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Filley A, Baldwin A, Ben-Natan AR, Hansen K, Arora A, Xiao A, Hammond D, Chen C, Tweedt I, Rohde J, Link T, Berven S, Sawyer A. The influence of osteoporosis on mechanical complications in lumbar fusion surgery: a systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100327. [PMID: 38962714 PMCID: PMC11219986 DOI: 10.1016/j.xnsj.2024.100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 07/05/2024]
Abstract
Background Adults undergoing spine surgery often have underlying osteoporosis, which may be a risk factor for postoperative complications. Although these associations have been described, osteoporosis remains profoundly underdiagnosed and undertreated in the spine surgery population. A thorough, comprehensive systematic review summarizing the relationships between bone mineral density (BMD) and specific complications of lumbar fusion surgery could be a valuable resource for raising awareness and supporting clinical practice changes. Methods PubMed, Embase, and Web of Science databases were searched for original clinical research articles reporting on BMD, or surrogate measure, as a predictor of complications in adults undergoing elective lumbar fusion for degenerative disease or deformity. Endpoints included cage subsidence, screw loosening, pseudarthrosis, vertebral fracture, junctional complications, and reoperation. Results A total of 71 studies comprising 12,278 patients were included. Overall, considerable heterogeneity in study populations, methods of bone health assessment, and definition and evaluation of clinical endpoints precluded meta-analysis. Nevertheless, low BMD was associated with higher rates of implant failures like cage subsidence and screw loosening, which were often diagnosed with concomitant pseudarthrosis. Osteoporosis was also a significant risk factor for proximal junctional kyphosis, particularly due to fracture. Many studies found surgical site-specific BMD to best predict focal complications. Functional outcomes were inconsistently addressed. Conclusions Our findings suggest osteoporosis is a significant risk factor for mechanical complications of lumbar fusion. These results emphasize the importance of preoperative osteoporosis screening, which allows for medical and surgical optimization of high-risk patients. This review also highlights current practical challenges facing bone health evaluation in patients undergoing elective surgery. Future prospective studies using standardized methods are necessary to strengthen existing evidence, identify optimal predictive thresholds, and establish specialty-specific practice guidelines. In the meantime, an awareness of the surgical implications of osteoporosis and utility of preoperative screening can provide for more informed, effective patient care.
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Affiliation(s)
- Anna Filley
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Avionna Baldwin
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Alma Rechav Ben-Natan
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Keith Hansen
- Department of General Surgery, University of California, San Francisco, CA, USA
| | - Ayush Arora
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Angel Xiao
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Deana Hammond
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Caressa Chen
- Loyola University Medical Center; Maywood IL, USA
| | - Isobel Tweedt
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, USA
| | - James Rohde
- Department of Integrative Biology, University of California Berkeley, USA
| | - Thomas Link
- Department of Radiology and Biomedical Imagery, University of California, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Aenor Sawyer
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
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Ai Y, Zhu C, Chen Q, Huang Y, Wang J, Ding H, Deng W, Song Y, Feng G, Liu L. Comparison of predictive value for cage subsidence between MRI-based endplate bone quality and vertebral bone quality scores following transforaminal lumbar interbody fusion: a retrospective propensity-matched study. Spine J 2024; 24:1046-1055. [PMID: 38301901 DOI: 10.1016/j.spinee.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/15/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND CONTEXT Cage subsidence after lumbar fusion can lead to many adverse outcomes. Low bone mineral density (BMD) is a widely recognized risk factor for cage subsidence. Conventional methods can predict and evaluate BMD, but there are many shortcomings. Recently, MRI-based assessment of bone quality in specific parts of the vertebral body has been proposed, including scores for vertebral bone quality (VBQ) and endplate bone quality (EBQ). However, the predictive accuracy of the two scoring systems for cage subsidence after transforaminal lumbar interbody fusion (TLIF) remains unknown. Therefore, we investigated MRI-based VBQ and EBQ scores for assessing bone quality and compared their predictive value for cage subsidence after TLIF. PURPOSE To compare the predictive value between MRI-based VBQ and EBQ scores for cage subsidence after TLIF. STUDY DESIGN/SETTING A retrospective case-control study. PATIENTS SAMPLE Patients with degenerative lumbar diseases underwent single-level TLIF at our medical center between 2014 and 2020, all of whom had preoperative MRIs available. OUTCOMES MEASURES Cage subsidence, disc height, VBQ score, EBQ score, upper and lower vertebral body bone quality (UL-VBQ) score. METHODS Data were retrospectively examined for a consecutive sample of 346 patients who underwent TLIF at our medical center between 2014 and 2020. Patients who subsequently experienced cage subsidence or not were matched to each other based on propensity scoring, and the two matched groups (52 patients each) were compared using conditional logistic regression to investigate the association between the potential radiographic factors and cage subsidence. Scores for VBQ and EBQ were assessed for their ability to predict cage subsidence in the matched patients based on the area under the receiver operative characteristic curve (AUC). RESULTS Among matched patients, those who suffered cage subsidence had significantly higher VBQ score (3.7 vs 3.1, p<.001) and EBQ score (5.0 vs 4.3, p<.001), and regression linked greater risk of subsidence to higher VBQ score (OR 4.557, 95% CI 1.076-19.291, p=.039) and higher EBQ score (OR 5.396, 95% CI 1.158-25.146, p=.032). A cut-off VBQ score of 3.4 predicted the cage subsidence among matched patients with an AUC of 0.799, sensitivity of 84.6%, and specificity of 69.2%. A cut-off EBQ score of 4.7 predicted subsidence with an AUC of 0.829, sensitivity of 76.9%, and specificity of 82.7%. CONCLUSION Higher VBQ and EBQ scores are associated with a greater risk of cage subsidence following TLIF, and EBQ may perform better because of greater specificity.
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Affiliation(s)
- Youwei Ai
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China
| | - Ce Zhu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China
| | - Qian Chen
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China; Department of Orthopaedics and Laboratory of Biological Tissue Engineering and Digital Medicine, Affiliated Hospital of North Sichuan Medical College, No. 1 Maoyuan South Rd, Nanchong, Sichuan, China
| | - Yong Huang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China
| | - Juehan Wang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China
| | - Hong Ding
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China
| | - Wei Deng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China; Department of Orthopedics, Pidu District People's Hospital, the Third Affiliated Hospital of Chengdu Medical College, No. 666 Deyuan North Rd, Chengdu 611730, Sichuan, China
| | - Yueming Song
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China
| | - Ganjun Feng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China
| | - Limin Liu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 GuoXue Rd Chengdu 610041, Sichuan, China.
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Hudson M, Meyer J, Evans A, Krishna C, Smith ZA, Bakhsheshian J. Evaluating osteoporosis and bone quality in the aging spine: modern considerations for surgical management in the geriatric population. GeroScience 2024:10.1007/s11357-024-01171-7. [PMID: 38703277 DOI: 10.1007/s11357-024-01171-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024] Open
Abstract
Surgical management paradigms of spinal pathologies in the aging population carry inherent substantial risks, with surgical complications being more prevalent among patients with osteoporosis compared to those with normal bone mineral density. In this narrative review, we aim to highlight important clinical understanding and considerations in perioperative evaluation and management of patients elected to undergo spinal surgery. Osteoporosis is a well-defined risk factor for mechanical complications following spinal surgery, and as such, perioperative optimization of bone health in the setting of surgery for geriatric patients remains a critical research area alongside intraoperative surgical augmentation techniques. Surgical techniques to circumvent challenges with instrumentation of poor bone mineral density have included augmentation of pedicle screw fixation, including segmental bicortical screw fixation techniques, cement augmentation with fenestrated screws, or use of expandable pedicle screws to improve bone-implant interface. Judicious selection of treatment modalities and subsequent perioperative optimization is paramount to minimize surgical complications. Contemporary guidelines and evolving paradigms in perioperative evaluation, optimization, and management of the aging spine include the advent of quantitatively evaluating computed tomography (CT) via assessment of the magnitude of Hounsfield units. Prescribing pharmacotherapeutic agents and monitoring bone health requires a multidisciplinary team approach, including endocrinologists and geriatricians to coordinate high-quality care for advanced-age patients who require surgical management of their spinal disorders.
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Affiliation(s)
- Miles Hudson
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA.
| | - Jenna Meyer
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alexander Evans
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Chandan Krishna
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Murata K, Fujibayashi S, Otsuki B, Shimizu T, Matsuda S. Low hounsfield unit values at sagittal section on computed tomography predicts vertebral fracture following short spinal fusion. J Orthop Sci 2024; 29:726-733. [PMID: 36948903 DOI: 10.1016/j.jos.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Preoperative identification of osteoporosis during spine surgery is of critical importance. Additionally, the Hounsfield units (HU) measured using computed tomography (CT) have gained considerable attention. This study aimed to propose a more accurate and convenient screening method for predicting vertebral fractures after spinal fusion in elderly patients by analyzing the HU value of different range of interests of thoracolumbar spine. METHODS Our sample pool for analysis consisted of 137 elderly female patients aged >70 years who underwent one- or two-level spinal fusion surgery with a diagnosis of adult degenerative lumbar disease. The HU values of the anterior 1/3 of the vertebral bodies based on sagittal plane and those of vertebral bodies based on axial plane at T11-L5 were measured using the perioperative CT. The incidence of postoperative vertebral fractures with respect to the HU value was investigated. RESULTS Vertebral fractures were identified in 16 patients during the mean follow-up period of 3.8 years. While no significant association was found between HU value of L1 vertebral body or minimum HU value from axial plane and the incidence of the postoperative vertebral fracture, the minimum vertebral HU value of the anterior 1/3 of vertebral body from sagittal plane was associated with the incidence of the postoperative vertebral fracture. Patients with a minimum anterior 1/3 vertebral HU value of <80 had a higher incidence of postoperative vertebral fractures. The adjacent vertebral fractures occurred at the level of the vertebra with the lowest HU value, with a high probability. The existence of the vertebra with a minimum HU value of <80 within two levels of upper instrumented vertebrae was a risk factor for adjacent vertebral fracture. CONCLUSION HU measurement of the anterior 1/3 of vertebral body predicts the risk of vertebral fracture after short spinal fusion surgery.
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Affiliation(s)
- Koichi Murata
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Sakyo, Kyoto, 606-8507, Japan.
| | - Shunsuke Fujibayashi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Sakyo, Kyoto, 606-8507, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Sakyo, Kyoto, 606-8507, Japan
| | - Takayoshi Shimizu
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Sakyo, Kyoto, 606-8507, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Sakyo, Kyoto, 606-8507, Japan
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Lechtholz-Zey EA, Ayad M, Gettleman BS, Mills ES, Shelby H, Ton AT, Shah I, Wang JC, Hah RJ, Alluri RK. Systematic Review and Meta-Analysis of the Effect of Osteoporosis on Reoperation Rates and Complications after Surgical Management of Lumbar Degenerative Disease. J Bone Metab 2024; 31:114-131. [PMID: 38886969 PMCID: PMC11184153 DOI: 10.11005/jbm.2024.31.2.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND There is considerable heterogeneity in findings and a lack of consensus regarding the interplay between osteoporosis and outcomes in patients with lumbar degenerative spine disease. Therefore, the purpose of this systematic review and meta-analysis was to gather and analyze existing data on the effect of osteoporosis on radiographic, surgical, and clinical outcomes following surgery for lumbar degenerative spinal disease. METHODS A systematic review was performed to determine the effect of osteoporosis on the incidence of adverse outcomes after surgical intervention for lumbar degenerative spinal diseases. The approach focused on the radiographic outcomes, reoperation rates, and other medical and surgical complications. Subsequently, a meta-analysis was performed on the eligible studies. RESULTS The results of the meta-analysis suggested that osteoporotic patients experienced increased rates of adjacent segment disease (ASD; p=0.015) and cage subsidence (p=0.001) while demonstrating lower reoperation rates than non-osteoporotic patients (7.4% vs. 13.1%; p=0.038). The systematic review also indicated that the length of stay, overall costs, rates of screw loosening, and rates of wound and other medical complications may increase in patients with a lower bone mineral density. Fusion rates, as well as patient-reported and clinical outcomes, did not differ significantly between osteoporotic and non-osteoporotic patients. CONCLUSIONS Osteoporosis was associated with an increased risk of ASD, cage migration, and possibly postoperative screw loosening, as well as longer hospital stays, incurring higher costs and an increased likelihood of postoperative complications. However, a link was not established between osteoporosis and poor clinical outcomes.
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Affiliation(s)
- Elizabeth A. Lechtholz-Zey
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Mina Ayad
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Brandon S. Gettleman
- Department of Orthopaedic Surgery, University of South Carolina School of Medicine, Columbia, SC,
USA
| | - Emily S. Mills
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Hannah Shelby
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Andy T. Ton
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Ishan Shah
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Jeffrey C. Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Raymond J. Hah
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Ram K. Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
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Jiang F, Li X, Liu L, Xie Z, Wu X, Wang Y. Automated machine learning-based model for the prediction of pedicle screw loosening after degenerative lumbar fusion surgery. Biosci Trends 2024; 18:83-93. [PMID: 38417874 DOI: 10.5582/bst.2023.01327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
The adequacy of screw anchorage is a critical factor in achieving successful spinal fusion. This study aimed to use machine learning algorithms to identify critical variables and predict pedicle screw loosening after degenerative lumbar fusion surgery. A total of 552 patients who underwent primary transpedicular lumbar fixation for lumbar degenerative disease were included. The LASSO method identified key features associated with pedicle screw loosening. Patient clinical characteristics, intraoperative variables, and radiographic parameters were collected and used to construct eight machine learning models, including a training set (80% of participants) and a test set (20% of participants). The XGBoost model exhibited the best performance, with an AUC of 0.884 (95% CI: 0.825-0.944) in the test set, along with the lowest Brier score. Ten crucial variables, including age, disease diagnosis: degenerative scoliosis, number of fused levels, fixation to S1, HU value, preoperative PT, preoperative PI-LL, postoperative LL, postoperative PT, and postoperative PI-LL were selected. In the prospective cohort, the XGBoost model demonstrated substantial performance with an accuracy of 83.32%. This study identified crucial variables associated with pedicle screw loosening after degenerative lumbar fusion surgery and successfully developed a machine learning model to predict pedicle screw loosening. The findings of this study may provide valuable information for clinical decision-making.
