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Arimura D, Kanai T, Shinohara A, Katsumi S, Mori K, Saito M. Hounsfield unit to serum pentosidine ratio predicts screw loosening after lumbar interbody fusion. BMC Musculoskelet Disord 2024; 25:1065. [PMID: 39725963 DOI: 10.1186/s12891-024-08236-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 12/20/2024] [Indexed: 12/28/2024] Open
Abstract
PURPOSE This study aimed to identify whether the ratio of the vertebral Hounsfield unit to serum pentosidine (H/P ratio), which reflects bone density and quality, can predict screw loosening after spinal fusion surgery. METHODS A retrospective case-control study was conducted in 35 patients (mean age 71 ± 10.4 years, 18 men) who underwent spinal interbody fusion for lumbar spine disease between June 2020 and February 2022. Screw loosening was evaluated by computed tomography at 12 months postoperatively. Information was collected on patient background characteristics, including age, sex, body mass index, diagnosis, dialysis status, smoking history, diabetes, steroid use, and osteoporosis. Imaging parameters, the surgical method used, number of fixed intervertebral segments, intervertebral level (including L5/S1 or not), and the H/P ratio were also investigated. Risk factors associated with screw loosening and pseudarthrosis were examined in univariable and multivariable logistic regression analyses. A P-value of < 0.05 was considered statistically significant. RESULTS Screw loosening occurred in 14 of 35 patients (40%). Multivariate analysis revealed that the H/P ratio (odds ratio 0.09, confidence interval 0.02-0.53, P = 0.007) was a significant risk factor for screw loosening at 12 months postoperatively. CONCLUSION This study demonstrates that the H/P ratio, which reflects both bone density and deterioration of bone quality in the vertebral body, may serve as a predictor of screw loosening at 12 months after lumbar spinal surgery.
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Affiliation(s)
- Daigo Arimura
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-19-18 Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - Tomoaki Kanai
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-19-18 Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Akira Shinohara
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-19-18 Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Shunsuke Katsumi
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-19-18 Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Keiichiro Mori
- Department of Urology, The Jikei University School of Medicine, 3-19-18 Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-19-18 Nishi-shimbashi, Minato-ku, Tokyo, 105-8471, Japan
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Jiang F, Li X, Liu L, Xie Z, Wu X, Wang Y. Automated machine learning-based model for the prediction of pedicle screw loosening after degenerative lumbar fusion surgery. Biosci Trends 2024; 18:83-93. [PMID: 38417874 DOI: 10.5582/bst.2023.01327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
The adequacy of screw anchorage is a critical factor in achieving successful spinal fusion. This study aimed to use machine learning algorithms to identify critical variables and predict pedicle screw loosening after degenerative lumbar fusion surgery. A total of 552 patients who underwent primary transpedicular lumbar fixation for lumbar degenerative disease were included. The LASSO method identified key features associated with pedicle screw loosening. Patient clinical characteristics, intraoperative variables, and radiographic parameters were collected and used to construct eight machine learning models, including a training set (80% of participants) and a test set (20% of participants). The XGBoost model exhibited the best performance, with an AUC of 0.884 (95% CI: 0.825-0.944) in the test set, along with the lowest Brier score. Ten crucial variables, including age, disease diagnosis: degenerative scoliosis, number of fused levels, fixation to S1, HU value, preoperative PT, preoperative PI-LL, postoperative LL, postoperative PT, and postoperative PI-LL were selected. In the prospective cohort, the XGBoost model demonstrated substantial performance with an accuracy of 83.32%. This study identified crucial variables associated with pedicle screw loosening after degenerative lumbar fusion surgery and successfully developed a machine learning model to predict pedicle screw loosening. The findings of this study may provide valuable information for clinical decision-making.
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Affiliation(s)
- Feng Jiang
- Southeast University Medical College, Nanjing, Jiangsu, China
| | - Xinxin Li
- Southeast University Medical College, Nanjing, Jiangsu, China
| | - Lei Liu
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Zhiyang Xie
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Xiaotao Wu
- Southeast University Medical College, Nanjing, Jiangsu, China
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
| | - Yuntao Wang
- Southeast University Medical College, Nanjing, Jiangsu, China
- Department of Spine Surgery, Southeast University ZhongDa Hospital, Nanjing, Jiangsu, China
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Bokov A, Kalinina S, Khaltyrov M, Pavlova S, Bulkin A. Supplementary posterior fusion in patients operated on employing TLIF may decrease the instrumentation failure rate. Front Surg 2023; 10:1259946. [PMID: 38186390 PMCID: PMC10766769 DOI: 10.3389/fsurg.2023.1259946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND It is supposed that additional posterior fusion may provide additional stability of the pedicle screw; however, the clinical impact of additional posterior fusion in patients treated with TLIF remains uncertain. The objective of this study is to assess the clinical efficacy of circumferential fusion in patients treated with TLIF. MATERIALS AND METHODS This is a single-center retrospective evaluation of consecutive 179 patients with degenerative lumbar stenosis and instability of spinal segments. Patients with axial pain and neurogenic claudication or radiculopathy associated with spinal stenosis were enrolled during the period from 2012 to 2018. Transforaminal lumbar interbody fusion (TLIF) with a single cage was used to treat patients. In 118 cases a supplementary posterior fusion was made. The duration of follow-up accounted for 24 months, logistic regression analysis was used to assess factors that influence the complication rate. RESULTS The rate of pedicle screw loosening was growing with radiodensity getting decreased and was more frequent in patients with two level fusion. An increase in pedicle screw loosening rate correlated with anterior nonunion Tan 2 and 3 grade while both posterior complete and incomplete fusion resulted in a decline in the complication rate. Lumbosacral fusion, bilateral facet joints` resection and laminectomy turned out to be insignificant factors. The overall goodness of fit of the estimated general multivariate model was χ2 = 87.2230; P < 0.0001. To confirm clinical relevance of those findings, a univariate logistic regression was performed to assess the association between clinically significant pedicle screw instability and posterior fusion in patients operated on employing TLIF. The results of logistic regression analysis demonstrate that additional posterior fusion may decrease the rate of instrumentation failure that requires revision surgery in patients treated with TLIF [B0 = 1.314321; B1 = -3.218279; p = 0.0023; OR = 24.98507; 95% CI (3.209265; 194.5162), the overall goodness of fit of the estimated regression was χ2 = 22.29538, p = <0.0001]. CONCLUSION Circumferential fusion in patients operated on employing TLIF is associated with a decline in the rate of pedicle screw loosening detected by CT imaging and clinically significant instrumentation failure.
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Affiliation(s)
- Andrey Bokov
- Institute of Traumatology and Orthopedics, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Svetlana Kalinina
- Department of Neurosurgery, Institute of Traumatology and Orthopedics, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Mingiyan Khaltyrov
- Department of Neurosurgery, Institute of Traumatology and Orthopedics, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Svetlana Pavlova
- Department of Neurosurgery, Institute of Traumatology and Orthopedics, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Anatoliy Bulkin
- Institute of Traumatology and Orthopedics, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
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Lee M, Lee E, Lee JW. Value of computed tomography Hounsfield units in predicting pedicle screw loosening in the thoracic spine. Sci Rep 2022; 12:18279. [PMID: 36316434 PMCID: PMC9622837 DOI: 10.1038/s41598-022-23142-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022] Open
Abstract
We evaluated the feasibility of using the Hounsfield unit (HU) value of the vertebral body to predict screw loosening in the thoracic spine. Consecutive patients who underwent thoracic spinal fusion surgery (from 2014 to 2020) were retrospectively identified. Patients with pedicle screw loosening in the upper instrumented vertebra (UIV) on postoperative computed tomography were included in the "loosening" group. The control group comprised an equal number of age-, sex-, and UIV-matched patients without screw loosening. Preoperative HU values at the UIV and lumbar T-scores were compared between the groups; receiver operating characteristic curves were constructed for HU values and T-scores to predict screw loosening, and the best cutoff values were determined. The same statistical analyses were performed for each subgroup, i.e., upper (T1-T4) and lower (T9-T12) thoracic levels. Forty-six patients each were included in the loosening and control groups. A significant between-group difference of HU values was noted for the lower thoracic UIV (loosening = 99.3, control = 126.3; p = 0.02) but not for the upper thoracic UIV (loosening = 171.8, control = 146.0, p = 0.70). T-scores did not differ between the groups for the lower (p = 0.14) and upper (p = 0.56) thoracic UIV. For the lower thoracic UIV, the area under the receiver operating characteristic curve was 0.660 for HUs (p = 0.01; 95% confidence interval [CI] 0.541-0.766) and 0.601 (p = 0.13; 95% CI 0.480-0.713) for T-scores. The optimal cutoff value for HUs was 126.3. Using this cutoff, HU values showed a better positive predictive value, negative predictive value, and accuracy compared to T-scores in predicting screw loosening.
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Affiliation(s)
- Minsu Lee
- grid.412480.b0000 0004 0647 3378Department of Radiology, Seoul National University Bundang Hospital, 82, Gumiro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Eugene Lee
- grid.412480.b0000 0004 0647 3378Department of Radiology, Seoul National University Bundang Hospital, 82, Gumiro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Joon Woo Lee
- grid.412480.b0000 0004 0647 3378Department of Radiology, Seoul National University Bundang Hospital, 82, Gumiro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Radiology, Seoul National University College of Medicine, 103, Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
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Cornaz F, Farshad M, Widmer J. Location of pedicle screw hold in relation to bone quality and loads. Front Bioeng Biotechnol 2022; 10:953119. [PMID: 36118575 PMCID: PMC9478651 DOI: 10.3389/fbioe.2022.953119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Sufficient screw hold is an indispensable requirement for successful spinal fusion, but pedicle screw loosening is a highly prevalent burden. The aim of this study was to quantify the contribution of the pedicle and corpus region in relation to bone quality and loading amplitude of pedicle screws with traditional trajectories. Methods: After CT examination to classify bone quality, 14 pedicle screws were inserted into seven L5. Subsequently, Micro-CT images were acquired to analyze the screw’s location and the vertebrae were split in the midsagittal plane and horizontally along the screw’s axis to allow imprint tests with 6 mm long sections of the pedicle screws in a caudal direction perpendicular to the screw’s surface. Force-displacement curves in combination with the micro-CT data were used to reconstruct the resistance of the pedicle and corpus region at different loading amplitudes. Results: Bone quality was classified as normal in three specimens, as moderate in two and as bad in two specimens, resulting in six, four, and four pedicle screws per group. The screw length in the pedicle region in relation to the inserted screw length was measured at an average of 63%, 62%, and 52% for the three groups, respectively. At a calculated 100 N axial load acting on the whole pedicle screw, the pedicle region contributed an average of 55%, 58%, and 58% resistance for the normal, moderate, and bad bone quality specimens, respectively. With 500 N load, these values were measured at 59%, 63%, and 73% and with 1000 N load, they were quantified at 71%, 75%, and 81%. Conclusion: At lower loading amplitudes, the contribution of the pedicle and corpus region on pedicle screw hold are largely balanced and independent of bone quality. With increasing loading amplitudes, the contribution of the pedicle region increases disproportionally, and this increase is even more pronounced in situations with reduced bone quality. These results demonstrate the importance of the pedicle region for screw hold, especially for reduced bone quality.
