Article

Is It Beneficial to Remove the Pedicle Screw Instrument After Successful Posterior Fusion of Thoracolumbar Burst Fractures?

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Abstract

Case-control study. To investigate the clinical and radiological outcomes of pedicle screw removal after successful fusion of thoracolumbar burst fractures. Implant removal is a common procedure in orthopedic surgery, although the benefits of and indications for removal remain controversial. Previous studies on pedicle screw removal have reported conflicting outcomes, because the study subjects and surgical goals were heterogeneous in nature. We studied 45 consecutive patients who underwent implant removal and a control cohort of 45 age- and sex-matched patients who retained their spinal implants after successful posterior fusion of thoracolumbar burst fractures using pedicle screw instrument. In most cases, long-segment instrumentation with short-segment posterior fusion was performed. The mean elapsed period prior to implant removal after index fracture surgery was 18.3 ± 17.6 months. A visual analogue scale for back pain was applied, the Oswestry disability index calculated, and radiological parameters derived at the time of implant removal and 1 and 2 years postoperatively obtained. These data were compared with those of the control group evaluated at the same times after index fracture surgery. Patient demographics, mechanisms of injury, fracture morphologies, and the outcomes of index fracture surgery were similar between the 2 groups. The mean visual analogue scale and Oswestry disability index scores were better at both the 1- and 2-year follow-ups in the implant removal group than in the control group (all P values = 0.000). The segmental motion angle of the implant removal group was 1.6° ± 1.5° at the time of implant removal, and increased significantly to 5.8° ± 3.9° at 1-year follow-up (P = 0.000), and was maintained at this level at the 2-year follow-up (5.9° ± 4.1°) (P = 0.000). In patients treated successfully for thoracolumbar burst fractures, pedicle screw removal is beneficial because it alleviates pain and disability. Restoration of the segmental motion angle after implant removal may contribute to the clinical improvement. 3.

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... Surgical site infection, pain, implant breakage or loosening, and soft tissue irritation are indications for implant removal (6,7). However, in some successful asymptomatic cases, the indications for implant removal remain controversial. ...
... However, in some successful asymptomatic cases, the indications for implant removal remain controversial. Pedicle screw removal may eliminate the potential risks of metal fretting, infection, micromotion, disc degeneration, allergic reaction, and osteopenia caused by stress shielding (5,7,8); however, implant removal as a second surgical operation is accompanied by the risks of surgical site infection, neurovascular injury, and refracture (7,9). ...
... However, in some successful asymptomatic cases, the indications for implant removal remain controversial. Pedicle screw removal may eliminate the potential risks of metal fretting, infection, micromotion, disc degeneration, allergic reaction, and osteopenia caused by stress shielding (5,7,8); however, implant removal as a second surgical operation is accompanied by the risks of surgical site infection, neurovascular injury, and refracture (7,9). ...
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Objective Fractures of the thoracolumbar spine are the most common fractures of the spinal column. This retrospective cohort study aimed to determine whether it is necessary to remove implants of patients aged over 65 years after the fixation of thoracolumbar and lumbar burst fractures without fusion. Methods This retrospective cohort study included 107 consecutive patients aged ≥65 years without neurological deficits, who underwent non-fusion short posterior segmental fixation for thoracolumbar or lumbar burst fractures. Outcome measures included the visual analog score (VAS), Oswestry Disability Index (ODI), residual symptoms, complications, and imaging parameters. Patients were divided into groups A (underwent implant removal) and B (implant retention) and were examined clinically at 1, 3, 6, and 12 months postoperatively and annually thereafter, with a final follow-up at 48.5 months. Results Overall, 96 patients with a mean age of 69.4 (range, 65–77) years were analyzed. At the latest follow-up, no significant differences were observed in functional outcomes and radiological parameters between both groups, except in the local motion range (LMR) ( P = 0.006). Similarly, between preimplant removal and the latest follow-up in group A, significant differences were found only in LMR ( P < 0.001). Two patients experienced screw breakage without clinical symptoms. Significant differences were only found in operation time, blood loss, ODI, and fracture type between minimally invasive group and open group. Conclusions Similar radiological and functional outcomes were observed in elderly patients, regardless of implant removal. Implant removal may not be necessary after weighing the risks and benefits for elderly patients. Patients should be informed about the possibility of implant breakage and accelerating degeneration of adjacent segments in advance.
... Pooled standard deviation of age with data extractable from 5 studies was 11.5 years. 28,31,33,35,36 The cumulative percentage of the studied population that was male was 63.7%. The most common level of burst fracture was L1 with 254 fractures (37.7%). ...
... Jeon et al were the only study to perform short-segment fusion with autoiliac corticocancellous bone graft. 35 The most common time of implant removal was 12 months (10-24 months) with followup occurring 12-120 months post-operatively (Table 2). ...
... 30,31,34 Given its invaluable use as a surrogate of deformity correction after thoracolumbar burst fracture fixation, 12 of the 13 included studies in this systematic review reported the Cobb Angle as an outcome measure. [29][30][31][32][33][34][35][36][37][38][39][40] Seven of these studies demonstrated that there was statistically significant loss of CA correction after implant removal. In their 2016 study, Aono et al found that just before implant removal at 12 months there was surgical reduction loss by 2.38 degrees, which deteriorated by another 7.58 degrees after removal. ...
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Study Design Systematic review and meta-analysis. Objectives To compare biomechanical and functional outcomes between implant removal and implant retention following posterior surgical fixation of thoracolumbar burst fractures. Methods A search of the MEDLINE, EMBASE, Google Scholar and Cochrane Databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Results Of the 751 articles initially retrieved, 13 published articles pooling 673 patients were included. Meta-analysis revealed there was a statistically significant improvement in sagittal Cobb Angle by 16.48 degrees (9.13-23.83, p < 0.01) after surgical stabilization of thoracolumbar burst fractures. This correction decremented to 9.68 degrees (2.02-17.35, p < 0.01) but remained significant at the time of implant removal approximately 12 months later. At final follow-up, the implant removal group demonstrated a 10.13 degree loss (3.00-23.26, p = 0.13) of reduction, while the implant retention group experienced a 10.17 degree loss (1.79-22.12, p = 0.10). There was no statistically significant difference in correction loss between implant retention and removal cohorts (p = 0.97). Pooled VAS scores improved by a mean of 3.32 points (0.18 to 6.45, p = 0.04) in the combined removal group, but by only 2.50 points (-1.81 to 6.81, p = 0.26) in the retention group. Oswestry Disability Index scores also improved after implant removal by 7.80 points (2.95-12.64, p < 0.01) at 1 year and 11.10 points (5.24-16.96, p < 0.01) at final follow-up. Conclusions In younger patients with thoracolumbar burst fractures who undergo posterior surgical stabilization, planned implant removal results in superior functional outcomes without significant difference in kyphotic angle correction loss compared to implant retention.
... Although this approach is widely accepted with satisfying outcomes, several studies found the vertebral body to recollapse and kyphosis to recur after surgery, especially after implant removal [6,7]. Therefore, whether the implant should be removed after vertebral healing is controversial in the context of this nonfusion surgery [8][9][10]. The decision for implant removal is not easy to make because there are no classification systems or criteria that can help to estimate whether the healed vertebral body will have sufficient strength after implant removal. ...
... In our experience, although most of the patients experienced fracture union after surgery, not all the fractured vertebrae healed perfectly. Cavities or lesions can remain in the healed vertebral bodies, as observed in figures from previously reported studies in the literature [9,[11][12][13]. Given that focal regions of bone loss have been proven to reduce the structural competence of vertebrae, these cavity lesions may be significantly related to the recurrence of vertebral collapse after implant removal [14][15][16]. ...
... Instrumentation removal after vertebral healing is considered beneficial in cases of posterior short-segment fixation without fusion [9,10]. However, its indication is unclear because the vertebra may recollapse after implant removal. ...
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Background: Thoracolumbar burst fractures can be treated with posterior short-segment fixation. However, no classification can help to estimate whether the healed vertebral body will have sufficient stability after implant removal. We aimed to develop a Healing Pattern Classification (HPC) to evaluate the stability of the healed vertebra based on cavity size and location. Methods: Fifty-two thoracolumbar burst fracture patients treated with posterior short-segmental fixation without fusion and followed up for an average of 3.2 years were retrospectively studied. The HPC was divided into 4 types: type I - no cavity; type II - a small cavity with or without the violation of one endplate; type III - a large cavity with or without the violation of one endplate; and type IV - a burst cavity with the violation of both endplates or the lateral cortical shell. The intraobserver and interobserver intraclass correlation coefficients (ICCs) of the HPC were assessed. The demographic characteristics and clinical outcomes of the cohort were compared between the stable group (types I and II) and the unstable group (types III and IV). Logistic regression was conducted to evaluate risk factors for unstable healing. Results: The intraobserver and interobserver ICCs of the HPC were 0.86 (95% CI = 0.74-0.90) and 0.77 (95% CI = 0.59-0.86), respectively. While the unstable healing group (types III and IV) accounted for 59.6% of the patients, most of these patients were asymptomatic. The preoperative Load Sharing Classification (LSC) comminution score may predict the occurrence of unstable healing (OR = 8.4, 95% CI = 2.4-29.7). Conclusions: A reliable classification for assessing the stability of a healed vertebra was developed. With type I and II healing, the vertebra is considered stable, and the implant can be removed. With type III healing, the vertebra may have healing potential, but the implant should not be removed unless type II healing is achieved. With type IV healing, the vertebra is considered extremely unstable, and instrumentation should be maintained. Assessing the LSC comminution score preoperatively may help to predict unstable healing after surgery.
... When fracture consolidation is present, posterior implants have become dispensable [9]. Possible concerns of in situ implants are thought to be disc degeneration, facet arthrosis, micromotion, metal fretting, infections and osteopenia caused by stress shielding [9][10][11][12][13]. On the contrary, removing the implant is accompanied with risks such as surgical site infection, neurovascular injury, loss of reduction and refracture [10,14,15]. ...
... Possible concerns of in situ implants are thought to be disc degeneration, facet arthrosis, micromotion, metal fretting, infections and osteopenia caused by stress shielding [9][10][11][12][13]. On the contrary, removing the implant is accompanied with risks such as surgical site infection, neurovascular injury, loss of reduction and refracture [10,14,15]. So far, there is no unanimity about the necessity and timing of the removal of implants. ...
... Previous studies on implant removal focused merely on removal after surgery for deformity correction and low back pain, or only described results of implant removal because of implant related symptoms [9,12,[14][15][16][17]. Some described only small cohorts [2,4,16] or focused largely on removal of long-segment fixation [10]. Other studies focused on the posterior stabilization itself, but advocated routine removal of implants to regain mobility of the spine and minimize potential damage [4,18]. ...
Article
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Purpose: Debate remains whether posterior implants after thoracolumbar spine fracture stabilization should be removed routinely or only in symptomatic cases. Implant related problems might be resolved or even prevented but removal includes secondary risks. The aim of this study was to evaluate safety, patient satisfaction and quality of life after implant removal. Methods: A retrospective cohort study was performed concerning 102 patients that underwent posterior implant removal after stabilization of a traumatic thoracolumbar fracture between 2003 and 2015. Patients were invited to fill in SF-36, EQ-5D and RMDQ questionnaires after implant removal. Additionally, questions concerning satisfaction were presented. Cobb angles before and after removal were measured and in- or decrease of symptoms was gathered from hospital charts. Results: Mean age at removal was 38 years and time from implant removal to questionnaire was approximately 7 years, 62 patients filled in the questionnaires. Complications were present in 8% and quality of life was reported as fairly good. Patients had less back pain related disability compared to chronic low back pain patients. After removal there was a kyphosis increase which did not correspond with worsened clinical outcome. Removal decreased most symptoms and even asymptomatic patients reported benefit in most cases. An increase of symptoms after removal was reported in 11% of patients. Conclusion: Implant removal is generally safe and provides high patient satisfaction. Overall, patients have a fairly good quality of life. Most symptomatic and asymptomatic patients report benefit from removal. However, low risks of complications and increase of symptoms have to be weighted for individual patients.
... Jeon et al. 10 reported 45 patients with implant removal and 45 age-and gender-matched patients with implant retainment after being successfully treated for thoracolumbar (T11-L2) burst fractures. Both the mean VAS for back pain and the mean ODI in the implant removal group were signi cantly lower than those in the control group at the 1-year and 2-year follow-up. ...
... As for ROM of the xed vertebral segments, studies 10 Based on our study covering the whole course of treatment, we concluded that patients with thoracolumbar fractures (T11-L3) in group A can achieve a functional segmental ROM 11.5° on average and restore 41.6% of the normal value, which is in accordance with Ko's ndings. Meanwhile, the average ROM in group B was close to Jeon's ndings and did little to improve spinal mobility. ...
... Ko et al. observed 60 patients who received posterior xation without fusion for thoracolumbar and lumbar fractures (T11-L3), and then they underwent implant removal at a mean time of 12.2 months.They concluded that, based on 38 months of follow-up after implant removal, the total mean ROM was 9.12°2 5 . In addition, Jeon et al.10 studied 45 cases with thoracolumbar fractures (T11-L2) treated by longsegment instrumentation (4.4 levels on average) with short-segment fusion (1.2 levels on average). The time from index fracture surgery to implant removal was 18.3 months on average. ...
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Background Posterior fixation without fusion can treat thoracolumbar and lumbar traumatic fractures effectively. However, whether patients benefit from implant removal, as well as the correlation between the range of motion (ROM) of the involved segments and the removal time, has not been determined. Methods Fifty consecutive cases with thoracolumbar traumatic fractures that had undergone implant removal at different times were enrolled. We found 17 patients (Group A), 21 patients (Group B), and 12 patients (Group C) underwent implant removal following the index surgery within 12 months, between 12 to 24 months, and over 24 months, respectively. Clinical and radiological outcomes, including visual analog scale (VAS) for back pain, patient satisfaction, the Oswestry disability index (ODI) and EuroQol five dimensions questionnaire (EQ-5D) for quality of life and segmental ROM were analyzed. Results The average follow-up time was 9.1 ± 5.7 months after implant removal. There were no significant differences in VAS and patient satisfaction among the three groups at the same observation time points. Patients of group A gained the lowest ODI and highest EQ-5D scores after removal and at final follow-up than those in group B and C. The best ROM was obtained in Group A followed by Group B and C (11.5 ± 6.2°, 5.5 ± 1.6° and 2.4 ± 0.6°, respectively). Conclusions Immobilization of the involved segments over 24 months may lead to ankylosis. Regained segmental ROM is correlated negatively with implant removal time. Patients have implant removal within 12 months can gain a better quality of life.