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Affiliation(s)
- Feng Jiang
- Southeast University Medical College, Nanjing, Jiangsu, China
| | - Xinxin Li
- Southeast University Medical College, Nanjing, Jiangsu, China
| | - Lei Liu
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Zhiyang Xie
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Xiaotao Wu
- Southeast University Medical College, Nanjing, Jiangsu, China
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Yuntao Wang
- Southeast University Medical College, Nanjing, Jiangsu, China
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
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Zhang Q, Zhao F, Zhang Y, Gong X. Longitudinal Study on Pre- and Post-Operation CT Imaging for Predicting Pedicle Screw Loosening in Patients with Lumbar Degenerative Disease. Ther Clin Risk Manag 2024; 20:185-194. [PMID: 38496352 PMCID: PMC10942252 DOI: 10.2147/tcrm.s453639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/08/2024] [Indexed: 03/19/2024] Open
Abstract
Purpose We conducted a longitudinal study to examine the predictive role of risk factors in the occurrence of pedicle screw loosening, assessed through pre- and post-operative computed tomography (CT) scans. Methods A total of 103 patients with degenerative lumbar disease who had undergone L4/5 pedicle screw fixation (involving 412 screws) were included in this study. They were subsequently categorized into two groups-the "loosening group" and the "non-loosening group". The axial and sagittal angles of the screw trajectory in pre- and post-operative CT images were measured, and the deviation angles were computed. Additionally, measurements were taken of the Hounsfield unit (HU) within the screw entry point area, the pedicle, and the vertebral body in preoperative CT images. Logistic regression analysis was employed to ascertain the risk factors influencing the occurrence of screw loosening. Results Elderly patients who experienced screw loosening tended to have bilateral screw issues at the L5 level (p < 0.005). The HU of the pedicle (p < 0.001), age (p < 0.001), and the axial deviation angle (p = 0.014) were identified as independent factors predicting screw loosening. Additionally, when HU of the pedicle < 126.5 or age ≥ 53.5 years, the axial deviation angle was found to be smaller in the group experiencing screw loosening (p = 0.018 and p = 0.019). Conclusion Loosening of screws positioned at L5 was found to be more prevalent in elderly patients, particularly exhibiting a bilateral occurrence. Independent predictors of this phenomenon included a low HU value in the pedicle, advanced age in patients, and a substantial axial deviation angle. In the case of elderly patients with a low HU value in the pedicle, a reduced axial surgical deflection was necessitated to prevent the occurrence of screw loosening.
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Affiliation(s)
- Qian Zhang
- Medical College of Soochow University, Suzhou, People’s Republic of China
- Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, People’s Republic of China
- Department of Radiology, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, People’s Republic of China
| | - Fanfan Zhao
- Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, People’s Republic of China
| | - Yu Zhang
- Department of Radiology, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, People’s Republic of China
| | - Xiangyang Gong
- Medical College of Soochow University, Suzhou, People’s Republic of China
- Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, People’s Republic of China
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Ishikawa Y, Katsumi K, Mizouchi T, Sato M, Yamazaki A. Importance of computed tomography Hounsfield units in predicting S1 screw loosening after lumbosacral fusion. J Clin Neurosci 2023; 113:1-6. [PMID: 37126935 DOI: 10.1016/j.jocn.2023.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/08/2023] [Accepted: 04/22/2023] [Indexed: 05/03/2023]
Abstract
We investigated whether computed tomography (CT) Hounsfield unit (HU) values of the S1 screw trajectory can predict screw loosening after lumbosacral fixation. We analysed 102 patients (58 men and 44 women) who underwent L5-S1 interbody fusion between April 2018 and October 2019. We reviewed the characteristics of patients including body mass index, smoking, comorbidity with diabetes mellitus, and interbody fusion types. Bone mineral density (BMD) was obtained from the lumbar spine and total hip using dual-energy X-ray absorptiometry. Additionally, we reviewed the S1 screw lengths and diameters. HU values of both L1 vertebral bodies and bilateral S1 screw trajectories were measured on preoperative CT. At six months postoperatively, S1 screws on CT were assessed. Screws with a 1 mm or more radiolucent zone were defined as "loosening". Seventeen patients had loosened screws, and 85 patients did not. The patient characteristics did not significantly differ between the two groups. Both total hip BMD and L1 HU values were low in the loosening patient group (both p = 0.03). Of the 204 total S1 screws, 25 screws were loosened, and 179 screws were not. The screw length was short (p = 0.01), and the HU value of the S1 screw trajectory was low (p < 0.001) in the loosening screw group. Based on receiver operating characteristic analyses of these factors, the area under the curve of HU value of the S1 screw trajectory was the highest (0.79). Measuring the HU value of both the L1 vertebral body and S1 screw trajectory aids in predicting screw loosening.
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Affiliation(s)
- Yuya Ishikawa
- Spine Center, Department of Orthopedic Surgery, Niigata Central Hospital, 1-18 Shinkocho, Chuo-ku, Niigata, Niigata 950-8556, Japan; Department of Orthopedic Surgery, Niigata City General Hospital, 463-7, Shumoku, Chuo-ku, Niigata, Niigata 950-1197, Japan.
| | - Keiichi Katsumi
- Spine Center, Department of Orthopedic Surgery, Niigata Central Hospital, 1-18 Shinkocho, Chuo-ku, Niigata, Niigata 950-8556, Japan
| | - Tatsuki Mizouchi
- Spine Center, Department of Orthopedic Surgery, Niigata Central Hospital, 1-18 Shinkocho, Chuo-ku, Niigata, Niigata 950-8556, Japan
| | - Masayuki Sato
- Spine Center, Department of Orthopedic Surgery, Niigata Central Hospital, 1-18 Shinkocho, Chuo-ku, Niigata, Niigata 950-8556, Japan
| | - Akiyoshi Yamazaki
- Spine Center, Department of Orthopedic Surgery, Niigata Central Hospital, 1-18 Shinkocho, Chuo-ku, Niigata, Niigata 950-8556, Japan
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Zhao H, Wang YJ, Wang RG, Liu D, Duan YQ, Liu YJ, Zeng YH, Zhao QP, Zhang ZP. Three-Dimensional Hounsfield Units Measurement of Pedicle Screw Trajectory for Predicating Screw Loosening in Lumbar Fusion Surgery. Clin Interv Aging 2023; 18:485-493. [PMID: 37008803 PMCID: PMC10065021 DOI: 10.2147/cia.s389059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Purpose Dual-energy X-ray absorptiometry (DXA) is commonly used for evaluation of bone mineral density before spinal surgery, but frequently leads to overestimation in degenerative spinal diseases due to osteoproliferation factors. We introduce a novel method to compare the predictive ability of Hounsfield Units (HU) and DXA methods to predict screw loosening after lumbar interbody fusion surgery in degenerative spinal diseases by measuring HU of pedicle screw trajectory on computed tomography (CT) images preoperatively. Patients and Methods This retrospective study was conducted on patients who underwent posterior lumbar fusion surgery for degenerative diseases. CT HUs measurement was performed using medical imaging software, including the cancellous region on cross-sections of the vertebral body and three-dimensional pedicle screw trajectory. Receiver operating characteristic (ROC) curve analyses were performed for the risk of pedicle screw loosening in association with the Hounsfield scale and preoperative BMD, and the area under the curve (AUC) and the cutoff values were calculated. Results A total of 90 patients were enrolled and were divided into loosening (n = 33, 36.7%) and non-loosening groups (n = 57, 63.3%). No significant differences in age, gender, length of fixation and preoperative BMD were found between both groups. The loosening group showed lower CT HU values in the vertebral body and screw trajectory than the non-loosening group. Screw trajectory HU (ST-HU) exhibited a higher AUC value than vertebral body HU (B-HU). The cutoff values of B-HU and ST-HU were 160 and 110 HUs, respectively. Conclusion Three-dimensional pedicle screw trajectory HU values yields a stronger predictive value than vertebral body HU values and BMD and may provide more guidance for surgery. The risk of screw loosening is significantly increased at ST-HU <110 or B-HU <160 at L5 segment.
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Affiliation(s)
- He Zhao
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yan-jun Wang
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Rui-guo Wang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Da Liu
- Department of Orthopaedics, General Hospital of Western Theatre Command of PLA, Chengdu, Sichuan, 610083, People’s Republic of China
| | - Ya-qing Duan
- Department of Imaging, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yang-jin Liu
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yu-hong Zeng
- Department of Osteoporosis, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Qin-peng Zhao
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Zheng-ping Zhang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
- Correspondence: Zheng-ping Zhang, Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, No. 76 Nanguo Road, Xi’an, Shaanxi, 710054, People’s Republic of China, Tel +86 17791674069, Email
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Computed Tomography-Based Prediction of Lumbar Pedicle Screw Loosening. BIOMED RESEARCH INTERNATIONAL 2023; 2023:8084597. [PMID: 36743516 PMCID: PMC9891825 DOI: 10.1155/2023/8084597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/03/2023] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
Objective Pedicle screw loosening is one of the main complications after pedicle screw fixation. However, there are few reliable measures for prediction of screw loosening. The current study was carried out to find an effective method to use preoperative CT scanning as a predictor of screw loosening in the elderly patients and provide guidance for preoperative surgical planning. Methods Patients who were treated with lumbar pedicle screw fixation procedure in our department for degenerative lumbar disorders between January 2015 and January 2021 were retrospectively included in the current study. CT scan attenuation of each vertebra was measured with Hounsfield units (HU). Screw loosening was determined in postoperatively X-ray tests. One-way analysis of variance (ANOVA) and receiver operating characteristic (ROC) curve analysis were carried out with IBMSPSS 24.00 software. Results Screw loosening was observed in 44 of 215 patients (124 male, 91 female, average age 58.4 ± 7.6 years) during a mean follow-up time of 19.0 ± 11.2 months (range 12-32 months). No significant differences were found among the patients concerning patient gender, BMI, habit of smoking, and whether or not the patient had diabetes or suffered from spondylolisthesis (P > 0.05). The average HU value of lumbar vertebra was 122.4 ± 32.8 HU in the screw loosening group and 142.4 ± 38.2 HU in the control group, and the difference was significant (P < 0.01). ROC curve analysis revealed that the average HU value of L1-L5 has a relatively larger area under the curve (AUC) of 0.689 (95% CI: 0.605-0.773). With the sensitivity of 68% and specificity of 57%, a HU cut-off value of ≤124 HU is a plausible cut-off point to predict screw loosening. Conclusions A prospective CT scan HU value-based prediction can be used to decide whether or not to use screw augmentation methods. A cut-off L1-L5 average HU value of 124 HU can be used as an independent risk factor for screw loosening in instrumented lumbar vertebra. More predictive indexes should be involved to achieve higher sensitivity and specificity in future clinical practice.
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Uemura K, Fujimori T, Otake Y, Shimomoto Y, Kono S, Takashima K, Hamada H, Takenaka S, Kaito T, Sato Y, Sugano N, Okada S. Development of a system to assess the two- and three-dimensional bone mineral density of the lumbar vertebrae from clinical quantitative CT images. Arch Osteoporos 2023; 18:22. [PMID: 36680601 DOI: 10.1007/s11657-023-01216-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
This study developed a system to quantify the lumbar spine's bone mineral density (BMD) in two and three dimensions for osteoporosis screening using quantitative CT images. Measuring the two-dimensional BMD could reproduce the BMD measurement performed in dual-energy X-ray absorptiometry, and an accurate diagnosis of osteoporosis was possible. PURPOSE To date, the assessment of bone mineral density (BMD) using CT images has been made in three dimensions, leading to errors in detecting osteoporosis based on the two-dimensional assessments of BMD using dual-energy X-ray absorptiometry (DXA-BMD). Herein, we aimed to develop a system that measures two- and three-dimensional lumbar BMD from quantitative CT images and validated the accuracy of the system in diagnosing osteoporosis with regard to the DXA classification. METHODS Fifty-nine pairs of spinal CT and DXA images were analyzed. First, the three-dimensional BMD was measured at the axial slice of the L1 vertebra on CT images (L1-vBMD). Then, the L1-L4 vertebrae were segmented from the CT images to measure the three-dimensional BMD at the trabecular region of the L1-L4 vertebral bodies (CT-vBMD). Lastly, the segmented vertebrae were projected onto the coronal plane to measure the two-dimensional BMD (CT-aBMD). Each parameter was correlated with DXA-BMD, and the receiver operating characteristic (ROC) curve to diagnose osteoporosis was assessed. RESULTS The correlation coefficients of DXA-BMD with L1-vBMD, CT-vBMD, and CT-aBMD were 0.364, 0.456, and 0.911, respectively (all p < 0.01). In the ROC curve analysis to diagnose osteoporosis, the area under the curve for CT-aBMD (0.941) was significantly higher than those for L1-vBMD (0.582) and CT-vBMD (0.657) (both p < 0.01). CONCLUSION Compared with L1-vBMD and CT-vBMD, CT-aBMD could accurately predict DXA-BMD and detect patients with osteoporosis. Given that our method can quantify BMD in both two and three dimensions, it could be used to screen for osteoporosis from quantitative CT images.
