Yu, Ching-Hsiao; Wang, Chen-Ti
It is unclear whether using artificial cages increases fusion rates compared with use of bone chips alone in posterior lumbar interbody fusion for patients with lumbar spondylolisthesis. We hypothesized artificial cages for posterior lumbar interbody fusion would provide better clinical and radiographic outcomes than bone chips alone. We assumed solid fusion would provide good clinical outcomes. We clinically and radiographically followed 34 patients with spondylolisthesis having posterior lumbar interbody fusion with mixed autogenous and allogeneic bone chips alone and 42 patients having posterior lumbar interbody fusion with implantation of artificial cages packed with morselized bone graft. Patients with the artificial cage had better functional improvement in the Oswestry disability index than those with bone chips alone, whereas pain score, patient satisfaction, and fusion rate were similar in the two groups. Postoperative disc height ratio, slip ratio, and segmental lordosis all decreased at final followup in the patients with bone chips alone but remained unchanged in the artificial cage group. The functional outcome correlated with radiographic fusion status. We conclude artificial cages provide better functional outcomes and radiographic improvement than bone chips alone in posterior lumbar interbody fusion for lumbar spondylolisthesis, although both techniques achieved comparable fusion rates. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. PMID:18846411
Coe, Jeffrey D; Zucherman, James F; Kucharzyk, Donald W; Poelstra, Kornelis A; Miller, Larry E; Kunwar, Sandeep
The increasing adoption of minimally invasive techniques for spine surgery in recent years has led to significant advancements in instrumentation for lumbar interbody fusion. Percutaneous pedicle screw fixation is now a mature technology, but the role of expandable cages is still evolving. The capability to deliver a multiexpandable interbody cage with a large footprint through a narrow surgical cannula represents a significant advancement in spinal surgery technology. The purpose of this report is to describe a multiexpandable lumbar interbody fusion cage, including implant characteristics, intended use, surgical technique, preclinical testing, and early clinical experience. Results to date suggest that the multiexpandable cage allows a less invasive approach to posterior/transforaminal lumbar interbody fusion surgery by minimizing iatrogenic risks associated with static or vertically expanding interbody prostheses while providing immediate vertebral height restoration, restoration of anatomic alignment, and excellent early-term clinical results. PMID:27729817
Tokuhashi, Yasuaki; Ajiro, Yasumitsu; Umezawa, Natsuki
Posterior lumbar interbody fusion is considered to be an excellent fusion procedure to stabilize anterior support, correct alignment in the sagittal and coronal plane, and achieve foraminal decompression by lifting the disk height. The metal interbody cage in posterior lumbar interbody fusion is thought to be useful to prevent collapse of the graft bone and to correct and maintain disk height; however, some studies have noted a gradual decrease of disk height due to cage subsidence. Therefore, to investigate the significance of cage subsidence, 86 disk levels radiographically confirmed to have good union in 66 patients with posterior lumbar interbody fusion combined with pedicle screw fixation and a single metal cage for degenerative lumbar disease were retrospectively evaluated. The follow-up period ranged from 3 years to 10 years 3 months, with a mean of 7 years 9 months. Cage subsidence often showed a gradual increase over time. At final follow-up, subsidence averaged 4.0 mm on the cranial surface and 2.7 mm on the caudal surface. Although the average increase of disk height was 3.2 mm immediately postoperatively, the final disk height decreased by 4.2 mm on average from that time. The degree of cage subsidence and decrease of disk height were not correlated with the final clinical results. Subsidence was not correlated with bone mineral density in the vertebral body, body weight, or site of the insertion. On the other hand, the wedge shape of the cage and the thickness of the resected endplate had a significant influence on cage subsidence.
Shin, Hyun Chul; Yi, Seong; Kim, Sang Hyun; Yoon, Do Heum
This study sought to determine the outcomes of posterior lumbar interbody fusion (PLIF), via a unilateral approach, in selected patients who presented with unilateral leg pain and segmental instability of the lumbar spine. Patients with a single level of a herniated disc disease in the lumbar spine, unilateral leg pain, chronic disabling lower back pain (LBP), and a failed conservative treatment, were considered for the procedure. A total of 41 patients underwent a single-level PLIF using two PEEK™ (Poly-Ether-Ether-Ketone) cages filled with iliac bone, via a unilateral approach. The patients comprised 21 women and 20 men with a mean age of 41 years (range: 22 to 63 years). Two cages were inserted using a unilateral medial facetectomy and a partial hemilaminectomy. At follow-up, the outcomes were assessed using the Prolo Scale. The success of the fusion was determined by dynamic lumbar radiography and/or computerized tomography scanning. All the patients safely underwent surgery without severe complications. During a mean follow-up period of 26 months, 1 patient underwent percutaneous pedicle screw fixation due to persistent LBP. A posterior displacement of the cage was found in one patient. At the last follow up, 90% of the patients demonstrated satisfactory results. An osseous fusion was present in 85% of the patients. A PLIF, via a unilateral approach, enables a solid union with satisfactory clinical results. This preserves part of the posterior elements of the lumbar spine in selected patients with single level instability and unilateral leg pain. PMID:16807980
Devkota, P; Shrestha, S K; Krishnakumar, R; Renjithkumar, J
The ideal surgical treatment of spondylolisthesis still remains controversial. There are several methods of treatment and posterior lumbar interbody fusion (PLIF) is one of them. We analyze the results of spondylolisthesis treated by PLIF in term of radiological union, improvement of pre-operative symptoms like back pain, radiating pain and return to normal activities including that of employment, by the review of the medical records. Total of 72 patients, 20 male and 52 female and the age ranges from 15 to 68 years with the mean age being 44.38 years were included in the study. Thirty (41.66%) patients had isthmic spondylolisthesis, 26 (36.12%) had congenital spondylolisthesis, and 16 (22.22%) cases had degenerative spondylolisthesis. There were 38 (52.77%) cases of grade I, 14 (19.44%) cases of grade II and 20 (27.77%) cases of grade III according to the grading criteria of Meyerding. According to the evaluation criteria used by Stauffer and Coventry, 59 patients (81.94%) got good results, eight patients (11.11%) belonged to the fair group and five cases (6.94%) had the poor results. This study showed that PLIF is one of the effective and reliable techniques for the management of spondylolisthesis.
Maraki, Sofia; Bantouna, Vasiliki; Lianoudakis, Efstratios; Stavrakakis, Ioannis; Scoulica, Efstathia
The first case of a spinal epidural abscess caused by Roseomonas mucosa following instrumented posterior lumbar fusion is presented. Although rare, because of its highly resistant profile, Roseomonas species should be included in the differential diagnosis of epidural abscesses in both immunocompromised and immunocompetent hosts.
Corniola, Marco V; Jägersberg, Max; Stienen, Martin N; Gautschi, Oliver P
A variety of implant-related short and long-term complications after lumbar fusion surgery are recognized. Mid to long-term complications due to cage migration and/or cage subsidence are less frequently reported. Here, we report a patient with a complete cage migration into the superior adjacent vertebral body almost 20 years after the initial posterior lumbar interbody fusion procedure. In this patient, the cage migration/subsidence was clinically silent, but a selective decompression for adjacent segment degenerative lumbar spinal stenosis was performed. We discuss the risk factors for cage migration/subsidence in view of the current literature.
Fan, Guoxin; Wu, Xinbo; Yu, Shunzhi; Sun, Qi; Zhang, Hailong; Gu, Xin
The aim of this study was to directly compare the clinical outcomes of posterior lumbar interbody fusion (PLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in three-level lumbar spinal stenosis. This retrospective study involved a total of 60 patients with three-level degenerative lumbar spinal stenosis who underwent MIS-TLIF or PLIF from January 2010 to February 2012. Back and leg visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) scale were used to assess the pain, disability, and health status before surgery and postoperatively. In addition, the operating time, estimated blood loss, and hospital stay were also recorded. There were no significant differences in back VAS, leg VAS, ODI, SF-36, fusion condition, and complications at 12-month follow-up between the two groups (P > 0.05). However, significantly less blood loss and shorter hospital stay were observed in MIS-TLIF group (P < 0.05). Moreover, patients undergoing MIS-TLIF had significantly lower back VAS than those in PLIF group at 6-month follow-up (P < 0.05). Compared with PLIF, MIS-TLIF might be a prior option because of noninferior efficacy as well as merits of less blood loss and quicker recovery in treating three-level lumbar spinal stenosis. PMID:27747244
Zhang, Yang; Shan, Jian-Lin; Liu, Xiu-Mei; Li, Fang; Guan, Kai; Sun, Tian-Sheng
Background There have been few studies comparing the clinical and radiographic outcomes between the Dynesys dynamic stabilization system and posterior lumbar interbody fusion (PLIF). The objective of this study is to compare the clinical and radiographic outcomes of Dynesys and PLIF for lumbar degenerative disease. Methods Of 96 patients with lumbar degenerative disease included in this retrospectively analysis, 46 were treated with the Dynesys system and 50 underwent PLIF from July 2008 to March 2011. Clinical and radiographic outcomes were evaluated. We also evaluated the occurrence of radiographic and symptomatic adjacent segment degeneration (ASD). Results The mean follow-up time in the Dynesys group was 53.6 ± 5.3 months, while that in the PLIF group was 55.2 ± 6.8 months. At the final follow-up, the Oswestry disability index and visual analogue scale score were significantly improved in both groups. The range of motion (ROM) of stabilized segments in Dynesys group decreased from 7.1 ± 2.2° to 4.9 ± 2.2° (P < 0.05), while that of in PLIF group decreased from 7.3 ± 2.3° to 0° (P < 0.05). The ROM of the upper segments increased significantly in both groups at the final follow-up, the ROM was higher in the PLIF group. There were significantly more radiographic ASDs in the PLIF group than in the Dynesys group. The incidence of complications was comparable between groups. Conclusions Both Dynesys and PLIF can improve the clinical outcomes for lumbar degenerative disease. Compared to PLIF, Dynesys stabilization partially preserves the ROM of the stabilized segments, limits hypermobility in the upper adjacent segment, and may prevent the occurrence of ASD. PMID:26824851
Melgar, Miguel A; Tobler, William D; Ernst, Robert J; Raley, Thomas J; Anand, Neel; Miller, Larry E; Nasca, Richard J
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
Takeuchi, Mikinobu; Kamiya, Mitsuhiro; Wakao, Norimitsu; Hirasawa, Atsuhiko; Kawanami, Katsuhisa; Osuka, Koji; Takayasu, Masakazu
The purpose of this study is to compare intervertebral bone fusion and clinical outcomes in L4-5 posterior lumbar interbody fusion (PLIF) using the same posterior instrumentation with four combinations of one of three types of interbody cage with one of two bone grafts, iliac and local or only local. In 67 patients who underwent L4-5 PLIF, 19 patients had the Brantigan cage and iliac and local bone graft, 18 with the TELAMON C cage and iliac and local bone graft, 16 with the TELAMON C cage and local bone graft (TL), and 14 with the OIC PEEK cage and local bone graft. Clinical assessments were based on Japanese Orthopaedic Association (JOA) scores and on the visual analogue scale (VAS). The bone fusion assessments were based on radiography and CT scans according to the Brantigan, Steffee, and Fraser criteria. More than 2 years after surgery, these assessments were made. In the results, the fusion outcome for the group receiving TL was significantly less than those for the other three groups. In TL, multivariate logistic regression analysis showed that the inside volume of the cage of ≥2.0 mL was the only significant factor for incomplete fusion. Moreover, the VAS (low back pain) score was significantly higher for TL than for the other three groups. In conclusions, we believe that the large volume inside the cage (≥2.0 mL) with local bone graft may lead incomplete interbody bone fusion and residual postsurgical low back pain after PLIF.
Posterior lumbar interbody fusion with cortical bone trajectory screw fixation versus posterior lumbar interbody fusion using traditional pedicle screw fixation for degenerative lumbar spondylolisthesis: a comparative study.
Sakaura, Hironobu; Miwa, Toshitada; Yamashita, Tomoya; Kuroda, Yusuke; Ohwada, Tetsuo
OBJECTIVE Several biomechanical studies have demonstrated the favorable mechanical properties of the cortical bone trajectory (CBT) screw. However, no reports have examined surgical outcomes of posterior lumbar interbody fusion (PLIF) with CBT screw fixation for degenerative spondylolisthesis (DS) compared with those after PLIF using traditional pedicle screw (PS) fixation. The purposes of this study were thus to elucidate surgical outcomes after PLIF with CBT screw fixation for DS and to compare these results with those after PLIF using traditional PS fixation. METHODS Ninety-five consecutive patients underwent PLIF with CBT screw fixation for DS (CBT group; mean followup 35 months). A historical control group consisted of 82 consecutive patients who underwent PLIF with traditional PS fixation (PS group; mean follow-up 40 months). Clinical status was assessed using the Japanese Orthopaedic Association (JOA) scale score. Fusion status was assessed by dynamic plain radiographs and CT. The need for additional surgery and surgery-related complications was also evaluated. RESULTS The mean JOA score improved significantly from 13.7 points before surgery to 23.3 points at the latest follow-up in the CBT group (mean recovery rate 64.4%), compared with 14.4 points preoperatively to 22.7 points at final follow-up in the PS group (mean recovery rate 55.8%; p < 0.05). Solid spinal fusion was achieved in 84 patients from the CBT group (88.4%) and in 79 patients from the PS group (96.3%, p > 0.05). Symptomatic adjacent-segment disease developed in 3 patients from the CBT group (3.2%) compared with 9 patients from the PS group (11.0%, p < 0.05). CONCLUSIONS PLIF with CBT screw fixation for DS provided comparable improvement of clinical symptoms with PLIF using traditional PS fixation. However, the successful fusion rate tended to be lower in the CBT group than in the PS group, although the difference was not statistically significant between the 2 groups.
Huang, Yun-Peng; Du, Cheng-Fei; Cheng, Cheng-Kung; Zhong, Zheng-Cheng; Chen, Xuan-Wei; Wu, Gui; Li, Zhe-Cheng; Ye, Jin-Duo; Lin, Jian-Hua; Wang, Li Zhen
Objective To investigate the biomechanical effects of the lumbar posterior complex on the adjacent segments after posterior lumbar interbody fusion (PLIF) surgeries. Methods A finite element model of the L1–S1 segment was modified to simulate PLIF with total laminectomy (PLIF-LAM) and PLIF with hemilaminectomy (PLIF-HEMI) procedures. The models were subjected to a 400N follower load with a 7.5-N.m moment of flexion, extension, torsion, and lateral bending. The range of motion (ROM), intradiscal pressure (IDP), and ligament force were compared. Results In Flexion, the ROM, IDP and ligament force of posterior longitudinal ligament, intertransverse ligament, and capsular ligament remarkably increased at the proximal adjacent segment in the PLIF-LAM model, and slightly increased in the PLIF-HEMI model. There was almost no difference for the ROM, IDP and ligament force at L5-S1 level between the two PLIF models although the ligament forces of ligamenta flava remarkably increased compared with the intact lumbar spine (INT) model. For the other loading conditions, these two models almost showed no difference in ROM, IDP and ligament force on the adjacent discs. Conclusions Preserved posterior complex acts as the posterior tension band during PLIF surgery and results in less ROM, IDP and ligament forces on the proximal adjacent segment in flexion. Preserving the posterior complex during decompression can be effective on preventing adjacent segment degeneration (ASD) following PLIF surgeries. PMID:27870867
Sakaura, Hironobu; Yamashita, Tomoya; Miwa, Toshitada; Ohzono, Kenji; Ohwada, Tetsuo
The incidence of symptomatic adjacent segment pathology (ASP) after fusion surgery for adult low-grade isthmic spondylolisthesis (IS) has been reported to be relatively low compared with other lumbar disease entities. However, there has been no study of symptomatic ASP incidence using posterior lumbar interbody fusion (PLIF) with pedicle screw instrumentation. We investigated the incidence of symptomatic ASP after PLIF with pedicle screw instrumentation for adult low-grade IS and identified significant risk factors for symptomatic ASP. We retrospectively studied records of 40 consecutive patients who underwent PLIF with pedicle screw instrumentation at the Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki, Japan. The patients were followed for ≥ 4 years. Patients' medical records were retrospectively examined for evidence of symptomatic ASP. Age at time of surgery, sex, fusion level, whole lumbar lordosis, segmental lordosis, preexisting laminar inclination angle, and facet tropism at the cranial fusion segment were analyzed to identify risk factors for symptomatic ASP. Four patients (ASP group) developed symptomatic ASP at the cranial segment adjacent to the fusion. There were no significant differences in age, sex, fusion level, lumbar lordosis, segmental lordosis, or facet tropism at the cranial segment adjacent to the fusion between the ASP and the non-ASP groups. In contrast, laminar inclination angle at the cranial vertebra adjacent to the fusion was significantly higher in the ASP group than in the non-ASP group. Four patients (10%) developed symptomatic ASP after PLIF with transpedicular fixation for adult low-grade IS. Preexisting laminar horizontalization at the cranial vertebra adjacent to the fusion was a significant risk factor for symptomatic ASP. PMID:24436872
Wang, Ya-Peng; An, Ji-Long; Sun, Ya-Peng; Ding, Wen-Yuan; Shen, Yong; Zhang, Wei
Objective The aim of this study was to compare the curative effect between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and the posterior lumbar interbody fusion (PLIF) in obese patients with lumbar disk prolapse. Patients and methods In this study, 72 patients who underwent lumbar disk prolapse therapy in the Third Hospital of Hebei Medical University between March 2011 and 2015 were retrospectively analyzed and were divided into two groups, MIS-TLIF group (n=35) and PLIF group (n=37), according to different surgical procedures. Several clinical parameters were compared between these two groups. Results Compared with PLIF, MIS-TLIF was associated with longer operative time, less blood loss, less postoperative drainage and shorter postoperative time in bed; moreover, patients in the MIS-TLIF group had lower levels of serum creatine kinase on 1, 3 and 5 postoperative days. At the 3- and 6-month follow-up, Visual Analog Scale (VAS) scores of low back pain of patients in the MIS-TLIF group were significantly reduced and Japanese Orthopaedic Association (JOA) scores were increased, whereas the Oswestry Disability Index (ODI) showed no significant difference between the two groups. Conclusion Obese patients can achieve good efficacy with MIS-TLIF or PLIF treatment, but MIS-TLIF surgery showed longer operative time, fewer traumas and bleeding volume, less incidence of short-term pain, low complication rate and faster postoperative recovery. PMID:28176906
Starkweather, Angela R.; Witek-Janusek, Linda; Nockels, Russ P.; Peterson, Jonna; Mathews, Herb L.
Minimally invasive transforaminal lumbar interbody fusion (TLIF) offers equivalent postoperative fusion rates compared to posterior lumbar fusion (PLF) and minimizes the amount of iatrogenic injury to the spinal muscles. The objective of this study was to examine the difference in pain perception, stress, mood disturbance, quality of life, and immunological indices throughout the perioperative course among patients undergoing TLIF and PLF. A prospective, nonrandomized descriptive design was used to evaluate these measures among patients undergoing TLIF (n = 17) or PLF (n = 18) at 1 week prior to surgery (T1), the day of surgery (T2), 24 hours postoperatively (T3), and 6 weeks postoperatively (T4). Among TLIF patients, pain, stress, fatigue, and mood disturbance were significantly decreased at the 6-week follow-up visit (T4) compared to patients who underwent PLF. The TLIF group also demonstrated significantly higher levels (near baseline) of CD8 cells atT4 than the PLF group. Interleukin-6 levels were significantly higher in the TLIF group as well, which may be an indicator of ongoing nerve regeneration and healing. Knowledge concerning the effect of pain and the psychological experience on immunity among individuals undergoing spinal fusion can help nurses tailor interventions to improve outcomes, regardless of the approach used. PMID:18330408
Lee, Chong-Suh; Kang, Kyung-Chung; Chung, Sung-Soo; Park, Won-Hah; Shin, Won-Ju; Seo, Yong-Gon
OBJECTIVE There is a lack of evidence of how back muscle strength changes after lumbar fusion surgery and how exercise influences these changes. The aim of this study was to evaluate changes in back muscle strength after posterior lumbar interbody fusion (PLIF) and to measure the effects of a postoperative exercise program on muscle strength and physical and mental health outcomes. METHODS This prospective study enrolled 59 women (mean age 58 years) who underwent PLIF at 1 or 2 spinal levels. To assess the effects of a supervised lumbar stabilization exercise (LSE), the authors allocated the patients to an LSE (n = 26) or a control (n = 33) group. The patients in the LSE group performed the LSEs between 3 and 6 months postoperatively. Back extensor strength, visual analog scale (VAS) scores in back pain, and physical component summary (PCS) and mental component summary (MCS) scores on the 36-Item Short Form Health Survey were determined for the both groups. RESULTS Mean strength of the back muscles tended to slightly decrease by 7.5% from preoperatively to 3 months after PLIF (p = 0.145), but it significantly increased thereafter and was sustained until the last follow-up (38.1%, p < 0.001). The mean back muscle strength was similar in the LSE and control groups preoperatively, but it increased significantly more in the LSE group (64.2%) than in the control group (21.7%) at the last follow-up 12 months after PLIF (p = 0.012). At the last follow-up, decreases in back pain VAS scores were more significant among LSE group patients, who had a pain reduction on average of 58.2%, than among control group patients (reduction of 26.1%) (p = 0.013). The patients in the LSE group also had greater improvement in both PCS (39.9% improvement) and MCS (20.7% improvement) scores than the patients in the control group (improvement of 18.0% and 1.1%, p = 0.042 and p = 0.035, respectively). CONCLUSIONS After PLIF, strength in back muscles decreased until 3 months postoperatively but
Chedid, Mokbel K; Tundo, Kelly M; Block, Jon E; Muir, Jeffrey M
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.
Lu, Kang; Liliang, Po-Chou; Wang, Hao-Kuang; Liang, Cheng-Loong; Chen, Jui-Sheng; Chen, Tai-Been; Wang, Kuo-Wei; Chen, Han-Jung
OBJECT Multilevel long-segment lumbar fusion poses a high risk for future development of adjacent-segment degeneration (ASD). Creating a dynamic transition zone with an interspinous process device (IPD) proximal to the fusion has recently been applied as a method to reduce the occurrence of ASD. The authors report their experience with the Device for Intervertebral Assisted Motion (DIAM) implanted proximal to multilevel posterior lumbar interbody fusion (PLIF) in reducing the development of proximal ASD. METHODS This retrospective study reviewed 91 cases involving patients who underwent 2-level (L4-S1), 3-level (L3-S1), or 4-level (L2-S1) PLIF. In Group A (42 cases), the patients received PLIF only, while in Group B (49 cases), an interspinous process device, a DIAM implant, was put at the adjacent level proximal to the PLIF construct. Bone resection at the uppermost segment of the PLIF was equally limited in the 2 groups, with preservation of the upper portion of the spinous process/lamina and the attached supraspinous ligament. Outcome measures included a visual analog scale (VAS) for low-back pain and leg pain and the Oswestry Disability Index (ODI) for functional impairment. Anteroposterior and lateral flexion/extension radiographs were used to evaluate the fusion status, presence and patterns of ASD, and mobility of the DIAM-implanted segment. RESULTS Solid interbody fusion without implant failure was observed in all cases. Radiographic ASD occurred in 20 (48%) of Group A cases and 3 (6%) of Group B cases (p < 0.001). Among the patients in whom ASD was identified, 9 in Group A and 3 in Group B were symptomatic; of these patients, 3 in Group A and 1 in Group B underwent a second surgery for severe symptomatic ASD. At 24 months after surgery, Group A patients fared worse than Group B, showing higher mean VAS and ODI scores due to symptoms related to ASD. At the final follow-up evaluations, as reoperations had been performed to treat symptomatic ASD in some
Diedrich, O; Kraft, C N; Perlick, L; Schmitt, O
The development of intervertebral cages has significantly innovated the original technique of posterior lumbar interbody fusion (PLIF). In this study we present the results of patients treated for degenerative or postoperative segmental spinal instabilities by PLIF with cages and pedicular stabilisation (360 degrees-instrumentation). Between 1992 and 1999 we implanted either CFRP-, PEEK- or Titanium-cages in 86 patients. 78 patients were adequately followed up over a period of at least 12 months (average 2,6 years). 5 patients were stabilised over 2 segments, so that ultimately 83 fused segments were evaluated.15% of all patients had an excellent, 51% a good, 28% a moderate and 5% an insufficient clinical result. Degenerative instabilities had a better outcome with 73% good or excellent clinical results, compared to postoperative instabilities (56%). Based on stringent radiographic fusion criteria we found true bony fusion in 52% of all segments after 12 months, 63% after 24 months, 72% after 36 months, and 78% after 48 months. In 21 segments cage packing was performed with autologous spongiosa, while in 62 segments a combination of cortical bone and spongiosa obtained from osseous structures at the operation-site were used as packing material. At the 24 month radiographic control we found a slightly higher fusion rate for those segments treated with autologous spongiosa obtained from the iliac crest. Neither for cages nor for pedicular screws was implant failure or material fatigue found. Serious entero-, pulmo-, cardio- or urological complications were not observed. Nonetheless the necessity for operative revision was 9%. A postoperative semiquantitative evaluation of segments neighbouring the fused vertebra revealed in 28% an increase in degenerative changes. Particularly after 360 degrees-instrumentation, interpretation of the fusion-status should be based on structural and not on functional criteria. The modification of PLIF with cages compared to the use of
Kim, Jin Hak; Kim, Jin Woo; Kim, Go We
Background Previous reports have observed differences only in infection rates between posterolateral fusion and posterior lumbar interbody fusion (PLIF). There have been no reports that describe the particular features of surgical site infection (SSI) in PLIF. In this study, we endeavor to identify the distinguishing characteristics and risk factors of SSI in PLIF. Methods Our study undertook a review of a case series of an institute. Patients who had undergone PLIF consecutively in the author's hospital were reviewed. Two proactive procedures were introduced during the study period. One was irrigation of the autolocal bone, and the other was the intradiscal space irrigation with a nozzle. Infection rate and risk factors were analyzed. For subgroup analysis, the elapsed time to a diagnosis (ETD), clinical manifestations, hematologic findings, and causative bacteria were examined in patients with SSI. Results In a total of 1,831 cases, there were 30 cases of SSI (1.6%). Long operation time was an independent risk factor (p = 0.008), and local bone irrigation was an independent protective factor (p = 0.001). Two cases of referred SSI were included in the subgroup analysis. There were 6/32 (19%) superficial incisional infections (SII), 6/32 (19%) deep incisional infections (DII), and 20/32 (62%) organ/space infections (O/SI). The difference of incidence among three groups was significant (p = 0.002).The most common bacteria encountered were methicillin-resistant Staphylococcus epidermidis followed by methicillin-resistant S. aureus in incisional infections, and no growth followed by S. epidermidis in O/SI. ETD was 8.5 ± 2.3 days in SII, 8.7 ± 2.3 days in DII and 164.5 ± 131.1 days in O/SI (p = 0.013). Conclusions The rate of SSI in PLIF was 1.6%, with the most common type being O/SI. The causative bacteria of O/SI was of lower virulence than in the incisional infection, and thus diagnosis was delayed due to its latent and insidious feature. Contamination of auto
Xiao, Lizu; Xiong, Donglin; Zhang, Qiang; Jian, Jin; Zheng, Husan; Luo, Yuhui; Dai, Juanli; Zhang, Deren
Degenerative disc disease (DDD) causes gradual intervertebral space collapse, concurrent discogenic or facet-induced pain, and possible compression radiculopathy. A new minimal invasion procedure of percutaneous posterior-lateral lumbar interbody fusion (PPLIF) using a B-Twin stand-alone expandable spinal spacer (ESS) was designed to treat this disease and evaluated by follow-up more than 1 year. 12 cases with chronic low back pain and compressive radiculopathy due to DDD refractory were selected to conservative treatment. Under fluoroscopy in the posterior-lateral position, a K-wire was advanced into the intervertebral space and a dilator and working cannula were introduced into the disc space step by step. Discectomy and endplate scratching were performed through the cannula using pituitary forceps and endplate curettage. An ESS was inserted into the intervertebral space by a B-Twin expandable spinal delivery system after some bone graft chips implanted into the disc space. The ongoing study includes intraoperative difficulties, complications, radiologic evidence of fusion and clinical outcome as scored by pre- and postoperative questionnaires pertaining to pain intensity and degree of disability. The 12 procedures of lumbar interbody fusion using stand-alone expandable spinal system through percutaneous approach were successful. Radiologic study demonstrated fusion in a total of 11 cases and only 1 exception after more than 1 year visiting. The values of Visual Analog Scale (VAS) on movement and Oswestry Disability Index (ODI) dropped by more than 80 and 67.4%, respectively. Disk space heights averaging 9.0 mm before procedure were increased to 11.5 mm 1 month (a significant difference compared with preprocedure, P < 0.01) after surgery and stabilized at 10.8 mm upon final follow-up (a significant difference compared with preprocedure, P < 0.01). The results demonstrated that the percutaneous approach for posterior-lateral lumbar interbody fusion using
An, Ki-Chan; Kong, Gyu-Min; Park, Dae-Hyun; Youn, Ji-Hong; Lee, Woon-Seong
Study Design Retrospective. Purpose To compare the clinical and radiological outcomes of posterolateral lumbar interbody fusion (PLIF) and posterolateral lumbar fusion (PLF) in monosegmental vacuum phenomenon within an intervertebral disc. Overview of Literature The vacuum phenomenon within an intervertebral disc is a serious form of degenerative disease that destabilizes the intervertebral body. Outcomes of PLIF and PLF in monosegmental vacuum phenomenon are unclear. Methods Monosegmental instrumented PLIF and PLF was performed on 84 degenerative lumbar disease patients with monosegmental vacuum phenomenon (PLIF, n=38; PLF, n=46). Minimum follow-up was 24 months. Clinical outcomes of leg and back pain were assessed using visual analogue scales for leg pain (LVAS) and back pain (BVAS), and the Oswestry disability index (ODI). The radiographic outcome was the estimated bony union rate. Results LVAS, BVAS, and ODI improved in both groups. There was no significant difference in the degree of these improvements between PLIF and PLF patients (p>0.05). Radiological union rate was 91.1% in PLIF group and 89.4% in PLF group at postoperative 24 months (p>0.05). Conclusions No significant differences in clinical results and union rates were found between PLIF and PLF patients. Selection of the operation technique will reflect the surgeon's preferences and patient condition. PMID:26949464
Kim, Jin Wook; Yoon, Seung Hwan; Oh, Seong Hoon; Roh, Sung Woo; Rim, Dae Cheol; Kim, Tae Sung
Objective This multi-center clinical study was designed to determine the long-term results of patients who received a one-level posterior lumbar interbody fusion with expandable cage (Tyche® cage) for degenerative spinal diseases during the same period in each hospital. Methods Fifty-seven patients with low back pain who had a one-level posterior lumbar interbody fusion using a newly designed expandable cage were enrolled in this study at five centers from June 2003 to December 2004 and followed up for 24 months. Pain improvement was checked with a Visual Analogue Scale (VAS) and their disability was evaluated with the Oswestry Disability Index. Radiographs were obtained before and after surgery. At the final follow-up, dynamic stability, quality of bone fusion, interveretebral disc height, and lumbar lordosis were assessed. In some cases, a lumbar computed tomography scan was also obtained. Results The mean VAS score of back pain was improved from 6.44 points preoperatively to 0.44 at the final visit and the score of sciatica was reduced from 4.84 to 0.26. Also, the Oswestry Disability Index was improved from 32.62 points preoperatively to 18.25 at the final visit. The fusion rate was 92.5%. Intervertebral disc height, recorded as 9.94±2.69 mm before surgery was increased to 12.23±3.31 mm at postoperative 1 month and was stabilized at 11.43±2.23 mm on final visit. The segmental angle of lordosis was changed significantly from 3.54±3.70° before surgery to 6.37±3.97° by 24 months postoperative, and total lumbar lordosis was 20.37±11.30° preoperatively and 24.71±11.70° at 24 months postoperative. Conclusion There have been no special complications regarding the expandable cage during the follow-up period and the results of this study demonstrates a high fusion rate and clinical success. PMID:19096552
Kombos, Theodoros; Bode, Frank
Background. Posterior lumbar interbody fusion (PLIF) is a common surgical treatment for degenerative spinal instability, but many surgeons consider obesity a contraindication for elective spinal fusion. The aim of this study was to analyze whether obesity has any influence on hospitalization parameters, change in clinical status, or complications. Methods. In this prospective study, regression analysis was used to analyze the influence of the body mass index (BMI) on operating time, postoperative care, hospitalization time, type of postdischarge care, change in paresis or sensory deficits, pain level, wound complications, cerebrospinal fluid leakage, and implant complications. Results. Operating time increased only 2.5 minutes for each increase of BMI by 1. The probability of having a wound complication increased statistically with rising BMI. Nonetheless, BMI accounted for very little of the variation in the data, meaning that other factors or random chances play a much larger role. Conclusions. Obesity has to be considered a risk factor for wound complications in patients undergoing elective PLIF for degenerative instability. However, BMI showed no significant influence on other kinds of peri- or postoperative complications, nor clinical outcomes. So obesity cannot be considered a contraindication for elective PLIF. PMID:27478866
Miwa, Toshitada; Yamashita, Tomoya; Kuroda, Yusuke; Ohwada, Tetsuo
Study Design Clinical case series. Purpose In the posterior lumbar interbody fusion (PLIF) procedure in our institute, the cephalad screw trajectory follows a mediolateral and caudocephalad directed path according to the original cortical bone trajectory (CBT) method. However, the starting point of the caudal screw is at the medial border of the pedicle on an articular surface of the superior articular process, and the trajectory takes a mediolateral path parallel to the cephalad endplate. The incidence of caudal screw loosening after PLIF with this modified CBT screw method was investigated, and significant risk factors for caudal screw loosening were evaluated. Overview of Literature A biomechanical study of this modified caudal screw trajectory using the finite element method reported about a 20% increase in uniaxial yield pullout load compared with the traditional trajectory. However, there has been no clinical study concerning the fixation strength of this modified caudal screw trajectory. Methods The subjects were 193 consecutive patients who underwent single-level PLIF with modified CBT screw fixation. Caudal screw loosening was checked in computed tomography at 6 months after surgery, and screw loosening was defined as a radiolucency of 1 mm or more at the bone-screw interface. Results The incidence of caudal screw loosening after lumbosacral PLIF (46.2%) was significantly higher than that after floating PLIF (6.0%). No significant differences in sex, brand of the instruments, and diameter and length of the caudal screw were evident between patients with and without caudal screw loosening. Patients with caudal screw loosening were significantly older at the time of surgery than patients without caudal screw loosening. Conclusions Fixation strength of the caudal screw after floating PLIF with this modified CBT screw technique was sufficiently acceptable. Fixation strength after the lumbosacral procedure was not. PMID:27559442
Choi, Man Kyu; Park, Bong Jin; Park, Chang Kyu; Kim, Sung Min
Objective Although trunk muscles in the lumbar spine preserve spinal stability and motility, little is known about the relationship between trunk muscles and spinal fusion rate. The aim of the present study is to evaluate the correlation between trunk muscles cross sectional area (MCSA) and fusion rate after posterior lumbar interbody fusion (PLIF) using stand-alone cages. Methods A total of 89 adult patients with degenerative lumbar disease who were performed PLIF using stand-alone cages at L4–5 were included in this study. The cross-sectional area of the psoas major (PS), erector spinae (ES), and multifidus (MF) muscles were quantitatively evaluated by preoperative lumbar magnetic resonance imaging at the L3–4, L4–5, and L5–S1 segments, and bone union was evaluated by dynamic lumbar X-rays. Results Of the 89 patients, 68 had bone union and 21 did not. The MCSAs at all segments in both groups were significantly different (p<0.05) for the PS muscle, those at L3–4 and L4–5 segments between groups were significantly different (p=0.048, 0.021) for the ES and MF muscles. In the multivariate analysis, differences in the PS MCSA at the L4–5 and L5–S1 segments remained significant (p=0.048, 0.043 and odds ratio=1.098, 1.169). In comparison analysis between male and female patients, most MCSAs of male patients were larger than female's. Fusion rates of male patients (80.7%) were higher than female's (68.8%), too. Conclusion For PLIF surgery, PS muscle function appears to be an important factor for bone union and preventing back muscle injury is essential for better fusion rate. PMID:27226860
Matsumura, Akira; Namikawa, Takashi; Kato, Minori; Ozaki, Tomonori; Hori, Yusuke; Hidaka, Noriaki; Nakamura, Hiroaki
The purpose of this study was to assess the clinical results of posterior corrective surgery using a multilevel transforaminal lumbar interbody fusion (TLIF) with a rod rotation (RR) and to evaluate the segmental corrective effect of a TLIF using CT imaging. The medical records of 15 consecutive patients with degenerative lumbar kyphoscoliosis (DLKS) who had undergone posterior spinal corrective surgery using a multilevel TLIF with an RR technique and who had a minimum follow-up of 2 years were retrospectively reviewed. Radiographic parameters were evaluated using plain radiographs, and segmental correction was evaluated using CT imaging. Clinical outcomes were evaluated with the Scoliosis Research Society Patient Questionnaire-22 (SRS-22) and the SF-36. The mean follow-up period was 46.7 months, and the mean age at the time of surgery was 60.7 years. The mean total SRS-22 score was 2.9 before surgery and significantly improved to 4.0 at the latest follow-up. The physical functioning, role functioning (physical), and social functioning subcategories of the SF-36 were generally improved at the latest follow-up, although the changes in these scores were not statistically significant. The bodily pain, vitality, and mental health subcategories were significantly improved at the latest follow-up (p < 0.05). Three complications occurred in 3 patients (20%). The Cobb angle of the lumbar curve was reduced to 20.3° after surgery. The overall correction rate was 66.4%. The pelvic incidence-lumbar lordosis (preoperative/postoperative = 31.5°/4.3°), pelvic tilt (29.2°/18.9°), and sagittal vertical axis (78.3/27.6 mm) were improved after surgery and remained so throughout the follow-up. Computed tomography image analysis suggested that a 1-level TLIF can result in 10.9° of scoliosis correction and 6.8° of lordosis. Posterior corrective surgery using a multilevel TLIF with an RR on patients with DLKS can provide effective correction in the coronal plane but allows only
Kuraishi, Shugo; Mukaiyama, Keijiro; Shimizu, Masayuki; Ikegami, Shota; Futatsugi, Toshimasa; Hirabayashi, Hiroki; Ogihara, Nobuhide; Hashidate, Hiroyuki; Tateiwa, Yutaka; Kinoshita, Hisatoshi; Kato, Hiroyuki
Study Design Multicenter analysis of two groups of patients surgically treated for degenerative L4 unstable spondylolisthesis. Purpose To compare the clinical and radiographic outcomes of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) for degenerative L4 unstable spondylolisthesis. Overview of Literature Surgery for lumbar degenerative spondylolisthesis is widely performed. However, few reports have compared the outcome of PLF to that of PLIF for degenerative L4 unstable spondylolisthesis. Methods Patients with L4 unstable spondylolisthesis with Meyerding grade II or more, slip of >10° or >4 mm upon maximum flexion and extension bending, and posterior opening of >5 degree upon flexion bending were studied. Patients were treated from January 2008 to January 2010. Patients who underwent PLF (n=12) and PLIF (n=19) were followed-up for >2 years. Radiographic findings and clinical outcomes evaluated by the Japanese Orthopaedic Association (JOA) score were compared between the two groups. Radiographic evaluation included slip angle, translation, slip angle and translation during maximum flexion and extension bending, intervertebral disc height, lumbar lordotic angle, and fusion rate. Results JOA scores of the PLF group before surgery and at final follow-up were 12.3±4.8 and 24.1±3.7, respectively; those of the PLIF group were 14.7±4.8 and 24.2±7.8, respectively, with no significant difference between the two groups. Correction of slip estimated from postoperative slip angle, translation, and maintenance of intervertebral disc height in the PLIF group was significantly (p<0.05) better than those in the PLF group. However, there was no significant difference in lumbar lordotic angle, slip angle and translation angle upon maximum flexion, or extension bending. Fusion rates of the PLIF and PLF groups had no significant difference. Conclusions The L4–L5 level posterior instrumented fusion for unstable spondylolisthesis using both PLF and PLIF
Bader, R J; Steinhauser, E; Rechl, H; Mittelmeier, W; Bertagnoli, R; Gradinger, R
In addition to autogenous or allogeneic bone grafts, fusion cages composed of metal or plastic are being used increasingly as spacers for interbody fusion of spinal segments. The goal of this study was the mechanical testing of carbon fiber reinforced plastic (CFRP) fusion cages used for anterior lumbar interbody fusion. With a special testing device according to American Society for Testing and Materials (ASTM) standards, the mechanical properties of the implants were determined under four different loading conditions. The implants (UNION cages, Medtronic Sofamor Danek) provide sufficient axial compression, shear, and torsional strength of the implant body. Ultimate axial compression load of the fins is less than the physiological compression loads at the lumbar spine. Therefore by means of an appropriate surgical technique parallel grooves have to be reamed into the endplates of the vertebral bodies according to the fin geometry. Thereby axial compression forces affect the implants body and the fins are protected from damaging loading. Using a supplementary anterior or posterior instrumentation, in vivo failure of the fins as a result of physiological shear and torsional spinal loads is unlikely. Due to specific complications related to autogenous or allogeneic bone grafts, fusion cages made of metal or carbon fiber reinforced plastic are an important alternative implant in interbody fusion.
Hayashi, Kazunori; Matsumura, Akira; Konishi, Sadahiko; Kato, Minori; Namikawa, Takashi; Nakamura, Hiroaki
Study Design Retrospective study. Objective To compare clinical outcomes, radiographic evaluations including bony union rate and incidence of osteoporotic vertebral fractures (OVFxs), and perioperative complications following posterior lumbar interbody fusion (PLIF) between patients ≥80 years of age and those <80 years. Methods Ninety-six patients ≥70 years old who underwent PLIF were reviewed. We divided the patients into the two age groups, ≥80 group (n = 19) and <80 group (n = 77), and compared the clinical outcomes using Japanese Orthopaedics Association (JOA) scores and the Short-Form Health Survey (SF-36). We also evaluated bony union and the incidence of OVFxs in the both groups. Results The JOA score improved 47.6% in the ≥80 group and 49.1% in the <80 group. There were no significant differences between the two groups. Only the bodily pain component of the SF-36 improved significantly in the ≥80 group, and seven of eight components (exception was general health) improved significantly in the <80 group. Bony union rate was significantly superior in the <80 group (94.8%) compared with that of the ≥80 group (73.7%, p = 0.013). OVFx prevalence and incidence were not significantly different between the two groups, although postoperative OVFx worsened the JOA score improvement in the ≥80 group (38.8%, p = 0.02). Conclusions The present study indicated that surgical outcomes of PLIF in patients ≥80 years were comparable to those < 80 years. However, bony union rate was significantly lower and postoperative OVFx worsened the clinical outcomes in patients ≥80 years. PMID:27781186
Phan, Kevin; Maharaj, Monish; Assem, Yusuf; Mobbs, Ralph J
Lumbar interbody fusion represents an effective surgical intervention for patients with lumbar degenerative diseases, spondylolisthesis, disc herniation, pseudoarthrosis and spinal deformities. Traditionally, conventional open anterior lumbar interbody fusion and posterior/transforaminal lumbar interbody fusion techniques have been employed with excellent results, but each with their own advantages and caveats. Most recently, the antero-oblique trajectory has been introduced, providing yet another corridor to access the lumbar spine. Termed the oblique lumbar interbody fusion, this approach accesses the spine between the anterior vessels and psoas muscles, avoiding both sets of structures to allow efficient clearance of the disc space and application of a large interbody device to afford distraction for foraminal decompression and endplate preparation for rapid and thorough fusion. This review aims to summarize the early clinical results and complications of this new technique and discusses potential future directions of research.
Phan, Kevin; Malham, Greg; Seex, Kevin; Rao, Prashanth J.
Degenerative disc and facet joint disease of the lumbar spine is common in the ageing population, and is one of the most frequent causes of disability. Lumbar spondylosis may result in mechanical back pain, radicular and claudicant symptoms, reduced mobility and poor quality of life. Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct deformity. The surgical options for interbody fusion of the lumbar spine include: posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), minimally invasive transforaminal lumbar interbody fusion (MI-TLIF), oblique lumbar interbody fusion/anterior to psoas (OLIF/ATP), lateral lumbar interbody fusion (LLIF) and anterior lumbar interbody fusion (ALIF). The indications may include: discogenic/facetogenic low back pain, neurogenic claudication, radiculopathy due to foraminal stenosis, lumbar degenerative spinal deformity including symptomatic spondylolisthesis and degenerative scoliosis. In general, traditional posterior approaches are frequently used with acceptable fusion rates and low complication rates, however they are limited by thecal sac and nerve root retraction, along with iatrogenic injury to the paraspinal musculature and disruption of the posterior tension band. Minimally invasive (MIS) posterior approaches have evolved in an attempt to reduce approach related complications. Anterior approaches avoid the spinal canal, cauda equina and nerve roots, however have issues with approach related abdominal and vascular complications. In addition, lateral and OLIF techniques have potential risks to the lumbar plexus and psoas muscle. The present study aims firstly to comprehensively review the available literature and evidence for different lumbar interbody fusion (LIF) techniques. Secondly, we propose a set of recommendations and guidelines
Daniels, Alan H; Kawaguchi, Satoshi; Contag, Alec G; Rastegar, Farbod; Waagmeester, Garrett; Anderson, Paul A; Arthur, Melanie; Hart, Robert A
OBJECTIVE Beginning in 2008, the Centers for Medicare and Medicaid Service (CMS) determined that certain hospital-acquired adverse events such as surgical site infection (SSI) following spine surgery should never occur. The following year, they expanded the ruling to include deep vein thrombosis (DVT) and pulmonary embolism (PE) following total joint arthroplasty. Due to their ruling that "never events" are not the payers' responsibility, CMS insists that the costs of managing these complications be borne by hospitals and health care providers, rather than billings to health care payers for additional care required in their management. Data comparing the expected costs of such adverse events in patients undergoing spine and orthopedic surgery have not previously been reported. METHODS The California State Inpatient Database (CA-SID) from 2008 to 2009 was used for the analysis. All patients with primary procedure codes indicating anterior cervical discectomy and fusion (ACDF), posterior lumbar interbody fusion (PLIF), lumbar laminectomy (LL), total knee replacement (TKR), and total hip replacement (THR) were analyzed. Patients with diagnostic and/or treatment codes for DVT, PE, and SSI were separated from patients without these complication codes. Patients with more than 1 primary procedure code or more than 1 complication code were excluded. Median charges for treatment from primary surgery through 3 months postoperatively were calculated. RESULTS The incidence of the examined adverse events was lowest for ACDF (0.6% DVT, 0.1% PE, and 0.03% SSI) and highest for TKA (1.3% DVT, 0.3% PE, 0.6% SSI). Median inpatient charges for uncomplicated LL was $51,817, compared with $73,432 for ACDF, $143,601 for PLIF, $74,459 for THR, and $70,116 for TKR. Charges for patients with DVT ranged from $108,387 for TKR (1.5 times greater than index) to $313,536 for ACDF (4.3 times greater than index). Charges for patients with PE ranged from $127,958 for TKR (1.8 times greater than
Schwender, James D.; Safriel, Yair; Gilbert, Thomas J.; Mehbod, Amir A.; Denis, Francis; Transfeldt, Ensor E.; Wroblewski, Jill M.
Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups. PMID:19125304
Massey, Gene M; Caputo, Adam M; Michael, Keith W; Isaacs, Robert E; Brown, Christopher R
Facet cysts are a relatively common source of neural compression in the lumbar spine. Open decompression and fusion are frequently used to treat the stenosis and instability associated with this pathology. Recently, anterior lumbar interbody fusion (ALIF) has increased in popularity for the treatment of lumbar degenerative conditions. ALIF may achieve indirect decompression of the neural elements with less surgical morbidity than conventional open approaches. To date, there are no published reports describing the use of indirect decompression or interbody fusion for the treatment of facet cysts. We report a patient who developed an L4-L5 facet cyst secondary to degenerative changes and spondylolisthesis. ALIF with posterior instrumentation was used to address his condition. Six months after surgery, the patient had complete resolution of his symptoms. MRI revealed complete resolution of the facet cyst. This patient provides previously unreported evidence that interbody fusion alone may result in facet cyst resolution. Clinical studies are needed to evaluate if interbody fusion can consistently relieve the symptoms associated with facet cysts without the use of direct decompression.
Evaluation of Coflex interspinous stabilization following decompression compared with decompression and posterior lumbar interbody fusion for the treatment of lumbar degenerative disease: A minimum 5-year follow-up study.
Yuan, Wei; Su, Qing-Jun; Liu, Tie; Yang, Jin-Cai; Kang, Nan; Guan, Li; Hai, Yong
Few studies have compared the clinical and radiological outcomes between Coflex interspinous stabilization and posterior lumbar interbody fusion (PLIF) for degenerative lumbar disease. We compared the at least 5-year clinical and radiological outcomes of Coflex stabilization and PLIF for lumbar degenerative disease. Eighty-seven consecutive patients with lumbar degenerative disease were retrospectively reviewed. Forty-two patients underwent decompression and Coflex interspinous stabilization (Coflex group), 45 patients underwent decompression and PLIF (PLIF group). Clinical and radiological outcomes were evaluated. Coflex subjects experienced less blood loss, shorter hospital stays and shorter operative time than PLIF (all p<0.001). Both groups demonstrated significant improvement in Oswestry Disability Index and visual analogue scale back and leg pain at each follow-up time point. The Coflex group had significantly better clinical outcomes during early follow-up. At final follow-up, the superior and inferior adjacent segments motion had no significant change in the Coflex group, while the superior adjacent segment motion increased significantly in the PLIF group. At final follow-up, the operative level motion was significantly decreased in both groups, but was greater in the Coflex group. The reoperation rate for adjacent segment disease was higher in the PLIF group, but this did not achieve statistical significance (11.1% vs. 4.8%, p=0.277). Both groups provided sustainable improved clinical outcomes for lumbar degenerative disease through at least 5-year follow-up. The Coflex group had significantly better early efficacy than the PLIF group. Coflex interspinous implantation after decompression is safe and effective for lumbar degenerative disease.
Yeoman, Chevas; Chung, Woosik M.; Chappuis, James L; Freedman, Brett
Study Design Retrospective case series. Purpose To present radiographic outcomes following anterior lumbar interbody fusion (ALIF) utilizing a modular interbody device. Overview of Literature Though multiple anterior lumbar interbody techniques have proven successful in promoting bony fusion, postoperative subsidence remains a frequently reported phenomenon. Methods Forty-three consecutive patients underwent ALIF with (n=30) or without (n=11) supplemental instrumentation. Two patients underwent ALIF to treat failed posterior instrumented fusion. The primary outcome measure was presence of fusion as assessed by computed tomography. Secondary outcome measures were lordosis, intervertebral lordotic angle (ILA), disc height, subsidence, Bridwell fusion grade, technical complications and pain score. Interobserver reliability of radiographic outcome measures was calculated. Results Forty-three patients underwent ALIF of 73 motion segments. ILA and disc height increased over baseline, and this persisted through final follow-up (p<0.01). Solid anterior interbody fusion was present in 71 of 73 motion segments (97%). The amount of new bone formation in the interbody space increased over serial imaging. Subsidence >4 mm occurred in 12% of patients. There were eight surgical complications (19%): one major (reoperation for nonunion/progressive subsidence) and seven minor (five subsidence, two malposition). Conclusions The use of a modular interbody device for ALIF resulted in a high rate of radiographic fusion and a low rate of subsidence. The large endplate and modular design of the device may contribute to a low rate of subsidence as well as maintenance of ILA and lordosis. Previously reported quantitative radiographic outcome measures were found to be more reliable than qualitative or categorical measures. PMID:25346811
Zaidi, Hasan Aqdas; Shah, Ashish; Kakarla, Udaya Kumar
The purpose of this case report was to describe a novel method to retrieve a herniated lumbar interbody cage. Transforaminal lumbar interbody fusion (TLIF) is an increasingly popular method of spinal fixation and fusion. Unexpected retropulsion of an interbody is a rare event that can result in intractable pain or motor compromise necessitating surgical retrieval of the interbody. Both anterior and posterior approaches to removing migrated cages may be associated with significant surgical morbidity and mortality. A 60-year-old woman underwent an L4-S1 TLIF coupled with pedicle screw fixation at a previous hospital 5 years prior to admission. She noted sudden-onset bilateral lower extremity weakness and right-sided foot drop. Magnetic resonance imaging and radiographs were notable for purely centrally herniated interbody. A posterior, midline transdural approach was used to retrieve the interbody. Situated in between nerve rootlets to the ventral canal, this virgin corridor allowed us to easily visualize and protect neurological structures while safely retrieving the interbody. The patient experienced an immediate improvement in symptoms and was discharged on postoperative day 3. At 12-month follow-up, she had no evidence of cerebrospinal fluid (CSF) leak and had returned to normal activities of daily living. While the risk of CSF leak may be higher with a transdural approach, we maintain that avoiding unnecessary retraction of the nerve roots may outweigh this risk. To our knowledge, this is the first case report of a transdural approach for the retrieval of a retropulsed lumbar interbody cage.
Gandhoke, Gurpreet S; Ricks, Christian; Tempel, Zachary; Zuckerbraun, Brian; Hamilton, D Kojo; Okonkwo, David O; Kanter, Adam S
In deformity surgery, anterior lumbar interbody fusion provides excellent biomechanical support, creates a broad surface area for arthrodesis, and induces lordosis in the lower lumbar spine. Preoperative MRI, plain radiographs, and, when available, CT scan should be carefully assessed for sacral slope as it relates to pubic symphysis, position of the great vessels (especially at L4/5), disc space height, or contraindication to an anterior approach. This video demonstrates the steps in an anterior surgical procedure with minimal open exposure. The video can be found here: https://youtu.be/r3bC4_vu1hQ .
Medrano, Belen G.; Noriega, David C.
Study Design Retrospective study. Purpose To analyze outcomes of posterior lumbar interbody fusion (PLIF) stand-alone cages. Overview of Literature PLIF for degenerative disk disease using stand-alone cages has lost its popularity owing to implant-related complications and pseudoarthrosis. Methods We analyzed the records of 45 patients (18 women, 27 men), operated between January 1994 and December 1996, with a mean follow-up of 18 years 3 months (20 years 3 months–22 years 3 months). Clinical outcomes were measured using visual analogue score (VAS), Oswestry disability index (ODI), Odom's criteria, and radiological measurements of fusion rate, Cobb angle, and implant-related complications conducted at the preoperative evaluation, hospital discharge, 12-month follow-up, and final follow-up. Results Preoperative mean VAS (back) was 6.9 and VAS (radicular) was 7.2, with mean improvements (p <0.05) of 2.9 and 3.1, respectively, at the final follow-up. Median preoperative ODI was 64.5, with a mean improvement to 34 and 42 at the 12-month and final follow-ups, respectively (p <0.05). Odom's criteria at the 12-month follow-up were excellent in 11.2% patients, good in 57.7%, fair in 31.1%, and poor in none of the patients; at the final follow-up, no patient was classified as excellent, 71.1% as good, 22.2% as fair, and 6.7% as poor (p <0.05). Pseudoarthrosis was observed in five patients (11.1%), of whom, three (6.6%) required re-operation. Preoperative disk height was 9.23 mm, which increased to 13.33 mm in the immediate postoperative evaluation and was maintained at 10.0 mm at the final follow-up (p <0.05). The preoperative mean L1–S1 Cobb angle was 34.7°, which changed to 44.7° in the immediate postoperative evaluation and dropped to 39.7° at the final follow-up (p <0.005). Conclusions PLIF stand-alone cages were associated with good clinical outcomes. Although the fusion rate was excellent, maintenance of disk heights and a lordotic alignment were not achieved
Gomez-Moreta, Juan A.; Hernandez-Vicente, Javier
Background We present our experience in the treatment of patients with isthmic or degenerative spondylolisthesis, by means of a posterior lumbar interbody fusion (PLIF) and instrumented posterolateral fusion (IPLF), and we compare them with those published in the literature. We analyse whether there exists any statistical association between the clinical characteristics of the patient, radiological characteristics of the disease and our surgical technique, with the complications and the clinical-radiological prognosis of the cases. Method We designed a prospective study. A total of 36 cases were operated. The patients included were 14 men and 22 women, with an average age of 57.17±27.32 years. Our technique consists of PLIF+IPLF, using local bone for the fusion. The clinical results were evaluated with the Visual Analogical Scale (VAS) and the Kirkaldy-Willis criteria. The radiological evaluation followed the Bratingan (PLIF) and Lenke (IPLF) methodology. A total of 42 variables were statistically analysed by means of SPSS18. We used the Paired Student's T-test, logistic regression and Pearson's Chi-square-test. Results The spondylolisthesis was isthmic in 15 cases and degenerative in 21 cases. The postoperative evaluations had excellent or good results in 94.5% (n = 34), with a statistically significant improvement in the back pain and sciatica (p < 0.01). The rate of circumferential fusion reached was approximately 92%. We had 13.88% of transitory morbility and 0% of mortality associated with our technique. A greater age, degree of listhesis or length of illness before the intervention, weakly correlated with worse clinical results (p< -0.2). In our series, the logistical regression showed that the clinical characteristics of the patient, radiological characteristics of the lesion and our surgical technique were not associated with greater postoperative complications. Conclusion Although a higher level of training is necessary, we believe that the described
Chatham, Lillian S; Patel, Vikas V; Yakacki, Christopher M; Dana Carpenter, R
There is a need to better understand the effects of intervertebral spacer material and design on the stress distribution in vertebral bodies and endplates to help reduce complications such as subsidence and improve outcomes following lumbar interbody fusion. The main objective of this study was to investigate the effects of spacer material on the stress and strain in the lumbar spine after interbody fusion with posterior instrumentation. A standard spacer was also compared with a custom-fit spacer, which conformed to the vertebral endplates, to determine if a custom fit would reduce stress on the endplates. A finite element (FE) model of the L4-L5 motion segment was developed from computed tomography (CT) images of a cadaveric lumbar spine. An interbody spacer, pedicle screws, and posterior rods were incorporated into the image-based model. The model was loaded in axial compression, and strain and stress were determined in the vertebra, spacer, and rods. Polyetheretherketone (PEEK), titanium, poly(para-phenylene) (PPP), and porous PPP (70% by volume) were used as the spacer material to quantify the effects on stress and strain in the system. Experimental testing of a cadaveric specimen was used to validate the model's results. There were no large differences in stress levels (<3%) at the bone-spacer interfaces and the rods when PEEK was used instead of titanium. Use of the porous PPP spacer produced an 8-15% decrease of stress at the bone-spacer interfaces and posterior rods. The custom-shaped spacer significantly decreased (>37%) the stress at the bone-spacer interfaces for all materials tested. A 28% decrease in stress was found in the posterior rods with the custom spacer. Of all the spacer materials tested with the custom spacer design, 70% porous PPP resulted in the lowest stress at the bone-spacer interfaces. The results show the potential for more compliant materials to reduce stress on the vertebral endplates postsurgery. The custom spacer provided a
Voronov, Leonard I.; Vastardis, Georgios; Zelenakova, Julia; Carandang, Gerard; Havey, Robert M.; Waldorff, Erik I.; Zindrick, Michael R.
Introduction We hypothesized that an Integrated Lumbar Interbody Fusion Device (PILLAR SA, Orthofix, Lewisville, TX) will function biomechanically similar to a traditional anterior interbody spacer (PILLAR AL, Orthofix, Lewisville, TX) plus posterior instrumentation (FIREBIRD, Orthofix, Lewisville, TX). Purpose of this study was to determine if an Integrated Interbody Fusion Device (PILLAR SA) can stabilize single motion segments as well as an anterior interbody spacer (PILLAR AL) + pedicle screw construct (FIREBIRD). Methods Eight cadaveric lumbar spines (age: 43.9±4.3 years) were used. Each specimen's range of motion was tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) under intact condition, after L4-L5 PILLAR SA with intervertebral screws and after L4-L5 360° fusion (PILLAR AL + Pedicle Screws and rods (FIREBIRD). Each specimen was tested in flexion (8Nm) and extension (6Nm) without preload (0 N) and under 400N of preload, in lateral bending (±6 Nm) and axial rotation (±5 Nm) without preload. Results Integrated fusion using the PILLAR SA device demonstrated statistically significant reductions in range of motion of the L4-L5 motion segment as compared to the intact condition for each test direction. PILLAR SA reduced ROM from 8.9±1.9 to 2.9±1.1° in FE with 400N follower preload (67.4%), 8.0±1.7 to 2.5±1.1° in LB, and 2.2±1.2 to 0.7±0.3° in AR. A comparison between the PILLAR SA integrated fusion device versus 360° fusion construct with spacer and bilateral pedicle screws was statistically significant in FE and LB. The 360° fusion yielded motion of 1.0±0.5° in FE, 1.0±0.8° in LB (p0.05). Conclusions The PILLAR SA resulted in motions of less than 3° in all modes of motion and was not as motion restricting as the traditional 360° using bilateral pedicle screws. The residual segmental motions compare very favorably with published biomechanical studies of other interbody integrated fusion devices. PMID:25694931
Abe, Tetsuya; Funayama, Toru; Noguchi, Hiroshi; Nakayama, Keita; Miura, Kousei; Nagashima, Katsuya; Kumagai, Hiroshi; Yamazaki, Masashi
When ossification of the yellow ligament (OYL) occurs in the lumbar spine and extends to the lateral wall of the spinal canal, facetectomy is required to remove all of the ossified lesion and achieve decompression. Subsequent posterior fixation with interbody fusion will then be necessary to prevent postoperative progression of the ossification and intervertebral instability. The technique of lateral lumbar interbody fusion (LLIF) has recently been introduced. Using this procedure, surgeons can avoid excess blood loss from the extradural venous plexus and detachment of the ossified lesion and the ventral dura mater is avoidable. We present a 55-year-old male patient with OYL at L3/4 and anterior spondylolisthesis of L4 vertebra, with concomitant ossification of the posterior longitudinal ligament, who presented with a severe gait disturbance. He underwent a 2-stage operation without complications: LLIF for L3/4 and L4/5 was performed at the initial surgery, and posterior decompression fixation using pedicle screws from L3 to L5 was performed at the second surgery. His postoperative progress was favorable, and his interbody fusion was deemed successful. Here, we present the first reported case of LLIF for OYL of the lumbar spine. This procedure can be a good option for OYL of the lumbar spine. PMID:28352485
Lee, Chong-Suh; Chung, Sung-Soo; Lee, Jun-Young; Yum, Tae-Hoon; Shin, Seong-Kee
Study Design Prospective observational study. Purpose To introduce the techniques and present the surgical outcomes of mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segments of the spine combined with lateral lumbar interbody fusion (LLIF) for the correction of adult spinal deformity Overview of Literature Although LLIF is increasingly used to correct adult spinal deformity, the correction of sagittal plane deformity with LLIF alone is reportedly suboptimal. Methods Thirty-two consecutive patients with adult spinal deformity underwent LLIF combined with mini-open ALIF at the L5–S1 or L4–S1 levels followed by 2-stage posterior fixation. ALIF was performed for a mean 1.3 levels and LLIF for a mean 2.7 levels. Then, percutaneous fixation was performed in 11 patients (percutaneous group), open correction with facetectomy with or without laminectomy in 16 (open group), and additional pedicle subtraction osteotomy (PSO) in 5 (PSO group). Spinopelvic parameters were compared preoperatively and postoperatively. Hospitalization data and clinical outcomes were recorded. Results No major medical complications developed, and clinical outcomes improved postoperatively in all groups. The mean postoperative segmental lordosis was greater after ALIF (17.5°±5.5°) than after LLIF (8.1°±5.3°, p <0.001). Four patients (12.5%) had lumbar lordosis with a pelvic incidence of ±9° preoperatively, whereas this outcome was achieved postoperatively in 30 patients (93.8%). The total increase in lumbar lordosis was 14.7° in the percutaneous group, 35.3° in the open group, and 57.0° in the PSO group. The ranges of potential lumbar lordosis increase were estimated as 4°–25°, 23°–42°, and 45°–65°, respectively. Conclusions Mini-open ALIF combined with LLIF followed by posterior fixation may be a feasible technique for achieving optimal sagittal balance and reducing the necessity of more extensive surgery. PMID:27994777
Epstein, Nancy E.
