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Jiang F, Li X, Liu L, Xie Z, Wu X, Wang Y. Automated machine learning-based model for the prediction of pedicle screw loosening after degenerative lumbar fusion surgery. Biosci Trends 2024; 18:83-93. [PMID: 38417874 DOI: 10.5582/bst.2023.01327] [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: 03/01/2024]
Abstract
The adequacy of screw anchorage is a critical factor in achieving successful spinal fusion. This study aimed to use machine learning algorithms to identify critical variables and predict pedicle screw loosening after degenerative lumbar fusion surgery. A total of 552 patients who underwent primary transpedicular lumbar fixation for lumbar degenerative disease were included. The LASSO method identified key features associated with pedicle screw loosening. Patient clinical characteristics, intraoperative variables, and radiographic parameters were collected and used to construct eight machine learning models, including a training set (80% of participants) and a test set (20% of participants). The XGBoost model exhibited the best performance, with an AUC of 0.884 (95% CI: 0.825-0.944) in the test set, along with the lowest Brier score. Ten crucial variables, including age, disease diagnosis: degenerative scoliosis, number of fused levels, fixation to S1, HU value, preoperative PT, preoperative PI-LL, postoperative LL, postoperative PT, and postoperative PI-LL were selected. In the prospective cohort, the XGBoost model demonstrated substantial performance with an accuracy of 83.32%. This study identified crucial variables associated with pedicle screw loosening after degenerative lumbar fusion surgery and successfully developed a machine learning model to predict pedicle screw loosening. The findings of this study may provide valuable information for clinical decision-making.
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Affiliation(s)
- Feng Jiang
- Southeast University Medical College, Nanjing, Jiangsu, China
| | - Xinxin Li
- Southeast University Medical College, Nanjing, Jiangsu, China
| | - Lei Liu
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Zhiyang Xie
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Xiaotao Wu
- Southeast University Medical College, Nanjing, Jiangsu, China
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Yuntao Wang
- Southeast University Medical College, Nanjing, Jiangsu, China
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
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Schleifenbaum S, Vogl AC, Heilmann R, von der Hoeh NH, Heyde CE, Jarvers JS. Biomechanical comparative study of midline cortical vs. traditional pedicle screw trajectory in osteoporotic bone. BMC Musculoskelet Disord 2023; 24:395. [PMID: 37198565 PMCID: PMC10193652 DOI: 10.1186/s12891-023-06502-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION In lumbar spinal stabilization pedicle screws are used as standard. However, especially in osteoporosis, screw anchorage is a problem. Cortical bone trajectory (CBT) is an alternative technique designed to increase stability without the use of cement. In this regard, comparative studies showed biomechanical superiority of the MC (midline cortical bone trajectory) technique with longer cortical progression over the CBT technique. The aim of this biomechanical study was to comparatively investigate the MC technique against the not cemented pedicle screws (TT) in terms of their pullout forces and anchorage properties during sagittal cyclic loading according to the ASTM F1717 test. METHODS Five cadavers (L1 to L5), whose mean age was 83.3 ± 9.9 years and mean T Score of -3.92 ± 0.38, were dissected and the vertebral bodies embedded in polyurethane casting resin. Then, one screw was randomly inserted into each vertebra using a template according to the MC technique and a second one was inserted by freehand technique with traditional trajectory (TT). The screws were quasi-static extracted from vertebrae L1 and L3, while for L2, L4 and L5 they were first tested dynamically according to ASTM standard F1717 (10,000 cycles at 1 Hz between 10 and 110 N) and then quasi-static extracted. In order to determine possible screw loosening, there movements were recorded during the dynamic tests using an optical measurement system. RESULTS The pull-out tests show a higher pull-out strength for the MC technique of 555.4 ± 237.0 N compared to the TT technique 448.8 ± 303.2 N. During the dynamic tests (L2, L4, L5), 8 out of the 15 TT screws became loose before completing 10,000 cycles. In contrast, all 15 MC screws did not exceed the termination criterion and were thus able to complete the full test procedure. For the runners, the optical measurement showed greater relative movement of the TT variant compared to the MC variant. The pull-out tests also revealed that the MC variant had a higher pull-out strength, measuring at766.7 ± 385.4 N, while the TT variant measured 637.4 ± 435.6 N. CONCLUSION The highest pullout forces were achieved by the MC technique. The main difference between the techniques was observed in the dynamic measurements, where the MC technique exhibited superior primary stability compared to the conventional technique in terms of primary stability. Overall, the MC technique in combination with template-guided insertion represents the best alternative for anchoring screws in osteoporotic bone without cement.
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Affiliation(s)
- Stefan Schleifenbaum
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
- ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Semmelweisstraße 14, D-04103, Leipzig, Germany
| | - Ann-Cathrin Vogl
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
- ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Semmelweisstraße 14, D-04103, Leipzig, Germany
| | - Robin Heilmann
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
- ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Semmelweisstraße 14, D-04103, Leipzig, Germany
| | - Nicolas Heinz von der Hoeh
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
| | - Christoph-Eckhard Heyde
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany
- ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Semmelweisstraße 14, D-04103, Leipzig, Germany
| | - Jan-Sven Jarvers
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Liebigstraße 20, D-04103, Leipzig, Germany.
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Liu YY, Xiao J, He L, Yin X, Song L, Zhou R, Zeng J, Liu P, Dai F. Risk factor analysis of bone cement leakage for polymethylmethacrylate-augmented cannulated pedicle screw fixation in spinal disorders. Heliyon 2023; 9:e15167. [PMID: 37089395 PMCID: PMC10113860 DOI: 10.1016/j.heliyon.2023.e15167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023] Open
Abstract
Objective To investigate the risk factors of cement leakage (CL) for polymethylmethacrylate-augmented cannulated pedicle screw (CPS) in spinal degenerative diseases and provided technical guidance for clinical surgery. Methods This study enrolled 276 patients with spinal degenerative disease and osteoporosis who were augmented using CPSs (835 screws in total) from May 2011 to June 2018 in our hospital. The patients' age, sex, bone mineral density (BMD), diagnosis, augmented positions, number of CPS implanted, and CL during surgery were recorded. CL was observed by postoperative computed tomography (CT) and was classified by Yeom typing. Results A total of 74 (74/835, 8.9%) CPSs in 64 patients leaked (64/276, 23.2%). CL was significantly correlated with the number and position of screws (P < 0.05), but not with sex, age, and BMD (P > 0.05). The position, number of CPSs, fracture, degenerative scoliosis, ankylosing spondylitis, and revision surgery were risk factors for CL (P < 0.05). Augmentation of the thoracic vertebral body, fracture, and ankylosing spondylitis were independent risk factors for Type S. Augmentation of the lumbar vertebral body, lumbar disc herniation, and lumbar spondylolisthesis were independent risk factors for Type B (P < 0.05). Conclusions CL has a high incidence in clinical practice. High-risk factors for leakage should be addressed to avoid serious complications. Particularly, it is necessary to develop alternative solutions once CPSs can't be used in surgery caused by CL.
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Affiliation(s)
- Yao-yao Liu
- Department of Spine Surgery, Daping Hospital, Army Medical Center of PLA, Chongqing, 400042, PR China
| | - Jun Xiao
- Guangzhou Rocket Force Special Service Convalescent Center, Guangzhou, 510515, PR China
| | - Lei He
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, PR China
| | - Xiang Yin
- Department of Spine Surgery, Daping Hospital, Army Medical Center of PLA, Chongqing, 400042, PR China
| | - Lei Song
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, PR China
| | - Rui Zhou
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, PR China
| | - Jing Zeng
- Guangzhou Rocket Force Special Service Convalescent Center, Guangzhou, 510515, PR China
| | - Peng Liu
- Department of Spine Surgery, Daping Hospital, Army Medical Center of PLA, Chongqing, 400042, PR China
- Corresponding author. Department of Spine surgery, Daping Hospital, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, PR China.
| | - Fei Dai
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, PR China
- Corresponding author. Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, PR China.
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Morimoto T, Kobayashi T, Hirata H, Tsukamoto M, Yoshihara T, Toda Y, Mawatari M. Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020407. [PMID: 36837608 PMCID: PMC9964565 DOI: 10.3390/medicina59020407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 02/22/2023]
Abstract
Fixation using cement-augmented pedicle screws (CAPS) is being increasingly performed. However, CAPS-associated cement leakage is a critical problem that can lead to cardiopulmonary cement embolism (CPCE). This narrative review aimed to explore the incidence of and risk factors and treatment strategies for CPCE and cement leakage-related complications after CAPS fixation. Data were extracted from each article, including characteristics of CPCE after CAPS fixation (incidence, location, diagnostic method and criteria, treatment, and outcome and prognosis). Overall, 28 case series and 14 case reports that met the inclusion criteria were included. Of the 1974 cases included in the review, CPCE was noted in 123, symptomatic CPCE in 35, and death in six, respectively. The frequencies of PCE and symptomatic PCE after CAPS fixation were 6% (range: 0-28.6%) and 1.3% (range: 0-26%), respectively. The range of frequencies of PCE and symptomatic PCE after CAPS fixation may have been wide because the definition of CPCE and data collection methods differed among the reports analyzed. Since PCE due to large cement emboli may be primarily related to the surgical technique, improved technique, such as minimizing the number of CAPSs by injecting low-volume high-viscosity cement at low velocity and pressure, and careful observation of cement leakage during CAPS insertion may reduce PCE associated with cement leakage. Spinal surgeons should pay more attention to the occurrence of CPCE during and after CAPS insertion, which can cause serious complications in some patients.
