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van Tiel J, Tan T, Tee J, Marion T, Öner F, Rutges J. Outcome of traumatic thoracolumbar spine fractures in elderly: A systematic review. BRAIN & SPINE 2024; 4:102775. [PMID: 38510601 PMCID: PMC10951749 DOI: 10.1016/j.bas.2024.102775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/01/2024] [Accepted: 02/19/2024] [Indexed: 03/22/2024]
Abstract
Introduction Adequate guidelines for treatment of people over 65 years, suffering traumatic thoracolumbar spine fractures without neurologic deficit, are currently lacking. Research question The aim of this study was to systematically review the available literature regarding the outcome of conservative and surgical treatment of thoracolumbar spinal trauma in elderly patients. Material and methods A systematic review according the PRISMA guidelines was performed. Pubmed, Web of Science, EMBASE and the Cochrane Central register were searched until June 2021. Risk of bias of the included studies was evaluated. Clinical and radiological results, as well as complications of conservative or surgical treatment were reviewed. Results Six articles were included (one prospective randomized trial, two prospective and three retrospective cohort studies). In these studies conflicting results were observed with regard to pain, radiological results and complications following both conservative and surgical treatment strategies for thoracolumbar spine fractures in elderly. Discussion and conclusion Treatment of thoracolumbar fractures in elderly should focus on early mobilization to reduce complications and hospital stay. This may improve functional outcome and prevent worsening of frailty in this vulnerable group of patients. To elucidate the optimal treatment for elderly patient with thoracolumbar fractures, future research should focus on patient specific treatment rather than the mere difference between outcome of surgical and conservative treatment.
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Affiliation(s)
- J. van Tiel
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - T. Tan
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - J. Tee
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - T.E. Marion
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - F.C. Öner
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J.P.H.J. Rutges
- Department of Orthopedic Surgery, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Awake Percutaneous Fixation for Unstable Fractures of the Spine in High-risk Patients: A Retrospective Study. J Am Acad Orthop Surg 2022; 30:e1033-e1042. [PMID: 35333815 DOI: 10.5435/jaaos-d-21-00959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/04/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Unstable fractures in sick or elderly patients are on the rise. These patients who are at high risk for surgery present a challenge for surgeons and anesthesiologists. In patients with American Society of Anesthesiologists (ASA) scores 3 to 4, the risk is even higher because of the high rate of intraoperative complications. METHODS All patients with ASA scores 3 to 4 who presented with unstable fractures of the spine to a level-one trauma center were assessed, and they underwent awake spinal percutaneous fixation, with mild sedation and local anesthesia. Demographics, radiology, and the outcome were collected. RESULTS Nineteen patients were operated between the years 2019 and 2021. Average follow-up was 12 months (range 8 to 24 months); six patients were female and 13 males. The average age was 77.7 years; the ASA score was 3 to 4 in all patients. There were 10 extension-type injuries, six unstable burst injuries, two chance fractures, and one teardrop fracture. All patients underwent unilateral fixation, and just one patient underwent bilateral fixation; cement augmentation was done in 16 of the patients. No neurologic complication was observed. One case of infection presented 4 months after surgery. All patients were discharged ambulating. CONCLUSIONS Awake fixation in extreme cases is safe and feasible; a dedicated team including an anesthesiologist and radiologist is needed to treat these cases safely and quickly.
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Sasagawa T. Facet Joint Violation by Thoracolumbar Percutaneous Pedicle Screw and Its Effect on Progression of Facet Joint Osteoarthritis. Asian Spine J 2021; 16:542-550. [PMID: 34551500 PMCID: PMC9441432 DOI: 10.31616/asj.2021.0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/11/2021] [Indexed: 11/23/2022] Open
Abstract
Study Design A retrospective study. Purpose This study aimed to investigate the rate and associated factors of facet violation (FV) in percutaneous pedicle screws (PPS) from the thoracic to the lumbar spine and the effect of FV on facet osteoarthritis (OA) progression. Overview of Literature Some reports claim PPS has a higher FV rate than conventional open surgery. However, previous reports of FV in PPS were limited to the lumbar spine; only a few reports included the thoracic spine. Methods The present study includes 1,028 PPS inserted from T4 to S1 in 218 patients. The rate of FV and facet OA progression after FV were assessed using computed tomography (CT) scans conducted postoperatively at 1 week and 6 months or more. To identify factors associated with FV or facet OA progression after FV, a multivariate logistic regression analysis was conducted. To investigate whether FV caused facet OA progression, we compared OA progression between patients with FV and matched controls. Results FV was observed in 68 (6.6%) of the 1,028 facets, and the thoracic spine was identified as an independent factor associated with FV. OA progression was detected in 48.2% of the cases with FV via CT scans conducted postoperatively at a mean duration of 22.6 months. The time between CT scans was identified as an independent factor for facet OA progression after FV. The rate of OA progression in patients with FV was significantly greater than that of the controls. Conclusions FV was observed in 6.6% of the patients, and the thoracic spine was identified as an independent factor associated with FV. OA progression of a violated facet occurs over time. FV is considered a complication leading to facet OA progression.
