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Fan J, Liu T, Dong X, Sun S, Zhang H, Yang C, Yin X, Liao B, Li X. Effect of Zoledronic Acid on the Vertebral Body Bone Mineral Density After Instrumented Intervertebral Fusion in Postmenopausal Women With Osteoporosis. Global Spine J 2023; 13:1280-1285. [PMID: 34212769 PMCID: PMC10416581 DOI: 10.1177/21925682211027833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To evaluate the effect of zoledronic acid, an anti-osteoporosis treatment, during the perioperative period on vertebral body bone mineral density (BMD) after spinal fusion surgery in postmenopausal women with osteoporosis. METHODS The medical records of postmenopausal patients with osteoporosis who underwent instrumented intervertebral fusion for lumbar degenerative disease between July 2016 and May 2018 were reviewed. Patients with comorbidities or condition which might affect bone metabolism were excluded. Forty-six patients did not receive anti-osteoporosis treatment before surgery and during the postoperative follow-up (untreated group). Another 46 patients who was treated with zoledronic acid perioperatively were matched for age and body mass index to patients in the untreated group. Preoperative and postoperative dual-energy X-ray absorptiometry (DEXA) records and lumbar BMD values of the involved spinal segments and of the cephalad levels, as well as of the femoral neck were recorded. RESULTS A significant decrease of cephalad vertebral BMD values was observed in the untreated group (-11.47%, P < 0.001), with a slight decrease of the femoral neck (-1.28%, P > 0.05). Zoledronic acid prevented rapid bone loss after instrumented intervertebral fusion surgery, with a bone loss in the cephalad levels of -0.76 ± 4.71% compared to -11.47 ± 16.45% in the untreated group (P < 0.001). while the change in BMD of the femoral neck in the treated group was 1.52 ± 5.88% compared to -1.28 ± 6.58% in the untreated group (P = 0.036). CONCLUSIONS Perioperative zoledronic acid treatment may offer protection against a significant decrease in BMD of cephalad vertebrae after spinal fusion surgery among postmenopausal women with osteoporosis.
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Affiliation(s)
- Junjun Fan
- Department of Orthopedics, Tangdu Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Tao Liu
- Department of Orthopedics, Tangdu Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China
- State Key Laboratory of Cancer Biology, Biotechnology Center, School of Pharmacy, The Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Xin Dong
- Department of Orthopedics, Tangdu Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Siguo Sun
- Department of Orthopedics, Tangdu Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Hongtao Zhang
- Department of Orthopedics, Tangdu Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Chunbao Yang
- Department of Orthopedics, 985 hospital of PLA, Taiyuan, Shanxi, China
| | - Xin Yin
- Department of Orthopedics, the fourth medical center of PLAGH, Beijing, China
| | - Bo Liao
- Department of Orthopedics, Tangdu Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Xiaoxiang Li
- Department of Orthopedics, Tangdu Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China
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Chiu YC, Yang SC, Kao YH, Tu YK. Percutaneous Sacroplasty for Symptomatic Sacral Pedicle Screw Loosening. Indian J Orthop 2023; 57:96-101. [PMID: 36660492 PMCID: PMC9789267 DOI: 10.1007/s43465-022-00773-7] [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: 06/20/2022] [Accepted: 09/07/2022] [Indexed: 11/25/2022]
Abstract
Background This study aimed to evaluate the efficacy of fluoroscopy-guided percutaneous sacroplasty in patients with sacral pedicle screws loosening after instrumented spinal fusion. Methods We retrospectively reviewed the medical records of 18 patients who underwent percutaneous sacroplasty to treat sacral pedicle screws loosening from January 2016 to December 2019. Imaging studies, visual analog scale (VAS), length of hospital stay, and complications were recorded. The clinical outcomes based on the Oswestry disability index (ODI) and the modified Brodsky's criteria (MBC) were also evaluated to determine the efficacy of percutaneous sacroplasty. Results All patients had undergone at least 1 year of follow-up in our institute (range, 12-24 months). The average VAS score was 5.6 (range, 4-7) before surgery and decreased to 1.7 (range, 1-3) at the final visit. All patients were discharged on the next day after surgery. No patients experienced complications, such as cement leakage, deep infection, or neurologic deterioration. All patients achieved good or excellent outcomes based on the MBC. The ODI scores improved from 51.8 preoperatively to 25.6 postoperatively. Conclusion Percutaneous sacroplasty was an effective treatment approach for relieving the patient's symptoms caused by sacral pedicle screws loosening and could be a valuable treatment alternative to extensive revision surgery. Level of clinical evidence IV.
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Affiliation(s)
- Yen-Chun Chiu
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, No. 1, E-Da Road, Kaohsiung City, 82445 Taiwan, ROC
| | - Shih-Chieh Yang
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, No. 1, E-Da Road, Kaohsiung City, 82445 Taiwan, ROC
| | - Yu-Hsien Kao
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, No. 1, E-Da Road, Kaohsiung City, 82445 Taiwan, ROC
| | - Yuan-Kun Tu
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, No. 1, E-Da Road, Kaohsiung City, 82445 Taiwan, ROC
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Kao FC, Hsu YC, Chen TS, Tu YK, Liu PH. Incidence and risk factors of vertebral body collapse after posterior instrumented spinal fusion in elderly patients: An observational study. Medicine (Baltimore) 2022; 101:e31604. [PMID: 36343049 PMCID: PMC9646654 DOI: 10.1097/md.0000000000031604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This study investigates the incidence and risk factors of new vertebral body collapse (VC) after posterior instrumented spinal fusion in patients older than 70 years. This retrospective study analyzed the data of elderly patients who underwent posterior instrumented spinal fusion in the thoracolumbar spine between January 2013 and December 2017. The 2 subsamples comprised of patients who had experienced vertebral compression fracture (VCF) before the index spinal surgery (group 1, n = 324) and those who had not (group 2, n = 1040). We recorded and analyzed their baseline characteristics, their underlying comorbidities, and the details of their current instrumented spinal fusion. The incidences of new VC and screw loosening were recorded. In groups 1 and 2, the incidences of new VC were 31.8% and 22.7%, respectively, and those of new VC with screw loosening were 25.6% and 33%, respectively. The risk factor was upper screw level at the thoracolumbar junction (hazard ratio [HR] = 2.181, 95% confidence interval [CI]: 1.135-4.190) with previous VCF. The risk factors were age ≥ 80 years (HR = 1.782, 95% CI: 1.132-2.805), instrumented levels > 4 (HR = 1.774, 95% CI: 1.292-2.437), and peptic ulcer (HR = 20.219, 95% CI: 2.262-180.731) without previous VCF. Clinicians should closely monitor new VC after posterior instrumented spinal fusion in elderly patients with previous VCF with upper screw level at the thoracolumbar junction and in patients without previous VCF aged ≥ 80 years, with instrumented levels > 4 and peptic ulcer.
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Affiliation(s)
- Feng-Chen Kao
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Orthopedics, E-Da Dachang Hospital, Kaohsiung, Taiwan
| | - Yao-Chun Hsu
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Gastroenterology, E-Da Hospital, Kaohsiung, Taiwan
| | - Tzu-Shan Chen
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan
- Department of Medical Imaging and Radiological Sciences, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- * Correspondence: Yuan-Kun Tu, Department of Orthopedics, E-Da Hospital/I-Shou University; No. 1, E-Da Rd., Yan-Chao District, Kaohsiung 824, Taiwan (e-mail: )
| | - Pao-Hsin Liu
- Department of Biomedical Engineering, College of Medicine, I-Shou University, Kaohsiung, Taiwan
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Chan AK, Wozny TA, Bisson EF, Pennicooke BH, Bydon M, Glassman SD, Foley KT, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, Alvi MA, Guan J, Haid RW, Mummaneni PV. Classifying Patients Operated for Spondylolisthesis: A K-Means Clustering Analysis of Clinical Presentation Phenotypes. Neurosurgery 2021; 89:1033-1041. [PMID: 34634113 DOI: 10.1093/neuros/nyab355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/16/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Trials of lumbar spondylolisthesis are difficult to compare because of the heterogeneity in the populations studied. OBJECTIVE To define patterns of clinical presentation. METHODS This is a study of the prospective Quality Outcomes Database spondylolisthesis registry, including patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis. Twenty-four-month patient-reported outcomes (PROs) were collected. A k-means clustering analysis-an unsupervised machine learning algorithm-was used to identify clinical presentation phenotypes. RESULTS Overall, 608 patients were identified, of which 507 (83.4%) had 24-mo follow-up. Clustering revealed 2 distinct cohorts. Cluster 1 (high disease burden) was younger, had higher body mass index (BMI) and American Society of Anesthesiologist (ASA) grades, and globally worse baseline PROs. Cluster 2 (intermediate disease burden) was older and had lower BMI and ASA grades, and intermediate baseline PROs. Baseline radiographic parameters were similar (P > .05). Both clusters improved clinically (P < .001 all 24-mo PROs). In multivariable adjusted analyses, mean 24-mo Oswestry Disability Index (ODI), Numeric Rating Scale Back Pain (NRS-BP), Numeric Rating Scale Leg Pain, and EuroQol-5D (EQ-5D) were markedly worse for the high-disease-burden cluster (adjusted-P < .001). However, the high-disease-burden cluster demonstrated greater 24-mo improvements for ODI, NRS-BP, and EQ-5D (adjusted-P < .05) and a higher proportion reaching ODI minimal clinically important difference (MCID) (adjusted-P = .001). High-disease-burden cluster had lower satisfaction (adjusted-P = .02). CONCLUSION We define 2 distinct phenotypes-those with high vs intermediate disease burden-operated for lumbar spondylolisthesis. Those with high disease burden were less satisfied, had a lower quality of life, and more disability, more back pain, and more leg pain than those with intermediate disease burden, but had greater magnitudes of improvement in disability, back pain, quality of life, and more often reached ODI MCID.
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Affiliation(s)
- Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Thomas A Wozny
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Brenton H Pennicooke
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kevin T Foley
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, Tennessee, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA.,Department of Orthopedic Surgery, Duke University, Durham, North Carolina, USA
| | - Eric A Potts
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina, USA
| | - John J Knightly
- Atlantic Neurosurgical Specialists, Morristown, New Jersey, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York, USA
| | | | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina, USA
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York, USA
| | | | - Mohammed A Alvi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jian Guan
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Regis W Haid
- Atlanta Brain and Spine Care, Atlanta, Georgia, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Koppula BR, Morton KA, Al-Dulaimi R, Fine GC, Damme NM, Brown RKJ. SPECT/CT in the Evaluation of Suspected Skeletal Pathology. ACTA ACUST UNITED AC 2021; 7:581-605. [PMID: 34698290 PMCID: PMC8544734 DOI: 10.3390/tomography7040050] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/10/2021] [Accepted: 09/16/2021] [Indexed: 01/16/2023]
Abstract
Dedicated multi-slice single-photon emission computed tomography/computed tomography (SPECT/CT) cameras have become widely available and are becoming a mainstay of clinical practice. The integration of SPECT and CT allow for precise anatomic location of scintigraphic findings. Fusion imaging with SPECT/CT can improve both sensitivity and specificity by reducing equivocal interpretation in comparison to planar scintigraphy or SPECT alone. This review article addresses the technique, basic science principles, and applications of integrated SPECT/CT in the evaluation of musculoskeletal pathology.
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Vargas-Moreno A, Diaz-Orduz R, Berbeo-Calderón M. Venous anatomy of the lumbar region applied to anterior lumbar interbody fusion (ALIF): Proposal of a new classification. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 7:100078. [PMID: 35141643 PMCID: PMC8820002 DOI: 10.1016/j.xnsj.2021.100078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/28/2022]
Abstract
Background Anterior lumbar interbody fusion (ALIF) is a good alternative for the surgical treatment of lumbar degenerative disc disease. The primary vascular complications regarding this intervention involve the common iliac vein bifurcation complex (CIVC). Currently, no classification system allows defining which patients are more prone to these complications. We aimed to perform a retrospective study evaluating the anatomy of the common iliac CIVC at the L5-S1 disc proposing a novel classification system as it relates to the ALIF difficulty. Methods 91 consecutive patients who underwent ALIF at the L5-S1 level were included. We categorize the CIVC at the L5-S1 disc space into four types according to the veins position along the disc space. The patient records were reviewed for demographic information, surgical characteristics, and complications. The surgical difficulty was rated at the end of the procedure. Results 54% of the patients were women. The mean age was 52.5 ± 14.8 years. Mean surgical bleeding was 152 ml (range 20ml -3000 ml), and mean surgical time was 79 ± 13.3 minutes. Berbeo-Diaz-Vargas (BDV) classification type 4 was found in 43.9% of the patients. The surgical complexity was associated with the bleeding magnitude and surgical time spent (p<0.01), not being related to the corporal mass index or sacral slope. Bleeding magnitude, surgical time, and surgical complexity were significantly related to the BDV classification system (p<0.01). Weighted Cohen´s kappa index for the BDV scale was 0.89 (95% IC 0.822 – 0.974). Conclusions BDV scale is a reliable and reproducible tool for the classification of CIVC significantly related to a higher incidence of bleeding, prolonged operating time, and increased perceived difficulty by the surgeon.
