Short Fusion Research Articles

Disability, Health-Related Quality of Life and Mortality in Lumbar Spine Fusion Patients-A 5-Year Follow-Up and Comparison With a Population Sample.

Study Design:Prospective follow-up study.Objectives:We aimed to assess the effect of lumbar spine fusion (LSF) on disability, health-related quality of life and mortality in a 5-year follow-up, and to compare these results with the general population.Methods:523 consecutive LSF operations were included in a prospective follow-up. Disability was assessed by the Oswestry Disability Index (ODI), and HRQoL by the 36-item Short Form (SF-36) questionnaire using the physical and mental summary scores (PCS and MCS). The patients were compared with an age-, sex-, and residential area matched general population cohort.Results:The preoperative ODI in the patients was 46 (SD 16), and the change at 5 years was −26 (95% CI: −24 to −28), p < 0.001. In the population, ODI (baseline 13, SD 16) remained unchanged. The preoperative PCS in the patients was 27 (SD 7), in the population 45 (SD 11), and the increase in the patients at 5 years was 8 (95% CI: 7 to 9), p < 0.001. The patients did not reach the population in ODI or PCS. The baseline MCS in the patients was 47 (SD 13), and the change at 5 years 4 (95% CI: 3 to 7), p < 0.001. MCS of the females reached the population at 5-year follow-up. When analyzing short and long fusions separately, comparable changes were seen in both subgroups. There was no difference in mortality between the patients (3.4%) and the population (4.8%), hazard ratio (HR) 0.86.Conclusions:Although the patients who had undergone LSF benefited from surgery still at 5 years, they never reached the physical level of the population.

Influence of Depressive Symptoms on the Outcome of Lumbar Spine Fusion-A 5-year Follow-up Study.

Prospective follow-up study. The aim of this study was to assess whether depressive symptoms change the outcome of lumbar spine fusion (LSF) surgery at a 5-year follow-up. Previous reports of the influence of depressive symptoms on the results of spine surgery are controversial, but the patient characteristics and indications for surgery varied widely between the studies. The influence of depressive symptoms on the 5-year outcome of LSF has not been studied. The study was based on data from a local LSF database from two hospitals comprising 392 consecutive patients (mean age 61 years, 277 women) who underwent an instrumented LSF and fulfilled the 5-year follow-up. At the 5-year follow-up, the patients were compared with a control group from the general population (n = 477, age-, sex-, and residential area-matched) extracted from Official Statistics of Finland. The prevalence of depressive symptoms was evaluated using the Depression Scale (DEPS; 0-30) and disability was evaluated by the Oswestry Disability Index (ODI; 0-100%). A DEPS score ≥12 was considered to indicate depressive symptoms. Before surgery, 35% of the patients had depressive symptoms. The proportion diminished to 13% at 3 months postoperatively and increased to 24% at 5 years. In the population, the prevalence was 11% at baseline and 10% at the 5-year follow-up. The preoperative ODI was 54 in the patients with depressive symptoms, and it was 41 in the patients with no depressive symptoms. The changes at 5-year follow-up were -20 and -18, correspondingly. The same congruence was preserved when analyzing short and long fusions separately. These changes were statistically and clinically significant. In the control population, the ODI remained around 24 in depressive people and 10 in nondepressive people. Our data suggest that patients with and without depressive symptoms may benefit equally well from LSF. 3.

Biomechanics of the effect of subaxial cervical spine degeneration on atlantoaxial complex in idiopathic retro-odontoid pseudotumor development

ObjectivesRetro-odontoid pseudotumor (ROP), with no rheumatoid arthritis, atlantoaxial instability, or other primary diseases, is defined as idiopathic retro-odontoid pseudotumor (IROP). Cervical spine degeneration is associated with IROP development. This study aims to evaluate the effect of cervical spine degeneration on the atlantoaxial complex and find the possible biomechanical mechanism of IROP development. MethodsThis study was performed using a three-dimensional (3D) finite element (FE) analysis. A degenerated FE model (FEM) and five operation FEMs (C1-C2 fusion, C0-C2 fusion, C0-C3 fusion, C0-C4 fusion, and C1 posterior arch resection) were established based on a normal 3D FEM of the cervical spine including C0-T1 with the main ligaments and muscles. The parameters, including the C1-C2 range of motions (ROMs) and odontoid-related ligaments’ stresses in degenerated and operation FEMs, were obtained and compared with those in normal FEM. ResultsCompared to normal FEM, degenerated FEM had reduced C3-C7 ROMs and increased C1-C2 ROMs and odontoid-related ligaments’ stresses. After internal fixation, C1-C2 ROMs and most odontoid-related ligaments’ stresses were greatly decreased, but with no significant differences among C0-C2, C0-C3, C0-C4, and C1-C2 fusion models. For the C1 posterior arch resection model, C1-C2 ROMs and most odontoid-related ligaments’ stresses increased, compared with normal FEM. ConclusionsCervical spine degeneration plays an important part in IROP development in biomechanics. Atlantoaxial complex compensates for cervical spine degeneration, with increased C1-C2 ROMs and odontoid-related ligaments’ stresses. Atlantoaxial fusion or short segmental occipitocervical fusion can effectively reduce the stress and should be considered in IROP treatment.

