Treatment of osteoporotic late collapse of a vertebral body of thoracic and lumbar spine

Although osteoporotic late collapse of a vertebral body is a common infirmity of old age, it has not been well studied, and no consensus regarding treatment of this condition has been reached. Forty-five patients with osteoporotic late collapse of a vertebral body were classified into six types based on the appearance on the lateral projection of a radiograph and the presence or absence of neurologic symptoms and were evaluated on imaging and clinical outcome. We concluded that the treatment of osteoporotic late collapse of a vertebral body can be individualized based on several factors such as the presentation of the fracture and neurologic condition. Conservative treatment can be selected in patients without neurologic involvement who have the concave type with anterior spur or sclerotic change or flat type with uniform compression of collapse. If the patients in those types of collapse show neurologic involvement, decompression and reconstruction through a posterior approach, including an eggshell procedure and the short segment pedicle screw system, are more suitable. Anterior decompression with anterior strut bone graft and anterior spinal instrumentation should be done for wedged type of collapse regardless of neurologic status.     

退变性腰椎侧凸后路长节段固定融合术后近端交界性后凸的危险因素分析

目的:探讨退变性腰椎侧凸(degenerative lumbar scoliosis,DLS)后路长节段固定融合术后发生近端交界性后凸(proximal junctional kyphosis,PJK)的危险因素。方法:回顾性分析2009年4月~2014年5月于我院行长节段(≥5个椎体)固定融合手术、年龄≥45岁、随访时间≥2年的DLS患者共60例。将随访时出现PJK的患者纳入PJK组,其余患者纳入对照组。用单变量分析比较两组患者个体资料、手术资料和影像学参数间的差异,找出潜在的危险因素,然后用Logistic回归分析确定独立危险因素。个体资料包括性别、年龄、体重指数(BMI)、骨密度(BMD)和T-值。手术资料包括固定融合椎体数、最上端固定椎(UIV)位置、最下端固定椎(UIV)位置、截骨操作和椎间融合。影像学参数包括侧凸Cobb角、胸椎后凸角(TK)、胸腰段后凸角(TLK)、腰椎前凸角(LL)、骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS)、总矢状位序列(GSA)、矢状位平衡(SVA)和交界区后凸角(PJA1为UIV+1上终板与UIV下终板的夹角;PJA_2为UIV+2上终板与UIV下终板的夹角)等。结果:研究共纳入DLS患者60例,年龄63.2±6.4岁(45~74岁),术前Cobb角28.51°±10.94°(10.7°~55.1°),手术平均固定融合节段6.7±1.3个(5~9个)。随访40.3±11.1个月(24~59个月),末次随访时11例患者发生PJK(PJK组),49例患者未发生PJK(对照组),PJK发生率为18.3%。与对照组相比,PJK组有更多的BMD0.850g/cm2例数(100.0%vs 36.1%,P=0.005);更多的UIV位于T11-L1例数(100.0%vs 69.4%,P=0.030);更多的术前PJA19°例数(45.5%vs 10.2%,P=0.013)、术前TLK≥15°例数(63.6%vs 22.4%,P=0.012)、术前SS25°例数(90.9%vs 46.9%,P=0.016)、术后即刻PJA_2≥5°例数(100.0%vs 46.9%,P=0.001)和术后即刻PJA_2增长≥3°例数(90.9%vs 46.9%,P=0.016)。Logistic回归分析示术前PJA_19°(OR=19.432,P=0.017)、术前SS25°(OR=23.131,P=0.022)和术后即刻PJA_2增长≥3°(OR=22.382,P=0.025)为发生PJK的独立危险因素。结论:术前PJA_19°、术前SS25°和术后即刻PJA2增大≥3°是发生PJK的独立危险因素,BMD0.850g/cm~2、UIV位于T11-L1、术前TLK≥15°和术后即刻PJA_2≥5°是发生PJK的潜在危险因素。     

Transforaminal interbody fusion versus anterior-posterior interbody fusion of the lumbar spine: a financial analysis

