients undergoing PLF procedures with and without rhBMP2. Complication and reoperation rates were analyzed within 1 year of the index procedure. Complications assessed include: acute renal failure, deep vein thrombosis, dural tear, hematoma, heterotopic ossification, incision and drainage, cardiac complications, nervous system complications, osteolysis, pneumonia, pseudarthrosis, pulmonary embolism, radiculopathy, respiratory complications, sepsis, urinary retention, urinary tract infection, mechanical, and wound complications. Chi-square analysis was used to calculate the complication differences between the groups. Our data revealed higher overall complication rates in patients undergoing PLF with rhBMP2 versus no_rhBMP2 (76.9% vs 68.8%, P < .05). Stratified by gender, rhBMP2 males had higher rates of mechanical complications, pseudarthrosis, and reoperations compared with no_rhBMP2 males ( P < .05), whereas rhBMP2 females had higher rates of pseudarthrosis, urinary tract infection, and urinary retention compared with no_rhBMP2 females ( P < .05). Our data revealed higher overall complication rates in PLF patients given rhBMP2 compared with no_rhBMP2. Furthermore, our data suggests that rhBMP2-associated complications may be gender specific.

The effects of local insulin application to lumbar spinal fusions in a rat model.

PubMed

Koerner, John D; Yalamanchili, Praveen; Munoz, William; Uko, Linda; Chaudhary, Saad B; Lin, Sheldon S; Vives, Michael J

2013-01-01

The rates of pseudoarthrosis after a single-level spinal fusion have been reported up to 35%, and the agents that increase the rate of fusion have an important role in decreasing pseudoarthrosis after spinal fusion. Previous studies have analyzed the effects of local insulin application to an autograft in a rat segmental defect model. Defects treated with a time-released insulin implant had significantly more new bone formation and greater quality of bone compared with controls based on histology and histomorphometry. A time-released insulin implant may have similar effects when applied in a lumbar spinal fusion model. This study analyzes the effects of a local time-released insulin implant applied to the fusion bed in a rat posterolateral lumbar spinal fusion model. Our hypothesis was twofold: first, a time-released insulin implant applied to the autograft bed in a rat posterolateral lumbar fusion will increase the rate of successful fusion and second, will alter the local environment of the fusion site by increasing the levels of local growth factors. Animal model (Institutional Animal Care and Use Committee approved) using 40 adult male Sprague-Dawley rats. Forty skeletally mature Sprague-Dawley rats weighing approximately 500 g each underwent posterolateral intertransverse lumbar fusions with iliac crest autograft from L4 to L5 using a Wiltse-type approach. After exposure of the transverse processes and high-speed burr decortication, a Linplant (Linshin Canada, Inc., ON, Canada) consisting of 95% microrecrystalized palmitic acid and 5% bovine insulin (experimental group) or a sham implant consisting of only palmitic acid (control group) was implanted on the fusion bed with iliac crest autograft. As per the manufacturer, the Linplant has a release rate of 2 U/day for a minimum of 40 days. The transverse processes and autograft beds of 10 animals from the experimental and 10 from the control group were harvested at Day 4 and analyzed for growth factors. The

Postoperative Complications Associated With rhBMP2 Use in Posterior/Posterolateral Lumbar Fusion

PubMed Central

Esmail, Nabil; Buser, Zorica; Cohen, Jeremiah R.; Brodke, Darrel S.; Meisel, Hans-Joerg; Park, Jong-Beom; Youssef, Jim A.; Wang, Jeffrey C.; Yoon, S. Tim

2017-01-01

Study Design: Retrospective database review. Objective: Posterior/posterolateral lumbar fusion (PLF) is an effective treatment for a variety of spinal disorders; however, variations in surgical technique have different complication profiles. The aim of our study was to quantify the frequency of various complications in patients undergoing PLF with and without human recombinant bone morphogenetic protein 2 (rhBMP2). Methods: We queried the orthopedic subset of the Medicare database (PearlDiver) between 2005 and 2011 for patients undergoing PLF procedures with and without rhBMP2. Complication and reoperation rates were analyzed within 1 year of the index procedure. Complications assessed include: acute renal failure, deep vein thrombosis, dural tear, hematoma, heterotopic ossification, incision and drainage, cardiac complications, nervous system complications, osteolysis, pneumonia, pseudarthrosis, pulmonary embolism, radiculopathy, respiratory complications, sepsis, urinary retention, urinary tract infection, mechanical, and wound complications. Chi-square analysis was used to calculate the complication differences between the groups. Results: Our data revealed higher overall complication rates in patients undergoing PLF with rhBMP2 versus no_rhBMP2 (76.9% vs 68.8%, P < .05). Stratified by gender, rhBMP2 males had higher rates of mechanical complications, pseudarthrosis, and reoperations compared with no_rhBMP2 males (P < .05), whereas rhBMP2 females had higher rates of pseudarthrosis, urinary tract infection, and urinary retention compared with no_rhBMP2 females (P < .05). Conclusion: Our data revealed higher overall complication rates in PLF patients given rhBMP2 compared with no_rhBMP2. Furthermore, our data suggests that rhBMP2-associated complications may be gender specific. PMID:29662744

Techniques of lumbar-sacral spine fusion in spondylosis: systematic literature review and meta-analysis of randomized clinical trials.

PubMed

Umeta, Ricardo S G; Avanzi, Osmar

2011-07-01

Spine fusions can be performed through different techniques and are used to treat a number of vertebral pathologies. However, there seems to be no consensus regarding which technique of fusion is best suited to treat each distinct spinal disease or group of diseases. To study the effectiveness and complications of the different techniques used for spinal fusion in patients with lumbar spondylosis. Systematic literature review and meta-analysis. Randomized clinical studies comparing the most commonly performed surgical techniques for spine fusion in lumbar-sacral spondylosis, as well as those reporting patient outcome were selected. Identify which technique, if any, presents the best clinical, functional, and radiographic outcome. Systematic literature review and meta-analysis based on scientific articles published and indexed to the following databases: PubMed (1966-2009), Cochrane Collaboration-CENTRAL, EMBASE (1980-2009), and LILACS (1982-2009). The general search strategy focused on the surgical treatment of patients with lumbar-sacral spondylosis. Eight studies met the inclusion criteria and were selected with a total of 1,136 patients. Meta-analysis showed that patients who underwent interbody fusion presented a significantly smaller blood loss (p=.001) and a greater rate of bone fusion (p=.02). Patients submitted to fusion using the posterolateral approach had a significantly shorter operative time (p=.007) and less perioperative complications (p=.03). No statistically significant difference was found for the other studied variables (pain, functional impairment, and return to work). The most commonly used techniques for lumbar spine fusion in patients with spondylosis were interbody fusion and posterolateral approach. Both techniques were comparable in final outcome, but the former presented better rates of fusion and the latter the less complications. Copyright © 2011 Elsevier Inc. All rights reserved.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 3: assessment of economic outcome.

PubMed

Ghogawala, Zoher; Whitmore, Robert G; Watters, William C; Sharan, Alok; Mummaneni, Praveen V; Dailey, Andrew T; Choudhri, Tanvir F; Eck, Jason C; Groff, Michael W; Wang, Jeffrey C; Resnick, Daniel K; Dhall, Sanjay S; Kaiser, Michael G

2014-07-01

A comprehensive economic analysis generally involves the calculation of indirect and direct health costs from a societal perspective as opposed to simply reporting costs from a hospital or payer perspective. Hospital charges for a surgical procedure must be converted to cost data when performing a cost-effectiveness analysis. Once cost data has been calculated, quality-adjusted life year data from a surgical treatment are calculated by using a preference-based health-related quality-of-life instrument such as the EQ-5D. A recent cost-utility analysis from a single study has demonstrated the long-term (over an 8-year time period) benefits of circumferential fusions over stand-alone posterolateral fusions. In addition, economic analysis from a single study has found that lumbar fusion for selected patients with low-back pain can be recommended from an economic perspective. Recent economic analysis, from a single study, finds that femoral ring allograft might be more cost-effective compared with a specific titanium cage when performing an anterior lumbar interbody fusion plus posterolateral fusion.

Modeled cost-effectiveness of transforaminal lumbar interbody fusion compared with posterolateral fusion for spondylolisthesis using N(2)QOD data.

PubMed

Carreon, Leah Y; Glassman, Steven D; Ghogawala, Zoher; Mummaneni, Praveen V; McGirt, Matthew J; Asher, Anthony L

2016-06-01

OBJECTIVE Transforaminal lumbar interbody fusion (TLIF) has become the most commonly used fusion technique for lumbar degenerative disorders. This suggests an expectation of better clinical outcomes with this technique, but this has not been validated consistently. How surgical variables and choice of health utility measures drive the cost-effectiveness of TLIF relative to posterolateral fusion (PSF) has not been established. The authors used health utility values derived from Short Form-6D (SF-6D) and EQ-5D and different cost-effectiveness thresholds to evaluate the relative cost-effectiveness of TLIF compared with PSF. METHODS From the National Neurosurgery Quality and Outcomes Database (N(2)QOD), 101 patients with spondylolisthesis who underwent PSF were propensity matched to patients who underwent TLIF. Health-related quality of life measures and perioperative parameters were compared. Because health utility values derived from the SF-6D and EQ-5D questionnaires have been shown to vary in patients with low-back pain, quality-adjusted life years (QALYs) were derived from both measures. On the basis of these matched cases, a sensitivity analysis for the relative cost per QALY of TLIF versus PSF was performed in a series of cost-assumption models. RESULTS Operative time, blood loss, hospital stay, and 30-day and 90-day readmission rates were similar for the TLIF and PSF groups. Both TLIF and PSF significantly improved back and leg pain, Oswestry Disability Index (ODI) scores, and EQ-5D and SF-6D scores at 3 and 12 months postoperatively. At 12 months postoperatively, patients who had undergone TLIF had greater improvements in mean ODI scores (30.4 vs 21.1, p = 0.001) and mean SF-6D scores (0.16 vs 0.11, p = 0.001) but similar improvements in mean EQ-5D scores (0.25 vs 0.22, p = 0.415) as patients treated with PSF. At a cost per QALY threshold of $100,000 and using SF-6D-based QALYs, the authors found that TLIF would be cost-prohibitive compared with PSF at a

Degenerative lumbar scoliosis in elderly patients: dynamic stabilization without fusion versus posterior instrumented fusion.

PubMed

Di Silvestre, Mario; Lolli, Francesco; Bakaloudis, Georgios

2014-01-01

Posterolateral fusion with pedicle screw instrumentation is currently the most widely accepted technique for degenerative lumbar scoliosis in elderly patients. However, a high incidence of complications has been reported in most series. Dynamic stabilization without fusion in patients older than 60 years has not previously been compared with the use of posterior fusion in degenerative lumbar scoliosis. To compare dynamic stabilization without fusion and posterior instrumented fusion in the treatment of degenerative lumbar scoliosis in elderly patients, in terms of perioperative findings, clinical outcomes, and adverse events. A retrospective study. Fifty-seven elderly patients were included. There were 45 women (78%) and 12 men (22%) with a mean age of 68.1 years (range, 61-78 years). All patients had degenerative de novo lumbar scoliosis, associated with vertebral canal stenosis in 51 cases (89.4%) and degenerative spondylolisthesis in 24 patients (42.1%). Clinical (Oswestry Disability Index, visual analog scale, Roland-Morris Disability Questionnaire) and radiological (scoliosis and lordosis corrections) outcomes as well as incidence of complications. Patients were divided into two groups: 32 patients (dynamic group) had dynamic stabilization without fusion and 25 patients (fusion group) underwent posterior instrumented fusion. All the patients' medical records and X-rays were reviewed. Preoperative, postoperative, and follow-up questionnaires were obtained to evaluate clinical outcomes. At an average follow-up of 64 months (range, 42-90 months), clinical results improved similarly in both groups of patients. Statistically superior scoliosis and final lordosis corrections were achieved with posterior fusion (56.9% vs. 37.3% and -46.8° vs. -35.8°, respectively). However, in the dynamic group, incidence of overall complications was lower (25% vs. 44%), and fewer patients required revision surgery (6.2% vs. 16%). Furthermore, lower average values of operative

Comparison of the osteogenesis and fusion rates between activin A/BMP-2 chimera (AB204) and rhBMP-2 in a beagle's posterolateral lumbar spine model.

PubMed

Zheng, Guang Bin; Yoon, Byung-Hak; Lee, Jae Hyup

2017-10-01

Activin A/BMP-2 chimera (AB204) could promote bone healing more effectively than recombinant bone morphogenetic protein 2 (rhBMP-2) with much lower dose in a rodent model, but there is no report about the effectiveness of AB204 in a large animal model. The purpose of this study was to compare the osteogenesis and fusion rate between AB204 and rhBMP-2 using biphasic calcium phosphate (BCP) as a carrier in a beagle's posterolateral lumbar fusion model. This is a randomized control animal study. Seventeen male beagle dogs were included. Bilateral posterolateral fusion was performed at the L1-L2 and L4-L5 levels. Biphasic calcium phosphate (2 cc), rhBMP-2 (50 µg)+BCP (2 cc), or AB204 (50 µg)+BCP (2 cc) were implanted into the intertransverse space randomly. X-ray was performed at 4 and 8 weeks. After 8 weeks, the animals were sacrificed, and new bone formation and fusion rate were evaluated by manual palpation, computed tomography (CT), and undecalcified histology. The AB204 group showed significantly higher fusion rate (90%) than the rhBMP-2 group (15%) or the Osteon group (6.3%) by manual palpation. On x-ray and CT assessment, fusion rate and the volume of newly formed bone were also significantly higher in AB204 group than other groups. In contrast, more osteolysis was found in rhBMP-2 group (40%) than in AB204 group (10%) on CT study. In histologic results, new bone formation was sufficient between transverse processes in AB204 group, and obvious trabeculation and bone remodeling were observed. But in rhBMP-2 group, new bone formation was less than AB204 group and osteolysis was observed between the intertransverse spaces. A low dose of AB204 with BCP as a carrier significantly promotes the fusion rate in a large animal model when compared with the rhBMP-2. These findings demonstrate that AB204 could be an alternative to rhBMP-2 to improve fusion rate. Copyright © 2017 Elsevier Inc. All rights reserved.

Instrumented circumferential fusion for tuberculosis of the dorso-lumbar spine. A single or double stage procedure?

PubMed

El-Sharkawi, Mohammad Mostafa; Said, Galal Zaki

2012-02-01

The purpose of this study was to present our experience in treating dorso-lumbar tuberculosis by one-stage posterior circumferential fusion and to compare this group with a historical group treated by anterior debridement followed by postero-lateral fusion and stabilization. Between 2003 and 2008, 32 patients with active spinal tuberculosis were treated by one-stage posterior circumferential fusion and prospectively followed for a minimum of two years. Pain severity was measured using Visual Analogue Scale (VAS). Neurological assessment was done using the Frankel scale. The operative data, clinical, radiological, and functional outcomes were also compared to a similar group of 25 patients treated with anterior debridement and fusion, followed 10-14 days later by posterior stabilization and postero-lateral fusion. The mean operative time and duration of hospital stay were significantly longer in the two-stage group. The mean estimated blood loss was also larger, though insignificantly, in the two-stage group. The incidence of complications was significantly lower in the one-stage group. At final follow-up, all 34 patients with pre-operative neurological deficits showed at least one Frankel grade of neurological improvement, all 57 patients showed significant improvement of their VAS back pain score, the mean kyphotic angle has significantly improved, all patients achieved solid fusion and 43 (75.4%) patients returned to their pre-disease activity level or work. Instrumented circumferential fusion, whether in one or two stages, is an effective treatment for dorso-lumbar tuberculosis. One-stage surgery, however, is advantageous because it has lower complication rate, shorter hospital stay, less operative time and blood loss.

Rational decision making in a wide scenario of different minimally invasive lumbar interbody fusion approaches and devices.

PubMed

Pimenta, Luiz; Tohmeh, Antoine; Jones, David; Amaral, Rodrigo; Marchi, Luis; Oliveira, Leonardo; Pittman, Bruce C; Bae, Hyun

2018-03-01

With the proliferation of a variety of modern MIS spine surgery procedures, it is mandatory that the surgeon dominate all aspects involved in surgical indication. The information related to the decision making in patient selection for specific procedures is mandatory for surgical success. The objective of this study is to present decision-making criteria in minimally invasive surgery (MIS) selection for a variety of patients and pathologies. In this article, practicing surgeons who specialize in various MIS approaches for spinal fusion were engaged to provide expert opinion and literature review on decision making criteria for several MIS procedures. Pros, cons, relative limitations, and case examples are provided for patient selection in treatment with MIS posterolateral fusion (MIS-PLF), mini anterior lumbar interbody fusion (mini-ALIF), lateral interbody fusion (LLIF), MIS posterior lumbar interbody fusion (MIS-PLIF) and MIS transforaminal lumbar interbody fusion (MIS-TLIF). There is a variety of aspects to consider when deciding which modern MIS surgical approach is most appropriate to use based on patient and pathologic characteristics. The surgeon must adapt them to the characteristic of each type of patients, helping them to choose the most effective and efficient therapeutic option for each case.

Impact of Lumbar Fusion on Health Care Resource Utilization.

PubMed

Mina, Curtis; Carreon, Leah Y; Glassman, Steven D

2016-02-01

A longitudinal cohort. The aim of this study was to determine the extent of health care resource utilization decrease 2 years after lumbar spinal fusion. Despite the assumption that surgery will minimize the need for ongoing nonsurgical treatment, the impact of lumbar fusion on subsequent health care resource utilization has not been effectively studied. Patients who had continuous coverage by a major insurer during the year before decompression and posterolateral instrumented spinal fusion, and the 2 and a half years following were identified. All charges processed during this time-period were collected. Charges associated with the index surgery, the 90-day postoperative period, and those unrelated to spinal care were excluded. Associations with Oswestry Disability Index (ODI) score improvement at 2 years after surgery and health care resource utilization were determined. Sixty-six patients were included in the analysis. The mean age was 59 years and 39% were males. There was a decrease in health care utilization costs 1 year after surgery ($3267.59) compared with pre-op ($4246.32), but this was not statistically significant (P = 0.197). There was a statistically significant decrease in costs during the second year after surgery ($1420.97) compared with either pre-op (P = 0.000) or 1-year costs (P = 0.001). No statistically significant correlations could be found between change in ODI scores and costs incurred at either year post-op. Health care utilization decreased at 1 year and significantly at 2 years after lumbar fusion. However, there was no correlation between use of nonsurgical resources and clinical outcome based on ODI scores. This raises the question as to whether these resources were used in a rational manner. This cooperative study between a major insurer and a tertiary spine center provides improved insight into the cost profile of lumbar fusion surgery. Further study is needed to determine whether ongoing post-op treatment is necessary

The transition zone above a lumbosacral fusion.

PubMed

Hambly, M F; Wiltse, L L; Raghavan, N; Schneiderman, G; Koenig, C

1998-08-15

The clinical and radiographic effect of a lumbar or lumbosacral fusion was studied in 42 patients who had undergone a posterolateral fusion with an average follow-up of 22.6 years. To examine the long-term effects of posterolateral lumbar or lumbosacral fusion on the cephalad two motion segments (transition zone). It is commonly held that accelerated degeneration occurs in the motion segments adjacent to a fusion. Most studies are of short-term, anecdotal, uncontrolled reports that pay particular attention only to the first motion segment immediately cephalad to the fusion. Forty-two patients who had previously undergone a posterolateral lumbar or lumbosacral fusion underwent radiographic and clinical evaluation. Rate of fusion, range of motion, osteophytes, degenerative spondylolisthesis, retrolisthesis, facet arthrosis, disc ossification, dynamic instability, and disc space height were all studied and statistically compared with an age- and gender-matched control group. The patient's self-reported clinical outcome was also recorded. Degenerative changes occurred at the second level above the fused levels with a frequency equal to those occurring in the first level. There was no statistical difference between the study group and the cohort group in the presence of radiographic changes within the transition zone. In those patients undergoing fusion for degenerative processes, 75% reported a good to excellent outcome, whereas 84% of those undergoing fusion for spondylolysis or spondylolisthesis reported a good to excellent outcome. Radiographic changes occur within the transition zone cephalad to a lumbar or lumbosacral fusion. However, these changes are also seen in control subjects who have had no surgery.

Circumferential fusion is dominant over posterolateral fusion in a long-term perspective: cost-utility evaluation of a randomized controlled trial in severe, chronic low back pain.

PubMed

Soegaard, Rikke; Bünger, Cody E; Christiansen, Terkel; Høy, Kristian; Eiskjaer, Søren P; Christensen, Finn B

2007-10-15

Cost-utility evaluation of a randomized, controlled trial with a 4- to 8-year follow-up. To investigate the incremental cost per quality-adjusted-life-year (QALY) when comparing circumferential fusion to posterolateral fusion in a long-term, societal perspective. The cost-effectiveness of circumferential fusion in a long-term perspective is uncertain but nonetheless highly relevant as the ISSLS prize winner 2006 in clinical studies reported the effect of circumferential fusion superior to the effect of posterolateral fusion. A recent trial found no significant difference between posterolateral and circumferential fusion reporting cost-effectiveness from a 2-year viewpoint. A total of 146 patients were randomized to posterolateral or circumferential fusion and followed 4 to 8 years after surgery. The mean age of the cohort was 46 years (range, 20-65 years); 61% were females, 49% were smokers, 30% had primary diagnosis of isthmic spondylolisthesis, 35% had disc degeneration and no previous surgery, and 35% had disc degeneration and previous surgery. Eighty-two percent of patients have had symptoms for more than 2 years and 50% were out of the labor market due to sickness. The EQ-5D instrument was applied for the measurement of health-related quality of life and costs (2004 U.S. dollars) were measured in a full-scale societal perspective. Productivity costs were valued by the Friction Cost method, and both costs and effects were discounted. Arithmetic means and 95% bias-corrected, bootstrapped confidence intervals were reported. Nonparametric statistics were used for tests of statistical significance. Comprehensive sensitivity analysis was conducted and reported using cost-effectiveness acceptability curves. The circumferential group demonstrated clinical superiority over the posterolateral fusion group in functional outcome (P < 0.01), fusion rate (P < 0.04), and number of reoperations (P < 0.01) among others. Cost-utility analysis demonstrated circumferential fusion

Effects of combined teriparatide and zoledronic acid on posterior lumbar vertebral fusion in an aged ovariectomized rat model of osteopenia.

PubMed

Yishake, Mumingjiang; Yasen, Miersalijiang; Jiang, Libo; Liu, Wangmi; Xing, Rong; Chen, Qian; Lin, Hong; Dong, Jian

2018-03-01

There has been no study regarding the effect of a combination of teriparatide (TPTD) and zoledronic acid (ZA) on vertebral fusion. In this study, we investigate the effect of single and combined TPTD and ZA treatment on lumbar vertebral fusion in aged ovariectomized (OVX) rats. Sixty two-month-old female Sprague-Dawley rats were ovariectomized and underwent bilateral L4-L5 posterolateral intertransverse fusion after 10 months. The OVX rats received vehicle (control) treatment, or ZA (100 µg/kg, once), or TPTD (60 µg/kg/2 d for 42 d), or ZA + TPTD until they were euthanized at 6 weeks following lumbar vertebral fusion. The lumbar spine was harvested. Bone mineral density (BMD), bone fusion, bone volume (BV), and bone formation rate (BFR)were analyzed by dual-energy X-ray absorptiometry (DXA), radiography, micro-computed tomography, and histomorphometry. Compared with vehicle (control) treatment, ZA and TPTD monotherapy increased bone volume (BV) at fusion site, and ZA + TPTD combined therapy had an additive effect. Treatment with TPTD and ZA + TPTD increased the bone fusion rate when compared with the control group. ZA monotherapy did not alter the rate of bone fusion. The TPTD and ZA + TPTD treatment groups had increased mineral apposition rate (MAR), mineralizing surfaces/bone surface ((MS/BS), and BFR/BS compared with the OVX group. Our experiment confirm that the monotherapy with TPTD and combination therapy with ZA + TPTD in an OVX rat model of osteopenia following lumbar vertebral fusion surgery increased bone fusion mass and bone fusion rate, and ZA + TPTD combined therapy had an additive effect on bone fusion mass. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:937-944, 2018. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

Comparison of instrumented anterior interbody fusion with instrumented circumferential lumbar fusion.

PubMed

Madan, S S; Boeree, N R

2003-12-01

Posterior lumbar interbody fusion (PLIF) restores disc height, the load bearing ability of anterior ligaments and muscles, root canal dimensions, and spinal balance. It immobilizes the painful degenerate spinal segment and decompresses the nerve roots. Anterior lumbar interbody fusion (ALIF) does the same, but could have complications of graft extrusion, compression and instability contributing to pseudarthrosis in the absence of instrumentation. The purpose of this study was to assess and compare the outcome of instrumented circumferential fusion through a posterior approach [PLIF and posterolateral fusion (PLF)] with instrumented ALIF using the Hartshill horseshoe cage, for comparable degrees of internal disc disruption and clinical disability. It was designed as a prospective study, comparing the outcome of two methods of instrumented interbody fusion for internal disc disruption. Between April 1994 and June 1998, the senior author (N.R.B.) performed 39 instrumented ALIF procedures and 35 instrumented circumferential fusion with PLIF procedures. The second author, an independent assessor (S.M.), performed the entire review. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging (MRI) and provocative discography in all the patients. The outcome in the two groups was compared in terms of radiological improvement and clinical improvement, measured on the basis of improvement of back pain and work capacity. Preoperatively, patients were asked to fill out a questionnaire giving their demographic details, maximum walking distance and current employment status in order to establish the comparability of the two groups. Patient assessment was with the Oswestry Disability Index, quality of life questionnaire (subjective), pain drawing, visual analogue scale, disability benefit, compensation status, and psychological profile. The results of the study showed a satisfactory outcome (score< or =30) on the subjective (quality of life

Return to Golf After Lumbar Fusion.

PubMed

Shifflett, Grant D; Hellman, Michael D; Louie, Philip K; Mikhail, Christopher; Park, Kevin U; Phillips, Frank M

Spinal fusion surgery is being increasingly performed, yet few studies have focused on return to recreational sports after lumbar fusion and none have specifically analyzed return to golf. Most golfers successfully return to sport after lumbar fusion surgery. Case series. Level 4. All patients who underwent 1- or 2-level primary lumbar fusion surgery for degenerative pathologies performed by a single surgeon between January 2008 and October 2012 and had at least 1-year follow-up were included. Patients completed a specifically designed golf survey. Surveys were mailed, given during follow-up clinic, or answered during telephone contact. A total of 353 patients met the inclusion and exclusion criteria, with 200 responses (57%) to the questionnaire producing 34 golfers. The average age of golfers was 57 years (range, 32-79 years). In 79% of golfers, preoperative back and/or leg pain significantly affected their ability to play golf. Within 1 year from surgery, 65% of patients returned to practice and 52% returned to course play. Only 29% of patients stated that continued back/leg pain limited their play. Twenty-five patients (77%) were able to play the same amount of golf or more than before fusion surgery. Of those providing handicaps, 12 (80%) reported the same or an improved handicap. More than 50% of golfers return to on-course play within 1 year of lumbar fusion surgery. The majority of golfers can return to preoperative levels in terms of performance (handicap) and frequency of play. This investigation offers insight into when golfers return to sport after lumbar fusion surgery and provides surgeons with information to set realistic expectations postoperatively.

rhBMP-2 (ACS and CRM formulations) overcomes pseudarthrosis in a New Zealand white rabbit posterolateral fusion model.

PubMed

Lawrence, James P; Waked, Walid; Gillon, Thomas J; White, Andrew P; Spock, Christopher R; Biswas, Debdut; Rosenberger, Patricia; Troiano, Nancy; Albert, Todd J; Grauer, Jonathan N

2007-05-15

The study design consisted of a New Zealand white rabbit model of pseudarthrosis repair. Study groups consisting of no graft, autograft, or recombinant human bone morphogenetic protein-2 (rhBMP-2) with absorbable collagen sponge (ACS) or compression resistant matrix (CRM) were evaluated. To evaluate the relative efficacy of bone graft materials (autograft, ACS, and CRM). rhBMP-2 has been shown to have a 100% fusion rate in a primary rabbit fusion model, even in the presence of nicotine, which is known to inhibit fusion. Seventy-two New Zealand white rabbits underwent posterolateral lumbar fusion with iliac crest autograft. To establish pseudarthroses, nicotine was administered to all animals. At 5 weeks, the spines were explored and all pseudarthroses were redecorticated and implanted with no graft, autograft, rhBMP-2/ACS, or rhBMP-2/CRM. At 10 weeks, fusions were assessed by manual palpation and histology. Eight rabbits (11%) were lost to complications. At 5 weeks, 66 (97%) had pseudarthroses. At 10 weeks, attempted pseudarthrosis repairs were fused in 1 of 16 of no graft rabbits (6%), 5 of 17 autograft rabbits (29%), and 31 of 31 rhBMP-2 rabbits (with ACS or CRM) (100%). Histologic analysis demonstrated more mature bone formation in the rhBMP-2 groups. The 2 rhBMP-2 formulations led to significantly higher fusion rates and histologic bone formation than no graft and autograft controls in this pseudarthrosis repair model.

Transforaminal endoscopic treatment of lumbar radiculopathy after instrumented lumbar spine fusion.

PubMed

Telfeian, Albert E; Jasper, Gabriele P; Francisco, Gina M

2015-01-01

Transforaminal endoscopic discectomy and foraminotomy is a well-described minimally invasive technique for surgically treating lumbar radiculopathy caused by a herniated disc and foraminal narrowing. To describe the technique and feasibility of transforaminal foraminoplasty for the treatment of lumbar radiculopathy in patients who have already undergone instrumented spinal fusion. Retrospective study. Hospital and ambulatory surgery center After Institutional Review Board approval, charts from 18 consecutive patients with lumbar radiculopathy and instrumented spinal fusions who underwent endoscopic procedures between 2008 and 2013 were reviewed. The average pain relief one year postoperatively was reported to be 67.0%, good results as defined by MacNab. The average preoperative VAS score was 9.14, indicated in our questionnaire as severe and constant pain. The average one year postoperative VAS score was 3.00, indicated in our questionnaire as mild and intermittent pain. This is a retrospective study and only offers one year follow-up data for patients with instrumented fusions who have undergone endoscopic spine surgery. Transforaminal endoscopic discectomy and foraminotomy could be used as a safe, yet, minimally invasive and innovative technique for the treatment of lumbar radiculopathy in the setting of previous instrumented lumbar fusion. IRB approval: Meridian Health: IRB Study # 201206071J

Return to Golf After Lumbar Fusion

PubMed Central

Shifflett, Grant D.; Hellman, Michael D.; Louie, Philip K.; Mikhail, Christopher; Park, Kevin U.; Phillips, Frank M.

2016-01-01

Background: Spinal fusion surgery is being increasingly performed, yet few studies have focused on return to recreational sports after lumbar fusion and none have specifically analyzed return to golf. Hypothesis: Most golfers successfully return to sport after lumbar fusion surgery. Study Design: Case series. Level of Evidence: Level 4. Methods: All patients who underwent 1- or 2-level primary lumbar fusion surgery for degenerative pathologies performed by a single surgeon between January 2008 and October 2012 and had at least 1-year follow-up were included. Patients completed a specifically designed golf survey. Surveys were mailed, given during follow-up clinic, or answered during telephone contact. Results: A total of 353 patients met the inclusion and exclusion criteria, with 200 responses (57%) to the questionnaire producing 34 golfers. The average age of golfers was 57 years (range, 32-79 years). In 79% of golfers, preoperative back and/or leg pain significantly affected their ability to play golf. Within 1 year from surgery, 65% of patients returned to practice and 52% returned to course play. Only 29% of patients stated that continued back/leg pain limited their play. Twenty-five patients (77%) were able to play the same amount of golf or more than before fusion surgery. Of those providing handicaps, 12 (80%) reported the same or an improved handicap. Conclusion: More than 50% of golfers return to on-course play within 1 year of lumbar fusion surgery. The majority of golfers can return to preoperative levels in terms of performance (handicap) and frequency of play. Clinical Relevance: This investigation offers insight into when golfers return to sport after lumbar fusion surgery and provides surgeons with information to set realistic expectations postoperatively. PMID:27879299

Early-term and mid-term histologic events during single-level posterolateral intertransverse process fusion with rhBMP-2/collagen carrier and a ceramic bulking agent in a nonhuman primate model: implications for bone graft preparation.

PubMed

Khan, Safdar N; Toth, Jeffrey M; Gupta, Kavita; Glassman, Steven D; Gupta, Munish C

2014-06-01

We used a nonhuman primate lumbar intertransverse process arthrodesis model to evaluate biological cascade of bone formation using different carrier preparation methods with a single dose of recombinant human bone morphogenetic protein-2 (rhBMP-2) at early time points. To examine early-term/mid-term descriptive histologic and computerized tomographic events in single-level uninstrumented posterolateral nonhuman primate spinal fusions using rhBMP-2/absorbable collagen sponge (ACS) combined with ceramic bulking agents in 3 different configurations. rhBMP-2 on an ACS carrier alone leads to consistent posterolateral lumbar spine fusions in lower-order animals; however, these results have been difficult to replicate in nonhuman primates. Twelve skeletally mature, rhesus macaque monkeys underwent single-level posterolateral arthrodesis at L4-L5. A hydroxyapatite/β-tricalcium phosphate ceramic bulking agent in 3 formulations was used in the treatment groups (n=3). When used, rhBMP-2/ACS at 1.5 mg/cm (3.0 mg rhBMP-2) was combined with 2.5 cm of ceramic bulking agent per side. Animals were euthanized at 4 and 12 weeks postoperative. Computerized tomography scans were performed immediately postoperatively and every 4 weeks until they were euthanized. Sagittal histologic sections were evaluated for bone histogenesis and location, cellular infiltration of the graft/substitute, and bone remodeling activity. Significant histologic differences in the developing fusion appeared between the 3 rhBMP-2/ACS treatment groups at 4 and 12 weeks. At 4 weeks, bone formation appeared to originate at the transverse process and the intertransverse membrane. Cellular infiltration was greatest in granular ceramic groups compared with matrix ceramic group. Minimal to no residual ACS was identified at the early time point. At 12 weeks, marked ceramic remodeling was observed with continued bone formation noted in all carrier groups. At the early time period, histology showed that bone formation

Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion--systematic review and meta-analysis.

PubMed

Phan, Kevin; Thayaparan, Ganesha K; Mobbs, Ralph J

2015-01-01

To assess the clinical and radiographic outcomes and complications of anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF). A systematic literature search was conducted from six electronic databases. The relative risk and weighted mean difference (WMD) were used as statistical summary effect sizes. Fusion rates (88.6% vs. 91.9%, P = 0.23) and clinical outcomes were comparable between ALIF and TLIF. ALIF was associated with restoration of disk height (WMD, 2.71 mm, P = 0.01), segmental lordosis (WMD, 2.35, P = 0.03), and whole lumbar lordosis (WMD, 6.33, P = 0.03). ALIF was also associated with longer hospitalization (WMD, 1.8 days, P = 0.01), lower dural injury (0.4% vs. 3.8%, P = 0.05) but higher blood vessel injury (2.6% vs. 0%, P = 0.04). ALIF and TLIF appear to have similar success and clinical outcomes, with different complication profiles. ALIF may be associated with superior restoration of disk height and lordosis, but requires further validation in future studies.

Effects of Lumbar Fusion Surgery with ISOBAR Devices Versus Posterior Lumbar Interbody Fusion Surgery on Pain and Disability in Patients with Lumbar Degenerative Diseases: A Meta-Analysis.

PubMed

Su, Shu-Fen; Wu, Meng-Shan; Yeh, Wen-Ting; Liao, Ying-Chin

2018-06-01

Purpose/Aim: Lumbar degenerative diseases (LDDs) cause pain and disability and are treated with lumbar fusion surgery. The aim of this study was to evaluate the efficacy of lumbar fusion surgery with ISOBAR devices versus posterior lumbar interbody fusion (PLIF) surgery for alleviating LDD-associated pain and disability. We performed a literature review and meta-analysis conducted in accordance with Cochrane methodology. The analysis included Group Reading Assessment and Diagnostic Evaluation assessments, Jadad Quality Score evaluations, and Risk of Bias in Non-randomized Studies of Interventions assessments. We searched PubMed, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, ProQuest, the Airiti Library, and the China Academic Journals Full-text Database for relevant randomized controlled trials and cohort studies published in English or Chinese between 1997 and 2017. Outcome measures of interest included general pain, lower back pain, and disability. Of the 18 studies that met the inclusion criteria, 16 examined general pain (802 patients), 5 examined lower back pain (274 patients), and 15 examined disability (734 patients). General pain, lower back pain, and disability scores were significantly lower after lumbar fusion surgery with ISOBAR devices compared to presurgery. Moreover, lumbar fusion surgery with ISOBAR devices was more effective than PLIF for decreasing postoperative disability, although it did not provide any benefit in terms of general pain or lower back pain. Lumbar fusion surgery with ISOBAR devices alleviates general pain, lower back pain, and disability in LDD patients and is superior to PLIF for reducing postoperative disability. Given possible publication bias, we recommend further large-scale studies.

Correlation between radiographic parameters and functional scores in degenerative lumbar and thoracolumbar scoliosis.

PubMed

Simon, J; Longis, P-M; Passuti, N

2017-04-01

Adult scoliosis is a condition in which the spinal deformity occurs because of degeneration. Although various studies have agreed on the importance of restoring the sagittal balance, few have evaluated the relationship between functional scores and radiological parameters. The primary objective of this retrospective study was to demonstrate the correlation between radiographic parameters and functional outcomes in adult patients with lumbar or thoracolumbar degenerative scoliosis. The secondary objective was to assess the long-term effects of posterolateral fusion for treating this deformity. This single-centre retrospective study included 47 patients over 50years of age who had degenerative lumbar scoliosis treated with an instrumented posterolateral fusion; the mean follow-up was 6.4years (range 2 to 20). Radiographic analysis of A/P and lateral full spine standing radiographs was carried out with the KEOPS software. Three pelvic parameters (pelvic tilt, pelvic incidence, sacral slope), two spinal parameters (lumbar lordosis and thoracic kyphosis) and three sagittal balance parameters (C7 sagittal tilt, C7 Barrey's ratio and spinosacral angle) were calculated. The functional outcomes were evaluated through three self-assessment questionnaires: Oswestry Disability Index, SRS-30 and SF-36. The correlation between clinical and radiographic parameters was calculated with Spearman's correlation test. There was a significant correlation between the SF-36 (PCS) and the following three sagittal parameters: sacral slope (r=-0.31453; P=0.04), lumbar lordosis (r=-0.30198; P=0.0491) and spinosacral angle (r=-0.311967; P=0.0366). The mean ODI score was 33.61, which corresponds to minimal to moderate disability. The mean physical (PCS) and mental (MCS) component summary scores of the SF-36 were 37.70 and 38.40, respectively. The mean SRS-30 score was 3.07. It is essential that the sagittal balance be restored when treating degenerative lumbar scoliosis to generate better

Improving the clinical evidence of bone graft substitute technology in lumbar spine surgery.

PubMed

Hsu, Wellington K; Nickoli, M S; Wang, J C; Lieberman, J R; An, H S; Yoon, S T; Youssef, J A; Brodke, D S; McCullough, C M

2012-12-01

Bone graft substitutes have been used routinely for spine fusion for decades, yet clinical evidence establishing comparative data remains sparse. With recent scrutiny paid to the outcomes, complications, and costs associated with osteobiologics, a need to improve available data guiding efficacious use exists. We review the currently available clinical literature, studying the outcomes of various biologics in posterolateral lumbar spine fusion, and establish the need for a multicenter, independent osteobiologics registry.

A Narrative Review of Lumbar Fusion Surgery With Relevance to Chiropractic Practice.

PubMed

Daniels, Clinton J; Wakefield, Pamela J; Bub, Glenn A; Toombs, James D

2016-12-01

The purpose of this narrative review was to describe the most common spinal fusion surgical procedures, address the clinical indications for lumbar fusion in degeneration cases, identify potential complications, and discuss their relevance to chiropractic management of patients after surgical fusion. The PubMed database was searched from the beginning of the record through March 31, 2015, for English language articles related to lumbar fusion or arthrodesis or both and their incidence, procedures, complications, and postoperative chiropractic cases. Articles were retrieved and evaluated for relevance. The bibliographies of selected articles were also reviewed. The most typical lumbar fusion procedures are posterior lumbar interbody fusion, anterior lumbar interbody fusion, transforaminal interbody fusion, and lateral lumbar interbody fusion. Fair level evidence supports lumbar fusion procedures for degenerative spondylolisthesis with instability and for intractable low back pain that has failed conservative care. Complications and development of chronic pain after surgery is common, and these patients frequently present to chiropractic physicians. Several reports describe the potential benefit of chiropractic management with spinal manipulation, flexion-distraction manipulation, and manipulation under anesthesia for postfusion low back pain. There are no published experimental studies related specifically to chiropractic care of postfusion low back pain. This article describes the indications for fusion, common surgical practice, potential complications, and relevant published chiropractic literature. This review includes 10 cases that showed positive benefits from chiropractic manipulation, flexion-distraction, and/or manipulation under anesthesia for postfusion lumbar pain. Chiropractic care may have a role in helping patients in pain who have undergone lumbar fusion surgery.

Ureter Injury as a Complication of Oblique Lumbar Interbody Fusion.

PubMed

Lee, Hyeong-Jin; Kim, Jin-Sung; Ryu, Kyeong-Sik; Park, Choon Keun

2017-06-01

Oblique lumbar interbody fusion is a commonly used surgical method of achieving lumbar interbody fusion. There have been some reports about complications of oblique lumbar interbody fusion at the L2-L3 level. However, to our knowledge, there have been no reports about ureter injury during oblique lumbar interbody fusion. We report a case of ureter injury during oblique lumbar interbody fusion to share our experience. A 78-year-old male patient presented with a history of lower back pain and neurogenic intermittent claudication. He was diagnosed with spinal stenosis at L2-L3, L4-L5 level and spondylolisthesis at L4-L5 level. Symptoms were not improved after several months of medical treatments. Then, oblique lumbar interbody fusion was performed at L2-L3, L4-L5 level. During the surgery, anesthesiologist noticed hematuria. A retrourethrogram was performed immediately by urologist, and ureter injury was found. Ureteroureterostomy and double-J catheter insertion were performed. The patient was discharged 2 weeks after surgery without urologic or neurologic complications. At 2 months after surgery, an intravenous pyelogram was performed, which showed an intact ureter. Our study shows that a low threshold of suspicion of ureter injury and careful manipulation of retroperitoneal fat can be helpful to prevent ureter injury during oblique lumbar interbody fusion at the upper level. Copyright © 2017 Elsevier Inc. All rights reserved.

Improving the Clinical Evidence of Bone Graft Substitute Technology in Lumbar Spine Surgery

PubMed Central

Hsu, Wellington K.; Nickoli, M. S.; Wang, J. C.; Lieberman, J. R.; An, H. S.; Yoon, S. T.; Youssef, J. A.; Brodke, D. S.; McCullough, C. M.

2012-01-01

Bone graft substitutes have been used routinely for spine fusion for decades, yet clinical evidence establishing comparative data remains sparse. With recent scrutiny paid to the outcomes, complications, and costs associated with osteobiologics, a need to improve available data guiding efficacious use exists. We review the currently available clinical literature, studying the outcomes of various biologics in posterolateral lumbar spine fusion, and establish the need for a multicenter, independent osteobiologics registry. PMID:24353975

Fusion Rate and Clinical Outcomes in Two-Level Posterior Lumbar Interbody Fusion.

PubMed

Aono, Hiroyuki; Takenaka, Shota; Nagamoto, Yukitaka; Tobimatsu, Hidekazu; Yamashita, Tomoya; Furuya, Masayuki; Iwasaki, Motoki

2018-04-01

Posterior lumbar interbody fusion (PLIF) has become a general surgical method for degenerative lumbar diseases. Although many reports have focused on single-level PLIF, few have focused on 2-level PLIF, and no report has covered the fusion status of 2-level PLIF. The purpose of this study is to investigate clinical outcomes and fusion for 2-level PLIF by using a combination of dynamic radiographs and multiplanar-reconstruction computed tomography scans. This study consisted of 48 consecutive patients who underwent 2-level PLIF for degenerative lumbar diseases. We assessed surgery duration, estimated blood loss, complications, clinical outcomes as measured by the Japanese Orthopaedic Association score, lumbar sagittal alignment as measured on standing lateral radiographs, and fusion status as measured by dynamic radiographs and multiplanar-reconstruction computed tomography. Patients were examined at a follow-up point of 4.8 ± 2.2 years after surgery. Thirty-eight patients who did not undergo lumbosacral fusion comprised the lumbolumbar group, and 10 patients who underwent lumbosacral fusion comprised the lumbosacral group. The mean Japanese Orthopaedic Association score improved from 12.1 to 22.4 points by the final follow-up examination. Sagittal alignment also was improved. All patients had fusion in the cranial level. Seven patients had nonunion in the caudal level, and the lumbosacral group (40%) had a significantly poorer fusion rate than the lumbolumbar group (97%) did. Surgical outcomes of 2-level PLIF were satisfactory. The fusion rate at both levels was 85%. All nonunion was observed at the caudal level and concentrated at L5-S level in L4-5-S PLIF. Copyright © 2018 Elsevier Inc. All rights reserved.

Lumbar Disc Replacement for Junctional Decompensation After Fusion Surgery: Clinical and Radiological Outcome at an Average Follow-Up of 33 Months

PubMed Central

Sliwa, Karen; Weinberg, Ian R.; Sweet, Barry MBE; de Villiers, Malan; Candy, Geoffrey P.

2007-01-01

Background Failed fusion surgery remains difficult to treat. Few published data on disc replacement surgery after failed fusion procedures exist. Our objective was to evaluate outcomes of junctional lumbar disc replacement after previous fusion surgery and to correlate outcome with radiological changes to parameters of sagittal balance. Methods Out of a single-center prospective registry of 290 patients with 404 lumbar disc replacements, 27 patients had had a previous lumbar fusion operation on 1 to 4 lumbar segments and had completed a mean follow- up of 33 months (range: 18–56). We correlated the clinical outcome measures (patient satisfaction, 10-point pain score, and Oswestry Disability Index [ODI] score) to parameters of spinal sagittal alignment (sacral tilt, pelvic tilt, pelvic incidence, and lumbar lordosis). Results Postoperative hospital stay averaged 3.3 days (range: 2–8). Previously-employed patients went back to their jobs with a mean of 32 days (range: 21–42) after the procedure. At the latest follow-up, 1 of the patients considered the outcome to be poor, 3 fair, 8 good, and 15 excellent. Twenty-four patients “would undergo the operation again.” Average pain score decreased from 9.1 ± 1.0 (SD) to 3.2 ± 2.1 (P < .01). Average ODI decreased from 50.2 ± 9.9 preoperatively to 21.7 ± 14.2 (P ≤ .01). We found the change in pelvic tilt to be an independent predictor of better clinical outcome by multivariate analysis (P < .05). Conclusions In patients with junctional failure adjacent to a previous posterolateral fusion, disc replacement at the junctional level(s), compared with osteotomy and fusion surgery, offers the advantage of maintaining segmental mobility and correcting the flat-back deformity through a single approach with less operative time and blood loss. Early- to intermediate-term results are promising. The influence of changes in spinal sagittal alignment on clinical outcome needs to be addressed in future research. Clinical

Clinical and radiographic assessment of transforaminal lumbar interbody fusion using HEALOS collagen-hydroxyapatite sponge with autologous bone marrow aspirate.

PubMed

Carter, Jason D; Swearingen, Alan B; Chaput, Christopher D; Rahm, Mark D

2009-06-01

Studies have suggested that the use of bone marrow aspirate (BMA) with HEALOS (DePuy Spine, Raynham, MA), a collagen-hydroxyapatite sponge (CHS), is an effective substitute for autologous iliac crest bone graft when used in fusion procedures of the lumbar spine. To assess clinical and radiographic outcomes after implantation of BMA/CHS in patients undergoing transforaminal lumbar interbody fusion (TLIF) with posterolateral fusion (PLF). Case series radiographic outcome study. Twenty patients. Radiographs/computed tomography (CT) scans. From September 2003 to October 2004, 20 patients (22 interbody levels) were implanted with BMA/CHS via TLIF/PLF with interbody cages and posterior pedicle screws. All patients were retrospectively identified and invited for a 2-year prospective follow-up. Plain radiographs with dynamic films and CT scans were taken, and fusion was assessed in a blinded manner. Follow-up averaged 27 months (range: 24-29). Primary diagnosis included spondylolisthesis (17 patients), scoliosis with asymmetric collapse (2 patients), and postdiscectomy foraminal stenosis (1 patient). The overall fusion rate was 95% (21/22 levels, 19/20 patients). Anteriorly bridging bone was observed in 91% of the anteriorly fused levels (20/22), of which 65% (13/20) occurred through and around the cage and 35% (7/20) around the cage only. Unilateral or bilateral bridging of the posterior fusion masses was observed in 91% (20/22), with 55% occurring bilaterally (12/22). In 4 (18%) cases, bridging only occurred either posteriorly (2 cases) or anteriorly (2 cases). Complications included one deep wound infection. At the 2-year follow-up, BMA/CHS showed acceptable fusion rates in patients undergoing TLIF/PLF, and can be considered as an alternative source of graft material.

AxiaLIF system: minimally invasive device for presacral lumbar interbody spinal fusion

PubMed Central

Rapp, Steven M; Miller, Larry E; Block, Jon E

2011-01-01

Lumbar fusion is commonly performed to alleviate chronic low back and leg pain secondary to disc degeneration, spondylolisthesis with or without concomitant lumbar spinal stenosis, or chronic lumbar instability. However, the risk of iatrogenic injury during traditional anterior, posterior, and transforaminal open fusion surgery is significant. The axial lumbar interbody fusion (AxiaLIF) system is a minimally invasive fusion device that accesses the lumbar (L4–S1) intervertebral disc spaces via a reproducible presacral approach that avoids critical neurovascular and musculoligamentous structures. Since the AxiaLIF system received marketing clearance from the US Food and Drug Administration in 2004, clinical studies of this device have reported high fusion rates without implant subsidence, significant improvements in pain and function, and low complication rates. This paper describes the design and approach of this lumbar fusion system, details the indications for use, and summarizes the clinical experience with the AxiaLIF system to date. PMID:22915939

AxiaLIF system: minimally invasive device for presacral lumbar interbody spinal fusion.

PubMed

Rapp, Steven M; Miller, Larry E; Block, Jon E

2011-01-01

Lumbar fusion is commonly performed to alleviate chronic low back and leg pain secondary to disc degeneration, spondylolisthesis with or without concomitant lumbar spinal stenosis, or chronic lumbar instability. However, the risk of iatrogenic injury during traditional anterior, posterior, and transforaminal open fusion surgery is significant. The axial lumbar interbody fusion (AxiaLIF) system is a minimally invasive fusion device that accesses the lumbar (L4-S1) intervertebral disc spaces via a reproducible presacral approach that avoids critical neurovascular and musculoligamentous structures. Since the AxiaLIF system received marketing clearance from the US Food and Drug Administration in 2004, clinical studies of this device have reported high fusion rates without implant subsidence, significant improvements in pain and function, and low complication rates. This paper describes the design and approach of this lumbar fusion system, details the indications for use, and summarizes the clinical experience with the AxiaLIF system to date.

Analysis of Recombinant Human Bone Morphogenetic Protein-2 Use in the Treatment of Lumbar Degenerative Spondylolisthesis

PubMed Central

Yao, Qingqiang; Cohen, Jeremiah R.; Buser, Zorica; Park, Jong-Beom; Brodke, Darrel S.; Meisel, Hans-Joerg; Youssef, Jim A.; Wang, Jeffrey C.; Yoon, S. Tim

2016-01-01

Study Design Retrospective database review. Objective To identify trends of the recombinant human bone morphogenetic protein-2 (rhBMP-2) use in the treatment of lumbar degenerative spondylolisthesis (LDS). Methods PearlDiver Patient Record Database was used to identify patients who underwent lumbar fusion for LDS between 2005 and 2011. The distribution of bone morphogenetic protein use rate (BR) in various surgical procedures was recorded. Patient numbers, reoperation numbers, BR, and per year BR (PYBR) were stratified by geographic region, gender, and age. Results There were 11,335 fusion surgeries, with 3,461 cases using rhBMP-2. Even though PYRB increased between 2005 and 2008, there was a significant decrease in 2010 for each procedure: 404 (34.5%) for posterior interbody fusion, 1,282 (34.3%) for posterolateral plus posterior interbody fusion (PLPIF), 1,477 (29.2%) for posterolateral fusion, and 335 (22.4%) for anterior lumbar interbody fusion. In patients using rhBMP-2, the reoperation rate was significantly lower than in patients not using rhBMP-2 (0.69% versus 1.07%, p < 0.0001). Male patients had higher PYBR compared with female patients in 2008 and 2009 (p < 0.05). The West region and PLPIF had the highest BR and PYBR. Conclusions Our data shows that the revision rates were significantly lower in patients treated with rhBMP-2 compared with patients not treated with rhBMP-2. Furthermore, rhBMP-2 use in LDS varied by year, region, gender, and type of fusion technique. In the West region, the posterior approach and patients 65 to 69 years of age had the highest rate of rhBMP-2 use. PMID:27853658

[POSTERIOR LUMBAR INTERBODY FUSION FOR DOUBLE-SEGMENTAL BILATERAL ISTHMIC LUMBAR SPONDYLOLISTHESIS].

PubMed

Xing, Wenhua; Huo Hongjun; Yang, Xuejun; Xiao, Yulong; Zhao, Yan; Fu, Yu; Zhu, Yong; Li, Feng; Xin, Daqi

2015-12-01

To explore the effectiveness of posterior lumbar interbody fusion in the treatment of double-segmental bilateral isthmic lumbar spondylolisthesis. Between February 2008 and December 2013, 17 patients with double-segmental bilateral isthmic lumbar spondylolisthesis were treated with posterior lumbar interbody fusion. There were 12 males and 5 females, with an age ranged 48-69 years (mean, 55.4 years). The disease duration ranged from 11 months to 17 years (median, 22 months). According to the Meyerding classification, 30 vertebrea were rated as degree I, 3 as degree II, and 1 as degree III. L₄,₅ was involved in 14 cases and L₃,₄ in 3 cases. The preoperative visual analogue scale (VAS) score was 8.6 ± 3.2. Cerebrospinal fluid leakage occurred in 2 cases because of intraoperative dural tear; primary healing of incision was obtained, with no operation related complication in the other patients. The patients were followed up 1-6 years (mean, 3.4 years). At last follow-up, VAS score was decreased significantly to 1.1 ± 0.4, showing significant difference when compared with preoperative score (t=7.652, P=0.008). X-ray films showed that slippage vertebral body obtained different degree of reduction, with a complete reduction rate of 85% (29/34) at 1 week after operation. All patients achieved bony union at 6-12 months (mean, 7.4 months). According to the Lenke classification, 13 cases were rated as grade A and 4 cases as grade B. No internal fixation loosening and fracture were observed during the follow-up. Intervertebral disc height was maintained, no loss of spondylolisthesis reduction was found. It can obtain satisfactory clinical result to use spinal canal decompression by posterior approach, and screw fixation for posterior fusion in treatment of double-segmental bilateral isthmic lumbar spondylolisthesis. The key points to successful operation include accurate insertion of screw, effective decompression, distraction before reduction, rational use of

Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF

PubMed Central

Phan, Kevin; Malham, Greg; Seex, Kevin; Rao, Prashanth J.

2015-01-01

Degenerative disc and facet joint disease of the lumbar spine is common in the ageing population, and is one of the most frequent causes of disability. Lumbar spondylosis may result in mechanical back pain, radicular and claudicant symptoms, reduced mobility and poor quality of life. Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct deformity. The surgical options for interbody fusion of the lumbar spine include: posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), minimally invasive transforaminal lumbar interbody fusion (MI-TLIF), oblique lumbar interbody fusion/anterior to psoas (OLIF/ATP), lateral lumbar interbody fusion (LLIF) and anterior lumbar interbody fusion (ALIF). The indications may include: discogenic/facetogenic low back pain, neurogenic claudication, radiculopathy due to foraminal stenosis, lumbar degenerative spinal deformity including symptomatic spondylolisthesis and degenerative scoliosis. In general, traditional posterior approaches are frequently used with acceptable fusion rates and low complication rates, however they are limited by thecal sac and nerve root retraction, along with iatrogenic injury to the paraspinal musculature and disruption of the posterior tension band. Minimally invasive (MIS) posterior approaches have evolved in an attempt to reduce approach related complications. Anterior approaches avoid the spinal canal, cauda equina and nerve roots, however have issues with approach related abdominal and vascular complications. In addition, lateral and OLIF techniques have potential risks to the lumbar plexus and psoas muscle. The present study aims firstly to comprehensively review the available literature and evidence for different lumbar interbody fusion (LIF) techniques. Secondly, we propose a set of recommendations and guidelines

Does Lordotic Angle of Cage Determine Lumbar Lordosis in Lumbar Interbody Fusion?

PubMed

Hong, Taek-Ho; Cho, Kyu-Jung; Kim, Young-Tae; Park, Jae-Woo; Seo, Beom-Ho; Kim, Nak-Chul

2017-07-01

Retrospective, radiological analysis. To determine that 15° lordotic angle cages create higher lumbar lordosis in open transforaminal lumbar interbody fusion (TLIF) than 4° and 8° cages. Restoration of lumbar lordosis is important to obtain good outcome after lumbar fusion surgery. Various shapes and angles of cages in interbody fusion have been used; however, it is not proved that lordotic angle of cages determine lumbar lordosis. Sixty-seven patients were evaluated after TLIF using 15° cages and screw instrumentation. For comparison, TLIF using 4° lordotic angle cages in 65 patients and 8° cages in 49 patients were analyzed. Lumbar lordosis angles, segmental lordosis angles, disc height, and bony union rate were measured on the radiographs. The lumbar lordosis was 31.1° preoperatively, improved to 42.9° postoperatively, and decreased to 36.4° at the last follow-up in the 15° group. It was 35.8° before surgery, corrected to 41.5° after surgery, and changed to 33.6° at the last follow-up in the 4° group. In the 8° group, it was 32.7° preoperatively, improved to 39.1° postoperatively, and decreased to 34.5° at the last follow-up. These changes showed statistical significances (P < 0.001). The segmental lordosis at L4-5 was 6.6° before surgery, 13.1° after surgery, and 9.8° at the last follow-up in the 15° group. It was 6.9°, 9.5°, and 6.2° in the 4° group and 6.7°, 9.8°, and 8.1° in the 8° group, respectively (P < 0.001). The disc height restoration was better in the 15° group than in the 4° and 8° groups (P < 0.001). Bony union rate was not significant among the three groups (P = 0.087). The lordotic angle of the cages determined restoration of lumbar lordosis after TLIF. Cages with sufficient lordotic angle showed better restoration of lumbar lordosis and prevention of loss of correction. 4.

The Effects of Ketorolac Injected via Patient Controlled Analgesia Postoperatively on Spinal Fusion

PubMed Central

Park, Si-Young; Moon, Seong-Hwan; Park, Moon-Soo; Oh, Kyung-Soo

2005-01-01

Lumbar spinal fusions have been performed for spinal stability, pain relief and improved function in spinal stenosis, scoliosis, spinal fractures, infectious conditions and other lumbar spinal problems. The success of lumbar spinal fusion depends on multifactors, such as types of bone graft materials, levels and numbers of fusion, spinal instrumentation, electrical stimulation, smoking and some drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs). From January 2000 to December 2001, 88 consecutive patients, who were diagnosed with spinal stenosis or spondylolisthesis, were retrospectively enrolled in this study. One surgeon performed all 88 posterolateral spinal fusions with instrumentation and autoiliac bone graft. The patients were divided into two groups. The first group (n=30) was infused with ketorolac and fentanyl intravenously via patient controlled analgesia (PCA) postoperatively and the second group (n=58) was infused only with fentanyl. The spinal fusion rates and clinical outcomes of the two groups were compared. The incidence of incomplete union or nonunion was much higher in the ketorolac group, and the relative risk was approximately 6 times higher than control group (odds ratio: 5.64). The clinical outcomes, which were checked at least 1 year after surgery, showed strong correlations with the spinal fusion status. The control group (93.1%) showed significantly better clinical results than the ketorolac group (77.6%). Smoking had no effect on the spinal fusion outcome in this study. Even though the use of ketorolac after spinal fusion can reduce the need for morphine, thereby decreasing morphine related complications, ketorolac used via PCA at the immediate postoperative state inhibits spinal fusion resulting in a poorer clinical outcome. Therefore, NSAIDs such as ketorolac, should be avoided after posterolateral spinal fusion. PMID:15861498

Local effect of zoledronic acid on new bone formation in posterolateral spinal fusion with demineralized bone matrix in a murine model.

PubMed

Zwolak, Pawel; Farei-Campagna, Jan; Jentzsch, Thorsten; von Rechenberg, Brigitte; Werner, Clément M

2018-01-01

Posterolateral spinal fusion is a common orthopaedic surgery performed to treat degenerative and traumatic deformities of the spinal column. In posteriolateral spinal fusion, different osteoinductive demineralized bone matrix products have been previously investigated. We evaluated the effect of locally applied zoledronic acid in combination with commercially available demineralized bone matrix putty on new bone formation in posterolateral spinal fusion in a murine in vivo model. A posterolateral sacral spine fusion in murine model was used to evaluate the new bone formation. We used the sacral spine fusion model to model the clinical situation in which a bone graft or demineralized bone matrix is applied after dorsal instrumentation of the spine. In our study, group 1 received decortications only (n = 10), group 2 received decortication, and absorbable collagen sponge carrier, group 3 received decortication and absorbable collagen sponge carrier with zoledronic acid in dose 10 µg, group 4 received demineralized bone matrix putty (DBM putty) plus decortication (n = 10), and group 5 received DBM putty, decortication and locally applied zoledronic acid in dose 10 µg. Imaging was performed using MicroCT for new bone formation assessment. Also, murine spines were harvested for histopathological analysis 10 weeks after surgery. The surgery performed through midline posterior approach was reproducible. In group with decortication alone there was no new bone formation. Application of demineralized bone matrix putty alone produced new bone formation which bridged the S1-S4 laminae. Local application of zoledronic acid to demineralized bone matrix putty resulted in significant increase of new bone formation as compared to demineralized bone matrix putty group alone. A single local application of zoledronic acid with DBM putty during posterolateral fusion in sacral murine spine model increased significantly new bone formation in situ in our model. Therefore, our

Analysis of Recombinant Human Bone Morphogenetic Protein-2 Use in the Treatment of Lumbar Degenerative Spondylolisthesis.

PubMed

Yao, Qingqiang; Cohen, Jeremiah R; Buser, Zorica; Park, Jong-Beom; Brodke, Darrel S; Meisel, Hans-Joerg; Youssef, Jim A; Wang, Jeffrey C; Yoon, S Tim

2016-12-01

Study Design  Retrospective database review. Objective  To identify trends of the recombinant human bone morphogenetic protein-2 (rhBMP-2) use in the treatment of lumbar degenerative spondylolisthesis (LDS). Methods  PearlDiver Patient Record Database was used to identify patients who underwent lumbar fusion for LDS between 2005 and 2011. The distribution of bone morphogenetic protein use rate (BR) in various surgical procedures was recorded. Patient numbers, reoperation numbers, BR, and per year BR (PYBR) were stratified by geographic region, gender, and age. Results  There were 11,335 fusion surgeries, with 3,461 cases using rhBMP-2. Even though PYRB increased between 2005 and 2008, there was a significant decrease in 2010 for each procedure: 404 (34.5%) for posterior interbody fusion, 1,282 (34.3%) for posterolateral plus posterior interbody fusion (PLPIF), 1,477 (29.2%) for posterolateral fusion, and 335 (22.4%) for anterior lumbar interbody fusion. In patients using rhBMP-2, the reoperation rate was significantly lower than in patients not using rhBMP-2 (0.69% versus 1.07%, p  < 0.0001). Male patients had higher PYBR compared with female patients in 2008 and 2009 ( p  < 0.05). The West region and PLPIF had the highest BR and PYBR. Conclusions Our data shows that the revision rates were significantly lower in patients treated with rhBMP-2 compared with patients not treated with rhBMP-2. Furthermore, rhBMP-2 use in LDS varied by year, region, gender, and type of fusion technique. In the West region, the posterior approach and patients 65 to 69 years of age had the highest rate of rhBMP-2 use.

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery.

PubMed

Singla, Anuj; Yang, Scott; Werner, Brian C; Cancienne, Jourdan M; Nourbakhsh, Ali; Shimer, Adam L; Hassanzadeh, Hamid; Shen, Francis H

2017-05-01

OBJECTIVE Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion. METHODS A nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI. RESULTS The overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1-3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI

Laparoscopic bone dowel fusions of the lumbar spine.

PubMed

Silcox, D H

1998-10-01

Studies that show laparoscopic lumbar fusion to decrease cost or time of hospitalization or to increase the speed or incidence of return to activities are not currently available. Laparoscopic fusion of the lumbar spine appears to be a potentially attractive approach to treating axial back pain secondary to different causes. Although the technique is attractive because of its minimally invasive nature and marketing allure, it has yet to be established as to what the true clinical efficacy of this procedure will be. Further clinical study of these techniques with longer follow-up, and case-controlled studies should help clinicians to know the best fusion technique to offer patients.

Trayectoria de los tornillos pediculares lumbares y sacros: Comparación entre el abordaje por linea media versus el abordaje posterolateral tipo wiltse

PubMed Central

Gagliardi, Martín; Guiroy, Alfredo; Molina, Federico Fernández; Fasano, Francisco; Ciancio, Alejandro Morales; Mezzadri, Juan José; Jalón, Pablo

2017-01-01

Resumen Objetivos: El objetivo de este estudio fue comparar, en fusiones lumbosacras cortas, el ángulo de convergencia de los tornillos pediculares entre el abordaje posterolateral tipo Wiltse y el abordaje mediano convencional. Método: Se revisaron en forma retrospectiva los controles en tomografía axial computada (TAC) de 76 tornillos pediculares lumbares y sacros colocados por vía posterior, mediante un abordaje mediano convencional (n: 38) o por vía posterolateral transmuscular tipo Wiltse (n: 38). Se incluyeron fusiones lumbosacras cortas desde L3 a S1, en pacientes adultos, con patología degenerativa. Se excluyeron los tornillos con una brecha ósea >4 mm en cualquier dirección, los casos con instrumentaciones pediculares previas y aquellos con curvas en el plano coronal mayores de 20°. Resultados: Considerando la totalidad de los implantes, el ángulo de convergencia fue de 23,3° (+/- 15,82). La angulación promedio, en el grupo AW, fue de 29,3° (+/- 9,72). En el grupo AC, el grado de convergencia de los implantes fue de 17,2° (+/- 10,58). Esta diferencia fue estadísticamente significativa (P < 0,0001). Para el grupo AW, el grado de convergencia según nivel fue el siguiente: L3: 31,2° (+/- 1,9); L4: 31,4° (+/- 2,76); L5: 31,1° (+/- 5,62); S1: 24,2° (+/- 12,16). El promedio del ángulo del tornillo según nivel para el grupo AC fue: L3: 16° (+/- 7,16); L4: 20,3° (+/- 6,9) L5: 15,9° (+/- 13,38); S1: 15,2° (+/- 14,32). Los implantes del grupo AW tuvieron ángulos significativamente más convergentes que el grupo AC en todos los segmentos explorados. Conclusión: En las fusiones lumbosacras cortas, la utilización del abordaje tipo Wiltse permitió la colocación de tornillos pediculares con más convergencia que en el abordaje mediano convencional. La relevancia clínica de este hecho es desconocida y se requerirían trabajos prospectivos randomizados para determinar la misma. PMID:29142777

Comparative charge analysis of one- and two-level lumbar total disc arthroplasty versus circumferential lumbar fusion.

PubMed

Levin, David A; Bendo, John A; Quirno, Martin; Errico, Thomas; Goldstein, Jeffrey; Spivak, Jeffrey

2007-12-01

This is a retrospective, independent study comparing 2 groups of patients treated surgically for discogenic low back pain associated with degenerative disc disease (DDD) in the lumbosacral spine. To compare the surgical and hospitalization charges associated with 1- and 2-level lumbar total disc replacement and circumferential lumbar fusion. Reported series of lumbar total disc replacement have been favorable. However, economic aspects of lumbar total disc replacement (TDR) have not been published or studied. This information is important considering the recent widespread utilization of new technologies. Recent studies have demonstrated comparable short-term clinical results between TDR and lumbar fusion recipients. Relative charges may be another important indicator of the most appropriate procedure. We report a hospital charge-analysis comparing ProDisc lumbar disc replacement with circumferential fusion for discogenic low back pain. In a cohort of 53 prospectively selected patients with severe, disabling back pain and lumbar disc degeneration, 36 received Synthes ProDisc TDR and 17 underwent circumferential fusion for 1- and 2-level degenerative disc disease between L3 and S1. Randomization was performed using a 2-to-1 ratio of ProDisc recipients to control spinal fusion recipients. Charge comparisons, including operating room charges, inpatient hospital charges, and implant charges, were made from hospital records using inflation-corrected 2006 U.S. dollars. Operating room times, estimated blood loss, and length of stay were obtained from hospital records as well. Surgeon and anesthesiologist fees were, for the purposes of comparison, based on Medicare reimbursement rates. Statistical analysis was performed using a 2-tailed Student t test. For patients with 1-level disease, significant differences were noted between the TDR and fusion control group. The mean total charge for the TDR group was $35,592 versus $46,280 for the fusion group (P = 0.0018). Operating

Two-year outcomes of transforaminal lumbar interbody fusion.

PubMed

Poh, Seng Yew; Yue, Wai Mun; Chen, Li-Tat John; Guo, Chang-Ming; Yeo, William; Tan, Seang-Beng

2011-08-01

To evaluate the outcomes, fusion rates, complications, and adjacent segment degeneration associated with transforaminal lumbar interbody fusion (TLIF). 32 men and 80 women aged 15 to 85 (mean, 57) years underwent 141 fusions (84 one-level, 27 2-level, and one 3-level) and were followed up for 24 to 76 (mean, 33) months. 92% of the patients had degenerative lumbar disease, 15 of whom had had previous lumbar surgery. Radiographic and clinical outcomes were assessed at 2 years. The short-form 36 (SF-36) health survey, visual analogue scale (VAS) for pain, and the modified North American Spine Society (NASS) Low Back Pain Outcome Instrument were used. Of the 141 levels fused, 110 (78%) were fused with remodelling and trabeculae (grade I), and 31 (22%) had intact grafts but were not fully incorporated (grade II). No patient had pseudoarthroses (grade III or IV). For one-level fusions, poorer radiological fusion grades correlated with higher VAS scores for pain (p<0.01). All components of the SF-36, the VAS scores for pain, and the NASS scores improved significantly after TLIF (p<0.01), except for general health in the SF-36 (p=0.59). Improvement from postoperative 6 months to 2 years was not significant, except for physical function (p<0.01) and role function (physical) [p=0.01] in the SF-36. Two years after TLIF, 50% of the patients reported returning to full function, whereas 72% were satisfied. 26 (23%) of the patients had adjacent segment degeneration, but only 4 of them were symptomatic. TLIF is a safe and effective treatment for degenerative lumbar diseases.

Outcome of transforaminal lumbar interbody fusion in spondylolisthesis-A clinico-radiological correlation.

PubMed

Balasubramanian, Vijay Anand; Douraiswami, Balaji; Subramani, Suresh

2018-06-01

Lumbar spondylolisthesis is a common cause of morbidity in middle aged individuals. Spinal fusion with instrumentation has become the gold standard for lumbar segmental instability. Studies which correlate the improvement in radiology postoperatively with functional outcome show contrasting reports. This study is aimed at finding the correlation between clinical and radiological outcomes after surgery with transforaminal lumbar interbody fusion. A retrospective study in 35 patients who underwent transforaminal lumbar interbody fusion in a period of 1 year was done. Preoperative pain (VAS Score), functional ability (ODI), radiological parameters (slip angle, slip grade, disc height, foraminal height, lumbar lordosis) were compared with postoperative recordings at the last followup. Functional improvement (Macnab's criteria) and fusion (Lee's fusion criteria) were assessed. Statistical analysis was done with student's paired t -test and Pearson's correlation coefficient. VAS score, ODI improved from 8 to 2 and 70 to 15 respectively. Slip angle improved from 23°to 5° on an average. 80% patients showed fusion and 85% showed good clinical outcome at 1 year followup. Analyzing with Pearson correlation coefficient showed no significant relation between pain scores and radiological parameters. But there was statistically significant relation between radiological fusion and the final clinical outcome. TLIF produces spinal fusion in most individuals. Strong spinal fusion is essential for good clinical outcome in spondylolisthesis patients who undergo TLIF. Reduction in slip is not necessary for all patients with listhesis.

Review of early clinical results and complications associated with oblique lumbar interbody fusion (OLIF).

