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Wang D, Chen X, Han D, Wang W, Kong C, Lu S. Radiographic predictors of reaching minimal clinically important difference following lumbar fusion surgery in patients with degenerative lumbar spondylolisthesis. 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; 33:1786-1795. [PMID: 38093000 DOI: 10.1007/s00586-023-08051-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/16/2023] [Accepted: 11/12/2023] [Indexed: 06/18/2024]
Abstract
PURPOSE The present study aimed to (1) compare sagittal alignment between patients with degenerative lumbar spondylolisthesis (DLS) who reached or missed the minimal clinically important difference (MCID) for clinical outcomes following lumbar fusion surgery (LFS) and (2) identify radiographic predictors associated with MCID achievement in DLS patients. METHODS A total of 91 single-level DLS patients who underwent LFS and had a minimum of 1-year follow-up were enrolled in this study. The assessed radiographic parameters included thoracic kyphosis, lumbar lordosis (LL), segmental lumbar lordosis (SLL), slip percentage, sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and sagittal vertical axis. Changes in radiographic parameters were determined by subtracting the preoperative value from the final follow-up measurement. Clinical outcomes were assessed using the Oswestry Disability Index (ODI) and the visual analog scale (VAS) for both back and leg pain. MCID values were set at 10 points for ODI, 2.1 points for VAS back pain, and 2.8 points for VAS leg pain. Patients were assigned to the reached MCID (rMCID) and missed MCID (mMCID) groups based on the postoperative (post-op) recovery of clinical outcomes. RESULTS At the last follow-up, 68.1% (62/91), 72.5% (66/91), and 76.9% (70/91) of patients reached MCID for ODI, VAS back pain, and VAS leg pain, respectively. Concerning ODI, the rMCID group exhibited higher post-op LL (47.93° vs. 42.95°, P = 0.044), higher post-op SLL (17.08° vs. 14.41°, P = 0.032), higher post-op SS (34.46° vs. 30.63°, P = 0.027), higher ∆LL (5.90° vs. 2.44°, P = 0.017), higher ∆SLL (4.63° vs. - 1.03°, P < 0.001), higher ∆SS (4.76° vs. 1.23°, P = 0.002), lower post-op PT/PI (36.95% vs. 42.01%, P = 0.049), lower ∆PT (- 3.71° vs. 1.05°, P < 0.001), lower ∆PT/PI (- 7.45% vs. 1.97%, P < 0.001), and lower ∆PI-LL (- 5.43° vs. - 3.71°, P = 0.011) than the mMCID group. Regarding VAS back pain, the rMCID group showed higher post-op SLL (17.06° vs. 14.05°, P = 0.021), higher post-op SS (34.34° vs. 30.33°, P = 0.027), higher ∆SLL (3.93° vs. - 0.09°, P < 0.001), and lower ∆PT (- 2.91° vs. - 0.30°, P = 0.039) than the mMCID group. For VAS leg pain, higher ∆SLL (3.55° vs. 0.41°, P = 0.003) was observed in the rMCID group than in the mMCID group. Multivariate logistic regression analysis revealed that higher ∆SLL, higher ∆SS, and higher post-op SS were independent predictors for the achievement of MCID in patients with DLS. CONCLUSION DLS patients who reached MCID following LFS demonstrated improved post-op spinopelvic alignment. Higher ∆SLL, higher ∆SS, and higher post-op SS were the critical parameters associated with MCID achievement in patients with DLS.
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Affiliation(s)
- Dongfan Wang
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, 100053, China
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China
| | - Xiaolong Chen
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, 100053, China
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China
| | - Di Han
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, 100053, China
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China
| | - Wei Wang
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, 100053, China
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China
| | - Chao Kong
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, 100053, China
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China
| | - Shibao Lu
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, 100053, China.
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China.
