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Love SA, Gultian KA, Jalloh US, Stevens A, Kim TWB, Vega SL. Mesenchymal stem cells enhance targeted bone growth from injectable hydrogels with BMP-2 peptides. J Orthop Res 2024; 42:1599-1607. [PMID: 38323639 PMCID: PMC11161325 DOI: 10.1002/jor.25798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/08/2024] [Accepted: 01/20/2024] [Indexed: 02/08/2024]
Abstract
Osteoporosis is the most common chronic metabolic bone disease, and the prevalence of osteoporotic fractures is rapidly increasing with the aging population. While bisphosphonates can reduce bone loss and risk of fracture, these drugs are systemic, rely on long-term use, and patient compliance is low. Recombinant human bone morphogenetic protein-2 (BMP-2) is an FDA-approved protein that can offer a more targeted therapeutic than systemic treatments. DWIVA is a peptide sequence corresponding to the wrist epitope of BMP-2, and DWIVA-functionalized hydrogels feature osteoinductive propertiesin vitro and in vivo. This study reports that self-forming DWIVA-functionalized hydrogels injected into the intramedullary canal of rat femurs induce a local increase in trabecular bone in as little as 2 weeks. Increases in bone volume, trabecular thickness, and trabeculae count from DWIVA-laden hydrogels persist for at least 4 weeks, and the inclusion of mesenchymal stem cells (MSCs) significantly enhances the development of mineralized bone. Histological analysis of decalcified femurs also shows that hydrogel injections containing DWIVA peptide and MSCs stimulate unmineralized bone tissue formation and induce an increased count of osteoblasts and osteoclasts at the injection site after 4 weeks. Overall, the MSC-laden DWIVA peptide-functionalized hydrogels presented rapidly induce targeted bone formation and have the potential to form nascent bone within bones in jeopardy of an osteoporotic fracture such as the femur.
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Affiliation(s)
- Stacy A. Love
- Department of Biomedical Engineering, Rowan University, Glassboro, NJ
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ
| | | | - Umu S. Jalloh
- Department of Biomedical Engineering, Rowan University, Glassboro, NJ
| | - Anna Stevens
- Department of Biomedical Engineering, Rowan University, Glassboro, NJ
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - Tae Won B. Kim
- Department of Biomedical Engineering, Rowan University, Glassboro, NJ
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - Sebastián L. Vega
- Department of Biomedical Engineering, Rowan University, Glassboro, NJ
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ
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Hasan S, Al-Jamal M, Miller A, Higginbotham DO, Cavazos DR, Waheed M, Saleh E, McCarty SA. Efficacy and Outcome Measurement of iFactor/ABM/P-15 in Lumbar Spine Surgery: A Systematic Review. Global Spine J 2024; 14:1422-1433. [PMID: 37994908 PMCID: PMC11289567 DOI: 10.1177/21925682231217253] [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: 11/24/2023] Open
Abstract
STUDY DESIGN Systematic Review. OBJECTIVES To determine the efficacy and overall outcomes of iFactor/ABM/P-15 following lumbar spine surgery. METHODS We performed a search of the Cochrane Library, Medline Ovid, PubMed, and SCOPUS databases from inception until August 2023. Eligible studies included outcomes of patients receiving iFactor following lumbar spine surgery. The primary outcomes of interest were fusion rates and iFactor efficacy after lumbar surgery in patients who received iFactor. Secondary outcomes included patient-reported outcomes and complication rates. RESULTS A total of 766 titles were initially screened. After inclusion criteria were applied, 5 studies (388 patients) were included, which measured overall outcomes of iFactor/ABM/P-15 following lumbar spine surgery. These studies showed acceptable reliability for inclusion based on the Methodical Index for Non-Randomized studies and Critical Appraisal Skills Programme assessment tools. iFactor/ABM/P-15 facilitated significantly faster bone development in various procedures while maintaining favorable clinical outcomes compared to traditional grafts. CONCLUSIONS This systematic review found that iFactor/ABM/P-15 use for lumbar spine surgery maintains similar managing patient-reported outcomes relative to other grafting methods. In regard to rates of fusion, iFactor/ABM/P-15 showed a significantly faster rate of fusion when compared to traditional grafts including allograft, autograft, demineralized bone matrix (DBM), and recombinant human bone morphogenetic protein-2 (rhBMP-2). Future multicenter randomized control trials with larger sample sizes are recommended to further assess iFactor/ABM/P-15 efficacy in lumbar spine surgery.
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Affiliation(s)
- Sazid Hasan
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
- Department of Orthopaedic Surgery, Beaumont Hospital, Royal Oak, MI, USA
| | - Malik Al-Jamal
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Alex Miller
- Department of Orthopaedic Surgery, Beaumont Hospital, Royal Oak, MI, USA
| | | | - Daniel R. Cavazos
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI, USA
| | - Muhammad Waheed
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI, USA
| | - Ehab Saleh
- Department of Orthopaedic Surgery, Beaumont Hospital, Royal Oak, MI, USA
| | - Scott A. McCarty
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI, USA
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Zeitouni D, Pfortmiller D, Coric D, Kim PK, Smith MD, Dyer EH, Adamson TE, McGirt MJ, Rossi VJ. Does type of bone graft matter? A retrospective review of the use of biological bone grafts in patients undergoing elective 1-3 level spinal 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 2024; 33:1340-1346. [PMID: 38459270 DOI: 10.1007/s00586-023-08108-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 11/15/2023] [Accepted: 12/15/2023] [Indexed: 03/10/2024]
Abstract
OBJECTIVE There is a lack of strong evidence for use of expensive bone substitutes. This study compares perioperative data and patient reported quality-of-life outcomes across the varied types of bone graft extenders. The study analyzes the existing Quality and Outcomes Database and evaluates patient reported outcomes for 1-3 level lumbar fusion procedures comparing across different types of biologics bone graft. METHODS We retrospectively analyzed a prospectively collected data registry. Bone graft implant data were collected and grouped into the following categories: (1) Autograft with basic allograft (2) Enhanced, synthetic, or cellular allograft (3) Use of BMP. Preoperative and 1 year patient reported outcomes and perioperative data from the prospective collected registry were analyzed. RESULTS There were 384 patients included in this study. There were 168 (43.8%) patients in group 1, 133 (34.6%) patients in group 2, and 83 (21.6%) in group 3. There were no group differences in baseline or 1 year back pain, leg pain, ODI, or EQ-5D. The GLM Repeated Measures results indicate a significant difference within each of the three groups between the preoperative and postoperative measures for back pain, leg pain, ODI, and EQ-5D. The change over time was not significantly different between the groups. CONCLUSIONS Bone graft extenders are a significant contributor to the cost of lumbar fusion. This study demonstrates no difference in preoperative, and 1 year patient reported outcomes between the three groups. There was no significant difference in rate of reoperations across the three groups.
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Affiliation(s)
- Daniel Zeitouni
- Atrium Health Neurological Surgery, Charlotte, NC, USA.
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA.
| | - Deborah Pfortmiller
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA
| | - Domagoj Coric
- Atrium Health Neurological Surgery, Charlotte, NC, USA
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA
| | - Paul K Kim
- Atrium Health Neurological Surgery, Charlotte, NC, USA
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA
| | - Mark D Smith
- Atrium Health Neurological Surgery, Charlotte, NC, USA
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA
| | - E Hunter Dyer
- Atrium Health Neurological Surgery, Charlotte, NC, USA
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA
| | - Tim E Adamson
- Atrium Health Neurological Surgery, Charlotte, NC, USA
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA
| | - Matthew J McGirt
- Atrium Health Neurological Surgery, Charlotte, NC, USA
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA
| | - Vincent J Rossi
- Atrium Health Neurological Surgery, Charlotte, NC, USA
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave, Charlotte, NC, 28203, USA
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Sayeed A, Jawad A, Zakko P, Lee M, Park DK. Radiographic Fusion Outcomes for Trinity Cellular Based Allograft versus Local Bone in Posterolateral Lumbar Fusion. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00018. [PMID: 38648399 PMCID: PMC11037727 DOI: 10.5435/jaaosglobal-d-23-00196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Cellular-based autograft (CBA) is being used in posterolateral lumbar arthrodesis as a fusion supplementation alternative. OBJECTIVE To assess radiographic fusion in patients undergoing posterolateral lumbar fusion with unilateral Trinity CBA compared with contralateral local bone autograft as an internal control. METHODS A single surgeon's practice database was interrogated for consecutive patients undergoing primary posterolateral lumbar fusion with Trinity from 2018 to 2021. Patients had Trinity applied unilaterally, with local bone autograft applied contralaterally. Fusion was assessed postoperatively by using CT after 9 months. Demographics and patient-reported outcome measures were collected preoperatively and up to 12 months postoperatively. RESULTS Thirty-nine patients were included. There were 81 attempted fusion levels. Overall fusion rate, defined as bony bridging on at least one side of a given level for all levels fused, was 85.2% of patients. No statistically significant difference was observed in fusion rates between CBA versus local bone (79.0% versus 76.54% of levels attempted, respectively, P = 0.3527). Oswestry Disability Index improved by 3 months (P = 0.0152) and was maintained. Two patients required revision for symptomatic nonunion. CONCLUSIONS Similar radiographic fusion rates were achieved with Trinity and local bone. Trinity is a viable alternative to local bone in posterolateral lumbar fusion.
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Affiliation(s)
- Aatif Sayeed
- From the Corewell Health William Beaumont University Hospital, Royal Oak, MI (Dr. Sayeed, Dr. Jawad, Dr. Zakko and Dr. Park); The Ohio State University School of Medicine, Columbus, OH (Dr. Lee)
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Alentado VJ, Kazi FA, Potts CA, Zaazoue MA, Potts EA, Khairi SA. A Sodium Oxychlorosene-Based Infection Prevention Protocol Safely Decreases Postoperative Wound Infections in Adult Spinal Deformity Surgery. Cureus 2024; 16:e56109. [PMID: 38618460 PMCID: PMC11009892 DOI: 10.7759/cureus.56109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION This study sought to determine the efficacy of a complex multi-institutional sodium oxychlorosene-based infection protocol for decreasing the rate of surgical site infection after instrumented spinal surgery for adult spinal deformity (ASD). Infection prevention protocols have not been previously studied in ASD patients. METHODS A retrospective analysis was performed of patients who underwent posterior instrumented spinal fusion of the thoracic or lumbar spine for deformity correction between January 1, 2011, and May 31, 2019. The efficacy of a multi-modal infection prevention protocol was examined. The infection prevention bundle consisted of methicillin-resistant Staphylococcus aureus testing, chlorhexidine gluconate bathing preoperatively, sodium oxychlorosene rinse, vancomycin powder placement, and surgical drain placement at the time of surgery. RESULTS About 254 patients fit the inclusion criteria. Among these patients, nine (3.5%) experienced post-surgical deep-wound infection. Demographics and surgical characteristics amongst infected and non-infected cohorts were similar, although diabetes trended towards being more prevalent in patients who developed a postoperative wound infection (p=0.07). Among 222 patients (87.4%) who achieved a minimum of two years of follow-ups, 184 patients (82.9%) experienced successful fusion, comparing favorably with pseudarthrosis rates in the ASD literature. Rates of pseudarthrosis and proximal junction kyphosis were similar amongst infected and non-infected patients. CONCLUSION An intraoperative comprehensive sodium oxychlorosene-based infection prevention protocol helped to provide a low rate of infection after major deformity correction without negatively impacting other postoperative procedure-related metrics.
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Affiliation(s)
- Vincent J Alentado
- Neurological Surgery, Goodman Campbell Brain and Spine, Ascension St. Vincent Hospital Indianapolis, Indianapolis, USA
| | - Fezaan A Kazi
- Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Caroline A Potts
- Neurological Surgery, Goodman Campbell Brain and Spine, Ascension St. Vincent Hospital Indianapolis, Indianapolis, USA
| | - Mohamed A Zaazoue
- Neurological Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Eric A Potts
- Neurological Surgery, Goodman Campbell Brain and Spine, Ascension St. Vincent Hospital Indianapolis, Indianapolis, USA
| | - Saad A Khairi
- Neurological Surgery, Goodman Campbell Brain and Spine, Ascension St. Vincent Hospital Indianapolis, Indianapolis, USA
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Singh V, Oppermann M, Evaniew N, Soroceanu A, Nicholls F, Jacobs WB, Thomas K, Swamy G. Lateral Lumbar Interbody Fusion With rhBMP-2 can Achieve High Fusion Rates in Adult Spine Deformity Surgeries. Global Spine J 2024; 14:244-256. [PMID: 35586905 PMCID: PMC10676168 DOI: 10.1177/21925682221103512] [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 An ambispective, observational study of the prospective, institutional adult spine deformity (ASD) database. OBJECTIVES The study investigates the clinical and radiographic fusion rates with lateral interbody approach and rhBMP-2 in multiple-level lumbar fusion in the ASD population. Previous studies have reported over 10% pseudoarthrosis rate with multiple segment fusions. Lateral lumbar interbody fusion (LLIF) allows multiple-level, less-invasive access to the anterior lumbar spine. We hypothesized that fusion rates with lateral approach with rhBMP-2 use are superior to the published data on lumbar fusion in ASD patients. METHODS The institutional ASD database was searched to identify eligible patients with two or more levels of LLIF (T12-L5), >4 levels of posterior instrumentations and >2 years of follow-up between the years 2010 and 2018. Antero-posterior and lateral 36-inch standing radiographs for each patient and computed tomography scans in select patients were studied to ascertain fusion status and patients were divided into two groups based on fusion status. RESULTS The study included 179 patients with a mean age of 65.3 years and 74% female patients. The median number of interbody fusions was performed at 3 (IQR 3-4) levels. The mean follow-up duration was 4.4 years (SD = 1.9). 169 patients (94.5%) had successful arthrodesis, while 10 patients (5.5%) had radiological pseudoarthrosis at one level. Of the 10 patients, 8 (4.4%) were either clinically asymptomatic or had manageable back pain. Two patients (1.1%) required revision surgery for symptomatic pseudoarthrosis. CONCLUSION This is the largest known series of ASD patients investigating the fusion rates with multiple-level LLIFs. LLIF along with rhBMP-2 can achieve high fusion success across interbody fusion levels in multi-segmental ASD surgeries.
