Showing papers on "Lumbar vertebrae published in 2014"
TL;DR: The overall objective was to assess the safety and feasibility of stem cell transplantation into lumbar and/or cervical spinal cord regions in amyotrophic lateral sclerosis subjects.
Abstract: There is growing interest in the use of stem cells1–10 as a therapy in amyotrophic lateral sclerosis (ALS), a lethal neurological disorder characterized by the degeneration of motor neurons. Stem cells offer a means to replace lost cells, provide neurotrophic support, and improve the diseased microenvironment.1,7–10 Preclinical in vitro and in vivo evidence supports the therapeutic translation of stem cells,9 and studies by our group and others demonstrate that human spinal stem cells (HSSCs) produce protective growth factor profiles, differentiate into neurons, form synapses with host motor neurons, and have beneficial effects after intraspinal transplantation in G93A-SOD1 rats, an established model of ALS.2–6
In 2009, the US Food and Drug Administration (FDA) approved a phase 1 clinical trial examining the safety and feasibility of HSSC injections into the spinal cords of 18 ALS subjects. HSSCs were delivered using a novel intraspinal stabilization and injection device developed by our group.11–14 The first 12 trial subjects, representing Cohorts A to C, received HSSC transplants into the L2–L4 lumbar segments of the spinal cord. Group A subjects were nonambulatory and received 5 unilateral (A1, n = 3) or 10 total bilateral (A2, n = 3) lumbar injections. Subjects in Groups B and C were ambulatory and received 5 unilateral (n = 3) or 10 total bilateral (n = 3) lumbar injections, respectively. As previously described, interim results from these first 12 subjects demonstrated no serious adverse events associated with HSSC transplantation.15,16
Those encouraging results along with the critical need to maintain respiratory function in ALS subjects enabled FDA approval to complete HSSC injections into C3–C5 cervical segments of the spinal cord, the region where motor neurons involved in diaphragmatic function reside. To support these injections, the lumbar stabilization and injection device was adapted and optimized for cervical intraspinal HSSC delivery.12–14 Ambulatory subjects in Groups D (n = 3) and E (n = 3) received 5 unilateral cervical injections. Based on previous preclinical data demonstrating enhanced therapeutic efficacy of HSSC transplantation when injections were targeted to multiple spinal cord segments,2,4 subjects in Group E were the same subjects who previously received bilateral lumbar injections as part of Group C. This cohort represents the first examination of the feasibility of targeting both lumbar and cervical spinal cord segments in ALS subjects in separate surgeries.
The phase 1 trial consisting of 18 intraspinal transplantation surgeries in 15 ALS subjects was completed in May 2013. Here, we present the functional outcome data from the 6 subjects undergoing cervical stem cell transplantation surgery, including 3 subjects receiving both bilateral lumbar and unilateral cervical HSSC transplants. Data are also presented from the continued follow-up of the first 12 subjects receiving lumbar intraspinal HSSC transplants. Overall, results demonstrate that HSSCs can be safely transplanted into both lumbar and/or cervical human spinal cord segments, warranting future trial phases focused on cellular dosing and therapeutic efficacy.
176 citations
TL;DR: This research presents a novel probabilistic approach that allows us to assess the importance of knowing the carrier and removal status of canine coronavirus as a source of infection in animals and its role in the immune system is investigated.
Abstract: Conventional surgical methods for lumbar foraminal or far lateral stenosis can be categorized as total facetectomy with/without fusion and facet-preserving microforaminotomy. Total facetectomy offers sufficient decompression through the nerve root course. However, this often leads to segmental instability and back pain.1-4 A facet-preserving microdecompression technique using a paraspinal approach was reported by Reulen et al1 in 1987 and Wiltse and Spencer5 in 1988; this technique has since been modified by other surgeons. This technique enables direct access to a foraminal or far lateral lesion with minimal violation of the facet joint and less postoperative back pain.6 The success rates reported for open paraspinal foraminotomy are as high as 72% to 83%,4,7-14 and this technique has been considered the gold standard for the surgical treatment of lumbar foraminal or far lateral stenosis. However, some patients experience postoperative leg pain or dysesthesia, which are the primary causes of unfavorable outcomes.4,7,8,10,12 Excessive manipulation of the dorsal root ganglion is thought to cause dysesthesia.10,12 Moreover, a limited field of view in the paraspinal approach may lead to incomplete decompression.
To solve the above problems, various minimally invasive techniques have been developed. Some authors have reported the use of a technique known as percutaneous endoscopic foraminal discectomy and/or foraminoplasty.15-17 However, the application of these minimally invasive techniques has been limited to foraminal soft disc herniation or concurrent mild foraminal stenosis. We reported the technique of percutaneous endoscopic lumbar foraminotomy (ELF) for L5-S1 level.18 However, a safe approach to the stenotic foramen remains challenging, and a thorough decompression technique for hard bony stenosis has been difficult to achieve. Moreover, the practical application of this technique has been limited by its steep learning curve. We have developed a more practical form of this technique than that described in a previous study18 and applied it not only to the L5-S1 level but also other lumbar levels. The purpose of this study was to describe this advanced ELF technique and to demonstrate the clinical outcomes.
