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Tabarestani TQ, Drossopoulos PN, Huang CC, Bartlett AM, Paturu MR, Shaffrey CI, Chi JH, Ray WZ, Goodwin CR, Amrhein TJ, Abd-El-Barr MM. The Importance of Planning Ahead: A Three-Dimensional Analysis of the Novel Trans-Facet Corridor for Posterior Lumbar Interbody Fusion Using Segmentation Technology. World Neurosurg 2024; 188:e247-e258. [PMID: 38777315 DOI: 10.1016/j.wneu.2024.05.091] [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: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The rise of minimally invasive lumbar fusions and advanced imaging technologies has facilitated the introduction of novel surgical techniques with the trans-facet approach being one of the newest additions. We aimed to quantify any pathology-driven anatomic changes to the trans-facet corridor, which could thereby alter the ideal laterality of approach to the disc space. METHODS In this retrospective cohort study, we measured the areas and maximum permissible cannula diameters of the trans-facet corridor using commercially available software (BrainLab, Munich, Germany). Exiting and traversing nerve roots, thecal sacs, and lumbar vertebrae were manually segmented on T2-SPACE magnetic resonance imaging. Spondylolisthesis, disc protrusions, and disc space heights were recorded. RESULTS A total of 118 trans-facet corridors were segmented bilaterally in 16 patients (65.6 ± 12.1 years, 43.8% female, body mass index 29.2 ± 5.1 kg/m2). The mean areas at L1-L2, L2-L3, L3-L4, and L4-L5 were 89.4 ± 24.9 mm2, 124 ± 39.4 mm2, 123 ± 26.6 mm2, and 159 ± 42.7 mm2, respectively. The mean permissible cannula diameter at the same levels were 7.85 ± 1.43 mm, 8.98 ± 1.72 mm, 8.93 ± 1.26 mm, and 10.2 ± 1.94 mm, respectively. Both parameters increased caudally. Higher degrees for spondylolisthesis were associated with larger areas and maximum cannula diameters on regression analysis (P < 0.001). CONCLUSIONS Our results illustrate that pathology, like spondylolisthesis, can increase the area of the trans-facet corridor. By understanding this effect, surgeons can better decide on the optimal approach to the disc while taking into consideration a patient's unique anatomy.
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Affiliation(s)
- Troy Q Tabarestani
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Peter N Drossopoulos
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chuan-Ching Huang
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Alyssa M Bartlett
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mounica R Paturu
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | | | - John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, North Carolina, USA
| | - Wilson Z Ray
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Timothy J Amrhein
- Department of Radiology, Duke University Hospital, Durham, North Carolina, USA
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Lee JJ, Jacome FP, Hiltzik DM, Pagadala MS, Hsu WK. Evolution of Titanium Interbody Cages and Current Uses of 3D Printed Titanium in Spine Fusion Surgery. Curr Rev Musculoskelet Med 2024:10.1007/s12178-024-09912-z. [PMID: 39003679 DOI: 10.1007/s12178-024-09912-z] [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] [Accepted: 06/20/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE OF REVIEW To summarize the history of titanium implants in spine fusion surgery and its evolution over time. RECENT FINDINGS Titanium interbody cages used in spine fusion surgery have evolved from solid metal blocks to porous structures with varying shapes and sizes in order to provide stability while minimizing adverse side effects. Advancements in technology, especially 3D printing, have allowed for the creation of highly customizable spinal implants to fit patient specific needs. Recent evidence suggests that customizing shape and density of the implants may improve patient outcomes compared to current industry standards. Future work is warranted to determine the practical feasibility and long-term clinical outcomes of patients using 3D printed spine fusion implants. Outcomes in spine fusion surgery have improved greatly due to technological advancements. 3D printed spinal implants, in particular, may improve outcomes in patients undergoing spine fusion surgery when compared to current industry standards. Long term follow up and direct comparison between implant characteristics is required for the adoption of 3D printed implants as the standard of care.
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Affiliation(s)
- Justin J Lee
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA.
| | - Freddy P Jacome
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA
| | - David M Hiltzik
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA
| | - Manasa S Pagadala
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA
| | - Wellington K Hsu
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA
- Department of Orthopedic Surgery, Northwestern University, Chicago, IL, USA
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Calek AK, Cornaz F, Suter M, Fasser MR, Farshad M, Widmer J. Endplate weakening during cage bed preparation significantly reduces endplate load capacity. 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 2024; 33:2621-2629. [PMID: 38733400 DOI: 10.1007/s00586-024-08289-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024]
Abstract
PURPOSE To analyze the effect of endplate weakness prior to PLIF or TLIF cage implantation and compare it to the opposite intact endplate of the same vertebral body. In addition, the influence of bone quality on endplate resistance was investigated. METHODS Twenty-two human lumbar vertebrae were tested in a ramp-to-failure test. One endplate of each vertebral body was tested intact and the other after weakening with a rasp (over an area of 200 mm2). Either a TLIF or PLIF cage was then placed and the compression load was applied across the cage until failure of the endplate. Failure was defined as the first local maximum of the force measurement. Bone quality was assessed by determining the Hounsfield units (HU) on CT images. RESULTS With an intact endplate and a TLIF cage, the median force to failure was 1276.3N (693.1-1980.6N). Endplate weakening reduced axial endplate resistance to failure by 15% (0-23%). With an intact endplate and a PLIF cage, the median force to failure was 1057.2N (701.2-1735.5N). Endplate weakening reduced axial endplate resistance to failure by 36.6% (7-47.9%). Bone quality correlated linearly with the force at which endplate failure occurred. Intact and weakened endplates showed a strong positive correlation: intact-TLIF: r = 0.964, slope of the regression line (slope) = 11.8, p < 0.001; intact-PLIF: r = 0.909, slope = 11.2, p = 5.5E-05; weakened-TLIF: r = 0.973, slope = 12.5, p < 0.001; weakened-PLIF: r = 0.836, slope = 6, p = 0.003. CONCLUSION Weakening of the endplate during cage bed preparation significantly reduces the resistance of the endplate to subsidence to failure: endplate load capacity is reduced by 15% with TLIF and 37% with PLIF. Bone quality correlates with the force at which endplate failure occurs.
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Affiliation(s)
- Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mauro Suter
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Chen R, Zou K, Liu J, Li K, Zhou Y, Huang H, Yang F. Do modic changes affect the fusion rate in spinal interbody fusion surgery? A systematic review and network meta-analysis. J Clin Neurosci 2024; 125:110-119. [PMID: 38772174 DOI: 10.1016/j.jocn.2024.05.019] [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: 04/24/2024] [Accepted: 05/15/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE To compare the fusion rates of spinal interbody fusion in patients with modic changes (MCs). METHODS This meta-analysis was registered at PROSPERO, and the project number was CRD42024538023. This network meta-analysis was conducted according to the PRISMA 2020 statement. The PubMed, Embase, Web of Science Core Collection, ClinicalTrials.gov and Cochrane Library databases were searched from inception to March 28, 2024 for potential studies. STATA 13.0 and Review Manager 5.3 were used to perform the meta-analysis. RESULTS Seven studies with a total of 1162 patients or segments assigned to four groups according to MCs grade were identified. The fusion rate in the non-modic changes (NMCs) was significantly greater than that in the MCs at the 3-month (p = 0.0001) and 6-month (p = 0.002) follow-ups. No significant difference was detected in the fusion rate at 12-month (p = 0.34) and final follow-ups (p = 0.41). No significant difference was found in cervical fusion (p = 0.88) or transforaminal lumbar interbody fusion (TLIF) (p = 0.51). The fusion rate of NMCs was significantly greater than that of MCs in posterior lumbar interbody fusion (PLIF) (p < 0.00001). No significant differences were identified among the four groups in the overall comparison, cervical fusion or TLIF subgroups. The fusion rate in the NMCs was significantly greater than that in the MCs-2 and MCs-3 in the PLIF. CONCLUSION MCs decreased the fusion rate at the 3- and 6-month follow-ups. MCs-2 and MCs-3 decrease the fusion rate in PLIF.
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Affiliation(s)
- Rigao Chen
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, Sichuan Province, China
| | - Kai Zou
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, Sichuan Province, China
| | - Jianjia Liu
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, Sichuan Province, China
| | - Ke Li
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, Sichuan Province, China
| | - Yi Zhou
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, Sichuan Province, China
| | - Haoyun Huang
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, Sichuan Province, China
| | - Fei Yang
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, Sichuan Province, China.
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Zhong Y, Wang Y, Zhou H, Wang Y, Gan Z, Qu Y, Hua R, Chen Z, Chu G, Liu Y, Jiang W. Biomechanical study of two-level oblique lumbar interbody fusion with different types of lateral instrumentation: a finite element analysis. Front Med (Lausanne) 2023; 10:1183683. [PMID: 37457575 PMCID: PMC10345158 DOI: 10.3389/fmed.2023.1183683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023] Open
Abstract
Objective The aim of this study was to verify the biomechanical properties of a newly designed angulated lateral plate (mini-LP) suited for two-level oblique lumbar interbody fusion (OLIF). The mini-LP is placed through the lateral ante-psoas surgical corridor, which reduces the operative time and complications associated with prolonged anesthesia and placement in the prone position. Methods A three-dimensional nonlinear finite element (FE) model of an intact L1-L5 lumbar spine was constructed and validated. The intact model was modified to generate a two-level OLIF surgery model augmented with three types of lateral fixation (stand-alone, SA; lateral rod screw, LRS; miniature lateral plate, mini-LP); the operative segments were L2-L3 and L3-L4. By applying a 500 N follower load and 7.5 Nm directional moment (flexion-extension, lateral bending, and axial rotation), all models were used to simulate human spine movement. Then, we extracted the range of motion (ROM), peak contact force of the bony endplate (PCFBE), peak equivalent stress of the cage (PESC), peak equivalent stress of fixation (PESF), and stress contour plots. Results When compared with the intact model, the SA model achieved the least reduction in ROM to surgical segments in all motions. The ROM of the mini-LP model was slightly smaller than that of the LRS model. There were no significant differences in surgical segments (L1-L2, L4-L5) between all surgical models and the intact model. The PCFBE and PESC of the LRS and the mini-LP fixation models were lower than those of the SA model. However, the differences in PCFBE or PESC between the LRS- and mini-LP-based models were not significant. The fixation stress of the LRS- and mini-LP-based models was significantly lower than the yield strength under all loading conditions. In addition, the variances in the PESF in the LRS- and mini-LP-based models were not obvious. Conclusion Our biomechanical FE analysis indicated that LRS or mini-LP fixation can both provide adequate biomechanical stability for two-level OLIF through a single incision. The newly designed mini-LP model seemed to be superior in installation convenience, and equally good outcomes were achieved with both LRS and mini-LP for two-level OLIF.
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Affiliation(s)
- Yuan Zhong
- Department of Orthopaedic Surgery, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, Jiangsu Province, China
| | - Yujie Wang
- Department of Orthopaedic Surgery, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, Jiangsu Province, China
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Hong Zhou
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yudong Wang
- Suzhou Medical College, Soochow University, Suzhou, Jiangsu Province, China
| | - Ziying Gan
- Suzhou Medical College, Soochow University, Suzhou, Jiangsu Province, China
| | - Yimeng Qu
- Suzhou Medical College, Soochow University, Suzhou, Jiangsu Province, China
| | - Runjia Hua
- Suzhou Medical College, Soochow University, Suzhou, Jiangsu Province, China
| | - Zhaowei Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
- Suzhou Medical College, Soochow University, Suzhou, Jiangsu Province, China
| | - Genglei Chu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
- Suzhou Medical College, Soochow University, Suzhou, Jiangsu Province, China
| | - Yijie Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
- Suzhou Medical College, Soochow University, Suzhou, Jiangsu Province, China
| | - Weimin Jiang
- Department of Orthopaedic Surgery, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, Jiangsu Province, China
- Suzhou Medical College, Soochow University, Suzhou, Jiangsu Province, China
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Park DY, Heo DH. The Use of Dual Direction Expandable Titanium Cage With Biportal Endoscopic Transforaminal Lumbar Interbody Fusion: A Technical Consideration With Preliminary Results. Neurospine 2023; 20:110-118. [PMID: 37016859 PMCID: PMC10080444 DOI: 10.14245/ns.2346116.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/27/2023] [Indexed: 04/03/2023] Open
Abstract
Objective: Expandable cage technology has emerged for lumbar interbody fusion to restore intervertebral disc space height and alignment through a narrow surgical corridor. The purpose of this study is to present the technique of biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using dual direction expandable cage and provide early clinical results.Methods: We performed the biportal endoscopic TLIF using a dual direction expandable titanium cage for height restoration and a larger footprint in 10 patients. Clinical parameters including Oswestry Disability Index (ODI), visual analogue scale (VAS), and complications were retrospectively analyzed. Also, we investigated radiologic parameters using preoperative and postoperative x-ray images.Results: We successfully inserted dual direction expandable cages during biportal endoscopic TLIF. There was no significant subsidence or collapse of the expandable cages during the 6-month follow-up period. Lumbar lordosis and disc height were significantly increased after surgery. ODI and VAS scores were significantly improved at 6 months after surgery.Conclusion: In this report, we describe the first use of a dual direction expandable interbody TLIF cage that expands in both width and height in biportal endoscopic TLIF surgery. Early clinical and radiographic outcomes of this TLIF technique may be favorable in early 6-month follow-up.