PubMed

Phan, Kevin; Maharaj, Monish; Assem, Yusuf; Mobbs, Ralph J

2016-09-01

Lumbar interbody fusion represents an effective surgical intervention for patients with lumbar degenerative diseases, spondylolisthesis, disc herniation, pseudoarthrosis and spinal deformities. Traditionally, conventional open anterior lumbar interbody fusion and posterior/transforaminal lumbar interbody fusion techniques have been employed with excellent results, but each with their own advantages and caveats. Most recently, the antero-oblique trajectory has been introduced, providing yet another corridor to access the lumbar spine. Termed the oblique lumbar interbody fusion, this approach accesses the spine between the anterior vessels and psoas muscles, avoiding both sets of structures to allow efficient clearance of the disc space and application of a large interbody device to afford distraction for foraminal decompression and endplate preparation for rapid and thorough fusion. This review aims to summarize the early clinical results and complications of this new technique and discusses potential future directions of research. Copyright © 2016 Elsevier Ltd. All rights reserved.

Effect of TheraCyte-encapsulated parathyroid cells on lumbar fusion in a rat model.

PubMed

Chen, Sung-Hsiung; Huang, Shun-Chen; Lui, Chun-Chung; Lin, Tzu-Ping; Chou, Fong-Fu; Ko, Jih-Yang

2012-09-01

Implantation of TheraCyte 4 × 10(6) live parathyroid cells can increase the bone marrow density of the spine of ovariectomized rats. There has been no published study examining the effect of such implantation on spinal fusion outcomes. The purpose of this study was to examine the effect of TheraCyte-encapsulated parathyroid cells on posterolateral lumbar fusions in a rat model. Forty Sprague-Dawley rats underwent single-level, intertransverse process spinal fusions using iliac crest autograft. The rats were randomly assigned to two groups: Group 1 rats received sham operations on their necks (control; N = 20); Group 2 rats were implanted with TheraCyte-encapsulated 4 × 10(6) live parathyroid cells into the subcutis of their necks (TheraCyte; N = 20). Six weeks after surgery the rats were killed. Fusion was assessed by inspection, manual palpation, radiography, and histology. Blood was drawn to measure the serum levels of calcium, phosphorus, and intact parathyroid hormone (iPTH). Based on manual palpation, the control group had a fusion rate of 33 % (6/18) and the TheraCyte group had a fusion rate of 72 % (13/18) (P = 0.044). Histology confirmed the manual palpation results. Serum iPTH levels were significantly higher in the TheraCyte group compared with the control group (P < 0.05); neither serum calcium nor phosphorus levels were significantly different between the two groups. This pilot animal study revealed that there were more fusions in rats that received TheraCyte-encapsulated 4 × 10(6) live parathyroid cells than in control rats without significant change in serum calcium or phosphorus concentrations. As with any animal study, the results may not extrapolate to a higher species. Further studies are needed to determine if these effects are clinically significant.

[Axial lumbar interbody fusion: prospective monocentric study].

PubMed

Stulík, J; Adámek, S; Barna, M; Kaspříková, N; Polanecký, O; Kryl, J

2014-01-01

The aim of this prospective study was to evaluate clinical and radiographic results in the patients who underwent L5-S1 fixation using the technique of percutaneous lumbar interbody fusion (AxiaLIF). The study comprised 23 patients, 11 women and 12 men, who ranged from age of 21 to 63 years, with an average of 48.2 years. In all patients surgical posterior stabilisation involving the L5-S1 segment had previously been done. The initial indications for surgery were L5-S1 spondylolisthesis in 20 and L5-S1 spondylosis and stenosis in three patients. The AxiaLIF technique for L5-S1 fixation was indicated in overweight patients and in those after repeated abdominal or retroperitoneal surgery. A suitable position and shape of the sacrum or lumbosacral junction was another criterion. The patients were evaluated between 26 and 56 months (average, 40.4 months) after primary surgery and, on the basis of CT and radiographic findings, bone union and lumbosacral junction stability were assessed. The clinical outcome was investigated using the ODI and VAS systems and the results were statistically analysed by the Wilcoxon test for paired samples with statistical significance set at a level of 0.05. The average VAS value was 6.6 before surgery and, after surgery, 5.2 at three months, 4.2 at six months, 3.1 at one year, 2.9 at two years and 2.1 at three years (n=18). At two post-operative years, improvement in the VAS value by 56.1% was recorded. The average pre-operative ODI value was 25.1; the post-operative values were 17.0 at six months, 12.3 at one year, 10.6 at two years and 8.2 at three years (n=18). At two years after surgery the ODI value improved by 57.8%. To the question concerning their willingness to undergo, with acquired experience, surgery for the same diagnosis, 21 patients (91.3%) gave an affirmative answer. Neither screw breakage nor neurovascular damage or rectal injury was found. CT scans showed complete interbody bone fusion in 22 of the 23 patients (95

[Mechanical studies of lumbar interbody fusion implants].

PubMed

Bader, R J; Steinhauser, E; Rechl, H; Mittelmeier, W; Bertagnoli, R; Gradinger, R

2002-05-01

In addition to autogenous or allogeneic bone grafts, fusion cages composed of metal or plastic are being used increasingly as spacers for interbody fusion of spinal segments. The goal of this study was the mechanical testing of carbon fiber reinforced plastic (CFRP) fusion cages used for anterior lumbar interbody fusion. With a special testing device according to American Society for Testing and Materials (ASTM) standards, the mechanical properties of the implants were determined under four different loading conditions. The implants (UNION cages, Medtronic Sofamor Danek) provide sufficient axial compression, shear, and torsional strength of the implant body. Ultimate axial compression load of the fins is less than the physiological compression loads at the lumbar spine. Therefore by means of an appropriate surgical technique parallel grooves have to be reamed into the endplates of the vertebral bodies according to the fin geometry. Thereby axial compression forces affect the implants body and the fins are protected from damaging loading. Using a supplementary anterior or posterior instrumentation, in vivo failure of the fins as a result of physiological shear and torsional spinal loads is unlikely. Due to specific complications related to autogenous or allogeneic bone grafts, fusion cages made of metal or carbon fiber reinforced plastic are an important alternative implant in interbody fusion.

Cost-effectiveness of lumbar artificial intervertebral disc replacement: driven by the choice of comparator.

PubMed

Parkinson, Bonny; Goodall, Stephen; Thavaneswaran, Prema

2013-09-01

Lower back pain is a common and costly condition in Australia. This paper aims to conduct an economic evaluation of lumbar artificial intervertebral disc replacement (AIDR) compared with lumbar fusion for the treatment of patients suffering from significant axial back pain and/or radicular (nerve root) pain, secondary to disc degeneration or prolapse, who have failed conservative treatment. A cost-effectiveness approach was used to compare costs and benefits of AIDR to five fusion approaches. Resource use was based on Medicare Benefits Schedule claims data and expert opinion. Effectiveness and re-operation rates were based on published randomized controlled trials. The key clinical outcomes considered were narcotic medication discontinuation, achievement of overall clinical success, achievement of Oswestry Disability Index success and quality-adjusted life-years gained. AIDR was estimated to be cost-saving compared with fusion overall ($1600/patient); however, anterior lumbar interbody fusion and posterolateral fusion were less costly by $2155 and $807, respectively. The incremental cost-effectiveness depends on the outcome considered and the comparator. AIDR is potentially a cost-saving treatment for lumbar disc degeneration, although longer-term follow-up data are required to substantiate this claim. The incremental cost-effectiveness depends on the outcome considered and the comparator, and further research is required before any firm conclusions can be drawn. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.

Sacroiliac Joint Fusion Minimally Affects Adjacent Lumbar Segment Motion: A Finite Element Study

PubMed Central

Kiapour, Ali; Yerby, Scott A.; Goel, Vijay K.

2015-01-01

Background Adjacent segment disease is a recognized consequence of fusion in the spinal column. Fusion of the sacroiliac joint is an effective method of pain reduction. Although effective, the consequences of sacroiliac joint fusion and the potential for adjacent segment disease for the adjacent lumbar spinal levels is unknown. The objective of this study was to quantify the change in range of motion of the sacroiliac joint and the adjacent lumbar spinal motion segments due to sacroiliac joint fusion and compare these changes to previous literature to assess the potential for adjacent segment disease in the lumbar spine. Methods An experimentally validated finite element model of the lumbar spine and pelvis was used to simulate a fusion of the sacroiliac joint using three laterally placed triangular implants (iFuse Implant System, SI-BONE, Inc., San Jose, CA). The range of motion of the sacroiliac joint and the adjacent lumbar spinal motion segments were calculated using a hybrid loading protocol and compared with the intact range of motion in flexion, extension, lateral bending, and axial rotation. Results The range of motions of the treated sacroiliac joints were reduced in flexion, extension, lateral bending, and axial rotation, by 56.6%, 59.5%, 27.8%, and 53.3%, respectively when compared with the intact condition. The stiffening of the sacroiliac joint resulted in increases at the adjacent lumbar motion segment (L5-S1) for flexion, extension, lateral bending, and axial rotation, of 3.0%, 3.7%, 1.1%, and 4.6%, respectively. Conclusions Fusion of the sacroiliac joint resulted in substantial (> 50%) reductions in flexion, extension, and axial rotation of the sacroiliac joint with minimal (< 5%) increases in range of motion in the lumbar spine. Although the predicted increases in lumbar range of motion are minimal after sacroiliac joint fusion, the long-term clinical results remain to be investigated. PMID:26767156

Sacroiliac Joint Fusion Minimally Affects Adjacent Lumbar Segment Motion: A Finite Element Study.

PubMed

Lindsey, Derek P; Kiapour, Ali; Yerby, Scott A; Goel, Vijay K

2015-01-01

Adjacent segment disease is a recognized consequence of fusion in the spinal column. Fusion of the sacroiliac joint is an effective method of pain reduction. Although effective, the consequences of sacroiliac joint fusion and the potential for adjacent segment disease for the adjacent lumbar spinal levels is unknown. The objective of this study was to quantify the change in range of motion of the sacroiliac joint and the adjacent lumbar spinal motion segments due to sacroiliac joint fusion and compare these changes to previous literature to assess the potential for adjacent segment disease in the lumbar spine. An experimentally validated finite element model of the lumbar spine and pelvis was used to simulate a fusion of the sacroiliac joint using three laterally placed triangular implants (iFuse Implant System, SI-BONE, Inc., San Jose, CA). The range of motion of the sacroiliac joint and the adjacent lumbar spinal motion segments were calculated using a hybrid loading protocol and compared with the intact range of motion in flexion, extension, lateral bending, and axial rotation. The range of motions of the treated sacroiliac joints were reduced in flexion, extension, lateral bending, and axial rotation, by 56.6%, 59.5%, 27.8%, and 53.3%, respectively when compared with the intact condition. The stiffening of the sacroiliac joint resulted in increases at the adjacent lumbar motion segment (L5-S1) for flexion, extension, lateral bending, and axial rotation, of 3.0%, 3.7%, 1.1%, and 4.6%, respectively. Fusion of the sacroiliac joint resulted in substantial (> 50%) reductions in flexion, extension, and axial rotation of the sacroiliac joint with minimal (< 5%) increases in range of motion in the lumbar spine. Although the predicted increases in lumbar range of motion are minimal after sacroiliac joint fusion, the long-term clinical results remain to be investigated.

Surgical apgar score in patients undergoing lumbar fusion for degenerative spine diseases.

PubMed

Ou, Chien-Yu; Hsu, Shih-Yuan; Huang, Jian-Hao; Huang, Yu-Hua

2017-01-01

Lumbar fusion is a procedure broadly performed for degenerative diseases of spines, but it is not without significant morbidities. Surgical Apgar Score (SAS), based on intraoperative blood loss, blood pressure, and heart rate, was developed for prognostic prediction in general and vascular operations. We aimed to examine whether the application of SAS in patients undergoing fusion procedures for degeneration of lumbar spines predicts in-hospital major complications. One hundred and ninety-nine patients that underwent lumbar fusion operation for spine degeneration were enrolled in this retrospective study. Based on whether major complications were present (N=16) or not (N=183), the patients were subdivided. We identified the intergroup differences in SAS and clinical parameters. The incidence of in-hospital major complications was 8%. The duration of hospital stay for the morbid patents was significantly prolonged (p=0.04). In the analysis of multivariable logistic regression, SAS was an independent predicting factor of the complications after lumbar fusion for degenerative spine diseases [p=0.001; odds ratio (95% confidence interval)=0.35 (0.19-0.64)]. Lower scores were accompanied with higher rates of major complications, and the area was 0.872 under the receiver operating characteristic curve. SAS is an independent predicting factor of major complications in patients after fusion surgery for degenerative diseases of lumbar spines, and provides good risk discrimination. Since the scoring system is relatively simple, objective, and practical, we suggest that SAS be included as an indicator in the guidance for level of care after lumbar fusion surgery. Copyright © 2016 Elsevier B.V. All rights reserved.

Treating Traumatic Lumbosacral Spondylolisthesis Using Posterior Lumbar Interbody Fusion with three years follow up

PubMed Central

Tang, Shujie

2014-01-01

Objective: To analyze the surgical outcome of traumatic lumbosacral spondylolisthesis treated using posterior lumbar interbody fusion, and help spine surgeons to determine the treatment strategy. Methods: We reviewed retrospectively five cases of traumatic lumbosacral spondylolisthesis treated in our hospital from May 2005 to May 2010. There were four male and one female patient, treated surgically using posterior lumbar interbody fusion. The patients’ data including age, neurological status, operation time, blood loss, follow-up periods, X- radiographs and fusion status were collected. Results: All the cases were treated using posterior lumbar interbody fusion to realize decompression, reduction and fusion. Solid arthrodesis was found at the 12-month follow-up. No shift or breakage of the instrumentation was found, and all the patients were symptom-free at the last follow-up. Conclusion: Traumatic lumbosacral spondylolisthesis can be treated using posterior lumbar interbody fusion to realize the perfect reduction, decompression, fixation and fusion. PMID:25225542

Complications with axial presacral lumbar interbody fusion: A 5-year postmarketing surveillance experience

PubMed Central

Gundanna, Mukund I.; Miller, Larry E.; Block, Jon E.

2011-01-01

Background Open and minimally invasive lumbar fusion procedures have inherent procedural risks, with posterior and transforaminal approaches resulting in significant soft-tissue injury and the anterior approach endangering organs and major blood vessels. An alternative lumbar fusion technique uses a small paracoccygeal incision and a presacral approach to the L5-S1 intervertebral space, which avoids critical structures and may result in a favorable safety profile versus open and other minimally invasive fusion techniques. The purpose of this study was to evaluate complications associated with axial interbody lumbar fusion procedures using the Axial Lumbar Interbody Fusion (AxiaLIF) System (TranS1, Wilmington, North Carolina) in the postmarketing period. Methods Between March 2005 and March 2010, 9,152 patients underwent interbody fusion with the AxiaLIF System through an axial presacral approach. A single-level L5-S1 fusion was performed in 8,034 patients (88%), and a 2-level (L4-S1) fusion was used in 1,118 (12%). A predefined database was designed to record device- or procedure-related complaints via spontaneous reporting. The complications that were recorded included bowel injury, superficial wound and systemic infections, transient intraoperative hypotension, migration, subsidence, presacral hematoma, sacral fracture, vascular injury, nerve injury, and ureter injury. Results Complications were reported in 120 of 9,152 patients (1.3%). The most commonly reported complications were bowel injury (n = 59, 0.6%) and transient intraoperative hypotension (n = 20, 0.2%). The overall complication rate was similar between single-level (n = 102, 1.3%) and 2-level (n = 18, 1.6%) fusion procedures, with no significant differences noted for any single complication. Conclusions The 5-year postmarketing surveillance experience with the AxiaLIF System suggests that axial interbody lumbar fusion through the presacral approach is associated with a low incidence of complications

[Radiological study on the n-HA/PA66 cage used in the transforaminal lumbar interbody fusion].

PubMed

Sang, Pei-ming; Zhang, Ming; Chen, Bin-hui; Cai, Chang; Gu, Shi-rong; Zhou, Min

2014-08-01

To explore the effects of nano-hydroxyapatite/polyamide 66 (n-HA/PA66) cage on recovering and maintaining lumbar curvature, lumbar heights and fusion rate when used in the transforaminal lumbar interbody fusion. From February to July 2012, 50 patients with degenerative lumbar disease(lumbar disc herniation in 32 cases and lumbar spondylolisthesis in 18 cases) were treated with transforaminal lumbar interbody fusion using the n-HA/PA66 cage, and their preoperative and postoperative clinical outcomes were analyzed. The patients were followed up for 2, 4, 6 and 8 months after operation, during which the CR and CT film of lumbar vertebra were checked to get relative height of vertebral space, Taillard index,index of lumbar spinal curvature,angle of segmental and full lumbar lordosis. The data were analyzed respectively with pair t-test, analysis of variance or LSD-t-test. All the patients were followed up, and the duraion ranged from 8 to 13 months, with a mean of 11.32 months. There were significant differences in relative height of vertebral space, Taillard index, index of lumbar spinal curvature, angle of segmental and full lumbar lordosis after surgery, but there were no significant differences in different periods after operation. The fusion time of lumbar ranged from 4 to 8 months. The n-HA/PA66 cage can recover and maintain lumbar normal stability with higher rate of fusion and less complications.

The Quality and Readability of Information Available on the Internet Regarding Lumbar Fusion

PubMed Central

Zhang, Dafang; Schumacher, Charles; Harris, Mitchel B.; Bono, Christopher M.

2015-01-01

Study Design An Internet-based evaluation of Web sites regarding lumbar fusion. Objective The Internet has become a major resource for patients; however, the quality and readability of Internet information regarding lumbar fusion is unclear. The objective of this study is to evaluate the quality and readability of Internet information regarding lumbar fusion and to determine whether these measures changed with Web site modality, complexity of the search term, or Health on the Net Code of Conduct certification. Methods Using five search engines and three different search terms of varying complexity (“low back fusion,” “lumbar fusion,” and “lumbar arthrodesis”), we identified and reviewed 153 unique Web site hits for information quality and readability. Web sites were specifically analyzed by search term and Web site modality. Information quality was evaluated on a 5-point scale. Information readability was assessed using the Flesch-Kincaid score for reading grade level. Results The average quality score was low. The average reading grade level was nearly six grade levels above that recommended by National Work Group on Literacy and Health. The quality and readability of Internet information was significantly dependent on Web site modality. The use of more complex search terms yielded information of higher reading grade level but not higher quality. Conclusions Higher-quality information about lumbar fusion conveyed using language that is more readable by the general public is needed on the Internet. It is important for health care providers to be aware of the information accessible to patients, as it likely influences their decision making regarding care. PMID:26933614

The Quality and Readability of Information Available on the Internet Regarding Lumbar Fusion.

PubMed

Zhang, Dafang; Schumacher, Charles; Harris, Mitchel B; Bono, Christopher M

2016-03-01

Study Design An Internet-based evaluation of Web sites regarding lumbar fusion. Objective The Internet has become a major resource for patients; however, the quality and readability of Internet information regarding lumbar fusion is unclear. The objective of this study is to evaluate the quality and readability of Internet information regarding lumbar fusion and to determine whether these measures changed with Web site modality, complexity of the search term, or Health on the Net Code of Conduct certification. Methods Using five search engines and three different search terms of varying complexity ("low back fusion," "lumbar fusion," and "lumbar arthrodesis"), we identified and reviewed 153 unique Web site hits for information quality and readability. Web sites were specifically analyzed by search term and Web site modality. Information quality was evaluated on a 5-point scale. Information readability was assessed using the Flesch-Kincaid score for reading grade level. Results The average quality score was low. The average reading grade level was nearly six grade levels above that recommended by National Work Group on Literacy and Health. The quality and readability of Internet information was significantly dependent on Web site modality. The use of more complex search terms yielded information of higher reading grade level but not higher quality. Conclusions Higher-quality information about lumbar fusion conveyed using language that is more readable by the general public is needed on the Internet. It is important for health care providers to be aware of the information accessible to patients, as it likely influences their decision making regarding care.

Freeze-Dried Platelet-Rich Plasma Accelerates Bone Union with Adequate Rigidity in Posterolateral Lumbar Fusion Surgery Model in Rats

NASA Astrophysics Data System (ADS)

Shiga, Yasuhiro; Orita, Sumihisa; Kubota, Go; Kamoda, Hiroto; Yamashita, Masaomi; Matsuura, Yusuke; Yamauchi, Kazuyo; Eguchi, Yawara; Suzuki, Miyako; Inage, Kazuhide; Sainoh, Takeshi; Sato, Jun; Fujimoto, Kazuki; Abe, Koki; Kanamoto, Hirohito; Inoue, Masahiro; Kinoshita, Hideyuki; Aoki, Yasuchika; Toyone, Tomoaki; Furuya, Takeo; Koda, Masao; Takahashi, Kazuhisa; Ohtori, Seiji

2016-11-01

Fresh platelet-rich plasma (PRP) accelerates bone union in rat model. However, fresh PRP has a short half-life. We suggested freeze-dried PRP (FD-PRP) prepared in advance and investigated its efficacy in vivo. Spinal posterolateral fusion was performed on 8-week-old male Sprague-Dawley rats divided into six groups based on the graft materials (n = 10 per group): sham control, artificial bone (A hydroxyapatite-collagen composite) -alone, autologous bone, artificial bone + fresh-PRP, artificial bone + FD-PRP preserved 8 weeks, and artificial bone + human recombinant bone morphogenetic protein 2 (BMP) as a positive control. At 4 and 8 weeks after the surgery, we investigated their bone union-related characteristics including amount of bone formation, histological characteristics of trabecular bone at remodeling site, and biomechanical strength on 3-point bending. Comparable radiological bone union was confirmed at 4 weeks after surgery in 80% of the FD-PRP groups, which was earlier than in other groups (p < 0.05). Histologically, the trabecular bone had thinner and more branches in the FD-PRP. Moreover, the biomechanical strength was comparable to that of autologous bone. FD-PRP accelerated bone union at a rate comparable to that of fresh PRP and BMP by remodeling the bone with thinner, more tangled, and rigid trabecular bone.

Freeze-Dried Platelet-Rich Plasma Accelerates Bone Union with Adequate Rigidity in Posterolateral Lumbar Fusion Surgery Model in Rats

PubMed Central

Shiga, Yasuhiro; Orita, Sumihisa; Kubota, Go; Kamoda, Hiroto; Yamashita, Masaomi; Matsuura, Yusuke; Yamauchi, Kazuyo; Eguchi, Yawara; Suzuki, Miyako; Inage, Kazuhide; Sainoh, Takeshi; Sato, Jun; Fujimoto, Kazuki; Abe, Koki; Kanamoto, Hirohito; Inoue, Masahiro; Kinoshita, Hideyuki; Aoki, Yasuchika; Toyone, Tomoaki; Furuya, Takeo; Koda, Masao; Takahashi, Kazuhisa; Ohtori, Seiji

2016-01-01

Fresh platelet-rich plasma (PRP) accelerates bone union in rat model. However, fresh PRP has a short half-life. We suggested freeze-dried PRP (FD-PRP) prepared in advance and investigated its efficacy in vivo. Spinal posterolateral fusion was performed on 8-week-old male Sprague-Dawley rats divided into six groups based on the graft materials (n = 10 per group): sham control, artificial bone (A hydroxyapatite–collagen composite) –alone, autologous bone, artificial bone + fresh-PRP, artificial bone + FD-PRP preserved 8 weeks, and artificial bone + human recombinant bone morphogenetic protein 2 (BMP) as a positive control. At 4 and 8 weeks after the surgery, we investigated their bone union–related characteristics including amount of bone formation, histological characteristics of trabecular bone at remodeling site, and biomechanical strength on 3-point bending. Comparable radiological bone union was confirmed at 4 weeks after surgery in 80% of the FD-PRP groups, which was earlier than in other groups (p < 0.05). Histologically, the trabecular bone had thinner and more branches in the FD-PRP. Moreover, the biomechanical strength was comparable to that of autologous bone. FD-PRP accelerated bone union at a rate comparable to that of fresh PRP and BMP by remodeling the bone with thinner, more tangled, and rigid trabecular bone. PMID:27833116

Effects of Psoas Muscle Thickness on Outcomes of Lumbar Fusion Surgery.

PubMed

Verla, Terence; Adogwa, Owoicho; Elsamadicy, Aladine; Moreno, Jessica R; Farber, Harrison; Cheng, Joseph; Bagley, Carlos A

2016-03-01

Lumbar arthrodesis is a surgical option for treatment of lumbar pathologies. Stability of the spinal construct partly depends on load-bearing support from back muscles. Despite the role of the psoas muscle in upright spinal stabilization, data describing its clinical significance are scarce. We evaluated the effects of the psoas muscle thickness on outcomes after lumbar fusion surgery. A retrospective review was performed of hospital records (2007-2013) of adult patients undergoing lumbar fusion surgery. Patients ≥ 18 years old who had undergone ≥ 1 level of lumbar fusion with available preoperative magnetic resonance imaging scans and at least 1 year of follow-up were included. Axial psoas muscle thickness was measured at each lumbar intervertebral space. Psoas muscle thickness at each vertebral level was compared between patients with and without the occurrence of specific clinical outcomes. There were 257 patients included. The average age was 58.15 years; about 45% of patients were men. Most of the patients underwent a transforaminal interbody fusion surgery (58.4%). The average psoas muscle thickness ranged from 11.49 mm at L1-2 to 36.51 mm at L4-5. Patients with postoperative hip flexor weakness and increased time to ambulation had significantly smaller psoas muscle thickness. Also, patients with >50% improvement in visual analog scale pain score had significantly greater psoas muscle thickness. This study shows that the psoas muscle can be beneficial in overall postoperative rehabilitation with early ambulation and greater improvement in functional outcomes. Given the role of the psoas muscle in spinal stabilization, the effect of psoas muscle thickness on postoperative functional outcomes warrants further investigation. Copyright © 2016 Elsevier Inc. All rights reserved.

Complications and Morbidities of Mini-open Anterior Retroperitoneal Lumbar Interbody Fusion: Oblique Lumbar Interbody Fusion in 179 Patients

PubMed Central

Mac-Thiong, Jean-Marc; Hilmi, Radwan; Roussouly, Pierre

2012-01-01

Study Design A retrospective study including 179 patients who underwent oblique lumbar interbody fusion (OLIF) at one institution. Purpose To report the complications associated with a minimally invasive technique of a retroperitoneal anterolateral approach to the lumbar spine. Overview of Literature Different approaches to the lumbar spine have been proposed, but they are associated with an increased risk of complications and a longer operation. Methods A total of 179 patients with previous posterior instrumented fusion undergoing OLIF were included. The technique is described in terms of: the number of levels fused, operative time and blood loss. Persurgical and postsurgical complications were noted. Results Patients were age 54.1 ± 10.6 with a BMI of 24.8 ± 4.1 kg/m2. The procedure was performed in the lumbar spine at L1-L2 in 4, L2-L3 in 54, L3-L4 in 120, L4-L5 in 134, and L5-S1 in 6 patients. It was done at 1 level in 56, 2 levels in 107, and 3 levels in 16 patients. Surgery time and blood loss were, respectively, 32.5 ± 13.2 minutes and 57 ± 131 ml per level fused. There were 19 patients with a single complication and one with two complications, including two patients with postoperative radiculopathy after L3-5 OLIF. There was no abdominal weakness or herniation. Conclusions Minimally invasive OLIF can be performed easily and safely in the lumbar spine from L2 to L5, and at L1-2 for selected cases. Up to 3 levels can be addressed through a 'sliding window'. It is associated with minimal blood loss and short operations, and with decreased risk of abdominal wall weakness or herniation. PMID:22708012

Complications and Morbidities of Mini-open Anterior Retroperitoneal Lumbar Interbody Fusion: Oblique Lumbar Interbody Fusion in 179 Patients.

PubMed

Silvestre, Clément; Mac-Thiong, Jean-Marc; Hilmi, Radwan; Roussouly, Pierre

2012-06-01

A retrospective study including 179 patients who underwent oblique lumbar interbody fusion (OLIF) at one institution. To report the complications associated with a minimally invasive technique of a retroperitoneal anterolateral approach to the lumbar spine. Different approaches to the lumbar spine have been proposed, but they are associated with an increased risk of complications and a longer operation. A total of 179 patients with previous posterior instrumented fusion undergoing OLIF were included. The technique is described in terms of: the number of levels fused, operative time and blood loss. Persurgical and postsurgical complications were noted. Patients were age 54.1 ± 10.6 with a BMI of 24.8 ± 4.1 kg/m(2). The procedure was performed in the lumbar spine at L1-L2 in 4, L2-L3 in 54, L3-L4 in 120, L4-L5 in 134, and L5-S1 in 6 patients. It was done at 1 level in 56, 2 levels in 107, and 3 levels in 16 patients. Surgery time and blood loss were, respectively, 32.5 ± 13.2 minutes and 57 ± 131 ml per level fused. There were 19 patients with a single complication and one with two complications, including two patients with postoperative radiculopathy after L3-5 OLIF. There was no abdominal weakness or herniation. Minimally invasive OLIF can be performed easily and safely in the lumbar spine from L2 to L5, and at L1-2 for selected cases. Up to 3 levels can be addressed through a 'sliding window'. It is associated with minimal blood loss and short operations, and with decreased risk of abdominal wall weakness or herniation.

Hybrid circumferential fixation for degenerative lumbosacral spine disease: posterior lumbar interbody fusion plus universal clamp rod-band instrumentation: a novel technique for lumbosacral fixation.

PubMed

Tegos, Stergios; Charitidis, Charalampos; Korovessis, Panagiotis G

2014-04-01

Retrospective study on circumferential hybrid instrumentation with posterior lumbar interbody fusion (PLIF) and the novel posterior Universal Clamp (UC) instrumentation. This study evaluated the roentgenographic and clinical outcome after PLIF with PEEK cage augmented with UC posterior sublaminar fixation without posterior fusion. Although UC has been successfully used in scoliosis surgery, to our knowledge, this is the first report on its use in degenerative lumbosacral disease. Rigid pedicle screw lumbosacral fixation is associated with several intraoperative screw-related complications. The use of sublaminar bands and rods combined with PEEK PLIF should increase fusion rate and avoid screw-related complications. From a total of 295 consecutive patients who experienced degenerative lumbosacral disease and received posterior decompression, implantation of PLIF with PEEK cages and semirigid posterior fixation with sublaminar UC bands-rods without posterolateral fusion, 150 patients were eligible for this study with a follow-up of more than 2 years. Interbody fusion rate and global plus segmental sagittal spinal lordosis restoration were recorded pre- and postoperatively. Visual analogue scale and Oswestry Disability Index were used to assess functional outcome. Hybrid instrumentation expanded over 1 to 5 levels. Surgical time ranged from 45 to 225 minutes. Only 12.6% of the patients were transfused. There was no nerve root lesion or deep wound infection. Laminar fracture occurred intraoperatively in one case during band insertion. Interbody fusion was achieved in 94% of the operated segments. Lumbar lordosis improved from -36 ± 9° preoperatively to -53 ± 6° postoperatively. Segmental lordosis improved in L4-L5 segment from -5 ± 3° preoperatively to -12 ± 2° postoperatively and in L5-S1 from -9 ± 4° to -14 ± 2° postoperation. Oswestry Disability Index score improved from 44.9 preoperatively to 2.2 postoperatively (P < 0.001). No patient required further

Association between insurance status and patient safety in the lumbar spine fusion population.

PubMed

Tanenbaum, Joseph E; Alentado, Vincent J; Miller, Jacob A; Lubelski, Daniel; Benzel, Edward C; Mroz, Thomas E

2017-03-01

Lumbar fusion is a common and costly procedure in the United States. Reimbursement for surgical procedures is increasingly tied to care quality and patient safety as part of value-based reimbursement programs. The incidence of adverse quality events among lumbar fusion patients is unknown using the definition of care quality (patient safety indicators [PSI]) used by the Centers for Medicare and Medicaid Services (CMS). The association between insurance status and the incidence of PSI is similarly unknown in lumbar fusion patients. This study sought to determine the incidence of PSI in patients undergoing inpatient lumbar fusion and to quantify the association between primary payer status and PSI in this population. A retrospective cohort study was carried out. The sample comprised all adult patients aged 18 years and older who were included in the Nationwide Inpatient Sample (NIS) that underwent lumbar fusion from 1998 to 2011. The incidence of one or more PSI, a validated and widely used metric of inpatient health-care quality and patient safety, was the primary outcome variable. The NIS data were examined for all cases of inpatient lumbar fusion from 1998 to 2011. The incidence of adverse patient safety events (PSI) was determined using publicly available lists of the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Logistic regression models were used to determine the association between primary payer status (Medicaid and self-pay relative to private insurance) and the incidence of PSI. A total of 539,172 adult lumbar fusion procedures were recorded in the NIS from 1998 to 2011. Patients were excluded from the secondary analysis if "other" or "missing" was listed for primary insurance status. The national incidence of PSI was calculated to be 2,445 per 100,000 patient years of observation, or approximately 2.5%. In a secondary analysis, after adjusting for patient demographics and hospital characteristics, Medicaid

Constipation after thoraco-lumbar fusion surgery.

PubMed

Stienen, Martin N; Smoll, Nicolas R; Hildebrandt, Gerhard; Schaller, Karl; Tessitore, Enrico; Gautschi, Oliver P

2014-11-01

Thoraco-lumbar posterior fusion surgery is a frequent procedure used for patients with spinal instability due to tumor, trauma or degenerative disease. In the perioperative phase, many patients may experience vomiting, bowel irritation, constipation, or may even show symptoms of adynamic ileus possibly due to immobilization and high doses of opioid analgesics and narcotics administered during and after surgery. Retrospective single-center study on patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability in 2012. Study groups were built according to presence/absence of postoperative constipation, with postoperative constipation being defined as no bowel movement on postoperative days 0-2. Ninety-nine patients (39 males, 60 females) with a mean age of 57.1 ± 17.3 years were analyzed, of which 44 patients with similar age, gender, BMI and ASA-grades showed constipation (44.4%). Occurrence of constipation was associated with longer mean operation times (247 ± 62 vs. 214 ± 71 min; p=0.012), higher estimated blood loss (545 ± 316 vs. 375 ± 332 ml; p<0.001), and higher mean morphine dosages in the postoperative days 0-7 (the difference being significant on postoperative days 1 (48 mg vs. 30.9 mg, p=0.041) and 2 (43.2mg vs. 29.1mg, p=0.028). The equivalence dose of morphine administered during surgery was similar (339 ± 196 vs. 285 ± 144 mg; p=0.286). The use of laxatives in the postoperative days 0-7 was generally high in both study groups, while it was more frequent in patients experiencing constipation. One patient with constipation developed a sonographically confirmed paralytic ileus. Patients with constipation showed a tendency toward longer postoperative hospitalization (7.6 vs. 6.7 days, p=0.136). The rate of constipation was high after thoraco-lumbar fusion surgery. Moreover, it was associated with longer surgery time, higher blood loss, and higher postoperative morphine doses. Further trials are needed to

An Injectable Method for Posterior Lateral Spine Fusion

DTIC Science & Technology

2013-09-01

any problems that would prevent us from reaching our proposed goals. We have begun to establish optimal parameters for encapsulation of the MSCs...783–799 (2009). 3. U. Heise, J. F. Osborn, and F. Duwe, “ Hydroxyapatite ceramic as a bone substitute,” Int. Orthop. 14(3), 329–338 (1990). 4. H...gel and porous hydroxyapatite for posterolateral lumbar spine fusion,” Spine 30(10), 1134–1138 (2005). 9. M. R. Urist, “Bone: formation by

Pyogenic lumbar spondylodiscitis treated with transforaminal lumbar interbody fusion: safety and outcomes.

PubMed

Shetty, Ajoy Prasad; Aiyer, Siddharth N; Kanna, Rishi Mugesh; Maheswaran, Anupama; Rajasekaran, Shanmuganathan

2016-06-01

Our aim was to study the safety and outcomes of posterior instrumentation and transforaminal lumbar interbody fusion (TLIF) for treating pyogenic lumbar spondylodiscitis. Retrospective analysis was performed on prospectively collected data of 27 consecutive cases of lumbar pyogenic spondylodiscitis treated with posterior instrumentation and TLIF between January 2009 and December 2012. Cases were analysed for safety, radiological and clinical outcomes of transforaminal interbody fusion using bone graft ± titanium cages. Interbody metallic cages with bone graft were used in 17 cases and ten cases used only bone graft. Indications for surgical treatment were failed conservative management in 17, neurodeficit in six and significant bony destruction in four. There were no cases reporting cage migration, loosening, pseudoarthrosis or recurrence of infection at a mean follow-up of 30 months. Clinical outcomes were assessed using Kirkaldy-Willis criteria, which showed 14 excellent, nine good, three fair and one poor result. Mean focal deformity improved with the use of bone graft ± interbody cages, and the deformity correction was maintained at final follow-up. Mean pre-operative focal lordosis for the graft group was 8.5° (2-16.5°), which improved to 10.9 °(3.3-16°); mean pre-operative focal lordosis in the group treated with cages was 6.7 °(0-15°), which improved to 7°(0-15°) . TLIFs with cages in patients with pyogenic lumbar spondylodiscitis allows for acceptable clearance of infection, satisfactory deformity correction with low incidence of cage migration, loosening and infection recurrence.

Change of Lumbar Ligamentum Flavum after Indirect Decompression Using Anterior Lumbar Interbody Fusion.

PubMed

Ohtori, Seiji; Orita, Sumihisa; Yamauchi, Kazuyo; Eguchi, Yawara; Aoki, Yasuchika; Nakamura, Junichi; Miyagi, Masayuki; Suzuki, Miyako; Kubota, Gou; Inage, Kazuhide; Sainoh, Takeshi; Sato, Jun; Fujimoto, Kazuki; Shiga, Yasuhiro; Abe, Koki; Kanamoto, Hiroto; Inoue, Gen; Takahashi, Kazuhisa; Furuya, Takeo; Koda, Masao

2017-02-01

Retrospective case series. The purpose of this study was to examine changes in the ligamentum flavum thickness and remodeling of the spinal canal after anterior fusion during a 10-year follow-up. Extreme lateral interbody fusion provides minimally invasive treatment of the lumbar spine; this anterior fusion without direct posterior decompression, so-called indirect decompression, can achieve pain relief. Anterior fusion may restore disc height, stretch the flexure of the ligamentum flavum, and increase the spinal canal diameter. However, changes in the ligamentum flavum thickness and remodeling of the spinal canal after anterior fusion during a long follow-up have not yet been reported. We evaluated 10 patients with L4 spondylolisthesis who underwent stand-alone anterior interbody fusion using the iliac crest bone. Magnetic resonance imaging was performed 10 years after surgery. The cross-sectional area (CSA) of the dural sac and the ligamentum flavum at L1-2 to L5-S1 was calculated using a Picture Archiving and Communication System. Spinal fusion with correction loss (average, 4.75 mm anterior slip) was achieved in all patients 10 years postsurgery. The average CSAs of the dural sac and the ligamentum flavum at L1-2 to L5-S1 were 150 mm 2 and 78 mm 2 , respectively. The average CSA of the ligamentum flavum at L4-5 (30 mm 2 ) (fusion level) was significantly less than that at L1-2 to L3-4 or L5-S1. Although patients had an average anterior slip of 4.75 mm, the average CSA of the dural sac at L4-5 was significantly larger than at the other levels. Spinal stability induced a lumbar ligamentum flavum change and a sustained remodeling of the spinal canal, which may explain the long-term pain relief after indirect decompression fusion surgery.

The da Vinci robotic surgical assisted anterior lumbar interbody fusion: technical development and case report.

PubMed

Beutler, William J; Peppelman, Walter C; DiMarco, Luciano A

2013-02-15

Technique development to use the da Vince Robotic Surgical System for anterior lumbar interbody fusion at L5-S1 is detailed. A case report is also presented. To evaluate and develop the da Vinci robotic assisted laparoscopic anterior lumbar stand-alone interbody fusion procedure. Anterior lumbar interbody fusion is a common procedure associated with potential morbidity related to the surgical approach. The da Vinci robot provides intra-abdominal dissection and visualization advantages compared with the traditional open and laparoscopic approach. The surgical techniques for approach to the anterior lumbar spine using the da Vinci robot were developed and modified progressively beginning with operative models followed by placement of an interbody fusion cage in the living porcine model. Development continued to progress with placement of fusion cage in a human cadaver, completed first in the laboratory setting and then in the operating room. Finally, the first patient with fusion completed using the da Vinci robot-assisted approach is presented. The anterior transperitoneal approach to the lumbar spine is accomplished with enhanced visualization and dissection capability, with maintenance of pneumoperitoneum using the da Vinci robot. Blood loss is minimal. The visualization inside the disc space and surrounding structures was considered better than current open and laparoscopic techniques. The da Vinci robot Surgical System technique continues to develop and is now described for the transperitoneal approach to the anterior lumbar spine. 4.

Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis: a systematic review and meta-analysis.

PubMed

de Kunder, Suzanne L; van Kuijk, Sander M J; Rijkers, Kim; Caelers, Inge J M H; van Hemert, Wouter L W; de Bie, Rob A; van Santbrink, Henk

2017-11-01

Transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) are both frequently used as a surgical treatment for lumbar spondylolisthesis. Because of the unilateral transforaminal route to the intervertebral space used in TLIF, as opposed to the bilateral route used in PLIF, TLIF could be associated with fewer complications, shorter duration of surgery, and less blood loss, whereas the effectiveness of both techniques on back or leg pain is equal. The objective of this study was to compare the effectiveness of both TLIF and PLIF in reducing disability, and to compare the intra- and postoperative complications of both techniques in patients with lumbar spondylolisthesis. A systematic literature review and meta-analysis were carried out. We conducted a Medline (using PubMed), Embase (using Ovid), Cochrane Library, Current Controlled Trials, ClinicalTrials.gov and NHS Centre for Review and Dissemination search for studies reporting TLIF, PLIF, lumbar spondylolisthesis and disability, pain, complications, duration of surgery, and estimated blood loss. A meta-analysis was performed to compute pooled estimates of the differences between TLIF and PLIF. Forest plots were constructed for each analysis group. A total of 192 studies were identified; nine studies were included (one randomized controlled trial and eight case series), including 990 patients (450 TLIF and 540 PLIF). The pooled mean difference in postoperative Oswestry Disability Index (ODI) scores between TLIF and PLIF was -3.46 (95% confidence interval [CI] -4.72 to -2.20, p≤.001). The pooled mean difference in the postoperative VAS scores was -0.05 (95% CI -0.18 to 0.09, p=.480). The overall complication rate was 8.7% (range 0%-25%) for TLIF and 17.0% (range 4.7-28.8%) for PLIF; the pooled odds ratio was 0.47 (95% CI 0.28-0.81, p=.006). The average duration of surgery was 169 minutes for TLIF and 190 minutes for PLIF (mean difference -20.1, 95% CI -33.5 to -6.6, p=.003). The

Percutaneous Instrumentation of a Complex Lumbar Spine Fracture with Bilateral Pedicle Dissociation: Case Report and Technical Note.

PubMed

Luther, Evan; Urakov, Timur; Vanni, Steven

2018-06-11

 Complex traumatic lumbar spine fractures are difficult to manage and typically occur in younger patients. Surgical immobilization for unstable fractures is an accepted treatment but can lead to future adjacent-level disease. Furthermore, large variations in fracture morphology create significant difficulties when attempting fixation. Therefore, a surgical approach that considers both long-term outcomes and fracture type is of utmost importance. We present a novel technique for percutaneous fixation without interbody or posterolateral fusion in a young patient with bilateral pedicle dissociations and an acute-onset incomplete neurologic deficit.  A 20-year-old man involved in a motorcycle accident presented with unilateral right lower extremity paresis and sensory loss with intact rectal tone and no saddle anesthesia. Lumbar computed tomography (CT) demonstrated L2 and L3 fractures associated with bilateral pedicle dislocations. Lumbar magnetic resonance imaging showed draping of the conus medullaris/cauda equina anteriorly over the kyphotic deformity at L2 with minimal associated canal stenosis at L2 and L3. He was treated with emergent percutaneous fixation of the fracture segment without interbody or posterolateral fusion. Decompression was not performed because of the negligible amount of canal stenosis and high likelihood of cerebrospinal fluid leakage due to dural tears from the fractures. Surgical fixation of the L2 vertebra was achieved by cannulating the left pedicle with an oversized tap while holding the right pedicle in place with a normal tap and then driving screws into the left and right pedicles, respectively, thus reducing the free-floating fracture segment. At 18 months after surgery, a follow-up CT demonstrated good cortication across the prior pedicle fractures, and the instrumentation was removed without any obvious signs of instability or disruption of the alignment at the thoracolumbar junction.  We present a novel technique for

Matched Comparison of Fusion Rates between Hydroxyapatite Demineralized Bone Matrix and Autograft in Lumbar Interbody Fusion.

PubMed

Kim, Dae Hwan; Lee, Nam; Shin, Dong Ah; Yi, Seong; Kim, Keung Nyun; Ha, Yoon

2016-07-01

To compare the fusion rate of a hydroxyapatite demineralized bone matrix (DBM) with post-laminectomy acquired autograft in lumbar interbody fusion surgery and to evaluate the correlation between fusion rate and clinical outcome. From January 2013 to April 2014, 98 patients underwent lumbar interbody fusion surgery with hydroxyapatite DBM (HA-DBM group) in our institute. Of those patients, 65 received complete CT scans for 12 months postoperatively in order to evaluate fusion status. For comparison with autograft, we selected another 65 patients who underwent lumbar interbody fusion surgery with post-laminectomy acquired autograft (Autograft group) during the same period. Both fusion material groups were matched in terms of age, sex, body mass index (BMI), and bone mineral density (BMD). To evaluate the clinical outcomes, we analyzed the results of visual analogue scale (VAS), Oswestry Disability Index (ODI), and Short Form Health Survey (SF-36). We reviewed the CT scans of 149 fusion levels in 130 patients (HA-DBM group, 75 levels/65 patients; Autograft group, 74 levels/65 patients). Age, sex, BMI, and BMD were not significantly different between the groups (p=0.528, p=0.848, p=0.527, and p=0.610, respectively). The HA-DBM group showed 39 of 75 fused levels (52%), and the Autograft group showed 46 of 74 fused levels (62.2%). This difference was not statistically significant (p=0.21). In the HA-DBM group, older age and low BMD were significantly associated with non-fusion (61.24 vs. 66.68, p=0.027; -1.63 vs. -2.29, p=0.015, respectively). VAS and ODI showed significant improvement after surgery when fusion was successfully achieved in both groups (p=0.004, p=0.002, HA-DBM group; p=0.012, p=0.03, Autograft group). The fusion rates of the hydroxyapatite DBM and Autograft groups were not significantly different. In addition, clinical outcomes were similar between the groups. However, older age and low BMD are risk factors that might induce non-union after surgery with

Matched Comparison of Fusion Rates between Hydroxyapatite Demineralized Bone Matrix and Autograft in Lumbar Interbody Fusion

PubMed Central

Kim, Dae Hwan; Lee, Nam; Shin, Dong Ah; Yi, Seong; Kim, Keung Nyun

2016-01-01

Objective To compare the fusion rate of a hydroxyapatite demineralized bone matrix (DBM) with post-laminectomy acquired autograft in lumbar interbody fusion surgery and to evaluate the correlation between fusion rate and clinical outcome. Methods From January 2013 to April 2014, 98 patients underwent lumbar interbody fusion surgery with hydroxyapatite DBM (HA-DBM group) in our institute. Of those patients, 65 received complete CT scans for 12 months postoperatively in order to evaluate fusion status. For comparison with autograft, we selected another 65 patients who underwent lumbar interbody fusion surgery with post-laminectomy acquired autograft (Autograft group) during the same period. Both fusion material groups were matched in terms of age, sex, body mass index (BMI), and bone mineral density (BMD). To evaluate the clinical outcomes, we analyzed the results of visual analogue scale (VAS), Oswestry Disability Index (ODI), and Short Form Health Survey (SF-36). Results We reviewed the CT scans of 149 fusion levels in 130 patients (HA-DBM group, 75 levels/65 patients; Autograft group, 74 levels/65 patients). Age, sex, BMI, and BMD were not significantly different between the groups (p=0.528, p=0.848, p=0.527, and p=0.610, respectively). The HA-DBM group showed 39 of 75 fused levels (52%), and the Autograft group showed 46 of 74 fused levels (62.2%). This difference was not statistically significant (p=0.21). In the HA-DBM group, older age and low BMD were significantly associated with non-fusion (61.24 vs. 66.68, p=0.027; -1.63 vs. -2.29, p=0.015, respectively). VAS and ODI showed significant improvement after surgery when fusion was successfully achieved in both groups (p=0.004, p=0.002, HA-DBM group; p=0.012, p=0.03, Autograft group). Conclusion The fusion rates of the hydroxyapatite DBM and Autograft groups were not significantly different. In addition, clinical outcomes were similar between the groups. However, older age and low BMD are risk factors that might

[Anterior lumbar interbody fusion. Indications, technique, advantages and disadvantages].

PubMed

Richter, M; Weidenfeld, M; Uckmann, F P

2015-02-01

Anterior lumbar interbody fusion (ALIF) for lumbar interbody fusion from L2 to the sacrum has been an established technique for decades. The advantages and disadvantages of ALIF compared to posterior interbody fusion techniques are discussed. The operative technique is described in detail. Complications and avoidance strategies are discussed. This article is based on a selective literature search using PubMed and the experience of the authors in this medical field. The advantages of ALIF compared to posterior fusion techniques are the free approach to the anterior disc space without opening of the spinal canal or the neural foramina. This gives the possibility of an extensive anterior release and placement of the largest possible cages without the risk of neural structure damage. The disadvantages of ALIF are the additional anterior approach and the related complications. The most frequent complication is due to damage of vessels. The rate of complications is significantly increased in revision surgery. The ALIF technique meaningfully expands the repertoire of the spinal surgeon especially for the treatment of non-union after interbody fusion, in patients with epidural scar tissue at the index level and spinal infections. Advantages and disadvantages should be considered when evaluating the indications for ALIF.

More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: A review

PubMed Central

Epstein, Nancy E.

2016-01-01

Background: In the lumbar spine, do more nerve root injuries occur utilizing minimally invasive surgery (MIS) techniques versus open lumbar procedures? To answer this question, we compared the frequency of nerve root injuries for multiple open versus MIS operations including diskectomy, laminectomy with/without fusion addressing degenerative disc disease, stenosis, and/or degenerative spondylolisthesis. Methods: Several of Desai et al. large Spine Patient Outcomes Research Trial studies showed the frequency for nerve root injury following an open diskectomy ranged from 0.13% to 0.25%, for open laminectomy/stenosis with/without fusion it was 0%, and for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion it was 2%. Results: Alternatively, one study compared the incidence of root injuries utilizing MIS transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) techniques; 7.8% of PLIF versus 2% of TLIF patients sustained root injuries. Furthermore, even higher frequencies of radiculitis and nerve root injuries occurred during anterior lumbar interbody fusions (ALIFs) versus extreme lateral interbody fusions (XLIFs). These high frequencies were far from acceptable; 15.8% following ALIF experienced postoperative radiculitis, while 23.8% undergoing XLIF sustained root/plexus deficits. Conclusions: This review indicates that MIS (TLIF/PLIF/ALIF/XLIF) lumbar surgery resulted in a higher incidence of root injuries, radiculitis, or plexopathy versus open lumbar surgical techniques. Furthermore, even a cursory look at the XLIF data demonstrated the greater danger posed to neural tissue by this newest addition to the MIS lumbar surgical armamentariu. The latter should prompt us as spine surgeons to question why the XLIF procedure is still being offered to our patients? PMID:26904372

Negative effect of rapidly resorbing properties of bioactive glass-ceramics as bone graft substitute in a rabbit lumbar fusion model.

PubMed

Lee, Jae Hyup; Ryu, Hyun-Seung; Seo, Jun-Hyuk; Lee, Do-Yoon; Chang, Bong-Soon; Lee, Choon-Ki

2014-03-01

Bioactive glass-ceramics have the ability to directly bind to bones and have been widely used as bone graft substitutes due to their high osteoconductivity and biocompatibility. CaO-SiO2-P2O5-B2O3 glass-ceramics are known to have good osteoconductivity and are used as bone graft extenders. This study aimed to evaluate the effects of the resorbing properties of glass-ceramics in bone fusion after producing and analyzing three types of CaO-SiO2-P2O5-B2O3 glass-ceramics with high osteoconductivity that had enhanced resorption by having an increased B2O3 content. The three types of CaO-SiO2-P2O5-B2O3 glass-ceramics with B2O3 contents of 8.0, 9.0, and 9.5 weight % were designated and grouped as P20B80, P10B90, and P5B95, respectively. Glass-ceramic types were tested for fusion rates and bone formation by employing the lumbar 5-6 intertransverse process fusion model in 51 New Zealand male rabbits. Bioactivity was assessed by soaking in simulated body fluid (SBF). In vitro study results showed sufficient hydroxycarbonate apatite layer formation occurred for P20B80 in1 day, for P10B90 in 3 days, and for P5B95 in 5 days after soaking in SBF. For the rabbit lumbar spine posterolateral fusion model, the autograft group recorded a 100% fusion rate with levels significantly higher than those of P20B80 (29.4%), P10B90 (0%), and P5B95 (14.3%), with high resorbing properties. Resorbing property differences among the three glass-ceramic groups were not significant. Histological results showed new bone formation confirming osteoconductivity in all three types of glass-ceramics. Radiomorphometric results also confirmed the resorbing properties of the three glass-ceramic types. The high resorbing properties and osteoconductivity of porous glass-ceramics can be advantageous as no glass-ceramics remain in the body. However, their relatively fast rate of resorption in the body negatively affects their role as an osteoconductive scaffold as glass-ceramics are resorbed before bony fusion.

Current strategies for the restoration of adequate lordosis during lumbar fusion

PubMed Central

Barrey, Cédric; Darnis, Alice

2015-01-01

Not restoring the adequate lumbar lordosis during lumbar fusion surgery may result in mechanical low back pain, sagittal unbalance and adjacent segment degeneration. The objective of this work is to describe the current strategies and concepts for restoration of adequate lordosis during fusion surgery. Theoretical lordosis can be evaluated from the measurement of the pelvic incidence and from the analysis of spatial organization of the lumbar spine with 2/3 of the lordosis given by the L4-S1 segment and 85% by the L3-S1 segment. Technical aspects involve patient positioning on the operating table, release maneuvers, type of instrumentation used (rod, screw-rod connection, interbody cages), surgical sequence and the overall surgical strategy. Spinal osteotomies may be required in case of fixed kyphotic spine. AP combined surgery is particularly efficient in restoring lordosis at L5-S1 level and should be recommended. Finally, not one but several strategies may be used to achieve the need for restoration of adequate lordosis during fusion surgery. PMID:25621216

Minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis and degenerative spondylosis: 5-year results.

PubMed

Park, Yung; Ha, Joong Won; Lee, Yun Tae; Sung, Na Young

2014-06-01

Multiple studies have reported favorable short-term results after treatment of spondylolisthesis and other degenerative lumbar diseases with minimally invasive transforaminal lumbar interbody fusion. However, to our knowledge, results at a minimum of 5 years have not been reported. We determined (1) changes to the Oswestry Disability Index, (2) frequency of radiographic fusion, (3) complications and reoperations, and (4) the learning curve associated with minimally invasive transforaminal lumbar interbody fusion at minimum 5-year followup. We reviewed our first 124 patients who underwent minimally invasive transforaminal lumbar interbody fusion to treat low-grade spondylolisthesis and degenerative lumbar diseases and did not need a major deformity correction. This represented 63% (124 of 198) of the transforaminal lumbar interbody fusion procedures we performed for those indications during the study period (2003-2007). Eighty-three (67%) patients had complete 5-year followup. Plain radiographs and CT scans were evaluated by two reviewers. Trends of surgical time, blood loss, and hospital stay over time were examined by logarithmic curve fit-regression analysis to evaluate the learning curve. At 5 years, mean Oswestry Disability Index improved from 60 points preoperatively to 24 points and 79 of 83 patients (95%) had improvement of greater than 10 points. At 5 years, 67 of 83 (81%) achieved radiographic fusion, including 64 of 72 patients (89%) who had single-level surgery. Perioperative complications occurred in 11 of 124 patients (9%), and another surgical procedure was performed in eight of 124 patients (6.5%) involving the index level and seven of 124 patients (5.6%) at adjacent levels. There were slowly decreasing trends of surgical time and hospital stay only in single-level surgery and almost no change in intraoperative blood loss over time, suggesting a challenging learning curve. Oswestry Disability Index scores improved for patients with spondylolisthesis

Risk Factors for Blood Transfusion With Primary Posterior Lumbar Fusion.

PubMed

Basques, Bryce A; Anandasivam, Nidharshan S; Webb, Matthew L; Samuel, Andre M; Lukasiewicz, Adam M; Bohl, Daniel D; Grauer, Jonathan N

2015-11-01

Retrospective cohort study. To identify factors associated with blood transfusion for primary posterior lumbar fusion surgery, and to identify associations between blood transfusion and other postoperative complications. Blood transfusion is a relatively common occurrence for patients undergoing primary posterior lumbar fusion. There is limited information available describing which patients are at increased risk for blood transfusion, and the relationship between blood transfusion and short-term postoperative outcomes is poorly characterized. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing primary posterior lumbar fusion from 2011 to 2013. Multivariate analysis was used to find associations between patient characteristics and blood transfusion, along with associations between blood transfusion and postoperative outcomes. Out of 4223 patients, 704 (16.7%) had a blood transfusion. Age 60 to 69 (relative risk [RR] 1.6), age greater than equal to 70 (RR 1.7), American Society of Anesthesiologists class greater than equal to 3 (RR 1.1), female sex (RR 1.1), pulmonary disease (RR 1.2), preoperative hematocrit less than 36.0 (RR 2.0), operative time greater than equal to 310 minutes (RR 2.9), 2 levels (RR 1.6), and 3 or more levels (RR 2.1) were independently associated with blood transfusion. Interbody fusion (RR 0.9) was associated with decreased rates of blood transfusion. Receiving a blood transfusion was significantly associated with any complication (RR 1.7), sepsis (RR 2.6), return to the operating room (RR 1.7), deep surgical site infection (RR 2.6), and pulmonary embolism (RR 5.1). Blood transfusion was also associated with an increase in postoperative length of stay of 1.4 days (P < 0.001). 1 in 6 patients received a blood transfusion while undergoing primary posterior lumbar fusion, and risk factors for these occurrences were characterized. Strategies to minimize

Differences in 3D vs. 2D analysis in lumbar spinal fusion simulations.

PubMed

Hsu, Hung-Wei; Bashkuev, Maxim; Pumberger, Matthias; Schmidt, Hendrik

2018-04-27

Lumbar interbody fusion is currently the gold standard in treating patients with disc degeneration or segmental instability. Despite it having been used for several decades, the non-union rate remains high. A failed fusion is frequently attributed to an inadequate mechanical environment after instrumentation. Finite element (FE) models can provide insights into the mechanics of the fusion process. Previous fusion simulations using FE models showed that the geometries and material of the cage can greatly influence the fusion outcome. However, these studies used axisymmetric models which lacked realistic spinal geometries. Therefore, different modeling approaches were evaluated to understand the bone-formation process. Three FE models of the lumbar motion segment (L4-L5) were developed: 2D, Sym-3D and Nonsym-3D. The fusion process based on existing mechano-regulation algorithms using the FE simulations to evaluate the mechanical environment was then integrated into these models. In addition, the influence of different lordotic angles (5, 10 and 15°) was investigated. The volume of newly formed bone, the axial stiffness of the whole segment and bone distribution inside and surrounding the cage were evaluated. In contrast to the Nonsym-3D, the 2D and Sym-3D models predicted excessive bone formation prior to bridging (peak values with 36 and 9% higher than in equilibrium, respectively). The 3D models predicted a more uniform bone distribution compared to the 2D model. The current results demonstrate the crucial role of the realistic 3D geometry of the lumbar motion segment in predicting bone formation after lumbar spinal fusion. Copyright © 2018 Elsevier Ltd. All rights reserved.

Iliac Crest Bone Graft versus Local Autograft or Allograft for Lumbar Spinal Fusion: A Systematic Review.

PubMed

Tuchman, Alexander; Brodke, Darrel S; Youssef, Jim A; Meisel, Hans-Jörg; Dettori, Joseph R; Park, Jong-Beom; Yoon, S Tim; Wang, Jeffrey C

2016-09-01

Systematic review. To compare the effectiveness and safety between iliac crest bone graft (ICBG) and local autologous bone and allograft in the lumbar spine. A systematic search of multiple major medical reference databases identified studies evaluating spinal fusion in patients with degenerative joint disease using ICBG, local autograft, or allograft in the thoracolumbar spine. Six comparative studies met our inclusion criteria. A "low" strength of the overall body of evidence suggested no difference in fusion percentages in the lumbar spine between local autograft and ICBG. We found no difference in fusion percentages based on low evidence comparing allograft with ICBG autograft. There were no differences in pain or functional results comparing local autograft or allograft with ICBG autograft. Donor site pain and hematoma/seroma occurred more frequently in ICBG autograft group for lumbar fusion procedures. There was low evidence around the estimate of patients with donor site pain following ICBG harvesting, ranging from 16.7 to 20%. With respect to revision, low evidence demonstrated no difference between allograft and ICBG autograft. There was no evidence comparing patients receiving allograft with local autograft for fusion, pain, functional, and safety outcomes. In the lumbar spine, ICBG, local autograft, and allograft have similar effectiveness in terms of fusion rates, pain scores, and functional outcomes. However, ICBG is associated with an increased risk for donor site-related complications. Significant limitations exist in the available literature when comparing ICBG, local autograft, and allograft for lumbar fusion, and thus ICBG versus other fusion methods necessitates further investigation.

Transforaminal Percutaneous Endoscopic Discectomy and Foraminoplasty after Lumbar Spinal Fusion Surgery.

PubMed

Wu, Jian-Jun; Chen, Hui-Zhen; Zheng, Changkun

2017-07-01

The most common causes of pain following lumbar spinal fusions are residual herniation, or foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. The original surgeon may advise his patient that nothing more can be done in his opinion that the nerve was visually decompressed by the original surgery. Post-operative imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of failed lumbar spinal fusions by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain. The authors, having limited their practice to endoscopic surgery over the last 10 years, report on their experience gained during that period to relieve pain by transforaminal percutaneous endoscopic revision of lumbar spinal fusions. To assess the effectiveness of transforaminal percutaneous endoscopic discectomy and foraminoplasty in patients with pain after lumbar spinal fusion. Retrospective study. Inpatient surgery center. Sixteen consecutive patients with pain after lumbar spinal fusions presenting with back and leg pain that had supporting imaging diagnosis of foraminal stenosis and/or residual/recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections, were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open lumbar spinal fusions treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen in the case of foraminal stenosis, or to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla. The average follow-up time was 30.3 months, minimum 12 months. Outcome data at each visit

Effects of a Commercial Insurance Policy Restriction on Lumbar Fusion in North Carolina and the Implications for National Adoption

PubMed Central

Deyo, Richard A.; Lurie, Jon D.; Carey, Timothy S.; Tosteson, Anna N.A.; Mirza, Sohail K.

2015-01-01

Study design Analysis of the State Inpatient Database of North Carolina, 2005–2012, and the Nationwide Inpatient Sample, including all inpatient lumbar fusion admissions from non-federal hospitals. Objective To examine the influence of a major commercial policy change that restricted lumbar fusion for certain indications, and to forecast the potential impact if the policy were adopted nationally. Summary of Background Data Few studies have examined the effects of recent changes in commercial coverage policies that restrict the use of lumbar fusion. Methods We included adults undergoing elective lumbar fusion or re-fusion operations in North Carolina. We aggregated data into a monthly time series to report changes in the rates and volume of lumbar fusion operations for disc herniation or degeneration, spinal stenosis, spondylolisthesis, or revision fusions. Time series regression models were used to test for significant changes in the use of fusion operation following a major commercial coverage policy change initiated on January 1st, 2011. Results There was a substantial decline in the use of lumbar fusion for disc herniation or degeneration following the policy change on January 1st, 2011. Overall rates of elective lumbar fusion operations in North Carolina (per 100,000 residents) increased from 103.2 in 2005 to 120.4 in 2009, before declining to 101.9 by 2012. The population rate (per 100,000 residents) of fusion among those under age 65 increased from 89.5 in 2005 to 101.2 in 2009, followed by a sharp decline to 76.8 by 2012. There was no acceleration in the already increasing rate of fusion for spinal stenosis, spondylolisthesis or revision procedures, but there was a coincident increase in decompression without fusion. Conclusions This commercial insurance policy change had its intended effect of reducing fusion operations for indications with less evidence of effectiveness without changing rates for other indications or resulting in an overall reduction in

[Recalibration via a postero-lateral approach in recent traumatic stenosis of the dorsal and lumbar spine. Modalities and results apropos of 31 cases].

PubMed

Richaud, J; Bousquet, P; Ealet, G; Clamens, J; Beltchika, K; Lazorthes, Y

1990-01-01

The authors present 31 cases of spinal trauma affecting thoraco lumbar level with severe spinal canal stenosis secondary to compressive trauma of the anterior disco-corpereal region. Associated neurological disorders were of varying severity. 23 cases were investigated by computed tomography. In all cases, the surgical procedure involved rectification of spinal deformities, with initially a unilateral postero-lateral approach permitting anterior spinal canal recalibration, either by impaction of protrusive fragments or ablation of free disc fragments. The stabilization was usually achieved by complementary bilateral plates using Roy-Camille or Privat material in 22 cases, associated with postero-lateral arthrodesis by grafting with reconstruction of the articulo-pedicular structure in 19 cases. Emergency operation was done in 14 cases; in 5 cases operation was done on the 2nd or 3rd day and in 11 cases after the 3rd day. The functional spinal result was excellent, and recalibration was verified by tomography in all cases. In those cases showing neurological deficiency, good and early recovery was attributable to the suppression of spinal canal stenosis, and a consequently neurological improvement was always obtained, even for the most serious of lesions except those at the thoracis level superior to T10. The application of this postero-lateral approach for severe spinal trauma seems to represent, in all cases of recent lesions, an alternative to the anterior or combined methods. We do not share the opinion that delay in decompression does not influence the neurological prognosis and emergency operation is advisable.

No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises.

PubMed

Froholdt, Anne; Holm, Inger; Keller, Anne; Gunderson, Ragnhild B; Reikeraas, Olav; Brox, Jens I

2011-08-01

Reduced muscle strength and density observed at 1 year after lumbar fusion may deteriorate more in the long term. To compare the long-term effect of lumbar fusion and cognitive intervention and exercises on muscle strength, cross-sectional area, density, and self-rated function in patients with chronic low back pain (CLBP) and disc degeneration. Randomized controlled study with a follow-up examination at 8.5 years (range, 7-11 years). Patients with CLBP and disc degeneration randomized to either instrumented posterolateral fusion of one or both of the two lower lumbar levels or a 3-week cognitive intervention and exercise program were included. Isokinetic muscle strength was measured by a Cybex 6000 (Cybex-Lumex, Inc., Ronkonkoma, NY, USA). All patients had previous experience with the test procedure. The back extension (E) flexion (F) muscles were tested, and the E/F ratios were calculated. Cross-sectional area and density of the back muscles were measured at the L3-L4 segment by computed tomography. Patients rated their function by the General Function Score. Trunk muscle strength, cross-sectional area, density, and self-rated function. Fifty-five patients (90%) were included at long-term follow-up. There were no significant differences in cross-sectional area, density, muscle strength, or self-rated function between the two groups. The cognitive intervention and exercise group increased trunk muscle extension significantly (p<.05), and both groups performed significantly better on trunk muscle flexion tests (p<.01) at long-term follow-up. On average, self-rated function improved by 56%, cross-sectional area was reduced by 8.5%, and muscle density was reduced by 27%. Although this study did not assess the morphology of muscles likely damaged by surgery, trunk muscle strength and cross-sectional area above the surgical levels are not different between those who had lumbar fusion or cognitive intervention and exercises at 7- to 11-year follow-up. Copyright © 2011

Effect of lordosis angle change after lumbar/lumbosacral fusion on sacrum angular displacement: a finite element study.

PubMed

Mao, Ningfang; Shi, Jian; He, Dawei; Xie, Yang; Bai, Yushu; Wei, Xianzhao; Shi, Zhicai; Li, Ming

2014-11-01

To assess and characterize the sacrum angular displacements in response to lumbar lordosis after lumbar/lumbosacral fusion. A finite element model of the lower lumbar spine-pelvis was established and used to simulate the posterior fusion at L3-L5 and L4-S1. The lordosis angle in the fusion segments was set to five different conditions with respect to the intact model: 10° less than intact, 5° less than intact, same as intact, 5° more than intact, and 10° more than intact. Variations of the sacrum angular displacements with lordosis changes were analyzed under loading setting of axial compression, flexion, extension, lateral bending, and axial rotation. Compared with the intact lordosis, both increased and decreased lumbar lordosis angles caused the sacrum angular displacements to be increased. The lordosis angle increased by 10° induced the most substantial increase in sacrum angular displacements. In addition, the sacrum angular displacements of the L4-S1 fusion model at different lordosis angles were higher than those of the L3-L5 fusion model. The sacrum angular displacements occur as a result of the fusion surgery (L4-S1) and the changes in lumbar lordosis.

Computational comparison of three posterior lumbar interbody fusion techniques by using porous titanium interbody cages with 50% porosity.

PubMed

Lee, Yung-Heng; Chung, Chi-Jen; Wang, Chih-Wei; Peng, Yao-Te; Chang, Chih-Han; Chen, Chih-Hsien; Chen, Yen-Nien; Li, Chun-Ting

2016-04-01

This study investigated the biomechanical response of porous cages and lumbar spine segments immediately after surgery and after bone fusion, in addition to the long-term effects of various posterior lumbar interbody fusion (PLIF) techniques, by using the finite element method. Lumbar L3-L4 models based on three PLIF techniques (a single cage at the center of the intervertebral space, a single cage half-anterior to the intervertebral space, and two cages bilateral to the intervertebral space) with and without bone ingrowth were used to determine the biomechanical response of porous cages and lumbar segments instrumented with porous titanium cages (cage porosity=50%, pore diameter=1mm). The results indicated that bone fusion enhanced the stability of the lumbar segments with porous cages without any posterior instrumentation and reduced the peak von Mises stress in the cortical bones and porous cages. Two cages placed bilateral to the intervertebral space achieved the highest structural stability in the lumbar segment and lowest von Mises stress in the cages under both bone fusion conditions. Under identical loading (2-Nm), the range of motion in the single cage at the center of the intervertebral space with bone fusion decreased by 11% (from 1.18° to 1.05°) during flexion and by 66.5% (from 4.46° to 1.5°) during extension in the single cage half-anterior to the intervertebral space with bone fusion compared with no-fusion models. Thus, two porous titanium cages with 50% porosity can achieve high stability of a lumbar segment with PLIF. If only one cage is available, placing the cage half-anterior to the intervertebral space is recommended for managing degenerated lumbar segments. Copyright © 2016 Elsevier Ltd. All rights reserved.

Iliac Crest Bone Graft versus Local Autograft or Allograft for Lumbar Spinal Fusion: A Systematic Review

PubMed Central

Tuchman, Alexander; Brodke, Darrel S.; Youssef, Jim A.; Meisel, Hans-Jörg; Dettori, Joseph R.; Park, Jong-Beom; Yoon, S. Tim; Wang, Jeffrey C.

2016-01-01

Study Design  Systematic review. Objective  To compare the effectiveness and safety between iliac crest bone graft (ICBG) and local autologous bone and allograft in the lumbar spine. Methods  A systematic search of multiple major medical reference databases identified studies evaluating spinal fusion in patients with degenerative joint disease using ICBG, local autograft, or allograft in the thoracolumbar spine. Results  Six comparative studies met our inclusion criteria. A “low” strength of the overall body of evidence suggested no difference in fusion percentages in the lumbar spine between local autograft and ICBG. We found no difference in fusion percentages based on low evidence comparing allograft with ICBG autograft. There were no differences in pain or functional results comparing local autograft or allograft with ICBG autograft. Donor site pain and hematoma/seroma occurred more frequently in ICBG autograft group for lumbar fusion procedures. There was low evidence around the estimate of patients with donor site pain following ICBG harvesting, ranging from 16.7 to 20%. With respect to revision, low evidence demonstrated no difference between allograft and ICBG autograft. There was no evidence comparing patients receiving allograft with local autograft for fusion, pain, functional, and safety outcomes. Conclusion  In the lumbar spine, ICBG, local autograft, and allograft have similar effectiveness in terms of fusion rates, pain scores, and functional outcomes. However, ICBG is associated with an increased risk for donor site-related complications. Significant limitations exist in the available literature when comparing ICBG, local autograft, and allograft for lumbar fusion, and thus ICBG versus other fusion methods necessitates further investigation. PMID:27556001

Application of a narrow-surface cage in full endoscopic minimally invasive transforaminal lumbar interbody fusion.

