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ABSTRACT: Study Design. Matched Cohort ComparisonObjective. To compare the use of BMP or ICBG on the long term outcomes in patients undergoing long fusions to the sacrum for adult spinal deformity.Summary of Background Data. No long term studies beyond a 2 year f/u have been performed comparing the use of Bone Morphogenic Protein (BMP) versus Iliac Crest Bone Graft (ICBG) for fusion rates in long fusions to the sacrum in adult spinal deformity.Methods. A total of 63 consecutive patients from 1997-2006 consisting of 31 patients in the BMP group and 32 patients in the ICBG group, operated on at a single institution with a minimum 4-year follow-up (4-14 years) was analyzed. Inclusion criteria were ambulators who were candidates for long fusions (thoracic as the upper level) to the sacrum. Exclusion criteria were revisions, neuromuscular scoliosis, ankylosing spondylitis and patients who had both BMP and ICBG used for fusion. Oswestry Disability Index (ODI) and three domains of the SRS score were used to assess outcomes.Results. The two groups were similar with respect to age, gender, smoking history, comorbidities, BMI, number of fusion levels and Cobb angles. Eight patients in the BMP group had a posterior only while 23 had combined anterior and posterior (A/P) surgery. All 32 patients in the ICBG had A/P fusion. The average BMP/level was 11.1 mg (3-36 mg). The rate pseudarthrosis was 6.4% (2/31) in the BMP and 28.1% (9/32) in the ICBG group (P = 0.04) using Fisher exact test and odds ratio = 5.67. The fusion rates for BMP group were 93.5% and 71.9% for the ICBG group. ODIs were similar between groups. However, the BMP group demonstrated superior sum composite SRS scores in pain, self-image and function domains (p = 0.02).Conclusion. BMP is superior to ICBG in achieving fusion in long constructs in adult deformity surgery. The rate of pseudarthrosis was significantly higher in the ICBG group than BMP group. The concentration and dosage of rhBMP-2 used appears to have an effect on the rate of fusion and pseudarthrosis rate because no patient receiving >5mg/level had apparent or detected pseudarthroses (n = 20/20).
Spine 02/2013; · 2.08 Impact Factor
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ABSTRACT: STUDY DESIGN:: Retrospective case series. OBJECTIVE:: The purpose of this study was to determine the fusion rate and evaluate the complications associated with the application of recombinant human bone morphogenetic protein-2 (rhBMP-2) in posterior cervical fusion. SUMMARY OF BACKGROUND DATA:: The rates of fusion and complications associated with the use of rhBMP-2 in posterior cervical fusion is unclear, though recent work has shown up to a 100% fusion rate. METHODS:: We independently reviewed a consecutive series of patients who underwent posterior cervical, occipitocervical, or cervicothoracic instrumented fusion augmented with rhBMP-2. Two surgeons at a tertiary-referral, academic medical center performed all operations, and each patient had a minimum of 2-year follow-up. Fusion status was determined by bony bridging on computed tomography scans, absence of radiolucency around instrumentation, and absence of motion on lateral flexion/extension radiographs. RESULTS:: Fifty-seven patients with a mean age of 56.7±13.2 years and mean follow-up of 37.7±20.6 months were analyzed. Forty-eight patients (84.2%) had undergone previous cervical surgery, and 42.1% had a preexisting nonunion. Constructs spanned 5.6±2.6 levels; 19.3% involved the occiput, while 61.4% crossed the cervicothoracic junction. The mean rhBMP-2 dose was 21.1±8.7 mg per operation. Iliac crest autograft was used for 29.8% of patients. Six patients (10.5%) experienced nonunion; only 2 required revision. In each case of nonunion, instrumentation crossed the occipitocervical or cervicothoracic junction. However, none of the analyzed variables was statistically associated with nonunion. Fourteen patients (24.6%) suffered complications, with 7 requiring additional surgery. CONCLUSIONS:: The observed fusion rate of rhBMP-2-augmented posterior cervical, occipitocervical, and cervicothoracic fusions was 89.5%. This reflects the complicated nature of the patients included in the current study and demonstrates that rhBMP-2 cannot always overcome the biomechanical challenges entailed in spanning the occipitocervical or cervicothoracic junction.
