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Lovecchio FC, Vaishnav AS, Steinhaus ME, Othman YA, Gang CH, Iyer S, McAnany SJ, Albert TJ, Qureshi SA. Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion? Neurosurg Focus 2021; 49:E17. [PMID: 32871566 DOI: 10.3171/2020.6.focus20393] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology. METHODS The authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1-2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°-8°, 10°-12°, and 15°-20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted. RESULTS A total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°-8° cages, 1.6° with 10°-12° cages, and 3.4° with 15°-20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs -0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016). CONCLUSIONS Compared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1-2-level MIS for lumbar degenerative disease.
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Affiliation(s)
| | | | | | | | | | - Sravisht Iyer
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Steven J McAnany
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Todd J Albert
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Sheeraz A Qureshi
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
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Dowlati E, Alexander H, Voyadzis JM. Vulnerability of the L5 nerve root during anterior lumbar interbody fusion at L5-S1: case series and review of the literature. Neurosurg Focus 2021; 49:E7. [PMID: 32871560 DOI: 10.3171/2020.6.focus20315] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nerve root injuries associated with anterior lumbar interbody fusion (ALIF) are uncommonly reported in the literature. This case series and review aims to describe the etiology of L5 nerve root injury following ALIF at L5-S1. METHODS The authors performed a single-center retrospective review of prospectively collected data of patients who underwent surgery between 2017 and 2019 who had postoperative L5 nerve root injuries after stand-alone L5-S1 ALIF. They also reviewed the literature with regard to nerve root injuries after ALIF procedures. RESULTS The authors report on 3 patients with postoperative L5 radiculopathy. All 3 patients had pain that improved. Two of the 3 patients had a neurological deficit, one of which improved. CONCLUSIONS Stretch neuropraxia from overdistraction is an important cause of postoperative L5 radiculopathy after L5-S1 ALIF. Judicious use of implants and careful preoperative planning to determine optimal implant sizes are paramount.
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Affiliation(s)
- Ehsan Dowlati
- 1Department of Neurosurgery, MedStar Georgetown University Hospital; and
| | | | - Jean-Marc Voyadzis
- 1Department of Neurosurgery, MedStar Georgetown University Hospital; and
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Amara D, Mummaneni PV, Burch S, Deviren V, Ames CP, Tay B, Berven SH, Chou D. The impact of increasing interbody fusion levels at the fractional curve on lordosis, curve correction, and complications in adult patients with scoliosis. J Neurosurg Spine 2020:1-10. [PMID: 33186901 DOI: 10.3171/2020.6.spine20256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Radiculopathy from the fractional curve, usually from L3 to S1, can create severe disability. However, treatment methods of the curve vary. The authors evaluated the effect of adding more levels of interbody fusion during treatment of the fractional curve. METHODS A single-institution retrospective review of adult patients treated for scoliosis between 2006 and 2016 was performed. Inclusion criteria were as follows: fractional curves from L3 to S1 > 10°, ipsilateral radicular symptoms concordant on the fractional curve concavity side, patients who underwent at least 1 interbody fusion at the level of the fractional curve, and a minimum 1-year follow-up. Primary outcomes included changes in fractional curve correction, lumbar lordosis change, pelvic incidence - lumbar lordosis mismatch change, scoliosis major curve correction, and rates of revision surgery and postoperative complications. Secondary analysis compared the same outcomes among patients undergoing posterior, anterior, and lateral approaches for their interbody fusion. RESULTS A total of 78 patients were included. There were no significant differences in age, sex, BMI, prior surgery, fractional curve degree, pelvic tilt, pelvic incidence, pelvic incidence - lumbar lordosis mismatch, sagittal vertical axis, coronal balance, scoliotic curve magnitude, proportion of patients undergoing an osteotomy, or average number of levels fused among the groups. The mean follow-up was 35.8 months (range 12-150 months). Patients undergoing more levels of interbody fusion had more fractional curve correction (7.4° vs 12.3° vs 12.1° for 1, 2, and 3 levels; p = 0.009); greater increase in lumbar lordosis (-1.8° vs 6.2° vs 13.7°, p = 0.003); and more scoliosis major curve correction (13.0° vs 13.7° vs 24.4°, p = 0.01). There were no statistically significant differences among the groups with regard to postoperative complications (overall rate 47.4%, p = 0.85) or need for revision surgery (overall rate 30.7%, p = 0.25). In the secondary analysis, patients undergoing anterior lumbar interbody fusion (ALIF) had a greater increase in lumbar lordosis (9.1° vs -0.87° for ALIF vs transforaminal lumbar interbody fusion [TLIF], p = 0.028), but also higher revision surgery rates unrelated to adjacent-segment pathology (25% vs 4.3%, p = 0.046). Higher ALIF revision surgery rates were driven by rod fracture in the majority (55%) of cases. CONCLUSIONS More levels of interbody fusion resulted in increased lordosis, scoliosis curve correction, and fractional curve correction. However, additional levels of interbody fusion up to 3 levels did not result in more postoperative complications or morbidity. ALIF resulted in a greater lumbar lordosis increase than TLIF, but ALIF had higher revision surgery rates.
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Affiliation(s)
| | | | - Shane Burch
- 2Orthopedic Surgery, UCSF Spine Center, University of California, San Francisco, California
| | - Vedat Deviren
- 2Orthopedic Surgery, UCSF Spine Center, University of California, San Francisco, California
| | | | - Bobby Tay
- 2Orthopedic Surgery, UCSF Spine Center, University of California, San Francisco, California
| | - Sigurd H Berven
- 2Orthopedic Surgery, UCSF Spine Center, University of California, San Francisco, California
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Safaee MM, Tenorio A, Osorio JA, Choy W, Amara D, Lai L, Hu SS, Tay B, Burch S, Berven SH, Deviren V, Dhall SS, Chou D, Mummaneni PV, Eichler CM, Ames CP, Clark AJ. The effect of anterior lumbar interbody fusion staging order on perioperative complications in circumferential lumbar fusions performed within the same hospital admission. Neurosurg Focus 2020; 49:E6. [PMID: 32871562 DOI: 10.3171/2020.6.focus20296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anterior lumbar interbody fusion (ALIF) is a powerful technique that provides wide access to the disc space and allows for large lordotic grafts. When used with posterior spinal fusion (PSF), the procedures are often staged within the same hospital admission. There are limited data on the perioperative risk profile of ALIF-first versus PSF-first circumferential fusions performed within the same hospital admission. In an effort to understand whether these procedures are associated with different perioperative complication profiles, the authors performed a retrospective review of their institutional experience in adult patients who had undergone circumferential lumbar fusions. METHODS The electronic medicals records of patients who had undergone ALIF and PSF on separate days within the same hospital admission at a single academic center were retrospectively analyzed. Patients carrying a diagnosis of tumor, infection, or traumatic fracture were excluded. Demographics, surgical characteristics, and perioperative complications were collected and assessed. RESULTS A total of 373 patients, 217 of them women (58.2%), met the inclusion criteria. The mean age of the study cohort was 60 years. Surgical indications were as follows: degenerative disease or spondylolisthesis, 171 (45.8%); adult deformity, 168 (45.0%); and pseudarthrosis, 34 (9.1%). The majority of patients underwent ALIF first (321 [86.1%]) with a mean time of 2.5 days between stages. The mean number of levels fused was 2.1 for ALIF and 6.8 for PSF. In a comparison of ALIF-first to PSF-first cases, there were no major differences in demographics or surgical characteristics. Rates of intraoperative complications including venous injury were not significantly different between the two groups. The rates of postoperative ileus (11.8% vs 5.8%, p = 0.194) and ALIF-related wound complications (9.0% vs 3.8%, p = 0.283) were slightly higher in the ALIF-first group, although the differences did not reach statistical significance. Rates of other perioperative complications were no different. CONCLUSIONS In patients undergoing staged circumferential fusion with ALIF and PSF, there was no statistically significant difference in the rate of perioperative complications when comparing ALIF-first to PSF-first surgeries.
