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Agaronnik ND, Giberson-Chen C, Bono CM. Using advanced imaging to measure bone density, compression fracture risk, and risk for construct failure after spine surgery. Spine J 2024; 24:1135-1152. [PMID: 38437918 DOI: 10.1016/j.spinee.2024.02.018] [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: 07/04/2023] [Revised: 01/22/2024] [Accepted: 02/23/2024] [Indexed: 03/06/2024]
Abstract
Low bone mineral density (BMD) can predispose to vertebral body compression fractures and postoperative instrumentation failure. DEXA is considered the gold standard for measurement of BMD, however it is not obtained for all spine surgery patients preoperatively. There is a growing body of evidence suggesting that more routinely acquired spine imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can be opportunistically used to measure BMD. Here we review available studies that assess the validity of opportunistic screening with CT-derived Hounsfield Units (HU) and MRI-derived vertebral vone quality (VBQ) to measure BMD of the spine as well the utility of these measures in predicting postoperative outcomes. Additionally, we provide screening thresholds based on HU and VBQ for prediction of osteopenia/ osteoporosis and postoperative outcomes such as cage subsidence, screw loosening, proximal junctional kyphosis, and implant failure.
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Affiliation(s)
| | - Carew Giberson-Chen
- Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114
| | - Christopher M Bono
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114; Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114.
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2
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Leblond L, Godio-Raboutet Y, Tomi F, Glard Y, La Greca R, Clement T, Evin M. Sliding on cortical shell: Biomechanical characterization of the vertebral cannulation for pedicle screw insertion. Clin Biomech (Bristol, Avon) 2023; 110:106102. [PMID: 37769380 DOI: 10.1016/j.clinbiomech.2023.106102] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Pedicular screws pull-out has been well studied unlike their insertion. A need for characterizing cannulation before pedicle screw implantation is highlighted in literature and offers promising prospects for future intra-operation instrumentation. A reliable cannulation protocol for ex-vivo testing in swine and cadaver vertebrae is presented in this work to predict extra pedicular perforation. METHODS An MTS Acumen 3 A/T electrodynamic device, with a tri-axis 3 kN Kistler load cell mounted on a surgical tool was used to reproduce surgeon's gesture by moving at a constant rotational speed of 10°/mm and performing a three-section test. Perforation of the pedicle's cortical shell was planned through a design of experiment on the surgical tool angle at the entry point. Samples were scanned before and after mechanical tests and reproducibility of the protocol was tested on synthetic foam. Computation of the angle between cannulation tool and pedicle cortical shell was performed as well as cannulation coefficient of each perforation section. FINDINGS A total of 68 pedicles were tested: 19 perforated and 21 non-perforated human pedicles, 17 perforated and 16 non-perforated swine pedicles. The reproducibility of the protocol for cannulation coefficient computation resulted in an intraclass correlation coefficient of 0.979. Cannulation coefficients results presented variability within spinal levels as well as between swine and human model. Correlation between bone density and cannulation coefficient was found significant (p < 0.005). Torque measurement was found to be the best predictor of perforation. Threshold of angle for prediction of perforation was found to be 21.7°. INTERPRETATION Characterizing pedicle cannulation enables to predict extra pedicular perforation. Influence of bone mineral density and patient-specific morphology on pedicle cannulation has been highlighted together with a comparison of swine and cadaver models.
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Affiliation(s)
| | | | - Florent Tomi
- Aix Marseille Univ. Univ Gustave Eiffel, LBA, Marseille, France
| | - Yann Glard
- Department of Paediatric Orthopaedics, Saint Joseph Hospital, Marseille, France
| | | | - Thomas Clement
- Aix Marseille Univ. Univ Gustave Eiffel, LBA, Marseille, France
| | - Morgane Evin
- Aix Marseille Univ. Univ Gustave Eiffel, LBA, Marseille, France.
