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1.
George M. Ghobrial Daniel G. Eichberg John Paul G. Kolcun Karthik Madhavan Nathan H. Lebwohl Barth A. Green Joseph P. Gjolaj 《The spine journal》2017,17(10):1499-1505
Background Context
Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are common problems after long-segment (>5 levels) thoracolumbar instrumented fusions in the treatment of adult spinal deformity (ASD). No specific surgical strategy has definitively been shown to lower the risk of PJK as the result of a multifactorial etiology.Purpose
The study aimed to assess the incidence of PJK and PJF in patients treated with prophylactic polymethylmethacrylate (PMMA) cement augmentation at the uppermost instrumented vertebrae (UIV) and rostral adjacent vertebrae (UIV+1).Study Design/Setting
This is a retrospective cohort-matched surgical case series at an academic institutional setting.Patient Sample
Eighty-five adult patients over a 16-year enrollment period were identified with long-segment (>5 levels) posterior thoracolumbar instrumented fusions for ASD.Outcome Measures
Primary outcomes measures were PJK magnitude and PJF formation. Secondary outcomes measures were spinopelvic parameters, as well as global and regional sagittal alignment.Methods
The impact of adjunctive PMMA use in long-segment (≥5 levels) fusion for ASD was assessed in adult patients aged 18 and older. Patients were included with at least one of the following: lumbar scoliosis >20°, pelvic tilt >25°, sagittal vertical axis >5?cm, central sacral vertical line >2?cm, and thoracic kyphosis >60°. The frequency of PJF and the magnitude of PJK were measured radiographically preoperatively, postoperatively, and at maximum follow-up in controls (Group A) and PMMA at the UIV and UIV+1 (Group B).Results
Eighty-five patients (64±11.1 years) with ASD were identified: 47 control patients (58±10.6) and 38 patients (71±6.8) treated with PMMA at the UIV and UIV+1. The mean follow-up was 27.9 and 24.2 months in Groups A and B, respectively (p=.10). Preoperative radiographic parameters were not significantly different, except the pelvic tilt which was greater in Group A (26.6° vs. 31.4°, p=.03). Postoperatively, the lumbopelvic mismatch was greater in Group B (14.6° vs. 7.9°, p=.037), whereas the magnitude of PJK was greater in controls (9.36° vs. 5.65°, p=.023). The incidence of PJK was 36% (n=17) and 23.7% (n=9) in Groups A and B, respectively (p=.020). The odds ratio of PJK with vertebroplasty was 0.548 (95% confidence interval=0.211 to 1.424). Proximal junctional kyphosis was observed in 6 (12.8%) controls only (p=.031). The UIV+1 angle, a measure of PJK, was significantly greater in controls (10.0° vs. 6.8°, p=.02). No difference in blood loss was observed. No complications were attributed to PMMA use.Conclusions
The use of prophylactic vertebral cement augmentation at the UIV and rostral adjacent vertebral segment at the time of deformity correction appears to be preventative in the development of proximal junctional kyphosis and failure. 相似文献2.
Sanghyun Han Seung-Jae Hyun Ki-Jeong Kim Tae-Ahn Jahng Subum Lee Seung-Chul Rhim 《The spine journal》2017,17(7):962-968
Background Context
Little is known about the effect of rod stiffness as a risk factor of proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery.Purpose
The aim of this study was to compare radiographic outcomes after the use of cobalt chrome multiple-rod constructs (CoCr MRCs) and titanium alloy two-rod constructs (Ti TRCs) for ASD surgery with a minimum 1-year follow-up.Study Design
Retrospective case-control study in two institutes.Patient Sample
We included 54 patients who underwent ASD surgery with fusion to the sacrum in two academic institutes between 2002 and 2015.Outcome Measures
Radiographic outcomes were measured on the standing lateral radiographs before surgery, 1 month postoperatively, and at ultimate follow-up. The outcome measures were composed of pre- and postoperative sagittal vertical axis (SVA), pre- and postoperative lumbar lordosis (LL), pre- and postoperative thoracic kyphosis (TK)+LL+pelvic incidence (PI), pre- and postoperative PI minus LL, level of uppermost instrumented vertebra (UIV), evaluation of fusion after surgery, the presence of PJK, and the occurrence of rod fracture.Materials and Methods
We reviewed the medical records of 54 patients who underwent ASD surgery. Of these, 20 patients had CoCr MRC and 34 patients had Ti TRC. Baseline data and radiographic measurements were compared between the two groups. The Mann-Whitney U test, the chi-square test, and the Fisher exact test were used to compare outcomes between the groups.Results
The patients of the groups were similar in terms of age, gender, diagnosis, number of three-column osteotomy, levels fused, bone mineral density, preoperative TK, pre- and postoperative TK+LL+PI, SVA difference, LL change, pre- and postoperative PI minus LL, and location of UIV (upper or lower thoracic level). However, there were significant differences in the occurrence of PJK and rod breakage (PJK: CoCr MRC: 12 [60%] vs. Ti TRC: 9 [26.5%], p=.015; occurrence of rod breakage: CoCr MRC: 0 [0%] vs. Ti TRC: 11 [32.4%], p=.004). The time of PJK was less than 12 months after surgery in the CoCr MRC group. However, 55.5% (5/9) of PJK developed over 12 months after surgery in the Ti TRC group.Conclusions
Increasing the rod stiffness by the use of cobalt chrome rod and can prevent rod breakage but adversely affects the occurrence and the time of PJK. 相似文献3.
