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PubMed1997

A study of desmopressin and blood loss during spinal fusion for neuromuscular scoliosis: a randomized, controlled, double-blinded study.

BACKGROUND: Studies examining the use of desmopressin acetate (DDAVP) have shown variable results in DDAVP's efficacy for reducing blood loss. Studies of adults having cardiac surgery and of children having spinal fusion have suggested that patients with complicated medical histories and complex surgical procedures may benefit from use of DDAVP. Therefore, this study was designed to examine the homeostatic effects of DDAVP in children with severe cerebral palsy undergoing spinal fusion. METHODS: A randomized, double-blinded, and placebo-controlled trial of DDAVP was designed to enroll 40 patients. However, termination of the study was advised by the Institutional Review Board after 21 patients were enrolled. All patients had spastic quadriplegic-type cerebral palsy and were randomly assigned to one of two groups. The DDAVP group received 0.3 microg/kg DDAVP in 100 ml normal saline, and the placebo group received normal saline alone. All patients were anesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl. Factor VIIIC and von Willebrand's factor (vWF) concentrations were measured in blood drawn before DDAVP infusion and 1 h after infusion. Blood pressure was maintained at a systolic pressure of less than 100 mmHg. Use of crystalloids, packed erythrocytes, platelets, and fresh frozen plasma were based on criteria established by protocol. Estimated blood loss was assessed by weighing sponges and measuring suctioned blood from canisters. RESULTS: Estimated blood loss (intraoperative and postoperative) and amount of packed erythrocytes transfused were similar for the DDAVP and placebo groups. Concentrations of both factor VIIIC and vWF were significantly greater after DDAVP infusion when compared with concentrations after placebo infusion. CONCLUSIONS: In the children who had complex spinal fusion, there was no difference in estimated blood loss between those who received DDAVP and those who received a placebo. Administration of DDAVP significantly increased factor VIIIC and vWF levels.

Adolescent↗
PubMed1999

Percutaneous spinal fusion using bone morphogenetic protein-2 gene therapy.

OBJECT: Gene therapy has many potential applications in neurosurgery. One application involves bone morphogenetic protein-2 (BMP-2), a low-molecular-weight glycoprotein that induces bone formation in vivo. Numerous studies have demonstrated that the BMP-2 protein can enhance spinal fusion. This study was undertaken to determine whether direct injection of an adenoviral construct containing the BMP-2 gene can be used for spinal fusion. METHODS: Twelve athymic nude rats were used in this study. Recombinant, replication-defective type 5 adenovirus with the cytomegalovirus (CMV) promoter and BMP-2 gene (Ad-BMP-2) was used. A second adenovirus constructed with the CMV promoter and beta-galactosidase (beta-gal) gene (Ad-beta-gal) was used as a control. In three groups (four rats each) 7.5 microl of virus (5x10(8) particles/microl) was injected percutaneously and paraspinally at the lumbosacral junction: Group 1 received Ad-BMP-2 bilaterally; Group 2 received Ad-BMP-2 on the right, Ad-beta-gal on the left; and Group 3 received Ad-beta-gal bilaterally. Computerized tomography (CT) scans of the lumbosacral spine were obtained at 3, 5, 8, and 12 weeks. At 12 weeks, the animals were killed and underwent histological inspection. Ectopic bone formation was observed both on three-dimensionally reconstructed CT scans and histological examination in all rats at sites treated with Ad-BMP-2. Histological analysis demonstrated bone at different stages of maturity adjacent to the spinous processes, laminae, and transverse processes. CONCLUSIONS: Results of this study clearly demonstrated that it is possible to produce in vivo endochondral bone formation by using direct adenoviral construct injection into the paraspinal musculature, which suggests that gene therapy may be useful for spinal fusion in the future.

Adenoviridae↗
PubMed2001

Postoperative pain control using epidural catheters after anterior spinal fusion for adolescent scoliosis.