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Affiliation(s)
- Alejandro Vargas-Moreno
- Corresponding author at: Neurosurgery Department, Hospital Universitario San Ignacio,Cra.7 #40- 62, Bogotá, Colombia.
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McEntire BJ, Maslin G, Bal BS. Two-year results of a double-blind multicenter randomized controlled non-inferiority trial of polyetheretherketone (PEEK) versus silicon nitride spinal fusion cages in patients with symptomatic degenerative lumbar disc disorders. JOURNAL OF SPINE SURGERY 2020; 6:523-540. [PMID: 33102889 DOI: 10.21037/jss-20-588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background During lumbar spinal fusion, spacer cages are implanted to provide vertebral stability, restore sagittal alignment, and maintain disc and foraminal height. Polyetheretherketone (PEEK) is commonly used by most spine surgeons. Silicon nitride (Si3N4) is a less well-known alternative although it was first used as a spacer in lumbar fusion over 30 years ago. The present study was designed to see if Si3N4 cages would perform similarly to PEEK in a randomized controlled trial. Methods A non-inferiority multicenter 100-patient study was designed where both the observer and patient were blinded. Single- or double-level transforaminal lumbar interbody fusion with pedicle screw fixation using an oblique PEEK or Si3N4 cage was performed. The primary non-inferiority outcome was the Roland-Morris Disability Questionnaire (RMDQ). Secondary measures included the Oswestry Disability Questionnaire, Visual Analogue Scales (VAS) for back and leg pain, SF-36 Physical and Mental Function indices, patient and surgeon Likert scores on perceived recovery, and X-ray and CT radiological evaluations for subsidence, segmental motion, and fusion. Follow-up evaluations occurred at 3, 6, 12, and 24 months. Results After exclusions for protocol violations and canceled surgeries, 92 patients were randomized (i.e., 48 for PEEK and 44 for Si3N4). There were no differences in baseline demographics, pre-operative disabilities, or pain scores between the groups. Both treatment arms showed significant improvements in disability, pain, and recovery scores. No significant differences were observed for subsidence, segmental motion, or fusion. For the primary outcome (i.e., RMDQ scores), the non-inferiority of Si3N4 compared to PEEK could not be established using the original protocol criteria. However, the comparison was undermined by larger than anticipated patient fallout coupled with higher than expected RMDQ score standard deviations. A post hoc analysis coupled with a more extensive review of the literature was conducted which resulted in the selection of a revised clinically justified non-inferiority margin; and using this method, the non-inferiority of Si3N4 was affirmed. Conclusions This study demonstrated that the use of either PEEK or Si3N4 cages is safe and effective for patients undergoing lumbar spine fusion for chronic degenerative disc disease.
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Affiliation(s)
| | - Greg Maslin
- Biomedical Statistical Consulting, Wynnewood, PA, USA
| | - B Sonny Bal
- SINTX Technologies, Inc., Salt Lake City, UT, USA
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Kakadiya DG, Gohil DK, Soni DY, Shakya DA. Clinical, radiological and functional results of transforaminal lumbar interbody fusion in degenerative spondylolisthesis. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2020; 2:100011. [PMID: 35141582 PMCID: PMC8819860 DOI: 10.1016/j.xnsj.2020.100011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/03/2020] [Accepted: 06/09/2020] [Indexed: 11/30/2022]
Abstract
Purpose To evaluate the clinical, functional and radiographic outcomes of transforaminal lumbar interbody fusion (TLIF) in degenerative low-grade spondylolisthesis. Materials and Methods A prospective observational study of 120 consecutive patients (M:F = 24:96) with spondylolisthesis operated with TLIF. Clinical and functional outcome was assessed on Visual analogue Scale (VAS) and Oswestry Disability Index(ODI). The radiological outcome was assessed on sagittal alignment at a specific level, radiologic bony fusion/non-union, intervertebral disc heights and percentage of a slip in relation to the endplate. Clinical and radiological data were collected and analysed. Results The mean age was 50.97 years. The average follow-up was 14.5 months (12 to 18 months). Mean preoperative ODI was 38.73 and postoperatively 21.30. Analysing the radiological fusion with clinical scores, poorer radiological fusion grades correlated with higher VAS scores for pain. 70% of patients achieved >50% reduction in pain and 60% achieved > 30% reduction in ODI. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and lumbar lordosis (LL) were significantly greater in spondylolisthesis. PI, PT, and SS did not change statistically from the baseline postoperatively but increased LL and Segmental LL (P < 0.001). The results of our study showed a close relation between satisfactory clinical outcome (90%) and solid fusion (80%). There was however a significant number of patients with instrument failure that was found in association with fusion failure. There were no intra-operative complications. Conclusion TLIF is an effective option to achieve circumferential fusion without severe complications. An increased pelvic incidence may be an important factor predisposing to progression in developmental spondylolisthesis. TLIF increases global and segmental LL and provides a satisfactory outcome in symptomatic low-grade degenerative spondylolisthesis.
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Luo PJ, Tang YC, Zhou TP, Guo HZ, Guo DQ, Mo GY, Ma YH, Liu PJ, Zhang SC, Liang D. Risk Factor Analysis of the Incidence of Subsequent Adjacent Vertebral Fracture After Lumbar Spinal Fusion Surgery with Instrumentation. World Neurosurg 2019; 135:e87-e93. [PMID: 31715415 DOI: 10.1016/j.wneu.2019.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/02/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aimed to evaluate the risk factors for adjacent vertebral compression fractures after lumbar spinal fusion with instrumentation. METHODS A total of 669 patients who received lumbar instrumented spinal fusion between January 2012 and December 2015 were divided into 2 groups according to whether the adjacent vertebral body was fractured. The covariates recorded were age, sex, bone mineral density, and the number of fixed segments. The anatomic variables were pelvic incidence angle (PI), preoperative lumbar lordosis angle (Pre-LL), postoperative lumbar lordosis angle (Post-LL), Pre-LL minus Post-LL (Loss of LL), postoperative pelvic tilt (Post-PT), postoperative sacral slope, Pre-PI-LL mismatch (Pre-PI minus Pre-LL), and Post-PI-LL mismatch (Post-PI minus Post-LL). A 1-way analysis of variance (ANOVA) was performed with the aforementioned parameters, and binary logistic regression analysis was used to determine the relative risk factors. RESULTS The 669 patients were followed-up for a mean of 2.7 ± 1.1 years (range, 2-4 years). Twenty-seven patients demonstrated fractures in the adjacent vertebral body after surgery. Analysis by 1-way ANOVA demonstrated that age, PI, Pre-LL, Post-LL, Loss of LL, Post-PI-LL mismatch, Post-PT, and osteoporosis were potential risk factors (all parameters, P < 0.001). Furthermore, binary logistic regression analysis showed that a large Loss of LL, osteoporosis, and old age were also risk factors for adjacent vertebral compression fractures. CONCLUSIONS A greater Loss of LL, osteoporosis, and advanced age may be risk factors for fractures in the adjacent vertebral body of the fixed segment after lumbar fusion fixation.
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Affiliation(s)
- Pei-Jie Luo
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Baiyun District, Guangdong, China; The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yong-Chao Tang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Teng-Peng Zhou
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Baiyun District, Guangdong, China; The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hui-Zhi Guo
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Baiyun District, Guangdong, China; The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dan-Qing Guo
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guo-Ye Mo
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Baiyun District, Guangdong, China; The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan-Huai Ma
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Baiyun District, Guangdong, China; The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Pan-Jie Liu
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Baiyun District, Guangdong, China; The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shun-Cong Zhang
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Baiyun District, Guangdong, China; The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - De Liang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Sabou S, Lagaras A, Verma R, Siddique I, Mohammad S. Comparative study of multilevel posterior interbody fusion plus anterior longitudinal ligament release versus classic multilevel posterior interbody fusion in the treatment of adult spinal deformities. J Neurosurg Spine 2019; 31:46-52. [PMID: 30952136 DOI: 10.3171/2019.1.spine18754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sagittal imbalance and loss of lumbar lordosis are the main drivers of functional disability in adult degenerative scoliosis. The main limitations of the classic posterior lumbar interbody fusion technique are increased risk of neurological injury and suboptimal correction of the segmental lordosis. Here, the authors describe the radiological results of a modified posterior lumbar interbody fusion and compare the results with a historical cohort of patients. METHODS Eighty-two consecutive patients underwent surgical treatment for degenerative scoliosis/kyphosis in a single tertiary referral center for complex spinal surgery. Fifty-five patients were treated using the classic multilevel posterior lumbar interbody fusion (MPLIF) technique and 27 were treated using the modified MPLIF technique to include a release of the anterior longitudinal ligament (ALL) and the annulus. A radiographic review of both series of patients was performed by two independent observers. Functional outcomes were obtained, and patients were registered in the European Spine Tango registry. RESULTS The mean L4-5 disc angle increased by 3.14° in the classic MPLIF group and by 12.83° in MPLIF plus ALL and annulus release group. The mean lumbar lordosis increased by 15.23° in the first group and by 25.17° in the second group. The L4-S1 lordosis increased on average by 4.92° in the classic MPLIF group and increased by a mean of 23.7° in the MPLIF plus ALL release group when both L4-5 and L5-S1 segments were addressed. There were significant improvements in the Core Outcome Measures Index and EQ-5D score in both groups (p < 0.001). There were no vascular or neurological injuries observed in either group. CONCLUSIONS The authors' preliminary results suggest that more correction can be achieved at the disc level using posterior-based ALL and annulus release in conjunction with posterior lumbar interbody fusion. They demonstrate that ALL and annulus release can be performed safely using a posterior-only approach with minimal risk of vascular injury. However, the authors recommend that this approach should only be used by surgeons with considerable experience in anterior and posterior spinal surgery.
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Chan AK, Bisson EF, Bydon M, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, Chotai S, DiGiorgio AM, Haid RW, Mummaneni PV. Laminectomy alone versus fusion for grade 1 lumbar spondylolisthesis in 426 patients from the prospective Quality Outcomes Database. J Neurosurg Spine 2019; 30:234-241. [PMID: 30544348 DOI: 10.3171/2018.8.spine17913] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe AANS launched the Quality Outcomes Database (QOD), a prospective longitudinal registry that includes demographic, clinical, and patient-reported outcome (PRO) data to measure the safety and quality of spine surgery. Registry data offer "real-world" insights into the utility of spinal fusion and decompression surgery for lumbar spondylolisthesis. Using the QOD, the authors compared the initial 12-month outcome data for patients undergoing fusion and those undergoing laminectomy alone for grade 1 degenerative lumbar spondylolisthesis.METHODSData from 12 top enrolling sites were analyzed and 426 patients undergoing elective single-level spine surgery for degenerative grade 1 lumbar spondylolisthesis were found. Baseline, 3-month, and 12-month follow-up data were collected and compared, including baseline clinical characteristics, readmission rates, reoperation rates, and PROs. The PROs included Oswestry Disability Index (ODI), back and leg pain numeric rating scale (NRS) scores, and EuroQol-5 Dimensions health survey (EQ-5D) results.RESULTSA total of 342 (80.3%) patients underwent fusion, with the remaining 84 (19.7%) undergoing decompression alone. The fusion cohort was younger (60.7 vs 69.9 years, p < 0.001), had a higher mean body mass index (31.0 vs 28.4, p < 0.001), and had a greater proportion of patients with back pain as a major component of their initial presentation (88.0% vs 60.7%, p < 0.001). There were no differences in 12-month reoperation rate (4.4% vs 6.0%, p = 0.93) and 3-month readmission rates (3.5% vs 1.2%, p = 0.45). At 12 months, both cohorts improved significantly with regard to ODI, NRS back and leg pain, and EQ-5D (p < 0.001, all comparisons). In adjusted analysis, fusion procedures were associated with superior 12-month ODI (β -4.79, 95% CI -9.28 to -0.31; p = 0.04).CONCLUSIONSSurgery for grade 1 lumbar spondylolisthesis-regardless of treatment strategy-was associated with significant improvements in disability, back and leg pain, and quality of life at 12 months. When adjusting for covariates, fusion surgery was associated with superior ODI at 12 months. Although fusion procedures were associated with a lower rate of reoperation, there was no statistically significant difference at 12 months. Further study must be undertaken to assess the durability of either surgical strategy in longer-term follow-up.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 2Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 3Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin T Foley
- 5Department of Neurological Surgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Eric A Potts
- 6Department of Neurological Surgery, Indiana University, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | | | - Mark E Shaffrey
- 7Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Domagoj Coric
- 8Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | | | - Paul Park
- 10Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Y Wang
- 11Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Anthony L Asher
- 8Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Michael S Virk
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Silky Chotai
- 14Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee; and
| | - Anthony M DiGiorgio
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Regis W Haid
- 15Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
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12
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Chan AK, Bisson EF, Bydon M, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, DiGiorgio AM, Haid RW, Mummaneni PV. Obese Patients Benefit, but do not Fare as Well as Nonobese Patients, Following Lumbar Spondylolisthesis Surgery: An Analysis of the Quality Outcomes Database. Neurosurgery 2018; 86:80-87. [DOI: 10.1093/neuros/nyy589] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/05/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Given recent differing findings following 2 randomized clinical trials on degenerative lumbar spondylolisthesis (DLS) surgery, there is a need to better define how subsets of patients fare following surgery.