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Daniels AH, Balmaceno-Criss M, McDonald CL, Singh M, Knebel A, Kuharski MJ, Daher M, Alsoof D, Lafage R, Lafage V, Diebo BG. Segmental Sagittal Alignment in Lumbar Spinal Fusion: A Review of Evidence-Based Evaluation of Preoperative Measurement, Surgical Planning, Intraoperative Execution, and Postoperative Evaluation. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01153. [PMID: 38690883 DOI: 10.1227/ons.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/05/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Maintaining and restoring global and regional sagittal alignment is a well-established priority that improves patient outcomes in patients with adult spinal deformity. However, the benefit of restoring segmental (level-by-level) alignment in lumbar fusion for degenerative conditions is not widely agreed on. The purpose of this review was to summarize intraoperative techniques to achieve segmental fixation and the impact of segmental lordosis on patient-reported and surgical outcomes. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, Cochrane, and Web of Science databases were queried for the literature reporting lumbar alignment for degenerative lumbar spinal pathology. Reports were assessed for data regarding the impact of intraoperative surgical factors on postoperative segmental sagittal alignment and patient-reported outcome measures. Included studies were further categorized into groups related to patient positioning, fusion and fixation, and interbody device (technique, material, angle, and augmentation). RESULTS A total of 885 studies were screened, of which 43 met inclusion criteria examining segmental rather than regional or global alignment. Of these, 3 examined patient positioning, 8 examined fusion and fixation, 3 examined case parameters, 26 examined or compared different interbody fusion techniques, 5 examined postoperative patient-reported outcomes, and 3 examined the occurrence of adjacent segment disease. The data support a link between segmental alignment and patient positioning, surgical technique, and adjacent segment disease but have insufficient evidence to support a relationship with patient-reported outcomes, cage subsidence, or pseudoarthrosis. CONCLUSION This review explores segmental correction's impact on short-segment lumbar fusion outcomes, finding the extent of correction to depend on patient positioning and choice of interbody cage. Notably, inadequate restoration of lumbar lordosis is associated with adjacent segment degeneration. Nevertheless, conclusive evidence linking segmental alignment to patient-reported outcomes, cage subsidence, or pseudoarthrosis remains limited, underscoring the need for future research.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Mariah Balmaceno-Criss
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Christopher L McDonald
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Manjot Singh
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Ashley Knebel
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Michael J Kuharski
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Mohammad Daher
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Daniel Alsoof
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, New York, USA
| | - Bassel G Diebo
- Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
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Diebo BG, Balmaceno-Criss M, Lafage R, McDonald CL, Alsoof D, Halayqeh S, DiSilvestro KJ, Kuris EO, Lafage V, Daniels AH. Sagittal Alignment in the Degenerative Lumbar Spine: Surgical Planning. J Bone Joint Surg Am 2024; 106:445-457. [PMID: 38271548 PMCID: PMC10906213 DOI: 10.2106/jbjs.23.00672] [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] [Indexed: 01/27/2024]
Abstract
➤ Sagittal alignment of the spine has gained attention in the field of spinal deformity surgery for decades. However, emerging data support the importance of restoring segmental lumbar lordosis and lumbar spinal shape according to the pelvic morphology when surgically addressing degenerative lumbar pathologies such as degenerative disc disease and spondylolisthesis.➤ The distribution of caudal lordosis (L4-S1) and cranial lordosis (L1-L4) as a percentage of global lordosis varies by pelvic incidence (PI), with cephalad lordosis increasing its contribution to total lordosis as PI increases.➤ Spinal fusion may lead to iatrogenic deformity if performed without attention to lordosis magnitude and location in the lumbar spine.➤ A solid foundation of knowledge with regard to optimal spinal sagittal alignment is beneficial when performing lumbar spinal surgery, and thoughtful planning and execution of lumbar fusions with a focus on alignment may improve patient outcomes.
