Real-world persistence of twice-weekly teriparatide and factors associated with the discontinuation in patients with osteoporosis.

INTRODUCTION: A 28.2 µg twice-weekly formulation of teriparatide (2/W-TPD) was developed to provide comparably high efficacy for osteoporosis to a 56.5 µg once-weekly formulation while improving the safety and persistence rate. In the current study, we aimed to elucidate the real-world persistence of 2/W-TPD and to identify the factors associated with the discontinuation of 2/W-TPD in patients with severe osteoporosis. MATERIALS AND METHODS: This retrospective study included 90 patients who were treated with 2/W-TPD at three hospitals in Japan. Patient information was collected, including age, sex, distance to the hospital, family structure, comorbidities, previous treatment for osteoporosis, timing of the injection, side effects and duration of 2/W-TPD treatment, barthel index (BI), and bone mineral density (BMD) of the lumbar spine and femoral neck. We examined the factors influencing 2/W-TPD discontinuation using the Cox proportional hazards model. RESULTS: The 12 month completion rate of 2/W-TPD therapy was 47.5%. The Cox hazard analysis identified side effects [Hazard Ratio (HR) = 14.59, P < 0.001], low BMD of the femoral neck (HR = 0.04, P = 0.002), and morning injection (HR = 3.29, P = 0.006) as risk factors influencing the discontinuation of 2/W-TPD. Other variables, including age, did not contribute to the continuation of 2/W-TPD. CONCLUSION: One year continuation rate of 2/W-TPD was higher than the previously reported value of the once-weekly formulation in real-world setting, probably due to the lower incidence of side effects. Introducing injection of 2/W-TPD may further improve the persistence of TPD therapy for osteoporosis.

Is closed-suction drainage necessary for single-level lumbar decompression?: review of 560 cases.

BACKGROUND: Closed-suction drainage is commonly used for prevention of postoperative hematoma and associated neurologic compromise after lumbar decompression, but it remains unclear whether suction drainage reduces postoperative complications. QUESTIONS/PURPOSES: We evaluated the efficacy of closed-suction drainage in single-level lumbar decompression surgery. PATIENTS AND METHODS: We retrospectively reviewed 560 patients who underwent single-level lumbar decompression or discectomy. We routinely used closed-suction drainage in all spinal surgeries until July 2003, and thereafter, we did not use drains in single-level lumbar decompression surgery. These two groups (298 patients in the group that received drains, 262 in the group that did not receive drains) were compared for rates of wound infection and epidural hematoma. RESULTS: Mean operating time (55 versus 56 minutes) and intraoperative blood loss (64 versus 57 mL) were not different between the two groups. None of 560 patients had a wound infection requiring surgical intervention. The rate of postoperative hematoma was 0.7% in the group that received drains (two of 298 patients) and 0% in the group that did not receive drains (zero of 262 patients). CONCLUSIONS: In this study, the risk of wound infection and hematomas in single-level lumbar decompression surgery was not influenced by use of a drain. The use of postoperative wound drainage in patients with potential risk for epidural bleeding in situations such as multiple-level decompression, instrumentation surgery, anticoagulant therapy, trauma, and tumors or metastases needs additional study. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Role of major spine surgery using Kaneda anterior instrumentation for osteoporotic vertebral collapse.

