Ligamentous Augmentation to Prevent Proximal Junctional Kyphosis and Failure: A Biomechanical Cadaveric Study.

STUDY DESIGN: Biomechanical cadaveric study (level V). OBJECTIVE: To evaluate the effectiveness of polyethylene bands looped around the supra-adjacent spinous process (SP) or spinal lamina (SL) in providing strength to the cephalad unfused segment and reducing junctional stress. BACKGROUND: Proximal junctional kyphosis (PJK) is a pathologic kyphotic deformity adjacent to posterior spinal instrumentation after fusion constructs. Recent studies demonstrate a mismatch in stiffness between the instrumented construct and nonfused adjacent levels to be a causative factor in the development of PJK and proximal junction failure. To our knowledge, no biomechanical studies have addressed the effect of different methods of polyethylene band placement at the proximal junction. MATERIALS AND METHODS: Twelve fresh frozen cadavers were divided into 3 groups of 4: pedicle screw-based instrumentation from T10 to L5 ("control"), T10-L5 instrumentation with a polyethylene band to the T9 "SP," T10-L5 instrumentation with 2 polyethylene bands to the T9 "SL." Specimens were tested with an eccentric (10 mm anterior) load at 5 mm/min for 15 mm or until failure occurred. Failure was defined by the inflection point on the load versus deformation curves. Linear regression was utilized to evaluate the effect of augmentation on the load-to-failure. Significance was set at 0.05. RESULTS: Fractures occurred in all specimens tested. The mean peak load to failure was 2148 N (974-3322) for the SP group, and 1248 N (742-1754) for the control group (P > 0.05) and 1390 N (1080-2004) for the SL group. No difference existed between the control group and the SP group in terms of fracture level (P > 0.05). Net kyphotic angulation shows no differences among these 3 groups (P > 0.05). CONCLUSION: Although statistical significance was not achieved, ligament augmentation to the SP increased mean peak load-to-failure in a cadaveric PJK model.

Limited Intervention in Adult Scoliosis-A Systematic Review.

BACKGROUND/OBJECTIVES: Adult scoliosis is traditionally treated with long-segment fusion, which provides strong radiographic correction and significant improvements in health-related quality of life but comes at a high morbidity cost. This systematic review seeks to examine the literature behind limited interventions in adult scoliosis patients and examine the best approaches to treatment. METHODS: This is a MEDLINE- and PubMed-based literature search that ultimately included 49 articles with a total of 21,836 subjects. RESULTS: Our search found that long-segment interventions had strong radiographic corrections but also resulted in high perioperative morbidity. Limited interventions were best suited to patients with compensated deformity, with decompression best for neurologic symptoms and fusion needed to treat neurological symptoms secondary to up-down stenosis and to provide stability across unstable segments. Decompression can consist of discectomy, laminotomy, and/or foraminotomy, all of which are shown to provide symptomatic relief of neurologic pain. Short-segment fusion has been shown to provide improvements in patient outcomes, albeit with higher rates of adjacent segment disease and concerns for correctional loss. Interbody devices can provide decompression without posterior element manipulation. Future directions include short-segment fusion in uncompensated deformity and dynamic stabilization constructs. CONCLUSIONS: Limited interventions can provide symptomatic relief to adult spine deformity patients, with indications mostly in patients with balanced deformities and neurological pain.

Risk Factors for Postoperative Urinary Retention Following Lumbar Spine Surgery: A Review of Current Literature and Meta-Analysis.

STUDY DESIGN: Systematic Review and Meta-analysis. OBJECTIVE: Postoperative urinary retention (POUR) is a common complication following lumbar spine surgery (LSS) and timely recognition is imperative to avoid long-term consequences. The aim of the current meta-analysis was to systematically review the literature in order to identify risk factors associated with POUR after LSS. METHODS: In accordance with PRISMA guidelines, a systematic review of the literature was performed using Pubmed, EMBASE, and MEDLINE database for articles on POUR following LSS. A meta-analysis was performed comparing patients with and without POUR; and the factors associated with this adverse event were analyzed. The pooled data were reported as mean differences with 95% confidence intervals (CI; P < .05). Heterogeneity among the studies was evaluated using the I2 statistic. RESULTS: The meta-analysis included 10 studies compromised of 30,300 patients. Based on our analysis, patients who were male, were older in age, underwent instrumented fusion, had diabetes mellitus, coronary artery disease, or benign prostatic hypertrophy had significantly higher risk of developing POUR. Additionally, patients in who developed POUR had significantly longer surgical times and higher volumes of intra-operative fluid administration, as compared with non-POUR patients. The POUR patients also had a significantly higher association with urinary tract infection. Prior surgery, BMI, length of stay, and smoking status did not reveal any statistical association with POUR. CONCLUSIONS: Risk factors associated with POUR following LSS include male gender, older age, longer surgical times, fusion procedures, larger volumes of intraoperative infusions, and associated comorbidities like DM, CAD, and BPH.

