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Bernatz JT, Goh BC, Skjaerlund JD, Mikula AL, Johnson SE, Bydon M, Fogelson J, Elder B, Huddleston P, Karim M, Nassr A, Sebastian A, Freedman B. Intraoperative Surgeon Assessment of Bone: Correlation to Bone Mineral Density, CT Hounsfield Units, and Vertebral Bone Quality. Spine (Phila Pa 1976) 2024; 49:1125-1129. [PMID: 37855301 DOI: 10.1097/brs.0000000000004854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/12/2023] [Indexed: 10/20/2023]
Abstract
STUDY DESIGN Retrospective observational study of consecutive patients. OBJECTIVE The purpose of the study is to determine if a surgeon's qualitative assessment of bone intraoperatively correlates with radiologic parameters of bone strength. SUMMARY OF BACKGROUND DATA Preoperative radiologic assessment of bone can include modalities such as computed tomography (CT) Hounsfield units (HUs), dual-energy x-ray absorptiometry (DXA) bone mineral density with trabecular bone score (TBS) and magnetic resonance imaging vertebral bone quality (VBQ). Quantitative analysis of bone with screw insertional torque and pull-out strength measurement has been performed in cadaveric models and has been correlated to these radiologic parameters. However, these quantitative measurements are not routinely available for use in surgery. Surgeons anecdotally judge bone strength, but the fidelity of the intraoperative judgment has not been investigated. METHODS All adult patients undergoing instrumented posterior thoracolumbar spine fusion by one of seven surgeons at a single center over a 3-month period were included. Surgeons evaluated the strength of bone based on intraoperative feedback and graded each patient's bone on a 5-point Likert scale. Two independent reviewers measured preoperative CT HUs and magnetic resonance imaging VBQ. Bone mineral density, lowest T-score, and TBS were extracted from DXA within 2 years of surgery. RESULTS Eighty-nine patients were enrolled and 16, 28, 31, 13, and 1 patients had Likert grade 1 (strongest bone), 2, 3, 4, and 5 (weakest bone), respectively. The surgeon assessment of bone correlated with VBQ (τ=0.15, P =0.07), CT HU (τ=-0.31, P <0.01), lowest DXA T-score (τ=-0.47, P <0.01), and TBS (τ=-0.23, P =0.06). CONCLUSION Spine surgeons' qualitative intraoperative assessment of bone correlates with preoperative radiologic parameters, particularly in posterior thoracolumbar surgeries. This information is valuable to surgeons as this supports the idea that decisions based on feel in surgery have a statistical foundation.
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Affiliation(s)
- James T Bernatz
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Brian C Goh
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Sarah E Johnson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Jeremy Fogelson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Benjamin Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Paul Huddleston
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Mohammed Karim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Arjun Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Brett Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Razzouk J, Bouterse A, Shin D, Mbumbgwa P, Brandt Z, Patel M, Nguyen K, Cheng W, Danisa O, Ramos O. Correlations among MRI-based cervical and thoracic vertebral bone quality score, CT-based Hounsfield Unit score, and DEXA t-score in assessment of bone mineral density. J Clin Neurosci 2024; 126:63-67. [PMID: 38850762 DOI: 10.1016/j.jocn.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/31/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Further optimization of the validated vertebral bone quality (VBQ) score using magnetic resonance imaging (MRI) may expand its clinical utility for bone mineral density (BMD) assessment. This study evaluated the correlations among cervical and thoracic VBQ scores, the validated Hounsfield Unit (HU) measured on computed tomography (CT), and dual-energy x-ray absorptiometry (DEXA) values. METHODS We retrieved the medical and radiographic records of 165 patients who underwent synchronous MRI of the cervical and thoracic spine, as well as DEXA and CT imaging of the spine obtained within 1 year of each other between 2015 and 2022. Radiographic data consisted of the MRI-based cervical and thoracic VBQ scores, CT-based HU, and DEXA T-scores of the spine and hip. Patient age, sex, body mass index (BMI), and ethnicity were also obtained. RESULTS Mean cervical and thoracic VBQ scores were 3.99 ± 1.68 and 3.82 ± 2.11, respectively. Mean HU and DEXA T-scores of the spine and hip were 135.75 ± 60.36, -1.01 ± 1.15, and -0.47 ± 2.27. All correlations among VBQ, HU, and DEXA were insignificant except for weak correlations between cervical and thoracic VBQ, and cervical VBQ and HU. No correlations were observed between radiographic scores and patient age or BMI. No differences based on ethnicity or sex were observed with respect to cervical or thoracic VBQ, HU, or DEXA. CONCLUSION Cervical and thoracic VBQ scores are distinct from Hounsfield Unit and DEXA values. VBQ scoring in the cervical and thoracic spine is not influenced by patient age, ethnicity, sex, or BMI.
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Affiliation(s)
- Jacob Razzouk
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | | | - David Shin
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | | | - Zachary Brandt
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Meghna Patel
- School of Medicine, University of California, Riverside, Riverside, CA, USA
| | - Kai Nguyen
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis Memorial Veterans Hospital, Loma Linda, CA, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, CA, USA.
| | - Omar Ramos
- Twin Cities Spine Center, Minneapolis, MN, USA
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Girdler SJ, Lindsey MH, Sebastian AS, Nassr A. Osteoporosis Evaluation and Management in Spine Surgery. J Am Acad Orthop Surg 2024:00124635-990000000-01059. [PMID: 39083525 DOI: 10.5435/jaaos-d-24-00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/31/2024] [Indexed: 08/02/2024] Open
Abstract
Osteoporosis is a global health problem affecting over 200 million people worldwide and 54 million adults in the United States. Approximately half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime. In the United States, the direct medical cost related to osteoporosis is expected to exceed $25 billion by 2025. Management of osteoporosis in vertebral fractures and elective spine surgery is of the utmost concern, given the high prevalence of osteoporosis in the general population and the increased risk of complication in this population. New pharmacologic treatment options such as anabolic medications and diagnostic tools including Hounsfield unit measurements on routine computed tomography scans are available to orthopaedic and spinal surgeons to help best manage this condition. This review serves as an update to diagnosis, management, and treatment of patients with osteoporosis undergoing spinal surgery.
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Affiliation(s)
- Steven J Girdler
- From the Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Jacob A, Heumann M, Zderic I, Varga P, Ion N, Bocea B, Haschtmann D, Fekete T, Wirtz CR, Richards RG, Gueorguiev B, Loibl M. Cyclic testing of standalone ALIF versus TLIF in lumbosacral spines of low bone mineral density: an ex vivo biomechanical study. 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 2024:10.1007/s00586-024-08391-7. [PMID: 39017731 DOI: 10.1007/s00586-024-08391-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 06/13/2024] [Accepted: 06/30/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE Screwed anterior lumbar interbody fusion (SALIF) alleviates the need for supplemental posterior fixation leading to reduction of perioperative morbidity. Specifically, elderly and multimorbid patients would benefit from shorter operative time and faster recovery but tend to have low bone mineral density (BMD). The current study aimed to compare loosening, defined as increase of ROM and NZ, of SALIF versus transforaminal lumbar interbody fusion (TLIF) under cyclic loading in cadaveric spines with reduced BMD. METHODS Twelve human spines (L4-S2; 6 male 6 female donors; age 70.6 ± 19.6; trabecular BMD of L5 84.2 ± 24.4 mgHA/cm3, range 51-119 mgHA/cm3) were assigned to two groups. SALIF or TLIF were instrumented at L5/S1. Range of motion (ROM) and neutral zone (NZ) were assessed before and after axial cyclic loading (0-1150 N, 2000 cycles, 0.5 Hz) in flexion-extension (Flex-Ext), lateral bending, (LB), axial rotation (AR). RESULTS ROM of the SALIF specimens increased significantly in all loading directions (p ≤ 0.041), except for left AR (p = 0.053), whereas for TLIF it increased significantly in left LB (p = 0.033) and Flex (p = 0.015). NZ of SALIF showed increase in Flex-Ext and LB, whereas NZ of TLIF did not increase significantly in any motion direction. CONCLUSIONS Axial compression loading caused loosening of SALIF in Flex-Ext and LB, but not TLIF at L5/S1 in low BMD specimens. Nevertheless, Post-cyclic ROM and NZ of SALIF is comparable to TLIF. This suggests that, neither construct is optimal for the use in patients with reduced BMD.
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Affiliation(s)
- Alina Jacob
- Biomedical Department, AO Research Institute Davos, Davos, Switzerland.
- Department of Spine Surgery, Schulthess Clinic, Zurich, Switzerland.
| | | | - Ivan Zderic
- Biomedical Department, AO Research Institute Davos, Davos, Switzerland
| | - Peter Varga
- Biomedical Department, AO Research Institute Davos, Davos, Switzerland
| | - Nicolas Ion
- Faculty of Medicine Sibiu, Lucian Blaga University, Sibiu, Romania
| | - Bogdan Bocea
- Faculty of Medicine Sibiu, Lucian Blaga University, Sibiu, Romania
| | | | - Tamas Fekete
- Department of Spine Surgery, Schulthess Clinic, Zurich, Switzerland
| | | | - R Geoff Richards
- Biomedical Department, AO Research Institute Davos, Davos, Switzerland
| | - Boyko Gueorguiev
- Biomedical Department, AO Research Institute Davos, Davos, Switzerland
| | - Markus Loibl
- Department of Spine Surgery, Schulthess Clinic, Zurich, Switzerland
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Gelvez D, Dong K, Redlich N, Williams J, Bhandutia A, Shamassian B. Treatment Strategies in the Osteoporotic Spine. Orthop Clin North Am 2024; 55:403-413. [PMID: 38782511 DOI: 10.1016/j.ocl.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
This article reviews the appropriate assessment and management of osteoporotic compression fractures and discusses the implications of osteoporosis on initial patient evaluation, medical optimization for surgery, selection of instrumentation, and surgical technique. Adverse outcomes associated with osteoporosis are discussed. Failure to appropriately evaluate, optimize, and treat spine patients with osteoporotic bone can lead to disastrous complications. Weakened bone can lead to implant failure through cage subsidence and screw pullout, as well as, peri-implant fractures, failure of deformity correction, and proximal kyphosis. These risks must be taken into account when considering operative interventions in these patients.
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Affiliation(s)
- Daniel Gelvez
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA.
| | - Katherine Dong
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Nathan Redlich
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Jestin Williams
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Amit Bhandutia
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Berje Shamassian
- LSU-HSC Department of Neurosurgery, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
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Mathew J, Zuckerman SL, Lin H, Marciano G, Simhon M, Cerpa M, Lee NJ, Boddapati V, Lehman RA, Sardar ZM, Dyrszka MD, Lombardi JM, Lenke LG. Living with a C2-Sacrum Spinal Fusion: Surgical Outcomes and Quality of Life in Patients Fused from C2 to the Sacrum. Global Spine J 2024; 14:1542-1551. [PMID: 36604815 DOI: 10.1177/21925682221149389] [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] [Indexed: 01/07/2023] Open
Abstract
STUDY DESIGN Single center, retrospective cohort study. OBJECTIVES Little is known about the surgical outcomes and quality of life in patients with C2-sacrum posterior spinal fusion (PSF). Though it is thought to be a "final" construct, it remains unknown how patients fare postoperatively. We sought to evaluate the surgical outcomes and quality of life of patients after C2-sacrum PSF. METHODS Consecutive patients undergoing C2-Sacrum PSF from 2015-2020 by 4 surgeons at a single institution were included. The study time period for each patient began after their index operation that led to the C2-sacrum fusion. Dates of surgery, complications, reoperations, patient reported outcomes (PROs) including EuroQol 5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), Scoliosis Research Society (SRS) questionnaires, and activities of daily living (ADL) questions were collected and analyzed. Descriptive statistics, paired t-tests, student t-tests, and linear regression were used. RESULTS Of the 23 patients who underwent C2-sacrum PSF, 6 patients (26%) required a total of 10 reoperations after a mean of 1.5 years (range 0-4 years) after C2-sacrum PSF. Five reoperations were for mechanical failure; 3 for wound complications/infection; and 2 for instrumentation and spinous process prominence. PROs were collected on 18 patients with mean follow-up of 2.4 years (range .5-4.5) after their C2-sacrum PSF. At 6-months, both SRS-22 and ODI scores improved significantly after C2-sacrum PSF (SRS: 57.5 to 76.3, P = .0014; ODI: 47.0 to 31.7, P = .013). Similarly, at a mean 2.4 years postoperatively, mean ODI improved significantly (47.0 to 30.4, P = .0032). Six patients (33%) had minimal symptoms (ODI <20). The median postoperative EQ-5D score was .74 (range .19 to 1.0), which compares favorably to patients with hip/knee osteoarthritis (EQ-5D .63) and diabetes mellitus (DM) (EQ-5D .69) and hypertension (HTN). In terms of activities of daily living (ADL), 10 patients (56%) exercised regularly-a mean 4.5 days/week. 11 (61%) could do light aerobic activity (e.g. stationary bike). 10 (55%) were able to play with children/grandchildren as desired. Eight patients (44%) hiked, and 2 (11%) drove independently. 11 (61%) could tolerate short air-travel comfortably. Of the 17 patients who could toilet and perform basic hygiene preoperatively, 16 (94%) were able to do so postoperatively. CONCLUSION Though C2-sacrum PSF is thought to be a "final" construct, approximately 1 in 4 patients require subsequent operations. However, C2-sacrum PSF patients had a significant improvement in SRS and ODI scores by 6 months postop. Over 60% of patients were regularly performing light aerobic activity 2 years after their C2-sacrum PSF. EQ-5D suggests that this population fares better than those with degenerative hip/knee arthritis and similarly to those with common chronic conditions like DM and HTN.
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Affiliation(s)
- Justin Mathew
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hannah Lin
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Gerard Marciano
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Matthew Simhon
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Zeeshan M Sardar
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Marc D Dyrszka
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Joseph M Lombardi
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
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7
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Hudson M, Meyer J, Evans A, Krishna C, Smith ZA, Bakhsheshian J. Evaluating osteoporosis and bone quality in the aging spine: modern considerations for surgical management in the geriatric population. GeroScience 2024:10.1007/s11357-024-01171-7. [PMID: 38703277 DOI: 10.1007/s11357-024-01171-7] [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: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024] Open
Abstract
Surgical management paradigms of spinal pathologies in the aging population carry inherent substantial risks, with surgical complications being more prevalent among patients with osteoporosis compared to those with normal bone mineral density. In this narrative review, we aim to highlight important clinical understanding and considerations in perioperative evaluation and management of patients elected to undergo spinal surgery. Osteoporosis is a well-defined risk factor for mechanical complications following spinal surgery, and as such, perioperative optimization of bone health in the setting of surgery for geriatric patients remains a critical research area alongside intraoperative surgical augmentation techniques. Surgical techniques to circumvent challenges with instrumentation of poor bone mineral density have included augmentation of pedicle screw fixation, including segmental bicortical screw fixation techniques, cement augmentation with fenestrated screws, or use of expandable pedicle screws to improve bone-implant interface. Judicious selection of treatment modalities and subsequent perioperative optimization is paramount to minimize surgical complications. Contemporary guidelines and evolving paradigms in perioperative evaluation, optimization, and management of the aging spine include the advent of quantitatively evaluating computed tomography (CT) via assessment of the magnitude of Hounsfield units. Prescribing pharmacotherapeutic agents and monitoring bone health requires a multidisciplinary team approach, including endocrinologists and geriatricians to coordinate high-quality care for advanced-age patients who require surgical management of their spinal disorders.