OBJECTIVE
To investigate the impact of obesity on patient-reported outcomes (PROs) following DLS surgery.
METHODS
A total of 12 high-enrolling sites were queried, and we found 797 patients undergoing surgery for grade 1 DLS. For univariate comparisons, patients were stratified by BMI ≥ 30 kg/m2 (obese) and < 30 kg/m2 (nonobese). Baseline, 3-mo, and 12-mo follow-up parameters were collected. PROs included the North American Spine Society satisfaction questionnaire, numeric rating scale (NRS) back pain, NRS leg pain, Oswestry Disability Index (ODI), and EuroQoL-5D (EQ-5D) Questionnaire.
RESULTS
We identified 382 obese (47.9%) and 415 nonobese patients (52.1%). At baseline, obese patients had worse NRS back pain, NRS leg pain, ODI, and EQ-5D scores (P < .001, P = .01, P < .001, and P = .02, respectively). Both cohorts improved significantly for back and leg pain, ODI, and EQ-5D at 12 mo (P < .001). At 12 mo, similar proportions of obese and nonobese patients responded that surgery met their expectations (62.6% vs 67.4%, P = .24). In multivariate analyses, BMI was independently associated with worse NRS leg pain and EQ-5D at 12 mo (P = .01 and P < .01, respectively) despite adjusting for baseline differences.
CONCLUSION
Obesity is associated with inferior leg pain and quality of life—but similar back pain, disability, and satisfaction—12 mo postoperatively. However, obese patients achieve significant improvements in all PRO metrics at 12 mo.
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Affiliation(s)
- Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin T Foley
- Department of Neurological Surgery, University of Tennessee; Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Eric A Potts
- Department of Neurological Surgery, Indiana University; Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | | | - Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Domagoj Coric
- Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | | | - Paul Park
- Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miami, Florida
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Anthony L Asher
- Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Michael S Virk
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Regis W Haid
- Geisinger Health System Neurosciences Institute, Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California
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13
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Novel Procedure for Designing and 3D Printing a Customized Surgical Template for Arthrodesis Surgery on the Sacrum. Symmetry (Basel) 2018. [DOI: 10.3390/sym10080334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In this article, the authors propose a novel procedure for designing a customized 3D-printed surgical template to guide surgeons in inserting screws into the sacral zone during arthrodesis surgeries. The template is characterized by two cylindrical guides defined by means of trajectories identified, based on standard procedure, via an appropriate Computer-Aided-Design (CAD)-based procedure. The procedure is based on the definition of the insertion direction by means of anatomical landmarks that enable the screws to take advantage of the maximum available bone path. After 3D printing, the template adheres perfectly to the bone surface, showing univocal positioning by exploiting the foramina of the sacrum, great maneuverability due to the presence of an ergonomic handle, as well as a break system for the two independent guides. These features make the product innovative. Thanks to its small size and the easy anchoring, the surgeon can simply position the template on the insertion area and directly insert the screws, without alterations to standard surgical procedures. This has the effect of reducing the overall duration of the surgery and the patient’s exposure to X-rays, and increasing both the safety of the intervention and the quality of the results.
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14
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Kersten RFMR, Wu G, Pouran B, van der Veen AJ, Weinans HH, de Gast A, Öner FC, van Gaalen SM. Comparison of polyetheretherketone versus silicon nitride intervertebral spinal spacers in a caprine model. J Biomed Mater Res B Appl Biomater 2018; 107:688-699. [PMID: 30091515 DOI: 10.1002/jbm.b.34162] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 04/22/2018] [Accepted: 04/29/2018] [Indexed: 12/17/2022]
Abstract
Polyetheretherketone (PEEK) is commonly used as a spinal spacer for intervertebral fusion surgery. Unfortunately, PEEK is bioinert and does not effectively osseointegrate into living bone. In contrast, comparable spacers made of silicon nitride (Si3 N4 ) possess a surface nanostructure and chemistry that encourage appositional bone healing. This observational study was designed to compare the outcomes of these two biomaterials when implanted as spacers in an adult caprine model. Lumbar interbody fusion surgeries were performed at two adjacent levels in eight adult goats using implants of PEEK and Si3 N4 . At six-months after surgery, the operative and adjacent spinal segments were extracted and measured for bone fusion, bone volume, bone-implant contact (BIC) and soft-tissue implant contact (SIC) ratios, and biodynamic stability. The null hypothesis was that no differences in these parameters would be apparent between the two groups. Fusion was observed in seven of eight implants in each group with greater bone formation in the Si3 N4 group (52.6%) versus PEEK (27.9%; p = 0.2). There were no significant differences in BIC ratios between PEEK and Si3 N4 , and the biodynamic stability of the two groups was also comparable. The results suggest that Si3 N4 spacers are not inferior to PEEK and they may be more effective in promoting arthrodesis. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 00B: 000-000, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 688-699, 2019.
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Affiliation(s)
- Roel F M R Kersten
- Department of Orthopedic Surgery, Clinical Orthopedic Research Center midden-Nederland (CORCmN), Diakonessenhuis, Utrecht, The Netherlands.,Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gang Wu
- Department of Oral Implantology and Prosthetic Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit (VU), Amsterdam, The Netherlands
| | - Behdad Pouran
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
| | - Albert J van der Veen
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | - Harrie H Weinans
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
| | - Arthur de Gast
- Department of Orthopedic Surgery, Clinical Orthopedic Research Center midden-Nederland (CORCmN), Diakonessenhuis, Utrecht, The Netherlands
| | - F Cumhur Öner
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven M van Gaalen
- Department of Orthopedic Surgery, Clinical Orthopedic Research Center midden-Nederland (CORCmN), Diakonessenhuis, Utrecht, The Netherlands
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15
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Gnanasegaran G, Paycha F, Strobel K, van der Bruggen W, Kampen WU, Kuwert T, Van den Wyngaert T. Bone SPECT/CT in Postoperative Spine. Semin Nucl Med 2018; 48:410-424. [PMID: 30193648 DOI: 10.1053/j.semnuclmed.2018.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Back pain is a common problem and the diagnosis and treatment depend on the clinical presentation, yet overlap between pain syndromes is common. Imaging of patients with chronic back pain in both pre- and postoperative scenarios include radiological, radionuclide, and hybrid techniques. In general, these techniques have their own advantages and limitations. The aim of surgery is to eliminate pathologic segmental motion and accompanying symptoms, especially pain. However, surgical procedures are not without complications and localizing the cause of the pain is often challenging. Radiobisphosphonate bone SPECT/CT is reported to be useful in evaluating benign orthopedic conditions and it often provides valuable information such as accurate localization and characterization of bone abnormalities. In this review, routinely used spinal surgical techniques and procedures are discussed, as well as the acute and delayed complications related to spinal surgery, the role of conventional imaging, and the potential uses of radionuclide bone SPECT/CT to diagnose pseudoarthrosis, cage subsidence, loosening and misalignment, hardware failure, and postoperative infection.
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Affiliation(s)
- Gopinath Gnanasegaran
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, UK..
| | - Frédéric Paycha
- Department of Nuclear Medicine, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Klaus Strobel
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Wouter van der Bruggen
- Department of Radiology and Nuclear Medicine, Slingeland Hospital, Doetinchem, The Netherlands
| | | | - Torsten Kuwert
- Clinic of Nuclear Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium.; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
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16
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Drakhshandeh D, Miller JA, Fabiano AJ. Instrumented Spinal Stabilization without Fusion for Spinal Metastatic Disease. World Neurosurg 2018; 111:e403-e409. [PMID: 29275052 PMCID: PMC6022282 DOI: 10.1016/j.wneu.2017.12.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Spinal stabilization surgery is an integral part of the treatment of spinal metastatic disease. Bony fusion is the hallmark of spinal stabilization in non-oncology patients. Spinal oncology patients are unlikely to achieve bony fusion because of their overall prognosis and concurrent therapies. Stabilization surgery without fusion may be a reasonable approach for these patients. Literature evaluating the effectiveness of this approach is limited. The object of this study was to investigate the rate of instrumentation failure in patients undergoing posterior spinal instrumented stabilization without fusion for spinal metastatic disease. METHODS Data from consecutive cases of spinal surgery at our institution during an 81-month period were reviewed. Demographics, clinical notes, and computed tomography findings were recorded and used to evaluate instrumentation failures. Patients who underwent separation surgery that included laminectomy and posterior spinal instrumentation without fusion for spinal metastatic disease and had follow-up computed tomography scans >3 months postoperatively were selected for the study. RESULTS Twenty-seven patients were included in the study. Mean age was 64.85 ± 6.53 years. Nine patients were women. A mean of 1.61 ± 0.96 laminectomy levels was performed. A mean of 8.26 ± 1.48 screws was inserted. The mean postoperative discharge date was 5.07 ± 1.47 days. Mean follow-up duration was 12.17 ± 11.73 months. None of the patients had a change in instrumentation position, pedicle screw pullout, change in spinal alignment, or progressive deformity. No patient required reoperation or instrumentation revision or replacement. CONCLUSIONS Our experience suggests that instrumented spinal stabilization without fusion is an acceptable approach for patients with spinal metastatic disease.
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Affiliation(s)
- Dori Drakhshandeh
- Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - James A Miller
- Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, USA; Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Andrew J Fabiano
- Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, USA; Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.
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17
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Pimenta L, Marchi L, Oliveira L, Nogueira-Neto J, Coutinho E, Amaral R. Elastomeric Lumbar Total Disc Replacement: Clinical and Radiological Results With Minimum 84 Months Follow-Up. Int J Spine Surg 2018; 12:49-57. [PMID: 30280083 PMCID: PMC6162034 DOI: 10.14444/5009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Total lumbar disc replacement (TDR) devices have been designed to maintain motion, but both biomechanical and clinical data have indicated that a more controlled motion and additional load absorption in TDR would be beneficial. This work analyzed long-term results of an elastomeric disc (Physio-L) for degenerative lumbar conditions. MATERIAL AND METHODS This was a prospective, noncomparative, single-center clinical and radiological study. A total of 15 patients with predominant low back pain due degenerative disc disease received anterior total disc replacement with a Physio-L disc. Clinical outcomes were assessed both with a visual analog scale for pain and Oswestry Disability Index questionnaires. Radiological outcomes included implant failure, range of motion (ROM), facet degeneration, and adjacent level disease. Complication and reoperation rates were also recorded. The cases were assessed with a minimum follow-up of 84 months. RESULTS A total of 15 patients were enrolled (20 TDRs)-10 single-level cases (L5S1) and 5 two-level cases (L4L5/L5S1). After 84 months, clinical outcomes scores still demonstrated significant improvement compared with baseline (P < .001). Mean visual analog scale scores dropped from 7.1 to 2.9, and the Oswestry Disability Index improved from 50 to 16. No disc has experienced migration or breakage. The average range of motion value went from a baseline of 12.0° to 13.3° at 12 months, and at the final follow-up it decreased to 9.9°. Regarding the double-level cases, 3 of 5 (60%) had adverse events; just 1 single-level (10%) had adverse events. At final follow-up, radiological signs of facet degeneration were present in 7 of 15 patients (47%) but with only 1 of 15 (6.7%) symptomatic. Two patients (13%) required surgery at the adjacent level. At the 84-month follow-up, 16 of 18 prostheses (89%) were still active (2 revised to fusion and 2 were lost to follow-up). CONCLUSION The long-term follow-up data shows satisfactory clinical results for the use of Physio-L elastomeric TDR in the treatment of degenerative disc disease. Studies with bigger cohorts are needed to replicate results and add new information regarding other details.
