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Ozer AF, Akgun MY, Ucar EA, Hekimoglu M, Basak AT, Gunerbuyuk C, Toklu S, Oktenoglu T, Sasani M, Akgul T, Ates O. Can Dynamic Spinal Stabilization Be an Alternative to Fusion Surgery in Adult Spinal Deformity Cases? Int J Spine Surg 2024; 18:152-163. [PMID: 38561203 PMCID: PMC11287803 DOI: 10.14444/8588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Rigid stabilization and fusion surgery are widely used for the correction of spinal sagittal and coronal imbalance (SCI). However, instrument failure, pseudoarthrosis, and adjacent segment disease are frequent complications of rigid stabilization and fusion surgery in elderly patients. In this study, we present the results of dynamic stabilization and 2-stage dynamic stabilization surgery for the treatment of spinal SCI. The advantages and disadvantages are discussed, especially as an alternative to fusion surgery. METHODS In our study, spinal, sagittal, and coronal deformities were corrected with dynamic stabilization performed in a single session in patients with good bone quality (without osteopenia and osteoporosis), while 2-stage surgery was performed in patients with poor bone quality (first stage: percutaneous placement of screws; second stage: placement of dynamic rods and correction of spinal SCI 4-6 months after the first stage). One-stage dynamic spinal instrumentation was applied to 20 of 25 patients with spinal SCI, and 2-stage dynamic spinal instrumentation was applied to the remaining 5 patients. RESULTS Spinal SCI was corrected with these stabilization systems. At 2-year follow-up, no significant loss was observed in the instrumentation system, while no significant loss of correction was observed in sagittal and coronal deformities. CONCLUSION In adult patients with spinal SCI, single or 2-stage dynamic stabilization is a viable alternative to fusion surgery due to the very low rate of instrument failure. CLINICAL RELEVANCE This study questions the use of dynamic stabilization systems for the treatment of adult degenerative deformities. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Ali Fahir Ozer
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
- Spine Center, Koc University Hospital, Istanbul, Turkey
- Bioengineering and Orthopaedic Surgery Colleges of Engineering and Medicine, University of Toledo, Toledo, OH, USA
| | - Mehmet Yigit Akgun
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
- Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Ege Anil Ucar
- Faculty of Medicine, Koc University, Istanbul, Turkey
| | - Mehdi Hekimoglu
- Department of Neurosurgery, American Hospital, Istanbul, Turkey
| | | | | | - Sureyya Toklu
- Department of Neurosurgery, Erzurum Bolge Research and Education Hospital, Erzurum, Turkey
| | - Tunc Oktenoglu
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
- Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Mehdi Sasani
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
- Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Turgut Akgul
- Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Ozkan Ates
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
- Spine Center, Koc University Hospital, Istanbul, Turkey
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Karadag MK, Akgun MY, Basak AT, Ates O, Tepebasili MA, Gunerbuyuk C, Oktenoglu T, Sasani M, Ozer AF. Clinical and radiological analysis of the effects of three different lumbar transpedicular dynamic stabilization system on disc degeneration and regeneration. Front Surg 2023; 10:1297790. [PMID: 38162089 PMCID: PMC10757836 DOI: 10.3389/fsurg.2023.1297790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024] Open
Abstract
Objective This study aims to assess the clinical outcomes of three transpedicular dynamic systems in treating degenerative disc disease and evaluate their impact on both clinical and radiological aspects of the operated and adjacent segments. Materials and methods A total of 111 patients who underwent posterior transpedicular short-segment dynamic system procedures for treatment of degenerative disc disease were included. The patients were categorized into three groups, namely, Group 1 (Dynesys system, n = 38), Group 2 (Safinaz screw + PEEK rod, n = 37), and Group 3 (Safinaz screw + titanium rod, n = 36). Disc regeneration in the operated segment and disc degeneration in the operated, upper, and lower adjacent segments were assessed using the Pfirrmann Classification. Results Postoperatively, a statistically significant difference was observed in visual analog scale and Oswestry Disability Index scores (p < 0.001). However, no statistically significant difference was seen in disc degeneration/regeneration and degeneration scores of the upper and lower adjacent segments between the preoperative and postoperative groups (p = 0.763, p = 0.518, p = 0.201). Notably, a positive effect on disc regeneration at the operated level (32.4%) was observed. No significant differences were found between the groups in terms of operation rates, screw loosening, and screw breakage after adjacent segment disease (p > 0.05). Conclusion In patients without advanced degeneration, all three dynamic systems demonstrated the ability to prevent degeneration in the adjacent and operated segments while promoting regeneration in the operated segment. Beyond inhibiting abnormal movement in painful segments, maintaining physiological motion and providing axial distraction in the operated segment emerged as key mechanisms supporting regeneration.
