The cost-effectiveness of interbody fusions versus posterolateral fusions in 137 patients with lumbar spondylolisthesis.

PubMed

Bydon, Mohamad; Macki, Mohamed; Abt, Nicholas B; Witham, Timothy F; Wolinsky, Jean-Paul; Gokaslan, Ziya L; Bydon, Ali; Sciubba, Daniel M

2015-03-01

Reimbursements for interbody fusions have declined recently because of their questionable cost-effectiveness. A Markov model was adopted to compare the cost-effectiveness of posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (/TLIF) versus noninterbody fusion and posterolateral fusion (PLF) in patients with lumbar spondylolisthesis. Decision model analysis based on retrospective data from a single institutional series. One hundred thirty-seven patients underwent first-time instrumented lumbar fusions for degenerative or isthmic spondylolisthesis. Quality of life adjustments and expenditures were assigned to each short-term complication (durotomy, surgical site infection, and medical complication) and long-term outcome (bowel/bladder dysfunction and paraplegia, neurologic deficit, and chronic back pain). Patients were divided into a PLF cohort and a PLF plus PLIF/TLIF cohort. Anterior techniques and multilevel interbody fusions were excluded. Each short-term complication and long-term outcome was assigned a numerical quality-adjusted life-year (QALY), based on time trade-off values in the Beaver Dam Health Outcomes Study. The cost data for short-term complications were calculated from charges accrued by the institution's finance sector, and the cost data for long-term outcomes were estimated from the literature. The difference in cost of PLF plus PLIF/TLIF from the cost of PLF alone divided by the difference in QALY equals the cost-effectiveness ratio (CER). We do not report any study funding sources or any study-specific appraisal of potential conflict of interest-associated biases in this article. Of 137 first-time lumbar fusions for spondylolisthesis, 83 patients underwent PLF and 54 underwent PLIF/TLIF. The average time to reoperation was 3.5 years. The mean QALY over 3.5 years was 2.81 in the PLF cohort versus 2.66 in the PLIFo/TLIF cohort (p=.110). The mean 3.5-year costs of $54,827.05 after index interbody fusion were

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

PubMed

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

2017-05-01

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

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2018-03-01

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

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

PubMed

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

2015-12-01

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

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

PubMed Central

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

2014-01-01

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

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

PubMed

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

2016-04-01

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

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

PubMed

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

2018-06-01

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

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

PubMed

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

2017-06-01

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

Pedicle screw fixation for isthmic spondylolisthesis: does posterior lumbar interbody fusion improve outcome over posterolateral fusion?

PubMed

La Rosa, Giovanni; Conti, Alfredo; Cacciola, Fabio; Cardali, Salvatore; La Torre, Domenico; Gambadauro, Nicola Maria; Tomasello, Francesco

2003-09-01

Posterolateral fusion involving instrumentation-assisted segmental fixation represents a valid procedure in the treatment of lumbar instability. In cases of anterior column failure, such as in isthmic spondylolisthesis, supplemental posterior lumbar interbody fusion (PLIF) may improve the fusion rate and endurance of the construct. Posterior lumbar interbody fusion is, however, a more demanding procedure and increases costs and risks of the intervention. The advantages of this technique must, therefore, be weighed against those of a simple posterior lumbar fusion. Thirty-five consecutive patients underwent pedicle screw fixation for isthmic spondylolisthesis. In 18 patients posterior lumbar fusion was performed, and in 17 patients PLIF was added. Clinical, economic, functional, and radiographic data were assessed to determine differences in clinical and functional results and biomechanical properties. At 2-year follow-up examination, the correction of subluxation, disc height, and foraminal area were maintained in the group in which a PLIF procedure was performed, but not in the posterolateral fusion-only group (p < 0.05). Nevertheless, no statistical intergroup differences were demonstrated in terms of neurological improvement (p = 1), economic (p = 0.43), or functional (p = 0.95) outcome, nor in terms of fusion rate (p = 0.49). The authors' findings support the view that an interbody fusion confers superior mechanical strength to the spinal construct; when posterolateral fusion is the sole intervention, progressive loss of the extreme correction can be expected. Such mechanical insufficiency, however, did not influence clinical outcome.

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

PubMed

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

2014-08-01

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

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

PubMed

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

2017-03-01

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

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

PubMed Central

Gen, Hogaku; Sakuma, Yoshio; Koshika, Yasuhide

2018-01-01

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

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

PubMed

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

2018-04-01

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

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

PubMed

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

2009-06-15

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

Expandable Polyaryl-Ether-Ether-Ketone Spacers for Interbody Distraction in the Lumbar Spine

PubMed Central

Alimi, Marjan; Shin, Benjamin; Macielak, Michael; Hofstetter, Christoph P.; Njoku, Innocent; Tsiouris, Apostolos J.; Elowitz, Eric; Härtl, Roger

2015-01-01

Study Design Retrospective case series. Objective StaXx XD (Spine Wave, Inc., Shelton, CT, United States) is an expandable polyaryl-ether-ether-ketone (PEEK) wafer implant utilized in the treatment of lumbar degenerative disease. PEEK implants have been successfully used as interbody devices. Few studies have focused on expandable PEEK devices. The aim of the current study is to determine the radiographic and clinical outcome of expandable PEEK cages utilized for transforaminal lumbar interbody fusion in patients with lumbar degenerative diseases. Methods Forty-nine patients who underwent lumbar interbody fusion with implantation of expandable PEEK cages and posterior instrumentation were included. The clinical outcome was evaluated using the visual analog scale (VAS) and the Oswestry Disability Index (ODI). Radiographic parameters including disk height, foraminal height, listhesis, local disk angle of the index level/levels, regional lumbar lordosis, and graft subsidence were measured preoperatively, postoperatively, and at latest follow-up. Results At an average follow-up of 19.3 months, the minimum clinically important difference for the ODI and VAS back, buttock, and leg were achieved in 64, 52, 58, and 52% of the patients, respectively. There was statistically significant improvement in VAS back (6.42 versus 3.11, p < 0.001), VAS buttock (4.66 versus 1.97, p = 0.002), VAS leg (4.55 versus 1.96, p < 0.001), and ODI (21.7 versus 12.1, p < 0.001) scores. There was a significant increase in the average disk height (6.49 versus 8.18 mm, p = 0.037) and foraminal height (15.6 versus 18.53 mm, p = 0.0001), and a significant reduction in the listhesis (5.13 versus 3.15 mm, p = 0.005). The subsidence of 0.66 mm (7.4%) observed at the latest follow-up was not significant (p = 0.35). Conclusions Midterm results indicate that expandable PEEK spacers can effectively and durably restore disk and foraminal height and improve

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

PubMed Central

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

2011-01-01

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

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

PubMed

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

2011-01-01

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

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

PubMed

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

2012-04-01

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

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

PubMed Central

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

2012-01-01

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

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

PubMed

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

2012-06-01

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

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

PubMed

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

2013-08-01

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

Transforaminal lumbar interbody graft placement using an articulating delivery arm facilitates increased segmental lordosis with superior anterior and midline graft placement.

PubMed

Shau, David N; Parker, Scott L; Mendenhall, Stephen K; Zuckerman, Scott L; Godil, Saniya S; Devin, Clinton J; McGirt, Matthew J

2015-05-01

Transforaminal lumbar interbody fusion (TLIF) is a frequently performed method of lumbar arthrodesis in patients failing medical management of back and leg pain. Accurate placement of the interbody graft and restoration of lordosis has been shown to be crucial when performing lumbar fusion procedures. We performed a single-surgeon, prospective, randomized study to determine whether a novel articulating versus traditional straight graft delivery arm system allows for superior graft placement and increased lordosis for single-level TLIF. Thirty consecutive patients undergoing single-level TLIF were included and prospectively randomized to one of the 2 groups (articulated vs. straight delivery arm system). Three radiographic characteristics were evaluated at 6-week follow-up: (1) degree of segmental lumbar lordosis at the fused level; (2) the percent anterior location of the interbody graft in disk space; and (3) the distance (mm) off midline of the interbody graft placement. Randomization yielded 16 patients in the articulated delivery arm cohort and 14 in the straight delivery arm cohort. The articulating delivery arm system yielded an average of 14.7-degree segmental lordosis at fused level, 35% anterior location, and 3.6 mm off midline. The straight delivery arm system yielded an average of 10.7-degree segmental lordosis at fused level, 46% anterior location, and 7.0 mm off midline. All 3 comparisons were statistically significant (P<0.05). The study suggests that an articulating delivery arm system facilitates superior anterior and midline TLIF graft placement allowing for increased segmental lordosis compared with a traditional straight delivery arm system.

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

PubMed

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

2017-02-01

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

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

PubMed

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

2017-06-01

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

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

PubMed

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

2014-03-01

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

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

PubMed

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

2014-09-01

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

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

PubMed

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

2011-07-01

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

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

PubMed Central

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

2018-01-01

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

Analysis of Internet Information on Lateral Lumbar Interbody Fusion.

PubMed

Belayneh, Rebekah; Mesfin, Addisu

2016-07-01

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

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

PubMed

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

2018-02-01

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

Two-year outcomes of transforaminal lumbar interbody fusion.

PubMed

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

2011-08-01

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

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

PubMed

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

2016-10-06

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

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

PubMed

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

2014-10-01

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

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

PubMed

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

2016-04-01

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

Anterior lumbar fusion with titanium threaded and mesh interbody cages.

PubMed

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

1999-12-15

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

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

PubMed

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

2018-06-01

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

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

PubMed

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

2013-08-01

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

Comparison of interbody fusion approaches for disabling low back pain.

PubMed

Hacker, R J

1997-03-15

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

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

PubMed Central

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

2017-01-01

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

Evaluation of a polyetheretherketone (PEEK) titanium composite interbody spacer in an ovine lumbar interbody fusion model: biomechanical, microcomputed tomographic, and histologic analyses.

PubMed

McGilvray, Kirk C; Waldorff, Erik I; Easley, Jeremiah; Seim, Howard B; Zhang, Nianli; Linovitz, Raymond J; Ryaby, James T; Puttlitz, Christian M

2017-12-01

The most commonly used materials used for interbody cages are titanium metal and polymer polyetheretherketone (PEEK). Both of these materials have demonstrated good biocompatibility. A major disadvantage associated with solid titanium cages is their radiopacity, limiting the postoperative monitoring of spinal fusion via standard imaging modalities. However, PEEK is radiolucent, allowing for a temporal assessment of the fusion mass by clinicians. On the other hand, PEEK is hydrophobic, which can limit bony ingrowth. Although both PEEK and titanium have demonstrated clinical success in obtaining a solid spinal fusion, innovations are being developed to improve fusion rates and to create stronger constructs using hybrid additive manufacturing approaches by incorporating both materials into a single interbody device. The purpose of this study was to examine the interbody fusion characteristic of a PEEK Titanium Composite (PTC) cage for use in lumbar fusion. Thirty-four mature female sheep underwent two-level (L 2 -L 3 and L 4 -L 5 ) interbody fusion using either a PEEK or a PTC cage (one of each per animal). Animals were sacrificed at 0, 8, 12, and 18 weeks post surgery. Post sacrifice, each surgically treated functional spinal unit underwent non-destructive kinematic testing, microcomputed tomography scanning, and histomorphometric analyses. Relative to the standard PEEK cages, the PTC constructs demonstrated significant reductions in ranges of motion and a significant increase in stiffness. These biomechanical findings were reinforced by the presence of significantly more bone at the fusion site as well as ingrowth into the porous end plates. Overall, the results indicate that PTC interbody devices could potentially lead to a more robust intervertebral fusion relative to a standard PEEK device in a clinical setting. Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.

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

PubMed

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

2018-03-01

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

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

PubMed

Madan, S S; Boeree, N R

2003-12-01

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

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

PubMed

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

2016-07-01

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

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

PubMed Central

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

2016-01-01

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

Transforaminal lumbar interbody fusion versus posterolateral fusion in degenerative lumbar spondylosis

PubMed Central

Zhang, Bin-Fei; Ge, Chao-Yuan; Zheng, Bo-Long; Hao, Ding-Jun

2016-01-01

Abstract Objective: The aim of the study was to evaluate the efficacy and safety of transforaminal lumbar interbody fusion (TLIF) versus posterolateral fusion (PLF) in degenerative lumbar spondylosis. Methods: A systematic literature review was performed to obtain randomized controlled trials (RCTs) and observational studies (OSs) of TLIF and PLF for degenerative lumbar spondylosis. Trials performed before November 2015 were retrieved from the Medline, EMBASE, Cochrane library, and Chinese databases. Data extraction and quality evaluation of the trials were performed independently by 2 investigators. A meta-analysis was performed using STATA version 12.0. Results: Two RCTs and 5 OSs of 630 patients were included. Of these subjects, 325 were in the TLIF and 305 were in the PLF group. Results showed that TLIF did not increase the fusion rate based on RCTs (relative risk [RR] = 1.06; 95% confidence interval [CI]: 0.95–1.18; P = 0.321), but increased it based on OSs (RR = 1.14; 95% CI: 1.07–1.23; P = 0.000) and overall (RR = 1.11; 95% CI: 1.05–1.18; P = 0.001) as compared with PLF. TLIF was able to improve the clinical outcomes based on 1 RCT (RR = 1.33; 95% CI: 1.11–1.59, P = 0.002) and overall (RR = 1.19; 95% CI: 1.07–1.33; P = 0.001), but not based on OSs (RR = 1.11; 95% CI: 0.97–1.27; P = 0.129) as compared with PLF. There were no differences between TLIF and PLF in terms of visual analogue scale, Oswestry Disability Index, reoperation, complications, duration of surgical procedure, blood loss, and hospitalization. Conclusions: In conclusion, evidence is not sufficient to support that TLIF provides higher fusion rate than PLF, and this poor evidence indicates that TLIF might improve only clinical outcomes. Higher quality, multicenter RCTs are needed to better define the role of TLIF and PLF. PMID:27749558

Biomechanics of lateral lumbar interbody fusion constructs with lateral and posterior plate fixation: laboratory investigation.

PubMed

Fogel, Guy R; Parikh, Rachit D; Ryu, Stephen I; Turner, Alexander W L

2014-03-01

Lumbar interbody fusion is indicated in the treatment of degenerative conditions. Laterally inserted interbody cages significantly decrease range of motion (ROM) compared with other cages. Supplemental fixation options such as lateral plates or spinous process plates have been shown to provide stability and to reduce morbidity. The authors of the current study investigate the in vitro stability of the interbody cage with a combination of lateral and spinous process plate fixation and compare this method to the established bilateral pedicle screw fixation technique. Ten L1-5 specimens were evaluated using multidirectional nondestructive moments (± 7.5 N · m), with a custom 6 degrees-of-freedom spine simulator. Intervertebral motions (ROM) were measured optoelectronically. Each spine was evaluated under the following conditions at the L3-4 level: intact; interbody cage alone (stand-alone); cage supplemented with lateral plate; cage supplemented with ipsilateral pedicle screws; cage supplemented with bilateral pedicle screws; cage supplemented with spinous process plate; and cage supplemented with a combination of lateral plate and spinous process plate. Intervertebral rotations were calculated, and ROM data were normalized to the intact ROM data. The stand-alone laterally inserted interbody cage significantly reduced ROM with respect to the intact state in flexion-extension (31.6% intact ROM, p < 0.001), lateral bending (32.5%, p < 0.001), and axial rotation (69.4%, p = 0.002). Compared with the stand-alone condition, addition of a lateral plate to the interbody cage did not significantly alter the ROM in flexion-extension (p = 0.904); however, it was significantly decreased in lateral bending and axial rotation (p < 0.001). The cage supplemented with a lateral plate was not statistically different from bilateral pedicle screws in lateral bending (p = 0.579). Supplemental fixation using a spinous process plate was not significantly different from bilateral pedicle

In vitro comparison of endplate preparation between four mini-open interbody fusion approaches.

PubMed

Tatsumi, Robert; Lee, Yu-Po; Khajavi, Kaveh; Taylor, William; Chen, Foster; Bae, Hyun

2015-04-01

Discectomy and endplate preparation are important steps in interbody fusion for ensuring sufficient arthrodesis. While modern less-invasive approaches for lumbar interbody fusion have gained in popularity, concerns exist regarding their ability to allow for adequate disc space and endplate preparation. Thus, the purpose of this study was to quantitatively and qualitatively evaluate and compare disc space and endplate preparation achieved with four less-invasive approaches for lumbar interbody fusion in cadaveric spines. A total of 24 disc spaces (48 endplates) from L2 to L5 were prepared in eight cadaveric torsos using mini-open anterior lumbar interbody fusion (mini-ALIF), minimally invasive posterior lumbar interbody fusion (MAS PLIF), minimally invasive transforaminal lumbar interbody fusion (MAS TLIF) or minimally invasive lateral, transpsoas interbody fusion (XLIF) on two specimens each, for a total of six levels and 12 endplates prepared per procedure type. Following complete discectomy and endplate preparation, spines were excised and split axially at the interbody disc spaces. Endplates were digitally photographed and evaluated using image analysis software. Area of endplate preparation was measured and qualitative evaluation was also performed to grade the quality of preparation. The XLIF approach resulted in the greatest relative area of endplate preparation (58.3 %) while mini-ALIF resulted in the lowest at 35.0 %. Overall, there were no differences in percentage of preparation between cranial and caudal endplates, though this was significantly different in the XLIF group (65 vs 52 %, respectively). ALL damage was observed in 3 MAS TLIF levels. Percentage of endplate that was deemed to have complete disc removal was highest in XLIF group with 90 % compared to 65 % in MAS TLIF group, 43 % in MAS PLIF, and 40 % in mini-ALIF group. Endplate damage area was highest in the MAS TLIF group at 48 % and lowest in XLIF group at 4 %. These results demonstrate that

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

PubMed

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

2015-11-01

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

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

PubMed

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

2017-12-01

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

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

PubMed

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

2017-07-01

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

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

PubMed

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

2018-04-01

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

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

PubMed

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

2015-11-25

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

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

PubMed

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

2016-02-01

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

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

PubMed

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

2018-06-01

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

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

PubMed

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

2018-06-01

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

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

PubMed

Tuan Dao, Tien

2017-03-01

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

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

PubMed

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

2013-03-01

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

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

PubMed

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

2013-10-01

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

[Axial lumbar interbody fusion: prospective monocentric study].

PubMed

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

2014-01-01

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

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

PubMed

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

2018-04-01

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

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

PubMed

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

2009-06-01

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

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

PubMed

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

2017-08-01

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

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

PubMed Central

Barrett-Tuck, Rebecca; Del Monaco, Diana

2017-01-01

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

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

PubMed

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

2017-03-01

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

Transforaminal lumbar interbody fusion versus posterolateral fusion in degenerative lumbar spondylosis: A meta-analysis.

PubMed

Zhang, Bin-Fei; Ge, Chao-Yuan; Zheng, Bo-Long; Hao, Ding-Jun

2016-10-01

The aim of the study was to evaluate the efficacy and safety of transforaminal lumbar interbody fusion (TLIF) versus posterolateral fusion (PLF) in degenerative lumbar spondylosis. A systematic literature review was performed to obtain randomized controlled trials (RCTs) and observational studies (OSs) of TLIF and PLF for degenerative lumbar spondylosis. Trials performed before November 2015 were retrieved from the Medline, EMBASE, Cochrane library, and Chinese databases. Data extraction and quality evaluation of the trials were performed independently by 2 investigators. A meta-analysis was performed using STATA version 12.0. Two RCTs and 5 OSs of 630 patients were included. Of these subjects, 325 were in the TLIF and 305 were in the PLF group. Results showed that TLIF did not increase the fusion rate based on RCTs (relative risk [RR] = 1.06; 95% confidence interval [CI]: 0.95-1.18; P = 0.321), but increased it based on OSs (RR = 1.14; 95% CI: 1.07-1.23; P = 0.000) and overall (RR = 1.11; 95% CI: 1.05-1.18; P = 0.001) as compared with PLF. TLIF was able to improve the clinical outcomes based on 1 RCT (RR = 1.33; 95% CI: 1.11-1.59, P = 0.002) and overall (RR = 1.19; 95% CI: 1.07-1.33; P = 0.001), but not based on OSs (RR = 1.11; 95% CI: 0.97-1.27; P = 0.129) as compared with PLF. There were no differences between TLIF and PLF in terms of visual analogue scale, Oswestry Disability Index, reoperation, complications, duration of surgical procedure, blood loss, and hospitalization. In conclusion, evidence is not sufficient to support that TLIF provides higher fusion rate than PLF, and this poor evidence indicates that TLIF might improve only clinical outcomes. Higher quality, multicenter RCTs are needed to better define the role of TLIF and PLF.

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

PubMed

Fan, Wei; Guo, Li-Xin

2018-06-01

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

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

PubMed

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

2013-06-01

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

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

PubMed

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

2011-04-01

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

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

PubMed

Wang, Honggang; Zhou, Yue; Zhang, Zhengfeng

2016-05-01

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

Outcomes of extended transforaminal lumbar interbody fusion for lumbar spondylosis.

PubMed

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

2015-11-01

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

Kinematic efficacy of supplemental anterior lumbar interbody fusion at lumbosacral levels in thoracolumbosacral deformity correction with and without pedicle subtraction osteotomy at L3: an in vitro cadaveric study.

PubMed

Dahl, Benny T; Harris, Jonathan A; Gudipally, Manasa; Moldavsky, Mark; Khalil, Saif; Bucklen, Brandon S

2017-11-01

Pedicle subtraction osteotomy (PSO) is performed to treat rigid, sagittal spinal deformities, but high rates of implant failure are reported. Anterior lumbar interbody fusion has been proposed to reduce this risk, but biomechanical investigation is lacking. The goal of this study was to quantify the (1) destabilizing effects of a lumbar osteotomy and (2) contribution of anterior lumbar interbody fusion (ALIF) at the lumbosacral junction as recommended in literature. Fourteen fresh human thoracolumbosacral spines (T12-S1) were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Bilateral pedicle screws/rods (BPS) were inserted at T12-S1, cross connectors (CC) at T12-L1 and L5-S1, and anterior interbody spacers (S) at L4-5 and L5-S1. In one group, PSO was performed in seven specimens at L3. All specimens were sequentially tested in (1) Intact; (2) BPS; (3) BPS + CC; (4) BPS + S; and (5) BPS + S + CC; a second group of seven spines were tested in the same sequence without PSO. Mixed-model ANOVA with repeated measures was performed (p ≤ 0.05). At the osteotomy site (L2-L4), in FE, BPS, BPS + CC, BPS + S, BPS + CC + S reduced motion to 11.2, 12.9, 10.9, and 11.4%, respectively, with significance only found in BPS and BPS + S construction (p ≤ 0.05). All constructs significantly reduced motion across L2-L4 in the absence of PSO, across all loading modes (p ≤ 0.05). PSO significantly destabilized L2-L4 axial rotational stability, regardless of operative construction (p ≤ 0.05). Across L4-S1 and L2-S1, all instrumented constructs significantly reduced motion, in both PSO- and non-PSO groups, during all loading modes (p ≤ 0.05). These findings suggest anterior interbody fusion minimally immobilizes motion segments, and interbody devices may primarily act to maintain disc height. Additionally, lumbar osteotomy destabilizes axial rotational stability at the osteotomy site, potentially further increasing

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

PubMed

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

2016-03-01

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

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

PubMed

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

2018-04-06

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

Zoledronic acid infusion for lumbar interbody fusion in osteoporosis.

PubMed

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

2014-11-01

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

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

PubMed

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

2016-12-01

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

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

PubMed

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

2018-01-15

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

Flexibility and fatigue evaluation of oblique as compared with anterior lumbar interbody cages with integrated endplate fixation.

PubMed

Freeman, Andrew L; Camisa, William J; Buttermann, Glenn R; Malcolm, James R

2016-01-01

This study was undertaken to quantify the in vitro range of motion (ROM) of oblique as compared with anterior lumbar interbody devices, pullout resistance, and subsidence in fatigue. Anterior and oblique cages with integrated plate fixation (IPF) were tested using lumbar motion segments. Flexibility tests were conducted on the intact segments, cage, cage + IPF, and cage + IPF + pedicle screws (6 anterior, 7 oblique). Pullout tests were then performed on the cage + IPF. Fatigue testing was conducted on the cage + IPF specimens for 30,000 cycles. No ROM differences were observed in any test group between anterior and oblique cage constructs. The greatest reduction in ROM was with supplemental pedicle screw fixation. Peak pullout forces were 637 ± 192 N and 651 ± 127 N for the anterior and oblique implants, respectively. The median cage subsidence was 0.8 mm and 1.4 mm for the anterior and oblique cages, respectively. Anterior and oblique cages similarly reduced ROM in flexibility testing, and the integrated fixation prevented device displacement. Subsidence was minimal during fatigue testing, most of which occurred in the first 2500 cycles.

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

PubMed Central

Liu, Fubing; Jiang, Chun

2016-01-01

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

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

PubMed

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

2017-12-01

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

Ventral Dural Injury After Oblique Lumbar Interbody Fusion.

PubMed

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

2017-02-01

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

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

PubMed

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

2014-06-15

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

Lumbar lordosis restoration following single-level instrumented fusion comparing 4 commonly used techniques.

PubMed

Dimar, John R; Glassman, Steven D; Vemuri, Venu M; Esterberg, Justin L; Howard, Jennifer M; Carreon, Leah Y

2011-11-09

A major sequelae of lumbar fusion is acceleration of adjacent-level degeneration due to decreased lumbar lordosis. We evaluated the effectiveness of 4 common fusion techniques in restoring lordosis: instrumented posterolateral fusion, translumbar interbody fusion, anteroposterior fusion with posterior instrumentation, and anterior interbody fusion with lordotic threaded (LT) cages (Medtronic Sofamor Danek, Memphis, Tennessee). Radiographs were measured preoperatively, immediately postoperatively, and a minimum of 6 months postoperatively. Parameters measured included anterior and posterior disk space height, lumbar lordosis from L3 to S1, and surgical level lordosis.No significant difference in demographics existed among the 4 groups. All preoperative parameters were similar among the 4 groups. Lumbar lordosis at final follow-up showed no difference between the anteroposterior fusion with posterior instrumentation, translumbar interbody fusion, and LT cage groups, although the posterolateral fusion group showed a significant loss of lordosis (-10°) (P<.001). Immediately postoperatively and at follow-up, the LT cage group had a significantly greater amount of lordosis and showed maintenance of anterior and posterior disk space height postoperatively compared with the other groups. Instrumented posterolateral fusion produces a greater loss of lordosis compared with anteroposterior fusion with posterior instrumentation, translumbar interbody fusion, and LT cages. Maintenance of lordosis and anterior and posterior disk space height is significantly better with anterior interbody fusion with LT cages. Copyright 2011, SLACK Incorporated.

The surgical vascular anatomy of the minimally invasive lateral lumbar interbody approach: a cadaveric and radiographic analysis.

PubMed

Alkadhim, Mustafa; Zoccali, Carmine; Abbasifard, Salman; Avila, Mauricio J; Patel, Apar S; Sattarov, Kamran; Walter, Christina M; Baaj, Ali A

2015-11-01

The minimally invasive (MI) lateral lumbar interbody fusion (LLIF) approach has become increasingly popular for the treatment of degenerative lumbar spine disease. The neural anatomy of the lumbar plexus has been studied; however, the pertinent surgical vascular anatomy has not been examined in detail. The goal of this study is to examine the vascular structures that are relevant in relation to the MI-LLIF approach. Anatomic dissection of the lumbar spines and associated vasculature was performed in three embalmed, adult cadavers. Right and left surgeon perspective views during LLIF were for a total of six approaches. During the dissection, all vascular elements were noted and photographed, and anatomical relationships to the vertebral bodies and disc spaces were analyzed. In addition, several axial and sagittal MRI images of the lumbar spine were analyzed to complement the cadaveric analysis. The aorta descends along the left anterior aspect of lumbar vertebra with an average distance of 2.1 cm (range 1.9-2.3 cm) to the center of each intervertebral disc. The vena cava descends along the right anterior aspect of lumbar vertebrates with average distance of 1.4 cm (range 1.3-1.6 cm) to the center of the intervertebral disc. Each vertebral body has two lumbar arteries (direct branches from the aorta); one exits to the left and one to the right side of the vertebral body. The lumbar arteries pass underneath the sympathetic trunk, run in the superior margin of the vertebral body and extend all the way across it, with average length of 3.8 cm (range 2.5-5 cm). The mean distance between the arteries and the inferior plate of the superior disc space is 4.2 mm (range 2-5 mm) and mean distance of 3.1 cm (range 2.8-3.8 cm) between two arteries in adjacent vertebrae. One of the cadavers had an expected normal anatomical variation where the left arteries at L3-L4 anastomosed dorsally of the vertebral bodies at the middle of the intervertebral disc. Understanding the vascular

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

PubMed

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

2018-03-01

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

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

PubMed

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

2017-10-01

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

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

PubMed

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

2016-06-01

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

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

PubMed

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

2014-04-01

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

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

PubMed

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

2017-10-01

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

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

PubMed

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

2012-08-01

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

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

PubMed

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

2017-04-01

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

Biomechanical evaluation of CIBOR spine interbody fusion device.

PubMed

Chong, Alexander C M; Harrer, Seth W; Heggeness, Michael H; Wooley, Paul H

2017-07-01

The CIBOR PEEK spinal interbody fusion device is an anterior lumbar interbody fusion construct with a hollow center designed to accommodate an osteoinductive carbon foam insert to promote bony ingrowth to induce fusion where rigid stabilization is needed. Three different sizes of the device were investigated. Part-I: implants were tested under axial compression and rotation using polyurethane foam blocks. Part-II: simulated 2-legged stance using cadaveric specimen using the L5-S1 lumbar spine segment. Part-III: a survey feedback form was used to investigate two orthopedic surgeons concern regarding the implant. In Part-I, the subsidence hysteresis under axial compression loading was found to be statistical significant difference between these three implant sizes. It was noted that the implants had migration as rotation applied, and the amount of subsidence was a factor of the axial compression loads applied. In Part-II, a minor subsidence and carbon foam debris were observed when compared to each implant size. Poor contact surface of the implant with the end plates of the L5 or S1 vertebrae from the anterior view under maximum loads was observed; however, the implant seemed to be stable. Each surgeon has their own subjective opinion about the CIBOR implant. Two out of the three different sizes of the device (medium and large sizes) provided appropriate rigid stabilization at the physiological loads. Neither orthopedic surgeon was 100% satisfied with overall performance of the implant, but felt potential improvement could be made. This study indicates an option for operative treatment of spine interbody fusion, as the CIBOR spine interbody fusion device has a hollow center. This hollow center is designed to accommodate a carbon foam insert to promote bony ingrowth. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1157-1168, 2017. © 2016 Wiley Periodicals, Inc.

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

PubMed

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

2016-08-20

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

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

PubMed Central

Hey, Hwee Weng Dennis; Hee, Hwan Tak

2010-01-01

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

Biomechanical Analysis of Porous Additive Manufactured Cages for Lateral Lumbar Interbody Fusion: A Finite Element Analysis.

PubMed

Zhang, Zhenjun; Li, Hui; Fogel, Guy R; Liao, Zhenhua; Li, Yang; Liu, Weiqiang

2018-03-01

A porous additive manufactured (AM) cage may provide stability similar to that of traditional solid cages and may be beneficial to bone ingrowth. The biomechanical influence of various porous cages on stability, subsidence, stresses in cage, and facet contact force has not been fully described. The purpose of this study was to verify biomechanical effects of porous AM cages. The surgical finite element models with various cages were constructed. The partially porous titanium (PPT) cages and fully porous titanium (FPT) cages were applied. The mechanical parameters of porous materials were obtained by mechanical test. Then the porous AM cages were compared with solid titanium (TI) cage and solid polyetheretherketone (PEEK) cage. The 4 motion modes were simulated. Range of motion (ROM), cage stress, end plate stress, and facet joint force (FJF) were compared. For all the surgical models, ROM decreased by >90%. Compared with TI and PPT cages, PEEK and FPT cages substantially reduced the maximum stresses in cage and end plate in all motion modes. Compared with PEEK cages, the stresses in cage and end plate for FPT cages decreased, whereas the ROM increased. Comparing FPT cages, the stresses in cage and end plate decreased with increasing porosity, whereas ROM increased with increasing porosity. After interbody fusion, FJF was substantially reduced in all motion modes except for flexion. Fully porous cages may offer an alternative to solid PEEK cages in lateral lumbar interbody fusion. However, it may be prudent to further increase the porosity of the cage. Copyright © 2017 Elsevier Inc. All rights reserved.

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

PubMed

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

2016-03-01

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

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

PubMed Central

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

2014-01-01

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

Biomechanical analysis of an expandable lateral cage and a static transforaminal lumbar interbody fusion cage with posterior instrumentation in an in vitro spondylolisthesis model.

PubMed

Mantell, Matthew; Cyriac, Mathew; Haines, Colin M; Gudipally, Manasa; O'Brien, Joseph R

2016-01-01

Insufficient biomechanical data exist from comparisons of the stability of expandable lateral cages with that of static transforaminal lumbar interbody fusion (TLIF) cages. The purpose of this biomechanical study was to compare the relative rigidity of L4-5 expandable lateral interbody constructs with or without additive pedicle screw fixation with that of L4-5 static TLIF cages in a novel cadaveric spondylolisthesis model. Eight human cadaver spines were used in this study. A spondylolisthesis model was created at the L4-5 level by creating 2 injuries. First, in each cadaver, a nucleotomy from 2 channels through the anterior side was created. Second, the cartilage of the facet joint was burred down to create a gap of 4 mm. Light-emitting-diode tracking markers were placed at L-3, L-4, L-5, and S-1. Specimens were tested in the following scenarios: intact model, bilateral pedicle screws, expandable lateral 18-mm-wide cage (alone, with unilateral pedicle screws [UPSs], and with bilateral pedicle screws [BPSs]), expandable lateral 22-mm-wide cage (alone, with UPSs, and with BPSs), and TLIF (alone, with UPSs, and with BPSs). Four of the spines were tested with the expandable lateral cages (18-mm cage followed by the 22-mm cage), and 4 of the spines were tested with the TLIF construct. All these constructs were tested in flexion-extension, axial rotation, and lateral bending. The TLIF-alone construct was significantly less stable than the 18- and 22-mm-wide lateral lumbar interbody fusion (LLIF) constructs and the TLIF constructs with either UPSs or BPSs. The LLIF constructs alone were significantly less stable than the TLIF construct with BPSs. However, there was no significant difference between the 18-mm LLIF construct with UPSs and the TLIF construct with BPSs in any of the loading modes. Expandable lateral cages with UPSs provide stability equivalent to that of a TLIF construct with BPSs in a degenerative spondylolisthesis model.

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

PubMed

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

2018-02-01

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

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

PubMed

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

2018-06-06

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

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

PubMed

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

2018-05-01

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

MIS Single-position Lateral and Oblique Lateral Lumbar Interbody Fusion and Bilateral Pedicle Screw Fixation: Feasibility and Perioperative Results.

PubMed

Blizzard, Daniel J; Thomas, J Alex

2018-03-15

Retrospective review of prospectively collected data of the first 72 consecutive patients treated with single-position one- or two-level lateral (LLIF) or oblique lateral interbody fusion (OLLIF) with bilateral percutaneous pedicle screw and rod fixation by a single spine surgeon. To evaluate the clinical feasibility, accuracy, and efficiency of a single-position technique for LLIF and OLLIF with bilateral pedicle screw and rod fixation. Minimally-invasive lateral interbody approaches are performed in the lateral decubitus position. Subsequent repositioning prone for bilateral pedicle screw and rod fixation requires significant time and resources and does not facilitate increased lumbar lordosis. The first 72 consecutive patients (300 screws) treated with single-position LLIF or OLLIF and bilateral pedicle screws by a single surgeon between December 2013 and August 2016 were included in the study. Screw accuracy and fusion were graded using computed tomography and several timing parameters were recorded including retractor, fluoroscopy, and screw placement time. Complications including reoperation, infection, and postoperative radicular pain and weakness were recorded. Average screw placement time was 5.9 min/screw (standard deviation, SD: 1.5 min; range: 3-9.5 min). Average total operative time (interbody cage and pedicle screw placement) was 87.9 minutes (SD: 25.1 min; range: 49-195 min). Average fluoroscopy time was 15.0 s/screw (SD: 4.7 s; range: 6-25 s). The pedicle screw breach rate was 5.1% with 10/13 breaches measured as < 2 mm in magnitude. Fusion rate at 6-months postoperative was 87.5%. Two (2.8%) patients underwent reoperation for malpositioned pedicle screws with subsequent resolution of symptoms. The single-position, all-lateral technique was found to be feasible with accuracy, fluoroscopy usage, and complication rates comparable with the published literature. This technique eliminates the time and staffing associated with

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

PubMed

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

2018-06-01

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

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

PubMed Central

Lee, Ji-Ho; Lee, Dong-Oh; Lee, Jae Hyup; Shim, Hee Jong

2015-01-01

This study aims to assess the differences in the radiological and clinical results depending on the lordotic angles of the cage in posterior lumbar interbody fusion (PLIF). We reviewed 185 segments which underwent PLIF using two different lordotic angles of 4° and 8° of a polyetheretherketone (PEEK) cage. The segmental lordosis and total lumbar lordosis of the 4° and 8° cage groups were compared preoperatively, as well as on the first postoperative day, 6th and 12th months postoperatively. Clinical assessment was performed using the ODI and the VAS of low back pain. The pre- and immediate postoperative segmental lordosis angles were 12.9° and 12.6° in the 4° group and 12° and 12.0° in the 8° group. Both groups exhibited no significant different segmental lordosis angle and total lumbar lordosis over period and time. However, the total lumbar lordosis significantly increased from six months postoperatively compared with the immediate postoperative day in the 8° group. The ODI and the VAS in both groups had no differences. Cages with different lordotic angles of 4° and 8° showed insignificant results clinically and radiologically in short-level PLIF surgery. Clinical improvements and sagittal alignment recovery were significantly observed in both groups. PMID:25685795

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

PubMed

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

2016-06-01

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

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

PubMed

Epstein, Nancy E

2017-01-01

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

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

PubMed

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

2017-05-01

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

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

PubMed Central

2018-01-01

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

Biomechanical evaluation of a spherical lumbar interbody device at varying levels of subsidence.

PubMed

Rundell, Steven A; Isaza, Jorge E; Kurtz, Steven M

2011-01-01

Ulf Fernström implanted stainless steel ball bearings following discectomy, or for painful disc disease, and termed this procedure disc arthroplasty. Today, spherical interbody spacers are clinically available, but there is a paucity of associated biomechanical testing. The primary objective of the current study was to evaluate the biomechanics of a spherical interbody implant. It was hypothesized that implantation of a spherical interbody implant, with combined subsidence into the vertebral bodies, would result in similar ranges of motion (RoM) and facet contact forces (FCFs) when compared with an intact condition. A secondary objective of this study was to determine the effect of using a polyetheretherketone (PEEK) versus a cobalt chrome (CoCr) implant on vertebral body strains. We hypothesized that the material selection would have a negligible effect on vertebral body strains since both materials have elastic moduli substantially greater than the annulus. A finite element model of L3-L4 was created and validated by use of ROM, disc pressure, and bony strain from previously published data. Virtual implantation of a spherical interbody device was performed with 0, 2, and 4 mm of subsidence. The model was exercised in compression, flexion, extension, axial rotation, and lateral bending. The ROM, vertebral body effective (von Mises) strain, and FCFs were reported. Implantation of a PEEK implant resulted in slightly lower strain maxima when compared with a CoCr implant. For both materials, the peak strain experienced by the underlying bone was reduced with increasing subsidence. All levels of subsidence resulted in ROM and FCFs similar to the intact model. The results suggest that a simple spherical implant design is able to maintain segmental ROM and provide minimal differences in FCFs. Large areas of von Mises strain maxima were generated in the bone adjacent to the implant regardless of whether the implant was PEEK or CoCr.

Custom-Made Titanium 3-Dimensional Printed Interbody Cages for Treatment of Osteoporotic Fracture-Related Spinal Deformity.

PubMed

Siu, Timothy L; Rogers, Jeffrey M; Lin, Kainu; Thompson, Robert; Owbridge, Mark

2018-03-01

Advances in minimally invasive interbody fusion have greatly enhanced surgeons' capability to correct adult spinal deformity with reduced morbidity. However, the feasibility of such approaches is limited in patients with previous osteoporotic fractures as the resultant vertebral deformity renders the end plate geometry incongruous with conventional interbody implants. Current 3-dimensional (3D) printing technology offers a novel solution by fabricating custom-made implants tailored to individual anatomy. We present the results of a patient with osteoporotic lumbar fractures treated by such technology. A 74-year-old woman, with previous osteoporotic fractures at L2 and L3 resulting in concave deformity of the end plates, presented with intractable radiculopathy secondary to lateral recess and foraminal stenosis (L2-3 and L3-4). A minimally invasive lateral lumbar interbody fusion at L2-3 and L3-4 was considered favorable, but due to the associated vertebral collapse, off-the-shelf implants were not compatible with patient anatomy. In silico simulation based on preoperative computed tomography (CT) imaging was thus conducted to design customized cages to cater for the depressed recipient end plates and vertebral loss. The design was converted to implantable titanium cages through 3D additive manufacturing. At surgery, a tight fit between the implants and the targeted disk space was achieved. Postoperative CT scan confirmed excellent implant-end plate matching and restoration of lost disk space. The patient began to ambulate from postoperative day 1 and at 6-month follow-up resolution of radicular symptoms and CT evidence of interbody fusion were recorded. 3D-printed custom-made interbody cages can help overcome the difficulties in deformity correction secondary to osteoporotic fractures. Copyright © 2017 Elsevier Inc. All rights reserved.

Risk factor of contralateral radiculopathy following microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion.

PubMed

Yang, Yang; Liu, Zhong-Yu; Zhang, Liang-Ming; Dong, Jian-Wen; Xie, Pei-Gen; Chen, Rui-Qiang; Yang, Bu; Liu, Chang; Liu, Bin; Rong, Li-Min

2017-12-08

Microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is an advantageous method for treating lumbar degenerative disease; however, some patients show contralateral radiculopathy postoperatively. This study aims to investigate its risk factor. A total of 130 cases who underwent microendoscopy-assisted MIS-TLIF at L4-5 level were divided into symptomatic and asymptomatic groups according to the presence of postoperative contralateral radiculopathy. Both preoperative and postoperative radiographic parameters, as well as their changes were compared between the two groups, including lumbar lordosis (LL), surgical segmental angle (SSA), disc height (DH), contralateral foramen area (CFA) and contralateral canal area (CCA). Screw breach on contralateral L4 pedicle and decompression method (ipsilateral or bilateral canal decompression through unilateral route) were also analyzed as potential risk factors. Receiver operating characteristic (ROC) curve was drawn for the risk factor to determine the optimal threshold for predicting postoperative contralateral radiculopathy. Besides, clinical outcome assessment, involving Visual Analog Score (VAS) for back and leg, Japanese Orthopaedics Association Score (JOA) and Oswestry Disability Index (ODI), was also compared between the two groups before surgery and at final follow-up (at least 3 months after the surgery for asymptomatic patients or final treatments of contralateral radiculopathy for symptomatic cases). Postoperative contralateral radiculopathy occurred in 11 (8.5%) of the 130 patients. Both preoperative and postoperative CFA as well as its change were significantly decreased in symptomatic group compared with asymptomatic group (all P < 0.05). For the remaining four parameters (LL, SSA, DH, CCA), their preoperative, postoperative and change values showed no statistical difference between the two groups (all P > 0.05). Neither screw breach nor decompression method revealed

The Biomechanical Study of Extraforaminal Lumbar Interbody Fusion: A Three-Dimensional Finite-Element Analysis.

PubMed

Yang, Mingjie; Sun, Guixin; Guo, Song; Zeng, Cheng; Yan, Meijun; Han, Yingchao; Xia, Dongdong; Zhang, Jingjie; Li, Xinhua; Xiang, Yang; Pan, Jie; Li, Lijun; Tan, Jun

2017-01-01

Finite-element method was used to evaluate biomechanics stability of extraforaminal lumbar interbody fusion (ELIF) under different internal fixation. The L3-L5 level finite-element model was established to simulate decompression and internal fixation at L4-L5 segment. The intact finite model was treated in accordance with the different internal fixation. The treatment groups were exerted 400 N load and 6 N·m additional force from motion to calculate the angular displacement of L4-L5. The ROMs were smaller in all internal fixation groups than those in the intact model. Furthermore, the ROMs were smaller in ELIF + UPS group than in TLIF + UPS group under all operating conditions, especially left lateral flexion and right rotation. The ROMs were higher in ELIF + UPS group than in TLIF + BPS group. The ROMs of ELIF + UPS + TLFS group were much smaller than those in ELIF + UPS group, and as compared with TLIF + BPS group, there was no significant difference in the range of experimental loading. The biomechanical stability of ELIF with unilateral pedicle screw fixation is superior to that of TLIF with unilateral pedicle screw fixation but lower than that of TLIF with bilateral pedicle screws fixation. The stability of ELIF with unilateral fixation can be further improved by supplementing a translaminar facet screw.

Feasibility of the runt cow for in vivo testing of a spinal interbody prosthesis with preliminary results.

PubMed

Buttermann, Glenn R; Mendenhall, H Vincent

2012-04-01

The optimal lumbar spinal disc prosthesis has yet to be developed. Failures of clinical device studies may be minimized by appropriate large animal preclinical studies. The lumbar spine of the mature "runt" cow, Corrientes breed, has been shown to have a number of desirable characteristics to the human. This study assessed the feasibility of the "runt" cow for in vivo testing of human-sized lumbar interbody implants and the ability to perform common analyses of explants. Eight cows (four experimental and four controls) were compared. The experimental animals had transosseous implantation of the disc prosthesis at L4-L5, and their spines were harvested at four or six months. They were evaluated for the ease of surgical access and healing, motion segment mobility, ability to remove the implant nondestructively, and microradiography and histomorphology. All animals had successful implantation. All explantations were performed without alteration to the devices. All animals had surgical healing and intended device motion, and histology found device stability by demonstrating bone ingrowth into the device's porous plates. There was a significant 46% increase in the amount of trabecular bone adjacent to the implants. The mature runt cow allows for implantation of human-sized interbody and intrabody spinal prostheses. This animal model allowed for macro- and histological analysis of the implant and surrounding tissues. In vivo stability was demonstrated for the disc prosthesis while also allowing for evaluation of intended mobility. Additionally, this is the first study to suggest increased bone density supporting an interbody prosthesis.

Effects of Strontium Ranelate on Spinal Interbody Fusion Surgery in an Osteoporotic Rat Model

PubMed Central

Tsai, Tsung-Ting; Ho, Natalie Yi-Ju; Lai, Po-Liang; Fu, Tsai-Sheng; Niu, Chi-Chien; Chen, Lih-Huei; Chen, Wen-Jer

2017-01-01

Osteoporosis is a bone disease that afflicts millions of people around the world, and a variety of spinal integrity issues, such as degenerative spinal stenosis and spondylolisthesis, are frequently concomitant with osteoporosis and are sometimes treated with spinal interbody fusion surgery. Previous studies have demonstrated the efficacy of strontium ranelate (SrR) treatment of osteoporosis in improving bone strength, promoting bone remodeling, and reducing the risk of fractures, but its effects on interbody fusion surgery have not been adequately investigated. SrR-treated rats subjected to interbody fusion surgery exhibited significantly higher lumbar vertebral bone mineral density after 12 weeks of treatment than rats subjected to the same surgery but not treated with SrR. Furthermore, histological and radiographic assessments showed that a greater amount of newly formed bone tissue was present and that better fusion union occurred in the SrR-treated rats than in the untreated rats. Taken together, these results show significant differences in bone mineral density, PINP level, histological score, SrR content and mechanical testing, which demonstrate a relatively moderate effect of SrR treatment on bone strength and remodeling in the specific context of recovery after an interbody fusion surgery, and suggest the potential of SrR treatment as an effective adjunct to spinal interbody fusion surgery for human patients. PMID:28052066

Direct current stimulation of titanium interbody fusion devices in primates.

PubMed

Cook, Stephen D; Patron, Laura P; Christakis, Petros M; Bailey, Kirk J; Banta, Charles; Glazer, Paul A

2004-01-01

The fusion rate for anterior lumbar interbody fusion (ALIF) varies widely with the use of different interbody devices and bone graft options. Adjunctive techniques such as electrical stimulation may improve the rate of bony fusion. To determine if direct current (DC) electrical stimulation of a metallic interbody fusion device enhanced the incidence or extent of anterior bony fusion. ALIF was performed using titanium alloy interbody fusion devices with and without adjunctive DC electrical stimulation in nonhuman primates. ALIF was performed through an anterolateral approach in 35 macaques with autogenous bone graft and either a titanium alloy (Ti-6Al-4V) fusion device or femoral allograft ring. The fusion devices of 19 animals received high (current density 19.6 microA/cm2) or low (current density 5.4 microA/cm2) DC electrical stimulation using an implanted generator for a 12- or 26-week evaluation period. Fusion sites were studied using serial radiographs, computed tomography imaging, nondestructive mechanical testing and qualitative and semiquantitative histology. Fusion was achieved with the titanium fusion device and autogenous bone graft. At 12 weeks, the graft was consolidating and early to moderate bridging callus was observed in and around the device. By 26 weeks, the anterior callus formation was more advanced with increased evidence of bridging trabeculations and early bone remodeling. The callus formation was not as advanced or abundant for the allograft ring group. Histology revealed the spinal fusion device had an 86% incidence of bony fusion at 26 weeks compared with a 50% fusion rate for the allograft rings. DC electrical stimulation of the fusion device had a positive effect on anterior interbody fusion by increasing both the presence and extent of bony fusion in a current density-dependent manner. Adjunctive DC electrical stimulation of the fusion device improved the rate and extent of bony fusion compared with a nonstimulated device. The fusion

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

PubMed

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

2015-05-01

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

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

PubMed

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

2017-09-01

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

Effects of Anterior Plating on Clinical Outcomes of Anterior Lumbar Interbody Fusion.

PubMed

Snyder, Laura A; Kalb, Samuel; Kakarla, Udaya K; Porter, Randall W; Kaibara, Taro; Dickman, Curtis A; Theodore, Nicholas

2016-08-01

Retrospective review. To compare surgical outcomes of patients who have undergone anterior lumbar interbody fusion (ALIF) with and without plating. In biomechanical testing, ALIF constructs supplemented with plating (ALIFP) reduce range of motion and increase construct stiffness compared with ALIF alone. However, whether ALIFP constructs translate into improved clinical outcomes over ALIF alone is unknown. From 2004 through 2010, 231 patients underwent ALIF with (146) or without (85) plating. Eight patients lost to follow up were excluded from final evaluation. Patients' records were evaluated retrospectively for demographics, complications, and outcomes. At a mean follow-up of 13.7 months (range, 1-108 mo), the mean Economic, Functional, and Total Prolo scores for ALIF patients were 4.23, 3.63, and 7.87, respectively. The mean Oswestry Disability Index (ODI) was 24%. At a mean follow-up of 11.2 months (range, 1-93 mo), the mean Economic, Functional, and Total Prolo scores for ALIFP patients were 4.28, 3.67, and 7.95, respectively. The mean ODI was 22.9%. There was no significant difference between rate of complications or Prolo scores or ODI between the 2 groups (t test). Neither diabetes, hypertension, smoking, sex, nor age older than 55 years was significantly related to whether patients had higher Prolo scores with or without plating. Patients with a normal body mass index and ALIF had significantly better Prolo Economic scores and total scores than patients with a normal body mass index and ALIFP (P=0.04 and 0.02, independent samples t test). Patients were also stratified by surgical indication for surgery, and there was no significant difference in Prolo scores or ODI for patients who underwent ALIF alone versus ALIFP. Even when stratified by indication for surgery, anterior plating does not seem to improve Prolo scores or ODI, suggesting that not all patients undergoing ALIF require plating.

