Anterior approach with expandable cage implantation in management of unstable thoracolumbar fractures: Results of a series of 93 patients

Risk Factors for Cage Subsidence in Minimally Invasive Lateral Corpectomy for Osteoporotic Vertebral Fractures

Introduction

This study aims to investigate risk factors for cage subsidence following minimally invasive lateral corpectomy for osteoporotic vertebral fractures.

Methods

Eight males and 13 females (77.2±6.0 years old) with osteoporotic vertebral fractures who underwent single corpectomy using a wide-footprint expandable cage with at least a 1-year follow-up were retrospectively included. The endplate cage (EC) angle was defined as the angle between the vertebral body's endplate and the cage's base on the cranial and caudal sides. A sagittal computed tomography scan was performed immediately after surgery and at the final follow-up, with cage subsidence defined as subsidence of ≥2 mm on the cranial or caudal side. Risk factors were analyzed by dividing cases into groups with (n=6) and without (n=15) cage subsidence.

Results

No significant differences were noted in age, bone mineral density, number of fixed vertebrae, sagittal parameters, preoperative and final kyphosis angle, amount of kyphosis angle correction, bone union, screw loosening, and number of other vertebral fractures preoperatively and 1-year postoperatively between the two groups. No difference was noted in cranial EC angle, but a significant difference was noted in caudal EC angle in the group with (10.7±4.1°) and without (4.7±4.2°) subsidence (P=0.008). Logistic regression analysis with the dependent variable as presence or absence of subsidence showed that caudal EC angle (>7.5°) was a significant factor (odds ratio: 20, 95% confidence interval: 1.655-241.7, P=0.018).

Conclusions

In minimally invasive lateral corpectomy for osteoporotic vertebral fractures, a cage tilted more than 7.5° to the caudal vertebral endplate is a risk factor for cage subsidence. The cage should be placed as perpendicular to the endplate as possible, especially to the caudal vertebral body, to avoid cage subsidence.

Evaluation of Radiological and Neurological Outcomes after Anterior Cervical Corpectomy with Fusion using Expandable Cage Alone and Expandable Cage with Anterior Cervical Plating

Objective After anterior cervical corpectomy expandable cage were used with or without using anterior cervical plate for structural support are being preferred over autologous bone graft and other types of cages. Nowadays, the preferable type of cages and application of anterior cervical plate remain a debatable topic with studies giving divergent results. The purpose of this study is to evaluate the outcomes of expandable cages used alone or expandable cage used with anterior cervical plate following anterior cervical corpectomy.

Materials and Methods This study was conducted on 100 patients from January 2019 to December 2021 and all patients were undergone anterior cervical corpectomy and fusion and divided in two groups with expandable cage only (Group A) and expandable cage with anterior cervical plate (Group B). Various long-term benefits and radiological outcomes were studied in both groups.

Statistical Analysis and Results In this study, 100 patients were included and all patients underwent corpectomy followed by insertion of expandable cage alone or with anterior cervical plate. There was an improvement in C2–C7 Cobb's angle in group B was significantly higher than group A (p < 0.05) and decrease in Nurick's scale score in group B was significantly higher than group A (p < 0.05). The outcomes were measured with fusion rate (94%), subsidence rate (15%) and change in C2–C7 Cobb's angle was 4 degrees in this study.

Conclusion Expandable cage with or without anterior cervical plate was used after anterior cervical corpectomy for various cervical pathological conditions. In this study, we conclude the long-term benefits and radiological outcomes of two groups as expandable cage was used alone or with additional application of anterior cervical plate. In this study, the results were more in favor of additional application of anterior cervical plate as compared with expandable cage alone and more studies were required in future for more established long-term benefits and drawbacks.

Posterior unilateral approach with 270° spinal canal decompression and three-column reconstruction using double titanium mesh cage for thoracic and lumbar burst fractures

Objective

To evaluate the clinical effects of the posterior unilateral approach with 270° spinal canal decompression and three-column reconstruction using double titanium mesh cage (TMC) for thoracic and lumbar burst fractures.