Traumatic hyperextension-distraction injuries of the thoracolumbar spine: a technical note on surgical positioning.

PURPOSE: Hyperextension-distraction type injury of the thoracolumbar spine is an unstable fracture pattern that generally necessitates surgical stabilization by posterior instrumentation. Care must be taken when positioning these patients from supine to prone due to the unstable nature of their injury. The study objectives were (1) to describe a novel modification of the Jackson table turn technique, which may be safer and more effective than the conventional log-roll method and traditional Jackson table technique for positioning patients with hyperextension-distraction injuries of the thoracolumbar spine from supine to prone in the operating room and (2) to present two cases in which this technique was successfully performed. METHODS: Two patients were carefully positioned from supine to prone by our modification of the Jackson table turn technique, which utilizes a Wilson frame sandwiched between two flat-top Jackson frames. Case 1: a 65-year-old female presented status-post motor vehicle collision with a T9-T10 extension-distraction injury, requiring T7-T12 posterior spinal instrumented fusion (PSIF). Case 2: a 72-year-old female presented status-post motor vehicle collision with a T9-T10 extension-distraction injury and an unstable L1 burst fracture, requiring T7-L2 PSIF. RESULTS: Both patients remained hemodynamically stable and neurologically intact throughout positioning and postoperatively. CONCLUSIONS: This technique is safe and effective for positioning patients with hyperextension-distraction type injuries of the thoracolumbar spine from supine to prone in the operating room and may be superior to conventional methods. These slides can be retrieved under Electronic Supplementary Material.

Nanotechnology in Spine Surgery: A Current Update and Critical Review of the Literature.

OBJECTIVE: Nanotechnology is a promising field with numerous applications across various branches of medicine. The unique innate physical, chemical, and biological properties of nanoparticles enable them to serve as appropriate agents performing diverse functions at cellular and subcellular levels. Spinal pathologies constitute one major field where its applications are being explored. METHODS: A critical review of literature was performed to identify the current role of nanotechnology in spine surgery. A PubMed search was done using the following key words: "nanotechnology in neurosurgery," "nanotechnology in surgery," "nanotechnology in spine," "nanotechnology in spine surgery," "nanotechnology in disc regeneration," "nanotechnology in spinal injury," "nanotechnology in spinal cord regeneration," "nanotechnology in spine fusion," "nanotechnology in osteoporosis," "nanotechnology in spinal drug delivery," and "nanotechnology in spinal infection." Initial search revealed 347 articles. Articles were further screened. Duplicate articles, articles on nonnanotechnologic topics, nonspine articles, or articles with details not pertaining to the current field of interest and non-English language studies were excluded. RESULTS: A total of 76 articles were finally included. Nanotechnologic advancements in spine surgery include applications in spinal fusion, central nervous system drug delivery, neuronal regeneration, disk regeneration, spinal infection prophylaxis, management of osteoporosis, sutureless vascular anastomosis, molecular imaging, and theranostic medicine. CONCLUSIONS: Nanotechnology in spine surgery is still in its early stages. Eventually, we may see the implementation of nanotechnology as an alternative to existing treatment options. Concerns regarding safety of this technology need to be addressed through future research projects. Although promising, the exact role of nanotechnology in spine surgery remains to be seen.

Spinopelvic Dissociation: Comparison of Outcomes of Percutaneous versus Open Fixation Strategies.