Background: Major factors prompted the development of minimally invasive (MIS) extreme lateral interbody fusion (XLIF; NuVasive Inc., San Diego, CA, USE) for the thoracic/lumbar spine. These include providing interbody stabilization and indirect neural decompression while avoiding major visceral/vessel injury as seen with anterior lumbar interbody fusion (ALIF), and to avert trauma to paraspinal muscles/facet joints found with transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterior-lateral fusion techniques (PLF). Although anticipated pros of MIS XLIF included reduced blood loss, operative time, and length of stay (LOS), they also included, higher fusion, and lower infection rates. Unanticipated cons, however, included increased morbidity/mortality rates. Methods: We assessed the pros and cons (e.g., risks, complications, comparable value/superiority/inferiority, morbidity/mortality) of MIS XLIF vs. ALIF, TLIF, PLIF, and PLF. Results: Pros of XLIF included various biomechanical and technical surgical advantages, along with multiple cons vs. ALIF, TLIF, PLIF, and PLF. For example, XLIF correlated with a considerably higher frequency of major neurological deficits vs. other constructs; plexus injuries 13.28%, sensory deficits 0–75% (permanent in 62.5%), motor deficits 0.7–33.6%, and anterior thigh pain 12.5–25%. XLIF also disproportionately contributed to other major morbidity/mortality; sympathectomy, major vascular injuries (some life-ending others life-threatening), bowel perforations, and seromas. Furthermore, multiple studies documented no superiority, and the potential inferiority of XLIF vs. ALIF, TLIF, PLIF, and PLF. Conclusion: Reviewing the pros of XLIF (e.g. radiographic, technical, biomechanical) vs. the cons (inferiority, increased morbidity/mortality) vs. ALIF, TLIF, PLIF, and PLF, we question whether XLIF should remain part of the lumbar spinal surgical armamentarium. PMID:27843688
Farrokhi, Majid Reza; Rahmanian, Abdolkarim; Masoudi, Mohammad Sadegh
Spondylolisthesis is a heterogeneous disorder characterized by subluxation of a vertebral body over another in the sagittal plane. Its most common form is isthmic spondylolisthesis (IS). This study aims to compare clinical outcomes of posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF) with posterior instrumentation in the treatment of IS. We performed a randomized prospective study in which 80 patients out of a total of 85 patients with IS were randomly allocated to one of two groups: PLF with posterior instrumentation (group I) or PLIF with posterior instrumentation (group II). Posterior decompression was performed in the patients. The Oswestry low back pain disability (OLBP) scale and Visual Analogue Scale (VAS) were used to evaluate the quality of life (QoL) and pain, respectively. Fisher's exact test was used to evaluate fusion rate and the Mann-Whitney U test was used to compare categorical data. Fusion in group II was significantly better than in group I (p=0.012). Improvement in low back pain was statistically more significant in group I (p=0.001). The incidence of neurogenic claudication was significantly lower in group I than in group II (p=0.004). In group I, there was no significant correlation between slip Meyerding grade and disc space height, radicular pain, and low back pain. There was no significant difference in post-operative complications at 1-year follow-up. Our data showed that PLF with posterior instrumentation provides better clinical outcomes and more improvement in low back pain compared to PLIF with posterior instrumentation despite the low fusion rate.
Drazin, Doniel; Kim, Terrence T.; Johnson, J. Patrick
Lumbar fusion surgery involving lateral lumbar interbody graft insertion with posterior instrumentation is traditionally performed in two stages requiring repositioning. We describe a novel technique to complete the circumferential procedure simultaneously without patient repositioning. Twenty patients diagnosed with worsening back pain with/without radiculopathy who failed exhaustive conservative management were retrospectively reviewed. Ten patients with both procedures simultaneously from a single lateral approach and 10 control patients with lateral lumbar interbody fusion followed by repositioning and posterior percutaneous instrumentation were analyzed. Pars fractures, mobile grade 2 spondylolisthesis, and severe one-level degenerative disk disease were matched between the two groups. In the simultaneous group, avoiding repositioning leads to lower mean operative times: 130 minutes (versus control 190 minutes; p = 0.009) and lower intraoperative blood loss: 108 mL (versus 93 mL; NS). Nonrepositioned patients were hospitalized for an average of 4.1 days (versus 3.8 days; NS). There was one complication in the control group requiring screw revision. Lateral interbody fusion and percutaneous posterior instrumentation are both readily accomplished in a single lateral decubitus position. In select patients with adequately sized pedicles, performing simultaneous procedures decreases operative time over sequential repositioning. Patient outcomes were excellent in the simultaneous group and comparable to procedures done sequentially. PMID:26649303
TAKAHASHI, Toshiyuki; HANAKITA, Junya; OHTAKE, Yasufumi; FUNAKOSHI, Yusuke; OICHI, Yuki; KAWAOKA, Taigo; WATANABE, Mizuki
Instrumented lumbar fusion can provide immediate stability and assist in satisfactory arthrodesis in patients who have pain or instability of the lumbar spine. Lumbar adjunctive fusion with decompression is often a good procedure for surgical management of degenerative spondylolisthesis (DS). Among various lumbar fusion techniques, lumbar interbody fusion (LIF) has an advantage in that it maintains favorable lumbar alignment and provides successful fusion with the added effect of indirect decompression. This technique has been widely used and represents an advancement in spinal instrumentation, although the rationale and optimal type of LIF for DS remains controversial. We evaluated the current status and role of LIF in DS treatment, mainly as a means to augment instrumentation. We addressed the basic concept of LIF, its indications, and various types including minimally invasive techniques. It also has acceptable biomechanical features, and offers reconstruction with ideal lumbar alignment. Postsurgical adverse events related to each LIF technique are also addressed. PMID:27169496
Sardar, Zeeshan; Jarzem, Peter
Lumbar interbody fusion is a common procedure owing to the high prevalence of degenerative spinal disorders. During such procedures, carbon fiber-reinforced polymer (CFRP) cages are frequently utilized to fill the void created between adjacent vertebral bodies, to provide mechanical stability, and to carry graft material. Failure of such implants can lead to significant morbidity. We discuss the possible causes leading to the failure of a CFRP cage in a patient with rheumatoid arthritis. Review of a 49-year-old woman who underwent revision anterior lumbar interbody fusion 2 years after posterior instrumentation and transforaminal lumbar interbody fusion at L4-L5 and L5-S1. The patient developed pseudarthrosis at the two previously fused levels with failure of the posterior instrumentation. Revision surgery reveled failure with fragmentation of the CFRP cage at the L5-S1 level. CFRP implants can break if mechanical instability or nonunion occurs in the spinal segments, thus emphasizing the need for optimizing medical management and meticulous surgical technique in achieving stability.
Sardar, Zeeshan; Jarzem, Peter
Lumbar interbody fusion is a common procedure owing to the high prevalence of degenerative spinal disorders. During such procedures, carbon fiber–reinforced polymer (CFRP) cages are frequently utilized to fill the void created between adjacent vertebral bodies, to provide mechanical stability, and to carry graft material. Failure of such implants can lead to significant morbidity. We discuss the possible causes leading to the failure of a CFRP cage in a patient with rheumatoid arthritis. Review of a 49-year-old woman who underwent revision anterior lumbar interbody fusion 2 years after posterior instrumentation and transforaminal lumbar interbody fusion at L4–L5 and L5–S1. The patient developed pseudarthrosis at the two previously fused levels with failure of the posterior instrumentation. Revision surgery reveled failure with fragmentation of the CFRP cage at the L5–S1 level. CFRP implants can break if mechanical instability or nonunion occurs in the spinal segments, thus emphasizing the need for optimizing medical management and meticulous surgical technique in achieving stability. PMID:24436878
Guo, Song; Yan, Meijun; Han, Yingchao; Xia, Dongdong; Sun, Guixin; Li, Lijun; Tan, Jun
Background Transforaminal lumbar interbody fusion (TLIF) is an effective surgery for lumbar degenerative disease. However, this fusion technique requires resection of inferior facet joint to provide access for superior facet joint resection, which results in reduced lumbar spinal stability and unnecessary trauma. We have previously developed extraforaminal lumbar interbody fusion (ELIF) that can avoid back muscle injury with direct nerve root decompression. This study aims to show that ELIF enhances lumbar spinal stability in comparison to TLIF by comparing lumbar spinal stability of L4–L5 range of motion (ROM) on 12 cadaveric spine specimens after performing TLIF or ELIF. Methods 12 cadaveric spine specimens were randomly divided and treated in accordance with the different internal fixations, including ELIF with a unilateral pedicle screw (ELIF+UPS), TLIF with a unilateral pedicle screw (TLIF+UPS), TLIF with a bilateral pedicle screw (TLIF+BPS), ELIF with a unilateral pedicle screw and translaminar facet screw (ELIF+UPS+TLFS) and ELIF with a bilateral pedicle screw (ELIF+BPS). The treatment groups were exposed to a 400-N load and 6 N·m movement force to calculate the angular displacement of L4-L5 during anterior flexion, posterior extension, lateral flexion and rotation operation conditions. Results The ROM in ELIF+UPS group was smaller than that of TLIF+UPS group under all operating conditions, with the significant differences in left lateral flexion and right rotation by 36.15% and 25.97% respectively. The ROM in ELIF+UPS group was higher than that in TLIF+BPS group. The ROM in the ELIF+UPS+TLFS group was much smaller than that in the ELIF+UPS group, but was not significantly different than that in the TLIF+BPS group. Conclusions Despite that TLIF+BPS has great stability, which can be comparable by that of ELIF+UPS. Additionally, ELIF stability can be further improved by using translaminar facet screws without causing more tissue damage to patient. PMID
Epstein, Nancy E.
Background: In the lumbar spine, do more nerve root injuries occur utilizing minimally invasive surgery (MIS) techniques versus open lumbar procedures? To answer this question, we compared the frequency of nerve root injuries for multiple open versus MIS operations including diskectomy, laminectomy with/without fusion addressing degenerative disc disease, stenosis, and/or degenerative spondylolisthesis. Methods: Several of Desai et al. large Spine Patient Outcomes Research Trial studies showed the frequency for nerve root injury following an open diskectomy ranged from 0.13% to 0.25%, for open laminectomy/stenosis with/without fusion it was 0%, and for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion it was 2%. Results: Alternatively, one study compared the incidence of root injuries utilizing MIS transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) techniques; 7.8% of PLIF versus 2% of TLIF patients sustained root injuries. Furthermore, even higher frequencies of radiculitis and nerve root injuries occurred during anterior lumbar interbody fusions (ALIFs) versus extreme lateral interbody fusions (XLIFs). These high frequencies were far from acceptable; 15.8% following ALIF experienced postoperative radiculitis, while 23.8% undergoing XLIF sustained root/plexus deficits. Conclusions: This review indicates that MIS (TLIF/PLIF/ALIF/XLIF) lumbar surgery resulted in a higher incidence of root injuries, radiculitis, or plexopathy versus open lumbar surgical techniques. Furthermore, even a cursory look at the XLIF data demonstrated the greater danger posed to neural tissue by this newest addition to the MIS lumbar surgical armamentariu. The latter should prompt us as spine surgeons to question why the XLIF procedure is still being offered to our patients? PMID:26904372
Lee, Sandra; Vaidya, Rahul
Lumbar spinal fusion is advancing with minimally invasive techniques, bone graft alternatives, and new implants. This has resulted in significant reductions of operative time, duration of hospitalization, and higher success in fusion rates. However, costs have increased as many new technologies are expensive. This study was carried out to investigate the clinical outcomes and fusion rates of a low implant load construct of unilateral pedicle screws and a translaminar screw in transforaminal lumbar interbody fusion (TLIF) which reduced the cost of the posterior implants by almost 50%. Nineteen consecutive patients who underwent single level TLIF with this construct were included in the study. Sixteen patients had a TLIF allograft interbody spacer placed, while in three a polyetheretherketone (PEEK) cage was used. Follow-up ranged from 15 to 54 months with a mean of 32 months. A clinical and radiographic evaluation was carried out preoperatively and at multiple time points following surgery. An overall improvement in Oswestry scores and visual analogue scales for leg and back pain (VAS) was observed. Three patients underwent revision surgery due to recurrence of back pain. All patients showed radiographic evidence of fusion from 9 to 26 months (mean 19) following surgery. This study suggests that unilateral pedicle screws and a contralateral translaminar screw are a cheaper and viable option for single level lumbar fusion. PMID:19015896
Background Lumbar interbody fusion has become a well established method to diminish axial back pain as well as radiculopathy in patients with degenerative disc disease, stenosis, and instability. The concept of indirect decompression of the neural foramen and spinal canal while performing fusion became popular in the mid 1990’s with description of ALIF techniques. Morphometric analysis confirmed the extent of decompression of posterior elements with interbody height restoration. In an attempt to diminish potential complications associated with anterior or posterior approaches to the spine for interbody fusion, and with the hope of accomplishing fusion in a less invasive manner, lateral lumbar interbody fusion has become quite popular. This transpsoas approach to the disc space has been associated with a high incidence of neurologic complications. Even though this is the first technique to routinely recommend EMG monitoring to increase safety in the approach, neurologic injuries still occur. A newer oblique lateral lumbar interbody (OLLIF) approach has recently been described to lessen the incidence of neurologic injury. This technique also advocates use of EMG testing to lessen neurologic trauma. In spite of this precaution, neurologic insult has not been eliminated. In fact, even in patients whose electrical stimulation thresholds suggested a safe entry space into the disc, transient dysaesthesia continues to occur in 20-25 percent of cases. Purpose This pilot study reflects data and observations of a subset of patients treated with endoscopic foraminotomy preceding oblique lateral lumbar interbody fusion (OLLIF) to assess specifically potential improvements in dysaesthesia rates. Methods A select subset of patients undergoing OLLIF failed to meet electrodiagnostic criteria for safe disc access through Kambin’s triangle. These patients underwent an endoscopic foraminotomy and exiting nerve decompression prior to discectomy, endplate preparation and cage
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
Study Design Retrospective case series. Purpose 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. Overview of Literature 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. Methods 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. Results 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 mm2 and 78 mm2, respectively. The average CSA of the ligamentum flavum at L4–5 (30 mm2) (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. Conclusions 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. PMID:28243378
Ni, Jianqiang; Fang, Xiutong; Zhong, Weiye; Liu, Ning; Wood, Kirkham B.
5–S1 group (12.5%). A venous tear occurred during surgery and was successfully repaired in 6 of the 84 patients. Also, out of the 84 patients, 6 were found with pseudarthrosis during the follow-up, and these patients underwent a spinal fusion with instrumentation, with a posterior approach after a mean of 1 year. The complications secondary to the surgical approach were persistent abdominal pain (1/84, 1.2%) and wound dehiscence (1/84, 1.2%). Anterior lumbar interbody fusion for L4–L5 had better clinical results than the 2-segmental L4–L5/L5–S1 disc fusion, and the 2-segmental L4–L5/L5–S1 disc fusion had better clinical results than the L5–S1 disc fusion. Also, the 2-segmental L4–L5/L5–S1 disc fusion had a higher complication rate (27.3%), but there was no difference between the L4–L5 group (9.1%) and the L5–S1 group (12.5%). PMID:26512594
Reis, Marco T; Reyes, Phillip M; Bse; Altun, Idris; Newcomb, Anna G U S; Singh, Vaneet; Chang, Steve W; Kelly, Brian P; Crawford, Neil R
OBJECTIVE Lateral lumbar interbody fusion (LLIF) has emerged as a popular method for lumbar fusion. In this study the authors aimed to quantify the biomechanical stability of an interbody implant inserted using the LLIF approach with and without various supplemental fixation methods, including an interspinous plate (IP). METHODS Seven human cadaveric L2-5 specimens were tested intact and in 6 instrumented conditions. The interbody implant was intended to be used with supplemental fixation. In this study, however, the interbody was also tested without supplemental fixation for a relative comparison of these conditions. The instrumented conditions were as follows: 1) interbody implant without supplemental fixation (LLIF construct); and interbody implant with supplemental fixation performed using 2) unilateral pedicle screws (UPS) and rod (LLIF + UPS construct); 3) bilateral pedicle screws (BPS) and rods (LLIF + BPS construct); 4) lateral screws and lateral plate (LP) (LLIF + LP construct); 5) interbody LP and IP (LLIF + LP + IP construct); and 6) IP (LLIF + IP construct). Nondestructive, nonconstraining torque (7.5 Nm maximum) induced flexion, extension, lateral bending, and axial rotation, whereas 3D specimen range of motion (ROM) was determined optoelectronically. RESULTS The LLIF construct reduced ROM by 67% in flexion, 52% in extension, 51% in lateral bending, and 44% in axial rotation relative to intact specimens (p < 0.001). Adding BPS to the LLIF construct caused ROM to decrease by 91% in flexion, 82% in extension and lateral bending, and 74% in axial rotation compared with intact specimens (p < 0.001), providing the greatest stability among the constructs. Adding UPS to the LLIF construct imparted approximately one-half the stability provided by LLIF + BPS constructs, demonstrating significantly smaller ROM than the LLIF construct in all directions (flexion, p = 0.037; extension, p < 0.001; lateral bending, p = 0.012) except axial rotation (p = 0
Alimi, Marjan; Shin, Benjamin; Macielak, Michael; Hofstetter, Christoph P.; Njoku, Innocent; Tsiouris, Apostolos J.; Elowitz, Eric; Härtl, Roger
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
Bergen, Sophea R.; Staples, Miranda; Liang, Kevin; Raiszadeh, Ramin
Background Anterior lumbar interbody fusion (ALIF) is utilized in symptomatic spinal disc destabilization due to degenerative lumbar disc disease, isthmic and degenerative spondylolisthesis, internal disc disruption, or pseudarthrosis after non-operative treatments fail. The addition of a plasma-sprayed titanium coating (PTC) to polyether ether ketone spacers (PEEK) may reduce the rate of implant subsidence or non-union secondary to poor osseous-integration of non-coated PEEK or metal interbody systems. Methods A retrospective, non-randomized, single-center chart review, evaluated the post-surgical follow-up data of patients receiving a PTC PEEK implant during single or multi-level ALIF procedures to determine the clinical efficacy and rate of arthrodesis after utilization of a coated spacer. Standard roentgenographs or computed tomography were used to identify successful arthrodesis following the ALIF procedure and longitudinal clinical improvements were determined by scores on the Visual Analog Scale (VAS) for low back and leg pain. Results Forty-four subjects (48% male, mean=53 years) were included in this chart review. Follow-up radiology demonstrated radiographic union with bridging bone formation across the interbody space for 42/44 (96%) individuals with solid arthrodesis occurring at an average of 7.3 ± 2.3 months. Subjects demonstrated significant improvement in VAS low back pain (4.5 ± 2.4 point improvement, p=0.0001) and VAS leg pain (4.1 ± 3.3 point improvement, p=0.0001). While there was a significant reduction in the improvement of VAS low back pain of Worker's Compensation claimants as compared to other patients (3.9 ± 2.4 vs. 5.3 ± 2.1), there was no difference in VAS low back pain or leg pain when the data was stratified by gender, age, tobacco use, comorbidities, prior surgery, fusion construct length, use of supplemental posterior instrumentation, BMI, or diagnosis. Conclusions This study provides support that the addition of a PTC coating
Eissa, Ehab M.; Elmorsy, Haitham M.
Objective Mini-transforaminal lumbar interbody fusion (Mini-TLIF) and other minimally invasive approaches introduced for the purpose of treating lumbar degenerative disc disease and instability are achieving high success and safety rates as the conventional approaches. Moreover, it has less soft tissue damage, minimal blood loss, and less hospital stay. Methods A prospective study was conducted from 2012 to 2014 on 28 patients who were subjected to Mini-open TLIF combined with transpedicular screw fixation for spondylolisthesis and degenerative disc disease. Two paramedian approaches were done, 4 cm for each, to insert the pedicular screws, along with inserting unilateral TLIF cage with autologous bone graft. Decompression was done either unilateral or bilateral according to the patient side of radiculopathy. Sixteen patients (57.2%) were diagnosed with degenerative spondylolisthesis, 7 patients (25%) were diagnosed with isthmic type spondylolisthesis, and 5 patients (17.8%) were diagnosed with degenerative disc disease, 2 of them(7.1%) had previous operations at the same level. Twenty patients (71.4%) were operated at the L4/5 level, and 8 patients (28.6%) at the L5/S1 level. Results All patients were able to ambulate the next day of surgery. The mean estimated blood loss was 251.79mL. The average hospital stay was 4.14 days. The average follow-up was 9 months. The mean visual analog scale was 1.86 at discharge, 1.68 after 3 months, and 1.38 after 6 months. After 6 months of the operation, MacNab's criteria were good in 23 patients and excellent in 5 patients. We had one case with transient weakness, 2 cases of screw malposition without clinical manifestations, and one case of infection. Conclusion Mini-TLIF approach is an efficient and safe approach for treating instability and degenerative diseases of the lumbar spine. The clinical outcome is encouraging and it may be an operation of choice for lumbar spinal fusion in selected patients. PMID:28127376
Study Design. Retrospective case series. Objective. To describe a modified technique for mini-open transforaminal lumbar interbody fusion (TLIF) that improves visualization for decompression, fusion, and freehand pedicle screw insertion. Accuracy of freehand pedicle screw placement with this technique was assessed. Summary of Background Data. Mini-open TLIF is a minimally invasive technique that allows limited visualization of the bone and neural anatomy via an expandable tubular retractor inserted through the Wiltse plane. No significant modification that of this technique has been described in detail. Methods. In this study, 92 consecutive patients underwent one-level modified mini-open TLIF (MOTLIF). MOTLIF modifications consisted of (i) transmuscular dissection through the multifidus muscle rather than intermuscular dissection in the Wiltse plane; (ii) microsurgical detachment of multifidus from the facet rather than muscle dilation; (iii) en bloc total facetectomy (unilateral or bilateral, as needed for decompression); (iv) facet autograft used for interbody fusion; and (v) solid pedicle screws placed bilaterally by a freehand technique under direct vision. Results. The mean age was 53 years. Mean follow-up was 35 months (minimum 2 yrs). By 6 months, mean Visual Analog Scale for back and leg pain had improved from 51 to 19 and from 58 to 17, respectively, and mean Oswestry Disability Index (ODI) improved from 53 to 16. These improvements persisted at 2 years. Solid fusion, defined by computed tomography at 1 year, was achieved in 88.1%, whereas satisfactory fusion was achieved in 95.2% of patients. Pedicle screws were accurately placed in 335 of 336 imaged pedicles (pedicle breach grades: 91.1% grade 1; 8.6% grade 2; and 0.3% grade 3). Mean fluoroscopy time was 29.3 seconds. Conclusion. MOTLIF is a safe and effective minimally invasive technique with a high fusion rate. It allows accurate pedicle screw placement by a freehand technique. By eliminating bi
Strom, Russell G; Bae, Junseok; Mizutani, Jun; Valone, Frank; Ames, Christopher P; Deviren, Vedat
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
Background context: Lower back pain is one of the most prevalent and expensive health conditions in the Western world. The standard treatment, interbody fusion, is an invasive procedure that requires the stripping of muscles and soft tissue, leading to surgical morbidity. Current minimally invasive (MI) spinal fusions are technically demanding and suffer from technical limitations. Purpose: Oblique lumbar lateral interbody fusion (OLLIF) is a new technique for fusion of the lumbar spine that overcomes these complications. Outcome measures include patient demographics, reported outcomes, and surgical outcomes. Study design/Setting: Kambin's Triangle can easily be located as a silent window with an electrophysiological probe. Discectomy is performed through a single access portal with a 10 mm diameter. After a discectomy, the disc space is packed with beta-tricalcium phosphate soaked in autologous bone marrow, aspirated, and the cage is inserted. Finally, a minimally invasive posterior fixation is performed. Methods: OLLIF’s major innovation is to approach the disc through Kambin’s Triangle, aided by bilateral fluoroscopy. Results: We present data from 69 consecutive OLLIF surgeries on 128 levels with a control group of 55 consecutive open transformational lumbar interbody fusions (TLIFs) on 125 levels. For a single level OLLIF, the mean surgery time is 69 minutes (min) and blood loss is 29 ml. Surgery time was approximately twice as fast as open TLIF (mean: 135 min) and blood loss is reduced by over 80% compared to TLIF (mean: 355 ml). Conclusions: OLLIF is a minimally invasive fusion that significantly reduces surgery times compared to open surgery. OLLIF overcomes the difficulties of traditional open fusions, making it a safe and technically less demanding surgery than open or minimally invasive TLIF. PMID:26623206
Lindley, Timothy E; Viljoen, Stephanus V; Dahdaleh, Nader S
Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is commonly used for the treatment of a variety of degenerative spine disorders. Recently, steerable interbody cages have been developed which potentially allow for greater restoration of lumbar lordosis. Here we describe a technique and radiographic results following minimally invasive placement of steerable cages through a bilateral approach. A retrospective review was conducted of the charts and radiographs of 15 consecutive patients who underwent 19 levels of bilateral MIS-TLIF with the placement of steerable cages. These were compared to 10 patients who underwent 16 levels of unilateral MIS-TLIF with the placement of bullet cages. The average age, body mass index, distribution of the levels operated and follow-up were similar in both groups. The average height of the steerable cage placed was 10.9 mm compared to 8.5mm for bullet cages. The preoperative focal Cobb's angle per level was similar between both groups with a mean of -5.3 degrees for the steerable cage group and -4.8 degrees for the bullet cage group. There was a significant improvement in postoperative Cobb's angle after placement of a steerable cage with a mean of -13.7 (p<0.01) and this persisted at the last follow-up with -13 degrees (p<0.01). There was no significant change in Cobb's angle after bullet cage placement with -5.7 degrees postoperatively and a return to the baseline preoperative Cobb's angle of -4.8 at the last follow-up. Steerable cage placement for MIS-TLIF improves focal lordosis compared to bullet cage placement.
Xie, Lei; Wu, Wen-Jian; Liang, Yu
Background: 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. Methods: 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 (RRs) and weighted mean differences (WMDs) with 95% confidence intervals were calculated for the clinical outcomes and perioperative data. Results: 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). Conclusions: 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
Kepler, Christopher K; Bogner, Eric A; Herzog, Richard J; Huang, Russel C
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.
Yoshimoto, Hisashi; Sato, Shigenobu; Nakagawa, Izumi; Hyakumachi, Takahiko; Yanagibashi, Yasushi; Nitta, Fumihito; Masuda, Takeshi
The authors report the case of an 83-year-old woman with refractory sciatica attributable to isthmic spondylolisthesis at L-5. Her symptoms were successfully improved after posterior lumbar interbody fusion (PLIF) at L5-S1; however, notable swelling in her left leg suddenly developed 2 days postoperatively. Anterior migration of a fragment of bone graft was demonstrated on computed tomography scanning, and there was obvious occlusion of the left common iliac vein (CIV) on magnetic resonance venography. Ultrasonography revealed a thrombus in the left CIV at the site of compression. To prevent a pulmonary embolism during manipulation of the affected vein, an inferior vena cava filter was placed just before excision of the migrated bone fragment. The swelling in the patient's leg subsided quickly after the surgery, and she was treated with heparin and warfarin to prevent recurrent deep vein thrombosis (DVT). Six months after the second surgery, complete restoration of blood flow to the left CIV and no recurrence of DVT were demonstrated on magnetic resonance venography. Especially in elderly patients with degenerative disc disease, excessive curettage and impaction of disc materials during the PLIF procedure may cause migration of bone graft fragments. Surgeons should be aware of the possible vascular complications of PLIF.
The incidence of lumbar fusion for the treatment of various degenerative lumbar spine diseases has increased dramatically over the last twenty years. Many lumbar fusion techniques have been developed and popularized, each with its own advantages and disadvantages. Anterior lumbar interbody fusion (ALIF) initially introduced in the 1930’s, has become a common and widely accepted technique for lumbar fusions over the last decade offering several advantages over standard posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF). More recently, the lateral trans-psoas approach termed extreme, direct or lateral lumbar interbody fusion (XLIF, DLIF, LLIF) is gaining widespread popularity. The aim of this paper is to compare the approaches, advantages and disadvantages of ALIF and XLIF for L4/5 interbody fusion based on relevant literature. PMID:27683688
Epstein, Nancy E.
Background: Complications exclusive of new neurological deficits/injuries that follow extreme lateral interbody fusion (XLIF) and related lateral lumbar interbody techniques should be better recognized to determine the safety of these procedures. Unfortunately, a review of the XLIF literature did not accurately reflect the frequency of these “other complications” as few US surgeons publish such adverse events that may lead to medicolegal suits. Methods: Major complications occurring with XLIF included sympathectomy, major vascular injuries, bowel perforations, sterile seromas, and instrumentation failures. Results: The frequency of sympathectomy was 4% for XLIF vs. 15% for anterior lumbar interbody fusion (ALIF). There were three major vascular injuries for XLIF; one fatal intraoperative event, one life-threatening retroperitoneal hematoma, and one iatrogenic lumbar artery pseudoaneurysm that was successfully embolized. Two bowel perforations were reported, whereas a third was a “direct communication.” One patient developed a sterile recurrent seroma due to vancomycin powder utilized for an XLIF. One study cited malpositioning of an XLIF cage resulting in a lateral L3–L4 extrusion, whereas the second series looked at the 45% risk of cage-overhang when XLIF devices were placed in the anterior one-third of the vertebral body. Conclusion: Excluding new neurological deficits, XLIF techniques resulted in multiple other major complications. However, these small numbers likely reflect just the tip of the iceberg (e.g., 10%) and the remaining 90% may never be known as many US-based spine surgeons fail to publish such adverse events as they are discoverable in a court of law and may lead to medicolegal suits. PMID:27843680
Joseph, Jacob R; Smith, Brandon W; La Marca, Frank; Park, Paul
OBJECT Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and lateral lumbar interbody fusion (LLIF) are 2 currently popular techniques for lumbar arthrodesis. The authors compare the total risk of each procedure, along with other important complication outcomes. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies (up to May 2015) that reported complications of either MI-TLIF or LLIF were identified from a search in the PubMed database. The primary outcome was overall risk of complication per patient. Secondary outcomes included risks of sensory deficits, temporary neurological deficit, permanent neurological deficit, intraoperative complications, medical complications, wound complications, hardware failure, subsidence, and reoperation. RESULTS Fifty-four studies were included for analysis of MI-TLIF, and 42 studies were included for analysis of LLIF. Overall, there were 9714 patients (5454 in the MI-TLIF group and 4260 in the LLIF group) with 13,230 levels fused (6040 in the MI-TLIF group and 7190 in the LLIF group). A total of 1045 complications in the MI-TLIF group and 1339 complications in the LLIF group were reported. The total complication rate per patient was 19.2% in the MI-TLIF group and 31.4% in the LLIF group (p < 0.0001). The rate of sensory deficits and temporary neurological deficits, and permanent neurological deficits was 20.16%, 2.22%, and 1.01% for MI-TLIF versus 27.08%, 9.40%, and 2.46% for LLIF, respectively (p < 0.0001, p < 0.0001, p = 0.002, respectively). Rates of intraoperative and wound complications were 3.57% and 1.63% for MI-TLIF compared with 1.93% and 0.80% for LLIF, respectively (p = 0.0003 and p = 0.034, respectively). No significant differences were noted for medical complications or reoperation. CONCLUSIONS While there was a higher overall complication rate with LLIF, MI-TLIF and LLIF both have
Sherman, Blake P.; Lindley, Emily M.; Turner, A. Simon; Seim III, Howard B.; Benedict, James; Burger, Evalina L.
A prospective, randomized study was performed in an ovine model to compare the efficacy of an anorganic bovine-derived hydroxyapatite matrix combined with a synthetic 15 amino acid residue (ABM/P-15) in facilitating lumbar interbody fusion when compared with autogenous bone harvested from the iliac crest. P-15 is a biomimetic to the cell-binding site of Type-I collagen for bone-forming cells. When combined with ABM, it creates the necessary scaffold to initiate cell invasion, binding, and subsequent osteogenesis. In this study, six adult ewes underwent anterior-lateral interbody fusion at L3/L4 and L4/L5 using PEEK interbody rings filled with autogenous bone at one level and ABM/P-15 at the other level and no additional instrumentation. Clinical CT scans were obtained at 3 and 6 months; micro-CT scans and histomorphometry analyses were performed after euthanization at 6 months. Clinical CT scan analysis showed that all autograft and ABM/P-15 treated levels had radiographically fused outside of the rings at the 3-month study time point. Although the clinical CT scans of the autograft treatment group showed significantly better fusion within the PEEK rings than ABM/P-15 at 3 months, micro-CT scans, clinical CT scans, and histomorphometric analyses showed there were no statistical differences between the two treatment groups at 6 months. Thus, ABM/P-15 was as successful as autogenous bone graft in producing lumbar spinal fusion in an ovine model, and it should be further evaluated in clinical studies. PMID:20694847
Sherman, Blake P; Lindley, Emily M; Turner, A Simon; Seim, Howard B; Benedict, James; Burger, Evalina L; Patel, Vikas V
A prospective, randomized study was performed in an ovine model to compare the efficacy of an anorganic bovine-derived hydroxyapatite matrix combined with a synthetic 15 amino acid residue (ABM/P-15) in facilitating lumbar interbody fusion when compared with autogenous bone harvested from the iliac crest. P-15 is a biomimetic to the cell-binding site of Type-I collagen for bone-forming cells. When combined with ABM, it creates the necessary scaffold to initiate cell invasion, binding, and subsequent osteogenesis. In this study, six adult ewes underwent anterior-lateral interbody fusion at L3/L4 and L4/L5 using PEEK interbody rings filled with autogenous bone at one level and ABM/P-15 at the other level and no additional instrumentation. Clinical CT scans were obtained at 3 and 6 months; micro-CT scans and histomorphometry analyses were performed after euthanization at 6 months. Clinical CT scan analysis showed that all autograft and ABM/P-15 treated levels had radiographically fused outside of the rings at the 3-month study time point. Although the clinical CT scans of the autograft treatment group showed significantly better fusion within the PEEK rings than ABM/P-15 at 3 months, micro-CT scans, clinical CT scans, and histomorphometric analyses showed there were no statistical differences between the two treatment groups at 6 months. Thus, ABM/P-15 was as successful as autogenous bone graft in producing lumbar spinal fusion in an ovine model, and it should be further evaluated in clinical studies.
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.
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
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
Sedra, Fady; Lee, Robert; Dominguez, Ignacio; Wilson, Lester
We describe our experience using the RAVINE retractor (K2M, Leesburg, VA, USA) to gain access to the lateral aspect of the lumbar spine through a retroperitoneal approach. Postoperative neurological adverse events, utilising the mentioned retractor system, were recorded and analysed. We included 140 patients who underwent minimally invasive lateral lumbar interbody fusion (MI-LLIF) for degenerative spinal conditions between 2011 and 2015 at two major spinal centres. A total of 228 levels were treated, 35% one level, 40% two level, 20% three level and 5% 4 level surgeries. The L4/5 level was instrumented in 28% of cases. 12/140 patients had postoperative neurological complications. Immediately after surgery, 5% of patients (7/140) had transient symptoms in the thigh ranging from sensory loss, pain and paraesthesia, all of which recovered within 12weeks following surgery. There were five cases of femoral nerve palsy (3.6% - two ipsilateral and three contralateral), all of which recovered completely with no residual sensory or motor deficit within 6months. MI-LLIF done with help of the described retractor system has proved a safe and efficient way to achieve interbody fusion with minimal complications, mainly nerve related, that recovered quickly. Judicious use of the technique to access the L4/5 level is advised.
Chatterjee, Atanu; McConnell, Jeffrey R.; Jha, Deepak K.; Chakraburtty, Tapas
Study Design Prospective nonrandomized study. Purpose To find a possible correlation between clinical outcome and extent of lumbar spondylolisthesis reduction. Overview of Literature There is no consensus in the literature concerning whether a beneficial effect of reduction on outcome can be expected following reduction and surgical fusion for low grade lumbar spondylolisthesis. Methods Forty six patients with a mean age of 37.5 years (age, 17–48 years) with isthmic spondylolisthesis underwent interbody fusion with cages with posterior instrumentation (TLIF). Clinical outcome was measured using visual analogue score (VAS) and Oswestry disability index (ODI). Foraminal dimensions and disc heights were measured in standard digital radiographs. These were analyzed at baseline and 1 year after surgery and changes were compared. Radiographic fusion was judged with computed tomography scans at 1 year. Results Ninety percent of the patients had good or very good clinical results with fusion and instrumentation. Baseline and one-year postoperative mean VAS score was 6.33 (range, 5–8) and 0.76 (range, 0–3), respectively (p=0.004). Baseline and one-year postoperative, mean ODI score was 48 (range, 32–62) and 10 (range, 6–16), respectively (p<0.001). A mean spondylolisthesis slip of 32.1% was reduced to 6.7% at 1 year. Average anterior disc height, posterior disc height, vertical foraminal dimension), and foraminal) diameter improved from 9.8 to 11.7 mm (p=0.005), 4.5 to 5.8 mm (p=0.004), 11.3 to 12.6 mm (p=0.002), and 18.6 to 20.0 mm (p<0.001), respectively. The fusion rate was 75% with TLIF. There is no significant correlation between the improvements of ODI scores and the extent of slip reduction. Conclusions Neural decompression and interbody fusion can significantly improve pain and disability but the clinical outcome does not correlate with radiological improvement in the neural foraminal dimension. PMID:27114773
Tang, Ming-xing; Zhang, Hong-qi; Wang, Yu-xiang; Guo, Chao-feng; Liu, Jin-yang
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
Shi, Houyin; Ou, Yunsheng; Jiang, Dianming; Quan, Zhengxue; Zhao, Zenghui; Zhu, Yong
Abstract Background: A prospective, randomized, double-blind, placebo-controlled study was performed. The routine usage of TA in spinal surgery is controversial. Only a few studies have focused on patients undergoing posterior lumbar surgery for stenosis or spondylolisthesis, although a large clinical cohort exists in the population. This study aimed to evaluate the effect and safety of TA in reducing perioperative blood loss in posterior lumbar surgery for stenosis or spondylolisthesis. Methods: 100 eligible patients out of 126 were randomized to receive either a bolus dose of 30 mg/kg TA i.v, a maintenance dosage of 2 mg/kg/h TA, or an equivalent volume of normal saline. The pedicle screw system was used for fixing in all the patients, followed by decompression and posterior lumbar interbody fusion. The primary outcomes were intraoperative estimated blood loss and total blood loss. The secondary outcomes were receiving packed red blood cells and postoperative hemoglobin and hematocrit levels. Results: In total, 4 patients were excluded from the analyses, 50 patients were in the TA group, and 46 in the placebo group. The demographic and baseline data between the groups were not statistically different. The intraoperative estimated blood loss and the total blood loss were 33% and 41% lower in the TA group than the placebo group, respectively. The blood transfusion rate did not vary significantly (P = 0.191). Except a patient with a dural tear in the placebo group, no other complications were observed. Conclusion: TA significantly reduced the perioperative blood loss in patients undergoing posterior lumbar surgery for stenosis or spondylolisthesis. PMID:28072709
Liu, Fubing; Jiang, Chun
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
Lian, Xiaofeng; Berlin, Connor; Moriguchi, Yu; Zhang, Qiwei; Härtl, Roger
Introduction. A new generation of iCT scanner, Airo®, has been introduced. The purpose of this study is to describe how Airo facilitates minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Method. We used the latest generation of portable iCT in all cases without the assistance of K-wires. We recorded the operation time, number of scans, and pedicle screw accuracy. Results. From January 2015 to December 2015, 33 consecutive patients consisting of 17 men and 16 women underwent single-level or two-level MIS-TLIF operations in our institution. The ages ranged from 23 years to 86 years (mean, 66.6 years). We treated all the cases in MIS fashion. In four cases, a tubular laminectomy at L1/2 was performed at the same time. The average operation time was 192.8 minutes and average time of placement per screw was 2.6 minutes. No additional fluoroscopy was used. Our screw accuracy rate was 98.6%. No complications were encountered. Conclusions. Airo iCT MIS-TLIF can be used for initial planning of the skin incision, precise screw, and cage placement, without the need for fluoroscopy. “Total navigation” (complete intraoperative 3D navigation without fluoroscopy) can be achieved by combining Airo navigation with navigated guide tubes for screw placement. PMID:27529069
Domínguez, I; Luque, R; Noriega, M; Rey, J; Alia, J; Marco-Martínez, F
«Minimally invasive» techniques have been recently been developed in order to achieve good clinical results with a low incidence of complications. The extralateral interbody fusion or direct transpsoas is a minimally invasive anterior arthrodesis. A total of 97 patients with 138 segments received surgery between May 2012 and May 2015. The follow-up was from 12-44 months. The mean age was 68 years (41-86). The most common cause of intervention was the adjacent segment (30%), deformity (22%), and lumbar disc disease (21%). The interbody cage was implanted as: Single (stand-alone) in 33%, and additional fixation was used in the others: Screws, percutaneous unilateral (11%), bilateral (27%), or with a lateral plate (62%). The mean stay was 3.2 days (2-6). The score on a lumbar visual analogue scale decreased from 9 to 4.1, and dropped to 3 after one year. The improvement in disc height was from 8.4mm to 13.8mm, and a larger increase in the foramen diameter from 10.5 to 13.1mm, which were statistically significant. The early major complications recorded were, three motor femoral nerve injuries and retroperitoneal haematoma (4%), and the early minor were: two fractures (2%). As major late complications there was an abdominal hernia, a mobilization of 10mm and three radiculopathy (5%), and as minor late, three fracture, two mobilisations greater than 10mm, four mobilisations of less than 10mm, and one mobilisation of a screw plate (10%). The extralateral interbody fusion technique is a safe and reliable when performing a lumbar fusion by an alternative minimally invasive route.
Hironaka, Yasuo; Morimoto, Tetsuya; Motoyama, Yasushi; Park, Young-Su; Nakase, Hiroyuki
Surgical treatment for degenerative spinal disorders is controversial, although lumbar fusion is considered an acceptable option for disabling lower back pain. Patients underwent instrumented minimally invasive anterior lumbar interbody fusion (mini-ALIF) using a retroperitoneal approach except for requiring multilevel fusions, severe spinal canal stenosis, high-grade spondylolisthesis, and a adjacent segments disorders. We retrospectively reviewed the clinical records and radiographs of 142 patients who received mini-ALIF for L4-5 degenerative lumbar disorders between 1998 and 2010. We compared preoperative and postoperative clinical data and radiographic measurements, including the modified Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score for back and leg pain, disc height (DH), whole lumbar lordosis (WL), and vertebral wedge angle (WA). The mean follow-up period was 76 months. The solid fusion rate was 90.1% (128/142 patients). The average length of hospital stay was 6.9 days (range, 3–21 days). The mean blood loss was 63.7 ml (range, 10–456 ml). The mean operation time was 155.5 min (range, 96–280 min). The postoperative JOA and VAS scores for back and leg pain were improved compared with the preoperative scores. Radiological analysis showed significant postoperative improvements in DH, WL, and WA, and the functional and radiographical outcomes improved significantly after 2 years. The 2.8% complication rate included cases of wound infection, liquorrhea, vertebral body fractures, and a misplaced cage that required revision. Mini-ALIF was found to be associated with improved clinical results and radiographic findings for L4-5 disorders. A retroperitoneal approach might therefore be a valuable treatment option. PMID:24140782
Wang, Yu; Sun, Hong; Qin, Shuzhen
The clinical efficacy of minimally invasive lumbar interbody fusion via the intervertebral foramen combined with ozone (O3) therapy for the treatment of L3-L4 central-type lumbar disc herniation was explored. We recruited patients with sciatica who attended our hospital between July 2013 and October 2015 and underwent lumbar X-ray (anteroposterior and lateral view), lumbar flexion-extension radiographs, computed tomography, and magnetic resonance imaging after admission. Seventy-four patients with central-type lumbar disc herniation but no other complications were randomly selected and divided into the observation and control groups. The observation group comprised 37 patients treated with lumbar fusion using a channel system combined with O3 therapy, whereas the control group comprised 37 patients treated with lumbar fusion alone. The effects of the two therapies were evaluated using visual analog scale, Japanese Orthopaedic Association, and MacNab scores. There was no significant difference in scores between the two groups before surgery (P>0.05). The scores of the observation group after treatment were significantly lower than those before surgery and those of the control group (P<0.05). One patient in the observation group experienced no obvious improvement in symptoms after surgery, and two patients in the control group experienced postoperative recurrence; these three patients subsequently underwent laminectomy combined with planted bone fusion and internal fixation. There was no significant difference in total efficacy rates between the two groups (P>0.05). Lumbar fusion using a channel system combined with O3 therapy for the treatment of L3-L4 central-type lumbar disc herniation is safe and effective. It has the advantages of reduced trauma, fewer complications, and rapid pain relief, and it promotes the recovery of lumbar function. Strict mastery of the surgical indications is key to the success of the procedure; however, it is worth expanding its use in
Cho, Kyung Rae; Lee, Sun-Ho; Kim, Eun Sang
Objective We sought to determine minimum 4 years of clinical outcomes including fusion rate, revision rate and complications of patients who underwent placement of rectangular stand-alone cages. Methods Thirty-three cases of degenerative spine that had been followed for at least 4-years were reviewed retrospectively. Cages were inserted at L4-L5 level or L5-S1 in 27 or in 6 cases respectively. Visual analogue scale (VAS), Odom's criteria, fusion rate, intervertebral disc height and lumbar lordosis were determined pre- and post-operatively on standing x-rays. Amount of intra- and postoperative blood loss, total volume transfused, duration of surgery and perioperative complications were also evaluated. Results The mean VAS score of back pain and sciatica were improved from 8.0 and 7.0 points to 3.4 and 2.4 during 1 years follow-up visit and the scores was raised gradually. Also, during the follow-up, 94% of patients showed excellent or good outcomes by the Odom's criteria. Intervertebral disc height was increased from 8.2±1.4mm to 9.2±1.9mm at the first year of follow-up, however, found to be decreased and stabilized to 8.3±1.8mm after 2 years. The fusion rate was approximately 91% after 4 year postoperative. The segmental angle of lordosis was increased significantly by two years but it was not maintained after four years. A statistically insignificant change in total lumbar lordosis was also observed. Three patients (9%) had experienced perioperative complications. Conclusion The use of rectangular stand-alone cages for posterior lumbar interbody fusion (PLIF) resulted in a various degree of subsidence and demonstrate very low complication rate, high functional stability and improved clinical outcomes in patients with degenerative lumbar disc disease. PMID:24757473
Pooswamy, Shanmugasundaram; Muralidharagopalan, Niranjanan Raghavn; Subbaiah, Sivasubramaniam
Background: Spondylolisthesis refers to slippage of one vertebra over the other, which may be caused by a variety of reasons such as degenerative, trauma, and isthmic. Surgical management forms the mainstay of treatment to prevent further slip and worsening. However, there is no consensus regarding the best surgical option to treat these patients. This study compares TLIF and instrumented PLF in patients with Grade I and II spondylolisthesis and analysis the outcome with respect to functional outcome, pain, fusion rate, adequacy of medial facetectomy for decompression, and complications. Materials and Methods: Forty patients operated for spondylolisthesis by instrumented posterolateral or transforaminal fusion between January 1, 2010, and June 30, 2012 were included in this retrospective study. They were followed up for 3 years. Twenty one cases were of instrumented posterolateral fusion (PLF) and 19 cases were of transforaminal lumbar interbody fusion (TLIF). The patients were asked to fill up the Oswestry disability index (ODI), Dallas Pain Questionnaire (DPQ), and low back pain rating scale (LBPRS) preoperatively, at 1-month postoperatively, and at 6, 12, 24, and 36 months postoperatively. Radiological parameters were assessed using radiographs. Results: No significant differences were found in DPQ, LBPRS, or ODI scores preoperative, 1-month postoperative, and at 6, 12, 24 and 36 months followup. No significant difference was found between the two groups in blood loss. The only significant difference between the two groups was in the operative time, in which the instrumented PLF group had a mean of 50 min lesser than the TLIF group (P = 0.02). Conclusions: TLIF and instrumented PLF are equally efficacious options in the treatment of Grade I and II spondylolisthesis, except lytic type.
Lee, Jun Gue; Kim, Hyeun Sung
Objective The purpose of this study was to evaluate the clinical outcomes of minimally invasive extraforaminal lumbar interbody fusion (ELIF) for revision surgery. Methods From January 2011 to December 2012, 12 patients who underwent minimally invasive ELIF through the Kambin's triangle for revision surgery were included in this study. All patients underwent the surgical procedure in the following sequence: (1) epidural anesthesia, (2) exposing the Kambin's triangle toward the lateral part of the dura (partial resection of the superior articular process), (3) bilateral cage insertion for reinforcement of stabilization and fusion, and (4) percutaneous transpedicular screwing. Clinical outcomes were assessed using the visual analogue scale (VAS), and Oswestry disability index (ODI). Imaging and clinical findings including surgical techniques, clinical outcomes, and related complications were depicted and analyzed. Results The mean age of the patients (5 men, 7 women) was 60.7±13.4 years, and the mean follow-up period was 27.1±4.9 months. The mean VAS (back and leg) score improved significantly at final follow-up. The mean ODI score decreased as follows: preoperative, 76.78±6.08; 3 months after the surgery, 37.74±6.67; and at final follow-up, 29.91±2.98. Two patients presented with transient nerve root irritation, but there were no cases of incidental dural tear or serious infection. No significant neurological deterioration or major complication was noted in any of the patients. Conclusion Minimally invasive ELIF for revision surgery is an effective surgical option with a low complication rate. PMID:26834815
Hee, Hwan Tak
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
Kang, Heesuk; Hollister, Scott J; La Marca, Frank; Park, Paul; Lin, Chia-Ying
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.
Ahn, Junyoung; Tabaraee, Ehsan; Singh, Kern
Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has become a popular alternative to traditional methods of lumbar decompression and fusion. When compared with the open technique, the minimally invasive approach can result in decreased pain and blood loss as well as a shorter length of hospitalization. However, the narrower working channel through the tubular retractor increases the difficulty of decortication and bone grafting. Therefore, recombinant human bone morphogenetic proteins (rhBMP-2) is often utilized (although this is off-label) to create a more favorable interbody fusion environment. Recently, the use of rhBMP-2 has been associated with excessive bone growth in an MIS-TLIF. If this bone growth compresses the neighboring neural structures, patients may present with either new or recurrent radicular pain. Computed tomographic (CT) imaging can demonstrate heterotopic bone growth extending from the disk space into either the ipsilateral neuroforamen or lateral recess, which may result in the compression of the exiting or traversing root, respectively. The purpose of this article and the accompanying video is to demonstrate a technique for defining and resecting rhBMP-2-induced heterotopic bone growth following a previous MIS-TLIF.
Yang, Yang; Liu, Bin; Rong, Li-Min; Chen, Rui-Qiang; Dong, Jian-Wen; Xie, Pei-Gen; Zhang, Liang-Ming; Feng, Feng
Objective: To evaluate short-term and medium-term outcomes of microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF for lumbar degenerative disease. Methods: In this prospective, randomized control study, 50 cases received microendoscopy-assisted MIS-TLIF (MIS group), while another well-matched 50 cases accepted open TLIF (open group). Parameters between both groups, including surgical duration, intraoperative blood loss and radiologic exposure, postoperative analgesic usage and ambulatory time, visual analogue scale (VAS) for back and leg, functional scores, self-evaluation of surgical outcome (modified MacNab criteria), interbody fusion rate, adjacent segment degeneration (ASD) rate, as well as complication incidence were compared at 1 month and 24 months postoperatively. Results: Intraoperative blood loss and postoperative analgesic usage were significantly reduced in MIS group (P<0.05). Patients undergoing microendoscopy-assisted MIS-TLIF were able to ambulate earlier postoperatively than those receiving open TLIF (P<0.05). However, it showed prolonged surgical duration and enhanced radiologic exposure in MIS group (P<0.05). At 1 month postoperatively, MIS group was associated with more improvement of VAS and functional scores compared with open group (P<0.05). While at 24 months postoperatively, both groups revealed similar VAS and functional scores (P>0.05). Excellent and perfect scale rating by modified MacNab criteria, interbody fusion rate, ASD rate and complication incidence between both groups were nearly the same (P>0.05). Conclusions: Microendoscopy-assisted MIS-TLIF owns advantages of less iatrogenic injury, decreased blood loss, reduced analgesic usage and earlier rehabilitation, while it has drawbacks of more surgical duration and radiologic exposure. It is superior than open TLIF in terms of short-term clinical outcomes and has similar medium-term clinical outcomes. PMID:26885072
Kang, Moo Sung; Park, Jeong Yoon; Kim, Kyung Hyun; Kuh, Sung Uk; Chin, Dong Kyu; Kim, Keun Su; Cho, Yong Eun
Minimally invasive surgery with a transforaminal lumbar interbody fusion (MIS TLIF) is an important minimally invasive fusion technique for the lumbar spine. Lumbar spine reoperation is challenging and is thought to have greater complication risks. The purpose of this study was to compare MIS TLIF with unilateral screw fixation perioperative results between primary and revision surgeries. This was a prospective study that included 46 patients who underwent MIS TLIF with unilateral pedicle screw. The patients were divided into two groups, primary and revision MIS TLIF, to compare perioperative results and complications. The two groups were similar in age, sex, and level of operation, and were not significantly different in the length of follow-up or clinical results. Although dural tears were more common with the revision group (primary 1; revision 4), operation time, blood loss, total perioperative complication, and fusion rates were not significantly different between the two groups. Both groups showed substantial improvements in VAS and ODI scores one year after surgical treatment. Revision MIS TLIF performed by an experienced surgeon does not necessarily increase the risk of perioperative complication compared with primary surgery. MIS TLIF with unilateral pedicle screw fixation is a valuable option for revision lumbar surgery.
Kleiner, Jeffrey B; Kleiner, Hannah M; Grimberg, E John; Throlson, Stefanie J
Study design Disk material removed (DMR) during L4-5 and L5-S1 transforaminal lumbar interbody fusion (T-LIF) surgery was compared to the corresponding bone graft (BG) volumes inserted at the time of fusion. A novel BG delivery tool (BGDT) was used to apply the BG. In order to establish the percentage of DMR during T-LIF, it was compared to DMR during anterior diskectomy (AD). This study was performed prospectively. Summary of background data Minimal information is available as to the volume of DMR during a T-LIF procedure, and the relationship between DMR and BG delivered is unknown. BG insertion has been empiric and technically challenging. Since the volume of BG applied to the prepared disk space likely impacts the probability of arthrodesis, an investigation is justified. Methods A total of 65 patients with pathology at L4-5 and/or L5-S1 necessitating fusion were treated with a minimally invasive T-LIF procedure. DMR was volumetrically measured during disk space preparation. BG material consisting of local autograft, BG extender, and bone marrow aspirate were mixed to form a slurry. BG slurry was injected into the disk space using a novel BGDT and measured volumetrically. An additional 29 patients who were treated with L5-S1 AD were compared to L5-S1 T-LIF DMR to determine the percent of T-LIF DMR relative to AD. Results DMR volumes averaged 3.6±2.2 mL. This represented 34% of the disk space relative to AD. The amount of BG delivered to the disk spaces was 9.3±3.2 mL, which is 2.6±2.2 times the amount of DMR. The BGDT allowed uncomplicated filling of the disk space in <1 minute. Conclusion The volume of DMR during T-LIF allows for a predictable volume of BG delivery. The BGDT allowed complete filling of the entire prepared disk space. The T-LIF diskectomy debrides 34% of the disk relative to AD. PMID:27274320
Siddiqui, M Mashfiqul Arafin; Sta.Ana, Ana Rosario P.; Yeo, William
Study Design Comparison of prospectively collected data of patients undergoing minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) with and without recombinant human bone morphogenic protein 2 (BMP). Purpose To compare the clinical, radiological outcome and complications of patients undergoing MIS-TLIF with and without BMP. Overview of Literature BMP is an effective fusion enhancer with potential complications. Direct comparison of MIS-TLIF with and without BMP is limited to retrospective studies with short follow-up. Methods From June 2005 to February 2011, consecutive cases of MIS-TLIF performed by a single surgeon were included. North American Spine Society (NASS) score, Oswestry disability index (ODI), Short Form-36 (SF-36), and visual analogue score (VAS) were assessed preoperatively and at 6 and 24 months postoperatively. Fusion rates and complications were noted. Results The 252 cases comprised 104 non-BMP and 148 BMP cases. The BMP group was significantly older (mean age, 60.2 vs. 53.9; p<0.01). Preoperative scores were similar. Immediate postoperative morphine usage was significantly lower in the BMP group (12.4 mg vs. 20.1 mg, p<0.01). At 6 months, the BMP group had lower VAS back and leg pain scores (p<0.01). At 2 years, the BMP group had better leg pain scores (p<0.01), ODI (15.4 vs. 20.3, p=0.04) and NASS scores (8.8 vs. 15.8, p<0.01). Both groups showed significant clinical improvement compared to their preoperative levels. The BMP group attained a significantly higher rate of fusion at 6 months follow-up (88.4% vs. 76.8%, p=0.016) with no difference at 2 years. The non-BMP and BMP group had 12 (11.5%) and 9 (6.1%) complications and 5 (4.8%) and 2 (1.4%) reoperations, respectively. Conclusions The use of BMP to augment fusion in MIS-TLIF is an acceptable alternative that has potential benefits of less pain in early and intermediate postoperative follow-up. PMID:27994786
Epstein, Nancy E.
Background: There are frequent reports of lumbosacral plexus and other neurological injuries occurring with extreme lateral interbody fusions (XLIF) and other related lateral lumbar techniques. Methods: This review focuses on the new neurological deficits (e.g. lumbosacral plexus, root injuries) that occur following minimally invasive surgery (MIS) XLIF and other related lateral lumbar techniques. Results: A review of multiple articles revealed the following ranges of new postoperative neurological complications for XLIF procedures: plexus injuries 13.28%; sensory deficits 0–75% (permanent in 62.5%); motor deficits 0.7–33.6%; anterior thigh pain 12.5–25%. Of interest, in a study by Lykissas et al., the frequency of long-term neural injury following lateral lumber interbody fusion (LLIF) with BMP-2 (72 patients) was much higher than for LLIF performed with autograft/allograft (72 patients). The addition of bone morphogenetic protein led to persistent sensory deficits in 29 vs. 20 without BMP; persistent motor deficits in 35 with vs. 17 without BMP; and persistent anterior thigh/groin pain in 8 with vs. 0 without BMP. They should also have noted the unacceptably high incidence of neural injury occurring with LLIF alone without BMP. Conclusion: This review highlights the high risk of neural injury (up to 75% for sensory, 33.6% for motor, and an overall plexus injury rate of 13.28%) utilizing the XLIF and other similar lateral lumbar approaches. With such extensive neurological injuries, is the XLIF really safe, and should it still be performed? PMID:27843679
Chatha, Gurkirat; Foo, Stacy W L; Lind, Christopher R P; Budgeon, Charley; Bannan, Paul E
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.
Kim, Bum-Joon; Kim, Se-Hoon; Lee, Haebin; Lee, Seung-Hwan; Kim, Won-Hyung; Jin, Sung-Won
Objective Solid bone fusion is an essential process in spinal stabilization surgery. Recently, as several minimally invasive spinal surgeries have developed, a need of artificial bone substitutes such as demineralized bone matrix (DBM), has arisen. We investigated the in vivo bone growth rate of DBM as a bone void filler compared to a local autologous bone grafts. Methods From April 2014 to August 2015, 20 patients with a one or two-level spinal stenosis were included. A posterior lumbar interbody fusion using two cages and pedicle screw fixation was performed for every patient, and each cage was packed with autologous local bone and DBM. Clinical outcomes were assessed using the Numeric Rating Scale (NRS) of leg pain and back pain and the Korean Oswestry Disability Index (K-ODI). Clinical outcome parameters and range of motion (ROM) of the operated level were collected preoperatively and at 3 months, 6 months, and 1 year postoperatively. Computed tomography was performed 1 year after fusion surgery and bone growth of the autologous bone grafts and DBM were analyzed by ImageJ software. Results Eighteen patients completed 1 year of follow-up, including 10 men and 8 women, and the mean age was 56.4 (32–71). The operated level ranged from L3/4 to L5/S1. Eleven patients had single level and 7 patients had two-level repairs. The mean back pain NRS improved from 4.61 to 2.78 (p=0.003) and the leg pain NRS improved from 6.89 to 2.39 (p<0.001). The mean K-ODI score also improved from 27.33 to 13.83 (p<0.001). The ROM decreased below 2.0 degrees at the 3-month assessment, and remained less than 2 degrees through the 1 year postoperative assessment. Every local autologous bone graft and DBM packed cage showed bone bridge formation. On the quantitative analysis of bone growth, the autologous bone grafts showed significantly higher bone growth compared to DBM on both coronal and sagittal images (p<0.001 and p=0.028, respectively). Osteoporotic patients showed less bone
Lee, Sang-Ho; Erken, H. Yener
Background. Spinal fusion has been shown to be the preferred surgical option to reduce pain, recover function, and increase quality of life in the treatment of a variety of lumbar spinal disorders. The main goal of the present study is to report our clinical experience and results of percutaneous transforaminal endoscopic lumbar interbody fusion (PELIF) applications using the expandable spacer in a single institution. Methods. We performed a retrospective review of 18 patients with >12-month follow-up who had been operated on PELIF using expandable spacer from 2001 to 2007. Their clinical and radiological data were collected and analyzed. Results. The mean follow-up period was 46 months. The mean DH before the surgery was 8.3 mm which improved to 11.4 mm at the early postoperative period and regressed to 9.3 mm at the last follow-up visit. The VAS-B, VAS-L, and ODI scores at the last follow-up showed a 54%, 72%, and 69% improvement from the preoperative period, respectively. Conclusions. The presented PELIF technique with the expandable spacer seems to be a promising surgical technique for the treatment of a variety of lumbar spinal disorders. Conversely, radiological results including disc space subsidence make the stand-alone application of the expandable spacer debatable. PMID:28337448
Lee, Sang-Ho; Erken, H Yener; Bae, Junseok
Background. Spinal fusion has been shown to be the preferred surgical option to reduce pain, recover function, and increase quality of life in the treatment of a variety of lumbar spinal disorders. The main goal of the present study is to report our clinical experience and results of percutaneous transforaminal endoscopic lumbar interbody fusion (PELIF) applications using the expandable spacer in a single institution. Methods. We performed a retrospective review of 18 patients with >12-month follow-up who had been operated on PELIF using expandable spacer from 2001 to 2007. Their clinical and radiological data were collected and analyzed. Results. The mean follow-up period was 46 months. The mean DH before the surgery was 8.3 mm which improved to 11.4 mm at the early postoperative period and regressed to 9.3 mm at the last follow-up visit. The VAS-B, VAS-L, and ODI scores at the last follow-up showed a 54%, 72%, and 69% improvement from the preoperative period, respectively. Conclusions. The presented PELIF technique with the expandable spacer seems to be a promising surgical technique for the treatment of a variety of lumbar spinal disorders. Conversely, radiological results including disc space subsidence make the stand-alone application of the expandable spacer debatable.
