Morbidity and radiographic outcomes of severe scoliosis of 90° or more: a comparison of hybrid with total pedicle screw instrumentation

Objectives

Untreated severe scoliosis is associated with increased mortality and remains a significant surgical challenge. Few studies have reported mortality after the surgical treatment of severe scoliosis beyond a 2-year follow-up. The objectives of this study were to evaluate mortality beyond standard 2-year follow-up and compare radiographic outcomes using hybrid or pedicle screw instrumentation for severe scoliosis.

Methods

We evaluated 32 consecutive patients [11 males, mean age at surgery 15.3 (range 10.7–20.7) years] operated for a scoliosis of 90° or more using either hybrid (n = 15) or pedicle screw (n = 17) instrumentation. The follow-up time averaged 2.9 (2.0–6.6) years for radiographic and quality of life measurements and 5.5 years (2.0–9.0) years for mortality data. Of these patients, one had adolescent idiopathic scoliosis, three secondary scoliosis, and 28 neuromuscular scoliosis. Twelve patients in the hybrid and two patients in the pedicle screw groups underwent anteroposterior surgery (p < 0.001), and three patients in both groups had an apical vertebral column resection.

Results

One (3.1 %) patient died during follow-up for severe pneumonia. Preoperatively, the mean magnitude of the major curve was 109° (90°–127°) in the hybrid and 100° (90°–116°) in the pedicle screw groups (p = 0.015), and was corrected to 45° (19°–69°) in the hybrid and 27° (18°–40°) in the pedicle screw groups at the 2-year follow-up (p < 0.001), with a mean correction of the major curve of 59 % (37–81 %) in the hybrid versus 73 % (60–81 %) in the pedicle screw groups, respectively (p = 0.0023). There were six postoperative complications, including one transient spinal cord deficit necessitating reoperation in the hybrid group as compared with five complications in the pedicle screw group (p = 0.53).

Conclusions

The mid-term mortality rate after the surgical treatment of severe scoliosis was low. Severe scoliosis can be treated safely with significantly better correction of the spinal deformity using pedicle screws than hybrid instrumentation.     

X-Ray assessment of the effect of pedicle screw on vertebra and spinal canal growth in children before the age of 7 years

Purpose

To determine the reliability of pedicle screws placed in children younger than 7 years of age, and to evaluate the effect of pedicle screw insertion on further growth of the vertebra and spinal canal.

Methods

A retrospective study of 35 consecutive patients through Jan 2003–Dec 2010 for congenital scoliosis in <7 years children was performed at one spine center. Patients undergoing pedicle screw instrumentation of at least two levels, which had been followed-up for at least 24 months were included. Measurements were performed in instrumented and adjacent non-instrumented levels. The effect of pedicle screw insertion on further growth was evaluated.

Results

The average age at surgery was 4.4 year (53 months, range, 23–84 months). 190 segments in 35 patients met the inclusion criteria. 77 segments had no screws and 113 had at least one screw. There was a significant difference between the pre-operative and final follow-up values of the measurement of spinal canal and vertebral body parameters (P < 0.001). No significant difference existed between growth rates of vertebral bodies and the sagittal diameters of spinal canal with or without screws. The growth rates of vertebral bodies in lumbar spine were higher than in thoracic spine in both instrumented and adjacent groups.

Conclusion

Pedicle screw instrumentation does not cause a retardation effect on the development of vertebral bodies and the spinal canal in children at an early age. It is a safe and reliable procedure to achieve a stable fixation.     

Parameters influencing the outcome after total disc replacement at the lumbosacral junction. Part 2: distraction and posterior translation lead to clinical failure after a mean follow-up of 5 years

Purpose

The aim of the second part of the study was to investigate the influence of parameters that lead to increased facet joint contact or capsule tensile forces (disc height, lordosis, and sagittal misalignment) on the clinical outcome after total disc replacement (TDR) at the lumbosacral junction.