STUDY DESIGN: A retrospective study. OBJECTIVES: To investigate the clinical and radiographic results of spinal reconstruction using Kaneda anterior spinal instrumentation for osteoporotic vertebral collapse. SUMMARY OF BACKGROUND DATA: Recent advances in osteoporotic vertebral fracture treatment including kyphoplasty changes the role of major surgery for these pathologies. However, osteoporotic vertebral collapse with neurologic compromise remains requiring surgical decompression and reconstruction. METHODS: Thirty-one consecutive patients who underwent anterior spinal reconstruction for osteoporotic vertebral collapse with neurologic deficits were reviewed retrospectively. Twenty-six patients had single vertebral collapse and 5 had multiple lesions. They were 10 males and 21 females with mean age of 71 years. Mean follow-up period was 57 months. For anterior column support, iliac bone graft was used in 1 patient, cylindrical titanium cages in 12, and bioactive ceramic spacers in 18 patients. Kaneda anterior instrumentation was used in all the patients. Radiographic and clinical assessments were performed preoperatively and at the final follow-up. RESULTS: All the patients showed neurologic recovery. Visual analog scales (0 to 10) of low back pain and sciatic pain were 5.8 and 4.2 before surgery, and 2.1 and 0.6 at the final follow-up, respectively. Mean kyphosis of operative levels was 31 degrees before surgery, and improved to 13 degrees immediately after surgery and 21 degrees at the final follow-up. Posterior reinforcement was required in 6 patients (19%), who had severe osteoporosis and/or underwent multilevel corpectomies. Solid fusion was achieved in all patients at the final follow-up. CONCLUSIONS: The current study demonstrated the advantages of anterior spinal reconstruction in osteoporotic vertebral collapse: (1) safe and reliable decompression could be performed, and (2) 80% of patients were successfully treated with anterior spinal reconstruction alone. However, patients with multilevel corpectomies and/or severe osteoporosis highly required posterior reinforcement.

Motion-preserving surgery can prevent early breakdown of adjacent segments: Comparison of posterior dynamic stabilization with spinal fusion.

STUDY DESIGN: A retrospective study. OBJECTIVES: This study aims to determine the prevalence and nature of adjacent-segment deterioration after posterior ligamentoplasty, posterolateral lumbar fusion (PLF) versus posterior lumbar interbody fusion (PLIF). SUMMARY OF BACKGROUND: Motion-preserving technologies including disc arthroplasty and ligamentoplasty were gaining interest to reduce the risk of adjacent-segment morbidity. However, few clinical studies have reported the prevalence of adjacent-segment disease in motion-preserving surgeries. METHODS: Two-hundred and eighteen consecutive patients who had undergone single-level posterior L4-L5 pedicle-screw-instrumented fusion or ligamentoplasty were reviewed at minimum 2-year follow-up. They were 91 males and 127 females with mean age of 62 years. Follow-up period was averaged 41 months and follow-up rate was 97.3%. There were 78 cases of PLIF, 75 of PLF, and 65 of ligamentoplasty. Demographics were not statistically different among the 3 groups. Prevalence of adjacent-segment morbidity (radiculopathy associated with newly developed pathologies at neighboring levels) and required additional surgery were investigated. RESULTS: Prevalence of adjacent-segment morbidity was 14.1% in PLIF, 13.3% in PLF, and 9.2% in ligamentoplasty; the time to represent symptom was averaged 25.2, 39.3, and 51.8 postoperative months, respectively. Additional surgeries for adjacent-segment pathologies were required for 7.6% in PLIF, 6.7% in PLF, and 1.5% in ligamentoplasty. Although all PLF cases needed only decompression surgeries, 66.7% of reoperations in the PLIF group required fusion owing to progression of adjacent-segment instability. CONCLUSIONS: Prevalence of adjacent-segment disease and reoperation rate seemed to be lower in ligamentoplasty than fusion surgeries, but the difference was not significant. Ligamentoplasty circumvented adjacent-segment disease for longer period than fusion surgeries. Although the rates of additional surgeries in PLIF and PLF were comparable, PLIF developed adjacent-level instability and required fusion surgery more frequently than PLF.

Spinal Subdural Abscess Following Food Intoxication: A Case Report.

