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PURPOSE: Intra-Discal Vacuum phenomenon (IDVP) is well-recognised, yet poorly visualised and poorly understood radiological finding in disc degeneration, particularly with regard to its role in spinal alignment. CT analysis of the lumbar spine in an aging population aims to identify patterns associated with IDVP including lumbopelvic morphology and associated spinal diagnoses. METHODS: An analysis was performed of an over-60s population sample of 2020 unrelated abdominal CT scans, without acute spinal presentations. Spinal analysis included sagittal lumbopelvic reconstructions to assess for IDVP and pelvic incidence (PI). Subjects with degenerative pathologies, including previous vertebral fractures, auto-fusion, transitional vertebrae, and listhesis, were also selected out and analysed separately. RESULTS: The prevalence of lumbar spine IDVP was 50.3% (955/1898) and increased with age (125 exclusions). This increased in severity towards the lumbosacral junction (L1L2 8.3%, L2L3 10.9%, L3L4 11.5%, L4L5 23.9%, and L5S1 46.3%). A lower PI yielded a higher incidence of IDVP, particularly at L5S1 (p < 0.01). A total of 292 patients had IDVP with additional degenerative pathologies, which were more likely to occur at the level of isthmic spondylolisthesis, adjacent to a previous fracture or suprajacent to a lumbosacral transitional vertebra (p < 0.05). CONCLUSIONS: This study identified the prevalence and severity of IDVP in an aging population. Sagittal patterns that influence the pattern of IVDP, such as pelvic incidence and degenerative pathologies, provide novel insights into the function of aging spines.
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Degeneración del Disco Intervertebral , Vértebras Lumbares , Humanos , Vértebras Lumbares/diagnóstico por imagen , Anciano , Masculino , Femenino , Degeneración del Disco Intervertebral/epidemiología , Degeneración del Disco Intervertebral/diagnóstico por imagen , Persona de Mediana Edad , Anciano de 80 o más Años , Envejecimiento/patología , Envejecimiento/fisiología , Vacio , Tomografía Computarizada por Rayos X , PrevalenciaRESUMEN
PURPOSE: Coronal balance is a major factor impacting the surgical outcomes in adult spinal deformity (ASD). The Obeid coronal malalignment (O-CM) classification has been proposed to improve the coronal alignment in ASD surgery. Aim of this study was to investigate whether a postoperative CM < 20 mm and adherence to the O-CM classification could improve surgical outcomes and decrease the rate of mechanical failure in a cohort of ASD patients. METHODS: Multicenter retrospective analysis of prospectively collected data on all ASD patients who underwent surgical management and had a preoperative CM > 20 mm and a 2-year follow-up. Patients were divided in two groups according to whether or not surgery had been performed in adherence to the guidelines of the O-CM classification and according to whether or not the residual CM was < 20 mm. The outcomes of interest were radiographic data, rate of mechanical complications and Patient-Reported Outcome Measures. RESULTS: At 2 years, adherence to the O-CM classification led to a lower rate of mechanical complications (40 vs. 60%). A coronal correction of the CM < 20 mm allowed for a significant improvement in SRS-22 and SF-36 scores and was associated with a 3.5 times greater odd of achieving the minimal clinical important difference for the SRS-22. CONCLUSION: Adherence to the O-CM classification could reduce the risk of mechanic complications 2 years after ASD surgery. Patients with a residual CM < 20 mm showed better functional outcomes and a 3.5 times greater odd of achieving the MCID for the SRS-22 score.
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Escoliosis , Humanos , Adulto , Escoliosis/diagnóstico por imagen , Escoliosis/cirugía , Estudios Retrospectivos , Calidad de Vida , Periodo Posoperatorio , Resultado del TratamientoRESUMEN
This paper presents a comprehensive overview of the environmental impact of surgical procedures and highlights potential strategies to reduce the associated greenhouse gas emissions. We discuss procurement, waste management, and energy consumption, providing examples of successful interventions in each area. We also emphasize the importance of adopting the Green Theatre Checklist as a useful tool for clinicians aiming to implement sustainable surgical practices.