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Affiliation(s)
- Miles Hudson
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA.
| | - Jenna Meyer
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alexander Evans
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Chandan Krishna
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Wang D, Wang W, Han D, Muthu S, Cabrera JP, Hamouda W, Ambrosio L, Cheung JPY, Le HV, Vadalà G, Buser Z, Wang JC, Cho S, Yoon ST, Lu S, Chen X, Diwan AD. Clinical effectiveness of reduction and fusion versus in situ fusion in the management of degenerative lumbar spondylolisthesis: a systematic review and meta-analysis. 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 2024; 33:1748-1761. [PMID: 38043128 DOI: 10.1007/s00586-023-08041-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/02/2023] [Accepted: 11/03/2023] [Indexed: 12/05/2023]
Abstract
PURPOSE To compare the clinical effectiveness of reduction and fusion with in situ fusion in the management of patients with degenerative lumbar spondylolisthesis (DLS). METHODS The systematic review was conducted following the PRISMA guidelines. Relevant studies were identified from PubMed, Embase, Scopus, Cochrane Library, ClinicalTrials.gov, and Google Scholar. The inclusion criteria were: (1) comparative studies of reduction and fusion versus in situ fusion for DLS patients, (2) outcomes reported as VAS/NRS, ODI, JOA score, operating time, blood loss, complication rate, fusion rate, or reoperation rate, (3) randomized controlled trials and observational studies published in English from the inception of the databases to January 2023. The exclusion criteria included: (1) reviews, case series, case reports, letters, and conference reports, (2) in vitro biomechanical studies and computational modeling studies, (3) no report on study outcomes. The risk of bias 2 (RoB2) tool and the Newcastle-Ottawa scale was conducted to assess the risk of bias of RCTs and observational studies, respectively. RESULTS Five studies with a total of 704 patients were included (375 reduction and fusion, 329 in situ fusion). Operating time was significantly longer in the reduction and fusion group compared to in situ fusion group (weighted mean difference 7.20; 95% confidence interval 0.19, 14.21; P = 0.04). No additional significant intergroup differences were noted in terms of other outcomes analyzed. CONCLUSION While the reduction and fusion group demonstrated a statistically longer operating time compared to the in situ fusion group, the clinical significance of this difference was minimal. The findings suggest no substantial superiority of lumbar fusion with reduction over without reduction for the management of DLS.
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Affiliation(s)
- Dongfan Wang
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China
| | - Wei Wang
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China
| | - Di Han
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China
| | - Sathish Muthu
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India
- Department of Orthopaedics, Government Medical College, Karur, Tamil Nadu, India
- Department of Biotechnology, Faculty of Engineering, Karpagam Academy of Higher Education, Coimbatore, Tamil Nadu, India
| | - Juan P Cabrera
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, Concepción, Chile
- Faculty of Medicine, University of Concepción, Concepción, Chile
| | - Waeel Hamouda
- Department of Neurosurgery, Kasr Alainy Faculty of Medicine, Research and Teaching Hospitals, Cairo University, Cairo, Egypt
- Neurological & Spinal Surgery Service, Security Forces Hospital, Dammam, Saudi Arabia
| | - Luca Ambrosio
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Jason P Y Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Hai V Le
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Gianluca Vadalà
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Zorica Buser
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery and Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Samuel Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - S Tim Yoon
- Department of Orthopaedics, Emory University, Atlanta, GA, USA
| | - Shibao Lu
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China.
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China.
- Xuanwu Hospital of Capital Medical University, No.45 Changchun Street, Beijing, 100053, China.
| | - Xiaolong Chen
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, No.45 Changchun Street, Xicheng District, Beijing, China.
- National Center for Clinical Research on Geriatric Diseases, No.45 Changchun Street, Xicheng District, Beijing, China.
- Xuanwu Hospital of Capital Medical University, No.45 Changchun Street, Beijing, 100053, China.
| | - Ashish D Diwan
- Spine Service, Department of Orthopaedic Surgery, St. George Hospital Campus, Sydney, NSW, Australia.
- St. George & Sutherland Clinical School, University of New South Wales, Level 3, WR Pitney Building, Kogarah, Sydney, NSW, 2217, Australia.
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9
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Huang W, Gong Z, Zheng C, Chen Y, Ma X, Wang H, Jiang J. Preoperative Assessment of Bone Density Using MRI-Based Vertebral Bone Quality Score Modified for Patients Undergoing Cervical Spine Surgery. Global Spine J 2024; 14:1238-1247. [PMID: 36321883 PMCID: PMC11289558 DOI: 10.1177/21925682221138261] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
STUDY DESIGN Diagnostic accuracy study. OBJECTIVES Previous studies have reported the clinical application of the Vertebral Bone Quality (VBQ) scores for assessing bone density in operative lumbar spine patients. We aim to explore whether the method could be modified and applicable for patients undergoing cervical spine surgery. METHODS Adult patients receiving cervical spine surgery for degenerative diseases between September 2020 and March 2022 with non-contrast T1-weighted MRI and DEXA were included. Correlation between cervical VBQ scores and DEXA T-scores was analyzed using Pearson's correlation. Student's t test was used to present the discrepancy between the VBQ of patients with normal bone density (T ≥ -1.0) and patients with osteopenia/osteoporosis (T < -1.0). Statistical significance was set at P < .05. RESULTS Eighty-three patients (20 patients with T ≥ -1.0 vs 63 patients with T < -1.0 ) were included. Significant difference was found between the cervical VBQ between groups (2.99 ± .79 vs 3.80 ± .81, P < .001). Interclass correlation coefficient for inter-rater reliability was .82 (95% CI: .70-.93) and .91(95% CI: .84-.97) for intra-rater reliability. The area under the ROC curve was .78 (95% CI: .65-.90). The DEXA T-score of the femoral neck, total hip and the lowest DEXA T-score were found to be significantly correlated with the cervical VBQ score according to Pearson correlation analysis (P < .001). CONCLUSIONS This is the first study to apply the VBQ method to assess the bone density in preoperative cervical spine patients. Cervical VBQ scores were significantly correlated with DEXA T-score. With an overall accuracy of .78, the radiation-free and cost-effective method could be a potential tool for screening patients with osteopenia and osteoporosis before surgery.
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Affiliation(s)
- Weibo Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhaoyang Gong
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Chaojun Zheng
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaosheng Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongli Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianyuan Jiang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
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10
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Momtaz D, Prabhakar G, Gonuguntla R, Ahmad F, Ghali A, Kotzur T, Nagel S, Chaput C. The 8-item Modified Frailty Index Is an Effective Risk Assessment Tool in Anterior Cervical Decompression and Fusion. Global Spine J 2024; 14:914-921. [PMID: 36112749 PMCID: PMC11192130 DOI: 10.1177/21925682221127229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Case-control study; Level of evidence, 3. OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is one of the most common procedures for cervical diseases often with reliable outcomes. However, morbidity rates can be as high as 19.3% so appropriate patient selection and risk stratification is imperative. Our modified frailty index (MFI) predicts postoperative complications after other orthopaedic procedures. We hypothesized that this index would predict complications in a large cohort of ACDF patients. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, including patients who underwent ACDF from 2015-2020. An 8-item MFI score was calculated for each patient. We recorded 30-days postoperative complications, readmission, and reoperation rates, adjusting for baseline features using standard multivariate regression. This project was approved of by the University of Texas Health Science Center Institutional Review Board and an IRB exception was granted. RESULTS We identified 17 662 ACDF cases. Patients with MFI of 5 or greater had a 37.53 times increased odds of incurring postoperative complications compared to patients with MFI of 0 (P < .001) even when age, sex, race, and ethnicity were controlled for. Specifically, life-threatening Clavien-Dindo IV complications, as well as wound, cardiac, renal, and pulmonary complications were significantly increased in patients with an MFI of 5 or greater. Also, as MFI increased from 1-2 to 3-4 to 5 or greater, the odds of readmission increased from 1.36 to 2.31 to 5.42 times (P < .001) and odds of reoperation from 1.19 (P = .185) to 2.3 to 6.54 times (P < .001). Frailty was still associated with increased complications, readmission, and reoperation after controlling for demographic data, including age, as well as operative time and length of stay. CONCLUSION Frailty is highly predictive of postoperative complications, readmission, and reoperation following ACDF. Employing a simple frailty evaluation can guide surgical decision-making and patient counseling for cervical disease.
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Affiliation(s)
- David Momtaz
- Orthopaedics, The University of Texas Health Science Center at San Antonio, TX, USA
| | - Gautham Prabhakar
- Orthopaedics, The University of Texas Health Science Center at San Antonio, TX, USA
| | - Rishi Gonuguntla
- Orthopaedics, The University of Texas Health Science Center at San Antonio, TX, USA
| | - Farhan Ahmad
- Orthopaedics, Rush University Medical Center, Chicago, IL, USA
| | - Abdullah Ghali
- Orthopaedics, Baylor College of Medicine, Houston, TX, USA
| | - Travis Kotzur
- Orthopaedics, The University of Texas Health Science Center at San Antonio, TX, USA
| | - Sarah Nagel
- Orthopaedics, The University of Texas Health Science Center at San Antonio, TX, USA
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11
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Sircar K, Weber M, Walter SG, Ott N, Prescher A, Eysel P, Kernich N. Torque forces of expandable titanium vertebral body replacement cages during expansion and subsidence in the osteoporotic lumbar spine. Clin Biomech (Bristol, Avon) 2024; 114:106239. [PMID: 38599132 DOI: 10.1016/j.clinbiomech.2024.106239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND The application of expandable titanium-cages has gained widespread use in vertebral body replacement for indications such as burst fractures, tumors and infectious destruction. However, torque forces necessary for a satisfactory expansion of these implants and for subsidence of them into the adjacent vertebrae are unknown within the osteoporotic spine. METHODS Six fresh-frozen human, osteoporotic, lumbar spines were dorsally instrumented with titanium implants (L2-L4) and a partial corpectomy of L3 was performed. An expandable titanium-cage was inserted ventrally and expanded by both residents and senior surgeons until fixation was deemed sufficient, based on haptic feedback. Torque forces for expansion were measured in Nm. Expansion was then continued until cage subsidence occurred. Torque forces necessary for subsidence were recorded. Strain of the dorsal rods during expansion was measured with strain gauges. FINDINGS The mean torque force for fixation of cages was 1.17 Nm (0.9 Nm for residents, 1.4 Nm for senior surgeons, p = .06). The mean torque force for subsidence of cages was 3.1 Nm (p = .005). Mean peak strain of the dorsal rods was 970 μm/m during expansion and 1792 μm/m at subsidence of cages (p = .004). INTERPRETATION The use of expandable titanium-cages for vertebral body replacement seems to be a primarily safe procedure even within the osteoporotic spine as torque forces required for subsidence of cages are nearly three times higher than those needed for fixation. Most of the expansion load is absorbed by straining of the dorsal instrumentation. Rod materials other than titanium may alter the torque forces found in this study.
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Affiliation(s)
- Krishnan Sircar
- Department of Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener-Strasse 62, 50937 Cologne, Germany.
| | - Maximilian Weber
- Department of Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener-Strasse 62, 50937 Cologne, Germany
| | - Sebastian G Walter
- Department of Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener-Strasse 62, 50937 Cologne, Germany
| | - Nadine Ott
- Department of Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener-Strasse 62, 50937 Cologne, Germany
| | - Andreas Prescher
- Institute of Molecular and Cellular Anatomy, RWTH Aachen University Hospital, Wendlingweg 2, 52070 Aachen, Germany
| | - Peer Eysel
- Department of Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener-Strasse 62, 50937 Cologne, Germany
| | - Nikolaus Kernich
- Department of Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener-Strasse 62, 50937 Cologne, Germany
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12
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Nishida K, Park H, Ogiri M, Rossi A. Clinical and Economic Outcomes of Patients with Osteoporosis Undergoing Spine Fusion Surgery in Japan. Spine Surg Relat Res 2024; 8:163-170. [PMID: 38618219 PMCID: PMC11007240 DOI: 10.22603/ssrr.2023-0175] [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: 07/19/2023] [Accepted: 09/02/2023] [Indexed: 04/16/2024] Open
Abstract
Introduction Spinal fusion surgery with instrumentation is a treatment of choice for many spinal disorders; however, there is little data related to factors associated with early and late outcomes, especially among patients with poor bone quality (e.g., osteoporosis). We conducted this study to characterize the epidemiology and outcomes of patients undergoing spinal fusion surgery with instrumentation in Japan, especially in patients with poor bone quality and those needing additional fixation methods. Methods This retrospective observational study used real-world health insurance claims data from the Japanese Medical Data Vision. Adult patients undergoing an index spinal fusion procedure from April 1, 2010, to September 30, 2017, with procedural details, length of stay (LOS), total in-hospital costs, spine-related reoperation, all-cause readmission, and postoperative complications recorded. Data were summarized descriptively overall, by osteoporosis status, and additional fixation method used, and were analyzed in bivariate analyses. Multivariate logistic and linear regressions were used to explore associations between covariates and variables of interest. Results A total of 22,932 patients (mean age, 67.3 years; 51.2% male) met the study criteria and were included. A total of 5,288 (23.0%) patients had osteoporosis, and 2,507 (10.9%) needed additional fixation methods; these patients were older, more frequently female, and had higher Elixhauser comorbidity index scores. Osteoporosis and additional fixation use were also associated with longer LOS, higher hospital costs, and higher rates of complications. Conclusions Patients with osteoporosis and those needing additional fixation methods have a higher risk for procedural and postoperative complications, reoperation, longer LOS, and higher total hospital costs.