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Affiliation(s)
- Vishwajeet Singh
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Marcelo Oppermann
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan Evaniew
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alex Soroceanu
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Fred Nicholls
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - W. Bradley Jacobs
- Division of Neurosurgery Spine Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Ken Thomas
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Ganesh Swamy
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Park S, Jeong YH, Ha BJ, Yoo BS, Kim SH, Lee CK, Yi S, Ha Y, Kim KN, Shin DA. Fusion rate of Escherichia coli-derived recombinant human bone morphogenetic protein-2 compared with local bone autograft in posterior lumbar interbody fusion for degenerative lumbar disorders. Spine J 2023; 23:1877-1885. [PMID: 37516282 DOI: 10.1016/j.spinee.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND CONTEXT The use of recombinant human bone morphogenetic proteins-2 (rhBMP-2) for spinal fusion has been reported to be effective. However, most studies have focused on posterolateral and anterior lumbar interbody fusion, and few have investigated posterior lumbar interbody fusion (PLIF). PURPOSE This study aimed to determine the effectiveness and safety of the delivery of Escherichia coli-derived rhBMP-2 (E.BMP-2) with hydroxyapatite (HA) and β-tricalcium phosphate (β-TCP) poloxamer hydrogel composite carriers for PLIF. STUDY DESIGN A retrospective study. PATIENT SAMPLE Patients who underwent 1 to 3 levels of PLIF for lumbar degenerative disc disorders between 2015 and 2020 with a follow-up of ≥1 year were enrolled. In total, 254 patients (357 levels) were included in the analysis. The evaluation was performed at each segment level. In the E.BMP-2 group, 160 patients (221 levels) received autologous local bone with E.BMP-2 (maximum 0.5 mg/level), and in the control group, 94 patients (136 levels) received only local bone graft. OUTCOME MEASURES The primary outcome of this study was to compare the X-ray and CT fusion rates between the two groups. Secondary outcomes included analysis of the patients' clinical outcomes and postoperative complications on CT scans. METHODS Clinical evaluations were performed using a visual analog scale for back pain, the Oswestry Disability Index for disability, and physical and mental component summaries of the Short Form 36-Item Form Health Survey to assess functional effects and quality of life. The fusion was evaluated using radiography and CT. On radiography, solid fusion was defined when the difference between extension and flexion was less than 5°. On CT, solid fusion was defined when the upper and lower vertebral bodies were connected by the trabecular bone (bone bridge formation). In addition, complications such as osteolysis, cage subsidence, and screw loosening were investigated using CT. RESULTS All clinical results for low back pain, disability, and quality of life in both groups were excellent and showed statistically significant improvements compared with baseline (p<.0001). According to the X-ray evaluations, fusion was achieved in 92.31% (204/221) of the patients in the E.BMP-2 group and 82.35% (112/136) of the patients in the control group (p=.0041). According to the CT evaluations, the fusion rates were 93.21% (206/221) and 88.24% (120/136) in the E.BMP-2 and control groups (p=.1048), respectively. Except for screw loosening, which had a significantly higher incidence in the control group (p=.0014), the rates of most postoperative complications were not significantly different between the groups. CONCLUSIONS This study demonstrated that the adjunctive use of a low dose of E.BMP-2 with HA and β-TCP hydrogel can effectively promote bone fusion, making it a promising option for patients with limited autograft availability or compromised bone quality in PLIF.
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Affiliation(s)
- Sangman Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Yeong Ha Jeong
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Byeong Jin Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Beom Seok Yoo
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Soo-Heon Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Chang Kyu Lee
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea.
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Shih CM, Hsu CE, Chen KH, Pan CC, Lee CH. Surgical outcomes of anterior lumbar interbody fusion in revision lumbar interbody fusion surgery. J Orthop Surg Res 2023; 18:497. [PMID: 37443066 DOI: 10.1186/s13018-023-03972-6] [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: 03/16/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUNDS Anterior lumbar interbody fusion (ALIF) is an attractive option for revision lumbar interbody fusion as it provides wide access for implant removal and accommodation of large interbody grafts for fusion. However, revision lumbar interbody fusion surgery has not been found to result in significantly better functional outcomes compared with other approaches. To date, no prognostic factors of anterior lumbar interbody fusion in revision lumbar interbody fusion have been reported. In this study, we investigated the surgical results and possible prognostic factors of anterior lumbar interbody fusion in revision lumbar interbody fusion. METHODS Patients who received revision interbody fusion surgery between January 2010 and May 2018 in our hospital were reviewed. Clinical outcomes were determined according to whether the VAS score improvement in back pain and leg pain reached the minimum clinically important difference (MCID) and Macnab criteria. Radiographic outcomes were assessed with fusion rate, preoperative, and postoperative lumbar lordosis. Operative-relative factors that may affect clinical outcomes, such as BMI, existence of cage migration, cage subsidence, pseudarthrosis, previous procedure, and number of fusion segments, were collected and analyzed. RESULTS A total of 22 consecutive patients who received ALIF for revision interbody fusion surgery were included and analyzed. There were 9 men and 13 women with a mean age at operation of 56 years (26-78). The mean follow-up was 73 months (20-121). The minimal clinically important difference (MCID) was reached in 11 (50%) of the patients for back pain and 14 (64%) for leg pain. According to the modified Macnab criteria, 73% of the patients in this study had successful outcomes (excellent or good). The pain and lumbar lordosis had significant improvement (P < 0.05). Preoperative fusion segment ≥ 2 was shown to be a poor prognostic factor for back pain improvement reaching MCID (P = 0.043). CONCLUSIONS ALIF has proven effective for revision lumbar fusion surgery, yielding positive clinical and radiographic results. However, having two or more preoperative fusion segments can negatively impact back pain improvement. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Cheng-Min Shih
- Department of Orthopaedic Surgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
- College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Department of Physical Therapy, Hungkuang University, Taichung, Taiwan
| | - Cheng-En Hsu
- Department of Orthopaedic Surgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.
- Sports Recreation and Health Management Continuing Studies-Bachelor's Degree Completion Program, Tunghai University, Taichung, Taiwan.
| | - Kun-Hui Chen
- Department of Orthopaedic Surgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- College of Computing and Informatics, Providence University, Taichung, Taiwan
| | - Chien-Chou Pan
- Department of Orthopaedic Surgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Rehabilitation Science, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Cheng-Hung Lee
- Department of Orthopaedic Surgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Food Science and Technology, Hungkuang University, Taichung, Taiwan
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Tortolani PJ, Lucas SL, Pivazyan G, Wang W, Cunningham BW. Validation of Impaction Grafting for Single-Level Transforaminal Lumbar Interbody Fusion-Technical Pearls and MicroCT Analysis. Spine (Phila Pa 1976) 2023; 48:E70-E77. [PMID: 36728792 DOI: 10.1097/brs.0000000000004559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/11/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Cadaveric study. BACKGROUND CONTEXT Transforaminal lumbar interbody fusion (TLIF) represents a well-documented operative surgical technique utilized in the management of lumbar pathology requiring interbody arthrodesis. The microstructural properties of impaction grafting (IG) after TLIF has yet to be reported. PURPOSE The current study was designed first, to quantify the degree, to which IG augmentation would increase intrabody final bone volume and bone graft surface contact area with the endplates; secondly to quantify the volumes of locally harvested bone and bone needed for maximal impaction. MATERIALS AND METHODS Three cadaveric lumbosacral spine specimens were dissected into L1-L2, L3-L4, and L5-S1 motion segments for a total of 9 functional spinal units. Each interbody unit underwent a TLIF procedure with the implantation of an interbody spacer containing autogenous morselized bone. Microcomputed tomography scans were then performed to evaluate the final bone volume and bone surface contact area (BSCA). Subsequently, IG augmented TLIF procedure was carried and microcomputed tomography scans were repeated. RESULTS IG augmentation of TLIF exhibited a 346% increase in final bone volume (TLIF: 0.30 ± 0.07 cm 3 ; IG-TLIF: 1.34 ± 0.42 cm 3 ; P < 0.05) and a 152% increase in BSCA (TLIF: 45.06 ± 15.47%; IG-TLIF: 68.28 ± 6.85%; P < 0.05) when compared with the nonimpacted TLIF treatment. In addition, the average amount of autogenous bone collected was 8.21±2.08 cm 3 , which sufficiently fulfilled the requirements for bone grafting (TLIF: 1.23 ± 0.40 cm 3 ; IG-TLIF 6.42 ± 1.20 cm 3 ). CONCLUSIONS IG augmentation of TLIF significantly improved final bone volume in the disc space and BSCA with vertebral endplates in vitro. CLINICAL SIGNIFICANCE Greater BSCA and final volume of bone graft reflect promisingly on their potential to increase fusion rates. Clinical studies will be needed to corroborate these findings.
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Affiliation(s)
- Paul Justin Tortolani
- Department of Orthopedic Surgery, University of Maryland St. Joseph Medical Center, Towson, MD
| | | | - Gnel Pivazyan
- Department of Orthopedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, MD
- Department of Neurosurgery, MedStar Georgetown University Hospital, WA
| | | | - Bryan W Cunningham
- Department of Orthopedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, MD
- Department of Orthopedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
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Broussolle T, Roux JP, Chapurlat R, Barrey C. Murine models of posterolateral spinal fusion: A systematic review. Neurochirurgie 2023; 69:101428. [PMID: 36871885 DOI: 10.1016/j.neuchi.2023.101428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Rodent models are commonly used experimentally to assess treatment effectiveness in spinal fusion. Certain factors are associated with better fusion rates. The objectives of the present study were to report the protocols most frequently used, to evaluate factors known to positively influence fusion rate, and to identify new factors. METHOD A systematic literature search of PubMed and Web of Science found 139 experimental studies of posterolateral lumbar spinal fusion in rodent models. Data for level and location of fusion, animal strain, sex, weight and age, graft, decortication, fusion assessment and fusion and mortality rates were collected and analyzed. RESULTS The standard murine model for spinal fusion was male Sprague Dawley rats of 295g weight and 13 weeks' age, using decortication, with L4-L5 as fusion level. The last two criteria were associated with significantly better fusion rates. On manual palpation, the overall mean fusion rate in rats was 58% and the autograft mean fusion rate was 61%. Most studies evaluated fusion as a binary on manual palpation, and only a few used CT and histology. Average mortality was 3.03% in rats and 1.56% in mice. CONCLUSIONS These results suggest using a rat model, younger than 10 weeks and weighing more than 300 grams on the day of surgery, to optimize fusion rates, with decortication before grafting and fusing the L4-L5 level.
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Affiliation(s)
- T Broussolle
- Department of Spine Surgery, P. Wertheimer University Hospital, GHE, hospices civils de Lyon, université Claude-Bernard Lyon 1, Lyon, France; Inserm UMR 1033, université Claude-Bernard Lyon 1, Lyon, France.
| | - Jean-Paul Roux
- Inserm UMR 1033, université Claude-Bernard Lyon 1, Lyon, France
| | - R Chapurlat
- Inserm UMR 1033, université Claude-Bernard Lyon 1, Lyon, France
| | - C Barrey
- Department of Spine Surgery, P. Wertheimer University Hospital, GHE, hospices civils de Lyon, université Claude-Bernard Lyon 1, Lyon, France; Arts et métiers ParisTech, ENSAM, 151, boulevard de l'Hôpital, 75013 Paris, France
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11
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Cho M, You KH, Yeom JS, Kim H, Lee KB, Cho JH, Yang JJ, Lee JH. Mid-term efficacy and safety of Escherichia coli-derived rhBMP-2/hydroxyapatite carrier in lumbar posterolateral fusion: a randomized, multicenter 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 2023; 32:353-360. [PMID: 36394652 DOI: 10.1007/s00586-022-07440-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/07/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE This study aimed to evaluate the mid-term efficacy and safety of Escherichia coli-derived bone morphogenetic protein-2 (E.BMP-2)/hydroxyapatite (HA) in lumbar posterolateral fusion (PLF). METHODS This multicenter, evaluator-blinded, observational study utilized prospectively collected clinical data. We enrolled 74 patients who underwent lumbar PLF and had previously participated in the BA06-CP01 clinical study, which compared the short-term outcomes of E.BMP-2 with an auto-iliac bone graft (AIBG). Radiographs and CT scans were analyzed to evaluate fusion grade at 12, 24, and 36 months. Visual analog scale (VAS), Oswestry disability index (ODI), and Short Form-36 (SF-36) scores were measured preoperatively and at 36 months after surgery. All adverse events in this study were assessed for its relationship with E.BMP-2. RESULTS The fusion grade of the E.BMP-2 group (4.91 ± 0.41) was superior to that of the AIBG group (4.25 ± 1.26) in CT scans at 36 months after surgery (p = 0.007). Non-union cases were 4.3% in the E.BMP-2 and 16.7% in the AIBG. Both groups showed improvement in pain VAS, ODI, and SF-36 scores when compared to the baseline values, and there were no statistically significant differences between the two groups. No treatment-related serious adverse reactions were observed in either group. No neoplasm-related adverse events occurred in the E.BMP-2 group. CONCLUSIONS The fusion quality of E.BMP-2/HA was superior to that of AIBG. E.BMP-2/HA showed comparable mid-term outcomes to that of AIBG in terms of efficacy and safety in one-level lumbar PLF surgery.
