Anterior Posterior Fusion Research Articles

Circumferential fusion with lateral masses screws in cervical post-traumatic instability.

According to the AO cervical classification [1], a B-type fracture involves the posterior ligamentous complex with pure bony (B1), disco-ligamentous (B2) or distraction-extension (B3) fractures. In these cases, a complete reduction of eventual displacements is mandatory, together with a combined anterior-posterior fusion to restore the anterior column and recreate the posterior tension band. If an anterior cervical decompression and fusion (ACDF) with a cage and eventual plating is the choice for a single-level pathology, different techniques can be used for the posterior instrumentation and fusion [2–5]. In this specific case, the author performed a C5–6 ACDF with a tantalum cage without plating, and a posterior instrumentation of the lateral masses of C5 and C6.

The surgical treatment method for an adult posttraumatic thoracolumbar kyphosis patient with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is an inheritable bone disorder characterized by osseous fragility and ligamentous laxity. It is sometimes difficult to obtain bone union in patients with OI. The purpose of this report is to present a rare case of posttraumatic kyphosis due to a L1 burst fracture in a patient with OI, and to discuss how to treat it to achieve an adequate correction and circumferential fusion. The patient was a 29-year-old man with OI (Sillence type-IA) who had sustained an L1 fracture when he dived head first into a river. After 3 months of conservative therapy with a body cast, he showed disability at work because of his persistent low back pain and fatigue in his whole back. He showed no neurological disorder. Diagnostic imaging revealed localized kyphotic deformity at L1. Therefore, lumbar lordosis and thoracic kyphosis worsened. Anterior release and fusion, and posterior fusion were conducted. Three months after surgical treatment, circumferential fusion was obtained. His low back pain and fatigue in the whole back disappeared, and he could resume work without any difficulty. From the bone union standpoint, the surgical strategy for spinal correction in OI patients is still controversial because of the intractableness of bone union and fragility of the bone itself. The authors achieved circumferential union using anterior fusion and posterior fusion, in which wide bone bed is available owing to spared posterior elements of the spinal column.

Appropriate timing of surgical intervention for the proximal type of cervical spondylotic amyotrophy.

The purposes of this study were to evaluate the clinical outcome after surgical treatment of patients with the proximal type of cervical spondylotic amyotrophy (CSA) and to explore the appropriate timing for surgical intervention. A retrospective review was performed on a consecutive cohort of 41 patients who underwent surgical treatment for the proximal type of CSA between 1995 and 2011 at the Nagoya Spine Group Hospitals. We collected information regarding age, type of muscle atrophy, preoperative and final manual muscle test, duration of symptoms, high-intensity areas on T2-weighted MRI images, low-intensity areas on T1-weighted MRI images, levels of spinal canal stenosis, the compression lesion site, cervical kyphosis and surgical procedures (laminoplasty, anterior spinal fusion and posterior spinal fusion). Univariate analyses and multivariate logistic regression analysis were performed to identify correlates of a poor outcome. To explore the appropriate timing for performing surgery, we analyzed the data using receiver operating characteristic (ROC) analysis. The duration of CSA symptoms was 11.6 months on average. The surgical results were excellent for 25 patients, good for six, fair for nine and poor for one. On multivariate logistic regression analysis, the duration of symptoms was statistically associated with a poor surgical outcome (OR 1.393, p = 0.011). ROC analysis demonstrated that 4.3 months from the onset of CSA symptoms was the appropriate time to undergo surgery. Our results indicate that we should recommend surgical intervention to patients with the proximal type of CSA within about 4 months after the onset of symptoms if conservative treatment has not been successful.

Epidemiological Trends in the Utilization of Bone Morphogenetic Protein in Spinal Fusions From 2002 to 2011

