bluuebunny/crossref_metadata_2025 huggingface dataset:
Economic Evaluation of Lumbar Disc Herniation Surgery in Brazilian Health
Authors: Falavigna Asdrubal , Teles Alisson Roberto , Righesso Orlando , Gollo Maria Carolina Rosa , Scheverin Nicolas , Cheng Joseph S. , Riew K. Daniel
Published: May 2015

Introduction

Lumbar discectomy is one of the most common surgical procedures, with success rates greater than 80%. To better understand the meaning of a good outcome in lumbar disc herniation treatment, it is important to know how much the health care system or the patient need to pay to achieve a good result. The cost–utility studies are useful to evaluate the value of health care interventions. The objective of this study was to evaluate for the first time the cost-effectiveness of spine surgery in Latin America for lumbar discectomy in terms of cost per quality-adjusted life years (QALY) gained in Brazil.

Patients and Methods

Costs of medical treatment were recorded in 143 consecutive patients who underwent open discectomy for lumbar disc herniation. Direct medical costs comprised medical reimbursement and costs of hospitalization. Indirect costs were considered the disability losses. Utilities were estimated using SF-6D–derived utilities from a 12-month variation in SF-36. A 4-year horizon with 3% discounting was applied to health utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%. The costs were expressed in Reais (R$) and American Dollars ($), at an exchange rate of 2.4:1.

Results

Direct and indirect costs of open discectomy were estimated at an average of R$ 3.426,72 ($ 1,427.80) and R$ 2.027,67 ($ 844.86), respectively. The mean total cost of treatment was estimated at R$ 5.454,40 ($ 2,272.66) (± R$ 2.709,17/$ 1,128.82) The SF-6D utility gain was 0.0456 (95% CI: 0.03197–0.05923, p = 0.017) at 12 months. The 4-year discounted QALY gain was 0.176928. The estimated cost-utility ratio was R$ 30.828,35 ($ 12,845.14) per QALY gained. The sensitivity analysis showed a range of R$ 25.690,29 ($ 10,714.28)–R$ 38.535,44 ($ 16,056.43) per QALY gained.

Conclusion

Open discectomy is associated with a significant improvement in health utilities as measured by SF-6D. Open discectomy performed in the Brazilian Supplementary Health System provides a cost–utility ratio of R$ 30.828,35 ($ 12,845.14) per 1 quality-adjusted life year.
Reliability of Postoperative Multislice Computed Tomography in Assessment of Pedicle Screw Placement in Thoracic and Lumbar Spinal Fixation
Authors: Awadalla Akram , El Fiki Inas , Fatma Zaiton
Published: May 2015

Objective

This study aims to evaluate the reliability of three-dimensional (3D) volume rendering computed tomography (CT) in postoperative assessment of pedicle screw placement.

Methods

A total of 98 patients with previous spinal fixation surgery were included. All inserted screws were evaluated postoperatively within the first week using CT. Degree of misplacement and difference between CT images were recorded.

Results

Overall, 76, 68, and 39 misplaced screws were detected in 3D reformatted image, coronal reconstruction, and axial CT images, respectively. Dorsal spine had higher rate of violation 46 (9.95%) with the highest rate at T4 (12.8%) comparing it with lumber 32 (6.9%). Statistically significant differences were found between lateral and medial violation ( p = 0.03), between findings of CT 3D reformatted and axial image ( p = 0.04), and also in detecting end plate perforation and anterior vertebral encroachment in different CT images ( p = 0.013). Sensitivity for 3D reformatted image and axial image compared with surgical finding in six revised screws was 100 and 95.8% and specificity 100 and 88.7%, respectively. Highly momentous agreement reported with Kappa coefficient = 0.95 Â ± < 0.001.

Conclusion

The vertebral body and the pedicle are 3D structures. Therefore, we have to study them as they are. The postoperative evaluation of pedicle screw using CT 3D reconstruction was a reliable method and unveiled the deficiencies in conventional axial CT.
Outcomes following Complex Combat-Related Lumbosacral Dissociation Injuries
Authors: Wagner Scott , Kang Daniel , Lehman Ronald
Published: May 2015

Introduction

As war injury patterns have changed throughout Operations Iraqi and Enduring Freedom (OIF/OEF), a relative increase in the incidence of complex lumbosacral dissociation (LSD) injuries has been noted. LSD injuries are an anatomic separation of the spinal column from the pelvis, and represent a manifestation of severe, high energy trauma. We assessed the clinical outcomes of combat-related LSD injuries after operative treatment.

Methods

We performed a retrospective review of all patients surgically managed for complex LSD injuries since the beginning of current combat operations in the Middle East.

Results

A total of 20 patients met inclusion criteria and were treated as follows: posterior spinal fusion (12), sacroiliac screw fixation (7), and combined anterior–posterior fusion (1). The mean age was 28.2 years. The most common mechanism of injury was mounted improvised explosive device (IED, 50%). On average, 2.2 spinal regions were injured per patient. Neurologic dysfunction was present in four patients. Three patients underwent operative stabilization of their injuries before evacuation to the United States. Median time to surgery from injury was 12 days (range, 0–111 days). There was a 20% wound infection rate. Median follow-up was 45.5 months (range, 23.2–105.3 months), and one-third of all patients were medically retired because of their injuries. At most recent follow-up, 45% complained of chronic low back pain and 35% had persistent neurologic deficits; however, 30% were actively engaged in strenuous physical activities, including swimming, distance running, and training for special forces.