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Affiliation(s)
| | - Mehmet Yigit Akgun
- Department of Neurosurgery, Koc University Hospital, Istanbul, Türkiye
- Spine Center, Koc University Hospital, Istanbul, Türkiye
| | | | - Ozkan Ates
- Department of Neurosurgery, Koc University Hospital, Istanbul, Türkiye
- Spine Center, Koc University Hospital, Istanbul, Türkiye
| | | | | | - Tunc Oktenoglu
- Department of Neurosurgery, Koc University Hospital, Istanbul, Türkiye
- Spine Center, Koc University Hospital, Istanbul, Türkiye
| | - Mehdi Sasani
- Department of Neurosurgery, Koc University Hospital, Istanbul, Türkiye
- Spine Center, Koc University Hospital, Istanbul, Türkiye
| | - Ali Fahir Ozer
- Department of Neurosurgery, Koc University Hospital, Istanbul, Türkiye
- Spine Center, Koc University Hospital, Istanbul, Türkiye
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Yang S, Sun T, Zhang L, Cong M, Guo A, Liu D, Song M. Stress Distribution of Different Pedicle Screw Insertion Techniques Following Single-Segment TLIF: A Finite Element Analysis Study. Orthop Surg 2023; 15:1153-1164. [PMID: 36855914 PMCID: PMC10102325 DOI: 10.1111/os.13671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVES At present, a variety of posterior lumbar internal fixation implantation methods have been developed, which makes it difficult for spine surgeons to choose. The stress distribution of the internal fixation system is one of the important indexes to evaluate these technologies. Common insertion technologies include Roy Camille, Magerl, Krag, AO, and Weinstein insertion techniques. This study aimed to compare the distribution of von Mises stresses in different screw fixation systems established by these insertion technologies. METHODS Here, the three-dimensional finite element (FE) method was selected to evaluate the postoperative stress distribution of internal fixation. Following different pedicle screw insertion techniques, five single-segment transforaminal lumbar interbody fusion (TLIF) models were established after modeling and validation of the L1-S1 vertebrae FE model. RESULTS By analyzing the data, we found that stress concentration phenomenon was in all the models. Additionally, Roy-Camille, Krag, AO, and Weinstein insertion techniques led to the great stress on lumbar vertebra, intervertebral disc, and screw-rod fixation systems. Therefore, we hope that the results can provide ideas for clinical work and development of pedicle screws in the future. It is worth noting that flexion, unaffected side lateral bending, and affected side axial rotation should be limited for the patients with cages implanted. CONCLUSIONS Overall, our method obtained the results that Magerl insertion technique was the relatively safe approach for pedicle screw implantation due to its relatively dispersive stress in TLIF models.
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Affiliation(s)
- Simengge Yang
- Department of Orthopaedics, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Tianze Sun
- Department of Orthopaedics, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Liwen Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Menglin Cong
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Anyun Guo
- Department of Joint Trauma, General Hospital of Shenzhen University, Shenzhen, China
| | - Dakai Liu
- Department of Orthopaedics, The Second People's Hospital of Dalian, Dalian, China
| | - Mingzhi Song
- Department of Orthopaedics, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Department of Orthopaedics, The Third Affiliated Hospital of Dalian Medical University, Dalian, China
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Kaptan H, Kasimcan Ö, Özyörük Ş, Yılmaz M. Microscopic Unilateral Approach for Bilateral Decompression of Lumbar Spinal Stenosis. ARCHIVES OF IRANIAN MEDICINE 2022; 25:742-747. [PMID: 37543899 PMCID: PMC10685853 DOI: 10.34172/aim.2022.117] [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: 05/23/2021] [Accepted: 11/13/2021] [Indexed: 08/08/2023]
Abstract
BACKGROUND This is a study based on single-surgeon data on spinal stenosis surgery via microscopic approach. The aim is to evaluate the effectiveness of the unilateral approach to bilateral decompression and the usage of Taylor retractors and brain spatula in patients with spinal stenosis. METHODS This is a retrospective study on bilateral decompression for lumbar spinal stenosis using a microscopic unilateral approach by a single surgeon, between April 2015 and March 2018. In total, 50 patients were operated due to single level lumbar spinal stenosis. All patients were evaluated by preoperative and postoperative plain radiographs and magnetic resonance (MR) images. Walking distance (WD), visual analog scale (VAS) for pain and Odom's criteria were evaluated for follow-up. RESULTS One level of the lumbar spine was surgically decompressed in all patients. The median age of patients was 64.6 (51- 82). Of the patients, 72% (36) were women, and 28% (14) were men. Most patients had refractory low back pain (96%) after conservative treatment. The stenotic levels of the cases were as follows: L3-4, 23(46%); L4-5, 24(48%); and L5-S1, 3 (6%). VAS scores decreased in all patients after surgery. According to Odom's criteria, an excellent or good score was found in 43 patients at the 12th follow-up examination. WDs increased up to 1000 meters for 41 patients. CONCLUSION The microscopic unilateral approach to bilateral decompression is an effective method for decompression in spinal stenosis. Via this approach, surgical trauma is reduced and surgically induced instability is avoided as much as possible.
