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Farshad M, Tsagkaris C, Widmer J, Fasser MR, Cornaz F, Calek AK. Vertebropexy as a semi-rigid ligamentous alternative to lumbar spinal fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1695-1703. [PMID: 36930387 DOI: 10.1007/s00586-023-07647-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/26/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To develop ligamentous vertebral stabilization techniques ("vertebropexy") that can be used after microsurgical decompression (intact posterior structures) and midline decompression (removed posterior structures) and to elaborate their biomechanical characteristics. METHODS Fifteen spinal segments were biomechanically tested in a stepwise surgical decompression and ligamentous stabilization study. Stabilization was achieved with a gracilis or semitendinosus tendon allograft, which was attached to the spinous process (interspinous vertebropexy) or the laminae (interlaminar vertebropexy) in form of a loop. The specimens were tested (1) in the native state, after (2) microsurgical decompression, (3) interspinous vertebropexy, (4) midline decompression, and (5) interlaminar vertebropexy. In the intact state and after every surgical step, the segments were loaded in flexion-extension (FE), lateral shear (LS), lateral bending (LB), anterior shear (AS) and axial rotation (AR). RESULTS Interspinous vertebropexy significantly reduced the range of motion (ROM) in all loading scenarios compared to microsurgical decompression: in FE by 70% (p < 0.001), in LS by 22% (p < 0.001), in LB by 8% (p < 0.001) in AS by 12% (p < 0.01) and in AR by 9% (p < 0.001). Interlaminar vertebropexy decreased ROM compared to midline decompression by 70% (p < 0.001) in FE, 18% (p < 0.001) in LS, 11% (p < 0.01) in LB, 7% (p < 0.01) in AS, and 4% (p < 0.01) in AR. Vertebral segment ROM was significantly smaller with the interspinous vertebropexy compared to the interlaminar vertebropexy for all loading scenarios except FE. Both techniques were able to reduce vertebral body segment ROM in FE, LS and LB beyond the native state. CONCLUSION Vertebropexy is a new concept of semi-rigid spinal stabilization based on ligamentous reinforcement of the spinal segment. It is able to reduce motion, especially in flexion-extension. Studies are needed to evaluate its clinical application.
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Affiliation(s)
- Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christos Tsagkaris
- Institute of Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Institute of Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Institute of Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
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Dinizo M, Passias P, Kebaish K, Errico TJ, Raman T. The Approach to Pseudarthrosis After Adult Spinal Deformity Surgery: Is a Multiple-Rod Construct Necessary? Global Spine J 2023; 13:636-642. [PMID: 33858226 DOI: 10.1177/21925682211001880] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES Our goal was to evaluate the rate of rod fracture and persistent pseudarthrosis in cohorts of patients treated with a dual rod or multiple-rod construct in revision surgery for pseudarthrosis. METHODS A dual rod construct was used in 23 patients, and a multiple rod construct in 24 patients, spanning the pseudarthrosis level. Two-year fusion grading, and rates of pseudarthrosis and implant failure, were assessed. RESULTS There were no differences in patient or surgical characteristics between the groups: (2- rod construct: Age 60 ± 14, Levels 10 ± 5, 3-column osteotomy:17%; multiple-rod construct: Age: 62 ± 11, Levels 9 ± 4, 3-column osteotomy:30%). Patients in the multiple rod construct were transfused a greater volume of packed red blood cells (pRBCs) intraoperatively (2.6 ± 2.9 vs. 1.1 ± 1.5 U, p < 0.0001). At 2 year follow up there was no difference in fusion grades at the previous level of pseudarthrosis, the rate of rod fracture or pseudarthrosis between the 2 groups, or rate of reoperation for pseudarthrosis, rod fracture, wound infection, hardware prominence, or PJK/PJF. CONCLUSIONS Our data demonstrate no difference in fusion grade, or rates of rod fracture and revision at 2 years, after utilizing a dual rod versus multiple rod construct in revision surgery for pseudarthrosis. The low complication rates seen with either configuration warrant further investigation of the optimal instrumentation configuration.
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Affiliation(s)
- Michael Dinizo
- Department of Orthopaedic Surgery, 12297NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Anesthesiology, 25061NYU Langone Medical Center, New York, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, 12297NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Anesthesiology, 25061NYU Langone Medical Center, New York, NY, USA
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, 12297NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Anesthesiology, 25061NYU Langone Medical Center, New York, NY, USA
| | - Thomas J Errico
- Department of Orthopaedic Surgery, 12297NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Anesthesiology, 25061NYU Langone Medical Center, New York, NY, USA
| | - Tina Raman
- Department of Orthopaedic Surgery, 12297NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Anesthesiology, 25061NYU Langone Medical Center, New York, NY, USA
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Esplin N, Elhamdani S, Jeong SW, Moran M, Rogowski B, Pace J. Lumbar pedicle screw pseudoarthrosis salvage technique with moldable, bioabsorbable, calcium phosphate-based putty: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22288. [PMID: 36345206 PMCID: PMC9644411 DOI: 10.3171/case22288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Pseudoarthrosis is a complication of spinal fixation. Risk factors include infection, larger constructs, significant medical comorbidities, and diabetes. The authors present a case report of dilated pedicle screw pseudoarthrosis salvaged with moldable, settable calcium phosphate-based putty. OBSERVATIONS The patient presented with back pain and radiculopathy in the setting of poorly controlled diabetes. He was taken to the operating room for laminectomy and fusion complicated by postoperative infection requiring incision and drainage. He returned to the clinic 6 months later with pseudoarthrosis of the L4 screws and adjacent segment degeneration. He was taken for revision with extension of fusion. The L4 tracts were significantly dilated. A moldable, bioabsorbable polymer-based putty containing calcium phosphate was used to augment the dilated tract after decortication back to bleeding bone, allowing good purchase of screws. The patient did well postoperatively. LESSONS There are several salvage options for clinically significant pseudoarthrosis after spinal fixation, including anterior or lateral constructs, extension, and revision of fusion. The authors were able to obtain good screw purchase with dilated screw tracts after addition of moldable, bioabsorbable polymer-based putty containing calcium phosphate. It appears that this may represent an effective salvage strategy for dilated pseudoarthropathy in select settings to support extension of fusion.
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Affiliation(s)
- Nathan Esplin
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania; and
| | - Shahed Elhamdani
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania; and
| | - Seung W. Jeong
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania; and
| | - Michael Moran
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Brandon Rogowski
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jonathan Pace
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania; and
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Elhessy AH, Eltayeby HH, Kane SC, Garonzik IM, Conway JE, Conway JD. Fusion Revision Surgery With Reamer-Irrigator-Aspirator to Harvest Autograft After Spinal Pseudarthrosis. Cureus 2022; 14:e27503. [PMID: 35949743 PMCID: PMC9356659 DOI: 10.7759/cureus.27503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background and purpose Spinal pseudarthrosis (SPA) is a common complication after attempted cervical or lumbosacral spinal fusion surgery. Revision surgeries usually necessitate bone graft implementation as an adjunct to hardware revision. Iliac crest bone graft is the gold standard but availability can be limited and usage often leads to persistent postoperative pain at the donor site. There is scant literature regarding the use of reamer-irrigator-aspirator (RIA)-harvested bone graft in lumbar spinal fusion. This is a collaborative study between orthopedic surgery and neurosurgery departments to utilize femur intramedullary autograft harvested using the RIA system as an adjunct graft in SPA revision surgeries. Materials and methods A retrospective review was conducted at a single center between August 2014 and December 2017 of patients aged ≥ 18 years and diagnosed with cervical, thoracic, or lumbar SPA who underwent revision fusion surgery using femur intramedullary autograft harvested using the RIA system. Plain radiographs and CT scans were utilized to confirm successful fusion. Results Eleven patients underwent 12 SPA revision surgeries using the RIA system as a source for bone graft in addition to bone morphogenetic protein 2 (BMP-2) and allograft. The mean amount of graft harvested was 51.3 mL (range: 20-70 mL). Nine patients achieved successful fusion (81.8%). The average time to fusion was 9.1 months. Four patients (36.4%) had postoperative knee pain. Regarding patient position and approach for harvesting, 66.7% (n = 8) of cases were positioned prone and a retrograde approach was utilized in 91.7% (n = 11) of cases. Interpretation This is the first case series in known literature to report the RIA system as a reliably considerable source of autologous bone graft for SPA revision surgeries. It provides a useful adjunct to the known types of bone grafts. Patient positioning and the approach choice for graft harvesting can be adjusted according to the fusion approach and the surgeon’s preference.