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Affiliation(s)
| | | | | | | | | | | | - Serena S Hu
- 2Department of Orthopedic Surgery, Stanford University, Palo Alto, California
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Miscusi M, Trungu S, Ricciardi L, Forcato S, Ramieri A, Raco A. The anterior-to-psoas approach for interbody fusion at the L5-S1 segment: clinical and radiological outcomes. Neurosurg Focus 2020; 49:E14. [PMID: 32871565 DOI: 10.3171/2020.6.focus20335] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/10/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Over the last few decades, many surgical techniques for lumbar interbody fusion have been reported. The anterior-to-psoas (ATP) approach is theoretically supposed to benefit from the advantages of both anterior and lateral approaches with similar complication rates, even in L5-S1. At this segment, the anterior lumbar interbody fusion (ALIF) requires retroperitoneal dissection and retraction of major vessels, whereas the iliac crest does not allow the lateral transpsoas approach. This study aimed to investigate clinical-radiological outcomes and complications of the ATP approach at the L5-S1 segment in a single cohort of patients. METHODS This is a prospective single-center study, conducted from 2016 to 2019. Consecutive patients who underwent ATP at the L5-S1 segment for degenerative disc disease or revision surgery after previous posterior procedures were considered for eligibility. Complete clinical-radiological documentation and a minimum follow-up of 12 months were set as inclusion criteria. Clinical patient-reported outcomes, such as the visual analog scale for low-back pain, Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) scores, as well as spinopelvic parameters, were collected preoperatively, 6 weeks after surgery, and at the last follow-up visit. Intraoperative and perioperative complications were recorded. The fusion rate was evaluated on CT scans obtained at 12 months postoperatively. RESULTS Thirty-two patients met the inclusion criteria. The mean age at the time of surgery was 57.6 years (range 44-75 years). The mean follow-up was 33.1 months (range 13-48 months). The mean pre- and postoperative visual analog scale (7.9 ± 1.3 vs 2.4 ± 0.8, p < 0.05), Oswestry Disability Index (52.8 ± 14.4 vs 22.9 ± 6.0, p < 0.05), and SF-36 (37.3 ± 5.8 vs 69.8 ± 6.1, p < 0.05) scores significantly improved. The mean lumbar lordosis and L5-S1 segmental lordosis significantly increased after surgery. The mean pelvic incidence-lumbar lordosis mismatch and pelvic tilt significantly decreased. No intraoperative complications and a postoperative complication rate of 9.4% were recorded. The fusion rate was 96.9%. One patient needed a second posterior revision surgery for residual foraminal stenosis. CONCLUSIONS In the present case series, ATP fusion for the L5-S1 segment has resulted in valuable clinical-radiological outcomes and a relatively low complication rate. Properly designed clinical and comparative trials are needed to further investigate the role of ATP for different L5-S1 conditions.
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Affiliation(s)
- Massimo Miscusi
- 1Department of Neuroscience, Mental Health, and Sense Organs, "Sapienza" University of Rome, Sant'Andrea Hospital, Rome
| | - Sokol Trungu
- 1Department of Neuroscience, Mental Health, and Sense Organs, "Sapienza" University of Rome, Sant'Andrea Hospital, Rome
- 2Neurosurgery Unit, Cardinal G. Panico Hospital, Tricase; and
| | - Luca Ricciardi
- 1Department of Neuroscience, Mental Health, and Sense Organs, "Sapienza" University of Rome, Sant'Andrea Hospital, Rome
- 2Neurosurgery Unit, Cardinal G. Panico Hospital, Tricase; and
| | - Stefano Forcato
- 2Neurosurgery Unit, Cardinal G. Panico Hospital, Tricase; and
| | - Alessandro Ramieri
- 3Department of Orthopedics, Faculty of Pharmacy and Medicine, "Sapienza" University of Rome, Italy
| | - Antonino Raco
- 1Department of Neuroscience, Mental Health, and Sense Organs, "Sapienza" University of Rome, Sant'Andrea Hospital, Rome
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Martini ML, Nistal DA, Deutsch BC, Caridi JM. Characterizing the risk and outcome profiles of lumbar fusion procedures in patients with opioid use disorders: a step toward improving enhanced recovery protocols for a unique patient population. Neurosurg Focus 2020; 46:E12. [PMID: 30933913 DOI: 10.3171/2019.1.focus18652] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 01/14/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVEThe authors set out to conduct the first national-level study assessing the risks and outcomes for different lumbar fusion procedures in patients with opioid use disorders (OUDs) to help guide the future development of targeted enhanced recovery after surgery (ERAS) protocols for this unique population.METHODSData for patients with or without OUDs who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lateral transverse lumbar interbody fusion (LLIF) for lumbar disc degeneration (LDD) were collected from the 2013-2014 National (Nationwide) Inpatient Sample database. Multivariable logistic regression was implemented to analyze how OUD status impacted in-hospital complications, length of hospital stay, discharge disposition, and total charges by procedure type.RESULTSA total of 139,995 patients with LDD were identified, with 1280 patients (0.91%) also having a concurrent OUD diagnosis. Overall complication rates were higher in OUD patients (48.44% vs 31.01%, p < 0.0001). OUD patients had higher odds of pulmonary (p = 0.0006), infectious (p < 0.0001), and hematological (p = 0.0009) complications. Multivariate regression modeling of outcomes by procedure type showed that after ALIF, OUD patients had higher odds of nonhome discharge (p = 0.0007), extended hospitalization (p = 0.0002), and greater total charges (p = 0.0054). This analysis also revealed that OUD patients faced higher odds of complication (p = 0.0149 and p = 0.0471), extended hospitalization (p = 0.0439 and p = 0.0001), and higher total charges (p < 0.0001 and p < 0.0001) after PLIF and LLIF procedures, respectively.CONCLUSIONSObtaining a better understanding of the risks and outcomes that OUD patients face perioperatively is a necessary step toward developing more effective ERAS protocols for this vulnerable population. This study, which sought to characterize the outcome profiles for lumbar fusion procedures in OUD patients on a national level, found that this population tended to experience increased odds of complications, extended hospitalization, nonhome discharge, and higher total costs. Results from this study warrant future prospective studies to better the understanding of these associations and to further the development of better ERAS programs that may improve patient care and reduce cost burden.
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Staartjes VE, de Wispelaere MP, Schröder ML. Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. Neurosurg Focus 2020; 46:E7. [PMID: 30933924 DOI: 10.3171/2019.1.focus18646] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 01/29/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVEEnhanced recovery after surgery (ERAS) has led to a paradigm shift in various surgical specialties. Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process. Still, ERAS remains relatively new to spine surgery. The authors report their 5-year experience, focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures, including anterior lumbar interbody fusion (ALIF).METHODSA multimodal ERAS protocol was applied between November 2013 and October 2018. The authors analyze hospital stay, perioperative outcomes, readmissions, and adverse events obtained from a prospective institutional registry. Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive (MI) anterior or posterior fusion cases were included. Their institutional ERAS protocol contains 22 pre-, intra-, and postoperative elements, including preoperative patient counseling, MI techniques, early mobilization and oral intake, minimal postoperative restrictions, and regular audits.RESULTSA total of 2592 consecutive patients were included, with 199 (8%) undergoing fusion. The mean hospital stay was 1.1 ± 1.2 days, with 20 (0.8%) 30-day and 36 (1.4%) 60-day readmissions. Ninety-four percent of patients were discharged after a maximum 1-night hospital stay. Over the 5-year period, a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed (p < 0.001), with a concomitant decrease in adverse events in the overall cohort (p = 0.025) and without increase in readmissions. For fusion procedures, the rate of 1-night hospital stays increased from 26% to 85% (p < 0.001). Similarly, the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days (p < 0.001), with a notable concomitant decrease in variance, resulting in an estimated reduction in nursing costs of 46.8%.CONCLUSIONSApplication of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures, including ALIF, for treatment of degenerative spine conditions was safe and effective, without increase in readmissions. The data from this large case series stress the importance of the multidisciplinary, iterative improvement process to overcome the learning curve associated with ERAS implementation, and the importance of a dedicated perioperative care team. Prospective trials are needed to evaluate spinal ERAS on a higher level of evidence.
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Affiliation(s)
- Victor E Staartjes
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Gornet MF, Burkus JK, Dryer RF, Peloza JH, Schranck FW, Copay AG. Lumbar disc arthroplasty versus anterior lumbar interbody fusion: 5-year outcomes for patients in the Maverick disc investigational device exemption study. J Neurosurg Spine 2020; 31:347-356. [PMID: 31100723 DOI: 10.3171/2019.2.spine181037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite evidence of its safety and effectiveness, the use of lumbar disc arthroplasty has been slow to expand due in part to concerns about late complications and the risks of revision surgery associated with early devices. More recently, FDA approval of newer devices and improving reimbursements have reversed this trend in the United States. Additional long-term data on lumbar disc arthroplasty are still needed. This study reports the 5-year results of the FDA investigational device exemption clinical trial of the Medtronic Spinal and Biologics' Maverick total disc replacement. METHODS Patients with single-level degenerative disc disease from L4 to S1 were randomized 2:1 at 31 investigational sites. In the period from April 2003 to August 2004, 405 patients received the investigational device and 172 patients underwent the control procedure of anterior lumbar interbody fusion. Outcome measures included the Oswestry Disability Index (ODI), numeric rating scales (NRSs) for back and leg pain, the SF-36, disc height, interbody motion, heterotopic ossification (investigational device), adverse events (AEs), additional surgeries, and neurological status. Treatment was considered an overall success when all of the following criteria were met: 1) ODI score improvement ≥ 15 points over the preoperative score; 2) maintenance or improvement in neurological status compared with preoperatively; 3) disc height success, that is, no more than a 2-mm reduction in anterior or posterior height; 4) no serious AEs caused by the implant or by the implant and the surgical procedure; and 5) no additional surgery classified as a failure. RESULTS Compared to that in the control group, improvement in the investigational group was statistically greater according to the ODI and SF-36 Physical Component Summary (PCS) at 1, 2, and 5 years; the NRS for back pain at 1 and 2 years; and the NRS for leg pain at 1 year. The rates of heterotopic ossification increased over time: 1.0% (4/382) at 1 year, 2.6% (9/345) at 2 years, and 5.9% (11/187) at 5 years. Investigational patients had fewer device-related AEs and serious device-related AEs than the control patients at both 2 and 5 years postoperatively. Noninferiority of the composite measure overall success was demonstrated at all follow-up intervals; superiority was demonstrated at 1 and 2 years. CONCLUSIONS Lumbar disc arthroplasty is a safe and effective treatment for single-level lumbar degenerative disc disease, resulting in improved physical function and reduced pain up to 5 years after surgery.Clinical trial registration no.: NCT00635843 (clinicaltrials.gov).
