Management Of Degenerative Disc Disease Research Articles

Long-Term Results of Charité Lumbar Disc Replacement: A 17-Year Follow-Up in a Workers' Compensation Cohort.

Lumbar total disc replacement (TDR) is an alternative to lumbar fusion for the management of degenerative disc disease. This study aims to provide insight into the long-term clinical outcomes of lumbar TDR with a mean follow-up of 17.2 years in a group of workers' compensation patients. A total of 26 workers' compensation patients with radiographically confirmed discogenic low back pain were treated with the Charité total lumbar disc replacement. Visual analog scale (VAS) scores were assessed before and after the surgery. At follow-up, patients were assessed on quality of life, employment, further lumbar spine surgeries, and associated complications. Simple nonparametric statistical analysis was performed by the first author using Microsoft Excel. Sixteen patients (62%) were able to be contacted with a mean follow-up time of 17.2 years. VAS scores at 17 years were significantly lower than their preoperation level. Of those 16 patients, 81% returned to work and worked for an average of 9.1 years after surgery. Additionally, 6 (38%) patients underwent further lumbar spinal surgery, of whom 4 underwent fusions of the adjacent segment. Nearly all patients (94%) were satisfied with the surgery. This study suggests lumbar TDR may be a useful treatment for degenerative disc disease in select workers' compensation patients. Clinically relevant improvements in pain and employment can be achieved with the charite lumbar TDR in the treatment of degenerative disc disease in workers' compensation patients. These results are sustained over the long term.

Degenerative Lumbar Disc Disease: A Questionnaire Survey of Management Practice in India and Review of Literature.

Objective To identify the current management modalities practiced by neurosurgeons in India for degenerative lumbar disc disease. Materials and Methods Survey questionnaires were prepared in Google forms. It covered the following aspects of managing the lumbar disc pathology: (1) Demographic, institutional details, experience of surgeons, (2)choice of surgical procedures, (3) use of endoscopy and minimally invasive techniques, and (4) pre- and postoperative care. Responses obtained were entered in SPSS datasheet and analyzed. Results Of the 300 surveys sent, 80 were returned and response rate was 26.6%. But four surveys were highly incomplete and were discarded from the analysis. So, the study content is from the analysis of practices of 76 spinal surgeons working in different parts of the country. Majority of the spine surgeons ( n = 70) were neurosurgeons, while 6 were orthopaedic surgeons. Fifty-four were from urban area, 12 from semiurban area, and 10 from rural area. Forty-seven spine surgeons practiced in a teaching hospital. Total 73.6% of spine surgeons opted initial medical management. Sixty-three percent preferred microlumbar discectomy (MLD) and only eight neurosurgeons preferred minimally invasive techniques. None of the respondents used in situ fusion. Fifty-three percent of spine surgeons preferred early mobilization (first postoperative day). Fifty-nine percent preferred to follow-up patients clinically and opted for magnetic resonance imaging only when recurrence or infection was suspected. The institutional nature (government teaching, government nonteaching, private teaching, and private nonteaching) and location of the hospital (urban/semiurban/rural) were found to be influencing the preferred surgical technique, trial of medical management, or postoperative care and complications. Considerable practice variations exist for medical and perioperative management. Conclusion The preferred treatment of choice of majority was MLD, although laminectomy and discectomy were still used by many. Consensus lacks in the operative, perioperative, and postoperative management of degenerative disc disease. Present survey points toward the importance of making management guidelines for this common spinal surgical entity.

Full Percutaneous Treatment of Degenerative Disc Disease with Intradiscal Lumbar Interbody Fusion and Posterior Stabilization: Preliminary Results.

