Article

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

March 2015
Spine 40(11):1

DOI:10.1097/BRS.0000000000000870

Authors:

Chang HOON Jeon

Ajou University Medical Center

Han-Dong Lee

Ajou University Medical Center

Yu Sang Lee

Ajou University

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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.

The Necessity of Implant Removal after Fixation of Thoracolumbar Burst Fractures—A Systematic Review

Article

Full-text available

Mar 2023

Background: Thoracolumbar burst fractures are a common traumatic vertebral fracture in the spine, and pedicle screw fixation has been widely performed as a safe and effective procedure. However, after the stabilization of the thoracolumbar burst fractures, whether or not to remove the pedicle screw implant remains controversial. This review aimed to assess the benefits and risks of pedicle screw instrument removal after fixation of thoracolumbar burst fractures. Methods: Data sources, including PubMed, EMBASE, Cochrane Library, Web of Science, Google Scholar, and Clinical trials.gov, were comprehensively searched. All types of human studies that reported the benefits and risks of implant removal after thoracolumbar burst fractures, were selected for inclusion. Clinical outcomes after implant removal were collected for further evaluation. Results: A total of 4051 papers were retrieved, of which 35 studies were eligible for inclusion in the review, including four case reports, four case series, and 27 observational studies. The possible risks of pedicle screw removal after fixation of thoracolumbar burst fractures include the progression of the kyphotic deformity and surgical complications (e.g., surgical site infection, neurovascular injury, worsening pain, revision surgery), while the potential benefits of pedicle screw removal mainly include improved segmental range of motion and alleviated pain and disability. Therefore, the potential benefits and possible risks should be weighed to support patient-specific clinical decision-making about the removal of pedicle screws after the successful fusion of thoracolumbar burst fractures. Conclusions: There was conflicting evidence regarding the benefits and harms of implant removal after successful fixation of thoracolumbar burst fractures, and the current literature does not support the general recommendation for removal of the pedicle screw instruments, which may expose the patients to unnecessary complications and costs. Both surgeons and patients should be aware of the indications and have appropriate expectations of the benefits and risks of implant removal. The decision to remove the implant or not should be made individually and cautiously by the surgeon in consultation with the patient. Further studies are warranted to clarify this issue. Level of evidence: level 1.

Implant removal after short percutaneous pedicle fixation associated with SpineJack® kyphoplasty: is correction sustained?

Article

Full-text available

Dec 2022
ARCH ORTHOP TRAUM SU

Purpose This study objective was to evaluate sagittal correction loss after instrumentation removal in patients treated for thoracic or lumbar compression fractures treated with SpineJack® kyphoplasty associated with short percutaneous pedicle screw fixation. Methods This retrospective multicenter study was carried out in three major French trauma centers. All patients with a single type A thoracic or lumbar fracture, treated by the studied technique between 2017 and 2020, have been included. Demographic data, fracture type, removal procedure achievement and term were collected. Radiological parameters were measured at five timepoints: pre-operative, intra-operative, immediate post-operative, early post-operative (< 3 months) and at follow-up (1 year). Vertebral wedge angle (angle between the two endplates of the fractured vertebra) and traumatic regional angulation (TRA—calculated by subtracting regional kyphosis from the physiological reference values). Results 150 patients were included. Mean age was 48.6 ± 17.8 years. Average follow-up was 14.4 ± 3 months. 82 patients had secondary instrumentation removal. Mean time to removal was 6.4 ± 2.4 months. TRA correction loss between immediate post-operative and last follow-up was greater in removal group: 5.1 ± 5.6° versus 2.7 ± 4.7° (p = 0.01). Material was removed earlier in younger patients (p = 0.002). TRA correction loss was similar in the early and late removal groups (p = 0.83). Multivariate analysis identified only Magerl/AO A3 fractures as risk factor for loss of TRA correction (p = 0.007). Conclusion Instrumentation removal was associated with good radiological outcomes with a non-significant loss of vertebral wedge angle and tolerable loss of traumatic regional angulation (+ 2.4° compared to the no-removal group), even if performed early.

Is It Necessary to Remove the Implants After Fixation of Thoracolumbar and Lumbar Burst Fractures Without Fusion? A Retrospective Cohort Study of Elderly Patients

Article

Full-text available

Jul 2022

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.

Implant Removal Versus Implant Retention Following Posterior Surgical Stabilization of Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis

Article

Full-text available

Apr 2021

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.

Outcomes in Thoracolumbar and Lumbar Traumatic Fractures: Does Restoration of Unfused Segmental Mobility Correlated to Implant Removal Time？：a retrospective study

Preprint

Full-text available

Jan 2021

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.

Healing pattern classification for thoracolumbar burst fractures after posterior short-segment fixation

Article

Full-text available

Jun 2020
BMC MUSCULOSKEL DIS

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.

Healing Pattern Classification for Thoracolumbar Burst Fractures after Posterior Short-segment Fixation

Preprint

Full-text available

Jan 2020

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.

