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1.
J Spinal Disord Tech ; 28(9): E534-43, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24136056

RESUMO

STUDY DESIGN: A prospective randomized and blinded comparative study of 2 patient groups with >5-year follow-up. OBJECTIVE: To compare the clinical outcomes and postoperative posterior muscle changes in patients with advanced degenerative disk disease undergoing 2-level circumferential spinal fusion using a posterior midline versus a paraspinal approach. SUMMARY OF BACKGROUND DATA: Lumbar spinal fusion is often performed using a circumferential (anterior and posterior) technique. Paraspinal muscle alterations occur during the retraction of the muscles required for posterior instrumentation and fusion bed preparation, which may adversely affect outcomes. METHODS: Patients with advanced 2-level lumbar degenerative disk disease were randomized into 2 groups of 25 each for the approach to the posterior spine for their anterior-posterior fusion. A midline posterior skin incision was universal, but all patients were blinded to the fascial incision and exposure to the posterior spine. All had intertransverse and facet joint fusions with pedicle screw instrumentation. Outcomes (visual analog back and leg pain scale, pain drawing, Oswestry disability index, and self-assessment of procedure success) were assessed at various periods postoperatively. Preoperative and >1-year postoperative magnetic resonance images (MRI), including paraspinal muscles, were read by a radiologist who was blinded to the surgical approach and outcomes. RESULTS: No difference in operative time, blood loss, implant costs, or any other intraoperative parameter existed between the 2 patient groups. Although clinical improvement for all outcome scales was significant for both groups postoperatively, there was no difference between groups. Postoperative MRI T2 relaxation values were significantly increased at the operative levels and distally, but the changes were similar for both groups. CONCLUSIONS: Midline and paraspinal approaches result in similar outcomes in 2-level spinal fusions. We were unable to demonstrate that a paraspinal muscle-splitting approach to 2-level fusion was superior to the muscle-stripping midline approach. However, the study has low statistical power.


Assuntos
Vértebras Lombares/cirurgia , Músculos Paraespinais/cirurgia , Fusão Vertebral/métodos , Adulto , Feminino , Seguimentos , Humanos , Dor Lombar/etiologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Fusão Vertebral/efeitos adversos , Resultado do Tratamento
2.
Eur Spine J ; 23(2): 347-55, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24197480

RESUMO

PURPOSE: To compare single-level circumferential spinal fusion using pedicle (n = 27) versus low-profile minimally invasive facet screw (n = 35) posterior instrumentation. METHOD: A prospective two-arm cohort study with 5-year outcomes as follow-up was conducted. Assessment included back and leg pain, pain drawing, Oswestry disability index (ODI), pain medication usage, self-assessment of procedure success, and >1-year postoperative lumbar magnetic resonance imaging. RESULTS: Significantly less operative time, estimated blood loss and costs were incurred for the facet group. Clinical improvement was significant for both groups (p < 0.01 for all outcomes scales). Outcomes were significantly better for back pain and ODI for the facet relative to the pedicle group at follow-up periods >1 year (p < 0.05). Postoperative magnetic resonance imaging found that 20 % had progressive adjacent disc degeneration, and posterior muscle changes tended to be greater for the pedicle screw group. CONCLUSION: One-level circumferential spinal fusion using facet screws proved superior to pedicle screw instrumentation.


Assuntos
Parafusos Ósseos , Fusão Vertebral/métodos , Adulto , Feminino , Humanos , Vértebras Lombares/cirurgia , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Dor Pós-Operatória/etiologia , Estudos Prospectivos , Doenças da Coluna Vertebral/cirurgia , Fusão Vertebral/efeitos adversos , Resultado do Tratamento
3.
Int J Spine Surg ; 17(1): 60-68, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-36414378

RESUMO

BACKGROUND: Bone autograft options may be limited in revision spinal fusion cases. Reconstruction of the iliac bone graft (IBG) donor site with cancellous bone allograft allows for reharvest for patients who subsequently have another fusion. This study examined viability of the reconstructed IBG (RIBG) donor sites. Secondarily, we assessed the feasibility of whether the RIBG sites could be reharvested for obtaining a successful arthrodesis for a secondary fusion. METHODS: Prospectively collected data of 154 consecutive lumbar revision fusions were reviewed, of which 17 cases had their IBG donor site backfilled with allograft bone at the time of their primary fusion and subsequently had secondary surgery for a pseudarthrosis repair or fusion extension. Biopsies of the RIBG and computed tomography (CT) images were obtained at the time of secondary fusion. Histology analyzed the ratio of filled to unfilled lacunae and marrow cellularity. Histology controls were from normal iliac crest. Clinically, postoperative CT and >2-year outcomes (visual analog scale [VAS] and Oswestry Disability Index [ODI]) evaluated the feasibility of the secondary fusion surgery using RIBG. The RIBG fusion rate and outcomes were compared with clinical control revision groups that had IBG and/or bone morphogenetic protein (BMP) used for their revision fusion. RESULTS: CT images prior to RIBG harvest found bony healing of the original graft donor site in all except 1 case. RIBG bone marrow histology found lower cellularity vs controls, but this characteristic did not appear to compromise bone viability with filled lacunae in 83% ± 14% in the RIBG group, vs 88% ± 8% for iliac controls. After revision fusion, often combined with bone growth stimulator or BMP, repeat CT demonstrated solid spinal fusions in 16 of 17 patients, whereas control revision group fusion rates were approximately 80%. Clinical improvement was significant (VAS decrease = 3.8, ODI decrease = 16.5) and comparable with the IBG revision controls. CONCLUSION: RIBG using allograft remodels into viable predominately cancellous bone and is clinically feasible for revision fusion if IBG or BMP is unavailable. CLINICAL RELEVANCE: Reconstructed iliac bone graft is viable and may be used as a bone graft option.

