Revision Lumbar Spine Surgery Research Articles

Added value of 18Fluorine-fluorodeoxyglucose (18F-FDG) PET/MRI for evaluation of failed back surgery syndrome: comparison with non-contrast MRI.

Given increasing research suggesting the utility of positron emission tomography/magnetic resonance imaging (PET/MRI) in identifying the pain generator of low back pain, our study aims to assess its effectiveness in evaluating the source of pain in patients with failed back surgery syndrome (FBSS) by comparing the performance of fluorine-18-labeled fluorodeoxyglucose (18F-FDG) PET/MRI with conventional MRI. We retrospectively analyzed data from patients with FBSS who underwent 18F-FDG PET and MRI of the lumbar vertebrae and lower extremities for undetermined sources of pain. We assessed 1) The diagnostic reliability and efficacy of MRI and 18F-FDG PET/MRI according to correct differential diagnosis, affected level, and affected side of the pain source compared to the findings of selective root or peripheral nerve block or revision lumbar spine surgery; and 2) The association between standardized uptake value (SUV) and standardized uptake value ratio (SUVR) threshold and accuracy of the suspected pathology on 18F-FDG PET/MRI. Among 30 included patients, the diagnostic accuracy of pain source recognition was higher for 18F-FDG PET/MRI than for MRI alone (1.0 vs. 0.4 in spinal disease and 0.8 vs. 0 in lower extremity disease, both p < 0.05). SUVR values of 1.4-1.5 showed the highest accuracy (0.93), higher than the accuracy obtained using the SUV threshold (0.87). 18F-FDG PET/MRI added value to MRI alone in detecting of hypermetabolic activity associated with pain from spinal and non-spinal sources.

118. Patient expectations and surgical satisfaction in primary versus revision lumbar spine surgery

118. Patient expectations and surgical satisfaction in primary versus revision lumbar spine surgery

Patient expectations and surgical satisfaction in primary versus revision lumbar spine surgery

Patient expectations and surgical satisfaction in primary versus revision lumbar spine surgery

Minimally Invasive Surgical Techniques in Revision Lumbar Spine Surgery

Minimally Invasive Surgical Techniques in Revision Lumbar Spine Surgery

Results of revision lumbar spine surgery

Introduction: Lumbar degenerative disease is a common health problem all over the world and the need of revision surgery is still high with variable results. The aim of the work is to evaluate the clinical and radiological outcome in cases of redo surgery for lumbar degenerative pathology and to specify which pathology is responding well to revision surgery. Method: Twenty patients were operated upon for revision of previous failed back surgery. Selection of patients for revision surgery depends on confirmed radiological and clinical compression or instability. All patients were operated and followed at least 6 months after surgery. VAS score was used as a tool for evaluation of back and leg pain. Conclusion: Revision spine surgery provides better outcome and results depending on patient's general and physical condition with less chances of re infection specially if operated under proper aseptic precautions.

Advantages of Revision Transforaminal Full-Endoscopic Spine Surgery in Patients who have Previously Undergone Posterior Spine Surgery.