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Affiliation(s)
- Hülagü Kaptan
- DokuzEylül University, Medical School, Department of Neurosurgery, Izmir, Turkey
| | - Ömür Kasimcan
- Istinye University, Medical School, Department of Neurosurgery, Istanbul, Turkey
| | - Şafak Özyörük
- DokuzEylül University, Medical School, Department of Neurosurgery, Izmir, Turkey
| | - Murat Yılmaz
- DokuzEylül University, Medical School, Department of Neurosurgery, Izmir, Turkey
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Karadağ MK, Akıncı AT, Başak AT, Hekimoğlu M, Yıldırım H, Akyoldaş G, Aydın AL, Ateş Ö, Öktenoğlu T, Sasani M, Akgün MY, Günerbüyük C, Özer AF. Preoperative Magnetic Resonance Imaging Abnormalities Predictive of Lumbar Herniation Recurrence After Surgical Repair. World Neurosurg 2022; 165:e750-e756. [PMID: 35803567 DOI: 10.1016/j.wneu.2022.06.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion. METHODS Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form 36. RESULTS Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution. CONCLUSIONS Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen.
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Affiliation(s)
| | - Ahmet Tolgay Akıncı
- Neurosurgery Department, Trakya University School of Medicine, Edirne, Turkey
| | | | - Mehdi Hekimoğlu
- Neurosurgery Department, American Hospital, Istanbul, Turkey
| | - Hakan Yıldırım
- Radiology Department, American Hospital, Istanbul, Turkey
| | - Göktuğ Akyoldaş
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
| | - Ahmet Levent Aydın
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
| | - Özkan Ateş
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
| | - Tunç Öktenoğlu
- Neurosurgery Department, American Hospital, Istanbul, Turkey; Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
| | - Mehdi Sasani
- Neurosurgery Department, American Hospital, Istanbul, Turkey; Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
| | - Mehmet Yiğit Akgün
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
| | - Caner Günerbüyük
- Orthopedics Department, Koc University School of Medicine, Istanbul, Turkey
| | - Ali Fahir Özer
- Neurosurgery Department, American Hospital, Istanbul, Turkey; Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey.
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Özer AF, Başak AT, Özbek MA, Hekimoğlu M, Aydın AL, Ateş Ö, Günerbüyük C, Akgül T, Sasani M, Öktenoğlu T. Lumbar Dynamic Stabilization With 2-Stage Surgery: Early Results. Int J Spine Surg 2022; 16:8306. [PMID: 35728831 PMCID: PMC9421274 DOI: 10.14444/8306] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Screw loosening, which is a major problem in dynamic systems, can be easily overcome with 2-stage surgery. In this article, the clinical and radiological results of patients undergoing dynamic stabilization with a Dynesys device in 2 stages are discussed. METHODS A total of 10 male and 13 female adult patients were included in this single-center retrospective study conducted between 2018 and 2021. The mean age of the patients was 65.6 years. All of the patients had pain complaints that affected their daily lives. Bone density T scores were determined with the dual-energy x-ray absorptiometry method before patients were admitted for surgery. In the first surgery, Dynesys system pedicle screws were inserted. After 6 months of osteointegration, Dynesys system spacers and elastic bandages were placed. Preoperative, early postoperative, and late postoperative visual analog pain scale (VAS) scores and Oswestry Disability Index (ODI) scores were determined and statistically compared. RESULTS Patients were followed for an average of 30 months. Complications and recurrence were not observed. Neurological deficits were not observed after patients recovered from anesthesia. Significant improvement was observed in the ODI and VAS parameters in the preoperative (ODI: 66.2%, VAS: 7.8), early postoperative (ODI: 20.3%, VAS: 2.4), and late postoperative (ODI: 6.8% and VAS: 1.1) periods. Symptomatic improvement was seen in all patients. No screw breakage or loosening was detected by radiological evaluation in any of the patients during the 2-year follow-up period. CONCLUSIONS In our experience, the insufficiency of the proximal and distal end screws is eliminated when 2 stages of dynamic system stabilizations are completed after osteointegration of the screws. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Ali Fahir Özer
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
- Neurosurgery Department, American Hospital, Istanbul, Turkey
| | | | | | - Mehdi Hekimoğlu
- Neurosurgery Department, American Hospital, Istanbul, Turkey
| | - Ahmet Levent Aydın
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
| | - Özkan Ateş
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
| | - Caner Günerbüyük
- Orhopeaedics Department, Koc University School of Medicine, Istanbul, Turkey
| | - Turgut Akgül
- Orhopeaedics Department, Koc University School of Medicine, Istanbul, Turkey
| | - Mehdi Sasani
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
- Neurosurgery Department, American Hospital, Istanbul, Turkey
| | - Tunç Öktenoğlu
- Neurosurgery Department, Koc University School of Medicine, Istanbul, Turkey
- Neurosurgery Department, American Hospital, Istanbul, Turkey
