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PubMed2001

Trochanteric union in revision hip arthroplasty.

A total of 69 patients undergoing revision hip arthroplasty using a transtrochanteric approach who all had at least 1 previous transtrochanteric surgical approach. In 6 patients, it was the third time the trochanter was taken down, and in 2 patients, it was the fourth time. We believe this is the first review of trochanteric union in such a subgroup of patients. The mean age was 66 years (range, 46-82 years). Before revision, 49 of 69 patients (71%) had a united trochanter, whereas 20 of 69 (29%) had a pseudarthrosis. The overall pseudarthrosis rate decreased from 20 patients (29%) to 10 patients (14%) after revision surgery. The mean Harris hip score was 86 (range, 29-100). Repeated transtrochanteric osteotomy was not associated with any significant morbidity and did not affect the clinical outcome.

Aged↗

PubMed2002

[Surgical treatment of fractures of the clavicle--Indication, surgical technique and results].

UNLABELLED: 46 cases of clavicular fracture (25 of the middle third and 21 of the distal third) are reviewed concerning indications for surgery, surgical technique and postoperative results. In 32 cases surgery was necessary due to dislocation (in 7 cases with a rupture of the coracoclavicular ligaments), 3 times due to a complex trauma of the shoulder joint, 3 times due to a local neurovascular involvement, 3 times due to a delayed fracture healing and 3 times due to a pathological fracture. In two cases an open fracture required osteosynthesis. The most frequent surgical procedure was plate osteosynthesis using the following materials: 3.5 mm LCDC plate, the so called "Balser plate" and the "Ulrich plate", 3.5 mm reconstruction plate, 3.5 mm T-plate and compound plate. In 14 cases autogenous bone grafting was performed. Additional suture of the coracoclavicular ligaments was indicated in 7 patients. In every case early physiotherapy followed the surgical procedure. COMPLICATIONS: in 2 cases an avascular pseudarthrosis emerged after plate osteosynthesis without autogenous bone grafting. In one case a non-union developed due to infection. Moreover we found a loosening of a "Balser plate" and in one patient the development of keloid tissue. The functional outcome according to the Constant score was good. 32 patients achieved 89 out of 100 possible points (average follow up 31 months). In distal clavicle fractures we prefer the use of the "Balser plate" combined with a suture of the coracoclavicular ligaments. Due to the occurrance of delayed fracture healing with pseudarthrosis (2/25) in fractures of the middle third, the indication for surgical treatment has to be discussed. In case of local soft tissue trauma and damage of the periostal blood supply, plate osteosynthesis in combination with autogenous bone grafting should be performed.

Adolescent↗

PubMedDate not supplied

[Operative leg lengthening, technic, indications and results].

30 operative lengthenings of the lower limb had been performed during 1967 til 1981, all of them after the method described by Wagner. Indication of this treatment was given by a legshortening from minimum 4.0 and maximum 15.0 cm. Twelve lengtheningosteotomies occurred in the thigh, two in the thigh under simultaneous shortening of the opposite side and sixteen in the lower leg. In eight patients resulted a complete compensation, in 21 patients remained a length -- difference between 0.5 until 6.0 cm., in one patients resulted a further legshortening in account of a pseudarthrosis. The following severe complications occurred: necrosis of the skin (n = 3 and infected pseudarthrosis (n = 2). In one case we observed a fatigue fracture in the lower leg when taking away the metal plate. All of these complications could be cured under adequate surgical management.

Adolescent↗

PubMed1999

Bone SPECT of the back after lumbar surgery.