STUDY DESIGN: A prospective review of patients undergoing epidural catheter placement after anterior spinal fusion and instrumentation for adolescent scoliosis was performed. Data were collected using visual analog pain scores reflecting the patients' perception of their pain control. OBJECTIVES: To present the authors' technique for epidural catheter placement and dosing protocol, and to demonstrate the results from postoperative pain control after anterior spinal instrumented fusion for 10 consecutive patients. SUMMARY OF BACKGROUND DATA: The literature regarding the benefits of epidural catheters after spinal surgery is contradictory, even with controlled studies comparing epidural catheters with intravenous morphine patient-controlled anesthesia. The authors believe that this lack of consensus stems from varied epidural dosing protocols and techniques in catheter placement, which they have witnessed anecdotally at their own institution. This prompted the authors to develop and refine a standardized dosing and catheter placement protocol for pain control after spinal surgery. METHODS: Epidural catheters were placed intraoperatively before wound closure, then removed on postoperative Day 5. Dosing consisted of fentanyl (1 microg/kg) and hydromorphone (5 microg/kg) diluted in preservative-free saline (0.2 mL/kg). After surgery, dosing consisted of 0.1% ropivacaine and hydromorphone (10 microg/ml) continuously infused at 0.2 mL/kg/hour. Postoperative pain control was assessed on each postoperative day using a visual analog pain scale with choices ranging from 0 to 10. RESULTS: The arithmetic mean of the median pain scores after surgery was 2.1. The mean of the maximum pain scores for the 5 days was 4.1. Three patients required an epidural bolus and a 20% increase in the epidural infusion rate. One patient was judged to be excessively sleepy, so the epidural infusion rate was decreased by 20%. Pruritus requiring diphenhydramine developed in three patients. No other adverse effects related to epidural analgesia were noted. No catheters were accidentally pulled out or disconnected. CONCLUSION: By following the dosing protocol described, epidural catheters can be used safely and effectively to control postoperative pain after anterior instrumentation and spinal fusion for adolescent scoliosis.

Adolescent↗
PubMed2001

Pancreatitis after posterior spinal fusion for adolescent idiopathic scoliosis.

A case report describes an adolescent with idiopathic scoliosis who underwent a posterior spinal fusion and developed pancreatitis postoperatively. The patient recovered with parenteral nutrition support. We report this case to add to the literature that supports a benign disease course for postoperative pancreatitis in patients who have had posterior spinal fusion.

Adolescent↗
PubMedDate not supplied

Lung function in young persons after spinal fusion for scoliosis.

The long-term changes in vital capacity and in total lung capacity after spinal fusion for 43 scoliotic patients are described. The values recorded were seldom lower after surgery but did not show any marked subsequent increases with patient growth. Subsequent increases in volumes are less marked in the group of patients with paralytic scoliosis. These findings suggest that the psychological advantages of improving the patient's appearance by surgery and of preventing any respiratory condition from worsening may be achieved, although the total capacity and vital capacity are not much improved by spinal fusion.

Adolescent↗
PubMed1993

Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population.

Regional variations in lumbar spinal fusion rates suggest a poor consensus on surgical indications. Therefore, complications, costs, and reoperation rates were compared for elderly patients undergoing surgery with or without spinal fusion. Subjects were Medicare recipients who underwent surgery in 1985, with 4 years of subsequent follow-up. There were 27,111 eligible patients, of whom 5.6% had fusions. Mean age was 72 years. Patients undergoing fusion had a complication rate 1.9 times greater than those who had surgery without fusion. The blood transfusion rate was 5.8 times greater, nursing home placement rate 2.2 times greater, and hospital charges 1.5 times higher (all P < 0.0005). Six-week mortality was 2.0 times greater for patients undergoing fusions (P = 0.025). Reoperation rates at 4 years were no lower for patients who had fusion surgery and results were similar in most diagnostic subgroups. Indications for fusion among older patients require better definition, preferably based on outcomes from prospective controlled studies.

Aged↗
PubMed1984

Posterior spinal fusion using internal fixation with the Daab plate.