Is removal of the internal fixation after successful intervertebral fusion necessary? A case–control study based on patient-reported quality of life

Article

Full-text available

Mar 2022
J Orthop Surg Res

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.

Vacuum phenomenon as a predictor of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture: a single-center retrospective study

Article

Full-text available

Jan 2022
BMC MUSCULOSKEL DIS

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.

Is Removal of the Internal Fixation After Successful Intervertebral Fusion Necessary? A Case–control Study Based on Patient-reported Quality of Life

Preprint

Full-text available

Sep 2021

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.

Vacuum Phenomenon As A Predictor of Kyphosis After Implant Removal Following Posterior Pedicle Screw Fixation Without Fusion For Thoracolumbar Burst Fracture: A Single-Center Retrospective Study

Preprint

Full-text available

Jan 2021

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.

Vacuum Phenomenon as a Predictor of Kyphosis After Implant Removal Following Posterior Pedicle Screw Fixation Without Fusion for Thoracolumbar Burst Fracture: a Single-center Retrospective Study

Preprint

Full-text available

Jan 2021

Magnetic resonance imaging evaluation of intervertebral disc injuries can predict kyphotic deformity after posterior fixation of unstable thoracolumbar spine injuries

Article

Full-text available

Jul 2018

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.

Describing an old trick in posterior thoracal and lumbar ımplant removal surgery: follow-up results for at least 10 years

Article

Full-text available

Jul 2024

Study design Retrospective case series. Objectives We aimed to describe with a novel surgical approach for the removal of posterior thoracolumbar implant in patients with symptomatic failure of the implant and present our preliminary results with this method. Methods This retrospective, single-center study was performed in the neurosurgery department of a university hospital. Data were gathered from the medical files of 314 patients (243 women, 77.39%; 71 men, 22.61%) with symptomatic thoracolumbar implant failure that underwent implant removal operation using our novel technique between 2010 and 2020. Symptoms, radiological findings, intraoperative findings as well as clinical outcomes were evaluated. Results In our series, the average age was 46.5 years (range: 21–84) with a mean follow-up duration of 7 years (range: 3 months to 10 years). Preoperatively, the most common symptoms were leg pain and numbness of the lower extremity. Postoperatively, no major complications were noted. Clinical progression of symptoms was avoided by surgery in all patients, while we came across removal difficulties due to screw–screwdriver mismatch in 15 of 314 surgeries (4.78%). Our novel approach allowed successful screw removal including these challenging cases. Conclusions We suggest that our novel approach is a practical and effective for the removal of posterior thoracolumbar implant in cases with symptomatic failure attributed to screw–screwdriver mismatch. Further trials are warranted to assess the efficacy of this technique to overcome surgical problems associated with screw removal.

Buck technique supplemented by temporary intersegmental pedicle screw fixation to repair lumbar spondylolysis in youth

Article

Full-text available

Jun 2024
J Orthop Surg Res

Background Lumbar spondylolysis is a bone defect in the pars interarticularis of the lumbar vertebral, which is a common cause of low back pain in youth. Although non-surgical treatment is a mainstream option, surgery is necessary for patients with persistent symptoms. Buck technique is widely used as a classical direct repair technique, but it cannot achieve reduction of low-grade spondylolisthesis and reconstruction of lumbosacral sagittal balance. We have described a novel surgical procedure based on Buck technique with temporary intersegmental pedicle screw fixation, and report a series of clinical outcomes in 5 patients to provide a reference for the clinical treatment of young lumbar spondylolysis. Methods Five young patients with symptomatic lumbar spondylolysis with a mean age of 19.20 ± 5.41 years underwent surgical treatment after an average of 7.60 ± 1.52 months of failure to respond to conservative treatment, using a new surgical procedure based on Buck technique combined with temporary intersegmental pedicle screw fixation. Results Five patients were successfully operated without serious complications such as nerve and vascular injury. The average operation time was 109.00 ± 7.42 min, the interpretative average blood loss was 148.00 ± 31.14 ml, and the average fusion time was 11.20 ± 1.64 months. All patients were followed up for 2 years after surgery, and the visual analogue score (VAS) of low back pain and Oswestry disability index (ODI) scores were significantly improved compared with those before surgery, and the Henderson’s evaluation were rated excellent or good. After the removal of the internal fixation, it was observed that temporary intersegmental fixation could repair the isthmus, reduce lumbar spondylolisthesis, and reconstruct the sagittal balance of the lumbosacral vertebrae while preserving lumbar motion and preventing intervertebral disc degeneration. Postoperative MRI indicated the Pfirrmann classification of the affected discs: 1 case from grade III to grade II, 3 cases from grade II to grade I, and 1 case remained grade II. Conclusions Buck technique supplemented by temporary intersegmental pedicle screw fixation is a highly applicable and effective method for the treatment of adolescent lumbar spondylolysis. The isthmic fusion is accurate, and temporary intersegmental fixation can effectively prevent disc degeneration and reconstruct the sagittal balance of lumbosacral vertebra.

