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Liu C, Zhao M, Zhang W, Wang C, Hu B, Wang K, Xu W, Li L, Si H. Biomechanical assessment of different transforaminal lumbar interbody fusion constructs in normal and osteoporotic condition: a finite element analysis. Spine J 2024; 24:1121-1131. [PMID: 38316364 DOI: 10.1016/j.spinee.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 01/06/2024] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND CONTEXT With the aging population, osteoporosis, which leads to poor fusion, has become a common challenge for lumbar surgery. In addition, most people with osteoporosis are elderly individuals with poor surgical tolerance, and poor bone quality can also weaken the stability of internal fixation. PURPOSE This study compared the fixation strength of the bilateral traditional trajectory screw structure (TT-TT), the bilateral cortical bone trajectory screw structure (CBT-CBT), and the hybrid CBT-TT (CBT screws at the cranial level and TT screws at the caudal level) structure under different bone mineral density conditions. STUDY DESIGN A finite element (FE) analysis study. METHODS Above all, we established a healthy adult lumbar spine model. Second, under normal and osteoporotic conditions, three transforaminal lumbar interbody fusion (TLIF) models were established: bilateral traditional trajectory (TT-TT) screw fixation, bilateral cortical bone trajectory (CBT-CBT) screw fixation, and hybrid cortical bone trajectory screw and traditional trajectory screw (CBT-TT) fixation. Finally, a 500-N compression load with a torque of 10 N/m was applied to simulate flexion, extension, lateral bending, and axial rotation. We compared the range of motion (ROM), adjacent disc stress, cage stress, and posterior fixation stress of the different fusion models. RESULTS Under different bone mineral density conditions, the range of motion of the fusion segment was significantly reduced. Compared to normal bone conditions, the ROM of the L4-L5 segment, the stress of the adjacent intervertebral disc, the surface stress of the cage, and the maximum stress of the posterior fixation system were all increased in osteoporosis. Under most loads, the ROM and surface stress of the cage and the maximum stress of the posterior fixation system of the TT-TT structure are the lowest under normal bone mineral density conditions. However, under osteoporotic conditions, the fixation strength of the CBT-CBT and CBT-TT structures are higher than that of the TT-TT structures under certain load conditions. At the same time, the surface stress of the intervertebral fusion cage and the maximum stress of the posterior fixation system for the two structures are lower than those of the TT-TT structure. CONCLUSION Under normal bone mineral density conditions, transforaminal lumbar interbody fusion combined with TT-TT fixation provides the best biomechanictability. However, under osteoporotic conditions, CBT-CBT and CBT-TT structures have higher fixed strength compared to TT-TT structures. The hybrid CBT-TT structure exhibits advantages in minimal trauma and fixation strength. Therefore, this seems to be an alternative fixation method for patients with osteoporosis and degenerative spinal diseases. CLINICAL SIGNIFICANCE This study provides biomechanical support for the clinical application of hybrid CBT-TT structure for osteoporotic patients undergoing TLIF surgery.
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Affiliation(s)
- Chen Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Mengmeng Zhao
- School of Physics and Electronic Science, Shandong Normal University, Jinan, Shandong, 250014, P.R. China
| | - Wencan Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Chongyi Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Bingtao Hu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Kaibin Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Wanlong Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Le Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Haipeng Si
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China; Department of Orthopedics, Qilu Hospital of Shandong University(Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, 266035, P.R. China.
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Khalaf K, Nikkhoo M, Shams S, Niu CC, Cheng CH. Impact of osteoporosis and Cement-Augmented fusion on adjacent spinal levels Post-Fusion Surgery: Patient-Specific finite element analysis. J Biomech 2024; 166:112070. [PMID: 38569456 DOI: 10.1016/j.jbiomech.2024.112070] [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: 08/31/2023] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/05/2024]
Abstract
Cement-augmentation is a technique commonly used during posterior lumbar instrumented fusion (PLIF) to reinforce compromised osteoporotic vertebral bone, minimize the risk of loosening screws, enhance stability, and improve overall surgical outcomes. In this study, we introduce a novel segmented vertebral body regional modeling approach to investigate the effects of osteoporosis and cement-augmented lumbar fusion on disc biomechanics at spinal levels adjacent to the fused vertebrae. Using our previously validated personalized-poroelastic-osteoligamentous FE model of the spine, fusion was simulated at L4-L5, and the biomechanics of adjacent levels were studied for 30 patients (non-osteoporotic patients (N = 15), osteoporotic patients (N = 15)). PLIF models, with and without cement-augmentation, were developed and compared after an 8 h-rest period (200 N), following a 16 h-cyclic compressive loading of 500-1000 N (40 and 20 min, respectively). Movement in different directions (flexion/ extension/ lateral bending/ axial rotation) was simulated using 10Nm moment before and after cyclic loading. The material mapping algorithm was validated by comparing the results of voxel-based and parametric models. The FE cement-augmented models, subject to daily activity loading, demonstrated significant differences in disc height loss and fluid loss as compared to non-cemented models. The calculated axial stress and fiber strain values were also significantly higher for these models. This work demonstrates that although osteoporosis does not significantly alter the time-dependent characteristics of adjacent IVDs post-surgery, cement-augmentation increases the risk of adjacent segment disease (ASD) incidence. A holistic understanding of the trade-offs and long-term complex interplay between structural reinforcement modalities, including cement augmentation, and altered biomechanics warrants further investigation.
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Affiliation(s)
- Kinda Khalaf
- College of Medicine and Health Sciences, Khalifa University of Science and Technology, and Health Engineering Innovation Center, Abu Dhabi, United Arab Emirates.
| | - Mohammad Nikkhoo
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Biomedical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Shohreh Shams
- Department of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
| | - Chi-Chien Niu
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Hsiu Cheng
- School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.
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3
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Li R, Liu Y, Zhu Y, Lu M, Jiang W. Clinical and radiographic outcomes of oblique lumbar interbody fusion with anterolateral screw and rod instrumentation in osteopenia patients: a retrospective study. BMC Musculoskelet Disord 2023; 24:760. [PMID: 37749502 PMCID: PMC10521488 DOI: 10.1186/s12891-023-06873-1] [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: 09/29/2022] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
PURPOSE The purpose of this paper is to evaluate the clinical and radiographic outcomes of oblique lumbar interbody fusion (OLIF) to perform in L4/5 degenerative lumbar spondylolisthesis (DLS) patients who diagnosed with osteopenia. METHODS From December 2018 to 2021 March, 94 patients were diagnosed with degenerative spondylolisthesis underwent OLIF and divided into two groups with different bone mineral density. Anterolateral screw and rod instrumentation was applied in two groups. The primary outcomes were VAS, JOA and ODI. The secondary outcomes included disc height (DH), cross-sectional height of the intervertebral foramina (CSH), cross-sectional area of the dural sac (CSA), lumbar lordorsis (LL), pelvic titlt (PT), pelvic incidence (PI) and sacrum slop (SS). RESULTS All patients finished at least 1 years follow-up with 21.05 ± 4.42 months in the group A and 21.09 ± 4.28 months in the group B. The clinical symptoms were evaluated by VAS, JOA and ODI and 94 patients showed good outcomes at final follow-up (P < 0.05), with significant increases in DH, CSH and CSA. In group A, DH increased from 8.54 ± 2.48 to 11.11 ± 2.63 mm, while increased from 8.60 ± 2.29 to 11.23 ± 1.88 were recorded in group B. No statistical difference was found in DH between the two groups (P > 0.05). The cage subsidence was 1.14 ± 0.83 mm in group A and 0.87 ± 1.05 mm in group B (P > 0.05). There was no significant difference in the adjusted parameters of spino-pelvic between two groups (P > 0.05). CONCLUSION Oblique lumbar interbody fusion with anterolateral screw and rod instrumentation is feasible to be performed in osteopenia patients who diagnosed with degenerative spondylolisthesis.