Journal of spinal disorders & techniques 02/2013; · 1.21 Impact Factor
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ABSTRACT: STRUCTURED ABSTRACT: Study Design. Retrospective.Objective. This study's purpose was to report the spectrum of intraoperative events responsible for a loss or significant change in intraoperative monitoring (IOM) data.Summary of Background Data. The efficacy of spinal cord/nerve root monitoring is demonstrated in a large, single institution series of patients involving all levels of the spinal column (occiput to sacrum), and all spinal surgical procedures.Methods. Multimodality IOM included somatosensory evoked potentials (SSEP), descending neurogenic evoked potentials (DNEP), neurogenic motor evoked potentials (NMEP) and spontaneous and triggered EMG. 12,375 patients who underwent surgery for spinal pathology between January 1985 and December 2010 were reviewed. 59.3% (7178) of patients were female and 40.7% (5197) were male. Procedures by spinal level: cervical 29.7% (3671), thoracic/thoracolumbar 45.4% (5624) and lumbosacral 24.9% (3080). Age at time of surgery: >18 years 72.7% (242/8993), <18 years 27.3% (144/3382). 9633 (77.8%) patients were primary and 2742 (22.2%) were revision surgeries.Results. 406 instances of IOM data change/loss occurred in 386/12,375 (3.1%) patients. Causes for data degradation/loss included: instrumentation (n = 131), positioning (n = 85), correction (n = 56), systemic (n = 49), unknown (n = 24) and focal spinal cord compression (n = 15). Data loss/change was seen in revision (6.1%/167 pts.) surgeries more commonly than primary (2.3%/219 pts.; p<0.0001). 88.7% (n = 360) demonstrated data improvement following intervention versus 11.3% (n = 46) with no improvement in IOM data. One patient with improved data following intervention versus 14 with no improvement despite intervention had a permanent neurologic deficit (p<0.0001).Conclusion. IOM data identified 386 (3.1%) patients with loss/degradation of data in 12,375 spinal surgery procedures. Fortunately, in 93.3% of patients, intervention led to data recovery and no neurologic deficits. Reduction from a potential (worst-case scenario) 386 (3.1%) of patients with significant change/loss of IOM data to a permanent neurologic deficit rate of 15 (0.12%) patients was achieved (p<0.0001), thus confirming efficacy of intraoperative monitoring.
Spine 11/2012; · 2.08 Impact Factor
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ABSTRACT: Study Design. Retrospective investigation of cross-sectional data.Objective. To define the prevalence and determinants of preoperative vitamin D deficiency among adults undergoing spinal fusion.Summary of Background Data. Vitamin D plays a critical role in establishing optimal bone health, which, in turn, is vital to the success of spinal arthrodesis. Recently, hypovitaminosis D was documented in 43% of adults undergoing any orthopedic surgery.Methods. Serum 25-hydroxyvitamin D (25OHD) levels were routinely measured in adults undergoing spinal fusion at a single institution. Between January 2010 and March 2011, 313 patients were retrospectively identified for inclusion. Risk factors for vitamin D deficiency (<20 ng·mL) were analyzed using univariate analysis and multivariate logistic regression.Results. The rates of inadequacy (<30 ng·mL) and deficiency were 57% and 27%, respectively. While 260 patients were diagnosed with degenerative disease (spondylosis), ninety-nine had deformity, and there were seventy-three revision cases. There was a higher rate of smoking (P = 0.03) and lower age (P < 0.01) in the vitamin D-deficient subset. There was no gender difference. Increasing body mass index (P < 0.01), increasing Neck and Oswestry Disability Index scores (P = 0.03), and lack of vitamin D and/or multivitamin supplementation (P < 0.01) remained predictors of deficiency after multivariate analysis. Those with prior supplementation were older (P < 0.01) and more likely to be at least fifty years old than those without repletion (P < 0.01).Conclusion. Our investigation revealed a substantially high prevalence of vitamin D abnormality in the analyzed population. Although advanced age is a well-established risk factor for hypovitaminosis, young adults undergoing fusion should not be overlooked with regard to vitamin D screening; this age bracket is less likely to have been previously supplemented. Additionally, in the absence of better-recognized determinants, spinal disability indices may be useful in identifying those with deficiency.