INTRODUCTION: Spinal subdural abscess (SSA) or empyema is a rare pathology and its exact incidence is unknown. Staphylococcus aureus (S aureus) is the most frequently responsible organism. The patients with SSA may have one or more predisposing immunosuppressive conditions. However, here we report a rare case of SSA following food intoxication without any significant comorbidities. CASE REPORT: A 42-year-old healthy man presenting with fever, severe low back pain (LBP), and trunk motion restriction was transferred to our hospital. He had been treated for an unknown fever after food intoxication in another hospital. Eighteen days earlier, he and his colleagues together ate raw horse meat and briefly boiled chicken breast. They all had food intoxication on the following day. Subsequently, our patient began to have a high fever and severe LBP. Laboratory data showed leukocytosis of 16,000/mm3. Also, the C-reactive protein was elevated to 26 mg/dL. The blood culture result was consistent with S aureus. Magnetic resonance imaging (MRI) showed focal epidural fluid collection that appeared contiguous with the subdural fluid collection through a dural defect in the axial plane on T2-weighted (T2W) images. An emergent surgery was performed. Frank pus was expressed from the epidural space as well as from the subdural space through the defect. The pus later grew S aureus. The patient was started on antibiotic therapy postoperatively. The patient completely recovered 1 month after surgery. CONCLUSIONS: SSA following food intoxication is a very rare case. SSA can be identified with a small dural defect and the intrathecal fluid collection compressing the cauda equina in the axial plane on T2W magnetic resonance images. Having suspicion of epidural abscess and likewise subdural abscess and making an early diagnosis using MRI and an emergent surgery are important when the clinician notices a febrile patient with severe LBP and trunk motion stiffness.

The efficacy of osteoporotic treatment in patients with new spinal vertebral compression fracture pain, ADL, QOL, bone metabolism and fracture-healing - In comparison with weekly teriparatide with bisphosphonate.

We conducted a randomized control study to compare the effects of pain, QOL, bone metabolism and fracture healing by administering bisphosphonate (BP) or weekly teriparatide preparation (W-TPTD) to 43 patients (5 males and 38 females) with fresh spinal vertebral compression fractures for osteoporosis. The patients were aged between 61 and 93 years old (mean 78.1 years). In principle, a MRI was used for any diagnosis of new vertebral fractures. From this study, lumbar spine bone mineral density (BMD), after 24 weeks of administration, showed a significant increase (p < 0.05) in both the BP group (mean 5.3%) and in the W-TPTD group (mean 4.9%). The W-TPTD group showed a better Roland-Morris disability Questionnaire (RDQ) improvement throughout the whole period of the study compared with the BP group, the difference was statistically significant after 24 weeks of administration (p < 0.05). The EuroQol 5 dimensions (EQ-5D) and visual analogue scale (VAS) score significantly improved over time in both groups (p < 0.05). The fracture-healing rate was observed in 45% of the BP group and 73% of the W-TPTD group at Week 12, and a statistically significant higher fracture-healing rate was obtained in the W-TPTD group compared to the BP group (p < 0.05). The mean time of fracture-healing was 3.9 months for the BP group and 2.8 months in the W-TPTD group. Statistically significant faster fracture-healing was observed in the W-TPTD group (p < 0.05). At Week 12 and Week 24, P1NP was significantly higher in the W-TPTD group compared to that of the BP group (p < 0.05). TRACP-5b showed no major fluctuations during the study period in either group. These results suggest that W-TPTD may promote better fracture healing of any new osteoporotic vertebral compression fractures compared with a BP.

Effective prevention of surgical site infection using a Centers for Disease Control and Prevention guideline-based antimicrobial prophylaxis in lumbar spine surgery.

