International Journal of Spine Surgery最新文献

Background: Persistent concerns remain about the deleterious pathological effects of minimally invasive transannular puncture, such as occurs during discography and therapeutic intradiscal procedures. The objective of this study was to estimate the safety profile associated with fluoroscopically guided intradiscal delivery of nucleus pulposus (NP) allograft under clinical trial and real-world conditions.

Methods: This was a retrospective pooled analysis of adverse events (AEs) and clinical complaints captured from 4 different treatment populations (n = 392) and a database of commercial cases (n = 19,392 discs treated) with lumbar discogenic pain who underwent minimally invasive intradiscal NP allograft supplementation. All AEs were graded for severity as mild, moderate, or severe, and relatedness was judged as possibly, probably, or definitely. All serious AEs were adjudicated for outcome.

Results: There were 51 total AEs reported across all 4 clinical cohorts, and 6 AEs (12%) were judged to be related to the NP allograft product and the intradiscal procedure, with an additional 4 AEs (8%) related solely to the intradiscal procedure. None of the AEs was associated with infection (ie, discitis), neurological compromise, or escalation to surgical treatment. The product-attributable serious AE incidence was 0.26% (1/392). Of the commercial cases (n = 19,392 discs treated), no clinical AEs were reported from this cohort, with only 101 device complaints (0.521%) related primarily to delivery interface or packaging integrity.

Conclusions: Intradiscal NP allograft supplementation for symptomatic degenerative disc disease demonstrates a favorable safety profile. These findings serve to temper concerns about the risk of disc complications and accelerated degeneration following transannular puncture.

Clinical relevance: These findings validate that the NP allograft product and procedure have an exemplary safety profile. As a microinvasive, motion-preserving intervention, this procedure has the potential to bridge the therapeutic gap between conservative care and invasive spine surgery for patients suffering from discogenic back pain.

Level of evidence: 4:

Lumbar discectomy remains the most common surgical treatment for lumbar disc herniation, potentially providing quick pain relief for patients. However, while pain resolution is a key measure of short-term success, it does not guarantee long-term recovery. In patients with large annular defects (≥6 mm), the structural vulnerability left by discectomy predisposes patients to recurrent herniation, which can trigger a return of severe pain, diminished function, and the need for additional surgery. Revision surgeries for recurrent herniations are costly and are associated with a lower chance of positive patient outcomes compared with primary procedures.Bone-anchored annular closure devices aim to address the root structural cause of recurrent herniation by sealing the annular defect during discectomy to preserve disc integrity. Adding a bone-anchored annular closure device to discectomy reduces symptomatic reherniation and reoperation rates by more than 50%, prolonging pain-free intervals and improving quality of life. Patients treated with bone-anchored annular closure devices report low pain scores over long-term follow-up, faster return to work, and reduced opioid requirements.Cost-effectiveness analyses demonstrate that in patients with a large annular defect, bone-anchored annular closure devices achieve cost neutrality, or savings, within 2 to 5 years, with incremental cost-effectiveness ratios below accepted thresholds. By preventing the recurrence of lumbar herniation and the need for reoperation, bone-anchored annular closure technologies offer a clinically validated, economically prudent solution aligned with value-based care principles and durable, patient-centered success.

Background: Lumbar fusion eliminates motion at the operative level and is associated with altered load transfer and adjacent segment degeneration. Total joint replacement (TJR) of the lumbar spine is a motion segment reconstruction procedure performed via a bilateral transforaminal approach that allows direct neural decompression and replacement of both disc and facet function. This prospective investigational device exemption clinical trial compared TJR with a concurrent, propensity-score-weighted real-world evidence cohort treated with either instrumented transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody spine fusion (PLIF).

Methods: This multicenter investigational device exemption trial was conducted at 20 US sites. Patient-reported outcomes from 152 TJR subjects implanted with the MOTUS device were compared with 142 propensity score-weighted TLIF/PLIF controls. Lumbar-related disability was measured with the Oswestry Disability Index (ODI) and back and worst leg pain severity by a 100-mm visual analog scale (VAS). Minimal clinically important difference thresholds were ODI ≥ 15 points and VAS ≥ 20 mm; responder analyses were also conducted using ≥30% and substantial clinical benefit (≥50%) thresholds. Effect sizes were calculated using Cohen's d or h.

Results: Baseline characteristics were well balanced, and there were no statistically significant differences between study groups. At 12 months, mean ODI decreased by 45 points (71%) with TJR and 37 points (59%) with TLIF/PLIF. The adjusted between-group difference was 8.1 points (95% CI, 2.5-13.7; P = 0.005; Cohen's d = 0.39, small). VAS back and leg pain decreases were similar between groups, with no significant between-group differences. Minimal clinically important difference responder rates were high (>85%) for both procedures; the ≥30% ODI threshold favored TJR (90% vs 80%; P = 0.04).

