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PubMed1996

Efficacy of implanted bone growth stimulation in instrumented lumbosacral spinal fusion.

STUDY DESIGN: Ninety-four patients were assigned to groups either with or without implanted bone growth stimulation as an adjunct to instrumented animal fusion between May 1990 and December 1992. Consecutive groups with or without stimulation were compared prospectively; a small group was compared with random assignment of surgery with or without stimulation. OBJECTIVE: To test the efficacy of implanted bone growth stimulation in instrumented fusion, especially regarding high-rist patient groups including smokers, those with previous back surgery, and those with multiple fusion levels. SUMMARY OF BACKGROUND DATA: No reports have specifically addressed implanted bone growth stimulation with instrumented spinal fusion, although the effects of stimulation on long-bone and in situ spinal fusion have been reported. METHODS: Fusion surgery was performed by the same two surgeons for all patients, using autologous graft and instrumentation (pedicle screw and rod). Surgical indications and pre- and postoperative regimens were similar for all patients. Average follow-up period was 20.5 months. RESULTS: Ninety-six percent of patients with stimulation had solid fusion versus 85% fusion in patients who did not have stimulation. CONCLUSIONS: Implanted bone growth stimulation can improve fusion results in patients with instrumented lumbosacral fusion as has been demonstrated in in situ fusions. Patients in high-risk categories (smokers, those with multiple back surgeries, and multilevel fusions) also are demonstrated to have higher fusion rates with implanted bone growth stimulation than those without benefit of stimulation.

Adult↗
PubMed2001

Intravenous administration of propacetamol reduces morphine consumption after spinal fusion surgery.

We sought to determine the analgesic efficacy, opioid-sparing effects, and tolerability of propacetamol, an injectable prodrug of acetaminophen, in combination with morphine administered by patient-controlled analgesia (PCA) after spinal fusion surgery. Forty-two patients undergoing spinal stabilization surgery were randomized into two groups, which were given either an IV placebo or an IV injection of 2 g propacetamol every 6 h for 3 days after surgery. The postoperative opioid analgesic requirement was assessed with a PCA device used to self-administer morphine. Pain relief was evaluated by a visual analog pain scale and by verbal rating scores of pain relief at 8-h intervals for up to 72 h after surgery. The cumulative dose of morphine at 72 h was smaller in the Propacetamol group than in the Placebo group (60.3 +/- 20.5 vs 112.2 +/- 39.1 mg; P < 0.001). The pain scores were significantly lower in the Propacetamol group measured at two intervals of the study, although visual analog scale pain intensity scores were smaller than 3 in both groups. Most patients in the Placebo group obtained a greater degree of sedation on postoperative Day 3 (P < 0.05). This study demonstrates the usefulness of propacetamol as an adjunct to PCA morphine in the treatment of postoperative pain after spinal fusion.

Acetaminophen↗
PubMedDate not supplied

Diastematomyelia presenting as progressive weakness in an adult after spinal fusion for adolescent idiopathic scoliosis.

BACKGROUND CONTEXT: Diastematomyelia is uncommon and rarely presents in adulthood. This report draws attention to the fact that patients who underwent spinal fusion for deformity before the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) may have unrecognized spinal cord abnormalities. This should be considered if revision surgery is contemplated. PURPOSE: This case report focuses on the late presentation of lower-extremity weakness in a 44-year-old woman with a split cord malformation (diplomyelia), diastematomyelia and tethered cord syndrome. STUDY DESIGN/SETTING METHODS: The patient underwent instrumented posterior spinal fusion with a Harrington rod as a child for progressive thoracolumbar scoliosis. As an adult, she developed paraparesis after a traumatic event. The patient underwent decompressive laminectomy, subtotal resection of the old fusion mass and resection of the osseous septum. Postoperatively, an anterior spinal fluid leak in the lower thoracic region required repeated fascial grafting, resection of a pseudomeningocele and reverse left latissimus dorsi flap transfer. The leak was controlled, and the patient had near complete resolution of her paraparesis 1 year after her surgery. RESULTS: The case described herein is unusual in that patients with diplomyelia and diastematomyelia rarely are symptomatic in adulthood. However, trauma may precipitate the onset of neurologic symptoms. This patient underwent spinal surgeries to address deformity, pain and progressive lower-extremity weakness. Preoperative CT and MRI studies showed a split cord malformation and diastematomyelia at L1-L2 with spinal stenosis and tethering of both hemicords. CONCLUSIONS: Progressive weakness without any previous neurologic deficit or neurocutaneous stigmas of an underlying spinal cord abnormality may develop in the adult with unrecognized diastemotomyelia. This case demonstrates that a thorough preoperative workup of patients with complex spinal deformities is imperative.

