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PubMed1995

Experimental spinal fusion with recombinant human bone morphogenetic protein-2.

STUDY DESIGN: Lumbar intertransverse process arthrodesis using recombinant human bone morphogenetic protein-2 was performed in a previously established rabbit model for posterolateral spinal fusion and compared with fusions achieved using autogenous bone graft. OBJECTIVES: To qualitatively compare different recombinant human bone morphogenetic protein-2 dosages and carriers and to determine the efficacy of recombinant human bone morphogenetic protein-2 as a bone graft substitute to produce lumbar intertransverse process fusion in a validated rabbit model for posterolateral spinal fusion. SUMMARY OF BACKGROUND DATA: Autogenous bone was considered the most successful bone graft material used for spinal arthrodesis. Problems with its use may occur in 25-30% of patients and prompted the search for and investigation of bone graft substitutes and osteoinductive growth factors, such as bone morphogenetic proteins. Recombinant human bone morphogenetic protein-2 was used successfully in orthotopic sites to generate bone in animal mandibular and long bone defect models. METHODS: Posterolateral intertransverse process arthrodeses were performed at L5-L6 in 56 rabbits using recombinant human bone morphogenetic protein-2 or autogenous bone graft. Rabbits were killed either 5 weeks later to qualitatively compare fusions achieved using different recombinant human bone morphogenetic protein-2 dosages and carriers or 4 weeks later to compare the efficacy of recombinant human bone morphogenetic protein-2 in achieving spinal fusion compared with using autogenous bone graft. Inspection, manual palpation, radiography, histology, and biomechanic testing were used to assess the fusion. RESULTS: All rabbits implanted with recombinant human bone morphogenetic protein-2 achieved solid spinal fusion by manual palpation and were fused radiographically, whereas only 42% of the autograft control fusions were solid. More mature fusions with greater trabecular bone formation were shown radiographically and histologically in rabbits implanted with the high-dose recombinant human bone morphogenetic protein-2 than with the low-dose recombinant human bone morphogenetic protein-2. Fusions achieved using recombinant human bone morphogenetic protein-2 delivered in the collagen carrier were more remodeled and homogeneous compared with using recombinant human bone morphogenetic protein-2 delivered in autograft +/- collagen carrier. Fusions achieved with recombinant human bone morphogenetic protein-2 were biomechanically stronger and stiffer than fusions achieved using autogenous bone graft. CONCLUSIONS: Recombinant human bone morphogenetic protein-2 successfully and reliably achieved lumbar intertransverse process fusion in a validated rabbit model for posterolateral spinal fusion. Radiographically and histologically, greater and more rapid bone formation, consolidation, and remodeling were shown with recombinant human bone morphogenetic protein-2 compared with autogenous bone graft. Fusions achieved with recombinant human bone morphogenetic protein-2 were biomechanically stronger and stiffer than autograft fusions.

Animals↗
PubMed1983

Retroperitoneal fibrosis after anterior spinal fusion.

Three patients with lumbar anterior spinal fusion (two with Dwyer instrumentation) developed retroperitoneal fibrosis in relation to the operative site. This complication is possibly a reaction to the retroperitoneal insult. Haematoma, low-grade infection and metallic implant are other likely contributory factors. Its occurrence is affected by the laterality of surgical approach and extent of dissection. Radiologists should be aware of such a complication when investigating post-fusion patients. Early diagnosis and treatment prevent further renal damage.

Adult↗
PubMed1995

Lumbar spinal fusion using the Diapason system.

