Degenerative Lumbar Instability Research Articles

Supplementary posterior fusion in patients operated on employing TLIF may decrease the instrumentation failure rate.

It is supposed that additional posterior fusion may provide additional stability of the pedicle screw; however, the clinical impact of additional posterior fusion in patients treated with TLIF remains uncertain. The objective of this study is to assess the clinical efficacy of circumferential fusion in patients treated with TLIF. This is a single-center retrospective evaluation of consecutive 179 patients with degenerative lumbar stenosis and instability of spinal segments. Patients with axial pain and neurogenic claudication or radiculopathy associated with spinal stenosis were enrolled during the period from 2012 to 2018. Transforaminal lumbar interbody fusion (TLIF) with a single cage was used to treat patients. In 118 cases a supplementary posterior fusion was made. The duration of follow-up accounted for 24 months, logistic regression analysis was used to assess factors that influence the complication rate. The rate of pedicle screw loosening was growing with radiodensity getting decreased and was more frequent in patients with two level fusion. An increase in pedicle screw loosening rate correlated with anterior nonunion Tan 2 and 3 grade while both posterior complete and incomplete fusion resulted in a decline in the complication rate. Lumbosacral fusion, bilateral facet joints` resection and laminectomy turned out to be insignificant factors. The overall goodness of fit of the estimated general multivariate model was χ2 = 87.2230; P < 0.0001. To confirm clinical relevance of those findings, a univariate logistic regression was performed to assess the association between clinically significant pedicle screw instability and posterior fusion in patients operated on employing TLIF. The results of logistic regression analysis demonstrate that additional posterior fusion may decrease the rate of instrumentation failure that requires revision surgery in patients treated with TLIF [B0 = 1.314321; B1 = -3.218279; p = 0.0023; OR = 24.98507; 95% CI (3.209265; 194.5162), the overall goodness of fit of the estimated regression was χ2 = 22.29538, p = <0.0001]. Circumferential fusion in patients operated on employing TLIF is associated with a decline in the rate of pedicle screw loosening detected by CT imaging and clinically significant instrumentation failure.

P71. Should physical therapy be incorporated in patient care post 1-2 level lumbar fusions for degenerative lumbar instability? A comparative outcome analysis

BACKGROUND CONTEXT Fewer studies in the literature have examined the role of postoperative physical therapy (PT) after lumbar fusion. In the postoperative setting, much of the rehabilitation literature focuses on postdiscectomy patients. PURPOSE Evaluate and compare the changes in pain and functional scores between patients who completed physical therapy (PT) versus no-PT after their anterior or posterior 1-2 level lumbar fusions for degenerative lumbar instability. Our hypothesis was that the PT group may experience comparatively better functional and pain outcomes than their counterparts. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 123 patients with degenerative lumbar instability. OUTCOME MEASURES Oswestry disability index (ODI) and visual analog scale (VAS). METHODS A database of patients undergoing 1-2 level lumbar fusion surgery for degenerative disease was assembled. Demographic and outcome scores such as oswestry disability index (ODI) and visual analog scale (VAS) in patients who participated in postoperative PT vs those that did not were compared. RESULTS There were 72 and 51 patients in PT and no-PT that met the inclusion criteria, respectively. There were higher numbers of females (63.8%) in PT group. No-PT group had similar numbers of males and females. Mean ages for PT and no-PT groups were 61.4(±14.7) and 59.5(±14.1) years, respectively. Both groups were similar with respective to body mass index. A majority of the cases in both groups involved posterior/posterolateral approach; 55.5% of patients in PT group and 50.9% in no-PT had 1 level lumbar fusion. Mean change (preoperative vs 1-year postoperative) in ODI between the two groups differed significantly (PT vs no-PT: 18.8±13.9 and 9.3±17.5; p=0.019). Similarly, mean change in VAS was significantly different between the two groups (PT vs. no-PT: 3.2±2.18 and 1.05±2.08; p=0.026). None of our PT patients reported any change in pre vs 1-year postoperative followup employment status (35% retired, 38% employed full-time, 11% unemployed and 16% homemaker). Ninety-eight percent of no-PT patients reported no change in employment status during the same timeframe (46% retired, 25% employed full-time, 13% unemployed and 15% homemaker). CONCLUSIONS PT group reported significant improvements in functional and pain scores than their counterparts. Post-lumbar fusion rehabilitation may benefit the majority of adult patients undergoing lumbar fusion surgery for a degenerative indication. Prospective studies with standardized PT approach, additional patients and greater statistical power are needed to further understand the effects of physical therapy on patients undergoing lumbar fusions for degenerative lumbar instability. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Fewer studies in the literature have examined the role of postoperative physical therapy (PT) after lumbar fusion. In the postoperative setting, much of the rehabilitation literature focuses on postdiscectomy patients. Evaluate and compare the changes in pain and functional scores between patients who completed physical therapy (PT) versus no-PT after their anterior or posterior 1-2 level lumbar fusions for degenerative lumbar instability. Our hypothesis was that the PT group may experience comparatively better functional and pain outcomes than their counterparts. Retrospective. A total of 123 patients with degenerative lumbar instability. Oswestry disability index (ODI) and visual analog scale (VAS). A database of patients undergoing 1-2 level lumbar fusion surgery for degenerative disease was assembled. Demographic and outcome scores such as oswestry disability index (ODI) and visual analog scale (VAS) in patients who participated in postoperative PT vs those that did not were compared. There were 72 and 51 patients in PT and no-PT that met the inclusion criteria, respectively. There were higher numbers of females (63.8%) in PT group. No-PT group had similar numbers of males and females. Mean ages for PT and no-PT groups were 61.4(±14.7) and 59.5(±14.1) years, respectively. Both groups were similar with respective to body mass index. A majority of the cases in both groups involved posterior/posterolateral approach; 55.5% of patients in PT group and 50.9% in no-PT had 1 level lumbar fusion. Mean change (preoperative vs 1-year postoperative) in ODI between the two groups differed significantly (PT vs no-PT: 18.8±13.9 and 9.3±17.5; p=0.019). Similarly, mean change in VAS was significantly different between the two groups (PT vs. no-PT: 3.2±2.18 and 1.05±2.08; p=0.026). None of our PT patients reported any change in pre vs 1-year postoperative followup employment status (35% retired, 38% employed full-time, 11% unemployed and 16% homemaker). Ninety-eight percent of no-PT patients reported no change in employment status during the same timeframe (46% retired, 25% employed full-time, 13% unemployed and 15% homemaker). PT group reported significant improvements in functional and pain scores than their counterparts. Post-lumbar fusion rehabilitation may benefit the majority of adult patients undergoing lumbar fusion surgery for a degenerative indication. Prospective studies with standardized PT approach, additional patients and greater statistical power are needed to further understand the effects of physical therapy on patients undergoing lumbar fusions for degenerative lumbar instability.