Wang, Tao; Wang, Hui; Yang, Da-Long; Jiang, Li-Qiang; Zhang, Li-Jun; Ding, Wen-Yuan
Abstract This is a retrospective study. The purpose of this study is to explore incidence and risk factors for surgical site infection (SSI) after posterior lumbar surgery. SSI is a common complication after posterior lumbar surgery, bringing mental and physical pain and prolonging hospital stay. However, predisposing factors, as reported less, remain controversial. Patients who underwent posterior lumbar surgery at 3 centers between 2006 and 2016 were included. The possible factors include 3 aspects: demographic variables-age, sex, body mass index (BMI), waist-to-hip radio (WHR), hypertension, diabetes, heart disease, smoking, drinking, steroidal injection, surgical time between June and September, preoperative shower; blood test variables-white blood cell (WBC), neutrophil, red blood cell (RBC), hemoglobin (Hb), total protein (TP), albumin, albumin/globulin (A/G), C-reactive protein (CRP), procalcitonin (PCT), erythrocyte sedimentation rate (ESR) and surgical related variables-operation time, blood loss, operative level, instrumentation, incision length. Factors related with SSI were also performed by multivariate analysis. The prevalence of SSI was 3.00% (267 cases of 8879) had a postoperative wound infection. There were significant difference in WHR (0.92 vs 0.83), WBC (4.31 vs 6.69), TP (58.7 vs 65.2), albumin (36.9 vs 43.2), CRP (2.01 vs 0.57), PCT (0.097 vs 0.067), operation time (217.9 vs 195.7), blood loss (997.1 vs 915.3) and operative level (3.05 vs 2.45) and incision length (24.1 vs 20.0) between SSI group and non-SSI group. >60 years old, female, BMI <18.5 and >30.0, diabetes, male smoking, preoperative steroidal injection, surgical time between June and September, no preoperative shower, instrumentation surgery were risk factors for SSI after posterior lumbar surgery. Many factors, >60 years old, female, BMI, WHR, diabetes, male smoking, preoperative steroidal injection, surgical time between June and September, preoperative shower, WBC, TP, albumin
Choi, Won-Suh; Kim, Jin-Sung; Ryu, Kyeong-Sik; Hur, Jung-Woo; Seong, Ji-Hoon
Background. Minimally invasive spinal transforaminal lumbar interbody fusion (MIS-TLIF) at L5-S1 is technically more demanding than it is at other levels because of the anatomical and biomechanical traits. Objective. To determine the clinical and radiological outcomes of MIS-TLIF for treatment of single-level spinal stenosis low-grade isthmic or degenerative spondylolisthesis at L5-S1. Methods. Radiological data and electronic medical records of patients who underwent MIS-TLIF between May 2012 and December 2014 were reviewed. Fusion rate, cage position, disc height (DH), disc angle (DA), disc slope angle, segmental lordotic angle (SLA), lumbar lordotic angle (LLA), and pelvic parameters were assessed. For functional assessment, the visual analogue scale (VAS), Oswestry disability index (ODI), and patient satisfaction rate (PSR) were utilized. Results. A total of 21 levels in 21 patients were studied. DH, DA, SLA, and LLA had increased from their preoperative measures at the final follow-up. Fusion rate was 86.7% (18/21) at 12 months' follow-up. The most common cage position was anteromedial (15/21). The mean VAS scores for back and leg pain mean ODI scores improved significantly at the final follow-up. PSR was 88%. Cage subsidence was observed in 33.3% (7/21). Conclusions. The clinical and radiologic outcomes after MIS-TLIF at L5-S1 in patients with spinal stenosis or spondylolisthesis are generally favorable. PMID:27433472
Iwatsuki, Koichi; Ohnishi, Yu-Ichiro; Ohkawa, Toshika; Yoshimine, Toshiki
Study Design Retrospective study. Purpose To evaluate the initial fixation using the cortical bone trajectory (CBT) technique for posterior lumbar fusion through assessment of the clear zones around the screws and the risk factors involved. Overview of Literature Postoperative radiolucent zones (clear zones) are an indicator of poor conventional pedicle screw fixation. Methods Between January 2013 and April 2014, 19 patients (8 men and 11 women) underwent posterior lumbar interbody fusion or posterior lumbar fusion using the CBT technique. A total of 109 screws were used for evaluation with measurement of the maximum insertional torque of last two screw rotations. Clear zone-positivity on plain radiographs was investigated 6 months after surgery. The relation between intraoperative insertional torque and clear zone-positivity was investigated by one-way analysis of variance. In addition, the correlation between clear zone-positivity and gender, age (<75 years old or >75 years old), or operative stabilization level (<2 or >3 vertebral levels) was evaluated using the chi-square test. Results Clear zones were observed around six screws (5.50%) in five patients (26.3%). The mean insertional torque (4.00±2.09 inlbs) of clear zone-positive screws was lower than that of clear zone-negative screws (8.12±0.50 in-lbs), but the difference was not significant. There was a significant correlation between clear zone-positivity and operative level of stabilization. Conclusions The low incidence of clear zone-positive screws indicates good initial fixation using the CBT technique. Multilevel fusions may be risk factors for clear zone generation. PMID:26713120
Liu, Xiaoyang; Li, Guangrun; Wang, Jiefeng; Zhang, Heqing
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/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. PMID:26603050
Agarwal, Nitin; Hansberry, David R; Goldstein, Ira M
Perioperative vision loss following non-ocular surgery is a well-documented phenomenon. In particular, perioperative vision loss has been frequently cited following spinal surgery. Although the rate of vision compromise in spinal surgery is relatively low, the consequences can be quite severe and devastating for the patient. We report a 60-year-old woman who initially presented with back and left leg pain as well as paraparesis. Imaging studies of the lumbar spine showed bony erosion consistent with tumor infiltration of the L3 and L4 spinal segments. Laminectomy at the L2-L4 levels for decompression of the intraspinal tumor was performed. Pathology of the resected bone was consistent with metastatic adenocarincoma. Postoperatively, the patient suffered severe anemia and bilateral infarctions of the posterior cerebral arteries and occipital lobes resulting in vision compromise. Although a definitive pathogenesis remains unknown, preoperative cardiovascular issues and intraoperative hemodynamic instabilities have typically been implicated as high risk factors. High risk factors for this novel clinical presentation of visual compromise following posterior lumbar laminectomy with decompression for an intraspinal tumor are reported.
Subach, Brian R.; Copay, Anne G.
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
Miyakoshi, Naohisa; Hongo, Michio; Ishikawa, Yoshinori; Kudo, Daisuke; Shimada, Yoichi
Study Design Case-control study. Purpose To evaluate clinical and radiological results of transforaminal lumbar interbody fusion (TLIF) performed with cortical bone trajectory (CBT) pedicle screw insertion with those of TLIF using 'conventional' or percutaneous pedicle screw insertion. Overview of Literature CBT is a new trajectory for pedicle screw insertion in the lumbar spine; clinical and radiological results of TLIF using pedicle screws inserted with CBT are unclear. Methods In total, 26 patients (11 males, 15 females) were enrolled in this retrospective study and divided into three groups: TLIF with pedicle screw insertion by conventional minimally invasive methods via the Wiltse approach (M-TLIF, n=10), TLIF with percutaneous pedicle screw insertion (P-TLIF, n=6), and TLIF with pedicle screw insertion with CBT (CBT-TLIF, n=10). Surgical results and preand postoperative radiological findings were evaluated and compared. Results Intraoperative blood loss was significantly less with CBT-TLIF (p=0.03) than with M-TLIF. Postoperative lordotic angles did not differ significantly among the three groups. Complete fusions were obtained in 10 of 12 levels (83%) with M-TLIF, in seven levels (100%) with P-TLIF, and in 10 of 11 levels (91%) with CBT-TLIF. On postoperative computed tomography, correct positioning was seen in 84.1% of M-TLIF screws, 88.5% of P-TLIF screws, and 90% of CBT-TLIF screws. Conclusions CBT-TLIF resulted in less blood loss and a shorter operative duration than M-TLIF or P-TLIF. Postoperative rates of bone union, maintenance of lordotic angles, and accuracy of pedicle screw positions were similar among the three groups. PMID:26097661
Kok, D.; Donk, R. D.; Wapstra, F. H.; Veldhuizen, A. G.
Study Design/Objective. A single-centre, prospective, non-comparative study of 25 patients to evaluate the performance and safety of the Memory Metal Minimal Access Cage (MAC) in Lumbar Interbody Fusion. Summary of Background Data. Interbody fusion cages in general are designed to withstand high axial loads and in the meantime to allow ingrowth of new bone for bony fusion. In many cages the contact area with the endplate is rather large leaving a relatively small contact area for the bone graft with the adjacent host bone. MAC is constructed from the memory metal Nitinol and builds on the concept of sufficient axial support in combination with a large contact area of the graft facilitating bony ingrowth and ease in minimal access implantation due to its high deformability. Methods. Twenty five subjects with a primary diagnosis of disabling back and radicular leg pain from a single level degenerative lumbar disc underwent an interbody fusion using MAC and pedicle screws. Clinical performance was evaluated prospectively over 2 years using the Oswestry Disability Index (ODI), Short Form 36 questionnaire (SF-36) and pain visual analogue scale (VAS) scores. The interbody fusion status was assessed using conventional radiographs and CT scan. Safety of the device was studied by registration of intra- and post-operative adverse effects. Results. Clinical performance improved significantly (P < .0018), CT scan confirmed solid fusion in all 25 patients at two year follow-up. In two patients migration of the cage occurred, which was resolved uneventfully by placing a larger size at the subsequent revision. Conclusions. We conclude that the Memory Metal Minimal Access Cage (MAC) resulted in 100% solid fusions in 2 years and proved to be safe, although two patients required revision surgery in order to achieve solid fusion. PMID:22567409
A novel indication for a method in the treatment of lumbar tuberculosis through minimally invasive extreme lateral interbody fusion (XLIF) in combination with percutaneous pedicle screws fixation in an elderly patient
Wang, Qiyou; Xu, Yichun; Chen, Ruiqiang; Dong, Jianwen; Liu, Bin; Rong, Limin
Abstract Rationale: To describe a novel indication for a method through minimally invasive extreme lateral interbody fusion (XLIF) in combination with percutaneous pedicle screwsfixation in the treatment of lumbar tuberculosis (TB) in an elderly patient, and its clinical efficacy and feasibility. Lumbar TB is a destructive form of TB. Antituberculous treatment should be started as early as possible. In some circumstances, however, surgical debridement with or without stabilization of the spine appears to be beneficial and may be recommended. Surgeries through the approach of anterior or posterior are still challenging and often involve some complications. Patient concerns: The case is a 68-year-old female who was misdiagnosed as simple vertebral compression fracture and underwent L1 and L2 percutaneous vertebroplasty in another hospital 7 years ago. He complained of lumbosacral pain for 1 month this time. Magnetic resonance imaging (MRI) and computed tomography (CT) showed intervertebral space in L1/2 was seriously damaged like TB. Diagnoses: Lumbar tuberculosis Interventions: Antitubercular drugs, mini-invasive debridement with XLIF in combination with percutaneous pedicle screwsfixation was performed. This patient was followed up for 12 months. Outcomes: No obvious complication occurred during the operation and the wound healed well. Oswestry Disability Index (ODI: 56 vs 22) and visual analog scale (VAS: 4 vs 0) score significantly decreased atfinal follow-up of 12 months. Obvious recovery of kyphosis angle was found postoperatively (post: 14.8° vs pre: 33.5°). No recurrent infection occurred at the last follow-up. Lessons: Mini-invasive surgery by debridement through XLIF and percutaneous pedicle screwsfixation may be an effective and innovative treatment method for lumbar TB in the elderly. PMID:27902591
Makda, Junaid; Hong, Joseph; Patel, Ravi; Hilibrand, Alan S.; Anderson, David G.; Vaccaro, Alexander R.; Albert, Todd J.
The “off label” use of rhBMP-2 in the transforaminal lumbar interbody fusion (TLIF) procedure has become increasingly popular. Although several studies have demonstrated the successful use of rhBMP-2 for this indication, uncertainties remain regarding its safety and efficacy. The purpose of this study is to evaluate the clinical and radiographic outcomes of the single-level TLIF procedure using rhBMP-2. Patients who underwent a single-level TLIF between January 2004 and May 2006 with rhBMP-2 were identified. A retrospective evaluation of these patients included operative report(s), pre- and postoperative medical records, and dynamic and static lumbar radiographs. Patient-reported clinical outcome measures were obtained from a telephone questionnaire and included a modification of the Odom’s criteria, a patient satisfaction score, and back and leg pain numeric rating scale scores. Forty-eight patients met the study criteria and were available for follow-up (avg. radiographic and clinical follow-up of 19.4 and 27.4 months, respectively). Radiographic fusion was achieved in 95.8% of patients. Good to excellent results were achieved in 71% of patients. On most recent clinical follow-up, 83% of patients reported improvement in their symptoms and 84% reported satisfaction with their surgery. Twenty-nine patients (60.4%) reported that they still had some back pain, with an average back pain numeric rating score of 2.8. Twenty patients (41.7%) reported that they still had some leg pain, with an average leg pain numeric rating score was 2.4. Thirteen patients (27.1%) had one or more complications, including transient postoperative radiculitis (8/48), vertebral osteolysis (3/48), nonunion (2/48), and symptomatic ectopic bone formation (1/48). The use of rhBMP-2 in the TLIF procedure produces a high rate of fusion, symptomatic improvement and patient satisfaction. Although its use eliminates the risk of harvesting autograft, rhBMP-2 is associated with other
Danner, Simon M; Hofstoetter, Ursula S; Ladenbauer, Josef; Rattay, Frank; Minassian, Karen
Stimulation of different spinal cord segments in humans is a widely developed clinical practice for modification of pain, altered sensation, and movement. The human lumbar cord has become a target for modification of motor control by epidural and, more recently, by transcutaneous spinal cord stimulation. Posterior columns of the lumbar spinal cord represent a vertical system of axons and when activated can add other inputs to the motor control of the spinal cord than stimulated posterior roots. We used a detailed three-dimensional volume conductor model of the torso and the McIntyre-Richard-Grill axon model to calculate the thresholds of axons within the posterior columns in response to transcutaneous lumbar spinal cord stimulation. Superficially located large-diameter posterior column fibers with multiple collaterals have a threshold of 45.4 V, three times higher than posterior root fibers (14.1 V). With the stimulation strength needed to activate posterior column axons, posterior root fibers of large and small diameters as well as anterior root fibers are coactivated. The reported results inform on these threshold differences, when stimulation is applied to the posterior structures of the lumbar cord at intensities above the threshold of large-diameter posterior root fibers.
Gammal, Isaac D.; Bendo, John A.
Background Lateral transpsoas interbody fusion (LTIF) is a minimally invasive technique for achieving lumbar spinal fusion. While it has many advantages over open techniques it carries with it a distinct set of risks, most commonly post-operative ipsilateral thigh pain, weakness and sensory disturbances. It is vital for both the surgeon and patient to understand the risks for and outcomes of injury associated with this procedure. We conducted a systematic review of the literature to evaluate the incidence, risks, and long-term clinical outcomes of post-operative thigh symptoms in patients treated with LTIF. Methods We conducted a search of MEDLINE, EMBASE, CINAHL, Scopus, Web of Science and the Cochrane Collaboration Library, using keywords and MeSH terms, for English-language literature published through September 2014, as well as reference lists from key articles. Studies were then manually filtered to retrieve articles that met inclusion criteria. We were interested in studies that reported postoperative lower extremity symptoms after LTIF, such as pain, weakness and changes in sensation. The strength of evidence was determined based on precepts outlined by the Grades of Recommendation Assessment, Development and Evaluation Working Group (GRADE). Results A total of 392 articles were initially retrieved, with 24 ultimately meeting criteria for inclusion. The incidence of any post-operative thigh symptom varied, ranging as high as 60.7%, with 9.3% of patients experiencing a motor deficit related to direct nerve injury. Several studies reported cases of persistent symptoms at 6 months follow up. Additionally, inclusion of the L4-5 disc space and a longer duration of surgery were both identified as risks for developing postoperative thigh symptoms. Conclusion The risk of postoperative thigh symptoms after LTIF is high. Thigh pain, paresthesias and weakness were the most commonly reported symptoms. While most patients’ symptoms resolved by 6 months follow up
Gutke, Annelie; Hansson, Eva Roos; Zetherström, Gunilla; Ostgaard, Hans Christian
The classification of pelvic girdle pain can only be reached after lumbar causes have been excluded by a clinical examination. During clinical examination, the posterior pelvic pain provocation test is a well-established method for verifying pelvic girdle pain. However, a criticism of pelvic pain provocation tests is that they may have an effect on lumbar structures, thus yielding false-positive results. The posterior pelvic pain provocation test was performed with four groups of patients: patients with computed tomography-verified disc herniations (1) on the waiting list for surgery (14 women; 9 men); (2) 6 weeks after disc surgery (18 women, 12 men); (3) pregnant women seeking care for pelvic girdle pain (n = 25); and (4) women with persistent pelvic girdle pain after delivery (n = 32). The sensitivity of the posterior pelvic pain provocation test was 0.88 and the specificity was 0.89. The positive predictive value was 0.89 and the negative predictive value was 0.87. Analysis of only women showed similar results. In our study, the posterior pelvic pain provocation test was negative in patients with a well-defined lumbar diagnosis of lumbar disc herniation, both before and after disc surgery. Our results are an important step toward the more accurate classification of lumbopelvic pain.
Hussain, Namath S.; White, G. Zachary; Begun, Evan M.; Collins, Robert A.; Fahim, Daniel K.; Hiremath, Girish K.; Adbi, Fadumo M.; Yacob, Sammy A.
Study Design. This was a prospective clinical study that took place in an outpatient spine clinic. Objective. To demonstrate the short-/long-term outcomes from a large cohort of patients undergoing minimally invasive transforaminal lumbar interbody fusion (MITLIF). Summary of Background Data. Long-term prospective outcomes in patients undergoing minimally invasive spinal fusion for debilitating back pain has not been well studied. Methods. Presenting diagnosis was determined from clinical findings and radiographical (radiograph, magnetic resonance image, computed tomographic scan) evaluations preoperatively. Patients were assessed with outcome measures preoperatively, and postoperatively at 2 weeks, 3 months, 6 months, 12 months, 24 months, and annually 2 to 7 years (mean follow-up: 47 mo) final follow-up. The rate of postoperative complications and reoperations at the initial level of MITLIF and adjacent level(s) were followed. Fusion rates were assessed blinded and independently by radiograph. Results. Visual analogue scale scores decreased significantly from 7.0 preoperatively to 3.5 at mean 47-month follow-up. Oswestry Disability Index scores declined from 43.1 preoperatively to 28.2 at mean 47-month follow-up. Short-Form 36 mental component scores increased from 43.8 preoperatively to 49.7 at 47-month follow-up. Short-Form 36 physical component scores increased from 30.6 preoperatively to 39.6 at 47-month follow-up (P < 0.05). Conclusion. This prospectively collected outcomes study shows long-term statistically significant clinical outcomes improvement after MITLIF in patients with clinically symptomatic spondylolisthesis and degenerative disc disease with or without stenosis. MITLIF resulted in a high rate of spinal fusion and very low rate of interbody fusion failure and/or adjacent segment disease requiring reoperation while reducing postoperative complications. Level of Evidence: 3 PMID:24150437
Lavelle, William; McLain, Robert F.; Rufo-Smith, Candace; Gurd, David P.
Background Degenerative disc disease is common and debilitating for many patients. If conservative extensive care fails, anterior lumbar interbody fusion has proven to be an alternative form of surgical management. The Stabilis Stand Alone Cage(SAC) was introduced as a method to obtain stability and fusion. The purpose of this study was to determine whether the Stabilis Stand Alone Cage (SAC) is comparable in safety and efficacy to the Bagby and Kuslich (BAK) device. Methods As part of a prospective, randomized, controlled FDA trial, 73 patients underwent anterior interbody fusion using either the SAC(56%) or the BAK device (44%). Results Background characteristics were similar between the two groups. There was no significant difference between the SAC and BAK groups in mean operative time or mean blood loss during surgery. Adverse event rates did not differ between the groups. Assessment of plain radiographs could not confirm solid fusion in 63% of control and 71% of study patients. Functional scores from Owestry and SF-36 improved in both groups by the two-year follow-up. There were no significant differences between the SAC and BAK patients with respect to outcome. Conclusions Both the Stabilis Stand Alone Cage and the BAK Cage provided satisfactory improvement in function and pain relief, despite less than expected radiographic fusion rates. The apparent incongruency between fusion rates and functional outcomes suggests that either radiographs underestimate the true incidence of fusion, or that patients are obtaining good pain relief and improved function despite a lower rate of fusion than previously reported. This was a Level III study. PMID:25694930
Stundner, O.; Chiu, Y-L.; Sun, X.; Ramachandran, S-K.; Gerner, P.; Vougioukas, V.; Mazumdar, M.; Memtsoudis, S. G.
Despite the increasing prevalence of sleep apnoea, little information is available regarding its impact on the peri-operative outcome of patients undergoing posterior lumbar fusion. Using a national database, patients who underwent lumbar fusion between 2006 and 2010 were identified, sub-grouped by diagnosis of sleep apnoea and compared. The impact of sleep apnoea on various outcome measures was assessed by regression analysis. The records of 84 655 patients undergoing posterior lumbar fusion were identified and 7.28% also had a diagnostic code for sleep apnoea. Compared with patients without sleep apnoea, these patients were older, more frequently female, had a higher comorbidity burden and higher rates of peri-operative complications, post-operative mechanical ventilation, blood transfusion, and intensive care. Patients with sleep apnoea also had longer and more costly periods of hospitalisation. In the regression analysis, sleep apnoea emerged as an independent risk factor for the development of peri-operative complications (Odds Ratio (OR) 1.50, Confidence Interval (CI) 1.38;1.62), blood transfusions (OR 1.12, CI 1.03;1.23), mechanical ventilation (OR 6.97, CI 5.90;8.23), critical care services (OR 1.86, CI 1.71;2.03), prolonged hospitalisation and increased cost (OR 1.28, CI 1.19;1.37; OR 1.10, CI 1.03;1.18). Patients with sleep apnoea who undergo posterior lumbar fusion pose significant challenges to clinicians. PMID:24493191
MIZUNO, Masaki; KURAISHI, Keita; UMEDA, Yasuyuki; SANO, Takanori; TSUJI, Masanori; SUZUKI, Hidenori
A novel cortical bone trajectory (CBT) screw technique provides an alternative fixation technique for lumbar spine. Trajectory of CBT screw creates a caudo-cephalad path in sagittal plane and a medio-lateral path in axial plane, and engages cortical bone in the pedicle. The theoretical advantage is that it provides enhanced screw grip and interface strength. Midline lumbar fusion (MIDLF) is composed of posterior mid-line approach, microsurgical laminectomy, and CBT screw fixation. We adopted the MIDLF technique for lumbar spondylolisthesis. Advantages of this technique include that decompression and fusion are available in the same field, and it minimizes approach-related damages. To determine whether MIDLF with CBT screw is as effective as traditional approach and it is minimum invasive technique, we studied the clinical and radiological outcomes of MIDLF. Our results indicate that MIDLF is effective and minimum invasive technique. Evidence of effectiveness of MIDLF is that patients had good recovery score, and that CBT screw technique was safety in clinical and stable in radiological. MIDLF with CBT screw provides the surgeon with additional options for fixation. This technique is most likely to be useful for treating lumbar spondylolisthesis in combination with midline decompression and insertion of an interbody graft, such as the transforaminal lumbar interbody fusion or posterior lumbar interbody fusion techniques. PMID:25169139
Pereira, Paulo; Buzek, David; Franke, Jörg; Senker, Wolfgang; Kosmala, Arkadiusz; Hubbe, Ulrich; Manson, Neil; Rosenberg, Wout; Assietti, Roberto; Martens, Frederic; Barbanti Brodano, Giovanni; Scheufler, Kai-Michael
Minimally invasive lumbar interbody fusion (MILIF) offers potential for reduced operative morbidity and earlier recovery compared with open procedures for patients with degenerative lumbar disorders (DLD). Firm conclusions about advantages of MILIF over open procedures cannot be made because of limited number of large studies of MILIF in a real-world setting. Clinical effectiveness of MILIF in a large, unselected real-world patient population was assessed in this Prospective, monitored, international, multicenter, observational study. Objective: To observe and document short-term recovery after minimally invasive interbody fusion for DLD. Materials and Methods: In a predefined 4-week analysis from this study, experienced surgeons (≥30 MILIF surgeries pre-study) treated patients with DLD by one- or two-level MILIF. The primary study objective was to document patients’ short-term post-interventional recovery (primary objective) including back/leg pain (visual analog scale [VAS]), disability (Oswestry Disability Index [ODI]), health status (EQ-5D) and Patient satisfaction. Results: At 4 weeks, 249 of 252 patients were remaining in the study; the majority received one-level MILIF (83%) and TLIF was the preferred approach (94.8%). For one-level (and two-level) procedures, surgery duration was 128 (182) min, fluoroscopy time 115 (154) sec, and blood-loss 164 (233) mL. Time to first ambulation was 1.3 days and time to study-defined surgery recovery was 3.2 days. Patients reported significantly (P < 0.0001) reduced back pain (VAS: 2.9 vs 6.2), leg pain (VAS: 2.5 vs 5.9), and disability (ODI: 34.5% vs 45.5%), and a significantly (P < 0.0001) improved health status (EQ-5D index: 0.61 vs 0.34; EQ VAS: 65.4 vs 52.9) 4 weeks postoperatively. One adverse event was classified as related to the minimally invasive surgical approach. No deep site infections or deaths were reported. Conclusions: For experienced surgeons, MILIF for DLD demonstrated early benefits (short time to
Krenn, Matthias; Hofstoetter, Ursula S; Danner, Simon M; Minassian, Karen; Mayr, Winfried
Interest in transcutaneous electrical stimulation of the lumbosacral spinal cord is increasing in human electrophysiological and clinical studies. The stimulation effects on lower limb muscles depend on the depolarization of segmentally organized posterior root afferents and, thus, the rostro-caudal stimulation site. In previous studies, selective stimulation was achieved by varying the positions of single self-adhesive electrodes over the thoracolumbar spine. Here, we developed a multi-electrode surface array consisting of 3 × 8 electrode pads and tested its stimulation-site specificity. The array was placed longitudinally over the spine covering the T10-L2 vertebrae. Two different hydrogel layer configurations were utilized: a single layer adhered to all electrode pads of the array and a configuration comprised of eight separate strips attached to the three transverse electrode pads of each level. Voltage measurements demonstrated that an effectively focused field distribution along the longitudinal extent of the array was not accomplished when using the single continuous hydrogel layer, and segmental selective stimulation of the posterior root afferents was not possible. The separate strips produced a focused electric field distribution at the rostro-caudal level of the electrode pads selected for stimulation. This configuration allowed for the preferential elicitation of posterior root-muscle reflexes in either the L2-L4 innervated quadriceps or the L5-S2 innervated triceps surae muscle groups. Such multi-electrode array for transcutaneous spinal cord stimulation shall allow for improved control of stimulation conditions in electrophysiological studies and time-dependent and site-specific stimulation patterns for neuromodulation applications.
Yasuda, Taketoshi; Hori, Takeshi; Suzuki, Kayo; Kawaguchi, Yoshiharu
Study Design Retrospective study. Purpose The aims of the current study are to evaluate the minimum 10-year follow-up clinical results of anterior lumbar interbody fusion (ALIF) for degenerative spondylolisthesis. Overview of Literature ALIF has been widely used as a treatment regimen in the management of lumbar spondylolisthesis. Still much controversy exists regarding the factors that affect the postoperative clinical outcomes. Methods The author performed a retrospective review of 20 patients with degenerative spondylolisthesis treated with ALIF (follow-up, 16.4 years). The clinical results were assessed by the Japanese Orthopaedic Association (JOA) score for low back pain, vertebral slip and disc height index on the radiographs. Results The mean preoperative JOA score was 7.1 ± 1.8 points (15-point-method). At 1 year, 5 years, and 10 years or more after surgery, the JOA scores were assessed as 12.4 ± 2.2 points, 12.7 ± 2.6 points, 12.0 ± 2.5 points, respectively (excluding the data of reoperated cases). The adjacent disc degeneration developed in all cases during the long-term follow-up. The progressive pattern of disc degeneration was divided into three types. Initially, disc degeneration occurred due to disc space narrowing. After that, the intervertebral discs showed segmental instability with translation at the upper level. But the lower discs showed osteophyte formation, and occasionally lead to the collapse or spontaneous union. Conclusions The clinical results of the long-term follow-up data after ALIF became worse due to the adjacent disc degeneration. The progressive pattern of disc degeneration was different according to the adjacent levels. PMID:22708014
Jain, Ravikant; Kiyawat, Vivek
Background For surgical treatment of lumbar and lumbosacral tuberculosis, the anterior approach has been the most popular approach because it allows direct access to the infected tissue, thereby providing good decompression. However, anterior fixation is not strong, and graft failure and loss of correction are frequent complications. The posterior approach allows circumferential decompression of neural elements along with three-column fixation attained via pedicle screws by the same approach. The purpose of this study was to evaluate the outcome (functional, neurological, and radiological) in patients with lumbar and lumbosacral tuberculosis operated through the posterior approach. Methods Twenty-eight patients were diagnosed with tuberculosis of the lumbar and lumbosacral region from August 2012 to August 2013. Of these, 13 patients had progressive neurological deterioration or increasing back pain despite conservative measures and underwent posterior decompression and pedicle screw fixation with posterolateral fusion. Antitubercular therapy was given till signs of radiological healing were evident (9 to 16 months). Functional outcome (visual analogue scale [VAS] score for back pain), neurological recovery (Frankel grading), and radiological improvement were evaluated preoperatively, immediately postoperatively and 3 months, 6 months, and 1 year postoperatively. Results The mean VAS score for back pain improved from 7.89 (range, 9 to 7) preoperatively to 2.2 (range, 3 to 1) at 1-year follow-up. Frankel grading was grade B in 3, grade C in 7, and grade D in 3 patients preoperatively, which improved to grade D in 7 and grade E in 6 patients at the last follow-up. Radiological healing was evident in the form of reappearance of trabeculae formation, resolution of pus, fatty marrow replacement, and bony fusion in all patients. The mean correction of segmental kyphosis was 9.85° postoperatively. The mean loss of correction at final follow-up was 3.15°. Conclusions
Skovrlj, Branko; Guzman, Javier Z.; Caridi, John; Cho, Samuel K.
Study Design Case report. Objective The purpose of this report is to discuss the surgical management of lumbar vertebral osteomyelitis with a spinal epidural abscess (SEA) and present a single-stage, posterior-only circumferential decompression and reconstruction with instrumentation using an expandable titanium cage and without segmental nerve root sacrifice as an option in the treatment of this disease process. Methods We report a 42-year-old man who presented with 3 days of low back pain and chills who rapidly decompensated with severe sepsis following admission. Magnetic resonance imaging of his lumbosacral spine revealed intramuscular abscesses of the left paraspinal musculature and iliopsoas with SEA and L4 vertebral body involvement. The patient failed maximal medical treatment, which necessitated surgical treatment as a last resort for infectious source control. He underwent a previously undescribed procedure in the setting of SEA: a single-stage, posterior-only approach for circumferential decompression and reconstruction of the L4 vertebral body with posterior segmental instrumented fixation. Results After the surgery, the patient's condition gradually improved; however, he suffered a wound dehiscence necessitating a surgical exploration and deep wound debridement. Six months after the surgery, the patient underwent a revision surgery for adjacent-level pseudarthrosis. At 1-year follow-up, the patient was pain-free and off narcotic pain medication and had returned to full activity. Conclusion This patient is the first reported case of lumbar osteomyelitis with SEA treated surgically with a single-stage, posterior-only circumferential decompression and reconstruction with posterior instrumentation. Although this approach is more technically challenging, it presents another viable option for the treatment of lumbar vertebral osteomyelitis that may reduce the morbidity associated with an anterior approach. PMID:26835214
Skovrlj, Branko; Guzman, Javier Z; Caridi, John; Cho, Samuel K
Study Design Case report. Objective The purpose of this report is to discuss the surgical management of lumbar vertebral osteomyelitis with a spinal epidural abscess (SEA) and present a single-stage, posterior-only circumferential decompression and reconstruction with instrumentation using an expandable titanium cage and without segmental nerve root sacrifice as an option in the treatment of this disease process. Methods We report a 42-year-old man who presented with 3 days of low back pain and chills who rapidly decompensated with severe sepsis following admission. Magnetic resonance imaging of his lumbosacral spine revealed intramuscular abscesses of the left paraspinal musculature and iliopsoas with SEA and L4 vertebral body involvement. The patient failed maximal medical treatment, which necessitated surgical treatment as a last resort for infectious source control. He underwent a previously undescribed procedure in the setting of SEA: a single-stage, posterior-only approach for circumferential decompression and reconstruction of the L4 vertebral body with posterior segmental instrumented fixation. Results After the surgery, the patient's condition gradually improved; however, he suffered a wound dehiscence necessitating a surgical exploration and deep wound debridement. Six months after the surgery, the patient underwent a revision surgery for adjacent-level pseudarthrosis. At 1-year follow-up, the patient was pain-free and off narcotic pain medication and had returned to full activity. Conclusion This patient is the first reported case of lumbar osteomyelitis with SEA treated surgically with a single-stage, posterior-only circumferential decompression and reconstruction with posterior instrumentation. Although this approach is more technically challenging, it presents another viable option for the treatment of lumbar vertebral osteomyelitis that may reduce the morbidity associated with an anterior approach.
Etemadifar, Mohammad Reza; Hadi, Abdollah; Masouleh, Mehran Feizi
Background: Spondylolisthesis is a common cause of surgery in patients with lower back pain. Although posterolateral fusion and pedicle screw fixation are a relatively common treatment method for the treatment of spondylolisthesis, controversy exists about the necessity of adding interbody fusion to posterolateral fusion. The aim of our study was to assess the functional disability, pain, and complications in patients with spondylolisthesis treated by posterolateral instrumented fusion (PLF) with and without transforaminal lumbar interbody fusion (TLIF) in a randomized clinical trial. Materials and Methods: From February 2007 to February 2011, 50 adult patients with spondylolisthesis were randomly assigned to be treated with PLF or PLF+TLIF techniques (25 patients in each group) by a single surgeon. Back pain, leg pain, and disability were assessed before treatment and until 2 years after surgical treatment using visual analog scale (VAS) and oswestry disability index (ODI). Patients were also evaluated for postoperative complications such as infection, neurological complications, and instrument failure. Results: All patients completed the 24 months of follow-up. Twenty patients were females and 30 were males. Average age of the patients was 53 ± 11 years for the PLF group and 51 ± 13 for the PLF + TLIF group. Back pain, leg pain, and disability score were significantly improved postoperatively compared to preoperative scores (P < 0.001). At 3 months of follow-up, there was no statistically significant difference in VAS score for back pain and leg pain in both groups; however, after 6 months and 1 year and 2 years follow-up, the reported scores for back pain and leg pain were significantly lower in the PLF+TLIF group (P < 0.05). The ODI score was also significantly lower in the PLF+TLIF group at 1 year and 2 years of follow-up (P < 0.05). One screw breakage and one superficial infection occurred in the PLF+TLIF group, which had no statistical significance (P = 0
Wang, Tao; Wang, Hui; Yang, Da-Long; Jiang, Li-Qiang; Zhang, Li-Jun; Ding, Wen-Yuan
This is a retrospective study.The purpose of this study is to explore incidence and risk factors for surgical site infection (SSI) after posterior lumbar surgery.SSI is a common complication after posterior lumbar surgery, bringing mental and physical pain and prolonging hospital stay. However, predisposing factors, as reported less, remain controversial.Patients who underwent posterior lumbar surgery at 3 centers between 2006 and 2016 were included. The possible factors include 3 aspects: demographic variables-age, sex, body mass index (BMI), waist-to-hip radio (WHR), hypertension, diabetes, heart disease, smoking, drinking, steroidal injection, surgical time between June and September, preoperative shower; blood test variables-white blood cell (WBC), neutrophil, red blood cell (RBC), hemoglobin (Hb), total protein (TP), albumin, albumin/globulin (A/G), C-reactive protein (CRP), procalcitonin (PCT), erythrocyte sedimentation rate (ESR) and surgical related variables-operation time, blood loss, operative level, instrumentation, incision length. Factors related with SSI were also performed by multivariate analysis.The prevalence of SSI was 3.00% (267 cases of 8879) had a postoperative wound infection. There were significant difference in WHR (0.92 vs 0.83), WBC (4.31 vs 6.69), TP (58.7 vs 65.2), albumin (36.9 vs 43.2), CRP (2.01 vs 0.57), PCT (0.097 vs 0.067), operation time (217.9 vs 195.7), blood loss (997.1 vs 915.3) and operative level (3.05 vs 2.45) and incision length (24.1 vs 20.0) between SSI group and non-SSI group. >60 years old, female, BMI <18.5 and >30.0, diabetes, male smoking, preoperative steroidal injection, surgical time between June and September, no preoperative shower, instrumentation surgery were risk factors for SSI after posterior lumbar surgery.Many factors, >60 years old, female, BMI, WHR, diabetes, male smoking, preoperative steroidal injection, surgical time between June and September, preoperative shower, WBC, TP, albumin, CRP, PCT
Kuo, Chao-Hung; Chang, Peng-Yuan; Wu, Jau-Ching; Chang, Hsuan-Kan; Fay, Li-Yu; Tu, Tsung-Hsi; Cheng, Henrich; Huang, Wen-Cheng
OBJECTIVE In the past decade, dynamic stabilization has been an emerging option of surgical treatment for lumbar spondylosis. However, the application of this dynamic construct for mild spondylolisthesis and its clinical outcomes remain uncertain. This study aimed to compare the outcomes of Dynesys dynamic stabilization (DDS) with minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for the management of single-level spondylolisthesis at L4-5. METHODS This study retrospectively reviewed 91 consecutive patients with Meyerding Grade I spondylolisthesis at L4-5 who were managed with surgery. Patients were divided into 2 groups: DDS and MI-TLIF. The DDS group was composed of patients who underwent standard laminectomy and the DDS system. The MI-TLIF group was composed of patients who underwent MI-TLIF. Clinical outcomes were evaluated by visual analog scale for back and leg pain, Oswestry Disability Index, and Japanese Orthopaedic Association scores at each time point of evaluation. Evaluations included radiographs and CT scans for every patient for 2 years after surgery. RESULTS A total of 86 patients with L4-5 spondylolisthesis completed the follow-up of more than 2 years and were included in the analysis (follow-up rate of 94.5%). There were 64 patients in the DDS group and 22 patients in the MI-TLIF group, and the overall mean follow-up was 32.7 months. Between the 2 groups, there were no differences in demographic data (e.g., age, sex, and body mass index) or preoperative clinical evaluations (e.g., visual analog scale back and leg pain, Oswestry Disability Index, and Japanese Orthopaedic Association scores). The mean estimated blood loss of the MI-TLIF group was lower, whereas the operation time was longer compared with the DDS group (both p < 0.001). For both groups, clinical outcomes were significantly improved at 6, 12, 18, and 24 months after surgery compared with preoperative clinical status. Moreover, there were no differences between the 2
Basques, Bryce A.; Fu, Michael C.; Buerba, Rafael A.; Bohl, Daniel D.; Golinvaux, Nicholas S.; Grauer, Jonathan N.
Study Design Retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2010 that included 1,861 patients who had undergone elective posterior lumbar fusion. Objective To characterize factors that were independently associated with increased hospital length of stay (LOS) in patients who had undergone elective posterior lumbar fusion. Summary of Background Data Posterior lumbar spine fusion is a common surgical procedure used to treat lumbar spine pathology. LOS is an important clinical variable and a major determinant of inpatient hospital costs. There is lack of studies in the literature using multivariate analysis to specifically examine the predictors of LOS after elective posterior lumbar fusion. Methods Patients who underwent elective posterior lumbar fusion from 2005 to 2010 were identified in the ACS-NSQIP database. Preoperative and intraoperative variables were extracted for each case and a multivariate linear regression was performed to assess the contribution of each variable to LOS. Results A total of 1,861 elective posterior lumbar fusion patients were identified. The average age for patients in this cohort was 60.6 ± 13.9 years (mean ± standard deviation [SD]) with a body mass index (BMI) of 30.3 ± 6.2 kg/m2. 44.7% of patients were male. LOS ranged from 0 days to 51 days. Multivariate linear regression identified age (p < 0.001), morbid obesity (BMI ≥ 40 kg/m2, p < 0.001), American Society of Anesthesiologists (ASA) class (p = 0.001), operative time (p < 0.001), multilevel procedure (p = 0.001), and intraoperative transfusion (p < 0.001) as significant predictors of extended LOS. Conclusion The identified preoperative and intraoperative variables associated with extended LOS after elective posterior lumbar fusion may be helpful to clinicians for patient counseling and postoperative planning. PMID:24384669
Epstein, Nancy E.
Background: In a recent study entitled: “More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion (XLIF): A review”, Epstein documented that more nerve root injuries occurred utilizing minimally invasive surgery (MIS) versus open lumbar surgery for diskectomy, decompression of stenosis (laminectomy), and/or fusion for instability. Methods: In large multicenter Spine Patient Outcomes Research Trial reviews performed by Desai et al., nerve root injury with open diskectomy occurred in 0.13–0.25% of cases, occurred in 0% of laminectomy/stenosis with/without fusion cases, and just 2% for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion. Results: In another MIS series performed largely for disc disease (often contained nonsurgical disc herniations, therefore unnecessary procedures) or spondylolisthesis, the risk of root injury was 2% for transforaminal lumbar interbody fusion (TLIF) versus 7.8% for posterior lumbar interbody fusion (PLIF). Furthermore, the high frequencies of radiculitis/nerve root/plexus injuries incurring during anterior lumbar interbody fusions (ALIF: 15.8%) versus extreme lumbar interbody fusions (XLIF: 23.8%), addressing disc disease, failed back surgery, and spondylolisthesis, were far from acceptable. Conclusions: The incidence of nerve root injuries following any of the multiple MIS lumbar surgical techniques (TLIF/PLIF/ALIF/XLIF) resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques. Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients? PMID:26904373
Yu, Bin; Wu, Desheng; Shen, Bin; Zhao, Weidong; Huang, Yufeng; Zhu, Jianguang; Qi, Dongduo
Vertebral hemangiomas are benign lesions and are often asymptomatic. Most vertebral hemangiomas that cause cord compression and neurological symptoms are located in the thoracic spine and involve a single vertebra. The authors report the rare case of lumbar hemangiomas in a 60-year-old woman presenting with severe back pain and rapidly progressive neurological signs attributable to 2 noncontiguous lesions. After embolization of the feeding arteries, no improvement was noted. Thus, the authors performed open surgery using a combination of posterior decompression, intraoperative kyphoplasty, and segmental fixation. The patient experienced relief from back and leg pain immediately after surgery. At 3 months postoperatively, her symptoms and neurological deficits had improved completely. To the authors' knowledge, this is the first description of 2 noncontiguous extensive lumbar hemangiomas presenting with neurological symptoms managed by such combined treatment. The combined management seems to be an effective method for treating symptomatic vertebral hemangiomas.
Kuang, Lei; Chen, Yuqiao; Li, Lei; Lü, Guohua
The author retrospectively studied twenty-two patients who underwent revision lumbar surgeries using ALLIF with a self-anchored stand-alone polyetheretherketone (PEEK) cage. The operation time, blood loss, and perioperative complications were evaluated. Oswestry disability index (ODI) scores and visual analog scale (VAS) scores of leg and back pain were analyzed preoperatively and at each time point of postoperative follow-up. Radiological evaluation including fusion, disc height, foraminal height, and subsidence was assessed. The results showed that the ALLIF with a self-anchored stand-alone PEEK cage is safe and effective in revision lumbar surgery with minor surgical trauma, low access-related complication rates, and satisfactory clinical and radiological results. PMID:27885355
Braybrooke, Jason; Ahn, Henry; Gallant, Aimee; Ford, Michael; Bronstein, Yigel; Finkelstein, Joel; Yee, Albert
A prospective observational study was conducted on patients undergoing posterior lumbar spine surgery for degenerative spinal disorders. The study purpose was to evaluate the effect of wait time to surgery on patient derived generic and disease specific functional outcome following surgery. A prolonged wait to surgery may adversely affect surgical outcome. Although there is literature on the effect of wait time to surgery in surgical fields such as oncology, cardiac, opthamologic, and total joint arthroplasty, little is known regarding the effect of wait time to surgery as it pertains to the spinal surgical population. Consecutive patients undergoing elective posterior lumbar spinal surgery for degenerative disorders were recruited. Short-Form 36 and Oswestry disability questionnaires were administered (pre-operatively, and at 6 weeks, 6 months, and 1 year post-operatively). Patients completed a questionnaire regarding their experience with the wait time to surgery. The study cohort consisted of 70 patients with follow-up in 53/70 (76%). Time intervals from the onset of patient symptoms to initial consultation by family physician through investigations, spinal surgical consultation and surgery were quantified. Time intervals were compared to patient specific improvements in reported outcome following surgery using Cox Regression analysis. The effect of patient and surgical parameters on wait time was evaluated using the median time as a reference for those patients who had either a longer or shorter wait. Significant improvements in patient derived outcome were observed comparing post-operative to pre-operative baseline scores. The greatest improvements were observed in aspects relating to physical function and pain. A longer wait to surgery was associated with less improvement in outcome following surgery (SF-36 domains of BP, GH, RP, VT). A longer wait time to surgery negatively influences the results of posterior lumbar spinal surgery for degenerative conditions
YANG, PINGLIN; HE, XIJING; LI, HAOPENG; ZANG, QUANJIN; WANG, GUOYU
The present study aimed to analyze the indications, feasibility, safety and clinical effects of total spondylectomy and spine reconstruction through posterior or combined anterior-posterior approaches for thoracic lumbar and sacral vertebrae tumors. Between December 2009 and May 2012, 10 patients with thoracic lumbar and sacral vertebrae tumors were retrospectively analyzed. Different surgical indications and approaches were used according to the affected segments, the extent of lesion involvement and the specific pathology results. One-stage posterior or combined anterior-posterior total spondylectomy and reconstruction was used for the treatment of complicated thoracic lumbar and sacral vertebral malignant tumors and invasive benign tumors. The duration of surgery, levels of intraoperative blood loss and transfusions, and the clinical effects were observed. The average surgical duration was 6.8 h (range, 4.8–12 h), with an average blood loss level of 3,200 ml (range, 1,500–10,000 ml) and an average transfusion level of 2,500 ml. During the average 15 months (range, 3–29 months) follow up, two patients succumbed and one patient experienced tumor recurrence. Neither tumor reoccurrence nor metastasis was observed in all other patients. Personalized surgical indications and approaches according to the affected segments, the extent of lesion involvement and the specific pathology results would aid in the reduction of pain, the improvement of nerve function and the reduction of tumor recurrence. PMID:26998076
Nada, Mohamed; Mahran, Mahmoud A.; Aboud, Ahmed; Mahran, Moustafa G.; Nasef, Marwa A.A.; Gaber, Mohamed; Sabry, Tamer; Ibrahim, Mohamed H.; Taha, Mohamed H.
BACKGROUND: Children with cerebral palsy (CP) can present with severe secondary dystonia with or without associated spasticity of their extremities. OBJECTIVE: To assess the outcomes of combined anterior and posterior lumbar rhizotomy for the treatment of mixed hypertonia in the lower extremities of children with CP. METHODS: Fifty children with CP were subjected to combined anterior and posterior lumbar rhizotomies in a prospective study. Clinical outcome measurements were recorded preoperatively and were evaluated at 2, 6, and 12 months postoperatively. The operative techniques were performed by laminotomy from L1-S1, and intraoperative monitoring was used in all cases. All patients underwent intensive postoperative physiotherapy programs. RESULTS: Changes in muscle tone, joint range of motion, and dystonia were significant (P = .000) at postoperative assessment visits. CONCLUSION: This study demonstrated the potential of combined anterior and posterior lumbar rhizotomies to improve activities of daily living in children with CP and with mixed spasticity and dystonia. ABBREVIATIONS: BAD, Barry-Albright Dystonia Scale CAPR, combined anterior and posterior lumbar rhizotomy CP, cerebral palsy ITB, intrathecal baclofen MAS, modified Ashworth Scale ROM, range of motion SDR, selective dorsal rhizotomy PMID:27244465
Objective. The authors present the clinical results obtained in patients who underwent interspinous fusion device (IFD) implantation following posterior lumbar interbody fusion (PLIF). The purpose of this study is investigating the feasibility of IFD with PLIF in the treatment of lumbar spondylolisthesis. Methods. Between September 2013 and November 2014, 39 patients underwent PLIF and subsequent IFD (Romeo®2 PAD, Spineart, Geneva, Switzerland) implantation. Medical records of these patients were retrospectively reviewed to collect relevant data such as blood loss, operative time, and length of hospital stay. Radiographs and clinical outcome were evaluated 6 weeks and 12 months after surgery. Results. All 39 patients were followed up for more than one year. There were no major complications such as dura tear, nerve injuries, cerebrospinal fluid leakage, or deep infection. Both interbody and interspinous fusion could be observed on radiographs one year after surgery. However, there were 5 patients having early retropulsion of interbody fusion devices. Conclusion. The interspinous fusion device appears to achieve posterior fixation and facilitate lumbar fusion in selected patients. However, further study is mandatory for proposing a novel anatomic and radiological scoring system to identify patients suitable for this treatment modality and prevent postoperative complications. PMID:28164125
Zarate-Kalfopulos, Baron; Romero-Vargas, Samuel; Alcántara-Canseco, Cesar; Rosales-Olivarez, Luis Miguel; Alpizar-Aguirre, Armando; Reyes-Sánchez, Alejandro
Study Design Case report. Objective The diagnosis and surgical management of a patient with traumatic bilateral posterior dislocation of L4-L5 is presented with a thorough review of the existing literature. Summary of Background Data Traumatic dislocation of L4-L5 has been reported in the English literature in only five cases; of these, only two were retrolisthesis. Methods A 20-year-old patient was involved in a high-energy vehicular accident and presented with back pain and inability to ambulate. Neurological assessment showed motor strength grade 2/5 in the proximal lower-extremity muscle groups (L1-L3 myotomes) and 0/5 strength distally (L4-S1 myotomes); in addition, incontinence of sphincters was found. X-rays and computed tomography (CT) scan revealed a three-column ligamentous injury with posterior fracture-dislocation of the L4 vertebral body with complete posterior displacement of L4 to L5 vertebral body. The patient underwent posterior approach with reduction, transpedicular fixation, and posterolateral fusion with autologous bone graft. Results At 1-year follow-up, the patient had recovered muscular strength in proximal lower-extremities muscle groups, sphincter function had fully recovered, and he was able to ambulate with crutches. There was no recovery of distal extremity sensorimotor function. Plain radiograph and CT scan showed good alignment and progressive maturation of his fusion procedure. Conclusion Traumatic retrolisthesis of L4-L5 is a high-energy unstable fracture; reduction of the dislocation is challenging because of the heavy forces acting in the lower lumbar spine. Instrumented fusion restores alignment and maintains segmental stability.
Mannoji, Chikato; Murakami, Masazumi; Kinoshita, Tomoaki; Hirayama, Jiro; Miyashita, Tomohiro; Eguchi, Yawara; Yamazaki, Masashi; Suzuki, Takane; Aramomi, Masaaki; Ota, Mitsutoshi; Maki, Satoshi; Takahashi, Kazuhisa; Furuya, Takeo
Study Design Retrospective case-control study. Purpose To determine whether kissing spine is a risk factor for recurrence of sciatica after lumbar posterior decompression using a spinous process floating approach. Overview of Literature Kissing spine is defined by apposition and sclerotic change of the facing spinous processes as shown in X-ray images, and is often accompanied by marked disc degeneration and decrement of disc height. If kissing spine significantly contributes to weight bearing and the stability of the lumbar spine, trauma to the spinous process might induce a breakdown of lumbar spine stability after posterior decompression surgery in cases of kissing spine. Methods The present study included 161 patients who had undergone posterior decompression surgery for lumbar canal stenosis using a spinous process floating approaches. We defined recurrence of sciatica as that resolved after initial surgery and then recurred. Kissing spine was defined as sclerotic change and the apposition of the spinous process in a plain radiogram. Preoperative foraminal stenosis was determined by the decrease of perineural fat intensity detected by parasagittal T1-weighted magnetic resonance imaging. Preoperative percentage slip, segmental range of motion, and segmental scoliosis were analyzed in preoperative radiographs. Univariate analysis followed by stepwise logistic regression analysis determined factors independently associated with recurrence of sciatica. Results Stepwise logistic regression revealed kissing spine (p=0.024; odds ratio, 3.80) and foraminal stenosis (p<0.01; odds ratio, 17.89) as independent risk factors for the recurrence of sciatica after posterior lumbar spinal decompression with spinous process floating procedures for lumbar spinal canal stenosis. Conclusions When a patient shows kissing spine and concomitant subclinical foraminal stenosis at the affected level, we should sufficiently discuss the selection of an appropriate surgical procedure. PMID
Stundner, O; Chiu, Y-L; Sun, X; Ramachandran, S-K; Gerner, P; Vougioukas, V; Mazumdar, M; Memtsoudis, S G
Despite the increasing prevalence of sleep apnoea, little information is available regarding its impact on the peri-operative outcome of patients undergoing posterior lumbar fusion. Using a national database, patients who underwent lumbar fusion between 2006 and 2010 were identified, sub-grouped by diagnosis of sleep apnoea and compared. The impact of sleep apnoea on various outcome measures was assessed by regression analysis. The records of 84,655 patients undergoing posterior lumbar fusion were identified and 7.28% (n = 6163) also had a diagnostic code for sleep apnoea. Compared with patients without sleep apnoea, these patients were older, more frequently female, had a higher comorbidity burden and higher rates of peri-operative complications, post-operative mechanical ventilation, blood product transfusion and intensive care. Patients with sleep apnoea also had longer and more costly periods of hospitalisation. In the regression analysis, sleep apnoea emerged as an independent risk factor for the development of peri-operative complications (odds ratio (OR) 1.50, confidence interval (CI) 1.38;1.62), blood product transfusions (OR 1.12, CI 1.03;1.23), mechanical ventilation (OR 6.97, CI 5.90;8.23), critical care services (OR 1.86, CI 1.71;2.03), prolonged hospitalisation and increased cost (OR 1.28, CI 1.19;1.37; OR 1.10, CI 1.03;1.18). Patients with sleep apnoea who undergo posterior lumbar fusion pose significant challenges to clinicians.
Background Interbody fusion by open discectomy is the usual treatment for degenerative disk disease but requires a relatively long recovery period. The transforaminal posterolateral approach is a well-known standard in endoscopic spine surgery that allows direct access to the disk with progressive tissue dilation. The aim of this study was to assess the feasibility of percutaneous transforaminal interbody fusion (pTLIF) with percutaneous insertion of an expandable or a standard rigid interbody implant for patients with degenerative disk disease with or without spondylolisthesis and for revision surgery with the endoscopic posterolateral approach. Methods Between 2009 and 2014, the pTLIF procedure was performed in 30 patients. Ten patients underwent insertion of a rigid implant (group A) and the remaining 20 underwent insertion of an expandable titanium interbody implant as the initial procedure (n = 10) (group B) or after failed back surgery (n = 10) (group C). Patient outcomes were scored with visual analogic scale (VAS), Oswestry disability index (ODI) and modified Macnab criteria. Results The mean follow-up period was 38 (17) (range 11 to 67) months. The outcome was excellent in 18, good in 10 and fair in 2. No poor results and no major complications were reported. No significant (p<0.05) differences in VAS and ODI scores according to the study group were found. Median postoperative time until hospital discharge was 26 hours (20 to 68 hours). Postoperative values for VAS and ODI scores improved significantly (p<0.05) compared to preoperative data in all study groups. Conclusions These preliminary results have shown the feasibility and efficacy of the pTLIF procedure using a percutaneous posterolateral approach for the treatment of degenerative disk disease with or without spondylolisthesis up to grade 2 and in revision surgery. No significant differences in outcome were observed between an expandable and a rigid cage. Median postoperative time until hospital
Higashino, Kosaku; Fumitake, Tezuka; Yamashita, Kazuta; Hayashi, Fumio; Sairyo, Koichi
A lesion of the lumbar posterior endplate is sometimes identified in the spinal canal of children and adolescents; it causes symptoms similar to those of a herniated disc. However, the pathology of the endplate lesion and the pathology of the herniated disc are different. We present a rare case of a 23-year-old woman who developed progressive palsy of the lower leg caused by huge lumbar posterior endplate lesion after recurrent disc herniation. PMID:27648326
Andress, H-J; Braun, H; Helmberger, T; Schürmann, M; Hertlein, H; Hartl, W H
Current concepts of treating thoraco-lumbar burst-compression injuries are based on posterior transpedicular fixation techniques which are angular stable. However, the long-term results of this approach are controversial due to inconsistent reports and due to a paucity of data on late outcome. In the present study we analyzed 50 patients retrospectively who had an unstable burst-compression injury at T 11-L 2 (type A 3 according to Magerl) without a neurological deficit. All fractures were stabilized by an internal fixator either with or without transpedicular spongiosa grafting. Patients were treated between 1991 and 1997. Follow-up times ranged from 36 to 103 months. Follow-up examinations collected occupational, subjective and clinical data (activity score, Hannover spine score) and included radiographic measurements. The latter were used to calculate the sagittal index (SI) which measures deformities of the fractured vertebral body, and the sagittal plane kyphosis (SPK) which additionally describes an eventual destruction of the affected intervertebral disc. Compared with the preinjury status, the percentage of subjects who were able to do physical labor was reduced by half at follow-up, and four times as many patients had a permanent disability. Correspondingly, activity scores and Hannover spine scores declined significantly. After the initial surgical correction SI remained stable until follow-up, whereas SPK decreased again towards pre-operative values indicating a progressive deformity of the intervertebral disc space. Clinical results did not correlate with radiographic results, and neither the time until follow-up nor the type of fracture n or the use of transpedicular bone grafting affected clinical or radiographic results significantly.
Szlezak, Adam Michael; Georgilopoulos, Peter; Bullock-Saxton, Joanne Elizabeth; Steele, Michael Craig
Hamstring strain (HS) is a common musculoskeletal condition and abnormal neurodynamics has been shown to influence HS and delay recovery. The efficacy of stretching for preventing and treating HS remains uncertain despite extensive research and wide-spread use. The effects of cervical spine mobilisation on peripheral nervous system function, neurodynamics and muscle force in the upper limb have been reported. Very few studies have reported effects of lumbar spine mobilisation on these variables in the lower limb. This study aimed to determine immediate effects of either a unilateral zygopophyseal joint posteroanterior mobilisation or a static posterior chain muscle stretch on the range of passive straight leg raise (SLR) in comparison to a non-treatment control. Using a single-blinded, randomised controlled study design, 36 healthy participants were allocated into one of three groups (control; mobilisation; static posterior chain muscle stretch). Measures of SLR were taken before and after intervention for each group on the day of testing. A General Linear Model (GLM) and a paired sample t-test showed a significant difference between base line and post-intervention for the mobilisation group only (p < 0.001), and suggests that unilateral lumbar spine zygopophyseal joint mobilisation can immediately restore posterior chain neurodynamics.
Sun, Peidong; Zhao, Weidong; Bi, Zhenyu; Wu, Changfu; Ouyang, Jun
An understanding of the load transfer within spinal posterior column of lumbar spine is necessary to determine the influence of mechanical factors on potential mechanisms of the motion-sparing implant such as artificial intervertebral disc and the dynamic spine stabilization systems. In this study, a new method has been developed for evaluating the load bearing of spinal posterior column by the surface strain of spinal pedicle response to the loading of spinal segment. Six cadaveric lumbar spine segments were biomechanically evaluated between levels L1 and L5 in intact condition and the strain gauges were pasted to an inferior surface of L2 pedicles. Multidirectional flexibility testing used the Panjabi testing protocol; pure moments for the intact condition with overall spinal motion and unconstrained intact moments of ±8 Nm were used for flexion-extension and lateral bending testing. High correlation coefficient (0.967-0.998) indicated a good agreement between the load of spinal segment and the surface strain of pedicle in all loading directions. Principal compressive strain could be observed in flexion direction and tensile strain in extension direction, respectively. In conclusion, the new method seems to be effective for evaluating posterior spinal column loads using pedicles' surface strain data collected during biomechanical testing of spine segments.