Lumbar spinal fusion with the Diapason system was performed on 58 patients at Toho University Ohmori Hospital from November 1991 to November 1994. The first 44 consecutive patients were followed for more than 1 year, including 34 cases with degenerative diseases. Those 34 cases consisted of 22 men and 12 women, ages 19-78 years (average 47.4), with 49 vertebral levels; these patients were followed for an average of 26.3 months. The clinical improvement and rate of bony union after 1 year of surgery were examined and the intervertebral angulatory motion degree of fused vertebrae was measured using a radiographic functional photo image during 1 year. We also performed an experimental study to evaluate the rigidity of this system. There were no severe complications. Although there was no instrument breakage or screw migration, two cases of rod migration were observed in L5-S1 arthrodesis. A mean improvement rate of 84.3% in the Japanese Orthopaedics Association (JOA) score was revealed. Thirty-three of 34 (97.1%) patients demonstrated successful arthrodesis after their initial procedure. In 10 segments (20.4%) 3-5 degrees of angulatory mobility were still retained, and no angulatory motion was observed in 27 segments (55.1%) 3 months after the surgery; however, no angulatory motion was observed in 44 segments (89.8%) 1 year after the surgery. In our biomechanical study, we observed that the anterior intervertebral space became narrow and mobile with loading, but when the loading was removed, the space reverted to the initial site. This movement was thought to be due to a certain elasticity in the rod and screw, and not loosening at the connection level. This system was evaluated based on the results of both clinical and biomechanical study. Notwithstanding the fact that this method has been evaluated as semirigid fusion, it does provide satisfactory bony union in posterolateral fusion, with excellent clinical results.

Adult↗
PubMedDate not supplied

Correlation of coagulopathy and pulmonary insufficiency with blood transfusion in spinal fusions.

In a review of 210 spinal fusions, the platelet count and the arterial-alveolar oxygen tension ratio both decreased as the blood transfused increased, but were not correlated with positive fluid balance. In procedures that might require more than 70-80 ml/kg of blood, such as myelodysplastic, paralytic, and congenital spinal surgery, the coagulation system and arterial gases should be monitored frequently intraoperatively and postoperatively.

Adult↗
PubMed2000

Stopping nicotine exposure before surgery. The effect on spinal fusion in a rabbit model.

STUDY DESIGN: A double-blind, prospective, randomized study using a validated rabbit model of intertransverse process fusion. OBJECTIVES: To determine the effect of stopping prolonged nicotine exposure on autogenous bone graft incorporation in a rabbit lumbar spinal fusion model. SUMMARY OF BACKGROUND DATA: There is a growing body of evidence that systemic nicotine impairs healing of spinal fusions and fractures. However, it remains to be determined whether, if nicotine increases the nonunion rate of spinal fusion surgery, stopping nicotine exposure before surgery will negate this inhibitory effect. METHODS: Forty-seven rabbits were divided into two experimental groups and one control group. The two experimental groups were exposed to systemic nicotine for 8 weeks. Nicotine exposure was stopped in one group 1 week before surgery; nicotine exposure was continued in the other group throughout the study. All rabbits underwent an L5-L6 intertransverse process fusion with autogenous iliac crest bone graft. All rabbits were killed 35 days after surgery. Forty rabbits completed the study and underwent radiographic, biomechanical, and histologic testing. RESULTS: Fusion, as determined by a blinded examiner palpating the spine, occurred in 7 of 13 control rabbits, 4 of 13 rabbits that "quit" nicotine, and none of the 14 rabbits exposed to continuous nicotine. There was a statistically significant difference between the control and continuous nicotine (P = 0.0015) and between the discontinued nicotine and continuous nicotine groups (P = 0.025). Biomechanical testing showed no significant differences between groups (P = 0.11). A blinded musculoskeletal pathologist was unable to detect a difference between groups based on histologic analysis. CONCLUSIONS: Chronic nicotine exposure was shown to decrease spinal fusion rates. Discontinuing nicotine before surgery improved fusion rates.

Analysis of Variance↗
PubMed1989

Augmentation of spinal fusion with bone morphogenetic protein in dogs.

