Wallis interspinous implantation to treat degenerative spinal disease: description of the method and case series

Lumbar disc rehydration after dynamic stabilization: A systematic review

BACKGROUND

Interbody fusion combined with posterior screw fixation is a traditional method used for treating lumbar degenerative disease (LDD). But in recent years, there have been more and more reports about its complications. Dynamic Stabilization Systems (DSS) are another method for the treatment of LDD, but the clinical results are still inconclusive. The objective of this study is to review, analyze, and discuss the probability of disc rehydration by DSS designed for LDD by systematically reviewing previous relevant studies.

METHODS

The Pubmed, Web of Science, and Embase databases were searched using keywords for articles published before June 2022. The following keywords were used: rehydration, rehydrated, lumbar, spine, disc, spinal, degenerative disc disease, degenerative spine disease, vertebrae, vertebral column, thoracolumbar, and lumbosacral. The included studies were printed in English. Two independent investigators compiled all data. For the quality assessment, the Newcastle-Ottawa Scale was used to evaluate case-control studies, while the Joanna Briggs Institute critical appraisal checklist was used to evaluate the case series studies.

RESULTS

This systematic review included 7 studies comprised of 5 case series and 2 case-control studies. Seven articles involving 199 cases were enrolled for the data extraction. Of the 199 cases, 55 cases observed rehydration, as evaluated by Pfrimann grading on magnetic resonance imaging. The rehydration rate was 27.6% (55/199). DSS can provide positive clinical outcomes. Both visual analog scale and Oswestry Dysfunctional Index scores were significantly improved at the final follow-up.

CONCLUSION

DSS may promote disc rehydration and delay the development of LDD to some extent. Mechanical stretch may play an important role in the progress of intervertebral disc rehydration. It provides important evidence for the clinical application of DSS.

Comparison of long-term outcomes of spinal fusion surgeries supplemented with "topping-off" implants in lumbar degenerative diseases: A systematic review and network meta-analysis

Background Context

Spinal fusion surgery is a common treatment for lumbar degenerative diseases and has been associated with the long-term complication of adjacent segment disease (ASD). In recent years, the "topping-off" technique has emerged as a new surgical method, combining spinal fusion with a hybrid stabilization device (HSD) or interspinous process device (IPD) proximal to the fused vertebrae.

Methods

A literature search using the PubMed, Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science databases identified eligible studies comparing topping-off implant(s) with spinal fusion surgery for lumbar degenerative diseases. Risk of bias was assessed using the Cochrane RoB 2.0 tool for randomized controlled trials and the Newcastle-Ottawa scale for retrospective studies. Each outcome was analyzed using the statistical Confidence in NMA (CINeMA) 1.9.0 software.

Results

17 RCTs and retrospective studies that included 1255 participants and five interventions were identified. The topping-off implants device for intervertebral assisted motion (DIAM; OR = 0.235, p < 0.001), Dynesys (OR = 0.413, p < 0.001), and Coflex (OR = 0.417, p < 0.01) significantly lowered the incidence of radiographic adjacent segment degeneration (RASDeg) compared with spinal fusion surgery alone. Spinal fusion supplemented with DIAM significantly reduced the incidence of clinical adjacent segment disease (CASD) (OR = 0.358, p = 0.032).

Conclusions

Spinal fusion supplemented with DIAM substantially reduced the incidence of radiographic and clinical adjacent segment disease. No significant difference was observed between the treatment comparators for reoperation due to ASD and back pain relief score.

Lumbar disc rehydration in the bridged segment using the BioFlex dynamic stabilization system: A case report and literature review

BACKGROUND

In recent years, the mechanical concept of intervertebral disc regeneration has become more and more popular due to the increasing awareness of the importance of preservation of spine movement. Interestingly, there is increasing evidence, however, that dynamic stabilization systems may compensate non-physiological loads, limit pathological movement, normalize disc height and intradiscal pressure, and provide an adaptive environment for disc regeneration.

CASE SUMMARY

The patient was a 54-year-old man, who presented with a 10-year history of mechanical back pain, which had become progressively serious and radiated into the left lower limb with numbness 3 mo prior. He had decreased muscle strength (class IV) of the left dorsal extensor and plantar flexor. Magnetic resonance imaging scans showed L3-S1 disc degeneration and L4-L5 disc herniation. Because the patient did not respond to various conservative treatments, he underwent a posterior L4-5 discectomy with fixation of the BioFlex dynamic stabilization system (Bio-Spine, Seoul, Korea). Preoperative symptoms were relieved and lumbar function was markedly improved after the operation. L4-L5 disc rehydration of instrumented segment was noted on magnetic resonance imaging at the 2-year follow-up.