Materials and methods

From May 2013 to May 2018, 27 patients with single-level thoracic and lumbar burst fractures were enrolled. Every patient was followed for at least 18 months. Demographic data, neurologic status, back pain, canal compromise, anterior body compression, operative time, estimated blood loss and surgical-related complications were evaluated. Radiographs were reviewed to assess deformity correction, anterior body height correction, bony fusion and TMC subsidence.

Results

The average preoperative percentages of canal compromise and anterior body height compression were 58.4% and 50.5%, respectively. All surgeries were successfully completed in one phase, the operative time was 151.5 ± 25.5 min (range: 115-220 min), the estimated blood loss was 590.7 ± 169.9 ml (range: 400-1,000 ml). Neurological function recovery was significantly improved except for 3 grade A patients. The preoperative visual analog scale (VAS) scores for back pain were significantly decreased compared with the values at the last follow-up (P = 0.000). The correct deformity angle was 12.4 ± 4.7° (range: 3.9-23.3°), and the anterior body height recovery was 96.7%. The TMC subsidence at the last follow-up was 1.3 ± 0.7 mm (range: 0.3-3.1 mm). Bony fusion was achieved in all patients.

Conclusion

The posterior unilateral approach with 270° spinal canal decompression and three-column reconstruction using double TMC is a clinically feasible, safe and alternative treatment for thoracic and lumbar burst fractures.

Comparison of Effect of Navigation Versus No Navigation on Vertebral Body Screw Placement in Anterior Approach Surgery for Thoracolumbar Burst Fractures: A Randomized Controlled Trial

OBJECTIVE

We evaluated the effects of using a navigation technique with anterior approach surgery for thoracolumbar burst fractures on vertebral body screw placement and discussed its effects on the long-term prognosis of patients.

METHODS

We performed a prospective study of patients who had undergone anterior approach thoracolumbar surgery from May 2018 to August 2019. The 40 patients were randomly divided into the navigation group (NG) and control group (CG). In the NG, vertebral body screw placement was performed with 2-dimensional navigation guidance. For the CG, no navigation guidance was used. The clinical and radiological evaluations of the 2 groups were compared preoperatively, immediately after surgery, and at the final follow-up. Paired t tests and the χ² test were used to evaluate the clinical and radiological indicators.

RESULTS

No differences were found in the hospital stay, operation time, autologous blood recovery, postoperative drainage volume, Cobb angle of the preoperative coronal plane and sagittal plane, postoperative sagittal plane, postoperative Cobb angle of the coronal and sagittal planes measured on radiographs and computed tomography scans between the 2 groups (P > 0.05). The correction of the kyphosis deformity of the fracture segment was better in both groups (P < 0.001). The intraoperative blood loss and Cobb angle of the postoperative coronal plane in the NG was less than that in the CG (P < 0.05). Also, the 4 vertebral body screws in the NG were more parallel to the endplate than were those in the CG.

CONCLUSIONS

We found that the use of navigation can improve the accuracy of screw placement in anterior approach surgery for thoracolumbar burst fractures and improve patients' long-term prognosis.

Application of an Expandable Cage for Reconstruction of the Cervical Spine in a Consecutive Series of Eighty-Six Patients