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Xu DS, Bach K, Uribe JS. Minimally invasive anterior and lateral transpsoas approaches for closed reduction of grade II spondylolisthesis: initial clinical and radiographic experience. Neurosurg Focus 2019; 44:E4. [PMID: 29290134 DOI: 10.3171/2017.10.focus17574] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive anterior and lateral approaches to the lumbar spine are increasingly used to treat and reduce grade I spondylolisthesis, but concerns still exist for their usage in the management of higher-grade lesions. The authors report their experience with this strategy for grade II spondylolisthesis in a single-surgeon case series and provide early clinical and radiographic outcomes. METHODS A retrospective review of a single surgeon's cases between 2012 and 2016 identified all patients with a Meyerding grade II lumbar spondylolisthesis who underwent minimally invasive lateral lumbar interbody fusion (LLIF) or anterior lumbar interbody fusion (ALIF) targeting the slipped level. Demographic, clinical, and radiographic data were collected and analyzed. Changes in radiographic measurements, Oswestry Disability Index (ODI), and visual analog scale (VAS) scores were compared using the paired t-test and Wilcoxon signed rank test for continuous and ordinal variables, respectively. RESULTS The average operative time was 199.1 minutes (with 60.6 ml of estimated blood loss) for LLIFs and 282.1 minutes (with 106.3 ml of estimated blood loss), for ALIFs. Three LLIF patients had transient unilateral anterior thigh numbness during the 1st week after surgery, and 1 ALIF patient had transient dorsiflexion weakness, which was resolved at postoperative week 1. The mean follow-up time was 17.6 months (SD 12.5 months) for LLIF patients and 10 months (SD 3.1 months) for ALIF patients. Complete reduction of the spondylolisthesis was achieved in 12 LLIF patients (75.0%) and 7 ALIF patients (87.5%). Across both procedures, there was an increase in both the segmental lordosis (LLIF 5.6°, p = 0.002; ALIF 15.0°, p = 0.002) and overall lumbar lordosis (LLIF 2.9°, p = 0.151; ALIF 5.1°, p = 0.006) after surgery. Statistically significant decreases in the mean VAS and the mean ODI measurements were seen in both treatment groups. The VAS and ODI scores fell by a mean value of 3.9 (p = 0.002) and 19.8 (p = 0.001), respectively, for LLIF patients and 3.8 (p = 0.02) and 21.0 (p = 0.03), respectively, for ALIF patients at last follow-up. CONCLUSIONS Early clinical and radiographic results from using minimally invasive LLIF and ALIF approaches to treat grade II spondylolisthesis appear to be good, with low operative blood loss and no neurological deficits. Complete reduction of the spondylolisthesis is frequently possible with a statistically significant reduction in pain scores.
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Affiliation(s)
- David S Xu
- 1Division of Spinal Disorders, Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Konrad Bach
- 2Division of Spine, Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida
| | - Juan S Uribe
- 1Division of Spinal Disorders, Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Reid PC, Morr S, Kaiser MG. State of the union: a review of lumbar fusion indications and techniques for degenerative spine disease. J Neurosurg Spine 2019; 31:1-14. [PMID: 31261133 DOI: 10.3171/2019.4.spine18915] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/03/2019] [Indexed: 12/26/2022]
Abstract
Lumbar fusion is an accepted and effective technique for the treatment of lumbar degenerative disease. The practice has evolved continually since Albee and Hibbs independently reported the first cases in 1913, and advancements in both technique and patient selection continue through the present day. Clinical and radiological indications for surgery have been tested in trials, and other diagnostic modalities have developed and been studied. Fusion practices have also advanced; instrumentation, surgical approaches, biologics, and more recently, operative planning, have undergone stark changes at a seemingly increasing pace over the last decade. As the general population ages, treatment of degenerative lumbar disease will become a more prevalent-and costlier-issue for surgeons as well as the healthcare system overall. This review will cover the evolution of indications and techniques for fusion in degenerative lumbar disease, with emphasis on the evidence for current practices.
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Jaeger A, Giber D, Bastard C, Thiebaut B, Roubineau F, Flouzat Lachaniette CH, Dubory A. Risk factors of instrumentation failure and pseudarthrosis after stand-alone L5-S1 anterior lumbar interbody fusion: a retrospective cohort study. J Neurosurg Spine 2019; 31:338-346. [PMID: 31151106 DOI: 10.3171/2019.3.spine181476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE L5-S1 stand-alone anterior lumbar interbody fusion (ALIF) is a reliable technique to treat symptomatic degenerative disc disease but remains controversial for treatment of isthmic spondylolisthesis. In the present study the authors aimed to identify risk factors of instrumentation failure and pseudarthrosis after stand-alone L5-S1 ALIF and to evaluate whether instrumentation failure influenced the rate of fusion. METHODS The study included 64 patients (22 [34.4%] male and 42 [65.6%] female, mean age 46.4 years [range 21-65 years]) undergoing stand-alone L5-S1 ALIF using radiolucent anterior cages with Vertebridge plating fixation in each vertebral endplate. Clinical and radiographic data were reviewed, including age, sex, pelvic parameters, segmental sagittal angle (SSA), C7/sacro-femoral distance (SFD) ratio, C7 sagittal tilt, lumbar lordosis (LL), segmental LL, percentage of L5 slippage, L5-S1 disc angle, and posterior disc height ratio. Univariate and multivariate analyses were used to identify risk factors of instrumentation failure and pseudarthrosis. RESULTS At a mean follow-up of 15.9 months (range 6.6-27.4 months), fusion had occurred in 57 patients (89.1%). Instrumentation failure was found in 12 patients (18.8%) and pseudarthrosis in 7 patients (10.9%). The following parameters influenced the occurrence of instrumentation failure: presence of isthmic spondylolisthesis (p < 0.001), spondylolisthesis grade (p < 0.001), use of an iliac crest bone autograft (p = 0.04), cage height (p = 0.03), pelvic incidence (PI) (p < 0.001), sacral slope (SS) (p < 0.001), SSA (p = 0.003), and LL (p < 0.001). Instrumentation failure was statistically linked to the occurrence of L5-S1 pseudarthrosis (p < 0.001). On multivariate analysis, no risk factors were found. CONCLUSIONS L5-S1 isthmic spondylolisthesis and high PI seem to be risk factors for instrumentation failure in case of stand-alone L5-S1 ALIF, findings that support the necessity of adding percutaneous posterior pedicle screw instrumentation in these cases.
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Affiliation(s)
- Antoine Jaeger
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), Creteil, France
| | - David Giber
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), Creteil, France
| | - Claire Bastard
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), Creteil, France
| | - Benjamin Thiebaut
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), Creteil, France
| | - François Roubineau
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), Creteil, France
| | | | - Arnaud Dubory
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), Creteil, France
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Heo DH, Kim JS. Clinical and radiological outcomes of spinal endoscopic discectomy-assisted oblique lumbar interbody fusion: preliminary results. Neurosurg Focus 2018; 43:E13. [PMID: 28760027 DOI: 10.3171/2017.5.focus17196] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 11/06/2022]
Abstract
OBJECTIVE Direct neural decompression cannot be achieved by performing lateral lumbar interbody fusion (LLIF). To overcome the indirect decompressive effect of LLIF, additional endoscopic discectomy with oblique lumbar interbody fusion (OLIF) has been attempted. The purpose of this study was to assess the clinical and radiological outcomes of patients who underwent OLIF with additional endoscopic discectomy. METHODS Spinal endoscopic discectomy-assisted OLIF was attempted to remove herniated disc material. Only patients with a follow-up time that exceeded 12 months were enrolled. Clinical parameters examined were the Oswestry Disability Index and visual analog scale scores of back and leg pain. Postoperative MRI was also performed. RESULTS Fourteen patients were enrolled. Central and foraminal disc herniations were evident in 8 and 6 patients, respectively. Concomitant central or foraminal herniated discs were removed completely after additional endoscopic discectomy, and disc removal was confirmed by postoperative MRI. Mean preoperative visual analog scale scores and Oswestry Disability Index scores improved postoperatively. CONCLUSIONS OLIF with additional endoscopic discectomy results in successful direct neural decompression without posterior decompressive procedures. Endoscopic assistance might overcome the limitations of LLIF.
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Affiliation(s)
- Dong Hwa Heo
- Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon; and
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Heo DH, Son SK, Eum JH, Park CK. Fully endoscopic lumbar interbody fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results. Neurosurg Focus 2018; 43:E8. [PMID: 28760038 DOI: 10.3171/2017.5.focus17146] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [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: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive spine surgery can minimize damage to normal anatomical structures. Recently, fully endoscopic spine surgeries have been attempted for lumbar fusion surgery. In this study, the authors performed a percutaneous unilateral biportal endoscopic (UBE) technique as a minimally invasive surgery for lumbar fusion. The purpose of this study is to present the UBE technique of fully endoscopic lumbar interbody fusion (LIF) and to analyze the clinical results. METHODS Patients who were to undergo single-level fusion surgery from L3-4 to L5-S1 were enrolled. Two channels (endoscopic portal and working portal) were used for endoscopic lumbar fusion surgery. All patients underwent follow-up for more than 12 months. Demographic characteristics, diagnosis, operative time, and estimated blood loss were evaluated. MRI was performed on postoperative Day 2. Clinical evaluations (visual analog scale [VAS] for the leg and Oswestry Disability Index [ODI] scores) were performed preoperatively and during the follow-up period. RESULTS A total of 69 patients (24 men and 45 women) were enrolled in this study. The mean follow-up period was 13.5 months. Postoperative MRI revealed optimal direct neural decompression after fully endoscopic fusion surgery. VAS and ODI scores significantly improved after the surgery. There was no postoperative neurological deterioration. CONCLUSIONS Fully endoscopic LIF using the UBE technique may represent an alternative minimally invasive LIF surgery for the treatment of degenerative lumbar disease. Long-term follow-up and larger clinical studies are needed to validate the clinical and radiological results of this surgery.