Is Indirect Decompression and Fusion More Effective than Direct Decompression and Fusion for Treating Degenerative Lumbar Spinal Stenosis With Instability? A Systematic Review and meta-Analysis.

Study design: Systematic Review and Meta-analysis.Objective: Surgical alternatives to treat lumbar spinal stenosis and instability include indirect (ALIF, OLIF, and LLIF) and direct (TLIF or posterior lumbar interbody fusion) decompression and fusion interventions. Although both approaches have proven to be effective in reducing symptoms, it is unknown if there is any difference in effectiveness between them. In this systematic review and meta-analysis, we aimed to evaluate postoperative pain and disability in patients treated whit indirect vs direct decompression and fusion approaches.Methods: We conducted a systematic review of the literature consulting several databases and identified studies that enrolled patients diagnosed with degenerative lumbar spinal stenosis and instability treated with indirect or direct decompression and fusion techniques. Our primary endpoints were the visual analogue scale, Oswestry Disability Index, and the Japanese Orthopedics Association Back Pain Evaluation Questionnaire 1 year after the procedure. Secondary outcomes included complication rate, blood loss, and surgical time.Results: Nine retrospective and comparative studies were included enrolling a total of 1004 participants. Both surgical strategies had satisfactory clinical outcomes with no significant difference at 1 year. Although the complication rate was similar for both groups, the profile of the adverse events was different. In addition, patients treated with indirect decompression and fusion had significantly less blood loss and operative times.Conclusions: Indirect and direct decompression and fusion techniques are similarly effective in treating patients with lumbar spinal stenosis and instability. The ID group had significantly lower intraoperative blood loss and surgical time values.

Awake spinal fusion - Endoscopic facet sparing transforaminal lumbar interbody fusion under caudal epidural: A game changer

