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Duits AAA, van Urk PR, Lehr AM, Nutzinger D, Reijnders MRL, Weinans H, Foppen W, Oner FC, van Gaalen SM, Kruyt MC. Radiologic Assessment of Interbody Fusion: A Systematic Review on the Use, Reliability, and Accuracy of Current Fusion Criteria. JBJS Rev 2024; 12:01874474-202401000-00005. [PMID: 38194599 DOI: 10.2106/jbjs.rvw.23.00065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Lumbar interbody fusion (IF) is a common procedure to fuse the anterior spine. However, a lack of consensus on image-based fusion assessment limits the validity and comparison of IF studies. This systematic review aims to (1) report on IF assessment strategies and definitions and (2) summarize available literature on the diagnostic reliability and accuracy of these assessments. METHODS Two searches were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Search 1 identified studies on adult lumbar IF that provided a detailed description of image-based fusion assessment. Search 2 analyzed studies on the reliability of specific fusion criteria/classifications and the accuracy assessed with surgical exploration. RESULTS A total of 442 studies were included for search 1 and 8 studies for search 2. Fusion assessment throughout the literature was highly variable. Eighteen definitions and more than 250 unique fusion assessment methods were identified. The criteria that showed most consistent use were continuity of bony bridging, radiolucency around the cage, and angular motion <5°. However, reliability and accuracy studies were scarce. CONCLUSION This review highlights the challenges in reaching consensus on IF assessment. The variability in IF assessment is very high, which limits the translatability of studies. Accuracy studies are needed to guide innovations of assessment. Future IF assessment strategies should focus on the standardization of computed tomography-based continuity of bony bridging. Knowledge from preclinical and imaging studies can add valuable information to this ongoing discussion. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anneli A A Duits
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Orthopedic surgery, Diakonessenhuis, Utrecht, Zeist, the Netherlands
- Department of Orthopedics, Clinical Orthopedic Research Center (CORC-mN), Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands
| | - Paul R van Urk
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A Mechteld Lehr
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Don Nutzinger
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maarten R L Reijnders
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Harrie Weinans
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Wouter Foppen
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F Cuhmur Oner
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Steven M van Gaalen
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Orthopedic Surgery, Acibadem Internal Medical Center, Amsterdam, the Netherlands
| | - Moyo C Kruyt
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Developmental BioEngineering, University of Twente, Enschede, the Netherlands
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Segi N, Nakashima H, Shinjo R, Kagami Y, Machino M, Ito S, Ouchida J, Morishita K, Oishi R, Yamauchi I, Imagama S. Trabecular Bone Remodeling After Posterior Lumbar Interbody Fusion: Comparison of Three-Dimensional Porous Tantalum and Titanium-Coated Polyetheretherketone Interbody Cages. Global Spine J 2023:21925682231170613. [PMID: 37060284 DOI: 10.1177/21925682231170613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The criteria for determining completion of intervertebral stability after posterior lumbar interbody fusion (PLIF) remain controversial. Several new radiological indicators of bone growth and osteointegration have been established. We compared computed tomography (CT) findings related to osteointegration after PLIF with interbody cages of two different materials and designs. METHODS We retrospectively analyzed data from 103 patients who underwent PLIF with three-dimensional porous tantalum (Tn) cages or titanium-coated polyetheretherketone (TiP) cages. CT images obtained 3 months and 1 year after surgery were examined for trabecular bone remodeling (TBR), cancellous condensation (CC), and vertebral endplate cyst (VEC) formation. The incidences of each finding were compared by cage type, and rates of instrument failure and pseudarthrosis were determined. RESULTS Three months postoperatively, 87% of the levels with Tn cages exhibited TBR, whereas 96% of those with TiP cages did not (P < .001). Most levels with Tn cages levels exhibited TBR and no CC 3 months (81%) and 1 year (94%) after surgery. Although 78% of levels with TiP cages exhibited CC and no TBR 3 months after surgery, 59% exhibited both CC and TBR 1 year after surgery. Significantly fewer VECs formed around the Tn cages than around the TiP cages both 3 months (P = .002) and 1 year (P < .001) after surgery. Implant-related problems occurred at levels that exhibited neither TBR nor CC. CONCLUSIONS The porous tantalum cage may enable intervertebral stability that is comparable to bony fusion soon after surgery.
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Affiliation(s)
- Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Aichi, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryuichi Shinjo
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Aichi, Japan
| | - Yujiro Kagami
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Aichi, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sadayuki Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jun Ouchida
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuaki Morishita
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryotaro Oishi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ippei Yamauchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Kawakami M, Takeshita K, Inoue G, Sekiguchi M, Fujiwara Y, Hoshino M, Kaito T, Kawaguchi Y, Minetama M, Orita S, Takahata M, Tsuchiya K, Tsuji T, Yamada H, Watanabe K. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication. J Orthop Sci 2023; 28:46-91. [PMID: 35597732 DOI: 10.1016/j.jos.2022.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/17/2022] [Accepted: 03/29/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine. METHODS The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members. RESULTS Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided. CONCLUSIONS The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.
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Affiliation(s)
| | | | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University, Japan
| | - Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University, Japan
| | - Yasushi Fujiwara
- Department of Orthopaedic Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Masatoshi Hoshino
- Department of Orthopaedic Surgery, Osaka City General Hospital, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University, Japan
| | | | - Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Sumihisa Orita
- Center for Frontier Medical Engineering (CFME), Department of Orthopaedic Surgery, Chiba University, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Japan
| | | | - Takashi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Japan
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Wakayama Medical University, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University, Japan
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Ramakrishna VAS, Chamoli U, Mukhopadhyay SC, Diwan AD, Prusty BG. Measuring compressive loads on a 'smart' lumbar interbody fusion cage: Proof of concept. J Biomech 2023; 147:111440. [PMID: 36640615 DOI: 10.1016/j.jbiomech.2023.111440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/08/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
There are several complications associated with lumbar interbody fusion surgery however, pseudarthrosis (non-union) presents a multifaceted challenge in the postoperative management of the patient. Rates of pseudarthrosis range from 3 to 20 % in patients with healthy bone and 20 to 30 % in patients with osteoporosis. The current methods in post-operative follow-up - radiographs and CT, have high false positive rates and poor agreement between them. The aim of this study was to develop and test a proof-of-concept load-sensing interbody cage that may be used to monitor fusion progression. Piezoresistive pressure sensors were calibrated and embedded within a polyether ether ketone (PEEK) interbody cage. Silicone and poly (methyl methacrylate) (PMMA) were inserted in the graft regions to simulate early and solid fusion. The load-sensing cage was subjected to distributed and eccentric compressive loads up to 900 N between synthetic lumbar vertebral bodies. Under maximum load, the anterior sensors recorded a 56-58 % reduction in pressure in the full fusion state compared to early fusion. Lateral regions measured a 36-37 % stress reduction while the central location reduced by 45 %. The two graft states were distinguishable by sensor-recorded pressure at lower loads. The sensors more effectively detected left and right eccentric loads compared to anterior and posterior. Further, the load-sensing cage was able to detect changes in endplate stiffness. The proof-of-concept 'smart' cage could detect differences in fusion state, endplate stiffness, and loading conditions in this in vitro experimental setup.