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Kondrashov DG, Piple AS, Ungurean V, Schlauch AM, Rowland A, Tran T, Denisov A, Zaborovskii N, Raji OR. Spinolaminar locking plates improve fixation strength compared to pedicle screws: a biomechanical analysis. Spine Deform 2023; 11:1335-1345. [PMID: 37329420 DOI: 10.1007/s43390-023-00716-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/27/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Pedicle screw loosening is a significant complication of posterior spinal fixation, particularly among osteoporotic patients and in deformity constructs. In orthopedic trauma surgery, locking plates and screws have revolutionized the fixation of osteoporotic fractures. We have combined the traumatology principle of fixed-angle locking plate fixation with the spine principles of segmental instrumentation. METHODS A novel spinolaminar locking plate was designed based on morphometric studies of human thoracolumbar vertebrae. The plates were fixed to cadaveric human lumbar spines and connected to form 1-level L1-L2 or L4-L5 constructs and compared to similar pedicle screw constructs. Pure moment testing was performed to assess range of motion before and after 30,000 cycles of cyclic fatigue. Post-fatigue fixture pullout strength was assessed by applying a continuous axial tensile force oriented to the principal axis of the pedicle until pullout was observed. RESULTS Spinolaminar plate fixation resulted in superior pullout strength compared to pedicle screws (1,065 ± 400N vs. 714 ± 284N, p = 0.028). Spinolaminar plates performed equivalently to pedicle screws in range of motion reduction during flexion/extension and axial rotation. Pedicle screws outperformed the spinolaminar plates in lateral bending. Finally, no spinolaminar constructs failed during cyclic fatigue testing, whereas one pedicle screw construct did. CONCLUSIONS The spinolaminar locking plate maintained adequate fixation post-fatigue, particularly in flexion/extension and axial rotation compared to pedicle screws. Moreover, spinolaminar plates were superior to pedicle screw fixation with respect to cyclic fatiguing and pullout strength. The spinolaminar plates offer a viable option for posterior lumbar instrumentation in the adult spine.
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Affiliation(s)
- Dimitriy G Kondrashov
- St. Mary's Spine Center, 1 Shrader St., Suite 600, San Francisco, CA, 94117, USA.
- The Taylor Collaboration, San Francisco, CA, USA.
- San Francisco Orthopaedic Residency Program, San Francisco, CA, USA.
| | - Amit S Piple
- The Taylor Collaboration, San Francisco, CA, USA
| | | | - Adam M Schlauch
- San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | - Andrea Rowland
- San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | - Tien Tran
- The Taylor Collaboration, San Francisco, CA, USA
| | - Anton Denisov
- Hospital Quirónsalud Valle del Henares, Madrid, Spain
- Hospital Quirónsalud San José, Madrid, Spain
- Hospital 12 de Octubre Health Research Institute, Madrid, Spain
| | - Nikita Zaborovskii
- Vreden National Medical Research Center of Traumatology and Orthopedics, Saint-Petersburg, Russia
- Saint-Petersburg State University, Saint-Petersburg, Russia
| | - Oluwatodimu Richard Raji
- St. Mary's Spine Center, 1 Shrader St., Suite 600, San Francisco, CA, 94117, USA
- The Taylor Collaboration, San Francisco, CA, USA
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Biswas JK, Mondal N, Choudhury S, Malas A, Rana M. A finite element study and mathematical modeling of lumbar pedicle screw along with various design parameters. J Orthop Sci 2023; 28:992-1003. [PMID: 36175251 DOI: 10.1016/j.jos.2022.08.008] [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: 04/08/2022] [Revised: 07/04/2022] [Accepted: 08/24/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Lumbar pedicle screw is one of the most common and important elements in the field of lumbar surgery. It plays a great role in rectifying the spinal alignment and stabilization providing strength and stability to the affected area of spine. In spinal surgery, minimally invasive techniques and minor incisions are made which makes it less painful for the patients than the traditional methods. Moreover, the screws are not needed to be removed after the surgery which is yet another great advantage of the pedicle screw. METHOD In this study, 3D Finite Element (FE) model of human L4 vertebrae is taken for analysis using image processing tool. Pedicle screw design with varying mechanical and geometrical properties has been carried out at different applied loads on it along with considering the effect of frictional forces between all contact surfaces. RESULT Mathematical relationship among stress, strain, pitch of the screw and diameter have been developed for different thread profiles which will be beneficial for researchers for further development of pedicle screw implants. CONCLUSION Results from the different analysis shows that bending stress on the screw for different loads at triangular pitch is higher than the trapezoidal. Hence, trapezoidal thread is efficacious than triangular thread. In case of vertebral bone, the magnitude of stress is less for trapezoidal screw than triangular and stress has a linear relationship with pitch length. In term of strain, triangular thread develops more strain than trapezoidal thread. A set of mathematical relation has been developed for different thread profile based on pitch length, stress and strain which gives the idea about von Mises stress and strain.
