It is unclear whether using artificial cages increases fusion rates compared with use of bone chips alone in posterior lumbar\\u000a interbody fusion for patients with lumbar spondylolisthesis. We hypothesized artificial cages for posterior lumbar interbody\\u000a fusion would provide better clinical and radiographic outcomes than bone chips alone. We assumed solid fusion would provide\\u000a good clinical outcomes. We clinically and radiographically
Ching-Hsiao Yu; Chen-Ti Wang; Po-Quang Chen
... After the cage is inserted, surgeons often use metal screws, plates, and rods to further stabilize the spine. An interbody fusion can be performed using a variety of different ... can only be seen by the white metal markers. Bone graft is in the disk space ...
Although the Brantigan cage and Bagby and Kuslich (BAK) cage have different geometrical characteristics, clinical observations suggest that they are equally effective in restoring disc height and stability across the involved spinal segments. This study was designed to compare their performance as posterior lumbar interbody fusion devices at two levels in fresh ligamentous cadaver lumbar spines (L2–S1). After mounting in
Shih-Tien Wang; Vijay K. Goel; Chong-Yau Fu; Shinichiro Kubo; Woosung Choi; Chien-Lin Liu; Tain-Hsiung Chen
The authors review and compare posterior lumbar interbody fusion (PLIF) with transforaminal lumbar interbody fusion (TLIF).\\u000a A review of the literature is performed wherein the history, indications for surgery, surgical procedures with their respective\\u000a biomechanical advantages, potential complications, and grafting substances are presented. Along with the technical advancements\\u000a and improvements in grafting substances, the indications and use of PLIF and
Chad D. Cole; Todd D. McCall; Meic H. Schmidt; Andrew T. Dailey
Few reports have described the combined use of unilateral pedicle screw fixation and interbody fusion for lumbar stenosis. We retrospectively reviewed 79 patients with lumbar stenosis. The rationale and effectiveness of unilateral pedicle screw fixation were studied from biomechanical and clinical perspectives, aiming to reduce stiffness of the implant. All patients were operated with posterior interbody fusion using a diagonal
Jian Zhao; Feng Zhang; Xiaoqing Chen; Yu Yao
Background contextCurrent surgical trends increasingly emphasize the minimization of surgical exposure and tissue morbidity. Previous research questioned the ability of unilateral pedicle screw instrumentation to adequately stabilize posterior fusion constructs. No study to date has addressed the effects of reduced posterior instrumentation mass on interbody construct techniques. Unilateral surgical exposure for transforaminal lumbar interbody fusion (TLIF) allows ipsilateral pedicle screw
Andrew V. Slucky; Darrel S. Brodke; Kent N. Bachus; John A. Droge; John T. Braun
Posterior lumbar interbody fusion (PLIF) is a popular procedure for treating lumbar canal stenosis with spinal instability,\\u000a and several reports concerning fusion assessment methods exist. However, there are currently no definitive criteria for diagnosing\\u000a a successful interbody fusion in the lumbar spine. We suggested evaluating fusion status using computed tomography (CT) in\\u000a extension position to detect pseudoarthrosis more precisely. The
Hiroaki NakashimaYasutsugu; Yasutsugu Yukawa; Keigo Ito; Yumiko Horie; Masaaki Machino; Shunsuke Kanbara; Daigo Morita; Shiro Imagama; Naoki Ishiguro; Fumihiko Kato
Purpose Although instrumented posterior lumbar interbody fusion (PLIF) has been becoming a popular and effective method for treating\\u000a degenerative lumbar scoliosis, the clinical outcome is rarely reported. We retrospectively evaluated the clinical and radiographic\\u000a outcomes in patients with degenerative lumbar scoliosis after instrumented PLIF.\\u000a \\u000a \\u000a \\u000a \\u000a Materials and methods A total of 58 patient’s clinical characteristics had been reviewed retrospectively including clinical presentations, preoperative
Tai-Hsin Tsai; Tzuu-Yuan Huang; Ann-Shung Lieu; Kung-Shing Lee; Sui-Sum Kung; Cheng-Wei Chu; Shiuh-Lin Hwang
Posterior instrumentations have been used to supplement anterior lumbar interbody fusion with cages. Biomechanical studies on single-level anterior lumbar interbody fusion show that stand-alone cages supplemented with posterior translaminar facet or transfacet screw fixation exhibit comparable stability to those supplemented with pedicle screw/rod fixation, while stability of multilevel anterior lumbar interbody fusion remains mostly unknown. The objectives of this study are to compare the stabilization of three supplemental posterior fixations to two-level anterior lumbar interbody fusion, including translaminar facet fixation, transfacet screw fixation, and pedicle screw/rod fixation. Flexibility tests were conducted on fresh-frozen calf spines with moment up to 8.5 N m in flexion, extension, lateral bending, and axial rotation. Each specimen was tested at three stages: intact, anterior lumbar interbody fusion using Polyetheretherketone (PEEK) interbody cage at L3-L4 and L4-L5, and the same anterior lumbar interbody fusion plus one of the three supplemental posterior fixations. The addition of the supplemental posterior fixation increased stiffness at the fusion levels significantly in flexion (9.9 times), extension (5.4 times), and lateral bending (4.1 times). The pedicle screw/rod and translaminar screw fixations provide approximately 40% higher stiffness than the transfacet screw in lateral bending. The pedicle screw/rod fixation also displayed a trend of superior fixation in extension. Supplemental posterior fixation significantly improved stability of two-level anterior lumbar interbody fusion when compared to the stand-alone cages. Pedicle screw/rod system is still the "gold standard" in providing supplemental stability. However, both translaminar facet screws and transfacet screws are good alternatives to provide adequate fixation. PMID:23662340
Wang, Mei; Tang, Shu-Jie; McGrady, Linda M; Rao, Raj D
Summary ?Objective. To describe a microsurgical modification of the Ray Threaded Fusion Cage (TFC) instrumentation technique for achieving lumbar\\u000a interbody fusion.\\u000a \\u000a ?Technique. The lumbar fusion is established by application of two titanium cages through two different short skin incisions, first\\u000a on one and then on the other side. The spinous processes and the whole interspinous ligament are preserved. Under microscopic\\u000a control,
E. Kotilainen; P. Kotilainen
PURPOSE: Adjacent segment disease (ASD) is an increasing problematic complication following lumbar fusion surgeries. ASD requires appropriate treatment, although there are only few reports on surgery for ASD. This study aimed to clarify surgical outcomes of posterior lumbar interbody fusion (PLIF) for ASD. METHODS: Medical charts of 18 patients who underwent the second (repeat) PLIF for ASD were retrospectively investigated (average follow-up, 40 [27-66] months). Modified Japanese Orthopaedic Association (JOA) score and Whitecloud classification were used as outcome measures. RESULTS: Mean modified JOA score improved from 7.7 just before repeat PLIF to 11.4 at maximum recovery and declined to 10.2 at final follow-up. Mean recovery rate of modified JOA score was 52.9 % at maximum recovery and 31.6 % at final follow-up. According to Whitecloud classification, 17 patients (94 %) were excellent or good and only 1 was fair at maximum recovery, whereas 10 (56 %) were excellent or good, 6 were fair, and 2 were poor at final follow-up. Eight patients (44 %) deteriorated again because of recurrent ASD. Two poor patients underwent a third PLIF. CONCLUSION: PLIF is effective for ASD after PLIF in the short term, although it tends to lead to a high incidence of recurrent ASD. PMID:23775291
Miwa, Toshitada; Sakaura, Hironobu; Yamashita, Tomoya; Suzuki, Shozo; Ohwada, Tetsuo
The technique of posterior lumbar interbody fusion allows decompression of the spinal canal and interbody fusion through\\u000a one posterior incision. A number of techniques exist to achieve additional posterior stability. The literature reports wide\\u000a variation in outcomes for these different techniques. We assessed retrospectively the clinical and radiological outcome of\\u000a posterior lumbar interbody fusion (PLIF) supplemented with an instrumented postero-lateral
B. J. C. Freeman; P. Licina; S. H. Mehdian
Posterior lumbar interbody fusion (PLIF), as recommended with bilateral lumbar interbody cages and pedicle screw fixation, has increased the successful fusion rate to nearly 100%. Presently, a unilateral approach to the disc space with a variant of PLIF, the trans-foraminal interbody fusion is often used. There are few clinical studies of unilateral interbody fusion. The clinical and fusion results of unilateral interbody fusion are important as the usage of trans-foraminal interbody fusion procedure increases. This retrospective study of 26 consecutive patients treated with a unilateral cage asks whether fusion healing and clinical outcome is comparable with that obtained with bilateral cages. In this study, there were no pseudarthroses, instrumentation failures, or significant subsidence at any of the single cage levels. Disc space height and foraminal height were restored by the surgery and maintained at last follow-up. Using Prolo scores, 23/26 patients had clinical success (88%), and 3 were unsuccessful. Fusion was successful at all single cage fusion levels and overall in 23/26 (88%) reviewing all levels of fusion. In conclusion, fusion and clinical success rates were not diminished by the use of a unilateral interbody cage rather than the recommended 2 cages. This retrospective comparative study is a Level III-2 Therapeutic Study investigating the results of unilateral PLIF with a single interbody cage compared with historical series with interbody cages. PMID:17285054
Fogel, Guy R; Toohey, John S; Neidre, Arvo; Brantigan, John W
The ideal surgical treatment of spondylolisthesis still remains controversial. There are several methods of treatment and posterior lumbar interbody fusion (PLIF) is one of them. We analyze the results of spondylolisthesis treated by PLIF in term of radiological union, improvement of pre-operative symptoms like back pain, radiating pain and return to normal activities including that of employment, by the review of the medical records. Total of 72 patients, 20 male and 52 female and the age ranges from 15 to 68 years with the mean age being 44.38 years were included in the study. Thirty (41.66%) patients had isthmic spondylolisthesis, 26 (36.12%) had congenital spondylolisthesis, and 16 (22.22%) cases had degenerative spondylolisthesis. There were 38 (52.77%) cases of grade I, 14 (19.44%) cases of grade II and 20 (27.77%) cases of grade III according to the grading criteria of Meyerding. According to the evaluation criteria used by Stauffer and Coventry, 59 patients (81.94%) got good results, eight patients (11.11%) belonged to the fair group and five cases (6.94%) had the poor results. This study showed that PLIF is one of the effective and reliable techniques for the management of spondylolisthesis. PMID:21991702
Devkota, P; Shrestha, S K; Krishnakumar, R; Renjithkumar, J
Interbody lumbar fusions provide a proven logical solution to diseases of the intervertebral discs by eliminating motion of the segment. Historically, there are many techniques to achieve spinal fusion in the lumbar spine. These include anterior, posterior, and foramenal approaches, often in combination with various internal fixation devices. The surgeon's choice of the approach and mechanical or biological implant is
M. E. Janssen; C. Lam; R. Beckham
The first case of a spinal epidural abscess caused by Roseomonas mucosa following instrumented posterior lumbar fusion is presented. Although rare, because of its highly resistant profile, Roseomonas species should be included in the differential diagnosis of epidural abscesses in both immunocompromised and immunocompetent hosts. PMID:23596239
Maraki, Sofia; Bantouna, Vasiliki; Lianoudakis, Efstratios; Stavrakakis, Ioannis; Scoulica, Efstathia
. ?This study evaluated the bony union obtained through posterior lumbar interbody fusion (PLIF) using Ray's threaded fusion\\u000a cage (TFC) without other instrumentation. We assessed 25 consecutive patients who underwent treatment using this method. A\\u000a bone graft was placed in the cages only. No additional instrumentation, such as a pedicle screw system, was used. The study\\u000a group consisted of 12 men
Takeshi Fuji; Takenori Oda; Yasuji Kato; Satoru Fujita; Masamichi Tanaka
Summary. In posterior lumbar interbody vertebral fusion operations, variously sized, rectangular shaped, defatted, freeze-dried, gas-sterilised\\u000a cortical bone allografts were used in combination with cancellous bone autografts from excised posterior elements. Single-level\\u000a fusion, with or without internal fixation, was undertaken in 38 patients aged 50 years or less with disc herniation or a failed\\u000a discectomy (the younger group) and in 33
M. Kakiuchi; K. Ono
Background contextIn a large series of human patients undergoing open anterior lumbar interbody fusion with a tapered titanium fusion cage, recombinant human bone morphogenetic protein type 2 (rhBMP-2) on an absorbable collagen sponge carrier has been shown to decrease operative time and blood loss, to promote osteoinduction and fusion and to be a safe and effective substitute for iliac crest
Regis W. Haid; Charles L. Branch; Joseph T. Alexander; J. Kenneth Burkus
\\u000a Methods of spinal arthrodesis continue to evolve in efforts to treat back pain. The latest techniques include approaching\\u000a from the anterior, posterior, lateral, and posterolateral. The transforaminal interbody lumbar fusion (TLIF) developed by\\u000a Harms  is a modification of the posterior lumbar interbody fusion (PLIF). The procedure varies primarily in the access\\u000a to the spine, being a unilateral, posterolateral approach
Burak M. Ozgur; Scott C. Berta; Samuel A. Hughes
The purpose of this review is to update the reader on more recent, less invasive lumbar interbody fusion procedures. The article contains a brief history on the development of lumbar interbody fusion methods, as well as the indications and descriptions of the various open and minimally invasive procedures, their complications, and outcomes. In contrast to the more traditional open methods of performing anterior and posterior interbody fusions, surgeons doing the less invasive techniques of transforaminal lumbar interbody fusion, extreme lateral and direct lateral interbody fusion, and the presacral axial approach are reporting less morbidity, shorter hospital stays, high rates of fusion, and improved patient outcomes. Although each technique has a different anatomical plane of approach, the goal is to achieve a solid interbody fusion of the pain generating segment(s) without complications. PMID:23628562
Nasca, Richard J
Sixty consecutive patients undergoing posterior lumbar interbody fusion with a carbon fiber cage and posterolateral fusion using Steffee VSP (Depuy, Raynham, Mass) pedicle screw and plate instrumentation were reviewed. Perioperative complications, operative blood loss, and operative time were evaluated. Six dural tears, three transient sensory deficits, and two cases of deep venous thrombosis were reported. Operative blood loss for primary cases averaged 269 cc for one level and 569 cc for two levels fused. Patients with prior surgery averaged 378 cc for one level and 470 cc for two levels fused. Operative time for primary cases averaged 202 minutes for one level and 251 minutes for two levels fused. Patients with prior surgery required 208 minutes for one level and 251 minutes for two levels fused. Posterior lumbar interbody fusion with instrumented posterolateral fusion can be performed with a low intraoperative complication rate. Blood loss and operative time compare favorably with alternative methods of obtaining 360 degree fusion. Radiographic fusion was obtained in 100% of patients. Outcome analysis revealed 67% excellent or good results. PMID:14577526
Stromberg, Lynn; Toohey, John S; Neidre, Arvo; Ramsey, Michael; Brantigan, John W
In posterior lumbar interbody fusion, cage migrations and lower fusion rates compared to autologous bone graft used in the\\u000a anterior lumbar interbody fusion procedure are documented. Anatomical and biomechanical data have shown that the cage positioning\\u000a and cage type seem to play an important role. Therefore, the aim of the present study was to evaluate the impact of cage positioning
Alexander Abbushi; Mario ?abraja; Ulrich-Wilhelm Thomale; Christian Woiciechowsky; Stefan Nikolaus Kroppenstedt
The aim of the study was to compare clinical and radiological results of treatment thoraco-lumbar spine fractures by short segment transpedicular stabilization accompanied by three techniques of reconstruction: posterior lumbar interbody fusion, vertebral body Daniaux reconstruction and combination of both methods. AO system was used to classify the fractures. Frankel's grade system was used for assessment of neurological deficit on admission and subsequently in the postoperative and follow-up period. The height of the fractured vertebral body and angle of segmental kyphotic deformation was measured on lateral X-ray pre- and post-operatively and at last follow-up. To the retrospective analysis we included 167 patients operated in the Orthopaedic and Traumatology Department, Medical University of Lublin in years 1998-2007. Posterior lumbar interbody fusion was performed in 69 patients (41%), isolated vertebral body Daniaux reconstruction in 82 patients (49%) and combination of both methods was performed in 16 patients (10%). The follow-up period has ranged from 3 to 13 years (mean 6.9 years). The most common type of the fracture was a B type (104 patients -62%), followed by type A (43 patients--26%), and type C (20--patients 12%). The neurological deficit was present in 80 patients. The postoperative neurological improvement was noticed in 37 patients (46%), whereas in 46 patients (54%) neurological status has not changed after the treatment. From 87 patients without neurological symptoms, we observed postoperatively contemporary neurological complications in 11 (12.6%) cases. The biggest correction of fractured vertebral height (mean 0.15) and correction of segmental kyphotic deformity (mean 6.3 degrees) we have noticed in the group of isolated vertebralbody Daniaux reconstruction with use of bone grafts. However in every group of patients we observed significant loss of correction during follow-up period. At the latest follow-up assessment there were no differences in vertebral body height of segmental kyphotic deformation between the analyzed groups of patients. None of analyzed methods of treatment: posterior lumbar interbody fusion, vertebral body Daniaux reconstruction or combination of these methods did not protect from recurrence of kyphotic deformity. PMID:21853908
Weg?owski, Robert; Godlewski, Piotr; Blacha, Jan; Ko?odziej, Robert; Mazurkiewicz, Tomasz
This is a retrospective case series to evaluate clinical variables, complications and outcome of 50 patients who underwent anterior lumbar interbody fusion (ALIF) supplemented with posterior percutaneous pedicle screw fixation for degenerative conditions of the lumbar spine. Twenty-four patients underwent single-level fusion and 26 patients had a two-level fusion for a total of 76 levels fused. The mean lengths of the anterior and posterior (including repositioning) portions of the procedure were 131 and 102 min, respectively. The mean estimated blood loss for the entire procedure was 288 ml. The overall adverse event rate was 12%. The mean VAS score for leg pain, VAS score for back pain and mean ODI all improved postoperatively. This study found that ALIF using allograft bone and rhBMP-2 combined with percutaneous pedicle screw fixation had a high fusion rate and a low incidence of perioperative complications. Patient outcomes showed significant improvements in back and leg pain and physical functioning. PMID:21484538
Anderson, D Greg; Sayadipour, Amirali; Shelby, Kevin; Albert, Todd J; Vaccaro, Alexander R; Weinstein, Michael S
Degenerative disc disease (DDD) causes gradual intervertebral space collapse, concurrent discogenic or facet-induced pain,\\u000a and possible compression radiculopathy. A new minimal invasion procedure of percutaneous posterior-lateral lumbar interbody\\u000a fusion (PPLIF) using a B-Twin stand-alone expandable spinal spacer (ESS) was designed to treat this disease and evaluated\\u000a by follow-up more than 1 year. 12 cases with chronic low back pain and compressive
Lizu Xiao; Donglin Xiong; Qiang Zhang; Jin Jian; Husan Zheng; Yuhui Luo; Juanli Dai; Deren Zhang
\\u000a Anterior lumbar interbody fusion (ALIF) is a method of achieving intersegmental arthrodesis that is indicated for the treatment\\u000a of symptomatic degenerative disease [1, 2]. While ALIF has use for indications involving multiple levels and complex combinations\\u000a of anterior and posterior instrumentation, fusions for degenerative and deformity cases, spondylolisthesis [3, 4], and failed\\u000a posterior surgery with pseudoarthroses, a common indication remains
Henry E. Aryan; Sigurd H. Berven; Christopher P. Ames
OBJECTIVE: We prospectively compared surgical reduction or fusion in situ with posterior lumbar interbody fusion (PLIF) for adult isthmic spondylolisthesis in terms of surgical invasiveness, clinical and radiographical outcomes, and complications. METHODS: From January 2006 to June 2008, 88 adult patients with isthmic spondylolisthesis who underwent surgical treatment in our unit were randomized to reduced group (group 1, n = 45) and in situ group (group 2, n = 43), and followed up for average 32.5 months (range 24-54 months). The clinical and radiographical outcomes were compared between the two groups. RESULTS: The average operative time and blood loss during surgery showed insignificant difference (p > 0.05) between two groups. The radiological outcomes were significantly better in group 1, but there was no significant difference between two groups of clinical outcomes, depicting as VAS, ODI, JOA and patients' satisfaction surveys. Incident rate of surgical complications was similar in two groups, but in group 1 the complication seemed more severe because of two patients with neurological symptoms. CONCLUSIONS: For the adult isthmic spondylolisthesis without degenerative disease in adjacent level, single segment of PLIF with pedicle screw fixation is an effective and safe surgical procedure regardless of whether additional reduction had been conducted or not. Better radiological outcome does not mean better clinical outcome. PMID:23764766
Lian, Xiao-Feng; Hou, Tie-Sheng; Xu, Jian-Guang; Zeng, Bing-Fang; Zhao, Jie; Liu, Xiao-Kang; Yang, Er-Zhu; Zhao, Cheng
Background: With the rise of health care costs, there is increased emphasis on evaluating the cost of a particular surgical procedure for quality adjusted life year (QALY) gained. Recent data have shown that surgical intervention for the treatment of degenerative spondylolisthesis (DS) is as cost-effective as total joint arthroplasty. Despite these excellent outcomes, some argue that the addition of interbody fusion supplemented with bone morphogenetic protein (BMP) enhances the value of this procedure. Methods: This review examines the current research regarding the cost-effectiveness of the surgical management of lumbar DS utilizing interbody fusion along with BMP. Results: Posterolateral spinal fusion with instrumentation for focal lumbar spinal stenosis with DS can provide and maintain improvement in self-reported quality of life. Based on the available literature, including nonrandomized comparative studies and case series, the addition of interbody fusion along with BMP does not lead to significantly better clinical outcomes and increases costs when compared with more routine posterolateral fusion techniques. Conclusions: To enhance the value of the surgical management for DS, costs must decrease or there should be substantial improvement in effectiveness as measured by clinical outcomes. To date, there is insufficient evidence to support the use of interbody fusion devices along with BMP to treat routine cases of focal stenosis accompanied by DS, which are routinely adequately treated utilizing posterolateral fusion techniques.
Moatz, Bradley; Tortolani, P. Justin
Since its inception in the year 2001 the minimally invasive trans-psoas Lateral Lumbar Interbody Fusion (LLIF) approach has gained significant favor among spine surgeons. It is now routinely utilized to treat an array of spinal pathologies including degenerative disc disease, low grade spondylolisthesis, and adult spinal deformity. The intent of this video is to provide a step by step account of the basic procedural details when performing the LLIF procedure for a single level broad based degenerated lumbar disc with herniation. The video can be found here: http://youtu.be/dZFMqmCz6Q8. PMID:23829851
Kanter, Adam S; Gandhoke, Gurpreet S
\\u000a During the past 75 years, surgical technique, spinal instruments and instrumentation, and molecular biology have advanced\\u000a the notion of lumbar interbody fusion from what Mercer1 described, in 1936, as perhaps “technically impossible” to a routine operation with a high rate of success. Pedicle screw\\u000a augmentation of the posterior lateral interbody fusion (PLIF) described by Cloward2 made possible a decompressive operation
Alfred T. Ogden; Richard G. Fessler
The purpose of this study was to compare patients with lumbar spondylolisthesis submitted to two different surgical approaches, and evaluate the results and outcomes in both groups. In a two-year period, 60 adult patients with lumbar spondylolisthesis, both isthmic and degenerative, were submitted to surgery at the Biocor Institute, Brazil. All patients were operated on by the same surgeon (FLRD)
Fernando Luiz Rolemberg Dantas; Mirto Nelso Prandini; Mauro A. T. Ferreira
Posterior lumbar interbody fusion (PLIF) using interbody cages and posterior pedicle screw fixation has increased the successful fusion rate to nearly 100% in the lumbar spine. In the design of the cage, only the surface area of the opening for bone graft contact with the endplates varied with the width of the cage. When space is limited, the 9-mm width cages may be the largest size that can be used. Fusion is potentially compromised by the smaller surface area of bone graft. It is important to study the clinical and fusion success of these narrow cages. The authors report 90 patients who had PLIF with 9-mm Lumbar I/F Cages and pedicle screws. Minimum follow-up was 24 months (range, 2-5 years). Seventy-five patients (83%) had clinical success, and 15 (17%) were clinically unsuccessful. Fusion was successful in 82 patients (91.1%). Fusion success with the 9-mm cage was statistically lower than previously reported for the implant system as a whole (p = .0015). Mechanical failure did not occur with 9-mm cage usage. PMID:19602335
Fogel, Guy R; Toohey, John S; Neidre, Arvo; Brantigan, John W
Study design: ?Retrospective cohort study. Clinical question: ?Do more adult patients affected by low grade isthmic spondylolisthesis have significant clinical and radiological improvement following posterior lumbar interbody fusion (PLIF) than those who receive posterolateral fusion (PLF)? Methods: ?One hundred and fourteen patients affected by adult low grade isthmic spondylolisthesis, treated with posterior lumbar interbody fusion or posterolateral fusion, were reviewed. Clinical outcome was assessed by means of the questionnaires ODI, RMDQ and VAS. Radiographic evaluation included CT, MRI, and x-rays. The results were analyzed using the Student t-test. Results: ?The two groups were similar with respect to demographic and surgical characteristics. At an average follow-up of 62.1 months, 71 patients were completely reviewed. Mean ODI, RMDQ and VAS scores didn't show statistically significant differences. Fusion rate was similar between the two groups (97% in PLIF group, 95% in PLF group). Major complications occurred in 5 of 71 patients reviewed (7%): one in the PLIF group (3.6%), four in the PLF group (9.3%). Pseudarthrosis occurred in one case in the PLIF group (3,6%) and in two cases in PLF group (4.6%). Conclusions: ?In our series, there does not appear to be a clear advantage of posterior lumbar interbody fusion (PLIF) over posterolateral fusion (PLF) in terms of clinical and radiological outcome for treatment of adult low grade isthmic spondylolisthesis. PMID:23544021
Barbanti Bròdano, G; Lolli, F; Martikos, K; Gasbarrini, A; Bandiera, S; Greggi, T; Parisini, P; Boriani, S
Study Design Prospective longitudinal study. Purpose To determine if preoperative psychological status affects outcome in spinal surgery. Overview of Literature Low back pain is known to have a psychosomatic component. Increased bodily awareness (somatization) and depressive symptoms are two factors that may affect outcome. It is possible to measure these components using questionnaires. Methods Patients who underwent posterior interbody fusion (PLIF) surgery were assessed preoperatively and at follow-up using a self-administered questionnaire. The visual analogue scale (VAS) for back and leg pain severity and the Oswestry Disability Index (ODI) were used as outcome measures. The psychological status of patients was classified into one of four groups using the Distress and Risk Assessment Method (DRAM); normal, at-risk, depressed somatic and distressed depressive. Results Preoperative DRAM scores showed 14 had no psychological disturbance (normal), 39 were at-risk, 11 distressed somatic, and 10 distressed depressive. There was no significant difference between the 4 groups in the mean preoperative ODI (analysis of variance, p = 0.426). There was a statistically and clinically significant improvement in the ODI after surgery for all but distressed somatic patients (9.8; range, -5.2 to 24.8; p = 0.177). VAS scores for all groups apart from the distressed somatic showed a statistically and clinically significant improvement. Our results show that preoperative psychological state affects outcome in PLIF surgery. Conclusions Patients who were classified as distressed somatic preoperatively had a less favorable outcome compared to other groups. This group of patients may benefit from formal psychological assessment before undergoing PLIF surgery.
Lakkol, Sandesh; Budithi, Chakra; Bhatia, Chandra; Krishna, Manoj
The authors describe a hybrid technique that involves a combination of open decompression and posterior lumbar interbody fusion (PLIF) and percutaneously inserted pedicle screws. This technique allows performance of PLIF and decompression via a midline incision and approach without compromising operative time and visualization. Furthermore, compared to standard open decompression, this approach reduces post-operative wound pain because the small midline incision significantly reduces muscle trauma by obviating the need to dissect the paraspinal muscles off the facet joint complex and by avoiding posterolateral fusion, thus requiring limited lateral muscle dissection off the transverse processes. A series of patients with Grade I-II spondylolisthesis at L4-5 and moderate-severe canal/foraminal stenosis underwent midline PLIF at L4-5, with closure of the midline incision. Percutaneous pedicle screws were inserted, thereby minimizing local muscle trauma, reduction of the spondylolisthesis being performed by using a pedicle screw construct. Rods were inserted percutaneously to link the L4 and L5 pedicle screws. Image intensification was used to confirmed satisfactory screw placement and reduction of spondylolisthesis. The results of a prospective study comparing a standard open decompression and fusion technique for spondylolisthesis versus the minimally invasive hybrid technique are discussed. The minimally invasive technique resulted in shorter hospital stay, earlier mobilization and reduced postoperative narcotic usage. The long-term clinical outcomes were equivalent in the two groups. PMID:23658050
Mobbs, Ralph J; Sivabalan, Praveenan; Li, Jane; Wilson, Peter; Rao, Prashanth J
The unilateral transforaminal approach for lumbar interbody fusion as an alternative to the anterior (ALIF) and traditional posterior lumbar interbody fusion (PLIF) combined with pedicle screw instrumentation is gaining in popularity. At present, a prospective study using a standardized tool for outcome measurement after the transforaminal lumber interbody fusion (TLIF) with a follow-up of at least 3 years is not available
Lars Hackenberg; Henry Halm; Viola Bullmann; Volker Vieth; Marc Schneider; Ulf Liljenqvist
Study design: A prospective clinical study of posterior lumbar interbody fusion in grade I and II degenerative spondylolisthesis was conducted between Mar 2007 and Aug 2008. Purpose: The objective was to assess the clinicoradiological profile of structural v/s nonstructural graft on intervertebral disc height and its consequences on the low back pain (LBP) assessed by Visual analog score (VAS) score and oswestry disability index (ODI) . This study involved 28 patients. Inclusion criteria: Age of 30–70 years, symptomatic patient with disturbed Activities of daily living (ADL), single-level L4/L5 or L5/S1 grade I or grade II degenerative spondylolisthesis. Exclusion criteria: Patients with osteoporosis, recent spondylodiscitis, subchondral sclerosis, visual and cognitive impairment and all other types of spondylolisthesis. All the patients underwent short-segment posterior fixation using CD2 or M8 instrumentation, laminectomy discectomy, reduction and distraction of the involved vertebral space. In 53.5% (n = 15) of the patients, snugly fitted local bone chips were used while in 46.4% (n = 13) of the patients, cage was used. Among the cage group, titanium cage was used in nine (32.1%) and PEEK cages were used in four (14.2%) patients. In one patient, a unilateral PEEK cage was used. The mean follow-up period was 24 months. Among the 28 patients, 67.8% (n = 19) were females and 32.14% (n = 9) were males. 68.24% (n = 18) had L4/L5 and 35.71% (n = 10) had L5/S1 spondylolisthesis. 39.28% (n = 11) were of grade I and 60.71% (n = 17) were of grade II spondylolisthesis. Conclusions: There was a statistically significant correlation (P < 0.012 and P < 0.027) between the change in disc height achieved and the improvement in VAS score in both the graft group and the cage group. The increment in disc height and VAS score was significantly better in the cage group (2 mm ± SD vis-a-vis 7.2 [88%]) than the graft group (1.2 mm ± SD vis-a-vis 5 [62 %]).
Abdul, Q. R.; Qayum, M. S.; Saradhi, M. V.; Panigrahi, M. K.; Sreedhar, V.
Purpose of study: Transforaminal lumbar interbody fusion (TLIF) represents an increasingly popular alternative to the traditional anterior-posterior spinal fusion and posterior lumbar interbody fusion (PLIF) technique in the treatment of patients with spondylolisthesis. Previous reports have demonstrated a reduction in perioperative complications and cost. To date, however, no reports have been published demonstrating long-term efficacy of TLIF in stabilizing and
Scott Daffner; Josh Auerbach; Alan Hilibrand; Alexander Vaccaro; Todd Albert
Summary.\\u000a Background: The aim of using interbody fusion cages is to distract the degeneratively decreased disc height to decompress the neural\\u000a structures in the intervertebral foramina and allow bony fusion. Prerequisite for a successful fusion therapy is a high resistance\\u000a against subsidence and breakage. \\u000a \\u000a \\u000a \\u000a Method: Three types of implants, a cylindrical threaded titanium cage (RayTM) (1c), a bullet shaped PEEK
M. Krammer; R. Dietl; C. B. Lumenta; A. Kettler; H.-J. Wilke; A. Büttner; L. Claes
Background contextThe Lumbar I\\/F Cage is a carbon fiber reinforced polymer (CFRP) device designed to separate the mechanical and device functions of interbody fusion. A Investigational Device Exemption (IDE) clinical study of the CFRP cage was conducted during an enrollment period from 1991 to 1993. Based on the 2-year results of this study, the cage was approved by the US
John W. Brantigan; Arvo Neidre; John S. Toohey
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
S. S. Madan; N. R. Boeree
Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups.
Schwender, James D.; Safriel, Yair; Gilbert, Thomas J.; Mehbod, Amir A.; Denis, Francis; Transfeldt, Ensor E.; Wroblewski, Jill M.
Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups. PMID:19125304
Faundez, Antonio A; Schwender, James D; Safriel, Yair; Gilbert, Thomas J; Mehbod, Amir A; Denis, Francis; Transfeldt, Ensor E; Wroblewski, Jill M
Background: Utilization of the transforaminal lumbar interbody fusion (TLIF) approach for scoliosis offers the patients deformity correction and interbody fusion without the additional morbidity associated with more invasive reconstructive techniques. Published reports on complications associated with these surgical procedures are limited. The purpose of this study was to quantify the intra- and postoperative complications associated with the TLIF surgical approach in patients undergoing surgery for spinal stenosis and degenerative scoliosis correction. Methods: This study included patients undergoing TLIF for degenerative scoliosis with neurogenic claudication and painful lumbar degenerative disc disease. The TLIF technique was performed along with posterior pedicle screw instrumentation. The average follow-up time was 30 months (range, 15–47). Results: A total of 29 patients with an average age of 65.9 years (range, 49–83) were evaluated. TLIFs were performed at 2.2 levels on average (range, 1–4) in addition to 6.0 (range, 4–9) levels of posterolateral instrumented fusion. The preoperative mean lumbar lordosis was 37.6° (range, 16°–55°) compared to 40.5° (range, 26°–59.2°) postoperatively. The preoperative mean coronal Cobb angle was 32.3° (range, 15°–55°) compared to 15.4° (range, 1°–49°) postoperatively. The mean operative time was 528 min (range, 276–906), estimated blood loss was 1091.7 mL (range, 150–2500), and hospitalization time was 8.0 days (range, 3–28). A baseline mean Visual Analog Scale (VAS) score of 7.6 (range, 4–10) decreased to 3.6 (range, 0–8) postoperatively. There were a total of 14 (49%) hardware and/or surgical technique related complications, and 8 (28%) patients required additional surgeries. Five (17%) patients developed pseudoarthrosis. The systemic complications (31%) included death (1), cardiopulmonary arrest with resuscitation (1), myocardial infarction (1), pneumonia (5), and pulmonary embolism (1). Conclusion: This study suggests that although the TLIF approach is a feasible and effective method to treat degenerative adult scoliosis, it is associated with a high rate of intra- and postoperative complications and a long recovery process.
Burneikiene, Sigita; Nelson, E. Lee; Mason, Alexander; Rajpal, Sharad; Serxner, Benjamin; Villavicencio, Alan T.
To evaluate the clinical outcome, effectiveness and safety of the surgical management of traumatic lumbar spondylolisthesis\\u000a with transforaminal lumbar interbody fusion (TLIF) with short segmental instrumentation fixation. A retrospective review of\\u000a a consecutive series of 24 patients with traumatic lumbar spondylolisthesis treated with TLIF procedure was carried out. Intraoperative\\u000a spinal cord monitoring was used to confirm the peripheral neural function
Jian-guang Xu; Bing-fang Zeng; Wei-qing Kong; Wei Zhou; Yi-shan Fu; Bi-zeng Zhao; Tao Zhang; Xiao-feng Lian
Transforaminal lumbar interbody fusion (TLIF) was originally developed as a method for circumferential fusion via a single posterior approach and is now an extremely common procedure for the treatment of lumbar instability. More recently, minimally invasive techniques have been applied to this procedure with the goal of decreasing tissue disruption, blood loss and postoperative patient discomfort. Here we describe a minimally invasive tubular TLIF on a 60-year-old male with radiculopathy from an unstable L4-5 spondylolisthesis. The video can be found here: http://youtu.be/0BbxQiUmtRc. PMID:23829849
Kimball, Jon; Yew, Andrew; Getachew, Ruth; Lu, Daniel C
STUDY DESIGN:: A retrospective study. SUMMARY OF BACKGROUND DATA:: Posterior lumbar interbody fusion (PLIF) increases mechanical stress and can cause degenerative changes at the adjacent segment. However, the precise causes of adjacent segment disease (ASD) after PLIF are not known, and it is unclear whether simultaneous decompression surgery for symptomatic ASD is effective. OBJECTIVE:: To study, radiographically and symptomatically, the risk factors for adjacent segment disease (ASD) in the lumbar spine after L4/5 PLIF and to examine whether decompression surgery for the adjacent segment (L3/4) reduces the occurrence of symptomatic ASD. METHODS:: Fifty-four patients who underwent L4/5 PLIF for L4 degenerative spondylolisthesis and could be followed up for at least 2 years were included. Of these, 37 were treated simultaneously with decompression surgery at L3/4. We measured radiographic changes and assessed symptoms from the cranial adjacent segment. RESULTS:: Thirty-one patients (57.4%) met radiologic criteria for ASD. The length of follow-up (P=0.004) and simultaneous decompression surgery at L3/4 (P=0.009) were statistically significant factors for radiologic diagnosis of ASD. Seven patients (13.0%) had symptomatic ASD: 6 in the decompression group (16.2%) and 1 in the PLIF-only group (5.9%). Simultaneous decompression surgery did not reduce the incidence of symptomatic ASD (P=0.256). Local lordosis at the fused segment (P=0.005) and the sagittal angle of the facet joint at L3/4 (P=0.024) were statistically significant predictors of symptomatic ASD, which was accompanied by postoperative anterior listhesis above the fused segment (S group, 8.4%±8.0%; nonsymptomatic group: -0.7%±5.0%, P=0.024). CONCLUSIONS:: Patients whose facet joint at the adjacent segment had a more sagittal orientation had postoperative anterior listhesis, which caused symptomatic ASD. Simultaneous decompression surgery without fusion at the adjacent level was not effective for these patients, but rather, there was a possibility that it induced symptomatic ASD. PMID:22460400
Hikata, Tomohiro; Kamata, Michihiro; Furukawa, Mitsuru
The conservative and operative treatment strategies of hematogenous spondylodiscitis in septic patients with multiple risk\\u000a factors are controversial. The present series demonstrates the outcome of 18 elderly patients (median age, 72 years) with\\u000a septic hematogenous spondylodiscitis and intraspinal abscess treated with microsurgical decompression and debridement of the\\u000a infective tissue, followed by posterior stabilization and interbody fusion with iliac crest bone graft
Ralf G. Hempelmann; Eckhardt Mater; Ralph Schön
We report the updated results for a previously evaluated surgical treatment for adult low-grade isthmic spondylolisthesis. In 12 patients a decompressive laminectomy was performed followed by a circumferential fusion using posterior pedicle screw instrumented reduction and staged anterior cage-assisted interbody fusion. Average time to follow-up was 5.6 (range 4.9–6.6) years. The average Oswestry Disability Index at last follow-up was 14
M. Spruit; J. P. W. van Jonbergen; M. de Kleuver
Introduction Previous studies have confirmed the benefits and limitations of the presacral retroperitoneal approach for L5–S1 interbody fusion. The purpose of this study was to determine the safety and effectiveness of the minimally invasive axial lumbar interbody approach (AxiaLIF) for L4–S1 fusion. Methods In this retrospective series, 52 patients from four clinical sites underwent L4–S1 interbody fusion with the AxiaLIF two-level system with minimum 2-year clinical and radiographic follow-up (range: 24–51 months). Outcomes included back pain severity (on a 10-point scale), the Oswestry Disability Index (ODI), and Odom’s criteria. Flexion and extension radiographs, as well as computed tomography scans, were evaluated to determine fusion status. Longitudinal outcomes were assessed with repeated measures analysis of variance. Results Mean subject age was 52 ± 11 years and the male:female ratio was 1:1. Patients sustained no intraoperative bowel or vascular injury, deep infection, or neurologic complication. Median procedural blood loss was 220 cc and median length of hospital stay was 3 days. At 2-year follow-up, mean back pain had improved 56%, from 7.7 ± 1.6 at baseline to 3.4 ± 2.7 (P < 0.001). Back pain clinical success (ie, ?30% improvement from baseline) was achieved in 39 (75%) patients at 2 years. Mean ODI scores improved 42%, from 60% ± 16% at baseline to 35% ± 27% at 2 years (P < 0.001). ODI clinical success (ie, ?30% improvement from baseline) was achieved in 26 (50%) patients. At final follow-up, 45 (87%) patients were rated as good or excellent, five as fair, and two as poor by Odom’s criteria. Interbody fusion observed on imaging was achieved in 97 (93%) of 104 treated interspaces. During follow-up, five patients underwent reoperation on the lumbar spine, including facet screw removal (two), laminectomy (two), and transforaminal lumbar interbody fusion (one). Conclusion The AxiaLIF two-level device is a safe, effective treatment adjunct for patients with L4–S1 disc pathology resistant to conservative treatments.
Tobler, William D; Melgar, Miguel A; Raley, Thomas J; Anand, Neel; Miller, Larry E; Nasca, Richard J
The potential advantages of a mini-open transforaminal interbody fusion (TLIF) operation are reduced blood loss, shorter length of stay, and less soft-tissue trauma compared to the standard open technique. Prior reports from our group and others have demonstrated successful outcomes using MIS techniques in lumbar fusion surgery. In this 3D video, we demonstrate the key steps of the mini-open technique for a transforaminal lumbar interbody fusion using an expandable tubular retractor and contralateral percutaneous screw fixation for the treatment of a multiple recurrent disc herniation. The video demonstrates patient positioning, surgical opening with development of the Wiltse plane, placement of the tubular retractor, pedicle screw placement through both a percutaneous technique and a mini-open technique, decompression of the neural elements, graft insertion, and wound closure. The video can be found here: http://youtu.be/LYRU9lbBdNg. PMID:23829850
Amin, Beejal Y; Tu, Tsung-Hsi; Mummaneni, Praveen V
STUDY DESIGN:: Retrospective Comparative Radiographic Review. OBJECTIVE:: To determine if lateral to prone re-positioning prior to posterior fixation confers additional operative level lordosis in LLIF procedures. SUMMARY OF BACKGROUND DATA:: In a review of 56 consecutive patients who underwent LLIF, there was no statistically significant change in segmental lordosis from lateral to prone once a cage is in place. The greatest lordosis increase was observed after cage insertion. METHODS:: We reviewed 56 consecutive patients who underwent LLIF in the lateral position followed by posterior fixation in the prone position. Eighty-eight levels were fused. Disc space angle was measured on intraoperative C-arm images, and change in operative level segmental lordosis brought about by each of the following was determined: (1) cage insertion, (2) prone re-positioning, and (3) posterior instrumentation. Paired t-test was used to determine significance (?=0.05). RESULTS:: Mean lordosis improvement brought about by cage insertion was 2.6? (P=0.00005). There was a 0.1? mean lordosis change brought about by lateral to prone positioning (P=0.47). Mean lordosis improvement brought about by posterior fixation, including rod compression, was 1.0? (P=0.03). CONCLUSION:: In LLIF procedures, the largest increase in operative level segmental lordosis is brought about by cage insertion. Further lordosis may be gained by placing posterior fixation, including compressive maneuvers. Prone re-positioning after cage placement does not produce any incremental lordosis change. Therefore, posterior fixation may be performed in the lateral position without compromising operative level. PMID:22801455
Yson, Sharon C; Sembrano, Jonathan N; Santos, Edward Rainier G; Luna, Jeffrey Thomas P; Polly, David W
Background Comparatively little is known about the relation between the sagittal vertical axis and clinical outcome in cases of degenerative\\u000a lumbar spondylolisthesis. The objective of this study was to determine whether lumbar sagittal balance affects clinical outcomes\\u000a after posterior interbody fusion. This series suggests that consideration of sagittal balance during posterior interbody fusion\\u000a for degenerative spondylolisthesis can yield high levels of
Mi Kyung Kim; Sun-Ho Lee; Eun-Sang Kim; Whan Eoh; Sung-Soo Chung; Chong-Suh Lee
Background Anterior lumbar interbody fusion (ALIF) has gained widespread popularity for spinal disorders requiring fusion. The purpose\\u000a of this study was to analyze ALIF failures.\\u000a \\u000a \\u000a \\u000a \\u000a Methods The medical records of 223 patients treated with ALIF between January 2007 and June 2008 were retrospectively reviewed. Patients\\u000a with unfavorable outcomes, including subsequent posterior decompression at the index level or poor outcomes after ALIF were
Kyung-Chul Choi; Yong Ahn; Byung-Uk Kang; Joo-Hee Jang; Kyeong-Ki Kim; Yong Hwan Shin; Jong-Oh Choi; Sang-Ho Lee
The aim of this study was to observe the clinical effects of bilateral decompression via vertebral lamina fenestration for lumbar interbody fusion in the treatment of lower lumbar instability. The 48 patients comprised 27 males and 21 females, aged 47–72 years. Three cases had first and second degree lumbar spondylolisthesis and all received bilateral vertebral lamina fenestration for posterior lumbar interbody fusion (PLIF) using a threaded fusion cage (TFC), which maintains the three-column spinal stability. Attention was given to ensure the correct pre-operative fenestration, complete decompression and the prevention of adhesions. After an average follow-up of 26.4 months, the one year post-operative X-ray radiographs suggested that the successful fusion rate was 88.1%, and this was 100% in the two-year post-operative radiographs. Moreover, the functional recovery rate was 97.9%. Bilateral vertebral lamina fenestration for lumbar interbody fusion is an ideal surgical method for the treatment of lower lumbar instability. The surgical method retains the spinal posterior column and middle column and results in full decompression and reliable fusion by a limited yet effective surgical approach.
