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PubMed1994

Comparison of same-day sequential anterior and posterior spinal fusion with delayed two-stage anterior and posterior spinal fusion.

STUDY DESIGN: This was a retrospective review. Short-term outcomes were compared based on two different surgical techniques. OBJECTIVES: To determine the safety, efficacy, and cost effectiveness of two different surgical techniques of anterior and posterior spinal fusion for pediatric patients with spinal deformity. SUMMARY OF BACKGROUND DATA: Brown et al, Floman et al, and Bradford et al have reported on combined anterior and posterior spine fusions with a 1-2-week recovery period between stages. However, advances in surgical and anesthetic techniques combined with the prohibitive cost of prolonged hospitalization and theoretical advantages in pulmonary function and nutrition have led to increasing use of combined anterior and posterior spinal fusion under one anesthetic. METHODS: The authors reviewed records and radiographs of patients with pediatric spinal deformities who underwent anterior spine fusion/posterior spine fusion and instrumentation performed by the senior author (HAK) at one institution. RESULTS: Same-day sequential anterior spine fusion/posterior spine fusion resulted in less blood loss (575 +/- 275 ml; P < or = 0.0045), shorter hospital stay (8.00 +/- 2.68 days; P < or = 0.0001), and reduced hospital costs ($18,762 +/- $4,925; P < or = 0.0001). Operative time and complication rate were not affected. CONCLUSIONS: In selected patients with pediatric spinal deformity, experienced spinal surgeons can reduce blood loss, hospital stay, and costs by performing anterior and posterior spinal fusions sequentially under one anesthetic.

Adolescent↗
PubMed1997

The role of spinal fusion in surgery for lumbar spinal stenosis: a review.

The authors undertook a review of the literature and analysis of the local surgical experience for lumbar stenosis to define the role of simultaneous arthrodesis in the treatment of patients undergoing decompression for spinal stenosis. The restrained use of spinal fusion is recommended in spinal stenosis surgery because of the coexisting medical problems in the elderly patient population and the higher associated complication rate with spinal fusion and instrumentation. A spinal fusion is recommended when decompression is performed in an area of segmental instability as manifested by gross movement on flexion--extension radiographs; when the decompression coincides with an area of degenerative instability, as with scoliosis or spondylolisthesis; or when the decompression creates an iatrogenic instability by the disruption of the posterior elements. The use of spine instrumentation as an adjunct to fusion is recommended when an area of degenerative instability shows evident gross instability or has had additional destabilizing procedures, such as a discectomy or a facetectomy. Spinal fusion is not recommended for a routine decompressive laminectomy for lumbar stenosis or in the case of stable degenerative deformities. New fusion techniques may improve the outcome and decrease the morbidity associated with contemporary methods of spinal fusion and instrumentation.

Journal Article↗
PubMed1996

When is spinal fusion warranted in degenerative lumbar spinal stenosis?

This study, conducted by a group of neurosurgeons who devote a large portion of their professional time to the treatment of degenerative lumbar spine lesions, was prompted by the dramatic increase in the number of lumbar spinal fusion procedures performed over the last few years in a broad spectrum of disorders ranging from chronic incapacitating low back pain to lumbar spinal stenosis. In the authors' experience, lumbar spinal fusion is rarely warranted and often of dubious efficacy. To investigate this contradiction, the authors reviewed the medical literature on lumbar spinal fusion for the treatment of degenerative spinal stenosis. They have defined lumbar instability as objectively as possible, reviewed clinical and roentgenographic features, described spinal fusion techniques with the drawbacks of each, and evaluated outcomes of surgery for degenerative lumbar spinal stenosis with or without fusion. Findings demonstrate that spinal fusion is a technique of unproven benefit that should be used only in carefully selected patients until results of reliable, prospective, comparative clinical trials become available. In the authors' opinion lumbar spinal fusion should be used as the first-line treatment only in young patients with clinical manifestations directly related to lumbar instability as defined in this study, when decompression requires removal of both facet joints and of the disk (which is rarely the case) or when simple decompression is followed by a recurrence of symptoms ascribable to worsening vertebral slippage.

