Spinal fusion: A combined anterior and supplementary interspinous technique

Standard, noninstrumented, techniques of anterior interbody fusion are frequently followed by nonunion and collapse of the intervertebral space, probably because of persistent rocking movements, particularly in the sagittal plane. Elimination of these theoretical movements by supplementing an anterior interbody fusion with a posterior interspinous H-graft and a cerclage wire was considered to be biomechanically attractive without having the disadvantages associated with posterior instrumentation. In a prospective study a solid fusion was obtained at 16 of 17 operated levels, with a mediocre (± 50%) fusion as the exception. The height of the intervertebral space was increased at the majority of the fused levels. The technique is only applicable where neural arches are intact. The technique proved to be safe, simple, effective and inexpensive.     

A systematic review with meta-analysis of posterior interbody fusion versus posterolateral fusion in lumbar spondylolisthesis

Purpose

To compare the clinical effectiveness of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) for lumbar spondylolisthesis and to collect scientific evidence for determining which fusion method is better.

Methods

After systematic search, comparative studies were selected according to eligibility criteria. Checklists by Furlan and by Cowley were used to evaluate the risk of bias of the included randomized controlled trials (RCTs) and nonrandomized controlled studies, respectively. Weighed mean differences (WMDs) and risk differences were calculated for common outcomes. The final strength of evidence was expressed as different levels recommended by the GRADE Working Group.

Results

Four RCTs and five comparative observational studies were identified. Moderate-quality evidence indicated that PLIF was more effective than PLF for clinical satisfaction [odds ratios (OR) 0.49, 95 % confidence limits (95 % CI): (0.28, 0.88, P = 0.02)]. Moderate-quality evidence showed that no significant difference was found for the complication rate [OR 2.28, 95 % CI (0.97, 5.35), P = 0.06]. In secondary outcomes, moderate-quality evidence indicated that PLIF improved fusion rate [OR 0.32, 95 % CI (0.17, 0.61), P = 0.0006]. Low-quality evidence showed that PLIF resulted in a lower reoperation rate than PLF [OR 5.30, 95 % CI (1.47, 19.11), P = 0.01]. No statistical difference was found between the two groups with regard to blood loss [WMD = 76.52, 95 % CI (−310.68, 463.73), P = 0.70] and operating time [WMD = −1.20, 95 % CI (−40.36, 37.97), P = 0.95].

Conclusions

Moderate-quality evidence indicates that PLIF can improve the clinical satisfaction and increase the fusion rate compared to PLF. No superiority was found between the two fusion methods in terms of complication rate, amount of blood loss, and operating time for the treatment of lumbar spondylolisthesis.     

The influence of intervertebral disc tissue on anterior spinal interbody fusion: an experimental study on pigs

Intervertebral disc has been shown to be related to low back pain and nerve root injury in pathologic conditions. However, little is known about its influence on spinal fusion. With the development of minimal invasive operations, such as laparoscopic anterior spinal fusion with cages, insufficient discectomy may occur. With its inflammatory properties, the residue nucleus pulposus may have an effect on spinal fusion. In this study, a two-level lumbar spine interbody fusion (L3/4, L5/6) with a Brantigan cage was performed on ten Danish Landrace pigs. Each level was randomly assigned to one of the following methods: (1) implantation of Brantigan cage filled with autogenous iliac crest bone graft, or (2) implantation of Brantigan cage filled with a mixture of autograft and the nucleus pulposus tissue harvested from the disc level in which it was to be inserted. Each level was stabilized with two staples. The pigs were followed for 12 weeks in the same standardized condition. After sacrifice, the lumbar spines were taken out, and plain X-ray, computed tomographic (CT) scanning and histomorphometry were performed to study the fusion mass inside the cages. From plain radiographs, new bone formation could be seen inside and around the cage. CT evaluation showed that the nucleus pulposus level had a 20% (2/10) fusion rate, while the pure autograft level had a 70% (7/10) fusion rate ( P=0.07). The histological fusion rate was even lower in the nucleus pulposus level (10%), and was significantly different from the autograft level (70%, P=0.02). Histomorphometric parameters of new bone formation, bone marrow space and fibrous tissue differed significantly between the two levels ( P=0.04; P=0.02; P=0.04 respectively). We conclude that when nucleus pulposus is mixed with the autogenous bone graft, it can delay or decrease the bone formation inside the cage, thus influencing the final fusion.     