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Affiliation(s)
- Vivek A S Ramakrishna
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, Kensington, New South Wales, Australia; Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; School of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia.
| | - Uphar Chamoli
- Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; School of Biomedical Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Subhas C Mukhopadhyay
- School of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - Ashish D Diwan
- Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Spine Service, Department of Orthopaedic Surgery St. George Hospital Campus, Kogarah, New South Wales, Australia
| | - B Gangadhara Prusty
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, Kensington, New South Wales, Australia
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Beneficial influence of single-stage posterior surgery for the treatment of lumbar brucella spondylitis combined with spondylolisthesis. Sci Rep 2022; 12:19459. [PMID: 36376442 PMCID: PMC9663560 DOI: 10.1038/s41598-022-24223-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to evaluate the clinical efficacy of the single-stage posterior surgical treatment for patients of lumbar brucella spondylitis combined with spondylolisthesis. In this study, we performed a retrospective analysis of 16 patients with lumbar brucellosis spondylitis combined with spondylolisthesis from January 2015 to January 2019. All patients underwent single-stage posterior lumbar debridement, reduction, interbody fusion, and instrumentation. Preoperative and postoperative of the visual analog scale (VAS), the Oswestry disability index (ODI), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared. In addition, the spondylolisthesis reduction rate, reduction loss rate, interbody fusion rate, and complication rate were recorded. VAS, ODI, ESR, and CRP were conducted with repeated analysis of variance data at different follow-ups. The postoperative follow-up was 12-36 months, with an average of (25.0 ± 8.1) months. VAS, ODI, ESR, and CRP were significantly better at 2-week and 1-year follow-up than preoperative results (P = 0.000, respectively). In addition, 1 year after the operation, VAS, ODI, ESR, and CRP showed a significant improvement (P = 0.000, respectively). The average spondylolisthesis reduction in 2 weeks after operation was (91.2 ± 6.7)%, and the median reduction loss rate in 1 year after operation was 8.0 (5.0, 9.8)%. At the last follow-up, all patients achieved interbody fusion, no loosening and fracture of instrumentation were found, and no recurrence happened. Single-stage posterior operation for lumbar debridement, reduction, interbody fusion, and instrumentation is beneficial for treating lumbar brucellosis spondylitis combined with spondylolisthesis. Furthermore, the reconstruction of spinal stability may relieve pain, heal lesions, and improve patients' living.
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Liu H, Li J, Sun Y, Wang X, Wang W, Guo L, Zhang F, Zhang P, Zhang W. A Comparative Study of a New Retractor‐Assisted WILTSE TLIF, MIS‐TLIF, and Traditional PLIF for Treatment of Single‐Level Lumbar Degenerative Diseases. Orthop Surg 2022; 14:1317-1330. [PMID: 35603557 PMCID: PMC9251281 DOI: 10.1111/os.13289] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives To compare the clinical efficacy of a new retractor‐assisted Wiltse transforaminal lumbar interbody fusion (TLIF), minimally invasive TLIF (MIS‐TLIF), and traditional posterior lumbar interbody fusion (PLIF) in treating single‐level lumbar degenerative diseases. Methods A retrospective study was conducted by analyzing the clinical and imaging data of consecutive patients with single‐level lumbar degenerative diseases who underwent the new retractor‐assisted Wiltse TLIF, MIS‐TLIF, or traditional PLIF. This study enrolled 87 concurrent patients between June 2016 and December 2019 (Wiltse TLIF 29 cases; MIS‐TLIF 28 cases; PLIF 30 cases). The three groups were compared for perioperative indicators (including intraoperative blood loss, postoperative drainage volume, operation time, intraoperative fluoroscopy time, bedridden time), creatine kinase (CK), visual analog score (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score, intervertebral fusion rate, muscle atrophy, and fatty infiltration (including ratio of multifidus atrophy and ratio of lean‐to‐total cross‐sectional area [CSA]). Results Intraoperative blood loss (F = 62.628, p < 0.001), postoperative drainage volume (F = 72.048, p < 0.001), and bedridden time (χ2 = 62.289, p < 0.001) were significantly lower in the MIS‐TLIF and Wiltse groups than in the PLIF group. The operative and intraoperative radiation times of the MIS‐TLIF group were significantly longer than those of the Wiltse and PLIF groups. The CK concentration in the Wiltse and MIS‐TLIF groups were significantly lower than those in the PLIF group 1 day (F = 9.331, p < 0.001) and 3 days after surgery (F = 15.967, p < 0.001). The PLIF group's back pain VAS score was higher than those of the Wiltse and MIS‐TLIF groups. The PLIF group had a higher ODI 6 months (F = 3.282, p = 0.042) and 12 months (F = 5.316, p = 0.007) after surgery and a lower JOA score than the Wiltse and MIS‐TLIF groups 6 months (F = 3.234, p = 0.044) and 12 months (F = 3.874, p = 0.025) after surgery. The ratio of multifidus atrophy in the PLIF group (41.70 ± 8.84%) was significantly higher than those of the Wiltse group (24.13 ± 6.82%) and the MIS‐TLIF group (22.35 ± 5.03%). The ratio of lean‐to‐total CSA in the PLIF group was lower than those of the Wiltse and MIS‐TLIF groups after surgery (F = 8.852, p < 0.001). MIS‐TLIF group showed longer operation time (169.11 ± 29.38 min) and intraoperative fluoroscopy time (87.61 ± 3.13 s) than the Wiltse group. Conclusion Wiltse TLIF assisted by the new retractor is a more convenient and minimally invasive surgical method than the traditional PLIF and MIS‐TLIF methods, which are linked to a long learning curve and long operation and fluoroscopy time.