GUO, SHUGUANG; SUN, JUNYING; TANG, GENLIN
Segmental instability in degenerative disc disease is often treated with anterior lumbar interbody fusion (ALIF). Current\\u000a techniques require an additional posterior approach to achieve sufficient stability. The test device is an implant which consists\\u000a of a PEEK-body and an integrated anterior titanium plate hosting four diverging locking screws. The test device avoids posterior\\u000a fixation by enhancing stability via the locking
Philipp Schleicher; R. Gerlach; B. Schär; C. M. J. Cain; W. Achatz; R. Pflugmacher; N. P. Haas; F. Kandziora
Purpose of study: Workers compensation status is a predictor of clinical outcome in patients undergoing spinal fusion. The intent of this study was to examine the influence of workers compensation status on the chronological outcome of patients undergoing anterior lumbar interbody fusion (ALIF) with intervertebral fusion cages.Methods used: Patients with symptomatic lumbar disc disease were enrolled in prospective studies to
Harvinder Sandhu; Thomas Zdeblick; Kevin Foley; Fengyu Zheng; Safdar Khan
Background. Anterior or posterior interbody fusion is performed to stabilise the mechanically inadequate segment of the lumbar spine. Posterior lumbar interbody fusion allows for simultaneous decompression of the spinal canal and restoration of the sagittal profile. Anterior interbody fusion allows for stabilisation of the segment without opening the spinal canal. The choice of technique has been the subject of much discussion. Material and methods. 111 patients with degenerative discopathy in the lumbar spine were treated surgically with either PLIF (Posterior Lumbar Intervertebral Fusion) or ALIF (Anterior Lumbar Intervertebral Fusion). The former group consisted of patients with nerve root symptoms; the latter, of patient with discogenic spinal pain. The outcomes were evaluated according to the Oswestry Index, the VAS, and patient satisfaction. Results. There were significant differences between groups in clinical presentation and radiological imaging. The main indication in the PLIF group was the need to decompress the nerve root. In the ALIF group, with no need to open the spinal canal, anterior fusion was performed from the extraperitoneal approach. In preliminary outcome analysis postoperative improvement was noted sooner in the ALIF group. Completion of the outcome analysis is in progress to assess the long-term effectiveness of these techniques. Conclusions. In my opinion the emphasis should be placed on early and proper diagnostic assessment allowing for the introduction of appropriate treatment including surgical intervention, at least in some groups of patients. PMID:17675984
Wójcik, Andrzej S
Study Design: A prospective, non-comparative study of 27 patients to evaluate the safety and performance of the Memory Metal Spinal System used in a PLIF procedure in the treatment of spondylolisthesis, symptomatic spinal stenosis or degenerative disc disease (DDD). Objective: To evaluate the clinical performance, radiological outcome and safety of the Memory Metal Spinal System, used in a PLIF procedure, in the treatment of spondylolisthesis, symptomatic spinal stenosis or degenerative disc disease in human subjects. Summary of Background Data: Spinal systems that are currently available for correction of spinal deformities or degeneration such as lumbar spondylosis or degenerative disc disease, use components manufactured from stainless steel or titanium and typically comprise two spinal rods with associated connection devices. The Memory Metal Spinal System consists of a single square spinal rod made from a nickel titanium alloy (Nitinol) used in conjunction with connection devices. Nitinol is characterized by its shape memory effect and is a more flexible material than either stainless steel or titanium. With current systems there is loss of achieved reposition due to the elastic properties of the spine. By using a memory metal in this new system the expectation was that this loss of reposition would be overcome due to the metal’s inherent shape memory properties. Furthermore, we expect a higher fusion rate because of the elastic properties of the memory metal. Methods: Twenty-seven subjects with primary diagnosis of spondylolisthesis, symptomatic spinal stenosis or degenerative disc disease (DDD) were treated with the Memory Metal Spinal System in conjunction with the Brantigan IF® Cage in two consecutive years. Clinical performance of the device was evaluated over 2 years using the Oswestry Disability Index (ODI), Short Form 36 questionnaire (SF-36) and pain visual analogue scale (VAS) scores. Safety was studied by collection of adverse events intra-operative and during the followup. Interbody fusion status was assessed using radiographs and a CT scan. Results: The mean pre-operative ODI score of 40.9 (±14.52) significantly improved to 17.7 (±16.76) at 24 months postoperative. Significant improvement in the physical component from the SF36 questionnaire was observed with increases from the baseline result of 42.4 to 72.7 at 24 months (p<.0001); The emotional component in the SF36 questionnaires mean scores highlighted a borderline significant increase from 56.5 to 81.7 at 24 months (p=0.0441). The average level of leg pain was reduced by more than 50% postoperation (VAS values reduced from 5.7 (±2.45) to 2.2 (±2.76) at 24 month post-operation with similar results observed for back pain. CT indicated interbody fusion rate was not significantly faster compared to other devices in literature. No device related adverse events were recorded in this study. Conclusions: The Memory Metal Spinal System, different from other devices on the market with regard to material and the one rod configuration, is safe and performed very well by improving clinically important outcomes in the treatment of spondylolisthesis, symptomatic spinal stenosis or degenerative disc disease. In addition the data compares favorably to that previously reported for other devices in the literature.
Kok, D; Grevitt, M; Wapstra, FH; Veldhuizen, AG
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.
Rapp, Steven M; Miller, Larry E; Block, Jon E
The immediate stabilization provided by anterior interbody cage fixation is often questioned. Therefore, the role of supplementary\\u000a posterior fixation, particularly minimally invasive techniques such as translaminar screws, is relevant. The purpose of this\\u000a biomechanical study was to determine the immediate three-dimensional flexibility of the lumbar spine, using six human cadaveric\\u000a functional spinal units, in four different conditions: (1) intact, (2)
G. C. Rathonyi; T. R. Oxland; U. Gerich; S. Grassmann; L.-P. Nolte
Spondylolisthesis is a heterogeneous disorder characterized by subluxation of a vertebral body over another in the sagittal plane. Its most common form is isthmic spondylolisthesis (IS). This study aims to compare clinical outcomes of posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF) with posterior instrumentation in the treatment of IS. We performed a randomized prospective study in which 80 patients out of a total of 85 patients with IS were randomly allocated to one of two groups: PLF with posterior instrumentation (group I) or PLIF with posterior instrumentation (group II). Posterior decompression was performed in the patients. The Oswestry low back pain disability (OLBP) scale and Visual Analogue Scale (VAS) were used to evaluate the quality of life (QoL) and pain, respectively. Fisher's exact test was used to evaluate fusion rate and the Mann-Whitney U test was used to compare categorical data. Fusion in group II was significantly better than in group I (p=0.012). Improvement in low back pain was statistically more significant in group I (p=0.001). The incidence of neurogenic claudication was significantly lower in group I than in group II (p=0.004). In group I, there was no significant correlation between slip Meyerding grade and disc space height, radicular pain, and low back pain. There was no significant difference in post-operative complications at 1-year follow-up. Our data showed that PLF with posterior instrumentation provides better clinical outcomes and more improvement in low back pain compared to PLIF with posterior instrumentation despite the low fusion rate. PMID:22260338
Farrokhi, Majid Reza; Rahmanian, Abdolkarim; Masoudi, Mohammad Sadegh
Radiographic Adjacent Segment Degeneration at Five Years After L4/5 Posterior Lumbar Interbody Fusion With Pedicle Screw Instrumentation: Evaluation by Computed Tomography and Annual Screening With Magnetic Resonance Imaging.
STUDY DESIGN:: Retrospective clinical study. OBJECTIVE:: To investigate adjacent segment degeneration (ASD) at 5 years after L4/5 posterior lumbar interbody fusion (PLIF) with pedicle screw instrumentation and L4/5 decompression surgery using plain radiographs, CT and MRI, with evaluation of annual changes on MRI. SUMMARY OF BACKGROUND DATA:: Methods of evaluation have been inconsistent among studies of ASD. There is no report that ASD in the lumbar spine after PLIF at the same level is thoroughly evaluated on radiographs, CT, annual MRI changes, and the impact of decompression procedures. METHODS:: ASD was evaluated in 52 patients. Disc height, vertebral slip, intervertebral angle, and intervertebral range of motion were examined on plain radiographs. Facet joint degeneration on CT, and disc degradation and spinal stenosis on MRI were classified into categories, and facet sagittalization and tropism were measured on CT. The incidence of ASD was compared between decompression procedures. RESULTS:: The radiographic changes observed in the study were defined as radiographic ASD (R-ASD) without reoperation, since no patient required reoperation. R-ASD was rarely detected by radiography. At the L3/4 and L5/S1 levels, the incidences of facet joint degeneration, MRI-detected disc degeneration, and spinal stenosis were 21% and 23%, 27% and 17%, and 35% and 4%, respectively. Progressive disc degeneration at L3/4 was found significantly more frequently in patients with aggravation of facet degeneration (P<0.01); however, the severities of preoperative facet degeneration, facet sagittalization and tropism were not associated with progressive disc degeneration or spinal stenosis. In annual MRI, most R-ASD cases were detected within 3 years after surgery. Patients who underwent L4 total laminectomy had significantly more frequent R-ASD compared to those who received bilateral fenestration at L4/5 (P<0.01). CONCLUSION:: R-ASD was detected more frequently by CT and MRI than radiography. Preoperative facet joint degeneration and morphology were not always related to progressive disc degeneration or spinal stenosis. Annual MRI suggested that accelerated degeneration was due to lumbar spine fusion, rather than aging degeneration. Decompression with preservation of posterior connective components is recommended to prevent R-ASD. PMID:23429323
Imagama, Shiro; Kawakami, Noriaki; Kanemura, Tokumi; Matsubara, Yuji; Tsuji, Taichi; Ohara, Tetsuya; Katayama, Yoshito; Ishiguro, Naoki
BackgroundMinimally disruptive approaches to the anterior lumbar spine continue to evolve in a quest to reduce approach-related morbidity. A lateral retroperitoneal, trans-psoas approach to the anterior disc space allows for complete discectomy, distraction, and interbody fusion without the need for an approach surgeon.
Burak M. Ozgur; Henry E. Aryan; Luiz Pimenta; William R. Taylor
BACKGROUND:: Anterior lumbar interbody fusion (ALIF) and posterior lumbar interbody fusion (PLIF) surgery using one cage have been shown to have similar biomechanics compared to the use of two cages. However, there have been no reports on the biomechanical differences between using one versus two cages in transforaminal lumbar interbody fusion (TLIF) surgery. OBJECTIVE:: To determine the biomechanical differences between the use of one versus two cages in TLIF by finite element analysis. METHODS:: Three validated finite element models of L3-L5 lumbar segment were created [intact model (INT), single cage and paired cages TLIF models]. To study the biomechanics, a compressive preload of 400 N over 7.5 N-m was applied to the superior surfaces of the L3 vertebral body to simulate flexion, extension, rotation, and lateral bending. RESULTS:: There was no significant difference in the range of motion between single cage and paired cages TLIF models, less than 1° for all loading cases. Cage stress was high in the single cage TLIF model under all loading conditions. Bone graft stress was high in the single cage TLIF model. Pedicle screw stress was higher in single cage versus paired cages TLIF. CONCLUSION:: Single cage TLIF approximates biomechanical stability and increases the stress of the bone graft. The use of a single cage may simplify the standard TLIF procedure, shorten operative times, decrease cost, and provide satisfactory clinical outcomes. Thus, single cage TLIF is a useful alternative to traditional two cage TLIF. PMID:23632763
Xu, Hao; Ju, Wen; Xu, Neng; Zhang, Xiaojian; Zhu, Xiaodong; Zhu, Lifan; Qian, Xuefeng; Wen, Fengbiao; Wu, Weidong; Jiang, Fugui
Stand-alone cage for posterior lumbar interbody fusion in the treatment of high-degree degenerative disc disease: design of a new device for an "old" technique. A prospective study on a series of 116 patients.
Chronic lumbar pain due to degenerative disc disease affects a large number of people, including those of fully active age. The usual self-repair system observed in nature is a spontaneous attempt at arthrodesis, which in most cases leads to pseudoarthrosis. In recent years, many possible surgical fusion techniques have been introduced; PLIF is one of these. Because of the growing interest in minimally invasive surgery and the unsatisfactory results reported in the literature (mainly due to the high incidence of morbidity and complications), a new titanium lumbar interbody cage (I-FLY) has been developed to achieve solid bone fusion by means of a stand-alone posterior device. The head of the cage is blunt and tapered so that it can be used as a blunt spreader, and the core is small, which facilitates self-positioning. From 2003 to 2007, 119 patients were treated for chronic lumbar discopathy (Modic grade III and Pfirrmann grade V) with I-FLY cages used as stand-alone devices. All patients were clinically evaluated preoperatively and after 1 and 2 years by means of a neurological examination, visual analogue score (VAS) and Prolo Economic and Functional Scale. Radiological results were evaluated by polyaxial computed tomography (CT) scan and flexion-extension radiography. Fusion was defined as the absence of segmental instability on flexion-extension radiography and Bridwell grade I or II on CT scan. Patients were considered clinical "responders" if VAS evaluation showed any improvement over baseline values and a Prolo value >7 was recorded. At the last follow-up examination, clinical success was deemed to have been achieved in 90.5% of patients; the rate of bone fusion was 99.1%, as evaluated by flexion-extension radiography, and 92.2%, as evaluated by CT scan. Morbidity (nerve root injury, dural lesions) and complications (subsidence and pseudoarthrosis) were minimal. PLIF by means of the stand-alone I-FLY cage can be regarded as a possible surgical treatment for chronic low-back pain due to high-degree DDD. This technique is not demanding and can be considered safe and effective, as shown by the excellent clinical and radiological success rates. PMID:21404031
Costa, Francesco; Sassi, Marco; Ortolina, Alessandro; Cardia, Andrea; Assietti, Roberto; Zerbi, Alberto; Lorenzetti, Martin; Galbusera, Fabio; Fornari, Maurizio
Summary This is a radiographic report of 40 patients (20 men, 20 women) who underwent anterior lumbar interbody fusions (73 levels)\\u000a utilizing a “hybrid” interbody graft composed of femoral cortical allograft (FCA) bone and iliac crest cancellous autograft\\u000a bone. The average age at surgery was 38 years (range 17–64 years), and follow-up averaged 1.4 years (range 1.0–2.4 years).\\u000a Nineteen of the
D. C. Holte; J. P. O'Brien; P. Renton
Outcome after anterior spinal fusion has mainly been studied radiologically and reported fusion rates vary greatly. The aim of this study was to investigate radiological and long-term clinical outcome. The study comprised 120 consecutive patients, operated on during the period 1979–1987, with single-or two-level anterior interbody spinal fusion due to disc degeneration or isthmic spondylolisthesis with lumbar instability. In 64
F. B. Christensen; B. Karlsmose; E. S. Hansen; C. E. Bringer
Purpose To evaluate the clinical outcomes of cantilever transforaminal lumbar interbody fusion (c-TLIF) for upper lumbar diseases. Materials and Methods Seventeen patients (11 males, 6 females; mean ± SD age: 62 ± 14 years) who underwent c-TLIF using kidney type spacers between 2002 and 2008 were retrospectively evaluated, at a mean follow-up of 44.1 ± 12.3 months (2 year minimum). The primary diseases studied were disc herniation, ossification of posterior longitudinal ligament (OPLL), degenerative scoliosis, lumbar spinal canal stenosis, spondylolisthesis, and degeneration of adjacent disc after operation. Fusion areas were L1-L2 (5 patients), L2-L3 (9 patients), L1-L3 (1 patient), and L2-L4 (2 patients). Operation time, blood loss, complications, Japanese Orthopaedic Association (JOA) score for back pain, bone union, sagittal alignment change of fusion level, and degeneration of adjacent disc were evaluated. Results JOA score improved significantly after surgery, from 12 ± 2 to 23 ± 3 points (p < 0.01). We also observed significant improvement in sagittal alignment of the fusion levels, from - 1.0 ± 7.4 to 5.2 ± 6.1 degrees (p < 0.01). Bony fusion was obtained in all cases. One patient experienced a subcutaneous infection, which was cured by irrigation. At the final follow-up, three patients showed degenerative changes in adjacent discs, and one showed corrective loss of fusion level. Conclusion c-TLIF is a safe procedure, providing satisfactory results for patients with upper lumbar degenerative diseases.
Hioki, Akira; Hosoe, Hideo; Sugiyama, Seiichi; Suzuki, Naoki; Shimizu, Katsuji
The procedure of anterior lumbar interbody fusion (ALIF) is commonly performed on patients suffering from pain and/or neurological symptoms associated with disorders of the lumbar spine caused by disc degeneration and trauma. Surgery is indicated when prolonged conservative management proves ineffective. Because an important objective of the ALIF procedure is solid arthrodesis of the degenerative spinal segment, bone graft selection is critical. Iliac crest bone grafts (ICBG) remain the "gold standard" for achieving lumbar fusion. However, patient dissatisfaction stemming from donor site morbidity, lengthier operating times and finite supply of ICBG has prompted a search for better alternatives. Here presented is a literature review evaluating available bone graft options assessed within the clinical setting. These options include autografts, allograft-based, synthetic and cell-based technologies. The emphasis is on the contentious use of recombinant human bone morphogenetic proteins, which is in widespread use and has demonstrated both significant osteogenic potential and risk of complications. PMID:23658041
Mobbs, Ralph J; Chung, Mina; Rao, Prashanth J
Background The increase in the number of anterior lumbar interbody fusions being performed carries with it the potential for the long-term\\u000a complication of adjacent segmental degeneration. While its exact mechanism remains uncertain, adjacent segment degeneration\\u000a has become much more widespread. Using a nonlinear, three-dimensional finite element model to analyze and compare the biomechanical\\u000a influence of anterior lumbar interbody fusion and lumbar
Shujie Tang; Brandon J. Rebholz
Retrospective analysis of 222 cases of degenerative disc disease treated by threaded cage fusion. The objective was to determine the safety and efficiency of lumbar interbody fusions using screwed titanium cages and autogenous bone. Two hundred twenty-two patients had lumbar fusion at 243 levels between L2 and S1, at one or two disc spaces. Main indication was discogenic back pain with radicular leg radiation in degenerative discopathy complicated by disc protusion, segmental canal stenosis with chronic instability or spondylolysthesis of the first degree. Previous failed surgery after discectomy, nonunion or biologically cured discitis were other indications in selected cases. Results were classified as good to excellent in 80%, 15% improved but remained disabled, 5% had minimal or no improvement. Fusion rate was 91% at one year and 96% at 2 years. Peroperative dural tears occurred in 10 patients and transient neurological deficits in 9. A superficial infection occurred in one patient. Reoperation in the first three months included a cage revision in one patient and a foraminotomy in another. Two osteoporotic women needed an additional posterior fixation for kyphotic deformity. In conclusion, lumbar interbody fusion with threaded titanium cages appears to be efficacious with an acceptable rate of complications. Experience up to 7 years confirms that impression. Long term observation is needed before recommending this new method. PMID:11283452
Leclercq, T A; Matgé, G
Background: The posterior lumbar interbody fusion (PLIF) procedure allows restoration of the weight-bearing capacity to a more physiological ventral position and maintenance of disc space height. However, the procedure can be technically difficult and may cause complications. It has always been performed bilater- ally with paired cages; a single central cage has not been commonly used. Methods: Twenty-eight patients who
Kuo-Feng Huang; Tzu-Yung Chen
Numerous studies have assessed lumbar interbody fusion, but little data from direct interbody load measurements exists. This manuscript describes an interbody fusion cage with integrated 4-axis load cell that can simulate implant heights of 13, 15, 17, 19 and 21mm. The calibrated load cell was accurate to within 7.9% for point compressive loads over the central 8mm×8mm region, but up
Constantine K. Demetropoulos; Craig R. Morgan; Dilip K. Sengupta; Harry N. Herkowitz
Background contextIn cases of low back pain associated with biomechanical lumbar instability, anterior interbody fixation can be used as a surgical treatment, but its affect on facet joint capsule strains is unknown.
Jesse S. Little; Allyson Ianuzzi; Jonathan B. Chiu; Avi Baitner; Partap S. Khalsa
Between 2001 and 2005, 43 patients (average age 54.2, range 36–68 years) with recurrent lumbar disc herniation underwent reoperation\\u000a with the transforaminal lumbar interbody fusion (TLIF) technique at our unit. All cases were followed up for 24–72 months\\u000a (mean 45 months) and graded using the Japanese Orthopaedic Association (JOA) score system pre- and post-operation and during\\u000a the follow-up period. The leg pain of
Zhiming Chen; Jie Zhao; AiGang Liu; Jiandong Yuan; Zhonghai Li
Iatrogenic lumbar artery pseudoaneurysm is a very rare complication of spinal surgery. To the best of our knowledge, this is the first report of a lumbar artery pseudoaneurysm after extreme lateral interbody fusion (XLIF). The lesion was diagnosed by catheter spinal angiography and was effectively treated with embolization. PMID:20675335
Santillan, Alejandro; Patsalides, Athos; Gobin, Y Pierre
Minimally invasive approaches for lumbar interbody fusion have been popularized in recent years. The retroperitoneal transpsoas approach to the lumbar spine is a technique that allows direct lateral access to the intervertebral disc space while mitigating the complications associated with traditional anterior or posterior approaches. However, a common complication of this procedure is iatrogenic injury to the psoas muscle and surrounding nerves, resulting in postsurgical motor and sensory deficits. The TranS1 VEO system (TranS1 Inc, Raleigh, NC, USA) utilizes a novel, minimally invasive transpsoas approach to the lumbar spine that allows direct visualization of the psoas and proximal nerves, potentially minimizing iatrogenic injury risk and resulting clinical morbidity. This paper describes the clinical uses, procedural details, and indications for use of the TranS1 VEO system.
Hardenbrook, Mitchell A; Miller, Larry E; Block, Jon E
Minimally invasive approaches for lumbar interbody fusion have been popularized in recent years. The retroperitoneal transpsoas approach to the lumbar spine is a technique that allows direct lateral access to the intervertebral disc space while mitigating the complications associated with traditional anterior or posterior approaches. However, a common complication of this procedure is iatrogenic injury to the psoas muscle and surrounding nerves, resulting in postsurgical motor and sensory deficits. The TranS1 VEO system (TranS1 Inc, Raleigh, NC, USA) utilizes a novel, minimally invasive transpsoas approach to the lumbar spine that allows direct visualization of the psoas and proximal nerves, potentially minimizing iatrogenic injury risk and resulting clinical morbidity. This paper describes the clinical uses, procedural details, and indications for use of the TranS1 VEO system. PMID:23766663
Hardenbrook, Mitchell A; Miller, Larry E; Block, Jon E
Degenerative lumbar spinal stenosis (DLSS) has become increasingly common and is characterized by multilevel disc herniation and lumbar spondylolisthesis, which are difficult to treat. The current study aimed to evaluate the short-term clinical outcomes and value of the combined use of microendoscopic discectomy (MED) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for the treatment of multilevel DLSS with spondylolisthesis, and to compare the combination with traditional posterior lumbar interbody fusion (PLIF). A total of 26 patients with multilevel DLSS and spondylolisthesis underwent combined MED and MI-TLIF surgery using a single cage and pedicle rod-screw system. These cases were compared with 27 patients who underwent traditional PLIF surgery during the same period. Data concerning incision length, surgery time, blood loss, time of bed rest and Oswestry Disability Index (ODI) score prior to and following surgery were analyzed statistically. Statistical significance was reached in terms of incision length, blood loss and the time of bed rest following surgery (P<0.05), but there was no significant difference between the surgery time and ODI scores of the two groups. The combined use of MED and MI-TLIF has the advantages of reduced blood loss, less damage to the paraspinal soft tissue, shorter length of incision, shorter bed rest time, improved outcomes and shorter recovery times and has similar short-term clinical outcomes to traditional PLIF.
WU, HAN; YU, WEI-DONG; JIANG, RUI; GAO, ZHONG-LI
Background: The objective of this study was to determine the utility of balloon-assisted endoscopic retroperitoneal gasless\\u000a (BERG) exposure for anterior lumbar interbody fusion (ALIF) with a variety of interbody fusion devices. Methods: Between January\\u000a 1998 and February 2002, 46 individuals underwent (ALIF) with a variety of devices, including cylindrical cages, femoral ring\\u000a allografts, and Synmesh (Synthes, Philadelphia, PA, USA) cages.
R. M. Vazquez; G. T. Gireesan
There is increasing interest in the use of pelvic indices to evaluate sagittal balance and predict outcomes in patients with spinal disease. Conventional posterior lumbar fusion techniques may adversely affect lumbar lordosis and spinal balance. Minimally invasive fusion of the lumbar spine is rapidly becoming a mainstay of treatment of lumbar degenerative disc disease. To our knowledge there are no studies evaluating the effect of extreme lateral interbody fusion (XLIF) on pelvic indices. Hence, our aim was to study the effect of XLIF on pelvic indices related to sagittal balance, and report the results of a prospective longitudinal clinical study and retrospective radiographic analyses of patients undergoing XLIF in a single centre between January 2009 and July 2011. Clinical outcomes are reported for 30 patients and the retrospective analyses of radiographic data is reported for 22 of these patients to assess global and segmental lumbar lordosis and pelvic indices. Effect of XLIF on the correction of scoliotic deformity was assessed in 15 patients in this series. A significant improvement was seen in the visual analogue scale score, the Oswestry Disability Index and the Short Form-36 at 2months and 6months (p<0.0001). The mean pelvic index was 48.6°±11.9° (± standard deviation, SD) with corresponding mean sacral slopes and pelvic tilt of 32.0°±10.6° (SD) and 18.0°±9.5 (SD), respectively. XLIF did not significantly affect sacral slope or pelvic tilt (p>0.2). Global lumbar lordosis was not affected by XLIF (p>0.4). XLIF significantly increased segmental lumbar lordosis by 3.3° (p<0.0001) and significantly decreased the scoliotic Cobb angle by 5.9° (p=0.01). We found that XLIF improved scoliosis and segmental lordosis and was associated with significant clinical improvement in patients with lumbar degenerative disc disease. However, XLIF did not change overall lumbar lordosis or significantly alter pelvic indices associated with sagittal balance. Long-term follow-up with a larger cohort will be required to further evaluate the effects of XLIF on sagittal balance. PMID:23375396
Johnson, R D; Valore, A; Villaminar, A; Comisso, M; Balsano, M
BACKGROUND CONTEXT: The lateral transpsoas approach to interbody fusion is gaining popularity because of its minimally invasive nature and resultant indirect neurologic decompression. The acute biomechanical stability of the lateral approach to interbody fusion is dependent on the type of supplemental internal fixation used. The two-hole lateral plate (LP) has been approved for clinical use for added stabilization after cage instrumentation. However, little biomechanical data exist comparing LP fixation with bilateral pedicle screw and rod (PSR) fixation. PURPOSE: To biomechanically compare the acute stabilizing effects of the two-hole LP and bilateral PSR fusion constructs in lumbar spines instrumented with a lateral cage at two contiguous levels. STUDY DESIGN: Biomechanical laboratory study of human cadaveric lumbar spines. METHODS: Eighteen L1-S1 cadaveric lumbar spines were instrumented with lateral cages at L3-L4 and L4-L5 after intact kinematic analysis. Specimens (n=9 each) were allocated for supplemental instrumentation with either LP or PSR. Intact versus instrumented range of motion was evaluated for all specimens by applying pure moments (±7.5 Nm) in flexion/extension, lateral bending (LB) (left+right), and axial rotation (AR) (left+right). Instrumented spines were later subjected to 500 cycles of loading in all three planes, and interbody cage translations were quantified using a nonradiographic technique. RESULTS: Lateral plate fixation significantly reduced ROM (p<.05) at both lumbar levels (flexion/extension: 49.5%; LB: 67.3%; AR: 48.2%) relative to the intact condition. Pedicle screw and rod fixation afforded the greatest ROM reductions (p<.05) relative to the intact condition (flexion/extension: 85.6%; LB: 91.4%; AR: 61.1%). On average, the largest interbody cage translations were measured in both fixation groups in the anterior-posterior direction during cyclic AR. CONCLUSIONS: Based on these biomechanical findings, PSR fixation maximizes stability after lateral interbody cage placement. The nonradiographic technique served to quantify migration of implanted hardware and may be implemented as an effective laboratory tool for surgeons and engineers to better understand mechanical behavior of spinal implants. PMID:23685215
Nayak, Aniruddh N; Gutierrez, Sergio; Billys, James B; Santoni, Brandon G; Castellvi, Antonio E
Posterior lumbar interbody fusion (PLIF) and anterior lumbar interbody fusion (ALIF) have become routine alternatives to intertransverse process fusion. The use of Coblation® (ArthroCare Corporation, Sunnyvale, CA) allows for routine and reproducible removal of cartilaginous endplate down to the bony endplate. Our experience with this new technology is reviewed. The authors used Coblation® to prepare endplates of 10 consecutive patients
Henry E. Aryan; Christopher P. Ames; Bartek Szandera; Andrew D. Nguyen; Frank L. Acosta; William R. Taylor
Background The main indications for surgery for old thoracolumbar fractures are pain, progressive deformity, neurological damage, or increasing neurological deficit. These fractures have been one of the greatest therapeutic challenges in spinal surgery. Anterior, posterior, or combined anterior and posterior procedures have been successful to some extent. As far as we know, there is no report in the literature of transforaminal lumbar interbody fusion (TLIF) for old thoracolumbar fracture and dislocation. Methods Case report. Results A 26-year-old man with old fracture and dislocation of T12/L1 was treated with TLIF. At 12 months' follow-up, multi-slice computed tomography (CT) scans showed that solid fusion had been achieved between T12 and L1. Back pain had resolved completely at 2-year follow-up. Conclusions We performed TLIF for in a man with old fracture and dislocation of T12/L1, with good clinical outcome. TLIF might be an option in the treatment of old thoracolumbar fracture.
Fang, Xiangqian; Fan, Shunwu; Zhao, Xing
The objective of this study is to report eight cases of arterial complication following anterior lumbar interbody fusion (ALIF) and to analyze the data in order to identify possible risk factors. The authors have encountered six cases of common iliac artery occlusion and two cases of acute vasospasm as a complication of ALIF using two different approaches to spine: hypogastric-midline-transperitoneal
Samir S. Kulkarni; Gary L. Lowery; Raymond E. Ross; K. Ravi Sankar; V. Lykomitros
The Wilhelm Tell technique is a novel instrumented anterior lumbar interbody fusion (ALIF) procedure using a specially designed composite carbon fibre cage and a single short-threaded cancellous screw that obliquely passes through the upper adjacent vertebral body, the interbody cage itself and through the lower adjacent vertebral body. This single-stage fusion method, which is in principle a combination of the
Markus Wenger; Emanuel Vogt; Thomas-Marc Markwalder
Study Design This is a retrospective study that was done according to clinical and radiological evaluation. Purpose We analyzed the clinical and radiological outcomes of minimally invasive transforaminal lumbar interbody single level fusion. Overview of Literature Minimally invasive transforaminal lumbar interbody fusion is effective surgical method for treating degenerative lumbar disease. Methods The study was conducted on 56 patients who were available for longer than 2 years (range, 24 to 45 months) follow-up after undergoing minimally invasive transforminal lumbar interbody single level fusion. Clinical evaluation was performed by the analysis of the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) and the Kirkaldy-Willis score. For the radiological evaluation, the disc space height, the segmental lumbar lordotic angle and the whole lumbar lordotic angle were analyzed. At the final follow-up after operation, the fusion rate was analyzed according to Bridwell's anterior fusion grade. Results For the evaluation of clinical outcomes, the VAS score was reduced from an average of 6.7 prior to surgery to an average of 1.8 at the final follow-up. The ODI was decreased from an average of 36.5 prior to surgery to an average of 12.8 at the final follow-up. In regard to the clinical outcomes evaluated by the Kirkaldy-Willis score, better than good results were obtained in 52 cases (92.9%). For the radiological evaluation, the disc space height (p = 0.002), and the whole lumbar lordotic angle (p = 0.001) were increased at the final follow-up. At the final follow-up, regarding the interbody fusion, radiological union was obtained in 54 cases (95.4%). Conclusions We think that if surgeons become familiar with the surgical techniques, this is a useful method for minimally invasive spinal surgery.
Chung, Hung-Tae; Kim, Dong-Jun; Kim, Sang-Hyuk; Jeon, Sang-Ho
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. PMID:20938787
Kepler, Christopher K; Bogner, Eric A; Herzog, Richard J; Huang, Russel C
STUDY DESIGN:: Retrospective radiographic analysis. OBJECTIVE:: To determine which lumbar interbody technique is most effective for restoring lordosis, increasing disc height, and reducing spondylolisthesis. SUMMARY OF BACKGROUND DATA:: 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 disc height, and reduce spondylolisthesis. METHODS:: Lumbar interbody fusion techniques were retrospectively compared in terms of improvement of lordosis, disc height, and spondylolisthesis between preoperative and follow-up lateral radiographs. RESULTS:: Two hundred twenty 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°) and lateral (2.2°) groups significantly improved lordosis from preoperative to follow-up, while the transforaminal (0.8°) 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 disc height more than the transforaminal (0.5 mm) group. All three groups significantly reduced spondylolisthesis, with no difference between the groups. CONCLUSION:: 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 other groups. The anterior and lateral groups had significantly increased disc height compared to the transforaminal group. All three groups significantly reduced spondylolisthesis, with no difference between the groups. PMID:23511641
Watkins, Robert G; Hanna, Robert; Chang, David; Watkins, Robert G
Of 46 patients who underwent a lumbar or lumbo-sacral anterior interbody fusion at one or two levels, 16 were available for a follow-up of 16-20 years. The indications for operation were instability, degenerative disc disease, pseudarthrosis of a posterior fusion, and spondylolisthesis. Preoperative roentgenograms were compared with those made at follow-up 16 years (or more) later. In only a minority of patients was discopathy or instability found. The roentgenographic findings of the operated patients at a follow-up of at least 16 years were compared with those of a group of age- and sex-matched controls not previously treated for backache. We found that most degenerative changes of the adjacent discs occurred at a rate nearly similar to that in the corresponding levels of the controls. These results may suggest that lumbar anterior interbody spondylodesis does not accelerate the development of degenerative changes in adjacent discs. PMID:1441964
Van Horn, J R; Bohnen, L M
The aim of this study was to compare our experience with minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open midline transforaminal lumbar interbody fusion (TLIF). A total of 36 patients suffering from isthmic spondylolisthesis or degenerative disc disease were operated with either a MITLIF (n = 18) or an open TLIF technique (n = 18) with an average follow-up of 22 and 24 months, respectively. Clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index (ODI). There was no difference in length of surgery between the two groups. The MITLIF group resulted in a significant reduction of blood loss and had a shorter length of hospital stay. No difference was observed in postoperative pain, initial analgesia consumption, VAS or ODI between the groups. Three pseudarthroses were observed in the MITLIF group although this was not statistically significant. A steeper learning effect was observed for the MITLIF group. PMID:19023571
Schizas, Constantin; Tzinieris, Nicolas; Tsiridis, Elefterios; Kosmopoulos, Victor
Minimally invasive lumbar fusion is well described and is reported to offer significant advantages to patients in terms of blood loss, a reduction in post-operative pain and a quicker recovery. However, this technique may expose patients to a greater risk of complications when compared to open lumbar instrumented fusion that may negate these advantages. Between January 2007 and March 2001, we conducted a prospective observational study of 100 consecutive patients (48 males and 52 females, mean age of 54 years) to investigate complications occurring from minimally invasive lumbar interbody fusion surgery using an image-guided technique. All patients underwent post-operative CT scans to assess implant placement. Scanning was repeated at 6 months to assess bony fusion. We observed the following complications: 2.5% (11/435) pedicle screw misplacement, 1.7% (2/120) interbody cage misplacement; 0.8% (1/120) interbody cage migration; 0.8% (1/120) patients requiring a post-operative blood transfusion; 2% (2/100) venous thrombo-embolism and 3% (3/100) patients with complications thought to be related to the use of bone morphogenic protein. There were no occurrences of infection and no cerebrospinal fluid leaks. We concluded that the rate of complications from minimally invasive lumbar interbody fusion is low, and compares favourably with the rates of complication from open procedures. Moreover, computerised navigation systems can be used in place of real-time fluoroscopy to guide implant placement, without an increase in the rate of complications. PMID:23623657
Tsahtsarlis, Antonio; Efendy, Johnny L; Mannion, Richard J; Wood, Martin J
We report a case of thrombotic occlusion of left external iliac artery during the procedure of anterior lumbar interbody fusion.\\u000a The diagnosis was confirmed by computed tomography angiography. The patient also developed severe rhabdomyolysis postoperatively.\\u000a In spite of receiving emergent thromboendarterectomy, the patient expired on postoperative day 3. This report attempts to\\u000a remind spinal surgeons and anesthesiologists of this rare but
Jen-Hsuan Huang; Cheng-Hung Lee; Tzung-chieh Tsai; Shih-Yen Peng
The purpose of this study was to introduce a new approach for anterior lumbar interbody fusion (ALIF) and investigate the advantages, technical pitfalls, and complications of the laparoscopy-assisted mini-open lateral approach. Thirty-five patients with various disease entities were included. Blood loss, operation time, incision size, postoperative time to mobility, length of hospital stay, technical problems, and complications were analyzed. With
Chong Suh Lee; Sung Soo Chung; Kwang Hoon Chung
Anterior lumbar interbody fusion (ALIF) cages are expected to reduce segmental mobility. Current ALIF cages have different\\u000a designs, suggesting differences in initial stability. The objective of this study was to compare the effect of different stand-alone\\u000a ALIF cage constructs and cage-related features on initial segmental stability. Human multi-segmental specimens were tested\\u000a intact and with an instrumented L3\\/4 disc level. Five
Anthony Tsantrizos; Antonios Andreou; Max Aebi; Thomas Steffen
We retrospectively evaluated 488 percutaneous pedicle screws in 110 consecutive patients that had undergone minimally invasive\\u000a transforaminal lumbar interbody fusion (MITLIF) to determine the incidence of pedicle screw misplacement and its relevant\\u000a risk factors. Screw placements were classified based on postoperative computed tomographic findings as “correct”, “cortical\\u000a encroachment” or as “frank penetration”. Age, gender, body mass index, bone mineral density,
Moon-Chan Kim; Hung-Tae Chung; Jae-Lim Cho; Dong-Jun Kim; Nam-Su Chung
Stand-alone cage for posterior lumbar interbody fusion in the treatment of high-degree degenerative disc disease: design of a new device for an “old” technique. A prospective study on a series of 116 patients
Chronic lumbar pain due to degenerative disc disease affects a large number of people, including those of fully active age.\\u000a The usual self-repair system observed in nature is a spontaneous attempt at arthrodesis, which in most cases leads to pseudoarthrosis.\\u000a In recent years, many possible surgical fusion techniques have been introduced; PLIF is one of these. Because of the growing
Francesco Costa; Marco Sassi; Alessandro Ortolina; Andrea Cardia; Roberto Assietti; Alberto Zerbi; Martin Lorenzetti; Fabio Galbusera; Maurizio Fornari
Operative techniques for fusing an unstable por- tion of the lumbar spine or immobilizing a painful vertebral motion segment have been in use for many years. Lumbar fusion procedures initially were used to treat patients with infections (tuberculous spondy- litis) or misaligned spines (isthmic spondylolisthesis) (1-8). Early techniques involving the use of harvested autogenous bone graft without instrumentation were largely
Alan L. Williams; Matthew F. Gornet; J. Kenneth Burkus
Summary ??Study Design. Retrospective analysis of 357 cases of degenerative disc disease treated by interbody fusion with threaded titanium cages.\\u000a \\u000a ?Objective. To determine the safety and efficiency of cervical and lumbar interbody fusions using threaded titanium cages and autogenous\\u000a bone.\\u000a \\u000a \\u000a \\u000a ?Summary of Background Data. Stabilizing the anterior column by interbody fusion, though reported over 50 years ago, is less commonly done
G. Matgé; T. A. Leclercq
The purpose of this study was to determine whether it would be feasible to use oblique lumbar interbody fixation for patients with degenerative lumbar disease who required a fusion but did not have a spondylolisthesis. A series of CT digital images from 60 patients with abdominal disease were reconstructed in three dimensions (3D) using Mimics v10.01: a digital cylinder was superimposed on the reconstructed image to simulate the position of an interbody screw. The optimal entry point of the screw and measurements of its trajectory were recorded. Next, 26 cadaveric specimens were subjected to oblique lumbar interbody fixation on the basis of the measurements derived from the imaging studies. These were then compared with measurements derived directly from the cadaveric vertebrae. Our study suggested that it is easy to insert the screws for L1/2, L2/3 and L3/4 fixation: there was no significant difference in measurements between those of the 3-D digital images and the cadaveric specimens. For L4/5 fixation, part of L5 inferior articular process had to be removed to achieve the optimal trajectory of the screw. For L5/S1 fixation, the screw heads were blocked by iliac bone: consequently, the interior oblique angle of the cadaveric specimens was less than that seen in the 3D digital images. We suggest that CT scans should be carried out pre-operatively if this procedure is to be adopted in clinical practice. This will assist in determining the feasibility of the procedure and will provide accurate information to assist introduction of the screws. PMID:23814253
Wu, A M; Tian, N F; Wu, L J; He, W; Ni, W F; Wang, X Y; Xu, H Z; Chi, Y L
\\u000a Since 1991, when Obenchain described the first laparoscopic lumbar discectomy , the field of minimally invasive spine surgery\\u000a has continued to evolve. Surgeon and patient alike have been attracted by the advantages of minimally invasive surgery, including\\u000a less tissue trauma during the surgical approach, less postoperative pain, shorter hospital stays, and faster return to activities\\u000a of daily living. These reported
Burak M. Ozgur; Lissa C. Baird
Introduction: Patients with spinal injuries have been treated in the past by laminectomy in an attempt to decompress the spinal cord. The results have shown insignificant improvement or even a worsening of neurologic function and decreased stability without effectively removing the anterior bone and disc fragments compressing the spinal cord. The primary indication for anterior decompression and grafting is narrowing of the spinal canal with neurologic deficits that cannot be resolved by any other approach. One must think of subsequent surgical intervention for increased stability and compressive posterior fusion with short-armed internal fixators. Aim: To analyze the results and efficacy of spinal shortening combined with interbody fusion technique for the management of dorsal and lumbar unstable injuries. Materials and Methods: Twenty-three patients with traumatic fractures and or fracture-dislocation of dorsolumbar spine with neurologic deficit are presented. All had radiologic evidence of spinal cord or cauda equina compression, with either paraplegia or paraparesis. Patients underwent recapping laminoplasty in the thoracic or lumbar spine for decompression of spinal cord. The T-saw was used for division of the posterior elements. After decompression of the cord and removal of the extruded bone fragments and disc material, the excised laminae were replaced exactly in situ to their original anatomic position. Then application of a compression force via monosegmental transpedicular fixation was done, allowing vertebral end-plate compression and interbody fusion. Results: Lateral Cobb angle (T10–L2) was reduced from 26 to 4 degrees after surgery. The shortened vertebral body united and no or minimal loss of correction was seen. The preoperative vertebral kyphosis averaged +17 degrees and was corrected to +7 degrees at follow-up with the sagittal index improving from 0.59 to 0.86. The segmental local kyphosis was reduced from +15 degrees to ?3 degrees. Radiography demonstrated anatomically correct reconstruction in all patients, as well as solid fusion. Conclusion: This technique permits circumferential decompression of the spinal cord through a posterior approach and posterior interbody fusion.
Aly, Tarek A
Objective To document lumbar lordosis (LL) of the spine and its change during surgeries with the different height but the same angle setting of the anterior cage. Additionally, we attempted to determine if sufficient LL is achieved at different cage heights and to quantify the change in LL during multi-level anterior lumbar interbody fusion (ALIF). Methods The medical records and radiographs of 42 patients who underwent more than 2 level ALIFs between 2008 and 2009 were retrospectively reviewed. We evaluated 3 parameters seen on lateral whole spine radiographs : LL, pelvic incidence (PI), and sagittal vertical axis (SVA). The mean follow-up time was 28.1 months and the final follow-up radiographs of all patients were reviewed at least 2 years after surgery. Statistical analysis was performed using the paired t-tests. Results Lumbar lordosis had changed up to 30 degrees immediately and 2 years after surgery (preoperative mean LL, SVA : 22.45 degrees, 112.31 mm; immediate postoperative mean LL, SVA : 54.45 degrees, 37.36 mm; final follow-up mean LL, SVA : 49.56 degrees, 26.95 mm). Our goal of LL is to obtain as much PI as possible, preoperative mean PI value was 55.38±3.35. The pre-operative and two year post-surgery follow-up mean of the Japanese Orthopedic Association score were 9.2±0.6 and 13.2±0.6 (favorable outcome rate : 95%), respectively. In addition, we were able to obtain good clinical outcomes and sagittal balance with a subsidence rate of 22.7%. Conclusion We were able to achieve sufficient LL, such that it was similar to the PI, utilizing multi-level ALIF with the use of a tall cage with the same angle setting of the cage. We have found out that achieving sufficient lumbar lordosis and sagittal balance require an anterior lumbar cage with high angle and height.
Suh, Loo-Ree; Kim, Sung-Min; Lim, Young-Jin
Minimally invasive unilateral pedicle screw fixation for the treatment of degenerative lumbar diseases has won the support of many surgeons. However, few data are available regarding clinical research on unilateral pedicle screw fixation associated with minimally invasive techniques for the treatment of lumbar spinal diseases. The purpose of this study was to evaluate clinical outcomes in a selected series of patients with lumbar degenerative diseases treated with minimally invasive unilateral vs classic bilateral pedicle screw fixation and lumbar interbody fusion. Patients in the unilateral group (n=43) underwent minimally invasive unilateral pedicle screw fixation with the Quadrant system (Medtronic, Memphis, Tennessee). The bilateral group (n=42) underwent bilateral instrumentation via the classic approach. Visual analog scale pain scores, Oswestry Disability Index scores, fusion rate, operative time, blood loss, and complications were analyzed. Mean operative time was 75 minutes in the unilateral group and 95 minutes in the bilateral group. Mean blood loss was 220 mL in the unilateral group and 450 mL in the bilateral group. Mean postoperative visual analog scale pain score was 3.10±0.16 in the unilateral group and 3.30±1.10 in the bilateral group. Mean postoperative Oswestry Disability Index score was 15.67±2.3 in the unilateral group and 14.93±2.6 in the bilateral group. Successful fusion was achieved in 92.34% of patients in the unilateral group and 93.56% of patients in the bilateral group. Minimally invasive unilateral pedicle screw fixation is an effective and reliable option for the surgical treatment of lumbar degenerative disease. It causes less blood loss, requires less operative time, and has a fusion rate comparable with that of conventional bilateral fixation. PMID:23937756
Lin, Bin; Xu, Yang; He, Yong; Zhang, Bi; Lin, Qiuyan; He, Mingchang
This video describes a minimally invasive approach for treatment of symptomatic grade I spondylolisthesis and high-grade spinal stenosis. In this procedure, a unilateral approach for bilateral decompression is utilized in conjunction with a modified transforaminal lumbar interbody fusion and percutaneous pedicle screw fixation. The key steps in the procedure are outlined, and include positioning, fluoroscopic positioning/guidance, exposure with tubular retractor system, technique for ipsilateral and contra-lateral decompression, disc space preparation and interbody grafting, percutaneous pedicle screw and rod placement, and closure. The video can be found here: http://youtu.be/QTymO4Cu4B0. PMID:23829853
Chen, Kevin S; Than, Khoi D; Lamarca, Frank; Park, Paul
A randomized double-blind prospective study of pulsed electromagnetic fields for lumbar interbody fusions was performed on 195 subjects. There were 98 subjects in the active group and 97 subjects in the placebo group. A brace containing equipment to induce an electromagnetic field was applied to patients undergoing interbody fusion in the active group, and a sham brace was used in the control group. In the active group there was a 92% success rate, while the control group had a 65% success rate (P greater than 0.005). The effectiveness of bone graft stimulation with the device is thus established.
Mooney, V. (Univ. of California, Irvine (USA))
BackgroundLess invasive fusion approaches, such as extreme lateral interbody fusion (XLIF), have proliferated, but few reports have critically assessed fusion rates. To date, no studies have reported computed tomography (CT) documented fusion rates following XLIF.
