Two-year fusion and clinical outcomes in 224 patients treated with a single-level instrumented posterolateral fusion with iliac crest bone graft

BACKGROUND CONTEXT

Reported fusion rates for spine fusions using iliac crest bone graft (ICBG) vary between 40% and 100% because of different fusion techniques, patient comorbidity, diagnosis and assessment criteria.

PURPOSE

We report two-year results of single-level instrumented posterolateral fusions evaluated with radiographs, fine-cut computed tomography (CT) scans with reconstructions and outcome measures. STUDY DESIGN/ SETTING: Retrospective analysis of data from a prospective multicenter randomized clinical controlled trial.

PATIENT SAMPLE

Patients with various degenerative diagnoses enrolled in the control arm of a Food and Drug Administration (FDA)-regulated, multicenter trial of single-level decompression and posterolateral fusion for degenerative lumbar disease.

OUTCOME MEASURES

Short Form-36 (SF-36), Oswestry Disability Index (ODI), Numeric Rating Scales (0-20) for back, leg, and graft site pain, CT scans, anteroposterior and lateral flexion/extension radiographs.

METHODS

Patients enrolled in an FDA-regulated, multicenter trial at 29 sites with degenerative lumbar disease treated with single-level instrumented posterolateral fusion with ICBG were included in the analysis. Demographic and surgical data were collected. Clinical outcomes were followed using standard metrics. Fusion was assessed by independent radiologists at 6, 12, and 24 months postoperatively. Two fusion criteria were compared: anteroposterior and flexion/extension radiographs to assess motion and bridging bone, with CT scans as needed to confirm bridging bone; and CT scan assessment for bridging bone only.

RESULTS

One hundred ninety-four of 224 subjects (86.6%) completed the study. The mean operative time was 2.9 hours with a blood loss of 448.6 mL. The average graft volume was 36.3 mL. There were 21 (9.4%) wound infections, 18 (8.0%) incidental durotomies, 3 (1.3%) implant displacements, 2 (0.9%) malpositioned implants, and 17 (7.6%) graft-related complications. Twenty-seven patients (13.9%) required reoperation, the majority for nonunions. Fusion rates based on radiographs with selective CTs at 6, 12, and 24 months were 65.3%, 82.5%, and 89.3%, respectively. Fusion rates based on bridging bone on CT scans were 56.1%, 71.5%, 83.9%, respectively. Two-year improvement for all outcome measures was significant (p<.001)-ODI 25.3, SF-36 Physical Component Score (PCS) 12.2, back pain 7.9, and leg pain 7.1. Two years postoperatively, 60% of patients complained of graft site pain (mean pain score=8.5).

CONCLUSION

In a large series of patients who had primary single-level instrumented posterolateral fusion with ICBG, evidence of bridging bone on fine-cut CT scans improved with time to 83.9% at 24 months. Significant improvement from baseline was noted in all clinical outcome measures at all time intervals with 75% achieving minimum clinically important difference (MCID) for ODI and 66% achieving MCID for SF-36 PCS.

Clinical and radiographic analysis of an optimized rhBMP-2 formulation as an autograft replacement in posterolateral lumbar spine arthrodesis

BACKGROUND

Previous studies have demonstrated the ability of recombinant human bone morphogenetic protein to achieve a solid fusion in anterior lumbar interbody arthrodesis. The purpose of this study was to compare iliac crest bone graft and recombinant human bone morphogenetic protein-2, combined with a carrier consisting of bovine collagen and beta-tricalcium phosphate-hydroxyapatite to create a compression-resistant matrix, for instrumented single-level posterolateral arthrodesis.

METHODS

Four hundred and sixty-three patients with symptomatic single-level lumbosacral degenerative disease with no greater than grade-1 spondylolisthesis were treated with single-level instrumented posterolateral arthrodesis through an open midline approach. Patients were randomly assigned to either the recombinant human bone morphogenetic protein-2 matrix group (239 patients) or the autogenous iliac crest bone-graft group (224 patients). The Oswestry Disability Index, Short Form-36, and back and leg pain scores were determined preoperatively and at 1.5, three, six, twelve, and twenty-four months postoperatively. Radiographs and computed tomography scans were made at six, twelve, and twenty-four months postoperatively to evaluate for fusion.