Retrospective database analysis. A nationwide population-based database was analyzed to assess the utilization trends of bone morphogenetic protein (BMP) in spine fusion surgery from 2002-2011. The utilization of off-label BMP in spine procedures is not well characterized. The purpose of this study was to analyze a population-based database to characterize the national trends of BMP utilization in terms of incidence, demographics, costs, and mortality. Data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project was queried for each year from 2002-2011. Patients undergoing an anterior cervical fusion or posterior cervical fusion, anterior lumbar fusion or posterior lumbar fusion, or a posterior thoracic fusion were identified and separated into cohorts. The frequency of BMP utilization was assessed in each surgical cohort by year. Patient demographics, hospital parameters, costs, and mortality rates were assessed. The adjusted annual number of procedures with BMP increased from 1116 in 2002 to 79,294 in 2011 (P < 0.001), representing 26.9% of all spinal fusion procedures. The rate of BMP utilization within each surgical cohort also significantly increased during the 10-year period (P < 0.001). The posterior lumbar fusion cohort accounted for the majority of spinal fusions that used BMP, representing 76.8% of all spinal fusions between 2002 and 2011. The anterior lumbar fusion cohort was associated with the highest proportion of BMP utilization, peaking at 56.9% of all anterior lumbar interbody fusions in 2006. The trend of BMP utilization in the anterior cervical fusion cohort peaked in 2007 with 10.6% of cases and then declined to 6.4% in 2011. There was a statistically significant trend of older patients with increasing comorbidities receiving BMP during this period. Hospital costs (adjusted for inflation) significantly increased an average of $9560 from 2002-2010. There were no significant trends with regard to the length of hospitalization stay and mortality rates during this period. This nonconflicted study demonstrates that the utilization of BMP has dramatically increased from 2002-2011. Interestingly, off-label application of BMP accounts for the vast majority of BMP utilization. The increase in the total hospital costs is likely multifactorial; older patients with more comorbidities undergoing surgery as well as the increasing utilization of BMP are all likely contributory factors. The length of hospitalization stay and mortality rates did not increase during the 10-year period.

Current Trends in Demographics, Practice, and In-Hospital Outcomes in Cervical Spine Surgery

Retrospective database analysis. To investigate national trends of cervical spine surgical procedures from 2002 to 2011. There is a paucity of literature assessing the current practice trends and outcomes of cervical spine surgery following the 2008 Food and Drug Administration public health notifications regarding bone morphogenetic protein (BMP) utilization in cervical spine surgical procedures. The National Inpatient Sample database was accessed for each year across 2002 to 2011. Patients undergoing anterior cervical fusion, posterior cervical fusion, and posterior cervical decompression were identified. Patient and hospitalization parameters including demographics, BMP utilization, costs, early postoperative outcomes, and mortality were assessed for each surgical cohort. A Pearson correlation coefficient with a 95% confidence interval (P < 0.05) was used to analyze trends in patient and hospital outcome parameters during this 10-year period. A total of 307,188 cervical spine procedures were performed from 2002 to 2011. Both the anterior cervical fusion and posterior cervical fusion cohort demonstrated a statistically significant increase in the number of procedures performed over time (r = +0.9, P < 0.001). A significant uptrend in patient age (r = +1.0, P < 0.001) and comorbidity burden (r = +0.9, P < 0.001) was demonstrated during the studied decade. Overall, BMP utilization (r = +0.7, P = 0.02) also demonstrated a significant increase during this time period, but demonstrated a decline after peaking in 2007. The posterior cervical fusion cohort demonstrated the greatest comorbidity, length of stay, costs, and mortality. This study demonstrates that the number of cervical spine procedures has increased between 2002 and 2011, irrespective of the change in BMP utilization after the 2008 Food and Drug Administration warning. Despite an older patient population with greater comorbidities undergoing cervical spine surgeries, hospital length of stay and mortality has not significantly changed. However, we did note a significant increase in costs during this time period. These findings may be related to advances in surgical technology and instrumentation that may be associated with rising hospital costs.

