Bridwell Grading Research Articles

Successful Arthrodesis Using a Blended Allograft and Autograft Mixture in Lumbar Interbody Fusion: A Retrospective Case Series.

Introduction Achieving successful arthrodesis after lumbar interbody fusion remains a challenge, especially for minimally invasive surgical approaches that limit the amount of local bone autograft. However, using an allograft blend as an autograft extension mixture may hold promise but requires further research. The purpose of this study is to examine the impact of an allograft blend added to autograft on the quality of arthrodesis after lumbar interbody fusion in adult patients. Methods This study is a retrospective case series of adult patients (>21 years old) who underwent lumbar interbody fusion between October 2021 and January 2022, performed by a single spine surgeon. The quality of arthrodesis was assessed via the Bridwell grade (I-IV) for up to six months. The impact of surgical technique, age, sex, or amount of allograft utilized during fusion on Bridwell grade was assessed. Results Patients (n = 18; 27 levels fused) had a mean age of 58.6 (1.9) years and a mean BMI of 32.8 (1.2) kilograms per meter squared (kg/m²). A mean of 18.0 (standard deviation = 2.4) cubic centimeters (cc) (range: 3.4-50.0 cc) of allograft was used per fused level. A Bridwell grade of I (successful arthrodesis) was achieved at three months in 11.1% (3/27) of fusions and at six months in 85.2% (23/27) of fusions. Four fusions remained at a Bridwell grade of II at six months and subsequently achieved complete arthrodesis at 12 months. No patients received a Bridwell grade of IV (lucency with collapse of graft) at three- or six-month follow-up. There was no difference in Bridwell grade when stratified by surgical technique, age, sex, or amount of allograft used. Conclusion The allograft and autograft blend utilized in this study resulted in successful arthrodesis at all fused levels after one year, irrespective of surgical technique or other patient factors. Prospective studies with larger sample sizes are needed to corroborate the findings of this small case series.

Minimally invasive versus mini-open transforaminal lumbar interbody fusion in managing low-grade degenerative spondylolisthesis

Data backgroundBecause the traditional open-TLIF approach has several drawbacks, minimally invasive surgery (MIS) approaches for TLIF (MISTLIF) have been developed to speed up recovery after surgery and minimize pressure on the para-spinal muscles, necessitating a cost-utility analysis for comparison in healthcare reforms.Objectives and aim of the workThis study aimed to compare the radiological and clinical parameters between mini-open TLIF and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery in patients with single-level lumbar degenerative spondylolisthesis.HypothesisThis study hypothesizes that both minimally invasive and mini-open methods using sublaminar trimming laminoplasty (SLTL) (while preserving midline structures) and interbody cages have comparable mid- and long-term clinical and radiological outcomes.MethodsRetrospective analyses were performed on 120 patients who underwent single-level TLIF procedures with a minimum of two years of follow-up utilizing either the mini-open (n = 60) or MIS (n = 60) technique. Records of the operation's time frame, intraoperative fluoroscopy, blood loss, postoperative drainage volume, duration of bed rest, and complications were recorded. The Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for both groups were utilized to assess improvements in clinical scores, and t tests were employed to statistically compare the outcomes. For comparison, radiological parameters, including lumbar lordosis, pelvic incidence (PI), and localized lordosis at the index level, were measured preoperatively, postoperatively, and at the final follow-up. To assess postoperative interbody fusion, the Bridwell grading system was used.ResultsIn the Mini-open TLIF group, the average follow-up time was 24.91 ± 5.7 months, while in the MIS-TLIF group, the average follow-up time was 25.15 ± 4.2 months. In the MIS-TLIF group, the mean operation and radiological time were longer. However, compared to the Mini-open TLIF group, the MISTLIF group experienced less blood loss and a shorter hospital stay. The MIS-TLIF group outperformed the Open-TLIF group in terms of the VAS score for back pain and the ODI at less than 6 months following surgery, and the differences were statistically significant. However, at the final follow-up, there were no statistically significant differences in the VAS score for the back between the two groups, but the ODI score was significantly greater in the MIS-TLIF group. Both groups' lumbar lordosis and focal lordosis significantly improved at the index level, with the Mini-open-TLIF group showing more focal lordosis. The interbody fusion rate did not significantly differ between the two groups.ConclusionMIS-TLIF and mini-open-TLIF can be surgically effective in treating single-level degenerative lumbar spine spondylolisthesis.

Porous Cage Macro-Topography Improves Early Fusion Rates in Anterior Cervical Discectomy and Fusion.

