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PubMed1988

Decompression laminectomy and lateral spinal fusion in patients with previously failed lumbar spine surgery.

Sixty-two patients who had had previous failed lumbar disk surgery (average 1.4 surgeries) were treated with a decompression laminectomy and lateral spinal fusion. Follow up averaged 4.2 years and results were based on pain relief, improved function, and return to work as recorded on a patient questionnaire. Using a scoring system to quantify the change from the patients felt the surgery was very worthwhile, 32% had a good result, 29% had a fair result, and 38% had a poor result. However, 53% of the patients felt the surgery was very worthwhile, 37% rated it somewhat worthwhile, and 10% responded that the surgery was not worthwhile. Factors which statistically correlated with a higher improvement score were the presence of a unilateral radicular pain pattern, a year pain free interval since the previous surgery, and a myelogram which was more indicative of a disk herniation rather than cicatrix formation. Similarly, those patients who were found to have a recurrent or new disk at the time of surgery did better than those whose major finding was scar formation. The quality of the fusion mass was positively correlated with a better final result with questionable statistical significance (P = .06). Finally, those patients who were industrial improved much less and only 14% returned to work as compared to 61% of the non-industrial patients.

Adult↗
PubMed2004

Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: a comparison between surgeries performed with and without a vertical exponential filtered air-flow system.

STUDY DESIGN: This study retrospectively compared infection rates between adult patients after posterior spinal instrumentation procedures performed in a conventional versus an ultraclean air operating room. OBJECTIVE: To evaluate if the use of ultraclean air technology could decrease the infection rate after posterior spinal arthrodesis with instrumentation. SUMMARY OF BACKGROUND DATA: Postoperative wound infection after posterior arthrodesis remains a feared complication in spinal surgery. Although this frequent complication results in a significant problem, the employment of ultraclean air technology, as it is commonly used for arthroplasty, has not been reported as a possible alternative to reduce the infection rate after complex spine surgery. METHODS: One hundred seventy-nine patients having posterior spinal fusion with instrumentation were divided into 2 groups: group I included 139 patients operated in a conventional operating room, and group II included 40 patients operated in a vertical laminar flow operating room. Patient selection was performed favoring ultraclean air technology for elective cases in which high infection risk was considered. A statistical analysis of the infection rate and its associated risk factors between both groups was assessed. RESULTS: We observed 18 wound infections in group I and 0 in group II. Comparison of infection rates using the chi-squared test showed a statistically significant difference (P <0.017). CONCLUSION: The use of ultraclean air technology reduced the infection rate after complex spinal procedures and appears to be an interesting alternative that still needs to be prospectively studied with a randomized protocol.

Adolescent↗
PubMed2006

Comparison of 1-stage versus 2-stage anterior and posterior spinal fusion for severe and rigid idiopathic scoliosis--a randomized prospective study.

STUDY DESIGN: A randomized prospective study. OBJECTIVE: To compare safety, efficacy, and cost between 1-stage and 2-stage anterior and posterior spinal fusion in treating rigid thoracic adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Retrospective study issued different outcomes comparing 1-stage with 2-stage surgical procedures in treating neuromuscular and congenital scoliosis. A randomized prospective study in AIS has rarely been reported. METHODS.: Twenty-four patients were randomly divided into 2 groups. Group A underwent a 2-stage procedure, group B a 1-stage procedure. Inclusion criteria were: (1) AIS; (2) rigid single thoracic curve, > or =90 degrees on anteroposterior and > or =60 degrees on side bending view; and (3) pulmonary function tests, vital capacity > or =500 mL or FEV1 > or =50%. Exclusion criteria were: (1) curves either <90 degrees on anteroposterior or <60 degrees on bending view; and (2) pulmonary function tests, both vital capacity <500 mL and FEV1 <50%. The mean follow up was 3.3 years (range 2-5.1). Clinical outcomes between the 2 groups were analyzed. RESULTS: A statistical t test demonstrated no significant difference in age (P = 0.299), curves on anteroposterior (P = 0.908), on bending (P = 0.905), after surgery (P = 0.699), and at last follow-up (P = 0.946). No significant difference in blood loss (P = 0.089), transfusion (P = 0.334), operation time (P = 0.172), fusion segments anterior (P = 0.161), posterior (P = 0.546), wound drainage (P = 0.557), thoraco drainage (P = 0.948), and loss of correction at follow-up (P = 0.596). However, significant differences were found in length of stay (P < 0.001), patient cost of hospitalization (P < 0.001) between 2 groups, and curve correction (P < 0.001) in each group. Perioperative complications included 1 patient each with pneumonia, pneumothorax (group A), and ileus (group B). Screw nut loosing was found in 1 patient in group B, but no curve deteriorated. No neurologic deficit occurred in either group. CONCLUSION: A comparison of 1-stage versus 2-stage fusion in treating rigid thoracic curves in AIS did not show significant differences in safety or efficacy but did demonstrate significant difference in length of stay and patient cost.

