bluuebunny/crossref_metadata_2025 huggingface dataset:
The Ideal Cage Position for Achieving Both Indirect Neural Decompression and Segmental Angle Restoration in Lateral Lumbar Interbody Fusion (LLIF)
Authors: Park Se-Jun , Lee Chong-Suh , Chung Sung-Soo , Kang Sang-Soo , Park Hyun-Jin , Kim Se-Hun
Published: March 2018

Study Design:

A prospective radiographic analysis.

Objective:

To assess the ideal cage position for lateral lumbar interbody fusion (LLIF) together.

Summary of Background Data:

Achieving both indirect decompression and restoration of the segmental angle (SA) appear to be contrary to one another because the anteriorly located cage might be advantageous for restoring the SA, and posteriorly located cage might be favorable for achieving the indirect decompression effect. Little has been known about the significance of cage position in LLIF.

Methods:

Forty-one patients who underwent LLIF followed by percutaneous pedicle screw fixation for 94 levels were evaluated. Postoperative plain radiographs and magnetic resonance images were obtained 3 days after surgery. The cage position was determined by the anterior, middle, and posterior portions. The anterior and posterior disk heights, SA, cross-sectional area of the thecal sac (CSA), and the foraminal area (FA) were compared according to the cage position.

Results:

The cage was placed in the anterior area for 31 levels and middle for 63 levels. The cage height was 13.0±1.3 degrees. The increases in anterior disk height and SA were significantly greater in the anterior group (9.1 mm, 6.1 degrees) than those of the middle group (6.7 mm, 2.4 degrees). Posterior disk height increased by a mean of 4.5 mm, but its change did not differ according to the cage position. CSA and FA increased by 36.5% and 69.6%, respectively. There were no significant differences in the CSA and FA increases with respect to the cage position. Regression analysis showed that the increase of SA was affected by cage position, but the increase ratios of CSA and FA were not affected.

Conclusions:

The cage position within the anterior 1/3 of disk space is better for achieving the restoration of the SA without compromising the indirect neural decompression, if the height of cage is large enough.
Clinical and Radiographic Outcomes in Patients Undergoing Single-level Anterior Cervical Arthrodesis
Authors: Burkus John K. , Dryer Randall F. , Arnold Paul M. , Foley Kevin T.
Published: March 2018

Study Design:

A prospective study with historical controls.

Objectives:

To evaluate and compare the safety and effectiveness of recombinant human bone morphogenetic protein-2 (rhBMP-2) with allograft for anterior cervical discectomy and fusion (ACDF) in patients with symptomatic single-level cervical degenerative disk disease.

Summary of Background Data:

rhBMP-2 is an osteoinductive protein that has been shown to induce fusion when used as an implant with a suitable carrier in spine surgery. However, some previous studies have shown rhBMP-2 use to be associated with a higher complication rate.

Methods:

Investigational patients (224) with single-level cervical degenerative disk disease underwent ACDF with rhBMP-2 at a dose of 0.6 or 1.05 mg and were compared with historical control patients (486) treated with allograft spacer and cervical plate.

Results:

At 24 months, improvement was significantly greater in the investigational group (37.1 points) than in the control group for Neck Disability Index (P=0.002) and arm pain (P=0.031). The overall neurological success rate was higher in the investigational group (P<0.001). Neck pain and general health status (SF-36 PCS and MCS) were similar. Fusion rate in the investigational group was higher than in the control group (99.4% vs. 87.2%, P=0.002).

Cumulative adverse event rates at 24 months were similar; however, higher rates of dysphagia (P=0.001), local swelling (P=0.024), oropharyngeal pain (P=0.013), neck pain (P=0.019), and foraminal stenosis (P=0.002) were observed in the investigational group. Heterotopic ossification was also higher in the investigational group.

Conclusions:

At doses of 0.6 or 1.05 mg in a PEEK interbody cage, rhBMP-2 was effective in inducing fusion and improving Neck Disability Index and arm pain in single-level ACDF patients; however, higher rates of certain adverse events were observed in the investigational group.

Level of Evidence:

Level 2.
Lumbar Discectomy
Authors: Koen Errikos A. , Antonarakos Petros D. , Katranitsa Labrini T. , Poulis Kostas E. , Apostolou Thomas M. , Christodoulou Evangelos A. , Christodoulou Anastasios G.
Published: March 2018

Study Design:

We followed a longitudinal observational design with 2 assessment points, presurgery and postsurgery, in 83 consecutive patients undergoing single-level lumbar discectomy.

Objective:

Prognostic data can be gathered from commonly used generic outcome measures to identify patients at risk of persistent leg pain–associated chronicity, following lumbar discectomy

Summary of Background Data:

Suboptimal results observed, following open lumbar discectomy, have been connected to the interplay among presurgery pain characteristics, functional and psychosocial adaptations like persistent pain, disability, and depression. Outcome predictive qualities have been recently attributed to well-known outcome measures. However, most studies on prognostic indicators use multiple tools designs, inhibiting clinical application. Here we elaborate on predictive indications identified in 2 generic patient-rated questionnaires, Short Form-36 (SF-36) and McGill Pain, as many of their domains can evaluate factors related to unfavorable outcomes.

Methods:

For the prognostic value calculations, multivariate logistic [Short-Form McGill Pain Questionnaire (SF-MPQ)] and linear regression models (SF-36) were fitted to investigate the association between presurgery and postsurgery scores. In all models, the presurgical score at question was assigned as the dependent variable while age, sex and presurgery score at question were the independent variables.

