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PubMed1997

Clinical outcome after spinal fusion with a rigid versus a semi-rigid pedicle screw system.

Several biomechanical studies have evaluated the quality of fusion obtained with a rigid versus a semi-rigid pedicle screw implant. Some studies indicate that increased rigidity of the implant system results in an increased strength of the fusion mass. Other reports have underlined the risk of stress shielding due to rigid implant systems. Based on these findings some authors have recommended the use of a semi-rigid system. There are, however, few studies focusing on any possible difference in clinical outcome between the two different types of implant systems. Questionnaires were sent to 89 patients who had undergone primary spinal fusion with either a rigid or a semi-rigid pedicle-screw-based implant system. In every case the diagnosis was spondylolisthesis or degenerative lumbar disease. The questionnaires were analysed using forward stepwise logistic regression analysis. Eighty (90%) of the questionnaires were returned. There was a mean follow-up of 4 years (range 2-8 years). It was not possible to demonstrate any difference in clinical outcome between patients undergoing lumbar fusion with a rigid implant system and those given a semi-rigid system. The overall patient satisfaction rate was 69%, with no difference between the two types of implant. No difference in clinical outcome between the two types of implant was found. Considering the fact that the primary goal of spinal fusion procedure is to obtain a solid fusion mass, biomechanical tests favour the used of a rigid pedicle screw system. This fact combined with the fact that early mobilisation is possible with rigid implants justifies the use of rigid implant systems, although no difference in clinical outcome could be demonstrated in this study.

Adolescent↗
PubMed1998

Recombinant human morphogenetic protein: its future role in spinal fusions.

The marriage of basic scientific research and clinical application often leads to profound advances in our understanding of various disease processes and how they may be ameliorated. One such fortuitous combination has been the discovery of bone morphogenetic proteins (BMPs) and their potential application in spinal fusions. The goal of this article is to introduce the neurosurgeon to the basic biology of this protein family, current experimental data (in vitro and in vivo models) demonstrating their effectiveness in enhancing bony fusions, and preliminary clinical trials utilizing BMP in long bone fusions. Using this information, a proposal for the use of BMP in spinal fusions under various clinical scenarios will be discussed.

Journal Article↗
PubMed1996

Evaluation of collagen ceramic composite graft materials in a spinal fusion model.

Autogenous bone graft is highly effective in inducing a bone healing response in most clinical settings. However, significant morbidity can occur related to the harvest of an autograft. This makes the development of synthetic or purified nontissue bone grafting materials highly desirable. Both purified bovine Type I collagen and calcium phosphate ceramics have been proposed as promising osteoconductive bone graft substitute materials. One collagen ceramic composite, Collagraft, is approved for use in acute long bone fractures. This study evaluated composites of purified bovine Type I fibrillar collagen and a granular biphasic hydroxyapatite/tricalcium phosphate ceramic in the posterior segmental canine spinal fusion model. Materials were compared based on union score and mechanical testing in 3 separate fusion sites (L1-2, L3-4, L5-6). All composites were found to be inferior in union score to an equal volume of autogenous cancellous bone. In addition, the combination of the collagen ceramic composite with autogenous cancellous bone graft reduced the effectiveness of the autogenous bone graft significantly. These data should be a caution to the clinician who may consider use of collagen ceramic composites similar to Collagraft for spinal fusion applications.

Animals↗
PubMed2006

Comparison of intravenous patient-controlled analgesia with buprenorphine versus morphine after lumbar spinal fusion--a prospective randomized clinical trial.

