Posterior interbody fusion using a diagonal cage with unilateral transpedicular screw fixation for lumbar stenosis

Transforaminal Fusion Using Physiologically Integrated Titanium Cages with a Novel Design in Patients with Degenerative Spinal Disorders: A Pilot Study

More contemporary options have been presented in the last few years as surgical methods and materials have improved in patients with degenerative spine illnesses. The use of biologically integrated titanium cages of a unique design based on computer 3D modeling for the surgical treatment of patients with degenerative illnesses of the spine’s intervertebral discs has been proposed and experimentally tested. The goal of this study is to compare the radiographic and clinical outcomes of lumbar posterior interbody fusion with a 3D porous titanium alloy cage versus a titanium-coated polyetheretherketone (PEEK) cage, including fusion quality, time to fusion, preoperative and postoperative patient assessments, and the presence, severity, and other side effect characteristics. (1) Methods: According to the preceding technique, patients who were operated on with physiologically integrated titanium cages of a unique design based on 3D computer modeling were included in the study group. This post-surveillance study was conducted as a randomized, prospective, interventional, single-blind, center study to look at the difference in infusion rates and the difference compared to PEEK cages. The patients were evaluated using CT scans, Oswestry questionnaires (every 3, 6, and 12 months), and VAS scales. (2) Results: Six months following surgery, the symptoms of fusion and the degree of cage deflation in the group utilizing the porous titanium 3D cage were considerably lower than in the group using the PEEK cage (spinal fusion sign, p = 0.044; cage subsidence, p = 0.043). The control group had one case of cage migration into the spinal canal with screw instability, one case of screw instability without migration but with pseudoarthrosis formation and two surrounding segment syndromes with surgical revisions compared with the 3D porous titanium alloy cage group. (3) Conclusions: The technique for treating patients with degenerative disorders or lumbar spine instability with aspects of neural compression utilizing biologically integrated titanium cages of a unique design based on computer 3D printing from CT scans has been proven. This allows a new approach of spinal fusion to be used in practice, restoring the local sagittal equilibrium of the spinal motion segment and lowering the risk of pseudarthrosis and revision surgery.

Unilateral versus bilateral pedicle screw fixation with posterior lumbar interbody fusion for lumbar degenerative diseases: A meta-analysis

BACKGROUND

Both unilateral pedicle screw fixation with posterior lumbar interbody fusion (PLIF) and bilateral pedicle screw fixation with PLIF are used to treat lumbar degenerative diseases (LDD). However, which one is a better treatment for LDD remains considerable controversy. Therefore, the focus of this meta-analysis was to assess the merits and shortcomings of efficacy of these 2 surgical procedures for LDD.

METHODS

An extensive search of literature was performed in Pubmed/MEDLINE, Embase, CNKI, and WANFANG databases on unilateral versus bilateral pedicle screw fixation with PLIF fusion for LDD, from January 2007 to January 2017 and language was restricted to Chinese or English. The following variables were extracted: blood loss, operation time, length of hospital stay, Japanese Orthopedic Association (JOA) scores, visual analog scale (VAS) and Oswestry disability index (ODI) scores, fusion rate, total complications, infection, dural injury, and nerve injury. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

RESULTS

A total of 11 studies containing 844 patients were included in our study. The results showed that unilateral is better than bilateral pedicle screw fixation with PLIF in blood loss (P < .00001), operation time (P < .00001), the length of hospital stay (P = .003), and the final follow-up ODI scores (P = .04). However, there are no significant differences in JOA, VAS, and preoperative ODI scores. There are also no significant differences in fusion rate and complications (all P > .05).

CONCLUSION

Based on our meta-analysis, our results suggest that both unilateral pedicle screw fixation with PLIF and bilateral pedicle screw fixation with PLIF for LDD have effective results in clinical outcomes. Both 2 methods may result in clinical improvement and similar outcomes of fusion rate and complications; However, compared with bilateral fixation, unilateral fixation produces more satisfactory efficacy in the blood loss and the operation time.

Unilateral Pedicle Screw Fixation with Bone Graft vs. Bilateral Pedicle Screw Fixation with Bone Graft or Cage: A Comparative Study

BACKGROUND

The aim of this study was to explore the clinical efficacy of unilateral pedicle screw fixation with bone graft (UPSFB) in treating single-segment lumbar degenerative diseases (LDD), as compared to bilateral pedicle screw fixation with bone graft (BPSFB) or with cage (BPSFC).