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PURPOSE: Coronal malalignment (CM) causes pain, impairment of function and cosmetic problems for adult spinal deformity (ASD) patients in addition to sagittal malalignment. Certain types of CM are at risk of insufficient re-alignment after correction. However, CM has received minimal attention in the literature compared to sagittal malalignment. The purpose was to establish reliability for our recently published classification system of CM in ASD among spine surgeons. METHODS: Fifteen readers were assigned 28 cases for classification, who represented CM with reference to their full-length standing anteroposterior and lateral radiographs. The assignment was repeated 2 weeks later, then a third assignment was done with reference to additional side bending radiographs (SBRs). Intra-, inter-rater reliability and contribution of SBRs were determined. RESULTS: Intra-rater reliability was calculated as 0.95, 0.86 and 0.73 for main curve types, subtypes with first modifier, and subtypes with two modifiers respectively. Inter-rater reliability averaged 0.91, 0.75 and 0.52. No differences in intra-rater reliability were shown between the four expert elaborators of the classification and other readers. SBRs helped to increase the concordance rate of second modifiers or changed to appropriate grading in cases graded type A in first modifier. CONCLUSIONS: Adequate intra- and inter-rater reliability was shown in the Obeid-CM classification with reference to full spine anteroposterior and lateral radiographs. While side bending radiographs did not improve the classification reliability, they contributed to a better understanding in certain cases. Surgeons should consider both the sagittal and coronal planes, and this system may allow better surgical decision making for CM.
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Radiografía , Adulto , Humanos , Reproducibilidad de los Resultados , Escoliosis/diagnóstico por imagen , Columna Vertebral/diagnóstico por imagen , Posición de PieRESUMEN
Discuss the relevant literature on surgical and nonsurgical treatments for multiple myeloma (MM) and their complementary effects on overall treatment. Existing surgical algorithms designed for neoplasia of the spine may not suit the management of spinal myeloma. Less than a fifth of metastatic, including myelomatous lesions, occur in the cervical spine but have a poorer prognosis and surgery in this area carries a higher morbidity. With the advances of chemotherapy, early access to radiotherapy, early orthosis management, and high definition imaging, including CT and MRI, surgical indications in MM have changed. Medical decompression (or oncolysis), including in the presence of neurological deficit and orthotic stabilization, are proving viable nonsurgical options to manage MM. A key to decision making is the assessment and monitoring of biomechanical spinal stability as part of a multidisciplinary approach.
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Neoplasias de Cabeza y Cuello , Imagen por Resonancia Magnética , Mieloma Múltiple , Neoplasias de la Columna Vertebral , Tomografía Computarizada por Rayos X , Neoplasias de Cabeza y Cuello/diagnóstico por imagen , Neoplasias de Cabeza y Cuello/mortalidad , Neoplasias de Cabeza y Cuello/terapia , Humanos , Mieloma Múltiple/diagnóstico por imagen , Mieloma Múltiple/mortalidad , Mieloma Múltiple/terapia , Neoplasias de la Columna Vertebral/diagnóstico por imagen , Neoplasias de la Columna Vertebral/mortalidad , Neoplasias de la Columna Vertebral/terapiaRESUMEN
Wound closure after wide, local excision of an appendicular soft-tissue sarcoma (STS) can be challenging. This study evaluates the value of magnetic resonance imaging (MRI)-based tumour parameters in planning wound closure. A total of 71 patients with a primary limb-based STS, excluding vascular or osseous involvement, excluding the shoulder or hand and hip or foot were included. Axial MRI images were used to measure the circumferences and cross-sectional areas of the limb, bone, and tumour. The tumour diameter, length, and depth at the level of maximal tumour dimension were measured to identify the tumour's relative contribution to the planning of optimal wound closure management through primary closure (PC) or reconstructive surgery (RS). Eighteen patients required planned wound RS. Wound complications occurred in 14% overall. Tumours, which were closed by PC, were of significantly greater depth, shorter radial diameter, and shorter tumour circumference relative to those closed by RS. On multivariate analysis, tumour depth was the greatest contributory factor in predicting type of wound closure. A quantitative analysis of MRI-based tumour parameters demonstrates tumour depth as the most predictive factor in planning for the type of wound closure and may prove beneficial in providing greater insight into planned wound management of sarcoma resection.