Conclusion

This is the largest series of operatively managed lumbosacral dissociation patients currently reported. Our series suggests that combat-related lumbosacral dissociation injuries frequently result in persistent, long-term neurologic dysfunction, disability, and chronic pain. Operative management carries a high postoperative risk of infection. However, two-thirds of patients were able to remain on active duty after their injuries, and two patients were able to complete marathon training.
A Retrospective Clinical and Fusion Analysis of the STALIF-C Device with Stem Cell Derivative Bone Graft Material
Authors: Elshihabi Said
Published: May 2015

Introduction

Perform a retrospective review of a single site experience with the STALIF-C (Centinel Spine) integrated cervical fusion device and OsteoCel + stem cell–derived allograft material (NuVasive, Inc.).

Material and Methods

We reviewed all charts of patients undergoing an anterior cervical discectomy and fusion (ACDF one, two, and three levels), utilizing the STALIF-C device and Osteocel + bone graft material. Data comprised patients from January 2012 to April 2014, with an average final imaging follow-up of 5 months. All patients underwent the ACDF by the same surgeon at the same institution. Fusion criteria were assessed primarily by thin cut CT scans with multimodal reconstructions, but also with dynamic X-rays if CT imaging was unavailable. We implemented a standardized CT fusion criteria, for which all images were read by an independent Board Certified Neuroradiologist. Criteria for fusion was based on a grade 1 to 5 scale (CT imaging), and/or no movement on dynamic X-rays of greater than 2 degrees.

Results

A total of 101 patients were included in the study, with imaging and clinical follow-up obtained in 101 patients (100%). There were 39 males and 62 females, with an average age of 54. The break down in the number of levels treated was as follows: One level (49%), two levels (36%), and three levels (15%). Overall, 14% of the patients were active smokers, 11% had a history of former nicotine abuse, and 74% were nonsmokers. All the follow-up fusion assessments were done with thin cut CT scans with sagittal and coronal reconstructions, and dynamic X-rays. The fusion rates for the levels treated were as follows: one level (98%), two levels (94%), and three levels (87%). The integrated fusion rate was 95% without separating the procedures by levels. There were no incidents of hardware failure or break, with only one patient requiring a posterior cervical fusion for symptomatic pseudoarthrosis (multilevel fusion patient).

Conclusion

The STALIF-C integrated cervical fusion device, in conjunction with Osteocel + stem cell–derived bone graft material is a safe, effective, and reproducible fusion construct in the treatment of cervical degenerative disc disease. The rates of fusion, as compared with systematic meta-analyses in the literature, are comparable and in some cases superior to reported rates using standard cervical plating and cage constructs. To the best of our knowledge, this is the largest review analysis of any integrated cervical fusion device.
Surgical Outcome of Z-Plasty for Cervical Myelopathy: A Retrospective Study with Mean Follow-Up of 5 Years
Authors: Vu Truc , Vo Si
Published: May 2015

Introduction

It is generally accepted that laminoplasty is a safe and reliable surgical treatment for cervical spine myelopathy (CSM) because of the spinal canal stenosis. There are multiple techniques of laminoplasty for spinal cord decompression and most of them require expensive instruments or spacers to stabilize the lamina. In the Hospital for Traumatology and Orthopaedics at Ho Chi Minh city, Vietnam, we performed the Z-plasty operation (Sakou technique) since 2004 to present for patients with CSM with an effort to reduce the cost of treatment.

Patients and Methods

It is a retrospective study. Patients suffered from CSM treated by Z-plasty technique are selected. We performed the Sakou technique, which open one lamina to the left, then the next lamina to the right and the next one to the left, consecutively and respectively. To keep the lamina opened, we tight them in pairs with unabsorbable sutures. Patients were instructed to wear hard collar for 1 week, and then started to follow our rehabilitation program. We use JOA score system and recovery ratio of Hirabayashi to evaluate the neurologic outcome. For functional outcome of cervical spine evaluation, we use the Neck Disability Index (NDI).

Results

There were 36 patients with a mean follow-up of 5 years (range, 1–10 years), sex ratio approximately 3:1, and a mean age of 61 years. The mean operating time and blood loss per lamina were 40 minutes and 55 mL, respectively. The final canal expanding ratio was 25%. For surgical complications, there were only three cases of C5 palsy with full recovery after 1 year. There was no case of dura tear or infection. The mean pre- and postoperative JOA score were 11.1 and 14.7, respectively. The recovery ratio was 68%, with 71% of cases considered as good and excellent. For clinical outcome, the mean NDI was 0.18 with 88% of cases considered as good and excellent. The mean preoperative and final lordotic angle of cervical spine were 21.1 and 19.3 degrees, respectively, with no statistical significance.

Conclusion

The Z-plasty is a safe and reliable technique with a good outcome on neurological, anatomical, and clinical aspect which can be compared with other techniques. The absence of foreign bodies such as titanium plates or spacers reduces considerably the risk of infection and the cost of treatment. Considering the risk–benefit and cost–benefit ratio, this operation is particularly suitable for low-income patients in the developing countries.
A New Source of Structural Autograft for ACDF Surgery: Cervical Laminae
Authors: Liu Jiaming , Xiong Xu , Liu Zhili
Published: May 2015

Background

Autograft bone as a fusion substrate is still the gold standard in the procedure. However, few studies have reported that using autologous cervical laminae as the bone graft in ACDF during the combined posteroanterior cervical spine surgery.