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Affiliation(s)
- Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
- *Correspondence: Frédéric Cornaz,
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
| | - Jonas Widmer
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
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Feng X, Luo Z, Li Y, Yao Y, Qi W, Chen B, Liang H. Fixation stability comparison of bone screws based on thread design: buttress thread, triangle thread, and square thread. BMC Musculoskelet Disord 2022; 23:820. [PMID: 36042443 PMCID: PMC9426233 DOI: 10.1186/s12891-022-05751-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background The influence of thread profile on the fixation stability of bone screws remains unclear. This study aimed to compare the fixation stability of screws with different thread profiles under several loading conditions. Methods Bone screws that differed in thread profile (buttress, triangle, and square thread) only were made of stainless steel. Their fixation stabilities were evaluated individually by the axial pullout test and lateral migration test, besides, they were also evaluated in pairs together with a dynamic compression plate and a locking plate in polyurethane foam blocks under cyclic craniocaudal and torsional loadings. Results The triangle-threaded and square-threaded screws had the highest pullout forces and lateral migration resistance. When being applied to a dynamic compression plate, higher forces and more cycles were required for both triangle- and square-threaded screws to reach the same displacement under cyclic craniocaudal loading. On the other hand, the triangle-threaded screws required a higher torque and more cycles to reach the same angular displacement under cyclic torsional loading. When being applied to a locking plate, the square-threaded screws needed higher load, torque, and more cycles to reach the same displacement under both cyclic craniocaudal and torsion loadings. Conclusions The triangle-threaded screws had superior pullout strength, while square-threaded screws demonstrated the highest lateral migration resistance. Moreover, dynamic compression plate fixation with triangle- and square-threaded screws achieved more favorable fixation stability under craniocaudal loading, while triangle-threaded screws demonstrated superior fixation stability under torsional loading. Locking plate fixation with a square-threaded screw achieved better fixation stability under both loading types.
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Affiliation(s)
- Xiaoreng Feng
- Department of Orthopaedics and Traumatology, Yangjiang People's Hospital, No. 42 Dongshan Road, Jiangcheng District, 529500, Yangjiang, China.,Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Zhaopei Luo
- Department of Orthopaedics and Traumatology, Yangjiang People's Hospital, No. 42 Dongshan Road, Jiangcheng District, 529500, Yangjiang, China
| | - Yupeng Li
- Department of Orthopaedics and Traumatology, Yangjiang People's Hospital, No. 42 Dongshan Road, Jiangcheng District, 529500, Yangjiang, China
| | - Yiyi Yao
- Department of Orthopaedics and Traumatology, Yangjiang People's Hospital, No. 42 Dongshan Road, Jiangcheng District, 529500, Yangjiang, China
| | - Weichen Qi
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong, China
| | - Bin Chen
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - Hongfeng Liang
- Department of Orthopaedics and Traumatology, Yangjiang People's Hospital, No. 42 Dongshan Road, Jiangcheng District, 529500, Yangjiang, China.
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The Usefulness of Trabecular CT Attenuation Measurement at L4 Level to Predict Screw Loosening After Degenerative Lumbar Fusion Surgery: Consider Number of Fused Levels and Postoperative Sagittal Balance. Spine (Phila Pa 1976) 2022; 47:745-753. [PMID: 35102120 DOI: 10.1097/brs.0000000000004330] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To evaluate the absolute value of L4 trabecular region-of-interest (t-ROI) computed tomography (CT) attenuation, which can predict pedicle screw loosening, and determine the changes in value according to number of fused levels and sagittal balance in patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA Although osteoporosis was not diagnosed in spinal dual x-ray absorptiometry preoperatively, we encountered several cases of screw loosening within 1 year of lumbar fusion surgery. METHODS We enrolled 478 patients and analyzed factors related to screw loosening. We evaluated the association between L4 t-ROI CT attenuation and screw loosening and determined the best cutoff value of t L4 t-ROI CT attenuation for predicting screw loosening. RESULTS The number of fused levels, postoperative C7-S1 sagittal vertical axis (SVA), and L4 t-ROI CT attenuation were independently correlated with screw loosening. According to number of fused level and postoperative C7-T1 SVA (≥36.9 mm or <36.9 mm), in patients with one-level fusion and C7-S1 SVA less than 36.9 mm, the optimal cutoff point of the L4 t-ROI CT attenuation predicting screw loosening was 106.5 Hounsfield unit (HU). L4 t-ROI attenuation did not change until two-level fusions. In patients with three-level fusions and C7-S1 SVA less than 36.9 mm, the optimal cutoff point of the L4 t-ROI CT attenuation predicting screw loosening was 159.0 HU. The optimal cutoff point of L4 t-ROI CT attenuation in patients with three-level fusions and C7-S1 SVA more than or equal to 36.9 mm was 191.0 HU. CONCLUSION L4 t-ROI CT attenuation value considering number of fused levels and sagittal balance is an accurate measurement method to predict screw loosening. Spine surgeons should be aware of the L4 t-ROI attenuation before surgery to improve the fusion rate and reduce instrument-related complications of lumbar spine surgery in osteoporotic patients. LEVEL OF EVIDENCE 3.
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5-Year Revision Rates After Elective Multilevel Lumbar/Thoracolumbar Instrumented Fusions in Older Patients: An Analysis of State Databases. J Am Acad Orthop Surg 2022; 30:476-483. [PMID: 35196291 DOI: 10.5435/jaaos-d-21-00643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 01/15/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE The purpose of this study wasto evaluate cause-specific 5-year revision rates and risk factors for revision after elective multilevel lumbar instrumented fusion in older patients. METHODS Older patients (>60 years) who underwent elective multilevel (3+) lumbar instrumented fusions were identified in Healthcare Cost and Utilization Project state inpatient databases and followed for 5 years for revision operations because of mechanical failure, degenerative disease (DD), infection, postlaminectomy syndrome, and stenosis. Cox proportional hazards multivariate analyses were conducted to determine risk factors associated with revision for each diagnostic cause. RESULTS The cohort included 5,636 patients (female-3,285; average age-71.6 years). Most of the operations were 3 to 7 levels (97.4%), and the mean length of stay was 5.4 days. The overall 5-year revision rate was 16.5% with predominant etiologies of DD (50.7%), mechanical failure (32.2%), and stenosis (8.0%). The revision procedure at the index operation was associated with an increased revision risk for DD (hazards ratio [HR] = 1.59, 95% confidence interval [CI], 1.29 to 1.98, P < 0.001) and mechanical failure (HR = 1.56, 95% CI, 1.19 to 2.04, P = 0.020). Male sex was associated with a significantly reduced revision risk for DD (HR = 0.75, 95% CI, 0.62 to 0.91, P = 0.04). Age, race, and number of comorbidities had no notable effect on the overall or cause-specific risk of revision. DISCUSSION In this large database analysis, DD and mechanical failure were the most common etiologies comprising a 5-year revision rate of 16.5% after elective multilevel lumbar instrumented fusion in older patients. Revision operations and female patients carried the strongest risks for revision.
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Fasser MR, Gerber G, Passaplan C, Cornaz F, Snedeker JG, Farshad M, Widmer J. Computational model predicts risk of spinal screw loosening in patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2639-2649. [PMID: 35461383 DOI: 10.1007/s00586-022-07187-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 10/15/2021] [Accepted: 03/12/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Pedicle screw loosening is a frequent complication in lumbar spine fixation, most commonly among patients with poor bone quality. Determining patients at high risk for insufficient implant stability would allow clinicians to adapt the treatment accordingly. The aim of this study was to develop a computational model for quantitative and reliable assessment of the risk of screw loosening. METHODS A cohort of patient vertebrae with diagnosed screw loosening was juxtaposed to a control group with stable fusion. Imaging data from the two cohorts were used to generate patient-specific biomechanical models of lumbar instrumented vertebral bodies. Single-level finite element models loading the screw in axial or caudo-cranial direction were generated. Further, multi-level models incorporating individualized joint loading were created. RESULTS The simulation results indicate that there is no association between screw pull-out strength and the manifestation of implant loosening (p = 0.8). For patient models incorporating multiple instrumented vertebrae, CT-values and stress in the bone were significantly different between loose screws and non-loose screws (p = 0.017 and p = 0.029, for CT-values and stress, respectively). However, very high distinction (p = 0.001) and predictability (R2Pseudo = 0.358, AUC = 0.85) were achieved when considering the relationship between local bone strength and the predicted stress (loading factor). Screws surrounded by bone with a loading factor higher than 25% were likely to be loose, while the chances of screw loosening were close to 0 with a loading factor below 15%. CONCLUSION The use of a biomechanics-based score for risk assessment of implant fixation failure might represent a paradigm shift in addressing screw loosening after spondylodesis surgery.
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Affiliation(s)
- Marie-Rosa Fasser
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland.,Spine Biomechanics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Caroline Passaplan
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Frédéric Cornaz
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Jess G Snedeker
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland.,Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Jonas Widmer
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland. .,Spine Biomechanics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
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Ma C, Zou D, Qi H, Li C, Zhang C, Yang K, Zhu F, Li W, Lu WW. A novel surgical planning system using an AI model to optimize planning of pedicle screw trajectories with highest bone mineral density and strongest pull-out force. Neurosurg Focus 2022; 52:E10. [DOI: 10.3171/2022.1.focus21721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The purpose of this study was to evaluate the ability of a novel artificial intelligence (AI) model in identifying optimized transpedicular screw trajectories with higher bone mineral density (BMD) as well as higher pull-out force (POF) in osteoporotic patients.