Adult↗
PubMed1997

Tri-calcium phosphate ceramics and allografts as bone substitutes for spinal fusion in idiopathic scoliosis as bone substitutes for spinal fusion in idiopathic scoliosis: comparative clinical results at four years.

The authors present the results of a comparative study of two series of posterolateral arthrodeses for scoliosis performed using COTREL DUBOUSSET instrumentation. Fifty-four consecutive patients underwent surgery for idiopathic scoliosis using the same technique. Thirty received a graft consisting of a mixture of corticocancellous autologous and allogenic bone frozen at -80 degrees, and 24 patients were grafted with a mixture of cortico-cancellous autologous bone and sticks of tricalcium phosphate (TCP, Biosorb, SBM, Lourdes, France). All patients were seen at three, six and twelve months, then once a year for at least four years with clinical and radiological evaluation at each visit. At the final follow up visit, no radiologic signs of pseudoarthrosis were found in either group with a minimum follow-up of 4 years. The appearance of bone callus was considered satisfactory at 6 months in all cases; moreover callus seemed to be more important in the TCP series, although this assessment was subjective. TCP resorption was total after 2 years, while allograft fragments were visible on x-rays after 2 years. Minor mechanical complications occurred but did not influence the results. Loss of correction was 8% of that initially obtained in the allograft group and 2% in the TCP group. Loss of correction did not progress after 6 months in the TCP group and after 2 years in the allograft group. Based upon this experience, the use of synthetic bone substitutes such as TCP would appear to be a valuable alternative to allografts in posterolateral spinal arthrodesis for idiopathic scoliosis, and it would eliminate the risk of viral contamination inherent to allograft implantation. To our knowledge, there have been no previous comparative studies concerning the use of tricalcium phosphate versus allograft in the literature.

Adolescent↗
PubMed1997

Freeze-dried allograft for posterior spinal fusion in patients with neuromuscular spinal deformities.

STUDY DESIGN: The effectiveness and safety of freeze-dried allograft for posterior spinal fusion in patients with neuromuscular disorders were evaluated retrospectively. SUMMARY OF BACKGROUND DATA: Because the harvest of an adequate quantity of autogenous bone graft from patients with neuromuscular deformity who have instrumentation and fusion to the pelvis is difficult at best, an alternative graft source usually is needed. Allograft bone, most commonly processed fresh-frozen or freeze-dried, has been used frequently for posterior spinal fusion in patients with neuromuscular deformity. However, a relatively high risk of infection and pseudarthrosis has been reported for this procedure. METHODS: Forty patients with neuromuscular deformity with an average age at the time of surgery of 14 years and 2 months (range, 5 years, 4 months to 23 years, 8 months) met the inclusion criteria. All of these patients underwent more than 2 years of follow-up evaluation. They were evaluated for rates of infection, pseudarthrosis, and transmissible disease. RESULTS: Thirty-eight patients had solid fusion at the most recent follow-up visit. Definite pseudarthrosis was detected in one patient (2.5% of the study group), which was treated successfully. Another patient's (2.5%) spinal curve progression of more that 10 degrees and rod breakage led the authors to diagnoses a probable pseudarthrosis. She had a stable spine that did not require revision at 68 months after surgery. For the 32 patients who underwent posterior surgery only, the pseudarthrosis rate was 3.1%. There were no acute deep wound infections. Superficial infection occurred in two patients (5%) and delayed deep sterile drainage in one patient (2.5%). All cases of infection resolved with appropriate management. Delayed deep wound infection developed in one patient (2.5%) as a result of staphylococcus coagulase negative at 34 months after surgery. Successful treatment has consisted of implant removal, debridement, and appropriate antibiotics. Transmissible disease attributable to allograft has not been detected to date. CONCLUSION: Freeze-dried allograft fusion is a reliable and effective method for posterior spinal fusion in the patients with neuromuscular deformity.

Adolescent↗
PubMed1998

Complications in spinal fusion.

Complications in spinal fusion can lead to less than desirable results. The complications of spinal fusion in the cervical and lumbar spine are discussed. Methods of avoiding and correcting complications also are reviewed. Through a better understanding, it is hoped that complications can be prevented.