W. B. Rodgers; Edward J. Gerber; Jamie R. Patterson
Objective Although unilateral transforaminal lumbar interbody fusion (TLIF) is widely used because of its benefits, it does have some technical limitations. Removal of disk material and endplate cartilage is difficult, but essential, for proper fusion in unilateral surgery, leading to debate regarding the surgery's limitations in removing the disk material on the contralateral side. Therefore, authors have conducted a randomized, comparative cadaver study in order to evaluate the efficiency of the surgery when using conventional instruments in the preparation of the disk space and when using the recently developed high-pressure water jet system, SpineJet™ XL. Methods Two spine surgeons performed diskectomies and disk preparations for TLIF in 20 lumbar disks. All cadaver/surgeon/level allocations for preparation using the SpineJet™ XL (HydroCision Inc., Boston, MA, USA) or conventional tools were randomized. All assessments were performed by an independent spine surgeon who was unaware of the randomizations. The authors measured the areas (cm2) and calculated the proportion (%) of the disk surfaces. The duration of the disk preparation and number of instrument insertions and withdrawals required to complete the disk preparation were recorded for all procedures. Results The proportion of the area of removed disk tissue versus that of potentially removable disk tissue, the proportion of the area of removed endplate cartilage, and the area of removed disk tissue in the contralateral posterior portion showed 74.5 ± 17.2%, 18.5 ± 12.03%, and 67.55 ± 16.10%, respectively, when the SpineJet™ XL was used, and 52.6 ± 16.9%, 22.8 ± 17.84%, and 51.64 ± 19.63%, respectively, when conventional instrumentations were used. The results also showed that when the SpineJet™ XL was used, the proportion of the area of removed disk tissue versus that of potentially removable disk tissue and the area of removed disk tissue in the contralateral posterior portion were statistically significantly high (p < 0.001, p < 0.05, respectively). Also, compared to conventional instrumentations, the duration required to complete disk space preparation was shorter, and the frequency of instrument use and the numbers of insertions/withdrawals were lower when the SpineJet™ XL was used. Conclusion The present study demonstrates that hydrosurgery using the SpineJet™ XL unit allows for the preparation of a greater portion of disk space and that it is less traumatic and allows for more precise endplate preparation without damage to the bony endplate. Furthermore, the SpineJet™ XL appears to provide tangible benefits in terms of disk space preparation for graft placement, particularly when using the unilateral TLIF approach.
Huh, Han-Yong; Ji, Cheol; Ryu, Kyeong-Sik
Transforaminal lumbar interbody fusion (TLIF) is commonly used procedure for spinal fusion. However, there are no reports describing anterior cage dislodgement after surgery. This report is a rare case of anterior dislodgement of fusion cage after TLIF for the treatment of isthmic spondylolisthesis with lumbosacral transitional vertebra (LSTV). A 51-year-old man underwent TLIF at L4-5 with posterior instrumentation for the treatment of grade 1 isthmic spondylolisthesis with LSTV. At 7 weeks postoperatively, imaging studies demonstrated that banana-shaped cage migrated anteriorly and anterolisthesis recurred at the index level with pseudoarthrosis. The cage was removed and exchanged by new cage through anterior approach, and screws were replaced with larger size ones and cement augmentation was added. At postoperative 2 days of revision surgery, computed tomography (CT) showed fracture on lateral pedicle and body wall of L5 vertebra. He underwent surgery again for paraspinal decompression at L4-5 and extension of instrumentation to S1 vertebra. His back and leg pains improved significantly after final revision surgery and symptom relief was maintained during follow-up period. At 6 months follow-up, CT images showed solid fusion at L4-5 level. Careful cage selection for TLIF must be done for treatment of spondylolisthesis accompanied with deformed LSTV, especially when reduction will be attempted. Banana-shaped cage should be positioned anteriorly, but anterior dislodgement of cage and reduction failure may occur in case of a highly unstable spine. Revision surgery for the treatment of an anteriorly dislodged cage may be effectively performed using an anterior approach.
Oh, Hyeong Seok; Lee, Sang-Ho
Transforaminal lumbar interbody fusion (TLIF) is commonly used procedure for spinal fusion. However, there are no reports describing anterior cage dislodgement after surgery. This report is a rare case of anterior dislodgement of fusion cage after TLIF for the treatment of isthmic spondylolisthesis with lumbosacral transitional vertebra (LSTV). A 51-year-old man underwent TLIF at L4-5 with posterior instrumentation for the treatment of grade 1 isthmic spondylolisthesis with LSTV. At 7 weeks postoperatively, imaging studies demonstrated that banana-shaped cage migrated anteriorly and anterolisthesis recurred at the index level with pseudoarthrosis. The cage was removed and exchanged by new cage through anterior approach, and screws were replaced with larger size ones and cement augmentation was added. At postoperative 2 days of revision surgery, computed tomography (CT) showed fracture on lateral pedicle and body wall of L5 vertebra. He underwent surgery again for paraspinal decompression at L4-5 and extension of instrumentation to S1 vertebra. His back and leg pains improved significantly after final revision surgery and symptom relief was maintained during follow-up period. At 6 months follow-up, CT images showed solid fusion at L4-5 level. Careful cage selection for TLIF must be done for treatment of spondylolisthesis accompanied with deformed LSTV, especially when reduction will be attempted. Banana-shaped cage should be positioned anteriorly, but anterior dislodgement of cage and reduction failure may occur in case of a highly unstable spine. Revision surgery for the treatment of an anteriorly dislodged cage may be effectively performed using an anterior approach. PMID:24175028
Oh, Hyeong Seok; Lee, Sang-Ho; Hong, Soon-Woo
Introduction The purpose of this study was to describe procedural details of a minimally invasive presacral approach for revision of an L5-S1 Axial Lumbar Interbody Fusion rod. Case presentation A 70-year-old Caucasian man presented to our facility with marked thoracolumbar scoliosis, osteoarthritic changes characterized by high-grade osteophytes, and significant intervertebral disc collapse and calcification. Our patient required crutches during ambulation and reported intractable axial and radicular pain. Multi-level reconstruction of L1-4 was accomplished with extreme lateral interbody fusion, although focal lumbosacral symptoms persisted due to disc space collapse at L5-S1. Lumbosacral interbody distraction and stabilization was achieved four weeks later with the Axial Lumbar Interbody Fusion System (TranS1 Inc., Wilmington, NC, USA) and rod implantation via an axial presacral approach. Despite symptom resolution following this procedure, our patient suffered a fall six weeks postoperatively with direct sacral impaction resulting in symptom recurrence and loss of L5-S1 distraction. Following seven months of unsuccessful conservative care, a revision of the Axial Lumbar Interbody Fusion rod was performed that utilized the same presacral approach and used a larger diameter implant. Minimal adhesions were encountered upon presacral re-entry. A precise operative trajectory to the base of the previously implanted rod was achieved using fluoroscopic guidance. Surgical removal of the implant was successful with minimal bone resection required. A larger diameter Axial Lumbar Interbody Fusion rod was then implanted and joint distraction was re-established. The radicular symptoms resolved following revision surgery and our patient was ambulating without assistance on post-operative day one. No adverse events were reported. Conclusions The Axial Lumbar Interbody Fusion distraction rod may be revised and replaced with a larger diameter rod using the same presacral approach.
ObjectiveTo evaluate the biomechanics of lumbar motion segments instrumented with stand-alone OptiMesh system augmented with posterior fixation using facet or pedicle screws and the efficacy of discectomy and disc distraction.
Xiujun Zheng; Rahul Chaudhari; Chunhui Wu; Amir A. Mehbod; Serkan Erkan; Ensor E. Transfeldt
PURPOSE. To compare early outcome of transforaminal lumbar interbody fusion (TLIF) for lytic versus degenerative spondylolisthesis. METHODS. 14 women and 8 men aged 20 to 60 (mean, 36) years underwent TLIF for lytic (n=15) or degenerative (n=7) spondylolisthesis. Of the 15 patients with lytic spondylolisthesis, 9 involved L4/ L5 and 6 L5/S1. Of the 7 patients with degenerative spondylolisthesis, 3 involved L4/L5, 2 L5/S1, one L2/L3, and one L3/L4. The spondylolistheses were classified as grade II (n=15), grade III (n=4), and retrolisthesis (n=3). 11 patients with lytic and 2 with degenerative spondylolisthesis had sensory deficits (n=12), motor deficits (n=9), and diminished reflexes (n=7). Visual analogue score (VAS) for pain and the Oswestry Disability Index (ODI) of each patient were assessed at months 3, 6, and 12, and 6 monthly thereafter. Fusion status was assessed by radiologists. Comprehensive outcome of each patient was graded as excellent, good, fair, or poor. RESULTS. The mean VAS score for low back pain improved significantly from 7.4 preoperatively to 2.1 at year 1 (p<0.001), as did the mean VAS score for leg pain from 6.7 to 1.4 (p<0.001) and the mean ODI from 67.8% to 11.8% (p<0.001). No patient had any residual neurological deficit, and all achieved radiological fusion. The comprehensive outcome was excellent in 16 patients, good in 5, and fair in one. 16 patients returned to their previous level of activity. CONCLUSION. TLIF is a safe and effective surgical procedure for the treatment of lytic and degenerative spondylolisthesis. PMID:23255650
Ali, Y; Najmus-Sakeb, N; Rahman, M; Mhamud, S
We retrospectively evaluated 488 percutaneous pedicle screws in 110 consecutive patients that had undergone minimally invasive transforaminal lumbar interbody fusion (MITLIF) to determine the incidence of pedicle screw misplacement and its relevant risk factors. Screw placements were classified based on postoperative computed tomographic findings as "correct", "cortical encroachment" or as "frank penetration". Age, gender, body mass index, bone mineral density, diagnosis, operation time, estimated blood loss (EBL), level of fusion, surgeon's position, spinal alignment, quality/quantity of multifidus muscle, and depth to screw entry point were considered to be demographic and anatomical variables capable of affecting pedicle screw placement. Pedicle dimensions, facet joint arthritis, screw location (ipsilateral or contralateral), screw length, screw diameter, and screw trajectory angle were regarded as screw-related variables. Logistic regression analysis was conducted to examine relations between these variables and the correctness of screw placement. The incidence of cortical encroachment was 12.5% (61 screws), and frank penetration was found for 54 (11.1%) screws. Two patients (0.4%) with medial penetration underwent revision for unbearable radicular pain and foot drop, respectively. The odds ratios of significant risk factors for pedicle screw misplacement were 3.373 (95% CI 1.095-10.391) for obesity, 1.141 (95% CI 1.024-1.271) for pedicle convergent angle, 1.013 (95% CI 1.006-1.065) for EBL >400 cc, and 1.003 (95% CI 1.000-1.006) for cross-sectional area of multifidus muscle. Although percutaneous insertion of pedicle screws was performed safely during MITLIF, several risk factors should be considered to improve placement accuracy. PMID:21720727
Kim, Moon-Chan; Chung, Hung-Tae; Cho, Jae-Lim; Kim, Dong-Jun; Chung, Nam-Su
Minimally invasive lumbar fusion techniques have only recently been developed. The goals of these procedures are to reduce\\u000a approach-related soft tissue injury, postoperative pain and disability while allowing the surgery to be conducted in an effective\\u000a manner. There have been no prospective clinical reports published on the comparison of one-level transforaminal lumbar interbody\\u000a fusion in low-grade spondylolisthesis performed with an
Jian Wang; Yue Zhou; Zheng Feng Zhang; Chang Qing Li; Wen Jie Zheng; Jie Liu
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(?-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. PMID:23897113
Kang, Heesuk; Hollister, Scott J; La Marca, Frank; Park, Paul; Lin, Chia-Ying
Transforaminal lumbar interbody fusion (TLIF) is a relatively new and popular spinal fusion technique that has proven very useful since its introduction. To date, fusion rates for different combinations of modalities and materials have not been thoroughly compared and assessed. In this review of published reports, 29 papers met criteria for assessing fusion rates for three different interbody spacers and four different combinations of bone grafts and extenders. The spacers included Capstone, polyether ether ketones and Telamon cages, and the grafting materials reviewed were locally harvested bone, iliac crest bone with local, local bone plus recombinant human bone morphogenetic protein 2 and a mixture of local and allograft bone. Of these, it was found that only the Capstone cage and locally harvested bone achieved statistically significant higher fusion rates (96.46% ± 2.89% and 97.07% ± 1.94% respectively) than the other modalities and materials studied. Oswestry Disability Index scores and visual pain scales were also examined as indicators of overall improvement after using each spacer and graft; the Telamon cage and local bone mixed with rhBMP-2 stood out as conferring statistically significant greater improvements according to these two scales. Our findings are that Capstone and locally harvested bone alone are relatively superior in terms of fusion rates. PMID:23420741
Heida, Kenneth; Ebraheim, Molly; Siddiqui, Saaid; Liu, Jiayong
The Wilhelm Tell technique is a novel instrumented anterior lumbar interbody fusion (ALIF) procedure using a specially designed composite carbon fibre cage and a single short-threaded cancellous screw that obliquely passes through the upper adjacent vertebral body, the interbody cage itself and through the lower adjacent vertebral body. This single-stage fusion method, which is in principle a combination of the Louis technique and modern cage surgery, is reported to have a lower rate of pseudoarthrosis formation than stand-alone cage techniques. In addition, it eliminates both the surgical trauma of paravertebral muscle retraction and the risk of neural damage by poorly located pedicular screws. This anterior approach allows decompression of neural structures within the anterior part of the spinal canal and the foraminal region. It is the purpose of this case report, to present the successful application of this novel technique in a 32-year-old woman who concurrently suffered from severe instability-related back pain from L4/5 isthmic spondylolisthesis and marked L5/S1 degenerative disc disease. PMID:16459090
Wenger, Markus; Vogt, Emanuel; Markwalder, Thomas-Marc
A surgical sponge or cotton swab that is inadvertently left behind in a surgical wound eventually becomes a "textiloma". Such foreign material (also called "gossypiboma") can cause a foreign-body reaction in the surrounding tissue. Textiloma is mostly asymptomatic in chronic cases, but can be confused with other soft-tissue masses. Therefore, it is important to be aware of patients who present with a paraspinal soft-tissue mass and unusual or atypical symptoms. Imaging is helpful for arriving at the correct diagnosis. Here, we describe a case of textiloma in which the patient presented with low-back pain 6 years after laminectomy and lumbar discectomy. Spinal computed tomography (CT) and magnetic resonance imaging (MRI) revealed a mass lesion in the posterior paravertebral region. PMID:19560822
Naama, O; Quamous, O; Elasri, C A; Boulahroud, O; Belfkih, H; Akhaddar, A; Elmostarchid, B; Elbouzidi, A; Boucetta, M
BACKGROUND: Initial promise of a stand-alone interbody fusion cage to treat chronic back pain and restore disc height has not been realized. In some instances, a posterior spinal fixation has been used to enhance stability and increase fusion rate. In this manuscript, a new stand-alone cage is compared with conventional fixation methods based on the finite element analysis, with a
Shih-Hao Chen; Ching-Lung Tai; Chien-Yu Lin; Pang-Hsing Hsieh; Weng-Pin Chen
Lumbar nerve root anomalies are uncommon phenomena that must be recognized to avoid neural injury during surgery. The authors describe 2 cases of nerve root anomalies encountered during mini-open transforaminal lumbar interbody fusion (TLIF) surgery. One anomaly was a confluent variant not previously classified; the authors suggest that this variant be reflected in an amendment to the Neidre and Macnab classification system. They also propose strategies for identifying these anomalies and avoiding injury to anomalous nerve roots during TLIF surgery. Case 1 involved a 68-year-old woman with a 2-year history of neurogenic claudication. An MR image demonstrated L4-5 stenosis and spondylolisthesis and an L-4 nerve root that appeared unusually low in the neural foramen. During a mini-open TLIF procedure, a nerve root anomaly was seen. Six months after surgery this patient was free of neurogenic claudication. Case 2 involved a 60-year-old woman with a 1-year history of left L-4 radicular pain. Both MR and CT images demonstrated severe left L-4 foraminal stenosis and focal scoliosis. Before surgery, a nerve root anomaly was not detected, but during a unilateral mini-open TLIF procedure, a confluent nerve root was identified. Two years after surgery, this patient was free of radicular pain. PMID:23905960
Burke, Shane M; Safain, Mina G; Kryzanski, James; Riesenburger, Ron I
The efficacy of ‘limited posterior surgery’ for metastases in the thoracic and lumbar spine was studied prospectively in 51 patients (32 men and 19 women, mean age 64 years). The most common primary tumors were prostate, breast, and renal carcinoma, 37 patients had metastases in the thoracic spine and 14 in the lumbar spine. Indications for surgery were severe pain
B. Jónsson; L. Sjöström; C. Olerud; I. Andréasson; J. Bring; W. Rauschning
Minimally invasive lumbar fusion techniques have only recently been developed. The goals of these procedures are to reduce approach-related soft tissue injury, postoperative pain and disability while allowing the surgery to be conducted in an effective manner. There have been no prospective clinical reports published on the comparison of one-level transforaminal lumbar interbody fusion in low-grade spondylolisthesis performed with an independent blade retractor system or a traditional open approach. A prospective clinical study of 85 consecutive cases of degenerative and isthmic lower grade spondylolisthesis treated by minimally invasive transforaminal lumbar interbody fusion (MiTLIF) or open transforaminal lumbar interbody fusion (OTLIF) was done. A total of 85 patients suffering from degenerative spondylolisthesis (n = 46) and isthmic spondylolisthesis (n = 39) underwent one-level MiTLIF (n = 42) and OTLIF (n = 43) by two experienced surgeons at one hospital, from June 2006 to March 2008 (minimum 13-month follow-up). The following data were compared between the two groups: the clinical and radiographic results, operative time, blood loss, transfusion needs, X-ray exposure time, postoperative back pain, length of hospital stay, and complications. Clinical outcome was assessed using the visual analog scale (VAS) and the Oswestry disability index. The operative time, clinical and radiographic results were basically identical in both groups. Comparing with the OTLIF group, the MiTLIF group had significantly lesser blood loss, lesser need for transfusion, lesser postoperative back pain, and shorter length of hospital stay. The radiation time was significantly longer in MiTLIF group. One case of nonunion was observed from each group. Minimally invasive TLIF has similar surgical efficacy with the traditional open TLIF in treating one-level lower grade degenerative or isthmic spondylolisthesis. The minimally invasive technique offers several potential advantages including smaller incisions, less tissue trauma and quicker recovery. However, this technique needs longer X-ray exposure time. PMID:20411281
Wang, Jian; Zhou, Yue; Zhang, Zheng Feng; Li, Chang Qing; Zheng, Wen Jie; Liu, Jie
Introduction Traditional surgical management of lumbosacral spondylolisthesis is technically challenging and is associated with significant complications. The advent of minimally invasive surgical techniques offers 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 offers an alternative procedure for the surgical management of low-grade lumbosacral spondylolisthesis. Case presentation Three patients who had L5-S1 grade 2 spondylolisthesis and who presented with axial pain and lumbar radiculopathy were treated with a minimally invasive surgical technique. The patients-a 51-year-old woman and two men (ages 46 and 50)-were Caucasian. Under fluoroscopic guidance, spondylolisthesis was reduced with a percutaneous pedicle screw system, resulting in interspace distraction. Then, an axial presacral approach with the AxiaLIF System (TranS1, Inc., Wilmington, NC, USA) was used to perform the discectomy and anterior fixation. Once the axial rod was engaged in the L5 vertebral body, further distraction of the spinal interspace was made possible by partially loosening the pedicle screw caps, advancing the AxiaLIF rod to its final position in the vertebrae, and retightening the screw caps. The operative time ranged from 173 to 323 minutes, and blood loss was minimal (50 mL). Indirect foraminal decompression and adequate fixation were achieved in all cases. All patients were ambulatory after surgery and reported relief from pain and resolution of radicular symptoms. No perioperative complications were reported, and patients were discharged in two to three days. Fusion was demonstrated radiographically in all patients at one-year follow-up. Conclusions Percutaneous pedicle screw reduction combined with axial presacral lumbar interbody fusion offers a promising and minimally invasive alternative for the management of lumbosacral spondylolisthesis.
The authors report a case of rectal injury, rectocutaneous fistula, and pseudarthrosis after a TranS1 axial lumbar interbody fusion (AxiaLIF) L5-S1 fixation. The TranS1 AxiaLIF procedure is a percutaneous minimally invasive approach to transsacral fusion of the L4-S1 vertebral levels. It is gaining popularity due to the ease of access to the sacrum through the presacral space, which is relatively free from intraabdominal and neurovascular structures. This 35-year-old man had undergone the procedure for the treatment of degenerative disc disease. The patient subsequently presented with fever, syncope, and foul-smelling gas and bloody drainage from the surgical site. A CT fistulagram and flexible sigmoidoscopy showed evidence of rectocutaneous fistula, which was managed with intravenous antibiotic therapy and bowel rest with total parenteral nutrition. Subsequent studies performed 6 months postoperatively revealed evidence of pseudarthrosis. The patient's rectocutaneous fistula symptoms gradually subsided, but his preoperative back pain recurred prompting a revision of his L5-S1 spinal fusion. PMID:23790047
Siegel, Geoffrey; Patel, Nilesh; Ramakrishnan, Rakesh
Study Design/Objective. A single-centre, prospective, non-comparative study of 25 patients to evaluate the performance and safety of the Memory Metal Minimal Access Cage (MAC) in Lumbar Interbody Fusion. Summary of Background Data. Interbody fusion cages in general are designed to withstand high axial loads and in the meantime to allow ingrowth of new bone for bony fusion. In many cages the contact area with the endplate is rather large leaving a relatively small contact area for the bone graft with the adjacent host bone. MAC is constructed from the memory metal Nitinol and builds on the concept of sufficient axial support in combination with a large contact area of the graft facilitating bony ingrowth and ease in minimal access implantation due to its high deformability. Methods. Twenty five subjects with a primary diagnosis of disabling back and radicular leg pain from a single level degenerative lumbar disc underwent an interbody fusion using MAC and pedicle screws. Clinical performance was evaluated prospectively over 2 years using the Oswestry Disability Index (ODI), Short Form 36 questionnaire (SF-36) and pain visual analogue scale (VAS) scores. The interbody fusion status was assessed using conventional radiographs and CT scan. Safety of the device was studied by registration of intra- and post-operative adverse effects. Results. Clinical performance improved significantly (P < .0018), CT scan confirmed solid fusion in all 25 patients at two year follow-up. In two patients migration of the cage occurred, which was resolved uneventfully by placing a larger size at the subsequent revision. Conclusions. We conclude that the Memory Metal Minimal Access Cage (MAC) resulted in 100% solid fusions in 2 years and proved to be safe, although two patients required revision surgery in order to achieve solid fusion.
Kok, D.; Donk, R. D.; Wapstra, F. H.; Veldhuizen, A. G.
The purpose of this study was to describe the relation of the lumbar plexus with the psoas major and with the superficial\\u000a and deep landmarks close to it. Four cadavers were dissected and 22 computed tomography files of the lumbosacral region studied.\\u000a Cadaver dissections demonstrated that the lumbar plexus, at the level of L5, is within the substance of the
Juliana Farny; Pierre Drolet; Michel Girard
Background Little is known about the biomechanical effectiveness of transforaminal lumbar interbody fusion (TLIF) cages in different positioning and various posterior implants used after decompressive surgery. The use of the various implants will induce the kinematic and mechanical changes in range of motion (ROM) and stresses at the surgical and adjacent segments. Unilateral pedicle screw with or without supplementary facet screw fixation in the minimally invasive TLIF procedure has not been ascertained to provide adequate stability without the need to expose on the contralateral side. This study used finite element (FE) models to investigate biomechanical differences in ROM and stress on the neighboring structures after TLIF cages insertion in conjunction with posterior fixation. Methods A validated finite-element (FE) model of L1-S1 was established to implant three types of cages (TLIF with a single moon-shaped cage in the anterior or middle portion of vertebral bodies, and TLIF with a left diagonally placed ogival-shaped cage) from the left L4-5 level after unilateral decompressive surgery. Further, the effects of unilateral versus bilateral pedicle screw fixation (UPSF vs. BPSF) in each TLIF cage model was compared to analyze parameters, including stresses and ROM on the neighboring annulus, cage-vertebral interface and pedicle screws. Results All the TLIF cages positioned with BPSF showed similar ROM (<5%) at surgical and adjacent levels, except TLIF with an anterior cage in flexion (61% lower) and TLIF with a left diagonal cage in left lateral bending (33% lower) at surgical level. On the other hand, the TLIF cage models with left UPSF showed varying changes of ROM and annulus stress in extension, right lateral bending and right axial rotation at surgical level. In particular, the TLIF model with a diagonal cage, UPSF, and contralateral facet screw fixation stabilize segmental motion of the surgical level mostly in extension and contralaterally axial rotation. Prominent stress shielded to the contralateral annulus, cage-vertebral interface, and pedicle screw at surgical level. A supplementary facet screw fixation shared stresses around the neighboring tissues and revealed similar ROM and stress patterns to those models with BPSF. Conclusions TLIF surgery is not favored for asymmetrical positioning of a diagonal cage and UPSF used in contralateral axial rotation or lateral bending. Supplementation of a contralateral facet screw is recommended for the TLIF construct.
Spontaneous slip reduction of low-grade isthmic spondylolisthesis following circumferential release via bilateral minimally invasive transforaminal lumbar interbody fusion: technical note and short-term outcome.
STUDY DESIGN.: Retrospective clinical data analysis. OBJECTIVE.: To investigate and verify our philosophy of spontaneous slip reduction following circumferential release via bilateral minimally invasive transforaminal lumbar interbody fusion (Mini-TLIF) for treatment of low-grade symptomatic isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA.: Symptomatic isthmic spondylolisthesis usually requires surgical intervention, and the most currently controversial focus is on method and degree of reduction; and Mini-TLIF is an attractive surgical procedure for isthmic spondylolisthesis. METHODS.: Between February 2004 and June 2008, 21 patients with low-grade isthmic spondylolisthesis underwent Mini-TLIF in our institute. Total resection of the scar around the pars interarticularis liberated the nerve roots, achieving posterior release as well. The disc was thoroughly resected, and the disc space was gradually distracted and thoroughly released with sequential disc shavers until rupture of anulus conjunct with anterior longitudinal ligament, accomplishing anterior release, so as to insert Cages. Because of circumferential release, the slipped vertebrae would tend to obtain spontaneous reduction, and with pedicle screw fixation, additional reduction would be achieved without any application of posterior translation force. Radiographs, Visual Analogue Scale, and Oswestry Disability Index were documented. All the cases were followed up for 10 to 26 months. RESULTS.: Slip percentage was reduced from 24.2% ± 6.9% to 10.5% ± 4.0%, and foraminal area percentage increased from 89.1% ± 3.0% to 93.6% ± 2.1%. Visual Analogue Scale and Oswestry Disability Index decreased from 7.8 ± 1.5 to 2.1 ± 1.1 and from 53.3 ± 16.2 to 17.0 ± 7.8, respectively. No neurologic complications were encountered. There were no signs of instrumentation failure. The fusion rate approached 100%. CONCLUSION.: Slip reduction is based on circumferential release. The procedure can be well performed via Mini-TLIF, the outcome of which is equally gratifying to that of instrumented slip reduction and traditional midline approach. There is no need to fully reduce the slipped vertebrae. Circumferential release contributes to achieving spontaneous slip reduction partially, which aids sufficiently in the surgical treatment of low-grade isthmic spondylolisthesis. PMID:20714277
Pan, Jie; Li, Lijun; Qian, Lie; Zhou, Wei; Tan, Jun; Zou, Le; Yang, Mingjie
Lateral interbody fusion techniques are heavily reliant on fluoroscopy for retractor docking and graft placement, which expose both the patient and surgeon to high doses of radiation. Use of image-guided technologies with CT-based images, however, can eliminate this radiation exposure for the surgeon. We describe the surgical technique of performing lateral lumbar interbody fusion using CT navigation. PMID:23931938
Drazin, Doniel; Liu, John C; Acosta, Frank L
Lumbar spinal fusion is advancing with minimally invasive techniques, bone graft alternatives, and new implants. This has\\u000a resulted in significant reductions of operative time, duration of hospitalization, and higher success in fusion rates. However,\\u000a costs have increased as many new technologies are expensive. This study was carried out to investigate the clinical outcomes\\u000a and fusion rates of a low implant
Anil Sethi; Sandra Lee; Rahul Vaidya
The “off label” use of rhBMP-2 in the transforaminal lumbar interbody fusion (TLIF) procedure has become increasingly popular. Although several studies have demonstrated the successful use of rhBMP-2 for this indication, uncertainties remain regarding its safety and efficacy. The purpose of this study is to evaluate the clinical and radiographic outcomes of the single-level TLIF procedure using rhBMP-2. Patients who underwent a single-level TLIF between January 2004 and May 2006 with rhBMP-2 were identified. A retrospective evaluation of these patients included operative report(s), pre- and postoperative medical records, and dynamic and static lumbar radiographs. Patient-reported clinical outcome measures were obtained from a telephone questionnaire and included a modification of the Odom’s criteria, a patient satisfaction score, and back and leg pain numeric rating scale scores. Forty-eight patients met the study criteria and were available for follow-up (avg. radiographic and clinical follow-up of 19.4 and 27.4 months, respectively). Radiographic fusion was achieved in 95.8% of patients. Good to excellent results were achieved in 71% of patients. On most recent clinical follow-up, 83% of patients reported improvement in their symptoms and 84% reported satisfaction with their surgery. Twenty-nine patients (60.4%) reported that they still had some back pain, with an average back pain numeric rating score of 2.8. Twenty patients (41.7%) reported that they still had some leg pain, with an average leg pain numeric rating score was 2.4. Thirteen patients (27.1%) had one or more complications, including transient postoperative radiculitis (8/48), vertebral osteolysis (3/48), nonunion (2/48), and symptomatic ectopic bone formation (1/48). The use of rhBMP-2 in the TLIF procedure produces a high rate of fusion, symptomatic improvement and patient satisfaction. Although its use eliminates the risk of harvesting autograft, rhBMP-2 is associated with other complications that raise concern, including a high rate of postoperative radiculitis.
Makda, Junaid; Hong, Joseph; Patel, Ravi; Hilibrand, Alan S.; Anderson, David G.; Vaccaro, Alexander R.; Albert, Todd J.
Background: Posterior decompression, instrumentation, and posterolateral fusion are sur- gical procedures for the treatment of degenerative lumbar diseases. Solid fusion usually causes adjacent problems. This study investigated the clinical outcome and radiographic fate of the L5-S1 segment in patients who under- went posterior instrumented surgery for degenerative lumbar diseases. Methods: From January 1999 to December 2000, 181 patients (average age
Jen-Chung Liao; Wen-Jer Chen; Lih-Huei Chen; Chi-Chien Niu
Our objective was to evaluate the clinical efficacy and feasibility of posterior decompression with transforaminal thoracic interbody fusion (PTTIF) for thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) and ossification of the posterior longitudinal ligament (OPLL) at the same level. Between March 2004 and December 2008, 13 patients (five men and eight women, average age: 56years, range: 39-72years) who underwent PTTIF for concurrent OLF and OPLL were studied retrospectively. The clinical efficacy, operative time, blood loss, sagittal alignment and complications were investigated. Cerebrospinal fluid leakage occurred in three patients, all of whom healed well after repair. One patient developed a urinary tract infection and one developed a wound infection, but both were cured with appropriate antibiotic therapy. Neurological symptom deterioration occurred in one patient, but she returned to her preoperative baseline after completing methylprednisolone therapy. After an average 36.8months follow up, the mean Japanese Orthopaedic Association (JOA) score significantly increased from 4.3±1.3 preoperatively to 7.2±1.8 at 3months after the operation and 8.5±1.7 at the final follow-up (P<0.01), with an overall recovery rate of 63.2±21.8%. Postoperative imaging demonstrated an improvement in the local kyphosis (P<0.01), and as of the final follow up no cases of spinal instability or instrument loosening had occurred. We conclude that PTTIF provides satisfactory neurological recovery and stabilises the thoracic fusion through a single posterior approach. However, this procedure is not complication free and demands advanced technical expertise on the part of practitioners, particularly to avoid catastrophic spinal cord injuries. PMID:23313526
Liu, Fa-Jing; Chai, Yi; Shen, Yong; Xu, Jia-Xin; Du, Wei; Zhang, Peng
The management of spinal tuberculosis, especially in children, is controversial. In children, vertebral destruction is more\\u000a severe than adults because of the cartilaginous nature of their bone. Modern chemotherapy has significantly decreased mortality\\u000a in spinal tuberculosis, but morbidity remains high. Without early surgery, patients can develop severe kyphosis leading to\\u000a respiratory insufficiency, painful costopelvic impingement and paraplegia. Lumbar kyphosis results
Matthew Anthony Kirkman; Krishnamurthy Sridhar
BACKGROUND CONTEXT: Somatosensory evoked potentials (SSEP) are commonly used to monitor the spinal cord and nerve roots during operative procedures that put those structures at risk. The utility of SSEPs to evaluate cauda equina and nerve root function during posterior spinal arthrodesis with pedicular fixation for degenerative lumbar disease has been reported anecdotally and remains controversial.PURPOSE: An institution-wide review of
Mukund Gundanna; Mark Eskenazi; John Bendo; Jeffrey Spivak; Ronald Moskovich
We describe a man aged 26 years who presented with a neurological syndrome, which was found on lumbar radioculopathy to be due to a ganglion cyst originating from the posterior longitudinal ligament. Based on MRI findings, a cystic lesion was suspected, a round lesion at L4 level with no connection to the adjacent facet or to the dura matter. During
Hisatoshi Baba; Nobuaki Furusawa; Yasuhisa Maezawa; Kenzo Uchida; Yasuo Kokubo; Shinichi Imura; Sakon Noriki
Lateral transpsoas interbody fusion (LTIF) is a minimally invasive technique that permits interbody fusion utilizing cages\\u000a placed via a direct lateral retroperitoneal approach. We sought to describe the locations of relevant neurovascular structures\\u000a based on MRI with respect to this novel surgical approach. We retrospectively reviewed consecutive lumbosacral spine MRI scans\\u000a in 43 skeletally mature adults. MRI scans were independently
Christopher K. KeplerEric; Eric A. Bogner; Richard J. Herzog; Russel C. Huang
BACKGROUND: To investigate how unilateral cage-instrumented posterior lumbar interbody fusion (PLIF) affects the three-dimensional flexibility in degenerative disc disease by comparing the biomechanical characteristics of unilateral and bilateral cage-instrumented PLIF. METHODS: Twelve motion segments in sheep lumbar spine specimens were tested for flexion, extension, axial rotation, and lateral bending by nondestructive flexibility test method using a nonconstrained testing apparatus. The
Ti-Sheng Chang; Jia-Hao Chang; Chien-Shiung Wang; Hung-Yi Chen; Ching-Wei Cheng
Study Design A retrospective study. Purpose To analyze the treatment outcome of patients with lower thoracic and lumbar fractures combined with neurological deficits. Overview of Literature Although various methods of the surgical treatment for lower thoracic and lumbar fractures are used, there has been no surgical treatment established as a superior option than others. Methods Between March 2001 and August 2009, this study enrolled 13 patients with lower thoracic and lumbar fractures who underwent spinal canal decompression by removing posteriorly displaced bony fragments via the posterior approach and who followed up for more than a year. We analyzed the difference between the preoperative and postoperative extents of canal encroachment, degrees of neurologic deficits and changes in the local kyphotic angle. Results The average age of the patients was 37 years. There were 10 patients with unstable burst factures and 3 patients with translational injuries. Canal encroachment improved from preoperative average of 84% to 9% postoperatively. Local kyphosis also improved from 20.5° to 1.5°. In 92% (12/13) of the patients, neurologic deficit improved more than Frankel grade 1 and an average improvement of 1.7 grade was observed. Deterioration of neurologic symptoms was not observed. Although some loss of reduction of kyphotic deformity was observed at the final follow-up, serious complications were not observed. Conclusions When posteriorly displaced bony fragments were removed by the posterior approach, neurological recovery could be facilitated by adequate decompression without serious complications. The posterior direct decompression could be used as one of treatments for lower thoracic and lumbar fractures combined with neurologic injuries.
Jun, Deuk Soo; Ahn, Byoung Geun
The objective of this study was to investigate the efficacy of an injectable calcium phosphate cement/silk fibroin/human recombinant bone morphogenetic protein-2 composite (CPC/SF/rhBMP-2) in an ovine interbody fusion model. Twenty-four mature sheep underwent anterior lumbar interbody fusion at the levels of L1/2, L3/4, and L5/6 with random implantation of CPC/SF, CPC/rhBMP-2, CPC/SF/rhBMP-2, or autogenous iliac bone. After the sheep were sacrificed, the fusion segments were evaluated by manual palpation, CT scan, undestructive biomechanical testing, undecalcified histology, and histomorphology. The fusion rates of CPC/SF/rhBMP-2 were 55.56% and 77.78% at 6 and 12 months, respectively. The fusion was superior to all the biomaterial grafts in stiffness, and reached the same stiffness as the autograft at 12 months. The new bone formation was less than autograft at 6 months, but similar with that at 12 months. However, the ceramic residue volume of CPC/SF/rhBMP-2 was significantly decreased compared with CPC/SF and CPC/rhBMP-2 at both times. The results indicated that CPC/SF/rhBMP-2 composite had excellent osteoconduction and osteoinduction, and balanced degradation and osteogenesis. PMID:21381189
Gu, Yong; Chen, Liang; Yang, Hui-Lin; Luo, Zong-Ping; Tang, Tian-Si
BACKGROUND CONTEXT: 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. PURPOSE: 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. STUDY DESIGN: A retrospective study. PATIENT SAMPLE: 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%). OUTCOME MEASURES: Clinical (Oswestry Disability Index, visual analog scale, Roland-Morris Disability Questionnaire) and radiological (scoliosis and lordosis corrections) outcomes as well as incidence of complications. METHODS: 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. RESULTS: 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 duration (190 vs. 240 minutes) and blood loss (950 vs. 1,400 cc) were observed in the dynamic group than in the fusion group. CONCLUSIONS: In elderly patients with degenerative lumbar scoliosis, pedicle screw-based dynamic stabilization was less invasive with shorter operative duration, less blood loss, and lower adverse event rates than instrumented posterior fusion. Scoliosis curve reduction and lumbar lordosis were superior after fusion; however, dynamic stabilization achieved satisfying values of both these parameters, and these results were stable after an average follow-up of more than 5 years. Furthermore, there was no difference between the two techniques in terms of functional clinical outcomes at the last follow-up. PMID:23257571
Di Silvestre, Mario; Lolli, Francesco; Bakaloudis, Georgios
Summary \\u000a Due to the decreased trauma in anterior as well as posterior surgical approaches to the spine, microsurgical techniques have\\u000a been used more frequently in recent years. This article describes two new microsurgical techniques to approach the anterior\\u000a lumbar spine for interbody fusion as part of a posterior-anterior stabilization concept in various diseases like spondylolisthesis,\\u000a degenerative instability; failed back surgery
H. M. Mayer; K. Wiechert
Background The authors tested the hypotheses that after hip arthroplasty, ambulation distance is increased and the time required to reach three specific readiness-for-discharge criteria is shorter with a 4-day ambulatory continuous lumbar plexus block (cLPB) than with an overnight cLPB. Methods A cLPB consisting of 0.2% ropivacaine was provided from surgery until the following morning. Patients were then randomly assigned either to continue ropivacaine or to be switched to normal saline. Primary endpoints included (1) time to attain three discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation ? 30 m) and (2) ambulatory distance in 6 min the afternoon after surgery. Patients were discharged with their cLPB and a portable infusion pump, and catheters were removed on the fourth postoperative day. Results Patients given 4 days of perineural ropivacaine (n = 24) attained all three discharge criteria in a median (25th-75th percentiles) of 29 (24-45) h, compared with 51 (42-73) h for those of the control group (n = 23; estimated ratio = 0.62; 95% confidence interval, 0.45-0.92;P = 0.011). Patients assigned to receive ropivacaine ambulated a median of 34 (9-55) m the afternoon after surgery, compared with 20 (6-46) m for those receiving normal saline (estimated ratio = 1.3; 95% confidence interval, 0.6-3.0;P = 0.42). Three falls occurred in subjects receiving ropivacaine (13%),versusnone in subjects receiving normal saline. Conclusions Compared with an overnight cLPB, a 4-day ambulatory cLPB decreases the time to reach three predefined discharge criteria by an estimated 38% after hip arthroplasty. However, the extended infusion did not increase ambulation distance to a statistically significant degree.
Ball, Scott T.; Gearen, Peter F.; Le, Linda T.; Mariano, Edward R.; Vandenborne, Krista; Duncan, Pamela W.; Sessler, Daniel I.; Enneking, F. Kayser; Shuster, Jonathan J.; Theriaque, Douglas W.; Meyer, R. Scott
While new spine-stabilizing devices are beginning to appear as alternative methods of providing operative spine stability, a careful review of those methods used by the Spine Injury Service at Northwestern University was undertaken. The method of stabilization most frequently used was the Harrington distraction rod device. With the coming of the Luque rod "segmental instrumentation" technique, improved spine stability was attained, although the attributes of the Harrington distraction system could not be substituted by the Luque system. A natural spin-off was the combination of the Harrington and the Luque methods of internal fixation. This has been a significant addition to the spine surgeon's surgical armamentarium. Still there are problems of implant stability, for which the Jacobs AO rods were developed, and the need for better correction of the spine's malposition following fracture (Edwards system). Because of the concern for the placement of sublaminar wires beneath the lamina, particularly in the area of the very narrow thoracic neural canal, the "Wisconsin" system of spinous process wires was developed. The discussion in this chapter is limited to the statistical data gathered from the management of 646 fracture-dislocations of the spine, of which 374 were surgically managed. As noted in Table 39-3, there are hazards to the instrumentation of the thoracic, lumbar, and sacral spine. In this surgical group, neurologic deterioration occurred in 2.39%; however, there was evidence of significant "risk-benefit" in surgery, with 15.22% of surgical patients demonstrating neurologic improvement after surgery of at least one Frankel grade. When compared with those patients managed conservatively, 6.57% demonstrated neurologic improvement, whereas only 0.34% demonstrated neurologic deterioration. PMID:3819427
Meyer, P R
A prospective observational study was conducted on patients undergoing posterior lumbar spine surgery for degenerative spinal\\u000a disorders. The study purpose was to evaluate the effect of wait time to surgery on patient derived generic and disease specific\\u000a functional outcome following surgery. A prolonged wait to surgery may adversely affect surgical outcome. Although there is\\u000a literature on the effect of wait
Jason Braybrooke; Henry Ahn; Aimee Gallant; Michael Ford; Yigel Bronstein; Joel Finkelstein; Albert Yee
Objective Transpedicular screw fixation has some disadvantages such as postoperative back pain through wide muscle dissection, long operative time, and cephalad adjacent segmental degeneration (ASD). The purposes of this study are investigation and comparison of radiological and clinical results between interspinous fusion device (IFD) and pedicle screw. Methods From Jan. 2008 to Aug. 2009, 40 patients underwent spinal fusion with IFD combined with posterior lumbar interbody fusion (PLIF). In same study period, 36 patients underwent spinal fusion with pedicle screw fixation as control group. Dynamic lateral radiographs, visual analogue scale (VAS), and Korean version of the Oswestry disability index (K-ODI) scores were evaluated in both groups. Results The lumbar spine diseases in the IFD group were as followings; spinal stenosis in 26, degenerative spondylolisthesis in 12, and intervertebral disc herniation in 2. The mean follow up period was 14.24 months (range; 12 to 22 months) in the IFD group and 18.3 months (range; 12 to 28 months) in pedicle screw group. The mean VAS scores was preoperatively 7.16±2.1 and 8.03±2.3 in the IFD and pedicle screw groups, respectively, and improved postoperatively to 1.3±2.9 and 1.2±3.2 in 1-year follow ups (p<0.05). The K-ODI was decreased significantly in an equal amount in both groups one year postoperatively (p<0.05). The statistics revealed a higher incidence of ASD in pedicle screw group than the IFD group (p=0.029). Conclusion Posterior IFD has several advantages over the pedicle screw fixation in terms of skin incision, muscle dissection and short operative time and less intraoperative estimated blood loss. The IFD with PLIF may be a favorable technique to replace the pedicle screw fixation in selective case.
Kim, Ho Jung; Chun, Hyoung Joon; Oh, Suck Jun; Kang, Tae Hoon; Yang, Moon Sool
We studied the effects of hyperbaric oxygen (HBO) and zoledronic acid (ZA) on posterior lumbar fusion using a validated animal model. A total of 40 New Zealand white rabbits underwent posterior lumbar fusion at L5-6 with autogenous iliac bone grafting. They were divided randomly into four groups as follows: group 1, control; group 2, HBO (2.4 atm for two hours daily); group 3, local ZA (20 ?g of ZA mixed with bone graft); and group 4, combined HBO and local ZA. All the animals were killed six weeks after surgery and the fusion segments were subjected to radiological analysis, manual palpation, biomechanical testing and histological examination. Five rabbits died within two weeks of operation. Thus, 35 rabbits (eight in group 1 and nine in groups 2, 3 and 4) completed the study. The rates of fusion in groups 3 and 4 (p = 0.015) were higher than in group 1 (p < 0.001) in terms of radiological analysis and in group 4 was higher than in group 1 with regard to manual palpation (p = 0.015). We found a statistically significant difference in the biomechanical analysis between groups 1 and 4 (p = 0.024). Histological examination also showed a statistically significant difference between groups 1 and 4 (p = 0.036). Our results suggest that local ZA combined with HBO may improve the success rate in posterior lumbar spinal fusion. PMID:21586779
Yalçin, N; Öztürk, A; Ozkan, Y; Çelimli, N; Ozocak, E; Erdo?an, A; Sahin, N; Ilgezdi, S
Spontaneous cerebellar haemorrhage following spinal surgery is rare, with fewer than 20 patients reported in the literature. We present a 70-year-old woman who underwent a L5–S1 posterior lumbar interbody fusion for spondylolisthesis. Intraoperatively, an incidental durotomy occurred and was repaired uneventfully. A large amount of serosanguinous fluid was noted in the subfascial drain post-operatively. The patient became increasingly drowsy 36
Peter Khong; M. Jerry Day
Arthrodesis using interbody cages has demonstrated high fusion rates. However, permanent cages are exposed to stress-shielding, corrosion, and may require explanation when necessary. Polylactic acid (PLA) bioresorbable cages are developed for avoiding these problems, but significant tissue reaction has been reported with 70\\/30 PLDLLA in some preclinical animal studies. The objective was to evaluate 96\\/4 PLDLLA cages in a sheep
Jean Y. Lazennec; Abdallah Madi; Marc A. Rousseau; Bernard Roger; Gérard Saillant
Four patients underwent lumbar interbody fusion, performed via a video-assisted retroperitoneal laparoscopic approach, complementary to posterior osteosynthesis at the L2–L3, L3–L4 and\\/or L4–L5 level. In three cases the interventions were for lumbar fractures, and in one case for microcristalline arthritis. After surgical training on human cadavers and several porcine operative sessions, retroperitoneal lateral approaches on the left side were performed
F. Peretti; I. Hovorka; P. Fabiani; C. Argenson
Study Design Retrospective study. Purpose The aims of the current study are to evaluate the minimum 10-year follow-up clinical results of anterior lumbar interbody fusion (ALIF) for degenerative spondylolisthesis. Overview of Literature ALIF has been widely used as a treatment regimen in the management of lumbar spondylolisthesis. Still much controversy exists regarding the factors that affect the postoperative clinical outcomes. Methods The author performed a retrospective review of 20 patients with degenerative spondylolisthesis treated with ALIF (follow-up, 16.4 years). The clinical results were assessed by the Japanese Orthopaedic Association (JOA) score for low back pain, vertebral slip and disc height index on the radiographs. Results The mean preoperative JOA score was 7.1 ± 1.8 points (15-point-method). At 1 year, 5 years, and 10 years or more after surgery, the JOA scores were assessed as 12.4 ± 2.2 points, 12.7 ± 2.6 points, 12.0 ± 2.5 points, respectively (excluding the data of reoperated cases). The adjacent disc degeneration developed in all cases during the long-term follow-up. The progressive pattern of disc degeneration was divided into three types. Initially, disc degeneration occurred due to disc space narrowing. After that, the intervertebral discs showed segmental instability with translation at the upper level. But the lower discs showed osteophyte formation, and occasionally lead to the collapse or spontaneous union. Conclusions The clinical results of the long-term follow-up data after ALIF became worse due to the adjacent disc degeneration. The progressive pattern of disc degeneration was different according to the adjacent levels.