150 citations
TL;DR: The paradigm of spinal endoscopy is shifting from treatments of soft disc herniation to those of lumbar spinal stenosis, and percutaneous endoscopic endoscopic decompression (PED) techniques may vary according to the type of lumbsar stenosis.
Abstract: Percutaneous endoscopic lumbar discectomy has become a representative minimally invasive spine surgery for lumbar disc herniation. Due to the remarkable evolution in the techniques available, the paradigm of spinal endoscopy is shifting from treatments of soft disc herniation to those of lumbar spinal stenosis. Lumbar spinal stenosis can be classified into three categories according to pathological zone as follows: central stenosis, lateral recess stenosis and foraminal stenosis. Moreover, percutaneous endoscopic decompression (PED) techniques may vary according to the type of lumbar stenosis, including interlaminar PED, transforaminal PED and endoscopic lumbar foraminotomy. However, these techniques are continuously evolving. In the near future, PED for lumbar stenosis may be an efficient alternative to conventional open lumbar decompression surgery.
136 citations
TL;DR: Based on low-level evidence, the incorporation of a lumbar fusion may be considered an option when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor.
Abstract: There is no convincing medical evidence to support the routine use of lumbar fusion at the time of a primary lumbar disc excision. There is conflicting Class III medical evidence regarding the potential benefit of the addition of fusion in this circumstance. Therefore, the definite increase in cost and complications associated with the use of fusion are not justified. Patients with preoperative lumbar instability may benefit from fusion at the time of lumbar discectomy; however, the incidence of such instability appears to be very low (< 5%) in the general lumbar disc herniation population. Patients who suffer from chronic low-back pain, or are heavy laborers or athletes with axial low-back pain, in addition to radicular symptoms may also be candidates for fusion at the time of lumbar disc excision. Patients with a recurrent disc herniation have been treated successfully with both reoperative discectomy and reoperative discectomy combined with fusion. In patients with a recurrent lumbar disc herniation with associated spinal deformity, instability, or associated chronic low-back pain, consideration of fusion in addition to reoperative discectomy is recommended.
126 citations
TL;DR: Equivalent operative times were observed between the cohorts, although patients undergoing MIS fusion tended to lose less blood, be exposed to more fluoroscopy, and leave the hospital sooner than their open counterparts.
Abstract: Background
Although minimally invasive surgical (MIS) approaches to the lumbar spine for posterior fusion are increasingly being utilized, the comparative outcomes of MIS and open posterior lumbar fusion remain unclear.
120 citations
TL;DR: It is concluded that lumbar spinal stenosis quite frequently may be a consequence of SSA and that further studies are warranted.
Abstract: Background.Senile systemic amyloidosis (SSA) derived from wild-type transthyretin is a fairly common condition of old individuals, particularly men. The main presentation is by cardiac involvement, ...
120 citations
TL;DR: There is moderate evidence that the standalone anterior lumbar interbody fusion (ALIF) has better clinical outcomes than the ALIF plus instrumented, open PLF, but there is no conclusive evidence demonstrating improved clinical or radiographic outcomes based on the different inter body fusion techniques.
Abstract: Interbody fusion techniques have been promoted as an adjunct to lumbar fusion procedures in an effort to enhance fusion rates and potentially improve clinical outcome. The medical evidence continues to suggest that interbody techniques are associated with higher fusion rates compared with posterolateral lumbar fusion (PLF) in patients with degenerative spondylolisthesis who demonstrate preoperative instability. There is no conclusive evidence demonstrating improved clinical or radiographic outcomes based on the different interbody fusion techniques. The addition of a PLF when posterior or anterior interbody lumbar fusion is performed remains an option, although due to increased cost and complications, it is not recommended. No substantial clinical benefit has been demonstrated when a PLF is included with an interbody fusion. For lumbar degenerative disc disease without instability, there is moderate evidence that the standalone anterior lumbar interbody fusion (ALIF) has better clinical outcomes than the ALIF plus instrumented, open PLF. With regard to type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft; however, this was not associated with a difference in clinical outcome.
118 citations
TL;DR: There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation.
Abstract: Assessing the benefits of surgical treatments for sciatica is critical for clinical and policy decision-making. To compare minimally invasive (MI) and conventional microdiscectomy (MD) for patients with sciatica due to lumbar disc herniation. A systematic review and meta-analysis of controlled clinical trials including patients with sciatica due to lumbar disc herniation. Conventional microdiscectomy was compared separately with: (1) Interlaminar MI discectomy (ILMI vs. MD); (2) Transforaminal MI discectomy (TFMI vs. MD). Outcomes: Back pain, leg pain, function, improvement, work status, operative time, blood loss, length of hospital stay, complications, reoperations, analgesics and cost outcomes were extracted and risk of bias assessed. Pooled effect estimates were calculated using random effect meta-analysis. Twenty-nine studies, 16 RCTs and 13 non-randomised studies (n = 4,472), were included. Clinical outcomes were not different between the surgery types. There is low quality evidence that ILMI takes 11 min longer, results in 52 ml less blood loss and reduces mean length of hospital stay by 1.5 days. There were no differences in complications or reoperations. The main limitations were high risk of bias, low number of studies and small sample sizes comparing TF with MD. There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation. Studies comparing transforaminal MI with conventional surgery with sufficient sample size and methodological robustness are lacking.