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Özer AF, Akyoldaş G, Çevik OM, Aydın AL, Hekimoğlu M, Sasani M, Öktenoğlu T, Çerezci Ö, Süzer T. Lumbar Foraminal Stenosis Classification That Guides Surgical Treatment. Int J Spine Surg 2022; 16:8311. [PMID: 35710724 PMCID: PMC9421203 DOI: 10.14444/8311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There are numerous radiological and anatomical studies on lumbar foramina in the literature, but there are no distinctive studies about the relationship between treatment and the type of foraminal stenosis. This study was conducted to better evaluate foraminal stenosis and to plan treatment accordingly. METHODS Foraminal stenosis was divided into 2 groups: stable and unstable stenosis. Both groups were also divided into 4 subgroups in relation to the cause and type of compression and based on the structure of the intervertebral disc. The visual analog scale for leg pain (VAS-LP) and Oswestry Disability Index (ODI) scores were investigated before and after surgery. RESULTS A total of 115 patients (59 women and 56 men) underwent surgery for lumbar foraminal stenosis. The mean patient age was 56.1 years (range 17-80 years). The mean follow-up was 29 months (range 24-39 months). There were 36 patients (32%) with stable foraminal stenosis and 79 patients (68%) with unstable foraminal stenosis. The majority of the patients were identified as having unstable type 1 foraminal stenosis (45 of 115). The VAS-LP and ODI scores for each group decreased gradually during the follow-up periods and showed significant decrease during the last follow-up (P < 0.001). Interobserver and intraobserver agreement in the classification of foraminal stenosis was found to be nearly perfect. No patients experienced postoperative radiculopathy complication. Only 2 patients experienced superficial operation site infection and 1 showed deep wound infection. The patient who had a deep wound infection needed to repeat surgery for the infection. CONCLUSIONS We introduced a novel classification system for lumbar foraminal stenosis. We aimed to guide appropriate treatment modality depending on the determined classification. This classification helps to determine the optimal treatment. In the light of our findings, the patients who were operated according to our classification experienced satisfactory clinical outcomes and low complication rates. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Ali Fahir Özer
- Koç University School of Medicine, Neurosurgery Department, Istanbul, Turkey
- Neurosurgery Department, American Hospital, Istanbul, Turkey
| | - Göktuğ Akyoldaş
- Koç University School of Medicine, Neurosurgery Department, Istanbul, Turkey
| | - Orhun Mete Çevik
- Neurosurgery Department, Bakırköy Training and Research Hospital for Psychiatric and Nervous Diseases, Istanbul, Turkey
| | - Ahmet Levent Aydın
- Koç University School of Medicine, Neurosurgery Department, Istanbul, Turkey
| | - Mehdi Hekimoğlu
- Neurosurgery Department, American Hospital, Istanbul, Turkey
| | - Mehdi Sasani
- Koç University School of Medicine, Neurosurgery Department, Istanbul, Turkey
- Neurosurgery Department, American Hospital, Istanbul, Turkey
| | - Tunç Öktenoğlu
- Koç University School of Medicine, Neurosurgery Department, Istanbul, Turkey
- Neurosurgery Department, American Hospital, Istanbul, Turkey
| | - Önder Çerezci
- Physical Treatment and Rehabilitation Department, American Hospital, Istanbul, Turkey
| | - Tuncer Süzer
- Koç University School of Medicine, Neurosurgery Department, Istanbul, Turkey
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Biomechanical feasibility of semi-rigid stabilization and semi-rigid lumbar interbody fusion: a finite element study. BMC Musculoskelet Disord 2022; 23:10. [PMID: 34980068 PMCID: PMC8725514 DOI: 10.1186/s12891-021-04958-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 12/12/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Semi-rigid lumbar fusion offers a compromise between pedicle screw-based rigid fixation and non-instrumented lumbar fusion. However, the use of semi-rigid interspinous stabilization (SIS) with interspinous spacer and ligamentoplasty and semi-rigid posterior instrumentation (SPI) to assist interbody cage as fusion constructs remained controversial. The purpose of this study is to investigate the biomechanical properties of semi-rigidly stabilized lumbar fusion using SIS or SPI and their effect on adjacent levels using finite element (FE) method. METHOD Eight FE models were constructed to simulate the lumbosacral spine. In the non-fusion constructs, semi-rigid stabilization with (i) semi-rigid interspinous spacer and artificial ligaments (PD-SIS), and (ii) PI with semi-rigid rods were simulated (PD + SPI). For fusion constructs, the spinal models were implanted with (iii) PEEK cage only (Cage), (iv) PEEK cage and SIS (Cage+SIS), (v) PEEK cage and SPI (Cage+SPI), (vi) PEEK cage and rigid PI (Cage+PI). RESULT The comparison of flexion-extension range of motion (ROM) in the operated level showed the difference between Cage+SIS, Cage+SPI, and Cage+PI was less than 0.05 degree. In axial rotation, ROM of Cage+SIS were greater than Cage+PI by 0.81 degree. In the infrajacent level, while Cage+PI increased the ROM by 24.1, 27,7, 25.9, and 10.3% and Cage+SPI increased the ROM by 26.1, 30.0, 27.1, and 10.8% in flexion, extension, lateral bending and axial rotation respectively, Cage+SIS only increased the ROM by 3.6, 2.8, and 11.2% in flexion, extension, and lateral bending and reduced the ROM by 1.5% in axial rotation. The comparison of the von Mises stress showed that SIS reduced the adjacent IVD stress by 9.0%. The simulation of the strain energy showed a difference between constructs less than 7.9%, but all constructs increased the strain energy in the infradjacent level. CONCLUSION FE simulation showed semi-rigid fusion constructs including Cage+SIS and Cage+SPI can provide sufficient stabilization and flexion-extension ROM reduction at the fusion level. In addition, SIS-assisted fusion resulted in less hypermobility and less von Mises stress in the adjacent levels. However, SIS-assisted fusion had a disadvantage of less ROM reduction in lateral bending and axial rotation. Further clinical studies are warranted to investigate the clinical efficacy and safety of semi-rigid fusions.