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Affiliation(s)
- Keisuke Uemura
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Takahito Fujimori
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshito Otake
- Division of Information Science, Graduate School of Science and Technology, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Yuga Shimomoto
- Division of Information Science, Graduate School of Science and Technology, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Sotaro Kono
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuma Takashima
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hidetoshi Hamada
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shota Takenaka
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takashi Kaito
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshinobu Sato
- Division of Information Science, Graduate School of Science and Technology, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Seiji Okada
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Abudouaini H, Wu T, Liu H, Wang B, Chen H. The predictive value of Hounsfield units for titanium mesh cage subsidence after anterior cervical corpectomy and fusion. Front Surg 2023; 9:1012364. [PMID: 36684145 PMCID: PMC9852343 DOI: 10.3389/fsurg.2022.1012364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/01/2022] [Indexed: 01/09/2023] Open
Abstract
Objective To investigate whether bone mineral density (BMD) measured in Hounsfield units (HUs) correlates with titanium mesh cage (TMC) subsidence after anterior cervical corpectomy and fusion (ACCF). Methods A total of 64 patients who underwent one or two levels of ACCF with TMC with a mean follow-up of 19.34 ± 7.86 months were analysed. HU values were measured three times in 3 different planes in the upper and lower vertebrae according to published methods. Subsidence was defined as segmental height loss of more than 3 mm. Pearson correlation analysis was performed. Receiver operating characteristic (ROC) curve analysis was used to obtain optimal thresholds. A multivariate logistic regression analysis was also conducted. Results Twenty-two patients (34.38%) had evidence of TMC subsidence on follow-up x-ray. The mean HU values in the subsidence group (317.34 ± 32.32, n = 22) were significantly lower than those in the nonsubsidence group (363.07 ± 25.23 n = 42, p < 0.001, t test). At last follow-up, mean disc height loss was 4.80 ± 1.16 mm in the subsidence group and 1.85 ± 1.14 mm in the nonsubsidence group (p < 0.001). There was a negative correlation between HU values and disc height loss (Pearson's coefficient -0.494, p < 0.001). HU values decreased gradually from the C3 vertebra to the C7 vertebra, and the HU values of the C5, C6, and C7 vertebrae in the nonsubsidence group were significantly higher than those in the subsidence group (p < 0.05). Furthermore, there were significant differences between the groups in the segmental angle at the last follow-up and the mean changes in segmental angle (p < 0.05). The area under the ROC curve was 0.859, and the most appropriate threshold of the HU value was 330.5 (sensitivity 100%, specificity 72.7%). The multivariate logistic regression analysis showed that older age (p = 0.033, OR = 0.879), lower LIV HU value (p < 0.001, OR = 1.053) and a greater segmental angle change (p = 0.002, OR 6.442) were significantly associated with a higher incidence of TMC subsidence after ACCF. Conclusion There are strong correlations between a lower HU value and TMC subsidence after ACCF. More accurate assessment of bone quality may be obtained if HU measurement can be used as a routine preoperative screening method together with DXA. For patients with HU values <330.5, a more comprehensive and cautious preoperative plan should be implemented to reduce TMC subsidence.
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13
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Li J, Zhang Z, Xie T, Song Z, Song Y, Zeng J. The preoperative Hounsfield unit value at the position of the future screw insertion is a better predictor of screw loosening than other methods. Eur Radiol 2023; 33:1526-1536. [PMID: 36241918 PMCID: PMC9935714 DOI: 10.1007/s00330-022-09157-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/11/2022] [Accepted: 09/09/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Screw loosening is a widely reported issue after spinal screw fixation and triggers several complications after lumbar interbody fusion. Osteoporosis is an essential risk factor for screw loosening. Hounsfield units (HU) value is a credible indicator during bone mineral density (BMD) evaluation. As compared with the general evaluation of BMD, we hypothesized that specific measurements of HU at the precise location of the future screw insertion may be a better predictor of screw loosening. METHODS Clinical data of 56 patients treated by oblique lumbar interbody fusion (OLIF) of the L4-L5 segments with an anterior lateral single rod (ALSR) screw fixation were reviewed in this study. Vertebral bodies with ≥ 1 mm width radiolucent zones around the screw were defined as screw loosening. HU in the insertional screw positions, the central transverse plane, and the average values of three and four planes were measured. Regression analyses identified independent risk factors for screw loosening separately. The area under the receiver operating characteristic curve (AUC) was computed to evaluate predictive performance. RESULTS The local HU values were significantly lower in the loosening group, regardless of the selected measuring methods. The AUC of screw loosening prediction was higher in the insertional screw positions' HU than other frequently used methods. CONCLUSIONS The HU value measured in the insertional screw position is a better predictor of ALSR screw loosening than other methods. The risk of screw loosening should be reduced by optimizing the trajectory of the screw based on the measurement of HU in preoperative CT. KEY POINTS • Osteoporosis is an essential risk factor for screw loosening, and Hounsfield units (HU) are a credible predictor during bone mineral density (BMD) evaluation. • The HU value measured in the insertional screw position is a better predictor of screw loosening than other frequently used HU measurement methods. • The risk of screw loosening might potentially be reduced by optimizing the trajectory of the screw based on the measurement of HU in preoperative CT.
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Affiliation(s)
- Jingchi Li
- grid.412901.f0000 0004 1770 1022Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Zhuang Zhang
- grid.412901.f0000 0004 1770 1022Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Tianhang Xie
- grid.412901.f0000 0004 1770 1022Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Zhetao Song
- grid.13291.380000 0001 0807 1581Department of Imaging, Sichuan University, Chengdu, Sichuan People’s Republic of China
| | - Yueming Song
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Jiancheng Zeng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
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14
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Chiapparelli E, Okano I, Adl Amini D, Zhu J, Salzmann SN, Tan ET, Moser M, Sax OC, Echeverri C, Oezel L, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The association between lumbar paraspinal muscle functional cross-sectional area on MRI and regional volumetric bone mineral density measured by quantitative computed tomography. Osteoporos Int 2022; 33:2537-2545. [PMID: 35933479 DOI: 10.1007/s00198-022-06430-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/06/2022] [Indexed: 11/29/2022]
Abstract
UNLABELLED Osteosarcopenia is a common condition among elderly and postmenopausal female patients. Site-specific bone mineral density is more predictive of bone-related complications. Few studies have investigated muscle-bone associations. Our results demonstrated that in women, significant positive associations between paraspinal muscles FCSA and vBMD exist at different lumbosacral levels. These regional differences should be considered when interpreting bone-muscle associations in the lumbar spine. INTRODUCTION There is increasing evidence between bone and muscle volume associations. Previous studies have demonstrated comorbidity between osteoporosis and sarcopenia. Recent studies showed that sarcopenic subjects had a fourfold higher risk of concomitant osteoporosis compared to non-sarcopenic individuals. Although site-specific bone mineral density (BMD) assessments were reported to be more predictive of bone-related complications after spinal fusions than BMD assessments in general, there are few studies that have investigated level-specific bone-muscle interactions. The aim of this study is to investigate the associations between muscle functional cross-sectional area (FCSA) on magnetic resonance imaging (MRI) and site-specific quantitative computed tomography (QCT) volumetric bone mineral density (vBMD) in the lumbosacral region among spine surgery patients. METHODS We retrospectively reviewed a prospective institutional database of posterior lumbar fusion patients. Patients with available MRI undergoing posterior lumbar fusion were included. Muscle measurements and FCSA were conducted and calculated utilizing a manual segmentation and custom-written program at the superior endplate of the L3-L5 vertebrae level. vBMD measurements were performed and calculated utilizing a QCT pro software at L1-L2 levels and bilateral sacral ala. We stratified by sex for all analyses. RESULTS A total of 105 patients (mean age 61.5 years and 52.4% females) were included. We found that female patients had statistically significant lower muscle FCSA than male patients. After adjusting for age and body mass index (BMI), there were statistically significant positive associations between L1-L2 and S1 vBMD with L3 psoas FCSA as well as sacral ala vBMD with L3 posterior paraspinal and L5 psoas FCSA. These associations were not found in males. CONCLUSIONS Our results demonstrated that in women, significant positive associations between the psoas and posterior paraspinal muscle FCSA and vBMD exist in different lumbosacral levels, which are independent of age and BMI. These regional differences should be considered when interpreting bone and muscle associations in the lumbar spine.
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Affiliation(s)
- E Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - I Okano
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - D Adl Amini
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - J Zhu
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S N Salzmann
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - E T Tan
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - M Moser
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - O C Sax
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - C Echeverri
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - L Oezel
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - J Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - A A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - F P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - F P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - A P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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15
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New approaches to proven technology: force control posterior thoracolumbar fusion with an innovative pedicle screw system. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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16
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Jones C, Okano I, Arzani A, Dodo Y, Moser M, Reisener MJ, Chiapparelli E, Adl Amini D, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The predictive value of a novel site-specific MRI-based bone quality assessment, endplate bone quality (EBQ), for severe cage subsidence among patients undergoing standalone lateral lumbar interbody fusion. Spine J 2022; 22:1875-1883. [PMID: 35843534 DOI: 10.1016/j.spinee.2022.07.085] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/18/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Studies have shown that site-specific bone density measurements had more predictive value for complications than standard whole-region measurements. Recently, MRI-based assessments of vertebral bone quality (VBQ) were introduced. However, there have been few studies that investigate the association between site-specific MRI bone assessment and osteoporosis-related complications in patients undergoing lumbar interbody fusion. In this work, we created a novel site-specific MRI-based assessment of the endplate bone quality (EBQ) and assessed its predictive value for severe cage subsidence following standalone lateral lumbar interbody fusion (SA-LLIF). PURPOSE To investigate the predictive value of a novel MRI-based bone assessment for severe cage subsidence after SA-LLIF. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients who underwent SA-LLIF from 2008 to 2019 at a single, academic institution with available preoperative lumbar CT and T1-weighted MRIs. OUTCOME MEASURES Association between EBQ and severe subsidence after SA-LLIF. METHODS We retrospectively reviewed the records of SA-LLIF patients treated between 2008 and 2019. EBQ was measured using preoperative non-contrast T1-weighted MRIs of the lumbar spine. EBQ was defined as the average value of signal intensity of both endplates divided by that of the cerebrospinal fluid space at the level of L3. Bivariate and multivariable analyses with generalized linear mixed models were performed and set binary severe subsidence as the outcome. RESULTS Two hundred five levels in 89 patients were included. Fifty levels (24.4%) demonstrated severe subsidence. Bone mineral density measured by quantitative computed tomography was significantly lower in the subsidence group. Both VBQ and EBQ were significantly higher in the subsidence group. The EBQ plus Modic change (MC) model demonstrated that the effect of EBQ was independent of MC. In multivariate analyses adjusted with QCT-vBMD, EBQ showed a significant association with cage subsidence whereas VBQ only showed a marginal trend. The EBQ-based prediction model for severe subsidence showed better goodness of fit compared to the VBQ-based model. CONCLUSIONS High EBQ was an independent factor for severe cage subsidence after SA-LLIF and the EBQ-based model showed better goodness of fit compared to VBQ- or MC-based models. EBQ assessment before SA-LLIF may provide insight into a patient's risk for severe subsidence.
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Affiliation(s)
- Conor Jones
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666 Japan
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Yusuke Dodo
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666 Japan
| | - Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | | | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Lee M, Lee E, Lee JW. Value of computed tomography Hounsfield units in predicting pedicle screw loosening in the thoracic spine. Sci Rep 2022; 12:18279. [PMID: 36316434 PMCID: PMC9622837 DOI: 10.1038/s41598-022-23142-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022] Open
Abstract
We evaluated the feasibility of using the Hounsfield unit (HU) value of the vertebral body to predict screw loosening in the thoracic spine. Consecutive patients who underwent thoracic spinal fusion surgery (from 2014 to 2020) were retrospectively identified. Patients with pedicle screw loosening in the upper instrumented vertebra (UIV) on postoperative computed tomography were included in the "loosening" group. The control group comprised an equal number of age-, sex-, and UIV-matched patients without screw loosening. Preoperative HU values at the UIV and lumbar T-scores were compared between the groups; receiver operating characteristic curves were constructed for HU values and T-scores to predict screw loosening, and the best cutoff values were determined. The same statistical analyses were performed for each subgroup, i.e., upper (T1-T4) and lower (T9-T12) thoracic levels. Forty-six patients each were included in the loosening and control groups. A significant between-group difference of HU values was noted for the lower thoracic UIV (loosening = 99.3, control = 126.3; p = 0.02) but not for the upper thoracic UIV (loosening = 171.8, control = 146.0, p = 0.70). T-scores did not differ between the groups for the lower (p = 0.14) and upper (p = 0.56) thoracic UIV. For the lower thoracic UIV, the area under the receiver operating characteristic curve was 0.660 for HUs (p = 0.01; 95% confidence interval [CI] 0.541-0.766) and 0.601 (p = 0.13; 95% CI 0.480-0.713) for T-scores. The optimal cutoff value for HUs was 126.3. Using this cutoff, HU values showed a better positive predictive value, negative predictive value, and accuracy compared to T-scores in predicting screw loosening.