PURPOSE: It may be difficult to evaluate back pain in patients who have undergone spinal surgery, because symptoms may be secondary to all the possible abnormalities in patients who have not had surgery plus postoperative complications, including infection, unstable fusion sites, or transfer of biomechanical stresses to other regions. MATERIALS AND METHODS: Sixty-three patients with back pain and a history of lumbar spinal surgery had bone SPECT examinations. Twenty-eight patients had laminectomies, 10 had laminectomies with fusion, 10 had laminectomies with fusion and metallic stabilization devices (3 of which were removed), 7 had fusion without laminectomy, 7 had discectomies, and 1 had a fusion with metallic stabilization but no laminectomy. Eighty-seven percent of the fusions were posterior. The results of SPECT scanning were correlated with surgery, clinical information, and diagnostic radiologic studies. RESULTS: Patients with fusions tended to be scanned further out from the time of surgery than were patients with laminectomy alone or especially discectomy. Bone SPECT excluded bony abnormalities in the operative site in 7 of 63 patients. One hundred thirty-two lesions were uncovered, with facet abnormalities (n = 51) the most common followed by disc space-centered conditions (n = 29), pseudarthrosis (n = 20), sacroiliac joint (n = 18), vertebral body lesions (n = 9), and miscellaneous sites (n = 5). Sixty percent of the abnormalities located in the facets, disc spaces, and vertebral bodies were located in the operative field, whereas 29% were above and 11% were below it. CONCLUSION: Bone SPECT was useful in evaluating these patients to exclude bony lesions or to identify pseudarthrosis, abnormal facets, disc space-centered lesions, and sacroilitis.

Adult↗

PubMed1999

Functional outcome of plate fusions for disorders of the occipitocervical junction.

Twenty-eight patients with average followup of 27 months (range, 12-51 months) required occipitocervical fusion with plates. A 1992 to 1996 consecutive case series enrolled patients prospectively from two institutions. Five surgeons participated. Sixteen patients had inflammatory arthritis; four, osteogenesis imperfecta; three, tumors; three, congenital anomalies; one, pseudarthrosis after odontoid fracture; and one, osteoarthritis. Twenty-two of 28 (78.6%) patients had serious comorbid medical conditions. Additional halo immobilization of 6 weeks was used in 16 of 27 patients. Four patients required revision surgery. No patients showed a decline in neurologic status and average neurologic improvement was one Nurick grade. Two-year followup showed 13 (50%) excellent, nine (34.6%) good, two (7.7%) fair, and two (7.7%) poor outcomes based on a functional outcome scale. There were three deaths during the followup period (overall mortality rate of 10.7%). One death was attributable to airway obstruction, one death 14 months postoperatively was attributable to late Methicillin resistant Staphylococcus aureus sepsis at the bone graft donor site, and one death 41 months postoperatively was attributable to a stroke. The overall fusion rate was 85.2% (23 of 27 patients), with a 96.3% (26 of 27 patients) occipitocervical fusion rate. Three patients had a possible asymptomatic end segment pseudarthrosis with screw loosening. Twenty-two of 26 (84.6%) interviewed patients would choose the surgery again if given the choice.

Adolescent↗

PubMed2002

Anterior BAK instrumentation and fusion: complete versus partial discectomy.

Beginning in January 1994, a prospective, clinical study was done comparing the effectiveness of complete anterior (Group 1) versus partial reamed channel discectomies (Group 2) in 100 consecutive patients who had anterior BAK instrumentation and fusion using autogenous iliac crest bone graft. At 2 or more years of followup, all patients in Group 1 who had complete operative disc removal achieved solid arthrodesis. There were no revision surgeries. However, in Group 2, there were seven patients who had a pseudarthrosis and an additional patient with early postoperative cage displacement, which resulted in eight patients in Group 2 requiring revision surgery. The differences in operative preparation of the disc space for BAK instrumentation surgery resulting in complications proved to be significant. The use of interbody titanium cages dramatically increases the biomechanical efficacy of anterior fusions. Original proponents of cages advocated removing a cylindrical channel of disc material using a drill. A prospective review of 100 patients who had complete versus partial discectomy revealed 14% of patients in Group 2 eventually had a pseudarthrosis develop.

Adult↗

PubMedDate not supplied

Posterior spinal fusion in paralytic scoliosis and myelomeningocele.

The Shriners Hospital, Lexington, KY, experience with posterior spinal fusion for scoliosis in 50 patients with myelomeningocele was reviewed. Six patients were fused with Harrington rods and 47 of 50 patients were treated with some form of segmental fixation. The complication rate was 48% (24/50) resulting in 1.48 procedures per patient. The deep infection rate was 8% (4/50) and the pseudarthrosis rate was 16% (8/50). The use of modern segmental instrumentation systems has improved the pseudarthrosis rates for posterior spinal fusion in scoliosis associated with myelomeningocele but not to the point of displacing the current approach of an anterior and posterior spinal fusion.

Adolescent↗

PubMedDate not supplied

Adult idiopathic scoliosis treated by posterior spinal fusion and Harrington instrumentation.