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Drenaje , Terapia de Presión Negativa para Heridas , Sarcoma/cirugía , Neoplasias de los Tejidos Blandos/cirugía , Suturas , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Sarcoma/diagnóstico por imagen , Neoplasias de los Tejidos Blandos/diagnóstico por imagenRESUMEN
PURPOSE: To evaluate the radiographic, functional outcomes, complications and surgical specificities of L5 pedicle subtraction osteotomy for fixed sagittal and coronal malalignment. METHODS: A retrospective cohort of consecutive patients with prospectively collected data. Ten patients who underwent PSO at L5 were eligible for a 2-year minimum follow-up (average, 4.0 years). Patients were evaluated by standardized upright radiographs. Preoperative and postoperative radiographies, surgical data and complications were collected. RESULTS: All surgeries were revision surgeries. The mean lumbar lordosis before surgery was - 22.5° (range, 8° to - 33°) and improved to - 58.5° (range, - 40° to - 79°). The sagittal vertical axis demonstrated a preoperative mean sagittal malalignment of 13.7 cm (range 3.5 to 20 cm), with correction to 4.6 cm postoperatively. Three patients required additional surgery at the latest follow-up for rod breakage. CONCLUSIONS: PSO of L5 can be a safe and effective technique to treat and correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio of such a major surgery. Most patients are satisfied, particularly when sagittal balance is achieved.
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Lordosis/cirugía , Vértebras Lumbares/cirugía , Osteotomía/métodos , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
PURPOSE: To assess the efficacy of bisphosphonate therapy in the management of spinal aneurysmal bone cysts (ABCs). METHODS: A prospective study of six consecutive patients aged between 7 and 22 years with spinal ABCs treated with pamidronate (1 mg/kg) or zoledronate (4 mg). A visual analogue scale (VAS) for pain and radiological (contrast-enhanced MRI and CT scan at 3 and 6 months, then yearly X-rays) follow-up was continued for a minimum of 6 years. RESULTS: One patient with an unstable C2/3 failed to respond to a single dose of bisphosphonate and required surgical resection and stabilisation with autologous bone grafting. Another, with a thoraco-lumbar ABC, experienced progression of neurological dysfunction after one cycle of bisphosphonate and, therefore, required surgical resection and stabilisation. In all other patients pain progressively improved and was resolved after two to four cycles (VAS 7.3-0). These patients all showed reduction in peri-lesional oedema and increased ossification by 3 months. No patients have had a recurrence within the timeframe of this study. CONCLUSIONS: Bisphosphonate therapy can be used as the definitive treatment of spinal ABCs, except in patients with instability or progressive neurology, where surgical intervention is required. Clinicians should expect a patients symptoms to rapidly improve, their bone oedema to resolve by 3 months and their lesion to partially or completely ossify by 6-12 months.
