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Cheng X, Zhang K, Sun X, Tian H, Zhao C, Zhao J. Unilateral versus bilateral pedicle screw fixation with transforaminal lumbar interbody fusion for treatment of lumbar foraminal stenosis. Spine J 2022; 22:1687-1693. [PMID: 35688328 DOI: 10.1016/j.spinee.2022.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/09/2022] [Accepted: 05/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Transforaminal lumbar interbody fusion (TLIF) with bilateral pedicle screw fixation (BPSF) is an effective treatment for lumbar foraminal stenosis (LFS). However, the effects of TLIF with unilateral pedicle screw fixation (UPSF) on LFS treatment have not been clearly elucidated. PURPOSE We conducted this study to compare clinical outcomes and radiographic results of TLIF with UPSF and BPSF 2 years after the surgical treatment. DESIGN Prospective randomized study. PATIENT SAMPLE This study included 23 patients undergoing TLIF with UPSF and 25 patients undergoing TLIF with BPSF. OUTCOME MEASURES Clinical outcomes were evaluated by visual analog scale (VAS) for low back pain and leg pain and Oswestry Disability Index (ODI) score. Radiographic outcomes included foraminal height, disc space height, segmental lordosis, and final fusion rates. METHODS The clinical and radiographic outcomes were compared between the UPSF and BPSF group. The postoperative improvements were evaluated in either group. Intraoperative data such as duration of operation and estimated blood loss were collected. This study was registered at clinicaltrials.gov. RESULTS Analysis of the VAS and ODI scores showed significant improvements in clinical outcomes within each group. No significant differences between the 2 groups were noted in the improvements of the VAS and ODI scores. The mean operative duration and blood loss were significantly greater in the BPSF group than in the UPSF group. There were significant improvements in the height of the foramen and intervertebral space and segmental lordosis in both groups, while there was no significant difference between the groups in amount of the improvements. No significant difference was found in the final fusion rates. CONCLUSIONS TLIF is an appropriate procedure for LFS treatment. With balanced intervertebral support using a cage, UPSF could achieve similar and satisfactory effects on lumbar segmental stability and fusion compared to BPSF. The unilateral approach appears to be associated with slightly shorter operative time and less blood loss.
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Affiliation(s)
- Xiaofei Cheng
- Department of Orthopedic Surgery, Shanghai Key Laboratory of Orthopedic Implants, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, People's Republic of China
| | - Kai Zhang
- Department of Orthopedic Surgery, Shanghai Key Laboratory of Orthopedic Implants, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, People's Republic of China
| | - Xiaojiang Sun
- Department of Orthopedic Surgery, Shanghai Key Laboratory of Orthopedic Implants, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, People's Republic of China
| | - Haijun Tian
- Department of Orthopedic Surgery, Shanghai Key Laboratory of Orthopedic Implants, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, People's Republic of China
| | - Changqing Zhao
- Department of Orthopedic Surgery, Shanghai Key Laboratory of Orthopedic Implants, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, People's Republic of China
| | - Jie Zhao
- Department of Orthopedic Surgery, Shanghai Key Laboratory of Orthopedic Implants, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, People's Republic of China.
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Lafage R, Smith JS, Elysee J, Passias P, Bess S, Klineberg E, Kim HJ, Shaffrey C, Burton D, Hostin R, Mundis G, Ames C, Schwab F, Lafage V. Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications. Spine Deform 2022; 10:121-131. [PMID: 34460094 DOI: 10.1007/s43390-021-00397-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several methodologies have been proposed to determine ideal ASD sagittal spinopelvic alignment (SRS-Schwab classification) global alignment and proportion (GAP) score, patient age-adjusted alignment). A recent study revealed the ability and limitations of these methodologies to predict PJK. The aim of the study was to develop a new approach, inspired by SRS classification, GAP score, and age-alignment to improve the evaluation of the sagittal plane. METHOD A multi-center ASD database was retrospectively evaluated for surgically treated ASD patients with complete fusion of the lumbar spine, and minimum 2 year follow-up. The Sagittal age-adjusted score (SAAS) methodology was created by assigning numerical values to the difference between each patient's postoperative sagittal alignment and ideal alignment defined by previously reported age generational norms for PI-LL, PT, and TPA. Postoperative HRQOL and PJK severity between each SAAS categories were evaluated. RESULTS 409 of 667 (61.3%) patients meeting inclusion criteria were evaluated. At 2 year SAAS score showed that 27.0% of the patients were under-corrected, 51.7% over-corrected, and 21.3% matched their age-adjusted target. SAAS score increased as PJK worsened (from SAAS = 0.2 for no-PJK, to 4.0 for PJF, p < 0.001). Post-operatively, HRQOL differences between SAAS groups included ODI, SRS pain, and SRS total. CONCLUSION Inspired by SRS classification, the concept of the GAP score, and age-adjusted alignment targets, the results demonstrated significant association with PJK and patient reported outcomes. With a lower rate of failure and better HRQOL, the SAAS seems to represent a "sweet spot" to optimize HRQOL while mitigating the risk of mechanical complications.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA.
