Spinal motion preservation surgery: indications and applications

Return-to-Play Outcomes in Elite Athletes After Cervical and Lumbar Motion Preservation Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

The primary purpose of this article was to survey the present literature and report on return-to-play (RTP) outcomes in elite athletes after undergoing motion preservation spinal surgery (MPSS).

BACKGROUND

For elite performance, athletes require adequate mobility throughout the trunk, torso, and spine to achieve maximal force production. Therefore, elite athletes who have failed conservative treatment may seek to undergo motion-preserving surgical options, such as total disc arthroplasty and lumbar microdiscectomy. Individual studies have reported on RTP outcomes following individual motion preservation surgical procedures, but no systematic reviews have formally reported on RTP outcomes, postoperative performance, and reoperation rates on these procedures in elite athletes.

MATERIALS AND METHODS

A systematic review was conducted from inception until February 2024 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. One reviewer queried PubMed for relevant studies that reported on RTP outcomes in elite athletes after MPSS based on title and abstract (n = 1404). After the original search query, an additional reviewer screened full-length articles. A total of 11 studies met the inclusion criteria. Special consideration was given to RTP rates, postoperative performance, and reoperation rates.

RESULTS

A total of 612 elite athletes from the National Basketball Association, Major League Baseball, National Football League, National Hockey League, and other professional sporting organizations underwent cervical and lumbar MPSS to treat various spinal pathologies. Various motion-sparing techniques were used to treat various pathologies. After undergoing MPSS, RTP rates ranged from 75% to 100% for lumbar cases and 83.3% to 100% for cervical cases. Postoperative performance varied with some athletes performing at the same level before surgery and some performing at a decreased level.

CONCLUSIONS

MPSS is a feasible option when properly indicated. Future studies are needed to compare return to sport rates, postoperative performance, and reoperation rates between MPSS to spinal arthrodesis.

Preservation of Motion in Spine Surgery

The number of spinal procedures and spinal fusions continues to grow. Although fusion procedures have a high success rate, they have inherent risks such as pseudarthrosis and adjacent segment disease. New innovations in spine techniques have sought to eliminate these complications by preserving motion in the spinal column. Several techniques and devices have been developed in the cervical and lumbar spine including cervical laminoplasty, cervical disk ADA, posterior lumbar motion preservation devices, and lumbar disk ADA. In this review, advantages and disadvantages of each technique will be discussed.

A Systematic Review of Compliant Mechanisms as Orthopedic Implants

Currently available motion-preserving orthopedic implants offer many advantages but have several limitations to their use, including short device lifetime, high part count, loss of natural kinematics, and wear-induced osteolysis and implant loosening. Compliant mechanisms have been used to address some of these problems as they offer several potential advantages - namely, wear reduction, reduced part count, and the ability to achieve complex, patient-specific motion profiles. This article provides a systematic review of compliant mechanisms as orthopedic implants. Based on the PRISMA guidelines for an efficient review, this work identified fourteen implantable orthopedic devices that seek to restore anatomical motion by utilizing mechanical compliance. From reviewing these implants and their results, advantages and consequences for each are summarized. Trends were also identified in how these devices are capable of mitigating common challenges found in orthopedic design. Design considerations for the development of future compliant orthopedic implants are proposed and discussed.

Comparison of Adverse Outcomes Following Placement of Superion Interspinous Spacer Device Versus Laminectomy and Laminotomy

BACKGROUND

Current evidence suggests placement of the Superion interspinous spacer (SISS) device compared with laminectomy or laminotomy surgery offers an effective, less invasive treatment option for patients with symptomatic lumbar spinal stenosis. Both SISS placement and laminectomy or laminotomy have risks of complications and a direct comparison of complications between the 2 procedures has not been previously studied. The purpose of this study is to compare the short-term complications of the SISS with laminectomy or laminotomy and highlight device-specific long-term outcomes with SISS.

METHODS

Via retrospective review, 189 patients who received lumbar level SISSs were compared with 378 matched controls who underwent primary lumbar spine laminectomy or laminotomy; data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. Complications analyzed included rates of wound infection, pulmonary embolism, deep venous thrombosis, urinary tract infection, sepsis, septic shock, cardiac arrest, death, and reoperation within 30 days of index surgery. Differences between groups were analyzed using the χ²test. Device-specific complication (DSC) rates included device malfunction or misplacement (DM), device explantation (DE), spinous process fracture (SPF), and subsequent spinal surgery (SSS).

RESULTS

No differences in demographics or comorbidities existed between groups. There was no significant difference in rates of complications between groups. A total of 44.4% of patients in the SISS group experienced DSCs with 11.1% of patients experiencing DM, 21.1% experiencing an SPF, 20.1% requiring DE, and 24.3% requiring SSS. Having at least 1 DSC significantly increased odds of SSS, odds ratio >120, P < .0001.

CONCLUSION

Rates of 30-day complications in the SISS group were not significantly different from patients undergoing laminectomy or laminotomy. Rates of 2-year DSC within SISS and cumulative risk associated with these complications should be considered further as they likely represent need for additional procedures for patients and substantial cost to the healthcare system.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

Having no differences in adverse events between laminectomies or laminotomies and SISS plus evidence of substantial device-specific long-term adverse outcomes and reoperation should be given consideration when deciding on surgical intervention of 1-2 level lumbar spinal stenosis.

A new approach to the treatment of spinal instability: Fusion or structural reinforcement without surgery?

Spinal instability related low back pain is a common condition resulting from degeneration and loss of stiffness of the intervertebral joint. In order to restore stability, highly invasive surgical fusion is needed for patients who are not responding to conservative treatment. Given the risk and complications of surgery, there has been the urge for improvement with a less invasive solution. Formation of vertebral body osteophytes is a common observation that has been treated as a degenerative condition. However, recent studies have associated it with reduced motion of spinal segments. Unlike the traditional view, we regard it as adaptive reactions aiming to repair and hypothesize that the spinal segments could be stabilized or fused by intentionally induced osteophytes growth at the mobile parts of the intervertebral joint. This could be achieved by injecting Bone Morphogenetic Proteins to the anterior ends of the vertebral bodies and/or the facet joints on both sides of two consecutive vertebrae percutaneously. If verified, it would be the first time that fusion could be achieved without surgery. Hence it would provide a valuable alternative to current treatments of spinal instability. Preliminary test in favor of this hypothesis is presented and we recommend that a formal study with sufficient number of samples is needed for verification.

Clinical comparison between simple laminectomy and laminectomy plus posterior instrumentation in surgical treatment of cervical myelopathy

BACKGROUND

Posterior stabilization in patients treated with laminectomy for spondylotic cervical myelopathy is still a debate. Despite both being reported in literature by several authors, some controversies still exist. The aim of this study is to compare clinical and radiological outcomes in patients treated with laminectomy or laminectomy with posterior stabilization.

MATERIAL AND METHODS

We retrospectively evaluated 42 patients affected by cervical myelopathy (mean age 70.43 ± 5.03 years), 19 treated with laminectomy (group A) and 23 with laminectomy and posterior instrumentation (group B). Neurological status was assessed with Nurick scale, pain with VAS and radiological parameters with C2-C7 SVA, T1 slope and C2-C7 lordosis, clinical function with modified Japanese Orthopaedic Association score (JOA). Also, surgery time and blood loss were recorded. Student's t test was used for continuous variables, while Kruskal-Wallis test was used for categorical values.

RESULTS

No differences were found in postoperative Nurick scale (p = 0.587), VAS (p = 0.62), mJOA (p = 0.197) and T1 slope (p = 0.559), while laminectomy with fusion showed better postoperative cervical lordosis (p = 0.007) and C2-C7 SVA (p < 0.00001), but higher blood loss (p < 0.00001) and surgical time (p < 0.00001). Both groups showed better Nurick scale (p = 0.00017 for group A and p = 0.00081 for group B), VAS (p = 0.02 for group A and p = 0.046 for group B) and mJOA (p < 0.00001 for both groups) than preoperative values.

CONCLUSIONS

Both treatments are a valuable choice, offering some benefits and disadvantages against each other. Each procedure must be carefully evaluated on the basis of patients' general status, preoperative pain, signs of instability and potential benefits from cervical alignment correction.