Adolescent↗
PubMed1992

Latent psoas abscess after anterior spinal fusion.

This case is presented to emphasize that late infection should be considered in all postoperative patients as a cause of pain. A psoas abscess may remain dormant for many years after an anterior spinal procedure. It should be considered in the differential diagnosis of back pain and lumbar radiculopathy after anterior spinal fusion. The lumbar nerve plexus lies within the psoas muscle, and referred pain patterns may occur in the lumbar nerve distribution. In this case, dysesthesias occurred in the distribution of the genitofemoral nerve. The diagnosis and treatment of a psoas abscess has been greatly aided by use of CT and ultrasound. Either of these modalities may be used for directed percutaneous drainage of the abscess. The presence of metal fixation devices necessitates removal of the hardware in order to ensure eradication of the infection.

Adolescent↗
PubMed1999

A double-blind study of capacitively coupled electrical stimulation as an adjunct to lumbar spinal fusions.

STUDY DESIGN: A randomized double-blind prospective comparison with a placebo control. This report of the results is the first in an ongoing study. OBJECTIVES: To evaluate the effect of noninvasive capacitively coupled electrical stimulation on the success rate of lumbar spine fusion surgery, and to compare active with placebo stimulators as adjuncts to contemporary fusion techniques. SUMMARY OF BACKGROUND DATA: Previous studies have established the effectiveness of direct current and electromagnetic field stimulation as adjuncts for some forms of spinal fusion. None of the previous placebo-controlled studies on external bone stimulation included posterolateral fusion techniques, and most were conducted with prior generations of internal fixation hardware. METHODS: The investigation was conducted by 28 U.S. surgeons. Patients with a primary diagnosis of degenerative disc disease with or without other degenerative changes were selected. The study protocol defined success as a clinical outcome rated as excellent or good and a fusion documented as solid by both the investigator and the blinded independent radiologist. Disagreements on radiographic success were resolved by a second blinded independent reviewer. RESULTS: For the 179 patients who completed treatment and evaluation, the overall protocol success rate (both clinical and radiographic results rated as successes) was 84.7% for the active patients and 64.9% for the placebo patients. This difference is highly significant according to the Yates corrected chi-square test (P = 0.0043). Best improvements in patient outcomes (20% or greater success rate) occurred when active stimulation was used in conjunction with posterolateral fusion (P = 0.006) and when internal fixation also was incorporated (P = 0.013). DISCUSSION: This study was consistent in that active stimulation improved results for each stratification, although some strata had insufficient numbers of patients for the results to have statistical significance. Improved success rates when capacitively coupled stimulation is added to internal fixation are hypothesized to result from overcoming the biochemical effects of stress shielding. CONCLUSIONS: Capacitively coupled stimulation is an effective adjunct to primary spine fusion, especially for patients with posterolateral fusion and those with internal fixation.

Adult↗
PubMed2003

The use of postoperative subcutaneous closed suction drainage after posterior spinal fusion in adolescents with idiopathic scoliosis.

BACKGROUND The purpose of this prospective study was to assess the impact of closed suction drainage on transfusion requirements, frequency of dressing changes, and wound healing following posterior spinal fusion in adolescents with idiopathic scoliosis. METHODS Thirty patients were randomly assigned to one of two groups: drain or no drain. Although the group with drains received more postoperative autologous blood transfusions than the group with no drains (0.88 vs 0.5 unit), the difference was not statistically significant (P = 0.2131). In the undrained group, 58% of the patients had moderate to completely saturated dressings on the second postoperative day compared with only 17% of patients in the drained group. Three of 12 patients in the undrained group demonstrated a wound complication rate compared with no complications in the drained group. CONCLUSION In conclusion, subcutaneous closed suction drainage can improve immediate postoperative wound care without significantly increasing blood loss and transfusion requirements for patients undergoing surgery for idiopathic scoliosis.

