1
|
Arnold PM, Vaccaro AR, Sasso RC, Goulet B, Fehlings MG, Heary RF, Janssen ME, Kopjar B. Six-Year Follow-up of a Randomized Controlled Trial of i-FACTOR Peptide-Enhanced Bone Graft Versus Local Autograft in Single-Level Anterior Cervical Discectomy and Fusion. Neurosurgery 2023; 92:725-733. [PMID: 36700705 DOI: 10.1227/neu.0000000000002290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Previous analyses of the US Food and Drug Administration (FDA) Investigational Device Exemption study demonstrated the superiority of i-FACTOR compared with local autograft bone in single-level anterior cervical discectomy and fusion (ACDF) at 12 and 24 months postoperatively in a composite end point of overall success. OBJECTIVE To report the final, 6-year clinical and radiological outcomes of the FDA postapproval study. METHODS Of the original 319 subjects enrolled in the Investigational Device Exemption study, 220 participated in the postapproval study (106 i-FACTOR and 114 control). RESULTS The study met statistical noninferiority success for all 4 coprimary end points. Radiographic fusion was achieved in 99% (103/104) and 98.2% (109/111) in i-FACTOR and local autograft subjects, mean Neck Disability Index improvement from baseline was 28.6 (24.8, 32.3) in the i-FACTOR and 29.2 (25.6, 32.9) in the control group, respectively (noninferiority P < .0001). The neurological success rate at 6 years was 95.9% (70/73) in i-FACTOR subjects and 93.7% (70/75) in local autograft subjects (noninferiority P < .0001). Safety outcomes were similar between the 2 groups. Secondary surgery on the same or different cervical levels occurred in 20/106 (18.9%) i-FACTOR subjects and 23/114 (20.2%) local autograft subjects ( P = .866). Secondary outcomes (pain, SF-36 physical component score and mental component score) in i-FACTOR subjects were similar to those in local autograft subjects. CONCLUSION i-FACTOR met all 4 FDA-mandated noninferiority success criteria and demonstrated safety and efficacy in single-level anterior cervical discectomy and fusion for cervical radiculopathy through 6 years postoperatively. Safety outcomes are acceptable, and the clinical and functional outcomes observed at 12 and 24 months remained at 72 months.
Collapse
Affiliation(s)
| | - Alexander R Vaccaro
- Department of Orthopaedics, Thomas Jefferson University Hospital and Rothman Institute, Philadelphia, Pennsylvania, USA
| | - Rick C Sasso
- Indiana University School of Medicine, Indiana Spine Group, Carmel, Indiana, USA
| | - Benoit Goulet
- Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Michael G Fehlings
- University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Michael E Janssen
- Spine Education and Research Institute, Center for Spine and Orthopedics, Thornton, Colorado, USA
| | - Branko Kopjar
- Department of Health Services, University of Washington, Seattle, Washington, USA
| |
Collapse
|
2
|
Arnold PM, Vaccaro AR, Sasso RC, Goulet B, Fehlings MG, Heary RF, Janssen ME, Kopjar B. Two-Year Clinical and Radiological Outcomes in Patients With Diabetes Undergoing Single-Level Anterior Cervical Discectomy and Fusion. Global Spine J 2021; 11:458-464. [PMID: 32875918 PMCID: PMC8119920 DOI: 10.1177/2192568220914880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
STUDY DESIGN Secondary analysis of data from the multicenter, randomized, parallel-controlled Food and Drug Administration (FDA) investigational device exemption study. OBJECTIVE Studies on outcomes following anterior cervical discectomy and fusion (ACDF) in individuals with diabetes are scarce. We compared 24-month radiological and clinical outcomes in individuals with and without diabetes undergoing single-level ACDF with either i-FACTOR or local autologous bone. METHODS Between 2006 and 2013, 319 individuals with single-level degenerative disc disease (DDD) and no previous fusion at the index level underwent ACDF. The presence of diabetes determined the 2 cohorts. Data collected included radiological fusion evaluation, neurological outcomes, Neck Disability Index (NDI), Visual Analog Scale (VAS) scores, and the 36-Item Short Form Survey Version 2 (SF-36v2) Physical and Mental component summary scores. RESULTS There were 35 individuals with diabetes (11.1%; average body mass index [BMI] = 32.99 kg/m2; SD = 5.72) and 284 without (average BMI = 28.32 kg/m2; SD = 5.67). The number of nondiabetic smokers was significantly higher than diabetic smokers: 73 (25.70%) and 3 (8.57%), respectively. Preoperative scores of NDI, VAS arm pain, and SF-36v2 were similar between the diabetic and nondiabetic participants at baseline; however, VAS neck pain differed significantly between the cohorts at baseline (P = .0089). Maximum improvement for NDI, VAS neck and arm pain, and SF-36v2 PCS and MCS scores was seen at 6 months in both cohorts and remained stable until 24 months. CONCLUSIONS ACDF is effective for cervical radiculopathy in patients with diabetes. Diabetes is not a contraindication for patients requiring single-level surgery for cervical DDD.
Collapse
Affiliation(s)
- Paul M. Arnold
- Carle Spine Institute, IL, USA,Paul M. Arnold, Carle Spine Institute,
610 N. Lincoln Avenue, Urbana, IL 61801 USA.
| | | | - Rick C. Sasso
- Indiana University School of Medicine, Indiana Spine Group, IN, USA
| | | | | | | | | | | |
Collapse
|
3
|
Affiliation(s)
- Michael E. Janssen
- Center for Spine & Orthopedics, Denver, CO, USA,Michael E. Janssen, Center for Spine & Orthopedics, Denver, CO 80229, USA.