Results:

Overall, a statistically significant amelioration in both SF-MPQ and SF-36 scores was observed postsurgically. For the SF-MPQ leg cramping, gnawing, burning, and aching pain symptoms, when present presurgically, were the least responsive to treatment. For the SF-36, mental scores overall were less responsive than physical equivalents postoperatively, while general health perception improved only marginally. Differences in pain level scores did not correlate with an equivalent reduction in postsurgery anxiety and depression indices.

Conclusions:

SF-MPQ and SF-36 can assist in treatment decision, as they can readily identify patients at risk of unfavorable outcomes even in primary/clinical settings. The above findings additionally suggest a wider scope of clinical use for the above questionnaires allowing parallel processing and interpretation of the same patient data.

Levels of Evidence:

Level I.
Current Trends in Outpatient Spine Surgery
Authors: Ahn Junyoung , Bohl Daniel D. , Tabaraee Ehsan , Basques Bryce A. , Singh Kern
Published: March 2018

Because of the increasing pressure to contain health-care–related costs, the number of spinal surgeries performed in the outpatient setting has significantly increased. The higher perioperative efficiency and greater predictability of associated costs offer significant incentives for payers and providers to move surgical procedures into the outpatient setting. Nonetheless, judicious patient selection is advised to optimize outcomes.
Interobserver and Intraobserver Reliability in the Radiologic Assessment of Lumbar Interbody Fusion
Authors: Kroeze Robert J. , Graat Harm C.A. , Pluymakers Winand J. , Marting Louis N. , van Dijk Martijn , van Dijke Cees F. , vd Klis Anton H. , Verberne Steven J. , de Gruyter Albert J. , Temmerman Olivier P.P.
Published: March 2018

Study Design:

Retrospective cohort study comparing intraobserver and interobserver reliability of 3 different radiologic fusion classifications following uninstrumented single-level anterior lumbar interbody fusion.

Objective of the Study:

The objective of the study was to compare the intraobserver and interobserver reliability of 3 different radiologic spinal fusion scoring systems.

Summary of Background Data:

Knowledge regarding radiologic spinal fusion is crucial when studying patients that were treated with lumbar interbody fusion. The scoring system should be reliable and reproducible. Various radiologic classification systems coexist, but the reliability of these systems has thus far not been compared in a single consecutive group of patients. The aim of the present study was the identification of the most valid scoring system in the assessment of interbody fusion.

Methods:

We studied a retrospective consecutive cohort of 50 patients who underwent an anterior lumbar interbody fusion procedure by a single surgeon using a stand-alone cage performed between 1993 and 2002. Plain anterior-posterior, lateral radiographs, and flexion-extension radiographs were made during follow-up visits and were used for analysis. The interbody fusion was scored on these radiographic images using the 3 classification systems (Brantigan, Burkus, and the Radiographic Score) by 2 experienced musculoskeletal radiologists and 2 senior orthopedic spinal surgeons all of whom were blinded to clinical data and outcome.

Results:

Of the 3 classifications included in the current study, the Burkus classification had a moderate interobserver agreement and a substantial to perfect intraobserver agreement. The other classifications (Bratingan and the Radiographic Score) showed only fair interobserver agreement and moderate to substantial agreement among all observers. No significant differences in reliability between orthopedic surgeons and radiologists were found for all 3 classifications.

Conclusions:

The Burkus classification system was classified as most reliable in this, but showed only moderate interobserver agreement. Therefore, the need for a more reliable classification system for the radiographic assessment of lumbar interbody fusion still exists to date.
Cross-Sectional Area of the Lumbar Spine Trunk Muscle and Posterior Lumbar Interbody Fusion Rate
Authors: Choi Man Kyu , Kim Sung Bum , Park Chang Kyu , Malla Hridayesh P. , Kim Sung Min
Published: March 2018

Study Design:

A retrospective study.

Objective:

To investigate the relationship between trunk muscle cross-sectional area (MCSA) and fusion rate after posterior lumbar interbody fusion using pedicle screw fixation (PLIF-PSF).

Summary of Background Data:

Although trunk muscles of the lumbar spine contribute to spinal stability and alignment, effect of trunk muscles on spinal fusion rate and time to fusion is unclear.

Methods:

A total of 192 adult patients with degenerative lumbar disease who underwent PLIF-PSF at L3–L4 or L4–L5 were included. The MCSA of the flexor (psoas major, PS), extensor (erector spinae, ES; multifidus, MF) were measured using preoperative lumbar magnetic resonance imaging at 3 segments. Bone union was evaluated using lumbar dynamic plain radiography. Patients were divided into 2 groups according to the presence of bone fusion.

Results:

Most PS MCSAs in the fusion group were significantly larger than in the nonfusion group, except for MCSA at the L2–L3 segment (all P<0.05). In cases of ES and MF MCSAs, 4 of 6 segments were significantly large. Multivariate analysis revealed that the PS MCSA at L4–L5 was an independent factor for decreased possibility of nonfusion status in both segments (OR=0.812, P=0.028). Pearson analysis demonstrated that the most trunk MCSAs were negatively correlated with time to fusion for both segments and PS MCSAs exhibited a significant correlation with time to fusion except for MCSA at the L2–L3 segment.