Eleraky, Mohammed; Papanastassiou, Ioannis; Tran, Nam D; Dakwar, Elias; Vrionis, Frank D
Single-stage posterior corpectomy for the management of spinal tumors has been well described. Anterior column reconstruction has been accomplished using polymethylmethacrylate (PMMA) or expandable cages (EC). The aim of this retrospective study was to compare PMMA versus ECs in anterior vertebral column reconstruction after posterior corpectomy for tumors in the lumbar and thoracolumbar spine. Between 2006 and 2009 we identified 32 patients that underwent a single-stage posterior extracavitary tumor resection and anterior reconstruction, 16 with PMMA and 16 with EC. There were no baseline differences in regards to age (mean: 58.2 years) or performance status. Differences between groups in terms of survival, estimated blood loss (EBL), kyphosis reduction (decrease in Cobb's angle), pain, functional outcomes, and performance status were evaluated. Mean overall survival and EBL were 17 months and 1165 ml, respectively. No differences were noted between the study groups in regards to survival (p = 0.5) or EBL (p = 0.8). There was a trend for better Kyphosis reduction in favor of the EC group (10.04 vs. 5.45, p = 0.16). No difference in performance status or VAS improvements was observed (p > 0.05). Seven patients had complications that led to reoperation (5 infections). PMMA or ECs are viable options for reconstruction of the anterior vertebral column following tumor resection and corpectomy. Both approaches allow for correction of the kyphotic deformity, and stabilization of the anterior vertebral column with similar functional and performance status outcomes in the lumbar and thoracolumbar area.
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
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.
Frati, Alessandro; Palmieri, Mauro; Vangelista, Tommaso; Caruso, Riccardo; Salvati, Maurizio; Raco, Antonino
Extrusion of disc material within the spinal canal complicates up to 28.6% of lumbar disc herniations. Due to the anatomical “corridors” created by the anterior midline septum and lateral membranes, relocation occurs with an anterior and anterolateral axial topography. Posterior migration is an extremely rare condition and anterior-to-posterior circumferential migration is an even rarer condition. Its radiological feature can be enigmatic and since, in more than 50% of cases, clinical onset is a hyperacute cauda equina syndrome, it may imply a difficult surgical decision in emergency settings. Surgery is the gold standard but when dealing with such huge sequestrations, standard microdiscectomy must be properly modified in order to minimize the risk of surgical trauma or traction on the nerve roots. PMID:28163949
Mashaly, Hazem; Paschel, Erin E; Khattar, Nicolas K; Goldschmidt, Ezequiel; Gerszten, Peter C
OBJECTIVE The development of symptomatic adjacent-segment disease (ASD) is a well-recognized consequence of lumbar fusion surgery. Extension of a fusion to a diseased segment may only lead to subsequent adjacent-segment degeneration. The authors report the use of a novel technique that uses dynamic stabilization instead of arthrodesis for the surgical treatment of symptomatic ASD following a prior lumbar instrumented fusion. METHODS A cohort of 28 consecutive patients was evaluated who developed symptomatic stenosis immediately adjacent to a previous lumbar instrumented fusion. All patients had symptoms of neurogenic claudication refractory to nonsurgical treatment and were surgically treated with decompression and dynamic stabilization instead of extending the fusion construct using a posterior lumbar dynamic stabilization system. Preoperative symptoms, visual analog scale (VAS) pain scores, and perioperative complications were recorded. Clinical outcome was gauged by comparing VAS scores prior to surgery and at the time of last follow-up. RESULTS The mean follow-up duration was 52 months (range 17-94 months). The mean interval from the time of primary fusion surgery to the dynamic stabilization surgery was 40 months (range 10-96 months). The mean patient age was 51 years (range 29-76 years). There were 19 (68%) men and 9 (32%) women. Twenty-three patients (82%) presented with low-back pain at time of surgery, whereas 24 patients (86%) presented with lower-extremity symptoms only. Twenty-four patients (86%) underwent operations that were performed using single-level dynamic stabilization, 3 patients (11%) were treated at 2 levels, and 1 patient underwent 3-level decompression and dynamic stabilization. The most commonly affected and treated level (46%) was L3-4. The mean preoperative VAS pain score was 8, whereas the mean postoperative score was 3. No patient required surgery for symptomatic degeneration rostral to the level of dynamic stabilization during the
Kim, Kyung-Hyun; Park, Jeong-Yoon; Park, Hyo-Suk; Kim, Keun-Su; Chin, Dong-Kyu; Cho, Yong-Eun
Purpose To determine the influence of different ratios of hydroxyapatite (HA)/beta tricalcium phosphate (β-TCP) and collagen augmentation for posterior lumbar fusion in a rat model. Materials and Methods We generated a posterior lumbar fusion model in 50 rats and divided it into five groups of equal number as follows; 1) autologous bone graft as group A, 2) 70% HA+30% β-TCP as group B, 3) 70% HA+30% β-TCP+collagen as group C, 4) 30% HA+70% β-TCP as group D, and 5) 30% HA+70% β-TCP+collagen as group E. Rats were euthanized at 12 weeks after surgery and fusion was assessed by manual palpation, quantitative analysis using microCT and histology. Results The score of manual palpation was significantly higher in group C than group E (3.1±1.1 vs. 1.8±0.8, p=0.033). However, in terms of microCT analysis, group D showed significantly higher scores than group B (5.5±0.8 vs. 3.1±1.1, p=0.021). According to quantitative volumetric analysis, 30% HA+70% β-TCP groups (group D and E) showed significantly reduced fusion mass at 12 weeks after surgery (123±14.2, 117±46.3 vs. 151±27.3, p=0.008, 0.003, respectively). Collagen augmentation groups revealed superior results in terms of both microCT score and histologic grade. Conclusion A 7:3 HA/β-TCP ratio with collagen augmentation rather than a 3:7 HA/β-TCP ratio could be a more favorable graft substitute for lumbar spinal fusion. There was positive role of collagen as an adjunct for spinal bone fusion process. PMID:28120573
Gagnon, Dany H; Longtin, Christian; Berbiche, Djamal; Gaudreault, Nathaly
This study aims to quantify the force applied during posterior-to-anterior lumbar vertebrae mobilizations of different grades (I to IV) and compare that force between experienced physiotherapists and final year physiotherapy students. Four experienced physiotherapists and four final year physiotherapy students participated in this study along with five healthy asymptomatic individuals. A manual therapy table positioned over three force plates allowed for measurements of the force oscillation frequency and intensity applied during grade I, II, III and IV posterior-to-anterior (PA) mobilizations at two lumbar vertebral levels (L2 and L4). Mixed model ANOVAs were used to compare the force applied between the experienced physiotherapists and students, and between the various grades. The results showed that the mean oscillation frequency was similar between the groups for all grades. Grade I and grade IV PA mobilizations showed similar mean oscillation frequency as did grade II and III PA mobilizations. The minimum and maximum force applied was higher for the physiotherapists than for the students for all mobilization grades (p values < 0.05). Similar mean maximum force values were recorded for PA mobilizations between grade I and II and between grade III and grade IV. Grade III and IV PA mobilizations yielded higher mean maximum force values than those recorded during grade I and grade II PA mobilizations. The method used in this study allowed for quantification of the force applied during lumbar PA mobilizations. Experienced physiotherapists apply greater force than physiotherapy students across all grades, despite similar oscillation frequency.
Hsieh, Chang-Sheng; Lee, Sang-Ho; Lee, Hyung Chang; Oh, Hyeong-Seok; Hwang, Byeong-Wook; Park, Sang-Joon; Chen, Jian-Han
Congenital hypoplasia of the spinal pedicle is a rare condition. Previously reported cases were treated conservatively or with posterior instrumented fusion. However, the absence or hypoplasia of the lumbar pedicle may increase the difficulty of pedicle screw fixation and fusion. Herein, the authors describe 2 cases of rare adult congenital hypoplasia of the right lumbar pedicles associated with spondylolisthesis. The patients underwent anterior lumbar interbody fusion with a stand-alone cage as well as percutaneous pedicle screw fixation. This method was used to avoid the difficulties associated with pedicle screw fixation and to attain solid fusion. Both patients achieved satisfactory outcomes after a minimum of 2 years of follow-up. This method may be an alternative for patients with congenital hypoplasia of the lumbar spinal pedicle.
Deukmedjian, Ara J; Cianciabella, Augusto J; Cutright, Jason; Deukmedjian, Arias
Background: Lumbar fusion is a proven treatment for chronic lower back pain (LBP) in the setting of symptomatic spondylolisthesis and degenerative scoliosis; however, fusion is controversial when the primary diagnosis is degenerative disc disease (DDD). Our objective was to evaluate the safety and effectiveness of lumbar fusion in the treatment of LBP due to DDD. Materials and Methods: Two-hundred and five consecutive patients with single or multi-level DDD underwent lumbar decompression and instrumented fusion for the treatment of chronic LBP between the years of 2008 and 2011. The primary outcome measures in this study were back and leg pain visual analogue scale (VAS), patient reported % resolution of preoperative back pain and leg pain, reoperation rate, perioperative complications, blood loss and hospital length of stay (LOS). Results: The average resolution of preoperative back pain per patient was 84% (n = 205) while the average resolution of preoperative leg pain was 90% (n = 190) while a mean follow-up period of 528 days (1.5 years). Average VAS for combined back and leg pain significantly improved from a preoperative value of 9.0 to a postoperative value of 1.1 (P ≤ 0.0001), a change of 7.9 points for the cohort. The average number of lumbar disc levels fused per patient was 2.3 (range 1-4). Median postoperative LOS in the hospital was 1.2 days. Average blood loss was 108 ml perfused level. Complications occurred in 5% of patients (n = 11) and the rate of reoperation for symptomatic adjacent segment disease was 2% (n = 4). Complications included reoperation at index level for symptomatic pseudoarthrosis with hardware failure (n = 3); surgical site infection (n = 7); repair of cerebrospinal fluid leak (n = 1), and one patient death at home 3 days after discharge. Conclusion: Lumbar fusion for symptomatic DDD can be a safe and effective treatment for medically refractory LBP with or without leg pain. PMID:26692696
Cunningham, Bryan W.; Tortolani, P. Justin; Fedder, Ira L.; Sefter, John C.; Davis, Charles
Background This prospective study analyzes the perioperative outcomes and long-term fusion success of 100 consecutive lumbar degenerative cases. The cases were managed using a non-threaded locking screw system, in conjunction with polyetheretherketone (PEEK) cages, for posterior lumbar interbody fusion (PLIF) procedures. These 100 cases were compared to another prospective study treating patients with the same inclusion and exclusion criteria using conventional plate-based pedicle screw spinal instrumentation augmented with carbon fiber interbody cages. Methods A total of 167 operative levels were treated in 100 patients (51 single-level, 39 two-level and 10 three-level cases). Eleven cases were revisions and 67 patients received interbody fusion cages. Patients had an average of 22.8 ± 4.0 months followup. Results: There was one instrumentation failure but no significant subsidence at the interbody fusion level. The disc space height was restored as part of the surgical procedure at the interbody cage levels: from 7.5 ± 2.3 mm preoperative to 9.0 ± 2.1 mm postoperative. There were 2 cases of pseudarthrosis (2 / 100 = 2%). The average operative time for 1-level cases was 111 ± 25 minutes; for 2-level cases it was 132.4 ± 21.8 minutes; and for 3-level cases it was 162.6 ± 33 minutes. Blood loss averaged 800 ± 473 cc for 1-level cases, 1055 ± 408 cc for 2 levels, and 1155 ± 714 cc for 3 levels. The length of stay was similar between the 3 groups (4.4 ± 1.2 days for single-level cases, 4.7 ± 1.1 for 2 levels, and 5.0 ± 1.1 for 3 levels; P > .05). There were 3 incidental durotomies, and 4 other patients developed infections postoperatively that required reoperation. Conclusion The disc and foraminal heights can be restored and maintained with a unilateral cage and pedicle screw construct. Unilateral transforaminal lumbar interbody fusion using a PEEK cage combined with a non-threaded locking pedicle screw and rod system results in similar fusion rates to
Chen, C Y; Chuang, Y L; Yao, M S; Chiu, W T; Chen, C L; Chan, W P
We present a 75-year-old man who, for 2 weeks, had progressive pain in both of his thighs when standing straight. MR imaging showed a sequestrated disk fragment, which had a signal intensity similar to that of a herniated disk with a rim enhancement in the posterior epidural space and a ruptured outermost annulus of the intervertebral disk at L2-3. Awareness of these MR imaging findings can help in the diagnosis of posterior epidural disk migration.
Zarate-Kalfopulos, Baron; Romero-Vargas, Samuel; Alcántara-Canseco, Cesar; Rosales-Olivarez, Luis Miguel; Alpizar-Aguirre, Armando; Reyes-Sánchez, Alejandro
Study Design Case report. Objective The diagnosis and surgical management of a patient with traumatic bilateral posterior dislocation of L4–L5 is presented with a thorough review of the existing literature. Summary of Background Data Traumatic dislocation of L4–L5 has been reported in the English literature in only five cases; of these, only two were retrolisthesis. Methods A 20-year-old patient was involved in a high-energy vehicular accident and presented with back pain and inability to ambulate. Neurological assessment showed motor strength grade 2/5 in the proximal lower-extremity muscle groups (L1–L3 myotomes) and 0/5 strength distally (L4–S1 myotomes); in addition, incontinence of sphincters was found. X-rays and computed tomography (CT) scan revealed a three-column ligamentous injury with posterior fracture-dislocation of the L4 vertebral body with complete posterior displacement of L4 to L5 vertebral body. The patient underwent posterior approach with reduction, transpedicular fixation, and posterolateral fusion with autologous bone graft. Results At 1-year follow-up, the patient had recovered muscular strength in proximal lower-extremities muscle groups, sphincter function had fully recovered, and he was able to ambulate with crutches. There was no recovery of distal extremity sensorimotor function. Plain radiograph and CT scan showed good alignment and progressive maturation of his fusion procedure. Conclusion Traumatic retrolisthesis of L4–L5 is a high-energy unstable fracture; reduction of the dislocation is challenging because of the heavy forces acting in the lower lumbar spine. Instrumented fusion restores alignment and maintains segmental stability. PMID:24353974
Chang, C K; Tsai, W S; Liu, H J; Pan, W C
Improper and invasive management of low back pain may lead to an unexpected tragedy, vertebral osteomyelitis. A 30-year-old female patient suffering from low back pain after a lumbar strain called on a herbal therapist and was given a herb massage with some unknown medication. Unfortunately, a persistent painful ulcer with discharge developed over her back. She was referred to our clinic shortly after where x-ray showed bony destruction over the spinous process, facet, and lamina of L4. Fistulectomy, debridement and spinal fusion were performed. A satisfactory outcome was finally achieved.
Staub, Blake N; Holman, Paul J
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.
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
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
Wang, Hui; Ma, Lei; Yang, Dalong; Wang, Tao; Liu, Sen; Yang, Sidong; Ding, Wenyuan
The purpose of this study was to explore incidence and risk factors of adjacent segment disease (ASD) following posterior decompression and instrumented fusion for degenerative lumbar disorders, and hope to provide references in decision making and surgical planning for both spinal surgeon and surgically treated patients.By retrieving the medical records from January 2011 to December 2013 in our hospital, 237 patients were retrospectively reviewed. According to the occurrence of ASD at follow up, patients were divided into 2 groups: ASD and N-ASD group. To investigate risk values for the occurrence of ASD, 3 categorized factors were analyzed statistically: Patient characteristics: age, sex, body mass index (BMI), bone mineral density (BMD), duration. Surgical variables: surgical strategy, number of fusion level, surgery segment, surgery time, blood loss, intraoperative superior facet joint violation. Radiographic parameters: preoperative lumbar lordosis, preoperative angular motion at adjacent segment, preoperative adjacent segment disc degeneration, preoperative paraspinal muscle degeneration.Postoperative ASD was developed in 15 of 237 patients (6.3%) at final follow up. There was no statistically significant difference between the 2 groups in patient characteristics of age, sex composition, BMD, duration, while the BMI was higher in ASD group than that in N-ASD group. There was no difference in surgical variables of surgical strategy, number of fusion level, surgery segment, surgery time, blood loss, while intraoperative superior facet joint violation was more common in ASD group than that in N-ASD group. There was no difference in radiographic parameters of preoperative lumbar lordosis, preoperative paraspinal muscle degeneration, while preoperative adjacent segment disc degeneration were more severe in ASD group than that in N-ASD group. The Logistic regression analysis revealed that, BMI >25 kg/m, preoperative disc degeneration, and superior facet joint
Wang, Hui; Ma, Lei; Yang, Dalong; Wang, Tao; Liu, Sen; Yang, Sidong; Ding, Wenyuan
Abstract The purpose of this study was to explore incidence and risk factors of adjacent segment disease (ASD) following posterior decompression and instrumented fusion for degenerative lumbar disorders, and hope to provide references in decision making and surgical planning for both spinal surgeon and surgically treated patients. By retrieving the medical records from January 2011 to December 2013 in our hospital, 237 patients were retrospectively reviewed. According to the occurrence of ASD at follow up, patients were divided into 2 groups: ASD and N-ASD group. To investigate risk values for the occurrence of ASD, 3 categorized factors were analyzed statistically: Patient characteristics: age, sex, body mass index (BMI), bone mineral density (BMD), duration. Surgical variables: surgical strategy, number of fusion level, surgery segment, surgery time, blood loss, intraoperative superior facet joint violation. Radiographic parameters: preoperative lumbar lordosis, preoperative angular motion at adjacent segment, preoperative adjacent segment disc degeneration, preoperative paraspinal muscle degeneration. Postoperative ASD was developed in 15 of 237 patients (6.3%) at final follow up. There was no statistically significant difference between the 2 groups in patient characteristics of age, sex composition, BMD, duration, while the BMI was higher in ASD group than that in N-ASD group. There was no difference in surgical variables of surgical strategy, number of fusion level, surgery segment, surgery time, blood loss, while intraoperative superior facet joint violation was more common in ASD group than that in N-ASD group. There was no difference in radiographic parameters of preoperative lumbar lordosis, preoperative paraspinal muscle degeneration, while preoperative adjacent segment disc degeneration were more severe in ASD group than that in N-ASD group. The Logistic regression analysis revealed that, BMI >25 kg/m2, preoperative disc degeneration, and superior
Emstad, Erik; del Monaco, Diana Cardenas; Fielding, Louis C; Block, Jon E
Intervertebral fusion cages have been in clinical use since the 1990s. Cages offer the benefits of bone graft containment, restored intervertebral and foraminal height, and a more repeatable, stable procedure compared to interbody fusion with graft material alone. Due to concerns regarding postoperative stability, loss of lordosis, and subsidence or migration of the implant, interbody cages are commonly used with supplemental fixation such as pedicle screw systems or anterior plates. While providing additional stability, supplemental fixation techniques increase operative time, exposure, cost, and morbidity. The VariLift® Interbody Fusion System (VariLift® system) has been developed as a standalone solution to provide the benefits of intervertebral fusion cages without the requirement of supplemental fixation. The VariLift® system, FDA-cleared for standalone use in both the cervical and lumbar spine, is implanted in a minimal profile and then expanded in situ to provide segmental stability, restored lordosis, and a large graft chamber. Preclinical testing and analyses have found that the VariLift® System is durable, and reduces stresses that may contribute to subsidence and migration of other standalone interbody cages. Fifteen years of clinical development with the VariLift® system have demonstrated positive clinical outcomes, continued patient maintenance of segmental stability and lordosis, and no evidence of implant migration. The purpose of this report is to describe the VariLift® system, including implant characteristics, principles of operation, indications for use, patient selection criteria, surgical technique, postoperative care, preclinical testing, and clinical experience. The VariLift® System represents an improved surgical option for a stable interbody fusion without requiring supplemental fixation. PMID:26060414
Caputo, Adam M; Michael, Keith W; Chapman, Todd M; Jennings, Jason M; Hubbard, Elizabeth W; Isaacs, Robert E; Brown, Christopher R
Extreme lateral interbody fusion (XLIF; NuVasive Inc., San Diego, CA, USA) is a minimally invasive lateral transpsoas approach to the thoracolumbar spine. Though the procedure is rapidly increasing in popularity, limited data is available regarding its use in deformity surgery. We aimed to evaluate radiographic correction using XLIF in adults with degenerative lumbar scoliosis. Thirty consecutive patients were followed for an average of 14.3 months. Interbody fusion was completed using the XLIF technique with supplemental posterior instrumentation. Plain radiographs were obtained on all patients preoperatively, postoperatively, and at most recent follow-up. Plain radiographic measurements of coronal Cobb angle, apical vertebral translation, segmental lordosis, global lordosis, disc height, neuroforaminal height and neuroforaminal width were made at each time point. CT scans were obtained for all patients 1 year after surgery to evaluate for fusion. There was significant improvement in multiple radiographic parameters from preoperative to postoperative. Cobb angle corrected 72.3%, apical vertebral translation corrected 59.7%, neuroforaminal height increased 80.3%, neuroforaminal width increased 7.4%, and disc height increased 116.7%. Segmental lordosis at L4-L5 increased 14.1% and global lordosis increased 11.5%. There was no significant loss of correction from postoperative to most recent follow-up. There was an 11.8% pseudoarthrosis rate at levels treated with XLIF. Complications included lateral incisional hernia (n=1), rupture of anterior longitudinal ligament (n=2), wound breakdown (n=2), cardiac instability (n=1), pedicle fracture (n=1), and nonunion requiring revision (n=1). XLIF significantly improves coronal plane deformity in patients with adult degenerative scoliosis. XLIF has the ability to correct sagittal plane deformity, although it is most effective at lower lumbar levels.
Lee, Gun-Ill; Chun, Hyoung-Joon; Choi, Kyu-Sun
Objective We conducted this study to report the efficacy of local application of vancomycin powder in the setting of surgical site infection (SSI) of posterior lumbar surgical procedures and to figure out risk factors of SSIs. Methods From February 2013 to December 2013, SSI rates following 275 posterior lumbar surgeries of which intrawound vancomycin powder was used in combination with intravenous antibiotics (Vanco group) were assessed. Compared with 296 posterior lumbar procedures with intravenous antibiotic only group from February 2012 to December 2012 (non-Vanco group), various infection rates were assessed. Univariate and multivariate analysis to figure out risk factors of infection among Vanco group were done. Results Statistically significant reduction of SSI in Vanco group (5.5%) from non-Vanco group (10.5%) was confirmed (p=0.028). Mean follow-up period was 8 months. Rate of acute staphylococcal SSIs reduced statistically significantly to 4% compared to 7.4% of non-Vanco group (p=0.041). Deep staphylococcal infection decreased to 2 compared to 8 and deep methicillin-resistant Staphylococcus aureus infection also decreased to 1 compared to 5 in non-Vanco group. No systemic complication was observed. Statistically significant risk factors associated with SSI were diabetes mellitus, history of cardiovascular disease, length of hospital stay, number of instrumented level and history of previous surgery. Conclusion In this series of 571 patients, intrawound vancomycin powder usage resulted in significant decrease in SSI rates in our posterior lumbar surgical procedures. Patients at high risk of infection are highly recommended as a candidate for this technique. PMID:27437012
Wang, Fei; Xu, Xi-ming; Wei, Xian-zhao; Zhu, Xiao-dong; Li, Ming
Abstract Selective fusion of the thoracolumbar/lumbar (TL/L) curve is an effective method for the treatment of Lenke type 5C curves. Several studies have demonstrated that spontaneous correction of the thoracic curve does indeed occur. However, how this correction occurs after isolated posterior segmental instrumentation of the structural lumbar curve has not been well described. The aim of this study was to evaluate the response of the thoracic curve to selective TL/L curve fusion in patients with Lenke type 5C adolescent idiopathic scoliosis (AIS) and assess the correlative clinical outcomes. Thirty-four consecutive patients with Lenke type 5C AIS were included in this study. All patients underwent selective TL/L curve instrumentation and fusion via the posterior approach. Coronal and sagittal radiographs were analyzed before surgery, at 1 week after surgery and at least 2 years after surgery. The preoperative coronal Cobb angle of the major TL/L curve was 45.4° ± 7.0°, and that of the minor thoracic curve was 25.4° ± 8.8°. The major TL/L and minor thoracic curves were corrected to postoperative angles of 9.5° ± 5.0° and 11.2° ± 5.2°, respectively, and measured 10.5° ± 6.0° and 13.4° ± 7.5° at the follow-up, respectively. The supine side-bending average Cobb angle of the thoracic curve was 9.9°. These results demonstrate satisfactory improvements because of coronal and sagittal restoration. Significant correlations were found between the preoperative and early postoperative conditions and the Cobb angle changes of the minor thoracic curve and the major TL/L curves (r = 0.42, P = 0.01). Significant correlations were also observed between the early and final follow-up postoperative conditions and the Cobb angle changes of the minor thoracic curve and the major TL/L curves (r = 0.57, P < 0.001). Significant correlations were observed between increased thoracic kyphosis (TK) and increased lumbar lordosis (LL
Background 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. Study design/setting 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. Methods 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. Results 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. Conclusions 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
Yaldiz, Can; Yaldiz, Mahizer; Ceylan, Nehir; Kacira, Ozlem Kitiki; Ceylan, Davut; Kacira, Tibet; Kizilcay, Gokhan; Tanriverdi, Taner
Owing to the increasing population of elderly patients, a large number of patients with degenerative spondylosis are currently being surgically treated. Although basic measures for decreasing postoperative surgical infections (PSIs) are considered, it still remains among the leading causes of morbidity and mortality. The aim of this retrospective analysis is to present possible causes leading to PSI in patients who underwent surgery for lumbar degenerative spondylosis and highlight how it can be avoided to decrease morbidity and mortality. The study included 540 patients who underwent posterior stabilization due to degenerative lumbar stenosis between January 2013 and January 2014. The data before and after surgery was retrieved from the hospital charts. Patients with degenerative lumbar stenosis who were operated upon in this study had >2 levels of laminectomy and facetectomy. For this reason, posterior stabilization was performed for all the patients included in this study. Determining the causes of postoperative infection (PI) following spinal surgeries performed with instrumentation is a struggle. Seventeen different parameters that may be related to PI were evaluated in this study. The presence of systemic diseases, unknown glove perforations, and perioperative blood transfusions were among the parameters that increased the prevalence of PI. Alternatively, prolene sutures, double-layered gloves, and the use of rifampicin Sv (RIS) decreased the incidence of PI. Although the presence of systemic diseases, unnoticed glove perforations, and perioperative blood transfusions increased PIs, prolene suture material, double-layered gloves, and the use of RIS decreased PIs.
Lee, Sang Hoon; Kim, Kyung Hyun; Cheong, Seong-Mee; Kim, Sumi; Kooh, Mirang
Objective Retrospective analysis to compare the effect and complication of epidural patient-controlled analgesia (epidural PCA) with intravenous patient-controlled analgesia (IV PCA) for the treatment of the post-operative pain after posterior lumbar instrumented fusion. Methods Sixty patients who underwent posterior lumbar instrumented fusion for degenerative lumbar disease at our institution from September 2007 to January 2008 were enrolled in this study. Out of sixty patients, thirty patients received IV PCA group and thirty patients received epidural PCA group. The pain scale was measured by the visual analogue scale (VAS) score. Results There were no significant difference between IV PCA group and epidural PCA group on the PCA related complications (p=0.7168). Ten patients in IV PCA group and six patients in epidural PCA group showed PCA related complications. Also, there were no significant differences in reduction of VAS score between two groups on postoperative 2 hours (p=0.9618) and 6 hours (p=0.0744). However, postoperative 12 hours, 24 hours and 48 hours showed the significant differences as mean of reduction of VAS score (p=0.0069, 0.0165, 0.0058 respectively). Conclusion The epidural PCA is more effective method to control the post-operative pain than IV PCA after 12 hours of spinal fusion operation. However, during the first twelve hours after operation, there were no differences between IV PCA and epidural PCA. PMID:22102950
Yaldiz, Can; Yaldiz, Mahizer; Ceylan, Nehir; Kacira, Ozlem Kitiki; Ceylan, Davut; Kacira, Tibet; Kizilcay, Gokhan; Tanriverdi, Taner
Abstract Owing to the increasing population of elderly patients, a large number of patients with degenerative spondylosis are currently being surgically treated. Although basic measures for decreasing postoperative surgical infections (PSIs) are considered, it still remains among the leading causes of morbidity and mortality. The aim of this retrospective analysis is to present possible causes leading to PSI in patients who underwent surgery for lumbar degenerative spondylosis and highlight how it can be avoided to decrease morbidity and mortality. The study included 540 patients who underwent posterior stabilization due to degenerative lumbar stenosis between January 2013 and January 2014. The data before and after surgery was retrieved from the hospital charts. Patients with degenerative lumbar stenosis who were operated upon in this study had >2 levels of laminectomy and facetectomy. For this reason, posterior stabilization was performed for all the patients included in this study. Determining the causes of postoperative infection (PI) following spinal surgeries performed with instrumentation is a struggle. Seventeen different parameters that may be related to PI were evaluated in this study. The presence of systemic diseases, unknown glove perforations, and perioperative blood transfusions were among the parameters that increased the prevalence of PI. Alternatively, prolene sutures, double-layered gloves, and the use of rifampicin Sv (RIS) decreased the incidence of PI. Although the presence of systemic diseases, unnoticed glove perforations, and perioperative blood transfusions increased PIs, prolene suture material, double-layered gloves, and the use of RIS decreased PIs. PMID:26200620
Shankar Ganesh, G; Mohanty, Patitapaban; Smita Pattnaik, Swati
Few studies have reported the effects of lumbar spine mobilization on neurodynamics. In a recent study, Szlezak et al. (2011) reported immediate improvement of posterior chain neurodynamics [range of passive straight leg raise (SLR)] following ipsilateral lumbar spine zygopophyseal (Z) joint mobilization. We re-duplicated the study with a 24 h follow-up measurement. Sixty healthy college students were assigned to two groups, mobilization and control. The mobilization group received ipsilateral grade 3 Maitland mobilizations to Z joint at a frequency of 2 MHz for 3 min and the control group received no treatment. The SLR was measured before and after the intervention for both the groups on the day of testing and 24-h later. Repeated measures ANOVA showed statistically significant pre to post improvement in SLR range after mobilization. The improvement was retained at 24-h. The results of the study are consistent with Szlezak et al. (2011).
Başer, Aykut; Alkış, Okan; Toktaş, Cihan; Zümrütbaş, Ali Ersin
Major vascular injuries during lumbar disc surgery are rare but well-recognized complications. However, vascular injuries of the branches of the aorta and ureteral injuries are very rare. Although its incidence is not known definitely, it is estimated to be 1/1000. Ureteral injuries comprise less than 1% of all genitourinary traumas. In this article, we report clinical progress of a patient who had simultaneous internal iliac artery and ureteral injury during lumbar discectomy. The patient was managed with primary ureteroureterostomy. To our knowledge, this is the first case reported with simultaneous ureter and iliac artery trauma during lumbar disc surgery. PMID:27274898
Darwish, Houssein A; Oldfield, Edward H
This report describes the circumstances of a patient with a cauda equina syndrome due to the development of a lumbar subdural CSF collection with ventral displacement of the cauda equina shortly following posterior fossa decompression for Chiari malformation Type I (CM-I). This unusual, but clinically significant, complication was successfully treated with percutaneous drainage of the extraarachnoid CSF collection. Although there are a few cases of intracranial subdural hygroma developing after surgery for CM-I, often attributed to a pinhole opening in the arachnoid, as far as the authors can determine, a spinal subdural hygroma associated with surgery for CM-I has not been recognized.
Fischer, Uwe M; Davies, Mark G; El Sayed, Hosam
Vascular injury is an uncommon complication of spine surgery. Among the different approaches, anterior lumbar interbody fusion has increased potential for vascular injuries, since the great vessels and their branches overly the disc spaces to be operated on, and retraction of these vessels is necessary to gain adequate surgical exposure. The reported incidence for anterior lumbar interbody fusion-associated vascular injuries ranges from 0% to 18.1%, with venous laceration as the most common type. We report a case of anterior lumbar interbody fusion-associated left common iliac artery dissection leading to delayed acute limb ischemia developing in early post-operative period.
Kim, Do-Keun; Lim, Hyunkeun; Oh, Chang Hyun
Objective Spinal fusion operation is an effective treatment in the spinal pathology, but it could change the physiological distribution of load at the instrumented and adjacent segments. This retrospective study compared the radiological and clinical outcomes of patients undergoing lumbar fusion with semirigid rods versus rigid rods system. Methods Using transpedicular fixation and posterior lumbar interbody fusion at the level of L4/L5, 20 patients were treated with semirigid rods (WavefleX, SR group), and 20 patients with rigid rods (titanium, RR group). Clinical and radiological outcomes were evaluated, including visual analog score for lower back pain and leg pain, Prolo functional and economic scores, statues of implanted instruments, fusion rate, and complications during 24-month follow-up. Results Clinical scores were significantly improved until postoperative 24-month follow-up as compared with preoperative scores in both groups (p<0.05), with similar levels of improvement observed at the same time points postoperatively between the 2 groups. Prolo economic scores were significantly improved in SR group compared to RR until 12 months, but this improvement became similar after 18 months. The overall fusion rate was 94.1% until the 24-month follow-up for both groups. No significant complication was observed in both groups. Conclusion The results of the present study indicate that semirigid rods system with posterior lumbar interbody fusion showed similar clinical and radiological result with rigid rods system until 2 years after instrumentation. The WavefleX rods system, as a semirigid rods with unique characteristics, may be an effective alternative treatment for patients in lumbar fusion. PMID:27437014
Efficacy of post-operative analgesia after posterior lumbar instrumented fusion for degenerative disc disease: a prospective randomized comparison of epidural catheter and intravenous administration of analgesics
Kluba, Torsten; Hofmann, Fabian; Bredanger, Sabine; Blumenstock, Gunnar; Niemeyer, Thomas
This prospective study aimed to compare the efficacy of epidural (EDA) versus intravenous (PCA) application of analgesics after lumbar fusion. Fifty-two patients scheduled for elective posterior instrumented lumbar fusion were randomized into two groups. EDA patients received an epidural catheter intraoperatively, and administration of ropivacain and sulfentanil was started after a normal postoperative wake-up test in the recovery room area. PCA patients received intravenous opioids in the post-operative period. Differences between EDA and PCA groups in terms of patient satisfaction with respect to pain relief were not significant. Nevertheless, EDA patients reported less pain on the third day after surgery. There were significantly more side effects in the EDA group, including complete reversible loss of sensory function and motor weakness. There were no major side effects, such as infection or persisting neurological deficits, in either group. The routine use of epidural anesthesia for lumbar spine surgery has too many risks and offers very little advantage over PCA. PMID:21808704
Wu, Ai-Min; Chen, Chun-Hui; Shen, Zhi-Hao; Feng, Zhen-Hua; Weng, Wan-Qing; Li, Shu-Min; Chi, Yong-Long; Yin, Li-Hui; Ni, Wen-Fei
Purpose. To investigate the evidence of minimally invasive (MI) versus open (OP) posterior lumbar fusion in treatment of lumbar spondylolisthesis from current prospective literatures. Methods. The electronic literature database of Pubmed, Embase, and Cochrane library was searched at April 2016. The data of operative time, estimated blood loss and length of hospital stay, visual analog scale (VAS) of both lower back pain and leg pain, Oswestry disability index (ODI), SF-36 PCS (physical component scores) and SF-36 MCS (mental component scores), complications, fusion rate, and secondary surgery were extracted and analyzed by STATA 12.0 software. Results. Five nonrandom prospective comparative studies were included in this meta-analysis. The meta-analysis showed that the MI group had a significantly longer operative time than OP group, less blood loss, and shorter hospital stay. No significant difference was found in back pain, leg pain, ODI, SF-36 PCS, SF-36 MCS, complications, fusion rate, and secondary surgery between MI and OP groups. Conclusion. The prospective evidence suggested that MI posterior fusion for spondylolisthesis had less EBL and hospital stay than OP fusion; however it took more operative time. Both MI and OP fusion had similar results in pain and functional outcomes, complication, fusion rate, and secondary surgery.
Wu, Ai-Min; Chen, Chun-Hui; Shen, Zhi-Hao; Feng, Zhen-Hua; Weng, Wan-Qing; Li, Shu-Min; Chi, Yong-Long; Yin, Li-Hui
Purpose. To investigate the evidence of minimally invasive (MI) versus open (OP) posterior lumbar fusion in treatment of lumbar spondylolisthesis from current prospective literatures. Methods. The electronic literature database of Pubmed, Embase, and Cochrane library was searched at April 2016. The data of operative time, estimated blood loss and length of hospital stay, visual analog scale (VAS) of both lower back pain and leg pain, Oswestry disability index (ODI), SF-36 PCS (physical component scores) and SF-36 MCS (mental component scores), complications, fusion rate, and secondary surgery were extracted and analyzed by STATA 12.0 software. Results. Five nonrandom prospective comparative studies were included in this meta-analysis. The meta-analysis showed that the MI group had a significantly longer operative time than OP group, less blood loss, and shorter hospital stay. No significant difference was found in back pain, leg pain, ODI, SF-36 PCS, SF-36 MCS, complications, fusion rate, and secondary surgery between MI and OP groups. Conclusion. The prospective evidence suggested that MI posterior fusion for spondylolisthesis had less EBL and hospital stay than OP fusion; however it took more operative time. Both MI and OP fusion had similar results in pain and functional outcomes, complication, fusion rate, and secondary surgery. PMID:28154826
Gallizzi, Michael A.; Sheets, Charles; Smith, Benjamin T.; Isaacs, Robert E.; Eure, Megan; Brown, Christopher R.
Background Sagittal balance restoration has been shown to be an important determinant of outcomes in corrective surgery for degenerative scoliosis. Lateral interbody fusion (LIF) is a less-invasive technique which permits the placement of a high lordosis interbody cage without risks associated with traditional anterior or transforaminal interbody techniques. Studies have shown improvement in lumbar lordosis following LIF, but only one other study has assessed sagittal balance in this population. The objective of this study is to evaluate the ability of LIF to restore sagittal balance in degenerative lumbar scoliosis. Methods Thirty-five patients who underwent LIF for degenerative thoracolumbar scoliosis from July 2013 to March 2014 by a single surgeon were included. Outcome measures included sagittal balance, lumbar lordosis, Cobb Angle, and segmental lordosis. Measures were evaluated pre-operative, immediately post-operatively, and at their last clinical follow-up. Repeated measures ANOVAs were used to assess the differences between pre-operative, first postoperative, and a follow-up visit. Results The average sagittal balance correction was not significantly different: 1.06cm from 5.79cm to 4.74cm forward. The average Cobb angle correction was 14.1 degrees from 21.6 to 5.5 degrees. The average change in global lumbar lordosis was found to be significantly different: 6.3 degrees from 28.9 to 35.2 degrees. Conclusions This study demonstrates that LIF reliably restores lordosis, but does not significantly improve sagittal balance. Despite this, patients had reliable improvement in pain and functionality suggesting that sagittal balance correction may not be as critical in scoliosis correction as previous studies have indicated. Clinical Relevance LIF does not significantly change sagittal balance; however, clinical improvement does not seem to be contingent upon sagittal balance correction in the degenerative scoliosis population. The DUHS IRB has determined this
Lackey, Alan; Phan, Kevin; Mobbs, Ralph
A systematic review and meta-analysis was performed to assess the effect of hybrid constructs which involve a total disc arthroplasty (TDA) with stand-alone anterior lumbar interbody fusion (ALIF) versus non-hybrid constructs including multi-level TDA, multi-level transforaminal lumbar interbody fusion (TLIF) with posterior transpedicular fixation or multi-level stand-alone ALIF as a surgical intervention for degenerative disc disease (DDD) in the lumbar spine. Primary outcomes analysed included the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for back pain. A systematic search of Medline, Embase, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Google Scholar was undertaken by two separate reviewers and a meta-analysis of the outcomes was performed. Three studies met our search criteria. When comparing hybrid constructs to multi-level TDA or lumbar fusion (LF) improvements in back pain were found with a VAS back pain score reduction of 1.38 (P<0.00001) postoperatively and a VAS back pain score reduction of 0.99 points (P=0.0006) at 2-years follow-up. Results so far slightly favour clinically significant improved VAS back pain score outcomes postoperatively and at 2-years follow-up for hybrid constructs in multi-level lumbar DDD of the spine when compared with non-hybrid multi-level LF or TDA. It cannot however be concluded that a hybrid construct is superior to multi-level LF or TDA based on this meta-analysis. The results highlight the need for further prospective studies to delineate best practice in the management of degenerative disc disease of the lumbar spine.
Lin, Yang; Chen, Wen-jian; Zhu, Wen-tao; Li, Feng; Fang, Huang; Chen, An-min; Xiong, Wei
The effect and safety of anterior debridement and fusion with a minimally invasive approach combined with posterior fixation via the Wiltse approach were assessed in the single-level lumbar pyogenic spondylodiscitis. Seventeen patients from 2007 to 2009 underwent anterior debridement and fusion with a minimally invasive approach combined with posterior fixation via the Wiltse approach. Postoperative follow-up time was 24-41 months. Data included the patients' general information, microbiology, operative time, intraoperative blood loss, postoperative complications, intervertebral fusion rate, and preoperative and final follow-up scores for American Spinal Injury Association (ASIA) impairment, visual analogue scale (VAS), and Oswestry Disability Index (ODI). Ten patients had undergone a prior spinal invasive procedure, and 7 had hematogenous infection. The infected segments included L1-2, L2-3, L3-4, and L4-5 in 1, 2, 5, and 9 cases, respectively. Thirteen bacterial cultures were positive for Staphylococcus aureus (5 cases), Staphylococcus epidermidis (4), Streptococcus (3), and Escherichia coli (1). The operative time was 213.8±45.6 min, and the intraoperative blood loss was 180.6±88.1 mL. Postoperative complications consisted of urinary retention (2 cases), constipation (3), and deep vein thrombosis (2). On the final follow-up, VAS scores and ODIs were significantly lower than those of preoperation, while the ASIA grades improved. All the cases achieved good intervertebral bony fusion. Anterior debridement and fusion with a minimally invasive approach combined with posterior fixation via the Wiltse approach can successfully treat single-level lumbar pyogenic spondylodiscitis, with less trauma and reliable immobilization. It is a viable option for clinical application.
Ozer, A. F.; Keskin, F.; Oktenoglu, T.; Suzer, T.; Ataker, Y.; Gomleksiz, C.; Sasani, M.
Surgery of lumbar disc herniation is still a problem since Mixter and Barr. Main trouble is dissatisfaction after the operation. Today there is a debate on surgical or conservative treatment despite spending great effort to provide patients with satisfaction. The main problem is segmental instability, and the minimally invasive approach via microscope or endoscope is not necessarily appropriate solution for all cases. Microsurgery or endoscopy would be appropriate for the treatment of Carragee type I and type III herniations. On the other hand in Carragee type II and type IV herniations that are prone to develop recurrent disc herniation and segmental instability, the minimal invasive techniques might be insufficient to achieve satisfactory results. The posterior transpedicular dynamic stabilization method might be a good solution to prevent or diminish the recurrent disc herniation and development of segmental instability. In this study we present our experience in the surgical treatment of disc herniations. PMID:23653862
Benezech, Jacques; Garlenq, Bruno; Larroque, Gilles
Posterior lumbar interbody fusion using cages, titanium rods, and pedicle screws is considered today as the gold standard of surgical treatment of lumbar degenerative disease and has produced satisfying long-term fusion rates. However this rigid material could change the physiological distribution of load at the instrumental and adjacent segments, a main cause of implant failure and adjacent segment disease, responsible for a high rate of further surgery in the following years. More recently, semirigid instrumentation systems using rods made of polyetheretherketone (PEEK) have been introduced. This clinical study of 21 patients focuses on the clinical and radiological outcomes of patients with lumbar degenerative disease treated with Initial VEOS PEEK®-Optima system (Innov'Spine, France) composed of rods made from PEEK-OPTIMA® polymer (Invibio Biomaterial Solutions, UK) without arthrodesis. With an average follow-up of 2 years and half, the chances of reoperation were significantly reduced (4.8%), quality of life was improved (ODI = 16%), and the adjacent disc was preserved in more than 70% of cases. Based on these results, combined with the biomechanical and clinical data already published, PEEK rods systems can be considered as a safe and effective alternative solution to rigid ones. PMID:26981285
Benezech, Jacques; Garlenq, Bruno; Larroque, Gilles
Posterior lumbar interbody fusion using cages, titanium rods, and pedicle screws is considered today as the gold standard of surgical treatment of lumbar degenerative disease and has produced satisfying long-term fusion rates. However this rigid material could change the physiological distribution of load at the instrumental and adjacent segments, a main cause of implant failure and adjacent segment disease, responsible for a high rate of further surgery in the following years. More recently, semirigid instrumentation systems using rods made of polyetheretherketone (PEEK) have been introduced. This clinical study of 21 patients focuses on the clinical and radiological outcomes of patients with lumbar degenerative disease treated with Initial VEOS PEEK(®)-Optima system (Innov'Spine, France) composed of rods made from PEEK-OPTIMA(®) polymer (Invibio Biomaterial Solutions, UK) without arthrodesis. With an average follow-up of 2 years and half, the chances of reoperation were significantly reduced (4.8%), quality of life was improved (ODI = 16%), and the adjacent disc was preserved in more than 70% of cases. Based on these results, combined with the biomechanical and clinical data already published, PEEK rods systems can be considered as a safe and effective alternative solution to rigid ones.
Reyes-Sánchez, Alejandro; Ramírez-Mora, Isabel; Rosales-Olivarez, Luis Miguel; Alpizar-Aguirre, Armando; Sánchez-Bringas, Guadalupe
Decompression surgery for lumbar spinal stenosis is a common procedure. After surgery, segmental instability sometimes occurs, therefore, different methods for restabilization have been developed. Dynamic stabilization systems have been designed to improve segmental stability. In this study, clinical results of patients with lumbar spinal stenosis that underwent decompression and stabilization with the Accuflex dynamic system are presented; clinical, radiographic, and magnetic resonance imaging (MRI) findings are fully described. Improvements in all clinical measurements, including visual analog scale for back and leg pain, Oswestry disability index, and SF-36 health status survey were noticed. At a 2-year follow-up, 22.22% of patients required hardware removal due to fatigue while in 83% of them no progression of disk degeneration was observed after implantation of the Accuflex system. Additionally, as demonstrated by the MRI images at follow up, three patients (16%) showed disk rehydration with one grade higher on the Pfirmann classification. Although a relatively high hardware failure was observed (22.22%), the use of the dynamic stabilization system Accuflex posterior to decompression procedures, showed clinical benefits and stopped the degenerative process in 83% the patients. PMID:20496039
Lee, Ho Jun
Lateral femoral cutaneous neuropathy occurring during spinal surgery is frequently related to iliac bone graft harvesting, but meralgia paresthetica (MP) can result from the patient being in the prone position. Prone position-related MP is not an uncommon complication after posterior spine surgery but there are only few reports in the literature on this subject. It is usually overlooked because of its mild symptoms and self-limiting course, or patients and physicians may misunderstand the persistence of lower extremity symptoms in the early postoperative period to be a reflection of poor surgical outcome. The authors report a case of prone position-related MP after posterior lumbar interbody fusion at the L3-4 and reviewed the literature with discussion on the incidence, pathogenesis, and possible risk factors related to this entity. PMID:19137086
Tsai, Tsung-Ting; Ho, Natalie Yi-Ju; Lai, Po-Liang; Fu, Tsai-Sheng; Niu, Chi-Chien; Chen, Lih-Huei; Chen, Wen-Jer
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
Klein, Anita; van Leeuwen, Peter; Hoormann, Jörg; Grönemeyer, Dietrich
Stimulation of the posterior tibial nerve has been associated with different somatosensory evoked potentials (SEP) recorded along the spine and thorax. The aim of this study was to register and describe the magnetic fields corresponding to different components of spinal SEP after stimulation of tibial nerves. In nine healthy subjects, right and left posterior tibial nerves were transcutaneously electrostimulated at the ankles. Neuromagnetic fields were registered over a circular 800 cm2 area of the lumbosacral spine using a 61-channel biomagnetometer. Magnetic field maps were constructed and examined visually for dipolar patterns. Equivalent current dipoles (ECD) were calculated for each somatosensory evoked field (SEF) using a least-squares fit in a spherical model. In seven subjects dipolar SEF were detected over the lower back at two separate latencies and locations and propagating ECD could be localized. Both the first and second components found agreed anatomically and functionally with respect to propagation in the underlying nerve fibers. It was possible to record and identify SEF which correspond to the SEP described in the literature. Dipole localization based on an equivalent current dipole model allowed a basic evaluation of the plausibility of the measurements with respect to the processes being examined.
Shigematsu, Hideki; Okuda, Akinori; Morimoto, Yasuhiko; Masuda, Keisuke; Nakajima, Hiroshi; Koizumi, Munehisa; Tanaka, Yasuhito
Study Design Case control study. Purpose To identify the most significant laboratory marker for early detection of surgical site infection (SSI) using multiple logistic regression analysis. Overview of Literature SSI is a serious complication of spinal instrumentation surgery. Early diagnosis and treatment are crucial. Methods We retrospectively reviewed the laboratory data of patients who underwent posterior lumbar instrumentation surgery for degenerative spinal disease from January 2003 to December 2014. Six laboratory markers for early SSI detection were considered: renewed elevation of the white blood cell count, higher at 7 than 4 days postoperatively; renewed elevation of the C-reactive protein (CRP) level, higher at 7 than 4 days postoperatively; CRP level of >10 mg/dL at 4 days postoperatively; neutrophil percentage of >75% at 4 days postoperatively; lymphocyte percentage of <10% at 4 days postoperatively; and lymphocyte count of <1,000/µL at 4 days postoperatively. Results Ninety patients were enrolled; five developed deep SSI. Multivariate regression analysis showed that a lymphocyte count of <1,000/µL at 4 days postoperatively was the sole significant independent laboratory marker for early detection of SSI (p=0.037; odds ratio, 11.9; 95% confidence interval, 1.2–122.7). Conclusions A lymphocyte count of <1,000/µL at 4 days postoperatively is the most significant laboratory marker for early detection of SSI. PMID:27994779
Rathinavelu, Barani; Krishnan, Venkatesh; Amritanand, Rohit; Sundararaj, Gabriel David
Study Design Retrospective clinical series. Purpose To study the clinical, functional and radiological results of patients with tuberculous spondylitis with and without paraplegia, treated surgically using the "Extended Posterior Circumferential Decompression (EPCD)" technique. Overview of Literature With the increasing possibility of addressing all three columns by a single approach, posterior and posterolateral approaches are gaining acceptance. A single exposure for cases with neurological deficit and kyphotic deformity requiring circumferential decompression, anterior column reconstruction and posterior instrumentation is helpful. Methods Forty-one patients with dorsal/dorsolumbar/lumbar tubercular spondylitis who were operated using the EPCD approach between 2006 to 2009 were included. Postoperatively, patients were started on nine-month anti-tuberculous treatment. They were serially followed up to thirty-six months and both clinical measures (including pain, neurological status and ambulatory status) and radiological measures (including kyphotic angle correction, loss of correction and healing status) were used for assessment. Results Disease-healing with bony fusion (interbody fusion) was seen in 97.5% of cases. Average deformity (kyphosis) correction was 54.6% in dorsal spine and 207.3% in lumbar spine. Corresponding loss of correction was 3.6 degrees in dorsal spine and 1.9 degrees in the lumbar spine. Neurological recovery in Frankel B and C paraplegia was 85.7% and 62.5%, respectively. Conclusions The EPCD approach permits all the advantages of a single or dual session anterior and posterior surgery, with significant benefits in terms of decreased operative time, reduced hospital stay and better kyphotic angle correction. PMID:25558312
Tessitore, Enrico; Molliqaj, Granit; Schaller, Karl; Gautschi, Oliver Pascal
Extreme lateral interbody fusion (XLIF) is an alternative to standard posterior approaches for achieving fusion in the lumbar spine. It allows exposure of the lateral aspect of the lumbar disc through a lateral approach with the possibility to insert a wide footprint interbody cage as a stand-alone procedure or associated with a uni- or bilateral percutaneous fixation. This is a retrospective series of 20 consecutive patients operated with a XLIF procedure from 2014 to 2015. N=10 women and N=10 men with a mean age of 67.5years (range 37.9-81.2) were included in the study. N=18 patients have been operated at one level, while N=2 patients underwent a double-level XLIF. The index levels were: L2-L3 in 2, L3-L4 in 7, L4-L5 in 9 and L3-L5 in 2 patients, respectively. The mean clinico-radiological follow-up was 9.8months (range 2.5-16.6). The clinical outcome was assessed with the Oswestry Disability Index (ODI), Euro-Qol (EQ)-5D, visual analogue scale (VAS) and EQ-5D index scores. Preoperative, postoperative and follow-up sagittal balance was assessed by EOS full spine X-ray. Furthermore, presence or absence of fusion was assessed by thin cuts CT scan at the end of the follow-up. The analysis highlighted a clear clinical improvement for the study collective. The mean ODI improved from 41.6 preoperatively to 23.5 at the last follow-up (p<0.0036). EQ-5D VAS and EQ-5D index improved from 45.5 to 71.8 (p<0.0001) and from 0.454 to 0.693 (p<0.0002), respectively. Analysis of the sagittal balance revealed an increase of the total lumbar lordosis, however not in a statistically significant manner (p=0.164). Furthermore, an increase of 55.7% in mean disc height (from 7.0mm to 10.9mm) has been observed (p<0.0001). Surprisingly, the right foramen height was increased in a statistically significant manner compared to the left one, but both of them increased in absolute values. However, foraminal area on both sides did not significantly increase. The mean canal area was 115.7mm(2
Jacobson, Robert E
A 65-year-old male originally had surgery for spondylolisthesis at L5-S1 in 2008 and then went on to have an L4-5 transforaminal lumbar interbody fusion (TLIF) with pedicle screw fixation from L4 to S1 and interbody graft in 2010. Despite having two surgical procedures, he continued with intractable back pain and was told he had a failed lumbar fusion. When he was evaluated with a computerized tomography (CT) scan from April 2015, it demonstrated an erosive nonunion of the L4-5 interbody fusion without incorporation of the polyetheretherketone (PEEK) cage. In an attempt to perform a minimally invasive stabilization of the L4-5 nonunion, he underwent a percutaneous lateral foraminal approach with an injection of Cortoss® cement (Stryker®, Malvern, PA) into the L4-5 interspace and around the graft. The objective was to stabilize the nonunion, resulting in intermediate relief of pain. PMID:28229033
Granville, Michelle; Jacobson, Robert E
A 65-year-old male originally had surgery for spondylolisthesis at L5-S1 in 2008 and then went on to have an L4-5 transforaminal lumbar interbody fusion (TLIF) with pedicle screw fixation from L4 to S1 and interbody graft in 2010. Despite having two surgical procedures, he continued with intractable back pain and was told he had a failed lumbar fusion. When he was evaluated with a computerized tomography (CT) scan from April 2015, it demonstrated an erosive nonunion of the L4-5 interbody fusion without incorporation of the polyetheretherketone (PEEK) cage. In an attempt to perform a minimally invasive stabilization of the L4-5 nonunion, he underwent a percutaneous lateral foraminal approach with an injection of Cortoss® cement (Stryker®, Malvern, PA) into the L4-5 interspace and around the graft. The objective was to stabilize the nonunion, resulting in intermediate relief of pain.
Comparison Study between Conventional Sequence and Slice-Encoding Metal Artifact Correction (SEMAC) in the Diagnosis of Postoperative Complications in Patients Receiving Lumbar Inter-Body Fusion and Pedicle Screw Fixation Surgery
Han, Sol Bee; Kwon, Jong Won
Background and Purpose Slice-Encoding Metal Artifact Correction (SEMAC) sequence is one of the metal artifact reduction techniques of anatomical structure, but there has been no report about evaluation of post-operative complications. The purpose of this article is to compare the anatomical visibility between fast spin echo (FSE) and FSE-SEMAC and to evaluate the additional value of FSE-SEMAC in diagnostic confidence of the complications. Materials and Methods We conducted a retrospective study with 54 patients who received lumbar spinal surgery and MR images including FSE-SEMAC. For the semi-quantitative evaluation, the visibility of anatomical structures (neural foramen, bone-inter-body cage interface, central canal, nerve root in epidural space, back muscle, and bone-pedicle screw interface) was evaluated. For qualitative evaluation, we evaluated FSE and FSE with FSE-SEMAC independently, and recorded the diagnostic confidence level of post-operative complications. Generalized estimating equation regression analysis was used for statistical analysis, and a weighted kappa was used for inter-observer agreement. Results Scores of 6 imaging findings with FSE-SEMAC were significantly higher than that of FSE (P-value < .0001). Inter-observer agreements show good reliability (weighted kappa = 0.45–0.75). Both reviewers deemed 37 (reviewer 1) or 19 more (reviewer 2) post-operative complications with FSE plus FSE-SEMAC, compared to FSE only. Except for central canal stenosis (P-value = .2408), diagnostic confidence level for other post-operative complications were significantly higher with FSE plus FSE-SEMAC (P-value = .0000) than FSE. Conclusions FSE-SEMAC significantly reduces image distortion, compared to FSE sequence in 3.0-T MR. Also, diagnostic confidence for post-operative complications was higher when FSE with additional FSE-SEMAC compared to FSE only. PMID:27711137
Phan, Kevin; Hogan, Jarred A; Assem, Yusuf; Mobbs, Ralph J
Recent developments have seen poly[aryl-ether-ether-ketone] (PEEK) being increasingly used in vertebral body fusion. More novel approaches to improve PEEK have included the introduction of titanium-PEEK (Ti-PEEK) composites and coatings. This paper aims to describe a potential complication of PEEK based implants relating to poorer integration with the surrounding bone, producing a "PEEK-Halo" effect which is not seen in Ti-PEEK composite implants. We present images from two patients undergoing anterior lumbar interbody fusion (ALIF). The first patient underwent an L5/S1 ALIF using a PEEK implant whilst the second patient underwent L4/L5 ALIF using a Ti-PEEK composite implant. Evidence of osseointegration was sought using CT imaging and confirmed using histological preparations of a sheep tibia model. The PEEK-Halo effect is demonstrated by a halo effect between the PEEK implant and the bone graft on CT imaging. This phenomenon is secondary to poor osseointegration of PEEK implants. The PEEK-Halo effect was not demonstrated in the second patient who received a Ti-PEEK composite graft. Histological analysis of graft/bone interface surfaces in PEEK versus Ti-PEEK implants in a sheep model further confirmed poorer osseointegration of the PEEK implant. In conclusion, the PEEK-Halo effect is seen secondary to minimal osseointegration of PEEK at the adjacent vertebral endplate following a PEEK implant insertion. This effect is not seen with Ti-PEEK implants, and may support the role of titanium in improving the bone-implant interface of PEEK substrates.
Phan, Kevin; Mobbs, Ralph J
We report on a case of a patient who underwent minimally invasive transforaminal lumbar interbody fusion (mi-TLIF) with objective physical activity measurements performed preoperatively and postoperatively at up to 12-months using wireless accelerometer technology. In the first postoperative month following surgery, the patient had reduced mobility, taking 2,397 steps over a distance of 1.8 km per day. However, the number of steps taken and distance travelled per day had returned to baseline levels by the second postoperative month. At one-year follow-up, the patient averaged 5,095 steps per day in the month over a distance of 3.8 km; this was a 60% improvement in both steps taken and distance travelled compared to the preoperative status. The use of wireless accelerometers is feasible in obtaining objective physical activity measurements before and after lumbar interbody fusion and may be applicable to other related spinal surgeries as well.
Lymphopenia and Elevated Blood C-Reactive Protein Levels at Four Days Postoperatively Are Useful Markers for Early Detection of Surgical Site Infection Following Posterior Lumbar Instrumentation Surgery
Shigematsu, Hideki; Koizumi, Munehisa; Nakajima, Hiroshi; Okuda, Akinori; Morimoto, Yasuhiko; Masuda, Keisuke; Tanaka, Yasuhito
Study Design Case-control study. Purpose To identify the characteristics of candidate indexes for early detection of surgical site infection (SSI). Overview of Literature SSI is a serious complication of spinal instrumentation surgery. Early diagnosis and treatment are crucial for the welfare of the patient postoperation. Methods We retrospectively reviewed laboratory data of patients who underwent posterior lumbar instrumentation surgery for degenerative spine disease. The sensitivity and specificity of six laboratory markers for early detection of SSI were calculated: greater elevation of the white blood cell count at day 7 than at day 4 postoperatively, greater elevation of the C-reactive protein (CRP) level at day 7 than at day 4 postoperatively, a CRP level of >10 mg/dL at 4 days postoperatively, neutrophil percentage of >75% at 4 days postoperatively, a lymphocyte percentage of <10% at 4 days postoperatively, and a lymphocyte count of <1,000/µL at 4 days postoperatively. Statistical analysis was via Fisher's exact test and a p-value of <0.05 was considered significant. Results In total, 85 patients were enrolled. Of these, five patients developed deep SSI. The sensitivity and specificity of each index were as follows: index 1, 20.0% and 77.5%; index 2, 20.0% and 83.8%; index 3, 40.0% and 97.5%; index 4, 40.0% and 86.3%; index 5, 0% and 96.3%; and index 6, 80.0% and 80.0%. A significant difference was noted for indexes 3 and 6. Conclusions A CRP level of >10 mg/dL at 4 days postoperatively would be useful for definitive diagnosis of SSI, and a lymphocyte count of <1,000/µL at 4 days postoperatively would be a useful screening test for SSI. Although laboratory markers for early detection of SSI have been frequently reported, we believe that it is important to understand the characteristics of each index for a precise diagnosis. PMID:27114760
Yang, Bo; Ou, Yunsheng; Jiang, Dianming; An, Hong; Liu, Bo; Zhang, Jian; Li, Kaiting
The present study is aimed to investigate the early clinical effects of nano-hydroxyapatite/polyamide 66 intervertebral fusion cage (n-HA/PA66 cage) for the treatment of lumbar degenerative diseases. We selected 27 patients with lumbar degenerative diseases who were managed by posterior decompression or reset operation combined with n-HA/PA66 cage intervertebral fusion and internal fixation from August 2010 to January 2012. The oswestry disability index (ODI), low back and leg pain visual analogue score (VAS), and intervertebral height (IH) were evaluated at preoperation, 1 week postoperation and the last follow-up period, respectively. Intervertebral bony fusion was evaluated at the last follow-up time. The patients were followed up for 12-24 months (averaged 19 months). The ODI, VAS and IH were significantly improved at 1 week postoperation and the last follow-up time compared with those at preoperative period (P < 0.05). But there was no significant difference between 1 week postoperative and the last follow-up time (P < 0.05). Brantigan's standard was used to evaluate fusion at the last follow-up time. There were 19 patients with grade 5 fusion, 8 with grade 4 fusion, with a fusion rate of 100%, and none with grade 1-3 fusions. There was no cage translocation and internal fixation breakage. These results suggested that n-HA/PA66 cage was an ideal biological material in the posterior lumbar interbody fusion and internal fixation operation for treatment of lumbar degenerative diseases. It can effectively maintain the intervertebral height and keep a high rate of bony fusion. The early clinical effect has been satisfactory.
Study Design A review of clinical and radiological outcomes of lumbar laminoplasty (LL) for the treatment of isthmic spondylolisthesis (ISL). Purpose The single session performance of posterior lumbar interbody fusion with allograft in the anterior column and providing the realignment of the vertebrae was presented as a preliminary report earlier. Overview of Literature Long-term surgical outcome of cervical laminoplasty in patients has been reported. But, outcome of LL in patients is unclear. Methods The long-term (5 years) year follow-up results of the LL technique are reported in this retrospective study. All patients underwent preoperative and postoperative direct X-ray, computed tomography, and magnetic resonance imaging. The patients that did not respond to conservative treatment were operated. Twenty-one (52.5%) female and 19 (47.5%) male patients were included. Results Mean age was 43,5 years (ranges, 22–57 years). The most common symptoms were low back pain (89%), pelvic and leg pain (69%) and reduction in walking distance (65%). A total of 180 pedicle screws were inserted in 40 patients; posterior lumbar interbody fusion and laminoplasty with reduction was performed in 20 patients for L4–L5, 12 patients for L5–S1, 4 patients for L3–L4–L5 and 4 patients for L4–L5-S1. Ten (25%) patients with ILL had accompanying spinal stenosis. The difference between preoperative and postoperative sagittal plane rotation and dislocation degrees and disc space heights were statistically significant in all patients (p<0.05). Solid grade 4 fusion was observed in 38 patients; in only 2 patients grade 2 pseudoarthrosis developed (5%), but these patients were asymptomatic. Visual analog scale, Prolo economical and functional scale was examined with an average follow-up 5.5 years. Conclusions LL technique has the advantages of shorter duration of operation, lack of graft donor site complications, protection of posterior column osseoligamentous structures and
Narita, Wataru; Takatori, Ryota; Arai, Yuji; Nagae, Masateru; Tonomura, Hitoshi; Hayashida, Tatsuro; Ogura, Taku; Fujiwara, Hiroyoshi; Kubo, Toshikazu
OBJECTIVE Extreme lateral interbody fusion (XLIF) is a minimally disruptive surgical procedure that uses a lateral approach. There is, however, concern about the development of neurological complications when this approach is used, particularly at the L4-5 level. The authors performed a prospective study of the effects of a new neural monitoring system using a finger electrode to prevent neurological complications in patients treated with XLIF and compared the results to results obtained in historical controls. METHODS The study group comprised 36 patients (12 male and 24 female) who underwent XLIF for lumbar spine degenerative spondylolisthesis or lumbar spine degenerative scoliosis at L4-5 or a lower level. Using preoperative axial MR images obtained at the mid-height of the disc at the treated level, we calculated the psoas position value (PP%) by dividing the distance from the posterior border of the vertebral disc to the posterior border of the psoas major muscle by the anteroposterior diameter of the vertebral disc. During the operation, the psoas major muscle was dissected using an index finger fitted with a finger electrode, and threshold values of the dilator were recorded before and after dissection. Eighteen cases in which patients had undergone the same procedure for the same indications but without use of the finger electrode served as historical controls. Baseline clinical and demographic characteristics, PP values, clinical results, and neurological complications were compared between the 2 groups. RESULTS The mean PP% values in the control and finger electrode groups were 17.5% and 20.1%, respectively (no significant difference). However, 6 patients in the finger electrode group had a rising psoas sign with PP% values of 50% or higher. The mean threshold value before dissection in the finger electrode group was 13.1 ± 5.9 mA, and this was significantly increased to 19.0 ± 1.5 mA after dissection (p < 0.001). A strong negative correlation was found
Kuh, Sung-Uk; Kim, Young-Soo; Cho, Young-Eun; Yoon, Young-Sul; Jin, Byung-Ho; Kim, Keun-Su; Chin, Dong-Kyu
The herniated lumbar disc (HLD) in adolescent patients is characterized by typical discogenic pain that originates from a soft herniated disc. It is frequently related to back trauma, and sometimes it is also combined with a degenerative process and a bony spur such as posterior Schmorl's node. Chemonucleolysis is an excellent minimally invasive treatment having these criteria: leg pain rather than back pain, severe limitation on the straight leg raising test (SLRT), and soft disc protrusion on computed tomography (CT). Microsurgical discectomy is useful in the cases of extruded or sequestered HLD and lateral recess stenosis due to bony spur because the nerve root is not decompressed with chymopapain. Spinal fusion, like as PLIF, should be considered in the cases of severe disc degeneration, instability, and stenosis due to posterior central bony spur. In our study, 185 adolescent patients, whose follow-up period was more than 1 year (the range was 1-4 years), underwent spinal surgery due to HLD from March, 1998 to December, 2002 at our institute. Among these cases, we performed chemonucleolysis in 65 cases, microsurgical discectomy in 94 cases, and posterior lumbar interbody fusion (PLIF) with cages in 33 cases including 7 reoperation cases. The clinical success rate was 91% for chemonucleolysis, 95% for microsurgical disectomy, and 89% for PLIF with cages, and there were no non- union cases for the PLIF patients with cages. In adolescent HLD, chemonucleolysis was the 1st choice of treatment because the soft adolescent HLD was effectively treated with chemonucleolysis, especially when the patient satisfied the chemonucleolysis indications.
Malham, Gregory M; Parker, Rhiannon M; Blecher, Carl M; Seex, Kevin A
OBJECT Intervertebral cage settling during bone remodeling after lumbar lateral interbody fusion (LIF) is a common occurrence during the normal healing process. Progression of this settling with endplate collapse is defined as subsidence. The purposes of this study were to 1) assess the rate of subsidence after minimally invasive (MIS) LIF by CT, 2) distinguish between early cage subsidence (ECS) and delayed cage subsidence (DCS), 3) propose a descriptive method for classifying the types of subsidence, and 4) discuss techniques for mitigating the risk of subsidence after MIS LIF. METHODS A total of 128 consecutive patients (with 178 treated levels in total) underwent MIS LIF performed by a single surgeon. The subsidence was deemed to be ECS if it was evident on postoperative Day 2 CT images and was therefore the result of an intraoperative vertebral endplate injury and deemed DCS if it was detected on subsequent CT scans (≥ 6 months postoperatively). Endplate breaches were categorized as caudal (superior endplate) and/or cranial (inferior endplate), and as ipsilateral, contralateral, or bilateral with respect to the side of cage insertion. Subsidence seen in CT images (radiographic subsidence) was measured from the vertebral endplate to the caudal or cranial margin of the cage (in millimeters). Patient-reported outcome measures included visual analog scale, Oswestry Disability Index, and 36-Item Short Form Health Survey physical and mental component summary scores. RESULTS Four patients had ECS in a total of 4 levels. The radiographic subsidence (DCS) rates were 10% (13 of 128 patients) and 8% (14 of 178 levels), with 3% of patients (4 of 128) exhibiting clinical subsidence. In the DCS levels, 3 types of subsidence were evident on coronal and sagittal CT scans: Type 1, caudal contralateral, in 14% (2 of 14), Type 2, caudal bilateral with anterior cage tilt, in 64% (9 of 14), and Type 3, both endplates bilaterally, in 21% (3 of 14). The mean subsidence in the DCS
Parker, Rhiannon M.
Background Symptomatic thoracic herniated discs have historically been treated using open exposures (i.e., thoracotomy), posing a clinical challenge given the approach related morbidity. Lateral interbody fusion (LIF) is one modern minimally disruptive alternative to thoracotomy. The direct lateral technique for lumbar pathologies has seen a sharp increase in procedural numbers; however application of this technique in thoracic pathologies has not been widely reported. Methods This study presents the results of three cases where LIF was used to treat symptomatic thoracic disc herniations. Indications for surgery included thoracic myelopathy, radiculopathy and discogenic pain. Patients were treated with LIF, without supplemental internal fixation, and followed for 24 months postoperatively. Results: Average length of hospital stay was 5 days. One patient experienced mild persistent neuropathic thoracic pain, which was managed medically. At 3 months postoperative all patients had returned to work and by 12 months all patients were fused. From preoperative to 24-month follow-up there were mean improvements of 83.3% in visual analogue scale (VAS), 75.3% in Oswestry Disability Index (ODI), and 79.2% and 17.4% in SF-36 physical (PCS) and mental component scores (MCS), respectively. Conclusions LIF is a viable minimally invasive alternative to conventional approaches in treating symptomatic thoracic pathology without an access surgeon, rib resection, or lung deflation. PMID:27683683
Gabriel, Alcalá-Cerra; Ángel, J. Paternina-Caicedo; Juan, J. Gutiérrez-Paternina; Luis, R. Moscote-Salazar; Hernando, R. Alvis-Miranda; Rubén, Sabogal-Barrios
Background: Posterior ligamentous complex injuries of the thoracolumbar (TL) spine represent a major consideration during surgical decision-making. However, X-ray and computed tomography imaging often does not identify those injuries and sometimes magnetic resonance imaging (MRI) is not available or is contraindicated. Objective: To determine the diagnostic accuracy of the ultrasound for detecting posterior ligamentous complex injuries in the TL spine. Materials and Methods: A systematic review was carried out through four international databases and proceedings of scientific meetings. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and their 95% confidence intervals (CIs) were estimated, by using weighted averages according to the sample size of each study. Summary receiver operating characteristic was also estimated. Results: A total of four articles were included in the meta-analysis, yielding a summary estimate: Sensitivity, 0.89 (95% CI, 0.86-0.92); specificity, 1.00 (95% CI, 0.98-1.00); positive likelihood ratio, 224.49 (95% CI, 30.43-1656.26); negative likelihood ratio, 0.11 (95% CI, 0.05-0.19); and diagnostic odds ratio, 2,268.13 (95% CI, 265.84-19,351.24). There was no statistically significant heterogeneity among results of included studies. Summary: Receiver operating characteristic (±standard error) was 0.928 ± 0.047. Conclusion and Recommendation: The present meta-analysis showed that ultrasound has a high accuracy for diagnosing posterior ligamentous complex injuries in patients with flexion distraction, compression, or burst TL fractures. On the basis of present results, ultrasound may be considered as a useful alternative when magnetic resonance imaging (MRI) is unavailable or contraindicated, or when its results are inconclusive. PMID:24381453
Hai, Y; Meng, X L; Li, D Y; Zhang, X N; Wang, Y S
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-up, and
Fuchs, Christoph; Niemeier, Thomas E; Neway, William E
Aortic pseudoaneurysm can create a constellation of symptoms that can mimic lumbar back pain. There are rare but well-documented reports of aortic pathology (aneurysms, pseudoaneurysms, and chronic contained aneurysm ruptures) eroding into the vertebral column causing neural compression. We report a case of a rapidly progressive aortic pseudoaneurysm in a patient with pre-existing lumbar spine pathology which had the potential for catastrophic intraoperative bleeding during a minimally invasive surgery (MIS) using the transforaminal lumbar interbody fusion (TLIF) technique. Postoperatively, the patient’s radicular pain resolved but her back pain remained. Further workup identified the pseudoaneurysm and the patient subsequently underwent open vascular repair. In this report, we highlight a lesser known mimicker of lumbar back pain. PMID:27882269
Dance, Cassie; DeBerard, M. Scott; Gundy Cuneo, Jessica
Purpose Chronic low back pain is highly prevalent and often treatment recalcitrant condition, particularly among workers’ compensation patients. There is a need to identify psychological factors that may predispose such patients to pain chronicity. The primary aim of this study was to examine whether pain acceptance potentially mediated the relationship between pain catastrophizing and post-surgical outcomes in a sample of compensated lumbar fusion patients. Patients and methods Patients insured with the Workers Compensation Fund of Utah and who were at least 2 years post-lumbar fusion surgery completed an outcome survey. These data were obtained from a prior retrospective-cohort study that administered measures of pain catastrophizing, pain acceptance, mental and physical health, and disability. Results Of the 101 patients who completed the outcome survey, 75.2% were male with a mean age of 42.42 years and predominantly identified as White (97.0%). The majority of the participants had a posterior lumbar interbody fusion surgery. Pain acceptance, including activity engagement and pain willingness, was significantly correlated with better physical health and mental health, and lower disability rates. Pain catastrophizing was inversely correlated with measures of pain acceptance (activity engagement r=−0.67, p<0.01, pain willingness r=−0.73, p<0.01) as well as the outcome measures: mental health, physical health, and disability. Pain acceptance significantly mediated the relationship between pain catastrophizing and both mental and physical health and also the relationship between pain catastrophizing and disability. Conclusion This study demonstrated that the relationship between pain catastrophizing and negative patient outcomes was potentially mediated by pain acceptance. Understanding this mediating relationship offers insight into how pain acceptance may play a protective role in patients’ pain and disability and has potential implications for pain
Telfeian, Albert E.
Background: Transforaminal lumbar interbody fusion (TLIF) is a well-accepted fusion technique that uses unilateral facet removal as an oblique corridor for inserting an interbody spacer. This manuscript focused on five cases of endoscopic foraminotomy for patients presenting with recurrent radiculopathy after TLIF procedures. Methods: After Institutional Review Board approval, charts from five patients with lumbar radiculopathy and instrumented TLIF procedures who underwent subsequent endoscopic procedures between 2011 and 2013 were reviewed. Results: The average pain relief 1 year postoperatively was reported to be 63.8%, good results as defined by MacNab. The average preoperative visual analog scale (VAS) score was 9.5, indicated in our questionnaire as severe and constant pain. The average 1 year postoperative VAS score was 3.5, indicated in our questionnaire as mild and intermittent pain. Conclusion: 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: Lifespan: IRB Study # 600415 PMID:25949850
Baker, Joseph F; Errico, Thomas J; Kim, Yong; Razi, Afshin
Degenerative spondylolisthesis is a common presentation, yet the best surgical treatment continues to be a matter of debate. Interbody fusion is one of a number of options, but its exact role remains ill defined. The aim of this study was to provide a contemporary review of the literature to help determine the role, if any, of interbody fusion in the surgical treatment of degenerative spondylolisthesis. A systematic review of the literature since 2005 was performed. Details on study size, patient age, surgical treatments, levels of slip, patient reported outcome measures, radiographic outcomes, complications and selected utility measures were recorded. Studies that compared a cohort treated with interbody fusion and at least one other surgical intervention for comparison were included for review. Only studies examining the effect in degenerative spondylolisthesis were included. Two authors independently reviewed the manuscripts and extracted key data. Thirteen studies were included in the final analysis. A total of 565 underwent interbody fusion and 761 underwent other procedures including decompression alone, interspinous stabilisation and posterolateral fusion with or without instrumentation. Most studies were graded Level III evidence. Heterogeneous reporting of outcomes prevented formal statistical analysis. However, in general, studies reviewed concluded no significant clinical or radiographic difference in outcome between interbody fusion and other treatments. Two small studies suggested interbody fusion is a better option in cases of definite instability. Interbody fusion only provided outcomes as good as instrumented posterolateral fusion. However, most studies were Level III, and hence, we remain limited in defining the exact role of interbody fusion-cases with clear instability appear to be most appropriate. Future work should use agreed-upon common outcome measures and definitions.
Pimenta, Luiz; Fortti, Fernanda; Oliveira, Leonardo; Marchi, Luis; Jensen, Rubens; Coutinho, Etevaldo; Amaral, Rodrigo
Degenerative and iatrogenic diseases may lead to loss of lordosis or even kyphotic thoracolumbar deformity and sagittal misalignment. Traditional surgery with three-column osteotomies is associated with important neurologic risks and postoperative morbidity. In a novel technique, the lateral transpsoas interbody fusion (LTIF) is complemented with the sacrifice of the anterior longitudinal ligament and anterior portion of the annulus followed by the insertion of a hyperlordotic interbody cage. This is a less invasive lateral technique named anterior column realignment (ACR) and aims to correct sagittal misalignment in adult spinal deformity (ASD), with or without the addition of minor posterior osteotomies. In this article, we provide an account of the evolution to the ACR technique, the literature, and the Brazilian experience in the treatment of adult spinal deformity with this novel advanced application of LTIF. In the presence of ASD, the risk-to-benefit ratio of a surgical correction must be evaluated. Less invasive surgical strategies can be alternatives to treat the deformity and provide better quality of life to the patient. ACR is an advanced application of lateral transpsoas approach, up to date has shown to be reliable and effective when used for ASD, and may minimize complications and morbidity from traditional surgical procedures. Long-term follow-up and comparative studies are needed to evaluate real benefit.
Sundaramurthy, Sharada; Suresh, H.B.; Anirudh, A.V.; Prakash Rozario, Anthony
Introduction Lumbar hernia is an uncommon abdominal wall hernia, making its diagnosis and management a challenge to the treating surgeon. Presentation may be misleading and diagnosis often missed. An imaging study forms an indispensable aid in the diagnosis and surgery is the only treatment option. Presentation of case A 42 year old male presented with history of pain in lower back of 4 years duration and was being treated symptomatically over 4 years with analgesics and physiotherapy. He had noticed a swelling over the left side of his mid-back and consequently on examination was found to have a primary acquired lumbar hernia arising from the deep superior lumbar triangle of Grynfelt. Diagnosis was confirmed by Computed Tomographic imaging. Discussion A lumbar hernia may be primary or secondary with only about 300 cases of primary lumbar hernia reported in literature. Lumbar hernias manifest through two possible defects in the posterior abdominal wall, the superior being more common. Management remains surgical with various techniques emerging over the years. The patient at our center underwent an open sublay mesh repair with excellent outcome. Conclusion A surgeon may encounter a primary lumbar hernia perhaps once in his lifetime making it an interesting surgical challenge. Sound anatomical knowledge and adequate imaging are indispensable. Inspite of advances in minimally invasive surgery, it cannot be universally applied to patients with lumbar hernia and management requires a more tailored approach. PMID:26812667
Lazennec, Jean-Yves; Aaron, Alain; Brusson, Adrien; Rakover, Jean-Patrick; Rousseau, Marc-Antoine
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.
Cincu, Rafael; Lorente, Francisco de Asis; Gomez, Joaquin; Eiras, Jose; Agrawal, Amit
Background: The spine surgeons have been combining anterior and posterolateral fusion (circumferential fusion) as the final solution to treat spinal disorders and many have been using it to treat failed back surgery syndrome (FBSS). In present study, we analyzed and compared the clinical and radiological outcomes in patients with transpedicular screw fixation and intervertebral autogenous posterior iliac crest bone graft or in patients with transpedicular screw fixation and intervertebral B-Twin system for FBSS with a follow-up period of 10 years after the surgery. Materials and Methods: This study was a retrospective case study performed on 55 patients with FBSS. Clinical and radiological changes were compared between the two groups of patients on the basis of improvement of back pain, radicular pain, and work capacity. Outcome was measured in terms of Oswestry Low Back Pain Disability Index, and the changes in pain and function were documented every year from before surgery until 2012. We analyzed the evolution of 55 cases of FBSS those underwent segmental circumferential posterior fusions from June 2001 to February 2003, operated by a single surgeon and followed up during 10 years until February 2012. The patients were divided into 2 groups: In 25 patients, posterolateral fusions with Legacy™ (Medtronic, Inc. NYSE: MDT) screws and intersomatic autogenous posterior iliac crest bone graft was performed, and, in 30 patients, posterolateral fusions with the same screws and intersomatic fusion B-Twin (Biomet Spain Orthopaedics, S.L.) system was performed. In all cases, we used posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) approach for intervertebral graft, and the artrodesis was supplemented at intertransverse level with Autologus Growth Factor (AGF-MBA INCORPORADO, S.A.). The outcome was measured in terms of Oswestry Low Back Pain Disability Index, and the changes in pain and function were documented every year and compared
CAT scan - lumbar spine; Computed axial tomography scan - lumbar spine; Computed tomography scan - lumbar spine; CT - lower back ... stopping.) A computer creates separate images of the spine area, called slices. These images can be stored, ...
Liao, Shu; Zhan, Yiqiang; Dong, Zhongxing; Yan, Ruyi; Gong, Liyan; Zhou, Xiang Sean; Salganicoff, Marcos; Fei, Jun
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.
Alonso-Bartolomé, P; Canga, A; Vázquez-Barquero, A; García-Valtuille, R; Abascal, F; Cerezal, L
Intradural disc herniation is a rare complication of degenerative disc disease. A correct diagnosis of this process is frequently difficult. If this entity is not preoperatively diagnosed and is omitted at surgery, severe neurologic sequels may be provoked. We report a case of a pathologically proven intradural disc herniation preoperatively diagnosed by MR imaging. Clinically, it was manifested by sudden onset of right leg ciatalgia and progressive right lower extremity weakness. The patient also referred a one-month history of sexual dysfunction. MR imaging revealed interruption of the low signal of the anulus fibrosus and of the posterior longitudinal ligament at L2-L3 level and a voluminous disc fragment migrated in the dural sac that showed rim enhancement with gadolinium.The clinical, neuroradiological, and surgical management of lumbar intradural disc herniation are reviewed.
Fehlandt, A F; Micheli, L J
A frequent cause of back pain in athletes and dancers is stress injury to the posterior vertebral elements. Stress fractures affect the pars interarticularis and, rarely, other vertebral regions. The authors present their experience with the diagnosis and treatment of a fourth lumbar inferior articular facet stress fracture in a ballerina in this brief report and discuss the literature concerning posterior element stress fractures.
Lee, Yu Chao; Osti, Orso Lorenzo
Lumbar degenerative disc disease is extremely common. Current evidence supports surgery in carefully selected patients who have failed non-operative treatment and do not exhibit any substantial psychosocial overlay. Fusion surgery employing the correct grafting and stabilization techniques has long-term results demonstrating successful clinical outcomes. However, the best approach for fusion remains debatable. There is some evidence supporting the more complex, technically demanding and higher risk interbody fusion techniques for the younger, active patients or patients with a higher risk of non-union. Lumbar disc arthroplasty and hybrid techniques are still relatively novel procedures despite promising short-term and mid-term outcomes. Long-term studies demonstrating superiority over fusion are required before these techniques may be recommended to replace fusion as the gold standard. Novel stem cell approaches combined with tissue engineering therapies continue to be developed in expectation of improving clinical outcomes. Results with appropriate follow-up are not yet available to indicate if such techniques are safe, cost-effective and reliable in the long-term. PMID:27559465
22630 - Lumbar Fusion (single interspace, posterior interbody technique), to 10.1%, CPT code 33405, Prosthetic Heart Valve (Aortic). Table 5. Manual...Calculations vs. Pyxis CPT Code Title Manual E Variance 22612 Lumbar Fusion (posterior or $1,048.59 $1059.30 $10.71 posterolateral technique)(single (1...interspace) 22558 Anterior Lumbar Interbody $1054.72 $1090.18 $35.46 Fusion Pyxis vs. Bar Coding 30 (3.2%) 22630 Lumber Fusion (single $4819.88
Zhang, Haiping; Niu, Xingbang; Wang, Biao; He, Simin; Hao, Dingjun
Abstract Rationale: Lumbar osteoid osteoma has a low incidence, which could easily lead to scoliosis. Patient concerns: Scoliosis secondary to lumbar osteoid osteoma could be easily misdiagnosed when patients do not complain of obvious symptoms. Diagnoses: We reported a case of a 9-year-old boy with back deformity that was firstly diagnosed with scoliosis at the local hospital. After prescribed with orthosis, the patient experienced aggravating pain that could not be relieved with painkillers. After he admitted to our hospital for further medical advice, he was prescribed to complete radiological examinations. Considering his radiological examination results and his medical history, correct diagnosis of lumbar osteoid osteoma was made. Interventions: Surgical intervention of posterior lesion resection was conducted after diagnosis. Intra-operative frozen pathology indicated features of osteoid osteoma. As the lesion involved inferior articular process of L5, which could cause lumbar instability after lesion resection, internal fixation was conducted at L4-S1 segment, and posterolateral bone fusion was also conducted at L5-S1 segment. Outcomes: Three months after operation, the patient showed marked improvement of scoliosis deformity and great relief of lumbar pain. Lessons subsections: Although spine osteoid osteoma is clinically rare, it shall not be overlooked when young patients present with scoliosis first. Radiological results including computed tomography and magnetic resonance imaging shall be taken carefully as reference when making diagnosis. Surgical intervention of lesion resection could well improve scoliosis and relieve lumbar pain. PMID:27893671
Peiró-García, A; Domínguez-Esteban, I; Alía-Benítez, J
The transpsoas approach, also known as extreme lateral interbody fusion (XLIF), to the lumbar spine is a novel minimally invasive technique with positive clinical outcomes and a low complication rate. There is a low risk of bleeding, due to this approach causing less soft tissue disruption than traditional spine surgery, but segmental arteries and great vessels can be damaged. Retroperitoneal haematoma is a major complication, with few cases reported. This is the first case reported in a Stand-alone XLIF and also the first case reported with haemorrhagic shock. Non-specific symptoms such tachycardia, hypotension, and anaemia are the most prevalent in this complication. With this case, our aim is to describe serious complications related to XLIF.
Bai, Jiayue; Zhang, Wei; Zhang, Xin; Sun, Yapeng; Ding, Wenyuan; Shen, Yong
Background The aim of this study was to analyze treatment outcomes and morbidity of contralateral neurological symptom in patients after TLIF surgery and to explore its possible causes. Material/Methods A retrospective study was conducted involving a total of 476 patients who underwent TILF from 2009 to 2012 in our hospital. These cases were divided into a symptomatic group (Group S) and a non-symptomatic group. The differences in contralateral foramen area and disc-height index(DHI) before and after surgery were compared between Group S and a random sample of 40 cases of non-symptomatic group patients (group N). In addition, according to whether the patient underwent second surgery, Group S patients were further divided into a transient neurologic symptoms group (Group T) and an operations exploration group (Group O). The time of symptom appearance, duration, and symptomatic severity (JOA VAS score) were compared between Group T and O. Results Among the 476 patients, 18 had postoperative contralateral neurological symptoms; thus, the morbidity was 3.7815%. The indicators in Group S were lower than in Group N in the differences in contralateral foramen area and disc-height index(DHI) before and after surgery (p<0.05). Five patients (Group O) in Group S had second surgery because of invalid conservative treatment. The surgical exploration rate was 1.0504%. Compared with Group T, the symptoms of Group O patients appeared earlier, persisted longer, and were more serious (p<0.05). Conclusions Contralateral neurological symptom is a potential complication after TLIF, and its causes are diverse. Surgical explorations should be conducted early for those patients with the complication who present with obvious nerve damage. PMID:26109143
Background Minimally invasive direct thoracic interbody fusion (MIS-DTIF) is a new single surgeon procedure for fusion of the thoracic vertebrae below the scapula (T6/7) to the thoracolumbar junction. In this proof of concept study, we describe the surgical technique for MIS-DTIF and report our experience and the perioperative outcomes of the first four patients who underwent this procedure. Study design/setting In this study we attempt to establish the safety and efficacy of MIS-DTIF. We have performed MIS-DTIF on six spinal levels in four patients with degenerative disk disease or disk herniation. We recorded surgery time, blood loss, fluoroscopy time, complications, and patient-reported pain. Methods Throughout the MIS-DTIF procedure, the surgeon is aided by biplanar fluoroscopic imaging and electrophysiological monitoring. The surgeon approaches the spine with a series of gentle tissue dilations and inserts a working tube that establishes a direct connection from the outside of the skin to the disk space. Through this working tube, the surgeon performs a discectomy and inserts an interbody graft or cage. The procedure is completed with minimally invasive (MI) posterior pedicle screw fixation. Results For the single level patients the mean blood loss was 90 ml, surgery time 43 minutes, fluoroscopy time 293 seconds, and hospital stay two days. For the two-level surgeries, the mean blood loss was 27 ml, surgery time 61 minutes, fluoroscopy time 321 seconds, and hospital stay three days. We did not encounter any clinically significant complications. Thirty days post-surgery, the patients reported a statistically significant reduction of 5.3 points on a 10-point sliding pain scale. Conclusions MIS-DTIF with pedicle screw fixation is a safe and clinically effective procedure for fusions of the thoracic spine. The procedure is technically straightforward and overcomes many of the limitations of the current minimally invasive (MI) approaches to the thoracic spine. MIS
Frank, Rachel M.; Slabaugh, Mark A.; Grumet, Robert C.; Virkus, Walter W.; Bush-Joseph, Charles A.; Nho, Shane J.
Context: Posterior hip pain is a relatively uncommon but increasingly recognized complaint in the orthopaedic community. Patient complaints and presentations are often vague or nonspecific, making diagnosis and subsequent treatment decisions difficult. The purposes of this article are to review the anatomy and pathophysiology related to posterior hip pain in the athletic patient population. Evidence Acquisition: Data were collected through a thorough review of the literature via a MEDLINE search of all relevant articles between 1980 and 2010. Results: Many patients who complain of posterior hip pain actually have pain referred from another part of the body—notably, the lumbar spine or sacroiliac joint. Treatment options for posterior hip pain are typically nonoperative; however, surgery is warranted in some cases. Conclusions: Recent advancements in the understanding of hip anatomy, pathophysiology, and treatment options have enabled physicians to better diagnosis athletic hip injuries and select patients for appropriate treatment. PMID:23015944
Eckardt, Mark A.; Hamamoto, Jason T.; Plotkin, Benjamin; Daubs, Michael D.; Wang, Jeffrey C.
Background Multiple studies have demonstrated that a significant amount of variability exists in various demineralized bone matrix (DBM) formulations, which casts doubts on its reliability in consistently promoting fusion. Bone marrow aspirate (BMA) is a cellular based graft that contains mesenchymal stem cells (MSCs) and growth factors can confer osteogenic and osteoinductive potential to DBM. The goal of this study was to describe the outcome of DBM enriched with concentrated BMA in patients undergoing combined lumbar interbody and posterolateral fusion. Methods Eighty patients with a minimum of 12 months of follow-up were evaluated. Fusion and rates of complication were evaluated. Functional outcomes were assessed based on the modified Odom’s criteria. Multiple logistic regression analysis was used to examine the effects of independent variables on fusion outcome. Results The overall rate of solid fusion (i.e patients with both solid posterolateral and interbody fusion) was 81.3% (65/80). Specifically, the radiographic evidence of solid posterolateral and interbody fusions were 81.3% (65/80) and 92.5% (74/80), respectively. Seven (8.75%) patients developed hardware-related complications, 2 (2.5%) patients developed a postoperative infection and 2 (2.5%) patients developed clinical pseudarthrosis. Charlson comorbidity index (CCI) scores of 3 and 4 were associated with non-solid unions (CCI-3, p = 0.048; CCI-4, p = 0.03). Excellent or good outcomes were achieved in 58 (72.5%) patients. Conclusions Patients undergoing lumbar fusion using an enriched bone graft containing concentrated BMA added to DBM can achieve successful fusion with relatively low complications and good functional outcomes. Despite these findings, more studies with higher level of evidence are needed to better understand the efficacy of this promising graft option. PMID:27909656
Lin, Chia-Ying; Wirtz, Tobias; LaMarca, Frank; Hollister, Scott J
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.
Yan, Bin; Nie, Lin
Objective: 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. Methods: 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. Results: 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). Conclusion: 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. PMID:26550337
Zhang, Shaobo; Lian, Qingquan; Yan, Haibo; Lin, Xianfa
The objective was to report a case of a 63-year-old man with a history of low back pain (LBP) and left leg pain for 2 years, and the symptom became more serious in the past 5 months. The patient was diagnosed with lumbar scoliosis combined with lumbar spinal stenosis (LSS) and lumbar disc herniation (LDH) at the level of L4-5 that was confirmed using Computerized Topography and Magnetic Resonance Imaging. The surgical team preformed a novel technique, “U” route transforaminal percutaneous endoscopic lumbar discectomy (PELD), which led to substantial, long-term success in reduction of pain intensity and disability. After removing the osteophyte mass posterior to the thecal sac at L4-5, the working channel direction was changed to the gap between posterior longitudinal ligament and thecal sac, and we also removed the herniation and osteophyte at L3-4 with “U” route PELD. The patient's symptoms were improved immediately after the surgical intervention; low back pain intensity decreased from preoperative 9 to postoperative 2 on a visual analog scale (VAS) recorded at 1 month postoperatively. The success of the intervention suggests that “U” route PELD may be a feasible alternative to treat lumbar scoliosis with LSS and LDH patients. PMID:28203471
Harrison, William D.; Harrison, David J.
Study Design. Case report. Objective. To identify a safe technique for salvage surgery following complications of total disc replacement. Summary of Background Data. Lumbar total disc replacement (TDR) is considered by some as the gold standard for discogenic back pain. Revision techniques for TDR and their complications are in their infancy. This case describes a successful method of fixation for this complex presentation. Methods and Results. A 48-year-old male with lumbar degenerative disc disease and no comorbidities. Approximately two weeks postoperatively for a TDR, the patient represented with acute severe back pain and the TDR polyethylene inlay was identified as dislocated anteriorly. Subsequent revision surgery failed immediately as the polyethylene inlay redislocated intraoperatively. Further radiology identified bilateral pedicle fractures, previously unseen on the plain films. The salvage fusion of L5/S1 reutilized the anterior approach with an interbody fusion cage and bone graft. The patient was then turned intraoperatively and redraped. The percutaneous pedicle screws were used to fix L5 to the sacral body via the paracoccygeal corridor. Conclusion. The robust locking screw in the percutaneous screw allowed a complete fixation of the pedicle fractures. At 3-year followup, the patient has an excellent result and has returned to playing golf. PMID:24294533
Chafetz, N.I.; Genant, H.K.; Moon, K.L.; Helms, C.A.; Morris, J.M.
Fifteen nuclear magnetic resonance (NMR) studies of 14 patients with herniated lumbar intervertebral disks were performed on the UCSF NMR imager. Computed tomographic (CT) scans done on a GE CT/T 8800 or comparable scanner were available at the time of NMR scan interpretation. Of the 16 posterior disk ruptures seen at CT, 12 were recognized on NMR. Diminished nucleus pulposus signal intensity was present in all ruptured disks. In one patient, NMR scans before and after chymopapain injection showed retraction of the protruding part of the disk and loss of signal intensity after chemonucleolysis. Postoperative fibrosis demonstrated by CT in one patient and at surgery in another showed intermediate to high signal intensity on NMR, easily distinguishing it from nearby thecal sac and disk. While CT remains the method of choice for evaluation of the patient with suspected lumbar disk rupture, the results of this study suggest that NMR may play a role in evaluating this common clinical problem.
Villavicencio, Alan T; Burneikiene, Sigita; Babuska, Jason M; Nelson, Ewell L; Mason, Alexander; Rajpal, Sharad
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.
Liu, Liehua; Liang, Yong; Zhou, Qiang; Zhang, Hong; Wang, Haoming; Li, Songtao; Zhao, Chen; Hou, Tianyong; Liu, Ling
We investigate the anatomy of the lumbosacral anterior great vessels using computer tomography (CT) angiography before L5/S1 anterior interbody surgery. Sixty-two adult patients were selected. The location of the abdominal aortic bifurcation and common iliac venous confluence in the lumbar vertebrae and the anatomic parameters of the iliac vascular space (e.g., distances from the included angle vertex of the iliac vascular space to the median sagittal plane and to the inferior boundary of L5 and distances between the left and right iliac vessels on the inferior boundary of L5 and on the superior boundary of S1) were analysed. Overall, 67.73% of the 62 cases had an abdominal aortic bifurcation located at L4 and L4/5 intervertebral disc; 61.29%, the common iliac venous confluence located at L5. The four distances mentioned above were 0.98 cm ± 0.38 cm, 2.01 cm ± 1.26 cm, 3.11 cm ± 1.35 cm and 4.34 cm ± 1.10 cm, respectively. A classification system of types A, B and C was developed. The calculated L5/S1 intervertebral space exposure percentages of types A, B and C were 32.21%, 82.58% and 54.68%, respectively. During L5/S1 anterior interbody surgery, type B intervertebral discs can be exposed conveniently, preventing injury of the iliac vessels, which was also observed in 54.68% and 32.21% of the type C and type A discs, respectively. Because the type A intervertebral disc has minimal exposure, the risk of iliac vascular injury is relatively high in these patients.
Wang, Hongli; Zhang, Fan; Lv, Feizhou; Jiang, Jianyuan; Liu, Dayong; Xia, Xinlei
Bone morphogenetic protein (BMP)-2 induces bone and cartilage tissue formation. Large amounts of BMP-2 are difficult to purify or to produce in vitro using eukaryotic cells. The goal of the present study was to assess the clinical use of Escherichia coli-derived recombinant human BMP-2 (ErhBMP-2) on bone fusion after cervical and lumbar spine surgery in a goat model, compared with the standard autogenous iliac bone grafting. Thirty-six goats were randomized to 3 groups: (A) autogenous iliac bone grafting, (B) cervical interbody fusion cage containing ß-tricalcium phosphate (ß-TCP), or (C) cervical interbody fusion cage containing ß-TCP+ErhBMP-2 (2.5 mg). Cervical bone repair was evaluated using radiographs and computed tomography scans at 0, 3, and 6 months. Histological analyses were performed on cervical samples. Two goats died from infection. The differences in intervertebral height among the groups were not significant 3 months postoperatively but became significant after 6 months between groups A vs B and C (P=.04); there was no difference between groups B and C at 6 months. Adding ErhBMP-2 significantly increased cervical fusion at 6 months (P=.04). Histological examinations showed that ß-TCP+ErhBMP-2 increased new bone area, material degradation rate, and depth of tissue penetration and decreased residual material area, all in a time-dependent manner. Escherichia coli-derived rhBMP-2 combined with an enhanced fusion cage containing ß-TCP induced bone formation in a goat model. Furthermore, its ability to promote bone fusion was similar to autogenous iliac bone grafting.
Doherty, Carolynne M; Forbes, Raeburn B
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
Kerboul, B; Courtois, B
The Hartshill frame is method for segmental osteosynthesis of the spine. It is attached at each vertebral level by sub-laminal metal wires. This frame therefore ensures immediate stability and avoids the need for a post-operative corset. It enables correction of frontal deformities (scoliosis) whilst retaining sagittal physiological curves (lumbar lordosis--dorsal kyphosis). It ensures the fixation of posterior spinal instability (destruction of posterior ligaments and bone tissue, spondylolisthesis, etc.). The Hartshill frame can thus be seen to be a posterior brace. It has been used in 92 patients, (53 lumbar disorders, 10 cases of scoliosis, 4 of kyphosis, 19 tumors, 6 fractures). Results are generally entirely satisfactory in the mid term apart from fractures (recurrence of initial displacement). Specific complications are of a neurological nature (cases of cutaneous hyperesthesia, one severe motor deficit) long-term problems with device and material are uncommon; rupture of sub-laminar wire 8 cases; secondary incurving of frame 1 case.
Hager, Staci M; Udermann, Brian E; Reineke, David M; Gibson, Mark H; Mayer, John M; Murray, Steven R
We evaluated the reliability of static and dynamic lumbar muscle endurance measurements on a BackUP lumbar extension dynamometer. Sixteen healthy participants (8 male; 8 female) volunteered for this investigation. Fifty percent of each participant's body weight was calculated to determine the weight load utilized for the static (holding time) and dynamic (repetitions) lumbar extension endurance tests. Four separate tests (2 static, 2 dynamic) were conducted with at least a 24-hour rest period between tests. Test-retest intraclass correlations were shown to be high (static lumbar endurance, ICC = 0.92 (p < 0.0005); dynamic lumbar endurance, ICC = 0.93 (p < 0.0005) for both of the performed tests. Our results demonstrated that static and dynamic lumbar endurance can be assessed reliably on a BackUP lumbar extension dynamometer. Key PointsReliability studies that test lumbar endurance on machines that effectively stabilize the pelvis and isolate the lumbar extensors are limited.This is the first study to report reliability measures of static and dynamic lumbar endurance on a BackUP lumbar extension dynamometer.Static and dynamic lumbar endurance on a BackUP lumbar extension dynamometer, which uses a variety of pelvic stabilization mechanisms, can be reliably assessed in apparently healthy individuals.Future research is necessary to examine the reliability of lumbar extension endurance on the BackUP dynamometer in patient populations and validity in various settings.
... may need a lumbar MRI if you have: Low back pain that does not get better after treatment Leg ... spine Injury or trauma to the lower spine Low back pain and a history or signs of cancer Multiple ...
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.
Putzer, Michael; Ehrlich, Ingo; Rasmussen, John; Gebbeken, Norbert; Dendorfer, Sebastian
Musculoskeletal simulations of lumbar spine loading rely on a geometrical representation of the anatomy. However, this data has an inherent inaccuracy. This study evaluates the influence of defined geometrical parameters on lumbar spine loading utilising five parametrised musculoskeletal lumbar spine models for four different postures. The influence of the dimensions of vertebral body, disc, posterior parts of the vertebrae as well as the curvature of the lumbar spine was studied. Additionally, simulations with combinations of selected parameters were conducted. Changes in L4/L5 resultant joint force were used as outcome variable. Variations of the vertebral body height, disc height, transverse process width and the curvature of the lumbar spine were the most influential. These parameters can be easily acquired from X-rays and should be used to morph a musculoskeletal lumbar spine model for subject-specific approaches with respect to bone geometry. Furthermore, the model was very sensitive to uncommon configurations and therefore, it is advised that stiffness properties of discs and ligaments should be individualised.
Altaf, Imran; Vohra, Anjum Habib; Shams, Shahzad
Objective: Cerebrospinal fluid leakage remains a significant cause of morbidity following posterior fossa surgery, and its treatment remains a difficult problem. The aim of the study was to propose a treatment algorithm for its management. Methods: A retrospective, single-center study was conducted on 147 patients who underwent elective posterior fossa surgery for a variety of diseases. Patients with post operative CSF leakage had either been treated initially with conservative measures including re-suturing of the wound, with CSF lumbar drainage to be employed in case the CSF leakage didn’t stop, or the initial intervention was the institution of CSF lumbar drainage simultaneously with conservative measures. VP (ventriculo-peritoneal) shunt was done in patients with gross hydrocephalus on postoperative CT brain. Results: There were 25 (17%) cases of CSF leakage, including 24 incisional CSF leaks and one case of CSF otorrhea. In eight patients with incisional CSF leakage treated initially with conservative measures including re-suturing of the wound, CSF leakage stopped in only two cases. CSF lumbar drainage instituted later on in six cases with persistent leakage stopped the CSF leakage. In fourteen patients managed initially with re-suturing of the wound and concomitant CSF lumbar drainage, CSF leakage settled in all the cases. Two patients with gross hydrocephalus on post operative CT were managed successfully with VP shunt. Re-suturing of the wound with concomitant CSF lumbar drainage was found to be significantly associated (p=0.003) with the stoppage of CSF leakage, and the settlement of meningitis (p= 0.014). Conclusion: Incisional CSF leaks after posterior fossa surgery should be managed with re-suturing of the wound and concomitant CSF lumbar drainage, instead of an initial trial of conservative therapy alone. PMID:28083041
Lui, Tun Hing
Different types of posterior calcaneal osteotomy are used for calcaneal realignment in the management of hindfoot deformity. We describe a percutaneous technique of posterior calcaneal osteotomy that can be either a Dwyer-type closing wedge osteotomy or displacement osteotomy.
Aydin, S; Kucukyuruk, B; Yildirim, H; Abuzayed, B; Bozkus, H; Vural, M
Lumbar discal cysts are extremely rare pathologies, with only few reports describing these lesions in the literature. Moreover, their definite pathogenesis is still unknown, with proposed theories based on radialogic and histologic findings. In this report, the authors present an acute formation of a discal cyst, which is reported for the first time. Also, we center our case on the discussion of the possible pathogenesis. Also, this is the first case of discal cyst reported in Turkey. A 67-year-old woman, whose complaints, and clinical and radiological findings demonstrated lumbar disc herniation with acute Modic 1 degererative changes of the adjacent end plates of L3-4 level. After medical and physical therapies, follow-up lumbar MRI has been taken to demonstrate a discal cyst formation on the adjacent intervertebral disc, showed cranially migrated cyst superior posterior on herniated disc, in 2 weeks period. The patient was treated by microsurgical resection of the cyst, and her complaints resolved completely.
Gao, Maofeng; Zou, Jun; Zhang, Zhigang; Luo, Zongping; Yang, Huilin
Pedicle-lengthening osteotomy (PLO) is a minimally invasive and effective surgical procedure for lumbar spinal stenosis syndrome. Compared with traditional surgery, PLO can effectively enlarge the spinal canal while minimizing the disruption of posterior anatomical structures of the lumbar vertebra, leading to reduced postoperative perineural scarring adhesion and good clinical outcomes using minimally invasive procedures. However, PLO is still in its early stages, and only a few relevant experimental and clinical studies have been reported. The present study was performed to investigate the influence of PLO on the stability of lumbar vertebrae. The results indicated that PLO can effectively enlarge the spinal canal, and no lumbar spondylolisthesis or other complications occurred in this study. Moreover, this procedure does not significantly affect the stability of the lumbar spine, suggesting a possible clinical application. PMID:27347315
Yu, Ji-Su; An, Duk-Hyun
[Purpose] To investigate the effects of erect sitting, slouched posture with cross-legged sitting, and erect posture with cross-legged sitting on the lumbar and pelvic angles, and gluteal pressure. [Subjects] For the experiments, 17 healthy women were recruited. [Methods] All subjects were asked to perform three sitting postures: erect sitting, slouched posture with cross-legged sitting, and erect posture with cross-legged sitting. Lumbar and pelvic angles were measured using a three-dimensional motion-capture system, and gluteal pressure was measured using a pressure mat. [Results] Compared to erector sitting, slouched posture with cross-legged sitting showed significantly greater lumbar flexion, posterior pelvic tilt, and left pelvic tilt. Compared to erect sitting, erect posture with cross-legged sitting showed significantly greater lumbar flexion and posterior pelvic tilt. Compared to erect posture with cross-legged sitting, slouched posture with cross-legged sitting showed significantly greater lumbar flexion and posterior pelvic tilt. Compared to erect sitting and erect posture with cross-legged sitting, slouched posture with cross-legged sitting showed significantly greater left gluteal pressure; there was no significant difference in right gluteal pressure. [Conclusion] An erect posture can reduce changes in lumbar and pelvic angles, and gluteal pressure compared to a slouched posture during cross-legged sitting.
Barrey, Cédric; Darnis, Alice
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.
Barrey, Cédric; Darnis, Alice
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
Singh, Kern; Park, Daniel K
Circumferential arthrodesis and reconstruction is necessary after a lumbar corpectomy in the setting of malignancy and infection. The advent of expandable cage technology now allows for safe anterior column reconstruction via a posterior approach with no transection and minimal retraction of the lumbar spinal nerve roots. Fifteen patients underwent a single-stage, circumferential corpectomy and anterior spinal reconstruction with an expandable cage via a midline, posterior, lateral lumbar extracavitary approach. Posterior segmental pedicle screw fixation and iliac crest bone graft was used in all cases. Fifteen lumbar extracavitary corpectomy nerve root-sparing procedures have been performed to date, with at least 1-year follow-up (12 tumors/3 infections). No patient suffered any neurological complications. One patient suffered from a postoperative myocardial infarction 10 days after the procedure. Two patients had medical complications that were treated without sequelae. We present a technical description and case series of patients undergoing a single-stage, circumferential corpectomy and anterior spinal reconstruction with an expandable cage via a midline, posterior, lateral lumbar extracavitary approach with at least 1-year follow-up. The technique is safe, technically feasible, and obviates an anterior approach in this oftentimes critically ill patient population.
Kumar, G Samson Sujit; Kulkarni, Vaijayantee; Haran, R P
Lumbo-costo-vertebral syndrome, which includes abnormalities of the vertebral bodies, ribs and trunk musculature, is very rare and only few cases have been reported. We report a case of 18-month-old female child with absent ribs, hemivertebrae, superior lumbar hernia (features of lumbo-costo-vertebral syndrome) and posterior spinal dysraphism, which to our knowledge is the first case in the English literature with such a combination of defects. Embryology and management of the case is discussed.
Ozdemir, Bulent; Kanat, Ayhan; Batcik, Osman Ersegun; Erturk, Cihangir; Celiker, Fatma Beyazal; Guvercin, Ali Riza; Yazar, Ugur
Disc fragments are well known to migrate to superior, inferior, or lateral sites in the anterior epidural space, posterior epidural migrated lumbar disc fragments is an extremely rare disorder, 61 cases have been reported to date. However, there were no cases with perforated ligamentum flavum (LF). We report a different case with perforation of ligamentum ligamentum by disc fragment. To the best of our knowledge, this is the first report of perforation LF by a posterior epidural migrated sequester disc. PMID:28250640
Vialle, Luis Roberto; Vialle, Emiliano Neves; Suárez Henao, Juan Esteban; Giraldo, Gustavo
Lumbar disc herniation is the most common diagnosis among the degenerative abnormalities of the lumbar spine (affecting 2 to 3% of the population), and is the principal cause of spinal surgery among the adult population. The typical clinical picture includes initial lumbalgia, followed by progressive sciatica. The natural history of disc herniation is one of rapid resolution of the symptoms (four to six weeks). The initial treatment should be conservative, managed through medication and physiotherapy, sometimes associated with percutaneous nerve root block. Surgical treatment is indicated if pain control is unsuccessful, if there is a motor deficit greater than grade 3, if there is radicular pain associated with foraminal stenosis, or if cauda equina syndrome is present. The latter represents a medical emergency. A refined surgical technique, with removal of the extruded fragment and preservation of the ligamentum flavum, resolves the sciatic symptoms and reduces the risk of recurrence over the long term. PMID:27019834
Ciricillo, S F; Weinstein, P R
Lumbar spinal stenosis, the results of congenital and degenerative constriction of the neural canal and foramina leading to lumbosacral nerve root or cauda equina compression, is a common cause of disability in middle-aged and elderly patients. Advanced neuroradiologic imaging techniques have improved our ability to localize the site of nerve root entrapment in patients presenting with neurogenic claudication or painful radiculopathy. Although conservative medical management may be successful initially, surgical decompression by wide laminectomy or an intralaminar approach should be done in patients with serious or progressive pain or neurologic dysfunction. Because the early diagnosis and treatment of lumbar spinal stenosis may prevent intractable pain and the permanent neurologic sequelae of chronic nerve root entrapment, all physicians should be aware of the different neurologic presentations and the treatment options for patients with spinal stenosis. Images PMID:8434469
Rodríguez-Vela, J.; Joven-Aliaga, E.; Herrera, A.; Vicente, J.; Suñén, E.; Loste, A.; Tabuenca, A.
It has been widely reported a vascular and neurologic damage of the lumbar muscles produced in the classic posterior approach for lumbar spinal fusions. The purpose of this study is to demonstrate a better clinical and functional outcome in the postoperative and short term in patients undergoing minimal invasive surgery (“mini-open”) for this lumbar spinal arthrodesis. We designed a prospective study with a 30 individuals cohort randomized in two groups, depending on the approach performed to get a instrumented lumbar circumferential arthrodesis: “classic posterior” (CL group) or “mini-open” approach (MO group). Several clinical and functional parameters were assessed, including blood loss, postoperative pain, analgesic requirements and daily life activities during hospital stay and at the 3-month follow-up. Patients of the “mini-open approach” group had a significant lower blood loss and hospital stay during admission. They also had significant lower analgesic requirements and faster recovery of daily life activities (specially moderate efforts) when compared to the patients of the “classic posterior approach” group. No significant differences were found between two groups in surgery timing, X-rays exposure or sciatic postoperative pain. This study, inline with previous investigations, reinforces the concept of minimizing the muscular lumbar damage with a mini-open approach for a faster and better recovery of patients’ disability in the short term. Further investigations are necessary to confirm these findings in the long term, and to verify the achievement of a stable lumbar spinal fusion. PMID:19399538
Kim, Jin Seong
Objectives To review surgical results of post-fusion lumbar flatback treated with pedicle subtraction osteotomy (PSO) or Smith-Petersen osteotomies (SPOs). Methods Twenty-eight patients underwent osteotomies. Radiological outcomes by sagittal vertical axis (SVA), and pelvic tilt (PT), T1 pelvic angle (T1PA), and pelvic incidence (PI)-lumbar lordosis (LL) at preoperative, postoperative 1 month, and final were evaluated. Oswestry Disability Index (ODI), visual analog scale (VAS) score of back pain/leg pain, and Scoliosis Research Society-22 score (SRS-22r) were analyzed and compared. Patients were divided into 2 groups (SVA ≤5 cm : normal, SVA >5 cm : positive) at final and compared outcomes. Results Nineteen patients (68%) had PSO and the other 9 patients had SPOs with anterior lumbar interbody fusions (ALIFs) (Mean age : 65 years, follow-up : 31 months). The PT, PI-LL, SVA, T1PA were significantly improved at 1 month and at final (p<0.01). VAS score, ODI, and SRS-22r were also significantly improved at the final (p<0.01). 23 patients were restored with normal SVA and the rest 5 patients demonstrated to positive SVA. SVA and T1PA at 1 month and SVA, PI-LL, and T1PA at final were significantly different (p<0.05) while the ODI, VAS, and SRS-22r did not differ significantly between the groups (p>0.05). Common reoperations were early 4 proximal junctional failures (14%) and late four rod fractures. Conclusion Our results demonstrate that PSO and SPOs with ALIFs at the lower lumbar are significantly improves sagittal balance. For maintenance of normal SVA, PI-LL might be made negative value and T1PA might be less than 11° even though positive SVA group was also significantly improved clinical outcomes. PMID:27847576
Cho, Kyu-Jung; Suk, Se-Il; Park, Seung-Rim; Kim, Jin-Hyok; Choi, Sung-Wook; Yoon, Young-Hyun; Won, Man-Hee
There is a debate regarding the distal fusion level for degenerative lumbar scoliosis. Whether a healthy L5-S1 motion segment should be included or not in the fusion remains controversial. The purpose of this study was to determine the optimal indication for the fusion to the sacrum, and to compare the results of distal fusion to L5 versus the sacrum in the long instrumented fusion for degenerative lumbar scoliosis. A total of 45 patients who had undergone long instrumentation and fusion for degenerative lumbar scoliosis were evaluated with a minimum 2 year follow-up. Twenty-four patients (mean age 63.6) underwent fusion to L5 and 21 patients (mean age 65.6) underwent fusion to the sacrum. Supplemental interbody fusion was performed in 12 patients in the L5 group and eleven patients in the sacrum group. The number of levels fused was 6.08 segments (range 4-8) in the L5 group and 6.09 (range 4-9) in the sacrum group. Intraoperative blood loss (2,754 ml versus 2,938 ml) and operative time (220 min versus 229 min) were similar in both groups. The Cobb angle changed from 24.7 degrees before surgery to 6.8 degrees after surgery in the L5 group, and from 22.8 degrees to 7.7 degrees in the sacrum group without statistical difference. Correction of lumbar lordosis was statistically better in the sacrum group (P = 0.03). Less correction of lumbar lordosis in the L5 group seemed to be associated with subsequent advanced L5-S1 disc degeneration. The change of coronal and sagittal imbalance was not different in both groups. Subsequent advanced L5-S1 disc degeneration occurred in 58% of the patients in the L5 group. Symptomatic adjacent segment disease at L5-S1 developed in five patients. Interestingly, the development of adjacent segment disease was not related to the preoperative grade of disc degeneration, which proved minimal degeneration in the five patients. In the L5 group, there were nine patients of complications at L5-S1 segment, including adjacent segment disease at
Kim, Suhyeong; Yi, Hyeon-Joong; Bak, Koang Hum; Kim, Dong Won; Lee, Yoon Kyoung
Objective Various procedures have been introduced for anterior interbody fusion in degenerative cervical disc disease including plate systems with autologous iliac bone, carbon cages, and cylindrical cages. However, except for plate systems, the long-term results of other methods have not been established. In the present study, we evaluated radiologic findings for cylindrical cervical cages over long-term follow up periods. Methods During 4 year period, radiologic findings of 138 patients who underwent anterior cervical fusion with cylindrical cage were evaluated at 6, 12, 24, and 36 postoperative months using plain radiographs. We investigated subsidence, osteophyte formation (anterior and posterior margin), cage direction change, kyphotic angle, and bone fusion on each radiograph. Results Among the 138 patients, a minimum of 36 month follow-up was achieved in 99 patients (mean follow-up : 38.61 months) with 115 levels. Mean disc height was 7.32 mm for preoperative evaluations, 9.00 for immediate postoperative evaluations, and 4.87 more than 36 months after surgery. Osteophytes were observed in 107 levels (93%) of the anterior portion and 48 levels (41%) of the posterior margin. The mean kyphotic angle was 9.87° in 35 levels showing cage directional change. There were several significant findings : 1) related subsidence [T-score (p=0.039) and anterior osteophyte (p=0.009)], 2) accompanying posterior osteophyte and outcome (p=0.05). Conclusion Cage subsidence and osteophyte formation were radiologically observed in most cases. Low T-scores may have led to subsidence and kyphosis during bone fusion although severe neurologic aggravation was not found, and therefore cylindrical cages should be used in selected cases. PMID:23091668
Iwasaki, Risa; Yokoyama, Ginga; Kawabata, Satoshi; Suzuki, Tomotaka
[Purpose] This study investigated the relationship between lumbar pelvic rhythm and the physical characteristics of stoop lifting. [Subjects and Methods] Participants performed a stoop lifting task under two conditions: with and without load. We assessed the lumbar kyphosis and sacral inclination angles using the SpinalMouse® system, as well as hamstring flexibility. During stoop lifting, surface electromyograms and the lumbar and sacral motions were recorded using a multi-channel telemetry system and flexible electrogoniometers. [Results] In the initial phase of lifting, lumbar extension was delayed by load; the delay showed a negative correlation with sacral inclination angle at trunk flexion, whereas a positive correlation was observed with electromyogram activity of the lumbar multifidus. Additionally, a positive correlation was observed between sacral inclination angle and hip flexion range of motion during the straight leg raise test. [Conclusion] We found that a disorder of the lumbar pelvic rhythm can be caused by both load and hamstring tightness. In the initial phase of stoop lifting, delayed lumbar extension is likely to lead to an increase in spinal instability and stress on the posterior ligamentous system. This mechanism shows that stoop lifting of a load may be harmful to the lower back of people with hamstring tightness. PMID:24567676
... ACL connect your thighbone (femur) to your shinbone (tibia). If either ligament is torn, it might cause ... ligaments connect the thighbone (femur) to the shinbone (tibia). The anterior and posterior cruciate ligaments form an " ...
Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.
Cedoz, M E; Larbre, J P; Lequin, C; Fischer, G; Llorca, G
Specific features of upper lumbar disk herniations are reviewed based on data from the literature and from a retrospective study of 24 cases treated surgically between 1982 and 1994 (seven at L1-L2 and 17 at L2-L3). Clinical manifestations are polymorphic, misleading (abdominogenital pain suggestive of a visceral or psychogenic condition, meralgia paresthetica, isolated sciatica; femoral neuralgia is uncommon) and sometimes severe (five cases of cauda equina syndrome in our study group). The diagnostic usefulness of imaging studies (radiography, myelography, computed tomography, magnetic resonance imaging) and results of surgery are discussed. The risk of misdiagnosis and the encouraging results of surgery are emphasized.
de Moraes, Frederico Barra; Cardoso, André Luiz Passos; Tristão, Newton Antônio; Pimenta, Wilson Eloy; Daher, Sérgio; de Souza Carneiro, Siderley; Barbosa, Nathalia Parrode Machado; de Lima Malta, Nayanne; Ribeiro, Noara Barros
We report a rare case of primary bone liposarcoma of the lumbar spine, for which only one case has been reported. A female patient, 60 years of age, with lumbar pain and left sciatalgy for six months. In the imaging exams, a destructive tumor was found in the L4 vertebral body, and magnetic resonance imaging (MRI) revealed a tumoral lesion with T1 hiposignal and T2 hypersignal. Histological diagnosis was difficult, and immunohistochemistry confirmed the diagnosis. Surgical treatment was performed with wide ressection, spinal cord decompression, and anterior and posterior fusion of L3 to L5 complemented by radiotherapy and chemotherapy. After three years, a computed tomography (CT) scan evidenced an expansive injury in the lung. Despite its rarity, liposarcoma should be considered in the differential diagnosis of sciatica and primary tumors of the spine. PMID:27027092
Moscovici, S; Paldor, I; Ramirez de-Noriega, F; Itshayek, E; Shoshan, Y; Spektor, S; Attia, M
We report a patient with minor head trauma-related bilateral hemispheric subdural hematoma (SDH) and subsequent delayed spinal SDH or presumed migration to the lumbar spine. An acutely confused 88-year-old man presented to the Emergency Department after minor head trauma. Head CT scan revealed a small hemispheric SDH. The patient was admitted for observation. CT scan 6 hours later showed bilateral SDH with extension to the tentorium. Three days later SDH had resolved leaving bilateral subdural hygromas. Local leg weakness localized to the lumbar spine developed on day 6; spinal CT scan and MRI revealed a posterior L5-S1 collection. A pure subacute subdural hematoma compressing the cauda equina was drained after an L5 laminectomy. His lower leg weakness improved. The patient was discharged to rehabilitation two weeks after surgery. Patients with traumatic SDH who develop late-onset neurological deterioration attributable to any region of the spine should be evaluated for spinal SDH.
Cho, Sung Ik; Lee, Jung Hwan
Lumbar intraspinal synovial cysts are included in the difference diagnosis of lumbar radiculopathy. Developing imaging modalities has result in increased reporting about these lesions. However, the case of bilateral new lumbar intraspinal synovial cysts after laminectomy has been rarely reported. We report of a rare case with bilateral lumbar intraspinal synovial cysts after laminectomy, requiring surgical excision. PMID:27799997
Lowery, G L; Kulkarni, S; Pennisi, A E
The results of spinal fusion, especially posteriorly above the lumbosacral junction, have been mixed. Autologous growth factor concentrate (AGF) prepared by ultraconcentration of platelets contains multiple growth factors having a chemotactic and mitogenic effect on mesenchymal stem cells and osteoblasts and may play a role in initiating bone healing. The purpose of this retrospective study is to review our results with AGF in lumbar spinal fusions. To date, AGF has been used in 39 patients having lumbar spinal fusion. The study group consisted of the first 19 consecutive cases to allow at least 6 months follow-up. The average follow-up was 13 months (range 6 to 18 months). Follow-up compliance was 91%. There were 7 men and 12 women. Average age was 52 years (range 30-72 years). Nine patients had prior back surgery. There were 8 smokers. AGF was used in posterior (n = 15) or anterior intradiscal (n = 4) fusions. AGF was used with autograft and coraline hydroxyapatite in all posterior fusions, and autograft, coral, and intradiscal spacer (carbon fiber spinal fusion cages or Synthes femoral ring) in intradiscal fusions. Posterior stabilization was used in all cases. Eight cases were single-level fusions, 6 were two-level, and 1 was a three-level fusion. Autologous iliac crest bone graft was taken in 14 cases and local autograft used in 5 cases. Posteriorly, a total of 23 levels were fused; of these, nine were at L5-S1, eight at L4-L5, five at L3-L4, and one at L2-L3. No impending pseudoarthroses were noted on plain radiographic examination at last follow-up visit. Solid fusion was confirmed in 3 patients having routine hardware removal, and in 2 patients who had surgery at an adjacent level. There was one posterior wound infection, which was managed without sequelae. When used as an adjunct to autograft, AGF offers theoretical advantages that need to be examined in controlled studies. Further study is necessary to determine whether coralline hydroxyapatite used as a
Khouri, Nejib; Glorion, Christophe; Lechevallier, Joël; Morin, Christian
Lumbar hyperlordosis of neuromuscular origin is rare and requires surgical treatment in order to preserve a good sitting posture. We report twenty-seven cases of a preponderantly sagittal hyperlordosis deformity of the lumbar spine in patients with neuromuscular disorders and identify the indications and results of treatment. Seventeen males and ten females, aged 13 to 27 years, underwent operations for a lumbar hyperlordosis of neuromuscular origin responsible for major difficulties in sitting. In all patients, the sacrum was horizontal and associated in twenty-six cases with marked pelvic anteversion. Eleven patients were treated surgically by a posterior approach. The sixteen remaining patients had a preliminary discectomy, followed by posterior correction and fusion. Lumbar hyperlordosis was reduced from 8° to 77° between L1 and S1. The horizontal sacrum was partially reduced with an improvement from 8° to 50°. Consequently, patients recovered a comfortable sitting position. One patient died of respiratory complications six weeks after surgery. Surgical correction is a demanding procedure which can be performed by a posterior approach. It is mandatory to analyse the spino-pelvic balance to avoid iliac retroversion and the loss of the role of the ischia in the sitting position. PMID:16967278
The tibialis posterior tendon is the largest and anteriormost tendon in the medial ankle. It produces plantar flexion and supination of the ankle and stabilizes the plantar vault. Sonographic assessment of this tendon is done with high-frequency, linear-array transducers; an optimal examination requires transverse retromalleolar, longitudinal retromalleolar, and distal longitudinal scans, as well as dynamic studies. Disorders of the posterior tibial tendon include chronic tendinopathy with progressive rupture, tenosynovitis, acute rupture, dislocation and instability, enthesopathies. The most common lesion is a progressive "chewing gum" lesion that develops in a setting of chronic tendinopathy; it is usually seen in overweight women over 50 years of age with valgus flat feet. Medial ankle pain must also be carefully investigated, and the presence of instability assessed with dynamic maneuvers (forced inversion, or dorsiflexion) of the foot. Sonography plays an important role in the investigation of disorders involving the posterior tibial tendon.
Rovira, M; Romero, F; Ibarra, B; Torrent, O
A group of 40 patients with symptoms of prolapsed lumbar disk, seven of which were recurrent after surgery, was studied by computed tomography. In all cases, the diagnosis was confirmed by myelography and posterior surgery. Computed tomography was performed after the disappearance of myelographic contrast medium. Positive herniated disk was shown by computed tomography in 88%. In postoperative cases, computed tomography after intravenous contrast enhancement favored the recognition of postoperative scar, rather than recurrent herniation. Computed tomography also facilitated the diagnosis of spondylotic lesions, which may accompany herniated disks. Computed tomography should reduce the need for myelography, which is reserved for cases with doubtful computed tomographic findings.
Brandão, Lara A; Young Poussaint, Tina
Pediatric brain tumors are the leading cause of death from solid tumors in childhood. The most common posterior fossa tumors in children are medulloblastoma, atypical teratoid/rhabdoid tumor, cerebellar pilocytic astrocytoma, ependymoma, and brainstem glioma. Location, and imaging findings on computed tomography (CT) and conventional MR (cMR) imaging may provide important clues to the most likely diagnosis. Moreover, information obtained from advanced MR imaging techniques increase diagnostic confidence and help distinguish between different histologic tumor types. Here we discuss the most common posterior fossa tumors in children, including typical imaging findings on CT, cMR imaging, and advanced MR imaging studies.
Zhu, J F; Crevoisier, R; King, D L; Henry, R; Mills, C M
Posterior crossbite, the most common malocclusion in young children, can be caused by a variety of skeletal, muscular, or dental factors. This condition produces insufficient maxillary arch width and is frequently associated with various oral sucking and postural habits. If left untreated, this problem can result in adverse skeletal growth changes. Various mechanical treatment modalities designed to expand the posterior maxillary arch width are available to correct this problem. The appropriate treatment method depends on the patient's age and level of cooperation as well as the determined etiology of the constriction.
Choudhury, A R; Taylor, J C
Twenty-eight patients presenting with low back pain, associated with sciatic or femoral neuropathy, were found to have lateral recess stenosis occurring as a result of hypertrophy of the facet joints, with preservation within normal limits of the sagittal AP diameter of the lumbar canal. Pathology was believed to be traumatic in origin, and the variable nature of the adhesions suggested recurrent inflammation; the hypertrophy of the facet joints may have been the result of traumatic inflammatory hyperaemia. Radiological investigations were unhelpful. The diagnosis of the condition was made at the time of surgical exploration by the findings of alteration of the facet joints, adhesions and fixity of the nerve roots, normal sagittal AP diameter of the canal, and absence of other significant lesions. Gratifying results were obtained with decompression by wide laminectomy with excision of overhanging facet joints and release of adhesions. PMID:894321
Fantry, Amanda; Lareau, Craig; Vopat, Bryan; Blankenhorn, Brad
Management of posterior malleolus fractures continues to be controversial, with respect to both need for fixation and fixation methods. Fixation methods include an open posterior approach to the ankle as well as percutaneous reduction and fixation with or without arthroscopy for visualization of the articular surface. Plain radiographs are unreliable in identifying fracture pattern and intraoperative reduction, making arthroscopy a valuable adjunct to posterior malleolus fracture management. In this article, we report a case of tibialis posterior tendon entrapment within a posterior malleolus fracture, as identified by arthroscopy and managed with open reduction. Tibialis posterior tendon entrapment within a posterior malleolus has not been previously reported. Ankle arthroscopy for posterior malleolus fractures provides an opportunity to identify soft-tissue or tendinous entrapment, articular surface reduction, and articular cartilage injuries unlikely to be identified with fluoroscopy alone and should be considered in reduction and fixation of posterior malleolus fractures.
Bansil, Rohit; Hirano, Yoshitaka; Sakuma, Hideo; Watanabe, Kazuo
Background: Another rare cause of lower back pain with radiculopathy is the discal cyst. It is believed to arise from degeneration of a herniated disc, although many other theories of its origin have been proposed. Here, we report a patient with lower back pain/radiculopathy attributed originally to a herniated lumbar disc, which transformed within 6 months into a discal cyst. Case Description: A 42-year-old male had a magnetic resonance (MR) documented herniated lumbar disc at the L4-5 level. It was managed conservatively for 6 months, after which symptoms recurred and progressed. The follow-up MR study revealed a discal cyst at the L4-5 without residual herniated disc. Of interest, the cyst communicated with the L4-5 intervertebral disc, which was herniated under the posterior longitudinal ligament and the disc space. During surgery, the cyst was completely removed, and his symptoms/signs resolved. Conclusion: A discal cyst develops as pathological sequelae of a degenerated herniated disc. Although rare, these lesions must be considered among the differential diagnoses in young patients with radicular back pain. MR study clearly documents these lesions, and surgical excision of the cyst is the treatment of choice. PMID:27843689
Joseph, Jacob R; Farooqui, Zishaan; Smith, Brandon W; Kahn, Elyne N; Liu, Xilin; La Marca, Frank; Park, Paul
OBJECTIVE Obesity and low-back pain associated with degenerative spondylosis or spondylolisthesis are common comorbid conditions. Many patients report that the pain and disability associated with degenerative lumbar disease are key factors in their inability to lose weight. The aim of this retrospective study was to determine if there is an association between improved functional status and weight loss following a successful transforaminal lumbar interbody fusion (TLIF) procedure. METHODS A retrospective cohort study of patients who underwent single-level TLIF was performed. Inclusion criteria were preoperative body mass index (BMI) greater than 30 kg/m(2), achievement of minimum clinically important difference in the Oswestry Disability Index (ODI, defined as improvement of 15 points), and minimum 1-year postoperative followup BMI. Preoperative and postoperative BMI, ODI, and visual analog scale (VAS) scores were compared. A subgroup analysis of patients who achieved substantial clinical benefit (SCB, defined as a net improvement of 18.8 points on the ODI) was also performed. RESULTS A total of 56 patients met the inclusion criteria. The mean age of the study population was 55.6 ± 13.7 years. The mean preoperative BMI was 34.8 ± 4.6 kg/m(2), the mean preoperative ODI was 66.2 ± 10.1, and the mean preoperative VAS score was 7.1 ± 1.7. The mean change in ODI was -33.1 ± 13.5 (p < 0.01) and the mean change in the VAS score was -4.1 ± 2.1 (p < 0.01). The mean change in BMI was +0.15 ± 2.1 kg/m(2) (range -4.2 to +6.5 kg/m(2); p = 0.6). SCB was achieved in 46 patients on the ODI. The mean preoperative BMI for patients with SCB was 34.8 ± 4.8 kg/m(2), and the mean postoperative BMI was 34.7 ± 5.0 kg/m(2). The mean change in BMI was -0.03 ± 1.9 kg/m(2) (p = 0.9). CONCLUSIONS Despite successful surgical intervention via TLIF with achievement of improved function and pain, obese patients did not have significant change in weight postoperatively.
Masala, Salvatore; Tarantino, Umberto; Nano, Giovanni; Iundusi, Riccardo; Fiori, Roberto Da Ros, Valerio Simonetti, Giovanni
Purpose. The purpose of this study was to evaluate the effectiveness of a new pedicle screw-based posterior dynamic stabilization device PDS Percudyn System Trade-Mark-Sign Anchor and Stabilizer (Interventional Spine Inc., Irvine, CA) as alternative minimally invasive treatment for patients with lumbar spine stenosis. Methods. Twenty-four consecutive patients (8 women, 16 men; mean age 61.8 yr) with lumbar spinal stenosis underwent implantation of the minimally invasive pedicle screw-based device for posterior dynamic stabilization. Inclusion criteria were lumbar stenosis without signs of instability, resistant to conservative treatment, and eligible to traditional surgical posterior decompression. Results. Twenty patients (83 %) progressively improved during the 1-year follow-up. Four (17 %) patients did not show any improvement and opted for surgical posterior decompression. For both responder and nonresponder patients, no device-related complications were reported. Conclusions. Minimally invasive PDS Percudyn System Trade-Mark-Sign has effectively improved the clinical setting of 83 % of highly selected patients treated, delaying the need for traditional surgical therapy.
Sanoussi, Samuila; Rachid, Sani; Sani, Chaibou Maman; Mahamane, Bawa; Addo, Guemou
We present two cases of rachipagus in two male infants and review the literature on this anomaly. These infants were from consanguineous marriages and cases of twins were reported in their families. In the first case it was a limb attached to the lower lumbar region with a rudimentary posterior arch. At the junction there was a lipomeningocele. Anatomical dissection of the limb identified the bones of the lower limb. In the second case, the parasites were joints of the upper limb that were attached to the chest by rudimentary posterior arches. In both cases there was only one spinal canal and a single spinal cord. Except the spina bifida in the first case no other malformation was diagnosed. The parasites were successfully excised. The two patients are well at one year of follow-up. Rachipagus is a rare embryogenic malformation with a good prognosis in the absence of associated congenital anomalies. PMID:22091327
Monobe, T; Fujita, T; Nakaue, Y; Nishi, N
A 49-year-old female presented a two-year history of pain in the right thigh and lower back. Neurological examination on admission demonstrated weakness of the right iliopsoas and quadriceps, hypesthesia on the right L1-2 dermatome. Radiological examination including myelography, CT myelography and discography disclosed an L1-2 herniated disc. Sagittal MRI also revealed an L1-2, an L4-5 and L5-S1 protruded disc. A posterior microdiscectomy (Love's method) was performed for the L1-2 disc. A controlateral protruded disc which compressed the L-2 nerve root was identified and partially removed. The postoperative myelography showed residual disc. The patient was free from pain and regained normal sensorimotor function. Love's posterior microdiscectomy has a disadvantage in that the operative field is limited. Careful surgical procedure was needed to avoid injury to nerve roots and the cauda equina in a tight L1-2 lumbar canal.
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.
Mattei, Tobias A; Rehman, Azeem A; Teles, Alisson R; Aldag, Jean C; Dinh, Dzung H; McCall, Todd D
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.
Singla, Anuj; Yang, Scott; Werner, Brian C; Cancienne, Jourdan M; Nourbakhsh, Ali; Shimer, Adam L; Hassanzadeh, Hamid; Shen, Francis H
OBJECTIVE Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion. METHODS A nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI. RESULTS The overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1-3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI
Subsidence of interbody devices into the vertebral body might result in serious clinical problems, especially when the devices are not well designed and analyzed. Recently, some novel designs were proposed to reduce the risk of subsidence, but those designs are based on the researcher's experience. The purpose of this study was to discover the interbody device design with excellent subsidence resistance by changing the device's shape. The three-dimensional nonlinear finite element models, which consisted of the interbody device and vertebral body, were created first. Then, the simulation-based genetic algorithm, which combined the finite element model and the searching algorithm, was developed by using ANSYS® Parametric Design Language. Finally, the numerical results were carefully validated with the use of biomechanical tests. The optimum shape design obtained in this study looks like a flower with many petals and it has excellent subsidence resistance when compared with the other designs provided by the past studies. The results of the present study could help surgeons to understand the subsidence resistance of interbody devices in terms of their shapes and has directly provided the design rationales to engineers.
Malandrino, Andrea; Noailly, Jérôme; Lacroix, Damien
The collagen network of the annulus fibrosus largely controls the functional biomechanics of the lumbar intervertebral discs (IVDs). Quantitative anatomical examinations have shown bundle orientation patterns, possibly coming from regional adaptations of the annulus mechanics. This study aimed to show that the regional differences in annulus mechanical behaviour could be reproduced by considering only fibre orientation changes. Using the finite element method, a lumbar annulus was modelled as a poro-hyperelastic material in which fibres were represented by a direction-dependent strain energy density term. Fibre orientations were calibrated to reproduce the annulus tensile behaviours measured for four different regions: posterior outer, anterior outer, posterior inner and anterior inner. The back-calculated fibre angles and regional patterns as well as the global disc behaviour were comparable with anatomical descriptions reported in the literature. It was concluded that annulus fibre variations might be an effective tool to calibrate lumbar spine IVD and segment models.
Vásquez-Ríos, Jorge Rodrigo; Nava-Bringas, Tania Inés
Antecedentes: el ejercicio es la intervención con mayor grado de evidencia de eficacia para el tratamiento del dolor crónico de la espalda baja, con beneficio superior en términos de dolor y funcionalidad, en comparación con cualquiera otra intervención. Existe una amplia variedad de ejercicios diseñados; sin embargo, actualmente los llamados ejercicios de estabilización lumbar adquiririeron una popularidad creciente entre los clínicos que están en contacto con enfermedades de la columna. Sin embargo, existe controversia en cuanto a la prescripción adecuada de los mismos y los múltiples protocolos publicados. Objetivo: analizar la bibliografía científica acerca del uso y prescripción de estos ejercicios para favorecer la mejor toma de decisiones enlos clínicos y diseñar, con base a la evidencia, el programa más adecuado para cada paciente. Conclusión: se encontró que este programa es una herramienta esencial en el tratamiento del dolor de espalda baja, en la etapa terapéutica y en la preventiva.
Kershner, David E; Binhammer, Robert T
A meticulous examination was performed on 56 vertebral columns from cadavers between 64 and 89 years of age. Identification of all contents within the dural sac was completed; however, the main focus was the cauda equina and lumbar region. In addition to scope dissection, radiographs and histological preparations were used to identify structures, tissue types, and any possible pathology. Discrete intrathecal ligamentous bands were observed in all cadavers examined. They were found randomly binding the dorsal nerve roots of the cauda equina to the dura. Occasional binding of the ventral nerve roots to the dorsal roots was observed. Histological examination demonstrated a dense collagen ligament varying between 0.13 and 0.35 microm in thickness and from 3 mm to 3.5 cm in length. The average number of ligaments found per cadaver was 18. These ligaments displayed a broad base attachment to the nerve root or dura of approximately 3 mm. Looping of the nerve roots associated with these ligaments was seen in one cadaver with a burst fracture. Electron microscopic studies of these ligaments demonstrated similarities to denticulate ligaments. It is suggested that the intrathecal ligaments represent remnants from fetal development of the denticulate ligaments.
Approximately 20-25% of all acute strokes occur in the posterior circulation. These strokes can be rather difficult to diagnose because they present in such diverse ways, and can easily be mistaken for more benign entities. A fastidious history, physical exam, high clinical suspicion, and appropriate use of imaging are essential for the emergency physician to properly diagnose and treat these patients. Expert stroke neurologist consultation should be utilized liberally.
Vicario, C; Lopez-Oliva, F; Sánchez-Lorente, T; Zimmermann, M; Asenjo-Siguero, J J; Ladero, F; Ibarzábal, A
Anterior cervical discectomy and interbody fusion (ACDF) is a widely accepted surgical technique in the treatment of cervical disc disease. Tantalum cages have been recently introduced in spine surgery for interbody fusion because of the advantages of their mechanical properties. We present the results of a prospective clinical and radiological study on 24 consecutive patients who underwent an ACDF with tantalum cages. Clinical evaluation was assessed preoperatively and after surgery by a questionnaire that included a Visual Analogic Scale (VAS) of neck and arm pain, the Oswestry Disability Index and the Zung Depression Scale. Results were classified by Odom's criteria. Radiological evaluation included flexion-extension X-rays, and changes in distance between spinous processes and Cobb angle were measured. Postoperatively patients were reviewed 3 and 12 months after surgery. A statistical significative improvement in all clinical data was reported. According to Odom's criteria in 75% of patients the results were considered like excellent or good. Only one case of radiological and clinical pseudoarthrosis was confirmed. No significative differences were reported 3 and 12 months after surgery. Tantalum cages are a very promising and usefull alternative among implants available for ACDF. Compatibility with MRI postoperative studies and the unnecessariness of autograft are some of their advantages.
Cisterna chyli is prone to injury in any retroperitoneal surgery. However, retroperitoneal chylous leakage is a rare complication after anterior spinal surgery. To the best of our knowledge, only ten cases have been reported in the English literature. We present a case of a 49-year-old man who had lumbar metastasis and associated radiculopathy. He had transient retroperitoneal chylous leakage after anterior tumor decompression, interbody bony fusion, and instrumental fixation from L2 to L4. The leakage stopped spontaneously after we temporarily clamped the drain tube. Intraperitoneal ascites accumulation developed thereafter due to nutritional loss and impaired hepatic reserves. We gathered ten reported cases of chylous leak after anterior thoracolumbar or lumbar spinal surgery, and categorized all these cases into two groups, depending on the integrity of diaphragm. Six patients received anterior spinal surgery without diaphragm splitting. Postoperative chylous leak stopped after conservative treatment. Another five cases received diaphragm splitting in the interim of anterior spinal surgery. Chylous leakage stopped spontaneously in four patients. The remaining one had a chylothorax secondary to postop chyloretroperitoneum. It was resolved only after surgical intervention. In view of these cases, all the chylous leakage could be spontaneously closed without complications, except for one who had a secondary chylothorax and required thoracic duct ligation and chemopleurodesis. We conclude that intraoperative diaphragm splitting or incision does not increase the risk of secondary chylothorax if it was closed tightly at the end of the surgery and the chest tube drainage properly done. PMID:17273839
Kele, Henrich; Xia, Annie; Weiler, Markus; Schwarz, Daniel; Bendszus, Martin; Pham, Mirko
Objective: To investigate the spatial pattern of lesion dispersion in posterior interosseous neuropathy syndrome (PINS) by high-resolution magnetic resonance neurography. Methods: This prospective study was approved by the local ethics committee and written informed consent was obtained from all patients. In 19 patients with PINS and 20 healthy controls, a standardized magnetic resonance neurography protocol at 3-tesla was performed with coverage of the upper arm and elbow (T2-weighted fat-saturated: echo time/repetition time 52/7,020 milliseconds, in-plane resolution 0.27 × 0.27 mm2). Lesion classification of the radial nerve trunk and its deep branch (which becomes the posterior interosseous nerve) was performed by visual rating and additional quantitative analysis of normalized T2 signal of radial nerve voxels. Results: Of 19 patients with PINS, only 3 (16%) had a focal neuropathy at the entry of the radial nerve deep branch into the supinator muscle at elbow/forearm level. The other 16 (84%) had proximal radial nerve lesions at the upper arm level with a predominant lesion focus 8.3 ± 4.6 cm proximal to the humeroradial joint. Most of these lesions (75%) followed a specific somatotopic pattern, involving only those fascicles that would form the posterior interosseous nerve more distally. Conclusions: PINS is not necessarily caused by focal compression at the supinator muscle but is instead frequently a consequence of partial fascicular lesions of the radial nerve trunk at the upper arm level. Neuroimaging should be considered as a complementary diagnostic method in PINS. PMID:27683851
Mora de Sambricio, A; Garrido Stratenwerth, E
Pleural effusion is a possible complication of the thoraco-abdominal approach to the spine. It is more commonly a reactive effusion, but it also may be caused by hemothorax, empyema or, less commonly, a chylothorax. The case of a chylothorax is reported as a late onset complication of a double anterior and posterior instrumented fusion of the lumbar spine. Its management and clinical outcome, and a review of the literature is presented.
Gelman, Joel; Wisenbaugh, Eric S.
Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty. PMID:26691883
I, Hoseok; Jeong, Yeon Joo; Choi, Kyung Un; Kim, Yeong-Dae
We report a case of a symptomatic angioleiomyoma in the left posterior mediastinum. A 66-year-old woman presented with left back and flank pain for 6 months. Chest computed tomography (CT) and magnetic resonance imaging (MRI) revealed a well-circumscribed 4.3 cm round mass. The mass was initially diagnosed as nerve sheath tumor, because of her symptoms and its close location to the sympathetic trunk and intercostal nerve. It was uneventfully removed through video-assisted thoracoscopic surgery. The pathology revealed an angioleiomyoma.
Park, J B; Ha, K Y; Chang, H
Atlantooccipital dislocation (AOD) is a rare and usually fatal injury. In the current study, the authors reported an extremely rare case of posterior AOD with Jefferson fracture and fracture-dislocation of C6-C7. The patient survived the injury and had only incomplete quadriplegia below the C7 segment with anterior cord syndrome. He was successfully managed with in situ occipitocervical fusion using the Cotrel-Dubousset rod system, corpectomy of C6, and anterior interbody fusion of C5-C7 with plating. To our knowledge, this is the first report of posterior AOD with two other non-contiguous cervical spine injuries. A high index of suspicion and careful examination of the upper cervical spine should be considered as the key to the diagnosis of AOD in cases that involve multiple or lower cervical spine injuries.
Lee, Shi-Uk; Hargens, Alan R.; Fredericson, Michael; Lang, Philipp K.
INTRODUCTION: Spinal lengthening in microgravity is thought to cause back pain in astronauts. A spinal compression harness can compress the spine to eliminate lengthening but the loading condition with harness is different than physiologic conditions. Our purpose was to compare the effect of spine compression with a harness in supine position on disk height and spinal curvature in the lumbar spine to that of upright position as measured using a vertically open magnetic resonance imaging system. METHODS: Fifteen healthy subjects volunteered. On day 1, each subject lay supine for an hour and a baseline scan of the lumbar spine was performed. After applying a load of fifty percent of body weight with the harness for thirty minutes, the lumbar spine was scanned again. On day 2, after a baseline scan, a follow up scan was performed after kneeling for thirty minutes within the gap between two vertically oriented magnetic coils. Anterior and posterior disk heights, posterior disk bulging, and spinal curvature were measured from the baseline and follow up scans. RESULTS: Anterior disk heights increased and posterior disk heights decreased compared with baseline scans both after spinal compression with harness and upright posture. The spinal curvature increased by both loading conditions of the spine. DISCUSSION: The spinal compression with specially designed harness has the same effect as the physiologic loading of the spine in the kneeling upright position. The harness shows some promise as a tool to increase the diagnostic capabilities of a conventional MR system.
Srinivas, Shreya; Shetty, Rohit; Collins, Iona
Low-lying cord is an uncommon entity, and cord compression due lumbar disc disease is rarely encountered. We discuss our experience with a case of lumbar cord compression secondary to a large disc protrusion, which caused myelopathy in a low-lying/tethered cord. A 77-year-old woman with known spina bifida occulta presented with 6-week history of severe low back pain and progressive paraparesis. Magnetic resonance imaging showed a low-lying tethered cord and a large disc prolapse at L2/3 causing cord compression with associated syringomyelia. Medical comorbidities precluded her from anterior decompression, and therefore a posterior decompression was performed. She recovered full motor power in her lower limbs and could eventually walk unaided. She had a deep wound infection, which was successfully treated with debridement, negative pressure therapy (vacuum-assisted closure pump), and antibiotics. Six months after surgery, her Oswestry Disability Index improved from 55% preoperatively to 20%. Posterior spinal cord decompression for this condition has been successful in our case, and we believe that the lumbar lordosis may have helped indirectly decompress the spinal cord by posterior decompression alone.
Crutch, Sebastian J; Lehmann, Manja; Schott, Jonathan M; Rabinovici, Gil D; Rossor, Martin N; Fox, Nick C
Posterior cortical atrophy (PCA) is a neurodegenerative syndrome that is characterized by a progressive decline in visuospatial, visuoperceptual, literacy and praxic skills. The progressive neurodegeneration affecting parietal, occipital and occipito-temporal cortices which underlies PCA is attributable to Alzheimer's disease (AD) in the majority of patients. However, alternative underlying aetiologies including Dementia with Lewy Bodies (DLB), corticobasal degeneration (CBD) and prion disease have also been identified, and not all PCA patients have atrophy on clinical imaging. This heterogeneity has led to diagnostic and terminological inconsistencies, caused difficulty comparing studies from different centres, and limited the generalizability of clinical trials and investigations of factors driving phenotypic variability. Significant challenges remain in identifying the factors associated with both the selective vulnerability of posterior cortical regions and the young age of onset seen in PCA. Greater awareness of the syndrome and agreement over the correspondence between syndrome-and disease-level classifications are required in order to improve diagnostic accuracy, research study design and clinical management. PMID:22265212
Saleh, Essam A.; Taibah, Abdel Kader; Achilli, Vittorio; Aristegui, Miguel; Mazzoni, Antonio; Sanna, Mario
Posterior fossa meningioma is the second most common tumor in the cerebellopontine angle. It has a higher rate of postoperative morbidity and mortality compared to acoustic neuroma. Forty posterior fossa meningioma patients managed in our centers were reviewed. Thirty-nine patients were managed surgically with 42 surgical procedures. The approaches used were the translabyrinthine approach in 18 patients (43%), the modified transcochlear in 11 cases (26%), the petro-occipital transsigmoid in 5 cases (12%), the suboccipital in 4 cases (10%), the petro-occipital trassigmoid transcervical in 2 cases (5%), the petro-occipital transsigmoid transtentorial in 1 case (2%), and a subtemporal transtentorial for another case (2%). Facial nerve anatomical integrity was preserved in 87% of procedures but was interrupted in 5 cases, with 4 of the latter subsequently repaired. Total tumor removal was accomplished in 38 cases. A second-stage total tumor removal is planned for the remaining case. There was only one case of perioperative death and no cases of radiological recurrence so far. ImagesFigure 1Figure 2Figure 3Figure 4p206-bFigure 5p207-bFigure 5 PMID:17171173
Macpherson, J. M.; Fung, J.; Peterson, B. W. (Principal Investigator)
This study examined the role of trunk extensor muscles in the thoracic and lumbar regions during postural adjustments in the freely standing cat. The epaxial extensor muscles participate in the rapid postural responses evoked by horizontal translation of the support surface. The muscles segregate into two regional groups separated by a short transition zone, according to the spatial pattern of the electromyographic (EMG) responses. The upper thoracic muscles (T5-9) respond best to posteriorly directed translations, whereas the lumbar muscles (T13 to L7) respond best to anterior translations. The transition group muscles (T10-12) respond to almost all translations. Muscles group according to vertebral level rather than muscle species. The upper thoracic muscles change little in their response with changes in stance distance (fore-hindpaw separation) and may act to stabilize the intervertebral angles of the thoracic curvature. Activity in the lumbar muscles increases along with upward rotation of the pelvis (iliac crest) as stance distance decreases. Lumbar muscles appear to stabilize the pelvis with respect to the lumbar vertebrae (L7-sacral joint). The transition zone muscles display a change in spatial tuning with stance distance, responding to many directions of translation at short distances and focusing to respond best to contralateral translations at the long stance distance.
Mahesh, Bijjawara; Upendra, Bidre; Vijay, S; Kumar, GC Arun; Reddy, Srinivas
Background: Spine surgery in elderly with comorbidities is reported to have higher complication rates and increased cost. However, the surgical outcome is good irrespective of the complications. Hence, it is essential to identify the factors affecting the complication rates in such patients and the measures to reduce them. This retrospective observational study determines the perioperative complications, their incidence and the measures to reduce complications in the elderly with comorbidities, operated by instrumented multilevel lumbar fusion. Materials and Methods: Patients aged 60 years and above with one or more comorbidities operated by multilevel instrumented lumbar fusion in our center between January 2012 and December 2013 were included in the study. Perioperative complications and their incidence were calculated. Age, number of levels fused, operative time, blood loss, and complication rates were correlated with the duration of stay and the incidence of perioperative complications using SPSS software. Measures to reduce complications are determined by these results and by review of literature. Results: Fifty two patients were included in the study (28 females and 24 males) with an average age of 69 years (range 60-84 years). Hypertension was the most common comorbidity followed by diabetes. Spondylolisthesis was the most common indication. Eleven complications were noted with an incidence of 21%. Three were systemic complications which required transfer to Intensive Care Unit. Local complications were incidental durotomy (three), transient root deficits (two), wound infections (one), and persistent radicular pain (two). Operative time and blood loss were significantly higher in patients with complications. Conclusion: Complication rates strongly correlate with the blood loss and operative time. Reducing the operative time and blood loss by intraoperative tranexamic acid, laminectomy using osteotome, simultaneous bilateral exposure and instrumentation and
Skovrlj, Branko; Belton, Patrick; Zarzour, Hekmat; Qureshi, Sheeraz A
AIM: To compare minimally invasive (MIS) and open techniques for MIS lumbar laminectomy, direct lateral and transforaminal lumbar interbody fusion (TLIF) surgeries with respect to length of surgery, estimated blood loss (EBL), neurologic complications, perioperative transfusion, postoperative pain, postoperative narcotic use, and length of stay (LOS). METHODS: A systematic review of previously published studies accessible through PubMed was performed. Only articles in English journals or published with English language translations were included. Level of evidence of the selected articles was assessed. Statistical data was calculated with analysis of variance with P < 0.05 considered statistically significant. RESULTS: A total of 11 pertinent laminectomy studies, 20 direct lateral studies, and 27 TLIF studies were found. For laminectomy, MIS techniques resulted in a significantly longer length of surgery (177.5 min vs 129.0 min, P = 0.04), shorter LOS (4.3 d vs 5.3 d, P = 0.01) and less perioperative pain (visual analog scale: 16 ± 17 vs 34 ± 31, P = 0.04). There is evidence of decreased narcotic use for MIS patients (postoperative intravenous morphine use: 9.3 mg vs 42.8 mg), however this difference is of unknown significance. Direct lateral approaches have insufficient comparative data to establish relative perioperative outcomes. MIS TLIF had superior EBL (352 mL vs 580 mL, P < 0.0001) and LOS (7.7 d vs 10.4 d, P < 0.0001) and limited data to suggest lower perioperative pain. CONCLUSION: Based on perioperative outcomes data, MIS approach is superior to open approach for TLIF. For laminectomy, MIS and open approaches can be chosen based on surgeon preference. For lateral approaches, there is insufficient evidence to find non-inferior perioperative outcomes at this time. PMID:26716097
Ulutaş, Murat; Çınar, Kadir; Seçer, Mehmet
Abstract Persistence of postoperative radicular pain after surgery for multifocal disc herniation (MFDH) is a clinical problem. This study aims to evaluate the effects of a combined treatment approach compared with unilateral stabilization on early postoperative radicular pain in patients with MFDH. Age, sex, level of operation, clinical findings, and radicular pain visual analogue scale (VAS) scores before surgery in the early postoperative period and at 3 months after surgery were retrospectively reviewed for 20 cases of multifocal lumbar disc herniation. The combined approach (translaminar and far lateral) was used for 13 cases. Seven cases underwent transforaminal lumbar interbody fusion (TLIF) and unilateral transpedicular stabilization following total facetectomy. The mean age of the sample was 49.4 ± 10.1 years and the female-to-male ratio was 8:12. The mean VAS scores for radicular pain in cases treated with the combined approach were 8.2, 4.07, and 2.3 in the preoperative and early postoperative periods and 3 months after surgery, respectively. The mean score for radicular pain improved by 50.4% in the early postoperative period and by 72% in the late postoperative period. The mean VAS scores for radicular pain in cases who underwent TLIF and unilateral stabilization after facetectomy were 8.4, 2.1, and 1.4 in the preoperative and early postoperative periods and 3 months after surgery, respectively. The mean VAS score for radicular pain improved by 75% in the early postoperative period and by 83.3% in the late postoperative period. The combined approach is an effective alternative in cases with MFDH. TLIF and unilateral segmental stabilization provide substantial decompression and eliminate mechanical compression by conserving the height of the intervertebral foramen in the event that sufficient decompression is unable to obtain. We suggest that elimination of chemical mediators, particularly those causing pain in the dorsal ganglion, contributes to
Ulutaş, Murat; Çınar, Kadir; Seçer, Mehmet
Persistence of postoperative radicular pain after surgery for multifocal disc herniation (MFDH) is a clinical problem. This study aims to evaluate the effects of a combined treatment approach compared with unilateral stabilization on early postoperative radicular pain in patients with MFDH.Age, sex, level of operation, clinical findings, and radicular pain visual analogue scale (VAS) scores before surgery in the early postoperative period and at 3 months after surgery were retrospectively reviewed for 20 cases of multifocal lumbar disc herniation. The combined approach (translaminar and far lateral) was used for 13 cases. Seven cases underwent transforaminal lumbar interbody fusion (TLIF) and unilateral transpedicular stabilization following total facetectomy.The mean age of the sample was 49.4 ± 10.1 years and the female-to-male ratio was 8:12. The mean VAS scores for radicular pain in cases treated with the combined approach were 8.2, 4.07, and 2.3 in the preoperative and early postoperative periods and 3 months after surgery, respectively. The mean score for radicular pain improved by 50.4% in the early postoperative period and by 72% in the late postoperative period. The mean VAS scores for radicular pain in cases who underwent TLIF and unilateral stabilization after facetectomy were 8.4, 2.1, and 1.4 in the preoperative and early postoperative periods and 3 months after surgery, respectively. The mean VAS score for radicular pain improved by 75% in the early postoperative period and by 83.3% in the late postoperative period.The combined approach is an effective alternative in cases with MFDH. TLIF and unilateral segmental stabilization provide substantial decompression and eliminate mechanical compression by conserving the height of the intervertebral foramen in the event that sufficient decompression is unable to obtain. We suggest that elimination of chemical mediators, particularly those causing pain in the dorsal ganglion, contributes to the absence
Grieff, Anthony N; Ghobrial, George M; Jallo, Jack
OBJECTIVE The aim in this paper was to evaluate the efficacy of long-acting liposomal bupivacaine in comparison with bupivacaine hydrochloride for lowering postoperative analgesic usage in the management of posterior cervical and lumbar decompression and fusion. METHODS A retrospective cohort-matched chart review of 531 consecutive cases over 17 months (October 2013 to February 2015) for posterior cervical and lumbar spinal surgery procedures performed by a single surgeon (J.J.) was performed. Inclusion criteria for the analysis were limited to those patients who received posterior approach decompression and fusion for cervical or lumbar spondylolisthesis and/or stenosis. Patients from October 1, 2013, through December 31, 2013, received periincisional injections of bupivacaine hydrochloride, whereas after January 1, 2014, liposomal bupivacaine was solely administered to all patients undergoing posterior approach cervical and lumbar spinal surgery through the duration of treatment. Patients were separated into 2 groups for further analysis: posterior cervical and posterior lumbar spinal surgery. RESULTS One hundred sixteen patients were identified: 52 in the cervical cohort and 64 in the lumbar cohort. For both cervical and lumbar cases, patients who received bupivacaine hydrochloride required approximately twice the adjusted morphine milligram equivalent (MME) per day in comparison with the liposomal bupivacaine groups (5.7 vs 2.7 MME, p = 0.27 [cervical] and 17.3 vs 7.1 MME, p = 0.30 [lumbar]). The amounts of intravenous rescue analgesic requirements were greater for bupivacaine hydrochloride in comparison with liposomal bupivacaine in both the cervical (1.0 vs 0.39 MME, p = 0.31) and lumbar (1.0 vs 0.37 MME, p = 0.08) cohorts as well. None of these differences was found to be statistically significant. There were also no significant differences in lengths of stay, complication rates, or infection rates. A subgroup analysis of both cohorts of opiate-naive versus
Marchi, Luis; Abdala, Nitamar; Oliveira, Leonardo; Amaral, Rodrigo; Coutinho, Etevaldo; Pimenta, Luiz
The purpose of this paper was to investigate the stand-alone lateral interbody fusion as a minimally invasive option for the treatment of low-grade degenerative spondylolisthesis with a minimum 24-month followup. Prospective nonrandomized observational single-center study. 52 consecutive patients (67.6 ± 10 y/o; 73.1% female; 27.4 ± 3.4 BMI) with single-level grade I/II single-level degenerative spondylolisthesis without significant spine instability were included. Fusion procedures were performed as retroperitoneal lateral transpsoas interbody fusions without screw supplementation. The procedures were performed in average 73.2 minutes and with less than 50cc blood loss. VAS and Oswestry scores showed lasting improvements in clinical outcomes (60% and 54.5% change, resp.). The vertebral slippage was reduced in 90.4% of cases from mean values of 15.1% preoperatively to 7.4% at 6-week followup (P < 0.001) and was maintained through 24 months (7.1%, P < 0.001). Segmental lordosis (P < 0.001) and disc height (P < 0.001) were improved in postop evaluations. Cage subsidence occurred in 9/52 cases (17%) and 7/52 cases (13%) spine levels needed revision surgery. At the 24-month evaluation, solid fusion was observed in 86.5% of the levels treated. The minimally invasive lateral approach has been shown to be a safe and reproducible technique to treat low-grade degenerative spondylolisthesis. PMID:22545019
The keratoprosthesis is the last solution for corneally blind patients that cannot benefit from corneal transplants. Keratoprostheses that have been designed to be affixed anteriorly usually necessitate multi-step surgical procedures and are continuously subjected to the extrusion forces generated by the positive intraocular pressure; therefore, clinical results in patients prove inconsistent. We proposed a novel keratoprosthesis concept that utilizes posterior corneal fixation which `a priori' minimizes the risk of aqueous leakage and expulsion. This prosthesis is implanted in a single procedure thereby reducing the number of surgical complications normally associated with anterior fixation devices. In addition, its novel design makes this keratoprosthesis implantable in phakic eyes. With an average follow-up of 13 months (range 3 to 25 months), our results on 21 cases are encouraging. Half of the keratoprostheses were implanted in severe burn cases, with the remainder in cases of pseudo- pemphigus. Good visual results and cosmetic appearance were obtained in 14 of 21 eyes.
Ou, Judy I; Wheeler, Sharon M; O'Brien, Joan M
This chapter focuses on the diagnosis and management of choroidal melanoma in light of recent findings from the COMS. Retinoblastoma is emphasized to describe recent trends in primary treatment away from EBRT and toward chemoreduction with local therapy. In addition, vascular and glial tumors of the retina and tumors of the retinal pigment epithelium are described because of the association between these lesions and systemic disease. Recent advances in treatment and genetic testing for these diseases are discussed. Finally, ocular metastasis, intraocular lymphoid tumors, and intraocular leukemia are included because of their importance in determining systemic treatment and prognosis. The chapter gives an overview of important posterior pole tumors and highlights recent developments in the management of each intraocular disease process.
Serra, T; Capelli, C; Toumpaniari, R; Orriss, I R; Leong, J J H; Dalgarno, K; Kalaskar, D M
Spinal fusion is the gold standard surgical procedure for degenerative spinal conditions when conservative therapies have been unsuccessful in rehabilitation of patients. Novel strategies are required to improve biocompatibility and osseointegration of traditionally used materials for lumbar cages. Furthermore, new design and technologies are needed to bridge the gap due to the shortage of optimal implant sizes to fill the intervertebral disc defect. Within this context, additive manufacturing technology presents an excellent opportunity to fabricate ergonomic shape medical implants. The goal of this study is to design and manufacture a 3D-printed lumbar cage for lumbar interbody fusion. Optimisations of the proposed implant design and its printing parameters were achieved via in silico analysis. The final construct was characterised via scanning electron microscopy, contact angle, x-ray micro computed tomography (μCT), atomic force microscopy, and compressive test. Preliminary in vitro cell culture tests such as morphological assessment and metabolic activities were performed to access biocompatibility of 3D-printed constructs. Results of in silico analysis provided a useful platform to test preliminary cage design and to find an optimal value of filling density for 3D printing process. Surface characterisation confirmed a uniform coating of nHAp with nanoscale topography. Mechanical evaluation showed mechanical properties of final cage design similar to that of trabecular bone. Preliminary cell culture results showed promising results in terms of cell growth and activity confirming biocompatibility of constructs. Thus for the first time, design optimisation based on computational and experimental analysis combined with the 3D-printing technique for intervertebral fusion cage has been reported in a single study. 3D-printing is a promising technique for medical applications and this study paves the way for future development of customised implants in spinal
Suslu, Hikmet Turan; Celikoglu, Erhan; Borekcı, Ali; Hıcdonmez, Tufan; Suslu, Hüsnü
Grade 5 spondylolisthesis or spondyloptosis is a rare condition. Generally, the surgical management of spondyloptosis includes multi-staged procedures instead of one-staged procedures. One-stage treatment for spondyloptosis is very rare. A 15-year-old girl with L5-S1 spondyloptosis was admitted with severe low back pain. There was no history of trauma. The patient underwent L5 laminectomy, L5-S1 discectomy, resection of sacral dome, reduction, L3-L4-L5-S1 pedicular screw fixation, and interbody-posterolateral fusion through the posterior approach. The reduction was maintained with bilateral L5-S1 discectomy, resection of the sacral dome, and transpedicular instrumentation from L3 to S1. In this particular case, one-staged approach was adequate for the treatment of L5-S1 spondyloptosis. One-staged surgery using the posterior approach may be adequate for the treatment of L5-S1 spondyloptosis while avoiding the risks inherent in anterior approaches. PMID:23125496
Hamoud, K.; May, H.; Hay, O.; Medlej, B.; Masharawi, Y.; Peled, N.; Hershkovitz, I.
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
Mizusaki, Danilo; Gotfryd, Alberto Ofenhejm
Objective To evaluate the clinical and radiographic response of the lumbar curve after fusion of the main thoracic, in patients with adolescent idiopathic scoliosis of Lenke type 1. Methods Forty-two patients with Lenke 1 adolescent idiopathic scoliosis who underwent operations via the posterior route with pedicle screws were prospectively evaluated. Clinical measurements (size of the hump and translation of the trunk in the coronal plane, by means of a plumb line) and radiographic measurements (Cobb angle, distal level of arthrodesis, translation of the lumbar apical vertebral and Risser) were made. The evaluations were performed preoperatively, immediately postoperatively and two years after surgery. Results The mean Cobb angle of the main thoracic curve was found to have been corrected by 68.9% and the lumbar curve by 57.1%. Eighty percent of the patients presented improved coronal trunk balance two years after surgery. In four patients, worsening of the plumb line measurements was observed, but there was no need for surgical intervention. Less satisfactory results were observed in patients with lumbar modifier B. Conclusions In Lenke 1 patients, fusion of the thoracic curve alone provided spontaneous correction of the lumbar curve and led to trunk balance. Less satisfactory results were observed in curves with lumbar modifier B, and this may be related to overcorrection of the main thoracic curve. PMID:26962505
Bogduk, N; Wilson, A S; Tynan, W
The L 1-4 dorsal rami tend to form three branches, medial, lateral, and intermediate, which are distributed, respectively, to multifidus, iliocostalis, and longissimus. The intertransversarii mediales are innervated by a branch of the dorsal ramus near the origin of the medial branch. The L 4 dorsal ramus regularly forms three branches while the L 1-3 levels the lateral and intermediate branches may, alternatively, arise from a short common stem. The L 5 dorsal ramus is much longer than the others and forms only a medial and an intermediate branch. Each lumbar medial branch innervates two adjacent zygapophysial joints and ramifies in multifidus, supplying only those fascicles which arise from the spinous process with the same segmental number as the nerve. The comparative anatomy of the lumbar dorsal rami is discussed and the applied anatomy with respect to 'rhizolysis', 'facet denervation' and diagnostic paraspinal electromyography is described. PMID:7076562
Algahtani, Abdulhadi; Aldarmahi, Ahmad; Hmoud, Mohammed; Marzuk, Yousef; Shirah, Bader
Objectives: Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headache, altered mental status, seizures, or loss of vision. In this study, we report the largest series of PRES coming from Saudi Arabia and explore the etiology, clinical presentation, and outcome. We also report new imaging findings associated with this condition. Methods: We performed a retrospective study of all cases of PRES admitted to King Abdulaziz Medical City, Jeddah, Saudi Arabia, between the years 2005 and 2015. A neurologist reviewed all charts and analyzed the clinical presentations, etiological factors, and outcomes, and a neuroradiologist reviewed the imaging studies. Only patients with clinical and imaging features consistent with PRES were included in the study. Results: We collected 31 patients who had clinical and radiological features consistent with PRES. Females were more affected than males (18 females and 13 males), and patients’ age ranged from 6 to 95 years, with a mean of 38.3 years. Patients were treated by removing the precipitating causes and treating the underlying conditions. Resolution of neurologic signs occurred within 2 to 3 weeks in all patients. Conclusion: In our opinion, PRES itself is usually a benign condition with complete recovery if the condition is recognized early and managed appropriately. Although clinical signs are nonspecific, the constellation of symptoms including headache, visual problems, seizures, and altered level of consciousness should suggest the possibility of PRES, especially in high-risk group. Abnormalities on magnetic resonance imaging are often characteristic and may be the first clue to the diagnosis. PMID:28042366
Röllinghoff, Marc; Schlüter-Brust, Klaus; Groos, Daniel; Sobottke, Rolf; Michael, Joern William-Patrick; Eysel, Peer; Delank, Karl Stefan
In the treatment of multilevel degenerative disorders of the lumbar spine, spondylodesis plays a controversial role. Most patients can be treated conservatively with success. Multilevel lumbar fusion with instrumentation is associated with severe complications like failed back surgery syndrome, implant failure, and adjacent segment disease (ASD). This retrospective study examines the records of 70 elderly patients with degenerative changes or instability of the lumbar spine treated between 2002 and 2007 with spondylodesis of more than two segments. Sixty-four patients were included; 5 patients had died and one patient was lost to follow-up. We evaluated complications, clinical/radiological outcomes, and success of fusion. Flexion-extension and standing X-rays in two planes, MRI, and/or CT scans were obtained pre-operatively. Patients were assessed clinically using the Oswestry disability index (ODI) and a Visual Analogue Scale (VAS). Surgery performed was dorsolateral fusion (46.9%) or dorsal fusion with anterior lumbar interbody fusion (ALIF; 53.1%). Additional decompression was carried out in 37.5% of patients. Mean follow-up was 29.4±5.4 months. Average patient age was 64.7±4.3 years. Clinical outcomes were not satisfactory for all patients. VAS scores improved from 8.6±1.3 to 5.6±3.0 pre- to post-operatively, without statistical significance. ODI was also not significantly improved (56.1±22.3 pre- and 45.1±26.4 post-operatively). Successful fusion, defined as adequate bone mass with trabeculation at the facets and transverse processes or in the intervertebral segments, did not correlate with good clinical outcomes. Thirty-five of 64 patients (54%) showed signs of pedicle screw loosening, especially of the screws at S1. However, only 7 of these 35 (20%) complained of corresponding back pain. Revision surgery was required in 24 of 64 patients (38%). Of these, indications were adjacent segment disease (16 cases), pedicle screw loosening (7 cases), and
Mehta, Roma Satish; Dabadghav, Rachana; Rairikar, Savita; Shayam, Ashok; Sancheti, Parag
Study Design Observational study. Purpose To correlate lumbar lordosis and lumbar core strength in information technology (IT) professionals. Overview of Literature IT professionals have to work for long hours in a sitting position, which can affect lumbar lordosis and lumbar core strength. Methods 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. Results 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). Conclusions 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. PMID:27340529
Been, Ella; Gómez-Olivencia, Asier; Kramer, Patricia A
The lordotic curvature of the lumbar spine (lumbar lordosis) in humans is a critical component in the ability to achieve upright posture and bipedal gait. Only general estimates of the lordotic angle (LA) of extinct hominins are currently available, most of which are based on the wedging of the vertebral bodies. Recently, a new method for calculating the LA in skeletal material has become available. This method is based on the relationship between the lordotic curvature and the orientation of the inferior articular processes relative to vertebral bodies in the lumbar spines of living primates. Using this relationship, we developed new regression models in order to calculate the LAs in hominins. The new models are based on primate group-means and were used to calculate the LAs in the spines of eight extinct hominins. The results were also compared with the LAs of modern humans and modern nonhuman apes. The lordotic angles of australopithecines (41° ± 4), H. erectus (45°) and fossil H. sapiens (54° ± 14) are similar to those of modern humans (51° ± 11). This analysis confirms the assumption that human-like lordotic curvature was a morphological change that took place during the acquisition of erect posture and bipedalism as the habitual form of locomotion. Neandertals have smaller lordotic angles (LA = 29° ± 4) than modern humans, but higher angles than nonhuman apes (22° ± 3). This suggests possible subtle differences in Neandertal posture and locomotion from that of modern humans.
Rudolph, Ch; Schaffranietz, L; Hellmundt, L; Vitzthum, H E; Olthoff, D
For surgery on lumbar disks by the posterior route, patients are placed either on a Wilson frame or in genupectoral position. The aim of the prospective study was to record and describe the haemodynamic changes resulting from the patients' position. After written informed consent had been received, 80 neurosurgical patients undergoing lumbar disk surgery were randomly divided into two groups; group I--Wilson frame, group II--genupectoral position. In each group, 20 patients received total intravenous anaesthesia (Alfentanil or Remifentanil, Propofol) and 20 balanced anaesthesia with Isoflurane and Alfentanil or Remifentanil. Haemodynamic parameters (mean arterial pressure--MAP and heart rate--HR) were recorded automatically at three measuring times (MT): firstly, after induction of anaesthesia; secondly, before re-direction; thirdly, after re-direction on the Wilson frame or in the genupectoral position. Induction of anaesthesia did not lead to a significant decrease in MAP (MT 1: 92.5 +/- 15.2 mmHg, MT 2: 89 +/- 13.4 mmHg, n = 80). In group I (n = 40), no significant changes were observed in MAP and HR at MT 3 (p = 0.882, p = 0.051). In comparison to group I, the genupectoral position was associated with significant drops in MAP and HR. The genupectoral position caused a significant decrease in MAP (p < 0.001) and HR (p = 0.016) at MT 3. Our data suggest that body weight or body mass index do not necessarily lead to a preference for one of the two possible positions of the patient. Complications resulting from haemodynamic changes were not seen in either group. We recommend the Wilson frame for neurosurgical lumbar disk surgery in cases of cardiovascular or cerebrovascular disorders. The adaptive capacities in the genupectoral position as a result of the modifying distribution of blood volume are limited in these patients. Furthermore, the dose-dependent effects of different anaesthetics on haemodynamic parameters in these prone positions should be explored.
Camp, Jon; Zhao, Kristin; Morel, Etienne; White, Dan; Magnuson, Dixon; Gay, Ralph; An, Kai-Nan; Robb, Richard
We hypothesize that the vertebra-to-vertebra patterns of spinal flexion and extension motion of persons with lower back pain will differ from those of persons who are pain-free. Thus, it is our goal to measure the motion of individual lumbar vertebrae noninvasively from dynamic fluoroscopic sequences. Two-dimensional normalized mutual information-based image registration was used to track frame-to-frame motion. Software was developed that required the operator to identify each vertebra on the first frame of the sequence using a four-point "caliper" placed at the posterior and anterior edges of the inferior and superior end plates of the target vertebrae. The program then resolved the individual motions of each vertebra independently throughout the entire sequence. To validate the technique, 6 cadaveric lumbar spine specimens were potted in polymethylmethacrylate and instrumented with optoelectric sensors. The specimens were then placed in a custom dynamic spine simulator and moved through flexion-extension cycles while kinematic data and fluoroscopic sequences were simultaneously acquired. We found strong correlation between the absolute flexionextension range of motion of each vertebra as recorded by the optoelectric system and as determined from the fluoroscopic sequence via registration. We conclude that this method is a viable way of noninvasively assessing twodimensional vertebral motion.
King, J D; Lowery, G L
The purposes of this study were to determine the long-term correction achieved by excision of lumbar hemivertebrae and the risk attendant. Seven patients had a follow-up of 41.14 months for lumbar hemivertebral excisions. Six had two-stage anterior vertebral body excision and, 7-8 days later, posterior lamina and pedicle excision with fusion. One patient had a single-stage correction. After surgery, the patients were in pantaloon casts or braces for a minimum of 6 months (supine, first 6-12 weeks). Hemivertebrae were at L2 (N = 1), L3 (N = 1), L4-L5 (N = 1), and L5-S1 (N = 4). Preoperative curves or hemivertebral angles averaged 36.6 degrees (range, 30-52 degrees). Average age was 7.5 years (range, 22 months to 12.5 years). Mean follow-up was 41.14 months. Surgical correction of the seven cases averaged 28.0 degrees. Two-stage procedures yielded 29.7 degrees correction with no complications; single-stage yielded 18 degrees correction, and the only complication was an L5 nerve root paresis.
Bisschop, Arno; Holewijn, Roderick M.; Kingma, Idsart; Stadhouder, Agnita; Vergroesen, Pieter-Paul A.; van der Veen, Albert J.; van Dieën, Jaap H.; van Royen, Barend J.
Study Design Biomechanical study. Objective Posterior instrumentation is used to stabilize the spine after a lumbar laminectomy. However, the effects on the adjacent segmental stability are unknown. Therefore, we studied the range of motion (ROM) and stiffness of treated lumbar spinal segments and cranial segments after a laminectomy and after posterior instrumentation in flexion and extension (FE), lateral bending (LB), and axial rotation (AR). These outcomes might help to better understand adjacent segment disease (ASD), which is reported cranial to the level on which posterior instrumentation is applied. Methods We obtained 12 cadaveric human lumbar spines. Spines were axially loaded with 250 N for 1 hour. Thereafter, 10 consecutive load cycles (4 Nm) were applied in FE, LB, and AR. Subsequently, a laminectomy was performed either at L2 or at L4. Thereafter, load-deformation tests were repeated, after similar preloading. Finally, posterior instrumentation was added to the level treated with a laminectomy before testing was repeated. The ROM and stiffness of the treated, the cranial adjacent, and the control segments were calculated from the load-displacement data. Repeated-measures analyses of variance used the spinal level as the between-subject factor and a laminectomy or instrumentation as the within-subject factors. Results After the laminectomy, the ROM increased (+19.4%) and the stiffness decreased (−18.0%) in AR. The ROM in AR of the adjacent segments also increased (+11.0%). The ROM of treated segments after instrumentation decreased in FE (−74.3%), LB (−71.6%), and AR (−59.8%). In the adjacent segments after instrumentation, only the ROM in LB was changed (−12.9%). Conclusions The present findings do not substantiate a biomechanical pathway toward or explanation for ASD. PMID:25649753
Hanson, K.M.; Cunningham, G.S.
The Markov Chain Monte Carlo (MCMC) technique provides a means to generate a random sequence of model realizations that sample the posterior probability distribution of a Bayesian analysis. That sequence may be used to make inferences about the model uncertainties that derive from measurement uncertainties. This paper presents an approach to improving the efficiency of the Metropolis approach to MCMC by incorporating an approximation to the covariance matrix of the posterior distribution. The covariance matrix is approximated using the update formula from the BFGS quasi-Newton optimization algorithm. Examples are given for uncorrelated and correlated multidimensional Gaussian posterior distributions.
Deoghare, Ashish B.; Kashyap, Siddharth; Padole, Pramod M.
Degenerative disc disease is a major source of lower back pain and significantly alters the biomechanics of the lumbar spine. Dynamic stabilization device is a remedial technique which uses flexible materials to stabilize the affected lumbar region while preserving the natural anatomy of the spine. The main objective of this research work is to investigate the stiffness variation of dynamic stabilization device under various loading conditions under compression, axial rotation and flexion. Three dimensional model of the two segment lumbar spine is developed using computed tomography (CT) scan images. The lumbar structure developed is analyzed in ANSYS workbench. Two types of dynamic stabilization are considered: one with stabilizing device as pedicle instrumentation and second with stabilization device inserted around the inter-vertebral disc. Analysis suggests that proper positioning of the dynamic stabilization device is of paramount significance prior to the surgery. Inserting the device in the posterior region indicates the adverse effects as it shows increase in the deformation of the inter-vertebral disc. Analysis executed by positioning stabilizing device around the inter-vertebral disc yields better result for various stiffness values under compression and other loadings. [Figure not available: see fulltext.
Lee, Ji-Yeon; Lee, Dong-Yeop; Hong, Ji-Heon; Yu, Jae-Ho; Kim, Jin Seop
[Purpose] The purpose of this study was to compare the effects of pelvic diagonal movements, made with and without resistance, on the thickness of lumbar multifidus muscles. [Subjects and Methods] Participants in this study were healthy subjects who had no musculoskeletal disorders or lumbar-related pain. Participants were positioned on their side and instructed to lie with their hip flexor at 40 degrees. Ultrasonography was used for measurement, and the values of two calculations were averaged. [Results] The thickness of ipsilateral lumbar multifidus muscles showed a significant difference following the exercise of pelvic diagonal movements. The results of anterior elevation movements and posterior depression movements also demonstrated significant difference. There was no significant difference in lumbar multifidus muscles thickness between movements made with and without resistance. [Conclusion] These findings suggest that pelvic diagonal movements can be an effective method to promote muscular activation of the ipsilateral multifidus. Furthermore, researchers have concluded that resistance is not required during pelvic diagonal movements to selectively activate the core muscles. PMID:28356650
Zhang, Kui; Chang, Yun-feng; Fan, Fei; Deng, Zhen-hua
The recent study was to assess the relationship between the radiologic anthropometry of the lumbar vertebral dimensions and stature in Chinese and to develop regression formulae to estimate stature from these dimensions. A total of 412 normal, healthy volunteers, comprising 206 males and 206 females, were recruited. The linear regression analysis were performed to assess the correlation between the stature and lengths of various segments of the lumbar vertebral column. Among the regression equations created for single variable, the predictive value was greatest for the reconstruction of stature from the lumbar segment in both sexes and subgroup analysis. When individual vertebral body was used, the heights of posterior vertebral body of L3 gave the most accurate results for male group, the heights of central vertebral body of L1 provided the most accurate results for female group and female group with age above 45 years, the heights of central vertebral body of L3 gave the most accurate results for the groups with age from 20-45 years for both sexes and the male group with age above 45 years. The heights of anterior vertebral body of L5 gave the less accurate results except for the heights of anterior vertebral body of L4 provided the less accurate result for the male group with age above 45 years. As expected, multiple regression equations were more successful than equations derived from a single variable. The research observations suggest lumbar vertebral dimensions to be useful in stature estimation among Chinese population.
Quiles, M; Marchisello, P J; Tsairis, P
The etiologic factors and pathologic findings in 38 patients with lumbar arachnoiditis are presented. Lumbar spine surgery and the injection of contrast materials prior to the diagnosis of this condition are considered the most important factors in its genesis. In this series, there was microscopic evidence of arachnoiditis ossificans in 3 patients and arachnoiditis calcificans in 1 patient.
Alen, Jose F.; Ramos, Ana; Lobato, Ramiro D.; Lagares, Alfonso
Lumbar synovial cysts frequently present with back pain, chronic radiculopathy and/or progressive symptoms of spinal canal compromise. These cysts generally appear in the context of degenerative lumbar spinal disease. Few cases of spontaneous hemorrhage into synovial cysts have been reported in the literature. PMID:20174835
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
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.
Abel, Mark F; Singla, Anuj; Feger, Mark A; Sauer, Lindsay D; Novicoff, Wendy
AIM To compare the posterior vs anterior approaches for fusion of Lenke 5 adolescent idiopathic scoliosis curves, matched for curve magnitude and for the distal level of fixation (dLOF) standardized to the third lumbar vertebrae (L3). METHODS A prospectively collected multicenter database was used for this retrospective comparative study. Our dependent variables included sagittal and coronal radiographic measurements, number of fused vertebrae, estimated blood loss, length of hospitalization and SRS total and individual domain scores at the two-year follow-up. Subject demographics were similar for all group comparisons. Independent t-test was used to compare groups for all analyses at P < 0.01. RESULTS For all matched cases of Lenke 5 curves, a selective approach was used only 50% of the time in cases undergoing a posterior fusion. When comparing a posterior selective approach to an anterior selective approach, surgeons utilizing a posterior approach fused significantly more levels than surgeons using an anterior approach with no other significant differences in radiographic or SRS outcomes (Ant = 4.8 ± 1.0 levels vs post = 6.1 ± 1.0 levels, P < 0.0001). When the dLOF was standardized to L3, the anterior approached provided significantly greater lumbar Cobb percent correction than the posterior approach (Ant = 69.1% ± 12.6% vs post = 54.6% ± 16.4%, P = 0.004), with no other significant radiographic or SRS score differences between approaches. CONCLUSION Surgeons treating Lenke 5c curves with a posterior instrumentation and fusion vs an anterior approach include more motion segments, even with a selective fusion. When controlled for the distal level of fixation, the anterior approach provides greater correction of the thoracolumbar curve. PMID:27672568
In advanced age, lumbar pain is less frequently caused by occupational stress and psychosomatic factors. Unstable segments and spondylo-arthrotic degeneration can lead to muscular strain whenever insufficient secondary stability and missing muscular equilibrium are involved. In the differential diagnosis one must distinguish between osteoporosis and spinal stenosis, which increases in frequency with age. Pain due to internal or gynecological problems must be excluded. From the therapeutic point of view, patients should be instructed in ergonomics and the simple application of physiotherapeutic procedures, e.g. heat and cold. Analgetics become increasingly important with age, consequently resulting in reduced use of antirheumatics. There exists enough evidence to show that muscular training of the lumbar muscles play an important role in the secondary prevention of lumbar pain in elderly people as well. Essentially, it can be stated that physical age is not directly related to possible ailment. The change of occupational obligations, with possibilities to adapt to personal stress levels, as well as the positive attitude towards everyday life in retirement have a major influence in accepting and handling ability of problems, concerning pain. In the department of Physical Medicine, Rehabilitation and Rheumatology of the Clinic Wilhelm Schulthess it was found that among 7806 patients with lower back pain (1990-1995) 43.3% involved the ages of 40 to 60 and 31.3% the ages of 60 to 80. More distinctly than in younger patients, older aged patients tend to show a marked discrepancy between radiological findings and effective pain. Lower back pains of elderly patients are of a different nature from those found in younger or middle-aged people. Ischialgia due to the protrusion of an intervertebral disk or an acute lumbovertebral syndrome caused by muscular instability are found much less frequently.
