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Sevillano-Perez E, Prado-Novoa M, Postigo-Pozo S, Peña-Trabalon A, Guerado E. L4 fixation is not necessary in L5-Iliac spinopelvic fixation after trauma, but coadjutant transilio-transsacral fixation is. Injury 2024; 55:111378. [PMID: 38309085 DOI: 10.1016/j.injury.2024.111378] [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: 11/16/2023] [Revised: 12/28/2023] [Accepted: 01/20/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Spinopelvic dissociation (SPD) is a severe injury characterized by a discontinuity between the spine and the bony pelvis consisting of a bilateral longitudinal sacral fracture, most of the times through sacral neuroforamen, and a horizontal fracture, usually through the S1 or S2 body. The introduction of the concept of triangular osteosynthesis has shown to be an advance in the stability of spinopelvic fixation (SPF). However, a controversy exists as to whether the spinal fixation should reach up to L4 and, if so, it should be combined with transiliac-transsacral screws (TTS). OBJECTIVE The purpose of this study is to compare the biomechanical behavior in the laboratory of four different osteosynthesis constructs for SPD, including spinopelvic fixation of L5 versus L4 and L5; along with or without TTS in both cases. MATERIAL AND METHODS By means of a formerly described method by the authors, an unstable standardized H-type sacral fracture in twenty synthetic replicas of a male pelvis articulated to the lumbar spine, L1 to sacrum, (Model: 1300, SawbonesTM; Pacific Research Laboratories, Vashon, WA, USA), instrumented with four different techniques, were mechanically tested. We made 4 different constructs in 5 specimen samples for each construct. Groups: Group 1. Instrumentation of the L5-Iliac bones with TTS. Group 2. Instrumentation of the L4-L5-Iliac bones with TTS. Group 3. Instrumentation of L5-Iliac bones without TTS. Group 4: Instrumentation of L4-L5-Iliac bones without TTS. RESULTS AND CONCLUSIONS According to our results, it can be concluded that in SPD, better stability is obtained when proximal fixation is only up to L5, without including L4 (alternative hypothesis), the addition of transiliac-transsacral fixations is essential.
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Affiliation(s)
| | - Maria Prado-Novoa
- Clinical Biomechanics Laboratory of Andalusia (BIOCLINA), University of Malaga, Malaga, Spain
| | - Sergio Postigo-Pozo
- Clinical Biomechanics Laboratory of Andalusia (BIOCLINA), University of Malaga, Malaga, Spain
| | - Alejandro Peña-Trabalon
- Clinical Biomechanics Laboratory of Andalusia (BIOCLINA), University of Malaga, Malaga, Spain
| | - Enrique Guerado
- School of Medicine, University of Malaga, Malaga, Spain; Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol, Marbella Malaga, Spain.
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Okamoto N, Okazaki R, Azuma S, Oshima Y. Clinical role of crosslink augmentation during short-segment posterior lumbar interbody fusion with total facetectomy: A propensity score-matched analysis. J Clin Neurosci 2024; 120:48-54. [PMID: 38185006 DOI: 10.1016/j.jocn.2023.12.023] [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: 12/06/2023] [Accepted: 12/30/2023] [Indexed: 01/09/2024]
Abstract
We investigated the clinical role of crosslink augmentation during PLIF with total facetectomy. We retrospectively reviewed 376 patients who underwent one- or two-segment PLIF with unilateral or bilateral total facetectomy between January 2017 and March 2022. The patients were categorized into two groups based on whether a crosslink was instrumented or not. Radiological outcome measurements included fusion status and implant failure rates on 12-month postoperative computed tomography. Patient-reported outcome measures included the Numerical Rating Scale for lower back pain, Oswestry Disability Index, and Short Form-12 Physical Component Summary scores, which were assessed preoperatively and at 12 months postoperatively. Surgery-related complications included surgical site infection, symptomatic implant failure, and epidural hematoma. Propensity score matching was performed to compare both groups after adjusting for confounding factors, including baseline and surgical procedural characteristics. A total of 200 cases were included in the propensity score calculation, and one-to-one matching was performed, resulting in 56 pairs with and without a crosslink. The fusion status (88.7 % vs. 85.5 %), screw loosening (14.3 % vs. 14.3 %), cage subsidence (17.9 % vs. 16.1 %), and cage dislodgement (5.4 % vs. 0 %) showed no significant difference between those with and without a crosslink, respectively. No significant differences were observed in the patient-reported outcomes or surgery-related complication rates between the groups. Crosslink augmentation during PLIF with total facetectomy is not recommended because it does not provide any radiological or clinical benefit and is associated with avoidable expenses.