MATERIAL/METHODS

Medical records were retrospectively collected between 01/2010 and 02/2015 in Longyao County Hospital. According to surgical methods used, all patients were divided into 3 groups: UPSFB group, BPSFB group, and BPSFC group. Clinical outcomes were evaluated by blood loss, blood transfusion, duration of operation, hospital stay, postoperative complications, interbody fusion rate, reoperation rate, medical expenses, patient satisfaction survey, and JOA score.

RESULTS

Ninety-five patients were included and underwent 2.5-year follow-up, with 7 patients lost to regular follow-up. As compared to the BPSFB group and BPSFC group, the UPSFB group had less blood loss and less blood transfusion, as well as shorter hospital stay (p<0.05). Medical expenses were far lower in the UPSFB group (p<0.001). There were no significant differences among the 3 groups in postoperative complications, interbody fusion rate, reoperation rate, JOA score, and patient satisfaction (all p>0.05).

CONCLUSIONS

As compared to BPSFB and BPSFC, UPSFB has the same reliability and effectiveness in treating single-segment LDD with unilateral radicular symptoms in a single lower extremity, with the additional advantage being less expensive.

Unilateral versus Bilateral Instrumentation in Spinal Surgery: A Systematic Review

Study Design Systematic review. Clinical Questions (1) What is the comparative efficacy of unilateral instrumentation compared with bilateral instrumentation in spine surgery? (2) What is the safety of unilateral instrumentation compared with bilateral instrumentation in spine surgery? Methods Electronic databases and reference lists of key articles were searched up to September 30, 2014, to identify studies reporting the comparative efficacy and safety of unilateral versus bilateral instrumentation in spine surgery. Studies including recombinant human bone morphogenetic protein 2 as adjunct therapy and those with follow-up of less than 2 years were excluded. Results Ten randomized controlled trials met the inclusion criteria: five compared unilateral with bilateral instrumentation using open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF), one used open posterolateral fusion, and four used minimally invasive TLIF/PLIF. There were no significant differences between unilateral and bilateral screw instrumentation with respect to nonunion, low back or leg pain scores, Oswestry Disability Index, reoperation, or complications. Conclusions The existing literature does not identify significant differences in clinical outcomes, union rates, and complications when unilateral instrumentation is used for degenerative pathologic conditions in the lumbar spine. The majority of published reports involve single-level lumbar unilateral instrumentation.

Asymmetric Posterior Thoracolumbar Fixation following a Posterolateral Transpedicular Approach for Unilateral Vertebral Disease

The present study aimed to evaluate the clinical outcomes of patients who underwent asymmetrical posterior screw fixation for the treatment of unilateral posterior vertebral pathological entities. The study included 21 patients with a spinal tumor who underwent asymmetrical posterior spinal fusion surgery between April 2009 and March 2012. The American Spinal Injury Association (ASIA) motor score visual analog scale (VAS) score were used as the outcome measure at admission and follow-up. Among the 21 patients, 12 were male and 9 were female, and mean age was 50.71 (range, 24–78) years. Mean follow-up was 16.04 (range, 4–47) months. Postoperatively, neurological findings did not deteriorate in any of the patients. Among the ASIA grade C and D patients, eight (38%) of them exhibited clinical stability or recovery to ASIA E, whereas none of the ASIA B patients scores changed postoperatively. Perioperative complications were noted in six patients (28%). Spinal stability and fusion were achieved in 18 (85%) patients. The surgical asymmetrical fixation technique described reduced the duration of surgery, and the patients required less dissection of paraspinal muscles than bilateral symmetrical fixation. Asymmetrical fixation provides good stabilization for unilateral thoracolumbar vertebral pathological entities, and facilitates rapid rehabilitation of such patients, who are often elderly with comorbidities.

Same-day discharge after minimally invasive transforaminal lumbar interbody fusion: a series of 808 cases

BACKGROUND

The versatility of transforaminal lumbar interbody fusion (TLIF) allows fusion at any level along with any necessary canal decompression. Unilateral TLIF with a single interbody device and unilateral pedicle fixation has proven effective, and minimally invasive techniques have shortened hospital stays. Reasonable questions have been raised, though, about whether same-day discharge is feasible and safe after TLIF surgery.