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Affiliation(s)
- Minjoon Cho
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Boramae-Ro 5-Gil, Dongjak-Gu, Seoul, 07061, Republic of Korea
| | - Ki-Han You
- Department of Orthopedic Surgery, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Jin Sup Yeom
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea.,Spine Center and Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyoungmin Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Kwang Bok Lee
- Department of Orthopaedic Surgery, School of Medicine, Research Institute of Clinical Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Jun Yang
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Dongguk Unviversity College of Medicine, Goyang, Korea
| | - Jae Hyup Lee
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Boramae-Ro 5-Gil, Dongjak-Gu, Seoul, 07061, Republic of Korea. .,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea.
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12
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Kim YH, Ha KY, Kim YS, Kim KW, Rhyu KW, Park JB, Shin JH, Kim YY, Lee JS, Park HY, Ko J, Kim SI. Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion. Asian Spine J 2022; 16:1022-1033. [PMID: 36573302 PMCID: PMC9827209 DOI: 10.31616/asj.2022.0435] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/28/2022] Open
Abstract
Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.
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Affiliation(s)
- Young-Hoon Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Youn-Soo Kim
- Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Ki-Won Kim
- Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Won Rhyu
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jae-Hyuk Shin
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Young-Yul Kim
- Department of Orthopaedic Surgery, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jun-Seok Lee
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaeryong Ko
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea,Corresponding author: Sang-Il Kim Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6775, Fax: +82-2-535-9837, E-mail:
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13
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Yang KS, Chen CW, Yau RB, Liang HC, Ko CC, Kuo JR, Chio CC, Lim SW. A novel surgical technique in transforaminal lumbar interbody fusion by the bone graft delivery device: evaluation of therapeutic effect in patients with minimally invasive spine surgery. BMC Surg 2022; 22:366. [PMID: 36289500 PMCID: PMC9597986 DOI: 10.1186/s12893-022-01773-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 08/17/2022] [Indexed: 11/28/2022] Open
Abstract
Background Transforaminal Lumbar Interbody Fusion (TLIF) is commonly associated with higher complications and longer operative time. This study aims to evaluate the effectiveness, safety, and usability of a novel minimally invasive surgery (MIS) bone graft delivery device.
Methods 73 consecutive patients with lumbar spondylosis, degenerative disc disease, spondylolisthesis, scoliosis or trauma were enrolled in this randomized controlled trial. Group 1 comprised 39 patients treated with the novel MIS bone graft delivery device. Group 2 consisted of 34 patients treated with the conventional system. The primary objective of the study was the assessment of the amount of bone graft delivery using the device. The secondary objectives were the effect of the device on operative time, pain relief, disability improvement, and bone fusion grade. Results Bone delivery amount was significantly higher in the MIS device group (6.7 ± 2.9 mL) compared to the conventional group (2.3 ± 0.5 mL), p < 0.001. Regarding the operation time, the MIS device group was associated significantly lower duration than the conventional group (p < 0.001). After a 3-month follow-up, 39.5% of the patients in the MIS device group and 3.5% of the patients in the conventional group were observed to achieve grade I fusion (complete fusion). There was a significant difference in fusion success rates (p < 0.01). Conclusion The novel MIS bone graft delivery device was associated with successful bone delivery. Our MIS device provides promising modality with less operative time and higher bone fusion rates than conventional modalities. Trial Registration This trial was retrospectively registered on ClinicalTrials.gov (Registration date: 11/19/2021; Registration number: NCT05190055). Supplementary Information The online version contains supplementary material available at 10.1186/s12893-022-01773-y.
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Affiliation(s)
- Kai-shun Yang
- grid.440682.c0000 0001 1866 919XDepartment of Spinal Surgery, First Affiliated Hospital of Dali University, Dali, Yunnan China
| | - Chih-Wei Chen
- grid.413876.f0000 0004 0572 9255Division of Neurosurgery, Department of Surgery, Chi Mei Medical Center, Tainan City, 710 Taiwan ,grid.411315.30000 0004 0634 2255Department of Occupational Safety and Health/Institute of Industrial Safety and Disaster Prevention, College of Sustainable Environment, Chia Nan University of Pharmacy and Science, Tainan City, 717 Taiwan
| | - Ru-Bin Yau
- grid.440682.c0000 0001 1866 919XDepartment of Spinal Surgery, First Affiliated Hospital of Dali University, Dali, Yunnan China
| | - Huang-Chien Liang
- grid.440372.60000 0004 1798 0973Department of Materials Engineering, Ming Chi University of Technology, New Taipei City, Taiwan
| | - Ching-Chung Ko
- grid.413876.f0000 0004 0572 9255Department of Medical Imaging, Chi-Mei Medical Center, Tainan City, Taiwan ,grid.411315.30000 0004 0634 2255Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Jinn-Rung Kuo
- grid.413876.f0000 0004 0572 9255Division of Neurosurgery, Department of Surgery, Chi Mei Medical Center, Tainan City, 710 Taiwan ,grid.413876.f0000 0004 0572 9255Department of Medical Research, Chi-Mei Medical Center, Tainan City, Taiwan
| | - Chung-Ching Chio
- grid.413876.f0000 0004 0572 9255Division of Neurosurgery, Department of Surgery, Chi Mei Medical Center, Tainan City, 710 Taiwan
| | - Sher-Wei Lim
- grid.413876.f0000 0004 0572 9255Division of Neurosurgery, Department of Surgery, Chi Mei Medical Center, Tainan City, 710 Taiwan ,grid.452538.d0000 0004 0639 3335Department of Nursing, Min-Hwei College of Health Care Management, Tainan City, Taiwan
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14
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Gouzoulis MJ, Kammien AJ, Zhu JR, Gillinov SM, Moore HG, Grauer JN. Single-level posterior lumbar fusions in patients with Ehlers Danlos Syndrome not found to be associated with increased postoperative adverse events or five-year reoperations. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 11:100136. [PMID: 35783003 PMCID: PMC9241136 DOI: 10.1016/j.xnsj.2022.100136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/19/2022] [Accepted: 06/08/2022] [Indexed: 11/15/2022]
Abstract
Background Ehlers Danlos Syndrome (EDS) is a rare connective tissue disorder that results from mutations in collagen genes. Potentially related to laxity and resultant degenerative changes, adult EDS patients may require posterior lumbar fusion (PLF). However, with low numbers, adequately powered outcome studies have been limited. The purpose of this study was to investigate risk of complications, readmissions and reoperations in adult patients with EDS following single-level PLF. Methods A retrospective study using the 2010 to 2020 MSpine Pearldiver dataset was performed. Adult patients undergoing single-level PLF (excluding any with anterior procedures) with and without EDS for which at least 90-day follow up was available were identified. Any cases performed for trauma, tumor, or infection were excluded.Single-level PLF EDS patients were then matched 1:4 with PLF non-EDS patients based on age, sex, and Elixhauser Comorbidity Index (ECI). Rates of ninety-day any, severe, and minor adverse events as well as readmissions were tabulated and compared with chi-square tests. Multivariate logistical regression was then performed (controlling for age, sex, and ECI).Reoperation surgeries over five years were assessed, Kaplan-Meier survival curves generated, and curves of those with and without EDS were compared with log rank test. Results In total, there were 170,100 single-level PLF case identified, of which 242 (0.14%) had EDS. After matching, there were 957 without EDS and 239 with EDS. On multivariate regression, there were no significant differences in 90-day any, severe, or minor adverse events, or readmissions (p>0.05 for each). Over five years, there were also not significant differences in rates of reoperation (p> 0.05). Conclusions For EDS patients undergoing PLF, the current study identified similar 90-day adverse events and 5-year reoperation rates compared to those without EDS. These findings may be useful for patient counseling and surgical planning for those with this rare condition.
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Affiliation(s)
- Michael J. Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Alexander J. Kammien
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Justin R. Zhu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Stephen M. Gillinov
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | | | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Corresponding Author: Jonathan N. Grauer, MD, PO Box 208071, New Haven, CT 06520-8071, Tel: 203-737-7464, Fax: 203-785-7132
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15
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Fogel G, Martin N, Lynch K, Pelletier MH, Wills D, Wang T, Walsh WR, Williams GM, Malik J, Peng Y, Jekir M. Subsidence and fusion performance of a 3D-printed porous interbody cage with stress-optimized body lattice and microporous endplates - a comprehensive mechanical and biological analysis. Spine J 2022; 22:1028-1037. [PMID: 35017054 DOI: 10.1016/j.spinee.2022.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 12/22/2021] [Accepted: 01/03/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND CONTEXT Cage subsidence remains a serious complication after spinal fusion surgery. Novel porous designs in the cage body or endplate offer attractive options to improve subsidence and osseointegration performance. PURPOSE To elucidate the relative contribution of a porous design in each of the two major domains (body and endplates) to cage stiffness and subsidence performance, using standardized mechanical testing methods, and to analyze the fusion progression via an established ovine interbody fusion model to support the mechanical testing findings. STUDY DESIGN/SETTING A comparative preclinical study using standardized mechanical testing and established animal model. METHODS To isolate the subsidence performance contributed by each porous cage design feature, namely the stress-optimized body lattice (vs. a solid body) and microporous endplates (vs. smooth endplates), four groups of cages (two-by-two combination of these two features) were tested in: (1) static axial compression of the cage (per ASTM F2077) and (2) static subsidence (per ASTM F2267). To evaluate the progression of fusion, titanium cages were created with a microporous endplate and internal lattice architecture analogous to commercial implants used in subsidence testing and implanted in an endplate-sparing, ovine intervertebral body fusion model. RESULTS The cage stiffness was reduced by 16.7% by the porous body lattice, and by 16.6% by the microporous endplates. The porous titanium cage with both porous features showed the lowest stiffness with a value of 40.4±0.3 kN/mm (Mean±SEM) and a block stiffness of 1976.8±27.4 N/mm for subsidence. The body lattice showed no significant impact on the block stiffness (1.4% reduction), while the microporous endplates decreased the block stiffness significantly by 24.9% (p<.0001). All segments implanted with porous titanium cages were deemed rigidly fused by manual palpation, except one at 12 weeks, consistent with robotic ROM testing and radiographic and histologic observations. A reduction in ROM was noted from 12 to 26 weeks (4.1±1.6° to 2.2±1.4° in lateral bending, p<.05; 2.1±0.6° to 1.5±0.3° in axial rotation, p<.05); and 3.3±1.6° to 1.9±1.2° in flexion extension, p=.07). Bone in the available void improved with time in the central aperture (54±35% to 83±13%, p<.05) and porous cage structure (19±26% to 37±21%, p=.15). CONCLUSIONS Body lattice and microporous endplates features can effectively reduce the cage stiffness, therefore reducing the risk of stress shielding and promoting early fusion. While body lattice showed no impact on block stiffness and the microporous endplates reduced the block stiffness, a titanium cage with microporous endplates and internal lattice supported bone ingrowth and segmental mechanical stability as early as 12 weeks in ovine interbody fusion. CLINICAL SIGNIFICANCE Porous titanium cage architecture can offer an attractive solution to increase the available space for bone ingrowth and bridging to support successful spinal fusion while mitigating risks of increased subsidence.
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Affiliation(s)
- Guy Fogel
- Spine Pain Begone Clinic, 2833 Babcock Rd Suite 306, San Antonio, TX 78229, USA
| | | | - Kelli Lynch
- NuVasive, 7475 Lusk Blvd., San Diego, CA 92129, USA
| | - Matthew H Pelletier
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Randwick, Sydney, NSW 2031, Australia
| | - Daniel Wills
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Randwick, Sydney, NSW 2031, Australia
| | - Tian Wang
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Randwick, Sydney, NSW 2031, Australia
| | - William R Walsh
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Randwick, Sydney, NSW 2031, Australia
| | | | - Jeremy Malik
- NuVasive, 7475 Lusk Blvd., San Diego, CA 92129, USA
| | - Yun Peng
- NuVasive, 7475 Lusk Blvd., San Diego, CA 92129, USA.
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16
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Alentado VJ, Berwanger RP, Konesco AM, Potts AJ, Potts CA, Stockwell DW, Dbeibo L, DePowell JJ, Horn EM, Khairi SA, McCanna SP, Mobasser JP, Rodgers RB, Potts EA. Use of an intraoperative sodium oxychlorosene-based infection prevention protocol to safely decrease postoperative wound infections after spine surgery. J Neurosurg Spine 2021; 35:817-823. [PMID: 34416716 DOI: 10.3171/2021.2.spine202133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative infection remains prevalent after spinal surgical procedures. Institutional protocols for infection prevention have improved rates of infection after spine surgery. However, prior studies have focused on only elective surgical patients. The aim of this study was to determine the efficacy of a multiinstitutional intraoperative sodium oxychlorosene-based infection prevention protocol for decreasing rate of infection after instrumented spinal surgery. METHODS A retrospective analysis was performed at two tertiary care institutions with level I trauma programs, and patients who underwent posterior instrumented spinal fusion between January 1, 2011, and May 31, 2019, were included. Postoperative deep wound infection rates were captured before and after implementation of a multiinstitutional infection prevention protocol. Possible adverse outcomes related to infection prevention techniques were also examined. In addition, consecutive patients treated from January 1, 2018, to May 31, 2019, were prospectively included in a database to collect preoperative and postoperative spine-specific quality of life measures and to assess the impact of postoperative infection on quality of life. RESULTS A total of 5047 patients fit the inclusion criteria. Of these, 1043 patients underwent surgery prior to protocol implementation. The infection rate of this cohort (3.5%) decreased significantly after protocol implementation (1.2%, p < 0.001). Postoperative sterile seroma rates did not differ between the preprotocol and postprotocol groups (0.7% vs 0.7%, p = 0.5). In the 1031 patients who underwent surgery between January 2018 and May 2019, the fusion rate was 89.2%. Quality of life outcomes between patients with infection and those without infection were similar, although statistical power was limited owing to the low rate of infection. Notably, 2 of 10 patients who developed deep wound infection died of infection-related complications. CONCLUSIONS An intraoperative sodium oxychlorosene-based infection prevention protocol helped to significantly decrease the rate of infection after spine surgery without negatively impacting other postoperative procedure-related metrics. Postoperative wound infection may be associated with higher-than-expected rate of postoperative mortality.