Clinical outcome after dorso-ventral stabilization of the thoracolumbar and lumbar spine with vertebral body replacement and dorsal stabilization

Article

Full-text available

May 2024
EUR SPINE J

Purpose Surgical stabilization of the spine by vertebral body replacement (VBR) is used for spinal disorders such as traumatic fractures to provide an anatomical re-adjustment of the spine to prevent late detrimental effects and pain [1–4]. This study addresses the clinical outcome after a ventral intervention with VBR and bisegmental fusion. Methods The study includes 76 patients (mean age: 59.34 ± 15.97; 34 females and 42 males) with fractures in the lower thoracic and lumbar spine. They were selected from patients of our hospital who received an anterolateral VBR surgery on the corresponding lower spine region over a nine-year period. Only patients were examined with X-rays and complete follow-up records. Exclusion criteria were changes due to degeneration and pathological fractures. Patients were divided into two groups, the thoracotomy group (Th10-L1) and the lumbotomy group (L2-5), respectively. Minimum one year after surgery, patients were asked about their well-being using a precasted questionnaire. Results No significant differences with respect to the subjective impression of the patients concerning their back pain, spinal functional impairment, their general functional status and their quality of life impairment. Unfortunately, however, only a rather modest but significant increase of the post-surgical life quality was reported. Conclusions Patients who underwent VBR in the lower thoracic or lumbar spine show modest long-term well-being. The results suggest that injuries to the lower thoracic or lumbar spine requiring vertebral body replacement should be classified as severe injuries since they adversely affect the patients’ long-term well-being. Trial registration Study of clinical outcome of patients after vertebral body replacement of the ventral thoracal and lumbal spine, DRKS00031452. Registered 10th March 2023 - Prospectively registered. Trial registration number DRKS00031452.

Buck technique supplemented by temporary intersegmental pedicle screw fixation to repair lumbar spondylolysis in youth

Preprint

Full-text available

Mar 2024

Background Lumbar spondylolysis is a bone defect in the pars interarticularis of the lumbar vertebral, which is a common cause of low back pain in youth. Although non-surgical treatment is a mainstream option, surgery is necessary for patients with persistent symptoms. Buck technique is widely used as a classical direct repair technique, but it cannot achieve reduction of low-grade spondylolisthesis and reconstruction of lumbosacral sagittal balance. We have described a novel surgical procedure based on Buck technique with temporary intersegmental pedicle screw fixation, and report a series of clinical outcomes in 5 patients to provide a reference for the clinical treatment of young lumbar spondylolysis. Methods Five young patients with symptomatic lumbar spondylolysis with a mean age of 21.50 ± 3.20 years underwent surgical treatment after an average of 7.60 ± 1.52 months of failure to respond to conservative treatment, using a new surgical procedure based on Buck technique combined with temporary intersegmental pedicle screw fixation. Results Five patients were successfully operated without serious complications such as nerve and vascular injury. The average operation time was 109.00 ± 7.42 minutes, the interpretative average blood loss was 148.00 ± 31.14ml, and the average fusion time was 11.20 ± 1.64 months. All patients were followed up for 2 years after surgery, and the visual analogue score (VAS) of low back pain and Oswestry disability index (ODI) scores were significantly improved compared with those before surgery, and the Henderson’s evaluation were rated excellent or good. After the removal of the internal fixation, it was observed that temporary intersegmental fixation could repair the isthmus, reduce lumbar spondylolisthesis, and reconstruct the sagittal balance of the lumbosacral vertebrae while preserving lumbar motion and preventing intervertebral disc degeneration. Postoperative MRI indicated the Pfirrmann classification of the affected discs: 1 case from grade III to grade II, 3 cases from grade II to grade I, and 1 case remained grade II. Conclusions Buck technique supplemented by temporary intersegmental pedicle screw fixation is a highly applicable and effective method for the treatment of adolescent lumbar spondylolysis. The isthmic fusion is accurate, and temporary intersegmental fixation can effectively prevent disc degeneration and reconstruct the sagittal balance of lumbosacral vertebra.

A Rapid and Safe Minimally Invasive Procedure for Percutaneous Pedicle Screw Removal: A Case-Control Study and Technical Description

Article

Full-text available

Jan 2024

Purpose Percutaneous pedicle screw fixation is a common minimally invasive treatment for traumatic thoracolumbar and lumbar fractures; however, research on hardware removal after successful healing is limited. We aimed to introduce a rapid, safe, minimally invasive, and cost-effective method for percutaneous pedicle screw removal. Patients and Methods We conducted a retrospective analysis of demographic (age, sex, body mass index, alcohol use, and current smoking), clinical (hypertension and diabetes mellitus), surgical (affected levels, number of screws, time of surgery, and blood loss), and treatment cost characteristics of 92 patients who had undergone percutaneous pedicle screw removal between May 2016 and February 2023. The first 57 patients underwent the conventional method, and the remaining 35 underwent the modified method. Independent-sample t-tests and chi-square tests were used to compare continuous and categorical variables, respectively, between the two groups. Results No significant differences were observed in the demographic parameters, complications, or affected levels between the groups. However, the average surgical time (P=0.000) was significantly shorter, and the average blood loss volume (P=0.002) and total cost (P=0.000) were significantly lower in the modified group than in the conventional group. Conclusion Compared with the conventional method, our modified method can shorten the surgical time, reduce blood loss, and reduce the total cost of treatment. It is a quick and safe minimally invasive method that does not require additional surgical instruments and is suitable for implementation in primary hospitals.