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Yaltirik C, Varol E, Etli M, Avci F, Ramazanoglu A, Onen M, Naderi S. Comparison of clinical and radiological results of dynamic and rigid instrumentation in degenerative lumbar spinal stenosis. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:350-356. [PMID: 36263334 PMCID: PMC9574106 DOI: 10.4103/jcvjs.jcvjs_63_22] [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: 04/28/2022] [Accepted: 08/01/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Lumbar spinal stenosis is defined as a clinical syndrome characterized by neurogenic claudication or radicular pain due to the narrowing of the spinal canal or neural foramen and the compression of its neural elements. Surgical treatment is applied to decompress the neural structures. In some cases, transpedicular instrumentation and fusion may also be applied. In this study, we aimed to investigate and compare the preoperative and postoperative, clinical and radiological aspects of patients with lumbar spinal stenosis who underwent lumbar instrumentation using a polyetheretherketone (PEEK) rod or a titanium rod. Materials and Methods: In this study, the files of 293 patients who underwent posterior lumbar transpedicular stabilization between January 2015 and February 2018 in the Neurosurgery Clinic of Ümraniye Training and Research Hospital were reviewed retrospectively. Patients who did not meet the study criteria were excluded, and 127 patients who met the criteria and underwent posterior lumbar transpedicular stabilization due to lumbar spinal stenosis and/or lumbar degenerative disc disease were retrospectively reviewed. The patients were divided into two groups, dynamic and rigid, according to the rod types used. The two groups were compared using various postoperative clinical and radiological parameters. Results: The demographic data, surgical data, Visual Analog Scale-Oswestry Disability Index (VAS-ODI) data, and radiological data of both groups were carefully examined. There were 63 patients in the rigid group and 64 patients in the dynamic group. The age range in both groups was from 30 to 78 years, with a mean age of 56.44 years; 99 of the cases were female and 28 were male. The analysis of the participants' demographic data showed no significant differences between the two groups. Compared with the preoperative data, the postoperative evaluations revealed a significant decrease in VAS and ODI, but no significant difference was observed between the two groups. There was no difference between the two groups in terms of duration of surgery, follow-up time, operating distances, hospitalization duration, pseudoarthrosis, or fusion. Regarding the total and segmental range of motion, the affection was less in the dynamic group, which allowed for more movement. While there was no difference in disc height index between the two preoperative groups, it was observed that it was better maintained in the rigid group in the postoperative long term. Regarding foraminal height (FH), there was no difference between the two groups in the preoperative and early postoperative periods, but in the long term, FH was better maintained in the dynamic group. The long-term follow-ups revealed that adjacent segment disease (ASD) had developed in 19 patients in the rigid group, whereas ASD developed in only nine patients in the dynamic group. Based on these results, the probability of developing significant ASD in the rigid group was higher. Conclusion: Previous experience with PEEK rod systems has demonstrated physiological spine movement, increased fusion rates, minimal complications, reduction in adjacent segment degeneration, and biomechanical compatibility. Although further long-term studies are needed and the cost of PEEK systems is likely to be a barrier, the results of the present study support the use of PEEK rods and other dynamic systems in spinal surgery.
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Postoperative Management Strategy of Surgical Site Infection following Lumbar Dynesys Dynamic Internal Fixation. Pain Res Manag 2021; 2021:2262837. [PMID: 34659599 PMCID: PMC8516528 DOI: 10.1155/2021/2262837] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/22/2021] [Indexed: 11/18/2022]
Abstract
Aim To research the incidence of surgical site infection (SSI) following lumbar Dynesys dynamic internal fixation and its management strategy. Methods We retrospectively analyzed all cases of lumbar Dynesys dynamic internal fixation performed from January 2010 to December 2019, and the data from patients with SSI were collected. The observational indicators included the incidence of SSI, general information of the patients, surgical details, inflammatory indicators, pathogenic bacteria, and treatment. SSI was defined as both early infection and delayed infection, and the cases were divided into Groups A and B, respectively. The relevant indicators and treatment were compared between the two groups. Results A total of 1125 cases of lumbar Dynesys dynamic internal fixation were followed up. Twenty-five cases of SSI occurred, and the incidence of SSI was 2.22% (25/1125). There were 14 cases of early infection (1.24%) and 11 cases of delayed infection (0.98%). Fourteen cases of early infection occurred 12.3 ± 8.3 days postoperatively (3–30), and 11 cases of delayed infection occurred 33.3 ± 18.9 months postoperatively (3–62). The inflammatory indicators of Group A were significantly higher than those of Group B (all P < 0.05), except for procalcitonin. The main infection site in Group A was located on the skin and subcutaneous tissue and around the internal instrument, while the main infection site in Group B was around the internal instrument. The main treatment for Group A was debridement and implant replacement, and the main treatment for Group B was implant removal. Summary. The incidence of SSI following lumbar Dynesys dynamic internal fixation was 2.22%, the incidence of early SSI was 1.24%, and the incidence of delayed SSI was 0.98%. If the main infection site of early infection is in the incision, debridement should be the main treatment method; if the infection site is around the internal fixation, implant replacement is recommended on the basis of debridement. Once delayed infection is diagnosed, implant removal is suggested.