4.
Spine (Phila Pa 1976) ; 44(24): 1685-1696, 2019 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-31404055

RESUMO

STUDY DESIGN: A prospective, multicenter, randomized, controlled, investigational device exemption (IDE) noninferiority trial. OBJECTIVE: The aim of this study was to compare the 5-year safety and effectiveness of the activL Artificial Disc with Control Total Disc Replacement (TDR) systems (ProDisc-L or Charité) in the treatment of patients with symptomatic single-level lumbar degenerative disc disease (DDD). SUMMARY OF BACKGROUND DATA: The activL Artificial Disc received Food and Drug Administration approval in 2015 based on 2-year follow-up data. METHODS: Eligible patients presented with symptomatic, single-level, lumbar DDD who failed ≥6 months of nonsurgical management. At entry, 324 patients were randomly allocated (2 : 1) to treatment with activL (n = 218) or Control (n = 106, including n = 65 ProDisc-L and n = 41 Charité) TDR. At 5-year follow up, a total of 261 patients (176 activL patients and 85 Control patients) were available for analysis. RESULTS: The primary composite endpoint at 5 years for activL patients was noninferior to Control TDR. Relative to baseline, reductions in back pain severity and improvements in Oswestry Disability Index (ODI) were maintained for both the activL and Control TDR groups through 5 years. The activL group showed significantly better range of motion for flexion-extension rotation, flexion-extension translation, and disc angle, compared with Control TDR. Freedom from a serious adverse event through 5 years was 64% in activL patients, 47% in Control patients (log-rank P = 0.0068). Freedom from index-level and adjacent-level reoperation was high for TDR patients, ranging between 94% and 99%, respectively. CONCLUSION: Long-term evidence supports lumbar total disc replacement as safe. The next-generation activL Artificial Disc is more effective at preserving range of motion than first-generation lumbar TDRs (ProDisc-L and Charité) and offers a higher safety profile. Other primary and secondary outcomes are similar between disc designs. LEVEL OF EVIDENCE: 2.


Assuntos
Degeneração do Disco Intervertebral/cirurgia , Próteses e Implantes , Substituição Total de Disco/instrumentação , Adulto , Dor nas Costas/etiologia , Feminino , Humanos , Degeneração do Disco Intervertebral/complicações , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Amplitude de Movimento Articular , Reoperação , Fusão Vertebral , Resultado do Tratamento
5.
Eur Spine J ; 17(2): 240-9, 2008 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-17973128

RESUMO

Prior imaging studies of scoliosis patients attempted to demonstrate a relationship between plain radiographic curve patterns and curve progression and pain, or used magnetic resonance imaging (MRI) to focus on spinal cord abnormalities. Pain in scoliosis patients may differ from nondeformity patients, yet may still be discogenic. The purpose of this study was to assess the possible relationship of degenerative disc findings on MRI to scoliosis patients' pain. This prospective study enrolled scoliosis and control patients, all of whom had assessment for back pain (visual analog scale) and disability (Oswestry Index) and spinal MRI to identify prevalence and distribution of degenerative disc findings. Specifically, we assessed 60 consecutive pediatric and adult idiopathic scoliosis patients who had progressed to surgical treatment, 60 age- and gender-matched asymptomatic controls, and 172 nondeformity symptomatic degenerative disc disease patients who had progressed to surgical treatment. All subjects had independent analysis of their preoperative MRI for disc degeneration, disc herniation, Schmorl's nodes, and inflammatory end plate changes. Imaging findings of the scoliosis patients were compared to those from asymptomatic and symptomatic control groups. Our results found that both pediatric and adult scoliosis patients had significantly more pain and disability than did asymptomatic controls (P < 0.001). The adult idiopathic scoliosis patients had pain and disability similar to those of surgical degenerative disc disease control groups. Disc degeneration and herniation (contained) were not related to pain. However, in the pediatric scoliosis patients, those with Schmorl's nodes often had greater pain than those without (P = 0.01). Adults with painful scoliosis, typically occurring at the apex of the scoliosis or at the lumbosacral junction, had a significantly higher frequency of inflammatory end plate changes on MRI than did controls (P < 0.001). Prior studies have demonstrated a correlation of inflammatory end plate changes to lumbar discogenic pain. In conclusions, scoliosis patients who have progressed to surgical intervention, pediatric patients have varying degrees of pain, and those with Schmorl's nodes may be at greater risk for pain. Adult scoliosis patients have multifactorial pain of which one component may be related to degeneration of the lower lumbar discs similar to that in nondeformity patients. Additionally, adult scoliosis patients may have MRI findings consistent with discogenic pain at the apex of their curvature, most commonly at the proximal lumbar levels.


