Fusion's Location and Quality within the Fixated Segment Following Transforaminal Interbody Fusion (TLIF)

Transforaminal interbody fusion (TLIF) has gained increased popularity over recent decades and is being employed as an established surgical treatment for several lumbar spine pathologies, including degenerative spondylosis, spondylolisthesis, infection, tumor and some cases of recurrent disc herniation. Despite the seemingly acceptable fusion rates after TLIF (up to 94%), the literature is still limited regarding the specific location and quality of fusion inside the fixated segment. In this single-institution, retrospective population-based study, we evaluated all post-operative computed tomography (CT) of patients who underwent TLIF surgery at a medium-sized medical center between 2010 and 2020. All CT studies were performed at a minimum of 1 year following the surgery, with a median of 2 years. Each CT study was evaluated for post-operative fusion, specifically in the posterolateral and intervertebral body areas. The fusion's quality was determined and classified in each area according to Lee's criteria, as follows: (1) definitive fusion: definitive bony trabecular bridging across the graft host interface; (2) probable fusion: no definitive bony trabecular crossing but with no gap at the graft host interface; (3) possible arthrosis: no bony trabecular crossing with identifiable gap at the graft host interface; (4) definite pseudarthrosis: no traversing trabecular bone with definitive gap. A total of 48 patients were included in this study. The median age was 55.6 years (SD ± 15.4). The median time from surgery to post-operative CT was 2 years (range: 1-10). Full definitive fusion in both posterolateral and intervertebral areas was observed in 48% of patients, and 92% showed definitive fusion in at least one area (either posterolateral or intervertebral body area). When comparing the posterolateral and the intervertebral area fusion rates, a significantly higher definitive fusion rate was observed in the posterolateral area as compared to the intervertebral body area in the long term follow-up (92% vs. 52%, p < 0.001). In the multivariable analysis, accounting for several confounding factors, including the number of fixated segments and cage size, the results remained statistically significant (p = 0.048). In conclusion, a significantly higher definitive fusion rate at the posterolateral area compared to the intervertebral body area following TLIF surgery was found. Surgeons are encouraged to employ bone augmentation material in the posterolateral area (as the primary site of fusion) when performing TLIF surgery.

A dynamic pedicle screw system using polyethylene insert for the lumbar spine

Rigid spinal fusion with instrumentation has been widely applied in treating degenerative spinal disorders and has shown excellent and stable surgical results. However, adjacent segment pathology or implants' loosening could be problematic due to the spine's segmental fusion. Therefore, this study verified a novel concept for posterior stabilization with polyethylene inserts inside a pedicle screw assembly using bone models. We observed that although the gripping capacity of the dynamic pedicle screw system using a tensile and compression tester was less than half that of the rigid pedicle screw system, the flexion-extension moment of the dynamic pedicle screws was significantly lower than that of the rigid pedicle screws. Furthermore, while the bending force of the rigid pedicle screw assembly increased linearly with an increase in the bending angle throughout the test, that of the dynamic pedicle screw assembly also increased linearly until a bending angle of 2.5° was reached. However, this angle decreased at a bending angle of more than 2.5°. Additionally, the fatigue test of 1.0 × 10⁶ cycles showed that the pull-out force of the dynamic pedicle screws from two different polyurethane foam blocks was significantly higher than that of the rigid pedicle screws. Therefore, based on our results, we propose that the device can be applied in clinical cases to reduce screw loosening and adjacent segment pathology.

Does Instrumentation of the Fractured Level in Thoracolumbar Fixation Affect the Functional and Radiological Outcome?

STUDY DESIGN

Retrospective comparative study.

OBJECTIVES

To compare radiological and functional outcomes of patients with fixation constructs utilizing pedicle screw stabilization at the fracture level (FL group) versus patients with non-fracture level (NFL group) fixation in single level fractures of the thoracolumbar junction (T11-L1).

METHODS

53 patients of whom fracture level screw was used in 34 (FL group) were compared to 19 patients in NFL group. Radiological parameters analyzed were sagittal index, bi-segmental kyphosis (Cobb) angle and degree of vertebral height restoration. Prospectively collected patient reported functional outcomes and post-operative complications were also studied. Stepwise regression analysis adjusted by age, gender and functional scores was performed to account for the small numbers and unequal sizes of the groups.