Lumbar interbody fusion can be performed anteriorly or posteriorly. An anterior approach generally requires an access surgeon and often is combined with a posterior fusion. A traditional posterior interbody fusion can destabilize the spinal motion segment and requires neural retraction. A new surgical technique, a transforaminal lumbar interbody fusion (TLIF), was recently described. It requires minimal neural retraction, and the disk space is exposed posterolaterally with removal of only one facet joint. This study compares the cost of an anterior-posterior one-level lumbar fusion with the cost of the same procedure performed using the TLIF technique. Table 1 lists the specific demographics. A retrospective review of the hospital charges of 80 patients undergoing interbody lumbar stabilization was conducted. The two groups consisted of 40 patients with an anterior-posterior fusion and 40 patients who were fused circumferentially using the TLIF technique. A cost analysis with normalization of 1998 dollars between the two groups was performed. The TLIF group had an average operative time of 213 minutes, compared with 269 minutes for the anterior-posterior group. In addition, an average additional 38 minutes were required to turn the patient from the anterior or posterior position. The average blood loss for the anterior-posterior procedure was 969 mL, compared with 489 mL for the TLIF group. Twenty-three of the anterior-posterior patients received an average of 2.2 units of blood and six of the TLIF patients received an average of 1.3 units. Use of the surgical intensive care unit was much lower in the TLIF group (38 of 40 patients versus 2 of 40 patients). The average length of stay was 6.1 days for the anterior-posterior group compared with an average of 3.3 days for the TLIF group. The average cost of the anterior-posterior patients was $49,085, compared with $33,784 for the TLIF group. Cost analysis between the two groups show the TLIF patients had an average savings of approximately $15,000 per admission. This cost comparison was conducted only for the time of the operative procedure. No attempt was made to analyze rates of fusion between the two groups or ultimate clinic outcome. There were no major complications in either group, and no patient returned to surgery for a lumbar spinal problem at the authors' hospital within 1 year of the index procedure.     

Surgical treatment for osteoporotic thoracolumbar vertebral collapse using vertebroplasty with posterior spinal fusion: a prospective multicenter study

Purpose

The study aimed to investigate the clinical outcomes and limitations after vertebroplasty with posterior spinal fusion (VP+PSF) without neural decompression for osteoporotic vertebral collapse.

Methods

We conducted a prospective multicenter study including 45 patients (12 men and 33 women, mean age: 77.0 years) evaluated between 2008 and 2012. Operation time, blood loss, visual analog scale (VAS) of back pain, neurological status, kyphosis angle in the fused area, and vertebral union of the collapsed vertebra were evaluated.

Results

The mean operation time was 162 min and blood loss was 381 mL. The postoperative VAS score significantly improved, and the neurological status improved in 35 patients (83 %), and none of the remaining patients demonstrated a deteriorating neurological status at two years post-operatively. The mean kyphosis angle pre-operatively, immediately post-operatively, and two years post-operatively was 23.8°, 10.7°, and 24.3°, respectively, and there was no significant difference between the angles pre-operatively and two years post-operatively. The extensive correction of kyphosis >16° was a risk factor for a higher correction loss and subsequent fracture. Union of the collapsed vertebra was observed in 43 patients (95 %) at two years post-operatively.

Conclusions

The present study suggests that spinal stabilization rather than neural decompression is essential to treat OVC. Short-segment VP+PSF can achieve a high union rate of collapsed vertebra and provide a significant improvement in back pain or neurological status with less invasive surgery, but has a limit of kyphosis correction more than 16°.

     

Results of fusion and instrumentation of thoracic and lumbar vertebral fractures in children: a prospective ten-year study

Background

Researches on the results of surgical treatment of thoracolumbar spine fractures are infrequent. The aim of this study was to determine midterm outcomes of surgical treatment of these fractures in a prospective survey.

Methods

A case series study on pediatric patients with the diagnosis of thoracic and/or lumbar vertebral fractures was conducted over a ten-year period. Surgically treated patients were evaluated in the follow-up period, based on back pain, independent function, neurological status, and radiographic indices.

Results

There were 102 pediatric individuals, 61 boys and 41 girls, aged 3–17 years (mean 12 years of age) with thoracic and/or lumbar spinal fractures. Motor vehicle accident was the most common mechanism of injury (45.0 %). L1 was the most frequent level of fractured vertebra (24.4 %), and pelvic fracture was the most common associated orthopedic injury (21.5 %). Totally, 20 patients underwent surgery, but only fifteen (14 boys and one girl) participated in follow-up (mean 49 months; range 12–81 months). Posterior spinal fusion and instrumentation was accomplished in 12 cases. Three patients were operated by anterior approach and fusion followed by posterior fusion and instrumentation because of delay in diagnosis. There were no major perioperative complications. Two cauda equina syndromes and two incomplete spinal cord injuries improved back to normal. Five cases (33.3 %) reported occasional back pain, and all patients were functionally independent. Radiographic indices improved significantly.

Conclusions

Spinal fusion and instrumentation in pediatric patients with unstable thoracolumbar vertebral fractures with or without spinal cord injuries have favorable radiographic and functional outcomes.     

The effect of prophylactic vertebroplasty on the incidence of proximal junctional kyphosis and proximal junctional failure following posterior spinal fusion in adult spinal deformity: a 5-year follow-up study

Background Context

The incidence of proximal junctional kyphosis (PJK) ranges from 5% to 46% following adult spinal deformity surgery. Approximately 66% to 76% of PJK occurs within 3 months of surgery. A subset of these patients, reportedly 26% to 47%, develop proximal junctional failure (PJF) within 6 months postoperatively. To date, there are no studies evaluating the impact of prophylactic vertebroplasty on PJK and PJF incidence at long-term follow-up.