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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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Song L, Xiao J, Zhou R, Li CC, Zheng TT, Dai F. Clinical evaluation of the efficacy of a new bone cement-injectable cannulated pedicle screw in the treatment of spondylolysis-type lumbar spondylolisthesis with osteoporosis: a retrospective study. BMC Musculoskelet Disord 2022; 23:951. [PMID: 36329431 PMCID: PMC9632048 DOI: 10.1186/s12891-022-05904-7] [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: 05/25/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose To investigate the clinical efficacy and safety of a bone cement-injectable cannulated pedicle screw (CICPS) in the treatment of spondylolysis-type lumbar spondylolisthesis with osteoporosis. Methods A retrospective study was conducted on 37 patients (Dual-energy X-ray bone density detection showed different degrees of osteoporosis) with spondylolysis-type lumbar spondylolisthesis who underwent lumbar spondylolisthesis reduction and fusion using a new type of injectable bone cement screw from May 2011 to March 2015. Postoperative clinical efficacy was evaluated by the Visual Analogue Scale (VAS) scores and the Oswestry Disability Index (ODI). Imaging indexes were used to evaluate the stability of internal fixation of the devices 1, 3, 6, and 12 months after surgery and annually thereafter. The safety of the CICPS was assessed by the prevalence of intraoperative and postoperative complications. Results A total of 124 CICPS were implanted intraoperatively. Bone cement leakage occurred in 3 screws (2.42%), and no clinical discomfort was found in any patients. All 37 patients were followed up with an average follow-up time of 26.6 ± 13.4 months (12–58 months). In the evaluation of the clinical effects of the operation, the average postoperative VAS score of the patients decreased from 4.30 ± 1.58 before surgery to 0.30 ± 0.70 after surgery (P < 0.001), and the ODI decreased from 47.27% ± 16.97% before surgery to 3.36% ± 5.70% after surgery (P < 0.001). No screw was loose, broken or pulled out. Conclusion CICPS is safe and effective in the treatment of spondylolysis-type lumbar spondylolisthesis complicated by osteoporosis.
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Affiliation(s)
- Lei Song
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Jun Xiao
- Department of Special Service Physiological Training, Guangzhou Special Service Recuperation Center of PLA Rocket Force, Guangzhou, 515515, People's Republic of China
| | - Rui Zhou
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Cong-Can Li
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Ting-Ting Zheng
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China.
| | - Fei Dai
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China.
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Yaman O, Zileli M, Sharif S. Decompression and fusion surgery for osteoporotic vertebral fractures: WFNS Spine Committee Recommendations. J Neurosurg Sci 2022; 66:327-334. [PMID: 35380203 DOI: 10.23736/s0390-5616.22.05640-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTODUCTION Osteoporotic vertebral fractures (OVF) are common due to aging populations. Their clinical management remains controversial. Although conservative approaches are sufficient in most cases, there are certain conditions where decompression or fusion surgery are necessary. This manuscript aims to clarify the indications and types of surgeries for OVF. EVIDENCE ACQUISITION A Medline and Pubmed search spanning the period between 2010 and 2020 was performed using the keywords "osteoporotic vertebral fractures and decompression surgery" and "osteoporotic vertebral fractures and fusion surgery". In addition, we reviewed up-to-date information on decompression and fusion in osteoporotic vertebral fracture (OVF) to reach an agreement in two consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee that was held in January and February 2021. The Delphi method was utilized to improve the validity of the questionnaire. EVIDENCE SYNTHESIS A total of 19 studies examining decompression and fusion surgery in OVF were reviewed. Literature supports the statement that decompression and fusion surgery are necessary for progressive neurological deficits after OVF. The Spine Section of the German Society for Orthopedics and Trauma (DGOU) classification revealed that it might help make surgical decisions. We also noted that in patients planning to undergo surgery to correct significant kyphosis after OVF, several techniques, including multilevel fixation, cement augmentation, preservation of sagittal balance, and avoiding termination at the apex of kyphosis are necessary to prevent complications. Additionally, it became clear that there is no consensus to choose the type of open surgery (anterior, posterior, combined, using cement or bone or vertebral body cage, the levels, and kind of instrumentation). The current literature indicated that implant failure in the osteoporotic spine is a common complication, and many techniques have been described to prevent implant failure in the osteoporotic spine. However, the superiority of one method over another is unclear. CONCLUSIONS Open surgery for osteoporotic vertebral fractures should be considered if neurologic deficits and significant painful kyphosis. The apparent indications of surgery and most ideal surgical technique for OVF remain unclear in the literature; therefore, the decision must be individualized.
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Affiliation(s)
- Onur Yaman
- Memorial Bahçelievler Spine Center, Istanbul, Turkey -
| | - Mehmet Zileli
- Ege University Neurosurgery Department, Izmir, Turkey
| | - Salman Sharif
- Neurosurgery Department, Liaquat Hospital, Karachi, Pakistan
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Wang Y, Yang L, Li C, Sun H. The Biomechanical Properties of Cement-Augmented Pedicle Screws for Osteoporotic Spines. Global Spine J 2022; 12:323-332. [PMID: 33611971 PMCID: PMC8907649 DOI: 10.1177/2192568220987214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
STUDY DESIGN This is a broad, narrative review of the literature. OBJECTIVE In this review, we describe recent biomechanics studies on cement-augmented pedicle screws for osteoporotic spines to determine which factors influence the effect of cement augmentation. METHODS A search of Medline was performed, combining the search terms "pedicle screw" and ("augmentation" OR "cement"). Articles published in the past 5 years dealing with biomechanical testing were included. RESULTS Several factors have been identified to impact the effect of cement augmentation in osteoporotic spines. These include the type of augmentation material, the volume of injected cement, the timing of augmentation, the severity of osteoporosis, the design of the pedicle screw, and the specific augmenting technique, among others. CONCLUSIONS This review elaborates the biomechanics of cement-augmented pedicle screws, determines which factors influence the augmentation effect, and identifies the risk factors of cement leakage in osteoporotic bone, which might offer some guidance when using this technique in clinical practice. Further, we provide information about newly designed screws and recently developed augmentation materials that provide higher screw stability as well as fewer cement-related complications.
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Affiliation(s)
- Yuetian Wang
- Department of Orthopedics, Peking University First
Hospital, Beijing, China
| | - Lei Yang
- Center for Health Science and
Engineering(CHSE), School of Materials Science and Engineering, Hebei University of
Technology, Tianjin, China
| | - Chunde Li
- Department of Orthopedics, Peking University First
Hospital, Beijing, China
| | - Haolin Sun
- Department of Orthopedics, Peking University First
Hospital, Beijing, China,Haolin Sun, Peking University First
Hospital, Beijing 100034, China.
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Yang K, You Y, Wu W. The Influence of Different Injection Hole Designs of Augmented Pedicle Screws on Bone Cement Leakage and Distribution Patterns in Osteoporotic Patients. World Neurosurg 2021; 157:e40-e48. [PMID: 34583006 DOI: 10.1016/j.wneu.2021.09.086] [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: 08/13/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare cement distribution and leakage for 2 bone cement-augmented screws with different designs of injection holes in patients and the impact of screw locations and bone mineral density (BMD) on the results. METHODS This study recruited 40 patients who underwent instrumentation with cement-augmented screws. Screw holes of group A were 4 holes located in the distal one third of screws, while screw holes of group B were 6 holes located in distal, middle, and proximal sites. Postoperative computed tomography images were obtained to evaluate the rate and type of cement leakage and the distribution pattern of cement. The lateral or center position of screw tip, BMD, and T-score were also analyzed for their influence on the results. RESULTS Of 192 screws, 80 (41.7%) exhibited cement leakage on postoperative computed tomography. The incidence of cement distribution in the posterior half and type B leakage in group B was significantly higher compared with group A. In group A, the probability of cement distribution in the posterior half was significantly increased when the screw was laterally inserted. For both groups, the higher incidence of cement distribution in the posterior half was correlated with lower BMD and T-score. CONCLUSIONS Our results showed that screws with injection holes closer to the screw tip had higher incidences of distribution in the anterior half of the body and lower incidences of type B leakage. Patients with lower BMD and T-scores should be closely monitored, and a more centered position is recommended for screw insertion.
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Affiliation(s)
- Kaiyun Yang
- Institute of Stomatology, Shandong University, Jinan, China
| | - Yunhao You
- Department of Spine Surgery, Shandong University Qilu Hospital, Jinan, China
| | - Wenliang Wu
- Department of Spine Surgery, Shandong University Qilu Hospital, Jinan, China.