Yasuda, Taketoshi; Hori, Takeshi; Suzuki, Kayo; Kawaguchi, Yoshiharu
PURPOSE: Supporters of minimally invasive approaches for transforaminal lumbar interbody fusion (TLIF) have reported short-term advantages associated with a reduced soft tissue trauma. Nevertheless, mid- and long-term outcomes and specifically those involving physical activities have not been adequately studied. The aim of this study was to compare the clinical outcomes of mini-open versus classic open surgery for one-level TLIF, with an individualized evaluation of the variables used for the clinical assessment. METHODS: A prospective cohort study was conducted of 41 individuals with degenerative disc disease who underwent a one-level TLIF from January 2007 to June 2008. Patients were randomized into two groups depending on the type of surgery performed: classic open (CL-TLIF) group and mini-open approach (MO-TLIF) group. The visual analog scale (VAS), North American Spine Society (NASS) Low Back Pain Outcome instrument, Oswestry Disability Index (ODI) and the Short Form 36 Health Survey (SF-36) were used for clinical assessment in a minimum 3-year follow-up (36-54 months). RESULTS: Patients of the MO-TLIF group presented lower rates of lumbar (p = 0.194) and sciatic pain (p = 0.427) and performed better in daily life activities, especially in those requiring mild efforts: lifting slight weights (p = 0.081), standing (p = 0.097), carrying groceries (p = 0.033), walking (p = 0.069) and dressing (p = 0.074). Nevertheless, the global scores of the clinical questionnaires showed no statistical differences between the CL-TLIF and the MO-TLIF groups. CONCLUSIONS: Despite an improved functional status of MO-TLIF patients in the short term, the clinical outcomes of mini-open TLIF at the 3- to 4-year follow-up showed no clinically relevant differences to those obtained with open TLIF. PMID:23764765
Rodríguez-Vela, Javier; Lobo-Escolar, Antonio; Joven, Eduardo; Muñoz-Marín, Javier; Herrera, Antonio; Velilla, José
BackgroundThe stability of the lumbar spine after ALIF with lateral plate fixation and\\/or posterior fixation has previously been investigated; however, stand-alone ALDF with plate has not. Previous clinical studies have demonstrated poor fusion rates with stand-alone anterior interbody fusion in the absence of posterior instrumentation. We review our initial experience with stand-alone ALDF with segmental plate fixation for degenerative disc
Henry E. Aryan; Daniel C. Lu; Frank L. Acosta; Christopher P. Ames
BACKGROUND Hip arthroplasty frequently requires potent postoperative analgesia, often provided with an epidural or posterior lumbar plexus local anesthetic infusion. However, American Society of Regional Anesthesia guidelines now recommend against epidural and continuous posterior lumbar plexus blocks during administration of various perioperative anticoagulants often administered after hip arthroplasty. A continuous femoral nerve block is a possible analgesic alternative, but whether it provides comparable analgesia to a continuous posterior lumbar plexus block after hip arthroplasty remains unclear. We therefore tested the hypothesis that differing the catheter insertion site (femoral versus posterior lumbar plexus) after hip arthroplasty has no impact on postoperative analgesia. METHODS Preoperatively, subjects undergoing hip arthroplasty were randomly assigned to receive either a femoral or posterior lumbar plexus stimulating catheter inserted 5 to 15 cm or 0 to 1 cm past the needletip, respectively. Postoperatively, patients received perineural ropivacaine, 0.2% (basal 6 mL/hour, bolus 4 mL, 30 min lockout) for at least two days. The primary end point was the average daily pain scores as measured with a numeric rating scale (0–10) recorded in the 24-h period beginning at 07:30 the morning after surgery, excluding twice-daily physical therapy sessions. Secondary end points included pain during physical therapy, ambulatory distance, and supplemental analgesic requirements during the same 24-h period, as well as satisfaction with analgesia during hospitalization. RESULTS The mean (SD) pain scores for subjects receiving a femoral infusion (n = 25) were 3.6 (1.8) versus 3.5 (1.8) for patients receiving a posterior lumbar plexus infusion (n = 22) resulting in a group difference of 0.1 (95% confidence interval ?0.9 to 1.2; P = 0.78). Because the confidence interval was within a prespecified ?1.6 to 1.6 range, we conclude that the effect of the two analgesic techniques on postoperative pain was equivalent. Similarly, we detected no differences between the two treatments with respect to the secondary end points, with one exception: subjects with a femoral catheter ambulated a median (10th–90th percentiles) 2 (0–17) m the morning after surgery, compared with 11 (0–31) m for subjects with a posterior lumbar plexus catheter (data nonparametric; P = 0.02). CONCLUSIONS After hip arthroplasty, a continuous femoral nerve block is an acceptable analgesic alternative to a continuous posterior lumbar plexus block when using a stimulating perineural catheter. However, early ambulatory ability suffers with a femoral infusion.
Ilfeld, Brian M.; Mariano, Edward R.; Madison, Sarah J.; Loland, Vanessa J.; Sandhu, NavParkash S.; Suresh, Preetham J.; Bishop, Michael L.; Kim, T. Edward; Donohue, Michael C.; Kulidjian, Anna A.; Ball, Scott T.
The literature reports on the safety and efficacy of titanium cages (TCs) with additional posterior fixation for anterior lumbar interbody fusion. However, these papers are limited to prospective cohort studies. The introduction of TCs for spinal fusion has resulted in increased costs, without evidence of superiority over the established practice. There are currently no prospective controlled trials comparing TCs to
Patrick J. McKenna; Brian J. C. Freeman; Robert C. Mulholland; Michael P. Grevitt; John K. Webb; S. H. Mehdian
Object Iliac crest autograft has traditionally been considered the gold standard for lumbar spine fusion, though it is not without drawbacks related to harvesting site pain and other complications. Bone graft alternatives, such as recombinant human bone morphogenetic protein 2 (rh-BMP2), are now widely used but also have unique risk profiles and substantially increase costs. The purpose of the current study was to compare the efficacy of rh-BMP2 and synthetic silicate calcium phosphate (SiCaP) as bone graft substitutes on fusion rates and clinical outcomes in patients undergoing single-level lumbar stand-alone extreme lateral interbody fusion (XLIF).Methods A prospective, randomized, controlled, clinical, and radiographic study was performed at a single institution. Thirty patients with L4-L5 degenerative disc disease (DDD) were enrolled. Patients were randomized into one of two groups, 15 underwent lumbar single-level stand-alone XLIF using SiCaP, and 15 using rh-BMP2. Clinical and radiographic results were compared between the study groups. Pain (visual analogue scale) and disability (Oswestry disability index) were assessed preoperatively and at postoperative weeks 1 and 6 and postoperative months 3, 6, 12, 24, and 36. Radiographic evaluations were performed at 6, 12, 24, and 36 months. Neurological examinations and adverse events were recorded at each visit.Results No intraoperative complications were observed in either treatment group, and clinical outcomes were similarly improved between bone graft substitutes from baseline to 36 months postoperative. Complications were transient hip flexion weakness (13%), insufficient indirect decompression (7%), subsidence (17%), excessive bone formation (4%), and adjacent segment disease (14%). Complication rates between the groups were similar, though with slightly more instances of subsidence in the SiCaP group and higher rates of excessive bone formation and adjacent segment disease in the rh-BMP2 group. Rates of fusion at different time points were different between the groups, with the SiCaP patients progressing more slowly toward solid fusion. However, at 36 months, 100% of patients undergoing XLIF achieved solid fusion.Conclusions In stand-alone XLIF, SiCaP and rhBMP-2 bone graft substitutes both resulted in complete long-term fusion. rhBMP-2, however, seemed to result in more rapid early postoperative fusion, though with one instance of excessive bone formation in one patient that required subsequent surgical intervention. PMID:23444134
Pimenta, Luiz; Marchi, Luis; Oliveira, Leonardo; Coutinho, Etevaldo; Amaral, Rodrigo
Purpose of study: Circumferential fusion has become a common procedure in lumbar spine fusion both as a primary and as a salvage procedure. The present study documented that ALIF with Brantigan cage improves fusion rate and spinal sagittal alignment and removes pain originating from the disc. We have analyzed the effects of circumferential fusion using ALIF brantigan cages and titanium
Cody Bünger; Bjarke Christensen; Ebbe Hansen
Expert's comment concerning Grand Rounds case entitled "Minimal access bilateral transforaminal lumbar interbody fusion for high-grade isthmic spondylolisthesis" (by Nasir A. Quraishi and Y. Raja Rampersaud; doi:10.1007/s00586-012-2623-2).
This Expert's Comment discusses the Grand Rounds Case entitled "Minimal Access Bilateral Transforaminal Lumbar Interbody Fusion for High-Grade Isthmic Spondylolisthesis" by Nasir A Quraishi and Raja Y Rampersaud. It puts a technically elegant surgical method for minimally invasive reduction and arthrodesis of isthmic spondylolistheses into the context of short and long term outcomes and questions the motivations for performing such minimally invasive procedures in the absence of any proven mid or long term advantages over more traditional techniques. In addition, the use of BMP in spinal arthrodesis is discussed on the background of recently published IPD metaanalyses from the Infuse spinal FDA trials. PMID:23868222
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 degenerative lumbar deformity remains unknown and more studies are required to validate the safety and efficiency.
Hey, Hwee Weng Dennis; Hee, Hwan Tak
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 degenerative lumbar deformity remains unknown and more studies are required to validate the safety and efficiency. PMID:20419002
Hey, Hwee Weng Dennis; Hee, Hwan Tak
Recombinant Human Bone Morphogenetic Protein-2-Augmented Transforaminal Lumbar Interbody Fusion for the Treatment of Chronic Low Back Pain Secondary to the Homogeneous Diagnosis of Discogenic Pain Syndrome.
Study Design: A retrospective observational study.Objective: To assess clinical outcomes; perioperative complications; revision surgery rates; and BMP-2-related osteolysis, heterotopic bone, and unexplained postoperative radiculitis (BMPP) in a group of patients treated with BMP-2-augmented transforaminal lumbar interbody fusion (bTLIF) for the homogeneous diagnosis of discogenic pain syndrome (DPS) and to put forth the algorithm used to make the diagnosis.Summary of Background Data: There is a paucity of literature describing outcomes of TLIF for the homogeneous diagnosis of DPS, an old but controversial member of the lumbar degenerative disease family.Methods: The registry from a single-surgeon was queried for patients who had undergone bTLIF for the homogeneous diagnosis of DPS, which was made via specific diagnostic algorithm. Clinical outcomes were determined by analyzing point-improvement from typical outcome questionnaires (OQs) and the data from Patient Satisfaction and Return to Work (RTW) questionnaires. Independent record review was employed to assess all outcomes.Results: 80% of the cohort (36/45) completed pre-op and post-op OQs at an average follow-up of 41.9 ± 11.9 months, which demonstrated significant clinical improvement: ODI = 16.4 (p<0.0001), SF12-PCS = 10.0 (p<0.0001), and a Numeric Rating Scale for back pain = 2.3 (p<0.0001). The median patient satisfaction score was 9.0 (10 = complete satisfaction), and 84.4% (27/32) of the cohort were able to return to their pre-op job, with or without modification. There were 3 perioperative complications; 4 revision surgeries; and 11 cases of benign BMPP. There were no incidents of the intraoperative dural tears or nerve root injury, and neither litigation involvement (11/36, P>0.17), preoperative depression (15/36, P >0.19), nor prior discectomy/decompression (14/36, P<0.37) were predictors of outcomes.Conclusions: Although limited by retrospective design and small cohort, the results of this investigation suggest that bTLIF is a reasonable treatment option for patients who suffer DPS and affords high patient satisfaction. A larger study is needed to confirm these findings. PMID:24042711
Corenman, Donald S; Gillard, Douglas M; Dornan, Grant; Strauch, Eric
Purpose Little is known about the prevalence and epidemiological characteristics of lumbar ossification of the posterior longitudinal ligament (OPLL). We analyzed the rate of lumbar OPLL in an outpatient unit where primary care physicians are working in Japan, to better understand the epidemiological characteristics of the disease. Methods We analyzed consecutive, first-time visiting outpatients who received abdominal and pelvic computed tomography (CT) scan at the Department of General Medicine, Asahikawa Medical University Hospital, Japan, between April 2009 and March 2012. Each parameter such as age, sex, and clinical presentation was investigated. Results Out of 393 patients who underwent abdominal and pelvic CT scan, 33 (8.4%) were diagnosed as lumbar OPLL. When compared with patients without lumbar OPLL (n = 360), there was no significant difference in gender, body mass index (BMI), presence of hypertension, diabetes mellitus or hyperlipidemia, and smoking habit, while the age in patients with lumbar OPLL was significantly higher. Conclusion These results suggest for the first time that lumbar OPLL is frequently observed in elderly people in the primary care setting, in Japan.
Okumura, Toshikatsu; Ohhira, Masumi; Kumei, Shima; Nozu, Tsukasa
Anterior lumbar interbody fusion (ALIF) with cylindrical cages and supplemental posterior fixation has been widely used for internal disc derangement. However, most researchers have focused on single-level ALIF. Therefore, the biomechanical performance of various fixation constructs after two-level ALIF is not well characterized. This research used three-dimensional finite element models (FEM) with a nonlinear contact analysis to evaluate the initial
Chang-Yuan Fan; Ching-Chi Hsu; Ching-Kong Chao; Shang-Chih Lin; Kuo-Hua Chao
Study Design This is a prospective study. Purpose We compared the outcomes of segmental decompression and wide decompression in patients who had multilevel lumbar foraminal stenosis with back pain. Overview of Literature Wide decompression and fusion in patients with multilevel lumbar foraminal stenosis may increase the risk of perioperative complications. Methods From March 2005 to December 2007, this study prospectively examined 87 patients with multilevel lumbar foraminal stenosis and who were treated by segmental or wide decompression along with posterior fusion using pedicle screw fixation, and these patients could be followed-up for a minimum of 2 years. Of the 87 patients, 45 and 42 patients were assigned to the segmental decompression group (group 1) and the wide decompression group (group 2), respectively. We compared the clinical and radiological outcomes of the patients in these two groups. Results There were no significant differences between groups 1 and 2 in terms of the levels of postoperative pain based on the visual analogue scale, the Oswestry Disability Score, the clinical results based on the Kirkaldy-Willis Criteria, the complication rate or the posterior fusion rate. On the other hand, the mean operating times in groups 1 and 2 were 153 ± 32 minutes and 187 ± 36 minutes, respectively (p < 0.05). The amount of blood loss during surgery and on the first postoperative day was 840 ± 236 ml and 1,040 ± 301 ml in groups 1 and 2, respectively (p < 0.05). Conclusions These results suggest that segmental decompression offers promising and reproducible clinical and radiological results for patients suffering from multilevel lumbar foraminal stenosis.
Seong, Yoon Jae; Suh, Kuen Tak; Kim, Jeung Il; Lim, Jong Min; Goh, Tae Sik
Background We compared the efficacy of combined posterior lumbar plexus–sciatic nerve block with that of combined femoral–obturator–sciatic nerve block as anesthesia for anterior cruciate ligament reconstruction surgery, because both block combinations have been recommended for lower limb arthroscopic and reconstructive surgery. Methods Forty-eight patients undergoing elective unilateral anterior cruciate ligament reconstruction under local anesthesia were randomized to undergo either combined posterior lumbar plexus–sciatic nerve block (Group 1), or combined femoral–obturator–sciatic nerve block (Group 2). Blocks were performed using nerve stimulation and bupivacaine 0.5% mixed with lignocaine 2%. Systolic and diastolic blood pressure, heart rate, and pulse oximetry were recorded. Quality of anesthesia, motor and sensory block, time to first analgesic use, sedation, and need for general anesthesia were recorded, along with verbal postoperative pain scores, and side effects. Results No patient in Group 1 and two patients in Group 2 needed general anesthesia. Complete sensory blockade was higher in Group 1 than in Group 2. However, complete motor blockade was similar in both groups. In Group 1, verbal pain scores were lower than in Group 2. Time to first analgesic was similar between the two groups. Total analgesic consumption was lower in Group 1. No significant differences were found for heart rate, pulse oximetry, or systolic and diastolic blood pressure between the groups, and no signs of toxicity were encountered. Conclusion Combined posterior lumbar plexus–sciatic nerve block provided more comfortable intraoperative anesthesia and better postoperative analgesia than combined femoral–obturator–sciatic nerve block for anterior cruciate ligament reconstruction surgery.
Tharwat, Ayman I
Posterior epidural migration (PEM) of free disc fragments is rare, and reported PEM patients usually presented with radicular signs. An uncommon case involving a patient with cauda equina syndrome due to PEM of a lumbar disc fragment is reported with a review of the literature. The patient described in this report presented with an acute cauda equina syndrome resulting from disc fragment migration at the L3-L4 level that occurred after traction therapy for his lower back pain. The radiological characteristics of the disc fragment were the posterior epidural location and the ring enhancement. A fenestration was performed and histologically confirmed sequestered disc material was removed. An early postoperative examination revealed that motor, sensory, urological, and sexual functions had been recovered. At late follow-up, the patient was doing well after 18 months. Sequestered disc fragments may occasionally migrate to the posterior epidural space of the dural sac. Definite diagnosis of posteriorly located disc fragments is difficult because the radiological images of disc fragments may mimic those of other more common posterior epidural lesions. PMID:11563623
Döso?lu, M; Is, M; Gezen, F; Ziyal, M I
. Our purpose was: (1) to compare the biomechanical properties of an interbody reconstruction using two standard threaded cages\\u000a (18-mm diameter), a reconstruction using a single mega-cage (24-mm diameter), and a reconstruction using dual nested cages\\u000a (22-mm diameter); and (2) to quantify the surface area of the cancellous bone bed exposed by reaming for the cages. Each motion\\u000a segment was
Hideki Murakami; William C. Horton; Norio Kawahara; Katsuro Tomita; William C. Hutton
STUDY DESIGN:: Cadaveric biomechanical study. OBJECTIVE:: To investigate the kinematic response of a stand-alone lateral lumbar interbody cage compared with supplemental posterior fixation with either facet or pedicle screws after lateral discectomy. SUMMARY OF BACKGROUND DATA:: Lateral interbody fusion is a promising minimally invasive fixation technique for lumbar interbody arthrodesis. The biomechanical stability of stand-alone cage placement compared with supplemental posterior fixation with either facet or bilateral pedicle screws remains unclear. METHODS:: A 6-degree of freedom spine simulator was used to test flexibility in 7 human cadaveric specimens. Flexion-extension, lateral-bending, and axial-rotation were tested in the intact condition, followed by destabilization through a lateral discectomy at L2-L3 and L4-L5. Specimens were then reconstructed at both operative segments in the following sequence: (1) lateral interbody cage placement; (2) either Discovery facet screws or the Viper F2 system using a transfacet-pedicular trajectory randomized to L2-L3 or L4-L5; and (3) removal of facet screw fixation followed by placement of bilateral pedicle screw instrumentation. Acute range of motion (ROM) was quantified and analyzed. RESULTS:: All 4 reconstruction groups, including stand-alone interbody cage placement, bilateral Discovery facet screws, the Viper F2 system, and bilateral pedicle screw-rod stabilization, resulted in a significant decrease in acute ROM in all loading modes tested (P<0.05). There were no significant differences observed between the 4 instrumentation groups (P>0.05). Although not statistically significant, the Viper F2 system resulted in greatest reduction of acute ROM in both flexion-extension and axial rotation versus all other treatments (P>0.05). CONCLUSIONS:: Stand-alone interbody cage placement results in a significant reduction in acute ROM at the operative segment in the absence of posterior supplemental fixation. If added fixation is desired, facet screw placement, including the Viper F2 facet screw system using an integrated compression washer and transfacet-pedicular trajectory, provides similar acute stability to the spinal segment compared with traditional bilateral pedicle screw fixation in the setting of lateral interbody cage deployment. PMID:23381181
Kretzer, Ryan M; Molina, Camilo; Hu, Nianbin; Umekoji, Hidemasa; Baaj, Ali A; Serhan, Hassan; Cunningham, Bryan W
BackgroundPosterior epidural migration of an extruded disk fragment is rare, and posterior migration of the free fragments causing cauda equina syndrome is exceptionally rare. The disk fragment must transgress through numerous anatomical restraints including the nerve roots in such cases.
Abad Cherif El Asri; Okacha Naama; Ali Akhaddar; Miloudi Gazzaz; Adil Belhachmi; Brahim El Mostarchid; Mohamed Boucetta
Objective Anterior lumbar interbody fusion (ALIF) employing a special carbon cage through a retroperitoneal, minimally invasive, endoscopically assisted approach using a new retracting system. Indications For the approach: Anterior lumbar interbody fusion. Replacement of the vertebral body in fractures and metastases. For the anterior fusion: Spondylolisthesis. Postnucleotomy syndrome. Segmental instability. Contraindications For the approach: Infiltrating retroperitoneal tumors. Important retroperitoneal fibrosis.
Stefan Gödde; Michael Dienst; Ekkehard Fritsch
Between March 1988 and March 1990, 45 patients underwent a spondylodesis using transpedicular screws and plates of the "Variable Screw Placement Spinal Fixation System". The indications for operation were spondylolisthesis (13), spondylolisthesis plus discopathy at the adjacent level (4), degenerative discopathy (13), pseudarthrosis after interbody fusion (7), disc herniations (4) and disc herniations plus degenerative discopathy of the adjacent segment (4). In 1992, 43 patients were available for follow-up. The mean follow-up was 3.85 years. Side effects or complications of a more permanent character were seen 25 times in 43 patients. Eight patients had evidence of screw failure: loosening (5), fracture (2), and malposition (1). Complications, screw failure and reoperation all adversely affected clinical outcome. Overall only 60% of the patients reported a positive clinical outcome at follow-up. In our opinion transpedicular instrumentation is a logical system to provide rigid stabilisation, but it has a high learning curve. The original V.S.P. system with its bulky plates and screws appears to be particularly prone to giving a high rate of unwanted side effects not offset by a high clinical success rate. PMID:9265790
Bohnen, I M; Schaafsma, J; Tonino, A J
Dynamic stabilization devices have been introduced to clinics as an alternative to rigid fixation. The stiffness of these devices varies widely, whereas the optimal stiffness, achieving a predefined stabilization of the spine, is unknown. This study was focused on the determination of stiffness values for posterior stabilization devices achieving a flexible, semi-flexible or rigid connection between two vertebrae. An extensively validated finite element model of a lumbar spinal segment L4-5 with an implanted posterior fixation device was used in this study. The model was exposed to pure moments of 7.5 and 20Nm around the three principal anatomical directions, simulating flexion, extension, lateral bending and axial rotation. In parametrical studies, the influence of the axial and bending fixator stiffness on the spinal range of motion was investigated. In order to examine the validity of the computed results, an in-vitro study was carried out. In this, the influence of two posterior stabilization devices (DSS and rigidly internal fixator) on the segmental stabilization was investigated. The finite element (FE)-model predicted that each load direction caused a pairing of stiffness relations between axial and bending stiffness. In flexion and extension, however, the bending stiffness had a neglectable effect on the segmental stabilization, compared to the axial stiffness. In contrast, lateral bending and axial rotation were influenced by both stiffness parameters. Except in axial rotation, the model predictions were in a good agreement with the determined in-vitro data. In axial rotation, the FE-model predicted a stiffer segmental behavior than it was determined in the in-vitro study. It is usually expected that high stiffness values are required for a posterior stabilization device to stiffen a spinal segment. We found that already small stiffness values were sufficient to cause a stiffening. Using these data, it may possible to develop implants for certain clinical indications. PMID:19038390
Schmidt, Hendrik; Heuer, Frank; Wilke, Hans-Joachim
Bone morphogenetic protein (BMP) has been reported to cause early inflammatory changes, ectopic bony formation, adjacent level fusion, radiculitis, and osteolysis. The authors describe the case of a patient who developed inflammatory fibroblastic cyst formation around the BMP sponge after a lumbar fusion, resulting in compressive lumbar radiculopathy. A 70-year-old woman presented with left L-4 and L-5 radiculopathy caused by a Grade I spondylolisthesis with a left herniated disc at L4-5. She underwent a minimally invasive transforaminal lumbar interbody fusion with BMP packed into the interbody cage at L4-5. Her neurological symptoms resolved immediately postoperatively. Six weeks later, the patient developed recurrence of radiculopathy. Radiological imaging demonstrated an intraspinal cyst with a fluid-fluid level causing compression of the left L-4 and L-5 nerve roots. Reexpoloration of the fusion was performed, and a cyst arising from the posterior aspect of the cage was found to compress the axilla of the left L-4 nerve root and the shoulder of the L-5 nerve root. The cyst was decompressed, and the wall was partially excised. A collagen BMP sponge was found within the cyst and was removed. Postoperatively, the patient's radiculopathy resolved and she went on to achieve interbody fusion. Bone morphogenetic protein can be associated with inflammatory cyst formation resulting in neural compression. Spine surgeons should be aware of this complication in addition to the other reported BMP-related complications. PMID:22176433
Choudhry, Osamah J; Christiano, Lana D; Singh, Rahul; Golden, Barbara M; Liu, James K
Purpose Although posterior lumbar interbody fusion (PLIF) using stand-alone cages was a popular arthrodesis method, the effectiveness\\u000a of using such cages has been questioned. We assessed retrospectively the long-term clinical and radiological outcomes of PLIF\\u000a surgery using stand-alone cages for the treatment of degenerative lumbar spine disease, the incidences of pseudoarthrosis,\\u000a and its risk factors.\\u000a \\u000a \\u000a \\u000a \\u000a Methods Between May 2000 and May 2005,
Jin Hoon Park; Sung Woo Roh
The posterior median approach to the lumbar spine may cause significant injury to the erector spinae muscles (ESM) which is minimized using the paralateral approach suggested by Ray. We have adopted this approach and have extended it into the disc space to allow cage implantation from outside the foramen (EPLIF - extraforaminal posterior lumbar interbody fusion). The initial exposure of the posterior vertebral elements between the ESM and the deep lumbar fascia is sufficient to attain the entry points of pedicle screws. The intervertebral foramen and posterior annulus fibrosus are then exposed after which distant lateral disc herniations may be removed, the foramen/lateral recess may be decompressed or an EPLIF performed following clearing and vertical distraction of the disc space. This is followed by ipsilateral transpedicular fixation (TpF), contralateral fixation (second approach) by TpF or translaminar screws. Indications are given for foraminal and extraforaminal disc herniation, stenosis of the foramen and/or of the lateral recess, posterolateral fusion, TpF and EPLIF. The submuscular approach and EPLIF have proven to be valuable alternatives to standard techniques. PMID:21301809
Lumbar spondylolysis, a well known cause of low back pain, usually affects the pars interarticularis of a lower lumbar vertebra and rarely involves the articular processes. We report a rare case of bilateral spondylolysis of inferior articular processes of L4 vertebra that caused spinal canal stenosis with a significant segmental instability at L4/5 and scoliosis. A 31-year-old male who had suffered from low back pain since he was a teenager presented with numbness of the right lower leg and scoliosis. Plain X-rays revealed bilateral spondylolysis of inferior articular processes of L4, anterolisthesis of the L4 vertebral body, and right lateral wedging of the L4/5 disc with compensatory scoliosis in the cephalad portion of the spine. MR images revealed spinal canal stenosis at the L4/5 disc level. Posterior lumbar interbody fusion of the L4/5 was performed, and his symptoms were relieved.
Morozumi, Naoki; Hoshikawa, Takeshi; Ogawa, Shinji; Ishii, Yushin; Itoi, Eiji
Lumbar spondylolysis, a well known cause of low back pain, usually affects the pars interarticularis of a lower lumbar vertebra and rarely involves the articular processes. We report a rare case of bilateral spondylolysis of inferior articular processes of L4 vertebra that caused spinal canal stenosis with a significant segmental instability at L4/5 and scoliosis. A 31-year-old male who had suffered from low back pain since he was a teenager presented with numbness of the right lower leg and scoliosis. Plain X-rays revealed bilateral spondylolysis of inferior articular processes of L4, anterolisthesis of the L4 vertebral body, and right lateral wedging of the L4/5 disc with compensatory scoliosis in the cephalad portion of the spine. MR images revealed spinal canal stenosis at the L4/5 disc level. Posterior lumbar interbody fusion of the L4/5 was performed, and his symptoms were relieved. PMID:22111522
Koakutsu, Tomoaki; Morozumi, Naoki; Hoshikawa, Takeshi; Ogawa, Shinji; Ishii, Yushin; Itoi, Eiji
Background Lumbar spine fusion rates can vary according to the surgical technique. Although many studies on spinal fusion have been conducted and reported, the heterogeneity of the study designs and data handling make it difficult to identify which approach yields the highest fusion rate. This paper reviews studies that compared the lumbosacral fusion rates achieved with different surgical techniques. Methods Relevant randomized trials comparing the fusion rates of different surgical approaches for instrumented lumbosacral spinal fusion surgery were identified through highly sensitive and targeted keyword search strategies. A methodological quality assessment was performed according to the checklist suggested by the Cochrane Collaboration Back Review Group. Qualitative analysis was performed. Results A literature search identified six randomized controlled trials (RCTs) comparing the fusion rates of different surgical approaches. One trial compared anterior lumbar interbody fusion (ALIF) plus adjunctive posterior transpedicular instrumentation with circumferential fusion and posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF). Three studies compared PLF with circumferential fusion. One study compared three fusion approaches: PLF, PLIF and circumferential fusion. Conclusions One low quality RCT reported no difference in fusion rate between ALIF with posterior transpedicular instrumentation and circumferential fusion, and PLIF and circumferential fusion. There is moderate evidence suggesting no difference in fusion rate between PLF and PLIF. The evidence on the fusion rate of circumferential fusion compared to PLF from qualitative analysis was conflicting. However, no general conclusion could be made due to the scarcity of data, heterogeneity of the trials included, and some methodological defects of the six studies reviewed.
Lee, Choon Sung; Lee, Dong-Ho; Kim, Yung-Tae; Lee, Hee Sang
Study Design. Prospective clinical study. Objective. This study compares the clinical results of anterior lumbar total disc replacement and posterior transpedicular dynamic stabilization in the treatment of degenerative disc disease. Summary and Background Data. Over the last two decades, both techniques have emerged as alternative treatment options to fusion surgery. Methods. This study was conducted between 2004 and 2010 with a total of 50 patients (25 in each group). The mean age of the patients in total disc prosthesis group was 37,32 years. The mean age of the patients in posterior dynamic transpedicular stabilization was 43,08. Clinical (VAS and Oswestry) and radiological evaluations (lumbar lordosis and segmental lordosis angles) of the patients were carried out prior to the operation and 3, 12, and 24 months after the operation. We compared the average duration of surgery, blood loss during the surgery and the length of hospital stay of both groups. Results. Both techniques offered significant improvements in clinical parameters. There was no significant change in radiologic evaluations after the surgery for both techniques. Conclusion. Both dynamic systems provided spine stability. However, the posterior dynamic system had a slight advantage over anterior disc prosthesis because of its convenient application and fewer possible complications.
Oktenoglu, Tunc; Ozer, Ali Fahir; Sasani, Mehdi; Ataker, Yaprak; Gomleksiz, Cengiz; Celebi, Irfan
A 77-year-old male presented with a history of severe lower back pain for 10 years with radiculopathy, positive claudication type symptoms in his calf with walking, and severe "burning" in his legs bilaterally with walking. Magnetic resonance imaging (MRI) revealed lumbar stenosis at the L3-L4 and L4-L5 levels. During the direct or extreme lateral interbody fusion (DLIF/XLIF) procedure, bilateral posterior tibial, femoral, and ulnar nerve somatosensory evoked potentials (SSEPs) were recorded with good morphology of waveforms observed. Spontaneous electromyography (S-EMG) and triggered electromyography (T-EMG) were recorded from cremaster and ipsilateral leg muscles. A left lateral retroperitoneal transpsoas approach was used to access the anterior disc space for complete discectomy, distraction, and interbody fusion. T-EMG ranging from 0.05 to 55.0 mA with duration of 200 microsec was used for identification of the genitofemoral nerve using a monopolar stimulator during the approach. The genitofemoral nerve (L1-L2) was identified, and the guidewire was redirected away from the nerve. Post-operatively, the patient reported complete pain relief and displayed no complications from the procedure. Intraoperative SSEPs, S-EMG, and T-EMG were utilized effectively to guide the surgeon's approach in this DLIF thereby preventing any post-operative neurological deficits such as damage to the genitofemoral nerve that could lead to groin pain. PMID:21313792
Jahangiri, Faisal R; Sherman, Jonathan H; Holmberg, Andrea; Louis, Robert; Elias, Jeff; Vega-Bermudez, Francisco
Introduction. The use of extreme lateral interbody fusion (XLIF) and other lateral access surgery is rapidly increasing in popularity. However, limited data is available regarding its use in scoliosis surgery. The objective of this study was to evaluate the clinical outcomes of adults with degenerative lumbar scoliosis treated with XLIF. Methods. Thirty consecutive patients with adult degenerative scoliosis treated by a single surgeon at a major academic institution were followed for an average of 14.3 months. Interbody fusion was completed using the XLIF technique with supplemental posterior instrumentation. Validated clinical outcome scores were obtained on patients preoperatively and at most recent follow-up. Complications were recorded. Results. The study group demonstrated improvement in multiple clinical outcome scores. Oswestry Disability Index scores improved from 24.8 to 19.0 (P?0.001). Short Form-12 scores improved, although the change was not significant. Visual analog scores for back pain decreased from 6.8 to 4.6 (P?0.001) while scores for leg pain decreased from 5.4 to 2.8 (P?0.001). A total of six minor complications (20%) were recorded, and two patients (6.7%) required additional surgery. Conclusions. Based on the significant improvement in validated clinical outcome scores, XLIF is effective in the treatment of adult degenerative scoliosis.
Caputo, Adam M.; Michael, Keith W.; Chapman, Todd M.; Massey, Gene M.; Howes, Cameron R.; Isaacs, Robert E.; Brown, Christopher R.
STUDY DESIGN:: A retrospective study. OBJECTIVE:: To determine the clinical and radiological outcomes of the long-term results of instrumented MIS-TLIF in unstable, single level, low-grade, isthmic spondylolisthesis (IS) or degenerative spondylosis (DS) including degenerative spondylolisthesis, foraminal stenosis with central stenosis, degenerative disc disease, and recurrent disc herniation. SUMMARY OF BACKGROUND DATA:: MIS-TLIF is a common surgical procedure to treat lumbar spondylolisthesis. However, there are no studies that have documented the long-term results of MIS-TLIF. METHODS:: Forty-four patients who had undergone instrumented MIS-TLIF between July 2003 and January 2005, were retrospectively reviewed. The Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), patient satisfaction rate (PSR), and the patient's return-to-work status were used to assess clinical and functional outcomes. Radiological follow-up were carried out in patients to check for adjacent segmental degeneration (ASD). The plain radiographs, CT and MRI were used in all patients in last follow-up period. RESULTS:: The mean VAS scores for back and leg pain decreased from 5.8 and 7 to 3.5 and 3.7 respectively in the DS group (n=19) and from 6.8 and 6.9 to 1.8 and 2.0 respectively in the IS group (n=25) (P<0.001). The mean ODI scores improved from 61.7% to 21.5% in the DS group and from 53.9% to 16% in the IS group (P<0.001). PSR was 80% and 81% in the DS and IS groups, respectively. Evidence of fusion was observed radiologically in 24 (96%) and 19 (100%) of the patients in the IS and the DS group respectively, giving an overall fusion rate of 97.7% (43/44). The final ASD rate, observed using radiography, was 68.4% (13/19) in the DS, and 40% (10/25) in the IS group. However, 15.8% (3/19) in the DS and 4% (1/25) in the IS group had symptoms associated with ASD. CONCLUSIONS:: The long-term clinical and radiologic outcomes after instrumented MIS-TLIF in patients with unstable single-level spine are favorable. PMID:23027364
Kim, Jin-Sung; Jung, Byungjoo; Lee, Sang-Ho
Summary ?This retrospective study compares clinical outcome following two different types of surgery for thoracolumbar burst fractures.\\u000a Forty-six patients with thoracolumbar burst fractures causing encroachment of the spinal canal greater than 50% were operated\\u000a on within 30 days performing either: combined anterior decompression and stabilisation and posterior stabilisation (Group\\u000a 1) or posterior distraction and stabilisation using pedicle instrumentation (AO internal fixator)
H. D. Been; G. J. Bouma
Purpose The proposed the thoracolumbar injury classification system (TLICS) for thoracolumbar injury cites the integrity of the posterior ligamentous complex (PLC). However, no report has elucidated the severity of damage in thoracic and lumbar injury with classification schemes by presence of the PLC injury. The purpose of this study was to accurately assess the severity of damage in thoracic and lumbar burst fractures with the PLC injuries. Materials and Methods One hundred consecutive patients treated surgically for thoracic and lumbar burst fractures were enrolled in this study. There were 71 men and 29 women whose mean age was 36 years. Clinical and radiologic data were investigated, and the thoracolumbar injury classification schemes were also evaluated. All patients were divided into two groups (the P group with PLC injuries and the C group without PLC injuries) for comparative examination. Results Fourth-one of 100 cases showed PLC injuries in MRI study. The load sharing classification score was significantly higher in the P group [7.8±0.2 points for the P group and 6.9±1.1 points for the C group (p<0.001)]. The TLICS (excluded PLC score) score was also significantly higher in the P group [6.2±1.1 points for the P group and 4.0±1.4 points for the C group (p<0.001)]. Conclusion The presence of PLC injury significantly influenced the severity of damage. In management of thoracic lumbar burst fractures, evaluation of PLC injury is important to accurately assess the severity of damage.
Yukawa, Yasutsugu; Ito, Keigo; Kanbara, Shunsuke; Morita, Daigo; Kato, Fumihiko
Extreme lateral interbody fusion (XLIF; NuVasive Inc., San Diego, CA, USA) is a minimally invasive lateral transpsoas approach to the thoracolumbar spine. Though the procedure is rapidly increasing in popularity, limited data is available regarding its use in deformity surgery. We aimed to evaluate radiographic correction using XLIF in adults with degenerative lumbar scoliosis. Thirty consecutive patients were followed for an average of 14.3months. Interbody fusion was completed using the XLIF technique with supplemental posterior instrumentation. Plain radiographs were obtained on all patients preoperatively, postoperatively, and at most recent follow-up. Plain radiographic measurements of coronal Cobb angle, apical vertebral translation, segmental lordosis, global lordosis, disc height, neuroforaminal height and neuroforaminal width were made at each time point. CT scans were obtained for all patients 1year after surgery to evaluate for fusion. There was significant improvement in multiple radiographic parameters from preoperative to postoperative. Cobb angle corrected 72.3%, apical vertebral translation corrected 59.7%, neuroforaminal height increased 80.3%, neuroforaminal width increased 7.4%, and disc height increased 116.7%. Segmental lordosis at L4-L5 increased 14.1% and global lordosis increased 11.5%. There was no significant loss of correction from postoperative to most recent follow-up. There was an 11.8% pseudoarthrosis rate at levels treated with XLIF. Complications included lateral incisional hernia (n=1), rupture of anterior longitudinal ligament (n=2), wound breakdown (n=2), cardiac instability (n=1), pedicle fracture (n=1), and nonunion requiring revision (n=1). XLIF significantly improves coronal plane deformity in patients with adult degenerative scoliosis. XLIF has the ability to correct sagittal plane deformity, although it is most effective at lower lumbar levels. PMID:23906522
Caputo, Adam M; Michael, Keith W; Chapman, Todd M; Jennings, Jason M; Hubbard, Elizabeth W; Isaacs, Robert E; Brown, Christopher R
The purpose of the study was to evaluate the efficiency of patient-controlled analgesia (PCA) combined with continuous epidural\\u000a block in patients who underwent lumbar spine surgery. In group 1 (postoperative PCA group), 23 patients were administered\\u000a postoperative continuous epidural block in combination with analgesics, which was self-regulated by the patient using a device.\\u000a In contrast, the 22 patients in group
H. Matsui; M. Kanamori; N. Terahata; K. Miaki; N. Makiyama; T. Satone; H. Tsuji
The in vitro multidirectional flexibility analysis was conducted to investigate the initial biomechanical effect of biomimetic artificial intervertebral disc replacement from either anterior or posterior approach in a cadaveric lumbosacral spine model. Two designs of anterior total and posterior subtotal artificial discs were developed using bioactive three-dimensional fabric and bioresorbable hydroxyapatite\\/poly-l-lactide material (3DF disc). Both models were designed to obtain
Yoshihisa Kotani; Bryan W. Cunningham; Kuniyoshi Abumi; Anton E. Dmitriev; Niabin Hu; Manabu Ito; Yasuo Shikinami; Paul C. McAfee; Akio Minami
Surgery of lumbar disc herniation is still a problem since Mixter and Barr. Main trouble is dissatisfaction after the operation. Today there is a debate on surgical or conservative treatment despite spending great effort to provide patients with satisfaction. The main problem is segmental instability, and the minimally invasive approach via microscope or endoscope is not necessarily appropriate solution for all cases. Microsurgery or endoscopy would be appropriate for the treatment of Carragee type I and type III herniations. On the other hand in Carragee type II and type IV herniations that are prone to develop recurrent disc herniation and segmental instability, the minimal invasive techniques might be insufficient to achieve satisfactory results. The posterior transpedicular dynamic stabilization method might be a good solution to prevent or diminish the recurrent disc herniation and development of segmental instability. In this study we present our experience in the surgical treatment of disc herniations.
Ozer, A. F.; Keskin, F.; Oktenoglu, T.; Suzer, T.; Ataker, Y.; Gomleksiz, C.; Sasani, M.
Decompression surgery for lumbar spinal stenosis is a common procedure. After surgery, segmental instability sometimes occurs, therefore, different methods for restabilization have been developed. Dynamic stabilization systems have been designed to improve segmental stability. In this study, clinical results of patients with lumbar spinal stenosis that underwent decompression and stabilization with the Accuflex dynamic system are presented; clinical, radiographic, and magnetic resonance imaging (MRI) findings are fully described. Improvements in all clinical measurements, including visual analog scale for back and leg pain, Oswestry disability index, and SF-36 health status survey were noticed. At a 2-year follow-up, 22.22% of patients required hardware removal due to fatigue while in 83% of them no progression of disk degeneration was observed after implantation of the Accuflex system. Additionally, as demonstrated by the MRI images at follow up, three patients (16%) showed disk rehydration with one grade higher on the Pfirmann classification. Although a relatively high hardware failure was observed (22.22%), the use of the dynamic stabilization system Accuflex posterior to decompression procedures, showed clinical benefits and stopped the degenerative process in 83% the patients.
Reyes-Sanchez, Alejandro; Ramirez-Mora, Isabel; Rosales-Olivarez, Luis Miguel; Alpizar-Aguirre, Armando; Sanchez-Bringas, Guadalupe
In the following study the use of cages and autogenous bone grafts were compared in the operative treatment of isthmic spondylolisthesis with the posterior stabilization and Anterior Lumbosacral Interbody Fusion (ALIF). 55 patients were divided into two groups. Autogenous bone grafts were used in the first group (34 patients) and titanium interbody implants (cages) in the second group (21 patients). The mean follow up period in the first group was 8.6 years and 3.4 years in the second group. The radiological outcome was based upon the evaluation of the degree of spondylolisthesis, the angle of the lumbar lordosis, the height of the interbody space and intervertebral foramen and the evaluation of the spinal fusion. The objective clinical outcome assessment was based on Oswestry Disability Index. Subjective clinical evaluation was performed with the use of Visual Analog Pain Score (VAS) and the two questions concerning the evaluation of success of the operative treatment and a possible agreement to the following operation if necessary. The use of autogenous bone grafts alone in ALIF was related to the significant loss of achieved segmental spine anatomy restoration. The implantation of the cages prevented the loss of slippage correction, permanently reconstructed the anatomical conditions in the area of the operated spinal segment. PMID:22744517
Pankowski, Rafal; Smoczynski, Andrzej; Roclawski, Marek; Ceynowa, Marcin; Kloc, Wojciech; Wasilewski, Wojciech; Jende, Piotr; Liczbik, Wieslaw; Beldzinski, Piotr; Libionka, Witold; Pierzak, Olaf; Adamski, Stanislaw; Niedbala, Miroslaw
The objectives of this study were to examine charge data and long-term outcomes of two approaches for anterior lumbar interbody fusion (IF) through retrospective chart review: a mini-open lateral interbody fusion (“XLIF”) and an Open anterior interbody fusion (ALIF). Of 202 patients who underwent one-level or two-level surgery, 87 underwent ALIF and 115 underwent XLIF, all with transpedicular fixation. Complications
William D. Smith; Ginger Christian; Sherrie Serrano; Kyle T. Malone
This study investigates the biomechanical stability of a large interbody spacer inserted by a lateral approach and compares the biomechanical differences with the more conventional transforaminal interbody fusion (TLIF), with and without supplemental pedicle screw (PS) fixation. Twenty-four L2-L3 functional spinal units (FSUs) were tested with three interbody cage options: (i) 18?mm XLIF cage, (ii) 26?mm XLIF cage, and (iii) 11?mm TLIF cage. Each spacer was tested without supplemental fixation, and with unilateral and bilateral PS fixation. Specimens were subjected to multidirectional nondestructive flexibility tests to 7.5?N·m. The range of motion (ROM) differences were first examined within the same group (per cage) using repeated-measures ANOVA, and then compared between cage groups. The 26?mm XLIF cage provided greater stability than the 18?mm XLIF cage with unilateral PS and 11?mm TLIF cage with bilateral PS. The 18?mm XLIF cage with unilateral PS provided greater stability than the 11?mm TLIF cage with bilateral PS. This study suggests that wider lateral spacers are biomechanically stable and offer the option to be used with less or even no supplemental fixation for interbody lumbar fusion. PMID:23213284
Pimenta, Luiz; Turner, Alexander W L; Dooley, Zachary A; Parikh, Rachit D; Peterson, Mark D
This study investigates the biomechanical stability of a large interbody spacer inserted by a lateral approach and compares the biomechanical differences with the more conventional transforaminal interbody fusion (TLIF), with and without supplemental pedicle screw (PS) fixation. Twenty-four L2-L3 functional spinal units (FSUs) were tested with three interbody cage options: (i) 18?mm XLIF cage, (ii) 26?mm XLIF cage, and (iii) 11?mm TLIF cage. Each spacer was tested without supplemental fixation, and with unilateral and bilateral PS fixation. Specimens were subjected to multidirectional nondestructive flexibility tests to 7.5?N·m. The range of motion (ROM) differences were first examined within the same group (per cage) using repeated-measures ANOVA, and then compared between cage groups. The 26?mm XLIF cage provided greater stability than the 18?mm XLIF cage with unilateral PS and 11?mm TLIF cage with bilateral PS. The 18?mm XLIF cage with unilateral PS provided greater stability than the 11?mm TLIF cage with bilateral PS. This study suggests that wider lateral spacers are biomechanically stable and offer the option to be used with less or even no supplemental fixation for interbody lumbar fusion.