BACKGROUND: Opioid-based patient-controlled analgesia (PCA) has been used widely and effectively after spine surgery. The untoward effects of intravenous opioids could vary with the drug and dose applied. Buprenorphine, a partial opioid agonist, might be devoid of the adverse effects which the traditional opioids have. We conducted this prospective randomized clinical trial to evaluate the efficacy and safety of buprenorphine for intravenous PCA after spine surgery. METHODS: Fifty patients undergoing elective lumbar spinal fusion were randomly assigned to either buprenorphine or morphine group. PCA was administered in a double-blind manner for a 2-day postoperative course. The evaluation was initiated after patients were transferred to the post-anesthetic care unit. Pain assessment with visual analog scale (VAS) at rest and after pain elicitation by sitting was carried out and recorded at 6, 24, 48 hrs after surgery. Untoward effects were also collected. RESULTS: Twenty-five patients were randomized to each group. One patient in the buprenorphine group dropped out from the study due to dizziness. There was no difference between the groups with respect to the baseline variables. The VAS scores at rest and after elicitation of pain by sitting showed no difference between both groups. The delivered volume of buprenorphine, the numbers of demand and delivery, and the demand/delivery ratio were higher in buprenorphine than morphine group at 6 hr after surgery but were not different later. No major complications occurred in both groups. The pruritus incidence in buprenorphine group was significantly lower than in morphine group (0 vs. 24%, P = 0.02). Other adverse effects were similar in both groups. CONCLUSIONS: Both buprenorphine and morphine by intravenous PCA provided adequate pain relief after posterior lumbar spinal fusion. The incidences of side effects were similar in both groups except for pruritus which did not appear in buprenorphine group. Buprenorphine was as efficient as morphine and safe for intravenous PCA after spine surgery.

Analgesia, Patient-Controlled↗
PubMed2001

Evaluation of carriers of bone morphogenetic protein for spinal fusion.

STUDY DESIGN: Posterolateral lumbar transverse process fusion in a rabbit model was performed using two different carriers for recombinant human morphogenetic protein-2, one having a porous structure and the other being a Type I collagen sheet. OBJECTIVES: To compare the effectiveness of two different carriers for recombinant human morphogenetic protein-2 in achieving lumbar intertransverse process arthrodesis. SUMMARY OF BACKGROUND DATA: The application of osteoinductive growth factors at various anatomic sites, such as in long bones and spinal segments, has been performed experimentally by many researchers. Although many carriers of osteoinductive factors have been reported, the most effective carrier has not been established. We have reported the efficacy of sintered bovine bone, True Bone Ceramics, which is coated with Type I collagen as a carrier of recombinant human bone morphogenetic protein-2 in achieving lumbar intertransverse process arthrodesis. True Bone Ceramics is a crystallized form of bone minerals made from sintering bovine bone at high temperatures and possesses natural trabecular structure. The crystalline character of True Bone Ceramics is similar to that of artificial hydroxyapatite. In this study we focused on the structure of two different carriers to facilitate osteosynthesis in lumbar arthrodesis. METHODS: Fifty-four adult rabbits underwent bilateral lumbar intertransverse process arthrodesis at L4-L5. The animals were divided into five groups and had implants placed as follows: Group 1, autograft group, harvested autologous corticocancellous bone from the posterior iliac crest; Group 2, TBC group, True Bone Ceramics alone; Group 3, TBC-TBMP group, True Bone Ceramics coated with Type I collagen infiltrated with 100 microg of recombinant human bone morphogenetic protein-2; Group 4, collagen group, Type I collagen sheet; and Group 5, collagen-BMP group, implanted collagen sheet containing 100 microg of recombinant human bone morphogenetic protein-2. Spinal fusion was evaluated by radiographic analysis, manual palpation, biomechanical testing, and histologic examination at both 3 and 6 weeks after surgery. RESULTS: Radiographs in the TBC-TBMP group showed a continuous trabecular pattern within the intertransverse area at 3 weeks after surgery. The fusion mass in the intertransverse area was more prominent than in the other groups. At 3 weeks after surgery the TBC-TBMP group had higher fusion rates based on manual palpation, and the fusions showed significantly higher tensile strength and stiffness. The histologic findings in the TBC-TBMP group at 3 weeks after surgery showed a cortical bone rim around the edge of the fusion mass, and contiguous new bone appearing between the recipient bone and the matrix of TBC without evidence of foreign body formation. In the collagen-BMP group, less mature bone formation was present within the grafted area and the new bone was not contiguous, even at 6 weeks after surgery. CONCLUSIONS: As a carrier for recombinant human bone morphogenetic protein-2, True Bone Ceramics, possessing a bony or porous structure, was more effective than a Type I collagen sheet in achieving a faster and stronger lumbar spinal fusion in a rabbit model.

