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ABSTRACT: To determine if epidural anesthesia is a reasonable technique for anterior lumbar interbody fusion.
Retrospective chart review.
Academic university hospital.
The charts of patients who underwent an anterior lumbar interbody fusion between January 1, 2001 and November 1, 2008 were reviewed. A total of 102 consecutive patients, of whom 19 received an epidural and 83 underwent general anesthesia, met inclusion criteria. Postoperative pain, nausea, opioid administration, operating room time, anesthesia time, Postanesthesia Care Unit (PACU) time, and total hospital time were compared.
In the PACU, patients receiving epidural anesthesia showed reductions in median immediate [numerical rating scale (NRS) 0 vs 7; P < 0.001] and peak (NRS 4 vs 8; P = 0.001) postoperative pain scores, and postoperative mean arterial pressure (69.7 vs 90.3; P < 0.001). Epidural anesthesia patients also needed significantly less intravenous morphine-equivalent medication both intraoperatively (5 vs 29; P < 0.001) and postoperatively (3.34 vs 10; P = 0.021).
Epidural anesthesia for anterior lumbar interbody fusion is potentially beneficial compared with general anesthesia, showing improved perioperative pain control.
Journal of clinical anesthesia 11/2011; 23(7):521-6. · 1.32 Impact Factor
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The Journal of Bone and Joint Surgery 11/2010; 92(15):2615-6. · 3.27 Impact Factor
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Spine 09/2010; 35(20):E1011. · 2.08 Impact Factor
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ABSTRACT: A preintervention and postintervention design was used to examine a total of 200 patients.
After successful implementation at our institution of a perioperative oral multimodal analgesia protocol in major joint arthroplasty, a modified regimen was provided to patients undergoing spine procedures.
A proactive, multimodal approach is currently recommended for the management of acute postoperative pain. Inadequate postoperative analgesia can negatively influence surgical outcome and duration of rehabilitation. Routine use of intravenous patient controlled analgesia (IV PCA) after surgery can result in substantial functional interference, side effects, and lead to untoward events as a result of programming errors.
A preintervention and postintervention design was used to compare a historical control group of spine surgery patients who received conventional IV PCA (N=100) with a prospective group who received some form of perioperative oral multimodal analgesia (N=100). The new regimen included preoperative and postoperative scheduled extended-release oxycodone, gabapentin, and acetaminophen, intraoperative dolasetron and as-needed postoperative short-acting oral oxycodone. Patient surveys and chart audits were used to measure pain intensity, functional interference from pain, opioid consumption, analgesic-related side effects, and patient satisfaction over the first 24 hours postoperatively.
Patients who received the new perioperative multimodal oral regimen had significantly less opioid consumption (P<0.001), lower ratings of Least Pain (P<0.01), and experienced less nausea (P<.001), drowsiness (P<0.05), interference with walking (P=0.05), and coughing and deep breathing (P<0.05) compared with the IV PCA group.
This quality improvement study shows some safety and significant advantages of a multimodal perioperative oral analgesic regimen compared with standard IV PCA after spine surgery.
Journal of spinal disorders & techniques 04/2010; 23(2):139-45. · 1.21 Impact Factor
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ABSTRACT: Retrospective cohort.
The purpose of this study is to determine the fusion rates of a consecutive series of anterior cervical decompressions and fusions with allograft patella using both static and dynamic plates.
Anterior cervical diskectomy and fusion (ACDF) has been shown to improve symptoms of radiculopathy and myelopathy. The gold standard for obtaining fusion is using autogenous iliac crest bone graft (ICBG). The complication rate of using ICBG can be as high as 20%. To minimize this morbidity, various forms of allograft are presently used. We have used patellar allograft that we hypothesize exhibits a good combination of strength and sufficient porosity to facilitate fusion.