Background and objectives: Expandable cages are frequently used to reconstruct the anterior spinal column after a corpectomy. In this retrospective study, we evaluated the perioperative advantages and disadvantages of corpectomy reconstruction with an expandable cage. Materials and Methods: Eighty-six patients (45 male and 41 female patients, medium age of 61.3 years) were treated with an expandable titanium cage for a variety of indications from January 2012 to December 2019 and analyzed retrospectively. The mean follow-up was 30.7 months. Outcome was measured by clinical examination and visual analogue scale (VAS); myelopathy was classified according to the EMS (European Myelopathy Scale) and gait disturbances with the Nurick score. Radiographic analysis comprised measurement of fusion, subsidence and the C2–C7 angle. Results: Indications included spinal canal stenosis with myelopathy (46 or 53.5%), metastasis (24 or 27.9%), spondylodiscitis (12 or 14%), and fracture (4 or 4.6%). In 39 patients (45.3%), additional dorsal stabilization (360° fusion) was performed. In 13 patients, hardware failure occurred, and in 8 patients, adjacent segment disease occurred. Improvement of pain symptoms, myelopathy, and gait following surgery were statistically significant (p < 0.05), with a medium preoperative VAS of 8, a postoperative score of 3.2, and medium EMS scores of 11.3 preoperatively vs. 14.3 postoperatively. Radiographic analysis showed successful fusion in 74 patients (86%). As shown in previous studies, correction of the C2–C7 angle did not correlate with improvement of neurological symptoms. Conclusion: Our results show that expandable titanium cages are a safe and useful tool in anterior cervical corpectomies for providing adequate anterior column support and stability.

Isolated unstable burst fractures of the fifth lumbar vertebra: functional and radiological outcome after posterior stabilization with reconstruction of the anterior column: About 6 cases and literature review

INTRODUCTION

L5 burst fractures represent a small percentage of all spine fractures. Treatment strategy has not yet been standardized. Anatomical features and their biomechanical characteristics create fracture patterns which differ from those at the thoracolumbar junction. The objective of this study was to evaluate L5 burst fracture surgical treatment outcomes after posterior stabilization and reconstruction of the anterior column.

PATIENTS AND METHODS

Six patients with fifth lumbar isolated unstable burst fractures were analyzed. Medical records, radiographs, and clinical scores were obtained. The results were evaluated based on restoration of vertebral body height, spinal lordosis/kyphosis, canal compromise and sagittal alignment at several phases of treatment.

RESULTS

No patient showed neurologic deterioration, regardless of treatment. The median preoperative anterior vertebral height was 41mm and postoperative was 48mm. The median preoperative kyphotic angle as measured by Cobb angle (local and regional) was 21.5 degrees and 33 degrees which improved respectively by 7.5 and 5.5 degrees following instrumentation. The median amount of backward protrusion of bony fragment into the canal was measured at 67% preoperatively and at 35% postoperatively. There were no pseudarthrosis and anterior arthrodesis solid fusion was visible in all cases. There were a sagittal alignment restoration. At one year of follow up, fusion was obtained in all the cases, all patients had minimal to moderate disability using Oswestry Disability Index. The ability to return to work revealed a good-to-excellent long-term result.

DISCUSSION

The results of treatment of 5th lumbar unstable burst fractures with posterior stabilization and reconstruction of the anterior column show benefit on durable functional outcome, spine stabilization and radiologic parameters.

LEVEL OF EVIDENCE

IV, retrospective study.

Thoracoscopic Correction of Post-traumatic Kyphosis with an Expandable Cage: Radiologic and Patient-Reported Outcomes

Study Design

Retrospective cohort study.

Purpose

To determine the long-term functional and radiological outcomes after thoracoscopic post-traumatic kyphosis (PTK) correction (PTKC).

Overview of Literature

PTK after insufficient treatment of unstable fractures usually presents with pain and decreased back function. The results of PTKC using a minimally invasive thoracoscopic approach with an anterior titanium cage have not previously been reported.

Methods

Data in this study were collected from all patients who underwent thoracoscopic PTKC with an expandable cage between 2007 and 2017. Kyphosis and intervertebral body height were assessed on radiographic material. Quality of life (QOL) and functional outcome scores were determined by the Euroquol 5 dimensions (EQ5D) and the Oswestry Disability Index (ODI). Additionally, satisfaction and subjective symptom improvement were determined.