Animals↗
PubMed2002

The effect of hyperbaric oxygen therapy on spinal fusion: using the model of posterolateral intertransverse fusion in rabbits.

BACKGROUND: The purpose of this study is to evaluate the facilitating effect of hyperbaric oxygen (HBO) on posterolateral intertransverse fusion using a validated rabbit model. METHODS: Twenty-four male New Zealand rabbits underwent posterolateral intertransverse fusion at L5-L6 with autogenous iliac bone graft. They were evenly divided into two groups: the HBO group and the normal room air (RA) group. Each group had six rabbits killed at 4 weeks and 8 weeks, respectively. The rabbits in the HBO groups were treated with 100% oxygen at 2.5 atm for 2 hours a day. After being killed, all rabbits were subjected to radiographic examination, manual testing, and torsional loading to evaluate the results of spinal fusion. RESULT: Radiographic union of intertransverse fusion areas at 4-week RA, 4-week HBO, 8-week RA, and 8-week HBO were 2 of 12, 7 of 12, 7 of 12, and 10 of 12, respectively. Solid union proven by manual palpation was found to be zero of six, three of six, four of six, and five of six of the cases, respectively. The average peak torsional momentums were 2120.2, 2576.5, 2661.6, and 3079.8 N-mm, respectively. Spinal fusion was significantly improved in the HBO groups at both 4 weeks and 8 weeks. CONCLUSION: The results of this study suggest that intermittent hyperbaric oxygen therapy will hasten the bone healing process and improve the fusion rate as compared with the non-HBO group.

Animals↗
PubMed1985

Effects of spinal fusion on the proteoglycans of the canine intervertebral disc.

Posterior lumbar two-level spinal fusion was undertaken in 10 mature beagles. The animals were sacrificed 6 and 12 months later. Two months before sacrifice control and experimental animals received intravenously Na2(35)SO4 (1 mCi/kg). Discs encompassed by the fusion and those adjacent to it were dissected into the nucleus pulposus and annulus fibrosus (AF), which were analysed separately. Proteoglycans (PGs) were extracted with 4.0 M guanidine HCl and purified by CsCl density gradient ultracentrifugation. The hydrodynamic size and ability of the PG subunits to aggregate in the presence of hyaluronic acid were investigated by Sepharose CL-2B chromatography. The PG subunits were analysed for their galactosamine (galN), glucosamine (glcN), hexuronic acid, and protein content or were subjected to digestion with papain or chondroitin-ABC-lyase to establish the size of the chondroitin (CS) and keratan (KS) sulphate chains and the KS-PG core protein complex. Decreased ability to aggregate of PGs isolated from discs 6 and 12 months after surgery was demonstrated. While their hydrodynamic size after 6 months was generally the same or smaller than those in control tissues, the PG population present after 12 months was larger, particularly in the AF. Analysis of PG subunits from fusion discs afforded galN/glcN, galN/protein, and hexuronic acid/protein ratios that were compatible with the presence in these tissues of PGs in which the proportion of CS attached to core protein was greater than in control tissues. These studies provide the first experimental evidence that a metabolic response of discs in a fused segment may be accompanied by the biosynthesis of a new PG population whose structure is similar to that present in immature tissues.

Animals↗
PubMedDate not supplied

Spinal fusion in Duchenne's muscular dystrophy.