Revision lumbar spine surgery via a posterior approach is more challenging than primary surgery because of epidural or perineural scar tissue. It demands more extensive removal of the posterior structures to confirm intact bony landmarks and could cause iatrogenic instability; therefore, fusion surgery is often added. However, adjacent segment disease after fusion surgery could be a problem, and further exposure of the posterior muscles could result in multiple operated back syndrome. To address these problems, we now perform transforaminal full-endoscopic spine surgery (TF-FES) as revision surgery in patients who have previously undergone posterior lumbar surgery. There have been several reports on the advantages of TF-FES, which include feasibility of local anesthesia, minimal invasiveness to posterior structures, and less scar tissue with fewer adhesions. In this study, we aim to assess the clinical outcomes of revision TF-FES and its advantages. We evaluated 48 consecutive patients with a history of posterior lumbar spine surgery who underwent revision TF-FES (at 60 levels) under local anesthesia. Intraoperative blood loss, operating time, and complication rate were evaluated. Postoperative outcomes were assessed using the modified Macnab criteria and visual analog scale (VAS) scores for leg pain, back pain, and leg numbness. We also compared the outcome of revision FES with that of primary FES. Mean operating time was 70.5 ± 14.4 (52-106) minutes. Blood loss was unmeasurable. The clinical outcomes were rated as excellent at 16 levels (26.7%), good at 28 (46.7%), fair at 10 (16.7%), and poor at 6 (10.0%). The mean preoperative VAS score was 6.0 ± 2.6 for back pain, 6.8 ± 2.4 for leg pain, and 6.3 ± 2.8 for leg numbness. At the final follow-up, the mean postoperative VAS scores for leg pain, back pain, and leg numbness were 4.3 ± 2.5, 3.8 ± 2.6, and 4.6 ± 3.2, respectively. VAS scores for all three parameters were significantly improved (p < 0.05). There was no significant difference in operating time, intraoperative blood loss, or the complication rate between revision FES and primary FES. Clinical outcomes of revision TF-FES in patients with a history of posterior lumbar spine surgery were acceptable (excellent and good in 73.4% of cases). TF-FES can preserve the posterior structures and avoid scar tissue and adhesions. Therefore, TF-FES could be an effective procedure for patients who have previously undergone posterior lumbar spine surgery.

The utility of the CADISS® system in the dissection of epidural fibrosis in revision lumbar spine surgery (A case series)

This was a prospective, open label, observational case study. We enrolled 21 patients for revision spine surgery with the CADISS® System at two Belgium sites. The primary assessment was the number of successful removals of epidural fibrosis without cutting. The amount of MESNA used, total dissection and procedure time were recorded. For secondary criterion, the surgeons assessed global satisfaction, facilitation of dissection, quickness of action, usability, bleeding reduction and visualisation of the cleavage plane using an 11-point Likert scale (0-10). Due to the exploratory nature, no formal statistical analysis was planned. We calculated the percentage and confidence interval of successful procedures, the medians and corresponding interquartile range of the Likert criterion, and the mean (±SD) of the amount of MESNA used, CADISS® dissection time and total procedure time. 24 fibrosis dissections were performed in 19 patients and 23 were successful (95.8%, CI: 78.9%; 99.9%). The mean amount of MESNA used, mean dissection time and procedure time were 16ml (±4.94), 16.5min (±16.1) and 86.3min (±25.1), respectively. No dural tears were reported. The mean global satisfaction score was 9.0 (8.0-9.0). All other Likert criterion had scores of 8.0 or 9.0, excluding quickness of action, which scored 7.0 (6.0-9.0). The CADISS® System in revision spine surgery has potential to effectively reduce dissection complications.

Adult revision surgery of prior hook-and-rod wire instrumentation for idiopathic scoliosis

Adolescent idiopathic scoliosis patients treated with spinal fusion may develop adjacent segment disease and curve progression into adulthood. Revision operations can be challenging, especially for adult patients treated with outdated instrumentation such as sublaminar hooks and/or wires. The authors demonstrate revision lumbar spine surgery in a 38-year-old female with scoliosis progression from junctional degeneration below a prior T5–L3 posterior instrumented arthrodesis with a hook-and-rod wire system. They also demonstrate safe application of an ultrasonic bone scalpel for completion of a Smith-Petersen osteotomy. The patient provided written, informed consent for all material presented in this case demonstration.The video can be found here: https://youtu.be/3PmaFtNcqKc.

Long-term Radiological and Clinical Outcomes After Using Bone Marrow Mesenchymal Stem Cells Concentrate Obtained With Selective Retention Cell Technology in Posterolateral Spinal Fusion.