... This result is especially relevant because kyphosis after implant removal and whether implants should be removed have recently been topics of discussion in the literature. [11,12,23,24] For example, Jeon et al [23] reported improvement in functional outcomes after implant removal in patients who underwent long-segment fixation using the fusion technique. In contrast, Chou et al [24] found no changes in radiological and functional outcomes after implant removal in patients treated with short-segment fixation. ...
... This result is especially relevant because kyphosis after implant removal and whether implants should be removed have recently been topics of discussion in the literature. [11,12,23,24] For example, Jeon et al [23] reported improvement in functional outcomes after implant removal in patients who underwent long-segment fixation using the fusion technique. In contrast, Chou et al [24] found no changes in radiological and functional outcomes after implant removal in patients treated with short-segment fixation. ...
Article
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The aim of the present study is to identify factors correlated with kyphotic deformity after thoracolumbar spine injuries. We performed a retrospective case-control study with data from thoracolumbar spine fracture patients who were treated with posterior spinal fixation. Patients with a follow-up period shorter than 6 months and who experienced low-energy trauma were excluded. Intervertebral disc injuries (IDIs) were graded from 0 to 3 upon admission in accordance with Sander's classification of traumatic intervertebral disc lesions. Vertebral wedge angles (VWAs) and local kyphosis angles (LKAs) were also measured. Patients were allocated to kyphosis and control groups if they had LKA correction losses of ≥10° and <10°, respectively. Forty-eight patients followed over a median period of 25 months were included. The median correction loss at the site of the injured vertebral body was 2.0°. The median LKA correction loss was 9.0°. Twenty-three and 25 patients were allocated to the kyphosis and control groups, respectively. Univariate analysis revealed that the median age was significantly lower in the kyphosis (35 years) than control group (56 years). The level of injury and IDI severity also significantly differed between groups, with a significantly greater proportion of more severe IDI cases in the kyphosis than control group. Finally, significantly more patients in kyphosis group underwent fusion (kyphosis, 19 vs control, 13) and implant removals (kyphosis, 19 vs control, 10). Multiple regression analysis revealed that IDI severity according to Sander's classification (P = .005; odds ratio, 5.263; 95% confidence interval [CI], 1.637-16.927) and implant removal (P = .011; odds ratio, 7.980; 95% CI, 1.603-39.728) were significantly associated with kyphotic deformity. IDI severity at initial magnetic resonance imaging (MRI) evaluation and implant removal are associated with kyphotic deformity after posterior fixation of thoracolumbar spine injuries. Thus, initial MRI evaluation of IDIs could be used to predict of recurrent kyphosis.
... Posterior instrumentation removal after ACR is another issue that may be debated. In general, the need and potential benefits of implant removal after thoracolumbar fracture stabilization remains controversial and substantially varies between different countries [33][34][35][36][37]. Posterior instrumentation removal after monosegmental ACR, however, is essential to restore mobility in the nonfused segment and to provide the patients with the potentially beneficial effects of sparing one motion segment. ...
... Limitations of our study include the relatively small sample size and the retrospective study design. Moreover, fusion was not assessed due to the lack of follow-up CT imaging, and posterior instrumentation was only removed in half of the patients after monosegmental ACR to regain mobility of the spared segment [33]. Finally, when relating the clinical and radiological outcome of monosegmental ACR to that of bisegmental ACR, we were aware that the average degree of vertebral body injury had been greater in the bisegmental than in the monosegmental ACR group. ...
Article
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Introduction: In combined posterior-anterior stabilization of thoracolumbar burst fractures, the expandable vertebral body replacement device (VBRD) is typically placed bisegmentally for anterior column reconstruction (ACR). The aim of this study, however, was to assess feasibility, outcome and potential pitfalls of monosegmental ACR using a VBRD. In addition, clinical and radiological outcome of monosegmental ACR was related to that of bisegmental ACR using the same thoracoscopic technique. Methods: Thirty-seven consecutive neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2) treated by combined posterior-anterior stabilization were included. Monosegmental ACR was performed in 18 and bisegmental ACR in 19 patients. Fracture type and extent of vertebral body comminution were determined on preoperative CT scans. Monosegmental and bisegmental kyphosis angles were analyzed preoperatively, postoperatively and at final radiological follow-up. Clinical outcome was assessed after a minimum of 2 years (74 ± 45 months; range 24-154; follow-up rate 89.2%) using VAS Spine Score, RMDQ, ODI and WHOQOL-BREF. Results: Monosegmental ACR resulted in a mean monosegmental and bisegmental surgical correction of - 15.6 ± 7.7° and - 14.7 ± 8.1°, respectively. Postoperative monosegmental and bisegmental loss of correction averaged 2.7 ± 2.7° and 5.2 ± 3.7°, respectively. Two surgical pitfalls of monosegmental ACR were identified: VBRD positioning (1) onto the weak cancellous bone (too far cranially to the inferior endplate of the fractured vertebra) and (2) onto a significantly compromised inferior endplate with at least two (even subtle) fracture lines. Ignoring these pitfalls resulted in VBRD subsidence in five cases. When relating the clinical and radiological outcome of monosegmental ACR to that of bisegmental ACR, no significant differences were found, except for frequency of VBRD subsidence (5 vs. 0, P = 0.02) and bisegmental loss of correction (5.2 ± 3.7° vs. 2.6 ± 2.5°, P = 0.022). After exclusion of cases with VBRD subsidence, the latter did not reach significance anymore (4.9 ± 4.0° vs. 2.6 ± 2.5°, P = 0.084). Conclusions: This study indicates that monosegmental ACR using a VBRD is feasible in thoracolumbar burst fractures if the inferior endplate is intact (incomplete burst fractures) or features only a single simple split fracture line (burst-split fractures). If the two identified pitfalls are avoided, monosegmental ACR may be a viable alternative to bisegmental ACR in selected thoracolumbar burst fractures to spare a motion segment and to reduce the distance for bony fusion.
... A recent meta-analysis suggested there is no signi cant difference between non-fusion and fusion in terms of radiological outcome, functional outcome, neurologic improvement, or implant failure rate, but nonfusion is associated with signi cantly reduced operative time and blood loss [8]. Also, implant removal, which is performed secondarily after bone union, decreases the stiffness of the xed segment, which in turn could alleviate the concentration of stress in adjacent segments [9,10]. However, the occurrence of secondary kyphosis has recently attracted attention, with reports that 29%-43% of patients developed it after implant removal [11,12]. ...
... These ndings should be helpful in the clinical setting because there has been little consensus to date on what constitutes routine implant removal in the context of healed fracture. Even though implant removal is probably common practice among spine surgeons after bone union, because it decreases the stiffness of the xed segment and reduces the concentration of stress in the adjacent segments [15], the recurrence of kyphotic deformity is a recognized shortcoming of implant removal following posterior xation, affecting 29%-43% of patients [9,10]. Given that the prognostic factors for secondary kyphotic deformity have not been established yet, our ndings can serve as a reference to assist physicians in deciding whether implant removal should be conducted or not. ...
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Background: Posterior pedicle screw fixation without fusion has been commonly applied for thoracolumbar burst fracture. Implant removal is performed secondarily after bone union. However, the occurrence of secondary kyphosis has recently attracted attention. Secondary kyphosis results in poor clinical outcomes. The purpose of this was to determine predictors of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture. Methods: This retrospective study reviewed 60 consecutive patients with thoracolumbar burst fracture who underwent implant removal following posterior pedicle screw fixation without fusion. Inclusion criteria were non-osteoporotic fracture and T11-L4 burst fracture. Old age, sex, initial severe wedge deformity, initial severe kyphosis, and vacuum phenomenon were examined as factors potentially associated with final kyphotic deformity (defined as kyphotic angle greater than 25°) or loss of correction. Logistic regression analysis was performed using propensity score matching. Results: Among the 31 female and 29 male patients (mean age 39 years), final kyphotic deformity was found in 17 cases (28%). Multivariate analysis showed a significant association with the vacuum phenomenon. Loss of correction was found in 35 cases (58%) and showed a significant association with the vacuum phenomenon. There were no significant associations with other factors. Conclusions: The findings of this study suggest that the vacuum phenomenon before implant removal may be a predictor of secondary kyphosis of greater than 25° after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture, but that old age, sex, initial severe kyphosis, and initial severe wedge deformity may not be predictors.
... A recent meta-analysis suggested there is no signi cant difference between non-fusion and fusion in terms of radiological outcome, functional outcome, neurologic improvement, or implant failure rate, but nonfusion is associated with signi cantly reduced operative time and blood loss [8]. Also, implant removal, which is performed secondarily after bone union, decreases the stiffness of the xed segment, which in turn could alleviate the concentration of stress in adjacent segments [9,10]. However, the occurrence of secondary kyphosis has recently attracted attention, with reports that 29%-43% of patients developed it after implant removal [11,12]. ...
... These ndings should be helpful in the clinical setting because there has been little consensus to date on what constitutes routine implant removal in the context of healed fracture. Even though implant removal is probably common practice among spine surgeons after bone union, because it decreases the stiffness of the xed segment and reduces the concentration of stress in the adjacent segments [15], the recurrence of kyphotic deformity is a recognized shortcoming of implant removal following posterior xation, affecting 29%-43% of patients [9,10]. Given that the prognostic factors for secondary kyphotic deformity have not been established yet, our ndings can serve as a reference to assist physicians in deciding whether implant removal should be conducted or not. ...
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Background: Posterior pedicle screw fixation without fusion has been commonly applied for thoracolumbar burst fracture. Implant removal is performed secondarily after bone union. However, the occurrence of secondary kyphosis has recently attracted attention. Secondary kyphosis results in poor clinical outcomes. The purpose of this was to determine predictors of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture. Methods: This retrospective study reviewed 60 consecutive patients with thoracolumbar burst fracture who underwent implant removal following posterior pedicle screw fixation without fusion. Inclusion criteria were non-osteoporotic fracture and T11-L4 burst fracture. Old age, sex, initial severe wedge deformity, initial severe kyphosis, and vacuum phenomenon were examined as factors potentially associated with final kyphotic deformity (defined as kyphotic angle greater than 25°) or loss of correction. Logistic regression analysis was performed using propensity score matching. Results: Among the 31 female and 29 male patients (mean age 39 years), final kyphotic deformity was found in 17 cases (28%). Multivariate analysis showed a significant association with the vacuum phenomenon. Loss of correction was found in 35 cases (58%) and showed a significant association with the vacuum phenomenon. There were no significant associations with other factors. Conclusions: The findings of this study suggest that the vacuum phenomenon before implant removal may be a predictor of secondary kyphosis of greater than 25° after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture, but that old age, sex, initial severe kyphosis, and initial severe wedge deformity may not be predictors.
... 18 Surgical removal of pedicle screws has been much discussed, 10,19 and remains controversial due to the associated risks of secondary surgery and potential for instability following removal. 20 However, when unexplainable recurrent pain is severe, screw removal has been recommended, [21][22][23][24] and may also reduce risks of metal toxicity and hypersensitivity. 25 We hypothesized that patients with recurrent pain, despite successful arthrodesis, would exhibit pedicle screw loosening. ...
... This study was unable to determine whether screw loosening is present in patients without recurrent pain since unwarranted instrumentation removal for purely observational purposes would not be in the best interests of the patients. However, our observations of patient pain perception are in agreement with several studies, suggesting that pedicle instrumentation removal following successful arthrodesis may relieve recurrent pain, [21][22][23][24] potentially caused by pedicle screw loosening. Further research will be necessary to fully evaluate clinical and pain outcomes and to establish pedicle screw loosening as a causative factor. ...
Article
Pedicle screw loosening has been implicated in recurrent back pain after lumbar spinal fusion, but the degree of loosening has not been systematically quantified in patients. Instrumentation removal is an option for patients with successful arthrodesis, but remains controversial. Here, we quantified pedicle screw loosening by measuring screw insertion and/or removal torque at high statistical power (beta = 0.02) in N = 108 patients who experienced pain recurrence despite successful fusion after posterior instrumented lumbar fusion with anterior lumbar interbody fusion (L2-S1). Between implantation and removal, pedicle screw torque was reduced by 58%, indicating significant loosening over time. Loosening was greater in screws with evoked EMG threshold under 11 mA, indicative of screw misplacement. A theoretical stress analysis revealed increased local stresses at the screw interface in pedicles with decreased difference in pedicle thickness and screw diameter. Loosening was greatest in vertebrae at the extremities of the fused segments, but was significantly lower in segments with one level of fusion than in those with two or more. Clinical significance: These data indicate that pedicle screws can loosen significantly in patients with recurrent back pain and warrant further research into methods to reduce the incidence of screw loosening and to understand the risks and potential benefits of instrumentation removal. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2673-2681, 2017.
... Axelsson et al. reported that late implant removal could restore mobility in fractured segments without bone grafting, depending upon the outcomes of radiostereometry analysis (13). However, whether a decision could be made based on a patient's symptoms rather than the imaging evidence about the necessity of removal surgery is unclear (14). Oh et al. reported that conducting the removal operation within 12 months after the rst surgery could ensure better recovery of the range of motion (ROM) but advised that this surgery should only be recommended to patients with symptoms(15). ...
... Chou et al. reported a series of 69 patients who were followed up for up to 66 months (range: 47-108 months); of these cases, 47 patients underwent implant removal and 22 did not, and there were no statistically signi cant differences in the radiological and functional outcomes between these two groups (8), even though eight patients in the implant retention group experienced screw breakage. However, Jeon et al. reported that, in a case-control study with 45 patients in each group, at 18.3 ± 17.6 months after xation removal, the range of segmental motion was increased signi cantly, and pain (as evaluated with a visual analog scale) and physical function (as evaluated using the Oswestry Disability Index) were improved (14). ...