One-stage foci debridement for cervical tuberculosis

Objective To evaluate the effectiveness of one-stage debridement for cervical tuberculosis at different segments.Methods Clinical data of 54 patients (male 20,female 34) with cervical tuberculosis treated by one-stage debridement from Jan 1998 to Dec 2011 were reviewed retrospectively.The average age of these patients was 45.4 years (range,26-75 years).Among them,12 cases were involved in single level (C2 1 case,C4 2 cases,C5 3 cases,C6 4 cases,C7 2 cases); 36 cases in the adjacent two levels (C1,2 3 cases,C2,3 2 cases,C3,4 5 cases,C4,5 6 cases,C5,6 14 cases,C6,7 5 cases,C7T1 1 case); 5 cases in three levels(C4 6 2 cases,C5-7 2 cases,C3,5,6 1 case)and 1 case in four levels (C4-7).Five cases were involved in other spinal levels (T6 1 case,T 3 cases,L3,4 1 case).Comorbidity of cervical ossification of the posterior longitudinal ligament was found in 1 case.Before surgery,the mean VAS and JOA scores were 5.9 (range,4-9) and 10.5 (range,7-12) respectively and the mean Cobb angle of lesion segment was 26.7°± 9.1°.All cases underwent regular anti-TB treatment preoperatively,and surgical treatment were performed when blood sedimentation (ESR) was lower than 50 mm/1 h.According to the segmental involvement,different surgical approaches were performed including anterior debridement with anterior or anterior-posterior internal fixation and fusion,submandibular approach debridement with posterior occipital cervical fusion or atlantoaxial fusion.Results Mean follow-up duration was 27.3 months (range,13-52 months).Symptoms were improved significantly in all cases.Mean time of union was 3.2 months (range,2-4 months).At the last follow-up,the mean VAS and JOA scores were 5.9 (range,4-9)and 10.5 (range,7-12) respectively,and the mean Cobb angle of lesion segment was 6.8°.Regular anti-TB treatment was performed postoperatively for 18 to 20 months.Intraoperative esophageal injury was found in one case of upper cervical tuberculosis which was cured uneventfully after gastrointestinal tubation for 1 week.No cervical tuberculosis recurrence,graft loosening or pseudarthrosis was found in follow-up.Conclusion With preoperative anti-TB treatment,cervical tuberculosis can be treated by one-stage foci debridement according to the segmental involvement and deformity.Postoperative regular anti-TB treatment is a crucial factor for the final recovery of cervical tuberculosis. Key words: Cervical vertebrae; Tuberculosis; Surgical procedures, operative

Long-term surgical outcomes of cervical myelopathy with athetoid cerebral palsy

To understand the long-term surgical outcomes and prognostic factors for the operative treatment of cervical myelopathy (CM) in patients with athetoid cerebral palsy (ACP). We retrospectively reviewed 24 patients with ACP who underwent surgery for CM at our hospital between March 2002 and June 2008. All patients had more than 5 years follow-up. Anterior fusion (11 patients), posterior fusion (1 patient), or combined anterior and posterior (AP) fusion (7 patients) and C1-2 fusion (5 patients) surgeries were performed. Surgical outcomes (average follow-up 102 months), as assessed using modified JOA (mJOA) scores, the Neck Disability Index (NDI), and a visual analog scale (VAS) were compared between the preoperative and postoperative states. Preoperatvie cervical kyphosis decreased mJOA scores significantly. Long-term follow-up clinical outcomes demonstrated that 10 patients showed favorable (excellent and good) outcomes and 11 patients had non-favorable (fair and worse) outcomes. According to the mJOA scores, patients showed postoperative improvement (7.10-10.45). NDI decreased from 68.46 to 31.66. A second operation was done in seven cases due to instrument failure, progressive kyphotic deformities and adjacent segment degeneration. A preoperative botulinum toxin injection significantly decreased (p < 0.05) the incidence of a second operation. Patients with ACP have high incidence of instrument failure. Strong surgical fixation, bone fusion and perioperative immobilizations using botulinum toxin injection should be carefully planned preoperatively.

Obese Class III patients at significantly greater risk of multiple complications after lumbar surgery: an analysis of 10,387 patients in the ACS NSQIP database

Background contextPrior studies on the impact of obesity on spine surgery outcomes have focused mostly on lumbar fusions, do not examine lumbar discectomies or decompressions, and have shown mixed results regarding complications. Differences in sample sizes and body mass index (BMI) thresholds for the definition of the obese versus comparison cohorts could account for the inconsistencies in the literature. PurposeThe purpose of the study was to analyze whether different degrees of obesity influence the complication rates in patients undergoing lumbar spine surgery. Study design/settingThis was a retrospective cohort analysis of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2010. Patient samplePatients in the de-identified, risk-adjusted, and multi-institutional ACS NSQIP database undergoing lumbar anterior fusion, posterior fusion, transforaminal lumbar interbody fusion/posterior lumbar interbody fusion (TLIF/PLIF), discectomy, or decompression were included. Outcome measuresPrimary outcome measures were 30-day postsurgical complications, including pulmonary embolism and deep vein thrombosis, death, system-specific complications (wound, pulmonary, urinary, central nervous system, and cardiac), septic complications, and having one or more complications overall. Secondary outcomes were time spent in the operating room, blood transfusions, length of stay, and reoperation within 30 days. MethodsPatients undergoing lumbar anterior fusion, posterior fusion, TLIF/PLIF, discectomy, or decompression in the ACS NSQIP, 2005 to 2010, were categorized into four BMI groups: nonobese (18.5–29.9 kg/m2), Obese I (30–34.9 kg/m2), Obese II (35–39.9 kg/m2), and Obese III (greater than or equal to 40 kg/m2). Obese I to III patients were compared with patients in the nonobese category using chi-square test and analysis of variance. Multivariate linear/logistic regression models were used to adjust for preoperative risk factors. ResultsData were available for 10,387 patients undergoing lumbar surgery. Of these, 4.5% underwent anterior fusion, 17.9% posterior fusion, 6.3% TLIF/PLIF, 40.7% discectomy, and 30.5% decompression. Among all patients, 25.6% were in the Obese I group, 11.5% Obese II, and 6.9% Obese III. On multivariate analysis, Obese I and III had a significantly increased risk of urinary complications, and Obese II and III patients had a significantly increased risk of wound complications. Only Obese III patients, however, had a statistically increased risk of having increased time spent in the operating room, an extended length of stay, pulmonary complications, and having one or more complications (all p<.05). ConclusionsPatients with high BMI appear to have higher complication rates after lumbar surgery than patients who are nonobese. However, the complication rates seem to increase substantially for Obese III patients. These patients have longer times spent in the operating room, extended hospitals stays, and an increased risk for wound, urinary, and pulmonary complications and for having at least one or more complications overall. Surgeons should be aware of the increased risk of multiple complications for patients with BMI greater than or equal to 40 kg/m2.