98 citations
TL;DR: Bomechanical studies have confirmed the added stress on adjacent segments in the cervical and lumbar spine after fusion surgery, and this contributes to the biomechanical stress put on the adjacent cervical segments postfusion.
Abstract: EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Understand the forces that predispose adjacent cervical segments to degeneration. 2. Understand the challenges of radiographic evaluation in the diagnosis of cervical and lumbar adjacent segment disease. 3. Describe the changes in biomechanical forces applied to adjacent segments of lumbar vertebrae with fusion. 4. Know the risk factors for adjacent segment disease in spinal fusion. Adjacent segment disease (ASD) is a broad term encompassing many complications of spinal fusion, including listhesis, instability, herniated nucleus pulposus, stenosis, hypertrophic facet arthritis, scoliosis, and vertebral compression fracture. The area of the cervical spine where most fusions occur (C3-C7) is adjacent to a highly mobile upper cervical region, and this contributes to the biomechanical stress put on the adjacent cervical segments postfusion. Studies have shown that after fusion surgery, there is increased load on adjacent segments. Definitive treatment of ASD is a topic of continuing research, but in general, treatment choices are dictated by patient age and degree of debilitation. Investigators have also studied the risk factors associated with spinal fusion that may predispose certain patients to ASD postfusion, and these data are invaluable for properly counseling patients considering spinal fusion surgery. Biomechanical studies have confirmed the added stress on adjacent segments in the cervical and lumbar spine. The diagnosis of cervical ASD is complicated given the imprecise correlation of radiographic and clinical findings. Although radiological and clinical diagnoses do not always correlate, radiographs and clinical examination dictate how a patient with prolonged pain is treated. Options for both cervical and lumbar spine ASD include fusion and/or decompression. Current studies are encouraging regarding the adoption of arthroplasty in spinal surgery, but more long-term data are required for full adoption of arthroplasty as the standard of care for prevention of ASD.
95 citations
TL;DR: Suboptimal glycemic control in diabetic patients undergoing degenerative lumbar spine surgery leads to increased risk of acute complications and poor outcomes, and patients with uncontrolled DM, or poor glucose control, may benefit from improving gly glucose control prior to surgery.
Abstract: STUDY DESIGN Retrospective database analysis. OBJECTIVE To assess the effect glycemic control has on perioperative morbidity and mortality in patients undergoing elective degenerative lumbar spine surgery. SUMMARY OF BACKGROUND DATA Diabetes mellitus (DM) is a prevalent disease of glucose dysregulation that has been demonstrated to increase morbidity and mortality after spine surgery. However, there is limited understanding of whether glycemic control influences surgical outcomes in patients with DM undergoing lumbar spine procedures for degenerative conditions. METHODS The Nationwide Inpatient Sample was analyzed from 2002 to 2011. Hospitalizations were isolated on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification, procedural codes for lumbar spine surgery and diagnoses codes for degenerative conditions of the lumbar spine. Patients were then classified into 3 cohorts: controlled diabetic, uncontrolled diabetic, and nondiabetic. Patient demographic data, acute complications, and hospitalization outcomes were determined for each cohort. RESULTS A total of 403,629 (15.7%) controlled diabetic patients and 19,421 (0.75%) uncontrolled diabetic patients underwent degenerative lumbar spine surgery from 2002 to 2011. Relative to nondiabetic patients, uncontrolled diabetic patients had significantly increased odds of cardiac complications, deep venous thrombosis, and postoperative shock; in addition, uncontrolled diabetic patients also had an increased mean length of stay (approximately, 2.5 d), greater costs (1.3-fold), and a greater risk of inpatient mortality (odds ratio=2.6, 95% confidence interval=1.5-4.8, P<0.0009). Controlled diabetic patients also had increased risk of acute complications and inpatient mortality when compared with nondiabetic patients, but not nearly to the same magnitude as uncontrolled diabetic patients. CONCLUSION Suboptimal glycemic control in diabetic patients undergoing degenerative lumbar spine surgery leads to increased risk of acute complications and poor outcomes. Patients with uncontrolled DM, or poor glucose control, may benefit from improving glycemic control prior to surgery. LEVEL OF EVIDENCE 3.
86 citations
TL;DR: The upper lumbar spine is more flexible in individuals in their twenties compared to those in their sixties, and decreases as position changes from standing to 90°sitting.