Anterior cervical discectomy and fusion (ACDF) aims to improve pain, relieve neural compression, achieve rapid solid bony arthrodesis, and restore cervical alignment. Bony fusion occurs as early as 3 months and up to 24 months after ACDF. The correlations between bony fusion and clinical outcomes after ACDF remain unclear. Macro-topographic and porous features have been introduced to interbody cage technology, aiming to improve the strength of the bone-implant interface to promote early fusion. In this study, we aimed to compare clinical outcomes and CT-evaluated fusion rates in patients undergoing ACDF using one of two different interbody cages: traditional NanoMetalene™ (NM) cages and NM cages with machined porous features (NMRT). This was a prospective, observational, nonrandomised, cohort study of consecutive patients undergoing ACDF. The NM cage cohort was enrolled first, then the NMRT cohort second. The visual analogue scale, neck disability index, and 12-item Short Form Survey scores were evaluated preoperatively and at 6 weeks, 3 months, and 6 months. The minimum clinical follow-up period was 12 months. Plain radiographs were obtained on postoperative day 2 to assess instrumentation positioning, and computed tomography (CT) was performed at 3 and 6 months postoperatively to assess interbody fusion (Bridwell grade). Eighty-nine (52% male) patients with a mean age of 62 ± 10.5 years were included in this study. Forty-one patients received NM cages, and 48 received NMRT cages. All clinical outcomes improved significantly from baseline to 6 months. By 3 months, the NMRT group had significantly higher CT fusion rates than the NM group (79% vs 56%, p=0.02). By 6 months, there were no significant differences in fusion rates between the NMRT and NM groups (83% vs 78%, p=0.69). The mean Bridwell grade at 6 months was 1.4 ± 0.7 in the NMRT group and 1.8 ± 1.0 in the NM group (p=0.08). With both NM and NMRT cages, serial improvements in postoperative clinical outcomes were associated with fusion progression on CT. NMRT cages demonstrated significantly better fusion at 3 months and a trend toward higher quality of fusion at 6 months compared with NM cages, suggesting earlier cage integration with NMRT. An early 3-month postoperative CT is adequate for fusion assessment in almost 80% of patients undergoing ACDF with an NMRT cage, permitting an earlier return to activity.

Comparison of Fusion Rates among Various Demineralized Bone Matrices in Posterior Lumbar Interbody Fusion.

Background and Objectives: Posterior lumbar interbody fusion (PLIF) plays a crucial role in addressing various spinal disorders. The success of PLIF is contingent upon achieving bone fusion, as failure can lead to adverse clinical outcomes. Demineralized bone matrix (DBM) has emerged as a promising solution for promoting fusion due to its unique combination of osteoinductive and osteoconductive properties. This study aims to compare the effectiveness of three distinct DBMs (Exfuse®, Bongener®, and Bonfuse®) in achieving fusion rates in PLIF surgery. Materials and Methods: A retrospective review was conducted on 236 consecutive patients undergoing PLIF between September 2016 and February 2019. Patients over 50 years old with degenerative lumbar disease, receiving DBM, and following up for more than 12 months after surgery were included. Fusion was evaluated using the Bridwell grading system. Bridwell grades 1 and 2 were defined as 'fusion', while grades 3 and 4 were considered 'non-fusion.' Clinical outcomes were assessed using visual analog scale (VAS) scores for pain, the Oswestry disability index (ODI), and the European quality of life-5 (EQ-5D). Results: Fusion rates were 88.3% for Exfuse, 94.3% for Bongener, and 87.7% for Bonfuse, with no significant differences. All groups exhibited significant improvement in clinical outcomes at 12 months after surgery, but no significant differences were observed among the three groups. Conclusions: There were no significant differences in fusion rates and clinical outcomes among Exfuse, Bongener, and Bonfuse in PLIF surgery.

Sacrolumbar Interbody Fusion (SLIF): Feasibility, Technical Nuances, Biomechanical Assessment, and Clinical Outcomes.

S1-L5 transdiscal screw fixation is a direct stabilization technique used for surgical treatment of high-grade (III-IV) L5-S1 spondylolisthesis. It has not been used for nonspondylolisthetic cases or in combination with an interbody cage (IC). This study aimed to develop a novel, direct S1-L5 sacrolumbar interbody fusion (SLIF) technique, a combination of IC and sacrolumbar transdiscal screw. SLIF was tested in cadaveric, clinical, and finite element analysis settings. Three cadaveric lumbar spines were used to test the SLIF procedure before clinical application. Eight patients underwent the SLIF procedure. Clinical outcomes were evaluated by visual analog score for leg and back pain, short form 36, Oswestry disability index, and neurological examination. CT scans of the lumbar spine were used to assess the hardware placement and subsequent fusion. Finite element analysis was performed on a healthy human CT-based L5-S1 model. Intact segment, unilateral facetectomy and discectomy, SLIF, and transforaminal lumbar interbody fusion (TLIF) procedures were compared in terms of the range of motion (ROM), von Mises stress on hardware, and shear-induced directional deformity. Additionally, the same set of tests were conducted in an osteoporotic model. Excellent hardware placement was feasible in three cadavers and eight patients. Preoperative neurological deficits improved in all patients. Statistically significant improvements were obtained on all self-reported questionnaire scores. All patients developed solid, Bridwell grade I fusions. Biomechanical testing revealed similar outcomes for TLIF and SLIF regarding the ROM. However, the screw's von Mises stress and shear-induced directional deformity were low for SLIF of healthy and osteoporotic bone. SLIF is a feasible, safe, and effective L5-S1 fusion option suitable for all clinical scenarios. It provides several biomechanical advantages, yielding excellent clinical outcomes.

