History Of Spinal Fusion Research Articles

Spinal catheter revision in pediatric intrathecal baclofen pumps: risk factors and postoperative outcomes.

Intrathecal baclofen (ITB) pumps are commonly used in pediatric patients with cerebral palsy (CP) and medically refractory spasticity. However, catheter malfunction and associated risk factors are not well understood. The aim of this study was to examine potential risk factors for spinal catheter malfunction and characterize postoperative follow-up to understand the clinical consequences. Patients who received ITB pump replacement or revision at Boston Children's Hospital between 2010 and 2023 were retrospectively reviewed. The spinal catheter revision cohort (SCRC) included patients whose spinal catheter was occluded requiring lumbar catheter revision. The second cohort included abdominal pump replacements only (APRC). Between-group comparisons and multivariable regression identified factors associated with catheter revision and postoperative outcomes. Forty-one (33.6%) patients underwent spinal catheter revision and were compared with 81 patients (66.4%) who underwent abdominal pump replacement only. Younger age at surgery and an elevated preoperative lower-extremity modified Ashworth scale grade were associated with spinal catheter revision (p < 0.05). Catheter model type, tip location, and history of spinal fusion were not associated with obstruction. Postoperatively, SCRC patients experienced a higher rate of infection (17.1%) relative to APRC patients (0%) within 30 days from their ITB pump replacement procedure (p < 0.05) and greater likelihood of subsequent ITB system removal compared with the APRC (24.4% vs 7.4%, p < 0.05). Although not differing preoperatively, SCRC patients had lower postoperative ITB doses when compared with the APRC group (median dose 143 vs 350 µg/day, p < 0.05) at hospital discharge and remained statistically different at the 6-month and 1-year follow-ups (p < 0.05). There were no postoperative differences in baclofen overdose, withdrawal, or median number of hospital readmissions within 30 days. Overall, 31.7% of spinal catheter revisions were unanticipated by the clinical team at time of surgery. Younger age at surgery and increased preoperative lower-extremity tone may be risk factors for catheter obstruction, resulting in a higher rate of postoperative infection and subsequent ITB pump removal compared with pump replacement alone. Spinal catheter occlusion can complicate revision or replacement procedures, especially when unanticipated. Routine clinical assessment may be inadequate for diagnosing insidious catheter malfunction. Catheter occlusion deserves further study, and routine assessment of catheter patency may be warranted to prevent suboptimal tone therapy.

Body Mass Index Does Not Drive the Risk for Early Postoperative Instability After Total Hip Arthroplasty: A Matched Cohort Analysis

BackgroundInstability remains the leading cause of revision following total hip arthroplasty (THA). The objective of the present investigation was to determine whether an elevated body mass index (BMI) is associated with an increased risk of instability after primary THA. MethodsAn administrative claims database was queried for patients undergoing elective, primary THA for osteoarthritis between 2010 and 2022. Patients who underwent THA for a femoral neck fracture were excluded. Patients who had an elevated BMI were grouped into the following cohorts: 25 to 29.9 (n = 2,313), 30 to 34.9 (n = 2,230), 35 to 39.9 (n = 1,852), 40 to 44.9 (n = 1,450), 45 to 49.9 (n = 752), and 50 to 59.9 (n = 334). Patients were matched 1:1 based on age, sex, and Elixhauser Comorbidity Index, as well as a history of spinal fusion, neurodegenerative disorders, and alcohol abuse, to controls with a normal BMI (20 to 24.9). A multivariate logistic regression controlling for age, sex, Elixhauser Comorbidity Index, and additional risk factors for dislocation was used to evaluate dislocation rates at 30 days, 90 days, 6 months, 1 year, and 2 years. Rates of revision for instability were similarly compared at 1 year and 2 years postoperatively. ResultsNo significant differences in dislocation rate were observed between control patients and each of the evaluated BMI classes at all evaluated postoperative intervals (all P values > .05). Similarly, the risk of revision for instability was comparable between the normal weight cohort and each evaluated BMI class at 1 year and 2 years postoperatively (all P values > .05). ConclusionsControlling for comorbidities and known risk factors for instability, the present analysis demonstrated no difference in rates of dislocation or revision for instability between normal-weight patients and those in higher BMI classes.

