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Mao Y, Patel AA, Meade S, Benzel E, Steinmetz MP, Mroz T, Habboub G. Review of mechanisms of expandable spine surgery devices. Expert Rev Med Devices 2024:1-10. [PMID: 38557229 DOI: 10.1080/17434440.2024.2337295] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/06/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Expandable devices such as interbody cages, vertebral body reconstruction cages, and intravertebral body expansion devices are frequently utilized in spine surgery. Since the introduction of expandable implants in the early 2000s, the variety of mechanisms that drive expansion and implant materials have steadily increased. By examining expandable devices that have achieved commercial success and exploring emerging innovations, we aim to offer an in-depth evaluation of the different types of expandable cages used in spine surgery and the underlying mechanisms that drive their functionality. AREAS COVERED We performed a review of expandable spinal implants and devices by querying the National Library of Medicine MEDLINE database and Google Patents database from 1933 to 2024. Five major types of mechanical jacks that drive expansion were identified: scissor, pneumatic, screw, ratchet, and insertion-expansion. EXPERT OPINION We identified a trend of screw jack mechanism being the predominant machinery in vertebral body reconstruction cages and scissor jack mechanism predominating in interbody cages. Pneumatic jacks were most commonly found in kyphoplasty devices. Critically reviewing the mechanisms of expansion and identifying trends among effective and successful cages allows both surgeons and medical device companies to properly identify future areas of development.
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Affiliation(s)
- Yuncong Mao
- Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Arpan A Patel
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Seth Meade
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Edward Benzel
- Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Michael P Steinmetz
- Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Thomas Mroz
- Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Ghaith Habboub
- Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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Song KS, Yoon BI, Ham DW. Transpedicular Intravertebral Cage Augmentation Using Expandable Cage in Kummell Disease: Technical Note and Case Series. World Neurosurg 2024; 184:119-124. [PMID: 38266993 DOI: 10.1016/j.wneu.2024.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE To demonstrate the surgical techniques for transpedicular intravertebral cage augmentation (TPICA) using an expandable cage for Kummell disease, which requires posterior surgical stabilization, and provide the preliminary surgical outcomes. METHODS Six consecutive patients undergoing TPICA surgery using an expandable cage with a minimum 6-month follow-up were evaluated. Radiographic analysis to evaluate the local kyphosis angle, restoration ratio of anterior vertebral height of the index vertebra, and clinical outcomes including the Oswestry Disability Index, EuroQol 5-dimension instrument, and visual analog scale for back and leg pain, were compared between the preoperative and final follow-ups. RESULTS All patients showed improvements in all clinical outcomes and were able to walk independently without support at the last follow-up. In radiographic evaluation, the mean preoperative restoration ratio of anterior vertebral height was 41.2 ± 15.6%, which increased postoperatively to 70.3 ± 20.5% (1.70 times) and 62.4 ± 20.0% at the last follow-up (1.51 times). The mean preoperative local kyphosis angle was 10.5 ± 14.8 and was corrected to 6.0 ± 10.0 at the last follow-up. A slight loss of correction was observed between the postoperative period and the last follow-up; however, there was no clinical significance. CONCLUSIONS Expandable cages in TPICA may allow easier surgical manipulation for cage insertion around the pedicle entrance, minimizing damage to the fractured vertebral body's end plates while achieving satisfactory height restoration compared to static cages, and may also provide wider indications for TPICA surgery.
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Affiliation(s)
- Kwang-Sup Song
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea.
| | - Byung-Il Yoon
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Dae-Woong Ham
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
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Weinstein MA, Ayala GA, Roura R, Christmas KN, Warren DH, Simon P. Transforaminal lumbar interbody fusion with an expandable interbody device: Two-year clinical and radiographic outcomes. N Am Spine Soc J 2023; 16:100286. [PMID: 38025939 PMCID: PMC10652136 DOI: 10.1016/j.xnsj.2023.100286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
Background The use of interbody cages as an adjunct to lumbar spinal fusion remains an important technique to enhance segmental stability, promote solid arthrodesis, maintain neuroforaminal decompression, and preserve/improve segmental lordosis. Appropriate segmental lumbar lordosis and sagittal balance is well-known to be critical for long-term patient outcomes. This study sought to evaluate the radiographic and clinical results of TLIF in patients using an articulating, expandable cage. Primary endpoint was clinical and radiographic outcomes, including complications, at 12 and 24 months. Methods A total of 37 patients underwent open single-level or 2-level TLIF by a single surgeon using an expandable cage with concomitant bilateral pedicle screws and posterolateral arthrodesis. Clinical outcomes included ODI and VAS for back and legs. Radiographic outcomes included pelvic incidence and tilt, lumbar and segmental lordoses, and disc height at the operative level(s). All outcomes were collected at baseline, 2-weeks, 6-weeks, 3-months, 6-months, 12-months, and 24-months postop. Results A total of 28 patients were available for analysis. Nine patients failed to follow-up at 24 months. Mean ODI scores showed significant improvement, from pre-to-postoperative at 24 months (55%; p<.0001). VAS for back and legs was significantly lower at 24 months on average by 72 and 79%, respectively (p<.0001 for both). Both segmental and lumbar lordoses significantly improved by 5.3° and 4.2° (p<.0001 and p=.049), respectively. Average disc height improved by 49% or 6.1 mm (p<.001). No device-related complications nor instances of measured subsidence. One patient had a superficial infection, and another had an intraoperatively repaired incidental durotomy. Conclusions The use of an expandable cage contributed to improvement in both segmental and lumbar lordosis with no reported complications at 24-month follow-up. All clinical measures significantly improved as well. The expandable cage design represents an effective and safe option to increase cage size and allow significant segmental lordosis correction.
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Affiliation(s)
- Marc A. Weinstein
- Department of Orthopaedics and Sports Medicine of the University of South Florida Morsani School of Medicine, 13330 USF Laurel Drive, Tampa, FL, USA
- Florida Orthopaedic Institute, 13020 Telecom Prkw. N., Tampa, FL, USA
| | - Giovanni A. Ayala
- Foundation for Orthopaedic Research and Education, 4115 W Spruce St, Tampa, FL 33607, USA
| | - Raúl Roura
- Foundation for Orthopaedic Research and Education, 4115 W Spruce St, Tampa, FL 33607, USA
| | - Kaitlyn N. Christmas
- Foundation for Orthopaedic Research and Education, 4115 W Spruce St, Tampa, FL 33607, USA
| | - Deborah H. Warren
- Foundation for Orthopaedic Research and Education, 4115 W Spruce St, Tampa, FL 33607, USA
| | - Peter Simon
- Department of Orthopaedics and Sports Medicine of the University of South Florida Morsani School of Medicine, 13330 USF Laurel Drive, Tampa, FL, USA
- Foundation for Orthopaedic Research and Education, 4115 W Spruce St, Tampa, FL 33607, USA
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Lee S, Kim JG, Kim HJ. Comparison of surgical outcomes between lumbar interbody fusions using expandable and static cages: a systematic review and meta-analysis. Spine J 2023; 23:1593-1601. [PMID: 37473812 DOI: 10.1016/j.spinee.2023.07.012] [Citation(s) in RCA: 1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 07/07/2023] [Accepted: 07/16/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The use of static cages for lumbar interbody fusion (LIF) can cause complications such as end plate violation, graft subsidence, and nerve injury. Therefore, expandable cages that allow for in-situ expansion have been developed to overcome these problems. However, it remains uncertain whether expandable cages have better surgical outcomes than static cages do. PURPOSE We aimed to determine the effectiveness of expandable cages by analyzing studies that compared the surgical outcomes between the use of expandable cages and static cages. STUDY DESIGN A systematic review and meta-analysis. METHODS The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to conduct this meta-analysis and systematic review. The primary outcomes of this study were anterior disc height, posterior disc height, segmental lordosis (SL), lumbar lordosis (LL), subsidence rate, numeric rating scale (NRS) scores for back and leg pain, and Oswestry Disability Index (ODI). RESULTS Thirteen studies with 1,700 patients were included in the meta-analysis. Compared with static cages for LIFs, expandable cages significantly increased the anterior disc height (standardized mean difference 0.478, 95% confidence interval [CI] 0.088-0.867, p=.0162) and segmental lordosis (sMD 0.307, 95% CI 0.159-0.454, p<.0001). There were no significant differences in the posterior disc height, lumbar lordosis, subsidence rate, back pain, leg pain, or ODI between the two groups. CONCLUSION Expandable cages show no clear clinical benefit over static cages.