Percutaneous transforaminal endoscopic surgery (PTES) and mini-incision L5/S1 OLIF with a self-lock cage for the surgical treatment of L5 spondylolisthesis

ObjectivesWe reported thirteen cases of percutaneous transforaminal endoscopic surgery (PTES) under local anesthesia and mini-incision L5/S1 OLIF (OLIF51) with a self-lock cage for the treatment of L5 spondylolisthesis.MethodsFrom Jan 2019 to Feb 2020, the patients with L5 spondylolisthesis with nerve root symptoms undergoing PTES and OLIF51 were included in this study. PTES under local anesthesia was performed in a prone position, and OLIF51 with a self-lock cage and allograft was then undertaken through a left abdominal mini-incision and oblique retroperitoneal approach between bilateral iliac vessels with the external oblique, internal oblique and transverse abdominal muscles bluntly separated in turn for L5/S1 in a right oblique position under general anesthesia. Back and leg pain were preoperatively and postoperatively evaluated using the VAS, and the clinical outcomes were evaluated with the ODI before surgery and at the 2-year follow-up. The anterior and posterior intervertebral space height (AISH, PISH), lumbar lordotic, and surgical segmental lordotic angle (SLA) were measured on lumbar spine X-rays preoperatively and postoperatively. The fusion status was assessed according to Bridwell’s fusion grades.ResultsThirteen cases of L5 spondylolisthesis were included. The operation duration was 49.1 ± 5.6 min for PTES and 73.6 ± 8.2 min for OLIF. There was blood loss of 25 (15–45) ml. The incision length was 7.5 ± 1.1 mm for PTES and 46.8 ± 3.8 mm for OLIF. The hospital stay was 5 (4–6) days, and the follow-up duration was 29 (24–37) months. For the clinical evaluation, the VAS of back and leg pain significantly dropped after surgery (p < 0.001), and the ODI significantly decreased from 64.7 ± 7.8% to 12.9 ± 4.3% 2 years after surgery (p < 0.001). AISH, PISH and SLA significantly improved after surgery (p < 0.05). Fusion grades based on the Bridwell grading system at the 2-year follow-up were grade I in 9 segments (69.2%) and grade II in 4 segments (30.8%). No patients had any form of permanent iatrogenic nerve damage or major complications. No failure of instruments was observed.ConclusionsPTES and mini-incision OLIF51 with a self-lock cage is a viable option of minimally invasive surgery for L5 spondylolisthesis, which can achieve direct neurologic decompression, satisfactory fusion and hardly destroys the rectus abdominis and its sheath, paraspinal muscles and bone structures.

Reducing surgical site infections after spine surgery: the optimal amount of normal saline for intra-wound irrigation

BACKGROUND CONTEXTSurgical site infection (SSI) following lumbar surgery can increase healthcare costs and lead to poor clinical outcome. Irrigation of wounds with saline solution is widely accepted globally and safe for nearly all kinds of surgery. However, the efficacy of different volumes of wound irrigation has not been addressed in elective spine surgery. The role and the optimal amount of intraoperative wound saline irrigation in preventing SSI in clean spinal surgery remain unclear. PURPOSEWe aimed to investigate if insufficient intraoperative irrigation may be a risk factor for postoperative SSI. Additionally, we investigated the optimal amount of normal saline (NS) for irrigation to prevent postoperative SSI. STUDY DESIGNThis is a retrospective study of patients with degenerative spinal stenosis who were treated surgically. Patients were grouped according to the amount of intra-wound irrigation during surgery. PATIENT SAMPLEWe included 444 patients with degenerative lumbar spinal conditions who had undergone one to five level open spinal fusion surgeries from January 2015 through April 2020. OUTCOME MEASURESThe definition of superficial or deep SSI in this study was based on the Centers for Disease Control and Prevention criteria for SSI. The fusion status accessed was based on the Bridwell grading system at the final follow-up. Self-reported and clinical outcome measures include visual analog scale and Oswestry Disability Index. METHODSA total of 193 patients underwent irrigation with a bulb syringe with manual method (B group) with 2,000 mL NS; 251 patients underwent interpulse battery-powered device irrigation (P group) with >6,000 mL NS. Based on our protocolized departmental guidelines, all patients received the same preoperative preparation and standard surgical steps and postoperative care plan. Patients’ demographic and surgical parameters were recorded. The main outcome measures included superficial wound infection, deep infection and overall infection. RESULTSThe incidence of overall SSI was 4.66% in the B group and 1.59% in the P group. The univariate analysis revealed a significant correlation with DM and irrigation amount per hour during surgery but not age, BMI, smoking, operative duration, fusion level, or blood loss. We determined the optimal irrigation amount during surgery as 1,400 mL per hour based on the receiver operating characteristic (ROC) curve (sensitivity, 92.3%; specificity, 44.1%). This was statistically significant (p=.033) with an odds ratio of 9.284 (95% confidence interval 1.2–72.0). In the analysis of surgical factors, the infection group had a significantly lower irrigation amount during surgery. To summarize, patients with diabetes and those receiving less than 1,400 mL of NS/hour had a higher likelihood of developing SSI. CONCLUSIONSWe observed that diabetes and lower volume of intraoperative irrigation were both risk factors for postoperative SSI following degenerative lumbar spine surgery. To reduce SSI in lumbar spine surgery, intra-wound irrigation with more than 1,400 mL/h of NS was recommended.