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Affiliation(s)
- Dong Hwa Heo
- Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon
| | - Sang Kyu Son
- Department of Neurosurgery, Spine Center, Gangdong Hospital, Busan; and
| | - Jin Hwa Eum
- Department of Neurosurgery, Spine Center, Centum Hospital, Changwon, Korea
| | - Choon Keun Park
- Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon
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Malham GM, Parker RM. Early experience of placing image-guided minimally invasive pedicle screws without K-wires or bone-anchored trackers. J Neurosurg Spine 2018; 28:357-363. [PMID: 29372857 DOI: 10.3171/2017.7.spine17528] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 01/31/2023]
Abstract
OBJECTIVE Image guidance for spine surgery has been reported to improve the accuracy of pedicle screw placement and reduce revision rates and radiation exposure. Current navigation and robot-assisted techniques for percutaneous screws rely on bone-anchored trackers and Kirchner wires (K-wires). There is a paucity of published data regarding the placement of image-guided percutaneous screws without K-wires. A new skin-adhesive stereotactic patient tracker (SpineMask) eliminates both an invasive bone-anchored tracker and K-wires for pedicle screw placement. This study reports the authors' early experience with the use of SpineMask for "K-wireless" placement of minimally invasive pedicle screws and makes recommendations for its potential applications in lumbar fusion. METHODS Forty-five consecutive patients (involving 204 screws inserted) underwent K-wireless lumbar pedicle screw fixation with SpineMask and intraoperative neuromonitoring. Screws were inserted by percutaneous stab or Wiltse incisions. If required, decompression with or without interbody fusion was performed using mini-open midline incisions. Multimodality intraoperative neuromonitoring assessing motor and sensory responses with triggered electromyography (tEMG) was performed. Computed tomography scans were obtained 2 days postoperatively to assess screw placement and any cortical breaches. A breach was defined as any violation of a pedicle screw involving the cortical bone of the pedicle. RESULTS Fourteen screws (7%) required intraoperative revision. Screws were removed and repositioned due to a tEMG response < 13 mA, tactile feedback, and 3D fluoroscopic assessment. All screws were revised using the SpineMask with the same screw placement technique. The highest proportion of revisions occurred with Wiltse incisions (4/12, 33%) as this caused the greatest degree of SpineMask deformation, followed by a mini midline incision (3/26, 12%). Percutaneous screws via a single stab incision resulted in the fewest revisions (7/166, 4%). Postoperative CT demonstrated 7 pedicle screw breaches (3%; 5 lateral, 1 medial, 1 superior), all with percutaneous stab incisions (7/166, 4%). The radiological accuracy of the SpineMask tracker was 97% (197/204 screws). No patients suffered neural injury or required postoperative screw revision. CONCLUSIONS The noninvasive cutaneous SpineMask tracker with 3D image guidance and tEMG monitoring provided high accuracy (97%) for percutaneous pedicle screw placement via stab incisions without K-wires.
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Affiliation(s)
| | - Rhiannon M Parker
- 2Research Department, Greg Malham Neurosurgeon, Melbourne, Victoria, Australia
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Saini N, Zaidi M, Barry MT, Heary RF. Previously unreported complications associated with integrated cage screws following anterior lumbar interbody fusion: report of 2 cases. J Neurosurg Spine 2018; 28:311-316. [PMID: 29303470 DOI: 10.3171/2017.6.spine161443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/06/2022]
Abstract
Anterior lumbar interbody fusion (ALIF) is a widely performed surgical treatment for various lumbar spine pathologies. The authors present the first reports of virtually identical cases of complications with integrated screws in stand-alone interbody cages. Two patients presented with the onset of S-1 radiculopathy due to screw misplacements following an ALIF procedure. In both cases, an integrated screw from the cage penetrated the dorsal aspect of the S-1 cortical margin of the vertebra, extended into the neural foramen, and injured the traversing left S-1 nerve roots. Advanced neuroimaging findings indicated nerve root impingement by the protruding screw tip. After substantial delays, radiculopathic symptoms were treated with removal of the offending instrumentation, aggressive posterior decompression of the bony and ligamentous structures, and posterolateral fusion surgery with pedicle screw fixation. Postoperative radiographic findings demonstrated decompression of the symptomatic nerve roots via removal of the extruded screw tips from the neural foramina.
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Affiliation(s)
- Neginder Saini
- 1Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Mohammad Zaidi
- 1Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Maureen T Barry
- 2Department of Radiology, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Robert F Heary
- 1Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
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Spoor JKH, Dallenga AHG, Gadjradj PS, de Klerk L, van Biezen FC, Bijvoet HWC, Harhangi BS. A novel noninstrumented surgical approach for foramen reconstruction for isthmic spondylolisthesis in patients with radiculopathy: preliminary clinical and radiographic outcomes. Neurosurg Focus 2018; 44:E7. [PMID: 29290136 DOI: 10.3171/2017.10.focus17571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/06/2022]
Abstract
OBJECTIVE The health care costs for instrumented spine surgery have increased dramatically in the last few decades. The authors present a novel noninstrumented surgical approach for patients with isthmic spondylolisthesis, with clinical and radiographic results. METHODS Charts of patients who underwent this technique were reviewed. The procedure consisted of nerve root decompression by reconstruction of the intervertebral foramen. This was achieved by removal of the pedicle followed by noninstrumented posterolateral fusion in which autologous bone graft from the right iliac crest was used. Outcomes regarding radicular complaints, bony fusion, progression of the slip, and complications were evaluated using patient history and radiographs obtained at follow-up intervals of 3-18 months after surgery. RESULTS A total of 58 patients with a mean age of 47 years were treated with this method. Partial removal of the pedicle was performed in 93.1% of the cases, whereas in 6.9% of the cases the entire pedicle was removed. The mean duration of surgery was 216.5 ± 54.5 minutes (range 91-340 minutes). The mean (± SD) duration of hospitalization was 10.1 ± 2.9 days (range 5-18 days). After 3 months of follow-up, 86% of the patients reported no leg pain, and this dropped to 81% at last follow-up. Radiographic follow-up showed bony fusion in 87.7% of the patients. At 1 year, 5 patients showed progression of the slip, which in 1 patient prompted a second operation within 1 year. No major complications occurred. CONCLUSIONS Treatment of isthmic spondylolisthesis by reconstruction of the intervertebral neuroforamen and posterolateral fusion in situ is a safe procedure and has comparable results with the existing techniques. Cost-effectiveness research comparing this technique to conventional instrumented fusion techniques is necessary to evaluate the merits for both patients and society.
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Affiliation(s)
| | | | - Pravesh S Gadjradj
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Leiden University Medical Center, Leiden; and
| | - Luuk de Klerk
- 3Department of Orthopedic Surgery, Sint Maartenskliniek, Nijmegen, The Netherlands
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Kadam A, Wigner N, Saville P, Arlet V. Overpowering posterior lumbar instrumentation and fusion with hyperlordotic anterior lumbar interbody cages followed by posterior revision: a preliminary feasibility study. J Neurosurg Spine 2017; 27:650-660. [PMID: 28960160 DOI: 10.3171/2017.5.spine16926] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' aim in this study was to evaluate whether sagittal plane correction can be obtained from the front by overpowering previous posterior instrumentation and/or fusion with hyperlordotic anterior lumbar interbody fusion (ALIF) cages in patients undergoing revision surgery for degenerative spinal conditions and/or spinal deformities. METHODS The authors report their experience with the application of hyperlordotic cages at 36 lumbar levels for ALIFs in a series of 20 patients who underwent revision spinal surgery at a single institution. Included patients underwent staged front-back procedures: ALIFs with hyperlordotic cages (12°, 20°, and 30°) followed by removal of posterior instrumentation and reinstrumentation from the back. Patients were divided into the following 2 groups depending on the extent of posterior instrumentation and fusion during the second stage: long constructs (≥ 6 levels with extension into thoracic spine and/or pelvis) and short constructs (< 6 levels). Preoperative and postoperative standing radiographs were evaluated to measure segmental lordosis (SL) along with standard sagittal parameters. Radiographic signs of pseudarthrosis at previously fused levels were also sought in all patients. RESULTS The average patient age was 54 years (range 30-66 years). The mean follow-up was 11.5 months (range 5-26 months). The mean SL achieved with 12°, 20°, and 30° cages was 13.1°, 19°, and 22.4°, respectively. The increase in postoperative SL at the respective surgically treated levels for 12°, 20°, and 30° cages that were used to overpower posterior instrumentation/fusion averaged 6.1° (p < 0.05), 12.5° (p < 0.05), and 17.7° (p < 0.05), respectively. No statistically significant difference was found in SL correction at levels in patients who had pseudarthrosis (n = 18) versus those who did not (n = 18). The mean overall lumbar lordosis increased from 44.3° to 59.8° (p < 0.05). In the long-construct group, the mean improvement in sagittal vertical axis was 85.5 mm (range 19-249.3 mm, p < 0.05). Endplate impaction/collapse was noted in 3 of 36 levels (8.3%). The anterior complication rate was 13.3%. No neurological complications or vascular injuries were observed. CONCLUSIONS ALIF in which hyperlordotic cages are used to overpower posterior spinal instrumentation and fusion can be expected to produce an increase in SL of a magnitude that is roughly half of the in-built cage lordotic angle. This technique may be particularly suited for lordosis correction from the front at lumbar levels that have pseudarthrosis from the previous posterior spinal fusion. Meticulous selection of levels for ALIF is crucial for safely and effectively performing this technique.