PubMed

He, Er-Xing; Guo, Jing; Ling, Qin-Jie; Yin, Zhi-Xun; Wang, Ying; Li, Ming

2017-06-01

Spinal endoscopy has been widely applied in lumbar discectomy and decompression. However, endoscopic lumbar interbody fusion still remains a technical challenge due to the limited space within the working trocar for cage implantation. The purpose of this study was to investigate the feasibility and effectiveness of using a narrow-surface fusion cage in full endoscopic minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for the treatment of lumbar degenerative disease. From Jun 2013 to Dec 2014, a total of 42 patients (23 males, 19 females) underwent full endoscopic MIS-TLIF at our hospital was recruited. An 8-mm-wide narrow-surface fusion cage was selected for all cases. Perioperative parameters and complications were recorded. Comparisons on visual analog scale (VAS) and oswestry disability index (ODI) scores before and after surgery were performed. At the last follow-up, Nakai grading system was applied to assess patients' satisfaction; meanwhile, interbody fusion was evaluated by computed tomography. Mean operation time was 233.1 ± 69.5 min, and mean blood loss during surgery was 221.8 ± 98.5 ml. Two patients (4.8%) developed neurological complications. Postoperative follow-up ranged from 24 to 36 months (mean 27.6 ± 3.8 months). VAS and ODI scores were significantly improved 3 months after surgery and at the final follow-up, respectively (P < 0.05). Outcome of surgery was graded as excellent for 32 patients, good for 8 patients, and acceptable for 2 patients, corresponding to a success rate ("good" and "excellent") of 95.2%. Thirty-nine of the 42 patients demonstrated solid interbody fusion at the last follow-up, indicating a fusion rate of 92.9%. Application of a narrow-surface fusion cage in full endoscopic MIS-TLIF for the treatment of lumbar degenerative disease is feasible and effective. The clinical outcome and fusion success of this procedure were acceptable and promising. Copyright © 2017 IJS Publishing Group Ltd

Effect of Lumbar Lordosis on the Adjacent Segment in Transforaminal Lumbar Interbody Fusion: A Finite Element Analysis.

PubMed

Zhao, Xin; Du, Lin; Xie, Youzhuan; Zhao, Jie

2018-06-01

We used a finite element (FE) analysis to investigate the biomechanical changes caused by transforaminal lumbar interbody fusion (TLIF) at the L4-L5 level by lumbar lordosis (LL) degree. A lumbar FE model (L1-S5) was constructed based on computed tomography scans of a 30-year-old healthy male volunteer (pelvic incidence,= 50°; LL, 52°). We investigated the influence of LL on the biomechanical behavior of the lumbar spine after TLIF in L4-L5 fusion models with 57°, 52°, 47°, and 40° LL. The LL was defined as the angle between the superior end plate of L1 and the superior end plate of S1. A 150-N vertical axial preload was imposed on the superior surface of L3. A 10-N/m moment was simultaneously applied on the L3 superior surface along the radial direction to simulate the 4 basic physiologic motions of flexion, extension, lateral bending, and torsion in the numeric simulations. The range of motion (ROM) and intradiscal pressure (IDP) of L3-L4 were evaluated and compared in the simulated cases. In all motion patterns, the ROM and IDP were both increased after TLIF. In addition, the decrease in lordosis generally increased the ROM and IDP in all motion patterns. This FE analysis indicated that decreased spinal lordosis may evoke overstress of the adjacent segment and increase the risk of the pathologic development of adjacent segment degeneration; thus, adjacent segment degeneration should be considered when planning a spinal fusion procedure. Copyright © 2018. Published by Elsevier Inc.

Sagittal alignment after lumbar interbody fusion: comparing anterior, lateral, and transforaminal approaches.

PubMed

Watkins, Robert G; Hanna, Robert; Chang, David; Watkins, Robert G

2014-07-01

Retrospective radiographic analysis. To determine which lumbar interbody technique is most effective for restoring lordosis, increasing disk height, and reducing spondylolisthesis. Lumbar interbody fusions are performed in hopes of increasing fusion potential, correcting deformity, and indirectly decompressing nerve roots. No published study has directly compared anterior, lateral, and transforaminal lumber interbody fusions in terms of ability to restore lordosis, increase disk height, and reduce spondylolisthesis. Lumbar interbody fusion techniques were retrospectively compared in terms of improvement of lordosis, disk height, and spondylolisthesis between preoperative and follow-up lateral radiographs. A total of 220 consecutive patients with 309 operative levels were compared by surgery type: anterior (184 levels), lateral (86 levels), and transforaminal (39 levels). Average follow-up was 19.2 months (range, 1-56 mo), with no statistical difference between the groups. Intragroup analysis showed that the anterior (4.5 degrees) and lateral (2.2 degrees) groups significantly improved lordosis from preoperative to follow-up, whereas the transforaminal (0.8 degrees) group did not. Intergroup analysis showed that the anterior group significantly improved lordosis more than both the lateral and transforaminal groups. The anterior (2.2 mm) and lateral (2.0 mm) groups both significantly improved disk height more than the transforaminal (0.5 mm) group. All 3 groups significantly reduced spondylolisthesis, with no difference between the groups. After lumbar interbody fusion, improvement of lordosis was significant for both the anterior and lateral groups, but not the transforaminal group. Intergroup analysis showed the anterior group had significantly improved lordosis compared to both the other groups. The anterior and lateral groups had significantly increased disk height compared to the transforaminal group. All the 3 groups significantly reduced spondylolisthesis

Comparison of Clinical and Radiologic Results of Mini-Open Transforaminal Lumbar Interbody Fusion and Extreme Lateral Interbody Fusion Indirect Decompression for Degenerative Lumbar Spondylolisthesis

PubMed Central

Gen, Hogaku; Sakuma, Yoshio; Koshika, Yasuhide

2018-01-01

Study Design Retrospective study. Purpose In this study, we compared the postoperative outcomes of extreme lateral interbody fusion (XLIF) indirect decompression with that of mini-open transforaminal lumbar interbody fusion (TLIF) in patients with lumbar degenerative spondylolisthesis. Overview of Literature There are very few reports examining postoperative results of XLIF and minimally invasive TLIF for degenerative lumbar spondylolisthesis, and no reports comparing XLIF and mini-open TLIF. Methods Forty patients who underwent 1-level spinal fusion, either by XLIF indirect decompression (X group, 20 patients) or by mini-open TLIF (T group, 20 patients), for treatment of lumbar degenerative spondylolisthesis were included in this study. Invasiveness of surgery was evaluated on the basis of surgery time, blood loss, hospitalization period, and perioperative complications. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), disc angle (DA), disc height (DH), and slipping length (SL) were evaluated before surgery, immediately after surgery, and at 12 months after surgery. Cross-sectional spinal canal area (CSA) was also measured before surgery and at 1 month after surgery. Results There was no significant difference between the groups in terms of surgery time or hospitalization period; however, X group showed a significant decrease in blood loss (p<0.001). Serious complications were not observed in either group. In clinical assessment, no significant differences were observed between the groups with regard to the JOABPEQ results. The change in DH at 12 months after surgery increased significantly in the X group (p<0.05), and the changes in DA and SL were not significantly different between the two groups. The change in CSA was significantly greater in the T group (p<0.001). Conclusions Postoperative clinical results were equally favorable for both procedures; however, in comparison with mini-open TLIF, less blood loss and greater

Comparison of Clinical and Radiologic Results of Mini-Open Transforaminal Lumbar Interbody Fusion and Extreme Lateral Interbody Fusion Indirect Decompression for Degenerative Lumbar Spondylolisthesis.

PubMed

Kono, Yutaka; Gen, Hogaku; Sakuma, Yoshio; Koshika, Yasuhide

2018-04-01

Retrospective study. In this study, we compared the postoperative outcomes of extreme lateral interbody fusion (XLIF) indirect decompression with that of mini-open transforaminal lumbar interbody fusion (TLIF) in patients with lumbar degenerative spondylolisthesis. There are very few reports examining postoperative results of XLIF and minimally invasive TLIF for degenerative lumbar spondylolisthesis, and no reports comparing XLIF and mini-open TLIF. Forty patients who underwent 1-level spinal fusion, either by XLIF indirect decompression (X group, 20 patients) or by mini-open TLIF (T group, 20 patients), for treatment of lumbar degenerative spondylolisthesis were included in this study. Invasiveness of surgery was evaluated on the basis of surgery time, blood loss, hospitalization period, and perioperative complications. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), disc angle (DA), disc height (DH), and slipping length (SL) were evaluated before surgery, immediately after surgery, and at 12 months after surgery. Cross-sectional spinal canal area (CSA) was also measured before surgery and at 1 month after surgery. There was no significant difference between the groups in terms of surgery time or hospitalization period; however, X group showed a significant decrease in blood loss ( p <0.001). Serious complications were not observed in either group. In clinical assessment, no significant differences were observed between the groups with regard to the JOABPEQ results. The change in DH at 12 months after surgery increased significantly in the X group ( p <0.05), and the changes in DA and SL were not significantly different between the two groups. The change in CSA was significantly greater in the T group ( p <0.001). Postoperative clinical results were equally favorable for both procedures; however, in comparison with mini-open TLIF, less blood loss and greater correction of DH were observed in XLIF.

Effect of zoledronic acid on lumbar spinal fusion in osteoporotic patients.

PubMed

Ding, Qirui; Chen, Jian; Fan, Jin; Li, Qingqing; Yin, Guoyong; Yu, Lipeng

2017-11-01

To investigate the effect of zoledronic acid (ZA) on lumbar spinal fusion in patients with osteoporosis. This retrospective study includes 94 osteoporotic patients suffering from lumbar degenerative diseases or lumbar fracture who underwent lumbar spinal fusion in our institution from January 2013 to August 2014. They were divided into ZA group and control group according to whether the patient received ZA infusion or not. The patients in ZA group were given 5 mg intravenous ZA at the 3rd-5th days after operation. All patients took daily oral supplement of 600 mg calcium carbonate and 800 IU vitamin D during the follow-up after operation. The Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Short Form 36 (SF-36) scores were recorded preoperatively and post-operatively to evaluate the clinic outcomes; the spinal fusion was assessed by X-ray or CT Scan. 64 patients finished the final follow-up, including 30 patients in ZA group and 34 patients in control group. No significant difference was observed in gender, age, and preoperative BMI VAS, ODI, and SF-36 scores between the two groups (P > 0.05). The post-operative VAS and ODI scores decreased rapidly at 3 and 6 months, but rose back slightly at 12 and 24 months in both groups. On the contrary, post-operative SF-36 scores increased rapidly at 3 and 6 months, while fell back slightly at 12 and 24 months, with a statistically significant difference between the two groups at 12 months, but not at 3 and 6 month post-operation. The spinal fusion rate in ZA group was 90% at 6 months, 92% at 12 months, while it was 75% at 6 months, 92.86% at 12 months in control group, significantly different between the two groups at 12 months, but not at 6 months. In the whole follow-up period, adjacent vertebral compressing fracture occurred in five patients in control group, none in ZA group. No pedicle screw loosening was observed in ZA group, with six in control group. Zoledronic acid accelerates

Uninstrumented Posterior Lumbar Interbody Fusion: Have Technological Advances in Stabilizing the Lumbar Spine Truly Improved Outcomes?

PubMed

Prolo, Laura M; Oklund, Sally A; Zawadzki, Nadine; Desai, Manisha; Prolo, Donald J

2018-04-06

Since the 1980s, numerous operations have replaced posterior lumbar interbody fusion (PLIF) with human bone. These operations often involve expensive implants and complex procedures. Escalating expenditures in lumbar fusion surgery warrant re-evaluation of classical PLIF with allogeneic ilium and without instrumentation. The purpose of this study was to determine the long-term fusion rate and clinical outcomes of PLIF with allogeneic bone (allo-PLIF). Between 1981 and 2006, 321 patients aged 12-80 years underwent 339 1-level or 2-level allo-PLIFs for degenerative instability and were followed for 1-28 years. Fusion status was determined by radiographs and as available, by computed tomography scans. Clinical outcome was assessed by the Economic/Functional Outcome Scale. Of the 321 patients, 308 were followed postoperatively (average 6.7 years) and 297 (96%) fused. Fusion rates were lower for patients with substance abuse (89%, P = 0.007). Clinical outcomes in 87% of patients were excellent (52%) or good (35%). Economic/Functional Outcome Scale scores after initial allo-PLIF on average increased 5.2 points. Successful fusion correlated with nearly a 2-point gain in outcome score (P = 0.001). A positive association between a patient characteristic and outcome was observed only with age 65 years and greater, whereas negative associations in clinical outcomes were observed with mental illness, substance abuse, heavy stress to the low back, or industrial injuries. The total complication rate was 7%. With 3 decades of follow-up, we found that successful clinical outcomes are highly correlated with solid fusion using only allogeneic iliac bone. Copyright © 2018 Elsevier Inc. All rights reserved.

Negative Effect of Rapidly Resorbing Properties of Bioactive Glass-Ceramics as Bone Graft Substitute in a Rabbit Lumbar Fusion Model

PubMed Central

Lee, Jae Hyup; Ryu, Hyun-Seung; Seo, Jun-Hyuk; Lee, Do-Yoon; Chang, Bong-Soon

2014-01-01

Background Bioactive glass-ceramics have the ability to directly bind to bones and have been widely used as bone graft substitutes due to their high osteoconductivity and biocompatibility. CaO-SiO2-P2O5-B2O3 glass-ceramics are known to have good osteoconductivity and are used as bone graft extenders. Methods This study aimed to evaluate the effects of the resorbing properties of glass-ceramics in bone fusion after producing and analyzing three types of CaO-SiO2-P2O5-B2O3 glass-ceramics with high osteoconductivity that had enhanced resorption by having an increased B2O3 content. The three types of CaO-SiO2-P2O5-B2O3 glass-ceramics with B2O3 contents of 8.0, 9.0, and 9.5 weight % were designated and grouped as P20B80, P10B90, and P5B95, respectively. Glass-ceramic types were tested for fusion rates and bone formation by employing the lumbar 5-6 intertransverse process fusion model in 51 New Zealand male rabbits. Bioactivity was assessed by soaking in simulated body fluid (SBF). Results In vitro study results showed sufficient hydroxycarbonate apatite layer formation occurred for P20B80 in1 day, for P10B90 in 3 days, and for P5B95 in 5 days after soaking in SBF. For the rabbit lumbar spine posterolateral fusion model, the autograft group recorded a 100% fusion rate with levels significantly higher than those of P20B80 (29.4%), P10B90 (0%), and P5B95 (14.3%), with high resorbing properties. Resorbing property differences among the three glass-ceramic groups were not significant. Histological results showed new bone formation confirming osteoconductivity in all three types of glass-ceramics. Radiomorphometric results also confirmed the resorbing properties of the three glass-ceramic types. Conclusions The high resorbing properties and osteoconductivity of porous glass-ceramics can be advantageous as no glass-ceramics remain in the body. However, their relatively fast rate of resorption in the body negatively affects their role as an osteoconductive scaffold as glass

[Sustained release of recombinant human bone morphogenetic protein-2 combined with stromal vascular fraction cells in promoting posterolateral spinal fusion in rat model].

PubMed

Yuan, Wei; Zheng, Jun; Qian, Jinyu; Zhou, Xiaoxiao; Wang, Minghui; Wang, Xiuhui

2017-07-01

To observe the effect of stromal vascular fraction cells (SVFs) from rat fat tissue combined with sustained release of recombinant human bone morphogenetic protein-2 (rhBMP-2) in promoting the lumbar fusion in rat model. SVFs were harvested from subcutaneous fat of bilateral inguinal region of 4-month-old rat through the collagenase I digestion. The sustained release carrier was prepared via covalent bond of the rhBMP-2 and β-tricalcium phosphate (β-TCP) by the biominetic apatite coating process. The sustained release effect was measured by BCA method. Thirty-two rats were selected to establish the posterolateral lumbar fusion model and were divided into 4 groups, 8 rats each group. The decalcified bone matrix (DBX) scaffold+PBS, DBX scaffold+rhBMP-2/β-TCP sustained release carrier, DBX scaffold+SVFs, and DBX scaffold+rhBMP-2/β-TCP sustained release carrier+SVFs were implanted in groups A, B, C, and D respectively. X-ray films, manual spine palpation, and high-resolution micro-CT were used to evaluate spinal fusion at 8 weeks after operation; bone mineral density (BMD) and bone volume fraction were analyzed; the new bone formation was evaluated by HE staining and Masson's trichrome staining, osteocalcin (OCN) was detected by immunohistochemical staining. The cumulative release amount of rhBMP-2 was about 40% at 2 weeks, indicating sustained release effect of rhBMP-2; while the control group was almost released within 2 weeks. At 8 weeks, the combination of manual spine palpation, X-ray, and micro-CT evaluation showed that group D had the strongest bone formation (100%, 8/8), followed by group B (75%, 6/8), group C (37.5%, 3/8), and group A (12.5%, 1/8). Micro-CT analysis showed BMD and bone volume fraction were significantly higher in group D than groups A, B, and C ( P <0.05), and in group B than groups A and C ( P <0.05). HE staining, Masson's trichrome staining, and immunohistochemistry staining for OCN staining exhibited a large number of cartilage cells

The Influence of Pelvic Incidence and Lumbar Lordosis Mismatch on Development of Symptomatic Adjacent Level Disease Following Single-Level Transforaminal Lumbar Interbody Fusion.

PubMed

Tempel, Zachary J; Gandhoke, Gurpreet S; Bolinger, Bryan D; Khattar, Nicolas K; Parry, Philip V; Chang, Yue-Fang; Okonkwo, David O; Kanter, Adam S

2017-06-01

Annual incidence of symptomatic adjacent level disease (ALD) following lumbar fusion surgery ranges from 0.6% to 3.9% per year. Sagittal malalignment may contribute to the development of ALD. To describe the relationship between pelvic incidence-lumbar lordosis (PI-LL) mismatch and the development of symptomatic ALD requiring revision surgery following single-level transforaminal lumbar interbody fusion for degenerative lumbar spondylosis and/or low-grade spondylolisthesis. All patients who underwent a single-level transforaminal lumbar interbody fusion at either L4/5 or L5/S1 between July 2006 and December 2012 were analyzed for pre- and postoperative spinopelvic parameters. Using univariate and logistic regression analysis, we compared the spinopelvic parameters of those patients who required revision surgery against those patients who did not develop symptomatic ALD. We calculated the predictive value of PI-LL mismatch. One hundred fifty-nine patients met the inclusion criteria. The results noted that, for a 1° increase in PI-LL mismatch (preop and postop), the odds of developing ALD requiring surgery increased by 1.3 and 1.4 fold, respectively, which were statistically significant increases. Based on our analysis, a PI-LL mismatch of >11° had a positive predictive value of 75% for the development of symptomatic ALD requiring revision surgery. A high PI-LL mismatch is strongly associated with the development of symptomatic ALD requiring revision lumbar spine surgery. The development of ALD may represent a global disease process as opposed to a focal condition. Spine surgeons may wish to consider assessment of spinopelvic parameters in the evaluation of degenerative lumbar spine pathology. Copyright © 2017 by the Congress of Neurological Surgeons

Effect of Interbody Fusion on the Remaining Discs of the Lumbar Spine in Subjects with Disc Degeneration.

PubMed

Ryu, Robert; Techy, Fernando; Varadarajan, Ravikumar; Amirouche, Farid

2016-02-01

To study effects (stress loads) of lumbar fusion on the remaining segments (adjacent or not) of the lumbar spine in the setting of degenerated adjacent discs. A lumbar spine finite element model was built and validated. The full model of the lumbar spine was a parametric finite element model of segments L 1-5 . Numerous hypothetical combinations of one-level lumbar spine fusion and one-level disc degeneration were created. These models were subjected to 10 Nm flexion and extension moments and the stresses on the endplates and consequently on the intervertebral lumbar discs measured. These values were compared to the stresses on healthy lumbar spine discs under the same load and fusion scenarios. Increased stress at endplates was observed only in the settings of L4-5 fusion and L3-4 disc degeneration (8% stress elevation at L2,3 in flexion or extension, and 25% elevation at L3,4 in flexion only). All other combinations showed less endplate stress than did the control model. For fusion at L3-4 and degeneration at L4-5 , the stresses in the endplates at the adjacent level inferior to the fused disc decreased for both loading disc height reductions. Stresses in flexion decreased after fusion by 29.5% and 25.8% for degeneration I and II, respectively. Results for extension were similar. For fusion at L2-3 and degeneration at L4-5 , stresses in the endplates decreased more markedly at the degenerated (30%), than at the fused level (14%) in the presence of 25% disc height reduction and 10 Nm flexion, whereas in extension stresses decreased more at the fused (24.3%) than the degenerated level (5.86%). For fusion at L3-4 and degeneration at L2-3 , there were no increases in endplate stress in any scenario. For fusion at L4-5 and degeneration at L3-4 , progression of degeneration from I to II had a significant effect only in flexion. A dramatic increase in stress was noted in the endplates of the degenerated disc (L3-4 ) in flexion for degeneration II. Stresses are greater

Variability in Standard Outcomes of Posterior Lumbar Fusion Determined by National Databases.

PubMed

Joseph, Jacob R; Smith, Brandon W; Park, Paul

2017-01-01

National databases are used with increasing frequency in spine surgery literature to evaluate patient outcomes. The differences between individual databases in relationship to outcomes of lumbar fusion are not known. We evaluated the variability in standard outcomes of posterior lumbar fusion between the University HealthSystem Consortium (UHC) database and the Healthcare Cost and Utilization Project National Inpatient Sample (NIS). NIS and UHC databases were queried for all posterior lumbar fusions (International Classification of Diseases, Ninth Revision code 81.07) performed in 2012. Patient demographics, comorbidities (including obesity), length of stay (LOS), in-hospital mortality, and complications such as urinary tract infection, deep venous thrombosis, pulmonary embolism, myocardial infarction, durotomy, and surgical site infection were collected using specific International Classification of Diseases, Ninth Revision codes. Analysis included 21,470 patients from the NIS database and 14,898 patients from the UHC database. Demographic data were not significantly different between databases. Obesity was more prevalent in UHC (P = 0.001). Mean LOS was 3.8 days in NIS and 4.55 in UHC (P < 0.0001). Complications were significantly higher in UHC, including urinary tract infection, deep venous thrombosis, pulmonary embolism, myocardial infarction, surgical site infection, and durotomy. In-hospital mortality was similar between databases. NIS and UHC databases had similar demographic patient populations undergoing posterior lumbar fusion. However, the UHC database reported significantly higher complication rate and longer LOS. This difference may reflect academic institutions treating higher-risk patients; however, a definitive reason for the variability between databases is unknown. The inability to precisely determine the basis of the variability between databases highlights the limitations of using administrative databases for spinal outcome analysis. Copyright

Adjacent segment disease after instrumented fusion for adult lumbar spondylolisthesis: Incidence and risk factors.

PubMed

Zhong, Zhao-Ming; Deviren, Vedat; Tay, Bobby; Burch, Shane; Berven, Sigurd H

2017-05-01

A potential long-term complication of lumbar fusion is the development of adjacent segment disease (ASD), which may necessitate second surgery and adversely affect outcomes. The objective of this is to determine the incidence of ASD following instrumented fusion in adult patients with lumbar spondylolisthesis and to identify the risk factors for this complication. We retrospectively assessed adult patients who had undergone decompression and instrumented fusion for lumbar spondylolisthesis between January 2006 and December 2012. The incidence of ASD was analyzed. Potential risk factors included the patient-related factors, surgery-related factors, and radiographic variables such as sagittal alignment, preexisting disc degeneration and spinal stenosis at the adjacent segment. A total of 154 patients (mean age, 58.4 years) were included. Mean duration of follow-up was 28.6 months. Eighteen patients (11.7%) underwent a reoperation for ASD; 15 patients had reoperation at cranial ASD and 3 at caudal ASD. The simultaneous decompression at adjacent segment (p=0.002) and preexisting spinal stenosis at cranial adjacent segment (p=0.01) were identified as risk factors for ASD. The occurrence of ASD was not affected by patient-related factors, the types, grades and levels of spondylolisthesis, surgical approach, fusion procedures, levels of fusion, number of levels fused, types of bone graft, use of bone morphogenetic proteins, sagittal alignment, preexisting adjacent disc degeneration and preexisting spinal stenosis at caudal adjacent segments. Our findings suggest the overall incidence of ASD is 11.7% in adult patients with lumbar spondylolisthesis after decompression and instrumented fusion at a mean follow-up of 28.6 months, the simultaneous decompression at the adjacent segment and preexisting spinal stenosis at cranial adjacent segment are risk factors for ASD. Copyright © 2017. Published by Elsevier B.V.

Preservation or Restoration of Segmental and Regional Spinal Lordosis Using Minimally Invasive Interbody Fusion Techniques in Degenerative Lumbar Conditions: A Literature Review.

PubMed

Uribe, Juan S; Myhre, Sue Lynn; Youssef, Jim A

2016-04-01

A literature review. The purpose of this study was to review lumbar segmental and regional alignment changes following treatment with a variety of minimally invasive surgery (MIS) interbody fusion procedures for short-segment, degenerative conditions. An increasing number of lumbar fusions are being performed with minimally invasive exposures, despite a perception that minimally invasive lumbar interbody fusion procedures are unable to affect segmental and regional lordosis. Through a MEDLINE and Google Scholar search, a total of 23 articles were identified that reported alignment following minimally invasive lumbar fusion for degenerative (nondeformity) lumbar spinal conditions to examine aggregate changes in postoperative alignment. Of the 23 studies identified, 28 study cohorts were included in the analysis. Procedural cohorts included MIS ALIF (two), extreme lateral interbody fusion (XLIF) (16), and MIS posterior/transforaminal lumbar interbody fusion (P/TLIF) (11). Across 19 study cohorts and 720 patients, weighted average of lumbar lordosis preoperatively for all procedures was 43.5° (range 28.4°-52.5°) and increased 3.4° (9%) (range -2° to 7.4°) postoperatively (P < 0.001). Segmental lordosis increased, on average, by 4° from a weighted average of 8.3° preoperatively (range -0.8° to 15.8°) to 11.2° at postoperative time points (range -0.2° to 22.8°) (P < 0.001) in 1182 patient from 24 study cohorts. Simple linear regression revealed a significant relationship between preoperative lumbar lordosis and change in lumbar lordosis (r = 0.413; P = 0.003), wherein lower preoperative lumbar lordosis predicted a greater increase in postoperative lumbar lordosis. Significant gains in both weighted average lumbar lordosis and segmental lordosis were seen following MIS interbody fusion. None of the segmental lordosis cohorts and only two of the 19 lumbar lordosis cohorts showed decreases in lordosis postoperatively. These results suggest that

[COMPARISON OF EFFECTIVENESS AND CHANGE OF SAGITTAL SPINO-PELVIC PARAMETERS BETWEEN MINIMALLY INVASIVE TRANSFORAMINAL AND CONVENTIONAL OPEN POSTERIOR LUMBAR INTERBODY FUSIONS IN TREATMENT OF LOW-DEGREE ISTHMIC LUMBAR SPONDYLOLISTHESIS].

PubMed

Sun, Xin; Zeng, Rong; Li, Guangsheng; Wei, Bo; Hu, Zibing; Lin, Hao; Chen, Guanghua; Chen, Siyuan; Sun, Jiecong

2015-12-01

To compare the effectiveness and changes of sagittal spino-pelvic parameters between minimally invasive transforaminal lumbar interbody fusion and conventional open posterior lumbar interbody fusion in treatment of the low-degree isthmic lumbar spondylolisthesis. Between May 2012 and May 2013, 86 patients with single segmental isthmic lumbar spondylolisthesis (Meyerding degree I or II) were treated by minimally invasive transforaminal lumbar interbody fusion (minimally invasive group) in 39 cases, and by open posterior lumbar interbody fusion in 47 cases (open group). There was no significant difference in gender, age, disease duration, degree of lumbar spondylolisthesis, preoperative visual analogue scale (VAS) score, and Oswestry disability index (ODI) between 2 groups (P>0.05). The following sagittal spino-pelvic parameters were compared between 2 groups before and after operation: the percentage of slipping (PS), intervertebral height, angle of slip (AS), thoracolumbar junction (TLJ), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), spino-sacral angle (SSA), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Pearson correlation analysis of the changes between pre- and post-operation was done. Primary healing of incision was obtained in all patients of 2 groups. The postoperative hospital stay of minimally invasive group [(5.1 ± 1.6) days] was significantly shorter than that of open group [(7.2 ± 2.1) days] (t = 2.593, P = 0.017). The patients were followed up 11-20 months (mean, 15 months). The reduction rate was 68.53% ± 20.52% in minimally invasive group, and was 64.21% ± 30.21% in open group, showing no significant difference (t = 0.725, P = 0.093). The back and leg pain VAS scores, and ODI at 3 months after operation were significantly reduced when compared with preoperative ones (P < 0.05), but no significant difference was found between 2 groups (P > 0.05). The postoperative other sagittal spino

A Preliminary Report on the CO2 Laser for Lumbar Fusion: Safety, Efficacy and Technical Considerations.

PubMed

Villavicencio, Alan T; Burneikiene, Sigita; Babuska, Jason M; Nelson, Ewell L; Mason, Alexander; Rajpal, Sharad

2015-04-01

The purpose of this study was to evaluate potential technical advantages of the CO2 laser technology in mini-open transforaminal lumbar interbody fusion (TLIF) surgeries and report our preliminary clinical data on the safety and clinical outcomes. There is currently no literature discussing the recently redeveloped CO2 laser technology application for lumbar fusion. Safety and clinical outcomes were compared between two groups: 24 patients that underwent CO2 laser-assisted one-level TLIF surgeries and 30 patients that underwent standard one-level TLIF surgeries without the laser. There were no neural thermal injuries or other intraoperative laser-related complications encountered in this cohort of patients. At a mean follow-up of 17.4 months, significantly reduced lower back pain scores (P=0.013) were reported in the laser-assisted patient group compared to a standard fusion patient group. Lower extremity radicular pain intensity scores were similar in both groups. Laser-assisted TLIF surgeries showed a tendency (P = 0.07) of shorter operative times that was not statistically significant. Based on this preliminary clinical report, the safety of the CO2 laser device for lumbar fusion surgeries was assessed. There were no neural thermal injuries or other intraoperative laser-related complications encountered in this cohort of patients. Further investigation of CO2 laser-assisted lumbar fusion procedures is warranted in order to evaluate its effect on clinical outcomes.

A protocol of a randomized controlled multicenter trial for surgical treatment of lumbar spondylolisthesis: the Lumbar Interbody Fusion Trial (LIFT).

PubMed

de Kunder, Suzanne L; Rijkers, Kim; van Kuijk, Sander M J; Evers, Silvia M A A; de Bie, Rob A; van Santbrink, Henk

2016-10-06

With a steep increase in the number of instrumented spinal fusion procedures, there is a need for comparative data to develop evidence based treatment recommendations. Currently, the available data on cost and clinical effectiveness of the two most frequently performed surgeries for lumbar spondylolisthesis, transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF), are not sufficient. Therefore, current guidelines do not advise which is the most appropriate surgical treatment strategy for these patients. Non-randomized studies comparing TLIF and PLIF moreover suggest that TLIF is associated with fewer complications, less blood loss, shorter surgical time and hospital duration. TLIF may therefore be more cost-effective. The results of this study will provide knowledge on short- and long-term clinical and economical effects of TLIF and PLIF procedures, which will lead to recommendations for treating patients with lumbar spondylolisthesis. Multicenter blinded Randomized Controlled Trial (RCT; blinding for the patient and statistician, not for the clinician and researcher). A total of 144 patients over 18 years old with symptomatic single level lumbar degenerative, isthmic or iatrogenic spondylolisthesis whom are candidates for LIF (lumbar interbody fusion) surgery through a posterior approach will be randomly allocated to TLIF or PLIF. The study will consist of three parts: 1) a clinical effectiveness study, 2) a cost-effectiveness study, and 3) a process evaluation. The primary clinical outcome measures are: change in disability measured with Oswestry Disability Index (ODI) and change in quality adjusted life years (QALY) measured with EQ-5D-5L. Secondary clinical outcome measures are: Short Form (36) Health Survey (SF-36), VAS back pain, VAS leg pain, Hospital Anxiety Depression Scale (HADS), complications, productivity related costs (iPCQ) and medical costs (iMCQ). Measurements will be carried out at five fixed time points (pre

The morphometric study of l3-L4 and L4-L5 lumbar spine in Asian population using magnetic resonance imaging: feasibility analysis for transpsoas lumbar interbody fusion.

PubMed

Yusof, Mohd Imran; Nadarajan, Eswaran; Abdullah, Mohd Shafie

2014-06-15

Cross-sectional study on the measurement of relevant magnetic resonance imaging parameters in 100 patients presented for lumbar spine assessment. To determine anatomical position of lumbar plexus and major blood vessels in relation to vertebral body and anterior edge of psoas muscle at L3-L4 and L4-L5 and to define the safe working zone for transpsoas approach for lumbar fusion. Lateral transpsoas lumbar interbody fusion has been shown to be safe and provides alternative for lumbar fusion. However, proximity of neurovascular structures may not allow a safe passage for this procedure in the Asian population. Relevant parameters were measured from axial magnetic resonance images and analyzed, including the psoas muscle and vertebrae endplate diameters, lumbar plexus and psoas muscle distance, lumbar plexus and vertebra body distance, and vena cava to the anterior vertebrae body diameters. The mean anteroposterior diameters of the right and left psoas muscle ranged from 44.0 to 58.6 mm and 44.8 to 54.0 mm, respectively. The mean anteroposterior diameters of vertebra endplate of L3, L4, and L5 were 38.2 mm, 39.3 mm, and 41.4 mm, respectively. The mean distance of posterior border of vena cava from the vertebra body was 4.5 mm at L3-L4 and 14.1 mm at L4-L5. L3-L4 fusion is feasible at both sides in both sexes; however, at L4-L5 level, the procedure is feasible only on the left side. The safe working zone for transpsoas approach to lumbar spine is significantly narrower at L4-L5 in both sexes. Anterior edge of psoas muscle can be used as a reliable guide to locate lumbar plexus within psoas muscle. N/A.

Segmental and global lordosis changes with two-level axial lumbar interbody fusion and posterior instrumentation

PubMed Central

Melgar, Miguel A; Tobler, William D; Ernst, Robert J; Raley, Thomas J; Anand, Neel; Miller, Larry E; Nasca, Richard J

2014-01-01

Background Loss of lumbar lordosis has been reported after lumbar interbody fusion surgery and may portend poor clinical and radiographic outcome. The objective of this research was to measure changes in segmental and global lumbar lordosis in patients treated with presacral axial L4-S1 interbody fusion and posterior instrumentation and to determine if these changes influenced patient outcomes. Methods We performed a retrospective, multi-center review of prospectively collected data in 58 consecutive patients with disabling lumbar pain and radiculopathy unresponsive to nonsurgical treatment who underwent L4-S1 interbody fusion with the AxiaLIF two-level system (Baxano Surgical, Raleigh NC). Main outcomes included back pain severity, Oswestry Disability Index (ODI), Odom's outcome criteria, and fusion status using flexion and extension radiographs and computed tomography scans. Segmental (L4-S1) and global (L1-S1) lumbar lordosis measurements were made using standing lateral radiographs. All patients were followed for at least 24 months (mean: 29 months, range 24-56 months). Results There was no bowel injury, vascular injury, deep infection, neurologic complication or implant failure. Mean back pain severity improved from 7.8±1.7 at baseline to 3.3±2.6 at 2 years (p < 0.001). Mean ODI scores improved from 60±15% at baseline to 34±27% at 2 years (p < 0.001). At final follow-up, 83% of patients were rated as good or excellent using Odom's criteria. Interbody fusion was observed in 111 (96%) of 116 treated interspaces. Maintenance of lordosis, defined as a change in Cobb angle ≤ 5°, was identified in 84% of patients at L4-S1 and 81% of patients at L1-S1. Patients with loss or gain in segmental or global lordosis experienced similar 2-year outcomes versus those with less than a 5° change. Conclusions/Clinical Relevance Two-level axial interbody fusion supplemented with posterior fixation does not alter segmental or global lordosis in most patients. Patients with

Minimally Invasive Unilateral vs. Bilateral Pedicle Screw Fixation and Lumbar Interbody Fusion in Treatment of Multi-Segment Lumbar Degenerative Disorders.

PubMed

Liu, Xiaoyang; Li, Guangrun; Wang, Jiefeng; Zhang, Heqing

2015-11-25

BACKGROUND The choice for instrumentation with minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in treatment of degenerative lumbar disorders (DLD) remains controversial. The goal of this study was to investigate clinical outcomes in consecutive patients with multi-segment DLD treated with unilateral pedicle screw (UPS) vs. bilateral pedicle screw (BPS) instrumented TLIF. MATERIAL AND METHODS Eighty-four consecutive patients who had multi-level MIS-TLIF were retrospectively reviewed. All data were collected to compare the clinical outcomes between the 2 groups. RESULTS Both groups showed similar clinical function scores in VAS and ODI. The two groups differed significantly in operative time (P<0.001), blood loss (P<0.001), and fusion rate (P=0.043), respectively. CONCLUSIONS This study demonstrated similar clinical outcomes between UPS fixation and BPS procedure after MIS-TLIF for multi-level DLD. Moreover, UPS technique was superior in operative time and blood loss, but represented lower fusion rate than the BPS construct did.

One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series.

PubMed

Zhang, Hong-qi; Lin, Min-zhong; Li, Jin-song; Tang, Ming-xing; Guo, Chao-feng; Wu, Jian-huang; Liu, Jin-yang

2013-03-01

The purpose of this study is to compare the clinical outcomes of surgical management by one-stage posterior debridement, transforaminal lumbar interbody fusion (TLIF) and instrumentation and combined posterior and anterior approaches for lumbar spinal tuberculosis, and determine the clinical effectiveness of the posterior only surgical treatment for lumbar spinal TB at the same time. Thirty-seven patients who suffered lumbar tuberculosis were treated by two different surgical procedures in our center from May 2004 to June 2012. All the cases were divided into two groups: 19 cases in Group A underwent one-stage posterior debridement, TLIF and instrumentation, and 18 cases in Group B underwent posterior instrumentation, anterior debridement and bone graft in a single-stage procedure. The operation time, blood loss, lumbar kyphotic angle, recovery of neurological function and fusion time were, respectively, compared between Group A and Group B. The average follow-up period for Group A was 46.6 ± 16.7 months, and for Group B, 47.5 ± 15.0 months. It was obvious that the average operative duration and blood loss of Group A was less than those of Group B. Lumbar tuberculosis was completely cured and the grafted bones were fused in 10 months in all patients. There was no persistence or recurrence of infection and no differences in the radiological results in both groups. The kyphosis was significantly corrected after surgical management. The average pretreatment ESR was 60.7 ± 22.5 mm/h, which became normal (9.0 ± 2.8 mm/h) within 3 months in all patients. Surgical management by one-stage posterior debridement, TLIF and instrumentation for lumbar tuberculosis is feasible and effective. This approach obtained better clinical outcomes than combined posterior and anterior surgeries.

Biomechanical Characteristics of an Integrated Lumbar Interbody Fusion Device

PubMed Central

Voronov, Leonard I.; Vastardis, Georgios; Zelenakova, Julia; Carandang, Gerard; Havey, Robert M.; Waldorff, Erik I.; Zindrick, Michael R.

2014-01-01

Introduction We hypothesized that an Integrated Lumbar Interbody Fusion Device (PILLAR SA, Orthofix, Lewisville, TX) will function biomechanically similar to a traditional anterior interbody spacer (PILLAR AL, Orthofix, Lewisville, TX) plus posterior instrumentation (FIREBIRD, Orthofix, Lewisville, TX). Purpose of this study was to determine if an Integrated Interbody Fusion Device (PILLAR SA) can stabilize single motion segments as well as an anterior interbody spacer (PILLAR AL) + pedicle screw construct (FIREBIRD). Methods Eight cadaveric lumbar spines (age: 43.9±4.3 years) were used. Each specimen's range of motion was tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) under intact condition, after L4-L5 PILLAR SA with intervertebral screws and after L4-L5 360° fusion (PILLAR AL + Pedicle Screws and rods (FIREBIRD). Each specimen was tested in flexion (8Nm) and extension (6Nm) without preload (0 N) and under 400N of preload, in lateral bending (±6 Nm) and axial rotation (±5 Nm) without preload. Results Integrated fusion using the PILLAR SA device demonstrated statistically significant reductions in range of motion of the L4-L5 motion segment as compared to the intact condition for each test direction. PILLAR SA reduced ROM from 8.9±1.9 to 2.9±1.1° in FE with 400N follower preload (67.4%), 8.0±1.7 to 2.5±1.1° in LB, and 2.2±1.2 to 0.7±0.3° in AR. A comparison between the PILLAR SA integrated fusion device versus 360° fusion construct with spacer and bilateral pedicle screws was statistically significant in FE and LB. The 360° fusion yielded motion of 1.0±0.5° in FE, 1.0±0.8° in LB (p0.05). Conclusions The PILLAR SA resulted in motions of less than 3° in all modes of motion and was not as motion restricting as the traditional 360° using bilateral pedicle screws. The residual segmental motions compare very favorably with published biomechanical studies of other interbody integrated fusion devices. PMID:25694931

RhBMP-2-induced radiculitis in patients undergoing transforaminal lumbar interbody fusion: relationship to dose.

PubMed

Villavicencio, Alan T; Burneikiene, Sigita

2016-10-01

Recombinant human bone morphogenetic protein-2 (rhBMP-2) remains the primary synthetic osteoinductive material used in spinal fusion surgery today. The early inflammation reaction to rhBMP-2 manifesting with radicular symptoms has been previously reported in patients undergoing transforaminal lumbar interbody fusion (TLIF). There is a disagreement with regard to the factors affecting its occurrence and whether such symptoms are dose dependent. The purpose of this analysis was to determine the incidence of rhBMP-2-induced radiculitis and its relationship to dose. A retrospective cohort analysis was performed of the prospectively collected data. All consecutive patients (n=204) who underwent one- or two-level TLIF and instrumented posterolateral fusion with an off-label rhBMP-2 use were included in this analysis. The patients who developed new radicular symptoms after initial improvement postoperatively and had sterile fluid collections indicative of inflammatory process, or in the absence of any structural abnormalities that would explain these symptoms on imaging studies, were deemed to have rhBMP-2-induced radiculitis. Magnetic resonance imaging (MRI) scans were obtained for all patients who developed postoperative radicular symptoms. Correlations between the total rhBMP-2 dose, dose per spinal level, and incidence of radiculitis were evaluated while controlling for age, sex, number of TLIF levels, and surgeon. The incidence of postoperative radiculitis was 11.3% (23 out of 204). The average total rhBMP-2 dose was 4.9 mg (range=2.1-12) and the average dose per spinal level was 3.8 mg (range=1.05-12). Logistic regression analysis did not identify any significant correlations between the rhBMP-2 doses and the incidence of radiculitis (p=.6). The incidence of rhBMP-2-induced radiculitis in patients undergoing TLIF is quite high, but there were no dose-related correlations found. The study, however, cannot rule out a possibility that a larger variation in bone

Metabolic Syndrome and 30-Day Outcomes in Elective Lumbar Spinal Fusion.

PubMed

Chung, Andrew S; Campbell, David; Waldrop, Robert; Crandall, Dennis

2018-05-01

A retrospective cohort study. The aim of this study was to evaluate the effect of metabolic syndrome (MetS) on 30-day morbidity and mortality following elective lumbar spinal fusion. MetS is a variable combination of hypertension, obesity, elevated fasting plasma glucose, and dyslipidemia.MetS has been associated with an increased risk of postoperative morbidity and mortality in multiple surgical settings. To our knowledge, the effect of MetS on 30-day outcomes following elective lumbar spinal fusion has not been well studied. An analysis of ACS-NSQIP data was performed between 2006 and 2013. Patients undergoing elective posterior lumbar fusion were identified. Emergency procedures, infections, tumor cases, and revision surgeries were excluded. Patients were defined as having MetS if they had a history of hypertension requiring medication, diabetes, and a body mass index (BMI) ≥30 kg/m. One thousand five hundred ninety (10.2%) patients with MetS were identified. A mild increase in major (P = 0.040) and minor complications (P = 0.003) in patients with MetS was noted. MetS was associated with increased rates of pulmonary complications (1.9% compared with 1.0%; P = 0.001), sepsis (1.7% compared with 0.9%; P = 0.005), and acute post-op renal failure (0.4% compared with 0%; P < 0.001). Multivariate analysis confirmed MetS to be an independent predictor of pulmonary complications [odds ratio (OR) 1.51; 95% confidence interval (95% CI 1.00-2.27); P = 0.048], sepsis (OR 1.56; 95% CI 1.01-2.42; P = 0.039), and acute postoperative renal failure (OR 6.95; 95% CI 2.23-21.67; P = 0.001). MetS status was associated with a mild increase in total hospital length of stay (4.38 compared with 3.81 days; P < 0.001). While MetS is a predictor of postoperative acute renal failure, it only slightly increases the risk of overall complications and is not associated with increased rates of 30-day reoperations or readmissions following elective lumbar

Delayed lymphocele formation following lateral lumbar interbody fusion of the spine.

PubMed

Hey, Hwee Weng Dennis; Wong, Keng Lin; Gatam, Asrafi Rizki; Lim, Joel Louis; Wong, Hee-Kit

2017-05-01

This paper aims to describe the rare post-operative complication of a lymphocele formation after lateral lumbar interbody fusion. The patient in this case was a 76-year-old lady with a 10 year history of low back pain and neurogenic claudication. She had previously underwent multiple spine surgeries for her condition. She presented to our institution for a recurrence of her low back pain and right anterior thigh pain. She then underwent surgery in two stages; first, a mini-open lateral interbody fusion at L3/4 and L4/5; second, posterior instrumentation of T3 to S1 with sagittal spinal deformity correction. The patient recovered uneventfully in the initial post op period and was discharged within 8 days. However, she developed abdominal distension and discomfort 6 months after surgery. MRI and CT scan of her abdomen showed a retroperitoneal fluid collection compressing her left ureter, resulting in hydroureter and hydronephrosis. She was managed with a CT-guided drainage of the fluid collection. Fluid analysis was consistent with a lymphocele. Since the procedure, the patient has been asymptomatic for 2 years. Delayed lymphocele formation is a potential complication of lateral lumbar interbody fusion. When present, it can be managed conservatively with good results. This case suggests that surgeons should have a low threshold to investigate for a lymphocele development post-anterior or lateral lumbar spine surgery. The authors recommend the placement of a post surgical retroperitoneal drain, as it might assist in the early detection of a lymphocele formation.

Leg pain and psychological variables predict outcome 2-3 years after lumbar fusion surgery.

PubMed

Abbott, Allan D; Tyni-Lenné, Raija; Hedlund, Rune

2011-10-01

Prediction studies testing a thorough range of psychological variables in addition to demographic, work-related and clinical variables are lacking in lumbar fusion surgery research. This prospective cohort study aimed at examining predictions of functional disability, back pain and health-related quality of life (HRQOL) 2-3 years after lumbar fusion by regressing nonlinear relations in a multivariate predictive model of pre-surgical variables. Before and 2-3 years after lumbar fusion surgery, patients completed measures investigating demographics, work-related variables, clinical variables, functional self-efficacy, outcome expectancy, fear of movement/(re)injury, mental health and pain coping. Categorical regression with optimal scaling transformation, elastic net regularization and bootstrapping were used to investigate predictor variables and address predictive model validity. The most parsimonious and stable subset of pre-surgical predictor variables explained 41.6, 36.0 and 25.6% of the variance in functional disability, back pain intensity and HRQOL 2-3 years after lumbar fusion. Pre-surgical control over pain significantly predicted functional disability and HRQOL. Pre-surgical catastrophizing and leg pain intensity significantly predicted functional disability and back pain while the pre-surgical straight leg raise significantly predicted back pain. Post-operative psychomotor therapy also significantly predicted functional disability while pre-surgical outcome expectations significantly predicted HRQOL. For the median dichotomised classification of functional disability, back pain intensity and HRQOL levels 2-3 years post-surgery, the discriminative ability of the prediction models was of good quality. The results demonstrate the importance of pre-surgical psychological factors, leg pain intensity, straight leg raise and post-operative psychomotor therapy in the predictions of functional disability, back pain and HRQOL-related outcomes.

Pelvic incidence-lumbar lordosis mismatch predisposes to adjacent segment disease after lumbar spinal fusion.

PubMed

Rothenfluh, Dominique A; Mueller, Daniel A; Rothenfluh, Esin; Min, Kan

2015-06-01

to predispose to adjacent segment disease. Patients with such pelvic incidence-lumbar lordosis mismatch exhibit a 10-times higher risk for undergoing revision surgery than controls if sagittal malalignment is maintained after lumbar fusion surgery.

Radiographic Analysis of One-level Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF) With Unilateral Pedicle Screw Fixation for Lumbar Degenerative Diseases.

PubMed

Shen, Xiaolong; Wang, Lei; Zhang, Hailong; Gu, Xin; Gu, Guangfei; He, Shisheng

2016-02-01

A prospective randomized study was conducted. The purpose of this study was to assess the radiographic outcomes of one-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) with unilateral pedicle screw instrumentation for degenerative lumbar spine disease. MI-TLIF has become an increasingly popular method of lumbar arthrodesis. Recent technological advances in spinal instrumentation have culminated in the development of MI-TLIF with unilateral pedicle screw fixation. However, there are few published studies on radiographic outcomes of the MI-TLIF with unilateral pedicle screw fixation. A total of 65 patients with one-level degenerative lumbar spine disease were enrolled in this study. Patients were randomized into the unilateral or bilateral fixation group based on a computer-generated number list. Thirty-one patients (17 men and 14 women; average age, 57.3 y) were randomized to the unilateral group (group A) and 34 patients (16 men and 18 women; average age, 58.9 y) to the bilateral group (group B). All patients underwent minimally invasive decompression, interbody fusion, and pedicle screw fixation with the assistance of microscopic tubular retractor system (METRx-MD) and Sextant system. All patients were asked to follow-up at 3, 6, and thereafter once every 6 months after surgery. The visual analog scale (VAS), Oswestry disability index (ODI), and modified Prolo (mProlo) scores were obtained for all patients 24 hours before the operation and at each follow-up visit. The whole lumbar lordosis (WL), the segmental lordosis (SL), fusion level disk space angle, lumbar scoliosis angle, and segmental scoliosis angle were determined before and after surgery on standard x-rays. The disk height index (DI) and the lumber curvature index (LI) were also evaluated. The mean follow-up was 26.6 months, with a range of 18-36 months. All patients showed evidence of fusion at 12 months postoperatively. Statistically, there was no significant difference between

Biomechanics of coupled motion in the cervical spine during simulated whiplash in patients with pre-existing cervical or lumbar spinal fusion

PubMed Central

Huang, H.; Nightingale, R. W.

2018-01-01

Objectives Loss of motion following spine segment fusion results in increased strain in the adjacent motion segments. However, to date, studies on the biomechanics of the cervical spine have not assessed the role of coupled motions in the lumbar spine. Accordingly, we investigated the biomechanics of the cervical spine following cervical fusion and lumbar fusion during simulated whiplash using a whole-human finite element (FE) model to simulate coupled motions of the spine. Methods A previously validated FE model of the human body in the driver-occupant position was used to investigate cervical hyperextension injury. The cervical spine was subjected to simulated whiplash exposure in accordance with Euro NCAP (the European New Car Assessment Programme) testing using the whole human FE model. The coupled motions between the cervical spine and lumbar spine were assessed by evaluating the biomechanical effects of simulated cervical fusion and lumbar fusion. Results Peak anterior longitudinal ligament (ALL) strain ranged from 0.106 to 0.382 in a normal spine, and from 0.116 to 0.399 in a fused cervical spine. Strain increased from cranial to caudal levels. The mean strain increase in the motion segment immediately adjacent to the site of fusion from C2-C3 through C5-C6 was 26.1% and 50.8% following single- and two-level cervical fusion, respectively (p = 0.03, unpaired two-way t-test). Peak cervical strains following various lumbar-fusion procedures were 1.0% less than those seen in a healthy spine (p = 0.61, two-way ANOVA). Conclusion Cervical arthrodesis increases peak ALL strain in the adjacent motion segments. C3-4 experiences greater changes in strain than C6-7. Lumbar fusion did not have a significant effect on cervical spine strain. Cite this article: H. Huang, R. W. Nightingale, A. B. C. Dang. Biomechanics of coupled motion in the cervical spine during simulated whiplash in patients with pre-existing cervical or lumbar spinal fusion: A Finite Element Study. Bone

Bone marrow-derived mesenchymal stem cells assembled with low-dose BMP-2 in a three-dimensional hybrid construct enhances posterolateral spinal fusion in syngeneic rats.

PubMed

Hu, Tao; Abbah, Sunny Akogwu; Toh, Soo Yein; Wang, Ming; Lam, Raymond Wing Moon; Naidu, Mathanapriya; Bhakta, Gajadhar; Cool, Simon M; Bhakoo, Kishore; Li, Jun; Goh, James Cho-Hong; Wong, Hee-Kit

2015-12-01

The combination of potent osteoinductive growth factor, functional osteoblastic cells, and osteoconductive materials to induce bone formation is a well-established concept in bone tissue engineering. However, supraphysiological dose of growth factor, such as recombinant human bone morphogenetic protein 2 (rhBMP-2), which is necessary in contemporary clinical application, have been reported to result in severe side effects. We hypothesize that the synergistic osteoinductive capacity of low-dose bone morphogenetic protein 2 (BMP-2) combined with undifferentiated bone marrow-derived stromal cells (BMSCs) is comparable to that of osteogenically differentiated BMSCs when used in a rodent model of posterolateral spinal fusion. A prospective study using a rodent model of posterolateral spinal fusion was carried out. Thirty-six syngeneic Fischer rats comprised the patient sample. Six groups of implants were evaluated as follows (n=6): (1) 10 µg BMP-2 with undifferentiated BMSCs; (2) 10 µg BMP-2 with osteogenic-differentiated BMSCs; (3) 2.5 µg BMP-2 with undifferentiated BMSCs; (4) 2.5 µg BMP-2 with osteogenic-differentiated BMSCs; (5) 0.5 µg BMP-2 with undifferentiated BMSCs; and (6) 0.5 µg BMP-2 with osteogenic-differentiated BMSCs. Optimal in vitro osteogenic differentiation of BMSCs was determined by quantitative real-time polymerase chain reaction (qRT-PCR) gene analysis whereas in vivo bone formation capacity was evaluated by manual palpation, micro-computed tomography, and histology. Rat BMSCs cultured in fibrin matrix that was loaded into the pores of medical-grade poly epsilon caprolactone tricalcium phosphate scaffolds differentiated toward osteogenic lineage by expressing osterix, runt-related transcription factor 2, and osteocalcium mRNA when supplemented with dexamethasone, ascorbic acid, and β-glycerophosphate. Whereas qRT-PCR revealed optimal increase in osteogenic genes expression after 7 days of in vitro culture, in vivo transplantation study showed

Recombinant human bone morphogenetic protein-2-induced radiculitis in elective minimally invasive transforaminal lumbar interbody fusions: a series review.

PubMed

Mindea, Stefan A; Shih, Patrick; Song, John K

2009-06-15

Retrospective single center analysis. The purpose of our study is to quantify the development of a postoperative radiculitis in our minimally invasive transforaminal lumbar interbody fusion patient population. The application of recombinant human Bone Morphogenetic Protein-2 (BMP) in spinal surgery has allowed for greater success in spinal fusions. This has led to the FDA approving its use in anterior lumbar interbody fusion. However, its well-recognized benefits have generated its "off-label" use in the cervical, thoracic, and lumbar spine. Despite its benefits, the adverse effects of its inflammatory properties are just starting to get recognized. Some clear adverse reactions have been documented in the literature in the cervical spine. However, we feel that these inflammatory properties may be present in the lumbar spine as well. We performed a retrospective chart review of 43 patients who had undergone a minimally invasive transforaminal lumbar interbody fusions. Thirty-five of these patients had BMP and 8 patients did not have BMP. We documented whether there was a preoperative radiculopathy present and whether a radiculopathy was present postoperative. We reviewed radiographic postoperative imaging to establish a structural cause for any radiculopathy. If new or increasing radicular symptoms were present, we attempted to assess the duration of these symptoms. Our analysis, showed that 0 of the 8 patients of the non-BMP group had new radicular symptoms that were not attributed to structural causes. In the BMP group, 4 of the 35 patients (11.4%) had new radicular symptoms without structural etiology. Our analysis suggest that patients undergoing minimally invasive transforaminal lumbar interbody fusions procedures have a higher incidence of developing new radicular symptoms that could be attributed to BMP.

Influence of Alendronate and Endplate Degeneration to Single Level Posterior Lumbar Spinal Interbody Fusion

PubMed Central

Rhee, Wootack; Ha, Seongil; Lim, Jae Hyeon; Jang, Il Tae

2014-01-01

Objective Using alendronate after spinal fusion is a controversial issue due to the inhibition of osteoclast mediated bone resorption. In addition, there are an increasing number of reports that the endplate degeneration influences the lumbar spinal fusion. The object of this retrospective controlled study was to evaluate how the endplate degeneration and the bisphosphonate medication influence the spinal fusion through radiographic evaluation. Methods In this study, 44 patients who underwent single-level posterior lumbar interbody fusion (PLIF) using cage were examined from April 2007 to March 2009. All patients had been diagnosed as osteoporosis and would be recommended for alendronate medication. Endplate degeneration is categorized by the Modic changes. The solid fusion is defined if there was bridging bone between the vertebral bodies, either within or external to the cage on the plain X-ray and if there is less than 5° of angular difference in dynamic X-ray. Results In alendronate group, fusion was achieved in 66.7% compared to 73.9% in control group (no medication). Alendronate did not influence the fusion rate of PLIF. However, there was the statistical difference of fusion rate between the endplate degeneration group and the group without endplate degeneration. A total of 52.4% of fusion rate was seen in the endplate degeneration group compared to 91.3% in the group without endplate degeneration. The endplate degeneration suppresses the fusion process of PLIF. Conclusion Alendronate does not influence the fusion process in osteoporotic patients. The endplate degeneration decreases the fusion rate. PMID:25620981

Anterior lumbar fusion with titanium threaded and mesh interbody cages.

PubMed

Rauzzino, M J; Shaffrey, C I; Nockels, R P; Wiggins, G C; Rock, J; Wagner, J

1999-12-15

The authors report their experience with 42 patients in whom anterior lumbar fusion was performed using titanium cages as a versatile adjunct to treat a wide variety of spinal deformity and pathological conditions. These conditions included congenital, degenerative, iatrogenic, infectious, traumatic, and malignant disorders of the thoracolumbar spine. Fusion rates and complications are compared with data previously reported in the literature. Between July 1996 and July 1999 the senior authors (C.I.S., R.P.N., and M.J.R.) treated 42 patients by means of a transabdominal extraperitoneal (13 cases) or an anterolateral extraperitoneal approach (29 cases), 51 vertebral levels were fused using titanium cages packed with autologous bone. All vertebrectomies (27 cases) were reconstructed using a Miami Moss titanium mesh cage and Kaneda instrumentation. Interbody fusion (15 cases) was performed with either the BAK titanium threaded interbody cage (in 13 patients) or a Miami Moss titanium mesh cage (in two patients). The average follow-up period was 14.3 months. Seventeen patients had sustained a thoracolumbar burst fracture, 12 patients presented with degenerative spinal disorders, six with metastatic tumor, four with spinal deformity (one congenital and three iatrogenic), and three patients presented with spinal infections. In five patients anterior lumbar interbody fusion (ALIF) was supplemented with posterior segmental fixation at the time of the initial procedure. Of the 51 vertebral levels treated, solid arthrodesis was achieved in 49, a 96% fusion rate. One case of pseudarthrosis occurred in the group treated with BAK cages; the diagnosis was made based on the patient's continued mechanical back pain after undergoing L4-5 ALIF. The patient was treated with supplemental posterior fixation, and successful fusion occurred uneventfully with resolution of her back pain. In the group in which vertebrectomy was performed there was one case of fusion failure in a patient with

Is the use of minimally invasive fusion technologies associated with improved outcomes after elective interbody lumbar fusion? Analysis of a nationwide prospective patient-reported outcomes registry.

PubMed

McGirt, Matthew J; Parker, Scott L; Mummaneni, Praveen; Knightly, John; Pfortmiller, Deborah; Foley, Kevin; Asher, Anthony L

2017-07-01

Over the last decade, clinical investigators and biomedical industry groups have used significant resources to develop advanced technologies that enable less invasive spine fusions. These minimally invasive surgery (MIS) technologies often require increased expenditures by hospitals and payers. Although several small single center studies have suggested MIS technologies decrease surgical morbidity and reduce hospital stay, evidence documenting benefit from a patient perspective remains limited. Furthermore, MIS outcomes have yet to be evaluated from the perspective of multiple practice types representing the broad spectrum of US spine surgery. This study aimed to examine a population of patients who underwent one- or two-level interbody lumbar fusion diagnosed with lumbar stenosis or Grade 1 spondylolisthesis in an observational, prospective national registry for the purposes of determining how MIS and traditional open technologies affect postsurgical and patient-reported outcomes (PROs). This study used observational analysis of prospectively collected data. The sample consisted of cases from the National Neurosurgery Quality and Outcomes Database (N 2 QOD). Numeric rating scale for back and leg pain, Oswestry Disability Index, EuroQol-5D, return to work, and perioperative morbidity were the outcome measures. The N 2 QOD is a prospective PROs registry enrolling patients undergoing elective spine surgery from 60 hospitals in 27 US states via representative sampling. We analyzed the N 2 QOD aggregate dataset (2010-2014) to identify one- and two-level lumbar interbody fusion procedures performed for lumbar stenosis or Grade 1 spondylolisthesis with 12 months' follow-up where surgical instrumentation and implant types were clearly identified. Perioperative and 1-year outcomes were compared between cases performed with MIS enabling technologies versus traditional open technologies before and after propensity matching. There were 467 (24%) patients who underwent

[Clinical outcomes of single-level lumbar spondylolisthesis by minimally invasive transforaminal lumbar interbody fusion with bilateral tubular channels].

PubMed

Zeng, Z L; Jia, L; Yu, Y; Xu, W; Hu, X; Zhan, X H; Jia, Y W; Wang, J J; Cheng, L M

2017-04-01

Objective: To evaluate the clinical effectiveness of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for single-level lumbar spondylolisthesis treatment with bilateral Spotlight tubular channels. Methods: A total of 21 patients with lumbar spondylolisthesis whom underwent MIS-TLIF via bilateral Spotlight tubular channels were retrospectively analyzed from October 2014 to November 2015. The 21 patients included 11 males and 10 females ranged from 35 to 82 years (average aged 60.7 years). In term of spondylolisthesis category, there were 18 cases of degenerative spondylolisthesis and 3 cases of isthmic spondylolisthesis. With respect to spondylolisthesis degree, 17 cases were grade Ⅰ° and 4 cases were grade Ⅱ°. Besides, 17 cases at L(4-5) and 4 cases at L(5)-S(1)were categorized by spondylolisthesis levels. Operation duration, blood loss, postoperative drainage and intraoperative exposure time were recorded, functional improvement was defined as an improvement in the Oswestry Disability Index (ODI), Visual Analog Scale (VAS) was also employed at pre and post-operation (3 months and the last follow-up), to evaluate low back and leg pain. Furthermore, to evaluate the recovery of the intervertebral foramen and of lumbar sagittal curvature, average height of intervertebral space, Cobb angles of lumbar vertebrae and operative segments, spondylolisthesis index were measured. At the last follow-up, intervertebral fusion was assessed using Siepe evaluation criteria and the clinical outcome was assessed using the MacNab scale. Radiographic and functional outcomes were compared pre- and post-operation using the paired T test to determine the effectiveness of MIS-TLIF. Statistical significance was defined as P <0.05. Results: All patients underwent a successful MIS-TLIF surgery. The operation time (235.2±30.2) mins, intraoperative blood loss (238.1±130.3) ml, postoperative drainage (95.7±57.1) ml and intraoperative radiation exposure (47.1±8

Surgical Treatment for Discogenic Low-Back Pain: Lumbar Arthroplasty Results in Superior Pain Reduction and Disability Level Improvement Compared With Lumbar Fusion

PubMed Central

2007-01-01

Background The US Food and Drug Administration approved the Charité artificial disc on October 26, 2004. This approval was based on an extensive analysis and review process; 20 years of disc usage worldwide; and the results of a prospective, randomized, controlled clinical trial that compared lumbar artificial disc replacement to fusion. The results of the investigational device exemption (IDE) study led to a conclusion that clinical outcomes following lumbar arthroplasty were at least as good as outcomes from fusion. Methods The author performed a new analysis of the Visual Analog Scale pain scores and the Oswestry Disability Index scores from the Charité artificial disc IDE study and used a nonparametric statistical test, because observed data distributions were not normal. The analysis included all of the enrolled subjects in both the nonrandomized and randomized phases of the study. Results Subjects from both the treatment and control groups improved from the baseline situation (P < .001) at all follow-up times (6 weeks to 24 months). Additionally, these pain and disability levels with artificial disc replacement were superior (P < .05) to the fusion treatment at all follow-up times including 2 years. Conclusions The a priori statistical plan for an IDE study may not adequately address the final distribution of the data. Therefore, statistical analyses more appropriate to the distribution may be necessary to develop meaningful statistical conclusions from the study. A nonparametric statistical analysis of the Charité artificial disc IDE outcomes scores demonstrates superiority for lumbar arthroplasty versus fusion at all follow-up time points to 24 months. PMID:25802574

Workers' Compensation, Return to Work, and Lumbar Fusion for Spondylolisthesis.

PubMed

Anderson, Joshua T; Haas, Arnold R; Percy, Rick; Woods, Stephen T; Ahn, Uri M; Ahn, Nicholas U

2016-01-01

Lumbar fusion for spondylolisthesis is associated with consistent outcomes in the general population. However, workers' compensation is a risk factor for worse outcomes. Few studies have evaluated prognostic factors within this clinically distinct population. The goal of this study was to identify prognostic factors for return to work among patients with workers' compensation claims after fusion for spondylolisthesis. The authors used International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes to identify 686 subjects from the Ohio Bureau of Workers' Compensation who underwent fusion for spondylolisthesis from 1993 to 2013. Positive return to work status was recorded in patients who returned to work within 2 years of fusion and remained working for longer than 6 months. The criteria for return to work were met by 29.9% (n=205) of subjects. The authors used multivariate logistic regression analysis to identify prognostic factors for return to work. Negative preoperative prognostic factors for postoperative return to work included: out of work for longer than 1 year before fusion (P<.001; odds ratio [OR], 0.16); depression (P=.007; OR<0.01); long-term opioid analgesic use (P=.006; OR, 0.41); lumbar stenosis (P=.043; OR, 0.55); and legal representation (P=.042; OR, 0.63). Return to work rates associated with these factors were 9.7%, 0.0%, 10.0%, 29.2%, and 25.0%, respectively. If these subjects were excluded, the return to work rate increased to 60.4%. The 70.1% (n=481) of subjects who did not return to work had markedly worse outcomes, shown by higher medical costs, chronic opioid dependence, and higher rates of failed back syndrome, total disability, and additional surgery. Psychiatric comorbidity increased after fusion but was much higher in those who did not return to work. Future studies are needed to identify how to better facilitate return to work among similar patients with workers' compensation claims. Copyright 2016

Hybrid testing of lumbar CHARITE discs versus fusions.

PubMed

Panjabi, Manohar; Malcolmson, George; Teng, Edward; Tominaga, Yasuhiro; Henderson, Gweneth; Serhan, Hassan

2007-04-20

An in vitro human cadaveric biomechanical study. To quantify effects on operated and other levels, including adjacent levels, due to CHARITE disc implantations versus simulated fusions, using follower load and the new hybrid test method in flexion-extension and bilateral torsion. Spinal fusion has been associated with long-term accelerated degeneration at adjacent levels. As opposed to the fusion, artificial discs are designed to preserve motion and diminish the adjacent-level effects. Five fresh human cadaveric lumbar specimens (T12-S1) underwent multidirectional testing in flexion-extension and bilateral torsion with 400 N follower load. Intact specimen total ranges of motion were determined with +/-10 Nm unconstrained pure moments. The intact range of motion was used as input for the hybrid tests of 5 constructs: 1) CHARITE disc at L5-S1; 2) fusion at L5-S1; 3) CHARITE discs at L4-L5 and L5-S1; 4) CHARITE disc at L4-L5 and fusion at L5-S1; and 5) 2-level fusion at L4-L5-S1. Using repeated-measures single factor analysis of variance and Bonferroni statistical tests (P < 0.05), intervertebral motion redistribution of each construct was compared with the intact. In flexion-extension, 1-level CHARITE disc preserved motion at the operated and other levels, while 2-level CHARITE showed some amount of other-level effects. In contrast, 1- and 2-level fusions increased other-level motions (average, 21.0% and 61.9%, respectively). In torsion, both 1- and 2-level discs preserved motions at all levels. The 2-level simulated fusion increased motions at proximal levels (22.9%), while the 1-level fusion produced no significant changes. In general, CHARITE discs preserved operated- and other-level motions. Fusion simulations affected motion redistribution at other levels, including adjacent levels.

Axial presacral lumbar interbody fusion and percutaneous posterior fixation for stabilization of lumbosacral isthmic spondylolisthesis.

PubMed

Gerszten, Peter C; Tobler, William; Raley, Thomas J; Miller, Larry E; Block, Jon E; Nasca, Richard J

2012-04-01

Case series. To describe a minimally invasive surgical technique for treatment of lumbosacral spondylolisthesis. Traditional surgical management of lumbosacral spondylolisthesis is technically challenging and associated with significant complications. Minimally invasive surgical techniques offer patients treatment alternatives with lower operative morbidity risk. The combination of percutaneous pedicle screw reduction and an axial presacral approach for lumbosacral discectomy and fusion is an option for the surgical management of low-grade lumbosacral spondylolisthesis. Twenty-six consecutive patients with symptomatic L5-S1 level isthmic spondylolisthesis (grade 1 or grade 2) underwent axial presacral lumbar interbody fusion and percutaneous posterior fixation. Study outcomes included visual analogue scale for axial pain severity, Odom criteria, and radiographic fusion. The procedure was successfully completed in all patients with no intraoperative complications reported. Intraoperative blood loss was minimal (range, 20-150 mL). Median hospital stay was 1 day (range, <1-2 d). Spondylolisthesis grade was improved after axial lumbar interbody fusion (P<0.001) with 50% (13 of 26) of patients showing a reduction of at least 1 grade. Axial pain severity improved from 8.1±1.4 at baseline to 2.8±2.3 after axial lumbar interbody fusion, representing a 66% reduction from baseline (95% confidence interval, 54.3%-77.9%). At 2-year posttreatment, all patients showed solid fusion. Using Odom criteria, 81% of patients were judged as excellent or good (16 excellent, 5 good, 3 fair, and 2 poor). There were no perioperative procedure-related complications including infection or bowel perforation. During postoperative follow-up, 4 patients required reintervention due to recurrent radicular (n=2) or screw-related (n=2) pain. The minimally invasive presacral axial interbody fusion and posterior instrumentation technique is a safe and effective treatment for low-grade isthmic

Effects of Local Administration of Boric Acid on Posterolateral Spinal Fusion with Autogenous Bone Grafting in a Rodent Model.

PubMed

Kömürcü, Erkam; Özyalvaçlı, Gülzade; Kaymaz, Burak; Gölge, Umut Hatay; Göksel, Ferdi; Cevizci, Sibel; Adam, Gürhan; Ozden, Raif

2015-09-01

Spinal fusion is among the most frequently applied spinal surgical procedures. The goal of the present study was to evaluate whether the local administration of boric acid (BA) improves spinal fusion in an experimental spinal fusion model in rats. Currently, there is no published data that evaluates the possible positive effects if the local administration of BA on posterolateral spinal fusion. Thirty-two rats were randomly divided into four independent groups: no material was added at the fusion area for group 1; an autogenous morselized corticocancellous bone graft was used for group 2; an autogenous morselized corticocancellous bone graft with boric acid (8.7 mg/kg) for group 3; and only boric acid was placed into the fusion area for group 4. The L4-L6 spinal segments were collected at week 6, and the assessments included radiography, manual palpation, and histomorphometry. A statistically significant difference was determined between the groups with regard to the mean histopathological scores (p = 0.002), and a paired comparison was made with the Mann-Whitney U test to detect the group/groups from which the difference originated. It was determined that only the graft + BA practice increased the histopathological score significantly with regard to the control group (p = 0.002). Whereas, there was no statistically significant difference between the groups in terms of the manual assessment of fusion and radiographic analysis (respectively p = 0.328 and p = 0.196). This preliminary study suggests that BA may clearly be useful as a therapeutic agent in spinal fusion. However, further research is required to show the most effective dosage of BA on spinal fusion, and should indicate whether BA effects spinal fusion in the human body.

Low-energy fracture of posterolateral tibial plateau: treatment by a posterolateral prone approach.

PubMed

Yu, Guang-Rong; Xia, Jiang; Zhou, Jia-Qian; Yang, Yun-Feng

2012-05-01

Most of the posterolateral tibial plateau fractures are caused by low-energy injury. The posterior fracture fragment could not be exposed and reduced well through traditional approaches. The aim of this study was to review the results of surgical treatment of this kind of fracture using posterolateral approach with patient in prone position. The low-energy posterolateral fracture is defined as the main part of articular depression or split fragment limited within the posterior half of the lateral column. Direct reduction and buttress plate fixation through the posterolateral prone approach was applied in all the patients. In our series, 15 of 132 (11.4%) patients with tibial plateau fractures were identified as low-energy posterolateral fractures. The clinical outcomes were available in 14 of the 15 patients through phone interviews and chart reviews. Mean follow-up was 35.1 months (range: 24-48 months). All the patients had anatomic or good reductions (≤ 2 mm step/gap). Average range of motion was 0.7 degrees to 123.2 degrees (5-110 degrees to 0-140 degrees). The complications were limited to one superficial wound infection, two slight flexion contractures, and five implants removal. The average modified hospital for special surgery knee score was 93.4 (range: 86-100). The posterolateral prone approach provides excellent visualization, which can facilitate the reduction and posterior buttress plate fixation for low-energy posterolateral tibial plateau fractures and shows encouraging results. V, therapeutic study.