Preliminary application effect of unilateral biportal endoscopy technique combined with drug chemotherapy in thoracic and lumbar tuberculosis

Objective: To investigate the efficacy of debridement, decompression, interbody fusion and percutaneous screw internal fixation under the unilateral biportal endoscopy (UBE) combined with drug chemotherapy for thoracic and lumbar tuberculosis. Methods: A follow-up study. The clinical data of 9 patients who underwent UBE debridement, decompression, interbody fusion and percutaneous screw internal fixation combined with drug chemotherapy for thoracic and lumbar tuberculosis at the First Affiliated Hospital of Xinjiang Medical University from September 2021 to February 2022 were retrospectively analyzed. There were 4 males and 5 females, aged (52.4±13.5) years (ranged 27-71 years). All patients were given quadruple (isoniazid+rifampicin+pyrazinamide+ethambutol) anti-tuberculosis drugs chemotherapy for 2 to 4 weeks before surgery. The operation time, intraoperative blood loss, postoperative drainage volume, ambulation time, postoperative hospital stay and complications were recorded. The visual analog scale (VAS) of pain, Oswestry disability index (ODI), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the patients were compared before and after the surgery. The degree and improvement of spinal cord injury before and after surgery were assessed according to the American Spinal Injury Association (ASIA) neurological classification; and the Cobb angle was measured before and after surgery to assess kyphotic deformity and correction. X-ray or CT was reviewed at 6 months postoperatively and at the final follow-up, and surgical segmental fusion was evaluated using Bridwell grading criteria. Results: All patients completed the surgery successfully and were followed up for (14.6±1.9) months. The operation time was (182.2±27.5) minutes, the intraoperative blood loss was (222.2±66.7) ml, postoperative drainage volume was (43.3±17.0) ml, the ambulation time was (1.9±0.8) days, postoperative hospital stay was (5.9±1.5) days. Complications occurred in 2 patients (2/9), including 1 case of procedure-related complication. ESR and CRP returned to normal level at the 6-month postoperative follow-up. The VAS score and ODI were significantly improved when compared with those before the operation at each postoperative follow-up time point, and the differences were all statistically significant (all P<0.05). All patients were classified as ASIA grade E at the last follow-up. The postoperative Cobb angle decreased from 14.44°±2.07° to 9.00°±2.29°, and there was no significant loss of angle at the last follow-up. At the 6-month postoperative follow-up, 5 cases (5/9) were classified as Bridwell grade Ⅰ, 2 cases (2/9) as grade Ⅱ, and 1 case (1/9) as grade Ⅲ and Ⅳ, respectively; and all the patients were classified as grade Ⅰ at the last follow-up. Conclusion: Combined with drug chemotherapy, UBE debridement, decompression, interbody fusion and percutaneous screw internal fixation is a safe, feasible and effective therapy for thoracic and lumbar tuberculosis.

Biportal Endoscopic Transforaminal Lumbar Interbody Fusion Using Double Cages: Surgical Techniques and Treatment Outcomes.

To describe the surgical techniques and the treatment outcomes of biportal endoscopic transforaminal lumbar interbody fusion (BETLIF) using double cages. This study included 89 patients with 114 fusion segments between July 2019 and May 2021. One pure polyetheretherketone (PEEK) cage and 1 composite titanium-PEEK cage were used for interbody fusion. Clinical outcomes measures included visual analogue scale (VAS) scores for lower back pain and leg pain, Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) scores. Computed tomography (CT) of the lumbar spine 1 year postoperatively was used to evaluate the Bridwell interbody fusion grades. There were significant improvement in VAS for lower back pain from 5.2 ± 3.1 to 1.7 ± 2.1, VAS for leg pain from 6.3 ± 2.5 to 1.7 ± 2.0, ODI from 46.7 ± 17.0 to 12.7 ± 16.1, and JOA score from 15.6 ± 6.3 to 26.4 ± 3.2. The p-values were all < 0.001. The average hospital stay was 5.7 ± 1.1 days. The CT studies available for 60 fusion segments showed successful fusion (Bridwell grade I or grade II) in 56 segments (93.3%). Significant cage subsidence of more than 2 mm was only noted in 3 segments (5.0%). Complications included 1 dural tear, 2 pedicle screws malposition, and 2 epidural hematomas, in which 2 patients required reoperations. BETLIF with double cages provided good neural decompression and a sound environment for interbody fusion with a big cage footprint, a large amount of bone graft, endplate preservation, and segmental stability.

Hybrid surgery of percutaneous transforaminal endoscopic surgery (PTES) combined with OLIF and anterolateral screws rod fixation for treatment of multi-level lumbar degenerative diseases with intervertebral instability