Spino-Pelvic Thresholds for Prevention of Proximal Junctional Kyphosis Following Combined Anterior Column Realignment and Short Posterior Spinal Fusion in Degenerative Lumbar Kyphosis.

ObjectiveTo analyze ideal indication for combined anterior column realignment (ACR) with short posterior spinal fusion (PSF) and posterior column osteotomy (PCO) for preventing proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients with lower lumbar kyphosis and compensatory thoracolumbar lordosis.MethodsA retrospective study was conducted. This study included 27 ASD patients (average age of 66.6 years; one male and 26 females) with lower lumbar kyphosis and compensated thoracolumbar lordosis who underwent short PSF with PCO following ACR from 2006 to 2010. The minimum follow‐up period was 5 years. The patients were divided into two groups based on the sagittal vertical axis (SVA) of the last follow‐up radiographs, and a comparative analysis was performed evaluating spino‐pelvic parameters and clinical outcomes including the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and complications.ResultsThe mean follow‐up time of included patients was 109.7 months, and the mean number of fused segments was 3.7. The uppermost instrumented vertebra was L2 in 18 patients or L3 in nine patients, and lowermost instrumented vertebra was sacrum in all patients. The mean lumbar lordosis (LL) values in the optimal SVA and suboptimal SVA groups were 4.4° and 4.2° preoperatively (P = 0.639), −48.1° and −35° postoperatively (P = 0.007), and −45.2° and −20.7° at the last follow‐up (P < 0.05). Overcorrection was seen in seven patients in the optimal SVA group, whereas all of the patients of the suboptimal SVA group were in the category of undercorrection (P = 0.021). Pelvic incidence (PI) of optimal SVA group (<50 mm, n = 16) and suboptimal SVA group (≥50 mm, n = 11) was 44.1° and 53.8° (P = 0.009). The prevalence of PJK was significantly higher in the suboptimal SVA group (P = 0.008), and last follow‐up VAS for back pain (P < 0.05), and postoperative and last follow‐up ODI (P = 0.002 and P < 0.05) were statistically larger for the suboptimal group than the optimal group.ConclusionsCombined ACR with short PSF and PCO could effectively prevent sagittal decompensation of PJK and help achieve sagittal balance in the treatment of ASD patients with lower lumbar kyphosis, compensatory thoracolumbar lordosis, and especially low PI (<50°).

277. Is adjacent segment disease following instrumented short lumbosacral fusion influenced by postoperative sagittal alignment?