METHODS
An innovative pedicle screw trajectory planning system called Bone’s Trajectory was developed using a 3D graphic search and an AI-based finite element analysis model. The preoperative CT scans of 21 elderly osteoporotic patients were analyzed retrospectively. The AI model automatically calculated the number of alternative transpedicular trajectories, the trajectory BMD, and the estimated POF of L3–5. The highest BMD and highest POF of optimized trajectories were recorded and compared with AO standard trajectories.
RESULTS
The average patient age and average BMD of the vertebral bodies were 69.6 ± 7.8 years and 55.9 ± 17.1 mg/ml, respectively. On both sides of L3–5, the optimized trajectories showed significantly higher BMD and POF than the AO standard trajectories (p < 0.05). On average, the POF of optimized trajectory screws showed at least a 2.0-fold increase compared with AO trajectory screws.
CONCLUSIONS
The novel AI model performs well in enabling the selection of optimized transpedicular trajectories with higher BMD and POF than the AO standard trajectories.
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Affiliation(s)
- Chi Ma
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Da Zou
- Orthopaedic Department and
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing
| | - Huan Qi
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Chentian Li
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou; and
| | - Cheng Zhang
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Kedi Yang
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Feng Zhu
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
- Department of Orthopaedics, The University of Hong Kong–Shenzhen Hospital, Shenzhen, China
| | - Weishi Li
- Orthopaedic Department and
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing
| | - William W. Lu
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
- Department of Orthopaedics, The University of Hong Kong–Shenzhen Hospital, Shenzhen, China
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Su YF, Tsai TH, Lieu AS, Lin CL, Chang CH, Tsai CY, Su HY. Bone-Mounted Robotic System in Minimally Invasive Spinal Surgery for Osteoporosis Patients: Clinical and Radiological Outcomes. Clin Interv Aging 2022; 17:589-599. [PMID: 35497053 PMCID: PMC9041149 DOI: 10.2147/cia.s359538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/11/2022] [Indexed: 01/02/2023] Open
Abstract
Purpose Severe complications, including screw loosening events and low fusion rates, in spinal fusion surgery using the traditional open method are problematic. This retrospective study aimed to evaluate the rate of screw loosening and the clinical outcomes of bone-mounted miniature robot-assisted pedicle screw placement in patients treated for degenerative spinal disease. Patients and Methods Data were collected from the medical records of 118 patients (mean age, 69 years). Differences in clinical outcomes, including the Oswestry disability index, visual analog scale score, screw loosening rate, cage fusion rate, and complications, were evaluated among different bone mineral densities. Results The screw loosening and cage fusion rates for all patients, normal bone mineral density, osteopenia, and osteoporosis groups were 12%, 8.6%, 13.1%, and 14%, respectively, and 85.3%, 93%, 82.5%, and 81.4%, respectively. There was a higher screw loosening rate and a lower cage fusion rate in the osteopenia and osteoporosis groups than in the normal bone density group. The accuracy of the screw placement was 97.3%. There were no statistically significant differences in the Oswestry disability index and visual analog scale scores, and no major complications for dural tear or vascular or visceral injury. Conclusion Our study demonstrated an acceptable screw loosening rate in patients with osteoporosis compared to that in patients with normal bone mineral density. The robotic system resulted in accurate screw placement in patients with osteoporosis.
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Affiliation(s)
- Yu-Feng Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tai-Hsin Tsai
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ann-Shung Lieu
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Lung Lin
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hui Chang
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Yu Tsai
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Ph.D. Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University and National Health Research Institutes, Kaohsiung, Taiwan
- Post Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Correspondence: Cheng-Yu Tsai; Hui-Yuan Su, Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung, 80708, Taiwan, Tel +886-7-3215049, Fax +886-7-3215039, Email ;
| | - Hui-Yuan Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Scott-Young M, Lee SM(S, Nielsen D, Rathbone E, Rackham M, Hing W. Comparison of Mid- to Long-term Follow-up of Patient-reported Outcomes Measures After Single-level Lumbar Total Disc Arthroplasty, Multi-level Lumbar Total Disc Arthroplasty, and the Lumbar Hybrid Procedure for the Treatment of Degenerative Disc Disease. Spine (Phila Pa 1976) 2022; 47:377-386. [PMID: 34559766 PMCID: PMC8815823 DOI: 10.1097/brs.0000000000004253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aim of this article is to compare the mid- to long-term patient-reported outcome measures (PROMs) between single-level total disc arthroplasty (TDA), multi-level TDA, and hybrid constructs (combination of TDA and anterior lumbar interbody fusion [ALIF] across multiple levels) for symptomatic degenerative disc disease (DDD). SUMMARY OF BACKGROUND DATA The treatment of single-level DDD is well documented using TDA. However, there is still a paucity of published evidence regarding long-term outcomes on multi-level TDA and hybrid constructs for the treatment of multi-level DDD, as well as lack of long-term comparisons regarding treatment of single-level DDD and multi-level DDD. METHODS A total of 950 patients underwent surgery for single-level or multi-level DDD between July 1998 and February 2012 with single-level TDA (n = 211), multi-level TDA (n = 122), or hybrid construct (n = 617). Visual Analog Score for the back (VAS-B) and leg (VAS-L) were recorded, along with the Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ). RESULTS All PROMs in all groups showed statistically and clinically significant improvements (P < 0.005) in pain and function that is well above the corresponding minimum clinically important difference (MCID) and exceeds literature thresholds for substantial clinical benefit (SCB). Unadjusted analyses show that there were no statistically significant differences in the change scores between the surgery groups for VAS back and leg pain, and RMDQ up to 8 years' follow-up. Adjusted analyses showed the ODI improvement score for the single group was 2.2 points better (95% confidence interval [CI]: 0.6-3.9, P = 0.009) than in the hybrid group. The RMDQ change score was better in the hybrid group than in the multi-level group by 1.1 points (95% CI: 0.4-1.9, P = 0.003) at 6 months and a further 0.4 point at 2 years (95% CI: 0.1-0.8, P = 0.011). CONCLUSION In the setting of meticulous preoperative evaluation in establishing a precision diagnosis, clinically and statistically equivalent results can be achieved when treating symptomatic DDD through single-level TDA, multi-level TDA, and hybrid constructs. These results are sustained at mid- to long-term follow-up.Level of Evidence: 3.
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Affiliation(s)
- Matthew Scott-Young
- Gold Coast Spine, Gold Coast, Queensland, Australia
- Faculty of Health Science & Medicine, Bond University, Gold Coast, Queensland, Australia
| | | | - David Nielsen
- Department of Orthopedic Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Evelyne Rathbone
- Faculty of Health Science & Medicine, Bond University, Gold Coast, Queensland, Australia
| | | | - Wayne Hing
- Faculty of Health Science & Medicine, Bond University, Gold Coast, Queensland, Australia
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13
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Xu F, Zhou S, Zou D, Li W, Sun Z, Jiang S. The relationship between S1 screw loosening and postoperative outcome in patients with degenerative lumbar scoliosis. BMC Musculoskelet Disord 2022; 23:186. [PMID: 35227237 PMCID: PMC8883643 DOI: 10.1186/s12891-022-05107-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 02/09/2022] [Indexed: 11/29/2022] Open
Abstract
Background When choosing S1 as the lowest level of instrumentation, there are many complications may come out such as S1 screw loosening. Facing this problem, there has been various techniques for the protection of S1 screw including sacropelvic fixation, bicortical or tricortical insertion of S1 screw. Objective This study aimed to explore the risk factors for the S1 screw loosening, then to demonstrate the relationship between S1 screw loosening and postoperative outcome for patients with degenerative lumbar scoliosis (DLS). Methods Patients who underwent lumbosacral fixation for DLS were evaluated retrospectively. They were divided into two groups according to the S1 pedicle screw at the follow-up. Age, gender, bone mineral density, body mass index, history of smoking, the number of instrumented levels, comorbidities, complications and radiological parameters were collected. We established logistic regression analysis to determine independent risk factors for S1 screw loosening and multiple linear regression to identify whether S1 screw loosening would influence postoperative clinical outcome. Results S1 screw loosening rate was up to 41.0% (32/78). Patients were older in the S1 screw loosening group than those in the control group (P < 0.05). Compared with the control group, the rate of osteoporosis was higher in screw loosening group than that in the control group (P < 0.05). Older age and osteoporosis were independent risk factors for S1 screw loosening (P < 0.05). In the screw loosening group, the rate of hypertension was higher than that in the control group (P < 0.05). The relationship of S1 screw loosening and ODI was not significant in the multiple linear regression (P > 0.05). The clinical outcome was similar in the S1 screw loosening group and control group (P > 0.05). Conclusion Older age and osteoporosis are independent risk factors for the S1 screw loosening. Patients with complication of S1 screw loosening are not always along with worse clinical outcome. We should consider potential benefit, complications and medical cost when choosing the lowest instrumented vertebrae for patients with DLS.