BackgroundOblique lumbar interbody fusion (OLIF) has been used to treat lumbar intervertebral instability, which has some advantages including less trauma, less blood loss, faster recovery and bigger cage. However, it usually needs posterior screws fixation for biomechanical stability, and possible direct decompression for relieving neurologic symptoms. In this study, OLIF and anterolateral screws rod fixation through mini-incision were combined with percutaneous transforaminal endoscopic surgery (PTES) for the treatment of multi-level lumbar degenerative diseases (LDDs) with intervertebral instability. The purpose of study is to evaluate the feasibility, efficacy and safety of this hybrid surgery.MethodsFrom July 2017 to May 2018, 38 cases of multi-level LDDs of disc herniation, foramen stenosis, lateral recess stenosis or central canal stenosis with intervertebral instability and neurologic symptoms undergoing one-stage PTES combined with OLIF and anterolateral screws rod fixation through mini-incision were recruited in this retrospective study. The culprit segment was predicted according to the position of patient’s leg pain and PTES under local anesthesia was performed for the culprit segment in the prone position to enlarge the foramen, remove the flavum ligamentum and herniated disc for the lateral recess decompression and expose bilateral traversing nerve roots for the central spinal canal decompression through an unilateral incision. During the operation, communicate with the patients to confirm the efficacy using VAS. And then mini-incision OLIF using allograft, autograft bone harvested in PTES and anterolateral screws rod fixation were performed in the right lateral decubitus position under general anesthesia. Back and leg pain were preoperatively and postoperatively evaluated using VAS. And the clinical outcomes were evaluated with ODI at the 2-year follow-up. The fusion status was assessed according to Bridwell’s fusion grades.ResultsThere were 27 cases of 2-level, 9 cases of 3-level and 2 cases of 4-level LDDs with single-level instability on the X-ray, CT and MRI. Five cases of L3/4 instability and 33 cases of L4/5 instability were included. PTES was performed for 1 segment of 31 cases (25 cases of instability segment, 6 cases of no instability segment) and 2 segments including instability segment of 7 cases. Then, all instability segments were treated using mini-incision OLIF and anterolateral screws rod fixation. The average operation duration was 48.9 ± 7.3 min per level for PTES and 69.2 ± 11.6 min for OLIF and anterolateral screws rod fixation. The mean frequency of intraoperative fluoroscopy was 6 (5–9) times per level for PTES and 7 (5–10) times for OLIF. There was a mean blood loss of 30 (15–60) ml, and the incision length was 8.1 ± 1.1 mm for PTES and 40.0 ± 3.2 mm for OLIF. The mean hospital stay was 4 (3–6) days. The average follow-up duration was 31.1 ± 4.0 months. For the clinical evaluation, the VAS pain index and the ODI showed excellent outcomes. Fusion grades based on the Bridwell grading system at 2-year follow-up were grade I in 29 segments (76.3%) and grade II in 9 segments (23.7%). One patient encountered nerve root sleeves rupture during PTES and did not confront cerebrospinal fluid leakage or other abnormal clinical symptoms. There were two cases of hip flexion pain and weakness, which was relieved during 1 week after surgery. No patients had any form of permanent iatrogenic nerve damage and a major complication. No failure of instruments was observed.ConclusionsThe hybrid surgery of PTES combined with OLIF and anterolateral screws rod fixation is a good choice of minimally invasive surgery for multi-level LDDs with intervertebral instability, which can get direct neurologic decompression, easy reduction, rigid fixation and solid fusion, and hardly destroy the paraspinal muscles and bone structures.

A Mineralized Allograft in Lumbar Interbody Fusion – A Retrospective Chart Review Study

Background: Lumbar interbody fusion is a routine surgical intervention for treatment of degenerative disc disease to treat lumbar stenosis. Minimally invasive surgical approaches do not afford the opportunity to harvest large amounts of local bone autograft, therefore iliac crest autograft and or additional allograft material is strongly relied upon to achieve an arthrodesis. This study uses a blend of a blend of Ventris Medical’s osteoinductive allograft; Allocell® and SurGenTec’s nanoputty OsteoFlo® as an effective autograft extension material.&#x0D; Methods: A retrospective chart review was performed on patients that underwent lumbar interbody fusion between October 2021 and January 2022. Demographic information was recorded, three- and six-month follow-up radiographs were assessed, and arthrodesis was graded using the Bridwell Anterior Grading System.&#x0D; Results: A total of 18 patients were included in the study, representing 27 lumbar level fusions. A Bridwell grade of I (successful fusion) was achieved at three months in 11.1% of cases and at six months in 85.2% of cases. Four fusions remained a Bridwell grade of II at six months and were subsequently evaluated for complete arthrodesis. No patients received a Bridwell grade of IV (lucency with collapse of graft) at three- or six-month follow-up.&#x0D; Conclusions: The combination of OsteoFlo® and Allocell® contributed to successful arthrodesis status post lumbar fusion.

A single-arm retrospective study of the clinical efficacy of unilateral biportal endoscopic transforaminal lumbar interbody fusion for lumbar spinal stenosis.

The purpose of this study was to investigate the clinical efficacy of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) for lumbar spinal stenosis (LSS). Patients who underwent UBE-TLIF due to single-segment LSS between August 2019 and July 2021 were retrospectively included in the study. Clinical outcomes evaluated include operative time, estimated blood loss (including postoperative drainage), time to ambulation, postoperative hospital stay, complications, visual analog scale (VAS) scores of low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, Oswestry disability index (ODI), and modified Macnab criteria. Interbody bony fusion at the index level was assessed using Bridwell grading criteria. A total of 73 patients (29 males and 44 females) were enrolled in this study. All surgeries were successfully performed without intraoperative conversion to open surgery. Magnetic resonance imaging (MRI) revealed optimal direct neural decompression after UBE-TLIF. The mean operative time was 150.89 ± 15.58 min. The mean estimated blood loss was 126.03 ± 17.85 ml (postoperative drainage was 34.84 ± 8.31 ml). Time to ambulation was 2.0 ± 0.75 days after the procedure. Postoperatively, the mean hospital stay was 5.96 ± 1.38 days. VAS scores of low back pain and leg pain, JOA, and ODI were significantly improved postoperatively compared with those before the operation, and differences were statistically significant (P < 0.05). Excellent and good outcomes were reported by 87.67% of patients according to the modified Macnab criteria at the final follow-up. A total of nine perioperative complications occurred, with an incidence of 12.33%. X-ray or computerized tomography (CT) 6 months after the procedure showed that 37 cases (50.68%) presented with segmental fusion, 30 cases (41.10%) showed incomplete fusion, and 6 cases (8.22%) showed no signs of fusion. However, bony fusion was achieved in all cases at the final follow-up. UBE-TLIF for LSS has the advantages of less surgical invasiveness and fast postoperative recovery.

Biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation for lumbar brucellosis spondylitis.

This study aims to investigate the effectiveness and feasibility of biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation for lumbar brucellosis spondylitis (LBS). The data of 13 patients with LBS were retrospectively analyzed, who underwent biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation from May 2020 to June 2022. The patients' clinical data, the duration of operation, the estimated blood loss (including postoperative drainage), and complications were recorded. Clinical outcomes include serum agglutination test (SAT) measures Brucella antibody titer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the visual analog scale (VAS) scores of low back and leg, Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), American Spinal Injury Association neurological classification, and lordotic angle were analyzed. All patients were assessed using the modified Macnab criteria at the final follow-up. The intervertebral bone graft fusion was assessed using the Bridwell grading criteria. The mean operation duration was 177.31 ± 19.54 min, and the estimated blood loss was 176.15 ± 43.79 ml (including postoperative drainage was 41.15 ± 10.44 ml). The mean follow-up period was 13.92 ± 1.5 months. SAT showed that the antibody titers of 13 patients were normal 3 months after the operation and at the final follow-up. ESR and CRP levels returned to normal by the end of the 3-month follow-up. VAS scores of low back and leg, JOA score, and ODI significantly improved after the operation throughout the follow-up period (P < 0.05). Based on the modified Macnab criteria, 92.3% showed excellent to good outcomes. One patient had only a percutaneous screw internal fixation on the decompression side due to severe osteoporosis. One case suffered a superficial incision infection postoperatively that healed with dressing change and effective antibiotic treatment. Bony fusion was obtained in all patients at the last follow-up, including 12 cases with grade I and 1 case with grade II, with a fusion rate of 92.31%. Biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation is an effective, safe, and viable surgical procedure for the treatment of LBS.

Clinical Study on Treatment of Type II/III Lumbar Brucellar Spondylitis by Unilateral Biportal Endoscopy

Objective: Explore the feasibility and clinical efficacy of using unilateral biportal endoscopy for the treatment of Type II/III lumbar brucellar spondylitis. Methods: A retrospective study of the clinical data of 20 patients with Type II/III lumbar brucellar spondylitis admitted to the First Affiliated Hospital of Hebei North University from January 2020 to May 2022, including 15 males and 5 females, aged 41 - 60 years old, average age (48.11 ± 7.28) years old. After admission, the patient can isolate brucella through metagenomic Next-Generation Sequencing (mNGS), meeting the tertiary diagnostic criteria. Preoperative conventional drug treatment, unilateral biportal endoscopic minimally invasive surgery was performed when nutrition was improved, perioperative control of various indexes was stable, and erythrocyte sedimentation was declining. It was completed under an endoscope. The lesion was cleared, spinal nerve compression was relieved, interbody fusion was performed, and the spine was fixed by a percutaneous pedicle screw. Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Visual Analogue Scale (VAS), Japanese Orthopedic Association (JOA) score and Oswestry Disability Index (ODI) were analyzed at 1 month, 3 months, 6 months and the last follow-up. At the final follow-up of all patients, the clinical efficacy criteria and the Bridwell grading criteria were used to evaluate the recovery and intervertebral bone graft fusion, respectively. Results: All patients’ lower back and leg pain was relieved the next day after surgery. At a follow-up of one month after surgery, both systemic and local symptoms significantly improved. At the last follow-up, clinical symptoms disappeared and there was no tenderness or percussion pain in the local area. With the passage of time, 1 month, 3 months, 6 months after the operation, and the last follow-up are all evaluation indicators compared with those before the operation. No matter VAS, JOA, ODI score, or ESR, CRP is significantly improved compared with preoperative (P All 20 cases in this group reached the BS clinical cure standard, and the excellent rate of intervertebral bone graft fusion was 95%. Conclusion: On the basis of

Which Is Better in Clinical and Radiological Outcomes for Lumbar Degenerative Disease of Two Segments: MIS-TLIF or OPEN-TLIF?

To compare the clinical and radiological outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and traditional open transforaminal lumbar interbody fusion (OPEN-TLIF) in the treatment of two-level lumbar degenerative diseases. The clinical data of 112 patients were retrospectively analyzed, and were divided into an MIS-TLIF group and OPEN-TLIF group. The operative time, intraoperative fluoroscopy, blood loss, postoperative drainage volume, bed rest time, the content of creatine kinase(CK) and complications, were recorded. VAS score and ODI index were used to evaluate clinical efficacy. Bridwell grading was used to evaluate postoperative interbody fusion. Screw position was evaluated by Rao grading. Compared with the OPEN-TLIF group, the MIS-TLIF group had longer operation times, more intraoperative fluoroscopy times, but shorter postoperative bed times (p &lt; 0.05). There were no significant differences in blood loss, postoperative drainage and postoperative CK content between the two groups (p &gt; 0.05). There was no difference in VAS score and ODI index during the follow-up (p &gt; 0.05). There was no significant difference in the interbody fusion rate between the two groups (p &gt; 0.05). There was no significant difference in the distribution of type A screws, but the type B screw in the MIS-TLIF group was higher (p &lt; 0.05). There was no difference in the incidence of complications between the two groups (p &gt; 0.05). The postoperative quality of life score and radiological outcomes of the two types of surgery in two-level lumbar degenerative diseases was similar, and there was no significant difference in muscle injury and complications, but the operation time and intraoperative radiation exposurewere higher than in the OPEN-TLIF group, and the pedicle screws were more likely to deviate laterally out of the vertebral body. Therefore, OPEN-TLIF is recommended for patients with lumbar degenerative diseases of two segments.