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

PubMed

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

2016-10-01

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

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

PubMed

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

2016-04-01

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

Lateral retroperitoneal transpsoas interbody fusion in a patient with achondroplastic dwarfism.

PubMed

Staub, Blake N; Holman, Paul J

2015-02-01

The authors present the first reported use of the lateral retroperitoneal transpsoas approach for interbody arthrodesis in a patient with achondroplastic dwarfism. The inherent anatomical abnormalities of the spine present in achondroplastic dwarfism predispose these patients to an increased incidence of spinal deformity as well as neurogenic claudication and potential radicular symptoms. The risks associated with prolonged general anesthesia and intolerance of significant blood loss in these patients makes them ideal candidates for minimally invasive spinal surgery. The patient in this case was a 51-year-old man with achondroplastic dwarfism who had a history of progressive claudication and radicular pain despite previous extensive lumbar laminectomies. The lateral retroperitoneal transpsoas approach was used for placement of interbody cages at L1/2, L2/3, L3/4, and L4/5, followed by posterior decompression and pedicle screw instrumentation. The patient tolerated the procedure well with no complications. Postoperatively his claudicatory and radicular symptoms resolved and a CT scan revealed solid arthrodesis with no periimplant lucencies.

Does prone repositioning before posterior fixation produce greater lordosis in lateral lumbar interbody fusion (LLIF)?

PubMed

Yson, Sharon C; Sembrano, Jonathan N; Santos, Edward R G; Luna, Jeffrey T P; Polly, David W

2014-10-01

Retrospective comparative radiographic review. To determine if lateral to prone repositioning before posterior fixation confers additional operative level lordosis in lateral lumbar interbody fusion (LLIF) procedures. 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. 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. Disk 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 repositioning, and (3) posterior instrumentation. Paired t test was used to determine significance (α=0.05). Mean lordosis improvement brought about by cage insertion was 2.6 degrees (P=0.00005). There was a 0.1 degree 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 degree (P=0.03). 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 repositioning after cage placement does not produce any incremental lordosis change. Therefore, posterior fixation may be performed in the lateral position without compromising operative level sagittal alignment.

Two-year Outcomes from a Single Surgeon's Learning Curve Experience of Oblique Lateral Interbody Fusion without Intraoperative Neuromonitoring

PubMed Central

Fonseca, Ahtziri; Miller, Larry E

2017-01-01

Introduction Oblique lumbar interbody fusion (OLIF) is a newer procedure that avoids the psoas and lumbosacral plexus due to its oblique trajectory into the retroperitoneal space. While early experience with OLIF is reassuring, the longer-term clinical efficacy has not been well established. The purpose of this study was to describe two-year clinical outcomes with OLIF performed by a single surgeon during the learning curve without the aid of the neuromonitoring. Materials and methods Chart review was performed for the consecutive patients who underwent OLIF by a single surgeon. Back pain severity on a visual analog scale (VAS) and Oswestry Disability Index (ODI) were collected preoperatively and postoperatively at six weeks, three months, six months, one year and two years. Results A total of 21 patients (38 levels) were included in this study. The indications for surgery were degenerative disc disease (n=10, 47.6%), spondylolisthesis (n=9, 42.9%) and spinal stenosis (n=6, 28.6%). The median operating room time was 351 minutes (interquartile range (IQR): 279-406 minutes), blood loss was 40 ml (IQR: 30-150 ml), and hospital stay was 2.0 days (IQR: 1.0-3.5 days). The complication rate was 9.5%, both venous injuries. There were no other perioperative complications. Back pain severity decreased by 70%, on average, over two years (p <0.001). A total of 17 (81%) patients reported at least a two-point decrease from the baseline. The ODI scores decreased by 55%, on average, over two years (p <0.001), with 16 (76%) patients reporting at least a 15-point decrease from the baseline. Over two years, no symptomatic pseudarthrosis, hardware failure, reoperations, or additional complications were reported. Conclusions The oblique lateral interbody fusion performed without the intraoperative neuromonitoring was safe and clinically efficacious for up to two years. The complication rate in this cohort is similar to other published OLIF series and appears acceptable when

Two-year Outcomes from a Single Surgeon's Learning Curve Experience of Oblique Lateral Interbody Fusion without Intraoperative Neuromonitoring.

PubMed

Woods, Kamal; Fonseca, Ahtziri; Miller, Larry E

2017-12-22

Introduction Oblique lumbar interbody fusion (OLIF) is a newer procedure that avoids the psoas and lumbosacral plexus due to its oblique trajectory into the retroperitoneal space. While early experience with OLIF is reassuring, the longer-term clinical efficacy has not been well established. The purpose of this study was to describe two-year clinical outcomes with OLIF performed by a single surgeon during the learning curve without the aid of the neuromonitoring. Materials and methods Chart review was performed for the consecutive patients who underwent OLIF by a single surgeon. Back pain severity on a visual analog scale (VAS) and Oswestry Disability Index (ODI) were collected preoperatively and postoperatively at six weeks, three months, six months, one year and two years. Results A total of 21 patients (38 levels) were included in this study. The indications for surgery were degenerative disc disease (n=10, 47.6%), spondylolisthesis (n=9, 42.9%) and spinal stenosis (n=6, 28.6%). The median operating room time was 351 minutes (interquartile range (IQR): 279-406 minutes), blood loss was 40 ml (IQR: 30-150 ml), and hospital stay was 2.0 days (IQR: 1.0-3.5 days). The complication rate was 9.5%, both venous injuries. There were no other perioperative complications. Back pain severity decreased by 70%, on average, over two years (p <0.001). A total of 17 (81%) patients reported at least a two-point decrease from the baseline. The ODI scores decreased by 55%, on average, over two years (p <0.001), with 16 (76%) patients reporting at least a 15-point decrease from the baseline. Over two years, no symptomatic pseudarthrosis, hardware failure, reoperations, or additional complications were reported. Conclusions The oblique lateral interbody fusion performed without the intraoperative neuromonitoring was safe and clinically efficacious for up to two years. The complication rate in this cohort is similar to other published OLIF series and appears acceptable when

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

PubMed

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

2017-09-01

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

Lordosis restoration after anterior longitudinal ligament release and placement of lateral hyperlordotic interbody cages during the minimally invasive lateral transpsoas approach: a radiographic study in cadavers.

PubMed

Uribe, Juan S; Smith, Donald A; Dakwar, Elias; Baaj, Ali A; Mundis, Gregory M; Turner, Alexander W L; Cornwall, G Bryan; Akbarnia, Behrooz A

2012-11-01

In the surgical treatment of spinal deformities, the importance of restoring lumbar lordosis is well recognized. Smith-Petersen osteotomies (SPOs) yield approximately 10° of lordosis per level, whereas pedicle subtraction osteotomies result in as much as 30° increased lumbar lordosis. Recently, selective release of the anterior longitudinal ligament (ALL) and placement of lordotic interbody grafts using the minimally invasive lateral retroperitoneal transpsoas approach (XLIF) has been performed as an attempt to increase lumbar lordosis while avoiding the morbidity of osteotomy. The objective of the present study was to measure the effect of the selective release of the ALL and varying degrees of lordotic implants placed using the XLIF approach on segmental lumbar lordosis in cadaveric specimens between L-1 and L-5. Nine adult fresh-frozen cadaveric specimens were placed in the lateral decubitus position. Lateral radiographs were obtained at baseline and after 4 interventions at each level as follows: 1) placement of a standard 10° lordotic cage, 2) ALL release and placement of a 10° lordotic cage, 3) ALL release and placement of a 20° lordotic cage, and 4) ALL release and placement of a 30° lordotic cage. All four cages were implanted sequentially at each interbody level between L-1 and L-5. Before and after each intervention, segmental lumbar lordosis was measured in all specimens at each interbody level between L-1 and L-5 using the Cobb method on lateral radiography. The mean baseline segmental lordotic angles at L1-2, L2-3, L3-4, and L4-5 were -3.8°, 3.8°, 7.8°, and 22.6°, respectively. The mean lumbar lordosis was 29.4°. Compared with baseline, the mean postimplantation increase in segmental lordosis in all levels combined was 0.9° in Intervention 1 (10° cage without ALL release); 4.1° in Intervention 2 (ALL release with 10° cage); 9.5° in Intervention 3 (ALL release with 20° cage); and 11.6° in Intervention 4 (ALL release with 30° cage

Spine interbody implants: material selection and modification, functionalization and bioactivation of surfaces to improve osseointegration.

PubMed

Rao, Prashanth J; Pelletier, Matthew H; Walsh, William R; Mobbs, Ralph J

2014-05-01

The clinical outcome of lumbar spinal fusion is correlated with achievement of bony fusion. Improving interbody implant bone on-growth and in-growth may enhance fusion, limiting pseudoarthrosis, stress shielding, subsidence and implant failure. Polyetheretherketone (PEEK) and titanium (Ti) are commonly selected for interbody spacer construction. Although these materials have desirable biocompatibility and mechanical properties, they require further modification to support osseointegration. Reports of extensive research on this topic are available in biomaterial-centric published reports; however, there are few clinical studies concerning surface modification of interbody spinal implants. The current article focuses on surface modifications aimed at fostering osseointegration from a clinician's point of view. Surface modification of Ti by creating rougher surfaces, modifying its surface topography (macro and nano), physical and chemical treatment and creating a porous material with high interconnectivity can improve its osseointegrative potential and bioactivity. Coating the surface with osteoconductive materials like hydroxyapatite (HA) can improve osseointegration. Because PEEK spacers are relatively inert, creating a composite by adding Ti or osteoconductive materials like HA can improve osseointegration. In addition, PEEK may be coated with Ti, effectively bio-activating the coating. © 2014 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd.

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

PubMed

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

2016-06-01

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

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

PubMed

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

2014-08-01

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

[Effects of robot-assisted minimally invasive transforaminal lumbar interbody fusion and traditional open surgery in the treatment of lumbar spondylolisthesis].

PubMed

Cui, G Y; Tian, W; He, D; Xing, Y G; Liu, B; Yuan, Q; Wang, Y Q; Sun, Y Q

2017-07-01

Objective: To compare the clinical effects of robot-assisted minimally invasive transforaminal lumbar interbody fusion (TLIF) and traditional open TLIF in the treatment of lumbar spondylolisthesis. Methods: A total of 41 patients with lumbar spondylolisthesis accepted surgical treatment in Department of Spinal Surgery of Beijing Jishuitan Hospital From July 2015 to April 2016 were retrospectively analyzed. There were 16 cases accepted robot-assisted minimally invasive TLIF and 25 accepted traditional open TLIF. The operation time, X-ray radiation exposure time, perioperative bleeding, drainage volume, time of hospitalization, time for pain relief, time for ambulatory recovery, visual analogue scale (VAS), Oswestry disability index (ODI) and complications were compared. T test and χ(2) were used to analyze data. Results: There were no significant difference in gender, age, numbers, degrees, pre-operative VAS and ODI in spondylolisthesis (all P >0.05). Compared with traditional open TLIF group, the robot-assisted minimally invasive TLIF group had less perioperative bleeding ((187.5±18.4) ml vs . (332.1±23.5) ml), less drainage volume ((103.1±15.6) ml vs . (261.3±19.8) ml), shorter hospitalization ((7.8±1.9) days vs . (10.0±1.6) days), shorter time for pain relief ((2.8±1.0) days vs . (5.2±1.1) days), shorter time for ambulatory recovery ((1.7±0.9) days vs . (2.9±1.3) days) and less VAS of the third day postoperatively (2.2±0.9 vs . 4.2±2.4) ( t =2.762-16.738, all P <0.05), but need more operation time ((151.3±12.3) minutes vs . (102.2±7.1) minutes) and more X-ray radiation exposure ((26.1±3.3) seconds vs . (5.5±2.1) seconds) ( t =6.125, 15.168, both P <0.01). In both groups ODI was significantly lower in final follow-up than that of the pre-operation ( t =12.215, 14.036, P <0.01). Intervertebral disc height of the final follow-up in both groups were significantly larger than that of the preoperation (robot-assisted minimally invasive TLIF group: (11

Multilevel extreme lateral interbody fusion (XLIF) and osteotomies for 3-dimensional severe deformity: 25 consecutive cases

PubMed Central

McAfee, Paul C.; Shucosky, Erin; Chotikul, Liana; Salari, Ben; Chen, Lun; Jerrems, Dan

2013-01-01

Background This is a retrospective review of 25 patients with severe lumbar nerve root compression undergoing multilevel anterior retroperitoneal lumbar interbody fusion and posterior instrumentation for deformity. The objective is to analyze the outcomes and clinical results from anterior interbody fusions performed through a lateral approach and compare these with traditional surgical procedures. Methods A consecutive series of 25 patients (78 extreme lateral interbody fusion [XLIF] levels) was identified to illustrate the primary advantages of XLIF in correcting the most extreme of the 3-dimensional deformities that fulfilled the following criteria: (1) a minimum of 40° of scoliosis; (2) 2 or more levels of translation, anterior spondylolisthesis, and lateral subluxation (subluxation in 2 planes), causing symptomatic neurogenic claudication and severe spinal stenosis; and (3) lumbar hypokyphosis or flat-back syndrome. In addition, the majority had trunks that were out of balance (central sacral vertical line ≥2 cm from vertical plumb line) or had sagittal imbalance, defined by a distance between the sagittal vertical line and S1 of greater than 3 cm. There were 25 patients who had severe enough deformities fulfilling these criteria that required supplementation of the lateral XLIF with posterior osteotomies and pedicle screw instrumentation. Results In our database, with a mean follow-up of 24 months, 85% of patients showed evidence of solid arthrodesis and no subsidence on computed tomography and flexion/extension radiographs. The complication rate remained low, with a perioperative rate of 2.4% and postoperative rate of 12.2%. The lateral listhesis and anterior spondylolisthetic subluxation were anatomically reduced with minimally invasive XLIF. The main finding in these 25 cases was our isolation of the major indication for supplemental posterior surgery: truncal decompensation in patients who are out of balance by 2 cm or more, in whom posterior spinal

The efficacy of porous hydroxyapatite bone chip as an extender of local bone graft in posterior lumbar interbody fusion.

PubMed

Kim, Hyoungmin; Lee, Choon-Ki; Yeom, Jin-Sup; Lee, Jae-Hyup; Lee, Ki-Ho; Chang, Bong-Soon

2012-07-01

To evaluate whether a synthetic bone chip made of porous hydroxyapatite can effectively extend local decompressed bone graft in instrumented posterior lumbar interbody fusion (PLIF). 130 patients, 165 segments, who had undergone PLIF with cages and instrumentation for single or double level due to degenerative conditions, were investigated retrospectively by independent blinded observer. According to the material of graft, patients were divided into three groups. HA group (19 patients, 25 segments): with hydroxyapatite bone chip in addition to autologous local decompressed bone, IBG group (25 patients, 28 segments): with autologous iliac crest bone graft in addition to local decompressed bone and LB group (86 patients, 112 segments): with local decompressed bone only. Radiologic and clinical outcome were compared among groups and postoperative complications, transfusion, time and cost of operation and duration of hospitalization were also investigated. Radiologic fusion rate and clinical outcome were not different. Economic cost, transfusion and hospital stay were also similar. But operation time was significantly longer in IBG group than in other groups. There were no lasting complications associated with HA and LB group with contrast to five cases with persisting donor site pain in IBG group. Porous hydroxyapatite bone chip is a useful bone graft extender in PLIF when used in conjunction with local decompressed bone.

Open and Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Intermediate Results and Complications

PubMed Central

Hee, Hwan Tak

2015-01-01

Study Design Prospective study. Purpose To compare clinical and radiological outcomes of open vs. minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). Overview of Literature MI-TLIF promises smaller incisions and less soft tissue dissection resulting in lower morbidity and faster recovery; however, it is technically challenging. Methods Twenty-five patients with MI-TLIF were compared with 25 matched open TLIF controls. A minimum 2 year follow-up and a statistical analysis of perioperative and long-term outcomes were performed. Potential complications were recorded. Results The mean ages for the open and MI-TLIF cases were 44.4 years (range, 19-69 years) and 43.6 years (range, 20-69 years), respectively. The male:female ratio was 13:12 for both groups. Average follow-up was 26.9 months for the MI-TLIF group and 29.3 months for the open group. Operative duration was significantly longer in the MI-TLIF group than that in the open group (p<0.05). No differences in estimated blood loss, duration to ambulation, or length of stay were found. Significant improvements in the Oswestry disability index and EQ-5D functional scores were observed at 6-, 12-, and 24-months in both groups, but no significant difference was detected between the groups. Fusion rates were comparable. Cage sizes were significantly smaller in the MI-TLIF group at the L5/S1 level (p<0.05). One patient had residual spinal stenosis at the MI-TLIF level, and one patient who underwent two-level MI-TLIF developed a deep vein thrombosis resulting in a pulmonary embolism. Conclusions MI-TLIF and open TLIF had comparable long-term benefits. Due to technical constraints, patients should be advised on the longer operative time and potential undersizing of cages at the L5S1 level. PMID:25901228

Validity of the Japanese Orthopaedic Association scoring system based on patient-reported improvement after posterior lumbar interbody fusion.

PubMed

Fujimori, Takahito; Okuda, Shinya; Iwasaki, Motoki; Yamasaki, Ryoji; Maeno, Takafumi; Yamashita, Tomoya; Matsumoto, Tomiya; Wada, Eiji; Oda, Takenori

2016-06-01

The Japanese Orthopaedic Association (JOA) scoring system is a physician-based outcome that has been used to evaluate treatment effectiveness after lumbar surgery. However, patient-centered evaluation becomes increasingly important. There is no study that has examined the relationship between the JOA scoring system and patients' self-reported improvement. The purpose of the present study was to validate the JOA scoring system for assessment of patient-reported improvement after lumbar surgery. This is a retrospective review of prospectively collected data. The patient sample included 273 mail-in responders of the 466 consecutive patients who underwent posterior lumbar interbody fusion for spondylolisthesis between 1996 and 2008 in a single hospital. The outcome measures were the JOA scoring system and patients' self-reported improvement. Two hundred seventy three patients were divided into five anchoring groups based on self-reported improvement from "Much better" to "Much worse." Outcomes (ie, recovery rate, amount of change from preoperative condition, and postoperative score) based on the JOA scoring system were compared among groups. Using the patient's self-reported improvement scale as an anchor, the association among each of the outcomes was examined. The cutoff point and the area under the curve (AUC) that differentiated "Improved" from "Neither improved nor worse" was calculated using receiver operating characteristic (ROC) curve analysis. The recovery rate and postoperative score were significantly different in 9 of 10 pairs of anchoring groups. The amount of change was significantly different in six pairs. Spearman correlation coefficient for the 5-point scale anchors of patients' self-reported improvement was 0.20 (p=.001) for the baseline score, 0.31 (p<.001) for the amount of change, 0.55 (p<.001) for the recovery rate, and 0.56 (p<.001) for the postoperative score. According to ROC analysis, the best cutoff points and AUCs were 13 points and 0

Diagnosis of Lumbar Foraminal Stenosis using Diffusion Tensor Imaging.

PubMed

Eguchi, Yawara; Ohtori, Seiji; Suzuki, Munetaka; Oikawa, Yasuhiro; Yamanaka, Hajime; Tamai, Hiroshi; Kobayashi, Tatsuya; Orita, Sumihisa; Yamauchi, Kazuyo; Suzuki, Miyako; Aoki, Yasuchika; Watanabe, Atsuya; Kanamoto, Hirohito; Takahashi, Kazuhisa

2016-02-01

Diagnosis of lumbar foraminal stenosis remains difficult. Here, we report on a case in which bilateral lumbar foraminal stenosis was difficult to diagnose, and in which diffusion tensor imaging (DTI) was useful. The patient was a 52-year-old woman with low back pain and pain in both legs that was dominant on the right. Right lumbosacral nerve compression due to a massive uterine myoma was apparent, but the leg pain continued after a myomectomy was performed. No abnormalities were observed during nerve conduction studies. Computed tomography and magnetic resonance imaging indicated bilateral L5 lumbar foraminal stenosis. DTI imaging was done. The extraforaminal values were decreased and tractography was interrupted in the foraminal region. Bilateral L5 vertebral foraminal stenosis was treated by transforaminal lumbar interbody fusion and the pain in both legs disappeared. The case indicates the value of DTI for diagnosing vertebral foraminal stenosis.

Minimally Invasive Direct Lateral Interbody Fusion (MIS-DLIF): Proof of Concept and Perioperative Results.

PubMed

Abbasi, Hamid; Abbasi, Ali

2017-01-14

Minimally invasive direct lateral interbody fusion (MIS-DLIF) is a novel approach for fusions of the lumbar spine. In this proof of concept study, we describe the surgical technique and report our experience and the perioperative outcomes of the first nine patients who underwent this procedure. In this study we establish the safety and efficacy of this approach. MIS-DLIF was performed on 15 spinal levels in nine patients who failed to respond to conservative therapy for the treatment of a re-herniated disk, spondylolisthesis, or other severe disk disease of the lumbar spine. We recorded surgery time, blood loss, fluoroscopy time, patient-reported pain, and complications. Throughout the MIS-DLIF procedure, the surgeon is aided by biplanar fluoroscopic imaging to place an interbody graft or cage into the disc space through the interpleural space. A discectomy is performed in the same minimally invasive fashion. The procedure is usually completed with posterior pedicle screw fixation. MIS-DLIF took 44/85 minutes, on average, for 1/2 levels, with 54/112 ml of blood loss, and 0.3/1.7 days of hospital stay. Four of nine patients did not require overnight hospitalization and were discharged two to four hours after surgery. We did not encounter any clinically significant complications. At more than ninety days post surgery, the patients reported a statistically significant reduction of 4.5 points on a 10-point sliding pain scale. MIS-DLIF with pedicle screw fixation is a safe and clinically effective procedure for fusions of the lumbar spine. The procedure overcomes many of the limitations of the current minimally invasive approaches to the lumbar spine and is technically straightforward. MIS-DLIF has the potential to improve patient outcomes and reduce costs relative to the current standard of care and therefore warrants further investigation. We are currently expanding this study to a larger cohort and documenting long-term outcome data.

Assessment of Paraspinal Muscle Atrophy Percentage after Minimally Invasive Transforaminal Lumbar Interbody Fusion and Unilateral Instrumentation Using a Novel Contralateral Intact Muscle-Controlled Model.

PubMed

Ortega-Porcayo, Luis Alberto; Leal-López, Andres; Soriano-López, Miroslava Elizabeth; Gutiérrez-Partida, Carlos Francisco; Ramírez-Barrios, Luis Rodolfo; Soriano-Solis, Sergio; Rodríguez-García, Manuel; Soriano-Solis, Hector Antonio; Soriano-Sánchez, José Antonio

2018-04-01

Retrospective comparative clinical study. This study aimed to assess paraspinal muscle atrophy in patients who underwent minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and unilateral pedicle screw fixation using a novel contralateral intact muscle-controlled model. The increased incidence of paravertebral lumbar muscle injuries after open techniques has raised the importance of implementing minimally invasive spine surgical techniques using tubular retractors and minimally invasive screw placement. The functional cross-sectional area (FCSA) represents the lean muscle mass; furthermore, FCSA is a useful marker of the contractile ability of a muscle following a spine surgery. However, the benefits of unilateral fixation and MI-TLIF on paraspinal muscles have not been defined. We performed a retrospective imagenological review on eleven patients who underwent unilateral MI-TLIF and unilateral transpedicular screw lumbar placement. FCSAs of the multifidus and erector spinae were measured 1 year after surgery at adjacent levels and were compared to the contralateral intact muscles. Measurement differences between the surgical and nonsurgical sites were compared. The interobserver reliability was calculated using an intraclass correlation coefficient. The mean FCSA at the surgical site was 20.97±5.07 cm 2 at the superior level and 8.89±2.87 cm 2 at the inferior level. The mean FCSA at the contralateral nonsurgical site was 20.15±5.95 cm 2 at the superior level and 9.20±2.66 cm 2 at the inferior level was. The superior and inferior FCSA measurements showed no significant difference between the surgical and nonsurgical sites ( p =0.5, p =0.922, respectively). Using a mini-open tubular approach through the sulcus between the longissimus and iliocostalis, MI-TLIF and unilateral pedicle screw instrumentation produced minimal paraspinal muscle damage at the superior and inferior adjacent levels.

Assessment of Paraspinal Muscle Atrophy Percentage after Minimally Invasive Transforaminal Lumbar Interbody Fusion and Unilateral Instrumentation Using a Novel Contralateral Intact Muscle-Controlled Model

PubMed Central

Ortega-Porcayo, Luis Alberto; Leal-López, Andres; Soriano-López, Miroslava Elizabeth; Gutiérrez-Partida, Carlos Francisco; Ramírez-Barrios, Luis Rodolfo; Soriano-Solis, Sergio; Rodríguez-García, Manuel; Soriano-Solis, Hector Antonio

2018-01-01

Study Design Retrospective comparative clinical study. Purpose This study aimed to assess paraspinal muscle atrophy in patients who underwent minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and unilateral pedicle screw fixation using a novel contralateral intact muscle-controlled model. Overview of Literature The increased incidence of paravertebral lumbar muscle injuries after open techniques has raised the importance of implementing minimally invasive spine surgical techniques using tubular retractors and minimally invasive screw placement. The functional cross-sectional area (FCSA) represents the lean muscle mass; furthermore, FCSA is a useful marker of the contractile ability of a muscle following a spine surgery. However, the benefits of unilateral fixation and MI-TLIF on paraspinal muscles have not been defined. Methods We performed a retrospective imagenological review on eleven patients who underwent unilateral MI-TLIF and unilateral transpedicular screw lumbar placement. FCSAs of the multifidus and erector spinae were measured 1 year after surgery at adjacent levels and were compared to the contralateral intact muscles. Measurement differences between the surgical and nonsurgical sites were compared. The interobserver reliability was calculated using an intraclass correlation coefficient. Results The mean FCSA at the surgical site was 20.97±5.07 cm2 at the superior level and 8.89±2.87 cm2 at the inferior level. The mean FCSA at the contralateral nonsurgical site was 20.15±5.95 cm2 at the superior level and 9.20±2.66 cm2 at the inferior level was. The superior and inferior FCSA measurements showed no significant difference between the surgical and nonsurgical sites (p=0.5, p=0.922, respectively). Conclusions Using a mini-open tubular approach through the sulcus between the longissimus and iliocostalis, MI-TLIF and unilateral pedicle screw instrumentation produced minimal paraspinal muscle damage at the superior and inferior adjacent

An institutional six-year trend analysis of the neurological outcome after lateral lumbar interbody fusion: a 6-year trend analysis of a single institution.

PubMed

Aichmair, Alexander; Lykissas, Marios G; Girardi, Federico P; Sama, Andrew A; Lebl, Darren R; Taher, Fadi; Cammisa, Frank P; Hughes, Alexander P

2013-11-01

Retrospective case series. To evaluate the proportional trend over time of neurological deficits after lateral lumbar interbody fusion (LLIF) at a single institution. Because lumbar nerve roots converge to run as the lumbar plexus within or less frequently underneath the posterior part of the psoas muscle, they are prone to iatrogenic damage during the transpsoas approach in LLIF, and adverse postoperative neurological sequelae remain a major concern. The electronic medical records and office notes of 451 patients who had consecutively undergone LLIF between March 2006 and April 2012 at a single institution were retrospectively reviewed for reports on postoperative neurological deficits. A total of 293 patients (173 females and 120 males) met the study inclusion criteria and were followed postoperatively for a mean period of 15.4 ± 9.2 months (range: 6-53 mo). The number of included patients who underwent LLIF at our institution was 47 in the years 2006 to 2008 (group A), 155 in 2009 to 2010 (group B), and 91 in 2011 to 2012 (group C). Our data indicate a decreasing proportional trend during the past 6 years for postoperative sensory deficits (SDs), motor deficits (MDs), and anterior thigh pain (TP). The decreasing trends were statistically significant for the proportion of SDs in the immediate postoperative setting (P = 0.018) and close to statistically significant for SDs at last follow-up (P = 0.126), TP immediately after surgery (P = 0.098), and TP at last follow-up (P = 0.136). To the authors' best knowledge, this study constitutes the largest series of this sort to date, with regard to both sample size and study period. The present data indicate a decreasing proportional trend over time for SDs, MDs, and anterior TP, which can be considered a representation of an institutional learning curve during a 6-year time period of performing LLIF.

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

PubMed Central

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

2017-01-01

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

Results of instrumented posterolateral fusion in treatment of lumbar spondylolisthesis with and without segmental kyphosis: A retrospective investigation.

PubMed

Chen, Szu-Yuan; Lu, Meng-Ling; Niu, Chi-Chien; Tsai, Tsung-Ting; Liao, Jen-Chung; Chen, Lih-Huei; Chen, Wen-Jer

2015-01-01

Treatment by posterolateral fusion (PLF) with pedicle-screw instrumentation can be unsuccessful in one-segment and low-grade lumbar spondylolisthesis. Segmental kyphosis, either rigid or dynamic, was hypothesized to be one of the factors interfering with the fusion results. From 2004 to 2005, 239 patients with single-segment and low-grade spondylolisthesis were recruited and divided into two groups: Group 1 consisting of 129 patients without segmental kyphosis and group 2 consisting of 110 patients with segmental kyphosis. All patients underwent instrumented PLF at the same medical institute, and the average follow-up period was 31 ± 19 months. We obtained plain radiographs of the lumbosacral spine with the anteroposterior view, the lateral view, and the dynamic flexion-extension views before the operation and during the follow-ups. The results of PLF in the two groups were then compared. There was no significant difference in the demographic data of the two groups, except for gender distribution. The osseous fusion rates were 90.7% in group 1 and 68.2% in group 2 (p < 0.001). Instrumented PLF resulted in significantly higher osseous fusion rate in patients without segmental kyphosis than in the patients with segmental kyphosis. For the patients with sagittal imbalance, such as rigid or dynamic kyphosis, pedicle-screw fixation cannot ensure successful PLF. Interbody fusion by the posterior lumbar interbody fusion or transforaminal lumbar interbody fusion technique might help overcome this problem.

Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients.

PubMed

Theologis, Alexander A; Mundis, Gregory M; Nguyen, Stacie; Okonkwo, David O; Mummaneni, Praveen V; Smith, Justin S; Shaffrey, Christopher I; Fessler, Richard; Bess, Shay; Schwab, Frank; Diebo, Bassel G; Burton, Douglas; Hart, Robert; Deviren, Vedat; Ames, Christopher

2017-02-01

OBJECTIVE The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD). METHODS Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed. RESULTS Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0

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

PubMed

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

2015-01-01

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

Screw Placement Accuracy for Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery: A Study on 3-D Neuronavigation-Guided Surgery

PubMed Central

Torres, Jorge; James, Andrew R.; Alimi, Marjan; Tsiouris, Apostolos John; Geannette, Christian; Härtl, Roger

2012-01-01

Purpose The aim of this study was to assess the impact of 3-D navigation for pedicle screw placement accuracy in minimally invasive transverse lumbar interbody fusion (MIS-TLIF). Methods A retrospective review of 52 patients who had MIS-TLIF assisted with 3D navigation is presented. Clinical outcomes were assessed with the Oswestry Disability Index (ODI), Visual Analog Scales (VAS), and MacNab scores. Radiographic outcomes were assessed using X-rays and thin-slice computed tomography. Result The mean age was 56.5 years, and 172 screws were implanted with 16 pedicle breaches (91.0% accuracy rate). Radiographic fusion rate at a mean follow-up of 15.6 months was 87.23%. No revision surgeries were required. The mean improvement in the VAS back pain, VAS leg pain, and ODI at 11.3 months follow-up was 4.3, 4.5, and 26.8 points, respectively. At last follow-up the mean postoperative disc height gain was 4.92 mm and the mean postoperative disc angle gain was 2.79 degrees. At L5–S1 level, there was a significant correlation between a greater disc space height gain and a lower VAS leg score. Conclusion Our data support that application of 3-D navigation in MIS-TLIF is associated with a high level of accuracy in the pedicle screw placement. PMID:24353961

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

PubMed

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

2017-01-01

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

Evaluation of Anterior Vertebral Interbody Fusion Using Osteogenic Mesenchymal Stem Cells Transplanted in Collagen Sponge.

PubMed

Yang, Wencheng; Dong, Youhai; Hong, Yang; Guang, Qian; Chen, Xujun

2016-05-01

The study used a rabbit model to achieve anterior vertebral interbody fusion using osteogenic mesenchymal stem cells (OMSCs) transplanted in collagen sponge. We investigated the effectiveness of graft material for anterior vertebral interbody fusion using a rabbit model by examining the OMSCs transplanted in collagen sponge. Anterior vertebral interbody fusion is commonly performed. Although autogenous bone graft remains the gold-standard fusion material, it requires a separate surgical procedure and is associated with significant short-term and long-term morbidity. Recently, mesenchymal stem cells from bone marrow have been studied in various fields, including posterolateral spinal fusion. Thus, we hypothesized that cultured OMSCs transplanted in porous collagen sponge could be used successfully even in anterior vertebral interbody fusion. Forty mature male White Zealand rabbits (weight, 3.5-4.5 kg) were randomly allocated to receive one of the following graft materials: porous collagen sponge plus cultured OMSCs (group I); porous collagen sponge alone (group II); autogenous bone graft (group III); and nothing (group IV). All animals underwent anterior vertebral interbody fusion at the L4/L5 level. The lumbar spine was harvested en bloc, and the new bone formation and spinal fusion was evaluated using radiographic analysis, microcomputed tomography, manual palpation test, and histologic examination at 8 and 12 weeks after surgery. New bone formation and bony fusion was evident as early as 8 weeks in groups I and III. And there was no statistically significant difference between 8 and 12 weeks. At both time points, by microcomputed tomography and histologic analysis, new bone formation was observed in both groups I and III, fibrous tissue was observed and there was no new bone in both groups II and IV; by manual palpation test, bony fusion was observed in 40% (4/10) of rabbits in group I, 70% (7/10) of rabbits in group III, and 0% (0/10) of rabbits in both groups

Outcomes of Posterolateral Fusion with and without Instrumentation and of Interbody Fusion for Isthmic Spondylolisthesis: A Prospective Study.

PubMed

Endler, Peter; Ekman, Per; Möller, Hans; Gerdhem, Paul

2017-05-03

Various methods for the treatment of isthmic spondylolisthesis are available. The aim of this study was to compare outcomes after posterolateral fusion without instrumentation, posterolateral fusion with instrumentation, and interbody fusion. The Swedish Spine Register was used to identify 765 patients who had been operated on for isthmic spondylolisthesis and had at least preoperative and 2-year outcome data; 586 of them had longer follow-up (a mean of 6.9 years). The outcome measures were a global assessment of leg and back pain, the Oswestry Disability Index (ODI), the EuroQol-5 Dimensions (EQ-5D) Questionnaire, the Short Form-36 (SF-36), a visual analog scale (VAS) for back and leg pain, and satisfaction with treatment. Data on additional lumbar spine surgery was searched for in the register, with the mean duration of follow-up for this variable being 10.6 years after the index procedure. Statistical analyses were performed with analysis of covariance or competing-risks proportional hazards regression, adjusted for baseline differences in the studied variables, smoking, employment status, and level of fusion. Posterolateral fusion without instrumentation was performed in 102 patients; posterolateral fusion with instrumentation, in 452; and interbody fusion, in 211. At 1 year, improvement was reported in the global assessment for back pain by 54% of the patients who had posterolateral fusion without instrumentation, 68% of those treated with posterolateral fusion with instrumentation, and 70% of those treated with interbody fusion (p = 0.009). The VAS for back pain and reported satisfaction with treatment showed similar patterns (p = 0.003 and p = 0.017, respectively), whereas other outcomes did not differ among the treatment groups at 1 year. At 2 years, the global assessment for back pain indicated improvement in 57% of the patients who had undergone posterolateral fusion without instrumentation, 70% of those who had posterolateral fusion with instrumentation

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

PubMed Central

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

2016-01-01

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

Minimally invasive surgery: lateral approach interbody fusion: results and review.

PubMed

Youssef, Jim A; McAfee, Paul C; Patty, Catherine A; Raley, Erin; DeBauche, Spencer; Shucosky, Erin; Chotikul, Liana

2010-12-15

A retrospective review of patients treated at 2 institutions with anterior lumbar interbody fusion using a minimally invasive lateral retroperitoneal approach, and review of literature. To analyze the outcomes from historical literature and from a retrospectively compiled database of patients having undergone anterior interbody fusions performed through a lateral approach. A paucity of published literature exists describing outcomes following lateral approach fusion surgery. Patients treated with extreme lateral interbody fusion (XLIF) were identified through retrospective chart review. Treatment variables included operating room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), complications, and fusion rate. A literature review, using the National Center for Biotechnology Information databases PubMed/MEDLINE and Google Scholar, yielded 14 peer-reviewed articles reporting outcomes scoring, complications, fusion status, long-term follow-up, and radiographic assessments related to XLIF. Published XLIF results were summarized and evaluated with current study data. A total of 84 XLIF patients were included in the current cohort analysis. OR time, EBL, and length of hospital stay averaged 199 minutes, 155 mL, and 2.6 days, respectively, and perioperative and postoperative complication rates were 2.4% and 6.1%. Mean follow-up was 15.7 months. Sixty-eight patients showed evidence of solid arthrodesis and no subsidence on computed tomography and flexion/extension radiographs. Results were within the ranges of those in the literature. Literature review identified reports of significant improvements in clinical outcomes scores, radiographic measures, and cost effectiveness. Current data corroborates and contributes to the existing body of literature describing XLIF outcomes. Procedures are generally performed with short OR times, minimal EBL, and few complications. Patients recover quickly, requiring minimal hospital stay, although transient hip

An Outcome and Cost Analysis Comparing Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Intraoperative Fluoroscopy versus Computed Tomography-Guided Navigation.

PubMed

Khanna, Ryan; McDevitt, Joseph L; Abecassis, Zachary A; Smith, Zachary A; Koski, Tyler R; Fessler, Richard G; Dahdaleh, Nader S

2016-10-01

Minimally invasive transforaminal lumbar interbody fusion (TLIF) has undergone significant evolution since its conception as a fusion technique to treat lumbar spondylosis. Minimally invasive TLIF is commonly performed using intraoperative two-dimensional fluoroscopic x-rays. However, intraoperative computed tomography (CT)-based navigation during minimally invasive TLIF is gaining popularity for improvements in visualizing anatomy and reducing intraoperative radiation to surgeons and operating room staff. This is the first study to compare clinical outcomes and cost between these 2 imaging techniques during minimally invasive TILF. For comparison, 28 patients who underwent single-level minimally invasive TLIF using fluoroscopy were matched to 28 patients undergoing single-level minimally invasive TLIF using CT navigation based on race, sex, age, smoking status, payer type, and medical comorbidities (Charlson Comorbidity Index). The minimum follow-up time was 6 months. The 2 groups were compared in regard to clinical outcomes and hospital reimbursement from the payer perspective. Average surgery time, anesthesia time, and hospital length of stay were similar for both groups, but average estimated blood loss was lower in the fluoroscopy group compared with the CT navigation group (154 mL vs. 262 mL; P = 0.016). Oswestry Disability Index, back visual analog scale, and leg visual analog scale scores similarly improved in both groups (P > 0.05) at 6-month follow-up. Cost analysis showed that average hospital payments were similar in the fluoroscopy versus the CT navigation groups ($32,347 vs. $32,656; P = 0.925) as well as payments for the operating room (P = 0.868). Single minimally invasive TLIF performed with fluoroscopy versus CT navigation showed similar clinical outcomes and cost at 6 months. Copyright © 2016 Elsevier Inc. All rights reserved.

Titanium vs. polyetheretherketone (PEEK) interbody fusion: Meta-analysis and review of the literature.

PubMed

Seaman, Scott; Kerezoudis, Panagiotis; Bydon, Mohamad; Torner, James C; Hitchon, Patrick W

2017-10-01

Spinal interbody fusion is a standard and accepted method for spinal fusion. Interbody fusion devices include titanium (Ti) and polyetheretherketone (PEEK) cages with distinct biomechanical properties. Titanium and PEEK cages have been evaluated in the cervical and lumbar spine, with conflicting results in bony fusion and subsidence. Using Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, we reviewed the available literature evaluating Ti and PEEK cages to assess subsidence and fusion rates. Six studies were included in the analysis, 3 of which were class IV evidence, 2 were class III, and 1 was class II. A total of 410 patients (Ti-228, PEEK-182) and 587 levels (Ti-327, PEEK-260) were studied. Pooled mean age was 50.8years in the Ti group, and 53.1years in the PEEK group. Anterior cervical discectomy was performed in 4 studies (395 levels) and transforaminal interbody fusion in 2 studies (192 levels). No statistically significant difference was found between groups with fusion (OR 1.16, 95% C.I 0.59-2.89, p=0.686, I 2 =49.7%) but there was a statistically significant the rate of subsidence with titanium (OR 3.59, 95% C.I 1.28-10.07, p=0.015, I 2 =56.9%) at last follow-up. Titanium and PEEK cages are associated with a similar rate of fusion, but there is an increased rate of subsidence with titanium cage. Future prospective randomized controlled trials are needed to further evaluate these cages using surgical and patient-reported outcomes. Copyright © 2017 Elsevier Ltd. All rights reserved.

Complication Rates in Posterior Lumbar Interbody Fusion (PLIF) Surgery With Human Bone Morphogenetic Protein 2: Medicare Population.

PubMed

Alobaidaan, Raed; Cohen, Jeremiah R; Lord, Elizabeth L; Buser, Zorica; Yoon, S Tim; Youssef, Jim A; Park, Jong-Beom; Brodke, Darrel S; Wang, Jeffrey C; Meisel, Hans-Joerg

2017-12-01

Retrospective cohort study among Medicare beneficiaries who underwent posterior lumbar interbody fusion (PLIF) surgery. To identify the complication rates associated with the use of bone morphogenetic protein 2 (BMP2) in PLIF. Human BMP2 is commonly used in the "off-label" manner for various types of spine fusion procedures, including PLIF. However, recent studies have reported potential complications associated with the recombinant human BMP2 (rhBMP2) use in the posterior approach. Medicare records within the PearlDiver database were queried for patients undergoing PLIF procedure with and without rhBMP2 between 2005 and 2010. We evaluated complications within 1 year postoperatively. Chi-square was used to compare the complication rates between the 2 groups. A total of 8609 patients underwent PLIF procedure with or without rhBMP2. Individual complication rates in the rhBMP2 group ranged from 0.45% to 7.68% compared with 0.65% to 10.99 in the non-rhBMP2 group. Complication rates for cardiac, pulmonary, lumbosacral neuritis, infection, wound, and urinary tract (include acute kidney failure and post-operative complications) were significantly lower in the rhBMP2 group ( P < .05). There was no difference in the rates of central nervous system complications or radiculitis between the 2 groups. Our data showed that the patients who received rhBMP2 had lower complication rates compared to the non-rhBMP2 group. However, use of rhBMP2 was associated with a higher rate of pseudarthrosis. We did not observe any difference in radiculitis and central nervous system complications between the groups.

Complication Rates in Posterior Lumbar Interbody Fusion (PLIF) Surgery With Human Bone Morphogenetic Protein 2: Medicare Population

PubMed Central

Alobaidaan, Raed; Cohen, Jeremiah R.; Lord, Elizabeth L.; Yoon, S. Tim; Youssef, Jim A.; Park, Jong-Beom; Brodke, Darrel S.; Wang, Jeffrey C.; Meisel, Hans-Joerg

2017-01-01

Study Design: Retrospective cohort study among Medicare beneficiaries who underwent posterior lumbar interbody fusion (PLIF) surgery. Objective: To identify the complication rates associated with the use of bone morphogenetic protein 2 (BMP2) in PLIF. Human BMP2 is commonly used in the “off-label” manner for various types of spine fusion procedures, including PLIF. However, recent studies have reported potential complications associated with the recombinant human BMP2 (rhBMP2) use in the posterior approach. Methods: Medicare records within the PearlDiver database were queried for patients undergoing PLIF procedure with and without rhBMP2 between 2005 and 2010. We evaluated complications within 1 year postoperatively. Chi-square was used to compare the complication rates between the 2 groups. Results: A total of 8609 patients underwent PLIF procedure with or without rhBMP2. Individual complication rates in the rhBMP2 group ranged from 0.45% to 7.68% compared with 0.65% to 10.99 in the non-rhBMP2 group. Complication rates for cardiac, pulmonary, lumbosacral neuritis, infection, wound, and urinary tract (include acute kidney failure and post-operative complications) were significantly lower in the rhBMP2 group (P < .05). There was no difference in the rates of central nervous system complications or radiculitis between the 2 groups. Conclusion: Our data showed that the patients who received rhBMP2 had lower complication rates compared to the non-rhBMP2 group. However, use of rhBMP2 was associated with a higher rate of pseudarthrosis. We did not observe any difference in radiculitis and central nervous system complications between the groups. PMID:29238641

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

PubMed

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

2016-12-01

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

Transforaminal Lumbar Interbody Fusion with Rigid Interspinous Process Fixation: A Learning Curve Analysis of a Surgeon Team's First 74 Cases.

PubMed

Doherty, Patrick; Welch, Arthur; Tharpe, Jason; Moore, Camille; Ferry, Chris

2017-05-30

Studies have shown that a significant learning curve may be associated with adopting minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) with bilateral pedicle screw fixation (BPSF). Accordingly, several hybrid TLIF techniques have been proposed as surrogates to the accepted BPSF technique, asserting that less/fewer fixation(s) or less disruptive fixation may decrease the learning curve while still maintaining the minimally disruptive benefits. TLIF with interspinous process fixation (ISPF) is one such surrogate procedure. However, despite perceived ease of adaptability given the favorable proximity of the spinous processes, no evidence exists demonstrating whether or not the technique may possess its own inherent learning curve. The purpose of this study was to determine whether an intraoperative learning curve for one- and two-level TLIF + ISPF may exist for a single lead surgeon. Seventy-four consecutive patients who received one- or two-Level TLIF with rigid ISPF by a single lead surgeon were retrospectively reviewed. It was the first TLIF + ISPF case series for the lead surgeon. Intraoperative blood loss (EBL), hospitalization length-of-stay (LOS), fluoroscopy time, and postoperative complications were collected. EBL, LOS, and fluoroscopy time were modeled as a function of case number using multiple linear regression methods. A change point was included in each model to allow the trajectory of the outcomes to change during the duration of the case series. These change points were determined using profile likelihood methods. Models were fit using the maximum likelihood estimates for the change points. Age, sex, body mass index (BMI), and the number of treated levels were included as covariates. EBL, LOS, and fluoroscopy time did not significantly differ by age, sex, or BMI (p ≥ 0.12). Only EBL differed significantly by the number of levels (p = 0.026). The case number was not a significant predictor of EBL, LOS, or fluoroscopy time (p ≥ 0

[Design and research progress of zero profile cervical Interbody cage].

PubMed

Zhu, Jia; Wang, Song; Liao, Zhenhua; Liu, Weiqiang

2017-02-01

Zero profile cervical interbody cage is an improvement of traditional fusion products and necessary supplement of emerging artificial intervertebral disc products. When applied in Anterior Cervical Decompression Fusion(ACDF), zero profile cervical interbody cage can preserve the advantages of traditional fusion and reduce the incidence of postoperative complications. Moreover, zero profile cervical interbody cage can be applied under the tabu symptoms of Artificial Cervical Disc Replacement(ACDR). This article summarizes zero profile interbody cage products that are commonly recognized and widely used in clinical practice in recent years, and reviews the progress of structure design and material research of zero profile cervical interbody cage products. Based on the latest clinical demands and research progress, this paper also discusses the future development directions of zero profile interbody cage.

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

PubMed

Villavicencio, Alan T; Burneikiene, Sigita

2016-10-01

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

High-dose tranexamic acid reduces intraoperative and postoperative blood loss in posterior lumbar interbody fusion.

PubMed

Kushioka, Junichi; Yamashita, Tomoya; Okuda, Shinya; Maeno, Takafumi; Matsumoto, Tomiya; Yamasaki, Ryoji; Iwasaki, Motoki

2017-03-01

OBJECTIVE Tranexamic acid (TXA), a synthetic antifibrinolytic drug, has been reported to reduce blood loss in orthopedic surgery, but there have been few reports of its use in spine surgery. Previous studies included limitations in terms of different TXA dose regimens, different levels and numbers of fused segments, and different surgical techniques. Therefore, the authors decided to strictly limit TXA dose regimens, surgical techniques, and fused segments in this study. There have been no reports of using TXA for prevention of intraoperative and postoperative blood loss in posterior lumbar interbody fusion (PLIF). The purpose of the study was to evaluate the efficacy of high-dose TXA in reducing blood loss and its safety during single-level PLIF. METHODS The study was a nonrandomized, case-controlled trial. Sixty consecutive patients underwent single-level PLIF at a single institution. The first 30 patients did not receive TXA. The next 30 patients received 2000 mg of intravenous TXA 15 minutes before the skin incision was performed and received the same dose again 16 hours after the surgery. Intra- and postoperative blood loss was compared between the groups. RESULTS There were no statistically significant differences in preoperative parameters of age, sex, body mass index, preoperative diagnosis, or operating time. The TXA group experienced significantly less intraoperative blood loss (mean 253 ml) compared with the control group (mean 415 ml; p < 0.01). The TXA group also had significantly less postoperative blood loss over 40 hours (mean 321 ml) compared with the control group (mean 668 ml; p < 0.01). Total blood loss in the TXA group (mean 574 ml) was significantly lower than in the control group (mean 1080 ml; p < 0.01). From 2 hours to 40 hours, postoperative blood loss in the TXA group was consistently significantly lower. There were no perioperative complications, including thromboembolic events. CONCLUSIONS High-dose TXA significantly reduced both intra

Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System?

PubMed

Schoenfeld, Andrew J; Makanji, Heeren; Jiang, Wei; Koehlmoos, Tracey; Bono, Christopher M; Haider, Adil H

2017-12-01

Whether compensation for professional services drives the use of those services is an important question that has not been answered in a robust manner. Specifically, there is a growing concern that spine care practitioners may preferentially choose more costly or invasive procedures in a fee-for-service system, irrespective of the underlying lumbar disorder being treated. (1) Were proportions of interbody fusions higher in the fee-for-service setting as opposed to the salaried Department of Defense setting? (2) Were the odds of interbody fusion increased in a fee-for-service setting after controlling for indications for surgery? Patients surgically treated for lumbar disc herniation, spinal stenosis, and spondylolisthesis (2006-2014) were identified. Patients were divided into two groups based on whether the surgery was performed in the fee-for-service setting (beneficiaries receive care at a civilian facility with expenses covered by TRICARE insurance) or at a Department of Defense facility (direct care). There were 28,344 patients in the entire study, 21,290 treated in fee-for-service and 7054 treated in Department of Defense facilities. Differences in the rates of fusion-based procedures, discectomy, and decompression between both healthcare settings were assessed using multinomial logistic regression to adjust for differences in case-mix and surgical indication. TRICARE beneficiaries treated for lumbar spinal disorders in the fee-for-service setting had higher odds of receiving interbody fusions (fee-for-service: 7267 of 21,290 [34%], direct care: 1539 of 7054 [22%], odds ratio [OR]: 1.25 [95% confidence interval 1.20-1.30], p < 0.001). Purchased care patients were more likely to receive interbody fusions for a diagnosis of disc herniation (adjusted OR 2.61 [2.36-2.89], p < 0.001) and for spinal stenosis (adjusted OR 1.39 [1.15-1.69], p < 0.001); however, there was no difference for patients with spondylolisthesis (adjusted OR 0.99 [0.84-1.16], p = 0.86). The

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

PubMed

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

2017-07-01

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

Comparison of posterior lumbar interbody fusion (PLIF) with autogenous bone chips and PLIF with cage for treatment of double-level isthmic spondylolisthesis.