RESULTS

Back pain score was significantly lower in the FL group (P < 0.025). Core Outcome Measures Index scores and leg pain scores, though low in the FL group, were not statistically significant. The regression analysis showed that the inclusion of the fracture-level screw was independently associated with a greater change in sagittal index and vertebral height restoration post-operatively. Sagittal index was maintained through to final follow up as well. The bi-segmental Cobb's angle correction was not associated with fracture-level screw construct. There was no significant difference between the groups for revision surgery, deep infection, implant failure or length of hospital stay.

CONCLUSION

The inclusion of the fracture-level pedicle screws in the fixation construct significantly improves the immediate and final measured radiological parameters, with improved functional scores in single level unstable vertebral fractures of the thoracolumbar junction.

Morbidity and Mortality in Patients over 90 Years of Age Following Posterior Stabilization for Acute Traumatic Odontoid Type II Fractures: A Retrospective Study with a Mean Follow-Up of Three Years

Odontoid type II fractures represent the most common cervical spine injuries in the elderly. The decision for surgical treatment in very elderly patients is still controversial. The aim of this study was to assess morbidity and mortality in patients over 90 years of age undergoing CT-guided posterior stabilization for unstable odontoid type II fractures. A total of 15 patients with an acute traumatic odontoid type II fracture who received surgical treatment for unstable odontoid type II fractures were retrospectively analyzed. Complications, morbidity, and mortality as well as length of ICU and hospital stay were determined. Clinical follow-up evaluation was based on outpatient presentation and information from family members and general practitioners. Finally, we conducted a comparison of complications rates between patients over 90 years of age and patients between 65 and 89 years old with a type II odontoid fracture after CT-guided posterior stabilization in our institution. The mean age was 91.4 years. Patients were predominately female (87%). In-hospital deaths did not occur. The average length of the hospital stay was 13.4 days and 1.9 days for the ICU. Blood transfusion was necessary in two patients (13%). Two patients (13%) developed urinary tract infection, one patient (7%) a delirium, and another epistaxis (7%). One patient (7%) developed pneumonic sepsis and fully recovered within several weeks. The mean follow-up was 36 months (range 9–72 months). Implant-related complications developed in one patient (7%). Five patients died during the follow-up period, with an average time to death of 26.6 months. Postoperative bracing was not needed in any of the patients. Posterior stabilization of unstable odontoid fractures type II using CT-guided navigation in patients over 90 years of age is a safe and effective procedure with low complications and mortality rates.

Treatment of Multiple Junctional Vertebra Fractures in a Single Case

We present a unique case of multiple junctional vertebra fractures in a single patient requiring surgical intervention, the variety of which has not yet been reported in the literature. A 15-year old female was admitted to our emergency department after a suicide attempt from jumping from the window of a five-floor building. On admission her general status was critical, Glasgow Coma Scale (GCS) was 6, and on painful stimuli she was able to move all four extremities. On her spinal CT, a C1 right arcus fracture, a C7 corpus fracture, an L3 and L5 burst fracture and a right sacrum fracture were detected. The patient also suffered from pneumothorax, pleural effusion and pulmonary contusions. After she was stable and extubated, she did not show any motor or sensory deficits. As the patient still had some pleural effusion and pulmonary contusions, posterior approaches were avoided at first and a C6-T1 anterior stabilization with mini plate-screws was performed. After her pulmonary problems resolved, a series of spinal instrumentation surgeries were performed over the following weeks. A case like this in which multiple traumatic junctional fractures were treated with different surgical techniques has not been reported in the literature before. It is important to emphasize if and when surgical intervention is needed. A multidisciplinary assessment of trauma surgeons, neurosurgeons and anesthesiologists is vital for forming a further treatment plan.