Abstract: The sagittal alignment of the spine changes depending on body posture and degenerative changes. This study aimed to observe changes in sagittal alignment of the lumbar spine with different positions (standing, supine, and various sitting postures) and to verify the effect of aging on lumbar sagittal alignment. Whole-spine lateral radiographs were obtained for young volunteers (25.4 ± 2.3 years) and elderly volunteers (66.7 ± 1.7 years). Radiographs were obtained in standing, supine, and sitting (30°, 60°, and 90°) positions respectively. We compared the radiological changes in the lordotic and segmental angles in different body positions and at different ages. Upper and lower lumbar lordosis were defined according to differences in anatomical sagittal mobility and kinematic behavior. Lumbar lordosis was greater in a standing position (52.79° and 53.90° in young and old groups, respectively) and tended to decrease as position changed from supine to sitting. Compared with the younger group, the older group showed significantly more lumbar lordosis in supine and 60° and 90° sitting positions (P = 0.043, 0.002, 0.011). Upper lumbar lordosis in the younger group changed dynamically in all changed positions compared with the old group (P = 0.019). Lower lumbar lordosis showed a decreasing pattern in both age groups, significantly changing as position changed from 30° to 60° (P = 0.007, 0.007). Lumbar lordosis decreases as position changes from standing to 90°sitting. The upper lumbar spine is more flexible in individuals in their twenties compared to those in their sixties. Changes in lumbar lordosis were concentrated in the lower lumbar region in the older group in sitting positions.
TL;DR: The purpose of this article was to review the current status of imaging and clinical practices for assessing fusion following spinal arthrodesis and to establish the two preferred imaging modalities for establishing the diagnosis of pseudarthrosis.
TL;DR: The lateral transpsoas approach to interbody fusion is capable of sustaining indirect decompression of the neural structures and resolving preoperative claudication and radiculopathy.
Abstract: Background
The minimally invasive lateral transpsoas retroperitoneal approach to address lumbar stenosis offers advantages to traditional approaches, including sparing of the AP annulus and longitudinal ligament and less risk to the peritoneal contents and retroperitoneal vascular structures. Few studies have presented longitudinal measures of radiographic indirect decompression and relief of pain and restoration of function using the lateral approach to spine fusion.
TL;DR: This longitudinal study demonstrated that converted bone mineral density values derived from routine lumbar spine multidetector row CT adequately differentiated patients with and without osteoporotic fractures and could predict incidental fractures and screw loosening after spondylodesis.
Abstract: BACKGROUND AND PURPOSE: Established methods of assessing bone mineral density are associated with additional radiation exposure to the patient. In this study, we aimed to validate a method of assessing bone mineral density in routine multidetector row CT of the lumbar spine. MATERIALS AND METHODS: In 38 patients, bone mineral density was assessed in quantitative CT as a standard of reference and in sagittal reformations derived from standard multidetector row CT studies without IV contrast. MDCT-to-quantitative CT conversion equations were calculated and then applied to baseline multidetector row scans of another 62 patients. After a mean follow-up of 15 ± 6 months, patients were re-assessed for incidental fractures and screw loosening after spondylodesis ( n = 49). RESULTS: We observed conversion equations bone mineral density MDCT = 0.78 × Hounsfield unit MDCT mg/mL (correlation with bone mineral density quantitative CT , R 2 = 0.92, P MDCT = 0.86 × Hounsfield unit MDCT mg/mL ( R 2 = 0.81, P MDCT than patients without fractures ( P MDCT ( P CONCLUSIONS: This longitudinal study demonstrated that converted bone mineral density values derived from routine lumbar spine multidetector row CT adequately differentiated patients with and without osteoporotic fractures and could predict incidental fractures and screw loosening after spondylodesis.
TL;DR: Psoas:lumbar vertebral index is independently and negatively associated with posttraumatic morbidity but not mortality in elderly, severely injured trauma patients and can be calculated quickly and easily and may help identify patients at increased risk of complications.
Abstract: Central sarcopenia as a surrogate for frailty has recently been studied as a predictor of outcome in elderly medical patients, but less is known about how this metric relates to outcomes after trauma. We hypothesized that psoas:lumbar vertebral index (PLVI), a measure of central sarcopenia, is associated with increased morbidity and mortality in elderly trauma patients. A query of our institutional trauma registry from 2005 to 2010 was performed. Data was collected prospectively for the Pennsylvania Trauma Outcomes Study (PTOS). Inclusion criteria: age >55 years, ISS >15, and ICU LOS >48 h. Using admission CT scans, psoas:vertebral index was computed as the ratio between the mean cross-sectional areas of the psoas muscles and the L4 vertebral body at the level of the L4 pedicles. The 50th percentile of the psoas:L4 vertebral index value was determined, and patients were grouped into high (>0.84) and low (≤0.83) categories based on their relation to the cohort median. Primary endpoints were mortality and morbidity (as a combined endpoint for PTOS-defined complications). Univariate logistic regression was used to test the association between patient factors and mortality. Factors found to be associated with mortality at p < 0.1 were entered into a multivariable model. A total of 180 patients met the study criteria. Median age was 74 years (IQR 63–82), median ISS was 24 (IQR 18–29). Patients were 58 % male and 66 % Caucasian. Mean PLVI was 0.86 (SD 0.25) and was higher in male patients than female patients (0.91 ± 0.26 vs. 0.77 ± 0.21, p < 0.001). PLVI was not associated with mortality in univariate or multivariable modeling. After controlling for comorbidities, ISS, and admission SBP, low PLVI was found to be strongly associated with morbidity (OR 4.91, 95 % CI 2.28–10.60). Psoas:lumbar vertebral index is independently and negatively associated with posttraumatic morbidity but not mortality in elderly, severely injured trauma patients. PLVI can be calculated quickly and easily and may help identify patients at increased risk of complications.
