Single-level Posterolateral Fusion (PLF) Alone and Posterior Interbody Fusion (PLIF/TLIF) Alone Lead to a Decreased Risk of Short-term Complications Compared to Combined PLF With PLIF/TLIF Procedures: A Matched Analysis

Radiologic and Clinical Evaluation of Posterolateral Versus Transforaminal Interbody Fusion in Degenerative Lumbar Spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The primary objective is to compare foraminal height (FH) and disk height (DH) differences in posterolateral (PLF) and transforaminal interbody fusions (TLIFs) and secondarily correlate these measurements with patient-reported outcomes.

BACKGROUND

The impact FH has on patient outcomes in degenerative lumbar spinal fusion surgery is unknown. Postoperative FH change and how it relates to patient-reported outcomes in posteriorly based procedures has not been well evaluated.

METHODS

A retrospective review of a subset of patients from a prospective cohort from the Canadian Spine Outcomes and Research Network was undertaken. Radiographic assessment preoperatively, at 3 months and 1 year, with standing lumbar spine radiographs were completed. FH and DH were recorded at each time interval, differences between groups were compared, and correlations with patient-reported outcomes were assessed.

RESULTS

One hundred nine patients were included (23 PLF and 86 TLIF). At 3-month follow-up, the change in FH was greater in the TLIF group (mean difference =2.3; 95% CI: 0.8-3.5, P =0.002). The change in FH remained significantly different at 12 months (mean difference=1.6, 95% CI: 0.2, 3.0 mm, P =0.028). The change in DH was greater in the TLIF group, with a mean difference between groups of 4.1 mm (95% CI: 2.5, 5.7, P <0.001) and 3.6 mm (95% CI: 2.0, 5.3, P <0.001). A positive change in FH correlated with less back pain, less disability, and improved physical function in the TLIF group ( P <0.05).

CONCLUSIONS

Patients treated with PLF lost FH over time. An increased difference in FH at 1 year was associated with improved function and less back pain in the TLIF group.

Dislodgment Effects of Different Cage Arrangements in Posterior Lumbar Interbody Fusion: A Finite Element Study

The vertebral cage has been widely used in posterior lumbar interbody fusion. The risk of cage dislodgment is high for patients undergoing lumbar fusion surgery. Therefore, the main objective of this study was to use a lumbar fusion model to investigate the effects of cage dislodgment on different cage arrangements after PLIF. Finite element analysis was used to compare three PEEK cage placements, together with the fibula-type cage, with respect to the four kinds of lumbar movements. The results revealed that a horizontal cage arrangement could provide a better ability to resist cage dislodgment. Overall lumbar flexion movements were confirmed to produce a greater amount of cage slip than the other three lumbar movements. The lower part of the lumbar fusion segment could create a greater amount of cage dislodgment for all of the lumbar movements. Using an autograft with a fibula as a vertebral cage cannot effectively reduce cage dislodgment. Considering the maximum movement type in lumbar flexion, we suggest that a horizontal arrangement of the PEEK cage might be considered when a single PEEK cage is placed in the fusion segment, as doing so can effectively reduce the extent of cage dislodgment.

Long-term efficacy of Waveflex semi-rigid-dynamic-internal-fixation system in delaying intervertebral disc degeneration at adjacent segments and improving spinal sagittal imbalance

The Waveflex semi-rigid-dynamic-internal-fixation system shows good short-term effects in the treatment of lumbar degenerative diseases, but there are few long-term follow-up studies, especially for recovery of sagittal balance. Fifty patients with lumbar degenerative diseases treated from January 2016 to October 2017 were retrospectively analysed: 25 patients treated with Waveflex semi-rigid-dynamic-internal-fixation system (Waveflex group) and 25 patients treated with double-segment PLIF (PLIF group). Clinical efficacy was evaluated by Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). Imaging data before surgery and at 3 months, 1 year, and 5 years postoperatively was used for imaging indicator assessment. Local disc degeneration of the cephalic adjacent segment (including disc height index (DHI), intervertebral foramen height (IFH), and range of motion (ROM)) and overall spinal motor function (including lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), and |PI-LL|) were analysed. Regarding clinical efficacy, comparison of VAS and ODI scores between the Waveflex and PLIF groups showed no significant preoperative or postoperative differences. The comparison of the objective imaging indicators showed no significant differences in the DHI, IFH, LL, |PI-LL|, and SS values between the Waveflex and PLIF groups preoperatively and 3 months postoperatively (P > 0.05). These values were significantly different at 1 and 5 years postoperatively (P < 0.05), and the Waveflex group showed better ROM values than those of the PLIF group (P < 0.05). PI values were not significantly different between the groups, but PT showed a significant improvement in the Waveflex group 5 years postoperatively (P < 0.05). The Waveflex semi-rigid dynamic fixation system can effectively reduce the probability of intervertebral disc degeneration in upper adjacent segments. Simultaneously, patients in the Waveflex group showed postoperative improvements in LL, spinal sagittal imbalance, and quality of life.