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Affiliation(s)
- Bassel G. Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Mariah Balmaceno-Criss
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Christopher L. McDonald
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Daniel Alsoof
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Sereen Halayqeh
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kevin J. DiSilvestro
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Eren O. Kuris
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alan H. Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Tan LX, Du XK, Tang RM, Rong LM, Zhang LM. Effect of spinal-pelvic sagittal balance on the clinical outcomes after lumbar fusion surgery. BMC Surg 2023; 23:334. [PMID: 37914985 PMCID: PMC10621172 DOI: 10.1186/s12893-023-02240-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 10/17/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Spinal-pelvic sagittal balance is important for maintaining energy-efficient posture in normal and diseased states.Few reports to date have evaluated the effect of spinal-pelvic sagittal balance on clinical outcomes after lumbar interbody fusion in patients with lumbar degenerative diseases (LDD). METHODS A total of 303 patients treated with posterior lumbar interbody fusion surgery for lumbar degenerative disease from January 2012 to December 2019 were enrolled in this retrospective study according to the inclusion criteria. Preoperative and postoperative spinal-pelvic sagittal parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and lumbar lordosis (LL) of the patients were evaluated and compared. 163 patients whose postoperative PI-LL ≤ 10° were divided into the spinal-pelvic match group (Group M), while 140 patients were divided into the spinal-pelvic mismatch group (Group MM). Preoperative and postoperative Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for back pain of both groups were compared. RESULTS There was no significant difference between the two groups in demographic and surgical data, except for blood loss in surgery. LL, PI, PT and SS of the patients at final follow-up were all statistically different from the preoperative values in the two groups(P < 0.05). There was no significant difference in LL, PI, PT and SS between the two groups before surgery. At the final follow-up, LL, PI and PT differed significantly between the two groups(P < 0.05). Compared with the preoperative results, ODI and VAS of low back in both groups decreased significantly at the final follow-up (P < 0.05). Significant differences in VAS and ODI were found between the two groups at the final follow-up (P < 0.05). The improvement rates of VAS and ODI of Group M are both significantly higher than Group MM. Regression analysis showed that age and spinal-pelvic match had significant effects on the improvement of patients' low back pain at the final follow-up. CONCLUSIONS lumbar interbody fusion can significantly improve the prognosis of patients with LDD. In terms of outcomes with an average follow-up time of more than 2 years, the spinal-pelvic match has a positive effect on patients' quality of life and the release of low back pain.
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Affiliation(s)
- Li-Xian Tan
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
- Department of Orthopedics, Dongguan Third People's Hospital, Dongguan, China
| | - Xiao-Kang Du
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Run-Min Tang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Li-Min Rong
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Liang-Ming Zhang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China.
- Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China.
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Xilong C, Kangkang W, Wanmei Y, Beibei L, Yunlei Z, Haiyang Y, Zikai H. Sagittal Spinopelvic Alignment in the Standing and Prone Positions of Patients with Old Traumatic Thoracolumbar Kyphosis: Relationship with Immediately Postoperative Parameters. World Neurosurg 2023; 176:e692-e696. [PMID: 37295468 DOI: 10.1016/j.wneu.2023.05.121] [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: 01/19/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the changes in spine-pelvis sagittal parameters from the standing position to the prone position and to study the relationship between sagittal parameters and immediately postoperative parameters. METHODS Thirty-six patients with old traumatic spinal fracture combined with kyphosis were enrolled. The preoperative standing position, prone position, and postoperative sagittal parameters of the spine and pelvis, including the local kyphosis Cobb angle (LKCA), thoracic kyphosis angle (TKA), lumbar lordosis angle (LLA), sacral slope (SS), pelvic tilt (PT), pelvic incidence minus lumbar lordosis angle (PI-LLA), and sagittal vertebral axis (SVA), were measured. The data of kyphotic flexibility and correction rate werecollected and analyzed. The parameters of the preoperative standing position, prone position and postoperative sagittal position were analyzed statistically. Correlation analysis and regression analysis of the preoperative standing and prone sagittal parameters and postoperative parameters were conducted. RESULTS There were significant differences in the preoperative standing position, prone position, and postoperative LKCA and TK. Correlation analysis showed that preoperative sagittal parameters of the standing position and prone position were all correlated with postoperative homogeneity. Flexibility was not related to the correction rate. Regression analysis showed preoperative standing, prone LKCA, and TK were linear with postoperative standing. CONCLUSIONS The LKCA and TK of old traumatic kyphosis obviously changed from the standing position to the prone position, which were linear with postoperative LKCA and TK and can be used to predict postoperative sagittal parameters. This change should be taken into account in the surgical strategy.