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Affiliation(s)
- Jayanta Kumar Biswas
- Department of Mechanical Engineering, National Institute of Technology, Patna, Bihar - 800005, India
| | - Nitesh Mondal
- Department of Mechanical Engineering, Ghani Khan Choudhury Institute of Engineering & Technology, Narayanpur, Malda - 732141, India
| | - Sandeep Choudhury
- Department of Aerospace Engineering and Applied Mechanics, Indian Institute of Engineering Science and Technology, Shibpur, Howrah - 711103, India
| | - Anindya Malas
- Department of Mechanical Engineering, National Institute of Technology, Patna, Bihar - 800005, India
| | - Masud Rana
- Department of Aerospace Engineering and Applied Mechanics, Indian Institute of Engineering Science and Technology, Shibpur, Howrah - 711103, India.
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Creze M, Ghaouche J, Missenard G, Lazure T, Cluzel G, Devilder M, Briand S, Soubeyrand M, Meyrignac O, Carlier RY, Court C, Bouthors C. Understanding a mass in the paraspinal region: an anatomical approach. Insights Imaging 2023; 14:128. [PMID: 37466751 DOI: 10.1186/s13244-023-01462-1] [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: 05/09/2023] [Accepted: 06/10/2023] [Indexed: 07/20/2023] Open
Abstract
The paraspinal region encompasses all tissues around the spine. The regional anatomy is complex and includes the paraspinal muscles, spinal nerves, sympathetic chains, Batson's venous plexus and a rich arterial network. A wide variety of pathologies can occur in the paraspinal region, originating either from paraspinal soft tissues or the vertebral column. The most common paraspinal benign neoplasms include lipomas, fibroblastic tumours and benign peripheral nerve sheath tumours. Tumour-like masses such as haematomas, extramedullary haematopoiesis or abscesses should be considered in patients with suggestive medical histories. Malignant neoplasms are less frequent than benign processes and include liposarcomas and undifferentiated sarcomas. Secondary and primary spinal tumours may present as midline expansile soft tissue masses invading the adjacent paraspinal region. Knowledge of the anatomy of the paraspinal region is of major importance since it allows understanding of the complex locoregional tumour spread that can occur via many adipose corridors, haematogenous pathways and direct contact. Paraspinal tumours can extend into other anatomical regions, such as the retroperitoneum, pleura, posterior mediastinum, intercostal space or extradural neural axis compartment. Imaging plays a crucial role in formulating a hypothesis regarding the aetiology of the mass and tumour staging, which informs preoperative planning. Understanding the complex relationship between the different elements and the imaging features of common paraspinal masses is fundamental to achieving a correct diagnosis and adequate patient management. This review gives an overview of the anatomy of the paraspinal region and describes imaging features of the main tumours and tumour-like lesions that occur in the region.
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Affiliation(s)
- Maud Creze
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France.