Bryce A. Basques William D. Long Nicholas S. Golinvaux Daniel D. Bohl Andre M. Samuel Adam M. Lukasiewicz Matthew L. Webb Jonathan N. Grauer 《The spine journal》2017,17(6):784-789
Background Context
Multiple methods are used to measure proximal junctional angle (PJA) and diagnose proximal junctional kyphosis (PJK) after fusion for adolescent idiopathic scoliosis (AIS); however, there is no gold standard. Previous studies using the three most common measurement methods, upper-instrumented vertebra (UIV)+1, UIV+2, and UIV to T2, have minimized the difficulty in obtaining these measurements, and often exclude patients for which measurements cannot be recorded.Purpose
The purpose of this study is to assess the technical feasibility of measuring PJA and PJK in a series of AIS patients who have undergone posterior instrumented fusion and to assess the variability in results depending on the measurement technique used.Study Design/Setting
A retrospective cohort study was carried out.Patient Sample
There were 460 radiographs from 98 patients with AIS who underwent posterior spinal fusion at a single institution from 2006 through 2012.Outcome Measures
The outcomes for this study were the ability to obtain a PJA measurement for each method, the ability to diagnose PJK, and the inter- and intra-rater reliability of these measurements.Methods
Proximal junctional angle was determined by measuring the sagittal Cobb angle on preoperative and postoperative lateral upright films using the three most common methods (UIV+1, UIV+2, and UIV to T2). The ability to obtain a PJA measurement, the ability to assess PJK, and the total number of patients with a PJK diagnosis were tabulated for each method based on established definitions. Intra- and inter-rater reliability of each measurement method was assessed using intra-class correlation coefficients (ICCs).Results
A total of 460 radiographs from 98 patients were evaluated. The average number of radiographs per patient was 5.3±1.7 (mean±standard deviation), with an average follow-up of 2.1 years (780±562 days). A PJA measurement was only readable on 13%–18% of preoperative filmsand 31%–49% of postoperative films (range based on measurement technique). Only 12%–31% of films were able to be assessed for PJK based on established definitions. The rate of PJK diagnosis ranged from 1% to 29%. Of these diagnoses, 21%–100% disappeared on at least one subsequent film for the given patient. ICC ranges for intra-rater and inter-rater reliability were 0.730–0.799 and 0.794–0.836, respectively.Conclusions
This study suggests significant limitations of the three most common methods of measuring and diagnosing PJK. The results of studies using these methods can be significantly affected based on the exclusion of patients for whom measurements cannot be made and choice of measurement technique. 相似文献4.
Tobias Lange Werner Schmoelz Georg Gosheger Martin Eichinger Christian H. Heinrichs Albert Schulze Boevingloh Tobias L. Schulte 《The spine journal》2017,17(8):1148-1155
Background Context
Proximal junctional kyphosis (PJK) is a challenging complication after rigid posterior instrumentation (RI) of the spine. Several risk factors have been described in literature so far, including the rigidity of the cranial aspect of the implant.Purpose
The aim of this biomechanical study was to compare different proximal implants designed to gradually reduce the stiffness between the instrumented and non-instrumented spine.Study Design/Setting
This is a biomechanical study.Methods
Eight calf lumbar spines (L2–L6) underwent RI with a titanium pedicle screw rod construct at L4–L6. The proximal transition segment (L3–L4) was instrumented stepwise with different supplementary implants—spinal bands (SB), cerclage wires (CW), hybrid rods (HR), hinged pedicle screws (HPS), or lamina hooks (LH)—and compared with an all-pedicle screw construct (APS). The flexibility of each segment (L2–L6) was tested with pure moments of ±10.0?Nm in the native state and for each implant at L3–L4, and the segmental range of motion (ROM) was evaluated.Results
On flexion and extension, the native uninstrumented L3–L4 segment showed a mean ROM of 7.3°. The CW reduced the mean ROM to 42.5%, SB to 41.1%, HR to 13.7%, HPS to 12.3%, LH to 6.8%, and APS to 12.3%. On lateral bending, the native segment L3–L4 showed a mean ROM of 15°. The CW reduced the mean ROM to 58.0%, SB to 78.0%, HR to 6.7%, HPS to 6.7%, LH to 10.0%, and APS to 3.3%. On axial rotation, the uninstrumented L3–L4 segment showed a mean ROM of 2.7°. The CW reduced the mean ROM to 55.6%, SB to 77.8%, HR to 55.6%, HPS to 55.6%, LH to 29.6%, and APS to 37.0%.Conclusions
Using CW or SB at the proximal transition segment of a long RI reduced rigidity by about 60% in relation to flexion and extension in that segment, whereas the other implants tested had a high degree of rigidity comparable with APS. Clinical randomized controlled trials are needed to elucidate whether this strategy might be effective for preventing PJK. 相似文献5.