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Affiliation(s)
- Sanghoon Lee
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea
| | - Jung Guel Kim
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea
| | - Ho-Joong Kim
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea.
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Su YH, Wu PK, Wu MH, Wong KW, Li WW, Chou SH. Comparison of the Radiographic and Clinical Outcomes Between Expandable Cage and Static Cage for Transforaminal Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 179:133-142. [PMID: 37579991 DOI: 10.1016/j.wneu.2023.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Yu-Hsiang Su
- Department of Education, China Medical University Hospital, Taichung, Taiwan
| | - Po-Kuan Wu
- Department of Orthopaedics, Chi Mei Medical Center, Tainan, Taiwan
| | - Meng-Huang Wu
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; TMU Biodesign Center, Taipei Medical University, Taipei, Taiwan; Department of Orthopaedics, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kin-Weng Wong
- Department of Orthopaedics, Chi Mei Medical Center, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Wei Li
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shih-Hsiang Chou
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Departments of Orthopedics, School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Orthopaedic Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Hiyama A, Katoh H, Sakai D, Sato M, Watanabe M. Early Radiological Assessment of Static and Expandable Cages in Lateral Single Position for Indirect Decompression- Lateral Lumbar Interbody Fusion. World Neurosurg 2023; 178:e453-e464. [PMID: 37506844 DOI: 10.1016/j.wneu.2023.07.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/10/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVE This study aimed to compare the postoperative alignment of static and expandable cages in lateral single-position (LSP) for indirect decompression in lateral lumbar interbody fusion (LLIF). METHODS We included sixty-seven patients who underwent LSP-LLIF for lumbar degenerative disease. We performed radiological assessments preoperatively and two weeks postoperatively using computed tomography and magnetic resonance imaging. We divided the patients into the expandable cage group (23 patients) and the static cage group (44 patients). We measured disc height (DH), segmental lordosis (SL), and foraminal area (FA) from computed tomography images and the area of the dural sac from magnetic resonance imaging. We recorded surgical outcomes and complications. RESULTS Both static and expandable cages demonstrated improvements in DH, SL, FA, and dural sac expansion. However, we found no statistically significant differences in the average change in DH (4.4 ± 2.1 mm vs. 4.2 ± 1.8 mm, P = 0.685), the average change in SL (1.0 ± 4.4° vs. 1.9 ± 3.6°, P = 0.310), or FA change (32.5 ± 31.7 mm2 vs. 34.9 ± 29.5 mm2, P = 0.966) between the expandable and static cage groups. We also found no statistically significant difference in dural sac enlargement between the two groups. We observed no significant differences in operation time, estimated blood loss, or length of hospital stay between the two groups. No severe adverse events or additional surgeries were reported. CONCLUSIONS In LSP-LLIF without facet joint resection or other posterior techniques, static and expandable cages showed comparable effectiveness in achieving increased DH, SL, FA, and indirect decompression.
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Affiliation(s)
- Akihiko Hiyama
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masato Sato
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Armocida D, Pesce A, Cimatti M, Proietti L, Santoro A, Frati A. Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Expandable Cages: Increased Risk of Late Postoperative Subsidence Without a Real Improvement of Perioperative Outcomes: A Clinical Monocentric Study. World Neurosurg 2021; 156:e57-e63. [PMID: 34492389 DOI: 10.1016/j.wneu.2021.08.127] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 05/30/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is one of several approaches to lumbar interbody fusion that has proven to be a safe and effective treatment for symptomatic lumbar degenerative disease The clinical outcomes of MIS-TLIF are generally favorable, but there is still controversy regarding its ability to restore sagittal alignment. For this reason, expandable transforaminal lumbar interbody fusion cages have been developed and designed to improve ability to restore disc height and segmental lordosis. The use of expandable cages in transforaminal lumbar interbody fusion has increased drastically; however, it is not clear how effective cage expansion is in regard to disc space lordosis, distraction, and long-term outcome. METHODS We reviewed a cohort of patients with symptomatic lumbar degenerative disc pathology who underwent MIS-TLIF at our institution. We compared clinical and radiographic outcomes of expandable versus nonexpandable cage use in MIS-TLIF focusing on mean changes in segmental lordosis, disc height, and postoperative complications. The results were compared with other studies reported in the international literature. RESULTS Mean change in segmental lordosis was not significantly different between the 2 groups. A significantly higher rate of postoperative subsidence was demonstrated in the expandable cage group. CONCLUSION This study established that expandable cage use in single-level transforaminal lumbar interbody fusion did not reduce the rate of postoperative complications, but rather significantly increased a patient's risk of postoperative subsidence. Expandable cages do not presently demonstrate improved clinical outcomes or improved sagittal alignment compared with static cages.
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Affiliation(s)
- Daniele Armocida
- Human Neurosciences Department, Sapienza University, Rome, Italy.
| | | | - Marco Cimatti
- Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Luca Proietti
- Division of Spinal Surgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy; Institute of Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Santoro
- Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Alessandro Frati
- Human Neurosciences Department, Sapienza University, Rome, Italy; IRCCS Neuromed, Pozzilli, Italy
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Macki M, Hamilton T, Haddad YW, Chang V. Expandable Cage Technology-Transforaminal, Anterior, and Lateral Lumbar Interbody Fusion. Oper Neurosurg (Hagerstown) 2021; 21:S69-S80. [PMID: 34128070 DOI: 10.1093/ons/opaa342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
This review of the literature will focus on the indications, surgical techniques, and outcomes for expandable transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and lateral lumbar interbody fusion (LLIF) operations. The expandable TLIF cage has become a workhorse for common degenerative pathology, whereas expandable ALIF cages carry the promise of greater lordotic correction while evading the diseased posterior elements. Expandable LLIF cages call upon minimally invasive techniques for a retroperitoneal, transpsoas approach to the disc space, obviating the need for an access surgeon and decreasing risk of injury to the critical neurovascular structures. Nuances between expandable and static cages for all 3 TLIF, ALIF, and LLIF operations are discussed in this review.
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Affiliation(s)
- Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Travis Hamilton
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Yazeed W Haddad
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
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Park P, Wang M, Than KD, Uribe J. Emerging Technologies in Spinal Surgery. Oper Neurosurg (Hagerstown) 2021; 21:S1. [PMID: 34128059 DOI: 10.1093/ons/opab064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/26/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Wang
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Khoi D Than
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Juan Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Canseco JA, Karamian BA, DiMaria SL, Patel PD, Divi SN, Chang M, Timmons T, Grewal L, Hallman H, Lee JK, Kaye ID, Woods BI, Kurd MF, Anderson DG, Rihn JA, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Static Versus Expandable Polyether Ether Ketone (PEEK) Interbody Cages: A Comparison of One-Year Clinical and Radiographic Outcomes for One-Level Transforaminal Lumbar Interbody Fusion. World Neurosurg 2021; 152:e492-e501. [PMID: 34098137 DOI: 10.1016/j.wneu.2021.05.128] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine the effect of static versus expandable polyether ether ketone (PEEK) cages on both clinical and radiographic outcomes. METHODS A retrospective cohort study was conducted on patients who underwent one-level transforaminal lumbar interbody fusion with either a static or expandable PEEK cage. Patient outcomes were obtained from chart review and radiographic outcomes were measured using standing, lateral radiographs. Recovery ratios and the proportion of patients achieving the minimally clinically important difference were calculated for Oswestry Disability Index (ODI), Physical Component Score-12, Mental Component Score-12, visual analogue scale for back, and visual analogue scale for leg at 1 year and compared between groups. Multivariate linear regression analysis was performed to determine the effect of cage type on the change in patient-reported outcome measures, controlling for demographic factors. RESULTS A total of 240 patients (137 static, 103 expandable) were included in the final analysis. ΔPhysical Component Score-12 scores at 3 months were significantly greater for the static group (16.0 vs. 10.0, P = 0.043) compared with the expandable group. Multivariate regression demonstrated that use of an expandable cage was associated with greater improvements in ΔODI (β: -7.82, P = 0.048) at 1 year. No differences were found in the perioperative change in sagittal spinal alignment within or between groups at 1 year. Subsidence rates failed to show any statistically significant difference between the 2 groups. CONCLUSIONS Transforaminal lumbar interbody fusion with an expandable PEEK cage is an independent predictor of improved ODI scores at 1 year. Our study showed no significant differences in subsidence rates or changes in sagittal spinal alignment between static and expandable PEEK cages.
