Posterior Lumbar Intervertebral Fusion Research Articles

Hydroxyapatite/collagen composite graft for posterior lumbar interbody fusion: a comparison with local bone graft

BackgroundAutologous bone has been used for posterior lumbar intervertebral fusion (PLIF). However, harvesting autologous bone graft is associated with donor site complications. We previously developed a hydroxyapatite/collagen (HAp/Col) composite as an osteoconductive artificial bone, characterized by having a highly porous structure with sponge‐like elasticity. This study aims to investigate the effectiveness of HAp/Col composite with bone marrow aspirate (BMA) as a graft substitute in PLIF for the treatment of lumbar spinal diseases.MethodsThis study prospectively investigated patients who received one-level PLIF. For the interbody fusion, two titanium cages were inserted. On the one side of interbody space, HAp/Col composite incorporated with BMA filling the titanium cage was grafted. On the other side, local bone graft (LBG) harvested during decompressive laminotomy was grafted and then one-level instrumentation using pedicle screws was performed. The target levels were at L2/3 in 2 cases, L3/4 in 3 cases, L4/5 in 36 cases, and L5/S in 5 cases. We evaluated clinical symptoms and radiological outcomes of 46 patients and compared the fusion status of HAp/Col composite with that of LBG.ResultsThe 1-year postoperative CT evaluation demonstrated that, in the HAp/Col, a complete fusion was observed in 38 patients (82.6%), whereas in the LBG, a complete fusion was observed in 35 patients (76.1%). There were no statistical differences between the HAp/Col and LBG. In the HAp/Col, incomplete fusion was observed in five patients (10.9%) and non-fusion in two patients (4.3%), and in the LBG, incomplete fusion was observed in nine patients (19.6%) and non-fusion in two patients (4.3%). At 2 years after the surgery, complete fusion increased to 44 patients (95.7%) in the HAp/Col and 41 patients (89.1%) in the LBG. There were no significant differences in the clinical scores for lumbar spine between patients with fusion and non-fusion.ConclusionsThe HAp/Col composite with BMA in the titanium cage can be effectively used as an alternative to conventional autologous LBG for intervertebral spinal fusion.Trial registration University hospital Medical Information Network, UMIN000045010, July 30th, 2021, Retrospectively registered, https://www.umin.ac.jp/english/.

The acupoint herbal plaster for the prevention and treatment of postoperative nausea and vomiting after PLIF with general anesthesia: study protocol for a multicenter randomized controlled trial

BackgroundPostoperative nausea and vomiting (PONV) are common in posterior lumbar intervertebral fusion (PLIF) patients undergoing general anesthesia. The previous clinical observation has shown that a traditional acupoint herbal plaster (AHP) is beneficial to patients with PONV. This trial aims to assess the effect of the AHP for the prevention and treatment of PONV after PLIF in patients with general anesthesia.MethodsA multicenter, parallel, randomized controlled trial (RCT) will be conducted. A total of 166 participants will be randomized to either a treatment group receiving an AHP or a control groups receiving an acupoint placebo plaster (APP) in a 1:1 ratio. The primary outcomes are the first occurrence and frequency of nausea and vomiting. The secondary outcomes include the severity grading of nausea and vomiting using a visual analog scale (VAS) measurement system, quality of life, and serological indicators. The safety evaluation is mainly about adverse events and skin reactions’ observation. Assessments will be carried out at the baseline, day 1, and day 2 (the end of the intervention). The central randomization system in the clinical trial (http://124.205.181.142:8082/xwtf/) will be used to conduct random allocation.DiscussionThis scientific methodology design of the trial is expected to provide clinical evidence to support the AHP for the prevention and treatment of PONV.Trial registrationThis study is retrospectively registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn) on 19 April 2018. ID: ChiCTR1800015768.