Transforaminal lumbar interbody fusion: a safe technique with satisfactory three to five year results

The unilateral transforaminal approach for lumbar interbody fusion as an alternative to the anterior (ALIF) and traditional posterior lumbar interbody fusion (PLIF) combined with pedicle screw instrumentation is gaining in popularity. At present, a prospective study using a standardized tool for outcome measurement after the transforaminal lumber interbody fusion (TLIF) with a follow-up of at least 3 years is not available in the current literature, although there have been reports on specific complications and cost efficiency. Therefore, a study of TLIF was undertaken. Fifty-two consecutive patients with a minimum follow-up of 3 years were included, with the mean follow-up being 46 months (36–64). The indications were 22 isthmic spondylolistheses and 30 degenerative disorders of the lumbar spine. Thirty-nine cases were one-level, 11 cases were two-level, and two cases were three-level fusions. The pain and disability status was prospectively evaluated by the Oswestry disability index (ODI) and a visual analog scale (VAS). The status of bony fusion was evaluated by an independent radiologist using anterior–posterior and lateral radiographs. The operation time averaged 173 min for one-level and 238 min for multiple-level fusions. Average blood loss was 485 ml for one-level and 560 ml for multiple-level fusions. There were four serious complications registered: a deep infection, a persistent radiculopathy, a symptomatic contralateral disc herniation and a pseudarthrosis with loosening of the implants. Overall, the pain relief in the VAS and the reduction of the ODI was significant (P<0.05) at follow-up. The fusion rate was 89%. At the latest follow-up, significant differences of the ODI were neither found between isthmic spondylolistheses and degenerative diseases, nor between one- and multiple-level fusions. In conclusion, the TLIF technique has comparable results to other interbody fusions, such as the PLIF and ALIF techniques. The potential advantages of the TLIF technique include avoidance of the anterior approach and reduction of the approach related posterior trauma to the spinal canal.     

斜外侧腰椎体间融合术初次术后邻近节段退变

[目的]评价斜外侧腰椎体间融合术(oblique lumbar interbody fusion,0LIF)治疗腰椎融合术后邻近节段退变的临床效果。[方法]回顾性分析2016年12月一2019年12月本院脊柱外科采用0LIF术治疗腰椎融合术后邻近节段退变50例患者的临床资料。[结果]50例患者均顺利完成手术,均未发生严重并发症。所有患者随访12?16个月,平均(13.74±1.63)个月。术后(12.66±3.64)周患者恢复完全负重活动。随访期间,患者术后疼痛逐步减缓,功能逐步改善。与术前相比较,末次随访时VAS和0DI评分均显著下降(P<0.05)。影像方面,与术前相比,末次随访时患者的腰椎前凸角(LL)显著增加(P<0.05),而侧凸Cobb角显著减少(P<0.05)。至末次随访时,50例患者再次手术椎间隙均达到骨性融合,椎间融合器无移位、下沉。[结论]采用0LIF治疗腰椎融合术后邻近节段退变具有较好的安全性和有效性。     

应用椎间融合器治疗下腰疾患的临床研究

目的总结应用椎间融合器结合或不结合附加内固定方法治疗下腰椎疾患的效果。方法对 12 6例下腰椎疾患的患者进行手术治疗 ,单纯应用椎间融合器 6例 ,椎间融合器加内固定 12 0例。结果全部患者均安全完成手术 ,未出现神经系统并发症 ,平均随访 39.7个月 (2 4～ 6 0个月 ) ,2年以上随访临床疗效优良率均在 90 %以上。结论采用椎间融合器结合或不结合附加内固定方法 ,可在充分减压的前提下 ,保持脊柱的稳定性 ,同时完成植骨融合 ,长期随访临床效果肯定。     

