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Miyashita T, Kato K, Yunde A, Ataka H, Tanno T. Comparison of facet fusion rates and clinical outcomes between cortical bone trajectory screw and percutaneous pedicle screw fixation for degenerative lumbar spondylolisthesis. Spine J 2024; 24:1202-1210. [PMID: 38437917 DOI: 10.1016/j.spinee.2024.02.017] [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: 11/08/2023] [Revised: 02/16/2024] [Accepted: 02/25/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND CONTEXT Cortical bone trajectory (CBT) screws have been introduced as an alternative technique for pedicle screw (PS) insertion because they have greater contact with the cortex and a greater uniaxial pullout load than traditional PS. CBT screwing can also minimize muscle dissection. However, CBT screws and traditional PSs have not yet been compared in terms of fusion rates and clinical outcomes for particular operative procedures. PURPOSE This study aimed to assess the fusion rate and clinical outcomes of facet fusion (FF) fixed with CBT screws (CBT-FF) and to compare them with those of FF fixed with percutaneous PS (PPS-FF). STUDY DESIGN Retrospective study. PATIENT SAMPLE Records of 68 patients who underwent CBT-FF for single-level degenerative lumbar spondylolisthesis (DLS) with at least 1 year of follow-up were retrospectively reviewed. The control group comprised 143 patients who underwent PPS-FF under the same conditions. OUTCOME MEASURES Computed tomography was performed to confirm fusion. Therapeutic effectiveness was assessed as a clinical outcome using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), Roland-Morris Disability Questionnaire (RMDQ), and visual analog scale (VAS) preoperatively and 1 year postoperatively. The rate of revision surgery was also calculated. Intraoperative blood loss was measured. METHODS Fusion rate, clinical outcomes, revision surgery rate, and intraoperative blood loss of CBT-FF and PPS-FF were compared. RESULTS The CBT-FF and PPS-FF fusion rates were 91.2% and 90.1%, respectively. The JOABPEQ category scores demonstrated therapeutic effectiveness in 74.5% and 77.1% of the patients for low back pain; the corresponding proportions for walking ability were 84.7% and 89.3%, respectively. No significant differences in therapeutic effectiveness were observed for any category, including the RMDQ and VAS scores for buttock and lower limb pain. Three patients required revision surgery for adjacent segment disease between 6 months and 3.5 years after CBT-FF (revision surgery rate, 4.4%), whereas the revision surgery rate for PPS-FF was 6.3% (9/143 cases). Average intraoperative blood loss was significantly less in the CBT-FF group than in the PPS-FF group. CONCLUSIONS Both procedures were equally useful in terms of fusion rate and clinical outcomes for DLS management.
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Affiliation(s)
- Tomohiro Miyashita
- Spine Center, Matsudo City General Hospital, 993-1 Sendabori, Matsudo, Chiba, 270-2296, Japan.
| | - Kei Kato
- Spine Center, Matsudo City General Hospital, 993-1 Sendabori, Matsudo, Chiba, 270-2296, Japan
| | - Atsushi Yunde
- Spine Center, Matsudo City General Hospital, 993-1 Sendabori, Matsudo, Chiba, 270-2296, Japan
| | - Hiromi Ataka
- Spine Center, Matsudo Orthopaedic Hospital, 1-161, Asahi-cho, Matsudo, Chiba, 271-0043, Japan
| | - Takaaki Tanno
- Spine Center, Matsudo Orthopaedic Hospital, 1-161, Asahi-cho, Matsudo, Chiba, 271-0043, Japan
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Sinz NJ, Hwang RW, Lee GH, Baker KC, Arnold P, Sasso R, Park D, Fischgrund J, Niu R, Kim DH. Pedicle Screw-Associated Violation of the Adjacent Unfused Facet Joint: Clinical Outcomes and Fusion Rates. Global Spine J 2024; 14:1477-1484. [PMID: 36510742 DOI: 10.1177/21925682221145651] [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] [Indexed: 12/15/2022] Open
Abstract
STUDY DESIGN Retrospective review of a prospective randomized trial. OBJECTIVES To compare outcome scores and fusion rates in patients with and without pedicle screw-associated facet joint violation (FJV) after a single-level lumbar fusion. METHODS Clinical outcomes data and computed tomography (CT) imaging were reviewed for 157 patients participating in a multicenter prospective trial. Post-operative CT scans at 12-months follow-up were examined for fusion status and FJV. Patient-reported outcomes (PROs) included Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for leg and low back pain. Chi-square test of independence was used to compare proportions between groups on categorical measures. Two-sample t-test was used to identify differences in mean patient outcome scores. Logistic regression models were performed to determine association between FJV and fusion rates. RESULTS Of the 157 patients included, there were 18 (11.5%) with FJV (Group A) and 139 (88.5%) without FJV (Group B). Patients with FJV experienced less improvement in ODI (P = .004) and VAS back pain scores (P = .04) vs patients without FJV. There was no difference in mean VAS leg pain (P = .4997). The rate of fusion at 12-months for patients with FJV (27.8%) was lower compared to those without FJV (71.2%) (P = .0002). Patients with FJV were 76% less likely to have a successful fusion at 12-months. CONCLUSION Pedicle screw-associated violation of the adjacent unfused facet joint during single-level lumbar fusion is associated with less improvement in back pain, back pain-associated disability, and a lower fusion rate at 1-year after surgery.