Conclusions:

Trunk MCSAs were significantly larger for a fusion group than a nonfusion group. As trunk MCSAs increased, fusion timing decreased.
Complications, Readmissions, and Revisions for Spine Procedures Performed by Orthopedic Surgeons Versus Neurosurgeons
Authors: Mabud Tarub , Norden Justin , Veeravagu Anand , Swinney Christian , Cole Tyler , McCutcheon Brandon A. , Ratliff John
Published: March 2018

Study Design:

Retrospective database analysis.

Objective:

To examine the impact of training pathway, either neurosurgical or orthopedic, on complications, readmissions, and revisions in spine surgery.

Summary of Background Data:

Training pathway has been shown to have an impact on outcomes in various surgical subspecialties. Although training pathway has not been shown to have a significant impact on spine surgery outcomes in the perioperative period, long-term results are unknown.

Materials and Methods:

A retrospective analysis of 197,682 patients receiving 1 of 3 common spine surgeries [lumbar laminectomy, lumbar fusion, and anterior cervical discectomy and fusion (ACDF)] between 2006 and 2010 was conducted. Patient data were obtained from a large claims database. Postoperative adverse effects, all-cause readmission, revision surgery rates, and intermediary payments in these cohorts of patients were compared between spine surgeons with either neurosurgical or orthopedic backgrounds.

Results:

Patient demographics, hospital-stay characteristics, and medical comorbidities were similar between neurosurgeons and orthopedic surgeons. The risks of surgical complications, all-cause readmission, and revision surgery were also similar between neurosurgeons and orthopedic surgeons across all procedure types assessed, with several minor exceptions: neurosurgeons had marginally higher odds of any complication for lumbar fusions [odds ratio (OR) 1.14; 95% confidence interval (CI), 1.09–1.20] and ACDFs (OR, 1.09; 95% CI, 1.04–1.15). Neurosurgeons also had slightly higher rates of revision surgery for concurrent lumbar laminectomy with fusion (OR, 1.14; 95% CI, 1.08–1.22), and ACDFs (OR, 1.20; 95% CI, 1.14–1.28). No associations between surgeon type and any particular complication were consistently observed for all procedure groups. There were also no associations between surgeon type and 30-day all-cause readmission. Median total intermediary payments were somewhat higher for neurosurgery patients for all procedure groups assessed.

Conclusions:

Few significant associations between surgeon type and patient outcomes exist in the context of spine surgery. Those which do are small and unlikely to be clinically meaningful.

Level of Evidence:

Level 3.
Graft Subsidence and Revision Rates Following Anterior Cervical Corpectomy
Authors: Weber Michael H. , Fortin Maryse , Shen Jian , Tay Bobby , Hu Serena S. , Berven Sigurd , Burch Shane , Chou Dean , Ames Christopher , Deviren Vedat
Published: March 2018

Study Design:

Retrospective cohort study.

Objective:

To assess the subsidence and revision rates associated with different interbody cages following anterior cervical corpectomy and reconstruction.

Summary of Background Data:

Different interbody cages are currently used for surgical reconstruction of the anterior and middle columns of the spine following anterior cervical corpectomy. However, subsidence and delayed union/nonunion associated with allograft and cage reconstruction are common complications, which may require revision with instrumentation.

Materials and Methods:

We reviewed the cases of 75 patients who underwent cervical corpectomy and compared the radiographic graft subsidence and revision rates for fibula allograft, titanium mesh cage, titanium expandable cage, and carbon fiber cages. Subsidence was calculated by comparing the immediate postoperative lateral x-ray films to those obtained during follow-up visits.

Results:

The average graft subsidence was 3 mm and revision rate was 25% for fibula allograft versus 2.9 mm and 11.1%, 2.9 mm and 18.8% for titanium mesh cages and titanium expandable cages, respectively. The average graft subsidence for carbon fiber cages was 0.7 mm with no revision surgery in this subset.

Conclusions:

Our findings suggest that subsidence and revision rates following anterior corpectomy and interbody fusion could be minimized with the use of a carbon fiber cage.
Dynamic Evaluation of the Cervical Spine and the Spinal Cord of Symptomatic Patients Using a Kinetic Magnetic Resonance Imaging Technique
Authors: Xiong Chengjie , Daubs Michael D. , Scott Trevor P. , Phan Kevin H. , Suzuki Akinobu , Ruangchainikom Monchai , Roe Allison K. , Aghdasi Bayan , Tan Yanlin , Wang Jeffrey C.
Published: March 2018

Purpose:

The purpose of this study was to examine the movement of the spinal cord and its relationship to the spinal canal in patients with mild spondylosis using kinetic magnetic resonance imaging (kMRI).

Methods:

Weight-bearing, multiposition kMRI was performed on symptomatic patients through a full range of flexion-extension. A total of 52 study patients were selected based on the C2–C7 Cobb angle of sagittal alignment: lordotic (from 30 to 45 degrees). We evaluated dynamic changes in different parameters from flexion-extension: spinal canal diameter (CD), spinal cord diameter (SCD), space available for the cord, anterior space available for the cord (ASAC), posterior space available for the cord (PSAC), average distance between the anterior canal and the cord (d-value), and global angle for the spinal canal and cord.

Results:

The CD tended to decrease from flexion to extension from C3/C4 to C6/C7, however, there were no significant differences at the proximal and distal levels, C2/C3 and C7/T1. There were no significant differences of SCD between different postures. The SCD tended to decrease from C2/C3 to C7/T1. The ASAC followed the same pattern as CD-values. The ASAC was narrowest at C4/C5 and C5/C6. The PSAC tended to increase from C2/C3 to C7/T1. The spinal cord shifted anteriorly with extension and posteriorly with flexion. In addition, the spinal cord maintained its curve with the movement.