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Affiliation(s)
- Jose A Canseco
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Stephen L DiMaria
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parthik D Patel
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Srikanth N Divi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael Chang
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tyler Timmons
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lovy Grewal
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Haydn Hallman
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph K Lee
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark F Kurd
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - D Greg Anderson
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Rihn
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Pennington Z, Hersh AM, Lo SL. Translocation of Cervical Vertebral Body Replacement Device into the Esophagus. World Neurosurg 2021; 150:144-6. [PMID: 33819708 DOI: 10.1016/j.wneu.2021.03.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/21/2022]
Abstract
Expandable vertebrectomy devices are a key technology that has facilitated the adoption of minimally invasive approaches to spine oncology surgery. However, advanced technology still requires proper attention to surgical fundamentals. Here we illustrate a cage of a misplaced expandable vertebrectomy device causing esophageal perforation. Examination of the postoperative radiographs suggests that haptic feedback from the expandable technology may have given the false impression of bony engagement. This case highlights the need for proper mortise work and complete visualization of the segments to be instrumented even during minimally invasive surgery.
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Stickley C, Philipp T, Wang E, Zhong J, Balouch E, O'Malley N, Leon C, Maglaras C, Manning J, Varlotta C, Buckland AJ. Expandable cages increase the risk of intraoperative subsidence but do not improve perioperative outcomes in single level transforaminal lumbar interbody fusion. Spine J 2021; 21:37-44. [PMID: 32890783 DOI: 10.1016/j.spinee.2020.08.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/17/2020] [Accepted: 08/29/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Expandable cages (EXP) are being more frequently utilized in transforaminal lumbar interbody fusions (TLIF). EXP were designed to reduce complications related to neurological retraction, enable better lordosis restoration, and improve ease of insertion, particularly in the advent of minimally invasive surgical (MIS) techniques, however they are exponentially more expensive than the nonexpandable (NE) alternative. PURPOSE To investigate the clinical results of expandable cages in single level TLIF. STUDY DESIGN/SETTING Retrospective review at a single institution. PATIENT SAMPLE Two hundred and fifty-two single level TLIFs from 2012 to 2018 were included. OUTCOME MEASURES Clinical characteristics, perioperative and neurologic complication rates, and radiographic measures. METHODS Patients ≥18 years of age who underwent single level TLIF with minimum 1 year follow-up were included. OUTCOME MEASURES clinical characteristics, perioperative and neurologic complications. Radiographic analysis included pelvic incidence-lumbar lordosis (PI-LL) mismatch, segmental lumbar lordosis (LL) mismatch, disc height restoration, and subsidence ≥2 mm. Statistical analysis included independent t tests and chi-square analysis. For nonparametric variables, Mann-Whitney U test and Spearman partial correlation were utilized. Multivariate regression was performed to assess relationships between surgical variables and recorded outcomes. For univariate analysis significance was set at p<.05. Due to the multiple comparisons being made, significance for regressions was set at p<.025 utilizing Bonferroni correction. RESULTS Two hundred and fifty-two TLIFs between 2012 and 2018 were included, with 152 NE (54.6% female, mean age 59.28±14.19, mean body mass index (BMI) 28.65±5.38, mean Charlson Comorbidity Index (CCI) 2.20±1.89) and 100 EXP (48% female, mean age 58.81±11.70, mean BMI 28.68±6.06, mean CCI 1.99±1.66) with no significant differences in demographics. Patients instrumented with EXP cages had a shorter length of stay (3.11±2.06 days EXP vs. 4.01±2.64 days NE; Z=-4.189, p<.001) and a lower estimated blood loss (201.31±189.41 mL EXP vs. 377.82±364.06 mL NE; Z=-6.449, p<.001). There were significantly more MIS-TLIF cases and bone morphogenic protein (BMP) use in the EXP group (88% MIS, p<.001 and 60% BMP, p<.001) as illustrated in Table 1. There were no significant differences between the EXP and NE groups in rates of radiculitis and neuropraxia. In multivariate regression analysis, EXP were not associated with a difference in perioperative outcomes or complications. Radiographic analyses demonstrated that the EXP group had a lower PI-LL mismatch than the NE cage group at baseline (3.75±13.81° EXP vs. 12.75±15.81° NE; p=.001) and at 1 year follow-up (3.81±12.84° EXP vs. 8.23±12.73° NE; p=.046), but change in regional and segmental alignment was not significantly different between groups. Multivariate regression demonstrated that EXP use was a risk factor for intraoperative subsidence (2.729[1.185-6.281]; p=.018). CONCLUSIONS Once technique was controlled for, TLIFs utilizing EXP do not have significantly improved neurologic or radiographic outcomes compared with NE. EXP increase risk of intraoperative subsidence. These results question the value of the EXP given the higher cost.
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Affiliation(s)
- Carolyn Stickley
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Travis Philipp
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Erik Wang
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Jack Zhong
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Eaman Balouch
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Nicholas O'Malley
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Carlos Leon
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Constance Maglaras
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Jordan Manning
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | | | - Aaron J Buckland
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA.
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Meyer M, Noudel R, Farah K, Graillon T, Prost S, Blondel B, Fuentes S. Isolated unstable burst fractures of the fifth lumbar vertebra: functional and radiological outcome after posterior stabilization with reconstruction of the anterior column: About 6 cases and literature review. Orthop Traumatol Surg Res 2020; 106:1215-1220. [PMID: 32354682 DOI: 10.1016/j.otsr.2020.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/06/2020] [Accepted: 03/16/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION L5 burst fractures represent a small percentage of all spine fractures. Treatment strategy has not yet been standardized. Anatomical features and their biomechanical characteristics create fracture patterns which differ from those at the thoracolumbar junction. The objective of this study was to evaluate L5 burst fracture surgical treatment outcomes after posterior stabilization and reconstruction of the anterior column. PATIENTS AND METHODS Six patients with fifth lumbar isolated unstable burst fractures were analyzed. Medical records, radiographs, and clinical scores were obtained. The results were evaluated based on restoration of vertebral body height, spinal lordosis/kyphosis, canal compromise and sagittal alignment at several phases of treatment. RESULTS No patient showed neurologic deterioration, regardless of treatment. The median preoperative anterior vertebral height was 41mm and postoperative was 48mm. The median preoperative kyphotic angle as measured by Cobb angle (local and regional) was 21.5 degrees and 33 degrees which improved respectively by 7.5 and 5.5 degrees following instrumentation. The median amount of backward protrusion of bony fragment into the canal was measured at 67% preoperatively and at 35% postoperatively. There were no pseudarthrosis and anterior arthrodesis solid fusion was visible in all cases. There were a sagittal alignment restoration. At one year of follow up, fusion was obtained in all the cases, all patients had minimal to moderate disability using Oswestry Disability Index. The ability to return to work revealed a good-to-excellent long-term result. DISCUSSION The results of treatment of 5th lumbar unstable burst fractures with posterior stabilization and reconstruction of the anterior column show benefit on durable functional outcome, spine stabilization and radiologic parameters. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Mikael Meyer
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Rémy Noudel
- Service de Neurochirurgie, Hôpital privé Clairval-Ramsay santé, 317, boulevard du Redon, 13009 Marseille, France
| | - Kaissar Farah
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Thomas Graillon
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Solène Prost
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Benjamin Blondel
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Stéphane Fuentes
- Aix-Marseille Université, APHM, CNRS, ISM, CHU Timone, Unité de chirurgie rachidienne, 264, rue Saint-Pierre, 13005 Marseille, France.