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Affiliation(s)
- Cui Xilong
- School of Mechatronics Engineering and Automation, Shanghai University, Shanghai, China; Spinal Deformity Clinical and Research Center of Anhui Province, Fuyang City, Anhui, China
| | - Wang Kangkang
- Department of Orthopedics, Fuyang People's Hospital, Fuyang City, Anhui, China; Spinal Deformity Clinical and Research Center of Anhui Province, Fuyang City, Anhui, China
| | - Yang Wanmei
- Department of Orthopedics, Fuyang People's Hospital, Fuyang City, Anhui, China; Spinal Deformity Clinical and Research Center of Anhui Province, Fuyang City, Anhui, China
| | - Li Beibei
- Spinal Deformity Clinical and Research Center of Anhui Province, Fuyang City, Anhui, China; Department of Orthopedics, The Sixth Fuyang People's Hospital, Fuyang City, Anhui, China
| | - Zhai Yunlei
- Department of Orthopedics, Fuyang People's Hospital, Fuyang City, Anhui, China; Spinal Deformity Clinical and Research Center of Anhui Province, Fuyang City, Anhui, China
| | - Yu Haiyang
- Department of Orthopedics, Fuyang People's Hospital, Fuyang City, Anhui, China; Spinal Deformity Clinical and Research Center of Anhui Province, Fuyang City, Anhui, China
| | - Hua Zikai
- School of Mechatronics Engineering and Automation, Shanghai University, Shanghai, China; Spinal Deformity Clinical and Research Center of Anhui Province, Fuyang City, Anhui, China.
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de Andrada Pereira B, Wangsawatwong P, Lehrman JN, Sawa AGU, Farber SH, Godzik J, O'Neill LK, Uribe JS, Kelly BP, Turner JD. Subtle segmental angle changes of single-level lumbar fusions and adjacent-level biomechanics: cadaveric study of optically measured disc strain. J Neurosurg Spine 2022; 37:525-534. [PMID: 35535834 DOI: 10.3171/2022.3.spine211221] [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: 09/14/2021] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Changes to segmental lordosis at a single level may affect adjacent-level biomechanics and overall spinal alignment with an iatrogenic domino effect commonly seen in adult spinal deformity. This study investigated the effects of different segmental angles of single-level lumbar fixation on stability and principal strain across the surface of the adjacent-level disc. METHODS Seven human cadaveric L3-S1 specimens were instrumented at L4-5 and tested in 3 conditions: 1) neutral native angle ("neutral"), 2) increasing angle by 5° of lordosis ("lordosis"), and 3) decreasing angle by 5° of kyphosis ("kyphosis"). Pure moment loads (7.5 Nm) were applied in flexion, extension, lateral bending, and axial rotation, followed by 400 N of axial compression alone and together with pure moments. Range of motion (ROM), principal maximum strain (E1), and principal minimum strain (E2) across different surface subregions of the upper adjacent-level disc (L3-4) were optically assessed. Larger magnitudes of either E1 or E2 indicate larger tissue deformations and represent indirect measures of increased stress. RESULTS At the superior adjacent level, a significant increase in ROM was observed in kyphosis and lordosis versus neutral in flexion (p ≤ 0.001) and extension (p ≤ 0.02). ROM was increased in lordosis versus neutral (p = 0.03) and kyphosis (p = 0.004) during compression. ROM increased in kyphosis versus neutral and lordosis (both p = 0.03) in compression plus extension. Lordosis resulted in increased E1 across the midposterior subregion of the disc (Q3) versus neutral during right lateral bending (p = 0.04); lordosis and kyphosis resulted in decreased E1 in Q3 versus neutral with compression (p ≤ 0.03). Lordosis decreased E1 in Q3 versus neutral during compression plus flexion (p = 0.01), whereas kyphosis increased E1 in all quartiles and increased E2 in the midanterior subregion versus lordosis in compression plus flexion (p ≤ 0.047). Kyphosis decreased E1 in Q3 (p = 0.02) and E2 in the anterior-most subregion of the disc (Q1) (p = 0.006) versus neutral, whereas lordosis decreased E1 in Q3 (p = 0.008) versus neutral in compression plus extension. CONCLUSIONS Lumbar spine monosegmental fixation with 5° offset from the neutral individual segmental angle altered the motion and principal strain magnitudes at the upper adjacent disc, with induced kyphosis resulting in larger principal strains compared with lordosis. Segmental alignment of single-level fusion influences adjacent-segment biomechanics, and suboptimal alignment may play a role in the clinical development of adjacent-segment disease.