Spine 09/2012; · 2.08 Impact Factor
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The Journal of Bone and Joint Surgery 05/2012; 94(10):943-51. · 3.27 Impact Factor
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Joshua D Auerbach,
Lawrence G Lenke,
Keith H Bridwell,
Jennifer K Sehn,
Andrew H Milby,
David Bumpass,
Charles H Crawford,
Brian A OʼShaughnessy, Jacob M Buchowski,
Michael S Chang,
Lukas P Zebala,
Brenda A Sides
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ABSTRACT: A retrospective review.
To characterize the risk factors for the development of major complications in 3-column osteotomies and determine whether the presence of a major complication affects ultimate clinical outcomes.
Three-column spinal osteotomies, including pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR), are common techniques to correct severe and/or rigid spinal deformities.
Two hundred forty consecutive PSO (n = 156) and VCR (n = 84) procedures in 237 patients were performed at a single institution between 1995 and 2008. Of these, 105 patients (87 PSOs, 18 VCRs) had complete preoperative and minimum 2-year postoperative clinical outcomes data available for analysis. Using established criteria, we reported complications as major or minor and further stratified complications as surgical versus medical and permanent versus transient. Risk factors for complications and their effect on Scoliosis Research Society (SRS) clinical outcomes at baseline and at 2 years or more were assessed.
Major medical and surgical complications occurred at similar rates in both PSOs and VCRs (38%, 33 of 87 vs. 22%, 4 of 18; P = 0.28). Overall, 24.8% (26 of 105) experienced major surgical complications (3 permanent) and 15.2% (16 of 105) experienced major medical complications (4 permanent). Patients with PSO were older (53 vs. 29 yr; P < 0.001), had greater estimated blood loss (1867 vs. 1278 mL; P = 0.02), and showed a trend toward fewer fused levels (10.1 vs. 12.2; P = 0.06). Risk factors for major complications included preoperative sagittal imbalance of 40 mm or more (P = 0.01), age 60 years and older (P = 0.01), and the presence of 3 or more medical comorbidities (P = 0.04). Both groups improved significantly from baseline in SRS subscores; however, patients with PSO started off worse but improved more than VCRs in both the pain (+1.0 vs. +0.1; P < 0.001) and function (+0.6 vs. +0.2; P = 0.01) domains, with no differences in final satisfaction (4.1 vs. 4.3; P = 0.54). PSO and VCR patients with no complications had slightly higher satisfaction scores than patients with minor-only complications, major transient complications, and major permanent complications. There were no significant differences among the groups with respect to change in SRS subscores from baseline, and all complication groups improved significantly from baseline (P = 0.04).
Major complications occurred in 35% of 3-column osteotomies and at similar rates for both PSO (38%) and VCR (22%) procedures. The presence of a major complication did not affect the ultimate clinical outcomes at 2 years or more.
Spine 02/2012; 37(14):1198-210. · 2.08 Impact Factor
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ABSTRACT: Malignant spinal tumors are frequently encountered in clinical practice. Most of these lesions are caused by metastatic or hematopoietic disease processes. It is useful for the practicing surgeon to have a framework for evaluating and treating these conditions. Equally important is the ability to recognize the rare patient who presents with a primary spinal malignancy, which requires a significantly different treatment protocol.
Instructional course lectures 01/2012; 61:553-65.