Pimenta, Luiz; Turner, Alexander W. L.; Dooley, Zachary A.; Parikh, Rachit D.; Peterson, Mark D.
Stimulation of the posterior tibial nerve has been associated with different somatosensory evoked potentials (SEP) recorded along the spine and thorax. The aim of this study was to register and describe the magnetic fields corresponding to different components of spinal SEP after stimulation of tibial nerves. In nine healthy subjects, right and left posterior tibial nerves were transcutaneously electrostimulated at the ankles. Neuromagnetic fields were registered over a circular 800 cm(2) area of the lumbosacral spine using a 61-channel biomagnetometer. Magnetic field maps were constructed and examined visually for dipolar patterns. Equivalent current dipoles (ECD) were calculated for each somatosensory evoked field (SEF) using a least-squares fit in a spherical model. In seven subjects dipolar SEF were detected over the lower back at two separate latencies and locations and propagating ECD could be localized. Both the first and second components found agreed anatomically and functionally with respect to propagation in the underlying nerve fibers. It was possible to record and identify SEF which correspond to the SEP described in the literature. Dipole localization based on an equivalent current dipole model allowed a basic evaluation of the plausibility of the measurements with respect to the processes being examined. PMID:16705268
Klein, Anita; van Leeuwen, Peter; Hoormann, Jörg; Grönemeyer, Dietrich
We report a pediatric baseball player having both a fracture of the posterior ring apophysis and spondylolysis. He was presented to a primary care physician complaining of back pain and leg pain. Despite conservative treatment for 3 months, the pain did not subside. He was referred to our clinic, and surgical intervention was carried out. First, a bony fragment of the caudal L5 apophyseal ring was removed following fenestration at the L5-S interlaminal space, bilaterally: and decompression of the bilateral S1 nerve roots was confirmed. Next, pseudoarthrosis of the L5 pars was refreshed and pedicle screws were inserted bilaterally. A v-shaped rod was inserted beneath the L5 spinous process, which stabilized the pars defects. After the surgery, back pain and leg pain completely disappeared. In conclusion, the v-rod technique is appropriate for the spondylolysis direct repair surgery, especially, in case the loose lamina would have a partial laminotomy.
Sumita, Takayuki; Shibuya, Isao; Kitahama, Yoshihiro; Kanamori, Yasuo; Matsumoto, Hironori; Koga, Soichi; Kitagawa, Yasuhiro; Dezawa, Akira
Decompression surgery for lumbar spinal stenosis is a common procedure. After surgery, segmental instability sometimes occurs,\\u000a therefore, different methods for restabilization have been developed. Dynamic stabilization systems have been designed to\\u000a improve segmental stability. In this study, clinical results of patients with lumbar spinal stenosis that underwent decompression\\u000a and stabilization with the Accuflex dynamic system are presented; clinical, radiographic, and
Alejandro Reyes-SanchezBaronZ; Barón Zárate-Kalfópulos; Isabel Ramírez-Mora; Luis Miguel Rosales-Olivarez; Armando Alpizar-Aguirre; Guadalupe Sánchez-Bringas
There are many issues to consider in evaluating the biomechanics of lumbar arthroplasty, which may consist of a nucleus replacement, a total disc replacement, or a mobile posterior device. The goal of spinal arthroplasty is to replicate or augment the function of the normal spinal elements, by taking into consideration both in the quantity and quality of motion that occurs across the replaced joint. This article describes the relevant parameters for studying the biomechanics of lumbar arthroplasty and briefly summarizes the current knowledge with regard to those parameters in some well-known lumbar nucleoplasty, facet replacement, and total disc arthroplasty devices. PMID:16326282
Crawford, Neil R
Background: The authors' concept of reduction and stabilization of thoracolumbar fractures has become more sophisticated. Depending upon the fracture classification, a posterior transpedicular, an isolated anterior or a combined approach is used. Fractures with a low degree of vertebral body comminution and only one-space disk injury are reduced and stabilized by the transpedicular approach. For reliable anterior interbody fusion, the
Peter Wendsche; Ján Ko?iš; Petr Viš?a; Vladimír Mužík
Study Design. A prospective randomized study inves- tigated the radiographic progress of fusion at 6, 12, and 24 months in 42 patients who underwent a single-level anterior lumbar interbody fusion using cylindrical inter- body fusion cages. Objective. To determine the patterns and rates of os- teoinduction associated with the use of recombinant hu- man bone morphogenetic protein type 2 (rhBMP-2)
J. Kenneth Burkus; John D. Dorchak; D. Lynn Sanders
The benefits of anterior interbody arthrodesis in deformity surgery are well known and include load sharing and increased fusion rates. A minimally invasive lateral transpsoas approach to the anterior lumbar spine is a promising alternative to traditional interbody techniques for the treatment of adult degenerative scoliosis. The reported advantages of the minimally invasive lateral transpsoas approach include reduced blood loss and shorter length of stay. However, there are several approach-related complications associated with this technique including injury to the nerves within the abdominal wall leading to abdominal wall paresis, bowel injury, and injury to the lumbar plexus. In this video, we demonstrate the key steps of the minimally invasive lateral retroperitoneal transpsoas technique for interbody fusion in the treatment of adult degenerative scoliosis. The video demonstrates patient positioning, surgical opening, passage through the anatomical safe zone, use of multidirectional EMG to navigate away from the lumbar plexus, placement of the expandable retractor, discectomy, endplate preparation, graft insertion, and wound closure. Special emphasis is placed on the approach. We highlight the relevant nerves passing through the abdominal wall with the aid of a microscope. The video can be found here: http://youtu.be/XU1OujNF8F8. PMID:23829840
Amin, Beejal Y; Mummaneni, Praveen V; Ibrahim, Tarik; Zouzias, Alex; Uribe, Juan
Acute unstable thoracic and lumbar spine fractures were treated with either Harrington rods and hooks, Luque rods with sublaminar wires, or A-O dynamic compression plates with pedicle screws. The results demonstrated failure of all three techniques to maintain the sagittal plane correction at 12 months' follow-up. Furthermore, in lumbar fractures, Harrington rods did not restore or maintain sagittal plane alignment as well as Luque rods or pedicle screws and plates. Lastly, the pedicle screw fixation system required a shorter segment fusion. PMID:8470006
Sasso, R C; Cotler, H B
Objectives: To describe an electrophysiological method for determining the relation between lumbar cord dorsal roots and cathode of epidural electrode for spinal cord stimulation (SCS).Materials and methods: Data has been collected from 13 subjects who have been under evaluation of effectiveness of SCS for control of spasticity. Induced muscle twitches from both quadriceps (Q), adductors (A), hamstrings (H), tibial anterior
M Murg; H Binder
Posterior cervical decompression and fusion can be performed for various spinal conditions. Previous rates of pseudoarthrosis have been reported in up to 38% of patients. The use of bone morphogenic protein (BMP) has been approved for use in certain anterior lumbar interbody fusion techniques to decrease the incidence of pseudoarthrosis. Bone morphogenic protein in the anterior cervical spine carries a potential increased risk of airway complications; however, few data exist on the safety and efficacy of BMP in the posterior cervical spine. The purpose of this study was to evaluate fusion success, safety, and heterotopic bone formation using BMP in posterior cervical fusion.Twenty-nine patients who received posterior cervical fusion with BMP were followed for a minimum of 12 months. Computed tomography scans were obtained at a minimum of 12 months postoperatively to evaluate for solid arthrodesis and the presence of heterotopic bone formation. Patients' demographic data and adverse events were evaluated. All patients underwent posterior cervical decompression and instrumented fusion of at least 1 level between 2006 and 2008. Of 37 patients eligible for the study, 29 agreed to participate. Three (10.3%) of 29 patients developed pseudoarthrosis, as found on computed tomography scan. None of these went on to further surgery. No evidence existed of heterotopic bone formation outside of the lateral masses or bone growth over the spinal canal or neuroforamen. No adverse events were related to the use of BMP in this series of posterior cervical fusions. Bone morphogenic protein can be used safely in posterior cervical spine fusion, but additional larger studies are recommended. Even with the use of bone morphogenic protein, the possibility of pseudoarthrosis exists. PMID:22691663
Hodges, Scott D; Eck, Jason C; Newton, Danette
Osteoplastic laminectomy has been used to treat lumbar canal stenosis and to prevent postoperative lumbar spinal instability by reconstructing the posterior element of the lumbar spine, which has been documented in many clinical studies. However, the biological sequence of repairing the posterior lumbar element, which is replaced at the time of surgery, has not yet been made clear. An in
Zhenglin Li; Toshihiko Taguchi; Toshikazu Gondo; Shinya Kawai; Kouichiro Toyoda
Aims: To determine the surgical approach in patients with multisegmental (four or more segments) OPLL of the cervi- cal spine. Methods and Materials: Data of 27 patients who had undergone either an anterior (corpectomy with excision of OPLL and interbody fusion=14 patients) or posterior ap- proach (laminectomy=12, laminoplasty=1 patient) for the multisegmental cervical OPLL was analyzed retrospectively. The patients in
VijendraK Jain; SubodhK Jain; PravinS Salunke; KH Vyas; SanjayS Behari; Deepu Banerji
Abducens nerve palsy associated with spinal surgery is extremely rare. We report an extremely rare case of abducens nerve palsy after lumbar spinal fusion surgery with inadvertent dural tearing, which resolved spontaneously and completely. A 61-year-old previous healthy man presented with chronic lower back pain of 6 weeks duration and 2 weeks history of bilateral leg pain. He was diagnosed as having isthmic spondylolisthesis at L4-5 and L5-S1, and posterior lumbar interbody fusion was conducted on L4-5 and L5-S1. During the operation, inadvertent dural tearing occurred, which was repaired with a watertight dural closure. The patient recovered uneventfully from general anesthesia and his visual analogue pain scores decreased from 9 pre-op to 3 immediately after his operation. However, on day 2 he developed headache and nausea, which were severe when he was upright, but alleviated when supine. This led us to consider the possibility of cerebrospinal fluid leakage, and thus, he was restricted to bed. After an interval of bed rest, the severe headache disappeared, but four days after surgery he experienced diplopia during right gaze, which was caused by right-side palsy of the abducens nerve. Under conservative treatment, the diplopia gradually disappeared and was completely resolved at 5 weeks post-op. PMID:20062577
Cho, Dae-Chul; Jung, Eul-Soo; Chi, Yong-Chul
Background To investigate how unilateral cage-instrumented posterior lumbar interbody fusion (PLIF) affects the three-dimensional flexibility in degenerative disc disease by comparing the biomechanical characteristics of unilateral and bilateral cage-instrumented PLIF. Methods Twelve motion segments in sheep lumbar spine specimens were tested for flexion, extension, axial rotation, and lateral bending by nondestructive flexibility test method using a nonconstrained testing apparatus. The specimens were divided into two equal groups. Group 1 received unilateral procedures while group 2 received bilateral procedures. Laminectomy, facectomy, discectomy, cage insertion and transpedicle screw insertion were performed sequentially after testing the intact status. Changes in range of motion (ROM) and neutral zone (NZ) were compared between unilateral and bilateral cage-instrumented PLIF. Results Both ROM and NZ, unilateral cage-instrumented PLIF and bilateral cage-instrumented PLIF, transpedicle screw insertion procedure did not revealed a significant difference between flexion-extension, lateral bending and axial rotation direction except the ROM in the axial rotation. The bilateral group's ROM (-1.7 ± 0. 8) of axial rotation was decreased significantly after transpedicle screw insertion procedure in comparison with the unilateral group (-0.2 ± 0.1). In the unilateral cage-instrumented PLIF group, the transpedicle screw insertion procedure did not demonstrate a significant difference between right and left side in the lateral bending and axial rotation direction. Conclusions Based on the results of this study, unilateral cage-instrumented PLIF and bilateral cage-instrumented PLIF have similar stability after transpedicle screw fixation in the sheep spine model. The unilateral approach can substantially reduce exposure requirements. It also offers the biomechanics advantage of construction using anterior column support combined with pedicle screws just as the bilateral cage-instrumented group. The unpleasant effect of couple motion resulting from inherent asymmetry was absent in the unilateral group.
We present a case of syphilitic posterior placoid chorioretinitis, an uncommon but distinct ocular manifestation of syphilis. Because of the ocular findings, a lumbar puncture was performed to evaluate for neurosyphilis, which was positive. The ocular symptoms resolved with intravenous penicillin. PMID:24113406
Gorovoy, Ian R; Desai, Shilpa
From April 1989 to April 1990, 13 patients with cervical spinal fracture/dislocation, spondylosis or metastasis were treated at the respective hospitals. There were 4 women and 9 men whose ages ranged from 25 to 70 years (mean 45 years). All of them were treated with neural decompression, bone grafting and anterior spinal interbody fusion. All iliac crest or fibular bone grafts were anchored to the vertebral bodies with plates and screws. The clinical outcomes were evaluated retrospectively. The results showed that all had improvement of neurological symptoms and signs. The radiographic evaluation revealed satisfactory alignment and sound union of the cervical spine in all 13 patients. No serious complications were found except screw loosening in two instances without impairment of clinical results. We concluded that anterior cervical plates provide effective stabilization which is essential for good results. Furthermore, from this study and a review of the literature, we advocated that it was not necessary for the tip of the screws to reach or even penetrate the posterior cortex of the vertebral body. PMID:1678412
Chen, I H; Yang, R S; Chen, P Q
STUDY DESIGN:: Cadaveric Biomechanical and Radiographical Analysis. OBJECTIVE:: The purpose of this study was to quantify the changes in intervertebral height and lateral and central recess areas afforded by lateral interbody fusion cages with two supplemental forms of internal fixation in cadaveric specimens. BACKGROUND DATA:: When conservative treatment for symptomatic lumbar stenosis fails, traditional intervention has been direct posterior decompression. The minimally invasive, lateral transpsoas approach may be a viable alternative to direct decompression by providing restoration of the foraminal and intervertebral dimensions, yet few reports have examined the anatomical and radiographical changes that occur using this technique. METHODS:: Computed tomography scans were taken of eighteen intact lumbar (L1-S1) cadaveric specimens under a 400 N pre-load. Intervertebral height, foraminal areas, and canal area were measured at L3-L4 and L4-L5. Thereafter, the cadaveric specimens were instrumented with lateral cages placed in the central or posterior third of the disc space at L3-L4 and L4-L5 and either (1) lateral plate (n=9) or (2) bilateral posterior pedicle screw fixation (n=9). All constructs were again subjected to a 400 N pre-load, post-instrumentation CT scans were taken, and changes in intervertebral height and lateral and central recess areas were calculated. RESULTS:: There was no effect of cage placement on any radiographic metric of indirect decompression for either fusion construct. In the lateral plate and pedicle screw groups, respectively, significant increases in average posterior disc height (30.9%, 60.1%), average right (35.3%, 61.5%) and left foraminal area (48.3%, 57.8%) and average canal area (32.3%, 33.3%) were observed. Pedicle screw instrumentation afforded a significantly greater increase in average posterior disc height and foraminal area compared to the lateral plate group, though there was no difference in the average increase in canal area afforded by either form of fixation. CONCLUSIONS:: The radiographic results reported here using a cadaveric model add validity to the underlying rationale described for the minimally invasive lateral approach technique. Increases in disc height, foraminal and canal areas were not dependent on cage positioning within the disc space. As intra-operative placement of a cage in the central portion of the disc is an easier and safer technique, our results suggest that central placement may be preferable in a clinical setting. PMID:23563336
Marulanda, German A; Nayak, Aniruddh; Murtagh, Ryan; Santoni, Brandon G; Billys, James B; Castellvi, Antonio E
Retrospective radiographic review of surgically treated double major curves (Lenke type 3C) in adolescent idiopathic scoliosis.\\u000a To evaluate the role of selective posterior thoracic correction and fusion in double major curves with third generation instrumentation\\u000a and to identify preoperative radiographic parameters that predict postoperative coronal spinal decompensation. Traditionally\\u000a the surgical treatment of double major curves consists of fusion of both
Hannes Behensky; Ashley A. Cole; Brian J. C. Freeman; Michael P. Grevitt; Hossein S. Mehdian; John K. Webb
Purpose Extreme lateral interbody fusion (XLIF) is a method for stabilization of the lumbar spine. Intraoperatively, the surgeon identifies\\u000a the lumbar nerve roots with a stimulator to prevent their injury. The objective of this study was to determine the extent\\u000a to which shallow rocuronium-induced neuromuscular block must be intraoperatively reversed for reliable identification of nerve\\u000a roots.\\u000a \\u000a \\u000a \\u000a \\u000a Methods General anesthesia (midazolam–propofol–sufentanil–oxygen\\/air\\/sevoflurane–rocuronium) was administered
Milan Adamus; Lumir Hrabalek; Tomas Wanek; Tomas Gabrhelik; Jana Zapletalova
STUDY DESIGN:: The study used a rabbit model to achieve anterior vertebral interbody fusion using osteogenic mesenchymal stem cells (OMSCs) transplanted in collagen sponge. OBJECTIVE:: We investigated the effectiveness of graft material for anterior vertebral interbody fusion using a rabbit model by examining the OMSCs transplanted in collagen sponge. SUMMARYOF BACKGROUND DATA:: 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- and long- term morbidity. Recently, MSCs 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. METHODS:: Forty mature male White Zealand rabbits (weigh, 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 histological examination at 8 and 12 weeks after surgery. RESULTS:: New bone formation and bony fusion was evident as early as 8 weeks in group I and III. And there was no statistically significant difference between at 8 and 12 weeks. At both time points, by microcomputed tomography and histological analysis, new bone formation was observed in both group 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 in 0% (0/10) of rabbits in both group II and IV. CONCLUSION:: These findings suggest that MSCs that have been cultured with osteogenic differentiation medium and loaded with collagen sponge could induce bone formation and anterior vertebral interbody fusion. And the rabbit model we developed will be useful in evaluating the effects of graft materials for anterior vertebral interbody fusion. Further study is needed to determine the most appropriate carrier for OMSCs and the feasibility in the clinical setting. PMID:22576723
Yang, Wencheng; Dong, Youhai; Hong, Yang; Guang, Qian; Chen, Xujun
Purpose of study: The spectrum of discogenic pain syndrome ranges from internal disc disruption (IDD), degenerative disc disease (DDD) and segmental instability. After failure of conservative treatment, surgical options would include fusion. This study was performed to determine whether the results of fusion differ between IDD and DDD.Methods used: Patient and radiographic data were entered prospectively on 118 patients who
Ashraf Ragab; Mark Flanum; Charles Galanis; Thomas Zdeblick
Surgical treatment of thoracic disc herniation is technically challenging from anterior, lateral or posterior approaches. Because of the deeply located thoracic discs and non-retractable thoracic thecal sac, standard anterior and lateral procedures for discectomy require extensive tissue dissection causing prolonged lengths of stay in hospital. In this video, the authors present a case of calcified disc herniation at the level of T10/11 causing paraplegia and voiding difficulty. The patient was operated on via an endoscope-assisted minimally invasive transforaminal thoracic interbody fusion (EA-TTIF). The herniated disc and calcification were removed through a 26-mm tubular retractor, under microscopes via a unilateral transpedicular approach. The endoscopes were used for direct visualization of the ventral thecal sac and confirmation of complete decompression. After the operation, the patient's neurological function completely recovered. Minimally invasive EA-TTIF is a viable and effective option for the surgical management of thoracic disc herniation. Thoracic interbody fusion can be achieved through a minimally invasive approach from the back. The video can be found here: http://youtu.be/54rRMtvSyCM. PMID:23829841
Liao, Chih-Hsiang; Wu, Jau-Ching; Huang, Wen-Cheng; Wang, Wei-Hsin; Chang, Peng-Yuan; Cheng, Henrich; Yang-Shih
The purpose of this study was to evaluate the surgical indication and clinical outcomes of endoscopic decompression for lumbar spinal canal stenosis. From September 1998 to March 2002, 250 consecutive patients underwent posterior endoscopic surgery for lumbar radiculopathy. Among these patients, 27 were treated by posterior endoscopic decompression for lumbar canal stenosis. There were 19 men and 8 women, and
Munehito Yoshida; Akitaka Ueyoshi; Kazuhiro Maio; Masaki Kawai; Yukihiro Nakagawa
Object In this study the authors report on the clinical outcomes, safety, and efficacy of lateral retroperitoneal transpsoas minimally invasive surgery-lumbar interbody fusion (MIS-LIF) at the L4-5 disc space in patients with spondylolisthesis. This approach has become an increasingly popular means of fusion. Its most frequent complication is lumbar plexus injury. Reported complication rates at the L4-5 disc space vary widely in the literature, bringing into question the safety of MIS-LIF for the L4-5 region, especially in patients with spondylolisthesis. Methods The authors retrospectively reviewed prospectively acquired multicenter databases of patients with Grade I and II L4-5 spondylolisthesis who had undergone elective MIS-LIF between 2008 and 2011. Clinical follow-up had been scheduled for 1, 3, 6, 12, and 24 months postoperatively. Outcome measures included estimated blood loss, operative time, length of hospital stay, integrity of construct, complications, fusion rates, visual analog scale (VAS), Oswestry Disability Index (ODI), and 36-Item Short Form Health Survey (SF-36). Results Eighty-four patients with L4-5 MIS-LIF were identified, 31 of whom met the study inclusion criteria: 26 adults with Grade I and 5 adults with Grade II L4-5 spondylolisthesis who had undergone elective MIS-LIF and subsequent posterior percutaneous pedicle screw fixation without surgical manipulation of the posterior elements (laminectomy, foraminotomy, facetectomy). The study cohort consisted of 9 males (29%) and 22 females (71%) with an average age of 61.5 years. The mean total blood loss was 94 ml (range 20-250 ml). The mean hospital stay and follow-up were 3.5 days and 18.2 months, respectively. The average score on the ODI improved from 50.4 preoperatively to 30.9 at the last follow-up (p < 0.0001). The SF-36 score improved from 38.1 preoperatively to 59.5 at the last follow-up (p < 0.0001). The VAS score improved from 69.9 preoperatively to 38.7 at the last follow-up (p < 0.0001). No motor weakness or permanent deficits were documented in any patient. Correction of deformity did not have any neurological complications. All patients had improvement in anterolisthesis. Residual postoperative listhesis across cases was noted in 4 patients (12.9%). Transient anterior thigh numbness (Sensory Dermal Zone III) was noted in 22.5% of patients. Conclusions With its established surgical corridors through the retroperitoneum and psoas muscle, the MIS-LIF combined with posterior percutaneous pedicle screw fixation/reduction is a safe, reproducible, and effective technique for patients with symptomatic degenerative spondylolisthesis at the L4-5 vertebral segment. PMID:23889186
Ahmadian, Amir; Verma, Sean; Mundis, Gregory M; Oskouian, Rod J; Smith, Donald A; Uribe, Juan S
Recombinant human bone morphogenetic protein-2 (rhBMP-2) promotes the induction of bone growth and is widely used in spine surgery to enhance arthrodesis. Recombinant human BMP-2 has been associated with a variety of complications including ectopic bone formation, adjacent-level fusion, local bone resorption, osteolysis, and radiculitis. Some of the complications associated with rhBMP-2 may be the result of rhBMP-2 induction of the inflammatory host response. In this paper the authors report on a patient with prior transforaminal lumbar interbody fusion (TLIF) using an interbody cage packed with rhBMP-2, in which rhBMP-2 possibly contributed to vascular injury during an attempted anterior lumbar interbody fusion. This 63-year-old man presented with a 1-year history of worsening refractory low-back pain and radiculopathy caused by a Grade 1 spondylolisthesis at L4-5. He underwent an uncomplicated L4-5 TLIF using an rhBMP-2-packed interbody cage. Postoperatively, he experienced marginal improvement of his symptoms. Within the next year and a half the patient returned with unremitting low-back pain and neurogenic claudication that failed to respond to conservative measures. Radiological imaging of the patient revealed screw loosening and pseudarthrosis. He underwent an anterior retroperitoneal approach with a plan for removal of the previous cage, complete discectomy, and placement of a femoral ring. During the retroperitoneal approach the iliac vein was adhered with scarring and fibrosis to the underlying previously operated L4-5 interbody space. During mobilization the left iliac vein was torn, resulting in significant blood loss and cardiac arrest requiring chest compression, defibrillator shocks, and blood transfusion. The patient was stabilized, the operation was terminated, and he was transferred to the intensive care unit. He recovered over the next several days and was discharged at his neurological baseline. The authors propose that the rhBMP-2-induced host inflammatory response partially contributed to vessel fibrosis and scarring, resulting in the life-threatening vascular injury during the reoperation. Spine surgeons should be aware of this potential inflammatory fibrosis in addition to other reported complications related to rhBMP-2. PMID:23560709
Rodgers, Shaun D; Marascalchi, Bryan J; Grobelny, Bartosz T; Smith, Michael L; Samadani, Uzma
Extreme lateral interbody fusion (XLIF) is a relatively new procedure for the treatment of degenerative disc disease avoiding the morbidity of anterior approaches. Ipsilateral L2-5 nerve root irritation and injury are well-described complications. We describe two patients with contralateral extremity symptoms, not reported so far. In the first patient the injury was caused by a displaced endplate fragment compressing the contralateral nerve root; in the second patient, the injury resulted from a far-lateral herniation after the XLIF procedure. Both patients experienced resolution of their symptoms after being reoperated. Overall, this complication was encountered in 2/32 levels treated during the study period. Overzealous endplate removal and breaking of the osteophytes in the opposite corner of the intervertebral disc, although desirable for maximal coronal deformity correction, may lead to irritation of the contralateral nerve roots. Attention is needed especially where the interbody cage is placed posteriorly or diagonally towards the neuralforamen. PMID:20965732
Papanastassiou, Ioannis D; Eleraky, Mohammad; Vrionis, Frank D
Autogenous tricortical iliac crest bone graft is the most widely used for the anterior cervical interbody fusion procedure. The authors performed systematic measurements to delineate the thickest areas of the iliac crest, so that surgeons would know where to select the appropriate grafts for cervical interbody fusion. The Department of Anatomy, Faculty of Medicine, Khon Kaen University, supplied 232 iliac crests (116 left; 116 right) dried hip bones donated by 67 Thai males and 49 Thai females. The deceased averaged 59 years of age (range, 26-86). The thickest part of the iliac crest extended from 3 to 5 cm posterior to the ASIS and ranged between 15.59 and 17.02 mm. These regions have an appropriate thickness for harvesting graft material. PMID:16518991
Khamanarong, Kimaporn; Kosuwon, Weerachai; Sirichativapee, Winai; Saejung, Surachai; Thepsuthammarat, Kaewjai
Background Unrecognized or untreated injury in patients with ankylosing spondylitis (AS) may develop anterior column spinal pseudoarthrosis with an open wedge bone defect. The methods of surgical treatment are controversial. Combined anterior and posterior stabilizations or posterior instrumentation with osteoclasis are beneficial as shown in an existing literature review.Case Report A 36-year-old Asian man with AS sustained a motor vehicle accident 2 years before presentation. At that time, his immediate magnetic resonance imaging scan demonstrated T10-T11bone edema and granulation tissue formation with fluid accumulation in T10-T11 disc space. He opted for conservative treatment. His back pain was then exacerbated 2 years after the accident, and he underwent three-dimensional (3D) computed tomography (CT) scan revealing a severe pseudoarthrosis with sclerotic margins across the T10 caudal end vertebra to the T11 upper end plate, with a maximal fracture gap of 15 mm. Spinal cord compression was not present. After selecting for an appropriate cage size with the aid of the preoperative 3D CT images, we used a single posterior approach to apply pedicle screws, removed pseudoarthrotic granulation tissue through an intertransverse posterior lateral approach without entering the spinal canal, and inserted a transforaminal lumbar interbody fusion (TLIF) cage with bone graft. There was radiographic evidence of spinal fusion at the 9-month follow-up, and the patient had resumed all normal daily activities.Conclusion The authors found that a less invasive single posterior surgical approach using a TLIF cage and pedicle screws could be applied to AS patients with combined thoracic pseudoarthrosis and an anterior column defect. Using a TLIF cage may provide circumferential stability immediately, bone graft fusion, and sagittal plane correction simultaneously. An appropriate cage size and placement selected with preoperative 3D CT images are the keys to success. PMID:23765917
Lo, Hung-Kai; Chiang, Tsay-I; Chang, Olivia Hui-Chiun; Chang, I-Chang
A prospective, single institution, clinical case-matched, radiographic study was undertaken. Thirty-two patients underwent posterior lumbar interbody fusion with cages containing laminectomized bone chips and posterolateral lumbar fusion with pedicle screws. Autogenous bone graft (3 mL) plus 3 mL of hydroxyapatite was placed in one side of a posterolateral gutter, and 6 mL of autogenous iliac bone graft was placed on the other side. Bony union, volumes of fusion mass, and bone absorption rates were postoperatively evaluated using simple radiographs and 3D-CT scans. Average postoperative Lenke scores at 3 and 6 months in the hydroxyapatite group were statistically higher than in the autograft group, but at 12 months no difference was found between the hydroxyapatite and autograft groups in terms of fusion rate. Complete fusion rates by 3D-CT were 86.7% in the hydroxyapatite group and 88.9% in the autograft group, which are not significantly different. Volumes of fusion mass and bone absorption rates at 12 months were 2.35 mL in the hydroxyapatite group and 1.31 mL in the autograft group. The mean fusion mass volume was greater in the hydroxyapatite group than in the autograft group. Lumbar posterolateral fusion using a mixture of hydroxyapatite artificial bone and autogenous bone graft showed good bony union similar to that shown with autogenous bone only. This study suggests that hydroxyapatite bone chips could be used usefully as a bone-graft extender in short-segment posterolateral spinal fusion. PMID:18615472
Lee, Jae Hyup; Hwang, Chang-Ju; Song, Byung-Wook; Koo, Ki-Hyung; Chang, Bong-Soon; Lee, Choon-Ki
Background contextThe XLP plate is an anterolateral instrumentation system developed as a part of the eXtreme Lateral Interbody Fusion (XLIF) system for lateral transpsoas interbody fusion, an alternative to anterior interbody fusion.
Karan Dua; Christopher K. Kepler; Russel C. Huang; Anna Marchenko
The surgical management of lumbar burst usually involves either a posterior or an anterior approach. Posterior-only procedures usually rely on ligamentotaxis or manual tamping of bone fragments for decompression of the spinal canal. Transpedicular corpectomies allow for circumferential surgery through a single posterior approach; however, they are rarely done for lumbar burst fractures. The presence of intervening nerve roots is
Dean Chou; Vincent Y. Wang; Nalin Gupta
Along this study, we evaluate an osseous substitute, natural Coral used in the lower cer-vical spine interbody fusions. We reviewed, in a retrospective study, 66 cases of lower cervical discopathies treated by radiculo-medullar decompression, coral arthrodesis and anterior osteosynthesis.
K. Ghiamphy; F. Gosset; P. Kehr
Introduction There are several practical problems encountered in the TLIF procedure with implantation of two titanium cages, such as difficulty\\u000a in achieving symmetric positioning with two cages, loosening of the first cage following insertion of the second cage and\\u000a higher direct costs to the patient.\\u000a \\u000a \\u000a \\u000a \\u000a Method From January 2005 to December 2007, a total of 76 consecutive patients treated with instrumented TLIF
Jian Zhou; Bo Wang; Jian Dong; Xilei Li; Xiaogang Zhou; Taolin Fang; Hong Lin
The viscoelastic lumbar disk prosthesis-elastic spine pad (LP-ESP(®)) is an innovative one-piece deformable but cohesive interbody spacer providing 6 full degrees of freedom about the 3 axes, including shock absorption. A 20-year research program has demonstrated that this concept provides mechanical properties very close to those of a natural disk. Improvements in technology have made it possible to solve the problem of the bond between the elastic component and the titanium endplates and to obtain an excellent biostability. The prosthesis geometry allows limited rotation and translation with resistance to motion (elastic return property) aimed at avoiding overload of the posterior facets. The rotation center can vary freely during motion. It thus differs substantially from current prostheses, which are 2- or 3-piece devices involving 1 or 2 bearing surfaces and providing 3 or 5 degrees of freedom. This design and the adhesion-molding technology differentiate the LP-ESP prosthesis from other mono-elastomeric prostheses, for which the constraints of shearing during rotations or movement are absorbed at the endplate interface. Seven years after the first implantation, we can document in a solid and detailed fashion the course of clinical outcomes and the radiological postural and kinematic behavior of this prosthesis. PMID:23412443
Lazennec, Jean-Yves; Aaron, Alain; Brusson, Adrien; Rakover, Jean-Patrick; Rousseau, Marc-Antoine
The posterior trunk roughly encompasses the upper back from the shoulders to the lumbar area above the iliac crests. Long-term outcomes in the treatment of defects of the spine and bony thorax have been proved superior if flaps were used. Many local muscle and fasciocutaneous flaps are available alternatives. A guideline, patterned according to arbitrary anatomic territories of the back, is suggested as a starting point for the selection of appropriate primary and secondary flap options. Depending on flap availability, the latissimus dorsi and trapezius muscles are the workhorse flaps for the upper back, whereas perforator flaps have become a useful alternative for the lumbar region in lieu of free flaps.
Hallock, Geoffrey G.
Lateral interbody cages have proven useful in lumbar fusion surgery. Spanning both lateral cortical rims while sparing the anterior longitudinal ligament, they restore disc height, improve coronal balance and add stability. The standard approach to their insertion is 90 degrees lateral transpsoas which is bloodless compared to other techniques of interbody cage insertion but requires neuro-monitoring and at L4/5 can be difficult because of iliac crest obstruction or an anterior plexus position. The oblique muscle-splitting approach with the patient in a lateral position, remains retroperitoneal, and on the left side enters the disc space through a window between psoas and the common iliac vein. Reports of this approach are few and none previously have described how to use the large lateral-type cages so effective at restoring spinal alignment. In this video we demonstrate our technique of anterior to psoas fusion of the lumbar spine with a retroperitoneal approach and gentle retraction of the psoas muscle. The video can be found here: http://youtu.be/OS2vNcX9JMA. PMID:23829843
Gragnaniello, Cristian; Seex, Kevin A
Gossypiboma is a mass formed by a retained surgical sponge and reactive tissue. The cases with gossypiboma are usually asymptomatic or with nonspecific symptoms, which delay diagnosis for months or years after surgery. We describe imaging findings in a 43-year-old woman with a symptomatic retained surgical sponge in a lumbar laminectomy site. Ultrasonography, computed tomography, magnetic resonance imaging (MRI), and diffusion-weighted MRI were performed. Gossypiboma should be considered in the differential diagnosis of a mass in a patient with a history of prior surgery. Diffusion-weighted MRI may provide important data for differential diagnosis of gossypiboma. With diffusion-weighted MRI, gossypiboma may be distinguished from an abscess by its low signal intensity and increased apparent diffusion coefficient (ADC) as compared to high signal intensity with low ADC in cases of abscess. PMID:19813177
Erdem, Gülnur; Ate?, Ozkan; Koçak, Ayhan; Alkan, Alpay
Background: We describe a new posterior dynamic stabilizing system that can be used to augment the mechanics of the degenerating lumbar segment. The mechanism of this system differs from other previously described surgical techniques that have been designed to augment lumbar biomechanics. The implant and technique we describe is an extension-limiting one, and it is designed to support and cushion the facet complex. Furthermore, it is inserted through an entirely percutaneous technique. The purpose of this technical note is to demonstrate a novel posterior surgical approach for the treatment of lumbar degenerative. Methods: This report describes a novel, percutaneously placed, posterior dynamic stabilization system as an alternative option to treat lumbar degenerative disk disease with and without lumbar spinal stenosis. The system does not require a midline soft-tissue dissection, nor subperiosteal dissection, and is a truly minimally invasive means for posterior augmentation of the functional facet complex. This system can be implanted as a stand-alone procedure or in conjunction with decompression procedures. Results: One-year clinical results in nine individual patients, all treated for degenerative disease of the lower lumbar spine, are presented. Conclusions: This novel technique allows for percutaneous posterior dynamic stabilization of the lumbar facet complex. The use of this procedure may allow a less invasive alternative to traditional approaches to the lumbar spine as well as an alternative to other newly developed posterior dynamic stabilization systems.
Smith, Zachary A.; Armin, Sean; Raphael, Dan; Khoo, Larry T.
To understand the role seating plays in the support of posture and spinal articulation, it is necessary to study the interface between a human and the seat. However, a method to quantify lumbar curvature in commercially available unmodified seats does not currently exist. This work sought to determine if the lumbar curvature for normal ranges of seated posture could be documented by using body landmarks located on the anterior portion of the body. The development of such a methodology will allow researchers to evaluate spinal articulation of a seated subject while in standard, commercially available seats and chairs. Anterior measurements of boney landmarks were used to quantify the relative positions of the ribcage and pelvis while simultaneous posterior measurements were made of lumbar curvature. The relationship between the anterior and the posterior measures was compared. The predictive capacity of this approach was evaluated by determining linear and second-order regressions for each of the four postures across all subjects and conducting a leave-one-out cross validation. The relationships between the anterior and posterior measures were approximated by linear and second-order polynomial regressions (r(2?) =? 0.829, 0.935 respectively) across all postures. The quantitative analysis showed that openness had a significant relationship with lumbar curvature, and a first-order regression was superior to a second-order regression. Average standard errors in the prediction were 5.9° for the maximum kyphotic posture, 9.9° for the comfortable posture, 12.8° for the straight and tall, and 22.2° for the maximum lordotic posture. These results show predictions of lumbar curvature are possible in seated postures by using a motion capture system and anterior measures. This method of lumbar curvature prediction shows potential for use in the assessment of seated spinal curvatures and the corresponding design of seating to accommodate those curvatures; however, additional inputs will be necessary to better predict the postures as lordosis is increased. PMID:22168743
Leitkam, Samuel T; Bush, Tamara Reid; Li, Mingfei
The use of technology in the treatment of degenerative spinal diseases has undergone rapid clinical and scientific development. It has been extensively studied in combination with various techniques for spinal stabilization from both the anterior and posterior approach. Minimally invasive and instrumental approach via posterior fixation is increasingly being used for the treatment of adult degenerative disc disease, stenosis, and deformity of the lumbar vertebrae. Posterior access to the lumbar disc spaces for posterolateral fusion scan has been technically challenging, frequently requiring the use of an approach surgery for adequate exposure. For successful surgery and suitable instrumental design, adequate anatomical knowledge of the lumbar vertebra is also needed. Anatomic features of lumbar vertebrae are of importance for posterior screw fixation technique. The morphometry of L1-L5 has been studied to facilitate the safe application of pedicle screws. Thus, we aimed to evaluate the morphometric landmarks of lumbar vertebrae such as pedicle, vertebral body, vertebral foramen, intervertebral space height and volume for safe surgical intervention using a posterior fixation approach to offer anatomical supports for lumbar discectomy, stenosis and cases of deformity. The features of the L1-L5 vertebral body, the detailed morphometric parameters of lumbar vertebrae and the intervertebral space were analyzed using computerized tomography scan, magnetic resonance imaging and also dry lumbar vertebrae. Additionally, intervertebral space volumes were measured using stereological methods to ensure safe surgical intervention. PMID:21550221
Karabekir, Hamit S; Gocmen-Mas, Nuket; Edizer, Mete; Ertekin, Tolga; Yazici, Canan; Atamturk, Derya
The three-dimentional stability provided by six spinal fixation devices with or without interbody bone graft has been studied in an in vitro biomechanical model using five-vertebral (T11-L3) fresh cadaveric thoracolumbar specimens. An injury was created at T12-L1 by complete transection of the posterior elements and posterior half of the intervertebral disc, leaving the anterior half of the intervertebral disc and anterior longitudinal ligament intact. The three-dimensional rotations and translations, measures of biomechanical instabilities, were determined under physiologic loads for the intact spine and the spinal constructs, ie, injured spine plus instrumentation. The tested devices were: Harrington reverse ratchet rods (HR); Luque rectangle rod (LR); Kaneda device without transverse fixator (KD); Kaneda device with transverse fixators (KT); transpedicular external fixator (EF). In addition, stability tests were performed for KT, EF, and Harrington compression rods with interbody bone graft following a corpectomy (KTB, EFB, and HCB). The constructs were more stable than the intact spine under the four loads in the following order: flexion: EFB, HCB, EF, HR, LR, KTB, and KT; extension: EFB, LR, EF, KTB, HR, and KT; lateral bending: KTB, KT, EFB, KD, EF, HCB, and HR; and axial rotation: EFB. PMID:2603059
Abumi, K; Panjabi, M M; Duranceau, J
The goal of a fusion of the lumbar spine is to obtain a primary solid arthrodesis thus to alleviate pain. Different circumferential\\u000a fusion techniques have been described such as combined anterior–posterior fusion (APF), instrumented posterior lumbar interbody\\u000a fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF). The TLIF procedure has rapidly gained popularity; because\\u000a of its posterolateral extracanalar discectomy and fusion,
Pier Paolo Mura; Mauro Costaglioli; Maurizio Piredda; Silvia Caboni; Silvia Casula
Lumbar stenosis is a well-defined pathologic condition with excellent surgical outcomes. Empiric evidence as well as randomized, prospective trials has demonstrated the superior efficacy of surgery compared to medical management for lumbar stenosis. Traditionally, lumbar stenosis is decompressed with open laminectomies. This involves removal of the spinous process, lamina, and the posterior musculoligamentous complex (posterior tension band). This approach provides excellent improvement in symptoms, but is also associated with potential postoperative spinal instability. This may result in subsequent need for spinal fusion. Advances in technology have enabled the application of minimally invasive spine surgery (MISS) as an acceptable alternative to open lumbar decompression. Recent studies have shown similar to improved perioperative outcomes when comparing MISS to open decompression for lumbar stenosis. A literature review of MISS for decompression of lumbar stenosis with tubular retractors was performed to evaluate the outcomes of this modern surgical technique. In addition, a discussion of the advantages and limitations of this technique is provided.
Wong, Albert P.; Smith, Zachary A.; Lall, Rohan R.; Bresnahan, Lacey E.; Fessler, Richard G.
\\u000a Injuries of the thoracic and lumbar spine in children are rare. The potential for continued growth, the presence of healthy\\u000a disc tissue, the elasticity of the soft tissues, and well-mineralized bone distinguish these injuries from those in the adult.\\u000a The immature spine has the capacity to remodel the vertebral body, but not the posterior elements. Restoration of height of\\u000a a
Robert N. Hensinger; Clifford L. Craig
Paracoccygeal approach to the L5-S1 junction with transsacral instrumentation was described recently as an alternative method\\u000a to transforaminal lumbar interbody fusion or posterior lumbar interbody fusion. A percutaneous L5-S1 discectomy, interbody\\u000a distraction, and fixation could be achieved while preserving the integrity of the muscles, ligaments, and disc anulus. Retroperitoneal\\u000a viscera and dorsal neural elements are avoided via the presacral safe
Samo K. Fokter
Paracoccygeal approach to the L5–S1 junction with transsacral instrumentation was described recently as an alternative method\\u000a to transforaminal lumbar interbody fusion or posterior lumbar interbody fusion. A percutaneous L5–S1 discectomy, interbody\\u000a distraction, and fixation could be achieved while preserving the integrity of the muscles, ligaments, and disc anulus. Retroperitoneal\\u000a viscera and dorsal neural elements are avoided via the presacral safe
Samo K. Fokter
It has been widely reported a vascular and neurologic damage of the lumbar muscles produced in the classic posterior approach\\u000a for lumbar spinal fusions. The purpose of this study is to demonstrate a better clinical and functional outcome in the postoperative\\u000a and short term in patients undergoing minimal invasive surgery (“mini-open”) for this lumbar spinal arthrodesis. We designed\\u000a a prospective
J. Rodríguez-Vela; A. Lobo-Escolar; E. Joven-Aliaga; A. Herrera; J. Vicente; E. Suñén; A. Loste; A. Tabuenca
The objectives of this study were to examine charge data and long-term outcomes of two approaches for anterior lumbar interbody fusion: a mini-open lateral approach (extreme lateral interbody fusion, XLIF) and an open anterior approach (anterior lumbar interbody fusion, ALIF) through retrospective chart review. A total of 202 patients underwent surgery: 87 with ALIF (Open) and 115 with XLIF (Mini-open) procedures, all with transpedicular fixation. Complications occurred in 16.7% of Open, and 8.2% of Mini-open, procedures (p = 0.041). The mean charges ($US) for one-level Mini-open and Open procedures were $91,995 and $102,146, and for two-level procedures were $124,540 and $144,183, respectively. All differences were statistically significant (p < 0.05). This represents a 10% cost-savings, based on charges, for one-level and 13.6% for two-level Mini-open compared to Open procedures. Functional outcomes improved significantly at two years for both cohorts, although the difference between groups was not statistically significant. In conclusion, the Mini-open approach, compared to the Open, resulted in clinical as well as cost benefits with similar long-term outcomes. PMID:22236486
Smith, William D; Christian, Ginger; Serrano, Sherrie; Malone, Kyle T
Single level axial lumbar interbody fusion (AxiaLIF) using a transsacral rod through a paracoccygeal approach has been developed\\u000a with promising early clinical results and biomechanical stability. Recently, the transsacral rod has been extended to perform\\u000a a two-level fusion at both L4–L5 and L5–S1 levels (AxiaLIF II). No biomechanical studies have been conducted on multilevel\\u000a fusion using the AxiaLIF technique. In
Serkan Erkan; Chunhui Wu; Amir A. Mehbod; Brian Hsu; Douglas W. Pahl; Ensor E. Transfeldt
We present a case of delayed oral extrusion of a screw after anterior cervical interbody fusion in a 68-year-old man with osteoporosis. Fifteen months earlier, he had undergone C5 corpectomy and anterior cervical interbody fusion at C4-6 for multiple spinal stenoses. The patient was nearly asymptomatic, except for a foreign body sensation in his throat. We conclude that the use of a mesh graft or other instrument in elderly patients and those with osteoporosis or problematic bone quality should be considered carefully and that if surgery were to be performed, periodic postoperative follow-up evaluations are mandatory.