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Affiliation(s)
- Bernardo de Andrada Pereira
- 1Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - Piyanat Wangsawatwong
- 1Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - Jennifer N Lehrman
- 1Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - Anna G U Sawa
- 1Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - S Harrison Farber
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jakub Godzik
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Luke K O'Neill
- 1Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - Juan S Uribe
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Brian P Kelly
- 1Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - Jay D Turner
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Bredow J, Meyer C, Oikonomidis S, Kernich C, Kernich N, Hofstetter CP, Heck VJ, Eysel P, Prasse T. Long-term Radiological and Clinical Outcome after Lumbar Spinal Fusion Surgery in Patients with Degenerative Spondylolisthesis: A Prospective 6-Year Follow-up Study. Orthop Surg 2022; 14:1607-1614. [PMID: 35711118 PMCID: PMC9363728 DOI: 10.1111/os.13350] [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: 07/31/2021] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To assess which radiological alignment parameters are associated with a satisfactory long‐term clinical outcome after performing lumbar spinal fusion for treating degenerative spondylolisthesis. Methods This single‐center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient‐reported outcome using four different questionnaires (COMI, EQ‐5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low‐grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females). Results The data of 17 patients after mono‐ or bisegmental lumbar fusion surgery to treat low‐grade lumbar spondylolisthesis and with a follow‐up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m2 and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8–21). The long‐term clinical outcome correlated significantly with the change of the pelvic tilt (rs = −0.515, P < 0.05) and the sagittal rotation (rs = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (rs = 0.637, P < 0.01) and the pelvic incidence (rs = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (rs = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires. Conclusions The surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long‐term clinical outcome after lumbar interbody fusion surgery.
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Affiliation(s)
- Jan Bredow
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, University of Cologne, Cologne, Germany
| | - Carolin Meyer
- Center for Spinal Surgery, Helios Klinikum Bonn/Rhein-Sieg, Bonn, Germany
| | - Stavros Oikonomidis
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | - Constantin Kernich
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | - Nikolaus Kernich
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | | | - Vincent J Heck
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | - Peer Eysel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany
| | - Tobias Prasse
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, Cologne, Germany.,University of Washington, Department of Neurological Surgery, Seattle, Washington, USA
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Park HY, Kim YH, Ha KY, Chang DG, Kim SL, Park SB. Are the Choice of Frame and Intraoperative Patient Positioning Associated With Radiologic and Clinical Outcomes in Long-instrumented Lumbar Fusion for Adult Spinal Deformity? Clin Orthop Relat Res 2022; 480:982-992. [PMID: 34904962 PMCID: PMC9007220 DOI: 10.1097/corr.0000000000002084] [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: 06/15/2021] [Accepted: 11/12/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies of patient positioning during spinal surgery evaluated intraoperative or immediate postoperative outcomes after short-instrumented lumbar fusion. However, patient positioning during long-instrumented fusion for an adult spinal deformity (ASD) might be associated with differences in intraoperative parameters such as blood loss and longer-term outcomes such as spine alignment, and comparing types of surgical tables in the context of these larger procedures and evaluating longer-term