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Stress distribution of different lumbar posterior pedicle screw insertion techniques: a combination study of finite element analysis and biomechanical test. Sci Rep 2021; 11:12968. [PMID: 34155224 PMCID: PMC8217271 DOI: 10.1038/s41598-021-90686-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 05/10/2021] [Indexed: 12/23/2022] Open
Abstract
At present, the pedicle screw is the most commonly used internal fixation device. However, there are many kinds of common posterior pedicle screw insertion techniques performed to reconstruct the lumbar stability. Therefore, spinal surgeons often face a difficult choice. The stress distribution of internal fixation system is an important index for evaluating safety. Unfortunately, little had been known about the difference of stress distribution of screw-rod systems that established by Roy-Camille, Magerl and Krag insertion techniques. Here, combination of finite element analysis and model measurement research was adopted to evaluate the difference of stress. Following different pedicle screw insertion techniques, three lumbar posterior surgery models were established after modeling and validation of the L1–S1 vertebrae finite element model. By analyzing the data, we found that stress concentration phenomenon was in all the postoperative models. Roy-Camille and Magerl insertion techniques led to the great stress on screw-rod systems. Then, fresh frozen calf spines were selected as a model for subsequent measurements. Fitted with a specially designed test pedicle screw, L5–L6 vertebrae were selected to repeat and verify the results of the finite element analysis. With the aid of universal testing machine and digital torque wrench, models simulated flexion, extension, lateral bending and rotation. Finally, the strain value was captured by the strain gauge and was then calculated as the stress value. Krag and Magerl were found to be the safer choice for pedicle screw insertion. Overall, our combination method obtained the reliable result that Krag insertion technique was the safer approach for pedicle screw implantation due to its relatively dispersive stress. Therefore, without the consideration of screw size, pedicle fill, bone density, and bone structures, we recommend the Krag insertion technique as the first choice to reconstruction of lumbar stability. Additionally, the combination method of finite element analysis and strain gauge measurement can provide a feasible way to study the stress distribution of spinal internal fixation.
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Özer AF, Aydın AL, Hekimoğlu M, Çerezci Ö, Başak AT, Ates O, Oktenoglu T, Sasani M. Should Iliac Wing Screws Be Included in Long Segment Dynamic Stabilization? Cureus 2021; 13:e13543. [PMID: 33815968 PMCID: PMC8009454 DOI: 10.7759/cureus.13543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background In this article, clinical satisfaction and radiological results are discussed in a series of patients where the iliac wings participate in dynamic stabilization. Dynamic stabilization is an effective alternative surgical treatment method, especially in clinical pictures that go with pain due to minor instabilities. Practically the unique surgical instrument used in multilevel instabilities is the Dynesys system. The most important drawback of the Dynesys system is that the S1 screws become loose in time. In this article, our aim is to find solution to S1 insufficiency by extension of the system to the iliac wings. Methods Nineteen patients (eight females, 11 males) with a mean age of 54.16 were included in the study. Patients had multilevel (level 2 and above) instability, iliac wings were included in the stabilized segments, and Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were used for patient follow-up. Results First year results showed a significant improvement in VAS and ODI. Regarding the complications, infection developed in one patient, loosening in the proximal iliac wing in one patient, and both S1 and iliac proximals in one patient, but no clinical findings were encountered. Conclusion When more than two levels of dynamic systems are used in chronic instability, especially in the elderly patients, S1 screws are loosened. In these patients, if the iliac bones are also included in stabilization, this problem is solved successfully. However unfortunately, Dynesys system does not have a screw suitable for the iliac bones.
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Affiliation(s)
- Ali Fahir Özer
- Neurosurgery, Koç University School of Medicine, Istanbul, TUR
| | | | | | - Önder Çerezci
- Physical Treatment and Rehabilitation, American Hospital, Istanbul, TUR
| | | | - Ozkan Ates
- Neurosurgery, Koç University School of Medicine, Istanbul, TUR
| | - Tunc Oktenoglu
- Neurosurgery, Koç University School of Medicine, Istanbul, TUR
| | - Mehdi Sasani
- Neurosurgery, Koç University School of Medicine, Istanbul, TUR
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Aydin AL, Sasani M, Erbulut DU, Oktenoglu T, Ozer AF. A new concept of motion preservation surgery of the cervical spine: PEEK rods for the posterior cervical region. Biomed Mater Eng 2020; 31:235-251. [PMID: 32894236 DOI: 10.3233/bme-206004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Laminectomy may cause kyphotic postoperative deformity in the cervical region leading to segmental instability over time. Laminoplasty may be an alternative procedure to laminectomy, as it protects the spine against post-laminectomy kyphosis; however, similar to laminectomy, laminoplasty may cause sagittal plane deformities by destructing or weakening the dorsal tension band. OBJECTIVE Using finite element analysis (FE), we attempted to determine whether a posterior motion preservation system (PEEK posterior rod system concept) could overcome the postoperative complications of laminectomy and laminoplasty and eliminate the side effects of rigid posterior stabilization in the cervical region. METHODS We compared PEEK rods in four different diameters with a titanium rod for posterior cervical fixation. The present study may lead to motion preservation systems of the cervical vertebra. RESULTS When PEEK rod is compared with titanium rod, considerable increase in range of motion is observed. CONCLUSIONS PEEK rod-lateral mass screw instrumentation systems may be useful in motion preservation surgery of the posterior cervical region.