Adolescent↗
PubMed2004

Clotting parameters and thromboelastography in children with neuromuscular and idiopathic scoliosis undergoing posterior spinal fusion.

STUDY DESIGN: An unblinded comparison of laboratory values between patients with idiopathic and neuromuscular scoliosis. OBJECTIVES: To compare standard tests of coagulation and thromboelastography (TEG) parameters between two groups of patients undergoing posterior spinal fusion (PSF). SUMMARY OF BACKGROUND DATA: Children with neuromuscular scoliosis such as cerebral palsy have more intraoperative blood loss than children with idiopathic scoliosis during PSF. Various reasons suggested for this include nutritional deficiencies, altered tissue integrity, hepatic dysfunction, and use of antiepileptic medications that can cause poor hemostasis and altered coagulation. We have observed alterations in coagulation factor levels in patients with cerebral palsy due to spastic quadriplegia with moderate blood volume loss (25% estimated blood volume). METHODS: In a prospective analysis, we compared standard tests of coagulation (prothrombin time [PT], partial thromboplastin time [PTT], platelet count, fibrinogen levels) and TEG at baseline and at a blood loss of 15% estimated blood volume in patients with idiopathic scoliosis and cerebral palsy undergoing PSF. RESULTS: There were no differences between the groups in terms of gender distribution and age. There was a significant difference between the baseline PT and PTT values, although both groups were within laboratory norms. After 15% blood volume loss, there were differences seen in the PT, PTT, maximum amplitude on the TEG, ionized calcium, and serum magnesium levels (P < 0.05). CONCLUSIONS: Children with cerebral palsy undergoing PSF have increased bleeding that starts earlier in the procedure than it does for patients with idiopathic scoliosis undergoing PSF. We found that, even though children with spastic quadriplegia had baseline PT and PTT values within normal limits, they were significantly different when compared with normal patients.

Adolescent↗
PubMed2004

The effects of propofol, small-dose isoflurane, and nitrous oxide on cortical somatosensory evoked potential and bispectral index monitoring in adolescents undergoing spinal fusion.

In this study we compared the effects of propofol, small-dose isoflurane, and nitrous oxide (N(2)O) on cortical somatosensory evoked potentials (SSEP) and bispectral index (BIS) monitoring in adolescents undergoing spinal fusion. Twelve patients received the following anesthetic maintenance combinations in a randomly determined order: treatment #1: isoflurane 0.4% + N(2)O 70% + O(2) 30%; treatment #2: isoflurane 0.6% + N(2)O 70% + O(2) 30%; treatment #3: isoflurane 0.6% + air + O(2) 30%; treatment #4: propofol 120 microg . kg(-1) . min(-1) + air + O(2) 30%. Cortical SSEP amplitudes measured during anesthesia maintenance with treatment #3 (isoflurane 0.6%/air) were more than those measured during maintenance with treatment #1 (isoflurane 0.4%/N(2)O 70%) (P < 0.0001) and treatment #2 (isoflurane 0.6%/N(2)O 70%) (P < 0.0052). Cortical SSEP amplitudes measured during treatment #4 (propofol 120 microg . kg(-1) . min(-1)/air) were more than treatment #1 (isoflurane 0.4%/N(2)O 70%) (P < 0.0001), treatment #2 (Iso 0.6%/N(2)O 70%) (P < 0.0007), and treatment #3 (isoflurane 0.6%/air) (P < 0.0191). In addition, average BIS values measured during treatments 1, 2, 3 and 4 were 62, 62, 61, and 44 respectively. Only treatment #4 (propofol 120 microg . kg(-1) . min(-1)/air) uniformly maintained BIS values less than 60. Our study demonstrates that propofol better preserves cortical SSEP amplitude measurement and provides a deeper level of hypnosis as measured by BIS values than combinations of small-dose isoflurane/N(2)O or small-dose isoflurane alone.