BACKGROUND CONTEXT Adjacent segment disease (ASD) is a common manifestation following lumbar fusion, potentially requiring revision of the construct. While several risk factor for the condition have been identified it is unclear what role sagittal imbalance following fusion plays in the development of ASD. Sagittal imbalance, when measured as mismatch between pelvic incidence and lumbar lordosis (PI-LL), has been associated with poorer clinical outcomes following lumbar surgery; however, it is unclear whether higher PI-LL contributes to ASD in the short lumbosacral fusion population. PURPOSE The aim of this study was to 1) determine the incidence of ASD among patients undergoing short lumbosacral fusion; 2) to evaluate if patients who went on to develop ASD have higher degree of PI-LL compared to those without (controls); 3) following subgroup analysis, determine if the relation between PI-LL and ASD was affected by length of fusion. STUDY DESIGN/SETTING Single institutional retrospective cohort study PATIENT SAMPLE A total of 126 patients undergoing instrumented short lumbosacral fusion were included OUTCOME MEASURES Radiographic evidence of postoperative ASD; Initial Postoperative PI-LL among ASD patients and controls METHODS Patients who underwent short instrumented lumbosacral fusion between the years of 2008 to 2019 at our institution were selected for the study. In addition, patients must have had a minimum of 2-year radiographic follow-up to meet inclusion criteria. Only elective cases for degenerative lumbar pathology were included; cases involving spinal infection, trauma, or malignancy were excluded. Postoperative PI-LL was measured using initial one-month postoperative standing radiographs. Subgroup analysis was also performed after separating the main cohort into 3 separate populations corresponding to the following fusion lengths: 5 segment (L2-S1), 4 segment (L3-S1), and 3 segment (L4-S1) fusions. PI-LL was compared between patients who went on to develop radiographic evidence of ASD and those who did not (controls) using student t-test. Significance was defined as p RESULTS Following application of inclusion and exclusion criteria, 126 patients with a mean age of 61.44 ± 12.22 years were selected for the study. Radiographic evidence of ASD was present in 59% of patients (n=74), with a mean time to ASD of 21.52 ± 21.74 months. No difference (p=0.781) was seen in initial postoperative PI-LL between ASD patients (11.42 ± 7.62) and controls (11.87 ± 9.94) in the main cohort. Following subgroup analysis, incidence of ASD was 57% (24/42) in L4-S1 fusions, 62% (29/47) in L3-S1 fusion, and 57% (21/37) among L2-S1 fusions. Postoperative rates of ASD were similar among the 3 cohorts (p=0.787). No difference was observed PI-LL between ASD patient and controls in the L4-S1 (10.74 ± 8.35 vs 8.89 ± 9.02, p=0.500), L3-S1 (11.69 ± 7.77 vs 11.24 ± 8.94, p=0.860), and L2-S1 fusion cohorts (11.81 ± 6.82 vs 15.98 ± 11.14, p=0.203). CONCLUSIONS No significant difference in PI-LL was observed between patients who went on to develop ASD and those who did not. Likewise, sagittal alignment was similar in each fusion length subgroup. Sagittal imbalance measured by PI-LL may not have a significant impact on the development of ASD following instrumented short lumbosacral fusion. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

211. Complications and outcomes in small vs large surgeries for ASD?

BACKGROUND CONTEXT Traditionally, adult spinal deformity (ASD) has been treated with long segment fusions with the goal of restoring sagittal and coronal alignment. Long segment fusions can be associated with high rates of complications and morbidity. Some patients are reluctant to undergo large procedures. Others have comorbidities excluding them as good surgical candidates for long fusions. PURPOSE To compare baseline and postoperative HRQL and radiographic outcomes and revisions and complications in small vs longer fusions for ASD. STUDY DESIGN/SETTING Retrospective analysis of a prospective, multicenter database PATIENT SAMPLE Surgical ASD patients OUTCOME MEASURES ODI, SF36-PCS, SRS22, NRS back and leg pain. METHODS A prospective database of operative ASD patients who completed two year follow up was analyzed. Prior thoracolumbar fusions were excluded. Patients were divided into short fusions (SF: £3 levels) and long fusions (LF: ³6 levels). LF and SF patients were compared in baseline alignment. Propensity matching (PSM) controlling for baseline alignment (TPA and maximum coronal cobb) was performed to compare SF and LF in HRQL improvement, postop alignment and complications. Subanalysis of SF identified which patients were more likely to have successful surgery. The level of significance was p RESULTS A total of 298 patients met inclusion criteria (SF n=20, mean levels fused 2.13; LF n=275, mean fusion levels 12.33). Prior to PSM, LF had greater PT, coronal cobb, and TPA. Following PSM, LF had better improvements in PILL (20.8 vs 3.37), PT (8.57 vs 0.21), TPA (8.68 vs 2.07), and coronal cobb (17.3 vs 5.33) all p CONCLUSIONS This study shows that a more limited fusion could be an alternative to the more traditional long segment fusion in carefully selected patients with adult spinal deformity since there were fewer complications but similar short-term (2-year) satisfaction rates and HRQL improvements. Patients undergoing long fusions had better improvements in alignment. The majority of sagittal only deformities undergoing short fusions required revision surgery. The durability of short fusions in the setting of ASD needs to be investigated with long term studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

P87. Does short segment reduction and fusion (TLIF) of spondylolytic spondylolisthesis normalize lumbar lordosis and improve spino-pelvic alignment?