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The Journal of Bone and Joint Surgery 11/2011; 93(22):e132(1-4). · 3.27 Impact Factor
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The Laryngoscope 09/2011; 121(11):2501; author reply 2502-3. · 1.75 Impact Factor
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ABSTRACT: Retrospective case series study.
To determine when the standard Smith-Robinson approach can be used successfully to approach the cervicothoracic junction (CTJ).
Most of techniques for exposing the anterior CTJ are associated with significant morbidity. To our knowledge, there is no reliable technique, which described to determine when the standard Smith-Robinson approach is adequate and when a more invasive approach, such as a sternal splitting approach, is necessary to approach the CTJ anteriorly.
We evaluated the ability of the following technique to preoperatively determine whether a standard Smith-Robinson approach can be used to approach the CTJ: on the lateral plain radiograph, a line was drawn from the intended skin incision site to the top of the manubrium (at the suprasternal notch) to the level of the disc space. If it appeared that this trajectory would allow adequate exposure of the CTJ, then the operation was performed through the standard Smith-Robinson approach. The records and radiographs of all patients who had undergone anterior cervicothoracic arthrodesis to T1 or below were evaluated.
A total of 99 patients who underwent an anterior cervicothoracic fusion using the standard Smith-Robinson approach were identifed. Using the proposed technique, there were no cases in which the planned lowest instrumented vertebra could not be safely reached through the standard Smith-Robinson approach. No procedure was abandoned or converted to a sternotomy approach.
Our results suggest that if the lowest instrumented vertebra can be seen on a lateral radiograph and a line passing from the intended skin incision site to this level lies on top of the manubrium, a routine Smith-Robinson approach can be used to expose the level. To our knowledge, this is the largest series outlining a simple guideline for approaching the anterior CTJ.
Journal of spinal disorders & techniques 05/2011; 25(5):264-7. · 1.21 Impact Factor
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ABSTRACT: Evaluation by simulation of screw insertion using fine-cut computed tomographic (CT) scans and screw trajectory software.
To evaluate the feasibility and optimal trajectory of the occipital condylar screw.
To the best of our knowledge, no large series examining the feasibility and optimal trajectory of occipital condylar screws have been published.
We simulated unicortical placement of a 4 × 18-mm screw using 1-mm sliced CT scans and 3-dimensional screw trajectory software in 314 occipital condyles of 157 patients. With the screw tip directed toward a point just below the tip of the basion on lateral fluoroscopy, 3 entry points were compared in view of success rate of screw placement, safe range of medial angulation in an axial plane, and maximum screw length.
The lateral entry point had the highest success rate (93.0%) of screw placement, mean safe range of the medial angulation (10.9°), and maximum screw length (20.7 mm), followed by the middle (92.0%, 10.8°, and 20.6 mm, respectively) and medial (74.2%, 7.7°, and 19.7 mm, respectively) entry points. While the lateral and the middle entry points did not have any statistically significant difference in the 3 parameters, they were significantly better than the medial entry point. All 3 entry points had highly variable ranges of safe medial angulation, making it difficult to provide a single recommended value.
Screw placement is feasible in up to 93% of the occipital condyles. The lateral and the middle entry points are significantly better than the medial entry point. Selection between the middle and the lateral entry points should be individualized taking into account local anatomic variation. Because the medial angulation of these screws is highly variable, preoperative 3-dimensional CT evaluation and possibly even intraoperative navigation may be required.
Spine 05/2011; 37(5):385-92. · 2.08 Impact Factor
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ABSTRACT: Injury to the internal carotid artery (ICA) is a potentially catastrophic complication of C1-lateral mass (C1-LM) or C1-C2 transarticular screw insertion.
This study was designed to determine the risk of injury to the ICA during placement of these screws using computed tomography angiography (CTA).
Radiographic analysis using CTA.
One hundred sixty CTAs were examined, for a total of 320 ICAs.
Not applicable.