Adolescent↗
PubMed1993

Anterior spinal fusion with Zielke instrumentation for idiopathic scoliosis. A frontal and sagittal curve analysis in 36 patients.

The authors have reviewed the records of 36 patients with idiopathic scoliosis who underwent a single-stage anterior spinal fusion with Zielke instrumentation to determine if any adverse frontal or secondary sagittal deformities or changes in balance resulted from the surgery. Spontaneous correction of uninstrumented thoracic curves was noted in five patients with double-major curves, and frontal balance was maintained or improved after operation in all but four patients. Kyphosis was increased in the instrumented segments in all patients. In the uninstrumented segments, however, thoracic kyphosis and lumbar lordosis were decreased in all but five patients after operation, whereas overall sagittal balance was not adversely affected by the surgery in any patient.

Adolescent↗
PubMed2026

Vancomycin Effectiveness in Reducing Surgical Site Infection in Posterior Spinal Fusion Surgery: A Retrospective Data Analysis of the STRIVE Trial.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To re-evaluate vancomycin as a preventive measure for surgical site infection (SSI). SUMMARY OF BACKGROUND DATA: Intrawound vancomycin powder is used to prevent SSIs in spinal surgery. Prior studies, often limited to single institutions or small samples, have shown mixed efficacy and potential increases in non- S. aureus and Gram-negative infections. We hypothesized that SSIs rates would be similar with and without intrawound vancomycin in posterior spinal fusion (PSF) surgery. METHODS: Prospectively collected data from the 3595 patients in the STaphylococcus aureus suRgical Inpatient Vaccine Efficacy (STRIVE) trial were stratified by intrawound antibiotic usage. Multivariate logistic regression assessed the effect of vancomycin use on SSI, adjusting for patient demographics and SSI-associated risk factors. Secondary outcomes included critical care stay, reoperation, sepsis, and hospital readmission. RESULTS: Of 3311 patients who underwent surgery, 847 (26%) received only intrawound vancomycin and 1534 (46%) received no intrawound antibiotics. Sixty (8%) patients developed postoperative SSI, of whom 20 (33%) had received intrawound vancomycin. Receiving intrawound vancomycin was not associated with SSI incidence versus no intrawound antibiotics [odds ratio (OR): 0.77; 95% CI: 0.42-1.42], critical care stay (OR: 0.94; 95% CI: 0.78-1.12), or sepsis (OR: 2.04; 95% CI: 0.62-6.73). However, intrawound vancomycin was associated with increased odds of hospital readmission (OR: 1.82; 95% CI: 1.28-2.6; P < 0.001) and reoperation (OR: 1.75; 95% CI: 1.18-2.6; P = 0.005). Factors significantly associated with intrawound vancomycin use included intraoperative antibiotic readministration (OR: 2.97; 95% CI: 1.36-6.5; P =0.006) and hospital location, lower odds in Europe (OR: 0.13; 95% CI: 0.06-0.29; P < 0.001) or Asia (OR: 0.02; 95% CI: 0-0.08; P < 0.001) versus North America. CONCLUSIONS: Intraoperative vancomycin use was not associated with reduced SSI incidence compared with no intrawound antibiotics after PSF surgery. LEVEL OF EVIDENCE: Level II.

Humans↗
PubMed2003

Effects of anterior lumbar spinal fusion on the distribution of nerve endings and mechanoreceptors in the rabbit facet joint: quantitative histological analysis.

The purpose of this study was to investigate the density and distribution of neural endings in rabbit lumbar facet joints after anterior spinal fusion and to evaluate the effects of intervertebral immobilization. An extraperitoneal approach was applied, and L5/6 was fixed with a plate and screws. Bilateral L4/5, L5/6, and L6/7 facet joint capsules were harvested from the rabbits 4, 8, and 16 weeks postoperatively. Capsular tissues were processed using a modified gold chloride staining method, and the specimens were sliced into 15-micro m sections. All sections were analyzed microscopically, and neural ending numbers per unit volume were calculated. Three types of neural ending were identified in each specimen: Pacinian corpuscles, Ruffini corpuscles, and free nerve endings. In the L5/6 fusion segment there was a significant decrease in the number of Pacinian corpuscles at 4 weeks and of Ruffini corpuscles at 4, 8, and 16 weeks after the fusion compared with the control; and in the L4/5 upper adjacent segment there was a significant increase in the number of free nerve endings. The number of Ruffini endings for the L6/7 lower adjacent segment was significantly lower more than 8 weeks after the fusion. These results suggest that immobilization of the intervertebral segment causes a reduction in the number of mechanoreceptors in the facet joint capsules because of the reduction in mechanical stimulation. Moreover, in the upper adjacent facet joint there may be neural sprouting caused by nociceptive stimulation.