BACKGROUND CONTEXT Spondylolytic spondylolisthesis is commonly associated with back pain and neurological symptoms. The primary localized kyphotic deformity at the level of the spondylolisthesis is compensated by increased lordosis across the remaining lumbar spine giving rise to a hyperlordotic lumbar spine. There is usually an associated increase in sacral slope and a corresponding decrease in pelvic tilt. PURPOSE This study was done to investigate the influence of short segment reduction and fusion (TLIF) for spondylolytic spondylolisthesis on the increased lumbar lordosis and the spino-pelvic alignment. STUDY DESIGN/SETTING Retrospective radiological analysis by two independent observers of standing preoperative and postoperative lumbar spine radiographs. Ethical approval was obtained for the study from the Institute Ethics Committee. PATIENT SAMPLE Thirty-seven consecutive patients from a single surgeon series of spondylolytic spondylolisthesis undergoing reduction and fusion (TLIF) performed between 2013 and 2019. OUTCOME MEASURES Measurements of the lumbar lordosis across the lumbar spine as a whole and individual motion segments, and sacral slope were taken using pre- and postoperative standing radiographs. METHODS Two independent observers, blinded of each other, reviewed the pre- and postoperative standing radiographs. Using PACS software they measured the lumbar lordosis across the lumbar spine as a whole and individual motion segments, and sacral slope. The lumber lordosis was measured from the superior border of S1 to superior border of L1. RESULTS Twenty-seven fusions were performed at L5/S1, nine at L4/5 and one at L3/4. Normalization of lordosis was noted at all spinal levels, including distant from the surgical site. Overall mean lumbar lordosis reduced from 63.43 degrees to 48.89 degrees (p CONCLUSIONS This study shows that short segment reduction and fusion for spondylolytic spondylolisthesis can normalize lumbar lordosis at all levels of the lumbar spine and this occurs level-by-level. There is also an associated spontaneous reduction in the sacral slope and therefore a corresponding improvement in the pelvic tilt leading to improved spino-pelvic alignment. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

140. Complications and revision rates in minimally invasive Mazor robotic-guided vs fluoroscopic-guided spinal fusions: the MIS ReFRESH prospective comparative study

BACKGROUND CONTEXT As robotic-guidance and minimally invasive approaches become more prevalent in spine surgery, there is a growing interest in high-level scientific evidence of their clinical value. MIS ReFRESH is the first prospective, multicenter study designed to compare robotic-guidance and fluoroscopic techniques for differences in surgical complications, revision surgery rates and exposure to intraoperative radiation. The MIS ReFRESH study assessed adults undergoing minimally invasive (MIS) lumbar fusions of 1-3 levels. PURPOSE To prospectively assess the impact of Mazor robotic-guidance compared to fluoro-guidance on the rates of surgical complications, revision surgery and intraoperative radiation exposure in MIS short lumbar fusions. STUDY DESIGN/SETTING Prospective, multicenter, controlled, partially randomized study. PATIENT SAMPLE Adult patients with degenerative lumbar conditions undergoing minimally invasive fusion of 1-3 levels. OUTCOME MEASURES Comparison of incidence of surgical complications, revision surgeries and intraoperative fluoroscopy time. Analysis of variables through Cox logistic regression model and a Kaplan Meyer Survival Curve of surgical complications. METHODS Data were prospectively collected from adult patients indicated for lumbar fusion surgery, including demographics, comorbidities, surgical complications, revision surgeries and use of intraoperative fluoroscopy (in seconds). A single site randomized patients between arms, while other sites enrolled exclusively to one arm. Primary endpoints were analyzed at 1-year follow-up. RESULTS A total of 9 sites enrolled 485 patients: 374 in the robot-guided arm (RG), and 111 in the fluoro-guided arm (FG). One site randomized patients, 16 to RG and 11 to FG. 93.2% of patients had >1 year follow-up and were included in the analysis of primary endpoints. There were no differences between the groups with regards to gender, Charlson Comorbidity Index (CCI), Diabetes, Cancer or HIV status. RG patients were significantly heavier, younger and included more smokers. Mean age of RG patients was 59.0 years vs 62.5 for FG (p=0.009) and BMI was 31.2 vs 28.1, respectively (p CONCLUSIONS In a prospective, multicenter, comparative study of MIS lumbar fusions, surgeries performed with Mazor robotic guidance were found to have a 5.2 times lower risk of developing a surgical complication and 8.8 times lower risk for revision surgery compared to fluoro-guidance during the first year of follow-up. Normalized surgical times/instrumentation were similar between the two groups and RG reduced fluoro time per screw by 80%, or approximately a minute per case. FDA DEVICE/DRUG STATUS Mazor Renaissance Robotics (Approved for this indication).