RESULTS

The mean operative time and mean blood loss in the recombinant human bone morphogenetic protein-2 matrix group (2.5 hours and 343.1 mL, respectively) were significantly less than those in the iliac crest bone-graft group (2.9 hours and 448.6 mL). Both groups showed similar improvements in clinical outcomes and reduced pain. At twenty-four months, 60% of the iliac crest bone-graft group reported donor-site pain. At twenty-four months, fusion was evident in 96% of the patients in the recombinant human bone morphogenetic protein-2 matrix group compared with 89% in the iliac crest bone-graft group (p = 0.014). There was a significant difference (p = 0.011) in the rate of failures because of nonunion (eighteen patients with an iliac crest bone graft compared with six patients with the recombinant human bone morphogenetic protein-2 matrix). Also, the number of patients requiring second surgeries was significantly higher in the iliac crest bone-graft group (thirty-six patients) compared with the recombinant human bone morphogenetic protein-2 matrix group (twenty patients) (p = 0.015).

CONCLUSIONS

The use of recombinant human bone morphogenetic protein-2 in instrumented posterolateral lumbar arthrodesis decreases operative time and blood loss and produces earlier and higher fusion rates than does iliac crest bone graft. Clinical outcomes are similar to those with iliac crest bone graft. Thus, the need for harvesting iliac crest bone is eliminated along with the morbidities associated with the harvest procedure.

The efficacy of rhBMP-2 for posterolateral lumbar fusion in smokers

STUDY DESIGN

Retrospective review of prospectively collected data, as part of an IRB-approved, FDA-regulated, randomized, nonblinded IDE trial of rhBMP-2 matrix for lumbar spinal fusion.

OBJECTIVES

The purpose of this study is to examine the influence of smoking on fusion rate and outcome in a large series of patients treated with an rhBMP-2 matrix (AMPLIFY) or iliac crest bone graft as part of a randomized IDE trial for single-level lumbar fusion.

SUMMARY OF BACKGROUND DATA

Preclinical studies suggest that bone morphogenetic proteins (BMPs) are able to reverse the negative influence of nicotine on fusion healing in animal models. It remains unclear if a similar benefit will be seen in humans, and if so, what formulation and amount of BMP will be required to achieve that improvement.

METHODS

We reviewed the clinical and radiographic records of 148 patients who underwent single-level instrumented lumbar fusion at three spine centers as part of an ongoing FDA-regulated IDE trial. Clinical outcome measures included Oswestry Disability Index, SF-36, back, and leg pain scores. Radiographic measures were plain radiographs with flexion-extension views and fine cut computed tomography scans with sagittal and coronal reconstruction. Fusion success was determined by independent radiologist readings.

RESULTS

At 2 years postoperatively, solid fusion was demonstrated in all 55 nonsmokers in the rhBMP-2 group (100%). Successful fusion was seen in 20 of 21 smokers in the rhBMP-2 group (95.2%). Fusion was achieved in 48 of 51 nonsmokers in the iliac crest bone graft (ICBG) group (94.1%), but only 16 of 21 smokers (76.2%) in the ICBG group.

CONCLUSIONS

The results of this study suggest that rhBMP-2 may enhance fusion rate in cigarette smokers undergoing single-level instrumented posterolateral lumbar fusion. Despite the improvement in fusion rate with rhBMP-2, clinical outcomes measures were still adversely affected in smokers.

The safety and efficacy of Isola-Galveston instrumentation and arthrodesis in the treatment of neuromuscular spinal deformities

BACKGROUND

Implant systems that realign and stabilize a deformed spine continue to evolve. The purpose of the study of this case series was to determine the safety and effectiveness of a system designed to integrate hook, wire, screw, and post anchors for the treatment of a wide spectrum of neuromuscular disorders associated with pelvic deformity or the potential for deformity.

METHODS

Forty-seven consecutive patients who had a spinal deformity that was due to cerebral palsy or an upper motor-neuron cerebral palsy-like disease (thirty-one patients), myelomeningocele (nine), Duchenne muscular dystrophy (four), or other disorders (three) were managed with Isola-Galveston instrumentation and arthrodesis. The average age at the time of the operation was fourteen years and three months (range, five years and four months to twenty-three years and nine months). Eight patients (17 percent) had an additional anterior discectomy and arthrodesis without instrumentation, and three (6 percent) had an additional decancellation egg-shell osteotomy. The forty-seven patients were followed for an average of forty-seven months (range, twenty-four to 100 months). The complications were tabulated to assess the safety of the procedure, and the correction of each deformity was calculated to determine the efficacy.