To report the preliminary results of a novel full percutaneous interbody fusion technique for the treatment of degenerative disc disease (DDD) resistant to conservative treatment with posterior stabilization with rods and screws and transforaminal placement of an 8-mm-width intradiscal cage. A total of 79 patients with lumbar spine DDD resistant to medical therapy and/or spondylolisthesis up to grade 2 were treated. We performed preoperative X-rays, CT and MRI. The outcomes were assessed using the VAS score and the Oswestry Disability Index at a 1-, 6- and 12-month follow-up and also included X-rays to evaluate the correct bone fusion and the absence of complications. Mean operation time was 130min, and mean postoperative time until hospital discharge was 2days. Postoperative values for VAS scores and ODI improved significantly compared to preoperative data: Mean preprocedural VAS was 7.49 ± 0.69 and decreased at 12-month follow-up to 1.31 ± 0.72, and mean preprocedural ODI was 29.94 ± 1.67 and decreased at 12-month follow-up to 12.75 ± 1.44. No poor results were reported, and no postprocedural sequelae were observed. In our experience, this preliminary report shows a feasible and safe full percutaneous alternative procedure and represents a minimally invasive management of degenerative disc disease with low back pain resistant to medical therapy with or without lumbar spondylolisthesis up to grade 2.

Non-Surgical Management of Degenerative Disc Disease by Reversing the Pathophysiology with Sit Up Exercise

Background: Millions of people all over the world are living with degenerative disc disease, some bed ridden, others with crippling pains, while some have intermittent pains that reduce their productivity. Appropriate treatment that will be preventive, curative, and cost-effective is still being sought for. Objective: To find out the treatment outcome of patients who were managed with sit up exercise for degenerative disc disease over a five year period. Methods: It was a prospective study of patients managed in our center for degenerative disc disease using sit up exercise from January 1, 2014 to December 31, 2018. Patients were clerked and physically examined in the clinic noting the site(s) of pain and muscle weaknesses. Sit up exercise and passive muscle movement (for those with muscle weakness) were done. Paracetamol and Diclofenac were given for pains. Results: Thirty five patients qualified for the study. Males were twenty. The average age was 57·14 years. Sixteen patients had pain and muscle weaknesses. In 96·97% of patients with pain and 83·33% of patients with muscle weakness, the symptoms/signs resolved within six months. Age played significant role in region involved P = 0·01, duration of symptoms P =0·00, and time for pain to resolve P = 0·00. There was significant relationship between gender and symptoms P = 0·04, and time for pain to resolve P = 0·01 Conclusion: Thirty four patients recovered with sit up exercise, while the 35th patient is still improving. Age and gender played significant roles in the disease. Funding Statement: There was no sponsorship. Declaration of Interests: There was no conflict of interest. Ethics Approval Statement: The study was component of our prospective data bank that was approved by our hospital research and ethics committee.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P119. Prospective randomized clinical controlled trial comparing clinical outcomes of nunec versus prestige cervical disc replacement with five-year follow-up

BACKGROUND CONTEXT Cervical disc replacement today is a very viable option in the management of degenerative disc disease. This 5-year prospective randomised controlled trial compared the combined (single & multilevel), clinical outcomes between NunecTM and Prestige. PURPOSE Our study hypothesis was that the clinical outcomes following anterior cervical decompression disc replacement using NunecTM (PEEK on PEEK) prosthesis is better than or same as Prestige (METAL on METAL) replacement at short to long term follow-up (6 months, 1, 2, 3, 4, and 5 years) STUDY DESIGN/SETTING Prospective Randomised Controlled Trial. PATIENT SAMPLE A total of 57 participants (NunecTM 28; Prestige® 29) were recruited after screening through a rigorous inclusion and exclusion criteriae. OUTCOME MEASURES Primary Outcome measures included (1) Visual Analogue score for Neck pain (VAS-NP) (2) Visual Analogue score for Arm pain (VAS-AP) (3) Neck Disability Index (NDI) (4) Depression and (5) Anxiety scores. Secondary outcome measures as evaluated in the follow-up clinics, included (1) return to work (2) clinical range of movement (3) adjacent segment re-operation (4) complications and (5) implant failure. METHODS Paired t-test was used to analyse any statistical difference between pre and postoperative scores and an unpaired t-test was used to compare the outcome scores between NunecTM and Prestige. RESULTS The mean duration of symptoms for NunecTM was 44.0 months (0–204; SD=52.1) and for Prestige 43.8 months (0–350; SD=78.3). The mean follow-up for NunecTM was 4.86years (2–6 years; SD=0.89) and for Prestige 4.52years (1–6 years; SD=1.18).Apart from NDI for NunecTM, comparison between pre and post-op outcome scores showed a statistically significant improvement (p .05). VAS-NP: CI=−2.27 to 1.27, P=.5733; VAS-AP: CI=−2.46 to 1.50, P=.6303; NDI: CI=−2.55 to 22.2, P=.1170; Anxiety: CI=−2.15 to 3.00, P=.7399; Depression: CI=−2.10 to 3.18, P=.6826. CONCLUSIONS This study validates our hypothesis that the clinical outcomes following anterior cervical decompression disc replacement using NunecTM is the same as Prestige (METAL on METAL) replacement at short to long-term follow-up. There is no tangible advantage in the choice between these two devices. However, there is a statistically significant improvement between the pre and postoperative clinical outcomes for both the devices