P137. Osteoporosis is a predictor of two-year adverse outcomes following short fusion for degenerative lumbar disease

BACKGROUND CONTEXT Spinal fusion is increasingly considered for management of patients with osteoporosis (OP) and degenerative disc disease (DDD). Little data is available regarding long-term outcomes in OP patients undergoing short-segment, lumbar fusion for DDD. PURPOSE Analyze the impact of OP on long-term outcomes in patients who have had 2-3-level lumbar fusions for degenerative disc disease. STUDY DESIGN/SETTING Retrospective review of the New York State Statewide Planning and Research Cooperative System (NYS SPARCS) database. PATIENT SAMPLE Patients with DDD undergoing 2-3-level lumbar fusion. OUTCOME MEASURES Frequency of 2-year medical and surgical complications and reoperations. METHODS Utilizing SPARCS, all patients from 2009-2011 with ICD-9 codes for DDD who underwent 2-3-level lumbar fusion were identified. Patients with bone mineralization disorders, systemic and endocrine disorders affecting bone quality were excluded. Surgical indications of trauma, systemic disease(s), and infection were excluded. Patients with and without OP were compared for demographics, hospital-related parameters, and 2-year complications and reoperations. Logistic regression models were utilized to identify predictors of complications. RESULTS A total of 29,028 patients (OP=1,353 (4.7%), No-OP=27,675) were included. OP patients were older (66.9 vs 52.6 years) as well as more often female (85.1% vs 48.4%) and white (82.8% vs 73.5%), all p CONCLUSIONS Patients with OP undergoing 2-3-level lumbar fusion for DDD were at higher risk of 2-year medical and surgical complications, and 3.4% of OP patients experienced implant-related complication. These findings highlight the importance of rigorous preoperative metabolic workup prior to spinal surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

222. Metabolic bone mineralization disorders (MBD) increase 2-year adverse outcome following lumbar short fusion for degenerative lumbar disease

222. Metabolic bone mineralization disorders (MBD) increase 2-year adverse outcome following lumbar short fusion for degenerative lumbar disease

Sacral Insufficiency Fracture Following Short-Segment Lumbosacral Fusion: Case Series and Review of the Literature.

Study Design:Retrospective case series.Objective:Sacral insufficiency fracture is a rare and serious complication following lumbar spine instrumented fusion. The purpose of this study was to describe the patient characteristics, presentation, evaluation, treatment options, and outcomes for patients with sacral insufficiency fracture after short-segment lumbosacral fusion.Methods:Six patients from our institutional database and 16 patients from literature review were identified with a sacral insufficiency fracture after short-segment (L4-S1 or L5-S1) lumbar fusion within 1 year of surgery.Results:Patients were 55% female with a mean age of 58 years and body mass index of 30 kg/m2. Osteoporosis or osteopenia was the most common comorbidity (85%). Half of patients sustained a sacral fracture after surgery from a posterior approach, while the others had anterior or anterior-posterior surgery. Mean time to fracture was 42 days with patients clinically presenting with new sacral pain (86%), radiculopathy (60%), or neurologic deficit (5%). Ultimately, 73% of patients underwent operative fixation often involving extension of the construct (75%) and fusion to the pelvis (69%). Men (P = .02) and patients with new radicular pain or neurologic deficit (P = .01) were more likely to undergo revision surgical treatment while women over 50 years of age were more likely to be treated conservatively (P = .003).Conclusions:Spine surgeons should monitor for sacral insufficiency fracture as a source of new-onset pain in the postoperative period in patients with a short segment fusion to the sacrum. The recognition of this complication should prompt an assessment of bone health and management of underlying bone fragility.

骨粗鬆症性第4腰椎椎体骨折後遅発性麻痺に対してX-coreを用い後方要素を温存したShort fusionの治療経験

骨粗鬆症性第4腰椎椎体骨折後遅発性麻痺に対してX-coreを用い後方要素を温存したShort fusionの治療経験

Technique of Biportal Endoscopic Transforaminal Lumbar Interbody Fusion.

Biportal endoscopic transforaminal lumbar interbody fusion (TLIF) may have advantages of minimally invasive fusion surgery as well as those of endoscopic surgery. The purpose of this study was to present the biportal endoscopic TLIF technique along with video presentations and a review of the literature on this technique. Basically, the biportal endoscopic TLIF technique is similar to minimally invasive TLIF with a tubular retractor. There were 2 options in the biportal endoscopic TLIF procedures. The first was the insertion of one long TLIF cage and the other was the insertion of 2 short posterior lumbar interbody fusion (PLIF) cages. After the interbody fusion procedures, percutaneous pedicles screw fixation was performed. Biportal endoscopic TLIF achieved complete neural decompression through laminectomy and facetectomy like conventional TLIF. Endplate preparation was performed completely under a clear and magnified endoscopic view. It was also feasible to insert a large TLIF cage or 2 cages for PLIF without exiting nerve root injury. Biportal endoscopic TLIF might have the advantages of endoscopic surgery as well as minimally invasive fusion surgery. Direct neural decompression, endplate preparation under endoscopic guidance, and the insertion of a large TLIF cage or 2 PLIF cages may be the merits of biportal endoscopic lumbar fusion procedures.