| |
Collapse
|
4
|
Dorenkamp BC, Janssen MK, Janssen ME. Improving blood product utilization at an ambulatory surgery center: a retrospective cohort study on 50 patients with lumbar disc replacement. Patient Saf Surg 2020; 13:45. [PMID: 31890030 PMCID: PMC6921547 DOI: 10.1186/s13037-019-0226-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 12/09/2019] [Indexed: 11/26/2022] Open
Abstract
Background There is minimal literature discussing anterior lumbar spine surgery in ambulatory surgery centers (ASCs). The main concern with the anterior approach to the lumbar spine is the potential for injury to great vessels. In our facility, there are two units of crossmatched blood available in addition to cell saver during the procedure. We retrospectively looked at 50 cases of lumbar total disc arthroplasty (TDA) in our ASC to determine utilization of blood products. Methods Medical records of 50 consecutive patients who underwent a lumbar TDA at a single ASC were reviewed. Surgeries completed at the ASC were all transferred from the post anesthesia care unit to an attached convalescence care center which allows up to 3 days of observation. Patients who had either a 1 or 2 level lumbar TDA were included in the study. Data consisting of demographics, American Society of Anesthesiologist Physical Status Classification System, length of stay, estimated blood loss, cell saver volume, transfusion, perioperative and postoperative complications were recorded. Preoperative, perioperative and postoperative medical records were reviewed. Results Medical records of 50 consecutive patients were reviewed. The mean age was 40.86 ± 9.45. Of these, 48 (96%) had a 1-level lumbar TDA, 1(2%) had a 2-level lumbar TDA, 1 (2%) had a lumbar TDA at L4/5 and an anterior lumbar interbody fusion at L5/S1. There were no mortalities; no patient had recorded perioperative complications. No patients received allogeneic blood transfusion, 4 (8%) were re-transfused with cell saver (2 receiving approximately 400 ml and 2 receiving approximately 200 ml of re-transfused blood). All 50 (100%) were discharged home in stable condition. We had 30-day follow-up data on 35 of 50 patients. Of the 35 patients reviewed, three (8.5%) of the patients were readmitted to the hospital. One additional patient was seen in the emergency department and discharged home after negative testing. No patient was readmitted for post-operative anemia. Conclusion The routine use of both cell saver and crossmatched blood in the operating suite for lumbar TDA may be an over-utilization of healthcare resources. In our review of 50 patients, we had no need for transfusion of allogeneic packed red blood cells (PRBCs) and only four of the 50 patients had enough blood output for re-transfusion from the cell saver. This opens the conversation for alternatives to crossmatched PRBCs being held in the operating room. Such alternatives may be the use of cell salvage, only type O blood in a cooler for each patient or keeping type O blood on constant hold in ASCs.
Collapse
Affiliation(s)
- Benjamin C Dorenkamp
- 1Orthopedic Surgery Residency, McLaren Greater Lansing, 401 W Greenlawn Ave, Lansing, MI 48910 USA
| | - Madisen K Janssen
- 2College of Osteopathic Medicine, Rocky Vista University, 8401 S Chambers Rd, Parker, CO 80134 USA
| | - Michael E Janssen
- Center for Spine & Orthopedics, 9005 Grant St #200, Denver, CO 80229 USA
| |
Collapse
|
5
|
Arnold PM, Sasso RC, Janssen ME, Fehlings MG, Heary RF, Vaccaro AR, Kopjar B. i-Factor™ Bone Graft vs Autograft in Anterior Cervical Discectomy and Fusion: 2-Year Follow-up of the Randomized Single-Blinded Food and Drug Administration Investigational Device Exemption Study. Neurosurgery 2019; 83:377-384. [PMID: 28945914 DOI: 10.1093/neuros/nyx432] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/09/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND i-Factor™ Bone Graft (Cerapedics Inc, Westminster, Colorado) is a composite bone substitute material consisting of P-15 synthetic collagen fragment adsorbed onto anorganic bone mineral suspended in an inert biocompatible hydrogel carrier. A pivotal, noninferiority, US FDA Investigational Device Exemption study demonstrated the benefits of i-Factor™ compared to local autograft bone in single-level anterior cervical discectomy and fusion at 1-yr postoperative. OBJECTIVE To report 2-yr follow-up. METHODS Subjects randomly received either autograft (n = 154) or i-Factor™ (n = 165) in a cortical ring allograft and followed using radiological, clinical, and patient-reported outcomes. RESULTS At 2 yr, the fusion rate was 97.30% and 94.44% in i-Factor™ and autograft subjects, respectively (P = .2513), and neurological success rate was 94.87% (i-Factor™) and 93.79% (autograft; P = .7869). Neck Disability Index improved 28.30 (i-Factor™) and 26.95 (autograft; P = .1448); Visual Analog Scale arm pain improved 5.43 (i-Factor™) and 4.97 (autograft) (p = .2763); Visual Analog Scale neck pain improved 4.78 (i-Factor™) and 4.41 (autograft; P = .1652), Short Form-36 (SF-36v2) Physical Component Score improved 10.23 (i-Factor™) and 10.18 (autograft; P = .4507), and SF36v2 Mental Component Score improved 7.88 (i-FactorTM) and 7.53 (autograft; P = .9872). The composite endpoint of overall success (fusion, Neck Disability Index improvement >15, neurological success, and absence of re-operations) was greater in i-Factor™ subjects compared to autograft subjects (69.83% and 56.35%, respectively, P = .0302). Twelve (7.45%) i-Factor™ subjects and 16 (10.53%) autograft subjects underwent re-operation (P = .3411). There were no allergic reactions associated with i-Factor™. CONCLUSION Use of i-Factor™ in anterior cervical discectomy and fusion is effective and safe, and results in similar outcomes compared to local autograft bone at 2 yr following surgery.
