Journal of spine surgery最新文献

Background: Adult spinal deformities (ASDs) requiring long fusions to the lumbosacral junction are notorious for L5-S1 pseudarthrosis and hardware-related complications. The minimally invasive surgery antepsoas (MIS-ATP) technique allows for substantial anterior column reconstruction thereby reducing the risk of posterior hardware-related complications. This study investigates the incidence of posterior hardware-related complications following long-segment fusion (seven or more vertebrae) using MIS-ATP and posterior percutaneous fixation (PPF).

Methods: This is a retrospective review of patients who underwent long spinal fusion (MIS-ATP + PPF) to the sacrum and pelvis for the management of ASD between 2008 and 2019. Postoperative clinical complications and radiographic parameters were collected and analyzed. The following postoperative variables were collected: surgical site infections, neuro-vascular injuries, implant fracture, implant displacement, hardware prominence and related pain, pseudarthrosis, junctional disease (proximal and distal), and need for surgical revision.

Results: A total of 143 patients were included in this study. The most common indications for fusion included: degenerative scoliosis (76.9%) and degenerative spondylolisthesis (17.5%). The average number of fused vertebrae per individual was 8.7. The most common levels fused were: T12-S1 anterior/T10-S1 posterior (53.1%). Forty-four patients (30.8%) experienced a total of 48 complications: pseudarthrosis (2.1%), deep infections (4.2%), painful iliac hardware (5.6%), pedicle screw complications (6.3%), and proximal junctional disease (PJD) (9.8%). Of these, 30 patients (21%) required revision surgery, mostly due to PJD (8 patients; 5.6%).

Conclusions: Long spinal fusions to the sacrum and pelvis are technically challenging and notorious for hardware failure (HF) and revision surgeries. The use of MIS-ATP fusion coupled with PPF could provide a safe and effective strategy against posterior HF. Furthermore, additional benefits of the MIS-ATP technique are inherent to its relatively safe approach-related profile.

Background: Spontaneous spinal epidural hematoma (SSEH) is a hematoma within the spinal epidural space without the underlying causes of trauma or iatrogenic and is considered a very rare neurosurgical emergency disease in children that can cause spinal cord compression and neurological dysfunction. This article provides useful information and guidance to the clinician about SSEH in children regarding its specific characteristics, clinical presentation, and management strategy to achieve a better outcome.

Case description: A 14-year-old boy presented with an acute onset of neck pain radiating to the right shoulder and progressive right hemiparesis. The cervical spine magnetic resonance imaging (MRI) revealed a right posterolateral hyperacute spinal epidural hematoma at C4-C7. The patient underwent an emergent open-door laminoplasty (C5-C6) with partial laminectomy (C4 and C7) and complete evacuation of the hematoma. The patient had a complete recovery after surgery with no neurological deficits. A literature search in the PubMed electronic database was performed to identify published English articles between January 2000 to December 2023 focusing on SSEH in children. We have found 81 articles with a total of 95 cases of SSEH in children, providing comparison data on sex, age, clinical presentation, etiology, location of the hematoma, treatment modalities, and outcomes.

Conclusions: SSEH in children is a very rare neurosurgical emergency disease. Prompt and proper examination is essential to establish the diagnosis and early surgical decompression. Adequate surgical decompression may reduce intradural pressure and increase the blood perfusion to the spinal cord, thus, this will eventually reduce ischemia and prevent secondary spinal injury. As a result, complete recovery can be expected.

Background: Airway-related complications are rare after cervical spine surgery but can be devastating and compromise a successful outcome. The objective of this systematic review is to provide an overview of the management of airway complications after anterior cervical spine surgery (ACSS) and propose a treatment algorithm for approaching the patient with a compromised airway.

Methods: A literature search was conducted in PubMed and adapted for use in other databases, including the Cochrane Register of Controlled Trials, Cochrane Library Health Technology Assessment Database, Embase, and the National Health Service (NHS) Economic Evaluation Database.

Results: A total of 117 papers received a full text review. Thirty-seven studies were categorized as "management" and included. An additional four references were extracted from other references for a total of 41 studies.