The results of posterior spinal fusion, supplemented by internal fixation with the Daab plate in 43 patients, are presented. The Daab plate is a quadruped implant placed longitudinally in the coronal plane and fixed by simply pinching it around the spinous processes. The cause of the instability necessitating fusion was acute trauma in eight patients, late posttraumatic condition in 11, pure degenerative process in seven and spondylolisthesis in nine patients. In addition, there were solitary cases of tuberculous spondylitis, pyogenic spondylitis and metastatic destruction of the vertebral body. The fusion site was cervical in three, thoracic in eight, thoracolumbar in 12 and lumbar or lumbosacral in 20 cases. The mean follow-up time was 19 months. The consolidation of the fused area could, apart from radiographs, ultimately be evaluated at removal of the implant in 39 patients. The fusion was successful in 37 patients. Compared with previous reports, this result must be considered satisfactory when the severity of the cases in this series is noted. Internal fixation in connection with posterior fusion is needed only exceptionally, but in complicated cases the Daab plate seems to afford a simple method of securing the position of the segments for the first postoperative months.

Adolescent↗
PubMed1979

Cardiac and respiratory function before and after spinal fusion in adolescent idiopathic scoliosis.

Ten girls with adolescent idiopathic scoliosis were studied before and 17-23 months after spinal fusion. None had any cardiac or respiratory disease complicating the scoliosis. They underwent a range of resting lung function tests and a progressive exercise test. The mean angle of scoliosis decreased from 65.8 to 27.3 degrees after operation but the only significant physiological benefit detected in this study was a decrease in the submaximal minute ventilation. The physiological benefit of spinal fusion was therefore much less prominent than the anatomical improvement of the spinal curvature.

Adolescent↗
PubMed1999

Can autologous bone culture predict spinal fusion capacity?

The capacity of the individual patient to initiate osteoblast proliferation as a predictor for successful lumbar spinal fusion has not yet been reported. The objectives of this study were, first, to analyze the relationship between in vitro osteoblast proliferation and clinical bony fusion in the individual patient in order to predict the fusion outcome and, second, to measure the effect of preoperative tobacco smoking on osteoblast proliferation. Sixty-one patients (mean age 46 years) underwent posterolateral lumbar fusion in the period 1994-1995. Thirty-eight patients received CD pedicle screw implants and 23 received posterolateral fusions alone. During surgery, autogenous iliac bone was harvested and 1 g of trabecular bone without blood or bone marrow was then isolated for cell culturing. The cultures were classified as excellent (confluence within 4 weeks), good (confluence between 4 and 6 weeks) and poor (no or poor growth). Spine fusion was evaluated by two independent observers from plain anterior-posterior, lateral, and flexion/extension radiographs taken 1 year postoperatively, and the functional outcome was measured by the Dallas Pain Questionnaire (DPQ). Twenty-three patients had excellent, 19 good, and 19 poor in vitro osteoblast proliferation. Bony fusion was obtained in 77% of patients: 83% in the CD instrumentation group and 70% in the non-instrumentation group (NS). There was no significant correlation between osteoblast proliferation and spinal fusion or functional outcomes when analyzing the CD instrumentation and non-instrumentation groups together or separately. Elderly patients had a significantly poorer osteoblast proliferation than younger patients (P < 0.008). Preoperative tobacco consumption had no discernible effect on osteoblast proliferation, and no correlation between smoking and fusion was found. Further refinement of autologous osteoblast culturing may provide a biological tool for selection of patients who require biological enhancement of their bone fusion capacity. The poorer osteoblast proliferation related to advanced age supports the important negative biological influence of age on bony fusion. However, with more sensitive testing and better discrimination, other results are possible - or can in any event not be excluded.

Adult↗
PubMed1994

The effect of electromagnetic pulsing on posterior lumbar spinal fusions in dogs.

This study evaluated the effect of pulsed electromagnetic fields (PEMF) on the healing of lumbar spinal fusions. Bilateral posterior facet fusions were performed at L1-2 and L4-5 in 24 adult mongrel dogs. After surgery, eight animals were stimulated with a pulse burst type signal (PEMF) for 30 minutes a day, and eight animals were stimulated with the same PEMF for 60 minutes a day. The remaining eight animals received no active PEMF stimulation and served as controls. Four animals from each group were euthanatized at 6 and 12 weeks, and the facet fusions were evaluated using high resolution radiographs and routine histology. No statistical difference in the radiographic or histologic appearance of the fusion mass could be detected between the stimulated and control groups at either 6 or 12 weeks. The results of this study suggest that PEMF stimulation had no effect on the healing of the primary posterior spinal fusions in this controlled experimental canine model.