- BioMaps, Université Paris-Saclay, Hôpital Kremlin-Bicêtre, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Jessica Ghaouche
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Gilles Missenard
- Department of Orthopedic Surgery, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU de Chirurgie Traumatologie Orthopédique-Chirurgie Plastique- Reconstruction, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Thierry Lazure
- Department of Pathology, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU Smart Imaging, Bicêtre hospital, Le Kremlin Bicêtre, France
| | - Guillaume Cluzel
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Matthieu Devilder
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Sylvain Briand
- Department of Orthopedic Surgery, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU de Chirurgie Traumatologie Orthopédique-Chirurgie Plastique- Reconstruction, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | | | - Olivier Meyrignac
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
- BioMaps, Université Paris-Saclay, Hôpital Kremlin-Bicêtre, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Robert-Yves Carlier
- Department of Radiology, Assistance Publique des Hôpitaux de Paris, GH Université Paris- Saclay, DMU Smart Imaging, Garches Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Charles Court
- Department of Orthopedic Surgery, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU de Chirurgie Traumatologie Orthopédique-Chirurgie Plastique- Reconstruction, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
| | - Charlie Bouthors
- Department of Orthopedic Surgery, Assistance Publique des Hôpitaux de Paris, GH Université Paris-Saclay, DMU de Chirurgie Traumatologie Orthopédique-Chirurgie Plastique- Reconstruction, Bicêtre Teaching Hospital, Le Kremlin-Bicêtre, France
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Nunley PD, Eastlack RK, Miller LE, Poelstra KA, Cox JB, Shedden PM, Stone M. Metal-Free Cortico-Pedicular Device for Supplemental Fixation in Lumbar Interbody Fusion. World Neurosurg 2023; 174:4-10. [PMID: 36871655 DOI: 10.1016/j.wneu.2023.02.119] [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: 02/15/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Pedicle screw fixation is a commonly utilized adjunct for lumbar interbody fusion, yet risks include screw malposition, pullout, loosening, neurovascular injury, and stress transfers leading to adjacent segment degeneration. This report describes the preclinical and initial clinical results of a minimally invasive, metal-free cortico-pedicular fixation device used for supplemental posterior fixation in lumbar interbody fusion. METHODS Safety of arcuate tunnel creation was evaluated in cadaveric lumbar (L1-S1) specimens. A finite element analysis study evaluated clinical stability of the device to pedicular screw-rod fixation at L4-L5. Preliminary clinical results were assessed by analysis of Manufacturer and User Facility Device Experience database complications, and 6-month outcomes in 13 patients treated with the device. RESULTS Among 35 curved drill holes in 5 lumbar specimens, no breaches of the anterior cortex were identified. The mean minimum distance from the anterior surface of the hole to the spinal canal ranged from 5.1 mm at L1-L2 to 9.8 mm at L5-S1. In the finite element analysis study, the polyetheretherketone strap provided comparable clinical stability and reduced anterior stress shielding compared to the conventional screw-rod construct. The Manufacturer and User Facility Device Experience database identified 1 device fracture with no clinical sequelae among 227 procedures. Initial clinical experience showed a 53% decrease in pain severity (P = 0.009), a 50% decrease in Oswestry Disability Index (P < 0.001), and no device-related complications. CONCLUSIONS Cortico-pedicular fixation is a safe and reproducible procedure that may address limitations of pedicle screw fixation. Longer term clinical data in large clinical studies are recommended to confirm these promising early results.