Conclusions: Most of the available evidence on airway compromise after ACSS is level III or IV. Similarly, most available evidence on the management of acute airway complications comes from case reports or anecdotal publications. There are currently no methods in place to stratify the risk of airway complications in patients undergoing these guidelines on the management of these complications when they occur. This review is focused on practice, including management of such complications with a proposed treatment algorithm.

Background: Minimally-invasive trans-facet lumbar interbody fusion (LIF) is an emerging technique that offers the advantages of being safe, enabling decompression, and facilitating patient recovery. An innovative cage that expands in two dimensions has been introduced to restore segmental lordosis and disc height while minimizing the risk of cage subsidence. This study aimed to report our surgical technique of trans-facet LIF utilizing the innovative cag and to report the early clinical outcomes.

Methods: We retrospectively reviewed the medical records and radiographs of patients who underwent trans-facet LIF with dual-dimension expandable cages from two institutions: Duke University Hospital and Vail-Summit Orthopaedics and Neurosurgery. The analysis covered patient demographics, Oswestry Disability Index (ODI), visual analogue scale (VAS) for back pain, surgical data, complications, and radiographic parameters. Clinical outcomes were compared between pre- and one year post-operation, while radiographic outcomes were compared between pre- and three months post-operation.

Results: Twenty patients with a mean age of 61.2 years were included. Seventeen patients (85.0%) had spondylolisthesis, and L4/5 (68.2%) was the most common pathology level. Twelve patients (60.0%) underwent awake surgery, and the mean operative time was 164.5±36.1 minutes, with an estimated blood loss of 64.0±39.5 mL and a hospital stay of 1.75±1.2 days. Four patients (20.0%) experienced cage subsidence; however, none required additional surgery. The VAS score significantly improved from a preoperative average of 7.3±2.7 to 2.6±1.6 one year post-operation (P=0.02). The ODI score also showed a significant decrease, from 48.7±22.9 preoperatively to 16.4±11.1 one year postoperatively (P=0.03). Notably, 80% and 83.3% of patients achieved the minimum clinically important difference in VAS and ODI scores, respectively. The degree of spondylolisthesis was significantly reduced from a median of 5.9 mm preoperatively to 0 mm postoperatively (P<0.001). Additionally, both anterior and posterior disc heights significantly increased after surgery, from 9.8±4.7 to 15.1±2.6 mm (anterior) and from 4.9±3.3 to 10.5±2.2 mm (posterior) (P<0.001 for both). The mean segmental lordosis increased by 2.9 degrees and was associated with cage height (P=0.03), while spinopelvic parameters remained unchanged.

Conclusions: Minimally-invasive trans-facet LIF with dual-dimension expandable cages demonstrates a substantial capacity for spondylolisthesis reduction and disc height restoration, and provides good short-term clinical outcomes. It may be the most appropriate method for deploying this large cage as it allows for a large, unobstructed pathway to the disc. However, future studies are needed to determine the long-term outcomes, including the arthrodesis rate.

Background: There is an increase in the volume of elective lumbar fusion surgeries. Various techniques have been described however the literature on cost comparisons of different fusion techniques is sparse. The aim of this study was to evaluate resource utilisation of single position (SP) lateral lumbar interbody fusion (LLIF) compared to dual position (DP) LLIF.

Methods: This retrospective study included all patients who underwent single-stage anterior to psoas (ATP) LLIF with navigated percutaneous pedicle screw (PPS) fixation by the senior author between September 2020 and September 2023. Demographic details, operative variables (duration of surgery, SP/DP) and complications (intra-operative, post-operative) were included. Variables related to resource usage included length of stay, implant fee, consumables fee, anaesthetist fee and facility fee.

Results: There were 6 patients in the SP group and 14 patients in the DP group. None of the patients had intra-operative complications. SP group was associated with a 44.6% decrease in the length of stay (P=0.023) compared to the DP group, holding CCI and levels constant. The median operative time for the SP and DP groups were 150 and 282.5 min respectively (P<0.001). The median consumables fee ($2,509 vs. $3,839, P<0.001) for the SP group were lower than the DP group.

