Global Spine

Study Design: Retrospective study. Objective: Previous studies have demonstrated that increased implant density (ID) results in improved coronal deformity correction. However, low-density constructs with strategically placed fixation points may achieve similar coronal correction. The purpose of this study was to identify key zones along the spinal fusion where high ID statistically correlated to improved coronal deformity correction. Our hypothesis was that high ID within the periapical zone would not be associated with increased percent Cobb correction. Methods: We identified patients with Lenke type 1 curves with a minimum 2-year follow up. The instrumented vertebral levels were divided into 4 zones: (1) cephalad zone, (2) caudal zone, (3) apical zone, and (4) periapical zone. High and low percent Cobb correction groups were compared, high percent Cobb group was defined as percent correction >67%. Total ID, total concave ID, total convex ID, and ID within each zone of the curve...

Introduction: To report a case of monoparesis caused by a vertebral artery (VA) anomaly and foraminal stenosis treated with microvascular decompression by the posterior approach. Material and Methods: A 51-year-old man was referred because of a 4-year history of progressive left shoulder pain refractory to other forms of treatment and a 7-month history of arm weakness. Clinical and radiologic evaluation showed an abnormally tortuous loop of left C5-6 cervical foramina with foraminal stenosis causing direct C6 nerve root compression. Results: Left posterior cervical C5-6 facetectomy and fusion was done to decompress the nerve root. The C6 nerve root was identified and well decompressed. The patient’s symptoms resolved after surgery, supporting the posterior decompression of a cervical nerve root compressed by a vertebral artery loop and stenosis for the relief of pain and weakness. Conclusion: Cervical root compression by an anomalous extracranial VA accompanied with foraminal stenos...

Purpose The aim of this study was to assess the impact of 3-D navigation for pedicle screw placement accuracy in minimally invasive transverse lumbar interbody fusion (MIS-TLIF). Methods A retrospective review of 52 patients who had MIS-TLIF assisted with 3D navigation is presented. Clinical outcomes were assessed with the Oswestry Disability Index (ODI), Visual Analog Scales (VAS), and MacNab scores. Radiographic outcomes were assessed using X-rays and thin-slice computed tomography. Result The mean age was 56.5 years, and 172 screws were implanted with 16 pedicle breaches (91.0% accuracy rate). Radiographic fusion rate at a mean follow-up of 15.6 months was 87.23%. No revision surgeries were required. The mean improvement in the VAS back pain, VAS leg pain, and ODI at 11.3 months follow-up was 4.3, 4.5, and 26.8 points, respectively. At last follow-up the mean postoperative disc height gain was 4.92 mm and the mean postoperative disc angle gain was 2.79 degrees. At L5-S1 level, th...

Revision lumbar spine surgeries are technically challenging with inconstant outcome results. This article discusses the preoperative, intraoperative, as well as postoperative management in these difficult patients. Successful intervention requires a detailed history and physical examination and carefully chosen diagnostic tests. Preoperative planning is paramount in these cases. The decision-making process should address the timing of the surgery, surgical approach, level of interbody fusion required, correction of sagittal imbalance, type of osteotomy, location of the osteotomy, and the end of the construct. Surgeons should be prepared to manage associated complications such as dural tear and massive blood loss. The use of autograft and/or biologic graft is necessary to help in achieving a successful fusion. Postoperative management includes prophylactic antibiotic, anticoagulation, nutritional support, and brace.

A multicenter, retrospective case series. In the past several years, screw fixation of the cervical spine has become commonplace. For the most part, this is a safe, low-risk procedure. While rare, screw backout or misplaced screws can lead to morbidity and increased costs. We report our experiences with this uncommon complication. A multicenter, retrospective case series was undertaken at 23 institutions in the United States. Patients were included who underwent cervical spine surgery from January 1, 2005, to December 31, 2011, and had misplacement of screws requiring reoperation. Institutional review board approval was obtained at all participating institutions, and detailed records were sent to a central data center. A total of 12 903 patients met the inclusion criteria and were analyzed. There were 11 instances of screw backout requiring reoperation, for an incidence of 0.085%. There were 7 posterior procedures. Importantly, there were no changes in the health-related quality-of-...

Study Design Retrospective chart review and review of literature. Objective Few case reports of traumatic L5-S1 displacement have been presented in the literature. Here we present two cases of traumatic spondylolisthesis showing both anterior and posterior displacement, the treatment algorithm, and a review of the literature. Methods The authors conducted a retrospective review of representative patients and a literature review of traumatic spondylolisthesis at the L5-S1 junction. Two representative patients were identified with traumatic spondylolisthesis: one with an anterior dissociation, and the other with a posterior dissociation. Results Radiographic, computed tomography, and magnetic resonance imaging illustrated the bony and soft tissue injury found in each patient, as well as the final stabilization and outcomes. Operative stabilization was necessary, and both patients were treated with open reduction internal fixation. The patient with posterior dissociation had complete r...