OBJECT: Antimicrobial prophylaxis (AMP) reduces the rate of surgical site infection (SSI) in lumbar spine surgery, but a great deal of variation exists regarding the timing and duration of AMP. The authors had previously used prophylactic antibiotics for 5 to 7 postoperative days. Based on the Centers for Disease Control and Prevention (CDC) guideline, the AMP period was changed to the day of surgery only. In the current study, the authors compared the rate of SSI in lumbar spine surgeries between two different protocols of AMP. METHODS: Data from 1597 consecutive uninfected patients who had undergone lumbar spine surgery between January 1999 and September 2004 were reviewed. The pathophysiologies among these patients included disc herniation in 686, degenerative spondylolisthesis in 340, spinal stenosis in 259, failed lumbar surgeries in 73, degenerative scoliosis in 52, isthmic spondylolisthesis in 48, spinal trauma in 34, foraminal stenosis in 27, spinal tumor in 27, and miscellaneous in 51 patients. The rate of SSI was compared between the two AMP groups. There were 1133 patients in the multiple-dose group, and 464 patients in the single-dose group. The rate of instrumentation surgery was not statistically different between the multiple-dose group (43%) and the single-dose group (39%). The overall rate of SSI was 0.7%. The SSI rate was 0.8% in the multiple-dose group and 0.4% in the single-dose group; the difference between the two was not significant. Regarding the organisms of SSI, resistant strains of bacteria were cultured in five (83.3%) of six patients in the multiple-dose group, whereas none was cultured in the single-dose group. CONCLUSIONS: Data in the current study did not demonstrate a difference in the rate of SSI between the two different AMP protocols. Based on the CDC guideline, a single dose of AMP was proven to be efficacious for the prevention of SSI in lumbar spine surgeries. A shorter duration of first-generation cephalosporin use may effectively prevent the emergence of antibiotic-resistant bacterial infection.

MRI-based Decision Making of Implant Removal in Deep Wound Infection After Instrumented Lumbar Fusion.

STUDY DESIGN: A retrospective study. OBJECTIVE: The aim of the study was to review the treatment of deep wound infection after posterior instrumented lumbar fusion, and thereby to optimize the decision-making process of implant removal or retention on the basis of magnetic resonance imaging (MRI) assessment. SUMMARY OF BACKGROUND DATA: Biofilm formed on the surface of the spinal implant prevents infiltration of antibiotics and makes the infection treatment more complicated. The decision of implant removal, if necessary, should be made appropriately, but the problem is a lack of consensus for implant removal or retention. METHODS: A total of 1445 consecutive patients who underwent posterior instrumented lumbar fusion were reviewed retrospectively. There were 23 deep wound infections (1.6%) requiring surgical treatment. MR images were used to evaluate the presence or absence of osteomyelitis of the instrumented vertebra and intervertebral abscess. RESULTS: Six patients in the negative MRI group (n=7) were successfully treated by a single salvage surgery without implant removal; fusion occurred in 86% of the patients. However, in the positive MRI group (n=13), 4 patients required implant removal at the initial surgery and 5 patients eventually warranted implant removal after an average of 2.4 additional operations. Notably, 3 of the 4 patients who kept the implants ended up with a loss of fixation stability attributed to screw loosening with a progressive destruction of the instrumented vertebra. Therefore, the fusion rate was only 23% for the MRI-positive patients. Furthermore, making a wrong decision regarding implant removal increased the number of salvage surgeries and frequently resulted in progressive bone destruction and pseudarthrosis. CONCLUSIONS: Once vertebral osteomyelitis and/or intervertebral abscess were evident in MR images, all the hardware should be removed. Failure to adhere to this recommendation resulted in multiple additional failed operations, and ultimately pseudarthrosis with further bony destruction.

Rationale, biomechanics, and surgical indications for Graf ligamentoplasty.

Graf ligamentoplasty stabilizes the unstable segment through coaptation of bilateral facet joints. Intervertebral disc height should be preserved to avoid postoperative neuroforaminal stenosis. Biomechanically and clinically, this procedure has the potential to treat "flexion instability" but cannot correct vertebral slippage or scoliotic deformity. Surgical indication or patient selection is the key to successful ligamentoplasty. The surgical indication is degenerative lumbar disorder with less than 25% of vertebral slip, minimal disc space narrowing, and coronal facet tropism. In the long-term, Graf ligamentoplasty may reduce the risk of adjacent-segment deterioration compared with spinal fusion.

New treatment of lumbar disc herniation involving 5-hydroxytryptamine2A receptor inhibitor: a randomized controlled trial.