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Affiliation(s)
- Don Young Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dong Hwa Heo
- Department of Neurosurgery, Spine Center, Champodonamu Spine Hospital, Seoul, Korea
- Corresponding Author Dong Hwa Heo Department of Neurosurgery, Endoscopic Spine Surgery Center, Champodonamu Hospital, 32 Baumoe-ro 35-gil, Seocho-gu, Seoul 06744, Korea
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Metzner F, Fischer B, Heyde CE, Schleifenbaum S. The effects of force application on the compressive properties of femoral spongious bone. Clin Biomech (Bristol, Avon) 2023; 101:105866. [PMID: 36577361 DOI: 10.1016/j.clinbiomech.2022.105866] [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: 09/21/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND End artefacts play a major role in uniaxial compression tests with cancellous bone specimens. They lead to misinterpretation of mechanical parameters of bones due to uncontrolled introduction of bending moments into the free ends of trabeculae. This work aims to simplify current methods preventing end-artefacts and furthermore to investigate the influence of end artefacts on plateau stress. METHODS 176 cylindrical cancellous bone specimens were taken from human femoral condyles and tested in uniaxial compression. The specimens were divided into 2 groups (direct, end-cap) and compressive modulus, maximum stress, plateau stress, energy absorbtion as well as apparent density were evaluated. Density values are from separate specimens which are immediately adjacent to the mechanical specimen. FINDINGS All mechanical parameters were significantly higher in the end-cap specimens than in the direct ones by about 30 - 40 %, thus reaching similar differences as the previous studies. Greatest differences between groups were determined for compressive modulus (45 %) and plateau stress (35 %). Energy absorbtion can be explained with great accuracy by plateau stress (P < 0.001; R2 = 0.95). Among all parameters plateau stress can be best explained by apparent density using an exponential function (P < 0.001; R2 = 0.38). INTERPRETATION The end-cap method used here to prevent end artefacts showed variations consistent with the literature when compared to the direct method. Additionally it was shown that the way in which the force is applied to the specimen has a major influence on the failure progression behavior, which was characterized using the plateau stress.
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Affiliation(s)
- F Metzner
- ZESBO - Centre for Research on Musculoskeletal Systems, University of Leipzig, Leipzig, Germany; Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany.
| | - B Fischer
- ZESBO - Centre for Research on Musculoskeletal Systems, University of Leipzig, Leipzig, Germany; Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - C-E Heyde
- ZESBO - Centre for Research on Musculoskeletal Systems, University of Leipzig, Leipzig, Germany; Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - S Schleifenbaum
- ZESBO - Centre for Research on Musculoskeletal Systems, University of Leipzig, Leipzig, Germany; Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany; Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, Germany
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Laubach M, Kobbe P, Hutmacher DW. Biodegradable interbody cages for lumbar spine fusion: Current concepts and future directions. Biomaterials 2022; 288:121699. [PMID: 35995620 DOI: 10.1016/j.biomaterials.2022.121699] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022]
Abstract
Lumbar fusion often remains the last treatment option for various acute and chronic spinal conditions, including infectious and degenerative diseases. Placement of a cage in the intervertebral space has become a routine clinical treatment for spinal fusion surgery to provide sufficient biomechanical stability, which is required to achieve bony ingrowth of the implant. Routinely used cages for clinical application are made of titanium (Ti) or polyetheretherketone (PEEK). Ti has been used since the 1980s; however, its shortcomings, such as impaired radiographical opacity and higher elastic modulus compared to bone, have led to the development of PEEK cages, which are associated with reduced stress shielding as well as no radiographical artefacts. Since PEEK is bioinert, its osteointegration capacity is limited, which in turn enhances fibrotic tissue formation and peri-implant infections. To address shortcomings of both of these biomaterials, interdisciplinary teams have developed biodegradable cages. Rooted in promising preclinical large animal studies, a hollow cylindrical cage (Hydrosorb™) made of 70:30 poly-l-lactide-co-d, l-lactide acid (PLDLLA) was clinically studied. However, reduced bony integration and unfavourable long-term clinical outcomes prohibited its routine clinical application. More recently, scaffold-guided bone regeneration (SGBR) with application of highly porous biodegradable constructs is emerging. Advancements in additive manufacturing technology now allow the cage designs that match requirements, such as stiffness of surrounding tissues, while providing long-term biomechanical stability. A favourable clinical outcome has been observed in the treatment of various bone defects, particularly for 3D-printed composite scaffolds made of medical-grade polycaprolactone (mPCL) in combination with a ceramic filler material. Therefore, advanced cage design made of mPCL and ceramic may also carry initial high spinal forces up to the time of bony fusion and subsequently resorb without clinical side effects. Furthermore, surface modification of implants is an effective approach to simultaneously reduce microbial infection and improve tissue integration. We present a design concept for a scaffold surface which result in osteoconductive and antimicrobial properties that have the potential to achieve higher rates of fusion and less clinical complications. In this review, we explore the preclinical and clinical studies which used bioresorbable cages. Furthermore, we critically discuss the need for a cutting-edge research program that includes comprehensive preclinical in vitro and in vivo studies to enable successful translation from bench to bedside. We develop such a conceptual framework by examining the state-of-the-art literature and posing the questions that will guide this field in the coming years.
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Affiliation(s)
- Markus Laubach
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Philipp Kobbe
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Dietmar W Hutmacher
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Max Planck Queensland Center for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD 4000, Australia.
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Does Preoperative Bone Mineral Density Impact Fusion Success in Anterior Cervical Spine Surgery? A Prospective Cohort Study. World Neurosurg 2022; 164:e830-e834. [PMID: 35605943 DOI: 10.1016/j.wneu.2022.05.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this study was to identify risk factors for pseudarthrosis in patients undergoing anterior cervical discectomy and fusion (ACDF) with a focus on the role of bone mineral density (BMD) on arthrodesis. METHODS We retrospectively reviewed a prospectively collected database of patients undergoing 1- to 4-level ACDF for degenerative indications between 2012 and 2018 at a single institution. All patients were required to have undergone a preoperative dual-energy x-ray absorptiometry (DEXA) scan. Fusion status was assessed on computed tomography (CT) scans obtained 1 year postoperatively. Patients were divided into subgroups based on fusion status and compared on the basis of demographic, BMD, and surgical variables to determine risk factors for pseudarthrosis. RESULTS We identified 79 patients for inclusion in this study. Fusion was achieved in 65 patients (82%), while 14 patients (18%) developed pseudarthrosis. The pseudarthrosis subgroup demonstrated significantly lower BMD than their counterparts who achieved successful fusion in both mean hip (-1.4 ± 1.2 vs. -0.2 ± 1.2, respectively; P = 0.002) and spine T-scores (-0.8 ± 1.8 vs. 0.6 ± 1.9, respectively; P = 0.02). The pseudarthrosis group had a substantially higher proportion of patients with osteopenia (57.1% vs. 20.0%) and osteoporosis (21.5% vs. 6.2%; P < 0.001) than the fusion group. Multivariate analysis demonstrated osteopenia (odds ratio [OR] 8.76, P = 0.04), osteoporosis (OR 9.97, P = 0.03), and low BMD (OR 11.01, P = 0.002) to be associated with an increased likelihood of developing pseudarthrosis. CONCLUSIONS The results of this study suggest that both osteopenia and osteoporosis are associated with increased rates of pseudarthrosis in patients undergoing elective ACDF.
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Loenen ACY, Noailly J, Ito K, Willems PC, Arts JJ, van Rietbergen B. Patient-Specific Variations in Local Strain Patterns on the Surface of a Trussed Titanium Interbody Cage. Front Bioeng Biotechnol 2022; 9:750246. [PMID: 35087797 PMCID: PMC8786731 DOI: 10.3389/fbioe.2021.750246] [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: 07/30/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: 3D printed trussed titanium interbody cages may deliver bone stimulating mechanobiological strains to cells attached at their surface. The exact size and distribution of these strains may depend on patient-specific factors, but the influence of these factors remains unknown. Therefore, this study aimed to determine patient-specific variations in local strain patterns on the surface of a trussed titanium interbody fusion cage.Materials and Methods: Four patients eligible for spinal fusion surgery with the same cage size were selected from a larger database. For these cases, patient-specific finite element models of the lumbar spine including the same trussed titanium cage were made. Functional dynamics of the non-operated lumbar spinal segments, as well as local cage strains and caudal endplate stresses at the operated segment, were evaluated under physiological extension/flexion movement of the lumbar spine.Results: All patient-specific models revealed physiologically realistic functional dynamics of the operated spine. In all patients, approximately 30% of the total cage surface experienced strain values relevant for preserving bone homeostasis and stimulating bone formation. Mean caudal endplate contact pressures varied up to 10 MPa. Both surface strains and endplate contact pressures varied more between loading conditions than between patients.Conclusions: This study demonstrates the applicability of patient-specific finite element models to quantify the impact of patient-specific factors such as bone density, degenerative state of the spine, and spinal curvature on interbody cage loading. In the future, the same framework might be further developed in order to establish a pipeline for interbody cage design optimizations.
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Affiliation(s)
- Arjan C. Y. Loenen
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI, Maastricht University Medical Center, Maastricht, Netherlands
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Jérôme Noailly
- Department of Information and Communication Technologies, BCN MedTech, Universitat Pompeu Fabra, Barcelona, Spain
| | - Keita Ito
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Paul C. Willems
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jacobus J. Arts
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI, Maastricht University Medical Center, Maastricht, Netherlands
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Bert van Rietbergen
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI, Maastricht University Medical Center, Maastricht, Netherlands
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- *Correspondence: Bert van Rietbergen,
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Lu T, Gao Z, Li J, Liu N, Wang Y, Liu C, He X. Construction of a new cervical anatomically adaptive titanium mesh cage based on measurements of cervical geometry: A morphological and cadaveric study. Exp Ther Med 2021; 22:1256. [PMID: 34603524 PMCID: PMC8453342 DOI: 10.3892/etm.2021.10691] [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] [Received: 02/06/2019] [Accepted: 07/22/2021] [Indexed: 11/29/2022] Open
Abstract
Mismatch between the titanium mesh cage and cervical geometries is an important factor that induces subsidence in anterior cervical corpectomy and fusion (ACCF). The aim of the present study was to construct a new quadrate anatomically adaptive titanium mesh cage (AA-TMC) that matches well with the cervical geometries and segmental alignment in one- and two-level ACCF. Computed tomography (CT) scans of 54 individuals were used to measure the cervical endplate geometries. X-rays of 74 young individuals were used to measure the intervertebral body angle (IBA) and intervertebral body height (IBH) of the surgical segments. The AA-TMC was designed based on these measured parameters. A total of 18 cervical cadaveric specimens underwent successive one- and two-level ACCF using the AA-TMC. Postoperatively, the specimens underwent CT scanning to assess the degree of matching of the TMC-endplate interface (TEI), IBA and IBH. A TEI interval <0.5 mm was considered well matching. In the sagittal plane, 93.8% of the inferior endplates were arched, whereas 94.8% of the superior endplates were flat. In the coronal plane, 82.9% of the inferior endplates and 93.8% of the superior endplates were flat. A total of 91.7 and 94.4% of the TEIs were well matched in one- and two-level ACCF, respectively. The postoperative IBA and IBH values were consistent with the values of young individuals. The AA-TMC achieved good matching with cervical geometries and segmental alignment in one- and two-level ACCF, and is proposed for use in ACCF to increase the contact at the TEI and achieve sufficient lordosis restoration.