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Han MS, Lee SS, Lee SK, Jang JW, Moon BJ, Lee JK. Single-Stage Posterior Circumferential Stabilization Using Double Small Cages for the Treatment of Thoracic and Lumbar Spine Fractures. World Neurosurg 2020; 144:e701-e709. [PMID: 32949794 DOI: 10.1016/j.wneu.2020.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/24/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Controversy remains regarding the optimal methods for resection of the vertebral body, reconstruction of the anterior column, and decompression of the spinal cord in patients who have severe vertebral body destruction of the thoracic or lumbar spine with associated neurologic impairment. We report an alternative technique for primary treatment and salvage involving single-stage corpectomy followed by reconstruction of the anterior column using double small mesh cages via the posterior-only approach. METHODS Plain radiographs and computed tomography scans, taken at different intervals, were used to measure local kyphosis, segmental height, and fusion grade. Pain was evaluated using the visual analog scale (VAS), and neurologic symptoms were classified according to Frankel grade. RESULTS The mean kyphotic deformity improved by 14.47 ± 9.06 degrees (P < 0.001), and the mean segmental height improved by 7.17 mm ± 6.11 mm (P < 0.001) after surgery. Fusion was achieved at 84% of patients, within a median interval of 12 months. Kyphotic recurrence was observed in 2 patients (11%), segmental height loss occurred in 1 patient (5%), and both kyphotic recurrence and segmental height loss occurred in 1 patient (5%). None of the patients reported worsening pain or neurologic symptoms after surgery, and there were no surgery-related complications such as neural injury, cerebrospinal fluid leakage, cage dislocation, surgical site infection, or cardiopulmonary complications. CONCLUSIONS Single-stage corpectomy followed by reconstruction of the anterior column using double small mesh cages via the posterior-only approach is a reliable and less invasive single-stage treatment and salvage option in selected cases.
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Affiliation(s)
- Moon-Soo Han
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Shin-Seok Lee
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Seul-Kee Lee
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Jae-Won Jang
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Bong Ju Moon
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Jung-Kil Lee
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea.
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15
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Chang HK, Huang M, Wu JC, Huang WC, Wang MY. Less Opioid Consumption With Enhanced Recovery After Surgery Transforaminal Lumbar Interbody Fusion (TLIF): A Comparison to Standard Minimally-Invasive TLIF. Neurospine 2020; 17:228-236. [PMID: 32252173 PMCID: PMC7136122 DOI: 10.14245/ns.1938422.211] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 03/01/2020] [Indexed: 02/04/2023] Open
Abstract
Objective The concept of enhanced recovery after surgery (ERAS) is relatively new to the neurosurgical field. The introduction of an ERAS protocol in lumbar fusion surgery has aimed to accelerate patient recovery from surgery by reducing in-hospital opioid consumption.
Methods Patients with 1- or 2-level degenerative lumbar spine disease and who underwent ERAS transforaminal lumbar interbody fusion (TLIF) were retrospectively reviewed. Patients’ general demographic data, in-hospital opioid dosage (converted to morphine equivalents), and hospital stay were compared to those who underwent standard minimally-invasive (MIS)-TLIF.
Results Twenty-four patients who received ERAS TLIF (the ERAS group) were compared to a series of 24 patients who received standard MIS-TLIF (the MIS group). The demographic data were similar. The operation time and blood loss significantly favored ERAS TLIF. The average daily opioid consumption was remarkably lower in the ERAS group than the MIS group. Average opioid dosage throughout the entire in-hospital period was also significantly reduced in the ERAS group compared to the MIS group. The average length of hospital stay was substantially shorter in the ERAS group (1.4 ± 1.13 days vs. 4.0±1.98 days, p <0.001).
Conclusion The present study demonstrated a significant decline in the consumption of opioids and in the hospital length of stay for patients undergoing ERAS TLIF for 1- or 2-level degenerative lumbar spine disease.
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Affiliation(s)
- Hsuan-Kan Chang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Meng Huang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Alvi MA, Kurian SJ, Wahood W, Goyal A, Elder BD, Bydon M. Assessing the Difference in Clinical and Radiologic Outcomes Between Expandable Cage and Nonexpandable Cage Among Patients Undergoing Minimally Invasive Transforaminal Interbody Fusion: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 127:596-606.e1. [PMID: 30954733 DOI: 10.1016/j.wneu.2019.03.284] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Minimally invasive transforaminal interbody fusion (MIS-TLIF) has been shown to have excellent outcomes for surgical management of degenerative disc disease. However, the challenge is in addressing coronal imbalance and restoring lumbar lordosis and sagittal alignment. Use of expandable cages in MIS-TLIF has been hypothesized to circumvent this disadvantage. An indirect meta-analysis of the evidence is presented comparing outcomes from expandable cages with those from nonexpandable cages, in patients undergoing MIS-TLIF. METHODS PRISMA guidelines were used to conduct a systematic review and meta-analysis to compare the clinical and radiologic outcomes of expandable cages and nonexpandable cages in patients undergoing MIS-TLIF. RESULTS Twelve studies (706 patients) were included in the meta-analysis. The mean increase in disc height was found to be significantly greater for the nonexpandable cages group than for the expandable cages group (1.33 mm; 95% confidence interval [CI], 1.28-1.38 vs. 1.14 mm,; 95% CI, 1.06-1.23; P < 0.001). No significant difference was found regarding change in lumbar lordosis at last follow-up between the 2 groups (P = 0.34). The mean change in segmental lordosis was found to be significantly higher for the expandable cage group (5.04°, 95% CI, 3.89-6.20 vs. 2.08°, 95% CI, 1.93-2.22; P < 0.001). We did not detect any significant difference in fusion rate (P = 0.33), subsidence rate (P = 0.41) or in reoperations (P = 0.56) at last follow-up between the 2 groups. CONCLUSIONS Our results indicate that there may not be a significant difference in clinical and radiologic parameters between expandable cages and nonexpandable cages among patients undergoing MIS-TLIF, and it is unclear if the higher cost of the expandable cages is justified.
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17
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Bayram S, Akgül T, Altan M, Pehlivanoğlu T, Kaya Ö, Özdemir MA, Şar C. Palliative Posterior Instrumentation versus Corpectomy with Cage Reconstruction Treatment for Thoracolumbar Pathological Fracture. Asian Spine J 2018; 13:318-324. [PMID: 30481977 PMCID: PMC6454292 DOI: 10.31616/asj.2018.0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/12/2018] [Indexed: 12/02/2022] Open
Abstract
Study Design Single-center, retrospective cohort study. Purpose We aimed to evaluate and compare the clinical outcomes in patients who underwent palliative posterior instrumentation (PPI) versus those who underwent corpectomy with cage reconstruction (CCR) for thoracolumbar pathological fracture. Overview of Literature The requirement for anterior support after corpectomy has been emphasized in the treatment of pathological fractures of the vertebrae. However, for patients with a relatively short life expectancy, anterior reconstruction may not be required and posterior instrumentation alone may provide adequate stabilization. Methods A total of 43 patients with metastases of the thoracolumbar spine underwent surgery in the department of orthopaedic and traumatology of Istanbul University Faculty of Medicine from 2003 to 2016. Surgical outcomes were assessed on the basis of survival status, pre- and postoperative pain, complication rate, and operation time. Results PPI was performed for 22 patients and CCR was performed for 21 patients. In the PPI group, the follow-up period of the five surviving patients was 32 months. The remaining 17 patients died with a mean survival duration of 12.3 months postoperatively. In the CCR group, the five surviving patients were followed up for an average of 14.1 months. The remaining 16 patients died with a mean survival duration of 18.7 months postoperatively. No statistically significant difference (p=0.812) was noted in the survival duration. The Visual Analog Scale scores of the patients were significantly reduced after both procedures, with no significant difference noted on the basis of the type of surgical intervention (p>0.05). The complication rate in the CCR group (33.3%) was higher compared with that in the PPI group (22.7%); however, this difference was not noted to be statistically significant (p=0.379). The average operation time in the PPI group (149 minutes) was significantly shorter (p=0.04) than that in the CCR group (192 minutes). Conclusions The PPI technique can decompress the tumor for functional improvement and can stabilize the spinal structure to provide pain relief.