Objective

This study aims to evaluate the feasibility of using autologous cervical laminae as the bone graft in ACDF and to describe the clinical and radiographic outcomes in patients undergoing combined posteroanterior cervical surgery using autologous laminae as bone graft in ACDF.

Material and Methods

Computed tomography (CT) scan of the cervical spine were performed in 50 adult cases. The heights of the laminae and the middle intervertebral space from C3 to C7 were measured on the CT planes. Then, 16 patients (nine males and seven females) with cervical spondylotic myelopathy underwent one-level combined posteroanterior procedure with anterior plate fixation from January 2010 to January 2013. Patients underwent combined posteroanterior surgery with laminectomy and ACDF. The structural laminae obtained from laminectomy were used as bone graft in ACDF. The clinical and radiographic outcomes of the patients were analyzed and the effectiveness and safety of the surgery was evaluated.

Results

The average height of the laminae and the middle intervertebral space from C3 to C7 were 11.18 ± 1.05 mm and the 5.75 ± 0.58 mm, respectively. Statistical significant difference was found between the heights of the laminae and the space ( p < 0.001). All the patients were followed up and the average follow-up period was 25.5 ± 3.1 months. All patients had immediate postoperative resolution of symptoms and radiographic evidence of solid fusion 3 months later. Postoperatively, excellent results were reported in 62.5%, good results in 18.8%, and fair results in 18.8% of the patients according to Odom criteria. Visual analog scale score of the neck and extremities pain was significantly decreased after the surgery ( p = 0.014). The average preoperative and postoperative lordosis angles of the cervical spine were 24.42 ± 13.84 degrees and 32.91 ± 7.79 degrees, and the difference was significant ( p < 0.01). Little loss of the angle was noted at final follow-up (32.91 ± 7.79 vs. 29.30 ± 7.88 degrees, p = 0.51). Anterior intervertebral space height was significantly increased ( p < 0.001) after the surgery and a little declined at final follow-up ( p = 0.43). No intraoperative complication was noted in the patients and three patients got self-limiting dysphagia postoperatively, who recovered spontaneously.

Conclusion

The height of the cervical laminae is adequate for bone graft in ACDF. Structural autograft harvested from the laminae provides a viable alternative to AIC grafting.
Ca2+ Regulates the Expression of Type II Collagen and Aggrecan in Intervertebral Disc Cells by Activating the Extracellular Calcium-Sensing Receptor
Authors: Bokhari Rakan , Epure Laura , Antoniou John , Mwale Fackson , Grant Michael
Published: May 2015

Introduction

Intervertebral disc (IVD) calcification frequently occurs with age as demonstrated by radiographic analysis of elderly spines and is enhanced in patients with scoliosis. In one study by Chanchairujira K. et al (Spine 2004;230:499–503), the degree of disc degeneration as measured by disc space height was significantly correlated with IVD calcification. Several systemic disorders such as hyperparathyroidism and chondrocalcinosis, which are related to calcium handling, arthritis, trauma, vertebral fusion, and infection, have been associated with IVD calcification. Our preliminary data suggest that ionic calcium content and expression of the extracellular calcium-sensing receptor (CaSR) are increased in NP and AF cells of human Thompson graded discs, however, a role in disc degeneration remains unknown.

Material and Methods

Cells: Human NP and AF cells were incubated in culture media containing various concentrations of calcium (1.0, 1.5, 2.5, and 5.0 mM) a CaSR agonist (5 µM), or IL-1β (10 ng/mL) for 7 days. Lysates were extracted and the expression of aggrecan and type II collagen (Col II) were measured by Western blotting. IVDs: Caudal IVDs from the tails of 20- to 24-month-old steers were isolated and the vertebral bone was removed. IVDs were cultured for 4 weeks in culture medium containing calcium (1.0, 2.5, or 5.0 mM), or a CaSR agonist (5 µM). NP and AF tissues were subjected to guanidium extraction and Western blotting was performed to determine the expression of aggrecan and Col II. Histological sections were prepared to determine degree of mineralization by von Kossa staining and expression of alkaline phosphatase.

Results

The expression of aggrecan and Col II decreased dose-dependently in both NP and AF cells following incubation with calcium or the CaSR agonist. A similar phenomenon was observed in the expression of aggrecan and Col II in IVDs following calcium incubation. In addition to decreases in Col II and aggrecan, increase in mineralization and expression of alkaline phosphatase was observed in calcium-incubated IVDs.

Conclusion

Our results suggest that changes in the local concentrations of calcium are not benign, and that activation of CaSR may be a contributing factor in IVD degeneration.
Evaluation of Proximal Junctional Kyphosis following Posterior Thoracic Instrumentation: The Effect of Posterior Anatomical Structures and Facet Joints: A Biomechanical Analysis on Fresh Sheep Spine
Authors: Korkmaz Murat , Akgul Turgut , Ozkunt Okan , Sariyilmaz Kerim , Dikici Fatih , Yazicioglu Onder
Published: May 2015

Introduction

Proximal junctional kyphosis (PJK) has traditionally been defined by a 10 degree or greater increase in kyphosis at the proximal junction as measured according to Cobb method. Especially patients who have advanced spine deformity are prone to PJK and it is related with aggressive treatment protocols. In this biomechanical study, we aimed to evaluate interspinous ligament complex disruption and facet joint degeneration on PJK development.