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Affiliation(s)
- Naoki Okamoto
- Department of Orthopaedic Surgery, Japanese Red Cross Saitama Hospital, Saitama, Japan 1-5 Shintoshin, Chuo-ku, Saitama 330-0081, Japan; University of Tokyo Spine Group (UTSG), 7-3-1, Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan.
| | - Rentaro Okazaki
- Department of Orthopaedic Surgery, Japanese Red Cross Saitama Hospital, Saitama, Japan 1-5 Shintoshin, Chuo-ku, Saitama 330-0081, Japan; University of Tokyo Spine Group (UTSG), 7-3-1, Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan
| | - Seiichi Azuma
- Department of Orthopaedic Surgery, Japanese Red Cross Saitama Hospital, Saitama, Japan 1-5 Shintoshin, Chuo-ku, Saitama 330-0081, Japan; University of Tokyo Spine Group (UTSG), 7-3-1, Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan
| | - Yasushi Oshima
- University of Tokyo Spine Group (UTSG), 7-3-1, Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan; Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan.
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Hsieh MK, Liu MY, Tsai TT, Lai PL, Tai CL. Biomechanical Comparison of Different Numbers and Configurations of Cross-Links in Long-Segment Spinal Fixation-An Experimental Study in a Porcine Model. Global Spine J 2023; 13:25-32. [PMID: 33511875 PMCID: PMC9837523 DOI: 10.1177/2192568221990646] [Citation(s) in RCA: 1] [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: 01/17/2023] Open
Abstract
STUDY DESIGN Biomechanical study. OBJECTIVE Cross-links are a type of common clinical spinal instrumentation. However, the effects of the position and number of cross-links have never been investigated in long-segment spinal fixation, and the variables have not been optimized. We conducted an in vitro biomechanical study by using a porcine long-segment spinal model with 5 different crosslink configurations to determine the optimal construct for clinical practice. METHODS Five modalities with paired segmental screws from T15-L5 were tested in 20 porcine spines. The spines without cross-links composed the control group, Group A; those with a single cross-link from L2-3 composed Group B; those with 2 cross-links from L1-2 and L3-4 composed Group C; those with 2 cross-links from T15-L1 and L4-5 composed Group D; and those with 3 cross-links from T15-L1, L2-3 and L4-5 composed Group E. Spinal stiffnesses in flexion, extension, lateral bending, and axial rotation were compared among 5 different cross-link configurations in 5-level porcine spinal units. RESULTS Flexional, extensional and lateral bending stiffnesses did not significantly change with an increasing number of cross-links or positions in the construct. Axial stiffness was significantly increased with 2 cross-links compared to one (P < 0.05) and with placement more distant from the center of the long spinal fixation construct (P < 0.05). CONCLUSIONS Two cross-links individually placed proximal and distal from the center of a construct is an optimal and efficient configuration to achieve biomechanical stability in non-rigid lumbar spines undergoing long-level fixation.
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Affiliation(s)
- Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine
Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, Taoyuan
| | - Mu-Yi Liu
- Ph.D. Program in Biomedical Engineering,
Collage of Engineering, Chang Gung University, Taoyuan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine
Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, Taoyuan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine
Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, Taoyuan,Po-Liang Lai, Department of Orthopaedic
Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial
Hospital and Chang Gung University College of Medicine, Taoyuan.
| | - Ching-Lung Tai
- Department of Orthopaedic Surgery, Spine
Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, Taoyuan,Graduate Institute of Biomedical
Engineering, Chang Gung University, Taoyuan,Ching-Lung Tai, Department of Orthopaedic
Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial
Hospital and Chang Gung University College of Medicine, Taoyuan; Graduate
Institute of Biomedical Engineering, Chang Gung University, Taoyuan.
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Is it a requirement or a preference to use cross-links in lumbar instrumentation? JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.7446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background/Aim: The use of cross-links (CL) is controversial due to reasons such as cost increases and instrument redundancy. While there are many biomechanical studies, the clinical data is limited. The aim of this study is to present the clinical effects of CL by putting forward postoperative clinical outcomes and long-term results of patients with (CL+) and without (CL-) CL augmentation.