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Affiliation(s)
- Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - HyeJin Park
- Health Economics and Market Access, Johnson & Johnson Medical, Seoul, Republic of Korea
| | - Mami Ogiri
- Health Economics and Market Access, Johnson & Johnson Medical J.J.K.K., Tokyo, Japan
| | - Anne Rossi
- Health Economics and Market Access, Johnson & Johnson Medical, Socresby, Australia
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13
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Zhang Z, Ling F, Chen K, Liu Y, Ding Q, Zhang Z. Postoperative screw pullout of severe spondylolisthesis in osteogenesis imperfecta: a case report with 3-year follow-up. Ann Med Surg (Lond) 2024; 86:1778-1781. [PMID: 38463063 PMCID: PMC10923305 DOI: 10.1097/ms9.0000000000001787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/24/2024] [Indexed: 03/12/2024] Open
Abstract
Introduction and importance Osteogenesis imperfecta (OI) is a rare skeletal disorder characterized by bone fragility and deformities in both paediatric and adult populations. The occurrence of severe spondylolisthesis in OI patients is even more infrequent. However, there is no consensus regarding the optimal treatment approach for OI patients afflicted with severe spondylolisthesis. The selection of surgical procedures and the effective management of postoperative complications present significant challenges in this context. Case presentation A 30-year-old male patient diagnosed with OI type IV (Sillence classification) underwent the lumbar laminectomy and postero-lateral fusion due to severe spondylolisthesis (grade Ⅲ). Following the surgery, the patient experienced postoperative screw pullout while on bedrest. However, aside from experiencing back pain, there were no neurological symptoms present. To address this issue, the patient received salvage treatment in the form of cast immobilization combined with bisphosphonates. At the 3-year follow-up, the patient exhibited absence of sciatic nerve pain and reported mild numbness in the lower extremities. Moreover, the patient demonstrated the ability to ambulate a distance exceeding 1500 m. Nevertheless, the persistence of sexual dysfunction was observed. Clinical discussion This study presented the initial instance of surgical complications observed in patients with severe spondylolisthesis and OI. This highlights the importance to exercise meticulous caution and thoroughness when assessing surgical interventions. Conclusion In cases where the fixation fails to offer adequate biomechanical stability, the administration of bisphosphonates and robust immobilization remains crucial, even in the presence of complications.
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Affiliation(s)
- Zhongtai Zhang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University
| | - Feng Ling
- Department of Orthopedics, Jiangsu Taizhou People’s Hospital, Taizhou, Jiangsu Province, China
| | - Kangwu Chen
- Department of Orthopedics, The First Affiliated Hospital of Soochow University
| | - Yuxuan Liu
- The Affiliated Stomatological Hospital of Soochow University, Suzhou Stomatological Hospital, Suzhou
| | - Qingfeng Ding
- Department of Orthopedics, The First Affiliated Hospital of Soochow University
| | - Zhigang Zhang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University
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14
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Fogel G, Musie J, Phillips TR, Shonnard M, Youssef S, Hirsch JA, Beall DP. Assessment and management of patients developing low energy vertebral compression fractures following basivertebral nerve ablation. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:249-251. [PMID: 37756701 DOI: 10.1093/pm/pnad132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Guy Fogel
- Christus Santa Rosa Spine Clinic, San Antonio, TX 78229, United States
| | - Jacob Musie
- University of Texas at San Antonio, San Antonio, TX 78249, United States
| | | | - Matthew Shonnard
- Baylor Scott & White PM&R Department, Baylor Institute for Rehabilitation, Dallas, TX 75246, United States
| | - Salma Youssef
- University College Dublin School of Medicine, University College Dublin, Belfield, Dublin 4D04 V1W8, Ireland
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School Department of Interventional Neuroradiology, Boston, MA 02114, United States
| | - Douglas P Beall
- Comprehensive Specialty Care, Edmond, OK 73034, United States
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15
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Wang S, Liu H, Yang K, Zhang X, Hu Y, Yang H, Qu B. The Significance of Combined OSTA, HU Value and VBQ Score in Osteoporosis Screening Before Spinal Surgery. World Neurosurg 2024; 182:e692-e701. [PMID: 38081584 DOI: 10.1016/j.wneu.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE This study aimed to assess the utility of a combined assessment using the Osteoporosis Self-Assessment Tool for Asians (OSTA), Hounsfield unit (HU) value, and vertebral bone quality (VBQ) score for preoperative osteoporosis (OP) screening in patients scheduled for spinal surgery. METHODS This study encompassed 288 participants, including 128 males and 160 females. Patients were stratified into 2 groups: the OP group (T-score ≤ -2.5) and the non-OP group (T-score > -2.5), determined by dual-energy X-ray absorptiometry (DEXA). Binary logistic regression was used to construct a combined diagnostic model, and the receiver operating characteristic (ROC) curve evaluated the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of these metrics individually or in combination to screen for OP. RESULTS Osteoporosis patients exhibited significantly lower OSTA and HU values in comparison to non-OP patients, while their VBQ scores were significantly higher (P < 0.001). The ROC curve analysis results indicated that within the male group, the combined diagnosis had a sensitivity of 93.8%, specificity of 82.3%, accuracy of 85.2%, PPV of 63.8%, and NPV of 97.5%. In the female group, the combined diagnosis had a sensitivity of 93.9%, specificity of 87.4%, accuracy of 90.0%, PPV of 83.6%, and NPV of 95.4%. CONCLUSIONS The combined use of OSTA, HU values, and VBQ scores in preoperative OP screening for spinal surgery demonstrates significantly higher accuracy and superior screening value compared to individual assessments. These results establish a robust scientific foundation for conducting preoperative OP screening in patients undergoing spinal surgery.
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Affiliation(s)
- Song Wang
- School of clinical medicine, Chengdu Medical College, Sichuan, China
| | - Hao Liu
- Department of Orthopaedics, First Affiliated Hospital of Chengdu Medical College, Sichuan, China
| | - Kunhai Yang
- School of clinical medicine, Chengdu Medical College, Sichuan, China
| | - Xiang Zhang
- School of clinical medicine, Chengdu Medical College, Sichuan, China
| | - Yongrong Hu
- School of clinical medicine, Chengdu Medical College, Sichuan, China
| | - Hongsheng Yang
- Department of Orthopaedics, First Affiliated Hospital of Chengdu Medical College, Sichuan, China
| | - Bo Qu
- Department of Orthopaedics, First Affiliated Hospital of Chengdu Medical College, Sichuan, China.
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Wang Z, Zhang J, Chen Q, Huang Y, Song Y, Liu L, Feng G. Different cervical vertebral bone quality scores for bone mineral density assessment for the patients with cervical degenerative disease undergoing ACCF/ACDF: computed tomography and magnetic resonance imaging-based study. J Orthop Surg Res 2023; 18:927. [PMID: 38053202 DOI: 10.1186/s13018-023-04422-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Bone mineral density (BMD) is important for the outcome of cervical spine surgery. As the gold standard of assessing BMD, dual-energy X-ray absorptiometry scans are often not ordered or go unreviewed in patients' charts. As the supplement, MRI-based vertebral bone quality (VBQ) was found to accurately predict osteopenia/osteoporosis and postoperative complications in lumbar spine. However, discussion of the efficiency of VBQ in cervical spine is lacking. And measurement methods of VBQ in cervical spine are diverse and not universally acknowledged like lumbar spine. We aimed to compare the predictive performance of three kinds of different Cervical-VBQ (C-VBQ) scores for bone mineral density assessment in patients undergoing cervical spine surgery. HU value of cervical spine was set as a reference. METHODS Adult patients receiving cervical spine surgery for degenerative diseases were retrospectively included between Jan 2015 and Dec 2022 in our hospital. The VBQ scores and HU value were measured from preoperative MRI and CT. The correlation between HU value/C-VBQs (named C-VBQ1/2/3 according to different calculating methods) and DEXA T-score was analyzed using univariate linear correlation and Pearson's correlation. We evaluated the predictive performance of those two parameters and achieved the most appropriate cutoff value by comparing the receiver operating characteristic (ROC) curves. RESULTS 106 patients (34 patients with T ≥ - 1.0 vs 72 patients with T < - 1.0) were included (mean age: 51.95 ± 10.94, 48 men). According to Pearson correlation analysis, C-VBQ1/2/3 and HU value were all significantly correlated to DEXA T-score (Correlation Coefficient (r): C-VBQ1: - 0.393, C-VBQ2: - 0.368, C-VBQ3: - 0.395, HU value: 0.417, p < 0.001). The area under the ROC curve (AUC) was calculated (C-VBQ1: 0.717, C-VBQ2: 0.717, C-VBQ3: 0.727, HU value: 0.746). The AUC of the combination of C-VBQ3 and HU value was 0.786. At last, the most appropriate cutoff value was determined (C-VBQ1: 3.175, C-VBQ2: 3.005, C-VBQ3: 2.99, HU value: 299.85 HU). CONCLUSIONS Different MRI-based C-VBQ scores could all be potential and alternative tools for opportunistically screening patients with osteopenia and osteoporosis before cervical spine surgery. Among them, C-VBQ calculated in ASIC2-C7/SIT1-CSF performed better. We advised patients with C-VBQ higher than cutoff value to accept further BMD examination.
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Affiliation(s)
- Zhe Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jingyao Zhang
- Core Facilities of West China Hospital, Sichuan University, Chengdu, China
| | - Qian Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Huang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yueming Song
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
| | - Limin Liu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
| | - Ganjun Feng
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
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17
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Pan TY, Chang CC, Chen HT, Tsou HK, Lin YC, Hsu CH. Effectiveness of Teriparatide for Spine Fusion in Osteoporotic Patient: A Systematic Review and Meta-Analysis of Comparative Studies. World Neurosurg 2023; 179:8-17. [PMID: 37479030 DOI: 10.1016/j.wneu.2023.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Our goal was to assess teriparatide's (TP) effectiveness in improving radiographic and functional outcomes after spinal fusion surgery. This meta-analysis included randomized controlled trials (RCTs) and comparative cohort studies. The findings provide valuable insights and guidance for surgeons treating osteoporotic patients undergoing spinal fusion surgery. METHODS We conducted a systematic review to assess TP's efficacy in spinal fusion surgery for osteoporosis. Through thorough selection, data extraction, and quality assessment, we employed network meta-analysis to evaluate radiographic outcomes (fusion rate, screw loosening, vertebral fracture) and changes in bone mineral density measured by Hounsfield units. Functional outcomes were assessed using the Oswestry Disability Index scales. Our study aims to comprehensively understand TP's impact and effectiveness in spinal fusion surgery. RESULTS A total of 868 patients were included in the analysis. All patients underwent thoracolumbar internal fixation fusion surgery and were divided into following 2 groups: the TP treatment group and the control group. The results revealed significant differences in radiological outcomes. The fusion rate showed a significant difference, as well as screw loosening, and bone mineral density measured in Hounsfield units. However, there was no significant difference in vertebral fracture. The TP group demonstrated favorable effects with statistical significance. In terms of functional outcomes, there was no significant difference in the assessment of Oswestry Disability Index scores between the 2 treatment groups. CONCLUSIONS The meta-analysis demonstrated that the TP group exhibited significantly better outcomes, particularly in radiological measures, when compared to the control group. The use of TP in spinal fusion surgery shows promise in reducing postoperative complications and providing overall benefits.
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Affiliation(s)
- Tao-Yin Pan
- Minimally invasive spine and joint center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China
| | - Chien-Chun Chang
- Minimally invasive spine and joint center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China; Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan, Republic of China; Department of Orthopaedic, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China.
| | - Hsien-Te Chen
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan, Republic of China; Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan, Republic of China; Department of Sport Medicine, College of Health Care, China Medical University, Taichung, Taiwan, Republic of China
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China; Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County, Taiwan, Republic of China; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China
| | - Ying-Chao Lin
- School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China; Department of Neurological Institute, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, Republic of China
| | - Chin-Hsien Hsu
- Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan, Republic of China
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Boucas P, Mamdouhi T, Rizzo SE, Megas A. Cement Augmentation of Pedicle Screw Instrumentation: A Literature Review. Asian Spine J 2023; 17:939-948. [PMID: 37788974 PMCID: PMC10622820 DOI: 10.31616/asj.2022.0216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 10/05/2023] Open
Abstract
This literature review aimed to review the current understanding, indications, and limitations of pedicle screw instrumentation cement augmentation. Since they were first reported in the 1980s, pedicle screw cement augmentation rates have been increasing. Several studies have been published to date that describe various surgical techniques and the biomechanical changes that occur when cement is introduced through the screw-bone interface. This article provides a concise review of the uses, biomechanical properties, cost analysis, complications, and surgical techniques used for pedicle screw cement augmentation to help guide physician practices. A comprehensive review of the current literature was conducted, with key studies, and contributions from throughout history being highlighted. Patients with low bone mineral density are the most well-studied indication for pedicle screw cement augmentation. Many studies show that cement augmentation can improve pullout strength in patients with low bone mineral density; however, the benefit varies inversely with pathology severity and directly with technique. The various screw types are discussed, with each having its own mechanical advantages. Cement distribution is largely dependent on the filling method and volume of cement used. Cement composition and timing of cement use after mixing are critical considerations in practice because they can significantly alter the bone-cement and screw-cement interfaces. Overall, studies have shown that pedicle screw cement augmentation has a low complication rate and increased pullout strength, justifying its universal use in patients with a suboptimal bone-implant interface.
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Affiliation(s)
- Peter Boucas
- Department of Orthopaedic Surgery, Huntington Hospital Northwell Health, Huntington, NY,
USA
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY,
USA
| | - Tania Mamdouhi
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY,
USA
| | - Sarah E. Rizzo
- Department of Orthopaedic Surgery, Huntington Hospital Northwell Health, Huntington, NY,
USA
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY,
USA
| | - Andrew Megas
- Department of Orthopaedic Surgery, Grewal Orthopaedic and Spine Care, East Meadow, NY,
USA
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Costăchescu B, Niculescu AG, Grumezescu AM, Teleanu DM. Screw Osteointegration-Increasing Biomechanical Resistance to Pull-Out Effect. MATERIALS (BASEL, SWITZERLAND) 2023; 16:5582. [PMID: 37629873 PMCID: PMC10456840 DOI: 10.3390/ma16165582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023]
Abstract
Spinal disorders cover a broad spectrum of pathologies and are among the most prevalent medical conditions. The management of these health issues was noted to be increasingly based on surgical interventions. Spinal fixation devices are often employed to improve surgery outcomes, increasing spinal stability, restoring structural integrity, and ensuring functionality. However, most of the currently used fixation tools are fabricated from materials with very different mechanical properties to native bone that are prone to pull-out effects or fail over time, requiring revision procedures. Solutions to these problems presently exploited in practice include the optimal selection of screw shape and size, modification of insertion trajectory, and utilization of bone cement to reinforce fixation constructs. Nevertheless, none of these methods are without risks and limitations. An alternative option to increasing biomechanical resistance to the pull-out effect is to tackle bone regenerative capacity and focus on screw osteointegration properties. Osteointegration was reportedly enhanced through various optimization strategies, including use of novel materials, surface modification techniques (e.g., application of coatings and topological optimization), and utilization of composites that allow synergistic effects between constituents. In this context, this paper takes a comprehensive path, starting with a brief presentation of spinal fixation devices, moving further to observations on how the pull-out strength can be enhanced with existing methods, and further focusing on techniques for implant osteointegration improvement.