Comparison of TLIF With rhBMP-2 Versus No TLIF and Higher Posterolateral rhBMP-2 Dose At L5–S1 for Long Fusions to the Sacrum With Sacropelvic Fixation in Patients With Primary Adult Deformity

Comparvative case series. Data was prospectively entered and retrospectively analyzed. To evaluate the need for distal lumbar interbody fusion when sufficient recombinant human bone morphogenetic protein-2 (rhBMP-2) is used posterolaterally at L5-S1 in long spinal constructs for adult deformity via costs and radiographical and patient-reported outcome comparisons. Many authors and investigators have suggested that an interbody fusion is mandatory at L5-S1 with long fusion to the sacrum with sacropelvic fixation. Past studies have shown competitive fusion rates using rhBMP-2 versus iliac crest bone graft for long fusions. There are various advocates for anterior lumbar interbody fusion versus posterior lumbar interbody fusion versus transforaminal lumbar interbody fusion (TLIF). The optimal strategy remains elusive. Fifty-seven patients were studied at one institution. Thirty-one patients had no interbody fusion (NI group) with 20 mg of rhBMP-2 posterolaterally on 10 mL of carrier and 26 patients had TLIF at L5-S1 (TLIF group) with 6 mg of rhBMP-2 in the interbody space along with local bone graft and 6 mg of rhBMP-2 on carrier posterolaterally at L5-S1. Patients were followed for 24 to 87 months (mean follow-up, 3.92 yr). Demographics of the 2 groups were similar. There were no detected nonunions at L5-S1 in either group. By our limited cost analysis, the expense of performing a TLIF at L5-S1 is higher than that of using extra rhBMP-2 posterolaterally at that segment. Improvement in outcomes scores, namely Scoliosis Research Society-22 and Oswestry Disability Index, were the same statistically in both groups. Blood loss was greater in the TLIF group than the NI group. There were no identified rhBMP-2 adverse events in either group. Utilization of 20 mg of rhBMP-2 at L5-S1 has the potential to be less expensive than an interbody fusion in most patients having a primary long fusion for adult spinal deformity. The apparent fusion rates at L5-S1 were identical in both groups. Both strategies were successful in regard to improving patient outcomes and achieving apparent solid arthrodesis at the lumbosacral junction, which was the focus of this study. 2.

Recovery Room Radiographs Not Found to Have Incremental Utility Above Intraoperative Images After Lumbar Fusion Procedures

Retrospective case series. To characterize the clinical utility of imaging in the recovery room after lumbar fusion procedures. Two sets of images are commonly obtained at the end of lumbar fusion procedures: intraoperative fluoroscopic images near the time of wound closure and plain film images after the procedure in the recovery room. The latter may have low clinical utility. We identified a consecutive series of lumbar fusion procedures. A panel of 3 reviewers assessed intraoperative and recovery room series both for radiographical adequacy and for issues with the surgical construct. One hundred ninety cases were reviewed, of which 92 were posterolateral lumbar fusions, 42 were anterior lumbar interbody fusions, 24 were transforaminal lumbar interbody fusions, and 32 were anterior-posterior fusions. All intraoperative series were adequate, whereas only 90% of recovery room series were adequate. Recovery room series had visible issues with construct placement in 4 cases. In each of these cases, however, the issue was also clearly visible on the intraoperative series, was found to be acceptable clinically, and did not alter management in any way. This study demonstrates that recovery room images are inferior to intraoperative images and offer little or no incremental clinical utility for detecting issues with surgical constructs after lumbar fusion procedures. In settings where it is still performed, recovery room imaging might be discontinued to realize savings in cost, radiation exposure, and time. 4.