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Affiliation(s)
- Nathan J Sinz
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
| | - Raymond W Hwang
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Gyu-Ho Lee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kevin C Baker
- Bone & Joint Center, Dept. of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Paul Arnold
- Carle Neuroscience Institute, Urbana, IL, USA
| | - Rick Sasso
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IL, USA
| | - Daniel Park
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - Jeffrey Fischgrund
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - Ruijia Niu
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - David H Kim
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
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Dong W, Ren Z, Li S. Modified facet joint fusion for multilevel lumbar spinal stenosis: a retrospective study of 135 consecutive patients. Br J Neurosurg 2023; 37:1046-1051. [PMID: 33245247 DOI: 10.1080/02688697.2020.1850642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of modified facet joint fusion (MFF) for the treatment of multilevel (three-level or more) lumbar spinal stenosis (LSS). PATIENTS AND METHODS In this retrospective study, 135 consecutive patients who underwent initial MFF for multilevel LSS were included. Clinical outcomes included fusion rate, change of visual analogue scale pain scores for low back pain (VAS-LBP) and leg pain (VAS-LP), Japanese Orthopedic Association scores (JOA), Oswestry Disability Index (ODI) and MacNab classification before and after MFF. The complications were also analyzed. RESULTS The fusion rates were 46.7% (63/135) at 6-month and 89.6% (121/135) at 1-year. The mean VAS-LBP, VAS-LP, and ODI significantly decreased from 5.2 ± 0.6, 5.7 ± 0.8 and 65 ± 7.9 to 1.58 ± 0.4, 0.58 ± 0.3 and 20.8 ± 5.8, respectively (all p < 0.001). The mean JOA markedly improved from 10.0 ± 1.3 to 26.1 ± 1.5 (p < 0.001). Excellent/good results of MacNab classification were achieved in 88.9% (120/135) of the patients. The overall rate of complications after MFF was 5.9%, including poor wound healing (2.2%), calf muscular venous thrombosis (0.74%), deep venous thrombosis (0.74%), superficial wound infection (1.48%), transient foot drop (0.74%). All the complications were transient and improved without prolonged hospital stay and sequelae. CONCLUSION MFF may be safe and efficient for multilevel LSS with high fusion rate and significant symptom relief, which is worthy of further study.
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Affiliation(s)
- Wenfang Dong
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing China
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing China
| | - Zhinan Ren
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing China
| | - Shugang Li
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing China
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Lehr AM, Duits AA, Reijnders MR, Nutzinger D, Castelein RM, Oner FC, Kruyt MC. Assessment of Posterolateral Lumbar Fusion: A Systematic Review of Imaging-Based Fusion Criteria. JBJS Rev 2022; 10:01874474-202210000-00007. [PMID: 36325766 PMCID: PMC9612687 DOI: 10.2106/jbjs.rvw.22.00129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Noninvasive assessment of osseous fusion after spinal fusion surgery is essential for timely diagnosis of patients with symptomatic pseudarthrosis and for evaluation of the performance of spinal fusion procedures. There is, however, no consensus on the definition and assessment of successful posterolateral fusion (PLF) of the lumbar spine. This systematic review aimed to (1) summarize the criteria used for imaging-based fusion assessment after instrumented PLF and (2) evaluate their diagnostic accuracy and reliability. METHODS First, a search of the literature was conducted in November 2018 to identify reproducible criteria for imaging-based fusion assessment after primary instrumented PLF between T10 and S1 in adult patients, and to determine their frequency of use. A second search in July 2021 was directed at primary studies on the diagnostic accuracy (with surgical exploration as the reference) and/or reliability (interobserver and intraobserver agreement) of these criteria. Article selection and data extraction were performed by at least 2 reviewers independently. The methodological quality of validation studies was assessed with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) and