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Affiliation(s)
- Luiz Pimenta
- Instituto de Patologia da Coluna, São Paulo, Brazil
- University of California San Diego, San Diego, California
| | - Luis Marchi
- Instituto de Patologia da Coluna, São Paulo, Brazil
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18
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Abstract
Interbody fusion cages are routinely implanted during spinal fusion procedures to facilitate arthrodesis of a degenerated or unstable vertebral segment. Current cages are most commonly made from polyether-ether-ketone (PEEK) due to its favorable mechanical properties and imaging characteristics. However, the smooth surface of current PEEK cages may limit implant osseointegration and may inhibit successful fusion. We present the development and clinical application of the first commercially available porous PEEK fusion cage (COHERE®, Vertera, Inc., Atlanta, GA) that aims to enhance PEEK osseointegration and spinal fusion outcomes. The porous PEEK structure is extruded directly from the underlying solid and mimics the structural and mechanical properties of trabecular bone to support bone ingrowth and implant fixation. Biomechanical testing of the COHERE® device has demonstrated greater expulsion resistance versus smooth PEEK cages with ridges and greater adhesion strength of porous PEEK versus plasma-sprayed titanium coated PEEK surfaces. In vitro experiments have shown favorable cell attachment to porous PEEK and greater proliferation and mineralization of cell cultures grown on porous PEEK versus smooth PEEK and smooth titanium surfaces, suggesting that the porous structure enhances bone formation at the cellular level. At the implant level, preclinical animal studies have found comparable bone ingrowth into porous PEEK as those previously reported for porous titanium, leading to twice the fixation strength of smooth PEEK implants. Finally, two clinical case studies are presented demonstrating the effectiveness of the COHERE® device in cervical spinal fusion.
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19
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Kerolus M, Turel MK, Tan L, Deutsch H. Stand-alone anterior lumbar interbody fusion: indications, techniques, surgical outcomes and complications. Expert Rev Med Devices 2016; 13:1127-1136. [PMID: 27792409 DOI: 10.1080/17434440.2016.1254039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Anterior lumbar interbody fusion (ALIF) is a well-established technique to achieve lumbar spine fusion with various indications including degenerative disk disease, spondylolisthesis, recurrent disk herniation, adjacent level disease, pseudoarthrosis, as well as being used as part of the overall strategy to restore sagittal balance. ALIF can be an extremely useful tool in any spine surgeon's armamentarium. However, like any surgical procedure, proper patient selection is key to success. A solid understanding of the biomechanics, careful surgical planning, along with clear knowledge of the advantages and disadvantages of stand-alone ALIF will ensure optimal clinical outcome. Stand-alone ALIF may be a suitable surgical option in carefully selected patients that can provide good clinical results and adequate fusion rates without the need for posterior instrumentation. Areas covered: A brief overview of the indications, techniques, biomechanics, surgical outcome and complications of stand-alone ALIF is provided in this article with a review of the pertinent literature. Expert commentary: In this review we discuss the clinical evidence of using a stand-alone ALIF compared to other fusion techniques of the lumbar spine. The development of interbody cages with integrated screws has increased the arthrodesis rate and improved clinical outcomes while decreasing morbidity and operative time.
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Affiliation(s)
- Mena Kerolus
- a Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
| | - Mazda K Turel
- a Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
| | - Lee Tan
- a Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
| | - Harel Deutsch
- a Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
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20
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Heparin-Based Polyelectrolyte Complex Enhances the Therapeutic Efficacy of Bone Morphogenetic Protein-2 for Posterolateral Fusion in a Large Animal Model. Spine (Phila Pa 1976) 2016; 41:1199-1207. [PMID: 26953670 DOI: 10.1097/brs.0000000000001543] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The study was based on porcine posterolateral fusion model. OBJECTIVE The study aims to prove that polyelectrolyte complex (PEC) carrier could enhance the efficacy and safety profile of bone morphogenetic protein-2 (BMP-2). SUMMARY OF BACKGROUND DATA BMP-2 was introduced to enhance posterolateral fusion; however, extremely high doses of this molecule were often used which contributed to various complications. This was attributed to the poor modulation capacity of the traditional carrier absorbable collagen sponge (ACS). To reduce the efficacious dose of BMP-2 and its associated complications, heparin-based PEC was introduced. METHODS L3/L4 and L5/L6 two-level posterolateral spinal fusion was performed on six pigs using two doses of BMP-2 with PEC or ACS: (1) PEC with 800 μg BMP-2 (n = 2); (2) PEC with 400 μg BMP-2 (n = 2); (3) ACS with 800 μg BMP-2 (n = 1); (4) ACS with 400 μg of BMP-2 (n = 1). The construct was loaded into a rigid bioabsorbable cage for implantation. Fusion rate and quality were assessed 2 months after operation. RESULTS Manual palpation revealed successful fusion in all groups. Radiological fusion score of PEC groups was, however, higher than that of ACS groups. The newly formed bone in PEC groups appeared to be well integrated into the native bone with no overgrowth into the adjacent structure. On comparison, in ACS groups, large gaps were observed between the newly formed bone and the fusion bed with heterotopic ossification into the psoas muscle. The microarchitecture on the newly formed bone in PEC groups was superior to that in ACS groups, which was demonstrated by higher three-dimensional parameters. CONCLUSION The present study demonstrated that BMP-2 delivered by PEC induced successful posterolateral fusion in porcine model. The efficacy of BMP-2 was improved and bony overgrowth was reduced. The microarchitecture of BMP-2-induced bone tissue was also enhanced by PEC. LEVEL OF EVIDENCE N/A.
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21
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MacEwan MR, Talcott MR, Moran DW, Leuthardt EC. Novel spinal instrumentation to enhance osteogenesis and fusion: a preliminary study. J Neurosurg Spine 2016; 25:318-27. [PMID: 27081709 DOI: 10.3171/2016.1.spine13979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Instrumented spinal fusion continues to exhibit high failure rates in patients undergoing multilevel lumbar fusion or pseudarthrosis revision; with Grade II or higher spondylolisthesis; or in those possessing risk factors such as obesity, tobacco use, or metabolic disorders. Direct current (DC) electrical stimulation of bone growth represents a unique surgical adjunct in vertebral fusion procedures, yet existing spinal fusion stimulators are not optimized to enhance interbody fusion. To develop an advanced method of applying DC electrical stimulation to promote interbody fusion, a novel osteogenic spinal system capable of routing DC through rigid instrumentation and into the vertebral bodies was fabricated. A pilot study was designed to assess the feasibility of osteogenic instrumentation and compare the ability of osteogenic instrumentation to promote successful interbody fusion in vivo to standard spinal instrumentation with autograft. METHODS Instrumented, single-level, posterior lumbar interbody fusion (PLIF) with autologous graft was performed at L4-5 in adult Toggenburg/Alpine goats, using both osteogenic spinal instrumentation (plus electrical stimulation) and standard spinal instrumentation (no electrical stimulation). At terminal time points (3 months, 6 months), animals were killed and lumbar spines were explanted for radiographic analysis using a SOMATOM Dual Source Definition CT Scanner and high-resolution Microcat II CT Scanner. Trabecular continuity, radiodensity within the fusion mass, and regional bone formation were examined to determine successful spinal fusion. RESULTS Quantitative analysis of average bone density in pedicle screw beds confirmed that electroactive pedicle screws used in the osteogenic spinal system focally enhanced bone density in instrumented vertebral bodies. Qualitative and quantitative analysis of high-resolution CT scans of explanted lumbar spines further demonstrated that the osteogenic spinal system induced solid bony fusion across the L4-5 disc space as early as 6 weeks postoperatively. In comparison, inactive spinal instrumentation with autograft was unable to promote successful interbody fusion by 6 months postoperatively. CONCLUSIONS Results of this study demonstrate that novel osteogenic spinal instrumentation supports interbody fusion through the focal delivery of DC electrical stimulation. With further technical development and scientific/clinical validation, osteogenic spinal instrumentation may offer a unique alternative to biological scaffolds and pharmaceutical adjuncts used in spinal fusion procedures.
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Affiliation(s)
- Matthew R MacEwan
- Department of Biomedical Engineering, and.,Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Eric C Leuthardt
- Department of Biomedical Engineering, and.,Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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Chiu YC, Tsai TT, Yang SC, Chen HS, Kao YH, Tu YK. Impact of Instrumented Spinal Fusion on the Development of Vertebral Compression Fracture. Medicine (Baltimore) 2016; 95:e3455. [PMID: 27124040 PMCID: PMC4998703 DOI: 10.1097/md.0000000000003455] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Instrumented spinal fusion has become one of the most common surgeries for patients with various spinal disorders. Only few studies have reported subsequent vertebral compression fractures (VCFs) after instrumented spinal fusion. The purpose of this study was to evaluate the risk of new VCFs in patients undergoing instrumented spinal fusion.We obtained claims data from the National Health Insurance Research Database of Taiwan and retrospectively reviewed 6949 patients with instrumented spinal fusion as the spinal fusion cohort. Control subjects were individually matched at a ratio of 10:1 with those of the spinal fusion cohort according to age, sex, and the index day. Comorbidities were classified as those existing before the index day, and these included diabetes mellitus, hypertension, osteoporosis, and cerebrovascular accident. The end of the follow-up period for the analyses was marked on the day new VCFs developed, enrolment in the National Health Insurance was terminated, on the day of death, or until the end of 2012. We used the Cox proportion hazards model to analyze the hazard ratio (HR) for developing new VCFs.Patients with instrumented spinal fusion were significantly more likely to develop new VCFs (1.87% vs .25%, HR: 8.56; P < 0.001). Female, elderly, and osteoporotic patients had a high incidence of new VCFs after spinal fusion. The HR for developing new VCFs after instrumented spinal fusion was higher in patients younger than 65 years than in those 65 years or older (HR: 10.61 vs 8.09). Male patients with instrumented spinal fusion also had a higher HR of developing new VCFs than female patients (men, HR: 26.42; women, HR: 7.53).In our retrospective cohort study, patients who had undergone instrumented spinal fusion surgery exhibited an increased risk of developing new VCFs. Particularly, the HR increased in young (age <65 years) and male patients.
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Affiliation(s)
- Yen-Chun Chiu
- From the Department of Orthopedic Surgery, E-Da Hospital/I-Shou University (Y-CC, S-CY, H-SC, Y-HK, Y-KT), Kaohsiung, Taiwan, R.O.C.; and Department of Orthopedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital/Chang Gung University (T-TT), Taoyuan, Taiwan, R.O.C
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Li YC, Yang SC, Chen HS, Kao YH, Tu YK. Impact of lumbar instrumented circumferential fusion on the development of adjacent vertebral compression fracture. Bone Joint J 2016; 97-B:1411-6. [PMID: 26430018 DOI: 10.1302/0301-620x.97b10.34927] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
We evaluated the impact of lumbar instrumented circumferential fusion on the development of adjacent level vertebral compression fractures (VCFs). Instrumented posterior lumbar interbody fusion (PLIF) has become a popular procedure for degenerative lumbar spine disease. The immediate rigidity produced by PLIF may cause more stress and lead to greater risk of adjacent VCFs. However, few studies have investigated the relationship between PLIF and the development of subsequent adjacent level VCFs. Between January 2005 and December 2009, a total of 1936 patients were enrolled. Of these 224 patients had a new VCF and the incidence was statistically analysed with other covariants. In total 150 (11.1%) of 1348 patients developed new VCFs with PLIF, with 108 (72%) cases at adjacent segment. Of 588 patients, 74 (12.5%) developed new subsequent VCFs with conventional posterolateral fusion (PLF), with 37 (50%) patients at an adjacent level. Short-segment fusion, female and age older than 65 years also increased the development of new adjacent VCFs in patients undergoing PLIF. In the osteoporotic patient, more rigid fusion and a higher stress gradient after PLIF will cause a higher adjacent VCF rate.