Background: Trans-Kambin fusion offers the advantage of providing reduced morbidity and awake surgery allowing for patient's own neuromonitoring during the procedure, along with reduced hospital stay, early mobilization, reduced blood loss, and reduced operative time, while maintaining the standard of fusion that can be achieved with open/MISS transforaminal lumbar interbody fusion.Objective: Spinal fusions done under GA have restrictions when it comes to patients with OSA/COPD/Cardiac dysfunction, etc. Awake Endoscopic Spinal fusion surgeries can provide a novel solution to such patients.Material and Methods: EKLIF was performed in total of 19 patients with 17 single-level and 02 patients with multilevel lumbar discopathy and/or degenerative spondylolisthesis resulting in axial back pain and claudication, pseudoradicular, or radicular symptoms. Endoscopic discectomy and interbody cage insertion were performed through a 1 cm lateral incision used for transforaminal access, followed by percutaneous pedicle screw-rod fixation. Clinical outcome was assessed by early postoperative pain scores (visual analog score [VAS]). Fusion rates were assessed by X-rays at 6 months. Clinical outcome, time in the operating room, intraoperative blood loss, VAS at preoperative, immediate postoperative, and after 6 months were determined.Results: Excellent and good clinical results were obtained in 16 (84%) out of 19 patients at 6 months. The mean time spent in the operating room 71 min and no patient required a blood transfusion. The mean hospital stay was 2.8 days, with one patient having a prolonged stay of 8 days due to an intraoperative dural tear that was managed conservatively. There was no morbidity related to instrumentation. Postoperative stay was reduced with all patients mobilized on the next day of surgery. Fusion was visible in all patients on follow-up imaging at 6 months. The mean VAS of the study group before surgery was 6.63 with a significant change to 2.94 in the immediate postoperative period. At 6-month follow-up, the mean VAS was 1.3.Conclusions: EKLIF allows for safe and efficient minimally invasive treatment of single and multilevel degenerative lumbar instability with good clinical results. Further prospective studies investigating long-term functional results are required to assess the definitive merits of trans-Kambin fusion of the lumbar spine.

Paraspinal muscle damage in intermuscular and conventional lumbar spinal fixation: A comparative study

BackgroundThe conventional approach for lumbar fixation involves subperiosteal muscle dissection, and disruption of normal blood and nerve supply of the back muscles. Different transmuscular approaches, have been described for better preservation of normal neurovascular structures. This leads to less muscle damage and atrophy and consequently less postoperative pain. PurposeCompare between transmuscular approach and conventional approach for lumbar spine fixation. Study DesignA prospective comparative study carried at Neurosurgery Department, Zagazig University, during the period from February 2018 to February 2019. Patients and methods60 patients with degenerative lumbar instability were included in this study and randomly assigned to one of the two groups, Group A (transmuscular group) and Group B (conventional group). Outcome was assessed, using postoperative Visual Analogue Score (VAS) for back pain, change in pre and postoperative levels of Creatine Phospho-Kinase (CPK), and the postoperative change in the cross-sectional area of multifidus muscle, measured using axial CT cuts. ResultsAs regards the hospital stay, it was 1.5 days less in Group A than Group B (P<0.001). The serum CPK increased by only 3 folds in Group A in comparison to 15 folds increase in Group B, indicating less muscle damage (P<0.001). Postoperative Visual Analogue Scale (VAS) for back pain was higher in Group B than Group A (P<0.001). Decrease in cross-sectional muscle area in Group B (40%) was more than the decrease in cross-sectional area in Group A (10%), (P<0.001), which means more muscle atrophy in Group B than in Group A. ConclusionUsing the transmuscular approach for lumbar spine fixation is a more conservative approach, than the conventional approach, with less muscle atrophy, better preservation of anatomy, and less postoperative pain.

Effects of seated lumbar rotation manipulation in treating degenerative lumbar instability: a protocol for a randomized controlled trial

BackgroundDegenerative lumbar instability (DLI) is a common disease that causes low back pain (LBP) in clinic. It is difficult to completely recover from DLI, and it occurs repeatedly, which seriously affects the quality of life of patients. The epidemiological survey showed that 20–30% of low back pain was related to lumbar instability. Increasing evidence shows that seated lumbar rotation manipulation can effectively improve the clinical symptoms of patients with low back pain. The primary aim of this clinical trial is to observe the intervention effect of seated lumbar rotation manipulation on DLI patients.Method/designA total of 60 participants with DLI will be recruited and randomly allocated into the seated lumbar rotation manipulation group (the intervention group) or lumbar traction in supine position group (the control group) in this prospective, outcome assessor-blind, two-arm randomized controlled clinical trial. The treatment of the two groups lasted for 3 weeks, and the manipulation of the intervention group would be carried out once every other day, three times a week, a total of 9 times; the control group would be given lumbar traction once a day, five times a week, a total of 15 times. JOA (Japanese Orthopaedic Association) and VAS (Visual Analogue Scales) scores will be recorded as the primary outcomes before the treatment and at the 1st, 3rd, 5th, 8th, 10th, 12th, 15th, 17th, and 19th days after treatment and follow-up visit at the first, third, and sixth months. JOA efficacy evaluation standard will be used to evaluate the overall efficacy as the secondary outcomes.DiscussionThe results of this prospective, randomized controlled trial will provide a clinical evidence for the treatment of DLI with seated lumbar rotation manipulation.Trial registrationChinese Clinical Trial Registry ChiCTR2000032017. Registered on 18 April 2020, Prospective registration.