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Alkharsawi M, Shousha M, Boehm H, Alhashash M. Cement discoplasty for managing lumbar spine pseudarthrosis in elderly patients: a less invasive alternative approach for failed posterior lumbar spine interbody fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1728-1735. [PMID: 35347424 DOI: 10.1007/s00586-022-07186-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/29/2022] [Accepted: 03/12/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE A retrospective cohort study was performed to evaluate pseudoarthrosis treatment results by injection of cement in disc space of failed fusion in posterior lumbar interbody fusion in patients above 65 years. METHODS Forty-five patients above 65 years with symptomatic pseudarthrosis after lumbar spine fusion were treated by cement injection in the affected disc space. RESULTS There were 30 females and 15 males. The mean age at the operation was 74 ± 6.5 years (range 65-89). Discoplasty was performed after the primary fusion operations after a mean of 14 ± 1.3 months (range 12-24). The mean preoperative VAS was 7.5 (range 6-9), and ODI was 36 (range 30-45). Cement injection was done at one level in most of the cases (35 patients). In seven cases, two injection levels were done, and in three cases, three levels. Twenty-three patients had discoplasty only, while 22 had discoplasty and screws change, including 14 cases of extension of the instrumentation. The mean postoperative follow-up was 32 ± 6.5 months. The VAS improved to 3.5 (range 2-5) (p = 0.02) and ODI to 12.3 (range 5-35) (p = 0.001). Reoperation was indicated in two (4%) patients by screws loosening. Asymptomatic cement leakage occurred in the paravertebral space in seven cases (15.5%). CONCLUSION Cement discoplasty offers a less invasive reliable surgical solution in elderly patients with symptomatic lumbar pseudarthrosis in the elderly patients. In cases with screw loosening, discoplasty should be combined with screw revision.
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Affiliation(s)
- Mahmoud Alkharsawi
- Department of Spine Surgery, Zentralklinik Bad Berka, Robert-Koch-Allee 7, 99437, Bad Berka, Germany.
- Department of Orthopedic Surgery, Tanta University, Tanta, Egypt.
| | - Mootaz Shousha
- Department of Spine Surgery, Zentralklinik Bad Berka, Robert-Koch-Allee 7, 99437, Bad Berka, Germany
- Department of Orthopedic Surgery, Alexandria University, Alexandria, Egypt
| | - Heinrich Boehm
- Department of Spine Surgery, Zentralklinik Bad Berka, Robert-Koch-Allee 7, 99437, Bad Berka, Germany
| | - Mohamed Alhashash
- Department of Spine Surgery, Zentralklinik Bad Berka, Robert-Koch-Allee 7, 99437, Bad Berka, Germany
- Department of Orthopedic Surgery, Alexandria University, Alexandria, Egypt
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Indolent Infection After Lumbar Interbody Fusion: An Under-recognized Cause of Pseudarthrosis, Which Can Be Successfully Treated With Anterior Revision Fusion. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202203000-00005. [PMID: 35266911 PMCID: PMC8893294 DOI: 10.5435/jaaosglobal-d-21-00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/13/2022] [Indexed: 11/18/2022]
Abstract
Introduction: Methods: Results: Discussion:
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7
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Dietz N, Sharma M, Kelly M, Ugiliweneza B, Wang D, Osorio J, Karikari I, Drazin D, Boakye M. Recombinant Human Bone Morphogenetic Protein-2 Use in Adult Spinal Deformity Surgery: Comparative Analysis and Healthcare Utilization at 24 Months' Follow-up. Global Spine J 2022; 12:92-101. [PMID: 32844671 PMCID: PMC8965293 DOI: 10.1177/2192568220947377] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used to achieve fusion in adult spinal deformity (ASD) surgery. Our aim was to investigate the long-term impact of rhBMP-2 use for clinical outcomes and health care utilization in this patient population. METHODS We conducted an analysis using MarketScan to identify health resource utilization of rhBMP-2 use for ASD after surgical intervention compared to fusion without rhBMP-2 at 24 months' follow-up. Outcomes assessed included length of stay, complications, pseudoarthrosis, reoperation, outpatient services, and health care payments. RESULTS Of 7115 patients who underwent surgery for ASD, 854 received rhBMP-2 and 6261 were operated upon without use of rhBMP-2. One month after discharge, the rhBMP-2 cohort had a nonsignificant trend in fewer complications (15.38%) than those who did not receive rhBMP-2 (18.07%), P = .0558. At 12 months, pseudoarthrosis was reported in 2.8% of cases with no BMP and 01.14% of cases with BMP, P = .0048. Average payments at 12 months were $120 138 for the rhBMP-2 group and $118 373 for the no rhBMP-2 group, P = .8228. At 24 months, payments were $141 664 for the rhBMP-2 group and $144 179 for the group that did not receive rhBMP-2, P = .5946. CONCLUSIONS In ASD surgery, use of rhBMP-2 was not associated with increased complications or reoperations at index hospitalization and 1-month follow-up. Overall payments, including index hospitalization, readmissions, reoperations, and outpatient services were not different compared to those without the use of rhBMP-2 at 12 months and 24 months after discharge.
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Affiliation(s)
| | | | | | | | | | - Joseph Osorio
- University of California, San Diego, San Diego, CA, USA
| | | | - Doniel Drazin
- Pacific Northwest University of Health Sciences College of Medicine, Yakima, WA, USA
| | - Maxwell Boakye
- University of Louisville, Louisville, KY, USA,Maxwell Boakye, Department of Neurosurgery, School of Medicine, University of Louisville, 220 Abraham Flexner Way, Louisville, KY 40202, USA.