PubMed

Song, Deyong; Chen, Zhong; Song, Dewei; Li, Zaixue

2015-11-01

Spondylolytic defects involving multiple vertebral levels are rare. It is reported that only 1.48% of patients with back pain were diagnosed with multi-level spondylolysis. The incidence of multiple-level spondylolisthesis is even rarer, so far there have been few reports of multi-level isthmic spondylolisthesis in the literature. The aim of this study is to evaluate clinical and radiological outcomes of two different fusion techniques for treatment of double-level isthmic spondylolisthesis. Fifty-four patients who were managed surgically for treatment of double-level symptomatic isthmic spondylolisthesis were included in this study. Between May 2004 and September 2012, 29 consecutive patients underwent posterior lumbar interbody fusion (PLIF) with autogenous bone chips (group I) at Foshan Hospital of Traditional Chinese Medicine, Guangdong, China. Between March 2005 and December 2013, 25 consecutive patients underwent PLIF with cage (group II) at Zhujiang Hospital of Southern Medical University, Guangdong, China. The mean follow-up periods were 27.2 and 26.8 months, respectively. The mean VAS scores of back and leg pain significantly decreased from 7.2 to 2.2 and 5.8 to 2.1 in the group I and from 7.0 to 1.9 and 6.1 to 1.8 in the group II, respectively. In the group I, mean ODI scores improved significantly from 54% to 14.2% and, in the group II, from 60% to 12.6%. In both groups, VAS and ODI scores significantly changed from pre- to postoperatively (p<0.001), but postoperative outcome between groups was statistically not significant. Solid union was observed in 27 of 29 patients (89.6%) in the group I and in 22 of 25 patients (88%) in the group II, without statistically significant differences (p>0.05). In both groups, changes in disc height, degree of listhesis, and whole lumbar lordosis between the pre- and postoperative periods were significant. Clinical and functional outcomes demonstrate no significant differences between groups in treating back and leg pain

Cortical bone trajectory screw fixation versus traditional pedicle screw fixation for 2-level posterior lumbar interbody fusion: comparison of surgical outcomes for 2-level degenerative lumbar spondylolisthesis.

PubMed

Sakaura, Hironobu; Miwa, Toshitada; Yamashita, Tomoya; Kuroda, Yusuke; Ohwada, Tetsuo

2018-01-01

OBJECTIVE The cortical bone trajectory (CBT) screw technique is a new nontraditional pedicle screw (PS) insertion method. However, the biomechanical behavior of multilevel CBT screw/rod fixation remains unclear, and surgical outcomes in patients after 2-level posterior lumbar interbody fusion (PLIF) using CBT screw fixation have not been reported. Thus, the purposes of this study were to examine the clinical and radiological outcomes after 2-level PLIF using CBT screw fixation for 2-level degenerative lumbar spondylolisthesis (DS) and to compare these outcomes with those after 2-level PLIF using traditional PS fixation. METHODS The study included 22 consecutively treated patients who underwent 2-level PLIF with CBT screw fixation for 2-level DS (CBT group, mean follow-up 39 months) and a historical control group of 20 consecutively treated patients who underwent 2-level PLIF using traditional PS fixation for 2-level DS (PS group, mean follow-up 35 months). Clinical symptoms were evaluated using the Japanese Orthopaedic Association (JOA) scoring system. Bony union was assessed by dynamic plain radiographs and CT images. Surgery-related complications, including symptomatic adjacent-segment disease (ASD), were examined. RESULTS The mean operative duration and intraoperative blood loss were 192 minutes and 495 ml in the CBT group and 218 minutes and 612 ml in the PS group, respectively (p < 0.05 and p > 0.05, respectively). The mean JOA score improved significantly from 12.3 points before surgery to 21.1 points (mean recovery rate 54.4%) at the latest follow-up in the CBT group and from 12.8 points before surgery to 20.4 points (mean recovery rate 51.8%) at the latest follow-up in the PS group (p > 0.05). Solid bony union was achieved at 90.9% of segments in the CBT group and 95.0% of segments in the PS group (p > 0.05). Symptomatic ASD developed in 2 patients in the CBT group (9.1%) and 4 patients in the PS group (20.0%, p > 0.05). CONCLUSIONS Two-level PLIF with CBT

A Retrospective Analysis of Complications Associated With Bone Morphogenetic Protein 2 in Anterior Lumbar Interbody Fusion.

PubMed

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

2017-04-01

Retrospective review. The aim of our study was to quantify the frequency of complications associated with recombinant human bone morphogenetic protein 2 (rhBMP-2) use in anterior lumbar interbody fusion (ALIF). The orthopedic subset of the Medicare database (PearlDiver) was queried for this retrospective cohort study using International Statistical Classification of Diseases 9 (ICD-9) and Current Procedure Terminology (CPT) codes for ALIF procedures with and without rhBMP-2 between 2005 and 2010. Frequencies of complications and reoperations were then identified within 1 year from the index procedure. Complications included reoperations, pulmonary embolus, deep vein thrombosis, myocardial infarction, nerve-related complications, incision and drainage procedures, wound, sepsis, pneumonia, urinary tract infections, respiratory, heterotopic ossification, retrograde ejaculation, radiculopathy, and other medical complications. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess the statistical significance. We identified a total of 41 865 patients who had an ALIF procedure. A total of 14 384 patients received rhBMP-2 while 27 481 did not. Overall, 6016 (41.8%) complications within 1 year from surgery were noted within the group who received rhBMP-2 and 12 950 (47.1%) complications within 1 year from surgery were recorded in those who did not receive rhBMP-2 (OR = 0.81, CI = 0.77-0.84). Overall, exposure to rhBMP-2 was associated with significantly decreased odds of complications with exception to reoperation rates (0.9% rhBMP-2 vs 1.0% no rhBMP-2; OR = 0.88, CI = 0.71-1.09) and radiculopathy (4.4% rhBMP-2 vs 4.3% no rhBMP-2; OR = 1.02, CI = 0.93-1.13). The use of rhBMP-2 in patients undergoing ALIF procedure was associated with a significantly decreased rate of complications. Further studies are needed to elucidate a true incidence of complication.

A Retrospective Analysis of Complications Associated With Bone Morphogenetic Protein 2 in Anterior Lumbar Interbody Fusion

PubMed Central

Hindoyan, Kevork; Tilan, Justin; Cohen, Jeremiah R.; Brodke, Darrel S.; Youssef, Jim A.; Park, Jong-Beom; Yoon, S. Tim; Meisel, Hans-Joerg; Wang, Jeffrey C.

2017-01-01

Study Design: Retrospective review. Objective: The aim of our study was to quantify the frequency of complications associated with recombinant human bone morphogenetic protein 2 (rhBMP-2) use in anterior lumbar interbody fusion (ALIF). Methods: The orthopedic subset of the Medicare database (PearlDiver) was queried for this retrospective cohort study using International Statistical Classification of Diseases 9 (ICD-9) and Current Procedure Terminology (CPT) codes for ALIF procedures with and without rhBMP-2 between 2005 and 2010. Frequencies of complications and reoperations were then identified within 1 year from the index procedure. Complications included reoperations, pulmonary embolus, deep vein thrombosis, myocardial infarction, nerve-related complications, incision and drainage procedures, wound, sepsis, pneumonia, urinary tract infections, respiratory, heterotopic ossification, retrograde ejaculation, radiculopathy, and other medical complications. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess the statistical significance. Results: We identified a total of 41 865 patients who had an ALIF procedure. A total of 14 384 patients received rhBMP-2 while 27 481 did not. Overall, 6016 (41.8%) complications within 1 year from surgery were noted within the group who received rhBMP-2 and 12 950 (47.1%) complications within 1 year from surgery were recorded in those who did not receive rhBMP-2 (OR = 0.81, CI = 0.77-0.84). Overall, exposure to rhBMP-2 was associated with significantly decreased odds of complications with exception to reoperation rates (0.9% rhBMP-2 vs 1.0% no rhBMP-2; OR = 0.88, CI = 0.71-1.09) and radiculopathy (4.4% rhBMP-2 vs 4.3% no rhBMP-2; OR = 1.02, CI = 0.93-1.13). Conclusions: The use of rhBMP-2 in patients undergoing ALIF procedure was associated with a significantly decreased rate of complications. Further studies are needed to elucidate a true incidence of complication. PMID:28507884

Radiographic Appearance of Transforaminal Lumbar Interbody Fusion Performed With and Without Recombinant Human Morphogenetic Protein-2.

PubMed

Stensby, J Derek; Kaliney, Ryan W; Alford, Bennett; Shen, Francis H; Patrie, James T; Fox, Michael G

2016-03-01

The purpose of this study is to determine whether recombinant human morphogenetic protein-2 (rhBMP-2) alters the findings on routine radiographs performed after transforaminal lumbar interbody fusion (TLIF). A retrospective review of 256 TLIF procedures in 200 patients was performed over a 4-year period. The rhBMP-2 group included 204 TLIFs in 160 patients, and the control group included 52 TLIFs in 40 patients. Two musculoskeletal radiologists reviewed the postoperative radiographs for endplate resorption, resorption resolution, new bone formation, bridging bone, and allograft migration. Statistical analysis was performed using logistic regression. The median age was 53 years in the rhBMP-2 group and 54 years in the control group (p = 0.182). The groups were similar with regard to sex (p = 0.517), single or multilevel TLIF (p = 0.921), specific TLIF levels (p = 0.53), and median radiographic follow-up (373 vs 366 days; p = 0.34). Findings that were more common in the rhBMP-2 group than in the control group included endplate resorption (38% [78/204] vs 12% [6/52]; odds ratio [OR], 4.67; 95% CI, 1.99-12.54; p < 0.001), resorption resolution (59% [46/78] vs 0% [0/6]; OR, 8.09; 95% CI, 1.41 to ∞; p = 0.022), new bone formation (84% [171/204] vs 67% [35/52]; OR, 2.51; 95% CI, 1.24-4.99; p = 0.011), bridging bone (55% [112/204] vs 31% [16/52]; OR, 2.73; 95% CI, 1.43-5.34; p = 0.002), and allograft migration (17% [35/204] vs 2% [1/52]; OR, 6.30; 95% CI, 0.91-151.41; p = 0.065). A statistically significant higher frequency of endplate resorption, new bone formation, and bone bridging is present in TLIF augmented by rhBMP-2 compared with TLIF performed without rhBMP-2. Endplate resorption resolves without treatment in most cases after rhBMP-2 use.

Does Day of Surgery Affect Hospital Length of Stay and Charges Following Minimally Invasive Transforaminal Lumbar Interbody Fusion?

PubMed

Hijji, Fady Y; Narain, Ankur S; Haws, Brittany E; Khechen, Benjamin; Kudaravalli, Krishna T; Yom, Kelly H; Singh, Kern

2018-06-01

Retrospective Cohort. To determine if an association exists between surgery day and length of stay or hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Length of inpatient stay after orthopedic procedures has been identified as a primary cost driver, and previous research has focused on determining risk factors for prolonged length of stay. In the arthroplasty literature, surgery performed later in the week has been identified as a predictor of increased length of stay. However, no such investigation has been performed for MIS TLIF. A surgical registry of patients undergoing MIS TLIF between 2008 and 2016 was retrospectively reviewed. Patients were grouped based on day of surgery, with groups including early surgery and late surgery. Day of surgery group was tested for an association with demographics and perioperative variables using the student t test or χ analysis. Day of surgery group was then tested for an association with direct hospital costs using multivariate linear regression. In total, 438 patients were analyzed. In total, 51.8% were in the early surgery group, and 48.2% were in the late surgery group. There were no differences in demographics between groups. There were no differences between groups with regard to operative time, intraoperative blood loss, length of stay, or discharge day. Finally, there were no differences in total hospital charges between early and late surgery groups (P=0.247). The specific day on which a MIS TLIF procedure occurs is not associated with differences in length of inpatient stay or total hospital costs. This suggests that the postoperative course after MIS TLIF procedures is not affected by the differences in hospital staffing that occurs on the weekend compared with weekdays.

Perioperative surgical complications and learning curve associated with minimally invasive transforaminal lumbar interbody fusion: a single-institute experience.

PubMed

Park, Yung; Lee, Soo Bin; Seok, Sang Ok; Jo, Byung Woo; Ha, Joong Won

2015-03-01

As surgical complications tend to occur more frequently in the beginning stages of a surgeon's career, knowledge of perioperative complications is important to perform a safe procedure, especially if the surgeon is a novice. We sought to identify and describe perioperative complications and their management in connection with minimally invasive transforaminal lumbar interbody fusion (TLIF). We performed a retrospective chart review of our first 124 patients who underwent minimally invasive TLIF. The primary outcome measure was adverse events during the perioperative period, including neurovascular injury, implant-related complications, and wound infection. Pseudarthroses and adjacent segment pathologies were not included in this review. Adverse events that were not specifically related to spinal surgery and did not affect recovery were also excluded. Perioperative complications occurred in 9% of patients (11/124); including three cases of temporary postoperative neuralgia, two deep wound infections, two pedicle screw misplacements, two cage migrations, one dural tear, and one grafted bone extrusion. No neurologic deficits were reported. Eight complications occurred in the first one-third of the series and only 3 complications occurred in the last two-thirds of the series. Additional surgeries were performed in 6% of patients (7/124); including four reoperations (two for cage migrations, one for a misplaced screw, and one for an extruded graft bone fragment) and three hardware removals (one for a misplaced screw and two for infected cages). We found perioperative complications occurred more often in the early period of a surgeon's experience with minimally invasive TLIF. Implant-related complications were common and successfully managed by additional surgeries in this series. We suggest greater caution should be exercised to avoid the potential complications, especially when surgeon is a novice to this procedure.

Trends Analysis of rhBMP2 Utilization in Single-Level Anterior Lumbar Interbody Fusion in the United States.

PubMed

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

2018-04-01

Retrospective case study. To evaluate the trends and demographics of recombinant human bone morphogenetic protein 2 (rhBMP2) utilization in single-level anterior lumbar interbody fusion (ALIF) in the United States. Patients who underwent single-level ALIF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopedic insurance records. The year of procedure, age, gender, and region of the United States were analyzed for each patient. A total of 921 patients were identified who underwent a single-level ALIF in this study. The average rate of single-level ALIF with rhBMP2 utilization increased (35%-48%) from 2005 to 2009, but sharply decreased to 16.7% in 2010 and 15.0% in 2011. The overall incidence of single-level ALIF without rhBMP2 (0.20 cases per 100 000 patients) was more than twice of the incidence of single-level ALIF with rhBMP2 (0.09 cases per 100 000 patients). The average rate of single-level ALIF with rhBMP2 utilization is highest in West (41.4%), followed by Midwest (33.3%), South (26.5%) and Northeast (22.2%). The highest incidence of single-level ALIF with rhBMP2 was observed in the group aged less than 65 years (compared with any other age groups, P < .001), with an incidence of 0.21 per 100 000 patients. The incidence of rhBMP2 utilization in single-level ALIF increased from 2006 to 2009, but decreased in 2010 and 2011. The Northeast region had the lowest incidence of rhBMP2 utilization. The group aged less than 65 years trended to have the higher incidence of single-level ALIF with rhBMP2 utilization.

Lateral interbody fusion combined with open posterior surgery for adult spinal deformity.

PubMed

Strom, Russell G; Bae, Junseok; Mizutani, Jun; Valone, Frank; Ames, Christopher P; Deviren, Vedat

2016-12-01

OBJECTIVE Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD. METHODS All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients. RESULTS LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and

Cost-effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis associated low-back and leg pain over two years.

PubMed

Parker, Scott L; Adogwa, Owoicho; Bydon, Ali; Cheng, Joseph; McGirt, Matthew J

2012-07-01

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar spondylolisthesis allows for surgical treatment of back and leg pain while theoretically minimizing tissue injury and accelerating overall recovery. Although the authors of previous studies have demonstrated shorter length of hospital stay and reduced blood loss with MIS versus open-TLIF, short- and long-term outcomes have been similar. No studies to date have evaluated the comprehensive health care costs associated with TLIF procedures or assessed the cost-utility of MIS- versus open-TLIF. As such, we set out to assess previously unstudied end points of health care cost and cost-utility associated with MIS- versus open-TLIF. Thirty patients undergoing MIS-TLIF (n=15) or open-TLIF (n=15) for grade I degenerative spondylolisthesis associated back and leg pain were prospectively studied. Total back-related medical resource use, missed work, and health-state values (quality-adjusted life years [QALYs], calculated from EQ-5D with U.S. valuation) were assessed after two-year follow-up. Two-year resource use was multiplied by unit costs on the basis of Medicare national allowable payment amounts (direct cost) and work-day losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Difference in mean total cost per QALY gained for MIS- versus open-TLIF was assessed as incremental cost-effectiveness ratio (ICER: COSTmis-COSTopen/QALYmis-QALYopen). MIS versus open-TLIF cohorts were similar at baseline. By two years postoperatively, patients undergoing MIS- versus open-TLIF reported similar mean QALYs gained (0.50 vs. 0.41, P=0.17). Mean total two-year cost of MIS- and open-TLIF was $35,996 and $44,727, respectively. The $8,731 two-year cost savings of MIS- versus open-TLIF did not reach statistical significance (P=0.18) for this sample size. Although our limited sample size prevented statistical significance, MIS- versus open-TLIF was associated with reduced costs over

Does disc space height of fused segment affect adjacent degeneration in ALIF? A finite element study.

PubMed

Tang, Shujie; Meng, Xueying

2011-01-01

The restoration of disc space height of fused segment is essential in anterior lumbar interbody fusion, while the disc space height in many cases decreased postoperatively, which may adversely aggravate the adjacent segmental degeneration. However, no literature available focused on the issue. A normal healthy finite element model of L3-5 and four anterior lumbar interbody fusion models with different disc space height of fused segment were developed. 800 N compressive loading plus 10 Nm moments simulating flexion, extension, lateral bending and axial rotation were imposed on L3 superior endplate. The intradiscal pressure, the intersegmental rotation, the tresca stress and contact force of facet joints in L3-4 were investigated. Anterior lumbar interbody fusion with severely decreased disc space height presented with the highest values of the four parameters, and the normal healthy model presented with the lowest values except, under extension, the contact force of facet joints in normal healthy model is higher than that in normal anterior lumbar interbody fusion model. With disc space height decrease, the values of parameters in each anterior lumbar interbody fusion model increase gradually. Anterior lumbar interbody fusion with decreased disc space height aggravate the adjacent segmental degeneration more adversely.

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

PubMed

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

2018-03-01

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

Trends Analysis of rhBMP Utilization in Single-Level Posterior Lumbar Interbody Fusion in the United States

PubMed Central

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

2017-01-01

Study Design: Retrospective study. Objectives: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been widely used in spinal fusion surgery, but there is little information on rhBMP-2 utilization in single-level posterior lumbar interbody fusion (PLIF). The purpose of our study was to evaluate the trends and demographics of rhBMP-2 utilization in single-level PLIF. Methods: Patients who underwent single-level PLIF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database, a national database of orthopedic insurance records. The year of procedure, age, gender, and region of the United States were recorded for each patient. Results were reported for each variable as the incidence of procedures identified per 100 000 patients searched in the database. Results: A total of 2735 patients had single-level PLIF. The average rate of single-level PLIF with rhBMP-2 maintained at a relatively stable level (28% to 31%) from 2005 to 2009, but decreased in 2010 (9.9%) and 2011 (11.8%). The overall incidence of single-level PLIF without rhBMP-2 (0.68 cases per 100 000 patients) was statistically higher (P < .01) compared to single-level PLIF with rhBMP-2 (0.21 cases per 100 000 patients). The average rate of single-level PLIF with rhBMP-2 utilization was the highest in West (30.1%), followed by Midwest (26.9%), South (20.5%), and Northeast (17.8%). The highest incidence of single-level PLIF with rhBMP-2 was observed in the age group <65 years (0.3 per 100 000 patients). Conclusions: To our knowledge, this is the first study to report on the demographics associated with rhBMP-2 use in single-level PLIF. There was a 3-fold increase in the rate of PLIF without rhBMP-2 compared to PLIF with rhBMP-2, with both procedures being mainly done in patients less than 65 years of age. PMID:28989840

Trends Analysis of rhBMP Utilization in Single-Level Posterior Lumbar Interbody Fusion in the United States.

PubMed

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

2017-10-01

Retrospective study. Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been widely used in spinal fusion surgery, but there is little information on rhBMP-2 utilization in single-level posterior lumbar interbody fusion (PLIF). The purpose of our study was to evaluate the trends and demographics of rhBMP-2 utilization in single-level PLIF. Patients who underwent single-level PLIF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database, a national database of orthopedic insurance records. The year of procedure, age, gender, and region of the United States were recorded for each patient. Results were reported for each variable as the incidence of procedures identified per 100 000 patients searched in the database. A total of 2735 patients had single-level PLIF. The average rate of single-level PLIF with rhBMP-2 maintained at a relatively stable level (28% to 31%) from 2005 to 2009, but decreased in 2010 (9.9%) and 2011 (11.8%). The overall incidence of single-level PLIF without rhBMP-2 (0.68 cases per 100 000 patients) was statistically higher ( P < .01) compared to single-level PLIF with rhBMP-2 (0.21 cases per 100 000 patients). The average rate of single-level PLIF with rhBMP-2 utilization was the highest in West (30.1%), followed by Midwest (26.9%), South (20.5%), and Northeast (17.8%). The highest incidence of single-level PLIF with rhBMP-2 was observed in the age group <65 years (0.3 per 100 000 patients). To our knowledge, this is the first study to report on the demographics associated with rhBMP-2 use in single-level PLIF. There was a 3-fold increase in the rate of PLIF without rhBMP-2 compared to PLIF with rhBMP-2, with both procedures being mainly done in patients less than 65 years of age.

Current strategies for the restoration of adequate lordosis during lumbar fusion

PubMed Central

Barrey, Cédric; Darnis, Alice

2015-01-01

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

Minimally invasive trans-sacral approach to L5-S1 interbody fusion: Preliminary results from 1 center and review of the literature.

PubMed

Bradley, W Daniel; Hisey, Michael S; Verma-Kurvari, Sunita; Ohnmeiss, Donna D

2012-01-01

Lumbar interbody fusion has long been used for the treatment of painful degenerative spinal conditions. The anterior approach is not feasible in some patients, and the posterior approach is associated with a risk of neural complications and possibly muscle injury. A trans-sacral technique was developed that allows access to the L5-S1 disc space. The purposes of this study were to investigate the clinical outcome of trans-sacral interbody fusion in a consecutive series of patients from 1 center and to perform a comprehensive review of the literature on this procedure. A literature search using PubMed was performed to identify articles published on trans-sacral axial lumbar interbody fusion (AxiaLIF). Articles reviewed included biomechanical testing, feasibility of the technique, and clinical results. The data from our center were collected retrospectively from charts for the consecutive series, beginning with the first case, of all patients undergoing fusion using the AxiaLIF technique. In most cases, posterior instrumentation was also used. A total of 41 patients with at least 6 months' follow-up were included (mean follow-up, 22.2 months). The primary clinical outcome measures were visual analog scales separately assessing back and leg pain and the Oswestry Disability Index. Radiographic assessment of fusion was also performed. In the group of 28 patients undergoing single-level AxiaLIF combined with posterior fusion, the visual analog scale scores assessing back and leg pain and mean Oswestry Disability Index scores improved significantly (P < .01). In the remaining 13 patients, back pain improved significantly with a trend for improvement in leg pain. Reoperation occurred in 19.5% of patients; in half of these, reoperation was not related to the anterior procedure. A review of the literature found that the AxiaLIF technique was similar to other fusion techniques with respect to biomechanical properties and produced acceptable clinical outcomes, although results

Percutaneous Endoscopic Lumbar Reoperation for Recurrent Sciatica Symptoms: A Retrospective Analysis of Outcomes and Prognostic Factors in 94 Patients.

PubMed

Wu, Junlong; Zhang, Chao; Lu, Kang; Li, Changqing; Zhou, Yue

2018-01-01

Recurrent symptoms of sciatica after previous surgical intervention is a relatively common and troublesome clinical problem. Percutaneous endoscopic lumbar decompression has been proved to be an effective method for recurrent lumbar disc herniation. However, the prognostic factors and outcomes of percutaneous endoscopic lumbar reoperation (PELR) for recurrent sciatica symptoms were still unknown. The purpose of this study was to evaluate the outcomes and prognostic factors of patients who underwent PELR for recurrent sciatica symptoms. From 2009 to 2015, 94 patients who underwent PELR for recurrent sciatica symptoms were enrolled. The primary surgeries include transforaminal lumbar interbody fusion (n = 16), microendoscopic discectomy (n = 31), percutaneous endoscopic lumbar decompression (PELD, n = 17), and open discectomy (n = 30). The mean follow-up period was 36 months, and 86 (91.5%) patients had obtained at least 24 months' follow-up. Of the 94 patients with adequate follow-up, 51 (54.3%) exhibited excellent improvement, 23 (24.5%) had good improvement, and 7 (7.4%) had fair improvement according to modified Macnab criteria. The average re-recurrence rate was 9.6%, with no difference among the different primary surgery groups (PELD, 3/17; microendoscopic discectomy, 2/31; open discectomy, 3/30; transforaminal lumbar interbody fusion, 1/16). There was a trend toward greater rates of symptom recurrence in the primary group of PELD who underwent percutaneous endoscopic lumbar reoperation compared with other groups, but this did not reach statistical significance (P > 0.05). Multivariate analysis suggested that age, body mass index, and surgeon level was independent prognostic factors. Obesity (hazard ratio 13.98, 95% confidence interval 3.394-57.57; P < 0.001) was the risk factor affecting re-recurrence according to logistic regression analysis. PELR is a safe and effective treatment for recurrent sciatica symptoms regardless of different primary operation

Time-sequential changes of differentially expressed miRNAs during the process of anterior lumbar interbody fusion using equine bone protein extract, rhBMP-2 and autograft

NASA Astrophysics Data System (ADS)

Chen, Da-Fu; Zhou, Zhi-Yu; Dai, Xue-Jun; Gao, Man-Man; Huang, Bao-Ding; Liang, Tang-Zhao; Shi, Rui; Zou, Li-Jin; Li, Hai-Sheng; Bünger, Cody; Tian, Wei; Zou, Xue-Nong

2014-03-01

The precise mechanism of bone regeneration in different bone graft substitutes has been well studied in recent researches. However, miRNAs regulation of the bone formation has been always mysterious. We developed the anterior lumbar interbody fusion (ALIF) model in pigs using equine bone protein extract (BPE), recombinant human bone morphogenetic protein-2 (rhBMP-2) on an absorbable collagen sponge (ACS), and autograft as bone graft substitute, respectively. The miRNA and gene expression profiles of different bone graft materials were examined using microarray technology and data analysis, including self-organizing maps, KEGG pathway and Biological process GO analyses. We then jointly analyzed miRNA and mRNA profiles of the bone fusion tissue at different time points respectively. Results showed that miRNAs, including let-7, miR-129, miR-21, miR-133, miR-140, miR-146, miR-184, and miR-224, were involved in the regulation of the immune and inflammation response, which provided suitable inflammatory microenvironment for bone formation. At late stage, several miRNAs directly regulate SMAD4, Estrogen receptor 1 and 5-hydroxytryptamine (serotonin) receptor 2C for bone formation. It can be concluded that miRNAs play important roles in balancing the inflammation and bone formation.

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

PubMed

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

2012-05-01

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

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

PubMed

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

2009-10-01

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

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

PubMed

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

2017-12-01

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

Trends Analysis of rhBMP2 Utilization in Single-Level Anterior Lumbar Interbody Fusion in the United States

PubMed Central

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

2017-01-01

Study Design: Retrospective case study. Objective: To evaluate the trends and demographics of recombinant human bone morphogenetic protein 2 (rhBMP2) utilization in single-level anterior lumbar interbody fusion (ALIF) in the United States. Methods: Patients who underwent single-level ALIF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopedic insurance records. The year of procedure, age, gender, and region of the United States were analyzed for each patient. Results: A total of 921 patients were identified who underwent a single-level ALIF in this study. The average rate of single-level ALIF with rhBMP2 utilization increased (35%-48%) from 2005 to 2009, but sharply decreased to 16.7% in 2010 and 15.0% in 2011. The overall incidence of single-level ALIF without rhBMP2 (0.20 cases per 100 000 patients) was more than twice of the incidence of single-level ALIF with rhBMP2 (0.09 cases per 100 000 patients). The average rate of single-level ALIF with rhBMP2 utilization is highest in West (41.4%), followed by Midwest (33.3%), South (26.5%) and Northeast (22.2%). The highest incidence of single-level ALIF with rhBMP2 was observed in the group aged less than 65 years (compared with any other age groups, P < .001), with an incidence of 0.21 per 100 000 patients. Conclusions: The incidence of rhBMP2 utilization in single-level ALIF increased from 2006 to 2009, but decreased in 2010 and 2011. The Northeast region had the lowest incidence of rhBMP2 utilization. The group aged less than 65 years trended to have the higher incidence of single-level ALIF with rhBMP2 utilization. PMID:29662743

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

PubMed

Umeta, Ricardo S G; Avanzi, Osmar

2011-07-01

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

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

PubMed

Luther, Evan; Urakov, Timur; Vanni, Steven

2018-06-11

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

Dynamic stabilization using the Dynesys system versus posterior lumbar interbody fusion for the treatment of degenerative lumbar spinal disease: a clinical and radiological outcomes-based meta-analysis.

PubMed

Lee, Chang-Hyun; Jahng, Tae-Ahn; Hyun, Seung-Jae; Kim, Chi Heon; Park, Sung-Bae; Kim, Ki-Jeong; Chung, Chun Kee; Kim, Hyun-Jib; Lee, Soo-Eon

2016-01-01

OBJECTIVE The Dynesys, a pedicle-based dynamic stabilization (PDS) system, was introduced to overcome the drawbacks of fusion procedures. Nevertheless, the theoretical advantages of PDS over fusion have not been clearly confirmed. The aim of this study was to compare clinical and radiological outcomes of patients who underwent PDS using the Dynesys system with those who underwent posterior lumbar interbody fusion (PLIF). METHODS The authors searched PubMed, Embase, Web of Science, and the Cochrane Database. Studies that reported outcomes of patients who underwent PDS or PLIF for the treatment of degenerative lumbar spinal disease were included. The primary efficacy end points were perioperative outcomes. The secondary efficacy end points were changes in the Oswestry Disability Index (ODI) and back and leg pain visual analog scale (VAS) scores and in range of motion (ROM) at the treated and adjacent segments. A meta-analysis was performed to calculate weighted mean differences (WMDs), 95% confidence intervals, Q statistics, and I(2) values. Forest plots were constructed for each analysis group. RESULTS Of the 274 retrieved articles, 7 (which involved 506 participants [Dynesys, 250; PLIF, 256]) met the inclusion criteria. The Dynesys group showed a competitive advantage in mean surgery duration (20.73 minutes, 95% CI 8.76-32.70 minutes), blood loss (81.87 ml, 95% CI 45.11-118.63 ml), and length of hospital stay (1.32 days, 95% CI 0.23-2.41 days). Both the Dynesys and PLIF groups experienced improved ODI and VAS scores after 2 years of follow-up. Regarding the ODI and VAS scores, no statistically significant difference was noted according to surgical procedure (ODI: WMD 0.12, 95% CI -3.48 to 3.72; back pain VAS score: WMD -0.15; 95% CI -0.56 to 0.26; leg pain VAS score: WMD -0.07; 95% CI -0.47 to 0.32). The mean ROM at the adjacent segment increased in both groups, and there was no substantial difference between them (WMD 1.13; 95% CI -0.33 to 2.59). Although the

Effect of minimally invasive technique on return to work and narcotic use following transforaminal lumbar inter-body fusion: a review.

PubMed

Parker, Scott L; Lerner, Jason; McGirt, Matthew J

2012-01-01

Low back pain is one of the most prevalent and disabling musculoskeletal conditions affecting the working population in the United States. Informed, shared decision making among patients, clinicians, and case managers about treatment options for chronic low back pain-including the role of spinal fusion where medically necessary-can have a meaningful impact on return to work, normal function, and economic outcomes. Minimally invasive techniques for lumbar spinal fusion, including transforaminal lumbar interbody fusion (MIS TLIF) have recently been introduced with the goal of smaller operative wounds, less tissue trauma, and faster postoperative recovery when compared with open fusion. Although similar long-term clinical outcomes have been reported for MIS TLIF and open TLIF, the relative merits with respect to workplace productivity have not been comprehensively investigated. Time to return to work and narcotic independence after MIS TLIF and open TLIF are important parameters that may affect overall workplace productivity, and as such are the focus of this study. This study was performed via a review of the literature. We performed a systematic literature review to identify all published articles that reported on the postoperative outcomes of patients, as assessed by return to work or narcotic independence status or both, following MIS TLIF or open TLIF. A cumulative comparison was made for all included MIS TLIF versus open TLIF surgeries. Seventy-four published studies reported postoperative outcomes following MIS TLIF or open TLIF; only five (6.8%) studies directly described time to return to work or duration of narcotic use postoperatively or both, and were therefore included into the analysis of this review. Four studies in the published literature describe time to return to work following MIS TLIF or open TLIF, and two studies describe time to narcotic independence. Overall, the reviewed literature suggests that MIS TLIF may be associated with an accelerated

Properties of an interspinous fixation device (ISD) in lumbar fusion constructs: a biomechanical study.

PubMed

Techy, Fernando; Mageswaran, Prasath; Colbrunn, Robb W; Bonner, Tara F; McLain, Robert F

2013-05-01

Segmental fixation improves fusion rates and promotes patient mobility by controlling instability after lumbar surgery. Efforts to obtain stability using less invasive techniques have lead to the advent of new implants and constructs. A new interspinous fixation device (ISD) has been introduced as a minimally invasive method of stabilizing two adjacent interspinous processes by augmenting an interbody cage in transforaminal interbody fusion. The ISD is intended to replace the standard pedicle screw instrumentation used for posterior fixation. The purpose of this study is to compare the rigidity of these implant systems when supplementing an interbody cage as used in transforaminal lumbar interbody fusion. An in vitro human cadaveric biomechanical study. Seven human cadaver spines (T12 to the sacrum) were mounted in a custom-designed testing apparatus, for biomechanical testing using a multiaxial robotic system. A comparison of segmental stiffness was carried out among five conditions: intact spine control; interbody spacer (IBS), alone; interbody cage with ISD; IBS, ISD, and unilateral pedicle screws (unilat); and IBS, with bilateral pedicle screws (bilat). An industrial robot (KUKA, GmbH, Augsburg, Germany) applied a pure moment (±5 Nm) in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) through an anchor to the T12 vertebral body. The relative vertebral motion was captured using an optoelectronic camera system (Optotrak; Northern Digital, Inc., Waterloo, Ontario, Canada). The load sensor and the camera were synchronized. Maximum rotation was measured at each level and compared with the intact control. Implant constructs were compared with the control and with each other. A statistical analysis was performed using analysis of variance. A comparison between the intact spine and the IBS group showed no significant difference in the range of motion (ROM) in FE, LB, or AR for the operated level, L3-L4. After implantation of the ISD to augment

Mini-open lateral retroperitoneal lumbar spine approach using psoas muscle retraction technique. Technical report and initial results on six patients.

PubMed

Aghayev, Kamran; Vrionis, Frank D

2013-09-01

The main aim of this paper was to report reproducible method of lumbar spine access via a lateral retroperitoneal route. The authors conducted a retrospective analysis of the technical aspects and clinical outcomes of six patients who underwent lateral multilevel retroperitoneal interbody fusion with psoas muscle retraction technique. The main goal was to develop a simple and reproducible technique to avoid injury to the lumbar plexus. Six patients were operated at 15 levels using psoas muscle retraction technique. All patients reported improvement in back pain and radiculopathy after the surgery. The only procedure-related transient complication was weakness and pain on hip flexion that resolved by the first follow-up visit. Psoas retraction technique is a reliable technique for lateral access to the lumbar spine and may avoid some of the complications related to traditional minimally invasive transpsoas approach.

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

PubMed

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

2016-06-01

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

Comparison Perioperative Factors During Minimally Invasive Pre-Psoas Lateral Interbody Fusion of the Lumbar Spine Using Either Navigation or Conventional Fluoroscopy

PubMed Central

Zhang, Yue-Hui; White, Ian; Potts, Eric; Mobasser, Jean-Pierre

2017-01-01

Study Design: Retrospective clinical study. Objectives: The aim of this study was to compare intraoperative conditions and clinical results of patients undergoing pre-psoas oblique lateral interbody fusion (OLIF) using navigation or conventional fluoroscopy (C-ARM) techniques. Methods: Forty-two patients (22 patients by navigation and 20 by fluoroscopy) underwent the OLIF procedure at 2 medical centers, and records were reviewed. Clinical data was collected and compared between the 2 groups. Patients were followed-up with a range of 6 to 24 months. Results: There were no significant differences on demographic data between groups. The navigation group had zero radiation exposure (RE) to the surgeon and radiation time compared to the C-ARM group, with total RE of 44.59 ± 26.65 mGy and radiation time of 88.30 ± 58.28 seconds (P < .05). The RE to the patient was significantly lower in the O-ARM group (9.38 mGy) compared to the C-ARM group (44.59 ± 26.65 mGy). Operating room time was slightly longer in the navigation group (2.49 ± 1.35 hours) compared to the C-ARM group (2.30 ± 1.17 hours; P > .05), although not statistically significant. No differences were found in estimated blood loss, length of hospitalization, surgery-related complications, and outcome scores with an average of 8-month follow-up. Conclusions: Compared with C-ARM techniques, using navigation can eliminate RE to surgeon and decrease RE to the patient, and it had no significant effect on operating time, estimated blood loss, length of hospitalization, or perioperative complications in the patients with OLIF procedure. This study shows that navigation is a safe alternative to fluoroscopy during the OLIF procedure in the treatment of degenerative lumbar conditions. PMID:28989845

Do measures of surgical effectiveness at 1 year after lumbar spine surgery accurately predict 2-year outcomes?

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing L; Cheng, Joseph; Karikari, Isaac; Bagley, Carlos A

2016-12-01

OBJECTIVE With the recent passage of the Patient Protection and Affordable Care Act, there has been a dramatic shift toward critical analyses of quality and longitudinal assessment of subjective and objective outcomes after lumbar spine surgery. Accordingly, the emergence and routine use of real-world institutional registries have been vital to the longitudinal assessment of quality. However, prospectively obtaining longitudinal outcomes for patients at 24 months after spine surgery remains a challenge. The aim of this study was to assess if 12-month measures of treatment effectiveness accurately predict long-term outcomes (24 months). METHODS A nationwide, multiinstitutional, prospective spine outcomes registry was used for this study. Enrollment criteria included available demographic, surgical, and clinical outcomes data. All patients had prospectively collected outcomes measures and a minimum 2-year follow-up. Patient-reported outcomes instruments (Oswestry Disability Index [ODI], SF-36, and visual analog scale [VAS]-back pain/leg pain) were completed before surgery and then at 3, 6, 12, and 24 months after surgery. The Health Transition Index of the SF-36 was used to determine the 1- and 2-year minimum clinically important difference (MCID), and logistic regression modeling was performed to determine if achieving MCID at 1 year adequately predicted improvement and achievement of MCID at 24 months. RESULTS The study group included 969 patients: 300 patients underwent anterior lumbar interbody fusion (ALIF), 606 patients underwent transforaminal lumbar interbody fusion (TLIF), and 63 patients underwent lateral interbody fusion (LLIF). There was a significant correlation between the 12- and 24-month ODI (r = 0.82; p < 0.0001), SF-36 Physical Component Summary score (r = 0.89; p < 0.0001), VAS-back pain (r = 0.90; p < 0.0001), and VAS-leg pain (r = 0.85; p < 0.0001). For the ALIF cohort, patients achieving MCID thresholds for ODI at 12 months were 13-fold (p < 0

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

PubMed

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

2016-11-01

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

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

PubMed

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

2016-03-01

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

The Asfora Bullet Cage System Shows Comparable Fusion Rate Success Versus Control Cage in Posterior Lumbar Interbody Fusion in a Randomized Clinical Trial.

PubMed

Morgan, Jeremy P; Miller, Ashley L; Thompson, Paul A; Asfora, Wilson T

2016-04-01

Low back pain and degeneration of the intervertebral disc are an integrated malady that affects millions of Americans. Cage devices used in association with posterior lumbar interbody fusion (PLIF) have been shown to be an effective approach in the treatment of a number of lower spine disorders attributed to degenerative disc disease (DDD). This study was undertaken as part of a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE) study and compares the effectiveness of the Asfora Bullet Cage System (ABCS) to successfully fuse vertebra at one or two levels between L2 and S1 in patients with DDD to an FDA approved comparison device, the Medtronic-Sofamor Danek Inter Fix Threaded Fusion Device (MSDIFD). A total of 257 randomized participants were implanted with either the ABCS device (n = 132) or the MSDIFD device (n = 125) through an open posterior approach using autogenous local bone graft without the use of pedicle screws. Patients were evaluated prior to surgery and at the 24 month (24-M) visit for fusion status, deep tendon reflex status, sensory function, motor function, straight leg raise status, pain, disability, and device safety. Radiological evaluation and statistical analysis were performed by independent professionals. Evaluation of device success was performed at 24-M visit. From the original group of 257 patients, 59 were lost to follow-up. Primary measures of success at the 24-M visit involved pain and function, fusion, neurological status, and device-related adverse events measures. Pain and function improved in both (MSDIFD: 75.7 percent; ABCS: 82.6 percent). Fusion success with all radiographic points at 24-M visits was 79.4 percent MSDIFD and 88.2 percent ABCS. Neurological improvement was seen in both (MSDIFD: 77.0 percent; ABCS: 87.8 percent). One device-related grade 1 adverse event was reported in the MSDIFD group. Disc height preservation was equivalent for single level fusions (MSDIFD: 16.1 percent; ABCS: 20

Anterior lumbar interbody surgery for spondylosis results from a classically-trained neurosurgeon.

PubMed

Chatha, Gurkirat; Foo, Stacy W L; Lind, Christopher R P; Budgeon, Charley; Bannan, Paul E

2014-09-01

Anterior lumbar surgery for degenerative disc disease (DDD) is a relatively novel technique that can prevent damage to posterior osseous, muscular and ligamentous spinal elements. This study reports the outcomes and complications in 286 patients who underwent fusion - with artificial disc implants or combined fusion and artificial disc implants - by a single-operator neurosurgeon, with up to 24 months of follow-up. The visual analogue scale (VAS), Oswestry Disability Index (ODI), Short Form 36 (SF36) and prospective log of adverse events were used to assess the clinical outcome. Radiographic assessments of implant position and bony fusion were analysed. Intraoperative and postoperative complications were also recorded. Irrespective of pre-surgical symptoms (back pain alone or back and leg pain combined), workers' compensation status and type of surgical implant, clinically significant improvements in VAS, ODI and SF36 were primarily observed at 3 and/or 6 month follow-up, and improvements were maintained at 24 months after surgery. A 94% fusion rate was obtained; the overall complication was 9.8% which included 3.5% with vascular complications. The anterior lumbar approach can be used for treating DDD for both back pain and back and leg pain with low complication rates. With appropriate training, single-operator neurosurgeons can safely perform these surgeries. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

Three-year postoperative outcomes between MIS and conventional TLIF in1-segment lumbar disc herniation.

PubMed

Lv, You; Chen, Jingyang; Chen, Jinchuan; Wu, Yuling; Chen, Xiangyang; Liu, Yi; Chu, Zhaoming; Sheng, Luxin; Qin, Rujie; Chen, Ming

2017-06-01

The aim of this study is to assess the long-term clinical and radiological outcomes between minimally invasive (MIS) and conventional transforaminal lumbar interbody fusion (TLIF) in treating one-segment lumbar disc herniation (LDH). One-hundred and six patients treated by MIS-TLIF (50 cases) or conventional TLIF (56 cases) were included. Perioperative results were evaluated. Clinical outcomes were compared preoperatively and postoperatively. Radiologic parameters were based on a comparison of preoperative and three-year postoperative lumbar lordosis, segmental lordosis, sacral slope, the cross-sectional area of the paraspinal muscle and fusion rates. MIS TILF had significantly less blood, shorter operation time, mean return to work time and lower intramuscular pressure compared with the conventional group during the operation. VAS scores for lower back pain and ODI in MIS-TLIF were significantly decreased. The mean cross-sectional area of the paraspinal muscle was significantly decreased after surgery in the conventional TLIF group and no significant intragroup differences were established in the MIS-TLIF group. No significant differences were found in fusion rate, lumbar lordosis, segmental lordosis and sacral slope. Both MIS and conventional TLIF were beneficial for patients with LDH. However, MIS-TLIF manifests a great improvement in perioperative outcomes, low back pain, disability and preventing paraspinal muscle atrophy during the follow-up period observation.

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

PubMed

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

2015-10-17

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

The role of the vascular surgeon in anterior lumbar spine surgery.

PubMed

Asha, Mohammed Jamil; Choksey, Munchi S; Shad, Amjad; Roberts, Peter; Imray, Chris

2012-08-01

Advances in spinal fusion techniques have led to an increase in the need for safe access to the lumbar spine anteriorly. The aim of this study is to examine the procedure-related complications of anterior lumbar inter-body fusion (ALIF) or anterior lumbar disc replacement (ALDR) when performed jointly by a vascular-surgeon and a neurosurgeon in a single centre. A retrospective cohort analysis was conducted for all patients who underwent ALIF or ALDR between 2004 and 2010. Operative notes were examined to identify any procedure-specific complications. In-hospital postoperative complications were recorded. Outpatients' records were reviewed to record any late-onset postoperative complications. A total of 121 patients (68 female and 53 males) were included. Mean age was 44 years (range of 25-76). Eighty patients (66%) had ALIF while 24 patients (20%) underwent ALDR. The remaining 17 patients (14%) had combined procedure for multilevel disease. In all patients, a transperitoneal approach was performed by vascular surgeon. The main indication (88%) for performing surgery was degenerative lumbar disc disease. No visceral or 'major vascular' complications were reported in any patients. Only three patients had 'minor vascular' injuries. The only significant postoperative complication was self-limiting paralytic ileus affecting 18 patients (14.8%). Hospital stay ranged from 4 to 9 days (median of 5 days). The anterior lumbar approach is not generally favoured by many neurosurgeons, despite its many advantages, due to the significant risk of vascular injuries as reported in the literature. This risk is especially acknowledged by the emerging generation of neurosurgeons with very little general surgical exposure during the training years. Adopting a combined vascular and neurosurgical approach has been reported to reduce the risk of vascular injury in anterior lumbar surgery acceptably low. This team approach provides an excellent opportunity to preserve some key 'general

Comparative Prospective Study Reporting Intraoperative Parameters, Pedicle Screw Perforation, and Radiation Exposure in Navigation-Guided versus Non-navigated Fluoroscopy-Assisted Minimal Invasive Transforaminal Lumbar Interbody Fusion

PubMed Central

Kundnani, Vishal; Dutta, Shumayou; Patel, Ankit; Mehta, Gaurav; Singh, Mahendra

2018-01-01

Study Design Prospective cohort study. Purpose To compare intraoperative parameters, radiation exposure, and pedicle screw perforation rate in navigation-guided versus non-navigated fluoroscopy-assisted minimal invasive transforaminal lumbar interbody fusion (MIS TLIF). Overview of Literature The poor reliability of fluoroscopy-guided instrumentation and growing concerns about radiation exposure have led to the development of navigation-guided instrumentation techniques in MIS TLIF. The literature evaluating the efficacy of navigation-guided MIS TLIF is scant. Methods Eighty-seven patients underwent navigation- or fluoroscopy-guided MIS TLIF for symptomatic lumbar/lumbosacral spondylolisthesis. Demographics, intraoperative parameters (surgical time, blood loss), and radiation exposure (sec/mGy/Gy.cm2 noted from C-arm for comparison only) were recorded. Computed tomography was performed in patients in the navigation and non-navigation groups at postoperative 12 months and reviewed by an independent observer to assess the accuracy of screw placement, perforation incidence, location, grade (Mirza), and critical versus non-critical neurological implications. Results Twenty-seven patients (male/female, 11/16; L4–L5/L5–S1, 9/18) were operated with navigation-guided MIS TLIF, whereas 60 (male/female, 25/35; L4–L5/L5–S1, 26/34) with conventional fluoroscopy-guided MIS TILF. The use of navigation resulted in reduced fluoroscopy usage (dose area product, 0.47 Gy.cm2 versus 2.93 Gy.cm2), radiation exposure (1.68 mGy versus 10.97 mGy), and fluoroscopy time (46.5 seconds versus 119.08 seconds), with p-values of <0.001. Furthermore, 96.29% (104/108) of pedicle screws in the navigation group were accurately placed (grade 0) (4 breaches, all grade I) compared with 91.67% (220/240) in the non-navigation group (20 breaches, 16 grade I+4 grade II; p=0.114). None of the breaches resulted in a corresponding neurological deficit or required revision. Conclusions Navigation

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

PubMed

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

2016-02-01

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

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

PubMed

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

2011-04-01

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

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

PubMed

Parkinson, Bonny; Goodall, Stephen; Thavaneswaran, Prema

2013-09-01

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

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

PubMed

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

2014-12-01

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

Finite element analysis and cadaveric cinematic analysis of fixation options for anteriorly implanted trabecular metal interbody cages.

PubMed

Berjano, Pedro; Blanco, Juan Francisco; Rendon, Diego; Villafañe, Jorge Hugo; Pescador, David; Atienza, Carlos Manuel

2015-11-01

To assess, with finite element analysis and an in vitro biomechanical study in cadaver, whether the implementation of an anterior interbody cage made of hedrocel with nitinol shape memory staples in compression increases the stiffness of the stand-alone interbody cage and to compare these constructs' stiffness to other constructs common in clinical practice. A biomechanical study with a finite element analysis and cadaveric testing assessed the stiffness of different fixation modes for the L4-L5 functional spinal unit: intact spine, destabilized spine with discectomy, posterior pedicle-screw fixation, anterior stand-alone interbody cage, anterior interbody cage with bilateral pedicle screws and anterior interbody cage with two shape memory staples in compression. These modalities of vertebral fixation were compared in four loading modes (flexion, extension, lateral bending, and axial rotation). The L4-L5 spinal unit with an anterior interbody cage and two staples was stiffer than the stand-alone cage. The construct stiffness was similar to that of a model of posterior pedicular stabilization. The stiffness was lower than that of the anterior cage plus bilateral pedicle-screw fixation. The use of an anterior interbody implant with shape memory staples in compression may be an alternative to isolated posterior fixation and to anterior isolated implants, with increased stiffness.

A perioperative cost analysis comparing single-level minimally invasive and open transforaminal lumbar interbody fusion.