Adult↗
PubMed1997

Verification of the position of pedicle screws in lumbar spinal fusion.

Medial or lateral pedicle screw penetration with the potential to affect neural structures in a wellknown and frequent problem associated with posterior spinal fusion. We evaluated the placement of pedicle screws (n = 141) in 36 patients following posterior lumbar spinal fusion with Socon or Kluger instrumentation via a lateral transpedicular approach. The examination was based on CT and MR images performed after removal of the instrumentation, on average 1 year after implantation. We found seven pedicle screws with lateral cortical penetration of the pedicle and five screws with medial cortical penetration of the pedicle (8.5% pedicle penetration overall). No severe radicular complications accompanied these pedicle penetrations. The mean insertion angles of the pedicle screws at the L4 level were 22.6 degrees and 23.1 degrees for the left and the right side, respectively. At the L5 level the mean insertion angle was 20.5 degrees on the left side and 21.5 degrees on the right, and at the S1 level the mean angle was 16.2 degrees on the left and 15.2 degrees on the right. The results of this study indicate that the lateral transpedicular approach is a safe procedure for pedicle screw insertion.

Adult↗
PubMed1995

[Idiopathic scoliosis by spinal fusion and brace treatment: evaluation by gait analysis].

UNLABELLED: We have investigated the differences in gait between 68 idiopathic scoliosis patients and 186 normal subjects, and differences in gait before and after treatment of the scoliosis by two different methods. The idiopathic scoliosis patients were divided into two groups according to which treatment they had received; one group of 17 cases had been treated by spinal fusion and the other group of 51 cases had been treated by bracing. Gait analysis was performed using a 1.2 m wide and 10.8 m long force plate walkway. Three components of each step (the lateral, horizontal and vertical components) were measured. Gait velocity, step length, step width and cadence were evaluated as temporal and distance factors, and symmetry, reappearance, smoothness, sway, rhythm and impact were evaluated as gait factors. RESULTS: Before treatment, there was no difference in any temporal or distance factor between the scoliosis patients and the normal subjects. However, the index of symmetry, and of sway, in the vertical component prior to treatment in the scoliosis patients was significantly inferior to that in the normal subjects. A positive correlation was found between the index of sway in the vertical component and the pretreatment Cobb angle. This correlation was found in the right-convex single curve group and in the double curve group, but not in the left-convex single curve group. After spinal fusion, the step width became wider and the index of sway significantly improved, but index of symmetry was unchanged. No gait factor became worse postoperatively. In contrast, in the bracing group, the step width became wider, but the index of symmetry, and of sway in the vertical component, did not improve with the brace. The gait of scoliosis patients could be objectively and quantitatively analyzed by the force plate. The gait analysis was useful for evaluating the effects of spinal fusion, and of brace treatment, in idiopathic scoliosis patients.

Adolescent↗
PubMed1987

Painful pseudarthrosis following lumbar spinal fusion: detection by combined SPECT and planar bone scintigraphy.

Twenty-six adult patients more than 6-months post-lumbar spinal fusion were studied. Flexion and extension radiographs showing motion or bone scintigrams showing focal areas of increased activity within the fusion mass were considered positive for pseudarthrosis. Patients were classified as either symptomatic or asymptomatic. Among the 15 symptomatic patients, scintigraphy had a sensitivity of 0.78 and a specificity of 0.83 which was superior to the 0.43 sensitivity and 0.50 specificity of radiography. Six of the 11 asymptomatic patients had focal areas of increased activity in the bony fusion mass, possibly reflecting painless pseudarthrosis. Planar imaging was substantially enhanced by SPECT in 14 of the 26 cases. It is concluded that for the patient who remains symptomatic after lumbar spinal fusion, bone scintigraphy with SPECT is of significant value in detecting painful pseudarthrosis.

Adult↗
PubMed1976

Kinematic analysis of posterior spinal fusions in pigs.

Five pigs operated upon by posterior spinal fusion were examined by a roentgen stereophotogrammetric method during provoked motion. The healing process leading to marked rigidity within the spine was followed in two of the pigs. Varying degrees of stability in the fused area were achieved in the five animals. Movements were detected, not only when the fusions were not healed, but also in two cases of incomplete bony union between two operated segments.

Animals↗
PubMed1998

Video-assisted thoracoscopic surgery versus open thoracotomy for anterior thoracic spinal fusion. A comparative radiographic, biomechanical, and histologic analysis in a sheep model.