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OBJECTIVES/SPECIFIC AIMS: Cervical fusion is commonly performed for the management of degenerative disc disease, which can cause spinal stenosis and radiculopathy. Adjacent segment disease (ASD) is an adverse postsurgical outcome experienced by some patients as new radiculopathy, stenosis, or other symptomatic sequelae. We sought to assess whether fusion extension past the cervicothoracic junction reduces the risk of distal ASD after multilevel fusions ending at C7-T3. METHODS/STUDY POPULATION: We retrospectively reviewed all first-time patients undergoing instrumented cervical fusion of at least 2 spinal levels and whose distal level of fusion ranged from C7-T3, at the Johns Hopkins Medical Institutions, from 1999 to 2013. The primary outcome was reoperation for distal ASD. Using multiple logistic regression, ANOVA, and χ2 analysis, we determined the odds of ASD due to age, gender, distal level of fusion, surgical approach (anterior, posterior, or combined), smoking status, and race. RESULTS/ANTICIPATED RESULTS: Of the 158 patients who met the selection criteria, the mean age was 58.7±13.8 years, and 95 (60.1%) were female. Ten patients (6.3%) underwent reoperation for ASD. Patients whose fusions ended at C7 were significantly more likely to develop ASD and undergo reoperation (70%, p=0.007) than those whose fusions ended at T1. There were no differences in age, proximal fusion level, smoking status, BMI, gender, and patient-reported race between the reoperation and non-reoperation groups. Following a multivariable analysis, extending the distal fusion to T1 was again found to be protective against reoperation (OR=0.07, p=0.020). DISCUSSION/SIGNIFICANCE OF IMPACT: Our study shows that for multilevel instrumented cervical fusions that terminate within the cervicothoracic junction, fusion distal to the C7 vertebra is associated with decreased odds of reoperation for symptomatic ASD. Therefore, this study provides clinical evidence that may help surgeons determine the optimal distal fusion segment for multilevel fusions ending at C7-T3.

Complications and Rates of Subsequent Lumbar Surgery Following Lumbar Total Disc Arthroplasty and Lumbar Fusion.