PubMed

Singh, Kern; Nandyala, Sreeharsha V; Marquez-Lara, Alejandro; Fineberg, Steven J; Oglesby, Mathew; Pelton, Miguel A; Andersson, Gunnar B; Isayeva, Darya; Jegier, Briana J; Phillips, Frank M

2014-08-01

Emerging literature suggests superior clinical short- and long-term outcomes of MIS (minimally invasive surgery) TLIFs (transforaminal lumbar interbody fusion) versus open fusions. Few studies to date have analyzed the cost differences between the two techniques and their relationship to acute clinical outcomes. The purpose of the study was to determine the differences in hospitalization costs and payments for patients treated with primary single-level MIS versus open TLIF. The impact of clinical outcomes and their contribution to financial differences was explored as well. This study was a nonrandomized, nonblinded prospective review. Sixty-six consecutive patients undergoing a single-level TLIF (open/MIS) were analyzed (33 open, 33 MIS). Patients in either cohort (MIS/open) were matched based on race, sex, age, smoking status, medical comorbidities (Charlson Comorbidity index), payer, and diagnosis. Every patient in the study had a diagnosis of either degenerative disc disease or spondylolisthesis and stenosis. Operative time (minutes), length of stay (LOS, days), estimated blood loss (EBL, mL), anesthesia time (minutes), Visual Analog Scale (VAS) scores, and hospital cost/payment amount were assessed. The MIS and open TLIF groups were compared based on clinical outcomes measures and hospital cost/payment data using SPSS version 20.0 for statistical analysis. The two groups were compared using bivariate chi-squared analysis. Mann-Whitney tests were used for non-normal distributed data. Effect size estimate was calculated with the Cohen d statistic and the r statistic with a 95% confidence interval. Average surgical time was shorter for the MIS than the open TLIF group (115.8 minutes vs. 186.0 minutes respectively; p=.001). Length of stay was also reduced for the MIS versus the open group (2.3 days vs. 2.9 days, respectively; p=.018). Average anesthesia time and EBL were also lower in the MIS group (p<.001). VAS scores decreased for both groups, although these

Comparative effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion: 2-year assessment of narcotic use, return to work, disability, and quality of life.

PubMed

Adogwa, Owoicho; Parker, Scott L; Bydon, Ali; Cheng, Joseph; McGirt, Matthew J

2011-12-01

Retrospective cohort comparison between minimally invasive (MIS) and open transforaminal lumbar interbody fusion (TLIF). To assess 2 earlier unstudied endpoints (duration of narcotic use and return to work) and long-term pain, disability, and quality of life (QOL) for MIS-TLIF versus open-TLIF. MIS-TLIF for lumbar spondylolithesis theoretically allows for surgical treatment of back and leg pain while minimizing blood loss and tissue injury. Although earlier studies have shown shorter hospital stay and equivocal 6 and 24 month outcomes with MIS-TLIF versus open-TLIF, the effect of MIS techniques on postoperative narcotic use and return to work are poorly understood. Thirty patients undergoing MIS-TLIF (n = 15) or open-TLIF (n = 15) for grade I degenerative spondylolithesis-associated back and leg pain were enrolled. Two-year outcomes were assessed through phone interview and it included pain [visual analog scale (VAS)], low-back disability (Oswestry disability index), EuroQol-5D, occupational disability, and narcotic use. MIS-TLIF versus open-TLIF cohorts were similar at baseline. Median [interquartile range (IQR)] length of hospitalization after surgery was significantly less for MIS-TLIF versus open-TLIF [3 (3 to 3) vs 5.5 (4 to 6) d], P = 0.001. MIS-TLIF versus open-TLIF patients showed similar 2-year improvement in VAS for back pain, VAS for leg pain, Oswestry disability index, and EuroQol-5D scores. Overall, median (IQR) length of postoperative narcotic use was 3.0 (1.4 to 4.6) weeks and significantly shorter for MIS-TLIF versus open-TLIF patients [2.0 (1.0 to 3.0) vs 4.0 (1.4 to 4.6) wk, P = 0.008]. Overall, median (IQR) time to return to work was 13.9 (2.2 to 25.5) weeks and significantly shorter for MIS-TLIF versus open-TLIF patients [8.5 (4.4 to 21.4) vs 17.1 (1.8 to 35.9) wk, P = 0.02]. Both MIS-TLIF and open-TLIF provide long-term improvement in pain, disability, and EuroQol-5D in patients with back and leg pain from grade I degenerative spondylolithesis

Single transverse-orientation cage via MIS-TLIF approach for the treatment of degenerative lumbar disease: a technical note.

PubMed

Wang, Shan-Jin; Han, Ying-Chao; Pan, Fu-Min; Ma, Bin; Tan, Jun

2015-01-01

Single transverse cage placed in the anterior vertebral column can better maintain lumbar lordosis and sagittal alignment and is frequently used via the lateral transpsoas approach. However, there is no clear description in the literature of the steps required to place the single transverse cage during the instrumented transforaminal lumbar interbody fusion (TLIF) procedure for the treatment of degenerative lumbar disease. The objective of this study is to describe the technique using single transverse-orientation cage when performing TLIF procedures. We present 18 illustrative cases in which single transverse-orientation cage was placed according to a step-by-step technique that can be used during the TLIF procedure. Information acquired included procedure time, intraoperative blood loss and postoperative complications. The preoperative and postoperative Oswestry Disability Index (ODI) and the visual analogue scale (VAS) scores were recorded. Changes in disc height and segmental lordosis were measured at radiographs. The single transverse-orientation cage was successfully placed in 18 patients in a stepwise technique to achieve lumbar fusion. Using this technique, the patients significantly improved clinically and radiographically at postoperative visits. This is the first report demonstrating the safety and efficacy of instrumented TLIF with single transverse-orientation cage for the treatment of degenerative lumbar disease. Single transverse-orientation cage via MIS-TLIF approach can maintain greater lumbar lordosis and avoid the unique complications of lateral transpsoas approach. Understanding the options for cage placement is important for surgeons considering the use of this technique.

49 CFR 572.85 - Lumbar spine flexure.

Code of Federal Regulations, 2011 CFR

2011-10-01

...) of this section, the lumbar spine assembly shall flex by an amount that permits the thoracic spine to... to the thoracic spine box. Apply the force at any torso deflection rate between 0.5 and 1.5 degrees... 49 Transportation 7 2011-10-01 2011-10-01 false Lumbar spine flexure. 572.85 Section 572.85...

The effectiveness of low-dose and high-dose tranexamic acid in posterior lumbar interbody fusion: a double-blinded, placebo-controlled randomized study.

PubMed

Kim, Ki-Tack; Kim, Cheung-Kue; Kim, Yong-Chan; Juh, Hyung-Suk; Kim, Hyo-Jong; Kim, Hyeon-Soo; Hong, Se Jung; Hey, Hwee Weng Dennis

2017-11-01

Tranexamic acid is a proven drug used for reduction of intraoperative blood loss in spinal surgery. However, optimal dosing considering risk/benefits is not well established owing to the heterogeneity in patient selection and surgical procedures of previous studies. This study aimed to evaluate the effectiveness and safety of various tranexamic acid regimens in reducing perioperative blood loss in single-level posterior lumbar interbody fusion (PLIF). Patients were randomly grouped into three different interventions: low-dose tranexamic acid (LD), high-dose tranexamic acid (HD), and placebo-controlled (PC) groups. The HD and LD groups received 10 and 5 mg/kg of bolus loading dose and 2 and 1 mg/kg of continuous infusion until 5 h after surgery, respectively. Data on patient demographics and preoperative and 24-h postoperative laboratory values were collected. Outcome parameters include intraoperative blood loss, 24-h postoperative blood loss, and blood loss during removal of the last drain. Seventy-two patients (mean age 63.3 ± 7.6 years) showed similar baseline characteristics. Intraoperatively, blood loss was reduced by the administration of tranexamic acid (P = 0.04), contributed predominantly by a difference between the LD and HD groups (123 mL; P < 0.01). The 24-h postoperative blood loss was reduced (P < 0.01), contributed predominantly by a difference between the PC and LD groups (144 mL; P = 0.02). During the removal of the last drain, statistical difference was found between the PC and HD groups (125 mL; P = 0.00). No complications or side effects from tranexamic acid use were noted. Tranexamic acid administration for single-level PLIF was effective and safe in reducing perioperative blood loss in a dose-dependent manner. An HD regimen comprising 10 mg/kg of bolus loading dose and 2 mg/kg/h of continuous infusion is recommended. Level 1 study according to Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence.

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

PubMed

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

2015-04-01

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

Stand-alone lumbar cage subsidence: A biomechanical sensitivity study of cage design and placement.

PubMed

Calvo-Echenique, Andrea; Cegoñino, José; Chueca, Raúl; Pérez-Del Palomar, Amaya

2018-08-01

Spinal degeneration and instability are commonly treated with interbody fusion cages either alone or supplemented with posterior instrumentation with the aim to immobilise the segment and restore intervertebral height. The purpose of this work is to establish a tool which may help to understand the effects of intervertebral cage design and placement on the biomechanical response of a patient-specific model to help reducing post-surgical complications such as subsidence and segment instability. A 3D lumbar functional spinal unit (FSU) finite element model was created and a parametric model of an interbody cage was designed and introduced in the FSU. A Drucker-Prager Cap plasticity formulation was used to predict plastic strains and bone failure in the vertebrae. The effect of varying cage size, cross-sectional area, apparent stiffness and positioning was evaluated under 500 N preload followed by 7.5 Nm multidirectional rotation and the results were compared with the intact model. The most influential cage parameters on the FSU were size, curvature congruence with the endplates and cage placement. Segmental stiffness was higher when increasing the cross-sectional cage area in all loading directions and when the cage was anteriorly placed in all directions but extension. In general, the facet joint forces were reduced by increasing segmental stiffness. However, these forces were higher than in the intact model in most of the cases due to the displacement of the instantaneous centre of rotation. The highest plastic deformations took place at the caudal vertebra under flexion and increased for cages with greater stiffness. Thus, wider cages and a more anteriorly placement would increase the volume of failed bone and, therefore, the risk of subsidence. Cage geometry plays a crucial role in the success of lumbar surgery. General considerations such as larger cages may be applied as a guideline, but parameters such as curvature or cage placement should be determined for

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

PubMed

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

2017-12-01

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

Comparison Between Posterior Short-segment Instrumentation Combined With Lateral-approach Interbody Fusion and Traditional Wide-open Anterior-Posterior Surgery for the Treatment of Thoracolumbar Fractures

PubMed Central

Li, Xiang; Zhang, Junwei; Tang, Hehu; Lu, Zhen; Liu, Shujia; Chen, Shizheng; Hong, Yi

2015-01-01

Abstract The aim of the study was to compare the radiographic and clinical outcomes between posterior short-segment pedicle instrumentation combined with lateral-approach interbody fusion and traditional anterior-posterior (AP) surgery for the treatment of thoracolumbar fractures. Lateral-approach interbody fusion has achieved satisfactory results for thoracic and lumbar degenerative disease. However, few studies have focused on the use of this technique for the treatment of thoracolumbar fractures. Inclusion and exclusion criteria were established. All patients who meet the above criteria were prospectively treated by posterior short-segment instrumentation and secondary-staged minimally invasive lateral-approach interbody fusion, and classified as group A. A historical group of patients who were treated by traditional wide-open AP approach was used as a control group and classified as group B. The radiological and clinical outcomes were compared between the 2 groups. There were 12 patients in group A and 18 patients in group B. The mean operative time and intraoperative blood loss of anterior reconstruction were significantly higher in group B than those in group A (127.1 ± 21.7 vs 197.5 ± 47.7 min, P < 0.01; 185.8 ± 62.3 vs 495 ± 347.4 mL, P < 0.01). Two of the 12 (16.7%) patients in group A experienced 2 surgical complications: 1 (8.3%) major and 1 (8.3%) minor. Six of the 18 (33%) patients in group B experienced 9 surgical complications: 3 (16.7%) major and 6 (33.3%) minor. There was no significant difference between the 2 groups regarding loss of correction (4.3 ± 2.1 vs 4.2 ± 2.4, P = 0.89) and neurological function at final follow-up (P = 0.77). In both groups, no case of instrumentation failure, pseudarthrosis, or nonunion was noted. Compared with the wide-open AP surgery, posterior short-segment pedicle instrumentation, combined with minimally invasive lateral-approach interbody fusion, can achieve similar

Anterior interbody fusion for cervical osteomyelitis

PubMed Central

Bartal, A. D.; Schiffer, J.; Heilbronn, Y. D.; Yahel, M.

1972-01-01

Interbody fusion for stabilization of the cervical spine after osteomyelitic destruction of the body of C5 vertebra is reported in a patient with quadriplegia and sphincter disturbances secondary to an epidural abscess. The successful union of the bone graft along with complete neurological recovery after anterior decompression and evacuation of the epidural mass seem to justify the procedure. Images PMID:4554587

The recovery of damaged paraspinal muscles by posterior surgical treatment for patients with lumbar degenerative diseases and its clinical consequence.

PubMed

Cha, Jae-Ryong; Kim, Yong-Chan; Yoon, Wan-Keun; Lee, Won-Gyu; Kim, Tae-Hwan; Oh, Jae-Keun; Kim, Seok-Woo; Ohn, Suk Hoon; Cui, Ji Hao

2017-01-01

Posterior lumbar surgery can lead to damage on paraspinal muscles. Our study aimed to examine the recovery in the denervated paraspinal muscles by posterior lumbar surgery and to determine that of improvement in the lower back pain (LBP). Depending on surgical treatments, the patients were divided into two groups: The group I (interspinous implantation with decompression) and II (posterior lumbar interbody fusion with decompression). The paraspinal mapping score was recorded for individual muscle. In the group I, there was reinnervation in the denervated multifidus and erector spinae at the upper, surgical and lower levels at 12 months. In the group II, there was reinnervation in the denervated erector spinae at the upper, surgical and lower levels at 12 months. There was significant aggravation in the LBP in both groups at immediate postoperative. But there was significant improvement in it at 6 months in the group I and at 12 months in the group II. There was reinnervation in not only denervated multifidus and erector spinae at 12 months following interspinous ligament stabilization but also in denervated erector spinae at 12 months following pedicle screw fixation with fusion.

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

PubMed

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

2018-04-27

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

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: two-year outcomes.

PubMed

Corenman, Donald S; Gillard, Douglas M; Dornan, Grant J; Strauch, Eric L

2013-09-15

A retrospective observational study. To assess clinical outcomes, perioperative complications, revision surgery rates, and recombinant human bone morphogenetic protein-2 (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. 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. 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 and the data from Patient Satisfaction and Return to Work questionnaires. Independent record review was used to assess all outcomes. Eighty percent of the cohort (36/45) completed preoperative and postoperative outcome questionnaires at an average follow-up of 41.9 ± 11.9 months, which demonstrated significant clinical improvement: Oswestry Disability Index = 16.4 (P < 0.0001), 12-Item Short Form Health Survey physical component summary score = 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 preoperative job, with or without modification. There were 3 perioperative complications, 4 revision surgical procedures, and 11 cases of benign BMPP. There were no incidents of the intraoperative dural tears or nerve root injury, and litigation involvement (11/36, P > 0.17), preoperative depression (15/36, P > 0.19) or prior discectomy/decompression (14/36, P < 0.37) was not a predictor of

Remodeling of heat-treated cortical bone allografts for posterior lumbar interbody fusion: serial 10-year follow-up.

PubMed

Muramatsu, Koichi; Hachiya, Yudo; Izawa, Hiroyuki; Yamada, Harumoto

2012-12-01

We have selected heat-treated bone allografts as the graft material since the Tokai Bone Bank, the first regional bone bank in Japan, was established in 1992. In this study, we examined changes in bone mineral density (BMD), and morphology observed by magnetic resonance imaging (MRI), and histological findings of bone grafts in cases followed up for 7-10 years after bone grafting to grasp the remodeling of heat-treated cortical bone allografts for posterior lumber interbody fusion (PLIF). BMD of bone grafts was reduced by half at 10 years after grafting. MRI revealed that bone grafts were indistinguishable initially in only 22.2% of cases, whereas after a lengthy period of 10 years distinguishable in many cases. Histologically, new bone formation at the graft-host interface was observed earlier, at 1 year after grafting, than that at the periphery of canals in the specimens. The laminated structure of the cortical bone eroded over time, and fragmented bone trabeculae were observed in the specimens at 8 years or longer after grafting, though necrotic bone still remained in some sites.

Risk Factors for Blood Transfusion With Primary Posterior Lumbar Fusion.

PubMed

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

2015-11-01

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

Neurologic impairment from ectopic bone in the lumbar canal: a potential complication of off-label PLIF/TLIF use of bone morphogenetic protein-2 (BMP-2).

PubMed

Wong, David A; Kumar, Anant; Jatana, Sanjay; Ghiselli, Gary; Wong, Katherine

2008-01-01

Bone morphogenetic protein-2 (BMP-2) (Infuse) has been approved for use in anterior lumbar fusion in conjunction with an LT cage. However, off-label use is seen with anterior cervical fusion, posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF). The Federal Food and Drug Administration trial of BMP-2 in a PLIF application was halted because of a high incidence of ectopic bone forming in the neural canal (75%). The authors did not find a correlation between ectopic bone and increased leg pain. They concluded that the ectopic bone was a radiographic phenomenon and not associated with clinical findings. Complications using BMP in the cervical spine have been reported. Heretofore, there has not been a similar warning voiced for use of BMP in a lumbar PLIF or TLIF. The purpose was to report five cases of ectopic bone in the canal associated with PLIF/TLIF off-label use of BMP-2 potentially contributing to abnormal neurologic findings. This is an observational cohort study of patients referred to a tertiary care private medical center. This was a retrospective chart review of patients referred to a tertiary spine institute with complications after surgery where BMP-2 had been used in an off-label PLIF or TLIF application. Patient demographics, operating room (OR) notes from the index BMP surgery, imaging studies, and current clinical status were reviewed. Five cases of ectopic bone in the spinal canal with potential neurologic compromise were identified. It does appear that ectopic bone in the spinal canal associated with BMP-2 use in PLIF or TLIF may contribute to symptomatic neurologic findings in rare cases. Revision surgeries are difficult. This article challenges a previous publication, which concluded that the high incidence of ectopic bone was of no clinical significance. Isolating BMP anteriorly in the disc space using layered barriers of bone graft between the BMP and the annular defect may reduce the incidence of ectopic

Salvage Percutaneous Vertebral Augmentation Using Polymethyl Methacrylate in Patients with Failed Interbody Fusion.

PubMed

Yun, Dong-Ju; Hwang, Byeong-Wook; Oh, Hyeong-Seok; Kim, Jin-Sung; Jeon, Sang-Hyeop; Lee, Sang-Ho

2016-11-01

Percutaneous vertebral augmentation with cement is used as a salvage procedure for failed instrumentation. Few studies have reported the use of this procedure for failed anterior lumbar fusion in elderly patients with osteoporosis and other complicated diseases who have undergone a previous major operation. Between January 2007 and December 2015, the clinical and radiographic results of 8 patients with osteoporosis who showed subsidence and migration of the implant after an initial operation were examined. After the development of implant failure, the patients underwent vertebral augmentation with polymethyl methacrylate. Mean patient age was 73.4 years (range, 67-78 years), and mean bone mineral density was -2.96 (range, -2.1 to -3.8). The mean radiologic follow-up period between augmentation and the last follow-up examination was 16 months (range, 3-38 months). Although the subjective clinical outcome was not satisfying to the patients, no loss of correction, fractures, or screw loosening occurred during the follow-up period. The injection of cement around the instrument might help to stabilize it by providing strength to the axis and preventing further loosening. This salvage procedure could be an alternative in the management of cases with failed interbody fusion. Copyright © 2016 Elsevier Inc. All rights reserved.

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

PubMed

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

2004-09-01

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

Maintenance of Segmental Lordosis and Disk Height in Stand-alone and Instrumented Extreme Lateral Interbody Fusion (XLIF).

PubMed

Malham, Gregory M; Ellis, Ngaire J; Parker, Rhiannon M; Blecher, Carl M; White, Rohan; Goss, Ben; Seex, Kevin A

2017-03-01

A prospective single-surgeon nonrandomized clinical study. To evaluate the radiographic and clinical outcomes, by fixation type, in extreme lateral interbody fusion (XLIF) patients and provide an algorithm for determining patients suitable for stand-alone XLIF. XLIF may be supplemented with pedicle screw fixation, however, since stabilizing structures remain intact, it is suggested that stand-alone XLIF can be used for certain indications. This eliminates the associated morbidity, though subsidence rates may be elevated, potentially minimizing the clinical benefits. A fixation algorithm was developed after evaluation of patient outcomes from the surgeon's first 30 cases. This algorithm was used prospectively for 40 subsequent patients to determine the requirement for supplemental fixation. Preoperative, postoperative, and 12-month follow-up computed tomography scans were measured for segmental and global lumbar lordosis and posterior disk height. Clinical outcome measures included back and leg pain (visual analogue scale), Oswestry Disability Index (ODI), and SF-36 physical and mental component scores (PCS and MCS). Preoperatively to 12-month follow-up there were increases in segmental lordosis (7.9-9.4 degrees, P=0.0497), lumbar lordosis (48.8-55.2 degrees, P=0.0328), and disk height (3.7-5.5 mm, P=0.0018); there were also improvements in back (58.6%) and leg pain (60.0%), ODI (44.4%), PCS (56.7%), and MCS (16.1%) for stand-alone XLIF. For instrumented XLIF, segmental lordosis (7.6-10.5 degrees, P=0.0120) and disk height (3.5-5.6 mm, P<0.001) increased, while lumbar lordosis decreased (51.1-45.8 degrees, P=0.2560). Back (49.8%) and leg pain (30.8%), ODI (32.3%), PCS (37.4%), and MCS (2.0%) were all improved. Subsidence occurred in 3 (7.5%) stand-alone patients. The XLIF treatment fixation algorithm provided a clinical pathway to select suitable patients for stand-alone XLIF. These patients achieved positive clinical outcomes, satisfactory fusion rates, with

Radiographic and clinical outcomes following MIS-TLIF in patients with adult lumbar degenerative scoliosis.

PubMed

Zhao, Yongfei; Liang, Yan; Mao, Keya

2018-04-19

Patients suffering from adult lumbar degenerative scoliosis (ALDS) are commonly complicated with advanced age, osteoporosis, cardiopulmonary insufficiency, and some other medical comorbidity. Therefore, the traditional open surgery can lead to high rate of postoperative complications. The purposes of this study were to introduce our experiences and explore the efficacy and feasibility of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of patients with ALDS. From January 2008 to January 2014, a retrospective study of 22 patients with ALDS treated with MIS-TLIF was followed up at least 2 years. All patients suffered from one-level lumbar stenosis, and the nerve root block was performed to make sure the exact level. The clinical and radiographic outcomes were evaluated preoperatively and at the time of 2-year follow-up. The mean visual analog scale (VAS) back pain scores decreased from 6.2 ± 1.8 preoperatively to 2.2 ± 0.7 at 2-year follow-up (P < 0.05), and the mean VAS leg pain scores decreased from 8.2 ± 0.7 preoperatively to 1.4 ± 1.4 at 2-year follow-up (P < 0.05). The Oswestry Disability Index score improved from 62.4 ± 16.1% preoperatively to 24.2 ± 9.3% at 2-year follow-up (P < 0.05). The average lumbar curve was 20.7° ± 7.0° preoperatively and 12.7° ± 7.1° at 2-year follow-up (P < 0.05). The lumbar lordosis changed from - 39.5° ± 13.6° to - 43.6° ± 10.6° at 2-year follow-up (P < 0.05). Solid fusion was achieved in all patients. The technique of MIS-TLIF can be used to treat the patients with ALDS whose symptom is mainly from one-level lumbar stenosis, achieving favorable clinical outcomes and good fusion, with less blood loss and complications.

The Impact of Cage Dimensions, Positioning, and Side of Approach in Extreme Lateral Interbody Fusion.

PubMed

Alimi, Marjan; Lang, Gernot; Navarro-Ramirez, Rodrigo; Perrech, Moritz; Berlin, Connor; Hofstetter, Christoph P; Moriguchi, Yu; Elowitz, Eric; Härtl, Roger

2018-02-01

This is a retrospective single-center study. The aim of the study was to evaluate the impact of cage characteristics and position toward clinical and radiographic outcome measures in patients undergoing extreme lateral interbody fusion (ELIF). ELIF is utilized for indirect decompression and minimally invasive surgical treatment for various degenerative spinal disorders. However, evidence regarding the influence of cage characteristics in patient outcome is minimal. Patients undergoing ELIF between 2007 and 2011 were included in a retrospective study. Demographic and perioperative data, as well as cage characteristics and side of approach were extracted. Radiographic parameters including lumbar lordosis, foraminal height, and disc height as well as clinical outcome parameters (Oswestry Disability Index and Visual Analog Scale) were measured preoperatively, postoperatively, and at the latest follow-up examination. Cage dimensions, in situ position, and type were correlated with radiographic and clinical outcome parameters. In total, 84 patients with a total of 145 functional spinal units were analyzed. At the last follow-up of 17.7 months, radiographic and clinical outcome measures revealed significant improvement compared with before surgery with both, 18 and 22 mm cage anterior-posterior diameter subgroups (P≤0.05). Among cage characteristics, 22 mm cages presented superior restoration of foraminal and disc heights compared with 18 mm cages (P≤0.05). Neither position of the cage (anterior vs. posterior), nor the type (parallel vs. lordotic) had a significant impact on restoration of foraminal height and lumbar lordosis. Moreover, the side of surgical approach did not influence the amount of foraminal height increase. Cage anterior-posterior diameter is the determining factor in restoration of foraminal height in ELIF. Cage height, type, positioning, and side of approach do not have a determining role in radiographic outcome in the present study. Sustainable

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

PubMed

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

2014-07-01

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

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.

PubMed

Pan, Jie; Li, Lijun; Qian, Lie; Zhou, Wei; Tan, Jun; Zou, Le; Yang, Mingjie

2011-02-15

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

[Efficacy of Coflex in the treatment of lumbar spondylolisthesis].

PubMed

Hai, Y; Meng, X L; Li, D Y; Zhang, X N; Wang, Y S

2017-03-01

Objective: To study the clinical results of Coflex and lumbar posterior decompression and fusion in the treatment of lumbar degenerative spondylolisthesis at L(4-5). Methods: Thirty-eight patients with Grade Ⅰ degenerative spondylolisthesis, from January 2008 to December 2011 in Beijing Chaoyang Hospital, Capital Medical University were reviewed, and patients were divided into two groups by randomness. Group A was treated with Coflex and group B with pedicle instrumentation and interbody fusion. Fifteen patients were included in group A, and 23 patients were included in group B. In group A, the average age was (56.3±9.1) years. In group B, the average age was (58.2±11.2) years. The clinical results were evaluated by visual analogue scale (VAS) and Oswestry disability index (ODI). Slip distance (SD) was measured before and after surgery, and the changes of intervertebral angle at index level and adjacent level were also recorded. Results: The follow-up period was 36 to 68 months, with the average of (39±14) months in the both groups. The operation time and bleeding volume of patients in group A were significantly less than that of group B ( P <0.05). In both groups, the difference of ODI and VAS before operation and postoperative follow-up were statistically significant ( P <0.05). There was no significant difference between lumbar intervertebral angle and the sliding distance in group A at all time points. In the group B, there was a significant increase in the intervertebral angle and the sliding distance at L(3-4) and L(5)-S(1 )level after surgery, the difference at upper and below adjacent segment before and after surgery were statistically significant. Conclusions: Coflex interspinous dynamic stabilization system has same excellent clinical results as pedicle screw instrumentation and fusion surgery for the treatment of L(4-5) degenerative spondylolisthesis; no significant progression of spondylolisthesis been observed during more than 3 years follow

Novel spinal instrumentation to enhance osteogenesis and fusion: a preliminary study.

PubMed

MacEwan, Matthew R; Talcott, Michael R; Moran, Daniel W; Leuthardt, Eric C

2016-09-01

OBJECTIVE Instrumented spinal fusion continues to exhibit high failure rates in patients undergoing multilevel lumbar fusion or pseudarthrosis revision; with Grade II or higher spondylolisthesis; or in those possessing risk factors such as obesity, tobacco use, or metabolic disorders. Direct current (DC) electrical stimulation of bone growth represents a unique surgical adjunct in vertebral fusion procedures, yet existing spinal fusion stimulators are not optimized to enhance interbody fusion. To develop an advanced method of applying DC electrical stimulation to promote interbody fusion, a novel osteogenic spinal system capable of routing DC through rigid instrumentation and into the vertebral bodies was fabricated. A pilot study was designed to assess the feasibility of osteogenic instrumentation and compare the ability of osteogenic instrumentation to promote successful interbody fusion in vivo to standard spinal instrumentation with autograft. METHODS Instrumented, single-level, posterior lumbar interbody fusion (PLIF) with autologous graft was performed at L4-5 in adult Toggenburg/Alpine goats, using both osteogenic spinal instrumentation (plus electrical stimulation) and standard spinal instrumentation (no electrical stimulation). At terminal time points (3 months, 6 months), animals were killed and lumbar spines were explanted for radiographic analysis using a SOMATOM Dual Source Definition CT Scanner and high-resolution Microcat II CT Scanner. Trabecular continuity, radiodensity within the fusion mass, and regional bone formation were examined to determine successful spinal fusion. RESULTS Quantitative analysis of average bone density in pedicle screw beds confirmed that electroactive pedicle screws used in the osteogenic spinal system focally enhanced bone density in instrumented vertebral bodies. Qualitative and quantitative analysis of high-resolution CT scans of explanted lumbar spines further demonstrated that the osteogenic spinal system induced solid

Clinical outcome of trans-sacral interbody fusion after partial reduction for high-grade l5-s1 spondylolisthesis.

PubMed

Smith, J A; Deviren, V; Berven, S; Kleinstueck, F; Bradford, D S

2001-10-15

A clinical retrospective study was conducted. To evaluate the clinical and radiographic outcome of reduction followed by trans-sacral interbody fusion for high-grade spondylolisthesis. In situ posterior interbody fusion with fibula allograft has improved the fusion rates for patients with high-grade spondylolisthesis. The use of this technique in conjunction with partial reduction has not been reported. Nine consecutive patients underwent treatment of high-grade (Grade 3 or 4) spondylolisthesis with partial reduction followed by posterior interbody fusion using cortical allograft. The average age at the time of surgery was 27 years (range, 8-51 years), and the average follow-up period was 43 months (range, 24-72 months). Before surgery, eight patients had low back pain, seven patients had radiating leg pain, and five patients had hamstring tightness. The average grade of spondylolisthesis by Meyerding grading was 3.9 (range, 3-5). Charts and radiographs were evaluated, and outcomes were collected by use of the modified SRS outcomes instrument. Radiographic indexes demonstrated significant improvement with partial reduction and fusion. The slip angle, as measured from the inferior endplate of L5, improved from 41.2 degrees (range, 24-82 degrees ) before surgery to 21 degrees (range, 5-40 degrees ) after surgery. All the patients were extremely or somewhat satisfied with surgery. The two patients who underwent this operation without initial instrumentation experienced fractures of their interbody grafts. Both of these patients underwent repair of the pseudarthrosis with placement of trans-sacral pedicle screw instrumentation and subsequent fusion. Partial reduction followed by posterior interbody fusion is an effective technique for the management of high-grade spondylolisthesis in pediatric and adult patient populations, as assessed by radiographic and clinical criteria. Pedicle screw instrumentation with the sacral screws capturing L5 is recommended when this

Clinical comparison of Zero-profile interbody fusion device and anterior cervical plate interbody fusion in treating cervical spondylosis.

PubMed

Yan, Bin; Nie, Lin

2015-01-01

the aim of the study was to compare the clinical effect of Zero-profile interbody fusion device (Zero-P) with anterior cervical plate interbody fusion system (PCB) in treating cervical spondylosis. a total of 98 patients with cervical spondylosis (110 segments) in February 2011 to January 2013 were included in our hospital. All participants were randomly divided into observation group and control group with 49 cases in each group. The observation group was treated with Zero-P, while the control group received PCB treatment. Comparison of the two groups in neurological function score (JOA), pain visual analogue scale (VAS), the neck disability index (NDI), quality of life score (SF-36) and cervical curvature (Cobb angle) change were recorded and analyzed before and after treatment. The observation group was found with 90% excellent and good rate, which was higher than that of the control group (80%). Dysphagia rate in observational group was 16.33% (8/49), which was significantly less than that in control group (46.94%). Operation time and bleeding volume in the observation group was less than those in control group. Postoperative improvements of JOA score, VAS score, and NDI in observational group were also significantly better than that in control group (P<0.05). The clinical effect of Zero-P and PCB for the treatment of cervical spondylosis was quite fair, but Zero-P showed a better therapeutic effect with improvement of life quality.

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

PubMed

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

2017-01-01

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

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

PubMed

Werle, Stephan; AbuNahleh, Kais; Boehm, Heinrich

2016-08-01

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

"Push-Through" Rod Passage Technique for the Improvement of Lumbar Lordosis and Sagittal Balance in Minimally Invasive Adult Degenerative Scoliosis Surgery.

PubMed

Haque, Raqeeb M; Uddin, Omar M; Ahmed, Yousef; El Ahmadieh, Tarek Y; Hashmi, Sohaib Z; Shah, Amir; Fessler, Richard G

2016-10-01

Traditional open surgical techniques for correction of adult degenerative scoliosis (ADS) are often associated with increased blood loss, postoperative pain, and complications. Minimally invasive (MIS) techniques have been utilized to address these issues; however, concerns regarding improving certain alignment parameters have been raised. A new "push-through" technique for MIS correction of ADS has been developed wherein a rod is bent before its placement into the screw heads and then contoured further to yield improved correction of radiographic parameters. Preoperative and postoperative radiographic measurements of 3 patients who underwent MIS correction of scoliosis using the "push-through" technique were compared with 22 prior patients who had received traditional MIS correction. All patients received staged correction of scoliosis. The first stage involved insertion of lateral lumbar interbodies. Standing x-rays were then evaluated for overall global balance. The second stage involved appropriate MIS facetectomies, facet fusions, posterior transforaminal interbodies at lower lumbar segments, and finally the placement of rods.TECHNIQUE OVERVIEW:: (1) A long rod composed of titanium is bent with a mild lordosis and passed through the extensions of the screw heads cephalad to caudad. (2) The rod is passed fully through the incision so it extrudes from the caudal end of the construct. At this point, further lordosis is bent into the rods. (3) The rod is then pulled back into the appropriate position. (4) The unnecessary cephalad rod is then cut to appropriate length with a circular saw. (5) Rod reducers are then sequentially lowered and tightened to achieve the desired correction. Mean age for all patients was 66.02 years. Preoperative coronal Cobb, sagittal vertical axis (SVA), and pelvic incidence (PI) were similar in all patients, whereas lumbar lordosis (LL) was smaller (15.27 vs. 29.85 degrees, P=0.00389) and pelvic tilt (PT) was larger (37.00 vs. 27

Comparison of CD HORIZON SPIRE spinous process plate stabilization and pedicle screw fixation after anterior lumbar interbody fusion. Invited submission from the Joint Section Meeting On Disorders of the Spine and Peripheral Nerves, March 2005.

PubMed

Wang, Jeremy C; Haid, Regis W; Miller, Jay S; Robinson, James C

2006-02-01

The authors present the early clinical results obtained in patients who underwent SPIRE spinous process plate fixation following anterior lumbar interbody fusion (ALIF). Between May 2003 and January 2005, 32 patients underwent titanium cage and bone morphogenetic protein-augmented ALIF and subsequent SPIRE (21 cases) or bilateral pedicle screw (BPS; 11 cases) fixation. Pedicle screws were implanted using either the open approach (three cases) or using a tubular retractor (eight cases). Patients' charts were reviewed for operative time, estimated blood loss (EBL), hospital length of stay (LOS), and evidence of pseudarthrosis or hardware failure. In SPIRE plate-treated patients, the median EBL (75 ml) was lower than in BPS-treated patients (open BPS [150 ml]; tubular BPS [125 ml]). The median operative time in SPIRE plate-treated patients was also shorter (164 minutes compared with 239 and 250 minutes in the open and tubular BPS, respectively). The median LOS was 3 days for both the SPIRE and tubular BPS groups, but 4 days in the open BPS group. There were no instances of major surgery-induced complication, pseudarthrosis, or hardware failure during mean follow-up periods of 5.5, 7.2, and 4.9 months in the SPIRE, open PS, and tubular BPS groups, respectively. The SPIRE plate is easy to implant and is associated with minimal operative risk. Compared with BPS/rod constructs, SPIRE plate fixation leads to less EBL and shorter operative time, without an increase in the rate of pseudarthrosis. Hospital LOS was also shorter in SPIRE plate-treated patients, which is consistent with the goals of minimal access spinal technologies.

Lumbar Corsets Can Decrease Lumbar Motion in Golf Swing

PubMed Central

Hashimoto, Koji; Miyamoto, Kei; Yanagawa, Takashi; Hattori, Ryo; Aoki, Takaaki; Matsuoka, Toshio; Ohno, Takatoshi; Shimizu, Katsuji

2013-01-01

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 points Rotational and extension forces on the lumbar spine may cause golf-related low back pain Wearing 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

Lumbar corsets can decrease lumbar motion in golf swing.

PubMed

Hashimoto, Koji; Miyamoto, Kei; Yanagawa, Takashi; Hattori, Ryo; Aoki, Takaaki; Matsuoka, Toshio; Ohno, Takatoshi; Shimizu, Katsuji

2013-01-01

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.

The Use of a Dehydrated Amnion/Chorion Membrane Allograft in Patients Who Subsequently Undergo Reexploration after Posterior Lumbar Instrumentation

PubMed Central

Subach, Brian R.; Copay, Anne G.

2015-01-01

Background Context. Products that can reduce development of epidural fibrosis may reduce risk for ongoing pain associated with development of scar tissue and make subsequent epidural reexploration easier. Purpose. To evaluate the use of dehydrated human amnion/chorion membrane (dHACM) on the formation of soft tissue scarring in the epidural space. Study Design. Case series. Patient Sample. Five patients having transforaminal lumbar interbody lumbar fusion (TLIF) with posterior instrumentation and implantation of dHACM in the epidural space and subsequent epidural reexploration. Outcome Measures. Degree of scar tissue adjacent to the epidural space at reexploration. Intraoperative and postoperative complications related to dHACM and patient reported outcomes. Methods. The degree of scar tissue adjacent to the epidural space was assessed during the reexploration surgery. Patients' outcomes were collected using standard validated questionnaires. Results. Four of 5 cases had easily detachable tissue during epidural reexploration. Angiolipoma of 10% was noted in 1 case and 5% in 2 cases. Significant improvements in patient reported outcomes were observed. No intraoperative or postoperative complications occurred. Conclusions. Our findings suggest that dHACM implant during TLIF may have favorable effects on epidural fibrosis and is well tolerated. Further studies with larger cohorts are required to prove our results. PMID:25653880

Structural and mechanical evaluations of a topology optimized titanium interbody fusion cage fabricated by selective laser melting process.

PubMed

Lin, Chia-Ying; Wirtz, Tobias; LaMarca, Frank; Hollister, Scott J

2007-11-01

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. Copyright (c) 2007 Wiley Periodicals, Inc.

Tertiary syphilis in the lumbar spine: a case report.

PubMed

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

2017-07-24

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

[Lumbar spondylosis].

PubMed

Seichi, Atsushi

2014-10-01

Lumbar spondylosis is a chronic, noninflammatory disease caused by degeneration of lumbar disc and/or facet joints. The etiology of lumbar spondylosis is multifactorial. Patients with lumbar spondylosis complain of a broad variety of symptoms including discomfort in the low back lesion, whereas some of them have radiating leg pain or neurologenic intermittent claudication (lumbar spinal stenosis). The majority of patients with spondylosis and stenosis of the lumbosacral spine can be treated nonsurgically. Nonsteroidal anti-inflammatory drugs and COX-2 inhibitors are helpful in controlling symptoms. Prostaglandin, epidural injection, and transforaminal injection are also helpful for leg pain and intermittent claudication. Operative therapy for spinal stenosis or spondylolisthesis is reserved for patients who are totally incapacitated by their condition.

Assessment of Lumbar Lordosis and Lumbar Core Strength in Information Technology Professionals.

PubMed

Mehta, Roma Satish; Nagrale, Sanket; Dabadghav, Rachana; Rairikar, Savita; Shayam, Ashok; Sancheti, Parag

2016-06-01

Observational study. To correlate lumbar lordosis and lumbar core strength in information technology (IT) professionals. IT professionals have to work for long hours in a sitting position, which can affect lumbar lordosis and lumbar core strength. Flexicurve was used to assess the lumbar lordosis, and pressure biofeedback was used to assess the lumbar core strength in the IT professionals. All subjects, both male and female, with and without complaint of low back pain and working for two or more years were included, and subjects with a history of spinal surgery or spinal deformity were excluded from the study. Analysis was done using Pearson's correlation. For the IT workers, no correlation was seen between lumbar lordosis and lumbar core strength (r=-0.04); however, a weak negative correlation was seen in IT people who complained of pain (r=-0.12), while there was no correlation of lumbar lordosis and lumbar core in IT people who had no complains of pain (r=0.007). The study shows that there is no correlation of lumbar lordosis and lumbar core strength in IT professionals, but a weak negative correlation was seen in IT people who complained of pain.

Load-sharing through elastic micro-motion accelerates bone formation and interbody fusion.

PubMed

Ledet, Eric H; Sanders, Glenn P; DiRisio, Darryl J; Glennon, Joseph C

2018-02-13

Achieving a successful spinal fusion requires the proper biological and biomechanical environment. Optimizing load-sharing in the interbody space can enhance bone formation. For anterior cervical discectomy and fusion (ACDF), loading and motion are largely dictated by the stiffness of the plate, which can facilitate a balance between stability and load-sharing. The advantages of load-sharing may be substantial for patients with comorbidities and in multilevel procedures where pseudarthrosis rates are significant. We aimed to evaluate the efficacy of a novel elastically deformable, continuously load-sharing anterior cervical spinal plate for promotion of bone formation and interbody fusion relative to a translationally dynamic plate. An in vivo animal model was used to evaluate the effects of an elastically deformable spinal plate on bone formation and spine fusion. Fourteen goats underwent an ACDF and received either a translationally dynamic or elastically deformable plate. Animals were followed up until 18 weeks and were evaluated by plain x-ray, computed tomography scan, and undecalcified histology to evaluate the rate and quality of bone formation and interbody fusion. Animals treated with the elastically deformable plate demonstrated statistically significantly superior early bone formation relative to the translationally dynamic plate. Trends in the data from 8 to 18 weeks postoperatively suggest that the elastically deformable implant enhanced bony bridging and fusion, but these enhancements were not statistically significant. Load-sharing through elastic micro-motion accelerates bone formation in the challenging goat ACDF model. The elastically deformable implant used in this study may promote early bony bridging and increased rates of fusion, but future studies will be necessary to comprehensively characterize the advantages of load-sharing through micro-motion. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Impaction durability of porous polyether-ether-ketone (PEEK) and titanium-coated PEEK interbody fusion devices.

PubMed

Torstrick, F Brennan; Klosterhoff, Brett S; Westerlund, L Erik; Foley, Kevin T; Gochuico, Joanna; Lee, Christopher S D; Gall, Ken; Safranski, David L

2018-05-01

Various surface modifications, often incorporating roughened or porous surfaces, have recently been introduced to enhance osseointegration of interbody fusion devices. However, these topographical features can be vulnerable to damage during clinical impaction. Despite the potential negative impact of surface damage on clinical outcomes, current testing standards do not replicate clinically relevant impaction loading conditions. The purpose of this study was to compare the impaction durability of conventional smooth polyether-ether-ketone (PEEK) cervical interbody fusion devices with two surface-modified PEEK devices that feature either a porous structure or plasma-sprayed titanium coating. A recently developed biomechanical test method was adapted to simulate clinically relevant impaction loading conditions during cervical interbody fusion procedures. Three cervical interbody fusion devices were used in this study: smooth PEEK, plasma-sprayed titanium-coated PEEK, and porous PEEK (n=6). Following Kienle et al., devices were impacted between two polyurethane blocks mimicking vertebral bodies under a constant 200 N preload. The posterior tip of the device was placed at the entrance between the polyurethane blocks, and a guided 1-lb weight was impacted upon the anterior face with a maximum speed of 2.6 m/s to represent the strike force of a surgical mallet. Impacts were repeated until the device was fully impacted. Porous PEEK durability was assessed using micro-computed tomography (µCT) pre- and postimpaction. Titanium-coating coverage pre- and postimpaction was assessed using scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy. Changes to the surface roughness of smooth and titanium-coated devices were also evaluated. Porous PEEK and smooth PEEK devices showed minimal macroscopic signs of surface damage, whereas the titanium-coated devices exhibited substantial visible coating loss. Quantification of the porous PEEK deformation

Cauda Equina Syndrome Due to Vigorous Back Massage With Spinal Manipulation in a Patient With Pre-Existing Lumbar Disc Herniation: A Case Report and Literature Review.

PubMed

Yang, Si-Dong; Chen, Qian; Ding, Wen-Yuan

2018-04-01

Cauda equina syndrome (CES) resulting from acute lumbar disc herniation due to spinal massage is extremely rare. We present a case of CES caused by the acute worsening of a lumbar disc herniation after a vigorous back massage that included spinal manipulation. After vigorous back massage with spinal manipulation performed by a massage therapist, a 38-yr-old male patient experienced CES with severe numbness in both lower limbs, inability to walk due to weakness of bilateral lower limbs, and incontinence of urine and feces. The magnetic resonance imaging and computer tomography scan results showed that the L4-5 disc herniated down into the spinal canal, extensively compressing the ventral dural sac. The patient was successfully treated with an emergency operation including laminectomy, spinal canal decompression, discectomy, interbody fusion, and pedicle screw fixation. The muscle power in both lower limbs of the patient recovered rapidly to support standing only 1 wk later. Moreover, he regained continence of urine and feces. In conclusion, this case brings us novel knowledge that spinal massage or manipulation may worsen pre-existing disc herniation causing CES, and a timely emergency surgery is necessary and effective for treatment of CES-related symptoms.

Anterior cervical fusion with interbody cage containing β-tricalcium phosphate augmented with plate fixation: a prospective randomized study with 2-year follow-up

PubMed Central

Jiang, Lei-Sheng

2008-01-01

A variety of bone graft substitutes, interbody cages, and anterior plates have been used in cervical interbody fusion, but no controlled study was conducted on the clinical performance of β-tricalcium phosphate (β-TCP) and the effect of supplemented anterior plate fixation. The objective of this prospective, randomized clinical study was to evaluate the effectiveness of implanting interbody fusion cage containing β-TCP for the treatment of cervical radiculopathy and/or myelopathy, and the fusion rates and outcomes in patients with or without randomly assigned plate fixation. Sixty-two patients with cervical radiculopathy and/or myelopathy due to soft disc herniation or spondylosis were treated with one- or two-level discectomy and fusion with interbody cages containing β-TCP. They were randomly assigned to receive supplemented anterior plate (n = 33) or not (n = 29). The patients were followed up for 2 years postoperatively. The radiological and clinical outcomes were assessed during a 2-year follow-up. The results showed that the fusion rate (75.0%) 3 months after surgery in patients treated without anterior cervical plating was significantly lower than that (97.9%) with plate fixation (P < 0.05), but successful bone fusion was achieved in all patients of both groups at 6-month follow-up assessment. Patients treated without anterior plate fixation had 11 of 52 (19.2%) cage subsidence at last follow-up. No difference (P > 0.05) was found regarding improvement in spinal curvature as well as neck and arm pain, and recovery rate of JOA score at all time intervals between the two groups. Based on the findings of this study, interbody fusion cage containing β-TCP following one- or two-level discectomy proved to be an effective treatment for cervical spondylotic radiculopathy and/or myelopathy. Supplemented anterior plate fixation can promote interbody fusion and prevent cage subsidence but do not improve the 2-year outcome when compared with those treated

An Automated Method for Landmark Identification and Finite-Element Modeling of the Lumbar Spine.

PubMed

Campbell, Julius Quinn; Petrella, Anthony J

2015-11-01

The purpose of this study was to develop a method for the automated creation of finite-element models of the lumbar spine. Custom scripts were written to extract bone landmarks of lumbar vertebrae and assemble L1-L5 finite-element models. End-plate borders, ligament attachment points, and facet surfaces were identified. Landmarks were identified to maintain mesh correspondence between meshes for later use in statistical shape modeling. 90 lumbar vertebrae were processed creating 18 subject-specific finite-element models. Finite-element model surfaces and ligament attachment points were reproduced within 1e-5 mm of the bone surface, including the critical contact surfaces of the facets. Element quality exceeded specifications in 97% of elements for the 18 models created. The current method is capable of producing subject-specific finite-element models of the lumbar spine with good accuracy, quality, and robustness. The automated methods developed represent advancement in the state of the art of subject-specific lumbar spine modeling to a scale not possible with prior manual and semiautomated methods.

The influence of lumbar extensor muscle fatigue on lumbar-pelvic coordination during weightlifting.

PubMed

Hu, Boyi; Ning, Xiaopeng

2015-01-01

Lumbar muscle fatigue is a potential risk factor for the development of low back pain. In this study, we investigated the influence of lumbar extensor muscle fatigue on lumbar-pelvic coordination patterns during weightlifting. Each of the 15 male subjects performed five repetitions of weightlifting tasks both before and after a lumbar extensor muscle fatiguing protocol. Lumbar muscle electromyography was collected to assess fatigue. Trunk kinematics was recorded to calculate lumbar-pelvic continuous relative phase (CRP) and CRP variability. Results showed that fatigue significantly reduced the average lumbar-pelvic CRP value (from 0.33 to 0.29 rad) during weightlifting. The average CRP variability reduced from 0.17 to 0.15 rad, yet this change ws statistically not significant. Further analyses also discovered elevated spinal loading during weightlifting after the development of lumbar extensor muscle fatigue. Our results suggest that frequently experienced lumbar extensor muscle fatigue should be avoided in an occupational environment. Lumbar extensor muscle fatigue generates more in-phase lumbar-pelvic coordination patterns and elevated spinal loading during lifting. Such increase in spinal loading may indicate higher risk of back injury. Our results suggest that frequently experienced lumbar muscle fatigue should be avoided to reduce the risk of LBP.

Does impaction of titanium-coated interbody fusion cages into the disc space cause wear debris or delamination?

PubMed

Kienle, Annette; Graf, Nicolas; Wilke, Hans-Joachim

2016-02-01

A large number of interbody fusion cages are made of polyetheretherketone (PEEK). To improve bone on-growth, some are coated with a thin layer of titanium. This coating may fail when subjected to shear loading. The purpose of this testing was to investigate whether impaction of titanium-coated PEEK cages into the disc space can result in wear or delamination of the coating, and whether titanium cages with subtractive surface etching (no coating) are less susceptible to such failure. A biomechanical study was carried out to simulate the impaction process in clinical practice and to evaluate if wear or delamination may result from impaction. Two groups of posterior lumbar interbody fusion cages with a similar geometry were tested: n=6 titanium-coated PEEK and n=6 surface-etched titanium cages. The cages were impacted into the space in between two vertebral body substitutes (polyurethane foam blocks). The two vertebral body substitutes were fixed in a device, through which a standardized axial preload of 390 N was applied. The anterior tip of the cage was positioned at the posterior border of the space between the two vertebral body substitutes. The cages were then inserted using a drop weight with a mass representative of a surgical hammer. The drop weight impacted the insertion instrument at a maximum speed of about 2.6 m/s, which is in the range of the impaction speed in vivo. This was repeated until the cages were fully inserted. The wear particles were captured and analyzed according to the pertinent standards. The surface-etched titanium cages did not show any signs of wear debris or surface damage. In contrast, the titanium-coated PEEK cages resulted in detached wear particles of different sizes (1-191 µm). Over 50% of these particles had a size <10 µm. In median, on 26% of the implants' teeth, the coating was abraded. Full delamination was not observed. In contrast to the surface-etched implants, the titanium-coated PEEK implants lost some coating material

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral brucellosis.