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Affiliation(s)
- Minsu Lee
- grid.412480.b0000 0004 0647 3378Department of Radiology, Seoul National University Bundang Hospital, 82, Gumiro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Eugene Lee
- grid.412480.b0000 0004 0647 3378Department of Radiology, Seoul National University Bundang Hospital, 82, Gumiro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Joon Woo Lee
- grid.412480.b0000 0004 0647 3378Department of Radiology, Seoul National University Bundang Hospital, 82, Gumiro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Radiology, Seoul National University College of Medicine, 103, Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
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Chen T, Hu W, Peng Y, Li Y, Qiu J, Qiu X, Li P, Li S, Liang A, Gao W, Huang D. Evaluating bone quality and asymmetrical aplasia of the thoracic vertebral body in Lenke 1A adolescent idiopathic scoliosis using hounsfield units. Front Surg 2022; 9:1028873. [PMID: 36386502 PMCID: PMC9659626 DOI: 10.3389/fsurg.2022.1028873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Study Design Retrospective analysis. Objective To evaluate bone quality and investigate asymmetrical development of the thoracic vertebral body in adolescent idiopathic scoliosis (AIS) based on Hounsfield unit (HU) measurements obtained from computed-tomography (CT) scans. Summary of Background Data HU value demonstrated higher reliability and accuracy than the traditional method, indicating that they could be used to individually evaluate and effectively assess the bone quality of every vertebra in the CT films. Methods Total 30 AIS patients classified as Lenke Type 1A and 30 paired controls were included in this study. Regions of interest for HU value were measured on three horizontal images of the thoracic vertebrae. HU measurements of the whole vertebral body in each vertebra were obtained. Using HU value, we separately measured the concave and convex sides of each vertebral body in patients' group, as well as within the left and right sides in controls. Results In controls, the mean HU value of T1–T12 thoracic vertebral bodies was 240.03 ± 39.77, with no statistical differences among different levels. As for AIS patients, in the structural curve, the apical region had a significantly lower HU compared with the other regions, and asymmetrical change was found between the concave and convex sides, most significantly in the apical region. In the non-structural curve, the average HU value was 254.99 ± 44.48, and no significant difference was found either among the different levels of vertebrae or between the concave and convex sides. Conclusions Abnormal and asymmetrical changes in bone quality of the thoracic vertebral body in patients with Lenke 1A AIS were indicated. Low bone quality in the convex side of the structural curve indicated stronger internal fixation in surgery to correct the deformity.
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Affiliation(s)
- Taiqiu Chen
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
- Department of Orthopedics, People’s Hospital of Jieyang, Jieyang, China
| | - Wenjun Hu
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Peng
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yong Li
- Department of Radiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jincheng Qiu
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xianjian Qiu
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Pengfei Li
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shaoguang Li
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Anjing Liang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenjie Gao
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
- Correspondence: Wenjie Gao Dongsheng Huang
| | - Dongsheng Huang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
- Correspondence: Wenjie Gao Dongsheng Huang
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19
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Kim KH, Kim TH, Kim SW, Kim JH, Lee HS, Chang IB, Song JH, Hong YK, Oh JK. Significance of Measuring Lumbar Spine 3-Dimensional Computed Tomography Hounsfield Units to Predict Screw Loosening. World Neurosurg 2022; 165:e555-e562. [PMID: 35772704 DOI: 10.1016/j.wneu.2022.06.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Osteoporosis is a well-known risk factor of screw loosening. Classically, dual-energy x-ray absorptiometry (DEXA) scan is an easy and cost-effective method of detecting bone mineral density (BMD). However, T-score on DEXA scan can be overestimated in patients with degenerative changes of the spine. Our objective was to identify correlation between Hounsfield unit (HU) measured by 3-dimensional computed tomography (3D-CT) and screw loosening. METHODS A total of 113 patients treated with lumbosacral spinal fusion were reviewed and categorized into a screw loosening group and a normal group to compare their average values of preoperative CT HU. Screw loosening was defined as radiolucent area around screw that was thicker than 1 mm with a "double halo sign". RESULTS There were statistically significant differences in patient age and steroid use between screw loosening and non-loosening groups. There was no significant difference in BMD or T-score between the 2 groups. However, HU values measured in axial, coronal, and sagittal images were significantly different between the 2 groups. In the receiver operating characteristic for HU values measured in CT images, the greatest area under the curve was 0.774 and that was in case of Hounsfield unit measured by axial CT images from L1 to L4. CONCLUSIONS Preoperative CT HU is associated with screw loosening. It can be a better predictor of screw loosening than DEXA scan. The best predictor of screw loosening in this study is the average value of HU from L1 to L4 in axial cut.
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Affiliation(s)
- Kyeong Hwan Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Tae-Hwan Kim
- Department of Orthopedics, Hallym University Sacred Heart Hospital, Anyang, Korea; Spine Center, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Seok Woo Kim
- Department of Orthopedics, Hallym University Sacred Heart Hospital, Anyang, Korea; Spine Center, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Hee Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Heui Seung Lee
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - In Bok Chang
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Joon Ho Song
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Yong-Kil Hong
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae Keun Oh
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea; Spine Center, Hallym University Sacred Heart Hospital, Anyang, Korea.
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20
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Li JC, Yang ZQ, Xie TH, Song ZT, Song YM, Zeng JC. Deterioration of the fixation segment’s stress distribution and the strength reduction of screw holding position together cause screw loosening in ALSR fixed OLIF patients with poor BMD. Front Bioeng Biotechnol 2022; 10:922848. [PMID: 36110315 PMCID: PMC9468878 DOI: 10.3389/fbioe.2022.922848] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022] Open
Abstract
The vertebral body’s Hounsfield unit (HU) value can credibly reflect patients’ bone mineral density (BMD). Given that poor bone-screw integration initially triggers screw loosening and regional differences in BMD and strength in the vertebral body exist, HU in screw holding planes should better predict screw loosening. According to the stress shielding effect, the stress distribution changes in the fixation segment with BMD reduction should be related to screw loosening, but this has not been identified. We retrospectively collected the radiographic and demographic data of 56 patients treated by single-level oblique lumbar interbody fusion (OLIF) with anterior lateral single rod (ALSR) screw fixation. BMD was identified by measuring HU values in vertebral bodies and screw holding planes. Regression analyses identified independent risk factors for cranial and caudal screw loosening separately. Meanwhile, OLIF with ALSR fixation was numerically simulated; the elastic modulus of bony structures was adjusted to simulate different grades of BMD reduction. Stress distribution changes were judged by computing stress distribution in screws, bone-screw interfaces, and cancellous bones in the fixation segment. The results showed that HU reduction in vertebral bodies and screw holding planes were independent risk factors for screw loosening. The predictive performance of screw holding plane HU is better than the mean HU of vertebral bodies. Cranial screws suffer a higher risk of screw loosening, but HU was not significantly different between cranial and caudal sides. The poor BMD led to stress concentrations on both the screw and bone-screw interfaces. Biomechanical deterioration was more severe in the cranial screws than in the caudal screws. Additionally, lower stress can also be observed in fixation segments’ cancellous bone. Therefore, a higher proportion of ALSR load transmission triggers stress concentration on the screw and bone-screw interfaces in patients with poor BMD. This, together with decreased bony strength in the screw holding position, contributes to screw loosening in osteoporotic patients biomechanically. The trajectory optimization of ALSR screws based on preoperative HU measurement and regular anti-osteoporosis therapy may effectively reduce the risk of screw loosening.
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Affiliation(s)
- Jing-Chi Li
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
| | - Zhi-Qiang Yang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
| | - Tian-Hang Xie
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
| | - Zhe-Tao Song
- Department of Imaging, West China Hospital, Chengdu, China
| | - Yue-Ming Song
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
- *Correspondence: Yue-Ming Song, ; Jian-Cheng Zeng,
| | - Jian-Cheng Zeng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine for Sichuan University, Chengdu, China
- *Correspondence: Yue-Ming Song, ; Jian-Cheng Zeng,
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21
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Tsuda K, Tagami A, Yamada S, Yokota K, Chiba K, Yonekura A, Tomita M, Osaki M. Computed tomographic evaluation of three types of screw trajectories for posterior cervical spine fixation: Cervical pedicle screw, lateral mass screw, and paravertebral foramen screw. Medicine (Baltimore) 2022; 101:e29857. [PMID: 35839061 PMCID: PMC11132321 DOI: 10.1097/md.0000000000029857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/06/2022] [Indexed: 11/26/2022] Open
Abstract
Computed tomography (CT) attenuation values of cervical spine were evaluated in vivo using a clinically relevant group. To compare CT attenuation values between cervical pedicle screw (CPS), lateral mass screw (LMS), and paravertebral foramen screw (PVFS) trajectories. CPS and LMS are commonly used for posterior fixation of the cervical spine. The PVFS method has been reported as a new method. CT attenuation values along the screw trajectory are reportedly associated with screw stability. We identified 45 patients who had undergone whole-body CT for trauma with no injury to the cervical spine. Regions of interest (ROIs) were designated along the trajectories that would be used for CPS, LMS, and PVFS through vertebral pedicles and lateral masses of the C3-C6 vertebrae. CT attenuation values of each ROI were measured and compared between each screw trajectories at each cervical vertebral level. Participants were divided into Group I (age, 20-39 years; n = 12), Group II (age, 40-59 years; n = 17), and Group III (age, 60-79 years; n = 16). CT attenuation values of ROIs were compared between each age group. PVFS trajectories showed higher CT attenuation values than LMS trajectories at every vertebral level and also higher values than CPS trajectories at C5 and C6 levels. CT attenuation values at C3 were lower than those at C4 in the LMS trajectory and lower than those at C5 and C6 in the PVFS trajectory. CT attenuation values were lower in the elder group (>60 years old) than in the other 2 groups for all screw trajectories. CT attenuation values suggested that the PVFS technique may be useful for posterior fixation of the cervical spine in elder patients who require more secure fixation.
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Affiliation(s)
- Keiichi Tsuda
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Atsushi Tagami
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shuta Yamada
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuaki Yokota
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ko Chiba
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Yonekura
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masato Tomita
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Makoto Osaki
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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22
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Wanderman N, Glassman SD, Mkorombindo T, Dimar JR, Gum JL, Carreon LY. Evaluation of bone mineral density after instrumented lumbar fusion with computed tomography. Spine J 2022; 22:951-956. [PMID: 35189347 DOI: 10.1016/j.spinee.2022.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 01/07/2022] [Accepted: 02/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Computed tomography (CT) measurement of Hounsfield Units (HU) has been described as a tool for assessing BMD. For surgeons considering a revision lumbar fusion, knowledge of the BMD of the UIV is of value for surgical planning. However, the presence of metal artifact from instrumentation presents a potential confounder, and prior studies have not validated measurements of HU in this setting. PURPOSE To determine if HU can be measured reliably at the supra-adjacent and upper instrumented levels of a lumbar fusion. STUDY DESIGN Retrospective observational cohort PATIENT SAMPLE: Consecutive series of patients who had lumbar CT scans after an instrumented posterior lumbar fusion. OUTCOME MEASURES Hounsfield Units at the upper instrumented vertebra and levels proximal. METHODS We analysed pre- and postoperative CT scans of 50 patients who underwent L2 and distal instrumented lumbar fusion whose scans were no greater than 1 year apart, obtaining HU measurements of analogous axial cuts at the upper instrumented level (immediately caudal to the halo of the pedicle screw), as well as additional control levels above the construct. RESULTS The HU at the pre-and postoperative UIV exhibited a strong correlation (r=0.917, p<.001), as did one (r=0.887, p<.001) and two (r=0.853, p<.001) levels above the UIV. There were significant but predictable reductions in the postoperative HU compared to preoperative at one (-9.0±26.2) and two (-12.2±30.2) levels above the UIV, as well as T12 (-13.9±42.2). There was no significant difference in HU at the UIV (4.6±34.1). CONCLUSIONS Postoperative HU at the UIV was strongly correlated with and not significantly different from the preoperative HU. Although the HU in the vertebrae proximal to the UIV were slightly lower postoperatively, this change was predictable using a correction factor.
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Affiliation(s)
- Nathan Wanderman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; University of Louisville School of Medicine, 500 South Preston Street. Instructional Building, Room 305, Louisville, KY 40202, USA
| | - Tino Mkorombindo
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA.
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23
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Prediction of Sacral Screw Loosening after Lumbosacral Surgeries Involving Rigid Fixation of Sacral Bone Using Preoperative Computed Tomography Scans. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7123139. [PMID: 35655477 PMCID: PMC9152424 DOI: 10.1155/2022/7123139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/04/2022] [Accepted: 04/30/2022] [Indexed: 11/21/2022]
Abstract
Objective To find a preoperative computed tomography-based method to predict the incidence of sacral screw loosening and assist surgical planning. Methods Surgically treated patients for degenerative lumbosacral disorders with rigid pedicle screw fixation of patients with L5-S1 vertebra in our center from January 2016 to January 2021 were retrospectively included in the current study. CT scan attenuation of the horizontal plane of the sacrum was measured with Hounsfield units (HU). Postoperative X-ray tests were used to diagnose screw loosening. The data was analyzed by independent sample t-tests, X2 analysis, Pearson correlation analysis, and ROC curve analysis. Results A total of 162 (114 male, 48 female, average age 63.7 ± 7.3 years) patients were included in the final analysis. Significant differences were found between the screw loosening group and nonloosening group concerning the HU value of the sacrum at the horizontal plane (P < 0.01). In ROC curve analysis, AUC was 0.674 (95% CI: 0.592-0.756). A cutoff of 200 HU provided 64.8% sensitivity and 62.4% specificity, and a cutoff of 150 HU provided 90.2% sensitivity. Conclusions Analyzing 162 patients with at least 12 months of follow-up, we propose cutoff CT attenuation values of 200 HU and 150 HU to take moderate and radical measures of screw augmentation to prevent screw loosening in the sacral bone.