Ninety-one patients with idiopathic scoliosis, who underwent posterior spinal fusion and instrumentation from January 1977 to December 1982, were reviewed. All patients were 20 years or older at the time of surgery and none had undergone a prior surgical procedure. Indications for surgery included pain, progressive deformity, and pulmonary symptoms. All patients had a posterior spinal fusion with Harrington instrumentation and autogenous iliac bone graft, with the addition of segmental wiring in only eight. No patient had an anterior fusion or fusion to the sacrum. Follow-up averaged 3.5 years (range: 2-7 years). The average correction at the time of surgery was 38%, and 32% at the time of last follow-up. Seventy-nine percent of the patients reported complete relief of the symptom(s) for which they had surgery. There were 34 complications in 30 (33%) patients. Pseudarthrosis occurred in 14 (15%), requiring 15 additional procedures to achieve a solid arthrodesis. Urinary tract infection occurred in 8 (9%) patients and Harrington hook dislodgement in 5 (5%). One patient sustained a partial paraparesis with recovery to a minimal deficit. No deaths occurred. Although largely successful, posterior fusion with Harrington instrumentation for adult scoliosis has a significant incidence of pseudarthrosis and instrumentation problems.

Adult↗

PubMed1989

Complications with the variable spinal plating system.

From January 1986 to June of 1987, 40 patients underwent transpedicle fixation and fusion using the variable spinal plate system. Nineteen patients had undergone surgery at the same level or levels, and 21 patients had undergone no previous surgery. Diagnostic categories include spondylolisthesis, thoracolumbar and lumbar fractures, internal disc derangement, spinal stenosis, pseudarthrosis, mechanical instability, and fracture mal-union. Minimum follow-up has been 14 months, with the average being 20 months. Overall results showed 13 excellent, 12 good, seven fair, and eight poor. The overall complication rate was 45%. In those patients undergoing no previous surgery, it was 29%, but with those patients having previous surgery, it was 63%. Most of these complications were minor in nature and resolved before discharge. Implant failure occurred in seven patients, and consisted of screw breakage. Design modifications currently available should help minimize this complication. Although this method of internal fixation and fusion is technically demanding and has a high complication rate, it is considered to be indicated in lumbar fractures, revision of pseudarthrosis, spondylolisthesis with or without reduction, and failed surgery with marked instability.

Bone Plates↗

PubMed1990

Long scoliosis fusion to the sacrum in adults with nonparalytic scoliosis. An improved method.

The first 17 adults with nonparalytic scoliosis having long fusion to the sacrum treated with the Luque-Galveston technique were reviewed. There were 3 men and 14 women. Their average age at the time of surgery was 47 years and the mean follow-up period was 42 months. There were no neurologic complications and no patient developed significant loss of lumbar lordosis. Fusion occurred in 88% of patients. Two patients developed pseudarthrosis, neither of whom had anterior fusion at the level of pseudarthrosis. The best results occurred in patients who had two-stage procedures, with initial anterior lumbar fusion to the sacrum without instrumentation followed by posterior segmental instrumentation with the Galveston technique of fixation to the pelvis.

Female↗

PubMed1994

Lumbar and lumbosacral fusion using Steffee instrumentation.

Posterior and posterolateral spinal fusion with the Steffee variable plating system have been performed on 176 patients at Walter Reed Army Medical Center since November 1985. This report covers the authors' early experience using the Steffee device on 39 patients. All of the 39 patients (100%) were available for a minimum follow-up of 2 years. Complications occurred in 26% of the patients. Radiographic pseudarthrosis occurred in 8% of the patients. The findings suggest that lumbar and lumbosacral fusion supplemented with Steffee plate instrumentation are associated with a low incidence of pseudarthrosis and acceptable morbidity overall.

Adult↗

PubMed1999

Comparison of anterior and posterior instrumentation for correction of adolescent thoracic idiopathic scoliosis.