TL;DR: Adherence to the surgical tips presented in this article may lead to safe and effective freehand placement of cervical pedicle screws.
Abstract: Study design Retrospective cohort study. Objective To assess the safety and accuracy of subaxial cervical pedicle screw placement with freehand technique and to report the technical nuances. Summary of background data Although the efficacy and safety of freehand screw fixation in thoracic and lumbar vertebrae is proven, reports on this technique of screw insertion in the subaxial cervical spine are lacking. Methods From March 2012 to September 2013, 45 consecutive patients underwent posterior cervical fusion. The diagnoses were trauma (22 patients), degenerative disease (18 patients), discitis/osteomyelitis (2 patients), pathological fracture (2 patients), and postlaminoplasty kyphosis (1 patient). Preoperative computed tomography (CT) was performed in all patients. We included patients whose outer diameter of the pedicle was greater than 3.0 mm. The standard entry points were modified according to the CT anatomy of each patient. A small pilot hole was fashioned at a predetermined entry point. Then, a 2.5-mm diameter curved pedicle probe was slowly inserted with a medial trajectory into the pedicle. After ball-tip probing and tapping, the screw was inserted. If ball-tip probing was suggestive of risk to neurovascular structures, conversion to a lateral mass screw was performed. Postoperatively, a CT scan was performed in all patients and the conversion rate from pedicle to lateral mass screw was recorded. The breech rate of pedicle screws was also analyzed. Results There were 256 planned pedicle screws and 20 incidences (7.8%) of conversion to lateral mass screws. Lateral wall violation was observed in 14 pedicle screws (accuracy rate: 94.1%) on the postoperative CT scan. No medial, superior, and inferior pedicle wall violations were observed. There was no patient who developed symptoms related to vertebral artery stenosis. Conclusion Adherence to the surgical tips presented in this article may lead to safe and effective freehand placement of cervical pedicle screws. Level of evidence 3.
TL;DR: PI may play a predisposing role in the pathogenesis of lumbar disc degenerative diseases and the secondary structural and compensatory factors would lead to a straighter spine after disc degeneratives change.
Abstract: Purpose
A comparative study of the spinopelvic sagittal alignment in patients with lumbar disc degeneration or herniation (LDD/LDH) in normal population was designed to analyse the role of sagittal anatomical parameter (pelvic incidence, PI) and positional parameters in the pathogenesis and development of the disease. Several comparative studies of these patients with asymptomatic controls have been done. However, in previous studies without lumbar MRI, a certain number of asymptomatic LDD patients should have been included in the control group and then impacted on the results.
TL;DR: MITLIF offers several potential advantages including postoperative back pain and leg pain, intra-operative blood loss, transfusion and duration of hospital stay postoperatively in treating two-level lumbar degenerative disease, however, it required much more radiation exposure.
Abstract: Purpose
The purpose of this study was to compare the clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion in two-level degenerative lumbar disease.
TL;DR: LL and sacral slope had mildly but statistically improved in the interbody fusion cohort compared with PSF cohort and Sagittal alignment and pelvic tilt trended toward but did not reach statistical significance.