STUDY DESIGN: In this in vivo investigation, a sheep model was used to compare the efficacy of a video-assisted thoracoscopic approach and a traditional thoracotomy in promoting a successful interbody spinal arthrodesis. OBJECTIVES: To compare the incidence of successful anterior spinal arthrodesis among three stabilization techniques-iliac crest, Bagby and Kuslich device, and Z-plate--performed using a video-assisted thoracoscopic approach and conventional open thoracotomy approaches. SUMMARY OF BACKGROUND DATA: A clinical outcome study on open versus endoscopic spinal fusion is not yet available. Moreover, no basic scientific investigations have been conducted to determine whether the success of an endoscopic arthrodesis is comparable to that of a conventional open procedure. METHODS: Fourteen Western Crossbred sheep underwent three identical destabilization procedures at T5-T6, T7-T8, and T9-T10, in which the anterior and middle osteoligamentous columns of the spine were resected, followed by three randomized reconstruction procedures using iliac autograft alone, and Z-plate stabilization with iliac autograft. In seven sheep, the entire destabilization-reconstruction procedure was performed using a video-assisted thoracoscopic surgical approach. In the remaining seven, the procedure was performed by conventional open thoracotomy. RESULTS: Histomorphometric and biomechanical evaluation demonstrated that the video-assisted thoracoscopic approach and open thoracotomy arthrodesis had comparable bone formation and biomechanical properties (P > 0.05). However, the Z-plate fusions, as a group, demonstrated increased flexion-extension stiffness properties and trabecular bone formation compared with the autograft and Bagby and Kuslich device fusions (P < 0.05). CONCLUSIONS: Thoracic interbody spinal fusions performed by thoracoscopy have demonstrated histologic, biomechanical, and radiographic equivalence to those performed by a thoracotomy approach. However, in the endoscopy group, intraoperative complications causing longer operative times, higher estimated blood loss, and increased animal morbidity indicated a substantial learning curve associated with the adoption of this surgical technique.

Analysis of Variance↗
PubMedDate not supplied

Curve progression in Risser stage 0 or 1 patients after posterior spinal fusion for idiopathic scoliosis.

A retrospective review was performed to determine "crankshaft" prevalence in 86 immature patients who underwent posterior spinal fusion for idiopathic scoliosis. Tanner stage, chronologic age, bone age, and epiphyseal status were used as maturity indicators. Overall, 62 (72%) patients progressed < or = 10 degrees, 18 (21%) patients progressed 11-15 degrees, and six (7%) patients progressed > or = 16 degrees in the coronal plane. Tanner I patients with open triradiate cartilage had the highest rate of crankshaft occurrence; nine (75%) of 12 patients progressed >10 degrees (p < 0.05). Fifty-two percent of Tanner I, 26% of Tanner II, 11% of Tanner III, and no Tanner IV patients progressed >10 degrees (p < 0.05). Cobb angle increases of >10 degrees degrees occurred in 54% of patients with open triradiate cartilage (p < 0.05) and in 48% of patients with open capital femoral epiphyses (p < 0.05). Anterior and posterior spinal fusion should be considered in prepubertal (Tanner I) patients with open triradiate cartilage.

Adolescent↗
PubMed1993

Evaluation of bone-grafting materials in a new canine segmental spinal fusion model.

This paper describes a new canine segmental spinal fusion model for the comparison of bone-grafting materials. The test sites in the model are three separate posterior interfacet-interlaminar fusion sites in the lumbar spine (L1-2, L3-4, and L5-6). The outcome was assessed by scoring of the fusion sites for union and by mechanical testing of fused segments. The results from two experiments are presented. Autogenous cancellous bone was the most effective material tested and had a statistically superior score for union compared with all other materials (p = 0.01). The results with an osteoconductive matrix of collagen and ceramic alone were no better than those with the controls (no graft). However, addition of an extract of matrix-derived proteins (15-30 kDa) to the collagen-ceramic carrier appeared to improve the score for union. The inclusion of nonresorbed ceramic granules had no evident effect on the mechanical properties of fusions, with a comparable score for union. This model appears to be a sensitive and efficient method for the comparison of graft materials. Advantages over previously described models are discussed.

Animals↗
PubMed2000

[Effects on the adjacent segment after spinal fusion and instrumentation].