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Affiliation(s)
- Fei Xu
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.,Peking University Health Science Center, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Reasearch, Beijing, China
| | - Siyu Zhou
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.,Peking University Health Science Center, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Reasearch, Beijing, China
| | - Da Zou
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.,Peking University Health Science Center, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Reasearch, Beijing, China
| | - Weishi Li
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China. .,Beijing Key Laboratory of Spinal Disease Reasearch, Beijing, China.
| | - Zhuoran Sun
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Reasearch, Beijing, China
| | - Shuai Jiang
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.,Peking University Health Science Center, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Reasearch, Beijing, China
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14
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Xi X, Zeng Z, Li F, Wang C, Ma B, Xie N, Tsai TY, Li G, Yu Y, Cheng L. Caudad Insertion of Pedicle Screws Facilitates Interbody Distraction During Spondylolisthetic Vertebrae Restoration: A Retrospective Study. Pain Ther 2021; 10:1537-1550. [PMID: 34524629 PMCID: PMC8586389 DOI: 10.1007/s40122-021-00315-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/27/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Based on the results of long-term clinical and radiological follow-up studies of decompression and fusion with internal fixation for degenerative lumbar spondylolisthesis (DLS), we recognized that the direction of the pedicle screw affects the stability of the fixation. However, few studies have analyzed the role of pedicle screw insertion trajectory in disc height recovery after fusion. We therefore analyzed patients' general information, clinical efficacy and sagittal, coronal and implant parameters to determine whether there is a correlation between the insertion trajectory of screws and the recovery of intervertebral space height, with the ultimate aim to provide a basis for improving the clinical efficacy and radiological outcomes of patients with DLS and to identify an optimal technique for spine surgeons that would benefit patients with spondylolisthesis. METHODS From May 2015 to October 2019, patients who underwent single-segment decompression and fusion with internal fixation for DLS at our department were screened for enrollment in the study. The clinical history, pre- and post-operative lumbar sagittal parameters, intervertebral height, rate of recovery from spondylolisthesis and pedicle screw angle of inpatients were recorded and followed up for at least 6 months. Clinical assessments included the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for lower back and leg pain. Data on screw angle, fusion segment intervertebral space height and clinical outcome were the primary outputs. Pearson correlation and multivariate regression analyses were performed to investigate the relationship between the pedicle screw angle, the sagittal parameters of the fusion segment and clinical efficacy. RESULTS A total of 50 patients were initially enrolled, two patients were lost to follow-up after 6 months, 48 patients (17 men, 31 women) were eventually enrolled, and the follow-up rate was 96%. At least 6 months after the operation, vertebral spondylolisthesis improved to varying degrees [> 80% in 17 cases (35.4%) and > 20% in 43 cases (87.5%), respectively]. Changes in disc height (DH) were significantly associated with lower pedicle screw angle, while lumbar lordosis and segment lordosis remained the same. Multivariate regression analysis showed a significant negative correlation between the upper and lower pedicle screw angles and the change in DH (P < 0.05). At 2 weeks post-operation, the VAS score for low back pain and the ODI had improved significantly compared to pre-operation (P < 0.05). CONCLUSIONS These results suggest that the Caudad insertion trajectory technique of pedicle screws may be an ideal alternative for the treatment of DLS. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR): ChiCTR1800020368.
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Affiliation(s)
- Xin Xi
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
| | - Zhili Zeng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
| | - Fuping Li
- Department of Spine Surgery, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200434 China
| | - Cong Wang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, 200030 China
| | - Bin Ma
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ning Xie
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, 200030 China
| | - Guoan Li
- Department of Orthopedic Surgery, Orthopaedic Bioengineering Research Center, Newton-Wellesley Hospital/Harvard Medical School, Wellesley, MA USA
| | - Yan Yu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China. .,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China.
| | - Liming Cheng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
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15
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Clinical outcome following decompression and short or long instrumented fusion in lumbar degenerative spinal stenosis. A prospective case-control analysis. Clin Neurol Neurosurg 2021; 211:107038. [PMID: 34823153 DOI: 10.1016/j.clineuro.2021.107038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/27/2021] [Accepted: 11/13/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES There is limited data on the direct clinical comparison between short and long fusion following surgery for lumbar spinal stenosis. The hypothesis that regardless their baseline characteristics and morbidity, clinical outcome is similar in patients with lumbar stenosis treated with decompression plus posterior instrumented fusion in one or two versus three to five levels was tested. METHODS Subjects were divided into Group A and Group B corresponding to stenotic pathology and instrumented fusion in one or two levels and three to five levels, respectively. Primary outcome measures at one year were the change in SF-36 physical component (PCS) and Oswestry Disability Index (ODI). Secondary outcome measures included the EuroQol-5D (EQ-5D), the Visual Analog Scale (VAS), the mental component (MCS) of SF-36 scale and the Zung Self-Rating Depression Scale. RESULTS Seventy seven (77) patients were included (Group A, n = 42; Group B, n = 35). Patients in Group B were older, surgery lasted longer and intraoperative blood loss was greater than patients in Group A (p < 0.05). A significant clinical improvement was noted in both Groups on all scales (p < 0.01). Clinical outcome at one year was equally favorable in both Groups (p > 0.05). The evaluation of depression for Group A showed a significant improvement at one year (p = 0.02) compared to the preoperative status. CONCLUSIONS Older individuals are more likely to have multilevel stenosis and more co-morbidities and they were associated with longer instrumentation. However, complications are similar and clinical outcome is equally favorable compared to short instrumented fusion for fewer levels of disease.
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Bokov A, Bulkin A, Bratsev I, Kalinina S, Mlyavykh S, Anderson D. Augmentation of Pedicle Screws Using Bone Grafting in Patients with Spinal Osteoporosis. Sovrem Tekhnologii Med 2021; 13:6-10. [PMID: 35265344 PMCID: PMC8858411 DOI: 10.17691/stm2021.13.5.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/14/2022] Open
Abstract
UNLABELLED The aim of the study was to develop a new method of vertebral augmentation based on autologous and allogeneic bone chips to be used in pedicle screw fixation and to compare this method with the technique based on polymethyl methacrylate (PMMA). MATERIALS AND METHODS This prospective non-randomized study included 164 patients with degenerative pathologies or traumatic injuries of the lumbar spine and transitional thoracolumbar segments; 153 of the operated patients were followed up for 18 months. In these patients, radiodensity of the cancellous bone tissue was below 110 HU by the Hounsfield scale. Patients with degenerative spinal disorders underwent pedicle screw fixation using transforaminal interbody fusion; patients with traumatic spinal injuries underwent intermediate pedicle screw fixation, and those with a loss of vertebral body height by >50% underwent anterior fusion.The patients were divided into three groups: in group 1 (n=39), bone tissue augmentation was performed using PMMA; in group 2 (n=21), augmentation was done with bone chips; in group 3 (n=93), no augmentation was performed (control group). The follow-up period was 12 months; cases with fixator breakage or loosening were recorded. RESULTS After augmentation with PMMA, 11 cases (28.2%) of fixator destabilization were detected. With bone chips, fixator instability developed in 2 patients (9.5%) only, whereas in patients operated without augmentation, the instability was observed in 43 cases (46.2%). With PMMA augmentation, the incidence rate of fixator destabilization did not significantly differ from that in the control group (p=0.0801), while the use of bone chips resulted in a statistically significant decrease of this index compared to the control group (p=0.0023). A logistic regression analysis confirmed the superiority of the developed method over the PMMA-based vertebral augmentation. CONCLUSION The use of bone chips for vertebral augmentation provides a statistically significant decrease in the incidence of pedicle screw fixator destabilization in the post-operative period. By reducing the risk of proximal loosening and eliminating the risk of bone cement drainage into the spinal canal and vascular bed, the proposed method may become especially effective in patients with impaired bone density.
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Affiliation(s)
- A.E. Bokov
- Head of the Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A.A. Bulkin
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - I.S. Bratsev
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S.Ya. Kalinina
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S.G. Mlyavykh
- Director of the Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - D.G. Anderson
- Professor, Departments of Orthopaedic and Neurological Surgery; Clinical Director of the Spine Section, Orthopaedic Research Laboratory Thomas Jefferson University, 130 S., 9 St., Philadelphia, PA, 19107, USA
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Chang HK, Ku J, Ku J, Kuo YH, Chang CC, Wu CL, Lirng JF, Wu JC, Huang WC, Cheng H, Hsu SM. Correlation of bone density to screw loosening in dynamic stabilization: an analysis of 176 patients. Sci Rep 2021; 11:17519. [PMID: 34471158 PMCID: PMC8410763 DOI: 10.1038/s41598-021-95232-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022] Open
Abstract
Although osteoporosis has negative impacts on lumbar fusion, its effects on screw loosening in dynamic stabilization remain elusive. We aimed to correlate bone mineral density (BMD) with screw loosening in Dynesys dynamic stabilization (DDS). Consecutive patients who underwent 2- or 3-level DDS for spondylosis, recurrent disc herniations, or low-grade spondylolisthesis at L3-5 were retrospectively reviewed. BMD was assessed by the Hounsfield Unit (HU) in vertebral bodies (VB) and pedicles with and without cortical bone (CB) on pre-operative computed tomography (CT). Screw loosening was assessed by radiographs and confirmed by CT. HU values were compared between the loosened and intact screws. 176 patients and 918 screws were analyzed with 78 loosened screws found in 36 patients (mean follow-up: 43.4 months). The HU values of VB were similar in loosened and intact screws (p = 0.14). The HU values of pedicles were insignificantly less in loosened than intact screws (including CB: 286.70 ± 118.97 vs. 297.31 ± 110.99, p = 0.45; excluding CB: 238.48 ± 114.90 vs. 240.51 ± 108.91, p = 0.88). All patients had clinical improvements. In conclusion, the HU values, as a surrogate for BMD, were unrelated to screw loosening in DDS. Therefore, patients with compromised BMD might be potential candidates for dynamic stabilization rather than fusion.
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Affiliation(s)
- Hsuan-Kan Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Li-Nong St., Beitou District, Taipei, 112, Taiwan, ROC
| | - Jason Ku
- University of California, Los Angeles, USA
| | - Johnson Ku
- University of California, Los Angeles, USA
| | - Yi-Hsuan Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Chang Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Lan Wu
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Henrich Cheng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ming Hsu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Li-Nong St., Beitou District, Taipei, 112, Taiwan, ROC.
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18
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Bokov A, Pavlova S, Bulkin A, Aleynik A, Mlyavykh S. Potential contribution of pedicle screw design to loosening rate in patients with degenerative diseases of the lumbar spine: An observational study. World J Orthop 2021; 12:310-319. [PMID: 34055588 PMCID: PMC8152435 DOI: 10.5312/wjo.v12.i5.310] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/15/2021] [Accepted: 03/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The majority of published data report the results of biomechanical tests of various design pedicle screw performance. The clinical relevance and relative contribution of screw design to instrumentation stability have been insufficiently studied. AIM To estimate the contribution of screw design to rate of pedicle screw loosening in patients with degenerative diseases of the lumbar spine. METHODS This study is a prospective evaluation of 175 patients with degenerative diseases and instability of the lumbar spine segments. Participants underwent spinal instrumentation employing pedicle screws with posterior only or transforaminal interbody fusion. Follow-up was for 18 mo. Patients with signs of pedicle screw loosening on computed tomography were registered; logistic regression analysis was used to identify the factors that influenced the rate of loosening. RESULTS Parameters included in the analysis were screw geometry, type of thread, external and internal screw diameter and helical pitch, bone density in Hounsfield units, number of levels fused, instrumentation without anterior support, laminectomy, and unilateral and bilateral total facet joint resection. The rate of screw loosening decreased with the increment in outer diameter, decrease in core diameter and helical pitch. The rate of screw loosening correlated positively with the number of fused levels and decreasing bone density. Bilateral facet joint removal significantly favored pedicle screw loosening. The influence of other factors was insignificant. CONCLUSION Screw parameters had a significant impact on the loosening rate along with bone quality characteristics, the number of levels fused and the extensiveness of decompression. The significance of the influence of screw parameters was comparable to those of patient- and surgery-related factors. Pedicle screw loosening was influenced by helical pitch, inner and outer diameter, but screw geometry and thread type were insignificant factors.