An age-stratified follow-up of complications and clinical benefit of posterior lumbar intervertebral fusion procedure in middle-aged and older patients

To compare the complications and clinical scores of posterior lumbar intervertebral fusion (PLIF) in middle-aged and older patients of different ages, and to assess the risk of complications of PLIF in different ages, providing a reference for clinical treatment. The clinical data of 1 136 patients, who were more than 55 years old and underwent PLIF between June 2013 and June 2016, were retrospectively analyzed. According to the age of patients undergoing surgery, they were divided into 3 groups as 55-64 years old, 65-74 years old, and ≥75 years old. The general characteristics, comorbidities, and surgical data of the three groups were compared, with comparison the morbidity of complications. According to the minimal clinical important difference (MCID), the improvement of patient's pain visual analogue scale (VAS) score and the Oswestry disability index (ODI) score were compared. Univariate logistic regression analysis was used to analyze the difference of complications and the improvement of VAS and ODI scores. Multivariate logistic regression analysis was performed for the risk factors of complications. There were significant differences in the number of surgical fusion segments and osteoporosis between groups ( P<0.05); there was no significant difference in gender, body mass index, operation time, preoperative American Society of Anesthesiologists (ASA) classification, and comorbidities between groups ( P>0.05). All patients were followed up 6-62 months with an average of 27.4 months. Among the results of postoperative complications, there were significant differences in the total incidence of intraoperative complications, systemic complications, minor complications, and the percentage of improvement of ODI score to MCID between groups ( P<0.05); but there was no significant difference in the total incidence of complications at the end of long-term follow-up and the percentage of improvement of VAS score to MCID between groups ( P>0.05). Univariate logistic regression analysis showed that after adjusting the confounding factors, there were significant differences in intraoperative complications and the percentage of improvement of ODI score to MCID between 55-64 and 65-74 years old groups ( P<0.05); systemic complications, minor complications, complications at the end of long-term follow-up, and the percentage of improvement of ODI score to MCID in ≥75 years old group were significantly different from those in the other two groups ( P<0.05). Multivariate logistic regression analysis showed that age was a risk factor for systemic complications, minor complications, and complications at the end of long-term follow-up. Except for age, long operation time was a risk factor for intraoperative complications, increased number of fusion segments was a risk factor for systemic complications, the number of comorbidities was a risk factor for minor complications, and osteoporosis was a risk factor for complications at the end of long-term follow-up. The risk of surgical complications is higher in the elderly patients (≥75 years) with lumbar degenerative diseases than in the middle-aged and older patients (<75 years), while the improvements of postoperative VAS and ODI scores were similar. Under the premise of fully assessing surgical indications, PLIF has a positive effect on improving the elderly patients' quality of life.

Biomechanical Evaluation of Two Posterior Lumbar Intervertebral Fusion Surgical Scenarios Reinforced by a Rigid Posterior Fixation System in the Vertebral Column Analyzed by the Finite Element Method

Biomechanical Evaluation of Two Posterior Lumbar Intervertebral Fusion Surgical Scenarios Reinforced by a Rigid Posterior Fixation System in the Vertebral Column Analyzed by the Finite Element Method

Risk factors for surgical site infection following posterior lumbar intervertebral fusion

To analyze the risk factors of surgical site infection (SSI) following posterior lumbar intervertebral fusion. This retrospective case-control study was conducted in 2904 patients undergoing posterior lumbar intervertebral fusion from 2011 to 2016. Forty-three patients with SSI within 30 days after the operation served as the case group, and 334 randomly selected patients without infection served as the control group. Age, gender, diabetes, body mass index (BMI), albumin level, multilevel procedures, subcutaneous fat thickness, surgery duration and the percentage of lumbar multifidus muscle fat infiltration were analyzed, and univariate and multivariate logistic regression analyses were performed to identify the risk factors of SSI. Multivariate logical regression analysis identified a female gender, subcutaneous fat thickness, multilevel surgery, and lumbar multifidus muscle fat infiltration as significant risk factors for SSI (P < 0.05). BMI was not correlated with fat infiltration in the lumbar multifidus muscle (P > 0.05). A female gender, multilevel surgery, subcutaneous fat thickness and fat infiltration in the multifidus muscle are related to SSI following posterior lumbar intervertebral fusion. Fat infiltration in the multifidus muscle was a spine-specific risk factor for SSI independent of BMI.

