Should backache be treated with spinal fusion? Spinal fusion is the only treatment for discogenic pain.
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Use of electrical bone stimulation in spinal fusion.
Spinal fusion is commonly done to manage deformity, restore stability, and eliminate excessive motion at specific spinal levels. Pseudarthrosis limits the clinical success of spinal fusion. Three types of electrical stimulation, which is used to manage non-union in long bones, recently have been applied in an attempt to enhance the rate of spinal fusion. Direct current electrical stimulation is internal and thus eliminates dependence on patient compliance. Pulsed electromagnetic fields and capacitively coupled electrical stimulation are external techniques that require patient compliance but do not have the increased risk associated with implantable devices. Firm conclusions about efficacy are difficult to establish because of inconsistencies in both determining a reliable, reproducible end point for fusion and in incorporating the effect of patient parameters. Most data indicate a positive effect for use of direct current stimulation, but further studies are necessary to determine its appropriateness as an adjuvant to spinal fusion.
Animals↗
Gene therapy for spinal fusion.
Spinal fusion will continue to be an important part of the surgical treatment of spinal pathology for the foreseeable future. Traditional challenges to successful spinal fusion surgery include autograft donor site morbidity and pseudoarthrosis. Recent advances in the understanding of the biology of bone formation have allowed the development of therapeutic biologics. Although recombinant bone morphogenetic proteins delivered to the arthrodesis site will stimulate fusion, these proteins have been less successful in more challenging fusion situations (posterolateral), require supraphysiologic doses to promote fusion in humans, and are quite expensive. Gene therapy may represent the easiest method for the application of bone-forming biologic agents to promote spinal fusion. Both in vivo and ex vivo techniques of delivery of therapeutic genes have been used effectively to promote fusion in lower animals. Considerable research is required to identify gene therapy techniques and vectors with acceptable safety profiles and high fusion rates.
Animals↗
Functional activities in spinal muscular atrophy patients after spinal fusion.
Spinal muscular atrophy patients present with weakness, greater in the proximal muscles, leading to scoliosis and limited upper extremity function. The purpose of this study is to identify unique aspects of these patients and to understand how spinal fusion affects their function. Forty patients underwent Harrington or Luque rod instrumentation with functional evaluations preoperatively and 2 and 5 years postoperatively. Biomechanical assessment of function is important. Flexibility of the spine is functionally advantageous because distal strength is used to align weaker proximal segments. Postoperatively, lack of spinal flexibility resulted in a decline in gross motor function and increased use of UE aids due to a change in the trunk position in the weaker patients. The stronger patients' activities were maintained. Earlier mobilization in patients with Luque procedures did not improve postoperative function.
Activities of Daily Living↗
Radiographic outcomes of anterior spinal fusion versus posterior spinal fusion with thoracic pedicle screws for treatment of Lenke Type I adolescent idiopathic scoliosis curves.
STUDY DESIGN: Analysis of radiographic outcomes following surgical correction of scoliosis. OBJECTIVES: To compare the curve correction and derotation following anterior spinal fusion (ASF) versus posterior spinal fusion (PSF) with thoracic pedicle screws. SUMMARY OF BACKGROUND DATA: The benefits of ASF in adolescent idiopathic scoliosis include saving distal fusion levels and historically greater correction and derotation compared with PSF. However, comparative studies between ASF and PSF have generally consisted only of posterior hook instrumentation or hybrid constructs, with no direct comparisons between anterior fusion and thoracic pedicle screw (TPS) series. METHODS: We performed a retrospective review of the radiographic and medical records of 