Retrospective study. The aim of this study was to evaluate the long-term clinical and radiological outcomes of the use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology using Cellect with a particular collagen scaffold, Healos for posterolateral spinal fusion. With the increasing rate of spinal fusion, the problem of pseudarthrosis, which contributes to recurrent pain with patient disability, is considered to be the most common cause of revision lumbar spine surgery. Intensive research is being carried out to develop an alternative source of bone grafting and improve the spinal fusion rate. A retrospective review of hospital records was performed. Identified patients were contacted to have a clinical and radiological evaluation follow-up. Clinical outcome was evaluated using visual analog scales for the back pain (VAS), Oswestry Disability Index (ODI) scores, and quality of life (EQ-5D) questionnaire. Radiological outcome was evaluated by performing dynamic flexion/extension lateral views and calculation of segmental Cobb angle. Any implant-associated complication was reported. Computed tomography (CT) scans were also performed. Twenty-one patients were included and all patients achieved successful fusion. The mean difference of the segmental Cobb angle was 0.48° (range 0.3°-0.7°). Computed tomography scans showed solid bilateral fusion with bridging bone (Grade I) in all patients, but solid unilateral fusion with bridging bone (Grade II) was detected for one patient at one level. Patients started to resume working activities within a mean period of 3.5 months. The VAS score for the residual back pain was 4.1 ± 2.1, whereas the ODI was 10.5 ± 5.6 points, and the mean disability index was 21.1%. The use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology could be considered as an effective means for augmenting spinal fusion. 3.

The Influence of Pelvic Incidence and Lumbar Lordosis Mismatch on Development of Symptomatic Adjacent Level Disease Following Single-Level Transforaminal Lumbar Interbody Fusion.

Annual incidence of symptomatic adjacent level disease (ALD) following lumbar fusion surgery ranges from 0.6% to 3.9% per year. Sagittal malalignment may contribute to the development of ALD. To describe the relationship between pelvic incidence-lumbar lordosis (PI-LL) mismatch and the development of symptomatic ALD requiring revision surgery following single-level transforaminal lumbar interbody fusion for degenerative lumbar spondylosis and/or low-grade spondylolisthesis. All patients who underwent a single-level transforaminal lumbar interbody fusion at either L4/5 or L5/S1 between July 2006 and December 2012 were analyzed for pre- and postoperative spinopelvic parameters. Using univariate and logistic regression analysis, we compared the spinopelvic parameters of those patients who required revision surgery against those patients who did not develop symptomatic ALD. We calculated the predictive value of PI-LL mismatch. One hundred fifty-nine patients met the inclusion criteria. The results noted that, for a 1° increase in PI-LL mismatch (preop and postop), the odds of developing ALD requiring surgery increased by 1.3 and 1.4 fold, respectively, which were statistically significant increases. Based on our analysis, a PI-LL mismatch of >11° had a positive predictive value of 75% for the development of symptomatic ALD requiring revision surgery. A high PI-LL mismatch is strongly associated with the development of symptomatic ALD requiring revision lumbar spine surgery. The development of ALD may represent a global disease process as opposed to a focal condition. Spine surgeons may wish to consider assessment of spinopelvic parameters in the evaluation of degenerative lumbar spine pathology.

Role of Bone Marrow Mesenchymal Stem Cells Concentrate Using Selective Retention Cell Technology in Posterolateral Spinal Fusion

Introduction With increasing rate of spinal fusion, the problem of pseudarthrosis which contributes to recurrent pain with patient disability is considered to be the most common cause of revision lumbar spine surgery. Intensive research is being performed to develop an alternative source of bone grafting and improve the spinal fusion rate. Purpose Was to evaluate the long-term clinical and radiological outcome of the use bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology using Cellect (Depuy Spine, USA) with a particular collagen scaffold, Healos (Depuy Spine, USA) for posterolateral spinal fusion. Patient and Methods Retrospective review of the hospital records was performed. Then, the identified patients were contacted to have a clinical and radiological evaluation follow-up visit. Demographic data were reported. Preoperative diagnosis, surgical procedure report, previous spine surgery, postoperative complications and any re-operations were registered. Clinical outcome was evaluated using visual analog scales for the back pain (VAS), Oswestry Disability Index (ODI) scores, and quality of life (EQ-5D) questionnaire. Radiological outcome was evaluated by performing plain radiographs including anterior-posterior and dynamic flexion/extension lateral views. Segmental Cobb angle of the fused segment was calculated in the flexion/extension lateral views. Any implant associated complication, development of adjacent segment degeneration and any alteration of normal spinal curvature were reported. Computed tomography (CT) scans were also performed. Results All patients (100%) achieved successful fusion. The mean difference of the segmental Cobb angle was 0.5°, ranging from 0.3°-0.7°. CT scans showed solid bilateral fusion with bridging bone (Grade I) in all patients but solid unilateral fusion with bridging bone (Grade II) was detected at 1 patient at one level. Patients started to resume working activities within a mean period of 3.5 months. The VAS score for the residual back pain was 4.2 ±2 while the ODI was 10.7± 5.6 points with the mean disability index was 21.4%. Conclusion The use of bone marrow mesenchymal stem cells concentrate obtained with selective cell retention technology is shown be an effective mean for augmentation of spinal fusion.