Comparison of Clinical and Radiographic Results Between Posterior Pedicle-Based Dynamic Stabilization and Posterior Lumbar Intervertebral Fusion for Lumbar Degenerative Disease: A 2-Year Retrospective Study.

To compare outcomes between K-rod dynamic stabilization system (KDSS) and posterior lumbar intervertebral fusion (PLIF) for lumbar degenerative disease. This study retrospectively reviewed 98 patients who underwent lumbar surgery from March 2012 to June 2014, including 48 in the KDSS group and 50 in the PLIF group. All patients were followed up for at least 2 years. Duration of operation, blood loss, hospital stay, complications, and patient satisfaction were recorded and analyzed. Clinical outcomes were evaluated by visual analog scale and Oswestry Disability Index. Radiographic results including disk height index, foraminal height, and range of motion (ROM) were compared between groups. Compared with PLIF group, KDSS group had shorter duration of operation and less blood loss (P<0.001). There were no differences in hospital stay, complications, and patient satisfaction. Both groups demonstrated significant improvement in visual analog scale back and leg pain and Oswestry Disability Index. No significant difference was found between groups at any time point (P > 0.05). Postoperative disk height index and foraminal height increased significantly compared with preoperatively (P < 0.05). Although disk height index and foraminal height in KDSS group were smaller than PLIF group values, there were no significant differences between groups. ROM of total lumbar and implanted segment was decreased compared with preoperative ROM in both groups (P < 0.05), but the 2 values were higher in KDSS group (P < 0.05). Both KDSS and PLIF can improve clinical and radiographic outcomes for early-stage lumbar degenerative disease. Compared with PLIF, KDSS has better operative time, less blood loss, and better preservation of ROM, but prospective, randomized, controlled trials with larger sample size and longer follow-up are required.

Effects of heated medical elastic stockings on the prevention of deep venous thrombosis and hypothermia of lower limbs during posterior lumbar intervertebral fusion

Objective To develop a kind of heated medical elastic stockings to prevent the occurrence of deep vein thrombosis (DVT) and hypothermia in patients with lumbar degenerative diseases undergoing posterior lumbar intervertebral fusion (PLIF) . Methods A total of 180 patients with lumbar degenerative diseases undergoing PLIF from February 2015 to August 2017 were selected by purposive sampling method, and divided into routine group (group A) , normal elastic stockings (group B) , heated medical elastic stockings (group C) according to the sequence of operation time, with 60 cases in each group. On the premise of routine thermal protection measures and DVT basic preventive measures, group A did not wear stretch socks, group B wore normal elastic stockings, and group C wore heated medical elastic stockings. Patients in the group B and C were treated with normal and heated stretch stockings during anesthesia preparation 1 hour prior to surgery. The incidence rate of lower extremity DVT and hypothermia in each group was calculated by monitoring deep veins blood flow velocity of both lower limbs, D-dimer, foot temperature and the core temperature at each time node during the operation. Results In group C: left femoral superficial vein velocity was (17.47±3.07) cm/s; right femoral superficial vein velocity was (16.95±3.25) cm/s; left popliteal vein blood flow velocity was (16.03±3.37) cm/s; right popliteal vein blood flow velocity was (16.37±3.39) cm/s. All the results above were higher than those in group A and B (P<0.01) . The D-dimer were (587±129) μg/L at the end of surgery and (392±119) μg/L 24 h after surgery in group C, which were significantly lower than group A and B (P<0.01) . The incidence of DVT at the end of operation and 24 hour postoperation in group A was 8.3% and 15.0%, while 5.0% and 5.0% in group B respectively. There was no DVT occurrence in group C at the two time points, and the difference was statistically significant (P<0.01) . Comparing foot temperature and core temperature of each time point, it was significantly higher in group C than group A and B (P<0.05) . There were 8 cases of hypothermia in group C, and the incidence rate was 12.5%, which were both significantly lower than that in group A (56.7%) and group B (40.0%) (P<0.01) . Conclusions The heated elastic stockings can effectively reduce the risk of DVT and hypothermia in the patients with lumbar degenerative diseases undergoing PLIF and can be popularized in clinical practice. Key words: Venous thrombosis; Compression stockings; Hypothermia; Prevention

Comparison of outcomes between minimally invasive transforaminal lumbar interbody fusion and traditional posterior lumbar intervertebral fusion in obese patients with lumbar disk prolapse.