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Affiliation(s)
- Takeshi Sasagawa
- Department of Orthopedics Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
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Dong H, Hu L, Ruan B, Yu H, Xu X, Sun H, Feng X, Yang J, Wang Y, Tao Y. Clinical Outcomes of Thoracolumbar Burst Fracture Treated by Trans-Kambin triangle versus Transpedicular Bone Grafting Combined with Posterior Internal Fixation. World Neurosurg 2021; 156:e130-e138. [PMID: 34508909 DOI: 10.1016/j.wneu.2021.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The ideal management of thoracolumbar burst fracture (TLBF) remains controversial. We conducted this study to compare the effectiveness and safety of trans-Kambin triangle versus transpedicular bone grafting combined with posterior internal fixation (PIF) for TLBF. METHODS Fifty-four patients were retrospectively analyzed and divided into 2 groups: the observation group (PIF combined with bone grafting via the Kambin triangle, n = 28) and the control group (PIF combined with bone grafting via transpedicular, n = 26). The anterior vertebral height ratio, sagittal Cobb angle, visual analog scale score, Oswestry Disability Index, bone healing rate, and neurologic complications were measured. RESULTS All patients were followed up regularly for a mean period of 17.94 months (12 - 24 months). The anterior vertebral height ratio in the observation group was higher than that in the control group (93.93 ± 2.92 vs. 89.90 ± 5.54%, P = 0.006), and the loss of correction was lower (1.59 ± 1.20 vs. 3.00 ± 1.98%, P = 0.008). The observation group had lower sagittal Cobb angle at final follow-up (8.68 ± 3.75 vs. 11.33 ± 4.77 degrees, P = 0.046) and less correction loss (1.96 ± 1.32 ± 1.15 vs. 3.90 ± 2.39 degrees, P = 0.002). The visual analog scale score and Oswestry Disability Index in the observation group were lower (0.61 ± 0.43 vs. 0.92 ± 0.38, P = 0.016; 15.86 ± 4.11 vs. 19.18 ± 4.04, P = 0.010), while the fracture healing rate showed no significant difference (P > 0.05). No internal fixation failure or neurologic complications occurred in both groups during the follow-up. CONCLUSIONS Bone grafting via the Kambin triangle combined with PIF is a safe and effective technology for thoracolumbar burst fracture.
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Affiliation(s)
- Hui Dong
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Graduate School, Dalian Medical University, Dalian, China
| | - Le Hu
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Binjia Ruan
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Graduate School, Dalian Medical University, Dalian, China
| | - Hang Yu
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Xiaohang Xu
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hao Sun
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Xinmin Feng
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Jiandong Yang
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yongxiang Wang
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuping Tao
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Spiegl UJ, Hölbing PL, Jarvers JS, V D Höh N, Pieroh P, Osterhoff G, Heyde CE. Midterm outcome after posterior stabilization of unstable Midthoracic spine fractures in the elderly. BMC Musculoskelet Disord 2021; 22:188. [PMID: 33588814 PMCID: PMC7885444 DOI: 10.1186/s12891-021-04049-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/04/2021] [Indexed: 12/22/2022] Open
Abstract
Background The evidence for the treatment of midthoracic fractures in elderly patients is weak. The aim of this study was to evaluate midterm results after posterior stabilization of unstable midthoracic fractures in the elderly. Methods Retrospectively, all patients aged ≥65 suffering from an acute unstable midthoracic fracture treated with posterior stabilization were included. Trauma mechanism, ASA score, concomitant injuries, ODI score and radiographic loss of reduction were evaluated. Posterior stabilization strategy was divided into short-segmental stabilization and long-segmental stabilization. Results Fifty-nine patients (76.9 ± 6.3 years; 51% female) were included. The fracture was caused by a low-energy trauma mechanism in 22 patients (35.6%). Twenty-one patients died during the follow-up period (35.6%). Remaining patients (n = 38) were followed up after a mean of 60 months. Patients who died were significantly older (p = 0.01) and had significantly higher ASA scores (p = 0.02). Adjacent thoracic cage fractures had no effect on mortality or outcome scores. A total of 12 sequential vertebral fractures occurred (35.3%). The mean ODI at the latest follow up was 31.3 ± 24.7, the mean regional sagittal loss of reduction was 5.1° (± 4.0). Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral fractures during follow-up (p = 0.03). Conclusion Unstable fractures of the midthoracic spine are associated with high rates of thoracic cage injuries. The mortality rate was rather high. The majority of the survivors had minimal to moderate disabilities. Thereby, patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up.