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Sacramento, Davis, CA, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas, KS, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | | | - Christopher Ames
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, CA, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
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Wen J, Shi C, Yu L, Wang S, Xi Y, Ye X. Unilateral Versus Bilateral Percutaneous Pedicle Screw Fixation in Oblique Lumbar Interbody Fusion. World Neurosurg 2019; 134:e920-e927. [PMID: 31733381 DOI: 10.1016/j.wneu.2019.11.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To compare clinical and radiologic outcomes of unilateral pedicle screw (UPS) and bilateral pedicle screw (BPS) fixations after single-level oblique lateral interbody fusion procedures. METHODS This retrospective study included 74 patients receiving single-level oblique lateral interbody fusion at L3-4 or L4-5 (June 2014 to June 2017). These patients were divided into BPS (n = 36) and UPS (n = 38) groups. Perioperative outcomes included operative time, blood loss, medical expenses, and complication rates. Radiologic outcomes included fusion rates and cage subsidence rates. Clinical outcomes included disability measured by the Oswestry Disability Index and pain measured by the visual analog scale. RESULTS The operative time was significantly shorter in the UPS group (76.2 ± 4.4 minutes) compared with the BPS group (127.0 ± 5.6 minutes, P < 0.001). There was a significant between-group difference in medical expenses ($11,044.8 ± $470.7 in UPS group vs. $15,018.4 ± $547.1 in BPS, P < 0.001). Blood loss and hospital stay did not differ between groups. Oswestry Disability Index and visual analog scale scores significantly decreased in both groups at different time points postoperatively compared with preoperatively. The UPS group had lower Oswestry Disability Index and visual analog scale scores than the BPS group at 7 days postoperatively, but no between-group difference was found after 1-month follow-up. Fusion rate was 86.8% in UPS group and 91.7% in BPS group (P > 0.05). Cage subsidence rates did not differ between groups. CONCLUSIONS Oblique lateral interbody fusion with UPS fixation is an effective and reliable option for single-level lumbar diseases. Compared with BPS fixation, it resulted in less blood loss, required less operative time, and had comparable effects on radiologic and clinical outcomes.
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Affiliation(s)
- Jiankun Wen
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Changgui Shi
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lei Yu
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Shuang Wang
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yanhai Xi
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaojian Ye
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
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Buttermann G, Hollmann S, Arpino JM, Ferko N. Value of single-level circumferential fusion: a 10-year prospective outcomes and cost-effectiveness analysis comparing posterior facet versus pedicle screw fixation. 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 2019; 29:360-373. [PMID: 31583439 DOI: 10.1007/s00586-019-06165-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/24/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare the clinical and economic outcomes of facet versus pedicle screw instrumentation for single-level circumferential lumbar spinal fusion. METHODS Outcomes included self-assessment of back and leg pain, pain drawing, ODI, pain medication usage, and procedure success. The CEA was based on the 10-year data collected, and the base-case was from a US payer perspective. Costs included the index surgery, additional surgeries, outpatient/ED visits, and medications. To determine quality-adjusted life years (QALYs), ODI scores were used to predict SF-6D utilities. Sensitivity analyses were performed from a modified payer perspective including device costs and from a societal perspective including productivity loss. Discounted and undiscounted incremental costs and QALYs were calculated. Bootstrapping was performed to estimate the distribution of incremental costs and effects. RESULTS Clinical improvement was significant from pre-op to 10-year follow-up for both groups (p < 0.01 for all outcomes scales). Outcomes were significantly better for back pain and ODI for the facet versus pedicle group at all follow-up periods > 1 year (p < 0.05). In the CEA base-case, facets had more QALYs (0.68) and lower costs (- $8650) per person compared with pedicle screws. Therefore, facets were dominant (i.e., provided cost savings and greater QALYs) compared with pedicle screws. Facets had a 97% probability of being below a willingness-to-pay threshold of $20,000 per QALY gained and were estimated to be dominant over pedicle screws in 84% of the simulations. CONCLUSION One-level circumferential spinal fusion using facet screws was clinically superior and provided cost savings compared with pedicle screw instrumentation in the USA.