A consecutive series of 179 levels in 136 patients who underwent single and multilevel ACDF with allograft patella were retrospectively investigated. Final follow-up lateral cervical spine radiographs were evaluated for evidence of bony fusion. Fusions were graded independently by 2 of the investigators according to an interbody fusion classification proposed by Bridwell and colleagues, Spine, 1995. Fusion rates were compared with historical controls for single-level ACDF with autogenous ICBG and plating. Multivariate analysis was used to evaluate plate type, smoking, revision rate, and Odom's criteria compared with fusion.
Ninety-one consecutive single and 81 multilevel anterior cervical decompression and fusions with allograft patella were reviewed. Demographics were similar (average age 47.75 y). Average follow-up was 19.3 months. Fusion rates were 86% (159/179). Our revision rate was 8%. Eighty-one percent (85/98) union rate was noted in the single-level group, and 85% (69/81 levels) or 74% (28/38 patients) in the multilevel group.
Fusion rates were 86%. Plate design (static vs. dynamic) did not seem to affect fusion rates or clinical outcomes. There was a higher nonunion rate at the most inferior level of the multilevel fusions. Nonunions in the dynamic group were more commonly revised and had more kyphosis at final follow-up.
Journal of spinal disorders & techniques 09/2009; 22(6):392-8. · 1.21 Impact Factor
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ABSTRACT: The authors report the results of a prospective randomized multicenter study in which the results of cervical disc arthroplasty were compared with anterior cervical discectomy and fusion (ACDF) in patients treated for symptomatic single-level cervical degenerative disc disease (DDD).
Five hundred forty-one patients with single-level cervical DDD and radiculopathy were enrolled at 32 sites and randomly assigned to one of two treatment groups: 276 patients in the investigational group underwent anterior cervical discectomy and decompression and arthroplasty with the PRESTIGE ST Cervical Disc System (Medtronic Sofamor Danek); 265 patients in the control group underwent decompressive ACDF. Eighty percent of the arthroplasty-treated patients (223 of 276) and 75% of the control patients (198 of 265) completed clinical and radiographic follow-up examinations at routine intervals for 2 years after surgery. Analysis of all currently available postoperative 12- and 24-month data indicated a two-point greater improvement in the neck disability index score in the investigational group than the control group. The arthroplasty group also had a statistically significant higher rate of neurological success (p = 0.005) as well as a lower rate of secondary revision surgeries (p = 0.0277) and supplemental fixation (p = 0.0031). The mean improvement in the 36-Item Short Form Health Survey Physical Component Summary scores was greater in the investigational group at 12 and 24 months, as was relief of neck pain. The patients in the investigational group returned to work 16 days sooner than those in the control group, and the rate of adjacent-segment reoperation was significantly lower in the investigational group as well (p = 0.0492, log-rank test). The cervical disc implant maintained segmental sagittal angular motion averaging more than 7 degrees. In the investigational group, there were no cases of implant failure or migration.
The PRESTIGE ST Cervical Disc System maintained physiological segmental motion at 24 months after implantation and was associated with improved neurological success, improved clinical outcomes, and a reduced rate of secondary surgeries compared with ACDF.
Journal of Neurosurgery Spine 04/2007; 6(3):198-209. · 1.53 Impact Factor
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ABSTRACT: A biomechanical study on human cadaveric cervical spines with segmental fixation.
To quantify the strains across all segments of the spine after simulated fusion.
Clinical evidence suggests that degenerative changes occur at adjacent levels after cervical fusion. This may, in part be due to increased stress and motion at the adjacent segments.
Seven fresh frozen human cervical cadaveric spines were used. The spines were mounted onto frames at C2 and C7. Biomechanical testing was performed on a modified MTS tester. The specimens were tested in rotation control. To simulate fusion, a block was used to replace the disc. Fixation was enhanced using an anterior plate and stainless steel wire through the spinous processes. Testing was then performed with the same displacement magnitudes used for the intact spine. Displacement across 5 disc spaces was recorded using extensometers. The same preparation and testing was done for 1, 2, and 3-level simulated fusions. All data were normalized to the individual intact specimen.
