Fusion For Degenerative Pathology Research Articles

USO DAS UNIDADES HOUNSFIELD NO PLANEJAMENTO DA CIRURGIA ESPINHAL: REVISÃO SISTEMÁTICA E META-ANÁLISE

ABSTRACT Bone mineral density is a crucial factor in the success or failure of osteosynthesis in spine surgery; it shows the onset of osteoporosis and related complications. Its evaluation is verified by dual-energy X-ray absorptiometry (DEXA) and Hounsfield Unit (HU) measurement by CT scan. Objective: Determine the use of HU in surgical planning; compare utility in diagnosing osteoporosis by DEXA; and evaluate sensitivity in predicting complications. Method: A systemic literature review was conducted on PubMed, in line with PRISMA methodology. Including those who justified the use of pre-surgical planning, compared HU/DEXA, and assessed complications. For the statistical analysis, the χ2 was used. Results: 57 articles were identified by selecting nine that met the inclusion criteria. In patients undergoing spinal surgery for fixation and fusion for degenerative pathology, HU measurement showed a prevalence of osteoporosis of 58.5% (sensitivity 93.26%; specificity 90.22%), osteoporosis-associated complications of 24.5%, proper diagnosis of 71.98%, and screw release rate of 82.31%. Conclusions: UH measurement for the diagnosis of osteoporosis turns out to be more sensitive, specific, and predictive compared to DEXA, especially in elderly patients; it represents a useful tool in planning spinal surgery, minimizing the risk of complications such as screw release, fractures, pseudoarthrosis, subsidence of intersomatic devices, and kyphosis of the proximal junction. Level of evidence II; Study Design: Systematic Review and meta-analysis.

Incidental Durotomy Following Surgery for Degenerative Lumbar Disease and the Impact of Minimally Invasive Surgical Technique on the Rate and Need for Surgical Revision: A Case Series.

Incidental durotomy (ID) is a common complication during lumbar spine surgery. A paucity of literature has studied the impact of minimally invasive surgery (MIS) on durotomy rates and strategies for repair as compared to open surgery. To examine the impact that MIS techniques have on the durotomy rate, repair techniques, and need for surgical revision following surgery for degenerative lumbar disease as compared to open technique. A single-center retrospective review of consecutive cases between 2013 and 2016 was performed. All patients underwent lumbar decompression with or without instrumented fusion for degenerative pathology using either open posterior or MIS techniques. ID rate, closure technique, and need for surgical revision related to the durotomy were recorded. A total of 1,196 patients were included with an overall ID rate of 6.8%. There was no difference between open or minimally invasive surgical techniques (P=.14). There was a higher durotomy rate with open technique in patients that underwent decompression with fusion (P=.03) as well as in revision cases (P=.02). Primary repair was feasible more frequently in the open group (P=.001), whereas use of dural substitute (P < .001) was more common in the MIS group. Fibrin sealant was used routinely in both groups (P=.34). There were no failed repairs, regardless of technique used. MIS techniques may reduce durotomies in cases involving instrumentation or revisions. Use of dural substitute onlay and fibrin sealant was effective at preventing reoperation. Both MIS and open techniques result in a low rate of future surgical revision when a durotomy occurs.

90. Impact of patient-controlled analgesia on clinical outcomes after posterior lumbar spinal fusion surgery

BACKGROUND CONTEXT Optimal postoperative pain control is critical after spinal fusion surgery. Significant variability remains in the use of postoperative intravenous opioid patient-controlled analgesia (PCA) and very little data evaluating its utility compared to nurse-controlled analgesia (NCA) in lumbar fusion patients. PURPOSE We performed a retrospective evaluation of posterior lumbar spinal fusion patients being treated postoperatively with patient-controlled analgesia (PCA) and compared their pain-related outcomes to nurse-controlled analgesia (NCA). PCA utilization was independently associated with increased opioid prescription in the postoperative period. After controlling for preoperative opioid use, we found that opioid naive patients have worse pain control with PCA than NCA, and patients with very high opioid consumption (>90 MME/day) had greater rates of opioid-related adverse events with PCA. STUDY DESIGN/SETTING Retrospective clinical study, single institution. PATIENT SAMPLE A retrospective review from a single institution was conducted in consecutive patients treated with posterior lumbar spinal fusion for degenerative pathology. Patients with scoliosis, traumatic, neoplastic, infectious and minimally invasive treatments were excluded. OUTCOME MEASURES Postoperative numerical rating scale (NRS) pain scores, length of stay, and total opioid consumption were collected and compared. Opioid-related adverse events for each patient were also measured. METHODS Patients were divided into two cohorts: those treated postoperatively with PCA or NCA. Outcome measures were compared for patients in groups. Patients were stratified according to preoperative opioid consumption as naive, low (60 morphine milligram equivalents (MME) daily), high (61-90 MME) or very high (>90 MME) for analysis. RESULTS A total of 240 patients were identified: 62 and 178 patients in PCA and NCA groups, respectively. PCA patients had higher mean preoperative opioid consumption compared to the NCA group (49.2 vs 24.3 MME, p=0.009). PCA patients had higher mean opioid consumption in first 72 hours in all preoperative opioid consumption categories. Pain control and adverse event rates were similar between PCA and traditional opioid therapy in the low to high preoperative opioid consumption groups (>0 to 90 MME daily). Opioid naive patients had worse mean and highest NRS pain scores in the first 72 hours (all p 90 MME daily) had a greater rate of opioid-related adverse events (95% vs 70%, p CONCLUSIONS Postoperative PCA utilization is associated with significantly more opioid consumption and equal or worse postoperative pain scores compared to NCA after lumbar spinal fusion surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