Anterior Release Internal Distraction and Posterior Spinal Fusion for Severe and Rigid Scoliosis

Retrospective study. To report on the results of anterior release, posterior internal distraction (with or without further distraction), and subsequent posterior spinal fusion for severe and rigid scoliosis. For severe and rigid scoliosis, conventional procedures, such as posterior instrumentation combined with an anterior release, enable limited correction. Posterior vertebral column resection brings better correction but with a high rate of neurological complications or intraoperative neurological events. A total of 15 patients with severe and rigid scoliosis who underwent anterior release, posterior internal distraction (with or without further distraction), and subsequent posterior spinal fusion were retrospectively reviewed after a minimum follow-up of 2 years. The radiographical parameters were evaluated, and clinical records were reviewed. The average number of anteriorly removed discs was 4.1. Average posterior fusion length comprised 14.3 vertebrae. Overall, internal distraction corrected the mean Cobb angle by 58.1% (from 105.1° to 44.2°) compared with the initial curve magnitude. The mean preoperative scoliosis of 105.1° was corrected to 27.5° (74.3% correction) at the most recent follow-up. The correction rate of the proximal thoracic and thoracolumbar or lumbar curves was 48.1% and 82.1%, respectively. The preoperative thoracic kyphosis of 62.3° was corrected to 33.8° at the most recent follow-up. The preoperative lumbar lordosis of -66.1° was corrected to -46.3° at the most recent follow-up. The mean preoperative coronal imbalance of 0.8 cm improved to 0.5 cm at the most recent follow-up, and sagittal imbalance of 0.3 cm improved to 0.2 cm. Transient dyspnea occurred in one patient after the initial surgery and subsequently resolved. Two patients complained of concave soft-tissue pain after the first distraction. There were no neurological complications. Anterior release, posterior internal distraction, and subsequent posterior spinal fusion provide an effective alternative for severe and rigid scoliosis. 4.

Delayed postoperative neurological complication in a patient with congenital kyphoscoliosis: recovered by revision of the 4-rod instrumentation technique

The authors report a case of progressive congenital kyphoscoliosis in which the patient, a boy, originally underwent combined anterior and instrumented posterior spinal fusion at the age of 7 years and 3 months. Early proximal junctional kyphosis and implant failure mandated proximal extension of implants with 2 new rods connected to the old caudad short rods. At the 3-year follow-up, clinical and CT assessment revealed a thoracolumbar pseudarthrosis for which the patient underwent a 2-stage procedure without complication. Recordings of somatosensory evoked potentials intraoperatively were normal. Twelve hours after surgery, his neurological status started to progressively deteriorate. The patient was brought to the operating room, and the initially achieved correction was reversed by an apex-only exposure of the 4-rod system. After surgery the patient started to show progressive improvement in his neurological function. A final myelography was performed and showed free passage of the dye without evidence of obstruction. Clinically, the patient continued to improve and at his 3-month follow-up had near-complete resolution of his neurological deficits. Findings on his physical examination were normal at the final 12-year follow-up. Despite normal findings on intraoperative neuromonitoring, a delayed neurological deficit can occur after complex spine reconstruction. Preoperative risk assessment, surgical approach, and instrumentation deserve careful attention. Advantages of a 4-rod construct are discussed in this case.

Thoracal flat back is a risk factor for lumbar disc degeneration after scoliosis surgery