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Affiliation(s)
- Teng Lu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Zhongyang Gao
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Jialiang Li
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Ning Liu
- Department of Spine Surgery, Hanzhong Central Hospital, Hanzhong, Shaanxi 723000, P.R. China
| | - Yibin Wang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Chao Liu
- Department of Education, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Xijing He
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
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The Role of Vertebral Porosity and Implant Loading Mode on Bone-Tissue Stress in the Human Vertebral Body Following Lumbar Total Disc Arthroplasty. Spine (Phila Pa 1976) 2021; 46:E1022-E1030. [PMID: 33660678 DOI: 10.1097/brs.0000000000004023] [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
STUDY DESIGN Micro-computed tomography- (micro-CT-) based finite element analysis of cadaveric human lumbar vertebrae virtually implanted with total disc arthroplasty (TDA) implants. OBJECTIVE (1) Assess the relationship between vertebral porosity and maximum levels of bone-tissue stress following TDA; (2) determine whether the implant's loading mode (axial compression vs. sagittal bending) alters the relationship between vertebral porosity and bone-tissue stress. SUMMARY OF BACKGROUND DATA Implant subsidence may be related to the bone biomechanics in the underlying vertebral body, which are poorly understood. For example, it remains unclear how the stresses that develop in the supporting bone tissue depend on the implant's loading mode or on typical inter-individual variations in vertebral morphology. METHODS Data from micro-CT scans from 12 human lumbar vertebrae (8 males, 4 females; 51-89 years of age; bone volume fraction [BV/TV] = 0.060-0.145) were used to construct high-resolution finite element models (37 μm element edge length) comprising disc-vertebra-implant motion segments. Implants were loaded to 800 N of force in axial compression, flexion-, and extension-induced impingement. For comparison, the same net loads were applied via an intact disc without an implant. Linear regression was used to assess the relationship between BV/TV, loading mode, and the specimen-specific change in stress caused by implantation. RESULTS The increase in maximum bone-tissue stress caused by implantation depended on loading mode (P < 0.001), increasing more in bending-induced impingement than axial compression (for the same applied force). The change in maximum stress was significantly associated with BV/TV (P = 0.002): higher porosity vertebrae experienced a disproportionate increase in stress compared with lower porosity vertebrae. There was a significant interaction between loading mode and BV/TV (P = 0.002), indicating that loading mode altered the relationship between BV/TV and the change in maximum bone-tissue stress. CONCLUSION Typically-sized TDA implants disproportionately increase the bone-tissue stress in more porous vertebrae; this affect is accentuated when the implant impinges in sagittal bending.Level of Evidence: N/A.
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Segmental Height Decrease Adversely Affects Foraminal Height and Cervical Lordosis, But Not Clinical Outcome After Anterior Cervical Discectomy and Fusion Using Allografts. World Neurosurg 2021; 154:e555-e565. [PMID: 34325033 DOI: 10.1016/j.wneu.2021.07.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study was conducted to elucidate the clinical significance of postoperative segmental height decrease (SHD) in anterior cervical discectomy and fusion (ACDF) using allografts. METHODS We reviewed 88 patients who underwent ACDF using allografts as interbody spacers. Cervical lordosis, segmental lordosis, segmental height, foraminal height, fusion, allograft fracture, and resorption were assessed. Significant SHD was defined as that ≥2 mm. Neck pain visual analog scale (VAS) score, arm pain VAS score, and Neck Disability Index (NDI) score were also recorded. Significant segmental height decreased (SH-D) segments were compared with segmental height maintained (SH-M) segments. RESULTS Thirty-two patients (36.4%) and 34 segments (23.1%) demonstrated significant SHD. SH-D segments demonstrated significantly lower segmental lordosis (3.7 ± 4.1 vs. 0.9 ± 4.8°; P < 0.01), foraminal height (9.6 ± 1.1 vs. 8.7 ± 0.9 mm; P < 0.01), and fusion rate (88 [77.9%] vs. 20 [58.9%]; P = 0.04) than SH-M segments at the final follow-up, respectively. Furthermore, global lordosis was significantly lower in the SH-D group (18.3 ± 8.5 vs. 13.9 ± 8.9°, respectively; P = 0.02). However, neck and arm pain VAS scores and NDI score did not demonstrate a significant difference between patients with and without significant SHD. Logistic regression analysis demonstrated that higher allograft height (P = 0.03), greater allograft anteroposterior length (P = 0.04), and allograft resorption or fracture (P < 0.01) were associated with increased risk of significant SHD. Logistic regression analysis also demonstrated that allograft resorption or fracture (P < 0.01) was associated with risk of nonunion. CONCLUSIONS Significant SHD was associated with decreased segmental lordosis, global cervical lordosis, and foraminal height. However, significant SHD did not result in worsening of clinical symptoms. Larger allograft size was associated with risk of significant SHD. This study demonstrates provisional results that suggest allograft resorption or fracture may be a factor that adversely affects fusion or SHD.
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Jung JM, Chung CK, Kim CH, Yang SH, Ko YS, Choi Y. Intraoperative Radiographs in Single-level Lateral Lumbar Interbody Fusion Can Predict Radiographic and Clinical Outcomes of Follow-up 2 Years After Surgery. Spine (Phila Pa 1976) 2021; 46:772-780. [PMID: 33337681 DOI: 10.1097/brs.0000000000003889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
MINI Some of the improvements in DH, FH, and SLL achieved intraoperatively during lateral lumbar interbody fusion surgery were lost by the postoperative 1-week follow-up. An intraoperative radiograph can predict radiographic and clinical outcomes of the 2-year follow-up. The difference between preoperative DH and intraoperative DH should be >4.18 mm.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young San Ko
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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15
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Oblique Lateral Interbody Fusion versus Transforaminal Lumbar Interbody Fusion in Degenerative Lumbar Spondylolisthesis: A Single-Center Retrospective Comparative Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6693446. [PMID: 33824877 PMCID: PMC8007343 DOI: 10.1155/2021/6693446] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/18/2021] [Accepted: 03/15/2021] [Indexed: 12/21/2022]
Abstract
Objective To compare the efficacy of oblique lateral interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in single-level degenerative lumbar spondylolisthesis (DLS). Methods A retrospective analysis of patients who underwent single-level DLS surgery in our department from 2015 to 2018 was performed. According to the surgical method, the enrolled patients were divided into two groups, namely, the OLIF group who underwent OLIF combined with percutaneous pedicle screw fixation (PPSF) and the TLIF group. Clinical outcomes included operation time, operation blood loss, postoperative drainage, hospital stay, visual analog scale (VAS) score, Oswestry disability index (ODI), and complications, and imaging outcomes included upper vertebral slip, intervertebral space height (ISH), intervertebral foramen height (IFH), intervertebral space angle (ISA), lumbar lordosis (LL), and bone fusion rate. All outcomes were recorded and analyzed. Results A total of 65 patients were finally included, and there were 28 patients and 37 patients in the OLIF group and the TLIF group, respectively. The OLIF group showed shorter operation time, less blood loss, less postoperative drainage, and shorter hospital stay than the TLIF group (P < 0.05). The ISH, IFH, ISA, and LL were all larger in the OLIF group at postoperative and last follow-up (P < 0.05), but the degree of upper vertebral slip was found no difference between the two groups (P > 0.05). The bone graft fusion rate of OLIF group and TLIF group at 3 months, 6 months, and last follow-up was 78.57%, 92.86%, and 100% and 70.27%, 86.49%, and 97.30%, respectively, and no significant differences were found (P > 0.05). Compared with the TLIF group, the OLIF group showed a superior improvement in VAS and ODI at 1 month, 3 months, and 6 months postoperative (P < 0.05), but no differences were found at 12 months postoperative and the last follow-up (P > 0.05). There was no significant difference in complications between the two groups, with 4 patients and 6 patients in the OLIF group and TLIF group, respectively (P > 0.05). Conclusions Compared with TLIF, OLIF showed the advantages of less surgical invasion, better decompression effect, and faster postoperative recovery in single-level DLS surgery.
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16
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Li J, Zhang J, Tong T, Shen Y. Influence of Modic Changes on Cage Subsidence and Intervertebral Fusion after Single-Level Anterior Cervical Corpectomy and Fusion. J INVEST SURG 2020; 35:301-307. [PMID: 33283538 DOI: 10.1080/08941939.2020.1855487] [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] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This retrospective study aimed to determine the impact of Modic changes (MCs) on cage subsidence (CS) and intervertebral fusion after anterior cervical corpectomy and fusion (ACCF). METHODS This study enrolled 61 patients with MCs who underwent single-level ACCF between January 2010 and December 2015 at our institution. The control group included 63 age-matched patients without MCs treated during the same period. The results from clinical and radiological assessments were reviewed, and radiographic CS was defined by an intervertebral height at the final follow-up that was less than the postoperative intervertebral height. RESULTS No significant differences in gender, age, operative time, blood loss, or follow-up results were observed between the MCs and control groups. Significantly more patients experienced CS in the MCs group than in the control group (41.0% vs. 15.9%; p = 0.003). The frequencies of CS among patients with type I MCs (40.0%, 8/20) and type II MCs (41.5%, 17/41) were significantly higher than that in the control group (15.9%, 10/63; p < 0.05). Both groups showed significant improvements in clinical assessment scores after surgery and at final follow-up compared with preoperative values (p < 0.05). CONCLUSION In summary, all 61 patients with MCs who underwent ACCF achieved good fusion results. MCs in the surgical segment had no significant effect on intervertebral fusion, but both type 1 and type 2 MCs may increase the risk of CS.
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Affiliation(s)
- Jia Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.,The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingtao Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.,The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tong Tong
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.,The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yong Shen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.,The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, China
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Khalifeh JM, Dibble CF, Stecher P, Dorward I, Hawasli AH, Ray WZ. Transfacet Minimally Invasive Transforaminal Lumbar Interbody Fusion With an Expandable Interbody Device-Part I: 2-Dimensional Operative Video and Technical Report. Oper Neurosurg (Hagerstown) 2020; 19:E473-E479. [PMID: 32433755 DOI: 10.1093/ons/opaa100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Advances in operative techniques and minimally invasive technologies have evolved to maximize patient outcomes and radiographic results, while reducing morbidity and recovery time. OBJECTIVE To describe the operative technique for a transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) as a proposed modification to the standard approach MIS-TLIF. METHODS We present the case of a 72-yr-old man with left-sided lumbar radiculopathy. Preoperative imaging demonstrated degenerative lumbar anterolisthesis at L4-5, with associated canal and neuroforaminal stenosis. The patient underwent transfacet MIS-TLIF at L4-L5. We describe the preoperative planning, patient positioning, incision and dissection, pedicle screw insertion, transfacet approach to the working access corridor, discectomy, interbody device placement, fixation, and closure. RESULTS The transfacet MIS-TLIF utilizes 3 key techniques to safely maximize surgical correction: (1) a limited bony resection based on the superior articular process, leaving the medial inferior articular process, lateral superior articular process, and rostral pars intact, providing a working bony corridor that protects the traversing and exiting nerve roots; (2) decortication and release of the contralateral facet joint to provide additional capacity for indirect decompression and provide the first point of osseous fusion; and (3) placement of an expandable interbody device that provides additional indirect decompression to the working side and contralateral foramen. CONCLUSION The transfacet MIS-TLIF uniquely leverages a bony working corridor to access the disc space for discectomy and interbody placement. Transfacet MIS-TLIF is a feasible solution for lumbar spinal reconstruction to maximize direct and indirect decompression of the neuroforamina and central spinal canal in patients with lumbar degenerative diseases and low-grade spondylolisthesis.
