Journal of spine surgery最新文献

Background: Lumbar ligamentum flavum hematoma (LFH) is a rare cause of nerve root and/or cauda equina compression which is commonly treated using microsurgical laminectomy and posterior fixation. However, technological advances may allow for less invasive options to be used.

Case description: A 70-year-old female with lower back and right lower extremity radicular pain without relevant medical history. Muscle strength and tendon reflexes were normal. Lumbar computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lumbar dural sac and nerve root compression due to lumbar canal stenosis and lumbar LFH at L3-4. Full-endoscopic laminectomy (FEL) was performed at L3-4 after conservative treatment failed to provide sufficient improvement. Intraoperative observation revealed the presence of a hematoma during removal of the lumbar ligamentum flavum. Postoperatively, the lower back and right lower extremity radicular pain resolved. Postoperative MRI and CT demonstrated tomography revealed decompression of the lumbar dural sac and nerve root. The patient was discharged without any perioperative complications. No recurrence was observed for at least 3 months postoperatively.

Conclusions: FEL appears to be an effective and minimally invasive approach for lumbar LFH, owing to its ability to visualize and drain the hematoma from the ligamentum flavum and perform dural sac and nerve root decompression.

Background and objective: Anterior lumbar spine surgery provides a viable efficacious alternative to traditional posterior approaches. Vascular complications are usually managed with simple open surgical techniques. Rarely, massive venous haemorrhage transpires after a venous injury which may be life-threatening. Advanced endovascular devices and techniques provide alternatives to open surgery for the management of massive venous injury (MVI). The majority of descriptions utilise covered stents which often need to be adapted to the emergent situation and the venous anatomy. We aimed to review the venous anatomy, available endovascular devices, and describe techniques used to manage an MVI encountered during anterior lumbar spine surgery, and propose a staged, systematic approach for its endovascular management. These techniques can be used instead of, or combined with open techniques.

Methods: A review of national databases (PubMed, Ovid Medline and Google Scholar) was performed using literature from 2000 to 2024 in English. Keywords included terms "anterior" and "lumbar" and "spine" and "haemorrhage" and "venous injury" and "vascular injury" and "damage control" and "endovascular" and "venous thromboembolism". Studies that described the anatomy, incidence, endovascular surgical techniques, complications, clinical and radiological outcomes of anterior lumbar spine surgery were included.

Key content and findings: We reviewed the relevant anatomy, patient work-up, lists of useful available endovascular equipment and devices, the stages of management, specific endovascular strategies and techniques, and the post-operative management of the patient.

Conclusions: Endovascular surgery can deliver control and definitive management with lower blood loss, reduced physiological insult while preserving venous patency. It is more likely to permit the completion of the spinal procedure than open surgical repair. Expertise in endovascular techniques is mandatory for their deployment. The best outcome is only achieved with a team approach to the situation, with the recruitment of appropriately skilled personnel and equipment. Endovascular techniques should be included in contingency planning for MVI.

L5-S1 pedicle screw (PS) fixation is commonly used to stabilize lumbosacral degenerative disease. Rigid S1 PS fixation is challenging due to sacral morphology. Various S1 PS techniques have been developed to increase screw insertion torque, including the penetrating S1 endplate screw (S1 PES) technique. This study introduces percutaneous sacral endplate penetrating screw (PSEPS) technique using S1 percutaneous pedicle screw (PPS) with a safer and longer screw trajectory and a novel modified hollow probe (M-probe). Penetrating the S1 superior endplate with a conventional straight hollow probe is challenging due to the thickening of the S1 endplate and the shape of the anterior S1 endplate. Therefore, we developed the M-probe that can easily penetrate the S1 endplate. First, the conventional straight probe was inserted 20 degrees inward and directed towards the cranial aspect until it reached the cranial margin of the S1 endplate. It was then confirmed that the probe was positioned beyond the posterior wall of the vertebral body in the lateral view. The M-probe was replaced through the guidewire, and the guidewire was replaced with a cannula before the M-probe was advanced. The M-probe was advanced toward the anterior one-third of the S1 vertebral body endplate. When the tip arrives at the S1 endplate, the M-probe should be oriented cephalad to facilitate penetration of the endplate and then advanced to penetrate the endplate. Rotating the tip of the M-probe enlarges the bone hole in the S1 endplate, eliminating the need for tapping. The PSEPS technique demonstrated significantly higher insertion torque at S1 compared to L5, despite lower Hounsfield unit values at S1 PSEPS: 394.0±104.8 cNm). The M-probe allowed for easier endplate penetration and higher insertion torque without the need for tapping. The PSEPS technique using the M-probe offers enhanced stability and safety for lumbosacral interbody fusion.