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Affiliation(s)
- Vincent J Alentado
- 1Department of Neurosurgery, Indiana University, Indianapolis, Indiana
- 2Indiana University School of Medicine, Indianapolis, Indiana
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
| | | | | | - Alex J Potts
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
| | | | - David W Stockwell
- 1Department of Neurosurgery, Indiana University, Indianapolis, Indiana
- 2Indiana University School of Medicine, Indianapolis, Indiana
| | - Lana Dbeibo
- 5Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - John J DePowell
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
- 4St. Vincent Health, Indianapolis, Indiana; and
| | - Eric M Horn
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
- 4St. Vincent Health, Indianapolis, Indiana; and
| | - Saad A Khairi
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
- 4St. Vincent Health, Indianapolis, Indiana; and
| | - Shannon P McCanna
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
- 4St. Vincent Health, Indianapolis, Indiana; and
| | - Jean-Pierre Mobasser
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
- 4St. Vincent Health, Indianapolis, Indiana; and
| | - Richard B Rodgers
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
- 4St. Vincent Health, Indianapolis, Indiana; and
| | - Eric A Potts
- 3Goodman Campbell Brain and Spine, Carmel, Indiana
- 4St. Vincent Health, Indianapolis, Indiana; and
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17
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Yoshii T, Hashimoto M, Egawa S, Hirai T, Inose H, Okawa A. Hydroxyapatite/collagen composite graft for posterior lumbar interbody fusion: a comparison with local bone graft. J Orthop Surg Res 2021; 16:639. [PMID: 34689807 PMCID: PMC8543945 DOI: 10.1186/s13018-021-02798-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background Autologous bone has been used for posterior lumbar intervertebral fusion (PLIF). However, harvesting autologous bone graft is associated with donor site complications. We previously developed a hydroxyapatite/collagen (HAp/Col) composite as an osteoconductive artificial bone, characterized by having a highly porous structure with sponge‐like elasticity. This study aims to investigate the effectiveness of HAp/Col composite with bone marrow aspirate (BMA) as a graft substitute in PLIF for the treatment of lumbar spinal diseases. Methods This study prospectively investigated patients who received one-level PLIF. For the interbody fusion, two titanium cages were inserted. On the one side of interbody space, HAp/Col composite incorporated with BMA filling the titanium cage was grafted. On the other side, local bone graft (LBG) harvested during decompressive laminotomy was grafted and then one-level instrumentation using pedicle screws was performed. The target levels were at L2/3 in 2 cases, L3/4 in 3 cases, L4/5 in 36 cases, and L5/S in 5 cases. We evaluated clinical symptoms and radiological outcomes of 46 patients and compared the fusion status of HAp/Col composite with that of LBG. Results The 1-year postoperative CT evaluation demonstrated that, in the HAp/Col, a complete fusion was observed in 38 patients (82.6%), whereas in the LBG, a complete fusion was observed in 35 patients (76.1%). There were no statistical differences between the HAp/Col and LBG. In the HAp/Col, incomplete fusion was observed in five patients (10.9%) and non-fusion in two patients (4.3%), and in the LBG, incomplete fusion was observed in nine patients (19.6%) and non-fusion in two patients (4.3%). At 2 years after the surgery, complete fusion increased to 44 patients (95.7%) in the HAp/Col and 41 patients (89.1%) in the LBG. There were no significant differences in the clinical scores for lumbar spine between patients with fusion and non-fusion. Conclusions The HAp/Col composite with BMA in the titanium cage can be effectively used as an alternative to conventional autologous LBG for intervertebral spinal fusion. Trial registration University hospital Medical Information Network, UMIN000045010, July 30th, 2021, Retrospectively registered, https://www.umin.ac.jp/english/.
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Affiliation(s)
- Toshitaka Yoshii
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyo City, Tokyo, 113-8510, Japan.
| | - Motonori Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyo City, Tokyo, 113-8510, Japan
| | - Satoru Egawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyo City, Tokyo, 113-8510, Japan
| | - Takashi Hirai
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyo City, Tokyo, 113-8510, Japan
| | - Hiroyuki Inose
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyo City, Tokyo, 113-8510, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyo City, Tokyo, 113-8510, Japan
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18
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De Stefano FA, Elarjani T, Burks JD, Burks SS, Levi AD. Dose Adjustment Associated Complications of Bone Morphogenetic Protein: A Longitudinal Assessment. World Neurosurg 2021; 156:e64-e71. [PMID: 34530148 DOI: 10.1016/j.wneu.2021.08.142] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/28/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Bone morphogenetic protein (BMP) is a growth factor that aids in osteoinduction and promotes bone fusion. There is a lack of literature regarding recombinant human BMP-2 (rhBMP-2) dosage in different spine surgeries. This study aims to investigate the trends in rhBMP-2 dosage and the associated complications in spinal arthrodesis. METHODS A retrospective study was conducted investigating spinal arthrodesis using rhBMP-2. Variables including age, procedure type, rhBMP-2 size, complications, and postoperative imaging were collected. Cases were grouped into the following surgical procedures: anterior lumbar interbody fusion/extreme lateral interbody fusion (ALIF/XLIF), posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), posterolateral fusion (PLF), anterior cervical discectomy and fusion (ACDF), and posterior cervical fusion (PCF). RESULTS A total of 1209 patients who received rhBMP-2 from 2006 to 2020 were studied. Of these, 230 were categorized as ALIF/XLIF, 336 as PLIF/TLIF, 243 as PLF, 203 as ACDF, and 197 as PCF. PCF (P < 0.001), PLIF/TLIF (P < 0.001), and PLF (P < 0.001) demonstrated a significant decrease in the rhBMP-2 dose used per level, with major transitions seen in 2018, 2011, and 2013, respectively. In our sample, 129 complications following spinal arthrodesis were noted. A significant relation between rhBMP-2 size and complication rates (χ2= 73.73, P = 0.0029) was noted. rhBMP-2 dosage per level was a predictor of complication following spinal arthrodesis (odds ratio = 1.302 [1.05-1.55], P < 0.001). CONCLUSIONS BMP is an effective compound in fusing adjacent spine segments. However, it carries some regional complications. We demonstrate a decreasing trend in the dose/vertebral level. A decrease rhBMP-2 dose per level correlated with a decrease in complication rates.
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Affiliation(s)
| | - Turki Elarjani
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joshua D Burks
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephen S Burks
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan D Levi
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
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19
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Seeherman HJ, Wilson CG, Vanderploeg EJ, Brown CT, Morales PR, Fredricks DC, Wozney JM. A BMP/Activin A Chimera Induces Posterolateral Spine Fusion in Nonhuman Primates at Lower Concentrations Than BMP-2. J Bone Joint Surg Am 2021; 103:e64. [PMID: 33950879 DOI: 10.2106/jbjs.20.02036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Supraphysiologic bone morphogenetic protein (BMP)-2 concentrations are required to induce spinal fusion. In this study, a BMP-2/BMP-6/activin A chimera (BV-265), optimized for BMP receptor binding, delivered in a recombinant human collagen:CDHA [calcium-deficient hydroxyapatite] porous composite matrix (CM) or bovine collagen:CDHA granule porous composite matrix (PCM), engineered for optimal BV-265 retention and guided tissue repair, was compared with BMP-2 delivered in a bovine absorbable collagen sponge (ACS) wrapped around a MASTERGRAFT Matrix (MM) ceramic-collagen rod (ACS:MM) in a nonhuman primate noninstrumented posterolateral fusion (PLF) model. METHODS In vivo retention of 125I-labeled-BV-265/CM or PCM was compared with 125I-labeled-BMP-2/ACS or BMP-2/buffer in a rat muscle pouch model using scintigraphy. Noninstrumented PLF was performed by implanting CM, BV-265/CM, BV-265/PCM, or BMP-2/ACS:MM across L3-L4 and L5-L6 or L3-L4-L5 decorticated transverse processes in 26 monkeys. Computed tomography (CT) images were acquired at 0, 4, 8, 12, and 24 weeks after surgery, where applicable. Manual palpation, μCT (microcomputed tomography) or nCT (nanocomputed tomography), and histological analysis were performed following euthanasia. RESULTS Retention of 125I-labeled-BV-265/CM was greater than BV-265/PCM, followed by BMP-2/ACS and BMP-2/buffer. The CM, 0.43 mg/cm3 BMP-2/ACS:MM, and 0.05 mg/cm3 BV-265/CM failed to generate PLFs. The 0.15-mg/cm3 BV-265/CM or 0.075-mg/cm3 BV-265/PCM combinations were partially effective. The 0.25-mg/cm3 BV-265/CM and 0.15 and 0.3-mg/cm3 BV-265/PCM combinations generated successful 2-level PLFs at 12 and 24 weeks. CONCLUSIONS BV-265/CM or PCM can induce fusion in a challenging nonhuman primate noninstrumented PLF model at substantially lower concentrations than BMP-2/ACS:MM. CLINICAL RELEVANCE BV-265/CM and PCM represent potential alternatives to induce PLF in humans at substantially lower concentrations than BMP-2/ACS:MM.
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Affiliation(s)
- Howard J Seeherman
- Orthopedic Research and Pharmaceutical Development Consultant, Cambridge, Massachusetts
| | | | | | | | | | - Douglas C Fredricks
- Bone Healing Research Lab and Iowa Spine Research Lab Orthopedic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - John M Wozney
- Orthopedic Research and Pharmaceutical Development Consultant, Hudson, Massachusetts
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20
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Tung KK, Wu YC, Chen KH, Pan CC, Lu WX, Chin NC, Shih CM, Hsu FW, Lee CH. The radiological outcome in lumbar interbody fusion among rheumatoid arthritis patients: a 20-year retrospective study. BMC Musculoskelet Disord 2021; 22:658. [PMID: 34353311 PMCID: PMC8344185 DOI: 10.1186/s12891-021-04531-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical outcomes amongst Rheumatoid Arthritis (RA) patients have shown satisfactory results being reported after lumbar surgery. The increased adoption of the interbody fusion technique has been due to a high fusion rate and less invasive procedures. However, the radiographic outcome for RA patients after receiving interbody fusion has scarcely been addressed in the available literature. METHODS Patients receiving interbody fusion including ALIF, OLIF, and TLIF were examined for implant cage motion and fusion status at two-year follow-up. Parameters for the index correction level including ADH, PDH, WI, SL, FW, and FH were measured and compared at pre-OP, post-OP, and two-year follow-up. RESULTS We enrolled 64 RA patients at 104 levels (mean 64.0 years old, 85.9% female) received lumbar interbody fusion. There were substantial improvement in ADH, PDH, WI, SL, FW, and FH after surgery, with both ADH and PDH having significantly dropped at two-year follow up. The OLIF group suffered from a higher subsidence rate with no significant difference in fusion rate when compared to TLIF. The fusion rate and subsidence rate for all RA patients was 90.4 and 28.8%, respectively. CONCLUSIONS We revealed the radiographic outcomes of lumbar interbody fusions towards symptomatic lumbar disease in RA patients with good fusion outcome despite the relative high subsidence rate amongst the OLIF group. Those responsible for intra-operative endplate management should be more cautious to avoid post-OP cage subsidence.
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Affiliation(s)
- Kuan-Kai Tung
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yun-Che Wu
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kun-Hui Chen
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Biomedical Engineering, Hung Kuang University, Taichung, Taiwan.,Department of Computer Science and Information Engineering, Providence University, Taichung, Taiwan.,Department of Nursing, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Chien-Chou Pan
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Rehabilitation Science, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Wen-Xian Lu
- Department of Orthopedics, Feng Yuan Hospital Ministry of Health and Welfare, Taichung, Taiwan
| | - Ning-Chien Chin
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Min Shih
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Physical Therapy, Hung Kuang University, Taichung, Taiwan.,PhD Degree Program of Biomedical Science and Engineering, College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Fang-Wei Hsu
- Department of Orthopedics, Kuang Tien General Hospital, Taichung, Taiwan
| | - Cheng-Hung Lee
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan. .,National Chung Hsing University, Taichung, Taiwan. .,Department of Food Science and Technology, Hung Kuang University, Taichung, Taiwan.
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21
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Golubovsky JL, Ejikeme T, Winkelman R, Steinmetz MP. Osteobiologics. Oper Neurosurg (Hagerstown) 2021; 21:S2-S9. [PMID: 34128067 DOI: 10.1093/ons/opaa383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/06/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteobiologics are engineered materials that facilitate bone healing and have been increasingly used in spine surgery. Autologous iliac crest bone grafts have been used historically, but morbidity associated with graft harvesting has led surgeons to seek alternative solutions. Allograft bone, biomaterial scaffolds, growth factors, and stem cells have been explored as bone graft substitutes and supplements. OBJECTIVE To review current and emerging osteobiologic technologies. METHODS A literature review of English-language studies was performed in PubMed. Search terms included combinations of "spine," "fusion," "osteobiologics," "autologous," "allogen(e)ic," "graft," "scaffold," "bone morphogenic protein," and "stem cells." RESULTS Evidence supports allograft bone as an autologous bone supplement or replacement in scenarios where minimal autologous bone is available. There are promising data on ceramics and P-15; however, comparative human trials remain scarce. Growth factors, including recombinant human bone morphogenic proteins (rhBMPs) 2 and 7, have been explored in humans after successful animal trials. Evidence continues to support the use of rhBMP-2 in lumbar fusion in patient populations with poor bone quality or revision surgery, while there is limited evidence for rhBMP-7. Stem cells have been incredibly promising in promoting fusion in animal models, but human trials to this point have only involved products with questionable stem cell content, thereby limiting possible conclusions. CONCLUSION Engineered stem cells that overexpress osteoinductive factors are likely the future of spine fusion, but issues with applying viral vector-transduced stem cells in humans have limited progress.