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Affiliation(s)
- Jawad M Khalifeh
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher F Dibble
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Priscilla Stecher
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ian Dorward
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ammar H Hawasli
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Wilson Z Ray
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Tandon V, Franke J, Kalidindi KKV. Advancements in osteoporotic spine fixation. J Clin Orthop Trauma 2020; 11:778-785. [PMID: 32904223 PMCID: PMC7452352 DOI: 10.1016/j.jcot.2020.06.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 01/01/2023] Open
Abstract
With the global rise in the population of elderly along with other risk factors, spine surgeons have to encounter osteoporotic spine more often. Osteoporotic spine, however, causes problems in management, particularly where instrumentation is involved, resulting in screw loosening, pull out, pseudoarthroses or adjacent segment kyphosis. Osteoporosis alters the bio mechanics at the bone implant interface resulting in various degrees of fixation failure. Various advancements have been made in this field to deal with such issues in addition to modification of basic surgical techniques such as increasing the diameter and length of the screw, smaller pilot hole, under tapping, longer constructs, supplemental anterior fixation, sublaminar wires or laminar hooks, use of transverse connectors and triangulation techniques, among others. They include novel surgical techniques such as cortical bone trajectory, superior cortical trajectory, double screw technique, cross trajectory technique, bicortical screw technique or prophylactic vertebroplasty. Advances in the screw design include expandable screws, fenestrated screws, conical screws and coated screws. In addition to PMMA cement augmentation, other biodegradable cements have been introduced to mitigate the side effects of PMMA such as calcium phosphate, calcium apatite and hydroxyapatite. Pharmacotherapy with teriparatide can aid fusion and lower the rate of pedicle screw loosening. Many of these strategies have only bio mechanical evidence and require well designed clinical trials to establish their clinical efficacy. Though no single technique is fool proof, little modifications in the existing techniques or utilizing a combination of techniques without adding to the cost of the surgery may help to achieve a near-ideal result. Surgeons have to equip their armamentarium with all the recent advances, and should be open to novel thoughts and techniques.
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Affiliation(s)
- Vikas Tandon
- Department of Spine Service, Indian Spinal Injuries Center, Sector-C, Vasant Kunj, New Delhi, 110070, India,Corresponding author. Sr. Consultant and Unit Head, Department of Spine Service, Indian Spinal Injuries Center, Vasant Kunj, New Delhi, 110070, India.
| | - Jorg Franke
- Department of Orthopedics, Klinikum Magdeburg, Magdeburg, Germany
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Jung JM, Chung CK, Kim CH, Yang SH. Clinical and radiologic outcomes of single-level direct lateral lumbar interbody fusion in patients with osteopenia. J Clin Neurosci 2019; 64:180-186. [DOI: 10.1016/j.jocn.2019.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/07/2019] [Indexed: 11/27/2022]
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Lu T, Gao Z, He X, Li J, Liu N, Liang H, Wang Y, Wen Z, Zhang T, Wang D, Li H. [Effects of a new anatomical adaptive titanium mesh cage on supportive load at the cervical endplate: a morphological and biomechanical study]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:409-414. [PMID: 31068283 DOI: 10.12122/j.issn.1673-4254.2019.04.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the geometrical matching of a new anatomical adaptive titanium mesh cage (AA-TMC) with the endplate and its effect on cervical segmental alignment reconstruction in single- and two-level anterior cervical corpectomy and fusion (ACCF) and compare the compressive load at the endplate between the AA-TMC and the conventional titanium mesh cage (TMC). METHODS Twelve cervical cadaveric specimens were used to perform single- and two-level ACCF. The interbody angle (IBA), interbody height (IBH) and the interval between the AA-TMC and the endplate were evaluated by comparison of the pre- and postoperative X-ray images. The maximum load at the endplate was compared between the AA-TMC and TMC based on American Society for Testing and Materials (ASTM) F2267 standard. RESULTS No significant differences were found between the preoperative and postoperative IBA and IBH in either single-level ACCF (11.62°±2.67° vs 12.13°±0.69° and 23.90±2.18 mm vs 24.23±1.13 mm, respectively; P > 0.05) or two-level ACCF (15.63°±5.06° vs 16.16°±1.05°and 42.93±3.51 mm vs 43.04±1.70 mm, respectively; P > 0.05). The mean interval between the AA-TMC and the endplate was 0.37 ± 0.3 mm. Compared to the conventional TMC, the use of AA-TMC significantly increased the maximum load at the endplate in both single-level ACCF (719.7±5.5 N vs 875.8±5.2 N, P < 0.05) and two-level ACCF (634.3±5.9 N vs 873±6.1 N, P < 0.05). CONCLUSIONS The use of AA-TMC in single-level and two-level ACCF can significantly increase the maximum load at the endplate to lower the possibility of implant subsidence and allows effective reconstruction of the cervical alignment.
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Affiliation(s)
- Teng Lu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Zhongyang Gao
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Xijing He
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Jialiang Li
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Ning Liu
- Department of Spine Surgery, Hanzhong Central Hospital, Hanzhong 723000, China
| | - Hui Liang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Yibin Wang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Zhijing Wen
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Ting Zhang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Dong Wang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Haopeng Li
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
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Palepu V, Helgeson MD, Molyneaux-Francis M, Nagaraja S. The Effects of Bone Microstructure on Subsidence Risk for ALIF, LLIF, PLIF, and TLIF Spine Cages. J Biomech Eng 2019; 141:2718206. [DOI: 10.1115/1.4042181] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Indexed: 11/08/2022]
Abstract
Several approaches (anterior, posterior, lateral, and transforaminal) are used in lumbar fusion surgery. However, it is unclear whether one of these approaches has the greatest subsidence risk as published clinical rates of cage subsidence vary widely (7–70%). Specifically, there is limited data on how a patient's endplate morphometry and trabecular bone quality influences cage subsidence risk. Therefore, this study compared subsidence (stiffness, maximum force, and work) between anterior (ALIF), lateral (LLIF), posterior (PLIF), and transforaminal (TLIF) lumbar interbody fusion cage designs to understand the impact of endplate and trabecular bone quality on subsidence. Forty-eight lumbar vertebrae were imaged with micro-ct to assess trabecular microarchitecture. micro-ct images of each vertebra were then imported into image processing software to measure endplate thickness (ET) and maximum endplate concavity depth (ECD). Generic ALIF, LLIF, PLIF, and TLIF cages made of polyether ether ketone were implanted on the superior endplates of all vertebrae and subsidence testing was performed. The results indicated that TLIF cages had significantly lower (p < 0.01) subsidence stiffness and maximum subsidence force compared to ALIF and LLIF cages. For all cage groups, trabecular bone volume fraction was better correlated with maximum subsidence force compared to ET and concavity depth. These findings highlight the importance of cage design (e.g., surface area), placement on the endplate, and trabecular bone quality on subsidence. These results may help surgeons during cage selection for lumbar fusion procedures to mitigate adverse events such as cage subsidence.
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Affiliation(s)
- Vivek Palepu
- U.S. Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Division of Applied Mechanics, Silver Spring, MD 20993
| | - Melvin D. Helgeson
- Walter Reed National Military Medical Center, Department of Orthopaedics, Bethesda, MD 20889
| | - Michael Molyneaux-Francis
- U.S. Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Division of Applied Mechanics, Silver Spring, MD 20993
| | - Srinidhi Nagaraja
- U.S. Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Division of Applied Mechanics, 10903 New Hampshire Avenue, Building 62, Room 2210, Silver Spring, MD 20993 e-mail:
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Wang Y, Lu T, He X, Wen Z, Gao Z, Gao Z, Liang H. Effect of Dome-Shaped Titanium Mesh Cages on Cervical Endplate Under Cyclic Loading: An In Vitro Biomechanics Study. Med Sci Monit 2019; 25:142-149. [PMID: 30612133 PMCID: PMC6330843 DOI: 10.12659/msm.911888] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background This study aimed to verify the anti-subsidence ability of dome-shaped titanium mesh cage (TMC) used in anterior cervical corpectomy and fusion (ACCF). Material/Methods Thirty fresh human cervical vertebrae specimens were collected and randomly harvested into 2 groups: the traditional TMC group and the dome-shaped TMC group. The bone mineral density (BMD) of the specimens was recorded. Each group was biomechanically tested in axial compression with a cyclically loading range from 60 to 300 N at 0.5Hz for 10 000 cycles. The displacement data of the 2 groups were recorded every 10 cycles. Results There was no significant difference in bone mineral density between the 2 groups of cervical specimens. The traditional TMC group stabilized at 535±35 cycles while the dome-shaped TMC group stabilized at 1203±57 cycles, which showed that the rate of subsidence of the dome-shaped TMC group was significantly slower than that of the traditional TMC group (p<0.05). After reaching stability, both groups had a more gradual and sustained growth. The peak displacement during fatigue testing was −2.064±0.150mm in the traditional TMC group and −0.934±0.086mm in the dome-shaped TMC group, which showed a significant difference (p<0.05). Conclusions The dome-shaped TMC showed a smaller subsidence displacement and a gentler subsidence tendency following the same cyclic loading (compared to the traditional TMC). From a biomechanical point of view, the dome-shaped TMC has stronger anti-subsidence ability due to its unique structural design that closely matches the vertebral endplate.
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Affiliation(s)
- Yibin Wang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Teng Lu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Xijing He
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Zhijing Wen
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Zhengchao Gao
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Zhongyang Gao
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Hui Liang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
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Alkalay RN, Adamson R, Groff MW. The effect of interbody fusion cage design on the stability of the instrumented spine in response to cyclic loading: an experimental study. Spine J 2018. [PMID: 29526639 DOI: 10.1016/j.spinee.2018.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In the lumbar spine, end plate preparation for the interbody fusion cages may critically affect the cage's long-term performance. This study investigated the effect of the interbody cage design on the compliance and cage subsidence of instrumented spines under cyclic compression. PURPOSE We aimed to quantify the role of cage geometry and bone density on the stability of the spinal construct in response to cyclic compressive loads. STUDY DESIGN Changes in the cage-bone interface and the effect of bone density on these changes were evaluated in a human cadaveric model for three intervertebral cage designs. METHODS The intervertebral space of 27 functional cadaveric spinal units was instrumented with bilateral linear cages, single anterior conformal cages, or single unilateral oblique cages. Once augmented with a pedicle screw fixation system, the instrumented spine unit was tested under cyclic compression loads (400-1,200 N) to 20,000 cycles at a rate of 2 Hz. Compliance of the cage-bone interface and cage subsidence was computed. Two-way repeated multivariate analysis of variance was used to test the effects of cage design and bone density on the compliance and subsidence of the cages. RESULTS The anterior conformal shaped cage showed reduced interface stiffness (p<.01) and higher hysteresis (p<.01) and subsidence rate (10%-30%) than the bilateral linear and unilateral oblique-shaped cages. Bone density was not associated with the initial compliance of the cage-bone interface or the rate of cage subsidence. Higher bone density did decrease the rate of reduction in cage-bone interface stiffness under higher cyclic loads for the anterior conformal shaped and unilateral oblique cages. CONCLUSIONS Cage design and position significantly affected the degradation of the cage-bone interface under cyclic loading. Comparisons of subsidence rate between the different cage designs suggest the peripheral location of the cages, using the stronger peripheral subchondral bone of the apophyseal ring, to be advantageous in preventing the subsidence and failure of the cage-bone interface.
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Affiliation(s)
- Ron N Alkalay
- Center for Advanced Orthopaedic Studies, Department of Orthopaedics, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA.
| | - Robert Adamson
- Center for Advanced Orthopaedic Studies, Department of Orthopaedics, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
| | - Michael W Groff
- Center for Advanced Orthopaedic Studies, Department of Orthopaedics, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA; Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Wen Z, Lu T, Wang Y, Liang H, Gao Z, He X. Anterior Cervical Corpectomy and Fusion and Anterior Cervical Discectomy and Fusion Using Titanium Mesh Cages for Treatment of Degenerative Cervical Pathologies: A Literature Review. Med Sci Monit 2018; 24:6398-6404. [PMID: 30208015 PMCID: PMC6147051 DOI: 10.12659/msm.910269] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF) are 2 effective and safe surgical treatments of degenerative cervical pathologies and are associated with a high percentage of excellent clinical outcomes when a graft or device must be used during the surgery, such as an allograft, autograft, nano-hydroxyapatite/polyamide cages, poly-ether-ether-ketone (PEEK) cages, and titanium mesh cages (TMCs). Although TMCs have been used in cervical surgeries for almost 2 decades, no specific reviews have been performed introducing the state of this material. Thus, in the present review, we discuss the status of using TMCs in anterior cervical surgeries. Studies that tested the usage of TMCs in treating degenerative cervical pathologies were included in this review. The development and progress of TMCs, the biomechanical analysis of TMCs, the radiological and clinical assessment of TMCs, the advantages and disadvantages of using TMCs, and their prospects for future applications as a device of ACCF and ACDF in treating degenerative cervical pathologies are discussed. Studies included in this review showed that TMCs can provide sufficient biomechanical stability. Furthermore, the TMCs used in anterior cervical fusion avoid the donor-site morbidity and achieve a solid bony fusion. However, there are some shortcomings. The structural characteristics and the design of TMCs cause the TMC subsidence rate to remain high, thus resulting in multiple related complications. We believe that due to the virtues of TMCs, they are worthy of application and promotion. However, the structure of TMCs should be further optimized to reduce the TMC subsidence rate and subsidence-related complications, ultimately achieving excellent clinical results.