Clinical effect of manipulation therapy for the treatment of degenerative lumbar instability based on myofascial chain theory

To explore clinical effects of manipulation therapy in treating degenerative lumbar instability based on myofascial chain theory. Fifty-seven patients with degenerative lumbar spine instability were analyzed retrospectively from January 2018 to December 2019, and treated with massage manipulation therapy. Among them, 29 patients were treated with massage manipulation therapy based on the myofascial chain theory (myofascial chain group), including 14 males and 15 females, aged from 40 to 69 years old with an average of (51.76±5.07) years old, the courses of disease was (3.4±1.6) years. Twenty-eight patients were treated with massage manipulation therapy based on TCM meridian theory (TCM meridian group), including 12 males and 16 females, aged from 42 to 70 years old with an average of(52.48±4.31) years old, the courses of disease was (3.3±1.7) years. Before treatment, after treatment, 1 and 3 months after treatment, visual analogue scale (VAS) was used to evaluate pain degree of lumbar, Japanese Orthopaedic Association (JOA) and modified Oswestry Disability Index (ODI) were used to assess improvement of lumbar function, and changes of lumbar muscle tension were used to evaluate clinical effect. VAS score, JOA score, modified ODI score and lumbar muscle tension after treatment were significantly improved than those of before treatment between two groups (P<0.05) . There were no statistical difference in VAS score, JOA score, modified ODI score and lumbar muscle tension between two groups before treatment and after treatment immediately(P> 0.05). However, VAS score, JOA score, modified ODI score and lumbar muscle tension at one and three months after treatment in myofascial chain group weresignificantly better than that of TCM meridian group (P<0.05). Manipulation therapyon in treating degenerative lumbar instability based on myofascial chain theory could effectively relieve low back pain symptom and improve lumbar function. It is worthy of promoting.

Safety and Efficacy With Augmented Second-Generation Perforated Pedicle Screws in Treating Degenerative Spine Disease in Elderly Population.

Degenerative spine disease is a common cause of low back pain in people age 65 years or older. Nonsurgical treatment is tried first, but if it is unsuccessful, surgery is advocated. This has special connotations for both underlying disease and the biomechanical characteristics of osteoporotic bone. We conducted an observational study to investigate the clinical and radiological outcome in patients in this age group with poor bone quality and degenerative lumbar instability treated with fusion using perforated pedicle screws augmented with polymethylmethacrylate (PMMA). We collected prospective data on treatment, outcome, and patient characteristics from our institution's database. The primary outcome was a change in pain and physical function measured by the visual analog scale, the Core Outcome Measures Index, and the Oswestry Disability Index. Control participants were also analyzed for secondary complications such as hardware mobilization, fusion (as apparent on radiographs), and adjacent fractures or adjacent degenerative disc disease. We included 89 patients who underwent surgery between October 2015 and February 2018 at a mean age of 78 years (range, 67-88 years) and were then monitored for at least 12 months (range, 12-40 months). Findings on pain and function questionnaires showed improvement at 6 months after surgery, maintained at the final evaluation; 90% of patients had final score increases of ≥15 points. No patient developed clinical complications secondary to PMMA leakages. One patient had nonunion and screw breakage. No other patient had clinical or radiological nonunion. Of the control participants, 6 had adjacent disc disease, with 2 of them requiring instrumentation extension. Six deep infections required surgical revision without removal of material. PMMA-augmented cannulated pedicle screw instrumentation in spine fusion effectively and safely treats degenerative lumbar disease in patients who are age 65 years or older with poor bone quality.

Posterior Lumbar Interbody Fusion in Degenerative Lumbar Spine Disease and Risk of Adjacent Segment Disease

Objective: To determine the chances of adjacent segment disease (ASD) and risk factors after posterior lumbar interbody fusion (PLIF).&#x0D; Material and Methods: 110 patients of both genders with degenerative lumbar instability at L4/5 level were included in my study. We did PLIF in all our patients and followed our patients for one year. The following parameters were measured: the degree of lumbar lordosis, the degree lumbosacral angle, the disc space height and their dynamic angulation and the displacement of L3 over L4. We checked the outcome with the help of the Japanese orthopedic association (JOA) and Oswestry disability index (ODI). We divided the patients into groups A and B; group A includes patients with progression of degeneration at the proximal level (L3-L4), while group B with no progression of disease at proximal level.&#x0D; Results: The 86 patients (78.18%) were in group A, and 24 patients (21.88%) were in group B. There were no significant difference in radiological parameters of both groups; lumbosacral angle of lordosis, L3 laminar inclination angle, preoperative degenerative changes at proximal level, L4–L5 lordosis and BMD before surgery. The clinically and statistically significant differenceswere of the age of the patients falling in two groups. We found that at the completion of study ODI and JOA were not significantly different in both groups (P &gt;0.05).&#x0D; Conclusion: Degenerative lumbar disease is an age related disease with no significant effect of radiological degenerations on the final outcome of our patients.No other possible risk factor has a significant effect on outcome.