Fine-cut intravenous CTAs with multiplanar and three-dimensional reconstruction were reviewed. The position of the ICA in relation to the anterior cortex (AC) of C1, anterior end of the anterior tubercle (AT), and medial margin of the transverse foramen (TF) was measured bilaterally in three ascending and equidistant levels of the C1-AT.
The position of the ICA in relation to C1 was variable. The average distance between the ICA and the AC of C1 was only 3.7 mm. Furthermore, 96% of the time the posterior margin of the ICA was located posterior to the anteriormost aspect of the anterior C1 tubercle (average distance, 5.4 mm), making the ICA vulnerable to damage if a drill, tap, or screw was inserted to the depth of the anteriormost portion of the AT as seen on a lateral fluoroscopic or radiographic view. The medial margin of the ICA was located medial to the TF (a location potentially vulnerable to injury with bicortical screw placement) less often at the caudal aspect of the C1-AT (54%) than at its middle or cranial aspect (74% and 75%, respectively). No ICAs were located anterior to the medial 30% of the C1-LM or more medially.
Bicortical C1-LM or C1-C2 transarticular screw placement carries a potential risk of ICA injury. Given the wide variation in ICA location relative to C1, if bicortical C1 fixation is required, preoperative CTA should be considered to determine the optimal screw trajectory. In general, inferomedially angulated C1-LM screws appear to be safer with respect to the ICA injury than other potential trajectories.
The spine journal: official journal of the North American Spine Society 04/2011; 11(4):316-23. · 2.90 Impact Factor
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ABSTRACT: Spinal metastases are found in most patients who die of cancer. The number of patients with symptomatic spinal metastases likely will increase as therapy for the primary disease improves and as cardiovascular mortality decreases. Understanding the epidemiology of metastatic spine disease and its presentation is essential to developing a diagnostic strategy. Treatment may involve chemotherapy, corticosteroids, radiotherapy, surgery, and/or percutaneous procedures (eg, vertebroplasty, kyphoplasty). A rational treatment plan can help improve quality of life, preserve neurologic function, and prolong survival.
The Journal of the American Academy of Orthopaedic Surgeons 01/2011; 19(1):37-48. · 2.66 Impact Factor
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ABSTRACT: Comparative study.
To compare the radiographic and clinical outcomes of patients undergoing extension of a previous idiopathic scoliosis fusion to the sacrum using either autogenous bone graft or recombinant human bone morphogenetic protein-2 (rhBMP-2).
Extension of an existing idiopathic scoliosis fusion to the sacrum for distal degeneration or sagittal imbalance has been associated with a high rate of pseudarthrosis. We hypothesized that rhBMP-2 could be successfully used as a substitute for distant autograft in this challenging population.
Consecutive patients were identified from a single institution prospective database. The control group (autogenous harvesting without rhBMP-2, 1998-2002) included 24 of 25 patients with minimum 2-year follow-up while the study group (rhBMP-2 without distant autograft, 2002-2006) included 36 of 39 patients with minimum 2-year follow-up. Radiographs were measured using standard adult deformity criteria. Fusions were evaluated by independent observers using a published 4-point scale. Clinical outcomes were evaluated using Scoliosis Research Society and Oswestry Disability Index Questionnaires.
Groups were well matched with respect to demographic, radiographic, and surgical data with the following exceptions: the control group (autogenous graft, no BMP) was younger (43.5 vs. 49.8 years; P = 0.04), had more anterior levels fused (3.3 vs. 1.7; P = 0.01), more thoracoabdominal approaches (25% vs. 2.7%; P = 0.01), and greater estimated blood loss (1938 vs. 1221 mL; P = 0.01). There was 1 wound complication (deep infection) in each group. Rates of radiographic pseudarthrosis (11.1% vs. 20.8%) and revision for pseudarthrosis (5.6% vs. 12.5%) were lower in the rhBMP-2 group, although this did not reach statistical significance. Preoperative, postoperative, and improvements in Scoliosis Research Society and Oswestry Disability Index scores were similar between groups. We did not observe any increase in adverse events with the use of rhBMP-2.