Retrospective analysis. To examine complications and rates of subsequent surgery following lumbar spinal fusion (LF) and lumbar total disc arthroplasty (TDA) at up to 5-year follow-up. LF is commonly used in the management of degenerative disc disease causing pain refractory to nonoperative management. Lumbar TDA was developed as an alternative to fusion with the theoretical advantage of reducing rates of adjacent segment pathology and reoperation. Most prior reports comparing these 2 interventions have come from industry-sponsored investigational device exemption trials and no large-scale administrative database comparisons exist. The California Office of Statewide Health Planning and Development discharge database was queried for patients aged 18 to 65 years undergoing lumbar TDA and LF for degenerative disc disease from 2004 to 2010. Patient characteristics were collected, and rates of complications and readmission were identified. Rates of repeat lumbar surgery were calculated at 90-day and 1-, 3-, and 5-year follow-up intervals. A total of 52,877 patients met the inclusion criteria (LF = 50,462, TDA = 2415). Wound infections were more common following LF than TDA (1.03% vs. 0.25%, P < 0.001). Rates of subsequent lumbar surgery at 90-day and 1-year follow-up were lower with lumbar TDA than LF (90-day-TDA: 2.94% vs. LF: 4.01%, P = 0.007; 1-yr-TDA: 3.46% vs. LF: 4.78%, P = 0.009). However, there were no differences in rates of subsequent lumbar surgery between the 2 groups at 3-year and 5-year follow-up. Lumbar TDA was associated with fewer early reoperations, though beyond 1 year, rates of reoperation were similar. Lumbar TDA may be associated with fewer acute infections, though this may be approach related and unrelated to the device itself. 3.

The timed up and go test for lumbar degenerative disc disease

We report on the use and performance of an objective measure of functional impairment, the timed up and go (TUG) test, in clinical practice for patients with lumbar degenerative disc disease (DDD). We illustrate nine representative patients with lumbar DDD, who were selected from an ongoing prospective study, to report our clinical experience with the TUG test. In addition, a preliminary sample of 30 non-selected consecutive patients is presented. The following parameters were assessed preoperatively, and 3days and 6weeks postoperatively: back and leg pain using the visual analogue scale (VAS); functional impairment using the Oswestry disability index (ODI) and Roland–Morris disability index (RMDI); health-related quality of life using the EuroQol 5D (EQ5D) and Short-Form 12 (SF-12). The TUG test results improved by 2.6 and 5.4s after 3days and 6weeks compared to the baseline assessment. The mean VAS for back and leg pain decreased by 2.3 and 5.3, respectively, after 3days, and by 2.7 and 4.6 after 6weeks. The mean RMDI and ODI decreased by 3.4 and 23.3, respectively, after 3days, and by 7.0 and 28.0 after 6weeks. The mean EQ5D increased by 0.38 after 3days and 0.358 after 6weeks. The mean SF-12 mental component scale decreased by 0.2 after 3days and increased by 5.6 after 6weeks, whereas the mean SF-12 physical component scale increased by 6.4 after 3days and by 9.8 after 6weeks. The TUG test proved to be a useful, easy to use tool that could add a new, objective dimension to the armamentarium of clinical tests for the diagnosis and management of DDD. From our preliminary experience, we conclude that the TUG test accurately reflects a patient’s objective functional impairment before and after surgery.

One decade follow up after nucleoplasty in the management of degenerative disc disease causing low back pain and radiculopathy.

Objectives:Nucleoplasty is a minimally invasive procedure that is developed to treat patients with symptomatic, but contained disc herniations or bulging discs. The purpose of this study was to evaluate a decade follow-up of coblation nucleoplasty treatment for protruded lumbar intervertebral disc.Methods:In this retrospective study there a total 50 patients who underwent intradiscal coblation therapy for symptomatic, but contained lumbar degenerative disc disease were included. Relief of low back pain, leg pain and numbness after the operation were assessed by visual analog pain scale (VAS). Function of lower limb and daily living of patients were evaluated by the Oswestry disability index (ODI) and subjective global rating of overall satisfaction were recorded and analyzed.Results:There were 27 male and 23 female with followup mean follow up of 115 months (range 105–130 months) with a mean age was 52 years (range 26–74 years). Analgesic consumption was reduced or stopped in 90% of these cases after 1 year. At 24 months follow up VAS was four points and ODI was 7.2. In three patients, we repeated the cool ablation after 36 months, at L3–4 level in two cases. Ten patients continue to be asymptomatic after 114 months of intervention. There were no complications with the procedure including nerve root injury, discitis or allergic reactions.Conclusions:Nucleoplasty may provide intermittent relief in contained disc herniation without significant complications and minimal morbidity. In accordance with the literature the evidence for intradiscal coablation therapy is moderate in managing chronic discogenic low back pain; nucleoplasty appears to be safe and effective.