Unilateral versus bilateral Pedicle Screw Fixation associated with interbody fusion in degenerative Lumbar spine diseases

Abstract Background Lumbar interbody fusion is a recognized surgical technique in treatment of degenerative lumbar instability. Interbody fusion supplemented with pedicle screw fixation has several advantages over posterolateral fusion and has been advocated to improve fusion rates and clinical outcomes. Interbody fusion places the bone graft in the loadbearing position of the anterior and middle spinal columns thereby enhancing the potential for fusion. In addition, the interbody space has more vascularity than the posterolateral space, also increasing the potential for a solid fusion mass to form. Aim of the Work to assess safety and efficacy of unilateral pedicle screw fixation associated with interbody fusion in Lumbar spine degenerative diseases and to evaluate and compare outcomes of unilateral versus bilateral pedicle screw fixation associated with interbody fusion in lumbar spine degenerative diseases, as regard the operation time, bleeding, postoperative stay, cost, and the clinical and biomechanical results. Material &amp; Methods This observational prospective comparative study of the 2 groups who were operated either unilateral (Group A /25 patients) or bilateral (Group B/25 patients) pedicle screw fixation with interbody fusion was done. Patients were followed up for 1, 6, 12 months. This study occurred at Ain Shams University hospitals. Results No differences were observed between the two groups with respect to demographic data. The patients of the two groups had significant improvement in functional outcome compared to preoperatively, except in early postoperative VAS back and ODI in unilateral group which is better than bilateral group. However, no significant difference noticed in the further follow up. There was no significant difference comparing fusion rate, complication rate and duration of hospital stay between the two groups at postoperative follow-up. There was significantly less blood loss, shorter postoperative pain killer use and significantly shorter operation time in the unilateral PS fixation group as compared with the bilateral PS fixation group in our study. Conclusion Our study suggested TLIF with unilateral PS fixation was as safe and effective as that with bilateral PS fixation. Unilateral PS fixation may significantly reduce the intraoperative blood loss and shorten the operation time, somewhat improve the clinical outcome scores of ODI and VAS Back without significant difference comparing fusion rate, complication rate and duration of hospital stay between the two groups at postoperative follow-up. BPSF with TLIF likely causes more degeneration at the cranial adjacent segment compared with UPSF techniques. However, the long-term follow up is required to demonstrate the impact of these findings.

Efficacy and safety of tranexamic acid usage in patients undergoing posterior lumbar fusion: a meta-analysis

BackgroundThe purpose of this meta-analysis is to evaluate the efficacy and safety of tranexamic acid (TXA) for patients with degenerative lumbar disc herniation, stenosis or instability undergoing posterior lumbar fusion (PLF) surgery.MethodsWe searched PubMed, Embase, and Cochrane Library until May 1, 2018. Two reviewers selected studies, assessed quality, extracted data, and evaluated the risk of bias independently. Weighted mean difference (WMD) and relative risk (RR) were calculated as the summary statistics for continuous data and dichotomous data, respectively. We chose fixed-effects or random-effects models based on I2 statistics. RevMan 5.0 and STATA 14.0 software were used for data analysis.ResultsNine studies enrolling 713 patients for the study. The pooled outcomes demonstrated that TXA can decrease total blood loss (TBL) in patients underwent PLF surgery [WMD = -250.68, 95% CI (− 325.06, − 176.29), P<0.001], intraoperative blood loss (IBL) [WMD = -72.57, 95% CI (− 103.94, − 41.20), P<0.001], postoperative blood loss (PBL) [WMD = -127.57, 95% CI (− 149.39, − 105.75), P<0.001], and the loss of hemoglobin (Hb) in postoperative 24 h [WMD = -0.31, 95% CI (− 0.44, − 0.18), P<0.001]. However, there is no significant difference between two groups in transfusion rate [RR =0.34, 95% CI (0.09, 1.28), P = 0.11], and none thrombotic event was happened in the two groups.ConclusionOur meta-analysis demonstrated that TXA can decrease the Hb loss, TBL, IBL, PBL, and without increasing the risk of thrombotic event in patients with degenerative lumbar disc herniation, stenosis or instability underwent PLF surgery. However, there was no significant difference in blood transfusion rates between the two groups.