outcome scores seem important. QUESTIONS/PURPOSES (1) Do blood loss and the number of transfusions differ between patients who underwent multi-level spinal fusion with a Wilson frame and those with a four-poster frame? (2) Does restoration of lumbar lordosis and the sagittal vertical axis differ between patients who underwent surgery with the use of one frame or the other? (3) Do clinical outcomes as determined by Numeric Rating Scale and Oswestry Disability Index scores differ between the two groups of patients? (4) Are there differences in postoperative complications between the two groups? METHODS Among 651 patients undergoing thoracolumbar instrumented fusion between 2015 and 2018, 129 patients treated with more than four levels of initial fusion for an ASD were identified. A total of 48% (62 of 129) were eligible; 44% (57 of 129) were excluded because of a history of fusion, three-column osteotomy, or surgical indications other than degenerative deformity, and another 8% (10 of 129) were lost before the minimum 2-year follow-up period. Before January 2017, one surgeon in this study used only a Wilson frame; starting in January 2017, the same surgeon consistently used a four-poster frame. Forty patients had spinal fusion using the Wilson frame; 85% (34 of 40) of these had follow-up at least 2 years postoperatively (mean 44 ± 13 months). Thirty-two patients underwent surgery using the four-poster frame; 88% (28 of 32) of these were available for follow-up at least 2 years later (mean 34 ± 6 months). The groups did not differ in terms of age, gender, BMI, type of deformity, or number of fused levels. Surgical parameters such as blood loss and the total amount of blood transfused were compared between the two groups. Estimated blood loss was measured by the amount of suction drainage and the amount of blood that soaked gauze. The decision to transfuse blood was based on intraoperative hemoglobin values, a protocol that was applied equally to both groups. Radiologic outcomes including sagittal parameters and clinical outcomes such as the Numerical Rating Scale score for back pain (range 0-10; minimal clinically important difference [MCID] 2.9) and leg pain (range 0-10; MCID 2.9) as well as the Oswestry Disability Index score (range 0-100; MCID 15.4) were also assessed through a longitudinally maintained database by two spine surgeons who participated in this study. Repeated-measures analysis of variance was used to compare selected radiologic outcomes between the two groups over time. RESULTS Blood loss and the total amount of transfused blood were greater in the Wilson frame group than in the four-poster frame group (2019 ± 1213 mL versus 1171 ± 875 mL; mean difference 848 [95% CI 297 to 1399]; p = 0.003 for blood loss; 1706 ± 1003 mL versus 911 ± 651 mL; mean difference 795 [95% CI 353 to 1237]; p = 0.001 for transfusion). Lumbar lordosis and the sagittal vertical axis were less restored in the Wilson frame group than in the four-poster frame group (7° ± 10° versus 18° ± 14°; mean difference -11° [95% -17° to -5°]; p < 0.001 for lumbar lordosis; -22 ± 31 mm versus -43 ± 27 mm; mean difference 21 [95% CI 5 to 36]; p = 0.009 for the sagittal vertical axis). Such differences persisted at 2 years of follow-up. The proportion of patients with the desired correction was also greater in the four-poster frame group than in the Wilson frame group immediately postoperatively and at 2 years of follow-up (50% versus 21%, respectively; odds ratio 3.9 [95% CI 1.3 to 11.7]; p = 0.02; 43% versus 12%, respectively; odds ratio 5.6 [95% CI 1.6 to 20.3]; p = 0.005). We found no clinically important differences in postoperative patient-reported outcomes including Numeric Rating Scale and Oswestry Disability Index scores, and there were no differences in postoperative complications at 2 years of follow-up. CONCLUSION The ideal patient position during surgery for an ASD should decrease intra-abdominal pressure and induce lordosis as the abdomen hangs freely and hip flexion is decreased. The four-poster frame appears advantageous for long-segment fusions for spinal deformities. Future studies are needed to extend our analyses to different types of spinal deformities and validate radiologic and clinical outcomes with follow-up for more than 2 years. LEVEL OF EVIDENCE LEVEL III, therapeutic study.