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Affiliation(s)
- Andrey Bokov
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Svetlana Pavlova
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Anatoliy Bulkin
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Alexandr Aleynik
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Sergey Mlyavykh
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
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Zhang X, Zhu J, Li Y, Hao D, Gao W. A modified method to treat severe asymptomatic pre-existing degeneration of adjacent segment: a retrospective case-control study. BMC Surg 2021; 21:161. [PMID: 33757478 PMCID: PMC7989102 DOI: 10.1186/s12893-021-01163-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/17/2021] [Indexed: 12/04/2022] Open
Abstract
Background Pre-existing degeneration of adjacent segment is an important risk factor for adjacent-segment degeneration (ASD), but only limited and controversial studies have addressed its management. Methods
We retrospectively analyzed patients with symptomatic degeneration of the L5/S1 segment warranting surgical interference and severe asymptomatic degeneration of the L4/5 segment. Of these patients, those who underwent interbody fusion of the causative (L5/S1) segment and distraction of the intervertebral space and facet fusion of the adjacent L4/5 segment were included in Group A (n = 103), while those who underwent interbody fusion of both the L5/S1 and L4/5 segments were included in Group B (n = 81). Clinical and radiographic outcomes were evaluated. Results Mean follow-up time was 58.5 months (range, 48–75 months). We found no significant difference in clinical outcomes or incidence of ASD in the L3/4 segment between Groups A and B. Compared with Group B, Group A experienced less bleeding (315 ± 84 ml vs. 532 ± 105 ml), shorter operation time (107 ± 34 min vs. 158 ± 55 min) and lower costs (US $13,830 ± $2640 vs. US $16,020 ± $3380; P < 0.05). In Group A, the disc height ratio (DHR) of the L4/5 segment was significantly increased from a preoperative value of 0.40 ± 0.13 to a last–follow-up value of 0.53 ± 0.18 (P < 0.05), while the degree of canal stenosis (DCS) was decreased from a preoperative value of 34.3 ± 11.2% to a last–follow-up value of 15.9 ± 9.3 % (P < 0.05). Conclusions This modified method could be effective in treating severe asymptomatic pre-existing degeneration of adjacent segment in the lumbar spine. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01163-w.
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Affiliation(s)
- Xinliang Zhang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jinwen Zhu
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yibing Li
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Dingjun Hao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Wenjie Gao
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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Kim HJ, Dash A, Cunningham M, Schwab F, Dowdell J, Harrison J, Zaworski C, Krez A, Lafage V, Agarwal S, Carlson B, McMahon DJ, Stein EM. Patients with abnormal microarchitecture have an increased risk of early complications after spinal fusion surgery. Bone 2021; 143:115731. [PMID: 33157283 PMCID: PMC9518007 DOI: 10.1016/j.bone.2020.115731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/12/2022]
Abstract
Spine fusion is one of the most common orthopedic surgeries, with more than 400,000 cases performed annually. While these procedures correct debilitating pain and deformities, complications occur in up to 45%. As successful fusion rests upon early stability of hardware in bone, patients with structural skeletal deficits may be at particular risk for complications. Few studies have investigated this relationship, and none have used higher order imaging to evaluate microstructural mechanisms for complications. Standard DXA measurements are subject to artifact in patients with spinal disease and therefore provide limited information. The goal of this prospective study was to investigate pre-operative bone quality as a risk factor for early post-operative complications using high resolution peripheral QCT (HR-pQCT) measurements of volumetric BMD (vBMD) and microarchitecture. We hypothesized that patients with low vBMD and abnormal microarchitecture at baseline would have more skeletal complications post-operatively. Conversely, we hypothesized that pre-operative DXA measurements would not be predictive of complications. Fifty-four subjects (mean age 63 years, BMI 27 kg/m2) were enrolled pre-operatively and followed for 6 months after multi-level lumbar spine fusion. Skeletal complications occurred in 14 patients. Patients who developed complications were of similar age and BMI to those who did not. Baseline areal BMD and Trabecular Bone Score by DXA did not differ. In contrast, HR-pQCT revealed that patients who developed complications had lower trabecular vBMD, fewer and thinner trabeculae at both the radius and tibia, and thinner tibial cortices. In summary, abnormalities of both trabecular and cortical microarchitecture were associated the development of complications within the first six months following spine fusion surgery. Our results suggest a mechanism for early skeletal complications after fusion. Given the burgeoning number of fusion surgeries, further studies are necessary to investigate strategies that may improve bone quality and lower the risk of post-operative complications.
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Affiliation(s)
- Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexander Dash
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Matthew Cunningham
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Frank Schwab
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - James Dowdell
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Jonathan Harrison
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Caroline Zaworski
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexandra Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Sanchita Agarwal
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States of America
| | - Brandon Carlson
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Donald J McMahon
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Emily M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America.
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Spalteholz M, Gulow J. Percutaneous triangular stabilization of type 3 and type 4 fragility fractures of the pelvis usually leads to fracture healing despite high revision rates. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2020; 9:Doc05. [PMID: 33391966 PMCID: PMC7745701 DOI: 10.3205/iprs000149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This is a monocentric, retrospective study to analyze radiological findings as well as perioperative and postoperative complications in patients who underwent percutaneous triangular stabilization of type 3 and type 4 fragility fractures of the pelvis. From August 2017 to December 2018, 20 patients were treated surgically. Thirteen patients (65%) were followed-up and received a CT scan of the pelvis after an average time of 14.8 months. A total of 5 patients (38%) had to undergo revision surgery, 2 patients (15%) immediately, 3 patients (23%) in the interval. In 84.6% no fracture line was visible in the sacrum. Fracture healing of the anterior pelvic ring was observed in all cases. Our results show that percutaneous triangular stabilization of type 3 and type 4 fragility fractures of the pelvis usually leads to fracture healing. Radiological signs of loosening were observed in 62%, an implant removal due to symptomatic loosening was necessary in 23%.
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Affiliation(s)
| | - Jens Gulow
- Department of Spine Surgery, Helios Park-Klinikum Leipzig, Germany
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22
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Xu F, Zou D, Li W, Sun Z, Jiang S, Zhou S, Li Z. Hounsfield units of the vertebral body and pedicle as predictors of pedicle screw loosening after degenerative lumbar spine surgery. Neurosurg Focus 2020; 49:E10. [DOI: 10.3171/2020.5.focus20249] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors aimed to compare the efficacy of lumbar vertebral body Hounsfield units (HUs) and pedicle HUs at predicting pedicle screw loosening.METHODSThe authors retrospectively assessed 143 patients with L3–5 instrumentation. The patients were classified into one of two groups based on the status of their L3 screws (a screw loosening group or a control group). The pedicle HUs and vertebral HUs of L3 were measured using preoperative lumbar CT scans, and the pedicle HUs were measured in two ways: by excluding or by including cortical bone.RESULTSThe screw loosening rate was 20.3% (n = 29/143) at the 12-month follow-up. The vertebral body HUs and pedicle HUs in the screw loosening group were lower than those in the control group (vertebral body group: 98.6 HUs vs 121.4 HUs, p < 0.001; pedicle excluding cortical bone: 208.9 HUs vs 290.5 HUs, p = 0.002; pedicle including cortical bone: 249.4 HUs vs 337.5 HUs, p < 0.001). The pedicle HUs tended to have a higher area under the receiver operating characteristic curve value in predicting screw loosening, compared with that of vertebral body HUs, but the difference was not statistically significant (p > 0.05). Among patients with low vertebral body HUs of ≤ 130, the loosening rate was much lower in patients with pedicle HUs of ≤ 340 than in those with pedicle HUs of > 340 (31.0% vs 13.0%, respectively; p < 0.05).CONCLUSIONSVertebral body HUs alone are insufficient to accurately evaluate the risk of pedicle screw loosening. Therefore, it is important to collect both the pedicle HU and vertebral body HU measurements for surgical planning.
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Affiliation(s)
- Fei Xu
- 1Orthopaedic Department, Peking University Third Hospital; and
- 2Peking University Health Science Center, Haidian District, Beijing, China
| | - Da Zou
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Weishi Li
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Zhuoran Sun
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Shuai Jiang
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Siyu Zhou
- 1Orthopaedic Department, Peking University Third Hospital; and
| | - Zhuofu Li
- 1Orthopaedic Department, Peking University Third Hospital; and
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Zou D, Muheremu A, Sun Z, Zhong W, Jiang S, Li W. Computed tomography Hounsfield unit-based prediction of pedicle screw loosening after surgery for degenerative lumbar spine disease. J Neurosurg Spine 2020; 32:716-721. [PMID: 31899883 DOI: 10.3171/2019.11.spine19868] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 11/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors investigated the relation between Hounsfield unit (HU) values measured on CT and the risk of pedicle screw loosening in patients who underwent lumbar pedicle screw fixation for degenerative lumbar spine disease. METHODS Patients who were treated with lumbar pedicle screw fixation between July 2011 and December 2015 at the authors' department were reviewed. Age, sex, BMI, smoking and diabetes histories, range of fixation, and fusion method were recorded as the basic patient information. The HU values for lumbar bone mineral density (BMD) for the L1, L2, L3, and L4 vertebra were measured on CT scans. Logistic regression analysis was used to identify the independent influencing factors of pedicle screw loosening. RESULTS A total of 503 patients were included in the final analysis. The pedicle screw loosening rate at the 12-month follow-up was 30.0% (151 of 503 patients). There were no significant differences in sex, BMI, or histories of smoking and diabetes between the patients with (loosening group) and those without (nonloosening group) screw loosening (p > 0.05). The mean HU value of L1-4 was lower in the loosening group than the nonloosening group (106.3 ± 33.9 vs 132.6 ± 42.9, p < 0.001). In logistic regression analysis, being male (OR 2.065; 95% CI 1.242-3.433), HU value (OR 0.977; 95% CI 0.970-0.985), length of fixation (OR 3.616; 95% CI 2.617-4.996), and fixation to S1 (OR 1.699; 95% CI 1.039-2.777) were the independent influencing factors for screw loosening. CONCLUSIONS HU value measured on CT was an independent predictor for pedicle screw loosening, and lower HU value was significantly correlated with higher risk of screw loosening.