ObjectiveThe aim of this study was to compare the curative effect between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and the posterior lumbar interbody fusion (PLIF) in obese patients with lumbar disk prolapse.Patients and methodsIn this study, 72 patients who underwent lumbar disk prolapse therapy in the Third Hospital of Hebei Medical University between March 2011 and 2015 were retrospectively analyzed and were divided into two groups, MIS-TLIF group (n=35) and PLIF group (n=37), according to different surgical procedures. Several clinical parameters were compared between these two groups.ResultsCompared with PLIF, MIS-TLIF was associated with longer operative time, less blood loss, less postoperative drainage and shorter postoperative time in bed; moreover, patients in the MIS-TLIF group had lower levels of serum creatine kinase on 1, 3 and 5 postoperative days. At the 3- and 6-month follow-up, Visual Analog Scale (VAS) scores of low back pain of patients in the MIS-TLIF group were significantly reduced and Japanese Orthopaedic Association (JOA) scores were increased, whereas the Oswestry Disability Index (ODI) showed no significant difference between the two groups.ConclusionObese patients can achieve good efficacy with MIS-TLIF or PLIF treatment, but MIS-TLIF surgery showed longer operative time, fewer traumas and bleeding volume, less incidence of short-term pain, low complication rate and faster postoperative recovery.

Letter: Comparison of Posterior Lumbar Interbody Fusion and Posterolateral Lumbar Fusion in Monosegmental Vacuum Phenomenon within an Intervertebral Disc.

We read with great interest the article by An et al. [1] titled Comparison of Posterior Lumbar Interbody Fusion and Posterolateral Lumbar Fusion in Monosegmental Vacuum Phenomenon within an Intervertebral Disc. The authors analyzed retrospectively collected data involving 84 patients and described their experience with postero-lateral and posterior lumbar inter-vertebral fusion in situations of mono-segmental inter-vertebral disc vacuum. This issue remains controversial and the authors' description is definitely an eye-opener to the readers. It is a well-written article and has fore-grounded some of the major concerns of the contemporary medical fraternity. We do have some queries to the authors regarding this study:

Evaluation of efficacy of a new hybrid fusion device: a randomized, two-centre controlled trial.

BackgroundThe 360° fusion of lumbar segments is a common and well-researched therapy to treat various diseases of the spine. But it changes the biomechanics of the spine and may cause adjacent segment disease (ASD). Among the many techniques developed to avoid this complication, one appears promising. It combines a rigid fusion with a flexible pedicle screw system (hybrid instrumentation, “topping off”). However, its clinical significance is still uncertain due to the lack of conclusive data.Methods/DesignThe study is a randomized, therapy-controlled, two-centre trial conducted in a clinical setting at two university hospitals. If they meet the criteria, outpatients presenting with degenerative disc disease, facet joint arthrosis or spondylolisthesis will be included in the study and randomized into two groups: a control group undergoing conventional fusion surgery (PLIF - posterior lumbar intervertebral fusion), and an intervention group undergoing fusion surgery using a new flexible pedicle screw system (PLIF + “topping off”), which was brought on the market in 2013.Follow-up examination will take place immediately after surgery, after 6 weeks and after 6, 12, 24 and 36 months. An ongoing assessment will be performed every year.Outcome measurements will include quality of life and pain assessments using validated questionnaires (ODI - Ostwestry Disability Index, SF-36™ - Short Form Health Survey 36, COMI - Core Outcome Measure Index). In addition, clinical and radiologic ASD, sagittal balance parameters and duration of work disability will be assessed. Inpatient and 6-month mortality, surgery-related data (e.g., intraoperative complications, blood loss, length of incision, surgical duration), postoperative complications (e.g. implant failure), adverse events, and serious adverse events will be monitored and documented throughout the study.DiscussionNew hybrid “topping off” systems might improve the outcome of lumbar spine fusion. But to date, there is a serious lack of and a great need of convincing data on safety or efficacy, including benefits and harms to the patients, of these systems. Health care providers are particularly interested in such data as these implants are much more expensive than conventional implants. In such a case, randomized clinical trials are the best way to evaluate benefits and risks.Trial registrationNCT01852526

Instrumentation of Low Grade Lumbar Degenerative Spondylolisthesis, is Total Laminectomy Inevitable?