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Affiliation(s)
- Serkan Bayram
- Department of Orthopaedic and Traumatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Turgut Akgül
- Department of Orthopaedic and Traumatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Murat Altan
- Department of Orthopaedic and Traumatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Tuna Pehlivanoğlu
- Department of Orthopaedic and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Özcan Kaya
- Department of Orthopaedic and Traumatology, Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Mustafa Abdullah Özdemir
- Department of Orthopaedic and Traumatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Cüneyt Şar
- Department of Orthopaedic and Traumatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
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Jacobs C, Plöger MM, Scheidt S, Roessler PP, Koob S, Kabir K, Jacobs C, Wirtz DC, Burger C, Pflugmacher R, Trommer F. Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction. Oper Orthop Traumatol 2018; 30:369-378. [PMID: 30076428 DOI: 10.1007/s00064-018-0559-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/17/2017] [Accepted: 02/01/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim is to stabilize the thoracolumbar spine with a thoracoscopically implanted vertebral body replacement (VBR). To improve intraoperative depth perception and orientation, implantation is performed under three-dimensional (3D) thoracoscopic vision. INDICATIONS Vertebral burst fractures at the thoracolumbar junction (A4 AOSpine classification), pseudarthrosis, and posttraumatic instability with increasing kyphosis. CONTRAINDICATIONS Severe pulmonary dysfunctions, pulmonary or thoracic infections, previous thoracic surgery, and pulmonary adhesions. SURGICAL TECHNIQUE The patient is lying in a right lateral decubitus position. Localization of the fractured vertebra. Minimally invasive transthoracic approach. Perform single lung ventilation and insert the 3D thoracoscope two intercostal spaces above the working portal. Utilization of special binocular glasses for 3D vision of the operation field and secure resection of the fractured vertebra. Measurement of the bony defect and insertion of the expandable cage. Control of correct cage position under fluoroscopy. Insertion of a chest tube and inflate the left lung. POSTOPERATIVE MANAGEMENT Chest × ray Remove chest tube when output is <500 ml/24 h Early mobilization on the ward 6 weeks no weight-bearing >5 kg RESULTS: Between 2012 and 2017, 12 patients received a VBR under 3D thoracoscopic vision. After a mean follow up of 26 months, no cage dislocation was noticed and all patients recovered from the initial back pain. Complications were notable in two cases (17%) with a small pneumothorax after removal of the chest tube and postoperative pneumonia in one patient (8%). All responded to conservative treatment. Revision surgery was not necessary.
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Affiliation(s)
- C Jacobs
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany.
| | - M M Plöger
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - S Scheidt
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - P P Roessler
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - S Koob
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - K Kabir
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - C Jacobs
- Poliklinik für Kieferorthopädie, Universitätsklinikum Jena, Jena, Germany
| | - D C Wirtz
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - C Burger
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - R Pflugmacher
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - F Trommer
- Klinik für Unfallchirurgie und Orthopädie, Luisenhospital Aachen, Aachen, Germany
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Ould-Slimane M, Damade C, Lonjon G, Gilibert A, Cochereau J, Gauthé R, Lonjon N. Instrumented Circumferential Fusion in Two Stages for Instable Lumbar Fracture: Long-Term Results of a Series of 74 Patients on Sagittal Balance and Functional Outcomes. World Neurosurg 2017; 103:303-309. [PMID: 28433848 DOI: 10.1016/j.wneu.2017.04.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 01/11/2017] [Revised: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To report the radiologic and functional results of a multicenter, prospective case series of patients with comminuted lumbar fractures treated with 2-stage circumferential arthrodesis. METHODS A multicenter prospective case series of 74 patients with comminuted lumbar fractures was analyzed. The strategy entailed initial posterior osteosynthesis, followed by physical replacement with an expandable titanium cage filled with autologous bone via retroperitoneal lumbotomy. The mechanism of lesion formation and epidemiologic characteristics were recorded. Clinical and quality-of-life analyses (visual analog scale [VAS], Oswesty Disability Index [ODI], Short Form 12 [SF-12]) were performed over a minimum observation period of 1 year. Radiologic parameters, including deformity measurements, were recorded at each evaluation. Fusion was analyzed by means of a 1-year monitoring scan. RESULTS The mean patient age was 38.1 years, and median duration of follow-up was 2.1 years (interquartile range, 1.3-2.9). The distribution of fractures according to the Magerl classification scheme was as follows: A, 64.8%; B, 16.7%; C, 18.5%. At the last follow-up, fusion was considered certain in 57 cases (77%). The mean VAS score was 2.1 ± 1.3, mean ODI was 14.7 ± 8.0, mean SF-12 Physical Component Summary score was 43.2 ± 9.3, and mean SF-12 Mental Component Summary score was 50.8 ± 5.9. Correction of the regional sagittal deformity was significant during the postoperative period, with a mean increase in lordosis of 9.0° (P < 0.0001). The loss of mean correction at the last follow-up (-2.9°) was not significant. CONCLUSIONS Circumferential arthrodesis, including posterior osteosynthesis and physical replacement with an expandable cage and autologous graft, is applicable to the treatment of comminuted lumbar fractures. A high rate of fusion was obtained with significant and long-lasting correction of the sagittal deformity. Functional scores measured at 1 year suggest mild disability. The ODI, SF-12, and VAS scores were positively correlated with fusion at the last follow-up.
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Affiliation(s)
- Mourad Ould-Slimane
- Spine Unit, Department of Orthopedic Surgery, Rouen University Hospital, Rouen, France
| | - Camille Damade
- Spine Unit, Department of Orthopedic Surgery, Rouen University Hospital, Rouen, France
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Georges Pompidou European Hospital, Paris, France
| | - André Gilibert
- Health Informatics Department, Rouen University Hospital, Rouen, France
| | - Jérôme Cochereau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier, France
| | - Rémi Gauthé
- Spine Unit, Department of Orthopedic Surgery, Rouen University Hospital, Rouen, France
| | - Nicolas Lonjon
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier, France.