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Yurac R, Bravo JT, Silva Á, Marré B. Spondylolysis Repair Using a Minimally Invasive Modified Buck Technique with Neuronavigation and Neuromonitoring in High School and Professional Athletes: Technical Notes, Case Series, and Literature Review. World Neurosurg 2021; 155:54-63. [PMID: 34365047 DOI: 10.1016/j.wneu.2021.07.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spondylolysis is a defect in the pars interarticularis of the vertebra that occurs frequently in high-performance young athletes. Although nonsurgical management is the mainstay of treatment, surgery is an option for patients with persistent symptoms despite multiple cycles of nonsurgical treatment. Performing a minimally invasive technique reduces complications, postsurgery pain, and hospitalization time and leads to a quick recovery. The aim of this study was to report the clinical results of a series of 3 patients treated with a modification of the Buck technique with a minimally invasive approach. METHODS Three high-performance athletes between 17 and 18 years old who were managed nonsurgically for at least 6 months underwent a modified Buck technique repair with a minimally invasive approach using cannulated compression screws, with neuronavigation and neuromonitoring. Patients were followed at least 6 months with computed tomography scans to assess consolidation and fixation status. Following rehabilitation and in the absence of pain, all 3 athletes returned to their respective sports. No complications were reported. RESULTS All patients presented with bilateral spondylolysis, at L3 in 1 case and at L5 in 2 cases. Patients received conservative management for 12-36 months before surgery. After surgery, consolidation was obtained at 4 months in all patients, who returned to their sports activities in <6 months. CONCLUSIONS The proposed technique shows the advantages of performing minimally invasive surgery in young high-performance athletes, ensuring consolidation and early return to sports activity without complications.
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Affiliation(s)
- Ratko Yurac
- Spine Unit, Department of Orthopedic and Traumatology, Clínica Alemana, Santiago, Chile; Department of Orthopedic and Traumatology, School of Medicine, University del Desarrollo, Santiago, Chile.
| | - José T Bravo
- Department of Orthopedic and Traumatology, School of Medicine, University del Desarrollo, Santiago, Chile
| | - Álvaro Silva
- Spine Unit, Department of Orthopedic and Traumatology, Clínica Alemana, Santiago, Chile; Department of Orthopedic and Traumatology, School of Medicine, University del Desarrollo, Santiago, Chile
| | - Bartolomé Marré
- Spine Unit, Department of Orthopedic and Traumatology, Clínica Alemana, Santiago, Chile; Department of Orthopedic and Traumatology, School of Medicine, University del Desarrollo, Santiago, Chile
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Montenegro TS, Gonzalez GA, Saiegh FA, Philipp L, Hines K, Hattar E, Franco D, Mahtabfar A, Keppetipola KM, Leibold A, Atallah E, Fatema U, Thalheimer S, Wu C, Prasad SK, Jallo J, Heller J, Sharan A, Harrop J. Clinical outcomes in revision lumbar spine fusions: an observational cohort study. J Neurosurg Spine 2021; 35:437-445. [PMID: 34359034 DOI: 10.3171/2020.12.spine201908] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors compared primary lumbar spine fusions with revision fusions by using patient Oswestry Disability Index (ODI) scores to evaluate the impact of the North American Spine Society (NASS) evidence-based medicine (EBM) lumbar fusion indications on patient-reported outcome measures of revision surgeries. METHODS This study was a retrospective analysis of a prospective observational cohort of patients who underwent elective lumbar fusion between January 2018 and December 2019 at a single quaternary spine surgery service and had a minimum of 6 months of follow-up. A prospective quality improvement database was constructed that included the data from all elective lumbar spine surgeries, which were categorized prospectively as primary or revision surgeries and EBM-concordant or EBM-discordant revision surgeries based on the NASS coverage EBM policy. In total, 309 patients who met the inclusion criteria were included in the study. The ODIs of all groups (primary, revision, revision EBM concordant, and revision EBM discordant) were statistically compared. Differences in frequencies between cohorts were evaluated using chi-square and Fisher's exact tests. The unpaired 2-tailed Student t-test and the Mann-Whitney U-test for nonparametric data were used to compare continuous variables. Logistic regression was performed to determine the associations between independent variables (surgery status and NASS criteria indications) and functional outcomes. RESULTS Primary lumbar fusions were significantly associated with improved functional outcomes compared with revisions, as evidenced by ODI scores (OR 1.85, 95% CI 1.16-2.95 to achieve a minimal clinically important difference, p = 0.01). The percentage of patients whose functional status had declined at the 6-month postoperative evaluation was significantly higher in patients who had undergone a revision surgery than in those who underwent a primary surgery (23% vs 12.3%, respectively). An increase in ODI score, indicating worse clinical outcome after surgery, was greater in patients who underwent revision procedures (OR 2.14, 95% CI 1.17-3.91, p = 0.0014). Patients who underwent EBM-concordant revision surgery had significantly improved mean ODI scores compared with those who underwent EBM-discordant revision surgery (7.02 ± 5.57 vs -4.6 ± 6.54, p < 0.01). CONCLUSIONS The results of this prospective quality improvement program investigation illustrate that outcomes of primary lumbar fusions were superior to outcomes of revisions. However, revision procedures that met EBM guidelines were associated with greater improvements in ODI scores, which indicates that the use of defined EBM guideline criteria for reoperation can improve clinical outcomes of revision lumbar fusions.
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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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Abstract
This chapter provides an overview of the growth factors active in bone regeneration and healing. Both normal and impaired bone healing are discussed, with a focus on the spatiotemporal activity of the various growth factors known to be involved in the healing response. The review highlights the activities of most important growth factors impacting bone regeneration, with a particular emphasis on those being pursued for clinical translation or which have already been marketed as components of bone regenerative materials. Current approaches the use of bone grafts in clinical settings of bone repair (including bone grafts) are summarized, and carrier systems (scaffolds) for bone tissue engineering via localized growth factor delivery are reviewed. The chapter concludes with a consideration of how bone repair might be improved in the future.
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Chen CH, Hsu EL, Stupp SI. Supramolecular self-assembling peptides to deliver bone morphogenetic proteins for skeletal regeneration. Bone 2020; 141:115565. [PMID: 32745692 PMCID: PMC7680412 DOI: 10.1016/j.bone.2020.115565] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Abstract
Recombinant human bone morphogenetic proteins (BMPs) have shown clinical success in promoting bone healing, but they are also associated with unwanted side effects. The development of improved BMP carriers that can retain BMP at the defect site and maximize its efficacy would decrease the therapeutic BMP dose and thus improve its safety profile. In this review, we discuss the advantages of using self-assembling peptides, a class of synthetic supramolecular biomaterials, to deliver recombinant BMPs. Peptide amphiphiles (PAs) are a broad class of self-assembling peptides, and the use of PAs for BMP delivery and bone regeneration has been explored extensively over the past decade. Like many self-assembling peptide systems, PAs can be designed to form nanofibrous supramolecular biomaterials in which molecules are held together by non-covalent bonds. Chemical and biological functionality can be added to PA nanofibers, through conjugation of chemical moieties or biological epitopes to PA molecules. For example, PA nanofibers have been designed to bind heparan sulfate, a natural polysaccharide that is known to bind BMPs and potentiate their signal. Alternatively, PA nanofibers have been designed to synthetically mimic the structure and function of heparan sulfate, or to directly bind BMP specifically. In small animal models, these bio-inspired PA materials have shown the capacity to promote bone regeneration using BMP at doses 10-100 times lower than established therapeutic doses. These promising results have motivated further evaluation of PAs in large animal models, where their safety and efficacy must be established before clinical translation. We conclude with a discussion on the possiblity of combining PAs with other materials used in orthopaedic surgery to maximize their utility for clinical translation.