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Ehresman J, Pennington Z, Elsamadicy AA, Hersh A, Lubelski D, Lehner K, Cottrill E, Schilling A, Lakomkin N, Ahmed AK, Lo SF, Sciubba DM. Fenestrated pedicle screws for thoracolumbar instrumentation in patients with poor bone quality: Case series and systematic review of the literature. Clin Neurol Neurosurg 2021; 206:106675. [PMID: 34020324 DOI: 10.1016/j.clineuro.2021.106675] [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: 04/02/2021] [Revised: 04/27/2021] [Accepted: 05/02/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To describe the results of a single-surgeon series and systematically review the literature on cement-augmented instrumented fusion with fenestrated pedicle screws. METHODS All patients treated by the senior surgeon using fenestrated screws between 2017 and 2019 with a minimum of 6-months of clinical and radiographic follow-up were included. For the systematic review, we used PRISMA guidelines to identify all prior descriptions of cement-augmented instrumented fusion with fenestrated pedicle screws in the English literature. Endpoints of interest included hardware loosening, cement leakage, and pulmonary cement embolism (PCE). RESULTS Our series included 38 patients (mean follow-up 14.8 months) who underwent cement-augmented instrumentation for tumor (47.3%), deformity/degenerative disease (39.5%), or osteoporotic fracture (13.2%). Asymptomatic screw lucency was seen in 2.6%, cement leakage in 445, and pulmonary cement embolism (PCE) in 5.2%. Our literature review identified 23 studies (n = 1526 patients), with low reported rates of hardware loosening (0.2%) and symptomatic PCE (1.0%). Cement leakage, while common (55.6%), produced symptoms in fewer than 1% of patients. Indications for cement-augmentation in this cohort included: spine metastasis with or without pathologic fracture (n = 18; 47.3%), degenerative spine disease or fixed deformity with poor underlying bone quality (n = 15; 39.5%), and osteoporotic fracture (n = 5; 13.2%). CONCLUSION Cement-augmented fusion with fenestrated screws appears to be a safe, effective means of treating patients with poor underlying bone quality secondary to tumor or osteoporosis. High-quality evidence with direct comparisons to non-augmented patients is needed.
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Affiliation(s)
- Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN 55905, USA.
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Andrew Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kurt Lehner
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Andrew Schilling
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Nikita Lakomkin
- Department of Neurosurgery, Mayo Clinic, Rochester, MN 55905, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sheng-Fu Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA.
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11
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Jarvers JS, Schleifenbaum S, Pfeifle C, Oefner C, Edel M, von der Höh N, Heyde CE. Comparison of three different screw trajectories in osteoporotic vertebrae: a biomechanical investigation. BMC Musculoskelet Disord 2021; 22:418. [PMID: 33952236 PMCID: PMC8101169 DOI: 10.1186/s12891-021-04254-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 04/13/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Pedicle screw insertion in osteoporotic patients is challenging. Achieving more screw-cortical bone purchase and invasiveness minimization, the cortical bone trajectory and the midline cortical techniques represent alternatives to traditional pedicle screws. This study compares the fatigue behavior and fixation strength of the cement-augmented traditional trajectory (TT), the cortical bone trajectory (CBT), and the midline cortical (MC). METHODS Ten human cadaveric spine specimens (L1 - L5) were examined. The average age was 86.3 ± 7.2 years. CT scans were provided for preoperative planning. CBT and MC were implanted by using the patient-specific 3D-printed placement guide (MySpine®, Medacta International), TT were implanted freehand. All ten cadaveric specimens were randomized to group A (CBT vs. MC) or group B (MC vs. TT). Each screw was loaded for 10,000 cycles. The failure criterion was doubling of the initial screw displacement resulting from the compressive force (60 N) at the first cycle, the stop criterion was a doubling of the initial screw displacement. After dynamic testing, screws were pulled out axially at 5 mm/min to determine their remaining fixation strength. RESULTS The mean pull-out forces did not differ significantly. Concerning the fatigue performance, only one out of ten MC of group A failed prematurely due to loosening after 1500 cycles (L3). Five CBT already loosened during the first 500 cycles. The mean displacement was always lower in the MC. In group B, all TT showed no signs of failure or loosening. Three MC failed already after 26 cycles, 1510 cycles or 2144 cycles. The TT showed always a lower mean displacement. In the subsequent pull-out tests, the remaining mean fixation strength of the MC (449.6 ± 298.9 N) was slightly higher compared to the mean pull-out force of the CBT (401.2 ± 261.4 N). However, MC (714.5 ± 488.0 N) were inferior to TT (990.2 ± 451.9 N). CONCLUSION The current study demonstrated that cement-augmented TT have the best fatigue and pull-out characteristics in osteoporotic lumbar vertebrae, followed by the MC and CBT. MC represent a promising alternative in osteoporotic bone if cement augmentation should be avoided. Using the patient-specific placement guide contributes to the improvement of screws' biomechanical properties.
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Affiliation(s)
- J-S Jarvers
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.
| | - S Schleifenbaum
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.,ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig University, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - C Pfeifle
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany
| | - C Oefner
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.,ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig University, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - M Edel
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.,ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig University, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - N von der Höh
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany
| | - C-E Heyde
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Liebigstraße 20, 04103, Leipzig, Germany.,ZESBO - Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig University, Semmelweisstraße 14, 04103, Leipzig, Germany
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12
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Liu YY, Xiao J, Jin HJ, Wang Z, Yin X, Liu MY, Zhao JH, Liu P, Dai F. Comparison of unilateral and bilateral polymethylmethacrylate-augmented cannulated pedicle screw fixation for the management of lumbar spondylolisthesis with osteoporosis. J Orthop Surg Res 2020; 15:446. [PMID: 32993741 PMCID: PMC7526218 DOI: 10.1186/s13018-020-01975-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background Cannulated pedicle screw (CPS) augmented by polymethylmethacrylate (PMMA) can achieve satisfactory clinical efficacy in the treatment of lumbar spondylolisthesis with osteoporosis. However, accurate application of CPSs will help to avoid the difficulty of screw revision and reduce the incidence of PMMA-related complications. This study aimed to investigate the mid-term efficacy of CPS compared to unilateral and bilateral applications in this common lumbar degenerative disease. Methods May 2011 and May 2018, 50 patients with lumbar spondylolisthesis with osteoporosis who underwent posterior fixation and fusion using traditional pedicle screws or CPSs were included in the study. Patients were divided into two groups based on the application: the unilateral PMMA-augmented CPS group (UC, n = 29) and the bilateral PMMA-augmented CPS group (BC, n = 21). Operation time, blood loss, average hospitalization time, PMMA leakage, and other complications were recorded. The visual analog scale (VAS) and Oswestry disability index (ODI) scores were used to evaluate symptom recovery. Radiographic results were compared for intervertebral fusion and screw loosening. Results There were no significant differences in the baseline data of the two groups. The VAS and ODI scores improved significantly after surgery (P < 0.05), with no significant differences between the groups (P > 0.05). The operation time and blood loss in the UC group were significantly lower than those in the BC group (P < 0.05). However, the loss of intervertebral disk height and Taillard index did not differ significantly between the groups. The rates of PMMA leakage in the UC and BC groups were 7.0% and 11.9%, respectively (P < 0.05). Bony fusion was achieved in all groups without screw loosening at the last follow-up. Only one patient experienced superficial infection in both groups, while cerebrospinal fluid leakage was observed in two patients in the BC group. Conclusions Unilateral application of PMMA-augmented CPS may provide adequate clinical safety and effectiveness in the surgical treatment of lumbar spondylolisthesis with osteoporosis.
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Affiliation(s)
- Yao-Yao Liu
- Department of Spine Surgery, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Jun Xiao
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, People's Republic of China
| | - Huai-Jian Jin
- Department of Spine Surgery, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Zhong Wang
- Department of Spine Surgery, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Xiang Yin
- Department of Spine Surgery, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Ming-Yong Liu
- Department of Spine Surgery, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Jian-Hua Zhao
- Department of Spine Surgery, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Peng Liu
- Department of Spine Surgery, Army Medical Center of PLA, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, People's Republic of China.
| | - Fei Dai
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, People's Republic of China.