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Affiliation(s)
- Zhijing Wen
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Teng Lu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Yibin Wang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Hui Liang
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Shanxi xi'an, China (mainland)
| | - Zhengchao Gao
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Xijing He
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
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25
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Feng H, Li H, Ba Z, Chen Z, Li X, Wu D. Morphometry evaluations of cervical osseous endplates based on three dimensional reconstructions. INTERNATIONAL ORTHOPAEDICS 2018; 43:1521-1528. [PMID: 30091068 DOI: 10.1007/s00264-018-4053-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/06/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Accurate and comprehensive data on cervical endplates is essential for developing and improving cervical devices. However, current literature on vertebral disc geometry is scarce or not suitable. The aim of this study was to obtain quantitative parameters of cervical endplates and provide morphometric references for designing cervical devices. METHODS In this study, 19 human cervical spine cadaveric specimens were considered. Employing a reverse engineering system, the surface information of each endplate was recorded in digital cloud and then 3D reconstructed. A measurement protocol that included three sagittal and three frontal surface curves was developed. The information of surface curves and endplate concavity were obtained and analyzed. The parametric equations of endplate surfaces were deduced based on coordinates of landmarks, and the reliability was verified. RESULTS The cervical endplate surface had a trend that to be transversely elongated gradually. The concavity depths of inferior endplates (1.88 to 2.13 mm) were significantly larger than those of superior endplates (0.62 to 0.84 mm). The most-concave points in inferior endplates were concentrated in the central portion, while always located in post-median region in superior endplates. CONCLUSION These results will give appropriate guidelines to design cervical prostheses without sacrificing valuable bone stock. The parametric equations applied for generating surface profile of cervical endplates may provide great convenience for subsequent studies.
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Affiliation(s)
- Hang Feng
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, China
| | - Haoxi Li
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, China
| | - Zhaoyu Ba
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, China
| | - Zhaoxiong Chen
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, China
| | - Xinhua Li
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, China
| | - Desheng Wu
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, China.
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Godzik J, Kalb S, Reis MT, Reyes PM, Singh V, Newcomb AGUS, Chang SW, Kelly BP, Crawford NR. Biomechanical evaluation of interbody fixation with secondary augmentation: lateral lumbar interbody fusion versus posterior lumbar interbody fusion. JOURNAL OF SPINE SURGERY 2018; 4:180-186. [PMID: 30069505 DOI: 10.21037/jss.2018.05.07] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Many approaches to the lumbar spine have been developed for interbody fusion. The biomechanical profile of each interbody fusion device is determined by the anatomical approach and the type of supplemental internal fixation. Lateral lumbar interbody fusion (LLIF) was developed as a minimally invasive technique for introducing hardware with higher profiles and wider widths, compared with that for the posterior lumbar interbody fusion (PLIF) approach. However, the biomechanics of the interbody fusion construct used in the LLIF approach have not been rigorously evaluated, especially in the presence of secondary augmentation. Methods Spinal stability of 21 cadaveric lumbar specimens was compared using standard nondestructive flexibility studies [mean range of motion (ROM), lax zone (LZ), stiff zone (SZ) in flexion-extension, lateral bending, and axial rotation]. Non-paired comparisons were made among four conditions: (I) intact; (II) with unilateral interbody + bilateral pedicle screws (BPS) using the LLIF approach (referred to as the LLIF construct); (III) with bilateral interbody + BPS using the PLIF approach (referred to as the PLIF construct); and (IV) with no lumbar interbody fusion (LIF) + BPS (referred to as the no-LIF construct). Results With bilateral pedicle screw-rod fixation, stability was equivalent between PLIF and LLIF constructs in lateral bending and flexion-extension. PLIF and LLIF constructs had similar biomechanical profiles, with a trend toward less ROM in axial rotation for the LLIF construct. Conclusions LLIF and PLIF constructs had similar stabilizing effects.
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Affiliation(s)
- Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Samuel Kalb
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Marco T Reis
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Phillip M Reyes
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Anna G U S Newcomb
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Steve W Chang
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Brian P Kelly
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Neil R Crawford
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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27
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Godzik J, Martinez-del-Campo E, Newcomb AG, Reis MT, Perez-Orribo L, Whiting AC, Singh V, Kelly BP, Crawford NR. Biomechanical Stability Afforded by Unilateral Versus Bilateral Pedicle Screw Fixation with and without Interbody Support Using Lateral Lumbar Interbody Fusion. World Neurosurg 2018; 113:e439-e445. [DOI: 10.1016/j.wneu.2018.02.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 01/02/2023]
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Khashan M, Camisa W, Berven S, Leasure J. Stand-alone anterior interbody fusion for substitution of iliac fixation in long spinal fixation constructs. Arch Orthop Trauma Surg 2018; 138:479-486. [PMID: 29288274 DOI: 10.1007/s00402-017-2865-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The use of distal sacral anchorage solely, in long spinal fusions, may lead to substantial complications. Extending the fixation down to the ilium and the addition of anterior column support are both used to facilitate construct stability and improve fusion rates. In the current study, we aimed to determine whether supplementation of long thoracolumbar fixation constructs with stand-alone anterior interbody fusion (ALIF) cage with embedded screws can eliminate the biomechanical need for iliac screws fixation biomechanically. METHODS Seven lumbopelvic human cadavers (L1-full pelvis) were used. All specimens were tested with the following fixation constructs: bilateral L1-S1, bilateral L1-S1 with unilateral iliac screw, and bilateral L1-S1 with bilateral iliac screw. The three constructs were tested with and without the addition of stand-alone ALIF cage. We evaluated the multidirectional rigidity and the axial S1 screw strain. RESULTS The addition of an ALIF cage solely did not affect rigidity and resulted in mixed S1 screw strain results. One iliac screw was superior to ALIF in rigidity and inferior in S1 screws strain. Bilateral iliac fixation produced similar rigidity and lower S1 screws strain than unilateral iliac fixation. When ALIF was combined with bilateral iliac screws, it resulted in equal rigidity and lower S1 screws strain. CONCLUSION Our results do not support stand-alone ALIF cage as a substitute for iliac fixation in in long posterior lumbosacral fusion. They do support the use of stand-alone ALIF for the supplementation of bilateral iliac fixation in long lumbosacral fusions.
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Affiliation(s)
- Morsi Khashan
- University of California San Francisco-Department of Orthopaedics Surgery, 400 Parnassus Ave, San Francisco, CA, 94143, USA. .,Orthopedic Division, Tel-aviv Sourasky Medical Center, 6 Wizman Street, 64239, Tel Aviv, Israel.
| | - William Camisa
- The Taylor Collaboration, 450 Stanyan St., San Francisco, CA, 94117, USA
| | - Sigurd Berven
- University of California San Francisco-Department of Orthopaedics Surgery, 400 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Jeremi Leasure
- The Taylor Collaboration, 450 Stanyan St., San Francisco, CA, 94117, USA
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Oberkircher L, Krüger A, Hörth D, Hack J, Ruchholtz S, Fleege C, Rauschmann M, Arabmotlagh M. Anterior cement augmentation of adjacent levels after vertebral body replacement leads to superior stability of the corpectomy cage under cyclic loading-a biomechanical investigation. Spine J 2018; 18:525-531. [PMID: 29174458 DOI: 10.1016/j.spinee.2017.10.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/08/2017] [Accepted: 10/26/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND In the operative treatment of osteoporotic vertebral body fractures, a dorsal stabilization in combination with a corpectomy of the fractured vertebral body might be necessary with respect to the fracture morphology, whereby the osteoporotic bone quality may possibly increase the risk of implant failure. To achieve better stability, it is recommended to use cement-augmented screws for dorsal instrumentation. Besides careful end plate preparation, cement augmentation of the adjacent end plates has also been reported to lead to less reduction loss. PURPOSE The aim of the study was to evaluate biomechanically under cyclic loading whether an additional cement augmentation of the adjacent end plates leads to improved stability of the inserted cage. STUDY DESIGN/SETTING Methodical cadaver study. MATERIALS AND METHODS Fourteen fresh frozen human thoracic spines with proven osteoporosis were used (T2-T7). After removal of the soft tissues, the spine was embedded in Technovit (Kulzer, Germany). Subsequently, a corpectomy of T5 was performed, leaving the dorsal ligamentary structures intact. After randomization with respect to bone quality, two groups were generated: Dorsal instrumentation (cemented pedicle screws, Medtronic, Minneapolis, MN, USA)+cage implantation (CAPRI Corpectomy Cage, K2M, Leesburg, VA, USA) without additional cementation of the adjacent endplates (Group A) and dorsal instrumentation+cage implantation with additional cement augmentation of the adjacent end plates (Group B). The subsequent axial and cyclic loading was performed at a frequency of 1 Hz, starting at 400 N and increasing the load within 200 N after every 500 cycles up to a maximum of 2,200 N. Load failure was determined when the cages sintered macroscopically into the end plates (implant failure) or when the maximum load was reached. RESULTS One specimen in Group B could not be clamped appropriately into the test bench for axial loading because of a pronounced scoliotic misalignment and had to be excluded. The mean strength for implant failure was 1,000 N±258.2 N in Group A (no cement augmentation of the adjacent end plates, n=7); on average, 1,622.1±637.6 cycles were achieved. In Group B (cement augmentation of the adjacent end plates, n=6), the mean force at the end of loading was 1,766.7 N±320.4 N; an average of 3,572±920.6 cycles was achieved. Three specimens reached a load of 2,000 N. The differences between the two groups were significant (p=.006 and p=.0047) regarding load failure and number of cycles. CONCLUSIONS Additional cement augmentation of the adjacent end plates during implantation of a vertebral body replacement in osteoporotic bone resulted in a significant increased stability of the cage in the axial cyclic loading test.
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Affiliation(s)
- Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany.
| | - Antonio Krüger
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany
| | - Dominik Hörth
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany
| | - Juliana Hack
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, Philipps University Marburg, Germany
| | - Christoph Fleege
- Department of Spine Surgery, Johann Wolfgang Goethe University Frankfurt, Germany
| | - Michael Rauschmann
- Department of Spine Surgery, Johann Wolfgang Goethe University Frankfurt, Germany
| | - Mohammad Arabmotlagh
- Department of Spine Surgery, Johann Wolfgang Goethe University Frankfurt, Germany
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Du JY, Kiely PD, Bogner E, Al Maaieh M, Aichmair A, Salzmann SN, Huang RC. Early clinical and radiological results of unilateral posterior pedicle instrumentation through a Wiltse approach with lateral lumbar interbody fusion. JOURNAL OF SPINE SURGERY 2017; 3:338-348. [PMID: 29057341 DOI: 10.21037/jss.2017.06.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND To assess the clinical outcomes of 44 patients who underwent single-level lateral lumbar interbody fusion (LLIF) with unilateral pedicle screw instrumentation through a paramedian Wiltse approach. METHODS Demographic, comorbidity, clinical assessment, peri-operative, and complication data were assessed. Visual analog scale (VAS), Oswestry disability index (ODI), and short form-12 (SF-12) were used to assess clinical outcomes. Post-operative plain radiographs were assessed for subsidence, cage migration, and fusion. RESULTS Average age of patients at surgery was 60.8±10.6 years (range, 32-79 years), with 15 males and 29 females. Recombinant human bone morphogenic protein-2 (rhBMP-2) was used in 32 cases (73%) and 13 posterolateral fusions (30%). Average duration of surgery was 195.2±36.9 minutes (range: 111-295 minutes), with an estimated blood loss of 159.3±90.8 cc (range, 50-500 cc). There were no intra-operative complications. Average length of hospital stay was 4.2±2.5 days (range, 2-13 days). Four patients (9%) experienced neurological deficit, 2 of which resolved by 3-month follow-up and 2 of which improved but did not resolve by final follow-up at 11 and 16 months. There was significant improvement in VAS (P<0.001), ODI (P<0.001), and SF-12 physical component (P<0.001), but not for SF-12 mental component (P=0.053). Patients with minimum 6 months radiographic follow-up demonstrated successful fusion in 90% of cases (35/39), with 2 cases of grade 1 (5%) subsidence of the adjacent cranial vertebra, and no cases higher than grade 0 subsidence of the adjacent caudal vertebra. CONCLUSIONS Unilateral pedicle screw instrumentation following LLIF was associated with significant improvement in clinical outcomes and favorable radiographic outcomes.