Abstract: STUDY DESIGN Retrospective matched-cohort analysis. OBJECTIVE To evaluate the change in radiographical parameters in patients undergoing interbody fusion and posterior instrumentation compared with posterior spine fusion (PSF) alone for degenerative scoliosis. SUMMARY OF BACKGROUND DATA Little is known about the effect of lateral interbody fusion (LIF) on sagittal plane correction in the setting of degenerative scoliosis. We performed a retrospective study to investigate these changes compared with PSF. METHODS Between 1997 and 2011, 33 patients had LIF at 181 levels between T8 and L5 vertebrae for the treatment of degenerative scoliosis (mean; 5 ± 2 levels). Of those, 23 patients had additional anterior lumbar interbody fusion (ALIF) at 37 levels between L4 and S1 vertebrae (mean; 1.6 ± 0.5 levels). A 1:1 matched control of patients who underwent PSF was performed. Patients were matched by age, sex, and diagnosis. Clinical and radiographical data were collected and compared between the matched cohorts. RESULTS Lumbar lordosis (LL) was significantly restored in the LIF ± ALIF compared with PSF cohort (44° ± 14° vs. 36° ± 15°, P = 0.02). The segmental LL over the 102 LIF levels significantly improved from 12°± 10° to 21°± 13° postoperatively (P < 0.0001). However, the change over the 37 ALIF levels was not significant (from 30° ± 15° to 29° ± 9°, P = 0.8). Sagittal plane alignment was improved in the LIF ± ALIF compared with PSF cohort and trended toward but did not reach significance (3.8 ± 3.2 cm vs. 6.2 ± 5.7 cm, P = 0.09). Sacral slope was significantly higher in the LIF ± ALIF compared with PSF cohort (33° ± 11° vs. 28° ± 10°, P = 0.03). Pelvic tilt was lower in the LIF ± ALIF compared with PSF cohort and trended toward but did not reach significance (22° ± 10° vs. 26° ± 10°, P = 0.08). CONCLUSION LL and sacral slope had mildly but statistically improved in the interbody fusion cohort compared with PSF cohort. Sagittal alignment and pelvic tilt trended toward but did not reach statistical significance. Segmental LL was improved at LIF levels more than at ALIF levels. LEVEL OF EVIDENCE 3.
TL;DR: The results indicate that MIDLF is effective and minimum invasive technique, and that CBT screw technique was safety in clinical and stable in radiological outcomes.
Abstract: A novel cortical bone trajectory (CBT) screw technique provides an alternative fixation technique for lumbar spine. Trajectory of CBT screw creates a caudo-cephalad path in sagittal plane and a medio-lateral path in axial plane, and engages cortical bone in the pedicle. The theoretical advantage is that it provides enhanced screw grip and interface strength. Midline lumbar fusion (MIDLF) is composed of posterior midline approach, microsurgical laminectomy, and CBT screw fixation. We adopted the MIDLF technique for lumbar spondylolisthesis. Advantages of this technique include that decompression and fusion are available in the same field, and it minimizes approach-related damages. To determine whether MIDLF with CBT screw is as effective as traditional approach and it is minimum invasive technique, we studied the clinical and radiological outcomes of MIDLF. Our results indicate that MIDLF is effective and minimum invasive technique. Evidence of effectiveness of MIDLF is that patients had good recovery score, and that CBT screw technique was safety in clinical and stable in radiological. MIDLF with CBT screw provides the surgeon with additional options for fixation. This technique is most likely to be useful for treating lumbar spondylolisthesis in combination with midline decompression and insertion of an interbody graft, such as the transforaminal lumbar interbody fusion or posterior lumbar interbody fusion techniques.
TL;DR: The goal of this review is to discuss the mechanisms of postural degeneration, particularly the loss of lumbar lordosis commonly observed in the elderly in the context of evolution, mechanical, and biological studies of the human spine and to synthesize recent research findings to clinical management ofPostural malalignment.
Abstract: The goal of this review is to discuss the mechanisms of postural degeneration, particularly the loss of lumbar lordosis commonly observed in the elderly in the context of evolution, mechanical, and biological studies of the human spine and to synthesize recent research findings to clinical management of postural malalignment. Lumbar lordosis is unique to the human spine and is necessary to facilitate our upright posture. However, decreased lumbar lordosis and increased thoracic kyphosis are hallmarks of an aging human spinal column. The unique upright posture and lordotic lumbar curvature of the human spine suggest that an understanding of the evolution of the human spinal column, and the unique anatomical features that support lumbar lordosis may provide insight into spine health and degeneration. Considering evolution of the skeleton in isolation from other scientific studies provides a limited picture for clinicians. The evolution and development of human lumbar lordosis highlight the interdependence of pelvic structure and lumbar lordosis. Studies of fossils of human lineage demonstrate a convergence on the degree of lumbar lordosis and the number of lumbar vertebrae in modern Homo sapiens. Evolution and spine mechanics research show that lumbar lordosis is dictated by pelvic incidence, spinal musculature, vertebral wedging, and disc health. The evolution, mechanics, and biology research all point to the importance of spinal posture and flexibility in supporting optimal health. However, surgical management of postural deformity has focused on restoring posture at the expense of flexibility. It is possible that the need for complex and costly spinal fixation can be eliminated by developing tools for early identification of patients at risk for postural deformities through patient history (genetics, mechanics, and environmental exposure) and tracking postural changes over time.
TL;DR: Anterior lumbar interbody fusion with a vascular access surgeon and spine surgeon, using a separate cage and anterior screw-plate, provides a very robust and reliable construct with low complication rates, high fusion rates, and positive clinical outcomes, and it is cost-effective.