Animals↗
PubMed2002

The effect of ultrasound on the healing of muscle-pediculated bone graft in spinal fusion.

STUDY DESIGN: A rabbit model of posterolateral intertransverse process spine arthrodesis with and without the application of low-intensity ultrasound was used. OBJECTIVE: To determine the effects of low-intensity ultrasound on the healing of muscle-pediculated bone graft. SUMMARY OF BACKGROUND DATA: Earlier animal and clinical studies demonstrated the efficacy of low-intensity ultrasound stimulation in the acceleration of osteogenesis and fracture healing. This is the first study in which the beneficial effects of ultrasound on the healing of muscle-pediculated bone graft in spinal fusion have been assessed. METHODS: In this study, 20 New Zealand rabbits were randomly assigned to two groups to undergo either spinal fusion using muscle-pedicle bone graft with ultrasound (ultrasound group) or muscle-pedicle bone graft without ultrasound (control group). Muscle-pediculated bone grafts were prepared from the posterosuperior iliac crest, erector spine muscle, and internal and external oblique muscle. This graft was placed bilaterally between the L5 and L6 transverse processes. Ultrasound was performed 20 minutes per day over the rabbits' lumbar spine. The rabbits were killed 6 weeks after surgery. The lumbar spines were evaluated radiologically, macroscopically, and histologically. RESULTS: By macroscopic and radiologic findings, fusion was detected in 11 control group rabbits (55%) of the control group, and in 17 ultrasound group rabbits (85%). The fusion success rate for the rabbits treated with low-intensity ultrasound were statistically higher (P <0,05) than that for the control group. Histologic specimens showed increased bone formation in the fusions exposed to ultrasound. Mature fusions were present in rabbits that received ultrasound. CONCLUSION: Low-intensity ultrasound in white rabbits increased the rate and quality of spinal fusion using muscle-pediculated bone grafts.

Animals↗
PubMed1998

The advantages of intrathecal opioids for spinal fusion in children.

Two groups of 40 homogeneous patients (ASA physical status (1-2)) with idiopathic scoliosis undergoing spinal fusion with CD instrumentation were studied prospectively. Group A (intrathecal) received a mixture of morphine and sufentanil administered intrathecally at the level of L3-L4 after the induction of anaesthesia. Group B (control) had inhalation and intravenous narcotic anaesthesia. The use of intrathecal opioids resulted in a significant reduction of blood pressure without the use of any hypotensive agents and produced prolonged postoperative analgesia. There was no adverse effect on somatosensory evoked potentials. The dose requirement for the anaesthetic agents was significantly reduced and the blood loss was 27% of their blood volume compared with 53% in the control group. No long or short term impairment of cerebral or spinal function was observed. The use of intrathecal opioids supplemented with other anaesthetic agents is an alternative method with multiple benefits for any major surgery such as spinal fusion.

Adolescent↗
PubMed1990

Factors influencing the result of posterior spinal fusion in the treatment of adolescent idiopathic scoliosis.

Sixty-six consecutive patients with adolescent idiopathic scoliosis treated by posterior spinal fusion using Harrington distraction compression instrumentation were followed for a minimum of 3 years. Initial surgical correction was satisfactory, but during the follow-up period, mean 4.4 years (3-5 years), there was a loss of correction. Several factors (age, sex, the number of vertebrae in the fusions, and the use of cross wires) were important influences on correction. A method of assessing the balance of a posterior spinal fusion is described that is useful when assessing radiographs.

Adolescent↗
PubMed1987

The effect on the lumbosacral spine of long spinal fusion for idiopathic scoliosis. A minimum 10-year follow-up.

The effect on the lumbosacral spine of long spinal fusion in adolescent idiopathic scoliosis was studied in 22 patients. The average duration of follow-up was 12.8 years. Corrections of the coronal curves through instrumentation were satisfactory. However, a kyphosis was produced at the fused segment of the lumbar spine in more than half of the cases. The unfused intervertebral spaces distally were hypermobile in extension, which probably indicated early disc degeneration. The incidences of back pain and radiological degeneration were found to be low. There was no relationship between back symptoms and type of employment, pregnancies or radiological degeneration. Preservation of normal lumbar lordosis during spinal fusions was emphasized.