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Affiliation(s)
- Ahmet Levent Aydin
- Neurosurgery Department, School of Medicine, Koç University, Istanbul, Turkey
| | - Mehdi Sasani
- Neurosurgery Department, School of Medicine, Koç University, Istanbul, Turkey
| | | | - Tunc Oktenoglu
- Neurosurgery Department, School of Medicine, Koç University, Istanbul, Turkey
| | - Ali Fahir Ozer
- Neurosurgery Department, School of Medicine, Koç University, Istanbul, Turkey
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Krieg SM, Balser N, Pape H, Sollmann N, Albers L, Meyer B. Topping-off technique for stabilization of lumbar degenerative instabilities in 322 patients. J Neurosurg Spine 2020; 32:366-372. [PMID: 31731274 DOI: 10.3171/2019.8.spine181434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 08/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Semi-rigid instrumentation (SRI) was introduced to take advantage of the concept of load sharing in surgery for spinal stabilization. The authors investigated a topping-off technique in which interbody fusion is not performed in the uppermost motion segment, thus creating a smooth transition from stabilized to free motion segments. SRI using the topping-off technique also reduces the motion of the adjacent segments, which may reduce the risk of adjacent segment disease (ASD), a frequently observed sequela of instrumentation and fusion, but this technique may also increase the possibility of screw loosening (SL). In the present study the authors aimed to systematically evaluate reoperation rates, clinical outcomes, and potential risk factors and incidences of ASD and SL for this novel approach. METHODS The authors collected data for the first 322 patients enrolled at their institution from 2009 to 2015 who underwent surgery performed using the topping-off technique. Reoperation rates, patient satisfaction, and other outcome measures were evaluated. All patients underwent pedicle screw-based semi-rigid stabilization of the lumbar spine with a polyetheretherketone (PEEK) rod system. RESULTS Implantation of PEEK rods during revision surgery was performed in 59.9% of patients. A median of 3 motion segments (range 1-5 segments) were included and a median of 2 motion segments (range 0-4 segments) were fused. A total of 89.4% of patients underwent fusion, 73.3% by transforaminal lumbar interbody fusion (TLIF), 18.4% by anterior lumbar interbody fusion (ALIF), 3.1% by extreme lateral interbody fusion (XLIF), 0.3% by oblique lumbar interbody fusion (OLIF), and 4.9% by combined approaches in the same surgery. Combined radicular and lumbar pain according to a visual analog scale was reduced from 7.9 ± 1.0 to 4.0 ± 3.1, with 56.2% of patients indicating benefit from surgery. After maximum follow-up (4.3 ± 1.8 years), the reoperation rate was 16.4%. CONCLUSIONS The PEEK rod concept including the topping-off principle seems safe, with at least average patient satisfaction in this patient group. Considering the low rate of first-tier surgeries, the presented results seem at least comparable to those of most other series. Follow-up studies are needed to determine long-term outcomes, particularly with respect to ASD, which might be reduced by the presented approach.
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Affiliation(s)
- Sandro M Krieg
- 1Department of Neurosurgery
- 2TUM-Neuroimaging Center, and
| | | | | | - Nico Sollmann
- 1Department of Neurosurgery
- 2TUM-Neuroimaging Center, and
- 3Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Cecchinato R, Bourghli A, Obeid I. Revision surgery of spinal dynamic implants: a literature review and algorithm proposal. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:57-65. [PMID: 31916002 DOI: 10.1007/s00586-019-06282-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 12/14/2019] [Accepted: 12/29/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Dynamic stabilization of the spine has been performed since the 1990s with the double purpose of restoring spinal segmental stability and allowing residual movement at the operated level. When we take into account the different motion-preserving devices and the spinal areas where they are applied, we can identify three categories of spinal implants: anterior cervical, anterior lumbar, and posterior lumbar. However, as in all prosthetic procedures performed in orthopedic surgery, the life span of a joint replacement device is a central topic of discussion, and this is true also for spinal dynamic devices, being revision surgery a complex procedure in specific cases. MATERIALS AND METHODS We performed a literature review on the different dynamic spinal implants and the most common causes of failure, providing clinical cases as illustrative options for revision surgery. RESULTS The review of the literature showed a 11.3% to 22.6% revision rate in posterior lumbar dynamic systems, with a peak of 40.6% in case of adjacent segment disease. In lumbar TDRs, infection and severe dislocations are the most frequent causes of anterior revisions, while posterior pedicle screw fixation could be a suitable option in minimal subsidence or TDR displacement. An algorithm for the planning of revision surgery is proposed. CONCLUSIONS Surgical revision of spinal dynamic implants could be a demanding surgery especially in anterior approaches. Anterior cervical revision remains globally safe, but careful preoperative evaluation of vessels and ureter are suggested to avoid intraoperative complications in the lumbar spine. In posterior revision, a proper sagittal alignment of the spine should be restored. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- R Cecchinato
- GSpine4, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