Conclusions:

The kinematics of spinal cord motion may be associated with the pathogenesis of cervical spondylotic myelopathy. However, the spinal cord maintains its curve with position changes. Consequently, different motions of the cervical spine may affect spinal cord migration and cause changes in ASAC and PSAC.
Insertional Torque in Cervical Vertebrae Lateral Mass Screw Fixation
Authors: Shinohara Akira , Sairyo Koichi , Mishiro Takuya , Chikawa Takashi , Soshi Shigeru
Published: March 2018

Study Design:

This is a prospective multicenter comparison study.

Objective:

To measure the insertional torque (IT) for cervical vertebra lateral mass screw (LMS) fixation using the Magerl and Roy-Camille methods, at the discretion of the surgeon.

Summary of Background Data:

Current fixation methods for patients with preoperative cervical spine instability use LMSs; however, few studies have closely examined intraoperative IT. Patients’ bone quality was not measured.

Methods:

A total of 637 posterior cervical multiaxial screws were inserted for LMS (C3–C6) (Magerl technique, 423; Roy-Camille technique, 214) in 107 cases. Patients’ mean age was 66 years. Patients treated with the Magerl method were divided into 2 groups, with the men in the MM group and the women in the MF group. Similarly, patients treated with the Roy-Camille method were divided into 2 groups, with the men in the RM group and the women in the RF group. The contralateral cortex was penetrated, and the IT at cerclage was measured at the last time.

Results:

IT of the lateral mass screw was 53.8±22.4, 45.4±21, 45.5±16.9, and 34±16.4 cN.m in the MM group (258), MF group (165), RM group (163), and RF group (51), respectively. The MM group had a significantly higher IT than the other 3 groups, and the RM group had a significantly higher IT than the RF group. When the correlation between screw length and IT was evaluated, IT was significantly (P<0.05) higher with a longer screw by the Magerl method.

Conclusions:

The IT was higher with the Magerl method with a longer screw. Screw length and IT were not correlated with the Roy-Camille method; furthermore, the Roy-Camille method went through bilateral cortical bone perpendicularly, so that IT was determined by the fixation power in the cortical part of the bone, which was not thought to be affected by screw length.

Level of Evidence:

Level III.
Radiographic and Clinical Outcome of Silicate-substituted Calcium Phosphate (Si-CaP) Ceramic Bone Graft in Spinal Fusion Procedures
Authors: Alimi Marjan , Navarro-Ramirez Rodrigo , Parikh Karishma , Njoku Innocent , Hofstetter Christoph P. , Tsiouris Apostolos J. , Härtl Roger
Published: March 2018

Study Design:

Retrospective cohort study.

Objective:

To evaluate the radiographic and clinical outcome of silicate-substituted calcium phosphate (Si-CaP), utilized as a graft substance in spinal fusion procedures.

Summary of Background Data:

Specific properties of Si-CaP provide the graft with negative surface charge that can result in a positive effect on the osteoblast activity and neovascularization of the bone.

Methods:

This study included those patients who underwent spinal fusion procedures between 2007 and 2011 in which Si-CaP was used as the only bone graft substance. Fusion was evaluated on follow-up CT scans. Clinical outcome was assessed using Oswestry Disability Index, Neck Disability Index, and the visual analogue scale (VAS) for back, leg, neck, and arm pain.

Results:

A total of 234 patients (516 spinal fusion levels) were studied. Surgical procedures consisted of 57 transforaminal lumbar interbody fusion, 49 anterior cervical discectomy and fusion, 44 extreme lateral interbody fusion, 30 posterior cervical fusions, 19 thoracic fusion surgeries, 17 axial lumbar interbody fusions, 16 combined anterior and posterior cervical fusions, and 2 anterior lumbar interbody fusion. At a mean radiographic follow-up of 14.2±4.3 months, fusion was found to be present in 82.9% of patients and 86.8% of levels. The highest fusion rate was observed in the cervical region. At the latest clinical follow-up of 21.7±14.2 months, all clinical outcome parameters showed significant improvement. The Oswestry Disability Index improved from 45.6 to 13.3 points, Neck Disability Index from 40.6 to 29.3, VAS back from 6.1 to 3.5, VAS leg from 5.6 to 2.4, VAS neck from 4.7 to 2.7, and VAS arm from 4.1 to 1.7. Of 7 cases with secondary surgical procedure at the index level, the indication for surgery was nonunion in 3 patients.

Conclusions:

Si-CaP is an effective bone graft substitute. At the latest follow-up, favorable radiographic and clinical outcome was observed in the majority of patients.

Level of Evidence:

Level—III.
Screw Placement at the Apex Alters Surgical Outcomes of Moderate Lenke 1 Adolescent Idiopathic Scoliosis
Authors: Zheng Xin , Qian Bang-ping , Liu Zhen , Sun Xu , Zhu Ze-zhang , Wang Bin , Yu Yang , Qiu Yong
Published: March 2018

Study Design:

Retrospective study.

Objective of the Study:

The objective was to investigate the effect of apical pedicle screw placement on surgical outcomes of Lenke 1 adolescent idiopathic scoliosis (AIS).

Summary of the Background Data:

Pedicle screw instrumentation achieves satisfactory correction of scoliosis in thoracic AIS patients, but the effect of apical screw placement is unclear.

