Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors

No previous study has compared the complications between anterior/posterior and transforaminal interbody fusions. We performed a retrospective analysis of 164 patients to compare the complications and associated predictive factors of the two techniques of circumferential lumbar fusion. Fifty-three had same-day anterior/posterior fusion (group 1), and 111 had transforaminal interbody fusion (group 2). Mean operating time (p < 0.0001) and hospital stay (p < 0.0001) was significantly longer for group 1 patients. Average blood loss was greater for group 1 patients (p < 0.01). Higher complication rates were found in group 1 patients (p < 0.004). Wound infection occurred more frequently in patients with adjunctive treatment (p < 0.04). Hospital stay was an independent predictor of complications in both groups. In group 1, body mass index was independently associated with complications. In group 2, both hospital stay and adjunctive treatment were predictive of complications. Transforaminal lumbar interbody fusion is the preferred technique because it is associated with shorter operating time, less blood loss, shorter hospital stay, and lower incidence of complications.

Anterior fusion for idiopathic scoliosis

STUDY DESIGN

A review of the charts and radiographs of 22 patients with idiopathic lumbar, thoracolumbar, and thoracic scoliosis who underwent single-stage anterior fusion with rigid third-generation instrumentation and titanium surgical mesh implants.

OBJECTIVES

To validate a new technique for scoliosis correction by assessing the initial correction of deformity, trunk shift, and rotation. Perioperative statistics as well as complications were reviewed. The maintenance of sagittal balance and rate of fusion were also determined after a minimum of 2 years' follow-up.

SUMMARY OF BACKGROUND DATA

Posterior correction of scoliosis has been the preferred method of treatment since the introduction of Harrington rods. Recent advances in instrumentation and surgical techniques have allowed surgeons to approach scoliosis correction through the chest and abdomen. These new techniques must be validated before they become accepted alternatives to the standard of care.

METHODS

One male and 21 female patients, aged 11-18 years, were observed for an average of 44 months. Matched-pairs t tests were used to compare pre- and postoperative curve measurements.

RESULTS

Statistically significant curve improvements were seen when postoperative radiographs were compared with preoperative ones. The instrumented coronal plane curve was corrected 82%. A 65% spontaneous correction of the uninstrumented coronal plane curve was observed. Sagittal kyphosis improved 7 degrees, and apical rotation and tilt angles improved 71% and 80%, respectively. A mean loss of 4 degrees of correction was seen on final follow-up radiographs. Lumbar lordosis did not change significantly, and postoperative hyperlordosis was not detected. Ninety-six percent of all instrumented levels fused within 6 months. Although the perioperative complication rate was low, five patients (23%) had asymptomatic idiopathic retrolisthesis develop at the caudal end of the fused vertebrae.

CONCLUSIONS

Accepted correction of idiopathic scoliosis can be achieved with anterior instrumented fusion alone.

Anterior fibular strut grafting for the treatment of pseudoarthrosis in spondylolisthesis

Ten patients with a failed posterior spinal fusion for symptomatic spondylolisthesis were treated with retroperitoneal anterior lumbosacral interbody fusion. A fibular strut allograft was placed, followed by posterolateral fusion and instrumentation. The mean follow-up was 40 months (range 24-60 months). All patients complained of back pain and leg pain before surgery. All patients achieved solid fusion at L5-S1. One patient developed pseudoarthrosis at L4-5 and improved symptomatically with no postoperative complications.

Anterior cervical reconstruction using titanium cages with anterior plating

STUDY DESIGN

A preliminary outcome assessment study of titanium cage implants with anterior cervical plating in anterior cervical reconstruction.

OBJECTIVES

To evaluate the efficacy and safety of using titanium cage implants and anterior plating in cervical reconstruction.

SUMMARY OF BACKGROUND DATA

Anterior decompression and interbody fusion is a widely accepted surgical treatment for patients with cervical spondylosis. Tricortical iliac crest autograft has been the gold standard but is associated with morbidity at the bone graft donor site, whereas allograft fibula is associated with pseudarthrosis. Problems such as pseudarthrosis, graft collapse, and extrusion still persist with the accepted method of harvesting and implanting bone autografts.

