This study reports if shortening reconstruction procedure through posterior approach only can be used in osteoporotic unstable fracture as well as post-traumatic burst fracture.
An 80-year-old female patient with unstable burst osteoporotic fracture of L1 underwent posterior approach corpectomy and shortening reconstruction of the spinal column by non-expandable cages.
The surgery was uneventful, with average blood loss. Using of small profile cages has helped us to avoid root injury. Augmentation of the screw with cement and the compressive force applied to the spine column aids in obtaining a rigid construct with good alignment without any neurological complication.
Shortening reconstruction procedure through only posterior approach is a viable option in treating unstable osteoporotic fracture as well as post-traumatic fractures. Using non-expandable cage is advocated to avoid cage subsidence.
Osteoporotic fracture; Posterior corpectomy; Shortening reconstruction; Unstable burst fracture; Thoracolumbar fracture
Corpectomy and implantation of titanium cages is standard in pathological fracture treatment but additional single ventral instrumentation remains controversial with regard to rotational stability.
This study included 45 patients suffering from vertebral metastases with spinal stenosis, instability and/or neurological deficits secondary to pathological lumbar spine fractures and bone mineral density (BMD) ≥1.20 g/cm2. The clinical results of a single stage anterior decompression with corpectomy defect restoration with titanium cage and single double rod system in patients were evaluated at mean 36 months postoperatively with follow-up neurological and radiological exams at three months then every six months.
Evaluation of neurological recovery included grading following a modified Frankel scale. Contentment, disability and actual pain were evaluated using the visual analogue scale (VAS) and Oswestry disability index (ODI). BMD was measured using dual-energy X-ray absorptiometry (DXA).
Postoperative neurological evaluations showed improvement in all patients. In the radiological follow-up in 40 patients (89%) findings were similar compared to the postoperative control. In five patients (11%) a loss of correction at a mean of 8° degrees (Cobb angle) secondary to cage subsidence occurred. No breakage of the device or displacement of the instrumentation was seen. Overall the Frankel scale improved 0.65 points (p < 0.05) and the ODI improved 40.69 points (p < 0.05).
In lumbar spine fractures of metastatic origin with stenosis, instability and/or neurological deficit, a single stage ventral decompression and instrumentation in patients with BMD ≥1.20 g/cm2 should be considered.
Retrospective clinical series.
To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis.
Overview of Literature
The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy.
Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab's criteria.
Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab's criteria 61 (95.3%) patients reported a good to excellent outcome.
Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.
Thoracolumbar spine; Discitis; Anterior column reconstruction; Titanium cage
Interbody fusion surgery has been considered by many to be a treatment of choice for instability in lumbar degenerative disc disease. A posterior lumbar interbody fusion (PLIF) has the advantages of spinal canal decompression, anterior column reconstruction, and reduction of the sagittal slips from a single posterior approach. The PLIF using double cage was a standard practice till many studies reported comparable results and lesser complications with single cage. Iliac crest was considered as an appropriate source of bone graft until comparable spinal fusion rates using local bone graft and cage emerged. Till date, there has been no report of corticocancellous laminectomy bone chips alone being used for spinal fusion. In this paper, we present radiologic results of single level instrumented PLIF, where in only corticocancellous laminectomy bone chips were used as a fusion device.
Materials and Methods:
It is a retrospective cohort study of 35 consecutive patients, who underwent single level instrumented PLIF surgery, wherein only locally obtained bone chips was used for spinal fusion. The average follow-up was 26 months. The indications for the surgery were as follows: 19 patients had disc herniations, with back pain of instability type, normal disc height on radiology. Ten patients had grade 1 spondylolisthesis, with significant back pain and translational instability on radiography. Three patients were redo spine surgeries, and three patients had healed spondylodiscitis with significant back pain and instability. All patients were regularly followed up and decision of spinal fusion or no fusion was taken at 2 years using modified criteria of Lee.
Of total 35 patients, there were 24 males and 11 females, with a mean age of 41 years. There were 16 patients with definitive fusion, 15 patients with probable fusion, 04 patients with possible pseudoarthrosis, and no patient had definitive pseudoarthrosis. The mean time for fusion to occur was 18 months. The average loss of disc height, over 2 year follow up, was only 3 mm in 8 patients. Three patients had a localized kyphosis of more than 3° at the fusion level. The average blood loss was 356 ml and average operating time was 150 min.
Corticocancellous laminectomy bone chips alone can be used as a means of spinal fusion in patients with single level instrumented PLIF. This has got a good fusion rate.