Bone morphogenetic protein (BMP) induces mesenchymal cells to differentiate into cartilage and bone. To investigate the action of BMP on the growth of host bed-derived bone in experimental spinal fusions, posterior intervertebral spinal fusions of the lower thoracic spine were performed in 13 mature mongrel dogs. Four different fusion methods were used at single intervertebral levels within each dog. Three levels in each dog were used as controls for the BMP level. The spinal columns were examined by radiohistomorphometric methods at three weeks, six weeks, and 12 weeks and showed the BMP level to have two to three times more new bone than control levels. At the BMP level, an increase in the amount of new bone was observed in the interval from three to 12 weeks, in contrast to a decrease seen at the control levels. Fusion was present in five of seven of the BMP levels compared with zero of seven, one of seven, and two of seven in the control levels. The BMP level exhibited an increased number and volume of areas of de novo cartilage and woven bone formation at all time intervals compared to all control levels. The polylactic acid polymer carrier was not resorbed and partially retained in the fusion site. The preliminary observations suggest that BMP may serve as a useful adjunct in spinal fusions, but research is required to find a rapidly degradable delivery system. The objective of BMP research is to augment the host bed capacity for bone generation and regeneration and to spare children and adults the pain and complications involved in removing excessive volumes of iliac crest bone grafts.

Animals↗
PubMed2006

Fatal pulmonary fat embolism following spinal fusion surgery.

OBJECTIVE: To report the case of a fatal pulmonary fat embolism as a complication of spinal fusion surgery. DESIGN: Case report. SETTING: Pediatric intensive care unit at a freestanding tertiary care children's hospital. PATIENT: An adolescent female with neuromuscular scoliosis who underwent spinal fusion surgery with instrumentation and suffered a fatal pulmonary fat embolism. CONCLUSION: Spinal fusion surgery for neuromuscular scoliosis is a common operative procedure. Pulmonary fat embolism as a complication of this procedure is rare. This case emphasizes the need to be aware of this potentially fatal postoperative complication. Specifically evaluating for this rare complication may lead to understanding cases of unexplained deterioration and death.

Adolescent↗
PubMed1992

Patient outcomes after lumbar spinal fusions.

OBJECTIVES: To determine success and complication rates for lumbar spinal fusion surgery, predictors of good outcomes, and whether fusion improves success rates of laminectomy for specific low back disorders. DATA SOURCES: English-language journal articles published from 1966 through April 1991, identified through MEDLINE searching (spinal fusion plus limiting terms), bibliography review, and expert consultation. STUDY SELECTION: Articles were selected only if they reported at least 1 year of follow-up data enabling the classification of clinical outcomes as satisfactory or unsatisfactory for at least 30 patients. DATA EXTRACTION: Two reviewers independently extracted data on patient characteristics, surgical methods, patient outcomes, and quality of study methods. DATA SYNTHESIS: Of 47 articles, there were no randomized trials. Four nonrandomized studies compared surgery with and without fusion for herniated disks; three found no advantage for fusion. On average, 68% of patients had a satisfactory outcome after fusion, but the range was wide (16% to 95%), and the satisfactory outcome rate was lower in prospective than in retrospective studies. The most frequently reported complications were pseudarthrosis (14%) and chronic pain at the bone graft donor site (9%). Clinical outcomes did not differ by diagnosis or fusion technique, but were worse in studies with a greater number of previously operated patients. CONCLUSIONS: For several low back disorders no advantage has been demonstrated for fusion over surgery without fusion, and complications of fusions are common. Randomized controlled trials are needed to compare fusion, surgery without fusion, and nonsurgical treatments in rigorously defined patient groups.

Adult↗
PubMed2003

Spinal fusion in patients with Duchenne's muscular dystrophy and a low forced vital capacity.

Traditionally, spinal fusion has been denied to patients with scoliosis secondary to Duchenne's muscular dystrophy (DMD) when their forced vital capacity (FVC) is less than 30-40% of predicted values (PFVC). The reasons for this decision are a theoretically increased risk of adverse events from a prolonged anaesthetic and extensive surgery. This paper presents a retrospective analysis of 30 patients with DMD scoliosis who underwent posterior spinal fusion at the Royal National Orthopaedic Hospital. Two subgroups of patients were compared: those with more than 30% PFVC (17 patients) and those with less than 30% PVFC (13 patients). One patient in each group required a temporary tracheotomy and there were nine complications in total. The post-operative stay for patients in each group was similar (24 days in the >30% group, 20 days in the <30% group) and the complication rate was comparable with other published series. We conclude that spinal fusion can be offered to patients with DMD even in the presence of a low FVC.

Adolescent↗
PubMed2004

Cytokine release, pancreatic injury, and risk of acute pancreatitis after spinal fusion surgery.