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Affiliation(s)
- Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tiffany Ejikeme
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert Winkelman
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael P Steinmetz
- Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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22
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Darveau SC, Leary OP, Persad-Paisley EM, Shaaya EA, Oyelese AA, Fridley JS, Sampath P, Camara-Quintana JQ, Gokaslan ZL, Niu T. Existing clinical evidence on the use of cellular bone matrix grafts in spinal fusion: updated systematic review of the literature. Neurosurg Focus 2021; 50:E12. [PMID: 34062506 DOI: 10.3171/2021.3.focus2173] [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: 01/31/2021] [Accepted: 03/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal fusion surgery is increasingly common; however, pseudarthrosis remains a common complication affecting as much as 15% of some patient populations. Currently, no clear consensus on the best bone graft materials to use exists. Recent advances have led to the development of cell-infused cellular bone matrices (CBMs), which contain living components such as mesenchymal stem cells (MSCs). Relatively few clinical outcome studies on the use of these grafts exist, although the number of such studies has increased in the last 5 years. In this study, the authors aimed to summarize and critically evaluate the existing clinical evidence on commercially available CBMs in spinal fusion and reported clinical outcomes. METHODS The authors performed a systematic search of the MEDLINE and PubMed electronic databases for peer-reviewed, English-language original articles (1970-2020) in which the articles' authors studied the clinical outcomes of CBMs in spinal fusion. The US National Library of Medicine electronic clinical trials database (www.ClinicalTrials.gov) was also searched for relevant ongoing clinical trials. RESULTS Twelve published studies of 6 different CBM products met inclusion criteria: 5 studies of Osteocel Plus/Osteocel (n = 354 unique patients), 3 of Trinity Evolution (n = 114), 2 of ViviGen (n = 171), 1 of map3 (n = 41), and 1 of VIA Graft (n = 75). All studies reported high radiographic fusion success rates (range 87%-100%) using these CBMs. However, this literature was overwhelmingly limited to single-center, noncomparative studies. Seven studies disclosed industry funding or conflicts of interest (COIs). There are 4 known trials of ViviGen (3 trials) and Bio4 (1 trial) that are ongoing. CONCLUSIONS CBMs are a promising technology with the potential of improving outcome after spinal fusion. However, while the number of studies conducted in humans has tripled since 2014, there is still insufficient evidence in the literature to recommend for or against CBMs relative to cheaper alternative materials. Comparative, multicenter trials and outcome registries free from industry COIs are indicated.
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23
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Lo WC, Tsai LW, Yang YS, Chan RWY. Understanding the Future Prospects of Synergizing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery with Ceramics and Regenerative Cellular Therapies. Int J Mol Sci 2021; 22:3638. [PMID: 33807361 PMCID: PMC8037583 DOI: 10.3390/ijms22073638] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 12/14/2022] Open
Abstract
Transforaminal lumber interbody fusion (TLIF) is the last resort to address the lumber degenerative disorders such as spondylolisthesis, causing lower back pain. The current surgical intervention for these abnormalities includes open TLIF. However, in recent years, minimally invasive TLIF (MIS-TLIF) has gained a high momentum, as it could minimize the risk of infection, blood loss, and post-operative complications pertaining to fusion surgery. Further advancement in visualizing and guiding techniques along with grafting cage and materials are continuously improving the safety and efficacy of MIS-TLIF. These assistive techniques are also playing a crucial role to increase and improve the learning curve of surgeons. However, achieving an appropriate output through TLIF still remains a challenge, which might be synergized through 3D-printing and tissue engineering-based regenerative therapy. Owing to their differentiation potential, biomaterials such as stem/progenitor cells may contribute to restructuring lost or damaged tissues during MIS-TLIF, and this therapeutic efficacy could be further supplemented by platelet-derived biomaterials, leading to improved clinical outcomes. Thus, based on the above-mentioned strategies, we have comprehensively summarized recent developments in MIS-TLIF and its possible combinatorial regenerative therapies for rapid and long-term relief.
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Affiliation(s)
- Wen-Cheng Lo
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Lung-Wen Tsai
- Department of Medical Education and Research, Taipei Medical University Hospital, Taipei 11031, Taiwan;
| | - Yi-Shan Yang
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Ryan Wing Yuk Chan
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
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24
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Yu T, Zheng L, Chen G, Wang N, Wang X, Song C, Yan J, Xi C. A Study to Compare the Efficacy of a Biodegradable Dynamic Fixation System With Titanium Devices in Posterior Spinal Fusion Between Articular Processes in a Canine Model. J Biomech Eng 2021; 143:031010. [PMID: 33210131 DOI: 10.1115/1.4049154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/08/2022]
Abstract
The objective of this study was to apply a biodegradable dynamic fixation system (BDFS) for lumbar fusion between articular processes and compare the fusion results and biomechanical changes with those of conventional rigid fixation. Twenty-four mongrel dogs were randomly assigned to 2 groups and subjected to either posterior lumbar fusion surgery with a BDFS or titanium rods (TRs) at the L5-L6 segments. Six animals in each group were sacrificed at 8 or 16 weeks. Fusion conditions were evaluated by computed tomography (CT), manual palpation, biomechanical tests, and histological analysis. Biomechanical tests were performed at the L4-7 (for range of motion (ROM)) and L5-6 (for fusion stiffness) segments. Histological examination was performed on organs, surrounding tissues, and the fused area. The magnesium alloy components maintained their initial shape 8 weeks after the operation, but the meshing teeth were almost completely degraded at 16 weeks. The biomechanical analysis revealed an increased lateral bending ROM at 8 weeks and axial torsion ROM at 16 weeks. The L4-5 extension-flexion ROMs in the BDFS group were 2.29 ± 0.86 deg and 3.17 ± 1.08 deg at 16 weeks, respectively, compared with 3.22 ± 0.56 deg and 5.55 ± 1.84 deg in TR group. However, both groups showed similar fusion results. The BDFS design is suitable, and its degradation in vivo is safe. The BDFS can be applied for posterior lumbar fusion between articular processes to complete the fusion well. Additionally, the BDFS can reduce the decline in lateral motion and hypermotion of the cranial adjacent segment in flexion-extension motion.
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Affiliation(s)
- Tailong Yu
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Leyu Zheng
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Guanghua Chen
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Nanxiang Wang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, No. 600, Tianhe Road, Tianhe District, Guangzhou, Guangdong 510000, China
| | - Xiaoyan Wang
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Chengchao Song
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Jinglong Yan
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, Xuefu Road 246#, Harbin, Heilongjiang 150001, China
| | - Chunyang Xi
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, Xuefu Road 246#, Harbin, Heilongjiang 150001, China
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25
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Safaee MM, Tenorio A, Haddad AF, Wu B, Hu SS, Tay B, Burch S, Berven SH, Deviren V, Dhall SS, Chou D, Mummaneni PV, Eichler CM, Ames CP, Clark AJ. Anterior Lumbar Interbody Fusion With Cage Retrieval for the Treatment of Pseudarthrosis After Transforaminal Lumbar Interbody Fusion: A Single-Institution Case Series. Oper Neurosurg (Hagerstown) 2021; 20:164-173. [PMID: 33035339 DOI: 10.1093/ons/opaa303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/08/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The treatment of pseudarthrosis after transforaminal lumbar interbody fusion (TLIF) can be challenging, particularly when anterior column reconstruction is required. There are limited data on TLIF cage removal through an anterior approach. OBJECTIVE To assess the safety and efficacy of anterior lumbar interbody fusion (ALIF) as a treatment for pseudarthrosis after TLIF. METHODS ALIFs performed at a single academic medical center were reviewed to identify cases performed for the treatment of pseudarthrosis after TLIF. Patient demographics, surgical characteristics, perioperative complications, and 1-yr radiographic data were collected. RESULTS A total of 84 patients were identified with mean age of 59 yr and 37 women (44.0%). A total of 16 patients (19.0%) underwent removal of 2 interbody cages for a total of 99 implants removed with distribution as follows: 1 L2/3 (0.9%), 6 L3/4 (5.7%), 37 L4/5 (41.5%), and 55 L5/S1 (51.9%). There were 2 intraoperative venous injuries (2.4%) and postoperative complications were as follows: 7 ileus (8.3%), 5 wound-related (6.0%), 1 rectus hematoma (1.1%), and 12 medical complications (14.3%), including 6 pulmonary (7.1%), 3 cardiac (3.6%), and 6 urinary tract infections (7.1%). Among 58 patients with at least 1-yr follow-up, 56 (96.6%) had solid fusion. There were 5 cases of subsidence (6.0%), none of which required surgical revision. Two patients (2.4%) required additional surgery at the level of ALIF for pseudarthrosis. CONCLUSION ALIF is a safe and effective technique for the treatment of TLIF cage pseudarthrosis with a favorable risk profile.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Alexander Tenorio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Bian Wu
- Department of Vascular Surgery, University of California, San Francisco, San Francisco, California
| | - Serena S Hu
- Department of Orthopedic Surgery, Stanford University, Stanford, California
| | - Bobby Tay
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Shane Burch
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Sigurd H Berven
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Charles M Eichler
- Department of Vascular Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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26
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Shimizu T, Fujibayashi S, Otsuki B, Murata K, Matsuda S. Indirect Decompression Through Oblique Lateral Interbody Fusion for Revision Surgery After Lumbar Decompression. World Neurosurg 2020; 141:e389-e399. [DOI: 10.1016/j.wneu.2020.05.151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 11/24/2022]
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27
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ROSA FÁBIO, POKORNY GABRIEL, RODRIGUES RAQUEL, AMARAL RODRIGO, JENSEN RUBENS, PIMENTA LUIZ. EVALUATION OF INTERBODY FUSION TWO YEARS AFTER LLIF PROCEDURE. COLUNA/COLUMNA 2020. [DOI: 10.1590/s1808-185120201903223957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
ABSTRACT Objectives The LLIF technique, extreme lateral interbody fusion, reaches the disc laterally through the psoas muscle, offering adequate access to the disc space with the added benefit of preventing iatrogenic injury to abdominal vascular structures (aorta and vena cava), the sympathetic plexus (reduces incidence of retrograde ejaculation) and neural structures, that is, preservation of the spinal nerves that cross the posterior aspect of the muscle. The objective of this study is to verify the rates of interbody fusion with the LLIF technique. Methods Retrospective, single center, comparative, non-randomized study. The presence of bone mass with increased hypotransparency in the areas of fusion will be analyzed. For the evaluation of the fusion, the Classification of interbody fusion success: Brantigan, Steffee, Fraser (BSF) will be used. Results Fifty-nine (86%) patients presented complete fusion of the approached level (BSF-3) six months after the procedure. One year after the procedure, 87% of the patients had complete fusion. Similar results were confirmed at two years. Conclusions We conclude that the technique of lateral interbody arthrodesis is safe and effective for the treatment of low back pain, with a fusion rate of 90% in two years. Level of Evidence III. Retrospective study, single center, non-randomized.
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Affiliation(s)
- FÁBIO ROSA
- Instituto de Patologia da Coluna, Brazil
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28
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Okada R, Kaito T, Ishiguro H, Kushioka J, Otsuru S, Kanayama S, Bal Z, Kitaguchi K, Hashimoto K, Makino T, Takenaka S, Sakai Y, Yoshikawa H. Assessment of effects of rhBMP-2 on interbody fusion with a novel rat model. Spine J 2020; 20:821-829. [PMID: 31901554 DOI: 10.1016/j.spinee.2019.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The effects of using off-label recombinant human bone morphogenetic protein (rhBMP)-2 for interbody fusion are controversial. Although animal models of posterolateral fusion are well-established, establishing animal models to validate the safety and efficacy of interbody fusion is difficult, which may contribute to the inconsistent clinical results. PURPOSE To develop a novel animal model of interbody fusion in rat coccygeal vertebrae without destroying bony endplates. STUDY DESIGN An experimental animal study. METHODS Forty-five male Sprague-Dawley rats underwent coccygeal interbody fusion without violating vertebral endplates. The animals were divided into three different groups based on the materials that were implanted into the interbody space (1) allogeneic iliac bone (IB) alone (IB group), (2) IB and 3 µg of rhBMP-2 (BMP low-dose group), or (3) IB and 10 µg of rhBMP-2 (BMP high-dose group). Fusion rates were investigated using microcomputed tomography 6 weeks after the operation. The incidence of adverse events, including soft-tissue swelling, delayed wound healing, osteolysis, and ectopic bone formation were evaluated. The total number of adverse events (using the adverse event score) in each group and the swelling ratio (calculated using the surgical site tissue volume [TV; TV on postoperative day 1/preoperative TV]) were also evaluated. RESULTS The fusion rates in the BMP low- and high-dose groups (33.3% and 46.7%) were not significantly different, but both were significantly higher than that in the IB group (0%) (p=.042 and .006, respectively). Significant differences in the incidence of osteolysis, adverse event scores, and swelling ratios were observed only between the BMP high-dose and IB groups (p=.043, .006 and .014, respectively). CONCLUSIONS We developed a novel rat model of interbody fusion in which the vertebral endplates were not violated, reflecting the normal clinical setting. rhBMP-2 use increased the fusion rate, but a higher dose of rhBMP-2 did not lead to a higher fusion rate than that for low-dose rhBMP-2; conversely, it led to an increase in the occurrence of adverse events. CLINICAL SIGNIFICANCE This novel rat model of coccygeal interbody fusion that preserved bony endplates has clinical significance for validating the effectiveness of biologics or bone graft substitutes before clinical trial.