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Affiliation(s)
- U J Spiegl
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - P-L Hölbing
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - J-S Jarvers
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - N V D Höh
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - P Pieroh
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - G Osterhoff
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - C-E Heyde
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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Ould-Slimane M, Cantogrel P, Lefèvre E, Parent HF, Gauthé R. Minimally invasive unilateral lumbar interbody fusion (UNILIF) in over-80-year-olds. Continuous series of 42 patients at 1.4 years' follow-up. Orthop Traumatol Surg Res 2020; 106:275-279. [PMID: 32171688 DOI: 10.1016/j.otsr.2020.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/20/2019] [Accepted: 01/04/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In lumbar stenosis, surgery aims to improve quality of life in increasingly elderly patients. Minimally invasive techniques better suit the requirements of elderly patients with increasing functional demand. HYPOTHESIS The UNILIF unilateral lumbar interbody fusion technique improves functional scores at 1 year in over-80 year-olds, with low morbidity. METHOD Patients undergoing minimally invasive decompression with transforaminal lumbar interbody fusion (TLIF) associated to unilateral pedicle screwing for degenerative lumbar stenosis were analyzed at a minimum 1 year's follow-up. SF12, Oswestry Disability Index (ODI) and Quebec scores and sagittal spinopelvic radiographic parameters were assessed at follow-up. Surgical and general complications were also collated. RESULTS In all, 42 patients (64.3% female; mean age, 83.7±2.9 years) were treated by UNILIF at levels L2-L3 (3.8%), L3-L4 (15.4%), L4-L5 (71.2%) and L5-S1 (9.6%). Mean follow-up was 520±226 days (range, 340-1166 days). Mean preoperative SF12 score was 77.5±10.9, with significant improvement at last follow-up: 81.9±138 (p<0.05). Mean preoperative ODI was 44.4%±14.0, with significant improvement at last follow-up: 32.4%±13.3 (p<0.001). Mean preoperative Quebec score was 42.9±19.9, with significant improvement at last follow-up: 28.5±21.9 (p<0.001). Spinopelvic sagittal balance was not affected by the UNILIF procedure. There were no cases of infection or severe general complications during follow-up, although 2 cases of non-union required revision surgery. CONCLUSION Lumbar stenosis surgery by UNILIF improved functional scores at 1 year, with low morbidity. It is a suitable strategy for degenerative lumbar stenosis in elderly patients. LEVEL OF EVIDENCE IV, non-comparative cohort study.
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Affiliation(s)
- Mourad Ould-Slimane
- Service de chirurgie orthopédique et traumatologique, institut régional du Rachis, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - Pauline Cantogrel
- Service de chirurgie orthopédique et traumatologique, institut régional du Rachis, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - Emeric Lefèvre
- Service de chirurgie orthopédique et traumatologique, institut régional du Rachis, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | | | - Rémi Gauthé
- Service de chirurgie orthopédique et traumatologique, institut régional du Rachis, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France.