Conclusions: Substantial decreases in back impairment and pain severity were realized in both study groups. However, longitudinal improvement in ODI significantly favored patients treated with TJR.

Clinical relevance: Lumbar TJR combines decompression with motion preservation in a single procedure, potentially offering an alternative to fusion in selected patients. The advantage of utilizing a standard posterior operative approach with TJR is that it allows for direct decompression of the neural elements prior to implant placement.

Level of evidence: 2b.

As the population ages and the incidence of spine surgeries increases, better solutions are needed for the challenges of adequate pain control and lengthy hospital stays, which often result from difficulty with controlling pain, managing complications, or coordinating post-hospitalization care services. Thus, there is an inherent need for ways to improve pain and time to discharge. Minimally invasive techniques aim to minimize tissue disruption and can decrease pain and accelerate recovery. However, these techniques are not indicated for all spine patients, and not all spine surgeons are adequately trained in such techniques, thus limiting generalizability. In contrast, Enhanced Recovery After Surgery (ERAS) has recently been adopted within spine surgery as an alternative management strategy to optimize patient outcomes. Enhanced recovery principles mitigate the surgical stress response through a series of evidence-based, perioperative interventions that have demonstrated success with reducing postoperative pain and complications, increasing ambulation, and shortening length of stay. While still in its infancy within spine surgery, there is ample evidence for the successful implementation of ERAS programs for numerous spine procedures. However, further randomized trials will likely be needed to support the continued application of ERAS within spine surgery.

Background: Excessive stress on the pedicle screws or inadequate load-sharing with surrounding spinal components increases the mechanical demand and the risk of loosening or breakage. The lumbar interfacet cage (FFX device) is designed to prevent spinal instability and facet motion, enhancing facet joint fusion.

Objective: The present study aimed to compare the biomechanical performance of a lumbar interfacet cage when associated with a pedicle screw construct, compared with pedicle screws alone and pedicle screws associated with lumbar interbody cages, using the FE method.The authors hypothesized that implanting additional lumbar interfacet cages would reduce mechanical stress on pedicle screw constructs.

Study design: Comparative biomechanical study by finite element (FE) method.

Methods: A validated FE model for the lumbar spine was used to assess stress variations on pedicle screw constructs and discs in the prefusion stage following surgery. Modeled scenarios included (1) a short pedicle screw construct (L4/L5), with and without bilateral lumbar interfacet cage device placement and with or without interbody fusion cages, and (2) a long pedicle screw construct (L2-S1), with and without lumbar interfacet cage placement at all levels.

Results: Both facet and interbody cage placement in conjunction with short L4/L5 pedicle screw constructs significantly reduced mechanical loading on pedicle screws and rods compared with the pedicle screw construct alone. The placement of lumbar interfacet cages used in combination with pedicle screw constructs in long L2 to S1 constructs also significantly reduced stress loading on pedicle screws and rods, especially at the lower extremity of the construct.

Conclusions: The placement of facet cages in conjunction with pedicle screws can improve the load distribution of the construct, enhancing its stability and durability. This approach may help reduce the rate of pedicle screw loosening and breakage, which are complications commonly associated with long pedicle screw constructs.

Clinical relevance: Pedicle screw loosening and breakage remain frequent complications in lumbar fusion, especially in long constructs. This finite element analysis demonstrates that adding lumbar interfacet cages to pedicle screw constructs significantly reduces mechanical stress on screws and rods. By improving load distribution in both short and long constructs, the technique may decrease the risk of screw loosening and implant failure before fusion, potentially improving construct durability and reducing reoperation rates.

Level of evidence: 5:

Objective: This study aims to introduce an innovative technique for placing pedicle screws in patients with extremely small lumbar pedicles using an oblique view from a C-arm x-ray machine, achieving a comparable gripping force to conventional implanting for the treatment of thoracolumbar vertebral fractures.

Methods: A retrospective analysis was conducted on 11 patients with extremely small lumbar pedicles and thoracolumbar vertebral body fractures. The height of the vertebral body and Cobb angle were measured on computed tomography radiographs, and comparisons were made between pre- and postoperative values. Scores from the visual analog scale, Oswestry Disability Index, and Short Form-36 were recorded to evaluate the surgical outcomes.