Hwee Weng Dennis Hey Kimberly-Anne Tan Christabel Shao-En Neo Eugene Tze-Chun Lau Denise Ai-Wen Choong Leok-Lim Lau Gabriel Ka-Po Liu Hee-Kit Wong 《The spine journal》2017,17(5):615-621
Background Context
Adult spinal deformity correction sometimes involves long posterior pedicle screw constructs extending from the lumbosacral spine to the thoracic vertebra. As fusion obliterates motion and places supraphysiological stress on adjacent spinal segments, it is crucial to ascertain the ideal upper instrumented vertebra (UIV) to minimize risk of proximal junctional failure (PJF). The T10 vertebra is often chosen to allow bridging of the thoracolumbar junction into the immobile thoracic vertebrae on the basis that it is the lowest immobile thoracic vertebra strut by the rib cage.Purpose
This study aimed to characterize the range of motion (ROM) of each vertebral segment from T7 to S1 to determine if T10 is truly the lowest immobile thoracic vertebra.Study Design/Setting
This is a prospective, comparative study.Patient Sample
Seventy-nine adults (mean age of 45.4 years) presenting with low back pain or lower limb radiculopathy or both, without previous spinal intervention, metastases, fractures, infection, or congenital deformities of the spine, were included in the study.Outcome Measures
A ROM >5° across two vertebral segments as determined by the Cobb method from radiographs.Methods
Lumbar flexion-extension and neutral erect radiographs were obtained in randomized order using a slot scanner. Segmental ROM was measured from T7–T8 to L5–S1 and analyzed for significant differences using t tests. Age, gender, radiographical indices such as standard spinopelvic parameters, sagittal vertical axis (SVA), C7–T12 SVA, T1 slope, thoracic kyphosis (TK), and lumbar lordosis (LL) were studied via multivariate analysis to identify predictive factors for >5° change in ROM at the various segmental levels. There were no sources of funding and no conflicts of interest associated with this study.Results
In the thoracolumbar spine, significant decreases in ROM when compared with the adjacent caudad segment occurs up to T9–T10, with mean total ROM of 1.98±1.47° (p<.001) seen in T9–T10, 2.19±1.67° (p<.001) in T10–T11, and 3.92±3.21°(p<.001) in T11–T12. The total ROM of T8–T9 (2.53±1.79°) was not significantly different from that of T9–T10 (p=.261). At the thoracolumbar junction, absence of scoliosis (OR 11.37, p=.020), high pelvic incidence (OR 1.14, p=.046), and low T1 slope (OR 1.45, p=.030) were predictive of ROM >5°.Conclusions
Lumbar spine flexion-extension ROM decreases as it approaches the thoracolumbar junction. T10 is indeed the lowest immobile thoracic vertebra strut by the rib cage, and the last significant decrease in ROM is observed at T9–T10, in relation to T10–T11. However, because this also implies that a UIV of T10 would mean there is only one level of fixation above the relatively mobile segment, while respecting other factors that influence UIV selection, we propose the T9 vertebra as a more ideal UIV to fulfill the biomechanical concept of bridge fixation. However, this decision should still be taken on a case-by-case basis. 相似文献6.
Hwee Weng Dennis Hey Alex Quok An Teo Kimberly-Anne Tan Li Wen Nathaniel Ng Leok-Lim Lau Ka-Po Gabriel Liu Hee-Kit Wong 《The spine journal》2017,17(6):799-806
Background Context
The current prevailing school of thought in spinal deformity surgery is to restore sagittal balance with reference to the alignment of the spine when the patient is standing. This strategy, however, likely accounts for increased rates of proximal junctional failure.Purpose
The purpose of this study was to investigate the differences between the spine in standing and sitting positions as these may elucidate reasons for deformity correction failure.Study Design/Setting
A prospective, comparative study of 58 healthy patients presenting to a tertiary hospital over a 6-month period was carried out.Patient Sample
All patients presenting with a less than 3-month history of first episode lower back pain were included. Patients who had radicular symptoms, red flag symptoms, previous spine surgery, or visible spinal deformity during forward bending test were excluded. Pregnant patients were also excluded.Outcome Measures
Radiographic measurements including sagittal vertical axis (SVA), lumbar lordosis (LL), thoracolumbar angle (TL), thoracic kyphosis (TK), cervical lordosis (CL), pelvic incidence (PI), and pelvic tilt (PT) were collected. The sagittal apex and end vertebrae of all radiographs were also recorded.Methods
Basic demographic data (age, gender, and ethnicity) was recorded. Lateral standing and sitting radiographs were obtained using EOS technology. Statistical analysis was performed to compare standing and sitting parameters using chi-square tests for categorical variables and paired t tests for continuous variables.Results
Taking the standing position as the reference point, forward displacement of the SVA occurred during sitting by a mean of 6.39±3.87?cm (p<.001). This was accompanied by a reduction of LL and TK by a mean of 24.63±12.70° (p<.001) and 8.56±7.21°(p<.001), respectively. The TL became more lordotic by a mean of 3.25±7.30° (p<.001). The CL only reached borderline significance (p=.047) for increased lordosis by a mean of 3.45±12.92°. The PT also increased by 50% (p<.001). Despite relatively constant end vertebrae, the apex vertebra moved inferiorly for the thoracic curve (p<.006) and superiorly for the lumbar curve (p<.001) by approximately one vertebral level each.Conclusions
Sagittal spinal alignment changes significantly between standing and sitting positions. Understanding these differences is crucial to avoid overcorrection of LL, which may occur if deformity correction is based solely on the spine's standing sagittal profile. 相似文献7.
George M. Ghobrial Nathan H. Lebwohl Barth A. Green Joseph P. Gjolaj 《The spine journal》2017,17(11):1594-1600
Background Context
Prior reports have compared posterior column osteotomies with pedicle subtraction osteotomies in terms of utility for correcting fixed sagittal imbalance in adolescent patients with deformity. No prior reports have described the use of multilevel Smith-Petersen Osteotomies (SPOs) alone for surgical correction in the adult spinal deformity (ASD) population.Purpose
The study aimed to determine the utility of multilevel SPOs in the management of global sagittal imbalance in ASD patients.Study Design/Setting
This is a retrospective observational study at a single academic center.Patient Sample
The sample included 85 ASD patients.Outcome Measures
This is a radiographic outcomes cohort study.Methods
The radiographs of 85 ASD patients were retrospectively evaluated before and after long-segment (>5 spinal levels) fusion and multilevel SPO (≥3 levels) for sagittal imbalance correction. The number of osteotomies, correction in regional lumbar lordosis (LL), and correction per osteotomy was evaluated. Independent predictors of correction per SPO were evaluated with a hierarchical linear regression analysis.Results
Eighty-five patients (mean age: 67.5±11 years) were identified with ASD (372 SPOs). The mean preoperative sagittal vertical axis (SVA) and T1 pelvic angle (TPA) were 8.16±6.75?cm and 25°±13.23°, respectively. The mean postoperative central sacral vertical line (CSVL) and SVA were 0.67±0.70?cm and 1.29±5.41?cm, respectively. The mean improvement in SVA was 6.29?cm achieved with a correction of approximately 5.05° per SPO. The mean LL restoration was 20.3°±13.9°, and 33(39%) patients achieved a final pelvic incidence minus lumbar lordosis (PI-LL) ≤10°. Fifty-four (64%) achieved a postoperative PI-LL ≤15°, 75 (88%) with a PI-LL ≤20°, and 85 (100%) achieved a PI-LL ≤25°. Correction per SPO was similar regardless of prior fusion (4.87° vs. 5.72° for revisions, p=.192). In a subgroup analysis of SVA greater than 10?cm, there was no significant difference in the final LL, thoracic kyphosis, PI-LL, SVA, CSVL, and TPA, as compared with SVA <10?cm. The LL was the only independent predictor of osteotomy correction per level (LL: β coefficient=?0.108, confidence interval: ?0.141 to 0.071, p<.0001).Conclusions
Multilevel SPOs are feasible for restoration of LL as well as sagittal and coronal alignment in the ASD population with or without prior instrumented fusion. 相似文献8.