Materials and Methods:

Lenke 1 AIS patients with all pedicle screw instrumentation between January 2009 and January 2011 were reviewed. According to the presence of apical vertebra instrumentation, 38 patients (group A) were identified without apical screw placement. 25 patients (group B) instrumented with both concave, and convex apical screws and 50 patients (group C) with either concave or convex apical pedicle screw instrumentation were also enrolled according to matched age and Cobb angles. Cobb angle correction, apical vertebral derotation, misplacement of apical screws, functional outcomes, and patient satisfaction were evaluated.

Results:

Demographic parameters and preoperative Cobb angle, curve flexibility, and apex rotation were similar among the 3 groups (P>0.05). Postoperatively, there was no significant difference regarding the number of fused vertebrae, Cobb angle correction rate, or loss of correction. However, the degree of apical vertebral derotation was significantly lower in group A (17.8%) than in groups B (49.1%) and C (34.3%) (P<0.001). In group B, 6 screws inserted on the concavity and 5 on the convexity of the apex were identified as malpositioned; whereas in group C, 3 on the concavity and 2 on the convexity were malpositioned screws. Self-image and satisfaction were highest for patients in group B.

Conclusions:

For patients with moderate Lenke 1 AIS (Cobb angle, 50–70 degrees), the insertion of apical pedicle screws did not significantly improve curve correction, but it had a marked positive effect on the derotation of apical vertebrae, subsidence of the rib hump, and patient satisfaction.
Comparison of Curvature Between the Zero-P Spacer and Traditional Cage and Plate After 3-Level Anterior Cervical Discectomy and Fusion
Authors: Chen Yuanyuan , Liu Yang , Chen Huajiang , Cao Peng , Yuan Wen
Published: March 2018

Study Design:

A retrospective study.

Objective:

To compare clinical and radiologic outcomes of 3-level anterior cervical discectomy and fusion between a zero-profile (Zero-P) spacer and a traditional plate in cases of symptomatic cervical spine spondylosis.

Summary of Background Data:

Anterior cervical decompression and fusion is indicated for patients with anterior compression or stenosis of the spinal cord. The Zero-P spacers have been used for anterior cervical interbody fusion of 1 or 2 segments. However, there is a paucity of published clinical data regarding the exact impact of the device on cervical curvature of 3-level fixation.

Methods:

Clinical and radiologic data of 71 patients undergoing 3-level anterior cervical discectomy and fusion from January 2010 to January 2012 were collected. Zero-P spacer was implanted in 33 patients, and in 38 cases stabilization was accomplished using an anterior cervical plate and intervertebral cage. Patients were followed for a mean of 30.8 months (range, 24–36 mo) after surgery. Fusion rates, changes in cervical lordosis, and degeneration of adjacent segments were analyzed. Dysphagia was assessed using the Bazaz score, and clinical outcomes were analyzed using the Neck Disability Index and Japanese Orthopedic Association scoring system.

Results:

Neurological outcomes did not differ significantly between groups. Significantly less dysphagia was seen at 2- and 6-month follow-up in patients with the Zero-P implant (P<0.05); however, there was significant less cervical lordosis and the lordosis across the fusion in patients with the Zero-P implant (both P<0.05). Degenerative changes in the adjacent segments occurred in 4 patients in the Zero-P group and 6 patients in the standard-plate group (P=0.742); however, no revision surgery was done.

Conclusions:

Clinical results for the Zero-P spacer were satisfactory. The device is superior to the traditional plate in preventing postoperative dysphagia; however, it is inferior at restoring cervical lordosis. It may not provide better sagittal cervical alignment reconstruction in 3-level fixation. Prospective randomized trials with more patients and longer follow-up periods are required to confirm these observations.
Complications Related to the Recombinant Human Bone Morphogenetic Protein 2 Use in Posterior Cervical Fusion
Authors: Takahashi Shinji , Buser Zorica , Cohen Jeremiah R. , Roe Allison , Myhre Sue L. , Meisel Hans-Joerg , Brodke Darrel S. , Yoon S. Tim , Park Jong-Beom , Wang Jeffrey C. , Youssef Jim A.
Published: March 2018

Study Design:

A retrospective cohort study.

Objective:

To compare the complications between posterior cervical fusions with and without recombinant human bone morphogenetic protein 2 (rhBMP2).

Summary of Background Data:

Use of rhBMP2 in anterior cervical spinal fusion procedures can lead to potential complications such as neck edema, resulting in airway complications or neurological compression. However, there are no data on the complications associated with the “off-label” use of rhBMP2 in upper and lower posterior cervical fusion approaches.

Materials and Methods:

Patients from the PearlDiver database who had a posterior cervical fusion between 2005 and 2011 were identified. We evaluated complications within 90 days after fusion and data was divided in 2 groups: (1) posterior cervical fusion including upper cervical spine O-C2 (upper group) and (2) posterior cervical fusion including lower cervical spine C3–C7 (lower group). Complications were divided into: any complication, neck-related complications, wound-related complications, and other complications.

Results:

Of the 352 patients in the upper group, 73 patients (20.7%) received rhBMP2, and 279 patients (79.3%) did not. Likewise, in the lower group of 2372 patients, 378 patients (15.9%) had surgery with rhBMP2 and 1994 patients (84.1%) without. In the upper group, complications were observed in 7 patients (9.6%) with and 34 patients (12%) without rhBMP2. In the lower group, complications were observed in 42 patients (11%) with and 276 patients (14%) without rhBMP2. Furthermore, in the lower group the wound-related complications were significantly higher in the rhBMP2 group (23 patients, 6.1%) compared with the non-rhBMP2 group (75 patients, 3.8%).