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Affiliation(s)
- Charlotte H Chen
- Simpson Querrey Institute, Northwestern University, 303 East Superior Street, Chicago, IL 60611, USA; Department of Materials Science and Engineering, Northwestern University, 2220 Campus Drive, Evanston, IL 60208, USA
| | - Erin L Hsu
- Simpson Querrey Institute, Northwestern University, 303 East Superior Street, Chicago, IL 60611, USA; Department of Orthopaedic Surgery, Northwestern University, 676 North St. Clair Street, Chicago, IL 60611, USA
| | - Samuel I Stupp
- Simpson Querrey Institute, Northwestern University, 303 East Superior Street, Chicago, IL 60611, USA; Department of Materials Science and Engineering, Northwestern University, 2220 Campus Drive, Evanston, IL 60208, USA; Department of Chemistry, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA; Department of Biomedical Engineering, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA; Department of Medicine, Northwestern University, 676 North St. Clair Street, 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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14
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Driscoll JA, Lubbe R, Jakus AE, Chang K, Haleem M, Yun C, Singh G, Schneider AD, Katchko KM, Soriano C, Newton M, Maerz T, Li X, Baker K, Hsu WK, Shah RN, Stock SR, Hsu EL. 3D-Printed Ceramic-Demineralized Bone Matrix Hyperelastic Bone Composite Scaffolds for Spinal Fusion. Tissue Eng Part A 2019; 26:157-166. [PMID: 31469055 DOI: 10.1089/ten.tea.2019.0166] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Although numerous spinal biologics are commercially available, a cost-effective and safe bone graft substitute material for spine fusion has yet to be proven. In this study, "3D-Paints" containing varying volumetric ratios of hydroxyapatite (HA) and human demineralized bone matrix (DBM) in a poly(lactide-co-glycolide) elastomer were three-dimensional (3D) printed into scaffolds to promote osteointegration in rats, with an end goal of spine fusion without the need for recombinant growth factor. Spine fusion was evaluated by manual palpation, and osteointegration and de novo bone formation within scaffold struts were evaluated by laboratory and synchrotron microcomputed tomography and histology. The 3:1 HA:DBM composite achieved the highest mean fusion score and fusion rate (92%), which was significantly greater than the 3D printed DBM-only scaffold (42%). New bone was identified extending from the host transverse processes into the scaffold macropores, and osteointegration scores correlated with successful fusion. Strikingly, the combination of HA and DBM resulted in the growth of bone-like spicules within the DBM particles inside scaffold struts. These spicules were not observed in DBM-only scaffolds, suggesting that de novo spicule formation requires both HA and DBM. Collectively, our work suggests that this recombinant growth factor-free composite shows promise to overcome the limitations of currently used bone graft substitutes for spine fusion. Impact Statement Currently, there exists a no safe, yet highly effective, bone graft substitute that is well accepted for use in spine fusion procedures. With this work, we show that a three-dimensional printed scaffold containing osteoconductive hydroxyapatite and osteoinductive demineralized bone matrix that promotes new bone spicule formation, osteointegration, and successful fusion (stabilization) when implemented in a preclinical model of spine fusion. Our study suggests that this material shows promise as a recombinant growth factor-free bone graft substitute that could safely promote high rates of successful fusion and improve patient care.
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Affiliation(s)
- J Adam Driscoll
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | - Ryan Lubbe
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | - Adam E Jakus
- Simpson Querrey Institute, Chicago, Illinois.,Department of Materials Science and Engineering, Northwestern University Evanston, Illinois.,Transplant Division, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Kevin Chang
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | - Meraaj Haleem
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | - Chawon Yun
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | - Gurmit Singh
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | - Andrew D Schneider
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | - Karina M Katchko
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | | | - Michael Newton
- Orthopaedic Research Laboratory, Beaumont Health, Royal Oak, Michigan
| | - Tristan Maerz
- Orthopaedic Research Laboratory, Beaumont Health, Royal Oak, Michigan.,Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Xin Li
- Simpson Querrey Institute, Chicago, Illinois
| | - Kevin Baker
- Orthopaedic Research Laboratory, Beaumont Health, Royal Oak, Michigan.,Department of Orthopaedic Surgery, Oakland University-William Beaumont School of Medicine, Rochester, Michigan
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
| | - Ramille N Shah
- Simpson Querrey Institute, Chicago, Illinois.,Department of Materials Science and Engineering, Northwestern University Evanston, Illinois.,Transplant Division, Department of Surgery, Northwestern University, Chicago, Illinois.,Orthopaedic Research Laboratory, Beaumont Health, Royal Oak, Michigan.,Department of Biomedical Engineering, Northwestern University, Evanston, Illinois
| | - Stuart R Stock
- Simpson Querrey Institute, Chicago, Illinois.,Department of Cell and Molecular Biology, Northwestern University, Evanston, Illinois
| | - Erin L Hsu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois.,Simpson Querrey Institute, Chicago, Illinois
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15
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Safaee MM, Dalle Ore CL, Zygourakis CC, Deviren V, Ames CP. Estimating a price point for cost-benefit of bone morphogenetic protein in pseudarthrosis prevention for adult spinal deformity surgery. J Neurosurg Spine 2019; 30:814-821. [PMID: 30849745 DOI: 10.3171/2018.12.spine18613] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 12/17/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Bone morphogenetic protein (BMP) is associated with reduced rates of pseudarthrosis and has the potential to decrease the need for revision surgery. There are limited data evaluating the cost-benefit of BMP for pseudarthrosis-related prevention surgery in adult spinal deformity. METHODS The authors performed a single-center retrospective review of 200 consecutive patients with adult spinal deformity. Demographic data and costs of BMP, primary surgery, and revision surgery for pseudarthrosis were collected. Patients with less than 12 months of follow-up or with infection, tumor, or neuromuscular disease were excluded. RESULTS One hundred fifty-one patients (107 [71%] women) with a mean age of 65 years met the inclusion criteria. The mean number of levels fused was 10; BMP was used in 98 cases (65%), and the mean follow-up was 23 months. Fifteen patients (10%) underwent surgical revision for pseudarthrosis; BMP use was associated with an 11% absolute risk reduction in the rate of reoperation (17% vs 6%, p = 0.033), with a number needed to treat of 9.2. There were no significant differences in age, sex, upper instrumented vertebra, or number of levels fused in patients who received BMP. In a multivariate model including age, sex, number of levels fused, and the upper instrumented vertebra, only BMP (OR 0.250, 95% CI 0.078-0.797; p = 0.019) was associated with revision surgery for pseudarthrosis. The mean direct cost of primary surgery was $87,653 ± $19,879, and the mean direct cost of BMP was $10,444 ± $4607. The mean direct cost of revision surgery was $52,153 ± $26,985. The authors independently varied the efficacy of BMP, cost of BMP, and cost of reoperation by ± 50%; only reductions in the cost of BMP resulted in a cost savings per 100 patients. Using these data, the authors estimated a price point of $5663 in order for BMP to be cost-neutral. CONCLUSIONS Use of BMP was associated with a significant reduction in the rates of revision surgery for pseudarthrosis. At its current price, the direct in-hospital costs for BMP exceed the costs associated with revision surgery; however, this likely underestimates the true value of BMP when considering the savings associated with reductions in rehabilitation, therapy, medication, and additional outpatient costs.
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Affiliation(s)
| | | | - Corinna C Zygourakis
- 2Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Vedat Deviren
- 3Orthopedic Surgery, University of California, San Francisco, California; and
| | - Christopher P Ames
- Departments of1Neurological Surgery and
- 3Orthopedic Surgery, University of California, San Francisco, California; and
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Turel MK, Kerolus M, Deutsch H. Minimally Invasive Sacroiliac Fixation for Extension of Fusion in Cases of Failed Lumbosacral Fusion. J Neurosci Rural Pract 2018; 9:574-577. [PMID: 30271052 PMCID: PMC6126316 DOI: 10.4103/jnrp.jnrp_18_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Sacroiliac fusion and instrumentation extension for correction of failed lumbosacral fusions traditionally requires a long revision surgery. Reopening of the prior surgical incision to expose the prior instrumentation requires a large incision with increased blood loss, increased operative time, increased risk of infection, and longer hospitalization times. We describe the first case series using a minimally invasive surgical sacroiliac screw technique for extension of a prior fusion to the pelvis. Using two small 3-cm paramedian incisions on each side, we were able to obtain autologous iliac crest bone graft, place the sacroiliac screw minimally invasive, perform an arthrodesis, and connect the prior surgical hardware to the sacroiliac screw safely. A detailed review of surgical technique, clinical cases, and brief review of the literature is discussed.