Methods: In this retrospective cohort study, patients who underwent lumbar posterior instrumentation with CL+ (n = 164) and without CL- (n = 111) augmentation were evaluated. Demographic data, surgical results, preoperative and postoperative visual analogue scale (VAS), the Oswestry Disability Index (ODI) differences, and pseudoarthrosis and adjacent segment disease (ASD)-related recurrence for more than three years of follow-up were determined. Data of CL+ and CL- groups were compared.
Results: CL+ and CL- groups were similar in terms of age and gender (P = 0.319 and P = 0.777, respectively) There was no difference between the two groups in terms of bleeding amount, duration of surgery, and duration of hospitalization (P = 0.931, P = 0.669 and P = 0.518, respectively). Groups were similar in terms of VAS and ODI differences (P = 0.915 and P = 0.983, respectively), yet there was one case of infection in the CL+ group and two cases of infection detected in the CL- group. There were 13 ASDs in the CL+ group, and eight ASDs in the CL- group. Pseudoarthrosis was seen seven times in the CL+ group, while it was four in the CL- group.
Conclusion: It was observed that adding CL in patients who underwent lumbar instrumentation did not change the early period surgical results. The prevalence of complications was compatible with the scientific literature. In our study, there was no preventive advantage in terms of clinical or postoperative complications found in the use of CL.
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Han L, Yang H, Li Y, Li Z, Ma H, Wang C, Yuan J, Zheng L, Chen Q, Lu X. Biomechanical Evaluation of the Cross-link Usage and Position in the Single and Multiple Segment Posterior Lumbar Interbody Fusion. Orthop Surg 2022; 14:2711-2720. [PMID: 36102202 PMCID: PMC9531066 DOI: 10.1111/os.13485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 07/28/2022] [Accepted: 08/09/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Previous studies have neither explored the usage of cross-links nor investigated the optimal position of the cross-links in posterior lumbar interbody fusion (PLIF). This study evaluates biomechanical properties of cross-links in terms of different fixation segments and optimal position in single- and multi-segment posterior lumbar interbody fusion. METHODS Two finite element (FE) models of instrumented lumbosacral spine with single-(L4/5) and multi-segment (L3-S1) PLIF surgery were simulated. On the basis of the two models, the benefits of the usage of cross-links were assessed and compared with the status of no application of cross-links. Moreover, the effects of position of cross-links on multi-segment PLIF surgery were studied in Upper, Middle, and Lower positions. RESULTS No significant difference was found in the range of motion (ROM), intersegmental rotational angle (IRA) of adjacent segments, and intradiscal pressure (IDP) regardless of the usage of cross-links in the single-segment PLIF surgery, while the cross-link increased the maximum von Mises stress in the fixation (MSF) under the axial rotation (53.65 MPa vs 41.42 MPa). In the multi-segment PLIF surgery, the usage of cross-links showed anti-rotational advantages indicated by ROM (Without Cross-link 2.35o , Upper, 2.24o ; Middle, 2.26o ; Lower, 2.30o ) and IRA (Without Cross-link 1.19o , Upper, 1.08o ; Middle, 1.09o ; Lower, 1.13o ). The greatest values of MSF were found in without cross-link case under the flexion, lateral bending, and axial rotation (37.48, 62.61, and 86.73 MPa). The application of cross-links at the Middle and Lower positions had lower values of MSF (48.79 and 69.62 MPa) under the lateral bending and axial rotation, respectively. CONCLUSION The application of cross-links was not beneficial for the single-segment PLIF, while it was found highly advantageous for the multi-segment PLIF. Moreover, the usage of cross-links at the Middle or Lower positions resulted in a better biomechanical stability.
