Simultaneous Posterior Fusion Research Articles

Rhabdomyolysis after spinal fusion surgery: management schema and prevention of a catastrophic complication

Purpose Rhabdomyolysis is a clinical syndrome with the potential to cause cardiac arrhythmias, renal failure, and even death. Currently, there are no studies regarding risk factors for developing post-operative rhabdomyolysis (POR) after spinal fusion surgeries. Our objective was to study risk factors associated with, and to develop a decision-making framework for post-operative rhabdomyolysis after spinal fusion surgery. Methods We performed a retrospective cohort study of all spinal fusions of three or more levels over 2.25 years by a single surgeon at two centers. POR was defined as a creatine phosphokinase (CPK) greater than 2000 IU/L. Results 76 surgical procedures on 72 patients were identified. Rate of POR in our cohort was 22% (17/76). Male sex was associated with POR (p < 0.05). Previously validated risk factors: younger age, lower ASA score, elevated BMI, higher pre-operative creatinine, increased intraoperative blood loss, specific surgical positions, and length of surgery, were not associated with POR. In a logistic regression model, male gender increases the odds of POR in all patients 5.82-fold (p = 0.047). In patients without a second surgery within seven days, a logistic regression model suggests each additional level fused via transpsoas approach, and male gender, increases the risk of POR 1.81-times (p = 0.015), and 6.26-times (p = 0.047), respectively. In patients with posterior fusions, a logistic regression model suggests increasing the number of lateral levels fused via transpsoas approach in the same surgery, and male gender, increases the risk of POR 1.68-times and 6.34-times, respectively. In these same subgroups, increased thickness of the psoas major in lateral transpsoas fusions increased risk of POR (p = 0.023, p = 0.046, respectively). Conclusions In spinal fusions, increasing the number of lateral levels fused via transpsoas approach, and male gender, predispose patients to increased risk of POR in those without a second surgery within seven days, and in those with a simultaneous posterior fusion.

Simultaneous Posterior Fusion with Video Assisted Thoracoscopic Surgery (VATS) for Treatment of Kyphotic Deformities in Prone Position. A Series of 86 Cases

Background Data: The traditional position of the patient during VATS procedureis the lateral decubitus. This make the surgeon oriented to the field since this thesame position of the traditional thoracotomy and make it easy for conversionto open surgery if needed. Prone position; although may be difficult; has theadvantage of performing two major procedures; posterior fusion and anteriorreconstruction by at same time with minimized morbidity and mortality.Purpose: To evaluate the efficacy and safety of VATS in management of differentdorolumbar spine pathologies.Study Designs: Prospective clinical case study.Patients and Methods: Eighty six cases of kyphotic deformities due to variouspathologies (28 cases of fractures, 42 infection, 16 tumors) were treated bysimultaneous posterior fusion techniques and anterior reconstruction by VATSusing bone grafts, cages and spacers while the patient is in prone position. Themean follow up of the patients was 26.1 months. All patients were evaluatedradiographically preoperatively, postoperatively and at the end of follow upusing Cobb angle. Radiographs at the final follow up were assessed for fusion.VAS was used to evaluate pain of the thoracoscopic mini incision. All caseswere assessed neurologically by Frankel grading system and Denis pain scorefor back pain at the end of follow up. Operative time, intra and postoperativecomplications and blood loss were reported.Results: The mean age was 40.3 years. The regional Cobb angle improved from34.7° preoperatively to 11.6° postoperatively. Most of patients had improvedon both Frankel grading system and scores of pain. There was no indication toconvert any case to open procedure. No serious intraoperative complicationoccurred but one case of massive bleeding due to injury of one intercostal vesselthat has been controlled thoracoscopically. The postoperative complicationsincluded chest infection, delayed lung inflation, intercostals neuralgia andtransient neurological deficits.Conclusion: VATS using limited mini-incison provide an excellent and safeapproach for management of dorsolumbar pathologies. Prone position facilitateshandling of the spine both anteriorly and posteriorly at the same time to get themaximum benefit offered by both approaches without excessive morbidity tothe patient. (2012ESJ020)