PubMed

Abulizi, Yakefu; Liang, Wei-Dong; Muheremu, Aikeremujiang; Maimaiti, Maierdan; Sheng, Wei-Bin

2017-07-14

Spinal brucellosis is a less commonly reported infectious spinal pathology. There are few reports regarding the surgical treatment of spinal brucellosis in existing literature. This retrospective study was conducted to determine the effectiveness of single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral spinal brucellosis. From February 2012 to April 2015, 32 consecutive patients (19 males and 13 females, mean age 53.7 ± 8.7) with lumbosacral brucellosis treated by transforaminal decompression, debridement, interbody fusion, and posterior instrumentation were enrolled. Medical records, imaging studies, laboratory data were collected and summarized. Surgical outcomes were evaluated based on visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scale. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms and complications were investigated. Graft fusion was evaluated using Bridwell grading criteria. The mean follow-up period was 24.9 ± 8.2 months. Back pain and radiating leg pain was relieved significantly in all patients after operation. No implant failures were observed in any patients. Wound infection was observed in two patients and sinus formation was observed in one patient. Solid bony fusion was achieved in 30 patients and the fusion rate was 93.8%. The levels of ESR and CRP were returned to normal by the end of three months' follow-up. VAS and ODI scores were significantly improved (P < 0.05). According to JOA score, surgical improvement was excellent in 22 cases (68.8%), good in 9 cases (28.1%), moderate in 1 case (3.1%) at the last follow-up. Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation is an effective and safe approach for lumbosacral brucellosis.

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

PubMed

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

2016-06-10

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

Hybrids: good for cars and the environment-are they good for the spine too?

PubMed

Bono, Christopher M

2009-10-01

Erkan S, Rivera Y, Wu C, et al. Biomechanical comparison of a two-level Maverick disc replacement with a hybrid one-level disc replacement and one-level anterior lumbar interbody fusion. Spine J 2009;9:830-835 (in this issue).

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

PubMed

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

2017-03-01

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

Biomechanical evaluation of a biomimetic spinal construct.

PubMed

Wang, Tian; Ball, Jonathon R; Pelletier, Mattew H; Walsh, William R

2014-12-01

Laboratory spinal biomechanical tests using human cadaveric or animal spines have limitations in terms of disease transmission, high sample variability, decay and fatigue during extended testing protocols. Therefore, a synthetic biomimetic spine model may be an acceptable substitute. The goal of current study is to evaluate the properties of a synthetic biomimetic spine model; also to assess the mechanical performance of lateral plating following lateral interbody fusion. Three L3/4 synthetic spinal motion segments were examined using a validated pure moment testing system. Moments (±7.5 Nm) were applied in flexion-extension (FE), lateral bending (LB) and axial rotation (AR) at 1Hz for total 10000 cycles in MTS Bionix. An additional test was performed 12 hours after 10000 cycles. A ±10 Nm cycle was also performed to allow provide comparison to the literature. For implantation evaluation, each model was tested in the 4 following conditions: 1) intact, 2) lateral cage alone, 3) lateral cage and plate 4) anterior cage and plate. Results were analysed using ANOVA with post-hoc Tukey's HSD test. Range of motion (ROM) exhibited logarithmic growth with cycle number (increases of 16%, 37.5% and 24.3% in AR, FE and LB respectively). No signification difference (p > 0.1) was detected between 4 cycles, 10000 cycles and 12 hour rest stages. All measured parameters were comparable to that of reported cadaveric values. The ROM for a lateral cage and plate construct was not significantly different to the anterior lumbar interbody construct for FE (p = 1.00), LB (p = 0.995) and AR (p = 0.837). Based on anatomical and biomechanical similarities, the synthetic spine tested here provides a reasonable model to represent the human lumbar spine. Repeated testing did not dramatically alter biomechanics which may allow non-destructive testing between many different procedures and devices without the worry of carry over effects. Small intra-specimen variability

49 CFR 572.75 - Lumbar spine, abdomen, and pelvis assembly and test procedure.

Code of Federal Regulations, 2012 CFR

2012-10-01

... specified in Figure 42. (2) Adjust the dummy by— (i) Tightening the femur ballflange screws at each hip socket joint to 50 inch-pounds torque; (ii) Attaching the pelvis to the seating surface by a bolt D/605... drawing Figure 42. (iv) Tightening the mountings so that the pelvis-lumbar joining surface is horizontal...

49 CFR 572.75 - Lumbar spine, abdomen, and pelvis assembly and test procedure.

Code of Federal Regulations, 2013 CFR

2013-10-01

... specified in Figure 42. (2) Adjust the dummy by— (i) Tightening the femur ballflange screws at each hip socket joint to 50 inch-pounds torque; (ii) Attaching the pelvis to the seating surface by a bolt D/605... drawing Figure 42. (iv) Tightening the mountings so that the pelvis-lumbar joining surface is horizontal...

49 CFR 572.75 - Lumbar spine, abdomen, and pelvis assembly and test procedure.

Code of Federal Regulations, 2010 CFR

2010-10-01

... specified in Figure 42. (2) Adjust the dummy by— (i) Tightening the femur ballflange screws at each hip socket joint to 50 inch-pounds torque; (ii) Attaching the pelvis to the seating surface by a bolt D/605... drawing Figure 42. (iv) Tightening the mountings so that the pelvis-lumbar joining surface is horizontal...

49 CFR 572.75 - Lumbar spine, abdomen, and pelvis assembly and test procedure.

Code of Federal Regulations, 2011 CFR

2011-10-01

... specified in Figure 42. (2) Adjust the dummy by— (i) Tightening the femur ballflange screws at each hip socket joint to 50 inch-pounds torque; (ii) Attaching the pelvis to the seating surface by a bolt D/605... drawing Figure 42. (iv) Tightening the mountings so that the pelvis-lumbar joining surface is horizontal...

49 CFR 572.75 - Lumbar spine, abdomen, and pelvis assembly and test procedure.

Code of Federal Regulations, 2014 CFR

2014-10-01

... specified in Figure 42. (2) Adjust the dummy by— (i) Tightening the femur ballflange screws at each hip socket joint to 50 inch-pounds torque; (ii) Attaching the pelvis to the seating surface by a bolt D/605... drawing Figure 42. (iv) Tightening the mountings so that the pelvis-lumbar joining surface is horizontal...

Influence of Lumbar Lordosis on the Outcome of Decompression Surgery for Lumbar Canal Stenosis.

PubMed

Chang, Han Soo

2018-01-01

Although sagittal spinal balance plays an important role in spinal deformity surgery, its role in decompression surgery for lumbar canal stenosis is not well understood. To investigate the hypothesis that sagittal spinal balance also plays a role in decompression surgery for lumbar canal stenosis, a prospective cohort study analyzing the correlation between preoperative lumbar lordosis and outcome was performed. A cohort of 85 consecutive patients who underwent decompression for lumbar canal stenosis during the period 2007-2011 was analyzed. Standing lumbar x-rays and 36-item short form health survey questionnaires were obtained before and up to 2 years after surgery. Correlations between lumbar lordosis and 2 parameters of the 36-item short form health survey (average physical score and bodily pain score) were statistically analyzed using linear mixed effects models. There was a significant correlation between preoperative lumbar lordosis and the 2 outcome parameters at postoperative, 6-month, 1-year, and 2-year time points. A 10° increase of lumbar lordosis was associated with a 5-point improvement in average physical scores. This correlation was not present in preoperative scores. This study showed that preoperative lumbar lordosis significantly influences the outcome of decompression surgery on lumbar canal stenosis. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical anatomy and 3D virtual reconstruction of the lumbar plexus with respect to lumbar surgery.

PubMed

Lu, Sheng; Chang, Shan; Zhang, Yuan-zhi; Ding, Zi-hai; Xu, Xin Ming; Xu, Yong-qing

2011-04-14

Exposure of the anterior or lateral lumbar via the retroperitoneal approach easily causes injuries to the lumbar plexus. Lumbar plexus injuries which occur during anterior or transpsoas lumbar spine exposure and placement of instruments have been reported. This study aims is to provide more anatomical data and surgical landmarks in operations concerning the lumbar plexus in order to prevent lumbar plexus injuries and to increase the possibility of safety in anterior approach lumbar surgery. To study the applied anatomy related to the lumbar plexus of fifteen formaldehyde-preserved cadavers, Five sets of Virtual Human (VH) data set were prepared and used in the study. Three-dimensional (3D) computerized reconstructions of the lumbar plexus and their adjacent structures were conducted from the VH female data set. The order of lumbar nerves is regular. From the anterior view, lumbar plexus nerves are arranged from medial at L5 to lateral at L2. From the lateral view, lumbar nerves are arranged from ventral at L2 to dorsal at L5. The angle of each nerve root exiting outward to the corresponding intervertebral foramen increases from L1 to L5. The lumbar plexus nerves are observed to be in close contact with transverse processes (TP). All parts of the lumbar plexus were located by sectional anatomy in the dorsal third of the psoas muscle. Thus, access to the psoas major muscle at the ventral 2/3 region can safely prevent nerve injuries. 3D reconstruction of the lumbar plexus based on VCH data can clearly show the relationships between the lumbar plexus and the blood vessels, vertebral body, kidney, and psoas muscle. The psoas muscle can be considered as a surgical landmark since incision at the ventral 2/3 of the region can prevent lumbar plexus injuries for procedures requiring exposure of the lateral anterior of the lumbar. The transverse process can be considered as a landmark and reference in surgical operations by its relative position to the lumbar plexus. 3D

Clinical anatomy and 3D virtual reconstruction of the lumbar plexus with respect to lumbar surgery

PubMed Central

2011-01-01

Background Exposure of the anterior or lateral lumbar via the retroperitoneal approach easily causes injuries to the lumbar plexus. Lumbar plexus injuries which occur during anterior or transpsoas lumbar spine exposure and placement of instruments have been reported. This study aims is to provide more anatomical data and surgical landmarks in operations concerning the lumbar plexus in order to prevent lumbar plexus injuries and to increase the possibility of safety in anterior approach lumbar surgery. Methods To study the applied anatomy related to the lumbar plexus of fifteen formaldehyde-preserved cadavers, Five sets of Virtual Human (VH) data set were prepared and used in the study. Three-dimensional (3D) computerized reconstructions of the lumbar plexus and their adjacent structures were conducted from the VH female data set. Results The order of lumbar nerves is regular. From the anterior view, lumbar plexus nerves are arranged from medial at L5 to lateral at L2. From the lateral view, lumbar nerves are arranged from ventral at L2 to dorsal at L5. The angle of each nerve root exiting outward to the corresponding intervertebral foramen increases from L1 to L5. The lumbar plexus nerves are observed to be in close contact with transverse processes (TP). All parts of the lumbar plexus were located by sectional anatomy in the dorsal third of the psoas muscle. Thus, access to the psoas major muscle at the ventral 2/3 region can safely prevent nerve injuries. 3D reconstruction of the lumbar plexus based on VCH data can clearly show the relationships between the lumbar plexus and the blood vessels, vertebral body, kidney, and psoas muscle. Conclusion The psoas muscle can be considered as a surgical landmark since incision at the ventral 2/3 of the region can prevent lumbar plexus injuries for procedures requiring exposure of the lateral anterior of the lumbar. The transverse process can be considered as a landmark and reference in surgical operations by its relative

Lumbar spine CT scan

MedlinePlus

CAT scan - lumbar spine; Computed axial tomography scan - lumbar spine; Computed tomography scan - lumbar spine; CT - lower back ... CT scans rapidly makes detailed pictures of the lower back. The test may be used to look for: ...

High-repetition cyclic loading is a risk factor for a lumbar disorder.

PubMed

Navar, Daniel; Zhou, Bing-He; Lu, Yun; Solomonow, Moshe

2006-11-01

Epidemiological data suggest that prolonged exposure to cyclic lumbar flexion elicits a chronic neuromuscular disorder and disability in workers. This study provides a physiological and biomechanical assessment of various repetitions of cyclic lumbar flexion sessions as a risk factor for development of an acute neuromuscular disorder. An in vivo feline model was subjected to 10 minutes of cyclic (0.25-HZ) loading, followed by a 10-minute rest period, repeated three times in one experimental group, six times in a second group, and nine times in the third group, followed by rest for 7 hours. Displacement of the lumbar viscoelastic tissue and reflex electromyographic (EMG) activity from the lumbar multifidus muscle were monitored. Creep developed and accumulated during each load/rest period and partially recovered during the subsequent rest. Loading periods were characterized by a decrease in reflex EMG activity with superimposed spasms. In the 7-hour recovery period, initial hyperexcitability was present in all groups, whereas only the six- and nine-repetition groups displayed significant delayed hyperexcitability, indicating the presence of acute inflammation. The mathematical model developed fit the data reasonably well, as the R2 values were generally near 0.90. It was concluded that the resulting delayed muscular hyperexcitability constitutes an acute neuromuscular disorder associated with exposure to many repetitions of cyclic lumbar flexion. The acute disorder can become chronic if not allowed sufficient rest to resolve itself. Workers engaged in cyclic lumbar flexion (e.g., loading/unloading, assembly workers) should avoid long-term exposure in order to prevent the development of a chronic neuromuscular condition known as cumulative trauma disorder.

Elimination of Subsidence with 26-mm-Wide Cages in Extreme Lateral Interbody Fusion.

PubMed

Lang, Gernot; Navarro-Ramirez, Rodrigo; Gandevia, Lena; Hussain, Ibrahim; Nakhla, Jonathan; Zubkov, Micaella; Härtl, Roger

2017-08-01

Extreme lateral interbody fusion (ELIF) has gained popularity as a minimally invasive technique for indirect decompression. However, graft subsidence potentially threatens long-term success of ELIF. This study evaluated whether 26-mm-wide cages can eliminate subsidence and subsequent loss of decompression in ELIF. Patients undergoing ELIF surgery using a 26-mm-wide cage were analyzed retrospectively. Patient demographics and perioperative data for radiographic and clinical outcomes were recorded. Radiographic parameters included regional sagittal lumbar lordosis and foraminal and disc height. Clinical parameters were evaluated using the Oswestry Disability Index and visual analog scale. Subsidence of 26-mm-wide cages was compared with previous outcomes of patients undergoing ELIF using 18-mm-wide and 22-mm-wide cages. There were 21 patients and 28 spinal segments analyzed. Radiographic outcome measures such as disc and foraminal height revealed significant improvement at follow-up compared with before surgery (P = 0.001). Postoperative to last follow-up cage subsidence translated into 0.34 mm ± 0.26 and -0.55 mm ± 0.64 in disc and foraminal height loss, respectively. Patients with 26-mm-wide cages experienced less subsidence by means of disc (26 mm vs. 18 mm and 22 mm, P ≤ 0.05) and foraminal height (26 mm vs. 18 mm, P = 0.005; 26 mm vs. 22 mm, P = 0.208) loss compared with patients receiving 18-mm-wide and 22-mm-wide cages. The 26-mm-wide cages almost eliminated cage subsidence in ELIF. Compared with 18-mm-wide and 22-mm-wide cages, 26-mm-wide cages significantly reduced cage subsidence in ELIF at midterm follow-up. A 26-mm-wide cage should be used in ELIF to achieve sustained indirect decompression. Copyright © 2017. Published by Elsevier Inc.

Radiographic and Clinical Outcome of Silicate-substituted Calcium Phosphate (Si-CaP) Ceramic Bone Graft in Spinal Fusion Procedures.

PubMed

Alimi, Marjan; Navarro-Ramirez, Rodrigo; Parikh, Karishma; Njoku, Innocent; Hofstetter, Christoph P; Tsiouris, Apostolos J; Härtl, Roger

2017-07-01

Retrospective cohort study. To evaluate the radiographic and clinical outcome of silicate-substituted calcium phosphate (Si-CaP), utilized as a graft substance in spinal fusion procedures. Specific properties of Si-CaP provide the graft with negative surface charge that can result in a positive effect on the osteoblast activity and neovascularization of the bone. This study included those patients who underwent spinal fusion procedures between 2007 and 2011 in which Si-CaP was used as the only bone graft substance. Fusion was evaluated on follow-up CT scans. Clinical outcome was assessed using Oswestry Disability Index, Neck Disability Index, and the visual analogue scale (VAS) for back, leg, neck, and arm pain. A total of 234 patients (516 spinal fusion levels) were studied. Surgical procedures consisted of 57 transforaminal lumbar interbody fusion, 49 anterior cervical discectomy and fusion, 44 extreme lateral interbody fusion, 30 posterior cervical fusions, 19 thoracic fusion surgeries, 17 axial lumbar interbody fusions, 16 combined anterior and posterior cervical fusions, and 2 anterior lumbar interbody fusion. At a mean radiographic follow-up of 14.2±4.3 months, fusion was found to be present in 82.9% of patients and 86.8% of levels. The highest fusion rate was observed in the cervical region. At the latest clinical follow-up of 21.7±14.2 months, all clinical outcome parameters showed significant improvement. The Oswestry Disability Index improved from 45.6 to 13.3 points, Neck Disability Index from 40.6 to 29.3, VAS back from 6.1 to 3.5, VAS leg from 5.6 to 2.4, VAS neck from 4.7 to 2.7, and VAS arm from 4.1 to 1.7. Of 7 cases with secondary surgical procedure at the index level, the indication for surgery was nonunion in 3 patients. Si-CaP is an effective bone graft substitute. At the latest follow-up, favorable radiographic and clinical outcome was observed in the majority of patients. Level-III.

Lordosis Re-Creation in TLIF and PLIF: A Cadaveric Study of the Influence of Surgical Bone Resection and Cage Angle.

PubMed

Robertson, Peter A; Armstrong, William A; Woods, Daniel L; Rawlinson, Jeremy J

2018-04-24

Controlled cadaveric study of surgical technique in Transforaminal and Posterior Lumbar Interbody Fusion (TLIF & PLIF) OBJECTIVE.: To evaluate the contribution of surgical techniques and cage variables in lordosis re-creation in posterior interbody fusion (TLIF/PLIF). The major contributors to lumbar lordosis are the lordotic lower lumbar discs. The pathologies requiring treatment with segmental fusion are frequently hypolordotic or kyphotic. Current posterior based interbody techniques have a poor track record for recreating lordosis, although re-creation of lordosis with optimum anatomical alignment is associated with better outcomes and reduced adjacent segment change needing revision. It is unclear whether surgical techniques or cage parameters contribute significantly to lordosis re-creation. Eight instrumented cadaveric motion segments were evaluated with pre and post experimental radiological assessment of lordosis. Each motion segment was instrumented with pedicle screw fixation to allow segmental stabilization. The surgical procedures were unilateral TLIF with an 18° lordotic and 27 mm length cage, unilateral TLIF (18°, 27 mm) with bilateral facetectomy, unilateral TLIF (18°, 27 mm) with posterior column osteotomy, PLIF with bilateral cages (18°, 22 mm), and PLIF with bilateral cages (24°, 22 mm). Cage insertion used and 'insert and rotate' technique. Pooled results demonstrated a mean increase in lordosis of 2.2° with each procedural step (Lordosis increase was serially 1.8°, 3.5°, 1.6°, 2.5° & 1.6° through the procedures). TLIF and PLIF with posterior column osteotomy increased lordosis significantly compared with Unilateral TLIF and TLIF with bilateral facetectomy. The major contributors to lordosis re-creation were posterior column osteotomy, and PLIF with paired shorter cages rather than TLIF. This study demonstrates that the surgical approach to posterior interbody surgery influences lordosis gain and posterior column osteotomy

[Enlargement in managment of lumbar spinal stenosis].

PubMed

Steib, J P; Averous, C; Brinckert, D; Lang, G

1996-05-01

instability and to restore the normal static anatomy; thus bone resection is not necessary. At the present time all the lumbar stenoses with reduction in flexion are instrumented with spinal reduction and arthrodesis without opening the canal. The laminoarthrectomy and the enlargement are done when there is a fixed arthrosis which is rare in our practice and found in an older population. The follow-up shows a loss of reduction in some cases after reduction-instrumentation-arthrodesis and poses the question of an interbody fusion. We don't open the canal only for fusion (PLIF) if this is not necessary for the treatment of the stenosis. We think that, in such a situation, the future is ALIF with endoscopical approach. The problem is to determine which disc demanding this anterior fusion, is able to regenerate or not.

A comparison of radiographic and clinical outcomes of anterior lumbar interbody fusion performed with either a cellular bone allograft containing multipotent adult progenitor cells or recombinant human bone morphogenetic protein-2.

PubMed

Lee, Daniel Dongwhan; Kim, John Yongmin

2017-08-25

Both the map3 Cellular Allogeneic Bone Graft® and recombinant human bone morphogenetic protein 2 (rhBMP-2, Infuse®) were developed to provide an alternative to iliac crest autograft, thus eliminating the morbidity associated with its harvest. The recent literature concerning adverse events associated with the use of rhBMP-2, however, highlights the need for a safe and effective alternative. The multipotent adult progenitor cells (MAPC) found in map3 allograft may provide this alternative. The purpose of this study is to report 1-year outcomes of patients treated via anterior lumbar interbody fusion (ALIF) using either map3 Cellular Allogeneic Bone Graft or rhBMP-2 for bony fusion. This was a retrospective evaluation of 41 patients treated via ALIF with either map3 or rhBMP-2 in a polyetheretherketone cage with posterior stabilization at 1, 2, or 3 consecutive levels (L3-S1). Patients were equally divided between treatment groups. The Oswestry Disability Index (ODI) and visual analog scores (VAS) for pain were documented as part of the standard of care. An independent radiologist assessed bridging of bone, disc height, and lordosis. Primary outcome measures included radiographic analysis of fusion by plain film and CTs. Secondary clinical outcomes included visual analogue scale for neck and arm pain and low back disability index scores. The overall fusion rate was 91%, with no significant difference between groups. Improvements in ODI and VAS were observed among all patients (p < 0.001), with no significant difference between groups for ODI (p = 0.966) or VAS (p = 0.251). There was no significant difference in terms of changes to disc height and lordosis between groups (p < 0.05). The rhBMP-2 group had increased post-operative complications when compared to the map3 group, but the low numbers precluded statistical analysis. Improvements in radiographic and clinical findings were observed in both treatment groups one-year postoperatively. Map3 allograft

A 3D navigation template for guiding a unilateral lumbar pedicle screw with contralateral translaminar facet screw fixation: a study protocol for multicentre randomised controlled trials.

PubMed

Shao, Zhen-Xuan; He, Wei; He, Shao-Qi; Lin, Sheng-Lei; Huang, Zhe-Yu; Tang, Hong-Chao; Ni, Wen-Fei; Wang, Xiang-Yang; Wu, Ai-Min

2017-07-21

The incidence of lumbar disc degeneration disease has increased in recent years. Lumbar interbody fusion using two unilateral pedicle screws and a translaminar facet screw fixation has advantages of minimal invasiveness and lower costs compared with the traditional methods. Moreover, a method guided by a three-dimensional (3D) navigation template may help us improve the surgical accuracy and the success rate. This is the first randomised study using a 3D navigation template to guide a unilateral lumbar pedicle screw with contralateral translaminar facet screw fixation. Patients who meet the criteria of the surgery will be randomly divided into experimental groups and control groups by a computer-generated randomisation schedule. We will preoperatively design an individual 3D navigation template using CATIA software and MeditoolCreate. The following primary outcomes will be collected: screw angles compared with the optimal screw trajectories in 3D digital images, length of the wound incision, operative time, intraoperative blood loss and complications. The following secondary outcomes will be collected: visual analogue scale (VAS) for back pain, VAS for leg pain and the Oswestry Disability Index. These parameters will be evaluated on day 1 and then 3, 6, 12 and 24 months postoperatively. The study has been reviewed and approved by the institutional ethics review board of the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. The results will be presented at scientific communities and peer-reviewed journals. ChiCTR-IDR-17010466. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

[Finite element analysis of lumbar pelvic and proximal femur model with simulate lumbar rotatory manipulation].

PubMed

Hu, Hua; Xiong, Chang-Yuan; Han, Guo-Wu

2012-07-01

To study the changes of displacement and stress in the model of lumbar pelvic and proximal femur during lumbar rotatory manipulation. The date of lumbar pelvic and proximal femur CT scan by Mimics 10.01 software was established a lumbar pelvic and proximal femur geometric model, then the model was modified with Geomagic 9, at last the modified model was imported into hypermesh 10 and meshed with tetrahedron, at the same time,add disc and ligaments. According to the principle of lumbar rotatory manipulation,the lumbar rotatory manipulation were decomposed. The mechanical parameters assigned into the three-dimensional finite element model. The changes of displacement and stress in the model of lunbar pelvic and proximal femur under the four conditions were calculated with Abaqus model of Hypermesh 10. 1) Under the same condition,the displacement order of lumbar was L1>L2>L3>L5 L5, anterior column > middle column > posterior column. 2) Under the different conditions, the displacement order of lumbar,case 3>case 1>case 4>case 2. 3) Under the same conditions, the displacement order of lumbar inter-vertebral disc from L1,2 to L5S1 was L1,2>L2,3>L3,4>L4,5>L5S1, as for the same inter-vertebral disc, the order was: second quadrant>third quadrant>first quadrant>fourth quadrant. 4) Under the different conditions,the displacement order of the inter-vertebral disc was L1,2>L2,3>L3,4>L4,5>L5S1, but to same inter-vertebral disc: case 3>case 4>case 1 >case 2. 5) There were apparent displacement and stress concentration in pelvis and hip during the manipulation. 1) The principles of lumbar rotation manipulation closely related to the relative displacement caused by rotation of various parts of lumbar pelvic and proximal femur model; 2) During the process of lumbar rotatory manipulation, the angle of lateral bending and flexion can not be randomly increased; 3) During the process of lumbar rotatory manipulation, all the conditions of lumbar pelvic and proximal femur must be

Etiology of lumbar lordosis and its pathophysiology: a review of the evolution of lumbar lordosis, and the mechanics and biology of lumbar degeneration.

PubMed

Sparrey, Carolyn J; Bailey, Jeannie F; Safaee, Michael; Clark, Aaron J; Lafage, Virginie; Schwab, Frank; Smith, Justin S; Ames, Christopher P

2014-05-01

The goal of this review is to discuss the mechanisms of postural degeneration, particularly the loss of lumbar lordosis commonly observed in the elderly in the context of evolution, mechanical, and biological studies of the human spine and to synthesize recent research findings to clinical management of postural malalignment. Lumbar lordosis is unique to the human spine and is necessary to facilitate our upright posture. However, decreased lumbar lordosis and increased thoracic kyphosis are hallmarks of an aging human spinal column. The unique upright posture and lordotic lumbar curvature of the human spine suggest that an understanding of the evolution of the human spinal column, and the unique anatomical features that support lumbar lordosis may provide insight into spine health and degeneration. Considering evolution of the skeleton in isolation from other scientific studies provides a limited picture for clinicians. The evolution and development of human lumbar lordosis highlight the interdependence of pelvic structure and lumbar lordosis. Studies of fossils of human lineage demonstrate a convergence on the degree of lumbar lordosis and the number of lumbar vertebrae in modern Homo sapiens. Evolution and spine mechanics research show that lumbar lordosis is dictated by pelvic incidence, spinal musculature, vertebral wedging, and disc health. The evolution, mechanics, and biology research all point to the importance of spinal posture and flexibility in supporting optimal health. However, surgical management of postural deformity has focused on restoring posture at the expense of flexibility. It is possible that the need for complex and costly spinal fixation can be eliminated by developing tools for early identification of patients at risk for postural deformities through patient history (genetics, mechanics, and environmental exposure) and tracking postural changes over time.

Complications of Lumbar Artificial Disc Replacement Compared to Fusion: Results From the Prospective, Randomized, Multicenter US Food and Drug Administration Investigational Device Exemption Study of the Charité Artificial Disc

PubMed Central

Majd, Mohammed E.; Isaza, Jorge E.; Blumenthal, Scott L.; McAfee, Paul C.; Guyer, Richard D.; Hochschuler, Stephen H.; Geisler, Fred H.; Garcia, Rolando; Regan, John J.

2007-01-01

Background Previous reports of lumbar total disc replacement (TDR) have described significant complications. The US Food and Drug Administration (FDA) investigational device exemption (IDE) study of the Charité artificial disc represents the first level I data comparison of TDR to fusion. Methods In the prospective, randomized, multicenter IDE study, patients were randomized in a 2:1 ratio, with 205 patients in the Charité group and 99 patients in the control group (anterior lumbar interbody fusion [ALIF] with BAK cages). Inclusion criteria included confirmed single-level degenerative disc disease at L4-5 or L5-S1 and failure of nonoperative treatment for at least 6 months. Complications were reported throughout the study. Results The rate of approach-related complications was 9.8% in the investigational group and 10.1% in the control group. The rate of major neurological complications was similar between the 2 groups (investigational = 4.4%, control = 4.0%). There was a higher rate of superficial wound infection in the investigational group but no deep wound infections in either group. Pseudarthrosis occurred in 9.1% of control group patients. The rate of subsidence in the investigational group was 3.4%. The reoperation rate was 5.4% in the investigational group and 9.1% in the control group. Conclusions The incidence of perioperative and postoperative complications for lumbar TDR was similar to that of ALIF. Vigilance is necessary with respect to patient indications, training, and correct surgical technique to maintain TDR complications at the levels experienced in the IDE study. PMID:25802575

Interbody fusion cage design using integrated global layout and local microstructure topology optimization.

PubMed

Lin, Chia-Ying; Hsiao, Chun-Ching; Chen, Po-Quan; Hollister, Scott J

2004-08-15

An approach combining global layout and local microstructure topology optimization was used to create a new interbody fusion cage design that concurrently enhanced stability, biofactor delivery, and mechanical tissue stimulation for improved arthrodesis. To develop a new interbody fusion cage design by topology optimization with porous internal architecture. To compare the performance of this new design to conventional threaded cage designs regarding early stability and long-term stress shielding effects on ingrown bone. Conventional interbody cage designs mainly fall into categories of cylindrical or rectangular shell shapes. The designs contribute to rigid stability and maintain disc height for successful arthrodesis but may also suffer mechanically mediated failures of dislocation or subsidence, as well as the possibility of bone resorption. The new optimization approach created a cage having designed microstructure that achieved desired mechanical performance while providing interconnected channels for biofactor delivery. The topology optimization algorithm determines the material layout under desirable volume fraction (50%) and displacement constraints favorable to bone formation. A local microstructural topology optimization method was used to generate periodic microstructures for porous isotropic materials. Final topology was generated by the integration of the two-scaled structures according to segmented regions and the corresponding material density. Image-base finite element analysis was used to compare the mechanical performance of the topology-optimized cage and conventional threaded cage. The final design can be fabricated by a variety of Solid Free-Form systems directly from the image output. The new design exhibited a narrower, more uniform displacement range than the threaded cage design and lower stress at the cage-vertebra interface, suggesting a reduced risk of subsidence. Strain energy density analysis also indicated that a higher portion of

Diagnostic Lumbar Puncture

PubMed Central

Doherty, Carolynne M; Forbes, Raeburn B

2014-01-01

Diagnostic Lumbar Puncture is one of the most commonly performed invasive tests in clinical medicine. Evaluation of an acute headache and investigation of inflammatory or infectious disease of the nervous system are the most common indications. Serious complications are rare, and correct technique will minimise diagnostic error and maximise patient comfort. We review the technique of diagnostic Lumbar Puncture including anatomy, needle selection, needle insertion, measurement of opening pressure, Cerebrospinal Fluid (CSF) specimen handling and after care. We also make some quality improvement suggestions for those designing services incorporating diagnostic Lumbar Puncture. PMID:25075138

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

PubMed

Schröder, Marc L; Staartjes, Victor E

2017-05-01

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

Comparison of minimally invasive spine surgery using intraoperative computed tomography integrated navigation, fluoroscopy, and conventional open surgery for lumbar spondylolisthesis: a prospective registry-based cohort study.

PubMed

Wu, Meng-Huang; Dubey, Navneet Kumar; Li, Yen-Yao; Lee, Ching-Yu; Cheng, Chin-Chang; Shi, Chung-Sheng; Huang, Tsung-Jen

2017-08-01

To date, the surgical approaches for the treatment of lumbar spondylolisthesis by transforaminal lumbar interbody fusion (TLIF) using minimally invasive spine surgery assisted with intraoperative computed tomography image-integrated navigation (MISS-iCT), fluoroscopy (MISS-FS), and conventional open surgery (OS) are debatable. This study compared TLIF using MISS-iCT, MISS-FS, and OS for treatment of one-level lumbar spondylolisthesis. This is a prospective, registry-based cohort study that compared surgical approaches for patients who underwent surgical treatment for one-level lumbar spondylolisthesis. One hundred twenty-four patients from January 2010 to March 2012 in a medical center were recruited. The outcome measures were clinical assessments, including Short-Form 12, visual analog scale (VAS), Oswestry Disability Index, Core Outcome Measurement Index, and patient satisfaction, and blood loss, hospital stay, operation time, postoperative pedicle screw accuracy, and superior-level facet violation. All surgeries were performed by two senior surgeons together. Ninety-nine patients (40M, 59F) who had at least 2 years' follow-up were divided into three groups according to the operation methods: MISS-iCT (N=24), MISS-FS (N=23), and OS (N=52) groups. Charts and surgical records along with postoperative CT images were assessed. MISS-iCT and MISS-FS demonstrated a significantly lowered blood loss and hospital stay compared with OS group (p<.01). Operation time was significantly lower in the MISS-iCT and OS groups compared with the MISS-FS group (p=.002). Postoperatively, VAS scores at 1 year and 2 years were significantly improved in the MISS-iCT and MISS-FS groups compared with the OS groups. No significant difference in the number of pedicle screw breach (>2 mm) was found. However, a lower superior-level facet violation rate was observed in the MISS-iCT and OS groups (p=.049). MISS-iCT TLIF demonstrated reduced operation time, blood loss, superior-level facet

Can Fan-Beam Interactive Computed Tomography Accurately Predict Indirect Decompression in Minimally Invasive Spine Surgery Fusion Procedures?

PubMed

Janssen, Insa; Lang, Gernot; Navarro-Ramirez, Rodrigo; Jada, Ajit; Berlin, Connor; Hilis, Aaron; Zubkov, Micaella; Gandevia, Lena; Härtl, Roger

2017-11-01

Recently, novel mobile intraoperative fan-beam computed tomography (CT) was introduced, allowing for real-time navigation and immediate intraoperative evaluation of neural decompression in spine surgery. This study sought to investigate whether intraoperatively assessed neural decompression during minimally invasive spine surgery (MISS) has a predictive value for clinical and radiographic outcome. A retrospective study of patients undergoing intraoperative CT (iCT)-guided extreme lateral interbody fusion or transforaminal lumbar interbody fusion was conducted. 1) Preoperative, 2) intraoperative (after cage implantation, 3) postoperative, and 4) follow-up radiographic and clinical parameters obtained from radiography or CT were quantified. Thirty-four patients (41 spinal segments) were analyzed. iCT-based navigation was successfully accomplished in all patients. Radiographic parameters showed significant improvement from preoperatively to intraoperatively after cage implantation in both MISS procedures (extreme lateral interbody fusion/transforaminal lumbar interbody fusion) (P ≤ 0.05). Radiologic parameters for both MISS fusion procedures did not show significant differences to the assessed radiographic measures at follow-up (P > 0.05). Radiologic outcome values did not decrease when compared intraoperatively (after cage implantation) to latest follow-up. Intraoperative fan-beam CT is capable of assessing neural decompression intraoperatively with high accuracy, allowing for precise prediction of radiologic outcome and earliest possible feedback during MISS fusion procedures. These findings are highly valuable for routine practice and future investigations toward finding a threshold for neural decompression that translates into clinical improvement. If sufficient neural decompression has been confirmed with iCT imaging studies, additional postoperative and/or follow-up imaging studies might no longer be required if patients remain asymptomatic. Copyright © 2017

[Biomechanics changes of lumbar spine caused by foraminotomy via percutaneous transforaminal endoscopic lumbar discectomy].

PubMed

Qian, J; Yu, S S; Liu, J J; Chen, L; Jing, J H

2018-04-03

Objective: To analyze the biomechanics changes of lumbar spine caused by foraminotomy via percutaneous transforaminal endoscopic lumbar discectomy using the finite element method. Methods: Three healthy adult males (aged 35.6 to 42.3 years) without spinal diseases were enrolled in this study and 3D-CT scans were carried out to obtain the parameters of lumbar spine. Mimics software was applied to build a 3D finite element model of lumbar spine. Graded resections (1/4, 2/4, 3/4 and 4/4) of the left superior articular process of L(5) were done via percutaneous transforaminal endoscopic lumbar discectomy. Then, the pressure of the L(4/5) right facets, the pressure of the L(4/5) intervertebral disc and the motion of lumbar spine were recorded after simulating the normal flexion and extension, lateral flexion and rotation of the lumbar spine model during different resections. The data were compared among groups with analysis of variance. Results: Comparing with the normal group, after 1/4 resection of the left superior articular process of L(5), the pressure of the L(4/5) right facets showed significant differences during left lateral flexion and rotation of lumbar spine ( q =8.823, 8.248, both P <0.05); and the pressure of L(4/5) intervertebral disc also changed significantly during extension and right rotation of lumbar spine ( q =6.918, 6.438, both P <0.05); the motion of lumbar spine showed obvious differences during right lateral flexion and rotation ( q =6.845, 7.772, 13.58, all P <0.05). Comparing with the normal group, after 2/4 resection of the left superior articular process of L(5), the pressure of the L(4/5) right facets presented significant differences during all conditions ( q =5.670-17.830, all P <0.05); the pressure of L(4/5) intervertebral disc changed significantly during flexion, extension, lateral flexion and right rotation ( q =5.260, 17.150, 5.727, 8.890, 15.660, all P <0.05); the motion of lumbar spine also existed differences during extension

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

PubMed

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

2015-01-01

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

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

PubMed

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

2017-01-01

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

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

PubMed

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

2009-02-01

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

Lumbar lordosis.

PubMed

Been, Ella; Kalichman, Leonid

2014-01-01

Lumbar lordosis is a key postural component that has interested both clinicians and researchers for many years. Despite its wide use in assessing postural abnormalities, there remain many unanswered questions regarding lumbar lordosis measurements. Therefore, in this article we reviewed different factors associated with the lordosis angle based on existing literature and determined normal values of lordosis. We reviewed more than 120 articles that measure and describe the different factors associated with the lumbar lordosis angle. Because of a variety of factors influencing the evaluation of lumbar lordosis such as how to position the patient and the number of vertebrae included in the calculation, we recommend establishing a uniform method of evaluating the lordosis angle. Based on our review, it seems that the optimal position for radiologic measurement of lordosis is standing with arms supported while shoulders are flexed at a 30° angle. There is evidence that many factors, such as age, gender, body mass index, ethnicity, and sport, may affect the lordosis angle, making it difficult to determine uniform normal values. Normal lordosis should be determined based on the specific characteristics of each individual; we therefore presented normal lordosis values for different groups/populations. There is also evidence that the lumbar lordosis angle is positively and significantly associated with spondylolysis and isthmic spondylolisthesis. However, no association has been found with other spinal degenerative features. Inconclusive evidence exists for association between lordosis and low back pain. Additional studies are needed to evaluate these associations. The optimal lordotic range remains unknown and may be related to a variety of individual factors such as weight, activity, muscular strength, and flexibility of the spine and lower extremities. Copyright © 2014 Elsevier Inc. All rights reserved.

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

PubMed

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

2017-11-15

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

A New Volumetric Radiologic Method to Assess Indirect Decompression After Extreme Lateral Interbody Fusion Using High-Resolution Intraoperative Computed Tomography.

PubMed

Navarro-Ramirez, Rodrigo; Berlin, Connor; Lang, Gernot; Hussain, Ibrahim; Janssen, Insa; Sloan, Stephen; Askin, Gulce; Avila, Mauricio J; Zubkov, Micaella; Härtl, Roger

2018-01-01

Two-dimensional radiographic methods have been proposed to evaluate the radiographic outcome after indirect decompression through extreme lateral interbody fusion (XLIF). However, the assessment of neural decompression in a single plane may underestimate the effect of indirect decompression on central canal and foraminal volumes. The present study aimed to assess the reliability and consistency of a novel 3-dimensional radiographic method that assesses neural decompression by volumetric analysis using a new generation of intraoperative fan-beam computed tomography scanner in patients undergoing XLIF. Prospectively collected data from 7 patients (9 levels) undergoing XLIF was retrospectively analyzed. Three independent, blind raters using imaging analysis software performed volumetric measurements pre- and postoperatively to determine central canal and foraminal volumes. Intrarater and Interrater reliability tests were performed to assess the reliability of this novel volumetric method. The interrater reliability between the three raters ranged from 0.800 to 0.952, P < 0.0001. The test-retest analysis on a randomly selected subset of three patients showed good to excellent internal reliability (range of 0.78-1.00) for all 3 raters. There was a significant increase in mean volume ≈20% for right foramen, left foramen, and central canal volumes postoperatively (P = 0.0472; P = 0.0066; P = 0.0003, respectively). Here we demonstrate a new volumetric analysis technique that is feasible, reliable, and reproducible amongst independent raters for central canal and foraminal volumes in the lumbar spine using an intraoperative computed tomography scanner. Copyright © 2017. Published by Elsevier Inc.

49 CFR 572.175 - Upper and lower torso assemblies and torso flexion test procedure.

Code of Federal Regulations, 2012 CFR

2012-10-01

.../lower torso assembly is as follows: (1) Torque the lumbar cable (drawing 420-4130) (incorporated by... threaded attachment holes. Tighten the mountings so that the test material is rigidly affixed to the test...

49 CFR 572.175 - Upper and lower torso assemblies and torso flexion test procedure.

Code of Federal Regulations, 2013 CFR

2013-10-01

.../lower torso assembly is as follows: (1) Torque the lumbar cable (drawing 420-4130) (incorporated by... threaded attachment holes. Tighten the mountings so that the test material is rigidly affixed to the test...

49 CFR 572.175 - Upper and lower torso assemblies and torso flexion test procedure.

Code of Federal Regulations, 2014 CFR

2014-10-01

.../lower torso assembly is as follows: (1) Torque the lumbar cable (drawing 420-4130) (incorporated by... threaded attachment holes. Tighten the mountings so that the test material is rigidly affixed to the test...

Diagnosis and operatory treatment of the patients with failed back surgery caused by herniated disk relapse.

PubMed

Bodiu, A

2014-01-01

THE OBJECT OF STUDY: Analysis of surgical treatment results in patients with recurrent lumbar disc herniation by transforaminal lumbar interbody fusion (TLIF) and repeated laminotomy and discectomy for the improvement of pain and disability. Data analysis was performed on a complex diagnosis and treatment of 56 patients with recurrent lumbar disc herniation who had previously underwent 1-3 lumbar disc surgeries. An MRI investigation with paramagnetic contrast agent (gadolinium) was used for the diagnosis and differentiation of epidural fibrosis, and a dynamic lateral X-ray investigation was carried out for the identification of segmental instability. The evolution period after the previous surgery was between 1 and 3 years after the index surgery. Pain expression degree and dynamics were assessed with the pain visual analog scale (VAS) in early and late postoperative periods. Postoperative success was assessed by using a modified MacNab scale. The follow-up recording period after the last operation was of at least 1 year, ranging from 1 to 4 years. The surgical treatment was effective in most cases, recording a reduction in pain expression level from 7.2-7.7 points on the VAS scale to 1.7-2.1 in the early period and 2.2-2.6 in the late period (1 year). Repeated surgery was effective in 21 of 30 (70%) cases who underwent decompression surgery without fusion and in 20 of 26 (76.9%) cases who underwent repeated surgery with transforaminal lumbar interbody fusion (TLIF). Overall, postoperative success was assessed by using a modified MacNab scale. Repeated surgery is a viable option for patients who have clinical manifestations of recurrent disc herniation. Investigation with contrast agent by MRI allows differentiating disk herniation recurrences from epidural fibrosis. Supplementing repeated discectomies and decompression with intervertebral transforaminal fusion provide superior clinical outcomes, especially in patients with clinical and radiological signs of lumbar

Degenerative lumbar spinal stenosis and lumbar spine configuration

PubMed Central

Hamoud, K.; May, H.; Hay, O.; Medlej, B.; Masharawi, Y.; Peled, N.; Hershkovitz, I.

2010-01-01

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. PMID:20652366

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

PubMed

Christensen, Finn Bjarke

2004-10-01

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

Effect of multilevel lumbar disc arthroplasty on the operative- and adjacent-level kinematics and intradiscal pressures: an in vitro human cadaveric assessment.

PubMed

Dmitriev, Anton E; Gill, Norman W; Kuklo, Timothy R; Rosner, Michael K

2008-01-01

With lumbar arthroplasty gaining popularity, limited data are available highlighting changes in adjacent-level mechanics after multilevel procedures. Compare operative- and adjacent-segment range of motion (ROM) and intradiscal pressures (IDPs) after two-level arthroplasty versus circumferential arthrodesis. Cadaveric biomechanical study. Ten human cadaveric lumbar spines were used in this investigation. Biomechanical testing was performed according to a hybrid testing protocol using an unconstrained spine simulator under axial rotation (AR), flexion extension (FE), and lateral-bending (LB) loading. Specimens were tested in the following order: 1) Intact, 2) L3-L5 total disc replacement (TDR), 3) L3-L5 anterior interbody cages+pedicle screws. IDP was recorded at proximal and distal adjacent levels and normalized to controls (%intact). Full ROM was monitored at the operative and adjacent levels and reported in degrees. Kinematics assessment revealed L3-L5 ROM reduction after both reconstructions versus intact controls (p < .05). However, global quality of segmental motion distributed over L2-S1 was preserved in the arthroplasty group but was significantly altered after circumferential fixation. Furthermore, adjacent-level ROM was increased for the arthrodesis group under LB at both segments and during AR at L2-L3 relative to controls (p < .05). FE did not reveal any intergroup statistical differences. Nonetheless, after arthrodesis IDPs were increased proximally under all three loading modalities, whereas distally a significant IDP rise was noted during AR and LB (p < .05). No statistical differences in either biomechanical parameter were recorded at the adjacent levels between intact control and TDR groups. Our results indicate no significant adjacent-level biomechanical changes between arthroplasty and control groups. In contrast, significant alterations in ROM and IDP were recorded both proximally (ROM=LB & AR; IDP=AR, FE, LB) and distally (ROM=LB; IDP=AR & LB

Effect of Lumbar Progressive Resistance Exercise on Lumbar Muscular Strength and Core Muscular Endurance in Soldiers.

PubMed

Mayer, John M; Childs, John D; Neilson, Brett D; Chen, Henian; Koppenhaver, Shane L; Quillen, William S

2016-11-01

Low back pain is common, costly, and disabling for active duty military personnel and veterans. The evidence is unclear on which management approaches are most effective. The purpose of this study was to assess the effectiveness of lumbar extensor high-intensity progressive resistance exercise (HIPRE) training versus control on improving lumbar extension muscular strength and core muscular endurance in soldiers. A randomized controlled trial was conducted with active duty U.S. Army Soldiers (n = 582) in combat medic training at Fort Sam Houston, Texas. Soldiers were randomized by platoon to receive the experimental intervention (lumbar extensor HIPRE training, n = 298) or control intervention (core stabilization exercise training, n = 284) at one set, one time per week, for 11 weeks. Lumbar extension muscular strength and core muscular endurance were assessed before and after the intervention period. At 11-week follow-up, lumbar extension muscular strength was 9.7% greater (p = 0.001) for HIPRE compared with control. No improvements in core muscular endurance were observed for HIPRE or control. Lumbar extensor HIPRE training is effective to improve isometric lumbar extension muscular strength in U.S. Army Soldiers. Research is needed to explore the clinical relevance of these gains. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

Lumbar lordosis in female collegiate dancers and gymnasts.

PubMed

Ambegaonkar, Jatin P; Caswell, Amanda M; Kenworthy, Kristen L; Cortes, Nelson; Caswell, Shane V

2014-12-01

Postural deviations can predispose an individual to increased injury risk. Specifically, lumbar deviations are related to increased low back pain and injury. Dancers and gymnasts are anecdotally suggested to have exaggerated lumbar lordosis and subsequently may be at increased risk of lumbar pathologies. Our objective was to examine lumbar lordosis levels in dancers and gymnasts. We examined lumbar lordosis in 47 healthy collegiate females (17 dancers, 29 gymnasts; mean age 20.2 ± 1.6 yrs) using 2-dimensional sagittal plane photographs and the Watson MacDonncha Posture Analysis instrument. Participants' lordosis levels were cross-tabulated and a Mann-Whitney U-test compared lumbar lordosis between groups (p<0.05). Most participants (89.4%, n=42) exhibited either marked (dancers 50%, n=9; gymnasts 62.1%, n=18; combined 57.4%, n=27) or moderate (dancers 27.8%, n=5; gymnasts 34.5%, n=10; combined 31.9%, n=15) lumbar lordosis deviations. The distribution of lordosis was similar across groups (p=0.22). Most dancers and gymnasts had moderate or marked lumbar lordosis. The extreme ranges of motion required during dancing and gymnastics may contribute to the participants' high lumbar lordosis. Instructors should be aware that there may be links between repetitive hyperextension activities and lumbar lordosis levels in dancers and gymnasts. Thus, they should proactively examine lumbar lordosis in their dancers and gymnasts. How much age of training onset, regimens, survivor bias, or other factors influence lumbar lordosis requires study. Longitudinal studies are also needed to determine if lumbar lordosis levels influence lumbar injury incidence in dancers and gymnasts.

Simple prediction method of lumbar lordosis for planning of lumbar corrective surgery: radiological analysis in a Korean population.

PubMed

Lee, Chong Suh; Chung, Sung Soo; Park, Se Jun; Kim, Dong Min; Shin, Seong Kee

2014-01-01

This study aimed at deriving a lordosis predictive equation using the pelvic incidence and to establish a simple prediction method of lumbar lordosis for planning lumbar corrective surgery in Asians. Eighty-six asymptomatic volunteers were enrolled in the study. The maximal lumbar lordosis (MLL), lower lumbar lordosis (LLL), pelvic incidence (PI), and sacral slope (SS) were measured. The correlations between the parameters were analyzed using Pearson correlation analysis. Predictive equations of lumbar lordosis through simple regression analysis of the parameters and simple predictive values of lumbar lordosis using PI were derived. The PI strongly correlated with the SS (r = 0.78), and a strong correlation was found between the SS and LLL (r = 0.89), and between the SS and MLL (r = 0.83). Based on these correlations, the predictive equations of lumbar lordosis were found (SS = 0.80 + 0.74 PI (r = 0.78, R (2) = 0.61), LLL = 5.20 + 0.87 SS (r = 0.89, R (2) = 0.80), MLL = 17.41 + 0.96 SS (r = 0.83, R (2) = 0.68). When PI was between 30° to 35°, 40° to 50° and 55° to 60°, the equations predicted that MLL would be PI + 10°, PI + 5° and PI, and LLL would be PI - 5°, PI - 10° and PI - 15°, respectively. This simple calculation method can provide a more appropriate and simpler prediction of lumbar lordosis for Asian populations. The prediction of lumbar lordosis should be used as a reference for surgeons planning to restore the lumbar lordosis in lumbar corrective surgery.

Outcome of Percutaneous Lumbar Synovial Cyst Rupture in Patients with Lumbar Radiculopathy.