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Affiliation(s)
- Y-C Li
- E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
| | - S-C Yang
- E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
| | - H-S Chen
- E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
| | - Y-H Kao
- E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
| | - Y-K Tu
- E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
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Sabou S, Tseng THJ, Stephenson J, Siddique I, Verma R, Mohammad S. Correction of sagittal plane deformity and predictive factors for a favourable radiological outcome following multilevel posterior lumbar interbody fusion for mild degenerative scoliosis. 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; 25:2520-6. [PMID: 26626083 DOI: 10.1007/s00586-015-4338-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 12/26/2022]
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Shi Z, Gu T, Xin H, Wu J, Xu C, Zhang C, He Q, Ruan D. Intervention of rAAV-hTERT-Transducted Nucleus Pulposus Cells in Early Stage of Intervertebral Disc Degeneration: A Study in Canine Model. Tissue Eng Part A 2015; 21:2186-94. [PMID: 25953361 DOI: 10.1089/ten.tea.2014.0408] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To investigate the efficacy of recombinant adeno-associated virus (rAAV)-human telomerase reverse transcriptase (hTERT)-transducted nucleus pulposus cells (NPCs) in disc degeneration process in a canine disc degeneration model. METHODS The intervertebral disc degeneration of lumbar (L) 1-2, L3-4, and L5-6, from 12 female mongrels was prepared with the 20-gauge biopsy gun. Four weeks after animal model preparation, intervention experiment with rAAV-hTERT-transducted NPCs was conducted: group A, L1-2, serum-free medium with rAAV-hTERT modified NPCs; group B, L3-4, serum-free medium with NPCs; group C, L5-6, serum-free medium alone. Canines underwent digital radiography and magnetic resonance imaging 1 day before intervention, and 4, 8, and 12 weeks after intervention to evaluate the change of disc height and hydration status of interventional intervertebral discs. Twelve weeks after intervention, histological, biomechanical, and biochemical studies were carried out. RESULTS The rAAV-hTERT-transducted NPCs were constructed successfully. The mRNA level of hTERT from rAAV-hTERT-transfected NPCs increased obviously. There was no significant change of disc height index observed between groups and within groups. The relative grayscale index (RGI) was maintained 8 weeks after the intervention in group A, whereas in group B and group C, the RGI decreased significantly (p<0.05). No significant differences of the angle of lateral bending and extension-flexion bending were observed in group A compared with other groups (p>0.05). The morphology of disc structure was preserved in group A. In group B, the structure of inner annulus was broken down and the jelly-like nucleus pulposus (NP) tissue transmitted into the fibrocartilaginous tissue. In group C, the jelly-like NP tissue was completely replaced by fibrocartilaginous tissue. In the NP, the content of proteoglycan (PG) and collagen II was higher in group A than in group C (p<0.05). The content of PG was 13, 8.9, and 15.6 times higher than the content of collagen II in group A, group B, and group C, respectively. CONCLUSIONS In 12 weeks of observation, rAAV-hTERT-transducted NPCs could delay the degeneration process in the canine model which was superior than the capacity of NPCs in preserving structure integrity, content of extracellular matrix, and mechanical stability.
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Affiliation(s)
- Zhiyuan Shi
- 1 Department of Orthopedic Surgery, Navy General Hospital , Beijing, People's Republic of China .,2 Department of Burn and Plastic Surgery, Navy General Hospital , Beijing, People's Republic of China
| | - Tao Gu
- 1 Department of Orthopedic Surgery, Navy General Hospital , Beijing, People's Republic of China
| | - Hongkui Xin
- 1 Department of Orthopedic Surgery, Navy General Hospital , Beijing, People's Republic of China
| | - Jianhong Wu
- 1 Department of Orthopedic Surgery, Navy General Hospital , Beijing, People's Republic of China
| | - Cheng Xu
- 1 Department of Orthopedic Surgery, Navy General Hospital , Beijing, People's Republic of China
| | - Chao Zhang
- 1 Department of Orthopedic Surgery, Navy General Hospital , Beijing, People's Republic of China
| | - Qing He
- 1 Department of Orthopedic Surgery, Navy General Hospital , Beijing, People's Republic of China
| | - Dike Ruan
- 1 Department of Orthopedic Surgery, Navy General Hospital , Beijing, People's Republic of China
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Jacob C, Annoni E, Haas JS, Braun S, Winking M, Franke J. Burden of disease of reoperations in instrumental spinal surgeries in Germany. 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; 25:807-13. [PMID: 26118335 DOI: 10.1007/s00586-015-4073-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 06/13/2015] [Accepted: 06/14/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To estimate the incidence of instrumental spinal surgeries (ISS) and consecutive reoperations and to calculate the related resource utilization and costs. METHODS ISS and subsequent reoperations were identified retrospectively using surgery codes in claims data. The study period included January 01, 2009 to December 31, 2011. The reoperation rate was calculated for 1 year after the primary ISS. Resource utilization and costs were analyzed by group comparison. RESULTS A total of 3316 incident ISS patients were identified in 2010 with an annual reoperation rate of 9.98% (95% CI 8.98-11.02%). Mean costs per patient were €11,331 per ISS and €11,370 per reoperation, with €8432 directly attributed to the reoperation and €2938 to additional resources. CONCLUSIONS Costs of ISS and subsequent reoperations have a significant impact on health insurances budgets. The annual cost of reoperations exceeds the direct cost of the primary surgery driven by the need for further inpatient and outpatient care.
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Affiliation(s)
| | - Elena Annoni
- Medtronic International Trading Sàrl, Route de Molliau 31, 1131, Tolochenaz, Switzerland
| | | | | | - Michael Winking
- Klinikum Osnabrück GmbH, Am Finkenhügel 3, 49076, Osnabrück, Germany
| | - Jörg Franke
- Klinikum Dortmund, Beurhausstraße 40, 44137, Dortmund, Germany
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Bingqian C, Feng X, Xiaowen S, Feng Z, Xiaowen F, Yufeng Q, Qirong D. Modified posterior lumbar interbody fusion using a single cage with unilateral pedicle screws: a retrospective clinical study. J Orthop Surg Res 2015; 10:98. [PMID: 26122941 PMCID: PMC4486715 DOI: 10.1186/s13018-015-0243-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 06/22/2015] [Indexed: 11/17/2022] Open
Abstract
Background The traditional posterior lumbar interbody fusion (PLIF) technique usually involves implantation of two cages through a bilateral approach and bilateral laminectomy, which requires bilateral transpedicle screw fixation. The procedure itself has several negative impacts. Therefore, a modified PLIF procedure that includes insertion of a unilateral cage through the symptomatic side with supplementary unilateral pedicle screws has been conducted. Materials and methods Thirty-one patients with unilateral radiculopathy who were diagnosed with spinal stenosis along with degenerative disc disease and a herniated intervertebral disc with lumbar instability underwent a unilateral PLIF using a single cage and unilateral pedicle screws. The postoperative clinical evaluation was based on the visual analogue scale (VAS) and the Oswestry Disability Index (ODI) for back pain and leg pain at multiple time points following the surgery. Radiological assessments were performed with lateral plain radiographs taken preoperation, immediately postoperation, 1, 2, 3 and 6 months postoperation and at the most recent follow-up. Results The patients all underwent a single-level fusion, and the mean duration for the surgeries was 94 min. The mean haemorrhage volume was 250 ml, and no blood transfusion was required for any of the cases. Twelve months postoperatively, all patients had achieved an Excellent or Good outcome (Excellent in 28 patients and Good in 3). The mean pain score was 6.8 prior to surgery and decreased to 2.3 at the 3-month postoperative examination. No significant complications or neurological deterioration occurred. None of the 31 patients appeared to have any fusion failure. No broken screw, screw loosening, significant cage migration or subsidence was observed in any of the cases. A mean increase in the intervertebral disc height of 3.14 mm from the preoperative measurement to the most recent follow-up examination was determined to be statistically significant (p = 0.05). Conclusions Conducting PLIF using the diagonal insertion of a single cage with supplemental unilateral transpedicular screw instrumentation enables sufficient decompression and solid interbody fusion to be achieved with minimal invasion of the posterior spinal elements. This technique is a more clinically secure, straightforward and cost-effective way to perform PLIF.
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Affiliation(s)
- Chen Bingqian
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China. .,Department of Orthopaedics, Changshu NO.1 Peoples' Hospital Affiliated with Soochow University, 1# Shuyuan Road, Changshu, Jiangsu, 215500, China.
| | - Xue Feng
- Department of Orthopaedics, Changshu NO.1 Peoples' Hospital Affiliated with Soochow University, 1# Shuyuan Road, Changshu, Jiangsu, 215500, China.
| | - Shen Xiaowen
- Department of Orthopaedics, Changshu NO.1 Peoples' Hospital Affiliated with Soochow University, 1# Shuyuan Road, Changshu, Jiangsu, 215500, China.
| | - Zhang Feng
- Department of Orthopaedics, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China.
| | - Fang Xiaowen
- Department of Orthopaedics, Changshu NO.1 Peoples' Hospital Affiliated with Soochow University, 1# Shuyuan Road, Changshu, Jiangsu, 215500, China.
| | - Qian Yufeng
- Department of Orthopaedics, Changshu NO.1 Peoples' Hospital Affiliated with Soochow University, 1# Shuyuan Road, Changshu, Jiangsu, 215500, China.
| | - Dong Qirong
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Marfia G, Campanella R, Navone SE, Zucca I, Scotti A, Figini M, Di Vito C, Alessandri G, Riboni L, Parati E. Potential use of human adipose mesenchymal stromal cells for intervertebral disc regeneration: a preliminary study on biglycan-deficient murine model of chronic disc degeneration. Arthritis Res Ther 2014; 16:457. [PMID: 25293819 PMCID: PMC4223513 DOI: 10.1186/s13075-014-0457-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 09/16/2014] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Biglycan is an important proteoglycan of the extracellular matrix of intervertebral disc (IVD), and its decrease with aging has been correlated with IVD degeneration. Biglycan deficient (Bgn-/0) mice lack this protein and undergo spontaneous IVD degeneration with aging, thus representing a valuable in vivo model for preliminary studies on therapies for human progressive IVD degeneration. The purpose of the present study was to assess the possible beneficial effects of adipose-derived stromal cells (ADSCs) implants in the Bgn-/0 mouse model. METHODS To evaluate ADSC implant efficacy, Bgn-/0 mice were intradiscally (L1-L2) injected with 8x104 ADSCs at 16 months old, when mice exhibit severe and complete IVD degeneration, evident on both 7Tesla Magnetic Resonance Imaging (7TMRI) and histology. Placebo and ADSCs treated Bgn-/0 mice were assessed by 7TMRI analysis up to 12 weeks post-transplantation. Mice were then sacrificed and implanted discs were analyzed by histology and immunohistochemistry for the presence of human cells and for the expression of biglycan and aggrecan in the IVD area. RESULTS After in vivo treatment, 7TMRI revealed evident increase in signal intensity within the discs of mice that received ADSCs, while placebo treatment did not show any variation. Ultrastructural analyses demonstrated that human ADSC survival occurred in the injected discs up to 12 weeks after implant. These cells acquired a positive expression for biglycan, and this proteoglycan was specifically localized in human cells. Moreover, ADSC treatment resulted in a significant increase of aggrecan tissue levels. CONCLUSION Overall, this work demonstrates that ADSC implant into degenerated disc of Bgn-/0 mice ameliorates disc damage, promotes new expression of biglycan and increased levels of aggrecan. This suggests a potential benefit of ADSC implant in the treatment of chronic degenerative disc disease and prompts further studies in this field.
