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World Neurosurgery: X Apr 2024The recent development of minimally invasive surgical techniques (MIS) has made possible the correction of adult spinal deformity (ASD) with less blood loss and shorter... (Review)
Review
BACKGROUND/OBJECTIVE
The recent development of minimally invasive surgical techniques (MIS) has made possible the correction of adult spinal deformity (ASD) with less blood loss and shorter hospital stays. However, minimally invasive placement of pedicle screws at the proximal level of the construct can increase pseudarthrosis risk, leading to implant failure, kyphosis, and reoperations. We aggregate existing literature to describe pseudarthrosis rates at the proximal thoracic or thoracolumbar junction in MIS and subsequent reoperation rates.
METHODS
After a three-tied search strategy in PubMed, we identified 9 articles for study inclusion, describing outcomes from MIS correction of ASD, pseudarthrosis as complication, and surgery on 4+ levels. Baseline patient characteristics and combined rates of pseudarthrosis and reoperation were calculated.
RESULTS
A total of 482 patients were studied with an average [range] age of 65.5 [60.4,72], 6.3 [4.4,11] levels fused per patient, follow-up time of 28.3 [12,39] months, and 64.8% females. Pseudarthrosis was reported in 28 of 482 pooled patients (5.8%) of which 15 of 374 pooled patients (4.0%) ultimately underwent a reoperation for pseudarthrosis. Post-operative characteristics included an estimated blood loss (EBL) of 527.1 [241,1466] mL, operating time of 297.9 [183,475] minutes, and length of stay of 7.7 [5,10] days. Among the papers comparing MIS to open surgery, all reported a significantly lower EBL in patients treated with MIS.
CONCLUSION
This analysis demonstrate a measurable pseudarthrosis risk when using MIS to treat ASD, overwhelming requiring reoperation. The benefits of MIS must be considered against the drawbacks of pseudarthrosis when determining ASD management.
PubMed: 38444873
DOI: 10.1016/j.wnsx.2024.100282 -
Global Spine Journal Feb 2024Systematic literature review.
STUDY DESIGN
Systematic literature review.
OBJECTIVES
To analyze the evidence available reporting complications in single or two-level anterior cervical discectomy and fusion (ACDF) using a demineralized bone matrix (DBM), hydroxyapatite (HA), or beta-tricalcium phosphate (β-TCP).
METHODS
A systematic review of the literature using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases was performed in August 2020 to identify studies reporting complications in one or two-level ACDF surgery using DBM, HA, or β-TCP. The study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
RESULTS
A total of 1857 patients were included, 981 male and 876 female, across 17 articles; 5 prospective, and 12 retrospectives. We noted heterogeneity among the included studies concerning the study design and combination of graft materials utilized in them. However, we noted a higher incidence of adjacent segment disease (17.7%) and pseudoarthrosis (9.3%) in fusion constructs using DBM. Studies using β-TCP reported a higher incidence of pseudoarthrosis (28.2%) and implant failures (17.9%).
CONCLUSIONS
Degenerative cervical conditions treated with one or two-level ACDF surgery using DBM, HA, or β-TCP with or without cervical plating are associated with complications such as adjacent segment disease, dysphagia, and pseudarthrosis. However, consequent to the study designs and clinical heterogeneity of the studies, it is not possible to correlate these complications accurately with any specific graft material employed. Further well-designed prospective studies are needed to correctly know the related morbidity of each graft used for achieving fusion in ACDF.
PubMed: 38421333
DOI: 10.1177/21925682231157320 -
Global Spine Journal Feb 2024Systematic review.
STUDY DESIGN
Systematic review.
OBJECTIVES
The aim of this study is to analyze the complications related to multilevel anterior cervical discectomy and fusion (ACDF) using osteobiologics other than bone morphogenetic protein (BMP).
METHODS
A systematic review of the literature was conducted using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases. The search to identify studies reporting complications in multilevel ACDF surgery using osteobiologics other than bone morphogenetic protein was performed in August 2020. The study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA).
RESULTS
A total of 584 articles were found after searching the databases and removing duplicates. Next, screening was performed in a double reviewer process, and 153 eligible articles-with 4 retrospective studies-in full-text were selected; these met all inclusion criteria. A total of 197 patients received 3-level ACDF, while 72 patients received 4-level ACDF. Osteobiologics were used in all selected articles, allograft was used in 4 studies, autologous bone graft was utilized in 3 articles, and hydroxyapatite was used in 1 article. The main complications reported were dysphagia, adjacent segment disease, and pseudarthrosis.
CONCLUSIONS
Given the limited evidence, no conclusions on complications in multilevel ACDF using osteobiologics other than BMP could be made. However, descriptively, the most common complications found were dysphagia, adjacent segment disease, and pseudoarthrosis. Further prospective studies separately analyzing complications in multilevel ACDF by osteobiologics and a number of treated levels are needed.