After 1-level simulated fusion at C5-6, flexion-extension rotation increased by 60% at the superior adjacent level (C4-5) and by 15% at the adjacent inferior level (C6-7). Lateral bending increased by 51% at C4-5 and by 16% at C6-7. Axial rotation increased by 25% at C4-5 and by 200% at C6-7. Flexion-extension, lateral bending and axial rotation increased at all other segments, not only at adjacent segments, after 1, 2 and 3-level fixation.
Cervical fusion results in increased strains at adjacent levels, and to all other levels, inferiorly and superiorly. This study represents the first to quantify the increased strain at all adjacent levels.
Journal of Spinal Disorders & Techniques 09/2006; 19(6):407-10. · 1.50 Impact Factor
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ABSTRACT: To determine whether preoperative disc space height (DSH) influences the clinical outcomes of patients diagnosed with single-level symptomatic discogenic disease and treated with a stand-alone anterior lumbar interbody fusion with two tapered threaded fusion cages, we performed a retrospective analysis of 392 patients.
Preoperative radiographs were used to establish four study groups based on the patients' DSH: the tall disc group: DSH >15 mm; the intermediate tall group: DSH ranging from 10 to 15 mm; the intermediate collapsed group: DSH ranging from 5 to 10 mm; and the collapsed disc group: DSH <5 mm.
All of the patient groups exhibited improvement in their clinical outcomes. However, patients in the collapsed disc group (DSH of <5 mm) tended to have earlier and greater improvement in Oswestry Disability Index scores, Physical Component Summary scores of the Short Form-36, and Visual Analog Scale scores for low back pain.
Symptomatic disc degeneration can be readily identified with plain radiographic findings, and patients' symptoms can often be relieved predictably with a stand-alone interbody fusion procedure.
Journal of Spinal Disorders & Techniques 10/2005; 18(5):396-401. · 1.50 Impact Factor
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ABSTRACT: A retrospective review of a consecutive series of patients with acute thoracolumbar burst fractures who were surgically treated with an anterior corpectomy and fusion with anterolateral Z-plate fixation.
To evaluate the clinical and radiographic success of the management of acute thoracolumbar burst fractures by corpectomy, structural grafting, and anterolateral internal fixation.
Burst fractures are frequently associated with instability or neurologic deficit. Modern surgical procedures for these fractures have been performed via both anterior and posterior approaches. Anterior surgical treatment allows direct decompression of the neural elements and correction of deformity. Newer anterior instrumentation devices, combined with a structural graft, allow a stable construct that may obviate a posterior procedure. An anterior procedure generally requires fusion of only two levels compared to posterior fusion, which generally requires more.
A retrospective review of a consecutive series of patients with thoracolumbar burst fractures treated with anterior surgery, strut graft, and fixation with a Z-plate was carried out. Fractures were considered acute if surgically treated within 30 days. Clinical and radiographic evaluation was performed on all 35 patients with acute thoracolumbar burst fractures. Surgical indications were incomplete neurologic deficit, segmental kyphotic deformity, or significant comminution. All patients with acute thoracolumbar burst fractures with spinal cord injury were treated with an intravenous steroid protocol and were operated on within 24 hours of admission unless medically precluded. Forty-six percent (16 of 35) of patients with acute thoracolumbar burst fractures presented with a neurologic deficit.
All 16 patients with neurologic deficit demonstrated at least one Frankel grade improvement on final observation, with 11 (69%) patients demonstrating complete neurologic recovery. Thirty-three patients were treated with anterolateral instrumentation only. Twenty-nine of thirty patients demonstrated radiographic healing. Five were lost to follow-up observation. One patient required subsequent posterior fusion for increasing kyphotic deformity. There were no instances of hardware failure. Sagittal alignment was improved from a mean preoperative kyphosis of 18 degrees to 6 degrees at final follow-up observation.