Material and Methods

Randomly selected 21 sheeps were operated via posterior approach and pedicle screws were instrumented from T2 to T7. Three groups with seven samples were established to create junctional disruption. First group selected as control group (CG), of which posterior soft tissue and facet joints were preserved intact. In the second group (spinous group, SG), interspinous ligament complex which one segment cranial to UIV has been transected, and third group (facet group FG) where facet joint excision was performed. 25 N, 50 N, 100 N, 150 N, and 200 N forces applied at frequency of 5 Hz as 100 cycles axial to the samples. To determine strength of proximal junctional area in static loading 250 N, 275 N, and 300 N forces was applied. Changes in the proximal junctional region were defined radiologically. Lateral X-ray views were taken to measure interspinous distances, kyphosis angles, and discus heights. Abnormal PJK was defined by a proximal junctional angle greater than 10 degree and at least 10 degree greater than the corresponding preoperative measurement.

Results

In CG group, average interspinous distance was 6.6 ± 1.54 mm and kyphosis angle was 2.2 ± 0.46 degree before biomechanical testing, and they were measured as 9.4 ± 1.21 mm and 3.3 ± 0.44 degree respectively after forces applied to samples. In SG group, average interspinous distance was 6.2 ± 1.71 mm and kyphosis angle was 2.7 ± 1.09 degree before the experiment, and they were measured as 20.8 ± 5.66 mm and 15.1 ± 2.33 degrees, respectively, after biomechanical testing. In FG group, average interspinous distance was 4.8 ± 1.15 mm and kyphosis angle was −1 ± 4.14 degree before experiment, and they were measured as 11.1 ± 1.96 mm and 11 ± 2.87 degree, respectively, after forces applied to samples. Statistically significantly junctional kyphosis development was detected on both FG and SG group than group control group ( p < 0.05). PJK was seen significantly more frequently on SG group than FG group ( p < 0.05). Disc distances were similar in all groups ( p > 0.05).

Conclusion

Protecting interspinous ligament complex and facet joint on surgical treatment of spine deformity is mandatory to prevent PJK. To our knowledge, this is the first biomechanical study that reveals that the interspinous ligament complex is more effective in preventing PJK development than facet joints.
Comparison of the Clinical Outcome and Biomechanical Segmental Stability of Bilateral Laminotomy versus Bilateral Facet-Sparing Laminectomy in the Treatment of Spinal Stenosis
Authors: DiLorenzo Daniel , Moisi Marc , Page Jeni , Oskouian Rod
Published: May 2015

Introduction

The objective of decompressive surgery for lumbar or cervical stenosis is to treat the compressive pathology while minimizing iatrogenic destabilization of the spine. The surgical technique has consequently evolved from the radical laminectomy to a facet-sparing laminectomy and more recently to midline preserving techniques including bilateral laminotomy. Cadaveric studies have supported and characterized the biomechanical advantages of the bilateral laminotomy over facet-sparing laminectomy. In this study, we characterize and compare outcome and long-term follow-up between patients who have been treated with either of these two techniques at our institution.

Patients and Methods

We reviewed 100 patients comprising 50 who underwent bilateral facet-sparing laminectomy and 50 who underwent bilateral laminotomy. Clinical outcome measures include reduction in pain as assessed using visual analog scale. Biomechanical outcome measures included segmental motion at the operated segment as measured on postoperative flexion–extension X-rays obtained at long-term follow-up.

Results

Analyses of each of the surgical technique cohorts were performed. Clinical outcome as assessed by visual analog scale ratings was comparable between the two groups of patients undergoing either of bilateral laminectomy or bilateral laminotomy. An increase in the segmental angular movement at the operated level as measured from flexion extension studies was less in the patients undergoing bilateral laminotomy as compared with those undergoing bilateral laminectomy.

Conclusion

The bilateral laminotomy achieves successful decompression of spinal stenosis while preserving biomechanical stability of the involved spinal segments. For properly selected patients, this may provide a surgical option with clinical and biomechanical outcomes which are superior to those provided by facet-sparing laminectomy, which has supplanted to original radical laminectomy. Sparing of the midline osteoligamentous structures, as achieved using the bilateral laminotomy, represents a further advancement in surgical technique in the treatment of spinal stenosis, providing satisfactory clinical outcomes while further minimizing disruption of the normal spinal biomechanical stability.
Sacral Screw Strain in a Long Posterior Spinal Fusion Construct with Sacral Alar-Iliac versus Iliac Fixation
Authors: Kang Daniel , Lehman Ronald , Wagner Scott , Lenke Lawrence , Kebaish Khaled
Published: May 2015

Introduction

Long instrumented posterior fusion constructs to the lumbosacral spine have a significant rate of pseudoarthrosis and S1 screw failure. With the increasing popularity of Sacral Alar-Iliac (S2AI) fixation with its purported advantages of (1) decreased implant profile and (2) obviating the need for a lateral offset connector, the biomechanical properties with respect to S1 screw strain remain unknown. We set out to compare the biomechanical effect of S2AI versus traditional iliac screw fixation on S1 screw strain.