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Tang YC, Guo HZ, Guo DQ, Luo PJ, Li YX, Mo GY, Ma YH, Peng JC, Liang D, Zhang SC. Effect and potential risks of using multilevel cement-augmented pedicle screw fixation in osteoporotic spine with lumbar degenerative disease. BMC Musculoskelet Disord 2020; 21:274. [PMID: 32345282 PMCID: PMC7189525 DOI: 10.1186/s12891-020-03309-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/22/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The increase of augmented level and bone cement dose are accompanied by the rising incidence of cement leakage (CL) of cement-augmented pedicle screw instrumentation (CAPSI). But the effect and potential risks of the application of CAPSI to osteoporotic lumbar degenerative disease (LDD) have not been studied in the case of multilevel fixation. This study aimed to investigate the effectiveness and potential complications of using multilevel CAPSI for patients with osteoporotic LDD. METHODS A total of 93 patients with multilevel LDD were divided into the CAPSI group (46 subjects) and the conventional pedicle screw (CPS) group (47 subjects), including 75 cases for three levels and 18 cases for four levels. Relevant data were compared between two groups, including baseline data, clinical results, and complications. RESULTS In the CAPSI group, a total of 336 augmented screws was placed bilaterally. The CL was observed in 116 screws (34.52%). Three cemented screws (0.89%) were found loosened during the follow-up and the overall fusion rate was 93.47%. For perioperative complications, two patients (4.35%) experienced pulmonary cement embolism (PCE), one patient augmented vertebral fracture, and three patients (6.52%) wound infection. And in the CPS group, thirty-three screws (8.46%) suffered loosening in cranial and caudal vertebra with a fusion rate of 91.49%. The operation time and hospital stay of CAPSI group were longer than the CPS group, but CAPSI group has a lower screw loosening percentage (P<0. 05). And in terms of blood loss, perioperative complications, fusion rate, and VAS and ODI scores at the follow-up times, there were no significant differences between the two groups. CONCLUSIONS Patients with osteoporotic LDD underwent multilevel CPS fixation have a higher rate of screw loosening in the cranial and caudal vertebra. The application of cemented pedicle screws for multilevel LDD can achieve better stability and less screw loosening, but it also accompanied by longer operating time, higher incidence of CL, PCE and wound infections. Selective cement augmentation of cranial and caudal pedicle screws may be a worthy strategy to decrease the complications.
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Affiliation(s)
- Yong-chao Tang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407 China
| | - Hui-zhi Guo
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405 Guangdong People’s Republic of China
| | - Dan-qing Guo
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405 Guangdong People’s Republic of China
| | - Pei-jie Luo
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407 China
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405 Guangdong People’s Republic of China
| | - Yong-xian Li
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407 China
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405 Guangdong People’s Republic of China
| | - Guo-ye Mo
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407 China
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405 Guangdong People’s Republic of China
| | - Yan-huai Ma
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407 China
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405 Guangdong People’s Republic of China
| | - Jian-cheng Peng
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407 China
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405 Guangdong People’s Republic of China
| | - De Liang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407 China
| | - Shun-cong Zhang
- Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407 China
- The 1st Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405 Guangdong People’s Republic of China
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Zou D, Sun Z, Zhou S, Zhong W, Li W. Hounsfield units value is a better predictor of pedicle screw loosening than the T-score of DXA in patients with lumbar degenerative diseases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1105-1111. [PMID: 32211997 DOI: 10.1007/s00586-020-06386-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 03/18/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the performance of using Hounsfield units (HU) value derived from computed tomography and T-score of dual-energy X-ray absorptiometry (DXA) to predict pedicle screw loosening. METHODS We reviewed 253 patients aged ≥ 50 years undergoing pedicle screw fixation for lumbar degenerative diseases (LDD). The evaluation of screw loosening: radiolucent zones of ≥ 1 mm thick in X-ray. The criterion for osteoporosis: the lowest T-score ≤ - 2.5. The average HU value of L1-L4 was used to represent lumbar bone mineral density (BMD). The area under receiver operating characteristics curve (AUC) was used to evaluate the performance of predicting screw loosening. RESULTS One patient underwent reoperation for screw loosening at 9 months follow-up. At 12 months follow-up, the loosening rate was 30.6% (77/252) in the remaining 252 patients. Osteoporotic patients had higher loosening rate than non-osteoporotic patients (39.3% vs. 25.8%, P = 0.026). The T-score showed no significant difference between loosening group and non-loosening group (- 2.1 ± 1.5 vs. - 1.7 ± 1.6, P = 0.074), and so is the lowest lumbar BMD of DXA (0.83 ± 0.16 g/cm2 vs. 0.88 ± 0.19 g/cm2, P = 0.054). The HU value was lower in the loosening group (106.8 ± 34.4 vs. 129.8 ± 45.7, P < 0.001). The HU value (OR, 0.980; 95%CI 0.968-0.993; P = 0.002) was the independent influencing factor of screw loosening. The AUC of predicting screw loosening was 0.666 (P < 0.001) for HU value and 0.574 (P = 0.062) for T-score. CONCLUSIONS HU value is a better predictor of pedicle screw loosening than T-score of DXA in patients aged ≥ 50 years with LDD. We should not only focus on the DXA measurements when making surgical plans concerning lumbar fixation. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Da Zou
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Zhuoran Sun
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Siyu Zhou
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Woquan Zhong
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Weishi Li
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Patient-Reported Outcome Measures After Multilevel Lumbar Total Disc Arthroplasty for the Treatment of Multilevel Degenerative Disc Disease. Spine (Phila Pa 1976) 2020; 45:18-25. [PMID: 31425431 DOI: 10.1097/brs.0000000000003201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case series OBJECTIVE.: The aim of this study was to assess the patient-reported outcome measures (PROMs) and patient satisfaction of multilevel lumbar total disc arthroplasty (TDA) for symptomatic multilevel degenerative disc disease (MLDDD). SUMMARY OF BACKGROUND DATA TDA has been shown to be safe and effective for the treatment of symptomatic single level degenerative disc disease. There is minimal PROMs data on the mid- to long-term outcomes of multilevel TDA constructs. METHODS Prospectively collected PROMs were analyzed from patients receiving multilevel TDA for symptomatic MLDDD. Data were collected preoperatively and postoperatively at 3, 6, and 12 months, then yearly. PROMs included patient satisfaction, Visual Analog Score back and leg, Oswestry Disability Index, and Roland-Morris Disability Questionnaire. RESULTS One hundred twenty-two patients (77 men, 45 women) who had preoperative and at least 24-month follow-up data were included. The average age was 42 ± 8.2 years (range 21-61) and mean follow-up 7.8 years (range 2-10). The majority received two-level TDA, except two patients (1.6%) who received three-level TDA. The two- to three-level TDA's were at the levels L3-4, L4-5, and L5-S1, whereas most two levels (n = 110, 90.2%) were at L4-5 and L5-S1; the remainder (n = 10, 8.2%) being at L3-4 and L4-5. Implants used were Charité (DePuy Spine, Raynham, MA) in 119 patients (240 levels) and InMotion (DePuy Spine) in 3 patients (6 levels). Improvement in pain and disability scores were both clinically and statistically significant (P < 0.001), and this improvement was sustained in those patients over the course of their follow-up. Ninety-two percent of patients reported good or excellent satisfaction with treatment at final review. CONCLUSION Multilevel TDA constructs for MLDDD demonstrate favorable and sustained clinical outcomes at mid- to long-term follow-up. LEVEL OF EVIDENCE 4.
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Maragkos GA, Motiei-Langroudi R, Filippidis AS, Glazer PA, Papavassiliou E. Factors Predictive of Adjacent Segment Disease After Lumbar Spinal Fusion. World Neurosurg 2019; 133:e690-e694. [PMID: 31568911 DOI: 10.1016/j.wneu.2019.09.112] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Adjacent segment disease (ASD) is a long-term complication of lumbar spinal fusion. This study aims to evaluate demographic and operative factors that influence development of ASD after fusion for lumbar degenerative pathologies. METHODS A retrospective cohort study was performed on patients undergoing instrumented lumbar fusion for degenerative disorders (spondylolisthesis, stenosis, or intervertebral disk degeneration) with a minimum follow-up of 6 months. RESULTS Our inclusion criteria were met by 568 patients; 29.4% of patients had developed surgical ASD. Median follow-up was 2.8 years. Multivariate logistic regression analysis showed that decompression of segments outside the fusion construct had higher ASD (odds ratio = 2.6; P < 0.001), and those undergoing fusion for spondylolisthesis had lower ASD (odds ratio = 0.47; P = 0.003). CONCLUSIONS Results of our study show that the most important surgical factor contributing to ASD is decompression beyond fused levels. Hence caution should be exercised when decompressing spinal segments outside the fusion construct. Conversely, spondylolisthesis patients had the lowest ASD rates in our cohort.
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Affiliation(s)
| | - Rouzbeh Motiei-Langroudi
- Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA; Kentucky Neuroscience Institute, Lexington, Kentucky, USA
| | | | - Paul A Glazer
- Department of Orthopedics, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Bokov A, Bulkin A, Aleynik A, Kutlaeva M, Mlyavykh S. Pedicle Screws Loosening in Patients With Degenerative Diseases of the Lumbar Spine: Potential Risk Factors and Relative Contribution. Global Spine J 2019; 9:55-61. [PMID: 30775209 PMCID: PMC6362557 DOI: 10.1177/2192568218772302] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine risk factors that may affect the rate of pedicle screws loosening in patients with degenerative diseases of the lumbar spine. METHODS A total of 250 patients with a low-grade spondylolisthesis and lumbar instability associated with degenerative diseases were enrolled. Preoperatively patients underwent computed tomography (CT) and cancellous bone radiodensity of a vertebral body was measured in Hounsfield units (HU). Pedicle screw fixation was used to treat patients either with a posterior fusion only or in combination with transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and direct lateral interbody fusion (D-LIF). Minimal follow-up period accounted for 18 months. Cases with screw loosening were registered assessing association with risk factors using logistic regression. RESULTS The rate of screw loosening was in positive correlation with the number fused levels and decreasing bone radiodensity. Fusion with a greater load-bearing surface cage was associated with the decrease in rate of pedicle screws loosening. Incomplete reduction in case of spondylolisthesis, bilateral facet joints removal, and laminectomy performed without anterior support favored pedicle screws loosening development. The estimated model classifies correctly 79% of cases with the specificity and sensitivity accounting for 87% and 66% respectively. CONCLUSIONS The decreasing bone radiodensity in Hounsfield units has a considerable correlation with the rate of pedicle screws loosening. On the other hand, the length of fixation and applied surgical technique including fusion type also have a significant impact on complication rate. Spinal instrumentations should be planned by taking into account all potential risk factors and not characteristics relevant to bone quality assessment alone.