Hiroyuki Aono Keisuke Ishii Hidekazu Tobimatsu Yukitaka Nagamoto Shota Takenaka Masayuki Furuya Horii Chiaki Motoki Iwasaki 《The spine journal》2017,17(8):1113-1119
Background Context
Short-segment posterior spinal instrumentation for thoracolumbar burst fracture provides superior correction of kyphosis by an indirect reduction technique, but it has a high failure rate.Purpose
The purpose of the study we report here was to compare outcomes for temporary short-segment pedicle screw fixation with vertebroplasty and for such fixation without vertebroplasty.Study Design
This is a prospective multicenter comparative study.Patient Sample
We studied 62 consecutive patients with thoracolumbar burst fracture who underwent short-segment posterior instrumentation using ligamentotaxis with Schanz screws with or without vertebroplasty.Outcome Measures
Radiological parameters (Cobb angle on standing lateral radiographs) were used.Methods
Implants were removed approximately 1 year after surgery. Neurologic function, kyphotic deformity, canal compromise, and fracture severity were evaluated prospectively.Results
After surgery, all patients with neurologic deficit had improvement equivalent to at least one grade on the American Spinal Injury Association impairment scale and had fracture union. Kyphotic deformity was reduced significantly, and reduction of the vertebrae was maintained with and without vertebroplasty, regardless of load-sharing classification. Although no patient required additional anterior reconstruction, kyphotic change was observed at disc level mainly after implant removal with or without vertebroplasty.Conclusions
Temporary short-segment fixation yielded satisfactory results in the reduction and maintenance of fractured vertebrae with or without vertebroplasty. Kyphosis recurrence may be inevitable because adjacent discs can be injured during the original trauma. 相似文献9.
Peter G. Passias Gregory W. Poorman Cyrus M. Jalai Breton Line Bassel Diebo Paul Park Robert Hart Douglas Burton Frank Schwab Virginie Lafage Shay Bess Thomas Errico 《The spine journal》2017,17(8):1091-1099
Background Context
Adult spinal deformity (ASD) represents a constellation of complex malalignments affecting the spinal column. Corrective surgical procedures aimed at improving ASD can be equally challenging, and commonly require multiple index procedures and potential revisions before definitive management. There is a paucity of data comparing the outcomes of same-day(simultaneous [SIM]) and 2-day (staged [STA]) procedures for long spinal fusions for ASD. Using a large patient cohort with surgeon- and patient-reported outcomes will be particularly useful in determining the utility and effect of staging long spinal fusions for ASD.Purpose
This study aimed to compare intraoperative, perioperative, and 2-year outcomes of STA and SIM procedures correcting ASD.Study Design
This is a retrospective analysis of a prospective multicenter database.Patient Sample
A total of 142 patients (71 STA, 71 SIM) were included.Outcome Measures
Primary outcome measures were intra- and perioperative (6 weeks) complication rates. Secondary outcome measures were 2-year thoracolumbar and spinopelvic radiographic parameters, 2-year health-related quality of life (HRQoL) changes (Oswestry Disability Index [ODI] and Short Form-36 [SF-36]), and 2-year complication rates.Methods
Inclusion criteria included patients with ASD ≥18 years with 6-week and 2-year follow-up. Propensity score matching identified similar patients undergoing STA or SIM long spinal fusions based on surgical invasiveness, pelvic tilt, and sagittal vertical axis (SVA). Complications, HRQoL scores (Scoliosis Research Society-22 Patient Questionnaire [SRS-22r], SF-36, ODI), and patient characteristics were compared across and within treatment groups at follow-up with analysis of variance (ANOVA) and paired t tests at three surgical stages: intraoperatively, perioperatively (6 weeks), and postoperatively (>6 weeks).Results
A total of 142 patients were included (71 STA, 71 SIM). Matching STA and SIM groups based on degree of deformity and surgical invasiveness created two groups similar in overall correction of the surgery. Patients undergoing STA underwent more anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) procedures, whereas patients undergoing SIM had longer fusions. Charlson comorbidity index and revision status were similar between groups (p>.05). Staging procedures had significantly more complications causing reoperation (STA: 47% vs. SIM: 8%, p=.021), and had a greater number of perioperative complications requiring a return to the operating room (OR) (STA: 9.9% vs. SIM: 1.4%, p=.029). There was no difference in intraoperative complications, mortality, or perioperative infection or wound complications (p>.05) between the two procedures. At 2-year follow-up, incidence of revision surgery was higher in STA (STA: 21.1% vs. SIM: 8.5%, p=.033).Conclusion
Staged spinal fusions, which add ALIFs and LLIFs to the procedure, compared with similar-correction SIM procedures, result in similar intraoperative complication incidence, but significantly higher rates of peri- and postoperative complications leading to revision. Functional outcomes, radiographic parameters, and mortality were similar. This will aid surgeons in their determination of the optimal treatment for such complex procedures. 相似文献10.