Cervical Spinal Fracture in a Patient with Diffuse Idiopathic Skeletal Hyperostosis Having a History of Cervical Laminoplasty

An 87-year-old male having a history of C3-7 open-door cervical laminoplasty 20 years ago fell and sustained neck pain and paralysis with complete motor and sensory deficits below C6 (Frankel A). Computed tomography (CT) revealed ankylosis from C2 to C7 due to diffuse idiopathic skeletal hyperostosis (DISH) and a C5/6 fracture with C5 posterior displacement. We performed surgery the day after injury using a posterior approach for stabilization of the spinal column from C3 to T1. Translaminar screws (LS) were placed to the right (hinge side) of C3-7, lateral mass screws (LMS) to the left (open side) of C3-6, and pedicle screws to the left of C7 and bilaterally in T1. Bony fusion was achieved as seen on CT images 6 months after surgery. We conclude that long posterior stabilization using LMS and LS is an effective treatment for cervical fracture in patients with DISH having a history of cervical laminoplasty.

Isolated unstable burst fractures of the fifth lumbar vertebra: functional and radiological outcome after posterior stabilization with reconstruction of the anterior column: About 6 cases and literature review

INTRODUCTION

L5 burst fractures represent a small percentage of all spine fractures. Treatment strategy has not yet been standardized. Anatomical features and their biomechanical characteristics create fracture patterns which differ from those at the thoracolumbar junction. The objective of this study was to evaluate L5 burst fracture surgical treatment outcomes after posterior stabilization and reconstruction of the anterior column.

PATIENTS AND METHODS

Six patients with fifth lumbar isolated unstable burst fractures were analyzed. Medical records, radiographs, and clinical scores were obtained. The results were evaluated based on restoration of vertebral body height, spinal lordosis/kyphosis, canal compromise and sagittal alignment at several phases of treatment.

RESULTS

No patient showed neurologic deterioration, regardless of treatment. The median preoperative anterior vertebral height was 41mm and postoperative was 48mm. The median preoperative kyphotic angle as measured by Cobb angle (local and regional) was 21.5 degrees and 33 degrees which improved respectively by 7.5 and 5.5 degrees following instrumentation. The median amount of backward protrusion of bony fragment into the canal was measured at 67% preoperatively and at 35% postoperatively. There were no pseudarthrosis and anterior arthrodesis solid fusion was visible in all cases. There were a sagittal alignment restoration. At one year of follow up, fusion was obtained in all the cases, all patients had minimal to moderate disability using Oswestry Disability Index. The ability to return to work revealed a good-to-excellent long-term result.

DISCUSSION

The results of treatment of 5th lumbar unstable burst fractures with posterior stabilization and reconstruction of the anterior column show benefit on durable functional outcome, spine stabilization and radiologic parameters.

LEVEL OF EVIDENCE

IV, retrospective study.

Late-Onset Paraplegia in Old Healed Spinal Tuberculosis Due to Traumatic Fracture of Fusion Mass - A Rare Case Report

The natural healing of spinal tuberculosis occurs by spontaneous fusion of vertebral bodies with or without kyphotic deformity. Late-onset paraplegia secondary to the fracture of fusion mass in tuberculosis is one of the rare conditions which have not been extensively reported. A 56-year-old male patient sustained road traffic accident was diagnosed with a fracture of fusion mass in already healed tuberculosis. He was presented with weakness in both the lower limbs with ASIA-C grading of spinal cord injury. He was treated with posterior instrumented stabilization and decompression. The patient recovered well postoperatively and had regained his complete power of both lower limbs. Late-onset paraplegia in old healed spinal tuberculosis is a well-known entity that may be caused due to transaction of the cord by a bony ridge or when the formed granulation or fibrous tissue constricts the cord. Fusion mass fractures are not very uncommon in conditions such as ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Traumatic fractures tend to occur at the adjacent vertebral bodies to the fused ones as the biomechanical stress at the junctional site is far higher than at the center of the fused mass. In healed spinal tuberculosis, resultant deformity would be kyphosis. The angle of kyphosis is directly proportional to the resulting neurological deficit. Fractures of fused mass in healed tuberculosis are similar to the fractures in other ossifying bone lesions. The purpose of this article is to document the rare possibility of late-onset paraplegia in uninstrumented old healed spinal tuberculosis with kyphotic deformity, due to the fracture of fusion mass as seen in ankylosing spondylitis.