Background: The benefits of minimally invasive spinal surgery have seen an increase in uptake by surgeons and an increase in acceptability by patients. This retrospective cohort study aims to evaluate the efficacy and safety of unilateral biportal endoscopic (UbE) lumbar decompressive surgery with a focus on outcomes, technique, and temporal relationship between surgeon experience and operative times.

Methods: We performed a retrospective analysis of the first consecutive 105 patients undergoing UbE lumbar decompression (99 single-level and 6 double-level) for symptomatic herniated disc and/or spinal stenosis by a single surgeon at our institution. Data encompassed demographics, preoperative and postoperative assessments, operative details, complications, as well as patient-reported outcome measures (PROM).

Results: The 105 Asian patients presented with diverse symptoms, predominantly leg pain/radiculopathy (93.3%) and lower back pain (75.2%). The commonest level operated on was L4/5 (56.2%), and the operative time averaged 117.58 minutes per level, with shorter times being associated with increased surgical experience (r=-0.254, P=0.009) and longer times associated with higher body mass index (BMI) (r=0.209, P=0.03). Left-sided and L5/S1 level decompression were associated with quicker operative time, but without reaching statistical significance. In the immediate postoperative period, all patients experienced an improvement of symptoms with 54.3% experiencing complete symptomatic relief. The average length of hospitalization was 1.88 days. Complications were minimal with 3 dural tears (2.86%), 1 postoperative wound bleeding (0.95%) and no infective sequelae. PROM at 1- and 3-month mark showed significant improvements in Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and 36-item Short Form Survey (SF-36).

Conclusions: UbE lumbar decompression in Asian patients at our institution demonstrated favorable outcomes, in terms of symptomatic relief, functional scores and length of stay with few complications. Surgical times improved with increased experience, suggesting feasibility with practice. We recommend having adequate surgical experience in traditional approaches before transitioning to endoscopic decompression, and to embark on learning UbE approach with careful patient selection. Given inherent limitations such as retrospective single-cohort design and a short follow-up, further longer-term comparative studies are warranted to establish its superiority definitively.

Background: As healthcare becomes more expensive, hospitals and providers need to develop "value engineering" as a method to deliver the same quality of care for a lower cost. One key concept is to look at the entire cost of a procedure and begin to reduce costs one at a time within that procedure. We developed the BDC-15 as a method to harvest high quality bone graft and at a low cost while maintaining excellent results.

Methods: In this study, we present the first series of patients who underwent cervical fusion and lumbar fusion using exclusively the BDC-15 without any additional allograft.

Results: A total of 232 patients were entered into the study with 107 patients undergoing anterior cervical fusion surgery (one-, two-, or three-level) and 125 patients undergoing posterior lumbar fusion surgery (one- or two-level). Patients were followed for a mean of 13.4 months assessing fusion. For the cervical group, 95.3% of patients were fused at 6 months and for the lumbar group, 92% of patients were fused at 12 months. Complication rate was 4.7% (11 patients) due to admission for post-operative pain (6 patients), wound infection (3 patients), and hardware failure (2 patients). Average cost savings across all groups was $441,850 or approximately $1,904 per patient.