Corticocancellous laminectomy bone chips; Interbody cage; posterior lumbar interbody fusion
We describe a previously healthy, non-leukaemic young male presenting with neurological deficit and a pathological dislocation of D8 over D9 vertebra. The magnetic resonance imaging showed an enhancing soft tissue tumour. His basic laboratory workup as well as a bone marrow biopsy was normal. Through a single midline posterior approach, he underwent a decompressive laminectomy of D8 and D9 vertebra, anterior column reconstruction with a meshed titanium cage and posterior pedicle screw instrumentation. The histological diagnosis of granulocytic sarcoma was confirmed by appropriate immuno-histochemical studies. He received postoperative radiotherapy following which his wound dehiscesed and the tumour fungated and spread to his left thigh. He declined chemotherapy and unfortunately expired 9 months later. This case is presented to draw attention to the unusual presentation and to stress that granulocytic sarcoma should be kept in mind when making the differential diagnosis in patients with signs of spinal cord compression even in non-leukaemic individuals.
Granulocytic sarcoma; Non-leukaemia; Pathological dislocation; Surgery
Patients with spinal injuries have been treated in the past by laminectomy in an attempt to decompress the spinal cord. The results have shown insignificant improvement or even a worsening of neurologic function and decreased stability without effectively removing the anterior bone and disc fragments compressing the spinal cord. The primary indication for anterior decompression and grafting is narrowing of the spinal canal with neurologic deficits that cannot be resolved by any other approach. One must think of subsequent surgical intervention for increased stability and compressive posterior fusion with short-armed internal fixators.
To analyze the results and efficacy of spinal shortening combined with interbody fusion technique for the management of dorsal and lumbar unstable injuries.
Materials and Methods:
Twenty-three patients with traumatic fractures and or fracture-dislocation of dorsolumbar spine with neurologic deficit are presented. All had radiologic evidence of spinal cord or cauda equina compression, with either paraplegia or paraparesis. Patients underwent recapping laminoplasty in the thoracic or lumbar spine for decompression of spinal cord. The T-saw was used for division of the posterior elements. After decompression of the cord and removal of the extruded bone fragments and disc material, the excised laminae were replaced exactly in situ to their original anatomic position. Then application of a compression force via monosegmental transpedicular fixation was done, allowing vertebral end-plate compression and interbody fusion.
Lateral Cobb angle (T10–L2) was reduced from 26 to 4 degrees after surgery. The shortened vertebral body united and no or minimal loss of correction was seen. The preoperative vertebral kyphosis averaged +17 degrees and was corrected to +7 degrees at follow-up with the sagittal index improving from 0.59 to 0.86. The segmental local kyphosis was reduced from +15 degrees to −3 degrees. Radiography demonstrated anatomically correct reconstruction in all patients, as well as solid fusion.
This technique permits circumferential decompression of the spinal cord through a posterior approach and posterior interbody fusion.
Injury; laminoplasty; spine; shortening; spondylodesis
The true incidence of osteoporotic vertebral fractures is not well defined because many osteoporotic vertebral fractures are asymptomatic. Although the true incidence of neurological compromise as a result of osteoporotic vertebral fractures is not known, it is thought to be low. In this case report, we present a case of L1 osteoporotic vertebral fracture causing bilateral L5 nerve root compression and manifestation of bilateral foot-drop.
Pedicle screws were inserted in the vertebrae, 2 above and 2 below the L1 vertebra. A temporary rod was placed on the left. An L1 right hemilaminectomy via a posterior approach and a corpectomy were performed. The spinal cord was decompressed. Anterior fusion was carried out by placing titanium mesh cage into the vertebrectomy site as a strut graft via posterior approach, and posterolateral fusion with spongious allografts were added to the procedure.
Two years later the patient was completely symptom free and receiving medical treatment for osteoporosis, which was diagnosed as primary type.
If a fracture is detected on the posterior wall of the vertebral body in computerized tomography (CT) examination with plain radiographs, a magnetic resonance imaging (MRI) examination should be conducted in the presence of symptoms and physical findings suggestive of neurological compression. Follow-up neurological examinations should be carried out, and it should be kept in mind that most of the neurological symptoms may develop late and manifest as radiculopathy. The majority of the osteoporotic vertebral fractures can be managed conservatively with bed rest and orthosis, but cases with accompanying neurological deficit should be managed surgically using decompression and stabilization by fusion and instrumentation.