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Awwad W, Bourget-Murray J, Zeiadin N, Mejia JP, Steffen T, Algarni AD, Alsaleh K, Ouellet J, Weber M, Jarzem PF. Analysis of the spinal nerve roots in relation to the adjacent vertebral bodies with respect to a posterolateral vertebral body replacement procedure. J Craniovertebr Junction Spine 2017; 8:50-57. [PMID: 28250637 PMCID: PMC5324361 DOI: 10.4103/0974-8237.199869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study aims to improve the understanding of the anatomic variations along the thoracic and lumbar spine encountered during an all-posterior vertebrectomy, and reconstruction procedure. This information will help improve our understanding of human spine anatomy and will allow better planning for a vertebral body replacement (VBR) through either a transpedicular or costotransversectomy approach. SUMMARY OF BACKGROUND DATA The major challenge to a total posterior approach vertebrectomy and VBR in the thoracolumbar spine lies in the preservation of important neural structures. METHODS This was a retrospective analysis. Hundred normal magnetic resonance imaging (MRI) spinal studies (T1-L5) on sagittal T2-weighted MRI images were studied to quantify: (1) mid-sagittal vertebral body (VB) dimensions (anterior, midline, and posterior VB height), (2) midline VB and associated intervertebral discs height, (3) mean distance between adjacent spinal nerve roots (DNN) and mean distance between the inferior endplate of the superior vertebrae to its respective spinal nerve root (DNE), and (4) posterior approach expansion ratio (PAER). RESULTS (1) The mean anterior VB height gradually increased craniocaudally from T1 to L5. The mean midline and posterior VB height showed a similar pattern up to L2. Mean posterior VB height was larger than the mean anterior VB height from T1 to L2, consistent with anterior wedging, and then measured less than the mean anterior VB height, indicating posterior wedging. (2) Midline VB and intervertebral disc height gradually increased from T1 to L4. (3) DNN and DNE were similar, whereby they gradually increased from T1 to L3. (5) Mean PAER varied between 1.69 (T12) and 2.27 (L5) depending on anatomic level. CONCLUSIONS The dimensions of the thoracic and lumbar vertebrae and discs vary greatly. Thus, any attempt at carrying out a VBR from a posterior approach should take into account the specifications at each spinal level.
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Affiliation(s)
- Waleed Awwad
- Department of Orthopedic Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Jonathan Bourget-Murray
- Division of Orthopedic Surgery, Department of Surgery, Orthopedic Research Laboratory, McGill University Health Center, McGill University, Montreal, Canada; Division of Orthopedic Surgery, Department of Surgery, Faculty of Medicine, McGill University, Montreal, Canada
| | - Nadil Zeiadin
- Division of Orthopedic Surgery, Department of Surgery, Orthopedic Research Laboratory, McGill University Health Center, McGill University, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada
| | - Juan P Mejia
- Division of Orthopedic Surgery, Department of Surgery, Orthopedic Research Laboratory, McGill University Health Center, McGill University, Montreal, Canada
| | - Thomas Steffen
- Division of Orthopedic Surgery, Department of Surgery, Orthopedic Research Laboratory, McGill University Health Center, McGill University, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada
| | | | - Khalid Alsaleh
- Department of Orthopedic Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Jean Ouellet
- Division of Orthopedic Surgery, Department of Surgery, Orthopedic Research Laboratory, McGill University Health Center, McGill University, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada
| | - Michael Weber
- Division of Orthopedic Surgery, Department of Surgery, Orthopedic Research Laboratory, McGill University Health Center, McGill University, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada
| | - Peter F Jarzem
- Division of Orthopedic Surgery, Department of Surgery, Orthopedic Research Laboratory, McGill University Health Center, McGill University, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada
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Wewel JT, Nunna RS, Tan LA, Kasliwal MK, O'Toole JE. Novel reconstruction of the anterior craniocervical junction using an expandable cage with integrated fixation after total C2 spondylectomy for chordoma. J Clin Neurosci 2016; 30:157-160. [PMID: 26972706 DOI: 10.1016/j.jocn.2016.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/13/2016] [Indexed: 11/25/2022]
Abstract
Chordoma is a locally aggressive malignant tumor that generally occurs in the clivus, mobile spine and sacrum. While en bloc resection with wide margins has been advocated as the only cure for chordomas, tumor characteristics and violation of critical anatomical boundaries may preclude pursuing this treatment option in the cervical spine. We present a C2 chordoma in a 35-year-old man with epidural and prevertebral extension that was treated with a single stage anterior-posterior total C2 spondylectomy with novel reconstruction using an expandable cage with integrated fixation followed by stereotactic radiosurgery. Single stage intralesional total C2 spondylectomy via anterior transoral and posterior approaches was performed. The anterior column was reconstructed using an expandable cage with integrated fixation from the clivus to C3. The patient maintained his intact neurological status at 6 month follow-up with full resumption of activities of daily living without any significant morbidity.
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Affiliation(s)
- Joshua T Wewel
- Department of Neurosurgery, Rush University Medical Center, Rush Professional Office Building, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA.
| | - Ravi S Nunna
- Department of Neurosurgery, Rush University Medical Center, Rush Professional Office Building, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA
| | - Lee A Tan
- Department of Neurosurgery, Rush University Medical Center, Rush Professional Office Building, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA
| | - Manish K Kasliwal
- Department of Neurosurgery, Rush University Medical Center, Rush Professional Office Building, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA
| | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, Rush Professional Office Building, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA
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Perrini P, Gambacciani C, Martini C, Montemurro N, Lepori P. Anterior cervical corpectomy for cervical spondylotic myelopathy: Reconstruction with expandable cylindrical cage versus iliac crest autograft. A retrospective study. Clin Neurol Neurosurg 2015; 139:258-63. [PMID: 26528885 DOI: 10.1016/j.clineuro.2015.10.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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: 09/04/2015] [Revised: 10/15/2015] [Accepted: 10/17/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To compare retrospectively the clinical and radiographic outcomes between cervical reconstruction with expandable cylindrical cage (ECC) and iliac crest autograft after one- or two-level anterior cervical corpectomy for spondylotic myelopathy. PATIENTS AND METHODS Forty-two patients underwent cervical reconstruction with either iliac crest autograft and plating (20 patients) or ECC and plating (22 patients). The average clinical and radiological follow-up period was 77.54 ± 44.28 months (range 14-155 months). The authors compared clinical parameters (Nurick Myelopathy Grade, modified Japanese Orthopedic Association (mJOA) scores), perioperative parameters (hospital stays, complications) and radiological parameters (Cobb's angles of the fused segments and C2-C7 segments, cervical subsidence, fusion rate). Fusion was assessed on flexion-extension X-ray films. RESULTS No significant differences between the two groups were found in demographics, neurological presentation, preoperative sagittal alignment, clinical improvement and length of hospitalization. Patients of the autograft group experienced more postoperative complications, although the difference between the two treatment groups was not statistically significant (15 versus 4.5%, p=0.232). The fusion rate was 100% in both groups. The average lordotic increase of the segmental angle was significantly greater in the ECC group (p<0.05). Other radiological parameters were not significantly different in the two groups. CONCLUSION Cervical reconstruction either with iliac crest autograft and plating or ECC and plating provides good clinical results and similar fusion rates after one- or two-level corpectomy for spondylotic myelopathy. However, the use of ECC obviates donor site complications and provides a more significant increase of lordosis in segmental angle.
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Affiliation(s)
- Paolo Perrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy.