Methods

A total of 40 patients of a prospective cohort study who received TDR because of degenerative disc disease or osteochondrosis L5/S1 were invited to an additional follow-up for clinical (ODI and VAS for overall, back, and leg pain) and radiographic analysis (a change in disc height, lordosis, or sagittal vertebral misalignment compared with the preoperative state). Based on the final ODI, patients were retrospectively distributed into groups N (normal: <25 %) or F (failure ≥25 %) for radiographic parameter comparison. A correlation analysis was performed between the clinical and radiological results.

Results

A total of 34 patients were available at a mean follow-up of 59.5 months. Both groups (N = 24; F = 10 patients) presented a significant improvement in overall pain, back pain, and ODI over time. At the final follow-up, higher clinical scores correlated with a larger disc height, increased lordosis, and posterior translation of the superior vertebra, which was also reflected by significant differences in these parameters in the group comparison.

Conclusions

Parameters associated with increased facet joint capsule tensile forces lead to an inferior clinical outcome at mid-term follow-up. When performing TDR, we therefore suggest avoiding iatrogenic posterior translation and overdistraction (and consecutive lordosis).     

Five-year clinical and radiographic outcomes using pedicle screw only constructs in the treatment of adolescent idiopathic scoliosis

Purpose

To determine the mid-term clinical and radiographic impact of pedicle screw fixation in patients with adolescent idiopathic scoliosis (AIS).

Methods

A multicenter AIS database was retrospectively queried to identify 99 consecutive patients who underwent posterior spinal fusion using an all pedicle screw construct with a minimum of 5-year follow-up. Radiographic and clinical parameters were reviewed at regular intervals up to 5 years.

Results

The mean age was 14.4 ± 2.0 years with 79 % being female. The mean preoperative major curve was 51.7 ± 14.2° with a mean correction of 66 and 64 % at 2 and 5 years (p = 0.16). Pre-op thoracic kyphosis averaged 22.3 ± 12.9° and was 18.4 ± 10.6° at 5 years with no significant change from 2 years (p = 0.33). SRS total and domain scores demonstrated significant improvements at 2 years, which were slightly decreased at 5 years (p = 0.06). SRS scores of self-image (p = 0.99) and satisfaction (p = 0.18) were significantly improved after surgery with minimal change by 5 years. The change in SRS total scores from 2 to 5 years was attributed to differences in SRS scores of pain and mental health (p < 0.05).

Conclusions

Intermediate follow-up of patients with AIS treated with an all pedicle screw construct demonstrates maintenance of their coronal, and sagittal plane correction between 2- and 5-year follow-up. At 5 years, improvements in SRS scores were consistent with 2-year values, except for a decline in pain and mental health scores.     

CT evaluation of upper thoracic spine for surgical application of transarticular screw placement

Introduction

Although pedicle screw fixation has been increasingly used in the upper thoracic spine in recent years, controversies exist about the safety and complications such as nerve or vascular intrusion associated with the technique. In this study, an alternative method of transarticular screw fixation was validated.

Materials and methods

Morphometric analysis was performed on computed tomography (CT) scans of the upper thoracic zygapophysial joints of C7, T1, T2 and T3 in 20 male and 20 female patients in the axial and sagittal planes. The degree of screw angulation was recorded in the sagittal and axial planes and the screw length was measured at the spinal level from C7 to T3.

Results

The smallest medial–lateral diameter and anterior–posterior diameter of IAP was found at T3 in the female patients and C7 in the male patients. The screw trajectory length ranged from 14.9 to 20.5 mm in all patients. All the above measurements were significantly different between male and female patients at all levels (P < 0.05). The mean value of screw trajectory angle was 19.3°–20.1° in the axial plane and 44.3°–45.7° in the sagittal plane. There was no statistically significant difference (P > 0.05) between male and female patients in the axial and sagittal angles.

Conclusion

The morphometric data of C7–T3 zygapophysial joints indicate the suitable screw diameter and screw length for this technique. Transarticular screw fixation proved to be a potentially safe alternative to pedicle screw fixation in this region.     