Osteoporosis; Osteoporotic vertebral fracture; Radiculopathy; Neurological deficit; Nerve root compression; Foot drop; Posterior decompression
Posterior lumbar interbody fusion (PLIF) restores disc height, the load bearing ability of anterior ligaments and muscles, root canal dimensions, and spinal balance. It immobilizes the painful degenerate spinal segment and decompresses the nerve roots. Anterior lumbar interbody fusion (ALIF) does the same, but could have complications of graft extrusion, compression and instability contributing to pseudarthrosis in the absence of instrumentation. The purpose of this study was to assess and compare the outcome of instrumented circumferential fusion through a posterior approach [PLIF and posterolateral fusion (PLF)] with instrumented ALIF using the Hartshill horseshoe cage, for comparable degrees of internal disc disruption and clinical disability. It was designed as a prospective study, comparing the outcome of two methods of instrumented interbody fusion for internal disc disruption. Between April 1994 and June 1998, the senior author (N.R.B.) performed 39 instrumented ALIF procedures and 35 instrumented circumferential fusion with PLIF procedures. The second author, an independent assessor (S.M.), performed the entire review. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging (MRI) and provocative discography in all the patients. The outcome in the two groups was compared in terms of radiological improvement and clinical improvement, measured on the basis of improvement of back pain and work capacity. Preoperatively, patients were asked to fill out a questionnaire giving their demographic details, maximum walking distance and current employment status in order to establish the comparability of the two groups. Patient assessment was with the Oswestry Disability Index, quality of life questionnaire (subjective), pain drawing, visual analogue scale, disability benefit, compensation status, and psychological profile. The results of the study showed a satisfactory outcome (score≤30) on the subjective (quality of life questionnaire) score of 71.8% (28 patients) in the ALIF group and 74.3% (26 patients) in the PLIF group (P>0.05). On categorising Oswestry Index scores into "excellent", "better", "same", and "worse", we found no difference in outcome between the two groups: 79.5% (n=31) had satisfactory outcome with ALIF and 80% (n=28) had satisfactory outcome with PLIF. The rate of return to work was no different in the two groups. On radiological assessment, we found two nonunions in the circumferential fusion (PLIF) group (94.3% fusion rate) and indirect evidence of no nonunions in the ALIF group. There was no significant difference between the compensation rate and disability benefit rate between the two groups. There were three complications in ALIF group and four in the PLIF (circumferential) group. On the basis of these results, we conclude that it is possible to treat discogenic back pain by anterior interbody fusion with Hartshill horseshoe cage or with circumferential fusion using instrumented PLIF.
Disc degeneration; Interbody fusion; Cages
Cervical tuberculous spondylodiscitis is a serious, hazardous disorder and to our knowledge, hardly any reports focused on the use of titanium mesh cages in its treatment. The aim of this work is to evaluate the efficacy of using a titanium mesh cage compared to iliac crest grafting regarding correction of the deformity, fusion rate and to report the incidence of complications. A prospective, non-randomized multicentre study of 30 patients with cervical tuberculous spondylodiscitis presenting with a neglected kyphotic deformity. The average age was 44.5 years; 18 had neurological deficits. All patients had a single stage radical debridement, decompression, and instrumentation. The anterior column was reconstructed with a titanium mesh cage in 16 patients (Group 1) and an autogenous iliac bone strut graft in 14 (Group 2). Both groups were followed for a minimum of 2 years. Group 1 showed a better sagittal profile and local kyphosis was corrected from an average of 36° (10°–62°) to an average of −6° (+4° to −16°) compared to Group 2 corrected from an average of 30° (6°–48°) to an average of −1° (+2° to −13°). Group 1 patients showed a solid bony fusion without any recurrence of infection while Group 2 showed a higher incidence of nonunion and of persistent donor site morbidity. The use of titanium mesh cages effectively restores the sagittal profile while adding immediate stability. There is no donor site morbidity, recurrence, or persistence of infection associated with their implantation.
Titanium mesh cages; Tuberculosis; Spondylodiscitis; Cervical
Interbody fusion has become a mainstay of surgical management for lumbar fractures, tumors, spondylosis, spondylolisthesis and deformities. Over the years, it has undergone a number of metamorphoses, as novel instrumentation and approaches have arisen to reduce complications and enhance outcomes. Interbody fusion procedures are common and successful, complications are rare and most often do not involve the interbody device itself. We present here a patient who underwent an anterior L4 corpectomy with Harms cage placement and who later developed a fracture of the lumbar titanium mesh cage (TMC). This report details the presentation and management of this rare complication, as well as discusses the biomechanics underlying this rare instrumentation failure.