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Sanli I, Spoor A, Muijs SPJ, Öner FC. Less Invasive Surgery is Feasible in the Management of Traumatic Thoracolumbar Fractures in Isolated and Polytrauma Injury. Int J Spine Surg 2020; 13:561-567. [PMID: 31970052 DOI: 10.14444/6078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Less invasive stabilization systems (LISSs) have gained popularity. However, limited quality of life (QOL) and clinical outcome data exist for trauma patients treated with LISSs. The objective of this study is to describe QOL and outcome for posterior percutaneous pedicle screw fixation in the management of traumatic thoracolumbar fractures. Methods Between January 2006 and December 2011, data from all patients treated with a posterior percutaneous pedicle screw fixation technique for thoracolumbar fractures were collected and analyzed. Sixty-nine patients met the inclusion criteria. Additional vertebral reduction and cement augmentation was used in 25 patients, when there was more than 50% of vertebral body comminution. Results Mean follow up of 19 months (range = 6-49 months). Fifty-one percent of the study population consisted of polytrauma patients, with 22% having injury severity score ≥ 15. In 6 cases (8.7%) there were perioperative complications. Response rate for the follow-up health survey was 78%, with a satisfactory overall median EuroQuol score of 0.811 (Q1-Q3 95% confidence interval = 0.709-0.897). Conclusions Posterior percutaneous pedicle screw fixation proves to be effective in the management of traumatic thoracolumbar fractures, with a good overall functional outcome. Percutaneous techniques that reduce perioperative morbidity are an alternative approach well suited for damage control orthopaedics, as long as there are no neurological deficits. Especially in polytrauma patients with spine fractures, the spinal column can be stabilized in an emergency setting, while limiting the risks of "a second hit" at the patients' already frail condition. Level of Evidence 3.
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Affiliation(s)
- I Sanli
- Department of Orthopaedic Surgery, Maastricht University Medical Centre+, the Netherlands
| | - A Spoor
- Department of Orthopaedic Surgery, Elisabeth Hospital Tilburg, the Netherlands
| | - S P J Muijs
- Department of Orthopaedic Surgery, Utrecht University Medical Centre, the Netherlands
| | - F C Öner
- Department of Orthopaedic Surgery, Utrecht University Medical Centre, the Netherlands
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Laufer I, Bilsky MH. Advances in the treatment of metastatic spine tumors: the future is not what it used to be. J Neurosurg Spine 2019; 30:299-307. [PMID: 30835704 DOI: 10.3171/2018.11.spine18709] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 11/06/2022]
Abstract
An improved understanding of tumor biology, the ability to target tumor drivers, and the ability to harness the immune system have dramatically improved the expected survival of patients diagnosed with cancer. However, many patients continue to develop spine metastases that require local treatment with radiotherapy and surgery. Fortunately, the evolution of radiation delivery and operative techniques permits durable tumor control with a decreased risk of treatment-related toxicity and a greater emphasis on restoration of quality of life and daily function. Stereotactic body radiotherapy allows delivery of ablative radiation doses to the majority of spine tumors, reducing the need for surgery. Among patients who still require surgery for decompression of the spinal cord or spinal column stabilization, minimal access approaches and targeted tumor excision and ablation techniques minimize the surgical risk and facilitate postoperative recovery. Growing interdisciplinary collaboration among scientists and clinicians will further elucidate the synergistic possibilities among systemic, radiation, and surgical interventions for patients with spinal tumors and will bring many closer to curative therapies.
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Open versus minimally invasive percutaneous surgery for surgical treatment of thoracolumbar spine fractures- a multicenter randomized controlled trial: study protocol. BMC Musculoskelet Disord 2019; 20:397. [PMID: 31472691 PMCID: PMC6717640 DOI: 10.1186/s12891-019-2763-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 08/14/2019] [Indexed: 01/29/2023] Open
Abstract
Background Thoracolumbar fractures are most frequent along the spine, and surgical treatment is indicated for unstable fractures. Percutaneous minimally invasive surgery was introduced to reduce the pain associated with the open posterior approach and reduce the morbidity of the procedure by avoiding damage and dissection of the paravertebral muscles. The goal of this study is to compare the surgical treatment of fractures of the thoracolumbar spine treated by the conventional open approach and the percutaneous minimally invasive approach using similar types of pedicle spine fixation systems. Methods/designs This study is designed as a multi-center, randomized controlled trial of patients aged 18–65 years who are scheduled to undergo surgical posterior fixation. Treatment by the conventional open approach or percutaneous minimally invasive approach will be randomly assigned. The primary outcome measure is postoperative pain, which will be measured using the visual analogue scale (VAS). The secondary outcome parameters are intraoperative bleeding, postoperative drainage, surgery time, length of hospital stay, SF-36, EQ-5D-5 l, HADS, pain medication, deambulation after surgery, intraoperative fluoroscopy time, vertebral segment kyphosis, fracture vertebral body height, compression of the vertebral canal, accuracy of the pedicle screws, and breakage or release of the implants. Patient will be followed up for 1, 2, 3, 6, 12 and 24 months postoperatively and evaluated according to the outcomes using clinical and radiological examinations, plain radiographs and computed tomografy (CT). Discussion Surgical treatment of thoracolumbar fractures by the open or percutaneous minimally invasive approach will be compared in a multicenter randomized study using similar types of fixation systems, and the results will be evaluated according to clinical and radiological parameters at 1, 2, 3, 6, 12 and 24 months of follow-up. Trial registration ClinicalTrial.gov approval number: 1.933.631, code: NCT03316703 in may 2017.