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13
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Effect of Fenestrated Pedicle Screws with Cement Augmentation in Osteoporotic Patients Undergoing Spinal Fusion. World Neurosurg 2020; 143:e351-e361. [PMID: 32771604 DOI: 10.1016/j.wneu.2020.07.154] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Osteoporosis is a well-known risk factor for instrumentation failure and subsequent pseudoarthrosis after spinal fusion. In the present systematic review, we analyzed the biomechanical properties, clinical efficacy, and complications of cement augmentation via fenestrated pedicle screws in spinal fusion. METHODS We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reports appearing in the PubMed database up to March 31, 2020 were queried using the key words "cement," "pedicle screw," and "osteoporosis." We excluded non-English language studies, studies reported before 2000, studies that had involved use of cement without fenestrated pedicle screws, nonhuman studies, technical reports, and individual case reports. RESULTS Twenty-five studies met the inclusion criteria. Eleven studies had tested the biomechanics of cement-augmented fenestrated pedicle screws. The magnitude of improvement achieved by cement augmentation of pedicle screws increased with the degree of osteoporosis. The cement-augmented fenestrated pedicle screw was superior biomechanically to the alternative "solid-fill" technique. Fourteen studies had evaluated complications. Cement extravasation with fenestrated screw usage was highly variable, ranging from 0% to 79.7%. However, cement extravasation was largely asymptomatic. Thirteen studies had assessed the outcomes. The use of cement-augmented fenestrated pedicles decreased screw pull out and improved fusion rates; however, the clinical outcomes were similar to those with traditional pedicle screw placement. CONCLUSIONS The use of cement-augmented fenestrated pedicle screws can be an effective strategy for achieving improved pedicle screw fixation in patients with osteoporosis. A potential risk is cement extravasation; however, this complication will typically be asymptomatic. Larger comparative studies are needed to better delineate the clinical efficacy.
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14
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Abstract
PURPOSE OF REVIEW To provide information on characteristics and use of various ceramics in spine fusion and future directions. RECENT FINDINGS In most recent years, focus has been shifted to the use of ceramics in minimally invasive surgeries or implementation of nanostructured surface modification features to promote osteoinductive properties. In addition, effort has been placed on the development of bioactive synthetics. Core characteristic of bioactive synthetics is that they undergo change to simulate a beneficial response within the bone. This change is based on chemical reaction and various chemical elements present in the bioactive ceramics. Recently, a synthetic 15-amino acid polypeptide bound to an anorganic bone material which mimics the cell-binding domain of type-I collagen opened a possibility for osteogenic and osteoinductive roles of this hybrid graft material. Ceramics have been present in the spine fusion arena for several decades; however, their use has been limited. The major obstacle in published literature is small sample size resulting in low evidence and a potential for bias. In addition, different physical and chemical properties of various ceramics further contribute to the limited evidence. Although ceramics have several disadvantages, they still hold a great promise as a value-based graft material with being easily available, relatively inexpensive, and non-immunogenic.
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15
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Zou D, Sun Z, Zhou S, Zhong W, Li W. Hounsfield units value is a better predictor of pedicle screw loosening than the T-score of DXA in patients with lumbar degenerative diseases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1105-1111. [PMID: 32211997 DOI: 10.1007/s00586-020-06386-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 03/18/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the performance of using Hounsfield units (HU) value derived from computed tomography and T-score of dual-energy X-ray absorptiometry (DXA) to predict pedicle screw loosening. METHODS We reviewed 253 patients aged ≥ 50 years undergoing pedicle screw fixation for lumbar degenerative diseases (LDD). The evaluation of screw loosening: radiolucent zones of ≥ 1 mm thick in X-ray. The criterion for osteoporosis: the lowest T-score ≤ - 2.5. The average HU value of L1-L4 was used to represent lumbar bone mineral density (BMD). The area under receiver operating characteristics curve (AUC) was used to evaluate the performance of predicting screw loosening. RESULTS One patient underwent reoperation for screw loosening at 9 months follow-up. At 12 months follow-up, the loosening rate was 30.6% (77/252) in the remaining 252 patients. Osteoporotic patients had higher loosening rate than non-osteoporotic patients (39.3% vs. 25.8%, P = 0.026). The T-score showed no significant difference between loosening group and non-loosening group (- 2.1 ± 1.5 vs. - 1.7 ± 1.6, P = 0.074), and so is the lowest lumbar BMD of DXA (0.83 ± 0.16 g/cm2 vs. 0.88 ± 0.19 g/cm2, P = 0.054). The HU value was lower in the loosening group (106.8 ± 34.4 vs. 129.8 ± 45.7, P < 0.001). The HU value (OR, 0.980; 95%CI 0.968-0.993; P = 0.002) was the independent influencing factor of screw loosening. The AUC of predicting screw loosening was 0.666 (P < 0.001) for HU value and 0.574 (P = 0.062) for T-score. CONCLUSIONS HU value is a better predictor of pedicle screw loosening than T-score of DXA in patients aged ≥ 50 years with LDD. We should not only focus on the DXA measurements when making surgical plans concerning lumbar fixation. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Da Zou
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Zhuoran Sun
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Siyu Zhou
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Woquan Zhong
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Weishi Li
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
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16
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Liu YY, Xiao J, Yin X, Liu MY, Zhao JH, Liu P, Dai F. Clinical efficacy of Bone Cement-injectable Cannulated Pedicle Screw Short Segment Fixation for Lumbar Spondylolisthesis with Osteoporosise. Sci Rep 2020; 10:3929. [PMID: 32127607 PMCID: PMC7054412 DOI: 10.1038/s41598-020-60980-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/19/2020] [Indexed: 11/09/2022] Open
Abstract
Many clinical studies have shown a satisfactory clinical efficacy using bone cement-augmented pedicle screw in osteoporotic spine, however, few studies have involved the application of this type of screw in lumbar spondylolisthesis. This study aims to investigate the mid-term clinical outcome of bone cement-injectable cannulated pedicle screw (CICPS) in lumbar spondylolisthesis with osteoporosis. From 2011 to 2015, twenty-three patients with transforminal lumbar interbody fusion (TLIF) using CICPS for lumbar spondylolisthesis were enrolled in the study. Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) were used to evaluate faunctional recovery and physical pain; and operation time, blood loss and hospitalization time were recorded, respectively. Radiograph and computed tomography of lumbar spine was performed to assess loss of the intervertebral disc space height, fixation loosening, and the rate of bony fusion. The average follow-up time of 23 patients was 22.5 ± 10.2 months (range, 6–36 months). According to VAS and ODI scores, postoperative pain sensation and activity function were significantly improved (p < 0.05). The height of the intervertebral disc space was reduced by 0.4 ± 1.1 mm, and the bone graft fusion rate was 100%. No cases of internal fixation loosening or screw pullout was observed. CICPS using cement augmentation may suggest as a feasible surgical technique in osteoporotic patients with lumbar spondylolisthesis.
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Affiliation(s)
- Yao-Yao Liu
- Department of Spine surgery, Army Medical Center of PLA, Chongqing, 400042, People's Republic of China
| | - Jun Xiao
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, People's Republic of China
| | - Xiang Yin
- Department of Spine surgery, Army Medical Center of PLA, Chongqing, 400042, People's Republic of China
| | - Ming-Yong Liu
- Department of Spine surgery, Army Medical Center of PLA, Chongqing, 400042, People's Republic of China
| | - Jian-Hua Zhao
- Department of Spine surgery, Army Medical Center of PLA, Chongqing, 400042, People's Republic of China
| | - Peng Liu
- Department of Spine surgery, Army Medical Center of PLA, Chongqing, 400042, People's Republic of China.
| | - Fei Dai
- Department of Orthopedics, Southwest Hospital of Army Medical University, PLA, Chongqing, 400038, People's Republic of China.
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17
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Rometsch E, Spruit M, Zigler JE, Menon VK, Ouellet JA, Mazel C, Härtl R, Espinoza K, Kandziora F. Screw-Related Complications After Instrumentation of the Osteoporotic Spine: A Systematic Literature Review With Meta-Analysis. Global Spine J 2020; 10:69-88. [PMID: 32002352 PMCID: PMC6963360 DOI: 10.1177/2192568218818164] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
STUDY DESIGN Systematic literature review with meta-analysis. OBJECTIVE Osteoporosis is common in elderly patients, who frequently suffer from spinal fractures or degenerative diseases and often require surgical treatment with spinal instrumentation. Diminished bone quality impairs primary screw purchase, which may lead to loosening and its sequelae, in the worst case, revision surgery. Information about the incidence of spinal instrumentation-related complications in osteoporotic patients is currently limited to individual reports. We conducted a systematic literature review with the aim of quantifying the incidence of screw loosening in osteoporotic spines. METHODS Publications on spinal instrumentation of osteoporotic patients reporting screw-related complications were identified in 3 databases. Data on screw loosening and other local complications was collected. Pooled risks of experiencing such complications were estimated with random effects models. Risk of bias in the individual studies was assessed with an adapted McHarm Scale. RESULTS From 1831 initial matches, 32 were eligible and 19 reported screw loosening rates. Studies were heterogeneous concerning procedures performed and risk of bias. Screw loosening incidences were variable with a pooled risk of 22.5% (95% CI 10.8%-36.6%, 95% prediction interval [PI] 0%-81.2%) in reports on nonaugmented screws and 2.2% (95% CI 0.0%-7.2%, 95% PI 0%-25.1%) in reports on augmented screws. CONCLUSIONS The findings of this meta-analysis suggest that screw loosening incidences may be considerably higher in osteoporotic spines than with normal bone mineral density. Screw augmentation may reduce loosening rates; however, this requires confirmation through clinical studies. Standardized reporting of prespecified complications should be enforced by publishers.