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Comparative observational study of surgical outcomes of lumbar foraminal stenosis using minimally invasive microsurgical extraforaminal decompression alone versus posterior lumbar interbody fusion: a prospective cohort study. 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; 24:388-95. [DOI: 10.1007/s00586-014-3592-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 09/19/2014] [Accepted: 09/20/2014] [Indexed: 10/24/2022]
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Smuck M, Levin J, Zemper E, Ali A, Kennedy DJ. A quantitative study of intervertebral disc morphologic changes following plasma-mediated percutaneous discectomy. PAIN MEDICINE 2014; 15:1695-703. [PMID: 25186460 DOI: 10.1111/pme.12525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To quantitatively evaluate interval magnetic resonance imaging (MRI) changes in disc morphology following plasma-mediated percutaneous discectomy. DESIGN/SETTING A retrospective comparison of pretreatment and posttreatment MRIs at a single university spine clinic. SUBJECTS From a group of 60 consecutively treated patients, 15 met the study inclusion and exclusion criteria. All had either failed treatment or had other clinical reasons for a posttreatment MRI. METHODS Two independent physicians electronically measured disc protrusion size and disc height at the treatment discs and adjacent discs on pre- and posttreatment MRI scans. Additionally, images were compared for gross anatomic changes including disc degeneration by Pfirrman classification, new disc herniations, high intensity zone (HIZ), vertebral endplate changes, post-contrast enhancement, and changes in segmental alignment. Pearson r correlation was used to determine interobserver reliability between the two physicians' MRI measurements. Paired t-tests were calculated for comparisons of pre- and posttreatment MRI measurements, and an ANOVA was performed for comparison of pre- to posttreatment changes in disc height measurements at treatment levels relative to adjacent levels. RESULTS Correlation was high for measurement of disc height change (r = 0.89; P < 0.0001) and good for anteroposterior protrusion size change (r = 0.51; P = 0.0512). Disc height at treated discs demonstrated a small but statistically significant mean interval reduction of 0.48 mm (P = 0.0018). This remained significant when compared with the adjacent control discs (P < 0.0001). Pretreatment mean disc protrusion size (4.74 mm; range 3.75-6.55 mm) did not differ significantly (P = 0.1145) from posttreatment protrusion size (4.42 mm; range 2.55-7.95 mm). Gross anatomic changes at treatment levels included reduced disc protrusion size (N = 6), enlarged protrusion (N = 3), resolution of HIZ (N = 3), and improvement in endplate signal changes (N = 1). Also, 11/15 posttreatment MRIs included post-contrast images that showed epidural fibrosis (N = 1), rim enhancement (N = 2), and enhancement of the posterior annulus (N = 4). CONCLUSIONS Based on MRI examinations, subtle anatomic changes may occur following plasma-mediated percutaneous discectomy. Further study is required to determine the clinical relevance of these changes.
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Affiliation(s)
- Matthew Smuck
- PM&R Section, Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
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Lee SK, Kim SW, Ju CI, Lee SM, Kim MH. Posterior lumbar interbody fusion using an unilateral cage: a prospective study of clinical outcome and stability. KOREAN JOURNAL OF SPINE 2014; 11:52-6. [PMID: 25110483 PMCID: PMC4124929 DOI: 10.14245/kjs.2014.11.2.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 05/30/2014] [Accepted: 06/02/2014] [Indexed: 11/23/2022]
Abstract
Objective The purpose of this study was to evaluate the clinical and radiological results of instrumented posterior lumbar interbody fusion (PLIF) using an unilateral cage. Methods Seventeen patients with unilateral radiculopathy who underwent bilateral percutaneous screw fixation with a single fusion cage inserted on the symptomatic side for treatment of focal degenerative lumbar spine disease were prospectively enrolled in this study. Their clinical results, radiological parameters, and related complications were assessed 10 days, 3 months, and 12 months postoperatively. Results There was no pseudarthrosis, instrumented fusion failure, significant cage subsidence, or retropulsion in any patient. The surgery restored the disc space height and maintained it as of 12 months postoperatively and did not exacerbate the lumbar lordotic and scoliotic angles. All patients had excellent or good outcomes according to the modified MacNab's criteria. The mean pain score according to the visual analogue scale was 7.5 preoperatively but had improved to 2.5 when reassessed 3 months postoperatively. The improvement was maintained as of 12 months postoperatively. Conclusion In cases of uncomplicated unilateral radiculopathy, PLIF using a single cage can be an effective and safe procedure with the advantage of preserving the posterior elements of the contralateral side. A shorter operative time and greater cost-effectiveness than for PLIF using bilateral cages can be expected.
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Affiliation(s)
- Seok Ki Lee
- Department of Thoracic Surgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Seok Won Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Chang Il Ju
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Sung Myung Lee
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Myung Hoon Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
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Eck JC, Sharan A, Resnick DK, Watters WC, Ghogawala Z, Dailey AT, Mummaneni PV, Groff MW, Wang JC, Choudhri TF, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: Discography for patient selection. J Neurosurg Spine 2014; 21:37-41. [DOI: 10.3171/2014.4.spine14269] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Identifying the etiology of pain for patients suffering from chronic low-back pain remains problematic. Noninvasive imaging modalities, used in isolation, have not consistently provided sufficient evidence to support performance of a lumbar fusion. Provocative testing has been used as an adjunct in this assessment, either alone or in combination with other modalities, to enhance the diagnostic capabilities when evaluating patients with low-back pain. There have been a limited number of studies investigating this topic since the publication of the original guidelines. Based primarily on retrospective studies, discography, as a stand-alone test, is not recommended to formulate treatment strategies for patients with low-back pain. A single randomized cohort study demonstrated an improved potential of discoblock over discography as a predictor of success following lumbar fusion. It is therefore recommended that discoblock be considered as a diagnostic option. There is a possibility, based on a matched cohort study, that an association exists between progression of degenerative disc disease and the performance of a provocative discogram. It is therefore recommended that patients be counseled regarding this potential development prior to undergoing discography.
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Affiliation(s)
- Jason C. Eck
- 1Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Alok Sharan
- 2Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel K. Resnick
- 3Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | | | - Zoher Ghogawala
- 5Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | - Andrew T. Dailey
- 6Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Praveen V. Mummaneni
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael W. Groff
- 8Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey C. Wang
- 9Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Tanvir F. Choudhri
- 10Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York; and
| | - Sanjay S. Dhall
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Effects of Transplantation of hTIMP-1-Expressing Bone Marrow Mesenchymal Stem Cells on the Extracellular Matrix of Degenerative Intervertebral Discs in an In Vivo Rabbit Model. Spine (Phila Pa 1976) 2014; 39:E669-E675. [PMID: 24718065 DOI: 10.1097/brs.0000000000000316] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, randomized, and controlled animal study. OBJECTIVE To observe extracellular matrix (ECM) changes in degenerative intervertebral disc (IVD) after transplantation of bone marrow mesenchymal stem cells (BMSCs) virally transfected with a construct expressing "human tissue inhibitor of metalloproteinase 1" (hTIMP-1), and to discuss the feasibility of using this approach to treat IVD degeneration. SUMMARY OF BACKGROUND DATA Intervertebral disc (IVD) degeneration is characterized by decreased cell numbers, bioactivity of the nucleus pulposus, and remodeled ECM. Exogenous genes can be targeted into cells to produce inhibition of ECM degradation and increase ECM content in IVDs, and thereby potentially stop or reverse degenerative processes and modify disc structure. METHODS BMSCs were isolated from a pure New Zealand white rabbit and identified by flow cytometry. Transgenic BMSCs were acquired by transfection with a recombinant adenovirus vector carrying the hTIMP-1 gene. Animal models of IVD degeneration were established by annulus puncture and then given intra-nucleus pulposus injections according to their random assignment into 3 groups: (1) a transgenic BMSC transplantation (TgBT) group that received BMSCs transfected with an hTIMP-1-expressing adenovirus vector; (2) a BMSC transplantation (BT) group that received unaltered BMSCs; and (3) a control group that received cell-free phosphate-buffered saline. Degree of degeneration was evaluated 12 weeks after modeling. ECM content was quantified using immunohistochemistry and spectrophotography. Expression of hTIMP-1 was observed via quantitative polymerase chain reaction, western blot, and immunohistochemistry. RESULTS Significantly fewer degenerative changes and increased ECM content were observed in the TBT and BT groups than the control group animals (P < 0.05). The TBT group had greater ECM content than did the BT group (P < 0.05), as well as higher levels of hTIMP-1 mRNA and protein. CONCLUSION Transplantation of BMSCs transfected with hTIMP-1 can increase ECM content by inhibiting ECM degradation and promoting ECM synthesis. LEVEL OF EVIDENCE N/A.
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Jin L, Liu Q, Scott P, Zhang D, Shen F, Balian G, Li X. Annulus fibrosus cell characteristics are a potential source of intervertebral disc pathogenesis. PLoS One 2014; 9:e96519. [PMID: 24796761 PMCID: PMC4010482 DOI: 10.1371/journal.pone.0096519] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/08/2014] [Indexed: 01/07/2023] Open
Abstract
In the end stage of intervertebral disc degeneration, cartilage, bone, endothelial cells, and neurons appear in association with the worsening condition. The origin of the abnormal cells is not clear. This study investigated the properties of progenitor cells in the annulus fibrosus (AF) using one in vitro and two in vivo models. Cultivation of rabbit AF cells with chondrogenic media significantly increased expressions of collagen and aggrecan. Upon exposure to osteogenic conditions, the cultures showed increased mineralization and expression of osteopontin, runx2, and bmp2 genes. Two models were used in the in vivo subcutaneous implantation experiments: 1) rabbit AF tissue in a demineralized bone matrix (DBM) cylinder (DBM/AF), and, 2) rat intact and needle punctured lumbar discs. Bone formation in the AF tissue was detected and hypertrophic chondrocytes and osteoblasts were present 1 month after implantation of the DBM/AF to nude mice. In addition to collagen I and II, immunostaining shows collagen X and osteocalcin expression in DBM/AF specimens 4 months after implantation. Similar changes were detected in the injured discs. Almost the entire needle punctured disc had ossified at 6 months. The results suggest that AF cells have characteristics of progenitor cells and, under appropriate stimuli, are capable of differentiating into chondrocytes and osteoblasts in vitro as well as in vivo. Importantly, these cells may be a target for biological treatment of disc degeneration.
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Affiliation(s)
- Li Jin
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, United States of America
- * E-mail:
| | - Qihai Liu
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Phillip Scott
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Dawei Zhang
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Francis Shen
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Gary Balian
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Xudong Li
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, United States of America
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Shin DA, Yang BM, Tae G, Kim YH, Kim HS, Kim HI. Enhanced spinal fusion using a biodegradable porous mesh container in a rat posterolateral spinal fusion model. Spine J 2014; 14:408-15. [PMID: 24268394 DOI: 10.1016/j.spinee.2013.08.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 07/05/2013] [Accepted: 08/23/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Posterolateral fusion (PLF) with an autogenous iliac bone graft is the most common procedure for treating various lumbar spinal diseases. However, the limited success and associated morbidity from an iliac crest graft demands new biologically competent graft enhancers or substitutes. PURPOSE To investigate the feasibility of tubular mesh container made of bioabsorbable sutures (poly-1,4-dioxane-2-one, PDO) for spinal fusion. STUDY DESIGN Experimental animal study. METHODS A biodegradable PDO tubular mesh container was used to contain small pieces of bone grafts. Twenty Sprague-Dawley male rats underwent PLF between L4 and L5 transverse processes with bilateral iliac grafts. Experimental animals were assigned into two different groups: autograft-only group (N=10) that underwent PLF with autograft-only or mesh container group (N=10) that underwent PLF with tubular mesh container filled with autogenous bone grafts. The rats were sacrificed at 8 weeks postoperatively, and the lumbar spines were removed. Spinal fusion was evaluated by manual palpation, microcomputed tomography, three-point bending test, and histological examination. RESULTS Solid fusion was achieved in all cases of the mesh container group, whereas the autograft-only group showed 60% of solid fusion. New bone mass was higher and more solidly fused in the mesh container group than the autograft-only group (p<.01). Volume of fusion mass and density of bone were significantly higher in the mesh container group (p<.05). In all cases, inflammatory response was minimal. CONCLUSIONS This study demonstrated that a tubular mesh container made of bioabsorbable suture is useful to hold small pieces of bone grafts and to enhance spinal fusion.
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Affiliation(s)
- Dong-Ah Shin
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 120-752, Republic of Korea
| | - Bo Mi Yang
- School of Materials Science and Engineering, Gwangju Institute of Science and Technology, 123 Cheomdan-gwagiro, Buk-gu, Gwangju, 500-712, Republic of Korea
| | - Giyoong Tae
- School of Materials Science and Engineering, Gwangju Institute of Science and Technology, 123 Cheomdan-gwagiro, Buk-gu, Gwangju, 500-712, Republic of Korea
| | - Young Ha Kim
- Department of Chemistry, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Gu, Seoul, Republic of Korea
| | - Hyung-Seok Kim
- Department of Forensic Medicine, Chonnam National University Medical School, 42 Jebong-Ro, Dong-Gu, Gwangju, 501-757, Republic of Korea
| | - Hyoung-Ihl Kim
- Department of Medical System Engineering, Gwangju Institute of Science and Technology, 123 Cheomdan-gwagiro, Buk-gu, Gwangju, 500-712, Republic of Korea; Department of Neurosurgery, Presbyterian Medical Center, 1-300 Junghwasan-dong, Wansangu, Jeonju, Jeonbuk, Republic of Korea.