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Affiliation(s)
- Rintaro Okada
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Takashi Kaito
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan.
| | - Hiroyuki Ishiguro
- Department of Orthopedic Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Junichi Kushioka
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Satoru Otsuru
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sadaaki Kanayama
- Department of Orthopedic Surgery, Ikeda Municipal Hospital, Ikeda, Osaka, Japan
| | - Zeynep Bal
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Kazuma Kitaguchi
- Department of Orthopedic Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | | | - Takahiro Makino
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Shota Takenaka
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Yusuke Sakai
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
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Patient Perceptions of Iliac Crest Bone Grafting in Minimally Invasive Transforaminal Lumbar Interbody Fusion. Clin Spine Surg 2019; 32:430-434. [PMID: 31790370 DOI: 10.1097/bsd.0000000000000781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The objective of this study was to determine patients' perception of iliac crest bone graft (ICBG) harvesting and donor site pain following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA The incidence of donor site pain has been debated in the literature because of the varying techniques associated with its harvest. METHODS Patients undergoing primary, single-level MIS TLIF with ICBG were retrospectively identified. ICBG harvesting was performed using a percutaneous technique with a tubular retractor. A survey was administered to assess if patients could accurately describe which side of their iliac crest they believed was harvested, and if they were experiencing any pain perceived to be originating from the donor site. Patient characteristics were compared using χ analysis and independent t test. RESULTS In total, 82 patients were included. The majority of patients had the ICBG harvested from the left iliac crest (97.5%). Approximately half of the patients correctly identified the side of harvest (50.6%). 48.1% of patients reported they were not confident or had guessed on their response. Patients that reported pain from the ICBG were more likely to feel confident or somewhat confident in their harvest site identification (57.9% vs. 46.3%) but less likely to be correct (36.8% vs. 63.4%) than patients without pain. 22 patients (27.8%) correctly identified the side of harvest without guessing. Of these, 11 (13.9%) reported pain. CONCLUSIONS Approximately half of patients undergoing MIS TLIF with ICBG are able to correctly identify which side of their iliac crest was harvested. However, the majority of patients reporting pain were unable to correctly identify the side of harvest. This suggests that most patients are likely attributing other sources of pain to their ICBG. Therefore, rates of donor site pain may be over-reported in the current literature with contemporary harvesting techniques.
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Haws BE, Khechen B, Patel DV, Yoo JS, Guntin JA, Cardinal KL, Ahn J, Singh K. Impact of Iliac Crest Bone Grafting on Postoperative Outcomes and Complication Rates Following Minimally Invasive Transforaminal Lumbar Interbody Fusion. Neurospine 2019; 16:772-779. [PMID: 31284335 PMCID: PMC6944998 DOI: 10.14245/ns.1938006.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/07/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The relationship between bone graft technique and postoperative outcomes for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has not been well-defined. This study aims to determine the effect of iliac crest bone grafting (ICBG) on patient-reported outcomes (PROs) and complication rates following MIS TLIF. METHODS Primary, single-level MIS TLIF patients were consecutively analyzed. Patients that prospectively received a percutaneous technique of ICBG were compared to patients that retrospectively received bone morphogenetic protein-2 (BMP-2). Complication rates were assessed perioperatively and up to 1 year postoperatively. Changes in Oswestry Disability Index (ODI), visual analogue scale (VAS) back, and VAS leg pain were compared. Rates of minimum clinically important difference (MCID) achievement at final follow-up for ODI, VAS back, and VAS leg scores were compared. RESULTS One hundred forty-nine patients were included: 101 in the BMP-2 cohort and 48 in the ICBG cohort. The ICBG cohort demonstrated increases in intraoperative blood loss and shorter lengths of stay. ICBG patients also experienced longer operative times, though this did not reach statistical significance. No significant differences in complication or reoperation rates were identified. The ICBG cohort demonstrated greater improvements in VAS leg pain at 6-week and 12-week follow-up. No other significant differences in PROs or MCID achievement rates were identified. CONCLUSION Patients undergoing MIS TLIF with ICBG experienced clinically insignificant increases in intraoperative blood loss and did not experience increases in postoperative pain or disability. Complication and reoperation rates were similar between groups. These results suggest that ICBG is a safe option for MIS TLIF.
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Affiliation(s)
- Brittany E Haws
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Benjamin Khechen
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Dil V Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jordan A Guntin
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kaitlyn L Cardinal
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Kapustka B, Kiwic G, Chodakowski P, Miodoński JP, Wysokiński T, Łączyński M, Paruzel K, Kotas A, Marcol W. Anterior lumbar interbody fusion (ALIF): biometrical results and own experiences. Neurosurg Rev 2019; 43:687-693. [PMID: 31111262 PMCID: PMC7186239 DOI: 10.1007/s10143-019-01108-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/26/2019] [Accepted: 04/16/2019] [Indexed: 11/26/2022]
Abstract
Lumbar fusion is a mainstay in the treatment of low back pain resulting from degenerative disc disease. Anterior lumbar interbody fusion (ALIF) has become a reasonable treatment technique to achieve indirect foraminal decompression with high fusion rates. The aim of the study was to analyse the biometrical parameters of the lumbar spine and the clinical outcome. The medical records of 51 patients treated with ALIF between 2012 and 2016 were retrospectively reviewed. Anterior and posterior disc height (DH), lumbar lordosis (LL), local disc angle (LDA) and foraminal dimensions were obtained on pre- and postoperative plain radiographs and computed tomography scans using ImageJ and Surgimap software according to the pedicle–pedicle technique. To evaluate the interbody fusion status on the last follow-up CT scans, we used Bridwell criteria. Preoperative and 12 months postoperative Oswestry Disability Index (ODI) scores were determined for all patients. The average length of hospitalisation was 4 days. Most of the patients had degenerative disc disease with foraminal stenosis. Five patients had early complications like paresthesia of lower limbs, sympathetic dysfunction or wound infections, but there were no major complications. Statistically significant (P < .01) improvement was observed in foraminal dimensions (area = 49%, height = 33% and width = 19%), anterior DH (49%), posterior DH (69%), LDA (47%) and LL (17.5%). Posterior DH correlated significantly with foramen height improvement. Radiographic evidence of fusion according to the modified Bridwell criteria (grade I and grade II) was observed in 96% (49/51) of the patients in the last CT of the lumbar spine. We also observed significant improvement in functional recovery in 94% of patients. The mini-open ALIF approach is a reasonable alternative to the more extensive posterior approaches. ALIF significantly restores the height of the intervertebral disc, indirectly increases foraminal dimensions, increases lordosis angle with significant short and long-term pain relief and functional recovery.
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Affiliation(s)
- Bartosz Kapustka
- Department of Physiology, School of Medicine in Katowice, Medical University of Silesia, ul. Medyków 4, 40-752, Katowice, Poland
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Grzegorz Kiwic
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Paweł Chodakowski
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Jan P Miodoński
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Tomasz Wysokiński
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Mariusz Łączyński
- Department of Physiology, School of Medicine in Katowice, Medical University of Silesia, ul. Medyków 4, 40-752, Katowice, Poland
| | - Krzysztof Paruzel
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Adrian Kotas
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland
| | - Wiesław Marcol
- Department of Physiology, School of Medicine in Katowice, Medical University of Silesia, ul. Medyków 4, 40-752, Katowice, Poland.
- Department of Neurosurgery, Provincial Specialist Hospital No. 2, Jastrzębie - Zdrój, al. Jana Pawła II 7, 44-330, Jastrzębie - Zdrój, Poland.
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rhBMP in lumber fusion for lumbar spondylolisthesis: A systematic review and meta-analysis. Chin J Traumatol 2019; 22:51-58. [PMID: 30745112 PMCID: PMC6529368 DOI: 10.1016/j.cjtee.2018.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/15/2018] [Accepted: 07/05/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To compare the efficacy and safety of recombinant human bone morphogenetic protein (rhBMP) and iliac crest autograft in the fusion treatment of lumbar spondylolisthesis. METHODS The studies using randomized controlled trials to compare the rhBMP with iliac crest autograft in the treatment of lumbar spondylolisthesis were retrieved from Embase, Pubmed, ProQuest dissertations & theses (PQDT), China national knowledge infrastructure (CNKI), Chinese Biomedical Database, Wanfang Data, Cochrane Library (from March 1998 to March 2018). Postoperative fusion rate, clinical success rate, postoperative intervertebral height, complications, operation time, blood loss and duration of hospitalization were chosen as the outcome indicators. Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical software Revman 5.3 was used for data-analysis. RESULTS Eleven articles were included in the meta-analysis. The results showed that, comparing the efficacy of rhBMP with iliac crest autograft, statistical significance was found in the 24-month fusion rate post operation [95% CI (1.38, 24.70), p = 0.02] and operation time [95% CI (-14.22, -2.08), p = 0.008]. There is not sufficient evidence for statistical differences in the remaining indicators. CONCLUSION The current literature shows rhBMP is a safe and effective grafting material in the treatment of lumbar spondylolisthesis. Further evidence is dependent on the emergence of more randomized controlled trials with higher quality and larger sample sizes in the future.
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Yeramaneni S, Ames CP, Bess S, Burton D, Smith JS, Glassman S, Gum JL, Carreon L, Jain A, Zygourakis C, Avramis I, Hostin R. Center variation in episode-of-care costs for adult spinal deformity surgery: results from a prospective, multicenter database. Spine J 2018; 18:1829-1836. [PMID: 29578109 DOI: 10.1016/j.spinee.2018.03.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/31/2018] [Accepted: 03/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Adult spinal deformity (ASD) surgery is associated with significant resource utilization, costing more than $958 million in charges for Medicare patients and more than $1.7 billion in charges for managed care population in the last decade. Given the recent move toward bundled payment models, it is important to understand the various care components a patient receives over the course of a defined clinical episode, its associated cost, and the proportion of cost for each component toward the bundled payment. PURPOSE To examine the degree and determinants of variation in inpatient episode-of-care (EOC) cost, resource utilization, and patient-reported outcomes for patients undergoing ASD surgery across four spine deformity centers in the United States. STUDY DESIGN/SETTING Retrospective analysis of prospective, multicenter database. PATIENT SAMPLE Consecutive patients enrolled in an ASD database from four spinal deformity centers. OUTCOME MEASURES Total in-patient EOC costs and Short Form (SF)-6D. METHODS The study used a multicenter database of 210 consecutively enrolled operative patients from 2008 to 2013 at four participating centers in the United States. Demographic, surgical, and direct cost data, expressed in 2013 dollars, for the entire inpatient EOC were obtained from administrative databases from the respective hospitals. Mixed models and multivariable linear regression were used to evaluate the impact of center on total costs adjusting for patient characteristics, length of stay (LOS), and surgical factors. RESULTS A total of 126 patients with complete baseline and 2-year follow-up data were included. The percentages of patients from each center were 36.5%, 7.1%, 24.6%, and 31.7%. Overall, the mean patient age was 58.4±12.6 years, 86% were women, and 94% were Caucasian. The proportion of total cost variation explained by the center at which the patient was treated was 17%. After adjusting for patient, LOS, and surgical factors the cost variation reduced to 4%. In multivariable analysis, each additional level fused increased total cost variation by $2,500, whereas recombinant human bone morphogenetic protein-2 (BMP) use and posterior-only surgical approach lowered total EOC costs by $10,500 and $9,400, respectively. No significant difference was observed in 2-year quality-adjusted life year across centers. CONCLUSIONS Total EOC costs for ASD surgery varied significantly by center. Levels fused, BMP use, and surgical approach were the primary drivers of cost variation across centers. Differences in resource utilization had no impact on 2-year quality-adjusted life year improvement across centers.