Assuntos
Avaliação da Deficiência , Disco Intervertebral/patologia , Dor/patologia , Escoliose/patologia , Doenças da Coluna Vertebral/patologia , Adolescente , Adulto , Idoso , Estudos de Casos e Controles , Criança , Progressão da Doença , Feminino , Humanos , Vértebras Lombares/patologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Medição da Dor , Estudos Prospectivos , Escoliose/complicações , Doenças da Coluna Vertebral/complicações
6.
Spine (Phila Pa 1976) ; 43(3): 207-214, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-28604488

RESUMO

STUDY DESIGN: Prospective cohort study with >10-year follow-up. OBJECTIVE: To assess the long-term, >10-year clinical outcomes of anterior cervical discectomy and fusion (ACDF) and to compare outcomes based on primary diagnosis of disc herniation, stenosis or advanced degenerative disc disease (DDD), number of levels treated, and preexisting adjacent level degeneration. SUMMARY OF BACKGROUND DATA: ACDF is a proven treatment for patients with stenosis and disc herniation and results in significantly improved short- and intermediate-term outcomes. Motion preservation treatments may result in improved long-term outcomes but need to be compared to long-term ACDF outcomes reference. METHODS: Patients who had disc herniation, stenosis, and DDD and underwent ACDF with or without decompression were prospectively enrolled and followed for a minimum of 10 years with outcome assessment at various intervals. All 159 consecutive patients had autogenous tricortical iliac crest bone graft and plate instrumentation used. Outcomes included visual analog scale for neck and arm pain. pain drawing, Oswestry Disability Index, and self-assessment of procedure success. Preoperative adjacent-level disc degeneration, pseudarthrosis, and secondary operations were analyzed. RESULTS: For all diagnostic groups, significant outcomes improvement was seen at all follow-up periods for all scales relative to preoperative scores. Outcomes were not related to age, gender, number of levels treated, and minimally to preexisting degeneration at the adjacent level. The use of narcotic pain medication decreased substantially. Neurological deficits almost all resolved. Patient self-reported success ranged from 85% to 95%. Over the long term, additional surgery for pseudarthrosis (10%) occurred in the early follow-up period, and for adjacent segment degeneration (21%), which occurred linearly during the >10-year follow-up period. CONCLUSION: ACDF leads to significantly improved outcomes for all primary diagnoses and was sustained for >10 years' follow-up. Secondary surgeries were performed for pseudarthrosis repair and for symptomatic adjacent-level degeneration. LEVEL OF EVIDENCE: 2.


Assuntos
Discotomia/métodos , Degeneração do Disco Intervertebral/cirurgia , Deslocamento do Disco Intervertebral/cirurgia , Fusão Vertebral/métodos , Estenose Espinal/cirurgia , Adulto , Vértebras Cervicais , Descompressão Cirúrgica , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Prospectivos , Reoperação , Resultado do Tratamento
7.
Int J Spine Surg ; 12(5): 557-564, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30364904

RESUMO

BACKGROUND: Outpatient surgery has been shown safe and effective for anterior cervical discectomy and fusion (ACDF), and more recently, for 1-level cervical disc arthroplasty (CDA). The purpose of this analysis is to compare the safety and efficiency of 1-level and 2-level CDA performed in an ambulatory surgery center (ASC) and in a hospital setting. METHODS: The study was a retrospective collection and analysis of data from consecutive CDA patients treated in ASCs compared to a historical control group of patients treated in hospital settings who were classified as outpatient (0 or 1-night stay) or inpatient (2 or more nights). Surgery time, blood loss, return to work, adverse events (AEs), and subsequent surgeries were compared. RESULTS: The sample consisted of 145 ASC patients, 348 hospital outpatients, and 65 hospital inpatients. A greater proportion of 2-level surgeries were performed in hospital than ASC. Surgery times were significantly shorter in ASCs than outpatient or inpatient 1-level (63.6 ± 21.6, 86.5 ± 35.8, and 116.7 ± 48.4 minutes, respectively) and 2-level (92.4 ± 37.3, 126.7 ± 43.8, and 140.3 ± 54.5 minutes, respectively) surgeries. Estimated blood loss was also significantly less in ASC than outpatient and inpatient 1-level (18.5 ± 30.6, 43.7 ± 35.9, and 85.7 ± 98.0 mL, respectively) and 2-level (21.1 ± 12.3, 67.8 ± 94.9, and 64.9 ± 66.1 mL). There were no hospital admissions and no subsequent surgeries among ASC patients. ASC patients had 1 AE (0.7%) and hospital patients had 10 AEs (2.4%). Working patients returned to work after a similar number of days off, but fewer ASC patients had returned to work by the end of the 90-day period. CONCLUSIONS: Both 1- and 2-level CDA may be performed safely in an ASC. Surgeries in ASCs are of shorter duration and performed with less blood loss without increased AEs.