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Zhou J, Yuan C, Liu C, Liu M, Zhou L, Wang J. Assessment of vertebral bone mineral density and stand-alone oblique lumbar interbody fusion for adjacent segment disease and primary lumbar degenerative diseases. J Orthop Surg (Hong Kong) 2022; 30:10225536221091846. [PMID: 35410526 DOI: 10.1177/10225536221091846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the vertebral bone mineral density and the value of stand-alone oblique lumbar interbody fusion (SA OLIF) for the management of single-level adjacent segment disease (ASD) and primary lumbar degenerative diseases. PATIENTS AND METHODS Seventy-eight patients undergoing single-level SA OLIF was divided into index surgery group (n = 36) or revision surgery group (n = 42) at single center. The vertebral body Hounsfield units (HU) value was measured to assess bone mineral density of operated level by the preoperative CT. The following data were retrospectively collected and compared between the two groups: demographic, surgical data, clinical results, and complications. RESULTS No differences were found between the two groups in surgical data. The fusion segment HU values in the revision group were significantly higher than that in the index group (147.4 ± 35.3 vs 129.2 ± 38.4 p = .033). There were significant differences while comparing fusion segment HU values to L1-L4 horizontal plane (147.4 ± 35.3 vs 126.1 ± 28.4, p = .000) and L1 (147.4 ± 35.3 vs 126.8 ± 26.2, p = .000) in revision group, meanwhile, no statistically significant difference was observed in index group (p > .05). The cage subsidence was observed in the revision group (n = 2) and index group (n = 9) (p = .045). The patients with cage subsidence had significantly lower vertebral HU values. CONCLUSION SA OLIF is valid alternative to the traditional posterior approach in the management of ASD with good clinical outcomes at short-term follow-up. Increased HU values of fusion segment may play a role in the management of ASD by SA OLIF.
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Affiliation(s)
- Jing Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Chao Yuan
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Chao Liu
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Minghan Liu
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Lei Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
| | - Jian Wang
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, 105785The Third Military Medical University, Chongqing, China
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25
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Mierke A, Ramos O, Macneille R, Chung JH, Wycliffe N, Cheng W, Danisa OA. Intra- and inter-observer reliability of the novel vertebral bone quality score. 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 2022; 31:843-850. [PMID: 34984535 DOI: 10.1007/s00586-021-07096-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 11/21/2021] [Accepted: 12/18/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To assess the intra- and inter-observer reliability of the novel vertebral bone quality (VBQ) scoring system. METHODS Four orthopedic surgery residents at various levels of training (PGY1-4) evaluated 100 noncontrast, T1-weighted MRIs of the lumbar spine. VBQ was calculated as quotient of the median of L1-L4 average signal intensity (SI) and the L3 cerebral spinal fluid (CSF) SI, as described by Ehresman et al. All measurements were repeated 2 weeks later. We performed a stratified analysis based on patient history of instrumentation, pathology, and MRI manufacturer/magnet strength to determine their effect on VBQ reliability. Spinal pathologies included compression fracture, burst fracture, vertebral osteomyelitis, epidural abscess, or neoplasm. The interclass correlation coefficient (ICC) two-way mixed model on absolute agreement was used to analyze inter-rater and intra-rater reliability. ICC less than 0.40 was considered poor, 0.40-0.59 as fair, 0.60-0.74 as good, and greater than 0.75 as excellent. RESULTS Intra-observer reliability was excellent (≥ 0.75) for all four observers. When stratified by history of spinal instrumentation or spinal pathology, all raters showed excellent intra-observer reliability except one (0.71 and 0.69, respectively). When stratified by MRI manufacturer, intra-observer reliability was ≥ 0.75 for all raters. Inter-observer reliability was excellent (0.91) and remained excellent (≥ 0.75) when stratified by history of spinal instrumentation, spinal pathology, or MRI-manufacturer. CONCLUSIONS VBQ scores from spine lumbar MRIs demonstrate excellent intra-observer and inter-observer reliability. These scores are reliably reproduced in patients regardless of previous instrumentation, spinal pathology, or MRI manufacturer/magnetic field strength.
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Affiliation(s)
- Alex Mierke
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America.
| | - Omar Ramos
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
| | - Rhett Macneille
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
| | - Jun Ho Chung
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
| | - Nathaniel Wycliffe
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis VA Medical Center, Loma Linda, CA, United States of America
| | - Olumide A Danisa
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, 11406, Loma Linda, CA, United States of America
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Morimoto T, Tsukamoto M, Yoshihara T, Kobayashi T, Mawatari M. Letter to the Editor. Screw technique for lumbar spinal fusion. J Neurosurg Spine 2022; 37:315. [PMID: 35180695 DOI: 10.3171/2022.1.spine2215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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27
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Li D, Sun C, Jiang J, Lu F, Xia X, Wang H, Zou F, Ma X. A study of screw placement to obtain the optimal pull-out resistance of lumbar pedicle screws-analysis of Hounsfield units measurements based on computed tomography. BMC Musculoskelet Disord 2022; 23:124. [PMID: 35130888 PMCID: PMC8819881 DOI: 10.1186/s12891-022-05074-6] [Citation(s) in RCA: 4] [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: 09/20/2021] [Accepted: 01/25/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The screw path of lumbar pedicle screws in the vertebral body has certain variability. It is not clear whether the screw paths in different directions can obtain the same pull-out resistance. This study intends to use CT (Computed Tomography) to measure the Hounsfield unit (HU value) around the screw paths in different parts of the lumbar vertebral body to obtain the bone mineral density value of the corresponding parts which will provide some reference for the direction of lumbar pedicle screw placement. METHODS This retrospective study included 200 patients with lumbar degenerative diseases selected randomly from the case base and the patient's basic information was recorded. L1-L5 vertebral body was divided equally into the upper, middle and lower 1/3, which was consistent with the three sagittal entry directions of the pedicle screw head tilt, parallel endplate and caudal tilt, and the HU values were measured by CT cross-sectional scanning to indirectly reflect the local bone density values. The paired t-test (randomized block experiment) was used to compare the HU values of the upper, middle and lower 1 / 3 parts, with P < 0.05 being considered statistically significant. RESULTS Comparison of HU values in different parts of each vertebral body revealed that HU values in the middle 1/3 of the L1,L2 (163.88 ± 58.44 and 152.94 ± 59.45) and in the lower 1/3 of the L4 (149.86 ± 60.18) were higher than in the other two parts of the vertebral body of the same segment(P < 0.0001,P = 0.0069 and P = 0.0024, respectively); According to the results of each stratification, patients with younger age and better bone condition had higher HU values in the middle 1/3 of L1 and L2, and higher HU values in the lower 1/3 of L3, L4 and L5; With the increase of age, the decrease of bone condition and the difference of HU value in each vertebral body gradually decreased. CONCLUSION Although further follow-up studies are needed, based on the analysis of the statistical results, we speculate that from the perspective of obtaining the best pull-out resistance of the lumbar pedicle screws, the placement direction of L1 and L2 in the sagittal position may be as parallel to the endplate as possible; L3, L4, and L5 may be as appropriate as possible to the tail tilt theoretically.
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Affiliation(s)
- Dachuan Li
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Chi Sun
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Jianyuan Jiang
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Feizhou Lu
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Xinlei Xia
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Hongli Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Fei Zou
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China.
| | - Xiaosheng Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China.
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Lee JS, Son DW, Lee SH, Ki SS, Lee SW, Song GS, Woo JB, Kim YH. The Effect of Hounsfield Unit Value with Conventional Computed Tomography and Intraoperative Distraction on Postoperative Intervertebral Height Reduction in Patients Following Stand-Alone Anterior Cervical Discectomy and Fusion. J Korean Neurosurg Soc 2021; 65:96-106. [PMID: 34963207 PMCID: PMC8752891 DOI: 10.3340/jkns.2021.0131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/04/2021] [Indexed: 11/27/2022] Open
Abstract
Objective The most common complication of anterior cervical discectomy and fusion (ACDF) is cage subsidence and maintenance of disc height affects postoperative clinical outcomes. We considered cage subsidence as an inappropriate indicator for evaluating preservation of disc height. Thus, this study aimed to consider patients with complications such as reduced total disc height compared to that before surgery and evaluate the relevance of several factors before ACDF.
Methods We retrospectively reviewed the medical records of 40 patients who underwent stand-alone single-level ACDF using a polyetheretherketone (PEEK) cage at our institution between January 2012 and December 2018. Our study population comprised 19 male and 21 female patients aged 24–70 years. The minimum follow-up period was 1 year. Twenty-seven patients had preoperative bone mineral density (BMD) data on dual-energy X-ray absorptiometry. Clinical parameters included sex, age, body mass index, smoking history, and prior medical history. Radiologic parameters included the C2-7 cobb angle, segmental angle, sagittal vertical axis, disc height, and total intervertebral height (TIH) at the preoperative and postoperative periods. Cage decrement was defined as the reduction in TIH at the 6-month follow-up compared to preoperative TIH. To evaluate the bone quality, Hounsfield unit (HU) value was calculated in the axial and sagittal images of conventional computed tomography.
Results Lumbar BMD values and cervical HU values were significantly correlated (r=0.733, p<0.001). We divided the patients into two groups based on cage decrement, and 47.5% of the total patients were regarded as cage decrement. There were statistically significant differences in the parameters of measuring the HU value of the vertebra and intraoperative distraction between the two groups. Using these identified factors, we performed a receiver operating characteristic (ROC) curve analysis. Based on the ROC curve, the cut-off point was 530 at the HU value of the upper cortical and cancellous vertebrae (p=0.014; area under the curve [AUC], 0.727; sensitivity, 94.7%; specificity, 42.9%) and 22.41 at intraoperative distraction (p=0.017; AUC, 0.722; sensitivity, 85.7%; specificity, 57.9%). Using this value, we converted these parameters into a bifurcated variable and assessed the multinomial regression analysis to evaluate the risk factors for cage decrement in ACDF. Intraoperative distraction and HU value of the upper vertebral body were independent factors of postoperative subsidence.
Conclusion Insufficient intraoperative distraction and low HU value showed a strong relationship with postoperative intervertebral height reduction following single stand-alone PEEK cage ACDF.
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Affiliation(s)
- Jun Seok Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Dong Wuk Son
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Su Hun Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Sung Soon Ki
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Sang Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Geun Sung Song
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Joon Bum Woo
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Young Ha Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
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Zhou J, Yuan C, Liu C, Zhou L, Wang J. Hounsfield unit value on CT as a predictor of cage subsidence following stand-alone oblique lumbar interbody fusion for the treatment of degenerative lumbar diseases. BMC Musculoskelet Disord 2021; 22:960. [PMID: 34789220 PMCID: PMC8600787 DOI: 10.1186/s12891-021-04833-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 10/31/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND To investigate the correlation between vertebral Hounsfield unit (HU) values and cage subsidence in patients treated with stand-alone (SA) OLIF. METHODS A retrospective review of collected data was performed on 76 patients who underwent SA OLIF. We utilized the HU value for lumbar bone mineral density (BMD) obtained on preoperative CT. The vertebral HU values of patients with subsidence were compared to those without subsidence. The correlation between cage subsidence and clinical score was investigated. RESULTS Sixteen patients (21.1%) had at least radiographic evidence of interbody cage subsidence. The average cage subsidence was 2.5 ± 1.3 mm (range 0.9-4.8 mm). There were no significant differences in sex, BMI, preoperative diagnoses, or fused level (p > 0.05); however, there were significant differences between the cage subsidence group and the nonsubsidence group in age, average of the lowest T-score, and average HU value, including for the L1 vertebrae, L1-L4 horizontal plane, and L1-L4 sagittal plane (p < 0.05). The average HU value of the L1-L4 horizontal plane showed a more predictable AUC of 0.909 (95% CI, 0.834-0.984; P < 0.001) compared with the average of the lowest T-score following an AUC of 0.791 (95% CI, 0.674-0.909; P < 0.001). Based on logistic regression analysis, the average HU value of the L1-L4 horizontal plane (OR, 0.912; 95% CI, 0.861-0.966; P = 0.002) was an independent factor influencing cage subsidence. CONCLUSIONS Patients with lower average HU values of the lumbar vertebrae are at a much higher risk of developing cage subsidence after SA OLIF. Measurement of preoperative HU values on preexisting CT scans could be rapid, simple and feasible.
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Affiliation(s)
- Jing Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China
| | - Chao Yuan
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China
| | - Chao Liu
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China
| | - Lei Zhou
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China
| | - Jian Wang
- Department of Orthopaedic Surgery, Affiliated Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing, 400037, People's Republic of China.