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Quistes Óseos Aneurismáticos/tratamiento farmacológico , Conservadores de la Densidad Ósea/uso terapéutico , Difosfonatos/uso terapéutico , Enfermedades de la Columna Vertebral/tratamiento farmacológico , Columna Vertebral/patología , Adolescente , Adulto , Conservadores de la Densidad Ósea/efectos adversos , Niño , Difosfonatos/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Dimensión del Dolor , Estudios Prospectivos , Adulto JovenRESUMEN
BACKGROUND & AIM: Intraoperative epidural corticosteroids have been used to decrease post-operative pain post-discectomy. The objective of this study is to assess the efficacy of epidural corticosteroids on post-operative pain and length of post-operative hospital stay in patients undergoing unilateral lumbar microdiscectomy. METHODS: 150 consecutively treated, comparable patients with unilateral lumbar disc herniation were prospectively allocated randomly to receive either a sponge soaked in epidural corticosteroids or saline at the end of the operative procedure. The intensity of spontaneous pain was quantified by using the Oswestry low back pain index pre-operatively, at discharge, at week 1 follow-up and at 1st month of follow up. At the same intervals, each patient underwent the passive straight leg-raising test (PSLRT) and Visual Analogue Scale (VAS) testing. The duration of hospital stay, time taken to return to daily life activities and quantity of analgesia consumed post-operatively were also recorded. RESULTS: The mean hospital stay was 1.3 ± 0.9 days in the corticosteroids group (group 1) compared to 3.2 ± 1.2 in the control group (group 2). The mean interval until return to daily life activities was 6.7 ± 2.1 days in group 1 versus 9.6 ± 4.1 days in group 2. No statistically significant difference was measured between the steroid-treated and control groups when the data were stratified for sex, age, and site of disc herniation. Differences in the OLBI scores were statistically significant at all post-operative intervals. At baseline (preoperatively), group 1 (DepoMedrol™ group) had an average score of 72.3% (±2.6%) compared to 74.6% (±3.1%) in group 2 (Control group) (P = 0.45). At discharge, OLBI scores declined to 49.7% (±4.5%) in group 1 compared to 63.5% (±3.9%) in group 2 (P = 0.034). At week 1 follow-up, OLBI scores further declined to 41.3% (±2.9%) in group 1 versus 54.2% (±5.3%) in group 2 (P = 0.014). After one month of follow-up, OLBI scores were 34.1% (±6.7%) in group 1 and 42.6% (±4.1%) in group 2 (P = 0.004). Results of VAS and PSLRT are also documented in the manuscript. The mean postoperative analgesic medications consumed was 15.6 ± 1.9 mg of morphine equivalent in the corticosteroid group versus 10.3 ± 1.8 mg of morphine equivalent in the control group. No complications of treatment occurred in either groups. CONCLUSION: Intraoperative application of epidural corticosteroids, Depomedrol, significantly reduces post-operative pain, length of post-operative stay and duration to return to daily living activities following lumbar discectomy.
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Discectomía/efectos adversos , Desplazamiento del Disco Intervertebral/cirugía , Metilprednisolona/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Adolescente , Adulto , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Glucocorticoides/administración & dosificación , Humanos , Inyecciones Epidurales , Tiempo de Internación/tendencias , Vértebras Lumbares , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: Assessment of the integrity of the multifidus muscles and corresponding nerve roots, post-open (OSS) versus minimally invasive spinal surgery (MISS) for lumbar spine fractures. METHODS: We investigated the first six patients undergoing MISS in our institution and age- and sex-matched them with 6 random patients who previously had OSS. All had a similar lumbar fracture configuration without evidence of spinal cord injury. All were assessed using ultrasound muscle quantification and electromyographic studies at a minimum of 6 months post-operatively. Mean cross-sectional area (CSA) was measured at sequential levels within and adjacent to the operative field. Concentric needle electromyography was performed at instrumented and adjacent non-instrumented levels in each patient. RESULTS: Mean CSA across all lumbar multifidus muscles was 4.29 cm(2) in the MISS group, 2.26 cm(2) for OSS (p = 0.08). At the instrumented levels, mean CSA was 4.21 cm(2) for MISS and 2.03 cm(2) for OSS (p = 0.12). At non-instrumented adjacent levels, mean CSA was 4.46 cm(2) in the MISS group, 2.87 cm(2) for OSS (p = 0.05). Electromyography at non-instrumented adjacent levels demonstrated nerve function within normal limits in 5/6 levels in the MISS group compared to 1/6 levels in the OSS (p = 0.03). Instrumented levels demonstrated nerve function within normal limits in 5/12 levels in the MISS group compared with 4/12 in the OSS group, including moderate-severe denervation at 5 levels in the OSS group (p = 0.15). CONCLUSIONS: Posterior instrumented MISS demonstrates a significantly superior preservation of the medial branch of the posterior ramus of the spinal nerve and less muscle atrophy, particularly at adjacent levels when compared to OSS.