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Affiliation(s)
- Renjie Li
- Department of Orthopedic Surgery, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University, Suzhou Dushu Lake Hospital, Suzhou, Jiangsu, 215123, China
| | - Yijie Liu
- Department of Orthopedic Surgery, The first affiliated hospital of Soochow University, Suzhou, 215006, Jiangsu, China
| | - Yi Zhu
- Department of Orthopedic Surgery, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University, Suzhou Dushu Lake Hospital, Suzhou, Jiangsu, 215123, China
| | - Minhua Lu
- Department of Orthopedic Surgery, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University, Suzhou Dushu Lake Hospital, Suzhou, Jiangsu, 215123, China
| | - Weimin Jiang
- Department of Orthopedic Surgery, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University, Suzhou Dushu Lake Hospital, Suzhou, Jiangsu, 215123, China.
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Huang Y, Maimaiti A, Tian Y, Li Z, Kahaer A, Rexiti P. Biomechanical investigation of the hybrid lumbar fixation technique with traditional and cortical bone trajectories in transforaminal lumbar interbody fusion: finite element analysis. J Orthop Surg Res 2023; 18:549. [PMID: 37525283 PMCID: PMC10388474 DOI: 10.1186/s13018-023-04027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/17/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE To compare the biomechanical performance of the hybrid lumbar fixation technique with the traditional and cortical bone trajectory techniques using the finite element method. METHODS Four adult wet lumbar spine specimens were provided by the Department of Anatomy and Research of Xinjiang Medical University, and four L1-S1 lumbar spine with transforaminal lumbar interbody fusion (TLIF) models at L4-L5 segment and four different fixation techniques were established: bilateral traditional trajectory screw fixation (TT-TT), bilateral cortical bone trajectory screw fixation (CBT-CBT), hybrid CBT-TT (CBT screws at L4 and TT screws at L5) and TT-CBT (TT screws at L4 and CBT screws at L5). The range of motion (ROM) of the L4-L5 segment, von Mises stress of cage, internal fixation, and rod were compared in flexion, extension, left and right bending, and left and right rotation. RESULTS Compared with the TT-TT group, the TT-CBT group exhibited lower ROM of L4-L5 segment, especially in left-sided bending; the CBT-TT group had the lowest ROM of L4-L5 segment in flexion and extension among the four fixation methods. Compared with the CBT-CBT group, the peak cage stress in the TT-CBT group was reduced by 9.9%, 18.1%, 21.5%, 23.3%, and 26.1% in flexion, left bending, right bending, left rotation, and right rotation conditions, respectively, but not statistically significant (P > 0.05). The peak stress of the internal fixation system in the TT-CBT group was significantly lower than the other three fixation methods in all five conditions except for extension, with a statistically significant difference between the CBT-TT and TT-CBT groups in the left rotation condition (P = 0.017). In addition, compared with the CBT-CBT group, the peak stress of the rod in the CBT-TT group decreased by 34.8%, 32.1%, 28.2%, 29.3%, and 43.0% under the six working conditions of flexion, extension, left bending, left rotation, and right rotation, respectively, but not statistically significant (P > 0.05). CONCLUSIONS Compared with the TT-TT and CBT-CBT fixation methods in TLIF, the hybrid lumbar fixation CBT-TT and TT-CBT techniques increase the biomechanical stability of the internal fixation structure of the lumbar fusion segment to a certain extent and provide a corresponding theoretical basis for further development in the clinic.
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Affiliation(s)
- Ying Huang
- Xinjiang Medical University, Urumqi, China
| | - Abulikemu Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | | | - Alafate Kahaer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
- Key Laboratory of High Incidence Disease Research in Xingjiang (Xinjiang Medical University), Ministry of Education, Urumqi, China.
- Xinjiang Clinical Research Center for Orthopedics, Urumqi, China.
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5
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Peng JC, Guo HZ, Zhan CG, Huang HS, Ma YH, Zhang SC, Xu YR, Mo GY, Tang YC. Comparison of pedicle screw fixation with or without cement augmentation for treating single-segment isthmic spondylolisthesis in the osteoporotic spine. Sci Rep 2023; 13:827. [PMID: 36646752 PMCID: PMC9842729 DOI: 10.1038/s41598-023-27539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
The present study examined the necessity of cement-augmented pedicle screw fixation in osteoporotic patients with single-segment isthmic spondylolisthesis.Fifty-nine cases were reviewed retrospectively. Thirty-three cases were in the polymethylmethacrylate-augmented pedicle screw (PMMA-PS) group, and the other 26 cases were in the conventional pedicle screw (CPS) group. Evaluation data included operation time, intraoperative blood loss, hospitalization cost, hospitalization days, rates of fusion, screw loosening, bone cement leakage, visual analogue scale (VAS) scores, Oswestry disability index (ODI), lumbar lordosis (LL), pelvic tilt (PT) and sacral slope (SS).The operation time and blood loss in the CPS group decreased significantly compared to those in the PMMA-PS group. The average hospitalization cost of the PMMA-PS group was significantly higher than that of the CPS group. There was no significant difference in the average hospital stay between the 2 groups. The initial and last follow-up postoperative VAS and ODI scores improved significantly in the two groups. There were no significant differences in VAS and ODI between the 2 groups at each time point. The last postoperative spine-pelvic parameters were significantly improved compared with those preoperatively. In the PMMA-PS group, the fusion rate was 100%. The fusion rate was 96.15% in the CPS group. No significant difference was found between the two groups for the fusion rate. Nine patients in the PMMA-PS group had bone cement leakage. There was no screw loosening in the PMMA-PS group. There were 2 cases of screw loosening in the CPS group. There were no significant differences in screw loosening, postoperative adjacent segment fractures, postoperative infection or postoperative revision between the 2 groups. The use of PMMA-PS on a regular basis is not recommended in posterior lumbar interbody fusion for the treatment of single-segment isthmic spondylolisthesis with osteoporosis.