Animals↗
PubMed2005

Analysis of the lowest instrumented vertebra following anterior spinal fusion of thoracolumbar/lumbar adolescent idiopathic scoliosis: can we predict postoperative disc wedging?

STUDY DESIGN: A retrospective radiographic study. OBJECTIVES: To investigate which radiographic parameters correlate best to ultimate lowest instrumented vertebra (LIV) position and subjacent disc wedging following anterior spinal fusion (ASF) for thoracolumbar/lumbar (TL/L) adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: In an ASF of TL/L AIS, part of the operative goals are often to horizontalize and centralize the LIV, or potentially minimize subjacent disc wedging after surgery. To our knowledge, no study has investigated the specific radiographic parameters involved with obtaining these goals. METHODS: Sixty-one patients with TL/L AIS were treated with an instrumented ASF with a minimum 2-year follow-up. Preoperative and postoperative radiographs were examined measuring various radiographic parameters of the curve itself along with the LIV and subjacent disc. Specific correlation of these parameters to the coronal disc angle immediately below the LIV (disc angle), LIV translation, and global coronal balance (C7-CSVL distance) at 2 years postoperative was analyzed, respectively. RESULTS: The preoperative disc angle was 4.49 degrees +/- 5.48 and postoperative -5.85 degrees +/- 4.37. The change of the disc angle was significantly correlated to the LIV level relative to the preoperative lower end vertebra (LEV) (P < 0.006). Regressive analysis demonstrated the correlative parameters to the postoperative disc angle to be: preoperative upright disc angle; preoperative apex-LIV distance; and preoperative T12-LIV lordosis (P < 0.0001, r2 = 0.51). The correlative parameters to postoperative LIV translation were preoperative LIV translation and preoperative LIV rotation (P = 0.002, r2 = 0.2). The correlative parameter to postoperative C7-CSVL distance was only preoperative C7-CSVL distance (P < 0.0001, r2 = 0.3). CONCLUSIONS: Postoperative subjacent disc wedging occurs most often when the preoperative subjacent disc is nearly parallel and when a shorter fusion excluding the LEV is performed. Preoperative LIV rotation significantly correlates to postoperative LIV translation. Surgeons should note these preoperative predictive factors to optimize radiographic results of the operative treatment of TL/L AIS.

Adolescent↗
PubMed1998

Outcome assessment after spinal fusion: why and how?

Outcomes of medical interventions today must reflect a more complete array of measurements, including health status, patient satisfaction, medical costs, and quality of life. This article discusses the rationale and methodology involved with measurement of health status, particularly as it applies to spinal disorders and spinal fusion. Generic and disease-specific instruments are reviewed, and their limitations are also discussed.

Health Status Indicators↗
PubMed1994

The perioperative course of combined anterior and posterior spinal fusion.

A retrospective study was undertaken to characterize and compare the perioperative course of 91 cases of one- and two-stage combined anterior and posterior spinal fusions over a 7-year period. The two patient populations were similar regarding preoperative characteristics and the number of levels fused. Significantly decreased operative and anesthesia time, operative blood loss, and postoperative hospital days were seen in the one-stage population compared to the two-stage cases (P < 0.05). For the spinal deformity subgroup, a longer chest-tube duration, decreased anesthesia time, and decreased postoperative hospital stay in the one-stage group were the only significant differences. Surgical treatment delays were noted in 8% of one-stage cases and in 23% of two-stage cases. Complications occurred in 53% of all cases, with a significantly higher major complication rate in patients with preoperative medical comorbidities who underwent two-stage combined fusion versus one-stage reconstruction. Higher complication rates were also associated with an age greater than 40 years, the presence of medical comorbidities, and cases treated with a thoracoabdominal anterior approach.