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Background Intervertebral fusion and internal fixation are often applied to patients with lumbar spinal disease. Whether to remove the internal fixation after successful fusion remains uncertain, but such a question needs to be explored in light of concerns regarding patients’ quality of life and health insurance. We sought to probe if the removal of internal fixation after successful lumbar intervertebral fusion affects patients’ quality of life.Methods This was a real-world retrospective case–control study. Data of 102 patients who had undergone posterior lumbar fusion with cage and internal fixation to treat lumbar degenerative diseases were extracted from a single center from 2012 to 2020. Fifty-one patients had undergone internal fixation removal surgery, and 51 controls who retained internal fixations were matched according to demographic and medical characteristics. The quality of life of patients based on the Medical Outcomes Study Short Form 36 (SF-36) scale and their self-assessment were surveyed.ResultsThere was no statistical difference in the overall score of the SF-36 questionnaire between the two groups, but the general health (GH) subscore was lower in the case group than in the control group (P = 0.0284). Among those patients who underwent internal fixation removal, the quality of life was improved after instrument removal as indicated by an increased overall score (P = 0.0040), physical functioning (PF) (P = 0.0045), and bodily pain (BP) (P = 0.0008). Among patients with pre-surgery discomfort, instrument removal generated better outcomes in 25% and poor outcomes in 4.2%. Among patients without pre-surgery discomfort, instrument removal generated better outcomes in 7.4% and poor outcomes in 11.1%.ConclusionAmong patients who achieved successful posterior lumbar internal fixation, whether or not to remove the fixation instruments should be evaluated carefully. In patients experiencing discomfort, instrument removal could improve their quality of life, but the benefits and risks should be comprehensively explained to these patients. Instrument removal should not be routinely performed due to its limited or even negative effect in patients who do not report discomfort before surgery.
... A recent meta-analysis suggested there is no significant difference between non-fusion and fusion in terms of radiological outcome, functional outcome, neurologic improvement, or implant failure rate, but non-fusion is associated with significantly reduced operative time and blood loss [8]. Also, implant removal, which is performed secondarily after bone union, decreases the stiffness of the fixed segment, which in turn could alleviate the concentration of stress in adjacent segments [9,10]. However, the occurrence of secondary kyphosis has recently attracted attention, with reports that 29-43% of patients developed it after implant removal [11,12]. ...
... These findings should be helpful in the clinical setting because there has been little consensus to date on what constitutes routine implant removal in the context of healed fracture. Even though implant removal is probably common practice among spine surgeons after bone union, because it decreases the stiffness of the fixed segment and reduces the concentration of stress in the adjacent segments [16], the recurrence of kyphotic deformity is a recognized shortcoming of implant removal following posterior fixation, affecting 29-43% of patients [9,10]. Given that the prognostic factors for secondary kyphotic deformity have not been established yet, our findings can serve as a reference to assist physicians in deciding whether implant removal should be conducted or not. ...
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Background Posterior pedicle screw fixation without fusion has been commonly applied for thoracolumbar burst fracture. Implant removal is performed secondarily after bone union. However, the occurrence of secondary kyphosis has recently attracted attention. Secondary kyphosis results in poor clinical outcomes. The purpose of this was to determine predictors of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture. Methods This retrospective study reviewed 59 consecutive patients with thoracolumbar burst fracture who underwent implant removal following posterior pedicle screw fixation without fusion. Inclusion criteria were non-osteoporotic fracture and T11-L3 burst fracture. Old age, sex, initial severe wedge deformity, initial severe kyphosis, and vacuum phenomenon were examined as factors potentially associated with final kyphotic deformity (defined as kyphotic angle greater than 25°) or loss of correction. Logistic regression analysis was performed using propensity score matching. Results Among the 31 female and 28 male patients (mean age 38 years), final kyphotic deformity was found in 17 cases (29%). Multivariate analysis showed a significant association with the vacuum phenomenon. Loss of correction was found in 35 cases (59%) and showed a significant association with the vacuum phenomenon. There were no significant associations with other factors. Conclusions The findings of this study suggest that the vacuum phenomenon before implant removal may be a predictor of secondary kyphosis of greater than 25° after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture, but that old age, sex, initial severe kyphosis, and initial severe wedge deformity may not be predictors.
... Axelsson et al. reported that late implant removal could restore mobility in fractured segments without bone grafting, depending upon the outcomes of radiostereometry analysis [13]. However, whether a decision could be made based on a patient's symptoms rather than the imaging evidence about the necessity of removal surgery is unclear [14]. Oh et al. reported that conducting the removal operation within 12 months after the first surgery could ensure better recovery of the range of motion (ROM) but advised that this surgery should only be recommended to patients with symptoms [15]. ...
... Chou et al. reported a series of 69 patients who were followed up for up to 66 months (range: 47-108 months); of these cases, 47 patients underwent implant removal and 22 did not, and there were no statistically significant differences in the radiological and functional outcomes between these two groups [8], even though eight patients in the implant retention group experienced screw breakage. However, Jeon et al. reported that, in a case-control study with 45 patients in each group, at 18.3 ± 17.6 months after fixation removal, the range of segmental motion was increased significantly, and pain (as evaluated with a visual analog scale) and physical function (as evaluated using the Oswestry Disability Index) were improved [14]. ...
Article
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Background Intervertebral fusion and internal fixation are often applied to patients with lumbar spinal disease. Whether to remove the internal fixation after successful fusion remains uncertain, but such a question needs to be explored in light of concerns regarding patients’ quality of life and health insurance. We sought to probe if the removal of internal fixation after successful lumbar intervertebral fusion affects patients’ quality of life. Methods This was a real-world retrospective case–control study. Data of 102 patients who had undergone posterior lumbar fusion with cage and internal fixation to treat lumbar degenerative diseases were extracted from a single center from 2012 to 2020. Fifty-one patients had undergone internal fixation removal surgery, and 51 controls who retained internal fixations were matched according to demographic and medical characteristics. The quality of life of patients based on the Medical Outcomes Study Short Form 36 (SF-36) scale and their self-assessment were surveyed. Results There was no statistical difference in the overall score of the SF-36 questionnaire between the two groups, but the general health (GH) subscore was lower in the case group than in the control group ( P = 0.0284). Among those patients who underwent internal fixation removal, the quality of life was improved after instrument removal as indicated by an increased overall score ( P = 0.0040), physical functioning (PF) ( P = 0.0045), and bodily pain (BP) ( P = 0.0008). Among patients with pre-surgery discomfort, instrument removal generated better outcomes in 25% and poor outcomes in 4.2%. Among patients without pre-surgery discomfort, instrument removal generated better outcomes in 7.4% and poor outcomes in 11.1%. Conclusion Among patients who achieved successful posterior lumbar internal fixation, whether or not to remove the fixation instruments should be evaluated carefully. In patients experiencing discomfort, instrument removal could improve their quality of life, but the benefits and risks should be comprehensively explained to these patients. Instrument removal should not be routinely performed due to its limited or even negative effect in patients who do not report discomfort before surgery.
... Hsieh et al. [11] suggested that removing spinal fixators after complete fusion could reduce the incidence of adverse effects at adjacent segments. Similarly, Jeon et al. [21] indicated that removing the internal fixation instrument could alleviate pain and disability and improve the clinical and radiographic outcome. ...
Article
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Background: Literature indicates that adjacent-segment diseases after posterior lumbar interbody fusion with pedicle screw fixation accelerate degenerative changes at unfused adjacent segments due to the increased motion and intervertebral stress. Sagittal alignment of the spine is an important consideration as achieving proper lordosis could improve the outcome of spinal fusion and avoid the risk of adjacent segment diseases. Therefore, restoration of adequate lumbar lordosis is considered as a major factor in the long-term success of lumbar fusion. This study hypothesized that the removal of internal fixation devices in segments that have already fused together could reduce stress at the disc at adjacent segments, particularly in patients with inadequate lordosis. The purpose of this study was to analyze the biomechanical characteristics of a single fusion model (posterior lumbar interbody fusion with internal fixation) with different lordosis angles before and after removal of the internal fixation device. Methods: Five finite element models were constructed for analysis; 1) Intact lumbar spine without any implants (INT), 2) Lumbar spine implanted with a spinal fixator and lordotic intervertebral cage at L4-L5 (FUS-f-5c), 3) Lumbar spine after removal of the spinal fixator (FUS-5c), 4) Lumbar spine implanted with a spinal fixator and non-lordotic intervertebral cage at L4-L5 (FUS-f-0c), and 5) Lumbar spine after removal of the spinal fixator from the FUS-f-0c model (FUS-0c). Results: The ROM of adjacent segments in the FUS-f-0c model was found to be greater than in the FUS-f-5c model. After removing the fixator, the adjacent segments in the FUS-5c and FUS-0c models had a ROM that was similar to the intact spine under all loading conditions. Removing the fixator also reduced the contact forces on adjacent facet joints and reduced the peak stresses on the discs at adjacent levels. The greatest increase in stress on the discs was found in the FUS-f-0c model (at both L2/L3 and L3/L4), with intervertebral stress at L3/L4 increasing by 83% when placed in flexion. Conclusions: This study demonstrated how removing the spinal fixation construct after bone fusion could reduce intradiscal pressure and facet contact forces at adjacent segments, while retaining a suitable level of lumbar lordosis.
... To tackle this, Zotti et al. [15] found that removing pedicle screws in patients with persistent lower back pain after solid fusion produced good to excellent clinical outcomes. Jeon et al. [16] analyzed clinical and radiological results after solid fusion of thoracolumbar fractures, and the results showed that removing internal fixators could significantly alleviate patient pain and disability, but the precise mechanism behind this was not clear. A lumbosacral finite element model developed by Hsieh et al. [17] showed that removal of spinal fixators after fusion could decrease the negative impact on adjacent segments. ...
Article
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Interbody fusion with posterior instrumentation is a common method for treating lumbar degenerative disc diseases. However, the high rigidity of the fusion construct may produce abnormal stresses at the adjacent segment and lead to adjacent segment degeneration (ASD). As such, biodegradable implants are becoming more popular for use in orthopaedic surgery. These implants offer sufficient stability for fusion but at a reduced stiffness. Tailored to degrade over a specific timeframe, biodegradable implants could potentially mitigate the drawbacks of conventional stiff constructs and reduce the loading on adjacent segments. Six finite element models were developed in this study to simulate a spine with and without fixators. The spinal fixators used both titanium rods and biodegradable rods. The models were subjected to axial loading and pure moments. The range of motion (ROM), disc stresses, and contact forces of facet joints at adjacent segments were recorded. A 3-point bending test was performed on the biodegradable rods and a dynamic bending test was performed on the spinal fixators according to ASTM F1717-11a. The finite element simulation showed that lumbar spinal fusion using biodegradable implants had a similar ROM at the fusion level as at adjacent levels. As the rods degraded over time, this produced a decrease in the contact force at adjacent facet joints, less stress in the adjacent disc and greater loading on the anterior bone graft region. The mechanical tests showed the initial average fatigue strength of the biodegradable rods was 145 N, but this decreased to 115N and 55N after 6 months and 12 months of soaking in solution. Also, both the spinal fixator with biodegradable rods and with titanium rods was strong enough to withstand 5,000,000 dynamic compression cycles under a 145 N axial load. The results of this study demonstrated that biodegradable rods may present more favourable clinical outcomes for lumbar fusion. These polymer rods could not only provide sufficient initial stability, but the loss in rigidity of the fixation construct over time gradually transfers loading to adjacent segments.
... Material removal should be proposed after consolidation. Several studies showed that lumbar spine segmental motion can be restored after material removal [23,24]. This would also avoid material breakage and adjacent segment injury. ...
Article
Introduction: Magerl type A thoracolumbar fracture is frequent, but consensus is lacking on management, which ranges from non-operative treatment to corpectomy. It is, however, essential to spare adjacent discs in young patients. Historically, Magerl defined type A fracture in terms of isolated bone involvement. Subsequently, several authors suggested that discal lesions are associated, but results were inconsistent. The present study assessed the presence of immediate post-trauma discal lesions and late degeneration. Hypothesis: Type A fracture does not entail discal lesion. Material and method: Fifty-four patients with type A fracture and immediate post-trauma MRI (76 fractures, 138 discs) were retrospectively reviewed. Twenty-seven also had follow-up MRI at a mean 32 months. Two observers analyzed adjacent discs on Oner's classification, on the immediate post-trauma MRI, and on follow-up MRI to assess disc degeneration. Results: Immediate post-trauma analysis of the cranial discs of the fractured vertebrae found 81% normal (type 1), none type 2, 7% type 3, 4% type 4, 7% type 5 and 1% type 6. Caudal discs were 97% type 1. Analysis at follow-up found degeneration in only 15% of cranial and 9% of caudal discs. Discussion: A large majority of type A fractures lead to no immediate discal lesions, and only 15% of cranial discs subsequently degenerate. MRI analyzing disc signal and morphology is essential before removing material. Level of evidence: IV, retrospective study.
... Material removal should be proposed after consolidation. Several studies showed that lumbar spine segmental motion can be restored after material removal [23,24]. This would also avoid material breakage and adjacent segment injury. ...
Article
Introduction: Magerl type A thoracolumbar fracture is frequent, but consensus is lacking on management, which ranges from non-operative treatment to corpectomy. It is, however, essential to spare adjacent discs in young patients. Historically, Magerl defined type A fracture in terms of isolated bone involvement. Subsequently, several authors suggested that discal lesions are associated, but results were inconsistent. The present study assessed the presence of immediate post-trauma discal lesions and late degeneration. Hypothesis: Type A fracture does not entail discal lesion. Material and method: Fifty-four patients with type A fracture and immediate post-trauma MRI (76 fractures, 138 discs) were retrospectively reviewed. Twenty-seven also had follow-up MRI at a mean 32 months. Two observers analyzed adjacent discs on Oner's classification, on the immediate post-trauma MRI, and on follow-up MRI to assess disc degeneration. Results: Immediate post-trauma analysis of the cranial discs of the fractured vertebrae found 81% normal (type 1), none type 2, 7% type 3, 4% type 4, 7% type 5 and 1% type 6. Caudal discs were 97% type 1. Analysis at follow-up found degeneration in only 15% of cranial and 9% of caudal discs. Discussion: A large majority of type A fractures lead to no immediate discal lesions, and only 15% of cranial discs subsequently degenerate. MRI analyzing disc signal and morphology is essential before removing material.
... This may represent measurement error or perhaps some change in disc height that occurs with instrumentation removal. Jeon et al 20 were able to demonstrate improved VAS scores and increased segmental motion after instrumentation removal for TL burst fractures. Early in our experience with percutaneous fixation, we routinely removed implants approximately 9 months after the index procedure. ...