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Affiliation(s)
- Hyung-Youl Park
- Department of Orthopedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Sanggye Paik Hospital, College of Medicine, the Inje University, Seoul, Korea
| | - Sang-ll Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Soo-Bin Park
- Department of Orthopedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
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Shahrestani S, Brown NJ, Acharya N, Diaz-Aguilar LD, Pham MH, Taylor WR. A case report of robotic-guided prone transpsoas lumbar fusion in a patient with lumbar pseudarthrosis, adjacent segment disease, and degenerative scoliosis. Int J Surg Case Rep 2022; 94:106999. [PMID: 35413668 PMCID: PMC9010754 DOI: 10.1016/j.ijscr.2022.106999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 03/27/2022] [Accepted: 03/27/2022] [Indexed: 10/26/2022] Open
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Lenz M, Oikonomidis S, Hartwig R, Gramse R, Meyer C, Scheyerer MJ, Hofstetter C, Eysel P, Bredow J. Clinical outcome after lumbar spinal fusion surgery in degenerative spondylolisthesis: a 3-year follow-up. Arch Orthop Trauma Surg 2022; 142:721-727. [PMID: 33372234 PMCID: PMC8994725 DOI: 10.1007/s00402-020-03697-9] [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: 06/21/2020] [Accepted: 12/03/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Lumbar spinal fusion surgery is a widely accepted surgical treatment in degenerative causes of lumbar spondylolisthesis. The benefit of reduction of anterior displacement and restoration of sagittal parameters is still controversially debated. Purpose of the underlying publication was to analyze the influence of radiographic sagittal parameters of the spine in aspects of changes in postoperative clinical outcome. MATERIALS AND METHODS By prospective analysis, we included patients with low-grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) with mono- or bisegmental fusion surgery with a minimum follow-up data of 3 years. For clinical outcome measures, COMI, ODI and EQ-5D were used. Spinopelvic parameters (sacral inclination, pelvic tilt, sacral slope and pelvic incidence, lumbar lordosis and lumbar index as well as anterior displacement and sagittal rotation) were measured on plain radiographs. RESULTS We could observe a significant benefit in clinical outcome after lumbar fusion surgery in low-grade spondylolisthesis in our mid-term follow-up data including 32 patients. By surgical reduction, we could see significant restoration of anterior displacement and sagittal rotation. Interestingly, a significant correlation between restoration of both sagittal rotation and sacral inclination and clinical outcome score was observed in the 3-year follow-up. CONCLUSION In low-grade spondylolisthesis, spinal fusion surgery is a well-established surgical procedure; however, the impact of sagittal parameters and reduction of anterior displacement remains controversial. Within our findings, restoration of sagittal parameters showed significant correlation to improvement in clinical outcome in our mid-term follow-up data.
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Affiliation(s)
- Maximilian Lenz
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - S. Oikonomidis
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - R. Hartwig
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - R. Gramse
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - C. Meyer
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - M. J. Scheyerer
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - C. Hofstetter
- Department of Neurological Surgery, UW Medicine Seattle, Seattle, WA USA
| | - P. Eysel
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - J. Bredow
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Biomechanical effects of lumbar fusion surgery on adjacent segments using musculoskeletal models of the intact, degenerated and fused spine. Sci Rep 2021; 11:17892. [PMID: 34504207 PMCID: PMC8429534 DOI: 10.1038/s41598-021-97288-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/23/2021] [Indexed: 12/25/2022] Open
Abstract
Adjacent segment disorders are prevalent in patients following a spinal fusion surgery. Postoperative alterations in the adjacent segment biomechanics play a role in the etiology of these conditions. While experimental approaches fail to directly quantify spinal loads, previous modeling studies have numerous shortcomings when simulating the complex structures of the spine and the pre/postoperative mechanobiology of the patient. The biomechanical effects of the L4–L5 fusion surgery on muscle forces and adjacent segment kinetics (compression, shear, and moment) were investigated using a validated musculoskeletal model. The model was driven by in vivo kinematics for both preoperative (intact or severely degenerated L4–L5) and postoperative conditions while accounting for muscle atrophies. Results indicated marked changes in the kinetics of adjacent L3–L4 and L5–S1 segments (e.g., by up to 115% and 73% in shear loads and passive moments, respectively) that depended on the preoperative L4–L5 disc condition, postoperative lumbopelvic kinematics and, to a lesser extent, postoperative changes in the L4–L5 segmental lordosis and muscle injuries. Upper adjacent segment was more affected post-fusion than the lower one. While these findings identify risk factors for adjacent segment disorders, they indicate that surgical and postoperative rehabilitation interventions should focus on the preservation/restoration of patient’s normal segmental kinematics.