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Affiliation(s)
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA, United States
| | | | - Kornelis A Poelstra
- The Robotic Spine Institute of Las Vegas at Nevada Spine Clinic, Las Vegas, NV, United States
| | - J Bridger Cox
- Neuroscience Specialists, Oklahoma City, OK, United States
| | - Peter M Shedden
- Greater Houston Neurosurgery Center, The Woodlands, TX, United States
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, LA, United States
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Muellner M, Chiapparelli E, Haffer H, Dodo Y, Salzmann SN, Adl Amini D, Moser M, Zhu J, Carrino JA, Tan ET, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The association between paraspinal muscle parameters and vertebral pedicle microstructure in patients undergoing lumbar fusion surgery. INTERNATIONAL ORTHOPAEDICS 2023; 47:1051-1060. [PMID: 36562815 PMCID: PMC10661537 DOI: 10.1007/s00264-022-05659-9] [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: 07/26/2022] [Accepted: 11/19/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Lumbar fusion surgery has become a standard procedure in spine surgery and commonly includes the posterior placement of pedicle screws. Bone quality is a crucial factor that affects pedicle screw purchase. However, the relationship between paraspinal muscles and the bone quality of the pedicle is unknown. The aim of the study was to determine the relationship between paraspinal muscles and the ex vivo bony microstructure of the lumbar pedicle. METHODS Prospectively, collected data of patients undergoing posterior lumbar fusion for degenerative spinal conditions was analyzed. Pre-operative lumbar magnetic resonance imaging (MRI) scans were evaluated for a quantitative assessment of the cross-sectional area (CSA), functional cross-sectional area (fCSA), and the proportion of intramuscular fat (FI) for the psoas muscle and the posterior paraspinal muscles (PPM) at L4. Intra-operative bone biopsies of the lumbar pedicle were obtained and analyzed with microcomputed tomography (µCT) scans. The following cortical (Cort) and trabecular (Trab) bone parameters were assessed: bone volume fraction (BV/TV), trabecular number (Tb.N), trabecular thickness (Tb.Th), connectivity density (CD), bone-specific surface (BS/BV), apparent density (AD), and tissue mineral density (TMD). RESULTS A total of 26 patients with a mean age of 59.1 years and a mean BMI of 29.8 kg/m2 were analyzed. fCSAPPM showed significant positive correlations with BV/TVTrab (ρ = 0.610; p < 0.001), CDTrab (ρ = 0.679; p < 0.001), Tb.NTrab (ρ = 0.522; p = 0.006), Tb.ThTrab (ρ = 0.415; p = 0.035), and ADTrab (ρ = 0.514; p = 0.007). Cortical bone parameters also demonstrated a significant positive correlation with fCSAPPM (BV/TVCort: ρ = 0.584; p = 0.002; ADCort: ρ = 0.519; p = 0.007). FIPsoas was negatively correlated with TMDCort (ρ = - 0.622; p < 0.001). CONCLUSION This study highlights the close interactions between the bone microstructure of the lumbar pedicle and the paraspinal muscle morphology. These findings give us further insights into the interaction between the lumbar pedicle microstructure and paraspinal muscles.
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Affiliation(s)
- Maximilian Muellner
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Henryk Haffer
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Yusuke Dodo
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Stephan N Salzmann
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, 1090, Vienna, Austria
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
- Department of Spine Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jiaqi Zhu
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York City, NY, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York City, NY, USA.
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Zhao H, Wang YJ, Wang RG, Liu D, Duan YQ, Liu YJ, Zeng YH, Zhao QP, Zhang ZP. Three-Dimensional Hounsfield Units Measurement of Pedicle Screw Trajectory for Predicating Screw Loosening in Lumbar Fusion Surgery. Clin Interv Aging 2023; 18:485-493. [PMID: 37008803 PMCID: PMC10065021 DOI: 10.2147/cia.s389059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Purpose Dual-energy X-ray absorptiometry (DXA) is commonly used for evaluation of bone mineral density before spinal surgery, but frequently leads to overestimation in degenerative spinal diseases due to osteoproliferation factors. We introduce a novel method to compare the predictive ability of Hounsfield Units (HU) and DXA methods to predict screw loosening after lumbar interbody fusion surgery in degenerative spinal diseases by measuring HU of pedicle screw trajectory on computed tomography (CT) images preoperatively. Patients and Methods This retrospective study was conducted on patients who underwent posterior lumbar fusion surgery for degenerative diseases. CT HUs measurement was performed using medical imaging software, including the cancellous region on cross-sections of the vertebral body and three-dimensional pedicle screw trajectory. Receiver operating characteristic (ROC) curve analyses were performed for the risk of pedicle screw loosening in association with the Hounsfield scale and preoperative BMD, and the area under the curve (AUC) and the cutoff values were calculated. Results A total of 90 patients were enrolled and were divided into loosening (n = 33, 36.7%) and non-loosening groups (n = 57, 63.3%). No significant differences in age, gender, length of fixation and preoperative BMD were found between both groups. The loosening group showed lower CT HU values in the vertebral body and screw trajectory than the non-loosening group. Screw trajectory HU (ST-HU) exhibited a higher AUC value than vertebral body HU (B-HU). The cutoff values of B-HU and ST-HU were 160 and 110 HUs, respectively. Conclusion Three-dimensional pedicle screw trajectory HU values yields a stronger predictive value than vertebral body HU values and BMD and may provide more guidance for surgery. The risk of screw loosening is significantly increased at ST-HU <110 or B-HU <160 at L5 segment.