Instrumentation of Low Grade Lumbar Degenerative Spondylolisthesis, is Total Laminectomy Inevitable? To evaluate the clinical outcomes of patients with degenerative spondylolisthesis myerding grade I and II who underwent Posterior lumbar Intervertebral Fusion (PLIF) without total laminectomy.

Three dimensional computed tomography (3D-CT) and radiographs assessment of interbody fusion after posterior lumbar intervertabral fusion.

Objective To evaluate the clinical application of three dimensional computed tomography (3D-CT) and radiographs in assessment of interbody fusion after posterior lumbar intervertebral fusion (PLIF). Methods Forty-three patients, consisting of 19 males and 24 females were treated with PLIF in single segment from March 2000 to June 2007. The mean age was 47.2 years. The interbody fusion was performed by autograft in 26 cases and autograft plus PEEK cages in 17 cases. The preoperative diagnosis were isthmus spondylolisthesis in 21 cases, degenerative spondylolisthesis in 15 cases, Lumbar disc herniation associated with instability in 3 cases, revision after primary lumbar discectomy in 3 cases, and far lateral disc herniation in 1 cases. The interbody fusion levels were L_(3,4) in 6 cases, L_(4,5) in 17 cases,and L_5S_1 in 20 cases. Twenty-four patients underwent two-level internal fixation, while 19 cases accepted three-level fixation. The posterior, lateral static radiograph, flexion-extension radiographs and 3D-CT were performed at follow-up visit . The modified Brantigan grade was used to assess the fusion rate. The interbody stability was assessed by the flexion-extension radiographs. Results The mean follow-up was 18 months (12-85 months). The fusion rates in X-rays and 3D-CT were 64% and 40%, respectively. The mean Brantigan grade in X-rays and 3D-CT were 2.70±1.10 and 2.19±1.16, respectively. The grade was significantly lower in 3D-CT (P< 0.05). The Brantigan grades in 3D-CT were also significantly lower than those in X-ray between the groups of isthmus spondylolisthesis and degenerative spondylolisthesis, two-level and three-level internal fixation, and autograft only and autograft plus PEEK cages. There were only 3 cases showing dynamic instability. The other cases (93%) had no instability according to dynamic X-rays ,even those were comfirmed of nonunion of the bone graft . Conclusion The lumbar 3D-CT is more accurate in assessment of interbody fusion. It is necessary to perform the 3D-CT before removal of the internal fixation. Key words: Lumbar vertebrae ; Spinal fusion ; Radiography ; Tomography ; X-ray computed ;

A Technical Modification of Cloward's Posterior Lumbar Interbody Fusion

The concept of interbody (intercorporal) fusion as a useful treatment for intervertebral disc disease in the cervical area has been well received. Thirty-two years have passed since Cloward first introduced his technique of posterior lumbar intervertebral fusion. The author believes that the delayed acceptance of this procedure is due to fear of technical difficulties. A technical modification of Cloward's posterior lumbar interbody fusion is introduced. It entails better technique in controlling epidural bleeding by careful positioning of the patient and the use of oxidized cellulose as a tampon in the epidural space. The integrity of the facet is preserved through a more limited interlaminal approach. Osteosynthesis of the grafts is assured by multiple perforations of the cortical plate in accordance with Robinson's principle utilized in cervical interbody fusion. The author believes that the modification simplifies the Cloward posterior lumbar interbody fusion. It also assures better stability after surgery by retention of the facet and lessening the dangers of settlement of the graft by preservation of the cortical plate. In a series of 75 cases, tomograms made 4 months after operation have shown a viable graft with active osteosynthesis between the graft and the adjoining vertebral bodies in 94%.