STUDY DESIGN: This was a prospective study of two cohort groups of patients (one group receiving anterior instrumentation and the other posterior instrumentation) receiving treatment for thoracic idiopathic scoliosis. OBJECTIVE: To present the 2-year postoperative results of a prospective multicenter study comparing the use of anterior instrumentation with that of posterior multisegmented hook instrumentation for the correction of adolescent thoracic idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Despite reports of satisfactory results, problems have been reported with posterior systems, including worsening of the lumbar curve after surgery and failure to correct hypokyphosis. Theoretically, the advantages of anterior instrumentation include prevention of lumbar curve decompensation by shortening the convexity of the thoracic curve. In addition, by removing the disc, better correction of thoracic hypokyphosis could be obtained. METHODS: Seventy-eight patients who underwent an anterior spinal fusion using flexible threaded rods and nuts (Harms-MOSS instrumentation, De Puy-Motech-Acromed, Cleveland, OH) were analyzed and compared with 100 patients who underwent posterior spinal fusion with multisegmented hook systems. Parameters of comparison included coronal and sagittal correction, balance, distal lumbar fusion levels, and complication. All patients had idiopathic thoracic curves of King Types II to V. The average age at surgery was 14 years in each group, the average preoperative curve 57 degrees, and the minimum duration of follow-up for all patients 24 months. All data were collected prospectively and analyzed via Epl into statistical analysis (Centers of Disease Control, Atlanta, GA). RESULTS: Average coronal correction of the main thoracic curve was 58% in the anterior group and 59% in the posterior group (P = 0.92). Analysis of sagittal contour showed that the posterior systems failed to correct a preoperative hypokyphosis (sagittal T5 to T12 less than 20 degrees) in 60% of cases, whereas 81% were normal postoperatively in the anterior group. However, hyperkyphosis (sagittal T5 to T12 greater than 40 degrees) occurred after surgery in 40% of the anterior group when the preoperative kyphosis was greater than 20 degrees. Postoperative coronal balance was equal in both groups. An average of 2.5 (range, 0-6) distal fusion levels were saved using the anterior spinal instrumentation according to the criteria used for determining posterior fusion levels in this study. Selective fusion of the thoracic curve (distal fusion level T11, T12, L1) was performed in 76 of 78 patients (97%) in the anterior group as compared with only 18 of 100 (18%) in the posterior group. Surgically confirmed pseudarthrosis occurred in 4 of 78 patients (5%) in the anterior group and in 1 of 100 patients (1%) in the posterior group (P = 0.10). Loss of correction greater than 10 degrees occurred in 18 of 78 patients (23%) in the anterior group and in 12 of 100 patients (12%) in the posterior group (P = 0.01). Implant breakage occurred in 24 patients (31%) of the anterior group and in only 1 patient (1%) of the posterior group. CONCLUSIONS: 1) Coronal correction and balance were equal in both the anterior and posterior groups, even though the anterior group had the majority of curves (97%) fused short or to L1, whereas only 18% were fused short or to L1 in the posterior group. 2) In the anterior group there was a better correction of sagittal profile in those with a preoperative hypokyphosis less than 20 degrees. However, hyperkyphosis (with a mean of 54 degrees) occurred in 40% of those in the anterior group with a preoperative kyphosis of more than 20 degrees. 3) An average of 2.5 lumbar levels can be saved with anterior fusion and instrumentation according to the criteria used for choosing posterior fusion levels in this study. 4) Using the 3.2-mm flexible rod in this study, loss of correction, pseudarthrosis, and rod breakage were unacceptably highe

Adolescent↗

PubMed1999

Complications and predictive factors for the successful treatment of flatback deformity (fixed sagittal imbalance).

STUDY DESIGN: This is an analysis of consecutive cases of flatback deformity (fixed sagittal imbalance), treated by one of two surgeons at a university hospital. OBJECTIVE: To define factors that contribute to results with treatment of flatback syndrome, classify types of sagittal deformities, and discuss complications. SUMMARY OF BACKGROUND DATA: There are few reports that detail the results and complications of current instrumentation and osteotomy techniques for correction of fixed sagittal deformities. METHODS: Twenty-eight patients treated with osteotomies for sagittal imbalance were eligible for 2-year minimum follow-up (average, 3.6 years). Patients were classified (segmental imbalance, Type 1; or global imbalance, Type 2) and evaluated by upright radiographs, chart review, and a questionnaire. RESULTS: Twenty-eight (100%) patients returned the questionnaire, and 28 had current radiographs. Five treatment groups were evaluated based on osteotomy type (anterior, posterior [Smith-Petersen], both, or pedicle subtraction) and use of anterior structural grafting. All patients were treated with modern bilateral hook-rod-screw constructs. Mean correction at the osteotomy levels was 25 degrees for Type 1 deformities and 30 degrees for Type 2 (P < 0.05). Sagittal correction averaged 6.6 cm in Type 2 deformities (P < 0.05). Questionnaire analysis showed a significant and persistent reduction in subjective pain level. There were seven patients with 11 total complications and no neurologic deficits. Associations among patients who were not satisfied with their results (n = 4) included insufficient sagittal correction (P = 0.045), pseudarthrosis (P = 0.045), coronal imbalance, and four or more medical comorbidities (P = 0.03). CONCLUSIONS: Satisfaction with the results of treatment may be reduced in patients with four or more major co-existent medical problems, insufficient sagittal correction, and resultant pseudarthrosis.