OBJECT: Serotonin or 5-hydroxytryptamine (5-HT) is a chemical mediator associated with nucleus pulposus-induced radiculopathy. Inhibition of 5-HT receptors may potentially alleviate symptoms in patients with lumbar disc herniation. This prospective randomized controlled study was performed to evaluate the efficacy of the 5-HT2A receptor inhibitor in the treatment of symptomatic lumbar disc herniation. METHODS: Forty patients with sciatica due to L4-5 or L5-S1 disc herniation were randomly allocated to treatment with the 5-HT2A inhibitor (sarpogrelate 300 mg/day) or nonsteroidal antiinflammatory drugs (NSAIDs; diclofenac 75 mg/day). Low-back pain, leg pain, and numbness were evaluated using a visual analog scale (VAS) before and after a 2-week course of treatment. The patients received only allocated medicine during the 2-week regimen and were thereafter allowed to choose any treatment options depending on their residual symptoms. One-year clinical outcomes were assessed based on the rates of additional medical interventions. The mean VAS score improvements in the 5-HT2A and NSAID groups were 33 and 46% for low-back pain, 32 and 32% for leg pain, and 35 and 22% for leg numbness, respectively. After the 2-week regimen, no additional medical interventions were required in 50% of 5-HT2A-treated patients and 15% of those receiving NSAIDs. Epidural or nerve root block procedures were performed in 35% of the 5-HT2A group and 45% of the NSAID group. Surgery was required in 20% of the 5-HT2A group and 30% of the NSAID group patients. CONCLUSIONS: The current study provided evidence that the efficacy of the 5-HT2A inhibitor was comparable with that of NSAID therapy for lumbar disc herniation. The 5-HT2A inhibitor has the potential to alleviate symptoms in patients with lumbar disc herniation.

A new endoscopic posterior cruciate ligament reconstruction: Minimization of graft angulation.

PURPOSE: The purpose of this report is to present a new surgical technique for endoscopic posterior cruciate ligament (PCL) reconstruction and to elucidate the preliminary results. Surgical Technique: The concept of this surgical technique is to minimize the graft angulation at the inner edge of the bone tunnel. The tibial entry point of the guide pin is under the tibial lateral subcondylar flare approximately 1 to 2 cm anterior to the posterior cortex and 4 cm distal to the joint surface. This creates less graft angulation on the posterior aspect of the tibia. A new drill system has been devised to allow antegrade femoral drilling starting from inside the notch. This method also allows better femoral tunnel orientation. As a substitute graft material, we use autogenous hamstring tendons, and we secure them with an EndoButton (Smith & Nephew, Mansfield, MA) and post screw. METHODS: Since 1995, 40 knees have undergone endoscopic PCL reconstruction. Twenty-one patients were evaluated after a minimum follow-up of 1 year (17.9 +/- 7.7 mo). The clinical evaluation was performed using the International Knee Documentation Committee (IKDC) form. RESULTS: The range of motion was rated as A for 17 cases, B in 3 cases, and C in one case. The total anteroposterior translation (KT-1000, manual-maximum) showed a range of 1.0 to 5.5 mm (mean, 2.8 mm). The ratings of the ligament examination were A in 9 cases and B in 12 cases. The final IKDC evaluation was A (normal) in 3 cases, B (nearly normal) in 17 cases, and C (abnormal) in 1 case. CONCLUSIONS: A good clinical outcome was achieved with our endoscopic PCL reconstruction. The reduction of the graft angulation may contribute to the good results for PCL reconstruction.

A minimum 10-year follow-up of posterior dynamic stabilization using Graf artificial ligament.

