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Daniels AH, Balmaceno-Criss M, McDonald CL, Singh M, Knebel A, Kuharski MJ, Daher M, Alsoof D, Lafage R, Lafage V, Diebo BG. Segmental Sagittal Alignment in Lumbar Spinal Fusion: A Review of Evidence-Based Evaluation of Preoperative Measurement, Surgical Planning, Intraoperative Execution, and Postoperative Evaluation. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01153. [PMID: 38690883 DOI: 10.1227/ons.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/05/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Maintaining and restoring global and regional sagittal alignment is a well-established priority that improves patient outcomes in patients with adult spinal deformity. However, the benefit of restoring segmental (level-by-level) alignment in lumbar fusion for degenerative conditions is not widely agreed on. The purpose of this review was to summarize intraoperative techniques to achieve segmental fixation and the impact of segmental lordosis on patient-reported and surgical outcomes. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, Cochrane, and Web of Science databases were queried for the literature reporting lumbar alignment for degenerative lumbar spinal pathology. Reports were assessed for data regarding the impact of intraoperative surgical factors on postoperative segmental sagittal alignment and patient-reported outcome measures. Included studies were further categorized into groups related to patient positioning, fusion and fixation, and interbody device (technique, material, angle, and augmentation). RESULTS A total of 885 studies were screened, of which 43 met inclusion criteria examining segmental rather than regional or global alignment. Of these, 3 examined patient positioning, 8 examined fusion and fixation, 3 examined case parameters, 26 examined or compared different interbody fusion techniques, 5 examined postoperative patient-reported outcomes, and 3 examined the occurrence of adjacent segment disease. The data support a link between segmental alignment and patient positioning, surgical technique, and adjacent segment disease but have insufficient evidence to support a relationship with patient-reported outcomes, cage subsidence, or pseudoarthrosis. CONCLUSION This review explores segmental correction's impact on short-segment lumbar fusion outcomes, finding the extent of correction to depend on patient positioning and choice of interbody cage. Notably, inadequate restoration of lumbar lordosis is associated with adjacent segment degeneration. Nevertheless, conclusive evidence linking segmental alignment to patient-reported outcomes, cage subsidence, or pseudoarthrosis remains limited, underscoring the need for future research.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Mariah Balmaceno-Criss
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Christopher L McDonald
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Manjot Singh
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Ashley Knebel
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Michael J Kuharski
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Mohammad Daher
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Daniel Alsoof
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, New York, USA
| | - Bassel G Diebo
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
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Flores-Milan G, Cuello CC, Pressman E, Marek J, Krafft PR, McBride P, Gassie K, Hayman E, Alikhani P. Risk Factors for Adjacent Segment Disease in Short Segment Lumbar Interbody Fusion-A Case Series. Oper Neurosurg (Hagerstown) 2023; 25:136-141. [PMID: 37163706 DOI: 10.1227/ons.0000000000000743] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/07/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Adjacent segment disease (ASD) is a common problem after lumbar spinal fusions. Ways to reduce the rates of ASD are highly sought after to reduce the need for reoperation. OBJECTIVE To find predisposing factors of ASD after lumbar interbody fusions, especially in mismatch of pelvic incidence and lumbar lordosis (PI-LL). METHODS We conducted a retrospective cohort study of all patients undergoing lumbar interbody fusions of less than 4 levels from June 2015 to July 2020 with at least 1 year of follow-up and in those who had obtained postoperative standing X-rays. RESULTS We found 243 patients who fit inclusion and exclusion criteria. Fourteen patients (5.8%) developed ASD, at a median of 24 months. Postoperative lumbar lordosis was significantly higher in the non-ASD cohort (median 46.4° ± 1.4° vs 36.9° ± 3.6°, P < .001), pelvic tilt was significantly lower in the non-ASD cohort (16.0° ± 0.66° vs 20.3° ± 2.4°, P = .002), PI-LL mismatch was significantly lower in the non-ASD cohort (5.28° ± 1.0° vs 17.1° ± 2.0°, P < .001), and age-appropriate PI-LL mismatch was less common in the non-ASD cohort (34 patients [14.8%] vs 13 [92.9%] of patients with high mismatch, P < .001). Using multivariate analysis, greater PI-LL mismatch was predictive of ASD (95% odds ratio CI = 1.393-2.458, P < .001) and age-appropriate PI-LL mismatch was predictive of ASD (95% odds ratio CI = 10.8-970.4, P < .001). CONCLUSION Higher PI-LL mismatch, both age-independent and when adjusted for age, after lumbar interbody fusion was predictive for developing ASD. In lumbar degenerative disease, correction of spinopelvic parameters should be a main goal of surgical correction.