Adolescent↗

PubMed2000

Three- and four-level anterior cervical discectomy and fusion with plate fixation: a prospective study.

STUDY DESIGN: A prospective study of 15 patients who underwent modified Smith-Robinson anterior cervical discectomy and fusion at three or four operative levels stabilized with an unicortical anterior plate. OBJECTIVES: To provide medium-term follow-up data on the surgical success and patient outcome of three- and four-level anterior cervical discectomies and fusions and to determine the effect that plate fixation has on the results. SUMMARY OF BACKGROUND DATA: The success of arthrodesis for anterior cervical fusion depends on several factors, including the number of surgical levels. The arthrodesis rate and outcome for patients having three- and four-level discectomy and fusion procedures is disappointing. Internal fixation putatively improves these parameters. METHODS: Fifteen patients (average age, 51 years; range, 35-77), were observed for an average of 42 months (range, 25-73) All had an anterior discectomy, burring of the endplates, placement of an autogenous tricortical iliac crest graft at three (12 patients) or four (3 patients) levels, and application of a Cervical Spine Locking Plate. All patients had follow-up office visits with examinations and radiographs. Radiographic union, postoperative pain relief, and neurologic recovery were evaluated. RESULTS: Solid arthrodesis was achieved at all levels in only 7 (47%) of the 15 patients after a single procedure. Of the 8 patients with pseudarthrosis, 3 had sufficient pain to necessitate revision surgery (with pain relief in two), 1 had pain without further surgery, and 4 no pain. Of the 7 with solid fusion, 3 had persistent pain, and 4 had none. Two in this group had a second procedure. All 4 patients with preoperative myelopathy improved, and 10 of the 11 with radiculopathy had resolution of arm symptoms. CONCLUSIONS: Three- and four-level modified Robinson cervical discectomy and fusion results in an unacceptably high rate of pseudarthrosis. The Cervical Spine Locking Plate alone does not appear to improve the arthrodesis rate.

Adult↗

PubMed2001

Subtotal corpectomy versus laminoplasty for multilevel cervical spondylotic myelopathy: a long-term follow-up study over 10 years.

STUDY DESIGN: A retrospective study was conducted. OBJECTIVE: To compare the long-term outcomes of subtotal corpectomy and laminoplasty for multilevel cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: No study has compared the long-term outcomes between subtotal corpectomy and laminoplasty for multilevel cervical spondylotic myelopathy. METHODS: In this study, 23 patients treated with subtotal corpectomy and 24 patients treated with laminoplasty were followed up for 10 to 14 years after surgery. Neurologic recovery, late deterioration, axial pain, radiographic results (degenerative changes at adjacent levels, alignment, and range of motion of the cervical spine), and surgical complications were compared between the two groups. RESULTS: No significant difference in neurologic recovery was found between the two groups 1 and 5 years after surgery, or at the latest follow-up assessment. Neurologic status deteriorated in one patient of the subtotal corpectomy group because of adjacent degeneration, and in one patient of the laminoplasty group because of hyperextension injury. Axial pain was observed in 15% of the corpectomy group and in 40% of the laminoplasty group (P < 0.05). In the corpectomy group, listhesis exceeding 2 mm developed at 38% of the upper adjacent levels, and osteophyte formation at 54% of the lower adjacent levels. In the laminoplasty group, kyphotic deformity developed in one patient (6%) after surgery. In the corpectomy group, the mean vertebral range of motion had decreased from 39.4 degrees to 19.2 degrees (49%) by the final follow-up assessment. In the laminoplasty group, the mean vertebral range of motion had decreased from 40.2 degrees to 11.6 degrees (29%) by the final follow-up assessment. Neurologic complications related to the surgery occurred in two patients (one myelopathy from bone graft dislodgement and one C5 root palsy from bone graft fracture) of the corpectomy group and four patients (C5 root palsy) of the laminoplasty group. All of these patients recovered over time. The corpectomy group needed longer operative time (P < 0.001) and tended to have more blood loss (P = 0.24). Six patients in the corpectomy group needed posterior interspinous wiring because of pseudarthrosis. CONCLUSIONS: Subtotal corpectomy and laminoplasty showed an identical effect from a surgical treatment for multilevel cervical spondylotic myelopathy. These neurologic recoveries usually last more than 10 years. In the subtotal corpectomy group, the disadvantages were longer surgical time, more blood loss, and pseudarthrosis. In the laminoplasty group, axial pain occurred frequently, and the range of motion was reduced severely.