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Affiliation(s)
- Elke Rometsch
- AO Foundation, Dübendorf, Switzerland,Elke Rometsch, AO Foundation, AO Clinical Investigation and Documentation (AOCID), Stettbachstrasse 6, 8600 Dübendorf, Switzerland.
| | | | | | | | | | | | - Roger Härtl
- NY Presbyterian Hospital–Weill Cornell Medical College, New York, NY, USA
| | | | - Frank Kandziora
- Center for Spine Surgery and Neurotraumatology, Frankfurt, Germany
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18
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Díaz-Romero Paz R, Sosa Henríquez M, Armas Melián K, Coloma Valverde G. Tendencias de actuación de los cirujanos de columna respecto a la osteoporosis. Neurocirugia (Astur) 2019; 30:268-277. [DOI: 10.1016/j.neucir.2019.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/13/2019] [Accepted: 04/17/2019] [Indexed: 01/01/2023]
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19
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Sun H, Liu C, Li X, Liu H, Zhang W, Yang H, Li C, Yang L. A novel calcium phosphate-based nanocomposite for the augmentation of cement-injectable cannulated pedicle screws fixation: A cadaver and biomechanical study. J Orthop Translat 2019; 20:56-66. [PMID: 31908934 PMCID: PMC6938802 DOI: 10.1016/j.jot.2019.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 08/03/2019] [Accepted: 08/07/2019] [Indexed: 12/26/2022] Open
Abstract
Background/objective Both polymethylmethacrylate (PMMA) and traditional calcium phosphate–based cements have some deficiencies as augmentation materials for pedicle screw fixation. Here, a novel calcium phosphate–based nanocomposite (CPN) for the augmentation of pedicle screw fixation was developed based on previous study, and the handling properties, biomechanical performance, and biodegradation behaviour of CPN were evaluated and compared with clinical PMMA by means of a cadaver study and animal tests. Methods Bone mineral density of the lumbar vertebrae was tested. Pedicle screws were placed into the lumbar vertebrae under the guidance of three dimensionally printed templates; each of which was designed based on computed tomography (CT) reconstruction of each vertebrae and augmented with either PMMA or CPN. X-ray and CT scan were used to evaluate the accuracy of screw placement and dispersion as well as interdigitation of bone cement. The axial pull-out strength and maximum torque were tested using a mechanical testing machine. Degradation behaviour of CPN was evaluated by in vitro immersion tests for 8 weeks and in vivo rabbit femur defect model for up to 6 months, respectively. Results Standard mechanical tests revealed that PMMA was much stronger than CPN after setting (compressive strength 95 vs. 49 MPa, respectively, p < 0.001). Results of the projection area and volume distribution of cement along the distal end of the screws revealed that CPN exhibited unique dispersing and interdigitation abilities compared with PMMA. Specifically, CPN dispersed uniformly and symmetrically along the screw, while PMMA was limited to the proximal part of the screw. Axial pull-out test results showed that the axial pull-out strengths of CPN- and PMMA-augmented pedicle screws were similar (1199 ± 225 N vs 1337 ± 483 N, respectively) and not significantly different (p = 0.47), although CPN was an intrinsically weaker material than PMMA. Similarly, CPN showed average torque values of 0.72 ± 0.31 N·m slightly lower than those of PMMA (0.96 ± 0.23 N·m), but statistically there was no significant difference between CPN and PMMA (p = 0.21). In a rabbit model of femoral bone defect, the implanted CPN maintained its clear boundary and there is no disintegration in the cement clump after 20 days and 24 weeks, and there was moderate bioabsorption of CPN and clearly new bone ingrowth at the absorbed sites after 24 weeks. Conclusion A new nanocomposite cement CPN, designed for replacing the nondegradable PMMA cement and overcoming the mechanical inferiority of calcium phosphate cement, was evaluated for its biomechanical and biodegradation behaviours in cement-injectable cannulated pedicle screws (CICPS) application. Although CPN is a mechanically weaker material than PMMA, CPN demonstrates similar biomechanical properties to PMMA in the application of augmentation for CICPS fixation in cadaveric vertebrae. This improvement in biomechanical property is attributed to a better dispersion and interdigitation mode of CPN. In addition, the animal study results suggest the in vivo absorption of CPN is slow enough and matches the bone ingrowth. The translational potential of this article This work reports a cadaveric and biomechanical study of novel CPN for the application in the augmentation of CICPS. The results suggest that CPN has equivalent or better biomechanical and interdigitation performance compared with PMMA. Together with the biodegradability and ossointegration capability, CPN reveals high translational potential as a new bone cements for load-bearing bone fixation and repair.
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Affiliation(s)
- Haolin Sun
- Department of Orthopedics, Peking University First Hospital, China
| | - Chun Liu
- Institute of Orthopedics, Department of Orthopedics, Soochow University, China
| | - Xuwen Li
- Department of Orthopedics, Peking University First Hospital, China
| | - Huiling Liu
- Institute of Orthopedics, Department of Orthopedics, Soochow University, China
| | - Weiguang Zhang
- Department of Human Anatomy, School of Basic Medical Sciences, Peking University, China
| | - Huilin Yang
- Institute of Orthopedics, Department of Orthopedics, Soochow University, China
| | - Chunde Li
- Department of Orthopedics, Peking University First Hospital, China
| | - Lei Yang
- Institute of Orthopedics, Department of Orthopedics, Soochow University, China.,Center for Health Science and Engineering, Tianjin Key Laboratory of Materials Laminating Fabrication and Interface Control Technology, School of Materials Science and Engineering, Hebei University of Technology, China
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Choy WJ, Walsh WR, Phan K, Mobbs RJ. Technical Note: Pedicle Cement Augmentation with Proximal Screw Toggle and Loosening. Orthop Surg 2019; 11:510-515. [PMID: 31179643 PMCID: PMC6595100 DOI: 10.1111/os.12467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 12/26/2022] Open
Abstract
Background Cement augmentation is a technique used to increase the stability and purchase of pedicle screws in poor quality bone. Various methods can be applied for cement delivery, such as cement injection before screw placement and the use of fenestrated screws. However, potential problems can arise with the use of cement augmentation. Case Presentation A 66‐year‐old man with a lower trunk deformity, severe kyphosis, and sagittal imbalance following fusion (L2‐5), with minimal comorbidities, was referred to our unit 9 months after surgery. Pain and progressive kyphosis were investigated clinically and radiographically with computed tomography (CT) scans to assess the status of the hardware and fusion. CT imaging revealed that cement was present only at the distal tip of the fenestrated screws at the L4 vertebral level. A non‐union was present along with loosening and a halo around the body of the pedicle screws, and there was evidence of pullout of inferior screws. Conclusion Single‐level cement augmentation of pedicle screw in a posterior construct and distal tip cement augmentation of the screw results in a fixed pivot point. Micromotion in cranio‐caudal loading during flexion and extension may result in screw toggling with the single‐level cement‐augmented tip as a fulcrum. This may cause screw loosening, which can lead to pullout and loss of construct stability. The halo around the screw suggests bone loss and/or a fibrous tissue interface, which further complicates revision surgery. Stress shielding and polymethylmethacrylate cement present additional difficulties. The findings of this technical note question the risks and benefits of cement‐augmented fenestrated pedicle screw fixation for spinal fusion. Although incidences of such cases are uncommon, surgeons should perform this technique with caution. Accurate restoration of lumbar lordosis during index procedures is important to minimize the risk of construct failure.