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Affiliation(s)
- Huanan Liu
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
| | - Jiaqi Li
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
| | - Yapeng Sun
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
| | - Xianzheng Wang
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
| | - WeiJian Wang
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
| | - Lei Guo
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
| | - Fei Zhang
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
| | - Peng Zhang
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
| | - Wei Zhang
- Department of Spinal Surgery The Third Hospital of Hebei Medical University Shijiazhuang China
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Zhang W, Li L, Zhou X, Li K, Liu C, Lin X, Lubisi N, Chen J, Si H. Concurrent Treatment with Vitamin K2 and D3 on Spine Fusion in Patients with Osteoporosis-Associated Lumbar Degenerative Disorders. Spine (Phila Pa 1976) 2022; 47:352-360. [PMID: 34919073 DOI: 10.1097/brs.0000000000004309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective and nonrandomized concurrent controlled trial. OBJECTIVE To address the early effects of concurrent treatment with vitamin K2 and vitamin D3 on fusion rates in patients who have undergone spinal surgery. SUMMARY OF BACKGROUND DATA Intervertebral pseudarthrosis has been reported after transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF), especially in patients with osteopenia or osteoporosis. No study has assessed the early effects of concurrent treatment with vitamin K2 and vitamin D3 on fusion rates. METHODS Patients with osteopenia or osteoporosis who underwent TLIF or PLIF in our department were included. Patients in the VK2+VD3 group received vitamin K2, vitamin D3, and calcium treatment, whereas subjects in the control group only received calcium and vitamin D3. Spine fusion was evaluated by computed tomography. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOA-BPEQ) and visual analog scale (VAS) were used to assess the clinical and neurological symptoms. Bone mineral density (BMD) and bone metabolism markers were measured for osteoporotic evaluation. RESULTS Seventy-eight patients were included, and nine patients subsequently discontinued because of 2019-nCoV. At six months postoperatively, complete fusion rates were significantly higher in the VK2+VD3 group than that in the control group (91.18% vs 71.43%, P = 0.036). At six months postoperatively, BMD was increased in the VK2+VD3 group and was higher than that in the control group, although there was no significant difference. At three months postoperatively, a significant increase in procollagen type I amino terminal propeptide (91.81%) and a slight decrease in C-terminal end peptide (8.06%) were observed in the VK2+VD3 group. In both groups, the JOA-BPEQ and VAS scores were significantly improved after spine surgery. CONCLUSION Administration of vitamin K2 and vitamin D3 can increase lumbar interbody fusion rates, improve clinical symptoms, promote bone information, and avoid further decline in BMD within six months after TLIF or PLIF.Level of Evidence: 3.
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Affiliation(s)
- Wencan Zhang
- Department of Orthopedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
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Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVE The aim of this study was to evaluate the prevalence of pseudarthrosis following antepsoas (ATP) lumbar and lumbosacral fusions. SUMMARY OF BACKGROUND DATA Pseudarthrosis is a feared complication following spinal fusions and may affect their clinical outcomes. To date there are no sufficient data on the fusion rate following ATP lumbar and lumbosacral arthrodesis. METHODS This is a retrospective review of 220 patients who underwent lumbar minimally invasive antepsoas (MIS-ATP) fusions between January 2008 and February 2019 who have at least 1-year postoperative computed tomography (CT) follow-up scans. Fusion was graded using CT scans imaging and adopting a 1-4 grading scale (1, definitely fused; 2, likely fused; 3, likely not fused; 4, definitely not fused/nonunion). Grades 3 or 4 indicate pseudarthrosis. RESULTS A total of 220 patients (average age: 66 years, 82 males (37.2%), and 127 (57.7%) smokers) were included. Eight patients (3.6%) developed pseudarthrosis. A total of 693 discs were addressed using the ATP approach. Of those, 681 (98.3%) were considered fused (641 levels [92.5%] were "definitely fused" and 40 levels [5.8%] were "Likely fused") and 12 discs (1.7%) developed pseudarthrosis (seven levels [1.0%] were "likely not fused" and five levels (0.7%) were "definitely not fused"). The highest rate of pseudarthrosis was found at L5-S1 (4.8%) compared to the L1-L5 discs (0-2%). Of 127 smokers, six developed pseudarthrosis (odds ratio = 2.3, P = 0.3). The fusion rates were 95.3% and 97.8% for smokers and nonsmokers, respectively. Of the eight patients who developed pseudarthrosis, only four (50%) were symptomatic, of whom two (25%) required revision surgery. Both of these patients were smokers. The overall revision rate due to pseudarthrosis was 0.9% (two of 220 patients). CONCLUSION The MIS-ATP technique results in a high fusion rate (96.4% of patients; 98.3% of levels). Pseudarthrosis was noted mostly at the L5-S1 discs and in smokers.Level of Evidence: 4.
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Kato S, Terada N, Niwa O, Yamada M. Factors Affecting Incomplete L5/S Posterior Lumbar Interbody Fusion, Including Spinopelvic Sagittal Parameters. Asian Spine J 2021; 16:526-533. [PMID: 34470098 PMCID: PMC9441434 DOI: 10.31616/asj.2021.0064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/01/2021] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective observational study. Purpose In this study we identify risk factors, including patient demographics, sagittal parameters, and clinical examinations, affecting incomplete L5/S posterior lumbar interbody fusion (PLIF). Overview of Literature The lumbosacral spine is considered to have an interbody fusion rate lower than that of the lumbar spine, but few studies have investigated the cause, including investigating the pelvis. We believe that pelvic morphology can affect L5/S interbody fusion of the lumbosacral spine. Methods We observed 141 patients (61 men, 80 women; average age, 65.8 years) who had undergone PLIF and checked for the presence of L5/S interbody fusion. We investigated factors such as age, gender, the presence of diffuse idiopathic skeletal hyperostosis (DISH), fusion level, and grade 2 osteotomy, as well as pre-, post-, and post-preoperative L5/S disk height and angle, lumbar lordosis, Visual Analog Scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and pelvic incidence (PI), comparing those with and without L5/S interbody fusion. In addition, we analyzed the patients classified into short-level (n=111) and multi-level fusion groups (n=30). Results Overall, the L5/S interbody fusion rate was 70% (short-level, 78%; multi-level, 40%). Age and pre- and post-preoperative L5/S disk angle were significantly different in each fusion level group. DISH presence, grade 2 osteotomy, and postoperative VAS and JOA scores were significantly different in the short-level fusion group, whereas PI was significantly different in the multi-level fusion group. Conclusions Incomplete union after L5/S PLIF correlates with advanced age, many fusion levels, and a large value of preoperative and a small value of post-preoperative L5/S disk angles.