Determinants of diaphragm inspiratory motion, diaphragm thickening, and its performance for predicting respiratory restrictive pattern in Duchenne muscular dystrophy.

Respiratory status is a key determinant of prognosis in patients with Duchenne muscular dystrophy (DMD). We aimed to evaluate the determinants of diaphragm ultrasound and its performance in predicting restrictive respiratory patterns in DMD. This was a retrospective study of DMD patients followed in our center and admitted for an annual checkup from 2015 to 2018. We included DMD patients who underwent diaphragm ultrasound and pulmonary functional tests. This study included 74 patients with DMD. The right diaphragm thickening fraction (TF) was significantly associated with age (P= .001), Walton score (P= .012), inspiratory capacity (IC) (P= .004), upright forced vital capacity (FVC) (P< .0001), supine FVC (P= .038), and maximal inspiratory pressure (MIP) (P= .002). Right diaphragm excursion was significantly associated with age (P< .0001), steroid use (P= .008), history of spinal fusion (P< .0001), body mass index (BMI) (P= .002), Walton score (P< .0001), IC (P< .0001), upright FVC (P< .0001), supine FVC (P< .0001), and MIP (P< .0001). A right diaphragm TF >28% and a right diaphragm excursion>25.4 mm were associated with an FVC >50% with, respectively, an area under the curve (AUC) of 0.95 (P= .001) and 0.93 (P< .001). A left diaphragm TF >26.8% and a left diaphragm excursion >21.5 mm were associated with an FVC >50% with, respectively, an AUC of 0.95 (P= .011) and 0.97 (P< .001). Diaphragm excursion and diaphragm TF can predict restrictive pulmonary insufficiency in DMD.

Do All Rigid and Unbalanced Spines Present the Same Risk of Dislocation After Total Hip Arthroplasty? A Comparison Study Between Patients With Ankylosing Spondylitis and History of Spinal Fusion

BackgroundSpines with ankylosis or with a history of lumbosacral fusions have been collectively classified as rigid and unbalanced, and associated with an increased rate of dislocation after total hip arthroplasty (THA). It remains unknown whether the cause of spinal arthrodesis influences the dislocation rate. MethodsA retrospective study was conducted from January 2000 to December 2017, with an institutional review board's approval to identify 2 cohorts with a history of THA: one with ankylosing spondylitis (AS) involving the lumbosacral spine and another cohort with a history of lumbosacral spinal fusion (SF). A chart review was performed to collect demographic and surgical variables. Lumbar lordosis angle (LLA), acetabular anteversion, and inclination angle measurements were taken for each patient. Kaplan-Meier survivorship curves were constructed and multivariable Cox regression was performed for analysis. ResultsThe AS and SF cohorts consisted of 142 and 135 patients, respectively. The SF group had a greater mean LLA (34.18°) than the AS group (21°). A total of 16 patients (11.85%) suffered from dislocation after primary elective THA in the SF group, whereas 4 patients (2.82%) in the AS group. After multivariable Cox regression analysis, increasing LLA and hips outside of the Lewinnek safe zone were found to be associated with a higher hazard of dislocation after THA. ConclusionWe found that the degree of lumbar spine curvature is more associated with dislocation after THA than the history of SF itself; specifically, an increase in lumbar lordosis angle of 1º increases the probability of dislocation by 13% among AS and SF patients.

History of Spinal Fusion: Where We Came from and Where We Are Going.

Spinal fusion surgery is performed all over the world to help patients with cervical and thoracolumbar pathology. As outcomes continue to improve in patients with spine-related pathology, it is important to understand how we got to modern day spinal fusion surgery. Scientific innovations have ranged from the first spinal fusions performed with basic instrumentation in the late nineteenth century to contemporary tools such as pedicle screws, bone grafts, and interbody devices. This article tracks this technological growth so that surgeons may better serve their patients in treating spine-related pain and disability.