Bone Plates↗
PubMed1999

Use of autologous growth factors in lumbar spinal fusion.

The results of spinal fusion, especially posteriorly above the lumbosacral junction, have been mixed. Autologous growth factor concentrate (AGF) prepared by ultraconcentration of platelets contains multiple growth factors having a chemotactic and mitogenic effect on mesenchymal stem cells and osteoblasts and may play a role in initiating bone healing. The purpose of this retrospective study is to review our results with AGF in lumbar spinal fusions. To date, AGF has been used in 39 patients having lumbar spinal fusion. The study group consisted of the first 19 consecutive cases to allow at least 6 months follow-up. The average follow-up was 13 months (range 6 to 18 months). Follow-up compliance was 91%. There were 7 men and 12 women. Average age was 52 years (range 30-72 years). Nine patients had prior back surgery. There were 8 smokers. AGF was used in posterior (n = 15) or anterior intradiscal (n = 4) fusions. AGF was used with autograft and coraline hydroxyapatite in all posterior fusions, and autograft, coral, and intradiscal spacer (carbon fiber spinal fusion cages or Synthes femoral ring) in intradiscal fusions. Posterior stabilization was used in all cases. Eight cases were single-level fusions, 6 were two-level, and 1 was a three-level fusion. Autologous iliac crest bone graft was taken in 14 cases and local autograft used in 5 cases. Posteriorly, a total of 23 levels were fused; of these, nine were at L5-S1, eight at L4-L5, five at L3-L4, and one at L2-L3. No impending pseudoarthroses were noted on plain radiographic examination at last follow-up visit. Solid fusion was confirmed in 3 patients having routine hardware removal, and in 2 patients who had surgery at an adjacent level. There was one posterior wound infection, which was managed without sequelae. When used as an adjunct to autograft, AGF offers theoretical advantages that need to be examined in controlled studies. Further study is necessary to determine whether coralline hydroxyapatite used as a bone graft extender in lumbar spinal fusion may help to obviate the need for secondary site graft harvesting.

Adult↗
PubMed1994

In vivo evaluation of recombinant human osteogenic protein (rhOP-1) implants as a bone graft substitute for spinal fusions.

STUDY DESIGN: Posterior spinal fusion segments were evaluated in adult mongrel dogs at 6, 12, and 26 weeks post-implantation. Four sites on each animal received implants consisting of recombinant human osteogenic protein-1 on a bone collagen carrier, bone collagen carrier alone, autogenous iliac crest bone, or no implant material. OBJECTIVE: To determine the efficacy of recombinant human osteogenic protein-1 as a bone graft substitute in achieving posterior spinal fusion and compare the results to those obtained using autogenous bone graft. SUMMARY OF BACKGROUND DATA: Posterior spinal fusion generally includes onlay grafting of autogenous or allogeneic bone after decortication of bony surfaces of the vertebral elements. The search for an acceptable bone graft substitute material has in recent years centered upon proteins capable of inducing bone in vivo. Recombinant human osteogenic protein-1 has demonstrated efficacy in healing large segmental osteoperiosteal defects in rabbits, dogs, and monkeys and appears ideally suited as a bone graft substitute for spinal fusions. METHODS: The quality of fusion and new bone formation was evaluated using plain films, computed tomography, and magnetic resonance imaging. RESULTS: Radiographic and histologic studies demonstrated that recombinant human osteogenic protein-1-treated fusion segments attained a stable fusion by 6 weeks post-implantation and were completely fused by 12 weeks. The autograft sites demonstrated fusion at 26 weeks post-implantation. CONCLUSIONS: The results indicated that recombinant human osteogenic protein-1 is an effective bone graft substitute for achieving stable posterior spinal fusions in a significantly more rapid fashion than can be achieved with autogenous bone graft.

Animals↗
PubMed1995

In vivo evaluation of demineralized bone matrix as a bone graft substitute for posterior spinal fusion.