Lumbar spine; Titanium mesh cage; Fracture
A retrospective study.
To analyze the treatment outcome of patients with lower thoracic and lumbar fractures combined with neurological deficits.
Overview of Literature
Although various methods of the surgical treatment for lower thoracic and lumbar fractures are used, there has been no surgical treatment established as a superior option than others.
Between March 2001 and August 2009, this study enrolled 13 patients with lower thoracic and lumbar fractures who underwent spinal canal decompression by removing posteriorly displaced bony fragments via the posterior approach and who followed up for more than a year. We analyzed the difference between the preoperative and postoperative extents of canal encroachment, degrees of neurologic deficits and changes in the local kyphotic angle.
The average age of the patients was 37 years. There were 10 patients with unstable burst factures and 3 patients with translational injuries. Canal encroachment improved from preoperative average of 84% to 9% postoperatively. Local kyphosis also improved from 20.5° to 1.5°. In 92% (12/13) of the patients, neurologic deficit improved more than Frankel grade 1 and an average improvement of 1.7 grade was observed. Deterioration of neurologic symptoms was not observed. Although some loss of reduction of kyphotic deformity was observed at the final follow-up, serious complications were not observed.
When posteriorly displaced bony fragments were removed by the posterior approach, neurological recovery could be facilitated by adequate decompression without serious complications. The posterior direct decompression could be used as one of treatments for lower thoracic and lumbar fractures combined with neurologic injuries.
Lower thoracic and lumbar; Unstable burst fracture; Posterior direct decompression; Neurologic manifestations
The role of spinal implants in the presence of infection is critically discussed. In this study 20 patients with destructive vertebral osteomyelitis were surgically treated with one-stage posterior instrumentation and fusion and anterior debridement, decompression and anterior column reconstruction using an expandable titanium cage filled with morsellised autologous bone graft. The patients' records and radiographs were retrospectively analysed and follow-up clinical and radiographic data obtained. At a mean follow-up of 23 months (range 12–56 months) all cages were radiographically fused and all infections eradicated. There were no cases of cage dislocation, migration or subsidence. Local kyphosis was corrected from 9.2° (range −20° to 64°) by 9.4° to −0.2° (range −32° to 40°) postoperatively and lost 0.9° during follow-up . All five patients with preoperative neurological deficits improved to Frankel score D or E. Patient-perceived disability caused by back pain averaged 7.9 (range 0–22) in the Roland–Morris score at follow-up. In cases of vertebral osteomyelitis with severe anterior column destruction the use of titanium cages in combination with posterior instrumentation is effective and safe and offers a good alternative to structural bone grafts. Further follow-up is necessary to confirm these early results.
Vertebral osteomyelitis; Spinal infection; Spondylodiscitis; Cages; Spinal fusion
Thirty-two patients with adolescent idiopathic scoliosis underwent anterior fusion with rigid single rod (third generation instrumentation) and titanium mesh cages. The mean follow-up was 31 (24–45) months and the mean age was 14.9 years. There were 8 patients with King type I, 10 with type II, 6 with type III, 4 with type IV and 4 with lumbar curves. Titanium mesh cages were used in all the lumbar procedures and at the cranial and caudal ends of the instrumented area in thoracic cases. All the patients were immobilized in an orthosis for 3–6 months postoperatively. Mean preoperative primary coronal Cobb angle of 56° was improved to 8.6°. Average correction rate was 84%. Sagittal balance was restored with a mean thoracic kyphosis of 28° and a mean lumbar lordosis of 38°. Spontaneous secondary curve decompensation did not occur and postoperative thoracolumbar junctional kyphosis was not seen. One case had to be revised due to proximal screw pull out and loss of correction.
Osteomyelitis of the cervical spine may lead to profound bony destruction. The presented case developed multilevel osteomyelitic destruction of the cervical spine after decompression due to cervical myelopathy. He could be cured by a multiple-stage procedure: step one: debridement and removal of all anterior implants with vacuum-assisted closure combined with dorsal instrumentation from C0 to T3; step two: anterior reconstruction with expandable titanium cages and plate. The patient regained walking with the aid of a walking frame. The following recommendations are given: multiple stage procedure, extensive debridement and stabilization via an anterior and posterior approach, use of titanium implants.