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Affiliation(s)
- Jerry Y Du
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY, USA
| | - Paul D Kiely
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY, USA
| | - Eric Bogner
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY, USA
| | - Motasem Al Maaieh
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY, USA
| | - Alexander Aichmair
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Stephan N Salzmann
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY, USA
| | - Russel C Huang
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY, USA
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Lu T, Liang H, Liu C, Guo S, Zhang T, Yang B, He X. Effects of Titanium Mesh Cage End Structures on the Compressive Load at the Endplate Interface: A Cadaveric Biomechanical Study. Med Sci Monit 2017; 23:2863-2870. [PMID: 28604653 PMCID: PMC5478219 DOI: 10.12659/msm.905466] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background This study aimed to evaluate whether obliquely angled and ring-shaped titanium mesh cage (TMC) end structures can improve the compressive load on the endplate interface in anterior cervical corpectomy and fusion (ACCF). Material/Methods A total of 23 volunteers underwent cervical lateral x-ray. The oblique angle of the superior endplate was measured, which was used to construct the gradient of the TMC end. Forty-two fresh cadaveric vertebral bodies were harvested and randomly distributed among four TMC groups with different ends. The baseline indicators of bone mineral density and anteroposterior and transverse dimensions were recorded. The superior endplate was placed at an angle of 12° when performing uniaxial compression testing. The maximum loads of the four TMCs were assessed. Results There were no significant differences among the groups regarding the baseline indicators. The conventional TMC had the lowest maximum load (1362.3±221.78 N, p<0.05), whereas the TMC with an obliquely end ring had the highest maximum load (2095.82±285.64 N, p<0.05). The maximum loads of the TMCs with oblique footprints and flat end ring were much higher than that of the conventional TMC (p<0.05) but significantly lower than that of the TMC with the obliquely end ring (p<0.05), with average values of 1806.91±246.98 N and 1725.3±213.33 N, respectively. Conclusions Both the ring shape and oblique angle of the TMC end contributed to an increase in compressive force and are advocated for use in TMC structure optimization to decrease the incidence of TMC subsidence in ACCF.
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Affiliation(s)
- Teng Lu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Hui Liang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Chao Liu
- Department of Education, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Shuai Guo
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Ting Zhang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Baohui Yang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Xijing He
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
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Rao PJ, Phan K, Giang G, Maharaj MM, Phan S, Mobbs RJ. Subsidence following anterior lumbar interbody fusion (ALIF): a prospective study. JOURNAL OF SPINE SURGERY 2017; 3:168-175. [PMID: 28744497 DOI: 10.21037/jss.2017.05.03] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Anterior lumbar interbody fusion (ALIF) is a widely used surgical technique for disorders of the lumbar spine. One potential complication is the subsidence of disc height in the post-operative period. Few studies have reported the rate of subsidence in ALIF surgery prospectively. We prospectively evaluated the rate of subsidence in adult patients undergoing ALIF. METHODS Results were obtained by reviewing scans of 147 patients. Disc heights were measured on radiographic scans taken pre-operatively in addition to post-operatively immediately, at 6 weeks and at 18 months. The anterior and posterior intervertebral disc heights were measured. Subsidence was defined as greater than or equal to 2 mm loss of height. RESULTS A total of 15 patients (10.2%) had subsidence, with 7 being male. Each case was of delayed cage subsidence (DCS) >6 weeks postoperatively. The mean subsidence was 4.7 mm (range, 2.4-7.8). Mean anterior disc height was 8.6±0.4 mm preoperatively, which improved to 15.1±0.5 mm at latest follow-up. Mean posterior disc height was 4.7±0.2 mm preoperatively, which improved to 8.7±0.4 mm at latest follow-up. The mean lumbar lordosis (LL) angle was 42.5°±10.8° and the mean local disc angle (LDA) was 6.7°±4.0°. The 91.2% (n=114/125) of patients with appropriate radiological follow-up demonstrated fusion by latest follow-up. There was no correlation between subsidence rate with patient reported outcomes [Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form 12 Item survey (SF-12)] and fusion rates. There was a significant negative correlation between LL and extent of subsidence (Pearson correlation =-0.754, P=0.012). CONCLUSIONS In conclusion, we found that the subsidence rate at follow-up was generally low following standalone ALIF for this patient series. Patient clinical outcomes and bony fusion rates were not significantly influenced by subsidence.
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Affiliation(s)
- Prashanth J Rao
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,University of New South Wales (UNSW), Sydney, Australia
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,University of New South Wales (UNSW), Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Gloria Giang
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,University of New South Wales (UNSW), Sydney, Australia
| | - Monish M Maharaj
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,University of New South Wales (UNSW), Sydney, Australia
| | - Steven Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Ralph J Mobbs
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,University of New South Wales (UNSW), Sydney, Australia
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Predisposing Factors for Intraoperative Endplate Injury of Extreme Lateral Interbody Fusion. Asian Spine J 2016; 10:907-914. [PMID: 27790319 PMCID: PMC5081326 DOI: 10.4184/asj.2016.10.5.907] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/29/2016] [Accepted: 03/28/2016] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN Retrospective study. PURPOSE To compare intraoperative endplate injury cases and no injury cases in consecutive series and to identify predisposing factors for intraoperative endplate injury. OVERVIEW OF LITERATURE Unintended endplate violation and subsequent cage subsidence is an intraoperative complication of extreme lateral interbody fusion (XLIF). It is still unknown whether it is derived from inexperienced surgical technique or patients' inherent problems. METHODS Consecutive patients (n=102; mean age, 69.0±0.8 years) underwent XLIF at 201 levels at a single institute. Preoperative and immediately postoperative radiographs were compared and cases with intraoperative endplate injury were identified. Various parameters were reviewed in each patient and compared between the injury and no injury groups. RESULTS Twenty one levels (10.4%) had signs of intraoperative endplate injury. The injury group had a significantly higher rate of females (p=0.002), lower bone mineral density (BMD) (p=0.02), higher rate of polyetheretherketone as cage material (p=0.04), and taller cage height (p=0.03) compared with the no injury group. Multivariate analysis indicated that a T-score of BMD as a negative (odds ratio, 0.52; 95% confidence interval, 0.27-0.93; p=0.03) and cage height as a positive (odds ratio, 1.84; 95% confidence interval, 1.01-3.17; p=0.03) were predisposing factors for intraoperative endplate injury. CONCLUSIONS Intraoperative endplate injury is correlated significantly with reduced BMD and taller cage height. Precise evaluation of bone quality and treatment for osteoporosis might be important and care should be taken not to choose excessively taller cage.
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Karaca S, Akpolat AO, Oztermeli A, Erdem MN, Aydogan M. Discrepancy between cervical disc prostheses and anatomical cervical dimensions. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2016; 50:544-547. [PMID: 27776930 PMCID: PMC6197307 DOI: 10.1016/j.aott.2016.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/20/2016] [Accepted: 03/02/2016] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aim of this study was to assess appropriateness of the sizes of available cervical disc prostheses based on tomographic measurement of human cervical vertebrae. METHODS The anatomic dimensions of the C3-C7 segments were measured on 50 patients (age range 26-47 years) with computerized tomography scan and compared with the sizes of the popular cervical total disc prostheses (CTDP) at the market [Bryan (Medtronic), Prodisc-C (Synthes), Prestige LP (Medtronic), Discover (DePuy)]. The mediolateral and anteriorposterior diameters of the upper and lower endplates were measured with a digital measuring system. RESULTS Overall, 43.7% of the largest implant footprints were smaller in the anterior-posterior diameter and 42.6% in the mediolateral diameter were smaller than cervical endplate measurements. Discrepancy of the level C5/C6 and C6/C7 was calculated as 56.2% at the anteroposterior diameter and 43.8% at the center of mediolateral diameter. CONCLUSION Large disparity has been found between the sizes of devices and cervical anatomic data. Companies that produce CTDP should take care of the anatomical dimensions and generate different sizes of CTDP. Spine surgeon should be familiar with the size mismatch in CTDP that may affect the clinical and radiological outcome of the surgery.
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Cadman J, Sutterlin C, Dabirrahmani D, Appleyard R. The importance of loading the periphery of the vertebral endplate. JOURNAL OF SPINE SURGERY (HONG KONG) 2016; 2:178-184. [PMID: 27757430 PMCID: PMC5067271 DOI: 10.21037/jss.2016.09.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/21/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Commercial fusion cages typically provide support in the central region of the endplate, failing to utilize the increased compressive strength around the periphery. This study demonstrates the increase in compressive strength that can be achieved if the bony periphery of the endplate is loaded. METHODS Sixteen cadaveric lumbar vertebrae (L1-L5) were randomly divided into two even groups. A different commercial mass produced implant (MPI) was allocated to each group: (I) a Polyether-ether-ketone (PEEK) anterior lumber inter-body fusion (ALIF) MPI; and (II) a titanium ALIF MPI. Uniaxial compression at a displacement rate of 0.5 mm/sec was applied to all vertebrae during two phases: (I) with the allocated MPI situated in the central region of the endplate; (II) with an aluminum plate, designed to load the bony periphery of the endplate. The failure load and mode of failure was recorded. RESULTS From phase 1 to phase 2, the failure load increased from 1.1±0.4 to 2.9±1.4 kN for group 1; and from 1.3±1.0 to 3.0±1.9 kN for group 2. The increase in strength from phase 1 to phase 2 was statistically significant for each group (group 1: P<0.01, group 2: P<0.05, paired t-test). There was no significant difference between the groups in either phase (P>0.05, t-test). The mode of failure in phase 1 was the implant being forced through the endplate for both groups. In phase 2, the mode of failure was either a fracture of the epiphyseal rim or buckling of the side wall of the vertebral body. CONCLUSIONS Loading the periphery of the vertebral endplate achieved significant increase in compressive load capacity compared to loading the central region of the endplate. Clinically, this implies that patient-specific implants which load the periphery of the vertebral endplate could decrease the incidence of subsidence and improve surgical outcomes.
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Affiliation(s)
- Joseph Cadman
- Orthopaedic Biomechanics Group, Department of Biomedical Science, Faculty of Medicine and Health Science, Macquarie University, NSW, Australia
| | - Chester Sutterlin
- University of Florida, FL, USA
- Spinal Health International, 511 Putter Lane, Longboat Key, FL, USA
| | - Danè Dabirrahmani
- Orthopaedic Biomechanics Group, Department of Biomedical Science, Faculty of Medicine and Health Science, Macquarie University, NSW, Australia
| | - Richard Appleyard
- Orthopaedic Biomechanics Group, Department of Biomedical Science, Faculty of Medicine and Health Science, Macquarie University, NSW, Australia
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Phan K, Mobbs RJ. Evolution of Design of Interbody Cages for Anterior Lumbar Interbody Fusion. Orthop Surg 2016; 8:270-7. [PMID: 27627708 PMCID: PMC6584298 DOI: 10.1111/os.12259] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/13/2016] [Indexed: 11/28/2022] Open
Abstract
Anterior lumbar interbody fusion (ALIF) is one of the surgical procedures for the relief of chronic back pain, radiculopathy and neurogenic claudication in patients with degenerative lumbar spine disease that is refractory to conservative therapy, low-grade spondylolisthesis and pseudo arthrosis. Over the past half century, both the surgical techniques and instrumentation required for ALIF have changed significantly. In particular, the designs of ALIF cage and the materials used have evolved dramatically, the common goal being to improve fusion rates and optimize clinical outcomes. The increasing popularity of ALIF is reflected by the increasing abundance of published studies reporting clinical outcomes, surgical techniques and grafting options for ALIF. Developments in cage designs include cylindrical Bagby and Kuslich, cylindrical ray, cylindrical mesh, lumbar-tapered, polyethyl-etherketone cage and integral fixation cages. Biologic implants include bone dowels and femoral ring allografts. Methods for optimization of cage design have included cage dimensions, use of novel composite cage materials and integral fixation technologies. However, the historical development and evolution of cages used for ALIF has not been extensively documented. This article therefore aims to provide an overview of the historical basis for the anterior approach, evolution in design of ALIF cage implants and potential future research directions.
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Affiliation(s)
- Kevin Phan
- Department of Neurosurgery, NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia
- Department of Neurosurgery, University of New South Wales, Sydney, Australia
- Department of Neurosurgery, Prince of Wales Hospital, Sydney, Australia
| | - Ralph J Mobbs
- Department of Neurosurgery, NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia.