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Affiliation(s)
- Andrey Bokov
- Privolzhskiy Research Medical University, Nizhny Novgorod, Russia
| | - Anatoliy Bulkin
- Privolzhskiy Research Medical University, Nizhny Novgorod, Russia
| | | | - Marina Kutlaeva
- Privolzhskiy Research Medical University, Nizhny Novgorod, Russia
| | - Sergey Mlyavykh
- Privolzhskiy Research Medical University, Nizhny Novgorod, Russia
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Wu X, Shi J, Wu J, Cheng Y, Peng K, Chen J, Jiang H. Pedicle screw loosening: the value of radiological imagings and the identification of risk factors assessed by extraction torque during screw removal surgery. J Orthop Surg Res 2019; 14:6. [PMID: 30616575 PMCID: PMC6322238 DOI: 10.1186/s13018-018-1046-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 12/18/2018] [Indexed: 02/05/2023] Open
Abstract
Background context Pedicle screw loosening is a common complication after spine surgeries. Traditionally, it was assessed by radiological approaches, both X-ray and CT (computed tomography) scan, while reports using mechanical method to study screw loosening after spine surgery are rare. The primary objective was to study the prevalent of pedicle screw loosening according to extraction torque during screw removal surgery and access the sensitivity and specificity of both X-ray and CT scan for diagnosing screw loosening. The second objective was to identify the risk factors for low extraction torque of pedicle screw that might lead to loosening. Methods Thirty-three patients who underwent pedicle screw removal surgery after at least 2 years from primary surgery were evaluated preoperatively for fixation stability by X-ray and CT scan. In total, 236 screws were taken out, and the extraction torque data was recorded and analyzed to identify the sensitivity and specificity of both imaging studies for screw loosening. Furthermore, risk factors that might contribute to low extraction torque were also studied. Results The mean extraction torque of removed screws was 1.55 ± 1.00 Nm; a torque force of less than 1.02 Nm was used to define a screw as loosened. According to such criterion, the loosening rate was found to be 33%. X-ray had a sensitivity of 24% and a specificity of 98%, while CT scan had a sensitivity of 22% and a specificity of 96%. Extraction torque of pedicle screws inserted in fractured vertebrae was significantly lower than those in non-fractured vertebrae (p = 0.009); meanwhile, screws of non-fusion surgery had lower extraction torque when compared to those in fusion surgery (p = 0.001). BMD (bone mineral density) and age had low but significant linear relationship with screw extraction torque (p = 0.01, R2 = 0.304; p = 0.045, R2 = 0.123). Conclusions Our findings showed that both X-ray and CT scan had high specificity for screw loosening detection, but their sensitivities were relatively low. Surgeons needed to be more cautious when assessing screw loosening merely according to radiological examination, and aware of that screws in fractured vertebrae or non-fusion surgery were vulnerable to loosening.
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Affiliation(s)
- Xiaoliang Wu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jiawei Shi
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jinyan Wu
- Respiratory Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yongquan Cheng
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kaiwen Peng
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianting Chen
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Hui Jiang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Kha ST, Ilyas H, Tanenbaum JE, Benzel EC, Steinmetz MP, Mroz TE. Trends in Lumbar Fusion Surgery Among Octogenarians: A Nationwide Inpatient Sample Study From 2004 to 2013. Global Spine J 2018; 8:593-599. [PMID: 30202713 PMCID: PMC6125930 DOI: 10.1177/2192568218756878] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVES Given the aging US population and natural degenerative process of the spine, more elderly patients with lumbar spinal disease are surgical candidates. Prior studies have assessed safety and efficacy of lumbar fusion (LF) surgeries in the elderly, but none have reviewed fusion procedures from an epidemiological standpoint. Here, we report 2004-2013 national trends in demographics, discharge time, and economic impact of LF procedures for octogenarians. METHODS The Nationwide Inpatient Sample database was queried from 2004 to 2013 for LF procedures in patients aged 80 to 89 years. Patients were grouped by fusion level, demographics, comorbidity score, insurance, and hospital characteristics. Postoperative variables include length of stay and total in-hospital charges. Data was evaluated using chi-squared tests and t tests. RESULTS The national sample included 17 471 LF procedures (mean age = 82.65 years). From 2004 to 2013, the annual number of LF procedures increased from 1144 to 2061 patients. Percentage of multilevel LF was relatively maintained (mean = 18%). The majority of patients were female (mean = 62%). The proportion of males increased during the study period (31.8% to 42.5%; P < .0001). The proportion of patients with a comorbidity score of 2 or 3 increased during the study period (P < .0001). Over time, average length of stay decreased (from 6 to 4.5 days; P < .0001), and total in-hospital charges increased (from $58 471 to $111 235; P < .0001). CONCLUSIONS These results suggest that more lumbar fusion procedures are being performed on octogenarians in recent years. While these patients are discharged from hospitals more quickly after surgery, there is also greater financial burden placed on patients, hospitals, and society.
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Affiliation(s)
- Stephanie T. Kha
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Joseph E. Tanenbaum
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Pedicle screw anchorage of carbon fiber-reinforced PEEK screws under cyclic loading. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1775-1784. [DOI: 10.1007/s00586-018-5538-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 02/21/2018] [Accepted: 02/25/2018] [Indexed: 12/12/2022]
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Scott-Young M, McEntee L, Schram B, Rathbone E, Hing W, Nielsen D. Concurrent Use of Lumbar Total Disc Arthroplasty and Anterior Lumbar Interbody Fusion: The Lumbar Hybrid Procedure for the Treatment of Multilevel Symptomatic Degenerative Disc Disease: A Prospective Study. Spine (Phila Pa 1976) 2018; 43:E75-E81. [PMID: 28598895 PMCID: PMC5757668 DOI: 10.1097/brs.0000000000002263] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/24/2017] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective study. OBJECTIVE The aim of this study was to evaluate clinical and patient outcomes post combined total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF), known as hybrid surgery for the treatment of multilevel symptomatic degenerative disc disease (DDD). SUMMARY OF BACKGROUND DATA Class I studies comparing the treatment of one-level lumbar DDD with TDA and ALIF have confirmed the effectiveness of those treatments through clinical and patient outcomes. Although the success of single-level disease is well documented, the evidence relating to the treatment of multilevel DDD with these modalities is emerging. With the evolution of the TDA technology, a combined approach to multilevel disease has developed in the form of the hybrid procedure. METHODS A total of 617 patients underwent hybrid surgery for chronic back pain between July 1998 and February 2012. Visual Analog Pain Scale for the back and leg were recorded along with the Oswestry Disability Index and Roland Morris Disability Questionnaire. RESULTS Both statistically and clinically significant (p < 0.005) reductions were seen in back and leg pain, which were sustained for at least 8 years postsurgery. In addition, significant improvements (P < 0.001) in self-rated disability and function were also maintained for at least 8 years. Patient satisfaction was rated as good or excellent in >90% of cases. CONCLUSION The results of this research indicate that improvements in both back and leg pain and function can be achieved using the hybrid lumbar reconstructive technique. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Matthew Scott-Young
- Gold Coast Spine, Gold Coast, Queensland, Australia
- Faculty of Health Science & Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Laurence McEntee
- Gold Coast Spine, Gold Coast, Queensland, Australia
- Faculty of Health Science & Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Ben Schram
- Faculty of Health Science & Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Evelyne Rathbone
- Faculty of Health Science & Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Wayne Hing
- Faculty of Health Science & Medicine, Bond University, Gold Coast, Queensland, Australia
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Acaroglu E, Guler UO, Cetinyurek-Yavuz A, Yuksel S, Yavuz Y, Ayhan S, Domingo-Sabat M, Pellise F, Alanay A, Perez Grueso FS, Kleinstück F, Obeid I. Decision analysis to identify the ideal treatment for adult spinal deformity: What is the impact of complications on treatment outcomes? ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:181-190. [PMID: 28454778 PMCID: PMC6197456 DOI: 10.1016/j.aott.2017.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 01/19/2017] [Accepted: 03/05/2017] [Indexed: 11/08/2022]
Abstract
Objective The aim of this study was to analyze the impact of treatment complications on outcomes in adult spinal deformity (ASD) using a decision analysis (DA) model. Methods The study included 535 ASD patients (371 with non-surgical (NS) and 164 with surgical (S) treatment) from an international multicentre database of ASD patients. DA was structured in two main steps; 1) Baseline analysis (Assessing the probabilities of outcomes, Assessing the values of preference -utilities-, Combining information on probability and utility and assigning the quality adjusted life expectancy (QALE) for each treatment) and 2) Sensitivity analysis. Complications were analyzed as life threatening (LT) and nonlife threatening (NLT) and their probabilities were calculated from the database as well as a thorough literature review. Outcomes were analyzed as improvement, no change and deterioration. Death/complete paralysis was considered as a separate category. Results All 535 patients were analyzed in regard to complications. Overall, there were 78 NLT and 12 LT complications and 3 death/paralysis. Surgical treatment offered significantly higher chances of clinical improvement but also was significantly more prone to complications (31.7% vs. 11.1%, p < 0.001). Conclusion Surgical treatment of ASD is more likely to cause complications compared to NS treatment. On the other hand, surgery has been shown to provide a higher likelihood of improvement in HRQoL scores. So, the decision on the type of treatment in ASD needs to take both chances of improvement and burden associated with S or NS treatments and better be arrived by the active participation of patients and physicians equipped with the present information. Level of evidence Level II, Decision analysis.