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Affiliation(s)
- Wen Jie Choy
- NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - William R Walsh
- Surgical & Orthopaedic Research Laboratory, Prince of Wales Clinical School, University of New South Wales, Sydney, Randwick, New South Wales, Australia
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, New South Wales, Australia
| | - Ralph J Mobbs
- NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, New South Wales, Australia
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21
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Mo GY, Guo HZ, Guo DQ, Tang YC, Li YX, Yuan K, Luo PJ, Zhou TP, Zhang SC, Liang D. Augmented pedicle trajectory applied on the osteoporotic spine with lumbar degenerative disease: mid-term outcome. J Orthop Surg Res 2019; 14:170. [PMID: 31171020 PMCID: PMC6555715 DOI: 10.1186/s13018-019-1213-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 05/22/2019] [Indexed: 01/24/2023] Open
Abstract
Purpose To compare the safety and efficiency of cement-augmented pedicle screw with traditional pedicle screw technique applied on the patients in the osteoporotic spine with lumbar degenerative diseases. Methods Fifty-six patients followed up at least 2 years were enrolled in our institute with retrospectively reviewed from January 2009 to June 2014, diagnosed as lumbar spondylolisthesis, or lumbar stenosis, with T score ≤− 2.5 SD of BMD, and received less than three-segment PLIF or TLIF. All patients were divided into 2 groups: 28 (2 males, 26 females) in polymethylmethacrylate-augmented pedicle screw group (PSA) group, the other 28 (3 males, 25 females) in traditional pedicle screw group (TPS). Surgical data including the operation time, intra-operative blood loss, hospitalization day and surgical complications were recorded, as well as the radiological parameters measured from the postoperative X-rays and CT scans containing the rates of fusion, screw loosening, and cage subsidence incidence. In addition, the visual analog scores (VAS) and Oswestry Disability Index (ODI) were evaluated preoperatively and postoperatively. Results The average follow-up period was 34.32 months (ranging from 24 months to 51 months). Compared with PSA group, operation time and average hospital stay in the TPS group decreased significantly (P < 0.05). While no statistical difference for blood loss between 2 groups (P > 0.05). At 2 years postoperation, from CT-scans, 2/172 screws loosening and 1/56 segment non-union occurred in PSA group, with significantly lower incidence than those in TPS group (8/152 screws loosening and 6/50 segments non-union occurred, P < 0.05). Regarding the cage subsidence, 24 segments found height loss (5.30 ± 1.92 mm) in PSA group without difference compared with that of 19 segments (4.78 ± 1.37 mm) in TPS group (P > 0.05). Besides, the number and the location of cages and the leakage of the cement were found out little related with the subsidence in the PSA group (P > 0.05). After surgeries, VAS and ODI at 1 month, 6 months, 12 months, and last follow-up improved significantly in two groups (P < 0.05). There were no significant differences in VAS and ODI preoperatively and postoperatively between 2 groups (P > 0.05). In addition, eight patients with asymptomatic trajectory PMMA leakages were detected. Conclusion Cement-augmented pedicle screw technique is effective and safe in the osteoporotic spine with lumbar degenerative diseases, with better fusion rates and less screw loosening incidence. There is no difference in the fusion rate and loosening rate between the two groups in the single segment patients; however, there are better fusion rate and lower pedicle screw loosening rate of the PSA group in the double or multiple group patients.
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Affiliation(s)
- Guo-Ye Mo
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Hui-Zhi Guo
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Dan-Qing Guo
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yong-Chao Tang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yong-Xian Li
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China.,The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Kai Yuan
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Pei-Jie Luo
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China.,The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Ten-Peng Zhou
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China.,The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Shun-Cong Zhang
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, People's Republic of China. .,The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.
| | - De Liang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
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22
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McCoy S, Tundo F, Chidambaram S, Baaj A. Clinical considerations for spinal surgery in the osteoporotic patient: A comprehensive review. Clin Neurol Neurosurg 2019; 180:40-47. [DOI: 10.1016/j.clineuro.2019.03.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/04/2019] [Accepted: 03/10/2019] [Indexed: 11/30/2022]
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23
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Wang Z, Liu Y, Rong Z, Wang C, Liu X, Zhang F, Zhang Z, Xu J, Dai F. Clinical evaluation of a bone cement-injectable cannulated pedicle screw augmented with polymethylmethacrylate: 128 osteoporotic patients with 42 months of follow-up. Clinics (Sao Paulo) 2019; 74:e346. [PMID: 31188908 PMCID: PMC6537661 DOI: 10.6061/clinics/2019/e346] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 12/21/2018] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To evaluate the safety and efficacy of a novel bone cement-injectable cannulated pedicle screw augmented with polymethylmethacrylate in osteoporotic spinal surgery. METHODS This study included 128 patients with osteoporosis (BMD T-score -3.2±1.9; range, -5.4 to -2.5) who underwent spinal decompression and instrumentation with a polymethylmethacrylate-augmented bone cement-injectable cannulated pedicle screw. Postoperative Visual Analogue Scale scores and the Oswestry Disability Index were compared with preoperative values. Postoperative plain radiographs and computed tomography (CT) scans were performed immediately after surgery; at 1, 3, 6, and 12 months; and annually thereafter. RESULTS The mean follow-up time was 42.4±13.4 months (range, 23 to 71 months). A total of 418 polymethylmethacrylate-augmented bone cement-injectable cannulated pedicle screws were used. Cement extravasations were detected in 27 bone cement-injectable cannulated pedicle screws (6.46%), mainly in cases of vertebral fracture, without any clinical sequela. The postoperative low back and lower limb Visual Analogue Scale scores were significantly reduced compared with the preoperative scores (<0.01), and similar results were noted for the Oswestry Disability Index score (p<0.01). No significant screw migration was noted at the final follow-up relative to immediately after surgery (p<0.01). All cases achieved successful bone fusion, and no case required revision. No infection or blood clots occurred after surgery. CONCLUSIONS The polymethylmethacrylate-augmented bone cement-injectable cannulated pedicle screw is safe and effective for use in osteoporotic patients who require spinal instrumentation.
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Affiliation(s)
- Zhengdong Wang
- Department of Orthopedics, National & Regional United Engineering Laboratory of Tissue Engineering, Southwest Hospital, Army Medical University, 400038, Chongqing, China
- Corresponding authors. E-mail: /
| | - Yaoyao Liu
- Department of Spine Surgery, Daping Hospital, Army Medical University, Daping Hospital, 400410, Chongqing, China
- Corresponding authors. E-mail: /
| | - Zhigang Rong
- Department of Orthopedics, National & Regional United Engineering Laboratory of Tissue Engineering, Southwest Hospital, Army Medical University, 400038, Chongqing, China
| | - Cheng Wang
- Department of Orthopedics, National & Regional United Engineering Laboratory of Tissue Engineering, Southwest Hospital, Army Medical University, 400038, Chongqing, China
| | - Xun Liu
- Department of Orthopedics, National & Regional United Engineering Laboratory of Tissue Engineering, Southwest Hospital, Army Medical University, 400038, Chongqing, China
| | - Fei Zhang
- Department of Orthopaedics, General Hospital of Xin Jiang Military Region, 830000, Xinjiang, China
| | - Zehua Zhang
- Department of Orthopedics, National & Regional United Engineering Laboratory of Tissue Engineering, Southwest Hospital, Army Medical University, 400038, Chongqing, China
| | - Jianzhong Xu
- Department of Orthopedics, National & Regional United Engineering Laboratory of Tissue Engineering, Southwest Hospital, Army Medical University, 400038, Chongqing, China
- Corresponding authors. E-mail: /
| | - Fei Dai
- Department of Orthopedics, National & Regional United Engineering Laboratory of Tissue Engineering, Southwest Hospital, Army Medical University, 400038, Chongqing, China
- Corresponding authors. E-mail: /
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24
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Perikal PJ, Srikantha U, Joshi KC, J AJ, Khanapure K, Varma RG, Hegde SA. Minimally Invasive Augmented Fixation for Anatomical Reduction of Grade 2 and Grade 3 Listhesis in Patients with Osteoporosis. Asian Spine J 2018; 12:887-892. [PMID: 30213172 PMCID: PMC6147869 DOI: 10.31616/asj.2018.12.5.887] [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: 10/11/2017] [Accepted: 01/05/2018] [Indexed: 11/25/2022] Open
Abstract
Study Design A retrospective study. Purpose To study the efficacy of augmented fixation for anatomical reduction of grade 2 and grade 3 listhesis in patients with osteoporosis. Overview of Literature Spondylolisthesis in osteoporotic patients requiring spinal fixation are associated with complications such as loss of surgical construct stability, screw pulling out, and screw loosening. Augmented fixation is a novel strategy to achieve necessary construct integrity. Methods Thirteen consecutive patients with grade 2 or grade 3 listhesis, with proven osteoporosis on dual energy X-ray absorptiometry (DEXA) scan, and who underwent augmented fixation for reduction of listhesis were retrospectively analyzed. In all patients, surgical access was achieved with a fixed 22 mm tubular retractor. A modified technique of bilateral, sequential, transforaminal decompression and discectomy, followed by reduction of listhesis using unilaterally placed augmented screws was employed in all the cases. Patients were followed up with plain X-rays at regular intervals to assess for implant stability and fusion status. All patients were started on medical treatment for osteoporosis. Results The mean age of the patients was 52.46 years, with 12 females and one male. The median T-score on DEXA scan was −3.0. Of the 13 patients, listhesis was at L4–L5 in five and at L5–S1 in eight. Nine patients had grade 2 listhesis, while four patients had grade 3 listhesis. Complete reduction was achieved in 10 patients. The median duration of follow-up was 18 months. Postoperative outcomes were satisfactory in all cases. Conclusions Augmented fixation is a useful technique for achieving anatomical reduction of listhesis in patients with osteoporosis.