Acute pancreatitis after posterior spinal fusion in children is associated with high intraoperative blood loss. Inflammation, oxidative stress, and pancreatitis markers were assessed during this period. Five of the 17 patients studied developed acute pancreatitis 3-7 days after surgery. Intraoperative blood loss (4850 +/- 2315 vs 1322 +/- 617 ml) and peak tumor necrosis factor alpha levels (15.29 +/- 5.3 vs 8.27 +/- 4.6 pg/ml) in the immediate postoperative period were significantly higher in these five patients than in controls, respectively. No differences were noted in serum interleukin 8, interleukin 6, pancreatis-associated protein, or urine malondialdehyde levels. Urine trypsin-associated peptide, elevated initially in all patients, was significantly higher in the acute pancreatitis group at diagnosis. Length of stay was significantly longer in the acute pancreatitis group. Greater blood loss and peak tumor necrosis factor alpha are associated with subsequent risk of acute pancreatitis, suggesting a role of ischemia-reperfusion injury.

Acute Disease↗
PubMedDate not supplied

Carrier materials for spinal fusion.

BACKGROUND CONTEXT: The rise in spinal fusion procedures has led to an increase in the available number and variety of bone graft substitutes. As our understanding of the biologic processes that influence bony fusion has improved, appreciation for the role of the carrier material involved in bone grafts has also increased. PURPOSE: The abundance of products available leaves a surgeon with many choices. Knowledge of the current advances will allow for more critical review of the literature and improved decision making when choosing bone graft materials. STUDY DESIGN/SETTING: Review of the English-language literature. METHODS: A critical review of basic science, animal and human studies that investigate the types and role of carrier materials used in spine surgery. RESULTS: The myriad of carrier material available to the spine surgeon is related to the many options in bone graft material. Allograft is an important osteoconductive agent but has its disadvantages especially in regard to disease transmission and immunogenicity. Collagen in various forms is an effective carrier for bone morphogenic protein and autogenous stem cells and can be easily combined with other bone graft materials. Synthetic options include hydroxyapatite and calcium phosphate ceramic materials with different formulations; all are osteoconductive only but can be combined with osteoinductive and/or osteogenic components. Bioabsorbable carriers are effective for use with bone morphogenic protein and can also be used in multiple forms and settings. CONCLUSIONS: Many bone graft carriers exist, and multiple studies have shown their efficacy. It appears that no one carrier is ideal but each situation might influence the choice of one carrier over another.

Animals↗
PubMed1983

Bilateral facet to spinous process fusion: a new technique for posterior spinal fusion after trauma.

A variety of options exist for the treatment of fracture/dislocation of the cervical spine, including prolonged traction immobilization, immobilization in an external device, and open surgical fusion. In cases of facet dislocation and flexion/compression injuries, the authors have found that surgical fusion is the most useful. However, in cases of facet fracture or disruption of the posterior neural arch, routine interspinous wiring techniques do not provide adequate rotational stability and may allow postsurgical redislocation before bony fusion. For these cases, a new technique using bilateral facet to spine wire loops has been developed. In the 25 cases reported here, the technique provided excellent stability against anterior horizontal displacements and rotational dislocations despite unilateral or bilateral facet fracture or disruption of the posterior neural arch.

Cervical Vertebrae↗
PubMed2004

Experimental study of carriers of bone morphogenetic protein used for spinal fusion.

Many materials have been used experimentally as carriers of osteoinductive growth factors. However, there is some doubt about whether the biomechanical strength of the materials affects spinal fusion from early stages of recovery. The aim of this study was to clarify which carrier was biomechanically more effective for bone morphogenetic proteins in spinal fusion. Three biomaterials, each having a different structure and biomechanical strength, were selected as carriers of recombinant human bone morphogenetic protein-2: (1) alpha-tricalcium phosphate cement, which has sufficient biomechanical strength; (2) sintered bovine bone (True Bone Ceramics) coated by type I collagen, which is similar to artificial hydroxyapatite; and (3) type I collagen sheet. Bilateral lumbar intertransverse process arthrodeses were designed in a rabbit model. Spinal fusions were evaluated by radiographic analysis, manual palpation, biomechanics (uniaxial tensile test), and histologic analysis (hematoxylin and eosin, and Villanueva-Goldner's trichrome stains) 3 and 6 weeks after surgery; they were then compared for the three carriers. For achieving the earliest solid spinal fusion, alpha-tricalcium phosphate cement (which has good inherent strength) and True Bone Ceramics (which has good porosity to allow bone penetration) did better than plain collagen (the commonly used carrier).