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Affiliation(s)
- Samrat Yeramaneni
- Center for Clinical Effectiveness, Baylor Scott & White Health, 8080 N. Central Expressway, Dallas, TX, 75206, USA.
| | - Christopher P Ames
- Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave, Room 779 M, San Francisco, CA, 94143-0112, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St Luke's/Rocky Mountain Hospital for Children, 1601 E. 19th Ave Suite 6250, Denver, CO 80128, USA
| | - Doug Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66103, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, 1215 Lee St, Charlottesville, VA, 22908, USA
| | - Steven Glassman
- Department of Orthopedic Surgery, University of Louisville Medical Center, 550 S. Jackson St, 1st Floor ACB, Louisville, KY, 40202, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY, 40202, USA
| | - Leah Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY, 40202, USA
| | - Amit Jain
- Department of Orthopedic Surgery, The Johns Hopkins University, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Corinna Zygourakis
- Department of Neurosurgery, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Ioannis Avramis
- Department of Orthopedic Surgery, Baylor Scoliosis Center, 4708 Alliance Blvd, Suite 800, Plano, TX, 75093, USA
| | - Richard Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, 4708 Alliance Blvd, Suite 800, Plano, TX, 75093, USA
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Jain N, Himed K, Toth JM, Briley KC, Phillips FM, Khan SN. Opioids delay healing of spinal fusion: a rabbit posterolateral lumbar fusion model. Spine J 2018; 18:1659-1668. [PMID: 29680509 DOI: 10.1016/j.spinee.2018.04.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/14/2018] [Accepted: 04/09/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Opioid use is prevalent in the management of pre- and postoperative pain in patients undergoing spinal fusion. There is evidence that opioids downregulate osteoblasts in vitro, and a previous study found that morphine delays the maturation and remodeling of callus in a rat femur fracture model. However, the effect of opioids on healing of spinal fusion has not been investigated before. Isolating the effect of opioid exposure in humans would be limited by the numerous confounding factors that affect fusion healing. Therefore, we have used a well-established rabbit model to study the process of spinal fusion healing that closely mimics humans. PURPOSE The objective of this work was to study the effect of systemic opioids on the process of healing of spinal fusion in a rabbit posterolateral spinal fusion model. STUDY DESIGN/SETTING This is a preclinical animal study. MATERIALS AND METHODS Twenty-four adult New Zealand white rabbits were studied in two groups after approval from the Institutional Animal Care and Use Committee (IACUC). The opioid group (n=12) received 4 weeks' preoperative and 6 weeks' postoperative transdermal fentanyl. Serum fentanyl levels were measured just before surgery and 4 weeks postoperatively to ensure adequate levels. The control group (n=12) received only perioperative pain control as necessary. All animals underwent a bilateral L5-L6 posterolateral spinal fusion using iliac crest autograft. Animals were euthanized at the 6-week postoperative time point, and assessment of fusion was done by manual palpation, plain radiographs, microcomputed tomography (microCT), and histology. RESULTS Twelve animals in the control group and 11 animals in the opioid group were available for analysis at the end of 6 weeks. The fusion scores on manual palpation, radiographs, and microCT were not statistically different. Three-dimensional microCT morphometry found that the fusion mass in the opioid group had a lower bone volume (p=.09), a lower trabecular number (p=.02), and a higher trabecular separation (p=.02) compared with the control group. Histologic analysis found areas of incorporation of autograft and unincorporated graft fragments in both groups. In the control group, there was remodeling of de novo woven bone to lamellar organization with incorporation of osteocytes, formation of mature marrow, and relative paucity of hypertrophied osteoblasts lining new bone. Sections from the opioid group showed formation of de novo woven bone, and hypertrophied osteoblasts were seen lining the new bone. There were no sections showing lamellar organization and development of mature marrow elements in the opioid group. Less dense trabeculae on microCT correlated with histologic findings of relatively immature fusion mass in the opioid group. CONCLUSIONS Systemic opioids led to an inferior quality fusion mass with delay in maturation and remodeling at 6 weeks in this rabbit spinal fusion model. These preliminary results lay the foundation for further research to investigate underlying cellular mechanisms, the temporal fusion process, and the dose-duration relationship of opioids responsible for our findings.
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Affiliation(s)
- Nikhil Jain
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 376 W 10th Ave, Columbus, OH 43210, USA
| | - Khaled Himed
- The Ohio State University School of Medicine, 376 W 10th Ave, Columbus, OH 43210, USA
| | - Jeffrey M Toth
- Department of Orthopaedics, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Karen C Briley
- Department of Radiology, Wright Center for Innovation and Biomedical Imaging, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Columbus, OH 43210, USA
| | - Frank M Phillips
- Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 376 W 10th Ave, Columbus, OH 43210, USA.
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The efficacy of electrical spinal fusion stimulators on fusion rates: a meta-analysis. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rate of Craniotomy Fusion After Free Bone Flap. World Neurosurg 2018; 118:e283-e287. [PMID: 29966791 DOI: 10.1016/j.wneu.2018.06.172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Craniotomy has been performed in neurologic surgery for over a century. Replacement of free bone flaps in routine craniotomies is widely practiced, however, the rate of fusion after free flap replacement is unknown. OBJECTIVE To assess timing and rate of fusion after routine craniotomies. METHODS A retrospective cohort study of 2200 patients who underwent craniotomies from 2002 to 2005. Fusion rates and time to fusion were evaluated. When time to fusion was taken into consideration, univariate and multivariate analyses of the impact of clinical factors on fusion rate were also examined. RESULTS Of 171 patients with postoperative computed tomography of over 2200 patients undergoing craniotomy, 103 (60%) demonstrated solid fusion, 26 (15%) had probable fusion, and 42 (25%) had not achieved fusion. There were no significant differences when fusion was compared with demographics such as age, sex, body mass index, and history of tobacco use. Radiation therapy had a significant impact on fusion: those receiving radiation were less likely to achieve fusion (P = 0.0082). The fusion rates at 12, 24, and 36 months after surgery were 15%, 41%, and 54%, respectively. CONCLUSION As expected, craniotomy fusion rates after free flap replacement increased steadily over time. We were not able to demonstrate that clinical factors such as age, sex, body mass index, diagnosis, fixation material, and radiation had an impact on fusion rate when time to fusion was accounted for. Patients receiving radiation, however, experienced fusion less frequently. Because of the scarcity of previous studies in this area, this current study serves as a platform for future studies on fusion rates after free flap replacement.
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Clinical Applications of Bone Tissue Engineering in Orthopedic Trauma. CURRENT PATHOBIOLOGY REPORTS 2018; 6:99-108. [PMID: 36506709 PMCID: PMC9733044 DOI: 10.1007/s40139-018-0166-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose of Review Orthopaedic trauma is a major cause of morbidity and mortality worldwide. Although many fractures tend to heal if treated appropriately either by nonoperative or operative methods, delayed or failed healing, as well as infections, can lead to devastating complications. Tissue engineering is an exciting, emerging field with much scientific and clinical relevance in potentially overcoming the current limitations in the treatment of orthopaedic injuries. Recent Findings While direct translation of bone tissue engineering technologies to clinical use remains challenging, considerable research has been done in studying how cells, scaffolds, and signals may be used to enhance acute fracture healing and to address the problematic scenarios of nonunion and critical-sized bone defects. Taken together, the research findings suggest that tissue engineering may be considered to stimulate angiogenesis and osteogenesis, to modulate the immune response to fractures, to improve the biocompatibility of implants, to prevent or combat infection, and to fill large gaps created by traumatic bone loss. The abundance of preclinical data supports the high potential of bone tissue engineering for clinical application, although a number of barriers to translation must first be overcome. Summary This review focuses on the current and potential applications of bone tissue engineering approaches in orthopaedic trauma with specific attention paid to acute fracture healing, nonunion, and critical-sized bone defects.
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Incidence and impact of implant subsidence after stand-alone lateral lumbar interbody fusion. Orthop Traumatol Surg Res 2018; 104:405-410. [PMID: 29292121 DOI: 10.1016/j.otsr.2017.11.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 08/18/2017] [Accepted: 11/08/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Few data are available on the occurrence after stand-alone lateral lumbar interbody fusion (LLIF) of implant subsidence, whose definition and incidence vary across studies. The primary objective of this work was to determine the incidence of subsidence 1 year postoperatively, using an original measurement method, whose validity was first assessed. The secondary objective was to assess the clinical impact of subsidence. HYPOTHESIS Implant subsidence after stand-alone LLIF is a common complication that can adversely affect clinical outcomes. MATERIAL AND METHODS Of 69 included patients who underwent stand-alone LLIF, 67 (97%) were re-evaluated at least 1 year later. Furthermore, 63 (91%) patients had two available computed tomography (CT) scans for assessing subsidence, one performed immediately after surgery and the other 1 year later. Reproducibility of the original measurement method was assessed in a preliminary study. Subsidence was defined as at least 4mm loss of fused space height. RESULTS The incidence of subsidence was 32% (20 patients). Subsidence was global in 7 (11%) patients and partial in 13 (21%) patients. Mean loss of height was 5.5±1.5mm. Subsidence predominated anteriorly in 50% of cases. The lordotic curvature of the fused segment was altered in 50% of patients, by a mean of 8°±3°. Fusion was achieved in 67/69 (97%) patients. The Oswestry score and visual analogue scale scores for low-back and nerve-root pain were significantly improved after 1 year in the overall population and in the groups with and without subsidence. DISCUSSION Reproducibility of our measurement method was found to be excellent. Subsidence was common but without significant clinical effects after 1 year. Nevertheless, subsidence can be associated with pain and can result in loss of lumbar lordosis, which is a potential risk factor for degenerative disease of the adjacent segments. A score for predicting the risk of subsidence will now be developed by our group as a tool for improving patient selection to stand-alone LLIF. LEVEL OF EVIDENCE IV, retrospective cohort study.
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Esmail N, Buser Z, Cohen JR, Brodke DS, Meisel HJ, Park JB, Youssef JA, Wang JC, Yoon ST. Postoperative Complications Associated With rhBMP2 Use in Posterior/Posterolateral Lumbar Fusion. Global Spine J 2018; 8:142-148. [PMID: 29662744 PMCID: PMC5898669 DOI: 10.1177/2192568217698141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Retrospective database review. OBJECTIVE Posterior/posterolateral lumbar fusion (PLF) is an effective treatment for a variety of spinal disorders; however, variations in surgical technique have different complication profiles. The aim of our study was to quantify the frequency of various complications in patients undergoing PLF with and without human recombinant bone morphogenetic protein 2 (rhBMP2). METHODS We queried the orthopedic subset of the Medicare database (PearlDiver) between 2005 and 2011 for patients undergoing PLF procedures with and without rhBMP2. Complication and reoperation rates were analyzed within 1 year of the index procedure. Complications assessed include: acute renal failure, deep vein thrombosis, dural tear, hematoma, heterotopic ossification, incision and drainage, cardiac complications, nervous system complications, osteolysis, pneumonia, pseudarthrosis, pulmonary embolism, radiculopathy, respiratory complications, sepsis, urinary retention, urinary tract infection, mechanical, and wound complications. Chi-square analysis was used to calculate the complication differences between the groups. RESULTS Our data revealed higher overall complication rates in patients undergoing PLF with rhBMP2 versus no_rhBMP2 (76.9% vs 68.8%, P < .05). Stratified by gender, rhBMP2 males had higher rates of mechanical complications, pseudarthrosis, and reoperations compared with no_rhBMP2 males (P < .05), whereas rhBMP2 females had higher rates of pseudarthrosis, urinary tract infection, and urinary retention compared with no_rhBMP2 females (P < .05). CONCLUSION Our data revealed higher overall complication rates in PLF patients given rhBMP2 compared with no_rhBMP2. Furthermore, our data suggests that rhBMP2-associated complications may be gender specific.
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Affiliation(s)
- Nabil Esmail
- University of Southern California, Los Angeles, CA, USA
| | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Jong-Beom Park
- Uijongbu St. Mary’s Hospital, The Catholic University of Korea School of Medicine, Uijongbu, Korea
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Hoppe S, Albers CE, Elfiky T, Deml MC, Milavec H, Bigdon SF, Benneker LM. First Results of a New Vacuum Plasma Sprayed (VPS) Titanium-Coated Carbon/PEEK Composite Cage for Lumbar Interbody Fusion. J Funct Biomater 2018. [PMID: 29538285 PMCID: PMC5872109 DOI: 10.3390/jfb9010023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to assess the performance of a new vacuum plasma sprayed (VPS) titanium-coated carbon/polyetheretherketone (PEEK) cage under first use clinical conditions. Forty-two patients who underwent a one or two segment transforaminal lumbar interbody fusion (TLIF) procedure with a new Ca/PEEK composite cage between 2012 and 2016 were retrospectively identified by an electronic patient chart review. Fusion rates (using X-ray), patient’s satisfaction, and complications were followed up for two years. A total of 90.4% of the patients were pain-free and satisfied after a follow up (FU) period of 29.1 ± 9 (range 24–39) months. A mean increase of 3° in segmental lordosis in the early period (p = 0.002) returned to preoperative levels at final follow-ups. According to the Bridwell classification, the mean 24-month G1 fusion rate was calculated as 93.6% and the G2 as 6.4%. No radiolucency around the cage (G3) or clear pseudarthrosis could be seen (G4). In conclusion, biological properties of the inert, hydrophobic surface, which is the main disadvantage of PEEK, can be improved with VPS titanium coating, so that the carbon/PEEK composite cage, which has great advantages in respect of biomechanical properties, can be used safely in TLIF surgery. High fusion rates, good clinical outcome, and low implant-related complication rates without the need to use rhBMP or additional iliac bone graft can be achieved.
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Affiliation(s)
- Sven Hoppe
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Christoph E Albers
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Tarek Elfiky
- Spine Surgery Unit, El-Hadra University Hospital, Alexandria University, Alexandria 21561, Egypt.
| | - Moritz C Deml
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Helena Milavec
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Sebastian F Bigdon
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Lorin M Benneker
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
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The Impact of L5 Sacralization on Fusion Rates and Clinical Outcomes After Single-level Posterior Lumbar Interbody Fusion (PLIF) at L4-L5 Level. Clin Spine Surg 2018; 31:E62-E68. [PMID: 28394774 DOI: 10.1097/bsd.0000000000000536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To determine the impact of L5 sacralization on fusion rates and clinical outcomes after single-level posterior lumbar interbody fusion (PLIF) surgery at the L4-L5 level. SUMMARY OF BACKGROUND DATA L5 sacralization can produce greater stress concentration at the adjacent segment (L4-L5); therefore, L4-L5 PLIF surgery in patients with L5 sacralization may negatively affect fusion rate and be associated with poor clinical outcomes. However, no study has examined the impact of L5 sacralization on fusion rates and clinical outcomes of patients who undergo L4-L5 PLIF surgery. MATERIALS AND METHODS Of 153 patients who underwent L4-L5 PLIF, data of 145 who met the study criteria were retrospectively reviewed. Among them, 31 patients had L5 sacralization (group A), whereas the remaining 114 patients did not (group B). The primary study endpoint was fusion rate evaluated using dynamic radiographs and computed tomographic scans. Secondary endpoints included (1) pain intensity in the lower back and radiating to the lower extremities on the visual analog scale; (2) clinical outcomes assessed using the Oswestry Disability Index and 12-item Short Form Health Survey; (3) surgical outcomes; and (4) complications. RESULTS Fusion rate evaluated using dynamic radiographs and computed tomographic scans at 6 months after surgery did not differ significantly between patients with and without sacralization (P=0.70 and 0.81, respectively), whereas fusion rate at 1 year after surgery did (P=0.04 and 0.04, respectively). In particular, patients with type II or III L5 sacralization had significantly lower fusion rates than those with other types of or no L5 sacralization. Pain intensity, clinical and surgical outcomes, and complications did not differ significantly between groups. CONCLUSIONS Patients with type II or III L5 sacralization may have worse fusion rates after L4-L5 PLIF surgery than those with type I or no sacralization.