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Affiliation(s)
- He Zhao
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yan-jun Wang
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Rui-guo Wang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Da Liu
- Department of Orthopaedics, General Hospital of Western Theatre Command of PLA, Chengdu, Sichuan, 610083, People’s Republic of China
| | - Ya-qing Duan
- Department of Imaging, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yang-jin Liu
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yu-hong Zeng
- Department of Osteoporosis, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Qin-peng Zhao
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Zheng-ping Zhang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
- Correspondence: Zheng-ping Zhang, Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, No. 76 Nanguo Road, Xi’an, Shaanxi, 710054, People’s Republic of China, Tel +86 17791674069, Email
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Gou P, Zhao Z, Yu C, Hou X, Gao G, Zhang T, Chang F. Efficacy of Recombinant Human Parathyroid Hormone versus Vertebral Augmentation Procedure on Patients with Acute Osteoporotic Vertebral Compression Fracture. Orthop Surg 2022; 14:2510-2518. [PMID: 36017765 PMCID: PMC9531108 DOI: 10.1111/os.13470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Although widely used in clinical practice, vertebral augmentation procedure (VAP) for osteoporotic vertebral compression fracture (OVCF) is not supported. Recently, the effect of recombinant human parathyroid hormone (1-34) (rhPTH) has been paid great attention for its efficacy in anti-osteoporosis and bone union. This study aims to explore the outcome of rhPTH on acute OVCF and compare it with VAP to clarify its therapeutic advantages. METHODS The retrospective study comprised 71 acute OVCF patients from January 2015 to March 2020: 22 received rhPTH treatment (rhPTH group) and 49 underwent VAP (VAP group). The rhPTH group was 15 women and seven men with an average of 76.18 years, and the VAP group were 35 women and 14 men with an average of 73.63 years. The thoracic/lumbar vertebrae were 14/8 in the rhPTH group and 29/20 in the VAP group. The average follow-up period was 14.05 months in the rhPTH group and 13.82 months in the VAP group. The two groups were assessed regarding the visual analog score (VAS), Oswestry Disability Index (ODI), OVCF bone union, bone mineral density (BMD), kyphotic angle (KA), anterior and posterior border height (ABH and PBH, respectively), adverse events and the health-related quality of life assessed by short form-36 health survey scores (SF-36). Categorical variables were analyzed by chi-square test and continuous variables between groups were analyzed by independent samples t-test or Mann-Whitney U test according to the normality. RESULTS During the follow-up, the VAS was significantly lower in the rhPTH group than in the VAP group at month 3 (0.39 ± 0.6 vs 0.68 ± 0.651) (p = 0.047), month 6 (0.45 ± 0.60 vs 2.18 ± 1.22) (p < 0.001), and month 12 (0.45 ± 0.60 vs 2.43 ± 1.49) (p < 0.001). At month 12, the ODI was significantly lower in the rhPTH group (18.59 ± 3.33%) than in the VAP group (28.93 ± 16.71%) (p < 0.001). Bone bridge was detected on sagittal computed tomography images of all fractured vertebrae in the rhPTH group. The BMD was significantly higher in the rhPTH group (87.66 ± 5.91 Hounsfield units [HU]) than in the VAP group (68.15 ± 11.32HU) (p < 0.001). There were no significant differences in the changes in KA, ABH, and PBH between groups (all p > 0.05). The incidence of new OVCF was significantly lower in the rhPTH group than in the VAP group (p = 0.042). All scores of SF-36 were significantly higher in the rhPTH group than in the VAP group (all p < 0.05). CONCLUSION In acute OVCF patients, rhPTH was better than VAP in increasing spinal BMD to promote OVCF healing, reduce new OVCF, and improve back pain, physical ability, and health-related quality of life.