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Affiliation(s)
- Bogdan Costăchescu
- “Gr. T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
- “Prof. Dr. N. Oblu” Emergency Clinical Hospital, 700309 Iasi, Romania
| | - Adelina-Gabriela Niculescu
- Research Institute of the University of Bucharest—ICUB, University of Bucharest, 050657 Bucharest, Romania;
- Department of Science and Engineering of Oxide Materials and Nanomaterials, Politehnica University of Bucharest, 011061 Bucharest, Romania
| | - Alexandru Mihai Grumezescu
- Research Institute of the University of Bucharest—ICUB, University of Bucharest, 050657 Bucharest, Romania;
- Department of Science and Engineering of Oxide Materials and Nanomaterials, Politehnica University of Bucharest, 011061 Bucharest, Romania
- Academy of Romanian Scientists, Ilfov No. 3, 050044 Bucharest, Romania
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Mraja HM, Gök H, Daadour IMF, Ulusoy OL, Şanlı T, Karadereler S, Enercan M, Hamzaoglu A. Cement Augmented Pedicle Screw Instrumentation in Pediatric Spine Surgery. World Neurosurg 2023; 174:e126-e130. [PMID: 36894000 DOI: 10.1016/j.wneu.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Osteoporosis in pediatric patients is rare. Osteomalacia and osteoporosis are known to develop in syndromic or neuromuscular scoliosis children. Spinal deformity surgery for pediatric patients with osteoporosis is challenging, associated with pedicle screw (PS) failure and compression fractures. Cement augmentation of PS is one several measures to prevent screw failure. It provides additional pull-out strength to the PS in the osteoporotic vertebra. METHODS In 2010-2020, an analysis of pediatric patients who had cement augmentation of PS with a minimum follow-up of 2 years was performed. Radiological and clinical evaluations were analyzed. RESULTS The study included 7 patients (4 girls, 3 boys) with a mean age of 13 years (range, 10-14 years) and mean follow-up of 3 years (range, 2-3 years). Only 2 patients underwent revision surgery. Total number of cement augmented PSs was 52 with an average of 7 per patient. Only 1 patient had lower instrumented vertebra vertebroplasty. There was no PS pull-out in the cement augmented levels, and there were no neurological deficits or pulmonary cement embolisms. One patient developed a PS pull-out in uncemented levels. Two patients developed compression fractures, one, with osteogenesis imperfecta, in the supra-adjacent levels (upper instrumented vertebra + 1 and upper instrumented vertebra + 2), and the other, with neuromuscular scoliosis, in the uncemented segments. CONCLUSIONS In this study, all cement augmented PSs provided satisfactory radiological outcomes without PS pull-out and adjacent vertebral compression fracture. In pediatric spine surgery, in osteoporotic patients with a poor bone purchase, cement augmentation may be used, especially in high-risk patients with osteogenesis imperfecta, neuromuscular scoliosis, and syndromic scoliosis.
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Affiliation(s)
| | - Halil Gök
- Scoliosis-Spine Center Istanbul, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | | | - Onur Levent Ulusoy
- Radiology Department, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | - Tunay Şanlı
- Scoliosis-Spine Center Istanbul, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | - Selhan Karadereler
- Scoliosis-Spine Center Istanbul, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | - Meriç Enercan
- Scoliosis-Spine Center Istanbul, Demiroglu Bilim University, Istanbul, Turkey
| | - Azmi Hamzaoglu
- Scoliosis-Spine Center Istanbul, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
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21
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Meaney P, Augustine R, Welteke A, Pfrommer B, Pearson AM, Brisby H. Transmission-Based Vertebrae Strength Probe Development: Far Field Probe Property Extraction and Integrated Machine Vision Distance Validation Experiments. SENSORS (BASEL, SWITZERLAND) 2023; 23:4819. [PMID: 37430734 DOI: 10.3390/s23104819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 07/12/2023]
Abstract
We are developing a transmission-based probe for point-of-care assessment of vertebrae strength needed for fabricating the instrumentation used in supporting the spinal column during spinal fusion surgery. The device is based on a transmission probe whereby thin coaxial probes are inserted into the small canals through the pedicles and into the vertebrae, and a broad band signal is transmitted from one probe to the other across the bone tissue. Simultaneously, a machine vision scheme has been developed to measure the separation distance between the probe tips while they are inserted into the vertebrae. The latter technique includes a small camera mounted to the handle of one probe and associated fiducials printed on the other. Machine vision techniques make it possible to track the location of the fiducial-based probe tip and compare it to the fixed coordinate location of the camera-based probe tip. The combination of the two methods allows for straightforward calculation of tissue characteristics by exploiting the antenna far field approximation. Validation tests of the two concepts are presented as a precursor to clinical prototype development.
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Affiliation(s)
- Paul Meaney
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, USA
- Electrical Engineering Department, Uppsala University, 751 05 Uppsala, Sweden
| | - Robin Augustine
- Electrical Engineering Department, Uppsala University, 751 05 Uppsala, Sweden
| | - Adrian Welteke
- Electrical Engineering Department, Helmut Schmidt University, 22043 Hamburg, Germany
| | | | - Adam M Pearson
- Geisel School of Medicine, Dartmouth College, Lebanon, NH 03766, USA
| | - Helena Brisby
- Orthopedic Department, Sahlgrenska Hospital, 413 45 Gothenburg, Sweden
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22
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Khan MA, Jennings JW, Baker JC, Smolock AR, Shah LM, Pinchot JW, Wessell DE, Kim CY, Lenchik L, Parsons MS, Huhnke G, Shek-Man Lo S, Lu Y, Potter C, Reitman C, Sahgal A, Sharma A, Yalla NM, Beaman FD, Kapoor BS, Burns J. ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update. J Am Coll Radiol 2023; 20:S102-S124. [PMID: 37236738 DOI: 10.1016/j.jacr.2023.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Majid A Khan
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | - Jack W Jennings
- Research Author, Washington University, Saint Louis, Missouri
| | - Jonathan C Baker
- Mallinckrodt Institute of Radiology Washington University School of Medicine, St. Louis, Missouri
| | - Amanda R Smolock
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah
| | | | | | - Charles Y Kim
- Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina
| | - Leon Lenchik
- Panel Vice-Chair, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew S Parsons
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, St. Louis, Missouri
| | - Gina Huhnke
- Deaconess Hospital, Evansville, Indiana American College of Emergency Physicians
| | - Simon Shek-Man Lo
- University of Washington School of Medicine, Seattle, Washington Commission on Radiation Oncology
| | - Yi Lu
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | - Christopher Potter
- Brigham & Women's Hospital, Boston, Massachusetts Committee on Emergency Radiology-GSER
| | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina North American Spine Society
| | - Arjun Sahgal
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Commission on Radiation Oncology
| | - Akash Sharma
- Mayo Clinic, Jacksonville, Florida Commission on Nuclear Medicine and Molecular Imaging
| | - Naga M Yalla
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri, Primary care physician
| | | | | | - Judah Burns
- Specialty Chair, Montefiore Medical Center, Bronx, New York
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23
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Angelini A, Mosele N, Gnassi A, Baracco R, Rodà MG, Cerchiaro M, Ruggieri P. Vertebra Plana: A Narrative Clinical and Imaging Overview among Possible Differential Diagnoses. Diagnostics (Basel) 2023; 13:diagnostics13081438. [PMID: 37189540 DOI: 10.3390/diagnostics13081438] [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: 03/27/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023] Open
Abstract
Vertebra plana is a rare radiologic condition characterized by a uniform loss of height of a vertebral body that represents a diagnostic challenge for surgeons. The purpose of this study was to review all possible differential diagnoses that may present with a vertebra plana (VP) described in the current literature. For that purpose, we performed a narrative literature review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, analyzing 602 articles. Patient demographics, clinical presentation, imaging characteristics and diagnoses were investigated. VP is not a pathognomonic feature of Langerhans cell histiocytosis, but other oncologic and non-oncologic conditions should be considered. The list of differential diagnoses, based on our literature review, can be recalled with the mnemonic HEIGHT OF HOMO: H-Histiocytosis; E-Ewing's sarcoma; I-Infection; G-Giant cell tumor; H-Hematologic neoplasms; T-Tuberculosis; O-Osteogenesis imperfecta; F-Fracture; H-Hemangioma; O-Osteoblastoma; M-Metastasis; O-Osteomyelitis, chronic.
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Affiliation(s)
- Andrea Angelini
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Nicolò Mosele
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Andrea Gnassi
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Riccardo Baracco
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Maria Grazia Rodà
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Mariachiara Cerchiaro
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
| | - Pietro Ruggieri
- Department of Orthopedics and Orthopedic Oncology, University of Padova, 35128 Padova, Italy
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Liu X, Zhou Q, Yu X, Tian J, Sun Z, Wang H. Comparison of Wiltse Approach of Pedicle Screw Fixation With or Without Vertebroplasty in the Treatment of Genant III Degree Osteoporotic Thoracolumbar Fractures: Analysis of Clinical Findings, Radiographic Parameters, and Follow-Up Complications. Global Spine J 2023:21925682231166324. [PMID: 37021369 DOI: 10.1177/21925682231166324] [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] [Indexed: 04/07/2023] Open
Abstract
STUDY DESIGN A retrospective case-control study. OBJECTIVE This study aimed to compare the effects of the Wiltse approach of pedicle screw fixation (PSF) either in combination with or without vertebroplasty (VP) in the treatment of Genant III degree osteoporotic thoracolumbar fractures (Genant III-OTLFs). METHODS A retrospective study of Genant III-OTLFs was performed from January 2018 to December 2019, including 54 cases of PSF + VP and 56 cases of PSF. Clinical indicators [visual analog scale (VAS) score, Oswestry disability index (ODI)], radiographic parameters [local kyphosis angle (LKA), percentage of anterior, central, and posterior vertebral heights (AVH%, CVH%, and PVH%, respectively)] and follow-up complications [adjacent vertebral fracture (AVF), residual pain (RP), vertebral height loss (VHL), and internal fixation failure (IFF)] were compared between the 2 groups. RESULTS No differences in surgical outcomes, clinical indicators, and radiographic parameters were observed between the 2 groups during the preoperation period and 7 days post-operatively (P > .05). However, the VAS score [2.0 (.6), 1.9 (.5)], ODI [23.7 (4.0), 22.6 (3.0)], LKA [9.5 (1.8), 10.6 (3.0)], AVH% [90.1 (2.7), 87.7 (6.0)], CVH% [92.5 (2.6), 91.3 (3.7)], and PVH% [93.4 (2.0), 92.7 (2.4)] at 1 year post-operatively and last follow-up of the PSF + VP group were better than those of the PSF group [2.5 (.8), 3.1 (1.1), 26.6 (3.8), 29.6 (4.6), 12.2 (1.6), 16.6 (3.2), 84.9 (4.0), 69.9 (6.6), 88.1 (3.1), 78.2 (5.1), 89.7 (2.3), 84.8 (4.6)], respectively (P < .001). During follow-up, the incidence of AVF had no difference (P > .05), while that of RP (32.1 vs 14.8%), VHL (33.9 vs 9.3%) and IFF (17.9 vs 5.6%) had statistical differences between them (P < .05). CONCLUSION The Wiltse approach of PSF combined with VP for Genant III-OTLFs can not only effectively relieve pain, restore vertebral height, and correcte kyphosis, but also better maintain vertebral height, delay kyphosis progression, and reduce complications during follow-up.
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Affiliation(s)
- Xiaolei Liu
- Department of Orthopedics, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qinqin Zhou
- Department of Anesthesiology, BenQ Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiao Yu
- Department of Orthopedics, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiwei Tian
- Department of Orthopedics, BenQ Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Zhongyi Sun
- Department of Orthopedics, BenQ Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Haibin Wang
- Department of Orthopedics, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
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25
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Schömig F, Becker L, Schönnagel L, Völker A, Disch AC, Schnake KJ, Pumberger M. Avoiding Spinal Implant Failures in Osteoporotic Patients: A Narrative Review. Global Spine J 2023; 13:52S-58S. [PMID: 37084355 PMCID: PMC10177307 DOI: 10.1177/21925682231159066] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES With an aging population, the prevalence of osteoporosis is continuously rising. As osseous integrity is crucial for bony fusion and implant stability, previous studies have shown osteoporosis to be associated with an increased risk for implant failure and higher reoperation rates after spine surgery. Thus, our review's purpose was to provide an update of evidence-based solutions in the surgical treatment of osteoporosis patients. METHODS We summarize the existing literature regarding changes associated with decreased bone mineral density (BMD) and resulting biomechanical implications for the spine as well as multidisciplinary treatment strategies to avoid implant failures in osteoporotic patients. RESULTS Osteoporosis is caused by an uncoupling of the bone remodeling cycle based on an unbalancing of bone resorption and formation and resulting reduced BMD. The reduction in trabecular structure, increased porosity of cancellous bone and decreased cross-linking between trabeculae cause a higher risk of complications after spinal implant-based surgeries. Thus, patients with osteoporosis require special planning considerations, including adequate preoperative evaluation and optimization. Surgical strategies aim towards maximizing screw pull-out strength, toggle resistance, as well as primary and secondary construct stability. CONCLUSIONS As osteoporosis plays a crucial role in the fate of patients undergoing spine surgery, surgeons need to be aware of the specific implications of low BMD. While there still is no consensus on the best course of treatment, multidisciplinary preoperative assessment and adherence to specific surgical principles help reduce the rate of implant-related complications.
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Affiliation(s)
- Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Luis Becker
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lukas Schönnagel
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Völker
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center, University Center for Orthopedics, Traumatology and Plastic Surgery, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St Marien gGmbH, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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26
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Zhang XY, Han Y. Comparison of the biomechanical effects of lumbar disc degeneration on normal patients and osteoporotic patients: A finite element analysis. Med Eng Phys 2023; 112:103952. [PMID: 36842775 DOI: 10.1016/j.medengphy.2023.103952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 12/17/2022] [Accepted: 01/07/2023] [Indexed: 01/10/2023]
Abstract
BACKGROUND Some older patients who suffered from both conditions (disc degeneration and osteoporosis) have higher surgical risks and longer postoperative recovery times. Understanding the relation between disc degeneration and osteoporosis is fundamental to know the mechanisms of orthopedic disorders and improve clinical treatment. However, there is a lack of finite element (FE) studies to predict the combined effects of disc degeneration and osteoporosis. So the aim of the present study is to explore the differences of biomechanical effects of lumbar disc degeneration on normal patients and osteoporotic patients. METHODS A normal lumbar spine finite element model (FEM) was developed based on the geometric information of a healthy male subject (age 35 years; height 178 cm; weight 65 kg). This normal lumbar spine FEM was modified to build three lumbar spine degeneration models simulating mild, moderate and severe grades of disc degeneration at the L4-L5 segment. Then the degenerative lumbar spine models for osteoporotic patients were constructed on the basis of the above-mentioned degeneration models. Firstly, the normal model (flexion: 8 Nm; extension: 6 Nm; lateral bending: 6 Nm; torsion: 4 Nm) and degenerative models (10 Nm) were calibrated under pure moment load, respectively. Secondly, under a 400 N follower load, the 7.5 Nm moments of different directions were applied on all models to simulate different motion postures. Finally, under the above loading conditions, we calculated and analyzed the range of motion (ROM), Mises stress in cortical (MSC1), Mises stress in endplate (MSE), Mises stress in cancellous (MSC2), and Mises stress in post (MSP). RESULTS Compared with disc degeneration patients without osteoporosis, the ROM, MSC1, and MSE of osteoporosis patients with various disc degeneration decreased in all postures, while the MSC2 and MSP increased. With increase in the degree of disc degeneration, the reduction proportions of ROM and MSE in osteoporotic patients gradually increased, while the reduction percentages in MSC1 of osteoporotic patients gradually decreased. The increase percentages of MSC2 in osteoporotic patients gradually increased. Given the progressive changes of disc degeneration, the changes in MSP in osteoporosis patients were uneven. CONCLUSION In summary, the effect of disc degeneration on flexibility in the two kinds of patients (osteoporosis and non-osteoporosis patients) was nearly same. By comparing the remaining biomechanical parameters (MSC1, MSE, MSC2, and MSP), we found that degenerated intervertebral discs caused changes in loading patterns of osteoporosis patients. Disc degeneration reduced the Mises stress in the cortical and endplate, which increased the Mises stress in the cancellous and post. That is to say, in order to cope with the changes in bone stresses caused by disc degeneration and osteoporosis, clinicians should be more careful in choosing the surgical option for osteoporotic patients with disc degeneration.
