Lumbar Spine In Extension Research Articles

One- or Two-Level Transforaminal Lumbar Interbody Fusion without Closed-Suction Wound Drainage

Background Data: Although many surgeons stopped using closed-suction drainage following simple spine decompression surgery, there is still debate regarding the necessity of wound drainage in more extensive lumbar spine surgical procedures. Purpose: To estimate the advantages and disadvantages of performing one- or two-level transforaminal lumbar interbody fusion (TLIF) without closed-suction drainage. Study Design: Retrospective clinical cohort study. Patients and Methods: The Fast-Track technique was performed in 36 consecutive TLIF surgeries between January and September 2016 without using wound drainage. Twenty-eight patients were females and 8 were males. Thirty patients had single-level TLIF and 6 double-level TLIF. The results of these patient series were retrospectively analyzed. The variables that were reviewed included blood transfusion, postoperative temperature, postoperative pain and the use of opiates during hospital stay, duration of surgery, duration of hospital stay, and incidence of postoperative complications such as neurological deficit, hematoma, postoperative wound infection, and revision surgery. Results: There was no postoperative allogenic blood transfusion; the patients did not develop postoperative neurological deficit; there were no cases of surgical revision as a result of significant postoperative hematoma or infection. There were two cases (5.5%) of revision surgery due to persistent CSF leakage from the wound. Four patients (11.1%) developed serous discharge from the wound, which was treated conservatively with frequent dressing and antibiotics. Four patients (11.1%) developed transient postoperative fever. The mean pain score in the first 2 days after surgery assessed by the Visual Analogue Score (VAS) was 6.1 points, and additional opiate in the first 2 postoperative days was mandatory in 30 patients (83.3%). Conclusion: Performing one- or two-level lumbar decompression and fusion without closed-suction wound drainage did not increase the rate postoperative infection or hematoma formation. Additionally, none of our patients required postoperative blood transfusion. (2018ESJ168)

Continuous Bilateral Erector of Spine Plane Block at T8 for Extensive Lumbar Spine Fusion Surgery: Case Report

Supplementary strategies, in combination with conventional analgesia, for pain control after lumbar fusion surgery remain limited. Here, we describe a 79-year-old woman who experienced pain (10/10 on a numeric rating scale) on postoperative day 1 after undergoing L2 to S1 spine fusion. Erector spinae plane (ESP) blocks were performed at T8 and, after a bolus of ropivacaine 0.2% (20 mL) per side, perineural catheters were placed bilaterally. Continuous infusion (5 mL/h) of ropivacaine 0.2% per side was maintained for 48 hours. During this period, 2 boluses (15 mL) per day of ropivacaine 0.2% were administered bilaterally to maintain optimal analgesia. Bilateral ESP catheterizations at T8, placed remotely from the surgical site, may be considered for patients undergoing extensive spinal fusion procedures, because they contribute to significant analgesic improvement, without significant motor block; the effect of the block remains mostly in the posterior rami of spinal nerves and in the posterior bony elements of the vertebrae. The risk for hematoma or bacterial colonization related to catheter placement at T8 level using epidural or ESP techniques is low; nevertheless, a delay in the diagnosis of postoperative epidural hematoma or abscess directly related to the surgical intervention is a potential concern in spine fusion surgery. However, the action of an ESP block is primarily in the posterior rami of the spinal nerves, which makes an eventual neuraxial compression less likely to be masked by an ESP block compared with an epidural block, because an ESP hematoma or infection will not directly impinge on the spinal cord. A 79-year-old woman experienced excruciating pain on post-operative day 1 after undergoing L2 to S1 spine fusion. Bilateral continuous erector spinae plane (ESP) blocks were performed at T8 and, after a bolus of ropivacaine 0.2% (20 mL) per side, a continuous infusion (5 mL/hour) of ropivacaine 0.2% per side was maintained for 48 hours, which provided effective analgesia. During this period, two boluses (15 mL) per day of ropivacaine 0.2% were administered bilaterally to maintain optimal analgesia. ESP catheterizations at T8, placed remotely from surgical site, may be considered in extensive lumbar spinal fusion cases.

67Ga Scintigraphy in the Evaluation of Postsurgical Low Back Pain

A 62-y-old man presented with chronic, diffuse lower back pain 8 mo after undergoing extensive lumbar spine surgery for osteomyelitis that included an L4 and L5 diskectomy with partial corpectomy, followed by anterior spinal fusion of L4 and L5 with a fibular allograft, and L3 to S1 posterior fusion

Continuous Spinal Analgesia after Extensive Lumbar Spine Surgery

A 77-year-old male underwent L-1 to S-1 spine decompression and fusion from L-3 to S-1. A 25 G spinal catheter was placed intraoperatively and bupivacaine 1.25 mg/ml, fentanyl 2 microg/ml and morphine 3 microg/ml infused. The patient was pain-free for the duration of the infusion. Continuous spinal analgesia was effective after extensive spinal surgery. The risks of post-dural puncture headache, infection of wound and/or meninges and the optimum drug doses and combinations are yet to be quantified in this setting.

