Effect of posterolateral fusion on thoracolumbar burs fractures

OBJECTIVE: To evaluate the efficacy and significance of posterolateral fusion in preventing failure of short-segment stabilization for the treatment of thoracolumbar burst fractures. METHODS: Sixty patients with thoracolumbar burst fractures were included in the study. The patients were classified into two groups (n equal to 30 in each group). In Group A, patients were treated in our hospital with short-segment instrumentation via posterolateral fusion with iliac bone. In Group B, patients were treated in other hospital with short-segment fixation without fusion. All cases came to our hospital for reexamination. There were 18 males and 12 females in Group A with a mean age of 42.3 years (range, 24 to 52 years) and 16 males and 14 females in Group B with a mean age of 41.5 years (range, 19 to 54 years). Radiographic (Cobb angle, kyphosis of the vertebral body, and sagittal index) and clinical outcomes (Low Back Outcome Score ) were analyzed after an average follow-up of 16 months. RESULTS: After operation, Cobb angle was reduced from 19.3 degrees to 3.1 degrees in Group A and from 19.1 degrees to 3.3 degrees in Group B (P>0.05). It was 5.9 degrees in Group A and 11. 9 degrees in Group B at the final follow-up (P<0.01). Its average loss of correction was 2.8 degree in Group A and 8.6 degrees in Group B. Average kyphosis of the vertebral body was reduced from 21.3 degrees to 6.2 degrees in Group A and from 21.7 degrees to 7.4 degrees in Group B (P>0.05). It was decreased to 7.9 degrees in Group A and 13.5 degrees in Group B at the final follow-up (P<0.01). Its average loss of correction was 1.7 degrees in Group A and 6.1 degrees in Group B. Sagittal index was reduced from 21.3 degrees to 3.6 degrees in Group A and from 20.5 degrees to 3.8 degrees in Group B (P<0.05). It was decreased to 5.1 degrees in Group A and 9.8 degrees in Group B at the final follow-up (P<0.01). Its average loss was 1.5 degrees in Group A and 6.0 degrees in Group B. In Group A, 73.3% of patients had an excellent result based on Low Back Outcome Score system, while that in Group B was only 43.3%. CONCLUSIONS: Posterolateral fusion is an effective measure to prevent implant failure, and decrease loss of correction, posttraumatic kyphosis and neurological deficit during the treatment of thoracolumbar burst fractures. Short-segment fixation of thoracolumbar burst fractures without fusion obviously increases failure rate and it is not an optional procedure.     

Documentation of outcomes for sacroiliac joint fusion: does prior spinal fusion influence the outcome?

Purpose

The purpose of this prospective case series (level II) was to determine the clinical outcomes of anterior SIJ fusion, comparing the outcomes of patients who had prior spinal fusions at any level compared to patients who have not.

Methods

This prospective study included 25 patients who underwent SIJ fusion with anterior plate fixation. All patients had failed non-operative treatment, had a positive Patrick test, and positive response to intra-articular SIJ injections with greater than 50 % pain relief. Patients had follow-up at 3, 6, 9 and 12 months where they completed Oswestry disability index (ODI) and Short Musculoskeletal Functional Assessment (SMFA) surveys. Outcome data are available for 19 patients who completed pre-operative and 12-month follow-up surveys. Their average time of the final follow-up was 1.1 years (range 10–33 months).

Results

Significant improvements between pre-operative and the final follow-up in ODI (p = 0.007) and SMFA (p = 0.01) were observed; the ODI assessed outcomes in patients who had previous spinal fusion surgery were significantly worse than those that did not at the final follow-up (p = 0.04).

Conclusion

Patients who have not undergone prior spinal fusion surgery, regardless of age, gender, and BMI have better outcomes following anterior SIJ fusion.     

Is the use of minimally invasive fusion technologies associated with improved outcomes after elective interbody lumbar fusion? Analysis of a nationwide prospective patient-reported outcomes registry

Background Context

Over the last decade, clinical investigators and biomedical industry groups have used significant resources to develop advanced technologies that enable less invasive spine fusions. These minimally invasive surgery (MIS) technologies often require increased expenditures by hospitals and payers. Although several small single center studies have suggested MIS technologies decrease surgical morbidity and reduce hospital stay, evidence documenting benefit from a patient perspective remains limited. Furthermore, MIS outcomes have yet to be evaluated from the perspective of multiple practice types representing the broad spectrum of US spine surgery.

Which procedure is better for lumbar interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody fusion?

Introduction

Both anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) surgeries are performed to obtain a solid fusion to treat lumbar spondylosis. This systematic review investigated whether surgical complications, nonfusion rate, radiographic outcome, and clinical outcome of ALIF were significantly different from those of TLIF.

Method

A computerized search of the electronic databases MEDLINE was conducted. Only therapeutic studies with a prospective or retrospective comparative design were considered for inclusion in the present investigation. Two reviewers independently extracted relevant data from each included study. Statistical comparisons were made when appropriate.

Results

Nine studies were determined to be appropriate for the systematic review, and all studies were retrospective comparative studies. Blood loss and operative time in ALIF was greater than in TLIF. There was no significant difference in the complication rate between ALIF and TLIF. The restoration of disc height, segmental lordosis, and whole lumbar lordosis in ALIF was superior to TLIF. However, clinical outcomes in ALIF were similar with TLIF, and there was no significant difference in nonfusion rate between the two techniques. Costs of ALIF were greater than those of TLIF.

Conclusion

Clinical outcomes and nonfusion rate in ALIF were similar to TLIF. However, the restoration of disc height, segmental lordosis, and whole lumbar lordosis in ALIF were superior to those in TLIF, while blood loss, operative time, and costs in ALIF were greater than in TLIF.     