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Affiliation(s)
- Xin-Ying Zhang
- Department of Infection Control, The Affiliated Hospital of Hebei University, Hebei, 071000, China
| | - Ye Han
- Department of Orthopaedics, The Affiliated Hospital of Hebei University, Hebei, 071000, China.
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27
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Peng JC, Guo HZ, Zhan CG, Huang HS, Ma YH, Zhang SC, Xu YR, Mo GY, Tang YC. Comparison of pedicle screw fixation with or without cement augmentation for treating single-segment isthmic spondylolisthesis in the osteoporotic spine. Sci Rep 2023; 13:827. [PMID: 36646752 PMCID: PMC9842729 DOI: 10.1038/s41598-023-27539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
The present study examined the necessity of cement-augmented pedicle screw fixation in osteoporotic patients with single-segment isthmic spondylolisthesis.Fifty-nine cases were reviewed retrospectively. Thirty-three cases were in the polymethylmethacrylate-augmented pedicle screw (PMMA-PS) group, and the other 26 cases were in the conventional pedicle screw (CPS) group. Evaluation data included operation time, intraoperative blood loss, hospitalization cost, hospitalization days, rates of fusion, screw loosening, bone cement leakage, visual analogue scale (VAS) scores, Oswestry disability index (ODI), lumbar lordosis (LL), pelvic tilt (PT) and sacral slope (SS).The operation time and blood loss in the CPS group decreased significantly compared to those in the PMMA-PS group. The average hospitalization cost of the PMMA-PS group was significantly higher than that of the CPS group. There was no significant difference in the average hospital stay between the 2 groups. The initial and last follow-up postoperative VAS and ODI scores improved significantly in the two groups. There were no significant differences in VAS and ODI between the 2 groups at each time point. The last postoperative spine-pelvic parameters were significantly improved compared with those preoperatively. In the PMMA-PS group, the fusion rate was 100%. The fusion rate was 96.15% in the CPS group. No significant difference was found between the two groups for the fusion rate. Nine patients in the PMMA-PS group had bone cement leakage. There was no screw loosening in the PMMA-PS group. There were 2 cases of screw loosening in the CPS group. There were no significant differences in screw loosening, postoperative adjacent segment fractures, postoperative infection or postoperative revision between the 2 groups. The use of PMMA-PS on a regular basis is not recommended in posterior lumbar interbody fusion for the treatment of single-segment isthmic spondylolisthesis with osteoporosis.
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Affiliation(s)
- Jian-Cheng Peng
- Longgang Orthopedics Hospital of Shenzhen, Shenzhen, 518100, China
| | - Hui-Zhi Guo
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Chen-Guang Zhan
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Hua-Sheng Huang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yan-Huai Ma
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Shun-Cong Zhang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yue-Rong Xu
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Guo-Ye Mo
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yong-Chao Tang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China. .,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.
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Razzouk J, Ramos O, Ouro-Rodrigues E, Samayoa C, Wycliffe N, Cheng W, Danisa O. Comparison of cervical, thoracic, and lumbar vertebral bone quality scores for increased utility of bone mineral density screening. 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; 32:20-26. [PMID: 36509887 DOI: 10.1007/s00586-022-07484-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 11/22/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the associations among the validated lumbar vertebral bone quality (VBQ) score, and cervical and thoracic VBQ scores. METHODS Radiographic records of 100 patients who underwent synchronous MRI of the cervical, thoracic, and lumbar spine were retrieved. DEXA-validated lumbar VBQ was calculated using median signal intensity (MSI) of the L1-L4 vertebrae and L3 CSF. VBQ was derived as the quotient of MSIL1-L4 divided by MSICSF. Cervical and thoracic VBQ were similarly obtained using C3-C6 and C5 CSF, and T5-T8 and T7 CSF, respectively. Paired sample t-tests were used to evaluate differences among regional VBQ scores. Independent sample t-tests were used to identify sex differences in VBQ. Regression models with one-way analysis of variance (ANOVA) were constructed to identify associations among all permutations of anthropometric and regional VBQ measures. RESULTS Mean cervical, thoracic, and lumbar VBQ scores were 3.06 ± 0.89, 2.60 ± 0.77, and 2.47 ± 0.61, respectively. Mean differences of .127 (p = 0.045) and - 0.595 (p < 0.001) were observed between thoracic and lumbar, and cervical and lumbar VBQ scores. Correlations of 0.324, 0.356, and 0.600 (p < 0.001) were found between cervical and lumbar, cervical and thoracic, and thoracic and lumbar VBQ scores. Regression with ANOVA predicting lumbar VBQ in relation to cervical and thoracic VBQ demonstrated R Square values of 0.105 and 0.360 (p < 0.001), and β coefficient values of 0.471 and 0.217 (p < 0.001), respectively. CONCLUSION Thoracic VBQ provides values representative of the validated lumbar VBQ score. Cervical VBQ scores are distinct from lumbar VBQ scores and do not provide adequate surrogate values of lumbar VBQ.
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Affiliation(s)
- Jacob Razzouk
- School of Medicine, Loma Linda University, Loma Linda, CA, USA.
- , 11252 Walnut Street, Redlands, CA, 92374, USA.
| | - Omar Ramos
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, Loma Linda, CA, 11406, USA
| | | | - Carlos Samayoa
- Patient Safety and Reliability, Loma Linda University, Loma Linda, CA, USA
| | - Nathaniel Wycliffe
- Department of Radiology, Loma Linda University Health, Loma Linda, CA, USA
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis VA Medical Center, Loma Linda, CA, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda Drive, Suite 213, Loma Linda, CA, 11406, USA
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van Abswoude DH, Pellikaan K, Rosenberg AGW, Davidse K, Coupaye M, Høybye C, Markovic TP, Grugni G, Crinò A, Caixàs A, Poitou C, Mosbah H, Weir T, van Vlimmeren LA, Rutges JPHJ, De Klerk LWL, Zillikens MC, van der Lely AJ, de Graaff LCG. Bone Health in Adults With Prader-Willi Syndrome: Clinical Recommendations Based on a Multicenter Cohort Study. J Clin Endocrinol Metab 2022; 108:59-84. [PMID: 36149817 PMCID: PMC9759176 DOI: 10.1210/clinem/dgac556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/13/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Prader-Willi syndrome (PWS) is a rare complex genetic syndrome, characterized by delayed psychomotor development, hypotonia, and hyperphagia. Hormone deficiencies such as hypogonadism, hypothyroidism, and growth hormone deficiency are common. The combination of hypotonia, low physical activity, and hypogonadism might lead to a decrease in bone mass and increase in fracture risk. Moreover, one would expect an increased risk of scoliosis due to hypotonia and low physical activity. OBJECTIVE To study the prevalence and risk factors for skeletal problems (reduced bone mineral density, fractures, and scoliosis) in adults with PWS. METHODS We retrospectively collected patient characteristics, medical history, medication, biochemical measurements, dual-energy X-ray absorptiometry scans, and spinal X-rays and reviewed the current literature. RESULTS We included 354 adults with PWS (median age 31 years; 43% males), of whom 51 (14%) had osteoporosis (T-score below -2.5) and 143 (54%) had osteopenia (T-score -1 to -2.5). The most prevalent modifiable risk factors for osteoporosis were hypogonadism, insufficient dairy intake, sedentary lifestyle, and corticosteroid use. Male sex was associated with osteoporosis (P = .005). Growth hormone treatment was not associated with osteoporosis. A history of vertebral fractures was present in 10 (3%) and nonvertebral fractures in 59 (17%). Scoliosis was present in 263 (80%), but no modifiable risk factors were identified. CONCLUSION Besides scoliosis, osteoporosis is common in adults with PWS. Based on the literature and the risk factors for osteoporosis found in our cohort, we provide practical clinical recommendations to avoid skeletal complications in these vulnerable patients.
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Affiliation(s)
| | | | - Anna G W Rosenberg
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical
Center, University Medical Center Rotterdam, 3015 GD
Rotterdam, The Netherlands
- Center for Adults with Rare Genetic Syndromes, Department of Internal
Medicine, Division of Endocrinology, Erasmus Medical Center, University Medical Center
Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome,
3015 GD Rotterdam, The
Netherlands
- Academic Center for Growth Disorders, Erasmus Medical Center, University
Medical Center Rotterdam, 3015 GD Rotterdam,
The Netherlands
| | - Kirsten Davidse
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical
Center, University Medical Center Rotterdam, 3015 GD
Rotterdam, The Netherlands
- Center for Adults with Rare Genetic Syndromes, Department of Internal
Medicine, Division of Endocrinology, Erasmus Medical Center, University Medical Center
Rotterdam, 3015 GD Rotterdam, The Netherlands
- Dutch Center of Reference for Prader-Willi Syndrome,
3015 GD Rotterdam, The
Netherlands
- Academic Center for Growth Disorders, Erasmus Medical Center, University
Medical Center Rotterdam, 3015 GD Rotterdam,
The Netherlands
| | - Muriel Coupaye
- Assistance Publique-Hôpitaux de Paris, Rare Diseases Center of reference
‘Prader-Willi Syndrome and obesity with eating disorders’ (PRADORT), Nutrition
Department, Institute of Cardiometabolism and Nutrition, ICAN, Pitié-Salpêtrière
Hospital, Sorbonne Université, INSERM, Nutriomics, F75013
Paris, France
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
| | - Charlotte Høybye
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- ENDO-ERN (European Reference Network)
- Department of Molecular Medicine and Surgery, Karolinska Institute and
Karolinska University Hospital, Stockholm,
Sweden
- Department of Endocrinology, Karolinska Institute and Karolinska University
Hospital, Stockholm, Sweden
| | - Tania P Markovic
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- Metabolism & Obesity Services, Royal Prince Alfred
Hospital, Camperdown, Australia
- Boden Initiative, Charles Perkins Centre, University of
Sydney, SydneyAustralia
| | - Graziano Grugni
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- ENDO-ERN (European Reference Network)
- Divison of Auxology, Istituto Auxologico Italiano, IRCCS,
Piancavallo (VB), Italy
| | - Antonino Crinò
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- Reference Center for Prader-Willi syndrome, Bambino Gesù Hospital, Research
Institute, Palidoro (Rome), Italy
| | - Assumpta Caixàs
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- Department of Endocrinology and Nutrition, Hospital Universitari Parc
Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de
Barcelona, Sabadell, Spain
- Department of Medicine, Universitat Autònoma de Barcelona,
Sabadell, Spain
| | - Christine Poitou
- Assistance Publique-Hôpitaux de Paris, Rare Diseases Center of reference
‘Prader-Willi Syndrome and obesity with eating disorders’ (PRADORT), Nutrition
Department, Institute of Cardiometabolism and Nutrition, ICAN, Pitié-Salpêtrière
Hospital, Sorbonne Université, INSERM, Nutriomics, F75013
Paris, France
- International Network for Research, Management & Education on adults
with Prader-Willi Syndrome (INfoRMEd-PWS)
- ENDO-ERN (European Reference Network)
| | - Helena Mosbah
- Assistance Publique-Hôpitaux de Paris, Rare Diseases Center of reference
‘Prader-Willi Syndrome and obesity with eating disorders’ (PRADORT), Nutrition
Department, Institute of Cardiometabolism and Nutrition, ICAN, Pitié-Salpêtrière
Hospital, Sorbonne Université, INSERM, Nutriomics, F75013
Paris, France
| | - Tessa Weir
- Department of Endocrinology, Nepean-Blue Mountains Hospital,
Sydney, NSW, Australia
- Northern Clinical School, Faculty of Medicine and Health, University of
Sydney, Sydney, NSW, Australia
| | - Leo A van Vlimmeren
- Department of Rehabilitation and Pediatric Physical Therapy, Radboud
University Medical Centrum, 6525 GA Nijmegen,
The Netherlands
| | - Joost P H J Rutges
- Department of Orthopedic surgery, Erasmus Medical Center, University
Medical Center Rotterdam, 3015 GD Rotterdam,
The Netherlands
| | - Luuk W L De Klerk
- Department of Orthopedic surgery, Sint Maartensclinic,
6500 GM Nijmegen, The
Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical
Center, University Medical Center Rotterdam, 3015 GD
Rotterdam, The Netherlands
- ENDO-ERN (European Reference Network)
- Academic Center for Rare Bone Disorders, Erasmus Medical Center, University
Medical Center Rotterdam, 3015 GD Rotterdam,
The Netherlands
- European Reference Network for rare bone diseases (ERN BOND)
| | - Aart J van der Lely
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical
Center, University Medical Center Rotterdam, 3015 GD
Rotterdam, The Netherlands
| | - Laura C G de Graaff
- Correspondence: Laura de Graaff, MD, PhD, Dept. of Internal Medicine, Erasmus
MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
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Medical optimization of osteoporosis for adult spinal deformity surgery: a state-of-the-art evidence-based review of current pharmacotherapy. Spine Deform 2022; 11:579-596. [PMID: 36454531 DOI: 10.1007/s43390-022-00621-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/19/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Osteoporosis is a common, but challenging phenomenon to overcome in adult spinal deformity (ASD) surgery. Several pharmacological agents are at the surgeon's disposal to optimize the osteoporotic patient prior to undergoing extensive reconstruction. Familiarity with these medications will allow the surgeon to make informed decisions on selecting the most appropriate adjuncts for each individual patient. METHODS A comprehensive literature review was conducted in PubMed from September 2021 to April 2022. Studies were selected that contained combinations of various terms including osteoporosis, specific medications, spine surgery, fusion, cage subsidence, screw loosening, pull-out, junctional kyphosis/failure. RESULTS Bisphosphonates, denosumab, selective estrogen receptor modulators, teriparatide, abaloparatide and romosozumab are all pharmacological agents currently available for adjunctive use. While these medications have been shown to have beneficial effects on improving bone mineral density in the osteoporotic patient, varying evidence is available on their specific effects in the context of extensive spine surgery. There is still a lack of human studies with use of the newer agents. CONCLUSION Bisphosphonates are first-line agents due to their low cost and robust evidence behind their utility. However, in the absence of contraindications, optimizing bone quality with anabolic medications should be strongly considered in preparation for spinal deformity surgeries due to their beneficial and favorable effects on fusion and hardware compared to the anti-resorptive medications.