CONCLUSION

Rehydration of the degenerated disc in our patient indicates that the BioFlex dynamic stabilization system may promote disc regeneration. Further research is needed to provide more evidence to support lumbar disc rehydration in the bridged segment using this system.

Short-term effects of minimally invasive dynamic neutralization system for the treatment of lumbar spinal stenosis: An observational study

The aim of the study was to evaluate the safety and short-term effects of dynamic stabilization via minimally invasive system for degenerative lumbar spinal stenosis. Patients with degenerative lumbar spinal stenosis and treated with Transforaminal Lumbar Interbody Fusion via minimally invasive minimally system (mis-TLIF) were served as the control group.From April 2011 to March 2015, 47 patients (29 male, 18 female; mean age 47.6 [range, 26-52] years) with lumbar spinal stenosis were treated with decompression and excision of herniated disk via the minimally invasive system combined with the dynamic fixation technique, and 42 patients as control group with mis-TLIF. Minimally invasive surgeries were performed via the posterior incision approach. The clinical outcomes were evaluated by comparing the Visual Analog Scale (VAS) score, Oswestry Disability Index (ODI) scores, and the ROMs of the adjacent segment before and after surgery. The postoperative complications related to the implants were identified.A total of 83 patients (43 of Dynesys group and 40 of mis-TLIF group) were followed for an average duration of >35 months. Dynesys stabilization resulted in significantly higher preservation of motion at the index level (P < .05), and significantly less hypermobility at the adjacent segments. VAS for the back and leg pain and ODI improved significantly (P < .05) in 2 groups; however, there is no significant difference between the groups. In Dynesys group, 3 cases suffered skin flay necrosis, 1 of them had a wound infection that was treated with washing and drainage combined with antibiotic therapy. Skin flay necrosis were also observed in 2 cases of mis-TLIF group. Reoperation was performed in one case of Dynesys group for rupture of the internal fixation. No rupture of internal fixation was observed in mis-TLIF group.The nonfusion fixation system Dynesys may be used to treat degenerative spinal stenosis without posterior element damage. This surgical technique is safe and effective. However, utilizing higher preservation of motion may lead to the failure of internal fixation.

Adjacent segmental degeneration following Wallis interspinous stabilization implantation: Biomechanical explanations and the value of magnetic resonance imaging

Adjacent segmental degeneration (ASD) is a major issue after pedicular fixation. This study examined the degeneration of the adjacent levels due to the insertion of the Wallis interspinous stabilization system compared with discectomy, using magnetic resonance imaging (MRI).Thirty-eight patients diagnosed with lumbar degeneration disorders at L4-L5 were reviewed: 19 patients underwent discectomy and Wallis system implantation (group A), and 19 patients underwent discectomy (group B). The Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were assessed preoperatively and postoperatively. ASD was evaluated by MRI.There was no difference in the preoperative ODI scores between the 2 groups (non-normal distribution, median, 50 (40, 50) vs 50 (50, 50), P = .331), but the postoperative ODI scores were different (non-normal distribution, median, 0 (0, 32) vs 20 (20, 30), P < .005). Similar results were observed for VAS. In group A, ASD occurred in 4 patients (21.1%) in the disc and 8 (42.1%) in the facet joint at L3/4, and in 4 (21.1%) in the disc and 5 (26.3%) in the facet joint at L5/S1. In Group B, ASD occurred in 3 patients (15.8%) in the disc at L3/4, and in 4 (21.1%) in the disc at L5/S1. In general, there was no difference between the 2 groups (P > .05), except at L3/4 (P = .015).ASD of the facet joint in the cranial segment occurred after Wallis system implantation, suggesting that the Wallis system cannot prevent ASD of the facet joint, but could have some other benefits for the discs.

The negative chronotropic effect during lumbar spine surgery: A systemic review and aggregation of an emerging model of spinal cardiac reflex

BACKGROUND

Hemodynamic perturbations in spine surgeries are predominantly reported in cervical and thoracic level procedures. The literature related to negative cardiovascular changes (decrease of heart rate and blood pressure) in lumbar spine procedures is still scarce and only highlighted in few case reports/letters until now.

METHODS

With the help of a systematic literature review with predefined criteria, we, therefore, examined and synthesized here the probable underlying common cause of these hemodynamic disturbances in lumbar spine surgeries. Data aggregation to a model was done by a case survey method and established by a cause-effect relationship.

RESULTS

There are only 5 cases that met our strict predefined criteria and that were aggregated to an emergent model of an autonomous reflex arc.

CONCLUSION

This review and consecutive data aggregation provides, for the first time, a concept of spinal cardiac reflex in lumbar spine surgeries.

Clinical outcome following DIAM implantation for symptomatic lumbar internal disk disruption: a 3-year retrospective analysis

BACKGROUND/OBJECTIVE

Internal disk disruption (IDD), an early event of lumbar disk degeneration, is the most common cause of low back pain. Since increased intradiskal pressure (IDP) is associated with symptoms and progression of disk degeneration, unloading a painful disk with an interspinous process device (IPD) is a rational treatment option. The goal of this study was to evaluate the effectiveness of dynamic stabilization with an IPD in the treatment of symptomatic IDD of the lumbar spine.

PATIENTS AND METHODS

Patients with symptomatic IDD were treated with implantation of an IPD, the device for intervertebral assisted motion (DIAM). Diagnosis of IDD was based on typical MRI finding of posterior annular high-intensity zone and positive provocative test on discography. IDP was analyzed intraoperatively. Axial back and leg pain was evaluated with visual analog scale, functional status with Oswestry Disability Index, and final clinical outcomes with Odom criteria. Data from 34 patients followed up for at least 3 years were collected.

RESULTS

DIAM implantation significantly reduced IDP (n=11, P<0.0001). All 34 patients reported symptom relief. Thirty-one patients (91%) remained symptom free until the last followups. Three patients (9%) experienced recurrence of pain, of which the causes were unrelated to the IDD or surgery. Disk status at the DIAM-implanted segments remained stable. Segmental flexion/extension mobility was preserved in 27 of 30 patients with preoperative mobility. No proximal or distal adjacent segment degeneration was observed. The final clinical outcomes were excellent/good in 31 and fair/poor in three patients.

CONCLUSION

For patients with symptomatic IDD, dynamic stabilization with DIAM provides pain relief and functional improvement. The implantation maintains disk status and prevents progression of disk degeneration, without compromising segmental flexion/extension mobility or causing adjacent segment degeneration.

Comparative and quantitative proteomic analysis of normal and degenerated human annulus fibrosus cells

Degeneration of the intervertebral disc (IVD) is a major chronic medical condition associated with back pain. To better understand the pathogenesis of IVD degeneration, we performed comparative and quantitative proteomic analyses of normal and degenerated human annulus fibrosus (AF) cells and identified proteins that are differentially expressed between them. Annulus fibrosus cells were isolated and cultured from patients with lumbar disc herniation (the experimental group, degenerated AF cells) and scoliosis patients who underwent orthopaedic surgery (the control group, normal AF cells). Comparative proteomic analyses of normal and degenerated cultured AF cells were carried out using 2-D electrophoresis, mass spectrometric analyses, and database searching. Quantitative analyses of silver-stained 2-D electrophoresis gels of normal and degenerated cultured AF cells identified 10 protein spots that showed the most altered differential expression levels between the two groups. Among these, three proteins were decreased, including heat shock cognate 71-kDa protein, glucose-6-phosphate 1-dehydrogenase, and protocadherin-23, whereas seven proteins were increased, including guanine nucleotide-binding protein G(i) subunit α-2, superoxide dismutase, transmembrane protein 51, adenosine receptor A3, 26S protease regulatory subunit 8, lipid phosphate phosphatase-related protein, and fatty acyl-crotonic acid reductase 1. These differentially expressed proteins might be involved in the pathophysiological process of IVD degeneration and have potential values as biomarkers of the degeneration of IVD.

Interspinous process stabilization with Rocker via unilateral approach versus X-Stop via bilateral approach for lumbar spinal stenosis: a comparative study

BACKGROUND

Rocker is a novel interspinous process stabilization (IPS) that can be installed via unilateral approach by virtue of its unique design. This controlled study compared the clinical outcome of Rocker versus X-Stop to access the feasibility and validity of the novel IPS.

METHODS

From March 2011 to September 2012, 32 patients treated with Rocker and 30 patients treated with X-Stop were enrolled in this study. The primary clinical outcome measure was Oswestry Disability Index (ODI) score. The secondary clinical outcome measure was Japanese orthopaedics association (JOA) score. Disc height index (DHI) and foraminal height index (FHI) were measured for postoperative radiographic evaluation. Implant failures were also recorded.