Spinal angiolipoma: Presentation of two cases and review of the literature for the years 2012–2017

Angiolipomas of the spinal canal are a rare condition of unknown origin. They are considered histologically benign; however, some have the potential to infiltrate adjacent structures. The aim of this systematic review was to suggest a potential mechanism for the pathogenesis of spinal angiolipomas, along with a useful approach for their preoperative management. A literature review of cases of spinal angiolipoma was performed. In addition, two of the cases encountered in our practice are presented. The first case refers to a 35-year-old male patient with a history of spinal fusion because of a T9 fracture, while the second concerns a 46-year-old male patient with an epidural mass extending outside the spinal canal, who underwent fine needle biopsy and embolisation of its feeding vessel. From the review of the literature performed, we were unable to identify any correlation between the infiltrative potential and the patients' demographic and tumour characteristics. Angiolipomas are considered to be sporadic, yet theories concerning their pathogenesis include reaction to harmful stimuli and congenital malformation of the adipose tissue. Fine needle biopsy may be mistakenly considered non-diagnostic, due to the presence of well-differentiated adipocytes.

Saturday, September 29, 2018 10:30 am–12:00 pm Applying Deformity Concepts in Your Practice

BACKGROUND CONTEXT Recent studies have shown that lumbar fusion procedures are associated with an increased risk of total hip arthroplasty (THA) dislocation. Some authors have speculated that the increased risk of dislocation is caused by mispositioning of the acetabular component due to spinal sagittal imbalance. Unfortunately, the exact relationship between spinal sagittal balance and cup orientation is unknown. Furthermore, hip instability affected by cup orientation changes due to spinal sagittal imbalance remains unclear. PURPOSE To investigate the effect of spinal sagittal alignment on cup anteversion in THA dislocation. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE A total of 29 patients that suffered a THA dislocation and had lumbar radiographs prior to their THA. OUTCOME MEASURES Cup anteversion, lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope before THA. METHODS Patients that suffered a THA dislocation were retrospectively identified. Patients were included if they had lumbar radiographs prior to their THA. Patient characteristics were recorded including history of spinal fusion, surgical approach, primary or revision THA, direction of dislocation, and time from THA to dislocation. Cross-table lateral hip radiographs were used to measure cup anteversion with normal acetabular anteversion defined as 15°±10°. Lateral lumbar spine radiographs were used to measure lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Normal sagittal balance was defined as a PI-LL difference of RESULTS Twenty-nine patients had full radiographic imaging. Among these patients, 62.1% dislocated following a primary THA and 37.9% following a revision THA. Abnormal spinal sagittal balance was identified in 20 patients (69.0%). One-fourth (n=8, 27.6%) of patients had undergone spinal fusion prior to THA. Abnormal cup anteversion was demonstrated in 51.7% of all patients (7% with cup anteversion 25°). Presence of a spinal fusion was not associated with cup anteversion, sagittal balance or time to dislocation (p>.05 each). Sagittal balance was not associated with direction of dislocation, time to dislocation, or cup anteversion (p>.05 each). CONCLUSIONS A majority of patients with a THA dislocation demonstrated abnormal sagittal balance. However, sagittal balance was not associated with acetabular cup anteversion. As such, the relationship between spinal deformity and dislocation rates after THA may not be due to inaccurate cup orientation. More work is necessary to further delineate the influence of spinal alignment on THA stability. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Risk Factors for Early Dislocation Following Primary Elective Total Hip Arthroplasty

BackgroundDislocation following total hip arthroplasty (THA) continues to be one of the most common reasons for revision THA. The purpose of this study is to measure the current rate of dislocation following THA in the United States. A secondary goal is to identify patients at highest risk of instability after THA. MethodsThe Nationwide Readmissions Database was used to identify cases of elective primary THA between 2012 and 2014. All readmissions associated with dislocations were identified. Kaplan-Meier curves were used to assess the time to dislocation in the study population. A multivariate logistic regression was modeled to assess risk factors associated with readmission for dislocation. ResultsA total of 207,285 THAs were identified between 2012 and 2014. Of the total, 2842 dislocation-associated readmissions (1.4%) were identified, at a median of 40 days post-THA. A history of spinal fusion was the strongest independent predictor of dislocation (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.97-3.04; P < .0001). Parkinson's disease was also significantly associated with dislocation (OR, 1.63; 95% CI, 1.05-2.51; P = .03), as well as dementia (OR, 1.96; 95% CI, 1.13-3.39; P = .02), depression (OR, 1.28; 95% CI, 1.13-1.43; P < .0001), and chronic lung disease (OR, 1.2; 95% CI, 1.07-1.33; P = .001). Inflammatory arthritis and avascular necrosis were independent risk factors for dislocation (OR, 1.56; 95% CI, 1.25-1.97; P < .0001; OR, 1.67; 95% CI, 1.45-1.93; P < .0001). ConclusionTHA is a highly effective procedure with a low overall rate of instability. A history of spinal fusion was the most significant independent risk factor for dislocation within the first 6 months following THA.