Background Context
Surgical treatment for adult spinal deformity improves patient quality of life; however, trends in surgical utilization in the elderly, who may be at higher risk for complications, remain unclear.Purpose
To identify trends in the utilization of adult deformity and determine complication rates among older patients.Study Design
This is a retrospective database analysis.Patient Sample
The Nationwide Inpatient Sample database was queried from 2004 to 2011 to identify adult patients who underwent spinal fusion of eight or more levels using International Classification of Diseases, Ninth Revision (ICD-9) coding.Outcome Measures
Incidence of surgery, complication rates, length of stay, and total hospital charges.Methods
The incidence of surgery was normalized to United States census data by age group. Trends in complications, length of stay, and inflation-adjusted hospital charges were determined using linear regression and Cochran-Armitage trend testing.Results
An estimated 29,237 patients underwent adult spinal deformity surgery with an increase from 2,137 to 5,030 cases per year from 2004 to 2011. Surgical incidence among patients 60 years and older increased from 1.9 to 6.5 cases per 100,000 people from 2004 to 2011 (p<.001), whereas utilization in patients younger than 60 increased from 0.59 to 0.93. Linear regression revealed that the largest increase in surgical utilization was for patients aged 65–69 years with an increase of 0.68 patients per 100,000 people per year (p<.001), followed by patients aged 70–74 years with a rate of 0.56 patients per 100,000 people per year (p=.001). Overall complication rates were 22.5% in 2004 and 26.7% in 2011. Although complication risk increased with age (≥60 vs. <60: relative risk 1.91 [1.83, 1.99], p<.001), within-age group rates were stable over time. Mean length of stay was 9.6 days in 2004 and 9.0 days in 2011. Inflation-adjusted mean hospital charges increased from $171,517 in 2004 to $303,479 in 2011 (p<.001).Conclusions
Operative management of adult spinal deformity increased 3.4-fold among patients ≥60 years from 2004 to 2011, with an associated 1.8-fold increase in hospital charges. Although the exact reasons for the striking increase in hospital charges remain unclear, some of the increase is likely related to decreasing reimbursement of charges by payors over the same period of time. The large majority of cases were performed in large academic centers, and growth in deformity trained spine specialists in these centers may have contributed to this trend. Despite the increased utilization of surgery for adult spinal deformity, in-hospital complications remained stable across all ages. 相似文献11.
Background Context
Acute fixed cervical kyphosis may be a rare presentation of conversion disorder, psychogenic dystonia, and potentially as a side effect from typical antipsychotic drugs. Haldol has been associated with acute dystonic reactions. In some cases, rigid deformities ensue. We are reporting a case of a fixed cervical kyphosis after the use of Haldol.Purpose
To present a case of a potential acute dystonic reaction temporally associated with Haldol ingestion leading to fixed cervical kyphosis.Study design
This is a case report.Methods
A patient diagnosed with bipolar disorder presented to the emergency room several times with severe neck pain and stiffness. The neck appeared fixed in flexion with extensive osteophyte formation over a 3-month period.Results
The patient's condition was resolved by a posterior-anterior-posterior surgical approach. It corrected the patient's cervical curvature from 88° to 5°.Conclusions
Acute dystonic reactions have the potential to apply enough pressure on bone to cause rapid osteophyte formation. 相似文献12.
Shujie Wang Yang Yang Jianguo Zhang Ye Tian Jianxiong Shen Shengru Wang 《The spine journal》2017,17(1):76-80
Background Context
Intraoperative monitoring (IOM) is an essential method for preventing postoperative spinal deficits during posterior vertebral column resection (VCR) surgery for treatment of severe spine deformities, but the IOM features directing at VCR procedures are rarely reported and need to be further clarified.Purpose
To evaluate an important surgical point that will lead to the IOM loss frequently, and then remind the surgeons to pay close attention to impending monitoring changes during posterior VCR surgery.Study Design/Setting
Retrospective study.Patient Sample
A total of 77 patients with severe spine deformities who underwent posterior VCR and deformity correction surgeries from January 2012 to May 2015 are retrospectively analyzed in our spine center.Outcome Measures
IOM (motor-evoked potentials [MEP] and somatosensory-evoked potentials) was used for intraoperative spinal function assessment.Methods
Patients were divided into 2 groups according to their preoperative spinal function, including 27 patients with preoperative spinal deficits and 50 patients with spinal normal. And the IOM data during surgery, especially among VCR procedures, were mainly analyzed in the present study.Results
With the VCR procedure almost complete, most patients showed varying degrees of IOM loss that included 37 cases showing obvious IOM degenerations and 21 cases showing significant IOM loss with alerts immediately. Moreover, the patients with preoperative spinal deficits have more significant decreasing percentage in MEP amplitude (81% vs. 68%, p<.05) than those patients without.Conclusions
With the VCR procedure almost complete, surgeons must pay closely attention to the IOM signals and should be ready to take corresponding surgical measures to deal with the impeding monitoring loss. 相似文献13.