Collapse
Affiliation(s)
- Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | | | | | - Michael G Fehlings
- Department of Neurosurgery, University of Toronto, The Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Robert F Heary
- Department of Neurological Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alexander R Vaccaro
- Rothman Institute Orthopaedics, Thomas Jefferson University Hospital, Philadelphia Pennsylvania
| | - Branko Kopjar
- Department of Health Services, University of Washington, Seattle, Washington
| |
Collapse
|
6
|
Fehlings MG, Kopjar B, Ibrahim A, Tetreault LA, Arnold PM, Defino H, Kale SS, Yoon ST, Barbagallo GM, Bartels RHM, Zhou Q, Vaccaro AR, Zileli M, Tan G, Yukawa Y, Brodke DS, Shaffrey CI, Santos de Moraes O, Woodard EJ, Scerrati M, Tanaka M, Toyone T, Sasso RC, Janssen ME, Gokaslan ZL, Alvarado M, Bolger C, Bono CM, Dekutoski MB. Geographic variations in clinical presentation and outcomes of decompressive surgery in patients with symptomatic degenerative cervical myelopathy: analysis of a prospective, international multicenter cohort study of 757 patients. Spine J 2018; 18:593-605. [PMID: 28888674 DOI: 10.1016/j.spinee.2017.08.265] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/20/2017] [Accepted: 08/29/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Degenerative cervical myelopathy (DCM) is a progressive degenerative spine disease and the most common cause of spinal cord impairment in adults worldwide. Few studies have reported on regional variations in demographics, clinical presentation, disease causation, and surgical effectiveness. PURPOSE The objective of this study was to evaluate differences in demographics, causative pathology, management strategies, surgical outcomes, length of hospital stay, and complications across four geographic regions. STUDY DESIGN/SETTING This is a multicenter international prospective cohort study. PATIENT SAMPLE This study includes a total of 757 symptomatic patients with DCM undergoing surgical decompression of the cervical spine. OUTCOME MEASURES The outcome measures are the Neck Disability Index (NDI), the Short Form 36 version 2 (SF-36v2), the modified Japanese Orthopaedic Association (mJOA) scale, and the Nurick grade. MATERIALS AND METHODS The baseline characteristics, disease causation, surgical approaches, and outcomes at 12 and 24 months were compared among four regions: Europe, Asia Pacific, Latin America, and North America. RESULTS Patients from Europe and North America were, on average, older than those from Latin America and Asia Pacific (p=.0055). Patients from Latin America had a significantly longer duration of symptoms than those from the other three regions (p<.0001). The most frequent causes of myelopathy were spondylosis and disc herniation. Ossification of the posterior longitudinal ligament was most prevalent in Asia Pacific (35.33%) and in Europe (31.75%), and hypertrophy of the ligamentum flavum was most prevalent in Latin America (61.25%). Surgical approaches varied by region; the majority of cases in Europe (71.43%), Asia Pacific (60.67%), and North America (59.10%) were managed anteriorly, whereas the posterior approach was more common in Latin America (66.25%). At the 24-month follow-up, patients from North America and Asia Pacific exhibited greater improvements in mJOA and Nurick scores than those from Europe and Latin America. Patients from Asia Pacific and Latin America demonstrated the most improvement on the NDI and SF-36v2 PCS. The longest duration of hospital stay was in Asia Pacific (14.16 days), and the highest rate of complications (34.9%) was reported in Europe. CONCLUSIONS Regional differences in demographics, causation, and surgical approaches are significant for patients with DCM. Despite these variations, surgical decompression for DCM appears effective in all regions. Observed differences in the extent of postoperative improvements among the regions should encourage the standardization of care across centers and the development of international guidelines for the management of DCM.
Collapse
Affiliation(s)
- Michael G Fehlings
- Department of Surgery, Toronto Western Hospital, 399 Bathurst St, Toronto, Ontario M5T 2S8, Canada.
| | - Branko Kopjar
- Department of Health Services, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Ahmed Ibrahim
- Department of Surgery, Toronto Western Hospital, 399 Bathurst St, Toronto, Ontario M5T 2S8, Canada
| | - Lindsay A Tetreault
- Department of Surgery, Toronto Western Hospital, 399 Bathurst St, Toronto, Ontario M5T 2S8, Canada; Graduate Entry Medicine, University College Cork, Cork, Ireland
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Helton Defino
- Department of Medicine, University of São Paulo, Ribeirão Preto, São Paulo 03178-200, Brazil
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - S Tim Yoon
- Department of Orthopaedic Surgery, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Giuseppe M Barbagallo
- Department of Neurosurgery, Policlinico "G. Rodolico" University Hospital, Via S. Sofia, Catania 95125, Italy
| | - Ronald H M Bartels
- Department of Neurosurgery, Radboud University Nijmegen Medical Centre, Geert Grooteplein Zuid 10, Nijmegen 6625, The Netherlands
| | - Qiang Zhou
- Department of Orthopedics, Southwest Hospital, First Affiliated Hospital of the Third Military Medical University, Gaoyan Rock Street 30, Chongqing, China
| | - Alexander R Vaccaro
- Rothman Institute, Thomas Jefferson University Hospital, 925 Chestnut St, Philadelphia, PA 19107, USA
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University, Erzene Mahallesi, Gençlik Caddesi, Izmir 35040, Turkey
| | - Gamaliel Tan
- Department of Orthopaedics, Alexandra Hospital, 378 Alexandra Rd, Singapore 159964
| | - Yasutsugu Yukawa
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1 Chome-10-6 Komei, Minato Ward, Nagoya 455-8530, Japan
| | - Darrel S Brodke
- Department of Orthopaedics, University of Utah, Salt Lake City, 590 Wakara Way, UT 84108, USA
| | - Christopher I Shaffrey
- Department of Neurological Surgery, University of Virginia, 1215 Lee St, Charlottesville, VA 22908, USA
| | - Osmar Santos de Moraes
- Department of Neurosurgery, Hospital Santa Marcelina, R. Santa Marcelina, São Paulo 08260-005, Brazil
| | - Eric J Woodard
- Department of Surgery, New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA
| | - Massimo Scerrati
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital, Via Conca, 71, Ancona 60126, Italy
| | - Masato Tanaka
- Department of Orthopedic Surgery, Okayama University Hospital, 2 Chome-5-1 Shikatacho, Kita Ward, Okayama 700-8558, Japan