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Affiliation(s)
- Jian-Cheng Peng
- Longgang Orthopedics Hospital of Shenzhen, Shenzhen, 518100, China
| | - Hui-Zhi Guo
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Chen-Guang Zhan
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Hua-Sheng Huang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yan-Huai Ma
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Shun-Cong Zhang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yue-Rong Xu
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Guo-Ye Mo
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yong-Chao Tang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China. .,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.
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6
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van Abswoude DH, Pellikaan K, Rosenberg AGW, Davidse K, Coupaye M, Høybye C, Markovic TP, Grugni G, Crinò A, Caixàs A, Poitou C, Mosbah H, Weir T, van Vlimmeren LA, Rutges JPHJ, De Klerk LWL, Zillikens MC, van der Lely AJ, de Graaff LCG. Bone Health in Adults With Prader-Willi Syndrome: Clinical Recommendations Based on a Multicenter Cohort Study. J Clin Endocrinol Metab 2022; 108:59-84. [PMID: 36149817 PMCID: PMC9759176 DOI: 10.1210/clinem/dgac556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/13/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Prader-Willi syndrome (PWS) is a rare complex genetic syndrome, characterized by delayed psychomotor development, hypotonia, and hyperphagia. Hormone deficiencies such as hypogonadism, hypothyroidism, and growth hormone deficiency are common. The combination of hypotonia, low physical activity, and hypogonadism might lead to a decrease in bone mass and increase in fracture risk. Moreover, one would expect an increased risk of scoliosis due to hypotonia and low physical activity. OBJECTIVE To study the prevalence and risk factors for skeletal problems (reduced bone mineral density, fractures, and scoliosis) in adults with PWS. METHODS We retrospectively collected patient characteristics, medical history, medication, biochemical measurements, dual-energy X-ray absorptiometry scans, and spinal X-rays and reviewed the current literature. RESULTS We included 354 adults with PWS (median age 31 years; 43% males), of whom 51 (14%) had osteoporosis (T-score below -2.5) and 143 (54%) had osteopenia (T-score -1 to -2.5). The most prevalent modifiable risk factors for osteoporosis were hypogonadism, insufficient dairy intake, sedentary lifestyle, and corticosteroid use. Male sex was associated with osteoporosis (P = .005). Growth hormone treatment was not associated with osteoporosis. A history of vertebral fractures was present in 10 (3%) and nonvertebral fractures in 59 (17%). Scoliosis was present in 263 (80%), but no modifiable risk factors were identified. CONCLUSION Besides scoliosis, osteoporosis is common in adults with PWS. Based on the literature and the risk factors for osteoporosis found in our cohort, we provide practical clinical recommendations to avoid skeletal complications in these vulnerable patients.
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Affiliation(s)
| | | | - Anna G W Rosenberg
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical
Center, University Medical Center Rotterdam, 3015 GD
Rotterdam, The Netherlands
- Center for Adults with Rare Genetic Syndromes, Department of Internal
Medicine, Division of Endocrinology, Erasmus Medical Center, University Medical Center
Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome,
3015 GD Rotterdam, The
Netherlands
- Academic Center for Growth Disorders, Erasmus Medical Center, University
Medical Center Rotterdam, 3015 GD Rotterdam,
The Netherlands
| | - Kirsten Davidse
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical
Center, University Medical Center Rotterdam, 3015 GD
Rotterdam, The Netherlands
- Center for Adults with Rare Genetic Syndromes, Department of Internal
Medicine, Division of Endocrinology, Erasmus Medical Center, University Medical Center
Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome,
3015 GD Rotterdam, The
Netherlands
- Academic Center for Growth Disorders, Erasmus Medical Center, University
Medical Center Rotterdam, 3015 GD Rotterdam,
The Netherlands
| | - Muriel Coupaye
- Assistance Publique-Hôpitaux de Paris, Rare Diseases Center of reference
‘Prader-Willi Syndrome and obesity with eating disorders’ (PRADORT), Nutrition
Department, Institute of Cardiometabolism and Nutrition, ICAN, Pitié-Salpêtrière
Hospital, Sorbonne Université, INSERM, Nutriomics, F75013
Paris, France
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
| | - Charlotte Høybye
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- ENDO-ERN (European Reference Network)
- Department of Molecular Medicine and Surgery, Karolinska Institute and
Karolinska University Hospital, Stockholm,
Sweden
- Department of Endocrinology, Karolinska Institute and Karolinska University
Hospital, Stockholm, Sweden
| | - Tania P Markovic
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- Metabolism & Obesity Services, Royal Prince Alfred
Hospital, Camperdown, Australia
- Boden Initiative, Charles Perkins Centre, University of
Sydney, SydneyAustralia
| | - Graziano Grugni
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- ENDO-ERN (European Reference Network)
- Divison of Auxology, Istituto Auxologico Italiano, IRCCS,
Piancavallo (VB), Italy
| | - Antonino Crinò
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- Reference Center for Prader-Willi syndrome, Bambino Gesù Hospital, Research
Institute, Palidoro (Rome), Italy
| | - Assumpta Caixàs
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- Department of Endocrinology and Nutrition, Hospital Universitari Parc
Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de
Barcelona, Sabadell, Spain
- Department of Medicine, Universitat Autònoma de Barcelona,
Sabadell, Spain
| | - Christine Poitou
- Assistance Publique-Hôpitaux de Paris, Rare Diseases Center of reference
‘Prader-Willi Syndrome and obesity with eating disorders’ (PRADORT), Nutrition
Department, Institute of Cardiometabolism and Nutrition, ICAN, Pitié-Salpêtrière
Hospital, Sorbonne Université, INSERM, Nutriomics, F75013
Paris, France
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- ENDO-ERN (European Reference Network)
| | - Helena Mosbah
- Assistance Publique-Hôpitaux de Paris, Rare Diseases Center of reference
‘Prader-Willi Syndrome and obesity with eating disorders’ (PRADORT), Nutrition
Department, Institute of Cardiometabolism and Nutrition, ICAN, Pitié-Salpêtrière
Hospital, Sorbonne Université, INSERM, Nutriomics, F75013
Paris, France
| | - Tessa Weir
- Department of Endocrinology, Nepean-Blue Mountains Hospital,
Sydney, NSW, Australia
- Northern Clinical School, Faculty of Medicine and Health, University of
Sydney, Sydney, NSW, Australia
| | - Leo A van Vlimmeren
- Department of Rehabilitation and Pediatric Physical Therapy, Radboud
University Medical Centrum, 6525 GA Nijmegen,
The Netherlands
| | - Joost P H J Rutges
- Department of Orthopedic surgery, Erasmus Medical Center, University
Medical Center Rotterdam, 3015 GD Rotterdam,
The Netherlands
| | - Luuk W L De Klerk
- Department of Orthopedic surgery, Sint Maartensclinic,
6500 GM Nijmegen, The
Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical
Center, University Medical Center Rotterdam, 3015 GD
Rotterdam, The Netherlands
- ENDO-ERN (European Reference Network)
- Academic Center for Rare Bone Disorders, Erasmus Medical Center, University
Medical Center Rotterdam, 3015 GD Rotterdam,
The Netherlands
- European Reference Network for rare bone diseases (ERN BOND)
| | - Aart J van der Lely
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical
Center, University Medical Center Rotterdam, 3015 GD
Rotterdam, The Netherlands
| | - Laura C G de Graaff
- Correspondence: Laura de Graaff, MD, PhD, Dept. of Internal Medicine, Erasmus
MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
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7