40 patients (two curve-matched groups) with Lenke Type I main thoracic adolescent idiopathic scoliosis. There were 20 patients who underwent open ASF with single-rod instrumentation with a mean age at surgery of 15 years + 6 months (range, 12-20 years) and 20 patients who underwent PSF with TPS constructs with a mean age at surgery of 13 + 6 (range, 12-15). Radiographic follow-up averaged 44.1 month (24-80) for the ASF group and 55.1 month (25-83) for the PSF/TPS group. We evaluated the sagittal alignment, Cobb angles, rib hump deformity (RH), apical rib spread difference (ARSD), and apical vertebral body-rib ratio (AVB-R), measures of rotation and thoracic torsion, between both groups. RESULTS: Before surgery, the main thoracic curve was 55.1 degrees (range, 47-66 degrees) for the ASF group and 52.5 degrees (range, 46-68 degrees ) for the PSF/TPS group (P = 0.16). Additionally, there was no difference in the pelvic tilt curves, thoracic kyphosis, lumbar lordosis, RH, or ARSD. However, there was a slightly greater preoperative thoracolumbar-lumbar (TL/L) curve (34.6 degrees versus 29.5 degrees , P = 0.04) and AVB-R (1.75 versus 1.5, P = 0.003) in the ASF group. After surgery, an average of 6.5 levels (range, 6-8) were fused in the ASF group, compared with 7.7 levels (range, 5-12) in the PSF/TPS group (P = 0.001) or 1.2 additional levels for PSF/TPS. At final postoperative follow-up, spontaneous pelvic tilt curve correction was greater in the ASF group (47% versus 35%), although this difference did not reach statistical significance (P = 0.07). For the main thoracic and TL/L curves, there was greater correction in the PSF/TPS group (62% versus 52%, P = 0.009; and 56% versus 41%, P = 0.03), respectively. Additionally, the PSF/TPS group demonstrated significantly greater RH correction (51% versus 26%, P = 0.005) and AVB-R ratio improvement (73% versus 32%, P < 0.0001). We also noted a trend towards increased correction of the ARSD in the PSF/TPS group (58% versus 32%, P = 0.07). Further, the postoperative thoracic kyphosis decreased 4.4 degrees in the PSF/TPS group (postop avg. 25.0 degrees ) and increased 5.7 degrees (average, 30.6 degrees ) in the ASF group (P = 0.04). CONCLUSIONS: In this curve-matched cohort of Lenke Type I curves, PSF with TPS provided superior instrumented correction of main thoracic curves and spontaneous correction of TL/L curves. Perhaps more importantly, PSF/TPS demonstrated improved correction of thoracic torsion and rotation as compared with ASF in terms of RH (P = 0.005) and AVB-R ratio (P= 0.0001), with only one additional spinal segment fused on average.
Adolescent↗
Effect of posterior spinal fusion on spinal balance in idiopathic scoliosis.
We analyzed the influence of posterior spinal fusion with Harrington rod instrumentation on spinal balance in 85 patients with primary thoracic curve patterns. Utilizing roentgenographic techniques of measurement, spinal decompensation was improved measurably in 64% of the patients, and lateral trunk shift improved in 82% of the patients with preoperative alterations of spinal balance.
Adolescent↗
Spinal bone density following spinal fusion.
Spinal bone densities were assessed in 25 patients following lumbar fusion and bracing, in an attempt to study bone remodeling by noninvasive methods. Dual-photon densitometry was used to study specific areas of autologous bone grafts and adjacent vertebrae above the fusion mass. Measurements were made preoperatively and at 6-week intervals postoperatively. The data for the first 12 months postoperatively are reported here. In all patients there was at first a consistent loss in density in the vertebrae above the fusion mass, averaging 15.7%. This was followed by a gradual density increase such that by 1 year postoperatively, in 60% of the subjects, the density of these vertebrae was higher than the preoperative level. In the grafted areas, bone changes were cyclical, demonstrating a remodeling pattern consistent with that described in animal literature for graft healing and also consistent with modern bone remodeling theory. There was a general tendency toward a gradual increase in the density of the fusion mass.
Adult↗
Thoracoscopic spinal fusion compared with posterior spinal fusion for the treatment of thoracic adolescent idiopathic scoliosis.