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Affiliation(s)
- Lin Han
- Department of OrthopaedicsShanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
| | - Haisong Yang
- Department of OrthopaedicsShanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
| | - Yongheng Li
- Biomechanics LaboratorySchool of Biological Science & Medical Engineering, Southeast UniversityNanjingChina
| | - Zhiyong Li
- Biomechanics LaboratorySchool of Biological Science & Medical Engineering, Southeast UniversityNanjingChina,School of Mechanical Medical and Process Engineering, Queensland University of TechnologyBrisbaneAustralia
| | - Hongdao Ma
- Department of OrthopaedicsShanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
| | - Chenfeng Wang
- Department of OrthopaedicsShanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
| | - Jincan Yuan
- Department of OrthopaedicsShanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
| | - Luyu Zheng
- School of Medicine, Zhengzhou UniversityZhengzhouChina
| | - Qiang Chen
- Biomechanics LaboratorySchool of Biological Science & Medical Engineering, Southeast UniversityNanjingChina
| | - Xuhua Lu
- Department of OrthopaedicsShanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
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Mirzaei F, Iranmehr A, Shokouhi G, Khadivi M, Shakeri M, Namvar M, Rafiei E, Matloubi B. The role of cross-link augmentation on fusion rate and patient satisfaction among patients with traumatic thoracolumbar spinal fracture: A randomized clinical trial. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:105-110. [PMID: 35526942 DOI: 10.1016/j.neucie.2021.01.003] [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: 10/02/2020] [Accepted: 01/04/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES Most of the studies evaluating the effect of cross links on spinal stability are performed in vitro on porcine or human spine segments and there is limited data regarding clinical benefits of cross link augmentation in traumatic injuries. In this study we aimed to evaluate the effects of cross-links insertion between rods on the fusion rates and post-surgical patients' satisfaction among patients with traumatic thoracolumbar fractures who underwent posterior spinal fixation with pedicle screws. MATERIALS AND METHODS This study was conducted as a randomized clinical trial on 60 patients suffering from traumatic thoracolumbar vertebrae fractures. Patients were randomized into three groups: A (without any cross-link), B (One cross-link insertion) and C (two cross-links insertion). Six months after surgery outcomes were evaluated: fusion rates (plain X-ray and CT scan), Back pain (Visual Analog Scale) and patient satisfaction (fair, good, excellent). RESULTS In group A 13 (65%) patients had structured bone fusion, but in 7 (35%) patients bone fusion was not observed. In both groups B and C, 19 patients (95%) had bone fusion, but only in 1 patient (5%) fusion failed (p=0.009). In group A, fair satisfaction has the highest rate (8 patients (40%)) compared to the other groups. The highest reported severity of back pain was observed in group A while the lowest reported intensity of back pain was related to group B (p=0.001). CONCLUSIONS Adding cross link to posterior spinal fixations of patients with traumatic thoracolumbar fractures can be associated with better final fusion results and patients' satisfaction. However it is necessary to design studies with greater sample sizes to confirm this theory. TRIAL REGISTRATION NUMBER IRCT20120527009878N3.
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Affiliation(s)
- Farhad Mirzaei
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arad Iranmehr
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghaffar Shokouhi
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Khadivi
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Moslem Shakeri
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohamad Namvar
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ebrahim Rafiei
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Bagher Matloubi
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
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Mirzaei F, Iranmehr A, Shokouhi G, Khadivi M, Shakeri M, Namvar M, Rafiei E, Matloubi B. The role of cross-link augmentation on fusion rate and patient satisfaction among patients with traumatic thoracolumbar spinal fracture: A randomized clinical trial. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00011-7. [PMID: 33676794 DOI: 10.1016/j.neucir.2021.01.002] [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: 10/02/2020] [Revised: 12/16/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Most of the studies evaluating the effect of cross links on spinal stability are performed in vitro on porcine or human spine segments and there is limited data regarding clinical benefits of cross link augmentation in traumatic injuries. In this study we aimed to evaluate the effects of cross-links insertion between rods on the fusion rates and post-surgical patients' satisfaction among patients with traumatic thoracolumbar fractures who underwent posterior spinal fixation with pedicle screws. MATERIALS AND METHODS This study was conducted as a randomized clinical trial on 60 patients suffering from traumatic thoracolumbar vertebrae fractures. Patients were randomized into three groups: A (without any cross-link), B (One cross-link insertion) and C (two cross-links insertion). Six months after surgery outcomes were evaluated: fusion rates (plain X-ray and CT scan), Back pain (Visual Analog Scale) and patient satisfaction (fair, good, excellent). RESULTS In group A 13 (65%) patients had structured bone fusion, but in 7 (35%) patients bone fusion was not observed. In both groups B and C, 19 patients (95%) had bone fusion, but only in 1 patient (5%) fusion failed (p=0.009). In group A, fair satisfaction has the highest rate (8 patients (40%)) compared to the other groups. The highest reported severity of back pain was observed in group A while the lowest reported intensity of back pain was related to group B (p=0.001). CONCLUSIONS Adding cross link to posterior spinal fixations of patients with traumatic thoracolumbar fractures can be associated with better final fusion results and patients' satisfaction. However it is necessary to design studies with greater sample sizes to confirm this theory. TRIAL REGISTRATION NUMBER IRCT20120527009878N3.