Treatment of Odontoid Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Narrative review.

OBJECTIVE

To establish recommendations for the treatment of odontoid fractures based on current literature and the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

METHODS

Narrative review of the literature. Analyzing treatment algorithms of German trauma and spine centers as members of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

RESULTS

There are many influencing factors leading to appropriate treatment of odontoid fractures such as age, bone quality, arthrosis, classification, and type of the fracture. Conservative nonoperative treatment is appropriate for stable undislocated displaced odontoid fractures. Anterior osteosynthesis with 1 or 2 screws leads to good results in the classical unstable type II odontoid fracture in patients with good bone quality. However, modifiers have been identified by the working group leading to higher complication and failure rates. For these cases, more stable constructs and/or posterior approaches are indicated.

CONCLUSIONS

Operation seems to be standard treatment for odontoid fractures. However, in the aged population, conservative treatment should be considered as morbidity and mortality rise significantly in the group of >75 years. Conservative treatment may also be started within stable nondislocated fractures, but then regular controls have to be performed. If operation is indicated, many influencing factors have to be considered for appropriate approach and technique. The classification of Anderson and D'Alonzo is still standard. To create an adequate treatment algorithm, dislocation displacement and instability have to be identified. Stable odontoid fractures are treated conservatively non-operatively, but if so regular controls have to be performed. Unstable and/or dislocated displaced odontoid fractures are treated by anterior osteosynthesis with 1 or 2 screws. The technique is demanding and leads to elevated complication and failure rates if modifiers are apparent. In these cases, posterior instrumentation or fusion of C1 and C2 is favorable. In the aged population (>80 years), operative therapy is critical as postoperative morbidity complication and mortality rates rise significantly. As there is still some bias in the treatment algorithms, the working group recommends establishment of a prospective study to result in more objective statements.

Posterior-only Stabilization for Traumatic Thoracolumbar Burst Fractures

Background

No consensus exists for the management of unstable thoracolumbar (TL) burst fractures. Surgical options include anterior, lateral, or posterior stabilization (or a combination), depending on the fracture. The potential benefits of anterior reconstruction come with increased operative time and associated morbidity. A posterior-only approach can offer stable correction without increased operative risks but may result in loss of kyphotic correction over time.

Purpose

To determine whether posterior-only stabilization is a viable treatment option for patients with traumatic TL fractures as opposed to anterior and combined approaches.

Methods

We performed a retrospective analysis of adult patients with TL burst fractures who underwent posterior­-only surgical intervention from 2005 to 2015. Operations were performed at two levels above and below the fractured segment using pedicle screw-rod fixation constructs with autograft and allograft. All patients received TL bracing for at least three months. Patients lost to follow­up were excluded.

Results

Sixty-four consecutive patients with posterior­-only stabilization were identified, with 18 lost to follow­up. Of the remaining 46 patients, 93% (n=43) were male and 7% (n=3) were female, with a mean age of 36.8 years. All patients were followed for 12 months. The mean time until the removal of the brace was 3.54 months. No patients required additional surgical intervention for spinal stabilization. Three patients experienced postoperative complications, all of which were related to infection.

Conclusions

Our data indicate that posterior­-only stabilization for traumatic TL burst fractures is a durable and effective option in select patients. The approach offers surgical intervention with a decreased perioperative risk as well as reduced morbidity and mortality, with a minimal increase in the risk of kyphotic deformity. Further prospective studies are necessary to validate these findings clinically.

Current concepts in spondylopelvic dissociation

INTRODUCTION

Spondylopelvic dissociation is an uncommon and complex injury that results from high-energy trauma with axial overloading through the sacrum. Due to the life-threatening nature of these injuries, standard Advanced Trauma Life Support^® (ATLS) protocol must be used in the trauma setting as part of the initial management of these patients. The key to diagnosis is a good physical exam coupled with high level of suspicion. Radicular neurological deficits commonly are present in spondylopelvic dissociation (L5's roots) and should be documented for future evaluations. Radiographic views and CT-scan is preferred for the diagnosis.