| | - Tomoaki Toyone
- Department of Orthopaedic Surgery, Teikyo University Chiba Medical Center, 2 Chome-11-1 Kaga, Itabashi, Tokyo 173-8606, Japan
| | - Rick C Sasso
- Indiana Spine Group, 13225 N Meridian St, Carmel, IN 46032, USA
| | - Michael E Janssen
- Spine Education and Research Institute, 9005 Grant St, Denver, CO 80229, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery/Spine Division, Johns Hopkins University, 3400 N. Charles St, Baltimore, MD 21218, USA
| | - Manuel Alvarado
- Department of Surgery, Hospital San Juan de Dios, Calle-C, Caracas, Venezuela
| | - Ciaran Bolger
- Department of Neurosurgery, Beaumont Hospital, PO Box 1297, Beaumont Rd, Dublin 9, Ireland
| | - Christopher M Bono
- Department of Orthopedics, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Mark B Dekutoski
- The CORE Institute, Sun City West, 14520 W Granite Valley Dr, AZ 85375, USA
| |
Collapse
|
7
|
Kadam A, Millhouse PW, Kepler CK, Radcliff KE, Fehlings MG, Janssen ME, Sasso RC, Benedict JJ, Vaccaro AR. Bone substitutes and expanders in Spine Surgery: A review of their fusion efficacies. Int J Spine Surg 2016; 10:33. [PMID: 27909654 DOI: 10.14444/3033] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN A narrative review of literature. OBJECTIVE This manuscript intends to provide a review of clinically relevant bone substitutes and bone expanders for spinal surgery in terms of efficacy and associated clinical outcomes, as reported in contemporary spine literature. SUMMARY OF BACKGROUND DATA Ever since the introduction of allograft as a substitute for autologous bone in spinal surgery, a sea of literature has surfaced, evaluating both established and newly emerging fusion alternatives. An understanding of the available fusion options and an organized evidence-based approach to their use in spine surgery is essential for achieving optimal results. METHODS A Medline search of English language literature published through March 2016 discussing bone graft substitutes and fusion extenders was performed. All clinical studies reporting radiological and/or patient outcomes following the use of bone substitutes were reviewed under the broad categories of Allografts, Demineralized Bone Matrices (DBM), Ceramics, Bone Morphogenic proteins (BMPs), Autologous growth factors (AGFs), Stem cell products and Synthetic Peptides. These were further grouped depending on their application in lumbar and cervical spine surgeries, deformity correction or other miscellaneous procedures viz. trauma, infection or tumors; wherever data was forthcoming. Studies in animal populations and experimental in vitro studies were excluded. Primary endpoints were radiological fusion rates and successful clinical outcomes. RESULTS A total of 181 clinical studies were found suitable to be included in the review. More than a third of the published articles (62 studies, 34.25%) focused on BMP. Ceramics (40 studies) and Allografts (39 studies) were the other two highly published groups of bone substitutes. Highest radiographic fusion rates were observed with BMPs, followed by allograft and DBM. There were no significant differences in the reported clinical outcomes across all classes of bone substitutes. CONCLUSIONS There is a clear publication bias in the literature, mostly favoring BMP. Based on the available data, BMP is however associated with the highest radiographic fusion rate. Allograft is also very well corroborated in the literature. The use of DBM as a bone expander to augment autograft is supported, especially in the lumbar spine. Ceramics are also utilized as bone graft extenders and results are generally supportive, although limited. The use of autologous growth factors is not substantiated at this time. Cell matrix or stem cell-based products and the synthetic peptides have inadequate data. More comparative studies are needed to evaluate the efficacy of bone graft substitutes overall.
Collapse
Affiliation(s)
- Abhijeet Kadam
- Pennsylvania Hospital of the University of Pennsylvania Health System, Philadelphia, PA
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Janssen ME, Zigler JE, Spivak JM, Delamarter RB, Darden BV, Kopjar B. ProDisc-C Total Disc Replacement Versus Anterior Cervical Discectomy and Fusion for Single-Level Symptomatic Cervical Disc Disease: Seven-Year Follow-up of the Prospective Randomized U.S. Food and Drug Administration Investigational Device Exemption Study. J Bone Joint Surg Am 2015; 97:1738-47. [PMID: 26537161 DOI: 10.2106/jbjs.n.01186] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In patients with single-level cervical degenerative disc disease, total disc arthroplasty can relieve radicular pain and preserve functional motion between two vertebrae. We compared the efficacy and safety of cervical total disc arthroplasty with that of anterior cervical discectomy and fusion (ACDF) for the treatment of single-level cervical degenerative disc disease between C3-C4 and C6-C7. METHODS Two hundred and nine patients at thirteen sites were randomly treated with either total disc arthroplasty with ProDisc-C (n = 103) or with ACDF (n = 106). Patients were assessed preoperatively; at six weeks and three, six, twelve, eighteen, and twenty-four months postoperatively; and then annually until seven years postoperatively. Outcome measures included the Neck Disability Index (NDI), the Short Form-36 (SF-36), postoperative neurologic parameters, secondary surgical procedures, adverse events, neck and arm pain, and satisfaction scores. RESULTS At seven years, the overall follow-up rate was 92% (152 of 165). There were no significant differences in demographic factors, follow-up rate, or patient-reported outcomes between groups. Both procedures were effective in reducing neck and arm pain and improving and maintaining function and health-related quality of life. Neurologic status was improved or maintained in 88% and 89% of the patients in the ProDisc-C and ACDF groups, respectively. After seven years of follow-up, thirty secondary surgical procedures had been performed in nineteen (18%) of 106 patients in the ACDF group compared with seven secondary surgical procedures in seven (7%) of 103 patients in the ProDisc-C group (p = 0.0099). There were no significant differences in the rates of any device-related adverse events between the groups. CONCLUSIONS Total disc arthroplasty with ProDisc-C is a safe and effective surgical treatment of single-level symptomatic cervical degenerative disc disease. Clinical outcomes after total disc arthroplasty with ProDisc-C were similar to those after ACDF. Patients treated with ProDisc-C had a lower probability of subsequent surgery, suggesting that total disc arthroplasty provides durable results and has the potential to slow the rate of adjacent-level disease. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Michael E Janssen