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Hsieh CS, Lee SH, Lee HC, Oh HS, Hwang BW, Park SJ, Chen JH. Congenital hypoplasia of the lumbar pedicle with spondylolisthesis: report of 2 cases. J Neurosurg Spine 2017; 26:430-434. [PMID: 28059687 DOI: 10.3171/2016.8.spine151137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 11/06/2022]
Abstract
Congenital hypoplasia of the spinal pedicle is a rare condition. Previously reported cases were treated conservatively or with posterior instrumented fusion. However, the absence or hypoplasia of the lumbar pedicle may increase the difficulty of pedicle screw fixation and fusion. Herein, the authors describe 2 cases of rare adult congenital hypoplasia of the right lumbar pedicles associated with spondylolisthesis. The patients underwent anterior lumbar interbody fusion with a stand-alone cage as well as percutaneous pedicle screw fixation. This method was used to avoid the difficulties associated with pedicle screw fixation and to attain solid fusion. Both patients achieved satisfactory outcomes after a minimum of 2 years of follow-up. This method may be an alternative for patients with congenital hypoplasia of the lumbar spinal pedicle.
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Affiliation(s)
| | - Sang-Ho Lee
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul
| | - Hyung Chang Lee
- Department of Cardiovascular Surgery, Wooridul Spine Hospital, Gimpo Airport, Seoul, Korea
| | | | | | | | - Jian-Han Chen
- Department of General Surgery, Buddhist Dalin Tzu Chi Hospital, Chia-Yi; and
- School of Medicine, Tzu Chi University, Hualien, Taiwan
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Theologis AA, Mundis GM, Nguyen S, Okonkwo DO, Mummaneni PV, Smith JS, Shaffrey CI, Fessler R, Bess S, Schwab F, Diebo BG, Burton D, Hart R, Deviren V, Ames C. Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients. J Neurosurg Spine 2016; 26:208-219. [PMID: 27767682 DOI: 10.3171/2016.8.spine151543] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD). METHODS Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed. RESULTS Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0.46), LL (62% vs 13%, p = 0.35), and PI-LL (68% vs 33%, p = 0.32). Despite more LS+Apex patients having major complications (56% vs 13%; p = 0.02) and postoperative leg weakness (31% vs 6%, p = 0.07), there were no intergroup differences in 2-year outcomes. CONCLUSIONS Long open posterior instrumented fusion with or without multilevel LIF is used to treat a variety of coronal and sagittal adult thoracolumbar deformities. The addition of multilevel LIF to open PSF with L5-S1 interbody support in this small cohort was often used in more severe coronal and/or lumbopelvic sagittal deformities and offered better correction of major Cobb angles, lumbopelvic parameters, and SVA than posterior-only operations. As these advantages came at the expense of more major complications, more leg weakness, greater blood loss, and longer operative times and hospital stays without an improvement in 2-year outcomes, future investigations should aim to more clearly define deformities that warrant the addition of multilevel LIF to open PSF and L5-S1 interbody fusion.
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Affiliation(s)
| | - Gregory M Mundis
- Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California
| | - Stacie Nguyen
- Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Praveen V Mummaneni
- Department of Neurologic Surgery, University of California, San Francisco, California
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Richard Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Shay Bess
- Department of Orthopaedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Frank Schwab
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and
| | - Robert Hart
- Department of Orthopedic Surgery, Oregon Health & Science University, Portland, Oregon
| | - Vedat Deviren
- Department of Orthopaedic Surgery, University of California, San Francisco
| | - Christopher Ames
- Department of Neurologic Surgery, University of California, San Francisco, California
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Reis MT, Reyes PM, Bse, Altun I, Newcomb AGUS, Singh V, Chang SW, Kelly BP, Crawford NR. Biomechanical evaluation of lateral lumbar interbody fusion with secondary augmentation. J Neurosurg Spine 2016; 25:720-726. [PMID: 27391398 DOI: 10.3171/2016.4.spine151386] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [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: 11/06/2022]
Abstract
OBJECTIVE Lateral lumbar interbody fusion (LLIF) has emerged as a popular method for lumbar fusion. In this study the authors aimed to quantify the biomechanical stability of an interbody implant inserted using the LLIF approach with and without various supplemental fixation methods, including an interspinous plate (IP). METHODS Seven human cadaveric L2-5 specimens were tested intact and in 6 instrumented conditions. The interbody implant was intended to be used with supplemental fixation. In this study, however, the interbody was also tested without supplemental fixation for a relative comparison of these conditions. The instrumented conditions were as follows: 1) interbody implant without supplemental fixation (LLIF construct); and interbody implant with supplemental fixation performed using 2) unilateral pedicle screws (UPS) and rod (LLIF + UPS construct); 3) bilateral pedicle screws (BPS) and rods (LLIF + BPS construct); 4) lateral screws and lateral plate (LP) (LLIF + LP construct); 5) interbody LP and IP (LLIF + LP + IP construct); and 6) IP (LLIF + IP construct). Nondestructive, nonconstraining torque (7.5 Nm maximum) induced flexion, extension, lateral bending, and axial rotation, whereas 3D specimen range of motion (ROM) was determined optoelectronically. RESULTS The LLIF construct reduced ROM by 67% in flexion, 52% in extension, 51% in lateral bending, and 44% in axial rotation relative to intact specimens (p < 0.001). Adding BPS to the LLIF construct caused ROM to decrease by 91% in flexion, 82% in extension and lateral bending, and 74% in axial rotation compared with intact specimens (p < 0.001), providing the greatest stability among the constructs. Adding UPS to the LLIF construct imparted approximately one-half the stability provided by LLIF + BPS constructs, demonstrating significantly smaller ROM than the LLIF construct in all directions (flexion, p = 0.037; extension, p < 0.001; lateral bending, p = 0.012) except axial rotation (p = 0.07). Compared with the LLIF construct, the LLIF + LP had a significant reduction in lateral bending (p = 0.012), a moderate reduction in axial rotation (p = 0.18), and almost no benefit to stability in flexion-extension (p = 0.86). The LLIF + LP + IP construct provided stability comparable to that of the LLIF + BPS. The LLIF + IP construct provided a significant decrease in ROM compared with that of the LLIF construct alone in flexion and extension (p = 0.002), but not in lateral bending (p = 0.80) and axial rotation (p = 0.24). No significant difference was seen in flexion, extension, or axial rotation between LLIF + BPS and LLIF + IP constructs. CONCLUSIONS The LLIF construct that was tested significantly decreased ROM in all directions of loading, which indicated a measure of inherent stability. The LP significantly improved the stability of the LLIF construct in lateral bending only. Adding an IP device to the LLIF construct significantly improves stability in sagittal plane rotation. The LLIF + LP + IP construct demonstrated stability comparable to that of the gold standard 360° fixation (LLIF + BPS).
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Affiliation(s)
- Marco T Reis
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | | | - Bse
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | - Idris Altun
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | - Anna G U S Newcomb
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | | | - Steve W Chang
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | - Brian P Kelly
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Neil R Crawford
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Abstract
OBJECTIVE The aim of this study was to evaluate the segmental correction obtained from 20° and 30° hyperlordotic cages (HLCs) used for anterior lumbar interbody fusion in staged anterior and posterior fusion in adults with degenerative spinal pathology and/or spinal deformities. METHODS The authors report a retrospective case series of 69 HLCs in 41 patients with adult degenerative spine disease and/or deformities who underwent staged anterior, followed by posterior, instrumentation and fusion. There were 29 females and 12 males with a mean age of 55 years (range 23-76 years). The average follow-up was 10 months (range 2-28 months). Radiographic measurements of segmental lordosis and standard sagittal parameters were obtained on pre- and postoperative radiographs. Implant subsidence was measured at the final postoperative follow-up. RESULTS For 30° HLCs, the mean segmental lordosis achieved was 29° (range 26°-34°), but in the presence of spondylolisthesis this was reduced to 19° (range 12°-21°) (p < 0.01). For 20° HLCs, the mean segmental lordosis achieved was 19° (range 16°-22°). The overall mean lumbar lordosis increased from 39° to 59° (p < 0.01). The mean sagittal vertical axis (SVA) reduced from 113 mm (range 38-320 mm) to 43 mm (range -13 to 112 mm). Six cages (9%) displayed a loss of segmental lordosis during follow-up. The mean loss of segmental lordosis was 4.5° (range 3°-10°). A total complication rate of 20% with a 4.1% transient neurological complication rate was observed. The mean blood loss per patient was 240 ml (range 50-900 ml). CONCLUSIONS HLCs provide a reliable and stable degree of segmental lordosis correction. A 30° HLC will produce correction of a similar magnitude to a pedicle subtraction osteotomy, but with a lower complication rate and less blood loss.
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Affiliation(s)
- Philip A Saville
- Department of Orthopaedic Surgery, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Abhijeet B Kadam
- Department of Orthopaedic Surgery, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Harvey E Smith
- Department of Orthopaedic Surgery, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Vincent Arlet
- Department of Orthopaedic Surgery, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, Pennsylvania
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Abstract
OBJECT Failed solid bony fusion, or pseudarthrosis, is a well-known complication of lumbar arthrodesis. Recent advances in radiographic technology, biologics, instrumentation, surgical technique, and understanding of the local biology have all aided in the prevention and treatment of pseudarthrosis. Here, the current literature on the diagnosis and management of lumbar pseudarthroses is reviewed. METHODS A systematic literature review was conducted using the MEDLINE and Embase databases in order to search for the current radiographie diagnosis and surgical treatment methods published in the literature (1985 to present). Inclusion criteria included: 1) published in English; 2) level of evidence I-III; 3) diagnosis of degenerative lumbar spine conditions and/or history of lumbar spine fusion surgery; and 4) comparative studies of 2 different surgical techniques or comparative studies of imaging modality versus surgical exploration. RESULTS Seven studies met the inclusion criteria for current radiographie imaging used to diagnose lumbar pseudarthrosis. Plain radiographs and thin-cut CT scans were the most common method for radiographie diagnosis. PET has been shown to be a valid imaging modality for monitoring in vivo active bone formation. Eight studies compared the surgical techniques for managing and preventing failed lumbar fusion. The success rates for the treatment of pseudarthrosis are enhanced with the use of rigid instrumentation. CONCLUSIONS Spinal fusion rates have improved secondary to advances in biologies, instrumentation, surgical techniques, and understanding of local biology. Treatment of lumbar pseudarthrosis includes a variety of surgical options such as replacing loose instrumentation, use of more potent biologies, and interbody fusion techniques. Prevention and recognition are important tenets in the algorithm for the management of spinal pseudarthrosis.
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Affiliation(s)
- Danielle S Chun
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
| | - Kevin C Baker
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
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Strom RG, Bae J, Mizutani J, Valone F, Ames CP, Deviren V. Lateral interbody fusion combined with open posterior surgery for adult spinal deformity. J Neurosurg Spine 2016; 25:697-705. [PMID: 27341052 DOI: 10.3171/2016.4.spine16157] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [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: 01/18/2023]
Abstract
OBJECTIVE Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD. METHODS All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients. RESULTS LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045). CONCLUSIONS LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.
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Affiliation(s)
| | - Junseok Bae
- Department of Neurological Surgery, Wooridul Spine Hospital, Seoul, South Korea; and
| | - Jun Mizutani
- Neurological Surgery, University of California, San Francisco, California
| | - Frank Valone
- Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri
| | - Christopher P Ames
- Neurological Surgery, University of California, San Francisco, California
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Abstract
OBJECTIVE Off-label therapies are widely used in clinical practice by spinal surgeons. Some patients and practitioners have advocated for increased regulation of their use, and payers have increasingly questioned reimbursment for off-label therapies. In this study, the authors applied a model that quantifies publication data to analyze the developmental process from initial on-label use to off-label innovation, using as an example recombinant human bone morphogenetic protein 2 (rhBMP-2) because of its wide off-label use. METHODS As a case study of off-label innovation, the developmental patterns of rhBMP-2 from FDA-approved use for anterior lumbar interbody fusion to several of its off-label uses, including posterolateral lumbar fusion, anterior cervical discectomy and fusion, and posterior lumbar interbody fusion/transforaminal lumbar interbody fusion, were evaluated using the "progressive scholarly acceptance" (PSA) model. In this model, PSA is used as an end point indicating acceptance of a therapy or procedure by the relevant scientific community and is reached when the total number of peer-reviewed studies devoted to refinement or improvement of a therapy surpasses the total number assessing initial efficacy. Report characteristics, including the number of patients studied and study design, were assessed in addition to the time to and pattern of community acceptance, and results compared with previous developmental study findings. Disclosures and reported conflicts of interest for all articles were reviewed, and these data were also used in the analysis. RESULTS Publication data indicated that the acceptance of rhBMP-2 off-label therapies occurred more rapidly and with less evidence than previously studied on-label therapies. Additionally, the community appeared to respond more robustly (by rapidly changing publication patterns) to reports of adverse events than to new questions of efficacy. CONCLUSIONS The development of off-label therapies, including the influence of investigative methods, regulation, and changing perspectives, can be characterized on the basis of publication patterns. The approach and findings in this report could inform future off-label development of therapies and procedures as well as attempts to regulate off-label use.
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Affiliation(s)
- Zane Schnurman
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Michael L Smith
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
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Adogwa O, Elsamadicy AA, Han JL, Cheng J, Karikari I, Bagley CA. Do measures of surgical effectiveness at 1 year after lumbar spine surgery accurately predict 2-year outcomes? J Neurosurg Spine 2016; 25:689-696. [PMID: 26722957 DOI: 10.3171/2015.8.spine15476] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [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: 01/22/2023]
Abstract
OBJECTIVE With the recent passage of the Patient Protection and Affordable Care Act, there has been a dramatic shift toward critical analyses of quality and longitudinal assessment of subjective and objective outcomes after lumbar spine surgery. Accordingly, the emergence and routine use of real-world institutional registries have been vital to the longitudinal assessment of quality. However, prospectively obtaining longitudinal outcomes for patients at 24 months after spine surgery remains a challenge. The aim of this study was to assess if 12-month measures of treatment effectiveness accurately predict long-term outcomes (24 months). METHODS A nationwide, multiinstitutional, prospective spine outcomes registry was used for this study. Enrollment criteria included available demographic, surgical, and clinical outcomes data. All patients had prospectively collected outcomes measures and a minimum 2-year follow-up. Patient-reported outcomes instruments (Oswestry Disability Index [ODI], SF-36, and visual analog scale [VAS]-back pain/leg pain) were completed before surgery and then at 3, 6, 12, and 24 months after surgery. The Health Transition Index of the SF-36 was used to determine the 1- and 2-year minimum clinically important difference (MCID), and logistic regression modeling was performed to determine if achieving MCID at 1 year adequately predicted improvement and achievement of MCID at 24 months. RESULTS The study group included 969 patients: 300 patients underwent anterior lumbar interbody fusion (ALIF), 606 patients underwent transforaminal lumbar interbody fusion (TLIF), and 63 patients underwent lateral interbody fusion (LLIF). There was a significant correlation between the 12- and 24-month ODI (r = 0.82; p < 0.0001), SF-36 Physical Component Summary score (r = 0.89; p < 0.0001), VAS-back pain (r = 0.90; p < 0.0001), and VAS-leg pain (r = 0.85; p < 0.0001). For the ALIF cohort, patients achieving MCID thresholds for ODI at 12 months were 13-fold (p < 0.0001) more likely to achieve MCID at 24 months. Similarly, for the TLIF and LLIF cohorts, patients achieving MCID thresholds for ODI at 12 months were 13-fold and 14-fold (p < 0.0001) more likely to achieve MCID at 24 months. Outcome measures obtained at 12 months postoperatively are highly predictive of 24-month outcomes, independent of the surgical procedure. CONCLUSIONS In a multiinstitutional prospective study, patient-centered measures of surgical effectiveness obtained at 12 months adequately predict long-term (24-month) outcomes after lumbar spine surgery. Patients achieving MCID at 1 year were more likely to report meaningful and durable improvement at 24 months, suggesting that the 12-month time point is sufficient to identify effective versus ineffective patient care.