Vertebral osteomyelitis; Spondylodiscitis; Cervical reconstruction
In cervical spondylotic myelopathy, extended anterior spinal cord decompression necessitates subsequent stable vertebral reconstruction. Reconstruction with an iliac crest graft and screw-plate fixation gives satisfactory clinical and radiological results, but they are often compromised by morbidity involving the bone harvest. The purpose of this study was to evaluate the contribution to cervical reconstruction of a biocompatible, radiolucent cage combined with screw-plate fixation, making use of bone harvested in situ. This prospective study was performed between July 2000 and March 2001 in eight women and nine men (mean age, 55 years) operated for cervical spondylotic myelopathy. Situated between levels C3 and C6, the cage was inserted after one corporectomy in ten patients, two corporectomies in five patients, and three corporectomies in two patients. The cage consisted of a polyester mesh impregnated with poly-L-lactic acid (PLLA) conferring temporary rigidity to the cage during bony fusion. Clinical and radiological follow-up (plain films, computed tomographic reconstruction in three cases) was performed at 2 months, 6 months, 12 months, 24 months and 36 months, postoperatively, with a mean followup of 30 months. Functional results were evaluated according to the Japanese Orthopaedic Association’s scoring system. An independent surgeon assessed the radiological evidence of anterior cervical fusion using the grades proposed by Bridwell . Every patient experienced neurological recovery. At last follow-up, radiological findings were consistent with grade I (complete fusion) in five cases, grade II (probable fusion) in ten cases, grade III (radiolucent halo in favor of non fusion) in one case, and grade IV (graft lysis) in one case with persistent neck pain. In three cases there was screw breakage (two grade II, one grade IV). None of these cases required surgical revision at latest follow-up. In extensive spinal cord decompression through an anterior approach, cervical reconstruction using the present type of cage can achieve clinical results comparable to conventional techniques. The rigidity of the cage meets biomechanical imperatives. Its radiolucency permits one to monitor the course of consolidation, contrary to metal cages. The cases of probable non-fusion and screw breakage were not accompanied by signs of instability on the flexion extension films. This cage meets the biologic and biomechanical imperatives of cervical reconstruction. It obviates complications involving bone harvest.
Cervical myelopathy; Cervical reconstruction; Mesh cage; Corporectomy; Fusion
A 26-year-old paraplegic schizophrenic Japanese woman suffered from severe kyphosis and back pain derived from lumbar burst fractures caused by jumping. She had already undergone resection of the L1 and L2 spinous processes for sharp angular kyphosis, but she still had severe kyphosis and back pain at the L1 and L2. Radiographical examination revealed fused anterior columns at L1 and L2 with severe local kyphosis and a significantly decreased percutaneous distance in the back. The patient underwent anterior instrumented bony resection including an L2 vertebral osteotomy: bilateral L2-L3 facetectomy and partial posterior osteotomy of the L2 vertebrae via a posterior approach followed by an anterior corpectomy of the L2 vertebrae and insertion of a cylindrical cage. No posterior instrumentation was used owing to the presence of atrophied paraspinal soft tissues. Lumbar interbody fusion was performed with vertebral body screws extending from T12 to L4 and corresponding anterior distension and posterior compression. The procedure corrected the kyphosis by 15° and enhanced local stability. Postsurgical visual analogue scale improved from 9.0 to 2.0 and Oswestry Disability Index from 40 to 17.8, respectively. In conclusion, we have demonstrated that anterolateral interbody fusion using extended fixation can compensate for posterior corrective surgery.
Transforaminal lumbar interbody fusion (TLIF) is commonly used procedure for spinal fusion. However, there are no reports describing anterior cage dislodgement after surgery. This report is a rare case of anterior dislodgement of fusion cage after TLIF for the treatment of isthmic spondylolisthesis with lumbosacral transitional vertebra (LSTV). A 51-year-old man underwent TLIF at L4-5 with posterior instrumentation for the treatment of grade 1 isthmic spondylolisthesis with LSTV. At 7 weeks postoperatively, imaging studies demonstrated that banana-shaped cage migrated anteriorly and anterolisthesis recurred at the index level with pseudoarthrosis. The cage was removed and exchanged by new cage through anterior approach, and screws were replaced with larger size ones and cement augmentation was added. At postoperative 2 days of revision surgery, computed tomography (CT) showed fracture on lateral pedicle and body wall of L5 vertebra. He underwent surgery again for paraspinal decompression at L4-5 and extension of instrumentation to S1 vertebra. His back and leg pains improved significantly after final revision surgery and symptom relief was maintained during follow-up period. At 6 months follow-up, CT images showed solid fusion at L4-5 level. Careful cage selection for TLIF must be done for treatment of spondylolisthesis accompanied with deformed LSTV, especially when reduction will be attempted. Banana-shaped cage should be positioned anteriorly, but anterior dislodgement of cage and reduction failure may occur in case of a highly unstable spine. Revision surgery for the treatment of an anteriorly dislodged cage may be effectively performed using an anterior approach.