RESULTS

There were 55 patients with complete data during 24 months follow-up. Among the 55 patients, 38 patients underwent IPS in combination with microdecompression. At the final follow-up, 49 patients achieved a minimal clinical important difference (≥ 8 points ODI improvement). The mean operative time was 53.6 min (range, 30 to 90 min) in Rocker group and 63.1 min (range, 30 to 100 min) in X-Stop group. The average blood loss was 111 ml (range, 50 to 400 ml) in Rocker group and 138 ml (range, 50 to 350 ml) in X-Stop group. ODI score were significantly improved from preoperative 46.8 ± 9.2 to 12.2 ± 2.6 at 24 months follow-up in the Rocker group and from preoperative 45.8 ± 9.8 to 11.8 ± 2.4 at 24 months follow-up in the X-Stop group. JOA score also improved significantly in both groups. The radiographic parameters of DHI and FHI in both groups increased immediately postoperatively, however, the improvements seemed to revert toward initial value during follow-up. Two patients in Rocker group demonstrated implant dislocation within one week postoperatively and one patient in X-Stop group demonstrated implant migration at two months postoperatively.

CONCLUSIONS

Preliminary clinical and radiographic outcome was similar between Rocker and X-Stop group. For patients of lumbar spinal stenosis with unilateral nerve root involved or mild-to-moderate central canal stenosis, Rocker offers a new alternative with less damage.

Bone resorption during the first year after implantation of a single-segment dynamic interspinous stabilization device and its risk factors

Background

Dynamic interspinous stabilization devices generally provide satisfactory results, but can result in recurrent lumbar disc herniation, spinous process fracture, or bone resorption of the spinous process. The purpose of this study was to investigate if the Wallis dynamic stabilization device is associated with bone resorption.

Methods

Patients who underwent single-segment posterior lumbar decompression and implantation of a Wallis dynamic interspinous stabilization device at the L4/5 level between January 1, 2009 and October 1, 2011 were included. Bone resorption rate, Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) score, and visual analogue scale (VAS) pain score were measured. Patient baseline and 1-year follow-up data were collected and analyzed. The bone resorption rate of the L4 and L5 spinous processes was calculated.

Results

Twenty four males and 20 females with a mean age of 42.7 ± 14.7 years were included. Twenty nine patients had significant bone resorption (bone resorption rate > 20%) and 15 had no bone resorption (bone resorption rate ≤ 20%) at 1 year after surgery. Lumbar lordosis ≥ 50° was associated with a lower bone resorption than lumbar lordosis < 50° and increasing BMI was associated with increased bone resorption. There were no significant differences between the bone resorption and no bone resorption groups in the improvement rate of VAS pain score, ODI, and JOA score at 1 year after surgery.

Conclusions

Significant bone resorption occurs within 1 year after implantation of the Wallis device in more than 50% of patients. However, it does not affect short-term functional results.

Molecular imaging of potential bone metastasis from differentiated thyroid cancer: a case report

INTRODUCTION

Molecular imaging of the spine is a rarely used diagnostic method for which only a few case reports exist in the literature. Here, to the best of our knowledge we present the first case of a combination of molecular imaging by single photon emission computer tomography and positron emission tomography used in post-operative spinal diagnostic assessment.

CASE PRESENTATION

We present the case of a 50-year-old Caucasian woman experiencing progressive spinal cord compression caused by a vertebral metastasis of a less well differentiated thyroid cancer. Following tumor resection and vertebral stabilization, total thyroidectomy was performed revealing follicular thyroid carcinoma pT2 pNxM1 (lung, bone). During follow-up our patient underwent five radioiodine therapy procedures (5.3 to 5.7 GBq each) over a two-year period. Post-therapeutic I-131 scans showed decreasing uptake in multiple Pulmonary metastases. However, following an initial decrease, stimulated thyroglobulin remained at pathologically increased levels, indicating further neoplastic activity. F18 Fludeoxyglucose positron emission tomography, which was performed in parallel, showed remaining hypermetabolism in the lungs but no hypermetabolism of the spinal lesions correlating with the stable neurological examinations. While on single photon emission computer tomography images Pulmonary hyperfixation of I-131 disappeared (most likely indicating dedifferentiation), there was persistent spinal hyperfixation at the operated level and even higher fixation at the spinal process of L3. Based on the negative results of the spinal F18 fludeoxyglucose positron emission tomography, a decision was made not to operate again on the spine since our patient was completely asymptomatic and the neurological risk seemed to be too high. During further follow-up our patient remained neurologically stable.

CONCLUSIONS

Molecular imaging by F18 fludeoxyglucose positron emission tomography helps to exclude metabolically active spinal metastases and to spare further risky surgery.