Interspinous posterior device (IPD) is a term used to identify a relatively recent group of implants used to treat lumbar spinal degenerative disease. This kind of device is classified as part of the group of the dynamic stabilization systems of the spine. The concept of dynamic stabilization has been replaced by that of dynamic neutralization of hypermobility, with the intention of clarifying that the primary aim of this kind of system is not the preservation of the movement, but the dynamic neutralization of the segmental hypermobility which is at the root of the pathological condition. The indications for the implantation of an IPD are spinal stenosis and neurogenic claudication, assuming that its function is the enlargement of the neural foramen and the decompression of the roots forming the cauda equina in the central part of the vertebral canal. In the last 10 years, use of these implants has been very common but to date, no long-term clinical follow-up regarding clinical and radiological aspects are available. The high rate of reoperation, recurrence of symptoms and progression of degenerative changes is evident in the literature. If these devices are effectively a miracle cure for lumbar spinal stenosis, why do the utilization and implantation of IPD remain extremely controversial and should they be investigated further? Excluding the problems related to the high cost of the device, the main problem remains the pathological substrate on which the device is explicit in its action: the degenerative pathology of the spine. PMID:25232541
Bursalı, Adem; Guvenal, Ahmet Burak; Yaman, Onur
Lumbar radiculopathy is generally caused by such well-recognized entity as lumbar disc herniation in neurosurgical practice; however rare pathologies such as thrombosed epidural varix may mimic them by causing radicular symptoms. In this case report, we present a 26-year-old man with the complaint of back and right leg pain who was operated for right L4–5 disc herniation. The lesion interpreted as an extruded disc herniation preoperatively was found to be a thrombosed epidural varix compressing the nerve root preoperatively. The nerve root was decompressed by shrinking the lesion with bipolar thermocoagulation and excision. The patient's complaints disappeared in the postoperative period. Thrombosed lumbar epidural varices may mimic lumbar disc herniations both radiologically and clinically. Therefore, must be kept in mind in the differential diagnosis of lumbar disc herniations. Microsurgical techniques are mandatory for the treatment of these pathologies and decompression with thermocoagulation and excision is an efficient method. PMID:27446525
Cho, Sung Min; Rhee, Woo Tack; Choi, Soo Jung; Eom, Dae Woon
The lumbar intraspinal epidural ganglion cyst has been a rare cause of the low back pain or leg pain. Ganglion cysts and synovial cysts compose the juxtafacet cysts. Extensive studies have been performed about the synovial cysts, however, very little has been known about the ganglion cyst. Current report is about two ganglion cysts associated with implicative findings in young male patients. We discuss about the underlying pathology of the ganglion cyst based on intraoperative evidences, associated disc herniation at the same location or severe degeneration of the ligament flavum that the cyst originated from in young patients.
Cheng, Zhaohui; Wang, Jian; Zheng, Qixin; Wu, Yongchao; Guo, Xiaodong
Abstract This retrospective cohort study was conducted to evaluate the clinical outcomes of radical anterolateral debridement and autogenous ilium with rib or titanium cage interbody autografting with transpedicle fixation for the treatment of thoracolumbar tuberculosis. Spinal tuberculosis operation aims to remove the lesions and necrotic tissues, remove spinal cord compression, and reconstruct spinal stability. However, traditional operation methods cannot effectively correct cyrtosis or stabilize the spine. In addition, the patient needs to stay in bed for a long time and may have many complications. So far, the best surgical method and fixation method for spinal tuberculosis remain controversial. There were a total of 43 patients, 16 involving spinal cord injury, from January 2004 to January 2011. The patients were surgically treated for radical anterolateral debridement via posterolateral incision and autogenous ilium with rib or titanium cage interbody autografting and single-stage transpedicle fixation. All the patients were followed up to determine the stages of intervertebral bone fusion and the corrections of spinal kyphosis with the restoration of neurological deficit. The erythrocyte sedimentation rate (ESR) of these patients decreased to normal levels for a mean of 2.8 months. The function of feeling, motion, and sphincter in 16 paraplegia cases gradually recovered after 1 week to 3 months postoperatively, and the American Spinal Injury Association scores significantly increased at the final follow-up. Intervertebral bone fusions were all achieved postoperatively. No internal fixation devices were loose, extracted, or broken. There was no correction degree loss during the follow-up. The method of radical anterolateral debridement and autogenous ilium with rib or titanium cage interbody autografting and single-stage transpedicle fixation was effective for the treatment of thoracolumbar tuberculosis, correcting kyphotic deformity, and reconstructing
Cai, B.; Ran, B.; Li, Q.; Li, Z.H.; Li, F.N.; Li, M.; Yan, W.J.
Our goal was to analyze the anatomical parameters of the lumbar spine spinous process for an interspinous stabilization device designed for the Chinese population and to offer an anatomical basis for its clinical application. The posterior lumbar spines (T12-S1) of 52 adult cadavers were used for measuring the following: distance between two adjacent spinous processes (DB), distance across two adjacent spinous processes (DA), thickness of the central spinous processes (TC), thickness of the superior margin of the spinous processes (TS), thickness of the inferior margin of the spinous processes (TI), and height of the spinous processes (H). Variance and correlation analyses were conducted for these data, and the data met the normal distribution and homogeneity of variance. DB decreased gradually from L1-2 to L5-S1. DA increased from T12-L1 to L2-3 and then decreased from L2-3 to L4-5. The largest H in males was noted at L3 (25.45±5.96 mm), whereas for females the largest H was noted at L4 (18.71±4.50 mm). Usually, TS of the adjacent spinous process was lower than TI. Based on the anatomical parameters of the lumbar spinous processes obtained in this study, an “H”-shaped coronal plane (posterior view) was proposed as an interspinous stabilization device for the Chinese population. This study reports morphometric data of the lumbar spinous processes in the Chinese population, which provides an anatomical basis for future clinical applications. PMID:25493388
Liu, Jingchen; Li, Ye; Wu, Yuntao
The present study aimed to evaluate the effect of using one-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion in the treatment of unstable hangman's fracture. A total of 13 patients with unstable hangman's fractures underwent C2 and C3 pedicle screw fixation, lamina interbody fusion or combined anterior C2-C3 fusion and imaging examinations to evaluate the fracture fixation and healing condition at three days and three months following surgery. Postoperative X-ray and computed tomography (CT) results showed high fracture reduction, good internal fixation position and reliable fracture fixation. The three-month postoperative CT showed good vertebral fracture healing. C2 and C3 pedicle screw fixation has a good curative effect in the treatment of unstable hangman's fracture. The direct fixation of the fracture enables early ambulation by the patients.
Douglas, Pamela Sylvia
Currently, many clinicians who help with breastfeeding problems are diagnosing "posterior" tongue-tie in infants and performing or referring for frenotomy. In this "Speaking Out" article, I argue that the diagnosis of "posterior" tongue-tie has successfully raised awareness of the importance of impaired tongue function in breastfeeding difficulty. However, the diagnosis of "posterior" tongue-tie also applies a reductionist, medicalized theoretical frame to the complex problem of impaired tongue function, risking unintended outcomes. Impaired tongue function arises out of multiple interacting and co-evolving factors, including the interplay between social behaviors concerning breastfeeding and mother-infant biology. Consideration of theoretical frames is vital if we are to build an evidence base through efficient use of the scarce resources available for clinical breastfeeding research and minimize unintended outcomes.
Sá, Pedro; Marques, Pedro; Alpoim, Bruno; Rodrigues, Elisa; Félix, António; Silva, Luís; Leal, Miguel
Lumbar stenosis is an increasingly common pathological condition that is becoming more frequent with increasing mean life expectancy, with high costs for society. It has many causes, among which degenerative, neoplastic and traumatic causes stand out. Most of the patients respond well to conservative therapy. Surgical treatment is reserved for patients who present symptoms after implementation of conservative measures. Here, a case of severe stenosis of the lumbar spine at several levels, in a female patient with pathological and surgical antecedents in the lumbar spine, is presented. The patient underwent two different decompression techniques within the same operation. PMID:26229836
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
Field, Antony; Ferrara, Lisa A.; Freeman, Andrew L.; Phan, Kevin
Background S1 screw failure and L5/S1 non-union are issues with long fusions to S1. Improved construct stiffness and S1 screw offloading can help avoid this. S2AI screws have shown to provide similar stiffness to iliac screws when added to L3–S1 constructs. We sought to examine and compare the biomechanical effects on an L2–S1 pedicle screw construct of adding S2AI screws, AxiaLIF, L5–S1 interbody support via transforaminal lumbar interbody fusion (TLIF), and to examine the effect of the addition of cross connectors to each of these constructs. Methods Two S1 screws and one rod with strain gauges (at L5/S1) were used in L2–S1 screw-rod constructs in 7 L1-pelvis specimens (two with low BMD). ROM, S1 screw and rod strain were assessed using a pure-moment flexibility testing protocol. Specimens were tested intact, and then in five instrumentation states consisting of: (I) Pedicle screws (PS) L2–S1; (II) PS + S2AI screws; (III) PS + TLIF L5/S1; (IV) PS + AxiaLIF L5/S1; (V) PS + S2AI + AxiaLIF L5/S1. The five instrumentation conditions were also tested with crosslinks at L2/3 and S1/2. Tests were conducted in flexion-extension, lateral bending and axial torsion with no compressive preload. Results S2A1 produces reduced S1 screw strain for flexion-extension, lateral bending and axial torsion, as well as reduced rod strain in lateral bending and axial torsion in comparison to AxiaLIF and interbody instrumentation, at the expense of increased rod flexion-extension strain. Cross-connectors may have a role in further reduction of S1 screw and rod strain. Conclusions From a biomechanical standpoint, the use of the S2AI technique is at least equivalent to traditional iliac screws, but offers lower prominence and ease of assembly compared to conventional sacroiliac stabilization. PMID:28097243
Ryu, H; Nishizawa, S; Yamamoto, S
A 12-year-old boy had a large dumb-bell-shaped cervical neurinoma originating at the C5 spinal root that was removed in a one-stage operation through the enlarged C4/5 intervertebral foramen. This technique required no laminectomy, discectomy or interbody fusion, which may frequently produce spinal deformity in children.
Skalpe, I O
Late sequelae (adhesive arachnoiditis) have been reported following myelography with the oily contrast medium (Pantopaque) and with the ionic water-soluble contrast media methiodal sodium (Abrodil, Conturex, Kontrast U) meglumine iothalamate (Conray Meglumine) and meglumine iocarmate (Bis-Conray, Dimer-X). Adhesive arachnoiditis has not yet been reported after the use of the nonionic water-soluble contrast medium metrizamide (Amipaque). Thus, this is considered the contrast medium of choice for lumbar myelography. Using the recommended dose of 10 ml with an iodine concentration of 170 mg/ml for this examination, adhesive arachnoiditis is unlikely to occur. Increased osmolality of spinal fluid after injection of contrast medium is related to increased frequency of arachnoiditis.
Yüksel, Kasım Zafer
Background Low back pain is a frequent condition that results in substantial disability and causes admission of patients to neurosurgery clinics. To evaluate and present the therapeutic outcomes in lumbar disc hernia (LDH) patients treated by means of a conservative approach, consisting of bed rest and medical therapy. Methods This retrospective cohort was carried out in the neurosurgery departments of hospitals in Kahramanmaraş city and 23 patients diagnosed with LDH at the levels of L3−L4, L4−L5 or L5−S1 were enrolled. Results The average age was 38.4 ± 8.0 and the chief complaint was low back pain and sciatica radiating to one or both lower extremities. Conservative treatment was administered. Neurological examination findings, durations of treatment and intervals until symptomatic recovery were recorded. Laségue tests and neurosensory examination revealed that mild neurological deficits existed in 16 of our patients. Previously, 5 patients had received physiotherapy and 7 patients had been on medical treatment. The number of patients with LDH at the level of L3−L4, L4−L5, and L5−S1 were 1, 13, and 9, respectively. All patients reported that they had benefit from medical treatment and bed rest, and radiologic improvement was observed simultaneously on MRI scans. The average duration until symptomatic recovery and/or regression of LDH symptoms was 13.6 ± 5.4 months (range: 5−22). Conclusions It should be kept in mind that lumbar disc hernias could regress with medical treatment and rest without surgery, and there should be an awareness that these patients could recover radiologically. This condition must be taken into account during decision making for surgical intervention in LDH patients devoid of indications for emergent surgery. PMID:28119770
Lumbar Interspinous Process Fixation and Fusion with Stand-Alone Interlaminar Lumbar Instrumented Fusion Implant in Patients with Degenerative Spondylolisthesis Undergoing Decompression for Spinal Stenosis
Postacchini, Franco; Menchetti, Pier Paolo Maria; Sessa, Pasquale; Paolino, Michela; Cinotti, Gianluca
Study Design Prospective cohort study. Purpose To assess the ability of a stand-alone lumbar interspinous implant (interspinous/interlaminar lumbar instrumented fusion, ILIF) associated with bone grafting to promote posterior spine fusion in degenerative spondylolisthesis (DS) with vertebral instability. Overview of Literature A few studies, using bilateral laminotomy (BL) or bilateral decompression by unilateral laminotomy (BDUL), found satisfactory results in stenotic patients with decompression alone, but others reported increased olisthesis, or subsequent need for fusion in DS with or without dynamic instability. Methods Twenty-five patients with Grade I DS, leg pain and chronic low back pain underwent BL or BDUL and ILIF implant. Olisthesis was 13% to 21%. Follow-up evaluations were performed at 4 to 12 months up to 25 to 44 months (mean, 34.4). Outcome measures were numerical rating scale (NRS) for back and leg pain, Oswestry disability index (ODI) and short-form 36 health survey (SF-36) of body pain and function. Results Fusion occurred in 21 patients (84%). None had increased olisthesis or instability postoperatively. Four types of fusion were identified. In Type I, the posterior part of the spinous processes were fused. In Type II, fusion extended to the base of the processes. In Type III, bone was present also around the polyetheretherketone plate of ILIF. In Type IV, even the facet joints were fused. The mean NRS score for back and leg pain decreased by 64% and 80%, respectively. The mean ODI score was decreased by 52%. SF-36 bodily pain and physical function mean scores increased by 53% and 58%, respectively. Computed tomography revealed failed fusion in four patients, all of whom still had vertebral instability postoperatively. Conclusions Stand-alone ILIF with interspinous bone grafting promotes vertebral fusion in most patients with lumbar stenosis and unstable Grade I DS undergoing BL or BDUL. PMID:26949455
Kanemura, Tokumi; Yamaguchi, Hidetoshi; Segi, Naoki; Ouchida, Jun
Study Design Retrospective study. Purpose To compare intraoperative endplate injury cases and no injury cases in consecutive series and to identify predisposing factors for intraoperative endplate injury. Overview of Literature Unintended endplate violation and subsequent cage subsidence is an intraoperative complication of extreme lateral interbody fusion (XLIF). It is still unknown whether it is derived from inexperienced surgical technique or patients' inherent problems. Methods Consecutive patients (n=102; mean age, 69.0±0.8 years) underwent XLIF at 201 levels at a single institute. Preoperative and immediately postoperative radiographs were compared and cases with intraoperative endplate injury were identified. Various parameters were reviewed in each patient and compared between the injury and no injury groups. Results Twenty one levels (10.4%) had signs of intraoperative endplate injury. The injury group had a significantly higher rate of females (p=0.002), lower bone mineral density (BMD) (p=0.02), higher rate of polyetheretherketone as cage material (p=0.04), and taller cage height (p=0.03) compared with the no injury group. Multivariate analysis indicated that a T-score of BMD as a negative (odds ratio, 0.52; 95% confidence interval, 0.27–0.93; p=0.03) and cage height as a positive (odds ratio, 1.84; 95% confidence interval, 1.01–3.17; p=0.03) were predisposing factors for intraoperative endplate injury. Conclusions Intraoperative endplate injury is correlated significantly with reduced BMD and taller cage height. Precise evaluation of bone quality and treatment for osteoporosis might be important and care should be taken not to choose excessively taller cage. PMID:27790319
... treatment while waiting for the results of the culture. Risks A lumbar puncture is considered a safe procedure with minimal risks. Most of the time, there are no complications. In some instances, a ...
.org Fractures of the Thoracic and Lumbar Spine Page ( 1 ) Spinal fractures can vary widely in severity. While some fractures are very serious injuries that require emergency treatment, other fractures can ...
Girotto, Vittorio; Gonzalez, Michael
Do young children have a basic intuition of posterior probability? Do they update their decisions and judgments in the light of new evidence? We hypothesized that they can do so extensionally, by considering and counting the various ways in which an event may or may not occur. The results reported in this paper showed that from the age of five,…
Agner, Celso; Dujovny, Manuel; Evenhouse, Raymond; Charbel, Fady T.; Sadler, Lewis
Posterior fossa cranioplasty has been suggested for improvement of neurological symptoms following craniectomy. However, there is no particular recommendation in the literature about techniques for prosthesis manufacture and implantation. We report our experience using rapid prototyping technology and stereolithography for pre-surgical implant design and production of cranioplasties. ImagesFigure 1Figure 2Figure 3Figure 4Figure 5 PMID:17171056
Yoshiiwa, Toyomi; Notani, Naoki; Ishihara, Toshinobu; Kawano, Masanori; Tsumura, Hiroshi
Study Design Cross-sectional study. Purpose To investigate the relationship between ligamentum flavum (LF) thickening and lumbar segmental instability and disc degeneration and facet joint osteoarthritis. Overview of Literature Posterior spinal structures, including LF thickness, play a major role in lumbar spinal canal stenosis pathogenesis. The cause of LF thickening is multifactorial and includes activity level, age, and mechanical stress. LF thickening pathogenesis is unknown. Methods We examined 419 patients who underwent computed tomography (CT) myelography and magnetic resonance imaging after complaints of clinical symptoms. To investigate LF hypertrophy, 57 patients whose lumbar vertebra had normal disc heights at L4–5 were selected to exclude LF buckling as a hypertrophy component. LF thickness, disc space widening angulation in flexion, segmental angulation, presence of a vacuum phenomenon, and lumbar lordosis at T12–S1 were investigated. Disc and facet degeneration were also evaluated. Facet joint orientation was measured via an axial CT scan. Results The mean LF thickness in all patients was 4.4±1.0 mm at L4–5. There was a significant correlation between LF thickness and disc degeneration; LF thickness significantly increased with severe disc degeneration and facet joint osteoarthritis. There was a tendency toward increased LF thickness in more sagittalized facet joints than in coronalized facet joints. Logistic regression analysis showed that LF thickening was influenced by segmental angulation and facet joint osteoarthritis. Patient age was associated with LF thickening. Conclusions LF hypertrophy development was associated with segmental instability and severe disc degeneration, severe facet joint osteoarthritis, and a sagittalized facet joint orientation. PMID:27994791
Park, Joon-Hee; Kim, Ho-Joong; Kang, Kyoung-Tak; Kim, Ka-Yeon; Chun, Heoung-Jae; Moon, Seong-Hwan; Lee, Hwan-Mo
The aim of this study is to investigate the change in biomechanical milieu following removal of pedicle screws or removal of spinous process with posterior ligament complex in instrumented single level lumbar arthrodesis. We developed and validated a finite element model (FEM) of the intact lumbar spine (L2-4). Four scenarios of L3-4 lumbar fusion were simulated: posterolateral fusion (PLF) at L3-4 using pedicle screw system with preservation of PLC (Pp WiP), L3-4 lumbar posterolateral fusion state after removal of pedicle screw system with preservation of PLC (Pp WoP), L3-4 using pedicle screw system without preservation PLC (Sp WiP), L3-4 lumbar posterolateral fusion state after removal of pedicle screw system without preservation of PLC (Sp WoP). For these models, we investigated the range of motion and maximal Von mises stress of disc in all segments under various moments. All fusion models demonstrated increase in range of motion at adjacent segments compared to the intact model.For the four fusion models, the WiP model s P had the largest increase in range of motion at each adjacent segment. This study demonstrated that removal of pedicle screw system and preservation of PLC after complete lumbar spinal fusion could reduce the stress of adjacent segments synergistically and might have beneficial effects in preventing ASD.
Park, Joon-Hee; Kim, Ho-Joong; Kang, Kyoung-Tak; Kim, Ka-yeon; Chun, Heoung-Jae; Moon, Seong-Hwan; Lee, Hwan-Mo
The aim of this study is to investigate the change in biomechanical milieu following removal of pedicle screws or removal of spinous process with posterior ligament complex in instrumented single level lumbar arthrodesis. We developed and validated a finite element model (FEM) of the intact lumbar spine (L2-4). Four scenarios of L3-4 lumbar fusion were simulated: posterolateral fusion (PLF) at L3-4 using pedicle screw system with preservation of PLC (Pp WiP), L3-4 lumbar posterolateral fusion state after removal of pedicle screw system with preservation of PLC (Pp WoP), L3-4 using pedicle screw system without preservation PLC (Sp WiP), L3-4 lumbar posterolateral fusion state after removal of pedicle screw system without preservation of PLC (Sp WoP). For these models, we investigated the range of motion and maximal Von mises stress of disc in all segments under various moments. All fusion models demonstrated increase in range of motion at adjacent segments compared to the intact model.For the four fusion models, the WiP model s P had the largest increase in range of motion at each adjacent segment. This study demonstrated that removal of pedicle screw system and preservation of PLC after complete lumbar spinal fusion could reduce the stress of adjacent segments synergistically and might have beneficial effects in preventing ASD.
Sugiura, Kosuke; Tonogai, Ichiro; Matsuura, Tetsuya; Higashino, Kosaku; Sakai, Toshinori; Suzue, Naoto; Nishisho, Toshihiko; Goda, Yuichiro; Sato, Ryosuke; Kondo, Kenji; Tezuka, Fumitake; Mineta, Kazuaki; Takeuchi, Makoto; Takahashi, Mitsuhiko; Egawa, Hiroshi; Sairyo, Koichi
A 32-year-old man underwent radiofrequency thermal annuloplasty (TA) with percutaneous endoscopic discectomy (PED) under local anesthesia for chronic low back pain. His diagnosis was discogenic pain with a high signal intensity zone (HIZ) in the posterior corner of the L4-5 disc. Flexion pain was sporadic, and steroid injection was given twice for severe pain. After the third episode of strong pain, PED and TA were conducted. The discoscope was inserted into the posterior annulus and revealed a migrated white nucleus pulposus which was stained blue. Then, after moving the discoscope to the site of the HIZ, a migrated slightly red nucleus pulposus was found, suggesting inflammation and/or new vessels penetrating the mass. After removing the fragment, the HIZ site was ablated by TA. To our knowledge, this is the first report of the discoscopic findings of HIZ of the lumbar intervertebral disc. PMID:24963428
Background Lateral interbody cages have been proven useful in spinal fusions. Spanning both lateral cortical rims while sparing the Anterior Longitudinal Ligament, the lateral interbody cages restore and maintain disc height while adding stability prior to supplemental fixation. The standard approach for their insertion is by a 90-degree lateral transpsoas method. This is relatively bloodless compared to other techniques although has its limitations, requiring neuro-monitoring and being, at times, very difficult at L4/5 due to iliac crest obstruction or an anterior plexus position. An oblique approach, with the patient in lateral decubitus, passes anterior to the iliac crest, retroperitoneal, and being anterior to psoas, eliminates the need for neuro-monitoring. Methods Twenty-one consecutive patients underwent surgery for a total of 32 levels instrumented with the ATP technique. Mean age at the time of surgery was 62.4±7.4 years. There was a 6 months minimum clinical follow up, with imaging to assess fusion, at 6 and 12 months. Indications included symptomatic degenerative lumbar spondylosis +/− spondylolisthesis, leg and back pain. All patients were assessed with the Oswestry Disability Index (ODI), Visual Analog Scale 100 mm for back pain (VASb) and for leg pain (VASl) preoperatively, at 3, 6 and 12 months. Last follow-up was at 12 months for 9 patients and the rest had 6 months follow up. Results Statistical analysis showed significance for the results in ODI, VASb and VASl with improvement in all components except for one patient with worsening VASl. Eight patients had complications related to surgery which were still present at last follow-up including moderate weakness of hip flexion and EHL weakness. Lateral cutaneous nerve (LCN) palsy on the side of the approach was also seen as well as sympathectomy effect related to the mobilization of the sympathetic trunk. One patient, who also suffered from multiple sclerosis, experienced psoas abscess 3 months
Phillips, Flip; Voshell, Martin G
The study of spatial vision is a long and well traveled road (which, of course, converges to a vanishing point at the horizon). Its various distortions have been widely investigated empirically, and most concentrate, pragmatically, on the space anterior to the observer. The visual world behind the observer has received relatively less attention and it is this perspective the current experiments address. Our results show systematic perceptual distortions in the posterior visual world when viewed statically. Under static viewing conditions, observer's perceptual representation was consistently 'spread' in a hyperbolic fashion. Directions to distant, peripheral locations were consistently overestimated by about 11 degrees from the ground truth and this variability increased as the target was moved toward the center of the observer's back. The perceptual representation of posterior visual space is, no doubt, secondary to the more immediate needs of the anterior visual world. Still, it is important in some domains including certain sports, such as rowing, and in vehicular navigation.
Kim, Hyeong-Suk; Park, Jung-Soo
Intervertebral intradural lumbar disc herniation (ILDH) is a quite rare pathology, and isolated intradural lumbar disc herniation is even more rare. Magnetic resonance imaging (MRI) may not be able to reveal ILDHs, especially if MRI findings show an intact lumbar disc annulus and posterior longitudinal ligament. Here, we present an exceedingly rare case of an isolated IDLH that we initially misidentified as a spinal intradural tumor, in a 54-year-old man hospitalized with a 2-month history of back pain and right sciatica. Neurologic examination revealed a positive straight leg raise test on the right side, but he presented no other sensory, motor, or sphincter disturbances. A gadolinium-enhanced MRI revealed what we believed to be an intradural extramedullary tumor compressing the cauda equina leftward in the thecal sac, at the L2 vertebral level. The patient underwent total L2 laminectomy, and we extirpated the intradural mass under microscopic guidance. Histologic examination of the mass revealed a degenerated nucleus pulposus. PMID:23091677
Zadeh, Jonathan R.; Buicko, Jessica L.; Patel, Chetan; Kozol, Robert; Lopez-Viego, Miguel A.
The Grynfeltt-Lesshaft hernia is a rare posterior abdominal wall defect that allows for the herniation of retro- and intraperitoneal structures through the upper lumbar triangle. While this hernia may initially present as a small asymptomatic bulge, the defect typically enlarges over time and can become symptomatic with potentially serious complications. In order to avoid that outcome, it is advisable to electively repair Grynfeltt hernias in patients without significant contraindications to surgery. Due to the limited number of lumbar hernioplasties performed, there has not been a large study that definitively identifies the best repair technique. It is generally accepted that abdominal hernias such as these should be repaired by tension-free methods. Both laparoscopic and open techniques are described in modern literature with unique advantages and complications for each. We present the case of an unexpected Grynfeltt hernia diagnosed following an attempted lipoma resection. We chose to perform an open repair involving a combination of fascial approximation and dual-layer polypropylene mesh placement. The patient's recovery was uneventful and there has been no evidence of recurrence at over six months. Our goal herein is to increase awareness of upper lumbar hernias and to discuss approaches to their surgical management. PMID:26697256
Olson, Michael W; Li, Li; Solomonow, Moshe
Human and animal models using electromyography (EMG) based methods have hypothesized that viscoelastic tissue properties becomes compromised by prolonged repetitive cyclic trunk flexion-extension which in turn influences muscular activation including the flexion-relaxation phenomenon. Empirical evidence to support this hypothesis, especially the development of viscoelastic tension-relaxation and its associated muscular response in passive cyclic activity in humans, is incomplete. The objective of this study was to examine the response of lumbar muscles to tension-relaxation development of the viscoelastic tissue during prolonged passive cyclic trunk flexion-extension. Activity of the lumbar muscles remained low and steady during the passive exercise session. Tension supplied by the posterior viscoelastic tissues decreased over time without corresponding changes in muscular activity. Active flexion, following the passive flexion session, elicited significant increase in paraspinal muscles EMG together with increase in the median frequency. It was concluded that reduction of tension in the lumbar viscoelastic tissues of humans occurs during cyclic flexion-extension and is compensated by increased activity of the musculature in order to maintain stability. It was also concluded that the ligamento-muscular reflex is inhibited during passive activities but becomes hyperactive following active cyclic flexion, indicating that moment requirements are the controlling variable. It is conceived that prolonged routine exposure to cyclic flexion minimizes the function of the viscoelastic tissues and places increasing demands on the neuromuscular system which over time may lead to a disorder and possible exposure to injury.
... If You Have Questions en español Resonancia magnética: columna lumbar What It Is Magnetic resonance imaging (MRI) ... MORE ON THIS TOPIC Magnetic Resonance Imaging (MRI): Cervical Spine Lumbar Puncture (Spinal Tap) Magnetic Resonance Imaging ( ...
Cai, Siyi; Kong, Xiangyi; Yan, Chengrui; Wang, Yipeng; Wan, Xueshuai; Zhang, Jialu; Qiu, Guixing; Yu, Keyi
The objective of this article is to report an unusual case of a spinal rod that protruded into the spinal canal after lumbar spine surgery.Only 4 cases of spinal rod migration with protrusion into the spinal canal have been reported. This is the first report of a case involving the use of posterior low lumbar segmental instrumentation with a screw-rod system. The left side of the rod gradually migrated and finally protruded into the canal and compressed the cord.A 60-year-old woman presented with pain and numbness of the posterior aspect of the left leg after a long-distance walk. Intermittent claudication became worse, and she developed pain and numbness in the perineal region. An x-ray showed that the left side of a spinal rod among the segmental spinal instruments that had been placed 10 years previously had protruded into the spinal canal.We removed the rod and decompressed the canal at the level of L5-S1. The patient became totally asymptomatic.Rods used as spinal instrumentation have the possibility of protruding into the spinal canal and endangering the nervous system. Long-term follow-up with radiological examinations should be conducted upon completion of spinal operations conducting using instrumentation.
Cai, Siyi; Kong, Xiangyi; Yan, Chengrui; Wang, Yipeng; Wan, Xueshuai; Zhang, Jialu; Qiu, Guixing; Yu, Keyi
Abstract The objective of this article is to report an unusual case of a spinal rod that protruded into the spinal canal after lumbar spine surgery. Only 4 cases of spinal rod migration with protrusion into the spinal canal have been reported. This is the first report of a case involving the use of posterior low lumbar segmental instrumentation with a screw–rod system. The left side of the rod gradually migrated and finally protruded into the canal and compressed the cord. A 60-year-old woman presented with pain and numbness of the posterior aspect of the left leg after a long-distance walk. Intermittent claudication became worse, and she developed pain and numbness in the perineal region. An x-ray showed that the left side of a spinal rod among the segmental spinal instruments that had been placed 10 years previously had protruded into the spinal canal. We removed the rod and decompressed the canal at the level of L5-S1. The patient became totally asymptomatic. Rods used as spinal instrumentation have the possibility of protruding into the spinal canal and endangering the nervous system. Long-term follow-up with radiological examinations should be conducted upon completion of spinal operations conducting using instrumentation. PMID:28328849
Choi, Seyoung; Lee, Minsun; Kwon, Byongan
Individual pelvic sacral angle was measured, compared and analyzed for the 6 male and female adults who were diagnosed with lumbar spinal stenosis, foraminal stenosis and mild spondylolisthesis in accordance with spinal parameters, pelvic parameters and occlusion state of sacroiliac joint presented by the author of this thesis based on the fact that the degree of lumbar excessive lordosis that was one of the causes for lumbar pain was determined by sacral slope. The measured values were compared with the standard values of the average normal range from 20 s to 40 s of normal Koreans stated in the study on the change in lumbar lordosis angle, lumbosacral angle and sacral slope in accordance with the age by Oh et al.  and sacral slope and pelvic sacral slope of each individual of the subjects for measurement were compared. Comparing the difference between the two tilt angles possessed by an individual is a comparison to determine how much the sacroiliac joint connecting pelvis and sacral vertebrae compensated and corrected the sacral vertebrae slope by pelvic tilt under the condition of synarthrodial joint.Under the condition that the location conforming to the line in which the sagittal line of gravity connects with pelvic ASIS and pubic pubic tuberele is the neutral location of pelvic tilt, sacral slope being greater than pelvic sacral slope means pelvic anterior tilting, whereas sacral slope being smaller than pelvic sacral slope means pelvic posterior tilting. On that account, male B, female A and female C had a pelvic posterior tilting of 16 degrees, 1 degree and 5 degrees respectively, whereas male A, male C and female B had a pelvic anterior tilting of 3 degrees, 9 degrees and 4 degrees respectively. In addition, the 6 patients the values of lumbar lordosis angle, lumbosacral angle and sacral slope that were almost twice as much as the normal standard values of Koreans. It is believed that this is because the pelvic sacral slope maintaining an angle that is
Morningstar, Mark W
Abstract Objective To test the hypothesis that restoring the lumbar lordosis will increase a patient's voluntary muscular strength and decrease back pain symptoms. Clinical Features A patient was diagnosed with mechanical low back pain. The initial radiographic study revealed a loss of the lumbar lordosis. The patient determined his maximum bench press prior to the treatment program. The treatment outcome was based upon post-intervention radiographs, a Borg pain scale, and the patient's post-intervention maximum bench press. Intervention and Outcome The treatment program consisted of warm-up exercises, spinal manipulation, rehabilitative exercises, neuromuscular re-education, and prescribed home care. The treatment period consisted of 12 visits in the first 4 weeks, followed by once weekly for another 12 weeks, for a total of 24 visits in 4 months. In the first month, the Borg scale decreased from 5/10 to 0/10, and after 4 months the lumbar lordosis was increased from 2° to 31°. The sacral base angle (Ferguson's angle) increased from 18° to 31°. The patient's maximum bench press also increased from 245 pounds to 305 pounds. Conclusion Restoration of the lumbar lordosis appears to have a positive effect on muscular strength. This study supports the previous premise that a lumbar lordosis provides an inherent mechanical advantage for strength and stability. PMID:19674610
Hofstetter, Christoph P; Hofer, Anna S; Wang, Michael Y
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. PMID:25793159
Chun, Eun Hee
Foraminal or extraforaminal Far Lateral Disc Herniations (FLDH) extending into or beyond the foraminal zone have been recognized as between 7-12% of all lumbosacral disc herniations. Conventional posterior laminectomy may not provide good access to a herniation that lies far lateral to the lateral margin of the pedicle. Use of the endoscopic technique through a percutaneous approach to treat such FLDH patients can decrease the surgical morbidity while achieving better outcomes. We made an effort to utilize the advantages of percutaneous endoscopic lumbar discectomy (PELD) and to determine the appropriate approach for FLDH at the level between the 5th Lumbar and first Sacral vertebrae(L5-S1). The authors present a case of an endoscopically resected lumbar extruded disc of the left extraforaminal zone with superior foraminal migration at the level of L5-S1, which had led to foot drop, while placing the endoscope in the anterior epidural space without facetectomy. PMID:26839673
Dai, Li-Yang; Jiang, Lei-Sheng
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 beta-tricalcium phosphate (beta-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 beta-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 beta-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 beta-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
Le Fourn, B; Loirat, Y; Sartre, J Y; Lejeune, F; Pannier, M
With a case of thoraco-lumbar defect, the authors discuss about different procedures to cover it. In this place, the better procedure is certainly the latissimus dorsi flap, in all combinations. The indication for omentoplasty at this spinal site should not be performed by first intention but by exclusion of other procedures, as in the case considered by the authors. It was a 37-year-old man, paraplegic from the age of 16, with a deep chronic spinal wound, secondary to sepsis of a posterior segmental fixations. A staphylococcus aureus infection which developed as a surgical complication was initially treated with antibiotics and surgical cleaning procedures without removing instrumentation. However, the infection remained active and the material was finally removed. Spinal immobilisation was strengthened by external fixation. The area was cleared of all suspect material, including bone graft, leaving a wide back-wound open to the spine. Spontaneous healing was first attempted, but the size and the chronicity of the wound led us to use pedicled greater omentum to close the defect. The omentum was pedicled on the right gastroepiploic vessels and transferred to the back wound through the posterior abdominal wall muscles, next to the right kidney. This procedure allows rapid healing. In association with suitable antibiotics, it has prevented any recurrent infection after 18 months of follow-up. It was no feasible to cover the wound with a latissimus dorsi flap, considering the importance of this muscle in the movements of a paraplegic and considering the initial impossibility of removing the external fixation.
Glennie, R Andrew; Dea, Nicolas; Kwon, Brian K; Street, John T
This study reviews the outcomes and revision rates of degenerative lumbar fusion surgery using cortical trajectory pedicle screws in lieu of traditional pedicle screw instrumentation. Pedicle screw fixation can be a challenge in patients with low bone mineral density. Wide posterior approaches to the lumbar spine exposing lateral to the facet joints and onto transverse processes causes an additional degree of muscular damage and blood loss not present with a simple laminectomy. A cortical bone trajectory pedicle screw has been proposed as an alternative to prevent screw pullout and decrease the morbidity associated with the wide posterior approach to the spine. We present a series of eight consecutive patients using a cortical bone trajectory instead of traditional pedicle screw fixation for degenerative conditions of the lumbar spine. A retrospective review of our institutional registry data identified eight patients who had cortical screws placed with the assistance of O-arm Stealth navigation (Medtronic Sofamor Danek, Memphis, TN, USA) from 2010-2013. We analyzed the need for revision, the maintenance of reduction and the incidence of screw pullout or breakage. Our review demonstrated that two of eight patients were revised at an average of 12months. The reasons for these revisions were pseudarthrosis and caudal adjacent segment failure. All patients who were revised had frank screw loosening. We present early clinical results of a new technique that has been shown to have a better fixation profile in laboratory testing. Our less than favorable early clinical results should be interpreted with caution and highlight important technical issues which should be considered.
Roentgenographic Measurement of Lumbar Intervertebral Disc Height ." Spine , 6(2):154:158. Andriacchi, T., Schultz, A... measured , enabling coupled motion (Wite and Panjabi, 1978), for example, in lateral bending of the lumbar spine , to be investigated. Two different...to seated position. They describe measured positions of the lumbar spine , sacrum, and inncminate with anatomical landmarks important to
Lins, E; Basedow, H
This is a case of lumbar disc protrusion in a 14 year old girl, with typical symptomatology. Special attention should be called to the rarity of this case. The clinical and myelographic diagnosis showed a lumbar herniation L 4/L5. Treatment was performed by lumbar hemilaminectomie. The post operative controll showed remission of the clinical findings.
Kim, Joon-Sung; Kim, Ji Yeon
Epidural steroid injections (ESI) are a common treatment for back pain management. ESI-related complications have increased with the growing number of procedures. We report a case of cervical meningomyelitis followed by multiple lumbar ESI. A 60-year-old male with diabetes mellitus presented to our hospital with severe neck pain. He had a history of multiple lumbar injections from a local pain clinic. After admission, high fever and elevated inflammatory values were detected. L-spine magnetic resonance imaging (MRI) revealed hematoma in the S1 epidural space. Antibiotic treatment began under the diagnosis of a lumbar epidural abscess. Despite the treatment, he started to complain of weakness in both lower extremities. Three days later, the weakness progressed to both upper extremities. C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord. Removal of the epidural abscess was performed, but there was no neurological improvement. PMID:26161360
Tucker, John A; Tucker, Sean T
The existence of the posterior commissure (PC) of the human larynx has been disputed (Hirano M, Sato K, et al. The posterior glottis. Trans Am Laryngol Assoc. 1986;107:70-75). "The term posterior commissure has no relevance to anatomical structure. The term commissure means a joining together. The bilateral vocal folds never join at their posterior ends. The posterior aspect of the glottis is a wall. The posterior lateral aspect of the posterior glottis is also the lateral wall of the posterior glottis" (Hirano M, Sato K, et al. The posterior glottis. Trans Am Laryngol Assoc. 1986;107:70-75). This study is intended to clarify the development of anatomical and morphological aspects of the PC in conjunction with a clinical classification of the larynx in sagittal view. This study uses human embryo and fetal laryngeal sections from the Carnegie Collection of Human Embryos (the world standard) and whole organ laryngeal sections from the Tucker Laryngeal Fetal Collection. Correlation of histologic and gross anatomical structure is made with the Hirano et al atlas, the Vidić Photographic Atlas of the Human Body, and the O'Rahilly Embryonic Atlas. Embryologic data clearly describe and illustrate the posterior union of the cricoid cartilage with formation of the PC. The anatomical functional aspects of the posterior lateral cricoid lamina as the supporting buttress of the articulating arytenoid cartilages are illustrated.
Koukoulias, Nikolaos E; Papastergiou, Stergios G
The authors present a case of calcified posterior cruciate ligament (PCL). A 61-year-old female presented in our department reporting 12 months history of knee pain that was getting worse during the night. The patient was under medication for epileptic seizure, osteoporosis and hyperthyroidism. X-rays demonstrated calcification of the PCL. CT and MRI excluded any other intra-articular and extra-articular pathology. Arthroscopic debridement of the calcium deposits was performed and the symptoms resolved immediately, while the postoperative x-rays were normal. Histological examination confirmed the calcium nature of the lesion. Two years postoperatively the patient remains asymptomatic. PMID:22669889
Nabeta, Masaharu; Yoshimoto, Hisashi; Sato, Shigenobu; Hyakumachi, Takahiko; Yanagibashi, Yasushi; Masuda, Takeshi
Discal cysts are rare lesions that can result in refractory sciatica. Because they are so rare, their exact origin and details of the clinical manifestations are still unknown. The authors report on five men treated for discal cysts. The mean age of the patients at the time of the surgery was 32 years (range 25-38 years). All patients suffered from lower-extremity pain and the results of the straight leg-raising test were positive in all cases. Three patients reported motor weakness and four had sensory disturbance-symptoms similar to those found in patients with lumbar disc herniation. Magnetic resonance imaging demonstrated spherically shaped extradural lesions of various sizes with low and high signal intensities on T1- and T2-weighted images, respectively. Discography revealed obvious communication between the cyst and the intervertebral disc with reproducible leg pain in all patients. All patients underwent posterior decompression and excision of the cysts either with or without additional discectomy. The radicular symptoms were remarkably improved in all patients immediately after surgery, and no recurrent lesions were noted during follow up.
Teplick, J.G.; Haskin, M.E.
In the postoperative patient ordinary radiographs of the spine generally add very little information, revealing the usual postoperative bone changes and often postoperative narrowing of the intervertebral space. Myelography may sometimes be informative, showing evidence of focal arachnoiditis or a focal defect at the surgical site. However, the latter finding is difficult to interpret. As experience with high-resolution CT scanning of the lumbar spine has been increasing, it is becoming apparent that this noninvasive and easily performed study can give considerably more information about the postoperative spine than any of the other current imaging methods. About 750 patients with previous lumbar laminectomies had CT scanning within a 28 month period.
Zylbersztejn, Sérgio; Spinelli, Leandro de Freitas; Rodrigues, Nilson Rodinei; Werlang, Pablo Mariotti; Kisaki, Yorito; Rios, Aldemar Roberto Mieres; Bello, Cesar Dall
This paper presents an update on degenerative stenosis of the lumbar spine, which is a common pathological condition among patients over the age of 65 years. The anamnesis and physical examination need to be precise, since radiography often only provides indirect signs. Magnetic resonance imaging is necessary if the symptoms persist. The treatment for lumbar stenosis is a matter of controversy. However, there seems to be some benefit from surgical treatment rather than conservative treatment, such that surgery brings improvements in symptoms and functions for a period of up to two years. PMID:27042635
Kelly, Marie; Jacobs, Dee; Wooten, Mary E.; Edeer, Ayse Ozcan
[Purpose] The purposes of this study were: 1) describe a hierarchy of electromyographic activity production, using percentage maximum voluntary contraction of lumbar iliocostalis and lumbar multifidus muscles during prone, quadruped and sitting exercises; and 2) identify optimal recruitment exercises for both lumbar iliocostalis as a global multi-segmental stabilizer and lumbar multifidus as a segmental stabilizer. [Subjects] Twelve healthy volunteers (six male and six female) aged 24 to 45 participated. [Methods] Surface electromyographic activity data were collected bilaterally from lumbar iliocostalis and lumbar multifidus muscles during exercises. [Results] Two-way ANOVA showed that prone extension, and prone alternate arm and leg lifting exercises produce a statistically significant difference in percent maximum voluntary contraction of lumbar iliocostalis and lumbar multifidus bilaterally compared to other exercises. Quadruped alternate arm and leg lifting exercises produce greater activity in lumbar multifidus muscle than sitting exercises [Conclusion] Prone exercises generate the greatest electromyographic activity and may be the most effective exercises for strengthening both lumbar iliocostalis and lumbar multifidus muscles. Quadruped alternate arm and leg lifting produces electromyographic activity at the recommended percent maximum voluntary contraction for training the lumbar multifidus in its role as a segmental stabilizer and is an effective training exercise for this goal. PMID:27821968
Dos Santos, Manuel Filipe Dias; de Santa Barbara, Rita de Cassia
Congenital encephalocele is a neural tube defect characterized by a sac-like protrusion of the brain, meninges, and other intracranial structures through the skull, which is caused by an embryonic development abnormality. The most common location is at the occipital bone, and its incidence varies according to different world regions. We report a case of an 1-month and 7-day-old male child with a huge interparietal-posterior fontanel meningohydroencephalocele, a rare occurrence. Physical examination and volumetric computed tomography were diagnostic. The encephalocele was surgically resected. Intradural and extradural approaches were performed; the bone defect was not primarily closed. Two days after surgery, the patient developed hydrocephaly requiring ventriculoperitoneal shunting. The surgical treatment of the meningohydroencephalocele of the interparietal-posterior fontanel may be accompanied by technical challenges and followed by complications due to the presence of large blood vessels under the overlying skin. In these cases, huge sacs herniate through large bone defects including meninges, brain, and blood vessels. The latter present communication with the superior sagittal sinus and ventricular system. A favorable surgical outcome generally follows an accurate strategy taking into account individual features of the lesion. PMID:26484324
Opdam, N.J.M.; van de Sande, F.H.; Bronkhorst, E.; Cenci, M.S.; Bottenberg, P.; Pallesen, U.; Gaengler, P.; Lindberg, A.; Huysmans, M.C.D.N.J.M.; van Dijken, J.W.
The aim of this meta-analysis, based on individual participant data from several studies, was to investigate the influence of patient-, materials-, and tooth-related variables on the survival of posterior resin composite restorations. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a search resulting in 12 longitudinal studies of direct posterior resin composite restorations with at least 5 years’ follow-up. Original datasets were still available, including placement/failure/censoring of restorations, restored surfaces, materials used, reasons for clinical failure, and caries-risk status. A database including all restorations was constructed, and a multivariate Cox regression method was used to analyze variables of interest [patient (age; gender; caries-risk status), jaw (upper; lower), number of restored surfaces, resin composite and adhesive materials, and use of glass-ionomer cement as base/liner (present or absent)]. The hazard ratios with respective 95% confidence intervals were determined, and annual failure rates were calculated for subgroups. Of all restorations, 2,816 (2,585 Class II and 231 Class I) were included in the analysis, of which 569 failed during the observation period. Main reasons for failure were caries and fracture. The regression analyses showed a significantly higher risk of failure for restorations in high-caries-risk individuals and those with a higher number of restored surfaces. PMID:25048250
Hegazy, Abdelmonem A; Hegazy, Raafat A
Despite the increasing recognition of the functional and clinical importance of lumbar lordosis, little is known about its description, particularly in Egypt. At the same time, magnetic resonance imaging (MRI) has been introduced as a noninvasive diagnostic technique. The aim of this study was to investigate the anatomy of the lumbar lordosis using midsagittal MRIs. Normal lumbar spine MRIs obtained from 93 individuals (46 males, 47 females; 25-57 years old) were evaluated retrospectively. The lumbar spine curvature and its segments "vertebrae and discs" were described and measured. The lumbar lordosis angle (LLA) was larger in females than in males. Its mean values increased by age. The lumbar height (LH) was longer in males than in females. At the same time, the lumbar breadth (LB) was higher in females than in males. Lumbar index (LI = LB/LH × 100) showed significant gender differences (P < 0.0001). Lordosis was formed by wedging of intervertebral discs and bodies of lower lumbar vertebrae. In conclusion, MRI might clearly reveal the anatomy of the lumbar lordosis. Use of LI in association with LLA could be useful in evaluation of lumbar lordosis.
Huang, Zhe-yuan; Ding, Zhen-qi; Liu, Hao-yuan; Fang, Jun; Liu, Hui; Sha, Mo
Background: Anterior decompression and reconstruction have gained wide acceptance as viable alternatives for unstable mid-lumbar burst fracture, but there are no mid and long term prospective studies regarding clinical and radiologic results of mid-lumbar burst fractures. Materials and Methods: An Institutional Review Board-approved prospective study of 56 consecutive patients of mid-lumbar burst fractures with a load-sharing score of 7 or more treated with anterior plating was carried out. All patients were evaluated for radiologic and clinical outcomes. The fusion status, spinal canal compromise, segmental kyphotic angle (SKA), vertebral body height loss (VBHL), and adjacent segment degeneration was examined for radiologic outcome, whereas the American Spinal Injury Association scale, the visual analog scale (VAS), and the employment status were used for clinical evaluation. Results: The patients underwent clinical and radiologic followup for at least 5 years after the surgery. At the last followup, there was no case of internal fixation failure, adjacent segment degeneration, and other complications. Interbody fusion was achieved in all cases. The average fusion time was 4.5 months. No patient suffered neurological deterioration and the average neurologic recovery was 1.3 grades on final observation. Based on VAS pain scores, canal compromise, percentage of VBHL and SKA, the difference was statistically significant between the preoperative period and postoperative or final followup (P < 0.05). Results at postoperative and final followup were better than the preoperative period. However, the difference was not significant between postoperative and final followup (P > 0.05). Thirty-four patients who were employed before the injury returned to work after the operation, 15 had changed to less strenuous work. Conclusion: Good mid term clinicoradiological results of anterior decompression with D-rod and titanium mesh fixation for suitable patients with mid-lumbar
Beguiristain, J L; Arriola, F J; Leyes, M
We report a case of pycnodysostosis in which several clefts in the laminas, interarticular parts, and pedicles of the whole lumbar spine were revealed for the first time on CT. We review similar findings in the literature, and discuss their pathogenesis.
Pappalardo, S; Cassarino, A; Braidotti, P
Arachnoid cysts are a rare cause of compression of the contents of the lumbar spinal canal; in the literature only about 100 cases are reported. The various methods of diagnosis are discussed in the light of a recent case observed by the authors.
García, Elena; Sánchez, Raquel; Martínez, Guillermo; Bernal, Carmen; Calatayud, M; Partida, M; Hawkins, Federico
Many problems may arise when defining whether adrenal lesions are primary to the adrenal glands or represent other tissue, whether they are benign or malignant and whether they are functioning or nonfunctioning. Adrenal imaging complements the clinical and hormonal evaluation of these patients. We present a patient with lumbar pain and bilateral adrenal masses.
Bhagat, Shaishav; Rai, Am S.
With an increasingly aging population, adult spinal deformity is becoming more common. This can be associated with increased morbidity. Results from multicentre studies of deformity surgery correction confirm complication rates as high as 40 percent. Most often a bad result is associated with inadequate restoration of the sagittal balance. Posterior vertebral body resection has been described as a method to correct significant deformity, but this is a complicated procedure. It is possible to do this in the thoracic spine where nerve roots can be sacrificed, but it is difficult in the lumbar spine due to the significant role of the lumbar nerve roots. We describe a safer technique for correction of deformity using a three stage process. This appears to be a good technique for revision surgery. PMID:27757434
Job, Joici; Branstetter, Barton F
The posterior skull base can be involved by a variety of pathologic processes. They can be broadly classified as: traumatic, neoplastic, vascular, and inflammatory. Pathology in the posterior skull base usually involves the lower cranial nerves, either as a source of pathology or a secondary source of symptoms. This review will categorize pathology arising in the posterior skull base and describe how it affects the skull base itself and surrounding structures.
Rubenstein, W.A.; Auh, Y.H.; Zirinsky, K.; Kneeland, J.B.; Whalen, J.P.; Kazam, E.
Intraperitoneal compartments may extend posteriorly to the level of known retroperitoneal structures at several locations within the abdomen. These locations include the posterior subhepatic or hepatorenal space, the splenorenal space, the retropancreatic recess, the paracolic gutters, and the pararectal fossae. Because of their posterior location, fluid collections within these compartments may be mistaken radiologically for retroperitoneal masses. The sectional anatomy of these spaces and particularly their appearance on computed tomographic scans, are illustrated in this paper.
Moser, Brad R
Dancers spend a lot of time in the relevé position in demi-pointe and en pointe in their training and their careers. Pain from both osseous and soft tissue causes may start to occur in the posterior aspect of their ankle. This article reviews the potential causes of posterior ankle impingement in dancers. It will discuss the clinical evaluation of a dancer and the appropriate workup and radiographic studies needed to further evaluate a dancer with suspected posterior ankle impingement.
Riddell, J S; Hadian, M
The actions of group II muscle afferents projecting to the lower-lumbar (L6 and L7) segments of the cat spinal cord were investigated by recording the cord dorsum and focal synaptic field potentials evoked by electrical stimulation of hindlimb muscle nerves. Cord dorsum potentials recorded over the lower-lumbar segments were generally much smaller than those produced by group II afferents terminating within the midlumbar and sacral segments. Only group II afferents of tibialis posterior produced potentials with an amplitude (mean maximal amplitude 39 μV, n = 7) approaching that of potentials over other segments. Focal synaptic potentials (mean maximal amplitudes 135–200 μV) were evoked by group II afferents of the following muscle nerves, listed in order of effectiveness: quadriceps, tibialis posterior (throughout L6 and L7), gastrocnemius soleus, flexor digitorum longus, posterior biceps-semitendinosus and popliteus (mainly within L7). Field potentials were recorded in the dorsal horn (laminae IV–V) and also more ventrally in a region which included the lateral part of the intermediate zone (lateral to the large group I intermediate field potentials) and often extended into the ventral horn (laminae V–VII). The latencies of the group II potentials are considered compatible with the monosynaptic actions of the fastest conducting group II muscle afferents. The results are compared with morphological evidence on the pattern of termination of group II muscle afferents in the lower-lumbar segments and with previous descriptions of the actions of group II muscle afferents in midlumbar and sacral segments. PMID:10618155
Kim, Yong-Chul; Bahk, Jae-Hyon; Lee, Sang-Chul; Lee, Youn-Woo
This study examined the net changes in temperature at various regions of the lower extremities in an attempt to identify the regions demonstrating the most significant temperature changes following a lumbar sympathetic ganglion block (LSGB). Thermography was performed before and after the LSGB in 26 sympathetic nerve system disorder cases. The inspection points were the anterior and posterior surfaces of the thigh, the knee and leg, and the dorsal and plantar surfaces of the feet. The net increases in skin temperature following the LSGB (deltaT(net)) at the plantar and dorsal surfaces of the feet, were 6.2 +/- 2.68 degrees C (mean +/- SD) and 3.9 +/- 1.89 degrees C, respectively, which were higher than those observed in the other regions of the lower extremities (p < 0.05). The areas, in order of decreasing deltaT(net), are as follows: the plantar surface of the foot, the dorsal surface of the foot, the shin, the anterior surface of the knee, the calf, the posterior surface of the knee, the anterior surface of the thigh, and the posterior surface of the thigh. There was one case of orthostatic hypotension during the thermography procedure. In conclusion, thermographic imaging is a useful method for demonstrating the success of a LSGB in various diseases. An evaluation of the deltaT(net) on the plantar surface of the feet using thermographic imaging is the most effective, simple, and safe method for assessing a successful LSGB.
Cho, Igsoo; Jeon, Chunbae; Lee, Sangyong; Lee, Daehee; Hwangbo, Gak
[Purpose] This study examined the effects of lumbar stabilization exercises on the functional disability and lumbar lordosis angles in patients with chronic low back pain. [Subjects] The subjects were 30 patients with chronic low back pain divided into a lumbar stabilization exercise group (n = 15) and a conservative treatment group (n = 15). [Methods] The lumbar stabilization exercise and conservative treatment groups performed an exercise program and conservative physical treatment, respectively. Both programs were performed 3 times a week for 6 weeks. The degree of functional disability was assessed by the Oswestry disability index, and lumbar lordosis angles were measured by plain radiography. [Results] The Oswestry disability index decreased significantly in the both groups; however, it was significantly lower in the lumbar stabilization exercise group. The lumbar lordosis angle increased significantly in the lumbar stabilization exercise group after treatment and was also significantly greater than that in the conservative treatment group. [Conclusion] Lumbar stabilization exercise is more effective than conservative treatment for improving functional disability and lumbar lordosis angles. PMID:26180363
Komesu, Yuko M.; Rogers, Rebecca G.; Kammerer-Doak, Dorothy N.; Barber, Matthew D.; Olsen, Ambre L.
OBJECTIVE The purpose of this study was to determine the effect of posterior repair (PR) on sexual function in patients who have undergone incontinence and/or pelvic reconstructive surgery. STUDY DESIGN A cohort study of women who underwent incontinence and/or prolapse surgery was performed. Participants completed the pelvic organ prolapse urinary incontinence sexual questionnaire (PISQ) before and after the operation. PISQ scores were compared between women who underwent PR and women who did not. RESULTS Of 73 study participants, 30 women underwent PR; 43 women did not (no PR). Although there was no difference in dyspareunia between groups pre-op, dyspareunia prevalence post-op was significantly lower in the no PR group. Preoperative PISQ scores were similar between groups. After the operation, both groups significantly improved their PISQ scores, without a difference between groups. CONCLUSION Although the incidence of dyspareunia differed between PR and no PR groups, overall improvement in sexual function was reflected in improved total PISQ scores that occurred irrespective of PR performance. PMID:17618777
Sundararajan, Srini; Prasad, Priya; Rouhana, Stephen W; Demetropoulos, Constantine K; Yang, King H; King, Albert I; Nolte, Lutz P
The purpose of this study was to determine the characteristics of eighteen lumbar spine motion segments subjected to lateral shear forces under quasi-static (0.5 mm/s) and dynamic (500 mm/s) test conditions. The quasi-static test was also performed on the lumbar spine of a side impact anthropomorphic test device, the EuroSID-2 (ES-2). In the quasi-static tests, the maximum force before disc-endplate separation in the PMHS lumbar motion segments was 1850 +/- 612 N, while the average linear stiffness of PMHS lumbar motion segments was 323 +/- 126 N/mm. There was a statistically significant difference between the quasi-static (1850 +/- 612 N) and dynamic (2616 +/- 1151 N) maximum shear forces. The ES-2 lumbar spine (149 N/mm) was more compliant than the PMHS lumbar segments under the quasi-static test condition.
Riedemann-Wistuba, M; Alonso-Pérez, M; Llaneza-Coto, J M
Although there are currently less invasive techniques available for the treatment of spinal injuries, open surgery is still required in many cases. Vascular injuries occurring during lumbar spine surgery, although uncommon, are of great importance due to their potential gravity. Clinical manifestations vary from an acute hemorrhagic shock that needs urgent treatment to save the patient's life, to insidious injuries or an asymptomatic evolution, and should be studied to choose the best therapeutic alternative. Four cases are reported that represent this range of possibilities and emphasize the importance of a careful surgical technique during lumbar spine interventions, and the need for high clinical suspicion, essential for the early diagnosis of these vascular complications. The current therapeutic options are also discussed.
Radło, Paweł; Smetkowski, Andrzej; Tesiorowski, Maciej
Lumbar disc herniation is one of the most common damage of musculoskeletal system. The incidence of pain of lumbosacral spine is estimated approximately on 60-90% in general population, whereas the incidence of disc herniation in patients experiencing low back pain is about 91%. Despite the high incidence and uncomplicated pathogenesis of disc disease there is a problem with the nomenclature. In the vast majority of cases, the naming confusion stems from ignorance of the etiology of low back pain. Different terminologies: morphological, topographical, Radiological and Clinical are used interchangeably. In addition, diagnosis is presented in a variety of languages: Polish, English and Latin. Moreover, the medical and traditional language are used alternately. The authors found in Polish literature more, than 20 terms to describe lumbar disc herniation. All of these terms in the meaning of the authors are used to determine one pathology--mechanical damage to the intervertebral disc and moving the disc material beyond the anatomical area.
Kawaguchi, Masahiko; Ishikawa, Norihiko; Shimizu, Satsuki; Shin, Hisato; Matsunoki, Aika; Watanabe, Go
Single Incision Endoscopic Surgery (SIES) has emerged as a less invasive surgery among laparoscopic surgeries, and this approach for incisional hernia was reported recently. This is the first report of SIES for an incisional lumbar hernia. A 66-year-old Japanese woman was referred to our institution because of a left flank hernia that developed after left iliac crest bone harvesting. A 20-mm incision was created on the left side of the umbilicus and all three trocars (12, 5, and 5 mm) were inserted into the incision. The hernial defect was 14 × 9 cm and was repaired with intraperitoneal onlay mesh and a prosthetic graft. The postoperative course was uneventful. SIES for lumbar hernia offers a safe and effective outcome equivalent compared to laparoscopic surgery. In addition, SIES is less invasive and has a cosmetic benefit.
