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Journal of Neurosurgery. Spine Sep 2023Lateral lumbar interbody fusion (LLIF) is a workhorse surgical approach for lumbar arthrodesis. There is growing interest in techniques for performing single-position...
OBJECTIVE
Lateral lumbar interbody fusion (LLIF) is a workhorse surgical approach for lumbar arthrodesis. There is growing interest in techniques for performing single-position surgery in which LLIF and pedicle screw fixation are performed with the patient in the prone position. Most studies of prone LLIF are of poor quality and without long-term follow-up; therefore, the complication profile related to this novel approach is not well known. The objective of this study was to perform a systematic review and pooled analysis to understand the safety profile of prone LLIF.
METHODS
A systematic review of the literature and a pooled analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting prone LLIF were assessed for inclusion. Studies not reporting complication rates were excluded.
RESULTS
Ten studies meeting the inclusion criteria were analyzed. Overall, 286 patients were treated with prone LLIF across these studies, and a mean (SD) of 1.3 (0.2) levels per patient were treated. The 18 intraoperative complications reported included cage subsidence (3.8% [3/78]), anterior longitudinal ligament rupture (2.3% [5/215]), cage repositioning (2.1% [2/95]), segmental artery injury (2.0% [5/244]), aborted prone interbody placement (0.8% [2/244]), and durotomy (0.6% [1/156]). No major vascular or peritoneal injuries were reported. Sixty-eight postoperative complications occurred, including hip flexor weakness (17.8% [21/118]), thigh and groin sensory symptoms (13.3% [31/233]), revision surgery (3.8% [3/78]), wound infection (1.9% [3/156]), psoas hematoma (1.3% [2/156]), and motor neural injury (1.2% [2/166]).
CONCLUSIONS
Single-position LLIF in the prone position appears to be a safe surgical approach with a low complication profile. Longer-term follow-up and prospective studies are needed to better characterize the long-term complication rates related to this approach.
Topics: Humans; Lumbar Vertebrae; Postoperative Complications; Spinal Fusion; Reoperation; Vascular System Injuries; Retrospective Studies
PubMed: 37310041
DOI: 10.3171/2023.4.SPINE221180 -
European Spine Journal : Official... May 2021Interbody cages are commonly used to augment interbody fusion. Commonly used materials include titanium (Ti) and polyetheretherketone (PEEK), with their inherent... (Meta-Analysis)
Meta-Analysis Review
Titanium (Ti) cages may be superior to polyetheretherketone (PEEK) cages in lumbar interbody fusion: a systematic review and meta-analysis of clinical and radiological outcomes of spinal interbody fusions using Ti versus PEEK cages.
AIM
Interbody cages are commonly used to augment interbody fusion. Commonly used materials include titanium (Ti) and polyetheretherketone (PEEK), with their inherent differences. The aim of this study is to perform a systematic review and meta-analysis to compare between the various clinical and radiological outcomes of Ti and PEEK interbody spinal cages.
METHODS
A systematic review and meta-analysis comparing clinical and radiological outcomes between Ti and PEEK interbody cages in patients undergoing spinal fusion was performed. PubMed, Scopus, Web of Science, Embase, and Cochrane Central Register of Controlled Trials database were searched. All studies that compared the clinical and radiological outcomes of patients who underwent Ti and PEEK cages were included. Subgroup analyses was performed to differentiate between patients who had cervical and lumbar interbody fusion.
RESULTS
A total of 11 articles were identified, with a total of 743 patients. Spinal fusion rates at final follow-up did not differ between Ti and PEEK cages (OR 1.50, 95% CI 0.57-3.94, P = 0.41), although in patients undergoing lumbar fusion, Ti cages demonstrated superior fusion (OR 2.12, 95% CI 1.05-4.28, P = 0.04). In patients with non-infective etiologies, Ti cages had a higher rate of cage subsidence (RR 2.17, 95% CI 1.13-4.16, P = 0.02). Both types of cages had similar operating time, postoperative hematoma formation, neuropathic pain, segmental angle correction and postoperative clinical outcome improvement.
CONCLUSION
In non-infective lumbar spine conditions, Ti cage may be the superior option due to the higher fusion rate.
LEVEL OF EVIDENCE
III.