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Thomas K, Wong KH, Steelman SC, Rodriguez A. Surgical Risk Assessment and Prevention in Elderly Spinal Deformity Patients. Geriatr Orthop Surg Rehabil 2019; 10:2151459319851681. [PMID: 31192027 PMCID: PMC6540502 DOI: 10.1177/2151459319851681] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 04/28/2019] [Accepted: 04/29/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction: Prevalence of adult deformity surgery in the elderly individuals continues to increase. These patients have additional considerations for the spine surgeon during surgical planning. We perform an informative review of the spinal and geriatric literature to assess preoperative and intraoperative factors that impact surgical complication occurrences in this population. Significance: There is a need to understand surgical risk assessment and prevention in geriatric patients who undergo thoracolumbar adult deformity surgery in order to prevent complications. Methods: Searches of relevant biomedical databases were conducted by a medical librarian. Databases searched included MEDLINE, Web of Science, CINAHL, IPA, Cochrane, PQ Health and Medical, SocINDEX, and WHO’s Global Health Library. Search strategies utilized Medical Subject Headings plus text words for extensive coverage of scoliosis and surgical technique concepts. Results: Degenerative scoliosis affects 68% of the geriatric population, and the rate of surgical interventions for this pathology continues to increase. Complications following spinal deformity surgery in this patient population range from 37% to 62%. Factors that impact outcomes include age, comorbidities, blood loss, and bone quality. Using these data, we summarize multimodal risk prevention strategies that can be easily implemented by spine surgeons. Conclusions: After evaluation of the latest literature on the complications associated with adult deformity surgery in geriatric patients, comprehensive perioperative management is necessary for improved outcomes. Preoperative strategies include assessing physiological age via frailty score, nutritional status, bone quality, dementia/delirium risk, and social activity support. Intraoperative strategies include methods to reduce blood loss and procedural time. Postoperatively, development of a multidisciplinary team approach that encourages early ambulation, decreases opiate use, and ensures supportive discharge planning is imperative for better outcomes for this patient population.
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Affiliation(s)
- Kevin Thomas
- Department of Neurosurgery, University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Ka Hin Wong
- Department of Neurosurgery, University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Susan C Steelman
- Division of Academic Affairs, University of Arkansas for Medical Sciences Library, Little Rock, AR, USA
| | - Analiz Rodriguez
- Department of Neurosurgery, University of Arkansas Medical Sciences, Little Rock, AR, USA
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Sharma M, Dietz N, Ugiliweneza B, Wang D, Drazin D, Boakye M. Differences in clinical outcomes and health care utilization between octogenarians and nonagenarians following decompression for lumbar spinal stenosis. A market scan analysis. Clin Neurol Neurosurg 2019; 182:63-69. [PMID: 31082620 DOI: 10.1016/j.clineuro.2019.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/02/2019] [Accepted: 04/30/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Lumbar spinal stenosis (LSS) in octogenarians and beyond has a significant impact on quality of life requiring surgical decompression and hence impact on health care utilization. Risk of surgical failure and impact on health care resources is always a concern in this patient population (more so in nonagenarians). The aim of our study was to compare clinical outcomes and healthcare utilization in patients (80-89 vs.90+) undergoing decompression for LSS. PATIENTS AND METHODS Data was extracted using ICD9/10 and CPT codes from MarketScan (2001-2015) in this retrospective study. We defined the comparative groups based on the age groups (80-89 and 90+), in patients with LSS. Outcomes of interest were: length of hospital stay, discharge disposition and utilization in the index hospitalization, 6- months, 12 months following index procedure as well as the associated health care utilization. Patient characteristics and outcomes among cohorts were compared using univariate tests. Outcomes were further compared using adjusted multivariable regression models. Statistical analysis was performed with SAS 9.4. RESULTS A cohort of 5387 was identified from the database, 96.38% were in the 80-89 age group and 3.62%were in the 90+ age group. The proportion of patients undergoing surgery for LSS among 80-89 (95.7-98.5%) and 90+ age group (1.5-4.3%) remained constant through the years. Interestingly, 13.83% and 16.92% of patients had Elixhauser comorbidity index of 3+ in 80-89 age group and 90+ age groups respectively. Decompression with fusion was performed in 19.4% of patients in 80-89 age group, compared to 9.74% of patients in 90+ age group. There was no difference in median length of hospital stay (3 days, p = 0.19) and complications across the cohorts (80-89: 16.7%; 90+: 18.46% p = 0.51). 