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Affiliation(s)
- Gabriel Flores-Milan
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
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Siegel N, Lambrechts MJ, Brush PL, Karamian B, Lee Y, Depalma M, Delvadia B, Song S, Toci GR, Canseco JA, Woods BI, Kaye ID, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Do On-Table Radiographs Predict Postoperative Sagittal Alignment after Posterior Lumbar Fusion? World Neurosurg 2023; 174:e118-e125. [PMID: 36889640 DOI: 10.1016/j.wneu.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023]
Abstract
OBJECTIVE To determine if intraoperative on-table lumbar lordosis and segmental lordosis correlate with postoperative lordosis following single-level posterolateral decompression and fusion (PLDF) or transforaminal lumbar interbody fusion (TLIF). METHODS Electronic medical records were reviewed for patients ≥18 years old who underwent PLDF or TLIF between 2012 and 2020. Lumbar lordosis and segmental lordosis were compared between pre-, intra-, and postoperative radiographs using paired t tests. Significance was set at P < 0.05. RESULTS A total of 200 patients met inclusion criteria. No significant differences in preoperative, intraoperative, or postoperative measurements were found between groups. Patients who underwent PLDF experienced less disc height loss over 1 year postoperatively (PLDF: 0.45 ± 0.9 mm vs. TLIF: 1.2 ± 1.4 mm, P < 0.001). Lumbar lordosis significantly decreased between intraoperative to postoperative radiographs at 2-6 weeks for PLDF (Δ: -4.0°, P < 0.001) and TLIF (Δ: -5.6°, P < 0.001), but no change was identified between the intraoperative and >6 month postoperative radiographs for PLDF (Δ: -0.3°, P = 0.634) or TLIF (Δ: -1.6°, P = 0.087). Segmental lordosis significantly increased from the preoperative to post-instrumentation intraoperative radiographs for PLDF (Δ: 2.7°, P < 0.001) and TLIF (Δ: 1.8°, P < 0.001), but it subsequently decreased at the final follow up for PLDF (Δ: -1.9°, P < 0.001) and TLIF (Δ: -2.3°, P < 0.001). CONCLUSIONS Subtle decreases in lumbar lordosis may be noticed in early postoperative radiographs compared with intraoperative images on Jackson operative tables. However, these changes are not present at 1-year follow-up as lumbar lordosis increases to a similar level as intraoperative fixation.
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Affiliation(s)
- Nicholas Siegel
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parker L Brush
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian Karamian
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Yunsoo Lee
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Michael Depalma
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Bela Delvadia
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Steven Song
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory R Toci
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Jain P, Khan MR. Comparison of novel stabilisation device with various stabilisation approaches: A finite element based biomechanical analysis. Int J Artif Organs 2022; 45:514-522. [PMID: 35393885 DOI: 10.1177/03913988221088334] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The treatment of spinal failure requires suitable instrumentation, which is based on numerous concepts such as rigid fixation, semi-rigid and dynamic stabilisation. In the present work, the biomechanical investigation of various fixation systems on the lumbar segment L2-L3 was performed employing finite element analysis. Different devices were considered: novel stabilisation device (NSD), rigid implant (RI) and existing dynamic stabilisation device (EDSD). All instrumented models were loaded with a condition of 400 N compressive force with a moment of 10Nm during flexion, extension, lateral bending and axial rotation. The results of range of motion change (RMC), von-Mises stress and strain were compared. The spinal biomechanics post instrumentation resulted significantly sensitive to the geometrical feature of the implant. The obtained results showed that NSD has intermediate motion characteristics in between dynamic stabilisation and rigid fixation. However, the optimum features of a novel stabilisation device for the treatment of spinal failure still need to be verified employing in-vivo, in-vitro studies.
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Affiliation(s)
- Pushpdant Jain
- School of Mechanical Engineering, VIT Bhopal University, Sehore, Madhya Pradesh, India
| | - Mohammed Rajik Khan
- Department of Industrial Design, National Institute of Technology Rourkela, Rourkela, Odisha, India
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Godinho MI, Carvalho V, Matos MT, Fernandes PR, Castro APG. Computational modeling of lumbar disc degeneration before and after spinal fusion. Clin Biomech (Bristol, Avon) 2021; 90:105490. [PMID: 34601326 DOI: 10.1016/j.clinbiomech.2021.105490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Advancing age and degeneration frequently lead to low back pain, which is the most prevalent musculoskeletal disorder worldwide. Degenerative changes in intervertebral discs and musculo-ligamentous incapacity to compensate sagittal imbalance are typically amongst the sources of instability, with spinal fusion techniques being the main treatment options to relieve pain. The aims of this work were to: (i) assess the link between ligament degeneration and spinal instability by determining the role of each ligament per movement, (ii) evaluate the impact of disc height reduction in degenerative changes, and (iii) unveil the most advantageous type of posterior fixation in Oblique Lumbar Interbody Fusion to prevent adjacent disc degeneration. METHODS Two L3-L5 finite element models were developed, being the first in healthy condition and the second having reduced L4-L5 height. Different degrees of degeneration were tested, combined with different fixation configurations for Oblique Lumbar Interbody Fusion. FINDINGS Facet capsular ligament and anterior longitudinal ligament were the most influential ligaments for spinal stability, particularly with increasing degeneration and disc height reduction. Pre-existent degeneration had lower influence than the fusion procedure for the risk of adjacent disc degeneration, being the highest stability and minimal degeneration achieved with bilateral fixation. Right unilateral fixation was more suited to reduce disc stress than left unilateral fixation. INTERPRETATION Bilateral fixation is the best option to stabilize the spinal segment, but unilateral right fixation may suffice. This has direct implications for clinical practice, and the extension to a population-based study will allow for more efficient fusion surgeries.
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Affiliation(s)
- M I Godinho
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - V Carvalho
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - M T Matos
- Hospital dos Lusíadas, Lisbon, Portugal
| | - P R Fernandes
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - A P G Castro
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal.
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