STUDY DESIGN: Posterior lumbar spinal fusion segments were evaluated in 9 adult mongrel dogs 6, 12, and 26 weeks after implantation. Four sites on each animal received implants consisting of demineralized bone matrix alone, demineralized bone matrix with allograft bone, allograft bone alone, and autograft bone. Each unilateral fusion spanned one motion segment with one intervening vertebral level left undisturbed using T13-L7. The fusions were evaluated radiographically, mechanically, and histologically. OBJECTIVE: The purpose of this study was to determine the efficacy of demineralized bone matrix as a bone graft substitute for stable posterior spinal fusion. SUMMARY OF BACKGROUND DATA: Posterior spinal fusion is a procedure commonly performed for spinal stabilization. Increasing the incidence and speed of stable spinal fusion is a primary goal in spinal surgery. Concerns have developed regarding the graft material used to induce bone healing at the fusion site. The advent of osteoinductive materials, such as demineralized bone matrix, may eliminate the need to harvest autograft bone and may circumvent the immunologic response and lower osteogenic potential associated with allograft bone. METHODS: The quality of fusion and new bone formation was evaluated radiographically using plain films, computed tomography, and magnetic resonance imaging. After the dogs were killed, each fusion segment was evaluated mechanically in torsion to determine stiffness and histologically to determine qualitative parameters of new bone formation and remodeling. RESULTS: Radiographic studies showed that autograft bone sites achieved stable fusion by 26 weeks after surgery. Conversely, the demineralized bone matrix alone and with allograft bone demonstrated some new bone formation at 6 and 12 weeks, but did not achieve fusion by 26 weeks. The fusion sites of allograft bone alone showed minimal new bone formation at all time periods. Mechanically, the autograft fusion sites demonstrated torsional stability that was significantly greater than that of all other fusion sites at all time periods. The remaining fusion sites showed equivalent torsional stiffness at all time periods. Histologic analysis confirmed the radiographic and mechanical findings. CONCLUSIONS: The results indicate that demineralized bone matrix alone or with allograft bone is ineffective in achieving stable posterior spinal fusions.

Animals↗
PubMed1997

1997 Volvo Award winner in clinical studies. The effect of pedicle screw instrumentation on functional outcome and fusion rates in posterolateral lumbar spinal fusion: a prospective, randomized clinical study.

STUDY DESIGN: A prospective randomized clinical study. OBJECTIVES: To evaluate supplementary pedicle screw fixation (Cotrel-Dubousset) in posterolateral lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: The rationale behind lumbar fusion is to eliminate pathologic motion to relieve pain. To improve fusion rates and to allow reduction, a rigid transpedicular screw fixation may be beneficial, but the positive effect of this may be counter-balanced by an increase in complications. METHODS: The inclusion criteria were severe, chronic low back pain from spondylolisthesis Grades 1 and 2 or from primary or secondary degenerative segmental instability. One hundred thirty patients were randomly allocated to receive no instrumentation (n = 66) or Cotrel-Dubousset instrumentation (n = 64) in posterolateral lumbar fusion. Variables were registered at the time of surgery and at 1 and 2 years after surgery. RESULTS: Follow-up was achieved in 97.7% of the patients. Fusion rates deduced from plain radiographs were not significantly different between instrumented and noninstrumented groups. The functional outcome assessed by the Dallas Pain Questionnaire improved significantly in both groups, and there were no significant differences in results between the two groups, except for significantly better (P < 0.06) functional outcome in relation to daily activities in the instrumented group when neural decompression had been performed. The global patients' satisfaction was 82% in the instrumented group versus 74% in the noninstrumented group (not significant). Fixation of instrumentation increased operation time, blood loss, and early reoperation rate significantly. Patients experienced only a few minor postoperative complications; none were major. Two infections appeared in the Cotrel-Dubousset group. Significant symptoms from misplacement of pedicle screws were seen in 4.8% of the instrumented patients. CONCLUSIONS: Lumbar posterolateral fusion with pedicle screw fixation increases the operation time, blood loss, and reoperation rate, and leads to a significant risk of nerve injury. The functional outcome improves significantly with high patient satisfaction, with or without instrumentation. No significant differences were observed between the two groups in functional outcome and fusion rate. The only gain in functional outcome from instrumentation was found in the daily activity category in patients with supplementary neural decompression. The results of this study do not justify the general use of pedicle screw fixation alone as an adjunct to posterolateral lumbar fusion.