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Affiliation(s)
- Pengguo Gou
- Department of Orthopedic Surgery, The Fifth Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Zhihui Zhao
- Department of Orthopedic Surgery, The Tianjin 4th Centre Hospital, Tianjin, Tianjin, China
| | - Chen Yu
- Department of Orthopedic Surgery, The Fifth Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xuefeng Hou
- Department of Orthopedic Surgery, The Fifth Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Gang Gao
- Department of Orthopedic Surgery, The Fifth Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ting Zhang
- Department of Orthopedic Surgery, The Fifth Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Feng Chang
- Department of Orthopedic Surgery, The Fifth Affiliated Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Rosinski AA, Mittal A, Odeh K, Ungurean V, Leasure J, Telles C, Kondrashov D. Alternatives to Traditional Pedicle Screws for Posterior Fixation of the Degenerative Lumbar Spine. JBJS Rev 2021; 9:01874474-202107000-00016. [PMID: 34319968 DOI: 10.2106/jbjs.rvw.20.00177] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Traditional pedicle screws are currently the gold standard to achieve stable 3-column fixation of the degenerative lumbar spine. However, there are cases in which pedicle screw fixation may not be ideal. Due to their starting point lateral to the pars interarticularis, pedicle screws require a relatively wide dissection along with a medialized trajectory directed toward the centrally located neural elements and prevertebral vasculature. In addition, low bone mineral density remains a major risk factor for pedicle screw loosening, pullout, and pseudarthrosis. The purpose of this article is to review the indications, advantages, disadvantages, and complications associated with posterior fixation techniques of the degenerative lumbar spine beyond the traditional pedicle screws. METHODS Comprehensive literature searches of the PubMed, Scopus, and Web of Science databases were performed for 5 methods of posterior spinal fixation, including (1) cortical bone trajectory (CBT) screws, (2) transfacet screws, (3) translaminar screws, (4) spinous process plates, and (5) fusion mass screws and hooks. Articles that had been published between January 1, 1990, and January 1, 2020, were considered. Non-English-language articles and studies involving fixation of the cervical or thoracic spine were excluded from our review. RESULTS After reviewing over 1,700 articles pertaining to CBT and non-pedicular fixation techniques, a total of 284 articles met our inclusion criteria. CBT and transfacet screws require less-extensive exposure and paraspinal muscle dissection compared with traditional pedicle screws and may therefore reduce blood loss, postoperative pain, and length of hospital stay. In addition, several methods of non-pedicular fixation such as translaminar and fusion mass screws have trajectories that are directed away from or posterior to the spinal canal, potentially decreasing the risk of neurologic injury. CBT, transfacet, and fusion mass screws can also be used as salvage techniques when traditional pedicle screw constructs fail. CONCLUSIONS CBT and non-pedicular fixation may be preferred in certain lumbar degenerative cases, particularly among patients with osteoporosis. Limitations of non-pedicular techniques include their reliance on intact posterior elements and the lack of 3-column fixation of the spine. As a result, transfacet and translaminar screws are infrequently used as the primary method of fixation. CBT, transfacet, and translaminar screws are effective in augmenting interbody fixation and have been shown to significantly improve fusion rates and clinical outcomes compared with stand-alone anterior lumbar interbody fusion. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander A Rosinski
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Ashish Mittal
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Khalid Odeh
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | | | | | | | - Dimitriy Kondrashov
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
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