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Jain N, Labaran L, Phillips FM, Khan SN, Jain A, Kebaish KM, Hassanzadeh H. Prevalence of Osteoporosis Treatment and Its Effect on Post-Operative Complications, Revision Surgery and Costs After Multi-Level Spinal Fusion. Global Spine J 2022; 12:1119-1124. [PMID: 33334188 PMCID: PMC9210228 DOI: 10.1177/2192568220976560] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To study the prevalence of pre-operative osteoporosis treatment, and its effect on risk of ORC, revision surgery and costs in osteoporotic patients undergoing ≥3-level spinal fusion for degenerative pathology. METHODS Patients and procedures of interest were included using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding. Our outcome measures were ORC at 1-year post-operatively and included instrumentation complications, pathological fracture, and revision surgery. Kaplan-Meier survival curves and Cox proportional hazards analysis was done to study the effect of osteoporosis treatment on risk of ORC. RESULTS We included a total of 849 patients with documented osteoporosis undergoing ≥3-level spinal fusion. White (85.6%), female (82.7%), and 60-79 years of age (79.9%) was the most common demographic. Of entire cohort, 121(14.3%) were on osteoporosis treatment prior to spinal fusion. Of treated patients, 52/121 (43.0%) had continued prescriptions at 1 year post-operatively. Treated patients and not-treated patients had 1-year ORC incidence of 9.1% and 15.0%, respectively. The average 1-year reimbursement/patient for managing ORC was $3,053 (treated) and $21,147 (not-treated). On adjusted cox analysis, pre-operative osteoporosis treatment was associated with a lower risk of ORC (HR: 0.53, 95% CI: 0.28-0.99, p = 0.04). CONCLUSIONS Pre-operative osteoporosis treatment is associated with lower risk of ORC and revision surgery at 1-year after ≥3-level spinal fusion. There is a low incidence of osteoporosis treatment prior to spinal fusion, and subsequently a low rate of treatment continuation after surgery. These findings highlight the need for heightened awareness, patient education and management of osteoporosis before elective multi-level spinal fusion.
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Affiliation(s)
- Nikhil Jain
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Lawal Labaran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Frank M. Phillips
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Safdar N. Khan
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Khaled M. Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA,Hamid Hassanzadeh, Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Dr, Charlottesville, VA 22903, USA.
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8
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Ding H, Hai Y, Liu Y, Guan L, Pan A, Zhang X, Han B, Li Y, Yin P. Cortical Trajectory Fixation Versus Traditional Pedicle-Screw Fixation in the Treatment of Lumbar Degenerative Patients with Osteoporosis: A Prospective Randomized Controlled Trial. Clin Interv Aging 2022; 17:175-184. [PMID: 35237030 PMCID: PMC8882472 DOI: 10.2147/cia.s349533] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/31/2022] [Indexed: 12/11/2022] Open
Abstract
Study Design Objective Methods Results Conclusion Trial Registration Number Date of Registration
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Affiliation(s)
- Hongtao Ding
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
| | - Yong Hai
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
- Correspondence: Yong Hai; Yuzeng Liu, Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China, Tel +86 10-85231229; +86 13801221889; +86 13811552832, Email ; ;
| | - Yuzeng Liu
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
| | - Li Guan
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
| | - Aixing Pan
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
| | - Xinuo Zhang
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
| | - Bo Han
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
| | - Yue Li
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
| | - Peng Yin
- Department of Spine Surgery, Beijing Chao-Yang Hospital, Capital Medical University of China, Beijing, People’s Republic of China
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9
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Viola A, Appiah J, Donnally CJ, Kim YH, Shenoy K. Bone Graft Options in Spinal Fusion: A Review of Current Options and the Use of Mesenchymal Cellular Bone Matrices. World Neurosurg 2021; 158:182-188. [PMID: 34875392 DOI: 10.1016/j.wneu.2021.11.130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Spinal fusion is the mainstay treatment for various spinal conditions ranging from lumbar and cervical stenosis to degenerative spondylolisthesis as well as extensive deformity corrections. A new emerging category of allograft is cellular bone matrices (CBMs), which take allogeneic mesenchymal stem cells and incorporate them into an osteoconductive and osteoinductive matrix. This study reviewed the current spinal fusion options and new emerging treatment options. METHODS Articles were searched using PubMed. The search included English publications since January 1, 2014, using the search terms "cellular bone matrix," "mesenchymal stem cells spinal fusion," "spinal arthrodesis AND mesenchymal stem cells," and "spine fusion AND cellular bone matrix." RESULTS Spinal fusion is accomplished through the use of allografts, autografts, and bone graft substitutes in combination or alone. An emerging category of allograft is CBMs, in which an osteoconductive and osteoinductive matrix is filled with mesenchymal stem cells. Studies demonstrate that CBMs have achieved equivalent or better fusion rates compared with traditional options for anterior cervical discectomy and fusions and posterolateral lumbar fusions; however, the studies have been retrospective and lacking control groups and therefore not ideal. CONCLUSIONS Many treatment options have been successfully used in spinal fusion. Newer allografts such as CBMs have shown promising results in both animal and clinical studies. Further research is needed to determine the therapeutic dose of mesenchymal stem cells delivered within CBMs.
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Affiliation(s)
- Anthony Viola
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA.
| | - Jude Appiah
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | | | - Yong H Kim
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | - Kartik Shenoy
- Mike O'Callaghan Military Medical Center, Nellis Air Force Base, Nevada, USA
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10
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Krenzlin H, Foelger A, Mailänder V, Blase C, Brockmann M, Düber C, Ringel F, Keric N. Novel Biodegradable Composite of Calcium Phosphate Cement and the Collagen I Mimetic P-15 for Pedicle Screw Augmentation in Osteoporotic Bone. Biomedicines 2021; 9:biomedicines9101392. [PMID: 34680509 PMCID: PMC8533375 DOI: 10.3390/biomedicines9101392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022] Open
Abstract
Osteoporotic vertebral fractures often necessitate fusion surgery, with high rates of implant failure. We present a novel bioactive composite of calcium phosphate cement (CPC) and the collagen I mimetic P-15 for pedicle screw augmentation in osteoporotic bone. Methods involved expression analysis of osteogenesis-related genes during osteoblastic differentiation by RT-PCR and immunostaining of osteopontin and Ca2+ deposits. Untreated and decalcified sheep vertebrae were utilized for linear pullout testing of pedicle screws. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (DEXA). Expression of ALPI II (p < 0.0001), osteopontin (p < 0.0001), RUNX2 (p < 0.0001), and osteocalcin (p < 0.0001) was upregulated after co-culture of MSC with CPC-P-15. BMD was decreased by 28.75% ± 2.6%. Pullout loads in untreated vertebrae were 1405 ± 6 N (p < 0.001) without augmentation, 2010 ± 168 N (p < 0.0001) after augmentation with CPC-P-15, and 2112 ± 98 N (p < 0.0001) with PMMA. In decalcified vertebrae, pullout loads were 828 ± 66 N (p < 0.0001) without augmentation, 1324 ± 712 N (p = 0.04) with PMMA, and 1252 ± 131 N (p < 0.0078) with CPC-P-15. CPC-P-15 induces osteoblastic differentiation of human MES and improves pullout resistance of pedicle screws in osteoporotic and non-osteoporotic bone.