METHODS

Thirty-four patients were treated by channel corpectomy followed by placement of a titanium cage packed with autogenous bone graft from the vertebral bodies to reconstruct the anterior column. An anterior cervical plate was added in 30 of 34 cases that involved decompression of two or more levels. The follow-up period ranged from 24 to 56 months, with an average follow-up period of 32 months, and included examination and radiography.

RESULTS

Six months after surgery, there was radiographic evidence of fusion in 97% of the patients. Eighty-eight percent of the patients (30 of 34) did not experience any complications (neither cage dislodgment nor hardware failure). Four patients had complications that included pseudarthrosis (1), extruded cage (1), cage in kyphosis (1), and radiculopathy (1).

CONCLUSIONS

Titanium cages provide immediate strong anterior column support with minimum hardware complications and avoid bone graft-site morbidity. Titanium cages, with concomitant use of anterior plating, offer an effective and safe alternative to bone autografts.

Cubital tunnel release with endoscopic assistance: results of a new technique

We evaluated the results of cubital tunnel release with endoscopic assistance. The study included 76 patients (85 elbows); 47 women and 29 men. Nine patients had bilateral procedures. Patients were excluded if they had less than 1 year of follow-up, associated pathology at the elbow to account for the nerve compression, or recurrent cubital tunnel syndrome. Before surgery, cases were categorized by stage of cubital tunnel syndrome according to Dellon's classification: 33 (39%) elbows were classified as mild, 35 (41%) moderate, and 17 (20%) severe. Surgical results were assessed according to a modified Bishop rating system. The mean follow-up period was 32 months (range, 12-52 months). Results were excellent in 42% of the elbows, good in 45%, fair in 11%, and poor in 2%. Recurrence occurred in 3 elbows. There were no serious complications. The results of this study support our recommendation of cubital tunnel release with endoscopic assistance as a safe and reliable technique for the treatment of cubital tunnel syndrome, especially in patients with mild to moderate symptoms.

Natural history of scoliosis in the institutionalized adult cerebral palsy population

STUDY DESIGN

Fifty-six residents with cerebral palsy and significant scoliosis or kyphosis at the Hazelwood Center in Louisville, Kentucky were studied periodically using radiographs to assess the degree of scoliosis, kyphosis, and pelvic obliquity and by clinical evaluation to assess functional status and skin condition.

OBJECTIVES

This study followed the natural history of untreated scoliosis to determine whether a decline in functional status is related to curve progression and whether the development of decubiti is associated with the degree of pelvic obliquity. Identifying the factors that affect functional decline may help develop treatment plans to minimize it.

SUMMARY OF BACKGROUND DATA

Significant structural deformities of the spine often accompany cerebral palsy. Despite the relatively large number of cases, little is known about the natural history of untreated scoliosis in the adult cerebral palsy population. Theoretically, curve progression will lead to pain, loss of ambulation or sitting balance, or even cardiopulmonary compromise, but few studies have been done to verify this.

METHODS

Single-factor analysis of variance was used to compare the curve progression rate within groups based on the structure of the curve, and the two-sample student t test was used to compare the average initial curve, the average final curve, the progression rate, and the amount of progression between groups based on functional decline. The two sample t test also was used to correlate the average pelvic obliquity and the size of the final curve with the presence or absence of decubiti.

RESULTS

Functionally, 10 patients (18%) declined during the course of the study. In these 10 patients, the average initial curve was 41.1 degrees, the average final curve was 80.6 degrees, and the average progression rate was 4.4 degrees per year. For the stable patients, the average initial curve was 33.9 degrees, the average final curve was 56.5 degrees, and the average progression rate was 3.0 degrees per year. The differences between the final curve and the absolute amount of progression were statistically significant (P = 0.018 and P = 0.03, respectively). Three patients developed decubiti. Their curve averaged 106 degrees, and their pelvic obliquity measured 45 degrees, both of which were significantly higher than those of the patients without decubiti.

CONCLUSIONS

The results of the present study demonstrate that in the adult patient with cerebral palsy and scoliosis, a definite correlation exists between deformity size and functional decline and decubiti. Progression rate also seems to be a factor in functional decline. Additional studies are needed to determine whether surgical intervention will halt or reverse the decline.