Background contextLumbar segments below fused scoliotic spines are thought to be exposed to extraordinary stress. Although positive sagittal imbalance has come into focus, reports about factors influencing the outcome of these segments remain inconclusive. PurposeOur study aimed at identifying spinal risk factors for the development of lumbar degenerative disc disease (DDD) in surgically treated patients with adolescent idiopathic scoliosis (AIS). Study design/settingRetrospective comparative prognostic study (Level III) was conducted. Thirty-three patients were seen at an average follow-up of 7.5 years after either isolated selective anterior (n=18) or long combined anterior-posterior fusion (n=15) for AIS. Outcome measuresSelf-reported Scoliosis Research Society 22 questionnaire, physical examination including the detection of segmental pain and unspecific back pain, preoperative and postoperative whole-spine standing radiographs, and magnetic resonance imaging were obtained. MethodsRadiographic evaluation included the measurement of regional, coronal, and sagittal curve parameters and the assessment of spinal balance. Magnetic resonance imaging evaluation was done for preoperative and postoperative lumbar discs, according to the classification of Pfirrmann. ResultsPatients with low DDD (Pfirrmann grading <3) had a significantly higher thoracal kyphosis angle (mean 28°) than patients with advanced DDD (mean 15°). There was a trend toward a more flat-type lumbar lordosis in patients with severe DDD. Positive sagittal imbalance was associated with advanced DDD. Follow-up coronal parameters, trunk imbalance, instrumentation length, and lowest instrumented vertebra selection had no influence on DDD. Specific segmental pain could be attributed to a significantly higher coronal trunk imbalance (21 vs. 11 mm). ConclusionsThis study establishes thoracal flat back as a risk factor for lumbar DDD after spinal fusion and supports the pathogenetic role of positive sagittal imbalance in this process.

Surgical treatment of Scheuermann’s kyphosis using a combined antero-posterior strategy and pedicle screw constructs: efficacy, radiographic and clinical outcomes in 111 cases

There is sparse literature on how best to correct Scheuermann's kyphosis (SK). The efficacy of a combined strategy with anterior release and posterior fusion (AR/PSF) with regard to correction rate and outcome is yet to be determined. A review of a consecutive series of SK patients treated with AR/PSF using pedicle screw-rod systems was performed. Assessment of demographics, complications, surgical parameters and radiographs including flexibility and correction measures, proximal junctional kyphosis angle (JKA+1) and spino-pelvic parameters was performed, focusing on the impact of curve flexibility on correction and clinical outcomes. 111 patients were eligible with a mean age of 23years, follow-up of 24months and an average of eight levels fused. Cobb angle at fusion level was 68° preoperatively and 37° postoperatively. Flexibility on traction films was 34% and correction rate 47%. Postoperative and follow-up Cobb angles were highly correlated with preoperative bending films (r=0.7, p<0.05). Screw density rate was 87%, with increased correction with higher screw density (p<0.001, r=0.4). Patients with an increased junctional kyphosis angle (JKA+1) were at higher risk of revision surgery (p=0.049). 22 patients sustained complication, and 21 patients had revision surgery. 42 patients with ≥24months follow-up were assessed for clinical outcomes (follow-up rate for clinical measures was 38%). This subgroup showed no significant differences regarding baseline parameters as compared to the whole group. Median approach-related morbidity (ArM) was 8.0%, SRS-sum score was 4.0, and ODI was 4%. There was a significant negative correlation between the SRS-24 self-image scores and the number of segments fused (r=-0.5, p<0.05). Patients with additional surgery had decreased clinical outcomes (SRS-24 scores, p=0.004, ArM, p=0.0008, and ODI, p=0.0004). The study highlighted that AR/PSF is an efficient strategy providing reliable results in a large single-center series. Results confirmed that flexibility was the decisive measure when comparing surgical outcomes with different treatment strategies. Findings indicated that changes at the proximal junctional level were impacted by individual spino-pelvic morphology and determined by the individually predetermined thoracolumbar curvature and sagittal balance. Results stressed that in SK correction, reconstruction of a physiologic alignment is decisive to achieving good clinical outcomes and avoiding complications.

Hospital Outcomes and Complications of Anterior and Posterior Cervical Fusion With Bone Morphogenetic Protein