Is restoration of vertebral body height after vertebral body fractures and minimally-invasive dorsal stabilization with polyaxial pedicle screws just an illusion?

Article

Full-text available

Oct 2023
ARCH ORTHOP TRAUM SU

Introduction Thoracolumbar spine fractures often require surgical treatment as they are associated with spinal instability. Optimal operative techniques and treatment are discussed controversially. Aim of our prospective cohort study was to investigate the sagittal alignment after reduction, the secondary loss of reduction and the subjective outcome as well as the causal correlation of these parameters after minimally invasive stabilization of thoracic and lumbar fractures with polyaxial pedicle screws. Materials and methods In a single-center study, a total of 78 patients with an average age of 61 ± 17 years who suffered a fracture of the thoracic or lumbar spine were included and subjected to a clinical and radiological follow-up examination after 8.5 ± 8 months. The kyphotic deformity was measured by determining the vertebral body angle, the mono- and bi-segmental wedge angle at three time points. The patients’ subjective outcome was evaluated by the VAS spine score. Results After surgical therapy, a significant reduction of the traumatic kyphotic deformity was shown with an improvement of all angles (vertebral body angle: 3.2° ± 4.4°, mono- and bi-segmental wedge angle: 3.1° ± 5.6°, 2.0° ± 6.3°). After follow-up, a significant loss of sagittal alignment was observed for all measured parameters with a loss of correction. However, no correlation between the loss of reduction and the subjective outcome regarding the VAS spine scale could be detected. Conclusion The minimally invasive dorsal stabilization of thoracic and lumbar spine fractures with polyaxial pedicle screws achieved a satisfactory reduction of the fracture-induced kyphotic deformity immediately postoperatively with a floss of reduction in the further course. However, maybe the main goal of this surgical procedure should be the prevention of a complete collapse of the vertebral body instead of a long-lasting restoration of anatomic sagittal alignment. Level of evidence II.

Severe major vessel injury during peadicle screw removal: a case report

Article

Full-text available

Jun 2023

Introduction Pedicle screw fixation (PSF) has been the standard therapy for the treatment of various spinal diseases. Although complications are identified regularly, iatrogenic vascular injury is one of the rare but life-threatening complications. In this literature, we describe the first case of inferior vena cava (IVC) injury during pedicle screw removal. Case description A 31-year-old man was treated by percutaneous pedicle screw fixation for an L1 compression fracture. After a year, the fracture healed well and hardware removal surgery was performed. During the procedure, the hardware on the right was removed unremarkably except for the L2 pedicle screw which slipped into the retroperitoneum because of the improper technique. The CT angiogram revealed the screw had breached the anterior cortex of the L2 vertebral body and penetrated the IVC. After multidisciplinary cooperation, the defect of IVC was reconstructed and the L2 screw was removed from the posterior approach in the end. Result The patient recovered well and was discharged after 3 weeks without further events. The removal of the contralateral implants was unremarkable at 7 months postoperatively. At the 3-year follow-up, the patient returned to his normal daily activity without any complaints. Conclusion Although pedicle screw removal is a rather simple procedure, severe complications may have occurred from this procedure. Surgeons should keep vigilant to avoid the complication noted in this case.

A practical method for the retrieval of tulip-head polyaxial pedicle screw by reusing the rod in revision and implants removal surgery: introduction of technique and evaluation of clinical outcomes

Article

Full-text available

Jun 2023
BMC Surg

Abstract Background The removal of spinal implants is needed in revision surgery or in some cases whose fracture had healed or fusion had occurred. The slip of polyaxial screw or mismatch of instruments would make this simple procedure intractable. Here we introduce a simple and practical method to address this clinical dilemma. Methods This is a retrospective study. The patients underwent new technique for retrieving the implants from July 2019 to July 2022 were labeled as group A, while the patients underwent traditional implants retrieval technique from January 2017 to January 2020 were labeled as group B. Patients in each group were subdivided into revision surgery group (r group) and simple implants removal group (s group) according to the surgery fashion. For the new technique, the retrieved rod was cut off to a proper length which was matched with the size of tulip head, and was replaced into the tulip head. After tightened with nut, a monoaxial screw-rod “construct” was formed. Then the “construct” can be retrieved by a counter torque. The operation duration, intraoperative blood loss, post-operative bacteria culture, hospital stay and costs were analyzed. Results A total of 116 polyaxial screws with difficult retrieval (43 screws in group A, 73 screws in group B) in 78 patients were recorded, in which 115 screws were successfully retrieved. Significant differences were found in the mean operation duration, intraoperative blood loss when comparing the r group in group A and B, as well as the s group in group A and B (P