An anatomic consideration of C2 vertebrae artery groove variation for individual screw implantation in axis

Study design

Retrospective case series.

Objectives

To identify the variation of C2 vertebral artery groove (VAG) based on the thin-slice computed tomography (CT) scan and choose an individual screw placement method to decrease risk of malposition.

Background

C2 pedicle screws can be successful anchors for a variety of cervical disorders. However, variations of VAG may cause malposition and breach when C2 transpedicle screw was inserted. Recognizing the variations of vertebrae artery groove (VAG) in C2 and choosing an individual screw placement method (transpedicle or translaminar) may be helpful for avoiding violation and decreasing the operation risk in upper cervical surgery.

Methods

From January 2009 to December 2010, a total 45 patients with upper cervical disorders underwent 1–mm-thin-slice CT scans along the C2 pedicle direction to obtain the consecutive spectrum of C2 VAG were included in this study. The C2 VAG (types I, II, III, and IV) was subgrouped based on parameter e (the vertical distance from the apex of VAG to the upper facet joint surface) and parameter a (horizontal distance from the entrance of VAG to the vertebrae canal). Subsequently, individual strategy was used to avoid the VAG violation.

Results

The variations of C2 VAG in these 45 patients include the following: type I 53 (58.9 %), type II 16 (17.8 %) type III 13 (14.4 %), and type IV 8 (8.9 %). Transpedicle screws of C2 were used in types I, III, and IV VAGs (n = 74); translaminar screws were inserted in type II subgroup (n = 16). Postoperative CT scans showed that there were two pedicle screws violated into the artery groove, and no translaminar screw breached into the vertebrae canal. All the other screws were in right position. None of the 45 patients had severe complications such as spinal cord injury, dura tear, and infection.

Conclusion

Thin-slice CT scan along the C2 pedicle direction to analysis the variations of C2 VAG can help choose an individual screw placement method (transpedicle or translaminar) with minimal complication for C2 screw fixation.     

Failure modes in conservative and surgical management of infectious spondylodiscitis

Purpose and methods

We reviewed the management, failure modes, and outcomes of 196 patients treated for infectious spondylodiscitis between January 1, 2000 and December 31, 2010, at the Spinal Unit, Aarhus University Hospital, Aarhus, Denmark. Patients with infectious spondylodiscitis at the site of previous spinal instrumentation, spinal metastases, and tuberculous and fungal spondylodiscitis were excluded.

Results

Mean age at the time of treatment was 59 (range 1–89) years. The most frequently isolated microorganism was Staphylococcus aureus. The lumbosacral spine was affected in 64 % of patients and the thoracic in 21 %. In 24 % of patients, there were neurologic compromise, four had the cauda equina syndrome and ten patients were paraplegic. Ninety-one patients were managed conservatively. Treatment failed in 12 cases, 7 patients required re-admission, 3 in-hospital deaths occurred, and 5 patients died during follow-up. Posterior debridement with pedicle screw instrumentation was performed in 75, without instrumentation in 19 cases. Seven patients underwent anterior debridement alone, and in 16 cases, anterior debridement was combined with pedicle screw instrumentation, one of which was a two-stage procedure. Re-operation took place in 12 patients during the same hospitalization and in a further 12 during follow-up. Two in-hospital deaths occurred, and five patients died during follow-up. Patients were followed for 1 year after treatment. Eight (9 %) patients treated conservatively had a mild degree of back pain, and one (1 %) patient presented with mild muscular weakness. Among surgically treated patients, 12 (10 %) had only mild neurological impairment, one foot drop, one cauda equine dysfunction, but 4 were paraplegic. Twenty-seven (23 %) complained of varying degrees of back pain.

Conclusions

Conservative measures are safe and effective for carefully selected patients without spondylodiscitic complications. Failure of conservative therapy requires surgery that can guarantee thorough debridement, decompression, restoration of spinal alignment, and correction of instability. Surgeons should master various techniques to achieve adequate debridement, and pedicle screw instrumentation may safely be used if needed.     