Thirteen patients with Duchenne's muscular dystrophy underwent spinal fusion and Harrington instrumentation between 1967 and 1979. Curve progression was the most common indication for surgery. Cardiorespiratory evaluation was most important in the timing of surgery. After 12 months of immobilization, all spines fused. Major and minor complications occurred in eight of 13 patients. The major benefit of surgery was improved or maintained sitting balance. Surgery is not recommended for patients with symptomatic cardiomyopathy, vital capacity less than 40%, a nonfunctional cough, or rapidly progressive deterioration in muscle strength with a projected life span of less than two years.

Adolescent↗
PubMed2002

The role of neurofibromin and melatonin in pathogenesis of pseudarthrosis after spinal fusion for neurofibromatous scoliosis.

We might hypothesize that the high rate of pseudarthrosis after spinal fusion for neurofibromatous scoliosis is related to two factors: the absence of neurofibromin and melatonin deficiency. Loss of the up-regulation of neurofibromin during the healing process might abolish the bone-forming effects mediated through platelet-derived growth factor (PDGF) and transforming growth factor (TGF) beta1. The absence of neurofibromin might cause an increase in the Ras activity that increases the mitogen-activated protein kinase (MAPK) with resultant disturbance of the regulatory mechanism of core binding transcription factor (Cbfa 1) and increase of osteocalcin. These effects might inhibit bone formation. Melatonin deficiency might cause defective bone formation and favour excess fibrous tissue formation.

Bone and Bones↗
PubMed1975

Spinal fusion with free periosteal grafts and its effect on vertebral growth in yound rabbits.

The effect of early fusion on growth of the spine has been studied in rabbits. Free periosteal grafts from the tibia were transplanted either posteriorly between the spinous and articular processes or postero-laterally between the articular and transverse processes. Sound bony fusion was achieved in both the thoracic and the lumbar spine. Spinal fusion caused local narrowing and wedging of the intervertebral spaces, followed by retardation of growth and wedging of the vertebrae. A progressive structural scoliosis developed after unilateral postero-lateral fusion and a lordosis developed after posterior fusion.

Animals↗
PubMed1992

Spinal fusion for back pain: a clinical and radiological review.

Eighty-one patients who had spinal fusions performed for back pain over a 7-year period were reviewed; 74% were satisfied with the outcome of their surgery, mainly because of the degree of pain relief obtained. Based on lateral radiographs of the fusion area in flexion and extension, there was a 34% pseudarthrosis rate in first-time fusions. However, there was no clear relationship between the integrity of fusion and clinical success, indicating that many factors other than bony fusion influence the eventual outcome of the operation.

Adult↗
PubMed1982

Posterolateral spinal fusion for the treatment of scoliosis in myelodysplasia.

Twenty-seven patients have undergone posterolateral spinal fusion for the treatment of scoliosis associated with myelodysplasia. Seventeen patients were girls, and 10 were boys. The average age at the time of surgery was 10.6 years in the girls and 11 years in the boys. The average preoperative curve was 78.52 degrees. All patients were fused at the sacrum; the upper level of fusion was at the fourth thoracic vertebra in 20 patients and at the third thoracic vertebra in 7 patients. Harrington instrumentation was used in 5 patients. The average improvement in curvature was 44.5%. Based on clinical and functional criteria, 16 patients had good results, 4 patients had fair results, and 7 patients had poor results.

Adolescent↗
PubMed1997

Utilization of type I collagen gel, demineralized bone matrix, and bone morphogenetic protein-2 to enhance autologous bone lumbar spinal fusion.

Autologous bone grafts are currently considered "gold standard" material for achieving long-term spinal arthrodesis. The present study was performed to determine whether demineralized bone matrix (DBM), type I collagen gels, or bone morphogenetic protein-2 (BMP-2) can improve autologous bone spinal fusions. Using a unilateral decompression-contralateral fusion technique in dogs, each of these materials was added to an autologous bone graft. Volumetric analysis, histological analysis, and biomechanical testing were performed to assess the effectiveness of each material. The DBM had an inhibitory effect on solid bone fusion of the spine, whereas the type I collagen gels improved the bony interface between the graft and the host spine. The BMP-2 strongly enhanced the amount of bone deposition at the fusion site and increased the number of intervertebral levels that were solidly fused. This study strongly supports the use of BMP-2 as an additive to autologous bone grafts in spine stabilization.