Lumbar Interbody Fusion Rates with Actifuse, i-FACTOR, and Vitoss BA Synthetic Bone Grafts

Introduction One surgical treatment modality for the management of degenerative disc disease causing back and/or leg pain is interbody fusion. Nonunion is associated with poor outcomes. The gold standard bone graft for augmenting and achieving fusion is iliac crest autograft but significant donor morbidity is associated with its harvest. Allografts require processing, to prevent transmission of infections, which impairs their osteogenic and osteoinductive properties. An alternative synthetic bone graft that avoids the morbidity of autograft is safe, and provides reliable fusion and is therefore desired. In our institution, we have used three synthetic bone grafts, Actifuse (Baxter, USA), i-FACTOR (Cerapedics, USA) and Vitoss BA (Stryker, USA), which all report to be bioactive and to enhance bone fusion in transforaminal lumbar interbody fusion (TLIF) procedures. They were all used in combination with morselized local autograft. Materials and Methods Patients undergoing TLIF surgery with one of the mentioned bone grafts were identified from hospital records. Postoperative radiographs were reviewed by an independent blinded radiologist for evidence of spanning trabeculae on orthogonal radiographs. Results A total of 40 patients (55 levels) were included. The number of patients, operated levels, follow-up, and cumulative and overall fusion rates for each bone graft group are demonstrated in Table 1. Conclusion Patients who underwent TLIF with a mixture of i-FACTOR combined morselized local autograft had a higher rate of fusion with a similar mean follow-up and higher cumulative fusion rates over the period studied than Actifuse and Vitoss BA. The smaller patient numbers in the Actifuse and Vitoss BA groups does limit comparisons. Disclosure of Interest None declared

Stem cells in preclinical spine studies

Background contextThe recent identification and characterization of mesenchymal stem cells have introduced a shift in the research focus for future technologies in spinal surgery to achieve spinal fusion and treat degenerative disc disease. Current and past techniques use allograft to replace diseased tissue or rely on host responses to recruit necessary cellular progenitors. Adult stem cells display long-term proliferation, efficient self-renewal, and multipotent differentiation. PurposeThis review will focus on two important applications of stem cells in spinal surgery: spine fusion and the management of degenerative disc disease. Study designReview of the literature. MethodsRelevant preclinical literature regarding stem cell sources, growth factors, scaffolds, and animal models for both osteogenesis and chondrogenesis will be reviewed, with an emphasis on those studies that focus on spine applications of these technologies. ResultsIn both osteogenesis and chondrogenesis, adult stem cells derived from bone marrow or adipose show promise in preclinical studies. Various growth factors and scaffolds have also been shown to enhance the properties and eventual clinical potential of these cells. Although its utility in clinical applications has yet to be proven, gene therapy has also been shown to hold promise in preclinical studies. ConclusionsThe future of spine surgery is constantly evolving, and the recent advancements in stem cell–based technologies for both spine fusion and the treatment of degenerative disc disease is promising and indicative that stem cells will undoubtedly play a major role clinically. It is likely that these stem cells, growth factors, and scaffolds will play a critical role in the future for replacing diseased tissue in disease processes such as degenerative disc disease and in enhancing host tissue to achieve more reliable spine fusion.