BIOMECHANICS AND CLASSIFICATION

The authors briefly describe the anatomy and biomechanics of the pelvis, and present the main classifications used to define this rare lesion.

TREATMENT

Discussion about setting the boundaries of surgical stabilization, if there is still a role for conservative treatment, the importance of the initial treatment and the timing of intervention. Decompression is mandatory in the presence of canal compromise and progressive neurological deficit, regardless of biomechanical criteria for surgery. Kyphotic deformity occurs at the site of sacral transverse fracture and also reduces anteroposterior pelvis diameter. The technique of reduction and posterior surgical stabilization is emphasized. If residual kyphosis remains after bilateral lumbopelvic fixation by shifting of the lower sacral segment, we use S2 and/or S3 screws connected to transitional rods to additional reduction. An illustrated case is shown.

COMPLICATIONS

The infection of the wound and the failure of the implants are the most frequent complications of this surgical treatment.

CONCLUSION

Posterior stabilization is widely recognized as crucial in the treatment of pelvic disruptions. The concept of circumferential restoration of pelvic ring by bilateral lumbopelvic fixation and anterior fixation seems to be a nice option to increase stabilization and avoid bone misalignment.

Posterior Shoulder Instability

CONTEXT

Posterior shoulder instability has become more frequently recognized and treated as a unique subset of shoulder instability, especially in the military. Posterior shoulder pathology may be more difficult to accurately diagnose than its anterior counterpart, and commonly, patients present with complaints of pain rather than instability. "Posterior instability" may encompass both dislocation and subluxation, and the most common presentation is recurrent posterior subluxation. Arthroscopic and open treatment techniques have improved as understanding of posterior shoulder instability has evolved.

EVIDENCE ACQUISITION

Electronic databases including PubMed and MEDLINE were queried for articles relating to posterior shoulder instability.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

In low-demand patients, nonoperative treatment of posterior shoulder instability should be considered a first line of treatment and is typically successful. Conservative treatment, however, is commonly unsuccessful in active patients, such as military members. Those patients with persistent shoulder pain, instability, or functional limitations after a trial of conservative treatment may be considered surgical candidates. Arthroscopic posterior shoulder stabilization has demonstrated excellent clinical outcomes, high patient satisfaction, and low complication rates. Advanced techniques may be required in select cases to address bone loss, glenoid dysplasia, or revision.

CONCLUSION

Posterior instability represents about 10% of shoulder instability and has become increasingly recognized and treated in military members. Nonoperative treatment is commonly unsuccessful in active patients, and surgical stabilization can be considered in patients who do not respond. Isolated posterior labral repairs constitute up to 24% of operatively treated labral repairs in a military population. Arthroscopic posterior stabilization is typically considered as first-line surgical treatment, while open techniques may be required in complex or revision settings.

A Case Report on Extruded Disc Acting as Buttonhole reventing Reduction in Traumatic Fracture and Lateral Dislocation of L1-l2 Vertebrae

INTRODUCTION

There is a scanty literature support describing the incidence, mechanism of lateral dislocations of thoracolumbar spine and its management describing the reduction techniques. Hereby we present an interesting case of extruded disc acting as buttonhole preventing the reduction of lateral dislocation of L1-L2 vertebrae and this would be the first of its variety to be described ever in literature.

CASE REPORT

A 30 year old female was referred to our hospital on post trauma day 7 with bilateral fascet fracture and lateral dislocation of L1-L2 vertebrae and fracture humerus on right arm following a road traffic accident. She presented with clinical signs consistent of cauda equina lesion. She underwent surgical reduction and TLIF L1-L2. On one year follow-up X-Rays showed maintenance of dorsolumbar saggital alignment without collapse.

CONCLUSION

Dislocations of spine are three column injuries, are highly unstable requiring surgical stabilisation. Posterior instrumentation is the routinely followed technique to achieve reduction and for posterolateral fusion. In this case lateral dislocation was reduced only after removal of the laterally extruded disc. After complete discectomy TLIF was considered a good option for restoring disc space height and maintaining saggital balance.