INTRODUCTION: Spinopelvic dissociation injuries are historically treated with open reduction with or without decompressive laminectomy. Recent technological advances have allowed for percutaneous fixation with indirect reduction. Herein, we evaluate outcomes and complications between patients treated with open reduction versus percutaneous spinopelvic fixation. METHODS: Retrospective review of patients undergoing spinopelvic fixation from a single, level one trauma center from 2012 to 2017. Patient information regarding demographics, associated injuries, and treatment outcome measures was recorded and analyzed. All fractures were classified via the AO Spine classification system. RESULTS: Thirty-one spinopelvic dissociations were identified: 15 treated with open and 16 with percutaneous techniques. The two treatment groups had similar preoperative characteristics including spinopelvic parameters (pelvic incidence and lumbar lordosis). Compared to open reduction internal fixation, percutaneous fixation of spinopelvic dissociation resulted in statistically significantly lower blood loss (171 cc versus 538 cc; p = 0.0013). There were no significant differences in surgical site infections (p = 0.48) or operating room time (p = 0.66). CONCLUSION: Percutaneous fixation of spinopelvic dissociation is associated with significantly less blood loss. Treatment outcomes in terms of infection, length of stay, operative cost, and final alignment between the open and percutaneous group were similar.

Nanotechnology in orthopedics: a clinically oriented review.

The utility of nanotechnology in medicine, specifically within the field of orthopedics, is a topic of extensive research. Our review provides a unique comprehensive overview of the current and potential future uses of nanotechnology with respect to orthopedic sub-specialties. Nanotechnology offers an immense assortment of novel applications, most notably the use of nanomaterials as scaffolds to induce a more favorable interaction between orthopedic implants and native bone. Nanotechnology has the capability to revolutionize the diagnostics and treatment of orthopedic surgery, however the long-term health effects of nanomaterials are poorly understood and extensive research is needed regarding clinical safety.

Concomitant Lumbar Stenosis and Aortic Pseudoaneurysm: A Case Report.

Aortic pseudoaneurysm can create a constellation of symptoms that can mimic lumbar back pain. There are rare but well-documented reports of aortic pathology (aneurysms, pseudoaneurysms, and chronic contained aneurysm ruptures) eroding into the vertebral column causing neural compression. We report a case of a rapidly progressive aortic pseudoaneurysm in a patient with pre-existing lumbar spine pathology which had the potential for catastrophic intraoperative bleeding during a minimally invasive surgery (MIS) using the transforaminal lumbar interbody fusion (TLIF) technique. Postoperatively, the patient's radicular pain resolved but her back pain remained. Further workup identified the pseudoaneurysm and the patient subsequently underwent open vascular repair. In this report, we highlight a lesser known mimicker of lumbar back pain.

Symptomatic Unilateral Spondylolysis Associated With Nonspondylolytic Lateral Clefts in Adults: Review of an Infrequently Reported Pathology.

Nonspondylolytic lateral clefts of the lumbar neural arch (laminolysis and pediculolysis) are rare pathologies that usually occur consequent to repetitive stress injuries in patients with unilateral spondylolysis. These lesions are different from the usual bilateral spondylolytic defects, and their management depends upon the chronicity and the type of bony defect. We hereby discuss the verdict of current literature on underlying pathomechanics and ideal management guidelines of these rare lesions.

Early, reliable, utilitarian predictive factors for fat embolism syndrome in polytrauma patients.

BACKGROUND: Fat embolism is one of the apocalyptic pulmonary complications following high energy trauma situations. Since delay in diagnosis may have devastating consequences, early, easily accessible and relatively inexpensive investigations for risk stratification may prove useful, especially in developing nations. MATERIALS AND METHODS: This prospective trial included a total of 67 young polytrauma patients, in whom the role of nine easily available, rapidly performable clinical or laboratory investigations (or observations noted at admission) in predicting the later occurrence of fat embolism syndrome were assessed. All the patients also underwent continuous monitoring of oxygen saturation with pulsoximetry. RESULTS: The correlation between initial serum lactate (within 12 hours of injury) and hypoxia was statistically significant. There was a trend towards correlation with FES(by Gurd's criteria) (P=0.07), Sensitivity of 24-hour monitoring of oxygen saturation in predicting later pulmonary deterioration approached 100%. CONCLUSIONS: The combination of three factors including polytrauma (with NISS >17), serum lactate >22 mmol/l at admission (within 12 hours of injury) fall in oxygen saturation (SaO2 below 90% in the initial 24 hours) predict the development of post-traumatic pulmonary complications, especially the fat embolism syndrome.