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31
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Wen Z, Mo X, Ma H, Li H, Liao C, Fu D, Cheung WH, Qi Z, Zhao S, Chen B. Study on the Optimal Surgical Scheme for Very Severe Osteoporotic Vertebral Compression Fractures. Orthop Surg 2022; 15:448-459. [PMID: 36444956 PMCID: PMC9891906 DOI: 10.1111/os.13609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/03/2022] [Accepted: 11/03/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Therapy of very severe osteoporotic compression fractures (VSOVCF) has been a growing challenge for spine surgeons. Opinions vary regarding the optimal surgical procedure for the treatment of VSOVCF and which internal fixation method is more effective is still under debate, and research on this topic is lacking. This retrospective study was conducted to compare the efficacy and safety of various pedicle screw fixation methods for treating VSOVCF. METHODS This single-center retrospective comparative study was conducted between January 2015 and September 2020. Two hundred and one patients were divided into six groups according to different surgical methods: 45 patients underwent long-segment fixation (Group 1); 39 underwent short-segment fixation (Group 2); 30 received long-segment fixation with cement-reinforced screws (Group 3); 32 received short-segment fixation with cement-reinforced screws (Group 4); 29 had long-segment fixation combined with kyphoplasty (PKP) (Group 5); and 26 cases had short-segment fixation combined with PKP (Group 6). The clinical records were reviewed and the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) score were used for clinical evaluation. The vertebral height (VH), fractured vertebral body height (FVBH), and Cobb's angle were objectively calculated and analyzed on lateral plain radiographs. Student's t-tests and one-way ANOVA among groups were conducted to analyze the continuous, and the chi-squared test was used to compare the dichotomous or categorical variables. The difference was considered statistically significant when the P-value was less than 0.05. RESULTS The six groups had similar distributions in age, gender, course of the disease, follow-up period, and injured level. In the postoperative assessment of the VAS score, the surgical intervention most likely to rank first in terms of pain relief was the short-segment fixation with cement-reinforced screws (Group 4). For the functional evaluation, the surgical intervention that is most likely to rank first in terms of ODI score was a short-segment fixation with cement-reinforced screws (Group 4), followed by long-segment fixation (Group 1). The long-segment fixation with cement-reinforced screws was the first-ranked surgical intervention for the maintenance of Cobb's angle and vertebral height, whereas the short-segment fixation performed the worst. The highest overall complication rate was in Group 6 with an incidence of 42.3% (11/26), followed by Group 2 with an incidence of 38.5% (15/39). CONCLUSION For the treatment of VSOVCF, the short-segment fixation with cement-reinforced screws is the most effective and optimal procedure, and should be used as the preferred surgical method if surgeons are proficient in using cemented screws; otherwise, directly and unquestionably use long-segment fixation to achieve satisfactory clinical results.
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Affiliation(s)
- Zhenxing Wen
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina,Guangdong Provincial Key Laboratory of Orthopedics and TraumatologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Xiaoyi Mo
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Hangzhan Ma
- Department of Orthopedics, Panyu Hospital of Chinese MedicineGuangzhou University of Chinese MedicineGuangzhouChina
| | - Haonan Li
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina,Guangdong Provincial Key Laboratory of Orthopedics and TraumatologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Changhe Liao
- Department of Orthopedics, Panyu Hospital of Chinese MedicineGuangzhou University of Chinese MedicineGuangzhouChina
| | - Dan Fu
- Department of OrthopaedicsKiang Wu HospitalMacauChina
| | - Wing Hoi Cheung
- Department of Orthopaedics and Traumatology, Prince of Wales HospitalThe Chinese University of Hong KongHong KongChina
| | - Zhichao Qi
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina,Department of OrthopaedicsThe Seventh Affiliated Hospital of Sun Yat‐sen UniversityShenzhenChina
| | - Shengli Zhao
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina,Guangdong Provincial Key Laboratory of Orthopedics and TraumatologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Bailing Chen
- Department of Spine Surgery, The First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina,Guangdong Provincial Key Laboratory of Orthopedics and TraumatologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
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Jones C, Okano I, Arzani A, Dodo Y, Moser M, Reisener MJ, Chiapparelli E, Adl Amini D, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The predictive value of a novel site-specific MRI-based bone quality assessment, endplate bone quality (EBQ), for severe cage subsidence among patients undergoing standalone lateral lumbar interbody fusion. Spine J 2022; 22:1875-1883. [PMID: 35843534 DOI: 10.1016/j.spinee.2022.07.085] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/18/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Studies have shown that site-specific bone density measurements had more predictive value for complications than standard whole-region measurements. Recently, MRI-based assessments of vertebral bone quality (VBQ) were introduced. However, there have been few studies that investigate the association between site-specific MRI bone assessment and osteoporosis-related complications in patients undergoing lumbar interbody fusion. In this work, we created a novel site-specific MRI-based assessment of the endplate bone quality (EBQ) and assessed its predictive value for severe cage subsidence following standalone lateral lumbar interbody fusion (SA-LLIF). PURPOSE To investigate the predictive value of a novel MRI-based bone assessment for severe cage subsidence after SA-LLIF. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients who underwent SA-LLIF from 2008 to 2019 at a single, academic institution with available preoperative lumbar CT and T1-weighted MRIs. OUTCOME MEASURES Association between EBQ and severe subsidence after SA-LLIF. METHODS We retrospectively reviewed the records of SA-LLIF patients treated between 2008 and 2019. EBQ was measured using preoperative non-contrast T1-weighted MRIs of the lumbar spine. EBQ was defined as the average value of signal intensity of both endplates divided by that of the cerebrospinal fluid space at the level of L3. Bivariate and multivariable analyses with generalized linear mixed models were performed and set binary severe subsidence as the outcome. RESULTS Two hundred five levels in 89 patients were included. Fifty levels (24.4%) demonstrated severe subsidence. Bone mineral density measured by quantitative computed tomography was significantly lower in the subsidence group. Both VBQ and EBQ were significantly higher in the subsidence group. The EBQ plus Modic change (MC) model demonstrated that the effect of EBQ was independent of MC. In multivariate analyses adjusted with QCT-vBMD, EBQ showed a significant association with cage subsidence whereas VBQ only showed a marginal trend. The EBQ-based prediction model for severe subsidence showed better goodness of fit compared to the VBQ-based model. CONCLUSIONS High EBQ was an independent factor for severe cage subsidence after SA-LLIF and the EBQ-based model showed better goodness of fit compared to VBQ- or MC-based models. EBQ assessment before SA-LLIF may provide insight into a patient's risk for severe subsidence.
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Affiliation(s)
- Conor Jones
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666 Japan
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Yusuke Dodo
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666 Japan
| | - Manuel Moser
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | | | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Dominik Adl Amini
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Huang W, Tian Y, Wang H, Zou F, Ma X, Jiang J, Li R. Comparative analysis of the biomechanics of anterior cervical discectomy and fusion with multiple segmental plates fixation versus single multilevel plate fixation: a finite element study. BMC Musculoskelet Disord 2022; 23:848. [PMID: 36071416 PMCID: PMC9450340 DOI: 10.1186/s12891-022-05796-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to compare the biomechanical differences between anterior cervical discectomy and fusion (ACDF) with multiple-level separate plates and conventional long plates by using finite element analysis. METHODS The following four finite element models were created to simulate various fixations: (1) C4-6 ACDF with multiple plates, (2) C4-6 ACDF with a single plate, (3) C3-6 ACDF with multiple plates, and (4) C3-6 ACDF with a single plate. The maximum Von-mises stress of the cage and fixation, compressive force of the adjacent intervertebral discs and range of motion (ROM) of different segments in the four models were calculated and analyzed. RESULTS For C4-6 ACDF, the maximum Von-mises stress of the cage and fixation was lower in the multiple plate fixation model in all motion states. Similarly, for the C3-6 ACDF models, the peak stress of the C3-4 and C5-6 cages was lower with multiple plates fixation in all motions but the stress of the C4-5 cage in the multiple plates model was slightly higher in flexion, bending and rotation. Besides, applying multiple plates in C3-6 ACDF models resulted in a decreased maximum stress of the fixation under different motions except for bending. In both the C4-6 ACDF and C3-6 ACDF models, the ROM values of the adjacent motion segments were lower in the multiple plates models in extension, bending and rotation. In the C4-6 ACDF models, the peak stress on the adjacent intervertebral discs in the multiple plates models was slightly smaller. In C3-6 ACDF models, the maximum stress on the adjacent intervertebral discs was larger in the single-plate model under flexion, bending and rotation movements. CONCLUSION Multiple plates fixation has a positive effect on increasing stiffness and maintaining the ROM of adjacent segments, indicating lower risk of construct failure and adjacent segment degeneration. Further studies are required to confirm its efficacy in clinical practice.
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Affiliation(s)
- Weibo Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, 12 Mid-Wulumuqi Road, Shanghai, 200040, China
| | - Ye Tian
- Department of Orthopedics, Huashan Hospital, Fudan University, 12 Mid-Wulumuqi Road, Shanghai, 200040, China
| | - Hongli Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, 12 Mid-Wulumuqi Road, Shanghai, 200040, China
| | - Fei Zou
- Department of Orthopedics, Huashan Hospital, Fudan University, 12 Mid-Wulumuqi Road, Shanghai, 200040, China
| | - Xiaosheng Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, 12 Mid-Wulumuqi Road, Shanghai, 200040, China
| | - Jianyuan Jiang
- Department of Orthopedics, Huashan Hospital, Fudan University, 12 Mid-Wulumuqi Road, Shanghai, 200040, China.
| | - Ruoyu Li
- Department of Orthopedics, Huashan Hospital, Fudan University, 12 Mid-Wulumuqi Road, Shanghai, 200040, China.
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Oitment C, Thornley P, Koziarz F, Jentzsch T, Bhanot K. A Review of Strategies to Improve Biomechanical Fixation in the Cervical Spine. Global Spine J 2022; 12:1596-1610. [PMID: 35020520 PMCID: PMC9393983 DOI: 10.1177/21925682211063855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Review the surgical techniques and construct options aimed at improving the biomechanical strength of cervical constructs. METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of the MEDLINE, Embase, and Cochrane Library databases was performed to identify all studies examining biomechanical strategies utilized in the osteoporotic cervical spine. Screening was performed in duplicate for all stages of the review process. RESULTS An initial search returned 3887 articles. After deletion of duplications and review of abstracts and full text, 39 articles met inclusion criteria. Overall, the surgical techniques reviewed aimed at obtaining rigid fixation in the setting of poor bone quality, or dispersing the forces at the bone-implant interface. We identified 6 key techniques to improve biomechanical fixation. These include bicortical fixation, appropriate screw selection (size and trajectory), PMMA augmentation, load sharing techniques, consideration of ancillary fixation around the occipitocervical junction, and supplementing the construct with post-operative collar or halo. CONCLUSION The summation of the literature highlights a framework of modalities available to surgeons to improve biomechanical fixation in the cervical spine. While these may improve construct strength in the setting of osteoporosis, there is a paucity of evidence available to make recommendations in this patient population.
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Affiliation(s)
- Colby Oitment
- Division of Orthopedic Surgery, Hamilton General Hospital, McMaster University, Hamilton, ON, Canada,Dr Colby Oitment, MD, McMaster University, Department of Orthopedic Surgery, Hamilton General HospitalAffiliation, McMaster University, 1200 Main St West, Hamilton, ON L8S 4L8, Canada.
| | - Patrick Thornley
- Division of Orthopedic Surgery, Hamilton General Hospital, McMaster University, Hamilton, ON, Canada
| | - Frank Koziarz
- Department of Graduate Studies, Health Research Methodology (HRM), and Epidemiology, McMaster University, Hamilton, ON, Canada
| | - Thorsten Jentzsch
- Division of Orthopaedic Surgery, St Michael’s Hospital, Toronto, ON, Canada,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kunal Bhanot
- Division of Orthopaedic Surgery, St Michael’s Hospital, Toronto, ON, Canada,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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35
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Paz RDR, Henríquez MS, Melián KA, Martin CB. Prevalence of Poor Bone Quality in Patients Undergoing Spine Surgery: A Comprehensive Approach. Global Spine J 2022; 12:1412-1419. [PMID: 33487013 PMCID: PMC9393977 DOI: 10.1177/2192568221989684] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
STUDY DESIGN A cross-sectional study. OBJECTIVES To investigate the prevalence of poor bone quality in patients requiring spine surgery through comprehensive evaluation with bone mass density (BMD), trabecular bone score (TBS), FRAX, and vitamin D status. METHODS we prospectively recruited patients of > 50 years old candidates for lumbar or cervical spine fusion surgery at our institution. Recorded data were: demographic, body mass index (BMI), risk factors for osteoporosis, daily calcium intake, FRAX score, disability index for lumbar and cervical spine, and VAS for pain. Serum 25 OH vitamin D, BMD using DXA, and TBS was also evaluated. RESULTS A total of 104 patients were recruited, osteoporosis by BMD was detected in 9.6%, and osteopenia in 34.6% of patients. 69.4% of patients with osteopenia had a degraded or partially degraded bone microarchitecture by TBS.Low levels of vitamin D were detected in 79.8% of patients. Increased pain was associated with low BMD levels. Adding TBS to BMD for the determination of bone strength resulted in 33.7% of patients with poor bone quality. Lastly, the combination of BMD, TBS, and FRAX revealed 37,5% of patients with poor bone quality. CONCLUSIONS Poor bone quality and low vitamin D levels are quite common among patients aged ≥ 50 years undergoing spine surgery. DXA alone seems not enough for preoperative identification of impaired bone quality cases. FRAX is useful for identifying high-risk patients and TBS is a valuable complement to DXA by adding the dimension of bone quality.