- Center for Spinal Disorders/Scientific Education and Research Institute, 9005 Grant Street, Suite 200, Thornton, CO 80229
| | - Jack E Zigler
- Texas Back Institute, 6020 West Parker Road, Suite 200, Plano, TX 75093
| | - Jeffrey M Spivak
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003
| | - Rick B Delamarter
- The Spine Institute, 2811 Wilshire Boulevard, Suite 850, Santa Monica, CA 90403
| | - Bruce V Darden
- OrthoCarolina Spine Center, 2001 Randolph Road, Charlotte, NC 28207
| | - Branko Kopjar
- Department of Health Services, University of Washington, 4333 Brooklyn Avenue N.E., Room 14-315, Seattle, WA 98195-9455. E-mail address:
| |
Collapse
|
9
|
Arnold PM, Fehlings MG, Kopjar B, Yoon ST, Massicotte EM, Vaccaro AR, Brodke DS, Shaffrey CI, Smith JS, Woodard EJ, Banco RJ, Chapman JR, Janssen ME, Bono CM, Sasso RC, Dekutoski MB, Gokaslan ZL. Mild diabetes is not a contraindication for surgical decompression in cervical spondylotic myelopathy: results of the AOSpine North America multicenter prospective study (CSM). Spine J 2014; 14:65-72. [PMID: 23981820 DOI: 10.1016/j.spinee.2013.06.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 03/08/2013] [Accepted: 06/01/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical spondylotic myelopathy (CSM) is a chronic spinal cord disease and can lead to progressive or stepwise neurologic decline. Several factors may influence this process, including extent of spinal cord compression, duration of symptoms, and medical comorbidities. Diabetes is a systemic disease that can impact multiple organ systems, including the central and peripheral nervous systems. There has been little information regarding the effect of diabetes on patients with coexistent CSM. PURPOSE To provide empirical data regarding the effect of diabetes on treatment outcomes in patients who underwent surgical decompression for coexistent CSM. STUDY DESIGN/SETTING Large prospective multicenter cohort study of patients with and without diabetes who underwent decompressive surgery for CSM. PATIENT SAMPLE Two hundred thirty-six patients without and 42 patients with diabetes were enrolled. Of these, 37 were mild cases and five were moderate cases. Four required insulin. There were no severe cases associated with end-organ damage. OUTCOME MEASURES Self-report measures include Neck Disability Index and version 2 of 36-Item Short Form Health Survey (SF-36v2), and functional measures include modified Japanese Orthopedic Association (mJOA) score and Nurick grade. METHODS We compared presurgery symptoms and treatment outcomes between patients with and without diabetes using univariate and multivariate models, adjusting for demographics and comorbidities. RESULTS Diabetic patients were older, less likely to smoke, and more likely to be on social security disability insurance. Patients with diabetes presented with a worse Nurick grade, but there were no differences in mJOA and SF-36v2 at presentation. Overall, there was a significant improvement in all outcome parameters at 12 and 24 months. There was no difference in the level of improvement between the patients with and without diabetes, except in the SF-36v2 Physical Functioning, in which diabetic patients experienced significantly less improvement. There were no differences in surgical complication rates between diabetic patients and nondiabetic patients. CONCLUSIONS Except for a worse Nurick grade, diabetes does not seem to affect severity of symptoms at presentation for surgery. More importantly, with the exception of the SF-36v2 Physical Functioning scores, outcomes of surgical treatment are similar in patients with diabetes and without diabetes. Surgical decompression is effective and should be offered to patients with diabetes who have symptomatic CSM and are appropriate surgical candidates.
Collapse
Affiliation(s)
- Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, 3901 Rainbow Blvd., Mail Stop 3021, Kansas City, KS 66160, USA.
| | - Michael G Fehlings
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, 399 Bathurst St, #4W-449, Toronto, ON, Canada
| | - Branko Kopjar
- Department of Health Services, University of Washington, Box 359455, 4333 Brooklyn Ave NE, Rm 14-315, Seattle, WA 98195-9455, USA
| | - Sangwook Tim Yoon
- Department of Orthopaedic Surgery, Emory University, Emory Orthopaedics & Spine Center, 59 Executive Park South, Atlanta, GA 30329, USA
| | - Eric M Massicotte
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, 399 Bathurst St, #4W-449, Toronto, ON, Canada
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107-4216, USA
| | - Darrel S Brodke
- Department of Orthopaedics, University of Utah, University Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Christopher I Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, PO Box 800212, Charlottesville, VA 22908-0212, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, PO Box 800212, Charlottesville, VA 22908-0212, USA
| | - Eric J Woodard
- Department of Orthopedic Surgery, New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA
| | - Robert J Banco
- Boston Spine Group, 299 Washington St, Newton, MA 02458, USA
| | - Jens R Chapman
- Department of Orthopaedics, University of Washington, Orthopaedic Trauma Surgery Clinic at Harborview, Harborview Medical Center, 1 West Clinic, Box 359798, 325 Ninth Ave, Seattle, WA 98104, USA
| | - Michael E Janssen
- Spine Education and Research Institute, Center for Spinal Disorders, 9005 Grant St., Suite 200, Thornton, CO 80229, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, USA
| | - Rick C Sasso
- Department of Orthopedic Surgery, Indiana Spine Group, 8040 Clearvista Parkway, Suite 450, Indianapolis, IN 46256, USA
| | - Mark B Dekutoski
- The CORE Institute, Center for Orthopedic Research and Education, 3010 W. Agua Fria Fwy #100, Phoenix, AZ 85027, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Meyer 7-109, 600 North Wolfe St., Baltimore, MD 21287, USA
| |
Collapse
|
10
|