Mitsuru Yagi Hideaki Ohne Tsunehiko Konomi Kanehiro Fujiyoshi Shinjiro Kaneko Masakazu Takemitsu Masafumi Machida Yoshiyuki Yato Takashi Asazuma 《The spine journal》2017,17(3):409-417
Background Context
Gait patterns and their relationship to demographic and radiographic data in patients with adult spinal deformity (ASD) have not been fully documented.Purpose
This study aimed to assess gait pattern in patients with ASD and the effect of corrective spinal surgery on gait.Design/Setting
This is a prospective case series.Patient Sample
The gait patterns of 33 consecutive women with ASD (age 67.1 years; body mass index [BMI] 22.5±2.5?kg/m2, Cobb angle 46.8±18.2°, coronal vertical axis [CVA] 1.5±3.7?cm, C7 sagittal vertical axis [SVA] 9.1±6.4?cm, pelvic incidence minus lumbar lordosis [PI?LL] 38.2±22.1°, and lean volume of the lower leg, 5.5±0.6?kg) before and after corrective surgery were compared with those of 33 age- and gender-matched healthy volunteers.Outcome Measures
Scoliosis Research Society Patient Questionnaire (SRS22r), Oswestry Disability Index (ODI), and forceplate analysis.Methods
All subjects underwent gait analysis on a custom-built forceplate using optical markers placed on all joints and spinal processes. Dual X-ray absorptiometry scores were used to calculate the lean composition of the lower legs. Subjects with ASD were followed for at least 2 years post operation.Results
Preop mean values showed that patients with ASD had a significantly worse gait velocity (54±10?m/min vs. 70.7±12.9?m/min, p<.01) and stride (97.8±13.4?cm vs. 115.3±15.1?cm, p<.01), but no difference was observed in the stance-to-swing ratio. The right and left ground reaction force vectors were also discordant in the ASD group (vertical direction; r=0.84 vs. r=.97, p=.01). The hip range of motion (ROM) was also significantly decreased in ASD. Correlation coefficient showed moderate correlations between the preoperative gait velocity and the gravity line (GL), PI, ROM of the lower extremity joints, and lean volume, and between the stride and the lean volume, GL, and PI?LL. Gait pattern, stride, and velocity all improved significantly in the patients with ASD after surgery, but were still not as good as in healthy volunteers. The SRS22r satisfaction domain correlated moderately with postoperative gait velocity (r=0.34).Conclusions
The patients with ASD had an asymmetric gait pattern and impaired gait ability compared with healthy volunteers. Gait ability correlated significantly with the GL, spinopelvic alignment, lower extremity joint ROM, and lean volume. The surgical correction of spinopelvic alignment and exercises to build muscle strength may improve the gait pattern and ability in patients with ASD. 相似文献14.
Background Context
Short-term readmission rates are becoming widely used as a quality and performance metric for hospitals. Data on unplanned short-term readmission after spine fusion for deformity in pediatric patients are limited.Purpose
To characterize the rate and risk factors for short-term readmission after spine fusion for deformity in pediatric patients.Study Design
This is a retrospective cohort study.Patient Sample
Data were obtained from the State Inpatient Database from New York, Utah, Nebraska, Florida, North Carolina (years 2006–2010), and California (years 2006–2011).Outcome Measures
Outcome measures included 30- and 90-day readmission rates.Materials and Methods
Inclusion criteria were patients aged 0–21 years, a primary diagnosis of spine deformity, and a primary 3+-level lumbar or thoracic fusion. Exclusion criteria included revision surgery at index admission and cervical fusion. Readmission rates were calculated and logistic analyses were used to identify independent predictors of readmission.Results
There were a total of 13,287 patients with a median age of 14 years. Sixty-seven percent were girls. The overall 30- and 90-day readmission rates were 4.7% and 6.1%. The most common reasons for readmission were infection (38% at 30 days and 33% at 90 days), wound dehiscence (19% and 17%), and pulmonary complications (12% and 13%). On multivariate analysis, predictors of 30-day readmission included male sex (p=.008), neuromuscular (p<.0001) or congenital scoliosis (p=.006), Scheuermann kyphosis (p=.003), Medicaid insurance (p<.0001), length of stay of ≤3 days or ≥6 days (p<.0001), and surgery at a teaching hospital (p=.011). Surgery at a hospital performing >80 operations/year was associated with a 34% reduced risk of 30-day readmission (95% confidence interval 12%-50%, p=.005) compared with hospitals performing <20 operations/year.Conclusions
The short-term readmission rate for pediatric spine deformity surgery is driven by patient-related factors, as well as several risk factors that may be modified to reduce this rate. 相似文献15.
Hwee Weng Dennis Hey Cheung-Kue Kim Won-Gyu Lee Hyung-Suk Juh Ki-Tack Kim 《The spine journal》2017,17(12):1837-1845
Background Context
The aim of spinal deformity correction is to restore the spine's functional alignment by balancing it in both the sagittal and coronal planes. Regardless of posture, the ideal coronal profile is straight, and therefore readily assessable.Purpose
This study compares two radiological methods to determine which better predicts postoperative standing coronal balance.Study Design/Setting
We conducted a single-center, radiographic comparative study between 2011 and 2015.Patient Sample
A total of 199 patients with a mean age of 55.1 years were studied. Ninety patients with degenerative lumbar scoliosis (DLS) and 109 ankylosing spondylitis (AS) were treated with posterior surgery during this period.Outcome Measures
Baseline clinical and radiographic parameters (sagittal and coronal) were recorded. Comparison was performed between the new supra-acetabular line (central sacral vertical line [CSVL1]) and conventional supra-iliac line (CSVL2) perpendicular methods of coronal balance assessment. These methods were also compared with the gold standard standing C7 plumb line.Methods
Each patient underwent standardized operative procedures and had perioperative spine X-rays obtained for assessment of spinal balance. Adjusted multivariate analysis was used to determine predictors of coronal balance.Results
Significant differences in baseline characteristics (age, gender, and radiographic parameters) were found between patients with DLS and AS. CSVL1, CSVL2, and C7 plumb line differed in all the perioperative measurements. These three radiological methods showed a mean right coronal imbalance for both diagnoses in all pre-, intra-, and postoperative radiographs. The magnitude of imbalance was the greatest for CSVL2 followed by CSVL1 and subsequently the C7 plumb line. A larger discrepancy between CSVL and C7 plumb line measurements intraoperatively than those postoperatively suggests a postural effect on these parameters, which is greater for CSVL2. Multivariate analysis identified that in DLS, the preoperative C7 plumb line was predictive of its postoperative value. CSVL1, but not CSVL2, was predictive of the postoperative C7 plumb line in patients with AS.Conclusions
The supra-acetabular line (CSVL1) is better, although not ideal, as compared with the supra-iliac line (CSVL2) in determining coronal balance. Because CSVL1 still cannot be relied on with a high predictive value, it is imperative that future studies continue to identify better intraoperative markers for achieving coronal balance. 相似文献16.