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Selection of the fusion and fixation range in the intervertebral surgery to correct thoracolumbar and lumbar tuberculosis: a retrospective clinical study. BMC Musculoskelet Disord 2021; 22:466. [PMID: 34020626 PMCID: PMC8140488 DOI: 10.1186/s12891-021-04335-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background To compare the diseased verses the non-diseased intervertebral surgery used in the treatment of thoracolumbar and lumbar spinal tuberculosis and to explore the best choice of fusion of fixation range. Methods Two hundred twenty-one patients with thoracolumbar and lumbar tuberculosis were categorized into two groups. One hundred eighteen patients underwent the diseased intervertebral surgery (lesion vertebral pedicle fixation, Group A) and 103 patients underwent the non-diseased intervertebral surgery (1 or 2 vertebral fixation above and below the affected vertebra, group B). Spinal tuberculosis diagnosis was confirmed in both groups of patients before lesion removal, bone graft fusion, and internal fixation. Clinical data and efficacy of the two surgical methods were then evaluated. Results The mean follow-up duration for both procedures was 65 months (50–68 months range). There were no significant differences in laboratory examinations, VAS scores, and the Cobb angle correction rate and the angle loss. However, significant differences existed in the operation time, blood loss, serosanguineous drainage volume, and blood transfusion requirement between the two groups. The diseased intervertebral surgery group performed significantly better than the non-diseased intervertebral surgery group in all of these areas. In both cases, the bone graft fused completely with the normal bone by the last follow-up, occuring at 50–86 months post surgery. Conclusion The diseased intervertebral surgery is a safe and feasible option for the treatment of thoracolumbar and lumbar tuberculosis. It effectively restores the physiological curvature of the spine and reduces the degeneration of adjacent vertebral bodies in the spinal column.
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Oikonomidis S, Heck V, Bantle S, Scheyerer MJ, Hofstetter C, Budde S, Eysel P, Bredow J. Impact of lordotic cages in the restoration of spinopelvic parameters after dorsal lumbar interbody fusion: a retrospective case control study. INTERNATIONAL ORTHOPAEDICS 2020; 44:2665-2672. [PMID: 32661634 PMCID: PMC7679311 DOI: 10.1007/s00264-020-04719-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022]
Abstract
Purpose Aim of this study was to compare the reconstruction of radiological sagittal spinopelvic parameters between lordotic (10°) and normal cages (0°) after dorsal lumbar spondylodesis. Methods This retrospective monocentric study included patients who received dorsal lumbar spondylodesis between January 2014 and December 2018. Inclusion criteria were degenerative lumbar diseases and mono- or bi-segmental fusions in the middle and lower lumbar region. Exclusion criteria were long-distance fusions (3 segments and more) and infectious and tumour-related diseases. The sagittal spinopelvine parameters (lumbar lordosis, segmental lordosis, sacral slope, pelvic incidence, and pelvic tilt) were measured pre- and post-operatively by two examiners at two different times. The patients were divided into 2 groups (group 1: lordotic cage, group 2: normal cage). Results One hundred thirty-eight patients (77 female, 61 male) with an average age of 66.6 ± 11.2 years (min.: 26, max.: 90) were included in the study based on the inclusion criteria. Ninety-two patients (66.7%) received 0° cages and 46 (33.3%) lordotic cages (10°). Segmental lordosis was increased by 4.2° on average in group 1 and by 6.5° in group 2 (p = 0.074). Average lumbar lordosis was increased by 2.1° in group 1 and by 0.6° in group 2 (p = 0.378). There was no significant difference in the correction of sagittal spinopelvic parameters. Inter- and inter-class reliability was between 0.887 and 0.956. Conclusion According to the results of our study, no advantages regarding sagittal radiological parameters for the implantation of a lordotic cage could be demonstrated.
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Affiliation(s)
- Stavros Oikonomidis
- Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Vincent Heck
- Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Sonja Bantle
- Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Max Joseph Scheyerer
- Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Stefan Budde
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany
| | - Peer Eysel
- Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Jan Bredow
- Faculty of Medicine and University Hospital Cologne, Department of Orthopedics and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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The prone transpsoas technique: preliminary radiographic results of a multicenter experience. 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; 30:108-113. [DOI: 10.1007/s00586-020-06471-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 12/28/2022]
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