Clinical and radiological outcome of anterior–posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients

Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups. This work is dedicated to the memory of Grace and Julia Hanson.     

Spontaneous wrist fusion: an unusual complication of Kienböck's disease

We report a case of spontaneous wrist fusion occurring in a patient with magnetic resonance image (MRI)-proven stage 1 Kienb?ck's disease. The purpose of this case report is to make hand surgeons aware of this potential finding and to alert hand surgeons and radiologists that diffuse MRI changes of the lunate may not necessarily be pathognomonic for Kienb?ck's disease.     

Cervical adjacent segment pathology following fusion: Is it due to fusion?

Adjacent segment pathology affects 25% of patients within ten years of anterior cervical diskectomy and fusion (ACDF). Laboratory studies demonstrate fused segments increase adjacent level stress including elevated intradiscal pressure and increased range of motion. Radiographic adjacent segment pathology (RASP) has been associated to ACDF in multiple statistically significant studies. Randomized controlled trials (RCTs) comparing anterior cervical discectomy and arthroplasty (ACDA) and ACDF have confirmed ACDF accelerates RASP. The question of greatest clinical interest is whether ACDA, artificial disc surgery, results in fewer adjacent level surgeries than ACDF. Current RCT follow up results reveal only non statistically significant trends favoring ACDA yet the post operative periods are only two to four years. Statistically significant increased RASP in ACDF patients however is already documented. The RCT patients’ average ages are in the mid forties with an expected longevity of up to forty more years. Early statistically significant increased RASP in the ACDF patients supports our prediction that given sufficient follow up of ten or more years, fusion will lead to statistically significant higher rate of adjacent level surgery compared to artificial disc surgery.     

Local secretion of IL-12 augments the therapeutic impact of dendritic cell–tumor cell fusion vaccination

Background

The development of dendritic cell (DC)–tumor fusion vaccines is a promising approach in cancer immunotherapy. Using fusion vaccines allows a broad spectrum of known and unidentified tumor-associated antigens to be presented in the context of MHC class I and class II molecules, with potent co-stimulation provided by the DCs. Although DC–tumor fusion cells are immunogenic, murine studies have shown that effective immunotherapy requires a third signal, which can be provided by exogenous interleukin 12 (IL-12). Unfortunately, systemic administration of IL-12 induces severe toxicity in cancer patients, potentially precluding clinical use of this cytokine to augment fusion vaccine efficacy. To overcome this limitation, we developed a novel approach in which DC–tumor fusion cells locally secrete IL-12, then evaluated the effectiveness of this approach in a murine B16 melanoma model.

Materials and methods

Tumor cells were stably transduced to secrete murine IL-12p70. These tumor cells were then electrofused to DC to form DC–tumor heterokaryons. These cells were used to treat established B16 pulmonary metastases. Enumeration of these metastases was performed and compared between experimental groups using Wilcoxon rank sum test. Interferon γ enzyme-linked immunosorbent spot assay was performed on splenocytes from treated mice.

Results

We show that vaccination with DCs fused to syngeneic melanoma cells that stably express murine IL-12p70 significantly reduces counts of established lung metastases in treated animals when compared with DC–tumor alone (P = 0.029). Interferon γ enzyme-linked immunosorbent spot assays suggest that this antitumor response is mediated by CD4⁺ T cells, in the absence of a tumor-specific CD8⁺ T cell response, and that the concomitant induction of antitumor CD4⁺ and CD8⁺ T cell responses required exogenous IL-12.

Conclusions

This study is, to the best of our knowledge, the first report that investigates the impact of local secretion of IL-12 on antitumor immunity induced by a DC–tumor fusion cell vaccine in a melanoma model and may aid the rational design of future clinical trials.     

Anatomical segmentectomy of the head of the pancreas along the embryological fusion plane: a feasible procedure?

BACKGROUND: Less extensive resection of the head of the pancreas has been the procedure of choice recently for low-grade malignant neoplasms. The anatomical detail of the head of the pancreas is currently insufficient for segmental resection along the embryological fusion plane. METHODS: The anatomy of the head of the pancreas was analyzed in 31 consecutive autopsy specimens. An anterior (n = 10) or posterior (n = 10) segmentectomy of the head of each pancreas was performed along the macroscopically found fusion plane. The pancreatic arteries, the portal vein, the bile duct, and the pancreatic duct were visualized by injecting 3 silicon dyes of different colors. Another 11 specimens were examined by pancreatography before and after anterior (n = 5) or posterior (n = 6) segmentectomy. Eight of these 11 specimens were stained immunohistochemically to reveal the distribution of pancreatic polypeptide cells after segmentectomy. RESULTS: The cleavage between the anterior and posterior segments was discovered at the anterior inferior edge or at the posterior superior edge of the head of the pancreas. Anterior segmentectomy was accomplished while preserving the anterior and posterior pancreaticoduodenal arcades and the lower bile duct in the posterior segment. Posterior segmentectomy involved the removal of the lower bile duct and the posterior pancreaticoduodenal arcades. Pancreatography after segmentectomy showed the division of the ducts of Wirsung and Santorini with the peripheral branches. The immunohistochemical boundary of pancreatic polypeptide cells coincided with the surgical plane. These results showed the anterior and posterior segments were originated from the embryologically dorsal and ventral primordia, respectively. CONCLUSIONS: The current anterior or posterior segmentectomy of the head of the pancreas corresponded to the resection of the embryologically dorsal or ventral primordium, respectively. Anterior segmentectomy of the head of the pancreas might be a clinically applicable procedure; however, posterior segmentectomy involving the resection of the lower bile duct may be impractical.