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Affiliation(s)
- Harald Krenzlin
- Department of Neurosurgery, University Medical Center Mainz, 55131 Mainz, Germany; (A.F.); (F.R.); (N.K.)
- Correspondence:
| | - Andrea Foelger
- Department of Neurosurgery, University Medical Center Mainz, 55131 Mainz, Germany; (A.F.); (F.R.); (N.K.)
| | - Volker Mailänder
- Max Planck Institute for Polymer Research, 55128 Mainz, Germany;
- Center for Translational Nanomedicine, University Medical Center Mainz, 55131 Maniz, Germany
| | - Christopher Blase
- Personalized Biomedical Engineering Lab, Frankfurt University of Applied Sciences, 60318 Frankfurt am Main, Germany;
| | - Marc Brockmann
- Department of Neuroradiology, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Christoph Düber
- Department of Radiology, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, 55131 Mainz, Germany; (A.F.); (F.R.); (N.K.)
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center Mainz, 55131 Mainz, Germany; (A.F.); (F.R.); (N.K.)
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11
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Mikula AL, St Jeor JD, Naylor RM, Bernatz JT, Patel NP, Fogelson JL, Larson AN, Nassr A, Sebastian AS, Freedman B, Currier BL, Bydon M, Kennel KA, Yaszemski MJ, Anderson PA, Elder BD. Teriparatide Treatment Increases Hounsfield Units in the Thoracic Spine, Lumbar Spine, Sacrum, and Ilium Out of Proportion to the Cervical Spine. Clin Spine Surg 2021; 34:E370-E376. [PMID: 34029261 DOI: 10.1097/bsd.0000000000001203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective chart review. OBJECTIVE The objective of this study was to compare the effect of teriparatide on Hounsfield Units (HU) in the cervical spine, thoracic spine, lumbar spine, sacrum, and pelvis. Second, to correlate HU changes at each spinal level with bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA). SUMMARY OF BACKGROUND DATA HU represent a method to estimate BMD and can be used either separately or in conjunction with BMD from DXA. MATERIALS AND METHODS A retrospective chart review included patients who had been treated with at least 6 months of teriparatide. HU were measured in the vertebral bodies of the cervical, thoracic, and lumbosacral spine and iliac crests. Lumbar and femoral neck BMD as measured on DXA was collected when available. RESULTS One hundred twenty-five patients were identified for analysis with an average age of 67 years who underwent a mean (±SD) of 22±8 months of teriparatide therapy. HU improvement in the cervical spine was 11% (P=0.19), 25% in the thoracic spine (P=0.002), 23% in the lumbar spine (P=0.027), 17% in the sacrum (P=0.11), and 29% in the iliac crests (P=0.09). Lumbar HU correlated better than cervical HU with BMD as measured on DXA. CONCLUSIONS Teriparatide increased average HU in the thoracolumbar spine to a proportionally greater extent than the cervical spine. The cervical spine had a higher baseline starting HU than the thoracolumbar spine. Lumbar HU correlated better than cervical and thoracic HU with BMD as measured on DXA.
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Affiliation(s)
| | | | | | - James T Bernatz
- Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | | | | | | | | | | | | | - Kurt A Kennel
- Endocrinology, Diabetes, and Metabolism, Mayo Clinic, Rochester, MN
| | | | - Paul A Anderson
- Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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12
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Echt M, Ranson W, Steinberger J, Yassari R, Cho SK. A Systematic Review of Treatment Strategies for the Prevention of Junctional Complications After Long-Segment Fusions in the Osteoporotic Spine. Global Spine J 2021; 11:792-801. [PMID: 32748633 PMCID: PMC8165922 DOI: 10.1177/2192568220939902] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-known complications after long-segment fusions in the thoracolumbar spine of osteoporotic patients. Recent advances in anti-resorptive and anabolic medications, instrumentation, surgical technique, and cement augmentation have all aided in the avoidance of junctional kyphosis. In this article, current literature on the prevention of PJK and PJF in the osteoporotic spine is reviewed. METHODS A systematic literature review was conducted using the PubMed/MEDLINE and Embase databases in order to search for the current preventive treatment methods for PJK and PJF published in the literature (1985 to present). Inclusion criteria included (1) published in English, (2) at least 1-year mean and median follow-up, (3) preoperative diagnosis of osteoporosis, (4) at least 3 levels instrumented, and (5) studies of medical treatment or surgical techniques for prevention of junctional kyphosis. RESULTS The review of the literature yielded 7 studies with low levels of evidence ranging from level II to IV. Treatment strategies reviewed addressed prophylaxis against ligamentous failure, adjacent vertebral compression fracture, and/or bone-implant interface failure. This includes studies on the effect of osteoporosis medication, cement augmentation, multi-rod constructs, and posterior-tension band supplementation. The role of perioperative teriparatide therapy maintains the highest level of evidence. CONCLUSIONS Perioperative teriparatide therapy represents the strongest evidence for preventive treatment, and further clinical trials are warranted. Use of cement augmentation, sublaminar tethers, and multi-rod constructs have low or insufficient evidence for recommendations. Future guidelines for adult spinal deformity correction may consider bone mineral density-adjusted alignment goals.