Conclusions: Autograft results in acceptable fusion rates and patient outcomes at a fraction of the cost of Allograft.

Background: Degenerative scoliosis occurs with asymmetric disc and facet degeneration and vertebral wedging. Intra-discal vacuum phenomenon (IDVP) is associated with advanced disc and facet degeneration, but typically poorly visualised on radiograph or magnetic resonance imaging (MRI), and has not been reported in the context of degenerative scoliosis. This radiographic observational case-control study aims to further investigate degenerative scoliosis through evaluation and characterisation of IDVP.

Methods: All scoliosis subjects were isolated from an over-60s population sample of 2020 digitalised computed tomography (CT) abdomen scans, yielding 136 subjects for analysis. One hundred and thirty-six age- and gender-matched non-scoliotic subjects with IDVP were chosen from the same cohort for comparison. The lumbar discs were analysed for severity, distribution and symmetry of IDVP. The lumbar spine was analysed for presence of scoliosis, calculation of pelvic incidence and presence of listhesis. Clinically significant back pain details were recorded and analysed.

Results: Subjects with S-shape curves accounted for 80% (n=109) and C-shape curves in 20% (n=27). Ninety-four (86%) with an S-curve had multilevel contralateral IDVP compared to 15 (55%) of C-curves. IDVP position was distributed towards the upper lumbar spine and with increased asymmetry (concavity-based). Back pain was not significantly increased in scoliotic subjects (39% vs. 32%, P=0.30) and not correlated with location, severity, laterality or distribution of IDVP.

Conclusions: CT analysis of degenerative scoliosis demonstrates predominantly multilevel contralateral asymmetric IDVP, with increased involvement of the upper lumbar spine and formation of S-shape curves, identifying a coronal compensatory correction in the presence of persistent degenerative mobility.

Background: The factors influencing bone healing in complete burst fractures-key to deciding between stabilization or vertebral replacement-remain poorly defined. Arterial vascularization and bone nutrition are known to affect healing or progression to necrosis. However, the role of vascular injury in vertebral fractures is not yet conclusively demonstrated and is not currently factored into the decision-making for ad initium vertebral body replacement surgery. This study aims to analyze the vascularization of the L1 vertebral body in Wistar rats and compare it to human anatomy. The goal is to evaluate the suitability of the Wistar rat as a model for studying vertebral blood supply.

Methods: Forty-three female Wistar rats (3 months old, 250-350 g) were used. After intraventricular injection of acrylic resin, three specimens underwent vascular corrosion-fluorescence. Twenty rats received latex injections and were converted into modified Spalteholz-cleared specimens. The remaining 20 underwent histological analysis of axial slices at upper, intermediate, and lower vertebral body levels. Cell nuclei of vascular endothelium, bone, cartilage, and marrow components were identified and analyzed by quadrant and central/peripheral distribution.

Results: Several vascular structures observed macroscopically matched human anatomy, including: lumbar segmental arteries (100%), horizontal metaphyseal anastomoses (Hma) (56.52%), vertical anastomoses between adjacent vertebrae (34.78%), primary periosteal arteries (Ppa) (60.87%), anterior spinal canal branch (Ascb) of the lumbar artery (69.57%), its ascending and descending branches (52.17%), posterior intervertebral anastomoses (17.39%), posterior nutritive artery origins (47.83%), medial spinal branches (86.96%) and radicular branches (Rbs) (65.22%). Histologically, the vascular density averaged 101.09 endothelial nuclei per mm². There was a clear predominance of endothelial cells in the anterocentral region. Statistically significant differences were found in cell density and proportion between central (CA) and peripheral (PA) areas (P<0.001), within central versus lateral regions (P<0.001), and between anterior and posterior regions (P=0.03). The distribution of vascular endothelium, bone, cartilage, and bone marrow components is described.

Conclusions: The vascular architecture of the L1 vertebral body in Wistar rats shows strong similarity to that of humans. These findings support the Wistar rat as a valid model for future studies on vertebral body vascularization and the role of ischemia in fracture healing and related pathologies.