Full-Endoscopic Lumbar Fusion Outcomes in Patients with Minimal Deformities: A Retrospective Study of Data Collected Between 2011 and 2015

Background: Open transforaminal lumbar interbody fusion (TLIF) is the gold standard treatment for back pain due to degenerative disc disease and lumbar instability. Traditional open TLIF has been associated with extensive tissue dissection, excessive blood loss, and slow recovery time. Full-endoscopic transforaminal lumbar interbody fusion (FE-TLIF) is an evolving treatment. Objectives: This study aims to review outcomes of FE-TLIF performed in an ambulatory surgery center (ASC) on patients with advanced disc disease with minimal spinal deformity. Study Design: This study employed a retrospective cohort design. Methods: This Western Institutional Review Board-approved study (#1-925640-1) assessed blood loss, operative time (OR time), post anesthesia care unit time (PACU time), and Visual Analog Scale (VAS) of 85 patients who underwent FE-TLIF between 2011 and 2015 and were followed up for 12 months. Relationships between risk factors (demographics, clinical presentation) and outcomes were analyzed. Results: No intraoperative complications were observed. There were 2 cases of postoperative sympathetically mediated pain and 3 reoperations. The number of decompression/fusion levels was crucial to OR time but had a smaller impact on PACU time. OR time for patients with 2-level fusion was 110 minutes longer than for those with one level operation. BMI and age had no significant effect on OR time. BMI had a modest effect on PACU time. Gender and age did not affect PACU time. A significant decrease in VAS was observed. Limitations: This study has several limitations, including the lack of a control group and reliance on patient-reported outcomes (VAS). In addition, fusion rate and global sagittal alignment were not measured. Although not statistically significant, the use of facet screws, unilateral, or bilateral pedicle screws presented variation in techniques within the group. Early recovery also diminished the incentive for long-term follow-up. Conclusion: FE-TLIF is a feasible technique for lumbar stabilization surgery in an ASC in select patients. This level-II study demonstrates safety in a variety of clinical presentations, including obesity, extremes of age, and anatomical access challenge. Larger clinical series are necessary to validate this technique, particularly for the treatment of patients with advanced spinal deformities. Key words: Full-endoscopic, minimally invasive spine surgery, postoperative complications, TLIF, lumbar fusion, low back pain

Short-term effects of combined pedicle/facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach for the treatment of degenerative lumbar spine diseases in the elderly

Objective To examine the feasibility and early effects of unilateral pedicle screw fixation in combination with contralateral translaminar facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach for the treatment of degenerative lumbar spine diseases in elderly patients. Methods A total of 82 elderly patients with degenerative lumbar spine diseases received treatment between January 2015 and June 2016.Of these patients, 25 had lumbar spinal stenosis, 42 had degenerative lumbar instability, 13 had giant lumbar disc herniation, and two had recurrent lumbar disc herniation; There were 69 cases of single segment and 13 cases of double segment lesions.Perioperative evaluation, imaging evaluation, and clinical evaluation were performed, and surgical complications were analyzed. Results The average length of incision was (2.6±0.4) cm in cases of single segment lesions and (4.4±0.5) cm in cases of two segment lesions.The mean operation time was (98.3±19.6) minutes and peri-operation blood loss was (232.2±25.8) ml.The post-operation height of the intervertebral disc space significantly increased at the last follow-up(P<0.05); the height of the intervertebral disc space was restored and well maintained with internal fixation showing no loosening, breakage or Cage shift.The post-operation lumbar coronal Cobb angle decreased(P<0.05)while the sagittal Cobb angle increased(P<0.05)at the last follow-up.There was no significant difference in the area and grade of the multifidus muscle on MRI 12 months after operation.Seventy-two patients were followed up for 12-18 months(mean=16.8 months), and there were 67 cases of intervertebral fusion(93.1%). The last follow-up showed a Japanese Orthopaedic Association(JOA)score of (25.8±1.7), which was significantly higher than the pre-operation score(10.6±1.3), with an excellence rate of 88.9%.The Oswestry Disability Index score was significantly reduced, from (50.9±21.6) at pre-operation to (9.6±4.8) at the last follow-up.There were 78 patients with primary wound healing, three cases of superficial wound necrosis, one case of dural tear, and one case of nerve root injury.No cardiovascular or cerebrovascular incident was observed during or after operation. Conclusions Combined pedicle/facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach shows satisfactory short-term effects when used for the treatment of degenerative lumbar spine diseases in the elderly and possesses advantages such as minimal invasiveness, limited bleeding, quick recovery, high fusion rates and significantly improved clinical outcomes.However, further clinical studies are required to assess its medium-and long-term efficacy. Key words: Spinal fusion; Surgical procedures minimally invasive; Arthritis, degenerative