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Affiliation(s)
- Farhad Mirzaei
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arad Iranmehr
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghaffar Shokouhi
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Khadivi
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Moslem Shakeri
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohamad Namvar
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ebrahim Rafiei
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Bagher Matloubi
- Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran
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Wang LN, Hu BW, Yang X, Wang L, Xiu P, Zhou CG, Liu LM, Song YM. Loss of Correction After Removal of Spinal Implants in Congenital Scoliosis. World Neurosurg 2020; 144:e916-e925. [DOI: 10.1016/j.wneu.2020.09.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/19/2020] [Accepted: 09/20/2020] [Indexed: 10/23/2022]
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Cornaz F, Widmer J, Snedeker JG, Spirig JM, Farshad M. Cross-links in posterior pedicle screw-rod instrumentation of the spine: a systematic review on mechanical, biomechanical, numerical and clinical studies. 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 2020; 30:34-49. [DOI: 10.1007/s00586-020-06597-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/13/2020] [Accepted: 09/05/2020] [Indexed: 12/14/2022]
Abstract
Abstract
Purpose
Dorsal screw-rod instrumentations are used for a variety of spinal disorders. Cross-links (CL) can be added to such constructs, however, no clear recommendations exist. This study aims to provide an overview of the available evidence on the effectiveness of CL, potentially allowing to formulate recommendations on their use.
Methods
A systematic literature review was performed on PubMed and 37 original articles were included and grouped into mechanical, biomechanical, finite element and clinical studies. The change in range of motion (ROM) was analyzed in mechanical and biomechanical studies, ROM, stiffness and stress distribution were evaluated in finite element studies and clinical outcome parameters were analyzed in clinical studies.
Results
A relative consistent reduction in ROM in axial rotation with CL-augmentation was reported, while minor and less consistent effects were observed in flexion–extension and lateral bending. The use of CLs was clinical beneficial in C1/2 fusion, while the limited clinical studies on other anatomic regions show no significant benefit for CL-augmentation.
Conclusion
While CL provides some additional axial rotation stability in most situations, lateral bending and flexion–extension are less affected. Based on clinical data, CL-augmentation can only be recommended for C1/2 instrumentations, while for other cases, further clinical studies are needed to allow for evidence-based recommendations.
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Grevenstein D, Scheyerer MJ, Meyer C, Borggrefe J, Hackl M, Oikonomidis S, Eysel P, Prescher A, Wegmann K. Impact of lumbar pedicle screw positioning on screw stability - A biomechanical investigation. Clin Biomech (Bristol, Avon) 2020; 74:66-72. [PMID: 32145671 DOI: 10.1016/j.clinbiomech.2020.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Screw loosening is a major complication following spondylodesis. While several modifications increase screw stability, some, such as screw augmentation, are associated with potential complications; new techniques are needed to minimize the risk of screw loosening without increasing complication rates. METHODS 13 fresh-frozen human lumbar vertebral bodies (L1 to L5) were dissected. In group 1 (n = 7), pedicle screws were implanted conventionally, while in group 2 (n = 6), the screws were positioned divergent in the sagittal pathway. Screw stability was tested under cyclic axial load; one testing-cycle included 1000 repetitions. The first cycle started with a load of 100 N while the load was increased by +20 N in each following cycle until failure. Failure was defined by either a >5 mm movement of the screw heads or triggering of the switch-off threshold. FINDINGS Average number of cycles until failure was increased in group 2 compared with group 1 (12,046 vs 9761 cycles), as was the average load to failure (Fmax 313 N vs 260 N). Overall, in group 2, the number of cycles until screw loosening or failure increased by 23% (p = 0.28), while the required force increased by 20% (p = 0.3). Statistically significant correlation between BMD and increased number of cycles completed as well as with increased load (p < 0.01) could be observed. INTERPRETATION The results demonstrate, that divergent screw-drift of pairs of screws in the sagittal plane tends to increase stability, especially in vertebral bodies with lower bone density. Moreover, we could demonstrate a correlation between BMD and stability of screw-fixation.