Methods

Five fresh-frozen human cadaveric specimens were instrumented from L2–pelvis, maintaining all osteoligamentous structures, with bilateral titanium 6.0 × 40-mm pedicle screws and 5.5-mm cobalt–chromium rods. Bilateral S1 pedicles were instrumented with 8.0 × 50-mm screws that were centrally cored out and two uniaxial strain gauges inserted at 0 and 90 degrees. S2AI fixation and/or iliac fixation with 8.0 × 80-mm titanium pedicle screws was performed to evaluate the following four different constructs: (1) bilateral S1 screws (control); (2) bilateral S2AI; (3) bilateral iliac; (4) hybrid (S2AI with contralateral iliac). Bilateral S1 screw strain was measured (microstrain), and pure moment loads (12.0 Nm) were applied in axial rotation (AR), flexion extension (FE), and lateral bending (LB). One way repeated measure ANOVA was used to analyze the S1 screw strain data.

Results

Compared with S1 screws alone, both S2AI fixation and iliac fixation significantly reduced sacral screw strain in FE by 58 and 67%, respectively ( p < 0.05), in AR by 35 and 41%, respectively ( p < 0.05), while no significant difference in LB for either construct ( p > 0.05). Hybrid constructs demonstrated a significant reduction in only FE, with reduction in screw strain by 56% for S2AI fixation and 59% for iliac fixation, with no difference in AR and LB moments. When S2AI fixation and iliac fixation were compared, there was no significant difference in screw strain for all bending moments ( p > 0.05). Similarly, hybrid constructs demonstrated no side-to-side significant difference between S2AI fixation and iliac fixation for all bending moments ( p > 0.05).

Conclusion

Both S2AI fixation and iliac fixation provide significant reduction in S1 sacral screw strain compared with sacral fixation alone. Bilateral S2AI fixation is a viable and biomechanically comparable to alternative traditional iliac fixation, and presents another option to achieve protection of the S1 sacral screws for long segment constructs to the pelvis.
Establishing the Injury Severity of Thoracolumbar Trauma: Confirmation of the Hierarchical Structure of the AOSpine Thoracolumbar Spine Injury Classification System
Authors: Schroeder Gregory , Vaccaro Alexander , Kepler Christopher , Koerner John , Oner Cumhur , Dvorak Marcel , Vialle Luiz , Aarabi Bizhan , Bellabarba Carlo , Fehlings Michael , Schnake Klaus , Kandziora Frank
Published: May 2015

Introduction

The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System (TLICS); however, the injury severity of each fracture has yet to be established. The objective of this study is to develop a validated regional and global injury severity scoring system for thoracolumbar trauma.

Material and Methods

A survey was sent to 100 AOSpine members from all six AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East). Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System including the morphology, neurologic grade, and patient-specific modifiers. A grade of zero was considered to be not severe at all, and a grade of 100 was the most severe injury possible.

Results

A total of 74 AOSpine surgeons from all six AO regions of the world numerically graded the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System to establish the injury severity score. The reported fracture severity increased significantly ( p < 0.0001) as the subtypes of fracture type A and type B increased, and a significant difference ( p < 0.0001) in severity was established for burst fractures with involvement of two versus one end plates. Finally, no regional or experiential difference in severity or classification was identified.

Conclusion

Development of a globally applicable injury severity scoring system for thoracolumbar trauma is possible. This study demonstrates no regional or experiential difference in perceived severity or thoracolumbar spine trauma. The AOSpine Thoracolumbar Spine Injury Classification System provides a logical approach to assessing these injuries and enables rational strategies for treatment.
Single-Stage Posterior Vertebral Body Resection and Reconstruction Using Expandable Cage for Unstable Mid and Lower Lumbar Burst Fractures
Authors: Kim Se-Hoon , Choi Jong-Il , Kim Bum-Joon , Ha Sung-Kon , Kim Sang-Dae , Lim Dong-Jun
Published: May 2015

Introduction

Patients with unstable mid and lower lumbar burst fractures require surgical treatment to relieve pain, address paralysis, and stabilize the spine to prevent further segmental deformity. However, controversy remains regarding the optimal surgical treatment. The purpose of this study is to examine the efficacy and safety of corpectomy and expandable cage placement via a single-stage posterior approach for unstable mid and lower lumbar burst fractures (below the L3).

Patients and Methods

A total of 11 patients underwent single-stage posterior-only vertebral column resection and vertebral body reconstruction using an expandable cage. Neurologic status was classified using the American Spinal Injury Association (ASIA) Impairment Scale, while functional outcome was analyzed using a visual analog scale (VAS) for back pain. Segmental Cobb angles were measured above and below the fractured vertebral body preoperatively, immediate postoperatively, and at the last follow-up.

Results

The preoperative neurologic status was ASIA grade E in two patients, grade D in five patients, grade C in two patients, and grade B in two patients. Postoperatively, neurologic stability was demonstrated in three patients (27%), and eight patients (73%) showed improvement in the ASIA grade. The mean preoperative VAS score was 8.3, which decreased to 4.5 postoperatively, and to 1.8 at the final follow-up. The mean preoperative segmental lordotic angle was 9.2 degrees, which increased to 16.9 degrees postoperatively, and decreased to 15.1 degrees at the last follow-up. The mean operating time was 208.8 minutes, and the mean blood loss was 588 mL. Regarding surgical complications, one patient experienced a dural tear and one patient demonstrated cage subsidence.