PubMed

Eshraghi, Yashar; Desai, Vimal; Cajigal Cajigal, Calvin; Tabbaa, Kutaiba

2016-01-01

Lumbar synovial cysts can result from spondylosis of facet joints. These cysts can encroach on adjacent nerve roots, causing symptoms of radiculopathy. Currently the only definitive treatment for these symptoms is surgery, which may involve laminectomy or laminotomy, with or without spinal fusion. Surgery has been reported to successfully relieve radicular pain in 83.5% of patients by Zhenbo et al. Little information is available concerning the efficacy and outcome of percutaneous fluoroscopic synovial cyst rupture for treatment of facet joint synovial cysts. The goal of this investigation was to assess the efficacy of fluoroscopically guided lumbar synovial cyst rupture, in particular for its relief of radicular symptoms and its potential to reduce the need for surgical intervention. Retrospective evaluation of a case series. University hospital and urban public health care system. With approval from the Institutional Review Board of Case Western Reserve University/ MetroHealth Medical Center, we reviewed the medical charts of patients with lumbar radiculopathy who underwent percutaneous lumbar synovial cyst rupture. The 30 patients in the cohort were treated by one pain specialist between 2006 and 2013. These patients were diagnosed with moderate to severe lower back pain, radiculopathy, and ranged in age from 42 to 80 years. Patients were followed up for a minimum of 6 months and up to 24 months. Pre- and post-procedure pain assessments were reviewed by clinical chart review. In addition post-procedure pain assessments and duration of pain relief were obtained with telephone interviews. Pain had been reported by the patients using a numeric rating scale of 0 - 10 (0 = no pain; 10 = worst possible pain). Charts were reviewed to determine if surgery was eventually performed to correct radicular symptoms. More than 6 months of pain relief was achieved in 14/30 patients (46%) and between one and 6 months of pain relief was achieved in 7/30 patients (23.3%). Nine

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

PubMed

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

2015-06-01

Several risk factors and causes of adjacent segment disease have been debated; however, no quantitative relationship to spino-pelvic parameters has been established so far. A retrospective case-control study was carried out to investigate spino-pelvic alignment in patients with adjacent segment disease compared to a control group. 45 patients (ASDis) were identified that underwent revision surgery for adjacent segment disease after on average 49 months (7-125), 39 patients were selected as control group (CTRL) similar in the distribution of the matching variables, such as age, gender, preoperative degenerative changes, and numbers of segments fused with a mean follow-up of 84 months (61-142) (total n = 84). Several radiographic parameters were measured on pre- and postoperative radiographs, including lumbar lordosis measured (LL), sacral slope, pelvic incidence (PI), and tilt. Significant differences between ASDis and CTRL groups on preoperative radiographs were seen for PI (60.9 ± 10.0° vs. 51.7 ± 10.4°, p = 0.001) and LL (48.1 ± 12.5° vs. 53.8 ± 10.8°, p = 0.012). Pelvic incidence was put into relation to lumbar lordosis by calculating the difference between pelvic incidence and lumbar lordosis (∆PILL = PI-LL, ASDis 12.5 ± 16.7° vs. CTRL 3.4 ± 12.1°, p = 0.001). A cutoff value of 9.8° was determined by logistic regression and ROC analysis and patients classified into a type A (∆PILL <10°) and a type B (∆PILL ≥10°) alignment according to pelvic incidence-lumbar lordosis mismatch. In type A spino-pelvic alignment, 25.5 % of patients underwent revision surgery for adjacent segment disease, whereas 78.3 % of patients classified as type B alignment had revision surgery. Classification of patients into type A and B alignments yields a sensitivity for predicting adjacent segment disease of 71 %, a specificity of 81 % and an odds ratio of 10.6. In degenerative disease of the lumbar spine a high pelvic incidence with diminished lumbar lordosis seems

Comparison of 368 patients undergoing surgery for lumbar degenerative spondylolisthesis from the SPORT trial with 955 from the NSQIP database.

PubMed

Golinvaux, Nicholas S; Basques, Bryce A; Bohl, Daniel D; Yacob, Alem; Grauer, Jonathan N

2015-03-01

Retrospective cohort. To compare demographics and perioperative outcomes between the Spine Patient Outcomes Research Trial (SPORT) lumbar degenerative spondylolisthesis arm and a similar population from the National Surgical Quality Improvement Program (NSQIP) database. SPORT is a well-known surgical trial that investigated the benefits of surgical versus nonsurgical treatment in patients with various lumbar pathologies. However, the external validity of SPORT demographics and outcomes has not been fully established. Surgical degenerative spondylolisthesis cases were identified from NSQIP between 2010 and 2012. This population was then compared with the SPORT degenerative spondylolisthesis study. These comparisons were based on published data from SPORT and included analyses of demographics, perioperative factors, and complications. The 368 surgical patients with degenerative spondylolisthesis in SPORT were compared with 955 patients identified in NSQIP. Demographic comparisons were as follows: average age and race (no difference; P > 0.05 for each), sex (9.1% more female patients in SPORT; P = 0.002), smoking status (6.6% more smokers in NSQIP; P = 0.002), and average body mass index (1.1 kg/m greater in NSQIP; P = 0.005). Larger differences were noted in what surgical procedure was performed (P < 0.001), with the most notable difference being that the NSQIP population was much more likely to include interbody fusion than the SPORT population (52.4% vs. 12.5%). Most perioperative factors and complication rates were similar, including average operative time, wound infection, wound dehiscence, postoperative transfusion, and postoperative mortality (no differences; P > 0.05 for each). Average length of stay was shorter in NSQIP compared with SPORT (3.7 vs. 5.8 d; P = 0.042). Though important differences in the distribution of surgical procedures were identified, this study supports the greater generalizability of the surgical SPORT degenerative spondylolisthesis

Vertebral Compression Fractures after Lumbar Instrumentation.

PubMed

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

2017-09-29

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

Lumbar interspinous bursitis in active polymyalgia rheumatica.

PubMed

Salvarani, Carlo; Barozzi, Libero; Boiardi, Luigi; Pipitone, Nicolò; Bajocchi, Gian Luigi; Macchioni, Pier Luigi; Catanoso, Mariagrazia; Pazzola, Giulia; Valentino, Massimo; De Luca, Carlo; Hunder, Gene G

2013-01-01

To evaluate the inflammatory involvement of lumbar interspinous bursae in patients with polymyalgia rheumatica (PMR) using magnetic resonance imaging (MRI). Ten consecutive, untreated new patients with PMR and pain in the shoulder and pelvic girdles were investigated. Seven patients with spondyloarthritis (4 with psoriatic spondyloarthrits, one with entheropatic spondyloarthritis, and 2 with ankylosing spondylitis) as well as 2 patients with spinal osteoarthritis and 2 patients with rheumatoid arthritis with lumbar pain served as controls. MRI of lumbar spine was performed in all PMR patients and controls. Nine patients (5 PMR patients and 4 controls) also had MRI of the thoracic spine. MRI evidence of interspinous lumbar bursitis was found in 9/10 patients with PMR and in 5/11 controls. A moderate to marked (grade ≥2 on a semiquantitative 0-3 scale) lumbar bursitis occurred significantly more frequently in patients with PMR than in control patients (60% vs. 9%, p=0.020). In most of the patients and controls lumbar bursitis was found at the L3-L5 interspaces. Only 2 patients had bursitis at a different level (one patient had widespread lumbar bursitis, and one control at L2-L4). No interspinous bursitis was demonstrated by MRI of the thoracic spine in patients and controls. Inflammation of lumbar bursae may be responsible for the low back pain reported by patients with PMR. The prominent inflammatory involvement of bursae including those of the lumbar spine supports the hypothesis that PMR may be a disorder affecting predominantly extra-articular synovial structures.

Relationship of the lumbar plexus branches to the lumbar spine: anatomical study with application to lateral approaches.

PubMed

Tubbs, Richard Isaiah; Gabel, Brandon; Jeyamohan, Shiveindra; Moisi, Marc; Chapman, Jens R; Hanscom, R David; Loukas, Marios; Oskouian, Rod J; Tubbs, Richard Shane

2017-07-01

Injuries to the lumbar plexus during lateral approaches to the spine are not uncommon and may result in permanent deficits. However, the literature contains few studies that provide landmarks for avoiding the branches of the lumbar plexus. The present anatomical study was performed to elucidate the course of these nerves in relation to lateral approaches to the lumbar spine. This is a quantitative anatomical cadaveric study. The lumbar plexus and its branches were dissected on 12 cadaveric sides. Metal wires were laid on the nerves along their paths on the posterior abdominal wall. Fluoroscopy was performed in the anteroposterior and lateral positions. The relationships between regional bony landmarks and the branches of the lumbar plexus were observed. When viewed laterally, the greatest concentration of nerves occurred from the posteroinferior aspect of L4, inferior along the posterior one-third of the body of L5, then at the level of the sacral promontory. On the basis of our study, approaches to the anterior two-thirds of the L4 vertebra and anterior third of L5 will result in the lowest chance of lumbar plexus nerve injury. In addition, lateral muscle dissection through the psoas major should be in a superior to inferior direction in order to minimize nerve injury. Laterally, the widest corridor between branches in the abdominal wall was between the subcostal and iliohypogastric nerves. The findings of our cadaveric study provide surgeons who approach the lateral lumbar spine with data that could decrease injuries to the branches of the lumbar plexus, thus lessening patient morbidity. Copyright © 2017 Elsevier Inc. All rights reserved.

Lumbar disc herniation in young children.

PubMed

Haidar, R; Ghanem, I; Saad, S; Uthman, I

2010-01-01

This article explores lumbar disc herniation in young children through focusing on matters relevant to patient presentation, physical examination, differential diagnosis, imaging and treatment. Major databases were searched for studies that addressed lumbar disc herniation in young children. Diagnosis of lumbar disc herniation in young children is usually delayed because of the rarity and lack of experience with this entity and the difficulty in extracting a reliable medical history. Nevertheless, lumbar disc herniation should be considered in the differential diagnosis of any young child presenting with a chief complaint of back pain and/or radiculopathy, especially in the setting of recent trauma. This should be coupled with a directed physical examination to elicit signs and narrow the differential diagnosis. Imaging studies, mainly magnetic resonance imaging, will help establish a diagnosis; yet radiographs are still required to exclude other spinal lesions. The initial management of lumbar disc herniation in children is the same as that in adults and consists of conservative treatment unless lumbar disc herniation affects the patient's motor and neurological functions in which case, early surgical treatment must be undertaken. Although the latter remains more difficult, current experience suggests a favourable outcome. Awareness of lumbar disc herniation will help the paediatrician extract a relevant medical history, perform a directed physical examination, and order appropriate imaging studies. This will aid in initiating early intervention, be it conservative or operative, and achieving a favourable outcome.

The Neandertal vertebral column 2: The lumbar spine.

PubMed

Gómez-Olivencia, Asier; Arlegi, Mikel; Barash, Alon; Stock, Jay T; Been, Ella

2017-05-01

Here we provide the most extensive metric and morphological analysis performed to date on the Neandertal lumbar spine. Neandertal lumbar vertebrae show differences from modern humans in both the vertebral body and in the neural arch, although not all Neandertal lumbar vertebrae differ from modern humans in the same way. Differences in the vertebral foramen are restricted to the lowermost lumbar vertebrae (L4 and L5), differences in the orientation of the upper articular facets appear in the uppermost lumbar vertebrae (probably in L1 and L2-L3), and differences in the horizontal angle of the transverse process appear in L2-L4. Neandertals, when compared to modern humans, show a smaller degree of lumbar lordosis. Based on a still limited fossil sample, early hominins (australopiths and Homo erectus) had a lumbar lordosis that was similar to but below the mean of modern humans. Here, we hypothesize that from this ancestral degree of lumbar lordosis, the Neandertal lineage decreased their lumbar lordosis and Homo sapiens slightly increased theirs. From a postural point of view, the lower degree of lordosis is related to a more vertical position of the sacrum, which is also positioned more ventrally with respect to the dorsal end of the pelvis. This results in a spino-pelvic alignment that, though different from modern humans, maintained an economic postural equilibrium. Some features, such as a lower degree of lumbar lordosis, were already present in the middle Pleistocene populations ancestral to Neandertals. However, these middle Pleistocene populations do not show the full suite of Neandertal lumbar morphologies, which probably means that the characteristic features of the Neandertal lumbar spine did not arise all at once. Copyright © 2017 Elsevier Ltd. All rights reserved.

Lumbar kinematic variability during gait in chronic low back pain and associations with pain, disability and isolated lumbar extension strength.

PubMed

Steele, James; Bruce-Low, Stewart; Smith, Dave; Jessop, David; Osborne, Neil

2014-12-01

Chronic low back pain is a multifactorial condition with many dysfunctions including gait variability. The lumbar spine and its musculature are involved during gait and in chronic low back pain the lumbar extensors are often deconditioned. It was therefore of interest to examine relationships between lumbar kinematic variability during gait, with pain, disability and isolated lumbar extension strength in participants with chronic low back pain. Twenty four participants with chronic low back pain were assessed for lumbar kinematics during gait, isolated lumbar extension strength, pain, and disability. Angular displacement and kinematic waveform pattern and offset variability were examined. Angular displacement and kinematic waveform pattern and offset variability differed across movement planes; displacement was highest and similar in frontal and transverse planes, and pattern variability and offset variability higher in the sagittal plane compared to frontal and transverse planes which were similar. Spearman's correlations showed significant correlations between transverse plane pattern variability and isolated lumbar extension strength (r=-.411) and disability (r=.401). However, pain was not correlated with pattern variability in any plane. The r(2) values suggested 80.5% to 86.3% of variance was accounted for by other variables. Considering the lumbar extensors role in gait, the relationship between both isolated lumbar extension strength and disability with transverse plane pattern variability suggests that gait variability may result in consequence of lumbar extensor deconditioning or disability accompanying chronic low back pain. However, further study should examine the temporality of these relationships and other variables might account for the unexplained variance. Copyright © 2014 Elsevier Ltd. All rights reserved.

Potential and Limitations of Neural Decompression in Extreme Lateral Interbody Fusion-A Systematic Review.

PubMed

Lang, Gernot; Perrech, Moritz; Navarro-Ramirez, Rodrigo; Hussain, Ibrahim; Pennicooke, Brenton; Maryam, Farah; Avila, Mauricio J; Härtl, Roger

2017-05-01

Extreme lateral interbody fusion (ELIF) is a powerful tool for interbody fusion and coronal deformity correction. However, evidence regarding the success of ELIF in decompressing foraminal, lateral recess, and central canal stenosis is lacking. We performed a systematic review of current literature on the potential and limitations of ELIF to indirectly decompress neural elements. A literature search using PubMed, Cochrane, and ScienceDirect databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Information on study design, sample size, population, procedure, number and location of involved levels, follow-up time, and complications as well as information on conflict of interest was extracted and evaluated. We selected 20 publications including 1080 patients for review. Most publications (90%) were retrospective case series. Most frequent indications for ELIF included degenerative disc disease, spinal stenosis, spondylolisthesis, and degenerative scoliosis. Most studies revealed significant improvement in radiographic and clinical outcome after ELIF. Mean foraminal area, central canal area, and subarticular diameter increased by 31.6 mm 2 , 28.5 mm 2 , and 0.85 mm. ELIF successfully improved foraminal stenosis. Contradictory results were found for indirect decompression of central canal stenosis. Data on lateral recess stenosis were scarce. Current data suggest ELIF to be an efficient technique in decompression of foraminal stenosis. Evidence on decompression of central canal or lateral recess stenosis via ELIF is low, and results are inconsistent. Most studies are limited by study design, sample size, and potential conflicts of interest. Copyright © 2017 Elsevier Inc. All rights reserved.

The LP-ESP(®) lumbar disc prosthesis with 6 degrees of freedom: development and 7 years of clinical experience.

PubMed

Lazennec, Jean-Yves; Aaron, Alain; Brusson, Adrien; Rakover, Jean-Patrick; Rousseau, Marc-Antoine

2013-02-01

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.

Use of minimally invasive spine surgical instruments for the treatment of bone tumors.

PubMed

Reeves, Russell A; DeWolf, Matthew C; Shaughnessy, Peter J; Ames, James B; Henderson, Eric R

2017-11-01

Orthopedic oncologists often encounter patients with minor bony lesions that are difficult to access surgically and therefore require large exposures out of proportion to the severity of disease that confer significant patient morbidity. Minimally invasive surgical techniques offer the advantage of smaller incisions, shorter operative times, decreased tissue damage, and decreased costs. A variety of surgical procedures have emerged using minimally invasive technologies, particularly in the field of spine surgery. Areas covered: In this article, we describe the Minimal Exposure Tubular Retractor (METRx TM ) System which is a minimally invasive surgical device that utilizes a series of dilators to permit access to a surgical site of interest. This system was developed for use in treatment of disc herniation, spinal stenosis, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion and spinal cord stimulation implantation. We also describe novel uses of this system for minimally invasive biopsy and treatment of benign and metastatic bone lesions at our institution. Expert commentary: Minimally invasive surgical techniques will continue to expand into the field of orthopedic oncology. With a greater number of studies proving the safety and effectiveness of this technique, the demand for minimally invasive treatments will grow.

Biomechanical effect of altered lumbar lordosis on intervertebral lumbar joints during the golf swing: a simulation study.

PubMed

Bae, Tae Soo; Cho, Woong; Kim, Kwon Hee; Chae, Soo Won

2014-11-01

Although the lumbar spine region is the most common site of injury in golfers, little research has been done on intervertebral loads in relation to the anatomical-morphological differences in the region. This study aimed to examine the biomechanical effects of anatomical-morphological differences in the lumbar lordosis on the lumbar spinal joints during a golf swing. The golf swing motions of ten professional golfers were analyzed. Using a subject-specific 3D musculoskeletal system model, inverse dynamic analyses were performed to compare the intervertebral load, the load on the lumbar spine, and the load in each swing phase. In the intervertebral load, the value was the highest at the L5-S1 and gradually decreased toward the T12. In each lumbar spine model, the load value was the greatest on the kypholordosis (KPL) followed by normal lordosis (NRL), hypolordosis (HPL), and excessive lordosis (EXL) before the impact phase. However, results after the follow-through (FT) phase were shown in reverse order. Finally, the load in each swing phase was greatest during the FT phase in all the lumbar spine models. The findings can be utilized in the training and rehabilitation of golfers to help reduce the risk of injury by considering individual anatomical-morphological characteristics.

A reappraisal of the anatomy of the human lumbar erector spinae.

PubMed Central

Bogduk, N

1980-01-01

In the lumbar region the longissimus thoracis and iliocostalis lumborum are separated by the erector spinae aponeurosis and its ventral reflection--the lumbar intermuscular aponeurosis. Lumbar fibres of the longissimus arise from the ilium and the lumbar intermuscular aponeurosis and insert into the accessory processes and proximal ends of the transverse processes of the lumbar vertebrae. Lumbar fibres of iliocostalis insert into the costal elements of the first four lumbar vertebrae. The lumbar insertions of these muscles are homologous to their thoracic insertions. The lumbar intermuscular aponeurosis is homologous to the lumbar intermuscular septum in the dog, cat and monkey. The details of attachment of the lumbar fibres of the erector spinae and of the lumbar intermuscular aponeurosis should be taken into account in biomechanical analyses of the lumbar vertebral column. Images Fig. 1(cont.) Fig. 1 Fig. 3 Fig. 4 Fig. 5 PMID:7216917

Correlation between lumbar dysfunction and fat infiltration in lumbar multifidus muscles in patients with low back pain.

PubMed

Hildebrandt, Markus; Fankhauser, Gabriela; Meichtry, André; Luomajoki, Hannu

2017-01-10

Lumbar multifidus muscles (LMM) are important for spinal motion and stability. Low back pain (LBP) is often associated with fat infiltration in LMM. An increasing fat infiltration of LMM may lead to lumbar dysfunction. The purpose of this study was to investigate whether there is a correlation between the severity of lumbar dysfunction and the severity of fat infiltration of LMM. In a cross-sectional study, 42 patients with acute or chronic LBP were recruited. Their MRI findings were visually rated and graded using three criteria for fat accumulation in LMM: Grade 0 (0-10%), Grade 1 (10-50%) and Grade 2 (>50%). Lumbar sagittal range of motion, dynamic upright and seated posture control, sagittal movement control, body awareness and self-assessed functional disability were measured to determine the patients' low back dysfunction. The main result of this study was that increased severity of fat infiltration in the lumbar multifidus muscles correlated significantly with decreased range of motion of lumbar flexion (p = 0.032). No significant correlation was found between the severity of fat infiltration in LMM and impaired movement control, posture control, body awareness or self-assessed functional disability. This is the first study investigating the relationship between the severity of fat infiltration in LMM and the severity of lumbar dysfunction. The results of this study will contribute to the understanding of the mechanisms leading to fat infiltration of LMM and its relation to spinal function. Further studies should investigate whether specific treatment strategies are effective in reducing or preventing fat infiltration of LMM.

Biomechanical advantages of supplemental accessory and satellite rods with and without interbody cages implantation for the stabilization of pedicle subtraction osteotomy.

PubMed

La Barbera, Luigi; Brayda-Bruno, Marco; Liebsch, Christian; Villa, Tomaso; Luca, Andrea; Galbusera, Fabio; Wilke, Hans-Joachim

2018-05-08

To investigate the effect of anterior interbody cages, accessory and satellite rods usage on primary stability and rod strains for PSO stabilization. Seven human cadaveric spine segments (T12-S1) underwent PSO at L4 with posterior fixation from L2 to S1. In vitro flexibility tests were performed under pure moments in flexion/extension (FE), lateral bending (LB) and axial rotation (AR) to determine the range of motion, while measuring the strains on the primary rods with strain gauge rosettes. Six constructs with 2, 3 and 4 rods, with and without interbody cages implantation adjacent to the PSO site, were compared. All constructs had comparable effects in reducing spine kinematics compared to the intact condition (- 94% in FE and LB; - 80% in AR). Supplementation of 2 rods with lateral accessory rods (4 rods) was the most effective strategy in minimizing primary rod strains, particularly when coupled to cages (p ≤ 0.005; - 50% in FE, - 42% in AR and - 11% in LB); even without cages, the strains were significantly reduced (p ≤ 0.009; - 26%, - 37%, - 9%). The addition of a central satellite rod with laminar hooks (3 rods) effectively reduced rod strains in FE (p ≤ 0.005; - 30%) only in combination with cages. The study supports the current clinical practice providing a strong biomechanical rationale to recommend 4-rod constructs based on accessory rods combined with cages adjacent to PSO site. Although weaker, the usage of accessory rods without cages and of a central satellite rod with hooks in combination with interbody spacers may also be justified. These slides can be retrieved under Electronic Supplementary Material.

The effect of a lumbar support pillow on lumbar posture and comfort during a prolonged seated task

PubMed Central

2013-01-01

Background Several risk factors exist for the development of low back pain, including prolonged sitting and flexed spinal curvature. Several investigators have studied lumbar support devices and spinal curvatures in sitting, however few have investigated a pain population and reported a quantitative measure of comfort. The purpose of the current project was to determine whether a lumbar support pillow, outfitted with a cut-out to accommodate the bulk of posterior pelvic soft tissue volume, is more effective than a standard chair in promoting a neutral spinal posture and improving subjective and objective measures of comfort in healthy individuals and patients with low back pain. Methods Twenty eight male participants with and without a history of low back pain sat in a standard office chair and in a chair with the lumbar support pillow for 30 minutes. Lumbar and thoracolumbar postures were measured through electromagnetic markers. Comfort was determined based on the least squares radius of centre of pressure shifting, measured at the buttock-chair interface as well as reported discomfort through visual analog scales. Chair support effects were assessed through ANOVA methods. The study was approved by the Canadian Memorial Chiropractic College research ethics board. Results There was a main effect of condition on lumbar posture (p = 0.006) and thoracolumbar posture (p = 0.014). In the lumbar region, the support and standard chair differed by 2.88° (95% CI; 1.01-4.75), with the lumbar support being closer to neutral than the standard chair. In the thoracolumbar region, the support and standard chair differed by -2.42° (95% CI; -4.22 to -0.62), with the standard chair being closer to neutral than the support device. The centre of pressure measure was significantly improved with the pillow (p = 0.017), however there were no subjective changes in comfort. Conclusions A lumbar support pillow with a cut-out for the posterior pelvic tissues improved an

Lumbar dorsal ramus syndrome.

PubMed

Bogduk, N

1980-11-15

Low back pain, referred pain in the lower limbs, and spasm of the back, gluteal, and hamstring muscles are clinical features which can be induced in normal volunteers by stimulating structures which are innervated by the lumbar dorsal rami. Conversely, they can be relieved in certain patients by selective interruption of conduction along dorsal rami. These facts permit the definition of a lumbar dorsal ramus syndrome, which can be distinguished from the intervertebral disc syndrome and other forms of low back pain. The distinguishing feature is that, in lumbar dorsal ramus syndrome, all the clinical features are exclusively mediated by dorsal rami and do not arise from nerve-root compression. The pathophysiology, pathology, and treatment of this syndrome are described. Recognition of this syndrome, and its treatment with relatively minor procedures, can obviate the need for major surgery which might otherwise be undertaken.

Treatment for Multiple Aspergillus Spondylitis Including a Hip Joint

PubMed Central

Oh, In-Soo; Seo, Jun-Yeong; Kim, Yoon-Chung

2009-01-01

Multiple aspergillus spondylitis (AS) is a life threatening infection that occurs more commonly in immunocompromised patients, and is commonly treated with antifungal agents. However, there is relatively little information available on the treatment of multiple AS. The authors encountered a 46-year-old man suffering from low back and neck pain with radiculomyelopathy after a liver transplant. The patient had concomitant multiple AS in the cervico-thoraco-lumbar spine and right hip joint, as confirmed by radiologic imaging studies. The pathological examination of a biopsy specimen revealed fungal hyphae at the cervical and lumbar spine. Anterior decompression and interbody fusion were performed for the cervical and lumbar lesions, which showed instability and related neurological symptoms. Additional antifungal therapy was also performed. The patient was treated successfully with remission of his symptoms. PMID:20404956

Treatment for multiple Aspergillus spondylitis including a hip joint.

PubMed

Oh, In-Soo; Seo, Jun-Yeong; Ha, Kee-Yong; Kim, Yoon-Chung

2009-12-01

Multiple aspergillus spondylitis (AS) is a life threatening infection that occurs more commonly in immunocompromised patients, and is commonly treated with antifungal agents. However, there is relatively little information available on the treatment of multiple AS. The authors encountered a 46-year-old man suffering from low back and neck pain with radiculomyelopathy after a liver transplant. The patient had concomitant multiple AS in the cervico-thoraco-lumbar spine and right hip joint, as confirmed by radiologic imaging studies. The pathological examination of a biopsy specimen revealed fungal hyphae at the cervical and lumbar spine. Anterior decompression and interbody fusion were performed for the cervical and lumbar lesions, which showed instability and related neurological symptoms. Additional antifungal therapy was also performed. The patient was treated successfully with remission of his symptoms.

Minimally invasive lumbar foraminotomy.

PubMed

Deutsch, Harel

2013-07-01

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.

Economic impact of minimally invasive lumbar surgery.

PubMed

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

2015-03-18

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

Re-exploration of the lumbar spine following simple discectomy: a review of 23 cases.

PubMed

Shiraishi, T; Crock, H V

1995-01-01

A retrospective study of 23 patients is presented, all of whom complained of recurrent symptoms of back and leg pain following simple discectomy. Five patients (22%) had been refused further surgery by the original surgeon on the grounds that they were psychologically disturbed. On examining the clinical records, 18 patients were reported to have had frank disc prolapses found at operation. In 5 cases, disc tissues were removed even though disc prolapses had not been demonstrated. Among the 18 patients in whom disc prolapses had been removed at their first operations, we found recurrent prolapses at reoperation in only 2 of them (11%). We treated 19 of these patients by nerve root canal and foraminal decompressions and 4 by anterior lumbar interbody fusion operations. The mean follow-up period was 34 months. Satisfactory relief of symptoms was achieved in 21 cases. In the published literature, even after the advent of CT and MRI, the incidence of recurrent disc prolapse at reoperation varies markedly from author to author. The reasons for these differences are discussed. They appear to relate to three factors: 1. failure to differentiate acute disc prolapse from annular bulging which develops and is inevitably associated with disc space narrowing; 2. difficulty in distinguishing between MRI findings of scar tissue enhancement and local perineural oedema due to persisting foraminal and nerve root canal stenosis; 3. failure to identify the existence of foraminal stenosis, which is sometimes demonstrated only in oblique plain X-rays showing facet hypertrophy and subluxations of zygapophyseal joints.(ABSTRACT TRUNCATED AT 250 WORDS)

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

PubMed

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

2013-02-01

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

Kinematic Evaluation of Association between Disc Bulge Migration, Lumbar Segmental Mobility, and Disc Degeneration in the Lumbar Spine Using Positional Magnetic Resonance Imaging

PubMed Central

Hu, Jonathan K.; Morishita, Yuichiro; Montgomery, Scott R.; Hymanson, Henry; Taghavi, Cyrus E.; Do, Duc; Wang, Jeff C.

2011-01-01

Degenerative disc disease and disc bulge in the lumbar spine are common sources of lower back pain. Little is known regarding disc bulge migration and lumbar segmental mobility as the lumbar spine moves from flexion to extension. In this study, 329 symptomatic (low back pain with or without neurological symptoms) patients with an average age of 43.5 years with varying degrees of disc degeneration were examined to characterize the kinematics of the lumbar intervertebral discs through flexion, neutral, and extension weight-bearing positions. In this population, disc bulge migration associated with dynamic motion of the lumbar spine significantly increased with increased grade of disk degeneration. Although no obvious trends relating the migration of disc bulge and angular segmental mobility were seen, translational segmental mobility tended to increase with disc bulge migration in all of the degenerative disc states. It appears that many factors, both static (intervertebral disc degeneration or disc height) and dynamic (lumbar segmental mobility), affect the mechanisms of lumbar disc bulge migration. PMID:24353937

Cerebriform connective tissue nevus of lumbar.

PubMed

Chen, Jinbo; Chen, Liuqing; Duan, Yiqun; Li, Dongsheng; Dong, Bilin

2015-02-01

Connective tissue nevi represents a kind of hamartoma, and coalescence of the lesions in a cerebriform mode in the lumbar region without Proteus syndrome is rarely seen. Here, we report a 26-year-old woman presenting with nodules and plaques in her left lumbar region of 26 years in duration. Histopathological examination and Masson-trichrome stain showed increased dermal collagen bundles in a haphazard array. The diagnosis of connective tissue nevi was made. This is the first case report on cerebriform connective tissue nevi without Proteus syndrome in the lumbar region. © 2014 Japanese Dermatological Association.

Management of Lumbar Conditions in the Elite Athlete.

PubMed

Hsu, Wellington K; Jenkins, Tyler James

2017-07-01

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

Management of lumbar spinal stenosis.

PubMed

Lurie, Jon; Tomkins-Lane, Christy

2016-01-04

Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality. © BMJ Publishing Group Ltd 2015.

One-stage posterior focus debridement, interbody grafts, and posterior instrumentation and fusion in the surgical treatment of thoracolumbar spinal tuberculosis with kyphosis in children: a preliminary report.

PubMed

Wang, Yu-Xiang; Zhang, Hong-Qi; Tang, Ming-Xing; Guo, Chao-Feng; Deng, Ang; Wu, Jian-Huang; Liu, Jin-Yang; Deng, Zhansheng; Chen, Jing

2016-08-01

The purpose of this study was to determine the efficacy and feasibility of surgical management of children with thoracolumbar spine tuberculosis with kyphosis by using one-stage posterior focus debridement, interbody grafts, and posterior instrumentation and fusion. From October 2010 to September 2013, 21 children with thoracolumbar spinal tuberculosis accompanied by kyphosis were treated with one-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion. There were 13 males and 8 females, aged from 7 to 13 years old (average age 9.9 years). The mean follow-up was 34 months (range26-48 months). Patients were evaluated before and after surgery in terms of ESR, neurologic status, pain, and kyphotic angle. Spinal tuberculosis was completely cured, and the grafted bones were fused in all 21 patients. There was no recurrent tuberculous infection. ESR got normal within 3 months in all patients. The ASIA neurologic classification improved in all cases. Pain relief was obtained in all patients. The average preoperative kyphosis was 29.7° (range 12-42°) and decreased to 5.5° (range 2-10°), postoperatively. There was no significant loss of the correction at the latest follow-up. Our results show that one-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion were an effective treatment for children with thoracolumbar spinal tuberculosis. It is characterized as minimum surgical trauma, good neurologic recovery, good correction of kyphosis, and prevention of progressive kyphosis.

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 7 2010-10-01 2010-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 7 2014-10-01 2014-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 7 2011-10-01 2011-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 7 2012-10-01 2012-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 7 2013-10-01 2013-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

The robotic lumbar spine: dynamics and feedback linearization control.

PubMed

Karadogan, Ernur; Williams, Robert L

2013-01-01

The robotic lumbar spine (RLS) is a 15 degree-of-freedom, fully cable-actuated robotic lumbar spine which can mimic in vivo human lumbar spine movements to provide better hands-on training for medical students. The design incorporates five active lumbar vertebrae and the sacrum, with dimensions of an average adult human spine. It is actuated by 20 cables connected to electric motors. Every vertebra is connected to the neighboring vertebrae by spherical joints. Medical schools can benefit from a tool, system, or method that will help instructors train students and assess their tactile proficiency throughout their education. The robotic lumbar spine has the potential to satisfy these needs in palpatory diagnosis. Medical students will be given the opportunity to examine their own patient that can be programmed with many dysfunctions related to the lumbar spine before they start their professional lives as doctors. The robotic lumbar spine can be used to teach and test medical students in their capacity to be able to recognize normal and abnormal movement patterns of the human lumbar spine under flexion-extension, lateral bending, and axial torsion. This paper presents the dynamics and nonlinear control of the RLS. A new approach to solve for positive and nonzero cable tensions that are also continuous in time is introduced.

Weightlifter Lumbar Physiology Health Influence Factor Analysis of Sports Medicine.

PubMed

Zhang, Xiangyang

2015-01-01

Chinese women's weightlifting project has been in the advanced world level, suggests that the Chinese coaches and athletes have many successful experience in the weight lifting training. Little weight lifting belongs to high-risk sports, however, to the lumbar spine injury, some young good athletes often due to lumbar trauma had to retire, and the national investment and athletes toil is regret things. This article from the perspective of sports medicine, weightlifting athletes training situation analysis and put forward Suggestions, aimed at avoiding lumbar injury, guarantee the health of athletes. In this paper, first of all to 50 professional women's weightlifting athletes doing investigation, found that 82% of the athletes suffer from lumbar disease symptoms, the reason is mainly composed of lumbar strain, intensity is too large, motion error caused by three factors. From the Angle of sports medicine and combined with the characteristics of the structure of human body skeleton athletes lumbar structural mechanics analysis, find out the lumbar force's two biggest technical movement, study, and regulate the action standard, so as to minimize lumbar force, for athletes to contribute to the health of the lumbar spine.

Weightlifter Lumbar Physiology Health Influence Factor Analysis of Sports Medicine

PubMed Central

Zhang, Xiangyang

2015-01-01

Chinese women's weightlifting project has been in the advanced world level, suggests that the Chinese coaches and athletes have many successful experience in the weight lifting training. Little weight lifting belongs to high-risk sports, however, to the lumbar spine injury, some young good athletes often due to lumbar trauma had to retire, and the national investment and athletes toil is regret things. This article from the perspective of sports medicine, weightlifting athletes training situation analysis and put forward Suggestions, aimed at avoiding lumbar injury, guarantee the health of athletes. In this paper, first of all to 50 professional women's weightlifting athletes doing investigation, found that 82% of the athletes suffer from lumbar disease symptoms, the reason is mainly composed of lumbar strain, intensity is too large, motion error caused by three factors. From the Angle of sports medicine and combined with the characteristics of the structure of human body skeleton athletes lumbar structural mechanics analysis, find out the lumbar force's two biggest technical movement, study, and regulate the action standard, so as to minimize lumbar force, for athletes to contribute to the health of the lumbar spine. PMID:26981162

Post-surgical functional recovery, lumbar lordosis, and range of motion associated with MR-detectable redundant nerve roots in lumbar spinal stenosis.

PubMed

Chen, Jinshui; Wang, Juying; Wang, Benhai; Xu, Hao; Lin, Songqing; Zhang, Huihao

2016-01-01

T1- and T2-weighted magnetic resonance images (MRI) can reveal lumbar redundant nerve roots (RNRs), a result of chronic compression and nerve elongation associated with pathogenesis of cauda equina claudication (CEC) in degenerative lumbar canal stenosis (DLCS). The study investigated effects of lumbar lordosis angle and range of motion on functional recovery in lumbar stenosis patents with and without RNRs. A retrospective study was conducted of 93 lumbar spinal stenosis patients who underwent decompressive surgery. Eligible records were assessed by 3 independent blinded radiologists for presence or absence of RNRs on sagittal T2-weighted MR (RNR and non-RNR groups), pre- and post-operative JOA score, lumbar lordosis angle, and range of motion. Of 93 total patients, the RNR group (n=37, 21/37 female) and non-RNR group (n=56; 31/56 female) had similar preoperative conditions (JOA score) and were not significantly different in age (mean 64.19 ± 8.25 vs. 62.8 ± 9.41 years), symptom duration (30.92 ± 22.43 vs. 28.64 ± 17.40 months), or follow-up periods (17.35 ± 4.02 vs. 17.75 ± 4.29 mo) (all p>0.4). The non-RNR group exhibited significantly better final JOA score (p=0.015) and recovery rate (p=0.002). RNR group patients exhibited larger lumbar lordosis angles in the neutral position (p=0.009) and extension (p=0.021) and larger range of motion (p=0.008). Poorer surgical outcomes in patients with RNRs indicated that elevated lumbar lordosis angle and range of motion increased risks of RNR formation, which in turn may cause poorer post-surgical recovery, this information is possibly useful in prognostic assessment of lumbar stenosis complicated by RNRs. Copyright © 2015 Elsevier B.V. All rights reserved.

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

PubMed Central

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

2007-01-01

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

Comparison of Expandable and Fixed Interbody Cages in a Human Cadaver Corpectomy Model: Fatigue Characteristics.

PubMed

Pekmezci, Murat; Tang, Jessica A; Cheng, Liu; Modak, Ashin; McClellan, Robert T; Buckley, Jenni M; Ames, Christopher P

2016-11-01

In vitro cadaver biomechanics study. The goal of this study is to compare the in situ fatigue life of expandable versus fixed interbody cage designs. Expandable cages are becoming more popular, in large part, due to their versatility; however, subsidence and catastrophic failure remain a concern. This in vitro analysis investigates the fatigue life of expandable and fixed interbody cages in a single level human cadaver corpectomy model by evaluating modes of subsidence of expandable and fixed cages as well as change in stiffness of the constructs with cyclic loading. Nineteen specimens from 10 human thoracolumbar spines (T10-L2, L3-L5) were biomechanically evaluated after a single level corpectomy that was reconstructed with an expandable or fixed cage and anterior dual rod instrumentation. All specimens underwent 98 K cycles to simulate 3 months of postoperative weight bearing. In addition, a third group with hyperlordotic cages was used to simulate catastrophic failure that is observed in clinical practice. Three fixed and 2 expandable cages withstood the cyclic loading despite perfect sagittal and coronal plane fitting of the endcaps. The majority of the constructs settled in after initial subsidence. The catastrophic failures that were observed in clinical practice could not be reproduced with hyperlordotic cages. However, all cages in this group subsided, and 60% resulted in endplate fractures during deployment of the cage. Despite greater surface contact area, expandable cages have a trend for higher subsidence rates when compared with fixed cages. When there is edge loading as in the hyperlordotic cage scenario, there is a higher risk of subsidence and intraoperative fracture during deployment of expandable cages.

Retroperitoneal hemorrhage from an unrecognized puncture of the lumbar right segmental artery during lumbar chemical sympathectomy: diagnosis and management.

PubMed

Shin, Ho-Jin; Choi, Yun-Mi; Kim, Hye-Jin; Lee, Sun-Jae; Yoon, Seok-Hyun; Kim, Kyung-Hoon

2014-12-01

Lumbar chemical sympathectomy has been performed using fluoroscopic guidance for needle positioning. An 84 year old woman with atherosclerosis obliterans was referred to the pain clinic for intractable cold allodynia of her right foot. A thermogram showed decreased temperature of both feet compared with temperatures above both ankles. The patient agreed to undergo lumbar chemical sympathectomy using fluoroscopy after being informed of the associated risks of nerve injury, hemorrhage, infection, transient back pain, and transient hypotension. During the procedure and three hours afterward, no abnormal signs or symptoms were found except an increase in right leg temperature. The patient was ambulatory after the procedure. However, one day after undergoing lumbar chemical sympathectomy, she visited our emergency department for abdominal discomfort and postural dizziness. Her blood pressure was 80/50 mmHg, and flank tenderness was noted. Retroperitoneal hemorrhage from the second right lumbar segmental artery was shown on computed tomography and angiography. Vital signs were stabilized immediately after embolization into the right lumbar segmental artery. Copyright © 2014 Elsevier Inc. All rights reserved.

Influences of posterior-located center of gravity on lumbar extension strength, balance, and lumbar lordosis in chronic low back pain.

PubMed

Kim, Dae-Hun; Park, Jin-Kyu; Jeong, Myeong-Kyun

2014-01-01

In patients with chronic low back pain, the center of gravity (COG) is abnormally located posterior to the center in most cases. The purpose of this study was to examine the effects of posterior-located COG on the functions (lumbar extension strength, and static and dynamic balance) and structure (lumbar lordosis angle and lumbosacral angle) of the lumbar spine. In this study, the COG of chronic low back pain patients who complained of only low back pain were examined using dynamic body balance equipment. A total of 164 subjects participated in the study (74 males and 90 females), and they were divided into two groups of 82 patients each. One group (n=82) consisted of patients whose COG was located at the center (C-COG); the other group (n=82) consisted of patients whose COG was located posterior to the center (P-COG). The following measures assessed the lumber functions and structures of the two groups: lumbar extension strength, moving speed of static and dynamic COGs, movement distance of the static and dynamic COGs, lumbar lordosis angle, and lumbosacral angle. The measured values were analyzed using independent t-tests. The group of patients with P-COG showed more decreases in lumbar extension strength, lumbar lordosis angle, and lumbosacral angle compared to the group of patients with C-COG. Also this group showed increases in moving speed and movement distance of the static COG. However, there were no differences in moving speed and movement distance of the dynamic COG between the two groups. These findings suggest that chronic LBP patients with P-COG have some disadvantages to establish lumbar extension strength and static and dynamic balance, which require specific efforts to maintain a neutral position and to control posture.

Chemoembolization for Hepatocellular Carcinoma Supplied by a Lumbar Artery

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kim, Han Myun, E-mail: seoul49@naver.com; Kim, Hyo-Cheol, E-mail: angiointervention@gmail.com; Woo, Sungmin, E-mail: j-crew7@hotmail.com

PurposeTo describe the radiologic findings and imaging response of hepatocellular carcinoma (HCC) supplied by the lumbar artery.MethodsBetween April 2004 and December 2012, we encountered HCC supplied by a lumbar artery in 21 patients. Two investigators retrospectively reviewed clinical and radiological findings of HCC supplied by the lumbar artery using computed tomography (CT) scans and digital subtraction angiograms.ResultsPatients had received 1–27 sessions of previous chemoembolization procedures (mean 7.7 sessions, median 4 sessions). Mean tumor size was 5.3 cm. The locations of HCC supplied by lumbar artery were the bare area (n = 14, 67 %) and segment VI (n = 7, 33 %). Tumor-feeding arteries arose from themore » main lumbar artery (n = 7), proximal anterior division (n = 4), and distal anterior division (n = 14). In 20 patients, selective chemoembolization through the tumor-feeding arteries of the lumbar artery was achieved. In 1 patient, nonselective embolization at the main lumbar artery was performed. There was no complication such as skin necrosis or paralysis. On the first follow-up enhanced CT scan, target tumors fed by the lumbar artery showed complete response (n = 6), partial response (n = 4), stable disease (n = 3), and progressive disease (n = 8), but overall tumor response was partial response (n = 1) and progressive disease (n = 20).ConclusionWhen HCC is located in the inferior tip or bare area of the liver, a lumbar artery may supply the tumor. Although selective chemoembolization via the tumor-feeding vessel of the lumbar artery can be achieved in most cases, overall tumor response is commonly unfavorable.« less

The NEtherlands Cervical Kinematics (NECK) trial. Cost-effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blind randomised multicenter study.

PubMed

Arts, Mark P; Brand, Ronald; van den Akker, Elske; Koes, Bart W; Peul, Wilco C

2010-06-16

Patients with cervical radicular syndrome due to disc herniation refractory to conservative treatment are offered surgical treatment. Anterior cervical discectomy is the standard procedure, often in combination with interbody fusion. Accelerated adjacent disc degeneration is a known entity on the long term. Recently, cervical disc prostheses are developed to maintain motion and possibly reduce the incidence of adjacent disc degeneration. A comparative cost-effectiveness study focused on adjacent segment degeneration and functional outcome has not been performed yet. We present the design of the NECK trial, a randomised study on cost-effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in patients with cervical disc herniation. Patients (age 18-65 years) presenting with radicular signs due to single level cervical disc herniation lasting more than 8 weeks are included. Patients will be randomised into 3 groups: anterior discectomy only, anterior discectomy with interbody fusion, and anterior discectomy with disc prosthesis. The primary outcome measure is symptomatic adjacent disc degeneration at 2 and 5 years after surgery. Other outcome parameters will be the Neck Disability Index, perceived recovery, arm and neck pain, complications, re-operations, quality of life, job satisfaction, anxiety and depression assessment, medical consumption, absenteeism, and costs. The study is a randomised prospective multicenter trial, in which 3 surgical techniques are compared in a parallel group design. Patients and research nurses will be kept blinded of the allocated treatment for 2 years. The follow-up period is 5 years. Currently, anterior cervical discectomy with fusion is the golden standard in the surgical treatment of cervical disc herniation. Whether additional interbody fusion or disc prosthesis is necessary and cost-effective will be determined by this trial. Netherlands Trial Register NTR1289.

The NEtherlands Cervical Kinematics (NECK) Trial. Cost-effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blind randomised multicenter study

PubMed Central

2010-01-01

Background Patients with cervical radicular syndrome due to disc herniation refractory to conservative treatment are offered surgical treatment. Anterior cervical discectomy is the standard procedure, often in combination with interbody fusion. Accelerated adjacent disc degeneration is a known entity on the long term. Recently, cervical disc prostheses are developed to maintain motion and possibly reduce the incidence of adjacent disc degeneration. A comparative cost-effectiveness study focused on adjacent segment degeneration and functional outcome has not been performed yet. We present the design of the NECK trial, a randomised study on cost-effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in patients with cervical disc herniation. Methods/Design Patients (age 18-65 years) presenting with radicular signs due to single level cervical disc herniation lasting more than 8 weeks are included. Patients will be randomised into 3 groups: anterior discectomy only, anterior discectomy with interbody fusion, and anterior discectomy with disc prosthesis. The primary outcome measure is symptomatic adjacent disc degeneration at 2 and 5 years after surgery. Other outcome parameters will be the Neck Disability Index, perceived recovery, arm and neck pain, complications, re-operations, quality of life, job satisfaction, anxiety and depression assessment, medical consumption, absenteeism, and costs. The study is a randomised prospective multicenter trial, in which 3 surgical techniques are compared in a parallel group design. Patients and research nurses will be kept blinded of the allocated treatment for 2 years. The follow-up period is 5 years. Discussion Currently, anterior cervical discectomy with fusion is the golden standard in the surgical treatment of cervical disc herniation. Whether additional interbody fusion or disc prothesis is necessary and cost-effective will be determined by this trial. Trial Registration Netherlands

Interventional Radiology Management of a Ruptured Lumbar Artery Pseudoaneurysm after Cryoablation and Vertebroplasty of a Lumbar Metastasis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Giordano, Aldo Victor; Arrigoni, Francesco, E-mail: arrigoni.francesco@gmail.com; Bruno, Federico

We describe the management of a complication (a lumbar artery pseudoaneurysm and its rupture) after combined procedure (cryoablation and vertebroplasty) on a lumbar (L2) metastasis from renal cell carcinoma. Review of the literature is also presented with discussion about the measures to be taken to prevent these types of complications.

ISASS Policy Statement – Lumbar Artificial Disc

PubMed Central

Garcia, Rolando

2015-01-01

Purpose The primary goal of this Policy Statement is to educate patients, physicians, medical providers, reviewers, adjustors, case managers, insurers, and all others involved or affected by insurance coverage decisions regarding lumbar disc replacement surgery. Procedures This Policy Statement was developed by a panel of physicians selected by the Board of Directors of ISASS for their expertise and experience with lumbar TDR. The panel's recommendation was entirely based on the best evidence-based scientific research available regarding the safety and effectiveness of lumbar TDR. PMID:25785243

Speculum lumbar extraforaminal microdiscectomy.

PubMed

Obenchain, T G

2001-01-01

Public interest, monetary pressures and improving diagnostic techniques have placed an increasing emphasis on minimalism in lumbar disc excision. Current techniques include microlumbar discectomy and minimally invasive spinal surgery. Both are good techniques but may be painful, require a hospital stay and/or are not widely used because of difficulty acquiring the necessary skills. The author therefore developed a less invasive microscopic technique that may be performed on a consistent outpatient basis with easily acquired skills. The purpose of this study was to describe a variant of minimally invasive lumbar disc excision, while assessing the effects on a small group of patients. The treatment protocol was a prospective community hospital-based case study designed to evaluate a less invasive method of excising herniated lumbar discs residing in the canal, foraminal or far lateral space. This study is comprised of 50 patients with all anatomic forms of lumbar disc herniations, inside or outside the canal, at all levels except the lumbosacral joint. Clinical results were measured by return to work time, the criteria of MacNab and by Prolo et al.'s economic and functional criteria. Selection criteria included adult patients with intractable low back and leg pain, plus an imaging study revealing a lumbar disc herniation consistent with the patient's clinical presentation. Mean patient age was 48 years. The male:female ratio was approximately 2:1. All patients failed at least 3 weeks of conservative therapy. Herniations occurred from the L2-3 space through L4-5, with 30 herniations being within and 20 outside the spinal canal. Both contained and extruded/sequestered herniations were treated. Excluded from the study were patients with herniations inside the spinal canal at the L5-S1 level. Surgical approach was by microscopic speculum transforaminal route for discs residing both within and outside the lumbar canal. The initial 50 consecutive patients had successful

Lumbar herniation following extended autologous latissimus dorsi breast reconstruction.

PubMed

Fraser, Sheila Margaret; Fatayer, Hiba; Achuthan, Rajgopal

2013-05-30

Reconstructive breast surgery is now recognized to be an important part of the treatment for breast cancer. Surgical reconstruction options consist of implants, autologous tissue transfer or a combination of the two. The latissimus dorsi flap is a pedicled musculocutaneous flap and is an established method of autologous breast reconstruction.Lumbar hernias are an unusual type of hernia, the majority occurring after surgery or trauma in this area. The reported incidence of a lumbar hernia subsequent to a latissimus dorsi reconstruction is very low. We present the unusual case of lumbar herniation after an extended autologous latissimus dorsi flap for breast reconstruction following a mastectomy. The lumbar hernia was confirmed on CT scanning and the patient underwent an open mesh repair of the hernia through the previous latissimus dorsi scar. Lumbar hernias are a rare complication that can occur following latissimus dorsi breast reconstruction. It should be considered in all patients presenting with persistent pain or swelling in the lumbar region.

Automatic Lumbar Spondylolisthesis Measurement in CT Images.