This paper reviewed the literatures about the pathology at the segments adjacent to the fusion segments. The hypertrophic degenerative arthritis of the facet joints and spinal stenosis were the most common pathologic conditions. The pathology usually occurred at the upper segment in the patients of spinal fusion; and the lower segment would also show degeneration in those of instrumentation. The reason lied mainly in the increased stress at the adjacent segment after surgery and the change of segmental motion pattern. Symptoms usually developed within the first 5 years after fusion. Diagnosis depends on the clinical manifest and X-ray examination. Surgical intervention should be indicated if the conservative therapy failed, and decompression and fusion were most commonly applied.

Humans↗
PubMed2006

Transient loss of motor-evoked responses associated with caudal injection of morphine in a patient with spondylolisthesis undergoing spinal fusion.

A 7-year-old girl having posterior spinal fusion for Grade 3 anterior spondylolisthesis at the L5/S1 level was administered 2.5 mg of morphine in 10 ml saline via the caudal epidural route before surgery. Motor-evoked responses were markedly diminished in her lower limbs for 1 h following this but returned spontaneously. She suffered no neurological injury. The cause for this is postulated to be transient cauda equina compression from the volume of injectate. This complication of caudal injection has not been reported before. The possible mechanisms for this are discussed. We believe that significant L5/S1 spondylolisthesis should be considered a contraindication to the use of caudal epidural injections.

Analgesics, Opioid↗
PubMed1996

Patient-controlled analgesia after spinal fusion for idiopathic scoliosis.

One hundred adolescents undergoing posterior spinal fusion for scoliosis were reviewed to assess the adequacy of postoperative patient-controlled analgesia. There were 94 females and 6 males. The mean settings for morphine dosage were a loading dose of 114.5 micrograms.kg-1, a bolus dose of 24.8 micrograms.kg-1, and a lockout interval of 9.9 minutes. This was used for an average of 75.8 h, with a 52.2% success rate. Adolescents using patient-controlled analgesia showed a great variability in morphine requirements with greater use as they became older. The requirement was not significantly different on the 1st, 2nd and 3rd postoperative days and the total consumption was 52.2 micrograms.kg-1.h-1. Nausea and vomiting occurred in 45% and pruritus in 15%. There were 7 cases of respiratory depression who all recovered promptly and completely. This method is associated with high morphine requirements in adolescents, but can be used safely.

Adolescent↗
PubMed2002

[Comparison of autograft, coralline graft, and xenograft in promoting posterior spinal fusion].

OBJECTIVES: Bone grafting constitutes a vital component in many reconstructive orthopaedic surgical procedures. They are widely used in patients undergoing thoracolumbar spinal surgery. The three choices of bone are autograft, coralline graft, and xenograft. The purpose of this study was to evaluate the contribution of autograft, coralline graft, and xenograft to spinal fusion. METHODS: Thirty-six New Zealand albino rabbits were divided into four groups of equal size. Decortication of posterior structures of the thoracal 10-12th vertebrae was performed in all rabbits. No graft material was used in group I (controls). The remaining three groups received autologous iliac crest bone graft, coralline graft, and xenograft dehydrated by solvents, respectively. The rabbits were sacrificed eight weeks postoperatively for manual, radiologic, histologic, and biomechanical evaluations. RESULTS: Manual and radiologic evaluations showed no fusion in the control group in which the lowest histologic and biomechanical scores were obtained. Manually and radiologically, fusion was found in 85.7% and in 78.5% with autologous iliac crest bone graft; in 61.1% and 61.1% with coralline graft, and in 55.5% and 50.0% with xenograft, respectively. CONCLUSION: Our data substantiates the use of coralline graft and xenograft as appropriate and efficient materials alternative to autografts in obtaining posterior spinal fusion.

Animals↗
PubMed2002

Ex vivo bone morphogenetic protein-9 gene therapy using human mesenchymal stem cells induces spinal fusion in rodents.