Topics: Benzophenones; Humans; Ketones; Lumbar Vertebrae; Polyethylene Glycols; Polymers; Spinal Fusion; Titanium; Treatment Outcome
PubMed: 33555365
DOI: 10.1007/s00586-021-06748-w -
Foot (Edinburgh, Scotland) Mar 2023Talonavicular arthrodesis is associated with a rate of non-union that ranges from 3 % to 37 %. Various fixation devices have been reported for talonavicular arthrodesis... (Review)
Review
UNLABELLED
Talonavicular arthrodesis is associated with a rate of non-union that ranges from 3 % to 37 %. Various fixation devices have been reported for talonavicular arthrodesis including screws, staples, plates, K-wires and intraosseous fix systems, however there is no definitive gold standard. This systematic review aims to compare clinical outcomes between different fixation devices for talonavicular arthrodesis.
METHODS
MEDLINE, EMBASE, CENTRAL and Google Scholar were reviewed for studies reporting on outcomes of different fixation techniques for talonavicular arthrodesis indicated for osteoarthritis, inflammatory and post-traumatic arthritis from 1946 to 2021. The primary outcome measure was union rate. Secondary outcome measures included functional improvement, cost, quality of life and patient satisfaction.
RESULTS
9 articles involving 141 cases of talonavicular arthrodesis were identified. Fusion rates were as follows: screw fixation (n = 75): 87.5 % to 100 %, staple fixation (n = 13): 100 %, intraosseous fix system (n = 16): 100 %, and K-wire fixation (n = 2): 100 %. One study utilised a dorsal locking plate with two supplemented compression screws (n = 9, fusion rate= 100 %) and two studies used a combination of screws with staples (n = 26, fusion rate= 96 %). 7 of 9 studies measured functional outcomes and pain relief with improvement demonstrated in all fixation techniques. Quality of life, satisfaction and cost were inadequately reported amongst the included studies. All studies were rated as serious risk of bias.
CONCLUSION
This systematic review consolidates the evidence for outcomes of different fixation techniques for TN arthrodesis, however a definitive judgement regarding the best fixation technique is unobtainable from current clinical evidence, due to lack of high-quality studies. With review of biomechanical studies and the limited clinical data, fixation with plate plus screw is most promising and would warrant further comparative study.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Quality of Life; Arthrodesis; Osteoarthritis; Bone Screws; Patient Satisfaction; Retrospective Studies
PubMed: 36842364
DOI: 10.1016/j.foot.2023.101966 -
Spine Oct 2014Systematic review. (Comparative Study)
Comparative Study Review
STUDY DESIGN
Systematic review.
OBJECTIVE
To summarize and critically review the economic literature evaluating the cost-effectiveness of minimal access surgery (MAS) compared with conventional open procedures for the cervical and lumbar spine.
SUMMARY OF BACKGROUND DATA
MAS techniques may improve perioperative parameters (length of hospital stay and extent of blood loss) compared with conventional open approaches. However, some have questioned the clinical efficacy of these differences and the associated cost-effectiveness implications. When considering the long-term outcomes, there seem to be no significant differences between MAS and open surgery.
METHODS
PubMed, EMBASE, the Cochrane Collaboration database, University of York, Centre for Reviews and Dissemination (NHS-EED and HTA), and the Tufts CEA Registry were reviewed to identify full economic studies comparing MAS with open techniques prior to December 24, 2013, based on the key questions established a priori. Only economic studies that evaluated and synthesized the costs and consequences of MAS compared with conventional open procedures (i.e., cost-minimization, cost-benefit, cost-effectiveness, or cost-utility) were considered for inclusion. Full text of the articles meeting inclusion criteria were reviewed by 2 independent investigators to obtain the final collection of included studies. The Quality of Health Economic Studies instrument was scored by 2 independent reviewers to provide an initial basis for critical appraisal of included economic studies.
RESULTS
The search strategy yielded 198 potentially relevant citations, and 6 studies met the inclusion criteria, evaluating the costs and consequences of MAS versus conventional open procedures performed for the lumbar spine; no studies for the cervical spine met the inclusion criteria. Studies compared MAS tubular discectomy with conventional microdiscectomy, minimal access transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion, and multilevel hemilaminectomy via MAS versus open approach.
CONCLUSION
Overall, the included cost-effectiveness studies generally supported no significant differences between open surgery and MAS lumbar approaches. However, these conclusions are preliminary because there was a paucity of high-quality evidence. Much of the evidence lacked details on methodology for modeling, related assumptions, justification of economic model chosen, and sources and types of included costs and consequences. The follow-up periods were highly variable, indirect costs were not frequently analyzed or reported, and many of the studies were conducted by a single group, thereby limiting generalizability. Prospective studies are needed to define differences and optimal treatment algorithms.