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Affiliation(s)
- Parichay J Perikal
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, Bangalore, India
| | - Umesh Srikantha
- Department of Neurosurgery, Aster CMI Hospital, Bangalore, India
| | - Krishna C Joshi
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, Bangalore, India
| | - Aniruddha Jagannath J
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, Bangalore, India
| | - Kiran Khanapure
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, Bangalore, India
| | - Ravi Gopal Varma
- Department of Neurosurgery, Aster CMI Hospital, Bangalore, India
| | - Sathyaranjandas Alanga Hegde
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, Bangalore, India
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25
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Rong Z, Zhang F, Xiao J, Wang Z, Luo F, Zhang Z, Xu J, Dai F. Application of Cement-Injectable Cannulated Pedicle Screw in Treatment of Osteoporotic Thoracolumbar Vertebral Compression Fracture (AO Type A): A Retrospective Study of 28 Cases. World Neurosurg 2018; 120:e247-e258. [PMID: 30149154 DOI: 10.1016/j.wneu.2018.08.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/06/2018] [Accepted: 08/08/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate safety and effectiveness of the novel polymethyl methacrylate-augmented bone cement-injectable cannulated pedicle screw (CICPS) in patients with thoracolumbar vertebral compression fractures (AO type A) associated with osteoporosis. METHODS We conducted a retrospective cohort study of 28 patients treated for osteoporosis-related thoracolumbar vertebral body compression fracture at our facility between 2011 and 2015. Treatment involved posterior thoracolumbar fusion or lumbar fusion using CICPS. Treatment effectiveness was evaluated using visual analog scale and Oswestry Disability Index scores, degree of fracture reduction, and correction of kyphosis. The safety of CICPS was mainly assessed in terms of intraoperative and postoperative complications. Radiography, computed tomography, and magnetic resonance imaging outcomes were also assessed. RESULTS All 28 patients had severe osteoporosis. The visual analog scale score at final follow-up (0.50 ± 0.69) was significantly (P < 0.001) lower compared with before surgery (4.93 ± 1.30). The Oswestry Disability Index score had also decreased from 57.39% ± 14.46% to 6.83% ± 15.38% at final follow-up (P < 0.001). Radiologic evaluation of vertebral height and Cobb angle showed good fracture reduction and satisfactory correction of kyphosis (preoperative vs. final follow-up, P < 0.001). There were no instances of screw loosening or symptomatic complications except for a few cases of cement leakage from CICPS (10.3%; cement leakage most common in AO type A3.3). CONCLUSIONS The use of CICPS and polymethyl methacrylate is an effective and safe surgical technique for management of osteoporosis-related vertebral fractures (AO type A), with good clinical outcomes and low complications rates.
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Affiliation(s)
- Zhigang Rong
- Department of Orthopaedics, National and Regional United Engineering Laboratory, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Fei Zhang
- Department of Orthopaedics, General Hospital of Xin Jiang Military Region, Xinjiang, China
| | - Jun Xiao
- Department of Orthopaedics, National and Regional United Engineering Laboratory, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Zhengdong Wang
- Department of Orthopaedics, National and Regional United Engineering Laboratory, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Fei Luo
- Department of Orthopaedics, National and Regional United Engineering Laboratory, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Zehua Zhang
- Department of Orthopaedics, National and Regional United Engineering Laboratory, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Jianzhong Xu
- Department of Orthopaedics, National and Regional United Engineering Laboratory, Southwest Hospital, Third Military Medical University, Chongqing, China.
| | - Fei Dai
- Department of Orthopaedics, National and Regional United Engineering Laboratory, Southwest Hospital, Third Military Medical University, Chongqing, China.
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Wang Z, Zhang W, Xu H, Lu A, Yang H, Luo ZP. Perfusion pressure of a new cannulating fenestrated pedicle screw during cement augmentation. Clin Biomech (Bristol, Avon) 2018; 57:42-47. [PMID: 29929060 DOI: 10.1016/j.clinbiomech.2018.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 04/25/2018] [Accepted: 06/04/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cannulating fenestrated pedicle screws are effective for fixating osteoporotic vertebrae. However, a major limitation is the excessive pressure required to inject a sufficient amount of cement into the vertebral body through the narrow hole of a pedicle screw. We have recently proposed a new cannulating fenestrated pedicle screw with a large hole diameter and a matched inner pin for screw-strength maintenance. Our purpose was to determine whether the new screw can significantly reduce bone-cement perfusion pressure during cement augmentation, METHODS: Two different methods were used to examine perfusion pressure. Hagen-Poisseuille's flow model in a tube was used to calculate pressure drop in the bone-cement channel. Experimentally, both Newtonian silicone oil and bone-cement (polymethyl methacrylate) were tested using a cement pusher through the cannulating screw at a constant rate of 2 ml/min. FINDINGS The internal hollow portion of the screw was the bottleneck of the perfusion, and the new design significantly reduced the perfusion pressure. Specifically, perfusion pressure dropped by 59% (P < 0.05) when diameter size was doubled. INTERPRETATION The new design effectively improved the application of bone-cement augmentation with the ease of bone-cement perfusion, thereby enhancing operational safety.
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Affiliation(s)
- Zhirong Wang
- Department of Orthopedic Surgery, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, Jiangsu 215600, PR China
| | - Wen Zhang
- Orthopaedic Institute, Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu 215007, PR China
| | - Hao Xu
- Orthopaedic Institute, Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu 215007, PR China
| | - Aiqing Lu
- Department of Orthopedic Surgery, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, Jiangsu 215600, PR China
| | - Huilin Yang
- Orthopaedic Institute, Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu 215007, PR China
| | - Zong-Ping Luo
- Orthopaedic Institute, Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu 215007, PR China.
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27
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Cao Y, Liang Y, Wan S, Jiang C, Jiang X, Chen Z. Pedicle Screw with Cement Augmentation in Unilateral Transforaminal Lumbar Interbody Fusion: A 2-Year Follow-Up Study. World Neurosurg 2018; 118:e288-e295. [PMID: 29969742 DOI: 10.1016/j.wneu.2018.06.181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate safety and efficacy of pedicle screw with polymethyl methacrylate (PMMA) augmentation in unilateral transforaminal lumbar interbody fusion (uTLIF) in osteoporotic patients. METHODS We randomly divided 50 osteoporotic patients with degenerative lumbar diseases diagnosed between February 2014 and November 2015 into 2 groups. One group underwent standard uTLIF, and the other group underwent uTLIF with PMMA augmentation. All patients were scheduled to attend a series of regular follow-up evaluations. Oswestry Disability Index, Japanese Orthopaedic Association score, visual analog scale score, lumbar lordotic angle, segmental lordotic angle, and disc space height (DSH) at each follow-up were collected and analyzed. RESULTS The 2-year follow-up was completed by 24 patients in the uTLIF group and 23 patients in the PMMA group. Oswestry Disability Index, Japanese Orthopaedic Association score, and visual analog scale score showed significant improvements after surgery in both groups, with no significant difference between groups. DSH in the uTLIF group was 8.7 ± 2.3 mm and in the PMMA group was 10.7 ± 1.6 mm. Fusion rate in the uTLIF group was 19/24 and in the PMMA group was 21/23. DSH and fusion rate in the PMMA group were higher than those in the uTLIF group. No severe complications were observed after PMMA injection. CONCLUSIONS Pedicle screw with PMMA augmentation can increase fixation stability and reduce DSH loss in uTLIF. Moreover, PMMA in the vertebral body did not impede the interbody fusion ability in uTLIF.
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Affiliation(s)
- Yuanwu Cao
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Liang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengcheng Wan
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun Jiang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoxing Jiang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Zixian Chen
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China.
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28
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Lai DM, Shih YT, Chen YH, Chien A, Wang JL. Effect of pedicle screw diameter on screw fixation efficacy in human osteoporotic thoracic vertebrae. J Biomech 2018; 70:196-203. [DOI: 10.1016/j.jbiomech.2017.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/19/2017] [Accepted: 10/15/2017] [Indexed: 11/27/2022]
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Liebsch C, Zimmermann J, Graf N, Schilling C, Wilke HJ, Kienle A. In vitro validation of a novel mechanical model for testing the anchorage capacity of pedicle screws using physiological load application. J Mech Behav Biomed Mater 2017; 77:578-585. [PMID: 29096123 DOI: 10.1016/j.jmbbm.2017.10.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/16/2017] [Accepted: 10/23/2017] [Indexed: 11/26/2022]
Abstract
Biomechanical in vitro tests analysing screw loosening often include high standard deviations caused by high variabilities in bone mineral density and pedicle geometry, whereas standardized mechanical models made of PU foam often do not integrate anatomical or physiological boundary conditions. The purpose of this study was to develop a most realistic mechanical model for the standardized and reproducible testing of pedicle screws regarding the resistance against screw loosening and the holding force as well as to validate this model by in vitro experiments. The novel mechanical testing model represents all anatomical structures of a human vertebra and is consisting of PU foam to simulate cancellous bone, as well as a novel pedicle model made of short carbon fibre filled epoxy. Six monoaxial cannulated pedicle screws (Ø6.5 × 45mm) were tested using the mechanical testing model as well as human vertebra specimens by applying complex physiological cyclic loading (shear, tension, and bending; 5Hz testing frequency; sinusoidal pulsating forces) in a dynamic materials testing machine with stepwise increasing load after each 50.000 cycles (100.0N shear force + 20.0N per step, 51.0N tension force + 10.2N per step, 4.2Nm bending moment + 0.8Nm per step) until screw loosening was detected. The pedicle screw head was fixed on a firmly clamped rod while the load was applied in the vertebral body. For the in vitro experiments, six human lumbar vertebrae (L1-3, BMD 75.4 ± 4.0mg/cc HA, pedicle width 9.8 ± 0.6mm) were tested after implanting pedicle screws under X-ray control. Relative motions of pedicle screw, specimen fixture, and rod fixture were detected using an optical motion tracking system. Translational motions of the mechanical testing model experiments in the point of load introduction (0.9-2.2mm at 240N shear force) were reproducible within the variation range of the in vitro experiments (0.6-3.5mm at 240N shear force). Screw loosening occurred continuously in each case between 140N and 280N, while abrupt failures of the specimen were observed only in vitro. In the mechanical testing model, no translational motion was detected in the screw entry point, while in vitro, translational motions of up to 2.5mm in inferior direction were found, leading to a slight shift of the centre of rotation towards the screw tip. Translational motions of the screw tip of about 5mm in superior direction were observed both in vitro and in the mechanical testing model, while they were continuous in the mechanical testing model and rapidly increasing after screw loosening initiation in vitro. The overall pedicle screw loosening characteristics were qualitatively and quantitatively similar between the mechanical testing model and the human vertebral specimens as long as there was no translation of the screw at the screw entrance point. Therefore, the novel mechanical testing model represents a promising method for the standardized testing of pedicle screws regarding screw loosening for cases where the screw rotates around a point close to the screw entry point.