Effect of Smoking Status on Successful Arthrodesis, Clinical Outcome, and Complications After Anterior Lumbar Interbody Fusion (ALIF).

PubMed

Phan, Kevin; Fadhil, Matthew; Chang, Nicholas; Giang, Gloria; Gragnaniello, Cristian; Mobbs, Ralph J

2018-02-01

Anterior lumbar interbody fusion (ALIF) is a surgical technique indicated for the treatment of several lumbar pathologies. Smoking has been suggested as a possible cause of reduced fusion rates after ALIF, although the literature regarding the impact of smoking status on lumbar spine surgery is not well established. This study aims to assess the impact of perioperative smoking status on the rates of perioperative complications, fusion, and adverse clinical outcomes in patients undergoing ALIF surgery. A retrospective analysis was performed on a prospectively maintained database of 137 patients, all of whom underwent ALIF surgery by the same primary spine surgeon. Smoking status was defined by the presence of active smoking in the 2 weeks before the procedure. Outcome measures included fusion rates, surgical complications, Short-Form 12, and Oswestry Disability Index. Patients were separated into nonsmokers (n = 114) and smokers (n = 23). Univariate analysis demonstrated that the percentage of patients with successful fusion differed significantly between the groups (69.6% vs. 85.1%, P = 0.006). Pseudarthrosis rates were shown to be significantly associated with perioperative smoking. Results for other postoperative complications and clinical outcomes were similar for both groups. On multivariate analysis, the rate of failed fusion was significantly greater for smokers than nonsmokers (odds ratio 37.10, P = 0.002). The rate of successful fusion after ALIF surgery was found to be significantly lower for smokers compared with nonsmokers. No significant association was found between smoking status and other perioperative complications or adverse clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Adult's Degenerative Scoliosis: Midterm Results of Dynamic Stabilization without Fusion in Elderly Patients—Is It Effective?

PubMed Central

Di Silvestre, Mario; Lolli, Francesco; Greggi, Tiziana; Vommaro, Francesco; Baioni, Andrea

2013-01-01

Study Design. A retrospective study. Purpose. Posterolateral fusion with pedicle screw instrumentation used for degenerative lumbar scoliosis can lead to several complications. In elderly patients without sagittal imbalance, dynamic stabilization could represent an option to avoid these adverse events. Methods. 57 patients treated by dynamic stabilization without fusion were included. All patients had degenerative lumbar de novo scoliosis (average Cobb angle 17.2°), without sagittal imbalance, associated in 52 cases (91%) with vertebral canal stenosis and in 24 (42%) with degenerative spondylolisthesis. Nineteen patients (33%) had previously undergone lumbar spinal surgery. Results. At an average followup of 77 months, clinical results improved with statistical significance. Scoliosis Cobb angle was 17.2° (range, 12° to 38°) before surgery and 11.3° (range, 4° to 26°) at last follow-up. In the patients with associated spondylolisthesis, anterior vertebral translation was 19.5% (range, 12% to 27%) before surgery, 16.7% (range, 0% to 25%) after surgery, and 17.5% (range, 0% to 27%) at followup. Complications incidence was low (14%), and few patients required revision surgery (4%). Conclusions. In elderly patients with mild degenerative lumbar scoliosis without sagittal imbalance, pedicle screw-based dynamic stabilization is an effective option, with low complications incidence, granting curve stabilization during time and satisfying clinical results. PMID:23781342

Zoledronic acid infusion for lumbar interbody fusion in osteoporosis.

PubMed

Tu, Chao-Wei; Huang, Kuo-Feng; Hsu, Hsien-Ta; Li, Hung-Yu; Yang, Stephen Shei-Dei; Chen, Yi-Chu

2014-11-01

Clinical outcomes of intravenous (IV) infusion of zoledronic acid (ZOL) for lumbar interbody fusion surgery (LIFS) remain unknown. We investigated the efficacy of IV ZOL on clinical outcome and bone fusion after LIFS. We retrospectively analyzed 64 patients with both degenerative lumbar spondylolisthesis and osteoporosis who underwent LIFS from January 2007 to April 2010. All patients were followed up for 2 y. Thirty-two were treated with an IV infusion of ZOL 3 d after surgery and a second injection 1 y later, and the other 32 patients did not receive ZOL. Preoperatively and every 3 mo postoperatively, oswestry disability index questionnaire and visual analog scale (VAS) scores for back and leg were compared. Preoperative and final postoperative follow-up to evaluate for subsequent compression fractures were also performed. Pedicle screw loosening, cage subsidence, and fusion rate were documented 2 y after surgery. At 2-y follow-up, a solid fusion was achieved in 75% of the ZOL group and only 56% of the control group. At final follow up, the incidence of final subsequent vertebral compression fractures (19% of the ZOL group and 51% of the control group, P = 0.006), pedicle screw loosening (18% of the ZOL group and 45% of the control group, P = 0.03), and cage subsidence >2 mm (28% of the ZOL group and only 54% of the control group, P = 0.04) were significantly lower in the ZOL group than in the control group. The ZOL group demonstrated improvement in VAS (for leg pain VAS, 2/10 for the ZOL group and 5/10 for the control group; for back pain VAS, 2/10 for the ZOL group and 6/10 for the control group) and oswestry disability index scores (7/25 for the ZOL group and 16/25 for the control group). ZOL treatment has beneficial effects on instrumented LIFS both radiographic and clinically. Thus, ZOL treatment can be recommended for osteoporosis patients undergoing LIFS. Copyright © 2014 Elsevier Inc. All rights reserved.

Biomechanics of an Expandable Lumbar Interbody Fusion Cage Deployed Through Transforaminal Approach

PubMed Central

Mica, Michael Conti; Voronov, Leonard I.; Carandang, Gerard; Havey, Robert M.; Wojewnik, Bartosz

2017-01-01

Introduction A novel expandable lumbar interbody fusion cage has been developed which allows for a broad endplate footprint similar to an anterior lumbar interbody fusion (ALIF); however, it is deployed from a minimally invasive transforaminal unilateral approach. The perceived benefit is a stable circumferential fusion from a single approach that maintains the anterior tension band of the anterior longitudinal ligament. The purpose of this biomechanics laboratory study was to evaluate the biomechanical stability of an expandable lumbar interbody cage inserted using a transforaminal approach and deployed in situ compared to a traditional lumbar interbody cage inserted using an anterior approach (control device). Methods Twelve cadaveric spine specimens (L1-L5) were tested intact and after implantation of both the control and experimental devices in two (L2-L3 and L3-L4) segments of each specimen; the assignments of the control and experimental devices to these segments were alternated. Effect of supplemental pedicle screw-rod stabilization was also assessed. Moments were applied to the specimens in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). The effect of physiologic preload on construct stability was evaluated in FE. Segmental motions were measured using an optoelectronic motion measurement system. Results The deployable expendable TLIF cage and control devices significantly reduced FE motion with and without compressive preload when compared to the intact condition (p<0.05). Segmental motions in LB and AR were also significantly reduced with both devices (p<0.05). Under no preload, the deployable expendable TLIF cage construct resulted in significantly smaller FE motion compared to the control cage construct (p<0.01). Under all other testing modes (FE under 400N preload, LB, and AR) the postoperative motions of the two constructs did not differ statistically (p>0.05). Adding bilateral pedicle screws resulted in further reduction of ROM

Retrospective exploration of risk factors for L5 radiculopathy following lumbar floating fusion surgery.

PubMed

Orita, Sumihisa; Yamagata, Masatsune; Ikeda, Yoshikazu; Nakajima, Fumitake; Aoki, Yasuchika; Nakamura, Junichi; Takahashi, Kazuhisa; Suzuki, Takane; Ohtori, Seiji

2015-10-17

Lumbar floating fusion occasionally causes postoperative adjacent segment disorder (ASD) at lumbosacral level, causing L5 spinal nerve disorder by L5-S1 foraminal stenosis. The disorder is considered to be one of the major outcomes of L5-S1 ASD, which has not been evaluated yet. The present study aimed to evaluate the incidence and risk factors of postoperative L5 spinal nerve disorder after lumbar interbody fusion extending to the L5 vertebra. We evaluated 125 patients with a diagnosis of spondylolisthesis who underwent floating fusion surgery with transforaminal lumbar interbody fusion with average postoperative period of 25.2 months. The patients were regarded as symptomatic with postoperative L5 spinal nerve disorder such as radicular pain/numbness in the lower limbs and/or motor dysfunction. We estimated and compared the wedging angle (frontal view) and height (lateral view) of the lumbosacral junction in pre- and postoperative plain X-ray images and the foraminal ratio (ratio of the narrower foraminal diameter to the wider diameter in the craniocaudal direction) in the preoperative magnetic resonance image. Risk factors for the incidence of L5 spinal nerve disorder were explored using multivariate logistic regression. Eight of the 125 patients (6.4%) were categorized as symptomatic, an average of 13.3 months after surgery. The wedging angle was significantly higher, and the foraminal ratio was significantly decreased in the symptomatic group (both P < 0.05) compared to the asymptomatic group. Multivariate logistic regression analysis of possible risk factors revealed that the wedging angle, foraminal ratio, and multileveled fusion were statistically significant. Higher wedging angle and lower foraminal ratio in the lumbosacral junction were significantly predictive for the incidence of L5 nerve root disorder as well as multiple-leveled fusion. These findings indicate that lumbosacral fixation should be considered for patients with these risk factors even

Increased incidence of pseudarthrosis after unilateral instrumented transforaminal lumbar interbody fusion in patients with lumbar spondylosis: Clinical article.

PubMed

Gologorsky, Yakov; Skovrlj, Branko; Steinberger, Jeremy; Moore, Max; Arginteanu, Marc; Moore, Frank; Steinberger, Alfred

2014-10-01

Transforaminal lumbar interbody fusion (TLIF) with segmental pedicular instrumentation is a well established procedure used to treat lumbar spondylosis with or without spondylolisthesis. Available biomechanical and clinical studies that compared unilateral and bilateral constructs have produced conflicting data regarding patient outcomes and hardware complications. A prospective cohort study was undertaken by a group of neurosurgeons. They prospectively enrolled 80 patients into either bilateral or unilateral pedicle screw instrumentation groups (40 patients/group). Demographic data collected for each group included sex, age, body mass index, tobacco use, and Workers' Compensation/litigation status. Operative data included segments operated on, number of levels involved, estimated blood loss, length of hospital stay, and perioperative complications. Long-term outcomes (hardware malfunction, wound dehiscence, and pseudarthrosis) were recorded. For all patients, preoperative baseline and 6-month postoperative scores for Medical Outcomes 36-Item Short Form Health Survey (SF-36) outcomes were recorded. Patient follow-up times ranged from 37 to 63 months (mean 52 months). No patients were lost to follow-up. The patients who underwent unilateral pedicle screw instrumentation (unilateral cohort) were slightly younger than those who underwent bilateral pedicle screw instrumentation (bilateral cohort) (mean age 42 vs. 47 years, respectively; p = 0.02). No other significant differences were detected between cohorts with regard to demographic data, mean number of lumbar levels operated on, or distribution of the levels operated on. Estimated blood loss was higher for patients in the bilateral cohort, but length of stay was similar for patients in both cohorts. The incidence of pseudarthrosis was significantly higher among patients in the unilateral cohort (7 patients [17.5%]) than among those in the bilateral cohort (1 patient [2.5%]) (p = 0.02). Wound dehiscence occurred for

Clinical and radiographic outcomes of bilateral decompression via a unilateral approach with transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis with stenosis.

PubMed

Cheng, Xiaofei; Zhang, Kai; Sun, Xiaojiang; Zhao, Changqing; Li, Hua; Ni, Bin; Zhao, Jie

2017-08-01

Laminectomy with posterior lumbar interbody fusion (PLIF) has been shown to achieve satisfactory clinical outcomes, but it leads to potential adverse consequences associated with extensive disruption of posterior bony and soft tissue structures. This study aimed to compare the clinical and radiographic outcomes of bilateral decompression via a unilateral approach (BDUA) with transforaminal lumbar interbody fusion (TLIF) and laminectomy with PLIF in the treatment of degenerative lumbar spondylolisthesis (DLS) with stenosis. This is a prospective cohort study. This study compared 43 patients undergoing BDUA+TLIF and 40 patients undergoing laminectomy+PLIF. Visual analog scale (VAS) for low back pain and leg pain, Oswestry Disability Index (ODI), and Zurich Claudication Questionnaire (ZCQ) score. The clinical outcomes were assessed, and intraoperative data and complications were collected. Radiographic outcomes included slippage of the vertebra, disc space height, segmental lordosis, and final fusion rate. This study was supported by a grant from The National Natural Science Foundation of China (81572168). There were significant improvements in clinical and radiographic outcomes from before surgery to 3 months and 2 years after surgery within each group. Analysis of leg pain VAS and ZCQ scores showed no significant differences in improvement between groups at either follow-up. The mean improvements in low back pain VAS and ODI scores were significantly greater in the BDUA+TLIF group than in the laminectomy+PLIF group. No significant difference was found in the final fusion rate at 2-year follow-up. The BDUA+TLIF group had significantly less blood loss, shorter length of postoperative hospital stay, and lower complication rate compared with the laminectomy+PLIF group. When compared with the conventional laminectomy+PLIF procedure, the BDUA+TLIF procedure achieves similar and satisfactory effects of decompression and fusion for DLS with stenosis. The BDUA+TLIF procedure

[A feasibility research of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) using hybrid internal fixation for recurrent lumbar disc herniation].

PubMed

Mao, Ke-ya; Wang, Yan; Xiao, Song-hua; Zhang, Yong-gang; Liu, Bao-wei; Wang, Zheng; Zhang, Xi-Feng; Cui, Geng; Zhang, Xue-song; Li, Peng; Mao, Ke-zheng

2013-08-01

To investigate the feasibility of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) using hybrid internal fixation of pedicle screws and a translaminar facet screw for recurrent lumbar disc herniation. From January 2010 to December 2011, 16 recurrent lumbar disc herniation patients, 10 male and 6 female patients with an average age of 45 years (35-68 years) were treated with unilateral incision MIS-TLIF through working channel. After decompression, interbody fusion and fixation using unilateral pedicle screws, a translaminar facet screw was inserted from the same incision through spinous process and laminar to the other side facet joint. The results of perioperative parameters, radiographic images and clinical outcomes were assessed. The repeated measure analysis of variance was applied in the scores of visual analogue scale (VAS) and Oswestry disablity index (ODI). All patients MIS-TLIF were accomplished under working channel including decompression, interbody fusion and hybrid fixation without any neural complication. The average operative time was (148 ± 75) minutes, the average operative blood loss was (186 ± 226) ml, the average postoperative ambulation time was (32 ± 15) hours, and the average hospitalization time was (6 ± 4) days. The average length of incision was (29 ± 4) mm, and the average length of translaminar facets screw was (52 ± 6) mm. The mean follow-up was 16.5 months with a range of 12-24 months. The postoperative X-ray and CT images showed good position of the hybrid internal fixation, and all facets screws penetrate through facets joint. The significant improvement could be found in back pain VAS, leg pain VAS and ODI scores between preoperative 1 day and postoperative follow-up at all time-points (back pain VAS:F = 52.845, P = 0.000;leg pain VAS:F = 113.480, P = 0.000;ODI:F = 36.665, P = 0.000). Recurrent lumbar disc herniation could be treated with MIS-TLIF using hybrid fixation through unilateral incision, and the

Stem cells from human fat as cellular delivery vehicles in an athymic rat posterolateral spine fusion model.

PubMed

Hsu, Wellington K; Wang, Jeffrey C; Liu, Nancy Q; Krenek, Lucie; Zuk, Patricia A; Hedrick, Marc H; Benhaim, Prosper; Lieberman, Jay R

2008-05-01

Mesenchymal stem cells derived from human liposuction aspirates, termed processed lipoaspirate cells, have been utilized as cellular delivery vehicles for the induction of bone formation in tissue engineering and gene therapy strategies. In this study, we sought to evaluate the efficacy of bone morphogenetic protein (BMP)-2-producing adipose-derived stem cells in inducing a posterolateral spine fusion in an athymic rat model. Single-level (L4-L5) intertransverse spinal arthrodesis was attempted with use of a type-I collagen matrix in five groups of athymic rats, with eight animals in each group. Group I was treated with 5 x 10(6) adipose-derived stem cells transduced with an adenoviral vector containing the BMP-2 gene; group II, with 5 x 10(6) adipose-derived stem cells treated with osteogenic media and 1 microg/mL of recombinant BMP-2 (rhBMP-2); group III, with 10 microg of rhBMP-2; group IV, with 1 microg of rhBMP-2; and group V, with 5 x 10(6) adipose-derived stem cells alone. The animals that showed radiographic evidence of healing were killed four weeks after cell implantation and were examined with plain radiographs, manual palpation, microcomputed tomography scanning, and histological analysis. All eight animals in group I demonstrated successful spinal fusion, with a large fusion mass, four weeks postoperatively. Furthermore, group-I specimens consistently revealed spinal fusion at the cephalad level (L3 and L4), where no fusion bed had been prepared surgically. In contrast, despite substantial BMP-2 production measured in vitro, group-II animals demonstrated minimal bone formation even eight weeks after implantation. Of the groups treated with the application of rhBMP-2 alone, the one that received a relatively high dose (group III) had a higher rate of fusion (seen in all eight specimens) than the one that received the low dose (group IV, in which fusion was seen in four of the eight specimens). None of the group-V animals (treated with adipose

Biomechanics of coupled motion in the cervical spine during simulated whiplash in patients with pre-existing cervical or lumbar spinal fusion: A Finite Element Study.

PubMed

Huang, H; Nightingale, R W; Dang, A B C

2018-01-01

Loss of motion following spine segment fusion results in increased strain in the adjacent motion segments. However, to date, studies on the biomechanics of the cervical spine have not assessed the role of coupled motions in the lumbar spine. Accordingly, we investigated the biomechanics of the cervical spine following cervical fusion and lumbar fusion during simulated whiplash using a whole-human finite element (FE) model to simulate coupled motions of the spine. A previously validated FE model of the human body in the driver-occupant position was used to investigate cervical hyperextension injury. The cervical spine was subjected to simulated whiplash exposure in accordance with Euro NCAP (the European New Car Assessment Programme) testing using the whole human FE model. The coupled motions between the cervical spine and lumbar spine were assessed by evaluating the biomechanical effects of simulated cervical fusion and lumbar fusion. Peak anterior longitudinal ligament (ALL) strain ranged from 0.106 to 0.382 in a normal spine, and from 0.116 to 0.399 in a fused cervical spine. Strain increased from cranial to caudal levels. The mean strain increase in the motion segment immediately adjacent to the site of fusion from C2-C3 through C5-C6 was 26.1% and 50.8% following single- and two-level cervical fusion, respectively (p = 0.03, unpaired two-way t -test). Peak cervical strains following various lumbar-fusion procedures were 1.0% less than those seen in a healthy spine (p = 0.61, two-way ANOVA). Cervical arthrodesis increases peak ALL strain in the adjacent motion segments. C3-4 experiences greater changes in strain than C6-7. Lumbar fusion did not have a significant effect on cervical spine strain. Cite this article : H. Huang, R. W. Nightingale, A. B. C. Dang. Biomechanics of coupled motion in the cervical spine during simulated whiplash in patients with pre-existing cervical or lumbar spinal fusion: A Finite Element Study. Bone Joint Res 2018;7:28-35. DOI: 10

Older Age and Leg Pain Are Good Predictors of Pain and Disability Outcomes in 2710 Patients Who Receive Lumbar Fusion.

PubMed

Cook, Chad E; Frempong-Boadu, Anthony K; Radcliff, Kristen; Karikari, Isaac; Isaacs, Robert

2015-10-01

Identifying appropriate candidates for lumbar spine fusion is a challenging and controversial topic. The purpose of this study was to identify baseline characteristics related to poor/favorable outcomes at 1 year for a patient who received lumbar spine fusion. The aims of this study were to describe baseline characteristics of those who received lumbar surgery and to identify baseline characteristics from a spine repository that were related to poor and favorable pain and disability outcomes for patient who received lumbar fusion (with or without decompression), who were followed up for 1 full year and discriminate predictor variables that were either or in contrast to prognostic variables reported in the literature. This study analyzed data from 2710 patients who underwent lumbar spine fusion. All patient data was part of a multicenter, multi-national spine repository. Ten relatively commonly captured data variables were used as predictors for the study. Univariate/multivariate logistic regression analyses were run against outcome variables of pain/disability. Multiple univariate findings were associated with pain/disability outcomes at 1 year including age, previous surgical history, baseline disability, baseline pain, baseline quality of life scores, and leg pain greater than back pain. Notably significant multivariate findings for both pain and disability include older age, previous surgical history, and baseline mental summary scores, disability, and pain. Leg pain greater than back pain and older age may yield promising value when predicting positive outcomes. Other significant findings may yield less value since these findings are similar to those that are considered to be prognostic regardless of intervention type.

The 'Lumbar Fusion Outcome Score' (LUFOS): a new practical and surgically oriented grading system for preoperative prediction of surgical outcomes after lumbar spinal fusion in patients with degenerative disc disease and refractory chronic axial low back pain.

PubMed

Mattei, Tobias A; Rehman, Azeem A; Teles, Alisson R; Aldag, Jean C; Dinh, Dzung H; McCall, Todd D

2017-01-01

In order to evaluate the predictive effect of non-invasive preoperative imaging methods on surgical outcomes of lumbar fusion for patients with degenerative disc disease (DDD) and refractory chronic axial low back pain (LBP), the authors conducted a retrospective review of 45 patients with DDD and refractory LBP submitted to anterior lumbar interbody fusion (ALIF) at a single center from 2007 to 2010. Surgical outcomes - as measured by Visual Analog Scale (VAS/back pain) and Oswestry Disability Index (ODI) - were evaluated pre-operatively and at 6 weeks, 3 months, 6 months, and 1 year post-operatively. Linear mixed-effects models were generated in order to identify possible preoperative imaging characteristics (including bone scan/99mTc scintigraphy increased endplate uptake, Modic endplate changes, and disc degeneration graded according to Pfirrmann classification) which may be predictive of long-term surgical outcomes . After controlling for confounders, a combined score, the Lumbar Fusion Outcome Score (LUFOS), was developed. The LUFOS grading system was able to stratify patients in two general groups (Non-surgical: LUFOS 0 and 1; Surgical: LUFOS 2 and 3) that presented significantly different surgical outcomes in terms of estimated marginal means of VAS/back pain (p = 0.001) and ODI (p = 0.006) beginning at 3 months and continuing up to 1 year of follow-up. In conclusion,  LUFOS has been devised as a new practical and surgically oriented grading system based on simple key parameters from non-invasive preoperative imaging exams (magnetic resonance imaging/MRI and bone scan/99mTc scintigraphy) which has been shown to be highly predictive of surgical outcomes of patients undergoing lumbar fusion for treatment for refractory chronic axial LBP.

Considerations in Spinal Fusion Surgery for Chronic Lumbar Pain: Psychosocial Factors, Rating Scales, and Perioperative Patient Education-A Review of the Literature.

PubMed

Gaudin, Daniel; Krafcik, Brianna M; Mansour, Tarek R; Alnemari, Ahmed

2017-02-01

Despite widespread use of lumbar spinal fusion as a treatment for back pain, outcomes remain variable. Optimizing patient selection can help to reduce adverse outcomes. This literature review was conducted to better understand factors associated with optimal postoperative results after lumbar spinal fusion for chronic back pain and current tools used for evaluation. The PubMed database was searched for clinical trials related to psychosocial determinants of outcome after lumbar spinal fusion surgery; evaluation of commonly used patient subjective outcome measures; and perioperative cognitive, behavioral, and educational therapies. Reference lists of included studies were also searched by hand for additional studies meeting inclusion and exclusion criteria. Patients' perception of good health before surgery and low cardiovascular comorbidity predict improved postoperative physical functional capacity and greater patient satisfaction. Depression, tobacco use, and litigation predict poorer outcomes after lumbar fusion. Incorporation of cognitive-behavioral therapy perioperatively can address these psychosocial risk factors and improve outcomes. The 36-Item Short Form Health Survey, European Quality of Life five dimensions questionnaire, visual analog pain scale, brief pain inventory, and Oswestry Disability Index can provide specific feedback to track patient progress and are important to understand when evaluating the current literature. This review summarizes current information and explains commonly used assessment tools to guide clinicians in decision making when caring for patients with lower back pain. When determining a treatment algorithm, physicians must consider predictive psychosocial factors. Use of perioperative cognitive-behavioral therapy and patient education can improve outcomes after lumbar spinal fusion. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparative Study of the Difference of Perioperative Complication and Radiologic Results: MIS-DLIF (Minimally Invasive Direct Lateral Lumbar Interbody Fusion) Versus MIS-OLIF (Minimally Invasive Oblique Lateral Lumbar Interbody Fusion).

PubMed

Jin, Jie; Ryu, Kyeong-Sik; Hur, Jung-Woo; Seong, Ji-Hoon; Kim, Jin-Sung; Cho, Hyun-Jin

2018-02-01

Retrospective observatory analysis. The purpose of this study was to compare the incidence of perioperative complication, difference of cage location, and sagittal alignment between minimally invasive oblique lateral lumbar interbody fusion (MIS-OLIF) and MIS-direct lateral lumbar interbody fusion (DLIF) in the cases of single-level surgery at L4-L5. MIS-DLIF using tubular retractor has been used for the treatment of lumbar degenerative diseases; however, blunt transpsoas dissection poses a risk of injury to the lumbar plexus. As an alternative, MIS-OLIF uses a window between the prevertebral venous structures and psoas muscle. A total of 43 consecutive patients who underwent MIS-DLIF or MIS-OLIF for various L4/L5 level pathologies between November 2011 and April 2014 by a single surgeon were retrospectively reviewed. A complication classification based on the relation to surgical procedure and effect duration was used. Perioperative complications until 3-month postoperatively were reviewed for the patients. Radiologic results including the cage location and sagittal alignment were also assessed with plain radiography. There were no significant statistical differences in perioperative parameters and early clinical outcome between 2 groups. Overall, there were 13 (59.1%) approach-related complications in the DLIF group and 3 (14.3%) in the OLIF group. In the DLIF group, 3 (45.6%) were classified as persistent, however, there was no persistent complication in the OLIF group. In the OLIF group, cage is located mostly in the middle 1/3 of vertebral body, significantly increasing posterior disk space height and foraminal height compared with the DLIF group. Global and segmental lumbar lordosis was greater in the DLIF group due to anterior cage position without statistical significance. In our report of L4/L5 level diseases, the OLIF technique may decrease approach-related perioperative morbidities by eliminating the risk of unwanted muscle and nerve manipulations. Using

The mechanism in junctional failure of thoraco-lumbar fusions. Part II: Analysis of a series of PJK after thoraco-lumbar fusion to determine parameters allowing to predict the risk of junctional breakdown.

PubMed

Faundez, Antonio A; Richards, Jonathon; Maxy, Philippe; Price, Rachel; Léglise, Amélie; Le Huec, Jean-Charles

2018-02-01

To identify risk factors, in 12 patients with junctional breakdown (JBD) after thoraco-sacral fusions and to test a software locating maximal bending moment on full spine EOS images. Twelve patients underwent long fusions for lumbar degenerative pathologies. Preop EOS images were compared to first postop EOS showing JBD. Parameters analyzed were: spinopelvic parameters [pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), spinosacral angle (SSA), lordosis, and kyphosis], proximal junctional angle (PJA), odontoid-hip axis angle (ODHA), and CIA. A new software estimated the location of maximum bending moment (M max ) before and after JBD. All patients except one had a JBD located between T10 and L1, diagnosed at average follow-up of 18.58 months. JBD was a fracture in six patients, severe adjacent disc degeneration in the remaining. Average PI was 52°. PT increased, SS decreased after JBD versus preop (p > 0.05). Average PJA was 34.5°. Global lordosis (GLL), upper lordosis (ULL), L4-S1 lordosis, and thoracic kyphosis (TK) were increased (p < 0.05). Lower lumbar lordosis (LLL), was not increased postJBD (p = 0.6). SVA, SSA, ODHA, and C7 slope were not modified (p > 0.05). CIA average value decreased by 7.5% after JBD. T1-T5 alignment was correlated to C7 slope before (R 2  = 0.77075) and after JBD (R 2  = 0.85409). ODHA decreased after JBD (p > 0.05). Most JBD occurred at or one level away from preoperative M max location. This study confirms the importance of harmonious distribution of lumbar (GLL, ULL, and ILL) and thoracic curves (TK, T1-T5 segment) in thoraco-sacral fusions. All patients showed an exaggerated ULL, resulting in a posterior shift and increased lever arm at the thoraco-lumbar junction, leading to JBD.

Responsiveness and minimal clinically important changes for the Tampa Scale of Kinesiophobia after lumbar fusion during cognitive behavioral rehabilitation.

PubMed

Monticone, Marco; Ambrosini, Emilia; Rocca, Barbara; Foti, Calogero; Ferrante, Simona

2017-06-01

The Tampa Scale of Kinesiophobia (TSK) is a commonly-used measure for the assessment of fear of movement beliefs in chronic complaints, but its responsiveness in subjects after lumbar fusion has been never reported. Evaluating the responsiveness and minimal clinically important differences (MCIDs) for the TSK and its subscales after lumbar fusion. Population-based cohort study. Secondary care rehabilitation hospital. In-patients undergoing rehabilitation after lumbar fusion. At the beginning and end of a four-week motor and cognitive-behavioral rehabilitation program, 180 patients completed the TSK. After the intervention, the global perceived effect (GPE) was analyzed to produce a dichotomous outcome (improved vs. stable). Responsiveness for the TSK and its subscales were calculated by distribution (effect size [ES], standardized response mean [SRM]) and anchor-based methods (receiver operating characteristics (ROC) curves; correlations between change scores of the TSK and its subscales and GPE). ROC curves were also used to compute MCID values. The ES ranged from 1.63 to 1.77 and the SRM from 1.25 to 1.39 for TSK and its subscales. The ROC analyses revealed a value of area under the curve (0.999 [95% CI: 0.978; 1.000], 0.998 [95% CI: 0.975; 1.000], 0.990 [95% CI: 0.962; 0.999] for the TSK, Harm and Activity Avoidance subscales, respectively). MCID values greater than 6 (95% CI: >5; >6), 4 (95% CI: >3; >5), and 2 (95% CI: >2; >2) were achieved for the TSK, Harm and Activity Avoidance subscales, respectively. Correlations between change scores of the TSK and its subscales and GPE were high (0.786-0.830). The TSK and its subscales were sensitive in detecting clinical changes in subjects undergoing rehabilitation after lumbar fusion. The obtained MCID values will help in the design of future randomized controlled trials and in the interpretation of the clinical impact of a rehabilitation program after lumbar fusion.

Hospital competitive intensity and perioperative outcomes following lumbar spinal fusion.

PubMed

Durand, Wesley M; Johnson, Joseph R; Li, Neill Y; Yang, JaeWon; Eltorai, Adam E M; DePasse, J Mason; Daniels, Alan H

2018-04-01

Interhospital competition has been shown to influence the adoption of surgical techniques and approaches, clinical patient outcomes, and health care resource use for select surgical procedures. However, little is known regarding these dynamics as they relate to spine surgery. This investigation sought to examine the relationship between interhospital competitive intensity and perioperative outcomes following lumbar spinal fusion. This study used the Nationwide Inpatient Sample dataset, years 2003, 2006, and 2009. Patients were included based on the presence of the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM) codes corresponding to lumbar spinal fusion, as well as on the presence of data on the Herfindahl-Hirschman Index (HHI). The outcome measures are perioperative complications, defined using an ICD-9-CM coding algorithm. The HHI, a validated measure of competition within a market, was used to assess hospital market competitiveness. The HHI was calculated based on the hospital cachement area. Multiple regression was performed to adjust for confounding variables including patient age, gender, primary payer, severity of illness score, primary versus revision fusion, anterior versus posterior approach, national region, hospital bed size, location or teaching status, ownership, and year. Perioperative clinical outcomes were assessed based on ICD-9-CM codes with modifications. In total, 417,520 weighted patients (87,999 unweighted records) were analyzed. The mean cachement area HHI was 0.31 (range 0.099-0.724). The average patient age was 55.4 years (standard error=0.194), and the majority of patients were female (55.8%, n=232,727). The majority of procedures were primary spinal fusions (92.7%, n=386,998) and fusions with a posterior-only technique (81.5%, n=340,271). Most procedures occurred in the South (42.5%, n=177,509) or the Midwest (27.0%, n=112,758) regions. In the multiple regression analysis, increased hospital

The biomechanics of a multilevel lumbar spine hybrid using nucleus replacement in conjunction with fusion.

PubMed

Dahl, Michael C; Ellingson, Arin M; Mehta, Hitesh P; Huelman, Justin H; Nuckley, David J

2013-02-01

Degenerative disc disease is commonly a multilevel pathology with varying deterioration severity. The use of fusion on multiple levels can significantly affect functionality and has been linked to persistent adjacent disc degeneration. A hybrid approach of fusion and nucleus replacement (NR) has been suggested as a solution for mildly degenerated yet painful levels adjacent to fusion. To compare the biomechanical metrics of different hybrid implant constructs, hypothesizing that an NR+fusion hybrid would be similar to a single-level fusion and perform more naturally compared with a two-level fusion. A cadaveric in vitro repeated-measures study was performed to evaluate a multilevel lumbar NR+fusion hybrid. Eight cadaveric spines (L3-S1) were tested in a Spine Kinetic Simulator (Instron, Norwood, MA, USA). Pure moments of 8 Nm were applied in flexion/extension, lateral bending, and axial rotation as well as compression loading. Specimens were tested intact; fused (using transforaminal lumbar interbody fusion instrumentation with posterior rods) at L5-S1; with a nuclectomy at L4-L5 including fusion at L5-S1; with NR at L4-L5 including fusion at L5-S1; and finally with a two-level fusion spanning L4-S1. Repeated-measures analysis of variance and corrected t tests were used to statistically compare outcomes. The NR+fusion hybrid and single-level fusion exhibited no statistical differences for range of motion (ROM), stiffness, neutral zone, and intradiscal pressure in all loading directions. Compared with two-level fusion, the hybrid affords the construct 41.9% more ROM on average. Two-level fusion stiffness was statistically higher than all other constructs and resulted in significantly lower ROM in flexion, extension, and lateral bending. The hybrid construct produced approximately half of the L3-L4 adjacent-level pressures as the two-level fusion case while generating similar pressures to the single-level fusion case. These data portend more natural functional

Do Lordotic Cages Provide Better Segmental Lordosis Versus Nonlordotic Cages in Lateral Lumbar Interbody Fusion (LLIF)?

PubMed

Sembrano, Jonathan N; Horazdovsky, Ryan D; Sharma, Amit K; Yson, Sharon C; Santos, Edward R G; Polly, David W

2017-05-01

A retrospective comparative radiographic review. To evaluate the radiographic changes brought about by lordotic and nonlordotic cages on segmental and regional lumbar sagittal alignment and disk height in lateral lumbar interbody fusion (LLIF). The effects of cage design on operative level segmental lordosis in posterior interbody fusion procedures have been reported. However, there are no studies comparing the effect of sagittal implant geometry in LLIF. This is a comparative radiographic analysis of consecutive LLIF procedures performed with use of lordotic and nonlordotic interbody cages. Forty patients (61 levels) underwent LLIF. Average age was 57 years (range, 30-83 y). Ten-degree lordotic PEEK cages were used at 31 lumbar interbody levels, and nonlordotic cages were used at 30 levels. The following parameters were measured on preoperative and postoperative radiographs: segmental lordosis; anterior and posterior disk heights at operative level; segmental lordosis at supra-level and subjacent level; and overall lumbar (L1-S1) lordosis. Measurement changes for each cage group were compared using paired t test analysis. The use of lordotic cages in LLIF resulted in a significant increase in lordosis at operative levels (2.8 degrees; P=0.01), whereas nonlordotic cages did not (0.6 degrees; P=0.71) when compared with preoperative segmental lordosis. Anterior and posterior disk heights were significantly increased in both groups (P<0.01). Neither cage group showed significant change in overall lumbar lordosis (lordotic P=0.86 vs. nonlordotic P=0.25). Lordotic cages provided significant increase in operative level segmental lordosis compared with nonlordotic cages although overall lumbar lordosis remained unchanged. Anterior and posterior disk heights were significantly increased by both cages, providing basis for indirect spinal decompression.

Influence of 45S5 Bioactive Glass in A Standard Calcium Phosphate Collagen Bone Graft Substitute on the Posterolateral Fusion of Rabbit Spine.

PubMed

Pugely, Andrew J; Petersen, Emily B; DeVries-Watson, Nicole; Fredericks, Douglas C

2017-01-01

Spinal fusion surgery is an effective but costly treatment for select spinal pathology. Historically iliac crest bone graft (ICBG) has remained the gold standard for achieving successful arthrodesis. Given well-established morbidity autograft harvest, multiple bone graft replacements, void fillers, and extenders have been developed. The objective of this study was to evaluate the in vivo efficacy and safety of two mineralized collagen bone void filler materials similar in composition. Both bone void fillers were composed of hydroxyapatite (HA), tricalcium phosphate (TCP) and bovine collagen. The first test article (Bi-Ostetic bioactive glass foam or "45S5") also contained 45S5 bioactive glass particles while the second test article (Formagraft or "FG") did not. 45S5 and FG were combined with bone marrow aspirate and iliac crest autograft and compared to ICBG in an established posterolateral spine fusion rabbit model. Sixty-nine mature New Zealand White rabbits were divided into 3 test cohorts: ICBG, 45S5, and FG. A Posterolateral fusion model previous validated was utilized to assess fusion efficacy. The test groups were evaluated for spine fusion rate, new bone formation, graft resorption and inflammatory response using radiographic, μCT, biomechanical and histological endpoints at 4, 8 and 12 weeks following implantation. There were 4 clinical complications unrelated to the graft materials and were evenly split between groups (ICBG graft harvest complications; hind limb mobility, chronic pain) and were euthanized. These omissions did not affect the overall outcome of the study. Radiographic scoring of the fusion sites indicated a normal healing response in all test groups, with no adverse reactions and similar progressions of new bone formation observed over time. All groups demonstrated significantly less range of motion in both flexion/extension and lateral bending compared to normal not-fused controls, which supports fusion results observed in the other

Bone morphogenetic protein 7 and autologous bone graft in revision surgery for non-union after lumbar interbody fusion.

PubMed

Werle, Stephan; AbuNahleh, Kais; Boehm, Heinrich

2016-08-01

Potential adverse and unknown long-term effects as well as additional costs limit the use of BMPs (Bone morphogenetic proteins) in primary fusion procedures. However, the proven osteoinductive properties render BMPs attractive for the attempt to reach fusion of symptomatic non-unions. The aim of this study is to evaluate the fusion rate and potential disadvantages of eptotermin alfa (rhBMP-7) used with autologous bone graft in revision procedures for lumbar pseudoarthrosis. At our institution, rhBMP-7 has been used to improve fusion rates in revision surgery for symptomatic pseudoarthrosis during the past 10 years. Eighty-four fusion procedures using rhBMP-7 between 08/2003 and 07/2011 were revisions due to symptomatic lumbar pseudoarthrosis. The surgical approach was posterior in three and combined anterior-posterior in 71 patients. Of those, 74 patients had either reached fusion or had follow-up of at least 39.5 months (range 21-80 months) in the case of pseudoarthrosis. These 74 patients have been included in a retrospective follow-up study. In 60 patients (81.1 %) the rhBMP-7 procedure was successful. In 14 patients, pseudoarthrosis persisted or fusion was questionable. Of those patients 12 accounted for persisting L5-S1 non-union. Persisting non-unions were found in 26.7 % of the study after four or more segment instrumentations compared to the 16.9 % after mono-, bi-, or three-segment instrumentation, and in four of 14 patients with spondylodesis of three or more levels above a pseudoarthrotic lumbosacral junction. Adverse effects related to the use of eptotermin alfa were rare in this group with symptomatic ectopic bone formation in one patient. Using rhBMP-7 with autologous bone graft in revisions for lumbar pseudoarthrosis via an anterior approach is safe and can lead to fusion even under unfavorable biomechanical conditions. However, successful outcome depends on the individual constellation. Treatment of non-unions of the lumbosacral junction

Posterolateral Rotatory Apprehension Test in Tennis Elbow.

PubMed

Chanlalit, Cholawish; Phorkhar, Termphong

2015-11-01

Tennis elbow is a syndrome that commonly diagnosed in patient who comes with lateral elbow pain. Instability pain in tennis elbow patient was observed and reported in many previous literatures. Posterolateral rotatory apprehension test was proposed for diagnosis of posterolateral rotatory instability of elbow. However, no review literatures that studied about posterolateral rotatory apprehensions test in tennis elbow. To find out the relationship between posterolateral rotatory apprehension test and tennis elbow. There were 44 patients that were recruited in this study. We examined the posterolateral rotatory apprehension test in tennis elbow patients. The examination was done in our outpatient clinic from March 2012 to April 2012. The data was collected to find out the ratio of negative test in tennis elbow patient. The results from the posterolateral rotatory apprehension test were negative in 43 patients. The ratio of the negative test result was 98%. A result from posterolateral rotatory apprehension test should be negative in general tennis elbow patients. If this test is used in a tennis elbow patients who are suspected with hidden instability and the result is positive, further evaluation is strongly suggested.

Evaluation of a Hybrid Dynamic Stabilization and Fusion System in the Lumbar Spine: A 10 Year Experience.

PubMed

Kashkoush, Ahmed; Agarwal, Nitin; Paschel, Erin; Goldschmidt, Ezequiel; Gerszten, Peter C

2016-06-10

The development of adjacent-segment disease is a recognized consequence of lumbar fusion surgery. Posterior dynamic stabilization, or motion preservation, techniques have been developed which theoretically decrease stress on adjacent segments following fusion. This study presents the experience of using a hybrid dynamic stabilization and fusion construct for degenerative lumbar spine pathology in place of rigid arthrodesis. A clinical cohort investigation was conducted of 66 consecutive patients (31 female, 35 male; mean age: 53 years, range: 25 - 76 years) who underwent posterior lumbar instrumentation with the Dynesys Transition Optima (DTO) implant (Zimmer-Biomet Spine, Warsaw, IN) hybrid dynamic stabilization and fusion system over a 10-year period. The median length of follow-up was five years. DTO consists of pedicle screw fixation coupled to a rigid rod as well as a flexible longitudinal connecting system. All patients had symptoms of back pain and neurogenic claudication refractory to non-surgical treatment. Patients underwent lumbar arthrodesis surgery in which the hybrid system was used for stabilization instead of arthrodesis of the stenotic adjacent level. Indications for DTO instrumentation were primary degenerative disc disease (n = 52) and failed back surgery syndrome (n = 14). The most common dynamically stabilized and fused segments were L3-L4 (n = 37) and L5-S1 (n = 33), respectively. Thirty-eight patients (56%) underwent decompression at the dynamically stabilized level, and 57 patients (86%) had an interbody device placed at the level of arthrodesis. Complications during the follow-up period included a single case of screw breakage and a single case of pseudoarthrosis. Ten patients (15%) subsequently underwent conversion of the dynamic stabilization portion of their DTO instrumentation to rigid spinal arthrodesis. The DTO system represents a novel hybrid dynamic stabilization and fusion construct. This 10-year experience found the device to be

Surgical outcomes of degenerative spondylolisthesis with L5-S1 disc degeneration: comparison between lumbar floating fusion and lumbosacral fusion at a minimum 5-year follow-up.

PubMed

Liao, Jen-Chung; Chen, Wen-Jer; Chen, Lih-Hui; Niu, Chi-Chien; Keorochana, Gun

2011-09-01

A retrospective clinical and radiographic study was performed. The purpose of this study was to compare outcomes of patients with degenerative spondylolisthesis and a preexisting degenerative L5-S1 disc treated with a lumbar floating fusion (LFF) versus lumbosacral fusion (LSF). Fusion for treatment of degenerative spondylolisthesis often ends at the L5 level. These patients usually had a preexisting L5-S1 disc degeneration; however, no literature mentions the role of prophylactic LSF in degenerative spondylolisthesis associated with L5-S1 disc degeneration. A total of 107 patients with a minimum 5-year follow-up who had lumbosacral or LFF with pedicle instrumentation for degenerative spondylolisthesis were included. UCLA (University of California, Los Angeles) classification was used to evaluate the radiographic results of the L5-S1 segment. The Oswestry Disability Index (ODI) and modified Brodsky's criteria were used to evaluate patients' clinical results. The incidence of adjacent segment disease (ASD) (includes radiographic and clinical ASD) of both ends was recorded. There were no statistically significant differences in sex, age distribution, or amount of follow-up between the LFF and LSF groups. The LSF group had a higher percentage of patients that underwent total L5 laminectomy with loss of L5-S1 posterior ligament integrity (LSF = 92% vs. LFF = 67%, P = 0.019). The higher incidence of cephalic ASD in the LSF group was statistically significant (LSF = 25% vs. LFF = 9.7%, P = 0.049). Although no patient in the LSF group developed L5-S1 ASD, need for L5-S1 segment revision surgery was not prevented with LSF. Clinical outcomes on the basis of the success rate (LFF = 85.5% vs.LSF = 70.8%, P = 0.103) and ODI difference (LFF = 28.97 ± 15.82 vs. LSF = 23.04 ± 10.97, P = 0.109), there were no statistically significant difference between these two groups. Posterior instrumentation with posterolateral LFF for the treatment of degenerative spondylolisthesis with

Outcomes of extended transforaminal lumbar interbody fusion for lumbar spondylosis.

PubMed

Talia, Adrian J; Wong, Michael L; Lau, Hui C; Kaye, Andrew H

2015-11-01

This study aims to assess the results of extended transforaminal lumbar interbody fusion (TLIF) for a two surgeon, single institution series. In total, extended TLIF with bilateral decompression was performed in 57 patients. Pain, American Spinal Injury Association scores, patient demographics, body mass index (BMI), perioperative indices and radiographic measurements were recorded and analysed. The surgeries were performed between February 2011 and January 2014 on 38 women and 19 men. The mean patient age was 62.86 years, and the mean BMI was 30.31 kg/m(2). In 49 patients, spondylolisthesis was the primary indication. The mean intraoperative time was 284.65 min, and this decreased as the series progressed. The median length of stay was 5 days (range: 2-9). The surgical complication rate was 19.3%. Two patients died from cardiopulmonary complications. Single level TLIF was performed in 78.9% of the cohort, with L4/5 the most commonly fused level. Significant pain reduction was achieved from a mean (± standard deviation) preoperative visual analogue scale (VAS) of 8.28 ± 1.39 to 1.50 ± 1.05 at 12 months postoperatively. No patients deteriorated neurologically. Spondylolisthesis was significantly corrected from a preoperative mean of 6.82 mm to 2.80 mm postoperatively. Although there is a learning curve associated with the procedure, extended TLIF with bilateral facet joint removal and decompression appeared to be a safe and effective alternative to other fusion techniques, and our results were comparable to other published case series. The stabilisation and correction of spinal deformity reduces pain, aids neurologic recovery and improves quality of life. Copyright © 2015 Elsevier Ltd. All rights reserved.

First clinical results of minimally invasive vector lumbar interbody fusion (MIS-VLIF) in spondylodiscitis and concomitant osteoporosis: a technical note.

PubMed

Rieger, Bernhard; Jiang, Hongzhen; Ruess, Daniel; Reinshagen, Clemens; Molcanyi, Marek; Zivcak, Jozef; Tong, Huaiyu; Schackert, Gabriele

2017-12-01

First description of MIS-VLIF, a minimally invasive lumbar stabilization, to evaluate its safety and feasibility in patients suffering from weak bony conditions (lumbar spondylodiscitis and/or osteoporosis). After informed consent, 12 patients suffering from lumbar spondylodiscitis underwent single level MIS-VLIF. Eight of them had a manifest osteoporosis, either. Pre- and postoperative clinical status was documented using numeric rating scale (NRS) for leg and back pain. In all cases, the optimal height for the cage was preoperatively determined using software-based range of motion and sagittal balance analysis. CT scans were obtained to evaluate correct placement of the construct and to verify fusion after 6 months. Since 2013, 12 patients with lumbar pyogenic spondylodiscitis underwent MIS-VLIF. Mean surgery time was 169 ± 28 min and average blood loss was less than 400 ml. Postoperative CT scans showed correct placement of the implants. Eleven patients showed considerable postoperative improvement in clinical scores. In one patient, we observed screw loosening. After documented bony fusion in the CT scan, the fixation system was removed in two cases to achieve lower material load. The load-bearing trajectories (vectors) of MIS-VLIF are different from those of conventional coaxial pedicle screw implantation. The dorsally converging construct combines the heads of the dorsoventral pedicle screws with laminar pedicle screws following cortical bone structures within a small approach. In case of lumbar spondylodiscitis and/or osteoporosis, MIS-VLIF relies on cortical bony structures for all screw vectors and the construct does not depend on conventional coaxial pedicle screws in the presence of inflamed, weak, cancellous or osteoporotic bone. MIS-VLIF allows full 360° lumbar fusion including cage implantation via a small, unilateral dorsal midline approach.

Analysis of Internet Information on Lateral Lumbar Interbody Fusion.

PubMed

Belayneh, Rebekah; Mesfin, Addisu

2016-07-01

Lateral lumbar interbody fusion (LLIF) is a surgical technique that is being increasingly used. The authors' objective was to examine information on the Internet pertaining to the LLIF technique. An analysis was conducted of publicly accessible websites pertaining to LLIF. The following search engines were used: Google (www.google.com), Bing (www.bing.com), and Yahoo (www.yahoo.com). DuckDuckGo (www.duckduckgo.com) was an additional search engine used due to its emphasis on generating accurate and consistent results while protecting searchers' privacy and reducing advertisements. The top 35 websites providing information on LLIF from the 4 search engines were identified. A total of 140 websites were evaluated. Each web-site was categorized based on authorship (academic, private, medical industry, insurance company, other) and content of information. Using the search term lateral lumbar interbody fusion, 174,000 Google results, 112,000 Yahoo results, and 112,000 Bing results were obtained. DuckDuckGo does not display the number of results found for a search. From the top 140 websites collected from each website, 78 unique websites were identified. Websites were authored by a private medical group in 46.2% of the cases, an academic medical group in 26.9% of the cases, and the biomedical industry in 5.1% of the cases. Sixty-eight percent of websites reported indications, and 24.4% reported contraindications. Benefits of LLIF were reported by 69.2% of websites. Thirty-six percent of websites reported complications of LLIF. Overall, the quality of information regarding LLIF on the Internet is poor. Spine surgeons and spine societies can assist in improving the quality of the information on the Internet regarding LLIF. [Orthopedics. 2016; 39(4):e701-e707.]. Copyright 2016, SLACK Incorporated.

Spondylectomy and lateral lumbar interbody fusion for thoracolumbar kyphosis in an adult with achondroplasia

PubMed Central

Miyazaki, Masashi; Kanezaki, Shozo; Notani, Naoki; Ishihara, Toshinobu; Tsumura, Hiroshi

2017-01-01

Abstract Rationale: Fixed thoracolumbar kyphosis with spinal stenosis in adult patients with achondroplasia presents a challenging issue. We describe the first case in which spondylectomy and minimally invasive lateral access interbody arthrodesis were used for the treatment of fixed severe thoracolumbar kyphosis and lumbar spinal canal stenosis in an adult with achondroplasia. Patient concerns: A 61-year-old man with a history of achondroplastic dwarfism presented with low back pain and radiculopathy and neurogenic claudication. Diagnoses: Plain radiographs revealed a high-grade thoracolumbar kyphotic deformity with diffuse degenerative changes in the lumbar spine. The apex was located at L2, the local kyphotic angle from L1 to L3 was 105°, and the anterior area was fused from the L1 to L3 vertebrae. MRI revealed significant canal and lateral recess stenosis secondary to facet hypertrophy. Interventions: We planned a front-back correction of the anterior and posterior spinal elements. We first performed anterior release at the fused part from L1 to L3 and XLIF at L3/4 and L4/5. Next, the patient was placed in the prone position. Spondylectomy at the L2 vertebra and posterior fusion from T10 to L5 were performed. Postoperative radiographs revealed L1 to L3 kyphosis of 32°. Outcomes: No complications occurred during or after surgery. Postoperatively, the patient's low back pain and neurological claudication were resolved. No worsening of kyphosis was observed 24 months postoperatively. Lessons: Circumferential decompression of the spinal cord at the apical vertebral level and decompression of lumbar canal stenosis were necessary. Front-back correction of the anterior and posterior spinal elements via spondylectomy and lateral lumbar interbody fusion is a reasonable surgical option for thoracolumbar kyphosis and developmental canal stenosis in patients with achondroplasia. PMID:29245270

Anterior lumbar instrumentation improves correction of severe lumbar Lenke C curves in double major idiopathic scoliosis

PubMed Central

Yeon, Howard B.; Weinberg, Jacob; Arlet, Vincent; Ouelett, Jean A.

2007-01-01

Fifteen skeletally immature patients with double major adolescent idiopathic scoliosis with large lumbar curves and notable L4 and L5 coronal plane obliquity were retrospectively studied. Seven patients who underwent anterior release and fusion of the lumbar curve with segmental anterior instrumentation and subsequent posterior instrumentation ending at L3 were compared with eight patients treated with anterior release and fusion without anterior instrumentation followed by posterior instrumentation to L3 or L4. At 4.5 years follow-up (range 2.5–7 years), curve correction, coronal balance and fusion rate were not statistically different between the two groups; however, the group with anterior instrumentation had improved coronal plane, near normalangulation in the distal unfused segment compared with the group without anterior instrumentation. In cases involving severe lumbar curvatures in the context of double major scoliosis, when as a first stage anterior release is chosen, the addition of instrumentation appears to restore normal coronal alignment of the distal unfused lumbar segment, and may in certain cases save a level compared with traditional fusions to L4. PMID:17464517

Miniopen Transforaminal Lumbar Interbody Fusion with Unilateral Fixation: A Comparison between Ipsilateral and Contralateral Reherniation

PubMed Central

Liu, Fubing; Jiang, Chun

2016-01-01

The aim of this study was to evaluate the risk factors between ipsilateral and contralateral reherniation and to compare the effectiveness of miniopen transforaminal lumbar interbody fusion (TLIF) with unilateral fixation for each group. From November 2007 to December 2014, clinical and radiographic data of each group (ipsilateral or contralateral reherniation) were collected and compared. Functional assessment (Visual Analog Scale (VAS) score and Japanese Orthopaedic Association (JOA)) and radiographic evaluation (fusion status, disc height, lumbar lordosis (LL), and functional spine unit (FSU) angle) were applied to compare surgical effect for each group preoperatively and at final followup. MacNab questionnaire was applied to further evaluate the satisfactory rate after the discectomy and fusion. No difference except pain-free interval was found between ipsilateral and contralateral groups. There was a significant difference in operative time between two groups. No differences were found in clinical and radiographic data for assessment of surgical effect between two groups. The satisfactory rate was decreasing in both groups with time passing after discectomy. Difference in pain-free interval may be a distinction for ipsilateral and contralateral reherniation. Miniopen TLIF with unilateral pedicle screw fixation can be a recommendable way for single level reherniation regardless of ipsilateral or contralateral reherniation. PMID:27885358

Porous biodegradable lumbar interbody fusion cage design and fabrication using integrated global-local topology optimization with laser sintering.

PubMed

Kang, Heesuk; Hollister, Scott J; La Marca, Frank; Park, Paul; Lin, Chia-Ying

2013-10-01

Biodegradable cages have received increasing attention for their use in spinal procedures involving interbody fusion to resolve complications associated with the use of nondegradable cages, such as stress shielding and long-term foreign body reaction. However, the relatively weak initial material strength compared to permanent materials and subsequent reduction due to degradation may be problematic. To design a porous biodegradable interbody fusion cage for a preclinical large animal study that can withstand physiological loads while possessing sufficient interconnected porosity for bony bridging and fusion, we developed a multiscale topology optimization technique. Topology optimization at the macroscopic scale provides optimal structural layout that ensures mechanical strength, while optimally designed microstructures, which replace the macroscopic material layout, ensure maximum permeability. Optimally designed cages were fabricated using solid, freeform fabrication of poly(ε-caprolactone) mixed with hydroxyapatite. Compression tests revealed that the yield strength of optimized fusion cages was two times that of typical human lumbar spine loads. Computational analysis further confirmed the mechanical integrity within the human lumbar spine, although the pore structure locally underwent higher stress than yield stress. This optimization technique may be utilized to balance the complex requirements of load-bearing, stress shielding, and interconnected porosity when using biodegradable materials for fusion cages.

Comparative Effectiveness and Economic Evaluations of Open Versus Minimally Invasive Posterior or Transforaminal Lumbar Interbody Fusion: A Systematic Review.

PubMed

Goldstein, Christina L; Phillips, Frank M; Rampersaud, Y Raja

2016-04-01

Systematic review of randomized and nonrandomized comparative studies. To summarize the literature examining comparative effectiveness and economic evaluation of minimally invasive versus open transforaminal/posterior lumbar interbody fusion (T/PLIF). Minimally invasive approaches to lumbar fusion have been proposed as an alternative to open surgery to decrease patient morbidity and improve clinical and patient-reported outcomes, with the possibility of secondary cost-savings. The comparative clinical and economic effectiveness of minimally invasive versus open T/PLIF remains largely undetermined. A systematic review of Medline, EMBASE, Web of Science, and Cochrane from database inception to September 2015 inclusive was performed. Reference lists were manually searched. Studies comparing MIS to open T/PLIF for degenerative lumbar conditions, including at least 10 patients in each arm and reporting at least one clinical, perioperative, radiographic, adverse event, or economic outcome, were included. Between database inception and October 2015, 45 studies meeting inclusion criteria were identified with 3472 subjects undergoing MIS fusion and 5925 having an open procedure. There were no significant differences in operative time between the two groups, whereas patients undergoing MIS fusion consistently demonstrated less blood loss (16.1-88.7%) and shorter hospital stays (15.0-64.0% shorter). There was no difference in variably reported VAS, ODI, SF-36, SF-12, or EQ-5D scores between the two techniques at intermediate to long-term follow-up (12-60 months). Complication rates and fusion rates were also equivalent between the two groups. Economic studies demonstrate cost-savings in favor of MIS fusion ranging from 2.5 to 49.3%. Limited quality comparative observational cohort and randomized controlled studies of MIS versus open T/PLIF consistently demonstrate improved perioperative outcomes including operative time, estimated blood loss, and length of stay with no

Instrumented posterior lumbar interbody fusion (PLIF) with interbody fusion device (Cage) in degenerative disc disease (DDD): 3 years outcome.

PubMed

Ahsan, M K; Hossain, M A; Sakeb, N; Khan, S I; Zaman, N

2013-10-01

This prospective interventional study carried out at Bangabandhu Sheikh Mujib Medical University and a private hospital in Dhaka, Bangladesh during the period from October 2003 to September 2011. Surgical treatment of degenerative disc disease (DDD) should aim to re-expand the interbody space and stabilize until fusion is complete. The present study conducted to find out the efficacy of using interbody fusion device (Cage) to achieve interbody space re-expansion and fusion in surgical management of DDD. We have performed the interventional study on 53 patients, 42 female and 11 male, with age between 40 to 67 years. All the patients were followed up for 36 to 60 months (average 48 months). Forty seven patients were with spondylolisthesis and 06 with desiccated disc. All subjects were evaluated with regard to immediate and long term complications, radiological fusion and interbody space re-expansion and maintenance. The clinical outcome (pain and disability) was scored by standard pre and postoperative questionnaires. Intrusion, extrusion and migration of the interbody fusion cage were also assessed. Forty seven patients were considered to have satisfactory outcome in at least 36 months follow up. Pseudoarthrosis developed in 04 cases and 06 patients developed complications. In this series posterior lumbar interbody fusion (PLIF) with interbody cage and instrumentation in DDD showed significant fusion rate and maintenance of interbody space. Satisfactory outcome observed in 88.68% cases.

Comparison of complications, costs, and length of stay of three different lumbar interbody fusion techniques: an analysis of the Nationwide Inpatient Sample database.

PubMed

Goz, Vadim; Weinreb, Jeffrey H; Schwab, Frank; Lafage, Virginie; Errico, Thomas J

2014-09-01

Lumbar interbody fusion (LIF) techniques have been used for years to treat a number of pathologies of the lower back. These procedures may use an anterior, posterior, or combined surgical approach. Each approach is associated with a unique set of complications, but the exact prevalence of complications associated with each approach remains unclear. To investigate the rates of perioperative complications of anterior lumbar interbody fusion (ALIF), posterior/transforaminal lumbar interbody fusion (P/TLIF), and LIF with a combined anterior-posterior interbody fusion (APF). Retrospective review of national data from a large administrative database. Patients undergoing ALIF, P/TLIF, or APF. Perioperative complications, length of stay (LOS), total costs, and mortality. The Nationwide Inpatient Sample database was queried for patients undergoing ALIF, P/TLIF, or APF between 2001 and 2010 as identified via International Classification of Diseases, ninth revision codes. Univariate analyses were carried out comparing the three cohorts in terms of the outcomes of interest. Multivariate analysis for primary outcomes was carried out adjusting for overall comorbidity burden, race, gender, age, and length of fusion. National estimates of annual total number of procedures were calculated based on the provided discharge weights. Geographic distribution of the three cohorts was also investigated. An estimated total of 923,038 LIFs were performed between 2001 and 2010 in the United States. Posterior/transforaminal lumbar interbody fusions accounted for 79% to 86% of total LIFs between 2001 and 2010, ALIFs for 10% to 15%, and APF decreased from 10% in 2002 to less than 1% in 2010. On average, P/TLIF patients were oldest (54.55 years), followed by combined approach (47.23 years) and ALIF (46.94 years) patients (p<.0001). Anterior lumbar interbody fusion, P/TLIF, and combined surgical costs were $75,872, $65,894, and $92,249, respectively (p<.0001). Patients in the P/TLIF cohort had the

90-day Readmission After Lumbar Spinal Fusion Surgery in New York State Between 2005 and 2014: A 10-year Analysis of a Statewide Cohort.

PubMed

Baaj, Ali A; Lang, Gernot; Hsu, Wei-Chun; Avila, Mauricio J; Mao, Jialin; Sedrakyan, Art

2017-11-15

MINI: We assessed 90-day readmission and evaluated risk factors associated with readmission after lumbar spinal fusion surgery in New York State. The overall 90-day readmission rate was 24.8%. Age, sex, race, insurance, procedure, number of operated spinal levels, health service area, and comorbidities are major risk factors for 90-day readmission. Retrospective cohort study. The aim of this study was to assess 90-day readmission and evaluate risk factors associated with readmission after lumbar fusion in New York State. Readmission is becoming an important metric for quality and efficiency of health care. Readmission and its predictors following spine surgery are overall poorly understood and limited evidence is available specifically in lumbar fusion. The New York Statewide Planning and Research Cooperative System (SPARCS) was utilized to capture patients undergoing lumbar fusion from 2005 to 2014. Temporal trend of 90-day readmission was assessed using Cochran-Armitage test. Logistic regression was used to examine predictors associated with 90-day readmission. There were 86,869 patients included in this cohort study. The overall 90-day readmission rate was 24.8%. On a multivariable analysis model, age (odds ratio [OR] comparing ≥75 versus <35 years: 1.24, 95% confidence interval [CI]: 1.13-1.35), sex (OR female to male: 1.19, 95% CI: 1.15-1.23), race (OR African-American to white: 1.60, 95% CI: 1.52-1.69), insurance (OR Medicaid to Medicare: 1.42, 95% CI: 1.33-1.53), procedure (OR comparing thoracolumbar fusion, combined [International Classification of Disease, Ninth Revision, ICD-9: 81.04] to posterior lumbar interbody fusion/transforaminal lumbar spinal fusion [ICD-9: 81.08]: 2.10, 95% CI: 1.49-2.97), number of operated spinal levels (OR comparing four to eight vertebrae to two to three vertebrae: 2.39, 95% CI: 2.07-2.77), health service area ([HSA]; OR comparing Finger Lakes to New York-Pennsylvania border: 0.67, 95% CI: 0.61-0.73), and comorbidity, i

Contralateral radiculopathy after transforaminal lumbar interbody fusion in the treatment of lumbar degenerative diseases: A Case Series.

PubMed

Hu, Hong-Tao; Ren, Liang; Sun, Xian-Ze; Liu, Feng-Yu; Yu, Jin-He; Gu, Zhen-Fang

2018-04-01

Transforaminal lumbar interbody fusion (TLIF) is an effective treatment for patients with degenerative lumbar disc disorder. Contralateral radiculopathy, as a complication of TLIF, has been recognized in this institution, but is rarely reported in the literature. In this article, we report 2 cases of contralateral radiculopathy after TLIF in our institution and its associated complications. In the 2 cases, the postoperative computed tomography (CT) and magnetic resonance image (MRI) showed obvious upward movement of the superior articular process, leading to contralateral foraminal stenosis. Revision surgery was done at once to partially resect the opposite superior facet and to relieve nerve root compression. After revision surgery, the contralateral radiculopathy disappeared. Contralateral radiculopathy is an avoidable potential complication. It is very important to create careful preoperative plans and to conscientiously plan the use of intraoperative techniques. In case of postoperative contralateral leg pain, the patients should be examined by CT and MRI. If CT and MRI show that the superior articular process significantly migrated upwards, which leads to contralateral foraminal stenosis, revision surgery should be done at once to partially resect the contralateral superior facet so as to relieve nerve root compression and avoid possible long-term impairment.

Morphometric MRI Imaging Study of the Corridor for the Oblique Lumbar Interbody Fusion Technique at L1-L5.

PubMed

Julian Li, Jia Xi; Mobbs, Ralph J; Phan, Kevin

2018-03-01

Anterior lumbar interbody fusion and lateral lumbar interbody fusion are associated with approach-related disadvantages. Oblique lumbar interbody fusion (OLIF) is the proposed solution, especially for upper lumbar levels. We analyzed the size and regional anatomy of the corridor used in the OLIF technique between levels L1 and L5. This is a morphometric study of 200 randomly selected magnetic resonance imaging (MRI) studies with features of lumbar degenerative disease. On MRI, the oblique corridor was defined as the smallest distance between the psoas major muscle and aorta or inferior vena cava (or common iliac artery) and measured at the L1/L2, L2/L3, L3/L4, and L4/L5 disc levels on both the left and right on the axial images at the mid-disc level. Mean distances of the oblique corridor on the left side were L1/L2 = 18.90 mm, L2/L3 = 15.50 mm; L3/L4 = 12.75 mm, and L4/L5 = 8.92 mm; on the right side, they were L1/L2 = 14.80 mm, L2/L3 = 5.50 mm, L3/L4 = 3.00 mm, and L4/L5 = 1.46 mm. For both sides, the corridor size was not significantly affected by sex, and it increased with age and decreased at the inferior lumbar disc levels. The L1/L2 and L2/L3 levels may be obstructed by the ipsilateral kidney and renal vasculature on both sides and the liver on the right side. A left-sided OLIF approach is viable for both sexes. Oblique access to the L1/L2 and L2/L3 disc levels is feasible regardless of age, whereas the L3/L4 and L4/L5 levels may be more suitable in older patients, especially for male patients. The right-sided approach is less likely to be performed effectively. Copyright © 2018 Elsevier Inc. All rights reserved.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: Meta-analysis of the Fusion Rates. What is the Optimal Graft Material?

PubMed

Parajón, Avelino; Alimi, Marjan; Navarro-Ramirez, Rodrigo; Christos, Paul; Torres-Campa, Jose M; Moriguchi, Yu; Lang, Gernot; Härtl, Roger

2017-12-01

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is an increasingly popular procedure with several potential advantages over traditional open TLIF. The current study aimed to compare fusion rates of different graft materials used in MIS-TLIF, via meta-analysis of the published literature. A Medline search was performed and a database was created including patient's type of graft, clinical outcome, fusion rate, fusion assessment modality, and duration of follow-up. Meta-analysis of the fusion rate was performed using StatsDirect software (StatsDirect Ltd, Cheshire, United Kingdom). A total of 1533 patients from 40 series were included. Fusion rates were high, ranging from 91.8% to 99%. The imaging modalities used to assess fusion were computed tomography scans (30%) and X-rays (70%). Comparison of all recombinant human bone morphogenetic protein (rhBMP) series with all non-rhBMP series showed fusion rates of 96.6% and 92.5%, respectively. The lowest fusion rate was seen with isolated use of autologous local bone (91.8%). The highest fusion rate was observed with combination of autologous local bone with bone extender and rhBMP (99.1%). The highest fusion rate without the use of BMP was seen with autologous local bone + bone extender (93.1%). The reported complication rate ranged from 0% to 35.71%. Clinical improvement was observed in all studies. Fusion rates are generally high with MIS-TLIF regardless of the graft material used. Given the potential complications of iliac bone harvesting and rhBMP, use of other bone graft options for MIS-TLIF is reasonable. The highest fusion rate without the use of rhBMP was seen with autologous local bone plus bone extender (93.1%). Published by Oxford University Press on behalf of Congress of Neurological Surgeons 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Decompression Surgery Alone Versus Decompression Plus Fusion in Symptomatic Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study With 3 Years of Follow-up.

PubMed

Ulrich, Nils H; Burgstaller, Jakob M; Pichierri, Giuseppe; Wertli, Maria M; Farshad, Mazda; Porchet, François; Steurer, Johann; Held, Ulrike

2017-09-15

Retrospective analysis of a prospective, multicenter cohort study. To estimate the added effect of surgical fusion as compared to decompression surgery alone in symptomatic lumbar spinal stenosis patients with spondylolisthesis. The optimal surgical management of lumbar spinal stenosis patients with spondylolisthesis remains controversial. Patients of the Lumbar Stenosis Outcome Study with confirmed DLSS and spondylolisthesis were enrolled in this study. The outcomes of this study were Spinal Stenosis Measure (SSM) symptoms (score range 1-5, best-worst) and function (1-4) over time, measured at baseline, 6, 12, 24, and 36 months follow-up. In order to quantify the effect of fusion surgery as compared to decompression alone and number of decompressed levels, we used mixed effects models and accounted for the repeated observations in main outcomes (SSM symptoms and SSM function) over time. In addition to individual patients' random effects, we also fitted random slopes for follow-up time points and compared these two approaches with Akaike's Information Criterion and the chi-square test. Confounders were adjusted with fixed effects for age, sex, body mass index, diabetes, Cumulative Illness Rating Scale musculoskeletal disorders, and duration of symptoms. One hundred thirty-one patients undergoing decompression surgery alone (n = 85) or decompression with fusion surgery (n = 46) were included in this study. In the multiple mixed effects model the adjusted effect of fusion compared with decompression alone surgery on SSM symptoms was 0.06 (95% confidence interval: -0.16-0.27) and -0.07 (95% confidence interval: -0.25-0.10) on SSM function, respectively. Among the patients with degenerative lumbar spinal stenosis and spondylolisthesis our study confirms that in the two groups, decompression alone and decompression with fusion, patients distinctively benefited from surgical treatment. When adjusted for confounders, fusion surgery was not associated with a more

Automatic lumbar vertebrae detection based on feature fusion deep learning for partial occluded C-arm X-ray images.

PubMed

Yang Li; Wei Liang; Yinlong Zhang; Haibo An; Jindong Tan

2016-08-01

Automatic and accurate lumbar vertebrae detection is an essential step of image-guided minimally invasive spine surgery (IG-MISS). However, traditional methods still require human intervention due to the similarity of vertebrae, abnormal pathological conditions and uncertain imaging angle. In this paper, we present a novel convolutional neural network (CNN) model to automatically detect lumbar vertebrae for C-arm X-ray images. Training data is augmented by DRR and automatic segmentation of ROI is able to reduce the computational complexity. Furthermore, a feature fusion deep learning (FFDL) model is introduced to combine two types of features of lumbar vertebrae X-ray images, which uses sobel kernel and Gabor kernel to obtain the contour and texture of lumbar vertebrae, respectively. Comprehensive qualitative and quantitative experiments demonstrate that our proposed model performs more accurate in abnormal cases with pathologies and surgical implants in multi-angle views.

Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion.