STUDY DESIGN: A retrospective long-term follow-up study. OBJECTIVES: To report minimum 10-year follow-up results of posterior dynamic stabilization using Graf artificial ligament and to evaluate the role and limitations of this procedure in the treatment of degenerative lumbar disorders. SUMMARY OF BACKGROUND: Motion-preserving surgeries, including artificial disc replacement and ligamentoplasty, are increasingly gaining interest to avoid adverse effects of spinal fusion, but literature addressing long-term results is sparse. METHODS: A total of 56 consecutive patients who underwent Graf ligamentoplasty were reviewed at a minimum 10-year follow-up. Forty-three patients in the original cohort had sufficient clinical and radiographic follow-up for analysis. The pathologies included degenerative spondylolisthesis in 23 patients, disc herniation with flexion instability in 13 patients, spinal stenosis with flexion instability in 4 patients, and degenerative scoliosis in 3 patients. Single-level procedures were performed in 36 patients; multilevel procedures were performed in 7 patients. Radiographic and clinical assessments were performed before surgery and at the final follow-up. RESULTS: Disability due to low back pain and/or sciatic symptoms was significantly improved in the patients with degenerative spondylolisthesis or flexion instability. However, degenerative scoliosis and/or laterolisthesis were associated with poor clinical improvement. In radiographic assessment, segmental lordosis was maintained in 10.9 degrees, and flexion-extension motion was averaged 3.6 degrees at the final follow-up. Facet arthrodesis eventually occurred in 14 patients (32.6%) at an average of 82 months after surgery. Additional surgeries were required in 3 patients (7.0%) for adjacent segment pathologies. CONCLUSION: The long-term results showed that Graf ligamentoplasty is an effective treatment option for low-grade degenerative spondylolisthesis and flexion instability. However, this procedure has limitations to correct spinal deformity, and is not advocated for the treatment of degenerative scoliosis and laterolisthesis.

A prospective randomized study of posterolateral lumbar fusion using osteogenic protein-1 (OP-1) versus local autograft with ceramic bone substitute: emphasis of surgical exploration and histologic assessment.

STUDY DESIGN: A prospective, randomized and controlled study. OBJECTIVES: To evaluate the osteoinductive property of Osteogenic Protein-1 (OP-1 or BMP-7) and fusion rate in human instrumented posterolateral lumbar fusion through radiographic examination, surgical exploration, and histologic assessment. SUMMARY OF BACKGROUND DATA: The use of osteoinductive agents is a current topic in spinal fusion. Numerous preclinical investigations have demonstrated efficacy of osteoinductive proteins in spinal fusion, but few human clinical studies have been reported. METHODS: Nineteen patients with L3-L4 or L4-L5 degenerative spondylolisthesis underwent posterolateral lumbar fusion using pedicle screw instrumentation. The patients were randomized to receive either OP-1 Putty (3.5 mg OP-1/g of collagen matrix per side) alone (n = 9), or local autograft with HA-TCP granules (n = 10). Fusion status was evaluated using plain radiography and CT scan. Radiographic fusion criteria included less than 5 degrees of angular motion, less than 2 mm of translation, and evidence of bridging bone in the posterolateral lumbar area in which the graft materials were placed following decortication. After a minimum 1-year follow-up, the patients who showed radiographic evidence of fusion underwent instrumentation removal and surgical exploration of the fusion site. Biopsy specimens were taken from the fusion mass and evaluated histologically. RESULTS: Radiographic fusion rate was 7 of 9 OP-1 patients and 9 of 10 control patients. Based on surgical exploration of these 16 patients, new bone formation was macroscopically observed in the posterolateral lumbar region in all cases; however, solid fusion was observed in 4 of 7OP-1 and 7 of 9 HA-TCP/autograft patients. Histologic assessment demonstrated viable bone in 6 of 7 OP-1 patients. All the control (HA-TCP/autograft) specimens contained viable bone and fibrous tissue surrounding ceramic granules, suggesting slow incorporation of the graft material. CONCLUSIONS: In a human posterolateral lumbar spine trial, OP-1 reliably induced viable amounts of new bone formation, but the fusion success rate evaluated by surgical exploration was only 4 of 7.

Non-fusion surgery for degenerative spondylolisthesis using artificial ligament stabilization: surgical indication and clinical results.