Does the Number of Interbody Devices Affect the Fusion Outcome in Short-Segment Posterior Lumbar Fusion?

INTRODUCTION

Interbody devices (IBDs) have been shown to improve outcomes when used in posterior lumbar fusion (PLF) surgery; however,the exact extent of their clinical benefit remains a current topic of interest. Our primary objective in this study was to identify whether the use of an IBD at every level of fusion construct would affect fusion outcomes such as adjacent segment pathology (ASP) and pseudarthrosis after one- to three-level PLF surgery.

METHODS

This was a single-institution retrospective study. We studied the association of factors such as smoking status, BMI, gender, age, and number of IBDs on the development of ASP and pseudarthrosis. To study the effect of independent variables on ASP and pseudoarthrosis, univariate and multivariate regression analyses were used.

RESULTS

The study included 2,061 patients with a history of posterior lumbar fusion who were identified and reviewed. Among these, 363 patients met our inclusion criteria; 247 patients had a minimum follow-up of six months and were finally included in the study. The median follow-up was 30 months. Among the 247 patients, 105 (42.5%) and 24 (9.7%) experienced ASP and pseudarthrosis, respectively. Gender and use of IBD significantly affected the presence of pseudarthrosis (with a higher rate in males and those without any IBDs). Gender, age, BMI, and use of IBDs did not affect ASP. Moreover, using an IBD at each fused level reduced the pseudarthrosis rate significantly compared to when IBDs were not used at all levels (7.3% vs. 27.6%, p <0.001), while there was no significant difference in the rate of ASP (43.6% vs. 34.5%, p = 0.35).

CONCLUSIONS

In patients undergoing one- to three-level PLF surgery, the use of an IBD at all levels of the fusion construct significantly reduces the rate of pseudarthrosis. There was no significant correlation between the rates of ASP. Studies with a larger sample size and a longer follow-up time are suggested to validate our results for pseudoarthrosis and ASP. Our results suggest the use of an IBD per fusion level in short-segment PLF surgeries.

Transforaminal Lumbar Interbody Fusion Versus Posterolateral Fusion Alone in the Treatment of Grade 1 Degenerative Spondylolisthesis

BACKGROUND

Transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone are two operations performed to treat degenerative lumbar spondylolisthesis. To date, it is unclear which operation leads to better outcomes.

OBJECTIVE

To compare TLIF vs PLF alone regarding long-term reoperation rates, complications, and patient-reported outcome measures (PROMs) in patients with degenerative grade 1 spondylolisthesis.

METHODS

A retrospective cohort study using prospectively collected data between October 2010 and May 2021 was undertaken. Inclusion criteria were patients aged 18 years or older with grade 1 degenerative spondylolisthesis undergoing elective, single-level, open posterior lumbar decompression and instrumented fusion with ≥1-year follow-up. The primary exposure was presence of TLIF vs PLF without interbody fusion. The primary outcome was reoperation. Secondary outcomes included complications, readmission, discharge disposition, return to work, and PROMs at 3 and 12 months postoperatively, including Numeric Rating Scale-Back/Leg and Oswestry Disability Index. Minimum clinically important difference of PROMs was set at 30% improvement from baseline.

RESULTS

Of 546 patients, 373 (68.3%) underwent TLIF and 173 underwent (31.7%) PLF. Median follow-up was 6.1 years (IQR = 3.6-9.0), with 339 (62.1%) >5-year follow-up. Multivariable logistic regression showed that patients undergoing TLIF had a lower odds of reoperation compared with PLF alone (odds ratio = 0.23, 95% CI = 0.54-0.99, P = .048). Among patients with >5-year follow-up, the same trend was seen (odds ratio = 0.15, 95% CI = 0.03-0.95, P = .045). No differences were observed in 90-day complications ( P = .487) and readmission rates ( P = .230) or minimum clinically important difference PROMs.