Conclusions:

Our data showed that the use of rhBMP2 does not increase the risk of complications in upper cervical spine fusion procedures. However, in the lower cervical spine, rhBMP2 may elevate the risk of wound-related complications. Overall, there were no major complications associated with the use of rhBMP2 for posterior cervical fusion approaches.

Level of Evidence:

Level III.
Changes in Pelvic Incidence, Pelvic Tilt, and Sacral Slope in Situations of Pelvic Rotation
Authors: Jin Hai-Ming , Xu Dao-Liang , Xuan Jun , Chen Jiao-Xiang , Chen Kai , Goswami Amit , Chen Yu , Kong Qiu-Yan , Wang Xiang-Yang
Published: March 2018

Study Design:

Digitally reconstructed radiograph-based study.

Objective:

Using a computer-based method to determine what degree of pelvic rotation is acceptable for measuring the pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). The effectiveness of a geometrical formula used to calculate the angle of pelvic rotation proposed in a previous article was assessed.

Summary of Background Data:

It is unclear whether PI, PT, and SS are valid with pelvic rotation while acquiring a radiograph.

Materials and Methods:

Ten 3-dimensionally reconstructed models were established with software and placed in a neutral orientation to orient all of the bones in a standing position. Next, 140 digitally reconstructed radiographs were obtained by rotating the models around the longitudinal axis of each pelvis in the software from 0 to 30 degrees at 2.5-degree intervals. PI, PT, and SS were measured. The rotation angle was considered to be acceptable when the change in the measured angle (compared with the “correct” position) was <6 degrees. The rotation angle (α) on the images was calculated by a geometrical formula. Consistency between the measured value and the set angle was assessed.

Results:

The acceptable maximum angle of rotation for reliable measurements of PI was 17.5 degrees, and the changes in PT and SS were within an acceptable range (<6 degrees) when the pelvic rotation increased from 0 to 30 degrees. The effectiveness of the geometrical formula was shown by the consistency between the set and the calculated rotation angles of the pelvis (intraclass correlation coefficient=0.99).

Conclusions:

Our study provides insight into the influence of pelvic rotation on the PI, PT, and SS. PI changes with pelvic rotation. The acceptable maximum angle for reliable values of PI, PT, and SS was 17.5 degrees, and the rotation angle of the pelvis on a lateral spinopelvic radiograph can be calculated reliably.
Measurement of Spinopelvic Parameters on Standing Lateral Lumbar Radiographs
Authors: Chung Nam-Su , Jeon Chang-Hoon , Lee Han-Dong , Won Suk-Hyeong
Published: March 2018

Study Design:

This was a radiographic validity and reliability study.

Objective:

We assessed the validity and reliability of measurements made on standing lateral lumbar radiographs, compared with lateral whole-spine radiographs, for evaluating spinopelvic parameters and lumbar lordosis (LL).

Summary of Background Data:

A lateral whole-spine radiograph is the gold standard image for measurement of spinopelvic parameters. However, little evidence is available on the reliability of measurements made on such radiograph. A standing lateral lumbar radiograph is routinely obtained from patients with back pain and/or a disability. This image can include upper end plate of L1 vertebra, sacral dome and both femoral heads. Thus, this radiograph can be used for evaluation of spinopelvic parameters.

Materials and Methods:

We randomly selected 50 sets of digital radiographs (standing lateral lumbar and lateral whole-spine radiographs) from our database. Three experienced spinal surgeons independently measured LL, pelvic incidence, pelvic tilt, and sacral slope on all images. A paired t test and Pearson correlation was used to analyze the validity of the lateral lumbar radiograph. Interobserver and intraobserver reliabilities were assessed by intraclass correlation coefficient.

Results:

Thee spinopelvic parameters and LL measured on lateral lumbar radiographs were similar to those measured on lateral whole-spine radiographs (All P-values >0.05, Pearson correlation coefficients, 0.807–0.969). The intraobserver and interobserver reproducibilities of both measurement types were good-to-excellent.

Conclusions:

Spinopelvic parameters and LL values measured on lateral lumbar radiographs were reproducibly similar to those measured on lateral whole-spine radiographs. Use of a standing lateral lumbar radiograph is reasonable when spinopelvic parameters and LL are to be measured.
Comparison of Decompression With and Without Fusion for Patients With Synovial Facet Cysts
Authors: van Dijke Maarten , Janssen Stein J. , Cha Thomas D. , Wood Kirkham B. , Borges Lawrence F. , Harris Mitchel B. , Bono Christopher M. , Schwab Joseph H.
Published: March 2018

Study Design:

This is a retrospective study.

Objective:

To compare (1) recurrence of radiculopathy and (2) back pain after decompression with and without fusion for patients with a symptomatic synovial cyst.

Background:

Previous work described favorable outcomes following cyst excision with and without fusion. Because of the association of facet cysts with spinal instability it is hypothesized that a decompression with fusion will lead to better outcomes. However, previous studies present contradicting results.

Methods:

We included 314 consecutive patients that underwent operative treatment for a facet cyst between 2003 and 2013 at 2 tertiary spine referral centers: 224 (71%) underwent decompression without fusion (35% spondylolisthesis), 90 (29%) underwent decompression with fusion (63% spondylolisthesis). Baseline data were compared between the groups. Bivariate log-rank analysis was used to compare outcomes between groups, followed by multivariable Cox regression analysis accounting for differences in baseline characteristics.