PubMed: 38421321
DOI: 10.1177/21925682231168083 -
Strategies in Trauma and Limb... 2023The management of bone union disorders is a complex problem in orthopaedics, requiring a reliable and comprehensive classification system for accurate diagnosis and... (Review)
Review
AIM AND BACKGROUND
The management of bone union disorders is a complex problem in orthopaedics, requiring a reliable and comprehensive classification system for accurate diagnosis and treatment. Despite advances in understanding pathophysiology, diagnosis, and treatment in this area, there is no generally accepted classification system. The aim of our work was to create a comprehensive classification, which will systemize the vast majority of bone union disorders, underline their differences and form the basis for their treatment.
METHODS
The key criteria for nonunion evaluation and treatment were identified based on the conducted literature review: Time from the initial event (delayed union or nonunion), location, type of pathology (A, Hypertrophic; B, Normotrophic; C, Oligotrophic) and the presence of hardware. Based on these criteria the ULBNC has been developed. Atrophic nonunions were excluded from this classification as they are considered segmental bone defects with special classification.
RESULTS
The ULBNC is based on the same principles of coding as the "gold standard" AO/OTA Fractures Classification system with alpha-numeric coding "from simple to complex." The choice of treatment method depends on the type, group, and subgroup of the nonunion as described.
CONCLUSION
Universal Long Bone Nonunion Classification (ULBNC) is an alphanumeric system that describes the localization, type of pathology and morphologic characteristics of a nonunion. The use of ULBNC in practice and research will optimize and standardize the treatment of various types of bone healing disorders and eventually improve clinical outcomes.
HOW TO CITE THIS ARTICLE
Solomin LN, Semenistyy AA, Komarov AV, . Universal Long Bone Nonunion Classification. Strategies Trauma Limb Reconstr 2023;18(3):169-173.
PubMed: 38404564
DOI: 10.5005/jp-journals-10080-1597 -
Clinics in Orthopedic Surgery Feb 2024The lumbosacral (LS) junction has a higher nonunion rate than other lumbar segments, especially in long-level fusion. Nonunion at L5-S1 would result in low back pain,...
BACKGROUND
The lumbosacral (LS) junction has a higher nonunion rate than other lumbar segments, especially in long-level fusion. Nonunion at L5-S1 would result in low back pain, spinal imbalance, and poor surgical outcomes. Although anterior column support at L5-S1 has been recommended to prevent nonunion in long-level LS fusion, fusion length requiring additional spinopelvic fixation (SPF) in LS fusion with anterior column support at L5-S1 has not been evaluated thoroughly. This study aimed to determine the number of fused levels requiring SPF in LS fusion with anterior column support at L5-S1 by assessing the interbody fusion status using computed tomography (CT) depending on the fusion length.
METHODS
Patients who underwent instrumented LS fusion with L5-S1 interbody fusion without additional augmentation and CT > 1 year postoperatively were included. The fusion rates were assessed based on the number of fused segments. Patients were divided into two groups depending on the L5-S1 interbody fusion status: those with union vs. those with nonunion. Binary logistic regression analyses were performed to identify risk factors for LS junctional nonunion.
RESULTS
Fusion rates of L5-S1 interbody fusion were 94.9%, 90.3%, 80.0%, 50.0%, 52.6%, and 43.5% for fusion of 1, 2, 3, 4, 5, and ≥ 6 levels, respectively. The number of spinal levels fused ≥ 4 ( < 0.001), low preoperative bone mineral density (BMD; adjusted odds ratio [aOR], 0.667; = 0.035), and postoperative pelvic incidence (PI) - lumbar lordosis (LL) mismatch (aOR, 1.034; = 0.040) were identified as significant risk factors for nonunion of L5-S1 interbody fusion according to the multivariate logistic regression analysis.
CONCLUSIONS
Exhibiting ≥ 4 fused spinal levels, low preoperative BMD, and large postoperative PI-LL mismatch were identified as independent risk factors for nonunion of anterior column support at L5-S1 in LS fusion without additional fixation. Therefore, SPF should be considered in LS fusion extending to or above L2 to prevent LS junctional nonunion.
Topics: Humans; Lumbar Vertebrae; Retrospective Studies; Lordosis; Tomography, X-Ray Computed; Spinal Fusion; Treatment Outcome
PubMed: 38304217
DOI: 10.4055/cios23183 -
Medicina (Kaunas, Lithuania) Jan 2024Although adult spinal deformity (ASD) surgery brought about improvement in the quality of life of patients, it is accompanied by high invasiveness and several...
Clinical and Radiologic Analysis of Minimally Invasive Anterior-Posterior Combined Surgery for Adult Spinal Deformity: Comparison of Oblique Lateral Interbody Fusion at L5/S1 (OLIF51) versus Transforaminal Interbody Fusion.