LEVEL OF EVIDENCE
3.
Topics: Cervical Vertebrae; Costs and Cost Analysis; Diskectomy; Health Care Costs; Humans; Laminectomy; Lumbar Vertebrae; Minimally Invasive Surgical Procedures; Quality-Adjusted Life Years; Spinal Diseases; Spinal Fusion
PubMed: 25299261
DOI: 10.1097/BRS.0000000000000571 -
Clinical Spine Surgery Nov 2016Systematic review and meta-analysis. (Meta-Analysis)
Meta-Analysis Review
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
To assess the safety and efficacy of cervical disk arthroplasty (CDA) compared with anterior cervical decompression and fusion (ACDF) for the treatment of 2-level cervical spondylopathy.
SUMMARY OF BACKGROUND DATA
CDA has emerged as a potential alternative to ACDF in patients with cervical disk degeneration. But there are no published systematic reviews and meta-analyses comparing CDA with ACDF for the treatment of 2-level cervical spondylopathy.
METHODS
The Pubmed, Embase, Web of science, Scopus, and Cochrane library databases were searched comparing CDA to ACDF in patients with 2-level cervical spondylopathy. Outcome measures were neck disability index, visual analog scale (VAS) of arm and neck pain, range of movement (ROM) at C2-C7, functional segment unit ROM, ROM at the operated level, and incidence of radiologic changes at adjacent levels approximately 2 years after surgery, as well as operating time and incidence of surgery-related complications. Mean difference (MD), odds ratios (OR), and their corresponding 95% confidence intervals (95% CIs) were calculated.
RESULTS
Six studies involving 646 patients were included. There were no significant differences in neck disability index (MD, -1.53; 95% CI -3.80 to 0.73), VAS neck pain (MD, -0.19; 95% CI -0.71 to 0.33), and VAS arm pain (MD, -0.23; 95% CI -0.61 to 0.16) between 2-level CDA and 2-level ACDF cases. ROM at C2-C7 (MD, 15.82; 95% CI, 10.66-20.99), functional segment unit ROM (MD, 8.58; 95% CI, 7.93-9.23), and ROM at the operated level (MD, 9.54; 95% CI, 7.73-11.35) were greater, but the incidence of radiologic changes at adjacent levels (OR, 0.29; 95% CI, 0.13-0.67) were lower, in 2-level CDA cases. In 2-level CDA cases, the operating time was longer (MD, 57.41; 95% CI, 24.67-90.14), but surgery-related complications rates (OR, 0.47; 95% CI, 0.30-0.74) was lower.
CONCLUSIONS
CDA may be a safe and effective alternative to ACDF for the treatment of 2-level cervical degenerative disease.
LEVEL OF EVIDENCE
Level II.
Topics: Arthroplasty; Cervical Vertebrae; Decompression, Surgical; Humans; Spinal Fusion; Spondylosis
PubMed: 27295435
DOI: 10.1097/BSD.0000000000000395 -
The Spine Journal : Official Journal of... Jun 2015Polyetheretherketone (PEEK) cages have been widely used during the past decade in patients with degenerative disorders of the cervical spine. Their radiolucency and low... (Review)
Review
BACKGROUND CONTEXT
Polyetheretherketone (PEEK) cages have been widely used during the past decade in patients with degenerative disorders of the cervical spine. Their radiolucency and low elastic modulus make them attractive attributes for spinal fusion compared with titanium and bone graft. Still, limitations are seen such as pseudoarthrosis, subsidence, and migration of the cages. Limited evidence on the clinical outcome of PEEK cages is found in the literature other than noncomparative cohort studies with only a few randomized controlled trials.
PURPOSE
To assess the clinical and radiographic outcome of PEEK cages in the treatment of degenerative disc disorders and/or spondylolisthesis in the cervical spine.
STUDY DESIGN
Systematic review of all randomized controlled trials and prospective and retrospective nonrandomized comparative studies with a minimum follow-up of 6 months and all noncomparative cohort studies with a long-term follow-up of more than 5 years.
OUTCOME MEASURES
The primary outcome variable was clinical performance. Secondary outcome variables consisted of radiographic scores.
METHODS
The MEDLINE, EMBASE, and Cochrane Library databases were searched according to the Preferred Reporting Items of Systematic reviews and Meta-Analyses statement and Meta-analysis Of Observational Studies in Epidemiology guidelines. No conflict of interest reported. No funding received.