Animals↗
PubMed2003

Inferior vena cava tear during posterior spinal fusion surgery.

Inferior vena cava tear is a rare but potentially lethal event associated with spinal surgery. Early recognition and repair are mandatory to minimize morbidity and mortality. Here we report a case of inferior vena cava tear which occurred during posterior spinal fusion surgery. Without marked bleeding from the surgical field, the patient was suddenly seized with a profound shock. Abdominal distension was found after resumption of the supine position from prone. Emergent exploratory laparotomy disclosed inferior vena cava tear. After repairing of the torn vessel, the patient was transferred to ICU. Unfortunately, patient expired two weeks later due to multiple-organ failure.

Female↗
PubMed2002

Resorbable cages for spinal fusion: an experimental goat model.

A biomechanical cadaver study and an in vivo monosegmental spinal fusion study were performed to evaluate a novel bioresorbable poly-L-lactic acid (PLLA) cage. The yield strength of a spinal segment was chosen as the main design parameter for the resorbable cages to be used in a goat model. A 3-year in vivo study revealed a significantly faster and more complete fusion using PLLA cages as compared to titanium cages with the same dimensions. In the PLLA group, the intervertebral grafting height did not change and bone remodeling within the cage was completed 2 years after implantation. In terms of degradation of the PLLA, similar features were observed in vivo and in vitro. Degradation was almost completed 3 years after implantation. Tissue reaction was mild during the 3-year period.

Absorbable Implants↗
PubMed1994

Effects of irradiation on posterior spinal fusions. A rabbit model.

STUDY DESIGN: The biological and biomechanical effects of irradiation on posterior bone graft healing in the lumbar spine of rabbits were investigated. Twenty-seven New Zealand white rabbits were divided into four groups. Each rabbit underwent a posterior lumbar spine fusion with autogenous iliac crest bone graft, and three of the experimental groups received perioperative irradiation. OBJECTIVES: This study evaluated the histologic and biomechanical effects of perioperative irradiation on posterior spinal fusions using a rabbit model. SUMMARY OF BACKGROUND DATA: Treatment of metastatic disease of the spine depends on the neurologic status of the patient, stability of the spine, location of the tumor, and the tissue of origin. Some patients require surgical decompression and stabilization. The response of a posterior spinal bone graft to irradiation has not been studied previously. METHODS: Group 1 (n = 7), the control group, did not receive irradiation. Group 2 (n = 6) received preoperative irradiation. Group 3 (n = 7) received immediate (day 3) postoperative irradiation, and Group 4 (n = 7) received delayed (day 21) postoperative irradiation. The radiation protocol consisted of 480 centigrade/fraction for 5 consecutive days. At 3 months, the rabbits were euthanatized. Nondestructive biomechanical testing was performed, followed by histologic evaluation of the fusion mass. RESULTS: Compared with the control group, Group 3 (immediate postoperative irradiation) specimens were less stiff in extension (P = .0001), flexion (P = .0006), compression (P = .018), and left lateral bending (P = .018). The preoperatively irradiated spines (Group 2) were less stiff in extension (P = .0008) and in compression (P = .035) than controls. The control group and the delayed irradiation group had the highest histologic scores and more mature fusion mass. The immediate postoperative irradiation group had the worst results, with consistent fibrous union of the graft. CONCLUSION: Healing of a posterior spinal fusion is influenced by the timing of radiation therapy. Adjuvant radiation therapy for patients with spinal neoplasm requiring a posterior fusion should, if possible, be delayed for 3 to 6 weeks postoperatively to maximize the probability of successful arthrodesis.

Animals↗