Retrospective database analysis. A nationwide population-based database was analyzed to identify the incidence of complications and mortality associated with bone morphogenetic protein (BMP) utilization in cervical spine fusion surgery. "Off-label" use of BMP as an adjunct in cervical fusions has been associated with increased complication rates in small case series. The incidence of complications with utilization of BMP is not well characterized on a national level. Data from the Nationwide Inpatient Sample were obtained for each year from 2002-2009. Patients undergoing anterior cervical fusion (ACF) or posterior cervical fusion for diagnoses of cervical myelopathy and/or radiculopathy were identified and separated into cohorts ("BMP" and "No BMP"). Patient demographics and comorbidities were compared. Complications, length of stay, costs, and mortality rates were assessed. Student t test and χ test were used to assess significant differences. A P value of less than 0.0005 was used to denote significance. A total of 213,421 ACFs and 20,334 posterior cervical fusions were identified from 2002-2009; 6.2% of all ACFs and 12.5% of posterior cervical fusions utilized BMP. Patients receiving BMP in the ACF group were older with greater comorbidities than patients who did not receive BMP (P < 0.0005). Both surgical groups with BMP experienced increased length of stay and costs. Overall complication rates were significantly greater when BMP was utilized in ACFs (P < 0.0005) due to a significantly higher rate of dysphagia (37.2 vs. 22.5 per 1000 cases) (P < 0.0005). Our study found that "off-label" use of BMP as an adjunct to cervical fusions was associated with increased rates of dysphagia in ACFs and increased costs for all cervical fusions. Our study does not measure long-term outcomes after discharge; however, the impact of increased inhospital costs, length of stay, and incidence of dysphagia with utilization of BMP should be considered prior to its use in cervical fusions.

Treatment of Iatrogenic Chyloretroperitoneum with Octreotide Following Spinal Deformity Correction: A Case Report.

Chylous fluid leakage is a rare but well-described complication of anterior spinal surgery1-6. Conservative treatment, including a drainage tube and a low-fat diet or total parenteral nutrition supplemented with oral medium-chain triglycerides, has had varying success. Treatment is often prolonged, requiring continuous drainage for up to six months in some reported series7. The use of octreotide, a somatostatin analogue, was first described in the general surgery literature for the treatment of chylothorax resulting from a ruptured thoracic duct2,4,5. Numerous reports have confirmed the success of octreotide in the treatment of chylous accumulations in the chest, peritoneal cavity, and retroperitoneum, although, to the best of our knowledge, there is no mention of its use in the orthopaedic literature. We report a case of chyloretroperitoneum following lumbar hemivertebrectomy that was successfully treated with octreotide. The patient and his parents were informed that data concerning the case would be submitted for publication, and they provided consent. No patient identifiers were used in the course of this investigation in accordance with Health Insurance Portability and Accountability Act regulations. A five-year-old boy with a midlumbar hemivertebra had undergone convex hemiepiphysiodesis from a combined anterior and posterior approach when he was three years old. The curve continued to progress, and he subsequently underwent a hemivertebrectomy with anterior spinal fusion and posterior spinal instrumentation and fusion two years later (Figs. 1 through 4⇓⇓⇓). During the left-sided anterior approach, we noted substantial scarring from the initial surgical procedure. The ureter was identified and protected. A steady accumulation of clear fluid was noted after the approach was completed. The fluid formed fat droplets when irrigated and appeared to be chyle. The source could not be identified, …

Single stage posterior instrumentation and anterior interbody fusion for tuberculosis of dorsal and lumbar spines

Background: Spine is the most common site for osseous involvement of tuberculosis, accounting around 50% cases of musculoskeletal tuberculosis. The most frequent sites of the involvement are the thoracic and lumbar spine. The anterior column is primarily affected resulting in progressive or residual kyphotic deformity even after the eradication of the disease by chemotherapy. Various surgical techniques like anterior fusion, posterior or combined fusion have been described. In this study we evaluated the clinical outcome and radiological results of single stage posterior instrumentation and anterior interbody fusion for tuberculosis of dorsal and lumbar spine. Methods: Details of the patients of tuberculosis of dorsal and lumbar spine operated with single stage posterior instrumentation and anterior interbody fusion from December 2004 to June 2008 were retrieved from the hospital database. There were 55 cases operated with this technique. Thirty patients, whose final details were available, were involved in this study. Pre-operative, post-operative and final follow up clinical and radiological assessments were performed. The follow up ranged from 18 to 60 months. Results: Average operation time was 5 hours 45 minutes and blood loss was 1100 ml. Anterior body fusion was achieved in all the patients. 93.3% of the patients had neurological improvement. Satisfactory post-operative kyphotic angle correction was achieved. There was minimal final loss of kyphotic correction. One patient had post-operative wound infection. Post operative paralytic ileus, chest infection, urinary tract infection, jaundice were the complications found in the patients. No graft related complication was seen. There was no recurrence of the disease in any of the cases. Conclusion: Single stage anterior debridement and interbody fusion with posterior instrumentation can be performed safely to achieve satisfactory clinical and radiographic outcomes in patients of thoracic and lumbar tuberculosis. DOI: http://dx.doi.org/10.3126/noaj.v2i1.8136 Nepal Orthopaedic Association Journal Vol.2(1) 2011: 21-26