PubMed

Willems, Paul

2013-02-01

Chronic low back pain (CLBP) is one of the main causes of disability in the western world with a huge economic burden to society. As yet, no specific underlying anatomic cause has been identified for CLBP. Imaging often reveals degenerative findings of the disc or facet joints of one or more lumbar motion segments. These findings, however, can also be observed in asymptomatic people. It has been suggested that pain in degenerated discs may be caused by the ingrowth of nerve fibers into tears or clefts of the annulus fibrosus or nucleus pulposus, and by reported high levels of pro-inflammatory mediators. As this so-called discogenic pain is often exacerbated by mechanical loading, the concept of relieving pain by spinal fusion to stabilise a painful spinal segment, has been developed. For some patients lumbar spinal fusion indeed is beneficial, but its results are highly variable and hard to predict for the individual patient. To identify those CLBP patients who will benefit from fusion, many surgeons rely on tests that are assumed to predict the outcome of spinal fusion. The three most commonly used prognostic tests in daily practice are immobilization in a lumbosacral orthosis, provocative discography and trial immobilization by temporary external transpedicular fixation. Aiming for consensus on the indications for lumbar fusion and in order to improve its results by better patient selection, it is essential to know the role and value of these prognostic tests for CLBP patients in clinical practice. The overall aims of the present thesis were: 1) to evaluate whether there is consensus among spine surgeons regarding the use and appreciation of prognostic tests for lumbar spinal fusion; 2) to verify whether a thoracolumbosacral orthosisis (TLSO) truly minimises lumbosacral motion; 3) to verify whether a TLSO can predict the clinical outcome of fusion for CLBP; 4) to assess whether provocative discography of adjacent segments actually predicts the long-term clinical

An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion.

PubMed

Cummock, Matthew D; Vanni, Steven; Levi, Allan D; Yu, Yong; Wang, Michael Y

2011-07-01

The minimally invasive transpsoas interbody fusion technique requires dissection through the psoas muscle, which contains the nerves of the lumbosacral plexus posteriorly and genitofemoral nerve anteriorly. Retraction of the psoas is becoming recognized as a cause of transient postoperative thigh pain, numbness, paresthesias, and weakness. However, few reports have described the nature of thigh symptoms after this procedure. The authors performed a review of patients who underwent the transpsoas technique for lumbar spondylotic disease, disc degeneration, and spondylolisthesis treated at a single academic medical center. A review of patient charts, including the use of detailed patient-driven pain diagrams performed at equal preoperative and follow-up intervals, investigated the survival of postoperative thigh pain, numbness, paresthesias, and weakness of the iliopsoas and quadriceps muscles in the follow-up period on the ipsilateral side of the surgical approach. Over a 3.2-year period, 59 patients underwent transpsoas interbody fusion surgery. Of these, 62.7% had thigh symptoms postoperatively. New thigh symptoms at first follow-up visit included the following: burning, aching, stabbing, or other pain (39.0%); numbness (42.4%); paresthesias (11.9%); and weakness (23.7%). At 3 months postoperatively, these percentages decreased to 15.5%, 24.1%, 5.6%, and 11.3%, respectively. Within the patient sample, 44% underwent a 1-level, 41% a 2-level, and 15% a 3-level transpsoas operation. While not statistically significant, thigh pain, numbness, and weakness were most prevalent after L4-5 transpsoas interbody fusion at the first postoperative follow-up. The number of lumbar levels that were surgically treated had no clear association with thigh symptoms but did correlate directly with surgical time, intraoperative blood loss, and length of hospital stay. Transpsoas interbody fusion is associated with high rates of immediate postoperative thigh symptoms. While larger

One-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis.

PubMed

Pang, Xiaoyang; Wu, Ping; Shen, Xiongjie; Li, Dongzhe; Luo, Chenke; Wang, Xiyang

2013-08-01

Retrospective analysis of the clinical study efficacy and feasibility of one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis. A total of 21 patients with lumbosacral tuberculosis (TB) collected from January 2004 to January 2010, underwent one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation. In addition, the clinical efficacy was evaluated based on the data on the lumbo-sacral angle, neuro-logical status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at specific time points. All cases were followed up for 16-36 months (average 24.9 ± 6.44 months). 18 patients suffered from evident neurological deficits preoperatively, of which 16 patients returned to normal at the final follow-up. Two patients with neurological dysfunction aggravated postoperative, experienced significant partial neurological recovery. With an effective and standard anti-TB chemotherapy treated, the values of ESR and CRP returned to normal levels 3-month later postoperative and maintained till the final follow-up. Preoperative lumbosacral angle was 20.89 ± 2.32° and returned 29.62 ± 1.41° postoperative. During long-term follow-up, there was only 1-3° lumbosacral angle loss. There was a significant difference between preoperative and postoperative lumbosacral angles. With effective and standard anti-TB chemotherapy, one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation for lumbosacral tuberculosis can effectively relieve pain symptoms, improve neurological function, and reconstruct the spinal stability.

Biomechanical Analysis of Lateral Lumbar Interbody Fusion Constructs with Various Fixation Options: Based on a Validated Finite Element Model.

PubMed

Zhang, Zhenjun; Fogel, Guy R; Liao, Zhenhua; Sun, Yitao; Liu, Weiqiang

2018-06-01

Lateral lumbar interbody fusion using cage supplemented with fixation has been used widely in the treatment of lumbar disease. A combined fixation (CF) of lateral plate and spinous process plate may provide multiplanar stability similar to that of bilateral pedicle screws (BPS) and may reduce morbidity. The biomechanical influence of the CF on cage subsidence and facet joint stress has not been well described. The aim of this study was to compare biomechanics of various fixation options and to verify biomechanical effects of the CF. The surgical finite element models with various fixation options were constructed based on computed tomography images. The lateral plate and posterior spinous process plate were applied (CF). The 6 motion modes were simulated. Range of motion (ROM), cage stress, endplate stress, and facet joint stress were compared. For the CF model, ROM, cage stress, and endplate stress were the minimum in almost all motion modes. Compared with BPS, the CF reduced ROM, cage stress, and endplate stress in all motion modes. The ROM was reduced by more than 10% in all motion modes except for flexion; cage stress and endplate stress were reduced more than 10% in all motion modes except for rotation-left. After interbody fusion, facet joint stress was reduced substantially compared with the intact conditions in all motion modes except for flexion. The combined plate fixation may offer an alternative to BPS fixation in lateral lumbar interbody fusion. Copyright © 2018 Elsevier Inc. All rights reserved.

Comparison between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Conventional Open Transforaminal Lumbar Interbody Fusion: An Updated Meta-analysis.

PubMed

Xie, Lei; Wu, Wen-Jian; Liang, Yu

2016-08-20

The previous studies agree that minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has better function outcomes, less blood loss, and shorter hospital stay, when compared to open-TLIF. However, there are no significance differences on operative time, complication, and reoperation rate between the two procedures. This could be from less relative literatures and lower grade evidence. The further meta-analysis is needed with more and higher grade evidences to compare the above two TLIF procedures. Prospective and retrospective studies that compared open-TLIF and MIS-TLIF were identified by searching the Medline, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and VIP database (the literature search comprised Medical Subject Heading terms and key words or Emtree term). The retrieval time ranged from the date when the database was founded to January 2015. Pooled risk ratios (RR s) and weighted mean differences (WMDs) with 95% confidence intervals were calculated for the clinical outcomes and perioperative data. Twenty-four studies (n = 1967 patients) were included in this review (n = 951, open-TLIF, n = 1016, MIS-TLIF). MIS-TLIF was associated with a significant decrease in the visual analog score (VAS)-back pain score (WMD = -0.44; P = 0.001), Oswestry Disabilities Index (WMD = -1.57; P = 0.005), early ambulation (WMD = -1.77; P = 0.0001), less blood loss (WMD = -265.59; P < 0.00001), and a shorter hospital stay (WMD = -1.89; P < 0.0001). However, there were no significant differences in the fusion rate (RR = 0.99; P = 0.34), VAS-leg pain (WMD = -0.10; P = 0.26), complication rate (RR = 0.84; P = 0.35), operation time (WMD = -5.23; P = 0.82), or reoperation rate (RR = 0.73; P = 0.32). MIS-TLIF resulted in a similar fusion rate with better functional outcome, less blood loss, shorter ambulation, and hospital stay; furthermore, it did not increase the complication or reoperation rate based on the existing evidence.

Biomechanical Evaluation of a Novel Apatite-Wollastonite Ceramic Cage Design for Lumbar Interbody Fusion: A Finite Element Model Study

PubMed Central

Şenköylü, Alpaslan; Aktaş, Erdem; Sarıkaya, Baran; Sipahioğlu, Serkan; Gürbüz, Rıza; Timuçin, Muharrem

2018-01-01

Objectives Cage design and material properties play a crucial role in the long-term results, since interbody fusions using intervertebral cages have become one of the basic procedures in spinal surgery. Our aim is to design a novel Apatite-Wollastonite interbody fusion cage and evaluate its biomechanical behavior in silico in a segmental spinal model. Materials and Methods Mechanical properties for the Apatite-Wollastonite bioceramic cages were obtained by fitting finite element results to the experimental compression behavior of a cage prototype. The prototype was made from hydroxyapatite, pseudowollastonite, and frit by sintering. The elastic modulus of the material was found to be 32 GPa. Three intact lumbar vertebral segments were modelled with the ANSYS 12.0.1 software and this model was modified to simulate a Posterior Lumbar Interbody Fusion. Four cage designs in different geometries were analyzed in silico under axial loading, flexion, extension, and lateral bending. Results The K2 design had the best overall biomechanical performance for the loads considered. Maximum cage stress recorded was 36.7 MPa in compression after a flexion load, which was within the biomechanical limits of the cage. Conclusion Biomechanical analyses suggest that K2 bioceramic cage is an optimal design and reveals essential material properties for a stable interbody fusion. PMID:29581974

Anterior decompression and fusion for Aspergillus osteomyelitis of the lumbar spine associated with paraparesis.

PubMed

Korovessis, P; Repanti, M; Katsardis, T; Stamatakis, M

1994-12-01

A very rare case of Aspergillus fumigatus osteomyelitis of the spine is described. The differential diagnosis, medical and operative treatment, and follow-up evaluation are reported. To increase knowledge about the pathogenesis and treatment of vertebral osteomyelitis resulting from Aspergillus and to emphasize that such cases still exist. Vertebral osteomyelitis from Aspergillus species is an infrequently described disease in Europe and only few cases have been previously reported. A 48-year-old woman with Aspergillus fumigatus spondylitis in the lumbar spine and tuberculosis-lung infection and concomitant debilitating systemic disease was afflicted with incomplete paraplegia and underwent successful combined operative and medical treatment. Early anterior decompression with spinal fusion, combined with Amphotericin B therapy, was crucial in bringing about complete neurologic recovery and maintaining the sagittal lumbar profile. Excellent clinical and radiologic results were shown in the 42-month follow-up period.

A prospective, multi-institutional comparative effectiveness study of lumbar spine surgery in morbidly obese patients: does minimally invasive transforaminal lumbar interbody fusion result in superior outcomes?

PubMed

Adogwa, Owoicho; Carr, Kevin; Thompson, Paul; Hoang, Kimberly; Darlington, Timothy; Perez, Edgar; Fatemi, Parastou; Gottfried, Oren; Cheng, Joseph; Isaacs, Robert E

2015-05-01

Obese and morbidly obese patients undergoing lumbar spinal fusion surgery are a challenge to the operating surgeon. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open-TLIF have been performed for many years with good results; however, functional outcomes after lumbar spine surgery in this subgroup of patients remain poorly understood. Furthermore, whether index MIS-TLIF or open-TLIF for the treatment of degenerative disc disease or spondylolisthesis in morbidly obese results in superior postoperative functional outcomes remains unknown. A total of 148 (MIS-TLIF: n = 40, open-TLIF: n = 108) obese and morbidly obese patients undergoing index lumbar arthrodesis for low back pain and/or radiculopathy between January 2003 and December 2010 were selected from a multi-institutional prospective data registry. We collected and analyzed data on patient demographics, postoperative complications, back pain, leg pain, and functional disability over 2 years. Patients completed the Oswestry Disability Index (ODI), Medical Outcomes Study Short-Form 36 (SF-36), and back and leg pain numerical rating scores before surgery and then at 12 and 24 months after surgery. Clinical outcomes and complication rates were compared between both patient cohorts. Compared with preoperative status, Visual Analog Scale (VAS) back and leg pain, ODI, and SF-36 physical component score/mental component score were improved in both groups. Both MIS-TLIF and open-TLIF patients showed similar 2-year improvement in VAS for back pain (MIS-TLIF: 2.42 ± 3.81 vs. open-TLIF: 2.33 ± 3.67, P = 0.89), VAS for leg pain (MIS-TLIF: 3.77 ± 4.53 vs. open-TLIF: 2.67 ± 4.10, P = 0.18), ODI (MIS-TLIF: 11.61 ± 25.52 vs. open-TLIF: 14.88 ± 22.07, P = 0.47), and SF-36 physical component score (MIS-TLIF: 8.61 ± 17.72 vs. open-TLIF: 7.61 ± 15.55, P = 0.93), and SF-36 mental component score (MIS-TLIF: 4.35 ± 22.71 vs. open-TLIF: 5.96 ± 21.09, P = 0.69). Postoperative complications

Comparing parecoxib and ketorolac as preemptive analgesia in patients undergoing posterior lumbar spinal fusion: a prospective randomized double-blinded placebo-controlled trial.

PubMed

Siribumrungwong, Koopong; Cheewakidakarn, Julin; Tangtrakulwanich, Boonsin; Nimmaanrat, Sasikaan

2015-03-18

Poor postoperative pain control is frequently associated with complications and delayed discharge from a hospital. Preemptive analgesia is one of the methods suggested for reducing postoperative pain. Opioids are effective for pain control, but there known addictive properties make physicians cautious about using them. Parecoxib and ketorolac are potent non-opioid NSAIDs that are attractive alternative drugs to opioids to avoid opioid-related side effects. However, there are no good head-to-head comparisons between these two drugs in the aspect of preemptive analgesic effects in lumbar spinal fusion surgery. This study aimed to compare the efficacy in terms of postoperative pain control and safety of parecoxib with ketorolac as preemptive analgesia in posterior lumbar spinal fusion patients. A prospective, double-blinded randomized controlled trial was carried out in patients undergoing posterior lumbar spinal fusion, who were randomized into 3 groups (n = 32). Parecoxib, ketorolac or a placebo was given to each patient via injection around 30 minutes prior to incision. The efficacy of postoperative pain control was assessed by a verbal numerical rating score (0-10). And various postoperative things were monitored for analysis, such as total opioid consumption, complications, and estimated blood loss. Both the ketorolac and parecoxib groups showed significantly better early postoperative pain reduction at the postanesthesia care unit (PACU) than the control group (p < 0.05). There were no differences between the pain scores of ketorolac and parecoxib at any time points. Complications and bleeding were not significantly different between all three groups. Preemptive analgesia using both ketorolac and parecoxib showed a significantly better early postoperative pain control in the PACU than the control group in patients undergoing lumbar spinal fusion. ClinicalTrials.gov NCT01859585. Registered 15 May 2013.

Minimally invasive versus open fusion for Grade I degenerative lumbar spondylolisthesis: analysis of the Quality Outcomes Database.

PubMed

Mummaneni, Praveen V; Bisson, Erica F; Kerezoudis, Panagiotis; Glassman, Steven; Foley, Kevin; Slotkin, Jonathan R; Potts, Eric; Shaffrey, Mark; Shaffrey, Christopher I; Coric, Domagoj; Knightly, John; Park, Paul; Fu, Kai-Ming; Devin, Clinton J; Chotai, Silky; Chan, Andrew K; Virk, Michael; Asher, Anthony L; Bydon, Mohamad

2017-08-01

OBJECTIVE Lumbar spondylolisthesis is a degenerative condition that can be surgically treated with either open or minimally invasive decompression and instrumented fusion. Minimally invasive surgery (MIS) approaches may shorten recovery, reduce blood loss, and minimize soft-tissue damage with resultant reduced postoperative pain and disability. METHODS The authors queried the national, multicenter Quality Outcomes Database (QOD) registry for patients undergoing posterior lumbar fusion between July 2014 and December 2015 for Grade I degenerative spondylolisthesis. The authors recorded baseline and 12-month patient-reported outcomes (PROs), including Oswestry Disability Index (ODI), EQ-5D, numeric rating scale (NRS)-back pain (NRS-BP), NRS-leg pain (NRS-LP), and satisfaction (North American Spine Society satisfaction questionnaire). Multivariable regression models were fitted for hospital length of stay (LOS), 12-month PROs, and 90-day return to work, after adjusting for an array of preoperative and surgical variables. RESULTS A total of 345 patients (open surgery, n = 254; MIS, n = 91) from 11 participating sites were identified in the QOD. The follow-up rate at 12 months was 84% (83.5% [open surgery]; 85% [MIS]). Overall, baseline patient demographics, comorbidities, and clinical characteristics were similarly distributed between the cohorts. Two hundred fifty seven patients underwent 1-level fusion (open surgery, n = 181; MIS, n = 76), and 88 patients underwent 2-level fusion (open surgery, n = 73; MIS, n = 15). Patients in both groups reported significant improvement in all primary outcomes (all p < 0.001). MIS was associated with a significantly lower mean intraoperative estimated blood loss and slightly longer operative times in both 1- and 2-level fusion subgroups. Although the LOS was shorter for MIS 1-level cases, this was not significantly different. No difference was detected with regard to the 12-month PROs between the 1-level MIS versus the 1-level open

Can cantilever transforaminal lumbar interbody fusion (C-TLIF) maintain segmental lordosis for degenerative spondylolisthesis on a long-term basis?

PubMed

Kida, Kazunobu; Tadokoro, Nobuaki; Kumon, Masashi; Ikeuchi, Masahiko; Kawazoe, Tateo; Tani, Toshikazu

2014-03-01

To determine if cantilever transforaminal lumbar interbody fusion (C-TLIF) using the crescent-shaped titanium interbody spacer (IBS) favors acquisition of segmental and lumbar lordosis even for degenerative spondylolisthesis (DS) on a long-term basis. We analyzed 23 consecutive patients who underwent C-TLIF with pedicle screw instrumentations fixed with compression for a single-level DS. Measurements on the lateral radiographs taken preoperatively, 2 weeks postoperatively and at final follow-up included disc angle (DA), segmental angle (SA), lumbar lordosis (LL), disc height (%DH) and slip rate (%slip). There was a good functional recovery with 100 % fusion rate at the mean follow-up of 62 months. Segmental lordosis (DA and SA) and %DH initially increased, but subsequently decreased with the subsidence of the interbody spacer, resulting in a significant increase (p = 0.046) only in SA from 13.2° ± 5.5° preoperatively to 14.7° ± 6.4° at the final follow-up. Changes of LL and %slip were more consistent without correction loss finally showing an increase of LL by 3.6° (p = 0.005) and a slip reduction by 6.7 % (p < 0.001). Despite the inherent limitation of placing the IBS against the anterior endplate of the upper vertebra in the presence of DS, the C-TLIF helped significantly restore segmental as well as lumbar lordosis on a long-term basis, which would be of benefit in preventing hypolordosis-induced back pain and the adjacent level disc disease.

One-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children.

PubMed

Hu, Xiongke; Zhang, Hongqi; Yin, Xinhua; Chen, Yong; Yu, Honggui; Zhou, Zhenhai

2016-03-01

The purpose of this study is to investigate the clinical efficacy and feasibility of one-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children. From December 2007 to May 2012, 13 patients (six males and seven females) suffering from lumbar spinal tuberculosis with kyphosis were admitted. All patients were treated with one-stage posterior focus debridement, fusion, and instrumentation. Then, the clinical efficacy was estimated by statistical analysis based on the data about Frankel grade, the Cobb angle of kyphosis, and erythrocyte sedimentation rate (ESR), which were collected at certain time. The age of all patients ranged from 5 to 13 years (average, 8.8 years). Operation time ranged from 120 to 190 min (average, 165 min). Intraoperative blood loss ranged from 200 to 800 ml (average, 460 ml). All patients were followed up for 24 to 57 months postoperatively (average, 33.5 months). The Cobb angle was changed significantly between preoperation and postoperation (P < 0.05), and there was no significant loss at the last follow-up. The preoperation ESR (62.5 ± 15.7) returned to normal (16.6 ± 8.1) within 3 months postoperatively in all patients (P < 0.05). Bone fusion was achieved within 3-5 months (average, 3.5 months). In the 13 cases, no postoperative severe complications occurred and neurologic function improved in various degrees. The outcomes of follow-up showed that one-stage posterior focus debridement, fusion, and instrumentation can be an effective treatment method for the lumbar spinal tuberculosis with kyphosis in children.

Kinematics of a selectively constrained radiolucent anterior lumbar disc: comparisons to hybrid and circumferential fusion.

PubMed

Daftari, Tapan K; Chinthakunta, Suresh R; Ingalhalikar, Aditya; Gudipally, Manasa; Hussain, Mir; Khalil, Saif

2012-10-01

Despite encouraging clinical outcomes of one-level total disc replacements reported in literature, there is no compelling evidence regarding the stability following two-level disc replacement and hybrid constructs. The current study is aimed at evaluating the multidirectional kinematics of a two-level disc arthroplasty and hybrid construct with disc replacement adjacent to rigid circumferential fusion, compared to two-level fusion using a novel selectively constrained radiolucent anterior lumbar disc. Nine osteoligamentous lumbosacral spines (L1-S1) were tested in the following sequence: 1) Intact; 2) One-level disc replacement; 3) Hybrid; 4) Two-level disc replacement; and 5) Two-level fusion. Range of motion (at both implanted and adjacent level), and center of rotation in sagittal plane were recorded and calculated. At the level of implantation, motion was restored when one-level disc replacement was used but tended to decrease with two-level disc arthroplasty. The findings also revealed that both one-level and two-level disc replacement and hybrid constructs did not significantly change adjacent level kinematics compared to the intact condition, whereas the two-level fusion construct demonstrated a significant increase in flexibility at the adjacent level. The location of center of rotation in the sagittal plane at L4-L5 for the one-level disc replacement construct was similar to that of the intact condition. The one-level disc arthroplasty tended to mimic a motion profile similar to the intact spine. However, the two-level disc replacement construct tended to reduce motion and clinical stability of a two-level disc arthroplasty requires additional investigation. Hybrid constructs may be used as a surgical alternative for treating two-level lumbar degenerative disc disease. Published by Elsevier Ltd.

Adult thoracolumbar and lumbar scoliosis treated with long vertebral fusion to the sacropelvis: a comparison between new hybrid selective spinal fusion versus anterior-posterior spinal instrumentation.

PubMed

Yagi, Mitsuru; Patel, Ravi; Lawhorne, Thomas W; Cunningham, Matthew E; Boachie-Adjei, Oheneba

2014-04-01

Combined anteroposterior spinal fusion with instrumentation has been used for many years to treat adult thoracolumbar/lumbar scoliosis. This surgery remains a technical challenge to spine surgeons, and current literature reports high complication rates. The purpose of this study is to validate a new hybrid technique (a combination of single-rod anterior instrumentation and a shorter posterior instrumentation to the sacrum) to treat adult thoracolumbar/lumbar scoliosis. This study is a retrospective consecutive case series of surgically treated patients with adult lumbar or thoracolumbar scoliosis. This is a retrospective study of 33 matched pairs of patients with adult scoliosis who underwent two different surgical procedures: a new hybrid technique versus a third-generation anteroposterior spinal fusion. Preoperative and postoperative outcome measures include self-report measures, physiological measures, and functional measures. In a retrospective case-control study, 33 patients treated with the hybrid technique were matched with 33 patients treated with traditional anteroposterior fusion based on preoperative radiographic parameters. Mean follow-up in the hybrid group was 5.3 years (range, 2-11 years), compared with 4.6 years (range, 2-10 years) in the control group. Operating room (OR) time, estimated blood loss, and levels fused were collected as surrogates for surgical morbidity. Radiographic parameters were collected preoperatively, postoperatively, and at final follow-up. The Scoliosis Research Society Patient Questionnaire (SRS-22r) and Oswestry Disability Index (ODI) scores were collected for clinical outcomes. Operating room time, EBL, and levels fused were significantly less in the hybrid group compared with the control group (p<.0001). The postoperative thoracic Cobb angle was similar between the hybrid and control techniques (p=.24); however, the hybrid technique showed significant improvement in the thoracolumbar/lumbar curves (p=.004) and the

Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of an Evidence-Based Clinical Care Pathway.

PubMed

Bradywood, Alison; Farrokhi, Farrokh; Williams, Barbara; Kowalczyk, Mark; Blackmore, C Craig

2017-02-01

Quality improvement with before and after evaluation of the intervention. To improve lumbar spine postoperative care and quality outcomes through a series of Lean quality improvement events designed to address root causes of error and variation. Lumbar spine fusion procedures are common, but highly variable in process of care, outcomes, and cost. We implemented a standardized lumbar spine fusion clinical care pathway through a series of Lean quality improvement events. The pathway included an evidence-based electronic order set; a patient visual tool; and multidisciplinary communication, and was designed to delineate expectations for patients, staff, and providers. To evaluate the effectiveness of the intervention, we performed a quality improvement study with before and after evaluation of consecutive patients from January 2012 to September 2014. Outcomes were hospital length of stay and quality measures before and after the April 1, 2013 intervention. Data were analyzed with chi-square and t tests for before and after comparisons, and were explored graphically for temporal trends with statistical process control charts. Our study population was 458 patients (mean 65 years, 65% women). Length of stay decreased from 3.9 to 3.4 days, a difference of 0.5 days (CI 0.3, 0.8, P < 0.001). Discharge disposition also improved with 75% (183/244) being discharged to home postintervention versus 64% (136/214) preintervention (P = 0.002). Urinary catheter removal also improved (P = 0.003). Patient satisfaction scores were not significantly changed. Applying Lean methods to produce standardized clinical pathways is an effective way of improving quality and reducing waste for lumbar spine fusion patients. We believe that quality improvements of this type are valuable for all spine patients, to provide best care outcomes at lowest cost. 4.

Spondylectomy and lateral lumbar interbody fusion for thoracolumbar kyphosis in an adult with achondroplasia: A case report.

PubMed

Miyazaki, Masashi; Kanezaki, Shozo; Notani, Naoki; Ishihara, Toshinobu; Tsumura, Hiroshi

2017-12-01

Fixed thoracolumbar kyphosis with spinal stenosis in adult patients with achondroplasia presents a challenging issue. We describe the first case in which spondylectomy and minimally invasive lateral access interbody arthrodesis were used for the treatment of fixed severe thoracolumbar kyphosis and lumbar spinal canal stenosis in an adult with achondroplasia. A 61-year-old man with a history of achondroplastic dwarfism presented with low back pain and radiculopathy and neurogenic claudication. Plain radiographs revealed a high-grade thoracolumbar kyphotic deformity with diffuse degenerative changes in the lumbar spine. The apex was located at L2, the local kyphotic angle from L1 to L3 was 105°, and the anterior area was fused from the L1 to L3 vertebrae. MRI revealed significant canal and lateral recess stenosis secondary to facet hypertrophy. We planned a front-back correction of the anterior and posterior spinal elements. We first performed anterior release at the fused part from L1 to L3 and XLIF at L3/4 and L4/5. Next, the patient was placed in the prone position. Spondylectomy at the L2 vertebra and posterior fusion from T10 to L5 were performed. Postoperative radiographs revealed L1 to L3 kyphosis of 32°. No complications occurred during or after surgery. Postoperatively, the patient's low back pain and neurological claudication were resolved. No worsening of kyphosis was observed 24 months postoperatively. Circumferential decompression of the spinal cord at the apical vertebral level and decompression of lumbar canal stenosis were necessary. Front-back correction of the anterior and posterior spinal elements via spondylectomy and lateral lumbar interbody fusion is a reasonable surgical option for thoracolumbar kyphosis and developmental canal stenosis in patients with achondroplasia.

The posterolateral corner of the knee.

PubMed

Vinson, Emily N; Major, Nancy M; Helms, Clyde A

2008-02-01

The purpose of this article is to review the clinical importance and MRI appearances of injuries to the posterolateral corner of the knee. Injuries to the posterolateral corner structures of the knee can cause significant disability due to instability, cartilage degeneration, and cruciate graft failure. Becoming familiar with the anatomy of this region can improve one's ability to detect subtle abnormalities and can perhaps lead to improvements in diagnosing and understanding injuries to this area.

Comprehensive comparing percutaneous endoscopic lumbar discectomy with posterior lumbar internal fixation for treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis: A retrospective case-control study.

PubMed

Sun, Yapeng; Zhang, Wei; Qie, Suhui; Zhang, Nan; Ding, Wenyuan; Shen, Yong

2017-07-01

The study was to comprehensively compare the postoperative outcome and imaging parameter characters in a short/middle period between the percutaneous endoscopic lumbar discectomy (PELD) and the internal fixation of bone graft fusion (the most common form is posterior lumbar interbody fusion [PLIF]) for the treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis after a previous lumbar internal fixation surgery.In this retrospective case-control study, we collected the medical records from 11 patients who received PELD operation (defined as PELD group) for and from 13 patients who received the internal fixation of bone graft fusion of lumbar posterior vertebral lamina decompression (defined as control group) for the treatment of the lumbar disc prolapse combined with stable retrolisthesis at Department of Spine Surgery, the Third Hospital of Hebei Medical University (Shijiazhuang, China) from May 2010 to December 2015. The operation time, the bleeding volume of perioperation, and the rehabilitation days of postoperation were compared between 2 groups. Before and after surgery at different time points, ODI, VAS index, and imaging parameters (including Taillard index, inter-vertebral height, sagittal dislocation, and forward bending angle of lumbar vertebrae) were compared.The average operation time, the blooding volume, and the rehabilitation days of postoperation were significantly less in PELD than in control group. The ODI and VAS index in PELD group showed a significantly immediate improving on the same day after the surgery. However, Taillard index, intervertebral height, sagittal dislocation in control group showed an immediate improving after surgery, but no changes in PELD group till 12-month after surgery. The forward bending angle of lumbar vertebrae was significantly increased and decreased in PELD and in control group, respectively.PELD operation was superior in terms of operation time, bleeding volume, recovery period, and financial

Complications of anterior cervical discectomy and fusion using recombinant human bone morphogenetic protein-2

PubMed Central

Carp, Julia; Sethi, Anil; Bartol, Stephen; Craig, Joseph; Les, Clifford M.

2007-01-01

The use of bone morphogenetic protein-2 (rhBMP-2) in spinal fusion has increased dramatically since an FDA approval for its use in anterior lumbar fusion with the LT cage. There are several reports of its use in transforaminal lumbar interbody fusion, posterolateral fusion, and anterior cervical fusion. Reports on adverse effects of rhBMP-2 when used in spinal fusion are scarce in literature. An Institutional Review Board approved retrospective study was conducted in patients undergoing anterior spinal fusion and instrumentation following diskectomy at a single center. Forty-six consecutive patients were included. Twenty-two patients treated with rhBMP-2 and PEEK cages were compared to 24 in whom allograft spacers and demineralized bone matrix was used. Patients filled out Cervical Oswestry Scores, VAS for arm pain, neck pain, and had radiographs preoperatively as well at every follow up visit. Radiographic examination following surgery revealed end plate resorption in all patients in whom rhBMP-2 was used. This was followed by a period of new bone formation commencing at 6 weeks. In contrast, allograft patients showed a progressive blurring of end plate-allograft junction. Dysphagia was a common complication and it was significantly more frequent and more severe in patients in whom rhBMP-2 was used. Post operative swelling anterior to the vertebral body on lateral cervical spine X-ray was significantly larger in the rhBMP-2 group when measured from 1 to 6 weeks after which it was similar. These effects are possibly due to an early inflammatory response to rhBMP-2 and were observed to be dose related. With the parameters we used, there was no significant difference in the clinical outcome of patients in the two groups at 2 years. The cost of implants in patients treated with rhBMP-2 and PEEK spacers was more than three times the cost of allograft spacers and demineralized bone matrix in 1, 2, and 3-level cases. Despite providing consistently good fusion rates

[Surgical treatment of degenerative lumbar scoliosis with multi-segment lumbar spinal stenosis].

PubMed

Lan, Jiaping; Tang, Xun; Xu, Yongqing; Zhou, Tianhua; Shi, Jian; Cui, Yi; Xiang, Qili; Cai, Zhijun; Zhao, Qingkai; Yang, Xiaoyong; Zhao, Caihua

2014-08-01

To explore the surgical indications, decompression and fusion method, and fusion level selection of degenerative lumbar scoliosis (DLS) and multi-segment lumbar spinal stenosis. Between April 2000 and November 2011, 46 cases of DLS and multi-segment lumbar spinal stenosis were treated with multi-level decompression by fenestration and crept enlargement plus internal fixation by interbody and posterior-lateral bone graft fusion (5 segments or above). Of 46 cases, 25 were male and 21 were female, with a mean age of 70.2 years (range, 65-81 years) and with a mean disease duration of 6.4 years (range, 4 years and 6 months to 13 years). X-ray films showed that the lumbar Cobb angle was (26.7 ± 10.0) degrees, and the lumbar lordotic angle was (20.3 ± 8.8)degrees. The lumbar CT and MRI images showed three-segment stenosis in 24 cases, four-segment stenosis in 17 cases, and five-segment stenosis in 5 cases. A total of 165 stenosed segments included 12 L1,2, 34 L2,3, 43 L3,4, 45 L4,5, and 31 L5 and S1. Visual analogue scale (VAS) score, Oswestry disability index (ODI), and Japanese Orthopedic Association (JOA) score (29 points) were employed to evaluate effectiveness. Thirteen patients had leakage of cerebrospinal fluid during operation, and no infection was found after corresponding treatment; pulmonary infection and urinary system infection occurred in 4 and 2 patients respectively, who relieved after received antibiotic therapy; 8 patients with poor wound healing received dressing change, adequate drainage, debridement and suture. No death, paralysis, central nervous system infection, or other complication was observed in these patients. Forty-six cases were followed up 12-72 months (mean, 36.2 months). Lumbago and backache and intermittent claudication of lower extremity were obviously improved. During follow-up, no screw incising, loosening and broken screws, or pseudarthrosis was noted under X-ray film and CT scanning. At last follow-up, the lumbar Cobb angle was

Postoperative dysesthesia in minimally invasive transforaminal lumbar interbody fusion: a report of five cases.

PubMed

Wang, Honggang; Zhou, Yue; Zhang, Zhengfeng

2016-05-01

Minimally invasive transforaminal lumbar interbody fusion (misTLIF) can potentially lead to dorsal root ganglion (DRG) injury which may cause postoperative dysesthesia (POD). The purpose of retrospective study was to describe the uncommon complication of POD in misTLIF. Between January 2010 and December 2014, 539 patients were treated with misTLIF in investigator group. POD was defined as dysesthetic pain or burning dysesthesia at a proper DRG innervated region, whether spontaneous or evoked. Non-steroidal antiinflammatory drugs, central non-opioid analgesic agent, neuropathic pain drugs and/or intervertebral foramen block were selectively used to treat POD. There were five cases of POD (5/539, 0.9 %), which consisted of one patient in recurrent lumbar disc herniation (1/36, 3 %), one patient in far lateral lumbar disc herniation (1/34, 3 %), and 3 patients in lumbar spondylolisthesis (3/201, 1 %). Two DRG injury cases were confirmed by revision surgery. After the treatment by drugs administration plus DRG block, all patients presented pain relief with duration from 22 to 50 days. A gradual pain moving to distal end of a proper DRG innervated region was found as the beginning of end. Although POD is a unique and rare complication and maybe misdiagnosed as nerve root injury in misTLIF, combination drug therapy and DRG block have an effective result of pain relief. The appearance of a gradual pain moving to distal end of a proper DRG innervated region during recovery may be used as a sign for the good prognosis.

Allogeneic mesenchymal precursor cells (MPCs) combined with an osteoconductive scaffold to promote lumbar interbody spine fusion in an ovine model.

PubMed

Wheeler, Donna L; Fredericks, Douglas C; Dryer, Randall F; Bae, Hyun W

2016-03-01

Advances in immunomagnetic cell sorting have enabled isolation and purification of pleuripotent stem cells from marrow aspirates and have expanded stem cell therapies to include allogeneic sources. This study aimed to determine the safety and efficacy of allogeneic mesenchymal precursor cells (MPCs) combined with an osteoconductive scaffold in lumbar interbody spinal fusion using an ovine model. Thirty-two skeletally mature ewes underwent a single-level interbody fusion procedure using a Polyetheretherketone fusion cage supplemented with either iliac crest autograft (AG) or an osteconductive scaffold (Mastergraft Matrix, Medtronic, Memphis, TN, USA) with 2.5×10(6) MPCs, 6.25×10(6) MPCs, or 12.5×10(6) MPCs. Plain radiographs and computed tomography scans were scored for bridging bone at multiple points during healing and at necropsy. The biomechanical competency of fusion was scored by manual palpation and quantified using functional radiographs at necropsy. Postnecropsy histopathology and histomorphometric analysis assessed the local response to MPC treatment and quantified the volume and connectivity of newly formed bridging bone. Safety was assessed by serum biochemistry, hematology, and organ histopathology. Mesenchymal precursor cell treatment caused no adverse systemic or local tissue responses. All analyses indicated MPCs combined with an osteoconductive scaffold achieved similar or better fusion success as AG treatment after 16 weeks, and increasing the MPC dose did not enhance fusion. Manual palpation of the fusion site indicated more than 75% of MPC-treated and 65% of AG-treated animals achieved rigid fusion, which was corroborated with functional radiography. Computed tomography fusion scores indicated all animals in the MPC- and AG-treatment groups were fused at 16 weeks, yet X-ray scores indicated only 67% of the AG-treated animals were fused. Histomorphometry analyses showed equivalent outcomes for fusion connectivity and bony fusion area for

Long-term effects of placing one or two cages in instrumented posterior lumbar interbody fusion.

PubMed

Zhang, Mingzheng; Pu, Fang; Xu, Liqiang; Zhang, Linlin; Yao, Jie; Li, Deyu; Wang, Yu; Fan, Yubo

2016-06-01

Posterior lumbar interbody fusion (PLIF) is an established surgical procedure for spine stabilization after the removal of an intervertebral disc. Researches have shown that inserting a single oblique cage has a similar immediate effect to coupled cages, and it has been proposed that single-cage PLIF is a useful alternative to traditional two-cage PLIF. However, it is not clear whether placing one or two cages represents the best choice for long-term fusion. The aim of this study is to examine how cage placement affects bone remodeling after PLIF surgery, and how this consequently impacts the long-term fusion process. A finite element model of a L3-L4 lumbar spine with PLIF was developed. The spinal segment was modeled with a partial laminectomy and a discectomy with partial facetectomy, and implanted with posterior pedicle screws. Two models were analyzed, one with coupled parallel cages and one with a single oblique cage. Adaptive bone remodeling was simulated according to Huiskes' criterion. The results showed that in the initial state prior to any bone remodeling, cage stress, cage subsidence and cage dislodgement in the single cage model were all greater than in the coupled cage model. In the final state after significant bone remodeling had taken place, these parameters had decreased in both models and the differences between the two models were reduced. Also, the single cage model demonstrated superior bone development in the bone graft when placed under a constant 400 N axial compressive load. Based on the long-term results, instrumented PLIF with a single cage could also be encouraged in clinical practice.

Concurrent Use of Lumbar Total Disc Arthroplasty and Anterior Lumbar Interbody Fusion: The Lumbar Hybrid Procedure for the Treatment of Multilevel Symptomatic Degenerative Disc Disease: A Prospective Study.

PubMed

Scott-Young, Matthew; McEntee, Laurence; Schram, Ben; Rathbone, Evelyne; Hing, Wayne; Nielsen, David

2018-01-15

A prospective study. The aim of this study was to evaluate clinical and patient outcomes post combined total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF), known as hybrid surgery for the treatment of multilevel symptomatic degenerative disc disease (DDD). Class I studies comparing the treatment of one-level lumbar DDD with TDA and ALIF have confirmed the effectiveness of those treatments through clinical and patient outcomes. Although the success of single-level disease is well documented, the evidence relating to the treatment of multilevel DDD with these modalities is emerging. With the evolution of the TDA technology, a combined approach to multilevel disease has developed in the form of the hybrid procedure. A total of 617 patients underwent hybrid surgery for chronic back pain between July 1998 and February 2012. Visual Analog Pain Scale for the back and leg were recorded along with the Oswestry Disability Index and Roland Morris Disability Questionnaire. Both statistically and clinically significant (p < 0.005) reductions were seen in back and leg pain, which were sustained for at least 8 years postsurgery. In addition, significant improvements (P < 0.001) in self-rated disability and function were also maintained for at least 8 years. Patient satisfaction was rated as good or excellent in >90% of cases. The results of this research indicate that improvements in both back and leg pain and function can be achieved using the hybrid lumbar reconstructive technique. 4.

Tertiary syphilis in the lumbar spine: a case report.

PubMed

Bai, Yang; Niu, Feng; Liu, Lidi; Sha, Hui; Wang, Yimei; Zhao, Song

2017-07-24

The incidence of tertiary syphilis involvement in the spinal column with destructive bone lesions is very rare. It is difficult to establish the correct diagnosis from radiographs and histological examination alone. Limited data are available on surgical treatment to tertiary syphilitic spinal lesions. In this article, we report a case of tertiary syphilis in the lumbar spine with osteolytic lesions causing cauda equina compression. A 44-year-old man who suffered with low back pain for 6 months and progressive radiating pain at lower extremity for 1 week. Radiologic findings showed osteolytic lesion and new bone formation in the parts of the bodies of L4 and L5. Serum treponema pallidum hemagglutination (TPHA) test was positive. A surgery of posterior debridement, interbody and posterolateral allograft bone fusion with instrumentation from L3 to S1 was performed. The low back pain and numbness abated after operation. But the follow-up radiographs showed absorption of the bone grafts and failure of instrumentation. A Charcot's arthropathy was formed between L4 and L5. It is challenging to diagnose the tertiary syphilis in the spine. Surgery is a reasonable auxiliary method to antibiotic therapy for patients who suffered with neuropathy. Charcot's arthropathy should be considered as an operative complication.

Biomechanical advantages of robot-assisted pedicle screw fixation in posterior lumbar interbody fusion compared with freehand technique in a prospective randomized controlled trial-perspective for patient-specific finite element analysis.

PubMed

Kim, Ho-Joong; Kang, Kyoung-Tak; Park, Sung-Cheol; Kwon, Oh-Hyo; Son, Juhyun; Chang, Bong-Soon; Lee, Choon-Ki; Yeom, Jin S; Lenke, Lawrence G

2017-05-01

There have been conflicting results on the surgical outcome of lumbar fusion surgery using two different techniques: robot-assisted pedicle screw fixation and conventional freehand technique. In addition, there have been no studies about the biomechanical issues between both techniques. This study aimed to investigate the biomechanical properties in terms of stress at adjacent segments using robot-assisted pedicle screw insertion technique (robot-assisted, minimally invasive posterior lumbar interbody fusion, Rom-PLIF) and freehand technique (conventional, freehand, open approach, posterior lumbar interbody fusion, Cop-PLIF) for instrumented lumbar fusion surgery. This is an additional post-hoc analysis for patient-specific finite element (FE) model. The sample is composed of patients with degenerative lumbar disease. Intradiscal pressure and facet contact force are the outcome measures. Patients were randomly assigned to undergo an instrumented PLIF procedure using a Rom-PLIF (37 patients) or a Cop-PLIF (41), respectively. Five patients in each group were selected using a simple random sampling method after operation, and 10 preoperative and postoperative lumbar spines were modeled from preoperative high-resolution computed tomography of 10 patients using the same method for a validated lumbar spine model. Under four pure moments of 7.5 Nm, the changes in intradiscal pressure and facet joint contact force at the proximal adjacent segment following fusion surgery were analyzed and compared with preoperative states. The representativeness of random samples was verified. Both groups showed significant increases in postoperative intradiscal pressure at the proximal adjacent segment under four moments, compared with the preoperative state. The Cop-PLIF models demonstrated significantly higher percent increments of intradiscal pressure at proximal adjacent segments under extension, lateral bending, and torsion moments than the Rom-PLIF models (p=.032, p=.008, and p

Direct lateral approach to lumbar fusion is a biomechanically equivalent alternative to the anterior approach: an in vitro study.

PubMed

Laws, Cory J; Coughlin, Dezba G; Lotz, Jeffrey C; Serhan, Hassan A; Hu, Serena S

2012-05-01

A human cadaveric biomechanical study of lumbar mobility before and after fusion and with or without supplemental instrumentation for 5 instrumentation configurations. To determine the biomechanical differences between anterior lumbar interbody fusion (ALIF) and direct lateral interbody fusion (DLIF) with and without supplementary instrumentation. Some prior studies have compared various surgical approaches using the same interbody device whereas others have investigated the stabilizing effect of supplemental instrumentation. No published studies have performed a side-by-side comparison of standard and minimally invasive techniques with and without supplemental instrumentation. Eight human lumbosacral specimens (16 motion segments) were tested in each of the 5 following configurations: (1) intact, (2) with ALIF or DLIF cage, (3) with cage plus stabilizing plate, (4) with cage plus unilateral pedicle screw fixation (PSF), and (5) with cage plus bilateral PSF. Pure moments were applied to induce specimen flexion, extension, lateral bending, and axial rotation. Three-dimensional kinematic responses were measured and used to calculate range of motion, stiffness, and neutral zone. Compared to the intact state, DLIF significantly reduced range of motion in flexion, extension, and lateral bending (P = 0.0117, P = 0.0015, P = 0.0031). Supplemental instrumentation significantly increased fused-specimen stiffness for both DLIF and ALIF groups. For the ALIF group, bilateral PSF increased stiffness relative to stand-alone cage by 455% in flexion and 317% in lateral bending (P = 0.0009 and P < 0.0001). The plate increased ALIF group stiffness by 211% in extension and 256% in axial rotation (P = 0.0467 and P = 0.0303). For the DLIF group, bilateral PSF increased stiffness by 350% in flexion and 222% in extension (P < 0.0001 and P = 0.0008). No differences were observed between ALIF and DLIF groups supplemented with bilateral PSF. Our data support that the direct lateral approach

Work intensity in sacroiliac joint fusion and lumbar microdiscectomy

PubMed Central

Frank, Clay; Kondrashov, Dimitriy; Meyer, S Craig; Dix, Gary; Lorio, Morgan; Kovalsky, Don; Cher, Daniel

2016-01-01

Background The evidence base supporting minimally invasive sacroiliac (SI) joint fusion (SIJF) surgery is increasing. The work relative value units (RVUs) associated with minimally invasive SIJF are seemingly low. To date, only one published study describes the relative work intensity associated with minimally invasive SIJF. No study has compared work intensity vs other commonly performed spine surgery procedures. Methods Charts of 192 patients at five sites who underwent either minimally invasive SIJF (American Medical Association [AMA] CPT® code 27279) or lumbar microdiscectomy (AMA CPT® code 63030) were reviewed. Abstracted were preoperative times associated with diagnosis and patient care, intraoperative parameters including operating room (OR) in/out times and procedure start/stop times, and postoperative care requirements. Additionally, using a visual analog scale, surgeons estimated the intensity of intraoperative care, including mental, temporal, and physical demands and effort and frustration. Work was defined as operative time multiplied by task intensity. Results Patients who underwent minimally invasive SIJF were more likely female. Mean procedure times were lower in SIJF by about 27.8 minutes (P<0.0001) and mean total OR times were lower by 27.9 minutes (P<0.0001), but there was substantial overlap across procedures. Mean preservice and post-service total labor times were longer in minimally invasive SIJF (preservice times longer by 63.5 minutes [P<0.0001] and post-service labor times longer by 20.2 minutes [P<0.0001]). The number of postoperative visits was higher in minimally invasive SIJF. Mean total service time (preoperative + OR time + postoperative) was higher in the minimally invasive SIJF group (261.5 vs 211.9 minutes, P<0.0001). Intraoperative intensity levels were higher for mental, physical, effort, and frustration domains (P<0.0001 each). After taking into account intensity, intraoperative workloads showed substantial overlap. Conclusion

Failed less invasive lumbar spine surgery as a predictor of subsequent fusion outcomes.

PubMed

Gillard, Douglas M; Corenman, Donald S; Dornan, Grant J

2014-04-01

It is not uncommon for patients to undergo less invasive spine surgery (LISS) prior to succumbing to lumbar fusion; however, the effect of failed LISS on subsequent fusion outcomes is relatively unknown. The aim of this study was to test the hypothesis that patients who suffered failed LISS would afford inferior subsequent fusion outcomes when compared to patients who did not have prior LISS. After IRB approval, registry from a spine surgeon was queried for consecutive patients who underwent fusion for intractable low back pain. The 47 qualifying patients were enrolled and split into two groups based upon a history for prior LISS: a prior surgery group (PSG) and a non-prior surgery group (nPSG). Typical postoperative outcome questionnaires, which were available in 80.9% of the patients (38/47) at an average time point of 40.4 months (range, 13.5-66.1 months), were comparatively analysed and failed to demonstrate significant difference between the groups, e.g. PSG v. nPSG: ODI--14.6 ± 10.9 vs. 17.2 ± 19.4 (P = 0.60); SF12-PCS--10.9 ± 11.0 vs. 8.7 ± 12.4 (p = 0.59); bNRS--3.0 (range -2-7) vs. 2.0 (range -3-8) (p = 0.91). Patient satisfaction, return to work rates, peri-operative complications, success of fusion and rate of revision surgery were also not different. Although limited by size and retrospective design, the results of this rare investigation suggest that patients who experience a failed LISS prior to undergoing fusion will not suffer inferior fusion outcomes when compared to patients who did not undergo prior LISS.

Early Outcomes of Primary Total Hip Arthroplasty After Prior Lumbar Spinal Fusion.

PubMed

Barry, Jeffrey J; Sing, David C; Vail, Thomas P; Hansen, Erik N

2017-02-01

The coexistence of degenerative hip disease and spinal pathology is not uncommon with the number of surgical treatments performed for each condition increasing annually. The limited research available suggests spinal pathology portends less pain relief and worse outcomes after total hip arthroplasty (THA). We hypothesize that primary THA patients with preexisting lumbar spinal fusions (LSF) experience worse early postoperative outcomes. This study is a retrospective matched cohort study. Primary THA patients at 1 institution who had undergone prior LSF (spine arthrodesis-hip arthroplasty [SAHA]) were identified and matched to controls of primary THA without LSF. Early outcomes (<90 days) were compared. From 2012 to 2014, 35 SAHA patients were compared to 70 matched controls. Patients were similar in age, sex, American Society of Anesthesiologist score, body mass index, and Charlson Comorbidity Index. SAHA patients had higher rates of complications (31.4% vs 8.6%, P = .008), reoperation (14.3% vs 2.9%, P = .040), and general anesthesia (54.3% vs 5.7%, P = .0001). Bivariate analysis demonstrated SAHA to predict reoperation (odds ratio, 5.67; P = .045) and complications (odds ratio, 4.89; P = .005). With the numbers available, dislocations (0% vs 2.8%), infections (0% vs 8.6%), readmissions, postoperative walking distance, and disposition only trended to favor controls (P > .05). Comparing controls to SAHA patients with <3 or ≥3 levels fused, longer fusions had increased cumulative postoperative narcotic consumption (mean morphine equivalents, 44.3 vs 46.9 vs 169.4; P = .001). Patients with preexisting LSF experience worse early outcomes after primary THA including higher rates of complications and reoperation. Lower rates of neuraxial anesthesia and increased narcotic usage represent potential contributors. The complex interplay between the lumbar spine and hip warrants attention and further investigation. Copyright © 2016 Elsevier Inc. All rights reserved.

Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.

PubMed

Pang, Xiaoyang; Shen, Xiongjie; Wu, Ping; Luo, Chenke; Xu, Zhengquan; Wang, Xiyang

2013-06-01

Retrospective analysis of the clinical efficacy and feasibility of patients with thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. A total of 18 patients with thoracolumbar tuberculosis (TB), between February 2007 and February 2011, underwent one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. And the clinical efficacy was evaluated based on surgery duration time, the blood loss, the postural drainage of time, neurological status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, the fate of bone graft fusion, kyphosis angle, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at certain time. The average follow-up period was 34 months (range 18-48 months). 18 patients suffered from seriously neurological deficits pre-operatively, of which 16 patients returned to normal at final follow-up. The surgery duration time was 197 ± 37.9 min, and the blood loss was 815 ± 348.5 ml. The postural drainage of time was 7.2 ± 2.7 days. The psoas abscesses disappeared in all cases, within the time range of 6-9 months (mean 7.4 ± 1.2 months). All patients of the grafted bones were thoroughly fused, with a fusion time ranging from 4 to 12 months (mean 7.8 months). Kyphosis angle was 44.32 ± 7.26° on average pre-operative and returned to 11.72 ± 2.85° at 6 weeks after operation; kyphosis angle was 13.10 ± 2.39° at final follow-up. The values of ESR and CRP were significant declined at 6 weeks post-operative, and returned to normal levels at final follow-up. With standardized anti-TB chemotherapy, thoracolumbar spinal tuberculosis with psoas abscesses could be effectively treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.

Importance of the back-café concept to rehabilitation after lumbar spinal fusion: a randomized clinical study with a 2-year follow-up.

PubMed

Christensen, Finn B; Laurberg, Ida; Bünger, Cody E

2003-12-01

A prospective, randomized, clinical study with a 2-year follow-up. To analyze the effect of three different rehabilitation strategies for lumbar spinal fusion patients. Fifteen percent to 40% of lumbar spinal fusion patients are not expected to improve significantly over a 2-year period. Optimization of present forms of rehabilitation could possibly further improve the outcome. Between 1996 and 1999, 90 patients who had undergone lumbar spinal fusion were 3 months after surgery randomized to one of three different rehabilitation groups. Video group participants watched a video of exercises for training and were subsequently and only once provided instruction regarding their use. The back-café group was provided the same program as the video group, but as a supplement met with a back-café with other fusion-operated patients three times over an 8-week period. The training group was provided physical therapy training twice weekly for 8 weeks. Functional outcome was evaluated at 6, 12, and 24 months after surgery by use of the low back pain rating scale and a questionnaire covering daily functions, work status, and a patient's contact with the primary sector. By 2-year follow-up, the back-café and video groups had less pain compared with the training group (P < 0.03). The back-café group was better at performing daily functions such as carrying bags of market items (P < 0.01), getting up from a chair (P < 0.01), and ascending staircases (P < 0.01) compared with the video and training groups. More in the back-café group resumed working after surgery compared with the two other groups (P < 0.04). The video group had significantly more contacts with general practitioners, physical therapists, and so on compared with the back-café and training groups (P < 0.001). The patients in the back-café group were significantly better at accomplishing a succession of daily tasks compared with the video and training groups 2 years after lumbar spinal fusion. At the 2-year

The effect of anterior longitudinal ligament resection on lordosis correction during minimally invasive lateral lumbar interbody fusion: Biomechanical and radiographic feasibility of an integrated spacer/plate interbody reconstruction device.

PubMed

Kim, Choll; Harris, Jonathan A; Muzumdar, Aditya; Khalil, Saif; Sclafani, Joseph A; Raiszadeh, Kamshad; Bucklen, Brandon S

2017-03-01

Lateral lumbar interbody fusion is powerful for correcting degenerative conditions, yet sagittal correction remains limited by anterior longitudinal ligament tethering. Although lordosis has been restored via ligament release, biomechanical consequences remain unknown. Investigators examined radiographic and biomechanical of ligament release for restoration of lumbar lordosis. Six fresh-frozen human cadaveric spines (L3-S1) were tested: (Miller et al., 1988) intact; (Battie et al., 1995) 8mm spacer with intact anterior longitudinal ligament; (Cho et al., 2013) 8mm spacer without intact ligament following ligament resection; (Galbusera et al., 2013) 13mm lateral lumbar interbody fusion; (Goldstein et al., 2001) integrated 13mm spacer. Focal lordosis and range of motion were assessed by applying pure moments in flexion-extension, lateral bending, and axial rotation. Cadaveric radiographs showed significant improvement in lordosis correction following ligament resection (P<0.05). The 8mm spacer with ligament construct provided greatest stability relative to intact (P>0.05) but did little to restore lordosis. Ligament release significantly destabilized the spine relative to intact in all modes and 8mm with ligament in lateral bending and axial rotation (P<0.05). Integrated lateral lumbar interbody fusion following ligament resection did not significantly differ from intact or from 8mm with ligament in all testing modes (P>0.05). Lordosis corrected by lateral lumbar interbody fusion can be improved by anterior longitudinal ligament resection, but significant construct instability and potential implant migration/dislodgment may result. This study shows that an added integrated lateral fixation system can significantly improve construct stability. Long-term multicenter studies are needed. Copyright © 2017 Elsevier Ltd. All rights reserved.

Hybrid Biosynthetic Autograft Extender for Use in Posterior Lumbar Interbody Fusion: Safety and Clinical Effectiveness.

PubMed

Chedid, Mokbel K; Tundo, Kelly M; Block, Jon E; Muir, Jeffrey M

2015-01-01

Autologous iliac crest bone graft is the preferred option for spinal fusion, but the morbidity associated with bone harvest and the need for graft augmentation in more demanding cases necessitates combining local bone with bone substitutes. The purpose of this study was to document the clinical effectiveness and safety of a novel hybrid biosynthetic scaffold material consisting of poly(D,L-lactide-co-glycolide) (PLGA, 75:25) combined by lyophilization with unmodified high molecular weight hyaluronic acid (10-12% wt:wt) as an extender for a broad range of spinal fusion procedures. We retrospectively evaluated all patients undergoing single- and multi-level posterior lumbar interbody fusion at an academic medical center over a 3-year period. A total of 108 patients underwent 109 procedures (245 individual vertebral levels). Patient-related outcomes included pain measured on a Visual Analog Scale. Radiographic outcomes were assessed at 6 weeks, 3-6 months, and 1 year postoperatively. Radiographic fusion or progression of fusion was documented in 221 of 236 index levels (93.6%) at a mean (±SD) time to fusion of 10.2+4.1 months. Single and multi-level fusions were not associated with significantly different success rates. Mean pain scores (+SD) for all patients improved from 6.8+2.5 at baseline to 3.6+2.9 at approximately 12 months. Improvements in VAS were greatest in patients undergoing one- or two-level fusion, with patients undergoing multi-level fusion demonstrating lesser but still statistically significant improvements. Overall, stable fusion was observed in 64.8% of vertebral levels; partial fusion was demonstrated in 28.8% of vertebral levels. Only 15 of 236 levels (6.4%) were non-fused at final follow-up.

The effects of massage therapy after decompression and fusion surgery of the lumbar spine: a case study.

PubMed

Keller, Glenda

2012-01-01

Spinal fusion and decompression surgery of the lumbar spine are common procedures for problems such as disc herniations. Various studies for postoperative interventions have been conducted; however, no massage therapy studies have been completed. The objective of this study is to determine if massage therapy can beneficially treat pain and dysfunction associated with lumbar spinal decompression and fusion surgery. Client is a 47-year-old female who underwent spinal decompression and fusion surgery of L4/L5 due to chronic disc herniation symptoms. The research design was a case study in a private clinic involving the applications of seven, 30-minute treatments conducted over eight weeks. Common Swedish massage and myofascial techniques were applied to the back, shoulders, posterior hips, and posterior legs. Outcomes were assessed using the following measures: VAS pain scale, Hamstring Length Test, Oswestry Disability Index, and the Roland-Morris Disability Questionnaire. Hamstring length improved (in degrees of extension) from pretreatment measurements in the right leg of 40° and left leg 65° to post-treatment measurement at the final visit, when the results were right 50° and left 70°. The Oswestry Disability Index improved 14%, from 50% to 36% disability. Roland-Morris Disability decreased 1 point, from 3/24 to 2/24. The VAS pain score decreased by 2 points after most treatments, and for three of the seven treatments, client had a post-treatment score of 0/10. Massage for pain had short-term effects. Massage therapy seemed to lengthen the hamstrings bilaterally. Massage therapy does appear to have positive effects in the reduction of disability. This study is beneficial for understanding the relationship between massage therapy and clients who have undergone spinal decompression and fusion. Further research is warranted.

Survivorship and clinical outcomes after multi-level anterior lumbar reconstruction with stand-alone anterior lumbar interbody fusion or hybrid construct.

PubMed

Chen, Benjamin; Akpolat, Yusuf T; Williams, Paul; Bergey, Darren; Cheng, Wayne K

2016-06-01

In multilevel disc disease, there is still uncertainty regarding whether multiple total disc replacement is more effective and safer than fusion. Our objective was to measure and compare the clinical outcome of multilevel hybrid constructs with stand-alone anterior lumbar interbody fusion (ALIF) using a retrospective analysis. Sixty-four patients with chronic low back pain determined to be from two or three-level degenerative disc disease were included. Thirty-three patients were treated with hybrid fusion and 31 with ALIF. Several parameters were retrospectively reviewed, including blood loss, operation time, hospital stay, Visual Analog Scale (VAS) score, Oswestry Disability Index (ODI), and survivorship without the need for revision surgery. Telephone follow-ups were conducted to ascertain survivorship, clinical outcomes (VAS, ODI) and patient satisfaction. Operation time was longer in the hybrid group (p=0.021). The hybrid group showed a significant improvement in VAS and ODI with 52.2% and 50.0% improvement versus 28.3% and 25.5% in the ALIF group (p<0.05). At the telephone follow-up for patient satisfaction, 95.7% (n=22) of the hybrid group were satisfied and 95.2% (n=21) of the ALIF group were satisfied. Seventy-four percent (n=17) in the hybrid group and 85.7% (n=18) in the ALIF group would choose to do the initial surgery again. Kaplan-Meier analysis showed 80.5% survivorship for hybrids and 75.9% for ALIF at 5years. With our clinical outcomes in VAS and ODI scores, these results, when taken together, indicate that hybrid fusion is a valid and viable alternative to ALIF fusion, with at least equal if not better clinical outcomes in terms of survivorship, back pain, and disability scores. Copyright © 2015 Elsevier Ltd. All rights reserved.

Pseudogout of the cervical and thoracic spine mimicking infection after lumbar fusion: case report.

PubMed

Bridges, Kelly J; Bullis, Carli L; Wanchu, Ajay; Than, Khoi D

2017-08-01

Pseudogout is a form of acute calcium pyrophosphate deposition (CPPD) disease that typically afflicts the elderly. CPPD commonly involves larger joints, such as the knees, wrists, shoulders, and hips, and has been known to involve the spine. The authors report the case of a 66-year-old woman with a recent history of lumbar laminectomy and fusion who presented 5 weeks postprocedure with a clinical and radiographic picture consistent with multilevel skip lesions involving the cervical and thoracic spine, thoracic discitis, and epidural abscess. Serial blood cultures and repeat biopsy samples were sterile. Subsequent wrist and ankle erythema, pain, and swelling led to synovial fluid analysis, and pseudogout was diagnosed. She was treated with an interleukin-1 inhibitor with immediate symptom relief. To the authors' knowledge, this is only the second report of spinal pseudogout presenting with a clinical and radiographic picture consistent with discitis and epidural abscess. This report is the first to report skip lesions of pseudogout occurring throughout the spine that are uniquely remote from a recent lumbar surgery.

The Relationship between Serum Vitamin D Levels and Spinal Fusion Success: A Quantitative Analysis

PubMed Central

Metzger, Melodie F.; Kanim, Linda E.; Zhao, Li; Robinson, Samuel T.; Delamarter, Rick B.

2015-01-01

Study Design An in vivo dosing study of vitamin D in a rat posterolateral spinal fusion model with autogenous bone grafting. Rats randomized to four levels of Vitamin D adjusted rat chow, longitudinal serum validation, surgeons/observers blinded to dietary conditions, and rats followed prospectively for fusion endpoint. Objective To assess the impact of dietary and serum levels of Vitamin D on fusion success, consolidation of fusion mass, and biomechanical stiffness after posterolateral spinal fusion procedure. Summary of Background Data Metabolic risk factors, including vitamin D insufficiency, are often overlooked by spine surgeons. Currently there are no published data on the causal effect of insufficient or deficient vitamin D levels on the success of establishing solid bony union after a spinal fusion procedure. Methods 50 rats were randomized to four experimentally controlled rat chow diets: normal control, vitamin D-deficient, vitamin-D insufficient, and a non-toxic high dose of vitamin D, four weeks prior to surgery and maintained post-surgery until sacrifice. Serum levels of 25(OH)D were determined at surgery and sacrifice using radioimmunoassay. Posterolateral fusion surgery with tail autograft was performed. Rats were sacrificed 12 weeks post-operatively and fusion was evaluated via manual palpation, high resolution radiographs, μCT, and biomechanical testing. Results Serum 25(OH)D and calcium levels were significantly correlated with vitamin-D adjusted chow (p<0.001). There was a dose dependent relationship between vitamin D adjusted chow and manual palpation fusion with greatest differences found in measures of radiographic density between high and deficient vitamin D (p<0.05). Adequate levels of vitamin D (high and normal control) yielded stiffer fusion than inadequate levels (insufficient and deficient) (p<0.05). Conclusions Manual palpation fusion rates increased with supplementation of dietary vitamin D. Biomechanical stiffness, bone volume and

Percutaneous full endoscopic lumbar foraminoplasty for adjacent level foraminal stenosis following vertebral intersegmental fusion in an awake and aware patient under local anesthesia: A case report.

PubMed

Yamashita, Kazuta; Higashino, Kosaku; Sakai, Toshinori; Takata, Yoichiro; Hayashi, Fumio; Tezuka, Fumitake; Morimoto, Masatoshi; Chikawa, Takashi; Nagamachi, Akihiro; Sairyo, Koichi

2017-01-01

Percutaneous endoscopic surgery for the lumbar spine has become established in the last decade. It requires only an 8 mm skin incision, causes minimal damage to the paravertebral muscles, and can be performed under local anesthesia. With the advent of improved equipment, in particular the high-speed surgical drill, the indications for percutaneous endoscopic surgery have expanded to include lumbar spinal canal stenosis. Transforaminal percutaneous endoscopic discectomy has been used to treat intervertebral stenosis. However, it has been reported that adjacent level disc degeneration and foraminal stenosis can occur following intervertebral segmental fusion. When this adjacent level pathology becomes symptomatic, additional fusion surgery is often needed. We performed minimally invasive percutaneous full endoscopic lumbar foraminoplasty in an awake and aware 50-year-old woman under local anesthesia. The procedure was successful with no complications. Her radiculopathy, including muscle weakness and leg pain due to impingement of the exiting nerve, improved after the surgery. J. Med. Invest. 64: 291-295, August, 2017.

Interdisciplinary Cognitive-Behavioral Therapy as Part of Lumbar Spinal Fusion Surgery Rehabilitation: Experience of Patients With Chronic Low Back Pain.

PubMed

Lindgreen, Pil; Rolving, Nanna; Nielsen, Claus Vinther; Lomborg, Kirsten

2016-01-01

Patients receiving lumbar spinal fusion surgery often have persisting postoperative pain negatively affecting their daily life. These patients may be helped by interdisciplinary cognitive-behavioral therapy which is recognized as an effective intervention for improving beneficial pain coping behavior, thereby facilitating the rehabilitation process of patients with chronic pain. The purpose of this study was to describe the lived experience of patients recovering from lumbar spinal fusion surgery and to explore potential similarities and disparities in pain coping behavior between receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy. We conducted semistructured interviews with 10 patients; 5 receiving cognitive-behavioral therapy in connection with their lumbar spinal fusion surgery and 5 receiving usual care. We conducted a phenomenological analysis to reach our first aim and then conducted a comparative content analysis to reach our second aim. Patients' postoperative experience was characterized by the need to adapt to the limitations imposed by back discomfort (coexisting with the back), need for recognition and support from others regarding their pain, a relatively long rehabilitation period during which they "awaited the result of surgery", and ambivalence toward analgesics. The patients in both groups had similar negative perception of analgesics and tended to abstain from them to avoid addiction. Coping behavior apparently differed among receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy. Receivers prevented or minimized pain by resting before pain onset, whereas nonreceivers awaited pain onset before resting. The postoperative experience entailed ambivalence, causing uncertainty, worry and insecurity. This ambivalence was relieved when others recognized the patient's pain and offered support. Cognitive-behavioral therapy as part of rehabilitation may have encouraged beneficial pain coping

Hybrid Rigid-Deformable Model for Prediction of Neighboring Intervertebral Disk Loads During Flexion Movement After Lumbar Interbody Fusion at L3-4 Level.

PubMed

Tuan Dao, Tien

2017-03-01

Knowledge of spinal loads in neighboring disks after interbody fusion plays an important role in the clinical decision of this treatment as well as in the elucidation of its effect. However, controversial findings are still noted in the literature. Moreover, there are no existing models for efficient prediction of intervertebral disk stresses within annulus fibrosus (AF) and nucleus pulposus (NP) regions. In this present study, a new hybrid rigid-deformable modeling workflow was established to quantify the mechanical stress behaviors within AF and NP regions of the L1-2, L2-3, and L4-5 disks after interbody fusion at L3-4 level. The changes in spinal loads were compared with results of the intact model without interbody fusion. The fusion outcomes revealed maximal stress changes (10%) in AF region of L1-2 disk and in NP region of L2-3 disk. The minimal stress change (1%) is noted at the NP region of the L1-2 disk. The validation of simulation outcomes of fused and intact lumbar spine models against those of other computational models and in vivo measurements showed good agreements. Thus, this present study may be used as a novel design guideline for a specific implant and surgical scenario of the lumbar spine disorders.

[The Postero-Lateral Approach--An Alternative to Closed Anterior-Posterior Screw Fixation of a Dislocated Postero-Lateral Fragment of the Distal Tibia in Complex Ankle Fractures].

PubMed

von Rüden, C; Hackl, S; Woltmann, A; Friederichs, J; Bühren, V; Hierholzer, C

2015-06-01

The dislocated posterolateral fragment of the distal tibia is considered as a key fragment for the successful reduction of comminuted ankle fractures. The reduction of this fragment can either be achieved indirectly by joint reduction using the technique of closed anterior-posterior screw fixation, or directly using the open posterolateral approach followed by plate fixation. The aim of this study was to compare the outcome after stabilization of the dislocated posterolateral tibia fragment using either closed reduction and screw fixation, or open reduction and plate fixation via the posterolateral approach in complex ankle fractures. In a prospective study between 01/2010 and 12/2012, all mono-injured patients with closed ankle fractures and dislocated posterolateral tibia fragments were assessed 12 months after osteosynthesis. Parameters included: size of the posterolateral tibia fragment relative to the tibial joint surface (CT scan, in %) as an indicator of injury severity, unreduced area of tibial joint surface postoperatively, treatment outcome assessed by using the "Ankle Fracture Scoring System" (AFSS), as well as epidemiological data and duration of the initial hospital treatment. In 11 patients (10 female, 1 male; age 51.6 ± 2.6 years [mean ± SEM], size of tibia fragment 42.1 ± 2.5 %) the fragment fixation was performed using a posterolateral approach. Impaired postoperative wound healing occurred in 2 patients of this group. In the comparison group, 12 patients were treated using the technique of closed anterior-posterior screw fixation (10 female, 2 male; age 59.5 ± 6.7 years, size of tibia fragment 45.9 ± 1.5 %). One patient of this group suffered an incomplete lesion of the superficial peroneal nerve. Radiological evaluation of the joint surface using CT scan imaging demonstrated significantly less dislocation of the tibial joint surface following the open posterolateral approach (0.60 ± 0.20 mm) compared to the closed

Biomechanical analysis of four different fixations for the posterolateral shearing tibial plateau fracture.

PubMed

Zhang, Wei; Luo, Cong-Feng; Putnis, Sven; Sun, Hui; Zeng, Zhi-Min; Zeng, Bing-Fang

2012-03-01

The posterolateral shearing tibial plateau fracture is uncommon in the literature, however with the increased usage of computer tomography (CT), the incidence of these fractures is no longer as low as previously thought. Few studies have concentrated on this fracture, least of all using a biomechanical model. The purpose of this study was to compare and analyse the biomechanical characteristics of four different types of internal fixation to stabilise the posterolateral shearing tibial plateau fracture. Forty synthetic tibiae (Synbone, right) simulated the posterolateral shearing fracture models and these were randomly assigned into four groups; Group A was fixed with two anterolateral lag screws, Group B with an anteromedial Limited Contact Dynamic Compression Plate (LC-DCP), Group C with a lateral locking plate, and Group D with a posterolateral buttress plate. Vertical displacement of the posterolateral fragment was measured using three different strengths of axial loading force, and finally loaded until fixation failure. It was concluded that the posterolateral buttress plate is biomechanically the strongest fixation method for the posterolateral shearing tibial plateau fracture. Copyright © 2011 Elsevier B.V. All rights reserved.

Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain.

PubMed

Pons, Tracey; Shipton, Edward A

2011-04-01

There are no comparative randomised controlled trials of physiotherapy modalities for chronic low back and radicular pain associated with multilevel fusion. Physiotherapy-based rehabilitation to control pain and improve activation levels for persistent pain following multilevel fusion can be challenging. This is a case report of a 68-year-old man who was referred for physiotherapy intervention 10 months after a multilevel spinal fusion for spinal stenosis. He reported high levels of persistent postoperative pain with minimal activity as a consequence of his pain following the surgery. The physiotherapy interventions consisted of three phases of rehabilitation starting with pool exercise that progressed to land-based walking. These were all combined with transcutaneous electrical nerve stimulation (TENS) that was used consistently for up to 8 hours per day. As outcome measures, daily pain levels and walking distances were charted once the pool programme was completed (in the third phase). Phase progression was determined by shuttle test results. The pain level was correlated with the distance walked using linear regression over a 5-day average. Over a 5-day moving average, the pain level reduced and walking distance increased. The chart of recorded pain level and walking distance showed a trend toward decreased pain with the increased distance walked. In a patient undergoing multilevel lumbar fusion, the combined use of TENS and a progressive walking programme (from pool to land) reduced pain and increased walking distance. This improvement was despite poor medication compliance and a reported high level of postsurgical pain.