Conclusion

The results of this small series suggest the feasibility, efficacy, and safety of this surgical option for unstable mid and lower lumbar burst fractures. This technique from a single posterior approach offers several advantages over traditional anterior or combined approaches using strut graft or nonexpandable implants.
Microsurgical Unilateral Approach Bilateral Decompression in Symptomatic Lumbar Spinal Canal Stenosis: Midterm Results in 89 Patients
Authors: Cheung Ka-Kin
Published: May 2015

Introduction

Surgical decompression is the gold standard in the treatment of symptomatic lumbar spinal canal stenosis (LSCS) without clinically significant instability. With the advent of microsurgical techniques and better accessories such as the tubular retractor system (TRS), unilateral approach bilateral decompression (UABD) has been advocated as the decompressive technique of choice because of the preservation of anatomically important stabilizing structures. This retrospective study evaluates the midterm results of UABD performed with and without the TRS in a regional hospital.

Patients and Methods

From April 2008 till November 2013, 89 patients with symptomatic LSCS without clinical instability had UABD performed. On the basis of the surgeons' preference, 56 cases were operated with the TRS employed. The mean follow-up was 30.8 months. Clinical outcomes were evaluated by the Visual Analogue Scale (VAS), Japanese Orthopaedic Association lumbar spine score (JOA score), Oswestry Disability Index (ODI), and Roland Morris Disability Quotient (RMDQ). Complications, rate of reoperation, and patient's subjective satisfaction were also evaluated.

Results

A total of 150 levels were decompressed (average, 1.7 levels per patient). The average operation time and blood loss per level was 99.4 minutes and 67.9 mL, respectively. The mean postoperative hospital stay was 4.5 days. The average leg VAS, JOA score, ODI, and RMDQ improved from 7.1, 15.5, 48.3% and 13.1 to 3.3, 22.1, 35.4% and 11.5, respectively, at final follow-up. The subjective satisfaction was 64%. Given the choice, 92% of these patients would choose to have the same procedure again. There were no statistical significant difference between the TRS and no TRS group in age; sex; side of approach; the preoperative, postoperative, and improvement in leg VAS, JOA score, ODI, and RMDQ; follow-up duration; operation time; and subjective satisfaction. Blood loss (67 vs. 178.4 mL, p = 0.09) and postoperation hospital stay (3.9 vs. 5.7 days, p = 0.003) were both in favor of the TRS. Overall, five incidental durotomies in the TRS group (8.9%) and 3 (9%) in non-TRS group were registered, giving rise to a total 9% of the incidental durotomy rate. All of these eight cases were treated conservatively and none of them needed any further procedures as a remedy. Otherwise, no remarkable perioperative morbidities had been recorded. Within the evaluation period, two cases from the TRS group need re-decompression with instrumented fusion because of symptomatic recurrence, equivalent to an overall 2.2% reoperation rate.

Conclusion

Microsurgical UABD generates satisfactory clinical outcomes in selected patients with symptomatic LSCS without clinical instability. No apparent clinical benefit was found in employing the TRS other than an average 1.8 day short postoperative hospital stay.
Prospective Study of Open Lumbar Discectomy in Different Stages of Disc Prolapse
Authors: Kumar Manoj , R. Heggunda Anoop , Shivannna Deepak
Published: May 2015

Introduction

Lumbar disc herniation has been recognized as an important cause of low back pain. Intervertebral disc prolapse occurs predominately in L4–L5 and L5–S1 level. It includes three stages mainly protrusion, extrusion, and sequestration. Results of operative treatment for disc lesion vary depending on the level of lesion and duration of symptoms, this study aims to assess the outcome of discectomy in the different stages of disc lesion.

Patients and Methods

A prospective study was done in 40 patients diagnosed with lumbar intervertebral disc prolapse. Demographic data, history, clinical examination, and details of investigations and intervention in the form of open lumbar discectomy/fenestration were recorded in the study proforma. Clinical follow-up was done at 2 weeks, 3 months, 6 months, and 1 year intervals regarding pain, disability, and the functional outcome were evaluated with VAS, Modified ODI score, and SF-36 questionnaire.

Results

In our series of 40 patients, 8 (20%) were in 21 to 30 years, 18 (45%) in 31 to 40 years, 5 (12.5%) in 41 to 50 years, 8 (20%) in 51 to 60 years, 1 (2.5%) in 61 to 70 years age groups. Overall, 47.5% of patients had disc protrusion, 40% had extrusion, and 12.5% had sequestration. Overall, 60% were males and 40% were females. Overall, 75% of patients had L4–L5 disc lesion, 12.5% had L5–S1 lesion, 10% had both L4–L5, L5–S1 lesion, and 2.5% had L3–L4 lesion. Fenestration was done in 82.5% patients and laminectomy done in 17.5%. Postoperatively, neurological deficits and SLRT improved. There were statistically significant reduction of pain, improvement in disability, and a better functional outcome at the end of 1 year as assessed by VAS, modified ODI score, and SF-36 questionnaire in all the three stages of disc lesion; however, the improvement was better in stage 1 and stage 2 compared with stage 3. Complications included superficial wound infection, neurological deficit, and failed back syndrome.