8.
J Biomech ; 49(2): 216-21, 2016 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-26726784

RESUMO

The spinous processes and supraspinous and interspinous ligaments (SSL and ISL, respectively) limit flexion and may relate to spinal curvature. Spinous process angles and mechanical properties of explanted human thoracic posterior SSL/ISL complexes were compared for scoliosis (n=14) vs. kyphosis (n=8) patients. The median thoracic coronal Cobb angle for scoliosis patients was 48°, and sagittal angles for kyphosis patients was 78°. Spinous processes were gripped and four strain steps of 4% were applied and held. Percent relaxation was calculated over each step, equilibrium load data were fit to an exponential equation, and a Kelvin model was fit to the load from all four curves. Failure testing was also performed. Median ligament complex dimensions from scoliosis and kyphosis patients were, respectively: ISL width=16.5mm and 16.0mm; SSL width=4.3mm and 3.8mm; ISL+SSL area=17.2mm and 25.7mm; these differences were not significant. Significant differences did exist in terms of spinous process angle vs. spine axis (47° for scoliosis and 32° for kyphosis) and SSL thickness (2.1mm for scoliosis and 3.0mm for kyphosis). Fourth-step median relaxation was 42% for scoliosis and 49% for kyphosis. Median linear region stiffness was 42N/mm for scoliosis and 51N/mm for kyphosis. Median failure load was 191N for scoliotic and 175N for kyphotic ligaments. Differences in loading, relaxation, viscoelastic and failure parameters were not statistically significant, except for a trend for greater initial rate of relaxation (T1) for scoliosis ligaments. However, we found significant morphological differences related to the spinous processes, which suggests a need for future biomechanical studies related to the musculoskeletal aspects of spinal alignment and posture.


Assuntos
Cifose/patologia , Ligamentos Articulares/fisiopatologia , Escoliose/patologia , Adolescente , Adulto , Fenômenos Biomecânicos , Módulo de Elasticidade , Humanos , Cifose/diagnóstico por imagem , Cifose/fisiopatologia , Masculino , Radiografia , Amplitude de Movimento Articular , Escoliose/diagnóstico por imagem , Escoliose/fisiopatologia , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/patologia , Adulto Jovem
9.
J Neurosurg Spine ; 24(1): 54-9, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26407089

RESUMO

OBJECTIVE: This study was undertaken to quantify the in vitro range of motion (ROM) of oblique as compared with anterior lumbar interbody devices, pullout resistance, and subsidence in fatigue. METHODS: Anterior and oblique cages with integrated plate fixation (IPF) were tested using lumbar motion segments. Flexibility tests were conducted on the intact segments, cage, cage + IPF, and cage + IPF + pedicle screws (6 anterior, 7 oblique). Pullout tests were then performed on the cage + IPF. Fatigue testing was conducted on the cage + IPF specimens for 30,000 cycles. RESULTS: No ROM differences were observed in any test group between anterior and oblique cage constructs. The greatest reduction in ROM was with supplemental pedicle screw fixation. Peak pullout forces were 637 ± 192 N and 651 ± 127 N for the anterior and oblique implants, respectively. The median cage subsidence was 0.8 mm and 1.4 mm for the anterior and oblique cages, respectively. CONCLUSIONS: Anterior and oblique cages similarly reduced ROM in flexibility testing, and the integrated fixation prevented device displacement. Subsidence was minimal during fatigue testing, most of which occurred in the first 2500 cycles.


Assuntos
Fenômenos Biomecânicos/fisiologia , Fadiga , Vértebras Lombares/cirurgia , Maleabilidade/fisiologia , Adulto , Idoso , Placas Ósseas , Cadáver , Feminino , Humanos , Região Lombossacral/cirurgia , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular/fisiologia , Fusão Vertebral/instrumentação
10.
J Bone Joint Surg Am ; 97(1): 3-9, 2015 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-25568388

RESUMO

BACKGROUND: Studies comparing operative with nonoperative treatment of a stable burst fracture of the thoracolumbar junction in neurologically intact patients have not shown a meaningful difference at early follow-up. To our knowledge, longer-term outcome data have not before been presented. METHODS: From 1992 to 1998, forty-seven consecutive patients with a stable thoracolumbar burst fracture and no neurological deficit were evaluated and randomized to one of two treatment groups: operative treatment (posterior or anterior arthrodesis) or nonoperative treatment (a body cast or orthosis). We previously reported the results of follow-up at an average of forty-four months. The current study presents the results of long-term follow-up, at an average of eighteen years (range, sixteen to twenty-two years). As in the earlier study, patients at long-term follow-up indicated the degree of pain on a visual analog scale and completed the Roland and Morris disability questionnaire, the Oswestry Disability Index (ODI) questionnaire, and the Short Form-36 (SF-36) health survey. Work and health status were obtained, and patients were evaluated radiographically. RESULTS: Of the original operatively treated group of twenty-four patients, follow-up data were obtained for nineteen; one patient had died, and four could not be located. Of the original nonoperatively treated group of twenty-three patients, data were obtained for eighteen; two patients had died, and three could not be located. The average kyphosis was not significantly different between the two groups (13° for those who received operative treatment compared with 19° for those treated nonoperatively). Median scores for pain (4 cm for the operative group and 1.5 cm for the nonoperative group; p = 0.003), ODI scores (20 for the operative group and 2 for the nonoperative group; p <0.001) and Roland and Morris scores (7 for the operative group and 1 for the nonoperative group; p = 0.001) were all significantly better in the group treated nonoperatively. Seven of eight SF-36 scores also favored nonoperative treatment. CONCLUSIONS: While early analysis (four years) revealed few significant differences between the two groups, at long-term follow-up (sixteen to twenty-two years), those with a stable burst fracture who were treated nonoperatively reported less pain and better function compared with those who were treated surgically.