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Affiliation(s)
- Murray Echt
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William Ranson
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Reza Yassari
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
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13
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Díaz-Romero R, Henríquez MS, Melián KA, Balhen-Martin C. Practice Patterns of Spine Surgeons Regarding Osteoporosis: An International Survey. Int J Spine Surg 2021; 15:376-385. [PMID: 33900997 DOI: 10.14444/8049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Osteoporosis (OP) represents a great challenge for the spine surgeon. Despite having effective pharmacological treatments for OP and surgical technical innovations, the awareness of spine surgeons regarding OP seems low. The purpose of this research was to assess practice patterns on the diagnosis and treatment of spine surgeons regarding OP. METHODS An electronic survey of ten multiple-choice questions was administered to members of the European Association of Neurosurgical Societies (EANS). The survey asked about the specialty, the workplace, and practice patterns and attitudes regarding OP and spine fusion surgery, pseudoarthrosis, and vertebral compression fractures (VCF). RESULTS A total of 122 surgeons completed the survey. In patients with suspected OP, 31.4% of surgeons would refer the patient to the OP specialist before surgery and 21.5% chose to perform the surgery without additional studies. A 66.4% of respondents would modify the surgical strategy in the case of OP. The most popular surgical techniques elected were cemented augmented screws (77.9%) and long-segment instrumentation (45.1%). Regarding pseudoarthrosis, 29.5% of surgeons opted to refer to the OP specialist, and 23.8% didn't consider any additional studies Concerning VCF management, 41.32% of respondents would refer the patient for treatment of OP, and the most common therapeutic strategy was conservatively treatment for 4 to 6 weeks and vertebroplasty or kyphoplasty if no improvement (55.74%).There was a higher proportion of surgeons that would not consider preoperative studies or referring patients with suspected OP for spine surgery (χ2 = 4.48, P = .03) and pseudoarthrosis (χ2 = 9.5, P = .002) compared to VCF. CONCLUSIONS There was a greater awareness regarding optimizing OP management in VCF compared to patients with suspected OP for spine arthrodesis or pseudoarthrosis. There still opportunities for improvement for the timely diagnosis and treatment of OP in spine surgery patients.
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Affiliation(s)
- Ricardo Díaz-Romero
- Universidad de Las Palmas de Gran Canaria, Spain.,Department of Neurosurgery of Hospital Insular of Las Palmas of Spain Neurosurgery
| | - Manuel Sosa Henríquez
- Universidad de Las Palmas de Gran Canaria, Spain.,Department Bone Metabolism and Osteoporosis of Hospital Insular of Las Palmas de Gran Canaria, Spain
| | - Kevin Armas Melián
- Department of Neurosurgery of Hospital Insular of Las Palmas of Spain Neurosurgery
| | - Claudia Balhen-Martin
- Department of Radiology, Hospital Perpetuo Socorro, Las Palmas de Gran Canaria, Spain
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14
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Löffler MT, Sollmann N, Burian E, Bayat A, Aftahy K, Baum T, Meyer B, Ryang YM, Kirschke JS. Opportunistic Osteoporosis Screening Reveals Low Bone Density in Patients With Screw Loosening After Lumbar Semi-Rigid Instrumentation: A Case-Control Study. Front Endocrinol (Lausanne) 2021; 11:552719. [PMID: 33505353 PMCID: PMC7832475 DOI: 10.3389/fendo.2020.552719] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 11/24/2020] [Indexed: 12/17/2022] Open
Abstract
Objective Decreased bone mineral density (BMD) impairs screw purchase in trabecular bone and can cause screw loosening following spinal instrumentation. Existing computed tomography (CT) scans could be used for opportunistic osteoporosis screening for decreased BMD. Purpose of this case-control study was to investigate the association of opportunistically assessed BMD with the outcome after spinal surgery with semi-rigid instrumentation for lumbar degenerative instability. Methods We reviewed consecutive patients that had primary surgery with semi-rigid instrumentation in our hospital. Patients that showed screw loosening in follow-up imaging qualified as cases. Patients that did not show screw loosening or-if no follow-up imaging was available (n = 8)-reported benefit from surgery ≥ 6 months after primary surgery qualified as controls. Matching criteria were sex, age, and surgical construct. Opportunistic BMD screening was performed at L1 to L4 in perioperative CT scans by automatic spine segmentation and using asynchronous calibration. Processing steps of this deep learning-driven approach can be reproduced using the freely available online-tool Anduin (https://anduin.bonescreen.de). Area under the curve (AUC) was calculated for BMD as a predictor of screw loosening. Results Forty-six elderly patients (69.9 ± 9.1 years)-23 cases and 23 controls-were included. The majority of surgeries involved three spinal motion segments (n = 34). Twenty patients had low bone mass and 13 had osteoporotic BMD. Cases had significantly lower mean BMD (86.5 ± 29.5 mg/cm³) compared to controls (118.2 ± 32.9 mg/cm³, p = 0.001), i.e. patients with screw loosening showed reduced BMD. Screw loosening was best predicted by a BMD < 81.8 mg/cm³ (sensitivity = 91.3%, specificity = 56.5%, AUC = 0.769, p = 0.002). Conclusion Prevalence of osteoporosis or low bone mass (BMD ≤ 120 mg/cm³) was relatively high in this group of elderly patients undergoing spinal surgery. Screw loosening was associated with BMD close to the threshold for osteoporosis (< 80 mg/cm³). Opportunistic BMD screening is feasible using the presented approach and can guide the surgeon to take measures to prevent screw loosening and to increase favorable outcomes.
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Affiliation(s)
- Maximilian T. Löffler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Freiburg im Breisgau, Germany
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Egon Burian
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Amirhossein Bayat
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neurosurgery, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Jan S. Kirschke
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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15
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Payne C, Jaffee S, Swink I, Cook D, Yeager M, Oh M, Schmidt G, Lindsey DP, Yerby SA, Cheng B. Comparative analysis of the lateral and posterolateral trajectories for fixation of the sacroiliac joint-a cadaveric study. J Orthop Surg Res 2020; 15:489. [PMID: 33092604 PMCID: PMC7579994 DOI: 10.1186/s13018-020-02013-w] [Citation(s) in RCA: 2] [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: 06/12/2020] [Accepted: 10/06/2020] [Indexed: 11/20/2022] Open
Abstract
Background A number of minimally invasive sacroiliac (SI) joint fusion solutions for placing implants exist, with reduced post-operative pain and improved outcomes compared to open procedures. The objective of this study was to compare two MIS SI joint fusion approaches that place implants directly across the joint by comparing the ilium and sacrum bone characteristics and SI joint separation along the implant trajectories. Methods Nine cadaveric specimens (n = 9) were CT scanned and the left and right ilium and sacrum were segmented. The bone density, bone volume fraction, and SI joint gap distance were calculated along lateral and posterolateral trajectories and compared using analysis of variance between the two orientations. Results Iliac bone density, indicated by the mean Hounsfield Unit, was significantly greater for each lateral trajectory compared to posterolateral. The volume of cortical bone in the ilium was greater for the middle lateral trajectory compared to all others and for the top and bottom lateral trajectories compared to both posterolateral trajectories. Cortical density was greater in the ilium for all lateral trajectories compared to posterolateral. The bone fraction was significantly greater in all lateral trajectories compared to posterolateral in the ilium. No differences in cortical volume, cortical density, or cancellous density were found between trajectories in the sacrum. The ilium was significantly greater in density compared with the sacrum when compared irrespective of trajectory (p < 0.001). The posterolateral trajectories had a significantly larger SI joint gap than the lateral trajectories (p < 0.001). Conclusion Use of the lateral approach for minimally invasive SI fusion allows the implant to interact with bone across a significantly smaller joint space. This interaction with increased cortical bone volume and density may afford better fixation with a lower risk of pull-out or implant loosening when compared to the posterolateral approach.