Adult↗
PubMed1995

Lumbar spinal fusion. Surgical rates, costs, and complications.

STUDY DESIGN: Literature review. OBJECTIVES: To assess the frequency of lumbar fusion procedures in the United States; changes in the incidence of fusion in the past 12 years; variations in fusion procedure rates among geographic regions of the nation and between the United States and other countries; costs of lumbar fusion; and rates of infrequent outcomes, which are best estimated from administrative data, including complications and deaths. SUMMARY OF BACKGROUND DATA: Several recent analyses have shown that lumbar spine fusion procedures are done more frequently and are associated with increased costs and rates of complications. METHODS: Qualitative review of the literature on frequency, costs, and complications of lumbar fusion. RESULTS AND CONCLUSIONS: The rates of lumbar fusion procedures are increasing rapidly, particularly for lumbar spinal stenosis in older patients. Fusion rates appear to vary markedly among individual surgeons, among small and large geographic regions in the nation, and between the United States and England. These variations are considerably more dramatic than variations in rates of lumbar discectomy. Fusion for spinal stenosis with spondylolisthesis is, as expected, associated with higher costs and complication rates than is decompressive surgery for this indication without fusion. Fusion rates are increasing rapidly and show dramatic geographic variations, suggesting differences in opinion within the surgical community regarding the appropriate indications for lumbar fusion. Studies are needed to determine whether the frequency, costs, and complications of lumbar fusion are justified by clinical benefits.

Humans↗
PubMed1988

Distracted cervical spinal fusion for management of caudal cervical spondylomyelopathy in large-breed dogs.

Using an autogenous bone graft (obtained from the iliac crest), 4-mm cancellous bone screws, and polymethylmethacrylate, a distracted cervical spinal fusion technique was performed on 10 dogs with myelographic evidence of caudal cervical spondylomyelopathy. All dogs had evidence of dynamic soft tissue spinal cord compression, as indicated by flexion, extension, and traction myelographic views. Of the 10 dogs, 4 previously had undergone surgery by use of ventral slot or cervical disk fenestration techniques, and their neurologic status had deteriorated after the original surgery. Preoperative neurologic status of the 10 dogs included nonambulatory tetraparesis (n = 5), severe ataxia with conscious proprioceptive deficits (n = 2), and mild ambulatory ataxia with conscious proprioceptive deficits (n = 3). Five dogs had signs of various degrees of cervical pain. Clinical improvement was observed in 8 of 10 dogs--either improved neurologic status or elimination of cervical pain. Implant loosening developed in 3 dogs; 2 of them were euthanatized because of lack of neurologic improvement. Radiographic evidence of bony cervical fusion was observed during a 9- to 24-week period in 6 of the 8 surviving dogs. The distracted cervical fusion technique appears to be a valid surgical procedure to manage cervical spondylomyelopathy in those dogs in which the lesions are limited to one cervical intervertebral disk space.

Animals↗
PubMedDate not supplied

Cognitive-behavioral intervention effects on adolescents' anxiety and pain following spinal fusion surgery.

BACKGROUND: Cognitive-behavioral interventions, typically effective in reducing anxiety and pain, have not been applied to adolescents undergoing major orthopaedic surgery. OBJECTIVES: To determine the effectiveness of three cognitive-behavioral interventions for reducing adolescents' postoperative anxiety and pain following spinal fusion surgery for scoliosis, and whether effectiveness depended on preoperative anxiety and age. METHODS: A randomized controlled trial with four groups receiving a videotape intervention (information only, coping only, information plus coping, or control) used a convenience sample of 109 adolescents (88 female, 93 White), 11-18 years of age (M = 14). Speilberger's (1983) State Anxiety scale assessed anxiety preoperatively and postoperatively on Day 2. A visual analogue scale assessed pain postoperatively on Days 2 and 4. RESULTS: Information plus coping was most effective for reducing postoperative anxiety in adolescents with high preoperative anxiety. Coping instruction led to less postoperative anxiety and pain for adolescents ages 13 and younger. The control group reported the highest levels of pain on Day 4. CONCLUSIONS: Cognitive-behavioral interventions designed to prepare adolescents for surgery should be tailored to individual factors and developmental needs, especially the adolescents' preoperative anxiety level and age.

Adaptation, Psychological↗