A new technique in posterior thoraco-lumbar implant removal surgery: Follow-up results for at least 10 years

Preprint

Full-text available

Nov 2022

Inroduction: Pedicle screw removing is not uncommon and require reoperations which is an immense burden on the patient and on the healthcare system.We aimed to describe with a novel surgical approach for the removal of posterior thoracolumbar implant in patients with symptomatic failure of the implant and present our preliminary results with this method. Materials and Methods: This retrospective, single-center study was performed in the neurosurgery department of a university hospital. Data were gathered from the medical files of 314 patients (243 women, 77.39%; 71 men, 22.61%) with symptomatic thoracolumbar implant failure that underwent implant removal operation using our novel technique between 2010 and 2020. Symptoms, radiological findings, intraoperative findings as well as clinical outcomes were evaluated. Results: In our series, the average age was 46.5 years (range: 21 to 84) with a mean follow-up duration of 7 years (range: 3 months to 10 years). Preoperatively, the most common symptoms were leg pain and numbness of the lower extremity. Postoperatively, no major complications were noted. Clinical progression of symptoms was avoided by surgery in all patients, while we came across removal difficulties due to screw-screwdriver mismatch in 15 of 314 surgeries (4.78%). Our novel approach allowed successful screw removal including these challenging cases. Conclusion: We suggest our novel approach is a practical and effective for the removal of posterior thoracolumbar implant in cases with symptomatic failure attributed to screw-screwdriver mismatch. Further trials are warranted to assess the efficacy of this technique to overcome surgical problems associated with screw removal.

A practice method for the retrieval of tulip-head polyaxial pedicle screw by reusing the rod in revision and implants removal surgery: introduction of technique and evaluation of clinical outcomes

Preprint

Full-text available

Oct 2022

Background The removal of spinal implants was needed in revision surgery or in some cases whose fracture had healed or fusion had occured. The slip of polyaxial screw or mismatch of instruments would make this simple procedure intractable. Here we introduced a simple and practical method to address this clinical dilemma. Methods This is a retrospective study. The patients underwent new technique for retrieving the implants from July 2019 to July 2022 were labeled as group A, while the patients January 2017 to January 2020 were labeled as group B. Patients in each group were subdivided into revision surgery group and simple implants removal group according to the surgery fashion. In the new technique, the retrieved rod was cut off to a proper length which was matched with the size of tulip head, and was replaced into the tulip head. After tightened with nut, a monoaxial screw-rod “construct” was formed. Finally, a counter torque was applied to remove the “construct”. The operation duration, intraoperative blood loss, post-operative bacteria culture, hospital stay and costs were documented and analyzed. Results A total of 116 polyaxial screws with difficult removal of 78 patients (43 screws in group A, 73 screws in group B) were successfully retrieved by using this method. Significant differences were found in the mean operation duration, intraoperative blood loss when comparing the r group in group A and B, as well as the s group in group A and B (P < 0.05). There were no significant differences in hospital stay and costs between group A and B. Three patients were found positive bacteria culture of drainage tube/tape in group A (3/30), while 7 patients in group B (7/48). The most prevalent bacteria was Propionibacterium acnes. Conclusion This technique is practical and safe in for the poly-axial screw with difficult retrieval. Reduced operation duration and intraoperative bloods loss may potentially alleviate the hospitalization burden of patients. Positive cultivation results are common after implants removal surgery, but they rarely represent an organized infection. A positive culture with P. acnes or S. epidermidis should be interpreted with caution.

Thoracolumbar burst fracture without neurological deficit: Review of the controversies and current evidence of treatment

Article

Mar 2022

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.

Percutaneous Pedicle Screw Fixation with Vertebral Augmentation Using a Bioengineered Degradable Bone Substitute for Thoracolumbar Fractures

Article

Jan 2021

Intraoperative biomechanics of lumbar pedicle screw loosening following successful arthrodesis

Preprint

Full-text available

Jan 2017

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.

Evaluation of disc degeneration adjacent to AOspine A fractures: pre- and post-operative MRI analysis

Article

Full-text available

Aug 2020

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.

Biomechanical analysis of single-level interbody fusion with different internal fixation rod materials: a finite element analysis

Article

Full-text available

Feb 2020
BMC MUSCULOSKEL DIS

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.

Posterior monoaxial screw fixation combined with distraction-compression technology assisted endplate reduction for thoracolumbar burst fractures: a retrospective study

Article

Full-text available

Jan 2020

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.

Posterior monoaxial screw fixation combined with distraction-compression technology assisted endplate reduction for thoracolumbar burst fractures: A retrospective study

Article

Full-text available

Jan 2020
BMC MUSCULOSKEL DIS

Abstract 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

Effect of lordosis on adjacent levels after lumbar interbody fusion, before and after removal of the spinal fixator: A finite element analysis

Article

Full-text available

Oct 2019
BMC MUSCULOSKEL DIS

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.