Cage; Transforaminal lumbar interbody fusion; Spondylolisthesis; Lumbosacral spine; Transitional vertebra
Various conditions such as fracture, dislocation, tumor, or infection adversely affect the vertebral body and lead to instability. Restoration of a stable anterior column is essential for normal spinal biomechanics. Various biological and mechanical spacers have been used to reconstruct the anterior column after corpectomy. In this retrospective review, the authors evaluated clinical charts and radiographs of 13 patients receiving titanium surgical mesh (TSM)-bone graft composite to reconstruct the anterior spinal column in the thoracic or lumbar region. The objective of this review was to evaluate the stability and efficacy of the TSM-bone graft composite in the anterior spine after a complete or partial corpectomy. Sixteen patients with involvement of the thoracic or lumbar vertebral column after trauma, tumor, or infection underwent partial or complete corpectomy. In all patients the anterior defect was reconstructed using a TSM-bone graft composite. Three patients died within 12 months postoperatively due to primary malignant process. Thirteen of 16 patient charts and radiographs were evaluated for anterior fusion status, settling of the TSM-bone graft composite, and hardware failure. No pseudoarthroses were noted. Evidence of solid anterior fusion was noted in all patients. The average settling of the TSM-bone graft construct was 3 mm. All patients presenting with only pain and no neurological symptoms (n = 9) experienced early pain relief. For patients presenting with neurological symptoms (n = 4), the recovery was complete in three and partial in one. No patient was made neurologically worse, and there were no vascular injuries intra- or postoperatively. The study suggests that TSM-bone graft composite offers excellent biomechanical stability in the immediate postoperative period, permitting progressive maturation of the fusion mass.
Key words Thoracic spine; Lumbar spine; Corpectomy; Titanium surgical mesh
This is a retrospective series.
We wanted to analyze the safety and effectiveness of using the newer generation metallic implants (pedicle screws and/or titanium mesh) for the treatment of tuberculous spondylitis.
Overview of the Literature
There have been various efforts to prevent the development of a kyphotic deformity after the treatment of tuberculous spondylitis, including instrumentation of the spine. Pedicle screws and titanium mesh cages have become more and more popular for treating various spinal problems.
Twenty two patients who had tuberculous spondylitis were treated with anterior radical debridement and their anterior column of spine was supported with a tricortical iliac bone graft (12 patients) or by mesh (10 patients). Supplementary posterior pedicle screw instrumentation was performed in 17 of 22 patients. The combination of surgeries were anterior strut bone grafting and posterior pedicle screws in 12 patients, anterior titanium mesh and posterior pedicle screws in 5 patients and anterior mesh only without pedicle screws in 5 patients. The patients were followed up with assessing the laboratory inflammatory parameters, the serial plain radiographs and the neurological recovery.
The erythrocyte sedimentation rate and C-reactive protein levels were eventually normalized and there was no case of persistent infection or failure to control infection in spite of a mettalic implant in situ. The overall correction of kyphotic deformity was initially 8.9 degrees, and the loss of correction was 6.2 degrees. In spite of some loss of correction, this technique effectively prevented clinically significant kyphotic deformity. The preoperative Frankel grades were B for 1 patient, C for 4, D for 4 and E for 13. At the final follow-up, 7 of 9 patients recovered completely to Frankel grade E and only two patients showed a Frankel grade of D.
Stabilizing the spine with pedicle screws and/or titanium mesh in patients with tubercuous spondylitis effectively prevents the development of kyphotic deformity and this did not prevent controlling infection when this technique was combined with radical debridement and anti-tuberculous chemotherapy.