Background: Although recognition of avascular necrosis of the vertebral body in post-traumatic cases has increased, it remains underdiagnosed and is one of the most unpredictable and challenging complications in spinal trauma. Vertebral arterial supply may play a key role in fracture healing, yet this remains unproven and is not currently considered in treatment algorithms. Surgical decisions between preserving or replacing the vertebral body in burst fractures are difficult, mainly due to limited knowledge of the biological factors influencing bone repair. This study aims to demonstrate the impact of vertebral vascular disruption on vertebral body fracture healing. We developed an experimental model in Wistar rats to replicate an L1 vertebral body fracture and analyze the normal healing sequence. Additionally, we examined the effects of disrupting the anterolateral blood supply on bone regeneration.

Methods: Seventy female Wistar rats were divided into two groups. Group 1 (n=35) underwent an L1 burst fracture induced by ultrasonic tools. Group 2 (n=35) received the same fracture, followed by electrocauterization of the anterolateral vertebral surfaces and placement of a synthetic barrier to prevent revascularization. Vertebral specimens were collected weekly for 6 weeks. Healing was assessed macroscopically and histologically using an image-processing algorithm trained to identify inflammatory, fibroblastic/cartilaginous, and bone tissue. The predominant tissue type was used to determine the healing stage.

Results: At week 1, the vascular disruption group showed significantly more inflammatory tissue (56.34%) than controls (24.25%, P=0.03), while fibroblastic/cartilaginous tissue was more common in controls (58.82% vs. 19.18%, P=0.03). By week 6, this tissue remained more prevalent in the intervention group (37.4%), while bone tissue predominated in controls (66.71% vs. 45.54%, P=0.009). Among animals already in the bone phase, trabecular structures were significantly more developed in controls (80% vs. 20%, P=0.031). Notably, all control animals reached the soft callus stage by week 1, whereas intervention animals only transitioned out of the inflammatory phase after the first week. Across all phases, progression was consistently faster in the control group, with statistical significance in the soft callus stage (P=0.002).

Conclusions: Disruption of the anterolateral vascular supply significantly delays healing in L1 vertebral body fractures in rats, evidenced by slower phase transitions and reduced bone maturation. These findings underscore the essential role of vascularization in successful vertebral repair and suggest it should be considered in future therapeutic strategies.

Background and objective: Systematic reviews and meta-analyses are essential tools in spine surgery, providing a rigorous method for synthesizing evidence from multiple studies to guide clinical decision-making. These reviews help address conflicting outcomes across studies and enhance statistical power, making them invaluable for evaluating the effectiveness and safety of surgical interventions. The purpose of this review is to outline how to design and conduct a systematic review and meta-analysis specifically in the field of spine surgery.

Methods: A preliminary search was performed across several key databases, including PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science, to identify relevant literature on spine surgery. The search strategy, search terms, inclusion and exclusion criteria, and screening process were detailed to ensure a comprehensive and standardized approach. This was followed by a narrative integration to synthesize and highlight significant trends, innovations, and gaps within the field.

Key content and findings: Systematic reviews in spine surgery are conducted through a standardized and repeatable approach to search for, evaluate, and synthesize information. At the top of the evidence-based hierarchy, systematic reviews can represent the most compelling evidence when they include high-quality research, combining outcomes from multiple primary studies into comprehensive findings. When augmented with a meta-analysis that employs statistical techniques to join the results of three or more studies, systematic reviews become invaluable tools for addressing research questions.

Conclusions: This first installment focuses on the development of a research question and methods for sourcing and screening relevant databases. A forthcoming companion manuscript will detail the execution phase, including quality assessment, risk of bias, and meta-analysis techniques tailored to spine surgery. The databases most frequently utilized for identifying studies are PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science. While not exhaustive, this document aims to serve as an introductory resource for those interested in undertaking or critically evaluating systematic reviews and meta-analyses within the domain of spine surgery.