Assuntos
Vértebras Lombares , Fraturas da Coluna Vertebral/terapia , Vértebras Torácicas , Adulto , Idoso , Idoso de 80 Anos ou mais , Moldes Cirúrgicos , Avaliação da Deficiência , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Aparelhos Ortopédicos , Medição da Dor , Estudos Prospectivos , Fraturas da Coluna Vertebral/complicações , Fraturas da Coluna Vertebral/cirurgia , Fusão Vertebral , Traumatismos do Sistema Nervoso/etiologia , Resultado do Tratamento
11.
Spine (Phila Pa 1976) ; 40(24): 1873-81, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26630435

RESUMO

STUDY DESIGN: A prospective, multicenter, randomized, controlled, investigational device exemption (IDE) noninferiority trial. OBJECTIVE: The aim of this study was to evaluate the comparative safety and effectiveness of lumbar total disc replacement (TDR) in the treatment of patients with symptomatic degenerative disc disease (DDD) who are unresponsive to nonsurgical therapy. SUMMARY OF BACKGROUND DATA: Lumbar TDR has been used to alleviate discogenic pain and dysfunction while preserving segmental range of motion and restoring stability. There is a paucity of data available regarding the comparative performance of lumbar TDR. METHODS: Patients presenting with symptomatic single-level lumbar DDD who failed at least 6 months of nonsurgical management were randomly allocated (2:1) to treatment with an investigational TDR device (activL, n = 218) or FDA-approved control TDR devices (ProDisc-L or Charité, n = 106). The hypothesis of this study was that a composite effectiveness outcome at 2 years in patients treated with activL would be noninferior (15% delta) to that in controls. RESULTS: The primary composite endpoint of this study was met, which demonstrated that the activL TDR was noninferior to control TDR (P < 0.001). A protocol-defined analysis of the primary composite endpoint also confirmed that activL was superior to controls (P = 0.02). Radiographic success was higher with activL versus controls (59% vs. 43%; P < 0.01). Mean back pain severity improved by 74% with activL and 68% with controls. Oswestry Disability Index scores decreased by 67% and 61% with activL and controls, respectively. Patient satisfaction with treatment was over 90% in both groups at 2 years. Return to work was approximately 1 month shorter (P = 0.08) with activL versus controls. The rate of device-related serious adverse events was lower in patients treated with activL versus controls (12% vs. 19%; P = 0.13). Surgical reintervention rates at the index level were comparable (activL 2.3%, control 1.9%). CONCLUSION: The single-level activL TDR is safe and effective for the treatment of symptomatic lumbar DDD through 2 years. LEVEL OF EVIDENCE: 2.


Assuntos
Degeneração do Disco Intervertebral/cirurgia , Disco Intervertebral/cirurgia , Dor Lombar/cirurgia , Substituição Total de Disco/efeitos adversos , Substituição Total de Disco/métodos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
12.
J Bone Joint Surg Am ; 86(4): 670-9, 2004 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15069129

RESUMO

BACKGROUND: Epidural steroid injection is a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation. The objective of this study was to determine the efficacy of epidural steroid injection in the treatment of patients with a large, symptomatic lumbar herniated nucleus pulposus who are surgical candidates. METHODS: One hundred and sixty-nine patients with a large herniation of the lumbar nucleus pulposus (a herniation of >25% of the cross-sectional area of the spinal canal) were followed over a three-year period. One hundred patients who had no improvement after a minimum of six weeks of noninvasive treatment were enrolled in a prospective, non-blinded study and were randomly assigned to receive either epidural steroid injection or discectomy. Evaluation was performed with the use of outcomes scales and neurological examination. RESULTS: Patients who had undergone discectomy had the most rapid decrease in symptoms, with 92% to 98% of the patients reporting that the treatment had been successful over the various follow-up periods. Only 42% to 56% of the fifty patients who had undergone the epidural steroid injection reported that the treatment had been effective. Those who did not obtain relief from the injection had a subsequent discectomy, and their outcomes did not appear to have been adversely affected by the delay in surgery resulting from the trial of epidural steroid injection. CONCLUSIONS: Epidural steroid injection was not as effective as discectomy with regard to reducing symptoms and disability associated with a large herniation of the lumbar disc. However, epidural steroid injection did have a role: it was found to be effective for up to three years by nearly one-half of the patients who had not had improvement with six or more weeks of noninvasive care.