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Presciutti S, Boden S. BMP and Beyond: A 25-Year Historical Review of Translational Spine Research at Emory University. Spine Surg Relat Res 2018; 2:1-10. [PMID: 31440639 PMCID: PMC6698547 DOI: 10.22603/ssrr.2017-0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 10/19/2017] [Indexed: 11/24/2022] Open
Abstract
A high rate of symptomatic spinal pseudoarthrosis and a wide range of complications associated with the use of iliac crest bone graft (the gold standard) have prompted the spine surgery community to seek alternative options to promote spinal fusion. Emory University has been one of the global leaders in this endeavor. This invited review covers the last 25 years of Emory's contributions to translational spine research, focusing specifically on our work with bone morphogenetic proteins (BMP) and the BMP signaling pathway. As a result of this work, recombinant human BMP-2 is the only Food and Drug Administration approved biologic bone graft substitute. It has been shown to significantly increase spinal fusion rates across the spinal column because of its potent ability to stimulate local bone formation through the recruitment of mesenchymal stem cells. This review covers our development of animal models of spinal fusion, our body of work regarding the translation of BMP from the benchtop to the clinic, the discovery of LMP-1 and strategies to enhance cellular responsiveness to BMPs, and the design of various small molecule drugs that can enhance local bone formation.
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Affiliation(s)
- Steven Presciutti
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia, USA
| | - Scott Boden
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia, USA
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Declining usage of rhBMP-2 in lumbar fusions for adult spinal deformity since 2008. J Clin Neurosci 2018; 47:62-65. [DOI: 10.1016/j.jocn.2017.10.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/22/2017] [Indexed: 12/12/2022]
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Le Pape S, Gauthe R, Du Pouget L, Gille O, Vital JM, Ould-Slimane M. Endopelvic Approach for Iliac Crest Bone Harvesting. World Neurosurg 2017; 106:764-767. [PMID: 28739516 DOI: 10.1016/j.wneu.2017.07.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The anterior approach to lumbar spine surgery has grown in popularity in the past few years; spinal fusion of the last 2 lumbar levels is often required. Although alternatives to bone grafting are available, including recombinant human bone morphogenetic protein 2 or bone substitutes, only cancellous autologous bone has all the required factors for bone growth. To avoid the use of bone substitutes, remote iliac crest bone harvesting remains the gold standard. However, this technique may lead to some unfavorable outcomes. CASE DESCRIPTION The patient was a 46-year-old man with severe back and left leg pain. Magnetic resonance imaging showed an inflammatory discopathy of L5-S1 associated with a left posterior lateral herniated disc. Conservative treatment failed, and surgical treatment of the lumbar disk disease and the herniated disc was scheduled. A novel iliac crest bone harvesting method was performed during the retroperitoneal approach to the anterior lumbar interbody fusion. The patient's postoperative course was uneventful. There were no adverse outcomes related to the bone donor site. CONCLUSIONS This is the first in vivo report of endopelvic iliac crest bone harvesting. This technique allows bone graft harvesting to be performed with the same retroperitoneal approach used for anterior lumbar interbody fusion. It avoids many common complications associated with the remote approach to the iliac crest.
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Affiliation(s)
- Sebastien Le Pape
- Regional Spine Institute, University Hospital of Rouen, Rouen, France.
| | - Remi Gauthe
- Regional Spine Institute, University Hospital of Rouen, Rouen, France
| | - Laure Du Pouget
- Department of Urology, University Hospital of Rouen, Rouen, France
| | - Olivier Gille
- Spine Unit 1, University Hospital Pellegrin, Bordeaux, France
| | - Jean-Marc Vital
- Spine Unit 1, University Hospital Pellegrin, Bordeaux, France
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Poorman GW, Jalai CM, Boniello A, Worley N, McClelland S, Passias PG. Bone morphogenetic protein in adult spinal deformity surgery: a meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2094-2102. [DOI: 10.1007/s00586-016-4841-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 10/03/2016] [Accepted: 10/23/2016] [Indexed: 12/16/2022]
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Liu Z, Zhu Y, Zhu H, He X, Liu X. Enhancement of posterolateral lumbar spine fusion using recombinant human bone morphogenetic protein-2 and mesenchymal stem cells delivered in fibrin glue. J Biomater Appl 2016; 31:477-487. [PMID: 27059496 DOI: 10.1177/0885328216643854] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mesenchymal stem cells have shown great potential for accelerating bone healing. In the present study, we evaluate the efficacy of fibrin glue/mesenchymal stem cells/recombinant human bone morphogenetic protein-2 composite for posterolateral spinal fusion in a rabbit model. Forty adult rabbits underwent posterolateral intertransverse fusion at the L5–L6 level. The animals were randomly divided into four groups based on the implant material: fibrin glue, fibrin glue/mesenchymal stem cells composite, fibrin glue-recombinant human bone morphogenetic protein-2 (fibrin glue/recombinant human bone morphogenetic protein-2) composite, and fibrin glue/mesenchymal stem cells/recombinant human bone morphogenetic protein-2 composite. After six weeks, the rabbits were euthanized for manual palpation, radiographic examination, biomechanical testing, and histology. Manual palpation results showed that the fusion rate for fibrin glue, fibrin glue/mesenchymal stem cells, fibrin glue/recombinant human bone morphogenetic protein-2, and fibrin glue/mesenchymal stem cells/recombinant human bone morphogenetic protein-2 was 0, 0, 40%, and 70%, respectively. Moreover, fusion rate determined by radiographic examination for fibrin glue, fibrin glue/mesenchymal stem cells, fibrin glue/recombinant human bone morphogenetic protein-2, and fibrin glue/mesenchymal stem cells/recombinant human bone morphogenetic protein-2 was 0, 0, 40%, and 80%, respectively. Gray analysis showed that fibrin glue/recombinant human bone morphogenetic protein-2 group had higher ossification area and density than fibrin glue group; and fibrin glue/mesenchymal stem cells/recombinant human bone morphogenetic protein-2 group had higher ossification area and density than fibrin glue/recombinant human bone morphogenetic protein-2 group. Formation of continuous bone masses between L5 and L6 level in mesenchymal stem cells/recombinant human bone morphogenetic protein-2/fibrin glue group was further confirmed by computed tomography scanning and three-dimensional reconstruction. Biomechanical testing demonstrated that the fusion strength (flexion, extension, lateral bending, and axial rotation) in fibrin glue/mesenchymal stem cells/recombinant human bone morphogenetic protein-2 group is significantly higher than that in fibrin glue/recombinant human bone morphogenetic protein-2 group. The formation of mature bone tissues between transverse processes of the fused specimens from both fibrin glue/recombinant human bone morphogenetic protein-2, and fibrin glue/mesenchymal stem cells/recombinant human bone morphogenetic protein-2 groups was confirmed by HE staining, and quantitative real-time polymerase chain reaction results showed the upregulation of CD31, type I collagen, osteocalcin, and osteonectin in the fibrin glue/mesenchymal stem cells/recombinant human bone morphogenetic protein-2 group. In conclusion, our findings show that mesenchymal stem cells delivered with recombinant human bone morphogenetic protein-2 using fibrin glue as carrier are more effective in enhancing spine fusion than recombinant human bone morphogenetic protein-2 without mesenchymal stem cells in the rabbit model.
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Affiliation(s)
- Zunpeng Liu
- Department of Orthopedics, First Affiliated Hospital, China Medical University, Shenyang, China
- Department of Orthopedics, Fourth Affiliated Hospital, China Medical University, Shenyang, China
| | - Yue Zhu
- Department of Orthopedics, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Haitao Zhu
- Department of Orthopedics, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Xiaoning He
- Department of Stomatology, Fourth Affiliated Hospital, China Medical University, Shenyang, China
| | - Xinchun Liu
- Department of Orthopedics, First Affiliated Hospital, China Medical University, Shenyang, China
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Anatomic feasibility of a new endopelvic approach for iliac crest bone harvesting. Surg Radiol Anat 2016; 38:1191-1194. [PMID: 27160584 DOI: 10.1007/s00276-016-1686-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE For the past few years, anterior exposure for surgery of the lumbar spine has gained popularity for the treatment of disk disease or spondylosis. Cancellous bone remains the gold standard for fusion. Iliac crest bone harvesting is safe but there are donor site complications. Bone substitutes exist, like recombinant human bone morphogenic protein-2 rhBMP-2. This alternative offers a high rate of fusion but with local and general complications. The aim of our study is to show the feasibility of an endopelvic approach for iliac bone crest harvesting to avoid donor site complication. METHOD Twenty anterior retroperitoneal lumbar spine approaches have been realized in the anatomy department of the University of Bordeaux. The volumes of cancellous bone have been measured and procedure complications have been reported. RESULTS The mean volume of cancellous bone was 5.9 cc, the maximum volume was 8.2 cc and the minimum volume was 4.5 cc. No complications have been reported during the approach or the bone harvesting. CONCLUSIONS Anterior retroperitoneal approach for iliac bone crest harvesting is a safe way to obtain sufficient volume of cancellous bone for a single lumbar spinal fusion. This exposure avoids the risks of an iliac crest donor site complications or rhBMP-2 complications.
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Nguyen HS, Shabani S, Patel M, Maiman D. Posterolateral lumbar fusion: Relationship between computed tomography Hounsfield units and symptomatic pseudoarthrosis. Surg Neurol Int 2015; 6:S611-4. [PMID: 26693390 PMCID: PMC4671137 DOI: 10.4103/2152-7806.170443] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 09/16/2015] [Indexed: 11/30/2022] Open
Abstract
Background: Assessment of bone quality can guide spinal surgery. However, surgeons infrequently evaluate bone quality in a quantitative manner. Recent literature suggests a role for computed tomography (CT) Hounsfield units (HUs) as a marker for bone quality. Limited data exist regarding its utility with respect to posterolateral lumbar fusion (PLF). Methods: From fall 2010 to winter 2012, 10 patients underwent revision surgery for symptomatic pseudoarthrosis (defined as intractable pain associated with either radiographic evidence of nonunion or intraoperative evidence of nonunion) after a prior L4–S1 PLF. These patients were age-matched (±5 years) to 10 patients who underwent L4–S1 PLF with no clinical signs of pseudoarthrosis at 1-year follow-up. Available CT imaging (with or without instrumentation) was evaluated from L1 to L5 for the averaged HU. Data were pooled among L1–L3 values and between L4 and L5 values. Results: Within the pseudoarthrosis group, the pooled L1–L3 HU value was similar to the pooled L4–L5 HU value (168.39 ± 22.84 HU vs. 166.98 ± 23.20 HU respectively, P = 0.89). The same pattern was observed for the control group (190.24 ± 37.13 HU vs. 201.89 ± 36.59 HU respectively, P = 0.44). On the other hand, the pooled L1–L3 and L4–L5 HU values were larger for the control group compared to the pseudoarthrosis group, with the pooled L4–L5 HU demonstrating statistical significance, P = 0.01. Conclusion: Currently, CT imaging is typically not obtained prior to lumbar fusion. Results demonstrated that CT HU values were significantly larger for patients who did not exhibit symptomatic pseudoarthrosis at 1-year follow-up compared to those who required revision surgery. As such, CT HU values may serve as a predictor for bony fusion to guide surgical management of patients under consideration for PLF.
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Affiliation(s)
- Ha Son Nguyen
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mohit Patel
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Dennis Maiman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to determine the fusion rate using recombinant human bone morphogenetic protein (rhBMP) in spinal surgery and to estimate the risk of cancer subsequent to their use. SUMMARY OF BACKGROUND DATA rhBMP may obviate the need for iliac crest bone graft harvest and provides similar or higher fusion rates than autologous bone graft. Recently, there are concerns that rhBMPs may either cause cancer or accelerate progression. METHODS Patients were treated by 2 spine surgeons between 2002 and 2012. Inclusion criteria were patients who resided in the state of Victoria, Australia, undergoing lumbar fusion (anterior, lateral, posterior, and posterolateral) with rhBMP [either rhBMP-2 (Infuse) or rhBMP-7 (OP-1)]. Exclusion criteria were patients who reported having an invasive cancer diagnosis before the spinal fusion procedure. The occurrence of incident cancers was obtained from record linkage to the Victorian Cancer Registry. RESULTS A total of 527 patients were included in the cohort, with a mean follow-up of 4.4 years (1.8-11.5). Patients received Infuse in 77% of cases and OP-1 in 23%. The mean Infuse does was 10.2 mg (2.5-48.0) and 3.3 mg (1.7-6.6) for OP-1. There was no significant difference in fusion rates between Infuse (90.1%) and OP-1 (91.9%) (P = 0.42). The overall success of interbody fusion with rhBMP was 93.5% at 12 months. Twenty-seven patients were diagnosed with an invasive cancer since treatment (20 Infuse and 7 OP-1 patients). Comparing the observed numbers in our study cohort with those expected on the basis of the Victorian population's age and sex-specific rates, we observed that the study cohort was not at a significantly increased risk of cancer. The standardized incidence ratio for cancer overall (of any type) was 0.84 [95% confidence interval (95% CI) 0.56-1.21]. CONCLUSION Off-label use of rhBMP provided high fusion rates with no evidence of a significantly increased risk of cancer. LEVEL OF EVIDENCE 4.
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