PLF与PLIF治疗峡部裂性腰椎滑脱的疗效比较

目的对比研究后外侧融合(posterolateral fusion,PLF)与后路椎间融合(posterior lumbar interbody fusion,PLIF)治疗Ⅰ～Ⅱ度峡部裂性腰椎滑脱的疗效。方法76例采取植骨融合附加椎弓根内固定的手术方法,33例采用后外侧融合,其余采用椎间融合,比较两种植骨方式术后植骨融合率和临床症状改善情况。结果临床优良率分别为81．82％和88．37％,两者无显著性差异(P>0．05);骨融合率分别为75．76％和90．7％,两者有显著性差异(P<0．05)。结论后外侧融合与椎间融合治疗Ⅰ～Ⅱ度峡部裂性腰椎滑脱的疗效相似,无明显差别。     

斜向单枚BAK植入后路腰椎椎体间融合术的生物力学及临床研究

目的 :对作者设计的单枚融合器后斜向植入后路腰椎椎体间融合术行生物力学评价及临床观察。方法 :生物力学研究 :12个小牛脊柱运动节段分为 2组 ,每组 6个。实验组行单侧小关节突、半椎板切除术 ,经侧后方斜向植入加长BAK融合器 1枚 ;对照组行常规后路双侧小关节突、全椎板切除术 ,后前向植入双枚融合器。分别测试两组的纵向压缩、屈曲、侧方弯曲、伸展及双向扭转刚度并进行比较。临床研究 :经后路斜向植入单枚融合器行腰椎椎体间融合术共 40例 ,平均随访 18个月 ,进行临床评价。结果 :生物力学研究显示实验组的垂直压缩刚度、左侧 (融合器植入侧 )弯曲刚度、双侧扭转刚度均较双枚融合器组增大 (P <0 0 5 )。临床随访结果显示 ,患者症状缓解率为 92 % ,术后 1年融合率 88% ,主观满意率 90 % ,所有患者均无融合器的移位。结论 :经侧后方斜向植入单枚融合器的腰椎椎体间融合术 ,能满足后路椎体间融合的生物力学要求 ,有损伤小、脊柱后柱稳定性好、可同时行椎管减压等优点 ,可以较理想地取代后路双枚融合器植入的腰椎椎体间融合术     

下腰椎后外侧融合的解剖学研究和临床应用

目的 :提高下腰椎后外侧植骨融合的成功率。方法 :测量分析L4～S1后外侧植骨区域 ,找出主要植骨床 ,应用椎弓根钉内固定系统后对主要植骨床的影响。临床应用 16例 ,观察其治疗结果。结果L4植骨床面积 :( 612 .0 0±89.0 0 )mm2 ;L5植骨床面积 :( 72 5 .0 0± 91.0 0 )mm2 ;S1植骨床面积 :( 4 67.0 0± 83 .0 0 )mm2 。主要植骨床面积 (上关节突至副突之间 ) ,L4:( 5 2 6.0 0± 3 4.0 0 )mm2 ,占总面积的 86% ;L5:( 5 3 7.0 0± 41.0 0 )mm2 ,占总面积的 74%。用Steffee钢板后占据植骨床面积的 65 %。临床应用 16例 ,随访平均 15个月 ( 8～ 3 0个月 ) ,疗效优良率 93 .7% ,植骨融合率 10 0 %。结论 :将大块骨植入上关节突—副突之间的主要植骨区 ,加用椎弓根钉系统内固定 ,有效地利用了后外侧有限的植骨床 ,保证了植骨材料与植骨床的紧密接触 ,促进了下腰椎后外侧植骨融合率的提高。     

Posterolateral fusion (PLF) versus transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis: a systematic review and meta-analysis

Background Context

Lumbar fusion is an effective and durable treatment for symptomatic lumbar spondylolisthesis; however, the current literature provides insufficient evidence to recommend an optimal surgical fusion strategy.