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Affiliation(s)
- David Grevenstein
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University Hospital of Cologne, Joseph-Stelzmann Strasse 24, 50931 Cologne, Germany.
| | - Max J Scheyerer
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University Hospital of Cologne, Joseph-Stelzmann Strasse 24, 50931 Cologne, Germany.
| | - Carolin Meyer
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University Hospital of Cologne, Joseph-Stelzmann Strasse 24, 50931 Cologne, Germany.
| | - Jan Borggrefe
- Department for Diagnostic and Interventional Radiology, Faculty of Medicine, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Michael Hackl
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University Hospital of Cologne, Joseph-Stelzmann Strasse 24, 50931 Cologne, Germany.
| | - Stavros Oikonomidis
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University Hospital of Cologne, Joseph-Stelzmann Strasse 24, 50931 Cologne, Germany.
| | - Peer Eysel
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University Hospital of Cologne, Joseph-Stelzmann Strasse 24, 50931 Cologne, Germany.
| | - Andreas Prescher
- Institute of Molecular and Cellular Anatomy, University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany.
| | - Kilian Wegmann
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University Hospital of Cologne, Joseph-Stelzmann Strasse 24, 50931 Cologne, Germany.
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Wang HW, Yin YH, Li T, Yu XG, Qiao GY. Effects of transverse connector on reduction and fixation of atlantoaxial dislocation and basilar invagination using posterior C1-C2 screw-rod technique. Spine J 2019; 19:1995-2002. [PMID: 31254651 DOI: 10.1016/j.spinee.2019.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The mechanical strength provided by internal fixation is crucial for maintaining reduction and facilitating bony fusion. Though satisfactory results with the C1-C2 technique have been acquired in most clinical reports, the related problems of fusion delay and pseudarthrosis still exist. To increase the chance of bony fusion, a transverse connector (TC) is frequently used to augment torsional stiffness of thoracolumbar screw/rod constructs. Nevertheless, the clinical implication of TC in the management of atlantoaxial dislocation (AAD) and basilar invagination (BI) remains largely unknown. PURPOSE To evaluate the effects of TC application on C1-C2 screw-rod constructs based on consecutive adult patients with AAD and BI in a single institution over a 10-year period. STUDY DESIGN A retrospective study. PATIENT SAMPLE Patients with AAD and BI, who were treated with posterior C1-C2 screw-rod technique with or without TC usage from June 2007 to June 2017 at a single institution. OUTCOME MEASURES The radiological measurements included the anterior atlantodental interval (AADI), posterior atlantodental interval (PADI), height of odontoid process above Chamberlain line, and cervicomedullary angle (CMA). Patients' neurologic status was evaluated with the Japanese Orthopaedic Association (JOA) score. Fusion status was evaluated at different follow-up periods. METHODS We compared the difference of clinical, radiological, and surgical outcomes between the TC and NTC groups postoperatively. RESULTS In total, there were 149 consecutive patients in the TC group and 168 patients in the NTC group. On average, 1.2 TCs per patient were used in the TC group. No significant differences were identified for operative time and blood loss between groups. There was also no statistical difference in the radiological measurements of AADI, PADI, Chamberlain line, and CMA between the TC and NTC groups preoperatively and postoperatively. A significantly higher JOA score was obtained in the TC group than that in the NTC group postoperatively. The fusion rates were higher in the TC group than those in the NCT group at the early stage postoperatively (3 and 6 months; p<.01). CONCLUSIONS Use of TCs seems to improve bony fusion and neurologic outcomes in the treatment of AAD and BI with C1-C2 screw-rod technique.
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Affiliation(s)
- Hua-Wei Wang
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China
| | - Yi-Heng Yin
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China
| | - Teng Li
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China
| | - Xin-Guang Yu
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China.