Results:

Patients undergoing decompression with fusion presented with a higher incidence of back pain (P=0.004) and spondylolisthesis (P<0.001), had more often bilateral decompressions (P<0.001), more facetectomies (P<0.001), and more levels of decompression (P=0.004) than those who underwent decompression alone. We found a difference in recurrence of radiculopathy (no fusion: 25% vs. fusion: 9.4%, P=0.029) in bivariate analysis. However, this difference did not hold when accounting for confounders (hazard ratio, 0.50, 95% confidence interval, 0.19–1.31, P=0.16). There was no difference in recurrence of back pain in bivariate (no fusion: 29% vs. fusion: 22%, P=0.51) and multivariable analysis (hazard ratio 0.51, 95% confidence interval, 0.23–1.14, P=0.10).

Conclusions:

We found, with the numbers evaluated, no difference in recurrence of radiculopathy or back pain between patients undergoing decompression with or without fusion after accounting for confounders. The decision for fusion should be considered in light of the extent of decompression and the existence of other pathology.

Level of Evidence:

Level III—therapeutic study.
Sports-related Concussion in Children and Adolescents
Authors: Refakis Christian A. , Turner Christian D. , Cahill Patrick J.
Published: March 2018

Concussions are becoming increasingly important to manage properly as sports participation continues to rise. Repeated injuries occurring before the brain has had a chance to recover from an initial insult are particularly dangerous and must be prevented. Although much national media attention has been devoted to concussions in professional sports, it is important to appreciate that athletes in any age group, children and adolescents in particular, are at risk of sports-related concussion. It is crucial to remove an athlete from play any time concussion is suspected. Once removed from play, recovery then begins with a period of cognitive and physical rest, followed by a gradual return to cognitive and athletic activities as symptoms resolve. Children and adolescents pose a unique challenge to the clinician managing their recovery, as the physical and cognitive rest periods required often involve time away from school and sports, which can be academically detrimental and socially isolating. Recently developed sideline assessment tools have greatly aided the urgent sideline assessment of an athlete suspected of having a concussion. In this article, a brief review of current guidelines is presented in tandem with the authors’ preferred treatment of concussion.
Sublaminar Decompression
Authors: Kebaish Khaled M. , Elder Benjamin D. , Lo Sheng-fu L. , Witham Timothy F.
Published: March 2018

Study Design:

Technical report and case illustration.

Objective:

To review the rationale and steps for a sublaminar decompression in the setting of adult deformity surgery and in degenerative spondylosis.

Summary of Background Data:

Several variations of lumbar laminotomy and posterior decompressions have been reported, although these are primarily in the setting of isolated lumbar stenosis, and often focus on treatment of central stenosis.

Materials and Methods:

Our operative technique is illustrated and 1 patient with a 1-year follow-up is presented to further describe this surgical approach.

Results and Surgical Techniques:

The patient underwent a lumbar decompression and fusion procedure. A sublaminar decompression with bilateral foraminotomies was performed at L4–L5, combined with instrumented posterior fusion.

Conclusions:

The presented sublaminar decompression technique allows for adequate decompression of the central canal, lateral recess, and neural foramina while providing maximum bone surface area for posterolateral as well as posterior fusion.
The Effect of Dynamic Versus Static Plating Systems on Fusion Rates and Complications in 1-Level and/or 2-Level Anterior Cervical Discectomy and Fusion
Authors: Schroeder Gregory D. , Kepler Christopher K. , Hollern Douglas A. , Rodrigues-Pinto Ricardo , Kurd Mark F. , Wilson Jefferson R. , Maltenfort Mitchell G. , Paul Jonathan T. , Fleischman Andrew N. , Dwight Kathryn , Millhouse Paul W. , Vaccaro Alexander R.
Published: March 2018

Study Design:

A systematic review.

Objective:

To determine the effect of plate design on fusion rates in patients undergoing a 1- and 2-level anterior cervical discectomy and fusion (ACDF).

Methods:

Articles published between January 1, 2002 and January 1, 2015 were systematically reviewed to determine the fusion rate of 1- and 2-level ACDFs using either a fully constrained or semiconstrained locking plate. Additional variables that were collected included the number of levels, the type of graft/cage used, the study design, the method for determining fusion, and complications.

Results:

Fifty-two articles and 3053 patients were included. No significant difference in the fusion rate for 1- and 2-level ACDF using a fully constrained plate (96.1%) and a semiconstrained plate (95.29%) was identified (P=0.84). No difference (P=0.85) in the total complication rate between fully constrained plates (3.20%) and semiconstrained plates (3.66%), or the rate of complications that required a revision (2.17% vs. 2.41%, P=0.82) was identified. However, semiconstrained plates had a nonsignificant increase in total dysphagia rates (odds ratio=1.660, P=0.28) and short-term dysphagia rates (odds ratio=2.349, P=0.10).

Conclusions:

In patients undergoing a 1- or 2-level ACDF, there is no significant difference in the fusion or complication rate between fully constrained plates and semiconstrained plates.

Level of Evidence:

Level II—systematic review.
Comparing the Effectiveness of Sagittal Balance, Foraminal Stenosis, and Preoperative Cord Rotation in Predicting Postoperative C5 Palsy
Authors: Chugh Arunit J.S. , Weinberg Douglas S. , Alonso Fernando , Eubanks Jason D.
Published: March 2018

Study Design:

Retrospective cohort review.

Objective:

To determine whether preoperative cord rotation is independently correlated with C5 palsy when analyzed alongside measures of sagittal balance and foraminal stenosis.