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Affiliation(s)
- Glenn Buttermann
- Midwest Spine & Brain Institute, 1950 Curve Crest Boulevard, Stillwater, MN, 55082, USA.
| | | | | | - Nicole Ferko
- Cornerstone Research Group, Burlington, ON, Canada
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Giorgi H, Prebet R, Andriantsimiavona R, Tropiano P, Blondel B, Parent HF. Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle screw fixation (UNILIF): morbidity, clinical and radiological 2-year outcomes of a 66-patient prospective series. 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 2018; 27:1933-1939. [DOI: 10.1007/s00586-017-5452-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 11/27/2017] [Accepted: 12/30/2017] [Indexed: 11/25/2022]
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Volkheimer D, Reichel H, Wilke HJ, Lattig F. Is pelvic fixation the only option to provide additional stability to the sacral anchorage in long lumbar instrumentation? A comparative biomechanical study of new techniques. Clin Biomech (Bristol, Avon) 2017; 43:34-39. [PMID: 28199880 DOI: 10.1016/j.clinbiomech.2017.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/23/2017] [Accepted: 02/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Supplementary iliac screws have the highest potential to protect S1-pedicle-screws from loosening in long fusion constructs. However, this technique bridges the iliosacral joint with potential disadvantages for the patient. This study aimed to evaluate if two different established fixation techniques can be used in addition to pedicle screws as alternative to iliac screws, and if these two techniques can provide similar stability when S1-pedicle-screws are loosened. METHODS Flexibility testing with pure moments of 7.5Nm was performed with six human osteopenic/osteoporotic L4-pelvis specimens. The following conditions were investigated: 1. Intact; 2. Destabilization L5/S1; 3. Fixation with rigid L4-S1 pedicle-screw-system; 4. Condition 3- loosening of S1-screws; 5. Condition 4- L5-S2-lamina-hooks; 6. Condition 4- L5/S1-translaminar-screws; 7. Condition 4- S2-ala-ilium screws. FINDINGS Application of compressive L5-S2-lamina-hooks or L5/S1-translaminar-screws next to pedicle screws in L5 and S1 was feasible in all specimens. L4-S1-pedicle-screw-instrumentation reduced the Range of Motion significantly compared to the destabilized condition. After simulation of S1 screw loosening, lamina hooks only reduced the Range of Motion in flexion/extension significantly. L5/S1-translaminar-screws had a higher stabilizing effect in lateral bending and axial rotation, but the effect of both systems was smaller than with an instrumentation extension to the os ilium. INTERPRETATION In long lumbar pedicle screw instrumentations including L5/S1, additional ilium screws have the highest potential to protect the S1-anchorage. Additional L5/S1-translaminar-screws can increase stability of the lumbosacral junction without bridging the iliosacral joint, whereas lamina hooks showed no significant biomechanical benefit.
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Affiliation(s)
- David Volkheimer
- Institute of Orthopedic Research and Biomechanics, Trauma Research Center Ulm (ZTF), Ulm University, Medical Center, Germany
| | | | - Hans-Joachim Wilke
- Institute of Orthopedic Research and Biomechanics, Trauma Research Center Ulm (ZTF), Ulm University, Medical Center, Germany.