PubMed

Liao, Shu; Zhan, Yiqiang; Dong, Zhongxing; Yan, Ruyi; Gong, Liyan; Zhou, Xiang Sean; Salganicoff, Marcos; Fei, Jun

2016-07-01

Lumbar spondylolisthesis is one of the most common spinal diseases. It is caused by the anterior shift of a lumbar vertebrae relative to subjacent vertebrae. In current clinical practices, staging of spondylolisthesis is often conducted in a qualitative way. Although meyerding grading opens the door to stage spondylolisthesis in a more quantitative way, it relies on the manual measurement, which is time consuming and irreproducible. Thus, an automatic measurement algorithm becomes desirable for spondylolisthesis diagnosis and staging. However, there are two challenges. 1) Accurate detection of the most anterior and posterior points on the superior and inferior surfaces of each lumbar vertebrae. Due to the small size of the vertebrae, slight errors of detection may lead to significant measurement errors, hence, wrong disease stages. 2) Automatic localize and label each lumbar vertebrae is required to provide the semantic meaning of the measurement. It is difficult since different lumbar vertebraes have high similarity of both shape and image appearance. To resolve these challenges, a new auto measurement framework is proposed with two major contributions: First, a learning based spine labeling method that integrates both the image appearance and spine geometry information is designed to detect lumbar vertebrae. Second, a hierarchical method using both the population information from atlases and domain-specific information in the target image is proposed for most anterior and posterior points positioning. Validated on 258 CT spondylolisthesis patients, our method shows very similar results to manual measurements by radiologists and significantly increases the measurement efficiency.

Comparison of erector spinae and hamstring muscle activities and lumbar motion during standing knee flexion in subjects with and without lumbar extension rotation syndrome.

PubMed

Kim, Si-hyun; Kwon, Oh-yun; Park, Kyue-nam; Kim, Moon-Hwan

2013-12-01

The aim of this study was to compare the activity of the erector spinae (ES) and hamstring muscles and the amount and onset of lumbar motion during standing knee flexion between individuals with and without lumbar extension rotation syndrome. Sixteen subjects with lumbar extension rotation syndrome (10 males, 6 females) and 14 healthy subjects (8 males, 6 females) participated in this study. During the standing knee flexion, surface electromyography (EMG) was used to measure muscle activity, and surface EMG electrodes were attached to both the ES and hamstring (medial and lateral) muscles. A three-dimensional motion analysis system was used to measure kinematic data of the lumbar spine. An independent-t test was conducted for the statistical analysis. The group suffering from lumbar extension rotation syndrome exhibited asymmetric muscle activation of the ES and decreased hamstring activity. Additionally, the group with lumbar extension rotation syndrome showed greater and earlier lumbar extension and rotation during standing knee flexion compared to the control group. These data suggest that asymmetric ES muscle activation and a greater amount of and earlier lumbar motion in the sagittal and transverse plane during standing knee flexion may be an important factor contributing to low back pain. Copyright © 2013 Elsevier Ltd. All rights reserved.

Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review.

PubMed

Goldstein, Christina L; Macwan, Kevin; Sundararajan, Kala; Rampersaud, Y Raja

2016-03-01

The objective of this study was to determine the clinical comparative effectiveness and adverse event rates of posterior minimally invasive surgery (MIS) compared with open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). A systematic review of the Medline, EMBASE, PubMed, Web of Science, and Cochrane databases was performed. A hand search of reference lists was conducted. Studies were reviewed by 2 independent assessors to identify randomized controlled trials (RCTs) or comparative cohort studies including at least 10 patients undergoing MIS or open TLIF/PLIF for degenerative lumbar spinal disorders and reporting at least 1 of the following: clinical outcome measure, perioperative clinical or process measure, radiographic outcome, or adverse events. Study quality was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) protocol. When appropriate, a meta-analysis of outcomes data was conducted. The systematic review and reference list search identified 3301 articles, with 26 meeting study inclusion criteria. All studies, including 1 RCT, were of low or very low quality. No significant difference regarding age, sex, surgical levels, or diagnosis was identified between the 2 cohorts (856 patients in the MIS cohort, 806 patients in the open cohort). The meta-analysis revealed changes in the perioperative outcomes of mean estimated blood loss, time to ambulation, and length of stay favoring an MIS approach by 260 ml (p < 0.00001), 3.5 days (p = 0.0006), and 2.9 days (p < 0.00001), respectively. Operative time was not significantly different between the surgical techniques (p = 0.78). There was no significant difference in surgical adverse events (p = 0.97), but MIS cases were significantly less likely to experience medical adverse events (risk ratio [MIS vs open] = 0.39, 95% confidence interval 0.23-0.69, p = 0.001). No difference in nonunion (p = 0.97) or reoperation rates (p = 0.97) was observed. Mean Oswestry

Cost Utility Analysis of Percutaneous Adhesiolysis in Managing Pain of Post-lumbar Surgery Syndrome and Lumbar Central Spinal Stenosis.

PubMed

Manchikanti, Laxmaiah; Helm, Standiford; Pampati, Vidyasagar; Racz, Gabor B

2015-06-01

The increase in the number of interventions for the management of chronic pain and associated escalation of healthcare costs has captured the attention of health policymakers, in no small part due to the lack of documentation of efficacy, cost-effectiveness, or cost utility analysis. A recent cost utility analysis of caudal epidural injections in managing chronic low back pain of various pathologies showed a high cost utility with improvement in quality of life years, competitive with various other modalities of treatments. However, there are no analyses derived from high-quality controlled studies related to the cost utility of percutaneous adhesiolysis in the treatment of post-lumbar surgery syndrome or lumbar central spinal stenosis. This analysis is based on 2 previously published controlled studies. To assess the cost utility of percutaneous adhesiolysis procedures in managing chronic low back and lower extremity pain secondary to post-lumbar surgery syndrome and lumbar central spinal stenosis. A private, specialty referral interventional pain management center in the United States. Two controlled studies were conducted assessing the clinical effectiveness of percutaneous adhesiolysis for post-lumbar surgery syndrome and lumbar central spinal stenosis in an interventional pain management setting utilizing contemporary interventional pain management practices. A cost utility analysis was performed with direct payment data for a total of 130 patients in treatment groups over a 2-year period. Various outcome measures were included with significant improvement, defined as at least 50% improvement with reduction in pain and disability status. The results of 2 controlled studies of low back pain with 60 and 70 patients and a 2-year follow-up with the actual reimbursement data showed cost utility for 1 year of quality-adjusted life year (QALY) of USD $2,652 for post-lumbar surgery syndrome and USD $2,649 for lumbar central spinal stenosis. The results of this

The Lumbar Pelvic Angle, the Lumbar Component of the T1 Pelvic Angle, Correlates With HRQOL, PI-LL Mismatch, and it Predicts Global Alignment.

PubMed

Protopsaltis, Themistocles S; Lafage, Renaud; Smith, Justin S; Passias, Peter G; Shaffrey, Christopher I; Kim, Han Jo; Mundis, Gregory M; Ames, Christopher P; Burton, Douglas C; Bess, Shay; Klineberg, Eric; Hart, Robert A; Schwab, Frank J; Lafage, Virginie

2018-05-15

Prospective multicenter analysis of adult spinal deformity (ASD) patients. The aim of this study was to introduce the lumbar pelvic angle (LPA), a novel parameter of spinopelvic alignment. The T1 pelvic angle (TPA), a measure of global spinopelvic alignment, correlates with health-related quality of life (HRQOL), but it may not be measureable on all intraoperative x-rays. In patients with previous interbody fusion at L5-S1, the plane of the S1 endplate can be blurred, creating error in pelvic incidence and lumbar lordosis (PI-LL) measure. The LPA is more readily measured on intraoperative imaging than the TPA. ASD patients were included with either coronal Cobb angle >20°, sagittal vertical axis (SVA) >5 cm, thoracic kyphosis >60°, or pelvic tilt (PT) >25°. Measures of disability included Oswestry Disability Index (ODI), Scoliosis Research Society (SRS), and Short Form (SF)-36. Baseline and 2-year follow-up radiographic and HRQOL outcomes were evaluated. Linear regressions compared LPA with radiographic parameters and HRQOL. A total of 852 ASD patients (407 operative) were enrolled (mean age 53.7). Baseline LPA correlated with PI-LL (r = 0.79), PT (r = 0.78), TPA (r = 0.82), and SVA (r = 0.61) (all P < 0.001). PI-LL, LPA, and TPA correlated with ODI (r = 0.42/0.29/0.45), SF-36 physical component score (-0.43/-0.28/-0.45) SRS (-0.354/-0.23/-0.37) with all P < 0.001. At 2 years' follow-up, LPA correlated with PI-LL (r = 0.77), PT (r = 0.78), TPA (r = 0.83), and SVA (r = 0.57) (all P < 0.001). Categorizing patients by increasing LPA (<7°; 7°-15°; >15°) revealed progressive increases in all HRQOL, PI-LL (-3.2°/12.7°/32.4°), and TPA (9.7°/20.1°/34.6°) with all P < 0.001. Moderate disability (ODI = 40) corresponded to LPA 10.1°, PI-LL 12.6°, and TPA 20.6°. Mild disability (ODI = 20) corresponded to LPA 7.2°, PI-LL 4.2°, and TPA 14.7°. LPA correlates with TPA, PI-LL, and HRQOL in ASD patients

The top 100 classic papers in lumbar spine surgery.

PubMed

Steinberger, Jeremy; Skovrlj, Branko; Caridi, John M; Cho, Samuel K

2015-05-15

Bibliometric review of the literature. To analyze and quantify the most frequently cited papers in lumbar spine surgery and to measure their impact on the entire lumbar spine literature. Lumbar spine surgery is a dynamic and complex field. Basic science and clinical research remain paramount in understanding and advancing the field. While new literature is published at increasing rates, few studies make long-lasting impacts. The Thomson Reuters Web of Knowledge was searched for citations of all papers relevant to lumbar spine surgery. The number of citations, authorship, year of publication, journal of publication, country of publication, and institution were recorded for each paper. The most cited paper was found to be the classic paper from 1990 by Boden et al that described magnetic resonance imaging findings in individuals without back pain, sciatica, and neurogenic claudication showing that spinal stenosis and herniated discs can be incidentally found when scanning patients. The second most cited study similarly showed that asymptomatic patients who underwent lumbar spine magnetic resonance imaging frequently had lumbar pathology. The third most cited paper was the 2000 publication of Fairbank and Pynsent reviewing the Oswestry Disability Index, the outcome-measure questionnaire most commonly used to evaluate low back pain. The majority of the papers originate in the United States (n=58), and most were published in Spine (n=63). Most papers were published in the 1990s (n=49), and the 3 most common topics were low back pain, biomechanics, and disc degeneration. This report identifies the top 100 papers in lumbar spine surgery and acknowledges those individuals who have contributed the most to the advancement of the study of the lumbar spine and the body of knowledge used to guide evidence-based clinical decision making in lumbar spine surgery today. 3.

A musculoskeletal model for the lumbar spine.

PubMed

Christophy, Miguel; Faruk Senan, Nur Adila; Lotz, Jeffrey C; O'Reilly, Oliver M

2012-01-01

A new musculoskeletal model for the lumbar spine is described in this paper. This model features a rigid pelvis and sacrum, the five lumbar vertebrae, and a rigid torso consisting of a lumped thoracic spine and ribcage. The motion of the individual lumbar vertebrae was defined as a fraction of the net lumbar movement about the three rotational degrees of freedom: flexion-extension lateral bending, and axial rotation. Additionally, the eight main muscle groups of the lumbar spine were incorporated using 238 muscle fascicles with prescriptions for the parameters in the Hill-type muscle models obtained with the help of an extensive literature survey. The features of the model include the abilities to predict joint reactions, muscle forces, and muscle activation patterns. To illustrate the capabilities of the model and validate its physiological similarity, the model's predictions for the moment arms of the muscles are shown for a range of flexion-extension motions of the lower back. The model uses the OpenSim platform and is freely available on https://www.simtk.org/home/lumbarspine to other spinal researchers interested in analyzing the kinematics of the spine. The model can also be integrated with existing OpenSim models to build more comprehensive models of the human body.

Automatic lumbar spine measurement in CT images

NASA Astrophysics Data System (ADS)

Mao, Yunxiang; Zheng, Dong; Liao, Shu; Peng, Zhigang; Yan, Ruyi; Liu, Junhua; Dong, Zhongxing; Gong, Liyan; Zhou, Xiang Sean; Zhan, Yiqiang; Fei, Jun

2017-03-01

Accurate lumbar spine measurement in CT images provides an essential way for quantitative spinal diseases analysis such as spondylolisthesis and scoliosis. In today's clinical workflow, the measurements are manually performed by radiologists and surgeons, which is time consuming and irreproducible. Therefore, automatic and accurate lumbar spine measurement algorithm becomes highly desirable. In this study, we propose a method to automatically calculate five different lumbar spine measurements in CT images. There are three main stages of the proposed method: First, a learning based spine labeling method, which integrates both the image appearance and spine geometry information, is used to detect lumbar and sacrum vertebrae in CT images. Then, a multiatlases based image segmentation method is used to segment each lumbar vertebra and the sacrum based on the detection result. Finally, measurements are derived from the segmentation result of each vertebra. Our method has been evaluated on 138 spinal CT scans to automatically calculate five widely used clinical spine measurements. Experimental results show that our method can achieve more than 90% success rates across all the measurements. Our method also significantly improves the measurement efficiency compared to manual measurements. Besides benefiting the routine clinical diagnosis of spinal diseases, our method also enables the large scale data analytics for scientific and clinical researches.

Physiotherapy and lumbar facet joint injections as a combination treatment for chronic low back pain. A narrative review of lumbar facet joint injections, lumbar spinal mobilizations, soft tissue massage and lower back mobility exercises.

PubMed

Chambers, Hannah

2013-06-01

The aim of this study was to summarize the available evidence on lumbar facet joint injections and the physiotherapy treatments, land-based lower back mobility exercise, soft tissue massage and lumbar spinal mobilizations for chronic low back pain (CLBP). The plausibility of physiotherapy and lumbar facet joint injections as a combination treatment is discussed. Using a systematic process, an online electronic search was performed using key words utilizing all available databases and hand searching reference lists. Using a critical appraisal tool from the Critical Appraisal Skills Programme (CASP), the literature was screened to include primary research. The main aspects of the research were summarized. The evidence for lumbar facet joint injections suggests an overall short-term positive effect on CLBP. Land-based lower back mobility exercise and soft tissue massage appear to have a positive effect on CLBP in the short term and possibly in the longer term. There is insufficient evidence to draw conclusions for lumbar spinal mobilizations. The review indicates that lumbar facet joint injections create a short period when pain is reduced. Physiotherapy treatments including land-based lower back mobility exercise and soft tissue massage may be of benefit during this time to improve the longer-term outcomes of patients with CLBP. It is not possible to make generalizations or firm conclusions. The current review highlights the need for further research. A randomized controlled trial is recommended to assess the impact of physiotherapy in combination with lumbar facet joint injections on CLBP. Copyright © 2013 John Wiley & Sons, Ltd.

Magnetic Resonance Imaging (MRI): Lumbar Spine (For Parents)

MedlinePlus

... Staying Safe Videos for Educators Search English Español Magnetic Resonance Imaging (MRI): Lumbar Spine KidsHealth / For Parents / Magnetic Resonance Imaging (MRI): Lumbar Spine What's in this article? What ...

The effects of an exercise with a stick on the lumbar spine and hip movement patterns during forward bending in patients with lumbar flexion syndrome.

PubMed

Yoon, Ji-yeon; Kim, Ji-won; Kang, Min-hyeok; An, Duk-hyun; Oh, Jae-seop

2015-01-01

Forward bending is frequently performed in daily activities. However, excessive lumbar flexion during forward bending has been reported as a risk factor for low back pain. Therefore, we examined the effects of an exercise strategy using a stick on the angular displacement and movement onset of lumbar and hip flexion during forward-bending exercises in patients with lumbar flexion syndrome. Eighteen volunteers with lumbar flexion syndrome were recruited in this study. Subjects performed forward-bending exercises with and without a straight stick in standing. The angular displacement and movement onset of lumbar and hip flexion during forward-bending exercises were measured by using a three dimensional motion analysis system. The significances of differences between the two conditions (with stick vs. without stick) was assessed using a one-way repeated analysis of variance. When using a stick during a forward-bending exercise, the peak angular displacement of lumbar flexion decreased significantly, and those of right and left-hip flexion increased significantly compared with those without a stick. The movement onset of lumbar flexion occurred significantly later, and the onset of right-hip flexion occurred significantly earlier with than without a stick. Based on these findings, a stick exercise was an effective method to prevent excessive lumbar flexion and more helpful in developing hip flexion during a forward-bending exercise. These findings will be useful for clinicians to teach self-exercise during forward bending in patients with lumbar flexion syndrome.

[A woman with a postoperative lumbar swelling].

PubMed

Hulshof, Hanna M; Elsenburg, Patric H J M; Frequin, Stephan T F M

2013-01-01

A 65-year-old woman had developed a large lumbar swelling in a period of four weeks following lumbar laminectomy. An MRI-scan revealed a large fluid collection, which had formed from the spinal canal. The diagnosis 'liquorcele', a rare complication of spine surgery, was established.

Lumbar puncture (image)

MedlinePlus

... is a clear fluid that circulates in the space surrounding the spinal cord and brain. CSF protects the brain and spinal cord from injury by acting like a liquid cushion. CSF is usually obtained through a lumbar ...

Lumbar muscle rhabdomyolysis after abdominal aortic surgery.

PubMed

Bertrand, M; Godet, G; Fléron, M H; Bernard, M A; Orcel, P; Riou, B; Kieffer, E; Coriat, P

1997-07-01

Lumbar muscle rhabdomyolysis has been very rarely reported after surgery. The aim of this study was to determine its incidence and main characteristics in a large population undergoing abdominal aortic surgery. Over a 21-mo period, 224 consecutive patients, 209 male and 15 female, mean age 65 +/- 10 yr, underwent abdominal aortic surgery (aortic aneurysm in 142 patients and occlusive aortic degenerative disease in 82 patients). Surgical incision was a midline incision with exaggerated hyperlordosis in 173 patients and a flank incision with a retroperitoneal approach in 51 patients. Postoperative rhabdomyolysis was diagnosed in 20 patients. In these patients, 9 (4%) experienced severe low back pain, and lumbar muscle rhabdomyolysis was confirmed by tomodensitometry (n = 6) or muscle biopsy (n = 3). The remaining 11 patients had lower limb muscle rhabdomyolysis. Rhabdomyolysis occurred after surgery of longer duration, which involved more frequent visceral artery reimplantation, with longer duration of aortic clamping and greater intraoperative bleeding. Lumbar rhabdomyolysis occurred in younger patients who were more frequently obese. On first postoperative day, the mean creatine kinase (CK) value was greater in lumbar rhabdomyolysis than in lower limb rhabdomyolysis (17,082 +/- 15,003 vs 3,313 +/- 3,120 IU/L, P < 0.05). Acute renal failure and postoperative death did not occur in patients with lumbar muscle rhabdomyolysis. Lumbar rhabdomyolysis was not a rare event after abdominal aortic surgery (4%). This syndrome was characterized by postoperative low back pain of unusual severity, which required analgesic therapy, and induced a very high increase in CK with typical findings at tomodensitometry or muscle biopsy but was not associated with postoperative renal failure.

Morphometric study of the lumbar spinal canal in the Korean population.

PubMed

Lee, H M; Kim, N H; Kim, H J; Chung, I H

1995-08-01

The anatomic dimensions of the vertebral body and spinal canal of the lumbar spine were analyzed in Koreans. To determine the normal dimension of the lumbar spinal canal in Koreans, to determine whether there are any racial differences in the morphometry of the lumbar spinal canal, and to provide criteria for diagnosing spinal stenosis in the Far Eastern Asian. Some radiologic and anatomic studies have been conducted regarding the size of the lumbar spinal canal of whites and blacks in western and African countries. One-thousand-eight-hundred measurements were performed on the transverse and sagittal diameters of vertebral bodies and spinal canals using complete sets of 90 lumbar vertebrae. The mean mid-sagittal diameter of the lumbar spinal canal in the Korean population was less than that measured in white and African populations, but there was no significant differences between the Korean, white, and African populations regarding the transverse diameter of the lumbar spinal canal. The mid-sagittal diameter of the lumbar spinal canal is narrowest in the Far Eastern Asian population; the radiologic criteria of spinal stenosis should be reconsidered for these people.

Hepatocellular Carcinoma Supplied by the Right Lumbar Artery

DOE Office of Scientific and Technical Information (OSTI.GOV)

Miyayama, Shiro, E-mail: s-miyayama@fukui.saiseikai.or.jp; Yamashiro, Masashi; Okuda, Miho

This study evaluated the clinical features of hepatocellular carcinoma (HCC) supplied by the right lumbar artery. Eleven patients with HCC supplied by the right lumbar artery were treated with chemoembolization. The patients' medical records were retrospectively analyzed. All patients underwent 6.7 {+-} 3.7 (mean {+-} SD) chemoembolization sessions, and the hepatic arterial branches were noted as being attenuated. The right inferior phrenic artery (IPA) was also embolized in 10 patients. The interval between initial chemoembolization and chemoembolization of the lumbar artery supply was 53.2 {+-} 26.9 months. Mean tumor diameter was 3.1 {+-} 2.4 cm and was located at themore » surface of S7 and S6. The feeding-branch arose proximal to the bifurcation of the dorsal ramus and muscular branches (n = 8) or from the muscular branches (n = 3) of the right first (n = 10) or second lumbar artery (n = 1). The anterior spinal artery originated from the tumor-feeding lumbar artery in one patient. All feeders were selected, and embolization was performed after injection of iodized oil and anticancer drugs (n = 10) or gelatin sponge alone in a patient with anterior spinal artery branching (n = 1). Eight patients died from tumor progression 10.1 {+-} 4.6 months later, and two patients survived 2 and 26 months, respectively. The remaining patient died of bone metastases after 32 months despite liver transplantation 10 months after chemoembolization. The right lumbar artery supplies HCC located in the bare area of the liver, especially in patients who undergo repeated chemoembolization, including chemoembolization by way of the right IPA. Chemoembolization by way of the right lumbar artery may be safe when the feeder is well selected.« less

Return to Golf After Lumbar Fusion.

PubMed

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

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

Spontaneous regression of posterior epidural migrated lumbar disc fragments: case series.

PubMed

Tarukado, Kiyoshi; Ikuta, Ko; Fukutoku, Yoshiaki; Tono, Osamu; Doi, Toshio

2015-06-01

Posterior epidural migrated lumbar disc fragments is an extremely rare disorder. Surgical treatment was performed in all reported cases. To the best of our knowledge, there are no reported cases of the use of conservative treatment for posterior epidural migrated lumbar disc fragments. To report the possibility of a spontaneous regression of posterior epidural migrated lumbar disc fragments. Case series. Four patients with posterior epidural migrated lumbar disc fragments were treated at Karatsu Red Cross Hospital between April 2008 and August 2010. Spontaneous regression of the posterior epidural migrated lumbar disc fragments with relief of symptoms was observed on magnetic resonance imaging (MRI) in three cases. Another patient underwent surgical treatment. The present and previously reported cases of posterior epidural migrated lumbar disc fragments were analyzed with respect to patient age, imaging features on MRI, the level of the lesion, clinical symptoms, treatment, and outcomes. Conservative treatment was successful, and spontaneous lesion regression was seen on MRI with symptom relief in three cases. Although posterior epidural migrated lumbar disc fragment cases are generally treated surgically, the condition can regress spontaneously over time, as do sequestrated disc fragments. Spontaneous regression of lumbar disc herniations is a widely accepted observation at present. Posterior epidural migrated lumbar disc fragments fall under the sequestrated type of disc herniation. In fact, the course of treatment for posterior epidural migrated lumbar disc fragments should be determined based on the symptoms and examination findings, as in cases of ordinary herniation. However, providing early surgical treatment is important if the patient has acute cauda equina syndrome or the neurologic symptoms worsen over time. Copyright © 2015 Elsevier Inc. All rights reserved.

Caudal lumbar vertebral fractures in California Quarter Horse and Thoroughbred racehorses.

PubMed

Collar, E M; Zavodovskaya, R; Spriet, M; Hitchens, P L; Wisner, T; Uzal, F A; Stover, S M

2015-09-01

To gain insight into the pathophysiology of equine lumbar vertebral fractures in racehorses. To characterise equine lumbar vertebral fractures in California racehorses. Retrospective case series and prospective case-control study. Racehorse post mortem reports and jockey injury reports were retrospectively reviewed. Vertebral specimens from 6 racehorses affected with lumbar vertebral fractures and 4 control racehorses subjected to euthanasia for nonspinal fracture were assessed using visual, radiographic, computed tomography and histological examinations. Lumbar vertebral fractures occurred in 38 Quarter Horse and 29 Thoroughbred racehorses over a 22 year period, primarily involving the 5th and/or 6th lumbar vertebrae (L5-L6; 87% of Quarter Horses and 48% of Thoroughbreds). Lumbar vertebral fractures were the third most common musculoskeletal cause of death in Quarter Horses and frequently involved a jockey injury. Lumbar vertebral specimens contained anatomical variations in the number of vertebrae, dorsal spinous processes and intertransverse articulations. Lumbar vertebral fractures examined in 6 racehorse specimens (5 Quarter Horses and one Thoroughbred) coursed obliquely in a cranioventral to caudodorsal direction across the adjacent L5-L6 vertebral endplates and intervertebral disc, although one case involved only one endplate. All cases had evidence of abnormalities on the ventral aspect of the vertebral bodies consistent with pre-existing, maladaptive pathology. Lumbar vertebral fractures occur in racehorses with pre-existing pathology at the L5-L6 vertebral junction that is likely predisposes horses to catastrophic fracture. Knowledge of these findings should encourage assessment of the lumbar vertebrae, therefore increasing detection of mild vertebral injuries and preventing catastrophic racehorse and associated jockey injuries. © 2014 EVJ Ltd.

[Lumbar canal stenosis in achondroplasia. Prevention and correction of lumbosacral lordosis].

PubMed

Gómez Prat, A; García Ollé, L; Ginebreda Martí, I; Gairí Tahull, J; Vilarrubias Guillamet, J

2001-02-01

To determine through the measurement of different angles the correction of lumbar hyperlordosis after bilateral femoral lengthening using the Icatme technique and to assess the absence of neurological symptomatology secondary to stenosis of the lumbar canal after femoral lengthening. Thirty-four patients with achondroplasia were studied. Mean age was 22.3 years. The patients underwent femoral lengthening using the Icatme technique. X rays of the lateral rachis taken before and after lengthening were used to measure a series of angles. The lumbar lordosis angle, Sez's angle and the L5S1 angle decreased while the lumbosacral angle, Jungham's angle and the sacrum angle increased, leading to correction of lumbar hyperlordosis, verticalization of the sacrum and improvement in thoracolumbar and lumbosacral inflection. Values were similar to the standard for individuals without achondroplasia. Femoral lengthening using the Icatme technique in achondroplastics modifies the statics of the lumbar spine, making them similar to those of nonachondroplastics. The procedure corrects lumbar hyperlordosis and prevents the appearance of neurological symptomatology due to stenosis of the lumbar canal. The incidence of neurological complications due to stenosis of the lumbar canal in achondroplastics who have undergone femoral lengthening is low compared with that of achondroplastics of the same age and sex who have not undergone this procedure.

Transforaminal Lumbar Puncture: An Alternative Technique in Patients with Challenging Access.

PubMed

Nascene, D R; Ozutemiz, C; Estby, H; McKinney, A M; Rykken, J B

2018-05-01

Interlaminar lumbar puncture and cervical puncture may not be ideal in all circumstances. Recently, we have used a transforaminal approach in selected situations. Between May 2016 and December 2017, twenty-six transforaminal lumbar punctures were performed in 9 patients (25 CT-guided, 1 fluoroscopy-guided). Seven had spinal muscular atrophy and were referred for intrathecal nusinersen administration. In 2, CT myelography was performed via transforaminal lumbar puncture. The lumbar posterior elements were completely fused in 8, and there was an overlying abscess in 1. The L1-2 level was used in 2; the L2-3 level, in 10; the L3-4 level, in 12; and the L4-5 level, in 2 procedures. Post-lumbar puncture headache was observed on 4 occasions, which resolved without blood patching. One patient felt heat and pain at the injection site that resolved spontaneously within hours. One patient had radicular pain that resolved with conservative treatment. Transforaminal lumbar puncture may become an effective alternative to classic interlaminar lumbar puncture or cervical puncture. © 2018 by American Journal of Neuroradiology.

Lumbar lordosis and sacral slope in lumbar spinal stenosis: standard values and measurement accuracy.

PubMed

Bredow, J; Oppermann, J; Scheyerer, M J; Gundlfinger, K; Neiss, W F; Budde, S; Floerkemeier, T; Eysel, P; Beyer, F

2015-05-01

Radiological study. To asses standard values, intra- and interobserver reliability and reproducibility of sacral slope (SS) and lumbar lordosis (LL) and the correlation of these parameters in patients with lumbar spinal stenosis (LSS). Anteroposterior and lateral X-rays of the lumbar spine of 102 patients with LSS were included in this retrospective, radiologic study. Measurements of SS and LL were carried out by five examiners. Intraobserver correlation and correlation between LL and SS were calculated with Pearson's r linear correlation coefficient and intraclass correlation coefficients (ICC) were calculated for inter- and intraobserver reliability. In addition, patients were examined in subgroups with respect to previous surgery and the current therapy. Lumbar lordosis averaged 45.6° (range 2.5°-74.9°; SD 14.2°), intraobserver correlation was between Pearson r = 0.93 and 0.98. The measurement of SS averaged 35.3° (range 13.8°-66.9°; SD 9.6°), intraobserver correlation was between Pearson r = 0.89 and 0.96. Intraobserver reliability ranged from 0.966 to 0.992 ICC in LL measurements and 0.944-0.983 ICC in SS measurements. There was an interobserver reliability ICC of 0.944 in LL and 0.990 in SS. Correlation between LL and SS averaged r = 0.79. No statistically significant differences were observed between the analyzed subgroups. Manual measurement of LL and SS in patients with LSS on lateral radiographs is easily performed with excellent intra- and interobserver reliability. Correlation between LL and SS is very high. Differences between patients with and without previous decompression were not statistically significant.

[THE ALTERNATIVE MODEL IN TRAINING FOR OPERATION MANAGEMENT ON LUMBAR SPINE].

PubMed

Zakondyrin, D E

2015-01-01

The authors proposed to use a lumbar part of calf carcass as a new biological model for training of basic practical skills in order to perform the neurosurgical operative interventions on the spine. The proximity of anatomico-surgical parameters of given model and human cavader lumbar spine was estimated. The study proved the possibility of use of lumbar part of calf carcass for training techniques of transpedicular fixation and microdiskectomy in lumbar part.

Slump sitting X-ray of the lumbar spine is superior to the conventional flexion view in assessing lumbar spine instability.

PubMed

Hey, Hwee Weng Dennis; Lau, Eugene Tze-Chun; Lim, Joel-Louis; Choong, Denise Ai-Wen; Tan, Chuen-Seng; Liu, Gabriel Ka-Po; Wong, Hee-Kit

2017-03-01

Flexion radiographs have been used to identify cases of spinal instability. However, current methods are not standardized and are not sufficiently sensitive or specific to identify instability. This study aimed to introduce a new slump sitting method for performing lumbar spine flexion radiographs and comparison of the angular range of motions (ROMs) and displacements between the conventional method and this new method. This study used is a prospective study on radiological evaluation of the lumbar spine flexion ROMs and displacements using dynamic radiographs. Sixty patients were recruited from a single spine tertiary center. Angular and displacement measurements of lumbar spine flexion were carried out. Participants were randomly allocated into two groups: those who did the new method first, followed by the conventional method versus those who did the conventional method first, followed by the new method. A comparison of the angular and displacement measurements of lumbar spine flexion between the conventional method and the new method was performed and tested for superiority and non-inferiority. The measurements of global lumbar angular ROM were, on average, 17.3° larger (p<.0001) using the new slump sitting method compared with the conventional method. They were most significant at the levels of L3-L4, L4-L5, and L5-S1 (p<.0001, p<.0001 and p=.001, respectively). There was no significant difference between both methods when measuring lumbar displacements (p=.814). The new method of slump sitting dynamic radiograph was shown to be superior to the conventional method in measuring the angular ROM and non-inferior to the conventional method in the measurement of displacement. Copyright © 2016 Elsevier Inc. All rights reserved.

Posteroanterior versus anteroposterior lumbar spine radiology

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tsuno, M.M.; Shu, G.J.

The posteroanterior view of the lumbar spine has important features including radiation protection and image quality; these have been studied by various investigators. Investigators have shown that sensitive tissues receive less radiation dosage in the posteroanterior view of the spine for scoliosis screening and intracranial tomography without altering the image quality. This paper emphasizes the importance of the radiation safety aspect of the posteroanterior view and shows the improvement in shape distortion in the lumbar vertebrae.

Return to Golf After Lumbar Fusion

PubMed Central

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

2016-01-01

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

Coexisting lumbar spondylosis in patients undergoing TKA: how common and how serious?

PubMed

Chang, Chong Bum; Park, Kun Woo; Kang, Yeon Gwi; Kim, Tae Kyun

2014-02-01

Information on the coexistence of lumbar spondylosis and its influence on overall levels of pain and function in patients with advanced knee osteoarthritis (OA) undergoing total knee arthroplasty (TKA) would be valuable for patient consultation and management. The purposes of this study were to document the prevalence and severity of coexisting lumbar spondylosis in patients with advanced knee OA undergoing TKA and to determine whether the coexisting lumbar spondylosis at the time of TKA adversely affects clinical scores in affected patients before and 2 years after TKA. Radiographic lumbar spine degeneration and lumbar spine symptoms including lower back pain, radiating pain at rest, and radiating pain with activity were assessed in 225 patients undergoing TKA. In addition, the WOMAC score and the SF-36 scores were evaluated before and 2 years after TKA. Potential associations of radiographic lumbar spine degeneration and lumbar spine symptom severities with pre- and postoperative WOMAC subscales and SF-36 scores were examined. All 225 patients had radiographic degeneration of the lumbar spine, and the large majority (89% [200 of 225]) had either moderate or severe spondylosis (72% and 17%, respectively). A total of 114 patients (51%) had at least one moderate or severe lumbar spine symptom. No association was found between radiographic severity of lumbar spine degeneration and pre- and postoperative clinical scores. In terms of lumbar spine symptoms, more severe symptoms were likely to adversely affect the preoperative WOMAC and SF-36 physical component summary (PCS) scores, but most of these adverse effects improved by 2 years after TKA with the exception of the association between severe radiating pain during activity and a poorer postoperative SF-36 PCS score (regression coefficient = -5.41, p = 0.015). Radiographic lumbar spine degeneration and lumbar spine symptoms are common among patients with advanced knee OA undergoing TKA. Severe lumbar spine symptoms

The evaluation of lumbar paraspinal muscle quantity and quality using the Goutallier classification and lumbar indentation value.

PubMed

Tamai, Koji; Chen, Jessica; Stone, Michael; Arakelyan, Anush; Paholpak, Permsak; Nakamura, Hiroaki; Buser, Zorica; Wang, Jeffrey C

2018-05-01

The cross-sectional area and fat infiltration are accepted as standard parameters for quantitative and qualitative evaluation of muscle degeneration. However, they are time-consuming, which prevents them from being used in a clinical setting. The aim of this study was to analyze the relationship between lumbar muscle degeneration and spinal degenerative disorders, using lumbar indentation value (LIV) as quantitative and Goutallier classification as qualitative measures. This is a retrospective analysis of kinematic magnetic resonance images (kMRI). Two-hundred and thirty patients with kMRIs taken in weight-bearing positions were selected randomly. The LIV and Goutallier classification were evaluated at L4-5. The correlation of these two parameters with patients' age, gender, lumbar lordosis (LL), range of motion, disc degeneration, disc height, and Modic change were analyzed. There was no significant trend of LIV among the different grades of Goutallier classification (p = 0.943). There was a significant increase in age with higher grades of Goutallier classification (p < 0.001). In contrast, there was no correlation between LIV and age (p = 0.799). The Goutallier classification positively correlated with LL (r = 0.377) and severe disc degeneration (r = 0.249). The LIV positively correlated with LL (r = 0.476) and degenerative spondylolisthesis (r = 0.184). Multinomial logistic regression analysis showed that age (p = 0.026), gender (p = 0.003), and LIV (p < 0.001) were significant predictors for patients with low LL (< 10°). Lumbar muscle quantity and quality showed specific correlation with age and spine disorders. Additionally, LL can be predicted by the muscle quantity, but not the quality. These time-saving evaluation tools potentially accelerate the study of lumbar muscles. These slides can be retrieved under Electronic Supplementary Material.

Quadratus lumborum asymmetry and lumbar spine injury in cricket fast bowlers.

PubMed

Kountouris, Alex; Portus, Marc; Cook, Jill

2012-09-01

Previous studies have demonstrated quadratus lumborum asymmetry in cricket fast bowlers, but there has been conflicting evidence regarding the relationship to lumbar spine injury, particularly vertebral bone stress injuries. This study investigated the relationship between quadratus lumborum asymmetry and lumbar spine injury in adolescent cricket fast bowlers. The study was a prospective cohort design. Magnetic resonance imaging of 38 adolescent cricket fast bowlers was completed prior to a cricket season, and the cross sectional area of the quadratus lumborum muscle was measured at each lumbar spinal level. The bowlers were followed through the cricket season and those that reported lumbar spine injuries were investigated and classified as either having a soft tissue injury or a bone stress injury. The pre-season cross sectional area of quadratus lumborum was associated with injury status at the conclusion of the cricket season. Twenty-one percent of the cohort developed lumbar bone stress injuries during the cricket season. There was no significant relationship between lumbar spine injury and quadratus lumborum cross sectional area. A high incidence of lumbar bone stress injuries was demonstrated in adolescent fast bowlers. Unlike previous research that demonstrated a link between lumbar spine bone stress injuries and quadratus lumborum cross-sectional area, no such relationship was found. Copyright © 2012 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Changes of lumbar posture and tissue loading during static trunk bending.

PubMed

Alessa, Faisal; Ning, Xiaopeng

2018-02-01

Static trunk bending is an occupational risk factor for lower back pain (LBP). When assessing relative short duration trunk bending tasks, existing studies mostly assumed unchanged spine biomechanical responses during task performance. The purpose of the current study was to assess the biomechanical changes of lumbar spine during the performance of relatively short duration, sustained trunk bending tasks. Fifteen participants performed 40-s static trunk bending tasks in two different trunk angles (30° or 60°) with two different hand load levels (0 or 6.8 kg). Results of the current study revealed significantly increased lumbar flexion and lumbar passive moment during the 40 s of trunk bending. Significantly reduced lumbar and abdominal muscle activities were also observed in most conditions. These findings suggest that, during the performance of short duration, static trunk bending tasks, a shift of loading from lumbar active tissues to passive tissues occurs naturally. This mechanism is beneficial in reducing the accumulation of lumbar muscle fatigue; however, lumbar passive tissue creep could be introduced due to prolonged or repetitive exposure. Copyright © 2017 Elsevier B.V. All rights reserved.

The association of spinal osteoarthritis with lumbar lordosis

PubMed Central

2010-01-01

Background Careful review of published evidence has led to the postulate that the degree of lumbar lordosis may possibly influence the development and progression of spinal osteoarthritis, just as misalignment does in other joints. Spinal degeneration can ensue from the asymmetrical distribution of loads. The resultant lesions lead to a domino- like breakdown of the normal morphology, degenerative instability and deviation from the correct configuration. The aim of this study is to investigate whether a relationship exists between the sagittal alignment of the lumbar spine, as it is expressed by lordosis, and the presence of radiographic osteoarthritis. Methods 112 female subjects, aged 40-72 years, were examined in the Outpatients Department of the Orthopedics' Clinic, University Hospital of Heraklion, Crete. Lumbar radiographs were examined on two separate occasions, independently, by two of the authors for the presence of osteoarthritis. Lordosis was measured from the top of L1 to the bottom of L5 as well as from the top of L1 to the top of S1. Furthermore, the angle between the bottom of L5 to the top of S1was also measured. Results and discussion 49 women were diagnosed with radiographic osteoarthritis of the lumbar spine, while 63 women had no evidence of osteoarthritis and served as controls. The two groups were matched for age and body build, as it is expressed by BMI. No statistically significant differences were found in the lordotic angles between the two groups Conclusions There is no difference in lordosis between those affected with lumbar spine osteoarthritis and those who are disease free. It appears that osteoarthritis is not associated with the degree of lumbar lordosis. PMID:20044932

Riding position and lumbar spine angle in recreational cyclists: A pilot study

PubMed Central

SCHULZ, SAMANTHA J.; GORDON, SUSAN J.

2010-01-01

This pilot study investigated the reliability of an inclinometer to assess lumbar spine angle in three different cycling positions, and explored the relationship between lumbar spine angle and riding position, anthropometry, bike measures and low back pain (LBP). Cyclists were recruited from two cycle clubs. Anthropometric variables and bike setup were measured before participants’ bikes were secured in a wind trainer. Cyclists then adopted three positions for riding, upright on the handlebars, on the brake levers and on the drops, according to a random allocation. The angle of the lumbar spine was measured; using an inclinometer, at zero minutes and after cyclists had completed 10 minutes of cycling. Intra-measurer reliability for inclinometer use to measure lumbar spine angle in each position was excellent (ICC=0.97). The angle of the lumbar spine changed significantly over 10 minutes in the brake position (p=0.004). Lumbar spine angle at 10 minutes was significantly different between the brake and drop positions (p=0.018, p<0.05), and between upright and drop positions (p=0.012, p<0.05). Lumbar spine angle was not related to anthropometric measures. The change in lumbar spine angle varied from one degree of extension to 12 degrees of flexion, with increased flexion occurring in 95% of trials. An inclinometer has excellent intra-measurer reliability to measure lumbar spine angle in cycling positions. Future research with a sample of 72 or more participants is required to determine if there is a significant relationship between LBP and lumbar spine angle in different cycling positions. PMID:27182345

Treatment of Spinal Tuberculosis by Debridement, Interbody Fusion and Internal Fixation via Posterior Approach Only.

PubMed

Tang, Ming-xing; Zhang, Hong-qi; Wang, Yu-xiang; Guo, Chao-feng; Liu, Jin-yang

2016-02-01

Surgical treatment for spinal tuberculosis includes focal tuberculosis debridement, segmental stability reconstruction, neural decompression and kyphotic deformity correction. For the lesions mainly involved anterior and middle column of the spine, anterior operation of debridement and fusion with internal fixation has been becoming the most frequently used surgical technique for the spinal tuberculosis. However, high risk of structural damage might relate with anterior surgery, such as damage in lungs, heart, kidney, ureter and bowel, and the deformity correction is also limited. Due to the organs are in the front of spine, there are less complications in posterior approach. Spinal pedicle screw passes through the spinal three-column structure, which provides more powerful orthopedic forces compared with the vertebral body screw, and the kyphotic deformity correction effect is better in posterior approach. In this paper, we report a 68-year-old male patient with thoracic tuberculosis who underwent surgical treatment by debridement, interbody fusion and internal fixation via posterior approach only. The patient was placed in prone position under general anesthesia. Posterior midline incision was performed, and the posterior spinal construction was exposed. Then place pedicle screw, and fix one side rod temporarily. Make the side of more bone destruction and larger abscess as lesion debridement side. Resect the unilateral facet joint, and retain contralateral structure integrity. Protect the spinal cord, nerve root. Clear sequestrum, necrotic tissue, abscess of paravertebral and intervertebral space. Specially designed titanium mesh cages or bone blocks were implanted into interbody. Fix both side rods and compress both sides to make the mesh cages and bone blocks tight. Reconstruct posterior column structure with allogeneic bone and autologous bone. Using this technique, the procedures of debridement, spinal cord decompression, deformity correction, bone grafting

Thoracic and lumbar spine responses in high-speed rear sled tests.

PubMed

Viano, David C; Parenteau, Chantal S; Burnett, Roger

2018-07-04

This study analyzed thoracic and lumbar spine responses with in-position and out-of-position (OOP) seated dummies in 40.2 km/h (25 mph) rear sled tests with conventional and all-belts-to-seat (ABTS) seats. Occupant kinematics and spinal responses were determined with modern (≥2000 MY), older (<2000 MY), and ABTS seats. The seats were fixed in a sled buck subjected to a 40.2 km/h (25 mph) rear sled test. The pulse was a 15 g double-peak acceleration with 150 ms duration. The 50th percentile Hybrid III was lap-shoulder belted in the FMVSS 208 design position or OOP, including leaning forward and leaning inboard and forward. There were 26 in-position tests with 11 <2000 MY, 8 ≥2000 MY, and 7 ABTS and 14 OOP tests with 6 conventional and 8 ABTS seats. The dummy was fully instrumented. This study addressed the thoracic and lumbar spine responses. Injury assessment reference values are not approved for the thoracic and lumbar spine. Conservative thresholds exist. The peak responses were normalized by a threshold to compare responses. High-speed video documented occupant kinematics. The extension moments were higher in the thoracic than lumbar spine in the in-position tests. For <2000 MY seats, the thoracic extension moment was 76.8 ± 14.6% of threshold and the lumbar extension moment was 50.5 ± 17.9%. For the ≥2000 MY seats, the thoracic extension moment was 54.2 ± 26.6% of threshold and the lumbar extension moment was 49.8 ± 27.7%. ABTS seats provided similar thoracic and lumbar responses. Modern seat designs lowered thoracic and lumbar responses. For example, the 1996 Taurus had -1,696 N anterior lumbar shear force and -205.2 Nm extension moment. There was -1,184 N lumbar compression force and 1,512 N tension. In contrast, the 2015 F-150 had -500 N shear force and -49.7 Nm extension moment. There was -839 N lumbar compression force and 535 N tension. On average, the 2015 F-150 had 40% lower lumbar spine responses than the 1996 Taurus. The OOP tests had

Pain intensity attenuates movement control of the lumbar spine in low back pain.

PubMed

Bauer, C M; Rast, F M; Ernst, M J; Oetiker, S; Meichtry, A; Kool, J; Rissanen, S M; Suni, J H; Kankaanpää, M

2015-12-01

Pain intensity attenuates muscular activity, proprioception, and tactile acuity, with consequent changes of joint kinematics. People suffering from low back pain (LBP) frequently show movement control impairments of the lumbar spine in sagittal plane. This cross-sectional, observational study investigated if the intensity of LBP attenuates lumbar movement control. The hypothesis was that lumbar movement control becomes more limited with increased pain intensity. The effect of LBP intensity, measured with a numeric rating scale (NRS), on lumbar movement control was tested using three movement control tests. The lumbar range of motion (ROM), the ratio of lumbar and hip ROM as indicators of direction specific movement control, and the recurrence and determinism of repetitive lumbar movement patterns were assessed in ninety-four persons suffering from LBP of different intensity and measured with an inertial measurement unit system. Generalized linear models were fitted for each outcome. Lumbar ROM (+ 0.03°, p = 0.24) and ratio of lumbar and hip ROM (0.01, p = 0.84) were unaffected by LBP intensity. Each one point increase on the NRS resulted in a decrease of recurrence and determinism of lumbar movement patterns (-3.11 to -0.06, p ⩽ 0.05). Our results indicate changes in movement control in people suffering from LBP. Whether decreased recurrence and determinism of lumbar movement patterns are intensifiers of LBP intensity or a consequence thereof should be addressed in a future prospective study. Copyright © 2015 Elsevier Ltd. All rights reserved.

An empirical study of preferred settings for lumbar support on adjustable office chairs.

PubMed

Coleman, N; Hull, B P; Ellitt, G

1998-04-01

The preferred settings for lumbar support height and depth of 43 male and 80 female office workers were investigated. All subjects were equipped with identical modern office chairs with foam-padded backrests adjustable in both height and depth. Measurements of lumbar support settings were recorded in the workplace, outside of working hours, on four different occasions, over a 5 week period. Preferred lumbar support height and depth settings extended to both extremes of the adjustment range. The mean preferred height setting was 190 mm above the compressed seat surface. The mean depth setting (horizontal distance from front of seat to lumbar support point) was 387 mm. A regression model examining the effects of standing height, Body Mass Index (BMI) and gender on mean preferred lumbar support height showed a significant relationship between preferred height and BMI. Higher lumbar supports were chosen by subjects with greater BMIs. Gender and standing height were not associated with preferred lumbar support height settings. Preferred lumbar support depth was not significantly associated with standing height, gender or BMI. Older subjects were more likely to readjust their lumbar support from a disrupted position than younger subjects, indicating that older users are more sensitive to the position of their lumbar support. Subjects who reported recent back pain or discomfort that they believed to be associated with their chair or office work were found to set their lumbar support significantly closer to the front of the seat, probably to ensure greater support for their back. Based on the evidence that a high proportion of users do make adjustments to the height and depth of their lumbar support, and the finding that different groups of users, with different physical characteristics, adjust the position of their lumbar support in distinct and predictable ways, the researchers conclude that office chairs with traditional padded fixed-height lumbar supports are unlikely

Contribution of hamstring fatigue to quadriceps inhibition following lumbar extension exercise.

PubMed

Hart, Joseph M; Kerrigan, D Casey; Fritz, Julie M; Saliba, Ethan N; Gansneder, Bruce; Ingersoll, Christopher D

2006-01-01

The purpose of this study was to determine the contribution of hamstrings and quadriceps fatigue to quadriceps inhibition following lumbar extension exercise. Regression models were calculated consisting of the outcome variable: quadriceps inhibition and predictor variables: change in EMG median frequency in the quadriceps and hamstrings during lumbar fatiguing exercise. Twenty-five subjects with a history of low back pain were matched by gender, height and mass to 25 healthy controls. Subjects performed two sets of fatiguing isometric lumbar extension exercise until mild (set 1) and moderate (set 2) fatigue of the lumbar paraspinals. Quadriceps and hamstring EMG median frequency were measured while subjects performed fatiguing exercise. A burst of electrical stimuli was superimposed while subjects performed an isometric maximal quadriceps contraction to estimate quadriceps inhibition after each exercise set. Results indicate the change in hamstring median frequency explained variance in quadriceps inhibition following the exercise sets in the history of low back pain group only. Change in quadriceps median frequency explained variance in quadriceps inhibition following the first exercise set in the control group only. In conclusion, persons with a history of low back pain whose quadriceps become inhibited following lumbar paraspinal exercise may be adapting to the fatigue by using their hamstring muscles more than controls. Key PointsA neuromuscular relationship between the lumbar paraspinals and quadriceps while performing lumbar extension exercise may be influenced by hamstring muscle fatigue.QI following lumbar extension exercise in persons with a history of LBP group may involve significant contribution from the hamstring muscle group.More hamstring muscle contribution may be a necessary adaptation in the history of LBP group due to weaker and more fatigable lumbar extensors.

Ultrasound-guided lumbar puncture in pediatric patients: technical success and safety.

PubMed

Pierce, David B; Shivaram, Giri; Koo, Kevin S H; Shaw, Dennis W W; Meyer, Kirby F; Monroe, Eric J

2018-06-01

Disadvantages of fluoroscopically guided lumbar puncture include delivery of ionizing radiation and limited resolution of incompletely ossified posterior elements. Ultrasound (US) allows visualization of critical soft tissues and the cerebrospinal fluid (CSF) space without ionizing radiation. To determine the technical success and safety of US-guided lumbar puncture in pediatric patients. A retrospective review identified all patients referred to interventional radiology for lumbar puncture between June 2010 and June 2017. Patients who underwent lumbar puncture with fluoroscopic guidance alone were excluded. For the remaining procedures, technical success and procedural complications were assessed. Two hundred and one image-guided lumbar punctures in 161 patients were included. Eighty patients (43%) had previously failed landmark-based attempts. One hundred ninety-six (97.5%) patients underwent lumbar puncture. Five procedures (2.5%) were not attempted after US assessment, either due to a paucity of CSF or unsafe window for needle placement. Technical success was achieved in 187 (95.4%) of lumbar punctures attempted with US guidance. One hundred seventy-seven (90.3%) were technically successful with US alone (age range: 2 days-15 years, weight range: 1.9-53.1 kg) and an additional 10 (5.1%) were successful with US-guided thecal access and subsequent fluoroscopic confirmation. Three (1.5%) cases were unsuccessful with US guidance but were subsequently successful with fluoroscopic guidance. Of the 80 previously failed landmark-based lumbar punctures, 77 (96.3%) were successful with US guidance alone. There were no reported complications. US guidance is safe and effective for lumbar punctures and has specific advantages over fluoroscopy in pediatric patients.