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Affiliation(s)
- Mazda K Turel
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mena Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Harel Deutsch
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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17
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Gnanasegaran G, Paycha F, Strobel K, van der Bruggen W, Kampen WU, Kuwert T, Van den Wyngaert T. Bone SPECT/CT in Postoperative Spine. Semin Nucl Med 2018; 48:410-424. [PMID: 30193648 DOI: 10.1053/j.semnuclmed.2018.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Back pain is a common problem and the diagnosis and treatment depend on the clinical presentation, yet overlap between pain syndromes is common. Imaging of patients with chronic back pain in both pre- and postoperative scenarios include radiological, radionuclide, and hybrid techniques. In general, these techniques have their own advantages and limitations. The aim of surgery is to eliminate pathologic segmental motion and accompanying symptoms, especially pain. However, surgical procedures are not without complications and localizing the cause of the pain is often challenging. Radiobisphosphonate bone SPECT/CT is reported to be useful in evaluating benign orthopedic conditions and it often provides valuable information such as accurate localization and characterization of bone abnormalities. In this review, routinely used spinal surgical techniques and procedures are discussed, as well as the acute and delayed complications related to spinal surgery, the role of conventional imaging, and the potential uses of radionuclide bone SPECT/CT to diagnose pseudoarthrosis, cage subsidence, loosening and misalignment, hardware failure, and postoperative infection.
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Affiliation(s)
- Gopinath Gnanasegaran
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, UK..
| | - Frédéric Paycha
- Department of Nuclear Medicine, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Klaus Strobel
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Wouter van der Bruggen
- Department of Radiology and Nuclear Medicine, Slingeland Hospital, Doetinchem, The Netherlands
| | | | - Torsten Kuwert
- Clinic of Nuclear Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium.; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
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18
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Yun DJ, Yu JW, Jeon SH, Lee HC, Lee SH. Salvage Anterior Lumbar Interbody Fusion for Pseudoarthrosis After Posterior or Transforaminal Lumbar Interbody Fusion: A Review of 10 Patients. World Neurosurg 2018; 111:e746-e755. [DOI: 10.1016/j.wneu.2017.12.155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 12/01/2022]
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Abstract
STUDY DESIGN Retrospective observational study. OBJECTIVE We investigated whether bone turnover markers could be a useful indicator for prediction of nonunion. SUMMARY OF BACKGROUND DATA Nonunion is a major complication of lumbar spinal fusion surgery. The involvement of bone turnover in the process of bony union in spinal fusion surgery is, however, poorly understood. METHODS Of the 74 patients analyzed, 13 were diagnosed with nonunion. We evaluated the significance of the following risk factors: age, sex, number of fused segments, serum levels of total alkaline phosphatase, procollagen type 1 amino-terminal propeptide (P1NP), tartrate-resistant acid phosphatase 5b (TRACP-5b), and albumin, and history of diabetes mellitus, cigarette smoking, or alcohol use. We also defined the bone turnover ratio (BTR) as a value that equals serum TRACP-5b concentration divided by serum P1NP concentration to evaluate patients' individual bone turnover balance and investigated the significance of BTR as a risk factor. RESULTS Univariate analysis showed that older age, malnutrition, and lower P1NP are risk factors for nonunion. Stepwise logistic regression analysis revealed that in the presence of lower P1NP, higher TRACP-5b becomes a risk factor. Furthermore, we identified BTR as the most significant risk factor for nonunion. The optimum cut-off value of BTR by receiver-operating characteristic curve was 11.74. CONCLUSION These findings show a relation between bone turnover and nonunion after spinal fusion surgery. The measurement of bone turnover markers could potentially be used to predict nonunion after spinal fusion surgery. LEVEL OF EVIDENCE 4.
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Clough BH, McNeill EP, Palmer D, Krause U, Bartosh TJ, Chaput CD, Gregory CA. An allograft generated from adult stem cells and their secreted products efficiently fuses vertebrae in immunocompromised athymic rats and inhibits local immune responses. Spine J 2017; 17:418-430. [PMID: 27765715 PMCID: PMC5309156 DOI: 10.1016/j.spinee.2016.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 09/21/2016] [Accepted: 10/12/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND CONTEXT Spine pain and the disability associated with it are epidemic in the United States. According to the National Center for Health Statistics, more than 650,000 spinal fusion surgeries are performed annually in the United States, and yet there is a failure rate of 15%-40% when standard methods employing current commercial bone substitutes are used. Autologous bone graft is the gold standard in terms of fusion success, but the morbidity associated with the procedure and the limitations in the availability of sufficient material have limited its use in the majority of cases. A freely available and immunologically compatible bone mimetic with the properties of live tissue is likely to substantially improve the outcome of spine fusion procedures without the disadvantages of autologous bone graft. PURPOSE This study aimed to compare a live human bone tissue analog with autologous bone grafting in an immunocompromised rat model of posterolateral fusion. DESIGN/SETTING This is an in vitro and in vivo preclinical study of a novel human stem cell-derived construct for efficacy in posterolateral lumbar spine fusion. METHODS Osteogenically enhanced human mesenchymal stem cells (OEhMSCs) were generated by exposure to conditions that activate the early stages of osteogenesis. Immunologic characteristics of OEhMSCs were evaluated in vitro. The secreted extracellular matrix from OEhMSCs was deposited on a clinical-grade gelatin sponge, resulting in bioconditioned gelatin sponge (BGS). Bioconditioned gelatin sponge was used alone, with live OEhMSCs (BGS+OEhMSCs), or with whole human bone marrow (BGS+hBM). Efficacy for spine fusion was determined by an institutionally approved animal model using 53 nude rats. RESULTS Bioconditioned gelatin sponge with live OEhMSCs did not cause cytotoxicity when incubated with immunologically mismatched lymphocytes, and OEhMSCs inhibited lymphocyte expansion in mixed lymphocyte assays. Bioconditioned gelatin sponge with live OEhMSC and BGS+hBM constructs induced profound bone growth at fusion sites in vivo, with a comparable rate of fusion with syngeneic bone graft (negative [0 of 10], BGS alone [0 of 10], bone graft [7 of 10], BGS+OEhMSC [10 of 15], and BGS+hBM [8 of 8]). CONCLUSIONS Collectively, these studies demonstrate that BGS+OEhMSC constructs possess low immunogenicity and drive vertebral fusion with efficiency matching syngeneic bone graft in rodents. We also demonstrate that BGS serves as a promising scaffold for spine fusion when combined with hBM.