Tuberculous spondylitis; Pedicle screw; Titanium mesh
To assess the efficacy and feasibility of vertebroplasty and posterior short-segment pedicle screw fixation for the treatment of traumatic lumbar burst fractures. Short-segment pedicle screw instrumentation is a well described technique to reduce and stabilize thoracic and lumbar spine fractures. It is relatively a easy procedure but can only indirectly reduce a fractured vertebral body, and the means of augmenting the anterior column are limited. Hardware failure and a loss of reduction are recognized complications caused by insufficient anterior column support. Patients with traumatic lumbar burst fractures without neurologic deficits were included. After a short segment posterior reduction and fixation, bilateral transpedicular reduction of the endplate was performed using a balloon, and polymethyl methacrylate cement was injected. Pre-operative and post-operative central and anterior heights were assessed with radiographs and MRI. Sixteen patients underwent this procedure, and a substantial reduction of the endplates could be achieved with the technique. All patients recovered uneventfully, and the neurologic examination revealed no deficits. The post-operative radiographs and magnetic resonance images demonstrated a good fracture reduction and filling of the bone defect without unwarranted bone displacement. The central and anterior height of the vertebral body could be restored to 72 and 82% of the estimated intact height, respectively. Complications were cement leakage in three cases without clinical implications and one superficial wound infection. Posterior short-segment pedicle fixation in conjunction with balloon vertebroplasty seems to be a feasible option in the management of lumbar burst fractures, thereby addressing all the three columns through a single approach. Although cement leakage occurred but had no clinical consequences or neurological deficit.
Burst fractures; Spinal trauma; Pedicle screw; Kyphoplasty; Bone cement
We reviewed the surgical treatment of 31 patients with burst fractures or teardrop dislocation fractures in the middle and lower cervical spine. Patients were treated with anterior instrumentation, posterior instrumentation, or a combination of both. Patients were evaluated radiographically and with the Frankel neurological outcomes grading scale. Anterior decompression and fusion restored the spinal canal diameter by approximately 60% whereas the posterior or combined approaches restored the canal diameter by only 6%. In addition, nine of 24 patients treated anteriorly gained improved neurological function whereas none of the patients treated posteriorly had neurological improvement. Based on the anatomical and neurological findings, the study demonstrates that anterior fusion is preferable to posterior fusion for the treatment of burst fractures and tear-drop dislocation fractures of the middle and lower cervical spine.
Middle and lower cervical spine; Burst fracture; Tear-drop dislocation fracture; Surgical treatment
Short-segment fixation alone to treat thoracolumbar burst fractures is common but it has a 20-50% incidence of implant failure and rekyphosis. A transpedicle body augmenter (TpBA) to reinforce the vertebral body via posterior approach has been reported to prevent implant failure and increase the clinical success rate in treating burst fracture. This article is to evaluate the longterm results of short-segment fixation with TpBA for treatment of thoracolumbar burst fractures.
Materials and Methods:
Patients included in the study had a single-level burst fracture involving T11-L2 and no distraction or rotation element with limited neurological deficit. Patients in the control group (n = 42) were treated with short-segment posterior instrumentation alone, whereas patients in the augmented group (n = 90) were treated with a titanium spacer designed for transpedicle body reconstruction. The followup was 48-101 months. The radiographic and clinical results were evaluated and compared by Student's t test and Fisher's exact test.
The blood loss, operation time and hospitalization were similar in both the groups. The immediate postoperative anterior vertebral restoration rate of the augmented group was similar to that of the control group (97.6% ± 2.4% vs. 96.6% ± 3.2%). The final anterior vertebral restoration was greater in the augmented group than in the control group (93.3% ± 3.4% vs. 62.5% ± 11.2%). Immediate postoperative kyphotic angles were not significantly different between the groups (3.0° ± 1.8° vs. 5.1° ± 2.3°). The final kyphotic angles were less in the augmented group than the control group (7.3° ± 3.5° vs. 20.1° ± 5.4°). The augmented group had less (P < 0.001) implant failure [0% (n=0) vs. 23.8% (n=10)] for the control group) and more patients (P < 0.001) with no pain or minimal or occasional pain (Grade P1 or P2) than the control group [90.0% (n=81) vs. 66.7% (n=28)]. All patients in the augmented group and 39 (92.8%) patients in the control group experienced neurological recovery to Frankel Grade E. Three patients in the control group had improvement to Frankel Grade D from Frankel Grade C, but later had deterioration to Frankel Grade C because of loosening and dislodgement of the implant.
Posterior body reconstruction with TpBA can maintain kyphosis correction and vertebral restoration, prevent implant failure and lead to better clinical results.
Burst fractures; kyphosis; posterior instrumentation; spinal trauma; thoracolumbar injury; transpedicle body augmenter
Object. The implantation of interbody fusion cages allows for the restoration of disc height and the enlargement of the neuroforaminal space. The purpose of this study was to compare the extent of subsidence occurring after conventional cage placement compared to a novel wider cage placement technique.
Methods. This study is a retrospective evaluation of radiographs of patients who underwent stand-alone single level anterior lumbar interbody fusion with lordotic titanium cages and rhBMP-2. Fifty-three patients were evaluated: 39 patients had wide cage placement (6 mm interdevice distance) and 14 had narrow cage placement (2 mm interdevice distance). Anterior and posterior intervertebral disc space heights were measured post-operatively and at follow-up imaging.