RESULTS

There were no deaths, acute wound infections, or serious neurological problems. Reoperation was necessary in five patients (11 percent). One reoperation was performed because of a delayed deep wound infection; one, because of delayed sterile drainage; and one, for a pseudarthrosis repair. The remaining two reoperations were done for removal of an implant because the cephalad portion had become prominent. In addition to the pseudarthrosis that required a reoperation, there were three possible pseudarthroses that did not require a reoperation (overall prevalence of pseudarthrosis, 9 percent). Postoperative bracing was used for eleven patients (23 percent); it did not influence the rate of pseudarthrosis or possible pseudarthrosis. The average preoperative scoliosis of 70 degrees was corrected to 24 degrees (a 66 percent correction) at the time of the latest follow-up, and the average preoperative pelvic obliquity of 27 degrees was corrected to 5 degrees (an 81 percent correction). A survey of the patients, parents, and caregivers indicated that 96 percent of them were satisfied or very satisfied with the result of the operation.

CONCLUSIONS

Isola-Galveston instrumentation seems as safe and effective as other types of instrumentation that have been studied in comparable series in the literature. Isola-Galveston instrumentation is probably more effective for the correction of pelvic obliquity and the maintenance of correction. Only a posterior procedure is used, and the instrumentation appears to decrease the need for an additional anterior approach. Spinal hook, wire, screw, and post anchors have been successfully integrated into one posterior spinal implant system.

Radiographic standing cervical segmental alignment in adult volunteers without neck symptoms

STUDY DESIGN

A radiographic evaluation of standing cervical and global sagittal alignment in 100 adult volunteers with no neck or radicular arm symptoms was undertaken.

OBJECTIVES

To document and define cervical standing lateral alignment and balance in a volunteer population without cervical problems.

SUMMARY OF BACKGROUND DATA

Minimal data exist on cervical segmental sagittal alignment distributions in stance.

METHODS

Radiographic measures of spinal alignment were collected and statistically analyzed.

RESULTS

Data were categorized into two age- and sex-matched groups. Group 1 had no cervical or lumbar symptoms. Group 2 had no cervical symptoms, but had lumbar symptoms. Mean total and segmental cervical alignment distributions were not statistically different between groups. Mean total cervical lordosis in stance for the entire group was -40.0 +/- 9.7 degrees. Thoracic and lumbar alignment were within previously reported measures and not statistically different between groups. Plumb line markers at C7 and sacral reference points were not statistically different between groups. Pearson correlations revealed that cervical sagittal plane alignment vaired inversely with thoracic alignment. Independent orthopedists noted cervical osteoarthritis was present in 17% of each group of volunteers with substantial kappa agreement (0.73) between observers. Intraobserver and interobserver reliability of sagittal alignment measures of 30 randomly remeasured radiographs revealed strong correlation between observations.

CONCLUSIONS

No differences in total cervical lordosis were noted between cervical asymptomatic volunteers with or without low back pain. Most cervical lordosis occurred at the C1-C2 level in stance, whereas only 6 degrees (15%) occurred at the lowest three cervical levels (C4-C7). Changes in cervical lordosis correlated inversely with changes in thoracic alignment.

Muscle fiber composition and length-tension relationships in rats chronically exposed to alcohol

Adult Fischer 344 rats were fed an alcohol diet (7-9 g/kg/day) for 12 weeks and were compared to pair-fed controls with regard to the contraction and fiber characteristics of the gastrocnemius and plantaris muscles of the leg. Muscles were isolated in situ with blood and nerve supplies intact. The muscles were stretched by 1 mm increments and were stimulated at each muscle length with a voltage (1 msec pulse) that had been observed to produce maximal twitch force at the initial muscle length. Maximal twitch tension was found to be only 10% less in alcohol than pair-fed rats and the increase in force resulting from stretching was approximately 15% less in alcohol than pair-fed rats. No significant changes in sciatic nerve conduction velocities were produced by alcohol exposure. Moreover, no significant differences in muscle weight or the number and size of Type I, Type IIa or Type IIb muscle fibers were observed. Although the 12 weeks of alcohol exposure affected muscle physiology and histology in the direction of increased impairment, the differences were not large enough to be statistically significant.