Aged↗

PubMed2001

Surgical treatment of congenital kyphosis.

STUDY DESIGN: In this study, 26 cases of congenital kyphosis and kyphoscoliosis treated surgically were retrospectively reviewed. OBJECTIVE: To assess the clinical outcomes and surgical indications for posterior only versus anteroposterior surgery in the child. SUMMARY OF BACKGROUND DATA: Congenital kyphosis usually is progressive without surgical intervention. Current recommended treatment includes posterior arthrodesis for deformities of less than 50 degrees to 60 degrees, and anterior release or decompression, anterior fusion, and posterior instrumented arthrodesis for large deformities and cord compression. METHODS: Cases involving myelodysplasia, spinal dysgenesis, and skeletal dysplasia were excluded from the study. Kyphoscoliosis was included if the kyphotic deformity was greater than the scoliotic deformity. Patients were grouped by age and surgical technique. The patients in group P1 underwent posterior arthrodesis at an age younger than 3 years, and those in group P2 underwent the procedure at an age older than 3 years. The patients in group AP1 underwent anterior and posterior procedures at an age younger than 3 years, and those in group AP2 underwent the procedures at an age older than 3 years. The preoperative deformity, complications, and postoperative deformity correction were analyzed. There were nine Type 1 (failure of formation), nine Type 2 (failure of segmentation), and eight Type 3 (mixed) deformities. Four patients had associated spinal dysraphism. Three patients with Type 1 deformities had clinical or radiographic evidence of cord compression. RESULTS: In Group P1, five patients at an average age of 16 months underwent posterior arthrodesis alone for an average kyphotic deformity of 49 degrees. The immediate postoperative correction improved over a period of 6 years and 9 months by an additional 10 degrees, resulting in a final deformity of 26 degrees. Pseudarthrosis developed in two patients, requiring fusion mass augmentation or anterior arthrodesis. Neither patient was instrumented. In Group P2, five patients at an average age of 13 years and 7 months underwent posterior arthrodesis with instrumentation for kyphotic deformity of 59 degrees. Approximately 30 degrees of intraoperative correction was achieved safely using compression instrumentation and positioning. No further correction occurred with growth. The final residual kyphotic deformity was 29 degrees after a follow-up period of 4 years and 5 months. In Group AP1, seven patients underwent anterior release or vertebra resection for deformity correction and posterior arthrodesis for an average kyphotic deformity of 48 degrees at the age of 16 months. There were no iatrogenic neurologic injuries. The final residual kyphotic deformity was 22 degrees after a follow-up period of 6 years and 3 months. In Group AP2, nine patients underwent anterior release or decompression with posterior arthrodesis for kyphotic deformity of 77 degrees at the age of 11 years and 6 months. The deformity was corrected to 37 degrees, with no significant loss over a follow-up period of 5 years and 2 months. There were two postoperative neurologic complications. CONCLUSIONS: After reviewing their experience, the authors made the following observations: 1) The pseudarthrosis rate was low even without routine augmentation of fusion mass if instrumentation was used; 2) gradual correction of kyphosis may occur with growth in patients younger than 3 years with Types 2 and 3 deformities after posterior fusion, but appears to be unpredictable; 3) the risk of neurologic injury with anterior and posterior fusion for kyphotic deformity was associated with greater age, more severe deformity, and preexisting spinal cord compromise.