QAREL (Quality Appraisal of Reliability Studies). RESULTS Of the 187 articles included from the first search, 47% used a classification system and 63% used ≥1 descriptive criterion related to osseous bridging (104 articles), absence of motion (78 articles), and/or absence of static signs of nonunion (39 articles). A great variation in terminology, cutoff values, and assessed anatomical locations was observed. While the use of computed tomography (CT) increased over time, radiographs remained predominant. The second search yielded 11 articles with considerable variation in outcomes and quality concerns. Agreement between imaging-based assessment and surgical exploration with regard to demonstration of fusion ranged between 55% and 80%, while reliability ranged from poor to excellent. CONCLUSIONS None of the available criteria for noninvasive assessment of fusion status after instrumented PLF were demonstrated to have both sufficient accuracy and reliability. Further elaboration and validation of a well-defined systematic CT-based assessment method that allows grading of the intertransverse and interfacet fusion mass at each side of each fusion level and includes signs of nonunion is recommended. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- A. Mechteld Lehr
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands,Email for corresponding author:
| | - Anneli A.A. Duits
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten R.L. Reijnders
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Don Nutzinger
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - René M. Castelein
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F. Cumhur Oner
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Moyo C. Kruyt
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Good 5-year postoperative outcomes after facet fusion using a percutaneous pedicle screw system for degenerative lumbar spondylolisthesis. Neurosurg Rev 2022; 45:2269-2276. [DOI: 10.1007/s10143-022-01747-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 12/17/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
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Seeherman HJ, Wilson CG, Vanderploeg EJ, Brown CT, Morales PR, Fredricks DC, Wozney JM. A BMP/Activin A Chimera Induces Posterolateral Spine Fusion in Nonhuman Primates at Lower Concentrations Than BMP-2. J Bone Joint Surg Am 2021; 103:e64. [PMID: 33950879 DOI: 10.2106/jbjs.20.02036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Supraphysiologic bone morphogenetic protein (BMP)-2 concentrations are required to induce spinal fusion. In this study, a BMP-2/BMP-6/activin A chimera (BV-265), optimized for BMP receptor binding, delivered in a recombinant human collagen:CDHA [calcium-deficient hydroxyapatite] porous composite matrix (CM) or bovine collagen:CDHA granule porous composite matrix (PCM), engineered for optimal BV-265 retention and guided tissue repair, was compared with BMP-2 delivered in a bovine absorbable collagen sponge (ACS) wrapped around a MASTERGRAFT Matrix (MM) ceramic-collagen rod (ACS:MM) in a nonhuman primate noninstrumented posterolateral fusion (PLF) model. METHODS In vivo retention of 125I-labeled-BV-265/CM or PCM was compared with 125I-labeled-BMP-2/ACS or BMP-2/buffer in a rat muscle pouch model using scintigraphy. Noninstrumented PLF was performed by implanting CM, BV-265/CM, BV-265/PCM, or BMP-2/ACS:MM across L3-L4 and L5-L6 or L3-L4-L5 decorticated transverse processes in 26 monkeys. Computed tomography (CT) images were acquired at 0, 4, 8, 12, and 24 weeks after surgery, where applicable. Manual palpation, μCT (microcomputed tomography) or nCT (nanocomputed tomography), and histological analysis were performed following euthanasia. RESULTS Retention of 125I-labeled-BV-265/CM was greater than BV-265/PCM, followed by BMP-2/ACS and BMP-2/buffer. The CM, 0.43 mg/cm3 BMP-2/ACS:MM, and 0.05 mg/cm3 BV-265/CM failed to generate PLFs. The 0.15-mg/cm3 BV-265/CM or 0.075-mg/cm3 BV-265/PCM combinations were partially effective. The 0.25-mg/cm3 BV-265/CM and 0.15 and 0.3-mg/cm3 BV-265/PCM combinations generated successful 2-level PLFs at 12 and 24 weeks. CONCLUSIONS BV-265/CM or PCM can induce fusion in a challenging nonhuman primate noninstrumented PLF model at substantially lower concentrations than BMP-2/ACS:MM. CLINICAL RELEVANCE BV-265/CM and PCM represent potential alternatives to induce PLF in humans at substantially lower concentrations than BMP-2/ACS:MM.