BACKGROUND: Posterior spinal fusion with segmental instrumentation is the gold standard for the surgical treatment of thoracic adolescent idiopathic scoliosis. More recently, anterior surgery and video-assisted thoracoscopic surgery with spinal instrumentation have become available. The purpose of the present study was to compare the radiographic and clinical outcomes as well as pulmonary function in patients managed with either anterior thoracoscopic or posterior surgery. METHODS: Radiographic data, Scoliosis Research Society patient-based outcome questionnaires, pulmonary function, and operative records were reviewed for fifty-one patients undergoing surgical treatment of scoliosis. Data were collected preoperatively, immediately postoperatively, and at the time of the final follow-up. The radiographic parameters that were analyzed included coronal curve correction, the most caudad instrumented vertebra tilt angle correction, coronal balance, and thoracic kyphosis. The operative parameters that were evaluated included the operative time, the estimated blood loss, the blood transfusion rate, the number of levels fused, the type of bone graft used, and the number of intraoperative and postoperative complications. The pulmonary function parameters that were analyzed included vital capacity and peak flow. RESULTS: The thoracoscopic group included twenty-eight patients with a mean age of 14.6 years, and the posterior fusion group included twenty-three patients with a mean age of 14.3 years. The percent correction was 54.5% for the thoracoscopic group and 55.3% for the posterior group. With the numbers available, there were no significant differences between the two groups in terms of kyphosis (p = 0.84), coronal balance (p = 0.70), or tilt angle (p = 0.91) at the time of the final follow-up. The mean number of levels fused was 5.8 in the thoracoscopic group, compared with 9.3 levels in the posterior group (p < 0.0001). The estimated blood loss in the thoracoscopic group was significantly less than that in the posterior fusion group (361 mL compared with 545 mL; p = 0.03), and the transfusion rate in the thoracoscopic group was significantly lower than that in the posterior fusion group (14% compared with 43%; p = 0.01). Operative time in the thoracoscopic group was significantly greater than that in the posterior group (6.0 compared with 3.3 hours, p < 0.0001). There were no intraoperative complications in either group. Vital capacity and peak flow had returned to baseline levels in both groups at the time of the final follow-up. Patients in the thoracoscopic group scored higher than those in the posterior group in terms of the total score (p < 0.0001) and all of the domains (p < 0.01) of the Scoliosis Research Society questionnaire at the time of the final follow-up. CONCLUSIONS: Thoracoscopic spinal instrumentation compares favorably with posterior fusion in terms of coronal plane curve correction and balance, sagittal contour, the rate of complications, pulmonary function, and patient-based outcomes. The advantages of the procedure include the need for fewer levels of spinal fusion, less operative blood loss, lower transfusion requirements, and improved cosmesis as a result of small, well-hidden incisions. However, the operative time for the thoracoscopic procedure was nearly twice that for the posterior approach. Additional study is needed to determine the precise role of thoracoscopic spinal instrumentation in the treatment of thoracic adolescent idiopathic scoliosis.
Adolescent↗
1995 Volvo Award in basic sciences. The use of an osteoinductive growth factor for lumbar spinal fusion. Part I: Biology of spinal fusion.
STUDY DESIGN: The histology of lumbar intertransverse process spinal fusion was studied in an experimental model in rabbits. OBJECTIVES: To qualitatively and quantitatively analyze the sequential histology of spinal fusion using a previously validated animal model. SUMMARY OF BACKGROUND DATA: Few previous studies have described the sequential histology during the posterolateral spinal fusion healing process using autogenous bone, and a basic understanding of the biology of this repair process is lacking. METHODS: Fourteen adult New Zealand white rabbits underwent single-level posterolateral lumbar intertransverse process arthrodesis with autogenous iliac bone graft. Animals were killed 1-10 weeks after surgery, and the fusion masses were analyzed histologically and quantitated using a semiautomated image analysis system. RESULTS: Three distinct phases of healing were identified (inflammatory, reparative, and remodeling) and occurred in sequence but in a delayed fashion in the central zone of the fusion mass compared with the outer transverse process zones. Membraneous bone formation, evident first at the ends of the fusion eminating from the decorticated transverse processes, was the predominant mechanism of healing. The central zone was somewhat different in that there was a period of endochondral bone formation during weeks 3 and 4 in this zone where cartilage formed and was converted to bone. Remodeling in the central zone had equilibrated with the transverse process zones by 10 weeks. CONCLUSIONS: Lumbar intertransverse process spinal fusion is a complex process from a spatial and temporal standpoint. When autogenous bone is used as the graft material, this process critically depends on a variety of factors from the decorticated host bone and exposed marrow. The persistence of a central cartilage zone may be related to some types of nonunions and deserves future investigation. This enhanced understanding of the biology of spinal fusion with autogenous bone graft will provide a foundation for optimizing the use of osteoinductive bone growth factors in this healing process.
Animals↗
Anterior spinal fusion in spinal tuberculosis using an iliac bone block.
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Humans↗
The effects of ketorolac injected via patient controlled analgesia postoperatively on spinal fusion.