Article
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Study design: Retrospective cohort. Objective: Facet fusion in minimally invasive spine surgery (MISS) may reduce morbidity and promote long-term construct stability. The study compares the maintenance of correction of thoracolumbar (TL) trauma patients who underwent MISS with facet fusion (FF) and without facet fusion (WOFF) and evaluates instrumentation loosening and failure. Methods: TL trauma patients who underwent MISS between 2006 and 2013 were identified and stratified into FF and WOFF groups. To evaluate progressive kyphosis and loss of correction, Cobb angles were measured at immediate postoperative, short-term, and long-term follow-up. Evidence of >2 mm of radiolucency on radiographs indicated screw loosening. If instrumentation was removed, postremoval kyphosis angle was obtained. Results: Of the 80 patients, 24 were in FF and 56 were in WOFF group. Between immediate postoperative and short-term follow-up, kyphosis angle changed by 4.0° (standard error [SE] 1.3°) in the FF and by 3.0° (SE 0.4°) in the WOFF group. The change between immediate postoperative and long-term follow-up kyphosis angles was 3.4° (S.E 1.1°) and 5.2° (S.E 1.6°) degrees in the FF and WOFF groups, respectively. Facet fusion had no impact on the change in kyphosis at short term (P = .49) or long term (P = .39). The screw loosening rate was 20.5% for the 80 patients with short-term follow-up and 68.8% for the 16 patients with long-term follow-up. There was no difference in screw loosening rate. Fifteen patients underwent instrumentation removal-all from the FF group. Conclusion: FF in MISS does not impact the correction achieved and maintenance of correction in patients with traumatic spine injuries.
... However, information should be provided beforehand regarding the possibility of screw breakage [31]. On the contrary, a case-control study by Jeon CH concluded that implants removal is beneficial because it alleviates pain and disability [32]. Furthermore, restoration of the segmental mobility may contribute to the functional improvement. ...
Article
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Background: The management of thoracolumbar burst fractures traditionally involves posterior pedicle screw fixation, but it has some drawbacks. The aim of this study is to evaluate the clinical and radiological outcomes of patients with thoracolumbar burst fractures. They were treated by a modified technique that monoaxial pedicle screws instrumentation and distraction-compression technology assisted end plate reduction. Methods: From March 2014 to February 2016, a retrospective study including 42 consecutive patients with thoracolumbar burst fractures was performed. The patients had undergone posterior reduction and instrumentation with monoaxial pedicle screws. The fractured vertebrae were also inserted screws as a push point. The distraction -compression technology was used as assisting end plate reduction. All patients were followed up at a minimum of 2 years. These parameters including segmental kyphosis, severity of fracture, neurological function, canal compromise and back pain were evaluated in preoperatively, postoperatively and at the final follow-up. Results: The average follow-up period was 28.9 ± 4.3 months (range, 24-39mo). No patients had postoperative implant failure at recent follow-up. The mean Cobb angle of the kyphosis was improved from 14.2°to 1.1° (correction rate 92.1%). At final follow-up there was 1.5% loss of correction. The mean preoperative wedge angle was improved from 17.1 ± 7.9°to 4.4 ± 3.7°(correction rate 74.3%). The mean anterior and posterior vertebral height also showed significant improvements postoperatively, which were maintained at the final follow-up(P < 0.05). The mean visual analogue scale (VAS) scores was 8 and 1.6 in preoperation and at the last follow-up, and there was significant difference (p < 0.05). Conclusion: Based on our experience, distraction-compression technology can assist reduction of collapsed endplate directly. Satisfactory fracture reduction and correction of segmental kyphosis can be achieved and maintained with the use of monoaxial pedicle screw fixation including the fractured vertebra. It may be a good treatment approach for thoracolumbar burst fractures.
... However, information should be provided beforehand regarding the possibility of screw breakage [31]. On the contrary, a case-control study by Jeon CH concluded that implants removal is beneficial because it alleviates pain and disability [32]. Furthermore, restoration of the segmental mobility may contribute to the functional improvement. ...
Article
Full-text available
Background: The management of thoracolumbar burst fractures traditionally involves posterior pedicle screw fixation, but it has some drawbacks. The aim of this study is to evaluate the clinical and radiological outcomes of patients with thoracolumbar burst fractures. They were treated by a modified technique that monoaxial pedicle screws instrumentation and distraction-compression technology assisted end plate reduction.
... Their study concluded that the removal of spinal fixation after complete spinal fusion might mitigate the pathological changes at adjacent segments. Jeon et al. [16] used radiological and clinical data to evaluate the benefits of removing pedicle screws after fusion, finding that removing the spinal fixation could significantly alleviate patients' disability and pain. ...
Article
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Background: Lumbar spinal fusion with rigid spinal fixators as one of the high risk factors related to adjacent-segment failure. The purpose of this study is to investigate how the material properties of spinal fixation rods influence the biomechanical behavior at the instrumented and adjacent levels through the use of the finite element method. Methods: Five finite element models were constructed in our study to simulate the human spine pre- and post-surgery. For the four post-surgical models, the spines were implanted with rods made of three different materials: (i) titanium rod, (ii) PEEK rod with interbody PEEK cage, (iii) Biodegradable rod with interbody PEEK cage, and (iv) PEEK cage without pedicle screw fixation (no rods). Results: Fusion of the lumbar spine using PEEK or biodegradable rods allowed a similar ROM at both the fusion and adjacent levels under all conditions. The models with PEEK and biodegradable rods also showed a similar increase in contact forces at adjacent facet joints, but both were less than the model with a titanium rod. Conclusions: Flexible rods or cages with non-instrumented fusion can mitigate the increased contact forces on adjacent facet joints typically found following spinal fixation, and could also reduce the level of stress shielding at the bone graft.
... Moreover, because it often involves young patients at the thoracolumbar junction or below, it seems mandatory to maintain the segmental mobility of the spine and therefore to propose implant removal when possible. In fact, several studies showed that the segmental mobility of the lumbar spine can be almost totally restored after implant removal, especially if removal occurs before 12 months [27][28][29]. That would also prevent from implant failure and adjacent segment disease. ...
Article
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Introduction: The management of type A thoracolumbar fractures varies from conservative treatment to multiple level fusion. Indeed, although Magerl defined the type A fracture as a strictly bone injury, several authors suggested associated disc lesions or degeneration after trauma. However, the preservation of mobility of the adjacent discs should be a major issue. This study was conducted to analyze the presence of immediate post-traumatic disc injuries and to know if discs degenerate after receiving treatment. Methods: We retrospectively reviewed the files of 27 patients with an AOspine A fracture, corresponding to 34 fractures (64 discs) with pre and post-operative MRI (mean follow-up: 32.4 months). Based on Pfirrmann's and Oner's classifications of disc injuries, two observers analyzed independently the type of lesion in the discs adjacent to the fractured vertebra in immediate post-trauma and at the last follow-up. Results: The immediate post-traumatic analysis according to Pfirrmann's classification found 97% of the cranial adjacent discs and 100% of the caudal discs classified Pfirrmann 3 or less. The analysis on the secondary MRI revealed that 78% of cranial adjacent discs and 88% of caudal adjacent discs still were classified Pfirrmann 3 or less. Conclusions: Since, the great majority of type A fractures does not cause immediate disc injuries, these fractures are, as described by Magerl, strictly bony injuries. The quality of the body reduction seems to prevent secondary degeneration. These results may encourage surgeons not to perform arthrodesis on type A fractures even for A3 and A4.
... 18 Surgical removal of pedicle screws has been much discussed, 10,19 and remains controversial due to the associated risks of secondary surgery and potential for instability following removal. 20 However, when unexplainable recurrent pain is severe, screw removal has been recommended, [21][22][23][24] and may also reduce risks of metal toxicity and hypersensitivity. 25 Importantly, the loosening of pedicle screws in vivo has not been thoroughly evaluated. ...
Preprint
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Pedicle screw loosening has been implicated in recurrent back pain after lumbar spinal fusion, but the degree of loosening has not been systematically quantified in patients. Instrumentation removal is an option for patients with successful arthrodesis, but remains controversial. Here, we quantified pedicle screw loosening by measuring screw insertion and/or removal torque at high statistical power (β = 0.98) in N = 108 patients who experienced pain recurrence despite successful fusion after posterior instrumented lumbar fusion with anterior lumbar interbody fusion (L2-S1). Between implantation and removal, pedicle screw torque was reduced by 58%, indicating significant loosening over time. Loosening was greater in screws with evoked EMG threshold under 11 mA, indicative of screw misplacement. A theoretical stress analysis revealed increased local stresses at the screw interface in pedicles with decreased difference in pedicle thickness and screw diameter. Loosening was greatest in vertebrae at the extremities of the fused segments, but was significantly lower in segments with one level of fusion than in those with two or more. Clinical significance These data indicate that pedicle screws can loosen significantly in patients with recurrent back pain and warrant further research into methods to reduce the incidence of screw loosening and to understand the risks and potential benefits of instrumentation removal.
... The authors found that implant removal had better outcomes in alleviating back pain and disability. 59 In 2021, Kweh et al. 60 conducted a systematic review and meta-analysis comparing the outcomes between implant removal and implant retention groups after posterior stabilization in TLBF. This study mainly focused on patients with no implant-related symptoms after posterior instrumentation. ...
Article
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Thoracolumbar burst fracture (TLBF) without neurological deficit (WOND) is a common spinal injury. The ideal classification for the diagnosis and the optimal management strategies of the patients, including conservative management, surgical approach, implant constructs, the need for spinal fusion, and implant removal, are still controversial and currently being investigated. This article reviews the current literature to provide updated evidence on these topics. In conclusion, the ideal classification and management of patients with TLBF WOND are still disputed. The PLC integrity plays an important role in the classifications and decision-making process of the treatment. The brace does not necessarily require in conservatively treated patients. Regarding surgical management, current evidence advocates the posterior-only short segment instrumentation with intermediate screw. Cementoplasty is another option for vertebral augmentation at the fractured level. Spinal fusion is not necessary for this type of injury. The MIS techniques provide equivalence outcomes and can safely replace the open approaches. Implant removal after the stabilization may provide some benefits, especially in younger patients.
Article
Purpose: To evaluate clinical and radiographical outcomes. Methods: Patients with thoracolumbar burst fractures and neurological deficits underwent minimally invasive decompression and intracorporeal bone grafting combined with percutaneous short-segment stabilization. Instrumentation was removed approximately 1 year after vertebral fracture union. Clinical and radiographical outcomes were analyzed. Results: The mean operative duration and intraoperative bleeding volume were 135±63 min and 120±200 ml, respectively. The average American Spinal Injury Association (ASIA) impairment scale scores were significantly improved at the final follow-up. The visual analog scale (VAS) score decreased from 7.8±1.1 preoperatively to less than 2.9±1.3 (P<0.05) 1 week postoperatively. The Oswestry Disability Index (ODI) decreased from 86.1±8.8 preoperatively to 15.9±6.4 (P<0.05) 1 year later. The canal stenosis index (CSI) improved from 43.4±12.0% to 93.8±4.8% (P<0.05). The sagittal Cobb angle (CA) was corrected from 17.8±7.5° to 4.0±1.9° (P<0.05) and remained at 4.9±2.0° (P>0.05) 1 year later. The sagittal index (SI) was corrected from 16.6±6.1° to 0.3±4.6° (P<0.05) and remained at 1.5+4.5° (P>0.05) 1 year later. The anterior vertebral height (AVH) increased from 49.3±11.1% to 97.6±6.5% (P<0.05) and remained at 95.7±6.0% (P>0.05) 1 year later. After implant removal, the total kyphosis correction losses were 1.5±0.8° for the CA, 2.0±1.1° for the SI and 3.4±2.1% for the AVH. One pullout screw and 1 broken rod were found in 2 patients. Conclusions: Minimally invasive decompression and intracorporeal bone grafting combined with percutaneous short-segment fixation yielded satisfactory results in decompression and immediate kyphosis correction. Additionally, this procedure resulted in maintenance of the vertebral height and prevented late correction loss after implant removal.
Article
Purpose: Posterior reduction and pedicle screw fixation is a widely used procedure for thoracic and lumbar vertebrae fractures. Usually, the pedicle screws would be removed after the fracture healing and screw tunnels would be left. The aim of this study is to evaluate the effect of screw tunnels on the biomechanical stability of the lumbar vertebral body after pedicle screws removal by finite element analysis (FEA). Methods: First, the CT values of the screw tunnels wall in the fractured vertebral bodies were measured in patients whose pedicle screws were removed, and they were then compared with the values of vertebral cortical bone. Second, an adult patient was included and the CT images of the lumbar spine were harvested. Three dimensional finite element models of the L1 vertebra with unilateral or bilateral screw tunnels were created based on the CT images. Different compressive loads were vertically acted on the models. The maximum loads which the models sustained and the distribution of the force in the different parts of the models were recorded and compared with each other. Results: The CT values of the tunnels wall and vertebral cortical bone were 387.126?62.342 and 399.204?53.612, which were not statistically different (P=0.149). The models of three dimensional tetrahedral mesh finite element of normal lumbar 1 vertebra were established with good geometric similarity and realistic appearance. After given the compressive loads, the cortical bone was the first one to reach its ultimate stress. The maximum loads which the bilateral screw tunnels model, unilateral screw tunnel model, and normal vertebral model can sustain were 3.97 Mpa, 3.83 Mpa, and 3.78 Mpa, respectively. For the diameter of the screw tunnels, the model with a diameter of 6.5 mm could sustain the largest load. In addition, the stress distributing on the outside of the cortical bone gradually decreased as the thickness of the tunnel wall increased. Conclusions: Based on the FEA, pedicle screw tunnels would not decrease the biomechanical stability and strength of the vertebral body. A large diameter of screw tunnel and thick tunnel wall were helpful for the biomechanical stability of the vertebral body.