| | - Guang-Yu Qiao
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China
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Abstract
STUDY DESIGN Retrospective review of a multicenter, prospective database. OBJECTIVE Our aim was to compare complication rates and maintenance of radiographic correction at 2 years after posterior spinal fusion (PSF) with or without cross-links in patients with cerebral palsy (CP)-related scoliosis. SUMMARY OF BACKGROUND DATA Cross-links are frequently used in PSF to correct scoliosis in patients with CP because they are thought to increase the stiffness and torsional rigidity of the construct. METHODS We reviewed the records of patients with CP who underwent primary PSF with or without cross-links between August 2008 and April 2015. Inclusion criteria were minimum follow-up of 2 years, availability of complications data (implant failure, surgical site infection, revision), and pre- and postoperative measurements of the major curve (measured using the Cobb method). The 256 patients included in this analysis had a mean age of 14.1 ± 2.7 years. Ninety-four patients had cross-links (57% using one cross-link; 43% using two cross-links) and 162 patients did not have cross-links. P < 0.05 was considered statistically significant. RESULTS The two groups did not differ significantly with regard to sex, age at surgery, preoperative menarche status, Gross Motor Function Classification System level, major curve magnitude, pelvic obliquity, kyphosis, and lordosis angles. There were no significant differences between groups in the correction achieved or the maintenance of correction at 2 years for the major curve, pelvic obliquity, kyphosis, or lordosis (all P > 0.05). Complication rates were similar between the cross-link group (16%, N = 15) and the non-cross-link group (14%, N = 22). CONCLUSION At 2 years after PSF to treat CP-related scoliosis, patients had no significant differences in the degree of correction achieved, the maintenance of correction, or the rate of complications between those whose fusion constructs used cross-links and those whose constructs did not. LEVEL OF EVIDENCE 3.
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Biomechanical Analysis of a Growing Rod with Sliding Pedicle Screw System for Early-Onset Scoliosis. JOURNAL OF HEALTHCARE ENGINEERING 2019; 2019:9535070. [PMID: 31281619 PMCID: PMC6594281 DOI: 10.1155/2019/9535070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/25/2019] [Indexed: 01/21/2023]
Abstract
Early-onset scoliosis (EOS) remains a challenging condition for which current nonfusion surgeries require iterative lengthening surgeries. A growing rod with sliding pedicle screw system (GRSPSS) was developed to treat spinal deformities without repeated operative lengthening. This study was performed to evaluate whether GRSPSS had similar stability as a conventional pedicle screw system to maintain deformity correction. A serial-linkage robotic manipulator with a six-axis load cell positioned on the end-effector was utilized to evaluate the mechanical stability of the GRSPSS versus conventional fixed scoliosis instrumentation. Ten skeletally mature thoracic female Katahdin sheep spines (T4-L1) were subjected to 2.5 Nm of flexion-extension (FE), lateral bending (LB), and axial rotation (AR) in 2° increments for each state. The overall range of motion (ROM), apical segment ROM, and stiffness were calculated and reported. A two-tailed paired t-test was used to detect significant differences (p < 0.05) between the fixed group and GRSPSS fixation. There were no significant differences in overall range of motion (ROM), apical segment ROM, or stiffness for FE or LB between the GRSPSS group and fixed group. In AR, the GRSPSS group showed increased ROM compared to the fixed group for the overall spine (36.0° versus 19.2°, p < 0.01) and for the instrumented T8-T10 segments (7.0° versus 2.9°, p=0.02). Similarly, the fixed rod elastic zone (EZ) stiffness was significantly greater than the GRSPSS EZ stiffness (0.29 N/m versus 0.17 N/m, p < 0.001). The space around the rod allows for the increased AR observed with the GRSPSS fusion technique and is necessary for axial growth. The GRSPSS fusion model shows equivalent flexion and LB stability to current fusion models and represents a stable fusion technique and may allow for longitudinal growth during childhood.