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Affiliation(s)
- Howard J Seeherman
- Orthopedic Research and Pharmaceutical Development Consultant, Cambridge, Massachusetts
| | | | | | | | | | - Douglas C Fredricks
- Bone Healing Research Lab and Iowa Spine Research Lab Orthopedic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - John M Wozney
- Orthopedic Research and Pharmaceutical Development Consultant, Hudson, Massachusetts
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Lara-Reyna J, Margetis K. Initial Experience With a Full Endoscopic Facet Fusion in Combination With Endoscopic Interbody Fusion. Cureus 2021; 13:e14327. [PMID: 33968535 PMCID: PMC8101511 DOI: 10.7759/cureus.14327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 11/05/2022] Open
Abstract
Background Facet fusion has been described in open and minimally invasive approaches to promote fusion. Our objective is to describe the technique of an endoscopic facet decortication and allograft placement as an adjunct to an interbody fusion. Methodology This was a descriptive analysis of patients who underwent endoscopic interbody fusion combined with facet fusion and percutaneous screw placement. General demographics, clinical presentation, length of stay, follow-up, and outcome were gathered. The technique involves endoscopic access to the Kambin's triangle, discectomy/endplate preparation, expandable cage/allograft insertion, and percutaneous pedicle screw placement. A midline incision was performed, and the endoscope was advanced over the facet joints at the desired level. After removing the soft tissue with grasping forceps, cautery was used to disrupt the facet capsule. An articulating high-speed bur was used to drill inside and over the dorsal surface of the joint. Finally, allograft chips were placed through the endoscope cannula. Results From May 2019 to December 2019, four patients underwent endoscopic interbody fusion. All were female, with a mean age of 67.5 years (SD: 12.7). All had chronic low back pain and radiculopathy associated with Grade 1 spondylolisthesis. Two (50%) of the patients underwent two-level fusion. The median hospital stay was two days. Two (50%) reported improvement of both low back and radiculopathy symptoms. None of the patients had a significant complication or required reoperation in eight months' mean follow-up. Conclusions Facet decortication and allograft placement are feasible using an endoscopic approach in conjunction with interbody fusion.
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Farrokhi M, Nourian NA, Nourian SMA. Letter to the editor regarding, "Potential significance of facet joint fusion or posteromedial fusion observed on CT imaging following attempted posterolateral or posterior interbody fusion" by Kim et al. Spine J 2020; 20:1889. [PMID: 33138971 DOI: 10.1016/j.spinee.2020.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 02/03/2023]
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Lehr AM, Oner FC, Delawi D, Stellato RK, Hoebink EA, Kempen DH, van Susante JL, Castelein RM, Kruyt MC. Increasing Fusion Rate Between 1 and 2 Years After Instrumented Posterolateral Spinal Fusion and the Role of Bone Grafting. Spine (Phila Pa 1976) 2020; 45:1403-1410. [PMID: 32459724 PMCID: PMC7515483 DOI: 10.1097/brs.0000000000003558] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/02/2020] [Accepted: 04/08/2020] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Two-year clinical and radiographic follow-up of a double-blind, multicenter, randomized, intra-patient controlled, non-inferiority trial comparing a bone graft substitute (AttraX Putty) with autograft in instrumented posterolateral fusion (PLF) surgery. OBJECTIVES The aim of this study was to compare PLF rates between 1 and 2 years of follow-up and between graft types, and to explore the role of bone grafting based on the location of the PLF mass. SUMMARY OF BACKGROUND DATA There are indications that bony fusion proceeds over time, but it is unknown to what extent this can be related to bone grafting. METHODS A total of 100 adult patients underwent a primary, single- or multilevel, thoracolumbar PLF. After instrumentation and preparation for grafting, the randomized allocation side of AttraX Putty was disclosed. The contralateral posterolateral gutters were grafted with autograft. At 1-year follow-up, and in case of no fusion at 2 years, the fusion status of both sides of each segment was blindly assessed on CT scans. Intertransverse and facet fusion were scored separately. Difference in fusion rates after 1 and 2 years and between grafts were analyzed with a Generalized Estimating Equations (GEE) model (P < 0.05). RESULTS The 2-year PLF rate (66 patients) was 70% at the AttraX Putty and 68% at the autograft side, compared to 55% and 52% after 1 year (87 patients). GEE analysis demonstrated a significant increase for both conditions (odds ratio 2.0, 95% confidence interval 1.5-2.7, P < 0.001), but no difference between the grafts (P = 0.595). Ongoing bone formation was only observed between the facet joints. CONCLUSION This intra-patient controlled trial demonstrated a significant increase in PLF rate between 1 and 2 years after instrumented thoracolumbar fusion, but no difference between AttraX Putty and autograft. Based on the location of the PLF mass, this increase is most likely the result of immobilization instead of grafting. LEVEL OF EVIDENCE 1.
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Affiliation(s)
- A. Mechteld Lehr
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F. Cumhur Oner
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Diyar Delawi
- Department of Orthopaedic Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Rebecca K. Stellato
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eric A. Hoebink
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
| | | | | | - René M. Castelein
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Moyo C. Kruyt
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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