STUDY DESIGN: A retrospective study. OBJECTIVES: To report midterm clinical and radiographic results of Graf artificial ligament stabilization in the treatment of degenerative spondylolisthesis and to evaluate the role of this procedure and its surgical indications for surgical success. SUMMARY OF BACKGROUND DATA: Nonfusion surgeries including artificial disc replacement and ligamentoplasty are increasingly gaining interest to avoid adverse effects of spinal fusion. METHODS: Sixty-four consecutive patients with degenerative spondylolisthesis underwent artificial ligament stabilization. Surgical indication was symptomatic degenerative spondylolisthesis with <25% of vertebral slip, coronal facet tropism, and minimal disc space narrowing. Radiographic and clinical assessments were performed before surgery, immediately after surgery, and at the final follow-up. Mean follow-up period was 67 months (36-112 months). RESULTS: Visual analog scales of low back pain and sciatic symptoms were significantly improved. Radiographic assessments demonstrated that segmental lordosis was maintained in 12.2 degrees , and flexion-extension motion was averaged 4.7 degrees at the final follow-up. Facet arthrodesis spontaneously occurred in 12 cases (18.8%) at an average of 59.5 months after surgery. Although vertebral slip was not improved, postoperative disc space narrowing was minimal. Additional surgeries were required in 4 cases for adjacent segment pathologies (6.3%). One patient (1.6%) underwent consequent spinal arthrodesis at the ligamentoplasty level. CONCLUSIONS: Artificial ligament stabilization did not improve the vertebral slip but maintained lordosis and preserved segmental motion in 80% of patients. This procedure is an effective alternative to spinal arthrodesis in the treatment of symptomatic degenerative spondylolisthesis (Grade I) with minimal disc space narrowing and coronal facet tropism.

Efficacy of serotonin receptor blocker for symptomatic lumbar disc herniation.

Serotonin is one of the chemical mediators associated with nerve root inflammation and sciatic symptoms in lumbar disc herniation. The efficacy of serotonin 5-HT(2A) receptor blocker was examined in 44 patients with symptomatic lumbar disc herniation. A selective 5-HT(2A) receptor blocker (sarpogrelate hydroxychloride) was administered orally at a dose of 300 mg per day for 2 weeks. Visual analog scales of low back pain, sciatic pain, and numbness were significantly improved after the administration of the serotonin 5-HT(2A) receptor blocker. Clinical results were good (> 50% pain relief) in 23 patients, fair (25%-50% pain relief) in five patients, and poor (< 25% of pain relief) in 16 patients. Nineteen patients eventually required surgery because of muscle weakness or cauda equina symptoms. The effect of 5-HT(2A) blocker was good in 64% of patients who had uncontained disc herniation, whereas all patients with contained disc herniation had fair or poor results. Patients with uncontained disc herniation responded more favorably to the 5-HT(2A) blocker treatment than patients with contained disc herniation. A 5-HT(2A) blocker has the potential to block the cascade of acute nerve root inflammation and to alleviate symptoms in lumbar disc herniation.

Pitfalls of anterior cervical fusion using titanium mesh and local autograft.

Cervical fusion cages have been developed to provide an anterior structural support without harvesting tricortical iliac bone. Limited numbers of investigations have focused on pitfalls of anterior cervical fusion using cage implants. The objective of this study is to report clinical results and implant-related complications in anterior cervical fusion using titanium mesh and anterior plating. Twenty-four cases with anterior cervical fusion using a titanium mesh with local autograft and anterior plating were reviewed. One-level fusion was performed in 7 cases, and 17 patients underwent two-level fusion with corpectomy. The mean follow-up period was 27 months. Radiographic assessment included sagittal alignment, fusion status, and complications related to cage implants. Iliac bone graft harvesting was obviated in all the patients, whereas 15 patients required concomitant use of ceramic bone substitute. Sagittal alignment of the operative level was lordotic in 19 cases (79%) and neutral in 5 cases (21%) at the final follow-up. No late kyphotic collapse was observed. Twenty-three cases (96%) achieved a solid fusion, whereas the time to fusion was averaged 6.2 months. Cage subsidence frequently occurred in 42% of upper vertebrae and 50% of lower vertebrae. The use of titanium mesh and local autograft for anterior cervical fusion obviated the need for harvesting iliac bone block and provided structural anterior column support. However, it required a longer period to achieve a solid fusion when compared with tricortical iliac autograft. Cage subsidence was frequently observed in the early postoperative period.