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Affiliation(s)
- Bret H. Clough
- Institute for Regenerative Medicine, Texas A&M Health Science Center, 206 Olsen Blvd, Room 228 MS1114, College Station, TX 77845, USA
| | - Eoin P. McNeill
- Institute for Regenerative Medicine, Texas A&M Health Science Center, 206 Olsen Blvd, Room 228 MS1114, College Station, TX 77845, USA
| | - Daniel Palmer
- Institute for Regenerative Medicine, Texas A&M Health Science Center, 206 Olsen Blvd, Room 228 MS1114, College Station, TX 77845, USA
| | - Ulf Krause
- Department of Orthopedic Surgery, Baylor Scott and White Hospital, Texas A&M Health Science Center, 2401 S. 31st St, Temple, TX 76508, USA,Institute for Transfusion Medicine and Transplant Immunology, University Hospital Muenster, 11 Domagkstr, Muenster 48149, Germany
| | - Thomas J. Bartosh
- Institute for Regenerative Medicine, Texas A&M Health Science Center, 206 Olsen Blvd, Room 228 MS1114, College Station, TX 77845, USA
| | - Christopher D. Chaput
- Department of Orthopedic Surgery, Baylor Scott and White Hospital, Texas A&M Health Science Center, 2401 S. 31st St, Temple, TX 76508, USA
| | - Carl A. Gregory
- Institute for Regenerative Medicine, Texas A&M Health Science Center, 206 Olsen Blvd, Room 228 MS1114, College Station, TX 77845, USA,Corresponding author. Institute for Regenerative Medicine, Texas A&M Health Science Center, 206 Olsen Blvd, Room 228 MS1114, College Station, TX 77845, USA. Tel.: (979) 436-9643; fax: (979) 436-9679. (C.A. Gregory)
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Mobbs RJ, Phan K, Thayaparan GK, Rao PJ. Anterior Lumbar Interbody Fusion as a Salvage Technique for Pseudarthrosis following Posterior Lumbar Fusion Surgery. Global Spine J 2016; 6:14-20. [PMID: 26835197 PMCID: PMC4733375 DOI: 10.1055/s-0035-1555656] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 04/08/2015] [Indexed: 11/08/2022] Open
Abstract
Study Design Retrospective analysis of prospectively collected observational data. Objective To assess the safety and efficacy of anterior lumbar interbody fusion (ALIF) as a salvage option for lumbar pseudarthrosis following failed posterior lumbar fusion surgery. Methods From 2009 to 2013, patient outcome data was collected prospectively over 5 years from 327 patients undergoing ALIF performed by a single surgeon (R.J.M.) with 478 levels performed. Among these, there were 20 cases of failed prior posterior fusion that subsequently underwent ALIF. Visual analog score (VAS), Oswestry Disability Index (ODI), and Short Form 12-item health survey (SF-12) were measured pre- and postoperatively. The verification of fusion was determined by utilizing a fine-cut computed tomography scan at 12-month follow-up. Results There was a significant difference between the preoperative (7.25 ± 0.8) and postoperative (3.1 ± 2.1) VAS scores (p < 0.0001). The ODI scale also demonstrated a statistically significant reduction from preoperative (56.3 ± 16.5) and postoperative (30.4 ± 19.3) scores (p < 0.0001). The SF-12 scores were significantly improved after ALIF salvage surgery: Physical Health Composite Score (32.18 ± 5.5 versus 41.07 ± 9.67, p = 0.0003) and Mental Health Composite Score (36.62 ± 12.25 versus 50.89 ± 10.86, p = 0.0001). Overall, 19 patients (95%) achieved successful fusion. Conclusions Overall, our results suggest that the ALIF procedure results not only in radiographic improvements in bony fusion but in significant improvements in the patient's physical and mental experience of pain secondary to lumbar pseudarthrosis. Future multicenter registry studies and randomized controlled trials should be conducted to confirm the long-term benefit of ALIF as a salvage option for failed posterior lumbar fusion.
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Affiliation(s)
- Ralph J. Mobbs
- Neurospine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, New South Wales, Australia,NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia,Address for correspondence Ralph J. Mobbs, MBBS, FRACS, MD Neurospine Clinic, Prince of Wales Private HospitalRandwick, Sydney, NSW 2031Australia
| | - Kevin Phan
- Neurospine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, New South Wales, Australia,NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia
| | - Ganesha K. Thayaparan
- Neurospine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, New South Wales, Australia
| | - Prashanth J. Rao
- Neurospine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, New South Wales, Australia,NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia
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Vitamin D Levels and 1-Year Fusion Outcomes in Elective Spine Surgery: A Prospective Observational Study. Spine (Phila Pa 1976) 2015; 40:1536-41. [PMID: 26165222 DOI: 10.1097/brs.0000000000001041] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE To investigate the association of perioperative vitamin D levels and nonunion rates and time to fusion in patients undergoing elective spine fusion. SUMMARY OF BACKGROUND DATA Although there is a clear link between bone mineral density and the risk of osteoporosis, it is unclear whether low vitamin D levels affect rates and timing of spinal fusion. METHODS Serum 25-OH vitamin D levels were measured perioperatively in adults undergoing elective spinal fusion between 2011 and 2012. Vitamin D levels <20 ng/mL were considered deficient. Univariate and multivariate logistic regression were performed to identify independent predictors of pseudarthrosis/nonunion within a minimum follow-up period of 12 months. Kaplan-Meier analysis was used to compare time to fusion between groups. RESULTS Of the 133 patients, 31 (23%) demonstrated vitamin D deficiency. Mean patient age was 57 ± 13 years; 44% were female and 94% were Caucasian. The cervical spine was fused in 49%, the lumbar spine in 47%, and the thoracic spine in 4%. Mean construct length was 2 levels (range 1-16). At 12-month follow-up, 112/133 (84%) patients demonstrated fusion (median time to fusion 8.4 mo). Nonunion at 12 months was associated with vitamin D deficiency (20% of patients with adequate vitamin D level vs. 38% of vitamin D-deficient patients, P = 0.063). Kaplan-Meier survival analysis demonstrated time to fusion was significantly longer in the vitamin D-deficient group (12 vs. 6 mo, P = 0.001). On multivariate analysis, vitamin D deficiency was an independent predictor of nonunion (odds ratio 3.449, P = 0.045) when adjusted for age, sex, obesity, fusion length, location, graft type, smoking, and bone morphogenetic protein use. CONCLUSION Vitamin D levels may affect nonunion rate and time to fusion. These results offer insight into the importance of the metabolic milieu for bony fusion as well as a potential avenue for therapeutic intervention. LEVEL OF EVIDENCE 3.
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Rao PJ, Loganathan A, Yeung V, Mobbs RJ. Outcomes of anterior lumbar interbody fusion surgery based on indication: a prospective study. Neurosurgery 2015; 76:7-23; discussion 23-4. [PMID: 25255259 DOI: 10.1227/neu.0000000000000561] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is limited information on clinical outcomes after anterior lumbar interbody fusion (ALIF) based on the indications for surgery. OBJECTIVE To compare the clinical and radiological outcomes of ALIF for each surgical indication. METHODS This prospective clinical study included 125 patients who underwent ALIF over a 2-year period. The patients were evaluated preoperatively and postoperatively. Outcome measures included the Short Form-12, Oswestry Disability Index, Visual Analog Scale, and Patient Satisfaction Index. RESULTS After a mean follow-up of 20 months, the clinical condition of the patients was significantly better than their preoperative status across all indications. A total of 108 patients had a Patient Satisfaction Index score of 1 or 2, indicating a successful clinical outcome in 86%. Patients with degenerative disk disease (with and without radiculopathy), spondylolisthesis, and scoliosis had the best clinical response to ALIF, with statistically significant improvement in the Short Form-12, Oswestry Disability Index, and Visual Analog Scale. Failed posterior fusion and adjacent segment disease showed statistically significant improvement in all of these clinical outcome scores, although the mean changes in the Short Form-12 Mental Component Summary, Oswestry Disability Index, and Visual Analog Scale (back pain) were lower. The overall radiological fusion rate was 94.4%. Superior radiological outcomes (fusion >90%) were observed in patients with degenerative disk disease (with and without radiculopathy), spondylolisthesis, and failed posterior fusion, whereas in adjacent segment disease, it was 80%. CONCLUSION ALIF is an effective treatment for degenerative disk disease (with and without radiculopathy) and spondylolisthesis. Although results were promising for scoliosis, failed posterior fusion, and adjacent segment disease, further studies are necessary to establish the effectiveness of ALIF in these conditions.