Regarding: Intradiscal Pulsed Radiofrequency Application Following Provocative Discography for the Management of Degenerative Disc Disease and Concordant Pain: A Pilot Study

Regarding: Intradiscal Pulsed Radiofrequency Application Following Provocative Discography for the Management of Degenerative Disc Disease and Concordant Pain: A Pilot Study

Intradiscal Pulsed Radiofrequency Application Following Provocative Discography for the Management of Degenerative Disc Disease and Concordant Pain: A Pilot Study

The development of diagnostic criteria and the use of provocative discography allow identifying the degenerative disc as causative structure for chronic low-back pain. Unfortunately, none of the available interventional treatment options have been demonstrated to be effective over a prolonged period of time for a considerable number of patients. Pathophysiological studies indicate sprouting of sensory nerves and inflammatory processes as underlying pain mechanisms. Pulsed radiofrequency (PRF) treatment in small and larger joints was described to reduce pain and improve healing by stimulating the immunology. Earlier findings of PRF applied in the disc annulus were promising. It is assumed that PRF applied in the nucleus would change the conductivity of nerve endings and provide a clinically relevant pain reduction. The application of the electric field of PRF in the disc may also activate the immune system, thus reducing the inflammation process of chronic pain. Pulsed radiofrequency in the nucleus was studied in 76 patients with discogenic pain confirmed by magnetic resonance imaging and provocative discography. At 3-month follow-up, 38% of the patients had > 50% pain reduction, at 12 month the effect is maintained in 29%. In patients with unsatisfactory pain relief 3 months after the intervention, secondary pain sources may have been revealed. The latter were treated accordingly. Of all patients, 56% had > 50% pain reduction 1 year after first treatment. Our findings suggest that PRF in the nucleus may be considered for patients with proven discogenic pain. A randomized controlled trial to confirm our findings is justified.▪

Results of Lumbar Total Disc Arthroplasty in Military Personnel

Evaluation of lumbar total disc arthroplasty (TDA) in military patients. To evaluate the clinical and radiographic outcomes of US military personnel who have undergone TDA for degenerative disc disease and to assess the retention versus discharge rate after undergoing this procedure. TDA was developed as an alternative to arthrodesis for the surgical management of degenerative disc disease with the goal of preserving motion and reducing adjacent segment disease. However, the indications and optimal candidates for this procedure are uncertain. Military members must maintain a certain level of physical fitness and be capable of meeting the demands of hazardous environments. This study reviews results of TDA performed on active duty military members. The surgery schedules from 2005 to 2008 were reviewed to identify military members who underwent single-level or 2-level TDA for degenerative disc disease after failing at least 6 months of conservative management. All patients had a minimum of 2-year follow-up. Preoperative and postoperative clinical assessments were completed using the Oswestry Disability Index (ODI) questionnaire and the numeric rating scale (NRS). Radiographs were evaluated to determine range of motion, height, and disc position at the operated levels. The retention rate of the patients in the military was also recorded. Statistical analysis of the data was carried out with significance assumed at the P < 0.05 level. Thirty-eight patients, implanted with a total of 56 discs, met the criteria for retrospective analysis. Twenty patients had single-level and 18 had 2-level TDA. Mean age was 35 (23 to 56 y) years. Mean follow-up was 28 months. The overall mean preoperative ODI and NRS of 53.6 and 7.3, significantly improved postoperatively to 27.7 and 3.3, respectively (P < 0.001). There was no difference in the postoperative ODI (P = 0.19) or NRS (P = 0.18) when comparing single-level and 2-level TDA. Clinical success was achieved in 79% of patients. Mean range of motion was 6.5 degrees and the mean disc height increased by 69%. Sixty-eight percent of patients returned to full active duty. This study showed clinical success approaching 80% in military patients who underwent lumbar TDA. Furthermore, close to 70% were able to return to their positions within the military. TDA, while more closely reapproximating the normal biomechanics of the spine, may provide patients with an improved alternative to spinal arthrodesis for degenerative disc disease.

Cervical spine surgery: an historical perspective.