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30
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Zhou J, Zhou L, Liu C, Yuan C, Wang J. [CT value of vertebral body predicting Cage subsidence after stand-alone oblique lumbar interbody fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1449-1456. [PMID: 34779172 DOI: 10.7507/1002-1892.202105058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the correlation between CT value and Cage subsidence in patients with lumbar degenerative disease treated with stand-alone oblique lumbar interbody fusion (OLIF). Methods The clinical data of 35 patients with lumbar degenerative diseases treated with stand-alone OLIF between February 2016 and October 2018 were retrospectively analyzed. There were 15 males and 20 females; the age ranged from 29 to 81 years, with an average of 58.4 years. There were 39 operative segments, including 32 cases of single-segment, 2 cases of double-segment, and 1 case of three-segment. Preoperative lumbar CT was used to measure the CT values of the axial position of L 1 vertebral body, the axial and sagittal positions of L 1-4 vertebral body, surgical segment, and the axial position of upper and lower vertebral bodies as the bone mineral density index, and the lowest T value was recorded by dual-energy X-ray absorptiometry. The visual analogue scale (VAS) and Oswestry disability index (ODI) scores were recorded before operation and at last follow-up. At last follow-up, the lumbar interbody fusion was evaluated by X-ray films of the lumbar spine and dynamic position; the lumbar lateral X-ray film was used to measure the subsidence of the Cage, and the patients were divided into subsidence group and nonsubsidence group. The univariate analysis on age, gender, body mass index, lowest T value, CT value of vertebral body, disease type, and surgical segment was performed to initially screen the influencing factors of Cage subsidence; further the logistic regression for multi-factor analysis was used to screen fusion independent risk factors for Cage subsidence. The receiver operating characteristic (ROC) curve and area under curve (AUC) were used to analyze the CT value and the lowest T value to predict the Cage subsidence. Spearman correlation analysis was used to determine the correlation between Cage subsidence and clinical results. Results All the 35 patients were followed up 27-58 months, with an average of 38.7 months. At last follow-up, the VAS and ODI scores were significantly decreased when compared with preoperative scores ( t=32.850, P=0.000; t=31.731, P=0.000). No recurrent lower extremity radiculopathy occurred and no patient required revision surgery. Twenty-seven cases (77.1%) had no Cage subsidence (nonsubsidence group); 8 cases (22.9%) had at least radiographic evidence of Cage subsidence, the average distance of Cage subsidence was 2.2 mm (range, 1.1-4.2 mm) (subsidence group). At last follow-up, there was 1 case of fusion failure both in the subsidence group and the nonsubsidence group, there was no significant difference in the interbody fusion rate (96.3% vs. 87.5%) between two groups ( P=0.410). Univariate analysis showed that the CT value of vertebral body (L 1 axial position, L 1-4 axial and sagittal positions, surgical segment, and upper and lower vertebral bodies axial positions) and the lowest T value were the influencing factors of Cage subsidence ( P<0.05). According to ROC curve analysis, compared with AUC of the lowest T value [0.738, 95% CI (0.540, 0.936)], the AUC of the L 1-4 axis CT value was 0.850 [95% CI (0.715, 0.984)], which could more effectively predict Cage subsidence. Multivariate analysis showed that the CT value of L 1-4 axis was an independent risk factor for Cage subsidence ( P<0.05). Conclusion The CT value measurement of the vertebral body based on lumbar spine CT before stand-alone OLIF can predict the Cage subsidence. Patients with low CT values of the lumbar spine have a higher risk of Cage subsidence. However, the Cage subsidence do not lead to adverse clinical results.
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Affiliation(s)
- Jing Zhou
- Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
| | - Lei Zhou
- Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
| | - Chao Liu
- Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
| | - Chao Yuan
- Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
| | - Jian Wang
- Department of Orthopedics, the First Affiliated Hospital of the Army Military Medical University, Chongqing, 400037, P.R.China
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Impact of preoperative treatment of osteoporosis on re-operations, complications and health care utilization in patients undergoing thoraco-lumbar spine fusions. A 5-year national database analysis. J Clin Neurosci 2021; 93:122-129. [PMID: 34656235 DOI: 10.1016/j.jocn.2021.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 07/27/2021] [Accepted: 09/09/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Identify the impact of preoperative treatment of Osteoporosis (OP) on reoperation rates, complications and healthcare utilization following thoraco-lumbar (TL) spine fusions. MATERIALS AND METHODS We used ICD9/10 and CPT codes to extract data from MarketScan (2000-2018). Patients were divided into two groups based on preoperative treatment of OP within one year prior to the index spinal fusion: medication (m-OP) cohort and non-medication (nm-OP) cohort. Outcomes (re-operation rates, re-admission, complications, healthcare utilization) were analyzed at 1-, 12-, 24- and 60-months. RESULTS Of 3606 patients, 65% (n = 2330) of patients did not receive OP medications (nm-OP). At index hospitalization, there were no difference in LOS (median nm-OP: 3 days vs. m-OP:4 days), discharge to home (nm-OP 80% vs. m-OP 75%) and complications (nm-OP 13% vs. m-OP 12%). Reoperation rates were not different among the cohorts at 1- (nm-OP 5.7% vs. m-OP 4.2%), 2- (nm-OP 9.4% vs. m-OP 7.8) and 5 years (nm-OP 16.9% vs. m-OP 14.8%). Patients in m-OP cohort incurred higher overall median payments at 1 year ($17,866 vs. $ 16,010), 2 years ($38,634 vs. $34,454) and 5 years ($94,797 vs. $91,072) compared to nm-OP cohort. CONCLUSION Preoperative treatment of OP had no impact on complications, LOS, discharge disposition following TL fusions at index hospitalization. Similarly, no impact of preoperative treatment was noted in terms of reoperation rates at 12-, 24- and 60 months following the index spine fusion. Patients who received preoperative treatment for OP incurred higher health care utilization at 12-, 24- and 60 months following surgery.
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Dimar J, Bisson EF, Dhall S, Harrop JS, Hoh DJ, Mohamed B, Wang MC, Mummaneni PV. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Osteoporosis Assessment. Neurosurgery 2021; 89:S19-S25. [PMID: 34490883 DOI: 10.1093/neuros/nyab317] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Osteoporosis is a metabolic bone disease that commonly affects the elderly. Degenerative spinal disease that may require surgical intervention is also prevalent in this susceptible population. If undiagnosed or untreated before spine surgery, osteoporosis may result in an increased risk of postoperative adverse events. Nontreatment of osteoporosis preoperatively may be related to a poor understanding of bone physiology, a lack of standardized treatment algorithms, limited cost-effective interventions, and reluctance by spine surgeons to be the primary provider of osteoporosis management. OBJECTIVE The objective of this evidence-based review is to develop guidelines for the preoperative assessment and treatment of osteoporosis in patients undergoing spine surgery. METHODS A systematic review of the literature was performed using the National Library of Medicine/PubMed database and Embase for studies relevant to preoperative diagnostic studies that predict increased risk of osteoporosis-related postoperative adverse events and whether the preoperative treatment of low bone mineral density (BMD) in patients with osteoporosis improves outcome. RESULTS Out of 281 studies, 17 met the inclusion criteria and were included for systematic review. The task force affirmed a Grade B recommendation that preoperative osteoporosis testing with a dual-energy X-ray absorptiometry scan (T-score < -2.5), a computed tomography scan (Hounsfield units <97.9), and serum vitamin D3 level (<20 ng/mL) predict an increased risk of osteoporosis-related adverse events after spine surgery. The task force determined a Grade B recommendation that preoperative osteoporosis treatment with teriparatide increases BMD, induces earlier and more robust fusion, and may improve select patient outcomes. There is insufficient evidence regarding preoperative treatment with bisphosphonates alone and postoperative outcome. CONCLUSION This evidence-based clinical guideline provides a recommendation that patients with suspected osteoporosis undergo preoperative assessment and be appropriately counseled about the risk of postoperative adverse events if osteoporosis is confirmed. In addition, preoperative optimization of BMD with select treatments improves certain patient outcomes.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/3-preoperative-osteoporosis-assessment.
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Affiliation(s)
- John Dimar
- Department of Orthopedics, University of Louisville, Pediatric Orthopedics, Norton Children's Hospital, Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Erica F Bisson
- Clinical Neurosciences Center, University of Utah Health, Salt Lake City, Utah, USA
| | - Sanjay Dhall
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - James S Harrop
- Department of Neurological Surgery and Department of Orthopedic Surgery, Thomas Jefferson University, Division of Spine and Peripheral Nerve Surgery, Delaware Valley SCI Center, Philadelphia, Pennsylvania, USA
| | - Daniel J Hoh
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Basma Mohamed
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Marjorie C Wang
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Chang HK, Ku J, Ku J, Kuo YH, Chang CC, Wu CL, Lirng JF, Wu JC, Huang WC, Cheng H, Hsu SM. Correlation of bone density to screw loosening in dynamic stabilization: an analysis of 176 patients. Sci Rep 2021; 11:17519. [PMID: 34471158 PMCID: PMC8410763 DOI: 10.1038/s41598-021-95232-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022] Open
Abstract
Although osteoporosis has negative impacts on lumbar fusion, its effects on screw loosening in dynamic stabilization remain elusive. We aimed to correlate bone mineral density (BMD) with screw loosening in Dynesys dynamic stabilization (DDS). Consecutive patients who underwent 2- or 3-level DDS for spondylosis, recurrent disc herniations, or low-grade spondylolisthesis at L3-5 were retrospectively reviewed. BMD was assessed by the Hounsfield Unit (HU) in vertebral bodies (VB) and pedicles with and without cortical bone (CB) on pre-operative computed tomography (CT). Screw loosening was assessed by radiographs and confirmed by CT. HU values were compared between the loosened and intact screws. 176 patients and 918 screws were analyzed with 78 loosened screws found in 36 patients (mean follow-up: 43.4 months). The HU values of VB were similar in loosened and intact screws (p = 0.14). The HU values of pedicles were insignificantly less in loosened than intact screws (including CB: 286.70 ± 118.97 vs. 297.31 ± 110.99, p = 0.45; excluding CB: 238.48 ± 114.90 vs. 240.51 ± 108.91, p = 0.88). All patients had clinical improvements. In conclusion, the HU values, as a surrogate for BMD, were unrelated to screw loosening in DDS. Therefore, patients with compromised BMD might be potential candidates for dynamic stabilization rather than fusion.
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Affiliation(s)
- Hsuan-Kan Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Li-Nong St., Beitou District, Taipei, 112, Taiwan, ROC
| | - Jason Ku
- University of California, Los Angeles, USA
| | - Johnson Ku
- University of California, Los Angeles, USA
| | - Yi-Hsuan Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Chang Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Lan Wu
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Henrich Cheng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ming Hsu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Li-Nong St., Beitou District, Taipei, 112, Taiwan, ROC.
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Yuan L, Zhang X, Zeng Y, Chen Z, Li W. Incidence, Risk, and Outcome of Pedicle Screw Loosening in Degenerative Lumbar Scoliosis Patients Undergoing Long-Segment Fusion. Global Spine J 2021; 13:1064-1071. [PMID: 34018438 DOI: 10.1177/21925682211017477] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To investigate the incidence, risk factors, and outcomes of pedicle screw loosening in degenerative lumbar scoliosis (DLS) undergoing long-segment spinal fusion surgery. METHODS One hundred and thirty DLS patients who underwent long-segment fusion surgery with at least a 12-month follow-up were studied. The incidence and risk factors of screw loosening were investigated. VAS, SRS-22, and ODI scores were obtained preoperatively and at follow-up. RESULTS One hundred and sixty-eight of 1784 (9.4%) screws showed evidence of loosening in 71 (54.6%) patients. Three patients required revision surgery. Screw loosening rates according to vertebral insertion level were lowest instrumented vertebra (LIV): 45.4%; uppermost instrumented vertebra (UIV):17.7%; one vertebra above the LIV: 0.5%; 2 vertebrae above the LIV: 0.4%. Multiple logistic regression analysis of possible risk factors indicated that preoperative lateral subluxation ≥8 mm (odds ratio [OR]: 2.68, 95% confidence interval [CI]: 1.16-6.20), osteopenia (OR: 5.52, 95% CI: 1.64-18.56), osteoporosis (OR: 8.19, 95% CI: 2.40-27.97), fusion to sacrum (OR: 2.55, 95% CI: 1.12-5.83), postoperative TLK greater than 10° (OR: 2.63, 95% CI: 1.14-6.04) and SVA imbalance (OR: 3.44, 95% CI: 1.17-10.14) were statistically significant. No difference was noted in preoperative, follow-up, and change of VAS, ODI, and SRS-22 scores. CONCLUSIONS Screw loosening in DLS underwent long-segment surgery is common and tends to occur in the LIV or UIV. Lateral subluxation ≥8 mm, osteopenia, osteoporosis, fusion to the sacrum, postoperative TLK greater than 10°, and SVA imbalance were the independent influencing factors. Screw loosening can be asymptomatic, while longer-term follow-up is required.
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Affiliation(s)
- Lei Yuan
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Xinling Zhang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Yan Zeng
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Zhongqiang Chen
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Weishi Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
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Tani S, Ishikawa K, Kudo Y, Tsuchiya K, Matsuoka A, Maruyama H, Emori H, Yamamura R, Hayakawa C, Sekimizu M, Oshita Y, Ozawa T, Shirahata T, Nagai T, Toyone T, Inagaki K. The effect of denosumab on pedicle screw fixation: a prospective 2-year longitudinal study using finite element analysis. J Orthop Surg Res 2021; 16:219. [PMID: 33771178 PMCID: PMC7995779 DOI: 10.1186/s13018-021-02360-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pedicle screw loosening is a major complication following spinal fixation associated with osteoporosis in elderly. However, denosumab is a promising treatment in patients with osteoporosis. The effect of denosumab on pedicle screw fixation is unknown. Therefore, we investigated whether denosumab treatment improves pedicle screw fixation in elderly patients with osteoporosis. METHODS This was a 2-year prospective open-label study. From February 2015 to January 2016, we included 21 patients with postmenopausal osteoporosis who received initial denosumab treatment. At baseline, 12 months, and 24 months, we measured volumetric bone mineral density (BMD) using quantitative computed tomography (QCT) and performed CT-based finite element analysis (FEA). Finite element models of L4 vertebrae were created to analyze the bone strength and screw fixation. RESULTS BMD increased with denosumab treatment. FEA revealed that both pullout strength of pedicle screws and compression force of the vertebra increased significantly at 12 and 24 months following denosumab treatment. Notably, pullout strength showed a stronger correlation with three-dimensional volumetric BMD around pedicle screw placement assessed by QCT (r = 0.83, at 24 months) than with two-dimensional areal BMD assessed by dual energy X-ray absorptiometry (r = 0.35, at 24 months). CONCLUSION To our knowledge, this is the first study to reveal that denosumab treatment achieved strong pedicle screw fixation with an increase in BMD around the screw assessed by QCT and FEA; therefore, denosumab could be useful for osteoporosis treatment during spinal surgery in elderly patients with osteoporosis.