Assuntos
Deslocamento do Disco Intervertebral/tratamento farmacológico , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares , Corticosteroides/administração & dosagem , Adulto , Anti-Inflamatórios/administração & dosagem , Discotomia/métodos , Humanos , Injeções Epidurais , Exame Neurológico , Estudos Prospectivos , Resultado do Tratamento
13.
Spine J ; 4(5): 495-505, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15363419

RESUMO

BACKGROUND: No conclusive evidence exists to determine that spinal steroid injections give lasting improvement in patients with predominantly axial low back pain resulting from lumbar degenerative disc disease (DDD). PURPOSE: The objectives of the study were to determine the effect of epidural steroid injections (ESIs) and intradiscal steroid injections (ISIs) in patients who exhibit DDD symptoms for more than 1 year and to determine whether patients with inflammatory end-plate changes are a unique subgroup of DDD patients in terms of treatment response. STUDY DESIGN: Pain and function in patients with DDD were prospectively assessed by an outcomes questionnaire before and after various spinal injections. Further correlation was made with end-plate inflammatory (Modic Type 1) changes identified on magnetic resonance imaging (MRI). PATIENT SAMPLE: ESI was performed in 232 patients who were referred for treatment of DDD, and discography with or without intradiscal steroid was performed in 171 patients who were possible spinal arthrodesis candidates. OUTCOME MEASURES: Pain and function were determined by a self-administered outcomes questionnaire that consisted of a visual analog pain scale, pain drawing, Oswestry Disability Index, use of pain medication and opinion of treatment success. METHODS: ESI was performed in 93 patients with DDD and inflammatory end-plate changes and in 139 patients without inflammatory end-plate changes. Patients with inflammatory end-plate changes (n=78) or without inflammatory end-plate changes (n=93), all of whom were considered fusion candidates, underwent discography with or without intradiscal steroid in a randomized fashion. Pain and function were prospectively determined by a self-administered outcomes survey (VAS pain, Oswestry Disability index [ODI], pain diagram [PD] and opinion of success) before and after the patients' injection for a 2-year follow-up period. MRI and discography results were correlated with patient outcomes scores. RESULTS: ESI was effective in improving pain and function, as assessed by outcomes scores at short-term follow-up. However, at 2 years, less than one-third had not had additional invasive treatment. Patients with inflammatory end-plate changes had greater improvement in ODI and PD scores in the first 6 months than did those patients without the end-plate changes. Intradiscal steroid injections into discs with concordant pain at the time of discography led to significant improvement in patients with inflammatory end-plate changes in all outcomes scales, but only minimal temporary improvement in patients without the end-plate changes. Disc pressure manometry at the time of discography found that discs with adjacent inflammatory end-plate changes reproduced symptoms at pressures significantly lower than those in other types of discs. CONCLUSIONS: Spinal steroid injections, both ESI and ISI, are beneficial for a small number of patients with advanced DDD and chronic low back pain. For those patients in whom a beneficial effect is found, spinal steroid injection is a low-risk and rapid treatment option. Spinal steroid injections are more effective in patients with MRI findings of discogenic inflammation, specifically adjacent inflammatory end-plate changes.


Assuntos
Betametasona/administração & dosagem , Glucocorticoides/administração & dosagem , Deslocamento do Disco Intervertebral/tratamento farmacológico , Adulto , Feminino , Seguimentos , Humanos , Injeções Intralesionais , Deslocamento do Disco Intervertebral/patologia , Dor Lombar/tratamento farmacológico , Dor Lombar/patologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
14.
Spine J ; 4(3): 265-74, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15125847

RESUMO

BACKGROUND CONTEXT: Currently, artificial spinal discs require transection or partial removal of the annulus fibrosis in order to excise the nucleus and implant a prosthetic nucleus or implant a total disc device, respectively. Preservation of the annulus for prosthetic disc replacement maintains the function of the annulus and may improve annulus load sharing with the prosthesis. PURPOSE: To quantify the biomechanical characteristics of an annular sparing intervertebral prosthetic disc (IPD) in a lumbar calf spine model. The aim of the study was to determine whether altering the stiffness of the elastic component of this unique prosthesis would correspond to changes of the overall reconstructed disc. STUDY DESIGN/SETTING: A biomechanical study was conducted in vitro using cadaveric calf spines such that each specimen served as its own control. Investigations were performed at the Minneapolis Medical Research Foundation, Orthopaedic Biomechanics Laboratory. METHODS: Six L45 or L56 motion segments (from which the posterior elements had been removed) were studied in axial compression, sagittal and lateral bending and torsion. These load states were applied to the intact, denucleated and prosthetically reconstructed disc using four IPDs of differing stiffness. RESULTS: Load-displacement testing demonstrated that stiffer IPDs resulted in a decreased range of motion and neutral zone, and greater stiffness of the reconstructed disc. Disc reconstruction with the stiffest IPD approximated the behavior of the intact disc. CONCLUSIONS: The overall biomechanical characteristics of a reconstructed disc are related to the stiffness of a nucleus prosthesis. The similarities in the mechanical behavior of reconstructed and intact discs suggest that additional feasibility studies for the annulus-sparing IPD are warranted.