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Affiliation(s)
- Shinichi Kato
- Department of Orthopedic Surgery, Restorative Medicine of Neuro-Musculoskeletal System, School of Medicine, Fujita Health University, Nagoya, Japan
| | - Nobuki Terada
- Department of Orthopedic Surgery, Restorative Medicine of Neuro-Musculoskeletal System, School of Medicine, Fujita Health University, Nagoya, Japan
| | - Osamu Niwa
- Department of Orthopedic Surgery, Restorative Medicine of Neuro-Musculoskeletal System, School of Medicine, Fujita Health University, Nagoya, Japan
| | - Mitsuko Yamada
- Department of Orthopedic Surgery, Restorative Medicine of Neuro-Musculoskeletal System, School of Medicine, Fujita Health University, Nagoya, Japan
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Ramakrishna VAS, Chamoli U, Rajan G, Mukhopadhyay SC, Prusty BG, Diwan AD. Smart orthopaedic implants: A targeted approach for continuous postoperative evaluation in the spine. J Biomech 2020; 104:109690. [PMID: 32139096 DOI: 10.1016/j.jbiomech.2020.109690] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/17/2020] [Accepted: 02/23/2020] [Indexed: 11/16/2022]
Abstract
Real-time health monitoring systems are emerging in diverse medical fields, tracking biological and physiological signals for direct feedback to the user. Orthopaedics is yet to adapt to innovative trends in health monitoring. Despite an evident entry point during orthopaedic surgeries, clinicians remain unable to objectively examine the structural integrity and biomechanics in the operated region through implantable sensors. As such, postoperative advice can be non-specific and poorly guided. This perspective discusses the clinical need for load-sensing implants that address biomechanical postoperative monitoring, taking the example of spinal interbody cages. Research has attempted to establish sensing approaches in different orthopaedic settings; however, they fail to meet mechanical sensing requirements or lack in vivo translatability, especially in the spine. Polymeric flexible sensors and Microelectromechanical Systems (MEMS) have favourable attributes aligned to the required features for in vivo load-sensing, although these approaches are yet to be tested extensively in orthopaedics. While inductive powering is promising, wireless energy transfer and telemetry are areas of ongoing research. This perspective proposes a thorough understanding of the relevant biomechanics to identify the pertinent sensing parameters, concurrent treatment of sensing and powering aspects, and utilisation of energy harvesting for sensing and data transmission. While sensing advancements have contributed to the rise of real-time health monitoring in other fields of medicine, orthopaedics has so far been overlooked. It is the application of these innovations that will lead to the development of a new generation of 'smart' implants for continuous postoperative evaluation.
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Affiliation(s)
- Vivek A S Ramakrishna
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, Kensington, New South Wales, Australia; Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; School of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - Uphar Chamoli
- Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; School of Biomedical Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, Ultimo, New South Wales, Australia.
| | - Ginu Rajan
- School of Electrical, Computer and Telecommunications Engineering, University of Wollongong, New South Wales, Australia
| | - Subhas C Mukhopadhyay
- School of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - B Gangadhara Prusty
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, Kensington, New South Wales, Australia
| | - Ashish D Diwan
- Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Spine Service, Department of Orthopaedic Surgery St. George Hospital Campus, Kogarah, New South Wales, Australia
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11
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Formica M, Vallerga D, Zanirato A, Cavagnaro L, Basso M, Divano S, Mosconi L, Quarto E, Siri G, Felli L. Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: a meta-analysis and systematic review. Musculoskelet Surg 2020; 104:1-15. [PMID: 31894472 DOI: 10.1007/s12306-019-00634-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/21/2019] [Indexed: 12/20/2022]
Abstract
The aim of this meta-analysis and systematic review is to summarize and critically analyze the influence of surgery-related factors in lumbar interbody fusion for degenerative spine diseases. A systematic review of the literature was carried out with a primary search being performed on Medline through PubMed. The 2009 PRISMA flowchart and checklist were taken into account. Sixty-seven articles were included in the analysis: 48 studies were level IV of evidence, whereas 19 were level III. All interbody fusion techniques analyzed have proved to reach a good fusion rate. An overall mean fusion rate of 93% (95% CI 92-95%, p < 0.001) was estimated pooling the selected studies. The influence of sagittal parameters and cages features in fusion rate was not clear. Autograft is considered the gold standard material. The use of synthetic bone substitutes and biological factors alone or combined with bone graft have shown conflicting results. Low level of evidence studies and high heterogeneity (χ2 = 271.4, df = 72, p < 0.001; I2 = 73.5%, τ2 = 0.05) in data analysis could result in the risk of bias. Further high-quality studies would better clarify these results in the future.
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Affiliation(s)
- M Formica
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - D Vallerga
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy.
| | - A Zanirato
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - L Cavagnaro
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - M Basso
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - S Divano
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - L Mosconi
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - E Quarto
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - G Siri
- Department of Mathematics, University of Genoa, Via Dodecaneso 35, 16146, Genoa, GE, Italy
| | - L Felli
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
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12
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Konomi T, Yasuda A, Fujiyoshi K, Yato Y, Asazuma T. Incidences and Risk Factors for Postoperative Non-Union after Posterior Lumbar Interbody Fusion with Closed-Box Titanium Spacers. Asian Spine J 2019; 14:106-112. [PMID: 31608613 PMCID: PMC7010511 DOI: 10.31616/asj.2019.0024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 04/17/2019] [Indexed: 11/26/2022] Open
Abstract
Study Design A retrospective, single-center clinical study with follow-up of more than 24 months. Purpose To evaluate the union rates and relevant risk factors for non-union after posterior lumbar interbody fusion (PLIF) using porous-coated closed-box titanium spacers. Overview of Literature Although the use of a closed-box interbody spacer for PLIF could avoid potential complications associated with the harvesting of autologous bone, few studies have reported detailed follow-up of fusion progression and risk factors for non-union in the early postoperative period. Methods PLIF using closed-box spacers without filling the autologous bone was performed in 78 (88 levels) consecutive patients. Surgical procedures included PLIF using traditional pedicle screw fixation (PLIF, n=37), PLIF using cortical bone trajectory screw fixation (CBT-PLIF, n=30), and transforaminal lumbar interbody fusion with traditional pedicle screw fixation (TLIF, n=11). Lateral dynamic radiography and computed tomography findings were investigated, and the relationship between the union status and variables that may be related to the risk of non-union was tested statistically. Results The overall bone union rates at 12 and 24 months were 68.0% and 88.5%, respectively. Incidences of bone cyst formation, subsidence, and retropulsion of spacers were 33.3%, 47.4%, and 14.1%, respectively. Union rates at 24 months were 94.6% in PLIF, 80.0% in CBT-PLIF, and 90.9% in TLIF. Multivariate logistic regression analyses showed that at 12 months postoperatively, the risk factor for non-union was age >75 years (p =0.02). In contrast, no significant risk factor was observed at 24 months. Conclusions These findings demonstrated the efficacy of interbody closed-box spacers for PLIF without the need to fill the spacer with autologous bone. However, the risk of non-union should be considered in elderly patients, especially intra-operatively and during the early postoperative stage.