Lee, Jin Soo; Hwang, Soo Hyun; Han, Jong Woo
We present a case of delayed oral extrusion of a screw after anterior cervical interbody fusion in a 68-year-old man with osteoporosis. Fifteen months earlier, he had undergone C5 corpectomy and anterior cervical interbody fusion at C4-6 for multiple spinal stenoses. The patient was nearly asymptomatic, except for a foreign body sensation in his throat. We conclude that the use of a mesh graft or other instrument in elderly patients and those with osteoporosis or problematic bone quality should be considered carefully and that if surgery were to be performed, periodic postoperative follow-up evaluations are mandatory. PMID:19096688
Lee, Jin Soo; Kang, Dong-Ho; Hwang, Soo Hyun; Han, Jong Woo
Introduction. The lateral transpsoas approach for lumbar interbody fusion (XLIF) is gaining popularity. Studies examining a surgeon's early experience are rare. We aim to report treatment, complication, clinical, and radiographic outcomes in an early series of patients. Methods. Prospective data from the first thirty patients treated with XLIF by a single surgeon was reviewed. Outcome measures included pain, disability, and quality of life assessment. Radiographic assessment of fusion was performed by computed tomography. Results. Average follow-up was 11.5 months, operative time was 60 minutes per level and blood loss was 50?mL. Complications were observed: clinical subsidence, cage breakage upon insertion, new postoperative motor deficit and bowel injury. Approach side-effects were radiographic subsidence and anterior thigh sensory changes. Two patients required reoperation; microforaminotomy and pedicle screw fixation respectively. VAS back and leg pain decreased 63% and 56%, respectively. ODI improved 41.2% with 51.3% and 8.1% improvements in PCS and MCS. Complete fusion (last follow-up) was observed in 85%. Conclusion. The XLIF approach provides superior treatment, clinical outcomes and fusion rates compared to conventional surgical approaches with lowered complication rates. Mentor supervision for early cases and strict adherence to the surgical technique including neuromonitoring is essential.
Malham, Gregory M.; Ellis, Ngaire J.; Parker, Rhiannon M.; Seex, Kevin A.
Background: Posterior endoscopic discectomy is an established method for treatment of lumbar disc herniation. Many studies have not been reported in literature for lumbar discectomy by Destandau Endospine System. We report a series of 300 patients operated for lumbar dissectomy by Destandau Endospine system. Materials and Methods: A total of 300 patients suffering from lumbar disc herniations were operated between January 2002 and December 2008. All patients were operated as day care procedure. Technique comprised localization of symptomatic level followed by insertion of an endospine system devise through a 15 mm skin and fascial incision. Endoscopic discectomy is then carried out by conventional micro disc surgery instruments by minimal invasive route. The results were evaluated by Macnab's criteria after a minimum followup of 12 months and maximum up to 24 months. Results: Based on modified Macnab's criteria, 90% patients had excellent to good, 8% had fair, and 2% had poor results. The complications observed were discitis and dural tear in five patients each and nerve root injury in two patients. 90% patients were able to return to light and sedentary work with an average delay of 3 weeks and normal physical activities after 2 months. Conclusion: Edoscopic discectomy provides a safe and minimal access corridor for lumbar discectomy. The technique also allows early postoperative mobilization and faster return to work.
Kaushal, Mohinder; Sen, Ramesh
Background and purpose Instrumented and non-instrumented methods of fusion have been compared in several studies, but the results are often inconsistent and conflicting. We compared the 2-year results of 3 methods of lumbar fusion when used in degenerative disc disease (DDD), using the Swedish Spine Register (SWESPINE). Methods All patients registered in SWESPINE for surgical treatment of DDD between January 1, 2000 and October 1, 2007 were eligible for the study. Patients who had completed the 2-year follow-up were included in the analysis. The outcomes of 3 methods of surgical fusion were assessed. Results Of 1,310 patients enrolled, 115 had undergone uninstrumented fusion, 620 instrumented posterolateral fusion, and 575 instrumented interbody fusion. Irrespective of the surgical procedure, quality of life (QoL) improved and back pain diminished. Change in QoL and functional disability and return to work was similar in the 3 groups. Patients who had undergone uninstrumented fusion had more back pain than the patients with instrumented interbody fusion at the 2-year follow-up (p = 0.02), although the difference was only 7 visual analog scale (VAS) units (95% CI: 1–13) on a 100-point scale. Moreover, 83% of the patients with uninstrumented fusion used analgesics at the end of follow-up as compared to 68% of the patients who had undergone surgery with one of the 2 instrumented fusion techniques. Interpretation In comparison with instrumented interbody fusion, uninstrumented fusion was associated with higher levels of back pain 2 years after surgery. We found no evidence for differences in QoL between uninstrumented fusion and instrumented interbody fusion.
This study is to compare the therapeutic effect of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody\\u000a fusion (TLIF) with pedicle screw fixation on treatment in adult degenerative spondylolisthesis. A retrospective analysis of\\u000a 187 patients to compare the complications and associated predictive factors of the two techniques of one level lumbar fusion.\\u000a Ninety-one had PLIF with two cages and
Deng-lu Yan; Fu-xing Pei; Jian Li; Cheng-long Soo
Summary The optimal treatment of thoracic and lumbar fractures remains controversial. While many authors recommend dorsal instrumentation with an internal fixator, others favour an anterior approach. To evaluate the posterior approach and to identify conditions under which an anterior approach should be preferred, 133 patients with unstable thoracic and lumbar fractures of the spine who underwent dorsal instrumentation with an
J. Oertel; W.-R. Niendorf; N. Darwish; H. W. S. Schroeder; M. R. Gaab
We describe a case of dorsal-lumbar vertebral tuberculosis (Pott's disease) first treated with antibiotic therapy, bed rest, and cast. After 2 months of treatment patient's symptoms worsened. Minimally invasive posterior vertebral stabilization was carried out, with excellent clinic and radiographic results. PMID:22358780
Rigotti, S; Boriani, L; Luzi, C A; Marocco, S; Angheben, A; Gasbarrini, A; Zorzi, C
In current TLIF practice, the choice of the cage size is empirical and primarily depends on the case volume and experience of the surgeon. We used a self-made modified distractor handle in TLIF procedure with the goal of standardizing the intervertebral space tension and determining the proper cage size.
Rewuti, Abuduaini; Chen, Zixian; Feng, Zhenzhou; Cao, Yuanwu; Jiang, Xiaoxing; Jiang, Chun
In recent years the general trend in spinal surgery has been one of reductionism and minimalization. A number of techniques have recently been developed that are applicable in the treatment of lumbar disc herniation and discogenic pain due to degenerative disc disease. The purpose of this manuscript is to examine two newer percutaneous disc treatment techniques, intradiscal electrothermal therapy (IDET) anuloplasty and nucleoplasty. The authors review the appropriate clinical treatment criteria, techniques, and lessons learned after performing these procedures in more than 100 patients. The IDET involves the percutaneous insertion of a specially designed thermal resistance probe followed by controlled heating of the intervertebral disc. This may result in disc shrinkage and reduction in pain. The nucleoplasty procedure involves the percutaneous removal of disc material by using a low-temperature resister probe to disintegrate and evacuate disc material, followed by thermal treatment of adjacent residual disc material. To date, no study has been published in which investigators examine the outcomes of this procedure for the treatment of radicular leg pain and low-back pain. Both IDET and nucleoplasty appear to be safe procedures. The IDET procedure may be an alternative to lumbar interbody fusion. Although its long-term role is being defined, this technique appears to provide intermediate-term relief of pain in a population of patients with discogenic low-back pain. Nucleoplasty may provide a percutaneous alternative to microdiscectomy in selected cases. PMID:15916404
Welch, William C; Gerszten, Peter C
Lumbar radiculopathy is a common problem. Nerve root compression can occur at different places along a nerve root's course including in the foramina. Minimal invasive approaches allow easier exposure of the lateral foramina and decompression of the nerve root in the foramina. This video demonstrates a minimally invasive approach to decompress the lumbar nerve root in the foramina with a lateral to medial decompression. The video can be found here: http://youtu.be/jqa61HSpzIA. PMID:23829856
1-4% of osteochondromas involve the spine. They are commonly found in the posterior elements of the vertebra and can cause radicular symptoms. We report a 35 year-old man, suffering from right leg pain, which became worse over five years. His neurological examination revealed a positive right straight leg raising test and L4-L5 hypoesthesia. Lumbar computerised tomography (CT) and magnetic resonance imaging (MRI) studies revealed an exophytic, pedunculated bony projection. Osteochondroma should be considered while evaluating a patient with low back pain or radiculopathy without a CT or MRI appearance of a herniated lumbar disc. PMID:15519877
Gürkanlar, Do?a; Aciduman, Ahmet; Günaydin, Ahmet; Koçak, Halit; Celik, Nur
There are few articles in the literature concerning anterior instrumentation in the surgical management of spinal tuberculosis in the exudative stage. So we report here 23 cases of active thoracolumbar spinal tuberculosis treated by one-stage anterior interbody autografting and instrumentation to verify the importance of early reconstruction of spinal stability and to evaluate the results of one-stage interbody autografting and
Dadi Jin; Dongbin Qu; Jianting Chen; Hao Zhang
We conducted a prospective, randomised study of 42 cervical interbody fusions undertaken with either an autologous tricortical graft or a cage. The factors assessed in the two groups were: (1) time taken to achieve fusion; (2) neck disability index; (3) pain score; (4) interbody height ratio; (5) interbody angle and (6) the influence of smoking on fusion. No statistical difference was seen in the time taken to achieve fusion, neck disability index, interbody height ratio, or interbody angles. Smoking did not have any effect on the fusion process. The pain score was significantly lower in the tricortical graft group at six months. We conclude that both methods of fusion give similar results, although tricortical graft fusion is cheaper than cage fusion, and is more effective in reducing the pain score. PMID:14516039
Siddiqui, A A; Jackowski, A
Interbody fusion techniques have been used for many years for the treatment of a variety of lumbar spine diagnoses. Part of the interest in increasing methods of interbody fusion has stemmed from concern that posterior fusion alone may allow micro-motion, which may generate pain in a ruptured or degenerated disc. Stabilization of the anterior segment led to the development of
Scott L Blumenthal; Donna D Ohnmeiss
Background: Degenerative lumbar scoliosis surgery can lead to development of adjacent segment degeneration (ASD) after lumbar or thoracolumbar fusion. Its incidence, risk factors, morbidity and correlation between radiological and clinical symptoms of ASD have no consensus. We evaluated the correlation between the occurrence of radiologic adjacent segment disease and certain imperative parameters. Materials and Methods: 98 patients who had undergone surgical correction and lumbar/thoracolumbar fusion with pedicle screw instrumentation for degenerative lumbar scoliosis with a minimum 5 year followup were included in the study. We evaluated the correlation between the occurrence of radiologic adjacent segment disease and imperative patient parameters like age at operation, sex, body mass index (BMI), medical comorbidities and bone mineral density (BMD). The radiological parameters taken into consideration were Cobb's angle, angle type, lumbar lordosis, pelvic incidence, intercristal line, preoperative existence of an ASD on plain radiograph and magnetic resonance imaging (MRI) and surgical parameters were number of the fusion level, decompression level, floating OP (interlumbar fusion excluding L5-S1 level) and posterolateral lumbar interbody fusion (PLIF). Clinical outcomes were assessed with the Visual Analogue Score (VAS) and Oswestry Disability Index (ODI). Results: ASD was present in 44 (44.9%) patients at an average period of 48.0 months (range 6-98 months). Factors related to occurrence of ASD were preoperative existence of disc degeneration (as revealed by MRI) and age at operation (P = 0.0001, 0.0364). There were no statistically significant differences between radiological adjacent segment degeneration and clinical results (VAS, P = 0.446; ODI, P = 0.531). Conclusions: Patients over the age of 65 years and with preoperative disc degeneration (as revealed by plain radiograph and MRI) were at a higher risk of developing ASD.
Ha, Kee-yong; Son, Jong-Min; Im, Jin-Hyung; Oh, In-Soo
Introduction Posterior epidural migration of thoracic disc herniation is extremely rare but may occur in the same manner as in the lumbar spine. Case presentation A 53-year-old Japanese man experienced sudden onset of incomplete paraplegia after lifting a heavy object. Magnetic resonance imaging revealed a posterior epidural mass compressing the spinal cord at the T9-T10 level. The patient underwent emergency surgery consisting of laminectomy at T9-T10 with right medial facetectomy, removal of the mass lesion, and posterior instrumented fusion. Histological examination of the mass lesion yielded findings consistent with sequestered disc material. His symptoms resolved, and he was able to resume walking without a cane 4 weeks after surgery. Conclusions Pre-operative diagnosis of posterior epidural migration of herniated thoracic disc based on magnetic resonance imaging alone may be overlooked, given the rarity of this pathology. However, this entity should be considered among the differential diagnoses for an enhancing posterior thoracic extradural mass.
Interspinous spacers were developed to treat local deformities such as degenerative spondylolisthesis. To treat patients with chronic instability, posterior pedicle fixation and rod-based dynamic stabilization systems were developed as alternatives to fusion surgeries. Dynamic stabilization is the future of spinal surgery, and in the near future, we will be able to see the development of new devices and surgical techniques to stabilize the spine. It is important to follow the development of these technologies and to gain experience using them. In this paper, we review the literature and discuss the dynamic systems, both past and present, used in the market to treat lumbar degeneration. PMID:23326674
Gomleksiz, Cengiz; Sasani, Mehdi; Oktenoglu, Tunc; Ozer, Ali Fahir
Interspinous spacers were developed to treat local deformities such as degenerative spondylolisthesis. To treat patients with chronic instability, posterior pedicle fixation and rod-based dynamic stabilization systems were developed as alternatives to fusion surgeries. Dynamic stabilization is the future of spinal surgery, and in the near future, we will be able to see the development of new devices and surgical techniques to stabilize the spine. It is important to follow the development of these technologies and to gain experience using them. In this paper, we review the literature and discuss the dynamic systems, both past and present, used in the market to treat lumbar degeneration.
Gomleksiz, Cengiz; Sasani, Mehdi; Oktenoglu, Tunc; Ozer, Ali Fahir
It has been widely reported a vascular and neurologic damage of the lumbar muscles produced in the classic posterior approach for lumbar spinal fusions. The purpose of this study is to demonstrate a better clinical and functional outcome in the postoperative and short term in patients undergoing minimal invasive surgery (“mini-open”) for this lumbar spinal arthrodesis. We designed a prospective study with a 30 individuals cohort randomized in two groups, depending on the approach performed to get a instrumented lumbar circumferential arthrodesis: “classic posterior” (CL group) or “mini-open” approach (MO group). Several clinical and functional parameters were assessed, including blood loss, postoperative pain, analgesic requirements and daily life activities during hospital stay and at the 3-month follow-up. Patients of the “mini-open approach” group had a significant lower blood loss and hospital stay during admission. They also had significant lower analgesic requirements and faster recovery of daily life activities (specially moderate efforts) when compared to the patients of the “classic posterior approach” group. No significant differences were found between two groups in surgery timing, X-rays exposure or sciatic postoperative pain. This study, inline with previous investigations, reinforces the concept of minimizing the muscular lumbar damage with a mini-open approach for a faster and better recovery of patients’ disability in the short term. Further investigations are necessary to confirm these findings in the long term, and to verify the achievement of a stable lumbar spinal fusion.
Rodriguez-Vela, J.; Joven-Aliaga, E.; Herrera, A.; Vicente, J.; Sunen, E.; Loste, A.; Tabuenca, A.
We present a rare case of septic arthritis of a lumbar facet joint with an associated epidural abscess resulting from Staphylococcus aureus. The infection was initially detected with planar bone scintigraphy and precisely localized with single photon emission computed tomography bone scintigraphy, despite an initially negative radiologic evaluation that included radiographs of the lumbar spine, lumbar myelography, and a postmyelography x-ray computed tomography scan. In the appropriate clinical setting, a bone scan demonstrating unilateral increased activity within the spine should raise the suspicion of inflammatory involvement of the posterior elements.
Swayne, L.C.; Dorsky, S.; Caruana, V.; Kaplan, I.L. (Morristown Memorial Hospital, NJ (USA))
Failure of interbody fusions in the lumbar spine are common due to reliance on the graft for structural support during healing by creeping substitution. Support of the interspace with an implant should result in improved fusion success. The objective of this study was to evaluate the stability of the implant in vivo and its potential as an adjunct to promote interbody arthrodesis. Prototype 3, a porous coated intervertebral spacer with extension lugs made of Ti-6A1-4V, was implanted vertically between adjacent lumbar vertebrae anteriorly in four baboons undergoing anterior interbody fusion. The animals were allowed freedom of activity for 6 months before being killed. A transperitoneal approach was made exposing the L4-L5 or L5-L6 interspace. At time of killing, clinical evaluation of the implant-vertebral body construct showed stability to manual stresses applied in extension, flexion, and rotation. Serial radiographs taken during the 6 months of implantation showed no change in position or displacement of the implants. Axial and torsional cyclic loads were applied to each spine at 1 cycle/s for 20,000 cycles. Statistical analysis of the motion profiles for intact and implanted spines demonstrated no significant difference in axial or rotational displacements at the arthrodesis level or adjacent unoperated levels, L1 and L4. The in vivo 6-month study in baboons confirmed implant stability and maintenance of disc space height. Variable osseous healing was noted. Release of plasma spray beading may have resulted from improper application on the implant or micromotion within the construct. A better method to mechanically interlock the plungers is being studied. Clinical trials based on this work appear justified. PMID:9588470
Nasca, R J; Montgomery, R D; Moeini, S M; Lemons, J E
Surgical Principle\\u000a \\u000a Posterior fusion of one or two levels of the lumbar spine with arthrodesis of the facet joints using screws. The technique\\u000a has been developed by one of us (Magerl [10–13]). It constitutes an improvement of a technique of transarticular screw fixation\\u000a first described by King in 1944 [7, 8] and modified by Boucher  (Figures 1a to 1c).
Bernard Jeanneret; Frank Kleinstiick; Friedrich Magerl
Text Version... Smith MD et al, Spine 1993: 18, 1984. Page 3. POSTERIOR CERVICAL BONE SCREWS ... Page 4. POSTERIOR CERVICAL BONE SCREWS ... More results from www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials
Swinging a golf club includes the rotation and extension of the lumbar spine. Golf-related low back pain has been associated with degeneration of the lumbar facet and intervertebral discs, and with spondylolysis. Reflective markers were placed directly onto the skin of 11young male amateur golfers without a previous history of back pain. Using a VICON system (Oxford Metrics, U.K.), full golf swings were monitored without a corset (WOC), with a soft corset (SC), and with a hard corset (HC), with each subject taking 3 swings. Changes in the angle between the pelvis and the thorax (maximum range of motion and angular velocity) in 3 dimensions (lumbar rotation, flexion-extension, and lateral tilt) were analyzed, as was rotation of the hip joint. Peak changes in lumbar extension and rotation occurred just after impact with the ball. The extension angle of the lumbar spine at finish was significantly lower under SC (38°) or HC (28°) than under WOC (44°) conditions (p < 0.05). The maximum angular velocity after impact was significantly smaller under HC (94°/sec) than under SC (177°/sec) and WOC (191° /sec) conditions, as were the lumbar rotation angles at top and finish. In contrast, right hip rotation angles at top showed a compensatory increase under HC conditions. Wearing a lumbar corset while swinging a golf club can effectively decrease lumbar extension and rotation angles from impact until the end of the swing. These effects were significantly enhanced while wearing an HC. Key pointsRotational and extension forces on the lumbar spine may cause golf-related low back painWearing lumbar corsets during a golf swing can effectively decrease lumbar extension and rotation angles and angular velocity.Wearing lumbar corsets increased the rotational motion of the hip joint while reducing the rotation of the lumbar spine. PMID:24149729
Hashimoto, Koji; Miyamoto, Kei; Yanagawa, Takashi; Hattori, Ryo; Aoki, Takaaki; Matsuoka, Toshio; Ohno, Takatoshi; Shimizu, Katsuji
The present study aimed to evaluate the early effects of interspinous spacers on lumbar degenerative disease. The clinical outcomes of 23 patients with lumbar degenerative disease, treated using interspinous spacer implantation alone or combined with posterior lumbar fusion, were retrospectively studied and assessed with a visual analogue scale (VAS) and the Oswestry Disability Index (ODI). Pre-operative and post-operative interspinous distance, disc space height, foraminal width and height and segmental lordosis were determined. The early effects and complications associated with the interspinous spacers were recorded. The surgical procedures performed with the in-space treatment were easy and minimally invasive. The VAS scores and ODI were improved post-operatively compared with pre-operatively. Significant changes in the interspinous distance, disc space height, foraminal width and height and segmental lordosis were noted. In-space treatment for degenerative lumbar disease is easy and safe, with good early effects. The in-space system provides an alternative treatment for lumbar degenerative disease. PMID:23407682
Zhou, Dong; Nong, Lu-Ming; DU, Rui; Gao, Gong-Ming; Jiang, Yu-Qing; Xu, Nan-Wei
A topology optimized lumbar interbody fusion cage was made of Ti-Al6-V4 alloy by the rapid prototyping process of selective laser melting (SLM) to reproduce designed microstructure features. Radiographic characterizations and the mechanical properties were investigated to determine how the structural characteristics of the fabricated cage were reproduced from design characteristics using micro-computed tomography scanning. The mechanical modulus of the designed cage was also measured to compare with tantalum, a widely used porous metal. The designed microstructures can be clearly seen in the micrographs of the micro-CT and scanning electron microscopy examinations, showing the SLM process can reproduce intricate microscopic features from the original designs. No imaging artifacts from micro-CT were found. The average compressive modulus of the tested caged was 2.97+/-0.90 GPa, which is comparable with the reported porous tantalum modulus of 3 GPa and falls between that of cortical bone (15 GPa) and trabecular bone (0.1-0.5 GPa). The new porous Ti-6Al-4V optimal-structure cage fabricated by SLM process gave consistent mechanical properties without artifactual distortion in the imaging modalities and thus it can be a promising alternative as a porous implant for spine fusion. PMID:17415762
Lin, Chia-Ying; Wirtz, Tobias; LaMarca, Frank; Hollister, Scott J
There is concern that cervical interbody fusion can result in accelerated degenerative changes occurring at adjacent spinal levels. The cervical spine clearly evolved to be mobile. It would seem to be desirable for spinal surgeons to have an alternative to fusion, and spinal arthroplasty is an appealing concept. The Bristol Disc is a mechanical device comprising two articulating components that result in motion with 6 df. It has been shown to have favorable kinematics when compared with intact and fused cadaveric spines. The current study attempts to record changes in the distribution of stresses within cervical intervertebral discs adjacent to the artificial disc or a simulated fusion. The technique used to measure intradiscal stress distributions is based on earlier work by McNally and Adams on lumbar intervertebral discs. The study generated stress profiles through cervical intervertebral discs statically loaded in four different postures in addition to recording changes in intradiscal pressure within both the nucleus and the annulus during flexion. Similar stress profiles were recorded from intact specimens and those with the artificial joint inserted. The artificial joint resulted in reduced stresses in the annulus compared with spines with a simulated fusion. The study demonstrates how different testing conditions can result in researchers being confronted with paradoxical data, and the simulation of muscle forces is recommended. PMID:14526192
Wigfield, Crispin C; Skrzypiec, Daniel; Jackowski, Andre; Adams, Mike A
Objective There are numerous reports on the primary stabilizing effects of the different cervical cages for cervical radiculopathy. But, little is known about the subsidence which may be clinical problem postoperatively. The goal of this study is to evaluate subsidence of cage and investigate the correlation between radiologic subsidence and clinical outcome. Methods To assess possible subsidence, the authors investigated clinical and radiological results of the one-hundred patients who underwent anterior cervical fusion by using AMSLU™ cage during the period between January 2003 and June 2005. Preoperative and postoperative lateral radiographs were measured for height of intervertebral disc space where cages were placed. Intervertebral disc space was measured by dividing the sum of anterior, posterior, and midpoint interbody distance by 3. Follow-up time was 6 to 12 months. Subsidence was defined as any change in at least one of our parameters of at least 3 mm. Results Subsidence was found in 22 patients (22%). The mean value of subsidence was 2.21 mm, and mean subsidence rate was 22%. There were no cases of the clinical status deterioration during the follow-up period. No posterior or anterior migration was observed. Conclusion The phenomenon of subsidence is seen in substantial number of patients. Nevertheless, clinical and radiological results of the surgery were favorable. An excessive subsidence may result in hardware failure. Endplate preservation may enables us to control subsidence and reduce the number of complications.
Joung, Young Il; Ko, Yong; Yi, Hyeong Joong; Lee, Seung Ku
Extreme lateral interbody fusion (XLIF) is a novel technique for the anterior disc replacement. The aim of this report was description of the surgical technique of XLIF. Based on our experience with first eleven patients we report advantages and drawbacks of this method. Patients who presented with symptomatic degenerative disc disease or failed back surgery syndrome were considered candidates for this surgery. The patient was placed in a true right lateral decubitus position and small (6 cm) left lateral skin incision was performed. Access to the lumbar spine was achieved by approach that passes through the retroperitoneally fat and psoas major muscle, using peroperative fluoroscopy. Expandable retractor was inserted, discectomy and replacement by Oracle (Synthes, USA) cage (with synthetic cancellous bone graft) to the interbody space was performed. XLIF represents save surgical method with maximally careful approach and spacious working portal. The new benefit of XLIF is based on the minimally invasive spine surgery technique through retroperitoneal space. The lateral access to the disc avoids the major vessels and nerves and implant placement in the anterior and bilateral position provides sagital and coronal plane imbalance correction. PMID:21404522
Hrabálek, L; Wanek, T; Adamus, M
Posterior knee pain is a common patient complaint. There are broad differential diagnoses of posterior knee pain ranging from common causes such as injury to the musculotendinous structures to less common causes such as osteochondroma. A precise understanding of knee anatomy, the physical examination, and of the differential diagnosis is needed to accurately evaluate and treat posterior knee pain. This article provides a review of the anatomy and important aspects of the history and physical examination when evaluating posterior knee pain. It concludes by discussing the causes and management of posterior knee pain.
Burst fracture of the low lumbar spine are rare and have not been well delineated in the literature. Thirty-one low lumbar burst fractures (L3-L5) were treated from 1981 through 1989. Average follow-up for 27 of the 31 patients was 46 months. Persistent complaints of back pain seemed to be found more in patients with long instrumentation and fusion and in patients with loss of lordosis. Conservative treatment of low lumbar burst fractures with body cast is a viable option in the neurologically intact patients with minimal height loss and minor angulation. If surgery is chosen, short rigid instrumentation (eg, transpedicular device) is best in accomplishing shorter fusion, maintaining vertebral height, and restoring lumbar lordosis. Harrington distraction rods improve vertebral height but produce loss of lumbar lordosis. Luque rods do not restore vertebral height and are only moderately effective in restoring lumbar lordosis. If patients are neurologically impaired in association with low lumbar burst fractures, posterior decompression by laminotomy or a transpedicular approach is generally effective. Maintaining vertebral height and restoring lumbar lordosis may be important in the prevention of disability from back pain. PMID:1838448
An, H S; Vaccaro, A; Cotler, J M; Lin, S
In this study we explore the hypothesis that estimates of failure loads in the thoracic spine by lumbar dual energy X-ray absorptiometry (DXA) are compromised of skeletal heterogeneity throughout the spine and artifacts of spinal DXA. We studied the correlation between mechanical failure loads of thoracic and lumbar vertebrae, and that of in situ vs. ex situ lumbar DXA with thoracic and lumbar fracture loads, respectively. One hundred and nineteen subjects (76 female, age 82+/-9yr; 43 male, age 77+/-11yr) were examined under in situ conditions (anterior-posterior direction), the scans being repeated ex situ (lateral projection) in 68 cases. The failure loads of thoracic vertebrae (T) 6 and 10, and lumbar vertebra (L) 3 were determined in axial compression, using a functional 3-segment unit. The correlation between thoracic failure loads (T6 vs. T10) was significantly (p<0.01) higher (r=0.85) than those between thoracic and lumbar vertebrae (r=0.68 and 0.61, respectively). Lateral ex situ DXA displayed a significantly higher correlation (p<0.05) with lumbar vertebral fracture loads than in situ anterior-posterior DXA (r=0.85 vs. 0.71), but the correlation of thoracic failure loads with lateral ex situ lumbar DXA was similar to that obtained in situ in anterior-posterior direction (r=0.69 vs. 0.69 for T10, and r=0.61 vs. 0.65 for T6). The correlation between fracture loads of different spinal segments, and between DXA and failure loads was not significantly different between men and women. The results demonstrate a substantial heterogeneity of mechanical competence throughout the spine in elderly individuals. Because of the high incidence of fractures in the thoracic spine, these findings suggest that, clinically, lateral DXA involves no relevant advantage over anterior-posterior measurements of the lumbar spine. PMID:11311698
Bürklein, D; Lochmüller, E; Kuhn, V; Grimm, J; Barkmann, R; Müller, R; Eckstein, F
The direct lateral interbody fusion (DLIF), a minimally invasive lateral approach for placement of an interbody fusion device, does not require nerve root retraction or any contact with the great vessels and can lead to short operative times with little blood loss. Due to anatomical restrictions, this procedure has not been used at the lumbosacral (L5-S1) junction. Lumbosacral transitional vertebrae (LSTV), a structural anomaly of the lumbosacral spine associated with low back pain, can result in a level being wrongly identified pre-operatively due to misnumbering of the vertebral levels. To our knowledge, use of the DLIF graft in this patient is the first report of an interbody fusion graft being placed at the disc space between the LSTV and S1 via the transpsoas route. We present a review of the literature regarding the LSTV variation as well as the lateral placement of interbody fusion grafts at the lumbosacral junction. PMID:22551586
Shirzadi, Ali; Birch, Kurtis; Drazin, Doniel; Liu, John C; Acosta, Frank
Background: For carefully selected patients with lumbar stenosis, decompression surgery is more efficacious than nonoperative treatment. However, some patients undergo repeat surgery, often because of complications, the failure to achieve solid fusion following arthrodesis procedures, or persistent symptoms. We assessed the probability of repeat surgery following operations for the treatment of lumbar stenosis and examined its association with patient age, comorbidity, previous surgery, and the type of surgical procedure. Methods: We performed a retrospective cohort analysis of Medicare claims. The index operation was performed in 2004 (n = 31,543), with follow-up obtained through 2008. Operations were grouped by complexity as decompression alone, simple arthrodesis (one or two disc levels and a single surgical approach), or complex arthrodesis (more than two disc levels or combined anterior and posterior approach). Reoperation rates were calculated for each follow-up year, and the time to reoperation was analyzed with proportional hazards models. Results: The probability of repeat surgery fell with increasing patient age or comorbidity. Aside from age, the strongest predictor was previous lumbar surgery: at four years the reoperation rate was 17.2% among patients who had had lumbar surgery prior to the index operation, compared with 10.6% among those with no prior surgery (p < 0.001). At one year, the reoperation rate for patients who had been managed with decompression alone was slightly higher than that for patients who had been managed with simple arthrodesis, but by four years the rates for these two groups were identical (10.7%) and were lower than the rate for patients who had been managed with complex arthrodesis (13.5%) (p < 0.001). This difference persisted after adjusting for demographic and clinical features (hazard ratio for complex arthrodesis versus decompression 1.56, 95% confidence interval, 1.26 to 1.92). A device-related complication was reported at the time of 29.2% of reoperations following an initial arthrodesis procedure. Conclusions: The likelihood of repeat surgery for spinal stenosis declined with increasing age and comorbidity, perhaps because of concern for greater risks. The strongest clinical predictor of repeat surgery was a lumbar spine operation prior to the index operation. Arthrodeses were not significantly associated with lower rates of repeat surgery after the first postoperative year, and patients who had had complex arthrodeses had the highest rate of reoperations. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Deyo, Richard A.; Martin, Brook I.; Kreuter, William; Jarvik, Jeffrey G.; Angier, Heather; Mirza, Sohail K.
Lumbar spinal stenosis, the results of congenital and degenerative constriction of the neural canal and foramina leading to lumbosacral nerve root or cauda equina compression, is a common cause of disability in middle-aged and elderly patients. Advanced neuroradiologic imaging techniques have improved our ability to localize the site of nerve root entrapment in patients presenting with neurogenic claudication or painful radiculopathy. Although conservative medical management may be successful initially, surgical decompression by wide laminectomy or an intralaminar approach should be done in patients with serious or progressive pain or neurologic dysfunction. Because the early diagnosis and treatment of lumbar spinal stenosis may prevent intractable pain and the permanent neurologic sequelae of chronic nerve root entrapment, all physicians should be aware of the different neurologic presentations and the treatment options for patients with spinal stenosis. Images
Ciricillo, S F; Weinstein, P R
Background/Objective: Pseudomeningocele is most commonly the result of a rent in the meninges during spine surgery. Noniatrogenic causes exist but are rare. Pseudomeningoceles may heal spontaneously, but they may also slowly enlarge. They rarely present as a mass within the abdomen. The objective of this study was to present the first case report of hydronephrosis secondary to lumbar pseudomeningocele. Design: Single case report and literature review. Methods: Single case report. Results: This man had undergone extensive lumbar spine surgery for pain and spondylolisthesis. He subsequently developed a pseudomeningocele that caused hydronephrosis of the left kidney. He was treated with surgical intervention and had resolution of his hydronephrosis and his flank and groin pain. He also had improvement of his back pain. Conclusions: This report shows an unusual cause of hydronephrosis—a pseudomeningocele presenting as an abdominal mass that compressed the ureter.
Hamilton, Rita G; Brown, Steven W; Goetz, Lance L; Miner, Michael
Posterior dynamic stabilization (PDS) indicates motion preservation devices that are aimed for surgical treatment of activity related mechanical low back pain. A large number of such devices have been introduced during the last 2 decades, without biomechanical design rationale, or clinical evidence of efficacy to address back pain. Implant failure is the commonest complication, which has resulted in withdrawal of some of the PDS devices from the market. In this paper the authors presented the current understanding of clinical instability of lumbar motions segment, proposed a classification, and described the clinical experience of the pedicle screw-based posterior dynamic stabilization devices.
Sengupta, Dilip K.; Herkowitz, Harry N.
Background: In the last several years, the lateral transpsoas approach to the thoracic and lumbar spine, also known as extreme lateral interbody fusion (XLIF) or direct lateral interbody fusion (DLIF), has become an increasingly common method to achieve fusion. Several recent large series describe several advantages to this approach, including less tissue dissection, smaller incisions, decreased operative time, blood loss, shorter hospital stay, reduced postoperative pain, enhanced fusion rates, and the ability to place instrumentation through the same incision. Indications for this approach have expanded and now include degenerative disease, tumor, deformity, and infection. Methods: A lateral X-ray confirms that the patient is in a truly lateral position. Next, a series of tubes and dilators are used, along with fluoroscopy, to identify the mid-position of the disk to be incised. After continued dilation, the optimal site to enter the disk space is the midpoint of the disk, or a position slightly anterior to the midpoint of the disk. XLIF typically allows for a larger implant to be inserted compared to TLIF or PLIF, and, if necessary, instrumentation can be inserted percutaneously, which would allow for an overall minimally invasive procedure. Results: Fixation techniques appear to be equal between XLIF and more traditional approaches. Some caution should be exercised because common fusion levels of the lumbar spine, including L4-5 and L4-S1, are often inaccessible. In addition, XLIF has a unique set of complications, including neural injuries, psoas weakness, and thigh numbness. Conclusion: Additional studies are required to further evaluate and monitor the short and long-term safety, efficacy, outcomes, and complications of XLIF procedures.
Arnold, Paul M.; Anderson, Karen K.; McGuire, Robert A.
Increasing numbers of posterior lumbar fusions are being performed. The purpose of this study was to identify trends in demographics, mortality and major complications in patients undergoing primary posterior lumbar fusion. We accessed data collected for the Nationwide Inpatient Sample for each year between 1998 and 2008 and analysed trends in the number of lumbar fusions, mean patient age, comorbidity burden, length of hospital stay, discharge status, major peri-operative complications and mortality. An estimated 1 288 496 primary posterior lumbar fusion operations were performed between 1998 and 2008 in the United States. The total number of procedures, mean patient age and comorbidity burden increased over time. Hospital length of stay decreased, although the in-hospital mortality (adjusted and unadjusted for changes in length of hospital stay) remained stable. However, a significant increase was observed in peri-operative septic, pulmonary and cardiac complications. Although in-hospital mortality rates did not change over time in the setting of increases in mean patient age and comorbidity burden, some major peri-operative complications increased. These trends highlight the need for appropriate peri-operative services to optimise outcomes in an increasingly morbid and older population of patients undergoing lumbar fusion. PMID:22371544
Pumberger, M; Chiu, Y-L; Ma, Y; Girardi, F P; Mazumdar, M; Memtsoudis, S G
Posterior reversible encephalopathy (PRE) is a recent syndrome characterized by headache, vomiting, seizures, visual loss, altered mental status with or without motor or sensitive deficit. Neuroimaging demonstrates symmetrical posterior cortical and subcortical lesions. The aetiology remains uncertain but vascular hypotheses is the most retained. We report a case of a 21 year old man with posterior cerebral encephalopathy, the toxic hypo these remains the most probable. PMID:15969236
Boughammoura-Bouatay, Amel; Chebel, Saber; Fitouri, Fitouri; Hizem, Yosr; Frih-Ayed, Mahbouba
The frequency of posterior sternoclavicular dislocations represents 0.019% of the shoulder injuries in the Centre of Traumatology\\u000a and Orthopedics of Dakar. The posterior form is 0.033% compared to the anterior form. The authors report the cases of posterior\\u000a sternoclavicular dislocations, occurred with seven men and one woman. Seven of these dislocations were located on the left\\u000a side, including one case
El Hadji Souleymane Camara; Ablaye Bousso; Mouhamed Tall; Mouhamed Habib Sy
This report describes a case of a professional baseball pitcher who developed acute left lumbar radicular symptoms after a baseball game and was subsequently sidelined for the rest of the season. Physical examination revealed depressed reflexes in the left posterior tibialis and left medial hamstring muscles, mild weakness in the left extensor hallucis longus, and positive dural tension signs. Magnetic
Joe Lee; Ronald J. Wisneski; Gregory E. Lutz
The new millennium has witnessed the emergence of minimally invasive, non-posterior based surgery of the lumbar spine, in particular via lateral based methodologies to discectomy and fusion. In contrast, and perhaps for a variety of reasons, anterior motion preservation (non-fusion) technologies are playing a comparatively lesser, though incompletely defined, role at present. Lateral based motion preservation technologies await definition of their eventual role in the armamentarium of minimally invasive surgical therapies of the lumbar spine. While injury to the major vascular structures remains the most serious and feared complication of the anterior approach, this occurrence has been nearly eliminated by the use of lateral based approaches for discectomy and fusion cephalad to L5-S1. Whether anterior or lateral based, non-posterior approaches to the lumbar spine share certain access related pitfalls and complications, including damage to the urologic and neurologic structures, as well as gastrointestinal and abdominal wall issues. This review will focus on the recognition, management and prevention of these anterior and lateral access related complications.
Fantini, Gary A; Pawar, Abhijit Y
Background: Posterior clinoidectomy is a useful procedure for maximizing exposure to the interpeduncular cistern via transcranial approaches for basilar tip aneurysms and select intracranial tumors. The value of posterior clinoidectomy during endonasal endoscopic transclival surgery is not well described. Methods: We performed endoscopic endonasal transsphenoidal extradural bilateral posterior clinoidectomy and dorsum sella removal on five silicon-injected cadaveric heads. The dorsum sella was split in the midline and removed from medial to lateral until the posterior clinoids were encountered. The posterior clinoid was dissected from the medial wall of the cavernous sinus and mobilized medially in order to detach it from the ligaments and carefully fractured it from the bony attachment to the petrous apex and carotid canal. Following this, the clival and dorsum sella dura was opened to expose the interpeduncular cistern and its contents. Results: The technical feasibility of endoscopic endonasal extradural posterior clinoidectomy was reproduced in all five cadaveric specimens. This technique was performed without damaging the vital structures, including preservation of the pituitary gland. After performing bilateral posterior clinoidectomy, the retrosellar dura was opened, allowing good visualization of the contents of the prepontine and interpeduncular cistern. Conclusion: We describe the technique of endoscopic endonasal extradural posterior clinoidectomy. We believe this approach is best suited for retrosellar pathology located in the interpeduncular cistern and is a useful adjunct to the transclival approach to increase the field of view and maximize the extent of resection.
Silva, Danilo; Attia, Moshe; Kandasamy, Jothy; Alimi, Marjan; Anand, Vijay K.; Schwartz, Theodore H.
The purpose of this study was to examine compartmentalization in human lumbar spine extensors. Structure and innervation of these muscles would suggest the possibility of more segmentally specific biomechanical functions than have been found in previous studies examining muscle activation patterns during simple spine bending and twisting tasks. We selected specialized tasks to more effectively investigate the degree of independent control possible within lumbar spine extensors. We recorded surface electromyograms (SEMG) from the right posterior lumbar region during performance of two segmentally specific bellydance skills by seven novice and five trained subjects. These movements were performed at two frequencies (0.5 and 1Hz). Cross-correlations were performed between pairs of rectified, low-pass filtered (6Hz) SEMG signals to determine temporal lags between rhythmic bursts. Results showed a difference in the timing of muscle activation above and below the third lumbar vertebra. Temporal asynchrony was independent of either skill level or tempo, suggesting a hard-wired capacity for independent control of adjacent muscle compartments. The results have implications for understanding trunk control in the context of postural stability and postural adaptation during locomotion, as well as for lower back functional assessment and rehabilitation. PMID:22554499
Nugent, Marilee M; Stapley, Paul J; Milner, Theodore E
This retrospective study evaluated a single surgeon's series of patients treated by multilevel cervical disc excision (two or three levels), allograft tricortical iliac crest arthrodesis, and anterior instrumentation. The objective of this retrospective study was to compare fusion success and clinical outcome between multilevel Smith-Robinson interbody grafting and tricortical iliac strut graft reconstruction, both supplemented with anterior instrumentation in the cervical spine. The incidence of nonunion for cervical discectomy and fusion varies widely depending on the number of disc levels involved, type of bone graft used, and whether the anterior grafting is supplemented with instrumentation. An alternative to multilevel interbody fusion is corpectomy and strut grafting, in which the incidence of nonunion has been reported to be 27% with autograft and 41% with allograft. Sixty-four consecutive patients who underwent allograft tricortical iliac crest reconstruction and anterior cervical plating were studied. The average follow-up was 39 months. There were 38 patients in the discectomy and interbody grafting group and 26 patients in the corpectomy and strut graft reconstruction group. Pseudoarthrosis occurred in 42% of the anterior cervical interbody fusion patients and 31% of the corpectomy patients. Nonunion in two-level interbody fusions occurred in 36% of the patients as compared to 10% for patients with one-level corpectomies; while 54% of patients with three-level interbody fusions and 44% of patients with two-level corpectomies were noted to have pseudoarthrosis. Higher percentages of nonunion were noted in multilevel interbody grafting than in corpectomy with strut grafting and when more vertebral levels were involved. These radiographic and clinical findings underscore the shortcomings of multilevel anterior cervical allograft reconstruction with plating. Corpectomy may be the preferred method when multiple disc levels are fused. In addition, anterior corpectomy affords decompression of significant osteophytes in a safer and quicker manner. In retrospective studies, there is a need for long-term follow-up before accurate statements can be made about the study population. PMID:9209883
Swank, M L; Lowery, G L; Bhat, A L; McDonough, R F
There is a debate regarding the distal fusion level for degenerative lumbar scoliosis. Whether a healthy L5-S1 motion segment should be included or not in the fusion remains controversial. The purpose of this study was to determine the optimal indication for the fusion to the sacrum, and to compare the results of distal fusion to L5 versus the sacrum in the long instrumented fusion for degenerative lumbar scoliosis. A total of 45 patients who had undergone long instrumentation and fusion for degenerative lumbar scoliosis were evaluated with a minimum 2 year follow-up. Twenty-four patients (mean age 63.6) underwent fusion to L5 and 21 patients (mean age 65.6) underwent fusion to the sacrum. Supplemental interbody fusion was performed in 12 patients in the L5 group and eleven patients in the sacrum group. The number of levels fused was 6.08 segments (range 4–8) in the L5 group and 6.09 (range 4–9) in the sacrum group. Intraoperative blood loss (2,754 ml versus 2,938 ml) and operative time (220 min versus 229 min) were similar in both groups. The Cobb angle changed from 24.7° before surgery to 6.8° after surgery in the L5 group, and from 22.8° to 7.7° in the sacrum group without statistical difference. Correction of lumbar lordosis was statistically better in the sacrum group (P = 0.03). Less correction of lumbar lordosis in the L5 group seemed to be associated with subsequent advanced L5-S1 disc degeneration. The change of coronal and sagittal imbalance was not different in both groups. Subsequent advanced L5-S1 disc degeneration occurred in 58% of the patients in the L5 group. Symptomatic adjacent segment disease at L5-S1 developed in five patients. Interestingly, the development of adjacent segment disease was not related to the preoperative grade of disc degeneration, which proved minimal degeneration in the five patients. In the L5 group, there were nine patients of complications at L5-S1 segment, including adjacent segment disease at L5-S1 and loosening of L5 screws. Seven of the nine patients showed preoperative sagittal imbalance and/or lumbar hypolordosis, which might be risk factors of complications at L5-S1. For the patients with sagittal imbalance and lumbar hypolordosis, L5-S1 should be included in the fusion even if L5-S1 disc was minimal degeneration.
Cho, Kyu-Jung; Suk, Se-Il; Kim, Jin-Hyok; Choi, Sung-Wook; Yoon, Young-Hyun; Won, Man-Hee
The purpose of this study was to develop and validate a classification of indications for fusion in lumbar degenerative disease. Nineteen spine surgeons reviewed a series of 32 case histories and selected the indication for fusion based on an outlined classification system. To determine the degree of interrater variability, K coefficients were calculated (K for all 32 cases, 0.63). Results from this study show the significant difficulty in classifying the indication for fusion in lumbar degenerative disease. The level of the 19 surgeons' agreement regarding surgical indication was only moderate, despite a study design that eliminated controversial issues of patient and procedure selection. To a significant extent, the difficulty in classifying indication for fusion underlines the importance of the process. If we cannot agree on why a specific patient is selected for fusion, it is then impossible to accurately compare outcomes for a given disease process or surgical technique. For this reason, an ongoing effort to refine nomenclature and classification is necessary. PMID:16689515
Glassman, Steven D; Carreon, Leah Y; Dimar, John R; Campbell, Mitchell J; Johnson, John R; Puno, Rolando M
Introduction Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30-50 years, with a male to female ratio of 2:1. There is little evidence to suggest that drug treatments are effective in treating herniated disc. Methods and outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, and surgery for herniated lumbar disc? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). Results We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. Conclusions In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics, antidepressants, bed rest, corticosteroids (epidural injections), cytokine inhibitors (infliximab), discectomy (automated percutaneous, laser, microdisectomy, standard), exercise therapy, heat, ice, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), percutaneous disc decompression, spinal manipulation, and traction.