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Mobbs RJ, Sivabalan P, Li J, Wilson P, Rao PJ. Hybrid technique for posterior lumbar interbody fusion: a combination of open decompression and percutaneous pedicle screw fixation. Orthop Surg 2013; 5:135-41. [PMID: 23658050 DOI: 10.1111/os.12042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 12/28/2012] [Indexed: 11/29/2022] Open
Abstract
The authors describe a hybrid technique that involves a combination of open decompression and posterior lumbar interbody fusion (PLIF) and percutaneously inserted pedicle screws. This technique allows performance of PLIF and decompression via a midline incision and approach without compromising operative time and visualization. Furthermore, compared to standard open decompression, this approach reduces post-operative wound pain because the small midline incision significantly reduces muscle trauma by obviating the need to dissect the paraspinal muscles off the facet joint complex and by avoiding posterolateral fusion, thus requiring limited lateral muscle dissection off the transverse processes. A series of patients with Grade I-II spondylolisthesis at L4-5 and moderate-severe canal/foraminal stenosis underwent midline PLIF at L4-5, with closure of the midline incision. Percutaneous pedicle screws were inserted, thereby minimizing local muscle trauma, reduction of the spondylolisthesis being performed by using a pedicle screw construct. Rods were inserted percutaneously to link the L4 and L5 pedicle screws. Image intensification was used to confirmed satisfactory screw placement and reduction of spondylolisthesis. The results of a prospective study comparing a standard open decompression and fusion technique for spondylolisthesis versus the minimally invasive hybrid technique are discussed. The minimally invasive technique resulted in shorter hospital stay, earlier mobilization and reduced postoperative narcotic usage. The long-term clinical outcomes were equivalent in the two groups.
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Affiliation(s)
- Ralph J Mobbs
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia.
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Wang H, Zhou Y, Huang B, Liu LT, Liu MH, Wang J, Li CQ, Zhang ZF, Chu TW, Xiong CJ. Utilization of stem cells in alginate for nucleus pulposus tissue engineering. Tissue Eng Part A 2013; 20:908-20. [PMID: 24102374 DOI: 10.1089/ten.tea.2012.0703] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In a general view of anatomy, intervertebral disc is composed of three parts: annulus fibrosus (AF), nucleus pulposus (NP), and cartilage endplate (CEP). Recently, several types of stem cells were successfully isolated from these corresponding regions, but up to now, no research was performed about which kind of stem cells is the most efficient candidate for NP tissue engineering or for stem cell-based disc regeneration therapy. In this study, we compared the regenerative potentials of the above-mentioned three kinds of disc-derived stem cells with that of the classic bone marrow (BM)-mesenchymal stem cells (MSCs) in a rabbit disc degeneration model. By magnetic resonance imaging (MRI), X-ray, histology, etc. evaluations, we found that cartilage endplate-derived stem cells (CESCs) showed superior capacity compared with the annulus fibrosus-derived stem cells (AFSCs), nucleus pulposus-derived stem cells (NPSCs), and BM-MSCs (p<0.05); additionally, when comparing the CESC group with the normal control group, there existed no statistical difference in X-ray (p>0.05). Those results demonstrated that the CESC-seeded alginate construct performed the most powerful ability for NP regeneration, while AFSCs showed the most inferior potency, NPSCs and BM-MSCs had similar regenerative capacity and located in the middle. All in all, our study showed that CESCs might act as an efficient seed cell source for NP tissue engineering, which paved a new way for the biological solution of disc degeneration diseases.
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Affiliation(s)
- Hai Wang
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University , Chongqing, P.R. China
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Mobbs RJ, Loganathan A, Yeung V, Rao PJ. Indications for anterior lumbar interbody fusion. Orthop Surg 2013; 5:153-63. [PMID: 24002831 PMCID: PMC6583544 DOI: 10.1111/os.12048] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 12/26/2012] [Indexed: 01/20/2023] Open
Abstract
Anterior lumbar interbody fusion (ALIF) has become a widely recognized surgical technique for degenerative pathology of the lumbar spine. Spinal fusion has evolved dramatically ever since the first successful internal fixation by Hadra in 1891 who used a posterior approach to wire adjacent cervical vertebrae in the treatment of fracture-dislocation. Advancements were made to reduce morbidity including bone grafting substitutes, metallic hardware instrumentation and improved surgical technique. The controversy regarding which surgical approach is best for treating various pathologies of the lumbar spine still exists. Despite being an established treatment modality, current indications of ALIF are yet to be clearly defined in the literature. This article discusses the current literature on indications on ALIF surgery.
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Affiliation(s)
- Ralph J Mobbs
- NeuroSpineClinic, Prince of Wales Private Hospital, Randwick, Sydney, Australia.
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Toll-Like Receptor 4 (TLR4) expression and stimulation in a model of intervertebral disc inflammation and degeneration. Spine (Phila Pa 1976) 2013; 38:1343-51. [PMID: 22850250 DOI: 10.1097/brs.0b013e31826b71f4] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN We measured the expression and responses of Toll-Like Receptor 4 (TLR4) activation in the intervertebral disc (IVD) in vitro and in vivo. We hypothesize that stimulation of the IVD with the TLR4 ligand lipopolysaccharide (LPS) results in upregulation of a coordinated set of proinflammatory mediators and inhibition of matrix expression, both consistent with a molecular profile of degeneration. OBJECTIVE To characterize early inflammatory and morphological changes induced by TLR4 activation in the IVD. SUMMARY OF BACKGROUND DATA TLR4 is a pattern recognition receptor activated in innate immunity that has been implicated in disease mechanisms of inflammatory cartilaginous degeneration. However, no study to date has examined the expression and responses of TLR4 in the IVD. METHODS IVD cells were stimulated with LPS in a dose-dependent manner, and inflammatory cytokine levels were measured by quantitative reverse transcription-polymerase chain reaction. Histological and inflammatory changes due to in vivo injection of LPS into the rat caudal IVD were measured by enzyme-linked immunosorbent assay and immunoblotting. RESULTS Baseline TLR4 expression in IVD tissue varied according to cell type. LPS stimulation resulted in significant increases in tumor necrosis factor α (TNF)-α, interleukin (IL)-1β, IL-6, and nitric oxide levels and significant inhibition in aggrecan and collagen-2. Intradiscal injection of LPS was found to cause moderate degenerative changes in the IVD, with increases in tissue levels of IL-1β, TNF-α, high mobility group box 1 protein (HMGB1), and macrophage migration inhibitory factor (MIF). CONCLUSION This study provides the first evidence that IVD cells express TLR4 and are responsive to TLR4 activation by upregulating a coordinated set of inflammatory cytokines. This study suggests that intradiscal injection of LPS offers a model for triggering inflammation of the IVD, demonstrating that inflammatory insults alone may potentially trigger degenerative changes of the IVD.
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Athanasakopoulos M, Mavrogenis AF, Triantafyllopoulos G, Koufos S, Pneumaticos SG. Posterior spinal fusion using pedicle screws. Orthopedics 2013; 36:e951-7. [PMID: 23823055 DOI: 10.3928/01477447-20130624-28] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Few clinical studies have reported polyetheretherketone (PEEK) rod pedicle screw spinal instrumentation systems (CD-Horizon Legacy PEEK rods; Medtronic, Minneapolis, Minnesota). This article describes a clinical series of 52 patients who underwent posterior spinal fusion using the PEEK Rod System between 2007 and 2010. Of the 52 patients, 25 had degenerative disk disease, 10 had lateral recess stenosis, 6 had degenerative spondylolisthesis, 6 had lumbar spine vertebral fracture, 4 had combined lateral recess stenosis and degenerative spondylolisthesis, and 1 had an L5 giant cell tumor. Ten patients had 1-segment fusion, 29 had 2-segment fusion, and 13 had 3-segment fusion. Mean follow-up was 3 years (range, 1.5-4 years); no patient was lost to follow-up. Clinical evaluation was performed using the Oswestry Disability Index and a low back and leg visual analog pain scale. Imaging evaluation of fusion was performed with standard and dynamic radiographs. Complications were recorded. Mean Oswestry Disability Index scores improved from 76% preoperatively (range, 52%-90%) to 48% at 6 weeks postoperatively, and to 34%, 28%, and 30% at 3, 6, and 12 months postoperatively, respectively. Mean low back and leg pain improved from 8 and 9 points preoperatively, respectively, to 6 and 5 points immediately postoperatively, respectively, and to 2 points each thereafter. Imaging union of the arthrodesis was observed in 50 (96%) patients by 1-year follow-up. Two patients sustained screw breakage: 1 had painful loss of sagittal alignment of the lumbar spine and underwent revision spinal surgery with pedicle screws and titanium rods and the other had superficial wound infection and was treated with wound dressing changes and antibiotics for 6 weeks. No adjacent segment degeneration was observed in any patient until the time of this writing.
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Clinical Evaluation of Percutaneous Vertebroplasty for Symptomatic Adjacent Vertebral Compression Fracture. ACTA ACUST UNITED AC 2013; 26:E130-6. [DOI: 10.1097/bsd.0b013e318278577f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Evaluation of thiol-modified hyaluronan and elastin-like polypeptide composite augmentation in early-stage disc degeneration: comparing 2 minimally invasive techniques. Spine (Phila Pa 1976) 2012; 37:E1296-303. [PMID: 22772576 DOI: 10.1097/brs.0b013e318266ecea] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An in vitro biomechanical and imaging study generated from an in vivo porcine model of early stage degenerative disc disease was used to evaluate mechanical property restoration, comparing 2 minimally invasive injection techniques. OBJECTIVE To evaluate the ability of an injectable hydrogel to restore the mechanical properties of spinal motion segments with early stage disc degeneration, comparing 2 minimally invasive injection techniques. SUMMARY OF BACKGROUND DATA Treatment of early-stage disc degeneration may benefit from a combination of tissue engineering and minimally invasive therapeutic approaches. A recently developed hydrogel, thiol-modified hyaluronan elastin-like polypeptide (TMHA/EP) composite, has demonstrated potential as an injectable nucleus replacement. METHODS From a total of thirteen 35-kg Yorkshire boars, early-stage lumbar disc degeneration was introduced into 10 pigs via injection of chondroitinase ABC. After degeneration, 8 pigs received TMHA/EP augmentation; 1 disc via direct needle injection and a second using a modified kyphoplasty approach. High-resolution magnetic resonance images were acquired of the excised spinal motion segments, followed by biomechanical testing in axial compression, flexion-extension, lateral bending, and torsion. RESULTS The degenerate control motion segments were generally less stiff and more flexible than healthy controls. The injection of TMHA/EP into the degenerated nucleus produced similar mechanical stiffness to healthy controls. The direct-injected discs showed a dispersive pattern of TMHA/EP within the nucleus, whereas the modified kyphoplasty method yielded a bolus of hydrogel. Yet, mechanical behavior was comparable considering the 2 minimally invasive augmentation techniques. CONCLUSION The TMHA/EP composite can restore initial mechanical behavior in early-stage disc degeneration. Although both augmentation methods yielded mechanical properties comparable with healthy controls, direct injection represents a simpler technique, uses a smaller-gauge needle, does not introduce air into the disc, and yields a dispersive pattern that may be beneficial for future delivery of cells or growth factors.
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Duncan JW, Bailey RA. An analysis of fusion cage migration in unilateral and bilateral fixation with transforaminal lumbar interbody fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:439-45. [PMID: 22878377 DOI: 10.1007/s00586-012-2458-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 07/02/2012] [Accepted: 07/22/2012] [Indexed: 12/30/2022]
Abstract
PURPOSE To investigate if instrumentation (unilateral vs. bilateral fixation) has an effect on the rate of fusion cage migration. METHODS This clinical study of transforaminal lumbar interbody fusion involved a prospective group of 116 patients who were randomly assigned to either unilateral (n = 57) or bilateral (n = 59) fixation. Fourteen were lost to follow-up (11 from the unilateral group and 3 from the bilateral group). RESULTS The unilateral fixation group consisted of 20 male and 26 female patients. In the unilateral group, the mean age was 53.5 years (range, 18-77), and the preoperative diagnosis consisted of degenerative disc disease, with or without herniated disc (n = 44), and degenerative spondylolisthesis with spinal stenosis (n = 2). The bilateral fixation group consisted of 20 male and 36 female patients. In the bilateral group, the mean age was 55.7 years (range, 26-82), and the preoperative diagnosis consisted of degenerative disc disease, with or without herniated disc (n = 40), and degenerative spondylolisthesis with spinal stenosis (n = 16). A total of 17 cases of cage migration were found; of these, 11 were from the unilateral group and 6 from the bilateral group, resulting in rates of cage migration of 23 and 11 % (p = 0.03), respectively. In regard to migration cases, 5 were male and 12 were female. Ages ranged from 27 to 79 years (mean age, 55 years). CONCLUSION We conclude that unilateral fixation is not stable enough to prevent fusion cage migration in some patients who undergo TLIF.