BMP-2 is a safe and effective alternative to iliac or rib harvesting when extending an existing idiopathic scoliosis fusion to the sacrum.
Spine 09/2010; 35(20):1843-8. · 2.08 Impact Factor
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ABSTRACT: Rates of adverse events after cervical arthroplasty mirror those of arthrodesis. Different patterns of adverse events occur including those related to any prosthetic devices such as subsidence, heterotrophic ossification, dislodgement, malposition, and infection. The use of proper indications, preoperative planning, and meticulous techniques can avoid the majority of these complications. Sizing and exact placement in the correct mechanical axis is essential and requires accurate biplanar fluoroscopic imaging. Further, spinal related events include clinical failure related to inadequate foramenal decompression and spinal cord injury. Compared with arthrodesis where residual foramenal stenosis may be tolerated, maintenance of motion by arthroplasty may cause loading in the uncus with further hypertrophy and persistent or recurrent symptoms. This is best prevented by assuring wide foramenal decompression at the time of arthroplasty. Spinal cord injury during implantation has not been reported. Wear of the bearing surfaces and formation of debris particles can cause loosening and prosthetic failure. This has not been reported as yet after cervical arthroplasty due to the relatively short time of follow-up for most devices. Two notable cases of apparent metal hypersensitivity causing formation of a pseudotumor have been seen after placement of a metal on metal cobalt-chrome prosthesis. The treatment of malpositioned or hardware-related events is by removal and arthrodesis usually not requiring corpectomy and fusion of other levels. Radiculopathy from foramenal stenosis at the index level site can be resolved with posterior microforamenotomy.
Techniques in Orthopaedics 05/2010; 25(2):138-144.
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ABSTRACT: Radiologic evaluation of computed tomography (CT) scans using screw insertion simulation software.
To investigate the optimal entry point and trajectory of atlantooccipital transarticular screws.
To our knowledge, no large series focusing on the placement of atlantooccipital transarticular screws have been published.
We used 1.0-mm sliced CT scans and 3-dimensional screw trajectory software to simulate 4.0-mm screw placement. Four entry points were evaluated. Screw placement success rate, safe range of medial angulation, and screw length using each entry point were determined.
CT scans of 126 patients were evaluated, for a total of 252 screws for each entry point. On simulation, the 2 lateral entry points showed significantly higher success rates and safe range of medial angulation than the 2 middle points. The 2 lateral entry points had similar success rates (98.0% for anteriolateral (AL) point and 97.6% for posteriolateral (PL) point). Although the safe range of medial angulation was significantly wider for the AL point (26.1 degrees) than for the PL point (23.7 degrees), the screw lengths were significantly longer for the PL point (32.6 mm) than for the AL point (29.4 mm). For both points, 30 degrees of medial angulation led to highest rate of successful screw placement, but the rate was only 79.4% and 80.2%, respectively.
Although there was no significant difference in success rates between AL and PL points, PL is likely the best entry point. Although 30 degrees medial and approximately 5 degrees upward angulation led to the highest rate of successful screw placement, the rate was only around 80%. Given the wide individual variation, we recommend that a preoperative 3-dimensional CT scan be obtained when attempting atlantooccipital transarticular screw fixation.
Spine 04/2010; 35(16):1562-70. · 2.08 Impact Factor
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ABSTRACT: Consecutive case series.
The purpose of this study was to analyze the pseudarthrosis rate in a large series of recombinant human bone morphogenetic protein-2 (rhBMP-2) augmented multilevel (> or =3 levels) anterior cervical fusions.
The reported pseudarthrosis rate following anterior cervical fusion varies from 0% to 20% for single-level and up to 50% for multilevel fusions. It has been postulated that the use of rhBMP-2 may decrease the pseudarthrosis rate.
A consecutive series of patients with cervical spondylosis and/or disc herniation who underwent anterior cervical fusion with rhBMP-2, structural allograft, and plate fixation with a minimum 2-year follow-up were analyzed by experienced, independent spine surgeons.