Siambanes, David; Kposowa, Augustine J; Michelsen, Steven
The results of lumbar diskography at post-diskectomy and nonoperative disk levels in postoperative patients and patients without prior back surgery were reviewed over 3 years. Other possible predictive factors, including disk degeneration (per the Adam's classification), end-point resistance, gender, and age, also were reviewed. The results revealed that no statistically significant association was noted between the presence of a prior diskectomy and the outcome of diskography. However, disk degeneration classified as ruptured and fissured correlated statistically with positive diskography. Additionally, age between 30 and 39 years and male gender were statistically associated with a positive diskogram. Disk levels displaying a poor end point during diskography injection (not amendable to pressurization) were statistically related to ruptured or fissured disk levels and thus positive diskography. Based on these results, the assumption that disabling low-back pain presenting after lumbar procedure is due to diskogenic disease arising from the surgical level is not supported.
Singleton, Alex; Agarwal, Vikas; Casagranda, Bethany; Hughes, Marion A; Rothfus, William E
Our patient, a 22-year-old starting wide receiver for an NCAA Division I football team, presented with low back pain and sciatica. A lumbar-spine MRI without contrast demonstrated findings suspicious for discal cyst. The patient was referred for surgery, and the lesion was resected. The rarity of discal cyst makes it difficult to diagnose because most radiologists are not aware of the entity. An organized approach to diagnosis can facilitate appropriate management.
Wortzman, G.; Steinhardt, M.I.
Three patients who had a diagnosis of congenitally absent lumbar pedicle underwent CT examination. Findings showed that each patient had an aberrant hypoplastic pedicle plus a retroisthmic defect in their ipsilateral lamina rather than an absent pedicle. Axial CT was the diagnostic modality of choice; reformated images were of little value. The differential diagnosis to be considered from the findings of plain film radiography includes pediculate thinning, neoplastic disease, neurofibroma, mesodermal dysplasia associated with neurofibromatosis, and vascular anomalies.
Man's quest for recognition has not escaped the physician, whose contributions to medicine perpetuate his name in print. It is a final grasp for professional immortality, which for men like Imhotep and Hippocrates, has prevailed for millennia. This fervor was particularly evident in the latter 19th century, which created a flurry of eponyms, often two or more physicians publishing the same clinical observation. This article reviews the eponym epidemic as it relates to lumbar radiculopathy.
Gatti, P; Valat, J P; Videgrain, M
From a series of 400 cases of lumbar spine phlebography by selective catheterisation, 4 serious thrombo-embolic episodes were observed, including 2 cases of severe pulmonary embolism which responded favourably to medical treatment. In 3 cases, risk factors were found (prolonged immobilisation in bed, past history of phlebitis). One case developed severe phlebitis of the lower limbs despite prophylactic treatment with low dose calcium heparin. In the other cases, no anti-coagulant therapy was prescribed before or during the examination.
Daly, Frank J; Bolender, David L; Jain, Deepali; Uyeda, Sheryl; Hoagland, Todd M
Integrated medical curricular changes are altering the historical regional anatomy approach to abdominal dissection. The renal system is linked physiologically and biochemically to the cardiovascular and respiratory systems; yet, anatomists often approach the urinary system as part of the abdomen and pelvic regions. As part of an integrated curriculum, the renal system must be covered relatively quickly after the thorax in the cadaver laboratory, often without the opportunity to fully appreciate the rest of the abdominal contents. This article provides dissection instructions that follow one of the historical surgical approaches for nephrectomy, including preservation of the posterior abdominal wall neurovasclature. Dissection procedures were developed for first-year medical students, intending this posterior approach to the kidneys to be their first introduction to the renal system. It has been successfully implemented with the first-year medical students at the University of New England, College of Osteopathic Medicine. Utilizing this posterior approach to the kidney enabled the study of the anatomy of the kidneys, suprarenal glands, and renal vessels, as well as the muscles of the lumbar spine, while maintaining the integrity of the anterior abdominal wall and peritoneal cavity for future gastrointestinal and reproductive system-based dissections.
markers 14 – 16 , 18 and ground force plates 7 , 18 , 19 to measure body positioning and ground reac- tion forces . These methods approach...data obtained in this setting do not refl ect the state of the lumbar spine in the upright position due to alterations in bone- muscle interactions...lumbar spine might be related to the greater forces acting on inferior levels through the lumbar spine 38 and that IVDs of inferior levels undergo
Sparrey, Carolyn J; Bailey, Jeannie F; Safaee, Michael; Clark, Aaron J; Lafage, Virginie; Schwab, Frank; Smith, Justin S; Ames, Christopher P
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.
Bellini, Chiara M.; Zweig, Thomas; Ferguson, Stephen; Raimondi, Manuela T.; Lamartina, Claudio; Brayda-Bruno, Marco; Fornari, Maurizio
The implantation of lumbar disc prostheses based on different design concepts is widely accepted. This paper reviews currently available literature studies on the biomechanics of TDA in the lumbar spine, and is targeted at the evaluation of possible relationships between the aims of TDA and the geometrical, mechanical and material properties of the various available disc prostheses. Both theoretical and experimental studies were analyzed, by a PUBMED search (performed in February 2007, revised in January 2008), focusing on single level TDA. Both semi-constrained and unconstrained lumbar discs seem to be able to restore nearly physiological IAR locations and ROM values. However, both increased and decreased ROM was stated in some papers, unrelated to the clinical outcome. Segmental lordosis alterations after TDA were reported in most cases, for both constrained and unconstrained disc prostheses. An increase in the load through the facet joints was documented, for both semi-constrained and unconstrained artificial discs, but with some contrasting results. Semi-constrained devices may be able to share a greater part of the load, thus protecting the surrounding biological structure from overloading and possible early degeneration, but may be more susceptible to wear. The next level of development will be the biomechanical integration of compression across the motion segment. All these findings need to be supported by long-term clinical outcome studies. PMID:18946684
Caralopoulos, Ilias N.; Bui, Cuong J.
Background Degenerative lumbar stenosis associated with spondylolisthesis is common in elderly patients. The most common symptoms are those of neurogenic claudication with leg pain. Surgery is indicated for those who fail conservative management. The generally accepted recommendation is to perform a laminectomy and a fusion at the involved level. Methods We reviewed our results for minimally invasive single-level decompression without fusion performed by the senior author in patients with symptomatic lumbar stenosis with spondylolisthesis with no dynamic instability from 2008 to 2011 at a single institution. Outcomes were measured using the visual analog scale (VAS), Prolo Economic Functional Rating Scale, and revised Oswestry Disability Index (ODI) at initial presentation and at 3-month, 6-month, and 1-year follow-up time points. Results Records for 28 patients (19 males, 9 females) were reviewed. The success rate, defined as improvement in pain and functional outcome without the need for surgical fusion, was 86%. VAS scores decreased by 6.3 points, Prolo scores increased by 3.5 points, and the ODI decreased by 31% at 1 year. All changes were statistically significant. Conclusion Minimally invasive decompression alone can be a reasonable alternative to decompression and fusion for patients with spondylolisthetic lumbar stenosis and neurogenic claudication with leg pain. Decompression without fusion should be considered for older patients and for patients who are not ideal fusion candidates. PMID:24688331
Tschen, Jaime A.
Background: The absence or loss of elastic fibers in the skin is referred to as dermal elastolysis. Purpose: This paper describes a woman with a distinctive clinical presentation of mid-dermal elastolysis characterized morphologically by multiple horizontal raised bands on the lower back. Methods: A 20-year-old Filipino woman presented with multiple asymptomatic, flesh-colored, raised, firm, linear, cord-like bands on the lumbar area of her back. There were neither similar lesions elsewhere nor a family member with this condition. Results: Microscopic examination of the raised band showed nearly complete absence of elastic fibers in the mid dermis. In contrast, a biopsy of symmetrically located normal-appearing skin showed a uniform distribution of elastic fibers throughout the dermis. Linear lumbar localized elastolysis is a descriptive designation that accurately reflects a correlation of the clinical and pathological changes of this condition. Conclusion: The clinical differential of raised horizontal cord-like bands on the lower back (without a family history of an inherited elastic fiber disorder, a prior history of trauma, or a significant change in weight or exercise habit) includes linear focal elastosis and linear lumbar localized elastolysis. Microscopic evaluation of a Verhoeff-van Gieson stained lesion specimen (which may be accompanied by a biopsy of normal-appearing skin for comparison) will readily differentiate these conditions. The former is usually characterized by increased elastic fibers, whereas the latter, as in this patient, shows a paucity or absence of elastic fibers in the mid dermis. PMID:23882313
Guppy, Kern H; Silverthorn, James W; Akins, Paul T
Intrathecal spinal catheters (lumbar drains) are indicated for several medical and surgical conditions. In neurosurgical procedures, they are used to reduce intracranial and intrathecal pressures by diverting CSF. They have also been placed for therapeutic access to administer drugs, and more recently, vascular surgeons have used them to improve spinal cord perfusion during the treatment of thoracic aortic aneurysms. Insertion of these lumbar drains is not without attendant complications. One complication is the shearing of the distal end of the catheter with a resultant retained fragment. The authors report the case of a 65-year-old man who presented with a subarachnoid hemorrhage due to the migration of a retained lumbar drain that sheared off during its removal. To the best of the authors' knowledge, this is the first case of rostral migration of a retained intrathecal catheter causing subarachnoid hemorrhage. The authors review the literature on retained intrathecal spinal catheters, and their findings support either early removal of easily accessible catheters or close monitoring with serial imaging.
The most common complication after lumbar discectomy is reherniation. As the first step in reducing the rate of recurrence, many studies have been conducted to find out the factors that may increase the reherniation risk. Some reported factors are age, sex, the type of lumbar disc herniation, the amount of fragments removed, smoking, alcohol consumption and the length of restricted activities. In this review, the factors studied thus far are summarized, excepting factors which cannot be chosen or changed, such as age or sex. Apart from the factors shown here, many other risk factors such as diabetes, family history, history of external injury, duration of illness and body mass index are considered. Few are agreed upon by all. The reason for the diverse opinions may be that many clinical and biomechanical variables are involved in the prognosis following operation. For the investigation of risk factors in recurrent lumbar disc herniation, large-scale multicenter prospective studies will be required in the future. PMID:24761206
Maroufi, Nader; Behtash, Hamid; Zekavat, Hajar; Parnianpour, Mohamad
The study design is a prospective, case–control. The aim of this study was to develop a reliable measurement technique for the assessment of lumbar spine kinematics using digital video fluoroscopy in a group of patients with low back pain (LBP) and a control group. Lumbar segmental instability (LSI) is one subgroup of nonspecific LBP the diagnosis of which has not been clarified. The diagnosis of LSI has traditionally relied on the use of lateral functional (flexion–extension) radiographs but use of this method has proven unsatisfactory. Fifteen patients with chronic low back pain suspected to have LSI and 15 matched healthy subjects were recruited. Pulsed digital videofluoroscopy was used to investigate kinematics of lumbar motion segments during flexion and extension movements in vivo. Intersegmental linear translation and angular displacement, and pathway of instantaneous center of rotation (PICR) were calculated for each lumbar motion segment. Movement pattern of lumbar spine between two groups and during the full sagittal plane range of motion were analyzed using ANOVA with repeated measures design. Intersegmental linear translation was significantly higher in patients during both flexion and extension movements at L5–S1 segment (p < 0.05). Arc length of PICR was significantly higher in patients for L1–L2 and L5–S1 motion segments during extension movement (p < 0.05). This study determined some kinematic differences between two groups during the full range of lumbar spine. Devices, such as digital videofluoroscopy can assist in identifying better criteria for diagnosis of LSI in otherwise nonspecific low back pain patients in hope of providing more specific treatment. PMID:19727854
Wen, Bingtao; Zhang, Xifeng; Zhang, Lin; Huang, Peng; Zheng, Guoquan
Abstract This study aimed to evaluate the safety and curative effect of percutaneous endoscopic transforaminal lumbar spinal canal decompression in the treatment of lumbar spinal stenosis. This retrospective study recruited 64 patients with lumbar spinal stenosis who underwent percutaneous endoscopic lumbar spinal canal decompression via surgical approach of posterolateral intervertebral foramen. The postoperation neurological function and pain status were evaluated by the visual analog scale (VAS) score of pain and the Oswestry disability index (ODI), and the patient satisfaction was evaluated according to the MacNab outcome criteria. The data, including preoperative comorbidities, operation time, the quantity of bleeding, bed rest time, and intraoperative and postoperative complications, were recorded. The mean operation time was 78 min, the mean quantity of bleeding was 20 mL and bed rest time was 6 h to 3 days. All patients were followed-up for 4 months to 5 years. The mean preoperative VAS score was 7.7 ± 1.2, while postoperative 3 months, 6 months, and final follow-up VAS scores were 2.8 ± 0.7, 2.1 ± 0.6, and 0.8 ± 0.6, respectively (P < 0.001). The mean preoperative ODI score was 72.4 ± 1.2, while postoperative 3 months, 6 months, and final follow-up ODI scores were 29.7 ± 4.9, 23.9 ± 4.0, and 12.5 ± 3.9, respectively (P < 0.001). The excellent and good rate reached 73.4% at the final follow-up. The percutaneous endoscopic transforaminal lumbar spinal canal decompression is an easy, safe, and effective minimally invasive surgery for patients with lumbar spinal stenosis. PMID:27977571
Yang, Hae-sun; Yoo, Won-gyu
[Purpose] This study investigated the effect of stretching with lumbar traction on VAS and Oswestry scale scores of lumbar 4–5 herniated intervertebral disc (HIVD) patients. [Subjects] We recruited 20 lumbar 4–5 HIVD patients. [Methods] We performed stretching with lumbar traction for lumbar 4–5 HIVD patients during 4 weeks. The VAS and Oswestry scales were measured before and 4 weeks after the intervention. [Results] The results showed a significant decrease in VAS scale scores for stretching with lumbar traction in lumbar 4–5 HIVD patients, from 18±1.29 to 2.1±1.35. The Oswestry scale scores also decreased significantly, from 20.35±2.01 to 3.5±2.84, after stretching with lumbar traction. [Conclusion] Thus, we suggest stretching with lumbar traction for lumbar 4–5 HIVD patients. PMID:25140094
Wang, Naiguo; Wang, Dachuan; Wang, Feng; Tan, Bingyi; Yuan, Zenong
Abstract The objective of this study was to investigate short segment decompression of degenerative lumbar scoliosis (DLS) and the efficiency of fusion treatment. After DLS surgery, the patients were retrospectively reviewed using the VAS (visual analog scale) and ODI (Oswestry Disability Index) to assess clinical outcomes. All patients underwent posterior lumbar decompressive laminectomy, pedicle screw internal fixation, and posterolateral bone graft fusion surgery. Radiographic measurements included the scoliotic Cobb angle, the fused Cobb angle, the anterior intervertebral angle (AIA), the sagittal intervertebral angle (SIA), and lumbar lordosis angle. The relationships between these parameters were examined by bivariate Pearson analysis and linear regression analysis. Preoperatively, the Cobb angle at the scoliotic segment was 15.4°, which decreased to 10.2° immediately following surgery (P < 0.05). The AIA significantly increased by the last follow-up (4.4 ± 3.4) compared with pre- and postoperative values (2.5 ± 2.8 and 2.2 ± 2.4, respectively; P < 0.05). However, the scoliotic Cobb angle and the AIA did not correlate with the VAS or ODI scores. At the final follow-up, no patients had pseudoarthrosis or internal instrumentation-related complications. Short fusion surgical treatment results in limited DLS correction, with correction loss over time. The AIA between the upper adjacent segment and proximal fused vertebra continues to increase postoperatively, which does not exacerbate clinical symptoms, as reflected by the low reoperation rates for repairing degeneration at adjacent levels. PMID:26632679
Lovi, Alessio; Brayda-Bruno, Marco; Zagra, Antonino; Corriero, Andrea; Giudici, Fabrizio; Minoia, Leone
Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18–65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy. PMID:20127495
Ramaswamy, Vijay; Taylor, Michael D
Posterior fossa ependymoma comprises two distinct molecular entities, ependymoma_posterior fossa A (EPN_PFA) and ependymoma_posterior fossa B (EPN_PFB), with differentiable gene expression profiles. As yet, the response of the two entities to treatment is unclear. To determine the relationship between the two molecular subgroups of posterior fossa ependymoma and treatment, we studied a cohort of 820 patients with molecularly profiled, clinically annotated posterior fossa ependymomas. We found that the strongest predictor of poor outcome in patients with posterior fossa ependymoma across the entire age spectrum was molecular subgroup EPN_PFA, which was recently reported in the paper entitled "Therapeutic impact of cytoreductive surgery and irradiation of posterior fossa ependymoma in the molecular era: a retrospective multicohort analysis" in the Journal of Clinical Oncology. Patients with incompletely resected EPN_PFA tumors had a very poor outcome despite receiving adjuvant radiation therapy, whereas a substantial proportion of patients with EPN_PFB tumors can be cured with surgery alone.
Cotes, Claudia; Bonfante, Eliana; Lazor, Jillian; Jadhav, Siddharth; Caldas, Maria; Swischuk, Leonard
The classification of posterior fossa congenital anomalies has been a controversial topic. Advances in genetics and imaging have allowed a better understanding of the embryologic development of these abnormalities. A new classification schema correlates the embryologic, morphologic, and genetic bases of these anomalies in order to better distinguish and describe them. Although they provide a better understanding of the clinical aspects and genetics of these disorders, it is crucial for the radiologist to be able to diagnose the congenital posterior fossa anomalies based on their morphology, since neuroimaging is usually the initial step when these disorders are suspected. We divide the most common posterior fossa congenital anomalies into two groups: 1) hindbrain malformations, including diseases with cerebellar or vermian agenesis, aplasia or hypoplasia and cystic posterior fossa anomalies; and 2) cranial vault malformations. In addition, we will review the embryologic development of the posterior fossa and, from the perspective of embryonic development, will describe the imaging appearance of congenital posterior fossa anomalies. Knowledge of the developmental bases of these malformations facilitates detection of the morphological changes identified on imaging, allowing accurate differentiation and diagnosis of congenital posterior fossa anomalies. PMID:26246090
Pollock, R G; Bigliani, L U
Recurrent posterior glenohumeral instability is regarded as a difficult problem to diagnose and treat. A careful history and physical examination are the most helpful tools in making this diagnosis. A positive posterior stress test, demonstrable posterior subluxation, and a sulcus sign are frequently present on examination. Special roentgenographic studies, such as the computerized arthrotomography (arthro-CT) scan, may be used in cases in which plain roentgenographs suggest bony glenoid abnormalities. When conservative therapy fails, there is no consensus on the operative treatment. Procedures that address the soft tissues, such as capsulorrhaphy and posterior labral repair, as well as those that alter the bony geometry of the joint, such as posterior bone blocks and glenoid or humeral osteotomies, have been described. Capsular laxity is the most common pathologic finding in the authors' experience, and they favor the use of a posterior-inferior capsular shift procedure to correct this problem. Augmentation of the repair with a posterior bone block is reserved for unusual cases, such as when glenoid hypoplasia is present or in certain revision situations.
Mair, S D; Zarzour, R H; Speer, K P
Nine athletes (seven football offensive linemen, one defensive lineman, and one lacrosse player) were found at arthroscopy to have posterior labral detachment from the glenoid. In our series, this lesion is specific to contact athletes who engage their opponents with arms in front of the body. All patients had pain with bench pressing and while participating in their sport, diminishing their ability to play effectively. Conservative measures were ineffective in relieving their symptoms. Examination under anesthesia revealed symmetric glenohumeral translation bilaterally, without evidence of posterior instability. Treatment consisted of glenoid rim abradement and posterior labral repair with a bioabsorbable tack. All patients returned to complete at least one full season of contact sports and weightlifting without pain (minimum follow-up, > or = 2 years). Although many injuries leading to subluxation of the glenohumeral joint occur when an unanticipated force is applied, contact athletes ready their shoulder muscles in anticipation of impact with opponents. This leads to a compressive force at the glenohumeral joint. We hypothesize that, in combination with a posteriorly directed force at impact, the resultant vector is a shearing force to the posterior labrum and articular surface. Repeated exposure leads to posterior labral detachment without capsular injury. Posterior labral reattachment provides consistently good results, allowing the athlete to return to competition.
Takeshima, Yasuhiro; Takahashi, Toshiyuki; Hanakita, Junya; Watanabe, Mizuki; Kitahama, Yoshihiro; Kuraishi, Keita; Uesaka, Toshio; Minami, Manabu; Nakase, Hiroyuki
A 39-year-old man presented with an extremely rare discal cyst at the L3-4 level manifesting as a left L4 radiculopathy. Two months after onset, he suffered right L4 radiculopathy with new lumbar disc protrusion. Five months after medical treatment, the patient's symptoms improved, and the discal cyst showed complete regression on magnetic resonance imaging. Most cases of discal cyst are surgically treated, with only two previous cases of spontaneous regression. The present case suggests clinical and radiological recovery of symptomatic lumbar discal cyst can be obtained by only conservative therapy.
MATSUI, HIROKI; IMAGAMA, SHIRO; ITO, ZENYA; ANDO, KEI; HIRANO, KENICHI; TAUCHI, RYOJI; MURAMOTO, AKIO; MATSUMOTO, TOMOHIRO; ISHIGURO, NAOKI
ABSTRACT Spinal epidural hematoma (SEH) is an uncommon disorder, and chronic SEHs are rarer than acute SEHs. However, there is few reported involving the bone change of the vertebral body in chronic SEHs. We present a case report of lumbar epidural hematoma that required differentiation from extramedullary spinal tumors by a long process because the CT scan revealed scalloping of the vertebral body and review the relevant literature. A 78-year-old man had experienced a gradual onset of low back pain and excruciating pain in both legs. Lumbar MRI on T1-weighted images revealed a space-occupying lesion with a hyperintense signal relative to the spinal cord with no enhancement on gadolinium adminisration. Meanwhile, T2-weighted images revealed a heterogeneous intensity change, accompanying a central area of hyperintense signals with a hypointense peripheral border at the L4 vertebra. Moreover, the CT scan demonstrated scalloping of the posterior wall of the L4 vertebral body which is generally suspected as the CT finding of spainal tumor. During the epidural space exploration, we found a dark red-colored mass surrounded by a capsular layer, which was fibrous and adhered to the flavum and dura mater. Microscopic histological examination of the resected mass revealed a mixture of the relatively new hematoma and the hematoma that was moving into the connective tissue. Accordingly, the hematoma was diagnosed as chronic SEH. The particular MRI findings of chronic SEHs are helpful for making accurate preoperative diagnoses of this pathology. PMID:25130006
El-Kadi, Matt; Ibinson, James; Donovan, Erin; Sullivan, Dan; Kadi, Rayyan
Background: Current health care practices aim for cost reduction to achieve maximal benefit. Because of the increasing number of spinal fusions, this area has become a target for both hospitals and payment organizations. Length of stay (LOS) is one potentially modifiable variable to help reduce overall cost. Attempting to predict the LOS in spinal surgery based on patient factors has not revealed a set of variables that are consistently associated with increased stay. Methods: Medical records from all patients who underwent posterior lumbar spinal fusion by a single neurosurgeon at a single facility were retrospectively examined in a blind fashion. Data were obtained including age, gender, body mass index (BMI), American society of Anesthesiologists (ASA) and analyzed to determine a potential relationship with LOS. Results: A total of 1360 patients were identified for analysis. There were significant but small correlations between age, ASA, BMI, and LOS. Conclusions: There is an effect of age, ASA, and BMI on LOS. However, the significance of this effect is small. Future studies aiming to identify additional factors, which could potentially be modifiable, in order to work on decreasing LOS in lumbar spinal fusion patients. PMID:27843684
Yu, W Y; Siu, C M
Twenty six patients with seat belt injuries of the lumbar spine were admitted into the Spinal Cord Injury Unit of the University Hospital, University of British Columbia, in the past 10 years. Four patients with pure ligamentous injuries were primarily treated surgically. Sixteen patients were treated with closed methods with a Stryker frame followed by a body cast or brace. Significant angulation with spinal deformity occurred in 6 patients. The common factor of failure of closed treatment was the inadequate reduction of initial angulation. When the initial angulation at the fracture site was adequately reduced, closed methods were associated with satisfactory results with no serious disability seen in long term follow-up. Open reduction with fixation with compression rods or wiring and fusion invariably leads to good results. It is recommended that patients with seat belt fractures of the lumbar spine may be treated by a closed method provided good reduction is obtained initially, otherwise open reduction and posterior fusion is more preferable.
Serhan, Hassan; Mhatre, Devdatt; Defossez, Henri; Bono, Christopher M.
Over the past few decades, remarkable advancements in the understanding of the origin of low-back pain and lumbar spinal disorders have been achieved. Spinal fusion is generally considered the “gold standard” in the treatment of low-back pain; however, fusion is also associated with accelerated degeneration of adjacent levels. Spinal arthroplasty and dynamic stabilization technologies, as well as the continuous improvement in diagnosis and surgical interventions, have opened a new era of treatment options. Recent advancements in nonfusion technologies such as motion-preservation devices and posterior dynamic stabilization may change the gold standard. These devices are designed with the intent to provide stabilization and eliminate pain while preserving motion of the functional spinal unit. The adaption of nonfusion technologies by the surgical community and payers for the treatment of degenerative spinal conditions will depend on the long-term clinical outcome of controlled randomized clinical studies. Although the development of nonfusion technology has just started and the adoption is very slow, it may be considered a viable option for motion preservation in coming years. This review article provides technical and surgical views from the past and from the present, as well as a glance at the future endeavors and challenges in instrumentation development for lumbar spinal disorders. © 2011 SAS - The International Society for the Advancement of Spine Surgery. Published by Elsevier Inc. All rights reserved. PMID:25802672
Chen, Hsin-Chuan; Huang, Teng-Le; Chen, Yen-Jen; Tsou, Hsi-Kai; Lin, Wei-Ching; Hung, Chih-Hung; Tsai, Chun-Hao; Hsu, Horng-Chaung; Chen, Hsien-Te
This study evaluates the safety and effectiveness of computed tomography- (CT-) assisted endoscopic surgery in the treatment of infectious spondylodiscitis of the thoracic and upper lumbar spine in immunocompromised patients. From October 2006 to March 2014, a total of 41 patients with infectious spondylodiscitis underwent percutaneous endoscopic surgery under local anesthesia, and 13 lesions from 13 patients on the thoracic or upper lumbar spine were selected for evaluation. A CT-guided catheter was placed before percutaneous endoscopic surgery as a guide to avoid injury to visceral organs, major vessels, and the spinal cord. All 13 patients had quick pain relief after endoscopic surgery without complications. The bacterial culture rate was 77%. Inflammatory parameters returned to normal after adequate antibiotic treatment. Postoperative radiographs showed no significant kyphotic deformity when compared with preoperative films. As of the last follow-up visit, no recurrent infections were noted. Traditional transthoracic or diaphragmatic surgery with or without posterior instrumentation is associated with high rates of morbidity and mortality, especially in elderly patients, patients with multiple comorbidities, or immunocompromised patients. Percutaneous endoscopic surgery assisted by a CT-guided catheter provides a safe and effective alternative treatment for infectious spondylodiscitis of the thoracic and upper lumbar spine.
Dharmasaroja, Pornpatr; Dharmasaroja, Permphan
Meralgia paresthetica is a well-known sensory syndrome describing paresthesia and/or anesthesia in the anterolateral aspect of the thigh that is supplied by the lateral femoral cutaneous nerve. Compression of the nerve usually occurs at the point where it passes between the anterior superior iliac spine and the inguinal ligament. Proximal lesions such as lumbar radiculopathy, lumbar disc herniation, and spinal stenosis have been reported to cause meralgia paresthetica-like syndrome. These proximal lesions directly injure L2 and L3 spinal nerve roots and cause a constant compression of the nerve roots. The presented paper introduces a hypothesis that this syndrome can be caused by transient injury to the L2 and L3 nerve roots by the upper adjacent disc bulge without definite compression. This hypothesis is supported by lumbar spine magnetic resonance imaging of a patient presenting with a meralgia paresthetica-like symptom during bending forward and twisting of the body, showing no L2/L3 herniated disc but mildly posterior bulging of T12/L1 disc. This hypothesis emphasizes an importance of appropriate postures in patients with meralgia paresthetica-like symptoms in order to prevent long-term morbidity.
Hansson, Tommy; Suzuki, Nobuyuki; Hebelka, Hanna; Gaulitz, Arne
Load and activity changes of the spine typically cause symptoms of nerve root compression in subjects with spinal stenosis. Protrusion of the intervertebral disc has been regarded as the main cause of the compression. The objective was to determine the changes in the size of the lumbar spinal canal and especially those caused by the ligamentum flavum and the disc during loaded MRI. For this purpose an interventional clinical study on consecutive patients was made. The lumbar spines in 24 supine patients were examined with MRI: first without any external load and then with an axial load corresponding to half the body weight. The effect of the load was determined through the cross-sectional areas of the spinal canal and the ligamentum flavum, the thickness of ligamentum flavum, the posterior bulge of the disc and the intervertebral angle. External load decreased the size of the spinal canal. Bulging of the ligamentum flavum contributed to between 50 and 85% of the spinal canal narrowing. It was concluded that the ligamentum flavum, not the disc had a dominating role for the load induced narrowing of the lumbar spinal canal, a finding that can improve the understanding of the patho-physiology in spinal stenosis.
Adib F, Curtis C, Bienkowski P Micheli LJ. Posterior cruciate ligament sprain. In: Frontera WR, Silver JK, Rizzo TD Jr, eds. Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, ...
Georgiadis, G M; Aronson, D D
Posterior transfer of the tendon of the anterior tibial muscle through the interosseous membrane to the calcaneus to prevent or correct a calcaneus deformity was performed in twenty patients (thirty-nine feet) who had a myelomeningocele. The average age of the patients at the time of the operation was 4.6 years, and they were followed for an average of six years. Satisfactory clinical and radiographic results were obtained in thirty-seven (95 per cent) of the thirty-nine feet. Two patients, one who was unable to walk and one who walked at home only, had a mild equinus deformity of the left foot. No patient had a clinical calcaneus deformity, but there was radiographic evidence of talipes calcaneus in one patient (two feet). The anterior tibial muscle functioned more consistently when the operation was performed after the patient was four years old and in patients who had a fifth lumbar or first sacral motor level.
Naroji, Swetha; Belin, Laurence J; Maltenfort, Mitchell Gil; Vaccaro, Alexander R; Schwartz, Daniel; Harrop, James S; Weinstein, Michael
Background: Femoral nerve palsy is not a common adverse effect of lumbar spinal surgery. Objective: To report 3 unique cases of femoral nerve neuropathy due to instrumentation and positioning during complex anterior and posterior spinal surgery. Methods: Case series Results: All 3 patients demonstrated femoral nerve neuropathy. The first patient presented postoperatively but after 6 months, the palsy resolved. Femoral nerve malfunctioning was documented in the second and third patients intraoperatively; however, with rapid patient repositioning and removal of offending instrumentation, postoperative palsy was avoided. Conclusions: Use of motor evoked potential monitoring of the femoral nerve during surgery is vital for the prevention of future neuropathies, an avoidable complication of spinal surgery. PMID:19777866
Achcar and Smith (1989) shows that performance of the Laplace method is often very sensitive to parametrization. Morris (1988) offers expansions based on...Berkeley Symp. 1, 453-468. Lindley, D.V. (1980). "Approximate Bayesian Methods" in Bayesian Statistics, J.M. Bernardo, M.H. DeGroot , D.V. Lindley...A.F.M. Smith, University Press, Valencia, Spain. Morris , C. "Approximating Posterior Distributions and Posterior Moments" In: Bayesian Statistics 3, J.M
Rózsa, Anikó; Szilvássy, Ildikó; Kovács, Krisztina; Boór, Krisztina; Gács, Gyula
We present the characteristics of posterior cortical atrophy--a very rare cortical dementia--in a 69 year old woman's case. Our patient's symptoms began with a visual problem which was initially explained by ophthalmological disorder. After neurological exam visual agnosia was diagnosed apart from other cognitive disorder (alexia without agraphia, acalculia, prosopagnosia, constructional disorder, clock-time recognition disorder, dressing apraxia, visuospatial disorientation). The brain MRI showed bilateral asymmetric parieto-occipital atrophy which is characteristic of posterior cortical atrophy.
Dong, Xuanliang Neil; Pinninti, Rajeshwar; Tvinnereim, Amy; Lowe, Timothy; Di Paolo, David; Shirvaikar, Mukul
The purpose of this study was to provide a novel stochastic assessment of inhomogeneous distribution of bone mineral density (BMD) from the Dual-energy X-ray Absorptiometry (DXA) scans of human lumbar vertebrae and identify the stochastic predictors that were correlated with the microarchitecture parameters of trabecular bone. Eighteen human lumbar vertebrae with intact posterior elements from 5 cadaveric spines were scanned in the posterior-anterior projection using a Hologic densitometer. The BMD map of human vertebrae was obtained from the raw data of DXA scans by directly operating on the transmission measurements of low- and high-energy X-ray beams. Stochastic predictors were calculated by fitting theoretical models onto the experimental variogram of the BMD map, rather than grayscale images, from DXA scans. In addition, microarchitecture parameters of trabecular bone were measured from the 3D images of human vertebrae acquired using a Micro-CT scanner. Significant correlations were observed between stochastic predictors and microarchitecture parameters. The sill variance, representing the standard deviation of the BMD map to some extent, had significantly positive correlations with bone volume, trabecular thickness, trabecular number and connectivity density. The sill variance was also negatively associated with bone surface to volume ratio and trabecular separation. This study demonstrates that the stochastic assessment of the inhomogeneous distribution of BMD from DXA scans of human lumbar vertebrae can reveal microarchitecture information of trabecular bone. However, future studies are needed to examine the potential of stochastic predictors from routine clinical DXA scans in providing bone fragility information complementary to BMD.
Felbaum, Daniel R; Stewart, Jeffrey J; Sandhu, Faheem A
Objective: Tandem cervical and lumbar spinal stenosis (TSS) is classically described as intermittent claudication, gait disturbance, and clinical findings of mixed myelopathy and polyradiculopathy. Rarely, patients can present with TSS manifesting in isolated lumbar pain. Several reports have demonstrated improved lumbar back pain and radiculopathy after decompressive cervical spine procedures. We present six patients with dramatic resolution of lumbar spine related symptoms after decompression of the cervical spinal cord despite presenting solely with lower back complaints. Methods: Clinical records of the senior author (F.A.S.) gathered from April 2006 to March 2013 were retrospectively reviewed identifying six patients presenting solely with lumbar symptoms and diagnosed with TSS based on history and physical examination. Results: Six patients with a mean age of 55 (range 39 to 60) presented with solely lower back symptoms and clinical findings suspicious for TSS. Mean follow-up time for all patients was 12 months (range three to 27 months, median 11.5 months). Three patients underwent a cervical procedure as the principal operation, while the remainder had the lumbar spine decompressed initially. All patients that underwent a cervical procedure initially experienced a dramatic decrease or complete resolution of their preoperative lower back pain and radiculopathy (mean preoperative VAS of 6.7 vs. 3.7 postoperative). The remainder of patients with persistent lumbar symptoms resolved after a subsequent cervical operation. Conclusion: Patients presenting with lumbar symptoms out of proportion to imaging require further investigation. We highlight the resolution of lumbar symptoms after a cervical procedure in a select group of patients presenting with lone lower back complaints. In patients presenting with symptoms disproportionate to lumbar imaging, treatment of cervical pathology may provide robust long-term relief of the initial lumbar-related presentation
Zander, Thomas; Dreischarf, Marcel; Schmidt, Hendrik
The loads between adjacent vertebrae can be generalised as a single spatial force acting at the intervertebral centre of reaction. The exact position in vivo is unknown. However, in rigid body musculoskeletal models that simulate upright standing, the position is generally assumed to be located at the discs' centres of rotation. The influence of the antero-posterior position of the centre of reaction on muscle activity and joint loads remains unknown. Thus, by using an inverse dynamic model, we varied the position of the centre of reaction at L4/L5 (i), simultaneously at all lumbar levels (ii), and by optimisation at all lumbar levels (iii). Variation of the centres of reaction can considerably influence the activities of lumbar muscles and the joint forces between vertebrae. The optimisation of the position of the centre of reaction reduced the maximum lumbar muscle activity and axial joint forces at L4/L5 from 17.5% to 1.5% of the muscle strength and from 490 N to 390 N, respectively. Thus, when studying individual postures, such as for therapeutic or preventive evaluations, potential differences between the centre of reaction and the centre of rotation might influence the study results. These differences could be taken into account by sensitivity analyses.
Sureda-Gómez, Miquel; Pascual-Carreras, Eudald; Adell, Teresa
The wnt signaling pathway is an intercellular communication mechanism essential in cell-fate specification, tissue patterning and regional-identity specification. A βcatenin-dependent signal specifies the AP (Anteroposterior) axis of planarians, both during regeneration of new tissues and during normal homeostasis. Accordingly, four wnts (posterior wnts) are expressed in a nested manner in central and posterior regions of planarians. We have analyzed the specific role of each posterior wnt and the possible cooperation between them in specifying and patterning planarian central and posterior regions. We show that each posterior wnt exerts a distinct role during re-specification and maintenance of the central and posterior planarian regions, and that the integration of the different wnt signals (βcatenin dependent and independent) underlies the patterning of the AP axis from the central region to the tip of the tail. Based on these findings and data from the literature, we propose a model for patterning the planarian AP axis.
Kim, Ji Soo; Lee, Hyung
Stroke in the distribution of the posterior circulation may present as acute onset spontaneous vertigo and imbalance. Although vertigo due to posterior circulation stroke is usually associated with other neurologic symptoms or signs, small infarcts in the cerebellum or brainstem can present with vertigo without other localizing symptoms. Approximately 17% of patients with isolated posterior inferior cerebellar artery territory infarction presented with isolated vertigo, nystagmus, and postural unsteadiness. A head impulse test can differentiate acute isolated vertigo associated with cerebellar stroke from more benign disorders involving the inner ear. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the anterior inferior cerebellar artery). In this case, evaluation of isolated audiovestibular loss may prevent the progression of acute vertigo and hearing loss into more widespread areas of infarction in the posterior circulation. In this article, the clinical syndromes and signs of acute vestibular syndrome due to posterior circulation stroke involving the brainstem and cerebellum are summarized.
Kasahara, Satoshi; Miyamoto, Kenji; Takahashi, Mitsuhiko; Yamanaka, Masanori; Takeda, Naoki
This study assessed the relationship of each movement direction on the lumbar spine and on the pelvis in regards to lumbar-pelvic coordination in the sitting position. Lumbar and pelvic motions were recorded using a flexible electrogoniometer in 12 healthy subjects during two different tasks in the sitting position. The coordination of the lumbar spine and pelvis was evaluated using the ratio of lumbar and pelvic angles (L/P ratio hereafter) in three motion phases. There were significant differences in the L/P ratio values between during the "forward bending" and "rising from a forward flexed position" phases (P<0.01). The L/P ratio value ( approximately -0.7) was consistent during the movement from an erect to a slumped sitting position as the lumbar spine and pelvis moved in opposing directions. This study shows that lumbar-pelvic coordination occurs in the sitting position. Lumbar-pelvic coordination is confirmed even if the movement tasks are different in the sitting position, and these findings show that aspects of a particular movement are dependent on the given movement task. These findings may provide greater insight into the kinematic changes involved in lumber-pelvic coordination, and help clinicians implement sitting exercises conducive to the independence of the patient.
... 49 Transportation 7 2010-10-01 2010-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) ANTHROPOMORPHIC TEST DEVICES Side Impact Hybrid Dummy 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for...
Cho, Newton; Keith, Julia; Pirouzmand, Fahard
Lumbar discal cysts are rare entities causing radicular pain with unknown etiologies. We report a case of a 42-year-old man who developed radiculopathy secondary to a lumbar discal cyst. Our case sheds some light on anatomy, possible etiological association and clinical course which can help management.
... Lumbar spine flexure. (a) When subjected to continuously applied force in accordance with paragraph (b... degrees at a force level of not less than 18 pounds and not more than 22 pounds, and straighten upon removal of the force to within 5 degrees of its initial position. (b) Test procedure. (1) The lumbar...
... Lumbar spine flexure. (a) When subjected to continuously applied force in accordance with paragraph (b... degrees at a force level of not less than 18 pounds and not more than 22 pounds, and straighten upon removal of the force to within 5 degrees of its initial position. (b) Test procedure. (1) The lumbar...
Gabrielsen, T.O.; Gebarski, S.S.; Knake, J.E.; Latack, J.T.; Yang, P.J.; Hoff, J.T.
Lumbar myelography was performed in 50 patients; 25 received iohexol and 25 received metrizamide. The two media produced radiographs of equal quality. However, iohexol is stable in solution, while metrizamide is not. Further, markedly less morbidity resulted from iohexol. These features indicate that iohexol may be superior to metrizamide as a contrast agent for lumbar myelography.
Tzagarakis, George; Balalis, Konstantine; Papaioannou, Alexandra
The mobility of the spine and the change in the angle of the curvatures are directly related to spinal pain and spinal stenosis. The aim of the study was the evaluation of morphology and mobility of the spine in patients who were subjected to decompression and posterior fusion with pedicle screws. The treatment group consisted of 20 patients who underwent posterior fixation of lumbar spine (one and two level fusion). The control group consisted of 39 healthy subjects. Mobility and curvatures of the spine were measured with a non-invasive device, the Spinal Mouse. Pain was evaluated with the Visual Analogue Scale (VAS). The Oswestry Disability Index (ODI) and the SF-36 were used to evaluate the degree of the functional disability and the quality of life, respectively. The measurements were recorded preoperatively and at 3, 6 and 12 months postoperatively. The mobility of the lumbar spine in the sagittal plane increased (p = 0.009) at 12 months compared to the measurements at 3 months. The mobility of the thoracic spine in the frontal plane increased (p = 0.009) at 12 months compared to the preoperative evaluation. The results of VAS, ODI and SF-36 PCS improved significantly (p<0.001). The levels of fusion exhibited a strong linear correlation (r = 0.651, p = 0.002) with the total trunk inclination in the upright position. Although pain, quality of life and spinal mobility in the sagittal and frontal planes significantly improved in the treatment group, these patients still had limited mobility and decreased curves/angles values compared to control group. PMID:27513643
Boachie-Adjei, O; Dendrinos, G K; Ogilvie, J W; Bradford, D S
Twenty-five consecutive adult women with nonparalytic spinal deformity were treated with fusion to the sacrum. Two patients were lost to follow-up and one patient died, leaving 22 patients for review. All patients underwent a first-stage anterior spinal fusion without instrumentation followed by a second-stage posterior spinal fusion with Luque-Galveston instrumentation. The average age of the patients was 47 years (range, 25-64 years). The average follow-up was 39 months (range, 24-60 months). Ten patients had had previous surgery in the area of the instrumentation. The main indications were pain (22 patients), loss of sagittal plane balance (17 patients), and progression of the deformity (13 patients). Additional procedures included anterior corpectomies (five patients), anterior and posterior osteotomies (two patients), posterior osteotomies (eight patients), and posterior decompression (five patients). The average curve correction was 27% for thoracic scoliosis and 44% for lumbar scoliosis. Physiologic sagittal plane realignment was obtained in four patients who presented preoperatively with sagittal plane deformities. Pain improvement was reported in 14 of 22 (63%) patients. Nineteen (82%) patients had 34 complications. Pseudarthrosis occurred in nine patients (41%) and was successfully repaired in four; hence the fusion rate was 77% at follow-up. Of the 23 patients, one died from pulmonary embolism, 15 (66%) were in good condition, one (4%) was in fair condition, and seven (30%) were in poor condition. Previous surgery and additional procedures such as vertebrectomies or osteotomies did not adversely affect the outcome. There were no permanent neurologic deficits related to the instrumentation or the passage of sublaminar wires. The Luque-Galveston method provided correction of sagittal plane deformities and flatback syndrome.
Papadokostakis, Georgios; Stergiopoulos, Konstantinos; Kampanis, Nikos; Katonis, Pavlos
The curvature of the lumbar spine and the risk of developing either osteoporosis (OP) or osteoarthritis (OA) are influenced by many common factors. The aim of this study is to determine whether lumbar lordosis is different between patients with either disease and healthy persons. A cross-sectional, blinded, controlled design was implemented. One hundred and twelve postmenopausal women were evaluated for bone mineral density as well as undergoing spinal radiography. Lordosis measurement was performed with Cobb’s method. The sample was divided in four groups: patients with OP (n = 34, L1–L5 = 40.7°, L1–S1 = 54.1°), patients with OA (n = 29, L1–L5 = 38°, L1–S1 = 52.3°), patients with both diseases (n = 20, L1–L5 = 41.8°, L1–S1 = 52.3°) and controls (n = 29, L1–L5 = 38.6°, L1–S1 = 51.8°). For all participants age, height, weight, body mass index, physical activity level and basal metabolic rate were measured and recorded. The results revealed that although the four groups have significant constitutional differences, lumbar lordosis was comparable between them. The reasons for the lack of association are discussed. PMID:19089464
Introduction Low back pain is non-specific in 85% of population. Posterior-to-anterior (PA) mobilization and press-up exercises are common physical therapy interventions used to treat low back pain. Aim The purpose of this study was to investigate the effect of posterior-to-anterior spinal mobilization and prone press-ups in non-specific low back pain. Materials and Methods The study design was double blind randomized clinical trial. Forty participants reporting to Physiotherapy Out-patient department in hospital who were 18-45 years of age and had diagnosis of non-specific low back pain were included. Primary outcome measures were lumbar extension range, pain and physical function. Results Both interventions resulted in significant reduction in the average pain scores for both groups. Similarly, gain in total lumbar extension was significant in both the PA mobilization group and the press-up group. Functional scores significantly improved for both the groups. Both the groups significantly differed in terms of pain, lumbar extension and functional scores. PA mobilization proved to be a superior intervention. Conclusion PA mobilization and press-ups can be used as an effective intervention in non-specific low back pain. PMID:27134987
Kesan, Krushnakumar V; Gupta, Rahul Kumar; Kothari, Paras; Gupta, Abhaya; Mudkhedkar, Kedar; Kamble, Ravikiran; Dikshit, K Vishesh
Urethral polyp is a rare cause of bladder outlet obstruction, voiding dysfunction, and hematuria in the pediatric age group. Urethral polyps are rarely associated with other congenital urinary tract anomalies. In this study, we report a case of solitary posterior urethral polyp with type I posterior urethral valve in a 7-day-old neonate presented with urinary retention and deranged renal function. The polyp was diagnosed on cystoscopy. Transurethral resection of the polyp with posterior urethral valve fulguration was performed. Pathologic assessment revealed a fibroepithelial lesion, which was consistent with congenital posterior urethral polyp.
Petty, P G; Hudgson, P; Hare, W S
It is generally accepted that chronic adhesive lumbar arachnoiditis is a cause of symptoms, notably back pain and/or pain (of almost any type, not necessarily 'anatomical') in the lower limbs, although there is no clearly defined clinical pattern which is clearly associated with this syndrome. There is no doubt that arachnoiditis occurs as a pathological and radiological entity due to a number of causes. In the view of the present authors, the nexus between the pathology and radiology on the one hand, and the patients' symptoms on the other hand, has not been demonstrated with any degree of scientific rigor.
Mendez, Jorge S; Huete, Isidro L; Tagle, Patricio M
We evaluated the fractures of the lumbar and sacral vertebral limbus by disc impingement at the peripheral ring apophysis in 23 adults associated with trauma in 16 of them. Lumbalgia, radicular pain and narrow canal symptoms are the presenting forms of this underdiagnosed pathology. CT is the best method of examination, while plain roentgenograms and MR are usually negative. Accurate diagnosis and surgical technique with larger exposure are needed to resect the fractured fragments and protruded disc material for decompressing the roots and the dural sac. Our results were very good on the majority of cases.
Thomsen, Thomas Laden; Roeder, Ole
Avoiding exposure of extremities to cold combined with pharmacologic treatment usually suffice in the attempt to suppress the related symptoms of Raynaud's syndrome. This case report describes a severe case of Raynaud's syndrome affecting the lower extremities of a 16-year-old female. She was referred to a centre of vascular surgery with severe vasospasms of the feet. After failed attempts of pharmacologic treatment, a laparoscopic lumbar sympathectomy was performed with no complications and a slight reduction of symptoms three years post-surgically.
Cugati, Goutham; Pande, Anil; Jain, Pradeep K; Symss, Nigel Peter; Ramamurthi, Ravi; Vasudevan, Chakravarthy M
An aneurysmal bone cyst (ABC) is a benign, locally proliferative vascular disorder of non-neoplastic osseous lesions in children and young adults. Seventy-five percent of ABCs occur before the age of 20 years. They comprise 1.4% of all primary bone tumors, and commonly occur in the long bones. Spinal ABCs are much rarer. We present to you one such rare case of ABC involving the lumbar spine which was successfully treated with surgery. The clinical pathological and radiological features are described. The treatment options available are discussed.
González-Álvarez, Francisco J.; Valenza, Marie C.; Torres-Sánchez, Irene; Cabrera-Martos, Irene; Rodríguez-Torres, Janet; Castellote-Caballero, Yolanda
ABSTRACT Background Few studies have explored the effects of stretching techniques on diaphragm and spine kinematics. Objective To determine whether the application of diaphragm stretching resulted in changes in posterior chain muscle kinematics and ribcage and abdominal excursion in healthy subjects. Method Eighty healthy adults were included in this randomized clinical trial. Participants were randomized into two groups: the experimental group, which received a diaphragmatic stretching technique, or the placebo group, which received a sham-ultrasound procedure. The duration of the technique, the position of participants, and the therapist who applied the technique were the same for both treatments. Participant assessment (cervical range of movement, lumbar flexibility, flexibility of the posterior chain, and rib cage and abdominal excursion) was performed at baseline and immediately after the intervention by a blinded assessor. Results The mean between-group difference [95% CI] for the ribcage excursion after technique at xiphoid level was 2.48 [0.97 to 3.99], which shows significant differences in this outcome. The remaining between-group analysis showed significant differences in cervical extension, right and left flexion, flexibility of the posterior chain, and ribcage excursion at xiphoid level (p<0.05) in favor of the experimental group. Conclusion Diaphragm stretching generates a significant improvement in cervical extension, right and left cervical flexion, flexibility of the posterior chain, and ribcage excursion at xiphoid level compared to a placebo technique in healthy adults. PMID:27333481
Kim, Han Myun; Kim, Hyo-Cheol Woo, Sungmin; Son, Kyu Ri; Cho, Seong Whi; Chung, Jin Wook
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 the 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.
Yao, Nuzhao; Wang, Cheng; Wang, Wenjun; Wang, Lushan
With minimally invasive technique becoming more popular, endoscopic operations such as arthroscopy or laparoscopy have become the standard of care in several other areas. In this study, we evaluated the 5-year follow-up outcomes of anterior cervical (Ahn et al. in Photomed Laser Surg 23:362-368, 2005) discectomy and interbody fusion (ACDF) performed via endoscopic approach. Sixty-seven patients who underwent anterior cervical discectomy and cage fusion performed using endoscopic technique were followed for at least 5 years. We reviewed the clinical and radiographic records of these patients. The postoperative radiographic measures accessed were the anterior intervertebral height (AIH) and the lordosis angle (LDA). Clinical outcomes were determined using the previously validated Japanese Orthopaedic Association (JOA) and the pain visual analog scale (VAS). Patients included had a minimal follow-up period of 5 years and based on the outcomes criteria (JOA, VAS), 86.6% of patients reported excellent or good results. The AIH increased on average 18.7% of the original height (p < 0.01), and the LDA were more physiologic at final follow-up. Of the 67 cases, there was no segmental instability, and the bone fusion rate was 100%. One patient required revision open ACDF due to adjacent segment disc herniation 6 years postoperatively. There were no intraoperative complications, dysphasia or esophageal injury in this study group. It indicated endoscopic technique for ACDF can obtain satisfactory results in patients with cervical disc herniation, cervical myelopathy, or radiculopathy. Compared with a traditional approach, this technique may be associated with less morbidity while improving cosmesis and postoperative recovery. Prospective randomized control trials are needed to directly compare these two procedures.
Iacoangeli, Maurizio; Ruscelli, Paolo; Della Costanza, Martina; Nasi, Davide; Scerrati, Massimo
This is a rare case of giant lumbar pseudomeningocele with intra-abdominal extension in patient with neurofibromatosis type 1 (NF1). The patient's clinical course is retrospectively reviewed. A 34-year-old female affected by NF1 was referred to our institution for persistent low back pain and MRI diagnosis of pseudomeningocele located at L3 level with paravertebral extension. From the first surgical procedure by a posterior approach until the relapse of the pseudomeningocele documented by MRI, the patient underwent two subsequent posterior surgical procedures to repair the dural sac defect with fat graft and fibrin glue. One month after the third operation, the abdominal MRI showed a giant intra-abdominal pseudomeningocele causing compression of visceral structures. The patient was asymptomatic. The pseudomeningocele was treated with an anterior abdominal approach and the use of the acellular dermal matrix (ADM) sutured directly on the dural defect on the anterolateral wall of the spinal canal. After six months of follow-up the MRI showed no relapse of the pseudomeningocele. Our case highlights the possible use of ADM as an effective and safe alternative to the traditional fat graft to repair challenging and large dural defects. PMID:28250774
Madigan, Luke; Vaccaro, Alexander R; Spector, Leo R; Milam, R Alden
Symptomatic lumbar degenerative disk disease, or discogenic back pain, is difficult to treat. Patients often report transverse low back pain that radiates into the sacroiliac joints. Radicular or claudicatory symptoms are generally absent unless there is concomitant nerve compression. Physical examination findings are often unremarkable. Radiographic examination may reveal disk space narrowing, end-plate sclerosis, or vacuum phenomenon in the disk; magnetic resonance imaging is useful for revealing hydration of the disk, annular bulging, or lumbar spine end-plate (Modic) changes in the adjacent vertebral bodies. The use of diskography as a confirmatory study remains controversial. Recent prospective, randomized trials and meta-analyses of the literature have helped expand what is known about degenerative disk disease. In most patients with low back pain, symptoms resolve without surgical intervention; physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment. Intradiskal electrothermal treatment has not been shown to be effective, and arthrodesis remains controversial for the treatment of discogenic back pain. Nucleus replacement and motion-sparing technology are too new to have demonstrated long-term data regarding their efficacy.
Cromie, Melinda J; Siston, Robert A; Giori, Nicholas J; Delp, Scott L
Abnormal anterior translation of the femur on the tibia has been observed in mid flexion (20-60 degrees ) following posterior stabilized total knee arthroplasty. The underlying biomechanical causes of this abnormal motion remain unknown. The purpose of this study was to isolate the effects of posterior cruciate ligament removal on knee motion after total knee arthroplasty. We posed two questions: Does removing the posterior cruciate ligament introduce abnormal anterior femoral translation? Does implanting a posterior stabilized prosthesis change the kinematics from the cruciate deficient case? Using a navigation system, we measured passive knee kinematics of ten male osteoarthritic patients during surgery after initial exposure, after removing the anterior cruciate ligament, after removing the posterior cruciate ligament, and after implanting the prosthesis. Passively flexing and extending the knee, we calculated anterior femoral translation and the flexion angle at which femoral rollback began. Removing the posterior cruciate ligament doubled anterior translation (from 5.1 +/- 4.3 mm to 10.4 +/- 5.1 mm) and increased the flexion angle at which femoral rollback began (from 31.2 +/- 9.6 degrees to 49.3 +/- 7.3 degrees). Implanting the prosthesis increased the amount of anterior translation (to 16.1 +/- 4.4 mm), and did not change the flexion angle at which femoral rollback began. Abnormal anterior translation was observed in low and mid flexion (0-60 degrees) after removing the posterior cruciate ligament, and normal motion was not restored by the posterior stabilized prosthesis.
Kertmen, Hayri; Gürer, Bora; Yilmaz, Erdal Resit; Sekerci, Zeki
Endoscopic surgery for lumbar disc herniation has been available for more than 30 years. Transforaminal percutaneous endoscopic lumbar discectomy is a well-known, safe, and effective method used for the treatment of the lumbar disc herniation. The published complications of the transforaminal percutaneous endoscopic lumbar discectomy consist of infections, thrombophlebitis, dysesthesia, dural tear, vascular injury, and death. Seizure after transforaminal percutaneous endoscopic lumbar discectomy is an extremely rare complication. A 20-year-old patient applied at our department who had undergone transforaminal percutaneous endoscopic lumbar. During the procedure, while performing the discography, non-ionic contrast media was administered into the thecal sac inadvertently. Two hours after surgery, the patient developed generalized tonic-clonic seizure of 5-min duration. Diagnosis of iohexol-induced seizure was made and the patient was treated supportively without anti-epileptics. Here we present the first case of seizure after transforaminal percutaneous endoscopic lumbar discectomy, which was caused by inadvertent administration of the contrast media into the thecal sac. PMID:27695562
Durrani, Khayyam; Foster, C Stephen
Although the phenomenon of fundus autofluorescence has been known for decades, it has only recently been recognized as a measure of retinal pigment epithelial function and health. Characteristic fundus autofluorescence patterns have been described in eyes affected by inflammation of the posterior segment, and these patterns have provided insights into the pathogenesis of posterior uveitis entities. In addition, preliminary data indicate that fundus autofluorescence characteristics may serve as markers of disease activity, allow prediction of visual prognosis, and may help determine the adequacy of therapy. We provide an overview of the current state of fundus autofluorescence imaging technology and review our current knowledge of fundus autoflourescence findings and their clinical use in the posterior uveitis entities.
Amonoo-Kuofi, H S; el-Badawi, M G; Fatani, J A; Butt, M M
The lumbosacral spines of two fetal and twelve adult cadavers have been studied by dissection. Evidence shows that the fifth lumbar intervertebral foramen is crossed on its external aspect by a strong, cord-like corporotransverse ligament passing obliquely downwards, forwards and medially from the inferior aspect of the accessory process of the fifth lumbar vertebra to the lateral surface of the intervertebral disc and the adjacent parts of the bodies of the fifth and first sacral vertebrae. Superficially, the ligament is related to another flat band--the lumbosacral hood. Together these ligaments separate and provide openings for the sympathetic ramus, the ventral ramus and blood vessels related to the intervertebral foramen. On the dorsal aspect, a tripartite ligament, the mamillo-transverso-accessory ligament, bears important relationships to the subdivisions of the dorsal ramus and also the zygapophyseal joint. The significance of these findings is discussed. Images Fig. 2 Fig. 3 Fig. 4 Fig. 1 Fig. 5 PMID:3248957
Cristante, Alexandre Fogaça; Rocha, Ivan Diasda; Marcon, Raphael Martus; de Barros Filho, Tarcísio Eloy Pessoa
OBJECTIVES: Hydrodiscectomy is a new technique used for percutaneous spinal discectomy that employs a high-intensity stream of water for herniated disc ablation and tissue aspiration. No previous clinical study has examined the effects of percutaneous hydrodiscectomy. The aim of this study is to evaluate the outcomes of hydrodiscectomy compared to open microdiscectomy regarding pain, function, satisfaction, complications and recurrence rates. METHODS: In this randomized clinical trial, patients referred to our tertiary hospital for lumbar back pain were recruited and included in the study if they had disc protrusion or small herniation in only one level, without neurological deficits and with no resolution after six weeks of conservative treatment. One group underwent open microdiscectomy, and the other group underwent percutaneous microdiscectomy via hydrosurgery. Function was evaluated using the Oswestry Disability Index and pain was assessed using a visual analog scale. Evaluations were performed preoperatively, and then during the first week and at one, three, six and twelve months postoperatively. Personal satisfaction was verified. Clinicaltrials.gov: NCT01367860. RESULTS: During the study period, 20 patients were included in each arm and 39 completed one-year of follow-up (one patient died of unrelated causes). Both groups exhibited equal improvement on the visual analog scale and Oswestry evaluations after treatment, without any significant differences. The improvement in the lumbar visual analog scale score was not significant in the hydrodiscectomy group (p=0.138). The rates of infection, pain, recurrence and satisfaction were similar between the two groups. CONCLUSION: Percutaneous hydrodiscectomy was demonstrated to be as effective as open microdiscectomy for reducing pain. The rates of complications and recurrence of herniation were similar between groups. Patient satisfaction with the treatment was also similar between groups. PMID:27276397
Săftescu-Jescu, C.; Bereteu, L.
Determining the center of pressure trajectories, as an indicator of postural stability or lumbar pathology, has been a challenging issue for researchers during the last decades. The paper advances an investigational method in order to determine a correlation between lumbar spine movements and feet center of pressure distribution. Five young healthy volunteers were simultaneously tested using an ultrasound based motion analyzing system and a force platform, while performing imposed tasks. Results showed specific patterns described by the center of pressure trajectories and a good coordination of angular amplitudes during lumbar spine movement.
Gower, D J; Baker, A L; Bell, W O; Ball, M R
Papilloedema is not always an adequate predictor of potential complications from lumbar puncture, and many clinicians are using computed tomography (CT) before lumbar puncture in an effort to identify more accurately the "at risk" patient. This paper identifies the following anatomical criteria defined by CT scanning that correlate with unequal pressures between intracranial compartments and predispose a patient to herniation following decompression of the spinal compartment: lateral shift of midline structures, loss of the suprachiasmatic and basilar cisterns, obliteration of the fourth ventricle, or obliteration of the superior cerebellar and quadrigeminal plate cisterns with sparing of the ambient cisterns. These criteria should be considered to be contraindications to lumbar puncture. Images PMID:3655817
Yang, H; Schaffer, K; Liu, L; Mahesh, M; Yousem, D M
We sought to establish a guide for identifying fellowship competency in performing fluoroscopically guided lumbar punctures. With a linear mixed-effects model, we compared the fluoroscopy time between the first and last 3 months of neuroradiology training. During 7 years, 55 fellows performed 1142 and 861 lumbar punctures in the first and last quarters of training. A target fluoroscopy time of 0.26 minutes, the upper 95% confidence interval, can serve as a fellowship benchmark for successfully achieving competence in fluoroscopically guided lumbar punctures.
Bandyopadhyay, Sabyasachi; Mondal, Kanchan Kumar; Das, Somnath; Gupta, Anindya; Biswas, Jaya; Bhattacharyya, Subir Kumar; Biswas, Gautam
Cortical blindness is defined as visual failure with preserved pupillary reflexes in structurally intact eyes due to bilateral lesions affecting occipital cortex. Bilateral oedema and infarction of the posterior and middle cerebral arterial territory, trauma, glioma and meningioma of the occipital cortex are the main causes of cortical blindness. Posterior reversible encephalopathy syndrome (PRES) refers to the reversible subtype of cortical blindness and is usually associated with hypertension, diabetes, immunosuppression, puerperium with or