Adolescent↗

PubMed2002

Increased rate of arthrodesis with strut grafting after multilevel anterior cervical decompression.

STUDY DESIGN: Reconstruction techniques after multilevel anterior cervical decompression were retrospectively compared. OBJECTIVE: To compare radiographic and clinical outcomes of multiple interbody grafting with strut grafting. SUMMARY OF BACKGROUND DATA: Previous studies have reported lower fusion rates for anterior cervical decompressions reconstructed with multiple interbody grafts as opposed to a single strut graft, although these techniques have never been directly compared in a consecutive series of patients who underwent surgery by a single surgeon. METHODS: Over a 20-year period, 190 patients underwent anterior cervical decompression and autogenous grafting without internal fixation and were followed for an average of 68 months. There were 98 two-level and 33 three-level discectomies with interbody grafting. These were compared with 16 one-level, 21 two-level, 20 three-level, and 2 four-level corpectomies with strut grafting. Radiographic and clinical outcomes were compared between the groups by chi2 and rank-sum analysis, respectively. RESULTS: Of the 59 patients who underwent strut grafting, 55 achieved a solid arthrodesis (93%), as compared with 87 of the 131 patients who underwent multiple interbody grafting (66%) (P = 0.0002). There were six cases of graft displacement or extrusion among the 59 patients who had strut grafts, as compared with no graft-related complications among the 131 patients who had interbody grafts (P < 0.0001). More "good" and "excellent" clinical outcomes were found among patients who underwent strut-grafting (88% vs 84%), although the difference was not statistically significant (P = 0.73). However, patients with a pseudarthrosis had significantly poorer clinical outcomes (P < 0.0001). CONCLUSIONS: A much higher fusion rate was achieved after corpectomy and strut grafting than after multilevel discectomy and interbody grafting. Although there were strut graft-related complications, four of these six complications occurred among patients who had a postlaminectomy kyphosis. Because pseudarthrosis resulted in poorer clinical outcomes, strut grafting should be considered after multilevel anterior cervical decompression to increase the likelihood of successful fusion.

Adult↗

PubMed2002

Lumbosacral stability of consolidated anteroposterior fusion after instrumentation removal determined by roentgen stereophotogrammetric analysis and direct surgical exploration.

STUDY DESIGN: The intervertebral stability of bony consolidated anteroposterior lumbosacral spondylodesis is evaluated by roentgen stereophotogrammetric analysis and direct surgical exploration before and after removal of the internal fixator. OBJECTIVES: To determine the remaining in vivo stability of spinal arthrodesis solely retained by a bony integrated carbon fiber cage. SUMMARY OF BACKGROUND DATA: Roentgen stereophotogrammetric analysis studies on posterolateral lumbar fusions demonstrate primary spinal stability after additional dorsal instrumentation, which is retained during bony fusion healing. Animal models show a persistent stabilizing effect of the fixator despite the presence of bony fusion. Although direct surgical inspection is the most reliable method to evaluate fused vertebrae, roentgen stereophotogrammetric analysis has also proven to be a highly accurate method to evaluate spinal stability. METHODS: In 10 patients lumbosacral fusion was performed using carbon interbody implants and an internal fixator. Ten months after initial surgery (range 7-15 months) the internal fixation was removed to reduce local soft tissue impingement as soon as bony fusion was achieved. Fusion site exploration in the course of instrumentation removal was performed by applying distraction, compression, and torque to the grafted area under fluoroscopic control. Any motion indicated a pseudarthrosis. Lumbosacral stability was evaluated by serial roentgen stereophotogrammetric analysis after fusion and after instrumentation removal. RESULTS: During instrumentation removal the mechanical stress test under fluoroscopic control did not indicate pseudarthrosis. After instrumentation removal, roentgen stereophotogrammetric analysis measurements revealed a nonsignificant increase in lumbosacral micromotions within the fused segment with 0.14, 0.31, and 0.44 mm in the transverse, vertical, and sagittal axes, respectively. CONCLUSIONS: The internal fixator could be removed without endangering the stability of the fusion. Direct surgical exploration confirmed the adequacy of roentgen stereophotogrammetric analysis as a reliable in vivo method to evaluate lumbosacral stability after anteroposterior fusion.

Adult↗