Conclusion

Open lumbar discectomy by fenestration/laminectomy is a safe, effective and reliable surgical procedure in all stages of intervertebral disc prolapse, the outcome is better in stage 1 and stage 2 lesions than in stage 3 lesions.
A Prospective Study to Assess Efficacy of Directly Observed Treatment Short Course Intermittent Regimen in Different Stages of Spinal Tuberculosis
Authors: Kumar Manoj , Shivraj N.
Published: May 2015

Introduction

Management of tuberculosis spine still possesses many challenges. Availability of antitubercular drugs has changed the outcome. However, present recommendation by the WHO of Directly Observed Treatment Short course (DOTS) has sound scientific basis, but the optimum duration is still controversial. We conducted a prospective study on a consecutive series of patients with spinal tuberculosis treated with Category I Revised National Tuberculosis Control Program (RNTCP) regime based on DOTS strategy from January 2011 to June 2014 to evaluate the efficacy and to come to a conclusion regarding optimum duration of treatment.

Patients and Methods

A prospective study of 60 consecutive patients of spinal tuberculosis treated with Category I RNTCP based on DOTS strategy. All the patients were followed for a minimum of 1 year. Surgical intervention was done in patients presenting with significant neurological deficits. Patients diagnosed clinicoradiologically and histopathologically ( n = 8) were enrolled in the study. The outcome was graded into excellent, good, fair, and poor based on clinical, laboratory including return of ESR to normal and correction of lymphocytosis and radiological like a return to normal bone density and sclerosis, bony ankylosis, and disappearance of marrow edema on MRI.

Results

In 60 cases, 63.4% ( n = 34) males and 36.7% ( n = 26) females. Overall, 10% ( n = 6) were with predestructive lesion, 53.3% ( n = 32) were in the early destructive phase, 30% ( n = 18) with mild angular kyphosis and 6.67% ( n = 4) with moderate angular kyphosis. Outcome of our study were excellent in 46.67% ( n = 28), good in 36.67% ( n = 22), fair in 10% ( n = 6), and poor in 6.67% ( n = 4). Duration to cure spinal tuberculosis 6 months 30% ( n = 18), 9 months 56.67% ( n = 34), and 12 months 13.33% ( n = 8).

Conclusion

The duration of treatment for cure of spinal tuberculosis was 100% ( n = 6) in predestructive and 37.5% ( n = 12) in early destructive phases was 6 months, 62.5% ( n = 20) early destructive, and 77.76% ( n = 14) mild kyphotic phases were 9 months and 22.2% ( n = 4) mild destructive and 100% ( n = 4) moderate kyphotic phases was 12 months. Favorable outcome and short duration of chemotherapy is needed in patients treated early.
Comparison of 9 versus 12 Months' Antitubercular Drug Regimen in Pott Spine: A Prospective Study
Authors: Mohapatra Bibhudendu
Published: May 2015

Objective

This study aims to evaluate and compare the outcomes of two antitubercular chemotherapy regimen prescribed for 9 months (group A) and 12 months (group B) on patients with Potts spine without neurological deficit.

Study Design

A prospective study in which 59 patients were included, who were prescribed either of the regimes. The outcome measures were noted immediately after the completion of the treatment, at 6 and 12 months. The variables were evaluated on the basis of clinical, hematological, and radiological criteria, which included pain, Hb, ESR, CRP, and kyphotic angle. A mixed model ANOVA was used to compare group A and group B across different times of assessment (0, 6, and 12 months posttreatment) for each variable separately. The level of significance was p < 0.05. Also, the differences from baseline at 6 and 12 months were compared across groups. As the data were not normally distributed, Mann Whitney U test was used. The p value was adjusted for multiple comparisons to be less than 0.05/2 or 0.025.

Result

Both the groups were demographically comparable. Pain (ODI) was found to be improved in both the groups, but on comparison 12-month regime was found to have reduced pain scores than 9-month regime during 6-month follow-up (ODI: group A 19.2 and group B 17.3) but in the 12-month follow-up showed no statistical difference in pain score (ODI: group A 13.9 and group B 12.6). There was no neurological deterioration in both groups. CRP improved in both the groups (group A 7.31 and group B 7.03) and no statistical significant difference was found between the two regimes. There was an increment in Hb levels and kyphotic angle in both the groups, but the comparison could not be drawn between the two groups for both the variables as baseline values were not comparable whereas ESR reduced in both the groups but because of the significant difference at baseline, none of the groups could be compared. To make the groups comparable, a nonparametric analysis was used which showed a statistically significant deterioration of kyphotic angle in group A (0.6 degree) than in group B (0.2 degree) at the end of 1-year follow-up, but it was not found to be significant clinically. Also, statistically significant results were obtained for Pain scores with better improvement of pain with –group A than group B (group A 14 and group B 10) but again the improvement was clinically nonsignificant.

Conclusion

After 1-year follow-up of patients who had completed their antitubercular treatment, we can conclude that there was no additional benefit of prescribing antitubercular therapy for 12 months over 9 months in patients of Potts spine (1 or 2 level) without any neurological deficit. Long-term follow-up is needed to further establish the advantage of 9-month regime over 12-month regime.
Evaluation of Anterior Cervical Fusion without Posterior Instrumentation in Quadriplegic Patients with Transected Spinal Cord
Authors: El Fiki Ahmed
Published: May 2015

Introduction

Traumatic quadriplegia is one of most serious conditions of cervical spine trauma, in almost all cases where the spinal cord is transected there is instability in three columns of vertebral column. Thus, 360-degree fusion is needed.