Patient Outcomes Following Short-segment Lumbar Fusion Are Not Affected by PI-LL Mismatch.

This is a retrospective cohort study. The objective of this study was to further elucidate the relationship between pelvic incidence-lumbar lordosis (PI-LL) mismatch and surgical outcomes in patients undergoing short segment lumbar fusions for degenerative lumbar disease. There are few studies examining the relationship between spinopelvic parameters and patient reported outcome measurements (PROMs) in short segment lumbar degenerative disease. A retrospective review was conducted at single academic institution. Patients undergoing 1- or 2-level lumbar fusion were retrospectively identified and separated into 2 groups based on postoperative PI-LL mismatch ≤10 degrees (NM) or PI-LL mismatch >10 degrees (M). Outcomes including the Physical Component Score (PCS)-12, Mental Component Score (MCS)-12, Oswestry Disability Index (ODI), Visual Analog Scale (VAS) back and leg scores were analyzed. Absolute PROM scores, the recovery ratio and the percentage of patients achieving minimum clinically important difference between groups were compared and a multiple linear regression analysis was performed. A total of 306 patients were included, with 59 patients in the NM group and 247 patients in the M group. Patients in the M group started with a higher degree of PI-LL mismatch compared with the NM group (22.2 vs. 7.6 degrees, P<0.001) and this difference increased postoperatively (24.7 vs. 2.5 degrees, P<0.001). There were no differences between the 2 groups in terms of baseline, postoperative, or Δ outcome scores (P>0.05). In addition, having a PI-LL mismatch was not found to be an independent predictor of any PROM on multivariate analysis (P>0.05). The findings in this study show that even though patients in the M group had a higher degree of mismatch preoperatively and postoperatively, there was no difference in PROMs. Level III.

Frailty and Post-Operative Outcomes in the Older Patients Undergoing Elective Posterior Thoracolumbar Fusion Surgery.

Background and AimFrailty is an independent predictor of mortality and adverse events (AEs) in patients undergoing surgery. This study aimed to quantify the ability of Modified Frailty Index (mFI) to predict AEs in older patients undergoing elective posterior thoracolumbar fusion surgery.MethodsWe retrospectively reviewed the results of 426 patients with the following diagnoses and follow-up evaluations of at least 12 months duration: lumbar disc herniation, 125; degenerative spondylolisthesis, 81; lumbar spinal canal stenosis, 187; and adult spinal deformities, 33. The cases were divided into two groups. The long spinal fusion (LSF) group was defined as ≥3 spinal levels with segmental pedicle-screw fixation. Short spinal fusion (SSF) were defined with at most two levels. The mFI used in the present study is an 11-variable assessment. The association of frailty with AEs was determined after adjusting for known and suspected confounders.ResultsFrailty was presented in 66 patients (15.5%) within the total population (LSF, 21.9% and SSF, 11.8%). Rates of AEs assessed in the study increased stepwise with an increase in the mFI for the two groups. The severity of frailty was an independent predictor of any, major, and minor complications in the LSF group and any, minor complication in the SSF group (P<0.05). A comparison of post-operative clinical outcomes showed that the ODI and SF-36 scores deteriorated as the mFI increased.ConclusionFrailty was shown to be an independent predictor of AEs in older patients undergoing elective posterior thoracolumbar fusion surgery, especially for patients undergoing LSF.

Management of spinal deformities and tibial pseudarthrosis in children with neurofibromatosis type 1 (NF-1)