OBJECTIVE: Ex vivo gene therapy with the use of human mesenchymal stem cells (hMSCs) and bone morphogenetic protein (BMP) genes provides a local supply of precursor cells and a supraphysiological dose of osteoinductive molecules that may promote bone formation in patients with inadequate hMSC populations because of age, osteoporosis, metastatic bone disease, iatrogenic depletion, or other metabolic derangements. This study was undertaken to evaluate the efficacy of ex vivo gene therapy with the use of hMSCs and the BMP-9 gene to promote spinal fusion in the rat. METHODS: Sixteen athymic nude rats were treated with hMSCs transduced with recombinant, replication-defective Type 5 adenovirus containing the cytomegalovirus promoter and either the BMP-9 (Ad-BMP-9) or the beta-galactosidase (Ad-beta-gal) gene. Ad-beta-gal served as the control. Each animal received a percutaneous, paraspinal injection of 10(6) hMSCs transduced with 50 plaque-forming units/cell adenovirus in the lumbar region, with Ad-BMP-9 on the left and Ad-beta-gal on the right. At 8 weeks postinjection, computed tomographic scans of the lumbosacral spine were obtained, and the lumbosacral spine specimens were examined histologically. RESULTS: Both computed tomographic studies and histological analysis clearly demonstrated large volumes of ectopic bone at the Ad-BMP-9-transduced hMSC injection sites, resulting in successful spinal fusion and no evidence of nerve root compression or local or systemic toxicity. The contralateral regions that were treated with Ad-beta-gal-transduced hMSCs showed no evidence of osteogenesis. CONCLUSION: The results of this study suggest that hMSC and BMP-9 ex vivo gene therapy may be useful in inducing spinal fusion as well as other related procedures and certainly warrants further clinical development.

Animals↗
PubMed1998

Complications of spinal fusion in adult patients more than 60 years of age.

This article describes the overall rate, characteristics, and predictive factors for major and minor complications in spinal fusion patients over 60 years of age (or greater) cared for in the authors' institution. Special emphasis is placed on establishing the most valid incidence of complications after spinal fusion by extracting the information directly from the pateint's permanent medical or clinical database record. Once the spinal surgery risk profile for the elderly patient is established, treatment interventions to modify these risks can be implemented and evaluated prospectively and longitudinally to maximize spinal surgery outcomes.

Aged↗
PubMed2006

Delayed hypopharyngeal and esophageal perforation after anterior spinal fusion: primary repair reinforced by pedicled pectoralis major flap.

STUDY DESIGN: This report documents a case of delayed hypopharyngeal and esophageal perforation after anterior spinal fusion and reviews relevant literature. OBJECTIVES: Presentation of an alternative solution of primary repair and reinforcement of a delayed esophageal and hypopharyngeal perforation after anterior spinal fusion. SUMMARY OF BACKGROUND DATA: Anterior plating is generally used for stabilization after cervical spine trauma. Esophageal and hypopharyngeal perforation is a rare but potentially life-threatening complication due to mediastinitis with consecutive septic shock and multiorgan failure. METHODS: Our patient was operated on after cervical trauma caused by car accident. The neurologic condition did not improve in the postoperative period. About 4 months later, the patient had increasing dysphagia as well as episodes of odynophagia. Flexible esophagoscopy showed a perforation of a part of the plate from the hypopharynx down to the proximal esophagus. Primary repair reinforced by a pedicled pectoralis major flap was done without complications. RESULTS: Postoperative fluoroscopy as well as endoscopy showed no signs of perforation. Swallowing was possible without any further episodes of dysphagia or odynophagia. Neck movement was unconfined. CONCLUSIONS: Primary repair reinforced by pedicled pectoralis major flap has been shown to be an alternative in case of combined hypopharyngeal and esophageal perforation due to orthopedic spine stabilization. Advantage of the pectoralis major muscle flap is no functional loss of neck movement.

Accidents, Traffic↗
PubMed1996

The effect of intraoperative blood loss on serum cefazolin level in patients undergoing instrumented spinal fusion. A prospective, controlled study.

STUDY DESIGN: This study is a prospective, controlled study of the effect of intraoperative and postoperative blood loss during spinal surgery on serum cefazolin level. OBJECTIVES: To determine what effect, if any, intraoperative blood loss has on serum antibiotic levels, and to determine if adjustment of the dose or dose interval is appropriate in operative cases of significant blood loss. SUMMARY OF BACKGROUND DATA: The problem of infection at the operative site after posterior spinal fusion with internal fixation is significant. It commonly has been accepted that blood loss results in a more rapid clearance of antibiotic. METHODS: Nineteen patients scheduled for elective spinal fusion with internal fixation were enrolled in this study. Each patient served as his or her own control. Baseline cefazolin clearance was determined the week before surgery. Cefazolin clearance again was determined intraoperatively. Blood loss was recorded throughout the procedure. RESULTS: The mean blood loss was 650 mL. There was no significant difference between preoperative and intraoperative cefazolin clearance, and there was no correlation between blood loss and cefazolin level. CONCLUSIONS: It is not necessary to give cefazolin at a dosing interval of less than 4 hours with blood losses of up to 1200 mL. This will maintain the antibiotic concentrations well above the minimum inhibitory concentration.

Adolescent↗