A total of 127 patients (54 men and 73 women with mean age of 54 +/- 10 years [range, 32-79]) were examined. Seventy-five (59.1%) patients underwent a 3-level fusion, 34 (26.7%) underwent a 4-level fusion, and 18 (14.2%) underwent a 5-level fusion. Of the 451 fusion segments, 14 segments (3.1%) in 13 of 127 patients (10.2%) had evidence of pseudarthrosis at 6 months following surgery. Of the 13 patients with a pseudarthrosis, 3 had a 3-level fusion (3/75 patients [4.0%]), 6 had a 4-level fusion (6/34 patients [17.4%]), and 4 had a 5-level fusion (4/18 patients [22.2%]). Five patients were asymptomatic and were not revised, but the remaining 8 patients required additional surgery. In 12 of 13 patients with a pseudarthrosis, the nonunion occurred at the lowest fusion level and at the cervicothoracic junction. The only statistically significant risk factor for developing a pseudarthrosis was the number of fusion levels.
In a large series of rhBMP-2 augmented multilevel fusions, the pseudarthrosis rate was 10.2% at 6 months following surgery. Since the risk of pseudarthrosis increases with the number of fusion levels, a long fusion lever arm may biomechanically overwhelm the biologic advantage of rhBMP-2. While rhBMP-2 is known to enhance fusion rates, it does not guarantee fusion in all situations.
Spine 03/2010; 35(7):747-53. · 2.08 Impact Factor
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ABSTRACT: Retrospective review of prospectively collected data.
To identify the cause of failed open-door laminoplasty and to describe the surgical strategies for revision surgery.
Although laminoplasty has become popular, few articles have addressed the cause of failed cervical laminoplasty requiring revision surgery.
All patients who required revision surgery following open-door cervical laminoplasty were identified. Clinical data, method of surgical revision, time between surgeries, Nurick grade, radiologic parameters, and complications were analyzed. Laminoplasty failures were classified into 3 categories: "technique related," "inadequate symptomatic relief after treatment," or "recurrence of symptoms due to disease progression."
A total of 130 patients underwent cervical laminoplasty over a 10-year period (1996-2006), and 12 patients (9.2%) required revision surgery. The mean age was 50.7 years at the time of the index laminoplasty (range, 34-67 years) and 51.8 years (range, 35-70 years) at the time of the revision surgery. Mean duration of symptoms was 7.3 months before the index procedure (range, 2-17 months) and 5.6 months (range, 1-14 months) before revision surgery. The mean time interval between the index procedure and revision surgery was 16.6 months (range, 4-43 months). Of the 12 patients who required revision surgery, 5 had global lordosis of <10 degrees, 4 developed local kyphosis >13 degrees, and 5 had increased degenerative spondylolisthesis. Nonmyelopathic causes resulted in 50% of the revision surgery. Of 12 patients, 3 (25%) required revision surgery due to technique-related factors; 1 (8%) required surgery due to inadequate symptomatic relief after treatment; and 8 (67%) required revision surgery due to disease progression.
Of the 130 patients who underwent cervical laminoplasty over a 10-year period, 12 patients (9.2%) required revision surgery. Although laminoplasty is generally successful, failures due to disease progression, technique-related factors, and inadequate symptomatic relief after treatment can occur. Patients should, therefore, be counseled regarding the potential need for revision surgery when undergoing open-door laminoplasty.
Spine 12/2009; 34(25):2760-8. · 2.08 Impact Factor
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ABSTRACT: Although there have been case reports describing the use of cervical disc arthroplasty for the treatment of myelopathy, there is a concern that motion preservation may maintain microtrauma to the spinal cord, negatively affecting the clinical results. As we are not aware of any studies on the use of arthroplasty in this scenario, we performed a cross-sectional analysis of two large, prospective, randomized multicenter trials to evaluate the efficacy of cervical disc arthroplasty for the treatment of myelopathy.