Article
Background: Posterior fixation without fusion can treat thoracolumbar and lumbar traumatic fractures effectively in certain cases. However, whether patients benefit from implant removal, and the correlation between the range of motion (ROM) of the involved segments and the removal time have not been determined. Methods: From 2018 to 2020, We retrospectively reviewed data of patients with AO spine type-A or B thoracolumbar or lumbar traumatic fractures who underwent implant removal. 17 patients (Group A), 21 patients (Group B), and 12 patients (Group C) underwent implant removal following the index surgery within 12 months, between 12 to 24 months, and over 24 months, respectively. Clinical and radiological outcomes, including visual analog scale (VAS) for back pain, patient satisfaction, Oswestry disability index (ODI) and EuroQol five dimensions questionnaire (EQ-5D) for quality of life and segmental ROM were analyzed. Results: The average follow-up time was 9.1±5.7 months after implant removal. There were no significant differences in VAS and patient satisfaction among three groups at the same observation time point. Patients in group A gained the lowest ODI and highest EQ-5D scores after removal and at final follow-up than those in group B and C. The best ROM was obtained in group A followed by group B and C (11.5±6.2°, 5.5±1.6° and 2.4±0.6°, respectively). Conclusions: Immobilization of the involved segments over 24 months may lead to loss of ROM. Regained segmental ROM is correlated negatively with implant removal time, and removing within 12 months promises a better ROM and quality of life.
Article
Study design: Cost-utility analysis (CUA). Objective: Determine the cost-effectiveness of pedicle screw removal after posterior fusion in thoracolumbar burst fractures. Summary of background data: Pedicle screw instrumentation is a standard fixation method for unstable thoracolumbar burst fracture. However, removal of the pedicle screw after successful fusion remains controversial because the clinical benefits remain unclear. CUA can help clinicians make appropriate decisions about optimal healthcare for pedicle screw removal after successful fusion in thoracolumbar burst fractures. Methods: We conducted a single-center, retrospective, longitudinal matched-cohort study of prospectively collected outcomes. In total, 88 consecutive patients who had undergone pedicle screw instrumentation for thoracolumbar burst fracture with successful fusion confirmed by CT were used in this study. In total, 45 patients wanted to undergo implant removal surgery (R group), and 43 decided not to remove the implant (NR group). A CUA was conducted from the healthcare perspective. The direct costs of healthcare were obtained from the medical bill of each patient. Changes in health-related quality of life (HRQoL) scores, validated by Short Form 6D, were used to calculate quality-adjusted life years (QALY). Total costs and gained QALY were calculated at 1 year (1 year) and 2 years (2 years) compared with baseline. Results are expressed as an incremental cost-effectiveness ratio (ICER). Different discount rates (0%, 3%, and 5%) were applied to both cost and QALY for sensitivity analysis. Results: Baseline patient variables were similar between the two groups (all P > 0.05). The additional benefits of implant removal (0.201 QALY at 2 years) were achieved with additional costs ($2,541 at 2 years), equating to an ICER of $12,641/QALY. Based on the different discount rates, the robustness of our study's results was also determined. Conclusions: Implant removal after successful fusion in a thoracolumbar burst fracture is cost-effective until postoperative year 2. Level of evidence: 3.
Article
Background: Around 5% of all trauma patients suffer from spinal trauma. Spinal fractures are mainly located in the thoracic and lumbar spine. For multisegmental vertebral fractures categorized as instable, combined dorsal instrumentation and ventral stabilization is recommended. Numerous vertebral body replacement systems are available for ventral stabilization. Objectives: The aim of the current study was to analyze radiological results following the implantation of a hydraulic expandable vertebral body replacement and the evaluation of patients' outcome three years after implantation. Materials and methods: All patients who suffered traumatic multisegmental fractures of the thoracic or lumbar spine in the period from September 2009 to September 2012 were included in this study. Patients with additional injuries or abnormal sensitivity or motor function were excluded from the current study. All patients underwent dorsal percutaneous instrumentation. Afterwards, implantation of the vertebral body replacement was performed via the mini-open approach at our level I trauma center. In the computed tomography and X‑ray imaging, the sagittal kyphotic angle was measured. Furthermore, the clinical outcome (patients' satisfaction, VAS spine score) was analyzed using a questionnaire. Results: During the above mentioned period, seven patients (four female; three male) underwent dorsal instrumentation and ventral trisegmental fusion and were identified fitting the inclusion/exclusion criteria and thus could be included in the study. Most fractures were located in the thoracic-lumbar junction and were categorized A4 according to the AO Spine classification system. The analysis of the radiological data showed a pre-operative average traumatic segmental angle of 18.1 ± 14.9°, which could be decreased by reposition procedure to 6.4 ± 1.7°. The complete follow-up, including the data three years after implantation of the vertebral body implant, was available for three patients. The traumatic segmental angle remained stable in the follow-up three years later. In one case, a subsidence of the implant of 1.5 mm was observed, having no influence on the patients' satisfaction. All three patients indicated to be very satisfied with their outcome. The VAS spine score rating was in the range between 62.4 and 70.2. Conclusions: The current study shows that in the case of multisegmental fractures complete reposition by ligamentotaxis and by the percutaneous instrumentation system is possible. In addition to the percutaneous dorsal instrumentation, the implantation of a hydraulically expandable vertebral body replacement may allow a stable fusion after complex traumatic fractures of the thoracic and lumbar spine. Patients are very satisfied with their outcome after this procedure.
Article
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Purpose of review: We will review the recent literature concerning the necessity of supplemental fusion to spinal instrumentation and discuss if temporal spinal fixation is a viable option for the treatment of unstable spine fractures. Advancements in minimally invasive techniques offer an alternative approach to traditional open stabilization for unstable spine fractures. The use of minimally invasive surgery offers many advantages concerning operative morbidly; fusion is not utilized and instrumentation can be removed in a delayed fashion. Recent findings: There are limited differences in amount of correction loss over time, and multiple studies report equivocal to superior results in patient's functional outcomes when comparing temporary internal stabilization to long segment instrumentation with fusion. Removal of implants can restore segmental motion. Review of the literature demonstrates that temporary internal stabilization for unstable fractures is a viable option. Close clinical and radiographic follow-up is recommended to avoid delayed spinal deformity.
Article
Introduction: Implant removal represents almost one third of all elective surgeries in orthopedics. There is no consensus regarding the time and need to remove the implants after vertebral fractures consolidation. The aim of this study was to assess the clinical and radiological effects of implant removal in patients with vertebral type A fracture who underwent a percutaneous intervention. Material and methods: We evaluated 31 patients (mean age of 38.2±7.5 years) with thoracolumbar vertebral fracture (T11-L5) who underwent implant removal surgery after 24 months of fracture first surgery by a percutaneous approach. Inclusion criteria focused on patients' preferences. The radiological parameters included fracture angle, initial sagittal index, compression percentage, degree displacement and deformation angle. The clinical variables included Visual Analog Scale and Oswestry Disability index. Results: There was no significant correction loss after removal surgery (before surgery and after 24 months): Fracture angle (16.8±0.5 vs 17.1±0.5; p˃0.05), initial sagittal index (12.5±0.5 vs 12.7±0.5; p˃0.05), kyphotic deformity (17.5±0.6 vs 17.8±0.7; p˃0.05), compression percentage (35.6±0.8 vs 36.0±0.7; p˃0.05), degree displacement (4.4±0.4 vs 4.5±0.3; p˃0.05) and deformation angle (23.0±0.7 vs 23.1±0.7; p˃0.05). Patients who presented symptoms before the surgery showed better Visual Analog Scale (1.2±0.6 pre vs 0.6±0.3 post, p˂0.05) and Oswestry Disability Index (20.1±6.8 pre vs 15.7±0.5, p˂0.05). No complications were reported. Discussion: Routine implant removal in patients undergoing a percutaneous approach to vertebral type A fracture is a safe technique and is associated with good clinical results without loss of radiological correction. In addition, this procedure could be indicated to patients who manifest symptoms since there is a clinical-radiological benefit. Level of proof: II; A multicenter prospective cohort study.
Article
Background Percutaneous-short segment screw fixation (SSSF) without bone fusion has proven to be a safe and effective modality for thoracolumbar spine fractures (TLSFs). When fracture consolidation is confirmed, pedicle screws are no longer essential, but clear indications for screw removal following fracture consolidation have not been established. Methods In total, we enrolled 31 patients with TLSFs who underwent screw removal following treatment using percutaneous-SSSF without fusion. Plain radiographs, taken at different intervals, measured local kyphosis using Cobb’ angle (CA), vertebra body height (VBH), and the segmental motion angle (SMA). A visual analogue scale (VAS) and the Oswestry disability index (ODI) were applied pre-screw removal and at the last follow-up. Results The overall mean CA deteriorated by 1.58° (p < 0.05) and the overall mean VBH decreased by 0.52 mm (p = 0.001). SMA preservation was achieved in 18 patients (58.1%) and kyphotic recurrence occurred in 4 patients (12.9%). SMA preservation was statistically significant in patients who underwent screw removal within 12 months following the primary operation (p = 0.002). Kyphotic recurrence occurred in patients with a CA ≥ 20° at injury (p < 0.001) with a median interval of 16.5 months after screw removal. No patients reported worsening pain or an increased ODI score after screw removal. Conclusion Screw removal within 12 months can be recommended for restoration of SMA with improvement in clinical outcomes. Although, TLSFs with CA ≥ 20° at the time of injury can help to predict kyphotic recurrence after screw removal, the clinical outcomes are less relevant.
Article
Study design: A prospective monocentric study. Objective: The aim of the current study was the analysis of patient outcome and radiological results 3 years after implantation of a hydraulic expandable vertebral body replacement (VBR) system. Summary of background data: Around 70% to 90% of all traumatic spinal fractures are located in the thoracic and lumbar spine. Dorso-ventral stabilization is a frequently used procedure in traumatic vertebral body fracture treatment. VBR systems can be used to bridge bony defects. In the current study, a new VBR expanded by water pressure with adjustable endplates is used. Methods: All patients who suffered a singular traumatic fracture to a thoracic or lumbar vertebral body (Th 5-L 5) in the period from November 2009 to December 2010 and (i) underwent dorsal instrumentation and (ii) afterwards received the implantation of a hydraulic VBR were included in this study. The clinical outcome (visual analogue scale [VAS] spine score, questionnaire) and radiological findings (sagittal angle, implant subsidence, and implant position) 3 years after implantation were analyzed. Results: The follow-up was successful for n = 47 patients (follow-up rate: 89%). Most of the patients (n = 40) were "generally/very satisfied" with their outcome. The mean rating of the VAS spine score was 65.2 ± 23.1 (range: 20.5-100.0). The analysis of the radiological data showed an average subsidence of the implants of 1.1 ± 1.2 mm (range 0.0-5.0 mm). After the initial operation, the local sagittal angle remained stable in the follow-up 3 years later both for the thoracic spine and lumbar spine. Furthermore, no change in the implant's position was observed. Conclusion: The implantation of a hydraulically expandable VBR allows a permanent stable fixation after traumatic fractures of the thoracic and lumbar spine. Level of evidence: 2.
Chapter
This chapter focuses on the clinical presentation, diagnosis, treatment options, and long-term prognosis of lumbar burst fractures utilizing both retrospective and prospective data ranging from 1975 to 2017.
Chapter
With the increase of an aging population worldwide, patient’s expectations and demands for an improved independent lifestyle have led to innovative strategies in the treatment of degenerative disc disease. Aside from all conservative modalities, new surgical techniques attempt to enable a rapid recovery by reducing iatrogenic injury and complications with shorter operative times. Over the past two decades, the debate over which approach may achieve the highest fusion rates has been opened to a more global view on its efficacy of restoring the overall coronal and sagittal balance of the spine. Thus, the analyses of respective spinopelvic interrelations using modern full body radiographic imaging in an upright standing position have received closer attention and have since been fully included in our therapeutic management and strategical planning. Furthermore, the increasing number of failed primary surgeries and/or adjacent segment degeneration with secondary kyphotic deformity constitute a distinct entity of challenges with rather individual and case-dependent solutions. Today’s advances in spinal instrumentation allow almost any operation to be performed in a minimally-invasive fashion. Regardless of selecting either the retroperitoneal corridor (ALIF, OLIF, LLIF) or traversing the spinal canal with or without osteotomy of the facet joints for segmental mobilsation (PLIF, TLIF, minimally-invasive-surgery (MIS)-TLIF), none of today’s standard techniques have proven to be superior to another. Although each approach has its own risks and benefits, fusion rates or clinical outcomes appear to be similar. However, there is fundamental consensus, that interbody fusion itself is preferable to posterolateral “on-lay” fusion techniques with less postoperative complications and lower rates of pseudarthrosis. In conclusion, the surgeon must always consider all technical options to tailor the treatment to the patient’s individual, but none the less realistic expectations.
Article
Bei der Vielzahl an Verletzungen der Wirbelsaule muss die Art und Hohe der Verletzung sowie die Anzahl der eingebundenen Segmente berucksichtigt werden. Eine Implantatentfernung an der BWS und LWS ist nach 12 Monaten und gesicherter ossarer Konsolidierung anzustreben. Im Falle von dorsoventralen Versorgungen, wobei die dorsale Stabilisierung unversehrte Segmente uberbruckt, kann eine Materialentfernung bei sicherer ventraler Fusion ab dem 6. Monat angestrebt werden. Bei zusatzlicher additiver ventraler Platte/Stab ist bereits bei partieller Konsolidierung eine fruhzeitige Materialentfernung nach 4 Monaten moglich. Bei dorsoventral-bisegmentaler Versorgung sollte die Indikation der Implantatentfernung kritisch gestellt werden. Ebenfalls sollte die Indikation zur Implantatentfernung bei degenerativen Erkrankungen kritisch abgewogen werden und z. B. nach vorheriger Infiltration mit Lokalanasthetikum zur Beurteilung der Schmerzreduktion erfolgen.
Article
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Background: The aim of this survey study was to evaluate the current opinion and practice of trauma and orthopaedic surgeons in the Netherlands in the removal of implants after fracture healing. Methods: A web-based questionnaire consisting of 44 items was sent to all active members of the Dutch Trauma Society and Dutch Orthopaedic Trauma Society to determine their habits and opinions about implant removal. Results: Though implant removal is not routinely done in the Netherlands, 89% of the Dutch surgeons agreed that implant removal is a good option in case of pain or functional deficits. Also infection of the implant or bone is one of the main reasons for removing the implant (> 90%), while making money was a motivation for only 1% of the respondents. In case of younger patients (< 40 years of age) only 34% of the surgeons agreed that metal implants should always be removed in this category. Orthopaedic surgeons are more conservative and differ in their opinion about this subject compared to general trauma surgeons (p = 0.002). Though the far majority removes elastic nails in children (95%).Most of the participants (56%) did not agree that leaving implants in is associated with an increased risk of fractures, infections, allergy or malignancy. Yet in case of the risk of fractures, residents all agreed to this statement (100%) whereas staff specialists disagreed for 71% (p < 0.001). According to 62% of the surgeons titanium plates are more difficult to remove than stainless steel, but 47% did not consider them safer to leave in situ compared to stainless steel. The most mentioned postoperative complications were wound infection (37%), unpleasant scarring (24%) and postoperative hemorraghe (19%). Conclusion: This survey indicates that there is no general opinion about implant removal after fracture healing with a lack of policy guidelines in the Netherlands. In case of symptomatic patients a majority of the surgeons removes the implant, but this is not standard practice for every surgeon.