Louis Boissière Mitsuru Takemoto Anouar Bourghli Jean-Marc Vital Ferran Pellisé Ahmet Alanay Caglar Yilgor Emre Acaroglu Francisco Javier Perez-Grueso Frank Kleinstück Ibrahim Obeid 《The spine journal》2017,17(4):480-488
Background Context:
Many radiological parameters have been reported to correlate with patient's disability including sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI?LL). European literature reports other parameters such as lumbar lordosis index (LLI) and the global tilt (GT). If most parameters correlate with health-related quality of life scores (HRQLs), their impact on disability remains unclear.Purpose
This study aimed to validate these parameters by investigating their correlation with HRQLs. It also aimed to evaluate the relationship between each of these sagittal parameters and HRQLs to fully understand the impact in adult spinal deformity management.Study Design
A retrospective review of a multicenter, prospective database was carried out.Patient Sample
The database inclusion criteria were adults (>18 years old) presenting any of the following radiographic parameters: scoliosis (Cobb ≥20°), SVA ≥5?cm, thoracic kyphosis ≥60° or PT ≥25°. All patients with complete data at baseline were included.Outcome Measures
Health-related quality of life scores, demographic variables (DVs), and radiographic parameters were collected at baseline.Methods
Differences in HRQLs among groups of each DV were assessed with analyses of variance. Correlations between radiographic variables and HRQLs were assessed using the Spearman rank correlation. Multivariate linear regression models were fitted for each of the HRQLs (Oswestry Disability Index [ODI], Scoliosis Research Society-22 subtotal score, or physical component summaries) with sagittal parameters and covariants as independent variables. A p<.05 value was considered statistically significant.Results
Among a total of 755 included patients (mean age, 52.1 years), 431 were non-surgical candidates and 324 were surgical candidates. Global tilt and LLI significantly correlated with HRQLs (r=0.4 and ?0.3, respectively) for univariate analysis. Demographic variables such as age, gender, body mass index, past surgery, and surgical or non-surgical candidate were significant predictors of ODI score. The likelihood ratio tests for the addition of the sagittal parameters showed that SVA, GT, T1 sagittal tilt, PI?LL, and LLI were statistically significant predictors for ODI score even adjusted for covariates. The differences of R2 values from Model 1 were 1.5% at maximum, indicating that the addition of sagittal parameters to the reference model increased only 1.5% of the variance of ODI explained by the models.Conclusion
GT and LLI appear to be independent radiographic parameters impacting ODI variance. If most of the parameters described in the literature are correlated with ODI, the impact of these radiographic parameters is less than 2% of ODI variance, whereas 40% are explained by DVs. The importance of radiographic parameters lies more on their purpose to describe and understand the malalignment mechanisms than their univariate correlation with HRQLs. 相似文献17.
Justin K. Scheer Malla Keefe Virginie Lafage Michael P. Kelly Shay Bess Douglas C. Burton Robert A. Hart Amit Jain Baron S. Lonner Themistocles S. Protopsaltis Richard Hostin Christopher I. Shaffrey Justin S. Smith Frank Schwab Christopher P. Ames 《The spine journal》2017,17(10):1397-1405
Background Context
Current metrics to assess patients' health-related quality of life (HRQOL) may not reflect a true change in the patients' specific perception of what is most important to them.Purpose
This study aimed to describe the initial experience of a Patient Generated Index (PGI) in which patients create their own outcome domains.Study Design
This is a single-center prospective study.Patient Sample
Patients with adult spinal deformity (ASD) comprise the study sample.Outcome Measures
Oswestry Disability Index (ODI), Short Form-36 (SF-36 Physical Component Score [PCS] and Mental Component Score [MCS]), Scoliosis Research Society-22r (SRS-22r), and PGI.Methods
Oswestry Disability Index, SF-36, SRS-22r, and PGI were administered preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 1 and 2 years. PGI correlations with ODI, SF-36, SRS total score, free-text frequency analysis of PGI exact response with text in ODI and SRS-22r questionnaires, and the responsiveness (effect size [ES]) of the HRQOL metrics were analyzed. No funding was used for this study and there are no conflicts of interest.Results
A total of 59 patients with 209 clinical encounters produced 370 PGI written response topics that included affect or emotions, relationships, activities of daily life, personal care, work, and hobbies. Mean preoperative PGI score was 18.6±13.5 (0–71.7 out of 100 [best]), and mean scores significantly improved at every postoperative time point (p<.05). Preoperative PGI scores significantly correlated with preoperative ODI (r=?0.28, p=.03), MCS (r=0.48, p<.01), and SRS total (r=0.57, p<.01). Postoperative PGI scores correlated with all HRQOL measures (p<.0001): ODI (r=?0.65), PCS (r=0.50), MCS (r=0.55), and SRS total (r=0.63). PGI responses exactly matched ODI and SRS-22r text at 47.8% and 35.4%, respectively, and at 63.2% and 58.9%, respectively, for categories. Patient Generated Index ES at a minimum of 1-year follow-up was ?2.39, indicating substantial responsiveness (|ES|>0.8). Effect sizes for ODI, SRS-22r total, SF-36 PCS, and SF-36 MCS were 2.16, ?2.06, ?2.05, and ?0.80, respectively.Conclusions
The PGI is easy to administer and offers additional information about the patients' perspective not captured in standard HRQOL metrics. Patient Generated Index scores correlated with all of the standard HRQOL scores and were more responsive than ODI, SF-36, and SRS-22r, suggesting that the PGI may be a step closer to one HRQOL measure that better encompasses concerns and goals of the individual patients. 相似文献18.