Anterior corpectomy, strut graft, and Z-plate fixation is an effective treatment for thoracolumbar burst fractures. It allows direct decompression of the spinal cord in the acute setting and was associated with a high rate of neurologic improvement, no instances of neurologic worsening in any case, and a low complication rate.
Spine 10/2004; 29(17):1901-8; discussion 1909. · 2.08 Impact Factor
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ABSTRACT: In anterior lumbar spinal fusion, patients treated with rhBMP-2 on a collagen sponge carrier had statistically superior outcomes compared to patients treated with autogenous bone graft. A collagen sponge carrier should replace autogenous bone graft for this patient population.
Orthopedics 08/2004; 27(7):723-8. · 2.66 Impact Factor
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ABSTRACT: In a retrospective analysis of two large multicenter clinical studies, 321 patients with degenerative lumbar disc disease were divided into two groups who underwent anterior lumbar interbody fusion using two threaded titanium fusion cages. To determine whether differences in surgical procedures and cage design affect anterior and posterior annular distraction and clinical outcomes, the authors evaluated the clinical and radiographic outcomes of patients treated with a stand-alone ALIF procedure. End-plate preservation techniques were associated with improved anterior and posterior disc space distraction compared with standard end-plate preparation techniques. Similarly, the use of the LT-CAGE device led to greater improvements in restoration of segmental lordosis than did the use of standard cylindric cages. Furthermore, these surgical benefits resulted in improved clinical outcomes as early as 3 months and were maintained over a 2-year follow-up period in patients with improved postoperative disc space distraction and lordosis. Placing cylindric cages in a lordotic or trapezoidal disc space can be accomplished only through asymmetric reaming of the vertebral end plates. In a lordotic disc space, the posterior portion of the disc must be reamed more than the anterior portion. This over-reaming inhibits distraction of the posterior disc space and limits restoration of neuroforaminal height. Reduced reaming and symmetric reaming of the vertebral end plates enable the surgeon to restore anatomic segmental lordosis across the disc space. The tapered cage configuration aids in maintaining segmental lordosis. Anatomic restoration of disc space contours has an impact on a patient's outcome after stand-alone anterior interbody fusion surgery.
Orthopedic Clinics of North America 02/2004; 35(1):25-32. · 1.25 Impact Factor
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ABSTRACT: A literature review was conducted of basic science research and clinical experiences describing the use of interbody cage devices for the management of degenerative spinal abnormalities.
To summarize current knowledge regarding the use of interbody fusion cages.
Degenerative conditions of the lumbar and cervical spine are a major societal expense and a leading cause of disability. Fusion surgery may be used to treat patients with some of these conditions. During the past decade, interbody cages have been popularized as a useful fusion technique with high rates of clinical and radiographic success reported. Cages may be implanted using a variety of surgical approaches to the disc space and can be used alone or with supplemental posterior fixation.
A literature review of biomechanical, biologic, and clinical studies of threaded interbody cages was performed.
Interbody cages have been shown to successfully promote fusion in a variety of animal models. In biomechanical studies, anteriorly placed threaded cages significantly stabilize the motion segment in all directions except extension. Posteriorly placed cages provide less stability as a result of the facetectomy required for placement of an appropriately sized device. Successful clinical and radiographic results have been reported with the use of interbody cages. Most reported cage failures are the result of technical difficulties with implantation or poor patient selection. Accurate radiographic assessment of fusion in the presence of a metal interbody cage remains challenging, and studies evaluating alternate biomaterial cages are underway.
Interbody cages are a useful technique for achieving spinal fusion and have been shown to have an acceptable clinical success rate in appropriately selected patients.