Commentary on: "Remote Cerebellar Hemorrhage after Revision Lumbar Spine Surgery".

One exceptionally rare complication of spine surgery is a remote cerebellar hemorrhage, which is defined as a hemorrhage that is remote from the site of surgery, either in the cranium or the spinal column. The existence of a remote cerebellar hemorrhage has been reported by several authors,1 2 3 and it appears to be more common after supratentorial surgery rather than spine surgery. Haller et al presented a case of an unexpected hemorrhage in the posterior fossa, which occurred remotely in time as well as remote to the site of surgery. For this particular case, the remote site involved a revision lumbar spine surgery. Posterior fossa hemorrhages have variable presentations. Prompt identification of the hemorrhage is essential to properly manage it and to obviate deleterious sequelae. The authors used appropriate clinical judgment in accordance with current standards of care to identify the root cause of the patient's new neurologic deficits. It was quickly determined that the patient's symptoms did not correlate with the surgical site or procedure, allowing the authors to effectively intervene and achieve a positive outcome. The pathophysiology of remote cerebellar hemorrhages after spine surgery is not completely understood, and several theories have been proposed.4 5 The most common presentation continues to be hypertension, followed by embolic infarct and stroke with hemorrhagic conversion. Another theory involves the downward displacement of the cerebellum, which occurs when there is a rapid decrease in the volume of cerebrospinal fluid (CSF) in the posterior fossa. This sagging of the cerebellum results in increased tension of the bridging veins in the posterior fossa, consequently increasing the risk of intraparenchymal or extraparenchymal hemorrhage. In this case, Haller et al identified a CSF leak as the likely cause of the cerebellar hemorrhage secondary to a sagging cerebellum. For patients who have undergone spine surgery and who develop new neurologic deficits not attributable to the site of surgery, hemorrhage of the posterior fossa may be considered and evaluated with a computed tomography scan of the head. Clinicians must be cognizant of any subtle changes in a patient's neurologic status and accurately recognize when symptoms are unrelated to the operative procedures. The authors made a keen observation that remote cerebellar hemorrhages may occur even in the absence of an initial intraoperatively identified CSF leak. They were able to appropriately and promptly intervene, positively affecting the patient outcome.

Effectiveness and safety of transforaminal lumbar interbody fusion in patients with previous laminectomy.

To determine the efficacy and safety of transforaminal lumbar interbody fusion (TLIF) for revision lumbar spine surgery in patients with previous laminectomy. The secondary objective was to evaluate the clinical and radiological outcome after such a procedure. Retrospective case series study. Eighty-two patients were included. There were 48 women (58.5 %) and 34 men (41.5 %) with a mean age of 51 years (range 26-84) at the time of index procedure. The outpatient and inpatient charts were reviewed to identify patients' demographic data, preoperative, perioperative, and postoperative data. The outcome measures were assessed by Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain. An independent spine surgeon and musculoskeletal radiologist reviewed the imaging studies. The average operative time was 160 min (range 131-250). The average estimated blood loss was 652 cc (100-1,400 cc). Nineteen patients (23.1 %) required blood transfusion. Five patients (6 %) had dural tear. One patient (1.2 %) had a surgical site infection. Two patients (2.4 %) had thromboembolic events. The average hospital stay was 3.8 days (2-5 days). At a mean follow-up of 28 months, there were statically significant improvement in the ODI and VAS for back and leg pain. None of the patients' radiographs showed hardware failure or pedicle screw loosening and no patient returned to the operating room for pseudarthrosis. The current study confirmed that TLIF approach in patients with previous laminectomy is effective and safe with good outcomes.