Abstract: Object The use of recombinant human bone morphogenetic protein–2 (rhBMP-2) in anterior lumbar interbody fusion (ALIF) is controversial regarding the reported complication rates and cost. The authors aimed to assess the complication rates of performing ALIF using rhBMP-2. Methods This is a prospective study of consecutive patients who underwent ALIF performed by a single spine surgeon and a single vascular surgeon between 2009 and 2012. All patients underwent placement of a polyetheretherketone (PEEK) cage filled with rhBMP-2 and a separate anterior titanium plate. Preoperative clinical data, operative details, postoperative complications, and clinical and radiographic outcomes were recorded for all patients. Clinical outcome measures included back and leg pain visual analog scale scores, Oswestry Disability Index (ODI), and SF-36 Physical and Mental Component Summary (PCS and MCS) scores. Radiographic assessment of fusion was performed using high-definition CT scanning. Male patients were screened pre- an...
TL;DR: This study demonstrates that even at an early stage in the condition, the sagittal profile of thoracic adolescent idiopathic scoliosis differs significantly from lumbar scolia, and both types of scoliotics differ from controls, but in different aspects.
TL;DR: This study explains one of the riddles of mammal evolution: the strong conservation of the number of trunk vertebrae and argues that this constancy results from strong selection against initial changes of these numbers in fast running and agile mammals, whereas such selection is weak in slower-running, sturdier mammals.
Abstract: The mammalian vertebral column is highly variable, reflecting adaptations to a wide range of lifestyles, from burrowing in moles to flying in bats. However, in many taxa, the number of trunk vertebrae is surprisingly constant. We argue that this constancy results from strong selection against initial changes of these numbers in fast running and agile mammals, whereas such selection is weak in slower-running, sturdier mammals. The rationale is that changes of the number of trunk vertebrae require homeotic transformations from trunk into sacral vertebrae, or vice versa, and mutations toward such transformations generally produce transitional lumbosacral vertebrae that are incompletely fused to the sacrum. We hypothesize that such incomplete homeotic transformations impair flexibility of the lumbosacral joint and thereby threaten survival in species that depend on axial mobility for speed and agility. Such transformations will only marginally affect performance in slow, sturdy species, so that sufficient individuals with transitional vertebrae survive to allow eventual evolutionary changes of trunk vertebral numbers. We present data on fast and slow carnivores and artiodactyls and on slow afrotherians and monotremes that strongly support this hypothesis. The conclusion is that the selective constraints on the count of trunk vertebrae stem from a combination of developmental and biomechanical constraints.
TL;DR: BMD of the lumbar spine and femoral neck in patients with normal BMD at baseline was stable and TCZ increased the BMD of patients who had osteopenia at baseline, which remained stable after 1 year of TCZ treatment.
Abstract: Objective. The aim of this study was to analyse the effects of therapy with tocilizumab (TCZ), an anti-IL-6 receptor antibody, on BMD of the lumbar spine and femoral neck in patients with RA. Methods. Eighty-six patients with active RA (indicated by a 28-joint DAS ESR >3.2) despite treatment with MTX 12 mg/week were included in this open-label prospective study and started on TCZ (8 mg/kg every 4 weeks). All patients used a stable dosage of MTX and were not allowed to use steroids or bisphosphonates during the study period. BMD of the lumbar spine and femoral neck was measured by dual-energy X-ray absorptiometry at baseline and 52 weeks after initiating TCZ. Results. Seventy-eight patients completed this study. BMD of the lumbar spine and femoral neck remained stable after 1 year of TCZ treatment. In 33 patients who had osteopenia at baseline, there was a significant increase in BMD of the lumbar spine [mean 0.022 (S.D.) 0.042, P < 0.05] and femoral neck [0.024 (0.0245), P < 0.05]. Conclusion. TCZ affects BMD in patients who had active RA despite treatment with MTX. BMD of the lumbar spine and femoral neck in patients with normal BMD at baseline was stable. TCZ increased the BMD of patients who had osteopenia at baseline.
TL;DR: In select patients with DLS, the outcome of D is comparable to DF at a minimum of 2 years, and the proportion of patients achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) is high.
Abstract: Background
Decompression alone (D) is a well-accepted treatment for patients with lumbar spinal stenosis (LSS) causing neurogenic claudication; however, D is controversial in patients with LSS who have degenerative spondylolisthesis (DLS). Our goal was to compare the outcome of anatomy-preserving D with decompression and fusion (DF) for patients with grade I DLS. We compared patients with DLS who had elective primary 1–2 level spinal D at 1 centre with a cohort who had 1–2 level spinal DF at 5 other centres.
TL;DR: A comprehensive overview on interspinous implants, their mechanisms of action, safety, cost, and effectiveness in the treatment of lumbar stenosis and degenerative disc diseases is provided.
Abstract: A large number of interspinous process devices (IPD) have been recently introduced to the lumbar spine market as an alternative to conventional decompressive surgery in managing symptomatic lumbar spinal pathology, especially in the older population. Despite the fact that they are composed of a wide range of different materials including titanium, polyetheretherketone, and elastomeric compounds, the aim of these devices is to unload spine, restoring foraminal height, and stabilize the spine by distracting the spinous processes. Although the initial reports represented the IPD as a safe, effective, and minimally invasive surgical alternative for relief of neurological symptoms in patients with low back degenerative diseases, recent studies have demonstrated less impressive clinical results and higher rate of failure than initially reported. The purpose of this paper is to provide a comprehensive overview on interspinous implants, their mechanisms of action, safety, cost, and effectiveness in the treatment of lumbar stenosis and degenerative disc diseases.