Intraoperative biomechanical assessment of lumbar spinal instability: validation of radiographic parameters indicating anterior column support in lumbar spinal fusion.

STUDY DESIGN: Lumbar spinal instability was evaluated using radiographic parameters and intraoperative biomechanical measurement. OBJECTIVES: To validate a conventional radiographic assessment using an intraoperative biomechanical measurement and to determine the radiographic parameters indicating anterior column support in lumbar spinal fusion. BACKGROUND: Posterior lumbar interbody fusion is gaining acceptance in the treatment of degenerative spondylolisthesis, whereas posterolateral fusion alone may result in good clinical outcomes. A quantitative biomechanical assessment of spinal instability is essential to determine the optimal method of spinal arthrodesis. MATERIALS AND METHODS: Nineteen cases with symptomatic degenerative spondylolisthesis were included in this study. All were candidates for pedicle-screw instrumented lumbar arthrodesis. A total of five L3-L4 segments and seventeen L4-L5 segments were investigated. Radiographic assessment included disc angle, range of motion (ROM), percent of slip, and percent of posterior disc height. Distraction stiffness of the operative segment was measured intraoperatively using a strain-gauged spreader. RESULTS: Disc angle in flexion and ROM were highly correlated to distraction stiffness. Severity of slip, disc space narrowing, and facet tropism did not influence the distraction stiffness. The cases with segmental kyphosis in flexion had significantly lower distraction stiffness than those showing segmental lordosis in flexion. CONCLUSIONS: Disc angle in flexion and ROM were the most prognostic parameters of lumbar distraction instability. Although the option of spinal arthrodesis method should be determined based on both clinical manifestation and imaging studies, the current study demonstrated that providing of anterior column support is biomechanically reasonable for degenerative spondylolisthesis with segmental kyphosis in flexion.

Clinical results of single-level posterior lumbar interbody fusion using the Brantigan I/F carbon cage filled with a mixture of local morselized bone and bioactive ceramic granules.

STUDY DESIGN: A retrospective study to evaluate the results of single-level posterior lumbar interbody fusion (PLIF) using the Brantigan I/F cage (DePuy AcroMed Corp., Raynham, MA) filled with a mixture of local morselized autologous bone and bioactive ceramic granules. OBJECTIVES: To report the clinical and radiologic results of PLIF using the Brantigan I/F cage for lumbar degenerative pathologies with instability. SUMMARY OF BACKGROUND DATA: The Brantigan I/F cage for PLIF was designed to improve the fusion success of interbody fusion by separating the mechanical and biologic functions of PLIF using an implant device and autologous bone from the iliac crest. Although high fusion rates have been reported, donor site morbidity caused by bone harvest from the iliac crest remains a concern. The possibility of accomplishing cage PLIF using a mixture of local morselized bone and a bone extender was studied. METHODS: A total of 25 patients underwent single-level PLIF using the Brantigan I/F cage filled with a mixture of local morselized bone and bioactive ceramic granules. All patients were observed for more than 2 years (average 2 years 7 months) and evaluated by clinical rating and radiograph. RESULTS: Preoperative Japanese Orthopedic Association clinical scores were significantly improved in all patients at the time of follow-up. The average improvement rate was 83.1%. There were no serious complications. Minor complications included two dural tears and two cases of thrombophlebitis. No patient required blood transfusion. All patients achieved radiographic fusion and radiographic stability, although two patients fused in a collapsed position. Regional alignment of the operated segments was restored at surgery and maintained at the time of final follow-up. There were statistical improvements in percent slip and percent posterior disc height in patients with spondylolisthesis. CONCLUSIONS: Posterior lumbar interbody fusion using the Brantigan I/F cage with a mixture of local morselized bone and bioactive ceramic granules can yield a solid union with satisfactory regional alignment and adequate disc height without harvest of iliac crest bone.