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Affiliation(s)
- Ricardo Díaz-Romero Paz
- Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain,Department of Neurosurgery of Hospital Insular of Las Palmas, Las Palmas de Gran Canaria, Spain,Ricardo Díaz-Romero Paz, Universidad de Las Palmas de Gran Canaria ULPGC, Department of Neurosurgery of Hospital Insular of las Palmas of Spain, Plaza Doctor Pasteur, s/n, 35016, Las Palmas de Gran Canaria, Spain.
| | - Manuel Sosa Henríquez
- Department Bone Metabolism and Osteoporosis of Hospital Insular of Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Kevin Armas Melián
- Department of Neurosurgery of Hospital Insular of Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Claudia Balhen Martin
- Department of Radiology of Hospital Perpetuo Socorro, Las Palmas de Gran Canaria, Spain
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The Impact of Osteoporosis on Adverse Outcomes After Short Fusion for Degenerative Lumbar Disease. J Am Acad Orthop Surg 2022; 30:573-579. [PMID: 35297812 DOI: 10.5435/jaaos-d-21-01258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/30/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Osteoporosis affects nearly 200 million individuals worldwide. There are little available data regarding outcomes in patients with osteoporosis who undergo short-segment lumbar fusion for degenerative disk disease (DDD). We sought to identify a relationship between osteoporosis and risk of adverse outcomes in patients with DDD undergoing short-segment lumbar fusion. METHODS Using the New York State Statewide Planning and Research Cooperative System, all patients with DDD who underwent 2- to 3-level lumbar fusion from 2009 through 2011 were identified. Patients with bone mineralization disorders and other systemic and endocrine disorders and surgical indications of trauma, systemic disease(s), and infection were excluded. Patients were stratified by the presence or absence of osteoporosis and compared for demographics, hospital-related parameters, and 2-year complications and revision surgeries. Multivariate binary logistic regression models were used to identify notable predictors of complications. RESULTS A total of 29,028 patients (osteoporosis = 1,353 [4.7%], nonosteoporosis = 27,675 [95.3%]) were included. Patients with osteoporosis were older (66.9 vs 52.6 years), more often female (85.1% vs 48.4%), and White (82.8% vs 73.5%) (all P < 0.001). The Charlson/Deyo comorbidity index did not significantly differ between groups. Hospital lengths of stay and total charges were higher for patients with osteoporosis (4.9 vs 4.1 days; $74,484 vs $73,724; both P < 0.001). Medical complication rates were higher in patients with osteoporosis, including acute renal failure and deep-vein thrombosis (both P < 0.01). This cohort also had higher rates of implant-related (3.4% vs 1.9%) and wound (9.8% vs 5.9%) complications (both P < 0.01). Preoperative osteoporosis was strongly associated with 2-year medical and surgical complications (odds ratios, 1.6 and 1.7) as well as greater odds of revision surgeries (odds ratio, 1.3) (all P < 0.001). CONCLUSION Patients with osteoporosis undergoing 2- to 3-level lumbar fusion for DDD were at higher risk of 2-year medical and surgical complications, especially implant-related and wound complications. These findings highlight the importance of rigorous preoperative metabolic workup and patients' optimization before spinal surgery.
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St. Jeor JD, Jackson TJ, Xiong AE, Freedman BA, Sebastian AS, Currier BL, Fogelson JL, Bydon M, Nassr A, Elder BD. Average Lumbar Hounsfield Units Predicts Osteoporosis-Related Complications Following Lumbar Spine Fusion. Global Spine J 2022; 12:851-857. [PMID: 33222537 PMCID: PMC9344520 DOI: 10.1177/2192568220975365] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
STUDY DESIGN Retrospective Study. OBJECTIVE To compare methods of assessing pre-operative bone density to predict risk for osteoporosis related complications (ORC), defined as proximal junctional kyphosis, pseudarthrosis, accelerated adjacent segment disease, reoperation, compression fracture, and instrument failure following spine fusions. METHODS Chart review of primary posterior thoracolumbar or lumbar fusion patients during a 7 year period. Inclusion criteria: preoperative dual-energy x-ray absorptiometry (DXA) test within 1 year and lumbar CT scan within 6 months prior to surgery with minimum of 1 year follow-up. Exclusion criteria: <18 years at time of index procedure, infection, trauma, malignancy, skeletal dysplasia, neuromuscular disorders, or anterior-posterior procedures. RESULTS 140 patients were included. The average age was 67.9 years, 83 (59.3%) were female, and 45 (32%) had an ORC. There were no significant differences in patient characteristics between those with and without an ORC. Multilevel fusions were associated with ORCs (46.7% vs 26.3%, p = 0.02). Patients with ORCs had lower DXA t-scores (-1.62 vs -1.10, p = 0.003) and average Hounsfield units (HU) (112.1 vs 148.1, p ≤ 0.001). Multivariable binary logistic regression analysis showed lower average HU (Adj. OR 0.00 595% CI 0.0001-0.1713, p = 0.001) was an independent predictor of an ORC. The odds of an ORC increased by 1.7-fold for every 25 point decrease in average HU. CONCLUSIONS The gold standard for assessing bone mineral density has been DXA t-scores, but the best predictor of ORC remains unclear. While both lower t-scores and average HU were associated with ORC, only HU was an independent predictor of ORC.
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Affiliation(s)
| | | | - Ashley E. Xiong
- Department of Orthopedic Surgery,
Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | - Mohamad Bydon
- Department of Neurological Surgery,
Mayo Clinic, Rochester, MN, USA
| | - Ahmad Nassr
- Department of Orthopedic Surgery,
Mayo Clinic, Rochester, MN, USA
| | - Benjamin D. Elder
- Department of Orthopedic Surgery,
Mayo Clinic, Rochester, MN, USA,Department of Neurological Surgery,
Mayo Clinic, Rochester, MN, USA,Department of Biomedical
Engineering, Mayo Clinic, Rochester, MN,Benjamin D. Elder, MD, PhD, Department of
Neurological Surgery, Mayo Clinic, Rochester, MN. 200 1st Street SW, Rochester,
MN 55905, USA.
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Innovation of Surgical Techniques for Screw Fixation in Patients with Osteoporotic Spine. J Clin Med 2022; 11:jcm11092577. [PMID: 35566703 PMCID: PMC9101243 DOI: 10.3390/jcm11092577] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Osteoporosis is a common disease in elderly populations and is a major public health problem worldwide. It is not uncommon for spine surgeons to perform spinal instrumented fusion surgeries for osteoporotic patients. However, in patients with severe osteoporosis, instrumented fusion may result in screw loosening, implant failure or nonunion because of a poor bone quality and decreased pedicle screw stability as well as increased graft subsidence risk. In addition, revision surgeries to correct failed instrumentation are becoming increasingly common in patients with osteoporosis. Therefore, techniques to enhance the fixation of pedicle screws are required in spinal surgeries for osteoporotic patients. To date, various instrumentation methods, such as a supplemental hook, sublaminar taping and sacral alar iliac screws, and modified screwing techniques have been available for reinforcing pedicle screw fixation. In addition, several materials, including polymethylmethacrylate and hydroxyapatite stick/granules, for insertion into prepared screw holes, can be used to enhance screw fixation. Many biomechanical tests support the effectiveness of these augmentation methods. We herein review the current therapeutic strategies for screw fixation and augmentation methods in the surgical treatment of patients with an osteoporotic spine.
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Hydroxyapatite Use in Spine Surgery—Molecular and Clinical Aspect. MATERIALS 2022; 15:ma15082906. [PMID: 35454598 PMCID: PMC9030649 DOI: 10.3390/ma15082906] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 04/03/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022]
Abstract
Hydroxyapatite possesses desirable properties as a scaffold in tissue engineering: it is biocompatible at a site of implantation, and it is degradable to non-toxic products. Moreover, its porosity enables infiltration of cells, nutrients and waste products. The outcome of hydroxyapatite implantation highly depends on the extent of the host immune response. Authors emphasise major roles of the chemical, morphological and physical properties of the surface of biomaterial used. A number of techniques have been applied to transform the theoretical osteoconductive features of HAp into spinal fusion systems—from integration of HAp with autograft to synthetic intervertebral implants. The most popular uses of HAp in spine surgery include implants (ACDF), bone grafts in posterolateral lumbar fusion and transpedicular screws coating. In the past, autologous bone graft has been used as an intervertebral cage in ACDF. Due to the morbidity related to autograft harvesting from the iliac bone, a synthetic cage with osteoconductive material such as hydroxyapatite seems to be a good alternative. Regarding posterolateral lumbar fusion, it requires the graft to induce new bone growth and reinforce fusion between the vertebrae. Hydroxyapatite formulations have shown good results in that field. Moreover, the HAp coating has proven to be an efficient method of increasing screw fixation strength. It can decrease the risk of complications such as screw loosening after pedicle screw fixation in osteoporotic patients. The purpose of this literature review is to describe in vivo reaction to HAp implants and to summarise its current application in spine surgery.
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Postoperative and Intraoperative Cement Augmentation for Spinal Fusion. World Neurosurg 2022; 160:e454-e463. [PMID: 35051634 DOI: 10.1016/j.wneu.2022.01.046] [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: 11/10/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To review outcomes of patients undergoing spinal fusion with prophylactic cement augmentation (CA) of pedicle screws and adjacent levels. METHODS In a retrospective case-control study, 59 patients underwent CA of pedicle screws for spinal fusion between 2003 and 2018. Most patients (83%) underwent postoperative CA, while 17% underwent intraoperative CA. Outcomes of CA techniques were compared, and patients undergoing CA for a thoracolumbar fusion (n = 51) were compared with a cohort not undergoing CA (n = 39). Mean follow-up was 3 years. RESULTS In patients receiving CA, survivorship free of proximal junctional kyphosis (PJK) was 94%, 60%, and 20% at 2, 5, and 10 years postoperatively. Survivorship free of revision was 95%, 83%, and 83% at 2, 5, and 10 years postoperatively. Development of PJK (P = 0.02, odds ratio [OR] 24.44) was associated with revision surgery. There were 4 (7%) cardiopulmonary complications. Patients who received CA for thoracolumbar fusion were older (70 years vs. 65 years) and were more likely to have osteoporosis (53% vs. 5%) than patients who did not receive CA. CA was associated with a decreased risk of PJK (P = 0.009, OR 0.16), while osteoporosis (P = 0.05, OR 4.10) and fusion length ≥8 levels (P = 0.06, OR 2.65) were associated with PJK. PJK was associated with revision surgery (P = 0.006, OR 12.65). CONCLUSIONS CA allows for substantial rates of radiographic PJK; however, this typically does not result in a need for revision surgery and leads to revision and PJK rates that are comparable to patients undergoing long segment fusions without osteoporosis.
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Kulkarni AG, Thonangi Y, Pathan S, Gunjotikar S, Goparaju P, Talwar I, Jaggi S, Shah S, Shah N, Kursija G. Should Q-CT Be the Gold Standard for Detecting Spinal Osteoporosis? Spine (Phila Pa 1976) 2022; 47:E258-E264. [PMID: 34545045 DOI: 10.1097/brs.0000000000004224] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective comparative study. OBJECTIVE Refinement of the guidelines for screening of osteoporosis and considering quantitative computed tomography (Q-CT) for detecting spinal osteoporosis. SUMMARY OF BACKGROUND DATA Spinal osteoporosis is often underestimated and under-evaluated due to either lack of availability of the diagnostic modality or lack of awareness about the possibility of overestimation by dual X-ray absorptiometry (DXA) scan. There is a need for reconsidering osteoporosis evaluation with a site specific and patient specific inclination. METHODS Post-menopausal women that underwent bone mineral density (BMD) evaluation from January-2018 to December-2020 with either Q-CT or DXA were evaluated. Comparison studies of the distribution of age and T-scores of the bone densities obtained from the two study groups: age-matched, sex-matched, and common skeletal site of interest (L1-4 vertebrae) were performed. Mann-Whitney U test, correlation and regression analyses were performed and bell curves were plotted. RESULTS Of the 718 women evaluated, 447 underwent Q-CT and 271 underwent DXA. There was no significant difference among the age distribution of the two study groups (P-value > 0.05). The mean and mode T-scores obtained by Q-CT and DXA were found to be -2.71, -3.8 and -1.63, -1.7 respectively. A highly significant difference in the T-scores was observed in the Q-CT and DXA groups (P-value < 0.0001). Among those who were screened by Q-CT, 58.16% were osteoporotic, 37.58% were osteopenic, and 4.25% were normal. The respective percentages in the DXA group were 30.63%, 49.82%, and 19.55%. CONCLUSION Q-CT provides more precise estimation of cancellous bone mineral density than DXA. With the reliance on DXA for spinal BMD estimation being questionable, new standards have to be established for spinal osteoporosis evaluation. Q-CT can be a better alternative to replace DXA as the gold standard for the evaluation of spinal osteoporosis.Level of Evidence: 2.
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Affiliation(s)
- Arvind G Kulkarni
- Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
| | - Yeshwanth Thonangi
- Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
| | - Sharukh Pathan
- Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
| | - Sharvari Gunjotikar
- Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
| | - Praveen Goparaju
- Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
| | - Inder Talwar
- Department of Radiodiagnosis, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
| | - Sunila Jaggi
- Department of Radiodiagnosis, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
| | - Sonali Shah
- Department of Radiodiagnosis, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
| | - Neha Shah
- Department of Radiodiagnosis, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, India
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Baksiova E, Ahuja S, Arabatzi F, Tsouknidas A. Posterior spinal stabilization: A biomechanical comparison of Laminar Hook Fusion to a Pedicle Screw System. Clin Biomech (Bristol, Avon) 2022; 91:105535. [PMID: 34837862 DOI: 10.1016/j.clinbiomech.2021.105535] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several spine instrumentation techniques have been introduced to correct inter-segmental alignment, or provide long-term stability. Whilst pedicle screws are considered the intervention of reference, we hypothesize that the week hold of osteoporotic bone, might be a clinical indicator for an alternative surgical approach. METHODS To put this to the test, a non-linear Finite Element model, of a ligamentous lumbosacral spine, was employed to examine a stabilization spanning over L3-L5. Two different immobilization techniques (a Pedicle Screw System and Laminar Hook Fusion) are compared as to their biomechanical response during 7.5 Nm flexion, lateral flexion and torsion, while considering a 280 N follower load. Fifteen analyses performed in total, simulating patients of healthy and osteoporotic Bone Mineral Density. FINDINGS Range of Motion was significantly reduced after instrumentation for both implant systems. This trend was more pronounced in the Pedicle Screw models, which were stressed to a higher degree. To evaluate implant loosening risk, we introduce the consideration of strain energy patterns around the screw tract. The notably higher intensity of these, for the osteoporotic model, taken into consideration with the weaker strength of the tissue and inconsistencies in the stress allocation between implant and bone, affirmed an increased risk for loosening of the Pedicle Screws in osteoporotic patients. INTERPRETATION The analysis provided refined insight as to the treatment of osteoporotic patients as well as to their postoperative care, as restriction of specific movements (e.g. through bracing), could significantly restrict the stress values in the bone-implant interface and thus, reduce implant failure.