Accuracy of percutaneous pedicle screws for thoracic and lumbar spine fractures: a prospective trial

Purpose

The percutaneous insertion technique requires surgical skill and experience. However, there have been few clinical reports evaluating the accuracy of minimally invasive pedicle screw placement using the conventional fluoroscopy method. The purpose of this study was to evaluate the accuracy of percutaneous pedicle screw placement in the treatment of thoracic and lumbar spine fractures using two-plane conventional fluoroscopy.

Methods

A prospective clinical trial was performed. A total of 502 percutaneous pedicle screws in 111 patients, all inserted with the assistance of conventional fluoroscopy, were evaluated. The safety and accuracy of pedicle screw placement were based on the evaluation of postoperative axial 3-mm slice computed tomography scans using the scoring system described by Zdichavsky et al. [Eur J Trauma 30:234–240, 2004; Eur J Trauma 30:241–247, 2004].

Results

427/502 pedicle screws (85 %) were classified as good and excellent concerning the best possible screw length and 494/502 (98 %) were found to have good or excellent position. One screw had to be revised due to medial position with a neurological deficit.

Conclusions

This study demonstrates the feasibility of placing percutaneous posterior thoracolumbar pedicle screws with the assistance of conventional fluoroscopy. Minimally invasive transpedicular instrumentation is an accurate, reliable and safe method to treat a variety of spinal disorders, including thoracic and lumbar spine fractures.     

Lumbar spine stability after combined application of interspinous fastener and modified posterior lumbar interbody fusion: a biomechanical study

Introduction

Posterior lumbar interbody fusion (PLIF) and internal fixation are commonly performed for the treatment of lower back pain due to lumbar spinal degeneration. We have developed a novel interspinous fixation device, the interspinous fastener (ISF) for potential use in the surgical management of degenerative spinal disease. The aim of this study was to assess the in vitro biomechanical characteristics of calf lumbar spine specimens after ISF fixation with modified PLIF.

Materials and methods

Ten lumbar spine (L3–L6) specimens from ten fresh calf cadavers (8–10 weeks of age) were used. Each specimen underwent sequential testing for each of the following four groups: no instrumentation (INTACT); interspinous fusion device fixation + PLIF (ISF); unilateral pedicle screw and titanium rod fixation + PLIF (UPS); bilateral pedicle screw and titanium rod fixation + PLIF (BPS). Outcome measures included angular range of motion (ROM) during unloaded and loaded (8 Nm) flexion, extension, left bending, right bending, left torsion and right torsion.

Results

For all unloaded and loaded assessments, ROM was significantly higher in the INTACT group compared with all other groups (P < 0.05). Similarly, ROM was significantly higher in the UPS group (indicating decreased stability) compared with the ISF and BPS groups (P < 0.05). The only significant difference between the ISF and BPS groups was in the ROM with unloaded extension (higher in the BPS group, P = 0.006).

Conclusions

We found that ISF fixation with PLIF of the lower lumbar spine provided biomechanical stability that was equivalent to that associated with bilateral pedicle screw/rod fixation with PLIF. The ISF shows potential as an alternative means of fixation in the surgical management of degenerative spinal disease.     

Five-year follow-up of total disc replacement compared to fusion: a randomized controlled trial

Purpose

To evaluate long-term clinical results of lumbar total disc replacement (TDR) compared with posterior lumbar fusion.

Methods

This prospective randomized controlled trial comprised 152 patients; 80 were randomized to TDR and 72 to fusion. All patients had chronic low back pain (CLBP) and had not responded to nonsurgical treatment. Primary outcome measure was global assessment of back pain (GA), secondary outcome measures were back and leg pain, Oswestry Disability Index (ODI), EQ5D, and SF-36. All measures were collected from SweSpine (Swedish national register for spinal surgery) at 1, 2, and 5 years. Follow-up rate at 5 years was 99.3 %.