Anterior debridement may not be necessary in the treatment of tuberculous spondylitis of the thoracic and lumbar spine in adults: a retrospective study.

PubMed

Wang, S-T; Ma, H-L; Lin, C-P; Chou, P-H; Liu, C-L; Yu, W-K; Chang, M-C

2016-06-01

Many aspects of the surgical treatment of patients with tuberculosis (TB) of the spine, including the use of instrumentation and the types of graft, remain controversial. Our aim was to report the outcome of a single-stage posterior procedure, with or without posterior decompression, in this group of patients. Between 2001 and 2010, 51 patients with a mean age of 62.5 years (39 to 86) underwent long posterior instrumentation and short posterior or posterolateral fusion for TB of the thoracic and lumbar spines, followed by anti-TB chemotherapy for 12 months. No anterior debridement of the necrotic tissue was undertaken. Posterior decompression with laminectomy was carried out for the 30 patients with a neurological deficit. The mean kyphotic angle improved from 26.1° (- 1.8° to 62°) to 15.2° (-25° to 51°) immediately after the operation. At a mean follow-up of 68.8 months (30 to 144) the mean kyphotic angle was 16.9° (-22° to 54°), with a mean loss of correction of 1.6° (0° to 10°). There was a mean improvement in neurological status of 1.2 Frankel grades in those with a neurological deficit. Bony union was achieved in all patients, without recurrent infection. Long posterior instrumentation with short posterior or posterolateral fusion is effective in the treatment of TB spine. It controls infection, corrects the kyphosis, and maintains correction and neurological improvement over time. With effective anti-TB chemotherapy, a posterior only procedure without debridement of anterior lesion is effective in the treatment of TB spondylitis, and an anterior procedure can be reserved for those patients who have not improved after posterior surgery. Cite this article: Bone Joint J 2016;98-B:834-9. ©2016 The British Editorial Society of Bone & Joint Surgery.

The Role of Posterior Screw Fixation in Single-Level Transforaminal Lumbar Interbody Fusion During Whole Body Vibration: A Finite Element Study.

PubMed

Fan, Wei; Guo, Li-Xin

2018-06-01

Few studies have evaluated the need for supplementary instrumentation after lumbar interbody fusion under the condition of whole body vibration (WBV) that is typically present in vehicles. This study aimed to determine the effect of posterior pedicle screw fixation on dynamic response of the whole lumbar spine to vertical WBV after transforaminal lumbar interbody fusion (TLIF). A previously validated nonlinear, osteoligamentous finite element (FE) model of the intact L1-sacrum human lumbar spine was modified to simulate single-level (L4-L5) TLIF without and with bilateral pedicle screw fixation (BPSF). Transit dynamic analysis was performed on the 2 developed models under a sinusoidal vertical vibration load of ±40 N and a compressive follower preload of 400 N. The resulting dynamic response results for the 2 models in terms of stresses and deformations were recorded and compared. When compared with no fixation, BPSF decreased dynamic responses of the spinal levels to the vertical vibration after TLIF. At the fused level (L4-L5), vibration amplitudes of the von-Mises stresses in L4 inferior endplate and L5 superior endplate decreased after BPSF by 48.0% and 46.4%, respectively. At other disc levels (L1-L2, L2-L3, L3-L4, and L5-S1), vibration amplitudes of the disc bulge, von-Mises stress in annulus ground substance and intradiscal pressure also produced 4.2%-9.0%, 2.3%-8.9%, and 3.4%-8.8% deceases, respectively, after BPSF. After TLIF, application of BPSF can be helpful in the prevention of spine injury during vertical WBV. Copyright © 2018 Elsevier Inc. All rights reserved.

Red Blood Cell Transfusion Need for Elective Primary Posterior Lumbar Fusion in A High-Volume Center for Spine Surgery

PubMed Central

Ristagno, Giuseppe; Beluffi, Simonetta; Tanzi, Dario; Belloli, Federica; Carmagnini, Paola; Croci, Massimo; D’Aviri, Giuseppe; Menasce, Guido; Pastore, Juan C.; Pellanda, Armando; Pollini, Alberto; Savoia, Giorgio

2018-01-01

(1) Background: This study evaluated the perioperative red blood cell (RBC) transfusion need and determined predictors for transfusion in patients undergoing elective primary lumbar posterior spine fusion in a high-volume center for spine surgery. (2) Methods: Data from all patients undergoing spine surgery between 1 January 2014 and 31 December 2016 were reviewed. Patients’ demographics and comorbidities, perioperative laboratory results, and operative time were analyzed in relation to RBC transfusion. Multivariate logistic regression analysis was performed to identify the predictors of transfusion. (3) Results: A total of 874 elective surgeries for primary spine fusion were performed over the three years. Only 54 cases (6%) required RBC transfusion. Compared to the non-transfused patients, transfused patients were mainly female (p = 0.0008), significantly older, with a higher ASA grade (p = 0.0002), and with lower pre-surgery hemoglobin (HB) level and hematocrit (p < 0.0001). In the multivariate logistic regression, a lower pre-surgery HB (OR (95% CI) 2.84 (2.11–3.82)), a higher ASA class (1.77 (1.03–3.05)) and a longer operative time (1.02 (1.01–1.02)) were independently associated with RBC transfusion. (4) Conclusions: In the instance of elective surgery for primary posterior lumbar fusion in a high-volume center for spine surgery, the need for RBC transfusion is low. Factors anticipating transfusion should be taken into consideration in the patient’s pre-surgery preparation. PMID:29385760

Bone bridge formation across the neuroforamen 14 years after instrumented fusion for isthmic spondylolisthesis—a case report

PubMed Central

Lim, Joel Louis; Tan, Kimberly-Anne

2017-01-01

This case report describes the first case of a bone bridge formation across the left L5/S1 neuroforamen after instrumented posterolateral fusion for L5/S1 isthmic spondylolisthesis. Our patient was a 70-year-old lady who had grade 2, L5/S1 isthmic spondylolisthesis and bilateral S1 nerve root compression. She suffered from mechanical low back pain and neurogenic claudication, with radicular pain over both S1 dermatomes. She underwent in-situ, instrumented, posterolateral fusion and was asymptomatic for more than 13 years before developing progressive onset of left radicular pain over the L5 dermatome. Imaging revealed a bisected left L5/S1 neuroforamen secondary to a bone bridge formation resulting in stenosis. The pars defect in this case may have had sufficient osteogenic and osteoinductive factors to heal following spinal stabilization. Although in-situ posterolateral fusion is an accepted surgical treatment for isthmic spondylolisthesis, surgeons should consider reduction of the spondylolisthesis and excision of the pars defects to avoid this possible long-term complication. PMID:28435923

Bone bridge formation across the neuroforamen 14 years after instrumented fusion for isthmic spondylolisthesis-a case report.

PubMed

Lim, Joel Louis; Tan, Kimberly-Anne; Hey, Hwee Weng Dennis

2017-03-01

This case report describes the first case of a bone bridge formation across the left L5/S1 neuroforamen after instrumented posterolateral fusion for L5/S1 isthmic spondylolisthesis. Our patient was a 70-year-old lady who had grade 2, L5/S1 isthmic spondylolisthesis and bilateral S1 nerve root compression. She suffered from mechanical low back pain and neurogenic claudication, with radicular pain over both S1 dermatomes. She underwent in-situ, instrumented, posterolateral fusion and was asymptomatic for more than 13 years before developing progressive onset of left radicular pain over the L5 dermatome. Imaging revealed a bisected left L5/S1 neuroforamen secondary to a bone bridge formation resulting in stenosis. The pars defect in this case may have had sufficient osteogenic and osteoinductive factors to heal following spinal stabilization. Although in-situ posterolateral fusion is an accepted surgical treatment for isthmic spondylolisthesis, surgeons should consider reduction of the spondylolisthesis and excision of the pars defects to avoid this possible long-term complication.

Lumbar foraminal stenosis, the hidden stenosis including at L5/S1.

PubMed

Orita, Sumihisa; Inage, Kazuhide; Eguchi, Yawara; Kubota, Go; Aoki, Yasuchika; Nakamura, Junichi; Matsuura, Yusuke; Furuya, Takeo; Koda, Masao; Ohtori, Seiji

2016-10-01

In patients with lower back and leg pain, lumbar foraminal stenosis (LFS) is one of the most important pathologies, especially for predominant radicular symptoms. LFS pathology can develop as a result of progressing spinal degeneration and is characterized by exacerbation with foraminal narrowing caused by lumbar extension (Kemp's sign). However, there is a lack of critical clinical findings for LFS pathology. Therefore, patients with robust and persistent leg pain, which is exacerbated by lumbar extension, should be suspected of LFS. Radiological diagnosis is performed using multiple radiological modalities, such as magnetic resonance imaging, including plain examination and novel protocols such as diffusion tensor imaging, as well as dynamic X-ray, and computed tomography. Electrophysiological testing can also aid diagnosis. Treatment options include both conservative and surgical approaches. Conservative treatment includes medication, rehabilitation, and spinal nerve block. Surgery should be considered when the pathology is refractory to conservative treatment and requires direct decompression of the exiting nerve root, including the dorsal root ganglia. In cases with decreased intervertebral height and/or instability, fusion surgery should also be considered. Recent advancements in minimally invasive lumbar lateral interbody fusion procedures enable effective and less invasive foraminal enlargement compared with traditional fusion surgeries such as transforaminal lumbar interbody fusion. The lumbosacral junction can cause L5 radiculopathy with greater incidence than other lumbar levels as a result of anatomical and epidemiological factors, which should be better addressed when treating clinical lower back pain.

Comparison of interbody fusion approaches for disabling low back pain.

PubMed

Hacker, R J

1997-03-15

This is a study comparing two groups of patients surgically treated for disabling low back pain. One group was treated with lumbar anteroposterior fusion (360 degrees fusion), the other with posterior lumbar interbody fusion and an interbody fixation device. To determine which approach provided the best and most cost-effective outcome using similar patient selection criteria. Others have shown that certain patients with disabling low back pain benefit from lumbar fusion. Although rarely reported, the costs of different surgical treatments appear to vary significantly, whereas the patient outcome may vary little. Since 1991, 75 patients have been treated Starting in 1993, posterior lumbar interbody fusion BAK was offered to patients as an alternative to 360 degrees fusion. The treating surgeon reviewed the cases. The interbody fixation device used (BAK; Spine-Tech, Inc., Minneapolis, MN) was part of a Food and Drug Administration study. Patient selection criteria included examination, response to conservative therapy, imaging, psychological profile, and discography. North American Spine Society outcome questionnaires, BAK investigation data radiographs, chart entries, billing records and patient interviews were the basis for assessment. Age, sex compensable injury history and history of previous surgery were similar. Operative time; blood loss, hospitalization time, and total costs were significantly different. There was a quicker return to work and closure of workers compensation claims for the posterior lumbar interbody fusion-BAK group. Patient satisfaction was comparable at last follow-up. Posterior lumbar interbody fusion-BAK achieves equal patient satisfaction but fiscally surpasses the 360 degrees fusion approach. Today's environment of regulated medical practice requires the surgeon to consider cost effectiveness when performing fusion for low back pain.

Extraforaminal Lumbar Interbody Fusion at the L5-S1 Level: Technical Considerations and Feasibility.

PubMed

Kurzbuch, Arthur Robert; Kaech, Denis; Baranowski, Pawel; Baranowska, Alicja; Recoules-Arche, Didier

2017-09-01

Background  Extraforaminal lumbar interbody fusion (ELIF) surgery is a muscle-sparing approach that allows the treatment of various degenerative spinal diseases. It is technical challenging to perform the ELIF approach at the L5-S1 level because the sacral ala obstructs the view of the intervertebral disk space. Methods  We reported earlier on the ELIF technique in which the intervertebral disk is targeted at an angle of 45 degrees relative to the midline. In this article we describe the technical process we developed to overcome the anatomic relation between the sacral ala and the intervertebral disk space L5-S1 that hinders the ELIF approach at this level. We then report in a retrospective analysis on the short-term clinical and radiologic outcome of 100 consecutive patients with degenerative L5-S1 pathologies who underwent ELIF surgery. Results  The L5-S1 ELIF approach could be realized in all patients. The short-term clinical outcome was evaluated 5 months after surgery: 92% of the patients were satisfied with their postoperative result; 8% had a poor result. Overall, 17% of the patients presented light radicular or low back pain not influencing their daily activity, and 82% of the patients working before surgery returned to work 3 to 7 months after surgery. The radiologic outcome was documented by computed tomography at 5 months after surgery and showed fusion in 99% of the patients. Lumbar magnetic resonance imaging performed in 5 patients at 6 months after surgery revealed the integrity of the paraspinal muscles. Conclusions  ELIF surgery at the L5-S1 level is technically feasible for various degenerative spinal diseases. Analysis of the clinical and radiologic data in a consecutive retrospective cohort of patients who underwent this surgical procedure showed a good short-term clinical outcome and fusion rate. Georg Thieme Verlag KG Stuttgart · New York.

The role of physical therapy and rehabilitation after lumbar fusion surgery for degenerative disease: a systematic review.

PubMed

Madera, Marcella; Brady, Jeremy; Deily, Sylvia; McGinty, Trent; Moroz, Lee; Singh, Devender; Tipton, George; Truumees, Eeric

2017-06-01

OBJECTIVE The purpose of this study was to provide a systematic and comprehensive review of the existing literature regarding postfusion rehabilitation. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the authors conducted an exhaustive review of multiple electronic databases. Potential articles were screened using inclusion/exclusion criteria. Two authors independently analyzed these studies using predefined data fields, including study quality indicators such as level of evidence and availability of accepted patient-reported outcomes measures. These findings were synthesized in a narrative format. A third author resolved disagreements regarding the inclusion of a study. RESULTS Twenty-one articles with I or II levels of evidence were included in the review. The authors divided the findings of the literature review into several groups: rehabilitation terminology, timing and duration of postfusion rehabilitation, the need for rehabilitation relative to surgery-related morbidity, rehabilitation's relationship to outcomes, and cognitive and psychosocial aspects of postsurgical rehabilitation. Current evidence generally supports formal rehabilitation after lumbar fusion surgery. Starting physical therapy at the 12-week postoperative mark results in better outcomes at lower cost than an earlier, 6-week start. Where available, psychosocial support improves outcomes. However, a number of the questions could not be answered with high-grade evidence. In these cases, the authors used "best evidence available" to make recommendations. There are many cases in which different types of caregivers use clinical terminology differently. The data supporting an optimal protocol for postfusion rehabilitation remains elusive but, using the data available, the authors have crafted recommendations and a model protocol, which is currently undergoing prospective study. CONCLUSIONS Rehabilitation has long been a common feature in

Is it possible to preserve lumbar lordosis after hybrid stabilization? Preliminary results of a novel rigid-dynamic stabilization system in degenerative lumbar pathologies.

PubMed

Formica, Matteo; Cavagnaro, Luca; Basso, Marco; Zanirato, Andrea; Felli, Lamberto; Formica, Carlo

2015-11-01

To evaluate the results of a novel rigid-dynamic stabilization technique in lumbar degenerative segment diseases (DSD), expressly pointing out the preservation of postoperative lumbar lordosis (LL). Forty-one patients with one level lumbar DSD and initial disc degeneration at the adjacent level were treated. Circumferential lumbar arthrodesis and posterior hybrid instrumentation were performed to preserve an initial disc degeneration above the segment that has to be fused. Clinical and spino-pelvic parameters were evaluated pre- and postoperatively. At 2-year follow-up, a significant improvement of clinical outcomes was reported. No statistically significant difference was noted between postoperative and 2-year follow-up in LL and in disc/vertebral body height ratio at the upper adjacent fusion level. When properly selected, this technique leads to good results. A proper LL should be achieved after any hybrid stabilization to preserve the segment above the fusion.

Application of Gelatin Sponge Impregnated with a Mixture of 3 Drugs to Intraoperative Nerve Root Block Combined with Robot-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery in the Treatment of Adult Degenerative Scoliosis: A Clinical Observation Including 96 Patients.

PubMed

Du, Jin Peng; Fan, Yong; Liu, Ji Jun; Zhang, Jia Nan; Chang Liu, Shi; Hao, Dingjun

2017-12-01

Application of nerve root block is mainly for diagnosis with less application in intraoperative treatment. The aim of this study was to observe clinical and imaging outcomes of application of gelatin sponge impregnated with a mixture of 3 drugs to intraoperative nerve root block combined with robot-assisted minimally invasive transforaminal lumbar interbody fusion surgery in to treat adult degenerative lumbar scoliosis. From January 2012 to November 2014, 108 patients with adult degenerative lumbar scoliosis were treated with robot-assisted minimally invasive transforaminal lumbar interbody fusion surgery combined with intraoperative gelatin sponge impregnated with a mixture of 3 drugs. Visual analog scale and Oswestry Disability Index scores were used to evaluate postoperative improvement of back and leg pain, and clinical effects were assessed according to the 36-Item Short-Form Health Survey. Imaging was obtained preoperatively, 1 week and 3 months postoperatively, and at the last follow-up. Fusion status, complications, and other outcomes were assessed. Follow-up was complete for 96 patients. Visual analog scale scores of leg and back pain on postoperative days 1-7 were decreased compared with preoperatively. At 1 week postoperatively, 3 months postoperatively, and last follow-up, visual analog scale score, Oswestry Disability Index score, coronal Cobb angle, and coronal and sagittal deviated distance decreased significantly (P = 0.000) and lumbar lordosis angle increased (P = 0.000) compared with preoperatively. Improvement rate of Oswestry Disability Index was 81.8% ± 7.4. Fusion rate between vertebral bodies was 92.7%. Application of gelatin sponge impregnated with 3 drugs combined with robot-assisted minimally invasive transforaminal lumbar interbody fusion for treatment of adult degenerative lumbar scoliosis is safe and feasible with advantages of good short-term analgesia effect, minimal invasiveness, short length of stay, and good long-term clinical

Associated lumbar scoliosis does not affect outcomes in patients undergoing focal minimally invasive surgery-transforaminal lumbar interbody fusion (MISTLIF) for neurogenic symptoms-a minimum 2-year follow-up study.

PubMed

Tay, Kae Sian; Bassi, Anupreet; Yeo, William; Yue, Wai Mun

2017-01-01

There is no current literature comparing outcomes of patients with and without lumbar scoliosis having neurologic symptoms undergoing minimally invasive surgery-transforaminal lumbar interbody fusion (MISTLIF) technique. This study aimed to determine whether associated lumbar scoliosis will result in different clinical, radiological, and operative outcomes in patients undergoing focal MISTLIF for neurogenic symptoms, without specific correction of the scoliosis. A retrospective case comparison study from prospectively collected hospital registry data was carried out. Two hundred and thirty eligible patients were evaluated and divided into two groups: Scoliosis Group (SG; n=57) with Cobb angle >10 degrees on anterioposterior (AP) plain lumbar spine radiographs and Non-Scoliosis Group (NSG; n=173) consisting of the remaining patients. Clinical outcomes were assessed using the Oswestry Disability Index, the North American Spine Society (NASS) Neurogenic Symptom Score, the NASS Satisfaction with Surgery Rating, the 36-Item Short-Form Health Survey (SF-36), and the Numerical Pain Rating Scale for back and leg pain. Radiological findings included Cobb angle, fusion, implant failure or loosening, and adjacent segment degeneration (ASD). Both groups were compared for demographics, perioperative parameters, complications, clinical, and radiological outcomes. Interobserver agreement (kappa statistics) for measurement of Cobb angle was calculated on all cases of both groups by two authors. Patients were evaluated preoperatively, at 6 months, and 2 years after surgery. The average follow-up was 2.88±1.47 years in the SG and 2.71±1.34 years in the NSG (p=.444). Differences in mean age (SG: 62.9±10.9 years and NSG: 57.6±13.1 years), estimated related risk of death (SG: 3.05±2.13 and NSG: 2.41±1.74), and gender (female=SG: 87.7% and NSG: 64.2%) were statistically significant (p<.05), whereas race distribution, body mass index |(BMI), spinal levels operated, number of levels

Is a drain tube necessary for minimally invasive lumbar spine fusion surgery?

PubMed

Hung, Pei-I; Chang, Ming-Chau; Chou, Po-Hsin; Lin, Hsi-Hsien; Wang, Shih-Tien; Liu, Chien-Lin

2017-03-01

This study aimed to evaluate if closed suction wound drainage is necessary in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF). This is a prospective randomized clinical study. Fifty-six patients who underwent MIS TLIF were randomly divided into groups A (with a closed suction wound drainage) and B (without tube drainage). Surgical duration, intraoperative blood loss, timing of ambulation, length of hospital stay and complications were recorded. Patients were followed up for an average of 25.3 months. Clinical outcome was assessed using the Oswestry disability index and visual analogue scale (VAS). Fusion rate was classified with the Bridwell grading system, based on plain radiograph. Both groups had similar patient demographics. The use of drains had no significant influence on perioperative parameters including operative time, estimated blood loss, length of stay and complications. Patients in group B started ambulation 1 day earlier than patients in group A (p < 0.001). Clinical outcomes were comparable between group A and group B. A drain tube can lead to pain, anxiety and discomfort during the postoperative period. We conclude that drain tubes are not necessary for MIS TLIF. Patients without drains had the benefit of earlier ambulation than those with drains.

Femoral Head Avascular Necrosis Is Not Caused by Arthroscopic Posterolateral Femoroplasty.

PubMed

Rupp, Robert E; Rupp, Sasha N

2016-05-01

This study was conducted to identify the risk of avascular necrosis of the femoral head after arthroscopic femoroplasty extending to the posterolateral femoral neck, the source of the primary blood supply to the femoral head. Cam lesions of femoroacetabular impingement are typically anterior along the junction of the femoral head and neck. However, anatomic variations can involve the posterolateral vascular region of the femoral head and neck. Femoroplasty involving this vascular region can lead to injury to the blood supply to the femoral head, with subsequent avascular necrosis. If the posterolateral portion of the cam lesion is preserved, persistent femoroacetabular impingement may occur. A retrospective review identified 112 patients who underwent arthroscopic femoroplasty for femoroacetabular impingement over a 2-year period. Of these patients, 14 had femoroplasty that extended to the posterolateral femoral head. Of this group, 5 had undergone magnetic resonance imaging (MRI) after femoroplasty and the other 9 were contacted to undergo MRI of the hip to evaluate for avascular necrosis. A radiologist and the senior author evaluated all MRI scans specifically for avascular necrosis of the femoral head. All procedures were performed by the senior author. Mean age of the 14 patients (8 women and 6 men) with femoroplasty that extended into the posterolateral vascular region of the femoral head was 44 years (range, 23-69 years). All 14 patients underwent MRI evaluation of the affected hip a mean of 25 months (range, 7-44 months) after femoroplasty. No MRI scans showed evidence of avascular necrosis of the femoral head. Femoroplasty of the posterolateral vascular region of the femoral head is not associated with avascular necrosis. Patients with femoroacetabular impingement and a cam lesion extending to the posterolateral femoral head can undergo femoroplasty of this region without the development of avascular necrosis. [Orthopedics. 2016; 39(3):177-180.]. Copyright

Lumbar degenerative spinal deformity: Surgical options of PLIF, TLIF and MI-TLIF

PubMed Central

Hey, Hwee Weng Dennis; Hee, Hwan Tak

2010-01-01

Degenerative disease of the lumbar spine is common in ageing populations. It causes disturbing back pain, radicular symptoms and lowers the quality of life. We will focus our discussion on the surgical options of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative spinal deformities, which include symptomatic spondylolisthesis and degenerative scoliosis. Through a description of each procedure, we hope to illustrate the potential benefits of TLIF over PLIF. In a retrospective study of 53 ALIF/PLIF patients and 111 TLIF patients we found reduced risk of vessel and nerve injury in TLIF patients due to less exposure of these structures, shortened operative time and reduced intra-operative bleeding. These advantages could be translated to shortened hospital stay, faster recovery period and earlier return to work. The disadvantages of TLIF such as incomplete intervertebral disc and vertebral end-plate removal and potential occult injury to exiting nerve root when under experienced hands are rare. Hence TLIF remains the mainstay of treatment in degenerative deformities of the lumbar spine. However, TLIF being a unilateral transforaminal approach, is unable to decompress the opposite nerve root. This may require contralateral laminotomy, which is a fairly simple procedure. The use of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) to treat degenerative lumbar spinal deformity is still in its early stages. Although the initial results appear promising, it remains a difficult operative procedure to master with a steep learning curve. In a recent study comparing 29 MI-TLIF patients and 29 open TLIF, MI-TLIF was associated with longer operative time, less blood loss, shorter hospital stay, with no difference in SF-36 scores at six months and two years. Whether it can replace traditional TLIF as the surgery of choice for

Biomechanical comparison of a two-level Maverick disc replacement with a hybrid one-level disc replacement and one-level anterior lumbar interbody fusion.

PubMed

Erkan, Serkan; Rivera, Yamil; Wu, Chunhui; Mehbod, Amir A; Transfeldt, Ensor E

2009-10-01

Multilevel lumbar disc disease (MLDD) is a common finding in many patients. Surgical solutions for MLDD include fusion or disc replacement. The hybrid model, combining fusion and disc replacement, is a potential alternative for patients who require surgical intervention at both L5-S1 and L4-L5. The indications for this hybrid model could be posterior element insufficiency, severe facet pathology, calcified ligamentum flavum, and subarticular disease confirming spinal stenosis at L5-S1 level, or previous fusion surgery at L5-S1 and new symptomatic pathology at L4-L5. Biomechanical data of the hybrid model with the Maverick disc and anterior fusion are not available in the literature. To compare the biomechanical properties of a two-level Maverick disc replacement at L4-L5, L5-S1, and a hybrid model consisting of an L4-L5 Maverick disc replacement with an L5-S1 anterior lumbar interbody fusion using multidirectional flexibility test. An in vitro human cadaveric biomechanical study. Six fresh human cadaveric lumbar specimens (L4-S1) were subjected to unconstrained load in axial torsion (AT), lateral bending (LB), flexion (F), extension (E), and flexion-extension (FE) using multidirectional flexibility test. Four surgical treatments-intact, one-level Maverick at L5-S1, two-level Maverick between L4 and S1, and the hybrid model (anterior fusion at L5-S1 and Maverick at L4-L5) were tested in sequential order. The range of motion of each treatment was calculated. The Maverick disc replacement slightly reduced intact motion in AT and LB at both levels. The total FE motion was similar to the intact motion. However, the E motion is significantly increased (approximately 50% higher) and F motion is significantly decreased (30%-50% lower). The anterior fusion using a cage and anterior plate significantly reduced spinal motion compared with the condition (p<.05). No significant differences were found between two-level Maverick disc prosthesis and the hybrid model in terms of

Current Evidence Regarding the Treatment of Pediatric Lumbar Spondylolisthesis: A Report From the Scoliosis Research Society Evidence Based Medicine Committee.

PubMed

Crawford, Charles H; Larson, A Noelle; Gates, Marilyn; Bess, R Shay; Guillaume, Tenner J; Kim, Han Jo; Oetgen, Matthew E; Ledonio, Charles G; Sanders, James; Burton, Douglas C

2017-09-01

Structured literature review. The Scoliosis Research Society requested an assessment of the current state of peer-reviewed evidence regarding pediatric lumbar spondylolisthesis to identify what is known and what research remains essential to further understanding. Pediatric lumbar spondylolisthesis is common, yet no formal synthesis of the published literature regarding treatment has been previously performed. A comprehensive literature search was performed. From 6600 initial citations with abstract, 663 articles underwent full-text review. The best available evidence regarding surgical and medical/interventional treatment was provided by 51 studies. None of the studies were graded Level I or II evidence. Eighteen of the studies were Level III, representing the current best available evidence. Thirty-three of the studies were Level IV. Although studies suggest a benign course for "low grade" (<50% slip) isthmic spondylolisthesis, extensive literature suggests that a substantial number of patients present for treatment with pain and activity limitations. Pain resolution and return to activity is common with both medical/interventional and operative treatment. The role of medical/interventional bracing is not well established. Uninstrumented posterolateral fusion has been reported to produce good clinical results, but concerns regarding nonunion exist. Risk of slip progression is a specific concern in the "high grade" or dysplastic type. Although medical/interventional observation has been reported to be reasonable in a small series of asymptomatic high-grade slip patients, surgical treatment is commonly recommended to prevent progression. There is Level III evidence that instrumentation and reduction lowers the risk of nonunion, and that circumferential fusion is superior to posterior-only or anterior-only fusion. There is Level III evidence that patients with a higher slip angle are more likely to fail medical/interventional treatment of high

Urinary Tract Infection Following Posterior Lumbar Fusion Procedures: An American College of Surgeons National Surgical Quality Improvement Program Study.

PubMed

Bohl, Daniel D; Ahn, Junyoung; Tabaraee, Ehsan; Ahn, Junho; Jain, Akshay; Grauer, Jonathan N; Singh, Kern

2015-11-01

Retrospective review of prospectively collected data. To determine the incidence and risk factors for the development of a urinary tract infection (UTI) after a posterior lumbar fusion procedure. UTI after surgery is common and has important clinical consequences for both patients and the health care system. Few studies have examined UTI after spinal fusion procedures. Patients undergoing posterior lumbar fusion procedures during 2011 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Statistical comparisons were made using multivariate regression with adjustment for demographic, comorbidity, and operative characteristics. A total of 10,825 patients met inclusion criteria. The incidence of a UTI was 1.77% (95% confidence interval = 1.52%-2.02%). Independent risk factors for a UTI were greater age (for 50-59 yr, relative risk [RR] = 1.0; 60-69 yr, RR = 2.1; ≥70 yr, RR = 3.5; P < 0.001), female sex (RR = 2.2, P < 0.001), dependent functional status (RR = 2.1, P = 0.010), malnutrition (RR = 2.3, P = 0.004), diabetic status (for non-insulin-dependent diabetes, RR = 1.5; for insulin-dependent diabetes, RR = 1.9; P = 0.011), and increased operative duration (for 120-179  min, RR = 1.4; 180-239  min, RR = 2.3; and for ≥240  min, RR = 2.7; P < 0.001).Patients who developed a UTI had a greater risk for systemic sepsis than other patients (11.5% vs. 0.63%; adjusted RR = 14.4, P < 0.001). Patients who developed a UTI had a greater risk for readmission than other patients (36.7% vs. 5.0%; adjusted RR = 6.1, P < 0.001). UTIs occur in nearly 1 in 50 patients undergoing posterior lumbar fusion procedures. Patients who are older, female, dependent, malnourished, or diabetic are at greater risk and should be counseled and monitored accordingly. In addition, morbidity associated with a UTI in this population is substantial

Psychological Predictors of Outcomes with Lumbar Spinal Fusion: A Systematic Literature Review.

PubMed

Wilhelm, Mark; Reiman, Michael; Goode, Adam; Richardson, William; Brown, Christopher; Vaughn, Daniel; Cook, Chad

2017-04-01

To review the predictive/risk psychological factors at baseline that are associated with a favourable (or non-favourable) outcome following lumbar spinal fusion (LSF). A computer-assisted literature search of PubMed, CINAHL complete and EMBASE for studies published between January 1, 1990 and October 1, 2014 with controlled vocabulary and key words related to LSF, degenerative lumbar spine diagnoses and appropriate terms for predictive variables. Each study was required to be a retrospective or prospective design that involved LSF (all forms). Quality assessment was conducted with the Quality In Prognosis Studies tool. A study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO# CRD42014008728). The majority of the eight accepted studies were observational, prospective cohorts (n = 6). High levels of baseline depression and lower SF-36 Mental Component Scores (MCS) lower quality of life were associated with non-favourable outcomes. Two studies were rated as high quality, five were moderate and one study had low quality. At present, there are a number of psychological variables that are associated with a poorer outcome with LSF. Higher levels of depression and lower scores on the SF-36 MCS are the most commonly implicated. However, based on the results of the studies using single arm designs there is not enough evidence to determine which psychological variables are influential in predicting outcomes for LSF. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Anatomy of the psoas muscle and lumbar plexus with respect to the surgical approach for lateral transpsoas interbody fusion.

PubMed

Kepler, Christopher K; Bogner, Eric A; Herzog, Richard J; Huang, Russel C

2011-04-01

Lateral transpsoas interbody fusion (LTIF) is a minimally invasive technique that permits interbody fusion utilizing cages placed via a direct lateral retroperitoneal approach. We sought to describe the locations of relevant neurovascular structures based on MRI with respect to this novel surgical approach. We retrospectively reviewed consecutive lumbosacral spine MRI scans in 43 skeletally mature adults. MRI scans were independently reviewed by two readers to identify the location of the psoas muscle, lumbar plexus, femoral nerve, inferior vena cava and right iliac vein. Structures potentially at risk for injury were identified by: a distance from the anterior aspect of the adjacent vertebral bodies of <20 mm, representing the minimum retraction necessary for cage placement, and extension of vascular structures posterior to the anterior vertebral body, requiring anterior retraction. The percentage of patients with neurovascular structures at risk for left-sided approaches was 2.3% at L1-2, 7.0% at L2-3, 4.7% at L3-4 and 20.9% at L4-5. For right-sided approaches, this rose to 7.0% at L1-2, 7.0% at L2-3, 9.3% at L3-4 and 44.2% at L4-5, largely because of the relatively posterior right-sided vasculature. A relationship between the position of psoas muscle and lumbar plexus is described which allows use of the psoas position as a proxy for lumbar plexus position to identify patients who may be at risk, particularly at the L4-5 level. Further study will establish the clinical relevance of these measurements and the ability of neurovascular structures to be retracted without significant injury.

Poor Nutrition Status and Lumbar Spine Fusion Surgery in the Elderly: Readmissions, Complications, and Mortality.

PubMed

Puvanesarajah, Varun; Jain, Amit; Kebaish, Khaled; Shaffrey, Christopher I; Sciubba, Daniel M; De la Garza-Ramos, Rafael; Khanna, Akhil Jay; Hassanzadeh, Hamid

2017-07-01

Retrospective database review. To quantify the medical and surgical risks associated with elective lumbar spine fusion surgery in patients with poor preoperative nutritional status and to assess how nutritional status alters length of stay and readmission rates. There has been recent interest in quantifying the increased risk of complications caused by frailty, an important consideration in elderly patients that is directly related to comorbidity burden. Preoperative nutritional status is an important contributor to both sarcopenia and frailty and is poorly studied in the elderly spine surgery population. The full 100% sample of Medicare data from 2005 to 2012 were utilized to select all patients 65 to 84 years old who underwent elective 1 to 2 level posterior lumbar fusion for degenerative pathology. Patients with diagnoses of poor nutritional status within the 3 months preceding surgery were selected and compared with a control cohort. Outcomes that were assessed included major medical complications, infection, wound dehiscence, and mortality. In addition, readmission rates and length of stay were evaluated. When adjusting for demographics and comorbidities, malnutrition was determined to result in significantly increased odds of both 90-day major medical complications (adjusted odds ratio, OR: 4.24) and 1-year mortality (adjusted OR: 6.16). Multivariate analysis also demonstrated that malnutrition was a significant predictor of increased infection (adjusted OR: 2.27) and wound dehiscence (adjusted OR: 2.52) risk. Length of stay was higher in malnourished patients, though 30-day readmission rates were similar to controls. Malnutrition significantly increases complication and mortality rates, whereas also significantly increasing length of stay. Nutritional supplementation before surgery should be considered to optimize postoperative outcomes in malnourished individuals. 3.

Effect of cage design, supplemental posterior instrumentation and approach on primary stability of a lumbar interbody fusion - A biomechanical in vitro study.

PubMed

Schmoelz, Werner; Sandriesser, Sabrina; Loebl, Oded; Bauer, Marlies; Krappinger, Dietmar

2017-10-01

There are various techniques and approaches for lumbar interbody fusion differing in access, cage type and type of supplemental posterior instrumentation. While a transforaminal access usually includes a hemifacetectomy, the facet joint can be preserved with a more lateral extraforaminal access. The supplemental posterior instrumentation required for both fusion techniques is still debated. The purpose of the present study was to compare primary stability of the two accesses for two different cage types with none, unilateral and bilateral supplemental posterior instrumentation. Six monosegmental lumbar functional spinal units (FSUs) were included in each of the two groups, and subjected to a flexibility test. As cages, a newly designed cage was compared to a standard cage in the following states: (a) native, (b) stand-alone cage, (c) bilateral internal fixator, (d) unilateral internal fixator, (e) unilateral facetectomy+bilateral internal fixator, (f) unilateral facetectomy+unilateral internal fixator and (g) unilateral facetectomy with stand-alone cage. For comparison the range of motion was normalized to the native state and the effects of the facetectomy, cage type, and supplemental instrumentation was compared. Within the subject comparison showed a significantly higher flexibility for the unilateral facetectomy in all motion directions (p<0.001). In between subject comparison showed a significant effect of cage type on flexibility in flexion/extension (p=0.002) and lateral bending (p=0.028) but not in axial rotation (p=0.322). The type of supplemental posterior fixation had a significant effect on the flexibility in all motion directions (stand-alone>unilateral fixator>bilateral fixator). Cage design and approach type are affecting the primary stability of lumbar interbody fusion procedures while the type of posterior instrumentation is the most influencing factor. Copyright © 2017 Elsevier Ltd. All rights reserved.

One and two level posterior lumbar interbody fusion (PLIF) using an expandable, stand-alone, interbody fusion device: a VariLift® case series

PubMed Central

Barrett-Tuck, Rebecca; Del Monaco, Diana

2017-01-01

Background Surgical interventions such as posterior lumbar interbody fusion (PLIF) with and without posterior instrumentation are often employed in patients with degenerative spinal conditions that fail to respond to conservative medical management. The VariLift® Interbody Fusion System was developed as a stand-alone solution to provide the benefits of an intervertebral fusion device without the requirement of supplemental pedicle screw fixation. Methods In this retrospective case series, 25 patients underwent PLIF with a stand-alone VariLift® expandable interbody fusion device without adjunctive pedicle screw fixation. There were 12 men and 13 women, with a mean age of 57.2 years (range, 33–83 years); single level in 18 patients, 2 levels in 7 patients. Back pain severity was reported as none, mild, moderate, severe and worst imaginable at baseline, 6 and 12 months. Preoperatively, 88% (22 of 25) of patients reported severe back pain. Results All patients experienced symptomatic improvement and, by 12 months postoperatively, 71% (15 of 21) of patients reported only mild residual pain. Overall, pain scores improved significantly from baseline to 12 months (P=0.0002). There were no revision surgeries and fusion was achieved 12 of 13 patients (92%) who returned for a 12-month radiographic follow-up. There were three cases of intractable postsurgical pain which required extended hospitalization or pain management, one wound infection and one case of surgical site dehiscence, both treated and resolved during inpatient hospitalization. Conclusions In this single-physician case series, the VariLift® device used in single or two-level PLIF provided effective symptom relief and produced a high fusion rate without the need for supplemental fixation. PMID:28435912

One and two level posterior lumbar interbody fusion (PLIF) using an expandable, stand-alone, interbody fusion device: a VariLift® case series.

PubMed

Barrett-Tuck, Rebecca; Del Monaco, Diana; Block, Jon E

2017-03-01

Surgical interventions such as posterior lumbar interbody fusion (PLIF) with and without posterior instrumentation are often employed in patients with degenerative spinal conditions that fail to respond to conservative medical management. The VariLift ® Interbody Fusion System was developed as a stand-alone solution to provide the benefits of an intervertebral fusion device without the requirement of supplemental pedicle screw fixation. In this retrospective case series, 25 patients underwent PLIF with a stand-alone VariLift ® expandable interbody fusion device without adjunctive pedicle screw fixation. There were 12 men and 13 women, with a mean age of 57.2 years (range, 33-83 years); single level in 18 patients, 2 levels in 7 patients. Back pain severity was reported as none, mild, moderate, severe and worst imaginable at baseline, 6 and 12 months. Preoperatively, 88% (22 of 25) of patients reported severe back pain. All patients experienced symptomatic improvement and, by 12 months postoperatively, 71% (15 of 21) of patients reported only mild residual pain. Overall, pain scores improved significantly from baseline to 12 months (P=0.0002). There were no revision surgeries and fusion was achieved 12 of 13 patients (92%) who returned for a 12-month radiographic follow-up. There were three cases of intractable postsurgical pain which required extended hospitalization or pain management, one wound infection and one case of surgical site dehiscence, both treated and resolved during inpatient hospitalization. In this single-physician case series, the VariLift ® device used in single or two-level PLIF provided effective symptom relief and produced a high fusion rate without the need for supplemental fixation.

Recombinant human bone morphogenetic protein-2 versus autogenous iliac crest bone graft for lumbar fusion: a meta-analysis of ten randomized controlled trials.

PubMed

Chen, Zhiguang; Ba, Gen; Shen, Tao; Fu, Qin

2012-12-01

Recombinant human bone morphogenetic protein-2 (rhBMP-2) as a substitute for iliac crest bone graft (ICBG) has been increasingly widely used in lumbar fusion. It has been proven non-inferior in fusion success and clinical outcomes when compared with ICBG. However, increasingly, some potentially uncommon and serious complications associated with the use of rhBMP-2 have been of great concern to surgeons. The purpose of this study was to determine whether rhBMP-2 could be considered an effective and, more importantly, a relatively safe substitute for ICBG in lumbar fusion. Randomized controlled trials that compared rhBMP-2 with ICBG for lumbar fusion were identified by computer and manual searching. The risk of bias and clinical relevance of the included studies were assessed. Publication bias was explored using funnel plot and statistical tests (Egger's test and Begg's test). Meta-analyses were performed using the Cochrane systematic review methods. Ten randomized controlled trials (1,342 patients) met the inclusion criteria. Compared with ICBG, the use of rhBMP-2 significantly decreased the risk of fusion failure at all time intervals (6 months: p < 0.0001, RR = 0.55, 95 % CI = 0.42-0.72; 12 months: p = 0.0003, RR = 0.53, 95 % CI = 0.37-0.75; 24 months: p < 0.00001, RR = 0.31, 95 % CI = 0.21-0.46) and the rate of reoperation (p = 0.0001, RR = 0.52, 95 % CI = 0.37-0.72). There was no statistical difference in clinical improvement on the Oswestry Disability Index, although a favorable trend in the rhBMP-2 group was found (p = 0.12, RR = 0.73, 95 % CI = 0.49-1.08). Subgroup analyses stratified by the type of surgical procedure yielded similar results. Owing to the different data formats, meta-analysis on adverse events was not performed. RhBMP-2 was superior to the ICBG for achieving fusion success and avoiding reoperation. However, evidence from the Food and Drug Administration document and subsequent independent studies has

Surgical excision of filum terminale arteriovenous fistulae after lumbar fusion: Value of indocyanine green and theory on origins (a technical note and report of two cases)

PubMed Central

Trinh, Victoria T.; Duckworth, Edward A.M

2011-01-01

Background: Intradural filum terminale arteriovenous fistulas (AVFs) are uncommon. We report two cases of this rare entity in which we used indocyanine green (ICG) videoangiography to identify the fistulous connection of each lesion. Case Description: Two male patients presented with unresolved lower extremity weakness and paresthesias following lumbar fusion surgery. In each case, angiography showed an AVF between the filum terminale artery (FTA), the distal segment of the anterior spinal artery (ASA), and an accompanying vein of the filum terminale. A magnetic resonance image (MRI) obtained before lumbar fusion was available in one of these cases and demonstrated evidence of the preexisting vascular malformation. Surgical obliteration of each fistulous connection was facilitated by the use of ICG videoangiography. This emerging technology was instrumental in pinpointing fistula anatomy and in choosing the exact segment of the filum for disconnection. Conclusion: Our findings indicate that intradural filum terminale AVFs may have a congenital origin and that ICG is a useful tool in their successful surgical management. As these cases demonstrate, spine surgeons should remain vigilant in evaluating patients based on their clinical symptomatology, even in the presence of obvious lumbar pathology. PMID:21697980

Delayed diagnosis of an isolated posterolateral corner injury: a case report.

PubMed

Welsh, Patrick; DeGraauw, Christopher; Whitty, David

2016-12-01

Isolated injuries to the posterolateral corner of the knee are a rare and commonly missed injury associated with athletic trauma, motor vehicle accidents, and falls. Delayed or missed diagnoses can negatively impact patient prognosis, contributing to residual instability, chronic pain, and failure of surgical repair to other ligaments. A 44-year-old male CrossFit athlete presented with a history of two non-contact hyperextension injuries to his left knee while walking on ice. The only positive finding was the Dial Test at 30 degrees of knee flexion, indicative of an isolated posterolateral corner injury. After a delay in diagnosis, the patient underwent a reconstruction of the posterolateral corner and subsequent rehabilitation. Early recognition of this injury is important as this can affect the prognosis and activities of daily living of the patient. This case will discuss the clinical presentation, diagnostic procedures, and management of an isolated posterolateral corner injury and highlight the importance of early recognition and referrals from primary contact healthcare practitioners.

A new extensile anterolateral retroperitoneal approach for lumbar interbody fusion from L1 to S1: a prospective series with clinical outcomes.

PubMed

Molloy, Sean; Butler, Joseph S; Benton, Adam; Malhotra, Karan; Selvadurai, Susanne; Agu, Obiekezie

2016-06-01

A variety of surgical approaches have been used for cage insertion in lumbar interbody fusion surgery. The direct anterior approach requires mobilization of the great vessels to access the intervertebral disc spaces cranial to L5/S1. With the lateral retroperitoneal transpsoas approach, it is difficult to access the L4/L5 intervertebral disc space due to the lumbar plexus and iliac crest, and L5/S1 is inaccessible. We describe a new anterolateral retroperitoneal approach, which is safe and reproducible to access the disc spaces from L1 to S1 inclusive, obviating the need for a separate direct anterior approach to access L5/S1. This paper had the following objectives: first, to report a reproducible novel single-incision, muscle-splitting, anterolateral pre-psoas surgical approach to the lumbar spine from L1 to S1; second, to highlight the technical challenges of this approach and highlight approach-related complications; and third, to evaluate clinical outcomes using this surgical technique in a prospective series of L1 to S1 anterior lumbar interbody fusions (ALIFs) performed as part of a 360-degree fusion for adult spinal deformity correction. This report used a prospective cohort study. A prospective series of patients (n=64) having ALIF using porous tantalum cages as part of a two-stage complex spinal reconstruction from L1 to S1 were studied. Data collected included blood loss, operative time, incision size, technical challenges, perioperative complications, and secondary procedures. Clinical outcome measures used included visual analogue scale (VAS) Back Pain, VAS Leg Pain, EuroQoL-5 Dimensions (EQ-5D), EQ-5D VAS, Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22). Pre- and postoperative radiographic parameters and clinical outcome measures were assessed. Mean follow-up time was 1.8 years. Mean blood loss was 68±9.6 mL. The mean VAS Back Pain score improved from 7.5±1.25 preoperatively to 2.5±1.7 at 3 months (p=.02), 1.2±0.5 at 6

Is dibotermin alfa a cost-effective substitute for autologous iliac crest bone graft in single level lumbar interbody spine fusion?

PubMed

Svedbom, Axel; Paech, Daniel; Leonard, Catherine; Donnell, David; Song, Fujian; Boszcyk, Bronek; Rothenfluh, Dominique A; Lloyd, Andrew; Borgman, Benny

2015-11-01

To evaluate the cost-effectiveness of dibotermin alfa compared with autologous iliac crest bone graft (ICBG) for patients undergoing single level lumbar interbody spinal fusion in a UK hospital setting. An individual patient data (IPD) meta-analysis of six randomized controlled clinical trials and two single arm trials compared dibotermin alfa on an absorbable collagen implantation matrix (ACIM) (n = 456) and ICBG (n = 244) on resource use, re-operation rates, and SF-6D (Short form 6-dimension) health utility (total N = 700). Failure-related second surgery, operating time, post-operative hospital stay, and quality-adjusted life years (QALYs) derived from the IPD meta-analysis were included as inputs in an economic evaluation undertaken to assess the cost-effectiveness of dibotermin alfa/ACIM versus ICBG for patients undergoing single level lumbar interbody spinal fusion. A four year time horizon and the United Kingdom (UK) National Health Service (NHS) and Personal Social Services (PSS) perspective was adopted in the base case, with sensitivity analyses performed to gauge parameter uncertainty. In the base case analysis, patients treated using dibotermin alfa/ACIM (12 mg pack) accrued 0.055 incremental QALYs at an incremental cost of £ 737, compared with patients treated with ICBG. This resulted in an incremental cost-effectiveness ratio (ICER) of £ 13,523, indicating that at a willingness-to-pay threshold of £ 20,000, dibotermin alfa/ACIM is a cost-effective intervention relative to ICBG from the NHS and PSS perspective. In a UK hospital setting, dibotermin alfa/ACIM is a cost-effective substitute for ICBG for patients who require lumbar interbody arthrodesis.

Revisions for screw malposition and clinical outcomes after robot-guided lumbar fusion for spondylolisthesis.

PubMed

Schröder, Marc L; Staartjes, Victor E

2017-05-01

OBJECTIVE The accuracy of robot-guided pedicle screw placement has been proven to be high, but little is known about the impact of such guidance on clinical outcomes such as the rate of revision surgeries for screw malposition. In addition, there are very few data about the impact of robot-guided fusion on patient-reported outcomes (PROs). Thus, the clinical benefit for the patient is unclear. In this study, the authors analyzed revision rates for screw malposition and changes in PROs following minimally invasive robot-guided pedicle screw fixation. METHODS A retrospective cohort study of patients who had undergone minimally invasive posterior lumbar interbody fusion (MI-PLIF) or minimally invasive transforaminal lumbar interbody fusion was performed. Patients were followed up clinically at 6 weeks, 12 months, and 24 months after treatment and by mailed questionnaire in March 2016 as a final follow-up. Visual analog scale (VAS) scores for back and leg pain severity, Oswestry Disability Index (ODI), screw revisions, and socio-demographic factors were analyzed. A literature review was performed, comparing the incidence of intraoperative screw revisions and revision surgery for screw malposition in robot-guided, navigated, and freehand fusion procedures. RESULTS Seventy-two patients fit the study inclusion criteria and had a mean follow up of 32 ± 17 months. No screws had to be revised intraoperatively, and no revision surgery for screw malposition was needed. In the literature review, the authors found a higher rate of intraoperative screw revisions in the navigated pool than in the robot-guided pool (p < 0.001, OR 9.7). Additionally, a higher incidence of revision surgery for screw malposition was observed for freehand procedures than for the robot-guided procedures (p < 0.001, OR 8.1). The VAS score for back pain improved significantly from 66.9 ± 25.0 preoperatively to 30.1 ± 26.8 at the final follow-up, as did the VAS score for leg pain (from 70.6 ± 22.8 to

The Efficacy of Vitamin C on Postoperative Outcomes after Posterior Lumbar Interbody Fusion: A Randomized, Placebo-Controlled Trial.

PubMed

Lee, Gun Woo; Yang, Han Seok; Yeom, Jin S; Ahn, Myun-Whan

2017-09-01

Vitamin C has critical features relavant to postoperative pain management and functional improvement; however, no study has yet evaluated the effectiveness of vitamin C on improving the surgical outcomes for spine pathologies. Thus, this study aimed to explore the impact of vitamin C on postoperative outcomes after single-level posterior lumbar interbody fusion (PLIF) for lumbar spinal stenosis in prospectively randomized design. We conducted a 1-year prospective, randomized, placebo-controlled, double-blind study to evaluate the impact of vitamin C on the postoperative outcomes after PLIF surgery. A total of 123 eligible patients were randomly assigned to either group A (62 patients with vitamin C) or group B (61 patients with placebo). Patient follow-up was continued for at least 1 year after surgery. The primary outcome measure was pain intensity in the lower back using a visual analogue scale. The secondary outcome measures were: (1) the clinical outcome assessed using the Oswestry Disability Index (ODI); (2) the fusion rate assessed using dynamic radiographs and computed tomography scans; and (3) complications. Pain intensity in the lower back was significantly improved in both groups compared with preoperative pain intensity, but no significant difference was observed between the 2 groups over the follow-up period. The ODI score of group A at the third postoperative month was significantly higher than the score of group B. After the sixth postoperative month, the ODI score of group A was slightly higher than the score of group B; however, this difference was not significant. The fusion rates at 1 year after surgery and the complication rates were not significantly different between the 2 groups. Postoperative pain intensity, the primary outcome measure, was not significantly different at 1 year after surgery between the 2 groups. However, vitamin C may be associated with improving functional status after PLIF surgery, especially during the first 3

[Controversies about instrumented surgery and pain relief in degenerative lumbar spine pain. Results of scientific evidence].

PubMed

Robaina-Padrón, F J

2007-10-01

studies in subgroups of patients. We still are needing randomized studies to compare the surgical results with the natural history of the disease, the placebo effect, or the conservative treatment. The European Guidelines for lumbar chronic pain management show a "strong evidence" indicating that complex and demanding spine surgery where different instrumentation is used, is not more effective than a simple, safer and cheaper posterolateral fusion without instrumentation. Recently, the literature published in this field is sending a message to use "minimally invasive techniques", abandon transpedicular fusions and clearly indicating that we must apply the knowledge accumulated at least along the last 20 years based on the scientific evidence. In conclusion, based in recent information, we must recommend the "abandon of the instrumented pathway" in a great number of present indications for degenerative spine surgery, and look for new strategies in the field of rehabilitation and conservative treatments correctly apply, using before the decompressive and instrumented surgery all the interventional and minimally invasive techniques that are presently offer in the field of modem lumbar chronic pain treatment.

Oligosaccharide nanomedicine of alginate sodium improves therapeutic results of posterior lumbar interbody fusion with cages for degenerative lumbar disease in osteoporosis patients by downregulating serum miR-155.

PubMed

Qu, Yang; Wang, Zhengming; Zhou, Haohan; Kang, Mingyang; Dong, Rongpeng; Zhao, Jianwu

2017-01-01

Degenerative lumbar disease (DLD) is a significant issue for public health. Posterior lumbar intervertebral fusion with cages (PLIFC) has high-level fusion rate and realignment on DLD. However, there are some complications following the surgery. Alginate oligosaccharides (AOS) have antioxidant and anti-inflammatory activities and may be suitable for infection therapy. MiR-155 is a biomarker associated with inflammatory and oxidative stress. AOS may promote PLIFC therapy by regulating miR-155. Pluronic nanoparticles and oligosaccharide nanomedicine of alginate sodium (ONAS) were prepared with ampicillin at size <200 nm. Ninety-six DLD osteoporosis patients received PLIFC and were evenly assigned into ONAS group (OG, oral administration of 100 mg ONAS daily) and control group (PG, 100 mg pluronic nanoparticles). Serum miR-155 level was measured by real-time quantitative PCR. The levels of superoxide dismutase (SOD), glutathione (GSH), aspartate aminotransaminase (AST), alanine aminotransferase (ALT), interleukin-1β (IL-1β), and interleukin-1 receptor antagonist (IL-1ra) were measured. Weighted mean difference (WMD), relative risk (RR), complications, surgery infection rate, fusion rate, and Japanese Orthopaedic Association (JOA) scores were used to evaluate therapeutic efficacy. After 1-month therapy, infection rates and side effects were lower in OG than those in PG (RR =0.64, 95% confidence interval [CI] [0.48, 0.84], P =0.001). The fusion rates were higher in OG than in PG (WMD =21.96, 95% CI [-0.24, 37.62], P =0.021). The JOA scores were higher in OG than in PG (RR =0.52, 95% CI [0.33, 0.84], P =0.007), and no significant difference was found for the visual analog scale and Oswestry Disability Index. Serum levels of miR-155, ALT, AST, and IL-1β were lower while SOD, GSH, and IL-1ra were higher in OG than in PG. MiR-155 mimic increased the levels of ALT, AST, and IL-1β and reduced the levels of SOD, GSH, and IL-1ra. In contrast, miR-155 inhibitor had reverse

Management of Lumbar Conditions in the Elite Athlete.

PubMed

Hsu, Wellington K; Jenkins, Tyler James

2017-07-01

Lumbar disk herniation, degenerative disk disease, and spondylolysis are the most prevalent lumbar conditions that result in missed playing time. Lumbar disk herniation has a good prognosis. After recovery from injury, professional athletes return to play 82% of the time. Surgical management of lumbar disk herniation has been shown to be a viable option in athletes in whom nonsurgical measures have failed. Degenerative disk disease is predominately genetic but may be accelerated in athletes secondary to increased physiologic loading. Nonsurgical management is the standard of care for lumbar degenerative disk disease in the elite athlete. Spondylolysis is more common in adolescent athletes with back pain than in adult athletes. Nonsurgical management of spondylolysis is typically successful. However, if surgery is required, fusion or direct pars repair can allow the patient to return to sports.

Delayed diagnosis of an isolated posterolateral corner injury: a case report

PubMed Central

Welsh, Patrick; DeGraauw, Christopher; Whitty, David

2016-01-01

Introduction: Isolated injuries to the posterolateral corner of the knee are a rare and commonly missed injury associated with athletic trauma, motor vehicle accidents, and falls. Delayed or missed diagnoses can negatively impact patient prognosis, contributing to residual instability, chronic pain, and failure of surgical repair to other ligaments. Case Presentation: A 44-year-old male CrossFit athlete presented with a history of two non-contact hyperextension injuries to his left knee while walking on ice. The only positive finding was the Dial Test at 30 degrees of knee flexion, indicative of an isolated posterolateral corner injury. After a delay in diagnosis, the patient underwent a reconstruction of the posterolateral corner and subsequent rehabilitation. Early recognition of this injury is important as this can affect the prognosis and activities of daily living of the patient. Summary: This case will discuss the clinical presentation, diagnostic procedures, and management of an isolated posterolateral corner injury and highlight the importance of early recognition and referrals from primary contact healthcare practitioners. PMID:28065990

Lumbar stenosis surgery: Spine surgeons not insurance companies should decide when enough is better than too much.

PubMed

Epstein, Nancy E

2017-01-01

Lumbar surgery for spinal stenosis is the most common spine operation being performed in older patients. Nevertheless, every time we want to schedule surgery, we confront the insurance industry. More often than not they demand patients first undergo epidural steroid injections (ESI); clearly they are not aware of ESI's lack of long-term efficacy. Who put these insurance companies in charge anyway? We did. How? Through performing too many unnecessary or overly extensive spinal operations (e.g., interbody fusions and instrumented fusions) without sufficient clinical and/or radiographic indications. Patients with lumbar spinal stenosis with/without degenerative spondylolisthesis (DS) are being offered decompressions alone and/or unnecessarily extensive interbody and/or instrumented fusions. Furthermore, a cursory review of the literature largely demonstrates comparable outcomes for decompressions alone vs. decompressions/in situ fusions vs. interbody/instrumented fusions. Too many older patients are being subjected to unnecessary lumbar spine surgery, some with additional interbody/non instrumented or instrumented fusions, without adequate clinical/neurodiagnostic indications. The decision to perform spine surgery for lumbar stenosis/DS, including decompression alone, decompression with non instrumented or instrumented fusion should be in the hands of competent spinal surgeons with their patients' best outcomes in mind. Presently, insurance companies have stepped into the "void" left by spinal surgeons' failing to regulate when, what type, and why spinal surgery is being offered to patients with spinal stenosis. Clearly, spine surgeons need to establish guidelines to maximize patient safety and outcomes for lumbar stenosis surgery. We need to remove insurance companies from their present roles as the "spinal police."

Vertebral Compression Fractures after Lumbar Instrumentation.

PubMed

Granville, Michelle; Berti, Aldo; Jacobson, Robert E

2017-09-29

Lumbar spinal stenosis (LSS) is primarily found in an older population. This is a similar demographic group that develops both osteoporosis and vertebral compression fractures (VCF). This report reviewed a series of patients treated for VCF that had previous lumbar surgery for symptomatic spinal stenosis. Patients that only underwent laminectomy or fusion without instrumentation had a similar distribution of VCF as the non-surgical population in the mid-thoracic, or lower thoracic and upper lumbar spine. However, in the patients that had previous short-segment spinal instrumentation, fractures were found to be located more commonly in the mid-lumbar spine or sacrum adjacent to or within one or two spinal segments of the spinal instrumentation. Adjacent-level fractures that occur due to vertebral osteoporosis after long spinal segment instrumentation has been discussed in the literature. The purpose of this report is to highlight the previously unreported finding of frequent lumbar and sacral osteoporotic fractures in post-lumbar instrumentation surgery patients. Important additional factors found were lack of preventative medical treatment for osteoporosis, and secondary effects related to inactivity, especially during the first year after surgery.

Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature: results of a multicenter, prospective, randomized investigational device exemption study of Charité intervertebral disc. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004.

PubMed

Geisler, Fred H; Blumenthal, Scott L; Guyer, Richard D; McAfee, Paul C; Regan, John J; Johnson, J Patrick; Mullin, Bradford

2004-09-01

Arthrodesis is the gold standard for surgical treatment of lumbar degenerative disc disease (DDD). Solid fusion, however, can cause stress and increased motion in the segments adjacent to the fused level. This may initiate and/or accelerate the adjacent-segment disease process. Artificial discs are designed to restore and maintain normal motion of the lumbar intervertebral segment. Restoring and maintaining normal motion of the segment reduces stresses and loads on adjacent level segments. A US Food and Drug Administration Investigational Device Exemptions multicentered study of the Charité artificial disc was completed. The control group consisted of individuals who underwent anterior lumbar interbody fusion involving BAK cages and iliac crest bone graft. This is the first report of Class I data in which a lumbar artificial disc is compared with lumbar fusion. Of 304 individuals enrolled in the study, 205 were randomized to the Charité disc-treated group and 99 to the BAK fusion-treated (control) group. Neurological status was equivalent between the two groups at 6, 12, and 24 months postoperatively. The number of patients with major, minor, or other neurological complications was equivalent. There was a greater incidence of both major and minor complications in the BAK fusion group at 0 to 42 days postoperatively. Compared with data reported in the lumbar fusion literature, the Charité disc-treated patients had equivalent or better mean changes in visual analog scale and Oswestry Disability Index scores. The Charité artificial disc is safe and effective for the treatment of single-level lumbar DDD, resulting in no higher incidence of neurological complications compared with BAK-assisted fusion and leading to equivalent or better outcomes compared with those obtained in the control group and those reported in the lumbar fusion literature.

Using spinopelvic parameters to estimate residual lumbar lordosis assuming previous lumbosacral fusion-a study of normative values.

PubMed

Hey, Hwee Weng Dennis; Tan, Kimberly-Anne; Kantharajanna, Shashidhar Bangalore; Teo, Alex Quok An; Chan, Chloe Xiaoyun; Liu, Ka-Po Gabriel; Wong, Hee-Kit

2018-03-01

Pelvic incidence (PI)=pelvic tilt (PT)+sacral slope (SS) is an established trigonometric equation which can be expanded from studying the fixed pelvis with the spine to a fixed spinopelvic complex with the remnant spine, in scenarios of spinopelvic fusion or ankylosis. For a fixed spinopelvic complex, we propose the equation termed: lumbar incidence (LI)=lumbar tilt (LT)+lumbar slope (LS). This study aimed to establish reference values for LI, LT, and LS at each lumbar vertebral level, and to show how LI can be used to determine residual lumbar lordosis (rLL). This is a cross-sectional study of prospectively collected data, conducted at a single academic tertiary health-care center. The study included 53 healthy patients aged 19-35 with first episode mechanical low back pain for a period of <3 months. Patients with previous spinal intervention, those with known or suspected spinal pathologies, and those who were pregnant, were excluded. Radiological measurements of LI, LT, LS, and rLL. All patients had full-body lateral standing radiographs obtained via a slot scanner. Basic global and regional radiographic parameters, spinopelvic parameters, and the aforementioned new parameters were measured. LI was correlated with rLL at each level by plotting LI against rLL on scatter plots and drawing lines-of-best-fit through the datapoints. The mean value of L5I was 22.82°, L4I was 6.52°, L3I was -0.92°, L2I was -5.56°, and L1I was -5.95°. LI turns negative at L3, LS turns negative at the L3/L4 apex, and LT remains positive throughout the lumbar spine. We found that the relationship of LI with its corresponding rLL follows a parabolic trend. Thus, rLL can be determined from the linear equations of the tangents to the parabolic lumbar spine. We propose the LI-rLL method for determining rLL as the LI recalibrates via spinopelvic compensation post instrumentation, and thus the predicted rLL will be based on this new equilibrium, promoting restoration of harmonized lordosis

Economic impact of minimally invasive lumbar surgery.

PubMed

Hofstetter, Christoph P; Hofer, Anna S; Wang, Michael Y

2015-03-18

Cost effectiveness has been demonstrated for traditional lumbar discectomy, lumbar laminectomy as well as for instrumented and noninstrumented arthrodesis. While emerging evidence suggests that minimally invasive spine surgery reduces morbidity, duration of hospitalization, and accelerates return to activites of daily living, data regarding cost effectiveness of these novel techniques is limited. The current study analyzes all available data on minimally invasive techniques for lumbar discectomy, decompression, short-segment fusion and deformity surgery. In general, minimally invasive spine procedures appear to hold promise in quicker patient recovery times and earlier return to work. Thus, minimally invasive lumbar spine surgery appears to have the potential to be a cost-effective intervention. Moreover, novel less invasive procedures are less destabilizing and may therefore be utilized in certain indications that traditionally required arthrodesis procedures. However, there is a lack of studies analyzing the economic impact of minimally invasive spine surgery. Future studies are necessary to confirm the durability and further define indications for minimally invasive lumbar spine procedures.

Human Perivascular Stem Cell-Based Bone Graft Substitute Induces Rat Spinal Fusion

PubMed Central

Chung, Choon G.; James, Aaron W.; Asatrian, Greg; Chang, Le; Nguyen, Alan; Le, Khoi; Bayani, Georgina; Lee, Robert; Stoker, David; Zhang, Xinli

2014-01-01

Adipose tissue is an attractive source of mesenchymal stem cells (MSCs) because of its abundance and accessibility. We have previously defined a population of native MSCs termed perivascular stem cells (PSCs), purified from diverse human tissues, including adipose tissue. Human PSCs (hPSCs) are a bipartite cell population composed of pericytes (CD146+CD34−CD45−) and adventitial cells (CD146−CD34+CD45−), isolated by fluorescence-activated cell sorting and with properties identical to those of culture identified MSCs. Our previous studies showed that hPSCs exhibit improved bone formation compared with a sample-matched unpurified population (termed stromal vascular fraction); however, it is not known whether hPSCs would be efficacious in a spinal fusion model. To investigate, we evaluated the osteogenic potential of freshly sorted hPSCs without culture expansion and differentiation in a rat model of posterolateral lumbar spinal fusion. We compared increasing dosages of implanted hPSCs to assess for dose-dependent efficacy. All hPSC treatment groups induced successful spinal fusion, assessed by manual palpation and microcomputed tomography. Computerized biomechanical simulation (finite element analysis) further demonstrated bone fusion with hPSC treatment. Histological analyses showed robust endochondral ossification in hPSC-treated samples. Finally, we confirmed that implanted hPSCs indeed differentiated into osteoblasts and osteocytes; however, the majority of the new bone formation was of host origin. These results suggest that implanted hPSCs positively regulate bone formation via direct and paracrine mechanisms. In summary, hPSCs are a readily available MSC population that effectively forms bone without requirements for culture or predifferentiation. Thus, hPSC-based products show promise for future efforts in clinical bone regeneration and repair. PMID:25154782

Lumbar Lordosis of Spinal Stenosis Patients during Intraoperative Prone Positioning

PubMed Central

Lee, Su-Keon; Song, Kyung-Sub; Park, Byung-Moon; Lim, Sang-Youn; Jang, Geun; Lee, Beom-Seok; Moon, Seong-Hwan; Lee, Hwan-Mo

2016-01-01

Background To evaluate the effect of spondylolisthesis on lumbar lordosis on the OSI (Jackson; Orthopaedic Systems Inc.) frame. Restoration of lumbar lordosis is important for maintaining sagittal balance. Physiologic lumbar lordosis has to be gained by intraoperative prone positioning with a hip extension and posterior instrumentation technique. There are some debates about changing lumbar lordosis on the OSI frame after an intraoperative prone position. We evaluated the effect of spondylolisthesis on lumbar lordosis after an intraoperative prone position. Methods Sixty-seven patients, who underwent spinal fusion at the Department of Orthopaedic Surgery of Gwangmyeong Sungae Hospital between May 2007 and February 2012, were included in this study. The study compared lumbar lordosis on preoperative upright, intraoperative prone and postoperative upright lateral X-rays between the simple stenosis (SS) group and spondylolisthesis group. The average age of patients was 67.86 years old. The average preoperative lordosis was 43.5° (± 14.9°), average intraoperative lordosis was 48.8° (± 13.2°), average postoperative lordosis was 46.5° (± 16.1°) and the average change on the frame was 5.3° (± 10.6°). Results Among all patients, 24 patients were diagnosed with simple spinal stenosis, 43 patients with spondylolisthesis (29 degenerative spondylolisthesis and 14 isthmic spondylolisthesis). Between the SS group and spondylolisthesis group, preoperative lordosis, intraoperative lordosis and postoperative lordosis were significantly larger in the spondylolisthesis group. The ratio of patients with increased lordosis on the OSI frame compared to preoperative lordosis was significantly higher in the spondylolisthesis group. The risk of increased lordosis on frame was significantly higher in the spondylolisthesis group (odds ratio, 3.325; 95% confidence interval, 1.101 to 10.039; p = 0.033). Conclusions Intraoperative lumbar lordosis on the OSI frame with a prone

Do intraoperative radiographs predict final lumbar sagittal alignment following single-level transforaminal lumbar interbody fusion?

PubMed

Salem, Khalid M I; Eranki, Aditya P; Paquette, Scott; Boyd, Michael; Street, John; Kwon, Brian K; Fisher, Charles G; Dvorak, Marcel F

2018-05-01

OBJECTIVE The study aimed to determine if the intraoperative segmental lordosis (as calculated on a cross-table lateral radiograph following a single-level transforaminal lumbar interbody fusion [TLIF] for degenerative spondylolisthesis/low-grade isthmic spondylolisthesis) is maintained at discharge and at 6 months postsurgery. METHODS The authors reviewed images and medical records of patients ≥ 16 years of age with a diagnosis of an isolated single-level, low-grade spondylolisthesis (degenerative or isthmic) with symptomatic spinal stenosis treated between January 2008 and April 2014. Age, sex, surgical level, surgical approach, and facetectomy (unilateral vs bilateral) were recorded. Upright standardized preoperative, early, and 6-month postoperative radiographs, as well as intraoperative lateral radiographs, were analyzed for the pelvic incidence, segmental lumbar lordosis (SLL) at the TILF level, and total LL (TLL). In addition, the anteroposterior position of the cage in the disc space was documented. Data are presented as the mean ± SD; a p value < 0.05 was considered significant. RESULTS Eighty-four patients were included in the study. The mean age of patients was 56.8 ± 13.7 years, and 46 patients (55%) were men. The mean pelvic incidence was 59.7° ± 11.9°, and a posterior midline approach was used in 47 cases (56%). All TLIF procedures were single level using a bullet-shaped cage. A bilateral facetectomy was performed in 17 patients (20.2%), and 89.3% of procedures were done at the L4-5 and L5-S1 segments. SLL significantly improved intraoperatively from 15.8° ± 7.5° to 20.9° ± 7.7°, but the correction was lost after ambulation. Compared with preoperative values, at 6 months the change in SLL was modest at 1.8° ± 6.7° (p = 0.025), whereas TLL increased by 4.3° ± 9.6° (p < 0.001). The anteroposterior position of the cage, approach, level of surgery, and use of a bilateral facetectomy did not significantly affect postoperative LL

Influence of lumbar lordosis restoration on thoracic curve and sagittal position in lumbar degenerative kyphosis patients.

PubMed

Jang, Jee-Soo; Lee, Sang-Ho; Min, Jun-Hong; Maeng, Dae Hyeon

2009-02-01

A retrospective study. To determine postsurgical correlations between thoracic and lumbar sagittal curves in lumbar degenerative kyphosis (LDK) and to determine predictability of spontaneous correction of thoracic curve and sacral angle after surgical restoration of lumbar lordosis and fusion. To our knowledge, there are only a limited number of articles about the relationship between thoracic and lumbar curve in sagittal thoracic compensated LDK. Retrospective review of 53 consecutive patients treated with combined anterior and posterior spinal arthrodesis. We included patients with sagittal thoracic compensated LDK caused by sagittal imbalance in this study. Total lumbar lordosis, thoracic kyphosis, sacral slope, and C7 plumb line were measured on the pre- and postoperative whole spine lateral views. Postoperative changes in thoracic kyphosis, sacral slope, and C7 plumb line according to the surgical lumbar lordosis restoration were measured and evaluated. The mean preoperative sagittal imbalance by plumb line was 78.3 mm (+/-76.5); this improved to 13.6 mm (+/-25) after surgery (P < 0.0001). Mean lumbar lordosis was 9.4 degrees (+/-19.2) before surgery and increased to 38.4 degrees (+/-13.1) at follow-up (P < 0.0001). Mean thoracic kyphosis was 1.1 degrees (+/-12.7) before surgery and increased to 17.6 degrees (+/-12.2) at follow-up (P < 0.0001). Significant preoperative correlations existed between kyphosis and lordosis (r = 0.772, P < 0.0001) and between lordosis and sacral slope (r = 0.785, P < 0.0001). Postoperative lumbar lordosis is correlated to thoracic kyphosis increase (r = 0.620, P < 0.0001). Postoperative lumbar lordosis is correlated to sacral slope increase (r = 0.722, P < 0.0001). Reciprocal relationship exists between lumbar lordosis and thoracic kyphosis in sagittal thoracic compensated LDK. Surgical restoration of lumbar lordosis for LDK brings about high level of statistical correlation to thoracic kyphosis improvement. At the same time, the

Higher Improvement in Patient-Reported Outcomes Can Be Achieved After Transforaminal Lumbar Interbody Fusion for Clinical and Radiographic Degenerative Spondylolisthesis Classification Type D Degenerative Lumbar Spondylolisthesis.