70.6% of patients in 80-89 age groups were discharged to home compared to 60.5% in 90+ age group (p = 0.0023). At 6 months follow-up, overall rate of new decompression, new fusion, re-fusion at index level were 2.38%, 0.59% and 0.33% only, with no differences across the cohorts. Interestingly, patients in 80-89 age group incurred higher outpatient services, number of medication refills and related payments at 6-months and 12-months follow-up, compared to patients in 90+ age group. Overall, combined median post-discharge payments at 12 months were similar across the groups [80-89 (median $ 40,257) and 90+ (median$ 36,161), p = 0.14]. CONCLUSION Using MarketScan database, there has been a gradual decline in the number of decompressions being performed for LSS in elderly patients (>80 years of age), however there is no change in the proportion of octogenarians and nonagenarians undergoing decompression for LSS. There was no difference in rate of reoperations and overall health care utilization among the groups. Surgery for LSS can be offered to nonagenarians (in appropriately selected patients) with no difference in clinical outcomes and health care utilization, compared to octogenarians.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Doniel Drazin
- Pacific Northwest University of Health Sciences College of Medicine, Yakima, WA, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA.
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Satake K, Kanemura T, Nakashima H, Ishikawa Y, Segi N, Ouchida J. Nonunion of Transpsoas Lateral Lumbar Interbody Fusion Using an Allograft: Clinical Assessment and Risk Factors. Spine Surg Relat Res 2018; 2:270-277. [PMID: 31435533 PMCID: PMC6690102 DOI: 10.22603/ssrr.2017-0096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/25/2018] [Indexed: 11/05/2022] Open
Abstract
Introduction This retrospective study was performed to evaluate the clinical influence of - and to identify the risk factors for nonunion of transpsoas lateral lumbar interbody fusion (LLIF) with use of allograft. Methods Sixty-three patients who underwent transpsoas LLIF (69.8 ± 8.9 years, 21 males and 42 females, 125 segments) were followed for a minimum 2 years postoperatively. For all LLIF segments, polyetheretherketone (PEEK) cages packed with allogenic bone were applied with supplemental bilateral pedicle screws (PSs). Bone bridge formation was evaluated by computed tomography (CT) 2 years postoperative, and a segment without any bridge formation was determined to be a nonunion. Sixty-one participants (96.8%) were classified into two groups for clinical evacuation: Group N that contained one or more nonunion segments and Group F that contained no nonunion segment. Visual analogue scales (VAS) scores and the effective rates of the five domains of the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were compared between Groups N and F. The risk factors for nonunion were determined by univariate and multivariate analyses. Results Twenty segments (16%) were diagnosed as nonunion. There were no significant differences in all VAS scores, and the ratio of effective cases in all domains of JOABPEQ between Group N (n = 14) and F (n = 47). Multivariate analysis identified percutaneous PS (PPS) usage (odds ratio [OR]: 3.14, 95% confidence interval: 1.13-8.68, p = 0.028) as a positive risk factor for nonunion. Conclusions We should be aware of the higher nonunion rate in the LLIF segments supplemented with PPS, though nonunion does not affect significantly clinical outcomes at 2 years postoperative.
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Affiliation(s)
- Kotaro Satake
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Tokumi Kanemura
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Konan, Japan
| | | | - Naoki Segi
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Jun Ouchida
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Konan, Japan
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