Radiographic Evaluation of Minimally Invasive Instrumentation and Fusion for Treating Unstable Spinal Column Injuries

Article

Full-text available

Jun 2019

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.

Étude des lésions discales immédiates et tardives à l’IRM dans le cadre des fractures thoracolombaires Magerl A : analyse de 76 fractures

Article

Jun 2019

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.

Immediate and late discal lesions on MRI in Magerl A thoracolumbar fracture: Analysis of 76 cases

Article

May 2019

Fractures et luxations récentes du rachis thoracique et lombaire de l’adulte

Article

Jul 2019

The clinical results and function of the intersegmental disc after posterior-only partial corpectomy for lumbar burst fractures

Article

Nov 2024
MEDICINE

We treated the burst spinal fracture with posterior subtotal corpectomy and reconstruction. In some cases, the endplate and the adjacent disc can be preserved during the operation. The adjacent disc retained its mobility after the removal of the posterior pedicle screws. This study evaluated the clinical results and function of the intersegmental caudal disc after the removal of posterior pedicle screws for lumbar burst fractures. The study analyzed retrospectively 36 patients with acute burst traumatic lumbar fractures who underwent posterior partial subtotal corpectomy and reconstruction with preservation of the inferior endplate of the fractured vertebral body and the adjacent caudal disc, and sequential removal of the posterior pedicle screw 1 year after the second surgery from March 2015 to December 2021. All patients were followed for approximately 1 year after pedicle screw removal. Demographic data, anterior vertebral body height, local kyphosis, motion, caudal disc degeneration, and clinical outcomes were evaluated. After removal of the posterior pedicle screws, the intersegmental disc retained a range of motion of 10.55 ± 5.58°, and the disc degeneration was graded by Pfirrmann criteria from 2.21 ± 1.15 before first surgery to 3.18 ± 1.46 at last follow-up after second surgery. There were 2 cases of superficial wound infection, and 5 cases of postoperative neuralgia recovering after 3 months. Anterior fusion was achieved, although postoperative subsidence of the mesh was observed in 6 cases and screw loosening in 9 cases. Posterior-only partial subtotal corpectomy with preservation of the adjacent caudal disc not only achieved a good clinical effect, but also preserved intersegmental caudal disc function after removal of posterior pedicle screws approximately 1 year later. This technique is a promising alternative for cases in which the endplate obviates injury.

Effective method of pedicle screw fixation in patients with neurologically intact thoracolumbar burst fractures: a systematic review of studies published over the last 20 years

Article

Nov 2024
NEUROCIRUGIA

Removal Versus Retention of Posterior Spinal Implants in Patients with Healed Thoracolumbar Fractures: Analysis of Clinical and Radiographic Outcomes-A Randomized Controlled Trial

Article

Full-text available

Oct 2024

Introduction: There is ongoing debate over whether to remove or retain posterior spinal implants following the successful union of thoracolumbar fractures. This study aimed to compare clinical and radiographic outcomes following removal versus retention of posterior spinal implants in patients with healed thoracolumbar fractures. Methods: All patients who underwent posterior short segment fixation for thoracolumbar (T11-L2) fractures and presented to the outpatient clinic of our institution (level I trauma center) from October 2020 to October 2022 were enrolled in the study. The participants were randomly assigned to one of the two groups. The EQ-5D-5L was the primary outcome of the study. The secondary outcomes were the Oswestry Disability Index (ODI), loss of correction, and incidence of complications. Results: A total of 52 patients were included in the final analysis with 26 patients in each group. During the 6-month and 1-year follow-up visits, the implant removal group had a statistically significant improvement in the EQ-Index, EQ-VAS, and ODI, while there were no significant differences in these parameters in the implant retention group. There was no significant difference between the two groups regarding loss of correction (P= 0.109). Conclusions: In patients who have undergone posterior instrumentation for thoracolumbar fractures, the removal of implants following fracture consolidation demonstrates enhanced clinical outcomes when compared to retaining the implants. Although loss of correction is marginally higher in the implant removal group than in the retention group, this disparity did not attain statistical significance, nor did it correlate with inferior clinical outcomes. Furthermore, the incidence of complications following implant removal remained minimal. These findings emphasize the favorable efficacy and safety profile of implant removal procedures within this patient population.