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Affiliation(s)
- Christopher Payne
- Neuroscience Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Stephen Jaffee
- Neuroscience Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Isaac Swink
- Neuroscience Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Daniel Cook
- Neuroscience Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Matthew Yeager
- Neuroscience Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Michael Oh
- Department of Neurosurgery, University of California Irvine, Irvine, CA, USA
| | - Gary Schmidt
- Orthopaedic Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Derek P Lindsey
- SI-BONE, Inc., 471 El Camino Real, Suite 101, Santa Clara, CA, 95051, USA.
| | - Scott A Yerby
- SI-BONE, Inc., 471 El Camino Real, Suite 101, Santa Clara, CA, 95051, USA
| | - Boyle Cheng
- Neuroscience Institute, Allegheny General Hospital, Pittsburgh, PA, USA
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16
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Zileli M, Dursun E. How to Improve Outcomes of Spine Surgery in Geriatric Patients. World Neurosurg 2020; 140:519-526. [DOI: 10.1016/j.wneu.2020.04.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 11/15/2022]
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17
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McCarthy MH, Weiner JA, Patel AA. Strategies to Achieve Spinal Fusion in Multilevel Anterior Cervical Spine Surgery: An Overview. HSS J 2020; 16:155-161. [PMID: 32523483 PMCID: PMC7253572 DOI: 10.1007/s11420-019-09738-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/18/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anterior cervical fusion offers surgeons a safe and reliable surgical option for single-level and multilevel pathology; however, multilevel fusions pose a higher risk of complications than single-level fusions, including possible pseudoarthrosis, adjacent segment disease, sagittal imbalance, and construct subsidence. Various techniques can be used to mitigate risk in multilevel anterior cervical fusion. QUESTIONS/PURPOSES We reviewed the literature to determine the best surgical strategies in multilevel anterior cervical fusion. METHODS We searched the PubMed database for articles published from January 1980 through July 2019. Two authors identified relevant articles and then manually screened them for others to include in this review. RESULTS We initially identified 1936 articles and included 48 in our review. We found that clinical outcomes of multilevel anterior cervical fusion can be optimized through the use of biologics and graft selection, the evaluation of pre-existing deformity, the assessment of comorbidities, and the selection of fusion levels. Meticulous surgical technique in conjunction with modern surgical tools, such as instrumentation and biologics, allow surgeons to address complex cervical problems while limiting morbidity and enhancing clinical outcomes. CONCLUSIONS Multilevel anterior cervical fusions offer a relatively safe and reliable treatment option for both single-level and multilevel pathology.
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Affiliation(s)
- Michael H. McCarthy
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair, Suite 1350, Chicago, IL 60611 USA
| | - Joseph A. Weiner
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair, Suite 1350, Chicago, IL 60611 USA
| | - Alpesh A. Patel
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair, Suite 1350, Chicago, IL 60611 USA
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Díaz-Romero Paz R, Sosa Henríquez M, Armas Melián K, Coloma Valverde G. Tendencias de actuación de los cirujanos de columna respecto a la osteoporosis. Neurocirugia (Astur) 2019; 30:268-277. [DOI: 10.1016/j.neucir.2019.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/13/2019] [Accepted: 04/17/2019] [Indexed: 01/01/2023]
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Mikula AL, Puffer RC, Jeor JDS, Bernatz JT, Fogelson JL, Larson AN, Nassr A, Sebastian AS, Freedman BA, Currier BL, Bydon M, Yaszemski MJ, Anderson PA, Elder BD. Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes. J Neurosurg Spine 2019; 32:50-55. [PMID: 31628287 DOI: 10.3171/2019.7.spine19654] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 07/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to assess whether Hounsfield units (HU) increase following teriparatide treatment and to compare HU increases with changes in bone mineral density (BMD) as measured by dual-energy x-ray absorptiometry (DEXA). METHODS A retrospective chart review was performed from 1997 to 2018 across all campuses at our institution. The authors identified patients who had been treated with at least 6 months of teriparatide and compared HU and BMD as measured on DEXA scans before and after treatment. RESULTS Fifty-two patients were identified for analysis (46 women and 6 men, average age 67 years) who underwent an average of 20.9 ± 6.5 months of teriparatide therapy. The mean ± standard deviation HU increase throughout the lumbar spine (L1-4) was from 109.8 ± 53 to 133.9 ± 61 HU (+22%, 95% CI 1.2-46, p value = 0.039). Based on DEXA results, lumbar spine BMD increased from 0.85 to 0.93 g/cm2 (+9%, p value = 0.044). Lumbar spine T-scores improved from -2.4 ± 1.5 to -1.7 ± 1.5 (p value = 0.03). Average femoral neck T-scores improved from -2.5 ± 1.1 to -2.3 ± 1.0 (p value = 0.31). CONCLUSIONS Teriparatide treatment increased both HU and BMD on DEXA in the lumbar spine, without a change in femoral BMD. The 22% improvement in HU surpassed the 9% improvement determined with DEXA. These results support some surgeons' subjective sense that intraoperative bone quality following teriparatide treatment is better than indicated by DEXA results. To the authors' knowledge, this is the first study demonstrating an increase in HU with teriparatide treatment.
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Affiliation(s)
| | - Ross C Puffer
- 1Department of Neurological Surgery, Mayo Clinic, Rochester
| | | | - James T Bernatz
- 3Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and
| | | | - A Noelle Larson
- 4Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ahmad Nassr
- 4Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arjun S Sebastian
- 4Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brett A Freedman
- 4Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamad Bydon
- 1Department of Neurological Surgery, Mayo Clinic, Rochester
| | | | - Paul A Anderson
- 3Department of Orthopedics and Rehabilitative Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and
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Liu L, Zhang S, Liu G, Yang B, Wu X. Early Clinical Outcome of Lumbar Spinal Fixation With Cortical Bone Trajectory Pedicle Screws in Patients With Osteoporosis With Degenerative Disease. Orthopedics 2019; 42:e465-e471. [PMID: 31185118 DOI: 10.3928/01477447-20190604-01] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 09/11/2018] [Indexed: 02/03/2023]
Abstract
This cohort study aimed to elucidate early surgical outcomes after midline lumbar fusion (MidLIF) with cortical bone trajectory (CBT) screw fixation compared with transforaminal lumbar interbody fusion (TLIF) using traditional pedicle screw (TPS) fixation for lumbar degenerative disease (LDD) in patients with osteoporosis. The authors randomly assigned 70 patients with osteoporosis who had LDD at 1 or 2 adjacent vertebral levels to undergo either MidLIF with CBT (CBT group) or TLIF with TPS fixation (TPS group) from February 2015 to March 2016. Pre- and postoperative lumbar Japanese Orthopaedic Association (JOA) scale scores were assessed and radiographic measurements on dynamic plain radiographs and computed tomography images were analyzed. The final data analysis included 31 patients in the CBT group (mean age, 73.42±6.74 years; t-score, -2.94±0.75) and 32 patients in the TPS group (mean age, 74.84±5.37 years; t-score, -2.92±0.66). Mean JOA score improved significantly in both groups, although no intragroup differences of JOA score improvement were found at the latest follow-up evaluation (P>.05). In addition, significantly higher rates of screw loosening (28.13% vs 6.5%, P=.03) and the amount of subsidence (3.01±0.52 vs 2.49±0.45 mm, P=.02) were found in the TPS group. Rate of radiographic fusion of both groups showed no statistical difference. Both groups of patients achieved a similar rate of radiographic fusion at the 1.5-year follow-up and experienced similar intra- or postoperative complications and postoperative recovery. The MidLIF with CBT screw fixation for short-level lumbar fusion in patients with osteoporosis provided improvement of clinical symptoms comparable to that of TLIF using traditional TPS fixation. In addition, statistically significant lumbar stability was found in the CBT group compared with the TPS group. [Orthopedics. 2019; 42(5):e465-e471.].