QUESTIONS/PURPOSES

We determined, in a high-volume spine practice, what proportion of patients having one- or two-level minimally invasive unilateral TLIF go home on the day of surgery or stay longer and compared the two groups in terms of outcome scores (VAS scores for back and leg pain, Waddell-Main Disability Index), complications, and hospital readmissions.

METHODS

We retrospectively studied all 1005 patients who underwent 1114 minimally invasive unilateral TLIF procedures by one surgeon between March 18, 2003, and April 12, 2013. For the first 43 months, Medicare patients (65 years or older) were not offered same-day discharge. All other patients were offered the chance to be discharged home on the same day if they felt well enough. Followup data were for 3 months. VAS scores for back and leg pain and Waddell-Main Disability Index were recorded in a prospectively maintained database and readmissions were ascertained by chart review. Data were available on 100% of discharges, 95% of preoperative outcome scores, and 81% of outcome scores out to 3 months.

RESULTS

Of the 1114 procedures, 808 went home the day of surgery, resulting in a 73% same-day discharge rate. Mean differences in outcome scores from preoperatively to 3 months were similar between groups, except for a difference in VAS lower leg pain in hospital stay patients, which was of borderline statistical and unlikely clinical significance (3.3 versus 2.7, p = 0.05). The only important differences between groups were slightly more medical complications and readmissions for patients 65 years and older who stayed in hospital overnight (3.9% versus 0%, p < 0.01); however, some self-selection bias toward staying overnight among patients with higher self-rated disability and pain scores likely accounted for this difference.

CONCLUSIONS

Surgeons experienced in minimally invasive spine surgery can consider same-day discharge for patients having minimally invasive unilateral TLIF procedures.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive versus open posterior lumbar interbody fusion: a systematic review

BACKGROUND

Although conventional open posterior lumbar interbody fusion (open PLIF) is efficacious in management of lumbar spinal instability, concerns exist regarding lengthy hospital stays, blood loss, and postoperative complications. Minimally invasive posterior lumbar interbody fusion (MIS PLIF) may be able to address these concerns, but the research on this topic has not been systematically reviewed.

QUESTIONS/PURPOSES

We performed a systematic review to determine whether MIS PLIF or open PLIF results in (1) better perioperative parameters, including blood loss, operative times, and length of hospital stay; (2) improved patient-reported outcome scores; and (3) improved disc distraction and (4) frequency of reoperation and complications when compared with open PLIF procedures.

METHODS

A literature search of the MEDLINE database identified seven studies that met our inclusion criteria. A total of seven articles were included; quality was assessed using the Methodological Index for Non-Randomised Studies (MINORS) scale. Descriptive statistics were used to describe the included articles.

RESULTS

In most studies, MIS PLIF was associated with decreased blood loss and shorter hospital stay but longer operative times. MIS PLIF resulted in better patient-related outcomes when compared with open PLIF in two studies in the short term, but most of the studies in this review found no short-term differences, and there was no difference at long-term followup in any studies. There was no significant difference in disc distraction. Both techniques appeared to have similar complication rates and reoperation rates.

CONCLUSIONS

Based on the available evidence, which we restricted to prospective and retrospective studies with control groups, but did not include any well-designed randomized trials, MIS PLIF might lead to better perioperative parameters, but there was little evidence for improved patient-reported outcomes in the MIS groups. Randomized controlled trials are needed to compare these two surgical techniques.

Bilateral decompression using a unilateral pedicle construct for lumbar stenosis

PURPOSE

To determine the effectiveness of bilateral decompression via a unilateral approach using unilateral pedicle screw fixation for two-level lumbar stenosis with instability.

METHODS

Between October 2006 and October 2010, 98 patients (61 men and 37 women) who had reached the three-year follow-up interval were treated with unilateral pedicle screw fixation at the authors' institution. All patients underwent two-level transforaminal lumbar interbody fusion (TLIF), and the mean age was 59.6 years (range, 40-72). Visual analog scale (VAS) scores and Oswestry Disability Index (ODI) were used to assess the pre-operative and postoperative clinical results. Fusion status, the disc space height, and the whole lumbar lordotic angle were analysed for the radiological evaluation.

RESULTS

The ODI scores decreased significantly in both early and late follow-up evaluations and the visual analog scale (VAS) score demonstrated significant improvement in late follow-up (P < 0.01). The disc space height (P < 0.05) and the whole lumbar lordotic angle (P < 0.05) were increased at the final follow-up. Successful fusion was achieved in all patients.