Assuntos
Artroplastia de Substituição/instrumentação , Disco Intervertebral/cirurgia , Prótese Articular , Vértebras Lombares/cirurgia , Animais , Artroplastia de Substituição/métodos , Bovinos , Elasticidade , Técnicas In Vitro , Disco Intervertebral/fisiopatologia , Amplitude de Movimento Articular , Suporte de Carga
15.
Am J Orthop (Belle Mead NJ) ; 33(3): 142-8, 2004 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-15074462

RESUMO

Osteonecrosis of the scaphoid is usually a posttraumatic condition, but idiopathic cases are well known to occur. Magnetic resonance imaging is useful in distinguishing the types of osteonecrosis. In posttraumatic osteonecrosis, MRI abnormalities are in the proximal scaphoid that are consistent with interosseous vascular disruption, whereas in idiopathic osteonecrosis, the entire scaphoid is affected. The MRI findings correlate with histologic findings of osteonecrosis, and the etiology may be an extraosseous insult to the scaphoid blood supply. We presented a series of 3 cases of idiopathic global osteonecrosis of the scaphoid. All patients were found to have diffuse swelling of the dorsal wrist and probable effusion, and all had slow clinical deterioration. All 3 patients had surgical procedures that included bone grafting or intracarpal arthrodesis. At 5- to 10-year follow-up, all were satisfied with their treatment.


Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Procedimentos Ortopédicos/métodos , Osteonecrose/diagnóstico , Osteonecrose/terapia , Osso Escafoide/patologia , Adulto , Biópsia por Agulha , Terapia Combinada/métodos , Feminino , Seguimentos , Humanos , Imuno-Histoquímica , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Medição de Risco , Estudos de Amostragem , Índice de Gravidade de Doença , Contenções , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
16.
J Biomech ; 46(10): 1714-21, 2013 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-23643028

RESUMO

The wound healing process includes filling the void between implant and tissue edges by collagenous connective repair tissue. This fibrous repair tissue may load share or stabilize implants such as spinal disc replacements. The objective of this study was the biomechanical characterization of human fibrous tissue compared to annulus fibrosus and nucleus pulposus. Human lumbar discs (10 nucleus and annulus) and 10 lumbar deep wound fibrous tissue specimens were sectioned into 12mm diameter×6mm high cylindrical samples. Confined compression testing, after 2h swelling at 0.11MPa, was performed at 5%, 10% and 15% strain over 3.5h. Unconfined dynamic testing (2-0.001Hz) was performed at 5-15% strain. Semi-quantitative histology estimated the proportion of proteoglycan to collagen. Fibrous tissue exhibited a decrease in height during the swelling period whereas annulus and nucleus tissues did not. The aggregate modulus was significantly less for fibrous tissue (p<0.002). Percent stress relaxation was greatest for the fibrous tissue and similar for annulus and nucleus. Dynamic testing found the storage modulus (E') was greater than the loss modulus (E″) for all tissues. Annulus were found to have greater E' and E″ than nucleus, whereas E' and E″ were similar between annulus and fibrous tissue. Fibrous tissue had the greatest increase in both moduli at greater frequencies, but had the lowest hydration and proteoglycan content. Fibrous tissue would not be a substitute for native tissue within the disc space but if adjacent to a disc prosthesis may impart some degree of intersegmental stability during acute loading activities.


Assuntos
Disco Intervertebral/fisiologia , Vértebras Lombares/fisiologia , Cicatrização/fisiologia , Adulto , Idoso , Fenômenos Biomecânicos , Colágeno/metabolismo , Elasticidade , Feminino , Humanos , Disco Intervertebral/lesões , Masculino , Pessoa de Meia-Idade , Proteoglicanas/metabolismo , Estresse Mecânico , Viscosidade , Adulto Jovem
18.
J Invest Surg ; 25(2): 112-22, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22439838

RESUMO

BACKGROUND: The optimal lumbar spinal disc prosthesis has yet to be developed. Failures of clinical device studies may be minimized by appropriate large animal preclinical studies. The lumbar spine of the mature "runt" cow, Corrientes breed, has been shown to have a number of desirable characteristics to the human. This study assessed the feasibility of the "runt" cow for in vivo testing of human-sized lumbar interbody implants and the ability to perform common analyses of explants. METHODS: Eight cows (four experimental and four controls) were compared. The experimental animals had transosseous implantation of the disc prosthesis at L4-L5, and their spines were harvested at four or six months. They were evaluated for the ease of surgical access and healing, motion segment mobility, ability to remove the implant nondestructively, and microradiography and histomorphology. RESULTS: All animals had successful implantation. All explantations were performed without alteration to the devices. All animals had surgical healing and intended device motion, and histology found device stability by demonstrating bone ingrowth into the device's porous plates. There was a significant 46% increase in the amount of trabecular bone adjacent to the implants. CONCLUSION: The mature runt cow allows for implantation of human-sized interbody and intrabody spinal prostheses. This animal model allowed for macro- and histological analysis of the implant and surrounding tissues. In vivo stability was demonstrated for the disc prosthesis while also allowing for evaluation of intended mobility. Additionally, this is the first study to suggest increased bone density supporting an interbody prosthesis.