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Vértebras Lumbares/cirugía , Región Lumbosacra/inervación , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Músculos Paraespinales/inervación , Fracturas de la Columna Vertebral/cirugía , Adolescente , Adulto , Anciano , Electromiografía , Femenino , Humanos , Región Lumbosacra/cirugía , Masculino , Persona de Mediana Edad , Complicaciones PosoperatoriasRESUMEN
STUDY DESIGN: Systematic literature review and meta-analysis. OBJECTIVES: Predicting patient risk of intraoperative neuromonitoring (IONM) alerts preoperatively can aid patient counselling and surgical planning. Sielatycki et al established an axial-MRI-based spinal cord classification system to predict risk of IONM alerts in scoliosis correction surgery. We aim to systematically review the literature on operative and radiologic factors associated with IONM alerts, including a novel spinal cord classification. METHODS: A systematic review and meta-analysis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. A literature search identifying all observational studies comparing patients with and without IONM alerts was conducted. Suitable studies were included. Patient demographics, radiological measures and operative factors were collected. RESULTS: 11 studies were included including 3040 patients. Relative to type 3 cords, type 1 (OR = .03, CI = .01-.08, P < .00001), type 2 (OR = .08, CI = .03, P <.00001) and all non-type 3 cords (OR = .05, CI = .02-.16, P < .00001) were associated with significantly lower odds of IONM alerts. Significant radiographic measures for IONM alerts included coronal Cobb angle (MD = 10.66, CI = 5.77-15.56, P < .00001), sagittal Cobb angle (MD = 9.27, CI = 3.28-14.73, P = .0009), sagittal deformity angle ratio (SDAR) (MD = 2.76, CI = 1.57-3.96, P < .00001) and total deformity angle ratio (TDAR) (MD = 3.44, CI = 2.27-4.462, P < .00001). Clinically, estimated blood loss (MD = 274.13, CI = -240.03-788.28, P = .30), operation duration (MD = 50.79, CI = 20.58-81.00, P = .0010), number of levels fused (MD = .92, CI = .43-1.41, P = .0002) and number of vertebral levels resected (MD = .43, CI = .01-.84, P = .05) were significantly greater in IONM alert patients. CONCLUSIONS: This study highlights the relationship of operative and radiologic factors with IONM alerts.
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STUDY DESIGN: Observational serial computed tomography (CT) analysis of the lumbar spine in a normal-aging population. OBJECTIVE: To assess the natural history of the intradiscal vacuum phenomenon (IDVP) and its role in disc degeneration. BACKGROUND: The natural history of disc degeneration is well described but our understanding of the end stage of pathogenesis remains incomplete. Magnetic resonance imaging loses accuracy with advanced degeneration, becoming hyporesonant and indistinct. Cadaveric specimens display adaptive changes in the disc with loss of the hydrostatic capacity of the nucleus, increased intradiscal clefts, and endplate impermeability. IDVP is associated with advanced disc degeneration and CT is the optimal modality to visualize this, yet these insights remain unreported. PATIENTS AND METHODS: Patients only included historic CT abdomen scans of those over 60 years of age without acute or relevant spinal pathology, with a diagnosis of at least one level with IDVP on the original CT scan, and all of whom had a similar scan >7 years later. A history of clinically significant back pain was also recorded. RESULTS: CT scans included 360 levels in 29 males and 31 females (mean: 68.9 y), displaying 82 levels of IDVP, with a second scan included after a mean of 10.3 years. Most levels displayed the same level of severity (persisted, 45) compared with where some progressed (26), regressed (8), and fused (3; P < 0.01). There was also an increased incidence, 37/60 (62%) of developing IDVP at another level. Disc heights were reduced with increased severity of IDVP. A record of back pain was evident in 31/60 patients, which was not significantly worse in those with worsening severity or additional level involvement over the study period. CONCLUSION: As disc degeneration advances, the associated IDVP persists in most cases, displaying a plateauing of severity over long periods, but rarely with progression to autofusion.