Results

Both groups showed clinical improvement at 5-year follow-up. For GA, 38 % (30/80) in the TDR group were totally pain free vs. 15 % (11/71) in the fusion group (p < 0.003). Back pain and improvement of back pain were better in the TDR group: VAS back pain at 5 years 23 ± 29 vs. 31 ± 27, p = 0.009, and VAS improvement of back pain at 5 years 40 ± 32 vs. 28 ± 32, p = 0.022. ODI and improvement in ODI were also better in the TDR group: ODI at 5 years 17 ± 19 vs. 23 + 17, p = 0.02 and ODI improvement at 5 years 25 ± 18 vs. 18 ± 19 (p = 0.02). There was no difference in complications and reoperations between the two groups.

Conclusions

Global assessment of low back pain differed between the two surgical groups at all follow-up occasions. Significant differences between groups concerning back pain, pain improvement, and ODI were present at 1 year and disappeared at 2 years, but reappeared at the 5-year follow-up.     

Dose response and structural injury in the disability of spinal injury

Introduction

In traumatic injury there is a clear relationship between the dose of energy involved, structural tissue damage and resultant disability after recovery. This relationship is often absent in cases of non-specific chronic low back pain that is perceived by patients as attributed to a workplace injury. There are many studies assessing risk factors for non-specific low back pain. However, studies addressing causality of back pain are deficient.

Purpose

To establish whether there exists a causal relationship between structural injury, low back pain and spinal disability.

Methods

Retrospective analysis of prospectively gathered validated spinal outcome measures [Oswestry disability index (ODI), low back outcome score (LBO), modified somatic perception (MSP), modified Zung depression index (MZD)] between patients with healed high energy thoracolumbar spinal fractures and patients with self-perceived work-related low back pain. Causality was established according to two of Bradford Hill’s criteria of medical causality, temporal and dose–response relationships.

Results

Twenty-three patients with spinal fractures (group 1) of average age 44 years were compared to 19 patients with self-reported back pain in the workplace pursuing claims for compensation (group 2) of average age 48 years. Both groups were comparable in terms of age and sex. The average ODI in group 1 was 28 % (SD 19) compared to 42 % (SD 19) in group 2 (P < 0.05). Similarly, LBOS was 39.7 versus 24.3 (P < 0.05), MSP 4.3 versus 9.3 (P < 0.05) and MZD 20.2 versus 34.8 (P < 0.05) in groups 1 and 2, respectively.

Conclusion

Despite high-energy trauma and significant structural damage to the spine, patients with the high energy injuries had better spinal outcome scores in all measures. There is no ‘dose–response’ relationship between structural injury, low back pain and spinal disability. This is the reverse of what would be anticipated if structural injury was the cause of disability in workplace reported onset of low back pain.     

Which posterior instrumentation is better for two-level anterior lumbar interbody fusion: translaminar facet screw or pedicle screw?

Purpose

To determine whether translaminar facet screws can provide stability equivalent to pedicle screws and whether the two posterior instrumentations have the same influence on the adjacent segments in two-level anterior lumbar interbody fusion.

Methods

In a biomechanical study conducted, we used 12 fresh human lumbar spines and tested an intact spine with a stand-alone two-level anterior lumbar interbody fusion and anterior fusion augmented with pedicle screws or translaminar facet screws, under 400 N compressive preloads and 7.5 N m moments in flexion, extension, axial rotation and lateral bending, and measured the stiffness of the operated level, range of motion and intradiscal pressure at the adjacent levels.

Results

We found a significant increase in the stiffness of the segments operated, range of motion and intradiscal pressure at the adjacent superior segment in the stand-alone two-level anterior lumbar interbody fusion during flexion, axial rotation and lateral bending, but a decrease in extension, when compared with the intact spine. The stiffness of operated segments, range of motion and intradiscal pressure in the adjacent segment are significantly higher in the two-level anterior lumbar interbody fusion augmented with posterior instrumentation than in the stand-alone two-level anterior lumbar interbody fusion. There was no significant difference between the two augmented constructs except that, at the adjacent superior segment, the intradiscal pressure was more in the construction augmented with a pedicle screw than with a translaminar facet screw in flexion.