Although adult spinal deformity (ASD) surgery brought about improvement in the quality of life of patients, it is accompanied by high invasiveness and several complications. Specifically, mechanical complications of rod fracture, instrumentation failures, and pseudarthrosis are still unsolved issues. To better improve these problems, oblique lateral interbody fusion at L5/S1 (OLIF51) was introduced in 2015 at my institution. The objective of this study was to compare the clinical and radiologic outcomes of anterior-posterior combined surgery for ASD between the use of OLIF51 and transforaminal interbody fusion (TLIF) at L5/S1. A total of 117 ASD patients received anterior-posterior correction surgeries either with the use of OLIF51 (35 patients) or L5/S1 TLIF (82 patients). In both groups, L1-5 OLIF and minimally invasive posterior procedures of hybrid or circumferential MIS were employed. The sagittal and coronal spinal alignment and spino-pelvic parameters were recorded preoperatively and at follow-up. The quality-of-life parameters and visual analogue scale were evaluated, as well as surgical complications at follow-up. The average follow-up period was thirty months (13-84). The number of average fused segments was eight (4-12). The operation time and estimated blood loss were significantly lower in OLIF51 than in TLIF. The PI-LL mismatch, LLL, L5/S1 segmental lordosis, and L5 coronal tilt were significantly better in OLIF51 than TLIF. The complication rate was statistically equivalent between the two groups. The introduction of OLIF51 for adult spine deformity surgery led to a decrease in operation time and estimated blood loss, as well as improvement in sagittal and coronal correction compared to TLIF. The circumferential MIS correction and fusion with OLIF51 serve as an effective surgical modality which can be applied to many cases of adult spinal deformity.
Topics: Adult; Animals; Humans; Lumbar Vertebrae; Quality of Life; Spinal Fusion; Minimally Invasive Surgical Procedures; Neurosurgical Procedures; Margins of Excision
PubMed: 38256368
DOI: 10.3390/medicina60010107 -
Korean Journal of Neurotrauma Dec 2023Spinal trauma accounts for a large portion of injuries to the spine area, particularly as societies are entering an era of aging populations. Consequently, spine... (Review)
Review
Spinal trauma accounts for a large portion of injuries to the spine area, particularly as societies are entering an era of aging populations. Consequently, spine fractures accompanied by osteoporosis are becoming more prevalent. Achieving successful fusion surgery in patients with spine fractures associated with osteoporosis is even more challenging. Pseudarthrosis in the spine does not yield clinically favorable results; however, considerable effort has been made to achieve successful fusion, and the advancement of bone graft substitutes has been particularly crucial in this regard. Autograft bone is considered the best fusion material but is limited in use due to the quantity that can be harvested during surgery and associated complications. Accordingly, various bone graft substitutes are currently being used, although no specific guidelines are available and this mainly depends on the surgeon's choice. Therefore, the purpose of this review, across part I/II, is to summarize bone graft substitutes commonly used in spine surgery for spine fusion in patients with spine trauma and to update the latest knowledge on the role of recombinant human bone morphogenetic protein-2.
PubMed: 38222832
DOI: 10.13004/kjnt.2023.19.e62 -
BMC Musculoskeletal Disorders Jan 2024Fifth lumbar vertebra (L5) spondylolysis has a lower bone union rate than non-L5 spondylolysis, but the reason for this is unknown. This study aimed to evaluate the...
BACKGROUND
Fifth lumbar vertebra (L5) spondylolysis has a lower bone union rate than non-L5 spondylolysis, but the reason for this is unknown. This study aimed to evaluate the differences in patient and lesion characteristics between L5 and non-L5 spondylolysis.
METHODS
A total of 410 patients with lumbar spondylolysis aged 18 years or younger who were treated conservatively were enrolled. Patients and lesions were divided into L5 and non-L5 (L2-L4) spondylolysis. Factors, including sex, age, presence of spina bifida occulta, stage of the main side lesion, whether the lesion was unilateral or bilateral, presence and stage of the contralateral side lesion and treatment duration, were evaluated at the first visit and compared between the two groups.
RESULTS
A total of 250 patients with 349 lesions were included. The bone union rate of L5 lesions was lower than that of non-L5 lesions (75% vs. 86%, p = 0.015). Patients with L5 spondylolysis were more likely to be male (86% vs. 66%) and younger (14.0 vs. 14.6 years) than patients with non-L5 spondylolysis. Lesions of L5 spondylolysis were more likely to be in a progressive stage (28% vs. 15%), less likely to be in a pre-lysis stage (28% vs. 43%) and more likely to be in a contralateral terminal stage (14% vs. 5.3%, p = 0.013) compared with lesions of non-L5 spondylolysis.