| | - Friederike Lattig
- Orthopedic University Hospital RKU, Ulm, Germany; Berit Paracelsus Clinic, Speicher, Switzerland
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Zeng ZY, Wu P, Yan WF, Song YX, Zhang JQ, Tang HC, Song GH, Han JF, Fan SW. Mixed Fixation and Interbody Fusion for Treatment Single-Segment Lower Lumbar Vertebral Disease: Midterm Follow-up Results. Orthop Surg 2016; 7:324-32. [PMID: 26790374 DOI: 10.1111/os.12214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/30/2015] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To investigate the midterm outcomes of unilateral pedicle screws combined with contralateral gunsight-guided translaminar facet screw fixation and interbody fusion for treatment of single-segment lower lumbar vertebral disease. METHODS A total of 78 patients with various lower lumbar single-segment vertebral diseases were treated in our department from January 2008 to December 2011. There were 21 males and 57 females, with an average age of 52.5 years, including lumbar disc degeneration (28 cases), local recurrence of lumbar disc herniation (9 cases), huge lumbar disc herniation (11 cases), lumbar disc herniation with spinal stenosis (13 cases), and lumbar degenerative spondylolisthesis (degree I) (17 cases). All patients were treated by unilateral pedicle screws in the median incision combined with contralateral gunsight-guided translaminar facet screw fixation and interbody fusion. RESULTS No wound infection or skin necrosis around incision was observed after operation. No leakage of cerebrospinal fluid or nerve injury occurred during and after operation. Excepting 4 cases, 74 cases were followed up for 18-60 months, averaged 33.5 months. All but one patient (98.6%) received interbody fusion. The intervertebral height of the indexed level was well restored and maintained. At final follow-up. During follow-up, there was no screw loosening or pedicle fracture observed. No apparent degeneration of adjacent segments. The mean Japanese Orthopaedic Association (JOA) scores was increased significantly from 12.79 ± 2.12 preoperatively to 25.8 ± 2.87 at the final follow-up. CONCLUSION Unilateral pedicle screw fixation combined with contralateral translaminar facet screw fixation and interbody fusion showed good mid-term outcomes in the treatment of single-segment lower lumbar vertebral disease, and can be used as an optimal choice for fixation and fusion of some single-segment lower lumbar vertebral diseases.
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Affiliation(s)
- Zhong-you Zeng
- Department of Orthopaedics, Sir Run Run Shaw Hospital of Medical College of Zhejiang University, Hangzhou, Zhejiang Province, China.,Second Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, Zhejiang Province, China
| | - Peng Wu
- Second Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, Zhejiang Province, China
| | - Wei-feng Yan
- Second Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, Zhejiang Province, China
| | - Yong-xing Song
- Second Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, Zhejiang Province, China
| | - Jian-qiao Zhang
- Second Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, Zhejiang Province, China
| | - Hong-chao Tang
- Second Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, Zhejiang Province, China
| | - Guo-hao Song
- Second Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, Zhejiang Province, China
| | - Jian-fu Han
- Second Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, Zhejiang Province, China
| | - Shun-Wu Fan
- Department of Orthopaedics, Sir Run Run Shaw Hospital of Medical College of Zhejiang University, Hangzhou, Zhejiang Province, China
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Buttermann GR, Thorson TM, Mullin WJ. Outcomes of posterior facet versus pedicle screw fixation of circumferential fusion: a 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 2013; 23:347-55. [PMID: 24197480 DOI: 10.1007/s00586-013-2999-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 08/31/2013] [Accepted: 08/31/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare single-level circumferential spinal fusion using pedicle (n = 27) versus low-profile minimally invasive facet screw (n = 35) posterior instrumentation. METHOD A prospective two-arm cohort study with 5-year outcomes as follow-up was conducted. Assessment included back and leg pain, pain drawing, Oswestry disability index (ODI), pain medication usage, self-assessment of procedure success, and >1-year postoperative lumbar magnetic resonance imaging. RESULTS Significantly less operative time, estimated blood loss and costs were incurred for the facet group. Clinical improvement was significant for both groups (p < 0.01 for all outcomes scales). Outcomes were significantly better for back pain and ODI for the facet relative to the pedicle group at follow-up periods >1 year (p < 0.05). Postoperative magnetic resonance imaging found that 20 % had progressive adjacent disc degeneration, and posterior muscle changes tended to be greater for the pedicle screw group. CONCLUSION One-level circumferential spinal fusion using facet screws proved superior to pedicle screw instrumentation.