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Affiliation(s)
- Tsunehiko Konomi
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
| | - Akimasa Yasuda
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
| | - Kanehiro Fujiyoshi
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
| | - Yoshiyuki Yato
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
| | - Takashi Asazuma
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
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13
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Koleva PM, Keefer JH, Ayala AM, Lorenzo I, Han CE, Pham K, Ralston SE, Kim KD, Lee CC. Hyper-Crosslinked Carbohydrate Polymer for Repair of Critical-Sized Bone Defects. Biores Open Access 2019; 8:111-120. [PMID: 31346493 PMCID: PMC6657362 DOI: 10.1089/biores.2019.0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study evaluated the safety and efficacy of a novel hyper-crosslinked carbohydrate polymer (HCCP) for the repair of critical-sized bone defects in comparison to two alternative treatments: autologous bone and poly(lactide-co-glycolide) with hyaluronic acid (PLGA/HA). Bilateral critical-sized defects were created in the lateral femoral condyles of skeletally mature New Zealand White rabbits, and they were subsequently implanted with HCCP, PLGA/HA, or autologous bone in a randomized manner. Clinical and behavioral observations were made daily, and radiological and histopathological evaluations were performed at 4, 10, and 16 weeks postimplantation. Defects implanted with HCCP showed progressive bone regeneration and bridging of the defect without adverse histological events. No signs of infection or inflammation associated with the implant material were observed in all animals that received HCCP implantation. A radiographic assessment performed at 16 weeks post-implantation showed significantly higher bone density and volume in defects implanted with HCCP compared to PLGA/HA. No statistically significant difference was observed in bone density and volume between HCCP and autologous bone. These findings demonstrate that HCCP is biocompatible, osteoconductive, and capable of promoting bone regeneration in vivo; therefore, it is suitable for both tissue engineering and the repair of critical-sized bone defects.
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Affiliation(s)
| | | | | | | | | | - Kristen Pham
- Molecular Matrix, Inc., West Sacramento, California
| | | | - Kee D Kim
- Department of Neurological Surgery, UC Davis School of Medicine, Sacramento, California
| | - Charles C Lee
- Department of Cell Biology and Human Anatomy, School of Medicine, University of California, Davis, California
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Park MK, Kim KT, Bang WS, Cho DC, Sung JK, Lee YS, Lee CK, Kim CH, Kwon BK, Lee WK, Han I. Risk factors for cage migration and cage retropulsion following transforaminal lumbar interbody fusion. Spine J 2019; 19:437-447. [PMID: 30142459 DOI: 10.1016/j.spinee.2018.08.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 08/09/2018] [Accepted: 08/09/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Transforaminal lumbar interbody fusion (TLIF) is a widely accepted surgical procedure, but cage migration (CM) and cage retropulsion (CR) are associated with poor outcomes. PURPOSE This study seeks to identify risk factors associated with these serious events. STUDY DESIGN A prospective observational longitudinal study. PATIENT SAMPLE Over a 5-year period, 881 lumbar levels in 784 patients were treated using TLIF at three spinal surgery centers. OUTCOME MEASURES We evaluated the odds ratio of the risk factors for CM with and without subsidence and CR in multivariate analysis. METHODS Our study classified CM into two subgroups: CM without subsidence and CM with subsidence. Cases of spinal canal and/or foramen intrusion of the cage was defined separately as CR. Patient records, operative notes, and radiographs were analyzed for factors potentially related to CM with subsidence, CM without subsidence, and CR. RESULTS Of 881 lumbar levels treated with TLIFs, CM without subsidence was observed in 20 (2.3%) and CM with subsidence was observed in 36 (4.1%) patients. Among the CM cases, CR was observed in 17 (17/56, 30.4%). The risk factors of CM without subsidence were osteoporosis (OR 8.73, p < .001) and use of a unilateral single cage (OR 3.57, p < .001). Osteoporosis (OR 5.77, p < .001) and endplate injury (OR 26.87, p < .001) were found to be significant risk factors for CM with subsidence. Risk factors of CR were osteoporosis (OR 7.86, p < .001), pear-shaped disc (OR 8.28, p = .001), endplate injury (OR 18.70, p < .001), unilateral single cage use (OR 4.40, p = .03), and posterior cage position (OR 6.45, p = .04). A difference in overall fusion rates was identified, with a rate of 97.1% (801 of 825) for no CM, 55.0% (11 of 20) for CM without subsidence, 41.7% (15 of 36) for CM with subsidence, and 17.6% (3 of 17) for CR at 1.5 years postoperatively. CONCLUSIONS Our results suggest that osteoporosis is a significant risk factor for both CM and CR. In addition, a pear-shaped disc, posterior positioning of the cage, the presence of endplate injury and the use of a single cage were correlated with the CM with and without subsidence and CR.
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Affiliation(s)
- Man-Kyu Park
- Department of Neurosurgery, Parkweonwook Hospital, 130, 4, Gwangan-ro, Suyeong-gu, Busan 48298, Republic of Korea
| | - Kyoung-Tae Kim
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130, Dongdeok-ro, Jung-gu, Daegu 41944, Republic of Korea.
| | - Woo-Seok Bang
- Department of Neurosurgery, Daegu Chamtntn hospital, 1807, Dalgubeol-daero, Seo-gu, Daegu, Republic of Korea
| | - Dae-Chul Cho
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130, Dongdeok-ro, Jung-gu, Daegu 41944, Republic of Korea
| | - Joo-Kyung Sung
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130, Dongdeok-ro, Jung-gu, Daegu 41944, Republic of Korea
| | - Young-Seok Lee
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - Chang Kyu Lee
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Jung-gu, Daegu, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada; Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
| | - Won-Kee Lee
- Medical Research Collaborating Center in Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Inbo Han
- Department of Neurosurgery, CHA University, School of Medicine, CHA Bundang Medical Center, Seongnam-si, Gyeonggido, Republic of Korea
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15
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Aono H, Takenaka S, Nagamoto Y, Tobimatsu H, Yamashita T, Furuya M, Iwasaki M. Fusion Rate and Clinical Outcomes in Two-Level Posterior Lumbar Interbody Fusion. World Neurosurg 2018; 112:e473-e478. [PMID: 29355805 DOI: 10.1016/j.wneu.2018.01.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Posterior lumbar interbody fusion (PLIF) has become a general surgical method for degenerative lumbar diseases. Although many reports have focused on single-level PLIF, few have focused on 2-level PLIF, and no report has covered the fusion status of 2-level PLIF. The purpose of this study is to investigate clinical outcomes and fusion for 2-level PLIF by using a combination of dynamic radiographs and multiplanar-reconstruction computed tomography scans. METHODS This study consisted of 48 consecutive patients who underwent 2-level PLIF for degenerative lumbar diseases. We assessed surgery duration, estimated blood loss, complications, clinical outcomes as measured by the Japanese Orthopaedic Association score, lumbar sagittal alignment as measured on standing lateral radiographs, and fusion status as measured by dynamic radiographs and multiplanar-reconstruction computed tomography. Patients were examined at a follow-up point of 4.8 ± 2.2 years after surgery. Thirty-eight patients who did not undergo lumbosacral fusion comprised the lumbolumbar group, and 10 patients who underwent lumbosacral fusion comprised the lumbosacral group. RESULTS The mean Japanese Orthopaedic Association score improved from 12.1 to 22.4 points by the final follow-up examination. Sagittal alignment also was improved. All patients had fusion in the cranial level. Seven patients had nonunion in the caudal level, and the lumbosacral group (40%) had a significantly poorer fusion rate than the lumbolumbar group (97%) did. CONCLUSIONS Surgical outcomes of 2-level PLIF were satisfactory. The fusion rate at both levels was 85%. All nonunion was observed at the caudal level and concentrated at L5-S level in L4-5-S PLIF.