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Affiliation(s)
- Prashanth J Rao
- *Neurospine Clinic, Randwick, Sydney, New South Wales, Australia; ‡Prince of Wales Hospital, Randwick, Sydney, New South Wales, Australia; §University of New South Wales, Sydney, Australia
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Abstract
BACKGROUND CONTEXT Revision surgery for pseudarthrosis after a lumbar spinal fusion has unpredictable functional results. PURPOSE The aim of this study was to determine the clinical outcomes of revision surgery to fuse the pseudarthrosis site based on the two most common diagnoses (degenerative disc disease [DDD] vs. spondylolisthesis). STUDY DESIGN Patients who had a revision surgery between 1995 and 2004 for lumbar pseudarthrosis after short segment lumbar spinal fusion were identified through the institution's Spine Center surgery database. A retrospective chart review of clinical, hospital, and anesthesia records was then performed. PATIENT SAMPLE Sixty-six patients were included in the study (28 patients with DDD and 38 patients with spondylolisthesis). Inclusion criteria were a surgical diagnosis of pseudarthrosis with a prior fusion of one or two motion segments, minimum 24 months of follow-up, and a diagnosis of either symptomatic DDD or spondylolisthesis as the primary indication for the index fusion surgery. OUTCOME MEASURES The Oswestry disability index (ODI) and a self-assessment questionnaire were used to evaluate clinical outcomes. METHODS A retrospective chart and radiographic review was performed. Statistical analysis was done using Student t test for ODI scores and chi-square test for discrete variables from the outcome questionnaires. RESULTS Follow-up radiographs were available for 64 patients (97%), and a fusion rate of 100% was found in both groups for the radiographs examined. The mean postoperative ODI score was 53.3 (30-84.4) for DDD patients and 37.2 (2.5-76) for the spondylolisthesis group (p<.01). Only 50% of the patients in the DDD group felt that their overall well-being had improved since the surgery. In the spondylolisthesis group, 64% of patients stated that their overall well-being had improved since their revision surgery. CONCLUSIONS The clinical outcomes after revision surgery for pseudarthrosis are worse in patients with DDD compared with spondylolisthesis despite successful repair of nonunion. Risks and benefits should be well discussed with the patients before deciding on surgical treatment for the management of pseudarthrosis, especially in patients with previous short-segment fusions done for DDD.
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25
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Will immediate postoperative imbalance improve in patients with thoracolumbar/lumbar degenerative kyphoscoliosis? A comparison between Smith-Petersen osteotomy and pedicle subtraction osteotomy with an average 4 years of follow-up. Spine (Phila Pa 1976) 2015; 40:E293-300. [PMID: 25901984 DOI: 10.1097/brs.0000000000000744] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective radiographical study. OBJECTIVE To compare compensatory behavior of coronal and sagittal alignment after pedicle subtraction osteotomy (PSO) and Smith-Petersen osteotomy (SPO) for degenerative kyphoscoliosis. SUMMARY OF BACKGROUND DATA There was a paucity of literature paying attention to the postoperative imbalance after PSO or SPO and natural evolution of the imbalance. METHODS A retrospective study was performed on 68 consecutive patients with degenerative kyphoscoliosis treated by lumbar PSO (25 patients) or SPO (43 patients) procedures at a single institution. Long-cassette standing radiographs were taken preoperatively, postoperatively, and at the last follow-up and radiographical parameters were measured. The lower instrumented vertebral level and level of osteotomy were compared between the patients with and without improvement. RESULTS Negative sagittal vertical axis (SVA) was observed in the PSO group postoperatively, implying an overcorrection of SVA. This negative SVA improved spontaneously during follow-up (P < 0.05). Coronal balance was found to worsen immediately postoperatively in the SPO group (P < 0.05). At the last follow-up, spontaneous improvement was observed in 15 patients and the average coronal balance decreased to 16.35 mm. For the 15 patients with improved coronal balance, fusion at L5 or above was more common compared with the 11 patients with persisted postoperative imbalance (P = 0.027), whereas no difference in term of levels of osteotomy was found (P > 0.05). CONCLUSION The overcorrection of SVA is more often seen in the PSO group. The coronal imbalance is more likely to occur in the SPO group. The postoperative sagittal imbalance often spontaneously improves with time. Lower instrumented vertebra at S1 or with pelvic fixation should be regarded as potential risk factors for persistent coronal imbalance in patients with SPO. LEVEL OF EVIDENCE 3.
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Lumbar transpedicular implant failure: a clinical and surgical challenge and its radiological assessment. Asian Spine J 2014; 8:281-97. [PMID: 24967042 PMCID: PMC4068848 DOI: 10.4184/asj.2014.8.3.281] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 06/29/2013] [Accepted: 07/04/2013] [Indexed: 11/08/2022] Open
Abstract
Study Design It is a multicenter, controlled case study review of a big scale of pedicle-screw procedures from January 2000 to June 2010. The outcomes were compared to those with no implant failure. Purpose The purpose of this study was to review retrospectively the outcome of 100 patients with implant failure in comparison to 100 control-patients, and to study the causes of failure and its prevention. Overview of Literature Transpedicular fixation is associated with risks of hardware failure, such as screw/rod breakage and/or loosening at the screw-rod interface and difficulties in the system assembly, which remain a significant clinical problem. Removal or revision of the spinal hardware is often required. Methods Two hundred patients (88 women, 112 men) were divided into 2 major groups, with 100 patients in group I (implant failure group G1) and 100 patients in group II (successful fusion, control group G2). We subdivided the study groups into two subgroups: subgroup a (single-level instrumented group) and subgroup b (multilevel instrumented group). The implant status was assessed based on intraoperative and follow-up radiographs. Results Implant failure in general was present in 36% in G1a, and in 64% in G1b, and types of implant failure included screw fracture (34%), rod fracture (24%), rod loosening (22%), screw loosening (16%), and failure of both rod and screw (4%). Most of the failures (90%) occurred within 6 months after surgery, with no reported cases 1 year postoperatively. Conclusions We tried to address the problem and study the causes of failure, and proposed solutions for its prevention.
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Mobbs RJ, Loganathan A, Yeung V, Rao PJ. Indications for anterior lumbar interbody fusion. Orthop Surg 2013; 5:153-63. [PMID: 24002831 PMCID: PMC6583544 DOI: 10.1111/os.12048] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 12/26/2012] [Indexed: 01/20/2023] Open
Abstract
Anterior lumbar interbody fusion (ALIF) has become a widely recognized surgical technique for degenerative pathology of the lumbar spine. Spinal fusion has evolved dramatically ever since the first successful internal fixation by Hadra in 1891 who used a posterior approach to wire adjacent cervical vertebrae in the treatment of fracture-dislocation. Advancements were made to reduce morbidity including bone grafting substitutes, metallic hardware instrumentation and improved surgical technique. The controversy regarding which surgical approach is best for treating various pathologies of the lumbar spine still exists. Despite being an established treatment modality, current indications of ALIF are yet to be clearly defined in the literature. This article discusses the current literature on indications on ALIF surgery.