Results

Fourteen patients were treated for symptomatic PTK using a combined thoracoscopic anterior and posterior approach. Nine patients received initial conservative fracture treatment and five patients underwent initial posterior fracture fixation. All patients presented with pain and without neurologic injury. The mean time between injury and PTKC was 15.4 months. Cobb angle (CA) improved with 10.6° immediately after PTKC. During the first follow-up, 4.8° kyphosis correction was lost, but CAs remained stable at longer follow-up. Bony fusion was achieved in 92% of the patients after 16 months. The majority of patients reported an improvement of symptoms 85 months after surgery, satisfaction with and willingness to undergo the procedure again. The mean EQ5D index score was 0.71 and the mean ODI score was 22.3.

Conclusions

The results of minimally invasive thoracoscopic PTKC using an expandable cage were satisfactory. The majority of the patients were satisfied after treatment and no neurological complications occurred. Functional and QOL scores were fairly good. Whereas some postoperative kyphosis correction was lost over time, bony fusion was achieved in the majority of the patients. The thoracoscopic approach minimizes surgical morbidity, does not lead to serious complications, and provides a good option for PTKC.

Spontaneous corpectomy and anterior arthrodesis in lumbar spine: how Ankylosing Spondylitis can resolve a vertebral fracture

Between the 80% and 90% of vertebral fractures in over 65 years people are due to osteoporosis. Over the 30% of patients affected by vertebral osteoporosis fractures needs of surgical treatment and the 12% presents complications requiring an invasive surgical approach. We report an unusual case of spontaneous corpectomy and anterior arthrodesis occurred in a patient suffering from Ankylosing Spondylitis. This event invites us to reflect about the magnitude of the biological power of the bone healing, even in adverse conditions.

Instrumented Circumferential Fusion in Two Stages for Instable Lumbar Fracture: Long-Term Results of a Series of 74 Patients on Sagittal Balance and Functional Outcomes

OBJECTIVE

To report the radiologic and functional results of a multicenter, prospective case series of patients with comminuted lumbar fractures treated with 2-stage circumferential arthrodesis.

METHODS

A multicenter prospective case series of 74 patients with comminuted lumbar fractures was analyzed. The strategy entailed initial posterior osteosynthesis, followed by physical replacement with an expandable titanium cage filled with autologous bone via retroperitoneal lumbotomy. The mechanism of lesion formation and epidemiologic characteristics were recorded. Clinical and quality-of-life analyses (visual analog scale [VAS], Oswesty Disability Index [ODI], Short Form 12 [SF-12]) were performed over a minimum observation period of 1 year. Radiologic parameters, including deformity measurements, were recorded at each evaluation. Fusion was analyzed by means of a 1-year monitoring scan.

RESULTS

The mean patient age was 38.1 years, and median duration of follow-up was 2.1 years (interquartile range, 1.3-2.9). The distribution of fractures according to the Magerl classification scheme was as follows: A, 64.8%; B, 16.7%; C, 18.5%. At the last follow-up, fusion was considered certain in 57 cases (77%). The mean VAS score was 2.1 ± 1.3, mean ODI was 14.7 ± 8.0, mean SF-12 Physical Component Summary score was 43.2 ± 9.3, and mean SF-12 Mental Component Summary score was 50.8 ± 5.9. Correction of the regional sagittal deformity was significant during the postoperative period, with a mean increase in lordosis of 9.0° (P < 0.0001). The loss of mean correction at the last follow-up (-2.9°) was not significant.

CONCLUSIONS

Circumferential arthrodesis, including posterior osteosynthesis and physical replacement with an expandable cage and autologous graft, is applicable to the treatment of comminuted lumbar fractures. A high rate of fusion was obtained with significant and long-lasting correction of the sagittal deformity. Functional scores measured at 1 year suggest mild disability. The ODI, SF-12, and VAS scores were positively correlated with fusion at the last follow-up.