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Affiliation(s)
- Hiroyuki Aono
- Orthopedic Surgery, Osaka National Hospital, Osaka, Japan.
| | - Shota Takenaka
- Orthopedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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16
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Zeitoun R, Hussein M. Approach to interpret images produced by new generations of multidetector CT scanners in post-operative spine. Br J Radiol 2017; 90:20170082. [PMID: 28869390 DOI: 10.1259/bjr.20170082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To reach a practical approach to interpret MDCT findings in post-operative spine cases and to change the false belief of CT failure in the setting of instruments secondary to related artefacts. METHODS We performed observational retrospective analysis of premier, early and late MDCT scans in 68 post-operative spine patients, with emphasis on instruments related complications and osseous fusion status. We used a grading system for assessment of osseous fusion in 35 patients and we further analysed the findings in failure of fusion, grade (D). RESULTS We observed a variety of instruments related complications (mostly screws medially penetrating the pedicle) and osseous fusion status in late scans. We graded 11 interbody and 14 posterolateral levels as osseous fusion failure, showing additional instruments related complications, end plates erosive changes, adjacent segments spondylosis and malalignment. CONCLUSION Modern MDCT scanners provide high quality images and are strongly recommended in assessment of the instruments and status of osseous fusion. In post-operative imaging of the spine, it is essential to be aware for what you are looking for, in relevance to the date of surgery. Advances in knowledge: Modern MDCT scanners allow assessment of instruments position and integrity and osseous fusion status in post-operative spine. We propose a helpful algorithm to simplify interpreting post-operative spine imaging.
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Affiliation(s)
- Rania Zeitoun
- Department of Diagnostic and Interventional Radiology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Manar Hussein
- Department of Diagnostic and Interventional Radiology, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Huang WM, Yu XM, Xu XD, Song RX, Yu LL, Yu XC. Posterior Lumbar Interbody Fusion with Interspinous Fastener Provides Comparable Clinical Outcome and Fusion Rate to Pedicle Screws. Orthop Surg 2017; 9:198-205. [PMID: 28544495 DOI: 10.1111/os.12328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 02/16/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To investigate the clinical feasibility and validity of interspinous fastener (ISF) for lumbar degenerative diseases. METHODS From October 2013 to March 2014, a total of 46 patients suffering from lumbar degenerative diseases underwent posterior lumbar interbody fusion (PLIF) randomly augmented by ISF or pedicle screws. The clinical outcome was primarily measured by Oswestry Disability Index (ODI) score. The minimal clinical important difference (MCID) was defined as an eight-point decrease in ODI. The second clinical outcome measurement was Japanese Orthopedic Association (JOA) score. Interbody fusion rates were evaluated by lumbar plain radiograph and computed tomography (CT) scan. Complications were also compared between groups. Statistical analyses were performed by SPSS version 13.0. Sample size calculation was performed before the study. The type I error α was set at 0.05 and the type II error β at 0.1. Based on these assumptions and adding 10% for possible drop-outs, sample size calculations indicated that a total of 46 patients were required for the study. Parametric data was compared by independent t-test and categorical variables were compared using χ2 -tests or Fisher exact tests depending on the sample size. A P-value of less than 0.05 was considered significantly statistically different. Fleiss kappa coefficients were calculated for intra-observer and inter-observer reliability. RESULTS A total of 43 patients completed the follow-up, with 22 cases in the ISF group and 21 patients in the pedicle screws group, respectively. Less intraoperative blood loss and shorter operation time were observed in the ISF group. The mean ODI significantly declined in both groups, with the ISF group's decreasing from preoperative 43.3 ± 8.2 to 21.4 ± 3.5 at 24-month follow-up and the pedicle screws group's decreasing from preoperative 42.9 ± 7.9 to 22.5 ±3.8 at 24-month follow-up, respectively. The ODI changes between groups had no statistical difference (P > 0.05). Of the 43 patients, 33 patients achieved an MCID. The bone fusion rate was 77.3% according to X-rays and 68.2% according to CT scans in the ISF group, and 81.0% according to X-rays and 76.2% according to CT scans in the pedicle screws group at the final follow-up. The intra-observer and inter-observer reliability assessed by the kappa value were 0.93 and 0.89, respectively. One patient in the pedicle screws group demonstrated screw loosening at the 6-month follow-up but was asymptomatic. One patient with spondylolisthesis in the ISF group demonstrated cage subsidence during the follow-up but also without related symptoms. CONCLUSION The less invasive ISF combined with PLIF provided comparable clinical outcome and a similar bone fusion rate to pedicle screws. The ISF could potentially serve as a new alternative for lumbar degenerative diseases.