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Affiliation(s)
- Christian Liebsch
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre Ulm, University of Ulm, Helmholtzstrasse 14, 89081 Ulm, Germany.
| | - Julia Zimmermann
- SpineServ GmbH & Co. KG, Söflinger Straße 100, 89077 Ulm, Germany.
| | - Nicolas Graf
- SpineServ GmbH & Co. KG, Söflinger Straße 100, 89077 Ulm, Germany.
| | | | - Hans-Joachim Wilke
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre Ulm, University of Ulm, Helmholtzstrasse 14, 89081 Ulm, Germany.
| | - Annette Kienle
- SpineServ GmbH & Co. KG, Söflinger Straße 100, 89077 Ulm, Germany.
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30
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Sun H, Liu C, Liu H, Bai Y, Zhang Z, Li X, Li C, Yang H, Yang L. A novel injectable calcium phosphate-based nanocomposite for the augmentation of cannulated pedicle-screw fixation. Int J Nanomedicine 2017; 12:3395-3406. [PMID: 28490878 PMCID: PMC5414751 DOI: 10.2147/ijn.s131962] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Polymethyl methacrylate (PMMA)-augmented cannulated pedicle-screw fixation has been routinely performed for the surgical treatment of lumbar degenerative diseases. Despite its satisfactory clinical outcomes and prevalence, problems and complications associated with high-strength, stiff, and nondegradable PMMA have largely hindered the long-term efficacy and safety of pedicle-screw fixation in osteoporotic patients. To meet the unmet need for better bone cement for cannulated pedicle-screw fixation, a new injectable and biodegradable nanocomposite that was the first of its kind was designed and developed in the present study. The calcium phosphate-based nanocomposite (CPN) exhibited better anti-pullout ability and similar fluidity and dispersing ability compared to clinically used PMMA, and outperformed conventional calcium phosphate cement (CPC) in all types of mechanical properties, injectability, and biodegradability. In term of axial pullout strength, the CPN-augmented cannulated screw reached the highest force of ~120 N, which was higher than that of PMMA (~100 N) and CPC (~95 N). The compressive strength of the CPN (50 MPa) was three times that of CPC, and the injectability of the CPN reached 95%. In vivo tests on rat femur revealed explicit biodegradation of the CPN and subsequent bone ingrowth after 8 weeks. The promising results for the CPN clearly suggest its potential for replacing PMMA in the application of cannulated pedicle-screw fixation and its worth of further study and development for clinical uses.
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Affiliation(s)
- Haolin Sun
- Department of Orthopedics, Peking University First Hospital, Beijing
| | - Chun Liu
- Department of Orthopedics, Institute of Orthopedics, First Affiliated Hospital
| | - Huiling Liu
- Department of Orthopedics, Institute of Orthopedics, First Affiliated Hospital
| | - Yanjie Bai
- School of Public Health, Medical College
| | - Zheng Zhang
- Department of Orthopedics, Peking University First Hospital, Beijing
| | - Xuwen Li
- Department of Orthopedics, Peking University First Hospital, Beijing
| | - Chunde Li
- Department of Orthopedics, Peking University First Hospital, Beijing
| | - Huilin Yang
- Department of Orthopedics, Institute of Orthopedics, First Affiliated Hospital.,International Research Center for Translational Orthopedics (IRCTO), Soochow University, Suzhou, China
| | - Lei Yang
- Department of Orthopedics, Institute of Orthopedics, First Affiliated Hospital.,International Research Center for Translational Orthopedics (IRCTO), Soochow University, Suzhou, China
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Fischer CR, Hanson G, Eller M, Lehman RA. A Systematic Review of Treatment Strategies for Degenerative Lumbar Spine Fusion Surgery in Patients With Osteoporosis. Geriatr Orthop Surg Rehabil 2016; 7:188-196. [PMID: 27847678 PMCID: PMC5098690 DOI: 10.1177/2151458516669204] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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
Purpose: To evaluate the current evidence in the literature on treatment strategies for degenerative lumbar spine fusion in patients with osteoporosis. Methods: A systematic review of the literature from 1950 to 2015. Results: The review of the literature yielded 15 studies on the effect of treatment options for osteoporosis on lumbar fusion rates. This study evaluated only degenerative lumbar spine conditions and excluded deformity patients. One study demonstrated an association between low bone mass as measured by Hounsfield units and lower fusion rates. Six studies evaluated perioperative medical treatment of osteoporosis and showed higher fusion rates in patients treated with alendronate and teriparatide. The strongest evidence was for perioperative teriparatide. Eight studies evaluated surgical treatment strategies in patients with osteoporosis and showed that cement augmentation of pedicle screws and expandable pedicle screws demonstrated improved fusion rates than traditional pedicle screws. The strongest evidence was for expandable pedicle screws. Conclusion: There are 15 articles evaluating osteoporosis in patients undergoing lumbar fusion and the highest level of evidence is for perioperative use of teriparatide.
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Affiliation(s)
- Charla R Fischer
- Department of Orthopedic Surgery, The Spine Hospital, Columbia University Medical Center, New York, NY, USA
| | - Gregory Hanson
- Dartmouth Hitchcock Medical Center, Geisel School of Medicine, Hanover, NH, USA
| | - Melinda Eller
- Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopedic Surgery, The Spine Hospital, Columbia University Medical Center, New York, NY, USA
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Xu Z, Hao D, Liu T, He B, Guo H, He L. Cause Analysis of Open Surgery Used After Percutaneous Vertebroplasty and Kyphoplasty. Med Sci Monit 2016; 22:2595-601. [PMID: 27444135 PMCID: PMC4968613 DOI: 10.12659/msm.898463] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The aim of this study was to analyze reasons why open surgery was done after percutaneous vertebroplasty and kyphoplasty. MATERIAL AND METHODS Patients (587 vertebral bodies) treated with percutaneous vertebroplasty or kyphoplasty in the Xi'an Honghui Hospital of Shanxi Province from January 2008 to January 2012 were retrospectively analyzed and 13 patients were enrolled in the study. These 13 patients had serious adverse events after percutaneous vertebroplasty or kyphoplasty. Their average age was 64.5 years old. Nine patients had spinal cord injury and 4 had nerve root injury. All the patients underwent open surgery within 4-12 h after definitive diagnosis. RESULTS All 13 cases were followed up (average time 14.1 months, range 3-47 months). Reasons for open surgery included cement extravasation (6 cases, 46.2%), puncture mistake (3 cases, 23.1%), and false selection of indications (4 cases, 30.8%). At last follow-up, skin feeling was better than that before open surgery in 4 cases with nerve root injury, and muscle strength recovered to grade 5 (3 cases) and grade 4 (1 case). In 9 cases with spinal cord injury, 7 patients improved and 2 remained at the same ASIA level. CONCLUSIONS The main reasons for open surgery after percutaneous vertebroplasty and kyphoplasty were cement extravasation (the most common reason), puncture mistake, and false selection of indications.
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Affiliation(s)
- Zhengwei Xu
- Department of Spinal Surgery, Affiliated Honghui Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China (mainland)
| | - Dingjun Hao
- Department of Spinal Surgery, Affiliated Honghui Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China (mainland)
| | - Tuanjiang Liu
- Department of Spinal Surgery, Affiliated Honghui Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China (mainland)
| | - Baorong He
- Department of Spinal Surgery, Affiliated Honghui Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China (mainland)
| | - Hua Guo
- Department of Spinal Surgery, Affiliated Honghui Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China (mainland)
| | - Limin He
- Department of Spinal Surgery, Affiliated Honghui Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China (mainland)
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