Effective Method of Pedicle Screw Fixation in Patients with Neurologically Intact Thoracolumbar Burst Fractures: A Systematic Review of Studies Published Over the Last 20 Years

Article

Full-text available

Jul 2024

Analyse radiologique du traitement mini-invasif des fractures thoracolombaires de type A d’après une série de 135 fractures

Article

Mar 2023

Radiological analysis of minimally invasive treatment of type A thoracolumbar fractures based on a series of 135 fractures

Article

Nov 2022

Introduction: Although the reduction of traumatic fractures of the thoracolumbar spine is of good quality during conventional so-called open procedures, the alternative minimally invasive approach also appears to confer good results. The aim of this study was to measure the radiological parameters before and after minimally invasive surgery, in order to assess the quality of the reduction of thoracolumbar compression fractures. Materials and methods: This retrospective, monocentric study included 112 patients with a mean age of 48.9 years, presenting with 135 type A thoracolumbar compression fractures treated by a posterior minimally invasive surgical approach comprising vertebral augmentation or posterior osteosynthesis or a mixed procedure. Results: The parameters analyzed were significantly lower whatever the procedure in the immediate postoperative period. Mean regional and local kyphosis, posterior wall displacement, and mean vertebral height were significantly lower (p<0.01). Fracture reduction was better when osteosynthesis was associated with vertebral augmentation. In the osteosynthesis subgroup with osteosynthesis hardware removal but without vertebral augmentation, we found a significant worsening of the regional kyphosis (p<0.05). Conclusion: The management of thoracolumbar compression fractures by a posterior minimally invasive approach allows excellent fracture reduction with a restoration of the spinal canal, vertebral height and kyphosis. Level of Evidence: IV

Influence of the facet joint angle on facet joint degeneration following pedicle screw fixation without fusion in thoracolumbar fractures

Article

Oct 2022
J BACK MUSCULOSKELET

Background: Posterior approach pedicle screw fixation without fusion is widely used in the treatment of neurologically intact type A3 thoracolumbar fractures. Objective: To analyze the influence of the facet joint (FJ) angle on FJ degeneration following posterior approach pedicle screw fixation without fusion in neurologically intact type A3 thoracolumbar fractures. Methods: Fifty-eight patients who underwent pedicle screw fixation via the traditional posterior approach (n= 28) or the Wiltse approach (n= 30) were enrolled. A CT scan was performed before fixation and before fixation removal (Within 1.5 to 2 years after fixation) to evaluate the FJs parameters, including FJ inclination (FJI), FJ tropism (FJT), FJ violation, and FJ degeneration grade (FJDG), of three fixed segments and the adjacent segment below the fixed segments. Results: There was no significant difference in FJ violation rate, FJDG deterioration, or FJ angle between the two groups (P> 0.05). FJDG deterioration showed a weak positive correlation with FJI and FJT before fixation, and the angular change in FJI (P< 0.05); and FJT before fixation and the angular change in FJI were risk factors for FJDG deterioration (P< 0.01). Conclusion: The Wiltse approach did not increase the rate of FJDG deterioration and FJs angle changes. However, the FJT before fixation and the angular change in FJI were risk factors for FJDG deterioration.

A COMPARISON OF TWO SURGICAL TREATMENTS FOR THORACOLUMBAR BURST FRACTURES: TEMPORARY OSTEOSYNTHESIS, AND ARTHRODESIS

Article

Jul 2022

Background /aim: We compared the clinical and radiological outcomes and complications of patients treated for thoracolumbar burst fractures via temporary percutaneous osteosynthesis or open definitive arthrodesis. Methods A retrospective case-control study was performed including patients treated between 2017 and 2019 for a burst fracture of the thoracolumbar junction, either with percutaneous osteosynthesis (case group) or open arthrodesis (control group). Clinical, functional, and radiographic results were analyzed and compared between treatment groups. Results We included 112 patients (56 osteosynthesis/56 arthrodesis, p = 1) in our study. The mean follow-up and mean age were 20 ± 3 months (20 ± 2 / 20 ± 3, p = 1), and 41 ± 10 years (40 ± 11 / 42 ± 10, p = .3), respectively. Fracture level was L1/L2 in 75% and T11/T12 in 25% of patients. The osteosynthesis group showed significantly shorter operative times (104 ± 20 min / 176 ± 18 min, p < .01) and inpatient stays (11.6 ± 1.5 days / 15.6 ± 3.8 days, p < .01). Both groups showed similar correction over kyphosis angle at final follow-up (5.8º ± 2.8º / 6º ± 0.2°, p = .57), but the osteosynthesis group showed increased segment mobility after hardware removal (3.8º ± 1.2º / 0.9º ± 0.3°, p < .01). There were no significant differences in complications, although the osteosynthesis group showed significantly lower need for blood transfusion (21% / 43%, p = .02). Conclusions Both methods of treatment yielded good clinical and radiological results with similar complication rates. Temporary osteosynthesis seems to be more beneficial than open arthrodesis because it requires shorter operative time and hospitalization, causes less bleeding, and facilitates spinal movement.

Outcomes in Thoracolumbar and Lumbar Traumatic Fractures: Does Restoration of Unfused Segmental Mobility Correlated to Implant Removal Time？

Article

Oct 2021

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.

Risks and benefits of timely screw removal after thoracolumbar spine fractures treated with non-fusion technique

Article

May 2021
J CLIN NEUROSCI

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.

Safety and utility of implant removal after percutaneous osteosynthesis of type A thoracolumbar and lumbar fracture

Article

Nov 2020

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.