扩张型椎间融合器治疗腰椎不稳定的临床观察

[目的]通过对腰椎不稳定患者使用扩张型椎间融合器治疗的临床观察，探讨其在腰椎不稳定中的治疗效果、适应证和注意事项。[方法]对42例患者均采用后路椎管减压，椎间盘组织切除，扩张型椎间融合器植入椎间融合，观察治疗效果。[结果]术后经6个月～6年随访，JOA评分优良率为95％，椎间隙高度恢复率、复位率、骨愈合率均达98．6％。[结论]正确选择手术适应证，注意术中技术操作，扩张型椎间融合器治疗腰椎不稳定可有效恢复椎间隙高度，提高骨愈合率。对Ⅰ-Ⅱ度腰椎滑脱可有效复位，保持腰椎稳定，改善临床症状，是一种治疗腰椎不稳定的理想方法。     

Selective fusion for adolescent idiopathic scoliosis: a review of current operative strategy

Selective fusion of thoracic and thoracolumbar/lumbar curves in adolescent idiopathic scoliosis is a concept critically debated in the literature. While some surgeons strongly believe that a more rigid and straighter spine provides predictably excellent outcomes, some surgeons recommend a mobile and less straight spine. This topic is a crucial part of surgical treatment of idiopathic scoliosis, particularly in young patients who will deal with the stress of the fusion mass at the proximal and distal junctions over many years. This study will review the literature on various aspects of selective fusion.     

Sagittal range of motion after extensive cervical fusion

Background contextComplicated cervical spine revision and deformity correction surgeries are becoming increasingly common. These challenging operations often necessitate fusion of the entire cervical spine. Patients frequently express concern over the likely loss of range of motion (ROM) of the neck postoperatively. However, we are aware of no study that specifically examines the sagittal cervical ROM after extensive cervical fusion.PurposeTo characterize sagittal ROM after extensive cervical fusion.Study designRetrospective case series.Patient sampleThirty patients were included.Outcome measuresRadiographs at final follow-up were measured for cervical ROM by the occipitocervical and cervicosternal angles with the neck in full flexion and extension.MethodsThe surgical and medical records at one tertiary referral academic institution were used to identify adults who had undergone extensive cervical fusion between 1996 and 2008. An “extensive cervical fusion” entailed an upper instrumented vertebra proximal to C3 and lower instrumented vertebra distal to C7. Radiographs at final follow-up were measured for cervical ROM by the occipitocervical and cervicosternal angles with the neck in full flexion and extension.ResultsThe average age at surgery was 58.3±10.0 years. The surgical levels were occiput–T1 (one patient), occiput–T4 (one patient), occiput–T6 (one patient), C1–T1 (one patient), C1–T2 (one patient), C2–T1 (nine patients), C2–T2 (eight patients), C2–T3 (six patients), and C2–T4 (two patients). Twenty-seven of the procedures were revisions. The other surgical indications were chin-on-chest deformity (one patient), cervical scoliosis (one patient), and multilevel cervical myelopathy (one patient). The mean follow-up period was 34.5±30.9 months (range, 6–154 months). The mean cervical ROM values by the occipitocervical and cervicosternal angles were 29.5±11.0° and 7.5±5.0°, respectively. The mean total cervical ROM value was 34.1±14.7°.ConclusionsA substantial degree of sagittal ROM can be maintained after extensive surgical fusion of the cervical spine.     

Labial fusion causing urinary incontinence in a postmenopausal female: a case report

Urinary incontinence is not described in the literature as the presenting symptom of labial fusion. This report discusses a 72-year-old postmenopausal woman who presented with complaints of urinary incontinence and was diagnosed to have complete labial fusion. Following failure of conservative treatment with topical estrogen cream a surgical separation of the fusion was performed. The surgical therapy alleviated all incontinence symptoms.     

Methods of evaluating lumbar and cervical fusion

Introduced in 1911, spinal fusion is now widely used to stabilize the cervical, thoracic, and lumbar spine. Despite advancements in surgical techniques, including the use of instrumentation and optimizing bone graft options, pseudarthrosis remains one of the most significant causes of clinical failure following attempted fusion. Diagnosis of this common complication is based on a focused clinical assessment and imaging studies. Pseudarthrosis classically presents with the onset of or return of axial or radicular symptoms during the first postoperative year. However, this diagnosis is complicated because other diagnoses can mimic these symptoms (such as infection or adjacent segment degeneration) and because many cases of pseudarthrosis are asymptomatic. Computed tomography and assessment of motion on flexion/extension radiographs are the two preferred imaging modalities for establishing the diagnosis of pseudarthrosis. The purpose of this article was to review the current status of imaging and clinical practices for assessing fusion following spinal arthrodesis.