Anterior lumbar sagittal alignment after anterior or lateral interbody fusion

PurposeAnterior or lateral interbody fusion is a treatment option for lumbar disc disease. A segmental change occurs after such surgery. This study was designed to evaluate the changes in the lumbar regional alignment after a single or two-level standalone anterior or lateral interbody fusion (ALIF or LLIF). MethodsData from patients referred to our institution between March 2013 and November 2015 for standalone ALIF or LLIF for low-grade isthmic spondylolisthesis or degenerative discopathy were retrospectively included in our analysis. Patients with a history of spinal fusion were excluded. Global and regional alignments were analyzed pre- and postoperatively. Pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), lumbar lordosis (LL), index segmental lordosis (ISL) and L4S1 lordosis were compared. Three groups according to the pelvic incidence (PI) (low, normal and high) were separately analyzed then compared. ResultsForty-one women and 27 men (mean age was 46 years; range 25–66) were included. The mean follow-up was 10.8 (range 3–34 months). The patients were globally well balanced preoperatively and remained after surgery (SVA stagnated from 16.76±28.42mm to 15.97±28.20mm, P=0.75). PT and LL did not vary. L4S1 lordosis, and ISL were significantly increased respectively from 30.56±8.59 to 34.58±7.47 (P=0.0026) and from 5.94±5.25 to 12.99±5.87 (P<0.0001) at latest follow-up. ConclusionDespite effective changes in the segmental lordosis at the index levels, our findings suggest that one or two-levels standalone ALIF or LLIF had no effect on the global balance and the lumbar lordosis. The three groups behaved similarly, the regional lordosis was redistributed in a better harmony (L4S1/LL ratio went up from 55% to 61%, P=0.01). Study typeRetrospective study. Level of evidence4.

G.P.163: Clinical features of Duchenne muscular dystrophy aged over 40 years

In the muscular dystrophy wards of 27 hospitals in Japan, of which 26 belong to the National Hospital Organization, and the other is the National Center of Neurology and Psychiatry, there are 733 patients diagnosed as Duchenne muscular dystrophy (DMD). Among them, 119 patients are 40 years and older. To elucidate their clinical feature, we made survey of their condition and medical treatment. Questionnaire includes results of gene analysis, muscle biopsy findings, time of loss of ambulation, respiratory condition, nutrition, treatment for cardiomyopathy, steroid therapy, and history of spinal fusion. Information of 79 patients was obtained. Among them, we analyzed data of 48 patients diagnosed based on loss of ambulation before 12 years old and gene analysis or muscle biopsy findings showing negative immunostaining of Dystrophin. Their age ranged from 40.2 to 51.0 years old (mean 43.7). Age of introduction of mechanical ventilation ranged from 15 to 40 years old (mean 24). Present respiratory conditions were non-invasive ventilation in 25 patients, and tracheal intermittent positive pressure ventilation in 23. Thirty-five patients preserved oral nutritional supply function, and others supplied with tube feeding. Ejection fraction of echocardiography ranged from 6 ∼ 69% (mean 46 n = 35), and the level of brain natriuretic peptide from 5.7 to 519 pg/ml (mean 52.9, n = 33). Medication for cardiomyopathy was as follows; 16 cases of beta-blocker, 25 angiotensin converting enzyme inhibitor, 21 diuretics, and 17 digitalis. Fourteen cases were administered more than 3 agents, whereas 9 no medication for cardiomyopathy. Three cases were administered steroid presently. Except them, there was no history of steroid administration. No spinal fusion was done in patients. Progress in multidisciplinary medical care for respiratory failure, cardiomyopathy, nutritional problems, and other related factors has extended the lifespan of DMD patients.