Adolescent↗
PubMed1988

The treatment of scoliosis in cerebral palsy by posterior spinal fusion with Luque-rod segmental instrumentation.

Thirty-three patients who had cerebral palsy and scoliosis underwent posterior spinal fusion with Luque-rod segmental instrumentation. The mean curve measured 65 degrees preoperatively and 30 degrees postoperatively. The mean loss of correction was 3 degrees after a mean length of follow-up of forty months. As of the time of writing, pseudarthrosis had not developed in any patient. No patient had a broken rod or an increased neurological deficit. There were no major pulmonary complications. The most common early postoperative complication was wound infection, which occurred in five patients, none of whom required removal of the hardware. We concluded that posterior spinal fusion with Luque-rod segmental instrumentation is an effective method of obtaining and maintaining correction of a spinal curve, with minimum complications, in patients who have cerebral palsy and progressive scoliosis.

Adolescent↗
PubMed1999

Axial symptoms and cervical alignments after cervical anterior spinal fusion for patients with cervical myelopathy.

This retrospective clinical study was designed to examine the relation between cervical alignment and axial symptoms developing after cervical anterior spinal fusion. Sixty patients with myelopathy treated with cervical anterior spinal fusion were reviewed. For radiographic evaluation, lordosis, enlargement of the fused segments and neural foramen, radiographic union, and degeneration of adjacent segment were reviewed before or after surgery or both. Twenty-three patients had axial symptoms. Only local kyphosis and narrowing of the neural foramen at the fused segment were recognized more often in patients with axial symptoms than in those without such symptoms. No less than 2 mm and < or = 5 mm in enlargement of the anterior disc space immediately after surgery resulted in maintenance of cervical lordosis. These findings suggest that > or = 2 mm and < or = 5 mm in enlargement of anterior vertebral body height during operation results in prevention of axial symptoms.

Adult↗
PubMed2001

Interobserver and intraobserver agreement of radiograph interpretation with and without pedicle screw implants: the need for a detailed classification system in posterolateral spinal fusion.

STUDY DESIGN: A prospective randomized clinical study in which four observers evaluated radiographs of posterolateral fusion masses. OBJECTIVES: To evaluate the accuracy of radiograph interpretation of the posterolateral spinal fusion mass when using a detailed classification system and to analyze the influence of metallic internal fixation devices on radiologic inaccuracy. SUMMARY OF BACKGROUND DATA: In general, the literature describing the classification criteria used for radiograph interpretation of spinal posterolateral fusion has serious deficiencies. There is a need for a detailed classification system. METHODS: Seventy patients were randomly allocated to receive no instrumentation (n = 36) or Cotrel-Dubousset instrumentation (n = 34) in posterolateral lumbar fusion. All four observers participated in a prestudy discussion and evaluated the radiographs (anteroposterior, lateral) taken at the 1-year follow-up evaluation. The observers scored the radiographs twice (30 days apart). Each level on each side was judged separately. A continuous intertransverse bony bridge involving at minimum one of the two sides indicated a fusion at that level. "Fusion" indicated this quality of fusion at all intended levels. If the fusion was doubtful on both sides of the interspace, the individual case could not be classified as "fused." RESULTS: The mean interobserver agreement was 86% (Kappa 0.53), and the mean intraobserver agreement was 93% (Kappa 0.78). No difference in interobserver and intraobserver agreement was found between patients with and without supplementary pedicle screw fixation. All mean Kappa values were classified as fair or good. The four observers identified a mean fusion rate of 81%. CONCLUSION: It is extremely difficult to interpret radiographic lumbar posterolateral fusion success. Such an assessment needs to be performed by use of a detailed radiographic classification system. The classification system presented here revealed good interobserver and intraobserver agreement, both with and without instrumentation. The classification showed acceptable reliability and may be one way to improve interstudy and intrastudy correlation of radiologic outcomes after posterolateral spinal fusion. Instrumentation did not influence reproducibility but may result in slightly underestimated fusion rates.

Adult↗