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Preoperative Assessment of Bone Quality in Spine Deformity Surgery: Correlation With Clinical Practice and Published Recommendations. Spine (Phila Pa 1976) 2019; 44:E735-E741. [PMID: 30540720 DOI: 10.1097/brs.0000000000002956] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The goals of this study were to (A) evaluate preoperative bone quality assessment and intervention practice over time and (B) review the current evidence for bone evaluation in spine fusion surgery. SUMMARY OF BACKGROUND DATA Deformity spine surgery has demonstrated improved quality of life in patients; however, its cost has made it controversial. If preoperative bone quality can be optimized then potentially these treatments could be more durable; however, at present, no clinical practice guidelines have been published by professional spine surgical organizations. METHODS A retrospective cohort review was performed on patients who underwent a minimum five-level primary or revision fusion. Preoperative bone quality metrics were evaluated over time from 2012 to 2017 to find potential trends. Subgroup analysis was conducted based on age, sex, preoperative diagnosis, and spine fusion region. RESULTS Patient characteristics including preoperative rates of pseudarthrosis and junctional failure did not change. An increasing trend of physician bone health documentation was noted (P = 0.045) but changes in other metrics were not significant. A sex bias favored females who had higher rates of preoperative DXA studies (P = 0.001), Vitamin D 25-OH serum labs (P = 0.005), Vitamin D supplementation (P = 0.022), calcium supplementation (P < 0.001), antiresorptive therapy (P = 0.016), and surgeon clinical documentation of bone health (P = 0.008) compared with men. CONCLUSION Our spine surgeons have increased documentation of bone health discussions but this has not affected bone quality interventions. A discrepancy exists favoring females over males in nearly all preoperative bone quality assessment metrics. Preoperative vitamin D level and BMD assessment should be considered in patients undergoing long fusion constructs; however, the data for bone anabolic and resorptive agents have less support. Clinical practice guidelines on preoperative bone quality assessment spine patients should be defined. LEVEL OF EVIDENCE 4.
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Weng F, Wang J, Yang L, Zeng J, Chu Y, Tian Z. Application value of expansive pedicle screw in the lumbar short-segment fixation and fusion for osteoporosis patients. Exp Ther Med 2018; 16:665-670. [PMID: 30112031 PMCID: PMC6090430 DOI: 10.3892/etm.2018.6248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 05/22/2018] [Indexed: 12/25/2022] Open
Abstract
Clinical value of expansive pedicle screw in lumbar short-segment fixation and fusion for patients with osteoporosis was investigated. A total of 80 patients with lumbar compression fracture but without obvious nerve compression were selected and divided into the observation group (n=40) and the control group (n=40) using a random number table. The observation group used the expansive pedicle screw, and the control group received conventional pedicle screw fixation and bone graft fusion. In the observation group, the operation and hospitalization time after operation were shorter and the intraoperative bleeding amount was less than that in control group (p<0.05). At 1 week, 1, 3 and 6 months after operation, the observation group had better straight leg raising test (SLRT) scores, higher lower limb sensory scores but lower visual analogue scale (VAS) scores than control group (p<0.05). Besides, the proportions of postoperative infection, dural mater tear, nerve root injury and spinal cord injury during operation in the observation group were lower than those in the control group (p<0.05), and the bone graft fusion rates at 3 and 6 months after operation were obviously superior to those in control group (p<0.05). Moreover, after operation, the spinal stenosis rate in the observation group was lower than that in control group (p<0.05), the vertebral height ratio was larger than that in control group (p<0.05), and the Cobb's angle was smaller than that in the control group (p<0.05). In addition, there was a negative correlation between bone mineral density (BMD) and hospitalization time after operation in the observation group (p<0.05). In conclusion, the internal fixation with expansive pedicle screw for osteoporosis patients with lumbar compression fracture is characterized by short operation time, less intraoperative bleeding, few complications, quick recovery of postoperative neurological function and satisfactory surgical effect. However, reasonable intervention in osteoporosis is also necessary.
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Affiliation(s)
- Fengbiao Weng
- Department of Orthopaedics, The First People's Hospital of Wujiang District, Suzhou, Jiangsu 215200, P.R. China
| | - Jiazi Wang
- Department of Orthopaedics, The First People's Hospital of Wujiang District, Suzhou, Jiangsu 215200, P.R. China
| | - Liwen Yang
- Department of Orthopaedics, The First People's Hospital of Wujiang District, Suzhou, Jiangsu 215200, P.R. China
| | - Jincai Zeng
- Department of Orthopaedics, The First People's Hospital of Wujiang District, Suzhou, Jiangsu 215200, P.R. China
| | - Yawei Chu
- Department of Orthopaedics, The First People's Hospital of Wujiang District, Suzhou, Jiangsu 215200, P.R. China
| | - Zhigang Tian
- Department of Orthopaedics, The First People's Hospital of Wujiang District, Suzhou, Jiangsu 215200, P.R. China
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Januszewski J, Vivas AC, Uribe JS. Limitations and complications of minimally invasive spinal surgery in adult deformity. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:109. [PMID: 29707558 DOI: 10.21037/atm.2018.01.29] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive spine (MIS) surgery has rapidly progressed from simple short segment fusions to large adult deformity corrections, with radiographic and clinical outcomes as good as those of open surgery. Anterior longitudinal ligament release (ALLR) and anterior column realignment (ACR) have been key advancements in the ability to correct deformity using MIS techniques. However, patient selection and appropriate preoperative workup is critical to obtain good outcomes and for complication avoidance. Despite favorable outcomes in spinal deformity surgery, MIS techniques are limited in (I) pronounced cervical or thoracic deformity; (II) patients with prior fusion mass; and (III) severe sagittal imbalance necessitating Schwab 5 osteotomy or higher. Guidelines for proper patient selection are needed to guide MIS spine surgeons in choosing the right candidate.
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Affiliation(s)
| | - Andrew C Vivas
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Juan S Uribe
- Division of Spinal Disorders, Barrow Neurological Institute, Phoenix, AZ, USA
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