Conclusions: SP LLIF with navigated PPS insertion described in this paper is a minimally invasive technique with reduced resource usage compared to DP LLIF.

Background: The predominant surgical procedure employed for patients with symptomatic cervical radiculopathy is anterior cervical discectomy and fusion (ACDF). ACDF typically involves the use of an interbody cage augmented with iliac crest bone graft (ICBG) or local autograft to enhance fusion rate. Substantial complications can arise from autograft use, including donor site morbidity, difficulties with ambulation, and diminished quality of life. This study aims to evaluate the effectiveness and safety of an allograft cellular bone matrix (ACBM) as an osteopromotive bone, in ACDF procedures.

Methods: This retrospective, single-center, consecutive case series included 73 patients who underwent an ACDF procedure. The surgical procedure involved the placement of an interbody cage supplemented with anterior plate fixation and an ACBM within the interbody spacer. Patient charts were reviewed to gather demographic information, radiographic findings, as well as perioperative and post-operative complications. Radiographic fusion was assessed at 6 and 12 months by a blinded, musculoskeletal-trained radiologist and a board-certified spinal surgeon reviewer. Any discrepancies were settled by a third, senior reviewer. Complete fusion was defined as: evidence of bridging bone across the disc space on CT, angular motion <3 degrees, and translational motion <2 mm on lateral radiographs. Complications were analyzed at 6, 12, and 15+ months post-operatively to assess clinical outcomes and device performance.

Results: A total of 73 patients (50 males, 23 females) with an average age of 54.6 (range, 31-77) years underwent an ACDF procedure between C3-T1 with an ACBM. The breakdown of levels operated on was 26%, 32%, 34%, and 8% for one, two, three, and four level procedures, respectively. There were three patients who received spinal injections for pain within the first year post-operatively. There were two patients who required secondary surgery within the first 12 months where supplemental posterior hardware was needed. Notably, there were no instances of cage subsidence, cage migration, cage/graft removal, or reoperation. There were no cases of chronic dysphasia. At 6 months, 45% of patients with available imaging demonstrated complete fusion, while 97.4% of patients with available imaging demonstrated complete fusion at 12 months.

Conclusions: At the 12-month follow-up, our study demonstrates a high fusion rate in a real-world population of up to 4 operative levels. There were no bone graft related complications or incidences of cage migration/subsidence. It is noteworthy that the study involved a significant number of multilevel cases (74% of cases). Despite this, our results align with historical fusion rates and provide support for the utilization of ACBMs as a fusion adjunct in ACDF procedures up to 4 levels.

Background: Spinal cord stimulators (SCS) have gained widespread popularity as an intriguing tool for managing chronic neurogenic pain. Despite the growing adoption of SCS as a therapeutic approach, there is a lack of demonstrated efficacy. The clinical utilization of SCS is on the rise, despite potential severe complications and the absence of clear evidence supporting its therapeutic benefits.

Case description: We present a challenging case of acute spinal epidural hematoma secondary to SCS placement in a liver transplant recipient. The patient exhibited acute bilateral leg weakness, sensory deficits, and urinary dysfunction, 2 days after SCS placement. Urgent surgical decompression was performed 3 days after the permanent placement of the SCS. Even with multiple debridement procedures the patient did not regain any function and remained paraplegic. This case underscores the importance of vigilant monitoring post operatively and timely intervention when epidural hematomas develop. The patient's intricate medical background, encompassing liver transplantation and chronic immunosuppression, contributed to the complexity of the case. Given these evident co-morbidities, the justification for SCS should have been unequivocal. However, what we observe is a vague clinical indication with minimal consideration for the associated risks.

Conclusions: This case highlights the need for cautious consideration of SCS due to its serious and lasting side effects in treating chronic back pain. Surgeons should reevaluate the widespread use of SCS, advocating for reserved usage in controlled trials until therapeutic benefits are firmly established. Despite potential pain relief, the risk of complications, including spinal epidural hematoma, should not be underestimated. Further research is urged to understand therapeutic benefits and assess short- and long-term complications comprehensively.