PubMed

Chen, Xi; Xu, Liang; Qiu, Yong; Chen, Zhong-Hui; Zhou, Qing-Shuang; Li, Song; Sun, Xu

2018-06-01

Clinical and radiographic degenerative spondylolisthesis (CARDS) classification defines a distinct subset of patients with kyphotic angulation at the involved segment (type D). Research using CARDS classification to investigate motion characteristics at involved segments or patient-related outcomes (PROs) following surgical intervention is sparse. We investigated the relationship between CARDS type D spondylolisthesis and dynamic instability and PROs in type D versus non-type D spondylolisthesis. We reviewed consecutive patients who received transforaminal lumbar interbody fusion for L4-5 spondylolisthesis between 2009 and 2015. Patients were assigned into type D and non-type D groups. Translational motion was determined by upright lumbar lateral radiography with supine sagittal magnetic resonance imaging or flexion and extension radiography. Demographics, radiographic parameters, and PROs were evaluated. Type D and non-type D groups comprised 34 and 163 patients, respectively. Compared with non-type D, type D group was characterized by lordotic angulation loss and higher degree of olisthesis on upright radiographs and demonstrated higher translational motion on upright lumbar lateral radiography with supine sagittal magnetic resonance imaging analysis. After surgery, mean reduction rate was significantly higher in type D group; type D had less slippage, but differences in slip angle and disc height were not significant. Preoperative Oswestry Disability Index and visual analog scale for back pain scores were higher in type D group. Type D spondylolisthesis and dynamic instability were associated with achieving minimal clinically important differences in PROs. CARDS type D spondylolisthesis is a distinct subset associated with dynamic instability and worse PROs. Higher improvement in PROs can be achieved in CARDS type D spondylolisthesis after surgery. Copyright © 2018 Elsevier Inc. All rights reserved.

The Efficacy of Vitamin C on Postoperative Outcomes after Posterior Lumbar Interbody Fusion: A Randomized, Placebo-Controlled Trial

PubMed Central

Yang, Han Seok; Yeom, Jin S.; Ahn, Myun-Whan

2017-01-01

Background Vitamin C has critical features relavant to postoperative pain management and functional improvement; however, no study has yet evaluated the effectiveness of vitamin C on improving the surgical outcomes for spine pathologies. Thus, this study aimed to explore the impact of vitamin C on postoperative outcomes after single-level posterior lumbar interbody fusion (PLIF) for lumbar spinal stenosis in prospectively randomized design. We conducted a 1-year prospective, randomized, placebo-controlled, double-blind study to evaluate the impact of vitamin C on the postoperative outcomes after PLIF surgery. Methods A total of 123 eligible patients were randomly assigned to either group A (62 patients with vitamin C) or group B (61 patients with placebo). Patient follow-up was continued for at least 1 year after surgery. The primary outcome measure was pain intensity in the lower back using a visual analogue scale. The secondary outcome measures were: (1) the clinical outcome assessed using the Oswestry Disability Index (ODI); (2) the fusion rate assessed using dynamic radiographs and computed tomography scans; and (3) complications. Results Pain intensity in the lower back was significantly improved in both groups compared with preoperative pain intensity, but no significant difference was observed between the 2 groups over the follow-up period. The ODI score of group A at the third postoperative month was significantly higher than the score of group B. After the sixth postoperative month, the ODI score of group A was slightly higher than the score of group B; however, this difference was not significant. The fusion rates at 1 year after surgery and the complication rates were not significantly different between the 2 groups. Conclusions Postoperative pain intensity, the primary outcome measure, was not significantly different at 1 year after surgery between the 2 groups. However, vitamin C may be associated with improving functional status after PLIF surgery

Description of the Posterolateral Rotatory Drawer Maneuver for the Identification of Posterolateral Corner Injury

PubMed Central

Angelini, Fábio Janson; Bonadio, Marcelo Batista; Helito, Camilo Partezani; da Mota e Albuquerque, Roberto Freire; Pécora, José Ricardo; Camanho, Gilberto Luis

2014-01-01

Injury to the posterolateral corner (PLC) is difficult to diagnose; most lesions of this type are included within the context of complex knee injuries. Study of the posterolateral complex is growing in importance because of the complex instability generated by these injuries. Although various physical examination tests are described for the diagnosis of PLC lesions, in 72% of cases these lesions are not identified at their initial presentation, which shows the difficulty in both performing these tests and interpreting the results. The maneuver described in this report is performed by executing external rotation of the leg. With the thumb of the proximally positioned hand, the examiner evaluates the positioning of the lateral tibial plateau in relation to the femoral condyle. With this maneuver, in lesions of the PLC and particularly lesions of its external rotation–restricting structures, we observe external rotation of the tibia and posterior subluxation of the lateral tibial plateau that cause the anterior edge of the tibial plateau to be posteriorized in relation to the anterior edge of the lateral femoral condyle. The idea behind this maneuver is not to eliminate the use of other tests but, rather, to add it to a diagnostic arsenal that still has interpretation flaws. PMID:24904781

Comparison between free-hand and O-arm-based navigated posterior lumbar interbody fusion in elderly cohorts with three-level lumbar degenerative disease.

PubMed

Wang, Yucheng; Chen, Kangwu; Chen, Hao; Zhang, Kai; Lu, Jian; Mao, Haiqing; Yang, Huilin

2018-06-06

This retrospective cohort study aims to evaluate the effects of introducing the O-arm-based navigation technique into the traditional posterior lumbar interbody fusion (PLIF) procedure treating elderly patients with three-level lumbar degenerative diseases. Forty-one consecutive elderly patients were enrolled according to the criteria. There were 21 patients in the free-hand group and 20 patients in the O-arm group. Both two groups underwent the PLIF with or without the O-arm-based navigation technique. The demographic features, clinical data and outcomes, and radiological information were collected for further analysis. The average follow-up time was 18.3 (range, 12-28) months in the free-hand group and 16.7 (range, 12-24) months in the O-arm group. Comparison between two groups revealed no significant difference regarding demographic features. The operation time took in the navigation group was significantly less than that in the free-hand group (222.55 ± 38.00 mins versus 255.19 ± 40.26 mins, P < 0.05). Both VAS and ODI were improved post-operatively in two groups while comparison between groups showed no difference. The accuracy rate of pedicle screw positioning was 88.7% in the free-hand group to 96.9% in the O-arm group (P < 0.05). The O-arm-based navigation is an efficacious auxiliary technique which could significantly improve the accuracy of pedicle screw insertion, especially in cases of patients with complex anatomic degenerative diseases, without sacrificing the feasibility and reliable outcome of traditional PLIF.

Hemothorax caused by the trocar tip of the rod inserter after minimally invasive transforaminal lumbar interbody fusion: case report.

PubMed

Maruo, Keishi; Tachibana, Toshiya; Inoue, Shinichi; Arizumi, Fumihiro; Yoshiya, Shinichi

2016-03-01

Minimally invasive surgery (MIS) for transforaminal lumbar interbody fusion (MIS-TLIF) is widely used for lumbar degenerative diseases. In the paper the authors report a unique case of a hemothorax caused by the trocar tip of the rod inserter after MIS-TLIF. A 61-year-old woman presented with thigh pain and gait disturbance due to weakness in her lower right extremity. She was diagnosed with a lumbar disc herniation at L1-2 and the MIS-TLIF procedure was performed. Immediately after surgery, the patient's thigh pain resolved and she remained stable with normal vital signs. The next day after surgery, she developed severe anemia and her hemoglobin level decreased to 7.6 g/dl, which required blood transfusions. A chest radiograph revealed a hemothorax. A CT scan confirmed a hematoma of the left paravertebral muscle. A chest tube was placed to treat the hemothorax. After 3 days of drainage, there was no active bleeding. The patient was discharged 14 days after surgery without leg pain or any respiratory problems. This complication may have occurred due to injury of the intercostal artery by the trocar tip of the rod inserter. A hemothorax after spine surgery is a rare complication, especially in the posterior approach. The rod should be caudally inserted in the setting of the thoracolumbar spine.

A Novel Technique of Posterolateral Suturing in Thoracoscopic Diaphragmatic Hernia Repair

PubMed Central

Boo, Yoon Jung; Rohleder, Stephan; Muensterer, Oliver J.

2017-01-01

Background  Closure of the posterolateral defect in some cases of congenital diaphragmatic hernia (CDH) can be difficult. Percutaneous transcostal suturing is often helpful to create a complete, watertight closure of the diaphragm. A challenge with the technique is passing the needle out the same tract that it entered so that no skin is caught when the knots are laid down into the subcutaneous tissue. This report describes a novel technique using a Tuohy needle to percutaneously suture the posterolateral defect during thoracoscopic repair of CDH. Case  We report a case of a 6-week-old infant who presented with a CDH and ipsilateral intrathoracic kidney that was repaired using thoracoscopic approach. The posterolateral part of the defect was repaired by percutaneous transcostal suturing and extracorporeal knot tying. To assure correct placement of the sutures and knots, a Tuohy needle was used to guide the suture around the rib and out through the same subcutaneous tract. The total operative time was 145 minutes and there were no perioperative complications. The patient was followed up for 3 months, during which there was no recurrence. Conclusion  Our percutaneous Tuohy technique for closure of the posterolateral part of CDH enables a secure, rapid, and tensionless repair. PMID:28804698

A Novel Technique of Posterolateral Suturing in Thoracoscopic Diaphragmatic Hernia Repair.

PubMed

Boo, Yoon Jung; Rohleder, Stephan; Muensterer, Oliver J

2017-01-01

Background  Closure of the posterolateral defect in some cases of congenital diaphragmatic hernia (CDH) can be difficult. Percutaneous transcostal suturing is often helpful to create a complete, watertight closure of the diaphragm. A challenge with the technique is passing the needle out the same tract that it entered so that no skin is caught when the knots are laid down into the subcutaneous tissue. This report describes a novel technique using a Tuohy needle to percutaneously suture the posterolateral defect during thoracoscopic repair of CDH. Case  We report a case of a 6-week-old infant who presented with a CDH and ipsilateral intrathoracic kidney that was repaired using thoracoscopic approach. The posterolateral part of the defect was repaired by percutaneous transcostal suturing and extracorporeal knot tying. To assure correct placement of the sutures and knots, a Tuohy needle was used to guide the suture around the rib and out through the same subcutaneous tract. The total operative time was 145 minutes and there were no perioperative complications. The patient was followed up for 3 months, during which there was no recurrence. Conclusion  Our percutaneous Tuohy technique for closure of the posterolateral part of CDH enables a secure, rapid, and tensionless repair.

SPECT/CT in patients with lower back pain after lumbar fusion surgery.

PubMed

Sumer, Johannes; Schmidt, Daniela; Ritt, Philipp; Lell, Michael; Forst, Raimund; Kuwert, Torsten; Richter, Richard

2013-10-01

The aim of the study was to investigate the incremental diagnostic value of skeletal hybrid imaging with single-photon emission computed tomography and X-ray computed tomography (SPECT/CT) over conventional nuclear medical imaging in patients with lower back pain after lumbar fusion surgery (LFS). This retrospective study comprised 37 patients suffering from lower back pain after LFS in whom three-phase planar bone scintigraphies of the lumbar spine including SPECT/CT of that region had been performed. The findings visible on these imaging data sets were classified into the following five diagnostic categories: (a) metal loosening; (b) insufficient stabilizing function of the metal implants indicated by metabolically active facet joint arthritis and/or intervertebral osteochondrosis in the instrumented region; (c) adjacent instability defined as metabolically active degenerative disease in the segments adjacent to the instrumented region; (d) indeterminate; and (e) normal. In the case of eight patients no lesions were visible on their planar scintigraphy and SPECT (planar/SPECT) or SPECT/CT images. In the remaining 29 patients, planar/SPECT disclosed 62 pathological foci of uptake within the graft region and SPECT/CT revealed 55. The rate of reclassification by SPECT/CT compared with planar/SPECT was 5/12 for lesions categorized as metal loosening by planar/SPECT, 16/29 for foci with a planar/SPECT diagnosis of insufficient stabilizing function, 7/20 when the planar/SPECT diagnosis had been adjacent instability, and 1/1 for the lesions indeterminate on planar/SPECT. Two lesions had been detected on SPECT/CT only. The overall rate of reclassification was 45.2% (28/62) (95% confidence interval, 33.4-57.5%). Because of its significantly higher accuracy compared with planar/SPECT, SPECT/CT should be the conventional nuclear medical procedure of choice for patients with lower back pain after LFS.

Posterolateral hip muscle strengthening versus quadriceps strengthening for patellofemoral pain: a comparative control trial.

PubMed

Khayambashi, Khalil; Fallah, Alireza; Movahedi, Ahmadreza; Bagwell, Jennifer; Powers, Christopher

2014-05-01

To compare the efficacy of posterolateral hip muscle strengthening versus quadriceps strengthening in reducing pain and improving health status in persons with patellofemoral pain (PFP). Comparative control trial. Rehabilitation facility. Persons with a diagnosis of PFP (N=36; 18 men, 18 women). Patients were alternately assigned to a posterolateral hip muscle strengthening group (9 men and 9 women) or a quadriceps strengthening group (9 men and 9 women). The posterolateral hip muscle strengthening group performed hip abductor and external rotator strengthening exercises, whereas the quadriceps strengthening group performed quadriceps strengthening exercises (3 times a week for 8wk). Pain (visual analog scale [VAS]) and health status (Western Ontario McMaster Universities Osteoarthritis Index [WOMAC]) were assessed at baseline, postintervention, and 6-month follow-up. Significant improvements in VAS and WOMAC scores were observed in both groups from baseline to postintervention and baseline to 6-month follow-up (P<.001). Improvements in VAS and WOMAC scores in the posterolateral hip exercise group were superior to those in the quadriceps exercise group postintervention and at 6-month follow-up (P<.05). Although both intervention programs resulted in decreased pain and improved function in persons with PFP, outcomes in the posterolateral hip exercise group were superior to the quadriceps exercise group. The superior outcomes obtained in the posterolateral hip exercise group were maintained 6 months postintervention. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

A Multicenter Radiographic Evaluation of the Rates of Preoperative and Postoperative Malalignment in Degenerative Spinal Fusions.

PubMed

Leveque, Jean-Christophe A; Segebarth, Bradley; Schroerlucke, Samuel R; Khanna, Nitin; Pollina, John; Youssef, Jim A; Tohmeh, Antoine G; Uribe, Juan S

2018-07-01

Multicenter, retrospective, institutional-review-board -approved study at 18 institutions in the United States with 24 treating investigators. This study was designed to retrospectively assess the prevalence of spinopelvic malalignment in patients who underwent one- or two-level lumbar fusions for degenerative (nondeformity) indications and to assess the incidence of malalignment after fusion surgery as well as the rate of alignment preservation and/or correction in this population. Spinopelvic malalignment after lumbar fusion has been associated with lower postoperative health-related quality of life and elevated risk of adjacent segment failure. The prevalence of spinopelvic malalignment in short-segment degenerative lumbar fusion procedures from a large sample of patients is heretofore unreported and may lead to an under-appreciation of these factors in surgical planning and ultimate preservation or correction of alignment. Lateral preoperative and postoperative lumbar radiographs were retrospectively acquired from 578 one- or two-level lumbar fusion patients and newly measured for lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt. Patients were categorized at preop and postop time points as aligned if PI-LL < 10° or malaligned if PI-LL≥10°. Patients were grouped into categories based on their alignment progression from pre- to postoperative, with preserved (aligned to aligned), restored (malaligned to aligned), not corrected (malaligned to malaligned), and worsened (aligned to malaligned) designations. Preoperatively, 173 (30%) patients exhibited malalignment. Postoperatively, 161 (28%) of patients were malaligned. Alignment was preserved in 63%, restored in 9%, not corrected in 21%, and worsened in 7% of patients. This is the first multicenter study to evaluate the preoperative prevalence and postoperative incidence of spinopelvic malalignment in a large series of short-segment degenerative lumbar fusions, finding over 25% of patients out of

Ventral Dural Injury After Oblique Lumbar Interbody Fusion.

PubMed

Chang, JaeChil; Kim, Jin-Sung; Jo, Hyunjin

2017-02-01

Oblique lumbar interbody fusion (OLIF) through the oblique corridor between the aorta and anterior border of psoas muscle is favored among spinal surgeons who employ minimally invasive techniques. We report a case of ventral dural tear after OLIF that was associated with the inaccurate trajectory direction of endplate preparation. This is the first report to our knowledge of ventral dural tear associated with OLIF. A 72-year-old woman presented with right leg pain and numbness. X-rays showed degenerative spondylolisthesis and loss of disc height at L4-L5 and L5-S1 levels. Magnetic resonance imaging revealed right-sided paracentral disc herniation at the L3-L4 level and foraminal disc herniation at L4-L5. The initial surgical plan was OLIF of L3-L4 and L4-L5 after percutaneous screw fixation without laminectomy. With the patient in the lateral position, discectomy and endplate preparation were done successfully at the L3-L4 level, and the same procedure was done at the L4-L5 level for OLIF. A sharp Cobbs elevator for endplate preparation triggered a ventral dural defect at the L4-L5 level. We changed the patient's position to attempt dural repair. The ventral dural defect could not be repaired because it was too large. After the herniated rootlets were repositioned, TachoComb was patched over the defect site. Postoperatively, the patient has no definite neurologic deficits. When a surgeon performs OLIF, ventral dural injury should be avoided during the procedure of endplate preparation and contralateral annular release. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparison of transforaminal lumbar interbody fusion outcomes in patients receiving rhBMP-2 versus autograft.

PubMed

Khan, Taleef R; Pearce, Kalin R; McAnany, Steven J; Peters, Colleen M; Gupta, Munish C; Zebala, Lukas P

2018-03-01

Recombinant human bone morphogenetic protein 2 (rhBMP-2) plays a pivotal role in complex spine surgery. Despite its limited approval, the off-label use of rhBMP-2 is prevalent, particularly in transforaminal lumbar interbody fusions (TLIFs). To determine the effectiveness and safety of rhBMP-2 use in TLIF procedures versus autograft. Retrospective cohort study. Patients older than 18 years undergoing spine surgery for lumbar degenerative spine disease at a single academic institution. Clinical outcome was determined according to patient records. Radiographic outcome was determined according to plain X-rays and computed tomography (CT). A retrospective study from 1997 to 2014 was conducted on 191 adults undergoing anterior-posterior instrumented spinal fusion with TLIF at a single academic institution. Patient data were gathered from operative notes, follow-up clinic notes, and imaging studies to determine complications and fusion rates. One hundred eighty-seven patients fit the criteria, which included patients with a minimum of one TLIF, and had a minimum 2-year radiographic and clinical follow-up. Patients were further classified into a BMP group (n=83) or non-BMP group (n=104). Three logistic regression models were run using rhBMP-2 exposure as the independent variable. The respective outcome variables were TLIF-related complications (radiculitis, seroma, osteolysis, and ectopic bone), surgical complications, and all complications. Bone morphogenetic protein (n=83) and non-BMP (n=104) groups had similar baseline demographics (sex, diabetes, pre-existing cancer). On average, the BMP and non-BMP groups were similarly aged (51.9 vs. 47.9 years, p>.05), but the BMP group had a shorter follow-up time (3.03 vs. 4.06 years; p<.001) and fewer smokers (8 vs. 21 patients; p<.048). The fusion rate for the BMP and non-BMP groups was 92.7% and 92.3%, respectively. The pseudoarthrosis rate was 7.5% (14 of 187 patients). Radiculitis was observed in seven patients in the BMP

Comparison of fusion rate and clinical results between CaO-SiO2-P2O5-B2O3 bioactive glass ceramics spacer with titanium cages in posterior lumbar interbody fusion.

PubMed

Lee, Jae Hyup; Kong, Chang-Bae; Yang, Jae Jun; Shim, Hee-Jong; Koo, Ki-Hyoung; Kim, Jeehyoung; Lee, Choon-Ki; Chang, Bong-Soon

2016-11-01

The CaO-SiO 2 -P 2 O 5 -B 2 O 3 glass ceramics spacer generates chemical bonding to adjacent bones with high mechanical stability to produce a union with the end plate, and ultimately stability. The authors aimed to compare the clinical efficacy and safety of CaO-SiO 2 -P 2 O 5 -B 2 O 3 glass ceramics with a titanium cage that is widely used for posterior lumbar interbody fusion (PLIF) surgery in the clinical field. This is a prospective, stratified randomized, multicenter, single-blinded, comparator-controlled non-inferiority trial. The present study was conducted in four hospitals and enrolled a total of 86 patients between 30 and 80 years of age who required one-level PLIF due to severe spinal stenosis, spondylolisthesis, or huge disc herniation. The Oswestry Disability Index (ODI), Short Form-36 Health Survey (SF-36), and pain visual analog scale (VAS) were assessed before surgery and at 3, 6, and 12 months after surgery. The spinal fusion rate was assessed at 6 and 12 months after surgery. The spinal fusion rate and the area of fusion, subsidence of each CaO-SiO 2 -P 2 O 5 -B 2 O 3 glass ceramics and titanium cage, and the extent of osteolysis were evaluated using a dynamic plain radiography and a three-dimensional computed tomography at 12 months after surgery. The present study was supported by BioAlpha, and some authors (JHL, C-KL, and B-SC) have stock ownership (<10,000 US dollars). From the plain radiography results, the 6-month fusion rates for the bioactive glass ceramics group and the titanium group were 89.7% and 91.4%, respectively. In addition, the 12-month fusion rates based on CT scan were 89.7% and 91.2%, respectively, showing no significant difference. However, the bone fusion area directly attached to the end plate of either bioactive glass ceramics or the titanium cage was significantly higher in the bioactive glass ceramics group than in the titanium group. The ODI, SF-36, back pain, and lower limb pain in both groups significantly improved

[Hybrid stabilization technique with spinal fusion and interlaminar device to reduce the length of fusion and to protect symptomatic adjacent segments : Clinical long-term follow-up].

PubMed

Fleege, C; Rickert, M; Werner, I; Rauschmann, M; Arabmotlagh, M

2016-09-01

Determination of the extent of spinal fusion for lumbar degenerative diseases is often difficult due to minor pathologies in the adjacent segment. Although surgical intervention is required, fusion seems to be an overtreatment. Decompression alone may be not enough as this segment is affected by multiple factors such as destabilization, low grade degeneration and an unfavorable biomechanical transition next to a rigid construct. An alternative surgical treatment is a hybrid construct, consisting of fusion and implantation of an interlaminar stabilization device at the adjacent level. The aim of this study was to compare long-term clinical outcome after lumbar fusion with a hybrid construct including an interlaminar stabilization device as "topping-off". A retrospective analysis of 25 lumbar spinal fusions from 2003 to 2010 with additional interlaminar stabilization device was performed. Through a matched case controlled procedure 25 congruent patients who received lumbar spinal fusion in one or two levels were included as a control group. At an average follow-up of 43 months pre- and postoperative pain, ODI, SF-36 as well as clinical parameters, such as leg and back pain, walking distance and patient satisfaction were recorded. Pain relief, ODI improvement and patient satisfaction was significantly higher in the hybrid group compared to the control group. SF-36 scores improved in both groups but was higher in the hybrid group, although without significance. Evaluation of walking distance showed no significant differences. Many outcome parameters present significantly better long-term results in the hybrid group compared to sole spinal fusion. Therefore, in cases with a clear indication for lumbar spinal fusion with the need for decompression at the adjacent level due to spinal stenosis or moderate spondylarthrosis, support of this segment with an interlaminar stabilization device demonstrates a reasonable treatment option with good clinical outcome. Also, the

An awake, minimally-invasive, fully-endoscopic surgical technique for treating lumbar radiculopathy secondary to heterotopic foraminal bone formation after a minimally invasive transforaminal lumbar interbody fusion with BMP: technical note

PubMed Central

2018-01-01

One complication associated with recombinant human bone morphogenetic protein (rhBMP-2) use in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is heterotopic bone growth at the neural foramen which results in the compression of neural structures. Here we present an awake, minimally invasive surgical approach for treating the radiculopathy that results from this excessive bone growth in the foramen. A 42-year-old male underwent a lumbar 4–sacral 1 MIS-TLIF by another surgeon. He did well in the initial postoperative period, but he began to note right leg pain and numbness in an L5 dermatomal pattern. The pain continued for 2 years despite interventional pain management, and he began to note left foot dorsiflexion weakness. An electromyography (EMG) showed a left L5 radiculopathy and a CT Lumbar spine demonstrated excessive bone growth in the right L4–5 neural foramen. The patient underwent an awake, endoscopic foraminotomy procedure utilizing a blunt tipped manual shaver drill system. The patient’s radicular symptoms improved immediately, and he remained asymptomatic at the 1 year follow up. Heterotopic foraminal bone growth is one potential complication of rhBMP-2 use in the MIS-TLIF procedure. The endoscopic procedure described here is a minimally invasive surgical option that can be performed in an awake patient and is suggested a unique salvage or rescue procedure to be considered for the treatment of this potential rhBMP-2 complication. PMID:29732437

Lumbar Spine Alignment in Six Common Postures: An ROM Analysis With Implications for Deformity Correction.

PubMed

Hey, Hwee Weng Dennis; Lau, Eugene Tze-Chun; Tan, Kimberly-Anne; Lim, Joel L; Choong, Denise; Lau, Leok-Lim; Liu, Ka-Po G; Wong, Hee-Kit

2017-10-01

A cross-sectional study of prospectively collected data. To compare lumbar spine alignment in six common postures, and estimate loss in range of motion (ROM) relative to standing. Ideal position for fusion of lumbar spine remains unknown. Although surgical fusion is necessary for deformity correction and symptom relief, the final position in which the vertebrae are immobilized should provide maximum residual function. Data were collected prospectively from 70 patients with low back pain recruited over a year. All subjects had x-rays performed in slump sitting, forward bending, supine, half squatting, standing, and backward bending postures. ROM quantified in terms of sagittal global and segmental Cobb angles was measured from L1 to S1. Loss of ROM relative to standing was calculated for each posture. Analysis of variance and unpaired t tests were used to identify differences in alignment between postures. Slump sitting gives the greatest lumbar flexion followed by forward bending, and supine postures (P < 0.001). Backward bending produces greater lumbar extension than standing (P = 0.035). Half-squatting and standing postures were not significantly different (P = 0.938). For all postures, L4-5 and L5-S1 segments remained in lordosis, with L4-5 having greater ROM than L5-S1. L1-2 turns kyphotic in lying supine, L2-3 at forward bending, and L3-4 at slump sitting in the form of a "kyphosing cascade." Should the entire lumbar spine be fused in standing position from L1-S1, there would likely be a mean loss of 47.6° of lumbar flexion and 5.9° of lumbar extension. The present study demonstrates the extent of flexibility required of the lumbar spine in assuming various postures. It also enables comparison of the differences in degree of motion occurring in the lumbar spine, both across postures and across segments. Significant loss in ROM, particularly flexion, is anticipated with fusion modeled after the lordotic standing lumbar spine. 2.

The activL® Artificial Disc: a next-generation motion-preserving implant for chronic lumbar discogenic pain

PubMed Central

Yue, James J; Garcia, Rolando; Miller, Larry E

2016-01-01

Degeneration of the lumbar intervertebral discs is a leading cause of chronic low back pain in adults. Treatment options for patients with chronic lumbar discogenic pain unresponsive to conservative management include total disc replacement (TDR) or lumbar fusion. Until recently, only two lumbar TDRs had been approved by the US Food and Drug Administration − the Charité Artificial Disc in 2004 and the ProDisc-L Total Disc Replacement in 2006. In June 2015, a next-generation lumbar TDR received Food and Drug Administration approval − the activL® Artificial Disc (Aesculap Implant Systems). Compared to previous-generation lumbar TDRs, the activL® Artificial Disc incorporates specific design enhancements that result in a more precise anatomical match and allow a range of motion that better mimics the healthy spine. The results of mechanical and clinical studies demonstrate that the activL® Artificial Disc results in improved mechanical and clinical outcomes versus earlier-generation artificial discs and compares favorably to lumbar fusion. The purpose of this report is to describe the activL® Artificial Disc including implant characteristics, intended use, surgical technique, postoperative care, mechanical testing, and clinical experience to date. PMID:27274317

Acute hospital costs after minimally invasive versus open lumbar interbody fusion: data from a US national database with 6106 patients.

PubMed

Wang, Michael Y; Lerner, Jason; Lesko, James; McGirt, Matthew J

2012-08-01

Retrospective multi-institutional database review. To determine if minimally invasive interbody fusion is associated with cost savings when compared with open surgery. Minimally invasive spine (MIS) surgeries are increasingly recognized as equivalent to open procedures. Although these techniques have been advocated for reducing pain, disability, and length of hospitalization, to date there has been little data demonstrating these benefits. This study analyzed inpatient hospital records from the Premier Perspective database (2002 to 2009), including patients who underwent a posterior lumbar fusion with interbody cage placement by ICD-9 code, and had implant charge codes that allowed determination if MIS pedicle screws were utilized. Exclusion criteria included a refusion surgery, deformity, >2 levels, and anterior fusion. Total costs were adjusted for covariates (age, sex, race, hospital geography and setting, payor, and comorbidities) using an analysis of covariance model. A total of 6106 patients were identified (1667 MIS and 4439 open). Length of stay (LOS) for 1-level MIS surgery averaged of 3.35 days versus 3.6 days for open surgery (P≤0.006). For 2-level MIS surgery LOS averaged of 3.4 days versus 4.03 days for open surgery (P≤0.001). Total inflation-adjusted acute hospitalization cost averaged $29,187 for 1-level MIS procedures versus $29,947 for open surgery, a nonsignificant difference (P=0.55). Total inflation-adjusted acute hospitalization cost averaged $2106 lower for 2-level MIS surgery (total costs of $33,879 for MIS vs. $35,984 for open surgery, P=0.0023). Cost savings were attributable primarily to lower room and board ($857), operating room ($359), pharmacy ($304), and laboratory ($166) costs in the MIS group. High variances in the 2-level open surgery with prolonged hospital stay also accounted for overall cost differences. This data from a large nationwide sample of hospitalizations demonstrates that MIS lumbar interbody fusion results in a

Effects of Preoperative Simulation on Minimally Invasive Hybrid Lumbar Interbody Fusion.

PubMed

Rieger, Bernhard; Jiang, Hongzhen; Reinshagen, Clemens; Molcanyi, Marek; Zivcak, Jozef; Grönemeyer, Dietrich; Bosche, Bert; Schackert, Gabriele; Ruess, Daniel

2017-10-01

The main focus of this study was to evaluate how preoperative simulation affects the surgical work flow, radiation exposure, and outcome of minimally invasive hybrid lumbar interbody fusion (MIS-HLIF). A total of 132 patients who underwent single-level MIS-HLIF were enrolled in a cohort study design. Dose area product was analyzed in addition to surgical data. Once preoperative simulation was established, 66 cases (SIM cohort) were compared with 66 patients who had previously undergone MIS-HLIF without preoperative simulation (NO-SIM cohort). Dose area product was reduced considerably in the SIM cohort (320 cGy·cm 2 NO-SIM cohort: 470 cGy·cm 2 ; P < 0.01). Surgical time was shorter for the SIM cohort (155 minutes; NO-SIM cohort, 182 minutes; P < 0.05). SIM cohort had a better outcome in Numeric Rating Scale back at 6 months follow-up compared with the NO-SIM cohort (P < 0.05). Preoperative simulation reduced radiation exposure and resulted in less back pain at the 6 months follow-up time point. Preoperative simulation provided guidance in determining the correct cage height. Outcome controls enabled the surgeon to improve the procedure and the software algorithm. Copyright © 2017 Elsevier Inc. All rights reserved.

Long constructs in the thoracic and lumbar spine with a minimally invasive technique.

PubMed

Roldan, H; Perez-Orribo, L; Spreafico, M; Ginoves-Sierra, M

2011-04-01

Literature about long implants used together with a minimally invasive spine surgery (MISS) technique is scarce. Our objective is to contribute our surgical experience in this field and to specifically focus on several technical details. A digitally-dissected canal along the paravertebral muscles was created linking the stab wounds on each side in relation with the pedicles to be cannulated. Screws were inserted following the percutaneous technique. Long rods were modelled, threaded through the extender sleeves along the paravertebral canal and pushed into the screw heads with the reduction forceps. When fusion was needed, the facet complex was decorticated with a drill. To insert a cross-link, a canal between the 2 rods was digitally created and the spinous process was drilled. 8 patients underwent surgery (age range: 25-77 years). Indications were postosteomyelitis kyphosis in 3 patients, bone tumor in 3, and spine fracture in 2. No blood transfusions were necessary during or after surgery. A cross-link was inserted in 2 patients. Posterolateral bone fusion was attempted in 4, but radiologically identifiable in none. In one patient a cantilever manoeuvre was done to correct kyphosis. Mean duration of surgery was 4 h. There were no clinical complications related to the operation or the hardware (mean follow-up of 7.14 months, range: 1-15 months). The application of MISS techniques can be broadened to long spinal constructs to assess fractures, tumors or deformity, especially in elderly or debilitated patients. Nevertheless, posterolateral fusion is still a challenge through these limited exposures. © Georg Thieme Verlag KG Stuttgart · New York.

Lumbar Spinal Stenosis: Who Should Be Fused? An Updated Review

PubMed Central

Hasankhani, Ebrahim Ghayem; Ashjazadeh, Amir

2014-01-01

Lumbar spinal stenosis (LSS) is mostly caused by osteoarthritis (spondylosis). Clinically, the symptoms of patients with LSS can be categorized into two groups; regional (low back pain, stiffness, and so on) or radicular (spinal stenosis mainly presenting as neurogenic claudication). Both of these symptoms usually improve with appropriate conservative treatment, but in refractory cases, surgical intervention is occasionally indicated. In the patients who primarily complain of radiculopathy with an underlying biomechanically stable spine, a decompression surgery alone using a less invasive technique may be sufficient. Preoperatively, with the presence of indicators such as failed back surgery syndrome (revision surgery), degenerative instability, considerable essential deformity, symptomatic spondylolysis, refractory degenerative disc disease, and adjacent segment disease, lumbar fusion is probably recommended. Intraoperatively, in cases with extensive decompression associated with a wide disc space or insufficient bone stock, fusion is preferred. Instrumentation improves the fusion rate, but it is not necessarily associated with improved recovery rate and better functional outcome. PMID:25187873

Bone Morphogenetic Protein Usage in Anterior Lumbar Interbody Fusion: What Else Can Go Wrong?

PubMed

Elias, Elias; Nasser, Zeina; Winegan, Lona; Verla, Terence; Omeis, Ibrahim

2018-03-01

Bone morphogenetic protein (BMP) graft showed promising outcome during early phases of its use. However, unreported adverse events and off-label use shattered its safe profile and raised concerns regarding its indication. In 2008 the U.S. Food and Drug Administration prohibited its use in anterior cervical spine procedures due to the possibility of edema, hematoma, and need to intubate. At the molecular level, BMPs act as multifactorial growth factors playing a role in cartilage, heart, and bone formation. However, its unfavorable effect on bone overgrowth or heterotopic ossification post spine surgeries has been described. Reported cases in the literature were limited to epidural bone formation. We present a rare and interesting case of a 59-year-old female, in whom BMP caused intradural bone growth several years after an anterior lumbar interbody fusion surgery. Caution must be exercised while using BMPs because of inadvertent complications. Copyright © 2017 Elsevier Inc. All rights reserved.

[Fusion implants of carbon fiber reinforced plastic].

PubMed

Früh, H J; Liebetrau, A; Bertagnoli, R

2002-05-01

Carbon fiber reinforced plastics (CFRP) are used in the medical field when high mechanical strength, innovative design, and radiolucency (see spinal fusion implants) are needed. During the manufacturing process of the material CFRP carbon fibers are embedded into a resin matrix. This resin material could be thermoset (e.g., epoxy resin EPN/DDS) or thermoplastic (e.g., PEAK). CFRP is biocompatible, radiolucent, and has higher mechanical capabilities compared to other implant materials. This publication demonstrates the manufacturing process of fusion implants made of a thermoset matrix system using a fiber winding process. The material has been used clinically since 1994 for fusion implants of the cervical and lumbar spine. The results of the fusion systems CORNERSTONE-SR C (cervical) and UNION (lumbar) showed no implant-related complications. New implant systems made of this CFRP material are under investigation and are presented.

Sagittal imbalance treated with L5 pedicle subtraction osteotomy with short lumbar fusion from L4 to sacrum using four screws into L4 for enhanced fixation two additional vertebral screws: a technical note.

PubMed

Wangdi, Kuenzang; Otsuki, Bungo; Fujibayashi, Shunsuke; Tanida, Shimei; Masamoto, Kazutaka; Matsuda, Shuichi

2018-02-07

To report on suggested technique with four screws in a single vertebra (two pedicle screws and two direct vertebral body screws) for enhanced fixation with just one level cranially to a pedicle subtraction osteotomy (PSO). A 60-year-old woman underwent L4/5 fusion surgery for degenerative spondylolisthesis. Two years later, she was unable to stand upright even for a short time because of lumbar kyphosis caused by subsidence of the fusion cage and of Baastrup syndrome in the upper lumbar spine [sagittal vertical axis (SVA) of 114 mm, pelvic incidence of 75°, and lumbar lordosis (LL) of 41°]. She underwent short-segment fusion from L4 to the sacrum with L5 pedicle subtraction osteotomy. We reinforced the construct with two vertebral screws at L4 in addition to the conventional L4 pedicle screws. After the surgery, her sagittal parameters were improved (SVA, 36 mm; LL, 54°). Two years after the corrective surgery, she maintained a low sagittal vertical axis though high residual pelvic tilt indicated that the patient was still compensating for residual sagittal misalignment. PSO surgery for sagittal imbalance usually requires a long fusion at least two levels above and below the osteotomy site to achieve adequate stability and better global alignment. However, longer fixation may decrease the patients' quality of life and cause a proximal junctional failure. Our novel technique may shorten the fixation area after osteotomy surgery. These slides can be retrieved under Electronic Supplementary Material.

Hemostatic techniques following multilevel posterior lumbar spine surgery: a randomized control trial.

PubMed

Wu, Jian; Jin, Yongming; Zhang, Jun; Shao, Haiyu; Yang, Di; Chen, Jinping

2014-12-01

This was a prospective, randomized controlled clinical study. To determine the efficacy of absorbable gelatin sponge in reducing blood loss, as well as shortening the length of hospital stay in patients undergoing multilevel posterior lumbar spinal surgery. Absorbable gelatin sponge is reported to decrease postoperative drain output and the length of hospital stay after multilevel posterior cervical spine surgery. However, there is a dearth of literature on prospective study of the efficacy of absorbable gelatin sponge in reducing postoperative blood loss, as well as shortening the length of hospital stay in patients undergoing multilevel posterior lumbar spinal surgery. A total of 82 consecutive patients who underwent multilevel posterior lumbar fusion or posterior lumbar interbody fusion between June 2011 and June 2012 were prospectively randomized into one of the 2 groups according to whether absorbable gelatin sponge for postoperative blood management was used or not. Demographic distribution, total drain output, blood transfusion rate, the length of stay, the number of readmissions, and postoperative complications were analyzed. Total drain output averaged 173 mL in the study group and 392 mL in the control group (P=0.000). Perioperative allogeneic blood transfusion rate were lower in the Gelfoam group (34.1% vs. 58.5%, P=0.046); moreover, length of stay in patients with the use of absorbable gelatin sponge (12.58 d) was significantly shorter (P=0.009) than the patients in the control group (14.46 d). No patient developed adverse reactions attributable to the absorbable gelatin sponge. Application of absorbable gelatin sponge at the end of multilevel posterior lumbar fusion can significantly decrease postoperative drain output and length of hospital stay.

Posterior lumbar interbody fusion using non resorbable poly-ether-ether-ketone versus resorbable poly-L-lactide-co-D,L-lactide fusion devices. Clinical outcome at a minimum of 2-year follow-up.

PubMed

Jiya, Timothy U; Smit, T; van Royen, B J; Mullender, M

2011-04-01

Previous papers on resorbable poly-L-lactide-co-D,L-lactide (PLDLLA) cages in spinal fusion have failed to report adequately on patient-centred clinical outcome measures. Also comparison of PLDLLA cage with a traditionally applicable counterpart has not been previously reported. This is the first randomized prospective study that assesses clinical outcome of PLDLLA cage compared with a poly-ether-ether-ketone (PEEK) implant. Twenty-six patients were randomly assigned to undergo instrumented posterior lumbar interbody fusion (PLIF) whereby either a PEEK cage or a PLDLLA cage was implanted. Clinical outcome based on visual analogue scale scores for leg pain and back pain, as well as Oswestry Disability Index (ODI) and SF-36 questionnaires were documented and analysed. When compared with preoperative values, all clinical parameters have significantly improved in the PEEK group at 2 years after surgery with the exception of SF-36 general health, SF-36 mental health and SF-36 role emotional scores. No clinical parameter showed significant improvement at 2 years after surgery compared with preoperative values in the PLDLLA patient group. Only six patients (50%) in the PLDLLA group showed improvement in the VAS scores for leg and back pain as well as the ODI, as opposed to 10 patients (71%) in the PEEK group. One-third of the patients in the PLDLLA group actually reported worsening of their pain scores and ODI. Three cases of mild to moderate osteolysis were seen in the PLDLLA group. Following up on our preliminary report, these 2-year results confirm the superiority of the PEEK implant to the resorbable PLDLLA implant in aiding spinal fusion and alleviating symptoms following PLIF in patients with degenerative spondylolisthesis associated with either canal stenosis or foramen stenosis or both and emanating from a single lumbar segment.

Quantification of Posterior Ankle Exposure Through an Achilles Tendon-Splitting Versus Posterolateral Approach

DTIC Science & Technology

2012-10-01

Ankle Exposure Through an Achilles Tendon - Splitting Versus Posterolateral Approach Jeanne C. Patzkowski, MD1; Kevin L. Kirk, DO1; Justin D. Orr, MD2...surgical exposure to the posterior ankle for trauma and reconstruction is a source of debate. We hypothesized that the Achilles tendon -splitting approach...fresh-frozen cadavers. Achilles tendon - splitting and posterolateral approaches were performed using a randomized crossover design for surgical

Effects of Lordotic Angle of a Cage on Sagittal Alignment and Clinical Outcome in One Level Posterior Lumbar Interbody Fusion with Pedicle Screw Fixation

PubMed Central

Lee, Ji-Ho; Lee, Dong-Oh; Lee, Jae Hyup; Shim, Hee Jong

2015-01-01

This study aims to assess the differences in the radiological and clinical results depending on the lordotic angles of the cage in posterior lumbar interbody fusion (PLIF). We reviewed 185 segments which underwent PLIF using two different lordotic angles of 4° and 8° of a polyetheretherketone (PEEK) cage. The segmental lordosis and total lumbar lordosis of the 4° and 8° cage groups were compared preoperatively, as well as on the first postoperative day, 6th and 12th months postoperatively. Clinical assessment was performed using the ODI and the VAS of low back pain. The pre- and immediate postoperative segmental lordosis angles were 12.9° and 12.6° in the 4° group and 12° and 12.0° in the 8° group. Both groups exhibited no significant different segmental lordosis angle and total lumbar lordosis over period and time. However, the total lumbar lordosis significantly increased from six months postoperatively compared with the immediate postoperative day in the 8° group. The ODI and the VAS in both groups had no differences. Cages with different lordotic angles of 4° and 8° showed insignificant results clinically and radiologically in short-level PLIF surgery. Clinical improvements and sagittal alignment recovery were significantly observed in both groups. PMID:25685795

[Analyses of segment motor function in patients with degenerative lumbar disease on the treatment of WavefleX dynamic stabilization system].

PubMed

Wu, Junsong; Du, Junhua; Jiang, Xiangyun; Wang, Quan; Li, Xigong; Du, Jingyu; Lin, Xiangjin

2014-06-17

To explore the changes of range-of-motion (ROM) in patients with degenerative lumbar disease on the treatment of WavefleX dynamic stabilization system and examine the postoperative lumbar regularity and tendency of ROM. Nine patients with degenerative lumbar disease on the treatment of WavefleX dynamic stabilization system were followed up with respect to ROMs at 5 timepoints within 12 months. Records of ROM were made for instrumented segments, adjacent segments and total lumbar. Compared with preoperation, ROMs in non-fusional segments with WavefleX dynamic stabilization system decreased statistical significantly (P < 0.05 or P < 0.01) at different timepoints; ROMs in adjacent segments increased at some levels without wide statistical significance. The exception was single L3/4 at Month 12 (P < 0.05) versus control group simultaneously at the levels of L3/4, L4/5 and L5/S1, ROMs decreased at Months 6 and 12 with wide statistical significance (P < 0.05 or P < 0.01). ROMs in total lumbar had statistical significant decrease (P < 0.01) in both group of non-fusional segments and hybrid group of non-fusion and fusion. The trends of continuous augments were observed during follow-ups. Statistically significant augments were also acquired at 4 timepoints as compared to control group (P < 0.01). The treatment of degenerative lumbar diseases with WavefleX dynamic stabilization system may limit excessive extension/inflexion and preserve some motor functions. Moreover, it can sustain physiological lordosis, decrease and transfer disc load in adjacent segments to prevent early degeneration of adjacent segment. Trends of motor function augment in total lumbar need to be confirmed during future long-term follow-ups.

Dynamic stabilization using the Dynesys system versus posterior lumbar interbody fusion for the treatment of degenerative lumbar spinal disease: a clinical and radiological outcomes-based meta-analysis.

PubMed

Lee, Chang-Hyun; Jahng, Tae-Ahn; Hyun, Seung-Jae; Kim, Chi Heon; Park, Sung-Bae; Kim, Ki-Jeong; Chung, Chun Kee; Kim, Hyun-Jib; Lee, Soo-Eon

2016-01-01

OBJECTIVE The Dynesys, a pedicle-based dynamic stabilization (PDS) system, was introduced to overcome the drawbacks of fusion procedures. Nevertheless, the theoretical advantages of PDS over fusion have not been clearly confirmed. The aim of this study was to compare clinical and radiological outcomes of patients who underwent PDS using the Dynesys system with those who underwent posterior lumbar interbody fusion (PLIF). METHODS The authors searched PubMed, Embase, Web of Science, and the Cochrane Database. Studies that reported outcomes of patients who underwent PDS or PLIF for the treatment of degenerative lumbar spinal disease were included. The primary efficacy end points were perioperative outcomes. The secondary efficacy end points were changes in the Oswestry Disability Index (ODI) and back and leg pain visual analog scale (VAS) scores and in range of motion (ROM) at the treated and adjacent segments. A meta-analysis was performed to calculate weighted mean differences (WMDs), 95% confidence intervals, Q statistics, and I(2) values. Forest plots were constructed for each analysis group. RESULTS Of the 274 retrieved articles, 7 (which involved 506 participants [Dynesys, 250; PLIF, 256]) met the inclusion criteria. The Dynesys group showed a competitive advantage in mean surgery duration (20.73 minutes, 95% CI 8.76-32.70 minutes), blood loss (81.87 ml, 95% CI 45.11-118.63 ml), and length of hospital stay (1.32 days, 95% CI 0.23-2.41 days). Both the Dynesys and PLIF groups experienced improved ODI and VAS scores after 2 years of follow-up. Regarding the ODI and VAS scores, no statistically significant difference was noted according to surgical procedure (ODI: WMD 0.12, 95% CI -3.48 to 3.72; back pain VAS score: WMD -0.15; 95% CI -0.56 to 0.26; leg pain VAS score: WMD -0.07; 95% CI -0.47 to 0.32). The mean ROM at the adjacent segment increased in both groups, and there was no substantial difference between them (WMD 1.13; 95% CI -0.33 to 2.59). Although the

The Asfora Bullet Cage System Shows Comparable Fusion Rate Success Versus Control Cage in Posterior Lumbar Interbody Fusion in a Randomized Clinical Trial.

PubMed

Morgan, Jeremy P; Miller, Ashley L; Thompson, Paul A; Asfora, Wilson T

2016-04-01

Low back pain and degeneration of the intervertebral disc are an integrated malady that affects millions of Americans. Cage devices used in association with posterior lumbar interbody fusion (PLIF) have been shown to be an effective approach in the treatment of a number of lower spine disorders attributed to degenerative disc disease (DDD). This study was undertaken as part of a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE) study and compares the effectiveness of the Asfora Bullet Cage System (ABCS) to successfully fuse vertebra at one or two levels between L2 and S1 in patients with DDD to an FDA approved comparison device, the Medtronic-Sofamor Danek Inter Fix Threaded Fusion Device (MSDIFD). A total of 257 randomized participants were implanted with either the ABCS device (n = 132) or the MSDIFD device (n = 125) through an open posterior approach using autogenous local bone graft without the use of pedicle screws. Patients were evaluated prior to surgery and at the 24 month (24-M) visit for fusion status, deep tendon reflex status, sensory function, motor function, straight leg raise status, pain, disability, and device safety. Radiological evaluation and statistical analysis were performed by independent professionals. Evaluation of device success was performed at 24-M visit. From the original group of 257 patients, 59 were lost to follow-up. Primary measures of success at the 24-M visit involved pain and function, fusion, neurological status, and device-related adverse events measures. Pain and function improved in both (MSDIFD: 75.7 percent; ABCS: 82.6 percent). Fusion success with all radiographic points at 24-M visits was 79.4 percent MSDIFD and 88.2 percent ABCS. Neurological improvement was seen in both (MSDIFD: 77.0 percent; ABCS: 87.8 percent). One device-related grade 1 adverse event was reported in the MSDIFD group. Disc height preservation was equivalent for single level fusions (MSDIFD: 16.1 percent; ABCS: 20

Three-year postoperative outcomes between MIS and conventional TLIF in1-segment lumbar disc herniation.

PubMed

Lv, You; Chen, Jingyang; Chen, Jinchuan; Wu, Yuling; Chen, Xiangyang; Liu, Yi; Chu, Zhaoming; Sheng, Luxin; Qin, Rujie; Chen, Ming

2017-06-01

The aim of this study is to assess the long-term clinical and radiological outcomes between minimally invasive (MIS) and conventional transforaminal lumbar interbody fusion (TLIF) in treating one-segment lumbar disc herniation (LDH). One-hundred and six patients treated by MIS-TLIF (50 cases) or conventional TLIF (56 cases) were included. Perioperative results were evaluated. Clinical outcomes were compared preoperatively and postoperatively. Radiologic parameters were based on a comparison of preoperative and three-year postoperative lumbar lordosis, segmental lordosis, sacral slope, the cross-sectional area of the paraspinal muscle and fusion rates. MIS TILF had significantly less blood, shorter operation time, mean return to work time and lower intramuscular pressure compared with the conventional group during the operation. VAS scores for lower back pain and ODI in MIS-TLIF were significantly decreased. The mean cross-sectional area of the paraspinal muscle was significantly decreased after surgery in the conventional TLIF group and no significant intragroup differences were established in the MIS-TLIF group. No significant differences were found in fusion rate, lumbar lordosis, segmental lordosis and sacral slope. Both MIS and conventional TLIF were beneficial for patients with LDH. However, MIS-TLIF manifests a great improvement in perioperative outcomes, low back pain, disability and preventing paraspinal muscle atrophy during the follow-up period observation.

Properties of an interspinous fixation device (ISD) in lumbar fusion constructs: a biomechanical study.

PubMed

Techy, Fernando; Mageswaran, Prasath; Colbrunn, Robb W; Bonner, Tara F; McLain, Robert F

2013-05-01

Segmental fixation improves fusion rates and promotes patient mobility by controlling instability after lumbar surgery. Efforts to obtain stability using less invasive techniques have lead to the advent of new implants and constructs. A new interspinous fixation device (ISD) has been introduced as a minimally invasive method of stabilizing two adjacent interspinous processes by augmenting an interbody cage in transforaminal interbody fusion. The ISD is intended to replace the standard pedicle screw instrumentation used for posterior fixation. The purpose of this study is to compare the rigidity of these implant systems when supplementing an interbody cage as used in transforaminal lumbar interbody fusion. An in vitro human cadaveric biomechanical study. Seven human cadaver spines (T12 to the sacrum) were mounted in a custom-designed testing apparatus, for biomechanical testing using a multiaxial robotic system. A comparison of segmental stiffness was carried out among five conditions: intact spine control; interbody spacer (IBS), alone; interbody cage with ISD; IBS, ISD, and unilateral pedicle screws (unilat); and IBS, with bilateral pedicle screws (bilat). An industrial robot (KUKA, GmbH, Augsburg, Germany) applied a pure moment (±5 Nm) in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) through an anchor to the T12 vertebral body. The relative vertebral motion was captured using an optoelectronic camera system (Optotrak; Northern Digital, Inc., Waterloo, Ontario, Canada). The load sensor and the camera were synchronized. Maximum rotation was measured at each level and compared with the intact control. Implant constructs were compared with the control and with each other. A statistical analysis was performed using analysis of variance. A comparison between the intact spine and the IBS group showed no significant difference in the range of motion (ROM) in FE, LB, or AR for the operated level, L3-L4. After implantation of the ISD to augment

Risk factors for acute surgical site infections after lumbar surgery: a retrospective study.

PubMed

Lai, Qi; Song, Quanwei; Guo, Runsheng; Bi, Haidi; Liu, Xuqiang; Yu, Xiaolong; Zhu, Jianghao; Dai, Min; Zhang, Bin

2017-07-19

Currently, many scholars are concerned about the treatment of postoperative infection; however, few have completed multivariate analyses to determine factors that contribute to the risk of infection. Therefore, we conducted a multivariate analysis of a retrospectively collected database to analyze the risk factors for acute surgical site infection following lumbar surgery, including fracture fixation, lumbar fusion, and minimally invasive lumbar surgery. We retrospectively reviewed data from patients who underwent lumbar surgery between 2014 and 2016, including lumbar fusion, internal fracture fixation, and minimally invasive surgery in our hospital's spinal surgery unit. Patient demographics, procedures, and wound infection rates were analyzed using descriptive statistics, and risk factors were analyzed using logistic regression analyses. Twenty-six patients (2.81%) experienced acute surgical site infection following lumbar surgery in our study. The patients' mean body mass index, smoking history, operative time, blood loss, draining time, and drainage volume in the acute surgical site infection group were significantly different from those in the non-acute surgical site infection group (p < 0.05). Additionally, diabetes mellitus, chronic obstructive pulmonary disease, osteoporosis, preoperative antibiotics, type of disease, and operative type in the acute surgical site infection group were significantly different than those in the non-acute surgical site infection group (p < 0.05). Using binary logistic regression analyses, body mass index, smoking, diabetes mellitus, osteoporosis, preoperative antibiotics, fracture, operative type, operative time, blood loss, and drainage time were independent predictors of acute surgical site infection following lumbar surgery. In order to reduce the risk of infection following lumbar surgery, patients should be evaluated for the risk factors noted above.

Clostridium difficile colitis in patients undergoing lumbar spine surgery.

PubMed

Skovrlj, Branko; Guzman, Javier Z; Silvestre, Jason; Al Maaieh, Motasem; Qureshi, Sheeraz A

2014-09-01

Retrospective database analysis. To investigate incidence, comorbidities, and impact on health care resources of Clostridium difficile infection after lumbar spine surgery. C. difficile colitis is reportedly increasing in hospitalized patients and can have a negative impact on patient outcomes. No data exist on estimates of C. difficile infection rates and its consequences on patient outcomes and health care resources among patients undergoing lumbar spine surgery. The Nationwide Inpatient Sample was examined from 2002 to 2011. Patients were included for study based on International Classification of Diseases, Ninth Revision, Clinical Modification, procedural codes for lumbar spine surgery for degenerative diagnoses. Baseline patient characteristics were determined and multivariable analyses assessed factors associated with increased incidence of C. difficile and risk of mortality. The incidence of C. difficile infection in patients undergoing lumbar spine surgery is 0.11%. At baseline, patients infected with C. difficile were significantly older (65.4 yr vs. 58.9 yr, P<0.0001) and more likely to have diabetes with chronic complications, neurological complications, congestive heart failure, pulmonary disorders, coagulopathy, and renal failure. Lumbar fusion (P=0.0001) and lumbar fusion revision (P=0.0003) were associated with increased odds of postoperative infection. Small hospital size was associated with decreased odds (odds ratio [OR], 0.5; P<0.001), whereas urban hospitals were associated with increased odds (OR, 2.14; P<0.14) of acquiring infection. Uninsured (OR, 1.62; P<0.0001) and patients with Medicaid (OR, 1.33; P<0.0001) were associated with higher odds of acquiring postoperative infection. C. difficile increased hospital length of stay by 8 days (P<0.0001), hospital charges by 2-fold (P<0.0001), and inpatient mortality to 4% from 0.11% (P<0.0001). C. difficile infection after lumbar spine surgery carries a 36.4-fold increase in mortality and costs

Early versus late initiation of rehabilitation after lumbar spinal fusion: economic evaluation alongside a randomized controlled trial.

PubMed

Oestergaard, Lisa G; Christensen, Finn B; Nielsen, Claus V; Bünger, Cody E; Fruensgaard, Soeren; Sogaard, Rikke

2013-11-01

Economic evaluation conducted alongside a randomized controlled trial with 1-year follow-up. To examine the cost-effectiveness of initiating rehabilitation 6 weeks after surgery as opposed to 12 weeks after surgery. In a previously reported randomized controlled trial, we assessed the impact of timing of rehabilitation after a lumbar spinal fusion and found that a fast-track strategy led to poorer functional ability. Before making recommendations, it seems relevant to address the societal perspective including return to work, quality of life, and costs. A cost-effectiveness analysis and a cost-utility analysis were conducted. Eighty-two patients undergoing instrumented lumbar spinal fusion due to degenerative disc disease or spondylolisthesis (grade I or II) were randomized to an identical protocol of 4 sessions of group-based rehabilitation and were instructed in home exercises focusing on active stability training. Outcome parameters included functional disability (Oswestry Disability Index) and quality-adjusted life years. Health care and productivity costs were estimated from national registries and reported in euros. Costs and effects were transformed into net benefit. Bootstrapping was used to estimate 95% confidence intervals (95% CI). The fast-track strategy tended to be costlier by €6869 (95% CI, -4640 to 18,378) while at the same time leading to significantly poorer outcomes of functional disability by -9 points (95% CI, -18 to -3) and a tendency for a reduced gain in quality-adjusted life years by -0.04 (95% CI, -0.13 to 0.01). The overall probability for the fast-track strategy being cost-effective does not reach 10% at conventional thresholds for cost-effectiveness. Initiating rehabilitation at 6 weeks as opposed to 12 weeks after surgery is on average more costly and less effective. The uncertainty of this result did not seem to be sensitive to methodological issues, and clinical managements who have already adapted fast-track rehabilitation

Evaluation of Anterior Vertebral Interbody Fusion Using Osteogenic Mesenchymal Stem Cells Transplanted in Collagen Sponge.

PubMed

Yang, Wencheng; Dong, Youhai; Hong, Yang; Guang, Qian; Chen, Xujun

2016-05-01

The study used a rabbit model to achieve anterior vertebral interbody fusion using osteogenic mesenchymal stem cells (OMSCs) transplanted in collagen sponge. We investigated the effectiveness of graft material for anterior vertebral interbody fusion using a rabbit model by examining the OMSCs transplanted in collagen sponge. Anterior vertebral interbody fusion is commonly performed. Although autogenous bone graft remains the gold-standard fusion material, it requires a separate surgical procedure and is associated with significant short-term and long-term morbidity. Recently, mesenchymal stem cells from bone marrow have been studied in various fields, including posterolateral spinal fusion. Thus, we hypothesized that cultured OMSCs transplanted in porous collagen sponge could be used successfully even in anterior vertebral interbody fusion. Forty mature male White Zealand rabbits (weight, 3.5-4.5 kg) were randomly allocated to receive one of the following graft materials: porous collagen sponge plus cultured OMSCs (group I); porous collagen sponge alone (group II); autogenous bone graft (group III); and nothing (group IV). All animals underwent anterior vertebral interbody fusion at the L4/L5 level. The lumbar spine was harvested en bloc, and the new bone formation and spinal fusion was evaluated using radiographic analysis, microcomputed tomography, manual palpation test, and histologic examination at 8 and 12 weeks after surgery. New bone formation and bony fusion was evident as early as 8 weeks in groups I and III. And there was no statistically significant difference between 8 and 12 weeks. At both time points, by microcomputed tomography and histologic analysis, new bone formation was observed in both groups I and III, fibrous tissue was observed and there was no new bone in both groups II and IV; by manual palpation test, bony fusion was observed in 40% (4/10) of rabbits in group I, 70% (7/10) of rabbits in group III, and 0% (0/10) of rabbits in both groups

Diagnosis of Lumbar Foraminal Stenosis using Diffusion Tensor Imaging.

PubMed

Eguchi, Yawara; Ohtori, Seiji; Suzuki, Munetaka; Oikawa, Yasuhiro; Yamanaka, Hajime; Tamai, Hiroshi; Kobayashi, Tatsuya; Orita, Sumihisa; Yamauchi, Kazuyo; Suzuki, Miyako; Aoki, Yasuchika; Watanabe, Atsuya; Kanamoto, Hirohito; Takahashi, Kazuhisa

2016-02-01

Diagnosis of lumbar foraminal stenosis remains difficult. Here, we report on a case in which bilateral lumbar foraminal stenosis was difficult to diagnose, and in which diffusion tensor imaging (DTI) was useful. The patient was a 52-year-old woman with low back pain and pain in both legs that was dominant on the right. Right lumbosacral nerve compression due to a massive uterine myoma was apparent, but the leg pain continued after a myomectomy was performed. No abnormalities were observed during nerve conduction studies. Computed tomography and magnetic resonance imaging indicated bilateral L5 lumbar foraminal stenosis. DTI imaging was done. The extraforaminal values were decreased and tractography was interrupted in the foraminal region. Bilateral L5 vertebral foraminal stenosis was treated by transforaminal lumbar interbody fusion and the pain in both legs disappeared. The case indicates the value of DTI for diagnosing vertebral foraminal stenosis.

Novel spinal instrumentation to enhance osteogenesis and fusion: a preliminary study.

PubMed

MacEwan, Matthew R; Talcott, Michael R; Moran, Daniel W; Leuthardt, Eric C

2016-09-01

OBJECTIVE Instrumented spinal fusion continues to exhibit high failure rates in patients undergoing multilevel lumbar fusion or pseudarthrosis revision; with Grade II or higher spondylolisthesis; or in those possessing risk factors such as obesity, tobacco use, or metabolic disorders. Direct current (DC) electrical stimulation of bone growth represents a unique surgical adjunct in vertebral fusion procedures, yet existing spinal fusion stimulators are not optimized to enhance interbody fusion. To develop an advanced method of applying DC electrical stimulation to promote interbody fusion, a novel osteogenic spinal system capable of routing DC through rigid instrumentation and into the vertebral bodies was fabricated. A pilot study was designed to assess the feasibility of osteogenic instrumentation and compare the ability of osteogenic instrumentation to promote successful interbody fusion in vivo to standard spinal instrumentation with autograft. METHODS Instrumented, single-level, posterior lumbar interbody fusion (PLIF) with autologous graft was performed at L4-5 in adult Toggenburg/Alpine goats, using both osteogenic spinal instrumentation (plus electrical stimulation) and standard spinal instrumentation (no electrical stimulation). At terminal time points (3 months, 6 months), animals were killed and lumbar spines were explanted for radiographic analysis using a SOMATOM Dual Source Definition CT Scanner and high-resolution Microcat II CT Scanner. Trabecular continuity, radiodensity within the fusion mass, and regional bone formation were examined to determine successful spinal fusion. RESULTS Quantitative analysis of average bone density in pedicle screw beds confirmed that electroactive pedicle screws used in the osteogenic spinal system focally enhanced bone density in instrumented vertebral bodies. Qualitative and quantitative analysis of high-resolution CT scans of explanted lumbar spines further demonstrated that the osteogenic spinal system induced solid

Laparoscopic surgery of postero-lateral segments: a comparison between transthoracic and abdominal approach.

PubMed

Fuks, David; Gayet, Brice

2015-06-01

Lesions located in the postero-lateral part of the liver (segments 6 and 7) have been considered as poor candidates for a laparoscopic liver resection due to the limited visualization and difficulty in bleeding control. Although no comparison has been done between transthoracic and abdominal resection of tumors located in the postero-lateral segments, we propose a description of these different strategies, specifying the benefits as well as the disadvantages of the various approaches.

In vitro and in vivo evaluation of osteoinductivity and bone fusion ability of an activin a/BMP2 chimera (AB204): a comparison study between AB204 and rhBMP-2.

PubMed

Zheng, Guang Bin; Lee, Jae Hyup; Jin, Yuan-Zhe

2017-12-01

This study compared osteoinductivity and osteogenic capacity between AB204 and rhBMP-2 using hMSCs in vitro and a beagle's posterolateral spinal fusion model. Cultured hMSCs were treated with AB204 or rhBMP-2 with low to high doses. Three male beagles were performed posterolateral spinal fusion with biphasic calcium phosphate (2 ml) + AB204 or rhBMP-2 (20, 50 or 200 µg). They were euthanized after 8 weeks. The fusion rate and bone formation of spine samples were examined. AB204 had higher alkaline phosphatase activity, mineralization and osteogenic-related gene expression than rhBMP-2. Fusion rates in all rhBMP-2 groups were 0. They were 100% for 50 μg and 200 μg AB204 groups. Therefore, AB204 showed higher osteogenicity than rhBMP-2. It could be a better bone graft substitute.

Evaluation of a polyetheretherketone (PEEK) titanium composite interbody spacer in an ovine lumbar interbody fusion model: biomechanical, microcomputed tomographic, and histologic analyses.

PubMed

McGilvray, Kirk C; Waldorff, Erik I; Easley, Jeremiah; Seim, Howard B; Zhang, Nianli; Linovitz, Raymond J; Ryaby, James T; Puttlitz, Christian M

2017-12-01

The most commonly used materials used for interbody cages are titanium metal and polymer polyetheretherketone (PEEK). Both of these materials have demonstrated good biocompatibility. A major disadvantage associated with solid titanium cages is their radiopacity, limiting the postoperative monitoring of spinal fusion via standard imaging modalities. However, PEEK is radiolucent, allowing for a temporal assessment of the fusion mass by clinicians. On the other hand, PEEK is hydrophobic, which can limit bony ingrowth. Although both PEEK and titanium have demonstrated clinical success in obtaining a solid spinal fusion, innovations are being developed to improve fusion rates and to create stronger constructs using hybrid additive manufacturing approaches by incorporating both materials into a single interbody device. The purpose of this study was to examine the interbody fusion characteristic of a PEEK Titanium Composite (PTC) cage for use in lumbar fusion. Thirty-four mature female sheep underwent two-level (L 2 -L 3 and L 4 -L 5 ) interbody fusion using either a PEEK or a PTC cage (one of each per animal). Animals were sacrificed at 0, 8, 12, and 18 weeks post surgery. Post sacrifice, each surgically treated functional spinal unit underwent non-destructive kinematic testing, microcomputed tomography scanning, and histomorphometric analyses. Relative to the standard PEEK cages, the PTC constructs demonstrated significant reductions in ranges of motion and a significant increase in stiffness. These biomechanical findings were reinforced by the presence of significantly more bone at the fusion site as well as ingrowth into the porous end plates. Overall, the results indicate that PTC interbody devices could potentially lead to a more robust intervertebral fusion relative to a standard PEEK device in a clinical setting. Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.

Nursing review of diagnosis and treatment of lumbar degenerative spondylolisthesis

PubMed Central

Epstein, Nancy E.; Hollingsworth, Renee D.

2017-01-01

Background: In the lumbar spine, degenerative spondylolisthesis or degenerative (not traumatic) slippage of one vertebral body over another is divided into 4 grades – grade I (25%), grade II (50%), grade III (75%), and grade IV (100%). Dynamic X-rays, magnetic resonance (MR), and computed tomography (CT) scans document the slip secondary to arthritic changes of the facet joint plus stenosis, ossification of the yellow ligament, disc herniations, and synovial cysts. MR best demonstrates soft tissue pathology whereas CT better delineates ossific/calcified disease. Methods: Grade I degenerative spondylolisthesis, typically found at the L4–L5 level followed by L3–L4 and L5S1, is more common in females (ratio 2:1) over the age of 65. Symptoms include radiculopathy (root pain) and neurogenic claudication (e.g., pain with ambulation, requiring the patient to stop, rest, sit down). Symptoms/signs may include unilateral/bilateral radiculopathy and uni/multifocal motor, reflex, and sensory deficits in. Some may also present with a cauda equina syndrome (e.g., paraparesis/sphincter dysfunction). Results: Surgery for grade I-II spondylolisthesis may include laminectomy alone, laminectomy/noninstrumented fusion or with an instrumented fusion. Older patients with osteoporosis are more likely to have no fusion or a noninstrumented fusion. All fusions utilize autograft harvested from the laminectomy that may or may not be combined with a bone graft expander (to increase the fusion mass) combined with autogenous bone marrow aspirate. The fusion mass is placed over the transverse processes following decortication. Conclusions: Patients with multilevel spinal stenosis and degenerative spondylolisthesis may require decompressive lumbar laminectomies alone or in combination with noninstrumented or instrumented fusions. PMID:29119044

Lateral Knee Compartment Portals: A Cadaveric Study Defining a Posterolateral Viewing Safety Zone.

PubMed

Dilworth, Brian; Fehrenbacher, Victor; Nyland, John; Clark, Jamie; Greene, Joseph W

2018-04-12

This study attempted to define a reproducible "safe zone" based on extra- and intra-articular knee anatomy for placing one or 2 accessory portals in the lateral tibiofemoral compartment for posterolateral region viewing. Standard portals were created in 10 cadaveric knees to enable posterolateral region arthroscopic lateral tibiofemoral joint compartment viewing. After identifying the lateral knee surface tissue "soft spot," an accessory posterolateral portal (A) was created using an 18-gauge spinal needle and 4-mm cannula under direct visualization of a 70° arthroscope through the anteromedial portal. A second accessory portal (B) was then created 1 cm posterior and 1 cm superior to portal A. Accessory portal locations were measured relative to capsular fold and popliteus tendon locations. Distances from the peroneal nerve, lateral collateral ligament, popliteus tendon, and the biceps tendon were determined. Statistical analysis compared portal location differences from key anatomical structures (P < .05). Accessory portal A (mean ± 95% confidence interval) was located 8.8 ± 2.7 mm from the popliteus tendon, 11.6 ± 2.7 mm from the lateral collateral ligament (LCL), 26.8 ± 2.3 mm from the peroneal nerve, and 4.9 ± 2.5 mm from the biceps tendon. Accessory portal B was located 17.3 ± 2.8 mm from the popliteus tendon, 20 ± 2.8 mm from the LCL, 30.3 ± 3.3 mm from the peroneal nerve, and 7.0 ± 4.8 mm from the biceps tendon. Accessory portal B was located a greater distance from the LCL and the popliteus tendon than portal A (P < .0001). Using intra- and extra-articular anatomic landmarks, both accessory portals could be safely placed in the lateral tibiofemoral joint compartment to enable posterolateral region viewing. Accessory portals used individually or in combination may enable easier posterolateral region viewing for arthroscopic repair of lateral tibiofemoral compartment structures. Lateral tibiofemoral compartment portals can be safely

Biomechanical and injury response to posterolateral loading from torso side airbags.

PubMed

Hallman, Jason J; Yoganandan, Narayan; Pintar, Frank A

2010-11-01

This study characterized thoracoabdominal response to posterolateral loading from a seat-mounted side airbag. Seven unembalmed post-mortem human subjects were exposed to ten airbag deployments. Subjects were positioned such that the deploying airbag first contacted the posterolateral thorax between T6 and L1 while stationary (n = 3 x 2 aspects) or while subjected to left lateral sled impact at ΔV = 6.7 m/s (n = 4). Chestband contours were analyzed to quantify deformation direction in the thoracic x-y plane (zero degrees indicating anterior and 180° indicating posterior), magnitude, rate, and viscous response. Skeletal injuries were consistent with posterolateral contact; visceral injuries consisted of renal (n = 1) or splenic (n = 3) lacerations. Deformation direction was transient during sled impact, progressing from 122 ± 5° at deformation onset to 90° following maximum deflection. Angles from stationary subjects progressed from 141 ± 9° to 120°. Peak normalized deflections, peak rates, and VCmax ranges were 0.075 - 0.171, 3.7 - 12.7 m/s, and 0.3 - 0.6 m/s with stationary airbag, respectively; ranges were 0.167 - 0.297, 7.4 - 18.3 m/s, and 0.7 - 3.0 m/s with airbag sled impact, respectively. Peak deflections were measured at angles between 99° - 135° and 98° - 125° for stationary and dynamic conditions, respectively. Because of deflection angle transience and localized injury response, both posterolateral and lateral injury metrics may be required for this boundary condition. Contrasted with flat rigid or anterolateral loading, biomechanical response to side airbag interaction may be augmented by peak normalized deflection or VCmax at 130°.