Results: All patients successfully underwent the surgery without intraoperative complications such as pedicle collapse, cerebrospinal fluid leakage, or nerve damage. The height of the anterior margin of the vertebral body and the compression rate of the anterior margin of the injured vertebrae showed significant improvement, as did the Cobb angle, with statistically significant differences (P < 0.05). The patients' visual analog scale, Oswestry Disability Index, and Short Form-36 scores were all significantly reduced compared to preoperative levels (P < 0.05). All cases demonstrated excellent reconstruction and maintenance of spinal stability, with the longest follow-up reaching 2 years postoperatively. No issues such as screw loosening or extraction were observed during this period.

Conclusions: The C-arm x-ray machine oblique radiograph-assisted external pedicle implanting approach offers a simple, accurate, and safe alternative for internal fixation surgery in patients with extremely small lumbar pedicles, without the need for an O-arm navigation system.

Clinical relevance: This retrospective cohort study confirms that the technique is a highly effective modality for managing thoracolumbar vertebral fractures with extremely narrow lumbar pedicles, reliably restoring and maintaining spinal stability, and thus offering a novel therapeutic option for clinicians.

Background: To evaluate the clinical and radiological outcomes of biportal endoscopic lumbar interbody fusion (BE-LIF) using the 30-degree endoscope in patients with lumbar spondylolisthesis and severe disc height loss and to highlight its technical advantages in endplate preparation and contralateral decompression.

Methods: This retrospective study included 21 patients with single-level Meyerding grade II spondylolisthesis and preoperative disc height <5 mm who underwent BE-LIF combined with percutaneous pedicle screw fixation between February 2023 and February 2025. Clinical outcomes were assessed using the visual analog scale for back and leg pain and the Oswestry Disability Index. Radiographic parameters, including vertebral slip, disc height, and foraminal height, were evaluated on standing lateral x-ray images, while fusion status was assessed using Bridwell grading on 6-month postoperative computed tomography scans.

Results: At a mean follow-up of 11.7 ± 2.6 months, all patients demonstrated statistically significant clinical improvement, visual analog scale scores decreased from 7.2 ± 0.6 to 1.5 ± 0.5 for low back pain, from 7.5 ± 0.5 to 1.7 ± 0.6 for leg pain, and the Oswestry Disability Index improved from 42.6 ± 5.7 to 15.7 ± 2.5 (P < 0.001). Radiologically, vertebral slip was reduced from 11.3 ± 1.5 mm to 2.1 ± 0.4 mm. Anterior and posterior disc heights increased from 5.6 ± 0.6 mm and 4.9 ± 0.5 mm to 8.5 ± 1.2 mm and 8.3 ± 1.4 mm, respectively. Foraminal height improved from 9.8 ± 1.7 mm to 14.7 ± 2.8 mm. Fusion was confirmed in all cases (Bridwell grade I: 28.6%, grade II: 71.4%), with no cage subsidence or major complications reported.

Conclusion: The use of the 30-degree endoscope in BE-LIF for spondylolisthesis with severe disc collapse provides enhanced visualization, facilitates safe and effective decompression, and results in favorable clinical and radiological outcomes.

Level of evidence: 3:

Background: Far-out syndrome is considered a rare spinal disorder characterized by L5 radiculopathy due to extraforaminal stenosis at the lumbosacral junction. Despite advancements in surgical techniques, managing far-out syndrome remains a significant challenge owing to the complex anatomical variations usually associated with the condition. This article reports 2 cases of far-out syndrome resulting from anterolateral vertebral osteophyte formation that underwent anterior decompression. A comprehensive review of the literature is also provided.

Case presentation: A 51-year-old man and a 72-year-old woman presented with progressive leg pain and neurogenic claudication associated with hypesthesia over the left L5 dermatome. Radiological findings in both patients revealed entrapment of the L5 nerve root by anterolateral vertebral osteophytes at the anterior exit zone of the foramen. One patient presented with Castellvi Type IV lumbosacral transitional vertebra, and the other patient showed spontaneous facet joint fusion at adjacent segments.

Case management: We performed anterior-extraperitoneal osteophytectomy using an ultrasonic bone dissector to decompress the extraforaminal stenosis, which resulted in successful resolution of the symptoms and improved neurological status. Both patients remained asymptomatic at the 1-year follow-up.

Conclusions: Extraforaminal stenosis at the lumbosacral junction due to anterolateral vertebral osteophytes usually occurs in patients with anatomical abnormalities such as lumbosacral transitional vertebra and adjacent segment fusion. Anterior decompression via extraperitoneal approach is an effective and safe treatment option for far-out syndrome, offering a viable alternative to the conventional posterior approach.

Level of evidence: 5: