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Piontkovskyi VK. A RETROSPECTIVE STUDY OF REPEATED SURGICAL INTERVENTIONS FOR THE LUMBAR INTERVERTEBRAL DISCS HERNIATION IN OLDER PATIENTS. BULLETIN OF PROBLEMS BIOLOGY AND MEDICINE 2018. [DOI: 10.29254/2077-4214-2018-4-1-146-112-115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Assaker R, Zairi F. Failed back surgery syndrome: to re-operate or not to re-operate? A retrospective review of patient selection and failures. Neurochirurgie 2015; 61 Suppl 1:S77-82. [PMID: 25662850 DOI: 10.1016/j.neuchi.2014.10.108] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 10/28/2014] [Accepted: 10/29/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Persisting pain after spine surgery remains a challenge for the patient and the pain physician. The etiology depends on age, pathology and the interval between the first and the revision surgery. In young patients who underwent initially to discectomy, the etiology of failed back surgery syndrome (FBSS) is commonly a recurrence of herniation whereas in the elderly population, who has previously undergone a spinal fusion, persisting pain might be due to secondary sagittal unbalance associated, as a consequence, to adjacent disc disease or pseudarthrosis. OBJECTIVE To review the etiology of failed back surgery syndrome and to discuss the radiological work-up and the treatment strategies. METHODS Retrospective analysis of 39 consecutive patients diagnosed with FBSS. For all cases, the following parameters were reviewed: original diagnosis and initial surgery, interval between the last surgery and the revision procedure, final diagnosis after revision. Treatment options were discussed. RESULTS Twelve patients have undergone decompressive procedures and 27 had one or multilevel fusion for various back and/or leg pain. In group 1 (decompressive surgery), the mean age of patients who had a disc herniation was 42.2 years and 69 years for patients who had laminectomies for lumbar stenosis. In group 2 (fusion), the mean age was 63.3. Loss of lumbar lordosis in elderly after one or several laminectomy(ies) was found to be a cause of failure because of sagittal kyphosis and consecutive back pain. In the fused group, suboptimal correction of lumbar lordosis could generate a pseudarthrosis, proximal junctional kyphosis and persisting pain. CONCLUSION Dealing with FBSS patients is far from simple but it corresponds to daily practice for spine surgeons. Clinical and radiological assessments should include a full diagnostic work-up focusing on sagittal balance. Surgical treatment and re-operation might be an option if a consistent source of pain is detected.
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Affiliation(s)
- R Assaker
- Department of Neurosurgery, Roger Salengro Teaching Hospital, 59037 Lille, France.
| | - F Zairi
- Department of Neurosurgery, Roger Salengro Teaching Hospital, 59037 Lille, France
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Factors affecting the postoperative progression of thoracic kyphosis in surgically treated adult patients with lumbar degenerative scoliosis. Spine (Phila Pa 1976) 2014; 39:E521-8. [PMID: 24480961 DOI: 10.1097/brs.0000000000000226] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective case series of patients treated surgically for degenerative lumbar scoliosis (DLS). OBJECTIVE To determine incidence and risk factors of progressive global thoracic kyphosis (pGTK) after surgery for DLS. SUMMARY OF BACKGROUND DATA Sagittal balance affects the surgical treatment of spinal deformity in adults. Little is known about the loss of sagittal balance due to pGTK, or about the risk factors for pGTK, after surgery for DLS. METHODS We reviewed records from a multicenter database of adults with DLS, treated with posterior spinal fusion. Inclusion required an age of 50 years or more at the time of surgery, an upper instrumented vertebra at T9 and below, more than 5 fused segments, and at least 2 years of follow-up. We included 73 patients with a mean age of 68.3 years (range, 51-77 yr) and a mean follow-up period of 3.6 years (range, 2-11 yr). Independent risk factors for pGTK were identified by logistic regression analysis. RESULTS Significant pGTK, defined as an increase in thoracic kyphosis of more than 10° from before surgery to the time of final follow-up, was observed in 41% of the patients. Loss of the sagittal vertical axis was larger in patients with pGTK than without (4.7 vs. 1.5 cm; P = 0.02). Risk analysis showed larger lumbar lordosis correction in patients with pGTK. Multivariate logistic regression analysis identified an age greater than 75 (odds ratio, 5.53; P = 0.02, 95% confidence interval [1.4-22.4]) and sacropelvic fusion (odds ratio = 2.66, P = 0.02, 95% confidence interval [1.5-11.1]) as independent risk factors for pGTK. CONCLUSION The pGTK incidence after surgery for DLS was 41%. Age, sacropelvic fusion, and a larger sagittal correction were identified as pGTK risk factors. Long-term follow-up will provide more data on the clinical impact of pGTK in elderly patients. LEVEL OF EVIDENCE 3.
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Hofstetter CP, Shin B, Tsiouris AJ, Elowitz E, Härtl R. Radiographic and clinical outcome after 1- and 2-level transsacral axial interbody fusion. J Neurosurg Spine 2013; 19:454-63. [DOI: 10.3171/2013.6.spine12282] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The paracoccygeal approach allows for instrumentation of L5/S1 and L4/5 by using a transsacral rod (AxiaLIF; TransS1, Inc.). The authors analyzed clinical and radiographic outcomes of 1- or 2-level AxiaLIF procedures with focus on durability of the construct.
Methods
This was a retrospective study of 38 consecutive patients who underwent either 1-level (32 patients) or 2-level (6 patients) AxiaLIF procedures at the authors' institution. The Oswestry Disability Index (minimum clinically important difference [MCID] ≥ 12) and visual analog scale ([VAS]; MCID ≥ 3) scores were collected. Disc height and Cobb angles were measured on pre- and postoperative radiographs. Bony fusion was determined on CT scans or flexion/extension radiographs.
Results
Implantation of a transsacral rod allowed for intraoperative distraction of the L5/S1 intervertebral space and resulted in increased segmental lordosis postoperatively. At a mean follow-up time of 26.2 ± 2.4 months, however, graft subsidence (1.9 mm) abolished partial correction of segmental lordosis. Moreover, subsidence of the construct reduced L5/S1 lordosis in patients with 1-level AxiaLIF by 3.2° and L4–S1 lordosis in patients with 2-level procedures by 10.1° compared with preoperative values (p < 0.01). Loss of segmental lordosis predicted failure to improve VAS scores for back pain in the patient cohort (p < 0.05). Overall, surgical intervention led to modest symptomatic improvement; only 26.3% of patients achieved an MCID of the Oswestry Disability Index and 50% of patients an MCID of the VAS score for back pain. At last follow-up, 71.9% of L5/S1 levels demonstrated bony fusion (1-level AxiaLIF 80.8%, 2-level AxiaLIF 33.3%; p < 0.05), whereas none of the L4/5 levels in 2-level AxiaLIF fused. Five constructs developed pseudarthrosis and required surgical revision.
Conclusions
The AxiaLIF procedure constitutes a minimally invasive technique for L5/S1 instrumentation, with low perioperative morbidity. However, the axial rod provides inadequate long-term anterior column support, which leads to subsidence and loss of segmental lordosis. Modification of the transsacral technique to allow for placement of a solid interposition graft may counteract subsidence of the construct.
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Affiliation(s)
| | | | - Apostolos John Tsiouris
- 2Neuroradiology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Yagi M, King AB, Cunningham ME, Boachie-Adjei O. Long-term Clinical and Radiographic Outcomes of Pedicle Subtraction Osteotomy for Fixed Sagittal Imbalance: Does Level of Proximal Fusion Affect the Outcome? Minimum 5-Year Follow-up. Spine Deform 2013; 1:123-131. [PMID: 27927428 DOI: 10.1016/j.jspd.2013.01.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 01/02/2013] [Accepted: 01/04/2013] [Indexed: 10/27/2022]
Abstract
STUDY DESIGN Retrospective case series of surgically treated adult patients with fixed sagittal imbalance. OBJECTIVE To assess clinical and radiographic changes after pedicle subtraction osteotomy (PSO) to treat adult fixed sagittal imbalance. BACKGROUND Although recent reports have shown favorable clinical outcomes for PSO, few reports have published long-term follow-up outcomes. It is also unknown whether long-term outcomes are correlated with the level of proximal fusion and the radiographic changes that are observed after PSO. MATERIALS AND METHODS We reviewed the charts, X-rays, and postoperative SRS-22 and Oswestry Disability Index (ODI) scores of 32 adult patients who presented with fixed sagittal imbalance and were treated with lumbar PSO. Long fusions were defined as those proximal to T6, and short fusions were defined as those below T8. Measured radiographic parameters included thoracic kyphosis, lumbar lordosis (LL), sacral slope, pelvic incidence, and sagittal balance (SVA). Statistical analysis included Student t test and chi-square test. A p value of < .05 and a confidence interval of 95% were considered statistically significant. RESULTS Among the reviewed cases were 23 women and 9 men, with a mean age of 50.9 years (range, 33-76 years) and a mean follow-up 8.6 years (range, 5-16 years). The LL increased from -16.0° preoperatively to -52.1° postoperatively. This metric decreased to -51.0° at final follow-up. The SVA decreased from 10.4 cm preoperatively to 3.6 cm postoperatively. The SVA increased to 5.4 cm at the final follow-up visit. There were 17 long fusions and 15 short fusions. The SRS scores at the final follow-up time point were: total, 3.63; function, 3.59; pain, 3.68; self-image, 3.46; mental health, 3.56; satisfaction, 4.26. A total of 16 patients exhibited minimal disability, 11 exhibited moderate disability, and 2 exhibited severe disability in ODI scores at the final follow-up visit (average, 28.2%). The SRS and ODI scores were not significantly different between groups (p = .64 for SRS; p = .59 for ODI). We observed no significant differences between groups with respect to the LL, sacral slope, or pelvic incidence. The observed increase in SVA at the final follow-up visit was significantly larger in the short fusion group compared with the increase we observed in the long fusion group (p = .03). The thoracic kyphosis (T5-T12) and proximal junctional angle at the final follow-up visit also significantly increased in patients who underwent a short fusion (p < .001). A total of 14 major complications occurred in 12 patients (8 in the short fusion group and 6 in the long fusion group) (p = .43). Eight patients required additional surgery to treat these complications. CONCLUSIONS In a group of adults presenting with fixed sagittal imbalance, PSO provided good sagittal balance and maintained favorable clinical outcomes in both the short and long fusion groups despite a slight decrease in the SVA and a high complication rate. The data suggest that the loss of sagittal balance may be attributed to increase global and junctional kyphosis in short fusion groups, and should be monitored for long-term outcomes. Particular attention should be paid to the long-term deterioration of the SVA in adults who present with fixed sagittal imbalance after PSO.
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Affiliation(s)
- Mitsuru Yagi
- Adult and Pediatric Spine and Scoliosis Surgery, Hospital for Special Surgery, 525 East 72nd Street, New York, NY 10021, USA; Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, Japan.
| | - Akilah B King
- Adult and Pediatric Spine and Scoliosis Surgery, Hospital for Special Surgery, 525 East 72nd Street, New York, NY 10021, USA
| | - Matthew E Cunningham
- Adult and Pediatric Spine and Scoliosis Surgery, Hospital for Special Surgery, 525 East 72nd Street, New York, NY 10021, USA
| | - Oheneba Boachie-Adjei
- Adult and Pediatric Spine and Scoliosis Surgery, Hospital for Special Surgery, 525 East 72nd Street, New York, NY 10021, USA
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Abstract
Patients with postoperative spinal deformities are being identified with increasing frequency as the number of instrumented spinal operations increases. Thus, it is important for the neurosurgeon to understand ways to minimize postoperative deformity and to understand its operative and nonoperative management. A variety of intra- and postoperative risk factors have been associated with postoperative deformity, including patient age, operative positioning, preoperative medical condition, and the use of prior radiation therapy. The evaluation of all patients who have been suspected of iatrogenic deformity should include a detailed physical examination, plain x-rays, and computed tomographic or magnetic resonance imaging, depending on the condition. Conservative therapy includes physical therapy and pain control, which may be effective in some patients. However, patients with flat-back syndrome typically require reoperation. A wide variety of reoperative procedures may be performed, depending on the area of the pathological deformity, extent of disease, and patient condition.
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Affiliation(s)
- Jay Jagannathan
- Department of Neurosurgery, University of Virginia Health Sciences Center, University of Virginia, Charlottesville, Virginia 22902, USA
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Abstract
STUDY DESIGN Retrospective study of consecutive patient series. OBJECTIVE To review the etiology of failed back surgery syndrome due to sagittal imbalance and radiographic and clinical results of surgical treatment of these patients who were treated with combined anterior and posterior arthrodesis. SUMMARY OF BACKGROUND DATA Sagittal imbalance after spinal fusion surgery may be a major source of pain and disability. Preventing iatrogenic sagittal imbalance should be a key objective during spinal fusion surgery. METHODS Retrospective review of revision spine surgery due to sagittal imbalance treated with combined anterior and posterior spinal arthrodesis in the 19 patients. Outcome variables included radiographic measures of preoperative, postoperative, and follow-up films, and a clinical assessment using the Verbal Analogue Scale (VAS), Oswestry Disability Index, Macnab criteria, Satisfactory Index Instrument, and a review of postoperative complications. RESULTS Mean age was 62 years (range, 49-74 years), and mean follow-up was 31 months (range, 24-37 months) for clinical and radiographic outcome variables. The mean preoperative sagittal imbalance was 116 (+/-65) mm, which improved to 32 mm (+/-29) after surgery. Mean lumbar lordosis was 15 degrees (+/-20 degrees) before surgery, and increased to 38 degrees (+/-13 degrees) at follow-up, an increase of 23 degrees. The mean VAS improved from 7.2 (back pain), 6.8 (leg pain) before the surgery to 3 (back pain), 3.2 (leg pain) after the surgery (P < 0.0001). The mean Oswestry Disability Index scores improved from 62 (+/-11) before the surgery to 36 (+/-12) after the surgery (P < 0.0001). Excellent or good outcome was demonstrated in 16 patients (84.2%). CONCLUSION Most common causes of revision spine surgery due to sagittal imbalance were failure to enhance lumbar lordosis and adjacent disc degeneration after lumbar fusion surgery. These patients were effectively treated with a combined anterior and posterior arthrodesis. Following these surgical treatment, sagittal balance was generally improved with fair-to-good clinical outcomes, high patient satisfaction, and low perioperative complication rates.
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Potter BK, Freedman BA, Verwiebe EG, Hall JM, Polly DW, Kuklo TR. Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients. ACTA ACUST UNITED AC 2005; 18:337-46. [PMID: 16021015 DOI: 10.1097/01.bsd.0000166642.69189.45] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE We retrospectively reviewed the results of 100 consecutive transforaminal lumbar interbody fusions (TLIFs) performed at one institution. The preoperative diagnoses included degenerative disk disease (55), spondylolisthesis (41; 22 isthmic, 19 degenerative), and degenerative adult scoliosis (4). There were 64 single-level, 33 two-level, 2 three-level, and 1 four-level TLIF (140 levels). METHODS The fusion mass was assessed by an independent observer using biplanar radiography, whereas clinical outcomes were assessed by means of several established outcome measures. RESULTS By level, the posterolateral fusion was judged to be probably or definitely solid in 78% of levels, whereas the interbody fusion was radiographically solid in 88% of levels, for an overall 93% fusion success/patient (94%/level). All patients had >24 months of postoperative clinical follow-up, and 82 patients (82%) were available for outcome measure assessment at an average follow-up of 34 months (range 24-61 months) postoperatively. Eighty-one percent of these patients reported a >50% decrease in their symptoms, and 76% of patients were satisfied with their results to the degree that they would have the procedure again. However, a large percentage of patients experienced incomplete relief of their symptoms. Twenty patients sustained minor complications, and there were no major complications. CONCLUSIONS We conclude that TLIF is a safe and effective method of achieving lumbar fusion with a 93% radiographic fusion success and a nearly 80% rate of overall patient satisfaction but frequently results in incomplete relief of symptoms. Complications resulting from the procedure are uncommon and generally minor and transient.
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Affiliation(s)
- Benjamin K Potter
- Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, Washington, DC, USA
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Abstract
The most common cause of iatrogenic flatback syndrome is Harrington distraction instrumentation extending into the lower lumbar spine. Other common causes and exacerbating factors include failure to enhance regional lordosis during lumbar fusion for degenerative spondylosis, development of pseudarthrosis or postoperative loss of correction, development of kyphosis at the thoracolumbar junction, development of degeneration and decompensation cephalad or caudad to a prior fusion, and hip flexion contractures. Prevention of flatback syndrome involves preoperative assessment of sagittal balance, avoidance of distraction instrumentation and extension of long fusions into the lower lumbar spine, enhancement of physiologic lordosis during lumbar fusions, and intraoperative positioning with the hips extended. Treatment of flatback syndrome involves corrective pedicle subtraction or Smith-Petersen osteotomies with segmental instrumentation. Polysegmental osteotomies and vertebral column resection may be utilized in cases of sloping global sagittal imbalance and related severe coronal imbalance, respectively. Following surgical treatment, sagittal balance is generally improved with fair-to-good clinical outcomes, high patient satisfaction, and moderately high perioperative complication rates.
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Affiliation(s)
- Benjamin K Potter
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue, Building 2, Washington, DC 20307, USA
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Potter BK, Kuklo TR, O’Brien MF. Sacro-iliac fixation for treatment of high-grade spondylolisthesis. ACTA ACUST UNITED AC 2004. [DOI: 10.1053/j.semss.2004.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lenke LG, Kuklo TR. Sacropelvic fixation techniquesin the treatment of pediatric spinal deformity. ACTA ACUST UNITED AC 2004. [DOI: 10.1053/j.semss.2004.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lehman RA, Kuklo TR, Belmont PJ, Andersen RC, Polly DW. Advantage of pedicle screw fixation directed into the apex of the sacral promontory over bicortical fixation: a biomechanical analysis. Spine (Phila Pa 1976) 2002; 27:806-11. [PMID: 11935101 DOI: 10.1097/00007632-200204150-00006] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A biomechanical study of human cadaveric sacra using insertional torque and bone mineral density was conducted to determine the optimal sagittal trajectory of S1 pedicle screws. OBJECTIVE To measure the maximal insertional torque of sacral promontory versus bicortical pedicle screw fixation. SUMMARY OF BACKGROUND DATA Fixation of instrumentation to the sacrum is commonly accomplished using S1 pedicle screws, with previous studies reporting biomechanical advantages of bicortical over unicortical S1 screws. The biomechanical effect of bicortical screws (paralleling the endplate) versus screws directed into the apex of the sacral promontory is unknown. METHODS For this study, 10 fresh frozen cadaver sacra were harvested and evaluated with dual-energy radiograph absorptiometry to assess bone mineral density. Matched 7.5-mm monoaxial stainless steel pedicle screws then were randomly assigned by side (left versus right) and placed bicortically or into the apex of the sacral promontory under direct visualization. Maximum insertional torque was recorded for each screw revolution with a digital torque wrench (TQJE1500, Snap-On Tools, Kenosha, WI). RESULTS Maximum bicortical S1 screw insertional torque averaged 5.22 +/- 0.83 inch-pounds, as compared with the maximum sacral promontory S1 screw insertional torque of 10.34 +/- 1.94 inch-pounds. This resulted in a 99% increase in maximum insertional torque (P = 0.005) using the "tricortical" technique, with the screw directed into the sacral promontory. Mean bone mineral density was 940 +/- 0.25 mg/cm2 (range, 507-1428 mg/cm2). The bone mineral density correlated with maximal insertional torque for the sacral promontory technique (r = 0.806; P = 0.005), but not for the bicortical technique (r = 0.48; P = 0.16). CONCLUSIONS The screws directed into the apex of the sacral promontory of the S1 pedicle resulted in an average 99% increase in peak insertional torque (P = 0.005), as compared with bicortical S1 pedicle screw fixation. Tricortical pedicle screw fixation correlates directly with bone mineral density.
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Affiliation(s)
- Ronald A Lehman
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed Army Medical Center, Washington, DC, USA
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Kuklo TR, Bridwell KH, Lewis SJ, Baldus C, Blanke K, Iffrig TM, Lenke LG. Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws. Spine (Phila Pa 1976) 2001; 26:1976-83. [PMID: 11547195 DOI: 10.1097/00007632-200109150-00007] [Citation(s) in RCA: 209] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An analysis of lumbosacral fusions for high-grade spondylolisthesis fusions with reduction and long fusions to the sacrum in ambulatory adults. OBJECTIVE To assess the clinical and radiographic results of lumbosacral fusions using bilateral S1 and iliac screws. SUMMARY OF BACKGROUND DATA S1 screws often fail with lumbosacral fusions, whereas L5-S1 pseudarthrosis is common in patients with deformity. MATERIALS AND METHODS A total of 81 patients (38 revision, 43 primary) with minimum 2-year follow-up (average, 4.2 years; range, 2.0-7.1 years) underwent L5-S1 fusion using S1 and iliac screws (158 screws). Forty-nine of 81 constructs (61%) included an anterior load-sharing/fixation device. Group 1 included isthmic spondylolisthesis (n = 42), whereas Group 2 included long fusions (> or =3 levels) to the sacrum (n = 39). In Group 2, 15 patients (Group 2A) were fused from L1, L2, or L3 to the sacrum (3-5 levels, average 3.3 levels) and 24 patients (Group 2B) were fused from the thoracic spine to the sacrum (6-17 levels, average 11.5 levels). Twelve patients had pseudarthrosis at L5-S1. A patient questionnaire was completed. RESULTS A total of 36 of the 38 revision patients had previous iliac crest harvesting, yet iliac screws were placed in 34 of 36 patients. Overall, 78 of 80 patients had iliac crest harvesting (one not attempted). None had loss of screw fixation or iliac crest fracture after harvesting. Four of the 81 patients (4.9%) had pseudarthrosis at L5-S1 after reconstruction. This included solid fusion in 10 of 12 patients presenting with L5-S1 pseudarthrosis. Fourteen percent of patients experienced some discomfort over the iliac screws; however, only one patient required screw removal. CONCLUSIONS Bilateral iliac screws coupled with bilateral S1 screws provide excellent distal fixation for lumbosacral fusions with a high fusion rate (95.1%) in high-grade spondylolisthesis and long fusions to the sacrum. Previous iliac crest harvesting does not prevent ipsilateral screw placement (34 of 36 patients) or additional iliac harvesting (78 of 80 patients).
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Affiliation(s)
- T R Kuklo
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
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Abstract
Pedicle screws have dramatically improved the outcomes of spinal reconstruction requiring spinal fusion. Short-segment surgical treatments based on the use of pedicle screws for the treatment of neoplastic, developmental, congenital, traumatic, and degenerative conditions have been proved to be practical, safe, and effective. The Funnel Technique provides a straightforward, direct, and inexpensive way to very safely apply pedicle screws in the cervical, thoracic, or lumbar spine. Carefully applied pedicle-screw fixation does not produce severe or frequent complications. Pedicle-screw fixation can be effectively and safely used wherever a vertebral pedicle can accommodate a pedicle screw--that is, in the cervical, thoracic, or lumbar spine. Training in pedicle-screw application should be standard in orthopaedic training programs since pedicle-screw fixation represents the so-called gold standard of spinal internal fixation.
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Affiliation(s)
- R W Gaines
- Columbia Spine Center, and the Department of Orthopaedic Surgery, University of Missouri Health Sciences Center, 65212, USA.
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Abstract
BACKGROUND The safety and the effectiveness of pedicle-screw instrumentation in the spine have been questioned despite its use worldwide to enhance stabilization of the spine. This review was performed to answer questions about the technique of insertion and the nature and etiology of complications directly attributable to the screws. METHODS We performed a retrospective review of all of the pedicle-screw procedures that were done by us from January 1, 1984, to December 31, 1993. We inserted 4790 screws during 915 operative procedures on 875 patients; 668 (76.3 percent) of the patients had a lumbosacral arthrodesis. The mean duration of follow-up was three years (range, two to five years). The accuracy of screw placement was assessed on intraoperative, immediate postoperative, and follow-up radiographs with use of a technique that was developed by one of us (F. D.); this technique has yet to be validated to determine the prevalence of various types of error. RESULTS Of the 4790 screws, 4548 (94.9 percent) had been inserted within the pedicle and the vertebral body. One hundred and thirty-four (2.8 percent) of the screws had perforated the anterior cortex, and this was the most common type of perforation. One hundred and fifteen (2.4 percent) of the screws were associated with complications that could be ascribed to the use of pedicle screws. The most common problem was late-onset discomfort or pain related to a pseudarthrosis or perhaps to the screws; this problem was associated with 1102 (23.0 percent) of the screws, used in 222 (24.3 percent) of the procedures. The symptoms necessitated removal of the instrumentation with or without repair of the pseudarthrosis. A pseudarthrosis was found during forty-six (20.7 percent) of the 222 procedures. Irritation of a nerve root occurred after nine procedures (1.0 percent) and was caused by eleven screws (0.2 percent); it was more commonly caused by medially placed screws. Three patients had residual neurological weakness despite removal of the screws. Twenty-five screws (0.5 percent), used in twenty procedures (2.2 percent), broke. The screws that broke were of an early design. A pseudarthrosis was found in thirteen of twenty patients who had broken screws. Sixteen of the twenty patients had an exploration; three of them were found to have a solid fusion, and thirteen were found to have a pseudarthrosis. The remaining four patients had evidence of a solid fusion on radiographs and had no pain. CONCLUSIONS There are few problems associated with the insertion of screws, provided that the surgeon is experienced and adheres to the principles and details of the operative technique. Our review revealed a low rate of postoperative complications related to pedicle screws. The problem of late-onset pain may be related to the implants or to the stiffness of the construct; however, it is difficult to accurately identify its exact etiology.
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Affiliation(s)
- J E Lonstein
- Twin Cities Spine Center, Minneapolis, Minnesota 55404, USA
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Affiliation(s)
- R B Winter
- Twin Cities Spine Center, Minneapolis, Minnesota 55404-4515, USA
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Masferrer R, Gomez CH, Karahalios DG, Sonntag VK. Efficacy of pedicle screw fixation in the treatment of spinal instability and failed back surgery: a 5-year review. J Neurosurg 1998; 89:371-7. [PMID: 9724109 DOI: 10.3171/jns.1998.89.3.0371] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to review retrospectively the outcome of 95 patients with various disorders leading to instability of the thoracolumbar and lumbar spine who were treated consecutively via a posterior surgical approach with pedicle screw fixation in which the Texas Scottish Rite Hospital system was used. METHODS All cases were managed according to the same protocol. Follow-up review averaged 29.6 months. Radiographic evidence of osseous union and the patient's current status were analyzed. Four screws were malpositioned, and there were two dural lacerations of a nerve root and one pedicle fracture. Deep wound infections developed in five patients (5.2%), and three patients had postoperative radicular pain. In one case, the rods disengaged from the screws; in four cases, hardware was removed but there were no broken screws. Neurological deficits improved in 85% of the surviving patients, and no patient was worse neurologically after surgery. The rate of osseous union was 96.8%. Three patients developed pseudarthrosis, one of whom was asymptomatic. Back pain improved in 80 patients. A solid bone fusion, however, was not necessarily associated with decreased back pain. CONCLUSIONS These results support the use of pedicle screw fixation as an effective and safe procedure for fusion of the thoracolumbar and lumbar spine and support the finding that complications can be minimal when a meticulous surgical technique is used. The proper selection of patients for surgery is probably the most important factor associated with good outcomes.
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Affiliation(s)
- R Masferrer
- Division of Neurological Surgery, Barrow Neurological Institute, Mercy Healthcare Arizona, Phoenix, USA
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Brown CA, Lenke LG, Bridwell KH, Geideman WM, Hasan SA, Blanke K. Complications of pediatric thoracolumbar and lumbar pedicle screws. Spine (Phila Pa 1976) 1998; 23:1566-71. [PMID: 9682313 DOI: 10.1097/00007632-199807150-00012] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This was a retrospective review of 223 consecutive cases (1986-1996) from one institution where 759 thoracolumbar and lumbar pedicle screws were used in the treatment of various pediatric spinal disorders in patients less than 18 years of age. OBJECTIVES To determine the incidence of short- and long-term (> 2 years follow-up) complications in this group of patients-specifically, complications related to instrumentation and those directly attributable to pedicle screws in these pediatric patients. SUMMARY OF BACKGROUND DATA Although much has been written regarding the use of pedicle screws in the adult population, no published study has examined complication rates with regard to thoracolumbar and lumbar pedicle screws placed for pediatric spinal disorders. METHODS A retrospective review of 223 consecutive cases involving 759 pedicle screws placed for a variety of pediatric spinal disorders was performed. Complications were divided into short term and long term (> 2 years follow-up) and into those relating to instrumentation and those relating to pedicle screws specifically. RESULTS Short-term complication occurred in 5 patients (2.2%) for a total of 17 screws ultimately removed. Only two of these patients had screws removed for lumbar radicular complaints. No residual sequellae resulted. No long-term (> 2 years postoperative) complications were noted. CONCLUSION Low short- and long-term complication rates specific for pediatric pedicle screws suggests that for properly trained spinal surgeons, pedicle screws fixation in the pediatric population can be performed safely to treat a variety of spinal disorders.
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Affiliation(s)
- C A Brown
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Masferrer R, Gomez CH, Karahalios DG, Sonntag VKH. Efficacy of pedicle screw fixation in the treatment of spinal instability and failed back surgery: a 5-year review. Neurosurg Focus 1998. [DOI: 10.3171/foc.1998.5.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The goal of this study was to review retrospectively the outcome of 95 patients with various disorders leading to instability of the thoracolumbar and lumbar spine who were treated consecutively via a posterior surgical approach with pedicle screw fixation in which the Texas Scottish Rite Hospital system was used.
Methods
All cases were managed according to the same protocol. Follow-up review averaged 29.6 months. Radiographic evidence of osseous union and the patient's current status were analyzed. Four screws were malpositioned, and there were two dural lacerations of a nerve root and one pedicle fracture. Deep wound infections developed in five patients (5.2%) and three patients had postoperative radicular pain. In one case, the rods disengaged from the screws; in four cases, hardware was removed but there were no broken screws. Neurological deficits improved in 85% of the patients and no patient was worse neurologically after surgery. The rate of osseous union was 96.8%. Three patients developed pseudarthrosis, one of whom was asymptomatic. Back pain improved in 80 patients (85%). A solid bone fusion, however, was not necessarily associated with decreased back pain.
Conclusions
These results support the use of pedicle screw fixation as an effective and safe procedure for fusion of the thoracolumbar and lumbar spine and support the finding that complications can be minimal when a meticulous surgical technique is used. The proper selection of patients for surgery is probably the most important factor associated with good outcomes.
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Thomsen K, Christensen FB, Eiskjaer SP, Hansen ES, Fruensgaard S, Bünger CE. 1997 Volvo Award winner in clinical studies. The effect of pedicle screw instrumentation on functional outcome and fusion rates in posterolateral lumbar spinal fusion: a prospective, randomized clinical study. Spine (Phila Pa 1976) 1997; 22:2813-22. [PMID: 9431617 DOI: 10.1097/00007632-199712150-00004] [Citation(s) in RCA: 344] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY DESIGN A prospective randomized clinical study. OBJECTIVES To evaluate supplementary pedicle screw fixation (Cotrel-Dubousset) in posterolateral lumbar spinal fusion. SUMMARY OF BACKGROUND DATA The rationale behind lumbar fusion is to eliminate pathologic motion to relieve pain. To improve fusion rates and to allow reduction, a rigid transpedicular screw fixation may be beneficial, but the positive effect of this may be counter-balanced by an increase in complications. METHODS The inclusion criteria were severe, chronic low back pain from spondylolisthesis Grades 1 and 2 or from primary or secondary degenerative segmental instability. One hundred thirty patients were randomly allocated to receive no instrumentation (n = 66) or Cotrel-Dubousset instrumentation (n = 64) in posterolateral lumbar fusion. Variables were registered at the time of surgery and at 1 and 2 years after surgery. RESULTS Follow-up was achieved in 97.7% of the patients. Fusion rates deduced from plain radiographs were not significantly different between instrumented and noninstrumented groups. The functional outcome assessed by the Dallas Pain Questionnaire improved significantly in both groups, and there were no significant differences in results between the two groups, except for significantly better (P < 0.06) functional outcome in relation to daily activities in the instrumented group when neural decompression had been performed. The global patients' satisfaction was 82% in the instrumented group versus 74% in the noninstrumented group (not significant). Fixation of instrumentation increased operation time, blood loss, and early reoperation rate significantly. Patients experienced only a few minor postoperative complications; none were major. Two infections appeared in the Cotrel-Dubousset group. Significant symptoms from misplacement of pedicle screws were seen in 4.8% of the instrumented patients. CONCLUSIONS Lumbar posterolateral fusion with pedicle screw fixation increases the operation time, blood loss, and reoperation rate, and leads to a significant risk of nerve injury. The functional outcome improves significantly with high patient satisfaction, with or without instrumentation. No significant differences were observed between the two groups in functional outcome and fusion rate. The only gain in functional outcome from instrumentation was found in the daily activity category in patients with supplementary neural decompression. The results of this study do not justify the general use of pedicle screw fixation alone as an adjunct to posterolateral lumbar fusion.
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Affiliation(s)
- K Thomsen
- Department of Orthopedic Surgery, University Hospital of Aarhus, Denmark
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Yoo JU, Ghanayem A, Petersilge C, Lewin J. Accuracy of using computed tomography to identify pedicle screw placement in cadaveric human lumbar spine. Spine (Phila Pa 1976) 1997; 22:2668-71. [PMID: 9399454 DOI: 10.1097/00007632-199711150-00016] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY DESIGN Utility of using computed tomography to predict pedicle screw misplacement. OBJECTIVE This study defines the sensitivity and specificity of predicting pedicle screw placement by experienced clinicians using a CT scan image. SUMMARY OF BACKGROUND DATA In clinical and research settings, the method most commonly used to evaluate pedicle screws placement has been computed tomography. However, no current literature describes the accuracy of this method of evaluating screw placement. METHOD Cobalt-chrome and titanium alloy pedicle screws of identical size were placed in six cadaveric human lumbar spine. Wide laminectomy was performed to allow complete visualization of the pedicles. Three consecutive lumbar levels were instrumented in each spine, giving 36 pedicle screw placements to identify. The instrumented spines were imaged, and four orthopaedic spine surgeons and a musculoskeletal radiologist were asked to read the images to identify the accuracy of screw placement within the pedicles. RESULTS The sensitivity rate of identifying a misplaced screw was 67 +/- 6% for cobalt-chrome screws compared with 86 +/- 5% for titanium screws (P < 0.005). The specificity rates of radiographic diagnosis of misplaced pedicle screws were 66 +/- 10% for cobalt-chrome screws and 88 +/- 8% for titanium screws (P < 0.005). Similarly, a statistically significant difference was found in the sensitivity rates of identifying screws placed correctly in the pedicle: 70 +/- 10% for cobalt-chrome screws versus 89 +/- 8% for titanium screws (P < 0.005). Overall accuracy rates were 68 +/- 7% for cobalt chrome screws versus 87 +/- 3% for titanium screws (P < 0.002). CONCLUSION Reliance on the computed tomography scan data alone in determining accuracy of pedicle screws can lead to inaccuracies in both clinical and research conditions.
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Affiliation(s)
- J U Yoo
- Department of Orthopedic Surgery, University Hospitals of Cleveland and Case Western Reserve University, OH 44106, USA
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Boos N, Webb JK. Pedicle screw fixation in spinal disorders: a European view. 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 1997; 6:2-18. [PMID: 9093822 PMCID: PMC3454634 DOI: 10.1007/bf01676569] [Citation(s) in RCA: 206] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Continuing controversy over the use of pedicular fixation in the United States is promoted by the lack of governmental approval for the marketing of these devices due to safety and efficacy concerns. These implants have meanwhile become an invaluable part of spinal instrumentation in Europe. With regard to the North American view, there is a lack of comprehensive reviews that consider the historical evolution of pedicle screw systems, the rationales for their application, and the clinical outcome from a European perspective. This literature review suggests that pedicular fixation is a relatively safe procedure and is not associated with a significantly higher complication risk than non-pedicular instrumentation. Pedicle screw fixation provides short, rigid segmental stabilization that allows preservation of motion segments and stabilization of the spine in the absence of intact posterior elements, which is not possible with non-pedicular instrumentation. Fusion rates and clinical outcome in the treatment of thoracolumbar fractures appear to be superior to that achieved using other forms of treatment. For the correction of spinal deformity (i.e., scoliosis, kyphosis, spondylolisthesis, tumor), pedicular fixation provides the theoretical benefit of rigid segmental fixation and of facilitated deformity correction by a posterior approach, but the clinical relevance so far remains unknown. In low-back pain disorders, a literature analysis of 5,600 cases of lumbar fusion with different techniques reveals a trend that pedicle screw fixation enhances the fusion rate but not clinical outcome. The most striking finding in the literature is the large range in the radiological and clinical results. For every single fusion technique poor and excellent results have been described. This review argues that European spine surgeons should begin to back up the evident benefits of pedicle screw systems for specific spinal disorders by controlled prospective clinical trials. This may prevent forthcoming medical licensing authorities from restricting the use of pedicle screw devices and dictating the practice of spinal surgery in Europe in the near future.
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Affiliation(s)
- N Boos
- Orthopaedic University Hospital, Zürich, Switzerland.
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Glassman SD, Johnson JR, Raque G, Puno RM, Dimar JR. Management of iatrogenic spinal stenosis complicating placement of a fusion cage. A case report. Spine (Phila Pa 1976) 1996; 21:2383-6. [PMID: 8915077 DOI: 10.1097/00007632-199610150-00018] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A case of iatrogenic spinal stenosis secondary to fusion cage retropulsion is presented. OBJECTIVES To highlight fusion cage retropulsion, a potential complication that may become more prevalent as the use of fusion cage instrumentation expands. The difficulty in management of this complication is emphasized. SUMMARY OF BACKGROUND DATA Early reports regarding fusion cage instrumentation have been encouraging. At this point, however, the potential benefits are better defined than the potential complications. METHODS A significant complication of fusion cage instrumentation and the limited literature on this subject are reviewed. RESULTS The patient underwent successful revision surgery after retropulsion of a fusion cage, however, an extensive surgical procedure including partial vertebral body resection was required. CONCLUSIONS The frequency and severity of complications related to fusion cage instrumentation remain poorly defined. Caution should be used in patient selection until additional experience more clearly defines the risk-to-benefit ratio for a given application of this new technology.
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Affiliation(s)
- S D Glassman
- Department of Orthopaedic Surgery, University of Louisville, Kentucky, USA
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Glassman SD, Dimar JR, Puno RM, Johnson JR. Salvage of instrumental lumbar fusions complicated by surgical wound infection. Spine (Phila Pa 1976) 1996; 21:2163-9. [PMID: 8893444 DOI: 10.1097/00007632-199609150-00021] [Citation(s) in RCA: 158] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
STUDY DESIGN This study retrospectively reviewed instrumented lumbar fusions complicated by surgical wound infection and managed by a protocol including antibiotic impregnated beads. OBJECTIVE To evaluate the potential for an acceptable clinical outcome in cases of instrumented lumbar fusion complicated by wound infection. SUMMARY OF BACKGROUND DATA Initial studies of pedicle screw instrumentation suggested an increased infection rate versus noninstrumented fusion. The presence of a metallic implant also complicates wound management. METHODS Eight hundred fifty-eight instrumented fusions were reviewed with 22 (2.6%) deep wound infections identified. Analysis included preoperative risk factors, surgical procedure, postoperative course, and clinical outcome. RESULTS Nineteen patients (mean age, 55 years) were reviewed at a minimum of 1 year after surgery. Sixteen (83%) reported significant preoperative health problems. Forty-seven percent of the patients had three- and four-level fusions. Mean operative time was 342 minutes. Mean estimated blood loss was 1620 mL. Infection was diagnosed at an average of 16 days after surgery with wound drainage as the most common presenting feature. Patients underwent between two and 10 (mean, 4.7) irrigation procedures. Seven patients had other significant noninfectious complications. At follow-up evaluation, no patient had recurrence of infection. By comparison to preoperative symptoms, 15 patients were improved, three were unchanged, and one deteriorated. Fusion was apparently solid in 14 patients, probable in four patients, and nonunion occurred in one patient. CONCLUSION Although wound infection is a significant complication, this study suggests that aggressive surgical management can result in preservation of an adequate fusion rate and maintenance of an acceptable postoperative outcome.
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Affiliation(s)
- S D Glassman
- Department of Orthopaedic Surgery, University of Louisville, Kentucky, USA
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Meter JJ, Polly DW, Miller DW, Popovic NA, Ondra SL. A method for radiographic evaluation of pedicle screw violation of the vertebral endplate. Technique. Spine (Phila Pa 1976) 1996; 21:1587-92. [PMID: 8817789 DOI: 10.1097/00007632-199607010-00020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
STUDY DESIGN This study evaluated the utility of intraoperative radiographs for minimizing the risk of pedicle screw tip violation of the superior vertebral endplate. OBJECTIVES An intraoperative radiographic technique is demonstrated that ensures that a screw has not penetrated the intervertebral disk. SUMMARY OF BACKGROUND DATA Although methods to avoid penetration of the medial pedicle cortex and the anterior body cortex have been described, no study has discussed screw penetration of the superior endplate and disc. METHODS Pedicle screws were inserted into 11 cadaveric lumbar spines, randomly, with the tip interior to the endplate, at the endplate, and through the endplate. Radiographs were evaluated to measure the penetration, if any, of the screws. Spine segments were dissected and evaluated anatomically. The anatomic and radiographic results were then compared. RESULTS The overall error rate for radiographs was 22/312 (7%). Oblique radiographs gave a much higher error rate. CONCLUSIONS A true lateral or anteroposterior radiographic view of the vertebra provides a high degree of certainty that the screw has not crossed the endplate when a "safe zone" of 3 mm remains superior to the screw tip. Intraoperative radiography can reduce concern about violation of the superior vertebral endplate.
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Affiliation(s)
- J J Meter
- Orthopaedic Surgery Service, Walter Reed Army Medical Center, Washington, DC., USA
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Yanase M, Sakou T, Taketomi E, Yone K. Transpedicular fixation of the lumbar and lumbosacral spine with screws. Application of the Diapason system. PARAPLEGIA 1995; 33:216-8. [PMID: 7609979 DOI: 10.1038/sc.1995.48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Forty-six patients with the Diapason transpedicular screw system for lumbar and lumbosacral fusions were analysed clinically. No implant breakage was observed, but one rod migrated. Additional sacral screws different in the length of the threaded portion are necessary in this system. Metallosis was noted in a few cases, but posed no significant clinical problems. This system, which is simple in structure, easy to use, and applicable to magnetic resonance scanning after surgery, is considered to be a useful instrumentation.
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Affiliation(s)
- M Yanase
- Department of Orthopaedic Surgery, Faculty of Medicine, Kagoshima University, Japan
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