In vitro comparison of endplate preparation between four mini-open interbody fusion approaches.

PubMed

Tatsumi, Robert; Lee, Yu-Po; Khajavi, Kaveh; Taylor, William; Chen, Foster; Bae, Hyun

2015-04-01

Discectomy and endplate preparation are important steps in interbody fusion for ensuring sufficient arthrodesis. While modern less-invasive approaches for lumbar interbody fusion have gained in popularity, concerns exist regarding their ability to allow for adequate disc space and endplate preparation. Thus, the purpose of this study was to quantitatively and qualitatively evaluate and compare disc space and endplate preparation achieved with four less-invasive approaches for lumbar interbody fusion in cadaveric spines. A total of 24 disc spaces (48 endplates) from L2 to L5 were prepared in eight cadaveric torsos using mini-open anterior lumbar interbody fusion (mini-ALIF), minimally invasive posterior lumbar interbody fusion (MAS PLIF), minimally invasive transforaminal lumbar interbody fusion (MAS TLIF) or minimally invasive lateral, transpsoas interbody fusion (XLIF) on two specimens each, for a total of six levels and 12 endplates prepared per procedure type. Following complete discectomy and endplate preparation, spines were excised and split axially at the interbody disc spaces. Endplates were digitally photographed and evaluated using image analysis software. Area of endplate preparation was measured and qualitative evaluation was also performed to grade the quality of preparation. The XLIF approach resulted in the greatest relative area of endplate preparation (58.3 %) while mini-ALIF resulted in the lowest at 35.0 %. Overall, there were no differences in percentage of preparation between cranial and caudal endplates, though this was significantly different in the XLIF group (65 vs 52 %, respectively). ALL damage was observed in 3 MAS TLIF levels. Percentage of endplate that was deemed to have complete disc removal was highest in XLIF group with 90 % compared to 65 % in MAS TLIF group, 43 % in MAS PLIF, and 40 % in mini-ALIF group. Endplate damage area was highest in the MAS TLIF group at 48 % and lowest in XLIF group at 4 %. These results demonstrate that

Congenital posterolateral diaphragmatic hernia.

PubMed

Woolley, M M

1976-04-01

The infant who is born with a posterolateral diaphragmatic hernia who becomes symptomatic at or soon after birth requires urgent care. Surgical reduction of the diaphragmatic hernia must be accomplished quickly. Respiratory and metabolic acidosis must be treated appropriately. The parents should be informed of the gravity of their infant's problem and reassurred by appropriate explanation of the nature of the defect and the therapeutic requirements. If the infant dies, the parents are in need of empathy, reassurance, and adequate explanation so that they do not have lingering doubts regarding the etiology of the anomaly and the adequacy of the therapy. If the infant lives, the medical team can share the feeling of a job well done.

Risk factor of contralateral radiculopathy following microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion.

PubMed

Yang, Yang; Liu, Zhong-Yu; Zhang, Liang-Ming; Dong, Jian-Wen; Xie, Pei-Gen; Chen, Rui-Qiang; Yang, Bu; Liu, Chang; Liu, Bin; Rong, Li-Min

2017-12-08

Microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is an advantageous method for treating lumbar degenerative disease; however, some patients show contralateral radiculopathy postoperatively. This study aims to investigate its risk factor. A total of 130 cases who underwent microendoscopy-assisted MIS-TLIF at L4-5 level were divided into symptomatic and asymptomatic groups according to the presence of postoperative contralateral radiculopathy. Both preoperative and postoperative radiographic parameters, as well as their changes were compared between the two groups, including lumbar lordosis (LL), surgical segmental angle (SSA), disc height (DH), contralateral foramen area (CFA) and contralateral canal area (CCA). Screw breach on contralateral L4 pedicle and decompression method (ipsilateral or bilateral canal decompression through unilateral route) were also analyzed as potential risk factors. Receiver operating characteristic (ROC) curve was drawn for the risk factor to determine the optimal threshold for predicting postoperative contralateral radiculopathy. Besides, clinical outcome assessment, involving Visual Analog Score (VAS) for back and leg, Japanese Orthopaedics Association Score (JOA) and Oswestry Disability Index (ODI), was also compared between the two groups before surgery and at final follow-up (at least 3 months after the surgery for asymptomatic patients or final treatments of contralateral radiculopathy for symptomatic cases). Postoperative contralateral radiculopathy occurred in 11 (8.5%) of the 130 patients. Both preoperative and postoperative CFA as well as its change were significantly decreased in symptomatic group compared with asymptomatic group (all P < 0.05). For the remaining four parameters (LL, SSA, DH, CCA), their preoperative, postoperative and change values showed no statistical difference between the two groups (all P > 0.05). Neither screw breach nor decompression method revealed

Effect of total lumbar disc replacement on lumbosacral lordosis.

PubMed

Kasliwal, Manish K; Deutsch, Harel

2012-10-01

Original article : To study effect of lumbar disc replacement on lumbosacral lordosis. There has been a growing interest in total disc replacement (TDR) for back pain with the rising concern of adjacent segment degeneration. Lumbar fusion surgery has been shown to lead to decrease in lumbar lordosis, which may account for postfusion pain resulting in less acceptable clinical outcome after successful fusion. TDR has recently emerged as an alternative treatment for back pain. There have been very few studies reporting lumbar sagittal outcome after TDR. Retrospective study of radiographic data of 17 patients who underwent TDR for single level degenerative disc disease at the author's institution was carried out. Study included measurement of preoperative and postoperative segmental and global lumbar lordosis and angle of lordosis. Patients age varied from 19 to 54 (mean, 35) years. Follow-up ranged from 12 to 24 months. TDR was performed at L4-5 level in 3 patients and L5-S1 level in 14 patients. The average values for segmental lordosis, global lordosis, and angle of lordosis at the operated level before and after surgery were 17.3, 49.7, and 8.6 degrees and 21.6, 54, and 9.5 degrees, respectively. There was a trend toward significant (P=0.02) and near significant (P=0.057) increase in segmental and global lordosis, respectively after TDR. Although prosthesis increased angle of lordosis at the level implanted in majority of the patients, the difference in preoperative and postoperative angle of lordosis was not significant (P=0.438). In addition, there was no correlation between the angle of implant of chosen and postoperative angle of lordosis at the operated level. The effect of TDR on sagittal balance appears favorable with an increase in global and segmental lumbar lordosis after single level TDR for degenerative disc disease. The degree of postoperative angle of lordosis was not affected by the angle of implant chosen at the operated level and varied

Barriers to and Budget Impact of Lumbar Total Disc Replacement Utilization.

PubMed

Sandhu, Faheem; Blumenthal, Scott; Grunch, Betsy; Kimball, Bent; Ferko, Nicole; Hollmann, Sarah

2017-12-15

: Evidence on the favorable efficacy, safety, and cost effectiveness of lumbar total disc replacement (TDR) compared with fusion for lumbar degenerative disc disease is mounting; however, a key barrier identified for TDR utilization is lack of coverage by US health insurers. Although economic considerations in a fee-for-service model should not be a determining factor in patient access, concerns regarding the budget impact of lumbar TDR surgery may unfortunately underlie coverage decisions. On the basis of the data available and economic modeling, the panel agreed that there is no indication that there would be a dramatic increase in patients seeking lumbar TDR. Considering several possible scenarios on potential growth in TDR utilization with coverage, as well as growth in the overall surgical pool of patients, economic modeling demonstrated that adoption of lumbar TDR would result in minimal or no budget impact for commercial insurance plans. Considering these model results and the economic literature, the panel concluded that adopting lumbar TDR within a coverage policy is expected to remain cost neutral for the insurer.

The role of the vascular surgeon in anterior lumbar spine surgery.

PubMed

Asha, Mohammed Jamil; Choksey, Munchi S; Shad, Amjad; Roberts, Peter; Imray, Chris

2012-08-01

Advances in spinal fusion techniques have led to an increase in the need for safe access to the lumbar spine anteriorly. The aim of this study is to examine the procedure-related complications of anterior lumbar inter-body fusion (ALIF) or anterior lumbar disc replacement (ALDR) when performed jointly by a vascular-surgeon and a neurosurgeon in a single centre. A retrospective cohort analysis was conducted for all patients who underwent ALIF or ALDR between 2004 and 2010. Operative notes were examined to identify any procedure-specific complications. In-hospital postoperative complications were recorded. Outpatients' records were reviewed to record any late-onset postoperative complications. A total of 121 patients (68 female and 53 males) were included. Mean age was 44 years (range of 25-76). Eighty patients (66%) had ALIF while 24 patients (20%) underwent ALDR. The remaining 17 patients (14%) had combined procedure for multilevel disease. In all patients, a transperitoneal approach was performed by vascular surgeon. The main indication (88%) for performing surgery was degenerative lumbar disc disease. No visceral or 'major vascular' complications were reported in any patients. Only three patients had 'minor vascular' injuries. The only significant postoperative complication was self-limiting paralytic ileus affecting 18 patients (14.8%). Hospital stay ranged from 4 to 9 days (median of 5 days). The anterior lumbar approach is not generally favoured by many neurosurgeons, despite its many advantages, due to the significant risk of vascular injuries as reported in the literature. This risk is especially acknowledged by the emerging generation of neurosurgeons with very little general surgical exposure during the training years. Adopting a combined vascular and neurosurgical approach has been reported to reduce the risk of vascular injury in anterior lumbar surgery acceptably low. This team approach provides an excellent opportunity to preserve some key 'general

Biomechanical and Injury Response to Posterolateral Loading from Torso Side Airbags

PubMed Central

Hallman, Jason J.; Yoganandan, Narayan; Pintar, Frank A.

2013-01-01

This study characterized thoracoabdominal response to posterolateral loading from a seat-mounted side airbag. Seven unembalmed post-mortem human subjects were exposed to ten airbag deployments. Subjects were positioned such that the deploying airbag first contacted the posterolateral thorax between T6 and L1 while stationary (n = 3 × 2 aspects) or while subjected to left lateral sled impact at ΔV = 6.7 m/s (n = 4). Chestband contours were analyzed to quantify deformation direction in the thoracic x–y plane (zero degrees indicating anterior and 180° indicating posterior), magnitude, rate, and viscous response. Skeletal injuries were consistent with posterolateral contact; visceral injuries consisted of renal (n = 1) or splenic (n = 3) lacerations. Deformation direction was transient during sled impact, progressing from 122 ± 5° at deformation onset to 90° following maximum deflection. Angles from stationary subjects progressed from 141 ± 9° to 120°. Peak normalized deflections, peak rates, and VCmax ranges were 0.075 – 0.171, 3.7 – 12.7 m/s, and 0.3 – 0.6 m/s with stationary airbag, respectively; ranges were 0.167 – 0.297, 7.4 – 18.3 m/s, and 0.7 – 3.0 m/s with airbag sled impact, respectively. Peak deflections were measured at angles between 99° – 135° and 98° – 125° for stationary and dynamic conditions, respectively. Because of deflection angle transience and localized injury response, both posterolateral and lateral injury metrics may be required for this boundary condition. Contrasted with flat rigid or anterolateral loading, biomechanical response to side airbag interaction may be augmented by peak normalized deflection or VCmax at 130°. PMID:21512911

[Particular posteromedial and posterolateral approaches for the treatment of tibial head fractures].

PubMed

Lobenhoffer, P; Gerich, T; Bertram, T; Lattermann, C; Pohlemann, T; Tscheme, H

1997-12-01

Tibial plateau fractures with depression of posterior aspects of the proximal tibia cause significant therapeutic problems. Posterior fractures on the medial side are mainly highly instable fracture-dislocations (Moore type I). Posterolateral fractures usually cause massive depression and destruction of the chondral surface. Surgical exposure of these fractures from anterior requires major soft tissue dissection and has a significant complication rate. However, incomplete restoration of the joint surface results in chronic postero-inferior joint subluxation, osteoarthritis and pain. We present new specific approaches for posterior fracture types avoiding large skin incisions, but allowing for atraumatic exposure, reduction and fixation. Posteromedial fracture-dislocations are exposed by a direct posteromedial skin incision and a deep incision between medial collateral ligament and posterior oblique ligament. The posteromedial pillar and the posterior flare of the proximal tibia are visualized. The inferior extent of the joint fragment can be reduced by indirect techniques or direct manipulation of the fragment. Fixation is achieved with subchondral lag screws and an anti-glide plate at the tip of the fragment. Posterolateral fractures are exposed by a transfibular approach: the skin is incised laterally, the peroneal nerve is dissected free. The fibula neck is osteotomized, the tibiofibular syndesmosis is divided and the fibula neck is reflected upwards in one layer with the meniscotibial ligament and the iliotibial tract attachment. Reflexion of the fibula head relaxes the lateral collateral ligament, allows for lateral joint opening and internal rotation of the tibia and thus exposes the posterolateral and posterior aspect of the tibial plateau. Fixation and buttressing on the posterolateral side can be achieved easily with this approach. In closure, the fibula head is fixed back with a lag screw or a tension-band system. These two exposures can be combined in

Lower thoracic degenerative spondylithesis with concomitant lumbar spondylosis.

PubMed

Hsieh, Po-Chuan; Lee, Shih-Tseng; Chen, Jyi-Feng

2014-03-01

Degenerative spondylolisthesis of the spine is less common in the lower thoracic region than in the lumbar and cervical regions. However, lower thoracic degenerative spondylolisthesis may develop secondary to intervertebral disc degeneration. Most of our patients are found to have concomitant lumbar spondylosis. By retrospective review of our cases, current diagnosis and treatments for this rare disease were discussed. We present a series of 5 patients who experienced low back pain, progressive numbness, weakness and even paraparesis. Initially, all of them were diagnosed with lumbar spondylosis at other clinics, and 1 patient had even received prior decompressive lumbar surgery. However, their symptoms continued to progress, even after conservative treatments or lumbar surgeries. These patients also showed wide-based gait, increased deep tendon reflex (DTR), and urinary difficulty. All these clinical presentations could not be explained solely by lumbar spondylosis. Thoracolumbar spinal magnetic resonance imaging (MRI), neurophysiologic studies such as motor evoked potential (MEP) or somatosensory evoked potential (SSEP), and dynamic thoracolumbar lateral radiography were performed, and a final diagnosis of lower thoracic degenerative spondylolisthesis was made. Bilateral facet effusions, shown by hyperintense signals in T2 MRI sequence, were observed in all patients. Neurophysiologic studies revealed conduction defect of either MEP or SSEP. One patient refused surgical management because of personal reasons. However, with the use of thoracolumbar orthosis, his symptoms/signs stabilized, although partial lower leg myelopathy was present. The other patients received surgical decompression in association with fixation/fusion procedures performed for managing the thoracolumbar lesions. Three patients became symptom-free, whereas in 1 patient, paralysis set in before the operation; this patient was able to walk with assistance 6 months after surgical decompression

Melorheostosis causing lumbar radiculopathy: a case report and a review of the literature.

PubMed

Saxena, Ankur; Neelakantan, Asha; Jampana, Ravi; Sangra, Meharpal

2013-08-01

Melorheostosis is a rare sclerosing bone disorder with a predilection for the appendicular skeleton. Involvement of the spine is infrequent and largely asymptomatic. Surgical treatment for spinal involvement is therefore uncommon with only one reported case of lumbar fusion for painful lumbosacral melorheostosis. We report a case of lumbar melorheostosis causing disabling radiculopathy treated with nerve root decompression. Melorheostosis of the lumbar spine causing radicular symptoms has not been reported before. Our message from the management of this particular patient is to consider surgical option in symptomatic individuals. Copyright © 2013 Elsevier Inc. All rights reserved.

Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes?

PubMed

Mayer, Tom G; Gatchel, Robert J; Brede, Emily; Theodore, Brian R

2014-02-01

Systematic reviews of lumbar fusion outcomes in purely workers' compensation (WC) patient populations have indicated mixed results for efficacy. Recent studies on lumbar fusions in the WC setting have reported return-to-work rates of 26% to 36%, reoperation rates of 22% to 27%, and high rates of persistent opioid use 2 years after surgery. Other types of lumbar surgery in WC populations are also acknowledged to have poorer outcomes than in non-WC. The possibility of improving outcomes by employing a biopsychosocial model with a continuum of care, including postoperative functional restoration in this "at risk" population, has been suggested as a possible solution. To compare objective socioeconomic and patient-reported outcomes for WC patients with different lumbar surgeries followed by functional restoration, relative to matched comparison patients without surgery. A prospective cohort study of chronic disabling occupational lumbar disorder (CDOLD) patients with WC claims treated in an interdisciplinary functional restoration program. A consecutive cohort of 564 patients with prerehabilitation surgery completed a functional restoration and was divided into groups based on surgery type: lumbar fusion (F group, N=331) and nonfusion lumbar spine surgery (NF group, N=233). An unoperated comparison group was matched for length of disability (U group, N=349). Validated patient-reported measures of pain, disability, and depression were administered pre- and postrehabilitation. Socioeconomic outcomes were collected via a structured 1-year "after" interview. All patients completed an intensive, medically supervised functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach. The writing of this article was supported in part by National Institutes of Health Grant 1K05-MH-71892; no conflicts of interest are noted among the authors. The F group had a longer length of disability compared with the NF and

What are the Risk Factors for Cerebrovascular Accidents After Elective Orthopaedic Surgery?

PubMed

Minhas, Shobhit V; Goyal, Preeya; Patel, Alpesh A

2016-03-01

Perioperative cerebrovascular accidents (CVAs) are one of the leading causes of patient morbidity, mortality, and medical costs. However, little is known regarding the rates of these events and risk factors for CVA after elective orthopaedic surgery. Our goals were to (1) establish the national, baseline proportion of patients experiencing a 30-day CVA and the timing of CVA; and (2) determine independent risk factors for 30-day CVA rates after common elective orthopaedic procedures. Patients undergoing elective TKA, THA, posterior or posterolateral lumbar fusion, anterior cervical discectomy and fusion, and total shoulder arthroplasty, from 2006 to 2012, were identified from the American College of Surgeons National Surgical Quality Improvement Program(®) database. A total of 42,150 patients met inclusion criteria. Thirty-day CVA rates were recorded for each procedure, and patients were assessed for characteristics associated with CVA through univariate analysis. Multivariate regression models were created to identify independent risk factors for CVA. A total of 55 (0.13%) patients experienced a CVA within 30 days of the procedure, occurring a median of 2 days after surgery (range, 1-30 days) with 0.08% of patients experiencing a CVA after TKA, 0.15% after THA, 0.00% after single-level anterior cervical discectomy and fusion, 0.38% after multilevel anterior cervical discectomy and fusions, 0.20% after single-level posterior or posterolateral lumbar fusion, 0.70% after multilevel posterior or posterolateral lumbar fusion, and 0.22% after total shoulder arthroplasty. Independent risk factors for CVA included age of 75 years or older (odds ratio [OR], 2.50; 95% CI, 1.44-4.35; p = 0.001), insulin-dependent diabetes mellitus (OR, 3.08; CI, 1.47-6.45; p = 0.003), hypertension (OR, 2.71; CI, 1.19-6.13; p = 0.017), history of transient ischemic attack (OR, 2.83; CI, 1.24-6.45; p = 0.013), dyspnea (OR, 2.51; CI, 1.30-4.86; p = 0.006), chronic obstructive pulmonary disease

[Effects of robot-assisted minimally invasive transforaminal lumbar interbody fusion and traditional open surgery in the treatment of lumbar spondylolisthesis].

PubMed

Cui, G Y; Tian, W; He, D; Xing, Y G; Liu, B; Yuan, Q; Wang, Y Q; Sun, Y Q

2017-07-01

Objective: To compare the clinical effects of robot-assisted minimally invasive transforaminal lumbar interbody fusion (TLIF) and traditional open TLIF in the treatment of lumbar spondylolisthesis. Methods: A total of 41 patients with lumbar spondylolisthesis accepted surgical treatment in Department of Spinal Surgery of Beijing Jishuitan Hospital From July 2015 to April 2016 were retrospectively analyzed. There were 16 cases accepted robot-assisted minimally invasive TLIF and 25 accepted traditional open TLIF. The operation time, X-ray radiation exposure time, perioperative bleeding, drainage volume, time of hospitalization, time for pain relief, time for ambulatory recovery, visual analogue scale (VAS), Oswestry disability index (ODI) and complications were compared. T test and χ(2) were used to analyze data. Results: There were no significant difference in gender, age, numbers, degrees, pre-operative VAS and ODI in spondylolisthesis (all P >0.05). Compared with traditional open TLIF group, the robot-assisted minimally invasive TLIF group had less perioperative bleeding ((187.5±18.4) ml vs . (332.1±23.5) ml), less drainage volume ((103.1±15.6) ml vs . (261.3±19.8) ml), shorter hospitalization ((7.8±1.9) days vs . (10.0±1.6) days), shorter time for pain relief ((2.8±1.0) days vs . (5.2±1.1) days), shorter time for ambulatory recovery ((1.7±0.9) days vs . (2.9±1.3) days) and less VAS of the third day postoperatively (2.2±0.9 vs . 4.2±2.4) ( t =2.762-16.738, all P <0.05), but need more operation time ((151.3±12.3) minutes vs . (102.2±7.1) minutes) and more X-ray radiation exposure ((26.1±3.3) seconds vs . (5.5±2.1) seconds) ( t =6.125, 15.168, both P <0.01). In both groups ODI was significantly lower in final follow-up than that of the pre-operation ( t =12.215, 14.036, P <0.01). Intervertebral disc height of the final follow-up in both groups were significantly larger than that of the preoperation (robot-assisted minimally invasive TLIF group: (11

Estimation of the Ideal Lumbar Lordosis to Be Restored From Spinal Fusion Surgery: A Predictive Formula for Chinese Population.

PubMed

Xu, Leilei; Qin, Xiaodong; Zhang, Wen; Qiao, Jun; Liu, Zhen; Zhu, Zezhang; Qiu, Yong; Qian, Bang-ping

2015-07-01

A prospective, cross-sectional study. To determine the independent variables associated with lumbar lordosis (LL) and to establish the predictive formula of ideal LL in Chinese population. Several formulas have been established in Caucasians to estimate the ideal LL to be restored for lumbar fusion surgery. However, there is still a lack of knowledge concerning the establishment of such predictive formula in Chinese population. A total of 296 asymptomatic Chinese adults were prospectively recruited. The relationships between LL and variables including pelvic incidence (PI), age, sex, and body mass index were investigated to determine the independent factors that could be used to establish the predictive formula. For the validation of the current formula, other 4 reported predictive formulas were included. The absolute value of the gap between the actual LL and the ideal LL yielded by these formulas was calculated and then compared between the 4 reported formulas and the current one to determine its reliability in predicting the ideal LL. The logistic regression analysis showed that there were significant associations of LL with PI and age (R = 0.508, P < 0.001 for PI; R = 0.088, P = 0.03 for age). The formula was, therefore, established as follows: LL = 0.508 × PI - 0.088 × Age + 28.6. When applying our formula to these subjects, the gap between the predicted ideal LL and the actual LL was averaged 3.9 ± 2.1°, which was significantly lower than that of the other 4 formulas. The calculation formula derived in this study can provide a more accurate prediction of the LL for the Chinese population, which could be used as a tool for decision making to restore the LL in lumbar corrective surgery. 3.

Effect of minimally invasive technique on return to work and narcotic use following transforaminal lumbar inter-body fusion: a review.

PubMed

Parker, Scott L; Lerner, Jason; McGirt, Matthew J

2012-01-01

Low back pain is one of the most prevalent and disabling musculoskeletal conditions affecting the working population in the United States. Informed, shared decision making among patients, clinicians, and case managers about treatment options for chronic low back pain-including the role of spinal fusion where medically necessary-can have a meaningful impact on return to work, normal function, and economic outcomes. Minimally invasive techniques for lumbar spinal fusion, including transforaminal lumbar interbody fusion (MIS TLIF) have recently been introduced with the goal of smaller operative wounds, less tissue trauma, and faster postoperative recovery when compared with open fusion. Although similar long-term clinical outcomes have been reported for MIS TLIF and open TLIF, the relative merits with respect to workplace productivity have not been comprehensively investigated. Time to return to work and narcotic independence after MIS TLIF and open TLIF are important parameters that may affect overall workplace productivity, and as such are the focus of this study. This study was performed via a review of the literature. We performed a systematic literature review to identify all published articles that reported on the postoperative outcomes of patients, as assessed by return to work or narcotic independence status or both, following MIS TLIF or open TLIF. A cumulative comparison was made for all included MIS TLIF versus open TLIF surgeries. Seventy-four published studies reported postoperative outcomes following MIS TLIF or open TLIF; only five (6.8%) studies directly described time to return to work or duration of narcotic use postoperatively or both, and were therefore included into the analysis of this review. Four studies in the published literature describe time to return to work following MIS TLIF or open TLIF, and two studies describe time to narcotic independence. Overall, the reviewed literature suggests that MIS TLIF may be associated with an accelerated

Kinematic efficacy of supplemental anterior lumbar interbody fusion at lumbosacral levels in thoracolumbosacral deformity correction with and without pedicle subtraction osteotomy at L3: an in vitro cadaveric study.

PubMed

Dahl, Benny T; Harris, Jonathan A; Gudipally, Manasa; Moldavsky, Mark; Khalil, Saif; Bucklen, Brandon S

2017-11-01

Pedicle subtraction osteotomy (PSO) is performed to treat rigid, sagittal spinal deformities, but high rates of implant failure are reported. Anterior lumbar interbody fusion has been proposed to reduce this risk, but biomechanical investigation is lacking. The goal of this study was to quantify the (1) destabilizing effects of a lumbar osteotomy and (2) contribution of anterior lumbar interbody fusion (ALIF) at the lumbosacral junction as recommended in literature. Fourteen fresh human thoracolumbosacral spines (T12-S1) were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Bilateral pedicle screws/rods (BPS) were inserted at T12-S1, cross connectors (CC) at T12-L1 and L5-S1, and anterior interbody spacers (S) at L4-5 and L5-S1. In one group, PSO was performed in seven specimens at L3. All specimens were sequentially tested in (1) Intact; (2) BPS; (3) BPS + CC; (4) BPS + S; and (5) BPS + S + CC; a second group of seven spines were tested in the same sequence without PSO. Mixed-model ANOVA with repeated measures was performed (p ≤ 0.05). At the osteotomy site (L2-L4), in FE, BPS, BPS + CC, BPS + S, BPS + CC + S reduced motion to 11.2, 12.9, 10.9, and 11.4%, respectively, with significance only found in BPS and BPS + S construction (p ≤ 0.05). All constructs significantly reduced motion across L2-L4 in the absence of PSO, across all loading modes (p ≤ 0.05). PSO significantly destabilized L2-L4 axial rotational stability, regardless of operative construction (p ≤ 0.05). Across L4-S1 and L2-S1, all instrumented constructs significantly reduced motion, in both PSO- and non-PSO groups, during all loading modes (p ≤ 0.05). These findings suggest anterior interbody fusion minimally immobilizes motion segments, and interbody devices may primarily act to maintain disc height. Additionally, lumbar osteotomy destabilizes axial rotational stability at the osteotomy site, potentially further increasing

Complications of Lumbar Artificial Disc Replacement Compared to Fusion: Results From the Prospective, Randomized, Multicenter US Food and Drug Administration Investigational Device Exemption Study of the Charité Artificial Disc

PubMed Central

Majd, Mohammed E.; Isaza, Jorge E.; Blumenthal, Scott L.; McAfee, Paul C.; Guyer, Richard D.; Hochschuler, Stephen H.; Geisler, Fred H.; Garcia, Rolando; Regan, John J.

2007-01-01

Background Previous reports of lumbar total disc replacement (TDR) have described significant complications. The US Food and Drug Administration (FDA) investigational device exemption (IDE) study of the Charité artificial disc represents the first level I data comparison of TDR to fusion. Methods In the prospective, randomized, multicenter IDE study, patients were randomized in a 2:1 ratio, with 205 patients in the Charité group and 99 patients in the control group (anterior lumbar interbody fusion [ALIF] with BAK cages). Inclusion criteria included confirmed single-level degenerative disc disease at L4-5 or L5-S1 and failure of nonoperative treatment for at least 6 months. Complications were reported throughout the study. Results The rate of approach-related complications was 9.8% in the investigational group and 10.1% in the control group. The rate of major neurological complications was similar between the 2 groups (investigational = 4.4%, control = 4.0%). There was a higher rate of superficial wound infection in the investigational group but no deep wound infections in either group. Pseudarthrosis occurred in 9.1% of control group patients. The rate of subsidence in the investigational group was 3.4%. The reoperation rate was 5.4% in the investigational group and 9.1% in the control group. Conclusions The incidence of perioperative and postoperative complications for lumbar TDR was similar to that of ALIF. Vigilance is necessary with respect to patient indications, training, and correct surgical technique to maintain TDR complications at the levels experienced in the IDE study. PMID:25802575

Optimal Pelvic Incidence Minus Lumbar Lordosis Mismatch after Long Posterior Instrumentation and Fusion for Adult Degenerative Scoliosis.

PubMed

Zhang, Hao-Cong; Zhang, Zi-Fang; Wang, Zhao-Han; Cheng, Jun-Yao; Wu, Yun-Chang; Fan, Yi-Ming; Wang, Tian-Hao; Wang, Zheng

2017-08-01

To evaluate the influence of Scoliosis Research Society (SRS)-Schwab sagittal modifiers of pelvic incidence minus lumbar lordosis mismatch (PI-LL) on clinical outcomes for adult degenerative scoliosis (ADS) after long posterior instrumentation and fusion. This was a single-institute, retrospective study. From 2012 to 2014, 44 patients with ADS who underwent posterior instrumentation and fusion treatment were reviewed. Radiological evaluations were investigated by standing whole spine (posteroanterior and lateral views) X-ray and all radiological measurements, including Cobb's angle, LL, PI, and the grading of vertebral rotation, were performed by two experienced surgeons who were blind to the operations. The patients were divided into three groups based on postoperative PI-LL and the classification of the SRS-Schwab: 0 grade PI-LL (<10°, n = 13); + grade PI-LL (10°-20°, n = 19); and ++ grade PI-LL (>20°, n = 12). The clinical outcomes were assessed according to Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), Visual Analog Scale (VAS), Lumbar Stiffness Disability Index (LSDI), and complications. Other characteristic data of patients were also collected, including intraoperative blood loss, operative time, length of hospital stay, complications, number of fusion levels, and number of decompressions. The mean operative time, blood loss, and hospital stay were 284.5 ± 30.2 min, 1040.5 ± 1207.6 mL, and 14.5 ± 1.9 day. At the last follow-up (2.6 ± 0.6 years), the radiological and functional parameters, except the grading of vertebral rotation, were all significantly improved in comparison with preoperative results (P < 0.05), but it was obvious that an ideal PI-LL (≤10°) was not achieved in some patients. Significant differences were only observed among the three groups in the ODI and LSDI. Patients with + grade PI-LL seemed to have the best surgical outcome compared to those with 0 and

Multi-planar bending properties of lumbar intervertebral joints following cyclic bending.

PubMed

Chow, Daniel H K; Luk, Keith D K; Holmes, Andrew D; Li, Xing-Fei; Tam, Steven C W

2004-02-01

To assess the changes in the multi-planar bending properties of intervertebral joints following cyclic bending along different directions. An in vitro biomechanical study using porcine lumbar motion segments. Repeated bending has been suggested as part of the etiology of gradual prolapse of the intervertebral disc, but the multi-planar changes in bending properties following cyclic loading have not been examined in detail. Porcine lumbar motion segments were subject to 1500 cycles of bending along directions of 0 degrees (flexion), 30 degrees, 60 degrees, or 90 degrees (right lateral bending). The multi-planar bending moments and hysteresis energies were recorded before loading and after various cycle numbers. Repeated bending at 30 degrees and 60 degrees resulted in greater decreases in mean bending moment and hysteresis energy than bending at 0 degrees or 90 degrees. No significant differences were seen between loading groups for the change in bending moment along the anterior testing directions, but significant differences were observed in the posterior and lateral testing directions, with bending at 30 degrees causing a significantly greater decrease in bending moment in the postero-lateral directions. The change in mechanical properties of porcine intervertebral joints due to cyclic bending depend on the direction of loading and the direction in which the properties are measured. Loading at 30 degrees provokes the most marked changes in bending moment and hysteresis energy.

Open and Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Intermediate Results and Complications

PubMed Central

Hee, Hwan Tak

2015-01-01

Study Design Prospective study. Purpose To compare clinical and radiological outcomes of open vs. minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). Overview of Literature MI-TLIF promises smaller incisions and less soft tissue dissection resulting in lower morbidity and faster recovery; however, it is technically challenging. Methods Twenty-five patients with MI-TLIF were compared with 25 matched open TLIF controls. A minimum 2 year follow-up and a statistical analysis of perioperative and long-term outcomes were performed. Potential complications were recorded. Results The mean ages for the open and MI-TLIF cases were 44.4 years (range, 19-69 years) and 43.6 years (range, 20-69 years), respectively. The male:female ratio was 13:12 for both groups. Average follow-up was 26.9 months for the MI-TLIF group and 29.3 months for the open group. Operative duration was significantly longer in the MI-TLIF group than that in the open group (p<0.05). No differences in estimated blood loss, duration to ambulation, or length of stay were found. Significant improvements in the Oswestry disability index and EQ-5D functional scores were observed at 6-, 12-, and 24-months in both groups, but no significant difference was detected between the groups. Fusion rates were comparable. Cage sizes were significantly smaller in the MI-TLIF group at the L5/S1 level (p<0.05). One patient had residual spinal stenosis at the MI-TLIF level, and one patient who underwent two-level MI-TLIF developed a deep vein thrombosis resulting in a pulmonary embolism. Conclusions MI-TLIF and open TLIF had comparable long-term benefits. Due to technical constraints, patients should be advised on the longer operative time and potential undersizing of cages at the L5S1 level. PMID:25901228

Outcome of Percutaneous Lumbar Synovial Cyst Rupture in Patients with Lumbar Radiculopathy.

PubMed

Eshraghi, Yashar; Desai, Vimal; Cajigal Cajigal, Calvin; Tabbaa, Kutaiba

2016-01-01

Lumbar synovial cysts can result from spondylosis of facet joints. These cysts can encroach on adjacent nerve roots, causing symptoms of radiculopathy. Currently the only definitive treatment for these symptoms is surgery, which may involve laminectomy or laminotomy, with or without spinal fusion. Surgery has been reported to successfully relieve radicular pain in 83.5% of patients by Zhenbo et al. Little information is available concerning the efficacy and outcome of percutaneous fluoroscopic synovial cyst rupture for treatment of facet joint synovial cysts. The goal of this investigation was to assess the efficacy of fluoroscopically guided lumbar synovial cyst rupture, in particular for its relief of radicular symptoms and its potential to reduce the need for surgical intervention. Retrospective evaluation of a case series. University hospital and urban public health care system. With approval from the Institutional Review Board of Case Western Reserve University/ MetroHealth Medical Center, we reviewed the medical charts of patients with lumbar radiculopathy who underwent percutaneous lumbar synovial cyst rupture. The 30 patients in the cohort were treated by one pain specialist between 2006 and 2013. These patients were diagnosed with moderate to severe lower back pain, radiculopathy, and ranged in age from 42 to 80 years. Patients were followed up for a minimum of 6 months and up to 24 months. Pre- and post-procedure pain assessments were reviewed by clinical chart review. In addition post-procedure pain assessments and duration of pain relief were obtained with telephone interviews. Pain had been reported by the patients using a numeric rating scale of 0 - 10 (0 = no pain; 10 = worst possible pain). Charts were reviewed to determine if surgery was eventually performed to correct radicular symptoms. More than 6 months of pain relief was achieved in 14/30 patients (46%) and between one and 6 months of pain relief was achieved in 7/30 patients (23.3%). Nine

Assessing the effects of lumbar posterior stabilization and fusion to vertebral bone density in stabilized and adjacent segments by using Hounsfield unit

PubMed Central

Öksüz, Erol; Deniz, Fatih Ersay; Demir, Osman

2017-01-01

Background Computed tomography (CT) with Hounsfield unit (HU) is being used with increasing frequency for determining bone density. Established correlations between HU and bone density have been shown in the literature. The aim of this retrospective study was to determine the bone density changes of the stabilized and adjacent segment vertebral bodies by comparing HU values before and after lumbar posterior stabilization. Methods Sixteen patients who had similar diagnosis of lumbar spondylosis and stenosis were evaluated in this study. Same surgical procedures were performed to all of the patients with L2-3-4-5 transpedicular screw fixation, fusion and L3-4 total laminectomy. Bone mineral density measurements were obtained with clinical CT. Measurements were obtained from stabilized and adjacent segment vertebral bodies. Densities of vertebral bodies were evaluated with HU before the surgeries and approximately one year after the surgeries. The preoperative HU value of each vertebra was compared with postoperative HU value of the same vertebrae by using statistical analysis. Results The HU values of vertebra in the stabilized and adjacent segments consistently decreased after the operations. There were significant differences between the preoperative HU values and the postoperative HU values of the all evaluated vertebral bodies in the stabilized and adjacent segments. Additionally first sacral vertebra HU values were found to be significantly higher than lumbar vertebra HU values in the preoperative group and postoperative group. Conclusions Decrease in the bone density of the adjacent segment vertebral bodies may be one of the major predisposing factors for adjacent segment disease (ASD). PMID:29354730

Biomechanical comparison of two surgical techniques for press-fit reconstruction of the posterolateral complex of the knee.

PubMed

Panzica, Martin; Janzik, Janne; Bobrowitsch, Evgenij; Krettek, Christian; Hawi, Nael; Hurschler, Christof; Jagodzinski, Michael

2015-11-01

To date, various surgical techniques to treat posterolateral knee instability have been described. Recent studies recommended an anatomical and isometric reconstruction of the posterolateral corner addressing the key structures, such as lateral collateral ligament (LCL), popliteus tendon (POP) and popliteofibular ligament (PFL). Two clinical established autologous respective local reconstruction methods of the posterolateral complex were tested for knot-bone cylinder press-fit fixation to assess efficacy of each reconstruction technique in comparison to the intact knee. The knot-bone cylinder press-fit fixation for both anatomic and isometric reconstruction techniques of the posterolateral complex shows equal biomechanical stability as the intact posterolateral knee structures. This was a controlled laboratory study. Two surgical techniques (Larson: fibula-based semitendinosus autograft for LCL and PFL reconstruction/Kawano: biceps femoris and iliotibial tract autograft for LCL, PFL and POP reconstruction) with press-fit fixation were used for restoration of posterolateral knee stability. Seven cadaveric knees (66 ± 3.4 years) were tested under three conditions: intact knee, sectioned state and reconstructed knee for each surgical technique. Biomechanical stress tests were performed for every state at 30° and 90° knee flexion for anterior-posterior translation (60 N), internal-external and varus-valgus rotation (5 Nm) at 0°, 30° and 90° using a kinemator (Kuka robot). At 30° and 90° knee flexion, no significant differences between the four knee states were registered for anterior-posterior translation loading. Internal-external and varus-valgus rotational loading showed significantly higher instability for the sectioned state than for the intact or reconstructed posterolateral structures (p < 0.05). There were no significant differences between the intact and reconstructed knee states for internal-external rotation, varus-valgus rotation and anterior

A comparison of commercially available demineralized bone matrices with and without human mesenchymal stem cells in a rodent spinal fusion model.

PubMed

Hayashi, Tetsuo; Lord, Elizabeth L; Suzuki, Akinobu; Takahashi, Shinji; Scott, Trevor P; Phan, Kevin; Tian, Haijun; Daubs, Michael D; Shiba, Keiichiro; Wang, Jeffrey C

2016-07-01

OBJECTIVE The efficacy of some demineralized bone matrix (DBM) substances has been demonstrated in the spinal fusion of rats; however, no previous comparative study has reported the efficacy of DBM with human mesenchymal stem cells (hMSCs). There is an added cost to the products with stem cells, which should be justified by improved osteogenic potential. The purpose of this study is to prospectively compare the fusion rates of 3 different commercially available DBM substances, both with and without hMSCs. METHODS Posterolateral fusion was performed in 32 mature athymic nude rats. Three groups of 8 rats were implanted with 1 of 3 DBMs: Trinity Evolution (DBM with stem cells), Grafton (DBM without stem cells), or DBX (DBM without stem cells). A fourth group with no implanted material was used as a control group. Radiographs were obtained at 2, 4, and 8 weeks. The rats were euthanized at 8 weeks. Overall fusion was determined by manual palpation and micro-CT. RESULTS The fusion rates at 8 weeks on the radiographs for Trinity Evolution, Grafton, and DBX were 8 of 8 rats, 3 of 8 rats, and 5 of 8 rats, respectively. A significant difference was found between Trinity Evolution and Grafton (p = 0.01). The overall fusion rates as determined by micro-CT and manual palpation for Trinity Evolution, Grafton, and DBX were 4 of 8 rats, 3 of 8 rats, and 3 of 8 rats, respectively. The Trinity Evolution substance had the highest overall fusion rate, however no significant difference was found between groups. CONCLUSIONS The efficacies of these DBM substances are demonstrated; however, the advantage of DBM with hMSCs could not be found in terms of posterolateral fusion. When evaluating spinal fusion using DBM substances, CT analysis is necessary in order to not overestimate fusion.

The efficacy of porous hydroxyapatite bone chip as an extender of local bone graft in posterior lumbar interbody fusion.

PubMed

Kim, Hyoungmin; Lee, Choon-Ki; Yeom, Jin-Sup; Lee, Jae-Hyup; Lee, Ki-Ho; Chang, Bong-Soon

2012-07-01

To evaluate whether a synthetic bone chip made of porous hydroxyapatite can effectively extend local decompressed bone graft in instrumented posterior lumbar interbody fusion (PLIF). 130 patients, 165 segments, who had undergone PLIF with cages and instrumentation for single or double level due to degenerative conditions, were investigated retrospectively by independent blinded observer. According to the material of graft, patients were divided into three groups. HA group (19 patients, 25 segments): with hydroxyapatite bone chip in addition to autologous local decompressed bone, IBG group (25 patients, 28 segments): with autologous iliac crest bone graft in addition to local decompressed bone and LB group (86 patients, 112 segments): with local decompressed bone only. Radiologic and clinical outcome were compared among groups and postoperative complications, transfusion, time and cost of operation and duration of hospitalization were also investigated. Radiologic fusion rate and clinical outcome were not different. Economic cost, transfusion and hospital stay were also similar. But operation time was significantly longer in IBG group than in other groups. There were no lasting complications associated with HA and LB group with contrast to five cases with persisting donor site pain in IBG group. Porous hydroxyapatite bone chip is a useful bone graft extender in PLIF when used in conjunction with local decompressed bone.

Radiographic and clinical outcomes following MIS-TLIF in patients with adult lumbar degenerative scoliosis.

PubMed

Zhao, Yongfei; Liang, Yan; Mao, Keya

2018-04-19

Patients suffering from adult lumbar degenerative scoliosis (ALDS) are commonly complicated with advanced age, osteoporosis, cardiopulmonary insufficiency, and some other medical comorbidity. Therefore, the traditional open surgery can lead to high rate of postoperative complications. The purposes of this study were to introduce our experiences and explore the efficacy and feasibility of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of patients with ALDS. From January 2008 to January 2014, a retrospective study of 22 patients with ALDS treated with MIS-TLIF was followed up at least 2 years. All patients suffered from one-level lumbar stenosis, and the nerve root block was performed to make sure the exact level. The clinical and radiographic outcomes were evaluated preoperatively and at the time of 2-year follow-up. The mean visual analog scale (VAS) back pain scores decreased from 6.2 ± 1.8 preoperatively to 2.2 ± 0.7 at 2-year follow-up (P < 0.05), and the mean VAS leg pain scores decreased from 8.2 ± 0.7 preoperatively to 1.4 ± 1.4 at 2-year follow-up (P < 0.05). The Oswestry Disability Index score improved from 62.4 ± 16.1% preoperatively to 24.2 ± 9.3% at 2-year follow-up (P < 0.05). The average lumbar curve was 20.7° ± 7.0° preoperatively and 12.7° ± 7.1° at 2-year follow-up (P < 0.05). The lumbar lordosis changed from - 39.5° ± 13.6° to - 43.6° ± 10.6° at 2-year follow-up (P < 0.05). Solid fusion was achieved in all patients. The technique of MIS-TLIF can be used to treat the patients with ALDS whose symptom is mainly from one-level lumbar stenosis, achieving favorable clinical outcomes and good fusion, with less blood loss and complications.

Biomechanical Analysis of Porous Additive Manufactured Cages for Lateral Lumbar Interbody Fusion: A Finite Element Analysis.

PubMed

Zhang, Zhenjun; Li, Hui; Fogel, Guy R; Liao, Zhenhua; Li, Yang; Liu, Weiqiang

2018-03-01

A porous additive manufactured (AM) cage may provide stability similar to that of traditional solid cages and may be beneficial to bone ingrowth. The biomechanical influence of various porous cages on stability, subsidence, stresses in cage, and facet contact force has not been fully described. The purpose of this study was to verify biomechanical effects of porous AM cages. The surgical finite element models with various cages were constructed. The partially porous titanium (PPT) cages and fully porous titanium (FPT) cages were applied. The mechanical parameters of porous materials were obtained by mechanical test. Then the porous AM cages were compared with solid titanium (TI) cage and solid polyetheretherketone (PEEK) cage. The 4 motion modes were simulated. Range of motion (ROM), cage stress, end plate stress, and facet joint force (FJF) were compared. For all the surgical models, ROM decreased by >90%. Compared with TI and PPT cages, PEEK and FPT cages substantially reduced the maximum stresses in cage and end plate in all motion modes. Compared with PEEK cages, the stresses in cage and end plate for FPT cages decreased, whereas the ROM increased. Comparing FPT cages, the stresses in cage and end plate decreased with increasing porosity, whereas ROM increased with increasing porosity. After interbody fusion, FJF was substantially reduced in all motion modes except for flexion. Fully porous cages may offer an alternative to solid PEEK cages in lateral lumbar interbody fusion. However, it may be prudent to further increase the porosity of the cage. Copyright © 2017 Elsevier Inc. All rights reserved.

[Effect of lumbar hybrid instrumentation and rigid fusion on the treated and the adjacent segments. A biomechanical study].

PubMed

Wiedenhöfer, B; Akbar, M; Fürstenberg, C H; Carstens, C; Hemmer, S; Schilling, C

2011-02-01

Degeneration of the upper adjacent segment after operative treatment of degenerative spinal diseases of the lumbar spine (degenerative disc disease DDD) is an unsolved problem. There is also no consensus on whether a rigid or dynamic treatment of DDD should be carried out to protect the segments. This study was carried out to evaluate the effect of bisegmental rigid 360° fusion and bisegmental hybrid fusion on the treated segment as well as on the upper adjacent segment under the aspect of segment protection. A total of six human spinal column preparations (L2-5) were tested under native conditions (NAT), with bisegmental rigid fusion (RIG 360°) and with hybrid fusion (Hybrid) in all three movement directions under physical load and with an preload. The range of motion (ROM) and neutral zone (NZ) were evaluated. The intradiscal pressure (IDP) was measured in the upper adjacent segment (OAS). The RIG 360° led to a significant reduction in movement in all directions compared to NAT but Hybrid only in lateral bending (LB). In the OAS the NZ was showed a much greater increase than the ROM. The RIG 360° showed an increase of the NZ in flexion-extension of 86.8% and in LB of 49.6% as well as a significant increase in axial rotation of 52.5%. The increase in the Hybrid was not significant compared to NAT in all directions. Pressure measurements in OAS showed no significant differences for RIG 360° and for Hybrid compared to NAT for both load scenarios. The range of motion of the treated segments for Hybrid were close to NAT in comparison to RIG 360° indicating a segment-protective effect. The hypothesis that rigid fusion has a significant effect on intersegmental mobility and the increase in intradiscal pressure in the upper adjacent segment could not be confirmed. The data indicate that the primary effect of fusion on the adjacent segment is very low but the fusion-linked increased frequency of extreme loads of the OAS falling within the significance level leads to

An Outcome and Cost Analysis Comparing Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Intraoperative Fluoroscopy versus Computed Tomography-Guided Navigation.

PubMed

Khanna, Ryan; McDevitt, Joseph L; Abecassis, Zachary A; Smith, Zachary A; Koski, Tyler R; Fessler, Richard G; Dahdaleh, Nader S

2016-10-01

Minimally invasive transforaminal lumbar interbody fusion (TLIF) has undergone significant evolution since its conception as a fusion technique to treat lumbar spondylosis. Minimally invasive TLIF is commonly performed using intraoperative two-dimensional fluoroscopic x-rays. However, intraoperative computed tomography (CT)-based navigation during minimally invasive TLIF is gaining popularity for improvements in visualizing anatomy and reducing intraoperative radiation to surgeons and operating room staff. This is the first study to compare clinical outcomes and cost between these 2 imaging techniques during minimally invasive TILF. For comparison, 28 patients who underwent single-level minimally invasive TLIF using fluoroscopy were matched to 28 patients undergoing single-level minimally invasive TLIF using CT navigation based on race, sex, age, smoking status, payer type, and medical comorbidities (Charlson Comorbidity Index). The minimum follow-up time was 6 months. The 2 groups were compared in regard to clinical outcomes and hospital reimbursement from the payer perspective. Average surgery time, anesthesia time, and hospital length of stay were similar for both groups, but average estimated blood loss was lower in the fluoroscopy group compared with the CT navigation group (154 mL vs. 262 mL; P = 0.016). Oswestry Disability Index, back visual analog scale, and leg visual analog scale scores similarly improved in both groups (P > 0.05) at 6-month follow-up. Cost analysis showed that average hospital payments were similar in the fluoroscopy versus the CT navigation groups ($32,347 vs. $32,656; P = 0.925) as well as payments for the operating room (P = 0.868). Single minimally invasive TLIF performed with fluoroscopy versus CT navigation showed similar clinical outcomes and cost at 6 months. Copyright © 2016 Elsevier Inc. All rights reserved.

Posterolateral complex knee injuries: magnetic resonance imaging with surgical correlation.

PubMed

Theodorou, D J; Theodorou, S J; Fithian, D C; Paxton, L; Garelick, D H; Resnick, D

2005-05-01

To describe the magnetic resonance imaging (MRI) findings of injuries of the posterolateral aspect of the knee and to evaluate the diagnostic capabilities of MRI in the assessment of these injuries. The MRI studies of 14 patients (mean age 33 years) with trauma to the posterolateral aspect of the knee were retrospectively reviewed, and the imaging findings were correlated with those of surgery. In all patients, MRI showed an intact iliotibial (ITB) band. MRI showed injury to the biceps tendon in 11 (79%), the gastrocnemius tendon in 1 (7%)), the popliteus tendon in 5 (36%), and the lateral collateral ligament (LCL) in 14 (100%) patients. Tear of the anterior cruciate ligament (ACL) was seen in 11 (79%) patients and tear of the posterior cruciate ligament (PCL) in 4 (29%) patients. With routine MRI, visualization of the popliteofibular or fabellofibular ligaments was incomplete. On MRI, the lateral meniscus and the medial meniscus were torn with equal frequency (n = 4; 29%). Osteochondral defects were seen in 5 (36%) cases and joint effusion in all 14 (100%) cases on MRI. Using surgical findings as the standard for diagnosis, MRI proved 86% accurate in the detection of injury to the ITB band, the biceps tendon (93%), the gastrocnemius tendon (100%), the popliteus tendon (86%), the LCL (100%), the ACL (79%), the PCL (86%), the lateral meniscus (90%), the medial meniscus (82%), and the osteochondral structures (79%). Surgical correlation confirmed the MRI findings of joint effusion in all cases. MRI is well suited for demonstrating the presence and extent of injuries of the major structures of the posterolateral complex of the knee, allowing characterization of the severity of injury.

Grafton and local bone have comparable outcomes to iliac crest bone in instrumented single-level lumbar fusions.

PubMed

Kang, James; An, Howard; Hilibrand, Alan; Yoon, S Tim; Kavanagh, Eoin; Boden, Scott

2012-05-20

Prospective multicenter randomized clinical trail. The goal of our 2-year prospective study was to perform a randomized clinical trial comparing the outcomes of Grafton demineralized bone matrix (DBM) Matrix with local bone with that of iliac crest bone graft (ICBG) in a single-level instrumented posterior lumbar fusion. There has been extensive research and development in identifying a suitable substitute to replace autologous ICBG that is associated with known morbidities. DBMs are a class of commercially available grafting agents that are prepared from allograft bone. Many such products have been commercially available for clinical use; however, their efficacy for spine fusion has been mostly based on anecdotal evidence rather than randomized controlled clinical trials. Forty-six patients were randomly assigned (2:1) to receive Grafton DBM Matrix with local bone (30 patients) or autologous ICBG (16 patients). The mean age was 64 (females [F] = 21, males [M] = 9) in the DBM group and 65 (F = 9, M = 5) in the ICBG group. An independent radiologist evaluated plain radiographs and computed tomographic scans at 6-month, 1-year, and 2-year time points. Clinical outcomes were measured using Oswestry Disability Index (ODI) and Medical Outcomes Study 36-Item Short Form Health Survey. Forty-one patients (DBM = 28 and ICBG = 13) completed the 2-year follow-up. Final fusion rates were 86% (Grafton Matrix) versus 92% (ICBG) (P = 1.0 not significant). The Grafton group showed slightly better improvement in ODI score than the ICBG group at the final 2-year follow-up (Grafton [16.2] and ICBG [22.7]); however, the difference was not statistically significant (P = 0.2346 at 24 mo). Grafton showed consistently higher physical function scores at 24 months; however, differences were not statistically significant (P = 0.0823). Similar improvements in the physical component summary scores were seen in both the Grafton and ICBG groups. There was a statistically significant greater mean

Anterior lumbar interbody surgery for spondylosis results from a classically-trained neurosurgeon.

PubMed

Chatha, Gurkirat; Foo, Stacy W L; Lind, Christopher R P; Budgeon, Charley; Bannan, Paul E

2014-09-01

Anterior lumbar surgery for degenerative disc disease (DDD) is a relatively novel technique that can prevent damage to posterior osseous, muscular and ligamentous spinal elements. This study reports the outcomes and complications in 286 patients who underwent fusion - with artificial disc implants or combined fusion and artificial disc implants - by a single-operator neurosurgeon, with up to 24 months of follow-up. The visual analogue scale (VAS), Oswestry Disability Index (ODI), Short Form 36 (SF36) and prospective log of adverse events were used to assess the clinical outcome. Radiographic assessments of implant position and bony fusion were analysed. Intraoperative and postoperative complications were also recorded. Irrespective of pre-surgical symptoms (back pain alone or back and leg pain combined), workers' compensation status and type of surgical implant, clinically significant improvements in VAS, ODI and SF36 were primarily observed at 3 and/or 6 month follow-up, and improvements were maintained at 24 months after surgery. A 94% fusion rate was obtained; the overall complication was 9.8% which included 3.5% with vascular complications. The anterior lumbar approach can be used for treating DDD for both back pain and back and leg pain with low complication rates. With appropriate training, single-operator neurosurgeons can safely perform these surgeries. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

Single transverse-orientation cage via MIS-TLIF approach for the treatment of degenerative lumbar disease: a technical note.

PubMed

Wang, Shan-Jin; Han, Ying-Chao; Pan, Fu-Min; Ma, Bin; Tan, Jun

2015-01-01

Single transverse cage placed in the anterior vertebral column can better maintain lumbar lordosis and sagittal alignment and is frequently used via the lateral transpsoas approach. However, there is no clear description in the literature of the steps required to place the single transverse cage during the instrumented transforaminal lumbar interbody fusion (TLIF) procedure for the treatment of degenerative lumbar disease. The objective of this study is to describe the technique using single transverse-orientation cage when performing TLIF procedures. We present 18 illustrative cases in which single transverse-orientation cage was placed according to a step-by-step technique that can be used during the TLIF procedure. Information acquired included procedure time, intraoperative blood loss and postoperative complications. The preoperative and postoperative Oswestry Disability Index (ODI) and the visual analogue scale (VAS) scores were recorded. Changes in disc height and segmental lordosis were measured at radiographs. The single transverse-orientation cage was successfully placed in 18 patients in a stepwise technique to achieve lumbar fusion. Using this technique, the patients significantly improved clinically and radiographically at postoperative visits. This is the first report demonstrating the safety and efficacy of instrumented TLIF with single transverse-orientation cage for the treatment of degenerative lumbar disease. Single transverse-orientation cage via MIS-TLIF approach can maintain greater lumbar lordosis and avoid the unique complications of lateral transpsoas approach. Understanding the options for cage placement is important for surgeons considering the use of this technique.

Distribution and Determinants of 90-Day Payments for Multilevel Posterior Lumbar Fusion: A Medicare Analysis.

PubMed

Jain, Nikhil; Phillips, Frank M; Khan, Safdar N

2018-04-01

A retrospective, economic analysis. The objective of this article is to analyze the distribution of 90-day payments, sources of variation, and reimbursement for complications and readmissions for primary ≥3-level posterior lumbar fusion (PLF) from Medicare data. A secondary objective was to identify risk factors for complications. Bundled payments represent a single payment system to cover all costs associated with a single episode of care, typically over 90 days. The dollar amount spent on different health service providers and the variation in payments for ≥3-level PLF have not been analyzed from a bundled perspective. Administrative claims data were used to study 90-day Medicare (2005-2012) reimbursements for primary ≥3-level PLF for deformity and degenerative conditions of the lumbar spine. Distribution of payments, sources of variation, and reimbursements for managing complications were studied using linear regression models. Risk factors for complications were studied by stepwise multiple-variable logistic regression analysis. Hospital payments comprised 73.8% share of total 90-day payment. Adjusted analysis identified several factors for variation in index hospital payments. The average 90-day Medicare payment for all multilevel PLFs without complications was $35,878 per patient. The additional average cost of treating complications with/without revision surgery within 90 days period ranged from $17,284 to $68,963. A 90-day bundle for ≥3-level PLF with readmission ranges from $88,648 (3 levels) to $117,215 (8+ levels). Rates and risk factors for complications were also identified. The average 90-day payment per patient from Medicare was $35,878 with several factors such as levels of surgery, comorbidities, and development of complications influencing the cost. The study also identifies the risks and costs associated with complications and readmissions and emphasize the significant effect these would have on bundled payments (additional burden of up

Distal junctional failure secondary to L5 vertebral fracture—a report of two rare cases

PubMed Central

Tan, Jiong Hao; Tan, Kimberly-Anne; Wong, Hee-Kit

2017-01-01

Distal junctional failure (DJF) with fracture at the last instrumented vertebra is a rare occurrence. In this case report, we present two patients with L5 vertebral fracture post-instrumented fusion of the lumbar spine. The first patient is a 78-year-old female who had multi-level degenerative disc disease, spinal stenosis and degenerative scoliosis involving levels T12 to L5. She underwent instrumented posterolateral fusion (PLF) from T12 to L5, and transforaminal lumbar interbody fusion (TLIF) at L2/3 and L4/5. Six months after her operation, she presented with a fracture of the L5 vertebral body necessitating revision of the L5 pedicle screws, with additional TLIF of L5/S1. The second patient is a 71-year-old female who underwent decompression and TLIF of L3/4 and L4/5 for degenerative spondylolisthesis. Six months after the surgery, she developed a fracture of the L5 vertebral body with loosening of the L5 screws. The patient declined revision surgery despite being symptomatic. DJF remains poorly understood as its rare incidence precludes sufficiently powered studies within a single institution. This report aims to contribute to the currently scarce literature on DJF. PMID:28435925

Similar Superior Patient-Reported Outcome Measures for Anterior and Posterolateral Approaches After Total Hip Arthroplasty: Postoperative Patient-Reported Outcome Measure Improvement After 3 months in 12,774 Primary Total Hip Arthroplasties Using the Anterior, Anterolateral, Straight Lateral, or Posterolateral Approach.

PubMed

Peters, Rinne M; van Beers, Loes W A H; van Steenbergen, Liza N; Wolkenfelt, Julius; Ettema, Harmen B; Ten Have, Bas L E F; Rijk, Paul C; Stevens, Martin; Bulstra, Sjoerd K; Poolman, Rudolf W; Zijlstra, Wierd P

2018-06-01

Patient-reported outcome measures (PROMs) are used to evaluate the outcome of total hip arthroplasty (THA). We determined the effect of surgical approach on PROMs after primary THA. All primary THAs, with registered preoperative and 3 months postoperative PROMs were selected from the Dutch Arthroplasty Register. Based on surgical approach, 4 groups were discerned: (direct) anterior, anterolateral, direct lateral, and posterolateral approaches. The following PROMs were recorded: Hip disability and Osteoarthritis Outcome Score Physical function Short form (HOOS-PS); Oxford Hip Score; EQ-5D index score; EQ-5D thermometer; and Numeric Rating Scale measuring pain, both active and in rest. The difference between preoperative and postoperative scores was calculated (delta-PROM) and used as primary outcome measure. Multivariable linear regression analysis was performed for comparisons. Cohen's d was calculated as measure of effect size. All examined 4 approaches resulted in a significant increase of PROMs after primary THA in the Netherlands (n = 12,274). The anterior and posterolateral approaches were associated with significantly more improvement in HOOS-PS scores compared with the anterolateral and direct lateral approaches. Furthermore, the posterolateral and anterior approaches showed greater improvement on Numeric Rating Scale pain scores compared with the anterolateral approach. No relevant differences in delta-PROM were seen between the anterior and posterolateral surgical approaches. Anterior and posterolateral surgical approaches showed more improvement in self-reported physical functioning (HOOS-PS) compared with anterolateral and direct lateral approaches in patients receiving a primary THA. However, clinical differences were only small. Copyright © 2018 Elsevier Inc. All rights reserved.

Pre-existing lumbar spine diagnosis as a predictor of outcomes in National Football League athletes.

PubMed

Schroeder, Gregory D; Lynch, T Sean; Gibbs, Daniel B; Chow, Ian; LaBelle, Mark; Patel, Alpesh A; Savage, Jason W; Hsu, Wellington K; Nuber, Gordon W

2015-04-01

It is currently unknown how pre-existing lumbar spine conditions may affect the medical evaluation, draft status, and subsequent career performance of National Football League (NFL) players. To determine if a pre-existing lumbar diagnosis affects a player's draft status or his performance and longevity in the NFL. Cohort study; Level 3. The investigators evaluated the written medical evaluations and imaging reports of prospective NFL players from a single franchise during the NFL Scouting Combine from 2003 to 2011. Players with a reported lumbar spine diagnosis and with appropriate imaging were included in this study. Athletes were then matched to control draftees without a lumbar spine diagnosis by age, position, year, and round drafted. Career statistics and performance scores were calculated. Of a total of 2965 athletes evaluated, 414 were identified as having a pre-existing lumbar spine diagnosis. Players without a lumbar spine diagnosis were more likely to be drafted than were those with a diagnosis (80.2% vs. 61.1%, respectively, P < .001). Drafted athletes with pre-existing lumbar spine injuries had a decrease in the number of years played compared with the matched control group (4.0 vs. 4.3 years, respectively, P = .001), games played (46.5 vs. 50.8, respectively, P = .0001), and games started (28.1 vs. 30.6, respectively, P = .02) but not performance score (1.4 vs. 1.8, respectively, P = .13). Compared with controls, players were less likely to be drafted if they had been diagnosed with spondylosis (62.37% vs. 78.55%), a lumbar herniated disc (60.27% vs. 78.43%), or spondylolysis with or without spondylolisthesis (64.44% vs. 78.15%) (P < .001 for all), but there was no appreciable effect on career performance; however, the diagnosis of spondylolysis was associated with a decrease in career longevity (P < .05). Notably, 2 athletes who had undergone posterior lateral lumbar fusion were drafted. One played in 125 games, and the other is still active and has

Current Concepts of Posterolateral Corner Injuries of the Knee

PubMed Central

Shon, Oog-Jin; Park, Jae-Woo; Kim, Beum-Jung

2017-01-01

The number of posterolateral corner (PLC) injury patients has risen owing to the increased motor vehicle accidents and sports activities. Careful examination is required because this injury is easy to overlook and may lead to chronic instability. The purpose of this article is to review the anatomy, biomechanics, diagnosis, classification and, treatment of PLC injuries and summarize the recent literatures regarding the treatment outcomes. PMID:29172386

ALIF and total disc replacement versus 2-level circumferential fusion with TLIF: a prospective, randomized, clinical and radiological trial.

PubMed

Hoff, Eike K; Strube, Patrick; Pumberger, Matthias; Zahn, Robert K; Putzier, Michael

2016-05-01

Prospective, randomized trial. The treatment of degenerative disc disease (DDD) with two-level fusion has been associated with a reasonable rate of complications. The aim of the present study was to compare (Hybrid) stand-alone anterior lumbar interbody fusion (ALIF) at L5/S1 with total disc replacement at L4/5 (TDR) as an alternative surgical strategy to (Fusion) 2-level circumferential fusion employing transforaminal lumbar interbody fusion (TLIF) with transpedicular stabilization at L4-S1. A total of 62 patients with symptomatic DDD of segments L5/S1 (Modic ≥2°) and L4/5 (Modic ≤2°; positive discography) were enrolled; 31 were treated with Hybrid and 31 with Fusion. Preoperatively, at 0, 12, and a mean follow-up of 37 months, clinical (ODI, VAS) and radiological evaluations (plain/extension-flexion radiographs evaluated for implant failure, fusion, global and segmental lordosis, and ROM) were performed. In 26 of 31 Hybrid and 24 of 31 Fusion patients available at the final follow-up, we found a significant clinical improvement compared to preoperatively. Hybrid patients had significantly lower VAS scores immediately postoperatively and at follow-up compared to Fusion patients. The complication rates were low and similar between the groups. Lumbar lordosis increased in both groups. The increase was mainly located at L4-S1 in the Hybrid group and at L1-L4 in the Fusion group. Hybrid patients presented with increased ROM at L4/5 and L3/4, and Fusion patients presented with increased ROM at L3/4, with significantly greater ROM at L3/4 compared to Hybrid patients at follow-up. Hybrid surgery is a viable surgical alternative for the presented indication. Approach-related inferior trauma and the balanced restoration of lumbar lordosis resulted in superior clinical outcomes compared to two-level circumferential fusion with TLIF.

Screw Placement Accuracy for Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery: A Study on 3-D Neuronavigation-Guided Surgery

PubMed Central

Torres, Jorge; James, Andrew R.; Alimi, Marjan; Tsiouris, Apostolos John; Geannette, Christian; Härtl, Roger

2012-01-01

Purpose The aim of this study was to assess the impact of 3-D navigation for pedicle screw placement accuracy in minimally invasive transverse lumbar interbody fusion (MIS-TLIF). Methods A retrospective review of 52 patients who had MIS-TLIF assisted with 3D navigation is presented. Clinical outcomes were assessed with the Oswestry Disability Index (ODI), Visual Analog Scales (VAS), and MacNab scores. Radiographic outcomes were assessed using X-rays and thin-slice computed tomography. Result The mean age was 56.5 years, and 172 screws were implanted with 16 pedicle breaches (91.0% accuracy rate). Radiographic fusion rate at a mean follow-up of 15.6 months was 87.23%. No revision surgeries were required. The mean improvement in the VAS back pain, VAS leg pain, and ODI at 11.3 months follow-up was 4.3, 4.5, and 26.8 points, respectively. At last follow-up the mean postoperative disc height gain was 4.92 mm and the mean postoperative disc angle gain was 2.79 degrees. At L5–S1 level, there was a significant correlation between a greater disc space height gain and a lower VAS leg score. Conclusion Our data support that application of 3-D navigation in MIS-TLIF is associated with a high level of accuracy in the pedicle screw placement. PMID:24353961

[Efficacy of Coflex in the treatment of lumbar spondylolisthesis].

PubMed

Hai, Y; Meng, X L; Li, D Y; Zhang, X N; Wang, Y S

2017-03-01

Objective: To study the clinical results of Coflex and lumbar posterior decompression and fusion in the treatment of lumbar degenerative spondylolisthesis at L(4-5). Methods: Thirty-eight patients with Grade Ⅰ degenerative spondylolisthesis, from January 2008 to December 2011 in Beijing Chaoyang Hospital, Capital Medical University were reviewed, and patients were divided into two groups by randomness. Group A was treated with Coflex and group B with pedicle instrumentation and interbody fusion. Fifteen patients were included in group A, and 23 patients were included in group B. In group A, the average age was (56.3±9.1) years. In group B, the average age was (58.2±11.2) years. The clinical results were evaluated by visual analogue scale (VAS) and Oswestry disability index (ODI). Slip distance (SD) was measured before and after surgery, and the changes of intervertebral angle at index level and adjacent level were also recorded. Results: The follow-up period was 36 to 68 months, with the average of (39±14) months in the both groups. The operation time and bleeding volume of patients in group A were significantly less than that of group B ( P <0.05). In both groups, the difference of ODI and VAS before operation and postoperative follow-up were statistically significant ( P <0.05). There was no significant difference between lumbar intervertebral angle and the sliding distance in group A at all time points. In the group B, there was a significant increase in the intervertebral angle and the sliding distance at L(3-4) and L(5)-S(1 )level after surgery, the difference at upper and below adjacent segment before and after surgery were statistically significant. Conclusions: Coflex interspinous dynamic stabilization system has same excellent clinical results as pedicle screw instrumentation and fusion surgery for the treatment of L(4-5) degenerative spondylolisthesis; no significant progression of spondylolisthesis been observed during more than 3 years follow

Determining clinical practice of expert physiotherapy for patients undergoing lumbar spinal fusion: a cross-sectional survey study.

PubMed

Janssen, Esther R C; Scheijen, Elle E M; van Meeteren, Nico L U; de Bie, Rob A; Lenssen, Anton F; Willems, Paul C; Hoogeboom, Thomas J

2016-05-01

To determine the content of current Dutch expert hospital physiotherapy practice for patients undergoing lumbar spinal fusion (LSF), to gain insight into expert-based clinical practice. At each hospital where LSF is performed, one expert physiotherapist received an e-mailed questionnaire, about pre- and postoperative physiotherapy and discharge after LSF. The level of uniformity in goals and interventions was graded on a scale from no uniformity (50-60 %) to very strong uniformity (91-100 %). LSF was performed at 34 of the 67 contacted hospitals. From those 34 hospitals, 28 (82 %) expert physiotherapists completed the survey. Twenty-one percent of the respondents saw patients preoperatively, generally to provide information. Stated postoperative goals and administered interventions focused mainly on performing transfers safely and keeping the patient informed. Outcome measures were scarcely used. There was no uniformity regarding advice on the activities of daily living. Dutch perioperative expert physiotherapy for patients undergoing LSF is variable and lacks structural outcome assessment. Studies evaluating the effectiveness of best-practice physiotherapy are warranted.

Development and Validation of a Prediction Model for Pain and Functional Outcomes After Lumbar Spine Surgery.

PubMed

Khor, Sara; Lavallee, Danielle; Cizik, Amy M; Bellabarba, Carlo; Chapman, Jens R; Howe, Christopher R; Lu, Dawei; Mohit, A Alex; Oskouian, Rod J; Roh, Jeffrey R; Shonnard, Neal; Dagal, Armagan; Flum, David R

2018-03-07

Functional impairment and pain are common indications for the initiation of lumbar spine surgery, but information about expected improvement in these patient-reported outcome (PRO) domains is not readily available to most patients and clinicians considering this type of surgery. To assess population-level PRO response after lumbar spine surgery, and develop/validate a prediction tool for PRO improvement. This statewide multicenter cohort was based at 15 Washington state hospitals representing approximately 75% of the state's spine fusion procedures. The Spine Surgical Care and Outcomes Assessment Program and the survey center at the Comparative Effectiveness Translational Network prospectively collected clinical and PRO data from adult candidates for lumbar surgery, preoperatively and postoperatively, between 2012 and 2016. Prediction models were derived for PRO improvement 1 year after lumbar fusion surgeries on a random sample of 85% of the data and were validated in the remaining 15%. Surgical candidates from 2012 through 2015 were included; follow-up surveying continued until December 31, 2016, and data analysis was completed from July 2016 to April 2017. Functional improvement, defined as a reduction in Oswestry Disability Index score of 15 points or more; and back pain and leg pain improvement, defined a reduction in Numeric Rating Scale score of 2 points or more. A total of 1965 adult lumbar surgical candidates (mean [SD] age, 61.3 [12.5] years; 944 [59.6%] female) completed baseline surveys before surgery and at least 1 postoperative follow-up survey within 3 years. Of these, 1583 (80.6%) underwent elective lumbar fusion procedures; 1223 (77.3%) had stenosis, and 1033 (65.3%) had spondylolisthesis. Twelve-month follow-up participation rates for each outcome were between 66% and 70%. Improvements were reported in function, back pain, and leg pain at 12 months by 306 of 528 surgical patients (58.0%), 616 of 899 patients (68.5%), and 355 of 464 patients (76

Postero-Lateral Disc Prosthesis Combined With a Unilateral Facet Replacement Device Maintains Quantity and Quality of Motion at a Single Lumbar Level

PubMed Central