TL;DR: A LIV at or distal to the LTV may prevent postoperative adding-on in Lenke type 2A curve, and the difference between the LIV and LTV levels is identified.
Abstract: Study design A retrospective, observational, and multicenter study. Objective To identify the ideal lower instrumented vertebra (LIV) to prevent distal adding-on after surgical correction of Lenke type 2A curve. Summary of background data LIV level may affect the risk of postsurgical adding-on. The choice of the last touching vertebra (LTV)-the most caudal vertebra of the main thoracic curve that touches the central sacral vertical line when standing-as an appropriate LIV has been validated for Lenke type 1A but not type 2A curve. Methods Radiographs obtained before, immediately after, and 2 years after surgery were evaluated for 116 consecutive patients who underwent posterior thoracic fusion surgery for Lenke type 2A curve. The LIV was proximal to the LTV in 18 patients (PLTV), distal in 43 (DLTV), and at the LTV in 55 (ALTV). Significant independent factors associated with adding-on were analyzed first by univariate analysis, and then by stepwise logistic regression analysis. Results Distal adding-on was present in 16 patients (13.8%) at follow-up: 9 PLTV (50.0%), 3 DLTV (7.0%), and 4 ALTV (7.3%). Adding-on was significantly more common in the PLTV group. One PLTV-group patient required revision surgery to treat adding-on. Univariate analysis identified the following significant factors associated with adding-on: the T2-T5 kyphosis angle and shoulder height before, immediately after, and 2 years after surgery; the lumbar Cobb angle at the 2-year follow-up; the 2-year postoperative lumbar curve correction rate; and the difference between the LIV and the end vertebra, neutral vertebra, and LTV levels. Significant independent risk factors identified by stepwise logistic regression analysis included the clavicle angle at follow-up, the correction rate of the lumbar curve immediately after surgery, and the difference between the LIV and LTV levels. Conclusion A LIV at or distal to the LTV may prevent postoperative adding-on in Lenke type 2A curve. Level of evidence 3.
TL;DR: The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority, although each additional 1,000 mg/m2 of GC received in the first 3 months was associated with a decrease in LS B MD Z-score.
Abstract: Summary
Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point.
TL;DR: The technique can be used to address the gaps in knowledge of lumbar kinematics, to improve the accuracy of the kinematic input into biomechanical models, and to support development of new disk replacement designs more closely replicating the natural lumbr biomechanics.
Abstract: Availability of accurate three-dimensional (3D) kinematics of lumbar vertebrae is necessary to understand normal and pathological biomechanics of the lumbar spine. Due to the technical challenges of imaging the lumbar spine motion in vivo, it has been difficult to obtain comprehensive, 3D lumbar kinematics during dynamic functional tasks. The present study demonstrates a recently developed technique to acquire true 3D lumbar vertebral kinematics, in vivo, during a functional load-lifting task. The technique uses a high-speed dynamic stereo-radiography (DSX) system coupled with a volumetric model-based bone tracking procedure. Eight asymptomatic male participants performed weight-lifting tasks, while dynamic X-ray images of their lumbar spines were acquired at 30 fps. A custom-designed radiation attenuator reduced the radiation white-out effect and enhanced the image quality. High resolution CT scans of participants' lumbar spines were obtained to create 3D bone models, which were used to track the X-ray images via a volumetric bone tracking procedure. Continuous 3D intervertebral kinematics from the second lumbar vertebra (L2) to the sacrum (S1) were derived. Results revealed motions occurring simultaneously in all the segments. Differences in contributions to overall lumbar motion from individual segments, particularly L2-L3, L3-L4, and L4-L5, were not statistically significant. However, a reduced contribution from the L5-S1 segment was observed. Segmental extension was nominally linear in the middle range (20%-80%) of motion during the lifting task, but exhibited nonlinear behavior at the beginning and end of the motion. L5-S1 extension exhibited the greatest nonlinearity and variability across participants. Substantial AP translations occurred in all segments (5.0 ± 0.3 mm) and exhibited more scatter and deviation from a nominally linear path compared to segmental extension. Maximum out-of-plane rotations (<1.91 deg) and translations (<0.94 mm) were small compared to the dominant motion in the sagittal plane. The demonstrated success in capturing continuous 3D in vivo lumbar intervertebral kinematics during functional tasks affords the possibility to create a baseline data set for evaluating the lumbar spinal function. The technique can be used to address the gaps in knowledge of lumbar kinematics, to improve the accuracy of the kinematic input into biomechanical models, and to support development of new disk replacement designs more closely replicating the natural lumbar biomechanics.