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Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg 2016; 136:1063-7. [PMID: 27312862 DOI: 10.1007/s00402-016-2487-8] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Pedicle screw fixation is the standard technique for the stabilization of the spine, a clinically relevant complication of which is screw loosening. This retrospective study investigates whether preoperative CT scanning can offer a predictor of screw loosening. METHODS CT-scan attenuation in 365 patients was evaluated to determine the mean bone density of each vertebral body. Screw loosening or dislocation was determined in CT scans postoperatively using the standard radiological criteria. RESULTS Forty-five of 365 patients (12.3 %; 24 male, 21 female) suffered postoperative screw loosening (62 of 2038 screws) over a mean follow-up time of 50.8 months. Revision surgeries were necessary in 23 patients (6.3 %). The correlation between decreasing mean CT attenuation in Hounsfield Units (HU) and increasing patient age was significant (p < 0.001). Mean bone density was 116.3 (SD 53.5) HU in cases with screw loosening and 132.7 (SD 41.3) HU in cases in which screws remained fixed. The difference was statistically significant (p = 0.003). CONCLUSION The determination of bone density with preoperative CT scanning can predict the risk of screw loosening and inform the decision to use cement augmentation to reduce the incidence of screw loosening.
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Gudavalli MR, Olding K, Joachim G, Cox JM. Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series. J Chiropr Med 2016; 15:121-8. [PMID: 27330514 DOI: 10.1016/j.jcm.2016.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The purpose of this case series is to report on changes in pain levels experienced by 69 postsurgical continued pain patients who received Cox Technic Flexion Distraction (CTFD). METHODS Fifteen doctors of chiropractic collected retrospective data from the records of the postsurgical continued pain patients seen in their clinic from February to July 2012 who were treated with CTFD, which is a type of chiropractic distraction spinal manipulation. Informed consent was obtained from all patients who met the inclusion criteria for this study. Data recorded included subjective patient pain levels at the end of the treatments provided and at 24 months following the last treatment. RESULTS Fifty-four (81%) of the patients showed greater than 50% reduction in pain levels at the end of the last treatment, and 13 (19%) showed less than 50% improvement of pain levels at the end of active care (mean, 49 days and 11 treatments). At 24-month follow-up, of 56 patients available, 44 (78.6%) had continued pain relief of greater than 50% and 10 (18%) reported 50% or less relief. The mean percentage of relief at the end of active care was 71.6 (SD, 23.2) and at 24 months was 70 (SD, 25). At 24 months after active care, 24 patients (43%) had not sought further care, and 32 required further treatment consisting of chiropractic manipulation for 17 (53%), physical therapy, exercise, injections, and medication for 9 (28%), and further surgery for 5 (16%). CONCLUSION Greater than 50% pain relief following CTFD chiropractic distraction spinal manipulation was seen in 81% of postsurgical patients receiving a mean of 11 visits over a 49-day period of active care.
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Affiliation(s)
- Maruti R Gudavalli
- Professor, Research Department, Palmer College of Chiropractic, Davenport, IA
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Abstract
Adult spinal deformity (ASD) is a very diverse condition that affects the quality of life of the involved individuals deeply. There is an ongoing discussion as to whether treatment should be surgical (which is potentially dangerous) or non-surgical.In addition to a systematic review of literature on the surgical treatment of ASD with special emphasis on complications, a decision-analysis was performed using the patient information within a European multi-centric database of ASD.The probabilities of improvement and complications as well as associated disease burden (utility) were calculated at the baseline and at first-year follow-up.Decision-analysis suggests that the chances of clinical improvement are significantly higher with surgical treatment. Though surgical treatment is significantly more prone to complications, the likelihood of improvement remains higher than that offered by non-surgical treatment.Surgical treatment of ASD appears to be associated with a higher likelihood of clinical improvement. Future work needs to focus on refining the criteria for appropriate patient selection and decreasing the incidence of complications. Cite this article: Acaroglu E, European Spine Study Group. Decision-making in the treatment of adult spinal deformity. EFORT Open Rev 2016;1:167-176. DOI: 10.1302/2058-5241.1.000013.
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Affiliation(s)
- Emre Acaroglu
- Ankara ARTES Spine and Spinal Cord Center, Ankara, Turkey
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Pedicle screw loosening: a clinically relevant complication? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:1005-16. [PMID: 25616349 DOI: 10.1007/s00586-015-3768-6] [Citation(s) in RCA: 258] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/10/2015] [Accepted: 01/11/2015] [Indexed: 12/27/2022]
Abstract
PURPOSE Literature studies showed a very wide range of pedicle screw loosening rates after thoracolumbar stabilization, ranging from less than 1 to 15 % in non-osteoporotic patients treated with rigid systems and even higher in osteoporotic subjects or patients treated with dynamic systems. Firstly, this paper aims to investigate how much this complication is affecting the success rate of pedicle screw fixation, in both non-osteoporotic and osteoporotic patients, and to discuss the biomechanical reasons which may be related to the variability of the rates found in the literature. The secondary aim was to summarize and discuss the published definitions and conventions about screw loosening from a clinical and radiological point of view. METHODS Narrative literature review. RESULTS Screw loosening appears to be a minor problem for fixation and fusion of healthy, non-osteoporotic bone. Pedicle screw fixation in osteoporotic bone is believed to be at risk of loosening, but clinical data are actually scarce. Both expandable and augmented screws may be a viable option to reduce the risk of loosening, but clinical evidence is missing. Posterior motion-preserving implants seems to have a significant risk of screw loosening. Standardization appears to be lacking regarding the radiological assessment. Marked differences in the loosening rates found based either on planar radiography or on CT scanning were observed. CONCLUSIONS Reported loosening rates primarily depended on the protocol used for the clinical examination during follow-up and on the conventions used for the radiological assessment. Aiming to a better comparability of published data, we recommend the authors of clinical studies to describe which criteria were used to assess a loosened screw, as well as the protocol of the clinical follow-up examination. Low-dose CT should be used for the assessment of screw loosening whenever possible.
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Abul-Kasim K, Ohlin A. Evaluation of implant loosening following segmental pedicle screw fixation in adolescent idiopathic scoliosis: a 2 year follow-up with low-dose CT. SCOLIOSIS 2014; 9:13. [PMID: 25177357 PMCID: PMC4149778 DOI: 10.1186/1748-7161-9-13] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/20/2014] [Indexed: 11/15/2022]
Abstract
Background The long term radiological status of screw fixation following scoliosis surgery with all pedicle screw construct is not previously studied. Aim To evaluate the incidence of loosening (implant failure) evaluated with low-dose CT two years following scoliosis surgery. Study design Retrospective study. Methods 81 consecutive patients with adolescent idiopathic scoliosis (AIS), aged 18 ± 3 years at 2 years follow-up (83% were female), subjected for scoliosis corrective surgery with all pedicle screw construct (total of 1666 screws) has been examined with plain radiography and with low dose CT 6 weeks and 2 years postoperatively. Results In 26 out of 81 (32%) patients there were signs of loosening of one or more screws, a maximum 3 screws. 47 out of 1666 (2.8%) screws showed evidence of loosening. Preoperative Cobb angle was 56° among patients with loosening compared with 53° among patients with no evidence of loosening (P = 0.288). In males there were signs of loosening in 8 out of 14 (57%) and in females 18 out of 67 (27%), (P = 0.027). Among cases with loosening, 14% had suboptimal screw placement at the first postoperative CT compared with 11% among patients with no evidence of loosening (P = 0.254). One patient with a loosened L4 screw had neurological deficit and subjected for revision of the construct. Out of 26 patients with evidence of loosening, 5 patients reported minor pain or discomfort, 1 patient had a minor proximal junctional kyphosis of about 15° and 3 patients showed evidence of pull-out of 3–5 mm at the upper end of the construct but no clinical complaint. With plain radiography loosening could be observed only in 11 out of 26 cases, 5 were in the lumbar region. Conclusions In a consecutive series of 81 cases with AIS who had underwent scoliosis surgery, one third showed, 2 years after the intervention, minor screw loosening. Males were more prone to develop screw loosening. In CT system that enables low-dose protocol, CT is recommended for the evaluation of evidence of screw loosening.
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Affiliation(s)
- Kasim Abul-Kasim
- Division of Neuroradiology, Diagnostic Centre for Imaging and Functional Medicine, Faculty of Medicine, Lund University, Skåne University Hospital, Malmö 205 02, Sweden
| | - Acke Ohlin
- Department of Orthopaedic Surgery, Faculty of Medicine, Lund University, Skåne University Hospital, Malmö 205 02, Sweden
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Prevalence of adjacent segment degeneration after spine surgery: a systematic review and meta-analysis. Spine (Phila Pa 1976) 2013; 38:597-608. [PMID: 22986837 DOI: 10.1097/brs.0b013e318273a2ea] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review of published prevalence of adjacent segment degeneration (ASD) after spine surgery. OBJECTIVE To evaluate the prevalence of ASD in patients after cervical and lumbar spine surgery. SUMMARY OF BACKGROUND DATA ASD is a common complication after spine surgery in long-term follow-up. A large body of literature has been reported on the topic, but no meta-analysis of the epidemiological data on ASD has been published METHODS We searched the MEDLINE until March 2012 published in English language that reported the prevalence of ASD after spine surgery. We determined the ASD rates by calculating proportions and 95% confidence interval (CI) for each study and then pooled the data to derive a pooled proportion and 95% CI. RESULTS A total of 94 studies with 34,716 patients from 19 countries were included. The occurrence of radiograph ASD ranged from 4.8% to 92.2%, and the pooled prevalence was 29.3% (95% CI, 22.7%-35.8%) by the random-effects model. The occurrence of symptoms ASD ranged from 0.0% to 30.3%, and the pooled prevalence was 7.4% (95% CI, 6.4%-8.5%). In cervical position, the occurrence of radiograph ASD and symptoms ASD was 32.8% (95% CI, 17.8%-47.9%) and 6.3% (95% CI, 4.8%-7.8%); in lumbar position, the occurrence of radiograph ASD and symptoms ASD was 26.6% (95% CI, 21.3%-31.9%) and 8.5% (95% CI, 6.4%-10.7%). In the 0.5- to 2- or less, more than 2- to 5- or less, and more than 5- to 20- or less year diagnosis time, the radiograph ASD prevalence was 21.8% (16.0%-27.6%), 33.6% (21.8%-45.4%), and 37.4% (10.7%-64.1%), respectively; and the symptoms ASD prevalence was 6.5% (4.8%-8.1%), 12.1% (8.2%-16.0%), and 3.2% (2.5%-4.0%), respectively. CONCLUSION Spine surgery is associated with significant risk of ASD. These figures may be useful in the estimation of the burden of the ASD after spine surgery.
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