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Affiliation(s)
- Owoicho Adogwa
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Aladine A Elsamadicy
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Jing L Han
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Joseph Cheng
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Isaac Karikari
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Carlos A Bagley
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
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Hofstetter CP, Hofer AS, Levi AD. Exploratory meta-analysis on dose-related efficacy and morbidity of bone morphogenetic protein in spinal arthrodesis surgery. J Neurosurg Spine 2015; 24:457-75. [PMID: 26613283 DOI: 10.3171/2015.4.spine141086] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [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: 01/02/2023]
Abstract
OBJECT Bone morphogenetic protein (BMP) is frequently used for spinal arthrodesis procedures in an "off-label" fashion. Whereas complications related to BMP usage are well recognized, the role of dosage is less clear. The objective of this meta-analysis was to assess dose-dependent effectiveness (i.e., bone fusion) and morbidity of BMP used in common spinal arthrodesis procedures. A quantitative exploratory meta-analysis was conducted on studies reporting fusion and complication rates following anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterolateral lumbar fusion (PLF) supplemented with BMP. METHODS A literature search was performed to identify studies on BMP in spinal fusion procedures reporting fusion and/or complication rates. From the included studies, a database for each spinal fusion procedure, including patient demographic information, dose of BMP per level, and data regarding fusion rate and complication rates, was created. The incidence of fusion and complication rates was calculated and analyzed as a function of BMP dose. The methodological quality of all included studies was assessed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were analyzed using a random-effects model. Event rates are shown as percentages, with a 95% CI. RESULTS Forty-eight articles met the inclusion criteria: ACDF (n = 7), PCF (n = 6), ALIF (n = 9), TLIF/PLIF (n = 17), and PLF (n = 9), resulting in a total of 5890 patients. In ACDF, the lowest BMP concentration analyzed (0.2-0.6 mg/level) resulted in a fusion rate similar to the highest dose (1.1-2.1 mg/level), while permitting complication rates comparable to ACDF performed without BMP. The addition of BMP to multilevel constructs significantly (p < 0.001) increased the fusion rate (98.4% [CI 95.4%-99.4%]) versus the control group fusion rate (85.8% [CI 77.4%-91.4%]). Studies on PCF were of poor quality and suggest that BMP doses of ≤ 2.1 mg/level resulted in similar fusion rates as higher doses. Use of BMP in ALIF increased fusion rates from 79.1% (CI 57.6%-91.3%) in the control cohort to 96.9% (CI 92.3%-98.8%) in the BMP-treated group (p < 0.01). The rate of complications showed a positive correlation with the BMP dose used. Use of BMP in TLIF had only a minimal impact on fusion rates (95.0% [CI 92.8%-96.5%] vs 93.0% [CI 78.1%-98.0%] in control patients). In PLF, use of ≥ 8.5 mg BMP per level led to a significant increase of fusion rate (95.2%; CI 90.1%-97.8%) compared with the control group (75.3%; CI 64.1%-84.0%, p < 0.001). BMP did not alter the rate of complications when used in PLF. CONCLUSIONS The BMP doses used for various spinal arthrodesis procedures differed greatly between studies. This study provides BMP dosing recommendations for the most common spine procedures.
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Affiliation(s)
| | - Anna S Hofer
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
| | - Allan D Levi
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
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Strube P, Putzier M, Streitparth F, Hoff EK, Hartwig T. Postoperative posterior lumbar muscle changes and their relationship to segmental motion preservation or restriction: a randomized prospective study. J Neurosurg Spine 2015; 24:25-31. [PMID: 26360146 DOI: 10.3171/2015.3.spine14997] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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: 11/06/2022]
Abstract
OBJECTIVE To date, it remains unclear whether the preservation of segmental motion by total disc replacement (TDR) or motion restriction by stand-alone anterior lumbar interbody fusion (ALIF) have an influence on postoperative degeneration of the posterior paraspinal muscles or the associated clinical results. Therefore, the purpose of the present prospective randomized study was to evaluate the clinical parameters and 3D quantitative radiological changes in the paraspinal muscles of the lumbar spine in surgically treated segments and superior adjacent segments after ALIF and TDR. METHODS A total of 50 patients with chronic low-back pain caused by single-level intervertebral disc degeneration (Pfirrmann Grade ≥ III) and/or osteochondrosis (Modic Type ≤ 2) without symptomatic facet joint degeneration (Fujiwara Grade ≤ 2, infiltration test) of the segments L4-5 or L5-S1 were randomly assigned to 2 treatment groups. Twenty-five patients were treated with a stand-alone ALIF and the remaining 25 patients underwent TDR. For ALIF and TDR, a retroperitoneal approach was used. At 1 week and at 12 months after surgery, CT was used to analyze paraspinal lumbar muscle tissue volume and relative fat content. Residual muscle tissue volume at 12 months and change in the relative fat content were compared between the groups. In addition, clinical parameters (visual analog scale [VAS] for low-back pain and Oswestry Disability Index [ODI] Questionnaire Version 2 for function) were compared. RESULTS Compared with 1 week after surgery, the radiological analysis at 12 months revealed a small decrease in the posterior muscle volume (the mean decrease was < 2.5%), along with a small increase in the relative fat content (the mean increase was < 1.9%), in both groups at the index and superior adjacent segments. At the adjacent segment, the ALIF group presented significantly less muscle tissue volume atrophy and a smaller increase in fat content compared with the TDR group. At final follow-up, the clinical parameters related to pain and function were significantly improved in both groups compared with 1 week postsurgery, but there were no differences between the groups. CONCLUSIONS Motion restriction via stand-alone ALIF and motion preservation via TDR both present small changes in the posterior lumbar paraspinal muscles with regard to volume atrophy or fatty degeneration at the index and superior adjacent segments. Therefore, although the clinical outcome was not affected by the observed muscular changes, the authors concluded that the expected negative influence of motion restriction on the posterior muscles compared with motion preservation does not occur on a clinically relevant level.
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Affiliation(s)
- Patrick Strube
- Klinik für Orthopädie der Friedrich-Schiller-Universität Jena, Waldkrankenhaus "Rudolf Elle" gGmbH, Eisenberg
| | - Michael Putzier
- Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin; and
| | | | - Eike K Hoff
- Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin; and
| | - Tony Hartwig
- Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin; and
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Lin Y, Li F, Chen W, Zeng H, Chen A, Xiong W. Single-level lumbar pyogenic spondylodiscitis treated with mini-open anterior debridement and fusion in combination with posterior percutaneous fixation via a modified anterior lumbar interbody fusion approach. J Neurosurg Spine 2015; 23:747-53. [PMID: 26340382 DOI: 10.3171/2015.5.spine14876] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 11/06/2022]
Abstract
OBJECT This study evaluated the efficacy and safety of mini-open anterior debridement and lumbar interbody fusion in combination with posterior percutaneous fixation for single-level lumbar pyogenic spondylodiscitis. METHODS This is a retrospective study. Twenty-two patients with single-level lumbar pyogenic spondylodiscitis underwent mini-open anterior debridement and lumbar interbody fusion in combination with posterior percutaneous fixation via a modified anterior lumbar interbody fusion (ALIF) approach. Patients underwent follow-up for 24 to 38 months. Clinical data, etiological examinations, operative time, intraoperative blood loss, American Spinal Injury Association (ASIA) grade, Japanese Orthopaedic Association (JOA) lumbar function score, visual analog scale (VAS) score, Oswestry Disability Index (ODI), postoperative complications, and the bony fusion rate were recorded. RESULTS The mean operative time was 181.1 ± 22.6 minutes (range 155-240 minutes). The mean intraoperative blood loss was 173.2 ± 70.1 ml (range 100-400 ml). Infection was found in lumbar vertebrae L2-3, L3-4, and L4-5 in 2, 6, and 14 patients, respectively. Bacterial cultures were positive in 15 patients, including 4 with Staphylococcus aureus, 6 with Staphylococcus epidermidis, 4 with Streptococcus, and 1 with Escherichia coli. Postoperative complications included urinary retention, constipation, and numbness in the thigh in 5, 3, and 2 patients, respectively. Compared with before surgery, the VAS scores and ODI were significantly lower at the final follow-up, the JOA scores were significantly higher, and the ASIA grades had improved. All patients achieved good intervertebral bony fusion. CONCLUSIONS Mini-open anterior debridement and lumbar interbody fusion in combination with posterior percutaneous fixation via a modified ALIF approach results in little surgical trauma and intraoperative blood loss, acceptable postoperative complications, and is effective and safe for the treatment of single-level lumbar pyogenic spondylodiscitis. This approach could be an alternative to the conventional open surgery.
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Affiliation(s)
- Yang Lin
- Department of Orthopedics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Feng Li
- Department of Orthopedics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Wenjian Chen
- Department of Orthopedics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Heng Zeng
- Department of Orthopedics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Anmin Chen
- Department of Orthopedics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Wei Xiong
- Department of Orthopedics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
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Abstract
OBJECT The object of this study was to determine the fusion rate and safety profile of an axial interbody arthrodesis of the L5-S1 motion segment. METHODS A systematic search of MEDLINE was conducted for literature published between January 1, 2000, and August 17, 2014. All peer-reviewed articles related to the fusion rate of L5-S1 and the safety profile of an axial interbody arthrodesis were evaluated. RESULTS Seventy-four articles were identified, but only 15 (13 case series and 2 retrospective cohort studies) met the study inclusion criteria. The overall pseudarthrosis rate at L5-S1 was 6.9%, and the rate of all other complications was 12.9%. A total of 14.4% of patients required additional surgery, and the infection rate was 5.4%. Deformity studies reported a significantly increased rate of complications (46.3%), and prospectively collected data demonstrated significantly higher complication (36.8%) and revision (22.6%) rates. Lastly, studies with a conflict of interest reported lower complication rates (12.4%). CONCLUSIONS A systematic review of the literature indicates that an axial interbody fusion performed at the lumbosacral junction is associated with a high fusion rate (93.15%) and an acceptable complication rate (12.90%). However, these results are based mainly on retrospective case series by authors with a conflict of interest. The limited prospective data available indicate that the actual fusion rate may be lower and the complication rate may be higher than currently reported.