Summary of Background Data:

Postoperative C5 palsy is a well-documented complication of cervical procedures with a prevalence of 4%–8%. Recent studies have shown a correlation with preoperative spinal cord rotation. There have been few studies, however, that have examined the role of sagittal balance and foraminal stenosis in the development of C5 palsy.

Methods:

A total of 77 patients who underwent cervical decompression—10 of whom developed C5 palsy—were reviewed. Sagittal balance was assessed using curvature angle and curvature index on radiographs and magnetic resonance image (MRI). Cord rotation was assessed on axial MRI. C4–C5 foraminal stenosis was assessed on sagittal MRI using area measurements and a grading scale. Demographics and information on surgical approach were gathered from chart review. Correlation with C5 palsy was performed by point-biserial, χ2, and regression analyses.

Results:

Point-biserial analysis indicated that only cord rotation showed significance (P<0.01). There was no statistical significance shown with surgical approach, sex, or age. In addition, changes in sagittal balance did not correlate with presence of C5 palsy. Logistic regression model yielded cord rotation as the only significant independent predictor of C5 palsy. For every degree of axial cord rotation, the likelihood ratio for suffering a C5 palsy was 3.93 (95% confidence interval, 2.01–8.66; P<0.05).

Conclusions:

This supports the independent capability of preoperative cord rotation to predict postoperative C5 palsy. Lack of correlation with measures of neuroforaminal stenosis potentially points to mechanisms other than direct compression as the etiology. In addition, the lack of correlation with postoperative changes in sagittal balance hints that measures of curvature angle and curvature index may not be appropriate to accurately predict this complication.

Level of Evidence:

Level 3.
Predictive Factors for Postoperative Follow-up: Which Patients are Prone to Loss to Follow-up After Spinal Surgery?
Authors: Ha Kee-Yong , Kim Sang-Il , Kim Young-Hoon , Kim Young-Ho , Oh In-Soo
Published: March 2018

Study Design:

Retrospective cohort study.

Objective:

To find out the predictive factors for the failure to follow-up in patients who underwent spinal surgery.

Summary of Background Data:

Causes for loss to follow-up range from geographical accessibility to dissatisfaction with surgeons. There were few reports that investigated loss to follow-up after spinal surgery.

Methods:

A total of 649 patients who underwent laminectomy and 193 patients who underwent L4–L5 fusion from August 2006 to August 2013 were enrolled in this retrospective study. In each surgical group, demographic data and comorbidities as assessed by the Charlson index were investigated and analyzed for correlation with follow-up. The between-group difference of failure to follow-up was also evaluated.

Results:

The fusion group (n=193) was more likely to follow-up and the between-group difference was statistically significant (P=0.047). In the laminectomy group (n=649), 271 patients (41.8%) made regular hospital visits. Those who were male, had a spouse, or had fewer comorbidities were less prone to loss to follow-up (P<0.001). Other parameters including age, number of spinal segments operated on during surgery, distance from home to hospital, income, education level, and whether or not patients exercised were also significantly correlated with follow-up compliance (P>0.05). In contrast, 51.8% (n=100) of patients who underwent fusion had regular follow-ups. The fusion group showed a statistical difference in follow-up rate based only on sex (P=0.002).

Conclusions:

Our study shows that patients who underwent decompression alone were less likely to attend follow-up than were patients who underwent fusion surgery. Whereas the factors correlated with loss to follow-up after laminectomy alone were sex, marital status, and number of comorbidities, the only predictor after fusion was male sex. Sex was the only shared risk factor for loss to follow-up.

Level of Evidence:

Level III.
The Influence of Single-level Versus Multilevel Decompression on the Outcome in Multisegmental Lumbar Spinal Stenosis
Authors: Ulrich Nils H. , Burgstaller Jakob M. , Held Ulrike , Winklhofer Sebastian , Farshad Mazda , Pichierri Giuseppe , Steurer Johann , Porchet François
Published: March 2018

Study Design:

This is prospective multicenter cohort study.

Objective:

To assess whether patients with confirmed multisegmental lumbar spinal stenosis benefit more from a single-level or a multilevel decompression.

Summary of Background Data:

In multisegmental lumbar spinal stenotic cases, the decision as to how many levels of stenosis need to be operated to achieve the best possible clinical outcome is still unknown and remains a controversy between spine surgeons.

Materials and Methods:

Patients of the Swiss Lumbar Stenosis Outcome Study (LSOS) with confirmed multisegmental LSS undergoing first-time decompression without fusion were enrolled in this study. The main outcomes of this study were Spinal Stenosis Measure (SSM) symptoms and function over time, measured at baseline, 6, 12, and 24 months follow-up. Further outcomes of interest were changes in SSM, numeric rating scale, feeling thermometer, the EQ-5D-EL, and the Roland and Morris disability questionnaire from baseline to 6, 12, and 24 months.

Results:

After 12 months, a total of 141 patients met the inclusion criteria; of these, 33 (23%) underwent a single-level and 108 (77%) a multilevel decompression. Multilevel decompression was associated with a significantly less favorable SSM symptoms and function score, respectively, as compared with single-level decompression. In all further outcomes of interest single-level as well as multilevel patients improved over time.

Conclusions:

Our study showed that in multisegmental stenotic cases a single-level decompression was associated with a significantly more favorable SSM symptoms and function score, respectively, as compared with multilevel decompression. This study provides evidence that in multisegmental stenotic cases a single-level decompression might be sufficient to improve patient’s symptoms and function.