Conclusions

Translaminar facet screws can provide stability equivalent to pedicle screws, but their influence on the adjacent segments is relatively lower; therefore, we suggest that translaminar facet screws be the choice in the optimal posterior instrumentation in a two-level anterior lumbar interbody fusion.     

Improvement in low back pain following spinal decompression: observational study of 119 patients

Study design

Prospective clinical observational study of low back pain (LBP) in patients undergoing laminectomy or laminotomy surgery for lumbar spinal stenosis (LSS).

Objectives

To quantify any change in LBP following laminectomy or laminotomy spinal decompression surgery.

Patients and methods

119 patients with LSS completed Oswestry Disability Index questionnaire (ODI) and Visual Analogue Scale for back and leg pain, preoperatively, 6 weeks and 1 year postoperatively.

Results

There was significant (p < 0.0001) reduction in mean LBP from a baseline of 5.14/10 to 3.03/10 at 6 weeks. Similar results were seen at 1 year where mean LBP score was 3.07/10. There was a significant (p < 0.0001) reduction in the mean ODI at 6 weeks and 1 year postoperatively. Mean ODI fell from 44.82 to 25.13 at 6 weeks and 28.39 at 1 year.

Conclusion

The aim of surgery in patients with LSS is to improve the resulting symptoms that include radicular leg pain and claudication. This observational study reports statistically significant improvement of LBP after LSS surgery. This provides frequency distribution data, which can be used to inform prospective patients of the expected outcomes of such surgery.     

Combined spinal arthrodesis with instrumentation for the management of progressive thoracolumbar kyphosis in children with mucopolysaccharidosis

Purpose

To evaluate the outcome and complications of a novel technique for the treatment of progressive thoracolumbar kyphosis in children with mucopolysaccharidosis (MPS).

Methods

The medical records and spinal imaging of four consecutive paediatric patients who underwent a single stage anteroposterior spinal fusion with segmental pedicle screw instrumentation were reviewed.

Results

Patients underwent spinal deformity correction at the mean age of 3 years (2.4–3.7) with mean clinical follow-up of 3.2 years (2.1–4.5) and mean postoperative radiographic follow-up was 2.4 years (0.8–3). Preoperative kyphosis was corrected from a mean angle of 65º (63º–70º) to 6.5º (–12º–13º). Vertebral subluxation at the apex of the deformity was corrected from an average 64 % (56–83 %) to 12 % (0–24 %). Spinal cord monitoring with somatosensory evoked potentials (SSEP) was successfully obtained and stable throughout surgery. No instrumentation failure, loss of correction or junctional problems occurred at final follow-up.

Conclusions

Anterior and posterior spinal arthrodesis with segmental pedicle screw instrumentation is a safety and reliable technique for the treatment of severe thoracolumbar kyphosis in children with MPS. This technique achieves excellent correction of the deformity with adequate decompression of the spinal canal. The fusion is limited to the thoracolumbar junction and interferes minimally with the longitudinal growth of the thorax. No neurological complications or intraoperative spinal cord monitoring events occurred. No loss of correction or junctional kyphosis was observed.     

Comparison of adjacent segment degeneration after successful posterolateral fusion with unilateral or bilateral pedicle screw instrumentation: a minimum 10-year follow-up

Background context

In the instrumented fusion, adjacent segment facet joint violation or impingement by pedicle screws is unavoidable especially in cephalad segment, despite taking specific intraoperative precautions in terms of surgical approach. In such circumstances, unlike its original purpose, unilateral pedicle screw instrumentation can contribute to reduce the degeneration of cephalad adjacent segment by preventing contralateral cephalad adjacent facet joint from the unavoidable injury by pedicle screw insertion. However, to our knowledge, no long-term follow-up study has compared adjacent segment degeneration (ASD) between unilateral and bilateral pedicle screw instrumented fusion.