Patients and Methods

A total of 12 patients with traumatic cervical spine fracture with transected spinal cord were operated only by anterior cervical fusion with anterior plating during the period from July 2011 to December 2013. Intraoperative cervical traction was done, 11 patients iliac bone graft was used after anterior decompression.

Results

All cases were reduced adequately and posterior fusion was not done, only Philadelphia neck collar kept for 3 months. Time of surgery was reduced. Three months' follow-up showed that there was no recent obvious radiological instability. Hospital stay was reduced and consequently bed-ridden hospital acquired infections were reduced.

Conclusion

Anterior fusion in traumatic cervical fractures with transected spinal cord is time saving and suitable for patients with complete quadriplegia and if spinal shock is present. Provided that, it was reduced with intraoperative cervical traction. But long-term follow-up is necessary.
Unstable C1 Ring Fractures Managed with Primary Internal Fixation without Fusion: A Retrospective Review
Authors: Bellabarba Carlo , Bransford Richard , Shatsky Joshua
Published: May 2015

Introduction

While the majority of C1 fractures are treated nonoperatively with external immobilization, there is a subset of C1 fractures known to be unstable. In addition, current literature-based outcomes of nonoperatively managed C1 ring fractures have not been completely favorable, and therefore, leave room for treatment alternatives. Our goal was to evaluate a series of unstable C1 fractures treated with primary internal fixation without fusion (ORIF) to assess clinical and radiographical outcomes.

Patients and Methods

A retrospective review of all patients with C1 fractures between September 2002 and November 2012 identified 10 consecutive patients from a level I trauma center (Harborview Medical Center, Seattle, Washington United States) who were treated with primary internal fixation without fusion. EMR charts and radiographs were reviewed. The surgical technique consisted of a posterior cervical approach to C1 arch and open reduction utilizing bilateral C1 lateral mass screws connected transversely with a rod. Primary outcome measures included radiographical reduction, maintenance of reduction, ROM, and complications. Pre- and postoperative CT scans were utilized to assess reduction.

Results

A total of 10 patients with mean age of 53 years were identified to have undergone primary C1 ORIF. The cohort consisted of eight males and two females of which eight unilateral sagittal split–type fractures and two Jefferson burst–type fractures were identified. Mean follow-up was 13 months. Of the 10 patients, there were 2 associated complications, 1 errant screw requiring return to the operating theater for reposition, and 1 osteonecrosis of the lateral mass though the fracture healed. Preoperative lateral mass displacement averaged 7.3 mm and postoperative displacement had a mean of 2.4 mm with a p value after reduction of < 0.002. No patient had serious complication resulting in neurologic deficit or vascular injury associated with the procedure. No patient went on to develop the previously described “cock-robin” deformity from subluxation of the lateral mass with settling of the occiput onto the C2 lateral mass and no patient had subsequent C1–C2 instability as defined by an ADI greater than 3 mm on flexion and extension films.

Conclusion

Patients with unstable C1 ring fractures can be successfully managed with primary open reduction and internal fixation with a transversely oriented construct using C1 lateral mass screws. Open reduction and internal fixation offers a viable treatment alternative to conservative management or fusion by restoring cervical alignment with C1 reduction and anatomical realignment. Internal fixation of the atlas without fusion prevents progressive, painful deformity, and the need for complex occipitocervical reconstruction procedures that have been reported with nonoperative management of these injuries.
The Effect of C1 Bursting Fracture on Comparative Anatomical Relationship between the Internal Carotid Artery and the Atlas
Authors: Kim Il Sup , Hong Jae Taek , Kim Moon Seok , Kim Joon Yeong
Published: May 2015

Purpose

When C1 arch displaced laterally in C1 bursting fracture, anatomical change between displaced bone and surrounding neurovascular structures can make placing C1 screw more challenging. This study was to describe the effect of the C1 bursting fracture on the location of the internal carotid artery (ICA) around the atlas.

Methods

The authors analyzed the morphology of the atlas and the ICA in 15 patients with C1 bursting fracture and compared the anatomical parameters with control group (77 patients) without any bone fractures or pathologies. All patients were evaluated with CT angiography for the assessment of anatomical parameter. The laterality of the ICA was classified into the following four groups: group 1 (lateral to the C1 lateral mass), group 2 (lateral half of the lateral mass), group 3 (medial half of the lateral mass), and group 4 (medial to the lateral mass). The distances of the ICA from the midline, anterior tubercle, and ventral surface of the C1 lateral mass were compared between two groups. The distance between the lateral margin of the longus capitis muscle and the inner edge of the transverse foramen was also measured.

Results

Medially located ICA (laterality groups 2 and 3) was more common in the C1 bursting fracture group than control group (76.7 vs. 42.8%). There were no significant differences between two groups for the distance from the midline, the distance from the anterior tubercle, and the distance from the ventral surface of the C1 lateral mass, respectively. The distance of the longus capitis muscle to transverse foramen was 2.52 ± 2.09 and 4.15 ± 3.09 mm in each group, and there was statistically significant difference ( p < 0.01).

Conclusion

Lateral displacement of the bony structure of C1 bursting fracture changes the relative location of the ICA medially, which increase the injury risk during the bicortical C1 screw insertion. These data suggest that CT angiography or enhanced CT scans may be essential study for C1 bursting fracture. These preoperative imaging studies can give information to choose the ideal fixation technique and the proper trajectory of the screws.