CONCLUSION

In a retrospective cohort study from a prospectively maintained registry, patients with grade 1 degenerative spondylolisthesis undergoing TLIF had significantly lower long-term reoperation rates than those undergoing PLF.

Use of biphasic calcium phosphate versus demineralized bone matrix: retrospective clinical and CT analysis of posterolateral fusion results

PURPOSE

Bone graft extenders have been developed to prevent donor site morbidity associated with iliac crest bone graft, but few studies compared the efficacy of various substitutes. Our purpose was to determine fusion rate and clinical outcome in patients undergoing lumbar arthrodesis using demineralized bone matrix (DBM) and biphasic calcium phosphate (BCP).

METHODS

Patients with degenerative spondylolisthesis undergoing one-level or two-level arthrodesis of lumbar spine were retrospectively reviewed. Two treatment groups placed either BCP or DBM, in addition to local autograft in lumbar posterolateral space. Three-dimensional CT exam and dynamic flexion-extension radiographs at postoperative 2-year were assessed for posterolateral fusion status and pain scale and Oswestry Disability Index (ODI) for clinical outcome.

RESULTS

Of the 148 patients reviewed (including 23 in one- and 58 patients in two-level in BCP group, and 47 in one- and 20 patients in two-level in DBM group), no significant differences were found in terms of age, sex, BMI, smoking, diabetes, steroids, number of level fused, non-union rate or revision surgery between BCP and DBM groups. Significantly improved pain scale of back and leg and ODI were found in both groups postoperatively without group difference. We found a comparable fusion rate in one-level surgery (100% versus 93.6%) and a superior fusion rate of BCP group in two-level surgery (98.3% versus 80.0%, p = 0.01).

CONCLUSION

Being a bone graft extender without osteoinductive property, with local autograft, BCP is comparable to DBM for one- and superior for two-level fusion. No significant difference was found in clinical outcomes.

Characteristics of interbody bone graft fusion after transforaminal lumbar interbody fusion according to intervertebral space division

BACKGROUND

According to intervertebral space division, the characteristics of interbody bone graft fusion after transforaminal lumbar interbody fusion (TLIF) were assessed via computed tomography (CT) scan to provide a theoretical basis for selecting the bone grafting site of interbody fusion.

METHODS

The medical records of 57 patients with lumbar spinal stenosis and disc herniation treated with TLIF were analysed retrospectively. In total, 57 segments received lumbar interbody fusion. A thin-layer CT scan was performed to evaluate fusion in each zone of the fusion space.

RESULTS

The fusion rates were 57.89% (n = 33) in the anterior cage zone, 73.68% (n = 42) in the posterior cage zone, 66.67% (n = 38) in the decompression zone, 26.32% (n = 15) in the contralateral decompression zone and 94.74% (n = 54) in the inner cage zone. There were significant differences among the fusion rates of the five zones (P < 0.001). Further pairwise comparison revealed that the fusion rates in the inner cage significantly differed from the anterior and posterior cages and decompression and contralateral decompression zones (P = 0.001, 0.002, 0.001 and 0.001, respectively).

CONCLUSION

We think the central cage zone (i.e., inner cage) should be the focus of bone grafting. Although there is small volume of bone graft on the posterior cage zone, the fusion rate is relatively high, only secondary to the inner cage zone. The fusion rate is of the contralateral decompression zone is lower although there is a bone graft.

Increased 30-Day Postoperative Readmission and Medical Complication Rates Among Patients 65 Years and Older Following Arthroscopic Rotator Cuff Repair

Purpose

Methods

Results

Conclusions

30-Day outcomes analysis of surgical management of radial head fractures comparing radial head arthroplasty to open reduction internal fixation

INTRODUCTION

Radial head arthroplasty and open reduction internal fixation are two commonly utilized treatment options for radial head fractures. The purpose of this study is to assess the incidence of and risk factors for short-term complications following radial head arthroplasty and open reduction internal fixation of radial head fractures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients that underwent radial head arthroplasty or open reduction internal fixation for radial head fractures between January 1st, 2015 and December 31st, 2017. The incidence of various 30-day complications, including unplanned readmission, reoperation, non-home discharge, mortality, surgical/medical complications, and extended length-of-stay were compared between the two propensity matched groups. Multivariate logistic regression was used to identify independent risk factors for various short-term complications.