Background: Anterior lumbar interbody fusion (ALIF) uses a broad-footprint interbody cage designed to maximize fusion rates for treating degenerative disc disease. Bone graft substitutes are being increasingly utilized during ALIF to replace or supplement autologous iliac crest bone grafts. This approach aims to optimize fusion efficacy while minimizing associated postoperative complications. The objective of this systematic review was to examine recent studies on fusion rates and postoperative complications associated with bone graft substitutes used in ALIF.

Methods: We conducted a systematic review of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, MEDLINE, and PubMed databases, to critically examine a decade of research (January 1, 2012, to July 6, 2023) on the effectiveness and safety of various bone graft substitutes in ALIF. This timeframe was chosen to build on a previous systematic review published in 2013. The PRISMA guidelines were used.

Results: In total, 27 articles met our stringent inclusion and exclusion criteria. A substantial portion of these studies (67%) focused on recombinant human bone morphogenetic protein-2 (rhBMP-2) and highlighted its efficacy for achieving high fusion rates. However, the literature presents a dichotomy regarding the association of rhBMP-2 with increased postoperative complications. Notably, the methodologies for evaluating spinal fusion varied across studies. Only one-third of studies employed computed tomography to assess interbody fusion at 12 months postoperatively, highlighting the urgent need to establish uniform fusion criteria to facilitate more accurate comparative analyses. Moreover, there was considerable variability in the criteria used for diagnosing and detecting postoperative complications, significantly influencing the reported incidence rates.

Conclusions: This review underscores the need for continued research into bone graft substitutes, particularly focusing on assessment of long-term complications. Future research endeavors should concentrate on developing comprehensive clinical guidelines to aid in the selection of the most suitable bone graft substitutes for use in ALIF, thereby enhancing patient outcomes and surgical efficacy.

Background: There is limited literature regarding radiological outcomes in the use of interlaminar devices as an adjunct to decompression compared to decompression alone (DA) for symptomatic lumbar spinal stenosis (LSS). This study aims to assess and compare 5-year radiological outcomes following spinal decompression and decompression with ILD (D + ILD).

Methods: We conducted a retrospective review of prospectively collected data of 94 patients who underwent spinal decompression with or without ILD insertion between 2007-2015. Patients with symptomatic LSS who met the study criteria were offered spinal decompression with or without ILD insertion. Those patients who accepted ILD insertion were placed in the D + ILD group (n=39); while those opting for DA, were placed in the DA group (n=55). Radiological indices were assessed preoperatively, immediate post-operative, 2 years and 5 years postoperatively.

Results: There were a total of 94 patients with 55 in the DA group and 39 in the D + ILD group. In both groups, there was no significant change post-operatively in the sagittal balance parameters namely, the mean pelvic incidence, pelvic tilt, sacral slope and pelvic incidence minus lumbar lordosis (PI - LL) during the 5-year follow-up. Comparing between the groups, there was no significant difference in sagittal balance parameters. Comparing between DA versus D + ILD, there was no significant difference in overall lordosis, but the D + ILD had a significant reduction in sagittal angle (at the index level) of 2.3° compared to the DA group (P=0.01). In the control group, there was no significant difference in the anterior disc, posterior disc and foraminal height post-operatively. In the D + ILD group, there was a significant mean increase of 1.3 mm in anterior disc height, 1.8 mm in posterior disc height and 4.7 mm in foraminal height compared to the control group. In both groups, there was significant improvement in all clinical outcomes namely 36-item short form survey physical component summary (SF36 PCS), 36-item short form survey mental component summary (SF36 MCS) and visual analogue scale (VAS). Comparing the groups, there was significant improvement in the D + ILD group in SF36 MCS (P=0.01) but no difference in SF36 PCS or VAS. Reoperation rates were equivalent.

Conclusions: Our study found that in the management of lumbar stenosis, the use of an ILD as an adjunct device compared to DA had significant improvement in anterior disc, posterior disc and foraminal height with expected focal kyphosis at the level of intervention without change in the lumbar lordosis and sagittal balance at 5 years.