As the prevalence of syphilis rises, an increase in tertiary syphilis with spinal involvement is predicted. We report what we believe to be the first case of compressive cervical spine syphilitic gummata, with central cord compression signs. We also review the relevant literature to date. The diagnosis of syphilis in the spine relies on the physician to be aware of it as part of the differential diagnosis. Treponemal laboratory tests are an important aid in establishing a diagnosis.

Introduction: A prior study showed the touched vertebra (TV), defined as the most cephalad thoracolumbar/lumbar vertebra “touched” by the center sacral vertical line (CSVL), as a potential landmark vertebra & recommended lowest instrumented vertebra (LIV) as well. We evaluated a large cohort of Lenke type 1 & 2 cases to determine if selecting the TV as the LIV will produce optimal positioning at a min. 5 yrs postoperative. Our hypothesis was that it would and that fusing short of the TV would lead to a suboptimal result. Material and Methods: 299 pts with Lenke 1 (n = 207) or Lenke 2 (n = 92) AIS curves at a min. 5 yr f/u were evaluated. The TV was selected on the preoperative x-ray by 2 independent examiners & confirmed for agreement. The LIV selected was compared to the preoperative TV as well as the LIV-CSVL distance at min. 5 yr f/u. Comparison was made on the LIV-CSVL distance in pts fused short of the TV, to the TV or distal to the TV using standard statistical software. Resul...

Study Design: Retrospective case control study. Objectives: Adjacent-level ossification development (ALOD) is a distinct form of adjacent segmental degeneration that has been recognized to occur after anterior cervical discectomy and fusion (ACDF). It is unclear whether ACDF with plate versus standalone has an effect on rates of ALOD. This retrospective case-control study aims to assess the rate of ALOD in a large series of patients undergoing ACDF with and without plate and factors causing ALOD. Methods: Data was collected for patients undergoing ACDF from January 2009 to July 2016. Data collected was from multiple centers and included demographic data, surgical data, radiological imaging at time of surgery, and serial follow-up imaging. The radiology for ALOD was independently reviewed. Cohorts were divided into ACDF with plate (Group P = plate) and ACDF without plate (Groups S = standalone) and outcomes were compared. Results: There were 260 patients with 138 (53%) in Group P and...

Study Design: Retrospective cohort study. Objective: To identify disparities in surgical decision making for lumbar disc pathologies based on patient demographics, hospital characteristics, and temporal characteristics of admission. Methods: A retrospective analysis of patients admitted for surgical intervention of disc herniation or degeneration was performed to observe the effect of demographic, hospital, and admission-related factors on the decision to perform an isolated decompression or decompression with single level fusion using the National Inpatient Sample. Results: Of 84 953 patients with lumbar disc pathologies, 69 975 patients were treated electively, and 14 978 patients were treated nonelectively. Hispanic and Asian/Pacific Islander patients were less likely to receive a fusion for elective cases compared with White patients (odds ratio [OR] 0.88, P = .004; OR 0.70, P < .001, respectively). In elective cases, privately insured and self-paying patients were less likel...

Introduction: A prior study showed the touched vertebra (TV), defined as the most cephalad thoracolumbar/lumbar vertebra “touched” by the center sacral vertical line (CSVL), as a potential landmark vertebra & recommended lowest instrumented vertebra (LIV) as well. We evaluated a large cohort of Lenke type 1 & 2 cases to determine if selecting the TV as the LIV will produce optimal positioning at a min. 5 yrs postoperative. Our hypothesis was that it would and that fusing short of the TV would lead to a suboptimal result. Material and Methods: 299 pts with Lenke 1 (n = 207) or Lenke 2 (n = 92) AIS curves at a min. 5 yr f/u were evaluated. The TV was selected on the preoperative x-ray by 2 independent examiners & confirmed for agreement. The LIV selected was compared to the preoperative TV as well as the LIV-CSVL distance at min. 5 yr f/u. Comparison was made on the LIV-CSVL distance in pts fused short of the TV, to the TV or distal to the TV using standard statistical software. Resul...