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Affiliation(s)
- Ralph J Mobbs
- NeuroSpineClinic, Prince of Wales Private Hospital, Randwick, Sydney, Australia.
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Papadakis M, Aggeliki L, Papadopoulos EC, Girardi FP. Common surgical complications in degenerative spinal surgery. World J Orthop 2013; 4:62-6. [PMID: 23610753 PMCID: PMC3631953 DOI: 10.5312/wjo.v4.i2.62] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 11/26/2012] [Accepted: 12/23/2012] [Indexed: 02/06/2023] Open
Abstract
The rapid growth of spine degenerative surgery has led to unrelenting efforts to define and prevent possible complications, the incidence of which is probably higher than that reported and varies according to the region of the spine involved (cervical and thoracolumbar) and the severity of the surgery. Several issues are becoming progressively clearer, such as complication rates in primary versus revision spinal surgery, complications in the elderly, the contribution of minimally invasive surgery to the reduction of complication rate. In this paper the most common surgical complications in degenerative spinal surgery are outlined and discussed.
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Salvage of lumbar pseudarthrosis with customized large-diameter pedicle screws: report of two cases. Spine (Phila Pa 1976) 2011; 36:E1489-92. [PMID: 21358490 DOI: 10.1097/brs.0b013e31820285cf] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A report of two cases using custom-manufactured pedicle screws for revision spinal arthrodesis for pseudarthrosis in the setting of widely dilated pedicle screw tracts. OBJECTIVE To present surgical outcomes of a previously unreported treatment for pseudarthrosis with widely dilated pedicle screw tracts. SUMMARY OF BACKGROUND DATA Techniques for revision of lumbar pseudarthrosis with severe screw loosening and widely dilated pedicle screw tracts represent a challenging clinical scenario. If stable fixation cannot be achieved, fixation may fail or adjacent normal levels may need to be included in the construct. METHODS Two patients presenting with painful pseudarthrosis after lumbar spinal fusion and instrumentation loosening with widely dilated pedicle screw tracts were treated with revision anterior and posterior spinal fusion using custom-manufactured large-diameter pedicle screws. RESULTS In both cases, the custom-manufactured pedicle screws achieved excellent purchase in the dilated pedicle screw tract. Both patients went on to solid fusion at 1 year after surgery. CONCLUSION This is a previously unreported technique for revision spinal fusion in the setting of loose instrumentation with widely dilated pedicle screw tracts.
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Ploumis A, Wu C, Mehbod A, Fischer G, Faundez A, Wu W, Transfeldt E. Revision of transforaminal lumbar interbody fusion using anterior lumbar interbody fusion: a biomechanical study in nonosteoporotic bone. J Neurosurg Spine 2010; 12:82-7. [DOI: 10.3171/2009.7.spine0921] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Transforaminal lumbar interbody fusion (TLIF) is a popular fusion technique for treating chronic low-back pain. In cases of interbody nonfusion, revision techniques for TLIF include anterior lumbar interbody fusion (ALIF) approaches. Biomechanical data of the revision techniques are not available. The purpose of this study was to compare the immediate construct stability, in terms of range of motion (ROM) and neutral zone (NZ), of a revision ALIF procedure for an unsuccessful TLIF. An in vitro biomechanical comparison of TLIF and its ALIF revision procedure was conducted on cadaveric nonosteoporotic human spine segments.
Methods
Twelve cadaveric lumbar motion segments with normal bone mineral density were loaded in unconstrained axial torsion, lateral bending, and flexion-extension under 0.05 Hz and ± 6-nm sinusoidal waveform. The specimens underwent TLIF (with posterior pedicle fixation) and anterior ALIF (with intact posterior fixation). Multidirectional flexibility testing was conducted following each step. The ROM and NZ data were measured and calculated for each test.
Results
Globally, the TLIF and revision ALIF procedures significantly reduced ROM and NZ compared with that of the intact condition. The revision ALIF procedures achieved similar ROM as the TLIF procedure.
Conclusions
Revision ALIF maintained biomechanical stability of TLIF in nonosteoporotic spines. Revision ALIF can be performed without sacrificing spinal stability in cases of intact posterior instrumentation.
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Affiliation(s)
- Avraam Ploumis
- 1‘S. Niarchos’ Rehab Unit/Orthopaedic Department, University Hospital of Ioannina, Ioannina, Greece
| | - Chunhui Wu
- 2Foundation for the Advancement of Spinal Knowledge, and
| | - Amir Mehbod
- 3Twin Cities Spine Center, Minneapolis, Minnesota
| | | | - Antonio Faundez
- 5Department of Orthopaedic Surgery, Hôpitaux Universitaires de Genève, Geneva, Switzerland; and
| | - Wentien Wu
- 6Buddhist TzuChi General Hospital, Taiwan, Republic of China
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Abe Y, Takahata M, Ito M, Irie K, Abumi K, Minami A. Enhancement of graft bone healing by intermittent administration of human parathyroid hormone (1-34) in a rat spinal arthrodesis model. Bone 2007; 41:775-85. [PMID: 17707711 DOI: 10.1016/j.bone.2007.06.025] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Revised: 05/29/2007] [Accepted: 06/27/2007] [Indexed: 01/06/2023]
Abstract
Bone grafting is commonly used to treat skeletal disorders associated with large bone defect or unstable joint. It can take several months, however, to achieve a solid union and bony fusion sometimes delays or fails especially in osteoporosis patients. Therefore, we used a rat spinal arthrodesis model to examine whether intermittent administration of human PTH(1-34) accelerates bone graft healing. Eighty-two male Sprague-Dawley rats underwent posterolateral spinal arthrodesis surgery using autologous bone grafts. Animals were given daily subcutaneous injections of hPTH(1-34) (40 microg/kg/day PTH group) or 0.9% saline vehicle (control group) from immediately after surgery till death. Five rats each were killed 2, 4, 7, and 14 days after the surgery, and mRNA expression analysis was performed on harvested grafted bone. Seven rats each were killed 14, 28, and 42 days after the surgery, and the lumbar spine, which contained the grafted spinal segment, was subjected to fusion assessment, microstructural analysis using three-dimensional micro-computed tomography, and histologic examination. Serum bone metabolism markers were analyzed. The results indicated that PTH administration decreased the time required for graft bone healing and provided a structurally superior fusion mass in the rat spinal arthrodesis model. PTH administration increased the fusion rate on day 14 (14% in the control group and 57% in the PTH group), accelerated grafted bone resorption, and produced a larger and denser fusion mass compared to control. mRNA expression of both osteoblast- and osteoclast-related genes was upregulated by PTH treatment, and serum bone formation and resorption marker levels were higher in the PTH group than in the control group. Histologically calculated mineral apposition rate, mineralized surface and osteoclast surface were also higher in the PTH group than in the control group. These findings suggest that intermittent administration of PTH(1-34) enhanced bone turn over dominantly on bone formation at the graft site, leading to the acceleration of the spinal fusion. Based on the results of this study, intermittent injection of hPTH(1-34) might be an efficient adjuvant intervention in spinal arthrodesis surgery and all other skeletal reconstruction surgeries requiring bone grafts.
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Affiliation(s)
- Yuichiro Abe
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15 Nishi-7, Sapporo, Japan
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