Lumbar spinal fusions have been performed for spinal stability, pain relief and improved function in spinal stenosis, scoliosis, spinal fractures, infectious conditions and other lumbar spinal problems. The success of lumbar spinal fusion depends on multifactors, such as types of bone graft materials, levels and numbers of fusion, spinal instrumentation, electrical stimulation, smoking and some drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs). From January 2000 to December 2001, 88 consecutive patients, who were diagnosed with spinal stenosis or spondylolisthesis, were retrospectively enrolled in this study. One surgeon performed all 88 posterolateral spinal fusions with instrumentation and autoiliac bone graft. The patients were divided into two groups. The first group (n=30) was infused with ketorolac and fentanyl intravenously via patient controlled analgesia (PCA) postoperatively and the second group (n=58) was infused only with fentanyl. The spinal fusion rates and clinical outcomes of the two groups were compared. The incidence of incomplete union or nonunion was much higher in the ketorolac group, and the relative risk was approximately 6 times higher than control group (odds ratio: 5.64). The clinical outcomes, which were checked at least 1 year after surgery, showed strong correlations with the spinal fusion status. The control group (93.1%) showed significantly better clinical results than the ketorolac group (77.6%). Smoking had no effect on the spinal fusion outcome in this study. Even though the use of ketorolac after spinal fusion can reduce the need for morphine, thereby decreasing morphine related complications, ketorolac used via PCA at the immediate postoperative state inhibits spinal fusion resulting in a poorer clinical outcome. Therefore, NSAIDs such as ketorolac, should be avoided after posterolateral spinal fusion.
Adult↗
Motion preservation technologies: alternatives to spinal fusion.
Spinal arthrodesis is a versatile and effective option in the management of instabilities, deformities, and painful spinal conditions. An increasing body of biomechanical and clinical evidence suggests that the relative immobility of fused spinal segments alters stress transfer, leading to adjacent-level degeneration. The development of nonfusion spinal prostheses has been driven by increasing concerns regarding these arthrodesis-related morbidities, including graft-site harvest, pseudarthrosis, and adjacent-level degeneration. Motion-sparing implants offer some theoretical advantages over fusion; however, judicious use of these products with careful patient selection is warranted until outcome studies can demonstrate their efficacy. In this article, we review the 3 major categories of nonfusion technologies: total disc replacement, prosthetic nuclear implants, and posterior stabilization devices.
Arthroplasty, Replacement↗
Long-term follow-up of spinal fusion in spinal muscular atrophy.
From 1966 to 1983, 11 females and eight males with spinal muscular atrophy were treated by arthrodesis. Seventeen of 19 patients were evaluated by follow-up physical examination, roentgenograms, and questionnaires. In order to compare long-term versus short-term results, changes in management, and factors contributing to morbidity and mortality, three groups were identified for study. Group I consisted of 11 patients operated between 1966 and 1983 and alive at follow-up evaluation. Group II consisted of five patients operated between 1980 and 1983. Group III consisted of three patients, all deceased at follow-up evaluation and operated before 1980. In Group I, the preoperative curve averaged 119 degrees and at final follow-up examination, 99 degrees. The average preoperative curve in Group II was 80 degrees and at follow-up examination, 49 degrees. Long-term follow-up vital capacities were obtained in nine patients. The average preoperative vital capacity was 1033 cm3, and the average vital capacity seven years postoperation was 860 cm3. Most patients reported improvement in sitting, balance, and comfort. All patients are wheelchair-bound, as they were before surgery. Few long-term respiratory problems were reported.
Adolescent↗
Should backache be treated with spinal fusion? The case for spinal fusion is unproved.
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Back Pain↗
The influence of lumbar lordosis on spinal fusion and functional outcome after posterolateral spinal fusion with and without pedicle screw instrumentation.
The aim of the current study was to examine the correlation between lumbar lordosis, spinal fusion, and functional outcome in patients suffering from severe low back pain, treated by posterolateral spinal fusion with or without pedicle screw instrumentation. One hundred thirty patients were randomly allocated to posterolateral lumbar fusion with or without Cotrel-Dubousset instrumentation. Functional outcome was assessed preoperatively, and 1 and 2 years postoperatively. Lordosis angles of the lumbar spine and fusion rates were assessed at the 1- and 2-year follow-up. No difference in lordosis angle was found between the two groups at any time. Lordosis was unchanged at 2 years compared with preoperative status in both groups. In the instrumented group, nonunion (23%) was followed by a decrease in lordosis at follow-up (p < 0.05). However, in the noninstrumented group, nonunion (14%) resulted in increased lordosis (p < 0.05). No correlation was found between functional outcome and lordosis angle. The current study showed no correlation between functional outcome and lordosis angle either before or after posterolateral spinal fusion. Use of instrumentation did not influence lumbar spinal alignment compared with noninstrumented fusions. The sagittal alignment was stable both 1 and 2 years after solid fusion. The failure mode of instrumented fusions was a reduced degree of lordosis in contrast to an increased degree of lordosis in patients with noninstrumented fusion.