Fehlings MG, Wilson JR, Kopjar B, Yoon ST, Arnold PM, Massicotte EM, Vaccaro AR, Brodke DS, Shaffrey CI, Smith JS, Woodard EJ, Banco RJ, Chapman JR, Janssen ME, Bono CM, Sasso RC, Dekutoski MB, Gokaslan ZL. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am 2013; 95:1651-8. [PMID: 24048552 DOI: 10.2106/jbjs.l.00589] [Citation(s) in RCA: 321] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cervical spondylotic myelopathy is the leading cause of spinal cord dysfunction worldwide. The objective of this study was to evaluate the impact of surgical decompression on functional, quality-of-life, and disability outcomes at one year after surgery in a large cohort of patients with this condition. METHODS Adult patients with symptomatic cervical spondylotic myelopathy and magnetic resonance imaging evidence of spinal cord compression were enrolled at twelve North American centers from 2005 to 2007. At enrollment, the myelopathy was categorized as mild (modified Japanese Orthopaedic Association [mJOA] score ≥ 15), moderate (mJOA = 12 to 14), or severe (mJOA < 12). Patients were followed prospectively for one year, at which point the outcomes of interest included the mJOA score, Nurick grade, Neck Disability Index (NDI), and Short Form-36 version 2 (SF-36v2). All outcomes at one year were compared with the preoperative values with use of univariate paired statistics. Outcomes were also compared among the severity classes with use of one-way analysis of variance. Finally, a multivariate analysis that adjusted for baseline differences among the severity groups was performed. Treatment-related complication data were collected and the overall complication rate was calculated. RESULTS Eighty-five (30.6%) of the 278 enrolled patients had mild cervical spondylotic myelopathy, 110 (39.6%) had moderate disease, and 83 (29.9%) had severe disease preoperatively. One-year follow-up data were available for 222 (85.4%) of 260 patients. There was a significant improvement from baseline to one year postoperatively (p < 0.05) in the mJOA score, Nurick grade, NDI score, and all SF-36v2 health dimensions (including the mental and physical health composite scores) except general health. With the exception of the change in the mJOA, the degree of improvement did not depend on the severity of the preoperative symptoms. These results remained unchanged after adjusting for relevant confounders in the multivariate analysis. Fifty-two patients experienced complications (prevalence, 18.7%), with no significant differences among the severity groups. CONCLUSIONS Surgical decompression for the treatment of cervical spondylotic myelopathy was associated with improvement in functional, disability-related, and quality-of-life outcomes at one year of follow-up for all disease severity categories. Furthermore, complication rates observed in the study were commensurate with those in previously reported cervical spondylotic myelopathy series.
Collapse
Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, West Wing, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. E-mail address for M.G. Fehlings:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Fehlings MG, Smith JS, Kopjar B, Arnold PM, Yoon ST, Vaccaro AR, Brodke DS, Janssen ME, Chapman JR, Sasso RC, Woodard EJ, Banco RJ, Massicotte EM, Dekutoski MB, Gokaslan ZL, Bono CM, Shaffrey CI. Perioperative and delayed complications associated with the surgical treatment of cervical spondylotic myelopathy based on 302 patients from the AOSpine North America Cervical Spondylotic Myelopathy Study. J Neurosurg Spine 2012; 16:425-32. [PMID: 22324802 DOI: 10.3171/2012.1.spine11467] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Rates of complications associated with the surgical treatment of cervical spondylotic myelopathy (CSM) are not clear. Appreciating these risks is important for patient counseling and quality improvement. The authors sought to assess the rates of and risk factors associated with perioperative and delayed complications associated with the surgical treatment of CSM. METHODS Data from the AOSpine North America Cervical Spondylotic Myelopathy Study, a prospective, multicenter study, were analyzed. Outcomes data, including adverse events, were collected in a standardized manner and externally monitored. Rates of perioperative complications (within 30 days of surgery) and delayed complications (31 days to 2 years following surgery) were tabulated and stratified based on clinical factors. RESULTS The study enrolled 302 patients (mean age 57 years, range 29-86) years. Of 332 reported adverse events, 73 were classified as perioperative complications (25 major and 48 minor) in 47 patients (overall perioperative complication rate of 15.6%). The most common perioperative complications included minor cardiopulmonary events (3.0%), dysphagia (3.0%), and superficial wound infection (2.3%). Perioperative worsening of myelopathy was reported in 4 patients (1.3%). Based on 275 patients who completed 2 years of follow-up, there were 14 delayed complications (8 minor, 6 major) in 12 patients, for an overall delayed complication rate of 4.4%. Of patients treated with anterior-only (n = 176), posterior-only (n = 107), and combined anterior-posterior (n = 19) procedures, 11%, 19%, and 37%, respectively, had 1 or more perioperative complications. Compared with anterior-only approaches, posterior-only approaches had a higher rate of wound infection (0.6% vs 4.7%, p = 0.030). Dysphagia was more common with combined anterior-posterior procedures (21.1%) compared with anterior-only procedures (2.3%) or posterior-only procedures (0.9%) (p < 0.001). The incidence of C-5 radiculopathy was not associated with the surgical approach (p = 0.8). The occurrence of perioperative complications was associated with increased age (p = 0.006), combined anterior-posterior procedures (p = 0.016), increased operative time (p = 0.009), and increased operative blood loss (p = 0.005), but it was not associated with comorbidity score, body mass index, modified Japanese Orthopaedic Association score, smoking status, anterior-only versus posterior-only approach, or specific procedures. Multivariate analysis of factors associated with minor or major complications identified age (OR 1.029, 95% CI 1.002-1.057, p = 0.035) and operative time (OR 1.005, 95% CI 1.002-1.008, p = 0.001). Multivariate analysis of factors associated with major complications identified age (OR 1.054, 95% CI 1.015-1.094, p = 0.006) and combined anterior-posterior procedures (OR 5.297, 95% CI 1.626-17.256, p = 0.006). CONCLUSIONS For the surgical treatment of CSM, the vast majority of complications were treatable and without long-term impact. Multivariate factors associated with an increased risk of complications include greater age, increased operative time, and use of combined anterior-posterior procedures.