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Affiliation(s)
- Soji Tani
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Koji Ishikawa
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan.
| | - Yoshifumi Kudo
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Koki Tsuchiya
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
- Department of Orthopaedic Surgery, Yamanashi Red Cross Hospital, 6663-1 Funatsu Fujikawaguchiko-machi, Minamitsuru-gun, Yamanashi, 401-0301, Japan
| | - Akira Matsuoka
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Hiroshi Maruyama
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Haruka Emori
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
- Department of Orthopaedic Surgery, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo Tsuzuki-ku, Yokohama, Kanagawa, Japan
| | - Ryo Yamamura
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Chikara Hayakawa
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Masaya Sekimizu
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Yusuke Oshita
- Department of Orthopaedic Surgery, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-Chuo Tsuzuki-ku, Yokohama, Kanagawa, Japan
| | - Tomoyuki Ozawa
- Department of Orthopaedic Surgery, Tokyo Kyosai Hospital, 2-3-8, Nakameguro, Meguro, Tokyo, 153-0061, Japan
| | - Toshiyuki Shirahata
- Department of Orthopaedic Surgery, Showa University Koto Toyosu Hospital, 5-1-38 Toyosu, Koto-ku, Tokyo, 135-8577, Japan
| | - Takashi Nagai
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Tomoaki Toyone
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
| | - Katsunori Inagaki
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666, Japan
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Assessing underlying bone quality in spine surgery patients: a narrative review of dual-energy X-ray absorptiometry (DXA) and alternatives. Spine J 2021; 21:321-331. [PMID: 32890786 DOI: 10.1016/j.spinee.2020.08.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/15/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023]
Abstract
Poor bone quality and low bone mineral density (BMD) have been previously tied to higher rates of postoperative mechanical complications in patients undergoing spinal fusion. These include higher rates of proximal junctional kyphosis, screw pullout, pseudoarthrosis, and interbody subsidence. For these reasons, accurate preoperative assessment of a patient's underlying bone quality is paramount for all elective procedures. Dual-energy X-ray absorptiometry (DXA) is currently considered to be the gold standard for assessing BMD. However, a growing body of research has suggested that in vivo assessments of BMD using DXA are inaccurate and have, at best, moderate correlations to postoperative mechanical complications. Consequently, there have been investigations into using alternative methods for assessing in vivo bone quality, including using computed tomography (CT) and magnetic resonance imaging (MRI) volumes that are commonly obtained as part of surgical evaluation. Here we review the data regarding the accuracy of DXA for the evaluation of spine bone quality and describe the alternative imaging modalities currently under investigation.
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The Association Between Endplate Changes and Risk for Early Severe Cage Subsidence Among Standalone Lateral Lumbar Interbody Fusion Patients. Spine (Phila Pa 1976) 2020; 45:E1580-E1587. [PMID: 32858739 DOI: 10.1097/brs.0000000000003668] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE The aim of this study was to investigate the association of Modic type endplate changes with the risk of severe subsidence after standalone lateral lumbar interbody fusion (SA-LLIF). SUMMARY OF BACKGROUND DATA It has been reported that certain endplate radiolographic features are associated with higher regional bone mineral density (BMD) in the adjacent vertebrae in the lumbar spine. It remains unclear whether these changes have protective effects against osteoporotic complications such as cage subsidence after lumbar surgery. METHODS We reviewed patients undergoing SA-LLIF from 2007 to 2016 with a follow-up >6 months. Cage subsidence was assessed utilizing the grading system by Marchi et al. As potential contributing factors for cage subsidence, we measured the endplate volumetric BMD (EP-vBMD) and the standard trabecular volumetric BMD measurement in the vertebral body. Modic changes (MC) on magnetic resonance imaging were measured as a qualitative factor for endplate condition. Univariate analysis and multivariate logistic regression analyses with a generalized mixed model were conducted. RESULTS Two hundred six levels in 97 patients were included in the final analysis. Mean age (± SD) was 66.7 ± 10.7. Sisty-sdpercent of the patients were female. Severe subsidence was observed in 66 levels (32.0%). After adjusting for age, bone morphogenetic protein (BMP) use, and number of levels fused, the presence of MC type 2 was significantly associated with lower risk of severe subsidence (OR = 0.28 [0.09-0.88], P = 0.029). Whereas, EP-vBMD did not demonstrate a statistical significance (p = 0.600). CONCLUSION The presence of a Modic type 2 change was significantly associated with lower odds of severe subsidence after SA-LLIF. Nonetheless, this significant association was independent from regional EP-vBMD values. This finding suggests that microstructural and/or material property changes associated with Modic type 2 changes might have a protective effect in this patient population. LEVEL OF EVIDENCE 4.
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Shirley M, Wanderman N, Keaveny T, Anderson P, Freedman BA. Opportunistic Computed Tomography and Spine Surgery: A Narrative Review. Global Spine J 2020; 10:919-928. [PMID: 32905730 PMCID: PMC7485075 DOI: 10.1177/2192568219889362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE This article seeks to provide a narrative review regarding the ability of opportunistic information available from computed tomography (CT) scans to guide decisions in spine surgery related to patient bone quality. METHODS A review of the literature (limited to human and English language) was performed via PubMed and Google Scholar using the search terms; "osteoporosis" AND "opportunistic" AND "computed tomography" AND "spine surgery." The titles and then abstracts of all identified citations were reviewed for inclusion by 2 of the authors (MS, BAF). Relevant articles were then studied in full text. RESULTS A review of the literature found 25 articles that were selected for inclusion in this narrative review. These articles were broadly divided into 4 subcategories: (1) opportunistic CT (oCT) and osteoporosis detection, (2) oCT data and the quality of screw fixation, (3) utilization of Hounsfield units to assess clinical and/or radiographic outcomes following spine fusion, and (4) virtual stress testing in spine surgery. CONCLUSION The literature on oCT, as well as associated virtual stress-testing techniques, demonstrate the potential to enhance spine surgery outcomes by preoperatively identifying at-risk patients in need of bone health optimization and informing best techniques for performing spinal fusion surgery on patients with diminished bone quality. While our narrative summary of the limited literature to date suggests a promising future for oCT data, significant additional research and/or radiographic workflow standardization is needed to validate these methods for clinical use.
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Affiliation(s)
| | | | - Tony Keaveny
- University of California at Berkeley, Berkeley, CA, USA
| | | | - Brett A. Freedman
- Mayo Clinic, Rochester, MN, USA,Brett A. Freedman, Department of Orthopedics, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Qian L, Chen W, Li P, Qu D, Liang W, Zheng M, Ouyang J. Comparison of the Pull-Out Strength between a Novel Micro-Dynamic Pedicle Screw and a Traditional Pedicle Screw in Lumbar Spine. Orthop Surg 2020; 12:1285-1292. [PMID: 32776487 PMCID: PMC7454205 DOI: 10.1111/os.12742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/16/2020] [Accepted: 06/03/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the strength of a novel micro-dynamic pedicle screw by comparing it to the traditional pedicle screw. METHODS Forty-five lumbar vertebrae received a traditional pedicle screw on one side and a micro-dynamic pedicle screw on the other side as follows (traditional group vs micro-dynamic group): 15 vertebrae underwent instant pull-out testing; 15 vertebrae underwent 5000-cyclic fatigue loading testing; and 15 vertebrae underwent 10,000-cyclic fatigue loading testing and micro-computed tomography (micro-CT) scanning. The peek pull-out force and normalized peek pull-out force after instant pull-out testing, 5000-cyclic and 10,000-cyclic fatigue loading testing were recorded to estimate the resistance of two types of screws. Bone mineral density was recorded to investigate the strength of the different screws in osteoporotic patients. And the semidiameter of the screw insertion area on micro-CT images after fatigue were compared to describe the performance between screw and bone surface. RESULTS The bone mineral density showed a weak correlation with peek pull-out force (r = 0.252, P = 0.024). The peek pull-out force of traditional pedicle screw after 10,000-cyclic fatigue loading were smaller than that of instant pull-out test in both osteoporotic (P = 0.017) and healthy group (P = 0.029), the peek pull-out force of micro-dynamic pedicle screw after 10,000-cyclic fatigue loading was smaller than that in instant pull-out test in osteoporotic group (P = 0.033), but no significant difference in healthy group (P = 0.853). The peek pull-out force in traditional group and micro-dynamic group underwent instant pull-out testing (P = 0.485), and pull-out testing after 5000-cyclic fatigue loading testing (P = 0.184) did not show significant difference. However, the peek pull-out force in micro-dynamic group underwent pull-test after 10,000-cyclic fatigue loading testing was significantly greater than that measured in traditional group (P = 0.005). The normalized peek pull-out force of traditional groups underwent instant pull-out testing, pull-out test after 5000-cyclic and 10,000-cyclic fatigue loading testing significantly decreased as the number of cycles increased (P < 0.001); meanwhile, the normalized peek pull-out force of micro-dynamic groups remained consistent regardless of the number of cycles (P = 0.133). The semidiameter after the fatigue loading test of the traditional screw insertion area was significantly larger than that of the micro-dynamic screw insertion area (P = 0.013). CONCLUSION The novel micro-dynamic pedicle screw provides stronger fixation stability in high-cyclic fatigue loading and non-osteoporotic patients versus the traditional pedicle screw, but similar resistance in low-cycle fatigue testing and osteoporotic group vs the traditional pedicle screw.
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Affiliation(s)
- Lei Qian
- Department of Anatomy, Southern Medical University Guangdong Provincial Key laboratory of Medical Biomechanics, Shenzhen Digital Orthopedic Engineering Laboratory, Guangzhou, China
| | - Weidong Chen
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Peng Li
- Department of Orthopedics, The Third Affiliated Hospital, Southern Medical University, Guangdong Provincial Key Laboratory of Bone and Joint Degeneration Diseases, Guangzhou, China
| | - Dongbin Qu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenjie Liang
- Department of Anatomy, Southern Medical University Guangdong Provincial Key laboratory of Medical Biomechanics, Shenzhen Digital Orthopedic Engineering Laboratory, Guangzhou, China
| | - Minghui Zheng
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Ouyang
- Department of Anatomy, Southern Medical University Guangdong Provincial Key laboratory of Medical Biomechanics, Shenzhen Digital Orthopedic Engineering Laboratory, Guangzhou, China
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Xu F, Zou D, Li W, Sun Z, Jiang S, Zhou S, Li Z. Hounsfield units of the vertebral body and pedicle as predictors of pedicle screw loosening after degenerative lumbar spine surgery. Neurosurg Focus 2020; 49:E10. [DOI: 10.3171/2020.5.focus20249] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors aimed to compare the efficacy of lumbar vertebral body Hounsfield units (HUs) and pedicle HUs at predicting pedicle screw loosening.METHODSThe authors retrospectively assessed 143 patients with L3–5 instrumentation. The patients were classified into one of two groups based on the status of their L3 screws (a screw loosening group or a control group). The pedicle HUs and vertebral HUs of L3 were measured using preoperative lumbar CT scans, and the pedicle HUs were measured in two ways: by excluding or by including cortical bone.RESULTSThe screw loosening rate was 20.3% (n = 29/143) at the 12-month follow-up. The vertebral body HUs and pedicle HUs in the screw loosening group were lower than those in the control group (vertebral body group: 98.6 HUs vs 121.4 HUs, p < 0.001; pedicle excluding cortical bone: 208.9 HUs vs 290.5 HUs, p = 0.002; pedicle including cortical bone: 249.4 HUs vs 337.5 HUs, p < 0.001). The pedicle HUs tended to have a higher area under the receiver operating characteristic curve value in predicting screw loosening, compared with that of vertebral body HUs, but the difference was not statistically significant (p > 0.05). Among patients with low vertebral body HUs of ≤ 130, the loosening rate was much lower in patients with pedicle HUs of ≤ 340 than in those with pedicle HUs of > 340 (31.0% vs 13.0%, respectively; p < 0.05).CONCLUSIONSVertebral body HUs alone are insufficient to accurately evaluate the risk of pedicle screw loosening. Therefore, it is important to collect both the pedicle HU and vertebral body HU measurements for surgical planning.
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Affiliation(s)
- Fei Xu
- 1Orthopaedic Department, Peking University Third Hospital; and
- 2Peking University Health Science Center, Haidian District, Beijing, China
| | - Da Zou
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Weishi Li
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Zhuoran Sun
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Shuai Jiang
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Siyu Zhou
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Zhuofu Li
- 1Orthopaedic Department, Peking University Third Hospital; and
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Iijima Y, Kotani T, Sakuma T, Nakayama K, Akazawa T, Kishida S, Muramatsu Y, Sasaki Y, Ueno K, Asada T, Sato K, Minami S, Ohtori S. Risk Factors for Loosening of S2 Alar Iliac Screw: Surgical Outcomes of Adult Spinal Deformity. Asian Spine J 2020; 14:864-871. [PMID: 32718132 PMCID: PMC7788364 DOI: 10.31616/asj.2020.0100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/22/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective study. Purpose To determine the risk factors for S2 alar iliac (S2AI) screw loosening and its association with lumbosacral fusion in patients with adult spinal deformity (ASD). Overview of Literature S2AI screws have been widely used for ASD surgery in recent years. However, no studies have analyzed the risk factors for loosening of S2AI screws and its association with lumbosacral fusion. Methods Cases of 50 patients with ASD who underwent long spinal fusion (>9 levels) with S2AI screws were retrospectively reviewed. Loosening of S2AI screws and S1 pedicle screws and bone fusion at the level of L5–S1 at 2 years after surgery were investigated using computed tomography. In addition, risk factors for loosening of S2AI screws were determined in patients with ASD. Results At 2 years after surgery, 33 cases (66%) of S2AI screw loosening and six cases (12%) of S1 pedicle screw loosening were observed. In 40 of 47 cases (85%), bone fusion at L5–S1 was found. Pseudarthrosis at L5–S1 was not significantly associated with S2AI screw loosening (19.3% vs. 6.3%, p=0.23), but significantly higher in patients with S1 screw loosening (83.3% vs. 4.9%, p<0.001). On multivariate logistic regression analyses, high upper instrumented vertebra (UIV) level (T5 or above) (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.0–18.6; p=0.045) and obesity (OR, 11.4; 95% CI, 1.2–107.2; p=0.033) were independent risk factors for S2AI screw loosening. Conclusions High UIV level (T5 or above) and obesity were independent risk factors for S2AI screw loosening in patients with lumbosacral fixation in surgery for ASD. The incidence of lumbosacral fusion is associated with S1 screw loosening, but not S2AI screw loosening.