Assuntos
Bovinos/cirurgia , Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Próteses e Implantes , Animais , Humanos , Masculino , Modelos Animais , Desenho de Prótese , Implantação de Prótese
19.
Orthopedics ; 34(11): e788-92, 2011 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-22049968

RESUMO

Although complications related to vertebroplasty or kyphoplasty are few, we treated 2 patients with vertebroplasty or kyphoplasty for pain, presumed to be due to vertebral compression fractures, which were subsequently found to be due to occult osteomyelitis/diskitis. The onset of their infections appeared to have preceded their vertebral body augmentation procedures and was possibly due to prior interventional procedures for histories of back pain.An 86-year-old woman had had 3 prior kyphoplasty procedures for fractures at T10, T11, and L1. She reported continued severe pain, and subsequent magnetic resonance imaging was misinterpreted for another fracture at T12, resulting in her fourth kyphoplasty. She became septic and had some improvement with antibiotics, but she declined specialty care and died. A 74-year-old man with chronic back pain had recently undergone lumbar facet joint injections. Computed tomography and subsequent bone scan found uptake at both L2 and L3. Despite abnormal erythrocyte sedimentation rate and C-reactive protein level and normal radiographic vertebral height, he underwent a vertebroplasty. His pain increased, and subsequent workup found L2-3 diskitis. He recovered with antibiotics and specialty care. Similar to prior reports of spondylodiskitis, both patients had multiple medical comorbidities.This article emphasizes the need for clinical reevaluation and scrutiny in the interpretation of imaging studies, including for infection in patients with continued pain after spinal procedures. The differential diagnosis of infectious etiology is an important consideration prior to vertebral cement augmentation for presumed fragility fracture.


Assuntos
Dor nas Costas/patologia , Discite/patologia , Osteomielite/patologia , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Dor nas Costas/etiologia , Cimentos Ósseos , Cimentação , Discite/complicações , Discite/tratamento farmacológico , Evolução Fatal , Feminino , Fraturas por Compressão/cirurgia , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Osteomielite/complicações , Osteomielite/tratamento farmacológico , Complicações Pós-Operatórias , Vertebroplastia/efeitos adversos
20.
Spine J ; 10(11): 1024-31, 2010 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-20970741

RESUMO

BACKGROUND CONTEXT: Unstable burst fractures of the thoracolumbar spine may be treated surgically. Vertebral body replacements (VBRs) give anterior column support and, when used with supplemental fixation, impart rigidity to the injured segments. Although some VBRs are expandable, device congruity to the vertebral end plates is imprecise and may lead to stress risers and device subsidence. PURPOSE: The objective of this study was to compare the rigidity of a VBR that self-adjusts to the adjacent vertebral end plates versus structural bone allograft and with an unsupported anterior column in a traumatic burst fracture reconstruction model. STUDY DESIGN: Biomechanical flexibility testing with rod strain measurement. PATIENT SAMPLE: Twelve T11-L3 human spine segments. OUTCOME MEASURES: Range of motion, neutral zone, and posterior fixation rod stress (moments). METHODS: Flexibility testing was performed to ± 6 Nm in flexion-extension, lateral bending, and axial rotation on 12 intact human T11-L3 specimens. Burst fractures were created in L1, and flexibility testing was repeated in three additional states: subtotal corpectomy with posterior instrumentation (PI) only from T12 to L2, reconstruction with a femoral strut allograft and PI, and reconstruction with a VBR (with self-adjusting end plates) and PI. The PI consisted of pedicle screws and strain gage instrumented rods that were calibrated to measure rod stress via flexion-extension bending moments. RESULTS: There was no statistical difference in range of motion or neutral zone between the strut graft and VBR constructs, which both had less motion than the PI-only construct in flexion/extension and torsion and were both less than the intact values in flexion/extension and lateral bending (p < .05). Posterior rod moments were significantly greater for the PI-only construct in flexion/extension relative to the strut graft and VBR states (p = .03). CONCLUSIONS: This study, which simulated the immediate postoperative state, suggests that a VBR with self-adjusting end plate components has rigidity similar to the standard strut graft when combined with PI. Posterior rod stress was not significantly increased with this type of VBR compared with the strut graft reconstruction. The benefits of burst fracture stabilization using a self-adjusting VBR ultimately will not be known until long-term clinical studies are performed.


Assuntos
Fixadores Internos , Fraturas da Coluna Vertebral/cirurgia , Fusão Vertebral/instrumentação , Coluna Vertebral/cirurgia , Fenômenos Biomecânicos , Cadáver , Humanos , Técnicas In Vitro , Amplitude de Movimento Articular , Fusão Vertebral/métodos
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