Introduction: A prior study showed the touched vertebra (TV), defined as the most cephalad thoracolumbar/lumbar vertebra “touched” by the center sacral vertical line (CSVL), as a potential landmark vertebra & recommended lowest instrumented vertebra (LIV) as well. We evaluated a large cohort of Lenke type 1 & 2 cases to determine if selecting the TV as the LIV will produce optimal positioning at a min. 5 yrs postoperative. Our hypothesis was that it would and that fusing short of the TV would lead to a suboptimal result. Material and Methods: 299 pts with Lenke 1 (n = 207) or Lenke 2 (n = 92) AIS curves at a min. 5 yr f/u were evaluated. The TV was selected on the preoperative x-ray by 2 independent examiners & confirmed for agreement. The LIV selected was compared to the preoperative TV as well as the LIV-CSVL distance at min. 5 yr f/u. Comparison was made on the LIV-CSVL distance in pts fused short of the TV, to the TV or distal to the TV using standard statistical software. Resul...

Study Design Systematic review. Clinical Questions (1) When used as an assistive device, do wearable exoskeletons improve lower extremity function or gait compared with knee-ankle-foot orthoses (KAFOs) in patients with complete or incomplete spinal cord injury? (2) When used as a rehabilitation device, do wearable exoskeletons improve lower extremity function or gait compared with other rehabilitation strategies in patients with complete or incomplete spinal cord injury? (3) When used as an assistive or rehabilitation device, are wearable exoskeletons safe compared with KAFO for assistance or other rehabilitation strategies for rehabilitation in patients with complete or incomplete spinal cord injury? Methods PubMed, Cochrane, and Embase databases and reference lists of key articles were searched from database inception to May 2, 2016, to identify studies evaluating the effectiveness of wearable exoskeletons used as assistive or rehabilitative devices in patients with incomplete or ...

Study Design: Systematic review and meta-analysis. Objectives: Arthrodesis has been a valid treatment option for spinal diseases, including spondylolisthesis and lumbar spinal stenosis. Posterolateral and posterior lumbar interbody fusion are amongst the most used fusion techniques. Previous reports comparing both methods have been contradictory. Thus, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to establish substantial evidence on which fusion method would achieve better outcomes. Methods: Major databases including PubMed, Embase, Web of Science and CENTRAL were searched to identify studies comparing outcomes of interest between posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF). We extracted data on clinical outcome, complication rate, revision rate, fusion rate, operation time, and blood loss. We calculated the mean differences (MDs) for continuous data with 95% confidence intervals (CIs) for each outcome and the...

Study Design: Scoping review. Objectives: To identify a practical and reproducible approach to organize Quality of Care Indicators (QoCI) in individuals with traumatic spinal cord injury (TSCI). Methods: A comprehensive literature review was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL) (Date: May 2018), MEDLINE (1946 to May 2018), and EMBASE (1974 to May 2018). Two independent reviewers screened 6092 records and included 262 full texts, among which 60 studies were included for qualitative analysis. We included studies, with no language restriction, containing at least 1 quality of care indicator for individuals with traumatic spinal cord injury. Each potential indicator was evaluated in an online, focused group discussion to define its categorization (healthcare system structure, medical process, and individuals with Traumatic Spinal Cord Injury related outcomes), definition, survey options, and scale. Results: A total of 87 indicators were identified fr...

Introduction: To report a case of monoparesis caused by a vertebral artery (VA) anomaly and foraminal stenosis treated with microvascular decompression by the posterior approach. Material and Methods: A 51-year-old man was referred because of a 4-year history of progressive left shoulder pain refractory to other forms of treatment and a 7-month history of arm weakness. Clinical and radiologic evaluation showed an abnormally tortuous loop of left C5-6 cervical foramina with foraminal stenosis causing direct C6 nerve root compression. Results: Left posterior cervical C5-6 facetectomy and fusion was done to decompress the nerve root. The C6 nerve root was identified and well decompressed. The patient’s symptoms resolved after surgery, supporting the posterior decompression of a cervical nerve root compressed by a vertebral artery loop and stenosis for the relief of pain and weakness. Conclusion: Cervical root compression by an anomalous extracranial VA accompanied with foraminal stenos...

A multicenter retrospective case series. Horner's syndrome is a known complication of anterior cervical spinal surgery, but it is rarely encountered in clinical practice. To better understand the incidence, risks, and neurologic outcomes associated with Horner's syndrome, a multicenter study was performed to review a large collective experience with this rare complication. We conducted a retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Medical records for 17 625 patients who received subaxial cervical spine surgery from 2005 to 2011 were reviewed to identify occurrence of 21 predefined treatment complications. Descriptive statistics were provided for baseline patient characteristics. Paired t test was used to analyze changes in clinical outcomes at follow-up compared to preoperative status. In total, 8887 patients who underwent anterior cervical spine surgery at the participating i...