Correlations between the sagittal plane parameters of the spine and pelvis and lumbar disc degeneration

BackgroundStudies have shown that lumbar disc herniation, degenerative lumbar instability, and other degenerative lumbar spinal diseases are often secondary to disc degeneration. By studying the intervertebral disc, researchers have clarified the pathological changes involved in intervertebral disc degeneration but have ignored the roles of biomechanical factors in the development of disc degeneration. This study aims to investigate the relationships among the location, scope, and extent of lumbar disc degeneration and sagittal spinal-pelvic parameters.MethodsA retrospective analysis was performed on the clinical data of 284 patients with lumbar degenerative disc diseases (lumbar disc herniation and degenerative lumbar instability) from January 2013 to December 2016. Statistics were calculated for the following: (1.) patients’ general information: name, sex, age, height, and weight. (2.) Measurements of sagittal parameters from total spinal radiographs: thoracic kyphosis (TK), Lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), T1 tilt angle (TA), and T1 pelvic angle (TPA). (3.) Location, scope, extent, and overall degree of lumbar disc degeneration. Parameters were analyzed in groups by sex, PI, and SVA, and a correlation analysis was performed for the location, scope, extent, and overall degree of lumbar intervertebral disc degeneration with 8 spinal-pelvic sagittal parameters.ResultsThe mean ages of the male and female patient groups were 59.00 and 53.28 years old, respectively (P < 0.05). The PT, location, scope, and overall degree of degradation were significantly different between the sexes (P < 0.05). Linear correlation analysis results showed that the overall degree and extent of degradation (r = 0.788, P < 0.01), LL and SS (r = 0.737, P < 0.01), PI and PT (r = 0.607, P < 0.01), and TPA and PT (r = 0.899, P < 0.01) were strongly correlated. The location values were 4.08 ± 0.72 in patients with PI≤50° and 3.62 ± 0.94 in patients with PI> 50° (P = 0.018). Different SVASVA groups differed in their overall degree of degeneration (P = 0.002).ConclusionsThe location of lumbar intervertebral disc degeneration is affected by spinal-pelvic sagittal morphology. Populations with small PI values tend to exhibit degeneration at the L4/5 and L5/S1 discs, and populations with large PI values tend to exhibit degeneration at the L3/4 and L4/5 discs. The SVA value and the overall degree of lumbar disc degeneration are positively correlated.

141 - Should Physical Therapy Be Incorporated in Patient Care After 1- or 2-Level Lumbar Fusion for Degenerative Lumbar Instability? A Comparative Outcome Analysis

141 - Should Physical Therapy Be Incorporated in Patient Care After 1- or 2-Level Lumbar Fusion for Degenerative Lumbar Instability? A Comparative Outcome Analysis

Fusion Rates of Intervertebral Polyetheretherketone and Titanium Cages without Bone Grafting in Posterior Interbody Lumbar Fusion Surgery for Degenerative Lumbar Instability.

Background Posterior lumbar interbody fusion (PLIF) surgery is a commonly used procedure for degenerative lumbar instability. Locally harvested bone is usually inserted into intervertebral cages to increase fusion rate. The fusion rate without bone application remains unknown. Our aim was to analyze retrospectively the fusion rates of intervertebral polyetheretherketone (PEEK) and titanium cages in PLIF surgery that were implanted without bone grafting using three-dimensional computed tomography (CT) scanning. Material and Methods Forty patients (age 43–83 years) with mono- or bisegmental degenerative instability were included. PEEK cages were used in 28 segments (25 patients), and titanium cages were used in 17 segments (15 patients) undergoing PLIF surgery plus pedicle screws. The primary outcome parameter was radiologic fusion rate measured by CT at follow-up. Secondary parameters included rate of implant failure and adjacent segment disease. Results No difference in mean age between groups was identified (PEEK: 69 ± 10 years; titanium: 62 ± 13 years). Mean follow-up was 39 ± 13 months in PEEK and 24 ± 12 months in the titanium group. Radiologic fusion rate was 32% of operated segments in PEEK and 53% in the titanium group. Screw loosening/adjacent-level disease was observed in 8% and 8% in the PEEK group and in 0% and 7% in the titanium group, respectively. Conclusion Radiologic fusion rates of PEEK and titanium cages without bone grafting is low in PLIF surgery, and therefore bone grafting should be performed if possible. Rate of implant failure and adjacent-level disease remains low despite reduced osseous fusion in the operated segments.