RESULTS

After propensity matching, a total of 435 patients were included in our analysis. 250 patients underwent radial head arthroplasty, and 185 patients underwent open reduction internal fixation. Arthroplasty treated patients had a significantly longer mean total operative time (p = .031) and length-of-stay (p = .003). No significant 30-day complications differences were found for unplanned readmission, reoperation, non-home discharge, mortality, surgical complications or medical complications. Independent risk factors for any complications of both procedures included a history of chronic obstructive pulmonary disease and American Society of Anesthesiologists class III. Significant risk factors for length-of-stay greater than two days included a history of bleeding disorder and American Society of Anesthesiologists class III.

CONCLUSION

Our study revealed there were no significant differences in 30-day perioperative surgical or medical complications from either surgical treatment of radial head fractures; however, radial head arthroplasty treated patients were met with a significantly longer length-of-stay and longer duration of operating time. We also identified risk factors that were independently associated with higher rates of complications regardless of treatment type.

The effect of posterior lumbar dynamic fixation and intervertebral fusion on paraspinal muscles

BACKGROUND

The aim of this study was to analyze the effect of unilateral K-rod dynamic internal fixation on paraspinal muscles for lumbar degenerative diseases.

METHODS

This study retrospectively collected 52 patients who underwent lumbar surgery with the K-rod group or PLIF. The operation time, intraoperative blood loss, postoperative drainage volume, postoperative exercise time were compared in the two groups. The visual analog scale (VAS) score and the oswestry dysfunction index (ODI) were employed to evaluate the clinical outcomes. The functional cross-sectional area (FCSA) of the paraspinal muscles and paraspinal muscles fat infiltration were measured to assess on the paraspinal muscles.

RESULTS

As compared with the PLIF group, the operation time, the postoperative time in the field, and the average postoperative hospital stay in the K-rod internal fixation group were significantly shortened. At the last follow-up, both the groups showed significant improvement in the VAS score and ODI. The FCSA atrophy of the upper and lower adjacent segments (UAS and LAS) of the K-rod internal group was significantly less than that of the PLIF group. The extent of increase in the fatty infiltration of the paraspinal muscles in the K-rod group was significantly lesser than that in the PLIF group. The postoperative low back pain of the two groups of patients was significantly positively correlated with the FCSA atrophy.

CONCLUSIONS

As compared to PLIF, the posterior lumbar unilateral K-rod dynamic internal fixation showed significantly lesser paraspinal muscle atrophy and fatty infiltration, which were significantly positively correlated with postoperative low back pain.

[Reasons analysis on unplanned reoperation of degenerative lumbar spine diseases]

Objective

To review the research on the reasons of unplanned reoperation (URP) for degenerative lumbar spine diseases, and to provide new ideas for improving the quality of surgery for degenerative lumbar spine diseases.

Methods

The literature about the URP of degenerative lumbar spine diseases at home and abroad in recent years was reviewed and analyzed.

Results

At present, the reasons for URP include surgical site infection (SSI), hematoma formation, cerebrospinal fluid leakage (CSFL), poor results of surgery, and implant complications. SSI and hematoma formation are the most common causes of URP, which happen in a short time after surgery; CSFL also occurs shortly after surgery but is relatively rare. Poor surgical results and implant complications occurred for a long time after surgery. Factors such as primary disease and surgical procedures have an important impact on the incidence of URP.

Conclusion

The main reasons for URP are different in various periods after lumbar spine surgery. Interventions should be given to patients with high-risk URP, which thus can reduce the incidence of URP and improve the surgery quality and patients' satisfaction.

Effect of Methadone and Tramadol Opioids on Stem Cells Based on Integrated Plasmonic-Ellipsometry Technique

Introduction: Plasmonic biosensors provide high sensitivity in detecting the low amount of biomarkers and pharmaceutical drugs. We studied the mesenchyme cell activity under the treatment of common sedative drugs of methadone and tramadol using the integrated plasmonic-ellipsometry technique. Methods: Mesenchymal stem cells were cultured on patterned plasmonic chips under the treatment of methadone and tramadol drugs. Three cultured chips were kept non-treated as the control ones. The plasmonic-ellipsometry technique was applied to study the signaling characteristic of the cells affected by these two drugs. In this technique, optical information regarding the amplitude ratio and phase change between p- and s-polarized light was recorded. Results: This drug treatment could affect the spectral plasmonic resonance and subsequently the phase shift (Δ) and the amplitude ratio (Ψ) values under p- and s-polarized impinging light. A more significant Δ value for tramadol treatment meant that the phase split was larger between p- and s-polarized light. Tramadol also had more prominent absolute Δ eff and Ψ eff values in comparison with methadone. Conclusion: We showed that tramadol caused more contrast in phase shift (Δ) and amplitude ratio (Ψ) between p- and s-polarized impinging light for cultured stem cells in comparison with methadone. It means that tramadol differentiated more the optical responses for p- and s-polarized lights compared to methadone. Our proposed technique possesses the potential of quantitative and qualitative analysis of drugs on humans even on a cell scale.