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Degeneración del Disco Intervertebral , Disco Intervertebral , Vértebras Lumbares , Tomografía Computarizada por Rayos X , Humanos , Femenino , Masculino , Degeneración del Disco Intervertebral/diagnóstico por imagen , Anciano , Persona de Mediana Edad , Vértebras Lumbares/diagnóstico por imagen , Disco Intervertebral/diagnóstico por imagen , Disco Intervertebral/patología , Anciano de 80 o más Años , VacioRESUMEN
STUDY DESIGN: Narrative literature review. OBJECTIVE: The aim of this study was to review published literature discussing sustainable health care and to identify aspects that pertain to spine surgery. SUMMARY OF BACKGROUND DATA: In recent years, research has investigated the contribution of surgical specialties to climate change. To our knowledge, no article has yet been published discussing the impact specific to spinal procedures and possible mitigation strategies. METHODS: A literature search was performed for the present study on relevant terms across four electronic databases. References of included studies were also investigated. RESULTS: Spine surgery has a growing environmental impact. Investigations of analogous specialties find that procurement is the single largest source of emissions. Carbon-conscious procurement strategies will be needed to mitigate this fully, but clinicians can best reduce their impact by adopting a minimalist approach when using surgical items. Reduced wastage of disposable goods and increased recycling are beneficial. Technology can aid remote access to clinicians, and also enable patient education. CONCLUSIONS: Spine-surgery-specific research is warranted to evaluate its carbon footprint. A broad range of measures is recommended from preventative medicine to preoperative, intraoperative, and postoperative spine care. LEVEL OF EVIDENCE: 5.
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Huella de Carbono , Columna Vertebral , Humanos , Columna Vertebral/cirugíaRESUMEN
Intoduction: Mechanical complications from spinal fusion including implant loosening or junctional failure result in poor outcomes, particularly in osteoporotic patients. While the use of percutaneous vertebral augmentation with polymethylmethacrylate (PMMA) has been studied for augmentation of junctional levels to offset against kyphosis and failure, its deployment around existing loose screws or in failing surrounding bone as a salvage percutaneous procedure has been described in small case series and merits review. Research Question: How effective and safe is the use of PMMA as a salvage procedure for mechanical complications in failed spinal fusion?. Materials and Methods: Systematic search of online databases for clinical studies using this technique. Results: 11 studies were identified, only consisting of two case reports and nine case series. Consistent improvements were observed in pre- to post-operative VAS and with sustained improvements at final follow-up. The extra- or para-pedicular approach was the most frequent access trajectory. Most studies cited difficulties with visibility on fluoroscopy, using navigation or oblique views as a solution for this. Discussion and Conclusions: Percutaneous cementation at a failing screw-bone interface stabilises further micromotion with reductions in back pain. This rarely used technique is manifested by a low but increasing number of reported cases. The technique warrants further evaluation and is best performed within a multidisciplinary setting at a specialist centre. Notwithstanding that underlying pathology may not be addressed, awareness of this technique may allow an effective and safe salvage solution with minimal morbidity for older sicker patients.
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PURPOSE: A normal sagittal vertical axis (SVA) after spinal deformity correction can yield mechanical complications of up to 30%. Post-operative compensatory pelvic orientation can produce a normal SVA. We assess relative pelvic version (RPV), an individualised measure, for persistent post-operative compensatory measures. METHODS: Adult spinal deformity (ASD) patients who were treated operatively, with a normal SVA (< ± 50 mm) at 6-week follow-up were included, who were then followed-up after 2 years. These only included patients with fusion of > 4 vertebrae extending to L5 or below. Six-week subgroups were made regarding pelvis orientation, relative pelvic version (RPV: anteversion, aligned, moderate or severe retroversion) with analysis of patient-related outcome measures (PROMs), complications and spino-pelvic sagittal parameters. RESULTS: At 6 weeks, 140 patients met the inclusion criteria, 5 (3.6%) patients had anteversion, 59 (42.1%) were aligned, 60 (42.9%) had moderate retroversion and 16 (11.4%) patients had severe retroversion. Follow-up after 2 years demonstrated increased RPV in all groups except the severe RPV group who were more likely to develop SVA > 50 mm. Complications occurred in all groups. Significant 2-year differences were observed between moderate and severe RPV for back pain and PROMs but not between other RPV groups. CONCLUSION: Adult spinal deformity patients with a normal SVA after spino-pelvic instrumentation carry a significant risk of retroversion progression post-operatively, followed by increased positive sagittal balance. Relative pelvic version (RPV) measurements when categorised into anteversion, aligned, moderate retroversion and severe retroversion at 6 weeks were predictive of PROMs at 2 years.