Purpose

To compare ASD after successful posterolateral fusion using either unilateral or bilateral pedicle screw instrumentation for patients with lumbar spinal stenosis and/or Grade 1 spondylolisthesis.

Study design

Retrospective case-control study.

Patient sample

One hundred forty-seven patients who had undergone one- or two-level posterolateral fusion with unilateral or bilateral pedicle screw instrumentation for lumbar spinal stenosis with or without low-grade spondylolisthesis and achieved successful fusion, with a minimum 10-year follow-up.

Outcome measure

The occurrence of radiologic ASD, Oswestry disability index (ODI) scores, and revision rates.

Methods

A total of 194 consecutive patients were contacted and encouraged to visit our hospital and to participate in our study. Radiologic ASD was evaluated at three motion segments: cephalad adjacent segment (first cephalad adjacent segment), one cephalad to cephalad adjacent segment (second cephalad adjacent segment), and caudal adjacent segment. Clinical outcomes were compared by ODI scores and revision rates.

Results

In total, 147 of 194 (75.8%) patients were available for at least 10 years of radiologic and clinical follow-up. Adjacent segment degeneration (in first cephalad or caudal adjacent segment) was noted in 55.9% (33 of 59 patients) of the unilateral group and 72.7% (64 of 88 patients) of the bilateral group (p=.035). The occurrence of ASD in each first cephalad and caudal adjacent segment was not significantly different between groups but that in second cephalad adjacent segment was significantly different between groups (p=.004). Clinical outcomes according to ODI showed significant difference between groups (p=.016), especially when ODI scores were compared in patients with ASD (p=.004).

Conclusions

In a minimum 10-year follow-up retrospective study of posterolateral fusion for lumbar spinal stenosis and/or Grade 1 spondylolisthesis, unilateral pedicle screw instrumentation showed a lower rate of radiologic ASD, especially in second cephalad adjacent segment, and a better clinical outcome by ODI.     

Effect of pulsed radiofrequency in treatment of facet-joint origin back pain in patients with degenerative spondylolisthesis

Background

Degenerative spondylolisthesis is a well-recognized source of low back pain mainly induced by facet joint pain. Pulsed radiofrequency (PRF) allows heat dissipation, thus producing a temporary injury that affects only type C fibers responsible for pain conduction.

Objectives

We attempted to test whether PRF is a better choice for facet pain due to spondylolisthesis compared to routine steroid injection.

Methods

Patients were randomly assigned to one of two groups: group one received pulsed RF, and group 2 received injection by steroids (triamcinolone) and bupivacaine.

Outcomes assessment

Multiple outcome measures were utilized which included the numeric rating scale (NRS), the Oswestry Disability Index (ODI), satisfaction status, and analgesic intake with assessment at 3, 6, and 12 months post-treatment. Significant pain relief was defined as 50 % or more, whereas significant improvement in disability score was defined as reduction of 40 % or more.

Results

Eighty patients were enrolled in the study and were divided into the two groups of study. PRF significantly reduced NRS at 6-month follow-up compared to steroid + bupivacaine. 75.6 ± 14.3 % at pre-treatment and 19.3 ± 9.5 % at 6 months (p = 0.001) in PRF group. The mean ODI is depicted in two groups of study (Fig. 1). Interestingly, ODI% was significantly lower in PRF group at 12 weeks and 6 months compare to steroid + bupivacaine group (p = 0.022 and 0.03, respectively), but it was not significantly different at 6 weeks (p = 0.31). Proportion of patients who did not require analgesics were significantly higher in PRF group compared to other group (p = 0.001) in Log-rank (Mantel–Cox) test.

Conclusion

Our results demonstrated that the application of PRF might be more effective than steroid and bupivacaine injection in decreasing back pain due to degenerative facet pain and improvement in function of patients.     

Posterior lumbar interbody fusion and segmental lumbar lordosis

Introduction

The sagittal plane of body produces a convex curve anteriorly referred to as the lordotic curve. Malalignment of lordotic curve leads to low back disorders and lumbar spinal surgery has been known to cause this. This study was a retrospective analysis of the effects of posterior lumbar interbody fusion using cages on segmental lumbar lordosis.