| | - Carlo Gambacciani
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | - Carlotta Martini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | - Paolo Lepori
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
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Donnelly DJ, Abd-El-Barr MM, Lu Y. Minimally Invasive Muscle Sparing Posterior-Only Approach for Lumbar Circumferential Decompression and Stabilization to Treat Spine Metastasis--Technical Report. World Neurosurg 2015; 84:1484-90. [PMID: 26100166 DOI: 10.1016/j.wneu.2015.06.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [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: 04/21/2015] [Revised: 06/09/2015] [Accepted: 06/11/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Palliative tumor resection and subsequent stabilization are important for maximizing function and quality of life for patients suffering from spinal metastases. However, traditional operative techniques for spinal metastases with vertebral body destruction involve extensive soft tissue dissection. In the lumbar spine, open 2-staged spine procedures are routinely required with an anterior retroperitoneal approach for corpectomy and cage insertion and posterior decompression and stabilization with pedicle screws and rods. Both stages require extensive soft tissue dissection that results in significant surgical morbidity, long recovery time, and subsequent delay in initiating postoperative chemoradiotherapy, as well as initially hampering patients' overall quality of life. A minimally invasive approach is desirable for achieving spinal stability, pain control, functional recovery, rapid initiation of adjuvant therapies, and overall patient satisfaction, especially in patients whose medical and surgical therapies are aimed at palliation rather than cure. PRESENTATION A 59-year-old man with renal cell carcinoma and a known L1 vertebral body metastasis presented with severe progressive low back pain and was found to have a pathologic L1 vertebral body fracture with focal kyphosis. INTERVENTION Here, we describe a minimally invasive muscle-sparing, posterior-only approach for L1 transpedicular hemicorpectomy and expandable cage placement, L1 laminectomy, and T11-L3 posterior instrumented stabilization. The surgical corridor was achieved through the Wiltse muscle plane between the multifidus and longissimus muscles so that minimal muscle detachment was required to achieve transpedicular access to the anterior and middle spinal columns. The L1 nerve root was completely skeletonized to allow adequate lumbar hemicorpectomy, tumor resection, and expandable titanium cage insertion. Lastly, percutaneous pedicle screws and rods were inserted from T11 to L3 for stabilization. RESULT The patient tolerated the procedure well with no complications and less than 200 mL estimated blood loss. Postoperative computed tomography revealed restoration of intervertebral height and adequate tumor resection with excellent placement of the expandable cage and posterior construct. The patient was discharged on postoperative day 4 and had nearly no back pain 3 weeks after surgery. Adjuvant therapies were started soon after. At the 6-month follow-up, the patient required minimal narcotic pain medication. Computed tomography scan demonstrated stable hardware with no evidence of failure. CONCLUSION A minimally invasive muscle-sparing, posterior-only approach is a promising surgical strategy for 360-degree decompression and stabilization for the treatment of lumbar spinal metastases with minimized blood loss, muscle detachment and postoperative pain, and fast postoperative recovery and initiation of adjuvant therapy.
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Affiliation(s)
- Dustin J Donnelly
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muhammad M Abd-El-Barr
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi Lu
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Talia AJ, Wong ML, Lau HC, Kaye AH. Safety of instrumentation and fusion at the time of surgical debridement for spinal infection. J Clin Neurosci 2015; 22:1111-6. [PMID: 25911501 DOI: 10.1016/j.jocn.2014.12.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/22/2014] [Accepted: 12/26/2014] [Indexed: 12/29/2022]
Abstract
The present study aims to assess the results of single-stage instrumentation and fusion at the time of surgical debridement of spinal infections; vertebral osteomyelitis or epidural abscess. Nine patients with spinal infection were treated with instrumentation and fusion after radical debridement in a single-stage operation. Predisposing factors and comorbidities, pain, American Spinal Injury Association motor scores, primary pathologies, microbiology and perioperative markers were recorded. Seven patients with pyogenic and two with tuberculous spinal infection were encountered; the most common pathogen was Staphylococcus aureus. Five patients were predisposed to infection because of diabetes mellitus. Duration of antibiotic therapy lasted up to 12 months. Six patients had thoracic infection, two lumbar and one cervical. No post-operative complications were encountered. There was a significant reduction in pain scores compared to pre-operatively. All patients with neurological deficits improved post-operatively. Despite introduction of hardware, no patients had a recurrence of their infection in the 12 month follow up period. Single-stage debridement and instrumentation appeared to be a safe and effective method of managing spinal infections. The combination of debridement and fusion has the dual benefit of removing a focus of infection and stabilising the spine. The current series confirms that placing titanium cages into an infected space is safe in a majority of patients. Stabilisation and correction of spinal deformity reduces pain, aids neurologic recovery and improves quality of life. The small patient population and retrospective nature limit the present study.
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Affiliation(s)
- Adrian J Talia
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia.
| | - Michael L Wong
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia
| | - Hui C Lau
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia
| | - Andrew H Kaye
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia
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Holland CM, Bass DI, Gary MF, Howard BM, Refai D. Thoracic lateral extracavitary corpectomy for anterior column reconstruction with expandable and static titanium cages: clinical outcomes and surgical considerations in a consecutive case series. Clin Neurol Neurosurg 2014; 129:37-43. [PMID: 25528373 DOI: 10.1016/j.clineuro.2014.11.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [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: 10/07/2014] [Revised: 11/13/2014] [Accepted: 11/29/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Many surgical interventions have emerged as effective means of restoring mechanical stability of the anterior column of the spine. The lateral extracavitary approach (LECA) allows for broad visualization and circumferential reconstruction of the spinal column. However, early reports demonstrated significant complication rates, protracted operative times, and prolonged hospitalizations. More recent reports have highlighted concerns for subsidence, particularly with expandable cages. Our work seeks to describe a single-surgeon consecutive series of patients undergoing LECA for thoracic corpectomy. Specifically, the objective was to explore the surgical considerations, clinical and radiographic outcomes, and complication profile of this approach. METHODS A retrospective study examined data from 17 consecutive patients in whom single or multi-level corpectomy was performed via a LECA by a single surgeon. Vertebral body replacement was achieved with either a static or expandable titanium cage. The Karnofsky Performance Scale (KPS) was utilized to assess patient functional status before and after surgery. Radiographic outcomes, particularly footplate-to-body ratio and subsidence, were assessed on CT imaging at 6 weeks after surgery and at follow-up of at least 6 months. RESULTS The majority of patients had post-operative KPS scores consistent with functional independence (≥70, 12/17 patients, 71%). Fourteen patients had improved or maintained function by last follow-up. In both groups, all patients had a favorable footplate-to-body ratio, and rates of subsidence were similar at both time points. Notably, the overall complication rate (24%) was significantly lower than that published in the literature, and no patient suffered a pneumothorax that required placement of a thoracostomy tube. CONCLUSION The LECA approach for anterior column reconstruction with static or expandable cages is an important surgical consideration with favorable surgical parameters and complication rates. Further, use of expandable cages may allow for reconstruction over a larger segment without increased risk of subsidence.
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Affiliation(s)
- Christopher M Holland
- Department of Neurosurgery, Emory University School of Medicine, 1365B Clifton Road NE, Atlanta 30322, USA; Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta 30322, USA.
| | - David I Bass
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta 30322, USA
| | - Matthew F Gary
- Department of Neurosurgery, Emory University School of Medicine, 1365B Clifton Road NE, Atlanta 30322, USA; Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta 30322, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, 1365B Clifton Road NE, Atlanta 30322, USA; Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta 30322, USA
| | - Daniel Refai
- Department of Neurosurgery, Emory University School of Medicine, 1365B Clifton Road NE, Atlanta 30322, USA; Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta 30322, USA; Emory Orthopaedics and Spine Center, 59 Executive Park South, Suite 3000, Atlanta 30329, USA
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Deukmedjian AR, Manwaring J, Le TV, Turner AWL, Uribe JS. Corpectomy cage subsidence with rectangular versus round endcaps. J Clin Neurosci 2014; 21:1632-6. [PMID: 24831343 DOI: 10.1016/j.jocn.2013.12.028] [Citation(s) in RCA: 14] [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] [Received: 12/05/2013] [Accepted: 12/13/2013] [Indexed: 11/30/2022]
Abstract
Corpectomy cages with rectangular endcaps utilize the stronger peripheral part of the endplate, potentially decreasing subsidence risk. The authors evaluated cage subsidence during cyclic biomechanical testing, comparing rectangular versus round endcaps. Fourteen cadaveric spinal segments (T12-L2) were dissected and potted at T12 and L2, then assigned to a rectangular (n=7) or round (n=7) endcap group. An L1 corpectomy was performed and under uniform conditions a cage/plate construct was cyclically tested in a servo-hydraulic frame with increasing load magnitude. Testing was terminated if the test machine actuator displacement exceeded 6mm, or the specimen completed cyclic loading at 2400 N. Number of cycles, compressive force and force-cycles product at test completion were all greater in the rectangular endcap group compared with the round endcap group (cycles: 3027 versus 2092 cycles; force: 1943 N versus 1533 N; force-cycles product: 6162kN·cycles versus 3973 kN·cycles), however these differences were not statistically significant (p ⩾ 0.076). After normalizing for individual specimen bone mineral density, the same measures increased to a greater extent with the rectangular endcaps (cycles: 3014 versus 1855 cycles; force: 1944 N versus 1444 N; force-cycles product: 6040 kN·cycles versus 2980 kN·cycles), and all differences were significant (p⩽0.030). The rectangular endcap expandable corpectomy cage displayed increased resistance to subsidence over the round endcap cage under cyclic loading as demonstrated by the larger number of cycles, maximum load and force-cycles product at test completion. This suggests rectangular endcaps will be less susceptible to subsidence than the round endcap design.