Animals↗
PubMedDate not supplied

The role of human bone morphogenetic proteins in spinal fusion.

The attainment of a stable arthrodesis is critical to the successful management of some types of spinal disorders. Autologous iliac-crest bone graft has been the most commonly utilized substance associated with predictable healing in spinal fusion applications. Although alternative graft substances exist, these have not been shown to be as uniformly effective in achieving spinal fusion. Because of the morbidity associated with bone autograft harvest, there is increasing interest in alternative graft substances and especially in the osteoinductive abilities of bone morphogenetic proteins (BMPs). Several animal models have demonstrated that BMP-containing allograft or synthetic carrier medium is as effective as or superior to autograft bone in promoting spinal fusion. Furthermore, the limited number of human trials utilizing BMPs to treat nonunions in the appendicular skeleton indicate that the results found in animal models will be reproducible in the clinical setting.

Animals↗
PubMed1990

Degenerative arthritis of the adjacent spinal joints following anterior cervical spinal fusion: clinicoradiologic and statistical correlations.

On the premise that cervical intersomatic spinal fusion in the treatment of traumatic or spondylolytic myelopathy and post-traumatic instability provokes degenerative arthritis due to functional overloading of the spaces adjacent to the fusion, 37 patients (average age 57, range 25-80) who had undergone spinal fusion by Cloward's technique were subjected to radiographic study and clinical evaluation. The average follow-up was 11.5 years (range 7-16 years). In comparison with a control group of the same age who had not undergone this operation, these patients' C3-C4 and C6-C7 spaces (adjacent to the most commonly fused vertebrae) were smaller by 16.7% and 15.9%, respectively. In spite of the worsening of the radiographic situation, from a clinical standpoint there was a significant improvement in the symptomatology of 86.5% of the patients. Thus the degenerative arthritis is both less evident and, as far as the long-term clinical outcome is concerned, less influential than could be expected. This finding is confirmed by the lack of statistical correlation between the clinical results and the radiographic evidence.

Adult↗
PubMedDate not supplied

Spinal fusion in Duchenne's muscular dystrophy.

The Women's and Children's Hospital experience with Luque spinal fusion in Duchenne's muscular dystrophy was reviewed from its commencement in 1983 to the present with a view to assessing the clinical and radiologic outcome and safety of the procedure. Seventeen boys have undergone spinal fusion. L-rod instrumentation was used in 10, six of whom had significant problems with sitting imbalance or progression of the scoliosis or both. In seven cases, distal instrumentation was taken to the pelvis with a Galveston construct and rigid crosslinking. Apart from some progression and sitting imbalance in the L-rod group, there were few complications. In the Galveston group, pelvic obliquity was corrected by a mean of 63%, and there was better maintenance of correction. There were no pseudoarthroses or instrument failures in the Galveston group. Of the total group, four patients had forced vital capacity (FVC) values < 25% predicted, and two required ventilation postoperative (< 48 h). There were no other respiratory complications. The effect of surgery on respiratory function remains uncertain. Spinal fusion with the Luque rod construct and pelvic fixation is a safe procedure. It provided a mean correction of 60% and control of pelvic obliquity without significant postoperative deterioration. In our experience, surgery can be safely performed with FVC value down to 20% predicted. On the basis of these data, one current practice is to instrument to the pelvis with a Galveston construct and Texas Scottish Rite Hospital cross-linking.

Adolescent↗
PubMed2002

Long-term functional outcome of pedicle screw instrumentation as a support for posterolateral spinal fusion: randomized clinical study with a 5-year follow-up.