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Affiliation(s)
- Yasushi Iijima
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Toshiaki Kotani
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsuyoshi Sakuma
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Keita Nakayama
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsutomu Akazawa
- Department of Orthopedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shunji Kishida
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Yuta Muramatsu
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Yu Sasaki
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Keisuke Ueno
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tomoyuki Asada
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Kosuke Sato
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Shohei Minami
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Sharma M, John K, Dietz N, Aljuboori Z, Madrigal FC, Adams S, Wang D, Ugiliweneza B, Drazin D, Boakye M. Factors Impacting Outcomes and Health Care Utilization in Osteoporotic Patients Undergoing Lumbar Spine Fusions: A MarketScan Database Analysis. World Neurosurg 2020; 141:e976-e988. [PMID: 32585375 DOI: 10.1016/j.wneu.2020.06.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/11/2020] [Accepted: 06/13/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify factors impacting long-term complications, reoperations, readmission rates, and health care utilization in patients with osteoporosis (OP) following lumbar fusions. METHODS We used International Classification of Disease, Ninth Revision, International Classification of Disease, Tenth Revision , and Current Procedural Terminology codes to extract data from MarketScan (2000-2016). Patients undergoing lumbar spine fusion were divided into 2 groups based on preoperative diagnosis: OP or non-OP. We used multivariable generalized linear regression models to analyze outcomes of interest (reoperation rates, readmissions, complications, health care utilization) at 1, 6, 12, and 24 months after discharge. RESULTS MarketScan identified 116,749 patients who underwent lumbar fusion with ≥24 months of follow-up; 6% had OP. OP patients had a higher incidence of complications (14% vs. 9%); were less likely to be discharged home (77% vs. 86%, P < 0.05); had more new fusions or refusions at 6 months (2.9% vs. 2.1%), 12 months (5% vs. 3.8%), and 24 months (8.5% vs. 7.4%); incurred more outpatient services at 12 months (80 vs. 61) and 24 months (148 vs. 115); and incurred higher overall costs at 12 months ($22,932 vs. $17,017) and 24 months ($48,379 vs. $35,888). Elderly OP patients (>65 years old) who underwent multilevel lumbar fusions had longer hospitalization, had higher complication rates, and incurred lower costs at 6, 12, and 24 months compared with young non-OP patients who underwent single-level lumbar fusion. CONCLUSIONS Patients of all ages with OP had higher complication rates and required revision surgeries at 6, 12, and 24 months compared with non-OP patients. Elderly OP patients having multilevel lumbar fusions were twice as likely to have complications and lower health care utilization compared with younger non-OP patients who underwent single-level fusion.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Kevin John
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Zaid Aljuboori
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Shawn Adams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Doniel Drazin
- Evergreen Hospital Neuroscience Institute, Kirkland, Washington, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.
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A screw position change at an early postoperative stage preceding the subsequent occurrence of screw loosening. 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 2020; 30:136-141. [PMID: 32577862 DOI: 10.1007/s00586-020-06510-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/07/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The authors recently proposed the novel radiologic assessment method to measure chronological screw position changes precisely. The aim of this study was to predict the late occurrence of screw loosening, which was diagnosed by the radiographic lucent zone, by evaluating screw position changes at an early postoperative stage using the novel method. METHODS Forty-three patients who underwent thoracolumbar screw fixation and follow-up computed tomography (CT) scans on the day, between 1 and 5 weeks, and at more than 6 months after surgery were retrospectively evaluated. Screw images were generated from CT data. Screw position changes were evaluated by superposing screw images on the day and between 1 and 5 weeks after surgery. Screw loosening was diagnosed by the radiographic lucent zone on CT images at 6 months or later post-surgery, and patients were classified into screw loosening and non-loosening groups. The early screw position changes were compared between the two groups. RESULTS Significant differences in early screw position changes were found between the screw loosening and non-loosening groups in Mann-Whitney U test (p = 0.001). On the receiver operating characteristic (ROC) curve analysis, the area under the ROC curve was 0.791, and the best cutoff value of early screw position change for the prediction of screw loosening was 0.83 mm with a sensitivity of 64.0% and a specificity of 88.9%. CONCLUSION We calculated a cutoff value of the screw position changes at an early postoperative stage for the prediction of subsequent development of screw loosening with the radiographic lucent zone.
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Wang M, Mummaneni PV, Xi Z, Chang CC, Rivera J, Guinn J, Mayer R, Chou D. Lower Hounsfield units on CT are associated with cage subsidence after anterior cervical discectomy and fusion. J Neurosurg Spine 2020; 33:425-432. [PMID: 32503001 DOI: 10.3171/2020.3.spine2035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A consequence of anterior cervical discectomy and fusion (ACDF) is graft subsidence, potentially leading to kyphosis, nonunion, foraminal stenosis, and recurrent pain. Bone density, as measured in Hounsfield units (HUs) on CT, may be associated with subsidence. The authors evaluated the association between HUs and subsidence rates after ACDF. METHODS A retrospective study of patients treated with single-level ACDF at the University of California, San Francisco, from 2008 to 2017 was performed. HU values were measured according to previously published methods. Only patients with preoperative CT, minimum 1-year follow-up, and single-level ACDF were included. Patients with posterior surgery, tumor, infection, trauma, deformity, or osteoporosis treatment were excluded. Changes in segmental height were measured at 1-year follow-up compared with immediate postoperative radiographs. Subsidence was defined as segmental height loss of more than 2 mm. RESULTS A total of 91 patients met inclusion criteria. There was no significant difference in age or sex between the subsidence and nonsubsidence groups. Mean HU values in the subsidence group (320.8 ± 23.9, n = 8) were significantly lower than those of the nonsubsidence group (389.1 ± 53.7, n = 83, p < 0.01, t-test). There was a negative correlation between the HU values and segmental height loss (Pearson's coefficient -0.735, p = 0.01). Using receiver operating characteristic curves, the area under the curve was 0.89, and the most appropriate threshold of HU value was 343.7 (sensitivity 77.1%, specificity 87.5%). A preoperative lower HU is a risk factor for postoperative subsidence (binary logistic regression, p < 0.05). The subsidence rate and distance between allograft and polyetheretherketone (PEEK) materials were not significantly different (PEEK 0.9 ± 0.7 mm, allograft 1.0 ± 0.7 mm; p > 0.05). CONCLUSIONS Lower preoperative CT HU values are associated with cage subsidence in single-level ACDF. Preoperative measurement of HUs may be useful in predicting outcomes after ACDF.
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Affiliation(s)
- Minghao Wang
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
- 2Department of Neurosurgery, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Zhuo Xi
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Chih-Chang Chang
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Joshua Rivera
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Jeremy Guinn
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Rory Mayer
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
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Okano I, Jones C, Salzmann SN, Reisener M, Sax OC, Rentenberger C, Shue J, Carrino JA, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Endplate volumetric bone mineral density measured by quantitative computed tomography as a novel predictive measure of severe cage subsidence after standalone lateral lumbar 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 2020; 29:1131-1140. [DOI: 10.1007/s00586-020-06348-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/18/2019] [Accepted: 02/18/2020] [Indexed: 11/28/2022]
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Takenaka S, Kaito T, Ishii K, Watanabe K, Watanabe K, Shinohara A, Harada T, Nakada F, Majima Y, Matsumoto M. Influence of novel design alteration of pedicle screw on pull-out strength: A finite element study. J Orthop Sci 2020; 25:66-72. [PMID: 30902538 DOI: 10.1016/j.jos.2019.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/19/2019] [Accepted: 03/01/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND We conducted a finite element study to assess the effectiveness of a novel pedicle screw design with two alterations in the distal and proximal portions. METHODS Finite element (FE) models of 24 vertebrae were constructed using computed tomographic data. Pull-out strength of 4 different pedicle screws were compared. The basic screw design was a dual threaded one (PS0), in which the proximal portion is double-threaded (cortical thread), and the distal portion is single-threaded (cancellous thread). In PS1, the inter-thread double-core shape was added to PS0 in the distal portion. Compared to PS0, in PS2, the proximal portion was elongated by 5 mm. PS3 had both PS1 and PS2 features. In addition, the 24 vertebrae were classified into 3 groups based on volumetric bone mineral density (vBMD) of the vertebral body: low <120 mg/cm3, moderate 120-170 mg/cm3, and high >170 mg/cm3. RESULTS The mean pull-out strengths (±SD) were 1137 ± 500 N, 1188 ± 520 N, 1191 ± 512 N, and 1242 ± 538 N for PS0, PS1, PS2, and PS3, respectively. In PS1, there was significant difference in the incremental ratio of pull-out strength to PS0 between the low and high vBMD groups (3.7 ± 1.6% vs. 5.0 ± 1.0%, p = 0.006). In PS2, there was a significant difference in the incremental ratio to PS0 between the moderate and high vBMD groups (7.6 ± 4.0% vs. 3.3 ± 1.8%, p < 0.001). In PS3, there was a significant difference in the incremental ratio to PS0 between the moderate and high vBMD groups (12.1 ± 4.8% vs. 8.5 ± 2.1%, p = 0.003). CONCLUSIONS The two design alterations showed the combined additive effect in the PS3 design. The moderate vBMD group has a balanced bone property to reflect the combined effects of the PS1 and PS2 design alterations.
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Affiliation(s)
- Shota Takenaka
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Ken Ishii
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kei Watanabe
- Department of Orthopaedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Akira Shinohara
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tomohisa Harada
- Department of Spinal Surgery, Rakuwakai Marutamachi Hospital, Kyoto, Japan
| | | | | | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
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Liu P, Zhou B, Chen F, Dai Z, Kang Y. Effect of Trabecular Microstructure of Spinous Process on Spinal Fusion and Clinical Outcomes After Posterior Lumbar Interbody Fusion: Bone Surface/Total Volume as Independent Favorable Indicator for Fusion Success. World Neurosurg 2019; 136:e204-e213. [PMID: 31899388 DOI: 10.1016/j.wneu.2019.12.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We assessed the trabecular microarchitecture of the spinous process as an autograft and investigated its correlations with fusion success and clinical outcomes for patients undergoing posterior lumbar interbody fusion. METHODS Micro-computed tomography reconstruction techniques were used to scan cancellous bone specimens from spinous processes. We then measured the microarchitectural parameters for 105 subjects. RESULTS The patient cohort included 44 older men and 61 postmenopausal women with a minimum of 2-year follow-up data available. The complete fusion rate was 87.6% (92 of 105) at the last follow-up. When stratified by fusion status, the union group had significantly greater bone surface/total volume (BS/TV) and trabecular number but significantly lower trabecular separation than the nonunion group. No statistically significant differences were observed between the 2 groups in the clinical variables, except for the bone mineral density at the femoral neck (P = 0.028). On binomial logistic regression analysis, BS/TV was identified as an independent predictor for fusion success (odds ratio, 8.532; P = 0.032). The receiver operating characteristic curve showed that BS/TV had excellent performance in predicting successful fusion (area under the curve, 0.807). Using a cutoff value for BS/TV of 3.145, a greater BS/TV was significantly associated with visual analog scale scores for lower back pain 6 months postoperatively and lower Oswestry disability index scores at 12 and 24 months postoperatively but not with visual analog scale scores for leg pain. CONCLUSIONS Our data suggest that microstructural deterioration of the spinal process as an autograft has detrimental effects on spinal fusion and clinical outcomes for patients undergoing instrumented posterior lumbar interbody fusion. Specifically, the microstructural parameter BS/TV has good potential for assessing lumbar bone quality and predicting fusion success.
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Affiliation(s)
- Ping Liu
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha City, China
| | - Bin Zhou
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha City, China
| | - Fei Chen
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha City, China
| | - Zhehao Dai
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha City, China
| | - Yijun Kang
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha City, China.
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Carlson BC, Robinson WA, Wanderman NR, Sebastian AS, Nassr A, Freedman BA, Anderson PA. A Review and Clinical Perspective of the Impact of Osteoporosis on the Spine. Geriatr Orthop Surg Rehabil 2019; 10:2151459319861591. [PMID: 31360592 PMCID: PMC6637832 DOI: 10.1177/2151459319861591] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction Osteopenia and osteoporosis are common conditions in the United States. The health consequences of low bone density can be dire, from poor surgical outcomes to increased mortality rates following a fracture. Significance This article highlights the impact low bone density has on spine health in terms of vertebral fragility fractures and its adverse effects on elective spine surgery. It also reviews the clinical importance of bone health assessment and optimization. Results Vertebral fractures are the most common fragility fractures with significant consequences related to patient morbidity and mortality. Additionally, a vertebral fracture is the best predictor of a subsequent fracture. These fractures constitute sentinel events in osteoporosis that require further evaluation and treatment of the patient's underlying bone disease. In addition to fractures, osteopenia and osteoporosis have deleterious effects on elective spine surgery from screw pullout to fusion rates. Adequate evaluation and treatment of a patient's underlying bone disease in these situations have been shown to improve patient outcomes. Conclusion With an increased understanding of the prevalence of low bone mass and its consequences as well an understanding of how to identify these patients and appropriately intervene, spine surgeons can effectively decrease the rates of adverse health outcomes related to low bone mass.
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Affiliation(s)
- Bayard C Carlson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Paul A Anderson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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