Results. The decrease in anterior intervertebral disc space height was 2.05 mm versus 3.92 mm (P < .005) and 1.08 mm versus 3.06 mm in posterior disc space height for the wide cage placement and the narrow cage placement respectively. The proportion of patients with subsidence greater than 2 mm was 41.0% in the wide cage patients and 85.7% for the narrow cage patients (P < .005).
Conclusions. The wider cage placement significantly reduced the amount of subsidence while allowing for a greater exposed surface area for interbody fusion.
A 35-year-old female patient sustained three contiguous vertebral fractures at the thoracolumbar junction while jumping off the third floor in a suicide attempt. Initial fracture treatment occurred in the setting of a multiple injury scenario. While the Th12 and the L1 vertebral fractures were considered stable, the L2 fracture exhibited a complete burst configuration with 80% canal compromise due to a posterior wall fragment causing paraplegia. A posterior pedicle screw stabilisation with indirect fracture reduction was carried out initially from T12 to L3. At 1 year follow-up the patient presented to us for new onset radiculopathy L2, and loss of correction. A circumferential revision surgery with an expandable cage was carried out to restore the anterior and posterior columns. Unfortunately again loss of reduction with kyphosis occurred, this time at the upper instrumented vertebra, which made another revision necessary. In this situation a longer construct was chosen using a combined approach and a Mesh cage. This later procedure was complicated by a postoperative paraparesis believed to be vascular in origin. Six months later a further complication involving MSSA deep wound infection required a series of irrigation debridement for healing. At the 2.5 years follow up the spine was stable and the patient had a neurologic recovery allowing her to ambulate with crutches. This Grand Round Case raises the question on the initial management of multiply injured patients with spine fracture, the classification of these fractures, the optimal initial internal fixation, the need for complementary anterior column reconstruction and the strategy when all these fails.
The literature reports on the safety and efficacy of titanium cages (TCs) with additional posterior fixation for anterior lumbar interbody fusion. However, these papers are limited to prospective cohort studies. The introduction of TCs for spinal fusion has resulted in increased costs, without evidence of superiority over the established practice. There are currently no prospective controlled trials comparing TCs to femoral ring allografts (FRAs) for circumferential fusion in the literature. In this prospective, randomised controlled trial, our objective was to compare the clinical outcome following the use of FRA (current practice) to the use of TC in circumferential lumbar spinal fusion. Full ethical committee approval and institutional research and development departmental approval were obtained. Power calculations estimated a total of 80 patients (40 in each arm) would be required to detect clinically relevant differences in functional outcome. Eighty-three patients were recruited for the study fulfilling strict entry requirements (>6 months chronic discogenic low back pain, failure of conservative treatment, one- or two-level discographically proven discogenic low back pain). The patients completed the Oswestry Disability Index (ODI), Visual Analogue Score (VAS) for back and leg pain and the Short-Form 36 (SF-36) preoperatively and also postoperatively at 6, 12 and 24 months, respectively. The results were available for all the 83 patients with a mean follow-up of 28 months (range 24–75 months). Five patients were excluded on the basis of technical infringements (unable to insert TC in four patients and FRA in one patient due to the narrowing of the disc space). From the remaining 78 patients randomised, 37 received the FRA and 41 received the TC. Posterior stabilisation was achieved with translaminar or pedicle screws. Baseline demographic data (age, sex, smoking history, number of operated levels and preoperative outcome measures) showed no statistical difference between groups (p<0.05) other than for the vitality domain of the SF-36. For patients who received the FRA, mean VAS (back pain) improved by 2.0 points (p<0.01), mean ODI improved by 15 points (p=<0.01) and mean SF-36 scores improved by >11 points in all domains (p<0.03) except that of general health and emotional role. For patients who received the TC, mean VAS improved by 1.1 points (p=0.004), mean ODI improved by 6 points (p=0.01) and SF-36 improved significantly in only two of the eight domains (bodily pain and physical function). Revision procedures and complications were similar in both groups. In conclusion, this prospective, randomised controlled clinical trial shows the use of FRA in circumferential lumbar fusion to be associated with superior clinical outcomes when compared to those observed following the use of TCs. The use of TCs for circumferential lumbar spinal fusion is not justified on the basis of inferior clinical outcome and the tenfold increase in cost.
Fusion; Lumbar spine; Randomised controlled trial; Femoral ring allograft; Titanium cage