This report describes a novel method of repair for a large thoracolumbar myelomeningocele with an associated lumbar kyphosis in the neonate. A Caucasian male child was born at term with an antenatal diagnosis of hydrocephalus and spina bifida. Lumbar spine X-ray showed a significant kyphosis at L2-L3 level. Kyphectomy was performed and a cervical plate was used to reduce the gibbus deformity and maintain a rigid construct. Local rotation flaps were elevated and advanced to cover the defect. Wound was well healed at 3-month follow-up and the patient remained shunt-free at 1 year. To our knowledge, this is the first description of myelomeningocele repair with kyphectomy and posterior fixation in a neonate. PMID:23828714
Duddy, John C; Caird, John; Connolly, Paul
The authors report the results of their biomechanical experimental study on the fixation of various lesions of the spine, using Roy Camille metal plates, and the results of Fischer -- Gonon (using Harrington rods) and Kempf -- Jaeger (using Kempf rods). They conclude to: the efficiency of the posterior techniques of fixation, the necessity, in the thoraco-lumbar and lumbar segments to associate an anterior graft (fibula), in order to reinforce the late stability, the best functional results achieved by a "short" fixation in association with an anterior graft (double approach technique). According to their experience, the authors advocate for the use of Roy Camille metal plates screwed in the pedicles, the Harrington or Kempf rods helping in the per operative course to gain further reduction, namely in cases of disymetrical displacements. PMID:6521810
Privat, J M; Ohanna, F; Bonnel, F; Frerebeau, P
Burst fractures in acute spinal traumas are a difficult problem to solve. Different approaches and techniques have been utilized, but with high incidence of morbidity and mortality, besides unsatisfactory clinical and radiological results. Mini-open approaches recently emerged and have been shown to be safe and effective in the treatment of several spinal conditions. Here we report a case of acute lumbar burst fracture at L2 treated by minimally invasive true lateral approach posteriorly instrumented with percutaneous pedicle screws. The minimum disruptive access in addition to a rigid construction allowed a lumbar corpectomy without the morbidity of standard open approaches, lowering surgery costs and accelerating the patient recovery with successfully clinical and radiological results.
Amaral, Rodrigo; Marchi, Luis; Oliveira, Leonardo; Coutinho, Thiago
The posterior bone block procedure is an uncommon surgical procedure used in the treatment of posterior shoulder instability.\\u000a The purpose of this study is to report the results of the posterior bone block procedure in the treatment of posterior shoulder\\u000a instability. We retrospectively reviewed 21 shoulders that had undergone a posterior bone block procedure in the treatment\\u000a of recurrent posterior
Elvire Servien; Gilles Walch; Zenia E. Cortes; T. Bradley Edwards; Daniel P. O’Connor
Posterior scleritis is an inflammatory process of the posterior part of the sclera. Its prevalence is very low and its diagnosis can be complicated due to the absence of external ocular signs. It is more frequent in women. In young patients it does not usually have other associated pathologies, but in those over 55 years nearly one-third of the cases have a relation with some systemic disease, above all rheumatoid arthritis. The diagnosis of this pathology can require a multidisciplinary approach and the collaboration of ophthalmologists with neurologists, internists or rheumatologists. This article describes a case of idiopathic bilateral posterior scleritis. PMID:21904415
Zurutuza, A; Andonegui, J; Berástegui, L; Arruti, N
Fifty-one spastic children who had undergone selective posterior lumbar rhizotomy between 1981 and 1984 were re-examined to determine whether the gains achieved had persisted and to look at other aspects that had not previously been explored in detail. The reduction of tone was maintained in all cases, while motor function continued to improve in 42 cases. Functional gains were greatest
Leila J. Arens; Warwick J. Peacock; Jonathan Peter
on based of Kendall and his colleagues assumptions believed was a weakness in muscles of abdomen and femur extensor will be cause of pelvic anterior turn and also increase of lumbar arc (Kendall, 2005).But recent researches have doubt about the true of this subject the purpose of this study was to Comparison powers of couple force of anterior & posterior
Abdolhamid Habibi; Mansour Sahebozamani; Yadollah Zibaye Yekta; Rohollah Valizadeh
No consensus has been reached regarding surgical management of degenerative spondylolisthesis. The optimal type of surgical procedure and surgical indications have not been precisely defined. In order to screen for predictors of outcome, we retrospectively studied patient outcomes after posterior decompression and fusion for isolated lumbar degenerative spondylolisthesis. Twenty-four consecutive patients (age range 50–78 years) underwent primary surgery for isolated
Marc-Antoine Rousseau; Jean-Yves Lazennec; Elisa C. Bass; Gérard Saillant
Non-fusion stabilization of the lumbar spine in the case of degenerative diseases with a dynamic pedicle screw rod Estabilização dinâmica da coluna lombar no tratamento das doenças degenerativas ARTIGO ORIGINAL \\/ ORIGINAL ARTICLE
Objective: To compare the results of the posterior non-fusion stabilizations and fusion in the treatment of painful degenerative diseases of the lumbar spine. Methods: Cosmic is a dynamic non-fusion pedicle screw rod system for the stabilization of the lumbar vertebral column. The hinged pedicle screw provides for the load being shared between the implant and the vertebral column and allows
Archibald von Strempel; Christoph Stoss; Dieter Moosmann; Arno Martin
Chronic low back pain is a major social, economic, and healthcare issue in the United States. Various techniques are utilized in managing discogenic pain, with or without disc herniation. Percutaneous techniques are rapidly replacing traditional open surgery in operations requiring discectomy, decompression, and fusion. The percutaneous access to the disc was first used in the 1950s to biopsy the disc with needles. Percutaneous access to the disc using endoscopic techniques was developed in the 1970s. Technical advances in the use of intradiscal therapies led to the development of intradiscal electrothermal annuloplasty (IDET), DISC Nucleoplasty, and DeKompressor, along with laser-assisted, endoscopic, and Nucleotome disc decompressions. The indications for percutaneous lumbar disc decompression include low back and lower extremity pain caused by a symptomatic disc. Internal disc disruptions and disc herniations are common causes of low back and/or lower extremity pain which may become chronic, if not diagnosed and treated. Annular tears lead to migration of the nuclear material and deranged internal architecture. In the chronically damaged intervertebral disc, leakage of nuclear material from annular tears can initiate, promote, and continue the inflammatory process and delay or stop recovery of vital remaining intradiscal tissue. The most often stated goal of central nuclear decompression is to lower the pressure in the nucleus and to allow room for the herniated fragment to implode inward. Provocative discography prior to percutaneous lumbar disc decompression is recommended. Percutaneous disc decompression may result in a small number of complications but occasionally, these could be serious. PMID:16703975
Singh, Vijay; Derby, Richard
Background Exposure of the anterior or lateral lumbar via the retroperitoneal approach easily causes injuries to the lumbar plexus. Lumbar\\u000a plexus injuries which occur during anterior or transpsoas lumbar spine exposure and placement of instruments have been reported.\\u000a This study aims is to provide more anatomical data and surgical landmarks in operations concerning the lumbar plexus in order\\u000a to prevent lumbar
Sheng Lu; Shan Chang; Yuan-zhi Zhang; Zi-hai Ding; Xin Ming Xu; Yong-qing Xu
The authors conducted a prospective study of 132 patients requiring interbody fusion without instrumentation following anterior cervical discectomy to compare the efficacy of tricortical iliac crest allograft versus autograft fusion substrates. The objectives of the study were to assess the potential differences in interspace collapse, angulation, maintenance of cervical alignment and lordosis, and clinical and radiographic fusion success rates between the two fusion substrates. The impact of habitual cigarette smoking on fusion rates was also examined. Autograft tricortical iliac crest bone was found to be superior to allograft bone as an interbody fusion substrate after both single- and multiple-level anterior cervical decompression procedures with respect to maintenance of cervical interspace height, interspace angulation, and radiographic and clinical fusion success rates. Cigarette consumption had a significant adverse effect on successful anterior cervical interbody fusion for both autograft and allograft substrate, an effect that was most pronounced among smokers treated with allograft bone (p = 0.004). PMID:8755747
Bishop, R C; Moore, K A; Hadley, M N
Summary Alkaptonuria is a rare, autosomal recessive metabolic disorder in which the homogentisic acid oxidase activity is absent.\\u000a Its incidence is as low as 0.001%. Ochronosis is the pigmentation of connective tissues and this pigmentation leads to degenerative\\u000a changes in alkaptonuric patients.\\u000a \\u000a Alkaptonuria most prominently involves the lumbar region, but lumbar disc herniation as the presenting feature of alkaptonuria\\u000a is not
D. Gürkanlar; M. Daneyemez; I. Solmaz; C. Temiz
Long-term results of cervical interbody fusion with PMMA were evaluated in a retrospective study. X-ray films of 83 patients were obtainable. Post-operative follow-up in this series was between 15 and 20 years. The results show that PMMA is engrafted after about 2 years. Stable vertebral interbody fusion is obtained in about 90% of cases. Development of malignoma was not observed. Resorptive bone alterations, which can be seen in about 2% of cases one to two years after operation are shown not to be progressive. This process heals and stable fusion develops. PMID:2812353
Böker, D K; Schultheiss, R; Probst, E M
Vertebral compression fractures (VCFs) can cause symptomatic spinal canal stenosis secondary to posterior wall retropulsion. This report describes four patients with VCF and lumbar stenosis secondary to posterior wall retropulsion who were treated with combined kyphoplasty and percutaneous interspinous spacer (IS) placement. Clinical and imaging follow-up ranged from 12-36 months. Outcomes were favorable. Combined kyphoplasty and percutaneous IS implant represents a minimally invasive, safe, and efficient option to treat VCF with symptomatic spinal stenosis. PMID:23101915
Bonaldi, Giuseppe; Cianfoni, Alessandro
We present two cases of rachipagus in two male infants and review the literature on this anomaly. These infants were from consanguineous marriages and cases of twins were reported in their families. In the first case it was a limb attached to the lower lumbar region with a rudimentary posterior arch. At the junction there was a lipomeningocele. Anatomical dissection of the limb identified the bones of the lower limb. In the second case, the parasites were joints of the upper limb that were attached to the chest by rudimentary posterior arches. In both cases there was only one spinal canal and a single spinal cord. Except the spina bifida in the first case no other malformation was diagnosed. The parasites were successfully excised. The two patients are well at one year of follow-up. Rachipagus is a rare embryogenic malformation with a good prognosis in the absence of associated congenital anomalies.
Sanoussi, Samuila; Rachid, Sani; Sani, Chaibou Maman; Mahamane, Bawa; Addo, Guemou
The authors report on 2 cases of anterior dislocation of the Maverick lumbar disc prosthesis, both occurring in the early postoperative period. These cases developed after experience with more than 50 uneventful cases and were therefore thought to be unrelated to the surgeon's learning curve. No similar complications have been previously reported. The anterior Maverick device has a ball-and-socket design made of cobalt-chromium-molybdenum metal plates covered with hydroxyapatite. The superior and inferior endplates have keels to resist translation forces. The patient in Case 1 was a 52-year-old man with severe L4-5 discogenic pain; and in Case 2, a 42-year-old woman with disabling L4-5 and L5-S1 discogenic back pain. Both patients were without medical comorbidities and were nonsmokers with no risk factors for osteoporosis. Both had undergone uneventful retroperitoneal approaches performed by a vascular access surgeon. Computed tomography studies on postoperative Day 2 confirmed excellent prosthesis placement. Initial recoveries were uneventful. Two weeks postoperatively, after stretching (extension or hyperextension) in bed at home, each patient suffered the sudden onset of severe abdominal pain with anterior dislocation of the Maverick prosthesis. The patients were returned to the operating room and underwent surgery performed by the same spinal and vascular surgeons. Removal of the Maverick prosthesis and anterior interbody fusion with a separate cage and plate were performed. Both patients had recovered well with good clinical and radiological recovery at the 6- and 12-month follow-ups. Possible causes of the anterior dislocation of the Maverick prosthesis include the following: 1) surgeon error: In both cases the keel cuts were neat, and early postoperative CT confirmed good placement of the prosthesis; 2) equipment problem: The keel cuts may have been too large because the cutters were worn, which led to an inadequate press fit of the implants; 3) prosthesis fault: Both plates of the dislocated implants looked normal and manufacturer analysis reported no fault; 4) patient factors: Both dislocations happened early in the postoperative period, after hyperextension of the spine while the patient was supine in bed. Bracing would not have reduced hyperextension. Dislocation of a lumbar spinal implant represents a life-threatening complication and should therefore be considered and recognized early. Radiographic and CT studies of both the lumbar spine (for prosthesis) and the abdomen (for hematoma) should be performed, as should CT angiography (for vessel damage or occlusion). Any anterior lumbar revision surgery is hazardous, and it is strongly advisable to have a vascular surgeon scrubbed. In cases of dislocation or extrusion of a lumbar interbody prosthesis, the salvage revision strategy is fusing the segment via the same anterior approach. Surgeons should be aware of the risk of anterior dislocation of the Maverick prosthesis. Keel cutters should be regularly checked for sharpness, as they may be implicated in the loosening of implants. Patients and their physical therapists should also avoid lumbar hyperextension in the early postoperative period. PMID:23768025
Gragnaniello, Cristian; Seex, Kevin A; Eisermann, Lukas G; Claydon, Matthew H; Malham, Gregory M
The tibialis posterior tendon is the largest and anteriormost tendon in the medial ankle. It produces plantar flexion and supination of the ankle and stabilizes the plantar vault. Sonographic assessment of this tendon is done with high-frequency, linear-array transducers; an optimal examination requires transverse retromalleolar, longitudinal retromalleolar, and distal longitudinal scans, as well as dynamic studies. Disorders of the posterior tibial tendon include chronic tendinopathy with progressive rupture, tenosynovitis, acute rupture, dislocation and instability, enthesopathies. The most common lesion is a progressive “chewing gum” lesion that develops in a setting of chronic tendinopathy; it is usually seen in overweight women over 50 years of age with valgus flat feet. Medial ankle pain must also be carefully investigated, and the presence of instability assessed with dynamic maneuvers (forced inversion, or dorsiflexion) of the foot. Sonography plays an important role in the investigation of disorders involving the posterior tibial tendon.
Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an aging population. This review focuses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focuses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high quality studies about the relative benefits and harms of commonly used treatments. Interpreting and comparing results of available research is limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favor a shared decision making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.
We observed the structure and form of adult annulus fibrosus of lumbar intervertebral disc at the fibrous layer level. The annulus fibrosus of lumbar interverbral disc was delaminated by using microsurgical technique. 8 testing points were taken in each layer and the angles between their fibers going and horizontal plane were measured. The results showed that the fiber going angle at each measurement point continually increased with the increase of fibrous layer from outside to inside along the radial direction in horizontal plane. The least fiber going angle was 25 degrees - 30 degrees. The fiber going angle at the same layer gradually increased from front to back. The fiber going angle was 70 degrees - 90 degrees at the middle of the back of annulus fibrosus of lumbar interverbral disc. The fiber going was consistent with the posterior longitudinal ligament going. Through the normalized equation and normalized line, the fiber going angle at any point in any layer could be obtained conveniently. We also observed that the annuli fibrosus were interlaced in the front, left and right of annulus fibrosus of lumbar intervertebral disc. And there were more interlaced areas in local sides of lumbar intervertebral disc, but there was no interlaced areas between layers near the middle of posterior annulus fibrosus. So we came to the conclusion: Annulus fibrosus of lumbar intervertebral disc has a special micro-structure in adaptation with its function. PMID:17899757
Zhu, Dong; Chen, Suhuan; Dong, Xin; Zhu, Weimin; Lu, Hui
BACKGROUND: Recent cadaver studies show stability against axial rotation with a cylindrical cage is marginally superior to a rectangular cage. The purpose of this biomechanical study in cadaver spine was to evaluate the stability of a new rectangular titanium cage design, which has teeth similar to the threads of cylindrical cages to engage the endplates. METHODS: Ten motion segments (five
Dilip K Sengupta; SMH Mehdian; Robert C Mulholland; John K Webb; Donna D Ohnmeiss
This retrospective study evaluated a single surgeon's series of patients treated by multilevel cervical disc excision (two or three levels), allograft tricortical iliac crest arthrodesis, and anterior instrumentation. The objective of this retrospective study was to compare fusion success and clinical outcome between multilevel Smith-Robinson interbody grafting and tricortical iliac strut graft reconstruction, both supplemented with anterior instrumentation in the
M. L. Swank; G. L. Lowery; A. L. Bhat; R. F. McDonough
BACKGROUND CONTEXT: The use of interbody fusion cages as a treatment for degenerative disc disease has become widespread. Low-profile cages have been developed to allow a closer fit when implanting bilateral cages in patients with smaller vertebral bodies. Some surgeons feel the open design also allows better bone contact and visualization. This is particularly true when two low-profile cages are
Michael Schiffman; Salvador A Brau; Robin Henderson; Gwen Gimmestad
The aim of this work was to add to the body of data on the frequency and severity of degenerative radiographic findings at adjacent levels after anterior cervical interbody fusion and on their clinical impact and to contribute to the insights about their pathogenesis. One hundred eighty patients who were treated by anterior cervical interbody fusion and who had a follow-up of >60 months were clinically and radiologically examined by independent investigators. For all patients, the long-term Odom score was compared with the score as obtained 6 weeks after surgery. For myelopathic cases, both the late Nurick and the Odom score were compared with the initial postoperative situation. For the adjacent disc levels, a radiologic "degeneration score" was defined and assessed both initially and at long-term follow-up. At late follow-up after anterior cervical interbody fusion, additional radiologic degeneration at the adjacent disc levels was found in 92% of the cases, often reflecting a clinical deterioration. The severity of this additional degeneration correlated with the time interval since surgery. The similarity of progression to degeneration between younger trauma patients and older nontrauma patients suggests that both the biomechanical impact of the interbody fusion and the natural progression of pre-existing degenerative disease act as triggering factors for adjacent level degeneration. PMID:15260088
Goffin, Jan; Geusens, Eric; Vantomme, Nicolaas; Quintens, Els; Waerzeggers, Yannic; Depreitere, Bart; Van Calenbergh, Frank; van Loon, Johan
Summary: Three cases of posterior cruciate ligament (PCL) laxity without posterolateral rotatory instability had magnetic resonance imaging scans that documented the structural continuity of the PCL. Tibial PCL recession was effective in eliminating symptomatic laxity in 1 case and lacked efficacy in the other 2 cases.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 6 (July), 1999: pp
Eugene E. Berg
This study evaluated the outcomes, complications, and recurrence rates of posterior cranial fossa meningiomas. We retrospectively reviewed our surgical experience with 64 posterior cranial fossa meningiomas. Mean age was 56 years with a female preponderance (67.2%). Headache was the most common symptom. Retrosigmoid approach was the commonest surgical procedure (23.4%). The incidence of cranial nerve related complications was 28%. Postoperatively facial nerve weakness was observed in 11%. The incidence of cerebrospinal fluid leak was 4.6%. Gross total resection was achieved in 37 patients (58%). Sixteen patients (25%) with residual tumors underwent Gamma knife radiosurgery. Recurrence or tumor progression was observed in 12 patients (18.7%). Operative mortality was 3.1%. At their last follow-up, 93% of the cases achieved Glasgow Outcome Scale scores 4 or 5. Total excision is the ideal goal which can be achieved with meningiomas located in certain location, such as lateral convexity, but for other posterior fossa meningiomas the close proximity of critical structures is a major obstacle in achieving this goal. In practicality, a balance between good functional outcome and extent of resection is important for posterior cranial fossa meningiomas in proximity to critical structures.
Javalkar, Vijayakumar; Banerjee, Anirban Deep; Nanda, Anil
In total hip arthroplasty, steep cup inclination should be avoided because it increases the risk of edge loading. Pelvic posterior tilt should be carefully monitored because it increases cup inclination and anteversion, leading to edge loading or impingement. The authors evaluated how much the pelvic tilt angle changes from the supine position referenced in planning for cup orientation preoperatively to the standing position 1 year after total hip arthroplasty (?ref). The pelvic tilt angle was measured in 124 patients who underwent total hip arthroplasty due to osteoarthritis, and the mean ?ref was -9.5°±5.3° (range, -23° to 5°). Preoperative compression fractures, spondylolisthesis, and disk-space narrowing were predictive of increased pelvic posterior tilt after total hip arthroplasty. The authors mathematically calculated how much change in pelvic posterior tilt was clinically possible with the original cup alignment, which ranged from 40° to 45° of radiographic inclination and 0° to 30° radiographic anteversion to more than 50° of inclination. Even if the maximum posterior tilt (23°) occurred, no edge loading would occur in almost half of those original cups. Surgeons should aim for 40° of inclination. When the original cup inclination was 40°, edge loading was prevented. Edge loading caused by steep cup inclination can be prevented by adjusting the cup orientation to account for predicted pelvic tilting, but spinal alignment must also be considered because lumbar kyphosis can increase postoperative pelvic posterior tilt. PMID:23746037
Kyo, Takayuki; Nakahara, Ichiro; Miki, Hidenobu
We present a method to compute the conditional distribution of a statistical shape model given partial data. The result is a "posterior shape model", which is again a statistical shape model of the same form as the original model. This allows its direct use in the variety of algorithms that include prior knowledge about the variability of a class of shapes with a statistical shape model. Posterior shape models then provide a statistically sound yet easy method to integrate partial data into these algorithms. Usually, shape models represent a complete organ, for instance in our experiments the femur bone, modeled by a multivariate normal distribution. But because in many application certain parts of the shape are known a priori, it is of great interest to model the posterior distribution of the whole shape given the known parts. These could be isolated landmark points or larger portions of the shape, like the healthy part of a pathological or damaged organ. However, because for most shape models the dimensionality of the data is much higher than the number of examples, the normal distribution is singular, and the conditional distribution not readily available. In this paper, we present two main contributions: First, we show how the posterior model can be efficiently computed as a statistical shape model in standard form and used in any shape model algorithm. We complement this paper with a freely available implementation of our algorithms. Second, we show that most common approaches put forth in the literature to overcome this are equivalent to probabilistic principal component analysis (PPCA), and Gaussian Process regression. To illustrate the use of posterior shape models, we apply them on two problems from medical image analysis: model-based image segmentation incorporating prior knowledge from landmarks, and the prediction of anatomically correct knee shapes for trochlear dysplasia patients, which constitutes a novel medical application. Our experiments confirm that the use of conditional shape models for image segmentation improves the overall segmentation accuracy and robustness. PMID:23837968
Albrecht, Thomas; Lüthi, Marcel; Gerig, Thomas; Vetter, Thomas
Objective Lumbar triangle hernias are rarely reported causes of low back pain. We describe the symptoms, signs, and anatomical location of 2 possible defects in the posterior abdominal wall where lumbar hernias may appear. The clinical diagnosis was challenging, and advanced imaging failed to initially uncover the conditions. Clinical Features We report 4 patients with spontaneous inferior lumbar triangle hernias (Petit triangle hernias) initially presenting to a primary care clinic with the primary complaint of low back pain. Intervention and Outcomes Thorough histories and examinations led to successful outcomes. All 4 patients were operated on to correct the defect. No recurrence has occurred. Conclusions Anatomical knowledge and clinical acumen led to correct diagnosis of these rare lumbar hernias. This information should help both medical and chiropractic clinicians detect these conditions, and aid in appropriate management.
Lillie, Gregory R.; Deppert, Eric
Adjacent segment degeneration (ASD) is discussed to impair long-term outcome after lumbar interbody fusion. Nevertheless the amount and origin of degeneration and its clinical relevance remain unclear. Only little data is published studying quantitative disc height reduction (DHR) as indicator for ASD in long-term follow-up. Forty patients (23 men, 17 women) (group 1: degenerative disc disease, n = 27; group 2: lytic spondylolisthesis, n = 13) underwent lumbar 360° instrumentation and fusion between 1991 and 1997. Preoperative and follow-up lateral lumbar radiographs were studied. Disc heights of first and second cephalad adjacent segments were measured by Farfan’s technique and Hurxthal’s technique modified by Pope. Clinical outcome was studied using Oswestry disability index (ODI) and visual analogue scale (VAS). Age, gender, prior surgery, fusion rate and number of fusion levels were investigated as potential factors affecting the outcome. Mean follow-up was 114 (72–161) months. Clinical outcome showed an improvement of 44.6% in ODI and 43.8% in VAS with a tendency towards better results in group 2. Fusion rate was 95%. Disc height of the first cephalad adjacent segment in all patients was reduced by on average 21% (Farfan, P < 0.001) and 19% (Pope, P < 0.001), respectively, and that of the second adjacent level by on average 16% (Farfan, P < 0.001) and 14% (Pope, P < 0.001), respectively. A tendency towards more disc height reduction (DHR) in the degenerative group was observed. Advanced age correlated with advanced DHR (P ? 0.003, r = 0.5). Multiple level fusion led to a more pronounced DHR than 1-level fusion (P = 0.028). There was a tendency towards more DHR in the first adjacent disc compared to the second. Gender, prior surgery of the fused segment and fusion level did not affect the amount of DHR. There was no correlation between the clinical outcome and DHR. Lumbar fusion is associated with DHR of adjacent discs. This may be induced by additional biomechanical stress, ongoing degeneration affecting the lumbar spine and advancing age. However, clinical outcome is not correlated with adjacent DHR.
Leistra, Freek; Bullmann, Viola; Osada, Nani; Vieth, Volker; Marquardt, Bjorn; Lerner, Thomas; Liljenqvist, Ulf; Hackenberg, Lars
As life expectancy increases, degenerative lumbar spinal stenosis (DLSS) becomes a common health problem among the elderly. DLSS is usually caused by degenerative changes in bony and/or soft tissue elements. The poor correlation between radiological manifestations and the clinical picture emphasizes the fact that more studies are required to determine the natural course of this syndrome. Our aim was to reveal the association between lower lumbar spine configuration and DLSS. Two groups were studied: the first included 67 individuals with DLSS (mean age 66 ± 10) and the second 100 individuals (mean age 63.4 ± 13) without DLSS-related symptoms. Both groups underwent CT images (Philips Brilliance 64) and the following measurements were performed: a cross-section area of the dural sac, vertebral body dimensions (height, length and width), AP diameter of the bony spinal canal, lumbar lordosis and sacral slope angles. All measurements were taken at L3 to S1. Vertebral body lengths were significantly greater in the DLSS group at all levels compared to the control, whereas anterior vertebral body heights (L3, L4, L5) and middle vertebral heights (L3, L5) were significantly smaller in the LSS group. Lumbar lordosis, sacral slope and bony spinal canal were significantly smaller in the DLSS compared to the control. We conclude that the size and shape of vertebral bodies and canals significantly differed between the study groups. A tentative model is suggested to explain the association between these characteristics and the development of degenerative spinal stenosis.
Hamoud, K.; May, H.; Hay, O.; Medlej, B.; Masharawi, Y.; Peled, N.; Hershkovitz, I.
Study design Retrospective cohort study of 1430 patients undergoing lumbar spinal fusion from 2002 - 2009. Objective: The goal of this study was to compare and evaluate the number of complications requiring reoperation in elderly versus younger patients. Summary of background data rhBMP-2 has been utilized off label for instrumented lumbar posterolateral fusions for many years. Many series have demonstrated predictable healing rates and reoperations. Varying complication rates in elderly patients have been reported. Materials and methods All patients undergoing instrumented lumbar posterolateral fusion of ??3 levels consenting to utilization of rhBMP-2 were retrospectively evaluated. Patient demographics, body mass index, comorbidities, number of levels, associated interbody fusion, and types of bone void filler were analyzed. The age of patients were divided into less than 65 and greater than or equal to 65 years. Complications related to the performed procedure were recorded. Results After exclusions, 482 consecutive patients were evaluated with 42.1% males and 57.9% females. Average age was 62 years with 250 (51.9%) < 65 and 232 (48.1%) ??65 years. Patients ??65 years of age stayed longer (5.0 days) in the hospital than younger patients (4.5 days) (p=0.005). Complications requiring reoperation were: acute seroma formation requiring decompression 15/482, 3.1%, bone overgrowth 4/482, 0.8%, infection requiring debridement 11/482, 2.3%, and revision fusion for symptomatic nonunion 18/482, 3.7%. No significant differences in complications were diagnosed between the two age groups. Statistical differences were noted between the age groups for medical comorbidities and surgical procedures. Patients older than 65 years underwent longer fusions (2.1 versus 1.7 levels, p=0.001). Discussion Despite being older and having more comorbidities, elderly patients have similar complication and reoperation rates compared to younger healthier patients undergoing instrumented lumbar decompression fusions with rhBMP-2.
Three patients with retinal detachments complicated by proliferative vitreoretinopathy underwent posteriorly located relaxing retinotomy to facilitate retinal reattachment. Six months postoperatively the retina remained attached in all cases, with an improvement in visual acuity in two cases (light perception to hand motion and 20/200 to 20/60) and a drop of one line in visual acuity in the third (20/20 to 20/25). PMID:2812694
Gremillion, C M; Peyman, G A
At the department of the sport and ballet trauma new methods of arthroscopic management of posterior posttraumatic knee instability (posterior static stabilization of knee joint with using of single-banded and double-banded transplants) in dependence on the kind, degree and form of instability, were worked out and implemented into clinical practice. Such methods permit to attain a compensated or subcompensated form of knee joint stability. Ad hoc methods of management were used in 23 patients (20 males and 3 females). A total of 62 patients (51 males and 11 females) got operative treatment at the department, that permitted us to estimate fairly different methods of operative treatment of posttraumatic posterior knee joint instability. An operational intervention was performed in average 6 month after trauma. We received data in patients which had been treated with use of new methods of operative treatment as follows: good results were drawn in 93.3% (22 patients), satisfactory results--in 6.7% of cases (1 patient). PMID:18819354
Mironov, S P; Orletski?, A K; Butkova, L L
Clinically and pathologically there are two kinds of posterior subcapsular cataracts: vacuolar-lacy and solid plaque. Vacuolar opacities occur in senile, diabetic, retinitis pigmentosa, steroid, and secondary cataracts (Elschnig pearls). Plaque opacities occur in congenital polar, myotonic dystrophy, and Turner syndrome (chromosome XO) cataracts. The vacuolar opacities tend to be more superficial (closer to the posterior capsule), whereas the plaque opacities are generally slightly deeper (more cortical). The vacuolar opacities show cellular proliferation of aberrantly migrated lens epithelial cells in the posterior pole which have added damage to the cataract by secretion of basement membrane, intra- and extra-cellular filaments, and release of cytolytic lysozymes causing liquefaction and necrosis. The plaque opacities are acellular. Both types of cataracts show breakdown of lens fibres into rounded up disorganized globules and some membranous whorls. The liquefied vacuolar opacity is more readily removed by extracapsular cataract extraction, but the retention of nucleated lens epithelial cells in the vacuolar type of opacity is the source of a secondary cataract or Hirchberg-Elschnig pearls which require a discussion or membranectomy to clear the visual axis. This article will review the salient features in the histopathology (light and electron microscopy) and morphology of PSC and amalgamate the findings reported by several investigators (Eshagian and Streeten, 1975; Eshagian, March, Goossens, and Rafferty, 1978, 1978; Eshagian, Rafferty, and Goossens, 1980, 1981; Eshagian, Rafferty, Goossens, and March, 1979; 1980; Streeten and Eshagian, 1978). PMID:6964282
Background context: The effects of aging and spinal degeneration on the mechanical properties of spinal ligaments are still unknown, although there have been several studies demonstrating those of normal spinal ligaments.Purpose: To investigate the mechanical properties of the human posterior spinal ligaments in human lumbar spine, and their relation to age and spinal degeneration parameters.Study design\\/setting: Destructive uniaxial tensile tests
Takahiro Iida; Kuniyoshi Abumi; Yoshihisa Kotani; Kiyoshi Kaneda
A prospective longitudinal study was performed to evaluate the vertebral body replacement system Synex associated with posterior\\u000a fixation in unstable burst fractures of the lumbar and thoracic spine. Within 24 months, we treated 28 patients (average age,\\u000a 41 years; range, 22–64 years; 14 women, 14 men) with acute unstable burst fractures without osteoporosis of the thoracolumbar\\u000a region (n=16) and the
Two similar groups of patients with unstable fractures and fracture dislocations of the thoracic or lumbar spine have been treated with the posterior application of Williams plates or Harrington distraction rods over a period of 10 years. The instrumentation was routinely removed from 13 to 19 months after insertion. The initial preoperative kyphotic angle was corrected by a mean of
M. Karjalainen; A. J. Aho; K. Katevuo
PURPOSE: Lumbar disc degeneration may be associated with intensity of neovascularization in disc herniations. Our study was designed to evaluate how much the severity of histodegeneration is related to the development of neovascularization and to the level of pleiotrophin in the herniated lumbar discs. METHODS: Surgically excised lumbar disc specimens were obtained from 29 patients with noncontained (i.e., extruding through the posterior longitudinal ligament) and 21 patients with contained disc herniations. The histodegeneration scores and levels of neovascularization were estimated according to semiquantitative analysis in lumbar disc and endplate samples. Immunohistochemical staining were performed to identify the newly formed blood vessels and to detect the presence of pleiotrophin in the specimens. RESULTS: Higher levels of disc and endplate neovascularity were registered in noncontained herniations. The level of neovascularization was significantly related to the score of histodegeneration in the herniated disc tissues but not in the endplate specimens. Both contained and noncontained herniations had the highest values of histodegeneration in conjunction with the highest level of neovascularization but the relations between neovascularity and degenerative changes remained to be significant only in the group of noncontained herniations. Registration or frequency of pleiotrophin positive cells did not correlate significantly with histodegeneration or level of neovascularization in the disc samples. CONCLUSION: Severe histodegeneration of the lumbar disc herniations is associated with enhanced neovascularization and potentially also spontaneous regression of the herniated tissue. PMID:23736847
Rätsep, Tõnu; Minajeva, Ave; Asser, Toomas
We report Ogilvie's syndrome following posterior spinal arthrodesis on a patient with thoracic and lumbar scoliosis associated with intraspinal anomalies. Postoperative paralytic ileus can commonly complicate scoliosis surgery. Ogilvie's syndrome as a cause of abdominal distension and pain has not been reported following spinal deformity correction and can mimic post-surgical ileus. 12 year old female patient with double thoracic and lumbar scoliosis associated with Arnold-Chiari 1 malformation and syringomyelia. The patient underwent posterior spinal fusion from T4 to L3 with segmental pedicle screw instrumentation and autogenous iliac crest grafting. She developed abdominal distension and pain postoperatively and this deteriorated despite conservative management. Repeat ultrasounds and abdominal computer tomography scans ruled out mechanical obstruction. The clinical presentation and blood parameters excluded toxic megacolon and cecal volvulus. As the symptoms persisted, a laparotomy was performed on postoperative day 16, which demonstrated ragged tears of the colon and cecum. A right hemi-colectomy followed by ileocecal anastomosis was required. The pathological examination of surgical specimens excluded inflammatory bowel disease and vascular abnormalities. The patient made a good recovery following bowel surgery and at latest followup 3.2 years later she had no abdominal complaints and an excellent scoliosis correction. Ogilvie's syndrome should be included in the differential diagnosis of postoperative ileus in patients developing prolonged unexplained abdominal distension and pain after scoliosis correction. Early diagnosis and instigation of conservative management can prevent major morbidity and mortality due to bowel ischemia and perforation.
Tsirikos, Athanasios I; Sud, Alok
Objective To compare the effects of lumbar stabilization exercises and lumbar dynamic strengthening exercises on the maximal isometric strength of the lumbar extensors, pain severity and functional disability in patients with chronic low back pain (LBP). Methods Patients suffering nonspecific LBP for more than 3 months were included prospectively and randomized into lumbar stabilization exercise group (n=11) or lumbar dynamic strengthening exercise group (n=10). Exercises were performed for 1 hour, twice weekly, for 8 weeks. The strength of the lumbar extensors was measured at various angles ranging from 0° to 72° at intervals of 12°, using a MedX. The visual analog scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ) were used to measure the severity of LBP and functional disability before and after the exercise. Results Compared with the baseline, lumbar extension strength at all angles improved significantly in both groups after 8 weeks. The improvements were significantly greater in the lumbar stabilization exercise group at 0° and 12° of lumbar flexion. VAS decreased significantly after treatment; however, the changes were not significantly different between the groups. ODQ scores improved significantly in the stabilization exercise group only. Conclusion Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP. However, the lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP.
Moon, Hye Jin; Kim, Dae Ha; Kim, Ha Jeong; Cho, Young Ki; Lee, Kwang Hee; Kim, Jung Hoo; Choi, Yoo Jung
Study Design An in-vitro study of the wear rates of the Charité lumbar total disc replacement. Objective To investigate the effect of anterior-posterior shear on the in-vitro wear rates of the Charité lumbar total disc replacement. Summary of Background Data Current standards prescribe only 4 degree of freedom (DOF) inputs for evaluating the in-vitro wear of total disc replacements, despite the functional spinal unit incorporating 6DOF. Anterior-posterior shear has been highlighted as a significant load, particularly in the lumbar spine. A previous study investigated the effect of an anterior-posterior shear on the ProDisc-L, finding that wear rates were not significantly different from 4DOF wear tests. Methods 6 Charité lumbar discs were mounted in a 5 active DOF spine wear simulator and tested under 4DOF (ISO18192) conditions. 6 further Charité lumbar discs were tested under 5DOF conditions, consisting of 4DOF conditions plus an anterior-posterior shear displacement of +2/-1.5mm. The displacement was decreased and then increased by a factor of 2, to investigate the effect of the magnitude of displacement. µCT scans were taken of the discs before and after wear testing, and the height loss of the discs calculated. These were compared to the same measurements taken from explanted Charite discs, µCT scanned at another institution. Results 4DOF wear rates (12.2±1.0mg/MC) were not significantly different from 4DOF tests on the ProDisc-L. Wear rates were significantly increased (p<0.01) for ‘standard’ 5DOF conditions (22.3±2.0 mg/MC), decreased 5DOF (24.3±4.9 mg/MC) and increased 5DOF (29.1±7.6mg/MC). The height loss of the explants and in-vitro tested discs were not significantly different (p>0.05). Conclusion The addition of anterior-posterior shear to wear testing inputs of the Charité lumbar total disc replacement increases the wear rate significantly, which is in direct contrast to the previous 5DOF testing on the ProDisc. This study highlights the importance of clinically relevant testing regimens, and that test inputs may be different for dissimilar design philosophies.
Vicars, R; Prokopovich, P; Brown, T D; Tipper, JL; Ingham, E; Fisher, J; Hall, RM
Abstract: Ossification of the Posterior Longitudinal Ligament (OPLL) is a condition caused by new bone developing in the posterior longitudinal ligament within the spinal canal. OPLL is a common cause of myelopathy in East Asian countries. Here, we report a case with OPLL in thoracic and lumbar spine in Kermanshah, West of Iran. Case: A 40 years old man gradually developed lower extremities paresis with defecation or voiding difficulties. Radiographic evaluation by computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the mass of ossification at the posterior aspect of the T2-T4 and T12-L1 of vertebral body with spinal cord compression. Although OPLL is a common cause of myelopathy in the East Asian countries, it should be included in differential diagnosis of myelopathy in other regions. Keywords: Ossification of the posterior longitudinal ligament (OPLL), Spinal canal, Myelopathy
Sepehri, Parandoush; Shobeiri, Elham
Posterior cortical atrophy (PCA) is a neurodegenerative syndrome that is characterised by progressive decline in visuospatial, visuoperceptual, literacy, and praxic skills. The progressive neurodegeneration affecting parietal, occipital, and occipitotemporal cortices that underlies PCA is attributable to Alzheimer's disease in most patients. However, alternative underlying causes, including dementia with Lewy bodies, corticobasal degeneration, and prion disease, have also been identified, and not all patients with PCA have atrophy on clinical imaging. This heterogeneity has led to inconsistencies in diagnosis and terminology and difficulties in comparing studies from different centres, and has restricted the generalisability of findings from clinical trials and investigations of factors that drive phenotypic variability. Important challenges remain, including the identification of factors associated not only with the selective vulnerability of posterior cortical regions but also with the young age of onset of PCA. Greater awareness of the syndrome and agreement over the correspondence between syndrome-level and disease-level classifications are needed to improve diagnostic accuracy, clinical management, and the design of research studies. PMID:22265212
Crutch, Sebastian J; Lehmann, Manja; Schott, Jonathan M; Rabinovici, Gil D; Rossor, Martin N; Fox, Nick C
Osteoconductive and totally bioresorbable spinal/cervical interbody fusion cages were fabricated from a forged composite of raw particulate hydroxyapatite/poly L-lactide (u-HA/PLLA) with an u-HA 40wt% fraction (F-u-HA 40). The mechanical strengths of three types of cages, designed for open-box, screw and cylinder constructs, were compared with those of existing metal and carbon-fiber/polymer cages. Compressive strengths of these composite cages surpassed those of existing metal and carbon-fiber cages. Fatigue resistance to alternate and static compressive loading persisted for longer than the minimum period (6 months) necessary for spinal devices in simulated body fluid (SBF) at 37 degrees C. These novel interbody fusion cages await clinical application in humans. PMID:12895589
Shikinami, Yasuo; Okuno, Masaki
The authors conducted a prospective and randomized study in 44 consecutive patients requiring cervical interbody fusion following anterior cervical discectomy to compare the efficacy of heterologous threaded cylindrical bone (Unilab Surgibone) versus titanium implant (Bak-C; Spine-Tech, Minneapolis ). The patients were evaluated between two and five years postoperatively and the objectives of the study were to assess the potential differences in implant shifting, interespace collapse, angulation, maintenance of cervical alignment and lordosis, and clinical and radiographic fusion success rates between the two fusion substrates. Clinical results were satisfactory with both types of implant. However the threaded cylindrical titanium implant was found to be superior to the heterologous threaded cylindrical bone as an interbody substrate after single -and multiple- level anterior cervical decompression procedures with respect to maintenance of cervical interspace height, interspace angulation and radiographic fusion success rates. PMID:15239013
Porras-Estrada, L F; Ugarriza-Echebarrieta, L F; Lorenzana-Honrado, L; Rodríguez-Sánchez, J A; García-Yagüe, L M; Fernández-Portales, I; Gómez-Perals, L; Cabezudo, J M
The authors retrospectively evaluated 30 patients with an anterior cervical interbody fusion for cervical spondylosis or disc herniation. Open box carbon fiber cages were used at 45 levels. The visual analogue scales (VAS), respectively for neck and for arm pain, and the neck disability index (NDI) improved significantly (p < 0.001). Fusion occurred in 87% of the operated levels. Subsidence of the cages into the endplates was observed in 49% of the operated levels, which increased to 54% when more levels were fused. No correlation between subsidence of the cage and clinical outcome or radiographic fusion was established. The authors conclude that cervical discectomy and interbody fusion using an open box carbon fiber cage is a satisfactory treatment option for degenerative cervical disease causing neck pain and radiculopathy, despite the relatively high percentage of subsidence of this cage. PMID:16305087
van der Haven, Ibo; van Loon, Piet J M; Bartels, Ronald H M A; van Susante, Job L C
We present a case of a revision spinal fusion in which successful bone graft reharvesting was performed from the posterior\\u000a iliac crest 4 years after initial intracortical harvesting. To date, only anterior iliac crest regeneration has been reported\\u000a in orthopedic trauma patients. A 70-year-old man with a history of two prior instrumented lumbar fusion operations developed\\u000a thoracolumbar kyphosis junctional to the
Elias C. Papadopoulos; Patrick F. O’Leary; Ioannis P. Pappou; Federico P. Girardi
Background Epidural analgesia with bupivacain, epinephrine and fentanyl provides excellent pain control after lumbar fusion surgery,\\u000a but pruritus and motor block are frequent side effects. Theoretically epidural ropivacain combined with oral oxycodone could\\u000a decrease the incidence of these side effects. The two regimens were compared in a prospective randomized trial.\\u000a \\u000a \\u000a \\u000a \\u000a Patients and methods 150 patients (87 women) treated with posterior instrumented lumbar
Eva Gulle; Carola Skärvinge; Karin Runberg; Yohan Robinson; Claes Olerud
Extreme lateral interbody fusion (XLIF) is a relatively new procedure for the treatment of degenerative disc disease avoiding the morbidity of anterior approaches. Ipsilateral L2–5 nerve root irritation and injury are well-described complications. We describe two patients with contralateral extremity symptoms, not reported so far. In the first patient the injury was caused by a displaced endplate fragment compressing the
Ioannis D. Papanastassiou; Mohammad Eleraky; Frank D. Vrionis
The lordotic curvature of the lumbar spine (lumbar lordosis) in humans is a critical component in the ability to achieve upright posture and bipedal gait. Only general estimates of the lordotic angle (LA) of extinct hominins are currently available, most of which are based on the wedging of the vertebral bodies. Recently, a new method for calculating the LA in skeletal material has become available. This method is based on the relationship between the lordotic curvature and the orientation of the inferior articular processes relative to vertebral bodies in the lumbar spines of living primates. Using this relationship, we developed new regression models in order to calculate the LAs in hominins. The new models are based on primate group-means and were used to calculate the LAs in the spines of eight extinct hominins. The results were also compared with the LAs of modern humans and modern nonhuman apes. The lordotic angles of australopithecines (41° ± 4), H. erectus (45°) and fossil H. sapiens (54° ± 14) are similar to those of modern humans (51° ± 11). This analysis confirms the assumption that human-like lordotic curvature was a morphological change that took place during the acquisition of erect posture and bipedalism as the habitual form of locomotion. Neandertals have smaller lordotic angles (LA = 29° ± 4) than modern humans, but higher angles than nonhuman apes (22° ± 3). This suggests possible subtle differences in Neandertal posture and locomotion from that of modern humans. PMID:22052243
Been, Ella; Gómez-Olivencia, Asier; Kramer, Patricia A
The microendoscopic discectomy (MED) technique has been one of the promising surgeries for lumbar disc herniation in the last few years. The purpose of this study is to report the feasibility of a minimally invasive technique for extraforaminal lumbar disc herniation. Ten patients with extraforaminal lumbar disc herniation (one at L3-4, four at L4-5, and five at L5-S1) underwent MED
Yuichi Takano; Nobuhiro Yuasa
Purpose of study: To date, there are few published data concerning work-related outcomes in patients undergoing lumbar fusion. The present observational study was designed to evaluate specific work-related outcomes in a population-based cohort of patients undergoing lumbar fusion.Methods used: A population-based database of 815 prospectively identified lumbar fusion patients was queried for patients with complete 2-year follow-up. From the resultant
William R. Klemme; Leila S. Nelson; Edgar G. Dawson; J. Kenneth Burkus; Kevin T. Foley; Stephen M. Papadopoulos
Low back pain is one of the most common ailments in the general population, which tends to increase in severity along with aging. While few patients have severe enough symptoms or underlying pathology to warrant surgical intervention, in those select cases treatment choices remain controversial and reimbursement is a substancial barrier to surgery. The object of this study was to examine outcomes of discogenic back pain without radiculopathy following minimally-invasive lateral interbody fusion. Twenty-two patients were treated at either one or two levels (28 total) between L2 and 5. Discectomy and interbody fusion were performed using a minimallyinvasive retroperitoneal lateral transpsoas approach. Clinical and radiographic parameters were analyzed at standard pre- and postoperative intervals up to 24 months. Mean surgical duration was 72.1 minutes. Three patients underwent supplemental percutaneous pedicle screw instrumentation. Four (14.3%) stand-alone levels experienced cage subsidence. Pain (VAS) and disability (ODI) improved markedly postoperatively and were maintained through 24 months. Segmental lordosis increased significantly and fusion was achieved in 93% of levels. In this series, isolated axial low back pain arising from degenerative disc disease was treated with minimally-invasive lateral interbody fusion in significant radiographic and clinical improvements, which were maintained through 24 months.