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Affiliation(s)
- Wei-Min Huang
- Department of Orthopaedics, General Hospital of Jinan Military Commanding Region, Jinan, China
| | - Xing-Ming Yu
- Postgraduate Training Base in General Hospital of Jinan Military Command, Liaoning Medical University, Jinzhou, China
| | - Xiao-Duo Xu
- Department of Orthopaedics, General Hospital of Jinan Military Commanding Region, Jinan, China
| | - Ruo-Xian Song
- Department of Orthopaedics, General Hospital of Jinan Military Commanding Region, Jinan, China
| | - Li-Li Yu
- Department of Statistics, General Hospital of Jinan Military Commanding Region, Jinan, China
| | - Xiu-Chun Yu
- Department of Orthopaedics, General Hospital of Jinan Military Commanding Region, Jinan, China
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Hayashi K, Matsumura A, Konishi S, Kato M, Namikawa T, Nakamura H. Clinical Outcomes of Posterior Lumbar Interbody Fusion for Patients 80 Years of Age and Older with Lumbar Degenerative Disease: Minimum 2 Years' Follow-Up. Global Spine J 2016; 6:665-672. [PMID: 27781186 PMCID: PMC5077711 DOI: 10.1055/s-0036-1578806] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/11/2016] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Kazunori Hayashi
- Department of Orthopedic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Akira Matsumura
- Department of Orthopedic Surgery, Osaka City General Hospital, Osaka, Japan,Address for correspondence Akira Matsumura, MD, PhD 2-13-22 Miyakojimahondori, Miyakojima-Ku534-0021, OsakaJapan
| | - Sadahiko Konishi
- Department of Orthopedic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Minori Kato
- Department of Orthopedic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Takashi Namikawa
- Department of Orthopedic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopedic Surgery, Osaka City Graduate School of Medicine, Osaka, Japan
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Silverman SL, Kupperman ES, Bukata SV. Fracture healing: a consensus report from the International Osteoporosis Foundation Fracture Working Group. Osteoporos Int 2016; 27:2197-2206. [PMID: 27112766 DOI: 10.1007/s00198-016-3513-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 02/02/2016] [Indexed: 12/14/2022]
Abstract
UNLABELLED We used the RAND UCLA appropriateness method to decide appropriateness of use of osteoporosis medication after incident fracture and potential for fracture healing and make suggestions for trial design for clinical and preclinical research. PURPOSE To develop appropriateness criteria to assist in the use and study of osteoporosis medications in patients with recent fracture and in the potential use of osteoporosis medications to enhance delayed fracture healing. To promote further research by suggesting preclinical and clinical trial design for studies where fracture healing is the endpoint. DESIGN RAND/UCLA appropriateness method (RUAM). PARTICIPANTS A panel of experts, both members and non-members of the International Osteoporosis Foundation Fracture Working Group, were identified consisting of geriatricians, rheumatologists, orthopedists, endocrinologists, and internists. This resulted in a round 1 panel of 15 panelists, round 2 panel of 15 members, and a round 3 panel of 14 members. MAIN OUTCOME MEASURE Agreement on statements and scenarios using RUAM. Three rounds of voting by panelists took place. Agreement in a third round was reached for 111 statements and scenarios, measured by median panel ratings and the amount of dispersion of panel ratings, based on the interpercentile range. RESULTS An expert panel validated a set of statements and scenarios about the use of osteoporosis medications after incident fracture and use of these medications to enhance delayed fracture healing and made recommendations for study designs to investigate the effect of osteoporosis medications on fracture healing. CONCLUSIONS The result of this exercise is intended to assist in improving patient care by identifying the appropriateness of use of osteoporosis medications after fracture and in fracture healing and to make suggestions for further preclinical and clinical research.
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Affiliation(s)
- S L Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
| | - E S Kupperman
- UCLA Department of Orthopedics, Santa Monica, CA, USA
| | - S V Bukata
- UCLA Department of Orthopedics, Santa Monica, CA, USA
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Takeuchi M, Kamiya M, Wakao N, Hirasawa A, Kawanami K, Osuka K, Takayasu M. Large volume inside the cage leading incomplete interbody bone fusion and residual back pain after posterior lumbar interbody fusion. Neurosurg Rev 2015; 38:573-8; discussion 578. [PMID: 25666390 DOI: 10.1007/s10143-015-0610-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 05/20/2014] [Accepted: 11/16/2014] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Mikinobu Takeuchi
- Department of Spine Center, Aichi Medical University Hospital, Karimata Yazako, Nagakute, Aichi, 480-1195, Japan,
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Abstract
This article reviews the imaging of lumbar spinal fusion and its major indications. The most common procedures are described for the purpose of allowing understanding of postoperative imaging. Imaging options are reviewed for preoperative workup, intraoperative guidance, and postoperative purposes. Examples of hardware integrity, fusion, and loosening are provided.
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Affiliation(s)
- Richard Zampolin
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Amichai Erdfarb
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Todd Miller
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
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Ouchida J, Yukawa Y, Ito K, Machino M, Inoue T, Tomita K, Kato F. Functional computed tomography scanning for evaluating fusion status after anterior cervical decompression fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:2924-9. [PMID: 25537819 DOI: 10.1007/s00586-014-3722-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 12/07/2014] [Accepted: 12/08/2014] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Nonunion is a major complication of anterior cervical fusion that causes poor outcomes and occasionally requires additional operative intervention. The purpose of this study is to evaluate the accuracy of functional computed tomography (CT) scanning for determining fusion status after anterior cervical fusion by comparing with functional radiographs. MATERIALS AND METHODS The fusion status in 59 patients treated by anterior cervical fusion was assessed by functional radiography and functional CT scanning at 6 and 12 months after surgery. Fusion rates and clinical symptoms were evaluated. Fusion on functional radiography was defined as less than 2 mm of motion between adjacent spinous processes and a particular bony trabeculation on functional CT; fusion was defined as nonexistence of a clear zone or a gas pattern and a particular bone connection on reconstructed sagittal-view images. RESULTS Functional radiographs demonstrated solid fusion in 83.9% at 6 months and 91.1% at 12 months postoperatively; functional CT showed solid fusion in 55.3 and 78.6%, respectively. The fusion rate detected on functional CT images was significantly lower than that on functional radiographs at each period. At 6 months postoperatively, patients with incomplete union on functional CT were more likely to have neck pain than those who had complete union on functional CT. (46.2 vs 13.3%, P < 0.05) CONCLUSION: Functional CT can detect nonunion more clearly than functional radiography. At 6 months postoperatively, patients with incomplete union on functional CT images were likely to have more neck pain. Functional CT may allow accurate detection of symptomatic nonunion after anterior cervical fusion.
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Affiliation(s)
- Jun Ouchida
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, 1-10-6 Komei, Minato-ku, Nagoya, Aichi, 455-8530, Japan.
| | - Yasutsugu Yukawa
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, 1-10-6 Komei, Minato-ku, Nagoya, Aichi, 455-8530, Japan
| | - Keigo Ito
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, 1-10-6 Komei, Minato-ku, Nagoya, Aichi, 455-8530, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, 1-10-6 Komei, Minato-ku, Nagoya, Aichi, 455-8530, Japan
| | - Taro Inoue
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, 1-10-6 Komei, Minato-ku, Nagoya, Aichi, 455-8530, Japan
| | - Keisuke Tomita
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, 1-10-6 Komei, Minato-ku, Nagoya, Aichi, 455-8530, Japan
| | - Fumihiko Kato
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, 1-10-6 Komei, Minato-ku, Nagoya, Aichi, 455-8530, Japan
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Makino T, Kaito T, Fujiwara H, Ishii T, Iwasaki M, Yoshikawa H, Yonenobu K. Does fusion status after posterior lumbar interbody fusion affect patient-based QOL outcomes? An evaluation performed using a patient-based outcome measure. J Orthop Sci 2014; 19:707-12. [PMID: 24916199 DOI: 10.1007/s00776-014-0591-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 05/18/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although delayed union or pseudoarthrosis after lumbar arthrodesis has been recognized as a major radiographic complication, little has been known about the effect of fusion status on the patient's quality-of-life (QOL) outcome. The purpose of this study was to investigate the effects of fusion status after posterior lumbar interbody fusion (PLIF) on QOL outcomes by using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). METHODS Among 100 patients who underwent single level PLIF for spinal canal stenosis, 29 who had not achieved fusion (incomplete fusion group) and 29 age- and sex ratio-matched patients who had achieved fusion (fusion group) 6 months after surgery were enrolled. Overall clinical evaluation was performed before and 6 months after surgery: the physician determined the Japanese Orthopaedic Association Score for Low Back Pain (JOA score); the JOABPEQ and visual analogue scale (VAS) values were collected. The recovery rate of the JOA score, changes in all JOABPEQ subdomain scores and in the VAS values were calculated. All variables were compared between the groups. RESULTS The preoperative JOA scores, JOABPEQ scores of all subdomains, and VAS values of all categories did not differ between the groups. The recovery rate was higher in the fusion group than the incomplete fusion group (p = 0.0185). The changes in the JOABPEQ scores for walking ability and social life function were significantly greater in the fusion group than the incomplete fusion group (walking ability, p = 0.0172; social life function, p = 0.0191). The postoperative VAS values and changes in the VAS values for all categories did not differ between the groups. CONCLUSIONS Incomplete fusion after PLIF correlated with poor improvement in walking ability and social life function. Therefore, the achievement of fusion after PLIF is essential to obtain better patient QOL outcomes.