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Pelvis , Vértebras Torácicas , Adulto , Dolor de Espalda , Humanos , Periodo Posoperatorio , Estudios RetrospectivosRESUMEN
AIMS: Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery. METHODS: A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed. RESULTS: The greatest gains in productivity were in avoiding repeat intraoperative scans (a mean of 248 minutes for patients who had two scans, and a mean 180 minutes for those who had a single scan). Optimizing accuracy was the biggest factor influencing this, which was reliant on incremental changes to the operating setup and technique. CONCLUSION: The application of lean principles to the introduction of ION for AIS surgery helps assimilate this method into the environment of the operating theatre. Data and stakeholder analysis identified a reproducible technique for using ION for AIS surgery, reducing operating time, and radiation exposure. Cite this article: Bone Joint J. 2020;102-B(1):5-10.
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Neuronavegación/métodos , Escoliosis/cirugía , Adolescente , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Tornillos Óseos/estadística & datos numéricos , Diseño de Equipo , Femenino , Fluoroscopía/estadística & datos numéricos , Humanos , Cuidados Intraoperatorios/métodos , Masculino , Bloqueantes Neuromusculares/administración & dosificación , Neuronavegación/instrumentación , Tempo Operativo , Posicionamiento del Paciente , Dosis de Radiación , Resultado del TratamientoRESUMEN
BACKGROUND: Mid-term clinical and radiological evaluation of a carbon-fiber cage in multilevel cervical spondylosis (MCS). Anterior cervical corpectomy and fusion (ACCF) using titanium mesh cages (TMC) has shown satisfactory outcomes, but with subsidence of up to 20%. Conventional long-fiber carbon fiber cages have shown a safe profile in discectomy/fusion (ACDF) but with minimal data in the setting of corpectomy. METHODS: Retrospective review of a single centre multi-surgeon cohort of MCS patients from 2007-2012. Follow-up period was a minimum of 3.5 years, mean 6 years. Outcomes included peri-operative, clinical [Nurick, European Myelopathy, Visual Analogue Scores (VAS), modified Japanese Orthopaedic Association (mJOA) scores and radiographic (C2C7, Cobb & ROM angles)]. RESULTS: A total of 102 consecutive patients were included. Mean length of stay was 5.5 (SD 3.5) days, blood loss 322 (SD 358) mL and operative time 98 (SD 31) min. Corpectomy levels included 72 single-level ACCF and 30 multiple ACCF. Fourteen had peri-operative complications. Three patients required early cage revisions. Mean pain scores improved from VAS neck 4.6 to 2.6 (P<0.01) and VAS arm 5.1 to 2.0 (P<0.01). Mean Nurick score improved from 1.2 to 0.4/4 (P<0.01). Mean follow-up EMS was 15.9/18 and mJOA was 14.0/17. Seventy follow-up radiographs were obtained. Flexion-extension angulation differences of >3 mm across the instrumented level were present in 5 patients, all of which displayed fusion of either grade 1 or 2. 7 had C2C7 kyphosis. Severe subsidence (>3 mm) was seen in 9 cases (13%). CONCLUSIONS: Mid-term outcomes of this carbon-fiber cage indicate that it is safe and durable for the treatment of MCS with a similar radiological profile to that of TMC.