Biomechanical Comparison of Transforaminal Lumbar Interbody Fusion With 1 or 2 Cages by Finite-Element Analysis

Anterior lumbar interbody fusion and posterior lumbar interbody fusion with 1 cage have been shown to have similar biomechanics compared with the use of 2 cages. However, there have been no reports on the biomechanical differences between using 1 or 2 cages in transforaminal lumbar interbody fusion (TLIF) surgery. To determine the biomechanical differences between the use of 1 or 2 cages in TLIF by finite-element analysis. Three validated finite-element models of the L3-L5 lumbar segment were created (intact model and single- and paired-cage TLIF models). To study the biomechanics, a compressive preload of 400 N over 7.5 N-m was applied to the superior surfaces of the L3 vertebral body to simulate flexion, extension, rotation, and lateral bending. There was no significant difference in the range of motion between single-cage and paired-cage TLIF models, < 1° for all loading cases. Cage stress was high in the single-cage TLIF model under all loading conditions. Bone graft stress was high in the single-cage TLIF model. Pedicle screw stress was higher in the single-cage compared with the paired-cage TLIF. Single-cage TLIF approximates biomechanical stability and increases the stress of the bone graft. The use of a single cage may simplify the standard TLIF procedure, shorten operative times, decrease cost, and provide satisfactory clinical outcomes. Thus, single-cage TLIF is a useful alternative to traditional 2-cage TLIF.

Infected primary non-Hodgkin lymphoma of spine

Primary bone lymphoma (PBL) comprises less than 5% of all malignant bone tumors and almost 7% of all extranodal lymphomas. Only 1.7% of all PBLs have been reported to involve the vertebrae. In our case, osteomyelitis was accidentally found during surgery, which might have resulted in the rapid collapse of vertebral body. This is the first report on primary lymphoma of the vertebrae with superimposed osteomyelitis in the English literature to the best of our knowledge. The patient reported here received anterior vertebrectomy and posterior interbody fusion with instrumentation for spinal instability. Tumor mass and the necrotic debris were removed. After the procedure, the patient received treatment with antibiotics and six cycles of chemotherapy. This case reminds us the possibility of hematologic seeding of bacteria in the tissue, especially with tumor necrosis. We suggest percutaneous needle aspiration for pathology and culture before making a decision whether or not to proceed with surgical decompression for fear of missing the occult bacterial infection.

Circumferential Fusion With Anterior Strut Grafting and Short-segment Multipoint Posterior Fixation for Burst Fractures in Skeletally Immature Patients

The Universal Clamp (UC) is a novel vertebral anchor consisting of a sublaminar polyester band connected to fusion rods by a titanium jaw locked with a screw. The authors prospectively studied patients treated for thoracic or lumbar burst fractures with short pedicle screw constructs reinforced with UCs to prevent screw pullout. Eleven patients below 18 years of age underwent 2-stage circumferential fusion for complete burst fractures (Magerl A 3.3). Two pedicle screws reinforced by 2 UCs were inserted in the vertebra proximal to the fracture and 2 pedicle screws reinforced by 2 UCs were inserted in the vertebra distal to the fracture. Within 7 days, cages filled with cancellous bone graft were added for anterior column support. T12 was fractured in 3 patients, L1 in 4, L3 in 2, and L4 in 2 patients. Preoperatively, 10 patients were neurologically intact (Frankel E) and 1 patient had an incomplete spinal cord injury (Frankel C). Mean operative duration for the posterior and anterior procedures was 110±24 and 120±35 minutes, respectively. Average intraoperative blood loss was 355±60 mL. Mean hospital stay was 11±2 days and follow-up averaged 36.1±5 months. Mean kyphotic deformity was corrected from 25±9 to 5.3±4.5 degrees postoperatively (79%), without subsequent loss of correction (P=0.17). Regional kyphosis improved by 20±8 degrees postoperatively, without subsequent loss of correction (P=0.09). No intraoperative complication was observed. There was no neurological deterioration. The patient who had a Frankel C lesion recovered 1 Frankel level (Frankel D) at final follow-up. None of the patients exhibited significant correction loss during follow-up, and there was no pseudarthrosis. Thoracic and lumbar complete burst fractures in skeletally immature patients can be treated using anterior bone graft cages and posterior instrumented fusion augmented with UCs to prevent pedicle screw pullout. With these constructs, which are short to preserve mobile intervertebral segments, kyphosis was corrected, fusion achieved, and correction maintained in all subjects without neurological worsening. Level IV.