Continued innovation in surgery requires a knowledge and understanding of historical advances with a recognition of successes and failures. To identify these successes and failures, we selectively reviewed historical literature on cervical spine surgery with respect to the development of (1) surgical approaches, (2) management of degenerative disc disease, and (3) methods to treat segmental instability. We performed a nonsystematic review using the keywords "cervical spine surgery" and "history" and "instrumentation" and "fusion" in combination with "anterior approach" and "posterior approach," with no limit regarding the year of publication. Used databases were PubMed and Google Scholar. In addition, the search was extended by screening the reference list of all articles. Innovative surgical approaches allowed direct access to symptomatic areas of the cervical spine. Over the years, we observed a trend from posterior to anterior surgical techniques. Management of the degenerative spine has evolved from decompressive surgery alone to the direct removal of the cause of neural impingement. Internal fixation of actual or potential spinal instability and the associated instrumentation have continuously evolved to allow more reliable fusion. More recently, surgeons have developed the basis for nonfusion surgical techniques and implants. The most important advances appear to be (1) recognition of the need to directly address the causes of symptoms, (2) proper decompression of neural structures, and (3) more reliable fusion of unstable symptomatic segments.

Trans-foraminal versus posterior lumbar interbody fusion: comparison of surgical morbidity

<title/>Background: Posterior lumbar interbody fusion (PLIF) and trans-foraminal lumbar interbody fusion (TLIF) are both accepted surgical approaches for spinal fusion in spondylolisthesis and degenerative disc disease. The unilateral approach of TLIF may minimize the risk of iatrogenic durotomy and nerve root injury; however, there is no definitive evidence to support either approach. We review our experience with TLIF versus PLIF to compare operative complications.Methods: We retrospectively reviewed 119 consecutive cases of PLIF or TLIF performed for degenerative disc disease or spondylolithesis at a single institution over 5 years and examined the incidences of operative complications and outcomes.Results: PLIF was performed in 76 (63%) patients and TLIF in 43 (37%). Patients were 48±13 years old and presented with mechanical back pain [109 (92%)], radicular pain [95 (80%)], and radicular motor weakness [10 (8%)]. Patients undergoing PLIF and TLIF had similar baseline demographic, clinical, and radiographic characteristics. PLIF was associated with a higher incidence of post-operative iatrogenic nerve root dysfunction [6 (7·8%) versus 1 (2%)] and durotomy [13 (17%) versus 4 (9%)]; however, these differences did not reach statistical significance. All cases of nerve root injury were transient and resolved by the third month post-operatively. Estimated operative blood loss, length of hospitalization, and other peri-operative indices were similar between cohorts. By 12 months, evidence of pseudoarthrosis was present in 2 (2·6%) and 2 (4·6%) patients with PLIF or TLIF, respectively. There was a similar incidence of improvement in radicular pain (88% versus 79%) and low back pain (74% versus 80%) between TLIF and PLIF.Conclusion: In our experience with surgical management of degenerative disc disease and spondylolesthesis, PLIF versus TLIF was associated with a trend toward a higher incidence of nerve root injury and durotomy. However, iatrogenic nerve root dysfunction was transient in all cases and 12-month pseudoarthrosis rates were similar between cohorts. Similar to previous clinical studies, the incidence of neurological complications and durotomy increases when an interbody fusion is performed through a posterior approach compared to non-interbody fusion techniques. However, the fusion rates with the interbody technique are also enhanced. TLIF and PLIF should only be considered when the goals of surgery cannot be addressed with decompression and traditional posterolateral fusion.

Hypertension intracrânienne idiopathique révélant une malformation d’Arnold-Chiari