Adult↗
Direct current electrical stimulation increases the fusion rate of spinal fusion cages.
STUDY DESIGN: A randomized experimental evaluation of direct current stimulation in a validated animal model with an experimental control group, using blinded radiographic, biomechanical, histologic, and statistical measures. OBJECTIVES: To evaluate the efficacy of the adjunctive use of direct current stimulation on the fusion rate and speed of healing of titanium interbody fusion cages packed with autograft in a sheep lumbar interbody fusion model. SUMMARY OF BACKGROUND DATA: Titanium lumbar interbody spinal fusion cages have been reported to be 90% effective for single-level lumbar interbody fusion. However, fusion rates are reported to be between 70% and 80% in patients with multilevel fusions or with risk factors such as obesity, tobacco use, or metabolic disorders. The authors hypothesized that direct current stimulation would increase the fusion rate of titanium interbody fusion cages packed with autograft in a sheep lumbar interbody fusion model. METHODS: Twenty-two sheep underwent lumbar discectomy and fusion at L4-L5 with an 11- x 20-mm Bagby and Kuslich (BAK) cage packed with autograft. Seven sheep received a BAK cage and no current. Seven sheep had a cage and a 40-microA current applied with a direct current stimulator. Eight sheep had a BAK cage and a 100-microA current applied. All sheep were killed 4 months after surgery. The efficacy of electrical stimulation in promoting interbody fusion was assessed by performing radiographic, biomechanical, and histologic analyses in a blinded fashion. RESULTS: The histologic fusion rate increased as the direct current dose increased from 0 microA to 40 microA to 100 microA (P < 0.009). Histologically, all animals in the 100-microA group had fusions in both the right and left sides of the cage. Direct current stimulation had a significant effect on increasing the stiffness of the treated motion segment in right lateral bending (P < 0.120), left lateral bending (P < 0.017), right axial rotation (P < 0.004), left axial rotation (P < 0.073), extension (P < 0.078), and flexion (P < 0.029) over nonstimulated levels. CONCLUSION: Direct current stimulation increased the histologic and biomechanical fusion rate and the speed of healing of lumbar interbody spinal fusion cages in an ovine model at 4 months.
Animals↗
Rationale for spinal fusion in lumbar spinal stenosis.
In order to define the indications for spinal fusion in patients undergoing decompression for lumbar spinal stenosis, 114 patients surgically treated were reviewed. Follow-up was 24 to 108 months. Patients were grouped into four categories: 15 with lateral recess stenosis, 45 with central-mixed stenosis, 43 with stenosis following prior lumbar surgery(s), and 11 with scoliosis and spinal stenosis. Only two patients with lateral recess stenosis underwent fusion with fair results. Approximately one-third of those with central-mixed stenosis required a fusion. Results were good in 70%. In those with stenosis following prior lumbar surgeries, although not statistically significant, those who had concomitant decompression and arthrodesis had a better outcome than those in whom decompression only was done. Patients with scoliosis and stenosis had decompression for significant motor and reflex deficits and fusion over the length of their major curves. Patients having decompression for lumbar stenosis with degenerative spondylolisthesis, isolated disc resorption with degenerative facet joints, intervertebral disc disease with instability, and those with scoliosis with multidirectional instabilities benefit from concomitant spinal fusion.
Female↗
Anterior lumbar interbody fusion--advances in spinal fusion technology.
AS MUCH AS 80% OF THE US POPULATION will be affected by back pain at some time during their lives. Some of the most common disorders are herniated disc, degenerative disc disease, degenerative spondylolisthesis, spinal stenosis, and revision of previously failed low back surgery. IF CONSERVATIVE TREATMENT for back pain fails, spinal fusion may be performed. Anterior lumbar interbody fusion effectively manages degenerative joint disease, instability, and spondylolisthesis. NURSES WHO PROVIDE CARE for patients undergoing this procedure help ensure patient safety and promote positive outcomes.
Adult↗