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Affiliation(s)
- Emmanuela Baksiova
- Laboratory for Biomaterials and Computational Mechanics, Department of Mechanical Engineering, University of Western Macedonia, 50100 Kozani, Greece; BETA CAE Systems International AG, Platz 4, CH-6039 Root D4, Switzerland
| | - Sashin Ahuja
- Welsh Centre for Spinal Surgery & Trauma, University Hospital of Wales, Cardiff CF14 4XW, UK
| | - Fotini Arabatzi
- Laboratory of Neuromechanics, Department of Physical Education and Sport Science at Serres, Aristotle University of Thessaloniki, Greece
| | - Alexander Tsouknidas
- Laboratory for Biomaterials and Computational Mechanics, Department of Mechanical Engineering, University of Western Macedonia, 50100 Kozani, Greece.
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Althoff AD, Kamalapathy P, Vatani J, Hassanzadeh H, Li X. Osteoporosis is associated with increased minor complications following single level ALIF and PSIF: an analysis of 7,004 patients. JOURNAL OF SPINE SURGERY 2021; 7:269-276. [PMID: 34734131 DOI: 10.21037/jss-21-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/13/2021] [Indexed: 11/06/2022]
Abstract
Background Osteoporosis is a prevalent disease that predisposes patients to fracture and additional post-operative complications, potentially contributing to decreased quality of life. The objective of the current study is to (I) characterize the demographic trends of individuals with osteoporosis undergoing single level posterior spine instrumentation and fusion (PSIF) and anterior lumbar interbody fusion (ALIF); (II) determine the association between osteoporosis and postoperative complications; (III) identify whether the use of bone strengthening medications is associated with improved outcomes. Methods A retrospective review of the Mariner Claims Database was conducted on patients undergoing single level ALIF (CPT 22558) and PSIF (CPT 22840) between 2011 and 2017. Diagnosis of osteoporosis (CPT 77080, CPT 77801, CPT 77082) included a bone density scan within two years of surgery. Patients with osteoporosis were 1:1 matched to controls. Patients taking bone enhancing medications prior to surgery were compared to those that did not take medications. Multivariable logistic regression analyses were performed to evaluate post-operative complication risk factors. Results 3,502 patients with diagnosed osteoporosis underwent ALIF and PSIF, of which 788 (22.5%) were treated with supplemental medication. Diagnosis of osteoporosis was associated with an increased risk of pulmonary embolism [1.1% vs. 0.4%, odds ratio (OR) 2.48, 95% confidence interval (CI): 1.36-4.53, P=0.003] and minor complications (16.7% vs. 12.9%, OR 1.15, 95% CI: 1.01-1.30, P=0.039). Revision rates two-years post-operatively were not significantly different between patients with osteoporosis and matched controls (P>0.05). There were no differences in outcomes between osteoporotic patients who received medications and those who did not receive medication (P>0.05). Conclusions Osteoporosis is common in a nationally-representative Medicare database cohort. Pre-operative diagnosis of osteoporosis is associated with increased minor complications following ALIF and PSIF. Pre-operative osteoporosis treatment is not associated with a significant difference in post-operative outcomes. The current study can guide pre-operative counseling in this cohort.
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Affiliation(s)
- Alyssa D Althoff
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Pramod Kamalapathy
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jasmine Vatani
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Xudong Li
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
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Impact of preoperative treatment of osteoporosis on re-operations, complications and health care utilization in patients undergoing thoraco-lumbar spine fusions. A 5-year national database analysis. J Clin Neurosci 2021; 93:122-129. [PMID: 34656235 DOI: 10.1016/j.jocn.2021.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 07/27/2021] [Accepted: 09/09/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Identify the impact of preoperative treatment of Osteoporosis (OP) on reoperation rates, complications and healthcare utilization following thoraco-lumbar (TL) spine fusions. MATERIALS AND METHODS We used ICD9/10 and CPT codes to extract data from MarketScan (2000-2018). Patients were divided into two groups based on preoperative treatment of OP within one year prior to the index spinal fusion: medication (m-OP) cohort and non-medication (nm-OP) cohort. Outcomes (re-operation rates, re-admission, complications, healthcare utilization) were analyzed at 1-, 12-, 24- and 60-months. RESULTS Of 3606 patients, 65% (n = 2330) of patients did not receive OP medications (nm-OP). At index hospitalization, there were no difference in LOS (median nm-OP: 3 days vs. m-OP:4 days), discharge to home (nm-OP 80% vs. m-OP 75%) and complications (nm-OP 13% vs. m-OP 12%). Reoperation rates were not different among the cohorts at 1- (nm-OP 5.7% vs. m-OP 4.2%), 2- (nm-OP 9.4% vs. m-OP 7.8) and 5 years (nm-OP 16.9% vs. m-OP 14.8%). Patients in m-OP cohort incurred higher overall median payments at 1 year ($17,866 vs. $ 16,010), 2 years ($38,634 vs. $34,454) and 5 years ($94,797 vs. $91,072) compared to nm-OP cohort. CONCLUSION Preoperative treatment of OP had no impact on complications, LOS, discharge disposition following TL fusions at index hospitalization. Similarly, no impact of preoperative treatment was noted in terms of reoperation rates at 12-, 24- and 60 months following the index spine fusion. Patients who received preoperative treatment for OP incurred higher health care utilization at 12-, 24- and 60 months following surgery.
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Varshneya K, Bhattacharjya A, Jokhai RT, Fatemi P, Medress ZA, Stienen MN, Ho AL, Ratliff JK, Veeravagu A. The impact of osteoporosis on adult deformity surgery outcomes in Medicare patients. 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 2021; 31:88-94. [PMID: 34655336 DOI: 10.1007/s00586-021-06985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify the impact of osteoporosis (OS) on postoperative outcomes in Medicare patients undergoing ASD surgery. BACKGROUND Patients with OP and advanced age experience higher than average rates of ASD. However, poor bone density could undermine the durability of a deformity correction. METHODS We queried the MarketScan Medicare Supplemental database to identify patients Medicare patients who underwent ASD surgery from 2007 to 2016. RESULTS A total of 2564 patients met the inclusion criteria of this study, of whom n = 971 (61.0%) were diagnosed with osteoporosis. Patients with OP had a similar 90-day postoperative complication rates (OP: 54.6% vs. non-OP: 49.2%, p = 0.0076, not significant after multivariate regression correction). This was primarily driven by posthemorrhagic anemia (37.6% in OP, vs. 33.1% in non-OP). Rates of revision surgery were similar at 90 days (non-OP 15.0%, OP 16.8%), but by 2 years, OP patients had a significantly higher reoperation rate (30.4% vs. 22.9%, p < 0.0001). In multivariate regression analysis, OP increased odds for revision surgery at 1 year (OR 1.4) and 2 years (OR 1.5) following surgery (all p < 0.05). OP was also an independent predictor of readmission at all time points (90 days, OR 1.3, p < 0.005). CONCLUSION Medicare patients with OP had elevated rates of complications, reoperations, and outpatient costs after undergoing primary ASD surgery.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA. .,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland.
| | - Anika Bhattacharjya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Rayyan T Jokhai
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Parastou Fatemi
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Zachary A Medress
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin N Stienen
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Allen L Ho
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - John K Ratliff
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
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Drakopoulos P, Flevas DA, Galanopoulos IP, Lepetsos P, Zafeiris C. Off-Label Use of Teriparatide in Spine. Cureus 2021; 13:e16522. [PMID: 34430132 PMCID: PMC8376240 DOI: 10.7759/cureus.16522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/12/2022] Open
Abstract
Teriparatide belongs to osteo-anabolic compounds and has been used in recent years to treat patients with osteoporosis, with the benefits of increased bone density. Its osteo-anabolic action has led to the investigation of the use of teriparatide for the improvement of bone quality. Apart from the enhancement of fracture union, teriparatide has been extensively studied in the promotion of fusion rate after spinal fusion. This study summarizes the preclinical and clinical results of the off-label use of teriparatide in the spine, and specifically its intermittent administration after instrumented spinal arthrodesis along with its impact on the spinal bone quality and spinal bone mineral density.
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Affiliation(s)
- Panagiotis Drakopoulos
- Laboratory for the Research of the Musculoskeletal System, University of Athens, KAT Hospital, Athens, GRC.,Orthopaedics, Thriasio General Hospital, Athens, GRC
| | - Dimitrios A Flevas
- Arthroscopy and Orthopaedic Surgery, Metropolitan General Hospital, Athens, GRC
| | | | | | - Christos Zafeiris
- Orthopaedics and Spine Surgery, Metropolitan General Hospital, Athens, GRC
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Dual-energy X-ray Absorptiometry Does Not Represent Bone Structure in Patients with Osteoporosis: A Comparison of Lumbar Dual-Energy X-Ray Absorptiometry with Vertebral Biopsies. Spine (Phila Pa 1976) 2021; 46:861-866. [PMID: 34100839 DOI: 10.1097/brs.0000000000003917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cross-sectional exploratory study. OBJECTIVE To evaluate the correlation between in vivo lumbar dual-energy x-ray absorptiometry (DXA) and parameters of bone architecture in micro-computed tomography (micro-CT) in patients with osteoporosis. SUMMARY OF BACKGROUND DATA DXA is the current diagnostic standard for evaluating osteoporosis. However, there are various concerns regarding its validity, especially in the spine. No study has so far investigated whether in vivo DXA correlates with the actual lumbar bone architecture. METHODS Lumbar DXA scans were compared with micro-CT analysis of vertebral biopsies in patients with osteoporotic vertebral fractures (fracture group) and those without (control group). Preoperatively, all patients underwent a DXA scan (L1-L4). Intraoperative biopsies from nonfractured vertebrae (preferably L3) were analyzed by micro-CT regarding bone quantity and quality. The groups were compared regarding differences in DXA and micro-CT results. In each group, a correlation analysis was performed between DXA and micro-CT. RESULTS The study included 66 patients (33 per group). Preoperative DXA results were worse in the fracture group than the control group (areal bone mineral density [aBMD] 0.95 vs. 1.31, T-score -1.97 vs. 0.92, each P < 0.001). Micro-CT analysis confirmed differences regarding quantitative parameters (bone/total volume: 0.09 vs. 0.12, P < 0.001) and qualitative parameters (connectivity index: 15.73 vs. 26.67, P < 0.001; structure model index: 2.66 vs. 2.27, P < 0.001; trabecular number: 2.11 vs. 2.28, P = 0.014) of bone architecture between both groups. The DXA results did not correlate with micro-CT parameters in the fracture group. In the control group, correlations were found for some parameters (bone/total volume vs. aBMD: r = 0.51, P = 0.005; trabecular number vs. aBMD: r = 0.56, P = 0.001). CONCLUSION These data constitute the first comparison of DXA measurements with microstructural analysis of vertebral biopsies in patients with osteoporosis. Our results indicate that lumbar DXA neither qualitatively nor quantitatively represents microstructural bone architecture and is therefore not a reliable tool for the evaluation of bone quality in the spine.Level of Evidence: 3.
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Fiani B, Newhouse A, Sarhadi KJ, Arshad M, Soula M, Cathel A. Special Considerations to Improve Clinical Outcomes in Patients with Osteoporosis Undergoing Spine Surgery. Int J Spine Surg 2021; 15:386-401. [PMID: 33900998 PMCID: PMC8059385 DOI: 10.14444/8050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Osteoporosis is a condition that is commonly encountered, with increasing diagnosis by the medical community with the aging population. Osteoporosis leaves patients susceptible to fragility fractures in the vertebrae and is also associated with degenerative changes, both of which may require intervention from a spine surgeon. The goal of this review is to concisely outline special nonoperative adjuncts, as well as preoperative, intraoperative, and postoperative considerations of osteoporotic patients undergoing spine intervention. METHODS A literature analysis was completed for this narrative review. A database search of PubMed and Google Scholar was conducted using "osteoporosis" combined with "spine," "spine surgery," and "spinal fusion" without exclusion based on publication date. Articles were screened to exclude duplicate articles and screened for their full text and English language availability. RESULTS The database search yielded recent publications from which the narrative review was completed. CONCLUSIONS Preoperatively, screening is traditionally completed with dual-energy x-ray absorptiometry (DEXA). Pharmacological therapy modalities currently include teriparatide, raloxifene, denosumab, bisphosphonates, and calcitonin. In order to prevent operative complications associated with osteoporosis, surgeons have found success in increasing the diameter and the length of pedicle screws, limiting pedicle tapping, achieving bicortical or even tricortical purchase, augmenting with polymethyl methacrylate, using iliosacral stabilization, preventing positive sagittal balance, and using adequate fusion products when necessary. Postoperatively, it is important to implant a care plan that includes adequate pain control and necessary care, and to understand risks associated with falls may increase risk of postoperative fragility fractures as well as instrumentation displacement. At this time there are no recommendations in regard to bracing in the postoperative setting. CLINICAL RELEVANCE This review article outlines the most current evidence-based medicine with regard to considerations in spine surgery of the osteoporotic patient, and aims to bring about new questions to be investigated in that paradigm.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
| | - Alexander Newhouse
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Mohammad Arshad
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
| | - Marisol Soula
- New York University School of Medicine, New York University, New York, New York
| | - Alessandra Cathel
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
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Kolz JM, Freedman BA, Nassr AN. The Value of Cement Augmentation in Patients With Diminished Bone Quality Undergoing Thoracolumbar Fusion Surgery: A Review. Global Spine J 2021; 11:37S-44S. [PMID: 33890808 PMCID: PMC8076807 DOI: 10.1177/2192568220965526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Osteoporosis predisposes patients undergoing thoracolumbar (TL) fusion to complications and revision surgery. Cement augmentation (CA) improves fixation of pedicle screws to reduce these complications. The goal of this study was to determine the value and cost-effectiveness of CA in TL fusion surgery. METHODS A systematic literature review was performed using an electronic database search to identify articles discussing the cost or value of CA. As limited information was available, the review was expanded to determine the mean cost of primary TL fusion, revision TL fusion, and the prevalence of revision TL fusion to determine the decrease of revision surgery necessary to make CA cost-effective. RESULTS Two studies were identified discussing the cost and value of CA. The mean cost of CA for two vertebral levels was $10 508, while primary TL fusion was $87 346 and revision TL fusion was $76 825. Using a mean revision rate of 15.4%, the use of CA for TL fusion would need to decrease revision rates by 13.7% to be cost-effective. Comparison studies showed a decreased revision rate of 11.3% with CA, which approaches this value. CONCLUSION CA for TL fusion surgery improves biomechanical fixation of pedicle screws and decreases complications and revision surgery in patients with diminished bone quality. The costs of CA are substantial and reported decreases in revision rates approach but do not reach the calculated value to be a cost-effective technique. Future studies will need to focus on the optimal CA technique to decrease complications, revisions, and costs.
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Affiliation(s)
| | | | - Ahmad N. Nassr
- Mayo Clinic, First Street SW, Rochester, MN, USA,Ahmad N. Nassr, Department of Orthopedic Surgery, 200 First Street SW, Rochester, MN 55905, USA.
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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 PMCID: PMC8059382 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, 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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