Adult↗
PubMed2002

Moving toward a standard for spinal fusion outcomes assessment.

Previous spinal fusion outcomes assessment studies have been complicated by inconsistencies in evaluative criteria and consequent variations in results. As a result, a general consensus is lacking on how to achieve comprehensive outcomes assessment for spinal fusion surgeries. The purpose of this article is to report the most validated and frequently used assessment measures to facilitate comparable outcomes studies in the future. Twenty-seven spinal fusion outcomes studies published between 1990 and 2000 were retrospectively reviewed. Study characteristics such as design, evaluative measures, and assessment tools were recorded and analyzed. Based on the reviewed literature, an outcomes assessment model is proposed including the Short Form-36 Health Survey, the Oswestry Disability Questionnaire, the North American Spine Society Patient Satisfaction Index, the Prolo Economic Scale, a 0-10 analog pain scale, medication use, radiographically assessed fusion status, and a generalized complication rate.

Humans↗
PubMed2002

Recombinant human bone morphogenetic protein-4 (rhBMP-4) enhanced posterior spinal fusion without decortication.

In posterior spinal fusion, insufficient decortication may decrease the number of bone marrow derived ostoprogenitor stem cells and affect the success of bony fusion. The finding of bone formation through interaction between rhBMP-4 and non-marrow derived mesenchymal cells constituted the basis of the current study. The aim is to investigate the possibility of molecular enhancement of posterior spinal fusion by site-specific application of rhBMP-4 with or without surgical decortication. Eighteen adult rabbits underwent single level bilateral posterior intertransverse process spinal fusion at L5-L6. one side with decortication, and the other side without decortication. Two animals underwent sham operation without bone grafts, the other 16 animals were randomly allocated into three groups, using hydroxyapatite-tricalcium phosphate (HA-TCP) ceramic blocks augmented with 0, 125 and 5 micromg [corrected] of rhBMP-4 respectively. Spinal fusion morphology was evaluated with sequential X-ray, microradiography and histomorphology. At week 7, complete bony fusion was achieved in none of the groups without rhBMP-4 irrespective of whether the bony contact surface was decorticated or not. In the groups with low dose rhBMP-4, complete fusion occurred in two of six un-decorticated sites (33%) and in three of six (50%) decorticated sites. 100% complete fusion was found in the high dose rhBMP-4 group independent of surgical decortication. The dorsal cortices of the un-decorticated transverse processes were replaced by newly formed trabecular bone through biological remodeling. This study suggested that rhBMP-4 can induce non-marrow derived mesenchymal cells to differentiate into osteogenic cells and thus enhance the high success rate of pesterior spinal fusion in both the decorticated and un-decorticated model.

Animals↗
PubMed2006

[Effects of calcitonin on the pathology of spinal fusion in rabbit models].

OBJECTIVE: To observe the effect of calcitonin on the pathology of fusion in lumbar posterior/facet spinal fusion in rabbit model. METHODS: Thirty-two male New Zealand white rabbits were used to establish spinal fusion model. Sixteen rabbits received calcitonin at a dose of 1 IU x kg(-1) x d(-1) were classified as calcitonin group, and the remaining 16 rabbits as control group. Rabbits were killed 1, 2, 4, and 8 weeks after operations. Haematoxylin-eosin staining was applied to observe the pathological process of spinal fusion. Expression of bone morphogenetic protein-2 (BMP2) was detected by immunohistochemistry. RESULTS: Bone resorption and fibrovascular stroma formation were the main histological presentation 1 week after surgery. Two and 4 weeks after surgery, more cartilage formed with varying degrees of mineralization, while less trabeculae could be observed in the phase of active bone formation. No remarked margin was seen between cartilage and bone tissues. Eight weeks after surgery, trabeculae distributed widely. The pathological process of spinal fusion in calcitonin group was faster than in control group. Emery scores showed significant differences at different time points (F = 265.44, P < 0.001). Calcitonin and time had a positively synergistic effect on Emery scores, and calcitonin caused significant difference in terms of Emery scores since the second week (F = 22.43, P < 0.001). Expressions of BMP, were significantly different at different time points (F = 1186.54, P < 0.001). Also, calcitonin and time had a synergistic effect on BMP2 expression (F = 13.14, P < 0. 001). CONCLUSIONS: Endochondral ossification exists in the spinal fusion process and may be the main way of ossification. Calcitonin may stimulate the expression of BMP2 and thus accelerate the process of spinal fusion.