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Affiliation(s)
- Takahiro Makino
- Department of Orthopedic Surgery, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashi, Kawachinagano, Osaka, 586-8521, Japan,
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Gotfryd AO, Pomar FDM, Carneiro Neto NJ, Franzin FJ, Rodrigues LMR, Poletto PR. Reliability analysis of radiographic methods for determination of posterolateral lumbossacral fusion. EINSTEIN-SAO PAULO 2014; 12:198-203. [PMID: 25003926 PMCID: PMC4891163 DOI: 10.1590/s1679-45082014ao2964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/27/2013] [Indexed: 11/22/2022] Open
Abstract
Objective To analyze intra and interobserver agreement of two radiographic methods for evaluation of posterolateral lumbar arthrodesis. Methods Twenty patients undergoing instrumented posterolateral fusion were evaluated by anteroposterior and dynamic lateral radiographs in maximal flexion and extension. The images were evaluated initially by 6 orthopedic surgeons, and after 8 weeks, reassessed by 4 of them, totaling 400 radiographic measurements. Intra and interobserver reliability were analyzed using the Kappa coefficient and Landis and Koch criteria. Results Intra and interobserver agreement regarding anteroposterior radiographs were, respectively, 76 and 63%. On lateral views, these values were 78 and 84%, respectively. However, the Kappa analysis showed poor intra and interobserver agreement in most cases, regardless of the radiographic method used. Conclusion There was poor intra and interobserver agreement in the evaluation of lumbosacral fusion by plain film in anteroposterior and dynamic lateral views, with no statistical superiority between the methods.
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Ito Z, Imagama S, Kanemura T, Satake K, Ando K, Kobayashi K, Shinjo R, Yagi H, Hida T, Ito K, Ishikawa Y, Tsushima M, Matsumoto A, El Zahlawy H, Yamaguchi H, Matsuyama Y, Ishiguro N. Volumetric change in interbody bone graft after posterior lumbar interbody fusion (PLIF): a prospective study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:2144-9. [DOI: 10.1007/s00586-014-3410-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 06/06/2014] [Accepted: 06/07/2014] [Indexed: 10/25/2022]
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The use of beta-tricalcium phosphate and bone marrow aspirate as a bone graft substitute in posterior lumbar interbody fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:1173-82. [PMID: 23073745 DOI: 10.1007/s00586-012-2541-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 07/14/2012] [Accepted: 10/02/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Due to the disadvantages of iliac crest bone and the poor bone quality of autograft gained from decompression surgery, alternative filling materials for posterior lumbar interbody fusion cages have been developed. β-Tricalcium phosphate is widely used in cages. However, data regarding the fusion rate of β-TCP assessed by computer tomography are currently not available. MATERIALS A prospective clinical trial involving 34 patients (56.7 years) was performed: 26 patients were treated with single-level, five patients double-level and three patients triple-level PLIF filled with β-TCP and bone marrow aspirate perfusion, and additional posterior pedicle screw fixation. Fusion was assessed by CT and X-rays 1 year after surgery using a validated fusion scale published previously. Functional status was evaluated with the visual analogue scale and the Oswestry Disability Index before and 1 year after surgery. RESULTS Forty-five levels in 34 patients were evaluated by CT and X-ray with a follow-up period of at least 1 year. Clinically, the average ODI and VAS for leg and back scores improved significantly (P < 0.001). CT assessment revealed solid fusion in 12 levels (26.67%) and indeterminate fusion in 15 levels (34.09%). Inadequate fusion (non-union) was detected in 17 levels (38.63%). CONCLUSION The technique of PLIF using β-TCP yielded a good clinical outcome 1 year after surgery, however, a high rate of pseudoarthrosis was found in this series therefore, we do not recommend β-TCP as a bone graft substitute using the PLIF technique.
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Abstract
STUDY DESIGN A retrospective study was conducted to investigate the impact of vertebral endplate cyst formation on union status after lumbar interbody fusion. OBJECTIVE To assess the impact of cyst formation at the vertebral endplate in the early detection of nonunion after lumbar interbody fusion. The relationship between vertebral endplate cyst formation and subsequent union status was evaluated retrospectively using dynamic x-ray and computed tomography (CT) and multiplanar reconstruction. SUMMARY OF BACKGROUND DATA Although many studies have reported on the assessment of bony union after lumbar interbody fusion, no study has reported on the radiological risk factors for nonunion in the early postoperative period. The meaning and importance of vertebral endplate cyst formation have not been reported and should be clarified. METHODS Radiological vertebral endplate changes at 93 levels were assessed in 76 patients after transforaminal lumbar interbody fusion, using a titanium cage with pedicle screw fixation. Computed tomographic findings for the vertebral endplate at 3 months were compared between nonunion and union cases. The relationship between vertebral endplate cyst formation and union status was tested statistically. RESULTS Fifty-nine union cases were compared with 17 nonunion cases. The overall union rate was 75.2% at 1 year and 82.8% at 2 years. At 1 year, the sensitivity of cyst formation for subsequent nonunion was 69.6%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 90.9%. Multivariate logistic regression analysis showed that a multioperated back was a significant predictor of cyst formation (odds ratio [OR]: 3.8; 95% confidence interval [CI]: 1.1-13.1) and that cyst formation and multioperated back were significant predictors of nonunion (OR: 12.3; 95% CI: 1.8-133 and OR: 116; 95% CI: 22.4-infinity, respectively). CONCLUSION These findings show a relationship between vertebral endplate cyst formation in the early postoperative period and nonunion after lumbar interbody fusion. Endplate cyst formation is a useful early predictor of subsequent nonunion.
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