Case control study of interbody fusion with simple decompression bone block in treating degenerative lumbar instability and spinal stenosis

To explore the value of the self-decompression bone block in interbody fusion. From April 2014 to May 2015, 42 patients with degenerative lumbar instability and spinal stenosis were treated by posterior vertebral lamina decompression and pedicle nail-rod fixation and unilateral modified transforaminal lumbar interbody fusion, including 18 males and 24 females. The treatment group had 24 cases with autologous pure decompression bone block as single interbody fusion material and the control group had 18 cases with cage and autologous bone as interbody fusion material. Clinical data, bone healing time, interbody fusion rate, intervertebral height and curative effect were analyzed in two groups. All the patients were followed up for 12 to 24 months with an average of 16 months. There was no significant difference in age, sex ratio, degree of lumbar instability, or follow-up time between two groups(P>0.05); and there was no significant difference in curative effect, intervertebral height loss, or interbody fusion rate between two groups(P>0.05). Using self-decompression bone block fusion can get high fusion rate, maintain good intervertebral height, obtain satisfactory curative effect. Its design was scientific and reasonable with less complication, which provide an effective, economic, and practical method for degenerative lumbar instability and spinal stenosis.

Treating low back pain resulted from lumbar degenerative instability using Chinese Tuina combined with core stability exercises: A randomized controlled trial

BackgroundThe therapeutic effect of Tuina combined with core stability exercises on low back pain resulted from lumbar degenerative instability is unclear. This article aims to evaluate whether core stability exercises can improve the effect of Tuina in this regard. MethodsThis trial was designed as a randomized controlled trial and carried out in Qingzhou hospital of Traditional Chinese medicine between June 2011 and June 2013. Eighty-eight patients with low-grade lumbar degenerative instability were included and divided randomly into experimental and control groups, 44 in each. The experimental group were treated using Tuina combined with core stability exercises, but the control group using Tuina alone. The evaluation of Visual analogue scale (VAS), Japanese Orthopaedic Association scores (JOA) and recurrence rate were performed. ResultsTwo weeks after treatment, JOA scores increased (p<0.05) and VAS decreased (p<0.05) significantly when compared with those before treatment in both groups, but there was no significant difference (p>0.05) between the two groups. At the end of six weeks, VAS scores (p<0.05) decreased and JOA scores (p<0.05) increased significantly when compared to those before treatment in both groups. In addition, the VAS (p<0.05) scores were significantly lower, JOA scores (p<0.05) were significantly higher in experimental group than those in control group. At the final follow-up, seven cases (17.1%) in experimental group and eighteen (43.9%) in control group recurred, the control group has a significantly higher recurrence rate (p<0.05). No adverse events occurred in the trial. ConclusionsChinese Tuina combined with core stability exercises has better effect than Tuina alone in treating low back pain resulted from low-grade lumbar degenerative instability.

Intervertebral Disc Changes after Vertebral Distraction Performed During Posterolateral Spine Fusion for Lumbar Segmental Instability

Analysis of intervertebral disc regeneration after disc height restoration by posterolateral spinal fusion with lumbar distraction of 68 patients diagnosed with degenerative lumbar instability.

Long-Term Outcome of Deep Wound Infection following Lumbar Arthrodesis for Degenerative Disc Disease

Introduction Deep wound infections are one of the most common and serious complications of spinal surgery. The impact of such infections on long-term outcomes is not well understood. The purpose of this study was to evaluate the functional status and satisfaction in patients who suffered a deep wound infection after undergoing lumbar arthrodesis for symptomatic degenerative disc disease. Patients and Methods The authors conducted a prospective study in 13 patients with a clinical and radiological diagnosis of symptomatic degenerative lumbar stenosis and instability; after undergoing decompression and instrumentation–augmented arthrodesis, the patients suffered a deep wound infection (infection group). A 3:1 (39 patients) matched cohort was selected for comparison (control group). All surgeries were performed during the same period and by a single surgeon. The postoperative infections were all treated in a similar manner and the instrumentation was not removed. Both groups were followed up and assessed with validated following outcome instruments: Numerical Rating Scale of pain, Oswestry Disability Index, 36-Item Short Form Health Survey, Beck Depression Inventory, and Hospital Anxiety and Depression Scale. Patient satisfaction was also determined. Results The median follow-up duration was 22 months (range, 6–108 months). The mean patient age was 62 ± 10 years, and 59.6% of the patients were female. There was no significant difference between the groups in pain, functional disability, quality of life, or depression and anxiety. However, 53.8% of the patients with infection were not satisfied with the procedure at the final evaluation, compared with 15.4% of the patients without a deep wound infection ( p = 0.003). Conclusion Patients with successfully treated postoperative deep wound infections do not have a difference in functional outcome compared with patients who underwent an identical operation but did not suffer a complicating infection. Patients who suffered an infection were more likely to be unsatisfied with the procedure than patients who did not.