Influence of Sex on Early Outcomes of Elective Lumbar Fusions: An Updated Propensity-Matched and Subgroup Analysis

OBJECTIVE

Existing data have demonstrated significant differences in morbidity and mortality measures between men and women undergoing various spinal surgeries. However, studies of lumbar fusion surgery have been limited. Thus, we investigated the effects of patient sex on 30-day perioperative outcomes after elective lumbar fusion spine surgery.

METHODS

Patients who had undergone lumbar fusion from 2015 to 2018 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching was used to determine whether the patient's sex had influenced the 30-day perioperative complications.

RESULTS

A total of 44,526 cases had met the inclusion criteria and were reviewed. Of the 44,526 patients, 13,715 had undergone posterior lumbar fusion, 21,993 had undergone posterior/transforaminal lumbar interbody fusion, and 8818 had undergone anterior/lateral lumbar interbody fusion. The women were more likely to be older, functionally dependent, and taking steroids for chronic conditions and to have a higher body mass index and lower preoperative hematocrit level. The men were more likely to be white, to smoke, and to have diabetes mellitus, hypertension, and bleeding disorders. In all cohorts, except for a higher incidence of urinary tract infection in the female patients and myocardial infarction in the male patients, no significant differences were found in morbidity and mortality between the sexes.

CONCLUSIONS

Several differences in demographics and baseline health status were found between men and women undergoing lumbar fusion. When attempting to control for comorbid conditions using propensity score matching, we found that sex was an independent predictor of urinary tract infection in women and myocardial infarction in men across major morbidity and mortality categories in patients undergoing lumbar fusion surgery.

Transforaminal lumbar interbody fusion with reduction of slippage of vertebrae for isthmic lumbar spondylolisthesis: Unilateral versus bilateral interbody fusion

OBJECTIVE

To investigate the radiological and clinical efficacy of transforaminal lumbar bilateral interbody fusion (TLBIF) versus transforaminal lumbar unilateral interbody fusion (TLUIF) with reduction of slippage of the vertebra in isthmic lumbar spondylolisthesis (ILS).

METHODS

A comparative retrospective study was conducted between patients undergoing TLBIF (n = 46) and TLUIF (n = 40). Demographic data, intraoperative data, complications, and radiographic parameters, including total lumbar lordosis (LL), intervertebral disc height (IDH), and foraminal height (FH), and the final fusion rate were evaluated and compared between the two groups. Clinical outcomes were assessed by the Visual Analog Scale (VAS) for low back pain and leg pain, and the Oswestry Disability Index (ODI).

RESULTS

Significant improvement in terms of radiographic and clinical outcomes was achieved in both groups during the period from pre-operation to at least 24 months post-operation (all, P < 0.05).

ORIGINAL SENTENCE

Analysis of back and leg pain by VAS score and radiographic data including LL, IDH and FH showed superior improvement in TLBIF group compared with TLUIF group. However, ODI was similar between the two groups.

REVISED

Analysis of radiographic data, including LL, IDH, and FH, showed superior improvement in the TLBIF group compared with the TLUIF group (all, P < 0.05). However, either back and leg pain by the VAS score or ODI was similar between the two groups (all, P > 0.05). The fusion rate was 100 % in the TLBIF group versus 95 % in the TLUIF group during the 24-month follow-up period. The operation time was longer and the complication rate was lower in the TLBIF group than in the TLUIF group (all, P < 0.05), while intraoperative blood loss was similar between the two groups (P > 0.05).

CONCLUSIONS

TLBIF with reduction did not cause significant procedure-associated complications in ILS patients. The therapeutic outcome of TLBIF was satisfactory and similar to that of TLUIF for ILS.

ORIGINAL SENTENCE

Compared with TLUIF, TLBIF appears to be associated with better radiological data, less postoperative back and leg discomfort, and quicker postoperative recovery.

REVISED

Compared with TLUIF, TLBIF appears to be associated with better radiological data, bone fusion rate, and similar patient-reported outcomes (PROs), including the ODI and VAS pain score for the back and leg.