The patients in the current study were a cohort of patients who were enrolled in the United States Food and Drug Administration Investigational Device Exemption studies of the Prestige ST and Bryan disc replacements (Medtronic, Memphis, Tennessee). The inclusion criteria were myelopathy and spondylosis or disc herniation at a single level from C3 to C7. Clinical outcome measures were collected preoperatively and at six weeks, three months, six months, twelve months, and twenty-four months postoperatively.
A total of 199 patients were included in the present study; 106 patients (53%) underwent arthroplasty, whereas ninety-three (47%) underwent arthrodesis. The Neck Disability Index, Short Form-36 scores, and specific arm and neck pain scores improved significantly from baseline at all time points. Patients in all four groups had improvement in the postoperative neurological status and gait function; at twenty-four months after surgery, 90% (95% confidence interval, 77.8% to 96.6%) of the patients in the arthroplasty group and 81% (95% confidence interval, 64.9% to 92.0%) of those in the arthrodesis group had improvement in or maintenance of the neurological status in the Prestige ST trial and 90% (95% confidence interval, 75.8% to 97.1%) of the patients in the arthroplasty group and 77% (95% confidence interval, 57.7% to 90.1%) of those in the arthrodesis group had improvement in or maintenance of the neurological status in the Bryan trial.
We found that patients in both the arthroplasty and arthrodesis groups had improvement following surgery; furthermore, improvement was similar between the groups, with no worsening of myelopathy in the arthroplasty group. While the findings at two years postoperatively suggest that arthroplasty is equivalent to arthrodesis for the treatment of cervical myelopathy for a single-level abnormality localized to the disc space, the present study did not evaluate the treatment of retrovertebral compression as occurs in association with ossification of the posterior longitudinal ligament, and we cannot comment on the treatment of this condition.
The Journal of Bone and Joint Surgery 10/2009; 91 Suppl 2:223-32. · 3.27 Impact Factor
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ABSTRACT: Comparative study.
To compare the radiographic outcome of patients undergoing long spinal deformity surgery to the sacrum/ilium, using either rhBMP-2 without iliac crest bone graft (ICBG) or ICBG without rhBMP-2.
rhBMP-2 has been shown to be more effective in promoting successful bone union in patients undergoing single level lumbar spinal fusion than ICBG. However, to the best of our knowledge, there are no studies that compare the efficacy of rhBMP-2 versus ICBG in long spinal deformity surgery.
To obtain uniform background, we selected patients with adult spinal deformity who underwent primary spinal fusion from the thoracic spine to the sacrum/ilium and had a minimum 2-year follow-up. Fifty-five consecutive patients, consisting of 32 patients who underwent a fusion using ICBG without rhBMP-2 (ICBG group) and 23 patients who underwent a fusion using rhBMP-2 without ICBG (BMP group) were analyzed.
The 2 groups were similar with respect to age, gender, smoking history, comorbidity, and body mass index. The average number of vertebrae fused (11.3 in both groups) and the degree of preoperative deformity (major Cobb angle 58.3 degrees in ICBG group vs. 54.2 degrees in BMP group) were also similar in both groups. All but 2 patients had both anterior and posterior surgery. Both groups were similar in terms of final deformity correction. The average total amount of rhBMP-2 used in the BMP group was 119.2 mg (anterior 11.6 mg/level; posterior 10.0 mg/level). Of the 32 patients in the ICBG group, 9 patients (28.1%) developed a pseudarthrosis, while only 1 of 23 patients (4.3%) in the BMP group developed a pseudarthrosis with the caveat that the follow-up period was shorter in the BMP group (average follow-up of 4.9 vs. 2.7 years).
The pseudarthrosis rate in the BMP group compares favorably to pseudarthrosis rate in ICBG group, suggesting that the use of rhBMP-2 without iliac harvesting leads to a competitive fusion rate in long adult spinal deformity surgery, while avoiding ICBG harvest site morbidity.
Spine 09/2009; 34(20):2205-12. · 2.08 Impact Factor