Shujie Wang Jianguo Zhang Ye Tian Jianxiong Shen Yu Zhao Hong Zhao Shugang Li Bin Yu Xisheng Weng 《The spine journal》2017,17(6):777-783
Background Context
Transcranial motor evoked potential (MEP) monitoring has been widely adopted in spine surgery, but so far the useful monitoring data for patients with preoperative spinal deficits (PPSDs) are limited. Originally we thought that they seemed technically more difficult and less reliable in performing the MEP monitoring to PPSDs.Purpose
Our objective was to study (1) the feasibility of MEP monitoring in PPSDs and the (2) the significance of rapid MEP loss.Study Design/Setting
A retrospective case notes study from a prospective patient register was used as the study design.Patient Sample
A total of 332 PPSDs who underwent posterior spine surgery with a reliable MEP monitoring were collected between September 2010 and December 2014.Outcome Measures
Relevant MEP loss was identified as rapid amplitude reduction (more than 80% MEP) associated with high-risk surgical maneuvers or high-risk diagnoses.Method
The muscles with higher strength were used to record the optimal MEP signal. MEP monitoring of these patients was considered to be feasible if reproducible signals had been obtained; moreover, sensitivity, specificity, positive predictive value (PPV), and negative predictive value were computed. The significance of the patients with rapid MEP loss was analyzed.Results
From a total of 332 PPSDs, 27 cases showed significant MEP loss (23 true positive, 4 false positive), and 21 showed new spinal deficits. Invalid MEP baselines were found in 11 paralysis and 6 severely incomplete paraplegia patients, and success rate of reliable MEP was 95.1% in PPSDs. The congenital kyphoscoliosis, tuberculous kyphoscoliosis, and thoracic spinal stenosis are considered high-risk diagnoses to result in MEP loss. The sensitivity of intraoperative MEP monitoring was 100%, the specificity 98.7%, the positive predictive value 85.2%, and the negative predictive value 100%.Conclusions
Intraoperative MEP monitoring is feasible for most of the PPSDs. The rapid MEP loss during high-risk diagnoses and complicated surgical procedures may indicate new spinal deficits. 相似文献19.
Hwee Weng Dennis Hey Chengyuan Gordon Wong Eugene Tze-Chun Lau Kimberly-Anne Tan Leok-Lim Lau Ka-Po Gabriel Liu Hee-Kit Wong 《The spine journal》2017,17(2):183-189
Background Context
Sitting spinal alignment is increasingly recognized as a factor influencing strategy for deformity correction. Considering that most individuals sit for longer hours in a “slumped” rather than in an erect posture, greater understanding of the natural sitting posture is warranted.Purpose
This study aimed to investigate the differences in sagittal spinal alignment between two common sitting postures: a natural, patient-preferred posture; and an erect, investigator-controlled posture that is commonly used in alignment studies.Design/Setting
This is a randomized, prospective study of 28 young, healthy patients seen in a tertiary hospital over a 6-month period.Patient Sample
Twenty-eight patients (24 men, 4 women), with a mean age of 24 years (range 19–38), were recruited for this study. All patients with first episode of lower back pain of less than 3 months' duration were included. The exclusion criteria consisted of previous spinal surgery, radicular symptoms, red flag symptoms, previous spinal trauma, obvious spinal deformity on forward bending test, significant personal or family history of malignancy, and current pregnancy.Outcome Measures
Radiographic measurements included sagittal vertical axis (SVA), lumbar lordosis (LL), thoracolumbar angle (TL), thoracic kyphosis (TK), and cervical lordosis (CL). Standard spinopelvic parameters (pelvic incidence, pelvic tilt [PT], and sacral slope) and sagittal apex and end vertebrae were also measured.Methods
Basic patient demographics (age, gender, ethnicity) were recorded. Lateral sitting whole spine radiographs were obtained using a slot scanner in the imposed erect and the natural sitting posture. Statistical analyses of the radiographical parameters were performed comparing the two sitting postures using chi-squared tests for categorical variables and paired t tests for continuous variables.Results
There was forward SVA shift between the two sitting postures by a mean of 2.9?cm (p<.001). There was a significant increase in CL by a mean of 11.62° (p<.001), and TL kyphosis by a mean of 11.48° (p<.001), as well as a loss of LL by a mean of 21.26° (p<.001). The mean PT increased by 17.68° (p<.001). The entire thoracic and lumbar spine has the tendency to form a single C-shaped curve with the apex moving to L1 (p=.002) vertebra in the majority of patients.Conclusions
In a natural sitting posture, the lumbar spine becomes kyphotic and contributes to a single C-shaped sagittal profile comprising the thoracic and the lumbar spine. This is associated with an increase in CL and PT, as well as a constant SVA. These findings lend insight into the body's natural way of energy conservation using the posterior ligamentous tension band while achieving sitting spinal sagittal balance. It also provides information on one of the possible causes of proximal junctional kyphosis or proximal junctional failure. 相似文献20.
E. Kyung Shin Chi Heon Kim Chun Kee Chung Yunhee Choi Dahae Yim Whei Jung Sung Bae Park Jung Hyeon Moon Won Heo Sung-Mi Kim 《The spine journal》2017,17(2):175-182