Summary of background dataThe skeletal system is affected in up to 60% of patients with neurofibromatosis type 1. The most commonly observed entities are spinal deformities and tibial dysplasia. Early recognition of radiologic osseous dystrophy signs is of utmost importance because worsening of the deformities without treatment is commonly observed and surgical intervention is often necessary. Due to the relative rarity and the heterogenic presentation of the disease, evidence regarding the best surgical strategy is still lacking.PurposeTo report our experience with the treatment of skeletal manifestations in pediatric patients with (neurofibromatosis type 1) NF-1 and to present the results with our treatment protocols.Materials and methodsThis is a retrospective, single expert center study on children with spinal deformities and tibial dysplasia associated with NF-1 treated between 2006 and 2020 in a tertiary referral institution.ResultsSpinal deformity: Thirty-three patients (n = 33) were included. Mean age at index surgery was 9.8 years. In 30 patients (91%), the deformity was localized in the thoracic and/or lumbar spine, and in 3 patients (9%), there was isolated involvement of the cervical spine. Eleven patients (33%) received definitive spinal fusion as an index procedure and 22 (67%) were treated by means of “growth-preserving” spinal surgery. Halo-gravity traction before index surgery was applied in 11 patients (33%). Progression of deformity was stopped in all patients and a mean curve correction of 60% (range 23–98%) was achieved. Mechanical problems with instrumentation requiring revision surgery were observed in 55% of the patients treated by growth-preserving techniques and in none of the patients treated by definitive fusion. One patient (3%) developed a late incomplete paraplegia due to a progressive kyphotic deformity.Tibial dysplasia: The study group comprised of 14 patients. In 5 of them (36%) pathological fractures were present on initial presentation. In the remaining 9 patients (64%), anterior tibial bowing without fracture was observed initially. Four of them (n = 4, 28%) subsequently developed a pathologic fracture despite brace treatment. Surgical treatment was indicated in 89% of the children with pathological fractures. This involved resection of the pseudarthrosis, autologous bone grafting, and intramedullary nailing combined with external fixation in some of the cases. In 50% of the patients, bone morphogenic protein was used “off-label” in order to promote union. Healing of the pseudarthrosis was achieved in all of the cases and occurred between 5 to 13 months after the index surgical intervention. Four of the patients treated surgically needed more than one surgical intervention in order to achieve union; one patient had a re-fracture. All patients had a good functional result at last follow-up.ConclusionEarly surgical intervention is recommended for the treatment dystrophic spinal deformity in children with NF-1. Good and sustainable curve correction without relevant thoracic growth inhibition can be achieved with growth-preserving techniques alone or in combination with short spinal fusion at the apex of the curve. Preoperative halo-gravity traction is a safe and very effective tool for the correction of severe and rigid deformity in order to avoid neurologic injury. Fracture union in tibial dysplasia with satisfactory functional results can be obtained in over 80% of the children by means of surgical resection of the pseudarthrosis, intramedullary nailing, and bone grafting. Wearing a brace until skeletal maturity is achieved is mandatory in order to minimize the risk of re-fracture.

A study of operative and non - operative management of dorsolumbar spine fracture (A study OF 40 cases)

In an epidemiological study traumatic injury to the thoracolumbar area constitute of 75% of total back skeletal injuries. Most of these injuries comprises of thoracolumbar segment of the spine (t10 to l2), also high incidence of neurological deficits is associated with thoracolumbar fractures. Numerous classifications were proposed on an anatomical basis to guide the management of TL fractures and define the indications for surgery but none of these classification systems have taken into account the stabilizing effect of para- spinal muscles. The aim of this article is to review the present literature on evidence of management of TL fractures using operative versus conservative techniques. 40 patients with dorsolumbar spine injuries falling into inclusion criteria were managed with conservative and operative intervention between December 2008 to January 2010. 16 patients were treated with operative intervention with short or long segmented fixation & fusion with bone grafts.24 patients were treated non operatively with DLSO brace and kept immobilised for 4-6 weeks. The maximum period of follow up was 18 to 24 months with a minimum period of follow up of 9 to 12 months. At follow up on regular check of neurological status, 50% of operatively treated patients were showing improvement. Patients treated non operatively had no or occasional pain according to pain score. 10 patients had excellent score treated operatively while 12 patients had good score. 8 patients treated non operatively had good to fair score according to grading for neurological improvement by SRS (scoliosis research society). Surgical intervention should be advocated in cases of unstable burst fractures of the dorsolumbar region, irrespective of status of neurological damage, but might be restricted in the patients with incomplete spinal cord injuries.

Comparision of Spinopelvis Alignment with Short Segment Reduction and Fusion (Plif) In Low and High Grade Spondylolistesis