Spine 09/2003; 28(15 Suppl):S2-7. · 2.08 Impact Factor
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ABSTRACT: Multicenter human clinical studies of patients undergoing anterior lumbar fusion have been conducted using recombinant bone morphogenetic protein or rhBMP-2 on an absorbable collagen sponge, marketed as INFUSE Bone Graft, or autograft implanted in the LT-CAGE Lumbar Tapered Fusion device. An integrated analysis of multiple clinical studies was performed using an analysis of covariance to adjust for preoperative variables in a total of 679 patients. Of these patients, 277 had their cages implanted with rhBMP-2 on an absorbable collagen sponge and 402 received autograft transferred from the iliac crest. The patients treated with rhBMP-2 had statistically superior outcomes with regard to length of surgery, blood loss, hospital stay, reoperation rate, median time to return to work, and fusion rates at 6, 12, and 24 months. Oswestry Disability Index scores and the Physical Component Scores and Pain Index of the SF-36 scale at 3, 6, 12, and 24 months showed statistically superior outcomes in the rhBMP-2 group.
Journal of Spinal Disorders & Techniques 05/2003; 16(2):113-22. · 1.50 Impact Factor
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ABSTRACT: Biomechanical analysis of the level above pars defects was performed using calf lumbar spines.
To evaluate whether complete spondylolysis contributes to the pathology of the upper adjacent motion segment to the pars defect.
It is well recognized that patients with spondylolysis show a higher incidence of spondylolisthesis or degenerative disc changes at the level of the pars defects. However, some authors have referred to the fact that disc damage may occur at the level above the defect and give rise to symptoms. However, no previous studies have been directed to the kinematic influence on the upper adjacent segment to pars defects.
Nine fresh-frozen calf lumbar spines were used for this study. The bony defects were created on the L4 pars articularis bilaterally. Three linear extensometers and one specially designed angular extensometer were mounted across the L3-L4 and L4-L5 motion units. Nondestructive static loads, including axial compression, flexion-extension, and axial rotation, were applied on the specimens in four different conditions as follows: 1) intact spine; 2) bilateral pars defects on the L4 laminae; 3) pars defect repair with Buck technique; and 4) pedicle screw-rod fixation at L4-L5 after removal of the interarticular screws. Testing was performed on a material testing machine (MTS 858 Bionix test system, Minneapolis, MN), and load-displacement curves were recorded with the extensometers. Each test was performed for over five full sinusoidal loading cycles, and data from the fifth cycle were collected and analyzed.
After creating the pars interarticularis defects at L4, mobility at both the L3-L4 and L4-L5 motion units were increased in all loading conditions. The normalized range of motion (% ROM) as compared with the intact specimens showed that the pars defects increased the mobility at the upper adjacent level (L3-L4) to 106.4% in flexion-extension and to 120.1% in axial rotation; the differences were significant (P < 0.01). Consequently, the increased mobility was stabilized by applying Buck screws through the defects on both sides; however, the effect was not statistically significant. Furthermore, pedicle screw-rod fixation applied at the L4-L5 segment increased the intervertebral motion at the upper adjacent level, and % ROM in axial rotation was significantly increased to 119.2% of the intact spine (P < 0.05). Comparing the treatments' effects on the L3-L4 segment and that on L4-L5, the Buck screws restored the stability of both segments to the level of the intact spine, whereas the pedicle screw system limited the motion of L4-L5 motion and, on the contrary, increased the L3-L4 motion.
This biomechanical study exhibited that bilateral pars interarticularis defects increased the intervertebral mobility, not only at the involved level but also at the upper adjacent level to the lysis. The increased mobility at the upper segment was reduced by the Buck screw technique. However, this was increased again by the pedicle screw system applied on the involved segment. If clinically applicable, fixation of the pars defect alone appears to cause less adjacent level mechanical stress than pedicle screw-rod motion segment fixation.
Spine 03/2003; 28(3):235-8. · 2.08 Impact Factor
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ABSTRACT: Study Design. Biomechanical analysis of the level above pars defects was performed using calf lumbar spines.
Objectives. To evaluate whether complete spondylolysis contributes to the pathology of the upper adjacent motion segment to the pars defect.