CONCLUSION

Bilateral decompression via a unilateral approach using unilateral pedicle screw fixation for two-level lumbar stenosis with instability, which can maintain the lumbar lordosis and the disc space height, is an effective and less invasive method than with bilateral constructs.

Comparison of unilateral versus bilateral pedicle screw fixation in lumbar interbody fusion: a meta-analysis

PURPOSE

This is a meta-analysis to compare the clinical results between unilateral and bilateral pedicle screw (PS) fixation in lumbar interbody fusion.

METHODS

We included published studies with no language and year restrictions. The criteria which Koes et al. designed in 1995 were used to evaluate the risk of bias of the included studies. All data were analyzed by Review Manager 5.1. The primary outcomes included fusion rate and screw complications, and the secondary outcomes were operative time, blood loss, and hospital time.

RESULTS

A total of five prospective studies with 407 patients were included in the current meta-analysis, and four of them were randomized controlled trials. There was no significant difference between unilateral PS fixation and bilateral PS fixation group in fusion rate and screw complications (fusion rate: OR 0.54, Z = 1.33, P = 0.18, I (2) = 0 %; screw complications: OR 1.45, Z = 0.71, P = 0.48; I (2) = 44 %). In the secondary outcomes, the operative time (Z = 3.35, P = 0.0008; I (2) = 95 %) and blood loss (Z = 4.35, P < 0.0001; I (2) = 98 %) was significantly higher in bilateral PS fixation group than in unilateral PS fixation group. Besides, no significant difference was found in hospital time (Z = 1.19, P = 0.24; I (2) = 99 %).

CONCLUSIONS

In our meta-analysis, we found that unilateral PS fixation in lumbar fusion was as effective as bilateral PS fixation for lumbar degenerative diseases without major instability, no significant difference was found in hospital time, fusion rate and screw complications. In terms of operative time and blood loss, unilateral PS fixation even produced better results.

Clinical study of bilateral decompression via vertebral lamina fenestration for lumbar interbody fusion in the treatment of lower lumbar instability

The aim of this study was to observe the clinical effects of bilateral decompression via vertebral lamina fenestration for lumbar interbody fusion in the treatment of lower lumbar instability. The 48 patients comprised 27 males and 21 females, aged 47–72 years. Three cases had first and second degree lumbar spondylolisthesis and all received bilateral vertebral lamina fenestration for posterior lumbar interbody fusion (PLIF) using a threaded fusion cage (TFC), which maintains the three-column spinal stability. Attention was given to ensure the correct pre-operative fenestration, complete decompression and the prevention of adhesions. After an average follow-up of 26.4 months, the one year post-operative X-ray radiographs suggested that the successful fusion rate was 88.1%, and this was 100% in the two-year post-operative radiographs. Moreover, the functional recovery rate was 97.9%. Bilateral vertebral lamina fenestration for lumbar interbody fusion is an ideal surgical method for the treatment of lower lumbar instability. The surgical method retains the spinal posterior column and middle column and results in full decompression and reliable fusion by a limited yet effective surgical approach.

Comparative study of unilateral and bilateral pedicle screw fixation in posterior lumbar interbody fusion

A prospective, randomized clinical study was performed to determine whether unilateral pedicle screw fixation was comparable with bilateral fixation in 1- or 2-segment lumbar interbody fusion. One hundred eight patients with lumbar degenerative diseases were randomly assigned to the unilateral (n=56) or bilateral (n=52) pedicle screw fixation group. Interbody fusion was performed in 1 or 2 levels with 1 cage. Operative time, blood loss, duration of hospital stay, functional outcome, fusion rate, and complication rate were recorded and compared statistically. The patients were followed for 3 years postoperatively.Successful radiographic fusion was documented in all patients. No flexion-extension hypermobility or pedicle screw loosening or breakage occurred during the follow-up period. No significant difference existed between the 2 groups when comparing the union rate, complication rate, and functional outcome scores (P>.05). However, compared with the bilateral pedicle screw group, a significant decrease occurred in operative time, duration of hospital stay, and blood loss in the unilateral group (P<.01). Unilateral pedicle screw fixation was as effective as bilateral fixation when performed in addition to 1- or 2-level lumbar interbody fusion. The authors recommend the use of unilateral fixation in lumbar interbody fusion with 1 cage for lumbar degenerative diseases without major instability.