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Biomechanical analysis of pedicle screw density in posterior spine instrumentation. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000778] [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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Maintenance of Derotation in Adolescent Idiopathic Scoliosis: a Novel Technique Measuring Postoperative Vertebral Rotation by Pedicle Screw Position. HSS J 2016; 12:18-25. [PMID: 26855623 PMCID: PMC4733693 DOI: 10.1007/s11420-015-9468-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 09/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current methods of measuring vertebral rotation by plain radiographs rely on anatomic landmarks that are not present in the postoperative spine or require advanced imaging. Furthermore, there are few studies on the incidence of crankshaft with modern pedicle instrumentation. QUESTIONS/PURPOSES We sought to (1) describe and validate a method of vertebral rotation measurement using plain radiographs and (2) measure postoperative rotation in a series of patients treated for adolescent idiopathic scoliosis. METHODS Patients with adolescent idiopathic scoliosis treated with surgery over a 6-year period were reviewed. Patients with computed tomography (CT) scans and radiographs within 60 days of another were included. Vertebral rotation was calculated by radiographic measurements and measured directly by CT scan. As an internal control, patients with two apical pedicle screws on all radiographs were analyzed. Rotation was measured for all patients with at least 1 year of radiographic follow-up. RESULTS Three thousand five hundred fifty-two instrumented spinal levels in 308 consecutive patients were reviewed. Ten patients with 93 screws were analyzed by CT and radiographs. The average discrepancy between computed tomography (CT) and radiographs was 3.3 ± 1.9°, with 81.7% (76/93) within 5°. Intra- and inter-rater reliabilities for measured axial rotation were excellent (intra-class correlation coefficient (ICC) = 0.879 and 0.900, respectively). One hundred swventy-eight patients were eligible with an average follow-up of 2.3 ± 1.2 years; 84.8% (151/178) had screw(s) visible on all images at the major curve apex. The average postsurgical rotation was 3.5 ± 2.9°; 19.2% (29/151) were measured to have a rotation over 5°, and 4.0% (6/151) demonstrated a rotation over 10°. Only 4.6% (7/151) of patients demonstrated a postoperative Cobb angle change over 10°. CONCLUSIONS Most major curves have apical pedicle screw instrumentation that can be followed by radiographs alone to measure rotation. Vertebral rotation measurement requires only plain radiographs and is a more sensitive determination for subtle postoperative crankshaft than change in Cobb angle.
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Garg S, Niswander C, Pan Z, Erickson M. Cross-Links Do Not Improve Clinical or Radiographic Outcomes of Posterior Spinal Fusion With Pedicle Screws in Adolescent Idiopathic Scoliosis: A Multicenter Cohort Study. Spine Deform 2015; 3:338-344. [PMID: 27927479 DOI: 10.1016/j.jspd.2014.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 11/17/2014] [Accepted: 12/14/2014] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective, comparative analysis. OBJECTIVES Comparative analysis was performed to determine the differences, if any, between adolescent idiopathic scoliosis (AIS) patients who underwent posterior spinal fusion (PSF) with and without cross-links. SUMMARY OF BACKGROUND DATA Cross-links are frequently used during PSF for AIS. It is unclear whether they provide any advantage for patients with all-pedicle screw constructs. METHODS A prospectively collected multicenter database of patients with AIS undergoing spinal fusion was retrospectively queried. Study inclusion criteria were primary PSF with all-pedicle screw fixation (greater than 90% fixation points) and minimum 2 years' follow-up. Collected data included demographics, radiographic measures, complications, Scoliosis Research Society-22r and Spinal Appearance Questionnaire (SAQ) scores. RESULTS A total of 500 patients were included (377 cross-link and 123 non-cross-link). Age, body mass index, gender, and preoperative major Cobb angle were not different between groups. Except for a slightly decreased lumbar Cobb angle (2.7°) in the cross-link group, no other radiographic measures were different at follow-up. Complications were not significantly different between groups: 21 of 377 (6%) crosslink and 9 of 123 (7%) non-cross-link. Infection occurred in 1 patient in the cross-link group and none in the non-cross link group. Reoperation occurred in 4 patients, all with cross-links (3 for implant removal and 1 for distal adding-on). Scoliosis Research Society-22r scores, total and individual domains, improved by a similar amount in both groups. At follow-up, parent and patient SAQ appearance scores were not significantly different. The SAQ expectations domain scores were similar for all visits and improved for both patients and parents. CONCLUSIONS There do not appear to be significant clinical or radiographic outcome differences in patients with AIS undergoing PSF based on the use of cross-links at 2-year follow-up. Surgeons should consider eliminating cross-links in patients with AIS who have PSF with all-pedicle screw constructs. This may have substantial cost savings without affecting patient outcome.
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Affiliation(s)
- Sumeet Garg
- Children's Hospital Colorado Orthopedics Institute, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA.
| | - Cameron Niswander
- Children's Hospital Colorado Orthopedics Institute, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA
| | - Zhaoxing Pan
- Children's Hospital Colorado Orthopedics Institute, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA
| | - Mark Erickson
- Children's Hospital Colorado Orthopedics Institute, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA
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Does addition of crosslink to pedicle-screw-based instrumentation impact the development of the spinal canal in children younger than 5 years of age? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:1391-8. [DOI: 10.1007/s00586-014-3727-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 12/14/2014] [Accepted: 12/14/2014] [Indexed: 11/30/2022]
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