MESNA for chemically assisted tissue dissection

Importance of the field: To date, surgical dissection is based only on mechanical forces. The use of a chemical product that is able to ease tissue dissection represents an important advance. MESNA (sodium-2-mercaptoethanesulfonate) has recently been validated for chemically assisted tissue dissection during surgery or invasive procedures. No other drugs are available for this.Areas covered in this review: An extensive literature search was conducted that included published articles and abstracts on the use of MESNA during surgery or invasive procedures in the experimental and clinical setting, since 1997. Clinically validated settings are ear, nose and throat (ENT), gynecological and orthopedic fields.What the reader will gain: A state-of-the-art overview of intraoperative applications of MESNA, and a consideration of the possible mechanisms underlying chemically assisted tissue dissection.Take home message: MESNA has been successfully used to ease abdominal myomectomies and excision of endometrial cysts; in ENT surgery, topical MESNA could be widely used, from ear and skull base to head and neck diseases, in both outpatient and operating-room settings. In revision lumbar spine surgery, its use resulted in significantly easier surgery and reduction of postoperative complications. Given the high efficacy and favorable complications rate, future applications in the surgical field are expected to increase.

Alternatives to Autogenous Bone Graft in Revision Lumbar Spine Surgery

Attaining spinal fusion depends on multiple biological factors and biomechanical factors. One important factor is the choice of bone graft material for the different spine locations. Although autogenous bone graft is the gold standard for bone grafting, it has its limitations. When considering revising lumbar fusion, one should correct all the possible factors that could have led to the pseudoarthrosis. These include the choice of bone graft material, preparation of the host graft surface, graft placement environment, and construct stability. This article focuses on the choice of graft materials as alternatives to human bone graft.

Effectiveness of a mucolythic agent as a local adjuvant in revision lumbar spine surgery

Aim of this prospective randomized trial was to analyze the effectiveness of MESNA in chemical dissection of peridural fibrosis in patients who underwent revision lumbar spine surgery. Between January 2003 and October 2006, 30 patients who underwent revision lumbar spine surgery were enrolled in the study. Patients were randomly assigned to one of two groups: a study group (A) and a control group (B). Once peridural fibrosis was exposed, MESNA (Uromixetan MESNA, 50 mg/ml) was intraoperatively applied on the fibrous tissue (Group A) to ease tissue dissection and enter the canal. In patients of Group B, saline solution was used. Surgical time, preoperative and 1 week postoperative hemoglobin (Hb), length of hospitalization (days), and incidence of perioperative complications were evaluated. The blinded surgeon assigned the surgeries to one of four categories as none, minimal, moderate, and severe basing on intraoperative difficulty in dissecting the fibrous tissue and intraoperative bleeding. Statistical analysis used chi-square analysis to evaluate the difference in surgery difficulty and the incidence of intraoperative complications between the two groups. The analysis of surgical time and hemoglobin levels was performed using a one-sample Wilcoxon test and Mann-Whitney U test. Patients in whom MESNA was used intraoperatively (Group A) presented better intraoperative and perioperative parameters with respect to the control group. Average surgical time and decrease in Hb postoperatively were more in the saline group (B) respect to MESNA (A) (P = 0.004 and P = 0.001, respectively), while no difference in average hospital stay was reported between the two groups. Surgeon-blinded intraoperative report on surgical difficulty showed a significant difference between the two groups (P < 0.05). Postoperatively, no complications directly attributable to the use of MESNA were experienced. The incidence of dural tears and intraoperative bleeding from epidural veins were significantly less in Group A with respect to the control group. MESNA contributed significantly to reduce the operative complications, with a diminution of the surgical time and the grade of difficult for the surgeon, confirming its ability as chemical dissector also for epidural fibrosis in revision lumbar spine surgery.

Findings and outcome of revision lumbar spine surgery

Findings and outcome of revision lumbar spine surgery