Summary of Background Data. It is well recognized that patients with spondylolysis show a higher incidence of spondylolisthesis or degenerative disc changes at the level of the pars defects. However, some authors have referred to the fact that disc damage may occur at the level above the defect and give rise to symptoms. However, no previous studies have been directed to the kinematic influence on the upper adjacent segment to pars defects.
Methods. Nine fresh-frozen calf lumbar spines were used for this study. The bony defects were created on the L4 pars articularis bilaterally. Three linear extensometers and one specially designed angular extensometer were mounted across the L3–L4 and L4–L5 motion units. Nondestructive static loads, including axial compression, flexion–extension, and axial rotation, were applied on the specimens in four different conditions as follows: 1) intact spine; 2) bilateral pars defects on the L4 laminae; 3) pars defect repair with Buck technique; and 4) pedicle screw–rod fixation at L4–L5 after removal of the interarticular screws. Testing was performed on a material testing machine (MTS 858 Bionix test system, Minneapolis, MN), and load–displacement curves were recorded with the extensometers. Each test was performed for over five full sinusoidal loading cycles, and data from the fifth cycle were collected and analyzed.
Results. After creating the pars interarticularis defects at L4, mobility at both the L3–L4 and L4–L5 motion units were increased in all loading conditions. The normalized range of motion (% ROM) as compared with the intact specimens showed that the pars defects increased the mobility at the upper adjacent level (L3–L4) to 106.4% in flexion–extension and to 120.1% in axial rotation; the differences were significant (P < 0.01). Consequently, the increased mobility was stabilized by applying Buck screws through the defects on both sides; however, the effect was not statistically significant. Furthermore, pedicle screw–rod fixation applied at the L4–L5 segment increased the intervertebral motion at the upper adjacent level, and % ROM in axial rotation was significantly increased to 119.2% of the intact spine (P < 0.05). Comparing the treatments’ effects on the L3–L4 segment and that on L4–L5, the Buck screws restored the stability of both segments to the level of the intact spine, whereas the pedicle screw system limited the motion of L4–L5 motion and, on the contrary, increased the L3–L4 motion.
Conclusions. This biomechanical study exhibited that bilateral pars interarticularis defects increased the intervertebral mobility, not only at the involved level but also at the upper adjacent level to the lysis. The increased mobility at the upper segment was reduced by the Buck screw technique. However, this was increased again by the pedicle screw system applied on the involved segment. If clinically applicable, fixation of the pars defect alone appears to cause less adjacent level mechanical stress than pedicle screw–rod motion segment fixation.
Spine 01/2003; 28(3):235-238. · 2.08 Impact Factor
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ABSTRACT: In a multicenter, prospective, randomized, nonblinded, 2-year study, 279 patients with degenerative lumbar disc disease were randomly divided into two groups that underwent interbody fusion using two tapered threaded fusion cages. The investigational group (143 patients) received rhBMP-2 on an absorbable collagen sponge, and a control group (136 patients) received autogenous iliac crest bone graft. Plain radiographs and computed tomographic scans were used to evaluate fusion at 6, 12, and 24 months after surgery. Mean operative time (1.6 hours) and blood loss (109.8 mL) were less in the investigational rhBMP-2 group than in the autograft control group (2.0 hours and 153.1 mL). At 24 months the investigational group's fusion rate (94.5%) remained higher than that of the control group (88.7%). New bone formation occurred in all investigational patients. At all intervals, mean postoperative Oswestry, back pain, and leg pain scores and neurologic status improved in both treatment groups with similar outcomes. In the control group, eight adverse events related to the iliac crest graft harvest occurred (5.9%), and at 24 months 32% of patients reported graft site discomfort and 16% were bothered by its appearance. Lumbar fusion using rhBMP-2 and a tapered titanium fusion cage can yield a solid union and eliminate the need for harvesting iliac crest bone graft.
Journal of Spinal Disorders & Techniques 11/2002; 15(5):337-49. · 1.50 Impact Factor
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The Journal of trauma 11/2002; 53(4):777-9. · 2.48 Impact Factor