- Department of Neurosurgery, University of New South Wales, Sydney, Australia.
- Department of Neurosurgery, Prince of Wales Hospital, Sydney, Australia.
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Malham GM, Parker RM, Blecher CM, Chow FY, Seex KA. Choice of Approach Does Not Affect Clinical and Radiologic Outcomes: A Comparative Cohort of Patients Having Anterior Lumbar Interbody Fusion and Patients Having Lateral Lumbar Interbody Fusion at 24 Months. Global Spine J 2016; 6:472-81. [PMID: 27433432 PMCID: PMC4947396 DOI: 10.1055/s-0035-1569055] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/16/2015] [Indexed: 11/03/2022] Open
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected registry data. OBJECTIVE This study aimed to compare the clinical and radiologic outcomes between comparative cohorts of patients having anterior lumbar interbody fusion (ALIF) and patients having lateral lumbar interbody fusion (LLIF). METHODS Ninety consecutive patients were treated by a single surgeon with either ALIF (n = 50) or LLIF (n = 40). Inclusion criteria were patients age 45 to 70 years with degenerative disk disease or grade 1 to 2 spondylolisthesis and single-level pathology from L1 to S1. Patient-reported outcome measures included pain (visual analog scale), disability (Oswestry Disability Index [ODI]), and quality of life (Short Form 36 physical component score [PCS] and mental component scores [MCS]). Assessment of fusion and measurement of lordosis and posterior disk height were performed on computed tomography scans. RESULTS At 24 months, patients having ALIF had significant improvements in back (64%) and leg (65%) pain and ODI (60%), PCS (44%), and MCS (26%; p < 0.05) scores. Patients having LLIF had significant improvements in back (56%) and leg (57%) pain and ODI (52%), PCS (48%), and MCS (12%; p < 0.05) scores. Fourteen complications occurred in the ALIF group, and in the LLIF group, there were 17 complications (p > 0.05). The fusion rate was 100% for ALIF and 95% for LLIF (p = 0.1948). ALIF added ∼6 degrees of lordosis and 3 mm of height, primarily measured at L5-S1, and LLIF added ∼3 degrees of lordosis and 2 mm of height between L1 to L5. Mean follow-up was 34.1 months. CONCLUSIONS In comparative cohorts of patients having ALIF and patients having LLIF at 24 months postoperatively, there were no significant differences in clinical outcomes, complication rates, or fusion rates.
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Affiliation(s)
- Gregory M. Malham
- Neuroscience Institute, Epworth Hospital, Melbourne, Victoria, Australia,Address for correspondence Gregory M. Malham, MB, ChB, FRACS Suite 2, Level 1, 517 St. Kilda Road, Melbourne, VIC 3004Australia
| | - Rhiannon M. Parker
- Research Department, Greg Malham Neurosurgeon, Melbourne, Victoria, Australia
| | - Carl M. Blecher
- Radiology Department, Epworth Hospital, Melbourne, Victoria, Australia
| | - Fiona Y. Chow
- Internal Medicine Institute, Epworth Hospital, Melbourne, Victoria, Australia
| | - Kevin A. Seex
- Neurosurgery Department, Macquarie University, Sydney, New South Wales, Australia
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Yang H, Jekir MG, Davis MW, Keaveny TM. Effective modulus of the human intervertebral disc and its effect on vertebral bone stress. J Biomech 2016; 49:1134-1140. [PMID: 26949100 DOI: 10.1016/j.jbiomech.2016.02.045] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 02/18/2016] [Accepted: 02/21/2016] [Indexed: 11/20/2022]
Abstract
The mechanism of vertebral wedge fractures remains unclear and may relate to typical variations in the mechanical behavior of the intervertebral disc. To gain insight, we tested 16 individual whole discs (between levels T8 and L5) from nine cadavers (mean±SD: 66±16 years), loaded in compression at different rates (0.05-20.0% strain/s), to measure a homogenized "effective" linear elastic modulus of the entire disc. The measured effective modulus, and average disc height, were then input and varied parametrically in micro-CT-based finite element models (60-μm element size, up to 80 million elements each) of six T9 human vertebrae that were virtually loaded to 3° of moderate forward-flexion via a homogenized disc. Across all specimens and loading rates, the measured effective modulus of the disc ranged from 5.8 to 42.7MPa and was significantly higher for higher rates of loading (p<0.002); average disc height ranged from 2.9 to 9.3mm. The parametric finite element analysis indicated that, as disc modulus increased and disc height decreased across these ranges, the vertebral bone stresses increased but their spatial distribution was largely unchanged: most of the highest stresses occurred in the central trabecular bone and endplates, and not anteriorly. Taken together with the literature, our findings suggest that the effective modulus of the human intervertebral disc should rarely exceed 100MPa and that typical variations in disc effective modulus (and less so, height) minimally influence the spatial distribution but can appreciably influence the magnitude of stress within the vertebral body.
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Affiliation(s)
- Haisheng Yang
- Orthopaedic Biomechanics Laboratory, Department of Mechanical Engineering, University of California, Berkeley, CA, USA.
| | - Michael G Jekir
- Orthopaedic Biomechanics Laboratory, Department of Mechanical Engineering, University of California, Berkeley, CA, USA
| | - Maxwell W Davis
- Orthopaedic Biomechanics Laboratory, Department of Mechanical Engineering, University of California, Berkeley, CA, USA
| | - Tony M Keaveny
- Orthopaedic Biomechanics Laboratory, Department of Mechanical Engineering, University of California, Berkeley, CA, USA; Department of Bioengineering, University of California, Berkeley, CA, USA.
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Bashkuev M, Checa S, Postigo S, Duda G, Schmidt H. Computational analyses of different intervertebral cages for lumbar spinal fusion. J Biomech 2015; 48:3274-82. [DOI: 10.1016/j.jbiomech.2015.06.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 05/27/2015] [Accepted: 06/21/2015] [Indexed: 10/23/2022]
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Chong E, Pelletier MH, Mobbs RJ, Walsh WR. The design evolution of interbody cages in anterior cervical discectomy and fusion: a systematic review. BMC Musculoskelet Disord 2015; 16:99. [PMID: 25907826 PMCID: PMC4416390 DOI: 10.1186/s12891-015-0546-x] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 03/30/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Anterior cervical discectomy with fusion is a common surgical procedure for patients experiencing pain and/or neurological deficits due to cervical spondylosis. Although iliac crest bone graft remains the gold standard today, the associated morbidity has inspired the search for alternatives, including allograft, synthetic and factor/cell-based grafts; and has further led to a focus on cage fusion technology. Compared to their graft counterparts, cage interbody implants have enhanced biomechanical properties, with designs constantly improving to maximise biocompatibility and osseointegration. We present a systematic review examining the historical progress of implant designs and performance, as well as an update on the currently available designs, and the potential future of cervical interbody implants. METHODS We performed a systematic review using the keywords "cervical fusion implant design", with no limits on year of publication. Databases used were PubMed, Medline, Embase and Cochrane. In addition, the search was extended to the reference lists of selected articles. RESULTS 180 articles were reviewed and 64 articles were eligible for inclusion. Exclusion criteria were based around study design, implant information and patient cohorts. The evolution of cage implant design has been shaped by improved understanding of ideal anatomy, progress in materials research and continuing experimentation of structural design. Originally, designs varied primarily in their choice of structure, however long-term studies have displayed the overall advantages of non-threaded, wedge shaped cages in complementing healthy anatomical profiles, and thus focus has shifted to refining material utilisation and streamlining anterior fixation. CONCLUSIONS Evolution of design has been dramatic over the past decades; however an ideal cage design has yet to be realised. Current research is focusing on the promotion of osseointegration through bioactiviation of surface materials, as well as streamlining anterior fixation with the introduction of integrated screws and zero profile designs. Future designs will benefit from a combination of these advances in order to achieve ideal disc heights, cervical alignments and fusions.
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Affiliation(s)
- Elizabeth Chong
- University of New South Wales, Randwick, NSW, 2031, Australia. .,Surgical and Orthopaedic Research Laboratory, Prince of Wales Clinical School, UNSW NSW, Randwick, 2031, Australia.
| | - Matthew H Pelletier
- Surgical and Orthopaedic Research Laboratory, Prince of Wales Clinical School, UNSW NSW, Randwick, 2031, Australia.
| | - Ralph J Mobbs
- University of New South Wales, Randwick, NSW, 2031, Australia. .,Neurospine Clinic, Randwick, NSW, 2031, Australia. .,Department of Spine Surgery, Prince of Wales Hospital, Barker St, Sydney, 2031, Australia.
| | - William R Walsh
- Surgical and Orthopaedic Research Laboratory, Prince of Wales Clinical School, UNSW NSW, Randwick, 2031, Australia.
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Tempel ZJ, Gandhoke GS, Bolinger BD, Okonkwo DO, Kanter AS. Vertebral body fracture following stand-alone lateral lumbar interbody fusion (LLIF): report of two events out of 712 levels. 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 2015; 24 Suppl 3:409-13. [DOI: 10.1007/s00586-015-3845-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/26/2015] [Indexed: 11/24/2022]
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Anterior lumbar interbody fusion: two-year results with a modular interbody device. Asian Spine J 2014; 8:591-8. [PMID: 25346811 PMCID: PMC4206808 DOI: 10.4184/asj.2014.8.5.591] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 11/27/2013] [Accepted: 12/15/2013] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN Retrospective case series. PURPOSE To present radiographic outcomes following anterior lumbar interbody fusion (ALIF) utilizing a modular interbody device. OVERVIEW OF LITERATURE Though multiple anterior lumbar interbody techniques have proven successful in promoting bony fusion, postoperative subsidence remains a frequently reported phenomenon. METHODS Forty-three consecutive patients underwent ALIF with (n=30) or without (n=11) supplemental instrumentation. Two patients underwent ALIF to treat failed posterior instrumented fusion. The primary outcome measure was presence of fusion as assessed by computed tomography. Secondary outcome measures were lordosis, intervertebral lordotic angle (ILA), disc height, subsidence, Bridwell fusion grade, technical complications and pain score. Interobserver reliability of radiographic outcome measures was calculated. RESULTS Forty-three patients underwent ALIF of 73 motion segments. ILA and disc height increased over baseline, and this persisted through final follow-up (p<0.01). Solid anterior interbody fusion was present in 71 of 73 motion segments (97%). The amount of new bone formation in the interbody space increased over serial imaging. Subsidence >4 mm occurred in 12% of patients. There were eight surgical complications (19%): one major (reoperation for nonunion/progressive subsidence) and seven minor (five subsidence, two malposition). CONCLUSIONS The use of a modular interbody device for ALIF resulted in a high rate of radiographic fusion and a low rate of subsidence. The large endplate and modular design of the device may contribute to a low rate of subsidence as well as maintenance of ILA and lordosis. Previously reported quantitative radiographic outcome measures were found to be more reliable than qualitative or categorical measures.
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Impact of subsidence on clinical outcomes and radiographic fusion rates in anterior cervical discectomy and fusion: a systematic review. ACTA ACUST UNITED AC 2014; 27:1-10. [PMID: 24441059 DOI: 10.1097/bsd.0b013e31825bd26d] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To provide a systematic review of published literature on the impact of subsidence on clinical outcomes and radiographic fusion rates after anterior cervical discectomy and fusion with plates or without plates. BACKGROUND Subsidence of interbody implants is common after anterior cervical spine fusions. The impact of subsidence on fusion rates and clinical outcomes is unknown. METHODS Systematic literature review on published articles on anterior cervical discectomy and fusion, which objectively measured graft subsidence, radiographic fusion rates, and clinical outcomes between April 1966 and December 2010. RESULTS A total of 35 articles that measured subsidence and provided fusion rates and/or clinical outcomes were selected for inclusion. The mean subsidence rate ranged from 19.3% to 42.5%. The rate of subsidence based on the type of implant ranged from 22.8% to 35.9%. The incidence of subsidence was not impacted by the type of implant (P=0.98). The overall fusion rate of the combined studies was 92.8% and was not impacted by subsidence irrespective of subsidence definition or the measurement technique used (P=0.19). Clinical outcomes were evaluated in 27 of 35 studies with all studies reporting an improvement in patient outcomes postoperatively. CONCLUSIONS Subsidence irrespective of the measurement technique or definition does not appear to have an impact on successful fusion and/or clinical outcomes. A validated definition and standard measurement technique for subsidence is needed to determine the actual incidence of subsidence and its impact on radiographic and clinical outcomes.