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Affiliation(s)
- Jan William Duncan
- Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, 711 West College Street, Suite 625, Los Angeles, CA 90012, USA
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Yang SC, Chen HS, Kao YH, Ma CH, Tu YK, Chung KC. Percutaneous vertebroplasty for symptomatic osteoporotic vertebral compression fracture adjacent to lumbar instrumented circumferential fusion. Orthopedics 2012; 35:e1079-85. [PMID: 22784904 DOI: 10.3928/01477447-20120621-26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to evaluate the efficacy and safety of percutaneous vertebroplasty for patients with symptomatic osteoporotic vertebral compression fractures adjacent to lumbar instrumented circumferential fusion. Between January 2005 and June 2010, eighteen patients in the authors' institution with lumbar instrumented circumferential fusion had adjacent symptomatic osteoporotic vertebral compression fractures. The patients received percutaneous vertebroplasty using polymethylmethacrylate bone cement augmentation. Radiographs and magnetic resonance imaging were used. The visual analog pain scale and modified Brodsky's criteria were used to compare clinical outcomes pre- and postoperatively. Minimum follow-up was 18 months. Dual-energy x-ray absorptiometry scan confirmed osteoporosis in all patients. The average interval between fusion surgery and sustaining osteoporotic vertebral compression fractures was 24.8 months. The average interval between sustaining osteoporotic vertebral compression fractures and undergoing percutaneous vertebroplasty was 49.3 days. One-level percutaneous vertebroplasty was performed in 13 patients, and 2 levels were performed in 5 patients. The patients' visual analog pain scale scores improved by an average of 53 points postoperatively. Fifteen patients returned to preinjury activities of daily living. The average restoration of the fractured vertebral body height was 12.1%. No major surgery-related complications, occurred except asymptomatic cement leakage in 3 patients. Elderly patients undergoing lumbar instrumented fusion surgery should be aware of the possibility of adjacent vertebral compression fractures. Percutaneous vertebroplasty is a minimally invasive and effective procedure to treat such adjacent segment disease.
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Affiliation(s)
- Shih-Chieh Yang
- Department of Orthopaedic Surgery and Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung County, Taiwan, Republic of China
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Abstract
Disc degeneration and associated disorders are among the most debated topics in the orthopedic literature over the past few decades. These may be attributed to interrelated mechanical, biochemical, and environmental factors. The treatment options vary from conservative approaches to surgery, depending on the severity of degeneration and response to conservative therapies. Spinal fusion is considered to be the "gold standard" in surgical methods till date. However, the association of adjacent level degeneration has led to the evolution of motion preservation technologies like spinal arthroplasty and posterior dynamic stabilization systems. These new technologies are aimed to address pain and preserve motion while maintaining a proper load sharing among various spinal elements. This paper provides an elaborative biomechanical review of the technologies aimed to address the disc degeneration and reiterates the point that biomechanical efficacy followed by long-term clinical success will allow these nonfusion technologies as alternatives to fusion, at least in certain patient population.
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Direct lateral approach to lumbar fusion is a biomechanically equivalent alternative to the anterior approach: an in vitro study. Spine (Phila Pa 1976) 2012; 37:819-25. [PMID: 21971125 DOI: 10.1097/brs.0b013e31823551aa] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [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 lumbar mobility before and after fusion and with or without supplemental instrumentation for 5 instrumentation configurations. OBJECTIVE To determine the biomechanical differences between anterior lumbar interbody fusion (ALIF) and direct lateral interbody fusion (DLIF) with and without supplementary instrumentation. SUMMARY OF BACKGROUND DATA Some prior studies have compared various surgical approaches using the same interbody device whereas others have investigated the stabilizing effect of supplemental instrumentation. No published studies have performed a side-by-side comparison of standard and minimally invasive techniques with and without supplemental instrumentation. METHODS Eight human lumbosacral specimens (16 motion segments) were tested in each of the 5 following configurations: (1) intact, (2) with ALIF or DLIF cage, (3) with cage plus stabilizing plate, (4) with cage plus unilateral pedicle screw fixation (PSF), and (5) with cage plus bilateral PSF. Pure moments were applied to induce specimen flexion, extension, lateral bending, and axial rotation. Three-dimensional kinematic responses were measured and used to calculate range of motion, stiffness, and neutral zone. RESULTS Compared to the intact state, DLIF significantly reduced range of motion in flexion, extension, and lateral bending (P = 0.0117, P = 0.0015, P = 0.0031). Supplemental instrumentation significantly increased fused-specimen stiffness for both DLIF and ALIF groups. For the ALIF group, bilateral PSF increased stiffness relative to stand-alone cage by 455% in flexion and 317% in lateral bending (P = 0.0009 and P < 0.0001). The plate increased ALIF group stiffness by 211% in extension and 256% in axial rotation (P = 0.0467 and P = 0.0303). For the DLIF group, bilateral PSF increased stiffness by 350% in flexion and 222% in extension (P < 0.0001 and P = 0.0008). No differences were observed between ALIF and DLIF groups supplemented with bilateral PSF. CONCLUSION Our data support that the direct lateral approach, when supplemented with bilateral PSF, is a minimally invasive and biomechanically stable alternative to the open, anterior approach to lumbar spine fusion.
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Kim HS, Park KH, Ju CI, Kim SW, Lee SM, Shin H. Minimally invasive multi-level posterior lumbar interbody fusion using a percutaneously inserted spinal fixation system : technical tips, surgical outcomes. J Korean Neurosurg Soc 2011; 50:441-5. [PMID: 22259691 DOI: 10.3340/jkns.2011.50.5.441] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 08/09/2011] [Accepted: 11/14/2011] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE There are technical limitations of multi-level posterior pedicle screw fixation performed by the percutaneous technique. The purpose of this study was to describe the surgical technique and outcome of minimally invasive multi-level posterior lumbar interbody fusion (PLIF) and to determine its efficacy. METHODS Forty-two patients who underwent mini-open PLIF using the percutaneous screw fixation system were studied. The mean age of the patients was 59.1 (range, 23 to 78 years). Two levels were involved in 32 cases and three levels in 10 cases. The clinical outcome was assessed using the visual analog scale (VAS) and Low Back Outcome Score (LBOS). Achievement of radiological fusion, intra-operative blood loss, the midline surgical scar and procedure related complications were also analyzed. RESULTS The mean follow-up period was 25.3 months. The mean LBOS prior to surgery was 34.5, which was improved to 49.1 at the final follow up. The mean pain score (VAS) prior to surgery was 7.5 and it was decreased to 2.9 at the last follow up. The mean estimated blood loss was 238 mL (140-350) for the two level procedures and 387 mL (278-458) for three levels. The midline surgical scar was 6.27 cm for two levels and 8.25 cm for three level procedures. Complications included two cases of asymptomatic medial penetration of the pedicle border. However, there were no signs of neurological deterioration or fusion failure. CONCLUSION Multi-level, minimally invasive PLIF can be performed effectively using the percutaneous transpedicular screw fixation system. It can be an alternative to the traditional open procedures.
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Affiliation(s)
- Hyeun Sung Kim
- Department of Neurosurgery, Daejeon Hurisarang Hospital, Daejeon, Korea
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Kim JS, Kroin JS, Li X, An HS, Buvanendran A, Yan D, Tuman KJ, van Wijnen AJ, Chen D, Im HJ. The rat intervertebral disk degeneration pain model: relationships between biological and structural alterations and pain. Arthritis Res Ther 2011; 13:R165. [PMID: 21996269 PMCID: PMC3308099 DOI: 10.1186/ar3485] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Revised: 06/09/2011] [Accepted: 10/13/2011] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Degeneration of the interverterbral disk is as a cause of low-back pain is increasing. To gain insight into relationships between biological processes, structural alterations and behavioral pain, we created an animal model in rats. METHODS Disk degeneration was induced by removal of the nucleus pulposus (NP) from the lumbar disks (L4/L5 and L5/L6) of Sprague Dawley rats using a 0.5-mm-diameter microsurgical drill. The degree of primary hyperalgesia was assessed by using an algometer to measure pain upon external pressure on injured lumbar disks. Biochemical and histological assessments and radiographs of injured disks were used for evaluation. We investigated therapeutic modulation of chronic pain by administering pharmaceutical drugs in this animal model. RESULTS After removal of the NP, pressure hyperalgesia developed over the lower back. Nine weeks after surgery we observed damaged or degenerated disks with proteoglycan loss and narrowing of disk height. These biological and structural changes in disks were closely related to the sustained pain hyperalgesia. A high dose of morphine (6.7 mg/kg) resulted in effective pain relief. However, high doses of pregabalin (20 mg/kg), a drug that has been used for treatment of chronic neuropathic pain, as well as the anti-inflammatory drugs celecoxib (50 mg/kg; a selective inhibitor of cyclooxygenase 2 (COX-2)) and ketorolac (20 mg/kg; an inhibitor of COX-1 and COX-2), did not have significant antihyperalgesic effects in our disk injury animal model. CONCLUSIONS Although similarities in gene expression profiles suggest potential overlap in chronic pain pathways linked to disk injury or neuropathy, drug-testing results suggest that pain pathways linked to these two chronic pain conditions are mechanistically distinct. Our findings provide a foundation for future research on new therapeutic interventions that can lead to improvements in the treatment of patients with back pain due to disk degeneration.
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Affiliation(s)
- Jae-Sung Kim
- Department of Biochemistry, Rush University Medical Center, Cohn Research BD 516, 1735 West Harrison Street, Chicago, IL 60612, USA
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Fusion performance of low-dose recombinant human bone morphogenetic protein 2 and bone marrow-derived multipotent stromal cells in biodegradable scaffolds: a comparative study in a large animal model of anterior lumbar interbody fusion. Spine (Phila Pa 1976) 2011; 36:1752-9. [PMID: 21673630 DOI: 10.1097/brs.0b013e31822576a4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A large animal study comparing interbody fusion of a bioresorbable scaffold loaded with either low-dose recombinant human bone morphogenetic protein 2 (rhBMP-2) or bone marrow-derived multipotent stromal cells (BMSCs). OBJECTIVE To compare the quality of fusion resulting from implantation of medical grade poly (ε-caprolactone)-20% tricalcium phosphate (mPCL/TCP) scaffolds and two different bone growth stimulating agents. SUMMARY OF BACKGROUND DATA Nondegradable cages have been used for interbody fusion with good results. However, the overall advantage of lifelong implantation of a nondegradable device remains a subject of ongoing debate. The use of bioresorbable scaffolds might offer superior alternatives. In this study, we evaluated the quality of fusion obtained with two potential bone graft substitutes. METHODS Eleven Yorkshire pigs underwent a bisegmental (L2/L3; L4/L5) anterior lumbar interbody fusion (ALIF) in four groups, namely: (1) mPCL/TCP + 0.6 mg rhBMP-2; (2) mPCL/TCP + BMSCs; (3) mPCL/TCP (negative control); and (4) autologous bone grafts (positive control). RESULTS. The mean radiographic scores at 9 months were 3.0, 1.7, 1.0, and 1.8 for groups 1 to 4, respectively. The bone volume fraction of group 1 was two-folds higher than group 2. Histology, micro-computed tomographic scanning and biomechanical evaluation demonstrated solid and comparable fusion between groups 1 and 4. However, group 2 showed inferior quality of fusion when compared with groups 1 and 4 while group 3 showed no fusion even at 9 months. In addition, there was no evidence of implant rejection, chronic inflammation or any other complications. CONCLUSION mPCL/TCP scaffolds loaded with low-dose rhBMP-2 is comparable to autograft bone as a bone graft substitute in this large animal ALIF model. Although BMSCs lagged behind autograft bone and rhBMP-2, evidence of bone ingrowth in this group warrants further investigation. Our results suggest that mPCL/TCP scaffolds loaded with rhBMP-2 or BMSCs may be a viable alternative to conventional cages and autograft bone.
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