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Affiliation(s)
- Glenn R Buttermann
- Midwest Spine Institute, 1950 Curve Crest Blvd, Stillwater, MN, 55082, USA,
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Hou Y, Shen Y, Liu Z, Nie Z. Which posterior instrumentation is better for two-level anterior lumbar interbody fusion: translaminar facet screw or pedicle screw? Arch Orthop Trauma Surg 2013; 133:37-42. [PMID: 23109094 DOI: 10.1007/s00402-012-1636-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Indexed: 02/09/2023]
Abstract
PURPOSE To determine whether translaminar facet screws can provide stability equivalent to pedicle screws and whether the two posterior instrumentations have the same influence on the adjacent segments in two-level anterior lumbar interbody fusion. METHODS In a biomechanical study conducted, we used 12 fresh human lumbar spines and tested an intact spine with a stand-alone two-level anterior lumbar interbody fusion and anterior fusion augmented with pedicle screws or translaminar facet screws, under 400 N compressive preloads and 7.5 N m moments in flexion, extension, axial rotation and lateral bending, and measured the stiffness of the operated level, range of motion and intradiscal pressure at the adjacent levels. RESULTS We found a significant increase in the stiffness of the segments operated, range of motion and intradiscal pressure at the adjacent superior segment in the stand-alone two-level anterior lumbar interbody fusion during flexion, axial rotation and lateral bending, but a decrease in extension, when compared with the intact spine. The stiffness of operated segments, range of motion and intradiscal pressure in the adjacent segment are significantly higher in the two-level anterior lumbar interbody fusion augmented with posterior instrumentation than in the stand-alone two-level anterior lumbar interbody fusion. There was no significant difference between the two augmented constructs except that, at the adjacent superior segment, the intradiscal pressure was more in the construction augmented with a pedicle screw than with a translaminar facet screw in flexion. CONCLUSIONS Translaminar facet screws can provide stability equivalent to pedicle screws, but their influence on the adjacent segments is relatively lower; therefore, we suggest that translaminar facet screws be the choice in the optimal posterior instrumentation in a two-level anterior lumbar interbody fusion.
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Affiliation(s)
- Yingnuo Hou
- Department of Spine Surgery, The People's Hospital of Xingtai, Xingtai 054001, China
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Méndez JR, Maldonado NF, Bovier EG. Artrodesis circunferencial: Plif más tornillos translaminofacetarios. COLUNA/COLUMNA 2013. [DOI: 10.1590/s1808-18512013000200006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Evaluar el resultado clínico y radiológico de 10 pacientes operados por patología degenerativa lumbar, en los que se les realizó artrodesis intersomática con injerto óseo tricortical de cresta ilíaca y artrodesis posterolateral instrumentada con tornillos translaminofacetarios. MÉTODOS: Se evaluaron 10 pacientes, 4 hombres y 6 mujeres operados por el mismo cirujano entre junio de 2006 y diciembre de 2007. RESULTADOS: Se obtuvo un significativo descenso de la discapacidad y del dolor (según las escalas de Oswestry y la escala visual analógica), obteniéndose una tasa de fusión del 100% al año de seguimiento. CONCLUSIONES: Los resultados clínicos y radiológicos de este estudio establecen a éste procedimiento como confiable, de bajo costo y baja morbilidad, con una alta tasa de fusión y buenos resultados clínicos.
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Wang M, Tang SJ, McGrady LM, Rao RD. Biomechanical comparison of supplemental posterior fixations for two-level anterior lumbar interbody fusion. Proc Inst Mech Eng H 2012; 227:245-50. [DOI: 10.1177/0954411912465057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Posterior instrumentations have been used to supplement anterior lumbar interbody fusion with cages. Biomechanical studies on single-level anterior lumbar interbody fusion show that stand-alone cages supplemented with posterior translaminar facet or transfacet screw fixation exhibit comparable stability to those supplemented with pedicle screw/rod fixation, while stability of multilevel anterior lumbar interbody fusion remains mostly unknown. The objectives of this study are to compare the stabilization of three supplemental posterior fixations to two-level anterior lumbar interbody fusion, including translaminar facet fixation, transfacet screw fixation, and pedicle screw/rod fixation. Flexibility tests were conducted on fresh-frozen calf spines with moment up to 8.5 N m in flexion, extension, lateral bending, and axial rotation. Each specimen was tested at three stages: intact, anterior lumbar interbody fusion using Polyetheretherketone (PEEK) interbody cage at L3–L4 and L4–L5, and the same anterior lumbar interbody fusion plus one of the three supplemental posterior fixations. The addition of the supplemental posterior fixation increased stiffness at the fusion levels significantly in flexion (9.9 times), extension (5.4 times), and lateral bending (4.1 times). The pedicle screw/rod and translaminar screw fixations provide approximately 40% higher stiffness than the transfacet screw in lateral bending. The pedicle screw/rod fixation also displayed a trend of superior fixation in extension. Supplemental posterior fixation significantly improved stability of two-level anterior lumbar interbody fusion when compared to the stand-alone cages. Pedicle screw/rod system is still the “gold standard” in providing supplemental stability. However, both translaminar facet screws and transfacet screws are good alternatives to provide adequate fixation.