| | - A Bourghli
- Orthopedic and Spinal Surgery Department, Kingdom Hospital, Riyadh, Saudi Arabia
| | - I Obeid
- Orthopedic Spinal Surgery Unit 1, Pellegrin Hospital, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France
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Kolesov SV, Kazmin AI, Shvets VV, Gushcha AO, Poltorako EN, Basankin IV, Krivoshein AE, Bukhtin KM, Panteleev AA, Sazhnev ML, Pereverzev VS. Comparison of Nitinol and Titanium Nails Effectiveness for Lumbosacral Spine Fixation in Surgical Treatment of Degenerative Spine Diseases. ACTA ACUST UNITED AC 2019. [DOI: 10.21823/2311-2905-2019-25-2-59-70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Relevance. Surgical decompression and decompression with stabilization are highly effective for treatment of spinal canal stenosis at the level of lumbar spine. However, complications developing after application of rigid fixation systems resulted in active introduction of dynamic implants into clinical practice.Purpose of the study — to compare effectiveness of nitinol and titanium nails for lumbosacral fixation in surgical treatment of degenerative spine diseases.Materials and methods. 220 patients who underwent surgeries in 4 hospitals were randomized into two groups, each consisting of 110 patients (1:1 ratio): a group of patients who underwent stabilization of the vertebral motor segments with rods of nitinol with the required volume of decompression at the operation level and a group of patients who underwent stabilization of the vertebral motor segments with standard rods of titanium with the required volume of decompression at the intervention level. Patients suffered clinically significant spinal canal stenosis in one or two adjacent segments: from L3 to S1. Outcomes were evaluated during three years postoperatively by VAS scale for spine and lower limbs, and by ODI and SF-36 scales.Results. All scales demonstrated better values in both groups of patients, namely, significant decrease of pain syndrome and improvement in mental and physical health. X-ray examination of all patients during the study period demonstrated restoration of lumbar lordosis. Group of patients with dynamic nails featured less complications rate related to metal implants including adjacent segment disease.Conclusion. Transpedicular fixation of lumbosacral spine by nitinol nails is an effective technique allowing to preserve motion along with stable fixation.
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Affiliation(s)
- S. V. Kolesov
- Priorov National Medical Research Center of Traumatology and Orthopedics
| | - A. I. Kazmin
- Priorov National Medical Research Center of Traumatology and Orthopedics
| | - V. V. Shvets
- Priorov National Medical Research Center of Traumatology and Orthopedics
| | | | | | - I. V. Basankin
- Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1
| | | | - K. M. Bukhtin
- Priorov National Medical Research Center of Traumatology and Orthopedics
| | - A. A. Panteleev
- Priorov National Medical Research Center of Traumatology and Orthopedics
| | - M. L. Sazhnev
- Priorov National Medical Research Center of Traumatology and Orthopedics
| | - V. S. Pereverzev
- Priorov National Medical Research Center of Traumatology and Orthopedics
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Sasani H, Solmaz B, Sasani M, Vural M, Ozer AF. Diagnostic Importance of Axial Loaded Magnetic Resonance Imaging in Patients with Suspected Lumbar Spinal Canal Stenosis. World Neurosurg 2019; 127:e69-e75. [PMID: 30857995 DOI: 10.1016/j.wneu.2019.02.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/08/2019] [Accepted: 02/09/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE AND BACKGROUND To study the efficacy of lumbar (AL) magnetic resonance imaging (MRI) in patients with suspected lumbar spinal stenosis (LSS), with and without AL compression. Supine MRI is used in the assessment of patients with LSS. However, MRI findings may poorly correlate with neurologic findings because of the morphologic changes of the lumbar spinal canal between upright standing and supine positions. In patients without significant stenosis in routine lumbar MRI, by applying AL, MRI can show significant LSS. METHODS This study included 103 consecutive patients (188 disc levels) who presented with neurogenic claudication with and without low back pain. AL was performed using a nonmagnetic compression device for 5 minutes. T1- and T2-weighted axial and sagittal sequences were obtained during AL applied to the spine. The dural sac cross-sectional area (DSCA) appeared to be narrow at each disc level of L4-5 to L5-S1 in all patients and was measured using T2-weighted images in routine supine and AL images. RESULTS The groups included patients with a reduction in the DSCA (>15 mm2) according to patient age and DSCA in routine spine MRI. The mean DSCA of the disc levels without and with AL were 138 mm2 and 123 mm2, with a mean difference of 15 mm2 at L4-5, 134 mm2 and 125 mm2 and a mean difference of 9 mm2 at L5-S1, respectively. CONCLUSIONS The use of AL MRI in patients with clinically suspected LSS could reduce the risk of misdiagnosis of stenosis, leading to inappropriate treatment.
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Affiliation(s)
- Hadi Sasani
- Department of Radiology, Faculty of Medicine, Namik Kemal University, Tekirdag, Turkey.
| | - Bilgehan Solmaz
- Department of Neurosurgery, Istanbul Research and Training Hospital, Istanbul, Turkey
| | - Mehdi Sasani
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Metin Vural
- Department of Radiology, American Hospital, Istanbul, Turkey
| | - Ali Fahir Ozer
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
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