Anterolateral versus posterior minimally invasive lumbar interbody fusion surgery for spondylolisthesis: comparison of outcomes from a global, multicenter study at 12-months follow-up.

BACKGROUND CONTEXT: Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches. PURPOSE: To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3-months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery. DESIGN: Prospective, multicenter, international, observational cohort study. PATIENT SAMPLE: Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion. OUTCOME MEASURES: Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months. METHODS: Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t-tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison. RESULTS: Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 ± 21.3 vs 25.8 ± 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390). CONCLUSIONS: Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach.

Simultaneous anterior vertebral column resection-distraction and posterior rod contouring for restoration of sagittal balance: report of a technique.

With an increasingly aging population, adult spinal deformity is becoming more common. This can be associated with increased morbidity. Results from multicentre studies of deformity surgery correction confirm complication rates as high as 40 percent. Most often a bad result is associated with inadequate restoration of the sagittal balance. Posterior vertebral body resection has been described as a method to correct significant deformity, but this is a complicated procedure. It is possible to do this in the thoracic spine where nerve roots can be sacrificed, but it is difficult in the lumbar spine due to the significant role of the lumbar nerve roots. We describe a safer technique for correction of deformity using a three stage process. This appears to be a good technique for revision surgery.

Morbidity and mortality in adult spinal deformity surgery: Norwich Spinal Unit experience.

PURPOSE: This study analyses the complications of spinal deformity surgery in adults to highlight pre-disposing factors. METHODS: The clinical records and imaging were reviewed for 48 consecutive patients, 12 males and 36 females, with a mean age of 64 (31-86), who had surgery for spinal deformity. Mean follow-up time was 36 months (24-60). Patient data recorded were age, diagnosis and co-morbidities; deformity assessment: curve type, sagittal and coronal balance, Cobb angle. Operation details: number of instrumented levels, duration and intra-operative complications. OUTCOME: complications, re-operations, balance and Cobb angle. RESULTS: 28 patients (58 %) had at least 1, 15 patients (27 %) had 2 and 5 patients (9.5 %) had more than 2 co-morbidities. Average time between 1st presentation and operation was 13 months (1-41). The mean number of levels fused was 10.8 (4-23). In addition to posterior pedicle screw instrumentation, 40 patients had chevron osteotomies and 8 had pedicle substraction osteotomies. Posterior interbody fusions were performed at one level in 17 of which 7 had 2 level fusion. Two patients had combined anterior and posterior approaches. Fusion to the pelvis was performed in 19 patients. There were a total of 27 major and minor complications in 19/48 (39.5 %) patients. Late complications included 5 patients who had revisions for proximal junctional kyphosis, 1 patient had revision for pseudoarthrosis and 4 patients had removal of mal-positioned screws. CONCLUSIONS: Factors associated with high complication rate in adult spinal deformity surgery are age, co-morbidities and severe sagittal imbalance at the time of presentation.

"Globus symptoms": a rare case of giant osteochondroma of the axis treated with high cervical extrapharyngeal approach.

Background Osteochondroma is the most common primary bone tumor, composing 35% of benign bone tumors and 9% of all bone tumors; 1.3 to 4.1% of all osteochondromas originate from the spine. A rare differential diagnosis for globus symptoms is an osteochondroma originating from the anterior surface of the axis. We describe a rare case of osteochondroma of the dens resulting in "globus symptoms" (the subjective sensation of a mass in the throat) treated with excision via the high cervical extrapharyngeal approach. Purpose To discuss the surgical management of this problem, with an emphasis on surgical approach used. The clinical history, examination, and investigations are presented and illustrated, along with clinical patient outcome. Study Design/Setting This article is a case report of a patient treated at the Department of Trauma and Orthopaedics in an active university teaching hospital. Methods Case presentation. For the discussion, we used handpicked articles, as well as MEDLINE and PubMed database searches with the keywords "C2," "dens," "osteochondroma," "globus," "extrapharyngeal approach." Results Uncomplicated procedure. Histological analysis confirmed a benign osteochondroma with no evidence of malignancy. The patient underwent an uncomplicated postoperative recovery and was discharged 24 hours after surgery, fully ambulatory and eating and drinking well. Conclusions The high cervical retropharyngeal approach is safe and reproducible for the excision of osteochondromas or osteophytes of the upper cervical spine.