A Comparison of the Torsional Stiffness of the Lumbar Spine in Flexion and Extension

Objective The main mechanism of injury to the spine is torsion especially when coupled with compression. In this study, the in vitro torsional stiffness of the lumbar spine segments is compared in flexion and extension positions by cyclic and failure testing. Methods Fifteen lumbar spines were sectioned from fresh cadavers into 15 L2/3 and 15 L45 motion segments. Each vertebral segment was then potted superiorly and inferiorly in polymethylmethacrylate, effectively creating a bone-disk-bone construct. The potted spinal segments were mounted in a mechanical testing system, preloaded in compression to 300 N, and axially rotated to 3° in both directions at a load rate of 1°/s. This was done over 3 cycles for each motion segment in the flexion and extension positions. Each specimen was then tested to torsional failure in either flexion or extension. Stiffness, torque, and energy were determined from cyclic and failure testing. Results The results showed that in all cases of cyclic testing, the higher segment extension resulted in higher torsional stiffness. In relative extension, the lumbar specimens were stiffer, generated higher torque values, and generally absorbed more energy than the relative flexion condition. There were no differences found in loading direction or failure testing. Conclusions Increasing the effective torsional stiffness of the lumbar spine in extension could provide a protective mechanism against interverbral disk injury. Restoration of segmental extension through increasing the lumbar lordosis may decrease the strain and reinjury of the joints, which can help reduce the extent of pain in the lumbar spine.

A Comparative Biomechanical Investigation of Anterior Lumbar Interbody Cages: Central and Bilateral Approaches*

Some biomechanical studies have been performed to evaluate the stabilization provided by interbody cages, but there are virtually no comparative data for the different designs. Furthermore, most investigators have used animal models, which may have led to different results due to morphological variation in the end plates and articular facets. The objectives of the current study were to evaluate whether two different anterior cage designs (BAK and SynCage) performed differently with respect to immediate stabilization of the spine, whether the cages stabilized the spine significantly compared with its intact condition, and whether the addition of supplementary translaminar screw fixation further stabilized the spine. Stabilization was defined as a reduction in motion after insertion of an implant. Twelve lumbar functional spinal units from human cadavera were tested under pure moments of flexion, extension, bilateral axial rotation, and bilateral lateral bending to a maximum of ten newton-meters. The relative intervertebral motions were measured, with use of an optoelectronic camera system, under three test conditions: with the spine intact, after insertion of anterior interbody cages, and after insertion of anterior interbody cages supplemented with translaminar screw fixation. Six specimens were tested for each type of cage: a bilateral, porous, threaded cylinder (BAK) and a central, porous, contoured implant with end-plate fit (SynCage). The cages performed in a similar manner in all directions of loading, with no significant differences between the two designs. The cages significantly stabilized the spine compared with its intact condition in flexion, axial rotation, and lateral bending (the median value for motion was 40, 48, and 29 percent of the value for the intact condition, respectively; p = 0.002 for all three directions). Compared with the cages alone, translaminar screw fixation provided no additional stabilizing effect in these directions but it significantly increased the stability of the spine in extension (the median value for motion was 34 percent of the value with the cages alone; p = 0.013). There were no differences in the stabilization provided by the two different cage designs. Use of the cages alone stabilized the spine in all directions except extension, and use of supplementary translaminar screw fixation provided additional stabilization only in extension. This study demonstrated that interbody cages do not stabilize the lumbar spine in extension, and this observation was not altered by the use of substantially different designs. If the lack of stabilization in extension is a clinical problem, possible solutions include the avoidance of extension postoperatively or the use of supplementary fixation.

Progression of scoliosis in Duchenne muscular dystrophy.

We reviewed the clinical charts and spinal radiographs of fifty-one boys who had Duchenne muscular dystrophy, had not had surgical treatment of the spine, and had been followed until death. All had scoliosis. None of the following variables was useful in predicting which curves would become severe: age when the patient initially walked, age when he ceased walking, age at onset of spinal collapse, surgical release of the iliotibial bands, or age at the time of death. Radiographs were made within eighteen months before death for thirty-three patients; in thirty-one of them, the final curve exceeded 40 degrees and in seventeen, 90 degrees. For the remaining eighteen patients, final radiographs were made more than eighteen months before death; at that time, eight of them already had a curve of more than 90 degrees. Although there was a relationship between extension of the lumbar spine and severity of scoliosis at the time of final follow-up, early maintenance of the lumbar spine in extension rarely prevented the development of a severe curve. For most of the patients who had a severe curve, sitting was difficult and was accompanied by breakdown of the skin and pain. When a patient's curve exceeded 35 degrees, the vital capacity usually was less than 40 per cent of the predicted normal value. Therefore, when walking becomes impossible for boys who have Duchenne muscular dystrophy, routine spinal arthrodesis should be considered.