Article
Full-text available
Pedicle screws have dramatically improved the outcomes of spinal reconstruction requiring spinal fusion. Short-segment surgical treatments based on the use of pedicle screws for the treatment of neo-plastic, developmental, congenital, traumatic, and degenerative conditions have been proved to be practical, safe, and effective. The Funnel Technique provides a straightforward, direct, and inexpensive way to very safely apply pedicle screws in the cervical, thoracic, or lumbar spine. Carefully applied pedicle-screw fixation does not produce severe or frequent complications. Pedicle-screw fixation can be effectively and safely used wherever a vertebral pedicle can accom-modate a pedicle screw — that is, in the cervical, thoracic, or lumbar spine. Training in pedicle-screw application should be standard in orthopaedic training programs since pedicle-screw fixation represents the so-called gold standard of spinal internal fixation. Pedicle screws have revolutionized the surgical treatment of spinal disorders, although their introduc-tion and widespread adoption by spinal surgeons has created one of the most difficult regulatory problems ever seen in orthopaedics.
Article
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The treatment of thoracolumbar burst fracture is a controversial issue. Although spinal fusion has been a touchstone of spinal fixation, nonfusion technique have become raising its popularity recently. Some studies suggested that nonfusion had several advantages over fusion. The aim of this prospective study was to compare long segment posterior instrumentation with fusion versus long-segment posterior instrumentation without fusion. For this purpose, 42 consecutive patients were assigned to two groups. Group 1 included 21 patients treated by long segment instrumentation with fusion (WF), whereas Group 2 included 21 patients treated by long segment instrumentation without fusion (WOF). Long segment instrumentation was hook fixation (claw hooks attached to second upper vertebra and infralaminar hooks attached to first upper vertebra) above and pedicle fixation (pedicle screws attached to first and second lower vertebrae) below the fractured vertebra. Measurements of local kyphosis, sagittal index and anterior vertebral height compression showed that both group had similar outcome at final follow-up. Moreover, there was no difference between the two groups according to low back outcome score. Also, implant failure rate (4.7%) was quite low in both groups. However, WF group had prolonged operative time, increased blood loss and donor site morbidity. Radiological and clinical parameters demonstrated that spinal fusion is not necessary in long segment posterior instrumentation for the management of thoracolumbar burst fractures.
Article
Full-text available
Implant removal because of pain after posterior fusion in the thoracic and lumbar spine is a widely performed operation. We conducted a retrospective study to examine whether patients benefit from implant removal. 57 patients (29 males, 28 females, mean age 46.5 years) who have undergone removal of pedicle screws because of pain and discomfort were interviewed 6-24 months postoperatively. Fracture was the initial diagnosis in 40% of the patients and degenerative spine disease in 58%. The following factors were evaluated: patient satisfaction and postoperative outcome, patients' native language and psychological background, operative data, hospital stay and complications. Pain decreased significantly from 62 to 48 on visual analogue scale postoperatively. Complications occurred in five patients (8.8%). 36 patients (61%) stated they had some benefit from the operation, but only seven patients (12%) were free of pain completely. 36 patients (63%) would undergo the same procedure again. Outcome in the subgroup of foreigners was significantly worse, though the psychological background did not affect the outcome. Preoperative diagnostic infiltration was helpful in 9 of 13 patients. Removal of pedicle screws because of back pain may be effective, but complete remission of symptoms could be achieved in only 12% of patients. However, 63% of patients would undergo hardware removal again. Preoperative diagnostic infiltration can help to predict the outcome but results are inconsistent. Communication difficulties may worsen the outcome. Surgeons should consider these results when planning implant removal and patients should be informed thoroughly to avoid too high expectations.
Article
Full-text available
The routine removal of orthopaedic fixation devices after fracture healing remains an issue of debate. There are no evidence-based guidelines on this matter, and little is known on surgeons' practice and perceived effectiveness of implant removal in different clinical settings. A 41-item questionnaire was distributed to 730 attendees of the AO Principles and Masters Courses of Operative Fracture Treatment in Davos, Switzerland, to assess their attitudes towards removal of different types of implants, and perceived benefits and risks with this common procedure. The response rate was 655/730 (89.7%), representing 54.6% of all 1199 course attendees. Surgeons from 65 countries (571 males and 84 females, mean age 39 +/- SD 9 years) took part in the survey. Fifty-eight percent of the participants did not agree that routine implant removal is necessary, and 49% and 58% did not agree that indwelling implants pose an excess risk for fractures or general adverse effects. Forty-eight percent felt that removal is riskier than leaving the implant in situ. Implant removal in symptomatic patients was rated to be moderately effective (mean rating on a 10-point-scale, 5.8, 95% confidence interval 5.7-6.0). Eighty-five percent of all participants agreed that implant removal poses a burden to hospital resources. Surgeons were undetermined whether implant removal is adequately reimbursed by payers of health care services (44% "I-don't-know"-answers). Many surgeons refuse a routine implant removal policy, and do not believe in clinically significant adverse effects of retained metal implants. Given the frequency of the procedure in orthopaedic departments worldwide, there is an urgent need for a large randomized trial to determine the efficacy and effectiveness of implant removal with regard to patient-centred outcomes.
Article
In view of the current level of knowledge and the numerous treatment possibilities, none of the existing classification systems of thoracic and lumbar injuries is completely satisfactory. As a result of more than a decade of consideration of the subject matter and a review of 1445 consecutive thoracolumbar injuries, a comprehensive classification of thoracic and lumbar injuries is proposed. The classification is primarily based on pathomorphological criteria. Categories are established according to the main mechanism of injury, pathomorphological uniformity, and in consideration of prognostic aspects regarding healing potential. The classification reflects a progressive scale of morphological damage by which the degree of instability is determined. The severity of the injury in terms of instability is expressed by its ranking within the classification system. A simple grid, the 3-3-3 scheme of the AO fracture classification, was used in grouping the injuries. This grid consists of three types: A, B, and C. Every type has three groups, each of which contains three subgroups with specifications. The types have a fundamental injury pattern which is determined by the three most important mechanisms acting on the spine: compression, distraction, and axial torque. Type A (vertebral body compression) focuses on injury patterns of the vertebral body. Type B injuries (anterior and posterior element injuries with distraction) are characterized by transverse disruption either anteriorly or posteriorly. Type C lesions (anterior and posterior element injuries with rotation) describe injury patterns resulting from axial torque. The latter are most often superimposed on either type A or type B lesions. Morphological criteria are predominantly used for further subdivision of the injuries. Severity progresses from type A through type C as well as within the types, groups, and further subdivisions. The 1445 cases were analyzed with regard to the level of the main injury, the frequency of types and groups, and the incidence of neurological deficit. Most injuries occurred around the thoracolumbar junction. The upper and lower end of the thoracolumbar spine and the T10 level were most infrequently injured. Type A fractures were found in 66.1%, type B in 14.5%, and type C in 19.4% of the cases. Stable type A1 fractures accounted for 34.7% of the total. Some injury patterns are typical for certain sections of the thoracolumbar spine and others for age groups. The neurological deficit, ranging from complete paraplegia to a single root lesion, was evaluated in 1212 cases.(ABSTRACT TRUNCATED AT 400 WORDS)
Chapter
A classification should allow the identification of any injury by means of a simple algorithm based on easily recognizable and consistent radiographic and clinical characteristics. In addition, it should provide a concise and descriptive terminology, information regarding the severity of the injury, and guidance as to the choice of treatment and should serve as a useful tool for future studies.
Objective: Assess the workload caused by elective routine removals of internal fracture fixation devices in a large university orthopedic and trauma unit when no premediated departmental removal policy existed. Materials and Methods: Data on all operations performed during a 7-year period were retrieved. Routine removals of internal fracture fixation implants were analyzed for demographic data and clinical details. Patients requiring additional procedures to manage the fracture besides simple hardware removal were excluded. Nationwide data were included for comparison. Results: A total of 5,095 routine implant removal operations were performed after uneventful fracture union. The mean age of the patients was 42 years. The five most common fracture types were fractures of the ankle, the proximal femur, the tibial shaft, the femoral shaft, and the thoracolumbar spine. In 63% of the procedures, a medium-size or large implant was removed. The mean operation time was 37 minutes. The removals accounted for 29% of all elective operations and for 15% of all operations at the department. The corresponding nationwide figure was 6.3% of all orthopedic operations, the number of implant removals in the whole country being 90 operations per 100,000 person-years. Conclusions: Without a strict departmental removal policy, a remarkable portion of the resources allocated for elective orthopedic operations was spent on routine hardware removal procedures. A more rational and selective attitude toward implant removals is desirable. Further research on the disadvantages of retained hardware and the complications of implant removals is required.
Article
Study design: Prospective consecutive series. Objective: To evaluate the post-traumatic disc degeneration and range of motion 10 years after short-segment fixation without fusion for thoracolumbar burst fractures with neurological deficit. Summary of background data: Early clinical results of short-segment fixation without fusion for thoracolumbar burst fractures were satisfactory. However, the long-term results have not been reported, and post-traumatic disc degeneration and preservation of thoracolumbar motion have not been elucidated. Methods: Twelve patients who had thoracolumbar burst fractures and associated incomplete neurological deficit, operatively treated within 4 days of admission and had their implants removed within 1 year, were prospectively followed for at least 10 years. Following indirect reduction and pedicle screw fixation, transpedicular intracorporeal hydroxyapatite grafting to the fractured vertebrae was performed. Results: Sagittal alignment was improved from a mean preoperative kyphosis of 17° to -2° (lordosis) by operation, but was found to have slightly deteriorated to 2° at the final follow-up observation. With respect to back pain, 8 patients did not report back pain. Three reported occasional minimal pain, and 1 reported moderate pain. None reported severe pain or needed daily dosages of analgesics.Regarding disc degeneration, the shape of the disc adjacent to the fractured vertebra had not changed from the preoperative to the 10-year postoperative magnetic resonance image (MRI). Although signal intensity of the disc had decreased by 1 grade from the preoperative to the 2-year postoperative MRI, the intensity had not changed from the 2-year postoperative MRI to the 10-year postoperative MRI. At the 10-year follow-up, flexion-extension radiographs revealed that a mean range of motion at the disc adjacent to the fractured vertebra was 12º (range; 5-19). Conclusion: This unprecedented 10-year follow-up study demonstrated that posterior indirect reduction, transpedicular hydroxyapatite grafting, and pedicle screw fixation does not require fusion to a segment, thereby preserves thoracolumbar motion without resulting in post-traumatic disc degeneration. Level of evidence: 4.
Article
Objective: Assess the workload caused by elective routine removals of internal fracture fixation devices in a large university orthopedic and trauma unit when no premediated departmental removal policy existed. Materials and Methods: Data on all operations performed during a 7-year period were retrieved. Routine removals of internal fracture fixation implants were analyzed for demographic data and clinical details. Patients requiring additional procedures to manage the fracture besides simple hardware removal were excluded. Nationwide data were included for comparison. Results: A total of 5,095 routine implant removal operations were performed after uneventful fracture union. The mean age of the patients was 42 years. The five most common fracture types were fractures of the ankle, the proximal femur, the tibial shaft, the femoral shaft, and the thoracolumbar spine. In 63% of the procedures, a medium-size or large implant was removed. The mean operation time was 37 minutes. The removals accounted for 29% of all elective operations and for 15% of all operations at the department. The corresponding nationwide figure was 6.3% of all orthopedic operations, the number of implant removals in the whole country being 90 operations per 100,000 person-years. Conclusions: Without a strict departmental removal policy, a remarkable portion of the resources allocated for elective orthopedic operations was spent on routine hardware removal procedures. A more rational and selective attitude toward implant removals is desirable. Further research on the disadvantages of retained hardware and the complications of implant removals is required.
Article
Minimizing the number of vertebral levels involved in fusion of a spine fracture is a common goal of internal fixation. This is achievable by utilizing traditional short-segment posterior fixation (SSPF). However, in SSPF there is reported up to a 54% incidence of instrument failure or unfavorable clinical outcome. Short-segment posterior fixation with pedicle fixation at the level of the fracture (short same-segment fixation) suggests biomechanical advantages toward maintenance of kyphosis correction and reducing failure rates. However its clinical efficacy is largely unknown. The team conducted a retrospective review of 25 thoracolumbar burst fracture patients who were treated with short same-segment fixation between September 2005 and April 2009. The primary outcome measure was incidence of reoperation and loss of kyphosis correction within the follow-up period. Long-term functional status and pain was also assessed. Average duration of the most recent follow-up was 21.64 months (range 3 to 42 months). Two patients (8%) required reoperation due to either hardware failure or pseudoarthrosis. Mean pre-operative kyphosis was 14.49°. Average post-operative kyphosis was -0.74° (lordosis). Average follow-up kyphosis of all cases was 10.78°. Excluding failures, average follow-up kyphosis was 8.67°. A mean of 15.23° of kyphosis correction was attained from pre-operation to post-operation (P < 0.0001). Average loss of kyphosis correction from immediate post-operation to most recent follow-up was -11.51° and -9.51 excluding the two failures (P < 0.0001). Average pre-operative to most-recent follow-up kyphosis correction was 3.72° (P = 0.067) and 5.51° excluding failures (P = 0.0024). At initial one-month follow-up, average disability score was 52.63% (range 16% to 84%). At most recent follow-up, average disability score was 5.5% (range 0% to 16%). One patient was lost to long-term follow-up. Mean difference from one-month follow-up to most recent follow-up (excluding failures) was 47.27% (P < 0.0001). Short same-segment fixation decreases implantation failure rate and reoperation rate compared to traditional SSPF, however long-term kyphosis correction was not maintained. Despite this loss of kyphosis correction, clinical pain and disability improved at long-term follow-up.