Complete bony coalition of the talus and navicular: decades of discomfort.

Tarsal coalition is a congenital disturbance of hindfoot development. Talonavicular coalition is among the rarest forms of aberrant bony union of the tarsus. It frequently occurs bilaterally and in association with a number of skeletal deformities. Some patients are asymptomatic and the anomaly is discovered incidentally on plain radiographs. For others, a troublesome bony prominence will be the principle complaint and in a small proportion of patients marked foot and ankle pain with activity will prove debilitating. The authors describe the case of a 54-year-old male with bilateral foot pain spanning for nearly two decades. Symptom onset was insidious and at the time of presentation, he was limited to 10-15 min of mobilisation on flat ground.

Presentation and outcome of primary tumors of the patella.

Demographics, pathology, and outcomes of 7 patellar tumors, including 2 giant cell tumors, 2 chondroblastomas, 1 osteoid osteoma, 1 osteitis fibrosa cystica, and 1 case of myelomatous infiltration, are described. Five male and 2 female patients with a mean age of 42.5 years were followed for an average of 3.5 years. Anterior knee pain was the main presenting symptom. Two patients presented with pathologic fracture. One patient with chondroblastoma underwent curettage only; the second patient underwent curettage and bone grafting. Both patients with giant cell tumors underwent total patellectomy. Patients with osteoblastoma and osteitis fibrosa cystica underwent excision of the lesion. The patient with myeloma underwent radiotherapy. Patellar tumors represent special management problems because of their subcutaneous location, relationship to the extensor mechanism, and difficulties in interpretation of radiographs. A satisfactory outcome can be expected in the majority because of the predominantly benign nature of the lesions and straightforward operative intervention after diagnosis.

In vivo comparison of screw versus plate and screw fixation for first metatarsophalangeal arthrodesis: does augmentation of internal compression screw fixation using a semi-tubular plate shorten time to clinical and radiologic fusion of the first metatarsophalangeal joint (MTPJ)?

A retrospective analysis of first metatarsophalangeal joint fusion in 26 consecutive patients (34 feet), treated between April 1998 and February 2002, comparing single compression screw versus a compression screw supplemented with a dorsal quarter tubular plate, was undertaken. The study aimed to assess whether or not plate augmentation of the single interfragmental compression screw lead to an earlier fusion. There were 18 women and 8 men with a mean age of 54.6 +/- 11.02 years and a mean follow-up of 2.9 +/- 1.1 years. Successful fusion was determined clinically and radiologically by means of identifying transarticular trabeculation. The overall incidence of fusion was 97.06% (33/34 fusions). Observed complications included 4 cases of superficial wound infection, each of which resolved with antibiotic therapy; 3 cases of paraesthesia involving the dorsomedial aspect of the big toe; and 2 cases of transfer metatarsalgia. Statistical analyses did not reveal any significant associations between the type of fixation and time to fusion, patient satisfaction, and complications. In regard to the methods of osteosynthesis compared in this investigation, the choice of first metatarsophalangeal fusion fixation can be determined based on surgeon's preference. ACFAS Level of Clinical Evidence: 2c.

Severe bilateral rachitic genu valgum in patients with nonbullous congenital ichthyosiform erythroderma: a report of two cases and review of literature.

We present two cases of ichthyosiform erythroderma associated with severe bilateral genu valgum. Other musculoskeletal features associated with this condition are described. The details and outcome of operative intervention for the correction of the deformities are discussed. The disturbances of the metabolism of vitamin D and medical management are discussed. A review of literature is presented.