Animals↗
PubMed2003

Case report: intraoperative left common iliac occlusion in a scheduled 360-degree spinal fusion.

STUDY DESIGN: This is a case report of a left common iliac artery occlusion identified as an intraoperative complication during a planned (combined anterior interbody and posterior fusion) 360 degrees spinal fusion. OBJECTIVE: The purpose of this report was to document the occurrence of this rare complication during a planned 360 degrees fusion and to increase the awareness of this potential intraoperative vascular complication. SUMMARY OF BACKGROUND DATA: Several cases of left iliac artery occlusion after anterior spinal surgery have been reported, but there has been no reported case of intraoperative iliac artery occlusion identified during a planned 360 degrees spinal fusion. METHODS: The patient was a 46-year-old woman with chronic low and mid back pain and left leg pain for several years. She was a 2-pack-a-day cigarette smoker for 30 years. She was diagnosed with internal disc disruption at L3-L4 and L4-L5, unresponsive to nonoperative treatment, and was scheduled for a 360 degrees spinal fusion. During the anterior procedure, the left iliac vessels were retracted with a Wiley retractor during the discectomy and fusion. It was noted that there was no pulse in the left common iliac artery as the anterior procedure neared completion. Intraoperative Doppler showed the left iliac artery was occluded, and a left iliac endarterectomy and thrombectomy were performed immediately. RESULTS: A significant occlusive plaque was separated distally and transected in a smooth fashion, and fresh thrombus was also removed. The procedure was successfully accomplished without any further complication with excellent restoration of arterial blood flow to the left lower extremity. Doppler study showed good triphasic flow in the iliac artery and all its branches. Because of the arterial repair, the posterior portion of the surgery was not undertaken at that time and was performed 2 weeks later. CONCLUSIONS: Early recognition and appropriate treatment can prevent serious sequelae. Great care and observation should be given to the patients before surgery, intraoperatively, as well as after surgery.

Arterial Occlusive Diseases↗
PubMed1996

Radiological and functional outcome after anterior lumbar interbody spinal fusion.

Outcome after anterior spinal fusion has mainly been studied radiologically and reported fusion rates vary greatly. The aim of this study was to investigate radiological and long-term clinical outcome. The study comprised 120 consecutive patients, operated on during the period 1979-1987, with single-or two-level anterior interbody spinal fusion due to disc degeneration or isthmic spondylolisthesis with lumbar instability. In 64 patients a supplemental facet joint fusion was performed. Clinical outcome was evaluated 5-13 years after surgery using the patient-administered Dallas Pain Questionnaire (DPQ). Radiological outcome was determined on the basis of radiographs taken at a 2-year follow-up assessed by independent observers. The radiological follow-up rate was 98%. Complete fusion was found in 52%, questionable fusion in 24%, and definitive pseudoarthrosis in 24% of patients. Radiological results were poor in patients who had undergone previous spinal surgery (P < 0.05) and in those with two-level fusion (P < 0.05). The DPQ reply rate was 80%. Sixty-six patients claimed improvement in all functional groups. Patients with complete or questionable union had significantly better results than did those with non-union (P < 0.01). Poorer functional outcome was found in patients who had undergone previous spinal surgery (P < 0.01) or fusion at the L4/L5 level (P < 0.05), in those who had responded poorly to the preoperative test brace (P < 0.05), and in those above 45 years old at the time of surgery (P < 0.05). Radiological and functional outcome did not vary according to whether patients were treated postoperatively with a plaster jacket or with facet screw fixation. The study demonstrated a functional success rate of approximately 66% following anterior lumbar spinal fusion after a mean follow-up of 8 years. There was a clear tendency for poorer prognosis for patients who had undergone previous spinal surgery, those aged above 45 years, those operated at the L4/L5 level and those who had responded poorly to the preoperative test brace. DPQ scores correlated well with radiological outcome.

Adolescent↗