RESULTS
A total of 223 studies were identified, of which 10 studies were included. These comprised two randomized controlled trials, five prospective comparative trials, and three retrospective comparative trials.
CONCLUSIONS
Minimal evidence for better clinical and radiographic outcome is found for PEEK cages compared with bone grafts in the cervical spine. No differences were found between PEEK, titanium, and carbon fiber cages. Future studies are needed to improve methodology to minimize bias. Publication of lumbar interbody fusion studies needs to be promoted because differences in clinical and/or radiographic scores are more likely to be demonstrated in this part of the spine.
Topics: Benzophenones; Biocompatible Materials; Cervical Vertebrae; Humans; Intervertebral Disc Degeneration; Ketones; Polyethylene Glycols; Polymers; Postoperative Complications; Prostheses and Implants; Spinal Fusion; Spondylolisthesis; Treatment Outcome
PubMed: 24374100
DOI: 10.1016/j.spinee.2013.08.030 -
Journal of Clinical Neuroscience :... Dec 2016A systematic review and meta-analysis was performed to assess the effect of hybrid constructs which involve a total disc arthroplasty (TDA) with stand-alone anterior... (Meta-Analysis)
Meta-Analysis Review
A systematic review and meta-analysis was performed to assess the effect of hybrid constructs which involve a total disc arthroplasty (TDA) with stand-alone anterior lumbar interbody fusion (ALIF) versus non-hybrid constructs including multi-level TDA, multi-level transforaminal lumbar interbody fusion (TLIF) with posterior transpedicular fixation or multi-level stand-alone ALIF as a surgical intervention for degenerative disc disease (DDD) in the lumbar spine. Primary outcomes analysed included the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for back pain. A systematic search of Medline, Embase, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Google Scholar was undertaken by two separate reviewers and a meta-analysis of the outcomes was performed. Three studies met our search criteria. When comparing hybrid constructs to multi-level TDA or lumbar fusion (LF) improvements in back pain were found with a VAS back pain score reduction of 1.38 (P<0.00001) postoperatively and a VAS back pain score reduction of 0.99 points (P=0.0006) at 2-years follow-up. Results so far slightly favour clinically significant improved VAS back pain score outcomes postoperatively and at 2-years follow-up for hybrid constructs in multi-level lumbar DDD of the spine when compared with non-hybrid multi-level LF or TDA. It cannot however be concluded that a hybrid construct is superior to multi-level LF or TDA based on this meta-analysis. The results highlight the need for further prospective studies to delineate best practice in the management of degenerative disc disease of the lumbar spine.
Topics: Humans; Intervertebral Disc Degeneration; Lumbar Vertebrae; Outcome Assessment, Health Care; Spinal Fusion; Total Disc Replacement
PubMed: 27475322
DOI: 10.1016/j.jocn.2016.06.011 -
Neuro-Chirurgie May 2023Rodent models are commonly used experimentally to assess treatment effectiveness in spinal fusion. Certain factors are associated with better fusion rates. The... (Review)
Review
BACKGROUND
Rodent models are commonly used experimentally to assess treatment effectiveness in spinal fusion. Certain factors are associated with better fusion rates. The objectives of the present study were to report the protocols most frequently used, to evaluate factors known to positively influence fusion rate, and to identify new factors.
METHOD
A systematic literature search of PubMed and Web of Science found 139 experimental studies of posterolateral lumbar spinal fusion in rodent models. Data for level and location of fusion, animal strain, sex, weight and age, graft, decortication, fusion assessment and fusion and mortality rates were collected and analyzed.
RESULTS
The standard murine model for spinal fusion was male Sprague Dawley rats of 295g weight and 13 weeks' age, using decortication, with L4-L5 as fusion level. The last two criteria were associated with significantly better fusion rates. On manual palpation, the overall mean fusion rate in rats was 58% and the autograft mean fusion rate was 61%. Most studies evaluated fusion as a binary on manual palpation, and only a few used CT and histology. Average mortality was 3.03% in rats and 1.56% in mice.
CONCLUSIONS
These results suggest using a rat model, younger than 10 weeks and weighing more than 300 grams on the day of surgery, to optimize fusion rates, with decortication before grafting and fusing the L4-L5 level.