Flank and Lumbar Hernia Repair.

PubMed

Beffa, Lucas R; Margiotta, Alyssa L; Carbonell, Alfredo M

2018-06-01

Flank and lumbar hernias are challenging because of their rarity and anatomic location. Several challenges exist when approaching these specific abdominal wall defects, including location, innervation of the lateral abdominal wall musculature, and their proximity to bony landmarks. These hernias are confined by the costal margin, spine, and pelvic brim, which makes closure of the defect, including mesh placement, difficult. This article discusses the anatomy of lumbar and flank hernias, the various etiologies for these hernias, and the procedural steps for open and robotic preperitoneal approaches. The available clinical evidence regarding outcomes for various repair techniques is also reviewed. Copyright © 2018 Elsevier Inc. All rights reserved.

The hybrid assisted limb (HAL) for Care Support, a motion assisting robot providing exoskeletal lumbar support, can potentially reduce lumbar load in repetitive snow-shoveling movements.

PubMed

Miura, Kousei; Kadone, Hideki; Koda, Masao; Abe, Tetsuya; Endo, Hirooki; Murakami, Hideki; Doita, Minoru; Kumagai, Hiroshi; Nagashima, Katsuya; Fujii, Kengo; Noguchi, Hiroshi; Funayama, Toru; Kawamoto, Hiroaki; Sankai, Yoshiyuki; Yamazaki, Masashi

2018-03-01

An excessive lumbar load with snow-shoveling is a serious problem in snowfall areas. Various exoskeletal robots have been developed to reduce lumbar load in lifting work. However, few studies have reported the attempt of snow-shoveling work using exoskeletal robots. The purpose of the present study was to test the hypothesis that the HAL for Care Support robot would reduce lumbar load in repetitive snow-shoveling movements. Nine healthy male volunteers performed repetitive snow-shoveling movements outdoors in a snowfall area for as long as possible until they were fatigued. The snow-shoveling trial was performed under two conditions: with and without HAL for Care Support. Outcome measures were defined as the lumbar load assessed by the VAS of lumbar fatigue after the snow-shoveling trial and the snow-shoveling performance, including the number of scoops, and snow shoveling time and distance. The mean of VAS of lumbar fatigue, the number of scoops, and snow-shoveling time and distance without HAL for Care Support were 75.4 mm, 50.3, 145 s, and 9.6 m, while with HAL for Care Support were 39.8 mm, 144, 366 s, and 35.4 m. The reduction of lumbar fatigue and improvement of snow-shoveling performance using HAL for Care Support were statistically significant. There was no adverse event during snow-shoveling with HAL for Care Support. In conclusion, the HAL for Care Support can reduce lumbar load in repetitive snow-shoveling movements. Copyright © 2017 Elsevier Ltd. All rights reserved.

Does change in isolated lumbar extensor muscle function correlate with good clinical outcome? A secondary analysis of data on change in isolated lumbar extension strength, pain, and disability in chronic low back pain.

PubMed

Steele, James; Fisher, James; Perrin, Craig; Conway, Rebecca; Bruce-Low, Stewart; Smith, Dave

2018-01-12

Secondary analysis of data from studies utilising isolated lumbar extension exercise interventions for correlations among changes in isolated lumbar extension strength, pain, and disability. Studies reporting isolated lumbar extension strength changes were examined for inclusion criteria including: (1) participants with chronic low back pain, (2) intervention ≥ four weeks including isolated lumbar extension exercise, (3) outcome measures including isolated lumbar extension strength, pain (Visual Analogue Scale), and disability (Oswestry Disability Index). Six studies encompassing 281 participants were included. Correlations among change in isolated lumbar extension strength, pain, and disability. Participants were grouped as "met" or "not met" based on minimal clinically important changes and between groups comparisons conducted. Isolated lumbar extension strength and Visual Analogue Scale pooled analysis showed significant weak to moderate correlations (r = -0.391 to -0.539, all p < 0.001). Isolated lumbar extension strength and Oswestry Disability Index pooled analysis showed significant weak correlations (r = -0.349 to -0.470, all p < 0.001). For pain and disability, isolated lumbar extension strength changes were greater for those "met" compared with those "not met" (p < 0.001-0.008). Improvements in isolated lumbar extension strength may be related to positive and meaningful clinical outcomes. As many other performance outcomes and clinical outcomes are not related, isolated lumbar extension strength change may be a mechanism of action affecting symptom improvement. Implications for Rehabilitation Chronic low back pain is often associated with deconditioning of the lumbar extensor musculature. Isolated lumbar extension exercise has been shown to condition this musculature and also reduce pain and disability. This study shows significant correlations between increases in isolated lumbar extension strength and reductions in pain and

High-Force Versus Low-Force Lumbar Traction in Acute Lumbar Sciatica Due to Disc Herniation: A Preliminary Randomized Trial.

PubMed

Isner-Horobeti, Marie-Eve; Dufour, Stéphane Pascal; Schaeffer, Michael; Sauleau, Erik; Vautravers, Philippe; Lecocq, Jehan; Dupeyron, Arnaud

This study compared the effects of high-force versus low-force lumbar traction in the treatment of acute lumbar sciatica secondary to disc herniation. A randomized double blind trial was performed, and 17 subjects with acute lumbar sciatica secondary to disc herniation were assigned to high-force traction at 50% body weight (BW; LT50, n = 8) or low force traction at 10% BW (LT10, n = 9) for 10 sessions in 2 weeks. Radicular pain (visual analogue scale [VAS]), lumbo-pelvic-hip complex motion (finger-to-toe test), lumbar-spine mobility (Schöber-Macrae test), nerve root compression (straight-leg-raising test), disability (EIFEL score), drug consumption, and overall evaluation of each patient were measured at days 0, 7, 1, 4, and 28. Significant (P < .05) improvements were observed in the LT50 and LT10 groups, respectively, between day 0 and day 14 (end of treatment) for VAS (-44% and -36%), EIFEL score (-43% and -28%) and overall patient evaluation (+3.1 and +2.0 points). At that time, LT50 specifically improved in the finger-to-toe test (-42%), the straight-leg-raising test (+58), and drug consumption (-50%). No significant interaction effect (group-by-time) was revealed, and the effect of traction treatment was independent of the level of medication. During the 2-week follow-up at day 28, only the LT10 group improved (P < .05) in VAS (-52%) and EIFEL scores (-46%). During this period, no interaction effect (group-by-time) was identified, and the observed responses were independent of the level of medication. For this preliminary study, patients with acute lumbar sciatica secondary to disc herniation who received 2 weeks of lumbar traction reported reduced radicular pain and functional impairment and improved well-being regardless of the traction force group to which they were assigned. The effects of the traction treatment were independent of the initial level of medication and appeared to be maintained at the 2-week follow-up. Copyright © 2016. Published by

[Precision of navigation-assisted surgery of the thoracic and lumbar spine].

PubMed

Arand, M; Schempf, M; Hebold, D; Teller, S; Kinzl, L; Gebhard, F

2003-11-01

The goal of these studies was to evaluate the accuracy of in vivo and in vitro application of CT- and C-arm-based navigation at the thoracic and lumbar spine. With CT based navigation, 82 pedicle screws were consecutively inserted, 53 into the thoracic and 29 into the lumbar spine. Seven (13%) perforations were detected at the thoracic spine and two (7%) at the lumbar spine. Additionally, minor perforations below the thread depth were seen in six (11%) thoracic and in two (7%) lumbar instrumentation. With C-arm-based navigation, 74 screws were consecutively placed into 38 thoracic and 36 lumbar pedicles. Perforations were noted in ten (26%) thoracic and four (11%) lumbar implants. Minor perforations were observed in another nine (24%) thoracic and ten (28%) lumbar pedicles. The observer-independent and standardized in vitro study based on a transpedicular 3.2-mm drill hole aiming a 4-mm steel ball in a plastic bone model showed pedicle perforations of the drill canal only in thoracic vertebrae, 1 of 15 in CT-based and 3 of 15 in C-arm navigation. The quantitative calculation of the smallest distance between the central line through the drill canal and the center of the steel ball resulted in 1.4 mm (0.5-4.8 mm) for the CT-based navigation at the thoracic spine and in 1.8 mm (0.5-3 mm) at the lumbar spine. For the C-arm based navigation the distance was 2.6 mm (0.9-4.8 mm) for the thoracic spine and 2 mm (1.2-3 mm) for the lumbar spine. In our opinion, the clinical results of the comparative accuracy of CT- and C-arm-based navigation in the present study showed moderate advantages of the CT-based technique in the thoracic spine, whereas CT- and C-arm based navigation had comparable perforation rates at the lumbar pedicle. The results of the experimental study correlated with the clinical data.

ALIF and total disc replacement versus 2-level circumferential fusion with TLIF: a prospective, randomized, clinical and radiological trial.

PubMed

Hoff, Eike K; Strube, Patrick; Pumberger, Matthias; Zahn, Robert K; Putzier, Michael

2016-05-01

Prospective, randomized trial. The treatment of degenerative disc disease (DDD) with two-level fusion has been associated with a reasonable rate of complications. The aim of the present study was to compare (Hybrid) stand-alone anterior lumbar interbody fusion (ALIF) at L5/S1 with total disc replacement at L4/5 (TDR) as an alternative surgical strategy to (Fusion) 2-level circumferential fusion employing transforaminal lumbar interbody fusion (TLIF) with transpedicular stabilization at L4-S1. A total of 62 patients with symptomatic DDD of segments L5/S1 (Modic ≥2°) and L4/5 (Modic ≤2°; positive discography) were enrolled; 31 were treated with Hybrid and 31 with Fusion. Preoperatively, at 0, 12, and a mean follow-up of 37 months, clinical (ODI, VAS) and radiological evaluations (plain/extension-flexion radiographs evaluated for implant failure, fusion, global and segmental lordosis, and ROM) were performed. In 26 of 31 Hybrid and 24 of 31 Fusion patients available at the final follow-up, we found a significant clinical improvement compared to preoperatively. Hybrid patients had significantly lower VAS scores immediately postoperatively and at follow-up compared to Fusion patients. The complication rates were low and similar between the groups. Lumbar lordosis increased in both groups. The increase was mainly located at L4-S1 in the Hybrid group and at L1-L4 in the Fusion group. Hybrid patients presented with increased ROM at L4/5 and L3/4, and Fusion patients presented with increased ROM at L3/4, with significantly greater ROM at L3/4 compared to Hybrid patients at follow-up. Hybrid surgery is a viable surgical alternative for the presented indication. Approach-related inferior trauma and the balanced restoration of lumbar lordosis resulted in superior clinical outcomes compared to two-level circumferential fusion with TLIF.

Differences between clinical "snap-shot" and "real-life" assessments of lumbar spine alignment and motion - What is the "real" lumbar lordosis of a human being?

PubMed

Dreischarf, Marcel; Pries, Esther; Bashkuev, Maxim; Putzier, Michael; Schmidt, Hendrik

2016-03-21

The individual lumbar lordosis and lumbar motion have been identified to play an important role in pathogenesis of low back pain and are essential references for preoperative planning and postoperative evaluation. The clinical "gold-standard" for measuring lumbar lordosis and its motion are radiological "snap-shots" taken while standing and during upper-body flexion and extension. The extent to which these clinically assessed values characterise lumbar alignment and its motion in daily life merits discussion. A non-invasive measurement-system was employed to measure lumbar lordosis and lumbar motion in 208 volunteers (age: 20-74yrs; ♀/♂: 115/93). For an initial short-term measurement, comparable with the clinical "snap-shot", lumbar lordosis and its motion were assessed while standing and during flexion and extension. Subsequently, volunteers were released to their daily lives while wearing the device, and measurements were performed during the following 24h. The average lumbar lordosis during 24h (8.0°) differed significantly from the standardised measurement while standing (33.3°). Ranges of motion were significantly different throughout the day compared to standing measurements. The influence of the factors age and gender on lordosis and its motion resulted in conflicting results between long- and short-term-measurements. In conclusion, results of short-term examinations differ considerably from the average values during real-life. These findings might be important for surgical planning and increase the awareness of the biomechanical challenges that spinal structures and implants face in real-life. Furthermore, long-term assessments of spinal alignment and motion during daily life can provide valid data on spinal function and can reveal the importance of influential factors. Copyright © 2016 Elsevier Ltd. All rights reserved.

Superior Recess Access of the Lumbar Facet Joint.

PubMed

Demir-Deviren, Sibel; Singh, Sukhminder; Hanelin, Joshua

2017-04-01

Descriptive approach to accessing the lumbar facet joint by superior recess. This study is aimed to describe an approach to accessing the lumbar facet joint through targeting the superior recess during lumbar facet joint injections. Lumbar facet joint injections are routinely performed for both the diagnosis and treatment of chronic low back pain. Previous studies either did not specify which part of the joint to target, or recommended targeting the inferior aspect of the joint to access the inferior recess. One study did mention the superior recess as an alternative to injecting the inferior recess, but none has focused on description of the technique. This is the first time this technique has been described. The records and fluoroscopic images were reviewed for all patients over a period of 9 months (January-September 2012) using the proposed technique. This resulted in a total of 48 patients; 15 men, 29 women, and a total of 117 facet joint intra-articular injections. Among these 48 patients, injections were repeated in total of 4 cases. The average time of injections among 4 repeat cases was 121 days. The success of the procedure was confirmed with an arthrogram demonstrating contrast flowing from the superior recess inferiorly through the joint space. Successful access of the lumbar facet joint through puncture of the superior recess was seen in 114 cases, with 3 unsuccessful attempts to enter facet joints due to osteophytes at involved levels. There were no complications observed during the procedure. We find this approach to be highly successful, safe, and well tolerated by the patient and recommend it as a technique for access of the lumbar facet joint in those patients in whom direct puncture of the inferior recess is difficult.

Barriers to and Budget Impact of Lumbar Total Disc Replacement Utilization.

PubMed

Sandhu, Faheem; Blumenthal, Scott; Grunch, Betsy; Kimball, Bent; Ferko, Nicole; Hollmann, Sarah

2017-12-15

: Evidence on the favorable efficacy, safety, and cost effectiveness of lumbar total disc replacement (TDR) compared with fusion for lumbar degenerative disc disease is mounting; however, a key barrier identified for TDR utilization is lack of coverage by US health insurers. Although economic considerations in a fee-for-service model should not be a determining factor in patient access, concerns regarding the budget impact of lumbar TDR surgery may unfortunately underlie coverage decisions. On the basis of the data available and economic modeling, the panel agreed that there is no indication that there would be a dramatic increase in patients seeking lumbar TDR. Considering several possible scenarios on potential growth in TDR utilization with coverage, as well as growth in the overall surgical pool of patients, economic modeling demonstrated that adoption of lumbar TDR would result in minimal or no budget impact for commercial insurance plans. Considering these model results and the economic literature, the panel concluded that adopting lumbar TDR within a coverage policy is expected to remain cost neutral for the insurer.

Three-dimensional lumbar segment movement characteristics during paediatric cerebral palsy gait.

PubMed

Kiernan, D; Malone, A; O'Brien, T; Simms, C K

2017-03-01

Kinematic analysis of the trunk during cerebral palsy (CP) gait has been well described. In contrast, movement of the lumbar spine is generally ignored. This is most likely due to the complex nature of the spine. As an alternative to using complex sensor protocols, this study modelled the lumbar region as a single segment and investigated characteristic patterns of movement during CP gait. In addition, the impact of functional level of impairment and the relationship with lower lumbar spinal loading were examined. Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited. A full barefoot 3-dimensional kinematic and kinetic analysis were conducted. Lumbar segment movement demonstrated increased forward flexion for CP children. This movement became more pronounced according to GMFCS level with GMFCS II children demonstrating increases of up to 8°. In addition, a moderate correlation was present between lumbar flexion/extension and L5/S1 sagittal moments (r=0.427 in the global frame and r=0.448 with respect to the pelvis, p<0.01). Children with CP demonstrated increased movement of the lumbar region compared to TD, with movement becoming more excessive as GMFCS level increased. Excessive forward flexion and loading at the lumbar spine were linked. However, the moderate correlation suggests other contributors to increased loading were present. In conclusion, this study is a first step at identifying how lumbar segment movement is altered during CP gait. Copyright © 2017 Elsevier B.V. All rights reserved.

Clostridium difficile colitis in patients undergoing lumbar spine surgery.

PubMed

Skovrlj, Branko; Guzman, Javier Z; Silvestre, Jason; Al Maaieh, Motasem; Qureshi, Sheeraz A

2014-09-01

Retrospective database analysis. To investigate incidence, comorbidities, and impact on health care resources of Clostridium difficile infection after lumbar spine surgery. C. difficile colitis is reportedly increasing in hospitalized patients and can have a negative impact on patient outcomes. No data exist on estimates of C. difficile infection rates and its consequences on patient outcomes and health care resources among patients undergoing lumbar spine surgery. The Nationwide Inpatient Sample was examined from 2002 to 2011. Patients were included for study based on International Classification of Diseases, Ninth Revision, Clinical Modification, procedural codes for lumbar spine surgery for degenerative diagnoses. Baseline patient characteristics were determined and multivariable analyses assessed factors associated with increased incidence of C. difficile and risk of mortality. The incidence of C. difficile infection in patients undergoing lumbar spine surgery is 0.11%. At baseline, patients infected with C. difficile were significantly older (65.4 yr vs. 58.9 yr, P<0.0001) and more likely to have diabetes with chronic complications, neurological complications, congestive heart failure, pulmonary disorders, coagulopathy, and renal failure. Lumbar fusion (P=0.0001) and lumbar fusion revision (P=0.0003) were associated with increased odds of postoperative infection. Small hospital size was associated with decreased odds (odds ratio [OR], 0.5; P<0.001), whereas urban hospitals were associated with increased odds (OR, 2.14; P<0.14) of acquiring infection. Uninsured (OR, 1.62; P<0.0001) and patients with Medicaid (OR, 1.33; P<0.0001) were associated with higher odds of acquiring postoperative infection. C. difficile increased hospital length of stay by 8 days (P<0.0001), hospital charges by 2-fold (P<0.0001), and inpatient mortality to 4% from 0.11% (P<0.0001). C. difficile infection after lumbar spine surgery carries a 36.4-fold increase in mortality and costs

Passive lumbar tissue loading during trunk bending at three speeds: An in vivo study.

PubMed

Ning, Xiaopeng; Nussbaum, Maury A

2015-08-01

Low back disorders are closely related with the magnitude of mechanical loading on human spine. However, spinal loading contributed by the lumbar passive tissues is still not well understood. In this study, the effect of motion speed on lumbar passive moment output was investigated. In addition, the increase of lumbar passive moment during trunk bending was modeled. Twelve volunteers performed trunk-bending motions at three different speeds. Trunk kinematics and muscle activities were collected and used to estimate instantaneous spinal loading and the corresponding lumbar passive moment. The lumbar passive moments at different ranges of trunk motion were compared at different speed levels and the relationship between lumbar passive moment lumbar flexion was modeled. A non-linear, two-stage pattern of increase in lumbar passive moment was evident during trunk flexion. However, the effect of motion speed was not significant on lumbar passive moments or any of the model parameters. As reported previously, distinct lumbar ligaments may begin to generate tension at differing extents of trunk flexion, and this could be the cause of the observed two-stage increasing pattern of lumbar passive moment. The current results also suggest that changes in tissue strain rate may not have a significant impact on the total passive moment output at the relatively slow trunk motions examined here. Copyright © 2015 Elsevier Ltd. All rights reserved.

Quantitative morphometric analysis of the lumbar vertebral facets and evaluation of feasibility of lumbar spinal nerve root and spinal canal decompression using the Goel intraarticular facetal spacer distraction technique: A lumbar/cervical facet comparison

PubMed Central

Satoskar, Savni R.; Goel, Aimee A.; Mehta, Pooja H.; Goel, Atul

2014-01-01

Objective: The authors evaluate the anatomic subtleties of lumbar facets and assess the feasibility and effectiveness of use of ‘Goel facet spacer’ in the treatment of degenerative spinal canal stenosis. Materials and Methods: Twenty-five lumbar vertebral cadaveric dried bones were used for the purpose. A number of morphometric parameters were evaluated both before and after the introduction of Goel facet spacers within the confines of the facet joint. Results: The spacers achieved distraction of facets that was more pronounced in the vertical perspective. Introduction of spacers on both sides resulted in an increase in the intervertebral foraminal height and a circumferential increase in the spinal canal dimensions. Additionally, there was an increase in the disc space or intervertebral body height. The lumbar facets are more vertically and anteroposteriorly oriented when compared to cervical facets that are obliquely and transversely oriented. Conclusions: Understanding the anatomical peculiarities of the lumbar and cervical facets can lead to an optimum utilization of the potential of Goel facet distraction arthrodesis technique in the treatment of spinal degenerative canal stenosis. PMID:25558146

Lumbar Disc Degenerative Disease: Disc Degeneration Symptoms and Magnetic Resonance Image Findings

PubMed Central

Saleem, Shafaq; Rehmani, Muhammad Asim Khan; Raees, Aisha; Alvi, Arsalan Ahmad; Ashraf, Junaid

2013-01-01

Study Design Cross sectional and observational. Purpose To evaluate the different aspects of lumbar disc degenerative disc disease and relate them with magnetic resonance image (MRI) findings and symptoms. Overview of Literature Lumbar disc degenerative disease has now been proven as the most common cause of low back pain throughout the world. It may present as disc herniation, lumbar spinal stenosis, facet joint arthropathy or any combination. Presenting symptoms of lumbar disc degeneration are lower back pain and sciatica which may be aggravated by standing, walking, bending, straining and coughing. Methods This study was conducted from January 2012 to June 2012. Study was conducted on the diagnosed patients of lumbar disc degeneration. Diagnostic criteria were based upon abnormal findings in MRI. Patients with prior back surgery, spine fractures, sacroiliac arthritis, metabolic bone disease, spinal infection, rheumatoid arthritis, active malignancy, and pregnancy were excluded. Results During the targeted months, 163 patients of lumbar disc degeneration with mean age of 43.92±11.76 years, came into Neurosurgery department. Disc degeneration was most commonly present at the level of L4/L5 105 (64.4%).Commonest types of disc degeneration were disc herniation 109 (66.9%) and lumbar spinal stenosis 37 (22.7%). Spondylolisthesis was commonly present at L5/S1 10 (6.1%) and associated mostly with lumbar spinal stenosis 7 (18.9%). Conclusions Results reported the frequent occurrence of lumbar disc degenerative disease in advance age. Research efforts should endeavor to reduce risk factors and improve the quality of life. PMID:24353850

Characterization of radiographic features of consecutive lumbar spondylolisthesis.

PubMed

Sun, Yapeng; Wang, Hui; Yang, Dalong; Zhang, Nan; Yang, Sidong; Zhang, Wei; Ding, Wenyuan

2016-11-01

Radiographic features of consecutive lumbar spondylolisthesis were retrospectively analyzed in a total of 17 patients treated for this condition at the Third Hospital of Hebei Medical University from June 2005 to March 2012.To investigate the radiographic features, pelvic compensatory mechanisms, and possible underlying etiologies of consecutive lumbar spondylolisthesis.To the best of our knowledge, there is no previous report concerning the characteristics of consecutive lumbar spondylolisthesis.The Taillard index and the lumbar lordosis (LL), pelvic incidence (PI), sacrum slope (SS), and pelvic tilt (PT) were determined on lateral X-ray images, and the angular displacement was analyzed on flexion-extension X-ray images. Correlation between LL and various pelvic parameters and correlation between Taillard index and angular displacement were assessed by Pearson correlation analysis.A total of 20 cases of isthmic spondylolisthesis and 14 of degenerative spondylolisthesis were retrospectively studied in 17 patients. The Taillard index and the angular displacement in the lower vertebrae were both larger than those in the upper vertebrae. Statistical analysis revealed that LL was correlated with PI and PT, whereas PI was correlated with PT and SS. However, no correlation was identified between Taillard index and angular displacement.In consecutive lumbar spondylolisthesis, the degree of vertebral slip and the angular displacement of the lower vertebrae were both greater than those of the upper vertebrae, indicating that the compensatory mechanism of the pelvis plays an important role in maintaining sagittal balance.

Characterization of radiographic features of consecutive lumbar spondylolisthesis

PubMed Central

Sun, Yapeng; Wang, Hui; Yang, Dalong; Zhang, Nan; Yang, Sidong; Zhang, Wei; Ding, Wenyuan

2016-01-01

Abstract Radiographic features of consecutive lumbar spondylolisthesis were retrospectively analyzed in a total of 17 patients treated for this condition at the Third Hospital of Hebei Medical University from June 2005 to March 2012. To investigate the radiographic features, pelvic compensatory mechanisms, and possible underlying etiologies of consecutive lumbar spondylolisthesis. To the best of our knowledge, there is no previous report concerning the characteristics of consecutive lumbar spondylolisthesis. The Taillard index and the lumbar lordosis (LL), pelvic incidence (PI), sacrum slope (SS), and pelvic tilt (PT) were determined on lateral X-ray images, and the angular displacement was analyzed on flexion–extension X-ray images. Correlation between LL and various pelvic parameters and correlation between Taillard index and angular displacement were assessed by Pearson correlation analysis. A total of 20 cases of isthmic spondylolisthesis and 14 of degenerative spondylolisthesis were retrospectively studied in 17 patients. The Taillard index and the angular displacement in the lower vertebrae were both larger than those in the upper vertebrae. Statistical analysis revealed that LL was correlated with PI and PT, whereas PI was correlated with PT and SS. However, no correlation was identified between Taillard index and angular displacement. In consecutive lumbar spondylolisthesis, the degree of vertebral slip and the angular displacement of the lower vertebrae were both greater than those of the upper vertebrae, indicating that the compensatory mechanism of the pelvis plays an important role in maintaining sagittal balance. PMID:27861359

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

PubMed

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

2015-11-01

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

RELIABILITY AND VALIDITY OF SUBJECTIVE ASSESSMENT OF LUMBAR LORDOSIS IN CONVENTIONAL RADIOGRAPHY.

PubMed

Ruhinda, E; Byanyima, R K; Mugerwa, H

2014-10-01

Reliability and validity studies of different lumbar curvature analysis and measurement techniques have been documented however there is limited literature on the reliability and validity of subjective visual analysis. Radiological assessment of lumbar lordotic curve aids in early diagnosis of conditions even before neurologic changes set in. To ascertain the level of reliability and validity of subjective assessment of lumbar lordosis in conventional radiography. A blinded, repeated-measures diagnostic test was carried out on lumbar spine x-ray radiographs. Radiology Department at Joint Clinical Research Centre (JCRC), Mengo-Kampala-Uganda. Seventy (70) lateral lumbar x-ray films were used for this study and were obtained from the archive of JCRC radiology department at Butikiro house, Mengo-Kampala. Poor observer agreement, both inter- and intra-observer, with kappa values of 0.16 was found. Inter-observer agreement was poorer than intra-observer agreement. Kappa values significantly rose when the lumbar lordosis was clustered into four categories without grading each abnormality. The results confirm that subjective assessment of lumbar lordosis has low reliability and validity. Film quality has limited influence on the observer reliability. This study further shows that fewer scale categories of lordosis abnormalities produce better observer reliability.

Embolization of Isolated Lumbar Artery Injuries in Trauma Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sofocleous, Constantinos T., E-mail: constant@pol.net; Hinrichs, Clay R.; Hubbi, Basil

Purpose. The purpose of the study was to evaluate the angiographic findings and results of embolotherapy in the management of lumbar artery trauma. Methods. All patients with lumbar artery injury who underwent angiography and percutaneous embolization in a state trauma center within a 10-year period were retrospectively reviewed. Radiological information and procedural reports were reviewed to assess immediate angiographic findings and embolization results. Long-term clinical outcome was obtained by communication with the trauma physicians as well as with chart review. Results. In a 10-year period, 255 trauma patients underwent abdominal aortography. Eleven of these patients (three women and eight men)more » suffered a lumbar artery injury. Angiography demonstrated active extravasation (in nine) and/or pseudoaneurysm (in four). Successful selective embolization of abnormal vessel(s) was performed in all patients. Coils were used in six patients, particles in one and gelfoam in five patients. Complications included one retroperitoneal abscess, which was treated successfully. One patient returned for embolization of an adjacent lumbar artery due to late pseudoaneurysm formation. Conclusions. In hemodynamically stable patients, selective embolization is a safe and effective method for immediate control of active extravasation, as well as to prevent future hemorrhage from an injured lumbar artery.« less

Does team lifting increase the variability in peak lumbar compression in ironworkers?

PubMed

Faber, Gert; Visser, Steven; van der Molen, Henk F; Kuijer, P Paul F M; Hoozemans, Marco J M; Van Dieën, Jaap H; Frings-Dresen, Monique H W

2012-01-01

Ironworkers frequently perform heavy lifting tasks in teams of two or four workers. Team lifting could potentially lead to a higher variation in peak lumbar compression forces than lifts performed by one worker, resulting in higher maximal peak lumbar compression forces. This study compared single-worker lifts (25-kg, iron bar) to two-worker lifts (50-kg, two iron bars) and to four-worker lifts (100-kg, iron lattice). Inverse dynamics was used to calculate peak lumbar compression forces. To assess the variability in peak lumbar loading, all three lifting tasks were performed six times. Results showed that the variability in peak lumbar loading was somewhat higher in the team lifts compared to the single-worker lifts. However, despite this increased variability, team lifts did not result in larger maximum peak lumbar compression forces. Therefore, it was concluded that, from a biomechanical point of view, team lifting does not result in an additional risk for low back complaints in ironworkers.

Lumbar spinal canal MRI diameter is smaller in herniated disc cauda equina syndrome patients

PubMed Central

Kruit, Mark C.; Peul, Wilco C.; Vleggeert-Lankamp, Carmen L. A.

2017-01-01

Introduction Correlation between magnetic resonance imaging (MRI) and clinical features in cauda equina syndrome (CES) is unknown; nor is known whether there are differences in MRI spinal canal size between lumbar herniated disc patients with CES versus lumbar herniated discs patients without CES, operated for sciatica. The aims of this study are 1) evaluating the association of MRI features with clinical presentation and outcome of CES and 2) comparing lumbar spinal canal diameters of lumbar herniated disc patients with CES versus lumbar herniated disc patients without CES, operated because of sciatica. Methods MRIs of CES patients were assessed for the following features: level of disc lesion, type (uni- or bilateral) and severity of caudal compression. Pre- and postoperative clinical features (micturition dysfunction, defecation dysfunction, altered sensation of the saddle area) were retrieved from the medical files. In addition, anteroposterior (AP) lumbar spinal canal diameters of CES patients were measured at MRI. AP diameters of lumbar herniated disc patients without CES, operated for sciatica, were measured for comparison. Results 48 CES patients were included. At MRI, bilateral compression was seen in 82%; complete caudal compression in 29%. MRI features were not associated with clinical presentation nor outcome. AP diameter was measured for 26 CES patients and for 31 lumbar herniated disc patients without CES, operated for sciatica. Comparison displayed a significant smaller AP diameter of the lumbar spinal canal in CES patients (largest p = 0.002). Compared to average diameters in literature, diameters of CES patients were significantly more often below average than that of the sciatica patients (largest p = 0.021). Conclusion This is the first study demonstrating differences in lumbar spinal canal size between lumbar herniated disc patients with CES and lumbar herniated disc patients without CES, operated for sciatica. This finding might imply that

Regional differences in lumbar spinal posture and the influence of low back pain

PubMed Central

Mitchell, Tim; O'Sullivan, Peter B; Burnett, Angus F; Straker, Leon; Smith, Anne

2008-01-01

Background Spinal posture is commonly a focus in the assessment and clinical management of low back pain (LBP) patients. However, the link between spinal posture and LBP is not fully understood. Recent evidence suggests that considering regional, rather than total lumbar spine posture is important. The purpose of this study was to determine; if there are regional differences in habitual lumbar spine posture and movement, and if these findings are influenced by LBP. Methods One hundred and seventy female undergraduate nursing students, with and without LBP, participated in this cross-sectional study. Lower lumbar (LLx), Upper lumbar (ULx) and total lumbar (TLx) spine angles were measured using an electromagnetic tracking system in static postures and across a range of functional tasks. Results Regional differences in lumbar posture and movement were found. Mean LLx posture did not correlate with ULx posture in sitting (r = 0.036, p = 0.638), but showed a moderate inverse correlation with ULx posture in usual standing (r = -0.505, p < 0.001). Regional differences in range of motion from reference postures in sitting and standing were evident. BMI accounted for regional differences found in all sitting and some standing measures. LBP was not associated with differences in regional lumbar spine angles or range of motion, with the exception of maximal backward bending range of motion (F = 5.18, p = 0.007). Conclusion This study supports the concept of regional differences within the lumbar spine during common postures and movements. Global lumbar spine kinematics do not reflect regional lumbar spine kinematics, which has implications for interpretation of measures of spinal posture, motion and loading. BMI influenced regional lumbar posture and movement, possibly representing adaptation due to load. PMID:19014712

A global CT to US registration of the lumbar spine

NASA Astrophysics Data System (ADS)

Nagpal, Simrin; Hacihaliloglu, Ilker; Ungi, Tamas; Rasoulian, Abtin; Osborn, Jill; Lessoway, Victoria A.; Rohling, Robert N.; Borschneck, Daniel P.; Abolmaesumi, Purang; Mousavi, Parvin

2014-03-01

During percutaneous lumbar spine needle interventions, alignment of the preoperative computed tomography (CT) with intraoperative ultrasound (US) can augment anatomical visualization for the clinician. We propose an approach to rigidly align CT and US data of the lumbar spine. The approach involves an intensity-based volume registration step, followed by a surface segmentation and a point-based registration of the entire lumbar spine volume. A clinical feasibility study resulted in mean registration error of approximately 3 mm between CT and US data.

Does lumbar dorsal ramus syndrome have an objective clinical basis?

PubMed

Annaswamy, Thiru M; Bierner, Samuel M; Doppalapudi, Hima

2013-12-01

Degenerative processes can cause chronic low back pain that occasionally creates impingement of the lumbar dorsal rami, resulting in a clinical syndrome previously described as lumbar dorsal ramus syndrome (LDRS). To evaluate the clinical basis of LDRS by comparing pain, disability, and objective measures of pathophysiology in 3 groups of subjects defined by needle electromyography examination (NEE) findings. Prospective group cohort study with retrospective chart review. Veterans Affairs medical center outpatient clinic. Subjects who had undergone lower limb NEE and lumbar magnetic resonance imaging. A total of 71 subjects' records that met the study criteria were retrospectively reviewed for interventional spine procedures performed and to measure the lumbosacral paraspinal cross-sectional area (PSP CSA); 28 of the 71 subjects underwent further clinical assessment. One-way analysis of variance was performed to evaluate group differences. In the retrospective arm: (1) PSP CSAs measured at 4 lower lumbar disk levels (average of 3 consecutive slices/level) bilaterally and overall left and right lumbar average PSP CSA and (2) the frequency and type of interventional spine procedures performed. In the prospective arm: (1) temporal changes of NEE abnormalities, (2) pain measured using the Visual Analog Scale, (3) Pain Disability Questionnaire responses, and (4) Short Form-36 scores. The right L5 CSA was significantly greater in the group with mechanical low back pain compared with the group with lumbar radicular syndrome (F = 3.3; P < .05). No significant group differences were noted in the number of spine procedures performed. No significant differences in pain or disability scores were found among the groups. NEE findings improved over time predominantly in the LDRS group. LDRS is a diagnosis with identifiable NEE (lumbar multifidus denervation) findings and magnetic resonance imaging findings that may include lower lumbar paraspinal atrophy. NEE (paraspinal

Lumbar Pseudomeningocele Causing Hydronephrosis

PubMed Central

Hamilton, Rita G; Brown, Steven W; Goetz, Lance L; Miner, Michael

2009-01-01

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. PMID:19264055

Lumbar subarachnoid drainage in cerebrospinal fluid leaks after lateral skull base surgery.

PubMed

Allen, Kyle P; Isaacson, Brandon; Purcell, Patricia; Kutz, Joe Walter; Roland, Peter S

2011-12-01

To determine the efficacy of lumbar drainage in managing cerebrospinal fluid (CSF) leak after lateral skull base surgery. Retrospective case review. Academic tertiary referral center. Patients who had a lumbar subarachnoid drain placed after a lateral skull base procedure between July 1999 and February 2010 were included. Patients were identified by searching medical records for lateral skull base approach Current Procedural Terminology codes. The following variables were recorded for each subject: diagnosis, type of lateral skull base operation, duration of lumbar drainage, need for revision surgery, and presence of meningitis. Successful cessation of postoperative CSF leakage. Five hundred eight charts were reviewed, and 63 patients were identified who received a lumbar drain after a lateral skull base operation. The most common diagnosis was acoustic neuroma in 61.9%. The most common skull base approaches were the translabyrinthine, middle fossa, and transpetrosal approaches. Approximately 60.3% of patients had CSF rhinorrhea, 23.8% had an incisional leak, and 14.3% had otorrhea. The mean duration of lumbar drainage was 4.6 days. Forty eight (76.2%) study subjects had resolution of their CSF leak with lumbar drainage. Fifteen patients (23.8%) required revision surgery to stop the CSF leak. Lumbar drainage was successful in 90% of leaks after the translabyrinthine approach but in only 50% of those undergoing a suboccipital approach, which was a statistically significant difference. Postoperative CSF leaks after lateral skull base surgery can be managed with a lumbar subarachnoid drain in a majority of cases but is more successful after the translabyrinthine than the suboccipital approach. Recurrent CSF leaks after lumbar drainage is likely to require a revision operation.

Is lumbar lordosis related to low back pain development during prolonged standing?

PubMed

Sorensen, Christopher J; Norton, Barbara J; Callaghan, Jack P; Hwang, Ching-Ting; Van Dillen, Linda R

2015-08-01

An induced-pain paradigm has been used in back-healthy people to understand risk factors for developing low back pain during prolonged standing. The purposes of this study were to (1) compare baseline lumbar lordosis in back-healthy participants who do (Pain Developers) and do not (Non-Pain Developers) develop low back pain during 2 h of standing, and (2) examine the relationship between lumbar lordosis and low back pain intensity. Cross-sectional. First, participants stood while positions of markers placed superficial to the lumbar vertebrae were recorded using a motion capture system. Following collection of marker positions, participants stood for 2 h while performing light work tasks. At baseline and every 15 min during standing, participants rated their low back pain intensity on a visual analog scale. Lumbar lordosis was calculated using marker positions collected prior to the 2 h standing period. Lumbar lordosis was compared between pain developers and non-pain developers. In pain developers, the relationship between lumbar lordosis and maximum pain was examined. There were 24 (42%) pain developers and 33 (58%) non-pain developers. Lumbar lordosis was significantly larger in pain developers compared to non-pain developers (Mean difference = 4.4°; 95% Confidence Interval = 0.9° to 7.8°, Cohen's d = 0.7). The correlation coefficient between lumbar lordosis and maximum pain was 0.46 (P = 0.02). The results suggest that standing in more lumbar lordosis may be a risk factor for low back pain development during prolonged periods of standing. Identifying risk factors for low back pain development can inform preventative and early intervention strategies. Copyright © 2015 Elsevier Ltd. All rights reserved.

The Use of Lumbar Spine Magnetic Resonance Imaging in Eastern China: Appropriateness and Related Factors

PubMed Central

Yu, Liedao; Wang, Xuanwei; Lin, Xiangjin; Wang, Yue

2016-01-01

Back pain is common and costly. While a general scene of back pain related practice in China remains unknown, there are signs of excessive use of lumbar spine magnetic resonance (MR). We retrospectively studied 3107 lumbar spine MRIs in Eastern China to investigate the appropriateness of lumbar spine MR use. Simple back pain is the most common chief complaint for ordering a lumbar MR study. Only 41.3% of lumbar spine MR studies identified some findings that may have potential clinical significance. Normal lumbar spine is the most common diagnosis (32.7%), followed by lumbar disc bulging and lumbar disc herniation. Walk difficulties, back injury and referred leg pain as chief complaints were associated with greater chance of detecting potentially clinically positive lumbar MR image findings, as compare with simple back pain. There was no difference in positive rates among orthopedic surgeon and specialists of other disciplines. Lumbar spine MR imaging was generally overused in Eastern China by various specialists, particularly at health assessment centers. For appropriate use of lumbar spine MR, orthopedic surgeons are no better than physicians of other disciplines. Professional training and clinical guidelines are needed to facilitate evidence-based back pain practice in China. PMID:26731106

[Efficacy of transforaminal lumbar epidural steroid injections in patients with lumbar radiculopathy].

PubMed

Çetin, Mehmet Fatih; Karaman, Haktan; Ölmez Kavak, Gönül; Tüfek, Adnan; Baysal Yildirim, Zeynep

2012-01-01

This study looks into the efficacy and safety of the transforaminal lumbar epidural steroid injection (TLESI) applied to patients with radiculopathy due to lumbar disk herniation. The patients' files which were applied TLESI, were retrospectively scanned. Patients who did not respond to one-month conservative treatment and who were detected to have bulging or protruding lumbar disk herniation as a result of imaging methods were included in the study. All applications were performed with C-arm fluoroscopy under local anesthesia by outpatient method. In all cases, a mix of 80 mg triamsinolone and 0.25% bupivacaine, was transforaminally injected to the anterior epidural area. Initial VAS pain scores were compared with the values of the 1, 3 and 6th months after the application. Patient satisfaction was determined through scoring. Furthermore, early and late term complications were collected for evaluation. A total of 222 patients were administered TLESI 460 times (average: 2.1, repeat interval: 1-6 times). The applications were carried out most frequently at the levels of L4-L5 and L5-S1. While the initial VAS score average was 8.2±0.7, after TLESI, it was 5.0±1.6, 4.8±1.5 and 5.1±1.5 in the 1, 3 and 6th months, respectively. 63.9% of the patients (n=142) defined the treatment as 'good and excellent'. No major complications were experienced and the overall minor complication rate was 11.1%. It was seen that TLESI was an efficient and safe method in the short and medium term.

The geometric curvature of the lumbar spine during restricted and unrestricted squats.

PubMed

Hebling Campos, Mário; Furtado Alaman, Laizi I; Seffrin-Neto, Aldo A; Vieira, Carlos A; Costa de Paula, Marcelo; Barbosa de Lira, Claudio A

2017-06-01

The main purpose of this study was to analyze the behavior of the geometric curvature of the lumbar spine during restricted and unrestricted squats, using a novel investigative method. The rationale for our hypothesis is that the lumbar curvature has different patterns at different spine levels depending on the squat technique used. Spine motion was collected via stereo-photogrammetric analysis in nineteen participants (11 males, 8 females). The reconstructed spine points at the upright neutral position and at the deepest position of the squat exercise were projected onto the sagittal plane of the trunk, a polynomial was fitted to the data, and were quantified the two-dimensional geometric curvature at lower, central and higher lumbar levels, besides the inclination of trunk and lumbosacral region, the overall geometric curvature and overall angle of the lumbar spine. The mean values for each variable were analysed with paired t-test (P<0.05). The lumbar presents a flexion from upright neutral posture to deepest point of the movement, but for the lower lumbar the flexion is less intense if the knees travel anteriorly past the toes. The trunk and the lumbosacral region lean forward in both squat techniques and these effects are also reduced in unrestricted squats. The data collected in the study are evidence that during barbell squats the lumbar curvature has different patterns at different spinal levels depending on the exercise technique. The lower lumbar spine appears to be less overloaded during unrestricted squats.

Effect of Load Carriage on Lumbar Spine Kinematics

DTIC Science & Technology

2013-01-01

reference frame and lordosis was reduced during all tasks with load. Superior levels became more lordotic, whereas inferior levels became more... lordosis , and IVD compressibility have been measured in both young 17 and adult 13 populations using upright MRI. However, these data cannot be...the kinematic behavior of the overall lumbar spine and func- tional spinal units. We hypothesized that IVD compression and lumbar lordosis increased

Extra-abdominal lumbar abscesses caused by retroperitoneal gastrointestinal perforations through the lumbar triangle of Petit: report of two cases diagnosed by CT.

PubMed

Coulier, Bruno; Gogoase, Monica; Ramboux, Adrien; Pierard, Frederic

2012-12-01

Extra-abdominal abscesses of gastrointestinal origin developing within the lumbar subcutaneous tissues are extremely rare. We report two cases of retroperitoneal bowel perforation presenting spontaneously at admission with a lumbar abscess trespassing the lumbar triangle of Petit, a classical "locus of minus resistencia" of the posterior abdominal wall. The first case was caused by perforation of a retrocecal appendicitis--being concomitantly responsible of a necrotizing fasciitis of the thigh--and in the second case perforation was caused by left colonic diverticulitis. In both cases, the full diagnosis was made with abdominal CT. The patients were threatened by a two-step surgical approach comprising a direct posterior percutaneous drainage of the abscess followed by classical laparotomy.

Biomechanical implications of lumbar spinal ligament transection.

PubMed

Von Forell, Gregory A; Bowden, Anton E

2014-11-01

Many lumbar spine surgeries either intentionally or inadvertently damage or transect spinal ligaments. The purpose of this work was to quantify the previously unknown biomechanical consequences of isolated spinal ligament transection on the remaining spinal ligaments (stress transfer), vertebrae (bone remodelling stimulus) and intervertebral discs (disc pressure) of the lumbar spine. A finite element model of the full lumbar spine was developed and validated against experimental data and tested in the primary modes of spinal motion in the intact condition. Once a ligament was removed, stress increased in the remaining spinal ligaments and changes occurred in vertebral strain energy, but disc pressure remained similar. All major biomechanical changes occurred at the same spinal level as the transected ligament, with minor changes at adjacent levels. This work demonstrates that iatrogenic damage to spinal ligaments disturbs the load sharing within the spinal ligament network and may induce significant clinically relevant changes in the spinal motion segment.

Sagittal endplate morphology of the lower lumbar spine.

PubMed

Lakshmanan, Palaniappan; Purushothaman, Balaji; Dvorak, Vlasta; Schratt, Walter; Thambiraj, Sathya; Boszczyk, Maximilian

2012-05-01

The sagittal profile of lumbar endplates is discrepant from current simplified disc replacement and fusion device design. Endplate concavity is symmetrical in the coronal plane but shows considerable variability in the sagittal plane, which may lead to implant-endplate mismatch. The aim of this investigation is to provide further analysis of the sagittal endplate morphology of the mid to lower lumbar spine study (L3–S1), thereby identifying the presence of common endplate shape patterns across these levels and providing morphological reference values complementing the findings of previous studies. Observational study. A total of 174 magnetic resonance imaging (MRI) scans of the adult lumbar spine from the digital archive of our centre, which met the inclusion criteria, were studied. Superior (SEP) and inferior (IEP) endplate shape was divided into flat (no concavity), oblong (homogeneous concavity) and ex-centric (inhomogeneous concavity). The concavity depth (ECD) and location of concavity apex (ECA) relative to endplate diameter of the vertebrae L3–S1 were determined. Flat endplates were only predominant at the sacrum SEP (84.5%). The L5 SEP was flat in 24.7% and all other endplates in less than 10%. The majority of endplates were concave with a clear trend of endplate shape becoming more ex-centric from L3 IEP (56.9% oblong vs. 37.4% ex-centric) to L5 IEP (4% oblong vs. 94.3% ex-centric). Ex-centric ECA were always found in the posterior half of the lumbar endplates. Both the oblong and ex-centric ECD was 2-3 mm on average with the IEP of a motion segment regularly possessing the greater depth. A sex- or age-related difference could not be found. The majority of lumbar endplates are concave, while the majority of sacral endplates are flat. An oblong and an ex-centric endplate shape can be distinguished, whereby the latter is more common at the lower lumbar levels. The apex of the concavity of ex-centric discs is located in the posterior half of the endplate

Lower thoracic degenerative spondylithesis with concomitant lumbar spondylosis.

PubMed

Hsieh, Po-Chuan; Lee, Shih-Tseng; Chen, Jyi-Feng

2014-03-01

Degenerative spondylolisthesis of the spine is less common in the lower thoracic region than in the lumbar and cervical regions. However, lower thoracic degenerative spondylolisthesis may develop secondary to intervertebral disc degeneration. Most of our patients are found to have concomitant lumbar spondylosis. By retrospective review of our cases, current diagnosis and treatments for this rare disease were discussed. We present a series of 5 patients who experienced low back pain, progressive numbness, weakness and even paraparesis. Initially, all of them were diagnosed with lumbar spondylosis at other clinics, and 1 patient had even received prior decompressive lumbar surgery. However, their symptoms continued to progress, even after conservative treatments or lumbar surgeries. These patients also showed wide-based gait, increased deep tendon reflex (DTR), and urinary difficulty. All these clinical presentations could not be explained solely by lumbar spondylosis. Thoracolumbar spinal magnetic resonance imaging (MRI), neurophysiologic studies such as motor evoked potential (MEP) or somatosensory evoked potential (SSEP), and dynamic thoracolumbar lateral radiography were performed, and a final diagnosis of lower thoracic degenerative spondylolisthesis was made. Bilateral facet effusions, shown by hyperintense signals in T2 MRI sequence, were observed in all patients. Neurophysiologic studies revealed conduction defect of either MEP or SSEP. One patient refused surgical management because of personal reasons. However, with the use of thoracolumbar orthosis, his symptoms/signs stabilized, although partial lower leg myelopathy was present. The other patients received surgical decompression in association with fixation/fusion procedures performed for managing the thoracolumbar lesions. Three patients became symptom-free, whereas in 1 patient, paralysis set in before the operation; this patient was able to walk with assistance 6 months after surgical decompression

Efficacy of different bone volume expanders for augmenting lumbar fusions.

PubMed

Epstein, Nancy E

2008-01-01

A wide variety of bone volume expanders are being used in performing posterolateral lumbar noninstrumented and instrumented lumbar fusions. This article presents a review of their efficacy based on fusion rates, complications, and outcomes. Lumbar noninstrumented and instrumented fusions frequently use laminar autografts and different bone graft expanders. This review presents the utility of multiple forms/ratios of DBMs containing allografts. It also discusses the efficacy of artificial bone graft substitutes, including HA and B-TCP. Dynamic x-ray and/or CT examinations were used to document fusion in most series. Outcomes were variously assessed using Odom's criteria or different outcome questionnaires (Oswestry Questionnaire, SF-36, Dallas Pain Questionnaire, and/or Low Back Pain Rating Scale). Performing noninstrumented and instrumented lumbar posterolateral fusions resulted in comparable fusion rates in many series. Similar outcomes were also documented based on Odom's criteria or the multiple patient-based questionnaires. However, in some studies, the addition of spinal instrumentation increased the reoperation rate, operative time, blood loss, and cost. Various forms of DBMs, applied in different ratios to autografts, effectively supplemented spinal fusions in animal models and patient series. beta-Tricalcium phosphate, which is used to augment autograft fusions addressing idiopathic scoliosis or lumbar disease, also proved to be effective. Different types of bone volume expanders, including various forms of allograft-based DBMs, and artificial bone graft substitutes (HA and B-TCP) effectively promote posterolateral lumbar noninstrumented and instrumented fusions when added to autografts.

Lumbar Nerve Root Occupancy in the Foramen in Achondroplasia

PubMed Central