What are the advances for surgical therapy of inflammatory diseases of the spine?

Prognosis of Symptomatic Pseudarthrosis Observed at 1 Year After Lateral Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to investigate the prognosis of symptomatic pseudarthrosis observed at 1 year after lateral lumbar interbody fusion (LLIF) surgery and to analyze the risk factors for persistent pseudarthrosis for 2 years postoperatively.

SUMMARY OF BACKGROUND DATA

Few articles have evaluated the prognosis of symptomatic pseudarthrosis following LLIF surgery.

METHODS

One hundred fifty-two patients with a minimum follow-up of 2 years were screened. Fusion status was assessed at 1 year postoperatively, and unfused segments were reevaluated at 2 years postoperatively. Dynamic x-rays and computed tomography images were acquired to evaluate the fusion status. Demographic data were evaluated to identify the risk factors associated with persistent pseudarthrosis. Clinical outcomes, including the visual analog scale (VAS) for back/leg pain and the Oswestry disability index (ODI), were evaluated preoperatively and at 1 and 2 years postoperatively.

RESULTS

Symptomatic pseudarthrosis was detected in 42 patients at 1 year postoperatively. Among them, 23 patients (54.8%) exhibited solid bony fusion 2 years postoperatively without further intervention. Fourteen patients (33.3%) showed asymptomatic pseudarthrosis, and the remaining five patients (11.9%) showed symptomatic pseudarthrosis. Multivariable analysis showed that diabetes (adjusted odds ratio [OR]: 2.817, P = 0.007), smoking (adjusted OR: 6.497, P = 0.008), and fusion at more than three levels (adjusted OR: 2.525, P = 0.031) were risk factors for persistent pseudarthrosis. Improvements in the VAS scores for back pain and ODI scores were significantly lower in the persistent pseudarthrosis group than in the final solid fusion group at 2 years postoperatively.

CONCLUSION

It is not necessary to intervene for all patients in whom symptomatic pseudarthrosis is detected at 1 year postoperatively because only 11.9% of them will show persistent symptomatic pseudarthrosis. However, early revision surgery should be considered when severe symptomatic pseudarthrosis associated with diabetes, smoking, and fusion at more than three levels is present.Level of Evidence: 4.

National trends in revision spinal fusion in the USA

Using the United States Nationwide Inpatient Sample, we identified national trends in revision spinal fusion along with a comprehensive comparison of comorbidities, inpatient complications and surgical factors of revision spinal fusion compared to primary spinal fusion.

In 2009, there were 410 158 primary spinal fusion discharges and 22 128 revision spinal fusion discharges. Between 2002 and 2009, primary fusion increased at a higher rate compared with revision fusion (56.4% vs 51.0%; p < 0.001). In 2009, the mean length of stay and hospital charges were higher for revision fusion discharges than for primary fusion discharges (4.2 days vs 3.8 days, p < 0.001; USD $91 909 vs. $87 161, p < 0.001). In 2009, recombinant human bone morphogenetic protein (BMP) was used more in revision fusion than in primary fusion (39.6% vs 27.6%, p < 0.001), whereas interbody devices were used less in revision fusion (41.8% vs 56.6%, p < 0.001).

In the multivariable logistic regression model for all spinal fusions, depression (odds ratio (OR) 1.53, p < 0.001), psychotic disorders (OR 1.49, p < 0.001), deficiency anaemias (OR 1.35, p < 0.001) and smoking (OR 1.10, p = 0.006) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges, adjusting for other variables. In terms of complications, after adjusting for all significant comorbidities, this study found that dural tears (OR 1.41; p < 0.001) and surgical site infections (OR 3.40; p < 0.001) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges (p < 0.001). A p-value < 0.01 was considered significant in all final analyses.

Cite this article: Bone Joint J 2014;96-B:807–16.

Safety of etanercept therapy in rheumatoid patients undergoing surgery: preliminary report

This is a preliminary report on a case-series of rheumatoid patients that underwent various kinds of elective surgery but did not withdraw etanercept therapy in spite of physician advise. Elective surgery consisted of right knee surgical prosthesis, bilateral cataract, bilateral hallux valgus, right hip prosthesis, bladder stone by cystoscopy and left inguinal hernia. All the patients had a regular healing rate. During follow-up (6-12 months) no one of these patients were suffering from infective complications after surgery. According to same recent literature results, our data suggest that it is the time to value rheumatoid patient preferences through a correct information about cost-benefit of this treatment to establish together with patients if etanercept therapy has to be discontinued before and after elective surgery. Finally, we think that adverse drug reaction surveillance has to be boosted, and editors of leading scientific journal should publish more papers on case-series about drug safety and tolerability in particular conditions.

Inflammatory arthritides of the spine: surgical versus nonsurgical treatment

Ankylosing spondylitis and rheumatoid arthritis are disorders that cause marked alterations in the structure and function of the axial skeleton. Ankylosing spondylitis causes calcification of spinal structures causing limited motion. Rheumatoid arthritis causes synovial hypertrophy, joint destruction, and spinal instability. Surgical therapy for patients with ankylosing spondylitis corrects angular deformities with spinal osteotomies, and stabilization for spinal fractures. Spinal operative therapy for rheumatoid arthritis concentrates on correction of abnormal motion in the cervical spine. Advances in the medical therapy of spondyloarthritis have resulted in control of the inflammation of the axial skeleton halting the damage to spinal structures. The new biologic therapies for ankylosing spondylitis prevent progression of disease. Similarly, these same biologic therapies can also control the progression of rheumatoid arthritis including the cervical spine. The new medical therapies are very effective in preventing joint damage. The need for surgical intervention for patients with ankylosing spondylitis and rheumatoid arthritis will become a rare event in the setting of the new medical therapies for these inflammatory arthropathies.

Revision strategies for lumbar pseudarthrosis

Management and avoidance of lumbar pseudarthrosis are among the most common and challenging tasks faced by reconstructive spine surgeons. The risks of pseudarthrosis can be broadly divided into two categories: those within a surgeon's control and those not within his/her control. These include biological factors, graft choices, site preparation, and surgical design. The authors review the biological factors that affect fusion and how they can be manipulated to avoid or manage lumbar pseudarthrosis. Surgical planning and construct design to prevent or treat pseudarthrosis will also be discussed. Additionally, the importance of restoring sagittal balance will be reviewed.