Materials and methods

We conducted a retrospective study involving 27 patients of which 16 were females and 11 were males. All patients underwent single level posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation. Intraoperatively, all patients had a change from knee chest position to prone to augment their lumbar lordosis. The minimum follow up was 2 years and fusion was achieved in 21 patients.

Results

Segmental lordotic angles increased from 15.2° to 20.6° at L4/5 level and from 17.8° to 24.5° at L5/S1 level, preoperative to postoperative, respectively (P < 0.01 at both levels).

Conclusion

Thus apparently, posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation results in creation and maintenance of lumbar lordosis.     

Unilateral versus bilateral fixation for lumbar spinal fusion: a systemic review and meta-analysis

Purpose

The objective of this study was to systematically compare the efficacy and safety of unilateral fixation to bilateral fixation for the lumbar degenerative disease.

Study design

Systematic review and meta-analysis.

Methods

We searched databases including PubMed Central, MEDLINE (from 1966), EMBASE (from 1980), and Cochrane Central Register of Controlled Trials databases for randomized controlled trials or non-randomized controlled trials that compare unilateral fixation with bilateral fixation for the treatment for lumbar disease. Exclusion criteria were non-controlled studies, follow-up <6 months, combined anterior and posterior surgery, lumbar tumors, and non-English writing paper. Methodologic quality was assessed, relevant data were retrieved, and the appropriate meta-analysis was performed. Two review authors independently selected studies, extracted data, and assessed the risk of bias. The main end points included the rate of fusion, visual analogue scale (VAS), Oswestry disability index (ODI), intra-operative blood loss, operating time, and the rate of complications.

Results

A total of seven studies were included in the meta-analysis. Four relevant randomized controlled trials, one prospective study, and two retrospective studies involving 499 patients were identified. Patients in unilateral pedicle fixation group compared with bilateral pedicle screw fixation group on the fusion rate, VAS, ODI scores, and complication rate demonstrated no significant differences (P > 0.05, respectively). However, intra-operative blood loss and operating time in unilateral fixation group were significantly less than bilateral fixation group (P < 0.0001, respectively).

Conclusions

Unilateral fixation seems to be an effective, feasible, and safe procedure in one or two segmental disease when compare with bilateral instrumentation.     

Clinical assessment of a CMC/PEO gel to inhibit postoperative epidural adhesion formation after lumbar discectomy: a randomized, control study

Purpose

To evaluate effectiveness of carboxymethylcellulose/polyethylene oxide (CMC/PEO) gel in improving clinical outcomes after the first-time lumbar discectomy.

Method

Ninety-three patients with herniated lumbar disc at L4–L5 or L5–S1 were enrolled and randomized into two groups: CMC/PEO gel treatment group and control group. All the patients underwent laminotomy and discectomy by posterior approach. The preoperative and postoperative Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) scores for lower-back pain and leg pain were analyzed and compared between two groups at 30- and 60-day time points.

Results

No patient presented with any clinically measurable adverse event during surgery. There were no significant differences between the treated group and the control group on the preoperative ODI and VAS scores. In general, the ODI and VAS scores decreased in both groups at all the time points. At the 30-day time point, the VAS scores for back pain and leg pain and the ODI scores in treatment group were lower by 9.9 % (P = 0.0302), 27.0 % (P = 0.0002) and 16.3 % (P = 0.0007) than those in control group. And at the 60-day time point, the ODI and VAS scores further decreased in both groups. The VAS scores for leg pain in treatment group were lower by 4.5 % than that in the control group (P = 0.0149). However, no significant difference was detected between two groups on the ODI and VAS scores for back pain.

Conclusions

The results demonstrated that CMC/PEO gel is effective in reducing posterior dural adhesions in the spine with no apparent safety issues. It can improve patients’ postoperative clinical outcome.