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Affiliation(s)
- Mei Wang
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shu-Jie Tang
- Department of Traditional Chinese Medicine, Jinan University Medical School, Guangzhou, China
| | - Linda M McGrady
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raj D Rao
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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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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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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Buttermann GR, Beaubien BP, Freeman AL, Stoll JE, Chappuis JL. Interbody device endplate engagement effects on motion segment biomechanics. Spine J 2009; 9:564-73. [PMID: 19457722 DOI: 10.1016/j.spinee.2009.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 03/06/2009] [Accepted: 03/30/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Stand-alone nonbiologic interbody fusion devices for the lumbar spine have been used for interbody fusion since the early 1990s. However, most devices lack the stability found in clinically successful circumferential fusion constructs. Stability results from cage geometry and device/vertebral endplate interface integrity. To date, there has not been a published comparative biomechanical study specifically evaluating the effects of endplate engagement of interbody devices. PURPOSE Lumbar motion segments implanted with three different interbody devices were tested biomechanically to compare the effects of endplate engagement on motion segment rigidity. The degree of additional effect of supplemental posterior and anterior fixation was also investigated. STUDY DESIGN/SETTING A cadaveric study of interbody fusion devices with varying degrees of endplate interdigitation. OUTCOME MEASURES Implanted motion segment range of motion (ROM), neutral zone (NZ), stiffness, and disc height. METHODS Eighteen human L23 and L45 motion segments were distributed into three interbody groups (n=6 each) receiving a polymeric (polyetheretherketone) interbody spacer with small ridges; a modular interbody device with endplate spikes (InFix, Abbott Spine, Austin, TX, USA); or dual tapered threaded interbody cages (LT [Lordotic tapered] cage; Medtronic, Memphis, TN, USA). Specimens were tested intact using a 7.5-Nm flexion-extension, lateral bending, and axial torsion flexibility protocol. Testing was repeated after implantation of the interbody device, anterior plate fixation, and posterior interpedicular fixation. Radiographic measurements determined changes in disc height and intervertebral lordosis. ROM and NZ were calculated and compared using analysis of variance. RESULTS The interbody cages with endplate spikes or threads provided a statistically greater increase in disc height versus the polymer spacer (p=.01). Relative to intact, all stand-alone devices significantly reduced ROM in lateral bending by a mean 37% to 61% (p< or =.001). The cages with endplate spikes or threads reduced ROM by approximately 50% and NZ by approximately 60% in flexion-extension (p< or =.02). Only the cage with endplate spikes provided a statistically significant reduction in axial torsion ROM compared with the intact state (50% decrease, p<.001). Posterior fixation provided a significant reduction in ROM in all directions versus the interbody device alone (p<.001). Anterior plating decreased ROM over interbody device alone in flexion-extension and torsion but did not have additional effect on lateral bending ROM. CONCLUSION The cages with endplate spikes or threads provide substantial motion segment rigidity compared with intact in bending modes. Only the cages with endplate spikes were more rigid than intact in torsion. All devices experienced increased rigidity with anterior plating and even greater rigidity with posterior fixation. It appears that the endplate engagement with spikes may be beneficial in limiting torsion, which is generally difficult with other "stand-alone" devices tested in the current and prior reports.