Bioactive glass grants equivalent fusion compared to autologous iliac crest bone for ALIF: a within-patient comparative study

PurposeTo determine within-patient fusion rates of chambers filled with bioactive glass versus autologous iliac crest bone on computed tomography (CT) following anterior lumbar interbody fusion (ALIF).MethodsA consecutive series of 40 patients (58 levels) that underwent single-level (L5-S1 only) or two-level (L5-S1 and L4-L5) ALIF were assessed. Indications for fusion were one or more of the following: degenerative disc disease with or without Modic changes, spondylolisthesis, and stenosis. Each intervertebral cage had a middle beam delimiting two chambers, one of which was filled with bioactive glass and the other with autologous iliac crest bone. CT scans were graded using the Bridwell classification (grade I, best; grade IV, worst). Patients were evaluated using the Oswestry Disability Index (ODI), and by rating pain in the lower back and legs on a Visual Analog Scale (pVAS); complications and reoperations were noted.ResultsAt 15 ± 5 months follow-up, there were no significant differences in fusion across chambers filled with bioactive glass versus chambers filled with autologous bone (p = 0.416). Two patients with Bridwell grade III at both chambers of the L4-L5 cages required reoperation using posterior instrumentation. Clinical assessment of the 38 remaining patients (54 levels) at 25 ± 2 months, revealed ODI of 15 ± 12, lower back pVAS of 1.4 ± 1.5 and legs pVAS of 1.9 ± 1.6.ConclusionsFor ALIF at L5-S1 or L4-L5, within-patient fusion rates were equivalent for bioactive glass compared to autologous iliac crest bone; thus, bioactive glass can substitute autologous bone, avoiding increased operative time and blood loss, as well as donor site morbidity.

Posterior Oblique Square Decompression with a Three-Step Wanding Technique in Tubular Minimally Invasive Transforaminal Lumbar Interbody Fusion: Technical Report and Mid-Long-Term Clinical Outcomes.

Although minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is the most common procedure in minimally invasive spine stabilization (MISt), details of the technique remain unclear. This technical report shows the mid-long-term clinical outcomes in patients who underwent posterior oblique square decompression (POSDe) with the three-step wanding technique of tubular MIS-TLIF for degenerative lumbar disease. Tubular MIS-TLIF (POSDe) was performed on 50 patients (males, 19; age, 69.2 ± 9.6 years), and traditional open surgery was performed (OS) on 27 (males, 4; age, 67.9 ± 6.6 years). We evaluated the clinical outcomes using the Visual Analog Scale for back pain, Japanese Orthopedic Association (JOA) scores, and JOA Back Pain Evaluation Questionnaire. We also assessed the fusion rate using the Bridwell grading system with computed tomography or plain radiography for at least 2 years postoperatively. Although there was no significant difference in the improvement rate of JOA scores between the two groups, the mean operation time and blood loss were significantly lower with MIS-TLIF than with OS. In the tubular MIS-TLIF group, there were no cases of deep wound infection; four cases had a pseudarthrosis, two had dural injury, and three had cage retropulsion. We revealed good clinical outcomes in patients who underwent POSDe.

Long-Term Clinical and Radiological Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion: 10-Year Follow-up Results.

BackgroundMany studies have reported that minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) provides satisfactory treatment comparable to other fusion methods. However, in the case of MI-TLIF, there are concerns about the long-term outcome compared to conventional bilateral PLIF due to the small amount of disc removal and the lack of autogenous bone graft. Long-term follow-up studies are still lacking as most of the previous reports have follow-up periods of up to 5 years.MethodsThirty patients who underwent MI-TLIF were followed up for > 10 years (mean, 11.1 years). Interbody fusion rates were determined using a modified Bridwell grading system. Adjacent segment disease (ASD) was defined as radiological adjacent segment degeneration (R-ASDeg) as seen on plain X-rays; reoperated adjacent segment disease referred to the subsequent need for revision surgery. Clinical outcomes after surgery were assessed based on back and leg pain as well as the Oswestry disability index (ODI).ResultsThe overall radiological fusion rate, at the 1-, 5-, and 10-year follow-up was 77.1%, 91.4%, and 94.3%, respectively. The incidence of R-ASDeg 1, 5, and 10 years after surgery was 6.7%, 16.7%, and 43.3% at the proximal adjacent segment and 4.8%, 14.3%, and 28.6% at the distal adjacent segment, respectively. R-ASDeg at either the proximal or distal segment was determined in 50.0% of the patients 10 years postoperatively. All clinical parameters improved significantly during follow-up, although the ODI and the visual analog scale (VAS) for leg pain at the 10-year follow-up were significantly worse in the R-ASDeg group than in the other patients (P = 0.009, P = 0.040).ConclusionMI-TLIF improved both clinical and radiological outcomes, and the improvements were maintained for up to 10 years after surgery. However, R-ASDeg developed in up to 50% of the patients within 10 years, and both leg pain on the VAS and the ODI were worse in patients with R-ASDeg.