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Abstract
OBJECT The anterior approach to the lumbar spine may be associated with iliac artery thrombosis. Intraoperative heparin can be administered to prevent thrombosis; however, there is a concern that this will increase the procedural blood loss. The aim of this study was to examine whether intraoperative heparin can be administered without increasing blood loss in anterior lumbar spine surgery. METHODS A prospective study of consecutive anterior approaches for lumbar spine surgery was performed between January 2009 and June 2014 by a single vascular surgeon and a single spine surgeon. Patients underwent an anterior lumbar interbody fusion (ALIF) at L4-5 and/or L5-S1, a total disc replacement (TDR) at L4-5 and/or L5-S1, or a hybrid procedure with a TDR at L4-5 and an ALIF at L5-S1. Heparin was administered intravenously when arterial flow to the lower limbs was interrupted during the procedure. Heparin was usually reversed on removal of the causative retraction. RESULTS The cohort consisted of 188 patients with a mean age of 41.7 years; 96 (51.1%) were male. Eighty-four patients (44.7%) had an ALIF, 57 (30.3%) had a TDR, and 47 (25.0%) had a hybrid operation with a TDR at L4-5 and an ALIF at L5-S1. One hundred thirty-four patients (71.3%) underwent a single-level procedure (26.9% L4-5 and 73.1% L5-S1) and 54 (28.7%) underwent a 2-level procedure (L4-5 and L5-S1). Seventy-two patients (38.3%) received heparinization intraoperatively. Heparin was predominantly administered during hybrid operations (68.1%), 2-level procedures (70.4%), and procedures involving the L4-5 level (80.6%). There were no intraoperative ischemic vascular complications reported in this series. There was 1 postoperative deep venous thrombosis. The overall mean estimated blood loss (EBL) for the heparin group (389.7 ml) was significantly higher than for the nonheparin group (160.5 ml) (p < 0.0001). However, when all variables were analyzed with multiple linear regression, only the prosthesis used and level treated were found to be significant in blood loss (p < 0.05). The highest blood loss occurred in hybrid procedures (448.1 ml), followed by TDR (302.5 ml) and ALIF (99.7 ml). There were statistically significant differences between the EBL during ALIF compared with TDR and hybrid (p < 0.0001), but not between TDR and hybrid. The L4-5 level was associated with significantly higher blood loss (384.9 ml) compared with L5-S1 (111.4 ml) (p < 0.0001). CONCLUSIONS During an anterior exposure for lumbar spine surgery, the administration of heparin does not significantly increase blood loss. The prosthesis used and level treated were found to significantly increase blood loss, with TDR and the L4-5 level having greater blood loss compared with ALIF and L5-S1, respectively. Heparin can be administered safely to help prevent thrombotic intraoperative vascular complications without increasing blood loss.
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Malham GM, Parker RM, Ellis NJ, Blecher CM, Chow FY, Claydon MH. Anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2: a prospective study of complications. J Neurosurg Spine 2014; 21:851-60. [PMID: 25279655 DOI: 10.3171/2014.8.spine13524] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [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: 12/19/2022]
Abstract
OBJECT The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in anterior lumbar interbody fusion (ALIF) is controversial regarding the reported complication rates and cost. The authors aimed to assess the complication rates of performing ALIF using rhBMP-2. METHODS This is a prospective study of consecutive patients who underwent ALIF performed by a single spine surgeon and a single vascular surgeon between 2009 and 2012. All patients underwent placement of a polyetheretherketone (PEEK) cage filled with rhBMP-2 and a separate anterior titanium plate. Preoperative clinical data, operative details, postoperative complications, and clinical and radiographic outcomes were recorded for all patients. Clinical outcome measures included back and leg pain visual analog scale scores, Oswestry Disability Index (ODI), and SF-36 Physical and Mental Component Summary (PCS and MCS) scores. Radiographic assessment of fusion was performed using high-definition CT scanning. Male patients were screened pre- and postoperatively regarding sexual dysfunction, specifically retrograde ejaculation (RE). RESULTS The study comprised 131 patients with a mean age of 45.3 years. There were 67 men (51.1%) and 64 women (48.9%). Of the 131 patients, 117 (89.3%) underwent ALIF at L5-S1, 9 (6.9%) at L4-5, and 5 (3.8%) at both L4-5 and L5-S1. The overall complication rate was 19.1% (25 of 131), with 17 patients (13.0%) experiencing minor complications and 8 (6.1%) experiencing major complications. The mean estimated blood loss per ALIF level was 115 ml. There was 1 incidence (1.5%) of RE. No significant vascular injuries occurred. No prosthesis failure occurred with the PEEK cage and separate anterior screw-plate. Back and leg pain improved 57.2% and 61.8%, respectively. The ODI improved 54.3%, with PCS and MCS scores improving 41.7% and 21.3%, respectively. Solid interbody fusion was observed in 96.9% of patients at 12 months. CONCLUSIONS Anterior lumbar interbody fusion with a vascular access surgeon and spine surgeon, using a separate cage and anterior screw-plate, provides a very robust and reliable construct with low complication rates, high fusion rates, and positive clinical outcomes, and it is cost-effective. The authors did not experience the high rates of RE reported by other authors using rhBMP-2.
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Dhall SS, Choudhri TF, Eck JC, Groff MW, Ghogawala Z, Watters WC, Dailey AT, Resnick DK, Sharan A, Mummaneni PV, Wang JC, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 5: correlation between radiographic outcome and function. J Neurosurg Spine 2014; 21:31-6. [PMID: 24980582 DOI: 10.3171/2014.4.spine14268] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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: 11/06/2022]
Abstract
In an effort to diminish pain or progressive instability, due to either the pathological process or as a result of surgical decompression, one of the primary goals of a fusion procedure is to achieve a solid arthrodesis. Assuming that pain and disability result from lost mechanical integrity of the spine, the objective of a fusion across an unstable segment is to eliminate pathological motion and improve clinical outcome. However, conclusive evidence of this correlation, between successful fusion and clinical outcome, remains elusive, and thus the necessity of documenting successful arthrodesis through radiographic analysis remains debatable. Although a definitive cause and effect relationship has not been demonstrated, there is moderate evidence that demonstrates a positive association between radiographic presence of fusion and improved clinical outcome. Due to this growing body of literature, it is recommended that strategies intended to enhance the potential for radiographic fusion are considered when performing a lumbar arthrodesis for degenerative spine disease.
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Affiliation(s)
- Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, California
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Kaiser MG, Groff MW, Watters WC, Ghogawala Z, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Wang JC, Dhall SS, Resnick DK. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 16: bone graft extenders and substitutes as an adjunct for lumbar fusion. J Neurosurg Spine 2014; 21:106-32. [PMID: 24980593 DOI: 10.3171/2014.4.spine14325] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [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: 01/16/2023]
Abstract
In an attempt to enhance the potential to achieve a solid arthrodesis and avoid the morbidity of harvesting autologous iliac crest bone (AICB) for a lumbar fusion, numerous alternatives have been investigated. The use of these fusion adjuncts has become routine despite a lack of convincing evidence demonstrating a benefit to justify added costs or potential harm. Potential alternatives to AICB include locally harvested autograft, calcium-phosphate salts, demineralized bone matrix (DBM), and the family of bone morphogenetic proteins (BMPs). In particular, no option has created greater controversy than the BMPs. A significant increase in the number of publications, particularly with respect to the BMPs, has taken place since the release of the original guidelines. Both DBM and the calciumphosphate salts have demonstrated efficacy as a graft extender or as a substitute for AICB when combined with local autograft. The use of recombinant human BMP-2 (rhBMP-2) as a substitute for AICB, when performing an interbody lumbar fusion, is considered an option since similar outcomes have been observed; however, the potential for heterotopic bone formation is a concern. The use of rhBMP-2, when combined with calcium phosphates, as a substitute for AICB, or as an extender, when used with local autograft or AICB, is also considered an option as similar fusion rates and clinical outcomes have been observed. Surgeons electing to use BMPs should be aware of a growing body of literature demonstrating unique complications associated with the use of BMPs.
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Affiliation(s)
- Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
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Kwon YK, Jang JH, Lee CD, Lee SH. Fracture of the L-4 vertebral body after use of a stand-alone interbody fusion device in degenerative spondylolisthesis for anterior L3-4 fixation. J Neurosurg Spine 2014; 20:653-6. [PMID: 24725181 DOI: 10.3171/2014.3.spine121018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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: 11/06/2022]
Abstract
Many studies attest to the excellent results achieved using anterior lumbar interbody fusion (ALIF) for degenerative spondylolisthesis. The purpose of this report is to document a rare instance of L-4 vertebral body fracture following use of a stand-alone interbody fusion device for L3-4 ALIF. The patient, a 55-year-old man, had suffered intractable pain of the back, right buttock, and left leg for several weeks. Initial radiographs showed Grade I degenerative spondylolisthesis, with instability in the sagittal plane (upon 15° rotation) and stenosis of central and both lateral recesses at the L3-4 level. Anterior lumbar interbody fusion of the affected vertebrae was subsequently conducted using a stand-alone cage/plate system. Postoperatively, the severity of spondylolisthesis diminished, with resolution of symptoms. However, the patient returned 2 months later with both leg weakness and back pain. Plain radiographs and CT indicated device failure due to anterior fracture of the L-4 vertebral body, and the spondylolisthesis had recurred. At this point, bilateral facetectomies were performed, with reduction/fixation of L3-4 by pedicle screws. Again, degenerative spondylolisthesis improved postsurgically and symptoms eased, with eventual healing of the vertebral body fracture. This report documents a rare instance of L-4 vertebral body fracture following use of a stand-alone device for ALIF at L3-4, likely as a consequence of angular instability in degenerative spondylolisthesis. Under such conditions, additional pedicle screw fixation is advised.
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