Topics: Rats; Male; Mice; Animals; Spinal Fusion; Disease Models, Animal; Rats, Sprague-Dawley; Spine; Lumbar Vertebrae; Bone Transplantation; Models, Animal
PubMed: 36871885
DOI: 10.1016/j.neuchi.2023.101428 -
Spine Mar 2017Systematic review and meta-analysis. (Review)
Review
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
The goal of this study was to (i) assess the risk of neurological injury after anterior cervical spine surgery (ACSS) with and without intraoperative neuromonitoring (ION) and (ii) evaluate differences in the sensitivity and specificity of ION for ACSS.
SUMMARY OF BACKGROUND DATA
Although ION is used to detect impending neurological injuries in deformity surgery, it's utility in ACSS remains controversial.
METHODS
A systematic search of multiple medical reference databases was conducted for studies on ION use for ACSS. Studies that included posterior cervical surgery were excluded. Meta-analysis was performed using the random-effects model for heterogeneity. Outcome measure was postoperative neurological injury.
RESULTS
The search yielded 10 studies totaling 26,357 patients. The weighted risk of neurological injury after ACSS was 0.64% (0.23-1.25). The weighted risk of neurological injury was 0.20% (0.05-0.47) for ACDFs compared with 1.02% (0.10-2.88) for corpectomies. For ACDFs, there was no difference in the risk of neurological injury with or without ION (odds ratio, 0.726; confidence interval, CI, 0.287-1.833; P = 0.498). The pooled sensitivities and specificities of ION for ACSS are 71% (CI: 48%-87%) and 98% (CI: 92%-100%), respectively. Unimodal ION has a higher specificity than multimodal ION [unimodal: 99% (CI: 97%-100%), multimodal: 92% (CI: 81%-96%), P = 0.0218]. There was no statistically significant difference in sensitivities between unimodal and multimodal [68% vs. 88%, respectively, P = 0.949].
CONCLUSION
The risk of neurological injury after ACSS is low although procedures involving a corpectomy may carry a higher risk. For ACDFs, there is no difference in the risk of neurological injury with or without ION use. Unimodal ION has a higher specificity than multimodal ION and may minimize "subclinical" intraoperative alerts in ACSS.
LEVEL OF EVIDENCE
3.
Topics: Cervical Vertebrae; Diskectomy; Humans; Monitoring, Intraoperative; Postoperative Complications; Retrospective Studies; Spinal Fusion
PubMed: 27390917
DOI: 10.1097/BRS.0000000000001767 -
Archives of Orthopaedic and Trauma... Aug 2023Ankle arthrodesis (AA) is often fixed using cannulated screws. The irritation from metalwork is a relatively common complication, but there is no consensus regarding the... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Ankle arthrodesis (AA) is often fixed using cannulated screws. The irritation from metalwork is a relatively common complication, but there is no consensus regarding the need to remove the screws on a systematic basis. The aim of this study was to determine (1) the proportion of screws removed after AA and (2) whether predictors of screw removal could be identified.
METHODS
This PRISMA-compliant systematic review was part of a larger previous protocol registered on the PROSPERO platform. Multiple databases were searched including studies in which patients undergone AA using screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS).
RESULTS
Forty-four series of patients from thirty-eight studies (1990 ankles, 1934 patients) were selected. The average follow-up was 40.8 months (range 12-110). In all studies, hardware was removed due to symptoms reported by patients and related to the screws. The pooled proportion of removal of metalwork was 3% (95% CI 2-4). The pooled proportion of fusion was 96% (95%CI 95-98), while the pooled proportion of complications and reoperations (excluding the removal of metalwork) stood at 15% (95% CI 11-18) and 3% (95% CI 2-4), respectively. The mean mCMS (50.8 ± 8.1, range 35-66) revealed only an overall fair quality of studies. The univariate analysis and the multivariate model showed that the year of publication (R = - 0.004; p = 0.01) and the number of screws (R = 0.08; p = 0.01) were associated with the screw removal rate. Specifically, we found that over time the removal rate decreased by 0.4% per year and that the use of three screws instead of two reduced the risk of removal of metalwork by 8%.
CONCLUSIONS
In this review, removal of metalwork after ankle arthrodesis using cannulated screws was needed in 3% of cases at an average follow-up of 40.8 months. It was indicated only in case of symptoms related to soft tissue irritation from screws. The use of three screws was paradoxically related to a reduced risk of removal of screws as compared to two-screw constructs.
LEVEL OF EVIDENCE
Level IV, systematic review of Level IV.
Topics: Humans; Ankle; Ankle Joint; Bone Screws; Arthrodesis; Retrospective Studies
PubMed: 36795152
DOI: 10.1007/s00402-023-04813-1