Comparison of Percutaneous versus Open Pedicle Screw Fixation for Treating Unstable Thoracolumbar Fractures

Article

Full-text available

Jan 2020

Minimally invasive decompression and intracorporeal bone grafting combined with temporary percutaneous short-segment pedicle screw for the treatment of thoracolumbar burst fracture with neurological deficits

Article

Nov 2019

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.

Thoracolumbar Instrumentation and Fusion for Degenerative Disc Disease: A Case-Based Approach

Chapter

Mar 2019

Sven Kevin Tschoeke

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.

Lumbar Burst Fractures

Chapter

May 2018

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.

Implant removal of osteosynthesis: the Dutch practice. Results of a survey

Article

Full-text available

Aug 2012

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.

CURRENT CONCEPTS REVIEW-The Use of Pedicle-Screw Internal Fixation for the Operative Treatment of Spinal Disorders

Article

Full-text available

Jan 1458

Robert W Gaines

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.

Long segment instrumentation of thoracolumbar burst fracture: Fusion versus nonfusion

Article

Full-text available

Jun 2009

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.

Implant removal after posterior stabilization of the thoraco-lumbar spine

Article

Full-text available

Sep 2009
ARCH ORTHOP TRAUM SU

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.

Surgeons' beliefs and perceptions about removal of orthopaedic implants

Article

Full-text available

Feb 2008
BMC MUSCULOSKEL DIS

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.

A comprehensive classification of thoracic and lumbar injuries

Article

Jan 1994

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)

Removal of Painful Orthopaedic Implants After Fracture Union

Article

Sep 2007

A Comprehensive Classification of Thoracic and Lumbar Injuries

Chapter

Jan 1998

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.

Routine Implant Removal after Fracture Surgery

Article

Nov 1996
J Trauma Inj Infect Crit Care

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.

Short-Segment Fixation Without Fusion for Thoracolumbar Burst Fractures With Neurological Deficit Can Preserve Thoracolumbar Motion Without Resulting in Post-traumatic Disc Degeneration A 10-Year Follow-up Study

Article

Apr 2013
SPINE

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.

Routine Implant Removal after Fracture Surgery: A Potentially Reducible Consumer of Hospital Resources in Trauma Units

Article

Nov 1996

Short Same-Segment Fixation of Thoracolumbar Burst Fractures

Article

Jan 2012

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.

The Quantitative Assessment of Risk Factors to Overstress at Adjacent Segments After Lumbar Fusion Removal of Posterior Ligaments and Pedicle Screws

Article

May 2011
SPINE

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.

Analysis of biomechanical changes after removal of instrumentation in lumbar arthrodesis by finite element analysis

Article

Jul 2010
MED BIOL ENG COMPUT

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.

Implant Removal for the Management of Infection After Instrumented Spinal Fusion

Article

Jun 2010

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.

Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries

Article

Feb 1994

Outcome After Wiltse Pedicle Screw Removal

Article

May 1996
J Spinal Disord

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.

Loss of Sagittal Plane Correction After Removal of Spinal Implants

Article

Oct 2000

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.

The Use of Pedicle-Screw Internal Fixation for the Operative Treatment of Spinal Disorders*

Article

Nov 2000

Robert W Gaines

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.

Measurement of Thoracic and Lumbar Fracture Kyphosis: Evaluation of Intraobserver, Interobserver, and Technique Variability

Article

Feb 2001

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.

Late Operative Site Pain With Isola Posterior Instrumentation Requiring Implant Removal

Article

Apr 2001

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.

Removal of lumbar instrumentation for the treatment of recurrent low back pain in the absence of pseudarthrosis

Article

Nov 2003

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.

Treatment of Thoracolumbar Burst Fractures with Variable Screw Placement or Isola Instrumentation and Arthrodesis

Article

Sep 2004
J SPINAL DISORD TECH

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.

Adjacent Segment Disease after Lumbar or Lumbosacral Fusion: Review of the Literature

Article

Oct 2004
SPINE

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.

Loss of Coronal Correction Following Instrumentation Removal in Adolescent Idiopathic Scoliosis

Article

Jan 2006
SPINE

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.

Radiographic Measurement Parameters in Thoracolumbar Fractures: A Systematic Review and Consensus Statement of the Spine Trauma Study Group

Article

Apr 2006
SPINE

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.

The Biomechanics of Long Versus Short Fixation for Thoracolumbar Spine Fractures

Article

Jun 2006
SPINE

Robert Mclain

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.

Safety and Efficacy of Implant Removal for Patients With Recurrent Back Pain After a Failed Degenerative Lumbar Spine Surgery

Article

Jun 2007
J SPINAL DISORD TECH

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.

Removal of Painful Orthopaedic Implants After Fracture Union

Article

Oct 2007

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.

Clinical and Radiographic Results After Implant Removal in Idiopathic Scoliosis

Article

Sep 2007
SPINE

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.

Do orthopaedic surgeons need a policy on the removal of metalwork? A descriptive national survey of practicing surgeons in the United Kingdom

Article

Apr 2008
INJURY

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

Jan 2004
251-64

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

Abstract

No full-text available