A multicenter, retrospective case series. In the past several years, screw fixation of the cervical spine has become commonplace. For the most part, this is a safe, low-risk procedure. While rare, screw backout or misplaced screws can lead to morbidity and increased costs. We report our experiences with this uncommon complication. A multicenter, retrospective case series was undertaken at 23 institutions in the United States. Patients were included who underwent cervical spine surgery from January 1, 2005, to December 31, 2011, and had misplacement of screws requiring reoperation. Institutional review board approval was obtained at all participating institutions, and detailed records were sent to a central data center. A total of 12 903 patients met the inclusion criteria and were analyzed. There were 11 instances of screw backout requiring reoperation, for an incidence of 0.085%. There were 7 posterior procedures. Importantly, there were no changes in the health-related quality-of-...

Study Design: Randomized controlled trial. Objectives: Lumbar interbody fusion with cages is performed to provide vertebral stability, restore alignment, and maintain disc and foraminal height. Polyetheretherketone (PEEK) is commonly used. Silicon nitride (Si3N4) is an alternative material with good osteointegrative properties. This study was designed to assess if Si3N4 cages perform similar to PEEK. Methods: A non-inferiority double-blind multicenter RCT was designed. Patients presenting with chronic low-back pain with or without leg pain were included. Single- or double-level instrumented transforaminal lumbar interbody fusion (TLIF) using an oblique PEEK or Si3N4 cage was performed. The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ). The non-inferiority margin for the RMDQ was 2.6 points on a scale of 24. Secondary outcomes included the Oswestry Disability Questionnaire (ODI), Visual Analogue Scales (VAS), SF-36 Physical Function, patient and surgeon Likert...

Study Design: Retrospective study. Objectives: This study retrospectively evaluates the outcome of the surgical treatment of early-onset scoliosis with proximal clawing rib fixation in hybrid growing-rod constructs. The study examines spinal deformity correction with spinal growth maintenance, and the complications associated with this technique. Method: A hybrid rib construct surgery with serial lengthening was utilized for the treatment of 71 patients. Mean age at surgery was 66.6 months and mean time for follow-up was 43.9 months. Results: The coronal Cobb angle in patients fell from 63.1° preoperatively to 51.6° at the last follow-up, with a correction of 16.8%. The sagittal Cobb angle fell from 66.7° preoperatively to 38° at the last follow-up, with a correction of 42.6%. Coronal balance fell from 22.8° preoperatively to 22.3°, and sagittal balance fell from 35.4 mm preoperatively to 24.39 mm. T1-S1 spine height increased from 248.7 mm preoperatively to 282.4 mm, with a mean ch...

Review and technical report. Intraoperative ultrasound has been used by spine surgeons since the early 1980s. Since that time, more advanced modes of intraoperative imaging and navigation have become widely available. Although the use of ultrasound during spine surgery has fallen out of favor, it remains the only true real-time imaging modality that allows surgeons to visualize soft tissue anatomy instantly and continuously while operating. It is our objective to demonstrate that for this reason, ultrasound is a useful adjunctive technique for spine surgeons, especially when approaching intradural lesions or when addressing pathology in the ventral spinal canal via a posterior approach. Using PubMed, the existing literature regarding the use of intraoperative ultrasound during spinal surgery was evaluated. Also, surgical case logs were reviewed to identify spinal operations during which intraoperative ultrasound was used. Illustrative cases were selected and reviewed in detail. This...

Retrospective study of registry data. Aging of society and recent advances in surgical techniques and general anesthesia have increased the demand for spinal surgery in elderly patients. Many complications have been described in elderly patients, but a multicenter study of perioperative complications in spinal surgery in patients aged 80 years or older has not been reported. Therefore, the goal of the study was to analyze complications associated with spine surgery in patients aged 80 years or older with cervical, thoracic, or lumbar lesions. A multicenter study was performed in patients aged 80 years or older who underwent 262 spinal surgeries at 35 facilities. The frequency and severity of complications were examined for perioperative complications, including intraoperative and postoperative complications, and for major postoperative complications that were potentially life threatening, required reoperation in the perioperative period, or left a permanent injury. Perioperative com...

A multicenter, retrospective cohort study. To evaluate clinical outcomes in patients with reintubation after anterior cervical spine surgery. A total of 8887 patients undergoing anterior cervical spine surgery were enrolled in the AOSpine North America Rare Complications of Cervical Spine Surgery study. Patients with or without complications after surgery were included. Demographic and surgical information were collected for patients with reintubation. Patients were evaluated using a variety of assessment tools, including the modified Japanese Orthopedic Association scale, Nurick score, Neck Disability Index, and Short Form-36 Health Survey. Nine cases of postoperative reintubation were identified. The total prevalence of this complication was 0.10% and ranged from 0% to 0.59% across participating institutions. The time to development of airway symptoms after surgery was within 24 hours in 6 patients and between 5 and 7 days in 3 patients. Although 8 patients recovered, 1 patient di...