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Biomechanical Evaluation of a Novel Autogenous Bone Interbody Fusion Cage for Posterior Lumbar Interbody Fusion in a Cadaveric Model. Spine (Phila Pa 1976) 2014; 39:E684-E692. [PMID: 24583726 DOI: 10.1097/brs.0000000000000291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A human cadaveric biomechanical study of a novel, prefabricated autogenous bone interbody fusion (ABIF) cage. OBJECTIVE To evaluate the biomechanical properties of the ABIF cage in a single-level construct with and without transpedicular screw and rod fixation. SUMMARY OF BACKGROUND DATA In current practice, posterior lumbar interbody fusion is generally carried out using synthetic interbody spacers or corticocancellous iliac crest bone graft (ICBG) in combination with posterior instrumentation. However, questions remain concerning the use of synthetic intervertebral implants as well as the morbidity ICBG harvesting. Therefore, ABIF cage has been developed to obviate some of the challenges in conventional posterior lumbar interbody fusion instrumentation and to facilitate the fusion process. METHODS Eighteen adult cadaveric lumbosacral (L3-S1) specimens were tested. Test conditions included single lumbosacral segments across (1) intact, (2) decompressed, (3) intervertebral cage alone, and (4) intervertebral cage with bilateral transpedicular fixation. Range of motion (ROM), neutral zone (NZ), and axial failure load were tested for each condition. RESULTS The ICBG, polyetheretherketone cage, or ABIF cage alone exhibited a significantly lower (P < 0.05) ROM and NZ than the decompressed spine. In comparison with the intact spine, all 3 test conditions without supplemental fixation were able to decrease ROM and NZ to near intact levels. When stabilized with pedicle screws, the ROM was significantly less and the NZ was significantly lower (P < 0.05) for each group both compared with the intact spine. In axial compression testing, the failure load of polyetheretherketone cage was the highest, with no significant difference between the ICBG and the ABIF cage. CONCLUSION These data suggest that the novel ABIF cage can bear the physiological intervertebral peak load, similar to ICBG. When combined with pedicle screw and rod fixation, it exhibits similar biomechanical properties as the polyetheretherketone cage plus posterior instrumentation. Based on the biomechanical properties of ABIF cage, the prospect of these cages in clinical practice is expected.
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Schnake KJ, Stavridis SI, Krampe S, Kandziora F. Additional anterior plating enhances fusion in anteroposteriorly stabilized thoracolumbar fractures. Injury 2014; 45:792-8. [PMID: 24326026 DOI: 10.1016/j.injury.2013.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 06/30/2013] [Accepted: 11/11/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION To prospectively evaluate the potential radiological and clinical effect of the additional application of an anterior plate in anteroposteriorly stabilized thoracolumbar fractures. PATIENTS AND METHODS 75 consecutive patients with unstable thoracolumbar fractures underwent posterior (internal fixator) and anterior stabilization (corpectomy cage with local autologous bone grafting). 40 (53.3%) patients received an additional anterior plate (Group A), while 35 (46.6%) (Group B) did not. Plain X-rays and CT-scans were obtained pre- and postoperatively, after 12 months and at the last follow-up (mean 32 months, range 22-72). Loss of reduction, cage subsidence to adjacent vertebrae, fusion rates and clinical results were evaluated. RESULTS 66 (87%) patients (36 Group A; 30 Group B) were available for follow-up. Patients in both groups were comparable regarding age, gender, comorbidities, localization and classification of fracture. Average loss of reduction was 2.4° in Group A, and 3.1° in Group B (not significant). Cage subsidence did not differ significantly between both groups, too. However, after 12 months the rate of continuous osseous bridging between endplates was significantly higher in Group A (63% vs. 25%) (p<0.05). After 32 months this difference was even higher (81% vs. 33%) (p<0.001). The bony fusion mass was located beneath or around the anterior plate in 94% of patients. There was no significant difference in clinical outcome. CONCLUSIONS Additional anterior plating in anteroposteriorly stabilized thoracolumbar fractures leads to significant faster fusion but does neither influence reduction loss nor cage subsidence. The anterior plate serves as a pathway for bone growth and increases biomechanical stability, resulting in a higher fusion rate.
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Affiliation(s)
- Klaus John Schnake
- Center for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main, Friedberger Landstraße 430, D-60389 Frankfurt am Main, Germany.
| | - Stavros I Stavridis
- Center for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main, Friedberger Landstraße 430, D-60389 Frankfurt am Main, Germany.
| | - Sebastian Krampe
- Center for Dialysis, Königin Elisabeth Herzberge Krankenhaus, Berlin, Herzbergstraße 79, D-10365 Berlin, Germany.
| | - Frank Kandziora
- Center for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main, Friedberger Landstraße 430, D-60389 Frankfurt am Main, Germany.
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Schnake KJ, Stavridis SI, Kandziora F. Five-year clinical and radiological results of combined anteroposterior stabilization of thoracolumbar fractures. J Neurosurg Spine 2014; 20:497-504. [PMID: 24606000 DOI: 10.3171/2014.1.spine13246] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Despite promising early clinical results, the long-term outcome of the use of expandable titanium cages to reconstruct the anterior column after traumatic burst fractures is still unknown. The purpose of this prospective study was to assess the clinical and radiological outcomes of the use of expandable titanium cages 5 years postoperatively. METHODS Eighty patients with traumatic thoracolumbar burst fractures (T4-L5) underwent posterior stabilization followed by anterior corpectomy and reconstruction using expandable titanium cages with or without additional anterior plating. After 5 years, fusion was evaluated by means of plain radiographs and CT scans, and the patients' scores on the Oswestry Disability Index (ODI), their neurological status, and clinical results were assessed. RESULTS Forty-five (56%) of the 80 patients could be examined after 5 years. There was a relatively high rate of complications related to thoracotomy (26%), but there were no complications directly related to the cages. Revision surgery was required in 1 case. The average postoperative loss of correction was only 2.4° due to minimal subsidence of the cages. No cage showed a radiolucent line or instability in flexion-extension views. Bony fusion, as assessed by CT scan, was achieved in 41 patients (91%). On clinical examination, 96% of all patients were ambulatory and showed minimal restriction of spinal range of motion; 71% did not need analgesic medication at all; and 67% were able to work. The average ODI score was 12. Thirty-one percent of patients complained of some kind of anterior approach-related complications. CONCLUSIONS Combined anteroposterior stabilization of thoracolumbar burst fractures with expandable titanium cages is a relative safe procedure with satisfactory radiological and clinical long-term outcome. High fusion rates can be achieved, with only minor loss of correction, typically occurring in the 1st year. However, open thoracotomy carries the risks of additional complications and development of post-thoracotomy syndrome.
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Affiliation(s)
- Klaus John Schnake
- Center for Spinal Surgery and Neurotraumatology, BG Unfallklinik Frankfurt, Germany
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Kim MC, Park JU, Kim WC, Lee HS, Chung HT, Kim MW, Chung NS. Can unilateral-approach minimally invasive transforaminal lumbar interbody fusion attain indirect contralateral decompression? A preliminary report of 66 MRI analysis. 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 2014; 23:1144-9. [DOI: 10.1007/s00586-014-3192-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 01/08/2014] [Accepted: 01/10/2014] [Indexed: 11/28/2022]
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Influences of endplate removal and bone mineral density on the biomechanical properties of lumbar spine. PLoS One 2013; 8:e76843. [PMID: 24244269 PMCID: PMC3820638 DOI: 10.1371/journal.pone.0076843] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 09/03/2013] [Indexed: 11/19/2022] Open
Abstract
Purpose To investigate (1) effects of endplate removal and bone mineral density (BMD) on biomechanical properties of lumbar vertebrae (2) whether the distributions of mechanical strength and stiffness of endplate are affected by BMD. Methods A total of thirty-one lumbar spines (L1-L5) collected from fresh cadavers were used in this study. Bone density was measured using lateral DEXA scans and parts of samples were performed with partial or entire endplate removal. All the specimens were divided into three BMD groups. According to endplate integrity of the lumbar vertebrae, each BMD group was then divided into three subgroups: subgroup A: intact endplate; subgroup B: central region of endplate removal; subgroup C: entire endplate removal. The axial compression test was conducted with material testing system at a speed of 2mm/min. The experimental results were statistically analyzed using SPSS 17.0. Results (1) Significant differences of biomechanical properties occurred among normal BMD, osteoporotic and serious osteoporotic group (P<0.05). (2) Spearman analysis showed that BMD was positively correlated with the failure load and stiffness of lumbar vertebrae. (3) For each BMD group, significant differences of biomechanical properties were found between subgroup A and C, and between subgroup B and C (P<0.05). (4) For each BMD group, there was no statistical difference of biomechanical properties between subgroup A and B (P>0.05). Conclusions Entire endplate removal can significantly decrease the structural properties of lumbar vertebrae with little change in biomechanical properties by preservation of peripheral region of the endplate. BMD is positively correlated to the structural properties of the lumbar vertebrae.
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Chen SH, Chiang MC, Lin JF, Lin SC, Hung CH. Biomechanical comparison of three stand-alone lumbar cages--a three-dimensional finite element analysis. BMC Musculoskelet Disord 2013; 14:281. [PMID: 24088294 PMCID: PMC3852219 DOI: 10.1186/1471-2474-14-281] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 09/24/2013] [Indexed: 11/16/2022] Open
Abstract
Background For anterior lumbar interbody fusion (ALIF), stand-alone cages can be supplemented with vertebral plate, locking screws, or threaded cylinder to avoid the use of posterior fixation. Intuitively, the plate, screw, and cylinder aim to be embedded into the vertebral bodies to effectively immobilize the cage itself. The kinematic and mechanical effects of these integrated components on the lumbar construct have not been extensively studied. A nonlinearly lumbar finite-element model was developed and validated to investigate the biomechanical differences between three stand-alone (Latero, SynFix, and Stabilis) and SynCage-Open plus transpedicular fixation. All four cages were instrumented at the L3-4 level. Methods The lumbar models were subjected to the follower load along the lumbar column and the moment at the lumbar top to produce flexion (FL), extension (EX), left/right lateral bending (LLB, RLB), and left/right axial rotation (LAR, RAR). A 10 Nm moment was applied to obtain the six physiological motions in all models. The comparison indices included disc range of motion (ROM), facet contact force, and stresses of the annulus and implants. Results At the surgical level, the SynCage-open model supplemented with transpedicular fixation decreased ROM (>76%) greatly; while the SynFix model decreased ROM 56-72%, the Latero model decreased ROM 36-91%, in all motions as compared with the INT model. However, the Stabilis model decreased ROM slightly in extension (11%), lateral bending (21%), and axial rotation (34%). At the adjacent levels, there were no obvious differences in ROM and annulus stress among all instrumented models. Conclusions ALIF instrumentation with the Latero or SynFix cage provides an acceptable stability for clinical use without the requirement of additional posterior fixation. However, the Stabilis cage is not favored in extension and lateral bending because of insufficient stabilization.
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Affiliation(s)
- Shih-Hao Chen
- Department of Mechanical Engineering, National Chiao Tung University, 1001 University Road, Hsinchu 30010, Taiwan.
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Hsu CC. Shape optimization for the subsidence resistance of an interbody device using simulation-based genetic algorithms and experimental validation. J Orthop Res 2013; 31:1158-63. [PMID: 23335363 DOI: 10.1002/jor.22317] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 12/28/2012] [Indexed: 02/04/2023]
Abstract
Subsidence of interbody devices into the vertebral body might result in serious clinical problems, especially when the devices are not well designed and analyzed. Recently, some novel designs were proposed to reduce the risk of subsidence, but those designs are based on the researcher's experience. The purpose of this study was to discover the interbody device design with excellent subsidence resistance by changing the device's shape. The three-dimensional nonlinear finite element models, which consisted of the interbody device and vertebral body, were created first. Then, the simulation-based genetic algorithm, which combined the finite element model and the searching algorithm, was developed by using ANSYS® Parametric Design Language. Finally, the numerical results were carefully validated with the use of biomechanical tests. The optimum shape design obtained in this study looks like a flower with many petals and it has excellent subsidence resistance when compared with the other designs provided by the past studies. The results of the present study could help surgeons to understand the subsidence resistance of interbody devices in terms of their shapes and has directly provided the design rationales to engineers.
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Affiliation(s)
- Ching-Chi Hsu
- Graduate Institute of Applied Science and Technology, National Taiwan University of Science and Technology, Taipei 10607, Taiwan, ROC.
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