Marchi, Luis; Oliveira, Leonardo; Amaral, Rodrigo; Castro, Carlos; Coutinho, Thiago; Coutinho, Etevaldo; Pimenta, Luiz
The aim of this study is to evaluate the efficacy of hydroxyapatite grafts in multilevel cervical interbody fusion during the one year follow-up. A total of 86 patients with degenerative cervical disc disease underwent all together 224 cervical interbody fusion procedures in which either Smith-Robinson or Cloward type hydroxyapatite grafts were used. The surgeries included radiculopathy in 38 cases, myelopathy in 20 cases and myeloradicuopathy in 28 patients. In 65 out of 86 patients, fusion was followed by an anterior instrumentation (plating). Postoperatively, patients were followed for a mean of 15.64 (range 11-23.3) months. All patients underwent radiography to evaluate fusion and the axis curvature. Excellent clinical results (86%), described as a complete or partial relief of symptoms with full return to preop activity, were obtained in patients with radiculopathy. There were 5 grafts mobilizations and one graft fracture. Two grafts extruded in non-instrumented patients and required repeated surgery. There were other three reoperations due to the hardware problems. One year fusion rate was obtained at 86% for two-level surgery, 80.1% for three-level surgery and 74% for four-level surgery. The mean (SD) hospital stay was 3.8 (0.7) days. A hydroxyapatite cheramic can be a very effective synthetic material for multilevel cervical interbody fusion. It is characterized by a high fusion rate and a small percentage of graft-related complications, especially when fusion procedure is followed by plating. PMID:21648347
Vuki?, Miroslav; Walters, Beverly C; Radi?, Ankica; Jurjevi?, Ivana; Marasanov, Sergej M; Rozankovi?, Marjan; Jednacak, Hrvoje
Using 15 mid-term human fetuses, we examined the role of the spine anterior and posterior longitudinal ligaments (ALL, PLL)\\u000a in ossification of the lumbar vertebral body. By 18 weeks, a pair of calcified tissue or cortical walls had developed on the\\u000a anterior and posterior sides of the ossification center. These calcified cortical walls were more highly eosinophilic than\\u000a trabecular or woven
Zhe Wu Jin; Kyung Jin Song; Nae Ho Lee; Takuo Nakamura; Mineko Fujimiya; Gen Murakami; Baik Hwan Cho
The lumbar epidural veins are opacified by injection of the lateral sacral and ascending lumbar veins with abdominal compression. This technique provides a good opacification of the entire lumbar epidural venous system. Some anatomical points are discussed and clarified. The interest of the technique in the diagnosis of discal herniations is emphasized. PMID:958619
Theron, J; Houtteville, J P; Ammerich, H; Alves de Souza, A; Adam, H; Thurel, C; Rey, A; Houdart, R
Background One structure, the ligamentum flavum, nearly always encountered in lumbar spinal operations, has not been examined as an important anatomical landmark. In this context, we describe its relevance in corridors of small surgical exposures created by minimally invasive spinal approaches.Material and Methods In cadaveric and intraoperative dissections, we introduce a systematic technique for resection of this ligament and clarify its anatomical relationships with the exiting nerve roots, pedicles, facet capsule, and midline epidural fat. Fixed human cadaveric spines were harvested en bloc to maintain the lower thoracic to sacral segments. A single coronal cut through the anterior portion of the pedicles ensured that the dorsal elements were intact. Viewed from the operative microscope, photographs depict the ligamentum flavum at various intraoperative steps.Results The ligamentum flavum can undergo safe en bloc sequential resection that widely exposes the disc space for discectomy and interbody fusion. Its superolateral and inferolateral attachments are identifiable landmarks, effective in locating the exiting nerve roots. Corners of the L4-L5 ligamentum flavum mark the axillae of the exiting nerve roots (i.e., its superolateral corner marks the axilla of the L4 nerve roots, and its inferolateral corner marks the shoulder of the L5 nerve roots).Conclusion Our cadaveric and microscopic surgical dissections show the ligamentum flavum as seen in the new corridors of small surgical exposures during minimally invasive surgeries of the lumbar spine. Identifying this landmark, surgeons can envision the location of the nerve roots to help prevent their injury. PMID:23765919
Losiniecki, Andrew J; Serrone, Joseph C; Keller, Jeffrey T; Bohinski, Robert J
INTRODUCTION: Reversible Posterior Leukoencephalopathy Syndrome was introduced into clinical practice in 1996 in order to describe unique syndrome, clinically expressed during hypertensive and uremic encephalopathy, eclampsia and during immunosuppressive therapy . First clinical investigations showed that leucoencephalopathy is major characteristic of the syndrome, but further investigations showed no significant destruction in white cerebral tissue [2, 3, 4]. In majority of cases changes are localise in posterior irrigation area of the brain and in the most severe cases anterior region is also involved. Taking into consideration all above mentioned facts, the suggested term was Posterior Reversible Encephalopathy Syndrome (PRES) for the syndrome clinically expressed by neurological manifestations derived from cortical and subcortical changes localised in posterior regions of cerebral hemispheres, cerebral trunk and cerebellum . CASE REPORT: Patient, aged 53 years, was re-hospitalized in Cardiovascular Institute "Dediwe" two months after successful aorto-coronary bypass performed in June 2001 due to the chest bone infection. During the treatment of the infection (according to the antibiogram) in September 2001, patient in evening hours developed headache and blurred vision. The recorded blood pressure was 210/120 mmHg so antihypertensive treatment was applied (Nifedipin and Furosemid). After this therapy there was no improvement and intensive headache with fatigue and loss of vision developed. Neurological examination revealed cortical blindness and left hemiparesis. Manitol (20%, 60 ccm every 3 hours) and i.v. Nytroglicerin (high blood pressure). Brain CT revealed oedema of parieto-occipital regions of both hemispheres, more emphasized on the right. (Figure 1a, b, c). There was no sign of focal ischemia even in deeper sections (Figure 1d, e, f). Following three days enormous high blood pressure values were registered. On the fourth day the significant clinical improvement occurred with lowering of blood pressure, better mental state and better vision. There was no sign of left hemiparesis on the 7th day. On the 9th day there were no symptoms or sign of disease. Control brain CT (15th day) was normal. ETHIOPATHOGENESIS: Most common causes of PRES are hypertensive encephalopathy [6-8], pre-eclampsia/eclampsia [9-12] cyclosporin A administration [13-22] and uremic encephalopathy . There are several theories about the mechanism for PRES in hypertensive encephalopathy (reversible vasospasm and hyperperfusion) and administration of cyclosporin A (neurotoxic effect). CLINICAL PICTURE: Most common symptoms are headache, nausea, vomiting, confusion, behavioural changes, changes of conciousness (from somnolencia to stupor), vision disturbances (blurred vision, haemianopsia, cortical blindness) and epileptic manifestations (mostly focal attacks with secondary generalisation). Mental functions are characterised with decreased activity and reactivity, confusion, loss of concentration and mild type of amnesia. Lethargy is often initial sign, sometimes accompanied with phases of agitation. Stupor and coma rarely occurred. DIAGNOSIS: In patients with hypertensive encephalopathy and eclampsia high blod pressure is registered. Neurological examination revealed vision changes and damages of mental function as well as increased reflex activity. Today, brain MRI and CT are considered the most important diagnostic method for the diagnosis and follow-up of patients with PRES . Brain MRI better detects smaller focal parenhim abnormalities than brain CT. The most often neuroradiological finding is relatively symmetrical oedema of white cerebral tissue in parieto-occipital regions of both cerebral hemispheres. Gray cerebral tissue is sometimes involved, usually in mild form of disease. Diagnosis of this "cortical" form of PRES is possible by MR FLAIR (Fluid-Attenuated Inversion Recovery) technique . TREATMENT: Therapeutic strategy depends on the cause of PRES and clinical picture. Most important are blood pres
Petrovi?, Branko; Kosti?, Vladimir; Sterni?, Nadezda; Kolar, Jovo; Tasi?, Nebojsa
A retrospective review of 206 consecutive thoracic and lumbar fusions revealed a variety of surgical procedures performed for instability and malalignment after severe trauma. Stabilization procedures included insertion of 103 Harrington distraction and 15 Harrington compression rods, 84 Weiss spings, six Luque rods, and 10 miscellaneous plates and wires as single or multiple devices in combination with anterior and/or posterior fusions. Complications of surgical fusion included nine unhooked rods, six fatigue fractures of rods and springs, five overdistractions of vertebrae, four cases of severe kyphosis, and two failures of reduction. A meaningful postoperative radiologic evaluation can be accomplished only when indications for surgical techniques, their radiologic appearance, and possible complications are known. PMID:6603137
Foley, M J; Calenoff, L; Hendrix, R W; Schafer, M F
The use of allografts, autologous iliac crest grafts, and cages for anterior cervical fusion is well documented, however there is no comparison regarding the effectiveness of maintaining the interbody space with the three approaches. We retrospectively measured the rate and amount of interspace collapse, segmental sagittal angulations, clinical results, and radiographic fusion success rates to determine which is the best fusion material. We assessed 73 patients who had one- and two-level cervical discectomies and interbody fusions without instrumentation. The three groups had similar clinical results and fusion rates. However, in the autograft group union occurred in 4 months. In the allograft group, union did not occur until 5.54 months. Moreover, the loss of cervical lordosis (2.75 degrees) was less in the cage group than in the allograft group (9.23 degrees). Additionally, the anterior interspace collapse (1.73 mm) in the cage group was less than the collapse recorded in the autograft group (2.82 mm) and in the allograft group (4 mm). An interspace collapse of 3 mm or greater was observed in 56.1% of the patients in the allograft group, compared with only 19% of the patients in the cage group. We showed that the cage is superior to the allograft and autograft in maintaining cervical interspace height and cervical lordosis after one-level and two-level anterior cervical decompression procedures. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). PMID:15662311
Kao, Feng-Chen; Niu, Chi-Chien; Chen, Lih-Huei; Lai, Po-Liang; Chen, Wen-Jer
A 55-year-old obese man (body mass index, 31.6 kg/m2) presented radiating pain and motor weakness in the left leg. Magnetic resonance imaging showed an epidural mass posterior to the L5 vertebral body, which was isosignal to subcutaneous fat and it asymmetrically compressed the left side of the cauda equina and the exiting left L5 nerve root on the axial T1 weighted images. Severe arthritis of the left facet joint and edema of the bone marrow regarding the left pedicle were also found. As far as we know, there have been no reports concerning a solitary epidural lipoma combined with ipsilateral facet arthorsis causing lumbar radiculopathy. Solitary epidural lipoma with ipsilateral facet arthritis causing lumbar radiculopathy was removed after the failure of conservative treatment. After decompression, the neurologic deficit was relieved. At a 2 year follow-up, motor weakness had completely recovered and the patient was satisfied with the result. We recommend that a solitary epidural lipoma causing neurologic deficit should be excised at the time of diagnosis.
Kim, Hong Kyun; Koh, Sung Hye
We hypothesize that the vertebra-to-vertebra patterns of spinal flexion and extension motion of persons with lower back pain will differ from those of persons who are pain-free. Thus, it is our goal to measure the motion of individual lumbar vertebrae noninvasively from dynamic fluoroscopic sequences. Two-dimensional normalized mutual information-based image registration was used to track frame-to-frame motion. Software was developed that required the operator to identify each vertebra on the first frame of the sequence using a four-point "caliper" placed at the posterior and anterior edges of the inferior and superior end plates of the target vertebrae. The program then resolved the individual motions of each vertebra independently throughout the entire sequence. To validate the technique, 6 cadaveric lumbar spine specimens were potted in polymethylmethacrylate and instrumented with optoelectric sensors. The specimens were then placed in a custom dynamic spine simulator and moved through flexion-extension cycles while kinematic data and fluoroscopic sequences were simultaneously acquired. We found strong correlation between the absolute flexionextension range of motion of each vertebra as recorded by the optoelectric system and as determined from the fluoroscopic sequence via registration. We conclude that this method is a viable way of noninvasively assessing twodimensional vertebral motion.
Camp, Jon; Zhao, Kristin; Morel, Etienne; White, Dan; Magnuson, Dixon; Gay, Ralph; An, Kai-Nan; Robb, Richard
SUMMARY.The pathology, diagnosis and management of posterior plagiocephaly remains highly controversial. While the rationale for surgical management of true lambdoid synostosis is undisputed, opinions vary greatly on how to manage severe, unresolving, non-synostotic cases. We reviewed 39 cases of posterior plagiocephaly, 37 of which were treated conservatively. Of these, 34 patients had a significant improvement over the following year with
E. S. O’Broin; D. Allcutt; M. J. Earley
Microendoscopic discectomy (MED), which combines traditional lumbar microsurgical techniques with endoscopy, is being used as a minimally invasive procedure for lumbar disc herniation. We reviewed 30 patients who underwent MED at our institution and compared their outcome with that of patients subjected to the conventional method. Laboratory data suggested that MED was less invasive surgery. Moreover, MED allowed an early
Hiroyuki Nakagawa; Mikio Kamimura; Shigeharu Uchiyama; Kenji Takahara; Toshiro Itsubo; Tadaatsu Miyasaka
Lumbar synovial cysts frequently present with back pain, chronic radiculopathy and/or progressive symptoms of spinal canal compromise. These cysts generally appear in the context of degenerative lumbar spinal disease. Few cases of spontaneous hemorrhage into synovial cysts have been reported in the literature.
Alen, Jose F.; Ramos, Ana; Lobato, Ramiro D.; Lagares, Alfonso
Lumbar punctures (LP) are complex, precise procedures done to obtain cerebro-spinal fluid from a patient for diagnostic purposes. Incorrect techniques resulting from inadequate training or supervision can result in sub-optimal outcomes. As tactile feedback is crucial for a successful lumbar puncture, this procedure serves as an ideal candidate for the development of a haptic training simulator. The intent of this
Paul Gorman; Thomas Krummel; Roger Webster; Monica Smith; David Hutchens
INTRODUCTION Foreign bodies in the urogenital tract are not uncommon. Hairpins, glass rods, umbilical tapes, ball point pen are described in lower urogenital tract. Retained gauze piece (gossypiboma) in posterior urethra may cause diagnostic dilemma. Symptoms and investigations may mimic stricture of posterior urethra. PRESENTATION OF CASE Two cases of retained gauze pieces in the urethra are described here. The micturating cystourethrogram was suggestive of posterior urethral stricture. DISCUSSION Two cases described here had retained gauze piece as a cause of filling defect and abnormal appearance in the micturating cystourethrogram. Gossypiboma may be a possibility where posterior urethral stricture are seen after previous surgery in paediatric age group. CONCLUSION In the setting of previous urogenital surgery gossypiboma should be kept in the differential diagnosis where posterior urethral stricture are seen in the paediatric age group.
Kumar, Bindey; Kumar, Prem; Sinha, Sanjay Kumar; Sinha, Neelam; Hasan, Zaheer; Thakur, Vinit Kumar; Anand, Utpal; Priyadarshi, Rajiv Nayan; Mandal, Manish
Background Beside symptoms and clinical signs radiological findings are crucial in the diagnosis of lumbar spinal stenosis (LSS). We investigate which quantitative radiological signs are described in the literature and which radilogical criteria are used to establish inclusion criteria in clincical studies evaluating different treatments in patients with lumbar spinal stenosis. Methods A literature search was performed in Medline, Embase and the Cochrane library to identify papers reporting on radiological criteria to describe LSS and systematic reviews investigating the effects of different treatment modalities. Results 25 studies reporting on radiological signs of LSS and four systematic reviews related to the evaluation of different treatments were found. Ten different parameters were identified to quantify lumbar spinal stenosis. Most often reported measures for central stenosis were antero-posterior diameter (< 10 mm) and cross-sectional area (< 70 mm2) of spinal canal. For lateral stenosis height and depth of the lateral recess, and for foraminal stenosis the foraminal diameter were typically used. Only four of 63 primary studies included in the systematic reviews reported on quantitative measures for defining inclusion criteria of patients in prognostic studies. Conclusions There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies.
Surgical treatment of lumbar spine conditions in athletes can produce excellent outcomes. Professional and competitive athletes participating in both noncontact and contact sports can return to their preinjury level of performance and have successful careers after lumbar discectomy for LDH. NFL players, especially offensive and defensive linemen, may experience greater improvement with lumbar discectomy than nonoperative treatment. Athletes who undergo direct pars repair for spondylolysis or grade I spondylolisthesis may be able to return to sports but their participation level may vary. Athletes and military personnel who undergo lumbar TDR are capable of returning to rigorous activities, including contact and extreme sports and unrestricted full-service military duty. Distal fusion level may be an independent negative predictor of successful RTP after posterior spinal fusion for adolescent idiopathic scoliosis. There is great variability in published RTP criteria, which are based primarily on authors’ opinions and experience. Athletes must demonstrate resolution of preoperative symptoms, full range of motion, and successful completion of a structured rehabilitation program before returning to play. Physicians must ultimately base their decision to release an athlete back to sport on each individual’s condition and on the chosen sport. PMID:22657997
Li, Ying; Hresko, M Timothy
In response to the rapid development and demand of outpatient endoscopic minimally invasive lumbar surgical technique, the SMART endoscopic spine system was developed for neurodecompression. This lumbar spine surgery is performed with a small skin incision, dilatation surgical technology, and an endoscopic-assisted spinal surgical system with progressive serial tubular retractors providing superior lighting and better visualization of the operative field for performing minimally invasive spinal surgery (MISS). The SMART system incorporates the advantages of posterior paramedian endoscopic assisted microdecompressive surgical spinal system and posterolateral endoscopic lumbar system. This versatile SMART endoscopic spine system with various sized working channels provides a generous and optimal access for endoscopic MISS of microdecompression of herniated lumbar disc, degenerative spinal disease, spinal stenosis, and removal of intraspinal lesions as well as creating an access for spinal arthroplasty and spinal fixation. With the unique features of the SMART system, the surgeon can take advantage of microscopic, endoscopic, or direct vision for microdecompressive spinal surgery, bridging endoscopic and conventional spinal surgery. It appears easy, safe, and efficacious. This less traumatic and easier outpatient MISS treatment leads to excellent result speedier recovery, and significant economic savings. The SMART endoscopic spine system, surgical indications, operative techniques, and the potential complications and their avoidance are described and discussed herein. PMID:17029182
Chiu, John C
Though peripheral conduction velocity is widely used to characterize afferent fibers according to somatosensory modality, disagreement exists as to whether or not conduction velocity varies along such an axon's length. Therefore, in this experiment, conduction velocities were measured over very short axonal segments (7.5 to 15 mm) within the posterior tibia1 nerve, sciatic nerve, and L7 dorsal root, using the
A. J. RINDOS; G. E. LOEB; H. LEVITAN
Cricket fast bowlers have a high incidence of serious lumbar injuries, such as lesions in the pars interarticularis. As lumbar loading is the causal mechanism of such injuries, the purpose of this study was to find relationships between lumbar spine kinetics, selected kinematic variables and the subsequent development of lumbar spine injury. At the beginning of the cricket season, the
René E D Ferdinands; Max Stuelcken; Andy Greene; Peter Sinclair; Richard Smith
The Markov Chain Monte Carlo (MCMC) technique provides a means to generate a random sequence of model realizations that sample the posterior probability distribution of a Bayesian analysis. That sequence may be used to make inferences about the model uncertainties that derive from measurement uncertainties. This paper presents an approach to improving the efficiency of the Metropolis approach to MCMC by incorporating an approximation to the covariance matrix of the posterior distribution. The covariance matrix is approximated using the update formula from the BFGS quasi-Newton optimization algorithm. Examples are given for uncorrelated and correlated multidimensional Gaussian posterior distributions.
Hanson, K.M.; Cunningham, G.S.
Objective: to present the experience of the authors with the treatment of the lumbar spine stenosis in 37 patients undergone a radicular decompression throught the technic of laminotomy and\\/or foraminotomy without laminectomia (fenestration), preserving the posterior structural elements11. Methods: a retrospective study performed on 37 patients seen during a period of jan\\/1996 to dec\\/2003, operated at the Hospital of the
Samuel Caputo de Castro; Antônio Geraldo; Diniz Roquette; Marcelo Batista Chioato; Samantha Martins Comácio; Diego Carvalho; Gomes de Moraes
The study design includes a prospective, randomised controlled study comparing total disc replacement (TDR) with posterior\\u000a fusion. The main objective of this study is to compare TDR with lumbar spinal fusion, in terms of clinical outcome, in patients\\u000a referred to a spine clinic for surgical evaluation. Fusion is effective for treating chronic low back pain (LBP), but has\\u000a drawbacks, such
Svante Berg; Tycho Tullberg; Björn Branth; Claes Olerud; Hans Tropp
Fusion and rigid instrumentation have been currently the mainstay for the surgical treatment of degenerative diseases of the spine over the last 4 decades. In all over the world the common experience was formed about fusion surgery. Satisfactory results of lumbar spinal fusion appeared completely incompatible and unfavorable within years. Rigid spinal implants along with fusion cause increased stresses of the adjacent segments and have some important disadvantages such as donor site morbidity including pain, wound problems, infections because of longer operating time, pseudarthrosis, and fatigue failure of implants. Alternative spinal implants were developed with time on unsatisfactory outcomes of rigid internal fixation along with fusion. Motion preservation devices which include both anterior and posterior dynamic stabilization are designed and used especially in the last two decades. This paper evaluates the dynamic stabilization of the lumbar spine and talks about chronologically some novel dynamic stabilization devices and thier efficacies.
Kaner, Tuncay; Ozer, Ali Fahir
STUDY DESIGN:: Case report. OBJECTIVE:: To describe the technique used to place bilateral lumbar transfacet pedicle screws. SUMMARY OF BACKGROUND DATA:: Transfacet pedicle screw fixation is a growing alternative and biomechanically comparable with traditional pedicle screw fixation. There is no clear description of technique steps for placing transfacet pedicle screws available in the literature, despite recognizing that screw placement is not intuitive even with fluoroscopy, and is dissimilar to placing traditional pedicle screws or translaminar facet screws. METHODS:: We present two illustrative cases where bilateral transfacet pedicle screws were placed for posterior instrumentation following a step by step technique which can be used in a mini-open or percutaenous procedure. RESULTS:: Postoperatively, both patients had adequately placed transfacet pedicle screws bilaterally on x-ray imaging with one patient demonstrating fusion and intact fixation at 11 months follow up. CONCLUSIONS:: Transfacet pedicle screws were successfully placed in two patients in a stepwise technique described to achieve lumbar fusion. PMID:23222099
Chin, Kingsley Richard; Seale, Jason; Cumming, Vanessa
Twenty patients with fractures of the thoracic and lumbar spine underwent computed tomography (CT) following Harrington distraction instrumentation and a spinal fusion. CT was done to search for a cause of persistent cord or nerve root compression in those patients who failed to improve and completely recover their partial neurologic deficit (14 cases). The most common abnormality was the presence of residual bone fragments originating in the burst fracture of a vertebral body displaced posteriorly, into the spinal canal. In patients with complications in the late recovery period, CT found exuberant callus indenting the canal or lack of fusion of the bone grafts placed in the anterolateral aspect of the vertebral bodies. This experience indicates that CT is the modality of choice for spinal canal evaluation in those patients who fail to have an optimal clinical course following fractures of the thoracic and lumbar spine treated with Harrington rods.
Golimbu, C.; Firooznia, H.; Rafii, M.; Engler, G.; Delman, A.
Total disc replacement and posterior dynamic stabilization represent alternatives to lumbar spinal fusion which should reduce the risk of adjacent segment degeneration. Disc replacement is indicated for pure discopathy without facet joint degeneration. Spinopelvic balance influences the implant's biomechanics. Therefore pelvic incidence, sacral slope, segmental lordosis and the mean axis of rotation need to be considered. Dynamic stabilization is indicated in moderate discopathy and facet joint degeneration, in degenerative spondylolisthesis grade I with a hypermobile segment and in dynamic lumbar stenosis. The combination of caudal fusion and cranial dynamic stabilization allows a better maintenance of lordosis with multiple level instrumentation and prevents adjacent segment degeneration. If pelvic incidence and sacral slope are high, L5-S1 should be fused because of elevated shear forces. PMID:21681502
Charles, Y P; Walter, A; Schuller, S; Steib, J-P
Background. The results of treatment in patients with transpedicular instrumented or interbody cage fusion for lumbar disc extrusions at L4-L5 level were retrospectively analyzed. The goal was to determine whether comparable clinical outcome can be achieved in cases with and without previous surgery. Methods. Ten patients who had first symptomatic acute massive disc herniation underwent herniotomy, posterior decompression as necessary,
Samo K. Fokter; Vilibald Vengust
Complete posterior fracture-dislocation of the lumbar spine at L4-L5 level occurred in an 18-year-old male patient, who remained neurologically intact. The body of L4 with the vertebral column above was totally displaced behind the body of L5. The posterior elements of L5 were fractured and displaced posteriorly with L4, and this led to marked widening of the canal with spontaneous neurologic decompression. Open reduction and internal fixation with a sacral rod and two Harrington rods restored the anatomic relationship. In spite of the good reduction immediately obtained after surgery, two months later the fracture showed some redisplacement. The implants were removed, and a bone graft was transplanted for additional support. Seven months after trauma, the patient is asymptomatic and the spine is solidly fused. In spite of the risk of neurologic deterioration involved during surgery, open reduction and internal fixation were performed because they offered the best chance of healing, producing a biomechanically sound spine, and decreasing the risk of delayed neurologic deterioration. Because of the relatively wide neural canal at the lumbar level and the absence of spinal cord from the neural elements at the level of the injury, the risk of permanent neurologic deficit being produced during surgery was considered minimal. PMID:2295165
Abdel-Fattah, H; Rizk, A H
The study design included an in vivo laboratory study. The objective of the study is to quantify the kinematics of the lumbar spinous processes in asymptomatic patients during un-restricted functional body movements with physiological weight bearing. Limited data has been reported on the motion patterns of the posterior spine elements. This information is necessary for the evaluation of traumatic injuries and degenerative changes in the posterior elements, as well as for improving the surgical treatment of spinal diseases using posterior procedures. Eight asymptomatic subjects with an age ranging from 50 to 60 years underwent MRI scans of their lumbar segments in a supine position and 3D models of L2–5 were constructed. Next, each subject was asked to stand and was positioned in the following sequence: standing, 45° flexion, maximal extension, maximal left and right twisting, while two orthogonal fluoroscopic images were taken simultaneously at each of the positions. The MRI models were matched to the osseous outlines of the images from the two orthogonal views to quantify the position of the vertebrae in 3D at each position. The data revealed that interspinous process (ISP) distance decreased from L2 to L3 to L4 to L5 when measured in the supine position; with significantly higher values at L2–3 and L3–4 compared with L4–5. These differences were not seen with weight-bearing conditions. During the maximal extension, the ISP distance at the L2–3 motion segment was significantly reduced, but no significant changes were detected at L3–4 and L4–5. During flexion the ISP distances were not significantly different than those measured in the MRI position at all segments. Going from the left to right twist positions, the L4–5 segment had greater amounts of ISP rotation, while all segments had similar ranges of translation in the transverse plane. The interspinous process distances were dependent on body posture and vertebral level.
Xia, Qun; Wang, Shaobai; Passias, Peter G.; Kozanek, Michal; Li, Gang; Grottkau, Brian E.; Wood, Kirkham B.
Lumbar spinal stenosis is a common condition in elderly patients and may lead to progressive back and leg pain, muscular weakness, sensory disturbance, and/or problems with ambulation. Multiple studies suggest that surgical decompression is an effective therapy for patients with symptomatic lumbar stenosis. Although traditional lumbar decompression is a time-honored procedure, minimally invasive procedures are now available which can achieve the goals of decompression with less bleeding, smaller incisions, and quicker patient recovery. This paper will review the technique of performing ipsilateral and bilateral decompressions using a tubular retractor system and microscope.
Popov, Victor; Anderson, David G.
We report sporadic, bilateral keratoglobus associated with posterior subcapsular cataract in a 43-year-old man. Slitlamp biomicroscopy showed symmetric arcus senilis-like deposits, a polygonal appearance resembling crocodile shagreen, an unusual endothelial appearance, and posterior subcapsular cataract. Orbscan® II pachymetry maps (Bausch & Lomb) demonstrated bilateral diffuse corneal thinning (359.53 ?m ± 21.15 [SD] in the right eye and 379.61 ± 11.49
Judy Y. F Ku; Christina N Grupcheva; Michael J Fisk; Franzco; Charles N. J McGhee
Subsidence of interbody devices into the vertebral body might result in serious clinical problems, especially when the devices are not well designed and analyzed. Recently, some novel designs were proposed to reduce the risk of subsidence, but those designs are based on the researcher's experience. The purpose of this study was to discover the interbody device design with excellent subsidence resistance by changing the device's shape. The three-dimensional nonlinear finite element models, which consisted of the interbody device and vertebral body, were created first. Then, the simulation-based genetic algorithm, which combined the finite element model and the searching algorithm, was developed by using ANSYS® Parametric Design Language. Finally, the numerical results were carefully validated with the use of biomechanical tests. The optimum shape design obtained in this study looks like a flower with many petals and it has excellent subsidence resistance when compared with the other designs provided by the past studies. The results of the present study could help surgeons to understand the subsidence resistance of interbody devices in terms of their shapes and has directly provided the design rationales to engineers. PMID:23335363
BACKGROUND: Lumbosacral fusion is a relatively common procedure that is used in the management of an unstable spine. The anterior interbody cage has been involved to enhance the stability of a pedicle screw construct used at the lumbosacral junction. Biomechanical differences between polyaxial and monoaxial pedicle screws linked with various rod contours were investigated to analyze the respective effects on
Shih-Hao Chen; Ruey Mo Lin; Hsiang-Ho Chen; Kai-Jow Tsai
Several choices are available for cervical interbody fusion after anterior cervical discectomy. A recent option is dense cancellous allograft (CS) which is characterized by an open-matrix structure that may promote vascularization and cellular penetration during early osseous integration. However, the biomechanical stability of CS should be comparable to that of the tricortical iliac autograft (AG) and fibular allograft (FA) to
Stephen I. Ryu; Jesse T. Lim; Sung-Min Kim; Josemaria Paterno; Daniel H. Kim
The goal of this systematic literature review was to determine, for patients with degenerative disc disease, which method of single-level anterior cervical interbody fusion using the anterior approach gives the best clinical and radiological outcome. The number of new techniques for obtaining a solid fusion has increased rapidly, but the rationale for choosing between different techniques is unclear. Randomised comparative studies on anterior cervical interbody fusions were identified in a sensitive Medline, Cochrane and Current Contents database search. Two independent reviewers evaluated the articles that met the selection criteria, using a checklist. The search yielded eight randomised, controlled trials for the systematic literature review. Three of these studies were judged to be of sufficient quality with regard to methodology and the information provided. In the three articles, five different treatment methods were investigated, four of which were interbody fusions. Fusion rates varied between 28% for an allograft method and 63% for a discectomy-alone method. In one study, kyphosis varied from 40% to 62% between treatments. Good clinical outcome (disability, pain and symptoms) ratings varied from 66% to 82%. A meta-analysis to determine the best method for an anterior interbody fusion could not be performed due to the heterogeneity of the methods reported and because no standard outcome parameter was used. From this systematic literature review, a gold standard for the treatment of degenerative disc disease could not be identified. PMID:10823429
van Limbeek, J; Jacobs, W C; Anderson, P G; Pavlov, P W
Study Design Analysis of the National Inpatient Sample database from 2000 to 2008. Objective To identify if metabolic syndrome is an independent risk factor for increased major perioperative complications, cost, length of stay and non-routine discharge. Summary of Background Data Metabolic syndrome is a combination of medical disorders that has been shown to increase the health risk of the general population. No study has analyzed its impact in the perioperative spine surgery setting. Methods We obtained the National Inpatient Sample from the Hospital Cost and Utilization Project for each year between 2000 and 2008. All patients undergoing primary posterior lumbar spine fusion were identified and separated into groups with and without metabolic syndrome. Patient demographics and health care system related parameters were compared. The outcomes of major complications, non-routine discharge, length of hospital stay and hospitalization charges were assessed for both groups. Regression analysis was performed to identify if the presence of metabolic syndrome was an independent risk factor for each outcome. Results An estimated 1,152,747 primary posterior lumbar spine fusion were performed between 2000 and 2008 in the US. The prevalence of metabolic syndrome as well as the comorbidities of the patients increased significantly over time. Patients with metabolic syndrome had significantly longer length of stay, higher hospital charges, higher rates of non-routine discharges and increased rates of major life-threatening complications compared to patients without metabolic syndrome. Conclusion Patients with metabolic syndrome undergoing primary posterior lumbar spinal fusion represent an increasing financial burden on the health care system. Clinicians should recognize that metabolic syndrome represents a risk factor for increased perioperative morbidity.
Memtsoudis, Stavros G.; Kirksey, Meghan; Ma, Yan; Chiu, Ya Lin; Mazumdar, Madhu; Pumberger, Matthias; Girardi, Federico P.
Lumbar Spinal Stenosis is a typical disease of the elderly patient that mainly originates in degenerative multisegmental changes of the lumbar vertebral column. The classical symptom of pain irradiation into the legs whilst walking and relief with standing is similar to peripheral arterial disease presentation but differs in the sense that symptoms can be triggered through lumbar extension and relieved with lumbar flexion whereas arterial disease is correlated with pathological arteriovascular findings. Diagnosis is usually confirmed through magnetic resonance imaging (MRI) and response to conservative treatment (analgetics, physiotherapy, epidural injections) is usually good in the majority of cases. Only a minority of about 20% of all cases show progressive disease and may necessitate surgical interventions. PMID:23531906
Nydegger, Alexander; Brühlmann, Pius; Steurer, Johann
Lumbar disk herniation is a significant cause of lumbar radiculopathy and results in billions of dollars in health care expenditure. Herniated lumbar disks cause mechanical and chemical irritation of the nerve roots leading to complaints of sciatica. Surgeons have several surgical options when approaching herniated disks, including various microsurgical procedures. The 3 most prominent studies to date on surgical and nonsurgical management of herniated disks agree on the efficacy of surgery over medical management in the short term but have some discrepancies when looking at long-term results. Cauda equina syndrome is a variation of lumbar disk herniation in which patients experience a combination of saddle anesthesia, abnormal lower extremity reflexes, and neurogenic bowel or bladder symptoms. PMID:21292152
Bruggeman, Adam J; Decker, Robert C
Lumbar epidural varices are rare and usually mimick lumbar disc herniations. Back pain and radiculopathy are the main symptoms of lumbar epidural varices. Perineural cysts are radiologically different lesions and should not be confused with epidural varix. A 36-year-old male patient presented to us with right leg pain. The magnetic resonance imaging revealed a cystic lesion at S1 level that was compressing the right root, and was interpreted as a perineural cyst. The patient underwent surgery via right L5 and S1 hemilaminectomy, and the lesion was coagulated and removed. The histopathological diagnosis was epidural varix. The patient was clinically improved and the follow-up magnetic resonance imaging showed the absence of the lesion. Lumbar epidural varix should be kept in mind in the differential diagnosis of the cystic lesions which compress the spinal roots.
Pusat, Serhat; Kural, Cahit; Aslanoglu, Atilla; Kurt, Bulent
Summary ?Object. This study was undertaken to determine whether a special postoperative pain administration of tramadol and diclofenac provides\\u000a any benefits in patients who underwent microsurgical lumbar discectomy.\\u000a \\u000a ?Methods. The study consisted of 60 patients undergoing microsurgical lumbar discectomy. Patients were randomly divided into two groups\\u000a based on the postoperative pain management: 1) Group A (n=30): no standardized pain therapy; these
R. Filippi; J. Laun; J. Jage; A. Perneczky
From a posterior approach long Schanz screws are inserted through the pedicles into the bodies of the two vertebrae just adjacent to the lesion and connected by the threaded Fixateur-interne-rods. By tightening the nuts the Schanz screws are fixed in all directions. The advantages of the F.I.-system are: excellent reposition by the long lever-arm of the Schanz screws, immobilization of only two segments avoiding the iatrogenic loss of mobility and lumbar lordosis, stability against flexion forces better than with Harrington distraction rods, additional rotational stability. PMID:6503540
Spinal arachnoiditis is a known but very rare late complication of subarachnoid hemorrhage (SAH). Since 1943, 17 cases of spinal arachnoiditis after intracranial hemorrhage have been reported internationally. The vast majority of these cases were related to aneurysmal SAH. All previously published cases have involved spinal arachnoiditis at the cervical and thoracic levels. In this report, we present an adult woman with lumbar spinal arachnoiditis causing cauda equina syndrome as a result of posterior circulation aneurysmal SAH. We believe this is the first reported case of this specific condition causing cauda equina syndrome. PMID:23790823
Whetstone, Kirk E; Crane, Deborah A
The purpose of this paper was to investigate the stand-alone lateral interbody fusion as a minimally invasive option for the treatment of low-grade degenerative spondylolisthesis with a minimum 24-month followup. Prospective nonrandomized observational single-center study. 52 consecutive patients (67.6 ± 10?y/o; 73.1% female; 27.4 ± 3.4?BMI) with single-level grade I/II single-level degenerative spondylolisthesis without significant spine instability were included. Fusion procedures were performed as retroperitoneal lateral transpsoas interbody fusions without screw supplementation. The procedures were performed in average 73.2 minutes and with less than 50cc blood loss. VAS and Oswestry scores showed lasting improvements in clinical outcomes (60% and 54.5% change, resp.). The vertebral slippage was reduced in 90.4% of cases from mean values of 15.1% preoperatively to 7.4% at 6-week followup (P < 0.001) and was maintained through 24 months (7.1%, P < 0.001). Segmental lordosis (P < 0.001) and disc height (P < 0.001) were improved in postop evaluations. Cage subsidence occurred in 9/52 cases (17%) and 7/52 cases (13%) spine levels needed revision surgery. At the 24-month evaluation, solid fusion was observed in 86.5% of the levels treated. The minimally invasive lateral approach has been shown to be a safe and reproducible technique to treat low-grade degenerative spondylolisthesis.
Marchi, Luis; Abdala, Nitamar; Oliveira, Leonardo; Amaral, Rodrigo; Coutinho, Etevaldo; Pimenta, Luiz
The purpose of this paper was to investigate the stand-alone lateral interbody fusion as a minimally invasive option for the treatment of low-grade degenerative spondylolisthesis with a minimum 24-month followup. Prospective nonrandomized observational single-center study. 52 consecutive patients (67.6 ± 10 y/o; 73.1% female; 27.4 ± 3.4 BMI) with single-level grade I/II single-level degenerative spondylolisthesis without significant spine instability were included. Fusion procedures were performed as retroperitoneal lateral transpsoas interbody fusions without screw supplementation. The procedures were performed in average 73.2 minutes and with less than 50cc blood loss. VAS and Oswestry scores showed lasting improvements in clinical outcomes (60% and 54.5% change, resp.). The vertebral slippage was reduced in 90.4% of cases from mean values of 15.1% preoperatively to 7.4% at 6-week followup (P < 0.001) and was maintained through 24 months (7.1%, P < 0.001). Segmental lordosis (P < 0.001) and disc height (P < 0.001) were improved in postop evaluations. Cage subsidence occurred in 9/52 cases (17%) and 7/52 cases (13%) spine levels needed revision surgery. At the 24-month evaluation, solid fusion was observed in 86.5% of the levels treated. The minimally invasive lateral approach has been shown to be a safe and reproducible technique to treat low-grade degenerative spondylolisthesis. PMID:22545019
Marchi, Luis; Abdala, Nitamar; Oliveira, Leonardo; Amaral, Rodrigo; Coutinho, Etevaldo; Pimenta, Luiz
Objective This is retrospective study of clinical and radiological outcomes of anterior cervical fusion using Bongros-HA™ (BioAlpha, Seongnam, Korea) which is a type of synthetic hydroxyapatite (HA) spacer to evaluate the efficacy in its clinical application and usefulness as a reliable alternative to autograft bone. Methods Twenty-nine patients were enrolled in this study and 40 segments were involved. All patients were performed anterior cervical interbody fusion using HA spacer and plating system. Indications for surgery were radiculopathy caused by soft-disc herniation or spondylosis in 18 patients, spondylotic myelopathy in 1 patient, and spinal trauma in 10 patients. Cervical spine radiographs were obtained on postoperative 1day, 1week, and then at 1, 2, 6, and 12 months in all patients to evaluate intervertebral disc height, and the degrees of lordosis. Cervical computed tomography was done at postoperative 12 month in all patients to confirm the fusion status. The mean period of clinical follow-up was 17 months. Results Complete interbody fusion was achieved in 100% of patients. Preoperative kyphotic deformities were corrected in all cases after surgery. Intervertebral disc height was well maintained during follow up period. There were no cases of graft extrusion, graft deterioration and graft fracture. Conclusion HA spacer is very efficient in achieving cervical fusion, maintaining intervertebral disc height, and restoring lordosis. When combined with the placement of a cervical plate, immediate stability can be achieved and graft related complication can be prevented.
Kim, Sung Chul; Kang, Sung Won; Kim, Se Hyuk; Cho, Ki Hong
Few histological studies on bone substitutes in human cervical spine are available and the biological processes of bone substitutes are not well documented. The authors studied four failure cases of cervical interbody fusion: two cases with hydroxyapatite (HA), one case with beta-tricalcium phosphate ceramic (beta-TCP) and one case with xenograft (bovine bone). Clinical data showed that all the patients experienced neck pain with or without numbness of upper extremity due to fusion failure. Successful fusions were achieved after the salvage surgeries in which autograft were used. Radiographs showed that radiolucent lines were present in all cases. Two HA substitutes fractured without complications. One of them sank into the vertebral body. Some small beta-TCP fragments were found under the microscope. Histological study demonstrated only a few newly formed bones at the interface of the substitutes. The fragments of HA were encapsulated by fibrous tissue. The degradation process and bone regeneration were more active in beta-TCP than in HA. The intertrabecular spaces of bovine bone were filled with fibrous tissue. The results suggest that a porous calcium phosphate ceramic with special design might assure bone ingrowth and meet the mechanical requirements in cervical interbody fusion. The complications of these materials in the cervical spine should be highlighted. PMID:16429285
Xie, Youzhuan; Chopin, Daniel; Hardouin, Pierre; Lu, Jianxi
\\u000a Methods of discectomy and lumbar decompression continue to evolve in efforts to perform a surgical decompression. A direct\\u000a decompression simply requires an operative corridor in which to access the spinal canal. We can study the same approach as\\u000a some of the latest fusion techniques, including approaches from the anterior, posterior, lateral, and posterolateral. The\\u000a transforaminal interbody lumbar fusion (TLIF) method
Burak M. Ozgur; Scott C. Berta; Andrew D. Nguyen
The effect of long-term excercise on the intervertebral disc collagen concentration (hydroxyproline), collagen-synthesizing enzymes (prolyl-4-hydroxylase, PH, and galactosyl-hydroxylysyl glucosyltransferase, GGT) and hydroxypyridinium crosslinks was studied in ten female beagle dogs. The dogs were run on a treadmill for 1 year starting at the age of 15 weeks. The daily running distance was gradually increased to 40km, which distance the dogs ran for the final 15 weeks. Ten untrained dogs from the same breeding colony served as controls. The nucleus pulposus and anterior and posterior halves of the annulus fibrosus of C2-3, T10-12, L4-5 disc segments were analysed. Crosslinks were measured from the anterior annulus fibrosus of the T10-11 disc. Hydroxyproline and hydroxypyridinium concentrations remained similar in both groups. PH and GGT were significantly elevated by running in the posterior annulus fibrosus of the thoracic and lumbar discs and in the lumbar nucleus pulposus. In the thoracic nucleus pulposus GGT was reduced significantly. The results suggest activated collagen metabolism in the posterior annulus fibrosus of the thoracic and lumbar discs as a result of locally increased strains on the spine. PMID:20058463
Puustjärvi, K; Takala, T; Wang, W; Tammi, M; Helminen, H J; Kovanen, V
Summary: We present an unusual case of a primary lumbar disk-space mass that presumably developed secondary to a chronic hyperextension spinal fracture associated with spinal stenosis. This injury resulted in the appearance of a lumbar intervertebral disk-space mass or pseudotumor. The pseudo- tumor most likely resulted from a prior spinal fracture, lead- ing to a fused hyperextension deformity in a
Robert A. Koenigsberg; Perry Black; Scott H. Faro; Jeffrey Rykken
Posterior polar cataract is a rare form of congenital cataract. It is usually inherited as an autosomal dominant disease, yet it can be sporadic. Five genes have been attributed to the formation of this disease. It is highly associated with complications during surgery, such as posterior capsule rupture and nucleus drop. The reason for this high complication rate is the strong adherence of the opacity to the weak posterior capsule. Different surgical strategies were described for the handling of this challenging entity, most of which emphasized the need for gentle maneuvering in dealing with these cases. It has a unique clinical appearance that should not be missed in order to anticipate, avoid, and minimize the impact of the complications associated with it.
Do young children have a basic intuition of posterior probability? Do they update their decisions and judgments in the light of new evidence? We hypothesized that they can do so extensionally, by considering and counting the various ways in which an event may or may not occur. The results reported in this paper showed that from the age of five, children's decisions under uncertainty (Study 1) and judgments about random outcomes (Study 2) are correctly affected by posterior information. From the same age, children correctly revise their decisions in situations in which they face a single, uncertain event, produced by an intentional agent (Study 3). The finding that young children have some understanding of posterior probability supports the theory of naive extensional reasoning, and contravenes some pessimistic views of probabilistic reasoning, in particular the evolutionary claim that the human mind cannot deal with single-case probability. PMID:17391661
Girotto, Vittorio; Gonzalez, Michel
III complexes (TAT) and in activated factor XII (XIIa) and (b) decrease in activated factor VII (VIIa), indicating a sim- ilar significant effect on coagulation in patients of both groups (P 5 0.9 for intergroup comparisons of postop- erative VIIa, XIIa, and TAT). Intraoperative activation of fibrinolysis was significantly less pronounced in the aprotinin group than in the placebo group
Claude Lentschener; Philippe Cottin; Frederic J. Mercier; Martine Wolf; Yasser Aljabi; Catherine Boyer-Neumann; Dan Benhamou
We present a case of an acute psoas muscle hematoma following percutaneous endoscopic lumbar discectomy. A 60-year-old female who presented with far lateral lumbar disc herniation underwent endoscopic discectomy on the right side at the L4-5 level. On the second postoperative day, the patient complained of severe right flank and leg pain and her blood pressure decreased. A computed tomography scan showed a large acute psoas muscle hematoma at right L4-5 level. The patient was transfused with packed red blood cells and placed at absolute bed rest. After observing the patient in intensive care, the severe flank and leg pain subsided, but the mild back pain persisted. Although percutaneous endoscopic lumbar discectomy is an effective minimally invasive surgical technique for the treatment of lumbar disc herniation, this case highlights the inherent risks of acute lumbar segmental vessel injury.
Kim, Hyeun Sung; Kim, Seok Won; Kim, Jong Gue