Collapse
|
12
|
Delamarter RB, Murrey D, Janssen ME, Goldstein JA, Zigler J, Tay BKB, Darden B. Results at 24 months from the prospective, randomized, multicenter Investigational Device Exemption trial of ProDisc-C versus anterior cervical discectomy and fusion with 4-year follow-up and continued access patients. SAS J 2010; 4:122-8. [PMID: 25802660 PMCID: PMC4365641 DOI: 10.1016/j.esas.2010.09.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Cervical total disk replacement (TDR) is intended to address pain and preserve motion between vertebral bodies in patients with symptomatic cervical disk disease. Two-year follow-up for the ProDisc-C (Synthes USA Products, LLC, West Chester, Pennsylvania) TDR clinical trial showed non-inferiority versus anterior cervical discectomy and fusion (ACDF), showing superiority in many clinical outcomes. We present the 4-year interim follow-up results. Methods Patients were randomized (1:1) to ProDisc-C (PDC-R) or ACDF. Patients were assessed preoperatively, and postoperatively at 6 weeks and 3, 6, 12, 18, 24, 36, and 48 months. After the randomized portion, continued access (CA) patients also underwent ProDisc-C implantation, with follow-up visits up to 24 months. Evaluations included Neck Disability Index (NDI), Visual Analog Scale (VAS) for pain/satisfaction, and radiographic and physical/neurologic examinations. Results Randomized patients (103 PDC-R and 106 ACDF) and 136 CA patients were treated at 13 sites. VAS pain and NDI score improvements from baseline were significant for all patients (P < .0001) but did not differ among groups. VAS satisfaction was higher at all time points for PDC-R versus ACDF patients (P = .0499 at 48 months). The percentage of patients who responded yes to surgery again was 85.6% at 24 months and 88.9% at 48 months in the PDC-R group, 80.9% at 24 months and 81.0% at 48 months in the ACDF group, and 86.3% at 24 months in the CA group. Five PDC-R patients (48 months) and no CA patients (24 months) had index-level bridging bone. By 48 months, approximately 4-fold more ACDF patients required secondary surgery (3 of 103 PDC-R patients [2.9%] vs 12 of 106 ACDF patients [11.3%], P = .0292). Of these, 6 ACDF patients (5.6%) required procedures at adjacent levels. Three CA patients required secondary procedures (24 months). Conclusions Our 4-year data support that ProDisc-C TDR and ACDF are viable surgical options for symptomatic cervical disk disease. Although ACDF patients may be at higher risk for additional surgical intervention, patients in both groups show good clinical results at longer-term follow-up.
Collapse
Affiliation(s)
- Rick B. Delamarter
- The Spine Center at Cedars-Sinai Medical Center, Los Angeles, CA
- Corresponding author: Rick B. Delamarter, MD, The Spine Institute at Saint John's Health Center, 1301 20th St, Ste 400, Santa Monica, CA 90404. Tel.: 310-828-7757; Fax: 310-828-6847. E-mail address:
| | - Daniel Murrey
- OrthoCarolina, PA, OrthoCarolina Spine Center, Charlotte, NC
| | | | | | | | - Bobby K-B Tay
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA
| | - Bruce Darden
- OrthoCarolina, PA, OrthoCarolina Spine Center, Charlotte, NC
| |
Collapse
|
13
|
Murrey DB, Janssen ME, Odum SM, Gottlieb JR, Spector LR, Darden BV. Two-Year Results of a Randomized Controlled Clinical Trial Comparing ProDisc-C and Anterior Cervical Discectomy and Fusion. Int J Spine Surg 2008; 2:76-85. [PMID: 25802606 PMCID: PMC4365824 DOI: 10.1016/sasj-2007-0124-rr] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 04/24/2008] [Indexed: 11/29/2022] Open
Abstract
Background Anterior cervical discectomy and fusion (ACDF) is a well-accepted procedure for the treatment of cervical radiculopathy. Hilibrand et al. reported that adjacent segment disease is known to occur at a rate of 2.9% per year after cervical fusion. Developers of cervical disc replacements postulate that maintaining more normal motion may reduce the rate of adjacent segment disease. The purpose of this study was to compare the 2-year efficacy and safety of ACDF and cervical total disc replacement surgery. Methods Eighty-seven patients from 2 sites of this 13 multicenter trial were randomized to treatment with either ACDF or cervical disc replacement surgery with the ProDisc-C (Synthes, Inc., West Chester, Pennsylvania) implant. Patient outcomes were assessed via neck disability index (NDI), visual analog pain scale (VAS), and health survey SF-36 (QualityMetric, Lincoln, Rhode Island). Forty-three patients were treated with ACDF using allograft and plating, and 44 were treated with cervical disc replacement. The average age was 44 (23 to 61) years. All surgical procedures were single level. Results At all measured time points, both groups showed statistically significant improvement over their preoperative baseline with regard to NDI, VAS arm and neck pain levels, SF-36 mental composite score (MCS), and physical composite score (PCS) (P < .05). At 24 months, the disc replacement group showed results equivalent to the ACDF group with regard to NDI, VAS arm and neck pain, and SF-36 MCS. At 24 months, the disc replacement group showed significantly greater improvement in SF- 36 PCS as compared to the ACDF group (P = .0359). Of note, there was a trend toward greater patient satisfaction in the disc replacement group as compared to the ACDF group (83% versus 71%, P = .144). Conclusions This study indicates that the tested disc replacement device achieves 2-year results ranging from equivalent to superior in comparison to ACDF in the treatment of symptomatic cervical disc disease. Long-term maintenance of these results has not yet been determined.
Collapse
Affiliation(s)
| | | | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, North Carolina
| | | | | | | |
Collapse
|
14
|
Abstract
This is a case report of intraoperative sagittal split fractures in multilevel cervical disc replacement using a keeled prosthesis. The patient's clinical course is discussed and outcomes measured with the SF-36 questionnaire, oswestry disability index, and visual analog scale neck pain are compared with the other patients at our institution that have undergone multilevel disc replacement. The patient did well and has not had any complications related to the device used or fractures. The risks and techniques to avoid this complication when using a keeled prosthesis are discussed in detail.