Adult thoracolumbar and lumbar scoliosis treated with long vertebral fusion to the sacropelvis: a comparison between new hybrid selective spinal fusion versus anterior-posterior spinal instrumentation

Background contextCombined anteroposterior spinal fusion with instrumentation has been used for many years to treat adult thoracolumbar/lumbar scoliosis. This surgery remains a technical challenge to spine surgeons, and current literature reports high complication rates.PurposeThe purpose of this study is to validate a new hybrid technique (a combination of single-rod anterior instrumentation and a shorter posterior instrumentation to the sacrum) to treat adult thoracolumbar/lumbar scoliosis.Study designThis study is a retrospective consecutive case series of surgically treated patients with adult lumbar or thoracolumbar scoliosis.Patient sampleThis is a retrospective study of 33 matched pairs of patients with adult scoliosis who underwent two different surgical procedures: a new hybrid technique versus a third-generation anteroposterior spinal fusion.Outcome measuresPreoperative and postoperative outcome measures include self-report measures, physiological measures, and functional measures.MethodsIn a retrospective case-control study, 33 patients treated with the hybrid technique were matched with 33 patients treated with traditional anteroposterior fusion based on preoperative radiographic parameters. Mean follow-up in the hybrid group was 5.3 years (range, 2–11 years), compared with 4.6 years (range, 2–10 years) in the control group. Operating room (OR) time, estimated blood loss, and levels fused were collected as surrogates for surgical morbidity. Radiographic parameters were collected preoperatively, postoperatively, and at final follow-up. The Scoliosis Research Society Patient Questionnaire (SRS-22r) and Oswestry Disability Index (ODI) scores were collected for clinical outcomes.ResultsOperating room time, EBL, and levels fused were significantly less in the hybrid group compared with the control group (p<.0001). The postoperative thoracic Cobb angle was similar between the hybrid and control techniques (p=.24); however, the hybrid technique showed significant improvement in the thoracolumbar/lumbar curves (p=.004) and the lumbosacral fractional curve (p<.0001). The major complication rate was less in the hybrid group compared with the control group (18% vs. 39%, p=.01). Clinical outcomes at final follow-up were not significantly different based on overall SRS-22r scores and ODI scores.ConclusionThe new hybrid technique demonstrates good long-term results, with less morbidity and fewer complications than traditional anteroposterior surgery select patients with thoracolumbar/lumbar scoliosis. This study received no funding. No potential conflict of interest-associated bias existed.     

Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors.

No previous study has compared the complications between anterior/posterior and transforaminal interbody fusions. We performed a retrospective analysis of 164 patients to compare the complications and associated predictive factors of the two techniques of circumferential lumbar fusion. Fifty-three had same-day anterior/posterior fusion (group 1), and 111 had transforaminal interbody fusion (group 2). Mean operating time (p < 0.0001) and hospital stay (p < 0.0001) was significantly longer for group 1 patients. Average blood loss was greater for group 1 patients (p < 0.01). Higher complication rates were found in group 1 patients (p < 0.004). Wound infection occurred more frequently in patients with adjunctive treatment (p < 0.04). Hospital stay was an independent predictor of complications in both groups. In group 1, body mass index was independently associated with complications. In group 2, both hospital stay and adjunctive treatment were predictive of complications. Transforaminal lumbar interbody fusion is the preferred technique because it is associated with shorter operating time, less blood loss, shorter hospital stay, and lower incidence of complications.     

保留椎体后壁的椎体次全切除术治疗多节段颈椎病的前瞻性研究

目的 报告一种改良椎体次全切除术术式,并与传统的椎体次全切除术比较。方法2003年3月—2005年1月,84例多节段颈椎病患者随机行保留椎体后壁的椎体次全切除术（PWCF）和经典的椎体次全切除术（ACF）各42例,比较两组手术时间、出血量、住院时间、住院费用、并发症、术后JOA评分、植骨融合率、节段高度、颈椎曲度等多项指标。结果两种术式术后短期JOA评分无明显差异。PWCF组较ACF组手术时间短、出血量少。术后3个月两组植骨融合率均为100％。颈椎曲度和节段高度两组无差异。结论PWCF是一种切实有效的颈椎前路减压植骨融合术式,具有简便、风险小和植骨融合率高的优点。     

椎板间撑开椎管潜行扩大减压治疗腰椎侧隐窝狭窄三联症

目的 :探讨椎板间撑开腰椎管潜行扩大减压的手术方法。方法 :对 79例腰椎管狭窄三联症行椎板间撑开突出椎间盘髓核摘除、椎管潜行扩大减压。结果 :依据临床症状 ,随访 6个月～ 4年 ,疗效 :优 68例 (93 75 % ) ,良 4例 (5 47% ) ,差 1例 (0 78% )。结论 :椎板间撑开潜行扩大椎管、摘除突出椎间盘髓核治疗腰椎侧隐窝狭窄三联症 ,操作简便 ,疗效好 ,并发症少 ,能最大限度的保持脊柱的稳定性。