CONCLUSIONS
L5 spondylolysis was characterised by a lower bone union rate, more males, younger age, more progressive stage and more contralateral pseudarthrosis than non-L5 spondylolysis.
Topics: Humans; Male; Female; Spondylolysis; Lumbar Vertebrae; Lumbosacral Region
PubMed: 38216892
DOI: 10.1186/s12891-024-07190-x -
International Journal of Spine Surgery Jan 2024As the elderly population grows, the increasing prevalence of osteoporosis presents a unique challenge for surgeons. Decreased bone strength and quality are associated...
BACKGROUND
As the elderly population grows, the increasing prevalence of osteoporosis presents a unique challenge for surgeons. Decreased bone strength and quality are associated with hardware failure and impaired bone healing, which may increase the rate of revision surgery and the development of complications. The purpose of this review is to determine the impact of osteoporosis on postoperative outcomes for patients with cervical degenerative disease or deformity.
METHODS
A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Medical Subject Headings terms involving spine surgery for cervical degenerative disease and osteoporosis were performed. This review focused on radiographic outcomes, as well as surgical and medical complications.
RESULTS
There were 16 studies included in the degenerative group and 9 in the deformity group. Across degenerative studies, lower bone mineral density was associated with increased rates of cage subsidence in osteoporotic patients undergoing operative treatment for cervical degenerative disease. Most studies reported varied results on the relationship between osteoporosis and other outcomes such as revision and readmission rates, costs, and perioperative complications. Our meta-analysis suggests that osteoporotic patients carry a greater risk of reduced fusion rates at 6 months and 1 year postoperatively. With respect to cervical deformity correction, although individual complication rates were unchanged with osteoporosis, the collective risk of incurring any complication may be increased in patients with poor bone stock.
CONCLUSIONS
Overall, the literature suggests that outcomes for osteoporotic patients after cervical spine surgery are multifactorial. Osteoporosis seems to be a significant risk factor for developing cage subsidence and pseudarthrosis postoperatively, whereas reports on medical and hospital-related metrics were inconclusive. Our findings highlight the challenges of caring for osteoporotic patients and underline the need for adequately powered studies to understand how osteoporosis changes the risk index of patients undergoing cervical spine surgery.
CLINICAL RELEVANCE
In patients undergoing cervical spine surgery for degenerative disease, osteoporosis is a significant risk factor for long-term postoperative complications-notably cage subsidence and pseudarthrosis. Given the elective nature of these procedures, interdisciplinary collaboration between providers should be routinely implemented to enable medical optimization of patients prior to cervical spine surgery.
PubMed: 38216297
DOI: 10.14444/8568 -
Cureus Dec 2023Interbody devices (IBDs) have been shown to improve outcomes when used in posterior lumbar fusion (PLF) surgery; however,the exact extent of their clinical benefit...
INTRODUCTION
Interbody devices (IBDs) have been shown to improve outcomes when used in posterior lumbar fusion (PLF) surgery; however,the exact extent of their clinical benefit remains a current topic of interest. Our primary objective in this study was to identify whether the use of an IBD at every level of fusion construct would affect fusion outcomes such as adjacent segment pathology (ASP) and pseudarthrosis after one- to three-level PLF surgery.
METHODS
This was a single-institution retrospective study. We studied the association of factors such as smoking status, BMI, gender, age, and number of IBDs on the development of ASP and pseudarthrosis. To study the effect of independent variables on ASP and pseudoarthrosis, univariate and multivariate regression analyses were used.
RESULTS
The study included 2,061 patients with a history of posterior lumbar fusion who were identified and reviewed. Among these, 363 patients met our inclusion criteria; 247 patients had a minimum follow-up of six months and were finally included in the study. The median follow-up was 30 months. Among the 247 patients, 105 (42.5%) and 24 (9.7%) experienced ASP and pseudarthrosis, respectively. Gender and use of IBD significantly affected the presence of pseudarthrosis (with a higher rate in males and those without any IBDs). Gender, age, BMI, and use of IBDs did not affect ASP. Moreover, using an IBD at each fused level reduced the pseudarthrosis rate significantly compared to when IBDs were not used at all levels (7.3% vs. 27.6%, p <0.001), while there was no significant difference in the rate of ASP (43.6% vs. 34.5%, p = 0.35).
CONCLUSIONS
In patients undergoing one- to three-level PLF surgery, the use of an IBD at all levels of the fusion construct significantly reduces the rate of pseudarthrosis. There was no significant correlation between the rates of ASP. Studies with a larger sample size and a longer follow-up time are suggested to validate our results for pseudoarthrosis and ASP. Our results suggest the use of an IBD per fusion level in short-segment PLF surgeries.
PubMed: 38186530
DOI: 10.7759/cureus.50113