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Decompression of lumbar spinal stenosis is the most common spinal surgery in those over 60 years of age. While this procedure has shown immediate and durable benefits, improvements in outcome have not changed significantly. Technical aspects of surgical decompression have evolved significantly. The recently introduced ultrasonic bone cutter allows a precise and safe peri-neural bone resection. The principles of preservation of stability, as described by Getty et al. have remained as relevant as when these were described 40 years ago.
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BACKGROUND: Thoracic hyperkyphosis can display pathological deterioration, resulting in either hyperlordotic cervical compensation or sagittal malalignment. Various techniques have been described to treat fixed malalignment. Pedicle subtraction osteotomy (PSO) is commonly used in the lumbar spine and frequently limited to the distal thoracic spine. This series focuses on the surgical specificities of proximal thoracic PSO, with clinical and radiological outcomes. OBJECTIVE: To report the surgical specificities and assess the clinical and radiological outcomes of proximal thoracic osteotomies for correction of rigid kyphotic deformities. METHODS: This is a retrospective review of 10 consecutive patients who underwent single level proximal thoracic PSO (T2-T5). Preoperative and postoperative full-body EOSTM radiographs, perioperative data, and complications were recorded. The surgical technique and its nuances were described in detail. RESULTS: Patients had mean age of 41.8 yr and 50% were female. The technique provided correction of segmental and global kyphosis, 26.6° and 29.5°, respectively. Patients reported reciprocal reduction in C2-C7 cervical lordosis (37.6°-18.6°, P < .001), significantly correlating with the reduction of thoracic hyperkyphosis (R = 0.840, P = .002). Mean operative time was 291 min, blood loss 1650 mL, and mean hospital stay was 13.8 d. Three patients reported complications that were resolved, including 1 patient who was revised because of a painful cross link. There were no neurological complications, pseudarthroses, instrumentation breakage, or wound infections at a minimum of 2-yr follow-up. CONCLUSION: Proximal thoracic PSO can be a safe and effective technique to treat fixed proximal thoracic hyperkyphosis leading to kyphosis reduction and craniocervical relaxation.
Asunto(s)
Cifosis/cirugía , Osteotomía/métodos , Fusión Vertebral/métodos , Vértebras Torácicas/cirugía , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Fijadores Internos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Fusión Vertebral/instrumentación , Resultado del TratamientoRESUMEN
STUDY DESIGN: Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. OBJECTIVE: To evaluate back and leg pain as a combined score in ASD and compare their relative and cumulative correlations with health-related quality of life (HRQOL) and sagittal parameters. SUMMARY OF BACKGROUND DATA: Pain and disability are commonly reported in patients with ASD. This can affect their back, their legs or both. ASD-associated pain has been correlated with numerous HRQOL scores and radiological parameters. METHODS: Preoperative pain intensity was assessed with a Numerical Rating Scale (NRS) for individual back and leg pain as well as a combined score, NRS20 (0-20, back plus leg pain).This yielded a range of static measures in all patients with ASD with differing burdens of disease. Linear regression analysis was performed to calculate the correlation between pain and HRQOL scores (Scoliosis Research Society 22, 36-Item Short Form Health Survey Physical Component Summary, 36-Item Short Form Health Survey Mental Component Summary, Core Outcome Measures Index, and Oswestry Disability Index), and radiological spinopelvic parameters (sagittal and coronal planes). RESULTS: A total of 1309 patients were included in this study. A combined score (NRS20) was better correlated with HRQOL (Pâ<â0.01 for all) and sagittal parameters (Pâ<â0.01 for all) than individual back or leg pain scores. Evaluation of the relative contributions of back and leg pain demonstrate a higher correlation with HRQOL scores for back pain and a higher correlation with sagittal parameters for leg pain. The distribution of NRS20 pain scores demonstrated three clear patterns of pain: back pain only, moderate back pain with varying mild-moderate leg pain, and severe equivalent back and leg pain. Similar values were noted for nonoperative and operative patients. CONCLUSION: The distribution and intensity of pain and its correlations with clinical and radiological parameters provide insight into the pathogenesis of ASD. A combined score has a simple yet valuable contribution to the assessment of symptoms in ASD. LEVEL OF EVIDENCE: 3.