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Affiliation(s)
- Armen R Deukmedjian
- Department of Neurosurgery and Brain Repair, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606, USA.
| | - Jotham Manwaring
- Department of Neurosurgery and Brain Repair, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606, USA
| | - Tien V Le
- Department of Neurosurgery and Brain Repair, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606, USA
| | | | - Juan S Uribe
- Department of Neurosurgery and Brain Repair, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606, USA
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Jandial R, Chen MY. Mini-open transpedicular lumbar vertebrectomy reconstructed with double cages and short segment fixation. Surg Neurol Int 2012; 3:S362-5. [PMID: 23248755 PMCID: PMC3520075 DOI: 10.4103/2152-7806.103869] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 09/28/2012] [Indexed: 11/24/2022] Open
Abstract
Background: The purpose of this study was to assess the feasibility of using dual expandable cages plus short segment posterior fixation for reconstruction of vertebral bodies following a mini-open transpedicular approach. Methods: A single posterior incision was used to perform a laminectomy of L2, a partial laminectomy of L1 and bilateral transpedicular approaches for a piecemeal vertebrectomy in a patient with spinal compression secondary to metastatic cancer. Subsequently, bilateral cages were placed through the transpedicular corridors and percutaneous pedicle screws were inserted a single level above and below the level of the vertebral column resection. Results: The bilateral transpedicular approach facilitated the use of a mini-open incision (6.0 cm) compared with the extensive dissection normally employed for a lateral extracavitary type approach in the lumbar region. The bilateral transpedicular approach at L2 allowed for a vertebrectomy and complete decompression of neurological elements. The use of expandable cages allowed the nerve roots to be preserved. Placement of the cages in the lateral position was straightforward despite minimal exposure. The reconstruction with double expandable cages appeared robust. Conclusions: In select patients requiring circumferential decompression of the lumbar spine, dual cage reconstruction decreases the technical difficulty of the operation and facilitates a mini-open approach. The durability of this construct will need biomechanical assessment and long-term clinical follow-up.
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Affiliation(s)
- Rahul Jandial
- Division of Neurosurgery City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, USA
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Park JH, Bae CW, Jeon SR, Rhim SC, Kim CJ, Roh SW. Clinical and radiological outcomes of unilateral facetectomy and interbody fusion using expandable cages for lumbosacral foraminal stenosis. J Korean Neurosurg Soc 2010; 48:496-500. [PMID: 21430975 DOI: 10.3340/jkns.2010.48.6.496] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [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: 07/12/2010] [Revised: 09/24/2010] [Accepted: 12/28/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Surgical treatment of lumbosacral foraminal stenosis requires an understanding of the anatomy of the lumbosacral area in individual patients. Unilateral facetectomy has been used to completely decompress entrapment of the L5 nerve root, followed in some patients by posterior lumbar interbody fusion (PLIF) with stand-alone cages. METHODS We assessed 34 patients with lumbosacral foraminal stenosis who were treated with unilateral facetectomy and PLIF using stand-alone cages in our center from January 2004 to September 2007. All the patients underwent follow-up X-rays, including a dynamic view, at 3, 6, 12, 24 months, and computed tomography (CT) at 24 months postoperatively. Clinical outcomes were analyzed with the mean numeric rating scale (NRS), Oswestry Disability Index (ODI) and Odom's criteria. Radiological outcomes were assessed with change of disc height, defined as the average of anterior, middle, and posterior height in plain X-rays. In addition, lumbosacral fusion was also assessed with dynamic X-ray and CT. RESULTS Mean NRS score, which was 9.29 prior to surgery, was 1.5 at 18 months after surgery. The decrease in NRS was statistically significant. Excellent and good groups with regard to Odom's criteria were 31 cases (91%) and three cases (9%) were fair. Pre-operative mean ODI of 28.4 decreased to 14.2 at post-operative 24 months. In 30 patients, a bone bridge on CT scan was identified. The change in disc height was 8.11 mm, 10.02 mm and 9.63 mm preoperatively, immediate postoperatively and at 24 months after surgery, respectively. CONCLUSION In the treatment of lumbosacral foraminal stenosis, unilateral facetectomy and interbody fusion using expandable stand-alone cages may be considered as one treatment option to maintain post-operative alignment and to obtain satisfactory clinical outcomes.
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Affiliation(s)
- Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Sattler M, Goesling T, Busche M, Krettek C, Bastian L. Secondary Collapse of an Expandable Cage After Vertebral Corpectomy. Eur J Trauma Emerg Surg 2007; 33:659-61. [PMID: 26815096 DOI: 10.1007/s00068-007-6021-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Accepted: 07/20/2006] [Indexed: 10/23/2022]
Abstract
Expandable vertebral body replacement systems have been increasingly used for anterior stabilization of spine. We report a secondary collapse of an expandable vertebral body replacement system. This specific complication has not been reported in the literature so far. The most obvious reason for failure was insufficient tightening of a locking screw. This paper emphasizes the importance of correct technical application.
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Kim JW, Park HC, Yoon SH, Oh SH, Roh SW, Rim DC, Kim TS. A Multi-center Clinical Study of Posterior Lumbar Interbody Fusion with the Expandable Stand-alone Cage (Tyche(R) Cage) for Degenerative Lumbar Spinal Disorders. J Korean Neurosurg Soc 2007; 42:251-7. [PMID: 19096552 DOI: 10.3340/jkns.2007.42.4.251] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [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: 03/16/2007] [Accepted: 08/29/2007] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This multi-center clinical study was designed to determine the long-term results of patients who received a one-level posterior lumbar interbody fusion with expandable cage (Tyche(R) cage) for degenerative spinal diseases during the same period in each hospital. METHODS Fifty-seven patients with low back pain who had a one-level posterior lumbar interbody fusion using a newly designed expandable cage were enrolled in this study at five centers from June 2003 to December 2004 and followed up for 24 months. Pain improvement was checked with a Visual Analogue Scale (VAS) and their disability was evaluated with the Oswestry Disability Index. Radiographs were obtained before and after surgery. At the final follow-up, dynamic stability, quality of bone fusion, interveretebral disc height, and lumbar lordosis were assessed. In some cases, a lumbar computed tomography scan was also obtained. RESULTS The mean VAS score of back pain was improved from 6.44 points preoperatively to 0.44 at the final visit and the score of sciatica was reduced from 4.84 to 0.26. Also, the Oswestry Disability Index was improved from 32.62 points preoperatively to 18.25 at the final visit. The fusion rate was 92.5%. Intervertebral disc height, recorded as 9.94+/-2.69 mm before surgery was increased to 12.23+/-3.31 mm at postoperative 1 month and was stabilized at 11.43+/-2.23 mm on final visit. The segmental angle of lordosis was changed significantly from 3.54+/-3.70 degrees before surgery to 6.37+/-3.97 degrees by 24 months postoperative, and total lumbar lordosis was 20.37+/-11.30 degrees preoperatively and 24.71+/-11.70 degrees at 24 months postoperative. CONCLUSION There have been no special complications regarding the expandable cage during the follow-up period and the results of this study demonstrates a high fusion rate and clinical success.
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Affiliation(s)
- Jin Wook Kim
- Department of Neurosurgery , Inha University, College of Medicine, Incheon, Korea
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