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Enhancing the stability of anterior lumbar interbody fusion: a biomechanical comparison of anterior plate versus posterior transpedicular instrumentation. Spine (Phila Pa 1976) 2008; 33:E38-43. [PMID: 18197089 DOI: 10.1097/brs.0b013e3181604644] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Biomechanical study using human cadaver spines. OBJECTIVE To assess the stabilizing effect of a supplemental anterior tension band (ATB, Synthes) plate on L5-S1 anterior lumbar interbody fusion (ALIF) using a femoral ring allograft (FRA) under physiologic compressive preloads, and to compare the results with the stability achieved using FRA with supplemental transpedicular instrumentation. SUMMARY OF BACKGROUND DATA Posterior instrumentation can improve the stability of ALIF cages. Anterior plates have been proposed as an alternative to avoid the additional posterior approach. METHODS Eight human specimens (L3 to sacrum) were tested in the following sequence: (i) intact, (ii) after anterior insertion of an FRA at L5-S1, (iii) after instrumentation with the ATB plate, and (iv) after removal of the plate and adding transpedicular instrumentation at the same level. Specimens were tested in flexion-extension, lateral bending, and axial rotation. Flexion-extension was tested under 0 N, 400 N, and 800 N compressive follower preload to simulate physiologic compressive preloads on the lumbar spine. RESULTS Stand-alone FRAs significantly decreased the range of motion (ROM) in all tested directions (P < 0.05); however, the resultant ROM was large in flexion-extension ranging between 6.1 +/- 3.1 degrees and 5.1 +/- 2.2 degrees under 0 N to 800 N preloads. The ATB plate resulted in a significant additional decrease in flexion-extension ROM under 400 N and 800 N preloads (P < 0.05). The flexion-extension ROM with the ATB plate was 4.1 +/- 2.3 under 0 N preload and ranged from 3.1 +/- 1.8 to 2.4 +/- 1.3 under 400 N to 800 N preloads. The plate did not significantly decrease lateral bending or axial rotation ROM compared with stand-alone FRA (P > 0.05), but the resultant ROM was 2.7 +/-1.9 degrees and 0.9 +/- 0.6 degrees , respectively. Compared with the ATB plate, the transpedicular instrumentation resulted in significantly less ROM in flexion-extension and lateral bending (P < 0.05), but not in axial rotation (P > 0.05). CONCLUSION The ATB plate can significantly increase the stability of the anterior FRA at L5-S1 level. Although supplemental transpedicular instrumentation results in a more stable biomechanical environment, the resultant ROM with the addition of a plate is small, especially under physiologic preload, suggesting that the plate can sufficiently resist motion. Therefore, clinical assessment of the ATB plate as an alternative to transpedicular instrumentation to enhance ALIF cage stability is considered reasonable.
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Niemeyer TK, Koriller M, Claes L, Kettler A, Werner K, Wilke HJ. In vitro study of biomechanical behavior of anterior and transforaminal lumbar interbody instrumentation techniques. Neurosurgery 2007; 59:1271-6; discussion 1276-7. [PMID: 17277690 DOI: 10.1227/01.neu.0000245609.01732.e4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To study the biomechanical behavior of lumbar interbody instrumentation techniques using titanium cages as either transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion (ALIF), with and without posterior pedicle fixation. METHODS Six fresh-frozen lumbar spines (L1-L5) were loaded with pure moments of +/-7.5 Nm in unconstrained flexion-extension, lateral bending, and axial rotation. Specimen were tested intact, after implantation of an ALIF or TLIF cage "stand-alone" in L2-L3 or L3-L4, and after additional posterior pedicle screw fixation. RESULTS In all loading directions, the range of motion (ROM) of the segments instrumented with cage and pedicle screw fixation was below the ROM of the intact lumbar specimen for both instrumentation techniques. A significant difference was found between the TLIF cage and the ALIF cage with posterior pedicle screw fixation for the ROM in flexion-extension and axial rotation (P < 0.05). Without pedicle screw fixation, the TLIF cage showed a significantly increased ROM and neutral zone compared with an ALIF cage "stand-alone" in two of the three loading directions (P < 0.05). CONCLUSION With pedicle screw fixation, the ALIF cage provides a higher segmental stability than the TLIF cage in flexion-extension and axial rotation, but the absolute biomechanical differences are minor. The different cage design and approach show only minor differences of segmental stability when combined with posterior pedicle screw fixation.
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Affiliation(s)
- Thomas K Niemeyer
- Spine Service, Department of Orthopaedic Surgery, University Hospital Tübingen, Tübingen, Germany.
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