Article
Finite element method. To investigate the changes in the disc stress and range of motion (ROM) at adjacent segments after lumbar fusion based on whether or not pedicle screws are removed and whether or not the continuity of the proximal posterior ligament complex (PLC) is preserved. The ablation of proximal PLC continuity and the presence of pedicle screws have been reported to affect the biomechanics at adjacent segments after lumbar fusion. However, there have been few studies regarding the quantitative assessment of their contribution to overstress at adjacent segments after lumbar fusion. In the validated intact lumbar finite element model (L2-L5), four types of L3-L4 fusion models were simulated. These models included the preservation of the PLC continuity with pedicle screws (Pp WiP), the preservation of PLC continuity without pedicle screws (Pp WoP), the sacrifice of PLC with pedicle screws (Sp WiP), and the sacrifice of PLC without pedicle screws (Sp WoP). In each scenario, the ROM, maximal von Mises stress of discs, and the facet joint contract force at adjacent segments were analyzed. RESULTS.: Among the four models, the Sp WiP yielded the greatest increase in the ROM and the maximal von Mises stress of the disc at adjacent segments under four moments. Following the SP WiP, the order of increase of the ROM and the disc stress was Pp WiP, Sp WoP, and Pp WoP. Furthermore, the increase of ROM and disc stress at the proximal adjacent segment was more than at the distal adjacent segment under all four moments in each model. The facet joint contact was also most increased in the Sp WiP under extension and torsion moment. The current study suggests that the preservation of the PLC continuity or the removal of pedicle screws after complete fusion could decrease the stress at adjacent segments, and their combination could act synergistically.
Article
The purpose of this study is to investigate the change in biomechanical milieu following removal of pedicle screws in instrumented single level lumbar arthrodesis. Using a validated finite element (FE) model of the intact lumbar spine (L2-5), two scenarios of L3-4 lumbar fusion were simulated: posterolateral fusion (PLF) at L3-4 using pedicle screws (PLF with pedicle screws; WiP) and L3-4 lumbar posterolateral fusion state after removal of pedicle screws (PLF without pedicle screws; WoP). The WiP model had greater range of motion (ROM) at each adjacent segment than the WoP model. This phenomenon became pronounced at the proximal adjacent segment under flexion moment. Similarly, removal of pedicle screws (the WoP model) relieved the maximal von Mises stress at adjacent segments under 4 moments compared to the WiP model. This study demonstrated that removal of pedicle screws could decrease stiffness of fusion segments, which would reduce the disk stress of adjacent segments.
Article
We operated on 21 patients with a postoperative deep wound infection. All the patients underwent implant removal and wide debridement. One patient lost to follow-up was excluded. To reduce the number of debridements and manage uncontrolled spine infection. There are a few reports on the treatment for postoperative spinal infection after instrumented spine fusion with implant removal and wide debridement. The clinical outcomes were assessed using the Oswestry disability index, visual analog scale of pain and patients' satisfaction. The functional outcomes of the Oswestry disability index were minimal in 13 patients and moderate in 7 at final follow-up. The serial changes of visual analog scale score of pain in the back and leg showed statistically significant decline after operation. Patients' satisfaction outcomes were better in 16 patients and unchanged in 4. Six patients of the preoperative spinal fusion group included the patients that already had fusion mass well developed by the time of implant removal. Bony union was not achieved in any patient of the preoperative nonspinal fusion group (n=14) by the last follow-up. In nonspinal fusion group, mean lordotic angle before the operation was 41 degrees decreasing after the operation to 39 degrees. At the final follow-up it was 30 degrees. Mean disc space height before the operation was 11.1 mm and it decreased to 8.1 mm at the final follow-up. The mean lordotic angle and disc space height at last follow-up was larger in the spinal fusion group than in the nonspinal fusion group. Our results indicate that implant removal and wide debridement for postoperative infection after posterior instrumented spine fusion can provide satisfactory results and could be one treatment option. However, the collapse of the disc space, loss of normal lordosis, and pseudoarthrosis are inevitable in patients with early postoperative infection.
Article
In view of the current level of knowledge and the numerous treatment possibilities, none of the existing classification systems of thoracic and lumbar injuries is completely satisfactory. As a result of more than a decade of consideration of the subject matter and a review of 1445 consecutive thoracolumbar injuries, a comprehensive classification of thoracic and lumbar injuries is proposed. The classification is primarily based on pathomorphological criteria. Categories are established according to the main mechanism of injury, pathomorphological uniformity, and in consideration of prognostic aspects regarding healing potential. The classification reflects a progressive scale of morphological damage by which the degree of instability is determined. The severity of the injury in terms of instability is expressed by its ranking within the classification system. A simple grid, the 3-3-3 scheme of the AO fracture classification, was used in grouping the injuries. This grid consists of three types: A, B, and C. Every type has three groups, each of which contains three subgroups with specifications. The types have a fundamental injury pattern which is determined by the three most important mechanisms acting on the spine: compression, distraction, and axial torque. Type A (vertebral body compression) focuses on injury patterns of the vertebral body. Type B injuries (anterior and posterior element injuries with distraction) are characterized by transverse disruption either anteriorly or posteriorly. Type C lesions (anterior and posterior element injuries with rotation) describe injury patterns resulting from axial torque. The latter are most often superimposed on either type A or type B lesions. Morphological criteria are predominantly used for further subdivision of the injuries. Severity progresses from type A through type C as well as within the types, groups, and further subdivisions. The 1445 cases were analyzed with regard to the level of the main injury, the frequency of types and groups, and the incidence of neurological deficit. Most injuries occurred around the thoracolumbar junction. The upper and lower end of the thoracolumbar spine and the T10 level were most infrequently injured. Type A fractures were found in 66.1%, type B in 14.5%, and type C in 19.4% of the cases. Stable type A1 fractures accounted for 34.7% of the total. Some injury patterns are typical for certain sections of the thoracolumbar spine and others for age groups. The neurological deficit, ranging from complete paraplegia to a single root lesion, was evaluated in 1212 cases.(ABSTRACT TRUNCATED AT 400 WORDS)
Article
Thirty-five patients were retrospectively reviewed after hardware removal after previous posterior lumbar spinal fusion by using Wiltse pedicle screw fixation. Pseudarthrosis was intraoperatively confirmed in 10 patients. Thirty of 35 patients were reviewed at an average of 17.5 months (range, 6-57 months). Of 30 patients, 30 had persistent back pain that limited activities and lumbar motion. Patients found to have pseudarthroses were significantly more likely to have less pain, use fewer narcotic medications, and have an improved quality of life after reoperation than patients found to have solid fusions. Postsurgical assessment of fusion is difficult, with instrumentation making exploration the most reliable method determining the state of arthrodesis. Accurate preoperative assessment of the fusion mass is the most important factor in deciding whether or not to reoperate on patients after Wiltse pedicle screw arthrodesis of the lumbar spine.
Article
A retrospective review of a clinical series was performed. To evaluate the incidence of adult patients who experienced spinal collapse after spinal implant removal after a long spinal arthrodesis, and to assess the various factors that may influence the likelihood of collapse after implant removal. Published reports describing the benefits or complications of spinal implant removal do not exist. Spinal implant removal, often considered a benign procedure, is even required by the Food and Drug Administration (FDA) for certain implants. The medical records and radiographs of 116 consecutive adult patients with long posterior instrumented fusions (>5 segments) were reviewed. The information obtained included original diagnosis, patient age, number of previous surgeries before implant removal, levels of anterior and posterior fusion, time from fusion to implant removal, time from implant removal to failure, and reason for hardware removal. Radiographs also were assessed including scoliosis, lordosis, and kyphosis measurements before implant removal, after hardware removal, after failure, and after revision surgery. Of 116 patients, 14 underwent spinal implant removal. Most of these patients reported prominent implants either proximally in the thoracic spine or distally in the ilium (Galveston technique). Of these 14 patients, 4 experienced increased pain and collapse after implant removal despite thorough intraoperative explorations demonstrating solid fusion. Spinal implant removal after long posterior fusion in adults may lead to spinal collapse and further surgery. Removal of instrumentation should be avoided or should involve partial removal of the prominent implant.
Article
Pedicle screws have dramatically improved the outcomes of spinal reconstruction requiring spinal fusion. Short-segment surgical treatments based on the use of pedicle screws for the treatment of neoplastic, developmental, congenital, traumatic, and degenerative conditions have been proved to be practical, safe, and effective. The Funnel Technique provides a straightforward, direct, and inexpensive way to very safely apply pedicle screws in the cervical, thoracic, or lumbar spine. Carefully applied pedicle-screw fixation does not produce severe or frequent complications. Pedicle-screw fixation can be effectively and safely used wherever a vertebral pedicle can accommodate a pedicle screw--that is, in the cervical, thoracic, or lumbar spine. Training in pedicle-screw application should be standard in orthopaedic training programs since pedicle-screw fixation represents the so-called gold standard of spinal internal fixation.
Article
Statistical analysis of various measurement techniques for thoracolumbar burst fracture kyphosis on lateral radiograph. To determine the most reliable measurement technique. The treatment of thoracic and lumbar burst fractures involves many factors, including the degree of resultant kyphosis. Although various methods have been described, no study has directly compared these methods for reliability and reproducibility. Fifty lateral radiographs of thoracic and lumbar burst fractures were randomly selected and measured on two separate occasions by three spine surgeons using five different measurement techniques. Radiograph quality, fracture type, and the center beam location were determined. Statistical analysis included analysis of variance for repeated measures and analysis of variance using a generalized linear model. Intraclass correlation coefficients were most consistent for Method 1 (rho = 0.83-0.94) followed by Method 4 (rho = 0.65-0.89) and Method 5 (rho = 0.73-0. 85). Intraobserver agreement (% of repeated measures within 5 degrees of the original measurement) ranged between 72% and 98% for all techniques for all three observers, with Method 1 showing the best agreement (84%-98%). Paired comparisons between observers varied considerably with interobserver reliability correlation coefficients ranging from 0.52 to 0.93. Method 1 showed the highest interobserver reliability coefficient (0.81, range 0.71-0.93) followed by Method 5 (0.71, range 0.68-0.75). Method 1 also had the highest percentage of agreement within categories (90% within 5 degrees ). Method 1 (measuring from the superior endplate of the vertebral body one level above the injured vertebral body to the inferior endplate of the vertebral body one level below) showed the best intraobserver and interobserver reliability overall.
Article
To elucidate the cause of late operative site pain in six cases of scoliosis managed with Isola posterior instrumentation that required removal of the implants. Microbiologic examination of wound swabs and enriched culture of operative tissue specimens was undertaken in all cases. Histologic study of the peri-implant membranes also was conducted. The presentation in all cases was similar: back pain appearing between 12-20 months after surgery, followed by a local wound swelling leading to a wound sinus. In only one of these cases was the discharge positive for bacterial growth. Implant removal was curative. Histologic examination of tissue specimens revealed a neutrophil-rich granulation tissue reaction suggestive of an infective etiology despite the failure to isolate organisms. Within the granulation tissue was metallic debris that varied from very sparse to abundant from fretting at the distal cross-connector junctions. A review of recent literature describing similar problems suggests that late onset spinal pain is a real entity and a major cause of implant removal. On reviewing the evidence for an infective etiology versus a metallurgic reaction etiology for these cases of late onset spinal pain, it was concluded that a subacute low-grade implant infection was the main cause. Histologic findings would seem to confirm low-grade infection. There may be more than one causative factor for late operative site pain, as it is possible that fretting at cross connection junctions may provide the environment for the incubation of dormant or inactive microbes.
Article
Removal of spine instrumentation for the treatment of recurrent low back pain remains controversial in the absence of pseudarthrosis and when no obvious pain generators are present. It is our practice to offer these patients surgical exploration and removal of instrumentation. Forty-five patients underwent an anterior and posterior lumbar spinal fusion. The removal of instrumentation was performed by the same surgeon and senior author of this paper (MRP). The reason for the revision surgery was recurrent low back and leg pain. All patients had a solid fusion based on a thorough surgical exploration of the fusion mass. Instrumentation was deemed either solid or loose at time of removal based on the purchase at the screw-bone interface. Final outcomes were determined using a functional and satisfactory questionnaire and compared between the two groups (Loose Instrumentation versus Solid Instrumentation). The majority of the patients in both groups would recommend the surgery to a family member (79% overall), would have the surgery again themselves (82%) and consider the surgery a success (77%). Pain was significantly decreased from pre-operatively to post-operatively and from pre-operative to final follow-up in both groups. The group of patients with loose instrumentation were significantly more likely to have a successful outcome than the group without loose instrumentation. This study indicates that the removal of instrumentation in the absence of pseudarthrosis is beneficial in the relief of low back pain and leg pain symptoms. Increased success rates were noted in patients with loose instrumentation. However, this classification was based on inter-operative inspection. Further studies of the ability to diagnose and predict success prior to surgery needs to be done.
Article
The controversy of burst fracture surgical management is addressed in this retrospective case study and literature review. The series consisted of 40 consecutive patients, index included, with 41 fractures treated with stiff, limited segment transpedicular bone-anchored instrumentation and arthrodesis from 1987 through 1994. No major acute complications such as death, paralysis, or infection occurred. For the 30 fractures with pre- and postoperative computed tomography studies, spinal canal compromise was 61% and 32%, respectively. Neurologic function improved in 7 of 14 patients (50%) and did not worsen in any. The principal problem encountered was screw breakage, which occurred in 16 of the 41 (39%) instrumented fractures. As we have previously reported, transpedicular anterior bone graft augmentation significantly decreased variable screw placement (VSP) implant breakage. However, it did not prevent Isola implant breakage in two-motion segment constructs. Compared with VSP, Isola provided better sagittal plane realignment and constructs that have been found to be significantly stiffer. Unplanned reoperation was necessary in 9 of the 40 patients (23%). At 1- and 2-year follow-up, 95% and 79% of patients were available for study, and a satisfactory outcome was achieved in 84% and 79%, respectively. These satisfaction and reoperation rates are consistent with the literature of the time. Based on these observations and the loads to which implant constructs are exposed following posterior realignment and stabilization of burst fractures, we recommend that three- or four-motion segment constructs, rather than two motion, be used. To save valuable motion segments, planned construct shortening can be used. An alternative is sequential or staged anterior corpectomy and structural grafting.