183. Patient outcomes following short-segment lumbar fusion are not affected by PI-LL mismatch

BACKGROUND CONTEXT Mismatch between pelvic incidence (PI) and lumbar lordosis (LL) has been emphasized as a reason for poor outcomes in deformity surgery and long-segment spinal fusions. However, literature assessing the importance of this spinopelvic relationship on patient outcomes in short segment lumbar fusions for degenerative lumbar disease is scarce. PURPOSE To determine whether patient reported outcomes are affected based on degree of postoperative PI-LL mismatch after 1- and 2-level lumbar fusion for degenerative pathology. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Three hundred and forty-eight patients who underwent a 1-2-level lumbar spine fusion procedure at a high-volume academic center were retrospectively identified. Patients were divided into two groups based on the presence of postoperative PI-LL mismatch ≤ 10° (NM) vs PI-LL mismatch >10° (M). OUTCOME MEASURES Patient reported outcome measures: SF-12 PCS and MCS, ODI, VAS Back, VAS Leg. Spinopelvic measurements: pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), lumbar lordosis (LL). METHODS Preoperative and postoperative radiographic measurements were obtained for all patients. Those with less than one-year follow-up were excluded. Univariate analysis with an independent t-test or Mann-Whitney U test was used to compare differences between groups. Multiple linear regression was used to determine if postoperative PI-LL mismatch was an independent predictor of change in each patient outcome. RESULTS Sixty-seven patients were included in the NM group compared to 281 patients in the M group. There were no baseline differences (p > 0.05) in age, sex, BMI, CCI, smoking status, follow-up, preoperative diagnosis, number of levels decompressed and fused, or number of cases with TLIF or ALIF. On univariate analysis, there was a significant difference pre- and postoperatively in PT, PI, LL and PI-LL between the two groups at baseline and postoperatively (p 0.05). In addition, having a postoperative PI-LL mismatch was not found to be an independent predictor of any health-related outcome score on multiple linear regression analysis. CONCLUSIONS Pelvic incidence minus lumbar lordosis is recognized as an important spinopelvic parameter to normalize in deformity surgery; however, this importance is less clear in short-segment lumbar fusion for degenerative pathology. The results of this study show that even though the M group had a higher degree of mismatch pre- and postoperatively, there was no difference in patient-reported outcomes before or after surgery. This is one of the first studies to report on short-term patient outcomes based on spinopelvic parameters in routine lumbar degenerative cases. Further research is needed to elucidate this important relationship. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters

BACKGROUND CONTEXT Lumbar fusion surgery can be performed through either anterior, lateral or posterior approaches. Although the relative advantage of anterior lumbar surgeries for the restoration of sagittal balance in spinal deformity is well-acknowledged, the comparative utility of these approaches in maintaining sagittal alignment following single level lumbar fusion remains unclear. PURPOSE A systematic review of the current literature was performed to assess the relative change in sagittal lumbar parameters including whole lumbar lordosis (WLL), segmental lumbar lordosis (SLL) and disc height (DH) following lumbar fusion using various approaches. STUDY DESIGN/SETTING Systematic review and meta-analysis. PATIENT SAMPLE All subjects in studies reporting imaging outcomes following single-level lumbar fusion, according to inclusion and exclusion criteria. OUTCOME MEASURES Lumbar sagittal parameters (SLL and WLL) and DH. METHODS A computerized literature search of all articles published up to April 17, 2017 was performed using PubMed and Cochrane databases. The following keywords were used: “anterior lumbar interbody fusion”, “ALIF”, “posterior lumbar interbody fusion”, “PLIF”, “trans-foraminal lumbar interbody fusion”, “TLIF”, “lumbar 360° fusion”, “circumferential lumbar fusion”, “combined anterior and posterior lumbar fusion”, “extreme lateral interbody fusion”, “LLIF”, “lateral lumbar interbody fusion”, “LLIF”, “direct lateral interbody fusion”, “DLIF”, “extraforaminal lumbar interbody fusion”, “ELIF”, with different combinations of operators including “AND”, “NOT” and “OR”. All studies were scored based on Methodological Index for NonRandomized Studies (MINORS) criteria. Pairwise comparisons of the fusion approach effect sizes were performed for the three imaging parameters. RESULTS A total of 1,563 articles under “ALIF”, 2,075 articles under “PLIF”, 1,032 articles under “TLIF”, 1,082 articles under “LLIF” and 894 under “circumferential lumbar fusion” were identified. The articles were further stratified on the basis of number of fusion levels. Only studies reporting relevant imaging outcomes following single-level fusion for degenerative pathologies were included in the final analysis. Using this strategy, a total of 14, 27, 25, 11 and 3 studies were included under ALIF, PLIF, TLIF, minimally invasive-TLIF and LLIF, respectively. Based on pairwise comparisons, ALIF significantly improved WLL and DH restoration as compared to all the other fusion modalities [ALIF vs. PLIF:2.5 (0.5–4.6) vs. 1.5 (0.2–2.4), p CONCLUSIONS Based on a systematic review of the literature, ALIF offers a significantly improved restoration of lumbar sagittal parameters following single-level lumbar fusion.