Comparative Study of Radiological and Clinical Outcomes in Patients Undergoing Minimally Invasive Lateral Lumbar Interbody Fusion Using Demineralized Bone Matrix Alone or with Low-Dose Escherichia coli–Derived rhBMP-2

To compare the results of interbody fusion in patients undergoing minimally invasive lateral lumbar interbody fusion (LLIF) using demineralized bone matrix (DBM) alone versus DBM+recombinant human bone morphogenetic protein-2 (rhBMP2). This retrospective case-controlled study was conducted in patients undergoing minimally invasive LLIF (n= 54) for lumbar interbody fusion; they were divided into 2 groups: DBM-only group and DMB+rhBMP2 group. The improvements of segmental and lumbar lordosis and restoration of disc height were measured, and the interbody fusion rates were determined using a modified Bridwell grading system. Clinical outcomes after surgery, such as visual analog scale scores of back pain and leg pain, and Oswestry disability index were compared. There were no significant differences in disc height, lumbar and segmental lordosis, or interbody fusion rate between the 2 groups. However, the proportion of Bridwell grade 1 as complete interbody bridging was higher in the DBM+rhBMP2 group than in the DBM-only group at both 6 and 12 months (P < 0.001). Clinical parameters showed equally significant improvement during follow-up in both groups, with no significant differences between the groups. In minimally invasive LLIF, adding Escherichia coli-derived rhBMP2 to DBM did not affect clinical outcomes or radiation parameters, but increased the speed of fusion and interbody bony bridging rate.

80. Cellular bone matrix in multilevel ACDF: A prospective evaluation of 1-year fusion rates and patient reported outcomes

<h3>BACKGROUND CONTEXT</h3> Multilevel ACDF has an increased risk of pseudarthrosis compared to single-level fusion. Most current graft options carry some degree of morbidity or downside. Cellular bone matrix (CBM) is an off the shelf product containing allograft bone, mesenchymal stem cells and demineralized bone matrix. It possesses osteoinductive, osteoconductive and osteogenic properties. Early studies have shown high fusion rates, good patient reported outcomes (PROs), and low morbidity. <h3>PURPOSE</h3> To assess 12-month PROs and fusion rates in patients undergoing multilevel ACDF using CBM. <h3>STUDY DESIGN/SETTING</h3> Prospective, single center case series performed in a large private hospital system. <h3>PATIENT SAMPLE</h3> Patients >18 indicated for a 2-4 level ACDF between C2 and T1. Exclusion criteria included 1) BMI over 40 2) diagnosis of metabolic bone disease, 3) active infection, open wounds or lack of appropriate skin coverage, 4) history of previous cervical surgery, 5) known metal sensitivity or allergy to any components of CBM, 6) immunocompromised state, 7) history of substance abuse, 8) workman's comp for neck pain, 9) Prisoners, pregnant mothers or those planning to become pregnant. <h3>OUTCOME MEASURES</h3> Primary outcome measure was the NDI, using an MCID of 17.3%. Secondary measures were Bridwell grade I or II fusion at 12 months and statistically significant improvement on VAS and SF-36. <h3>METHODS</h3> ACDF was performed at each pathologic level. The graft was prepared by removing the cancellous center of an allograft spacer and filling the void with CBM. Operative levels were fixed with a standard titanium plate.NDI, VAS and SF-36 as well as AP and lateral X-rays were completed preoperatively and at 3, 6 and 12 months. CT was obtained at 12 months. Fusion was determined by the presence of bridging bone on 12-month CT. X-rays were graded by the senior author using the Bridwell anterior fusion grading system. Changes in NDI, VAS and SF-36 were calculated using a 1 sample t-test with Bonferroni correction. p<0.05 was used for significance. <h3>RESULTS</h3> NDI improved from 51.7% ± 8.8 to 31.2% ± 13.4 by 3 months and 29.1 ± 13.8 at final follow-up (p <0.001). SF-36 PCS improved from 40.7 ± 6.2 to 51 ± 9.1 at final follow-up (p<0.005). SF-36 MCS improved from 48.4 ± 8.3 to 52.8 ± 7.5 at final follow-up, which fell short of statistical significance (p=0.200). VAS improved from 78.9mm ± 15.3 to 14.8mm ± 19.4 by 3 months and 12.3mm ± 18 at final follow-up (p<0.001). Grade I or II fusion was present in 31/33 levels (93.9%) and 11/13 patients (84.6%) at 6 months. One level demonstrated grade IV resorption and collapse at 6 months. By 12 months there was grade I or II fusion at 33/33 levels. CT scan demonstrated bridging bone within or behind the allograft spacer in 33/33 levels. There were no major adverse events. <h3>CONCLUSIONS</h3> CBM used in multilevel ACDF resulted in high patient satisfaction, high fusion rate, and low morbidity. NDI at final follow-up showed a mean improvement of 23%, surpassing the MCID of 17.3%. We also saw significant improvements in the VAS and SF-36 PCS at 3,6 and 12 months, as well the SF-36 MCS at 6 months. At 6 months there was 93.9% fusion by level, and 84.6% by patient. By 12 months 100% of patients were fused. To our knowledge this represents the first prospectively collected, nonindustry funded study of its kind which adds to a small yet growing body of research in support of CBM in the cervical spine. <h3>FDA DEVICE/DRUG STATUS</h3> ViVigen Cellular Bone Matrix (Approved for this indication)