STUDY DESIGN: A prospective randomized clinical study with a 5-year follow-up. OBJECTIVES: To analyze the long-term effect of supplementary transpedicular screw fixation on reoperation rate and functional outcome. SUMMARY OF BACKGROUND DATA: Within the past few years the benefit of supplemental pedicle screw fixation has been questioned as a standard procedure in lumbar spinal fusion surgery. The long-term effect of supplemental pedicle screw fixation is still unknown. METHODS: From 1992 through 1994 a total of 129 patients with severe chronic low back pain were randomly selected for either supplemental pedicle screw fixation (instrumented) or no pedicle screw instrumentation (noninstrumented) posterolateral spinal fusion. The Dallas Pain Questionnaire, Low Back Pain Rating Scale, and a questionnaire concerning work status assessed the outcome. RESULTS: A 5-year follow-up of 93% showed that the instrumented group had a 25% reoperation rate (removal of instrumentation with and without second fusion) compared with a reoperation rate of 14% in the noninstrumented group (fusion and decompression) (P < 0.03). A total of 51% were capable of working after 5 years compared with 40% before surgery. There was no difference in work capacity between the two groups at any point of observation. Overall, there was no significant difference between the instrumented and noninstrumented groups in regard to functional outcome as measured by both the Dallas Pain Questionnaire and Low Back Pain Rating Scale. When analyzing diagnostic subgroups at the 5-year follow-up, patients with isthmic spondylolisthesis had a significantly better outcome by use of a posterolateral fusion without supplemental instrumentation compared with an instrumented fusion (P < 0.03). However, patients with primary degenerative instability improved significantly more when instrumentation supported the posterolateral spinal fusions (P < 0.02). To the question "was it worth it?" 67% answered "yes" in the instrumented group whereas 70% did so in the noninstrumented groups (not significant). CONCLUSION: The long-term functional outcome of posterolateral spinal fusion improved significantly for boththose with and without pedicle screw instrumentation, with a global 70% satisfaction reported by the patients. Patients with isthmic spondylolisthesis Grades 1 and 2 with noninstrumented fusion had superior long-term outcomes after posterolateral spinal fusion in comparison with an instrumented fusion. In contrast, patients diagnosed as having primary degenerative instability improved significantly when the posterolateral fusion was supported by instrumentation. In actuality, pedicle screw instrumentation increased reoperation rate compared with noninstrumented posterolateral fusion.

Adult↗
PubMed2004

The effect of epidural vs intravenous analgesia for posterior spinal fusion surgery.

BACKGROUND: The study objective was to compare epidural vs intravenous postoperative analgesia in posterior spinal fusion surgery patients. METHODS: This prospective, double-blinded, randomized study was performed in a tertiary care teaching hospital involving 31 American Society of Anesthesiologists physical status I and II adolescent/young adult patients scheduled for elective posterior spinal fusion surgery for idiopathic scoliosis. Patients were divided into three treatment groups according to the epidural solution infused: group 1 (n = 10) 0.1% bupivacaine + 5 microg x ml(-1) fentanyl; group 2 (n = 12) 0.0625% bupivacaine + 5 microg x ml(-1) fentanyl; group 3 (n = 9) 0.9% sodium chloride (placebo). During general anesthesia all patients received a directly placed midthoracic epidural catheter with a set infusion rate followed by morphine sulfate intravenous patient-controlled analgesic device postoperatively. Morphine sulfate usage and visual analog scores were evaluated at 4 h intervals postoperatively for up to 96 h. Postoperative time to liquids, solid food, ambulation, length of stay, discontinuation of Foley catheter, and side effects were recorded. RESULTS: No consistent difference was detected on intravenous morphine dose usage, visual analog scores, or estimated pain scale over the whole follow-up period. No difference was observed in the epidural groups in time to oral intake of liquids or solids, ambulation, bowel sounds, or length of stay when compared with placebo. CONCLUSIONS: By evaluating morphine sulfate usage between groups, the analgesic effectiveness of continuous thoracic epidural analgesia bupivacaine and fentanyl doses used revealed no significant improvement over intravenous morphine sulfate analgesia alone in patients after posterior spinal fusion surgery.

Adolescent↗