Minimally invasive transforaminal interbody fusion (MIS-TLIF) has been shown to have excellent outcomes for surgical management of degenerative disc disease. However, the challenge is in addressing coronal imbalance and restoring lumbar lordosis and sagittal alignment. Use of expandable cages in MIS-TLIF has been hypothesized to circumvent this disadvantage. An indirect meta-analysis of the evidence is presented comparing outcomes from expandable cages with those from nonexpandable cages, in patients undergoing MIS-TLIF.PRISMA guidelines were used to conduct a systematic review and meta-analysis to compare the clinical and radiologic outcomes of expandable cages and nonexpandable cages in patients undergoing MIS-TLIF.Twelve studies (706 patients) were included in the meta-analysis. The mean increase in disc height was found to be significantly greater for the nonexpandable cages group than for the expandable cages group (1.33 mm; 95% confidence interval [CI], 1.28–1.38 vs. 1.14 mm,; 95% CI, 1.06–1.23; P < 0.001). No significant difference was found regarding change in lumbar lordosis at last follow-up between the 2 groups (P = 0.34). The mean change in segmental lordosis was found to be significantly higher for the expandable cage group (5.04°, 95% CI, 3.89–6.20 vs. 2.08°, 95% CI, 1.93–2.22; P < 0.001). We did not detect any significant difference in fusion rate (P = 0.33), subsidence rate (P = 0.41) or in reoperations (P = 0.56) at last follow-up between the 2 groups.Our results indicate that there may not be a significant difference in clinical and radiologic parameters between expandable cages and nonexpandable cages among patients undergoing MIS-TLIF, and it is unclear if the higher cost of the expandable cages is justified.

Anterior Lumbar Interbody Fusion in the Treatment of Mechanical Low Back Pain

A number of options exist for patients with intractable back pain and degenerative disc disease (DDD). Interbody fusion techniques exploit the mechanical advantages of the disc space anteriorly, including a large fusion bed, excellent blood supply and graft compression. Unlike posterior approaches, the anterior, retroperitoneal technique affords wide access to the disc space without necessitating significant retraction on the lumbar extensor muscles. Instrumentation options are rapidly advancing, but remain more limited than posterior approaches. The failure rate of stand-alone anterior lumbar interbody fusion (ALIF) remains a concern and a variety of percutaneous or less invasive posterior approaches have been devised to augment ALIF procedures. This article examines the role of stand-alone and posteriorly stabilized ALIF in the management of DDD.

Posterior Lumbar Interbody Fusion versus Circumferential Fusion Using the B-Twin Expandable Spinal System

We reviewed the medical files of 32 patients with degenerative disc disease, spinal stenosis, and spondylolisthesis who underwent posterior lumbar interbody fusion using the B-Twin system. In 12 of these patients, posterior lumbar interbody fusion has been supplemented with posterior lumbar-instrumented fusion (circumferential fusion) because of spinal instability. Clinical and functional outcomes were assessed. The quality of fusion and disc height were recorded. The mean follow-up was 36 months (range, 18 to 42 months). At the latest examination, clinical improvement and fusion were statistically significant in both groups; the mean Oswestry disability index improved from 55% to 24%, and to 22% in the patients with more than 20 months follow-up; the mean Rolland-Morris disability questionnaire improved from 52% to 29% (p < 0.001); 95.6% (22/23) of the levels managed with the B-Twin system alone and 92.9% (13/14) of the levels managed with circumferential fusion showed solid fusion; and the intervertebral disc height increased from 8.1 +/- 0.74 mm to 11.4 +/- 0.93 mm in the B-Twin group and from 7.7 +/- 0.75 mm to 10.6 +/- 0.91 mm in the circumferential fusion group. However, in comparing the two groups there was no statistical significant difference. The B-Twin system is safe and effective for the management of degenerative disc disease as a stand-alone device. The combination with posterior lumbar-instrumented fusion systems for circumferential fusion yields statistically significant differences in fusion rate and functional outcome.

11:06 8. The first prospective two year minimum follow-up of metal-on-metal

BACKGROUND CONTEXT: Motion preservation represents a new trend in the surgical management of degenerative disc disease. The Maverick TDR has been designed as a metal-on-metal prosthesis that clearly mimics the center of rotation of the damaged degenerative segment. By restoring height, stability, and functional load bearing of the diseased interspace, many believe that this functional restoration may prove a better long-term solution to degenerative disc disease as opposed to the gold standard of interbody fusion.