Collapse
Affiliation(s)
- Jason C Datta
- Spine Education and Research Institute, Denver, CO 80229, USA.
| | | | | | | |
Collapse
|
15
|
Abstract
STUDY DESIGN Prospective cohort. OBJECTIVE To determine the efficacy of a single-slice computed tomography (CT) angiogram to define the prevertebral anatomy in patients undergoing an anterior lumbar spine procedure. SUMMARY OF BACKGROUND DATA Preoperative planning with precise prevertebral anatomic details can help in mini-open anterior lumbar approaches. METHODS A total of 76 consecutive patients undergoing a minimal incision approach for anterior lumbar surgery were evaluated before surgery with CT angiography. The prevertebral anatomy was documented, and the patients were observed during treatment. RESULTS There were no complications related to CT angiography. This study directly influenced surgical decision making and the treatment options in 21% of patients. The vena caval confluence limited access to the L5-S1 disc in 3% of patients and at the L4-L5 disc in 92% of the patients. Prevertebral anatomic anomalies were found in 11.8% of patients. Atherosclerotic disease was discovered in 17% of the patients. The major complication rate was 7.5%. CT angiography correlated with intraoperative vascular anatomy in all cases. CONCLUSION Preoperative CT angiography before anterior approaches was determined to be effective in evaluating the prevertebral vascular anatomy.
Collapse
Affiliation(s)
- Jason C Datta
- Spine Education Research Institute, Denver, CO 80229, USA.
| | | | | | | |
Collapse
|
16
|
Abstract
Restoring a stable anterior column is essential to achieve normal spinal biomechanics. A variety of mechanical spacers have been developed and advocated for both anterior and posterior approaches. The ability to radiographically assess the "biology" of bone incorporation in these mechanical (metal) spacers is an inherent limitation. The femoral ring allograft (FRA) and posterior lumbar interbody fusion (PLIF) spacers have been developed as biological cages that permit restoration of the anterior column with a machined allograft bone (biological cage). Test results demonstrate that the FRA and PLIF Spacers have a compressive strength over 25,000 N. The pyramid shaped teeth on the surfaces and the geometry of the implant increase the resistance to expulsion at clinically relevant loads (1053 and 1236 N). The technique of anterior column reconstruction with both the FRA and the PLIF biological cages are discussed. Clinical experience with the PLIF biological cage (10 patients) and the FRA biological cage (90 patients) has not revealed any graft migration, infection, or subsidence. Additional posterior instrumentation may increase the stability of the motion segment, but the degree of stability necessary to achieve a biological union remains unclear. The incorporation of these biological cages can be monitored by conventional radiographic techniques. The method of insertion preserves the vertebral end-plates and can be performed by a minimally invasive or standard open procedure.
Collapse
Affiliation(s)
- M E Janssen
- Center for Spinal Disorders, Denver, CO 80229, USA
| | | | | | | |
Collapse
|
17
|
Abstract
STUDY DESIGN The morphology of sagittal T2-weighted magnetic resonance imaging (MRI) of the cervical spine was correlated with provocative discography and subsequent computed tomography (CT) discograms in 52 patients with discogenic pain. OBJECTIVES The authors determined if the morphology of cervical spine discs, as seen on MRI, correlates with discography/CT discograms in patients with discogenic pathology. SUMMARY OF BACKGROUND DATA Several studies have demonstrated a correlation between MRI and discography in the lumbar spine. No studies have attempted to show if this relationship exists in the cervical spine region. METHODS The morphology of cervical T2-weighted MRI was characterized with regard to the disc nuclear signal and posterior anulus status. Provocative discography was evaluated with regard to positive or negative responses. Computed tomography was performed after discography on each patient. RESULTS There was no correlation between pain response or morphology as seen on either discography or CT discography. A significant correlation was found between abnormality as seen on MRI and pain response on discography but the false-positive and false-negative rates were high. CONCLUSION Our results suggest that several MRI patterns correlate well with positive or negative cervical discography responses while several other patterns are equivocal. Magnetic resonance imaging is a useful adjunct to cervical discography but there are some MRI patterns that cannot be considered pathologic, and discography is required to diagnose discogenic pain syndrome.
Collapse
Affiliation(s)
- T A Parfenchuck
- Medical College of Georgia, Section of Orthopaedics, Augusta
| | | |
Collapse
|
18
|
Abstract
One hundred eighty patients with suspected lumbar disk disease were evaluated preoperatively with magnetic resonance imaging (MRI), myelography, and post-myelogram computerized tomography (CT) scan. Sixty patients underwent surgery on 102 disk levels, allowing for anatomic confirmation of the diagnosis. Eight negative explorations were performed. The correlation between preoperative interpretations of each test and the observed surgical findings was analyzed statistically. Based on this analysis, MRI accurately predicted the operative findings in 98 of 102 disk levels (96%), while the accuracy of myelography (81%) and post-myelogram CT scan (57%) was significantly less. When myelography and CT scan were utilized jointly, the accuracy was 84%, a significant improvement over either test alone, as a diagnostic modality. There was only one false positive MRI study in the evaluation of lumbar herniated disk. The results of this study reflect that MRI is a clinically superior diagnostic test in the evaluation of patients with suspected lumbar disk herniation, and that it should be the diagnostic study of choice when available. Its noninvasive nature, multiplanar capabilities, and the lack of ionizing radiation are particularly desirable for patient and physician.
Collapse
Affiliation(s)
- M E Janssen
- Lakewood Orthopaedic Clinic, Colo, Denver 80215
| | | | | | | |
Collapse
|
19
|
Abstract
Congenital defects of the pericardium are unusual. Patients may experience exertional chest pain, cardiac arrhythmias, syncope, sudden death, or incarceration of myocardium, or they may be entirely asymptomatic. We describe the case of a symptomatic pericardial herniation diagnosed by echocardiography and confirmed by cineangiography. Successful repair was accomplished using a polytetrafluoroethylene soft-tissue prosthesis.
Collapse
Affiliation(s)
- J E Chapman
- Section of Thoracic and Cardiac Surgery, Medical College of Georgia, Augusta 30912-2423
| | | | | | | |
Collapse
|