Article
Review of the literature. Review the definition, etiology, incidence, and risk factors associated with as well as potential treatment options. The development of pathology at the mobile segment next to a lumbar or lumbosacral spinal fusion has been termed adjacent segment disease. Initially reported to occur rarely, it is now considered a potential late complication of spinal fusion that can necessitate further surgical intervention and adversely affect outcomes. MEDLINE literature search. The most common abnormal finding at the adjacent segment is disc degeneration. Biomechanical changes consisting of increased intradiscal pressure, increased facet loading, and increased mobility occur after fusion and have been implicated in causing adjacent segment disease. Progressive spinal degeneration with age is also thought to be a major contributor. From a radiographic standpoint, reported incidence during average postoperative follow-up observation ranging from 36 to 369 months varies substantially from 5.2 to 100%. Incidence of symptomatic adjacent segment disease is lower, however, ranging from 5.2 to 18.5% during 44.8 to 164 months of follow-up observation. The rate of symptomatic adjacent segment disease is higher in patients with transpedicular instrumentation (12.2-18.5%) compared with patients fused with other forms of instrumentation or with no instrumentation (5.2-5.6%). Potential risk factors include instrumentation, fusion length, sagittal malalignment, facet injury, age, and pre-existing degenerative changes. Biomechanical alterations likely play a primary role in causing adjacent segment disease. Radiographically apparent, asymptomatic adjacent segment disease is common but does not correlate with functional outcomes. Potentially modifiable risk factors for the development of adjacent segment disease include fusion without instrumentation, protecting the facet joint of the adjacent segment during placement of pedicle screws,fusion length, and sagittal balance. Surgical management, when indicated, consists of decompression of neural elements and extension of fusion. Outcomes after surgery, however, are modest.
Article
Retrospective radiographic analysis of patients with adolescent idiopathic scoliosis (AIS) status after instrumentation removal. To evaluate the effect of instrumentation removal in surgically corrected AIS. Spinal instrumentation is occasionally removed for various reasons, most commonly for postoperative pain or infection, in surgically corrected AIS. The fate of instrumentation removal in adults has been previously reported with documented loss of sagittal alignment. However, to our knowledge, the long-term follow-up after instrumentation removal in AIS has not been reported. We retrospectively reviewed the preoperative, pre-instrumentation removal, postoperative following instrumentation removal, and latest follow-up radiographs of all patients with a primary diagnosis of AIS who underwent instrumentation removal after posterior spinal fusion. There were 21 patients (15 females, 6 males) from 2 institutions, at an average age of 14.8 years (range 9-19), who were originally treated between 1988 and 2002. Instrumentation removal occurred at an average of 2.4 years after surgery (range 8 months to 4 years, 2 months), with an average follow-up of 5.2 years (range 2-11). Fifteen patients underwent removal secondary to pain (2 of these with undetected infection) and 6 for known infection. Evaluation included coronal proximal thoracic, main thoracic, thoracolumbar/lumbar (TL/L), and sagittal T2-T5, T5-T12, T2-T12, T10-L2, T12-S1, and sagittal balance before surgery, before instrumentation removal, at immediate post-removal evaluation, and at latest follow-up. There were 12 main thoracic curves (Lenke type 1), 6 double thoracic curves (Lenke type 2), and 3 double major curves (Lenke type 3) in the series. Average proximal thoracic curve was 19.7 degrees (range 5 degrees -35 degrees ), the main thoracic curve 63.3 (range 42 degrees -112 degrees ), and the TL-L curve averaged 31.4 degrees (range 17 degrees -53 degrees ). There was an immediate loss of approximately 4 degrees (range 0 degrees -8 degrees ) in the main thoracic curve and 6 degrees (range 1 degrees -15 degrees ) in the TL/L curve after removal, with continued settling of an additional 6 degrees (10 degrees total, P = 0.002) in the main thoracic curve, and 3 degrees in the TL/L curve (9 degrees total, P = 0.01). There was also a significant difference in the group that underwent instrumentation removal <2 years after surgery compared to >2 years (main thoracic curve 13 degrees vs. 7 degrees , P = 0.017; TL/L 11 degrees vs. 7 degrees , P = 0.036). There were no significant changes in sagittal curvature or sagittal balance in either group (P > 0.39). Instrumentation removal in AIS is not always a benign process because the long-term follow-up of this cohort of patients shows a "settling" effect in the coronal plane of the main thoracic and TL/L curves after instrumentation removal. Interestingly, there was no change in the sagittal plane with time. Parents and patients should be counseled for this result when instrumentation removal is contemplated, and limited removal of focally symptomatic implants should be considered.
Article
Systematic review. To review the various radiographic parameters currently used to assess traumatic thoracolumbar injuries, emphasizing the validity and technique behind each one, to formulate evidence-based guidelines for a standardized radiographic method of assessment of these fractures. The treatment of thoracolumbar fractures is guided by various radiographic measurement parameters. Unfortunately, for each group of parameters, there has usually been more than 1 proposed measurement technique, thus creating confusion when gathering data and reporting outcomes. Ultimately, this effect results in clinical decisions being based on nonstandardized, nonvalidated outcome measures. Computerized bibliographic databases were searched up to January 2004 using key words and Medical Subject Headings on thoracolumbar spine trauma, radiographic parameters, and methodologic terms. Using strict inclusion criteria, 2 independent reviewers conducted study selection, data abstraction, and methodologic quality assessment. There were 18 original articles that ultimately constituted the basis for the review. Of radiographic measurement parameters, 3 major groups were identified, depicting the properties of the injured spinal column: sagittal alignment, vertebral body compression, and spinal canal dimensions, with 14 radiographic parameters reported to assess these properties. Based on a systematic review of the literature and expert opinion from an experienced group of spine trauma surgeons, it is recommended that the following radiographic parameters should be used routinely to assess thoracolumbar fractures: the Cobb angle, to assess sagittal alignment; vertebral body translation percentage, to express traumatic anterolisthesis; anterior vertebral body compression percentage, to assess vertebral body compression, the sagittal-to-transverse canal diameter ratio, and canal total cross-sectional area (measured or calculated); and the percent canal occlusion, to assess canal dimensions.
Article
Literature review. Provide an overview of biomechanical strengths and weaknesses of long and short fixation constructs applied in thoracolumbar fractures, along with a discussion of specific indications for selecting an instrumentation construct for a given fracture. Previous clinical and biomechanical studies have shown that segmental spinal instrumentation provides superior torsional, axial, and sagittal stability relative to nonsegmental systems. Multilevel fixation (long constructs) has proven reliable and effective in treating thoracic injuries, with or without anterior reconstruction. Short-segment pedicle instrumentation (short constructs) have proven effective in stabilizing thoracolumbar and lumbar fractures while limiting the disruption of lower lumbar motion segments. Loss of anterior column integrity leads to fixation failure when short constructs are not supplemented with further fixation or an anterior reconstruction. Review of the applicable clinical and biomechanical literature. Long constructs serve well in thoracic and thoracolumbar fractures, while short-segment fixation offers advantages in selected thoracolumbar and lumbar fractures. Anterior column integrity determines the risk of sagittal collapse and kyphosis at the thoracolumbar junction. Recognition of fundamental biomechanical principles is necessary to make either construct work reliably.
Article
The etiology of failed degenerative lumbar spine surgery may include a wide array of conditions. There is a group of patients who have recurrence of back pain despite a solid fusion in the absence of any obvious pain generator. Implant removal in those patients is a controversial optional treatment. The purpose of this study was to evaluate the efficacy and safety of implant removal and to determine the possible predictors of its efficacy. Twenty-five patients (10 M, 15 F) with an average age of 44 (18 to 74) were retrospectively evaluated. All patients had prior titanium posterior pedicle screw instrumentation and fusion for lumbar degenerative disorders. Twenty patients with increase in pain during palpation of the operative side underwent a preoperative anesthetic injection at the site of their trigger points. Patients' clinical charts, operative notes, and preoperative x-rays were evaluated. Relief of pain was evaluated by the percent Visual Analog Scale (VAS) pain change due to implant removal. Functional improvement was rated on a five-point scale. Predictors of pain relief were analyzed by using bivariate analysis. A P value <0.05 was considered significant. Average follow-up period was 20 (12 to 37) months. The median time after the index operation and the recurrence of pain was 13.5 (1 to 119) months. VAS decrease after implant removal was 50% (P<0.001). Functional improvement was reported by 84% of patients. One patient developed a superficial infection managed successfully. Bivariate analysis showed that percent VAS change after injection, months free of pain after the index operation, and provocation of pain by palpation were significant predictors for pain relief (P<0.05). Removal of the implant may be an efficient and safe procedure for carefully selected patients and the most consistent predictor of its efficacy is the percent pain relief after the diagnostic injection of the painful operative side.
Article
Persistent pain in the region of implanted hardware following fracture fixation commonly leads to implant removal. This prospective study evaluated patient outcomes and pain reduction following removal of orthopaedic hardware implanted for fracture fixation. Sixty patients who had been treated previously for a fracture and complained of pain in the region of the fracture fixation hardware constituted the study cohort. Patients were carefully examined by the treating physician to rule out other causes of pain such as infection and nonunion. Baseline data were recorded preoperatively. Data obtained postoperatively at three, six, and twelve months included a visual analog pain scale score and results on the Short Musculoskeletal Function Assessment Questionnaire and the Medical Outcomes Study Short Form-36. At the one-year interval, a patient satisfaction questionnaire was completed and outcomes were analyzed. There were no complications associated with implant removal surgery. Three patients did not have complete follow-up, leaving a total of fifty-seven patients with complete follow-up. At one year, all patients indicated that they were satisfied, that they would have the procedure done again, and that their overall function had improved. The scores for pain on the visual analog scale decreased from a mean (and standard deviation) of 5.5 +/- 2.5 before hardware removal to 1.3 +/- 1.8 after hardware removal, with an overall improvement at one year of 76% (p = 0.00001). At one year, thirty (53%) of the fifty-seven patients had complete resolution of pain. In addition, the results on the Short Musculoskeletal Function Assessment Questionnaire showed a 43% improvement from baseline (p = 0.0001), and the results on the physical component of the Short Form-36 showed a similar improvement of 40% (p = 0.0001). Following fracture-healing, removal of hardware is safe with minimal risk. Improvement in pain relief and function can be expected.
Article
Prospective radiographic and clinical analysis of patients with idiopathic scoliosis who had complete implant removal following posterior spinal fusion (PSF) at least 2 years previously. To evaluate the clinical and radiographic effect of implant removal after PSF for idiopathic scoliosis. Occasionally, implants must be removed following instrumented PSF. Indications for removal include infection and late operative site pain. Previously, it has been thought that there was little morbidity associated with implant removal in the presence of a solid fusion. However, recent studies have reported loss of coronal correction after implant removal in patients who had a PSF for adolescent idiopathic scoliosis. Few long-term studies have assessed the clinical or radiographic results of complete implant removal after PSF. We identified 56 patients who had undergone PSF for idiopathic scoliosis and subsequently had complete removal of all instrumentation. None of these patients had a pseudarthrosis at the time of implant removal. After IRB approval, 43 of 56 (77%) patients returned for new standing posteroanterior and lateral spine radiographs and completion of an SRS-22 questionnaire. For the 43 patients who had new radiographs and completed an SRS-22, the time from the original PSF to complete implant removal averaged 2.9 years (range, 7 months to 7.25 years). Twenty-two patients had implants removed because of infection, and 21 patients had implants removed secondary to pain. The average time from implant removal to completion of the most recent radiographs and SRS-22 questionnaire was 9.5 years (range, 3.2-17.9 years). Patients were considered to have had progression of deformity after implant removal if their Cobb angle measurements increased by more than 10 degrees . Two patients had 11 degrees to 20 degrees of coronal plane progression of their main thoracic curve. No patient had more than 10 degrees of coronal plane progression of a lumbar curve. Sagittal curve progression was identified more frequently. Nineteen patients had between an 11 degrees and 20 degrees increase in thoracic kyphosis, and 5 patients had >20 degrees of thoracic kyphosis progression. Patients with >20 degrees of thoracic kyphosis progression after implant removal had greater thoracic kyphosis before surgery and larger main thoracic and lumbar coronal curves at the time of implant removal. Progressive kyphosis did not correlate with: reason for implant removal, length of follow-up, or time from fusion to implant removal. Although total SRS-22 scores correlated inversely with increased thoracic kyphosis, this trend did not reach statistical significance. Implant removal after PSF for idiopathic scoliosis may be complicated by progression of deformity. Patients requiring implant removal should be appropriately counseled and monitored.
Article
Routine metalwork removal, in asymptomatic patients, remains a controversial issue. Current literature emphasises the potential hazards of implant removal and the financial implications encountered from these procedures. However, there is little literature guidance and no published research on current practice. To estimate the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal in asymptomatic patients. An analysis, by two independent observers, was performed on the postal questionnaire replies of 36% (500 out of 1390), randomly selected UK orthopaedic consultants. Four hundred and seven (81%) replies were received. A total of 345 (69%) were found to be suitable for analysis. The most significant results of our study (I) 92% of orthopaedic surgeons stated that they do not routinely remove metalwork in asymptomatic skeletally mature patients; (II) 60% of trauma surgeons stated that they do routinely remove metalwork in patients aged 16 years and under; (III) 87% of the practicing surgeons indicated that they believe it is reasonable to leave metalwork in for 10 years or more; (IV) only 7% of practicing trauma surgeons who replied to this questionnaire have departmental or unit policy. Our results demonstrate that most practicing trauma surgeons do comply with the evidence presented in the little literature available. However, we do believe that a general policy for metalwork removal is essential. Such a policy should include guidelines specific to age groups and level of surgeon who should be performing the removal procedure. Such a document would require further validated studies but would eventually serve to steer surgeons in achieving best practice.
Treatment of thoracolumbar burst fractures with variable screw placement or Isola instrumentation and arthrodesis: case series and literature review
  • Gf Alvine
  • Jm Swain
  • Ma Asher
Alvine GF, Swain JM, Asher MA, et al. Treatment of thoracolumbar burst fractures with variable screw placement or Isola instrumentation and arthrodesis: case series and literature review. J Spinal Disord Tech 2004 ; 17 : 251 – 64.