Fracture of anterior cervical plate implant – report of two cases

Anterior cervical plate is a convenient and popular implant employed after corpectomy and bone grafting for traumatic or degenerative cervical spine disease. Although short-segment anterior cervical surgery may adequately be managed with anterior plate fixation alone, multilevel anterior cervical constructs exhibit a relatively high complication rate warranting a simultaneous posterior fusion. We report two patients undergoing two-level anterior corpectomy/fusion with a fixed anterior plate alone and exhibiting plate fracture in conjunction with pseudoarthrosis. The instrument failure was mainly attributed to pseudoarthrosis. However, improper contouring of the plate causing microstructural damage might create a weak point and contributed to this unusual hardware failure.

Posterior cervical fusion failure in three morbidly obese patients following circumferential surgery

Background The stability of multilevel anterior corpectomy with fusion (ACF) is often enhanced by simultaneous posterior fusion (PF) which provides a “posterior tension band.” Three morbidly obese patients undergoing circumferential surgery had posterior fusions performed without autogenous iliac crest graft to avoid donor site morbidity. Methods Three morbidly obese patients (300–350 lbs.), averaging 48 years of age, presented with rapidly progressive moderate/severe myelopathies. Magnetic resonance imaging (MRI) and computed tomography (CT) studies demonstrated severe ventral ossification of the posterior longitudinal ligament. Two to four level plated ACFs were performed utilizing fibula strut allograft and plates. Posterior spinous process wiring/fusion from C2-T1 were completed with braided titanium cables, fibula strut allografts, Inductive Conductive Matrix (a form of demineralized bone matrix), and allograft bone to avoid iliac crest donor site morbidity in such morbidly obese patients. Halo devices were utilized until fusion was documented on postoperative X-ray and 2D-CT studies subsequently obtained 3, 6, and up to 12 months postoperatively. Patients were followed an average of 3 years. Results Postoperatively, all 3 patients demonstrated mild residual myelopathy (Nurick Grade 0-I). Nevertheless, all 3 exhibited posterior pseudarthroses accompanied by anterior strut/plate extrusion (1 patient), partial anterior graft pseudarthrosis (1 patient), and a delayed strut fracture (1 patient). The first 2 patients required secondary posterior fusions performed with autogenous iliac crest graft, while the third fused with 6 months of additional bracing. Conclusions Following circumferential cervical procedures, posterior fusions failed in 3 morbidly obese patients where iliac crest autograft was omitted in an attempt to avoid donor site morbidity.

Early reconstruction failures after multilevel cervical corpectomy.

A retrospective analysis of graft and plate complications after multilevel anterior cervical corpectomy and fusion (ACF) attributed to spondylosis, stenosis, and ossification of posterior longitudinal ligament was conducted. To identify factors contributing to graft and plate complications in this population. Biomechanical factors contributing to the increased morbidity associated with plated multilevel ACF were evaluated. Graft- and/or plate-related complications were retrospectively reviewed in 33 patients undergoing two-level ACF reconstructions and in seven patients having three-level ACF reconstructions performed with iliac crest grafting and instrumentation with a fixed-plated design (cervical spine locking plate). Neurologic status was assessed before surgery and after surgery using both the Nurick Grading Scale and modified JOA (Japanese Orthopaedic Association) Score. The patients were observed an average of 31.4 months after surgery. The follow-up included lateral flexion and extension radiographs and a neurologic examination. Two of the 33 patients undergoing two-level fusions available for long-term follow-up after surgery developed reconstruction failures. All of the remaining fusions were successful, demonstrated by lateral flexion and extension radiographs. Seven patients had plated three-level corpectomy reconstructions. Five of the seven who had anterior-only reconstruction failed. A two-level ACF reconstruction is reliable with an anterior strut graft and fixed screw plate construct. A three-level ACF reconstruction is not reliably achieved with an anterior-only construct. The construct failures may be attributed in part to the fixed-plated design being used, as well as the long lever arm of the construct. There is a 6% failure rate after fixed-plated (cervical spine locking plate) two-level ACF reconstruction but a 71% failure rate after three-level fixed-plated ACF reconstruction. Future consideration should be given to simultaneous posterior fusion.