Study Design: A prospective clinicoradiological study of PLIF was conducted in similar types and high grades &gt; 2 spondylolisthesis in 40 patients, with 20 patients as controls with grade &lt; 2. Objective: The objective was to assess the clinicoradiological profile of various spinopelvic parameters like pelvic incidence, pelvic version, sacrohorizontal angle, slip reduction and disc height increment using structural and standalone graft and its consequences on the post-operative outcome as assessed by Visual Analogue Score and Oswestry Disability Index. Methods: Before starting the study Institutional ethical committee approval was taken and approval no 654 was given for the study and prior consents were taken by all the patients included in the study and was documented. This study involved a total number of 40 patients of spondylolisthesis &gt;2 and 20 patients of &lt;2 of all the age groups with progressive neurological deficits, and pain not relieved by conservative measures. All patients underwent wide laminectomy, facetectomy, complete discectomy and posterior lumbar interbody fusion with intraoperative slip reduction maneuvers, disc height maintained with interbody stand-alone graft or structured grafts made of PEEK or Titanium cages. Conclusions There was no correlation between duration of symptoms and post operative pain reduction. A fusion rates of 92% were achieved with intra operative slip reduction. The results obtained in comparison with slip reduction and post operative pain reduction are directly proportional and statistically not significant. A decrease in pelvic version and increase in sacrohorizontal angle were noted following surgery. Restoration and incrementing the disc height is associated with statistically significant pain relief. Polyetheretherketone (PEEK) inter body spacer has best clinical and radiological outcome in terms of maintenance of the disc height followed by titanium cage and stand alone graft respectively. All these results had significant positive predictive value in all cases of spondylolisthesis &gt; 2 and was statistically insignificant in patients with grade &lt;2.

Outcomes following primary total hip arthroplasty with pre-existing spinal fusion surgery.

There is inconsistent evidence on whether prior spinal fusion surgery adversely impacts outcomes following total hip arthroplasty (THA). We conducted a systematic review and meta-analysis to assess the association between pre-existing spinal fusion surgery and the rate of complications following primary THA. We searched MEDLINE, Embase, Web of Science, and Cochrane Library up to October 2019 for randomized controlled trials (RCTs) and observational studies comparing outcomes of dislocation, revision, or reasons for revision in patients following primary THA with or without pre-existing spinal fusion surgery. Furthermore, we compared short (two or less levels) or long (three or more levels) spinal fusions to no fusion. Summary measures of association were relative risks (RRs) (with 95% confidence intervals (CIs)). We identified ten articles corresponding to nine unique observational studies comprising of 1,992,366 primary THAs. No RCTs were identified. There were 32,945 cases of spinal fusion and 1,752,362 non-cases. Comparing prior spinal fusion versus no spinal fusion in primary THA, RRs (95% CI) for dislocation was 2.23 (1.81 to 2.74; seven studies), revision 2.14 (1.63 to 2.83; five studies), periprosthetic joint infection 1.71 (1.53 to 1.92; four studies), periprosthetic fracture 1.52 (1.28 to 1.81; three studies), aseptic loosening 1.76 (1.54 to 2.01; three studies), and any complications 2.82 (1.37 to 5.80; three studies) were identified. Both short and long spinal fusions, when compared with no fusion, were associated dislocation, revision, or reasons for revision. Patients with prior spinal fusion are at risk of adverse events following primary THA. Measures that reduce the risk of these complications should be considered in this high-risk population when undergoing primary THA. These patients should also be counselled appropriately around their risks of undergoing THA. Cite this article: Bone Joint J 2020;102-B(6):664-670.

INFLUENCE OF THE MISDEF ALGORITHM ON THE THERAPEUTIC DECISION FOR VERTEBRAL DEFORMITY IN THE ADULT

ABSTRACT Objective The therapeutic decision in cases of adult spinal deformity takes numerous factors into account with a consequent variability in treatment options. The objective is to compare the impact of the MISDEF (minimally invasive spine deformity) algorithm on therapeutic decisions in cases of adult spinal deformity. Methods Prospective radiographic analysis of 40 cases of adult deformity. The cases were sent, in two steps, to 20 Latin American surgeons who had to choose among six treatment options with and without the use of the MISDEF. Results For the conducts of decompression, decompression and short fusion, decompression and fusion with interbody device, and osteotomy with extension of fusion to the thoracic spine, no significant differences were found when comparing decisions made with and without MISDEF. For osteotomy, we observed a tendency for the number of surgeons choosing this conduct to increase when the decision is made with MISDEF. We observed that the number of surgeons who decided on conservative treatment decreased with the use of MISDEF (p &lt;0.001). In cases with sagittal vertical axis &lt;6 cm or pelvic tilt &lt;25 ° or PI-LL (pelvic incidence minus lumbar lordosis) &lt;10 ° or coronal curve &lt;20 °, there was a decrease in the conservative treatment option and an increase in osteotomy with proximal extension of the fusion with the use of MISDEF. Conclusions There is a tendency to increase indications of osteotomy and decrease the conservative treatment option when making a decision with MISDEF. The use of the algorithm showed no significant impact on the therapeutic decision in severe cases of adult deformity. Level of Evidence II; Prospective comparative radiographic analysis.